Understanding and Managing Atrial Fibrillation in Patients with Kidney Disease.

Chronic kidney disease (CKD) is on the rise due to the increased rate of related comorbidities such as diabetes and hypertension. Patients with CKD are at higher risk of cardiovascular events and atrial fibrillation is more common in this patient population. It is estimated that the prevalence of chronic atrial fibrillation in patients with CKD is two to three times higher than general population. Furthermore, patients with CKD are less likely to stay in sinus rhythm. Atrial fibrillation presents a major burden in this population due to difficult treatment decisions in the setting of a lack of evidence from randomized clinical trials. Patients with CKD have higher risk of stroke with more than half having a CHADS2 score ≥ 2. Anticoagulation have been shown to significantly decrease embolic stroke risk, however bleeding complications such as hemorrhagic stroke is twofold higher with warfarin. Although newer novel anticoagulation drugs have shown promise with lower intracranial hemorrhage risk in comparison to warfarin, lack clinical trial data in CKD and the unavailability of an antidote remains an issue. In this review, we discuss the treatment options available including anticoagulation and the evidence behind them in patients with chronic kidney disease suffering from atrial fibrillation.

Prolactinoma and hyperprolactinaemia: a transcultural comparative study between Germany as a western, liberal, industrialised country and Syria as an oriental society with a strong Islamic tradition.

OBJECTIVE: Prolactinomas and hyperprolactinaemia cause hypogonadism and impairment of sexual and reproductive function. In this transcultural study, clinical characteristics of prolactinoma/hyperprolactinaemia were compared between a liberal, western, industrialised country and a more traditional, Islamic, oriental society. METHODS: Sixty-two Syrian patients with hyperprolactinaemia were compared to 62 German patients with hyperprolactinaemia. RESULTS: In Syria and Germany, prolactinoma and hyperprolactinaemia were more frequent in females than in males (Syria 87% females; Germany 63% females). Prolactinomas were larger in males, males were older at diagnosis in both countries. Recorded clinical symptoms were comparable, even if culturally determined differences in spontaneous reporting of and asking for symptoms might be considered. The average age of the Syrian patients at diagnosis of hyperprolactinaemia was more than 6 years lower than in the German cohort (33.4 ± 10.4 vs. 39.7 ± 17.6 years). In Germany, a variety of therapeutic regimens were applied. In Syria, bromocriptine was prescribed exclusively. DISCUSSION AND CONCLUSION: The differences may be attributed to culturally determined differences in sexual and reproductive behaviour, i.e. sexual intercourses of young, unmarried girls and women in association to the use of oral contraceptives regulating the menstrual cycle, maternal age at first delivery and birth frequency. Exclusive prescription of bromocriptine in Syria may be associated to limited resources and the safety of bromocriptine during pregnancy.

Left atrial appendage exclusion and the risk of thromboembolic events following mitral valve surgery.

OBJECTIVES: We aimed to evaluate left atrial appendage (LAA) exclusion in patients undergoing mitral valve surgery with respect to thromboembolic events. BACKGROUND: LAA is the predominant source of emboli in patients with atrial fibrillation. Prophylactic LAA exclusion at the time of heart surgery has been recommended to reduce the risk of future thromboembolism. METHODS: An observational cohort of 136 patients undergoing LAA exclusion during mitral valve surgery was identified between May 1993 and November 1998 at our institution. RESULTS: During a mean follow-up of 3.6 +/- 1.3 years, there were 14 (12.3%) thromboembolic events. Compared with patients who received warfarin upon hospital discharge, there were more thromboembolic events in patients not prescribed warfarin upon hospital discharge (n = 7/67, 10% vs n = 6/40, 15%, respectively). The warfarin status was not known for one patient. The majority of thromboembolic events (n = 10/14, 71%) occurred in those who underwent mitral valve repair. CONCLUSION: In this observational study, patients who undergo LAA exclusion during mitral valve surgery to reduce the risk of thromboembolism have a significant incidence of thromboembolic events, especially when warfarin therapy is not prescribed upon hospital discharge.