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Faculty & Disclosures

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    Faculty & Disclosures
    Prof. Hanne Christensen

    University of Copenhagen, Denmark

    Prof. Hanne Christensen lives in Copenhagen, Denmark, working as a clinical neurologist in Bispebjerg Hospital, mainly with stroke and acute neurology. Prof. Christensen holds a clinical professorship with the University of Copenhagen. read more

    Prof. Christensen has worked with stroke clinically and in research since 1998, with the focus of her work being clinical research, guidelines and implementation.

    In 2019, Prof. Christensen won the Danish prize for research that impacts patient care. She chairs the Action Plan for Stroke in Europe, and is on the board of the Danish Stroke Registry. She is senior guest editor for AHA Stroke Journal and is on the editorial boards of the European Stroke Journal and the International Journal of Stroke. She has published 211 medline-indexed scientific articles.

    Prof. Hanne Christensen discloses: Speaker’s bureau fees from Bayer and Bristol-Myers Squibb. Grants/research support from AstraZeneca and Bayer.
    Prof. Thorsten Steiner

    The Clinical Centre in Frankfurt Höchst, Frankfurt, Germany

    Prof. Thorsten Steiner is professor of neurology and neurointensive care and head of the Department of Neurology at the Clinical Centre in Frankfurt Höchst, Germany. He is a member of the School of Medicine at the University of Heidelberg, Germany. read more

    His main research interests are intensive stroke care, strategies to treat increased intracranial pressure, and invasive cerebral monitoring. He has contributed to various clinical stroke trials on haemostatics in intracranial haemorrhage, and thrombolysis and neuroprotectants in ischaemic stroke.

    He is first author of the European Stroke Organisation’s (ESO, former European Stroke Initiative – EUSI) recommendations for the management of intracerebral haemorrhage and the German Society of Neurology (DGN) guidelines, and principal coordinator of the ESO recommendations for the management of subarachnoid haemorrhage. Prof. Steiner has received several awards for his scientific achievements and his contributions to medical education. Among others, he received the “leading-edge publication” award from the Faculty of Medicine at the University of Heidelberg.

    Prof. Steiner is chairman of the Guidelines Committee of the ESO, council member of the DGN and the German Society for Internal Medical ICU Medicine, a member of the German Stroke Society and a founding board member of the NeuroCriticalCare Society, USA. He is co-editor of the German Interdisciplinary Collaboration of Internal Medical ICU Medicine.

    Prof. Thorsten Steiner discloses: Advisory board or panel fees from AstraZeneca and Boehringer Ingelheim (all relationships terminated). Consultant fees from AstraZeneca (relationship terminated). Speaker’s bureau fees from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb and Pfizer (all relationships terminated).
    Dr Truman Milling

    The University of Texas at Austin, TX, USA

    Dr Truman J Milling, Jr MD, is associate professor in the Departments of Neurology and Surgery and Perioperative Care at the University of Texas Dell Medical School in Austin, TX, USA. Dr Milling is also an attending physician in the Emergency Department at the Dell Seton Medical Center at the University of Texas. read more

    Dr Milling’s clinical and research focus is anticoagulation management in emergent bleeding and thromboembolic episodes. He has been principal or co-principal investigator on several clinical trials.

    Dr Milling served for 20 years on the editorial board of the Annals of Emergency Medicine and founded its News & Perspectives section. He has authored numerous peer-reviewed publications in New England Journal, Lancet, Circulation, JAMA and various other medical journals.

    Dr Truman Milling discloses: Advisory board or panel fees from CSL Behring. Consultant fees from Alexion, AstraZeneca, Cellphire, CSL Behring and Octapharma.
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    Integrating the latest evidence surrounding reversal agents for direct oral anticoagulants for patients experiencing intracerebral haemorrhage into clinical practice

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    Prof. Hanne Christensen lives in Copenhagen, Denmark, working as a clinical neurologist in Bispebjerg Hospital, mainly with stroke and acute neurology. Prof. Christensen holds a clinical professorship with the University of Copenhagen. read more

    Prof. Christensen has worked with stroke clinically and in research since 1998, with the focus of her work being clinical research, guidelines and implementation.

    In 2019, Prof. Christensen won the Danish prize for research that impacts patient care. She chairs the Action Plan for Stroke in Europe, and is on the board of the Danish Stroke Registry. She is senior guest editor for AHA Stroke Journal and is on the editorial boards of the European Stroke Journal and the International Journal of Stroke. She has published 211 medline-indexed scientific articles.

