Crucial safety issues on Janus kinase inhibitors in rheumatoid arthritis might be associated with the lack of LDL-cholesterol management: a reasoned literature analysis

This point of view explores the safety concerns of Janus kinase inhibitors (JAK-Is), used in treating rheumatoid arthritis (RA) and other rheumatologic conditions. Increasing evidence shows that JAK-Is may elevate the risk of venous thromboembolism (VTE), especially pulmonary embolism. This fact has prompted the European Medicines Agency to advise cautious use of these drugs in patients over 65, smokers, and those at risk of cardiovascular issues or cancer. The paper analyses the evidence on the association between VTE risk and RA and whether different JAK-Is pose different risks. It also probes the link between VTE, lipids, and JAK inhibition, noting that JAK-Is can alter HDL and LDL levels. On the other hand, some evidence indicates that tighter LDL-cholesterol control could mitigate VTE risk, particularly pulmonary embolism. Moreover, data from trials show little attention to treating this main cardiovascular and VTE risk factor in rheumatological patients. Although the lipid paradox theory emphasizes the U-shaped relationship between LDL cholesterol and cardiovascular risk in patients with RA, uncontrolled levels of clinically relevant LDL cholesterol remain closely linked to cardiovascular and VTE risk. In conclusion, high-potency statins could help to manage the increased cardiovascular and VTE risk concomitant to JAK-Is treatment in rheumatologic patients without depriving them of the best therapeutic choice and, in addition, reducing the inherent risk associated with the disease.

Initiation and development of a percutaneous left atrial appendage closure programme: A French centre's experience and literature review

BACKGROUND

Percutaneous left atrial appendage closure may be considered in selected patients with atrial fibrillation at significant risk of both thromboembolism and haemorrhage.

AIMS

To report the experience of a tertiary French centre in percutaneous left atrial appendage closure and to discuss the outcomes compared with previously published series.

METHODS

This was a retrospective observational cohort study of all patients referred for percutaneous left atrial appendage closure between 2014 and 2020. Patient characteristics, procedural management and outcomes were reported, and the incidence of thromboembolic and bleeding events during follow-up were compared with historical incidence rates.

RESULTS

Overall, 207 patients had left atrial appendage closure (mean age 75.3±8.6 years; 68% men; CHA₂DS₂-VASc score 4.8±1.5 ; HAS-BLED score 3.3±1.1), with a 97.6% (n=202) success rate. Twenty (9.7%) patients had at least one significant periprocedural complication, including six (2.9%) tamponades and three (1.4%) thromboembolisms. Periprocedural complication rates decreased from earlier to more recent periods (from 13% before 2018 to 5.9% after; P=0.07). During a mean follow-up of 23.1±20.2 months, 11 thromboembolic events were observed (2.8% per patient-year), a 72% risk reduction compared with the estimated theoretical annual risk. Conversely, 21 (10%) patients experienced bleeding during follow-up, with almost half of the events occurring during the first 3 months. After the first 3 months, the risk of major bleeding was 4.0% per patient-year, a 31% risk reduction compared with the expected estimated risk.

CONCLUSION

This real-world evaluation emphasizes the feasibility and benefit of left atrial appendage closure, but also illustrates the need for multidisciplinary expertise to initiate and develop this activity.

Investigation of Stroke Risk Factors and Prognostic Indicators in NVAF Patients with Low CHA2DS2-VASc Scores

The prognosis of patients with nonvalvular atrial fibrillation (NVAF) with a low CHA2DS2-VASc score (0-1) following a stroke is not well studied. In this investigation, stroke risk factors and prognostic markers in low-risk NVAF patients who are nonetheless at risk for stroke were examined.From January 2012 to January 2022, we retrospectively assessed atrial fibrillation (AF) patients at Xiamen University's Zhongshan Hospital for ischemic stroke. Along with a control group of patients with CHA2DS2-VASc scores of 0-1 who weren't suffering from a stroke, patients with CHA2DS2-VASc scores of 0-1 at the time of stroke were included in the study. Using multivariate logistic regression, independent risk factors were identified. To assess the cumulative occurrences of in-hospital mortality in patients with NVAF-related stroke, the Kaplan-Meier method was used.The study included 156 out of 3.237 inpatients with AF-related stroke who had CHA2DS2-VASc ratings of 0-1. Left atrial diameter (LAD) (odds ratio [OR]: 1.858, 95% confidence interval (CI) 1.136-3.036, P = 0.013), D-dimer (OR: 2.569, 95% CI 1.274-5.179, P = 0.008), and NT-proBNP (OR: 4.558, 95% CI 2.060-10.087, P = 0.000) were found to be independent risk factors for stroke in NVAF patients with a low CHA2DS2-VASc score. During hospitalization, nine patients with NVAF-related stroke died. In patients with NVAF-related stroke, NT-proBNP (hazard ratio: 3.504, 95% CI 1.079-11.379, P = 0.037) was an indicator of mortality risk.Patients with NVAF and CHA2DS2-VASc scores of 0-1 had independent risk factors for stroke in the form of LAD, D-dimer, and NT-proBNP. Notably, in low-risk NVAF patients with stroke, NT-proBNP was discovered to be a potent predictor of in-hospital death.

