Non–Vitamin K Antagonist Oral Anticoagulants, Clinical Use, Real-World Data, and Reversal of Anticoagulant Effect

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in clinical practice and is associated with a higher risk of thromboembolic events. CHA2DS2VASc score enables identification of those patients with AF who will most benefit from anticoagulation therapy and low-risk patients with AF who do not need any antithrombotic therapy. Antithrombotic drugs especially oral anticoagulants (OACs) are the mainstay of therapy to prevent stroke in patients with AF. Although vitamin K antagonists (VKAs) were the only available drugs for decades, numerous non–vitamin K antagonist oral anticoagulants (NOACs) have been developed and marketed for stroke prevention in recent years. The risk of stroke was reported to decline up to 68 % with OAC therapy, associated with good anticoagulation control with VKAs, assessed by time in therapeutic range (TTR). In low TTR values, VKAs were found to be associated with severe complications, and a minimum TTR of 58 % should be achieved to expect a net benefit from being on OAC therapy. Narrow therapeutic index, drug-drug interactions, and the need for close monitoring are the main disadvantages of VKAs, and management of patients have dramatically improved after the introduction of NOACs. NOACs have a more predictable anticoagulant affect which allows a fixed-dose regimen. The efficacy and safety of NOACs have been shown not only in large randomized controlled clinical trials but also in observational studies. The main advantages of NOACS such as “fixed-dose regimen” and “no need for regular anticoagulant therapy monitoring” may also be the Achilles heel of the use of these agents. Fixed-dose regimen may not be appropriate for elderly, for patients with chronic kidney disease, and for patients using interacting drugs. Adherence to NOAC therapy is another concern as it may be as low as 50 % in the chronic use of cardiovascular drugs, especially if the drug has no apparent affect to the patient. Thus, appropriate use of OACs among non-valvular AF (NVAF) patients is essential for stroke prophylaxis. We intended to review the use of OAC therapy among (NVAF) patients

Impaired fasting glucose is associated with increased perioperative cardiovascular event rates in patients undergoing major non-cardiothoracic surgery

<p>Abstract</p> <p>Background</p> <p>Diabetes mellitus (DM) is a well-established risk factor for perioperative cardiovascular morbidity and mortality in patients undergoing noncardiac surgery. However, the impact of preoperative glucose levels on perioperative cardiovascular outcomes in patients undergoing nonemergent, major noncardiothoracic surgery is unclear.</p> <p>Methods and Results</p> <p>A total of 680 patients undergoing noncardiothoracic surgery were prospectively evaluated. Patients older than 18 years who underwent an elective, nonday case, open surgical procedure were enrolled. Electrocardiography and cardiac biomarkers were obtained 1 day before surgery, and on days 1, 3 and 7 after surgery. Preoperative risk factors and laboratory test results were measured and evaluated for their association with the occurrence of in-hospital perioperative cardiovascular events. Impaired fasting glucose (IFG) defined as fasting plasma glucose values of 100 to 125 mg/dl; DM was defined as fasting plasma glucose ≥ 126 mg/dl and/or plasma glucose ≥ 200 mg/dl or the current use of blood glucose-lowering medication, and glucose values below 100 mg/dl were considered normal. Plasma glucose levels were significantly higher in patients with perioperative cardiovascular events (n = 80, 11.8%) in comparison to those without cardiovascular events (131 ± 42.5 <it>vs </it>106.5 ± 37.5, p < 0.0001). Multivariate analysis revealed that patients with IFG and DM were at 2.1- and 6.4-fold increased risk of perioperative cardiovascular events, respectively. Every 10 mg/dl increase in preoperative plasma glucose levels was related to a 11% increase for adverse perioperative cardiovascular events.</p> <p>Conclusions</p> <p>Not only DM but also IFG is associated with increased perioperative cardiovascular event rates in patients undergoing noncardiothoracic surgery.</p

Peripartum cardiomyopathy: Current state of knowledge, new developments and future directions

Peripartum cardiomyopathy (PPCM) is a form of idiopathic dilated cardiomyopathy affecting women in late pregnancy or early puerperium. Although initially described in the late 1800s, it has only recently been recognized as a distinct cardiac condition. The reported incidence and prognosis varies according to geography. The clinical course varies between complete recovery to rapid progression to chronic heart failure, heart transplantation or death. In spite of significant improvements in understanding the pathophysiology and management of the PPCM many features of this unique disease are poorly understood, including incidence, etiology, epidemiology, pathophysiology, predictors of prognosis and optimal therapy. The present article revisits these concepts and recent advances in PPCM

Impact of perioperative acute ischemic stroke on the outcomes of noncardiac and nonvascular surgery: a single centre prospective study

