732 research outputs found
Minimizing drug-drug interactions between dabigatran and levetiracetam through clinical management: a case report
No full textBACKGROUND: Direct oral anticoagulants (DOACs) are useful for stroke prevention in atrial fibrillation (AF) patients. However, the concomitant administration of Levetiracetam limited their use in clinical practice, although some authors raise doubts about clinical relevance of the interaction. CASE SUMMARY: We report a case of a 54-year-old male with AF, cirrhosis, and seizures, in which the assessment of Dabigatran plasma concentration was needed due to the concomitant use of Levetiracetam. In this case, no relevant reduction of trough Dabigatran plasma concentration was found. An increased peak serum level of dabigatran may be obtained delaying levetiracetam administration. The patient was then followed in our clinic and during 32 months of follow-up no ischaemic or haemorrhagic events occurred. DISCUSSION: The evaluation of DOACs concentration could be helpful to start a tailored therapy in frailty patients
Tailored Practical Management of Patients With Atrial Fibrillation: A Risk Factor-Based Approach
No full textThe management of antithrombotic therapy for thromboprophylaxis in patients with atrial fibrillation (AF) has been recently evolved by the progressive replacement of vitamin K antagonists with the non-vitamin K antagonist oral anticoagulants (NOACs). However, while these drugs are effective in reducing ischemic stroke/systemic embolism, a still high rate of cardiovascular events is present in the AF population. A tailored integrated approach to patients with AF is therefore necessary to reduce both thromboembolic events and cardiovascular disease. This approach should consist in the assessment of individual risk factors for ischemic and bleeding events in order to choose the most appropriate anticoagulant treatment according to patient's characteristics and preference. To this purpose, several risk scores have been developed and validated to stratify thromboembolic and hemorrhagic risk. This review provides an individual-based strategy for the management of patients with AF, from a risk-factor based approach to a tailored prescription and monitoring of NOACs. In particular, we reported an updated practical management strategy for AF patients in specific clinical situations such as those (1) experiencing a major bleeding, (2) requiring a switch to another antithrombotic regimen, (3) restarting anticoagulation after acute ischemic stroke, (4) suffering from an acute coronary artery disease (acute coronary syndrome or undergoing cardiac revascularization)
Gut barrier dysfunction and endotoxemia in heart failure: A dangerous connubium?
No full text: Heart failure (HF) is a leading cause of death worldwide despite recent advances in pharmacological treatments. Gut microbiota dysbiosis and gut barrier dysfunction with consequent bacterial translocation and increased blood endotoxemia has gained much attention as one of the key pathogenetic mechanisms contributing to increased mortality of patients at risk or with cardiovascular disease. Indeed, increased blood levels of lipopolysaccharide (LPS), a glycolipid of outer membrane of gut gram-negative bacteria, have been detected in patients with diabetes, obesity and nonalcoholic fatty liver disease or in patients with established coronary disease such as myocardial infarction or atrial fibrillation, suggesting endotoxemia as aggravating factor via systemic inflammation and eventually vascular damage. Upon interaction with its receptor Toll-like receptor 4 (TLR4) LPS may, in fact, act at different cellular levels so eliciting formation of proinflammatory cytokines or exerting a procoagulant activity. Increasing body of evidence pointed to endotoxemia as factor potentially deteriorating the clinical course of patients with HF, that, in fact, is associated with gut dysbiosis-derived changes of gut barrier functionality and eventually bacteria or bacterial product translocation into systemic circulation. The aim of this review is to summarize current experimental and clinical evidence on the mechanisms linking gut dysbiosis-related endotoxemia with HF, its potential negative impact with HF progression, and the therapeutic strategies that can counteract endotoxemia
Multiple arterial thrombosis in seronegative antiphospholipid syndrome. need for new diagnostic criteria
No full textBackground: Antiphospholipid syndrome (APS) is defined as thromboembolic complications and/or pregnancy morbidity in the presence of persistent increased titres of antiphospholipid antibodies. Nevertheless, some patients with clinical signs suggestive of APS are negative for diagnostic antibodies and may be classified as having seronegative-APS (SN-APS). Among the 'non-diagnostic' antibodies, a few studies have suggested that the IgG anti-vimentin/cardiolipin antibodies (AVA/CL) may be associated with risk of thrombosis.