Patient motivation and adherence to an on-demand app-based heart rate and rhythm monitoring for atrial fibrillation management: data from the TeleCheck-AF project

AIMS

The aim of this TeleCheck-AF sub-analysis was to evaluate motivation and adherence to on-demand heart rate/rhythm monitoring app in patients with atrial fibrillation (AF).

METHODS AND RESULTS

Patients were instructed to perform 60 s app-based heart rate/rhythm recordings 3 times daily and in case of symptoms for 7 consecutive days prior to teleconsultation. Motivation was defined as number of days in which the expected number of measurements (≥3/day) were performed per number of days over the entire prescription period. Adherence was defined as number of performed measurements per number of expected measurements over the entire prescription period.Data from 990 consecutive patients with diagnosed AF [median age 64 (57-71) years, 39% female] from 10 centres were analyzed. Patients with both optimal motivation (100%) and adherence (≥100%) constituted 28% of the study population and had a lower percentage of recordings in sinus rhythm [90 (53-100%) vs. 100 (64-100%), P < 0.001] compared with others. Older age and absence of diabetes were predictors of both optimal motivation and adherence [odds ratio (OR) 1.02, 95% coincidence interval (95% CI): 1.01-1.04, P < 0.001 and OR: 0.49, 95% CI: 0.28-0.86, P = 0.013, respectively]. Patients with 100% motivation also had ≥100% adherence. Independent predictors for optimal adherence alone were older age (OR: 1.02, 95% CI: 1.00-1.04, P = 0.014), female sex (OR: 1.70, 95% CI: 1.29-2.23, P < 0.001), previous AF ablation (OR: 1.35, 95% CI: 1.03-1.07, P = 0.028).

CONCLUSION

In the TeleCheck-AF project, more than one-fourth of patients had optimal motivation and adherence to app-based heart rate/rhythm monitoring. Older age and absence of diabetes were predictors of optimal motivation/adherence.

Elevated plasma Ninjurin-1 levels in atrial fibrillation is associated with atrial remodeling and thromboembolic risk

BACKGROUND

Nerve injury-induced protein 1 (Ninj1) is elevated in various inflammatory diseases. The soluble form of Ninj1 yield by matrix metalloproteinase cleavage is a secreted protein and inhibits cell adhesion and inflammation. However, the role of plasma Ninj1 in atrial fibrillation (AF) has not been reported. The present study aimed to investigate the correlation between plasma Ninj1 levels and AF.

METHODS

A total of 96 AF patients [age 66.00 (60.00, 72.00) years, male 56 (58.33%)] and 51 controls without AF [age 65.00 (55.00, 68.00) years, male 21 (41.18%)] were enrolled in this study. Plasma Ninj1 concentrations were detected using enzyme-linked immunosorbent assay. Also, the clinical characteristics, left atrial volume index (LAVI), CHA2DS2-VASc score, and HAS-BLED score were evaluated.

RESULTS

Plasma Ninj1 levels were significantly higher in patients with AF than in controls (P < 0.001). Plasma Ninj1 levels were positively correlated with LAVI (P = 0.019) and CHA2DS2-VASc score (P = 0.024). Logistic regression analysis confirmed that the Ninj1 plasma levels were associated with AF (P = 0.009). The receiver operating characteristic analysis showed that plasma Ninj1 had a predictive value for AF (P < 0.001).

CONCLUSIONS

Plasma Ninj1 levels were elevated in patients with AF, associated with left atrial enlargement and thromboembolic risk in AF.

