Cefazolin was better than nafcillin and oxacillin for bacteremic MSSA infections

Report here.

More bad news for morphine in acute decompensated heart failure

From a recent study:

Objective

The objective was to determine the relationship between short-term mortality and intravenous morphine use in ED patients who received a diagnosis of acute heart failure (AHF).

Methods

Consecutive patients with AHF presenting to 34 Spanish EDs from 2011 to 2014 were eligible for inclusion. The subjects were divided into those with (M) or without IV morphine treatment (WOM) groups during ED stay. The primary outcome was 30-day all-cause mortality, and secondary outcomes were mortality at different intermediate time points, in-hospital mortality, and length of hospital stay. We generated a propensity score to match the M and WOM groups that were 1:1 according to 46 different epidemiological, baseline, clinical, and therapeutic factors. We investigated independent risk factors for 30-day mortality in patients receiving morphine.

Results

We included 6,516 patients (mean age, 81 [SD, 10] years; 56% women): 416 (6.4%) in the M and 6,100 (93.6%) in the WOM group. Overall, 635 (9.7%; M, 26.7%; WOM, 8.6%) died by day 30. After propensity score matching, 275 paired patients constituted each group. Patients receiving morphine had a higher 30-day mortality (55 [20.0%] vs 35 [12.7%] deaths; hazard ratio, 1.66; 95% CI, 1.09-2.54; P = .017). In patients receiving morphine, death was directly related to glycemia (P = .013) and inversely related to the baseline Barthel index and systolic BP (P = .021) at ED arrival (P = .021). Mortality was increased at every intermediate time point, although the greatest risk was at the shortest time (at 3 days: 22 [8.0%] vs 7 [2.5%] deaths; OR, 3.33; 95% CI, 1.40-7.93; P = .014). In-hospital mortality did not increase (39 [14.2%] vs 26 [9.1%] deaths; OR, 1.65; 95% CI, 0.97-2.82; P = .083) and LOS did not differ between groups (median [interquartile range] in M, 8 [7]; WOM, 8 [6]; P = .79).

Conclusions

This propensity score-matched analysis suggests that the use of IV morphine in AHF could be associated with increased 30-day mortality.

Lumbar puncture in patients on dual antiplatelet therapy

Reasonably safe in this small study.

Review of enteropathies besides just celiac disease

Free full text here.

CLL review

From Mayo Clinic Proceedings.

Are beta blockers really cardioprotective?

From the results of a large prospective cohort study:

Objective

To assess the relationship between use of β-blockers and all-cause mortality in patients with and without diabetes.

Patients and Methods

Using data from the US National Health and Nutrition Examination Survey 1999-2010, we conducted a prospective cohort study. The study participants were followed-up from the survey participation date until December 31, 2011. We used a Cox proportional hazards model for all-cause mortality analysis. The multivariate-adjusted hazard ratios (HRs) of the participants taking β-blockers were compared with those of the participants not taking β-blockers.

Results

This study included 2840 diabetic participants and 14,684 nondiabetic participants. Compared with diabetic participants not taking a β-blocker, all-cause mortality was significantly higher in diabetic participants taking any β-blocker (HR, 1.49; 95% CI, 1.09-2.04; P=.01), taking a β1-selective β-blocker (HR, 1.60; 95% CI, 1.13-2.24; P=.007), or taking a specific β-blocker (bisoprolol, metoprolol, and carvedilol) (HR, 1.55; 95% CI, 1.09-2.21; P=.01). In addition, all-cause mortality in diabetic participants with coronary heart disease (CHD) was significantly higher in those taking beta-blockers, compared with those not taking beta-blockers (HR, 1.64; 95% CI, 1.08-2.48; P=.02), whereas that in non-diabetic participants with CHD was significantly lower in those taking beta-blockers (HR, 0.68; 95% CI, 0.50-0.94; P=.02). A propensity score–matched Cox proportional hazards model yielded similar results.

Conclusion

Use of β-blockers may be associated with an increased risk of mortality for patients with diabetes and among the subset who have CHD.

An editorial in the same issue provided a nice perspective on the overall issue of cardioprotection attributed to beta blockers.

Several important points can be made:

The idea of cardioprotective beta blockers came from trials in post MI patients, done decades ago, showing reduced mortality attributable to beta blockers.