Aims: The aim of this case report is to encourage the assessment of non-conventional antibodies in APS.Patient and methods: We report the case of a 69-year-old male patient with rapid onset of apparently unexplained multiple exclusively arterial thrombotic events in both coronary and peripheral vascular beds.
Results: The patient did not meet the diagnostic criteria for APS but was positive for AVA/CL, which result persisted on further testing at 3 and 6 months.
Discussion: Ongoing research has revealed the existence of non-criteria antibodies which may be relevant for the diagnosis of SN-APS and should be included in the classification criteria for the disease.
Learning points: In patients with unexplained multiple thrombosis without the conventional antibodies of antiphospholipid syndrome, the assessment of non-conventional antibodies should be considered.IgG anti-vimentin/cardiolipin antibodies may be associated with risk of thrombosis.Arterial thrombosis could be the only manifestation of antiphospholipid syndrome
Direct oral anticoagulants and advanced liver disease: A systematic review and meta‐analysis
No full textBackground: Direct oral anticoagulants (DOACs) are recommended for stroke prevention in patients with atrial fibrillation (AF) or for treatment of deep vein thrombosis, although some concerns about safety and efficacy were raised on the use of these drugs in patients with advanced liver disease (ALD). We want to investigate the association of DOACs use with the bleeding and ischaemic risk.
Material and methods: We performed a systematic review and metanalysis of clinical studies retrieved from PubMed (via MEDLINE) and Cochrane (CENTRAL) databases addressing the impact of DOACs therapy on bleeding events including intracranial haemorrhage (ICH), gastrointestinal and major bleeding. Secondary end points were all-cause death, ischaemic stroke/systemic embolism (IS/SE) and recurrence/progression of vein thrombosis (rDVT).
Results: 12 studies were included in the meta-analysis: a total of 43 532 patients with ALD or cirrhosis, of whom 27 574 (63.3%) were on treatment with DOACs and 15 958 were in warfarin/low molecular weight heparin. DOACs reduced the incidence of major bleeding by 61% (pooled Hazard Ratio [HR] 0.39, 95% Confidence Interval [CI] 0.21-0.70), ICH by 52% (HR 0.48, 95% CI 0.40-0.59), while no difference in the reduction of any and gastrointestinal bleeding were observed. DOACs reduced also rDVT by 82% (HR 0.18, 95%CI 0.06-0.57), but did not reduce death and IS/SE. No difference was shown according to oesophageal varices and Child Pugh score in the meta-regression analysis between warfarin/heparin and DOACs performed on each outcome.
Conclusions: DOACs are associated with a lower incidence of bleeding and may be an attractive therapeutic option in patients with cirrhosi
Association of proprotein convertase subtilisin/kexin type 9 (PCSK9) levels with abnormally high ankle-brachial index in atrial fibrillation
No full textBackground: High ankle-brachial index (ABI) has been associated with increased risk of worse out-comes in the general population. Few data on atrial fibrillation (AF) exist. Experimental data suggest that proprotein convertase subtilisin/kexin type 9 (PCSK9) contributes to vascular calcification but clinical data on this association are lacking. Aims: We wanted to investigate the relationship between circulating PCSK9 levels and an abnormally high ABI in patients suffering from AF. Methods: We analyzed data from 579 patients included in the prospective ATHERO-AF study. An ABI >= 1.4 was considered high. PCSK9 levels were measured coincidentally with ABI measurement. We used optimized cut-offs of PCSK9 for both ABI and mortality obtained from Receiver Operator Characteristic (ROC) curve analysis. All-cause mortality according to the ABI value was also analyzed. Results: One hundred and fifteen patients (19.9%) had an ABI >= 1.4. The mean (standard deviation [SD]) age was 72.1 (7.6) years, and 42.1% of patients were women. Patients with ABI >= 1.4 were older, more frequently male, and diabetic. Multivariable logistic regression analysis showed an association between ABI >= 1.4 and serum levels of PCSK9 >1150 pg/ml (odds ratio [OR], 1.649; 95% confidence interval [CI], 1.047-2.598; P = 0.031). During a median follow-up of 41 months, 113 deaths occurred. In multivariable Cox regression analysis, an ABI >= 1.4 (hazard ratio [HR], 1.626; 95% CI, 1.024-2.582; P = 0.039), CHA2DS2-VASc score (HR, 1.249; 95% CI, 1.088-1.434; P = 0.002), antiplatelet drug use (HR, 1.775; 95% CI, 1.153-2.733; P = 0.009), and PCSK9 >2060 pg/ml (HR, 2.200; 95% CI, 1.437-3.369; P <0.001) were associated with all-cause death. Conclusions: In AF patients, PCSK9 levels relate to an abnormally high ABI >= 1.4. Our data suggest PCSK9 role in contributing to vascular calcification in AF patients
Which kind of philosopher was Danilo Pejović?
