Treatment of chronic nonvalvular atrial fibrillation in the elderly: a decision analysis.

The objective of the study was to determine the preferred treatment strategy for elderly patients with chronic nonvalvular atrial fibrillation (CNVAF). A Markov decision-analytic model was used to compare three treatment strategies for CNVAF: 1) warfarin; 2) aspirin; and 3) no treatment. Five-year quality-adjusted life years (QALYs) were calculated for male and female cohorts aged 70 and 75 years. In the baseline analysis (effectiveness of warfarin = 0.70, effectiveness of aspirin = 0.45, utility of warfarin = 0.99, and utility of aspirin = 0.999) the quality-adjusted survival rates for 70-year-old males were 4.03 QALYs on warfarin, 4.02 QALYs on aspirin, and 3.95 QALYs on no treatment. Results were similar for all age and sex cohorts. Sensitivity analyses revealed that the results were very sensitive to the effectiveness of aspirin and the disutility of warfarin. The authors conclude that the optimal strategy for the treatment of CNVAF in elderly patients varies with the disutility assigned to warfarin therapy and the effectiveness value for aspirin therapy.     

Warfarin for dilated cardiomyopathy: a bloody tough pill to swallow?

Although current recommendations for the treatment of dilated cardiomyopathy include long-term anticoagulation to diminish the likelihood of systemic embolization, there have been no clinical trials examining the effectiveness of anticoagulation in preventing systemic embolization in these patients. Furthermore, those recommendations do not address the issue of the quality of life associated with long-term warfarin therapy. Using decision analysis, the authors examined the benefits and risks of long-term anticoagulation for patients 35 to 75 years of age who have dilated cardiomyopathy. The results show that anticoagulant therapy increases quality-adjusted life expectancy by 76 to 128 days, depending on the patient's age. Sensitivity analysis, however, demonstrates that the outcome is dependent on the disutility associated with long-term warfarin therapy. Interestingly, anticoagulation exerts most of its benefit by preventing pulmonary embolization, not systemic embolization. The authors conclude that the current recommendation to anticoagulate these patients, although probably correct for many patients, should take into consideration the change in lifestyle imposed by long-term anticoagulant therapy. For some patients, the benefit may not outweigh the sacrifice.     

Perioperative management of patients receiving anticoagulant or antiplatelet therapy: a clinician-oriented and practical approach

The management of patients who are receiving warfarin, aspirin, clopidogrel, or combinations of these drugs and require their interruption because of an elective surgical or other invasive procedure is a common and sometimes challenging clinical problem. For the practicing clinician, there are 2 key issues for perioperative anticoagulant management: 1) having an approach to stratify patients according to their risk for thromboembolism when warfarin or antiplatelet drug therapy is interrupted, and also having an approach to stratify patients according to the risk of bleeding associated with the surgery or procedure; and 2) determining which patients may require bridging anticoagulation and, if required, how to administer bridging, typically with a low-molecular-weight heparin, before and after surgery in a manner that minimizes the risk for bleeding. The overall goal is to minimize patients' risk for thromboembolism and bleeding throughout the perioperative period. The objective of this article is to provide an evidence-based but practical approach relating to these 2 key issues in a manner than can be applied to everyday clinical practice.     

A Monthly Critical Overview of Current Medicine Vol. 5 No. 9

Although morbidity and mortality remain high, we now have effective strategies to prevent development of the disease in many patients at risk. For those who do not benefit from prophylaxis, our understanding of optimal diagnostic strategy has improved, as has that of classic anticoagulation therapy with heparin and warfarin. Thrombolysis may also improve outcome.     

Managing pulmonary embolism

Although morbidity and mortality remain high, we now have effective strategies to prevent development of the disease in many patients at risk. For those who do not benefit from prophylaxis, our understanding of optimal diagnostic strategy has improved, as has that of classic anticoagulation therapy with heparin and warfarin. Thrombolysis may also improve outcome.     

