Riesgo de eventos embólicos en pacientes con miocardiopatía chagásica y fibrilación auricular a pesar de terapia antitrombótica: ¿es la anticoagulación suficiente? / Risk of Embolic Events in Patients with Chagasic Cardiomyopathy and Atrial Fibrillation Despite Antithrombotic Therapy: Is Anticoagulation Enough?

RESUMEN Introducción: La miocardiopatía chagásica (MC) difiere de otras causas de insuficiencia cardíaca en múltiples aspectos, destacándose el riesgo de embolias sistémicas. Sin embargo, pocos estudios han evaluado el riesgo de eventos embólicos en pacientes anticoagulados con MC en comparación con otras miocardiopatías. Objetivo: Nuestro objetivo fue analizar la incidencia de embolias sistémicas en una cohorte de pacientes anticoagulados con diagnóstico de fibrilación auricular (FA) con y sin MC. Material y métodos: Se realizó un estudio de cohorte retrospectivo en hospital de cuarto nivel en Colombia durante el periodo 2014-2020. Se incluyeron todos los pacientes con diagnóstico de miocardiopatía de cualquier etiología y FA que estuvieran en régimen de anticoagulación. El resultado primario fue la incidencia de eventos embólicos. Se realizó un análisis de supervivencia mediante modelos de riesgos proporcionales de Cox ajustados. Un valor de p <0,05 se consideró significativo. Todas las pruebas estadísticas fueron de dos colas. Resultados: Se evaluaron 149 pacientes anticoagulados con miocardiopatía (mediana de edad: 71 años; mujeres: 30,20%). La incidencia acumulada de eventos embólicos fue significativamente mayor en los pacientes con MC (17,50%) en comparación con aquellos con otras miocardiopatías (4,95%), a pesar de que estos últimos tenían una puntuación CHA2DS2-VASc significativamente mayor (p=0,013). Tras el análisis multivariado, los pacientes con MC tuvieron un riesgo significativamente mayor de eventos embólicos independientemente de la puntuación CHA2DS2-VASc y del tipo de anticoagulante prescrito (HR 5,65; IC 95% 1,46-21,83; p=0,012). Conclusiones: La MC se asoció con un riesgo significativamente mayor de eventos embólicos, a pesar del tratamiento anticoagulante en ambos grupos. Se requiere más investigación para comprender el origen de este riesgo observado y traducir este conocimiento en indicaciones específicas de anticoagulación para pacientes con MC.

ABSTRACT Background: Chagasic cardiomyopathy (CC) differs from other heart failure causes in multiple aspects, highlighting the risk of systemic embolisms. However, few studies have evaluated the risk of embolic events in anticoagulated patients with CC compared with other cardiomyopathies. Objective: We aimed to analyze the incidence of systemic embolisms in a cohort of anticoagulated patients diagnosed with atrial fibrillation (AF) with and without CC. Methods: A retrospective cohort study was carried out at a fourth level hospital in Colombia during the period 2014-2020. All patients diagnosed with cardiomyopathy of any etiology and AF, who were on an anticoagulation regimen were included. The primary outcome was the incidence of embolic events. A survival analysis was performed using adjusted Cox proportional hazard models. A p-value <0.05 was considered significant. All statistical tests were two-tailed. Results: A total of 149 anticoagulated patients with cardiomyopathy were evaluated (median age: 71 years; women: 30.20%). The cumulative incidence of embolic events was significantly higher in patients with CC (17.50%) compared with those presenting other cardiomyopathies (4.95%), despite that the latter had a significantly higher CHA2DS2-VASc score (p=0.013). After multivariate analysis, patients with CC had a significantly higher risk of embolic events regardless of the CHA2DS2-VASc score and the type of anticoagulant prescribed (HR 5.65; 95% CI 1.46-21.83; p=0.012). Conclusions: Chagasic cardiomyopathy was associated with a significantly higher risk of embolic events, despite anticoagulation therapy in both groups. More research is required to understand the origin of the risk observed in order to translate this knowledge into specific indications for anticoagulation in patients with CC.

Type 2 Diabetes Mellitus and Nonvalvular Atrial Fibrillation in Mexico: National Registries Raise a Red Flag

ABSTRACT Type 2 diabetes mellitus (T2DM) is one of the most common chronic diseases worldwide and is highly prevalent in Mexico, as 10.2% of the adult population harbors this condition. T2DM is usually associated with cardiovascular comorbidities, including arrhythmias. Metabolic impairment is one of the mechanisms that contribute to tissue remodeling that affects atrial structure, and concomitant, the cardiac conduction system, both could result in atrial fibrillation (AF). AF is estimated to affect more than a half million Mexicans, and its incidence is expected to keep rising. According to national registries, T2DM is present in 28.4% of Mexican patients with AF and the coexistence of both diseases is associated with a higher risk of stroke. In clinical practice, the CHA2DS2-VASc risk score is useful for stroke risk stratification in patients with AF to facilitate the adequate use of anticoagulation therapy. T2DM is among the items of the CHA2DS2-VASc score because it correlates with an intrinsic prothrombotic state. In this narrative review, we present information that highlights the need for optimal glucose control and adequate anticoagulation in subjects with T2DM and AF.

