Therapeutic achievement with long-term oral anticoagulants in post-myocardial infarction patients

Treatment with oral anticoagulant therapy entails a delicate balance between over( risk of bleeding) and under- (risk of thrombemboli) anticoagulation. Therapy is therefore monitored to maintain its anticoagulant effect within a narrow range. The main aim of this research was to determine the optimal intensity of long-term anticoagulant therapy in 3404 post-myocardial infarction patients. Chapter 1 gives a review of long-term clinical trials which assessed the mertts of anticoagulant therapy in the secondary prevention of morbidity and mortality after myocardial infarction. This review includes the results of more than thirty trials reported in the literature in the past forty years, however, unpublished data or results of small trials, were not considered. Few of these trials were randomized, and the level of anticoagulation was properly maintained in only some of these studies. The results of most of these trials have failed to convincingly demonstrate the beneficial effects of long-term anticoagulant therapy as a secondary preventive measure and the use of such therapy has therefore remained controversial. Chapters 2 and 3 describe the design and execution of the ASPECT (Anticoagulants in the Secondary Prevention of Events in Coronary Thrombosis) trial. The main results of this trial are submitted in Appendix-A. ASPECT was designed to be a randomized, double-blind, placebo controlled, multicentre trial which compared standard oral anticoagulant therapy with placebo with regards to mortality and cardiovascular events. Chapter 2 describes the design and procedures of the ASPECT trial in detail, in particular the methods for double-blind anticoagulant titration. Chapter 3 presents an outline of the data processing system as used in ASPECT. A standardized procedure which was developed for data handling insured a high level of data quality derived from the participating centres. Chapters 4, 5 and 6 addresses the effectiveness and safety of oral anticoagulant therapy. Chapter 4 reviews various methods, previously described, to evaluate therapeutic achievement of anticoagulant therapy in the ASPECT trial. In Chapter 5, the optimal achieved intensity of anticoagulant therapy required to prevent recurrence of arterial thromboembolic and haemorrhagic complications was quantitatively evaluated with regard to the international normalized ratio (INR) intensity preceding the event, enabling the calculation of INR-specific incidence rates. The INR expresses the level of anticoagulant therapy in an internationally agreed term. It is the common term for the prothrombin time as measured in a patient on oral anticoagulant therapy. Chapter 6 gives a detailed description of the risk of stroke in the ASPECT population. Finally, a discussion of the findings is provided in Chapter 7, followed by recommendations for further researc

901-97 Stroke and Long-term Anticoagulant Therapy in 3404 Post-Myocardial Infarction Patients

In a randomized, double-blind, placebo controlled trial (ASPECT) we studied 3404 post-myocardial infarction patients who suffered a stroke during long-term anticoagulant therapy. The duration of treatment ranged from 1 day to six years. Three years following randomization, 2% of the patients on anticoagulant therapy had a stroke compared to 4% in placebo.The incidence of stroke analyzed on “intention-to-treat” was 0.7 per 100 patient-years in the anticoagulant group and 1.2 per 100 patient-years in placebo, a hazard ratio (HR) of 0.60 with a 95% confidence interval (Cl) of 0.40 to 0.90, a 40% reduction in the risk of stroke in the anticoagulated group. A total of 19 intracranial bleeding was observed. The risk of hemorrhages was 8 times greater for anticoagulated patients compared to placebo. Eight of the 17 bleedings were fatal in the anticoagulant group and no fatal hemorrhages occurred in placebo. A total of 15 cerebral infarctions occurred in the anticoagulated group and 43 in placebo. Of the 14 hemorrhagic strokes, 6 were within INR 3.0–4.0 and 8 with an INR>4.0, Of the 7 non-hemorrhagic strokes, 2 were at INR<2, 3 within INR 3.0–4.0, 1 at INR>4.0, and no measurement was available in one patient. The total number of patients who died or were severely disabled as a result of cerebral stroke amounted to 13 in the anticoagulated group, compared to 18 in placebo.ConclusionThe results of the ASPECT trial indicated that long-term anticoagulant therapy substantially reduced the risk of stroke in post-myocardial infarction patients. The increased risk of bleeding complications associated with anticoagulant therapy was offset by a marked reduction in ischemic events

Discursos e imágenes sobre la desigualdad: Políticas públicas e institucionalización de la locura en el noroeste argentino (1935-1954)

En la presente investigación analizaremos la primera institución psiquiátrica del noroeste argentino, específicamente en la provincia de Tucumán, el Hospital de Alienados (HA), desde el evento que impulsó su creación –la negativa de traslados interprovin-ciales de pacientes a colonias nacionales en 1935– hasta el retorno a dicha práctica por parte del Estado nacional –en 1954–. Hasta la creación del HA, las posibles respuestas para las personas con problemáticas psiquiátricas eran el traslado a instituciones en otras pro-vincias o el encierro en un asilo de la ciudad y en establecimientos policiales. Ante las graves consecuencias de las últimas alternativas, y la cancelación de los traslados, tuvo que ser el propio Estado provincial el que hiciera frente a la problemática. El HA se constituyó como el primero en Argentina en pertenecer a un Estado provincial y no depender de las arcas nacionales. Este trabajo inaugural en los estudios historiográficos de la región nos permitirá analizar algunos procesos institucionales de las políticas en salud mental a nivel provincial y nacional, las concepciones sobre locura y encierro que se sostenían en aquella época, el flagelo de la pobreza como causa para enloquecer y el efecto de todo lo anterior en la opinión pública.In the present investigation we will analyze the first psychiatric institution in northwestern Argentina, specifically in the province of Tucumán, the Hospital de Alienados (HA), from the event that prompted its creation –the refusal of interprovincial transfers of patients to national colonies in 1935– until the return to this practice by the national State –in 1954–. Until the creation of the HA, the possible responses for people with psychiatric problems were transfer to institutions in other provinces or confinement in a city asylum and in police establishments. Given the serious consequences of the last alternatives, and the cancellation of the transfers, it had to be the provincial State itself that faced the problem. The HA was established as the first in Argentina to belong to a provincial State and not depend on the national coffers. This inaugural work in the historiographical studies of the region will allow us to analyze some institutional processes of mental health policies at the provincial and national level, the conceptions about madness and confinement that were held at that time, the scourge of poverty as a cause of craziness, and the effect of all of the above on public opinion.Fil: Golcman, Aida Alejandra. Universidad Nacional de Tucumán; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Tucumán; ArgentinaFil: Azar Bon, Benjamín. Universidad Nacional de Tucumán; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Tucumán; Argentin