Those trials were conducted in the pre-reperfusion era and thus tended to involve patients with chronically occluded arteries and larger infarcts with significant scars. This represents a substantially different population compared to the post MI patients we treat today.

The idea of cardioprotective beta blockers was inappropriately extrapolated to areas of cardiovascular medicine outside these clinical trials.

The editorial concludes:

..the only ironclad indication for cardioprotection with β-blockers remains heart failure with reduced ejection fraction,11, 12 the very indication that decades ago was the only contraindication for β-blocker therapy.4

Caffeine intake associated with reduced vascular stiffness

Findings here.

Related editorial here.

Tell me something I didn’t know: More expensive care isn’t necessarily better care

A JAMA Internal Medicine study.

An ABIM leader enters the debate over MOC

Defenders of the board certification establishment have been largely silent amidst the onslaught of criticism so it’s noteworthy when one of the speaks out. Here’s a viewpoint piece in JAMA. Heavy on unfounded assumptions, light on evidence,  unconvincing to me.

MOC or Drexit?

An interesting read at Kevin MD.

MINOCA: it’s definitely a thing

MINOCA (myocardial infarction with non obstructed coronary arteries) has been known for quite some time but is greatly under appreciated. Such patients meet the universal definition of MI but have coronary arteriograms demonstrating no lesions causing greater than 50% obstruction. They may be deceptively labeled as having “insignificant coronary artery disease.” Some will be misdiagnosed as stress cardiomyopathy (formerly Takotsubo) or myocarditis. What’s really going on? It’s a complex and poorly understood interplay of multiple factors. Mild (less than 50% obstructive) plaques may ulcerate or rupture. This may cause thrombus with obstruction which spontaneously recanalizes. Inflammation, endothelial dysfunction, coronary spasm and procoagulant influences may interact. Other patients may have type 2 MI. These mechanisms are reviewed in a recent editorial.

Mind what you eat and lose weight

Benefits of mindful eating.

Can midodrine help patients get off IV pressors faster?

A preliminary study suggests it can and a randomized clinical trial is in progress.

Microscopic colitis

Here is a free full text review.

From the review:

Microscopic colitis (MC), which is comprised of lymphocytic colitis and collagenous colitis, is a clinicopathological diagnosis that is commonly encountered in clinical practice during the evaluation and management of chronic diarrhea. With an incidence approaching the incidence of inflammatory bowel disease, physician awareness is necessary, as diagnostic delays result in a poor quality of life and increased health care costs. The physician faces multiple challenges in the diagnosis and management of MC, as these patients frequently relapse after successful treatment. This review article outlines the risk factors associated with MC, the clinical presentation, diagnosis and histologic findings, as well as a proposed treatment algorithm. Prospective studies are required to better understand the natural history and to develop validated histologic endpoints that may be used as end points in future clinical trials and serve to guide patient management.

Medical errors in nursing home patients

From a systematic review:

Medication errors (MEs) result in preventable harm to nursing home (NH) residents and pose a significant financial burden. Institutionalized older people are particularly vulnerable because of various organizational and individual factors. This systematic review reports the prevalence of MEs leading to hospitalization and death in NH residents and the factors associated with risk of death and hospitalization. A systematic search was conducted of the relevant peer-reviewed research published between January 1, 2000, and October 1, 2015, in English, French, German, or Spanish examining serious outcomes of MEs in NHs residents. Eleven studies met the inclusion criteria and examined three types of MEs: all MEs (n = 5), transfer-related MEs (n = 5), and potentially inappropriate medications (PIMs) (n = 1). MEs were common, involving 16–27% of residents in studies examining all types of MEs and 13–31% of residents in studies examining transfer-related MEs, and 75% of residents were prescribed at least one PIM. That said, serious effects of MEs were surprisingly low and were reported in only a small proportion of errors (0–1% of MEs), with death being rare. Whether MEs resulting in serious outcomes are truly infrequent, or are underreported because of the difficulty in ascertaining them, remains to be elucidated to assist in designing safer systems.

