Progression of cardiovascular risk factors in black Africans: 3 year follow up of the SABPA cohort study

Recent work identified a high prevalence of modifiable risk factors for cardiovascular disease (CVD) among urban black South Africans. The aim was to track the progression of CVD risk factors in a multiethnic sample of South Africans. Participants were 173 black (aged 47.5 ± 7.8 yrs) and 186 white teachers (aged 49.6 ± 9.9 yrs) that were examined at baseline and 3 years follow-up. Blacks demonstrated a substantially higher prevalence of composite CVD burden (defined as history of physician diagnosed heart disease, use of anti-hypertensives, anti-diabetic, or statin medications at either time point) compared to whites (49.1 vs. 32.0%, p ¼ 0.012) respectively. After controlling for baseline, the black participants demonstrated greater increases in 24 h systolic and diastolic blood pressure, total cholesterol, fasting glucose, fibrinogen, D-dimer, and waist circumference in comparison with whites. In summary, an adverse progression of CVD risk factors was observed in the whole sample, although to a larger degree in black participants. Aggressive treatment strategies for controlling risk factors in black Africans are needed to reduce the increasing burden of CVD in South Africa

Outcome of intracranial bleeding managed with prothrombin complex concentrate in patients on direct factor Xa inhibitors or vitamin K antagonists

Intracranial hemorrhage (ICH) is the most feared complication of anticoagulation with a high mortality and morbidity. Before registration of a specific reversal agent for factor Xa inhibitors (FXa-I), international guidelines recommended prothrombin complex concentrate (PCC), which also is the specific reversal agent for vitamin K antagonists (VKA). In two contemporary cohorts, we compared clinical outcomes between patients with FXa-I and VKA related ICH treated with PCC between 2014 and 2018. Primary outcome was effective hemostasis after 24 h, according to the International Society of Thrombosis and Hemostasis definition. Safety outcomes were defined as venous and arterial thromboembolic complications and death within 30 days. Thirty-six patients with FXa-I-ICH and 39 patients with VKA-ICH were available for analysis. Baseline characteristics were comparable between both groups, except for time from start of symptoms to presentation at the hospital. In the FXa-I-ICH cohort, 24 (73%) patients achieved effective hemostasis compared to 23 (62%) patients in the VKA-ICH cohort (crude odds ratio [OR] 1.62 [95%CI 0.59–4.48], adjusted OR 1.45 [95%CI 0.44–4.83]). Eight (24%) patients with FXa-I-ICH deceased compared to 17 (45%) patients with VKA-ICH (crude OR 0.38 [95%CI 0.14–1.24], adjusted OR 0.41 [95%CI 0.12–1.24]). In this observational cohort study, the outcome of ICH managed with PCC was similar in patients with FXa-I-ICH and in patients with VKA-ICH

Drink types unmask the health risks associated with alcohol intake – prospective evidence from the general population

Background & aims: Uncertainty still exists on the impact of low to moderate consumption of different drink types on population health. We therefore investigated the associations of different drink types in the form of beer/cider, champagne/white wine, red wine and spirits with various health outcomes. Methods: Over 500,000 participants were recruited to the UK Biobank cohort. Alcohol consumption was self-reported as pints beer/cider, glasses champagne/white wine, glasses of red wine, and measures of spirits per week. We followed health outcomes for a median of 7.02 years and reported all-cause mortality, cardiovascular events, ischemic heart disease, cerebrovascular events, and cancer. Results: In continuous analysis after excluding non-drinkers, beer/cider and spirits intake associated with an increased risk for all-cause mortality (beer/cider: hazard ratio, 1.56; 95% confidence interval, 1.45–1.68; spirits: 1.47;1.35–1.60), cardiovascular events (beer/cider: 1.25;1.17–1.33; spirits: 1.25;1.16–1.36), ischemic heart disease (beer/cider:1.12;0.99–1.26 [P=0.056]; spirits: 1.17;1.02–1.35), cerebrovascular disease (beer/cider: 1.63;1.32–2.02; spirits: 1.59;1.25–2.02) and cancer (beer/cider: 1.14;1.05–1.24; spirits: 1.14;1.03–1.26), while both champagne/white wine and red wine associated with a decreased risk for ischemic heart disease only (champagne/white wine: 0.84;0.72–0.98; red wine: 0.88;0.77–0.99). Conclusions: Our findings do not support the notion that alcohol from any drink type is beneficial to health. Consuming low levels of beer/cider and spirits already associated with an increased risk for all health outcomes, while wine showed opposite protective relationships only with ischemic heart disease

Clinical outcome of patients with a vitamin K antagonist-associated bleeding treated with prothrombin complex concentrate