    Prof. Hanne Christensen discloses: Speaker’s bureau fees from Bayer and Bristol-Myers Squibb. Grants/research support from AstraZeneca and Bayer.

    Take CE/CME Test

    Prof. Thorsten Steiner is professor of neurology and neurointensive care and head of the Department of Neurology at the Clinical Centre in Frankfurt Höchst, Germany. He is a member of the School of Medicine at the University of Heidelberg, Germany. read more

    His main research interests are intensive stroke care, strategies to treat increased intracranial pressure, and invasive cerebral monitoring. He has contributed to various clinical stroke trials on haemostatics in intracranial haemorrhage, and thrombolysis and neuroprotectants in ischaemic stroke.

    He is first author of the European Stroke Organisation’s (ESO, former European Stroke Initiative – EUSI) recommendations for the management of intracerebral haemorrhage and the German Society of Neurology (DGN) guidelines, and principal coordinator of the ESO recommendations for the management of subarachnoid haemorrhage. Prof. Steiner has received several awards for his scientific achievements and his contributions to medical education. Among others, he received the “leading-edge publication” award from the Faculty of Medicine at the University of Heidelberg.

    Prof. Steiner is chairman of the Guidelines Committee of the ESO, council member of the DGN and the German Society for Internal Medical ICU Medicine, a member of the German Stroke Society and a founding board member of the NeuroCriticalCare Society, USA. He is co-editor of the German Interdisciplinary Collaboration of Internal Medical ICU Medicine.

    Prof. Thorsten Steiner discloses: Advisory board or panel fees from AstraZeneca and Boehringer Ingelheim (all relationships terminated). Consultant fees from AstraZeneca (relationship terminated). Speaker’s bureau fees from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb and Pfizer (all relationships terminated).

    Take CE/CME Test

    Dr Truman J Milling, Jr MD, is associate professor in the Departments of Neurology and Surgery and Perioperative Care at the University of Texas Dell Medical School in Austin, TX, USA. Dr Milling is also an attending physician in the Emergency Department at the Dell Seton Medical Center at the University of Texas. read more

    Dr Milling’s clinical and research focus is anticoagulation management in emergent bleeding and thromboembolic episodes. He has been principal or co-principal investigator on several clinical trials.

    Dr Milling served for 20 years on the editorial board of the Annals of Emergency Medicine and founded its News & Perspectives section. He has authored numerous peer-reviewed publications in New England Journal, Lancet, Circulation, JAMA and various other medical journals.

    Dr Truman Milling discloses: Advisory board or panel fees from CSL Behring. Consultant fees from Alexion, AstraZeneca, Cellphire, CSL Behring and Octapharma.

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    Learning Objectives

    After watching this activity, participants should be better able to:

    • Recognize the risk of ICH amongst different patient populations receiving DOACs based on clinical trial and real-world evidence
    • Appraise the latest clinical trial and real-world evidence on the efficacy and safety of oral anticoagulant reversal strategies in the acute management of DOAC-ICH
    • Assess the factors guiding selection and administration of reversal agents and supportive care in the acute management of DOAC-ICH
    Overview

    In this activity, three renowned experts provide their insights on the impact of intracerebral haemorrhage (ICH) in patients receiving direct oral anticoagulants (DOACs), the efficacy and safety data associated with reversal agents for DOAC-ICH, and optimizing haemostatic stabilization in patients with DOAC-ICH.

    This activity is jointly provided by USF Health and touchIME. read more

    Target Audience

    Neurologists, neurosurgeons and critical care/emergency medicine physicians involved in the management of patients with ICH.

    Disclosures

    USF Health adheres to the Standards for Integrity and Independence in Accredited Continuing Education. All individuals in a position to influence content have disclosed to USF Health any financial relationship with an ineligible organization. USF Health has reviewed and mitigated all relevant financial relationships related to the content of the activity. The relevant relationships are listed below. All individuals not listed have no relevant financial relationships.

    Faculty

    Prof. Hanne Christensen discloses: Speaker’s bureau fees from Bayer and Bristol-Myers Squibb. Grants/research support from AstraZeneca and Bayer.

    Prof. Thorsten Steiner discloses: Advisory board or panel fees from AstraZeneca and Boehringer Ingelheim (all relationships terminated). Consultant fees from AstraZeneca (relationship terminated). Speaker’s bureau fees from AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb and Pfizer (all relationships terminated).

