The Changing Landscape for Stroke\ua0Prevention in AF: Findings From the GLORIA-AF Registry Phase 2

Background GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non\u2013vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase 1. Methods During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients\u2019 baseline characteristics. Atrial fibrillation disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Results Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age  6575 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score  652; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc = 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N = 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment. Conclusions The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in Asia and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701

Detecção da resistência de capim-arroz (Echinochloa sp.) ao herbicida quinclorac em regiões orizícolas do sul do Brasil Detection of Echinochloa sp. resistance to quinclorac in rice fields in Southern Brazil

O monitoramento da ocorrência de plantas de capim-arroz resistentes ao herbicida quinclorac foi realizado no Rio Grande do Sul e em Santa Catarina, visando determinar a origem da resistência e sua disseminação, bem como detectar práticas de manejo ou condições edafoclimáticas provavelmente envolvidas na seleção e distribuição geográfica do biótipo resistente. As sementes foram coletadas, purificadas e homogeneizadas, sendo os estudos realizados em laboratório e casa de vegetação. Em laboratório, foi conduzido teste de germinação padrão, embebendo as sementes dos biótipos nas doses de 0x, 1x, 2x, 6x, 16x e 32x a concentração recomendada de quinclorac (375 g ha-1), sendo avaliadas a curva de germinação e a porcentagem de controle aos 14 dias após semeadura (DAS); em casa de vegetação, foram utilizadas as mesmas doses, aspergidas sobre as plantas aos 20 dias após a emergência (DAE), com as plantas no estádio de quatro folhas a um perfilho. Foram avaliadas a porcentagem de controle e a massa seca aos 35 DAE; biótipos com coeficiente de resistência (RI) superior a quatro foram considerados resistentes. Neste estudo foram encontradas sementes de capim-arroz resistentes ao herbicida quinclorac. Elaborou-se mapa de distribuição dos biótipos resistentes nas áreas amostradas dos Estados do Rio Grande do Sul e Santa Catarina. O herbicida profoxydim é alternativa de controle dos biótipos de capim-arroz resistentes a quinclorac.<br>The monitoring of Echinochloa sp. plants resistant to quinclorac was conducted in Rio Grande do Sul and Santa Catarina, Brazil to determine the origin of resistance and its dissemination, as well as to detect practices or climatic conditions related to the selection and geographic distribution of the resistant biotype. The seeds were collected, purified and standardized, and trials conducted under growth chamber and greenhouse conditions. In the growth chamber, a standard germination test was conducted with the seeds being submitted to rates of 0x, 1x, 2x, 6x, 16x and 32x and to the recommended rate of quinclorac, followed by germination curve and seedlings survival evaluation 14 days after sowing (DAS); the same herbicide rates were evaluated under greenhouse conditions, applied over the plants 20 days after emergence (DAE). Dry weight and control were evaluated 35 DAE, and biotypes with RI above four were considered resistant. A map of both states was elaborated where distribution of resistance to quinclorac was showed graphically, followed by herbicide profoxydim test as an alternative for the resistant biotype control

Competitividade de biótipos de capim-arroz resistente e suscetível ao quinclorac Competitiveness of echinochloa biotypes resistant and susceptible to quinclorac

