1,720,990 research outputs found
Oral anticoagulation for atrial fibrillation in the era of non-vitamin K antagonist anticoagulants. Focus on very elderly patients
Full text linkIntroduction. Atrial fibrillation is the most common cardiac arrhythmia, characterized by irregular heart rhythm and associated with left atrial and left appendage thrombi formation that may cause ischemic stroke. Oral anticoagulant therapy has been shown to reduce the incidence of ischemic stroke in these patients by about two thirds, at the expense of an increase in bleeding. In the elderly, atrial fibrillation is particularly frequent, but anticoagulant therapy often encounter several issues: in fact, although ischemic risk increases with age, haemorrhagic risk is also high and often doctors prefers not to prescribe or discontinue oral anticoagulant therapy in fear of complications. The elderly patient, moreover, is often affected by multiple diseases, takes several drugs with potential risk of interactions and may have lower adherence to therapy.
Aim. To evaluate the impact of anticoagulation in the elderly patient, focusing on the subgroup of very elderly patients (i.e. 80 years of age) who are often not included in major clinical trials.
VENPAF. We initially conducted a retrospective "inception cohort" study involving all patients 80 years of age referred to the local Thrombosis Centre to start anticoagulant therapy with warfarin for atrial fibrillation (VENPAF study). From data analysis, we found that major haemorrhages rate is very high and tends to increase considerably over 85 years of age. Nevertheless, net clinical benefit appears to be maintained, as the calculated incidence of thromboembolism in the absence of anticoagulant therapy was higher in both age classes compared to the observed incidence of major haemorrhages.
About 20% of these patients had discontinued warfarin and this was often decided by the general practitioner or the specialist; main reasons for discontinuation were low life expectancy, fragility and excessive haemorrhagic risk. We found that therapy discontinuation was not associated with an improvement in prognosis, but indeed these patients faced high rates of mortality, ischemic and haemorrhagic events, regardless of persistence or discontinuation of anticoagulant therapy.
Analysing only patients who experienced a major bleeding event during anticoagulant therapy, we could highlight how the cumulative incidence of ischemic and haemorrhagic events was significantly higher in patients who suspended therapy than those who resumed it after the index event.control study. A case-control study was set to analyse which factors may possibly be associated with the development of intracranial haemorrhage with warfarin (the most serious complication of oral anticoagulant therapy). All patients followed by our Thrombosis Centre who developed intracranial bleeding in anticoagulant therapy were included; control group was created from anticoagulated patients paired for age, sex, and exposure to therapy in a 1:4 ratio. No variable was associated with the development of bleeding. We also could evaluate ischemic risk for each patient using HAS-BLED, ATRIA and ORBIT haemorrhage scores; these scores showed a predisposing capacity for particularly poor intracranial haemorrhage (c-statistic around 0.55 for all three scores).
Veneto Region Registry. After the analysis of cerebral bleedings during warfarin therapy, we focused on the use of non-vitamin K oral anticoagulants (NOAC), which demonstrated to halve cerebral bleeding as compared with warfarin in clinical trials. Using Veneto Region registries of pharmacological prescriptions, exemptions, and department discharge diagnoses, we were able to select patients who started oral anticoagulant therapy because of non-valvular atrial fibrillation and compared patients who started warfarin therapy versus those who started a NOAC. Results were broadly consistent with the literature, with similar efficacy and safety but a sharp reduction in intracranial bleedings and a mild reduction in mortality with NOAC, despite the good quality of warfarin anticoagulation achieved thanks to the thrombosis centers of our regions. Moreover, we found that patients treated with NOAC in Veneto region are on average older and at higher ischemic risk than patients treated with warfarin.
Finally, we analysed the subset of patients ≥80 years old and found a marked increase in gastrointestinal bleeding, especially from the lower tract, in patients treated with NOAC. However, ischemic stroke and total major bleedings rates were similar among the two groups and NOAC patients showed a lower risk of intracranial haemorrhage.
Conclusions. The present work analysed the effects of anticoagulant therapy in elderly patients with 80 years or more. Based on the different studies we conducted, it was possible to conclude that, despite the high risk of haemorrhage, clinical benefit for the prevention of stroke is in favour for the use of these drugs in this subset of patients. In fact, patients who suspended anticoagulant treatment had a worse prognosis than patients who persisted. Intracranial hemorrhage is the most fearful side effect of anticoagulant treatment, being related to very high rates of mortality and disability; from our findings, these events are more frequent in the elderly and are not predictable by common cardiovascular risk factors or good anticoagulation quality. Data on NOAC users, on the other hand, seem to confirm that the risk of intracranial bleeding is inferior to warfarin even in the very elderly, despite a significant increase in the risk of gastrointestinal haemorrhage. Overall, therefore, our data confirms NOAC as the preferred anticoagulant therapy in very elderly patients with non-valvular atrial fibrillation
Minimizing the risk of hemorrhagic stroke during anticoagulant therapy for atrial fibrillation
No full textIntroduction: Oral anticoagulation (OAC) is given for ischemic stroke
prevention in patients with nonvalvular atrial fibrillation. OAC’s most serious
complications are major bleeding and, in particular, hemorrhagic stroke.