Giant aneurysm of the left atrial appendage: A case report of a rare cause of dyspnea in a 55-year old woman

Introduction

Congenital aneurysm of the left atrial appendage (LAAA) is a very rare heart with potentially serious and life-threatening complications. Diagnosis is difficult because of the asymptomatic forms, until complications arise. Early surgery is the treatment of choice, but the recommendation today remains unclear.

Case report

We present a case of congenital giant left atrial appendage aneurysm (LAAA), in a 55-year-old, woman, without any medical or surgical history, who presented with dyspnea, in whom transthoracic echocardiograhpy demonstrated the presence of a giant left atrial aneurysm with thickening of the small mitral valve, a chest scan confirmed the diagnosis of LAAA and a myocardial magnetic resonance imaging revealed the presence of thickened mitral valve with bi-valvular balloonization and annular disjunction, thickening of the basal segments of the inferior and lateral wall, left atrial aneurysm with a dilated right coronary artery. Coronary angiography showed a tortuous coronary artery with a loop in the second segment without any significant stenosis. The patient is currently awaiting surgery.

Conclusion

Left atrial appendage aneurysm is a serious illness will likely require years of medical care and follow up in the absence of surgical treatment. The choice and timing of surgical, conservative or catheter treatment always remains a challenge. Our case report shows that medical treatment is a safe approach that will delay or avoid surgery.

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Left atrial appendage aneurysm is extremely rare.

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Asymptomatic, congenital or acquired.

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The prognosis depends greatly on early diagnosis and prompt medical and surgical treatment.

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The diagnosis is a real challenge.

[Tranexamic acid for bleeding prophylaxis in orthopedic surgery and trauma-standard or customized therapy?]

The use of tranexamic acid (TXA) is established in the treatment of bleeding, especially of bleeding due to hyperfibrinolysis. In recent years the prophylactic use of TXA in trauma and orthopedic surgery has increased leading to open questions regarding potentially associated risks and a possible classification as off label use. The available literature provides a sound basis for the recommendation that TXA can be used in these indications provided that an individual risk assessment is done in patients with increased risks for thromboembolic complications. Although the prophylactic use of TXA in orthopedic surgery and trauma is not explicitly listed in the product characteristics, it should not be regarded as an off label use.

Identifying patients with atrial fibrillation with a single CHA2DS2-VASC risk factor who are at higher risk of stroke

AIMS

Management of patients with a single CHA₂DS₂-VASc score risk factor is controversial. We attempt to identify the "truly low risk" AF patients who will not benefit from oral anticoagulation (OAC) treatment.

METHODS

Retrospective cohort analysis, all incident non-valvular AF (NVAF) cases between 2004 and 2015, and age 21 and older, with up to one thromboembolic risk factor besides sex (CHA₂DS₂-VASc score of up to 1 for men and up to 2 for women). A "low risk" score was created for these patients using a logistic regression model on the incidence of stroke within 30-2500 days following the NVAF diagnosis.

RESULTS

We identified 15,621 patients. Average age was 53.7 ± 12.3 years, 56.6% male. Mean follow-up was 5.5 years. Significant predictors of ischemic stroke were age 65-74 and diabetes (2 points each), hypertension, vascular disease, and chronic kidney disease stage 2-3 (1 point each). Stroke incidence ranged from 0.8% for score 0 and up to 3.4% for scores ≤ 2. Odds ratio for stroke among patient group with a score ≤ 2 was 4.3 (2.9-6.6) compared with score 0. Our risk score's area-under-the-curve (AUC) for prediction of stroke was 0.68 (0.65-0.71), compared with 0.60 (0.57-0.62) for the CHAD₂S₂-VASc score, within this low-risk group.

CONCLUSION

Patients considered at low or intermediate risk using traditional risk stratification schemes, with ≥ 2 points using this proposed low-risk index (65-74 years old, diabetics or a combination of chronic renal failure and an additional risk factor), had an overall stroke risk that may justify anticoagulation therapy.

Platelet Inhibition and Anticoagulation in Visceral Interventions

Background

Platelet inhibition and anticoagulation are widely used therapeutic approaches in many patients. Despite their undoubted cardiovascular benefits, they may cause gastrointestinal harm either spontaneously or as part of endoscopic procedures. Strategies which harmonize both aspects are, therefore, of clinical interest.

Method

The websites of the German (DGVS), European (ESGE), and American (ASGE) Societies of Gastroenterology and Endoscopy were searched for guidelines on antithrombotic agents and endoscopic procedures. Over and beyond this, PubMed was analyzed for originals and reviews by using the keywords "hemostasis affecting drugs," "antithrombotic drugs," "platelet inhibition," "anticoagulation," AND endoscopy.

