ABSTRACT
Fluoroquinolones (FQs) are routinely administered antibiotics that have demonstrated an increased propensity to cause major adverse cardiovascular events (MACE). We conducted a systematic review aimed to investigate the association between FQ usage and the risk of MACE. A comprehensive literature search was conducted using PubMed, Scopus, and the Cochrane Library from inception to September 2023 to retrieve studies comparing FQ administration with placebo and reporting the occurrence of MACE. Relevant studies that explored the occurrence of MACE, defined as "acute myocardial infarction, stroke, cardiovascular mortality, arrhythmia, or heart failure" with FQ usage were eligible for inclusion. Four studies with a total of 42,808 patients were included. Levofloxacin, moxifloxacin, and gatifloxacin were observed to have an increased propensity to cause MACE, particularly arrhythmias, whereas ciprofloxacin was associated with the lowest risk of causing MACE. Despite the methodological diversity in the included studies, this systematic review uncovered a consistent trend of heightened likelihood of MACE with FQ administration across studies, suggesting that elevated serum concentrations of some FQs may correlate with higher risks of MACE development. This systematic review emphasizes the need for cautious administration of FQs, particularly in patients with a preexisting cardiovascular condition. Routine cardiac monitoring using electrocardiograms is warranted for patients on high doses of FQs to preemptively detect the development of MACE, particularly arrhythmias.
ABSTRACT
BACKGROUND: Ischemic stroke is a devastating complication of atrial fibrillation (Afib). Anticoagulation is the gold standard to prevent stroke and systemic embolization. However, many patients have a contraindication to oral anticoagulation. The WATCHMAN device, which closes the left atrial appendage, is non-inferior to warfarin to prevent embolic events in clinical trials. Post-procedural anticoagulation is needed to avoid device-related thrombosis. The use of anticoagulants after WATCHMAN implantation in patients with high bleeding risks has been a source of debate. OBJECTIVE: This article summarizes the current evidence on anticoagulation following the implantation of the WATCHMAN device, focusing on patients who have an absolute contraindication to oral anticoagulation. OBSERVATION: The WATCHMAN device is efficacious and safe in preventing stroke and systemic embolization. Warfarin and aspirin are given for 45 days after implantation. If TEE at 45 days shows minimal residual peri-device flow (≤ 5mm) and no device-related thrombus, warfarin is stopped. This is followed by aspirin and clopidogrel for six months, then aspirin indefinitely. Antithrombotic therapy with aspirin and clopidogrel for six months followed by daily aspirin indefinitely may be feasible for patients with an absolute contraindication to OAC. DOACs are more convenient to use than warfarin, and limited evidence suggests that they are not inferior following implantation of the device. CONCLUSION: Following the WATCHMAN implantation, the most often utilized regimen is warfarin followed by antiplatelet treatment. In cases where there is a high risk of bleeding, antiplatelets alone may be sufficient. More research is needed to tailor the existing antithrombotic regimen to the needs of patients.
