ABSTRACT
In patients with nonvalvular atrial fibrillation (AF), the risk of stroke varies considerably according to individual clinical status. The CHA2DS2-VASc score is better than the CHADS2 score for identifying truly lower risk patients with AF. With the advent of novel oral anticoagulants (NOACs), the strategy for antithrombotic therapy has undergone significant changes due to its superior efficacy, safety and convenience compared with warfarin. Furthermore, new aspects of antithrombotic therapy and risk assessment of stroke have been revealed: the efficacy of stroke prevention with aspirin is weak, while the risk of major bleeding is not significantly different from that of oral anticoagulant (OAC) therapy, especially in the elderly. Reflecting these pivotal aspects, previous guidelines have been updated in recent years by overseas societies and associations. The Korean Heart Rhythm Society has summarized the new evidence and updated recommendations for stroke prevention of patients with nonvalvular AF. First of all, antithrombotic therapy must be considered carefully and incorporate the clinical characteristics and circumstances of each individual patient, especially with regards to balancing the benefits of stroke prevention with the risk of bleeding, recommending the CHA2DS2-VASc score rather than the CHADS2 score for assessing the risk of stroke, and employing the HAS-BLED score to validate bleeding risk. In patients with truly low risk (lone AF, CHA2DS2-VASc score of 0), no antithrombotic therapy is recommended, whereas OAC therapy, including warfarin (international normalized ratio 2-3) or NOACs, is recommended for patients with a CHA2DS2-VASc score > or =2 unless contraindicated. In patients with a CHA2DS2-VASc score of 1, OAC therapy should be preferentially considered, but depending on bleeding risk or patient preferences, antiplatelet therapy or no therapy could be permitted.
Subject(s)
Aged , Humans , Anticoagulants , Aspirin , Atrial Fibrillation , Heart , Hemorrhage , Patient Preference , Risk Assessment , Stroke , WarfarinABSTRACT
Metabolites isolated from Gelidiella species (Rhodophyta) have been few studied. We evaluated a sulfated polysaccharidic fraction from G. acerosa collected from two Brazilian beaches on the northwestern coast of Brazil (Flecheiras-F and Pedra Rachada-PR) on coagulation proteases and thrombosis. Their toxicity in vivo was also assessed. Enzymatic extractions yielded 1.40%, and similar chromatographic profiles (DEAE-cellulose) were obtained, with fractions (Ga-IâV) containing differences among the relative proportions of sulfate (5-42%), and revealing charge density patterns by electrophoresis. Ga-IV-PR had a discrete effect (3.01 IU mg-1) on normal human coagulation compared with heparin (193 IU mg-1) and was tested on coagulation proteases (thrombin and factor Xa) in the presence of antithrombin and in a model of venous thrombosis in rats using thromboplastin as the thrombogenic stimulus. The systems were inhibited; but at higher doses (>1.0 mg kg-1), this fraction reverted the antithrombotic effect. Regarding the toxicological study, consecutive Ga-IV (9 mg kg-1) for 14 days did not cause mortality in mice, but some biochemical and hematological parameters were discretely altered. Histopathological analysis revealed that increased liver and spleen sizes had no toxicological significance. Therefore, G. acerosa does not biochemically change its matrix polysaccharide composition and proved to be safe antithrombotic agent.
Poucos estudos mostram metabólitos isolados de rodofíceas de espécies Gelidiella. Avaliou-se uma fração polissacarídica sulfatada de G. acerosa coletada a partir de duas praias brasileiras do Nordeste do Brasil (Flecheiras-F e Pedra Rachada-PR) sobre proteases da coagulação e trombose, e em ensaio de toxicidade in vivo. Extrações enzimáticas renderam 1,40% e foram obtidos perfis cromatográficos semelhantes (DEAE-celulose), apresentando frações (Ga-IâV), contendo diferenças entre as proporções relativas de sulfato (5-42%), além de a eletroforese revelar diferenças na densidade de carga. A Ga-IV-PR apresentou discreto efeito (3,01 UI mg-1) sobre a coagulação humana normal comparada à heparina (193 UI mg-1) e foi testada sobre proteases da coagulação (trombina e fator Xa) na presença de antitrombina e em um modelo de trombose venosa em ratos usando tromboplastina com estímulo trombogênico, sendo inibidos esses sistemas. Entretanto, em elevadas doses (>1,0 mg kg-1) o efeito antitrombótico foi revertido. No estudo toxicológico, Ga-IV (9 mg kg-1) consecutiva durante 14 dias não causou mortalidade em camundongos, mas alterou discretamente alguns parâmetros bioquímicos e hematológicos. O aumento nos tamanhos do fígado e baço não apresentou significância toxicológica, segunda análise histopatológica. Portanto, G. acerosa não muda bioquimicamente a composição de polissacarídeo de sua matriz e detém agente antitrombótico seguro.