In-hospital antithrombotic therapy and outcomes of elderly patients on warfarin undergoing percutaneous coronary intervention: Insights from the WAR-STENT registry

In the patients on warfarin undergoing percutaneous coronary intervention included in the prospective, multicentre, observational WAR-STENT registry, age 75 years was associated with a significant increase in in-hospital major bleeding, length of hospitalization, and use of bare-metal stents, with no differences in the peri-procedural management and antithrombotic therapy

Clinical outcomes of Oral Anticoagulation and No Anticoagulation among end-stage Renal Disease patients on maintenance Hemodialysis with Atrial Fibrillation: A single-center prospective cohort study

Introduction@#The delicate balance of risk versus benefit of oral anticoagulation in the general population is well established but the decision to use these agents in end-stage renal disease (ESRD) remains complex and difficult owing to the paucity of clinical trials and lack of substantial evidence in literature for its safe and effective use in the hemodialysis population. This study aims to determine the difference in clinical outcomes between oral anticoagulation and no anticoagulation therapy among ESRD patients on maintenance hemodialysis with atrial fibrillation. @*Methods@#This is a prospective, single-center, observational study conducted in Perpetual Succour Hospital that included all ESRD patients on maintenance hemodialysis for at least 3 months with atrial fibrillation. Out of the 188 identified patients, only 69 patients were included in the study and were grouped according to how the cardiac dysrhythmia was approached either with oral anticoagulation or no use of oral anticoagulation. Basic demographic information were obtained as well as the etiology of ESRD, CHA2DS2-VASc Score and the HAS-BLED Score. Lastly, patients were prospectively followed for a period of 12 months and were then assessed for new onset of thromboembolic events, hemorrhagic events, calciphylaxis and all-cause mortality. @*Results@#At enrollment, 59 (85.5%) patients were identified to have no oral anticoagulation therapy and 10 (14.5%) were already receiving oral anticoagulation. Ischemic strokes were more prevalent among patients who were on oral anticoagulant (80%, p <0.0001). Patient outcomes differ significantly in terms of intracranial hemorrhage (30%, p= 0.0004) and gastrointestinal bleeding (50%, p <0.00001) which were noted among patients on oral anticoagulation. In relation to over-all mortality, acute myocardial infarction, peripheral arterial occlusive disease and calciphylaxis, there was no significant difference between the two groups. @*Conclusion@#This study suggests that the use of oral anticoagulation did not prevent ischemic strokes in ESRD patients on maintenance hemodialysis with atrial fibrillation and its use was associated with increased risk for intracranial hemorrhage and gastrointestinal bleeding. There was no significant difference in relation to all-cause mortality, acute myocardial infarction, peripheral arterial occlusive disease and calciphylaxis between the two study groups.

Ocupação apical por endomiocardiofibrose associada a trombo diagnosticada com ecocardiografia de contraste e resolvida com tratamento clínico / Apical occupation by endomyocardiofibrosis associated with thrombus diagnosed with contrast echocardiography and resolved with clinical treatment

A endomiocardiofibrose é uma doença negligenciada e predominante em países subdesenvolvidos. Apesar de sua frequência, ainda é considerada rara. Assim, a doença é marcada pelos seguintes achados: distorção arquitetural, alterações no enchimento ventricular e alterações da mobilidade segmentar. Ela afetando não só a dinâmica diastólica e sistólica, como também as funções das válvulas cardíacas. Em uma condição mais avançada da doença, pode haver formação de trombos apicais. Neste relato de caso, revisitamos a endomiocardiofibrose, apresentando um caso desafiador de paciente do sexo feminino de 52 anos, com clínica de insuficiência cardíaca classe funcional IV da New York Heart Association. A eletrocardiografia de repouso revelou ritmo sinusal com sobrecarga do ventrículo esquerdo com vetores de alta voltagem, infradesnivelamento retificado do segmento ST e onda T negativa em região anterolateral, podendo ser compatível com padrão de strain. Já na avaliação de imagens ecocardiográficas, revelou dilatação acentuada do átrio esquerdo, com ventrículos sem dilatações e imagem de ocupação apical hiperrefringente no interior do ventrículo esquerdo, sugerindo grande trombo séssil sobreposto à capa fibrosa endocárdica. Embora a conduta cirúrgica seja a mais apoiada em literatura em tais situações, a paciente aqui apresentada recebeu tratamento com anticoagulação oral por 1 mês e 24 dias. Ela evoluiu clinicamente bem, com melhora da classe funcional da New York Heart Association e, em ecocardiografia realizada 2 meses após o início da anticoagulação oral, houve demonstração da regressão da imagem de trombo apical, apoiada com a técnica de contraste endocavitário.(AU)