Inter- and intra-observer variability in the qualitative categorization of coronary angiograms.

The ABC classification of the American College of Cardiology and the American Heart Association is a commonly used categorization to estimate the risk and success of intracoronary intervention, as well as the probability of restenosis. To evaluate the reliability of qualitative angiogram readings, we randomly selected 200 films from single lesion angioplasty procedures. A repeated visual assessment (> or = 2 months interval) by two independent observers resulted in kappa values of inter and intra-observer variability for the ABC lesion classification and for all separate items that compile it. Variability in assessment is expressed in percentage of total agreement, and in kappa value, which is a parameter of the agreement between two or more observations in excess of the chance agreement. Percentage of total agreement and kappa value was 67.8% and 0.33 respectively for the ABC classification, indicating a poor agreement. Probably this is due to the deficiency of strict definitions. Further investigation has to demonstrate whether improvement can be achieved using complete and detailed definitions without ambiguity, and consensus after panel assessment

Optimal intensity of oral anticoagulant therapy after myocardial infarction

AbstractObjectives.This study attempted to determine the optimal intensity of anticoagulant therapy in patients after myocardial infarction.Background.Treatment with oral anticoagulant therapy entails a delicate balance between over- (risk of bleeding) and under-anticoagulant (risk of thromboemboli). The optimal intensity required to prevent the occurrence of either event (bleeding or thromboembolic) is not known.Methods.A method was used to determine the optimal intensity of anticoagulant therapy by calculating incidence rates for either event associated with a specific international normalized ratio. The numerator included events occurring at given international normalized ratios, and the denominator comprised the total observation time.Results.The study population included 3,404 myocardial infarction patients enrolled in the ASPECT (anticoagulants in the Secondary Prevention of Events in Coronary Thrombosis) trial. Total treatment was 6,918 patient-years. Major bleeding occurred in 57 patients (0.8/100 patient-years), and thromboembolic complications in 397 (5.7/100 patient-years). The incidence of the combined outcome (bleeding or thromboembolic complications) with international normalized ratio < 2 was 8.0/100 patient-years (283 events in 3,559 patient-years), with international normalized ratios between 2 and 3, 3.9/100 patient-years (33 events in 838 patient-years); 3.2/100 patient-years (57 events in 1,775 patient-years) for international normalized ratios between 3 and 4; 6.6/100 patient-years (37 events in 564 patient-years) for international normalized ratios between 4 and 5; and 7.7/100 patient-years (14 events in 182 patient-years) for international normalized ratios >5. After adjustment for achieved international normalized ratio levels, significant predictors were higher levels of systolic blood pressure and age.Conclusions.If equal weight is given to hemorrhagic and thromboembolic complications, these results suggest that the optimal intensity of long-term anticoagulant therapy for myocardial infarction patients lies between 2.0 and 4.0 international normalized ratio, with a trend to suggest an optimal intensity of 3.0 to 4.0

Prevalence of pre-eclampsia in women in the Middle East: a scoping review

Hypertensive disorders of pregnancy are the second most common cause of maternal deaths worldwide. Metabolic syndrome is recognized as one of the risk factors for pre-eclampsia. A recent study revealed a high prevalence of metabolic syndrome in the United Arab Emirates (UAE), particularly amongst Emirati women compared with global estimates. This finding raises the possibility that the prevalence of pre-eclampsia in the region may also be higher as research is increasingly demonstrating an association between pre-eclampsia and metabolic syndrome. We therefore conducted this scoping review of the literature to investigate the nature and extent of studies evaluating the prevalence of pre-eclampsia within the Middle East region to enable subsequent comparison of these findings with the global burden of pre-eclampsia, objectively identify gaps in the literature and inform the design of future studies to address these gaps. PubMed and Scopus were used to extract studies published over the last 20 years (2003–2023). The search terms used included (“Pre-eclampsia” AND “Prevalence”) OR (“Hypertension in pregnancy” AND “Prevalence”) OR (“Pregnancy” AND “Pre-eclampsia”) OR (“Pre-eclampsia” AND “Epidemiology”). We limited our studies to those from the Middle East (ME). A total of 556 relevant articles were identified following which 11 were shortlisted for review. There were four studies from Iran, two from Saudi Arabia, two from Qatar, one from Jordan, and one from Bahrain. The remaining study included 29 countries from Africa, Asia, Latin America, and the Middle East of which data from Jordan, Lebanon, the Occupied Palestinian Territory, and Qatar were included. There were four retrospective, two cross-sectional, and two cohort studies, one prospective study, one meta-analysis, and one descriptive-analytical study. The prevalence of pre-eclampsia in the studies ranged from 0.17 to 5%. We did not find any study investigating the prevalence of pre-eclampsia in the United Arab Emirates. Based on our findings, we conclude that there is a significant scarcity of research in this area, especially within the Middle East, and notably an absence of studies specifically pertaining to the UAE. Consequently, we assert that there is a pressing requirement for additional research to evaluate the prevalence of pre-eclampsia in the region