The evolution and impact of the American College of Chest Physicians consensus statement on antithrombotic therapy

The evolution of the American College of Chest Physicians consensus on antithrombotic therapy is reviewed, specifically with regard to the prevention and treatment of venous thromboembolism and the rules of evidence applied. A perspective on the impact of the recommendations is offered.     

经导管主动脉瓣植入术后抗血栓治疗中国专家共识

经导管主动脉瓣植入术(TAVI)现已成为治疗有症状重度主动脉瓣狭窄患者的有效措施,且适用人群也从老年高风险患者逐步扩展到中、低风险及较年轻患者,但其术后缺血性及出血性并发症仍不少见,并有一定的致死率和致残率。该专家共识复习了相关资料及研究进展,结合我国具体情况及国际指南,给出了TAVI术后抗血栓治疗的建议,以期提高我国TAVI术后患者生存率及生存质量,减少缺血及出血并发症。该共识从TAVI术后血栓形成及出血的危险因素和机制、缺血及出血风险评估、抗凝与抗血小板治疗的选择、抗血小板治疗的方案、抗血栓时程、瓣叶血栓及出血并发症的处理等方面进行了详尽的阐述。强调TAVI术后应综合评估患者缺血及出血事件发生的风险,方案的制定应个体化,进而改善患者预后。     

经导管主动脉瓣植入术后抗血栓治疗中国专家共识

经导管主动脉瓣植入术(TAVI)现已成为治疗有症状重度主动脉瓣狭窄患者的有效措施,且适用人群也从老年高风险患者逐步扩展到中、低风险及较年轻患者,但其术后缺血性及出血性并发症仍不少见,并有一定的致死率和致残率。该专家共识复习了相关资料及研究进展,结合我国具体情况及国际指南,给出了TAVI术后抗血栓治疗的建议,以期提高我国TAVI术后患者生存率及生存质量,减少缺血及出血并发症。该共识从TAVI术后血栓形成及出血的危险因素和机制、缺血及出血风险评估、抗凝与抗血小板治疗的选择、抗血小板治疗的方案、抗血栓时程、瓣叶血栓及出血并发症的处理等方面进行了详尽的阐述。强调TAVI术后应综合评估患者缺血及出血事件发生的风险,方案的制定应个体化,进而改善患者预后。     

75岁以上老年抗栓治疗专家共识

<正>75岁以上(≥75岁)老年人是心血管疾病的高发人群,且随着年龄增长,发病率呈显著增加趋势。约1/3罹患心肌梗死和2/3因心肌梗死死亡的患者超过75岁。制订《75岁以上老年抗栓治疗专家共识》,旨在通过总结临床研究结果并引入新的出血风险评分系统,提出适合我国75岁以上高龄患者的评价体系和抗栓建议。     

A consensus view of protein dynamics

The dynamics of proteins in aqueous solution has been investigated through a massive approach based on "state of the art" molecular dynamics simulations performed for all protein metafolds using the four most popular force fields (OPLS, CHARMM, AMBER, and GROMOS). A detailed analysis of the massive database of trajectories (>1.5 terabytes of data obtained using approximately 50 years of CPU) allowed us to obtain a robust-consensus picture of protein dynamics in aqueous solution.     

Comparing the 2010 North American and European atrial fibrillation guidelines

This article compares the important differences in the American College of Cardiology Foundation (ACCF)/American Heart Association (AHA)/Heart Rhythm Society (HRS), Canadian Cardiovascular Society (CCS), and European Society of Cardiology (ESC) 2010 guidelines on atrial fibrillation (AF). All guidelines recommend more lenient targets for ventricular rate control although the CCS guidelines recommend a target heart rate at rest <100 bpm whereas the the ACCF/AHA/HRS and ESC guidelines accept a target heart rate at rest <110 bpm with provisos. All the guidelines recommend that the choice of antiarrhythmic drug for maintenance of sinus rhythm be based on the underlying cardiovascular disease state. However, the CCS guidelines do not recommend that the use of Class IC drugs or sotalol be restricted in the presence of left ventricular hypertrophy alone. All the guidelines have incorporated dronedarone into their recommendations of antiarrhythmic drug therapy for maintenance of sinus rhythm. However, the CCS guidelines do not make a specific recommendation that the use of dronedarone is reasonable to decrease the risk of hospitalization for cardiovascular causes in patients with AF. The ACCF/AHA/HRS update makes a strong recommendation for catheter ablation in patients with paroxysmal AF who have failed a single anti-arrhythmic drug whereas the CCS and ESC guidelines make this a conditional recommendation. The CCS guidelines are the only guidelines at present that recommend dabigitran for prevention of stroke in high risk patients and suggest that dabigatran is preferred to warfarin for stroke prevention in most patient groups.     