Objetivou-se com este trabalho avaliar a competitividade de dois biótipos de capim-arroz, resistente e suscetível ao quinclorac, coletados em regiões orizícolas do Estado de Santa Catarina. O experimento foi instalado em ambiente protegido, e os tratamentos constaram de diferentes densidades de plantas dos biótipos de capim-arroz comprovadamente resistente (ITJ-13) e suscetível (ITJ-17) ao quinclorac, oriundos da região arrozeira de Itajaí/SC. No centro da unidade experimental, foram semeadas três sementes do biótipo de capim-arroz, considerado como o tratamento da unidade experimental. Na periferia foram semeadas dez sementes do biótipo oposto ao do tratamento (central). Dez dias após a germinação foi efetuado o desbaste, deixando-se apenas uma planta no centro da unidade experimental e um número variável de plantas do biótipo oposto, de acordo com o tratamento (0, 1, 2, 3, 4 ou 5 plantas por vaso). O delineamento experimental utilizado foi o completamente casualizado, em esquema fatorial 2 x 6, com quatro repetições. Aos 40 dias após a emergência, foram avaliados altura de plantas, número de afilhos e de folhas, área foliar, massa fresca e seca e conteúdo de água de colmos e folhas. Os dados foram analisados pelo teste F, sendo efetuado teste de Duncan para comparar o efeito de densidade de plantas e teste da Diferença Mínima Significativa (DMS) para avaliar diferenças entre os biótipos resistente e suscetível, além de correlação linear simples entre as variáveis avaliadas. Nas análises, utilizou-se o nível de 5% de probabilidade. Os biótipos estudados de capim-arroz resistente e suscetível ao quinclorac são similares quando sob alta intensidade de competição, com vantagem em algumas variáveis para o biótipo suscetível sob baixa ou moderada intensidade competitiva.<br>The objective of this research was to evaluate the competitive potential of two Echinochloa sp. biotypes, resistant and susceptible to quinclorac, collected in rice regions in the state of Santa Catarina. The trial was carried out under controlled environment, and the treatments consisted of plant densities of Echinochloa resistant or susceptible to quinclorac. At the center of the experimental unit, three seeds of the biotype were planted and considered as the treatment. Ten seeds of the opposite biotype were planted on the edges. Ten days after emergence, the number of plants was standardized, with only one plant left at the center of the experimental unit, and a variable number of plants on the edges (0, 1, 2, 3, 4 or 5 plants), according to the treatment. The experimental design consisted of completely randomized blocks in a factorial scheme 2 x 6, with four replications. Forty days after emergence, plant height, number of tillers and leaves, leaf area, fresh and dry weight and water content were evaluated. Data were analyzed by the F-test, using the DMRT test for the increasing density effect, and DMS test to compare the biotypes. All analyses were run at 5% significance level. A correlation matrix was built among the evaluated variables. The Echinochloa sp. biotypes studied, resistant and susceptible to quinclorac, are similar in behavior under high competition levels, with the susceptible ones being superior to the resistant ones in some of the variables studied, at low or moderate competition levels

Global variations in heart failure etiology, management, and outcomes

Importance: Most epidemiological studies of heart failure (HF) have been conducted in high-income countries with limited comparable data from middle- or low-income countries. Objective: To examine differences in HF etiology, treatment, and outcomes between groups of countries at different levels of economic development. Design, Setting, and Participants: Multinational HF registry of 23 341 participants in 40 high-income, upper–middle-income, lower–middle-income, and low-income countries, followed up for a median period of 2.0 years. Main Outcomes and Measures: HF cause, HF medication use, hospitalization, and death. Results: Mean (SD) age of participants was 63.1 (14.9) years, and 9119 (39.1%) were female. The most common cause of HF was ischemic heart disease (38.1%) followed by hypertension (20.2%). The proportion of participants with HF with reduced ejection fraction taking the combination of a β-blocker, renin-angiotensin system inhibitor, and mineralocorticoid receptor antagonist was highest in upper–middle-income (61.9%) and high-income countries (51.1%), and it was lowest in low-income (45.7%) and lower–middle-income countries (39.5%) (P &lt; .001). The age- and sex- standardized mortality rate per 100 person-years was lowest in high-income countries (7.8 [95% CI, 7.5-8.2]), 9.3 (95% CI, 8.8-9.9) in upper–middle-income countries, 15.7 (95% CI, 15.0-16.4) in lower–middle-income countries, and it was highest in low-income countries (19.1 [95% CI, 17.6-20.7]). Hospitalization rates were more frequent than death rates in high-income countries (ratio = 3.8) and in upper–middle-income countries (ratio = 2.4), similar in lower–middle-income countries (ratio = 1.1), and less frequent in low-income countries (ratio = 0.6). The 30-day case-fatality rate after first hospital admission was lowest in high-income countries (6.7%), followed by upper–middle-income countries (9.7%), then lower–middle-income countries (21.1%), and highest in low-income countries (31.6%). The proportional risk of death within 30 days of a first hospital admission was 3- to 5-fold higher in lower–middle-income countries and low-income countries compared with high-income countries after adjusting for patient characteristics and use of long-term HF therapies. Conclusions and Relevance: This study of HF patients from 40 different countries and derived from 4 different economic levels demonstrated differences in HF etiologies, management, and outcomes. These data may be useful in planning approaches to improve HF prevention and treatment globally