Background: Vitamin K antagonists (VKA) are used for the treatment of thromboembolism. Patients with severe VKA-associated bleeding require immediate restoration of haemostasis. Clinical studies on the effect of prothrombin complex concentrate (PCC) are heterogeneous with respect to outcome of bleeding. Objective: To evaluate the clinical outcome of patients treated with PCC for VKA-associated bleeding. Methods: We performed a cohort study of consecutive patients who received PCC for VKA-related bleeding in five Dutch hospitals. Data were collected by chart review on the bleeding event, international normalized ratio (INR), haemostatic efficacy, thromboembolic (TE) complications, and mortality. The primary outcome was effective haemostasis, assessed by an adaptation of the Sarode criteria with a surrogate outcome for patients with ICH without repeat CT. Results: One hundred patients were included. Mean age was 74 years, 54% were male and 79% received VKA for atrial fibrillation. Most patients presented with ICH (41%) or GI bleeding (36%). Effective haemostasis was achieved in 67/98 (68%) patients using the adapted classification. Surrogate outcomes were applied for 32 patients and data for two patients was missing. Median pre-treatment INR was 3.9 (IQR 2.9-5.8). One hour after PCC infusion, the INR was available for 50 patients and of these, 35 (70%) had an INR s1.4. TE complications occurred in five patients and 22 died (60% bleeding-related) within 30 days. Conclusion: PCC achieved effective haemostasis in 68% of evaluable patients with VKA-associated bleeding. TE complication rates were low, but mortality rates were high, due to the large number of patients with ICH

Design and rationale of DUTCH-AF:a prospective nationwide registry programme and observational study on long-term oral antithrombotic treatment in patients with atrial fibrillation

Introduction Anticoagulation therapy is pivotal in the management of stroke prevention in atrial fibrillation (AF). Prospective registries, containing longitudinal data are lacking with detailed information on anticoagulant therapy, treatment adherence and AF-related adverse events in practice-based patient cohorts, in particular for non-vitamin K oral anticoagulants (NOAC). With the creation of DUTCH-AF, a nationwide longitudinal AF registry, we aim to provide clinical data and answer questions on the (anticoagulant) management over time and of the clinical course of patients with newly diagnosed AF in routine clinical care. Within DUTCH-AF, our current aim is to assess the effect of non-adherence and non-persistence of anticoagulation therapy on clinical adverse events (eg, bleeding and stroke), to determine predictors for such inadequate anticoagulant treatment, and to validate and refine bleeding prediction models. With DUTCH-AF, we provide the basis for a continuing nationwide AF registry, which will facilitate subsequent research, including future registry-based clinical trials. Methods and analysis The DUTCH-AF registry is a nationwide, prospective registry of patients with newly diagnosed 'non-valvular' AF. Patients will be enrolled from primary, secondary and tertiary care practices across the Netherlands. A target of 6000 patients for this initial cohort will be followed for at least 2 years. Data on thromboembolic and bleeding events, changes in antithrombotic therapy and hospital admissions will be registered. Pharmacy-dispensing data will be obtained to calculate parameters of adherence and persistence to anticoagulant treatment, which will be linked to AF-related outcomes such as ischaemic stroke and major bleeding. In a subset of patients, anticoagulation adherence and beliefs about drugs will be assessed by questionnaire. Ethics and dissemination This study protocol was approved as exempt for formal review according to Dutch law by the Medical Ethics Committee of the Leiden University Medical Centre, Leiden, the Netherlands. Results will be disseminated by publications in peer-reviewed journals and presentations at scientific congresses

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

Die invloed van ouderdom as modulerende faktor tydens kardiovaskulêre reaktiwiteit

PhD (Fisiologie), North-West University, Potchefstroom CampusThe reactivity hypothesis postulates that increased cardiovascular reactivity as a consequence of the application of acute laboratory stressors is associated with the prognosis of hypertension (Matthews et al., 1993). The usefulness of the reactivity hypothesis is limited by the conflicting results of a number of studies (Anderson, 1993). It appears as if various factors influence the relationship between hypertension and hyper reactivity, e.g. the type of stressor and age. Different types of stressors, depending on whether the stressor is primarily physical, cognitive or psychological, give rise to different autonomous discharge patterns and cardiovascular reactivity patterns. The following hypothesis was investigated: changes in cardiovascular' reactivity with an increase in age partially occur due to physical changes in the cardiovascular system, and whether cardiovascular reactivity increases or decreases with age will depend on the autonomous discharge pattern, as induced by the specific stressor. Indirect continuous blood pressure was recorded by means of the Finapres apparatus. Systolic, mean and diastolic blood pressure and heart frequency were recorded during the different tests. Cardiovascular reactivity does not only differ from age group to age group, but also from stressor to stressor. The orthostatic test provided a clear and simple baroreceptor reflex reaction, but the structural changes in the vascular system with an increase in age do have an influence on blood pressure and heart frequency reactivity. A pressure decrease approximately seven seconds after the start of the test is observed almost solely in the case of the younger groups. With the inverted orthostatic test the pressure increase twelve seconds after the start of the test is much more prominent among the younger groups. The results are explained by the greater vascular compliance among the younger groups. The decreased blood pressure reactivity with an increase in age give rise to a decrease in reflex activity. In the case of the cold pressor test the structural changes in the vascular system also play an important role. The effect of the peripheral constriction is increased by the increased stiffness of the blood vessels. Consequently there is a more rapid and larger increase in blood pressure, and particularly systolic pressure, with an increase in age. Blood pressure and heart frequency decrease with an increase in age when the word-colour conflict test is applied, due to the reduced p-adrenergic influence on the cardiovascular system. Structural changes in the vascular system play an important role in cardiovascular reactivity, depending on the stressor which is applied. Each of the various stressors has a different cardiovascular reactivity pattern, which is each influenced in a different way by autonomous and cardiovascular changes with an increase in age. In studying the relationship between hypertension and hyper reactivity the role of age and the nature of the stressor must be taken into account.Doctora

