Obesity Paradox in Atrial Fibrillation and its Relation with the New Oral Anticoagulants.

Obesity, a chronic disease established as a global epidemic by the World Health Organization, is considered a risk factor for atrial fibrillation (AF), the most common sustained cardiac arrhythmia, which has high morbidity and mortality. Although both obesity and AF are diseases associated with negative outcomes, studies have shown the presence of an obesity paradox, in which patients with a high body mass index (BMI) and AF have a better prognosis than patients with a normal BMI. Despite the fact that the mechanisms that lead to this paradox are still uncertain, adequate anticoagulation in obese patients seems to play an important role in reducing adverse events in this group. In this perspective article, the authors discuss the relationship between new oral anticoagulants (NOACs), namely, apixaban, edoxaban and rivaroxaban (factor Xa inhibitors) and dabigatran (direct inhibitor of thrombin), and the obesity paradox, seeking to deepen the understanding of the mechanism that leads to this paradox.

Effectiveness and safety of dabigatran in Latin American patients with atrial fibrillation: Two years follow up results from GLORIA-AF registry.

BACKGROUND: Real-world data from different regions are needed to support the external validity of controlled trials and assess the impact of new oral anticoagulants (NOAC) in clinical practice. METHODS: "GLORIA-AF" is a large, ongoing, multicenter, global, prospective registry program in patients with newly diagnosed non-valvular atrial fibrillation (NVAF) at risk of stroke. Newly diagnosed patients with NVAF (within 4.5 months) and a CHA2DS2-VASc score ≥ 1 were consecutively enrolled. The study objective was to estimate the incidence rate of stroke and major bleeding after a two year follow up of patients on dabigatran that participated in the "GLORIA-AF" study (Phase II) in Latin America. RESULTS: Latin America included 378 eligible patients that received dabigatran in eight countries (Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, Perú, and Venezuela): 56.3% were male; mean age was 70.3 ± 10.8 years; 43.4% had paroxysmal AF; 36.0% persistent AF and 20.6% permanent AF. Mean CHA2DS2-VASc score was 3.2 ± 1.4; mean HAS-BLED score was 1.2 ± 0.8. Incidence rates for clinical events after 2-years of follow-up per 100 patient-years were as follows: stroke 0.33 (95% CI: 0.04-1.17), major bleeding 0.49 (95% CI: 0.10-1.42) and all-cause death 4.06 (95% CI: 2.63-6.00). Persistence with dabigatran at 6, 12 and 24 months was 91%, 86%, and 80%, respectively. CONCLUSION: These regional data shows the sustained safety and effectiveness of dabigatran over two years of follow-up, consistent with already available evidence. An increase in accessibility and incorporation of NOAC to anticoagulant treatment strategies could potentially have a positive impact on AF stroke prevention in Latin America.

Rivaroxaban in the cardiovascular world: a direct anticoagulant useful to prevent stroke and venous and arterial thromboembolism.

INTRODUCTION: Until recently, vitamin K antagonists (VKA) were the only drugs available for long-term anticoagulation. The use of these drugs is laborious due to their variable pharmacokinetics and pharmacodynamics. The advent of direct oral anticoagulants has produced a paradigm shift due to their low incidence of drug interactions, their stable plasma levels, and their lack of monitoring. Rivaroxaban, a factor Xa inhibitor, has been tested in different clinical scenarios and has proved to be effective and safe, even increasing the scope of the old VKA. Areas covered: A non-systematic review of the literature was conducted using the PubMed and Cochrane databases, focusing on randomized clinical trials and real-world observational studies that evaluated rivaroxaban in patients with atrial fibrillation, venous thromboembolism, and atherosclerotic coronary and peripheral vascular disease. Expert commentary: The role of rivaroxaban keeps expanding into areas that were unimaginable few years ago, in the light of solid evidence that has eliminated old strict paradigms. Nonetheless, it will be necessary to adjust costs and better understand the perceived barriers to its widespread implementation, to get fully acceptation of rivaroxaban for the different clinical conditions that have been suggested.

Segunda publicación nuevos anticoagulantes orales: guía práctica para los médicos / Second publication new oral anticoagulants: a practical guide for doctors

Resumen Los nuevos anticoagulantes orales suponen una atractiva alternativa para los clásicos antagonistas de la vitamina K (AVKs) en la prevención de ictus en pacientes con fibrilación auricular no valvular. A diferencia de los AVKs, estos anticoagulantes no requieren monitorización ni ajuste de dosis y poseen propiedades farmacológicas favorables. La falta de antídoto efi caz, su coste, o dudas en cuanto a la seguridad en los pacientes con enfermedad renal avanzada pueden explicar su lento ritmo de expansión. El uso seguro y eficaz de estos nuevos medicamentos depende en gran medida de la experiencia clínica entre la comunidad médica. Esta revisión discute las peculiaridades de los nuevos anticoagulantes orales, propor cionando algoritmos prácticos y fáciles de usar para su aplicación en la práctica clínica diaria.