二尖瓣成形术治疗二尖瓣关闭不全的疗效分析

目的分析二尖瓣瓣膜成形术(MVP)治疗中重度二尖瓣关闭不全(MR)患者的临床疗效。 方法以2013年6月至2017年6月徐州医科大学附属沭阳医院心胸外科收治的28例行MVP的MR患者为研究对象行回顾性分析,其中男性17例,女性11例;年龄50～72岁,平均(61.5±10.6)岁。所有患者术前均存在中重度MR。术前根据患者的合并症、病变部位的定位和合并腱索断裂与否,评估选择可行的MVP术式及合并手术：所有患者均采用正中切口、体外循环下手术治疗,术中行二尖瓣楔形切除、矩形切除及缘对缘缝合方法修补二尖瓣,合并腱索断裂或腱索冗长的行e-PTFE线人工腱索植入,常规行二尖瓣成型环植入,术中注水观察评估瓣膜成行效果。术中采取的二尖瓣成形方法统计：7例(25.0%)植入1～3根腱索,行二尖瓣矩切除术9例(32.1%),二尖瓣楔形切除术8例(28.6%),二尖瓣缘对缘缝合4例(14.3%),所有患者均置入鞍形二尖瓣成形环。对于合并心房颤动的患者同期行单纯左心耳切除术(LAA),或心房颤动射频消融术(AB)＋LAA;合并冠心病,则同期行冠状动脉搭桥术(CABG);合并中度及以上的三尖瓣关闭不全,则同期行三尖瓣成形环植入手术(TVP)。1例(3.6%)患者行MVP＋CABG,1例(3.6%)行MVP＋TVP＋LAA;3例(10.7%)行MVP＋TVP＋AB＋LAA;5例(17.9%)行MVP＋TVP;18例(64.3%)行单纯MVP。术后予华法林抗凝治疗3～6个月,合并心房颤动者终身抗凝治疗。统计所有患者采取的手术方式,包括合并手术、二尖瓣成形方法;对比患者术前及术后2年的返流、心功能改善情况以及LAD、左心室舒张末内径(LVEDD)、左心室射血分数(LVEF)水平的差异。 结果所有患者术前均为中重度返流,术后2年复查心脏彩超：21例(75.0%)无明显二尖瓣返流,6例(21.4%)二尖瓣轻度返流,1例(3.6%)二尖瓣中度返流。且所有患者的心功能较术前均提升1 ～ 2级。术前LAD[(49.42±12.58)mm],术后2年LAD[(38.17±9.84)mm],术前LVEDD[(50.91±7.93)mm],术后LVEDD[(44.37±7.42)mm],术后均较术前明显缩小;术前LVEF(51.69±9.71)%,术后LVEF(62.79±8.53)%,术后LVEF较术前明显增加。 结论MVP治疗MR安全有效、疗效显著,但远期效果还待进一步研究随访。     

Left atrial appendage as a source of stroke: to close (and how), or not to close (and why)

The left atrial appendage is considered the main source of emboli in strokes in patients with atrial fibrillation. Oral anticoagulant therapy significantly reduces the risk of cerebral embolic events compared to aspirin, but it is associated with bleeding complications, and is not always used. Closure of the left atrial appendage reduces the rate of thromboembolic events, and it is currently recommended in patients with atrial fibrillation submitted to mitral valve surgery. However, the formation of emboli in these patients may be due to other causes, as the role of the atrial appendage could be less important than is assumed. Moreover, not all patients are candidates for oral anticoagulation, and not all are kept in a proper therapeutic range, which could justify the formation of atrial thrombi. There are several methods for performing the closure of the appendage: direct suture in concomitant mitral surgery, epicardial exclusion by stapling or clips, or endovascular occlusion by percutaneous application. However, the results seem inconclusive with regards to their effectiveness for complete occlusion of the appendage, safety, and efficacy in preventing cerebral embolic events. To add to the confusion, some authors reveal no clear benefit in suture closure, and even describe an increased risk of thromboembolism. We present a review of left atrial appendage closure for the prevention of strokes, as well as the different procedures described above.     