Together with vitamin K antagonists (VKAs), direct oral anticoagulants
(DOAC) are now available which have a more rapid onset/offset of action
and more predictable anticoagulant effect. The advent of DOAC has given
to the clinician an opportunity to tailor OAC therapy in order to maximize
advantages and minimize complications.
Areas covered: This review covers data published in literature regarding the
risk of hemorrhagic stroke in patients taking OAC. Bleeding risk assessment
is discussed and different bleeding risk factors are presented. The paper will
also review clinical studies comparing DOAC against standard anticoagulation,
in regard to the risk of hemorrhagic stroke.
Expert opinion: Bleeding assessment is mandatory in order to select patients
at high hemorrhagic risk who will benefit the most from close monitoring.
Blood pressure, alcohol intake, concomitant medication and comorbidities
should be constantly evaluated and treated accordingly. During VKA therapy,
adherence and intensity of anticoagulation must be strictly monitored. DOAC
are associated with lower risk of hemorrhagic stroke than VKA. However,
periodic hepatic and renal checks as well as careful evaluation of time adherence are necessary to reduce the risk of bleeding
Efficacy and safety of rivaroxaban vs warfarin in high-risk patients with antiphospholipid syndrome: Rationale and design of the Trial on Rivaroxaban in AntiPhospholipid Syndrome (TRAPS) trial
No full textAntiphospholipid syndrome and the heart: A case series and literature review
No full textAntiphospholipid syndrome is a rare autoimmune disease characterised by a high tendency of developing thrombotic events. It is diagnosed in the presence of specific laboratory criteria (positivity for lupus anticoagulant, and the presence of anticardiolipin and aβ2GPI antibodies) and clinical criteria such as thrombosis in any district (arterial or venous) and pregnancy morbidity. Being a multisystem disease, heart is commonly affected by direct (autoimmune mediated action) or indirect (thrombosis) pathological mechanisms. Heart valve lesions are the most frequent manifestations; however, the haemodynamic significance is quite uncommon but when it occurs it may require surgery that further complicates the picture due to the high risk of thrombosis. Coronary arteries and myocardium are also affected leading to ischaemic heart disease and left ventricular dysfunction. Other findings include chronic thromboembolic pulmonary hypertension and accelerated atherosclerosis. The consequences of heart involvement may be significant in overt disease. The treatment of cardiac complications is challenging and requires an in depth knowledge of the disease
Fibroblast growth factor 23 and the bone-vascular axis: lessons learned from animal studies.
No full textCalcification of arteries and cardiac valves is observed commonly in dialysis patients and represents a major determinant of the heightened cardiovascular risk observed during chronic kidney disease (CKD) progression. Recent advances from clinical and basic science studies suggest that vascular calcification should be considered a systemic disease in which pathologic processes occurring in the bone and kidney contribute to calcium deposition in the vasculature. Among the factors potentially involved in the vascular-bone axis dysregulation associated with CKD, there now is increasing interest in the role of the phosphaturic hormone fibroblast growth factor 23 (FGF-23). Increased FGF-23 plasma levels are observed with a decrease in kidney function and predict the risk of future cardiovascular mortality. However, clinical data are still unclear about whether a direct pathogenetic effect of FGF-23 on vascular/kidney/bone health exists. In the last few years, a series of basic science studies, performed using engineered mice, have contributed important pathophysiologic information about FGF-23 activities. This review summarizes findings from these studies and discusses the potential role of FGF-23 during the pathologic interplay between kidney, vessels, and bone in CKD
Risk factors for intracranial hemorrhage during vitamin K antagonist therapy in patients with nonvalvular atrial fibrillation: A case-control study
No full textShift in relative contribution of radial and longitudinal mechanics to right ventricular ejection fraction between normal subjects and patients with pulmonary hypertension
No full textComprehensive analysis of left ventricular geometry and function by three-dimensional echocardiography in healthy adults
Full text linkBACKGROUND: Recent European Association of Echocardiography and American Society of Echocardiography guidelines on three-dimensional echocardiography state that normal values of left ventricular (LV) parameters for age and body size remain to be established.
METHODS: In 226 consecutive healthy subjects (125 women; age range, 18-76 years), comprehensive three-dimensional echocardiographic analyses of LV parameters were performed, and values were compared with those obtained by conventional echocardiography.