Update on hypertrophic cardiomyopathy

Form a recent review:

Most clinicians would recommend ICD therapy if any one of the five major risk factors is present, although recent debate has focused on whether at least two risk factors are required…

Previous cardiac arrest/ventricular tachycardia (secondary prevention)

Family history of premature sudden cardiac death

Left ventricular wall thickness greater than or equal to 30 mm

Previous episodes of documented NSVT (greater than or equal to 3 beats, rate greater than or equal to 120 bpm)

Unexplained syncope

Concerning treatment in general:

Many treatment options are currently available for HCM patients. This ranges from no treatment; lifestyle modifications, e.g. avoiding competitive sports in all patients with HCM; use of pharmacological agents e.g. beta blockers, calcium channel blockers, and diuretics; to surgical septal myectomy and transcoronary alcohol septal ablation of the myocardium (i.e. the creation of a limited septal infarct by direct injection of alcohol into a septal perforator artery) for individuals with significant left ventricular outflow tract obstruction with symptoms unresponsive to drug therapy. The single most important advance in the clinical management of HCM has involved the use of ICD therapy in the prevention of sudden death [12] . Recent studies indicate that treatment of individuals at highest risk of sudden death with an ICD is the most definitive form of therapy in preventing sudden death and easily surpasses empirically-based preventative strategies previously used in HCM, e.g. amiodarone and beta blockers.

Improved understanding of bicuspid aortic valve disease

A recent article cites findings coming out of the newly established International Bicuspid Aortic Valve Disease Registry.

New guidelines for ECG interpretation in athletes

Reviewed here.

Great info if you can access it. Unfortunately it is behind a pay wall and the graphics and text are too complicated for me to give key points here.

Don’t conflate type 2 MI and NSTEMI!

Confusion remains wide spread despite the publication of this distinction years ago. But now, according to this piece in Circulation, the coding world is finally catching up. ICD 10 now has a code for type 2 MI. Here are some of my take home points:

A type 2 MI is not an acute coronary syndrome.

On initial presentation the distinction is based on clinical circumstances and may occasionally be difficult.

Further investigation usually makes the distinction clear by the end of the hospitalization.

Type 2 MI, though a distinct category, is not a primary single entity in that it is always secondary to something else, one or more of many known conditions. For this reason it is heterogeneous and there are no guidelines for type 2 MI per se. Its treatment always consists of management of the underlying conditions that are altering the myocardial oxygen supply demand balance.

Though ICD 10 now recognizes the distinction, type 2 MI has yet to be excluded from certain performance and regulatory categories for MI due to acute coronary syndrome.

Those who conflate NSTEMI and type 2 MI not only expose their ignorance (or disregard) of the classification and pathophysiology of MI but also risk subjecting patients to inappropriate and potentially harmful treatments. An example is provided in the article.

Metformin monotherapy versus dual therapy with the addition of a sodium glucose co-transporter 2 inhibitor (SGLT-2)

From a recent systematic review:

Highlights

•Type 2 Diabetes Mellitus (T2DM) is a current global threat.

•Sodium-glucose co-transporter 2 inhibitor is a new approach for T2DM management.

•Combined therapy of SGLT2 inhibitor and metformin is more effective.

Abstract

Background

Type 2 Diabetes Mellitus (T2DM) is a chronic disorder and its treatment with only metformin often does not provide optimum glycemic control. Addition of sodium glucose cotransporter 2 inhibitor (SGLT2) will improve the glycemic control in patients on metformin alone. In this study, an attempt is made to investigate the combined therapy of SGLT-2 with metformin in managing T2DM in terms of lowering HbA1c and body weight and monotherapy using metformin alone in HbA1c and body weight reduction.

Objectives

To compare the clinical effectiveness of combined therapy using SGLT2 inhibitor and metformin with monotherapy using metformin alone in HbA1c and body weight reduction.

Method

A systematic review of the randomized controlled trials has been carried out and Cochrane risk of bias tool was used for the quality assessment. Patient, Intervention, Comparison and Outcomes (PICO) technique is used to select the relevant articles to meet the objective.

Results

The studies used in this article are multicenter, double-blinded randomized controlled trials on SGLT2 inhibitors with methformin, there were a total of 3897 participants, with a range of 182 to 1186 individual study size were included. Studies showed that combined therapy were more effective in HbA1c and body weight reduction as compared to monotherapy.

Possible health benefits of dietary magnesium

Report here.

Methamphetamine related heart failure: rising prevalence, distinct phenotype

From the AHA meeting abstracts:

Hypothesis: We hypothesized that in a VA population over a 15 year period, we would observe a rising prevalence of MethHF in admitted patients, along with a unique phenotype.

