[Anticoagulation of diabetic patients with nonvalvular atrial fibrillation]. / Anticoagulation des patients diabétiques avec fibrillation auriculaire non valvulaire.

Patients with diabetes have a higher risk of nonvalvular atrial fibrillation (NVAF), cerebral embolisms and anticoagulant-related intracranial bleeding when compared to nondiabetic patients. Non-vitamin K oral anticoagulants (NOACs) are progressively replacing antivitamin K agents among patients with NVAF. They are as efficacious as warfarin to reduce the risk of cerebral and systemic embolisms while reducing the risk of both severe and cerebral hemorrhages. Four studies reported results of prespecified subanalyses that compared results of efficacy and safety of NOACs (dabigatran, rivaroxaban, apixaban, edoxaban) in patients with and without diabetes, overall with similar results in both subgroups. ENGAGE AF-TIMI 48 is the only trial that reported a significant reduction of severe hemorrhages with edoxaban compared with warfarin in diabetic patients with NVAF.

Les patients avec diabète présentent un risque accru de fibrillation auriculaire non valvulaire (FANV), d'embolies cérébrales et d'hémorragies intra-crâniennes sous anticoagulants par rapport aux patients non diabétiques. Les anticoagulants oraux directs (AODs) remplacent progressivement les agents anti-vitamine K (coumariniques) chez les patients avec FANV. Ils se révèlent aussi efficaces que la warfarine pour réduire le risque d'embolies cérébrales et systémiques, tout en diminuant, comparativement, le risque d'hémorragies sévères et cérébrales. Quatre études ont rapporté les résultats d'une sous-analyse préspécifiée comparant les résultats d'efficacité et de sécurité des AODs (dabigatran, rivaroxaban, apixaban, édoxaban) chez les patients diabétiques et non diabétiques, avec des résultats globalement comparables dans les deux sous-groupes. L'étude ENGAGE AF-TIMI 48 est la seule à avoir rapporté une réduction significative des hémorragies sévères avec l'édoxaban par rapport à la warfarine chez les patients diabétiques.

[Coagulopathies, thrombotic risk and anticoagulation in COVID-19]. / Coagulopathies, risque thrombotique et anticoagulation dans la COVID-19.

Clinical observations indicate that COVID-19 often provokes coagulopathies, which have been associated with high morbidity and mortality rates. These coagulopathies likely result from Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection-elicited systemic inflammation and endothelial damage. Patients with severe COVID-19 are at high risk of venous and arterial thromboembolic diseases; they can also develop disseminated intravascular coagulation in the most advanced stages of the disease. Medical Organisations on Thrombosis and Hemostasis, among which the Belgian Society on Thrombosis and Haemostasis (BSTH), have formulated recommendations for the prophylaxis and treatment of COVID-19-related venous thromboembolism in ambulatory and hospitalised patients, as well as for the anticoagulation of COVID-19 patients in need of long-term anticoagulation for unrelated cause.These recommendations provide every hospital and primary care physicians with an easy-to-use clinical guidance; they mainly rely on limited level of evidence and are likely to evolve with knowledge of COVID-19 pathophysiology and availability of data from ongoing clinical trials.

Les observations cliniques indiquent qu'une grande proportion des patients atteints de la COVID-19 développent des coagulopathies plus ou moins sévères et associées à un taux élevé de morbidité et de mortalité. Ces troubles de la coagulation seraient liés à l'inflammation systémique et aux lésions endothéliales causées par l'infection par le SARS-CoV-2 («Severe Acute Respiratory Syndrome Coronavirus 2¼). Leur incidence augmente avec la sévérité de la COVID-19. Ils se traduisent par un risque accru de maladies thromboemboliques veineuses (MTEV) ou artérielles ou par le développement d'une coagulation intravasculaire disséminée (CIVD) aux stades cliniques les plus avancés. Les Organisations médicales de Thrombose et Hémostase, parmi lesquelles la Société Belge de Thrombose et Hémostase (BSTH), ont formulé des recommandations pour la prophylaxie et le traitement des MTEV associées à la COVID-19 chez le patient hospitalisé, ambulatoire, et le patient sous traitement anti-thrombotique au moment du développement de la maladie. Ces recommandations ont été rédigées afin de répondre à un besoin médical urgent, de manière adaptée aux soins de santé propres à chaque système local; elles reposent, essentiellement, sur un niveau de preuve limité et sont, dès lors, susceptibles d'évoluer avec une meilleure connaissance de la COVID-19 et la disponibilité des données des essais cliniques en cours.