Pre PCI hospital antithrombotic therapy for ST elevation myocardial infarction: striving for consensus

Strong evidence exists in favor of rapid transfer of a patient suffering an ST-elevation myocardial infarction (STEMI) to the nearest hospital with primary percutaneous coronary intervention (PCI) capability, assuming the time from first medical contact to balloon inflation can be achieved in less than 90 min. In many areas, PCI hospitals have successfully collaborated with regional non-PCI hospitals to provide primary PCI for STEMI; however, significant variations exist in how these programs are executed. For example, the pre PCI hospital administration of antithrombotic agents by emergency medical personnel can include aspirin, clopidogrel, unfractionated heparin, low molecular weight heparin, partial or full dose fibrinolytics or combinations thereof. There is little consensus on the optimal cocktail, dose and route of administration. Standardizing the pre PCI antithrombotic regimen across hospital systems may be one approach to improve timely administration of these therapies, and potentially improve STEMI outcomes.     

New and traditional therapy of congestive heart failure. A European view

Our experiences with new drugs in the therapy of congestive heart failure indicate that nitroprusside infusion favorably influences acute left ventricular failure resulting from acute myocardial infarction. Although this vasodilator is beneficial in improving hemodynamic derangements in the acute phase, its effects on enhancing both short-term and long-term survival in myocardial infarction pump dysfunction remain to be ascertained. Concerning the oral vasodilators, of the agents we have evaluated, oral isosorbide dinitrate has been the most useful in achieving improved cardiac function in chronic hemodynamic overload. In contrast, although long-term administration of oral slow-release phentolamine in chronic ischemic heart disease has decreased, increased left ventricular filling pressure and tended to enhance an increase in cardiac output with exercise, serious side-effects obviate the use of the agent in longterm therapy of cardiac failure. Dobutamine infusion provides pronounced enhancement of abnormal hemodynamics in chronic coronary heart disease; however, its use appears to worsen the degree of myocardial aerobic metabolism in patients with active ischemic heart disease. Digitalis and diuretics still play an important role in the therapy of most instances of chronic congestive heart failure.     

The European consensus on hepatitis C

The European Association for the Study of the Liver (EASL) International Consensus on Hepatitis C made by 72 experts in hepatology, epidemiology and virology at the EASL Consensus Conference, Paris, February, 1999 and confirmed by the 34th EASL Annual Meeting, Naples, 8-12 april 1999, is widely reviewed. Some newest and more effective strategies for treatment of the chronic viral hepatitis C were discussed during the Naples EASL meeting. Higher doses interferons (interferon-alpha or consensus interferon) plus ribavirin (or combination ribavirin and amantadine) for a longer period--12 months, improved efficacy of the treatment of chronic hepatitis C. An ultrarapid HCV clearance by daily hgh-dose interferon-alpha induction therapy in the start of the management plus ribavirin was achieved and discussed in naive patients and in nonresponders to standard therapy. A gene therapy by an effective genetic vaccine against HCV infection was widely discussed, too. Hepatitis C is an enormous present and future health burden to the world. Not until 2010, the most of therapeutic problems in patients with chronic persisted HCV infection would be resolved.     

Differences in European and North American approaches to the management of heart failure

In recent years many guidelines on the treatment of specific medical conditions have been published with the goal of advising physicians, promoting good clinical care, and achieving a degree of equity and equality in the delivery of care. Differences exist between European and American guidelines for the management of heart failure not just because of differences in health systems but also because there is little agreement on how to assess clinical trials and convey conclusions in a clear format. Current recommendations can be confusing and often do not reflect the complexities of modern personalized medicine.     