Conclusion

If elective endoscopy is planned, we should consider postponing the procedure in cases of temporally restricted platelet inhibition therapy or anticoagulation. Urgent endoscopy must balance the procedural risk against the risk of continuing or stopping the medication, with respect to thromboembolic events on the one hand and gastrointestinal bleeding on the other. There are decision criteria which facilitate individual risk stratification as a basis for diagnostic and therapeutic algorithms.

Key Message

If endoscopic interventions under platelet inhibition and/or anticoagulation cannot be postponed for a limited period of time, diagnostic and therapeutic strategies have to be performed against the background of well-defined decision criteria. These include the procedural risk (low vs. high) and the risk of thromboembolic events occurring (low vs. high) if the medication is stopped. In cases where both risks are considered to be high, an interdisciplinary approach should be favored.

Metastasectomy of left atrial mesenchymal chondrosarcoma

Metastasis of chondrosarcoma of skeletal origin to the heart is uncommonly reported in the literature, with the majority of cases involving right atrial metastases. Surgical resection remains the mainstay of treatment, and the literature has shown improved median survival with this form of therapy, possibly by reducing thromboembolic risk in this patient population. We report the case of a patient with metastatic mesenchymal chondrosarcoma of the left atrium who underwent resection, following a lack of response to anticoagulation therapy. This is the first report of surgical resection of left atrial metastatic disease prior to the onset of thromboembolic sequelae.

Obesity and hormonal contraception: an overview and a clinician's practical guide

BACKGROUND

The growing prevalence of obesity among the fertile female population poses a considerable problem to contraceptive providers. Obese women, who are more at risk for venous thromboembolism and cardiovascular events due to their condition, might be at an even higher risk of developing thromboembolic events when on medical contraception. Combined hormonal contraceptives might be less effective in obese women and may lead to unacceptable metabolic side effects for this population. In addition, the lack of safety data for weight loss drugs and the higher risk for complications during and after pregnancy require a close surveillance of the fertility status of obese patients.

OBJECTIVE

The aim of this narrative review is to summarize the available medical contraceptive options and to give the readers a practical guidance for a wise contraceptive choice with regards to obesity.

METHODS

A general literature review of peer-reviewed publications on the topic "obesity and contraception" was performed using the PubMed database.

RESULTS

Nowadays, there are many useful tools that help clinicians in choosing among the wide range of therapeutic possibilities, such as the World Health Organization (WHO) Medical Eligibility Criteria for contraceptive use. Furthermore, the great diversity of hormonal contraceptive formulations (combined hormonal formulations; progestin-only methods) and active substances (different estrogens and progestins) allow physicians to tailor therapies to patients' clinical peculiarities.

CONCLUSION

Long-acting reversible contraceptives [progestin-only implants, levonorgestrel-intra-uterine devices (IUDs) and copper IUDs] and progestin-only methods in general are excellent options for many categories of patients, including obese ones.

LEVEL OF EVIDENCE

V, narrative review.

COVID-19 associated atrial fibrillation: Incidence, putative mechanisms and potential clinical implications

Coronavirus disease 2019 (COVID-19) is a novel, highly transmittable and severe strain disease, which has rapidly spread worldwide. Despite epidemiological evidence linking COVID-19 with cardiovascular diseases, little is known about whether and how COVID-19 influences atrial fibrillation (AF), the most prevalent arrhythmia in clinical practice. Here, we review the available evidence for prevalence and incidence of AF in patients infected with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and discuss disease management approaches and potential treatment options for COVID-19 infected AF patients.

How to manage thromboembolic risk in patient with SARS-CoV-2-related disease in the Emergency Department: A case report of cardiogenic shock due to massive pulmonary embolism

BACKGROUND

Although the most known feature of SARS-CoV-2 associated infection is a mild to severe pneumonia, increasing evidence suggests the existence of an infection-associated risk of both arterial and venous thromboembolism (VTE), but the exact magnitude of this phenomenon is still unknown.Given that, it is important for the Emergency Physician to remember that a SARS-CoV-2 associated respiratory failure can be caused not only by the pulmonary parenchymal inflammation that characterizes the pneumonia, but also by an associated pulmonary thromboembolism.