Socioeconomic Implications of Long-Term Warfarin Use

Current guidelines recommend the use of warfarin in all patients with atrial fibrillation (AF) and/or an artificial heart valve who are at high risk of thromboembolism. While anticoagulation with warfarin greatly reduces this risk, a careful system of monitoring and management is necessary to maintain a therapeutic dose and minimize adverse events. This rigorous process places a burden on providers, and many patients managed in typical office practices are not optimally anticoagulated.To improve the quality and efficiency of anticoagulation and remove its burden from office-based physicians, newer treatment models have evolved, including anticoagulation clinics and self-monitoring by patients at home. While these newer models often incorporate innovative programs to streamline warfarin management, little is known about their individual or relative economic merits or those of traditional office-based care. The routine costs of anticoagulation within any model have not been well documented. The cost of warfarin is readily available; however, attendant expenses, such as dose adjustment, laboratory testing, and medical encounters, are difficult to gauge. Because of these challenges in collecting practice data, most estimates of the cost of anticoagulation services have relied upon assumptions about practice patterns. Assessing the cost of anticoagulation is easier in a clinic setting because all costs relate exclusively to anticoagulation. A recent study of anticoagulation clinics estimated that annual direct costs per patient for anticoagulation services totaled approximately $US280–$US380 (2002 values). Bleeding and other complications experienced by anticoagulated patients add additional types of costs, with inpatient care accounting for more than one-half of the total cost of managing excessive anticoagulation. When quality of life is considered alongside costs to gauge the cost effectiveness of warfarin therapy versus aspirin (acetylsalicylic acid), warfarin appears to be cost-saving in patients at high stroke risk and cost effective in those at moderate risk. For patients at lower risk of stroke, aspirin is more cost effective than warfarin.With the aging of the population and consequent increases in patient groups requiring anticoagulation, the US healthcare system greatly needs improvements to anticoagulation management. New research must determine which models of management will provide the most favorable outcomes for high-risk patients at the lowest cost to payors and society.     

Protein C,S and antithrombin III levels in patients with acute mechanical valve thrombosis

BACKGROUND: Mechanical prosthetic heart valve thrombosis is a serious complication with an incidence of 1-6%. The reduction in active vitamin-K dependent protein C and S levels caused by warfarin treatment also results in a prothrombotic state. This study was conducted to investigate the connection between protein C (PC), protein S (PS), antithrombin III (ATIII) deficiency and prosthetic mechanical valve thrombosis. METHODS: Twenty-nine of the 283 patients who underwent valve replacement with St. Jude medical prosthesis had mechanical valve thrombosis (group 2). The rest were considered as group 1. Twelve of the 29 patients (41.4%) had isolated aortic valve replacement, 12 had isolated mitral valve replacement (41.4%) and 5 patients had double valve replacement (17.2%). Most of the patients had rheumatic valve disease at their 1st operation. The mean time of occurrence for mechanical valve occlusion was 4.1+/-1.0 years following surgery. RESULTS: The values of PC, PS and ATIII were obtained when the mechanical valves stuck or at routine follow-up. PC, PS and ATIII levels were significantly lower in the mechanical valve thrombosis group. PC levels were 75.4+/-37.6% and 49.9+/-32.2% in group 1 and 2, respectively (p=0.001). PC, PS and ATIII values were mostly lower in the 2nd group but this difference only became significant after at least 2 years of warfarin usage. CONCLUSIONS: Natural anticoagulant levels can be low during the use of warfarin. In which case the dose can be increased in order to hold the international normalized ratio (INR) at 3-3.5. However, more frequent follow-up is required and patients should be investigated for hypercoagulation states or deficiency in anticoagulant proteins. Patients referred to hospital with any mechanical valve thrombosis or recurrent thromboembolism should be evaluated for hypercoagulant proteins.     

