Update on the clinical use of the low-molecular-weight heparin, parnaparin

Parnaparin is a low-molecular-weight heparin that has widely shown its efficacy and safety in prevention of venous thromboembolism, in the treatment of chronic venous disorders, and in the treatment of venous and arterial (stable and unstable angina, acute ST-segment elevation myocardial infarction) thrombosis. Parnaparin at the respective dosages of 3200, 4250, 6400, or 12800 IUaXa for a period ranging from 3 to 5 days to 6 months, is usually administered subcutaneously by means of once-daily regimen and is better tolerated than unfractionated heparin at the injection site. In the variety of commercially available low-molecular-weight heparins, parnaparin represents a useful therapeutic option, even though little evidence is available comparing the superiority or the equivalent efficacy and safety of parnaparin to that of the unfractionated heparin or placebo. This review summarizes the available literature on the use of parnaparin in different settings of cardiovascular diseases, including papers published during the past year and ongoing studies

Multipoint pacing by a left ventricular quadripolar lead improves the acute hemodynamic response to CRT compared with conventional biventricular pacing at any site

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Optimization of left ventricular pacing site plus multipoint pacing improves remodeling and clinical response to cardiac resynchronization therapy at 1 year

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Aspirin and recurrent venous thromboembolism

While there is conclusive evidence that aspirin plays a role in reducing the risk of clinically relevant venous thromboembolism (VTE) arising in a number of surgical and non-surgical situations at risk, little is known of the potential of aspirin for the long/term prevention of recurrent VTE. In two recent multicentre, double-blind studies (WARFASA and ASPIRE), the efficacy and safety of a low dose of aspirin (100 mg per day) were assessed in patients with unprovoked VTE who had completed an initial period of conventional treatment with vitamin K antagonists. The two studies used identical aspirin regimens and had similar enrollment criteria and outcome measures. When data from these two trials were pooled, there was a 32% reduction in the rate of recurrence of VTE (hazard ratio [HR], 0.68; 95% confidence interval [CI], 0.51-0.90) and a 34% reduction in the rate of major vascular events (HR, 0.66; 95% CI, 0.51-0.86). Moreover, these benefits were achieved with a low risk of bleeding. As patients with previous symptomatic atherosclerosis were not enrolled in these two studies, whether these results apply also to this category of patients is uncertain. We recently had the opportunity to review the clinical charts of 1919 consecutive patients presented with a first episode of VTE, which was either unprovoked or triggered by transient risk factors, and were followed up for an average period of four years after discontinuing anticoagulation. The rate of recurrent VTE in the 256 patients with a history of symptomatic atherosclerosis who had been given 80-160 mg of aspirin once daily (17.2%) did not differ from that (19.9%) observed in those without atherosclerosis who were left without any antithrombotic treatments. The implication of this observation is that whenever patients with symptomatic atherosclerosis are deemed to require long-term protection against recurrent VTE, they are unlikely to benefit from (resuming) aspirin. Conversely, aspirin in low doses offers an appealing, safe and highly cost-effective option for the long-term prevention of recurrent events in patients with unprovoked VTE who are free from symptomatic atherosclerotic lesions

Pegylated interferon-associated retinopathy is frequent in HCV patients with hypertension and justifies ophthalmologic screening.

Treatment with pegylated interferon alpha (PegIFN\u3b1) and ribavirin is still regarded as the standard of care for chronic hepatitis C. Retinopathy has been occasionally described but prospective, longitudinal data are lacking. We have investigated the frequency and clinical significance of retinopathy during therapy with PegIFN\u3b1 and ribavirin in 97 consecutive HCV patients. 54 (55.7%) and 43 (44.3%) patients were treated with PegIFN\u3b1 2a and PegIFN\u3b1 2b, respectively. Ophthalmologic examination was performed before therapy (baseline), at 3 and 6 months (3T and 6T, respectively) of therapy and 3 months after the end of therapy (3ET). All patients underwent the baseline and 3T examination, 90.7% underwent 6T and 3ET examination. Overall, 30.9% of patients developed retinopathy, as defined by the presence of cotton wool spots and/or retinal haemorrhages. Variables significantly associated with retinopathy during treatment were age (p=0.004), metabolic syndrome (p=0.05), hypertension (p<0.0001), cryoglobulinaemia (p=0.05) and preexisting intraocular lesions at baseline (p=0.05). By multivariate analysis, the only variable independently associated with PegIFN\u3b1-associated retinopathy was hypertension (HR=4.99, 95% CI 2.29-10.89). The frequency of retinopathy was significantly higher in hypertensive patients vs. those without hypertension at all time points (18.5% vs. 5.7% at baseline, p=0.05; 48.1% vs. 15.7% at 3T, p=0.0009; 68.0% vs. 19.1% at 6T, p<0.0001; 32.0% vs. 6.2%, p=0.0005 at 3ET). In one (1.1%) hypertensive patient, who developed bilateral branch retinal vein occlusion at 6T, the therapy was discontinued. A cost-analysis showed that screening for PegIFN\u3b1-associated retinopathy was cost-effective as compared to thyroid screening by TSH. Conclusion: Retinopathy is frequent during treatment with PegIFN\u3b1 and ribavirin, especially in hypertensive patients, who may develop serious complications. Screening for PegIFN\u3b1-associated retinopathy should be recommended for HCV patients with hypertension

Prevalence of Liver Disease in a Population of Asymptomatic Persons with Hepatitis C Virus Infection

Abstract BACKGROUND: The prevalence of significant liver disease in persons with asymptomatic hepatitis C virus (HCV) infection is unclear. OBJECTIVE: To determine the prevalence and severity of HCV infection in asymptomatic persons. DESIGN: Population-based cross-sectional study. SETTING: Northeastern Italy. PATIENTS: 4820 apparently healthy Telecom Italy employees or their relatives who underwent screening for cardiovascular risk factors. MEASUREMENTS: Initial screening for anti-HCV by enzyme-linked immunosorbent assay followed by HCV RNA testing by polymerase chain reaction and monitoring of alanine aminotransferase levels in viremic persons (92% of viremic persons also had liver biopsies to assess their METAVIR scores). RESULTS: 116 persons (2.4% [95% CI, 1.97% to 2.84%]) were positive for anti-HCV and 85 (1.76% [CI, 1.39% to 2.14%]) were also viremic. The ALT level was persistently normal in 39 (46%) of viremic patients and elevated in 46 (54%). Significant hepatic histologic abnormalities were detected in 19% (CI, 7.21% to 36.4%) of persons with persistently normal ALT levels and in 61% (CI, 45.4% to 74.9%) of viremic persons who had elevated ALT levels (P < 0.001). The prevalence of HCV infection and number of persons with chronic liver fibrosis increased with age (P = 0.003). CONCLUSIONS: Hepatitis C is histologically active and progressive in up to 40% of asymptomatic persons with HCV infection. The severity of liver disease correlates with abnormal ALT levels and increases with age