[Therapeutic revolution in the treatment of aortic stenosis : transcatheter aortic valve implantation (TAVI )]. / Révolution thérapeutique dans le traitement des sténoses aortiques : remplacement valvulaire aortique par voie transcathéter (TAVI).

Eighteen years after the birth of the concept, TAVI (Transcatheter Aortic Valve Implantation) has established itself as the treatment of choice for symptomatic patients with severe aortic valve stenosis at high surgical risk. Unlike surgical prosthesis, the benefit of which has been validated in observational studies, indications for TAVI are now based on the results of large randomized trials. The TAVI revolution continues today with the miniaturization of the equipment, the development of new closure systems, the availability of a wider range of prosthesis sizes and the growing experience of operators, all contributing to the widening of indications to lower risk patients.

Dix-huit ans après la naissance du concept, le TAVI («Transcatheter Aortic Valve Implantation¼) s'est affirmé comme un traitement de choix chez les patients symptomatiques avec rétrécissement valvulaire aortique serré à haut risque chirurgical. Contrairement aux prothèses chirurgicales, dont le bénéfice a été validé dans des études observationnelles, les indications concernant le TAVI s'appuient, aujourd'hui, sur les résultats de larges essais randomisés. La révolution du TAVI continue encore actuellement avec la miniaturisation du matériel, le développement de nouveaux systèmes de fermeture, la disponibilité d'un plus large éventail de tailles de prothèse et l'expérience croissante des opérateurs, le tout contribuant à l'élargissement des indications aux patients à risque intermédiaire.

[Direct oral anticoagulants : therapeutic breakthroughs over the past decade]. / Anticoagulants oraux directs. Avancée thérapeutique de la décennie.

In the past decade atrial fibrillation (AF) and venous thromboembolic disease (VTE) treatment have been revolutionized by direct oral anticoagulants (DOACs). Compared to vitamin K antagonists, DOACs have interesting advantages : standardized dosages (no need for monitoring), fast action, short half-life, (no food interaction and lower risk of intracranial bleeding). In addition to VTE and AF, DOACs have specific indications : prevention of postorthopedic surgery VTE and more recently, prevention of cardiovascular events in patients with stable coronaropathy and/or peripheral artery disease. Nevertheless, DOACs must be handled with care according to dosage regimens, contra-indications, drug-drug interactions. Other anticoagulants are in the pipeline. What will their indications be ? Future will tell us.

Ces 10 dernières années, l'arrivée des anticoagulants oraux directs (AODs) a révolutionné la prise en charge de la fibrillation auriculaire et de la maladie thromboembolique veineuse (MTEV). Par rapport aux antivitamines K, les AODs comptent plusieurs avantages : des posologies standardisées ne nécessitant pas de monitoring, une action rapide, une courte durée d'action, l'absence d'interaction alimentaire et un moindre risque d'hémorragie intracrânienne. Outre la MTEV et la fibrillation auriculaire, les AODs ont comme indication la prévention de la MTEV post-chirurgie orthopédique et, depuis peu, celle d'événements cardiovasculaires chez les coronariens stables et les patients souffrant d'artériopathie périphérique. Les AODs doivent, toutefois, être manipulés avec prudence : respect strict des schémas posologiques et des contre-indications, connaissance des interactions médicamenteuses. Dans un avenir proche, d'autres anticoagulants vont probablement élargir l'arsenal thérapeutique. Quelles seront leurs indications ? L'avenir nous le dira.

[How Itreat ... extended duration of anticoagulation in lower-limb deep venous thrombosis]. / Comment je traite... par anticoagulants la thrombose veineuse profonde des membres inférieurs après la phase aiguë.

Treatment of lower-limb deep vein thrombosis comprises three phases : the initial phase that includes the first 5 to 21 days, the long-term phase that includes the following 3 to 6 months and a potential extended phase (indefinite duration). After 3 to 6 months of anticoagulation, the treatment must be re-evaluated. Full or reduced dosage or complete cessation of anticoagulants can be proposed according to the individual benefit-risk balance. Risk assessment of recurrence may be challenging in the case of unprovoked venous thrombosis. Similarly, risk assessment of bleeding may be difficult. Consequently, a personalized decision must be made and regularly reassessed. As far as possible, it should also take into account the patient's preferences and lifestyle (dangerous sports, sedentary lifestyle, drug adherence,...). Further studies are still needed in order to better assess the individual risks and adapt the treatment.