CASE REPORT

A healthy 73-years old woman admitted to the ED for dyspnea, fever and thoracic pain. Cardiac ultrasound, electrocardiogram and clinical findings suggested a diagnosis of cardiogenic obstructive shock due to acute pulmonary embolism, successfully treated with thrombolysis. A CT angiography confirmed the pulmonary embolism (EP) diagnosis and showed bilateral pneumonia, caused by SARS-CoV-2 infection.

CONCLUSION

Considering the high prevalence of thromboembolic events in COVID-19 patients it is mandatory for the emergency physician to systematically evaluate signs of pulmonary thromboembolism, in order to perform the most patient-tailored therapy as soon as possible.

Sex-related differences in prevalence, treatment and outcomes in patients with atrial fibrillation

To analyze sex-related differences about AF prevalence, use of OAC and outcomes focusing on the older age classes. We used administrative data of the Lombardy Region, describing period prevalence, use of OAC and outcomes from 2002 to 2014 for all patients diagnosed with AF. AF prevalence over the 2002-2014 period was higher in males than in females (2.7% vs. 2.1%, p < 0.001), increasing with age. From 2003 to 2014, not treated AF patients decreased mostly in males (from 40.3 to 33.7% with respect to 43.7-39.8% in females). Age-stratified adjusted logistic regression analysis found that females were more likely treated with OAC when < 65 years in 2003 (OR 1.51, 95% CI 1.35-1.69) and in 2014 (OR 1.32, 95% CI 1.13-1.53); contrariwise, were less likely treated with OAC when age ≥ 75 years, in 2003 (OR 0.92, 95% CI 0.86-0.98) and in 2014 (OR 0.77, 95% CI 0.72-0.81).Adjusted Cox regression analysis confirmed that female AF patients had a higher risk of stroke (HR 1.18, 95% CI 1.14-1.21) and a lower risk of major bleeding (HR 0.83, 95% CI 0.80-0.86), while, had a lower risk for all-cause death (HR 0.82, 95% CI 0.80-0.83). AF prevalence was higher in male than in female patients, while thromboembolic risk was higher in female. Older female patients were under-treated with OAC particularly in recent years. Over long-term follow-up, female had a higher risk of stroke and a lower risk of major bleeding and all-cause death.

Is anticoagulant therapy always indicated in "medium-risk" patients with first diagnosed atrial fibrillation? Insights from a real world, 10-year observational study

BACKGROUND

The choice of antithrombotic prophylaxis in the so-called "medium-risk" patients (i.e., CHA₂DS₂-VASc score = 1 in males or 2 in females) is one of the major enigmatic issues in clinical management of atrial fibrillation (AF).

METHODS

We retrospectively evaluated 30-day and 1-year thromboembolic events in all consecutive medium-risk patients visited for first diagnosed AF in the local Emergency Department during a 10-year period. The main aim was to establish whether anticoagulant or antiplatelet therapy was effective to lower the thromboembolic risk in patients receiving these drugs. Bleeding events, related to anticoagulant or antiplatelet therapy, was defined as secondary end point.

RESULTS

The final study population consisted of 6389 (3640 males and 2749 females) patients for whom a complete dataset regarding targeted follow-up was available. Patients were then subdivided into two subgroups, according to performance of cardioversion and spontaneous sinus rhythm restoring. In both genders, no significant difference in thromboembolic or bleeding events was noted between patients who underwent cardioversion and were discharged with oral anticoagulant therapy or antiplatelet treatment versus those who were not treated with antithrombotic drugs. Moreover, no difference was also observed in thromboembolic or hemorrhagic event rate between low risk and "medium-risk" patients.

CONCLUSIONS

The results of this study suggest that anticoagulant or antiplatelet therapy would not produce clinical benefits in "medium-risk" AF patients.

Gender differences and management of stroke risk of nonvalvular atrial fibrillation in an upper middle-income country: Insights from the CARMEN-AF registry

BACKGROUND

Atrial Fibrillation (AF) is associated with an increased risk of stroke and systemic embolism. Several studies have suggested that female AF patients could have a greater risk for stroke. There is scarce information about clinical characteristics and use of antithrombotic therapies in Latin American patients with nonvalvular AF.

OBJECTIVE

To describe the gender differences in clinical characteristics, thromboembolic risk, and antithrombotic therapy of patients with nonvalvular AF recruited in Mexico, an upper middle-income country, into the prospective national CARMEN-AF Registry.