Endomyocardial fibrosis (EMF) is a neglected but prevalent disease in underdeveloped countries. Despite its frequency, it is still considered a rare disease. It is marked by the following findings: architectural distortion, ventricular filling changes, and segmental mobility changes affecting not only diastolic and systolic dynamics but also heart valve function. Apical thrombi can be formed in more advanced disease. In this case report, we revisit EMF and present the challenging case of a 52-year-old woman with New York Heart Association (NYHA) functional classification (FC) IV heart failure. Resting electrocardiography revealed sinus rhythm with left ventricular (LV) overload, high voltage vectors, rectified ST-segment depression, and a negative T-wave in the anterolateral region compatible with the strain pattern. The evaluation of echocardiographic images showed marked left atrial dilation, no ventricular dilatation, and hyper-refringent apical occupation within the LV suggestive of a large sessile thrombus superimposed on the endocardial fibrous layer. Although surgery is the most supported approach in the literature in such situations, this patient was treated with oral anticoagulants (OAC) for 1 month and 24 days. The patient progressed well with an improved NYHA FC. Endocavitary contrast echocardiography performed 2 months after OAC initiation showed regression of the apical thrombus image. (AU)

Successful Left Atrial Appendage Closure with Watchman Device Implantation in Two Patients with Inferior Vena Cava Filters

Percutaneous procedures through femoral access in patients with inferior vena cava (IVC) filter may be at risk of complications. We evaluated the feasibility and safety of left atrial appendage closure (LAAC) through femoral access in patients previously implanted with IVC filter. We described the WatchmanTM device implantation in two patients with formal contraindication for oral anticoagulation. First patient had a GreenfieldTM filter and the second one an OpteaseTM filter, and in this patient an attempt to withdrawal the filter immediately before the LAAC procedure failed. A femoral approach was performed in both patients using a 14 Fr sheath. Before crossing IVC filters, venographies did not detect any thrombus. All steps of IVC filter crossing were performed under fluoroscopic guidance. No immediate or intrahospital complications related to the procedure occurred. Herein, we presented two cases of successful LAAC closure with Watchman device in patients with two different kinds of IVC filters.

The antiphospholipid syndrome / El síndrome antifosfolipídico

ABSTRACT APS is a hypercoagulability condition characterized by the development of thrombosis and pregnancy morbidity (recurrent early miscarriages, fetal deaths after the 10th week of gestation and/or premature births), that occur in patients with antiphospholipid antibodies, namely lupus anticoagulant, anticardiolipin antibodies, and anti-(32-glycoprotein-I antibodies. It is usually isolated but can occur in the setting of another autoimmune disease, mainly systemic lupus erythematosus. Moreover antiphospholipid antibodies can be found in individuals without the disease. Treatment of thrombosis is based on indefinite anticoagulation while low-dose aspirin and low molecular weight heparin are the cornerstone of pregnancy morbidity treatment. Catastrophic antiphospholipid syndrome is treated with anticoagulation, plasma-exchange, and corticosteroids. Standardization of serological assays, inclusion of other antibodies and manifestations in the classification criteria, treatment of non-criteria manifestations and refractory cases are areas of uncertainty.

RESUMEN El SAF es una condición de hipercoagulabilidad caracterizada por el desarrollo de trombosis y morbilidad obstétrica (abortos recurrentes, muertes fetales antes de la semana 10 de gestación y/o partos prematuros) en pacientes con anticuerpos antifosfolipídicos, específicamente el anticoagulante lúpico, los anticuerpos anticardiolipina y anti-(32-glicoproteína-1. En la mayoría de los casos se presenta de forma aislada, pero puede asociarse a otras enfermedades autoinmunes como el lupus eritematoso sistêmico. Además, los anticuerpos antifosfolipídicos se pueden encontrar en individuos sin la enfermedad. El tratamiento de la trombosis se basa en anticoagulación indefinida, mientras que aspirina a dosis bajas y heparina de bajo peso molecular representan la base del tratamiento de la morbilidad obstétrica. El síndrome de anticuerpos antifosfolipídicos catastrófico se trata con una combinación de anticoagulación, corticoides y recambios plasmáticos. La estandarización de los ensayos serológicos, la inclusión de otros anticuerpos y otras manifestaciones en los criterios clasificatorios, el tratamiento de las manifestaciones no criterio y de los casos refractarios representan las áreas de incertidumbre del síndrome.