Methods: Among 9588 patients with diagnosis of heart failure treated at San Diego VA Medical Center in between 2005-2015, 480 were identified to have history of methamphetamine abuse as determined by ICD-9 diagnosis code and/or urine toxicology screen as well as a diagnosis code of heart failure. Demographic, diagnostic, and clinical characteristics of MethHF and heart failure patients without methamphetamine use (HF) were compared. ..

Results: From 2005-2015, the prevalence of methamphetamine usage among patients with heart failure increased linearly (Figure 1). A preliminary cohort comparison demonstrated MethHF had similar ejection fraction and BNP levels but trends toward increased troponin levels, more atrial fibrillation, and a higher GFR. MethHF patients had a greater risk of ER visits (2.3 per year vs 0.5 per year, p=0.01) and a trend towards a greater risk of all-cause hospital readmission...

Metformin use and the risk of B 12 deficiency

From a recent study:

Conclusion

Long-term metformin therapy is significantly associated with lower serum vitamin B12 concentration, yet those at risk are often not monitored for B12 deficiency. Because metformin is first line therapy for type 2 diabetes, clinical decision support should be considered to promote serum B12 monitoring among long-term metformin users for timely identification of the potential need for B12 replacement.

Metacognition: from study habits to clinical reasoning

This article was published in a pharmaceutical education journal but it has general applicability.

High risk medication administration in hospitalized elderly patients preceded falls

From a recent study:

Results

Of 328 falls, 62% occurred in individuals administered at least one high-risk medication within the 24 hours before the fall, with 16% of the falls involving individuals receiving two, and another 16% in individuals receiving three or more. High-risk medications were often administered at higher-than-recommended geriatric daily doses, in particular benzodiazepines and BRAs, for which the dose was higher than recommended in 29 of 51 cases (57%). Hospital EMR default doses were higher than recommended for 41% (12/29) of medications examined.

Conclusion

High-risk medications were administered to older fallers. Doses administered and EMR default doses were often higher than recommended. Decreasing EMR default doses for individuals aged 65 and older and warnings about the cumulative numbers of high-risk medications prescribed per person may be simple interventions that could decrease inpatient falls.

It would appear that EMR decision support contributed to the problem.

Medical error lunacy continues unabated

Green journal commentary, a must read.

Loeffler endocarditis

Case report and review.

What are residency programs doing to mitigate the July effect?

Here’s a report from the green journal:

Results

The response rate was 16% (65/418 programs); however, a total of 262 respondents from all 50 states where residency programs are located were included. Most respondents (n = 201; 77%) indicated that errors occur more frequently in July compared with other months. The most common identified errors included incorrect or delayed orders (n = 183, 70% and n = 167, 64%, respectively), errors in discharge medications (n = 144, 55%), and inadequate information exchange at handoffs (n = 143, 55%). Limited trainee experience (n = 208, 79%), lack of understanding hospital workflow, and difficulty using electronic medical record systems (n = 194; 74% and n = 188; 72%, respectively) were reported as the most common factors contributing to these errors. Programs reported instituting several efforts to prevent harm in July: for interns, additional electronic medical record training (n = 178; 68%) and education on handoffs and discharge processes (n = 176; 67% and n = 108; 41%, respectively) were introduced. Similarly, for senior residents, teaching sessions on how to lead a team (n = 158; 60%) and preferential placement of certain residents on harder rotations (n = 103; 39%) were also reported. Most respondents (n = 140; 53%) also solicited specific “July attendings” using a volunteer system or highest teaching ratings.

Difficulties with EMRs definitely contribute to the problem.

IU critical care

A collection of videos in critical care medicine.

Who are the most influential ER docs on Twitter?

Find out here.

We must be careful. Social media, where power and influence often surpass truth, may be contributing to the post-modernization of medicine.

Red flags for in residency candidates for negative outcomes

From a recent study:

Results

From a dataset of 260 residents who completed their residency over a 19-year period, 26 (10%) were osteopaths and 33 (13%) were international medical school graduates A leave of absence during medical school (p less than .001), failure to send a thank-you note (p=.008), a failing score on United States Medical Licensing Examination Step I (p=.002), and a prior career in health (p=.034) were factors associated with greater likelihood of a negative outcome. All four residents with a “red flag” during their medicine clerkships experienced a negative outcome (p less than .001).