    Dr Truman Milling discloses: Advisory board or panel fees from CSL Behring. Consultant fees from Alexion, AstraZeneca, Cellphire, CSL Behring and Octapharma.

    Content reviewer

    Dr Swetha Renati discloses: Advisory board or panel fees from: Bayer (relationship terminated).

    Touch Medical Contributors

    Sadaf Kazi has no financial interests/relationships or affiliations to disclose in relation to this activity.

    USF Health Office of Continuing Professional Development and touchIME staff have no financial interests/relationships or affiliations in relation to this activity.

    Requirements for Successful Completion

    In order to receive credit for this activity, participants must review the content and complete the post-test and evaluation form. Statements of credit are awarded upon successful completion of the post-test and evaluation form.

    If you have questions regarding credit please contact cpdsupport@usf.edu.

    Accreditations

    Physicians

    This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through a joint providership of USF Health and touchIME. USF Health is accredited by the ACCME to provide continuing medical education for physicians.

    USF Health designates this enduring material for a maximum of 0.75 AMA PRA Category 1 CreditTM.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    The European Union of Medical Specialists (UEMS) – European Accreditation Council for Continuing Medical Education (EACCME) has an agreement of mutual recognition of continuing medical education (CME) credit with the American Medical Association (AMA). European physicians interested in converting AMA PRA Category 1 CreditTM into European CME credit (ECMEC) should contact the UEMS (www.uems.eu).

    Advanced Practice Providers

    Physician Assistants may claim a maximum of 0.75 Category 1 credits for completing this activity. NCCPA accepts AMA PRA Category 1 CreditTM from organizations accredited by ACCME or a recognized state medical society.

    The AANPCP accepts certificates of participation for educational activities approved for AMA PRA Category 1 CreditTM by ACCME-accredited providers. APRNs who participate will receive a certificate of completion commensurate with the extent of their participation.

    Date of original release: 10 August 2023. Date credits expire: 10 August 2024.

    If you have any questions regarding credit please contact cpdsupport@usf.edu.

    This activity is CE/CME accredited

    To obtain the CE/CME credit(s) from this activity, please complete this post-activity test.

    Claim Credit
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    This Activity Is Funded By:

    An independent medical education grant from AstraZeneca.
    This activity is jointly provided by USF Health and touchIME.

    The information provided by this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical/clinical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.

    USF is an Equal Opportunity / Affirmative Action / Equal Access Institution.

    USF Health is accredited by the Accreditation Council for Continuing Medical Education, the American Nurses Credentialing Center and the Accreditation Council for Pharmacy Education to provide continuing education to healthcare professionals. As an accredited provider, USF Health is required to disclose personal information to relevant accredited bodies that certify CME to process credits/contact hours, comply with reporting requirements, and for internal recordkeeping and regulatory purposes. USF Health does not share or sell any individual’s contact information or unique identifiers to any commercial supporter, advertiser, or third party without the specific permission of the individual.

    Unapproved products or unapproved uses of approved products may be discussed by the faculty; these situations may reflect the approval status in one or more jurisdictions. The presenting faculty have been advised by touchIME and USF Health to ensure that they disclose any such references made to unlabelled or unapproved use. No endorsement by touchIME or USF Health of any unapproved products or unapproved uses is either made or implied by mention of these products or uses in touchIME or USF Health activities. touchIME and USF Health accept no responsibility for errors or omissions.

    This content is intended for healthcare professionals.

    Date of original release: 10 August 2023. Date credits expire: 10 August 2024.

    Claim Credit
    touchEXPERT OPINIONS
    Integrating the latest evidence surrounding reversal agents for direct oral anticoagulants for patients experiencing intracerebral haemorrhage into clinical practice
    0.75 CE/CME credit
    Question 1/5
    Which of the following was reported by a retrospective observational study as a reason for an increased incidence of OAC-ICH?

    DOAC, direct OAC; ICH, intracerebral haemorrhage; OAC, oral anticoagulant; VKA, vitamin K antagonist.

    The retrospective observational Capital Region Anticoagulation-related ICH (COOL-ICH) study included all adult patients in the Capital Region of Denmark admitted within 24 hours of onset of a spontaneous ICH related to oral anticoagulant therapy between 2010 and 2017. The study reported an increased use of OACs driven by an increased use of DOACs, and despite the lower risk of ICH in patients receiving DOACs, there was a parallel increase in OAC-ICH overall. The authors also noted that it is important to emphasize the strong evidence supporting the use of OACs as well as a more favourable risk/benefit ratio in DOACs in comparison with VKAs.