Le traitement de la thrombose veineuse profonde des membres inférieurs comprend trois étapes : le traitement initial qui inclut les 5 à 21 premiers jours, le traitement au long cours qui dure 3 à 6 mois et un éventuel traitement prolongé, d'une durée non définie. Après 3 à 6 mois d'anticoagulation, se pose le problème de l'arrêt éventuel du traitement ou de la réduction de posologie. Evaluer le risque de récidive à l'arrêt du traitement est parfois une gageure en cas de maladie thromboembolique non provoquée. De même, l'évaluation du risque hémorragique peut être difficile. La décision doit donc être personnalisée et réévaluée régulièrement. Dans la mesure du possible, elle doit aussi tenir compte des préférences et du mode de vie des patients (sports à risque, sédentarité, observance,...). Des études ultérieures sont nécessaires afin de mieux évaluer les risques individuels et d'adapter la prise en charge.

[Lower extremity artery disease. Angioplasty and stenting in 2019.] / Artériopathie oblitérante des membres inférieurs. Angioplastie et stenting en 2019.

Lower extremity artery disease (LEAD) is frequent and too often neglected. The ongoing evolution of endovascular techniques has revolutionised its management. Vascular surgery is still recommended in specific clinical situations. It can be performed alone or combined with angioplasty-stenting in a hybrid procedure. Various parameters related to the patient, his pathology and to the medical team must be considered especially as randomized trials comparing devices and techniques are lacking. Technical progress should not mask the high cardiovascular morbi-mortality risk of these patients. Therefore LEAD must be detected as soon as possible and optimally managed by a multidisciplinary team. According to clinical stage and comorbidities, the team can include a general practitioner, an angiologist, a cardiologist, a nephrologist, a diabetologist, an oncologist, a radiologist, a vascular surgeon, a dermatologist, etc. Medical treatment of atherosclerosis and prevention are mandatory, as well as walking exercise. Due to its high cardiovascular and amputation risk, chronic limb-threatening ischemia must be quickly and optimally managed by a multidisciplinary team.

L'artériopathie oblitérante des membres inférieurs (AOMI) est une pathologie fréquente, trop longtemps négligée. L'évolution constante des techniques endovasculaires a révolutionné sa prise en charge. La chirurgie vasculaire conserve aussi des indications bien établies, qu'elle soit réalisée seule ou associée à l'angioplastie-stenting (procédure hybride). Différents paramètres liés au patient, à sa pathologie et à l'expérience de l'équipe médicale doivent être pris en considération, d'autant qu'on déplore l'absence d'études randomisées permettant de comparer les différents matériels et techniques entre eux. Les progrès techniques ne doivent pas faire oublier que l'AOMI chronique comporte un très haut risque de morbi-mortalité cardio-vasculaire. Elle doit donc être dépistée le plus tôt possible et prise en charge de façon optimale par une équipe multidisciplinaire, associant en fonction du stade clinique et des comorbidités, médecin généraliste, angiologue, cardiologue, diabétologue, néphrologue, cancérologue, radiologue, chirurgien vasculaire, etc. Le traitement médical de la maladie athéromateuse et la prévention restent incontournables, sans oublier le rôle du réentraînement à la marche. En raison du risque cardiovasculaire élevé et du risque d'amputation, l'ischémie critique chronique doit être rapidement prise en charge de façon optimale par une équipe multidisciplinaire.

[Lower limb venous thrombosis : Management in the acute phase]. / La thrombose veineuse profonde des membres inférieurs : Prise en charge en aigu.

Venous thromboembolism is the third cardiovascular disease in Europe. The cornerstone of the treatment of deep vein thrombosis is anticoagulation. It aims at avoiding harmful complications : thrombosis extension and recurrence, pulmonary embolism and post-thrombotic syndrome. Due to low molecular weight heparins, and recently, to direct oral anticoagulants, most of the patients can get treatment as outpatients. Unfortunately, despite guideline publications, the management of these patients may be complicated in real life and not correspond to evidence-based medicine. This paper aims at helping the practitian when dealing with this potentially dangerous and often misleading disease. The management of the patient after a 3 to 6-month coagulation treatment will be discussed later in a dedicated paper.

La maladie thrombo-embolique veineuse est la troisième maladie cardio-vasculaire en Europe. Le traitement de la thrombose veineuse repose essentiellement sur l'anticoagulation qui vise à prévenir de redoutables complications : extension et récidive de la thrombose, embolie pulmonaire et syndrome post-thrombotique. Grâce aux héparines de bas poids moléculaire et, plus récemment, aux anticoagulants oraux directs, la majorité des patients peut être traitée en ambulatoire. Pourtant, malgré les recommandations qui ont été publiées, force est de constater que celles-ci ne sont pas toujours respectées dans la «vraie vie¼. Le but de cet article est d'aider le praticien dans la prise en charge initiale d'une pathologie potentiellement dangereuse et parfois difficile à cerner. La prise en charge du patient après 3 à 6 mois de traitement sera discutée dans un article ultérieur.

