Atrial Fibrillation and Anticoagulation in Hypertrophic Cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) represents a common inherited cardiac disorder with well-known complications Including stroke and sudden cardiac death. There is a recognised association between HCM and the development of AF. This review describes the epidemiology of AF within the HCM population and analyses the risk factors for the development of AF. It further discusses the outcomes associated with AF in this population, including the evidence in support of higher stroke risk in patients with HCM with AF compared with the general AF population. Finally, the evidence and recommendations for anticoagulation in this patient group are addressed

Non-vitamin K antagonist oral anticoagulants in atrial fibrillation accompanying mitral stenosis: the concept for a trial.

Patients at thromboembolic risk with non-valvular atrial fibrillation (AF) can now be managed either with a vitamin K antagonist (VKA) or with a fixed dose of a non-VKA oral anticoagulant (NOAC), while patients with valvular AF have been restricted to VKAs on the basis of a potentially higher risk and different mechanism of thrombosis, and the lack of sufficient data on the efficacy of NOACs. The terms 'non-valvular AF' and 'valvular AF' have not been however consistently defined. 'Valvular' AF has included any valvular disorder, including valve replacement and repair. In AF with rheumatic mitral disease, observational studies strongly suggest that VKA treatment is valuable. These patients have not been included in NOAC trials, but there is also no stringent argument to have excluded them. This is at sharp variance from patients with mechanical valves, also excluded from the pivotal Phase III trial comparing warfarin with NOACs, but in whom a single Phase II trial of dabigatran etexilate against VKA treatment was stopped prematurely because of increased rates of thromboembolism as well as increased bleeding associated with dabigatran. Until more data are available, such patients should be therefore managed with VKAs. We here propose an open-label randomized trial of one of the NOACs against the best of treatment available in regions of the world in which rheumatic heart disease is still highly prevalent, aiming at showing the superiority of the NOAC used against current standard treatment

Managing atrial fibrillation in the global community: The European perspective.

Atrial fibrillation is a common, global problem, with great personal, economic and social burdens. As populations age it increases in prevalence and becomes another condition that requires careful chronic management to ensure its effects are minimised. Assessment of the risk of stroke using well established risk prediction models is being aided by modern computerised databases and the choice of drugs to prevent strokes is ever expanding to try and improve the major cause of morbidity in AF. In addition, newer drugs for controlling rhythm are available and guidelines are constantly changing to reflect this. As well as medications, modern techniques of electrophysiology are becoming more widely embraced worldwide to provide more targeted treatment for the underlying pathophysiology. In this review we consider these factors to concisely describe how AF can be successfully managed

Outcomes associated with non-recommended dosing of rivaroxaban: results from the XANTUS study.

Aims: In Europe, the approved rivaroxaban dose for stroke prevention in patients with atrial fibrillation is 20 mg once daily (od), with 15 mg od recommended in patients with creatinine clearance [CrCl] 15-49 mL/min. Non-recommended doses are prescribed in real-world practice. This analysis of the XANTUS study assessed outcomes associated with non-recommended dosing and patient characteristics that may have impacted dose choice. Methods and results: Baseline characteristics and 1-year outcomes were compared in 4464/6784 patients with known CrCl, receiving recommended or non-recommended rivaroxaban doses; 3608 (80.8%) patients received recommended doses (mean CHADS2 score 1.9) and 856 (19.2%) non-recommended doses (mean CHADS2 score 2.5). Incidence rate (events/100 patient-years) for the composite of treatment-emergent adjudicated major bleeding, stroke/systemic embolism and death was 7.5 (95% confidence interval [CI] 5.7-9.8) and 4.8 (95% CI 4.1-5.7) with non-recommended and recommended doses, respectively (hazard ratio 1.55; 95% CI 1.2-2.1; P = 0.004). Incidence rates for the components of the composite were 3.7 and 2.6, 1.4 and 0.9, and 3.5 and 1.9, respectively. Adjustment for baseline characteristics showed similar rates of the composite outcome (hazard ratio 1.06; 95% CI 0.77-1.45; P = 0.719). Multivariable analysis identified age, anaemia, congestive heart failure, diabetes mellitus, CrCl, lower body weight, atrial fibrillation type, and vascular disease as predictors of non-recommended dosing. Conclusion: Non-recommended rivaroxaban dosing was associated with less favourable outcomes, possibly due to baseline characteristics, in addition to renal function, that may also affect physicians' dosing decisions. Trial registration number: Clinicaltrials.gov: NCT01606995

The year in cardiology: arrhythmias and pacing.