The influence of internet-based telemedicine on warfarin management: A systematic review and meta-analysis / 中国胸心血管外科临床杂志

@#Objective    To systematically evaluate the effects of telemedicine on the management of warfarin therapy. Methods    We searched PubMed, EMbase, Cochrane Library, Web of Science, CNKI, VIP, Wanfang Database (from inception to February 2020) and conducted retrospective literature searching to identify studies about the management of warfarin using telemedicine intervention techniques. R language software was used to evaluate the efficacy and safety of telemedicine on warfarin management. Results    A total of 7 239 articles were retrieved, and 12 articles were finally included according to inclusion and exclusion criteria, totaling 8 112 patients, including 3 726 patients in the intervention group and 4 386 patients in the control group. The results of meta-analysis showed that there was a statistical difference in the accurate international normalized ratio (INR) treatment target range time ratio between the intervention group and the control group (MD=6.52, 95%CI 2.13 to 10.92, P<0.01, I2=89%). The incidence of bleeding events (RR=0.61, 95%CI 0.46 to 0.81, P=0.97, I2=0%) and the incidence of thromboembolic events (RR=0.50, 95%CI 0.29 to 0.85, P=0.63, I2=0%) were not statistically different between the two groups. Conclusion    Existing evidence indicates that telemedicine management has a benefit in anticoagulant efficacy compared with conventional anticoagulant management in patients with thrombotic diseases, but there is no statistical difference in safety. Limited by the quantity and quality of the included studies, the above conclusion needs to be verified by more high-quality studies.

Meta-Analysis of the Efficacy and Safety of Uninterrupted NOACs in Patients Undergoing Atrial Fibrillation Catheter Ablation / 中国药学杂志

OBJECTIVE: To systematically assess the efficacy and safety of uninterrupted novel oral anticoagulation (NOAC) in patients undergoing atrial fibrillation catheter ablation. METHODS: Databases including multiple databases were searched electronically for randomized controlled trial (RCT) of NOAC in patients undergoing atrial fibrillation catheter ablation up to October, 2018. Two reviewers independently screened literatures according to the inclusion and exclusion criteria, extracted data, and assessed the methodological quality of the included studies. Then Meta-analysis was performed using Rev Man 5.3 software. RESULTS: A total of 5 RCTs involving 1 843 patients were included. Experimental group including apixaban, rivaroxaban and dabigatran; control group using warfarin. Efficacy outcome including stroke and transient ischemic attack (TIA); safety outcome was major bleeding. RESULTS were as followsthere was no significant difference between experimental group and control group in efficacy outcome; the safety of the experimental group was significantly superior to that of the control group. CONCLUSION: Compared with warfarin, uninterrupted NOACs during percutaneous atrial fibrillation catheter ablation could reduce the risk of major bleeding and would not increase the incident of stroke and TIA.

Application of standardized follow-up protocol in patients with mechanical heart valve replacement / 中国实用护理杂志

Objective To evaluate the effect of the standardized follow-up protocol based on telemedicine follow-up system in patients after mechanical heart valve replacement. Methods A prospective, nonrandomized, controlled clinical trial was performed on 109 patients who underwent mechanical heart valve replacement in the Affiliated Hospital of North Sichuan Medical College from January 2017 to June 2017. They were divided into two groups according to patient's willingness, place of residence and whether have sufficient technical facilities (computer or mobile device connected to the internet), including 56 patients in the control group and 53 patients in the observation group. The control group received routine follow-up guidance, and the observation group received standardized follow-up protocol, which were followed up for 6 months. The patients in the two groups were analyzed with thromboembolism, hemorrhagic event and International normalized ratio (INR) related to anticoagulation therapy during the follow-up period, and the quality of early anticoagulation therapy was evaluated with Time in therapeutic range (TTR), and the satisfaction of the patients with anticoagulation therapy was investigated. Results There was no significant difference in INR between the two groups during the follow-up period (P>0.05). The TTR of the control group and the observation group was 44.6% (4 516.6 d/10 127.0d) and 54.1% (5 576.1d/10 307 d), respectively, with statistically significant differences (t=-11.273, P<0.05).There were no significant differences between the two groups in the anticoagulant complications, thromboembolism, hemorrhagic events (P > 0.05). There was significant difference between the observation group and the control group in overall satisfaction with anticoagulation therapy and helpful in answering the patients'questions (Z=6.42, 5.62, P<0.05), while no statistically significant difference in service attitude to the follow-up period and satisfaction with the guidance that was provided (P > 0.05). Conclusion Standardized follow-up protocol based on telemedicine follow-up system is applied to patients after MHVR surgery, which is conducive to improving the quality of anticoagulant therapy and improving the satisfaction of patients, and providing reference for the development of "Internet+medical"mode in China.