RESULTS: Upper reference values (mean+ 2 SDs) for three-dimensional LV end-diastolic and end-systolic volumes were 85 and 34 mL/m(2) in men and 72 and 28 mL/m(2) in women, respectively. Indexing LV volumes to body surface area did not eliminate gender differences. Lower reference values (mean - 2 SDs) for ejection fraction were 54% in men and 57% in women and for stroke volume were 25 and 24 mL/m(2), respectively. Upper reference values for LV mass were 97 g/m(2) in men and 90 g/m(2) in women and for end-diastolic sphericity index were 0.49 and 0.48, respectively. Significant age dependency of LV parameters was identified and reported across age groups. Three-dimensional echocardiographic LV volumes were larger, ejection fraction was similar, and LV stroke volume and mass were significantly smaller in comparison with the corresponding values obtained by conventional echocardiography.
CONCLUSIONS: The investigators report a comprehensive analysis of LV geometry and function using three-dimensional echocardiography in a relatively large cohort of healthy Caucasian subjects with a wide age range. These may serve to establish age-specific and gender-specific reference ranges, which are crucial for the routine implementation of three-dimensional echocardiography to detect LV remodeling and dysfunction in clinical practice
Do a vendor-specific and a vendor-independent software for 3D echocardiographic analysis provide similar values for left ventricular volumes and ejection fraction?
No full textPurpose: Intervendor differences of 2D/3D strain measurements are well known issues that significantly limit their adoption in clinical routine. Whether a similar discordance affects also the quantitation of left ventricular (LV) geometry and function and the LV normative ranges for different 3D echo softwares has not been investigated.
Methods: Full-volume LV 3D data sets (35±6 vps) have been acquired in 235 healthy volunteers (44±14 years, range 18–76 years, 104 men) using a GE Vivid E9 scanner. Exclusion criteria were athletic training, pregnancy, body mass index > 30 kg/m2, and poor apical acoustic window. An experienced researcher analyzed all LV data sets using a vendor-specific software (EchoPac BT12, GE Healthcare, N). Three months later, the same researcher repeated the analysis with a vendor-independent DICOM-based software (4D LV Analysis 3.1, TomTec, D), being blinded from previous measurements.
Results: Despite the differences in LV parameters obtained with the two softwares were statistically significant (Table), Bland-Altman analysis shows a clinically irrelevant bias and reasonable limits of agreement for LV volumes and EF. LV mass measurements by EchoPac were slightly larger than those by TomTec and had relatively wider limits of agreement than LV volumes. Both softwares showed significant and consistent relationships of LV 3D parameters with age, gender and body size in healthy subjects (p<0.0001 for all relationships).
Conclusion: Our data shows that converting 3D data sets in DICOM format does not significantly affect the normative values for LV volumes and ejection fraction with respect to those provided by proprietary software. The availability of vendor-independent softwares and respective normative values will encourage the adoption of 3D echocardiography for routine LV quantitation in multi-vendor echo labs
Reasons and Consequences of Vitamin K Antagonists Discontinuation in Very Elderly Patients with Non-Valvular Atrial Fibrillation
No full textAnticoagulation in elderly patients with non-valvular atrial fibrillation (NVAF) is still a challenge and suspension of warfarin is common. Aim of this study is to analyse the aspects related to warfarin discontinuation in a real world population.This was an observational cohort study on Very Elderly NVAF patients naïve to warfarin therapy (VENPAF). Included subjects were at least 80 years old and started warfarin after NVAF diagnosis. Warfarin discontinuation was assessed and reason reported for discontinuation, person who decided to stop treatment, subsequent antithrombotic therapy and mortality, ischemic and bleeding events were collected.
During five years, 148 of 798 patients discontinued warfarin. Despite similar CHA2 DS2 -VASc score, thromboembolic and major bleeding events were significantly higher (p=0.01 and p=0.001, respectively) and time in therapeutic range (TTR) significantly lower (p<0.001) in patients who discontinued warfarin. Independent risk factors for warfarin discontinuation were vascular disease (HR 2.5, p<0.001), 85 years of age or older (HR 1.4, p=0.04), TTR <60% (HR 1.8, p=0.001) and bleeding events (HR 2.3, p<0.001). Main reasons for warfarin discontinuation were physician perceived frailty or low life expectancy (45.9%), bleeding complications (19.6%) and sinus rhythm restoration (16.9%). Event rate and deaths were very high especially in frail patients and in those with bleeding complications.
Discontinuation of warfarin is frequent in very elderly patients and is associated to increased risk of death and adverse events. Identification of elderly patients at high risk of bleeding and poor quality of anticoagulation during warfarin is still an unmet clinical problem
- …
