Selecting the right anticoagulant for stroke prevention in atrial fibrillation.

OBJECTIVE: The embolization of thrombi formed within the atria can occur in any form of atrial fibrillation (AF), i.e., paroxysmal, persistent, or permanent. Although ischemic stroke is the most frequent embolic event associated with AF, embolization to other sites in the pulmonary and systemic circulations may occasionally occur. To avert the risk of embolization, long-term oral anticoagulation therapy is recommended for all AF patients if the CHA2DS2-VASC score is at least 1 for men and at least 2 for women. Since anticoagulant therapy is associated with an increased risk of bleeding, the choice of oral anticoagulant agent should be made by careful consideration of the benefit-to-risk ratio. The use of a newer class of direct oral anticoagulants (DOACs) as an alternative to the anti-vitamin K (AVK) anticoagulants (warfarin, acenocumarol, etc.) can help mitigate the need for periodic monitoring of International Normalized Ratio (INR) and adverse bleeding events that are commonly associated with the use of AVK anticoagulants. Though the use of DOACs (dabigatran, rivaroxaban, edoxaban, apixaban, etc.) is gaining ground due to their relative safety profile and the low overall cost, quite a few clinicians remain skeptical about their use. PATIENTS AND METHODS: Our objective was to evaluate the risk of thromboembolism, stroke, neuropsychiatric illness, depression, and dementia, in patients with non-valvular atrial fibrillation who have been treated with either acenocumarol or apixaban, as well as to see the inflammatory status (ESR) and levels of fibrinogen. Our team at Municipal Emergency University Hospital, Timisoara, Romania, conducted a retrospective study using the medical records of AF patients who were treated with either apixaban or acenocumarol between 2016-2019. We divided the patients into two groups and compared the groups for the aforementioned outcomes. RESULTS: AF patients who were prescribed apixaban had a lower rate of stroke and psychiatric illness compared to those on acenocumarol. No significant correlation was found in terms of risk of developing depression or dementia between the groups. CONCLUSIONS: Non-valvular AF patients on apixaban had lower rates of thromboembolic events than the patients on acenocumarol. This article will serve as a reminder of the positive health and financial outcomes of apixaban use, especially to those healthcare systems that are still oblivious to the decrease in economic burden and gain in quality-adjusted life years (QALY) by the long-term use of NOACS/ DOACS instead of the AVK anticoagulants.

Customized laboratory TLR4 and TLR2 detection method from peripheral human blood for early detection of doxorubicin-induced cardiotoxicity.

Cancer treatments can have significant cardiovascular adverse effects that can cause cardiomyopathy and heart failure with reduced survival benefit and considerable decrease in the use of antineoplastic therapy. The purpose of this study is to assess the role of TLR2 and TLR4 gene expression as an early marker for the risk of doxorubicin-induced cardiomyopathy in correlation with early diastolic dysfunction in patients treated with doxorubicin. Our study included 25 consecutive patients who received treatment with doxorubicin for hematological malignancies (leukemia, lymphomas or multiple myeloma), aged 18-65 years, with a survival probability>6 months and with left ventricular ejection fraction>50%. Exclusion criteria consisted of the following: previous anthracycline therapy, previous radiotherapy, history of heart failure or chronic renal failure, atrial fibrillation, and pregnancy. In all patients, in fasting state, a blood sample was drawn for the assessment of TLR2 and TLR4 gene expression. Gene expression was assessed by quantitative reverse transcription PCR (qRT-PCR) using blood collection, RNA isolation, cDNA reverse transcription, qRT-PCR and quantification of the relative expression. At enrollment, all patients were evaluated clinically; an ECG and an echocardiography were performed. The average amount of gene expression units was 0.113 for TLR4 (range 0.059-0.753) and 0.218 for TLR2 (range 0.046-0.269). The mean mRNA extracted quantity was 113 571 ng/µl. As for the diastolic function parameters, criteria for diastolic dysfunction were present after 6 months in 16 patients (64%). In these patients, the mean values for TLR4 were 0.1198625 and for TLR2 were 0.16454 gene expression units. As for the diastolic function parameters, criteria for diastolic dysfunction were present after 6 months in 16 patients (64%). In these patients, the mean value for TLR2 was 0.30±0.19 and for TLR4 was 0.15±0.04. The corresponding values for the patients who did not develop diastolic dysfunction were 0.16±0.07 for TLR2 (P=0.01) and 0.11±0.10 for TLR4 (P=0.2). Our study suggests that TLR4 and TLR2 expression is higher in patients under doxorubicin therapy who develop diastolic dysfunction. This may suggest a predisposition to myocardial involvement, a higher sensitivity to doxorubicin cardiac effects.

The value of intermittent inotropic therapy in unhospitalized patients with refractory heart failure.

The treatment of intractable heart failure (New York Heart Association--NYHA IV) with inotropic support is a well established adjunct in the control of clinical status of end-stage heart failure patients but usually needs many admissions and a long period of hospitalization. In this study we report on the follow-up findings of 64 patients for 18 months who were seen in an outpatients congestive heart failure program. All patients had their full standard oral drug treatment, received intensive patient teaching and weekly inotropic infusions. We assess the effects of this comprehensive therapeutic approach on: 1) the number of hospital admissions, 2) length of stay and 3) the number of emergency room visits during the ensuing year. These data were compared with similar data from the year before entry in the program for each patient. All our patients showed NYHA class IV heart failure and received dobutamine to manage their chronic heart failure in an outpatient setting. The cause of heart failure was ischaemic in 34 (53.12%), idiopathic in 14 (21.87%), hypertension in 10 (15.62%), pulmonary hypertension in 7 (10.93%) and valvular heart disease in 6 (9.37%) patients. The mean period of observation was 382 days. For the period before entry in the program patients had 67 emergency room visits, 184 admissions, and 832 days spent in the hospital. After enrollment all these figures significantly decreased (p<0.001), patients heading 35 emergency room visits, 112 admissions and 518 days spent in the hospital. In conclusion, the intermittent inotropic therapy as an outpatient setting may be a valuable cost-effective therapeutic method, in patients with refractory heart failure and is associated with the reduction of emergency room visits, admissions and days spent in the hospital.

Assessment of treatment with orotate magnesium in early postoperative period of patients with cardiac insufficiency and coronary artery by-pass grafts (ATOMIC).

The benefit of the treatment with magnesium orotate (magnerot) was assessed in a randomised, single blind and placebo controlled study. Respecting the inclusion criteria were selected 32 patients with ischemia chronic failure in early postoperative period after CABG. The main improvements induced by magnesium orotate are the increase in exercise capacity (distance ambulated during 6 minutes walk test and ergospirometric parameters) and the reduction of ventricular premature beats. The treatment was well tolerated and the adverse reactions were not significant. The study strongly suggests the benefit of magnesium orotate added to classical antiischemic therapy in the complex management of coronary patients after CABG.