Application of standardized follow-up protocol in patients with mechanical heart valve replacement / 中国实用护理杂志

Objective@#To evaluate the effect of the standardized follow-up protocol based on telemedicine follow-up system in patients after mechanical heart valve replacement.@*Methods@#A prospective, nonrandomized, controlled clinical trial was performed on 109 patients who underwent mechanical heart valve replacement in the Affiliated Hospital of North Sichuan Medical College from January 2017 to June 2017. They were divided into two groups according to patient's willingness, place of residence and whether have sufficient technical facilities (computer or mobile device connected to the internet), including 56 patients in the control group and 53 patients in the observation group. The control group received routine follow-up guidance, and the observation group received standardized follow-up protocol, which were followed up for 6 months. The patients in the two groups were analyzed with thromboembolism, hemorrhagic event and International normalized ratio (INR) related to anticoagulation therapy during the follow-up period, and the quality of early anticoagulation therapy was evaluated with Time in therapeutic range (TTR), and the satisfaction of the patients with anticoagulation therapy was investigated.@*Results@#There was no significant difference in INR between the two groups during the follow-up period (P >0.05). The TTR of the control group and the observation group was 44.6% (4 516.6 d/10 127.0d) and 54.1% (5 576.1d/10 307 d), respectively, with statistically significant differences (t=-11.273, P < 0.05).There were no significant differences between the two groups in the anticoagulant complications, thromboembolism, hemorrhagic events (P > 0.05). There was significant difference between the observation group and the control group in overall satisfaction with anticoagulation therapy and helpful in answering the patients' questions (Z=6.42, 5.62, P < 0.05), while no statistically significant difference in service attitude to the follow-up period and satisfaction with the guidance that was provided (P > 0.05).@*Conclusion@#Standardized follow-up protocol based on telemedicine follow-up system is applied to patients after MHVR surgery, which is conducive to improving the quality of anticoagulant therapy and improving the satisfaction of patients, and providing reference for the development of "Internet + medical" mode in China.

Rotura espontánea de bazo en paciente tratado con acenocumarol / Spontaneous rupture of spleen in a patient treated with acenocoumarol

Aunque la causa más frecuente de rotura esplénica es la traumática, podemos encontrar roturas sin relación a un traumatismo previo. Se está objetivando un aumento de roturas espontáneas en relación con tratamiento anticoagulante. Presentamos el caso de un hombre en tratamiento con acenocumarol que presentó una rotura espontánea esplénica que requirió esplenectomía urgente. La rotura de bazo es una entidad grave que debe considerarse ante todo paciente con un abdomen agudo. Aunque las causas más frecuentes de rotura esplénica atraumática son las complicaciones neoplásicas e infecciosas, se han objetivado varios casos asociados a terapias antiagregantes y anticoagulantes. Dado el aumento de población que precisa anticoagulación oral, la sobredosificación con acenocumarol debe considerarse como una posible causa de rotura esplénica. Debemos sospechar esta entidad ante todo paciente en tratamiento con anticoagulación oral con un abdomen agudo.

The splenic rupture is most commonly related to trauma, but spontaneus ruptures have also been described with increasing frequency. We present a case of a male patient with spontaneous splenic rupture due to oral anticoagulant overdose that required urgent splenectomy. The spontaneous splenic rupture is a life-threatening condition that must be considered in patients with acute abdomen. Although most ruptures are associated with to neoplastic and infectious complications , recent reports have related rupture with anticoagulant and antiaggregant therapies. Moreover, since the number of patients undergoing oral anticoagulant therapies is growing, overdose of anticoagulant drugs must be considered as a possible ethiology of spontaneous splenic rupture and suspect this association in patient with acute abdomen undergoing anticoagulant therapy.

Adherencia al tratamiento anticoagulante oral por enfermedad tromboembólica venosa en adultos mayores / Adherence to the oral anticoagulant treatment for venous tromboembolic disease in older adults

Introducción: Los adultos mayores son más propensos a presentar inestabilidad en los niveles de anticoagulación y efectos adversos, donde pudiera influir la no adherencia al tratamiento. Objetivo: Determinar el comportamiento de la adherencia al tratamiento anticoagulante oral por enfermedad tromboembólica venosa en los adultos mayores. Métodos: Estudio descriptivo retrospectivo-prospectivo en 42 adultos mayores bajo tratamiento anticoagulante oral de junio a diciembre de 2014. Se analizaron variables sociodemográficas, enfermedades crónicas asociadas, dosis, grado de control, frecuencia de cumplimiento, complicaciones, tiempo en rango terapéutico, adherencia al tratamiento y factores que influyen en la adherencia. Resultados: El 71,4 por ciento de los casos presentó elevada adherencia al tratamiento. El tiempo en rango terapéutico de la población en estudio fue de 55,1 por ciento. Conclusiones: En los pacientes adultos mayores estudiados prevaleció la alta adherencia al tratamiento anticoagulante oral aunque predominó en ellos el inadecuado control de la anticoagulación(AU)

