Navigating the choice of oral anticoagulation therapy for atrial fibrillation in the NOAC era.

Atrial fibrillation (AF) is a major cause of ischaemic stroke. The majority of these strokes can be prevented by treatment with oral anticoagulation therapy. The advent of non-vitamin K antagonist oral anticoagulants (NOACs) has resulted in a choice of therapeutic agents available to physicians for anticoagulation for stroke prevention in patients with AF beyond the long-established vitamin K antagonists (VKAs). Pivotal trials have demonstrated non-inferiority of NOACs compared with VKAs, and in some cases superiority, for the prevention of stroke and systemic embolism in non-valvular AF. Yet there are no direct head-to-head comparator trials for the efficacy of NOACs. Therefore, the question of which oral anticoagulant for each individual patient can present a challenge to physicians. In this review article, we assess which patients with AF require anticoagulation, review the available therapeutic options, assessing the evidence base for each and offering guidance as to patient-specific factors that can influence this choice.

Ezetimibe: an update on its clinical usefulness in specific patient groups.

The aim of pharmacological lipid modification is to reduce low-density lipoprotein cholesterol (LDL-C) as a means of either secondary or primary prevention of cardiovascular disease. Statins are the first-line therapy for pharmacological lipid modification. Ezetimibe is a drug which reduces LDL-C by selectively inhibiting intestinal cholesterol absorption. This provides an alternative pharmacological approach to that of statin therapy to reduce LDL-C. Ezetimibe has been shown to significantly reduce levels of LDL-C and recently, as demonstrated in the IMPROVE-IT trial, to reduce the rate of cardiovascular events in high-risk patients. Ezetimibe therefore has an important role in pharmacological lipid modification. In this paper, we examine the body of research behind ezetimibe and assess its current clinical applications in different patient subgroups.

Prospective peer review of regional percutaneous interventional procedures: a tool for quality control and revalidation.

AIMS: Current quality measures of percutaneous coronary intervention (PCI) procedures are based on the incidence of major adverse cardiac events (MACE). This crude marker ignores the many clinical nuances that make for sound decision making in PCI. We have established a prospective peer review audit tool to determine the quality of PCI within our cardiac network, which consists of five PCI hospitals serving a population of 1.4 million people in Sussex, UK. METHODS AND RESULTS: Analysis of 10% of all PCI cases selected at random each month by a non-clinical audit manager is made by a rotating panel of two PCI operators and one cardiac surgeon. Each PCI case is assessed for anatomical suitability, lesion severity, strategic appropriateness and final outcome. Panel findings were reported back to the operator and the audit manager. A total of 326 cases were assessed by the review committee. Results were disseminated to individual operators. Coronary anatomy and lesion severity were considered appropriate for PCI in 94.2% and 96.0% of cases, respectively. Appropriateness of strategy was confirmed in 86.2% and the outcome considered satisfactory in 90.8%. A total of 242 subsequent cases were analysed to assess practice trends. This analysis demonstrated a statistically significant improvement in clinical decision making with respect to appropriateness of strategy (from 86.2% to 92.6%; p=0.004). CONCLUSIONS: Prospective peer review of percutaneous coronary intervention cases by a rotating regional committee is valuable in ensuring procedural quality.

Rescue angioplasty for failed fibrinolysis--long-term follow-up of a large cohort.

BACKGROUND: Fibrinolysis remains an important treatment for ST-elevation myocardial infarction, but fails to achieve adequate reperfusion in a significant proportion of cases. "Rescue" angioplasty is seen as the preferred treatment strategy in most contemporary centers although the literature provides conflicting evidence. METHODS: We retrospectively reviewed all cases of rescue angioplasty performed at our cardiothoracic center from July 1999 to June 2008. The diagnosis of failed lysis was made on the basis of an ECG demonstrating failure of ST segment resolution >50% at 90 min. Periprocedural data was taken from a dedicated procedural database and mortality data obtained from the UK Office of National Statistics. RESULTS: A total of 316 cases were performed. Patients were aged 61 ± 11 years. Thirty-day mortality was 8.9%. Thirty-day mortality in those presenting with cardiogenic shock was 50%, and in those requiring blood transfusion was also 50%. Thirty day mortality in those with TIMI III flow at the end of the procedure was significantly less than in those in whom this was not the case (6.6% vs. 23.3%; P < 0.001). One year mortality for the entire cohort was 10.1%. Longer-term follow-up revealed after 5.2 ± 2.3 years, survival in this cohort was 83%. Significant bleeding requiring blood transfusion occurred in 2.5% of cases. CONCLUSIONS: We have shown that rescue angioplasty can be performed with good procedural success rates and excellent long-term results. Limiting bleeding complications and achieving TIMI III flow appear to be major determinants of achieving good long term results.