The prevalence of pulmonary embolism among patients hospitalized for syncope is not well documented, and current guidelines pay little attention to a diagnostic workup for pulmonary embolism in these patients.

Despite more than 150 million people becoming infected worldwide, SARS-CoV-2 reinfections are uncommon. The risk of a second infection in the population who has recovered from COVID-19 is crucial to improve quarantine management and optimize the ongoing vaccination campaign. The rate of reinfection among health care workers has been reported,^1,2 but the rate of reinfection in the general population is less clear.^3,4

Background: The optimal timing to administer non–vitamin K oral anticoagulants ( NOAC s) in patients with acute ischemic stroke and atrial fibrillation is unclear. This prospective observational multicenter study evaluated the rates of early recurrence and major bleeding (within 90 days) and their timing in patients with acute ischemic stroke and atrial fibrillation who received NOAC s for secondary prevention. Methods and Results: Recurrence was defined as the composite of ischemic stroke, transient ischemic attack, and symptomatic systemic embolism, and major bleeding was defined as symptomatic cerebral and major extracranial bleeding. For the analysis, 1127 patients were eligible: 381 (33.8%) were treated with dabigatran, 366 (32.5%) with rivaroxaban, and 380 (33.7%) with apixaban. Patients who received dabigatran were younger and had lower admission National Institutes of Health Stroke Scale score and less commonly had a CHA ₂ DS ₂ ‐ VAS c score >4 and less reduced renal function. Thirty‐two patients (2.8%) had early recurrence, and 27 (2.4%) had major bleeding. The rates of early recurrence and major bleeding were, respectively, 1.8% and 0.5% in patients receiving dabigatran, 1.6% and 2.5% in those receiving rivaroxaban, and 4.0% and 2.9% in those receiving apixaban. Patients who initiated NOAC s within 2 days after acute stroke had a composite rate of recurrence and major bleeding of 12.4%; composite rates were 2.1% for those who initiated NOACs between 3 and 14 days and 9.1% for those who initiated >14 days after acute stroke. Conclusions: In patients with acute ischemic stroke and atrial fibrillation, treatment with NOAC s was associated with a combined 5% rate of ischemic embolic recurrence and severe bleeding within 90 days.

The impact of residual pulmonary obstruction on the outcome of patients with pulmonary embolism is uncertain.We recruited 647 consecutive symptomatic patients with a first episode of pulmonary embolism, with or without concomitant deep venous thrombosis. They received conventional anticoagulation, were assessed for residual pulmonary obstruction through perfusion lung scanning after 6 months and then were followed up for up to 3 years. Recurrent venous thromboembolism and chronic thromboembolic pulmonary hypertension were assessed according to widely accepted criteria.Residual pulmonary obstruction was detected in 324 patients (50.1%, 95% CI 46.2–54.0%). Patients with residual pulmonary obstruction were more likely to be older and to have an unprovoked episode. After a 3-year follow-up, recurrent venous thromboembolism and/or chronic thromboembolic pulmonary hypertension developed in 34 out of the 324 patients (10.5%) with residual pulmonary obstruction and in 15 out of the 323 patients (4.6%) without residual pulmonary obstruction, leading to an adjusted hazard ratio of 2.26 (95% CI 1.23–4.16).Residual pulmonary obstruction, as detected with perfusion lung scanning at 6 months after a first episode of pulmonary embolism, is an independent predictor of recurrent venous thromboembolism and/or chronic thromboembolic pulmonary hypertension.

Although early warning scores were originally derived as bedside tools for alerting the medical staff, they may serve as decision rules for the admission of medical patients. We conducted this study to investigate the ability of the Modified Early Warning Score (MEWS) to identify a subset of patients at risk of deterioration, who might benefit from an increased level of attention. Prospective, single centre, cohort study. A 64-bedded medical ward in a public, non-teaching Hospital in Italy. All patients consecutively admitted from 15th November 2005 to 9th June 2006. On admission, the attending physician measured five physiological parameters (systolic blood pressure, pulse rate, respiratory rate, body temperature and level of consciousness) and calculated the MEWS. The main outcome measures were in-hospital mortality and a composite of mortality and transfer to a higher level of care. A secondary end-point was the length of stay for discharged patients. In all, 1107 patients were admitted; 621 (56.1%) were women and 486 were men. Patients of female gender were also older (mean age 80.6 years) than men (mean age 77.1; p < 0.05). Of 1107, 995 patients (89.9%) were older than 64 years. A total of 966 patients were discharged, 102 deceased and 39 were transferred. In comparison with the lowest score, the risk of death was incremental among all the MEWS categories, as well as the risk of the combined outcome of death and transfer, and highly significant (risk of death, chi(2) for trend 136.307; risk of death or transfer, chi(2) for trend 105.762; p < 0.00001 for both). Patients with MEWS < or = 4 were discharged after a mean stay of 8.3 days, and alive patients with MEWS of five or more were discharged after a mean stay of 9.4 days (p = ns). A patient with a MEWS of zero at admission has a very low probability to die or to be transferred because of clinical instability (OR 0.14, 95% CI: 0.08-0.24). We have confirmed that the MEWS, even when calculated once on admission, is a simple but highly useful tool to predict a worse in-hospital outcome.

Background and Purpose—: Despite treatment with oral anticoagulants, patients with nonvalvular atrial fibrillation (AF) may experience ischemic cerebrovascular events. The aims of this case-control study in patients with AF were to identify the pathogenesis of and the risk factors for cerebrovascular ischemic events occurring during non–vitamin K antagonist oral anticoagulants (NOACs) therapy for stroke prevention. Methods—: Cases were consecutive patients with AF who had acute cerebrovascular ischemic events during NOAC treatment. Controls were consecutive patients with AF who did not have cerebrovascular events during NOACs treatment. Results—: Overall, 713 cases (641 ischemic strokes and 72 transient ischemic attacks; median age, 80.0 years; interquartile range, 12; median National Institutes of Health Stroke Scale on admission, 6.0; interquartile range, 10) and 700 controls (median age, 72.0 years; interquartile range, 8) were included in the study. Recurrent stroke was classified as cardioembolic in 455 cases (63.9%) according to the A-S-C-O-D (A, atherosclerosis; S, small vessel disease; C, cardiac pathology; O, other causes; D, dissection) classification. On multivariable analysis, off-label low dose of NOACs (odds ratio [OR], 3.18; 95% CI, 1.95–5.85), atrial enlargement (OR, 6.64; 95% CI, 4.63–9.52), hyperlipidemia (OR, 2.40; 95% CI, 1.83–3.16), and CHA ₂ DS ₂ -VASc score (OR, 1.72 for each point increase; 95% CI, 1.58–1.88) were associated with ischemic events. Among the CHA ₂ DS ₂ -VASc components, age was older and presence of diabetes mellitus, congestive heart failure, and history of stroke or transient ischemic attack more common in patients who had acute cerebrovascular ischemic events. Paroxysmal AF was inversely associated with ischemic events (OR, 0.45; 95% CI, 0.33–0.61). Conclusions—: In patients with AF treated with NOACs who had a cerebrovascular event, mostly but not exclusively of cardioembolic pathogenesis, off-label low dose, atrial enlargement, hyperlipidemia, and high CHA ₂ DS ₂ -VASc score were associated with increased risk of cerebrovascular events.