Introduction: Older adults are often more prone to present unbalanced levels of anticoagulation and adverse effects, and this condition could be influenced by non-adherence to treatment. Objective: To characterize the behavior of adherence to oral anticoagulant therapy for venous thromboembolic disease in older adults. Methods: A descriptive, retrospective-prospective study was conducted in 42 old people under oral anticoagulant treatment from June to December 2014. It analyzed sociodemographic variables, associated chronic diseases, doses, level of control, frequency of control, complications, length of time in therapeutic status, adherence to treatment and factors that affect it. Results: In 71.4 percent of patients, the percentage of adherence to treatment was high. The length of time in therapeutic status of the study population was 55.1 percent. Conclusions: The studied older patients showed high margin of adherence to oral anticoagulant therapy, although inadequate control of anticoagulation was also predominant(AU)

Variaciones de la Razón Normalizada Internacional en pacientes con prótesis valvulares complicados / Variations of the International Standard Ratio in complicated patients with valve prosthesis

Se llevó a cabo un estudio observacional, descriptivo y transversal de 51 pacientes portadores de prótesis valvulares, ingresados en el Cardiocentro del Hospital Provincial Docente Clinicoquirúrgico Saturnino Lora Torres de Santiago de Cuba por presentar trombosis valvular o episodios hemorrágicos, desde enero del 2012 hasta diciembre del 2014, a fin de estimar las variaciones en los valores de la Razón Normalizada Internacional y su asociación con estos eventos. Se aplicó la prueba de Ji al cuadrado. Preponderaron los afectados con trombosis valvular (60,4 por ciento) y Razón Normalizada Internacional menor de 2,5; mientras que esta última en las hemorragias fue superior a 3,5. Aquellos con más de un factor de riesgo asociado presentaron mayor cantidad de episodios trombóticos; eventos que tuvieron menor incidencia cuando se integraron warfarina y aspirina al tratamiento

An observational, descriptive and cross-sectional study of 51 patients with valve prosthesis was carried out. They were admitted to the Cardiology Center of Saturnino Lora Torres Teaching Clinical Surgical Provincial Hospital due to valve thrombosis or bleeding episodes, from January, 2012 to December, 2014, with the purpose of estimating the variations in the International Standard Ratio values and their association with these events. The chi-square test was carried out. Those patients affected with valve thrombosis (60.4 percent) and International Standard Ratio under 2.5 were predominant; while the latter in bleedings was over 3.5. The patients with more than one associated risk factor presented higher quantity of thrombosis episodes; events that had less incidence when warfarin and aspirin were included in the treatment

Evaluation of Quality of Anticoagulation Therapy Among Neurological Patients: An Institutional Based Study

Background: Oral anticoagulation (OAC) is used in neurology practice for primary and secondary stroke prevention in atrial fibrillation (AF), prosthetic mechanical valve; dilated cardiomyopathy (DCMP) and cerebral venous sinus thrombosis (CVST). This study evaluates the quality of oral anticoagulation therapy in neurology patients. Methods: Patients attending neurology service in KPC Medical College and Hospital, Jadavpur, Kolkata, West Benga (India); who were prescribed oral anticoagulant (OAC) were included. The international normalized ratio (INR) values of the patients who were already on OAC were analyzed. The level of anticoagulation, factors interfering with OAC and complications were noted. Results: Total 90 patients were included in study with median age 35±10 years. Ten were excluded as follow up was not done properly. Final study involves 80 patients. Fifty-eight patients received OAC for stroke prevention, 17 for cerebral venous sinus thrombosis (CVST) and 5 for deep vein thrombosis (DVT). Follow up was done for 2 years. Of the total 947 INR reports, 362 were below and 231 were above the therapeutic level. Stable INR was obtained in 36 patients only. INR level was improved by dose adjustment in 25 patients, and dietary adjustment in eight patients. Five patients were sensitive and three were resistant to OAC. Complications were noted in 14 instances. Conclusions: Stable therapeutic INR is difficult to maintain in neurological patients. However, modification of diet, drug and dose of oral anticoagulant may help in stabilization of INR. The findings support the need for educational interventions to improve the knowledge regarding OAT and, thereby, prevention of stroke.