[Transcranial color-coded sonography in the management of patients with cervical and intracranial arterial stenosis]. / L'écho-Doppler transcrânien dans la prise en charge des sténoses artérielles cervicales et intracrâniennes.

Technological innovations have endowed the development of powerful tools in medical imaging, such as transcranial color-coded sonography. In addition to other imaging techniques, its relevance in cerebrovascular disorders is increasing. This article aims to describe the technique through specification of its current indications in patients with arterial cervical and intracranial stenosis.

[Hokusai-VTE: edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism]. / L'etude clinique du mois. Hokusai-VTE: edoxaban versus warfarine dans le traitement de la maladie thromboembolique veineuse symptomatique.

Currently venous thromboembolic disease (VTE), i.e. deep venous thrombosis and pulmonary embolism, remains a major cause of morbidity and mortality all around the world. The Hokusai-VTE study is a randomized, double-blind trial to evaluate whether initial heparin (5 days) followed by the oral Xa factor inhibitor edoxaban (60 mg once daily) may be an alternative to the standard therapy, i.e. heparin (5 days) followed by warfarin (INR of 2.0-3.0) for the prevention of recurrent thromboembolism in patients with acute symptomatic VTE. In patients with VTE, including pulmonary embolism with right ventricular dysfunction, treatment with heparin followed by oral edoxaban 60 mg once daily was non inferior to the standard treatment with respect to efficacy and superior with respect to bleeding (fewer fatal and intracranial bleeds, but no statistical significance regarding major bleeding). Reducing the dosage of edoxaban to 30 mg once daily is safe in case of renal impairment and low body weight.

[Rivaroxaban: Xarelto--recommendations for pharmacists]. / Le Rivaroxaban (Xarelto): guide de la pratique officinale.

Rivaroxaban is one of the new oral anticoagulants (NOACs). It has many potential advantages in comparison with Vitamin K Antagonists (VKA). It has a predictable anticoagulant effect and does not theoretically require biological monitoring. It is also characterized by less food and drug interactions. However, due to major risks associated with over- and under-dosage, its optimal use in patients should be carefully followed by health care professionals. The aim of this article is to provide recommendations for pharmacists on the practical use of Xarelto in its different approved indications. This document is adapted from the practical user guide of rivaroxaban which was developed by an independent group of Belgian experts in the field of thrombosis and haemostasis.

[Detection of micro-embolic signals: a review of the literature]. / Détection de signaux micro-emboliques: revue de la littérature.

BACKGROUND: The detection of micro-embolic signals (MES), by transcranial Doppler sonography might be useful for risk stratification in patients with symptomatic and asymptomatic carotid or cerebral artery stenosis, dissections, aortic atheroma, interventional procedures, and right to left cardiac shunts. AIM: Review of the technique and clinical situations of MES detection. METHODS: PubMed search from 1990 to 2012. RESULTS: MES were found in 0,19, 48% versus 0,3, and 12% of patients with symptomatic and asymptomatic inferior than 30, 30 to 69, and 70 to 99% carotid stenosis, respectively. MES were related to the risk of recurrent stroke or transient ischemic attack (TIA). In the ACES study, the absolute annual risk of stroke or TIA after 2 years was 7% with vs 3% without MES. In patients with intracranial stenosis, the risk of stroke recurrence was 48% with vs 7% without MES at 13.6 months follow-up. MES were reported in 25% of the symptomatic versus none of the asymptomatic patients with intracranial stenosis. CONCLUSION: Detection of MES is feasible and reproducible for multicenter studies, using rigourous methodology and long lasting recordings. It may contribute to risk stratification, especially in patients with extra- or intracranial stenosis.

[2011 ESC guidelines on the diagnosis and treatment of peripheral artery diseases]. / Recommandations Européennes 2011 pour le diagnostic et le traitement des artériopathies périphériques.

In this article, we present the 2011 guidelines on the diagnosis and treatment of peripheral artery diseases. The document covers the diagnostic modalities and therapeutic strategies for the atherosclerotic disease of the extra-cranial carotid, mesenteric, renal, upper and lower extremity arteries indicating the class and level of evidence of the recommendations.

[How I treat...lower extremity deep vein thrombosis]. / Les thromboses veineuses des membres inférieurs.

Venous thromboembolism is a widespread and sometimes life-threatening disease. It is still often unadequately managed, however. This article aims at summing up the most recent national and international guidelines and points out usual pitfalls although some therapeutic uncertainties persist.

[New therapeutic guidelines in lower limb arteriopathy]. / Actualités thérapeutiques à propos de l'artériopathie des membres inférieurs.