WOS: 000337748900001PubMed ID: 24869617Background: Although ischemic stroke is a well-known complication of cardiovascular surgery it has not been extensively studied in patients undergoing noncardiac surgery. The aim of this study was to assess the predictors and outcomes of perioperative acute ischemic stroke (PAIS) in patients undergoing noncardiothoracic, nonvascular surgery (NCS). Methods: We prospectively evaluated patients undergoing NCS and enrolled patients older than 18 years who underwent an elective, non-daytime, open surgical procedure. Electrocardiography and cardiac biomarkers were obtained 1 day before surgery, and on postoperative days 1, 3 and 7. Results: Of the 1340 patients undergoing NCS, 31 (2.3%) experienced PAIS. Only age (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.01-3.2, p < 0.001) and preoperative history of stroke (OR 3.6, 95% CI 1.2-4.8, p < 0.001) were independent predictors of PAIS according to multivariate analysis. Patients with PAIS had more cardiovascular (51.6% v. 10.6%, p < 0.001) and noncardiovascular complications (67.7% v. 28.3%, p < 0.001). In-hospital mortality was 19.3% for the PAIS group and 1% for those without PAIS (p < 0.001). Conclusion: Age and preoperative history of stroke were strong risk factors for PAIS in patients undergoing NCS. Patients with PAIS carry an elevated risk of perioperative morbidity and mortality.Contexte : Même si l’AVC ischémique est une complication bien connue de la chirurgie cardiovasculaire, elle n’a pas fait l’objet d’études approfondies chez les patients soumis à une chirurgie non cardiaque. Le but de cette étude était d’évaluer les prédicteurs et les conséquences de l’AVC ischémique aigu périopératoire (IAPO) chez des patients soumis à une chirurgie non cardiothoracique et non vasculaire (NCNV). Méthodes : Nous avons évalué de manière prospective les patients soumis à une chirurgie NCNV et inscrit les patients de plus de 18 ans qui subissaient une intervention chirurgicale ouverte non urgente nécessitant une hospitalisation. L’électrocardiogramme et les biomarqueurs cardiaques étaient obtenus 1 jour avant la chirurgie et aux jours 1, 3 et 7 suivant la chirurgie. Résultats : Parmi les 1340 patients soumis à une chirurgie NCNV, 31 (2,3 %) ont présenté un AVC IAPO. Seuls l’âge (rapport des cotes [RC] 2,5, intervalle de confiance [IC] de 95 % 1,01–3,2, p < 0,001) et des antécédents préopératoires d’AVC (RC 3,6, IC de 95 % 1,2–4,8, p < 0,001) ont été des prédicteurs indépendants de l’AVC IAPO selon l’analyse multivariée. Les patients victimes d’un AVC IAPO avaient davantage de complications cardiovasculaires (51,6 % c. 10,6 %, p < 0,001) et non cardiovasculaires (67,7 % c. 28,3 %, p < 0,001). La mortalité perhospitalière a été de 19,3 % dans le groupe victime d’AVC IAPO et de 1 % chez les patients indemnes d’AVC IAPO (p < 0,001). Conclusion : L’âge et les antécédents préopératoires d’AVC sont des facteurs de risque importants à l’égard de l’AVC IAPO chez les patients soumis à une chirurgie NCNV. Les patients victimes d’un AVC IAPO sont exposés à un risque élevé de morbidité et de mortalité périopératoires

Coronary calcium score, albuminuria and inflammatory markers in type 2 diabetic patients: Associations and prognostic implications

WOS: 000311026100018PubMed ID: 22595190Aims: To investigate the relationship of coronary artery calcium (CAC) scores with common carotid artery intima media thickness (CCA-IMT), albuminuria and inflammatory factors in type 2 diabetes. Methods and results: 128 asymptomatic type 2 diabetic patients, with at least one cardiovascular risk factor in addition to diabetes, were included in the study. CAC scores, carotid arteries plaque formation and CCA-IMT were assessed. The patients were followed for a mean period of 36.6 +/- 3.3 months. Linear regression analysis identified the logarithmically transformed (Ln) albuminuria (beta = 0.32, P = 0.007), age (beta = 0.04, P = 0.001) and the uric acid (beta = 0.13, P = 0.04) as independent determinants of the CAC score. During follow-up period, cardiovascular events occurred in 18 out of 46 patients with CAC score >= 100 compared with 5 out of 82 patients with CAC score <100 (log rank, P < 0.0001). Multivariate Cox proportional hazards analysis identified LnCAC score (P < 0.0001), LnAlbuminuria (P = 0.01) and uric acid (P = 0.03) as independent predictors for cardiovascular events. Conclusions: There was a significant relationship between CAC score, albuminuria and inflammation in patients with type 2 diabetes. LnCAC score together with LnAlbuminuria and uric acid were identified as independent predictors of cardiovascular events in these patients

Enhanced platelet reactivity in pediatric depression: An observational study

Congress of the European-Society-of-Cardiology (ESC) -- AUG 31-SEP 04, 2013 -- Amsterdam, NETHERLANDSWOS: 000327744605337Depression is associated with poor prognosis for Cardiovascular Disease (CVD) including mortality. Among multiple mechanisms linking depression and CVD, changes in platelet reactivity are known to be one of the major confounders of such adverse association. However, there are very limited data in children. Thus, we evaluated some conventional hemostatic indices including whole blood platelet aggregation in patients with documented pediatric depression and compared these data with those obtained from healthy children. The pediatric patients fulfilled criteria for major depression with a minimum score of 19 on the 21-item Beck Depression Inventory Scale. Plasma fibrinogen, D-dimer, platelet count, mean platelet volume, and platelet aggregation induced by Adenosine Diphosphate (ADP) and collagen were measured in 67 pediatric patients with depression and matched by age and sex with 78 healthy controlsEuropean Soc Cardio