Prevalence of Atrial Fibrillation in Korean Population

Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice and has been a major public health problem. The prevalence of AF globally has been reported to range from 0.4% to 2% in the adult population; however, the prevalence widely varies depending on the study population. Although AF prevalence in Asian population is about 1% lower than that in European and North American population, the number of AF patients in Asia is rapidly increasing concomitant with the increased aging of the population. However, previous studies that reported AF epidemiology in the Korean population are limited. According to a recent report based on the national health claims database, prevalence of AF in 2015 was 0.7% in the entire Korean adult population and showed a continuous increase with population aging. Additionally, among patients with AF, mean CHA2DS2-VASc score was significantly increased and the number of high thromboembolic risk patients has increased over time. Although oral anticoagulation (OAC) prescription in AF patients increased from 35% to 51%, especially after introduction of non-vitamin K antagonist anticoagulants, a substantial proportion of Korean patients with AF still remain undertreated. In this review, we aimed to summarize temporal changes in the prevalence and incidence of AF and to evaluate the thromboembolic risk in patients with AF. In addition, we also discussed the utilization of OAC therapy in patients with AF in Korean population.

Quality of anticoagulation therapy in neurological patients in a tertiary care hospital in north India.

Background & objectives: There is paucity of studies on the quality of anticoagulation in neurological patients from India. This study evaluates the quality of oral anticoagulation therapy in neurology patients. Methods: Consecutive patients attending a tertiary care neurology service in north India who were prescribed oral anticoagulant (OAC), were included. Their international normalized ratio (INR) values were prospectively monitored and the earlier INR values of the patients who were already on OAC were retrospectively analyzed. The patients with multi-organ dysfunction, pregnancy and those below 18 yr of age were excluded. The therapeutic INR range was defined as per standard recommendations. The level of anticoagulation, factors interfering with OAC and complications were noted. Results: The results were based on 77 patients with median age 40 yr. Fifty one patients received OAC for secondary stroke prevention, 23 for cerebral venous sinus thrombosis (CVST) and three for deep vein thrombosis (DVT). A total 167.9 person-years of follow up was done with a median of 1.2 (0.3-9.3) years. Of the 1287 INR reports, 505 (39.3%) reports were in the therapeutic range, 496 (38.5%) were below and 282 (21.91%) were above the therapeutic level. Stable INR was obtained in 33 (42.86%) patients only. INR level was improved by dose adjustment in 20 (26%), drug modification in two (2.6%), and dietary adjustment in six (7.8%) patients. Three patients were sensitive and five were resistant to OAC. Complications were noted in 28 instances; thromboembolic in 16 and haemorrhagic stroke in 12. The overall complication rate was 16.7 per 100 person-years. Interpretation & conclusions: It may be concluded that stable therapeutic INR is difficult to maintain in neurological patients. Optimal modification of diet, drug and dose of oral anticoagulant may help in stabilization of INR.

Use of NOAC in Cardioversion

Cardioversion increases the risk for stroke or systemic embolic events, and patients scheduled for cardioversions need several weeks of anticoagulant treatment to prevent these adverse events. Anticoagulant therapy should be considered as a balancing act between the risk of stroke and the risk of life-threatening bleeding. The efficacy of non-vitamin K antagonist oral anticoagulants (NOACs) was found to be equal to, or even superior, to warfarin for the prevention of stroke, systemic embolism, and other outcomes in patients with atrial fibrillation, when all risk factors were considered. There have been few studies independently looking at the efficacy and safety profile of NOACs in cardioversion. The efficacy of both rivaroxaban and dabigatran in preventing stroke or major systemic embolic events post-cardioversion was found to be similar to that of warfarin. The efficacy of apixaban could not be compared based on the available data because of the limited number of procedures performed. However, all three NOACs were found to be safe for use in cardioversion when compared to warfarin.

Tratamiento anticoagulante oral en pacientes sometidos a remplazo valvular en un hospital general de Antofagasta, Chile / Oral anticoagulant treatment (OAT) in patients with cardiac valve replacement at a general hospital in Antofagasta, Chile

Introduccion: La atención de pacientes con reemplazo valvular cardíaco constituye una actividad importante en cardiología. Si bien el recambio valvular representa una alternativa terapéutica eficaz para el manejo de esta patología, muchos pacientes requieren de tratamiento anticoagulante oral (TACO) para lograr mayor sobrevida. Objetivos: Describir los resultados terapéuticos obtenidos en un cohorte de pacientes sometidos a recambio valvular, controlados en el Hospital Regional de Antofagasta. Resultados: Se identificaron 180 pacientes con reemplazo valvular de los cuales 135 cumplieron criterios de inclusión. Hubo 76 mujeres (56,3%), 59 hombres (43,7%); la edad global promedio fue 62 años (28-90), 59 años (30-90) en las mujeres y 64 (36-81) en los hombres. La válvula intervenida fue la aórtica en 69 pacientes (51,1%), mitral en 60 (44,5%), aórtica y mitral en 5 (3,7%), y tricúspide en 1 paciente (0,7%). No hubo casos de recambio valvular pulmonar. Se instalaron 122 válvulas mecánicas (90,4%) y 13 válvulas biológicas (9,6%). El INR promedio fue 2,64 (1,11-5,47). Según válvula intervenida el INR promedio fue: mitral 2,50 (1,11-4,89), aórtica: 2,75 (1,19-5,47), mitral y aórtica: 2,65 (1,28-3,74), y tricúspide: 1,87. Del total de cirugías valvulares, 77 (57,03%) se encontraron dentro del rango terapéutico deseado: (mitral 33/60, Aórtica 43/69 mitral y aórtica 0/5, Tricúspide: 0/1). 58 pacientes (42,97%) se encontraron fuera del rango terapéutico deseado. Conclusion: Los resultados obtenidos en nuestro centro se encuentran por debajo de las recomendaciones nacionales. La dificultad por obtener mejores resultados refuerza el uso de prótesis biológicas y la implementación óptima de un policlínico de tratamiento anticoagulante (TACO).