Kardiovaskulêre veranderinge gëinduseer deur middel van 'n binêre keusestelsel

MSc (Fisiologie), North-West University, Potchefstroom CampusThe purpose of this study was to trace cardiovascular reaction to concentration stress. Concentration stress was induced by means of a binary choice system which proved to be eminently suitable. for this purpose. Fisiological reaction takes place as a result of mental labour, that is, the integration of data and the answers thereto. A clear improvement in cardiac performance is observed where concentration stress is induced as reflected by the decrease in time interval measurings. Pre-ejection time, isovolumic contraction time and electromechanical systole as well as the reduction in the ratio of pre-ejection time on left ventricular ejection time and increase in left ventricular ejection time index. Stress on the vascular system increases as reflected by the increase in pressures, inclination time and crest time. When a moderate quantity of alcohol is administered and concentration stress is induced, reaction is practically the same as in the case of concentration stress only. The only clear decrease is in the peripheral resistance as reflected by a slight increase in inclination time and crest time. A slight decrease in diastolic pressure and a slight increase in pulse pressure therefore indicate an improved flow of blood - perfusion of organs also improves . A moderate quantity of alcohol during stress situations therefore slightly relieves the strain on the cardiovascular system. When caffeine is administered, in conjunction with induction of concentration stress, reaction is practically the same as in the case of concentration stress only. Heart rate clearly decreases and as a result some parameters do improve but isovolumic contraction time increases considerably. It would therefore indicate an increase in heart strain, possibly as a result of the direct influence of caffeine on the myocardium. Peripheral resistance decreases slightly as a result of the dilatory influence of caffeine. Consumption of caffeine, therefore, strains the heart even more heavily when combined with concentration stress. One might well conclude that the influence of alcohol or caffeine : is very slight in comparison to the loud and clear responses given by concentration stress. The consequences of concentration stress on the cardiovascular system therefore undoubtedly dominate those of caffeine and alcohol.Master

Die invloed van ouderdom as modulerende faktor tydens kardiovaskulêre reaktiwiteit

PhD (Fisiologie), North-West University, Potchefstroom CampusThe reactivity hypothesis postulates that increased cardiovascular reactivity as a consequence of the application of acute laboratory stressors is associated with the prognosis of hypertension (Matthews et al., 1993). The usefulness of the reactivity hypothesis is limited by the conflicting results of a number of studies (Anderson, 1993). It appears as if various factors influence the relationship between hypertension and hyper reactivity, e.g. the type of stressor and age. Different types of stressors, depending on whether the stressor is primarily physical, cognitive or psychological, give rise to different autonomous discharge patterns and cardiovascular reactivity patterns. The following hypothesis was investigated: changes in cardiovascular' reactivity with an increase in age partially occur due to physical changes in the cardiovascular system, and whether cardiovascular reactivity increases or decreases with age will depend on the autonomous discharge pattern, as induced by the specific stressor. Indirect continuous blood pressure was recorded by means of the Finapres apparatus. Systolic, mean and diastolic blood pressure and heart frequency were recorded during the different tests. Cardiovascular reactivity does not only differ from age group to age group, but also from stressor to stressor. The orthostatic test provided a clear and simple baroreceptor reflex reaction, but the structural changes in the vascular system with an increase in age do have an influence on blood pressure and heart frequency reactivity. A pressure decrease approximately seven seconds after the start of the test is observed almost solely in the case of the younger groups. With the inverted orthostatic test the pressure increase twelve seconds after the start of the test is much more prominent among the younger groups. The results are explained by the greater vascular compliance among the younger groups. The decreased blood pressure reactivity with an increase in age give rise to a decrease in reflex activity. In the case of the cold pressor test the structural changes in the vascular system also play an important role. The effect of the peripheral constriction is increased by the increased stiffness of the blood vessels. Consequently there is a more rapid and larger increase in blood pressure, and particularly systolic pressure, with an increase in age. Blood pressure and heart frequency decrease with an increase in age when the word-colour conflict test is applied, due to the reduced p-adrenergic influence on the cardiovascular system. Structural changes in the vascular system play an important role in cardiovascular reactivity, depending on the stressor which is applied. Each of the various stressors has a different cardiovascular reactivity pattern, which is each influenced in a different way by autonomous and cardiovascular changes with an increase in age. In studying the relationship between hypertension and hyper reactivity the role of age and the nature of the stressor must be taken into account.Doctora