During this last year, there has been much progress with regard to anticoagulant and ablation therapy for atrial fibrillation (AF). Apart from recently issued European Society of Cardiology Guidelines for the management of patients with supraventricular arrhythmias, there has been little progress in research in this field. Ventricular arrhythmias and device therapy have seen modest progress

Predicting pMDI formulation thermophysical properties using activity coefficient models

The Kigali amendment to Montreal protocol sets the timetable for phasing out of pMDI propellants HFA134a and HFA227ea, creating a requirement for green propellants to take their place. To assist this transition, accurate prediction of thermophysical properties that control aerosol generation of new formulations is crucial. A relevant challenge is how to predict property data such as saturated vapour pressure, surface tension and viscosity of propellant/excipient/drug mixtures using the smallest possible programme of physical testing. It is proposed to use a thermodynamic framework based on activity coefficients to model intermolecular forces between constituents, which are known to control multi-component thermophysical property behaviour. It is proposed to use the UNIFAC method, which is based on detailed physical understanding of molecular functional groups and their interactions, with the ability to capture azeotropic behaviour. Surface tension, viscosity and vapour pressure measurements of mixtures of HFA134a with ethanol at 20°C have been studied to validate the technique. Utilizing UNIFAC parameter fitting to the experimental dataset with non-linear least-squares optimization, a root mean square deviation (RMSD) of 7% in predicted surface tension, 6% in predicted viscosity and 2% in predicted vapour pressure was obtained. Previously unavailable UNIFAC interaction parameters for HFA-alcohol mixtures were created. The capability is highly versatile, accepting various thermophysical property data and giving good agreement with measured values for existing formulation mixtures. The framework can be readily applied to mixtures of green propellants such as HFA152a to extend experimental data when available and support insights into thermophysical properties and aerosol generation

Developing a complex educational–behavioural intervention:the TREAT intervention for patients with atrial fibrillation

This article describes the theoretical and pragmatic development of a patient-centred intervention for patients with atrial fibrillation (AF). Theoretical models (Common Sense Model, Necessity-Concerns Framework), clinical frameworks, and AF patient feedback contributed to the design of a one-off hour-long behaviour-change intervention package. Intervention materials consisted of a DVD, educational booklet, diary and worksheet, which were patient-centred and easy to administer. The intervention was evaluated within a randomised controlled trial. Several “active theoretical ingredients” were identified (for e.g., where patients believed their medication was less harmful they spent more time within the therapeutic range (TTR), with general harm scores predicting TTR at 6 months). Allowing for social comparison and adopting behaviour change techniques enabled accurate patient understanding of their condition and medication. The process of developing the intervention using theory-derived content and evaluation tools allowed a greater understanding of the mechanisms by which this intervention was successful. Alleviating concerns about treatment medication by educating patients can help to improve adherence. This process of intervention development could be adopted for a range of chronic illnesses and treatments. Critical elements should include the use of: (1) clinical guidelines; (2) appropriate theoretical models; (3) patient input; and (4) appropriate evaluation tools

Pseudo Leadership and Safety Culture

Search Amazon.com using the keyword “leadership,” and you are rewarded with a list of over 144,000 titles. There is no shortage of books and articles, many of them well written, with excellent ideas. So why is there still a constant cry for effective leadership in organizations? Often, the person in charge has personal blinders that prevent them from seeing or understanding how to implement the newest leadership idea or method. Either deliberately or subliminally, there is a disconnect from learning about leadership, and actually modelling and implementing what has been learned. Some current research in leadership theory can provide insight and tools to address this issue