METHODS

A total of 1423 consecutive patients, with at least one thromboembolic risk factor were enrolled in CARMEN-AF Registry during a three-year period (2014-2017). They were categorized according to Gender.

RESULTS

Overall, 48.6% were women, mean age 70 ± 12 years. Diabetes, smoking, alcoholism, non-ischemic cardiomyopathy, coronary artery disease, and obstructive sleep apnea were higher in men. Most women were found with paroxysmal AF (40.6%), and most men with permanent AF (44.0%). No gender differences were found in the use of vitamin K antagonists (VKA) (30.5% in women vs. 28.0% in men). No gender differences were found in the use of direct oral anticoagulants (DOAC) (33.8% women vs 35.4% men).

CONCLUSIONS

CARMEN-AF Registry demonstrates that in Mexico, regardless of gender, a large proportion of patients remain undertreated. No gender differences were found in the use of VKA or DOAC.

Combined use of antifibrinolytics and activated prothrombin complex concentrate (aPCC) is not related to thromboembolic events in patients with acquired haemophilia A: data from FAIR Registry

Antifibrinolytics combined with aPCC are not routinely administered to patients with acquired hemophilia A due to increased thrombotic risk. This association normalizes clot stability, and improves the efficacy of therapy, but can increase the risk of severe side effects. Due to these premises it has always raised doubts and perplexities in the clinics. We now report the data of the "FEIBA® on acquired haemophilia A Italian Registry (FAIR Registry)", a retrospective-prospective study that included 56 patients. This is the first study that assessed the clinical response of the combination of aPCC and antifibrinolytic agents in patients with acquired haemophilia A. A total of 101 acute bleeds were treated with aPCC. Antifibrinolytic agents were used in the treatment of 39.6% of total bleeds, based on both, a clinical assessment and an evaluation of bleeding. Twenty-five of the 30 patients (57.1%) treated with antifibrinolytic drugs showed serious co-morbidity. Among them, 40% presented severe cardiovascular diseases. All bleeds treated with combined therapy had a shorter duration of treatment (mean reduction 16.3%). All the treated patients presented a good tolerability and no arterial or venous thromboembolic events were reported. In our retrospective registry the combination of antifibrinolytics and aPCC appears safe and effective in the treatment of patients with AHA, especially in the case of severe and life-threatening bleeding, but this hypothesis needs to be confirmed in adequate, larger clinical trials.

Increased burden of comorbidities and risk of cardiovascular death in atrial fibrillation patients in Europe over ten years: A comparison between EORP-AF pilot and EHS-AF registries

BACKGROUND

In 2002, the European Society of Cardiology conducted the Euro Heart Survey (EHS), while in 2014concluded 1-year follow-up of the EURObservational Research Programme AF (EORP-AF) Pilot Registry.

METHODS

We analysed differences in clinical profiles, therapeutic approaches and outcomes between these two cohorts after propensity score matching (PSM).

RESULTS

After PSM, 5206 patients were analysed. In EORP-AF there were more elderly patients than EHS (p < .001). EORP-AF patients were more burdened with cardiovascular (CV) and non-CV comorbidities, with a higher proportion of patients with high thromboembolic risk. EORP-AF patients used more oral-anticoagulant (OAC) (p < .001). At 1-year follow-up EORP-AF patients had lower risk for thromboembolic and CV events, readmission for AF and other CV reasons (all p < .001), showing conversely a higher risk for CV death (p = .015). Kaplan-Meier curves showed that EORP-AF patients had higher risk for CV death (p < .0001) and all-cause death (p = .0019). Cox regression confirmed that EORP-AF patients were at higher risk for CV death (p = .021).

CONCLUSIONS

We found significant changes in AF epidemiology over a decade in Europe, with older patients, more burdened with comorbidities. A greater use of OAC was found. Despite a reduction in risk for thromboembolic events, a high risk of CV-related death was still evident.

The Role of Nonalcoholic Fatty Liver Disease on Cardiovascular Manifestations and Outcomes

Cardiovascular disease has been postulated as the leading cause of mortality among patients with nonalcoholic fatty liver disease (NAFLD), rather than from sequalae of liver disease specifically. While there is ample evidence validating the association between NAFLD and increased cardiovascular comorbidities, events, and mortality, current data presents a challenge in attributing this effect solely due to NAFLD given the rampant presence of insulin resistance and type 2 diabetes mellitus (T2DM). Endpoints of increased cardiovascular risk remains tightly linked to the concomitant presence of insulin resistance and T2DM. Prospective studies accentuating early detection of NAFLD are imperative to institute early intervention and prevent future cardiovascular events.