No full textU ovom kratkom prilogu autorica pokušava opisati narav Danila Pejovića kao filozofa. Njegovo bitno obilježje bila je filozofijska i svetovna suverenost.In this short contribution the author tries to describe the nature of Danilo Pejović as a philosopher. His main characteristic was a philosophical and secular sovereignity
Cancer and atrial fibrillation: Epidemiology, mechanisms, and anticoagulation treatment
No full textCancer patients are at an increased risk of developing atrial fibrillation (AF) and thrombosis. However, the management of anticoagulation in patients with both diseases may be challenging, and data on these patients are lacking. We summarize the current evidence on the incidence and prevalence of cancer in AF and vice versa and provide some practical considerations on the management of oral anticoagulation in specific clinical situations. Low-molecular weight heparins are not approved for thromboprophylaxis in AF, and management of warfarin can be difficult. The use of direct oral anticoagulants may be particularly attractive for their rapid onset/offset action and lower bleeding risk
Acute upper and lower gastrointestinal bleeding management in older people taking or not taking anticoagulants: a literature review
No full textAcute upper and lower gastrointestinal (GI) bleeding may be a potentially
life-threatening event that requires prompt recognition and an early effective
management, being responsible for a considerable number of hospital
admissions. Methods. We perform a clinical review to summarize the recent
international guidelines, helping the physician in clinical practice. Older people
are a vulnerable subgroup of patients more prone to developing GI bleeding
because of several comorbidities and polypharmacy, especially related to an
increased use of antiplatelet and anticoagulant drugs. In addition, older patients
may have higher peri-procedural risk that should be evaluated. The recent
introduction of reversal strategies may help the management of GI bleeding
in this subgroup of patients. In this review, we aimed to (1) summarize the
epidemiology and risk factors for upper and lower GI bleeding, (2) describe
treatment options with a focus on pharmacodynamics and pharmacokinetics
of different proton pump inhibitors, and (3) provide an overview of the clinical
management with flowcharts for risk stratification and treatment. In conclusion,
GI is common in older patients and an early effective management may
be helpful in the reduction of several complications
Long-term risk of hospitalization and death in patients with mechanical prosthetic heart valves
No full text: Mechanical prosthetic heart valves (MPHV) are commonly used for valvular heart disease in patients with long life expectancy. Few longitudinal data on hospitalizations specific causes in MPHV patients are available. We investigated the risk of all-cause hospitalization and mortality in MPHV patients. We performed a prospective observational ongoing study including MPHVs consecutive patients referring to the atherothrombosis outpatient clinic of the Policlinico Umberto I of Rome for the vitamin K antagonist (VKA) management. Study endpoints were all-cause, cardiovascular hospitalization and overall mortality. We included 305 MPHV patients (38.4% women, median age 60.2 years). The site of MPHV was aortic in 53.5%, mitral in 29.5% and mitro-aortic in 17%. During a median follow-up of 57.3 months, 142 hospitalizations occurred (8.16 per 100 person-years). The most common causes of hospitalization were cardiovascular disease (3.62 per 100 person-years), infections, surgery and bleeding. Predictors of cardiovascular hospitalization were atrial fibrillation (Hazard ratio [HR] 1.75, 95% confidence interval [95%CI] 1.04-2.95, p= 0.035), previous stroke/transient ischemic attack (HR 2.96, 95%CI 1.59-5.48, p=0.001) and peripheral artery disease (HR 2.42, 95%CI 1.09-5.36, p=0.030). During a median follow-up of 97.2 months, 61 deaths occurred (2.43 per 100 person-years). Age was directly associated with the risk of death (HR 1.088, 95%CI 1.054-1.122, p<0.001), while time in therapeutic range above the median was inversely associated (HR 0.436, 95%CI 0.242-0.786, p= 0.006). In conclusion, MPHV patients had a high incidence of hospitalizations, especially cardiovascular-related. The incidence of death is high, but it may be reduced by maintaining a good quality of anticoagulation
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