Conclusion

“Red flags” during EM clerkships, a leave of absence during medical school for any reason and failure to send post-interview thank-you notes may be associated with negative outcomes during an EM residency.

This was a study of emergency medicine residents. The applicability to other specialties is unknown.

The ECG: useful for assessing the prognosis of PE

From a recent paper:

Highlights

•The prognostic significance of ECG signs of RV strain in patients with acute pulmonary embolism is controversial.

•ECG signs of RV strain at admission were investigated in 1194 patients with acute PE of different severity.

•Qr pattern in lead V1 was the only ECG abnormality associated with in-hospital mortality in high-risk patients.

•In not high-risk patients, the presence of at least one ECG sign of RV strain was associated with RV dysfunction or injury.

•These findings highlight the need for early imaging investigations in stable patients with ECG signs of RV strain.

Abstract

Background

Several electrocardiographic (ECG) abnormalities have been described in patients with acute pulmonary embolism (PE), with discordant reportings about their prognostic value.

Methods

Consecutive patients with echocardiography performed within 48 h from admission and ECG at presentation, were included in this analysis. The primary study outcome was in-hospital death for high-risk patients and in-hospital death or clinical deterioration for intermediate-risk patients. As secondary outcomes, the associations among ECG abnormalities and both right ventricular dysfunction at echocardiography and baseline troponin elevation were considered.

Results

1194 patients were included in this analysis: 13.8% of patients were at high risk of early death, 61.7% were at intermediate risk and 24.5% were at low risk. ECG signs of RV strain showed a continuously decreasing prevalence from high-risk to intermediate-risk and low-risk patients. Differently, the prevalence of T- wave inversion was similar in high and intermediate-risk patients. In high-risk-patients, Qr pattern in lead V1 was the only ECG abnormality associated with in-hospital mortality, but this sign was detected in only 15.9% of this risk category; the presence of at least one ECG abnormality was not associated with the risk of in-hospital death. In not high-risk patients, the presence of at least one ECG abnormality was significantly associated with RVD and this association was confirmed for each individual ECG abnormality. Similar results were obtained as regards the baseline troponin elevation in 816 patients.

Conclusions

Among the electrocardiographic signs of RV strain/ischemia, Qr pattern in lead V1 was the only ECG abnormality associated with in-hospital mortality in high-risk patients. In not high-risk patients the demonstrated association among baseline ECG signs of RV strain/ischemia and RV dysfunction at echocardiography or troponin elevation highlights the need for early further investigations in patients with such ECG abnormalities.

ECG changes in hyperkalemia predict outcomes

From a recent report:

Methods

We collected records of all adult patients with potassium (K+) greater than or equal to 6.5 mEq/L in the hospital laboratory database from August 15, 2010, through January 30, 2015. A chart review identified patient demographics, concurrent laboratory values, ECG within one hour of K+ measurement, treatments and occurrence of adverse events within six hours of ECG. We defined adverse events as symptomatic bradycardia, ventricular tachycardia, ventricular fibrillation, cardiopulmonary resuscitation (CPR) and/or death. Two emergency physicians blinded to study objective independently examined each ECG for rate, rhythm, peaked T wave, PR interval duration and QRS complex duration. Relative risk was calculated to determine the association between specific hyperkalemic ECG abnormalities and short-term adverse events.

Results

We included a total of 188 patients with severe hyperkalemia in the final study group. Adverse events occurred within six hours in 28 patients (15%): symptomatic bradycardia (n=22), death (n=4), ventricular tachycardia (n=2) and CPR (n=2). All adverse events occurred prior to treatment with calcium and all but one occurred prior to K+-lowering intervention. All patients who had a short-term adverse event had a preceding ECG that demonstrated at least one hyperkalemic abnormality (100%, 95% confidence interval [CI] [85.7–100%]). An increased likelihood of short-term adverse event was found for hyperkalemic patients whose ECG demonstrated QRS prolongation (relative risk [RR] 4.74, 95% CI [2.01–11.15]), bradycardia (HR less than 50) (RR 12.29, 95%CI [6.69–22.57]), and/or junctional rhythm (RR 7.46, 95%CI 5.28–11.13). There was no statistically significant correlation between peaked T waves and short-term adverse events (RR 0.77, 95% CI [0.35–1.70]).