    Abbreviations:

    DOAC, direct OAC; ICH, intracerebral haemorrhage; OAC, oral anticoagulant; VKA, vitamin K antagonist.

    Reference:

    Grundtvig J, et al. Eur Stroke J. 2021;6:143–50.

    Question 2/5
    You are managing your patient with non-valvular atrial fibrillation using a DOAC. Which of the following factors would you consider when assessing the risk of DOAC-ICH in this patient?

    DOAC, direct oral anticoagulant; ICH, intracerebral haemorrhage.

    The risk factors for DOAC-ICH that have been reported include concomitant antiplatelet drugs use, increasing age, history of stroke or transient ischaemic stroke, history of bleeding, reduced serum albumin, reduced platelet count, race, hypertension and small vessel disease.1,2

    Abbreviations:

    DOAC, direct oral anticoagulant; ICH, intracerebral haemorrhage.

    References:

    1. Wu T, et al. J Neurol. 2022;269:664–75.
    2. Hert L, et al. Eur Stroke J. 2020;5:63–72.
    Question 3/5
    When managing your patient with DOAC-ICH, which of the following factors would you consider when determining if your patient should be given andexanet alfa?

    DOAC, direct oral anticoagulant; ICH, intracerebral haemorrhage.

    The procoagulant effects of andexanet alfa are achieved through the ability to sequester Factor Xa inhibitors. Andexanet alfa is currently indicated for patients treated with rivaroxaban and apixaban when reversal of anticoagulation is needed due to life-threatening or uncontrolled bleeding.

    Reference:

    FDA. Andexanet alfa PI. Available at: www.fda.gov/media/113279/download (accessed 17 July 2023).

    Question 4/5
    Following DOAC-ICH, the American Heart Association/American Stroke Association guidelines recommend the use of prothrombin complex concentrate in which setting?

    DOAC, direct oral anticoagulant; ICH, intracerebral haemorrhage.

    The American Heart Association/American Stroke Association guidelines state that the use of prothrombin complex concentrate may promote haemostasis in patients on direct thrombin inhibitors and Factor Xa inhibitors when specific reversal agents (idarucizumab and andexanet alfa, respectively) are not available.

    Reference:

    Greenberg SM, et al. Stroke. 2022;53:e282–361.

    Question 5/5
    Your patient has DOAC-ICH. Which of the following parameters would you use to determine the appropriate use of a DOAC reversal agent?

    DOAC, direct oral anticoagulant; ICH, intracerebral haemorrhage.

    The half-life of DOACs is based on creatinine clearance.1 It should therefore be one of the factors that are considered in conjunction with time since the last dose when determining whether a patient is anticoagulated.2 

    Abbreviation:

    DOAC, direct oral anticoagulant.

    References:

    1. Tomaselli GF, et al. J Am Coll Cardiol. 2020;76:594–622.
    2. Chaudhary R, et al. JAMA Netw Open. 2022;5:e2240145.
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    This Activity Is Funded By:

    An independent medical education grant from AstraZeneca.
    This activity is jointly provided by USF Health and touchIME.

    The information provided by this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical/clinical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.

    USF is an Equal Opportunity / Affirmative Action / Equal Access Institution.

    USF Health is accredited by the Accreditation Council for Continuing Medical Education, the American Nurses Credentialing Center and the Accreditation Council for Pharmacy Education to provide continuing education to healthcare professionals. As an accredited provider, USF Health is required to disclose personal information to relevant accredited bodies that certify CME to process credits/contact hours, comply with reporting requirements, and for internal recordkeeping and regulatory purposes. USF Health does not share or sell any individual’s contact information or unique identifiers to any commercial supporter, advertiser, or third party without the specific permission of the individual.

    Unapproved products or unapproved uses of approved products may be discussed by the faculty; these situations may reflect the approval status in one or more jurisdictions. The presenting faculty have been advised by touchIME and USF Health to ensure that they disclose any such references made to unlabelled or unapproved use. No endorsement by touchIME or USF Health of any unapproved products or unapproved uses is either made or implied by mention of these products or uses in touchIME or USF Health activities. touchIME and USF Health accept no responsibility for errors or omissions.

    This content is intended for healthcare professionals.

    Date of original release: 10 August 2023. Date credits expire: 10 August 2024.

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