Low cardiac output following open heart surgery and catecholamine therapy

The authors have studied the possible risk factors and complications of low cardiac output (LCO) following open heart operations. A retrospective analysis of 537 consecutive open heart operations has been performed with regards to the patients past medical and perioperative data. For statistical analysis the authors have applied the Chi-square test, T-probe, Mann-Whitney-test and logistical regression analysis by means of the SPSS software. Occurrence of various types of operations was as follows: coronary bypass (CABG): n = 266, 49.5%, combined CABG: n = 62, 11.5%, aortic valve replacement (AVR): n = 73, 13.6%, mitral valve replacement (MVR): n = 59, 11%, multiple valve replacement: n = 39, 7.3%, adult congenital surgery: n = 25, 4.7%. Aortic dissection repair: n = 6, 1.1%, miscellaneous: n = 7, 1.3%. LCO has developed in 7.3% (n = 39) of the patients. The authors have concluded that in the studied group of patients the independent risk factors of postoperative LCO are as follows: atrial fibrillation in the patient history, mitral valve disease, perioperative myocardial infarction, length of anaesthesia, NYHA stage, number of transfused units of blood, and the perioperative LDH value. Beyond these variables the cause of LCO in some cases was surely an intra or perioperative myocardial necrosis. At least a certain part of this perioperative myocardial damage must have been or might have been caused by the catecholamines given under compulsion for the treatment of LCO.     

Which acute stroke patients with atrial fibrillation are prescribed warfarin therapy? Results from one-year's experience in Dundee

The recommended treatment of ischaemic stroke patients with atrial fibrillation (AF) is anticoagulation therapy with warfarin sodium and if this is contraindicated then aspirin should be used. The management of patients on warfarin therapy can be complicated and there is a risk of intra-cranial haemorrhage in elderly patients. However, these are the patients who stand to gain the most benefit from this treatment and therefore increased use of warfarin for secondary prophylaxis is likely to lead to a lower rate of subsequent admissions and less morbidity. The recommended treatment for these patients has often not been fully instigated in practice. This study was carried out in order to determine whether a group of patients admitted to a teaching hospital with diagnosis of ischaemic stroke and atrial fibrillation received appropriate antithrombotic therapy. Details of patients admitted with acute stroke during 1997 were obtained from the Dundee Stroke Database and information was extracted from the relevant clinical notes. Twenty-five out of 42 patients (60%) were considered eligible for anticoagulation and 14 out of those 25 (56%) were found to be on warfarin either on admission or subsequently. Of patients aged less than 75 years, 8/10 (80%) were on warfarin, whereas only 6/15 (40%) of those aged 75 years and older were being anticoagulated.     

Anticoagulation during pregnancy

Anticoagulation of a pregnant woman is a complex issue for both the treating physician and the patient. In patients with mechanical prosthetic valves, long-term anticoagulation is mandatory to prevent thromboembolic complications; and in those with thrombophilic disorders and history of thromboembolism, anticoagulation is strongly indicated. With an increase in the number of patients with prosthetic heart valves, as well as the increase in maternal age, the issue of anticoagulation has become a very important one. Despite the widespread use of warfarin and unfractionated heparin during pregnancy, the optimal use of anticoagulants during pregnancy remains controversial because of a lack of appropriate prospective randomized clinical trials. In fact, even retrospective data on heparin provide miserably inadequate information for those making a decision on the correct dosing regimen. More recently, low molecular weight heparin has been proposed as a safer method of anticoagulation. This review summarizes current data and recommendations on anticoagulation during pregnancy.     

Hypercoagulable states and venous thrombosis

Many factors predispose patients to thromboembolic disease. A young person presenting with idiopathic deep venous thrombosis may never have its etiology elucidated, despite exhaustive testing. On the other hand, hypercoagulability is no mystery in an obese, bedridden, postoperative patient with a malignancy. Invasive or noninvasive testing should be performed in all suspicious cases. Patients with positive results should be treated promptly; those with negative findings should not be subjected to anticoagulation. The length of anticoagulation depends on the length of time the patient remains at risk of thrombosis and may vary from months to a lifetime. Patients over 40 should receive prophylactic minidose heparin for abdominal and thoracic surgery. Patients undergoing hip surgery require some form of anticoagulation--be it heparin, warfarin, aspirin, or dihydroergotamine-heparin. Because of lower morbidity and superior long-term efficacy, transvenous devices are favored over surgical techniques for inferior vena caval interruption.     