It’s an interesting lesson in the fact that all adverse events occurred before calcium was administered. In addition to the points made here, the ECG may also be beneficial in diagnosing hyperkalemia before the labs are back.

Distinguishing recurrent DVT from old DVT

It is difficult but there are some things you can look for. From a recent review:

Highlights

Lower limb deep venous thrombosis (DVT) recurrence represents a diagnostic challenge.

Ultrasound is the first choice examination when DVT is suspected.

This review highlights the validated criteria for DVT recurrence.

An increase in vein diameter between 2 and 4 mm requires further examination.

New diagnostic imaging techniques are currently under evaluation.

Abstract

Introduction

Recurrent deep vein thrombosis (DVT) is often suspected in patients after anticoagulant drug withdrawal. The clinical signs can be confused with the onset of post-thrombotic syndrome. For these reasons, diagnosis of DVT recurrence must rely on an accurate method.

Materials and methods

In order to assess this challenging clinical issue, we performed an overview of the literature regarding ultrasound criteria for the diagnosis of recurrent DVT through a Medline search, which included articles published from January 1, 1980 to February 20, 2017.

Results

Eighty-eight publications were found based on the defined keywords, of which nine articles with a relevant abstract were selected. By searching the reference lists of these nine articles, we obtained another 27 relevant articles. A new non-compressible vein or an increase in the diameter of a previously thrombosed vein segment by greater than 4 mm are sufficient to confirm the diagnosis of DVT recurrence. In contrast, an increase in diameter of less than 2 mm enables recurrence to be ruled out. An increase between 2 and 4 mm is deemed equivocal. Criteria based on echogenicity and Doppler venous blood flow are not reproducible. Other diagnostic imaging methods, mainly direct thrombus magnetic resonance imaging, are currently under evaluation.

Conclusions

Ultrasound remains the most useful test for the diagnosis of recurrent DVT. Further imaging tests need to be validated.

Catheter directed thrombolysis for DVT: what are the current recommendations?

Here’s from the latest review:

Highlights

•The initial treatment of acute DVT influences late complications.

•Post-thrombotic syndrome affects 40% of patients with symptomatic DVT.

•Catheter-directed thrombolysis (CDT) rapidly eliminates clot but increases bleeding.

•Randomized trials are inconclusive on whether CDT provides long-term benefit.

•A highly individualized approach should be used for patient selection.

That’s exactly the recommendation of the ACCP guidelines.

Is a DOAC appropriate for your post bariatric surgery patient? Maybe not!

From a recent study:

Highlights

•DOAC drug levels were tested in 18 post-BS patients and 18 matched controls.

•Five of 7 post-BS patients using rivaroxaban had subtherapeutic plasma levels.

•Patients using apixaban and dabigatran had blood levels within the expected range.

•After BS, we suggest cautious use, if at all, of DOACs, particularly rivaroxaban.

•Until more data become available, warfarin may be more suitable than DOACs after BS.

Abstract

Objective

To determine direct-acting oral anticoagulant (DOAC) blood levels in post-bariatric surgery (BS) patients treated with long-term anticoagulation therapy.

Methods

We identified from medical records patients who underwent BS during 2005–2016 and who were treated with DOACs. We offered testing DOAC blood levels to these patients and to age, sex, body mass index, and serum creatinine-matched individuals treated by DOACs who did not undergo BS.

Results

Overall, 36 individuals were enrolled, 18 post-BS patients and 18 control subjects. Of the post-BS patients, 12 underwent laparoscopic sleeve gastrectomy, 4 laparoscopic adjustable gastric banding and 2 laparoscopic Roux-en-Y gastric bypass surgery. Median time lapsed from surgery until study inclusion was 4.9 years. Five post-BS patients had peak drug levels below expected levels compared to none of the control subjects (P = 0.05). For patients who used apixaban (n = 9) and dabigatran (n = 2), peak drug levels were within the expected range. In contrast, for the 7 patients who used rivaroxaban, levels were below the expected range in 5, including all four who underwent sleeve gastrectomy and one following adjustable gastric banding. Peak rivaroxaban levels were significantly lower in the post-BS than the control group (P = 0.02).

Conclusion

This preliminary study suggests that all DOACs, particularly rivaroxaban, be cautiously used following BS, if used at all. Given that vitamin-K antagonists can be easily monitored, they may be a better choice, until more data on DOAC use in this patient population are available.