Atrial high-rate episodes and stroke prevention

While the benefit of oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation (AF) is well established, it is not known whether oral anticoagulation is indicated in patients with atrial high-rate episodes (AHRE) recorded on a cardiac implantable electronic device, sometimes also called subclinical AF, and lasting for at least 6 min in the absence of clinically diagnosed AF. Clinical evidence has shown that short episodes of rapid atrial tachycarrhythmias are often detected in patients presenting with stroke and transient ischaemic attack. Patients with AHRE have a higher likelihood of suffering from subsequent strokes, but their stroke rate seems lower than in patients with diagnosed AF, and not all AHRE episodes correspond to AF. The prognostic and pathological significance of AHRE is not yet fully understood. Clinical trials of OAC therapy are being conducted to determine whether therapeutic intervention would be beneficial to patients experiencing AHRE in terms of reducing the risk of stroke.

Major Outcomes in Atrial Fibrillation Patients with One Risk Factor: Impact of Time in Therapeutic Range Observations from the SPORTIF Trials

BACKGROUND

The benefits and harms of oral anticoagulation therapy in patients with only one stroke risk factor (ie, CHA2DS2-VASc = 1 in males, or 2 in females) has been a subject of debate.

METHODS

We analyzed all patients with only one stroke risk factor from the merged datasets of SPORTIF III and V trials. Anticoagulation control was defined according to time in therapeutic range (TTR).

RESULTS

Of the original trial cohort, 1097 patients had only one stroke risk factor. Stroke/systemic thromboembolic event had an incidence of 0.9 per 100 patient-years, with an incidence of 1.6 per 100 patient-years for all-cause death and 2.3%/patient-years for the composite outcome of stroke/systemic thromboembolic event/all-cause death. There were no significant differences in the risk for stroke/systemic thromboembolic event between sexes, nor between the different stroke risk factors amongst these atrial fibrillation patients with only one stroke risk factor. Cox regression analysis in patients treated with warfarin found only TTR to be inversely associated with stroke/systemic thromboembolic event (P = .034) and all-cause death (P = .015). Chronic heart failure was significantly associated with the outcome of all-cause death (P = .0019) and the composite outcome of stroke/systemic thromboembolic event/all-cause death (P = .021). There was a significant inverse linear association between TTR and the cumulative risk for both stroke/systemic thromboembolic event and all-cause death (both P <.001).

CONCLUSIONS

In atrial fibrillation patients with only one additional stroke risk factor (ie, CHA2DS2-VASc = 1 in males or 2 in females), rates of major adverse events (stroke/systemic thromboembolic event, mortality) were high, despite anticoagulation. TTR in warfarin-treated patients was inversely associated with the occurrence of both stroke/systemic thromboembolic event and all-cause death.

Device-identified atrial fibrillation at pacing clinics. Should it guide anticoagulation?

In recent years, there has been a significant increase in the number of devices implanted following improvement in their safety profile, extension of indications and reduction in cost. Although the reason remains largely the beneficial effect on heart rhythm stabilisation, implanted devices might also have additional advantages, notably identification of silent arrhythmia. Should clinicians therefore act on device-identified atrial fibrillation (AF) and should such identification be used to guide anticoagulation management? This review evaluates the current evidence on the management of device-identified asymptomatic AF.

Net Clinical Benefit of Non-vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Phase III Atrial Fibrillation Trials

OBJECTIVES

The evaluation of the "net clinical benefit" allows an integrated assessment of both the anti-ischemic and the prohemorrhagic effects of non-vitamin K antagonist oral anticoagulants compared with warfarin, and—in the absence of direct comparisons—may inform clinical decisions. We estimated the net clinical benefit of non-vitamin K antagonist oral anticoagulants versus warfarin across the 4 phase III clinical trials performed in patients with atrial fibrillation.

METHODS

We considered various composites of the main ischemic and hemorrhagic events, estimating the rate ratio of all treatment groups versus warfarin for each composite outcome. Because the clinical relevance of the various ischemic or hemorrhagic events is not identical, we then attributed to each of them a weight, according to its impact on death, as derived from previous studies. We evaluated a weighed net clinical benefit of each non-vitamin K antagonist oral anticoagulant compared with warfarin in the 4 trials.