Background: Care of patients with cardiac valve replacement often includes the need for anticoagulation which prevents complications that may decrease survival rate. Aim: to describe the experience with OAT in a cohort of patients with cardiac valve replacement at the Regional Hospital in Antofagasta Results: 135 out of 180 patients fulfilled inclusion criteria. There were 76 females (56.3%) and 59 males (43.7%), with a mean of 62 years old (28-90), 59 (30-90) in females and 64 (36-81) in males. The valve replaced was the aortic in 69 patients (51.1%), the mitral in 60 (44.5%), both the aortic and the mitral valve in 5 (3.7%). Only 1 patients had a tricuspid valve replaced. 122 mechanical valves (90.4%) and 13 biological valves (9.6%) were implanted. The overall mean INR was 2.64 (1.11 - 5.47). The mean INR value according to the valve replaced was: mitral valve 2.5 (1,11-4,89), aortic valve 2.75 (1.195.47) and mitral plus aortic valve 2.65 (1.28-3.74). Overall, 58 patients were found to be outside the therapeutic target. Conclusion: These results are less satisfactory than those proposed by national guidelines. The anticoagulant clinic must be optimized and more biological rather than mechanical valves should be used for cardiac valve replacement.

Agentes antitrombóticos en Terapia Intensiva: manejo práctico de los nuevos anticoagulantes orales directos / Antithrombotic agents in Intensive therapy: management practical of the new oral oral anticoagulants

Los nuevos anticoagulantes orales compiten actualmente, con alguna ventaja, con la terapéutica tradicional en la prevención de la cardioembolia en fibrilación auricular, y en la prevención y el tratamiento de la enfermedad tromboembólica venosa. Estudios recientes han demostrado una eficacia equivalente a la de los antagonistas de la vitamina K, con un mejor perfil de seguridad. Además, superan algunos inconvenientes de estos antagonistas, como la necesidad de ajuste de dosis y el monitoreo frecuente de la RIN, las múltiples interacciones farmacológicas y los cuidados con la dieta. Pero con los nuevos agentes debemos ser cautos, porque el riesgo de sangrado puede aumentar significativamente en ciertos grupos de pacientes con insuficiencia renal, añosos o muy frágiles. Aunque se emplean usualmente en dosis fijas, en casos especiales (peso <50 kg, edad avanzada, disfunción renal, alto riesgo de sangrado), esta dosis se debe modificar. Si bien, en la práctica clínica, no es necesario hacer pruebas de monitoreo de la coagulación, no contamos con pruebas adecuadas para evaluar su eficacia clínica y tampoco tenemos hoy, en nuestro medio, un antídoto eficaz en caso de sangrado importante. Sin embargo, se están realizando estudios con nuevas pruebas de hemostasia que pueden ayudarnos a interpretar el nivel de anticoagulación en estos pacientes y ya se han desarrollado antídotos para algunos de los anticoagulantes de acción directa que pronto estarán disponibles en nuestro medio.(AU)

New oral anticoagulants represent an interesting alternative to traditional therapy for the prevention of stroke in atrial fibrillation, and the thromboprophylaxis and treatment of venous thromboembolic disease. Several studies demonstrated equivalent efficacy to that of vitamin K antagonists with a more favourable safety profile. New oral anticoagulants overcome some of the main problems of these antagonists: the need of tailoring dosing, frequent interactions with other drugs and diet. But physicians have to keep in mind that new oral anticoagulants are not absolutely free of complications, and must be cautious with patients at high risk of bleeding. Also in special cases (<50 kg, advanced age, renal impairment) the usual dose must be adapted. At present there are not specific tests to evaluate the effect of these new anticoagulants, although it is usually not necessary to do any coagulation test in clinical practice. Another concern regarding new oral anticoagulants is the absence of specific antidotes, although specific antidotes are under clinical investigation and are soon going to be available in our country.(AU)