This article describes the recent therapeutic options for lower limb arteriopathy and, as much as possible, analyzes the medical and surgical treatments according to the recommendations and levels of evidence.

The ankle-brachial pressure index and a standardized questionnaire are easy and useful tools to detect peripheral arterial disease in non-claudicating patients at high risk.

AIM: This observational study (Survey of Peripheral Arterial Disease Epidemiology, SPADE) evaluated the prevalence of asymptomatic peripheral arterial disease (PAD) in general practice. METHODS: PAD was determined as an ankle-brachial pressure index (ABI) <0.9 measured with Doppler ultrasound. Included patients had a history of ischemic events and/or risk factors for PAD, but no spontaneous complaints of intermittent claudication. Patients with an ABI <0.9 filled in a standardized questionnaire and their drug use was registered. A total of 4 536 patients was included. RESULTS: The prevalence of PAD was 18.7% for the total population, 26.5% for those with a history of ischemic events and 15.2% for those without such history. The prevalence increased with age, but was independent of gender. A standard questionnaire revealed leg pain when walking uphill or when hurrying in 2/3 of patients with an ABI <0.9 and in 45% criteria for claudication were met. CONCLUSION: ABI detects PAD in a considerable number of asymptomatic patients at increased risk and followed in general practice. When properly questioned almost half of these patients appear to have intermittent claudication.

[Post-radiotherapy and atherosclerotic stenosis of the internal carotid artery treated by angioplasty and stenting]. / Sténose carotidienne mixte post-radique et athérosclérotique traitée par stenting carotidien protégé.

We report the case of a 70-year old man treated by surgery and radiotherapy for a neoplasic lesion of the tongue in whom severe symptomatic stenosis of the left internal carotid artery occurred a few years later. This lesion was successfully treated by percutaneous carotid angioplasty and stenting with distal embolic protection (PCAS). After a period of experimenting with angioplasty and stenting, PCAS is becoming a serious alternative for carotid thrombo-endarterectomy (TEA). Indications for PCAS are currently patients who, due to several reasons, are no good candidates for surgery. Several of large PCAS versus TEA randomized trials are underway and final results will help us determine the best indication for TEA or PCAS for both low and high risk patients with symptomatic or asymptomatic carotid stenosis.

[Raynaud's phenomenon]. / Le phénomène de Raynaud.

Raynaud's phenomenon (RP) is a common vascular disorder characterized by a recurrent transient vasospasm of the fingers and toes on exposure to cold or with emotional stress. Clinical criteria are used to distinguish patients with primary or idiopathic RP (formely Raynaud's disease) from those with secondary RP (formely Raynaud's syndrome). They include history, general physical examination, capillaroscopy, test for antinuclear antibody and erythrocyte sedimentation rate. More specific exams may be needed in selective cases. Excluding RP of occupational origin, the most common cause of secondary RP is a connective tissue disease (particularly scleroderma). RP may precede other clinical symptoms by several years, but most patients with RP will not progress to systemic disease. Nevertheless, primary RP may cause significant disability. We review the pathophysiology and clinical criteria of the disorder. Unfortunately, management of PR is still empirical and largely supportive.

Evaluation, severity and prognostic significance of silent myocardial ischaemia in vascular patients.

This paper intends to make an update of recent publications and guidelines for evaluation in coronary symptom-free patients undergoing vascular surgery. It emphasizes the role of preoperative clinical evaluation that should identify the most appropriate testing, and treatment strategies to optimize care of the patient and avoid unnecessary testing in this era of cost containment. Selective preoperative coronary artery disease screening and revascularization achieve excellent perioperative and late results after high-risk vascular surgery. Supplemental preoperative evaluation is discussed (exercise ECG, stress echocardiography and stress tomoscintigraphy). Asymptomatic patients with good functional capacity can undergo intermediate-risk surgery without further non-invasive testing. Conversely, further noninvasive testing is often considered for patients with poor functional capacity or moderate functional capacity but higher-risk surgery especially for patients with 2 or more intermediate risk predictors. Additional testing may be considered on an individual basis for patients without clinical markers but with poor functional capacity prior to vascular surgery, particularly those with several minor clinical risk predictors. Because of a higher prevalence of silent myocardial ischaemia in diabetes mellitus, these patients require specific care. Until further data are available, indications for myocardial revascularization in the perioperative setting are similar to those in the ACC/AHA guidelines for use of myocardial revascularization in general. General practitioners, cardiologists, angiologists, vascular surgeons and anaesthesiologists should collaborate and aim to slow down the progression of atherosclerosis by giving their patients an optimum secondary cardiovascular prevention.