RESULTS

The composite outcome of ischemic + hemorrhagic stroke was reduced by dabigatran 150 mg and apixaban. The composite of disabling stroke + life-threatening bleeding was reduced by all non-vitamin K antagonist oral anticoagulants. The composite of ischemic stroke + systemic embolism + myocardial infarction + hemorrhagic stroke + major bleeding was reduced by apixaban and edoxaban at both doses. By attributing weights to these events according to their impact on mortality, all non-vitamin K antagonist oral anticoagulants featured a favorable net clinical benefit compared with warfarin, albeit to a quantitatively different extent.

CONCLUSIONS

The choice of the proper antithrombotic treatment in patients with atrial fibrillation has to consider the net clinical benefit of each drug. However, all non-vitamin K antagonist oral anticoagulants have a better efficacy/safety profile than warfarin in patients with atrial fibrillation.

The safety and efficacy of antithrombotic therapy in patients undergoing cardiac rhythm device implantation: a meta-analysis

AIMS

The meta-analysis was to assess the safety and efficacy of periprocedural antithrombotic therapy and to evaluate the risk factors potentially associated with bleeding among patients undergoing cardiac implantable electronic devices implantations.

METHODS AND RESULTS

A systematic literature search of PubMed, EMBASE, and Cochrane Controlled Trials Register was performed. Anticoagulation and antiplatelet therapies were assessed separately. Uninterrupted anticoagulation was associated with significant lower bleeding risk compared with heparin bridging strategy [odds ratio (OR) = 0.31, 95% confidence interval (CI) 0.18-0.53, and P < 0.0001], but there was no significant difference in thromboembolic risk between these two strategies (OR = 0.82, 95% CI 0.32-2.09, and P = 0.65). The haematoma rate was significantly increased in dual antiplatelet therapy group (OR = 6.84, 95% CI 4.16-11.25, and P < 0.00001), but not in single antiplatelet therapy (OR = 1.52, 95% CI 0.93-2.46, and P = 0.09). Clopidogrel increased the risk of haematoma vs. aspirin (OR = 2.91, 95% CI 1.27-6.69, and P = 0.01). Otherwise, a lower risk of haematoma was observed in pacemaker group vs. cardiac resynchronization therapy and/or implantable cardioverter defibrillator group (OR = 0.64, 95% CI 0.50-0.82, and P = 0.0004).

CONCLUSION

This meta-analysis suggested that uninterrupted oral anticoagulation seems to be the better strategy, associated with a lower risk of bleeding complications rather than heparin bridging, and dual antiplatelet therapy carried a significant risk of bleeding whereas single antiplatelet therapy was relatively safe among patients undergoing cardiac implantable electronic devices implantations. Meanwhile, cardiac resynchronization therapy and/or implantable cardioverter defibrillator implantations increase the bleeding.

[Retrospective study on bleeding and thromboembolic complications related to tooth extraction, in 93 patients usually treated by antithrombotic therapy]

INTRODUCTION

Tooth extraction for patients treated by AVK and/or platelet aggregation inhibitor is performed according to local habits rather than to a consensus. We had for objective to assess hemorrhagic and thromboembolic risks for patients for whom treatment with AVK and/or platelet aggregation inhibitor was modified before tooth extraction.

MATERIALS AND METHODS

Ninety-three patient files were examined retrospectively. The following data was collected: epidemiological data, ASA score, nature and changes of antithrombotic therapy, preoperative INR, number teeth extracted, postoperative complications (bleeding and thromboembolic events).

RESULTS

Thirty-seven patients were treated with oral anticoagulants, 41 by a platelet aggregation inhibitor, 10 by double platelet aggregation inhibitor therapy, and 5 by an AVK-platelet aggregation inhibitor combination. At D0, the mean INR was decreased to 1.4, 4 patients with high thromboembolic risk had received heparin relay treatment; the treatment was stopped for 9 of the 56 patients on monotherapy with antiplatelet therapy, 4 were switched from clopidogrel to lysine acetylate; clopidogrel was stopped for 7 patients under combination therapy. Seven hundred and twenty-six avulsions (mean 8.1 per patient) were performed, 41 patients presented with mild/moderate bleeding, easily resolved. A patient presented with delayed hemorrhage at D6 (AVK overdose). No thromboembolic complication was reported.

DISCUSSION

The modification of antithrombotic treatment, as for surgery at high risk of bleeding, seems to limit the risk of bleeding without increasing thromboembolic risk.