心脏超声对风湿性瓣膜病术后房颤自动复律的预测

目的对风湿性心脏病(风心病)心房颤动患者术后自动恢复窦性心律与不能恢复窦性心律患者的心脏超声指标进行对比分析,探讨自动恢复窦性心律的可能因素。方法选择风心病二尖瓣置换术患者515例,术前心电图检查均示有房颤,按照术后自动恢复窦性心律情况分为非自动恢复窦律对照组及自动恢复窦律组,对左房直径(LAD)、右房直径(RAD)、心脏射血分数(EF)、左室缩短率(FS)等超声指标进行比较分析。结果术后维持窦律时间较长组LAD、左房容积(LAV)明显低于非自动复律组(P<0.01),而EF、FS则明显高于非自动复律组(P<0.01)。结论从心脏超声指标分析,风心病瓣膜置换术后房颤自动恢复窦性心律及窦性心律维持时间与左房大小及心功能有密切关系。     

Economic Evaluation of the Combined Use of Warfarin and Low-dose Aspirin Versus Warfarin Alone in Mechanical Valve Prostheses

Background

The use of combined therapy of antiplatelet and anticoagulant versus anticoagulant alone to reduce instances of thromboembolic events in patients with heart valve prostheses is an established standard of care in many countries but not in Egypt. A previous Markov model cost-effectiveness study on Egyptian patients aged 50–60 years demonstrated that the combined therapy reduces the overall treatment cost. However, due to the lack of actual real-world data on cost-effectiveness and the limitation of the Markov model study to 50- to 60-year-old patients, the Egyptian medical community is still questioning whether the added benefit is worth the cost.

Objective

To assess, from the perspective of the Egyptian health sector, the cost-effectiveness of the combined use of warfarin and low-dose aspirin (75 mg) versus that of warfarin alone in patients with mechanical heart valve prostheses who began therapy between the age of 15 and 50 years.

Methods

An economic evaluation was conducted alongside a randomized, controlled trial to assess the cost-effectiveness of the combined therapy in patients with mechanical valve prostheses. A total of 316 patients aged between 15 and 50 years were included in the study and randomly assigned to a group treated with both warfarin and aspirin or a group treated with warfarin alone.

Results

The patients in the combined therapy group exhibited a significantly longer duration of protection against the first event. Fewer primary events were observed in the patients treated with warfarin plus aspirin than in those treated with warfarin alone (1.4 %/year, vs. 4.8 %/year), and a higher mean quality-adjusted life-years (QALYs) value over 4 years was obtained for the group treated with warfarin plus aspirin (difference 0.058; 95 % CI 0.013–0.118), although this difference did not reach a conventional level of statistical significance. The total costs over a 4-year period were lower with the combined therapy (difference ?US$244; 95 % CI ?US$483.1 to ?US$3.8), which yielded an incremental cost-effectiveness ratio of ?US$4206 per QALY gained. Thus, the combined therapy was dominant. All costs were reported in US dollars (USD) for the financial year 2014.

Conclusions

The results of this analysis indicate that from the perspective of the Egyptian health sector, the addition of aspirin to the typical warfarin therapy is more effective and less costly for patients with mechanical valve prostheses than treatment with warfarin alone. This combined strategy could be adopted to prevent the complications of mechanical valve prostheses. Our study adds to the body of evidence supporting the option of warfarin-plus-aspirin therapy for patients with mechanical valve prostheses.

     

Percutaneous mitral commissurotomy. 5-year results

Long-term results of percutaneous mitral commissurotomy were evaluated in 410 patients with mean age of 31 years (18 to 68 years). 48% of patients had mean thickened leaflets, 35% had calcified valves and 17% had flexible leaflets and subvalvular apparatus. Procedure was performed with a double balloon in 57% and with Inoue's balloon in 43% patients. A good immediate results was obtained in 77% of patients. A good result was defined as a mitral valve area > or = 1.5 cm2 without mitral regurgitation. Clinical follow-up concern 378 patients. The actuarial 5 years rate were 84% in our serie, without surgery or new percutaneous mitral commissurotomy and good functional results (NYHA class I or II) were 71%. Valvular anatomy, immediate results (mitral valve area), history of mitral commissurotomy, old patients, atrial fibrillation can influence strongly the results.     