European consensus on the histopathology of inflammatory bowel disease

The histologic examination of endoscopic biopsies or resection specimens remains a key step in the work-up of affected inflammatory bowel disease (IBD) patients and can be used for diagnosis and differential diagnosis, particularly in the differentiation of UC from CD and other non-IBD related colitides. The introduction of new treatment strategies in inflammatory bowel disease (IBD) interfering with the patients' immune system may result in mucosal healing, making the pathologists aware of the impact of treatment upon diagnostic features. The European Crohn's and Colitis Organisation (ECCO) and the European Society of Pathology (ESP) jointly elaborated a consensus to establish standards for histopathology diagnosis in IBD. The consensus endeavors to address: (i) procedures required for a proper diagnosis, (ii) features which can be used for the analysis of endoscopic biopsies, (iii) features which can be used for the analysis of surgical samples, (iv) criteria for diagnosis and differential diagnosis, and (v) special situations including those inherent to therapy. Questions that were addressed include: how many features should be present for a firm diagnosis? What is the role of histology in patient management, including search for dysplasia? Which features if any, can be used for assessment of disease activity? The statements and general recommendations of this consensus are based on the highest level of evidence available, but significant gaps remain in certain areas.     

Thrombo-embolism and antithrombotic therapy for heart failure in sinus rhythm. A joint consensus document from the ESC Heart Failure Association and the ESC Working Group on Thrombosis

Chronic heart failure (HF) with either reduced or preserved ejection fraction is common and remains an extremely serious disorder with a high mortality and morbidity. Many complications related to HF can be related to thrombosis. Epidemiological and pathophysiological data also link HF to an increased risk of thrombosis, leading to the clinical consequences of sudden death, stroke, systemic thrombo-embolism, and/or venous thrombo-embolism. This consensus document of the Heart Failure Association (EHFA) of the European Society of Cardiology (ESC) and the ESC Working Group on Thrombosis reviews the published evidence and summarizes 'best practice', and puts forward consensus statements that may help to define evidence gaps and assist management decisions in everyday clinical practice. In HF patients with atrial fibrillation, oral anticoagulation is recommended, and the CHA(2)DS(2)-VASc and HAS-BLED scores should be used to determine the likely risk-benefit ratio (thrombo-embolism prevention vs. risk of bleeding) of oral anticoagulation. In HF patients with reduced left ventricular ejection fraction who are in sinus rhythm there is no evidence of an overall benefit of vitamin K antagonists (e.g. warfarin) on mortality, with risk of major bleeding. Despite the potential for a reduction in ischaemic stroke, there is currently no compelling reason to use warfarin routinely for these patients. Risk factors associated with increased risk of thrombo-embolic events should be identified and decisions regarding use of anticoagulation individualized. Patient values and preferences are important determinants when balancing the risk of thrombo-embolism against bleeding risk. New oral anticoagulants that offer a different risk-benefit profile compared with warfarin may appear as an attractive therapeutic option, but this would need to be confirmed in clinical trials.     

Antibiotic therapy against Pseudomonas aeruginosa in cystic fibrosis: a European consensus.

Cystic fibrosis (CF) is the most common lethal hereditary disorder with autosomal recessive heredity in caucasians. The majority of CF patients suffer from chronic respiratory infection with the opportunistic bacterial pathogen Pseudomonas aeruginosa. No consensus among clinicians has been reached so far concerning antibiotic treatment against P. aeruginosa in CF patients. Consensus answers to 24 important questions in this context, based on current evidence, are presented, given by a panel of 34 European experts. Questions addressed and answered are: The diagnosis of P. aeruginosa lung colonization in CF; The impact of P. aeruginosa on the clinical state of CF patients; The assessment of P. aeruginosa susceptibility against antibiotics and the importance of these results for the clinician; The use of monotherapy versus combination therapy; The development of microbial resistance; The achievement of optimal airway concentrations; The effects of subinhibitory concentrations of antibiotics on P. aeruginosa; Statements on the pharmacokinetics of antibiotics in CF patients; Recommendations for doses and dosing intervals and length of treatment regimens; and Toxic side effects due to repeated antibiotic therapy was addressed. The expert panel answered further questions on the use of fluoroquinolones in children with CF, on the administration of nebulized antibiotics and whether prevention of P. aeruginosa lung colonization is possible in CF using antibiotic therapy. Problems of antibiotic therapy at home and in the hospital were addressed, a consensus statement on regular maintenance treatment, or treatment on demand, was given and different routes of administration of antibiotics were recommended for different clinical situations. Finally, the factors which determine the choice of the antibiotic, the dosage, and the duration of the treatment in cystic fibrosis patients were addressed and the design of future antibiotic studies in the context of Pseudomonas aeruginosa lung infection in cystic fibrosis patients were recommended.