Abstract New oral anticoagulants suppose an attractive alternative for classical vitamin K antagonists (AVKs) in stroke prevention for patients with non-valvular atrial fibrillation. Unlike AVKs, these anticoagulants do not require monitoring or dose adjustment and have favourable pharmacological properties. The lack of an effective antidote, its cost, or doubts regarding the safety of patients with advanced kidney disease may explain its slow rate of expansion. The safe and effective use of these new medications depends largely on clinical experience among the medical community. This review discusses the peculiarities of the new oral anticoagulants, providing practical and easy-to-use algorithms for their application in daily clinical practice.

Manejo perioperatorio de pacientes con tratamiento anticoagulante crónico / Perioperative management of patients with chronic anticoagulant therapy

Resumen La terapia anticoagulante es ampliamente utilizada en la práctica clínica, como profilaxis en pacientes con riesgo de presentar fenómenos tromboembólicos o como tratamiento en aquellos que han presentado algún evento trombótico. Cada vez es más frecuente enfrentarse a pacientes en tratamiento anticoagulante crónico que serán intervenidos mediante procedimientos quirúrgicos, por lo que es importante y necesario conocer el manejo perioperatorio de los diferentes fármacos anticoagulantes, para disminuir los riesgos y complicaciones asociados a la suspensión o mantención de estos en el período perioperatorio. Para lograr este objetivo se debe evaluar y balancear el riesgo de sangrado versus el riesgo de eventos tromboembólicos, considerando la condición médica de cada paciente y el tipo de procedimiento quirúrgico que recibirá. La recomendación para fármacos anticoagulantes orales antagonistas de vitamina K es mantenerlos en cirugías con bajo riesgo de sangrado y suspenderlos 5 días antes de procedimientos quirúrgicos con riesgo hemorrágico moderado y alto, controlando el international normalized ratio el día previo a la cirugía. Los nuevos anticoagulantes orales no requieren monitorización de rutina, recomendándose suspenderlos a las 24-96 h previas al procedimiento quirúrgico, dependiendo del riesgo hemorrágico de cada cirugía y de la función renal. En relación con los anticoagulantes parenterales, la heparina no fraccionada en infusión intravenosa se recomienda suspenderla 4-5 h antes de la cirugía, mientras que la utilizada vía subcutánea, 12 h previas a la intervención quirúrgica. Las heparinas de bajo peso molecular en dosis de tratamiento se sugiere descontinuarlas 24 h previas a la cirugía, mientras que las usadas en dosis profilácticas, solo 12 h antes.

Anticoagulant therapy is widely used in clinical practice, as prophylaxis in patients at risk of presenting thromboembolic phenomena or as treatment in those who have presented a thrombotic event. It is increasingly the number of patients on chronic anticoagulant therapy to undergo surgical procedures, so it is important and necessary to know the perioperative management of the different anticoagulant drugs to reduce the risks and complications associated with suspension or maintenance of these in the perioperative period. To achieve this goal, the risk of bleeding should be evaluated and balanced against the risk of thromboembolic events, considering the medical condition of each patient and the type of surgical procedure to which they have undergone. The recommendation for vitamin K antagonist oral anticoagulant drugs is to maintain them for surgeries at low risk of bleeding and to suspend them 5 days before surgical procedures with moderate and high bleeding risk, controlling 'International Normalized Ratio' the day before surgery. The new oral anticoagulants do not require routine monitoring, recommending suspending them 24-96 h prior to the surgical procedure, depending on the hemorrhagic risk of each surgery and renal function of patient. In relation to parenteral anticoagulants, unfractionated heparin in intravenous infusion is recommended to be discontinued 4-5 h prior to surgery, while the subcutaneous route, 12 h prior to surgery. Low-molecular-weight heparins in treatment doses should be suspended 24 h prior to surgery, while in prophylactic doses, only 12 h earlier.

Nuevos anticoagulantes en cardiología / New anticoagulants in Cardiology

Los nuevos anticoagulantes orales son una alternativa más para el tratamiento y la prevención de la enfermedad tromboembólica, como su farmacología es nueva, aquí presentamos una revisión de los aspectos farmacológicos más importantes de su dosificación, variaciones de acuerdo con las diferentes características de los pacientes, hasta los protocolos recomendados para cirugía y para intercambio de diferentes anticoagulantes, también las ventajas y contraindicaciones, así como algunas recomendaciones de antídotos.

The new oral anticoagulants are an alternative for the treatment and prevention of thromboembolic disease, as itspharmacology is new, here is a review of the most important aspects from drug dosing and dose variations accordingto different patient, characteristics also present the recommended protocols for surgery and exchange of differentanticoagulants benefits and contraindications as well as some recommendations of antidotes.