社区老年房颤患者抗凝治疗现状单中心横断面调查分析

目的:了解社区65岁及以上老年房颤患者抗凝治疗和社区随访情况,为进一步规范抗凝治疗提供理论基础和建议.方法:采用回顾性分析方法,入选2017-2018年本社区65岁及以上老年人心电图或动态心电图诊断房颤的166例患者,通过查阅居民电子健康档案、门诊随访和电话随访方式,记录性别、年龄、主要疾病诊断、CHA2DS2-VAS...     

A therapeutic HIV vaccine: how good is good enough?

The goal of a therapeutic HIV vaccine is to attenuate HIV disease progression in those already infected. Our objective was to establish comparative efficacy and cost-effectiveness thresholds at which a therapeutic vaccine would make a valuable contribution to HIV care. Using an HIV computer simulation model, we compared therapeutic vaccination with HIV standard of care without vaccination. Input data were obtained from the literature. Base case and sensitivity analyses related to vaccine magnitude, penetrance, durability, and cost. In the base case (0.5 log magnitude, 25% penetrance, 3-year durability, and US$ 4000 per series), vaccination increased quality-adjusted life expectancy (QALE) by 0.50 months compared to no vaccination (cost-effectiveness ratio US$ 89,900 per quality-adjusted life year (QALY)). Increasing vaccine penetrance to 50% increased the projected QALE benefit to 0.91 months (cost-effectiveness ratio US$ 45,500/QALY). Even modestly effective therapeutic HIV vaccines may produce small but meaningful increases in life expectancy and compare favorably to alternative uses of scarce HIV care resources.     

Mitral valve surgery in the elderly

We report a retrospective study about 34 patients operated for on mitral valve between 1981 and 2000. All patients were aged more than 65 years. 82% of them were in the class III or IV of the NYHA. 31 of patients had a valvular mitral replacement (by a mechanical protheses in 24 cases and a biological protheses in 7 cases) and 3 patients had a mitral valve reconstruction. An aortic valve replacement was associated in 7 cases, and a myocardial revascularisation in 4 cases. The early mortality rate was 17,6% and the late mortality was 12%. The high mortality is meanly related to the associate lesions (coronarography) and the prognosis is a better with the improvement of surgical technics and perioperative management.     

Asthma And Depression

Abstract

Thromboprophylaxis with oral anticoagulants (OACs) is an important but under-used element of atrial fibrillation (AF) treatment. Reduction of stroke risk with anticoagulants comes at the price of increased bleeding risk. Patients with AF receiving anticoagulants require heightened attention with transition from one care setting to another. Patients presenting for emergency care of anticoagulant-related bleeding should be triaged for the severity and source of the bleeding using appropriate measures, such as discontinuing the OAC, administering vitamin K, when appropriate, to reverse warfarin-induced bleeding, or administering clotting factors for emergent bleeding. Reversal of OACs in patients admitted to the hospital for surgery can be managed similarly to patients with bleeding, depending on the urgency of the surgical procedure. Patients with AF who are admitted for conditions unrelated to AF should be assessed for adequacy of stroke risk prophylaxis and bleeding risk. Newly diagnosed AF should be treated in nearly all patients with either warfarin or a newer anticoagulant. Patient education is critically important with all anticoagulants. Close adherence to the prescribed regimen, regular international normalized ratio testing for warfarin, and understanding the stroke risk conferred by both AF and aging are goals for all patients receiving OACs. Detailed handoff from the hospitalist to the patient's primary care physician is required for good continuity of care. Monitoring by an anticoagulation clinic is the best arrangement for most patients. The elderly, or particularly frail or debilitated patients who are transferring to long-term care, need a detailed transfer of information between settings, education for the patient and family, and medication reconciliation. Communication and coordination of care among outpatient, emergency, inpatient, and long-term care settings are vital for patients with AF who are receiving anticoagulants to balance stroke prevention and bleeding risk.