Ticagrelor in patients with diabetes and stable coronary artery disease with a history of previous percutaneous coronary intervention (THEMIS-PCI) : a phase 3, placebo-controlled, randomised trial

Background: Patients with stable coronary artery disease and diabetes with previous percutaneous coronary intervention (PCI), particularly those with previous stenting, are at high risk of ischaemic events. These patients are generally treated with aspirin. In this trial, we aimed to investigate if these patients would benefit from treatment with aspirin plus ticagrelor. Methods: The Effect of Ticagrelor on Health Outcomes in diabEtes Mellitus patients Intervention Study (THEMIS) was a phase 3 randomised, double-blinded, placebo-controlled trial, done in 1315 sites in 42 countries. Patients were eligible if 50 years or older, with type 2 diabetes, receiving anti-hyperglycaemic drugs for at least 6 months, with stable coronary artery disease, and one of three other mutually non-exclusive criteria: a history of previous PCI or of coronary artery bypass grafting, or documentation of angiographic stenosis of 50% or more in at least one coronary artery. Eligible patients were randomly assigned (1:1) to either ticagrelor or placebo, by use of an interactive voice-response or web-response system. The THEMIS-PCI trial comprised a prespecified subgroup of patients with previous PCI. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, or stroke (measured in the intention-to-treat population). Findings: Between Feb 17, 2014, and May 24, 2016, 11 154 patients (58% of the overall THEMIS trial) with a history of previous PCI were enrolled in the THEMIS-PCI trial. Median follow-up was 3·3 years (IQR 2·8–3·8). In the previous PCI group, fewer patients receiving ticagrelor had a primary efficacy outcome event than in the placebo group (404 [7·3%] of 5558 vs 480 [8·6%] of 5596; HR 0·85 [95% CI 0·74–0·97], p=0·013). The same effect was not observed in patients without PCI (p=0·76, p interaction=0·16). The proportion of patients with cardiovascular death was similar in both treatment groups (174 [3·1%] with ticagrelor vs 183 (3·3%) with placebo; HR 0·96 [95% CI 0·78–1·18], p=0·68), as well as all-cause death (282 [5·1%] vs 323 [5·8%]; 0·88 [0·75–1·03], p=0·11). TIMI major bleeding occurred in 111 (2·0%) of 5536 patients receiving ticagrelor and 62 (1·1%) of 5564 patients receiving placebo (HR 2·03 [95% CI 1·48–2·76], p<0·0001), and fatal bleeding in 6 (0·1%) of 5536 patients with ticagrelor and 6 (0·1%) of 5564 with placebo (1·13 [0·36–3·50], p=0·83). Intracranial haemorrhage occurred in 33 (0·6%) and 31 (0·6%) patients (1·21 [0·74–1·97], p=0·45). Ticagrelor improved net clinical benefit: 519/5558 (9·3%) versus 617/5596 (11·0%), HR=0·85, 95% CI 0·75–0·95, p=0·005, in contrast to patients without PCI where it did not, p interaction=0·012. Benefit was present irrespective of time from most recent PCI. Interpretation: In patients with diabetes, stable coronary artery disease, and previous PCI, ticagrelor added to aspirin reduced cardiovascular death, myocardial infarction, and stroke, although with increased major bleeding. In that large, easily identified population, ticagrelor provided a favourable net clinical benefit (more than in patients without history of PCI). This effect shows that long-term therapy with ticagrelor in addition to aspirin should be considered in patients with diabetes and a history of PCI who have tolerated antiplatelet therapy, have high ischaemic risk, and low bleeding risk