Upstream versus downstream thrombin inhibition

Introduction: For a long time, vitamin K antagonists (VKA) have been the preferred drugs for the anticoagulation management of both atrial fibrillation and venous thromboembolism. Hereby, the major purpose is to attenuate the onset of thrombosis without affecting hemostasis.

Areas covered: Nowadays, non-vitamin K anticoagulants (NOAC), a new class of oral anticoagulants is available for the above-mentioned indications. NOAC are at least as effective and safer with regard to intracranial bleedings compared to VKA, but major bleedings still occur. For this reason, the search for safer anticoagulants is still ongoing.

Expert commentary: There are several unmet needs in NOAC management, including selection of optimal drug and dose, uncertainty on specific conditions and lack of drug persistence. There remains to be an important need for safer anticoagulants; ‘upstream’ anticoagulants including inhibitors of factor XIa may provide additional benefit related to fewer bleeding complications.     

Anticoagulant cessation following atrial fibrillation ablation: limits of the ECG-guided approach

Introduction: Long-term cessation of oral anticoagulation (OAC) following successful catheter or surgical ablation of atrial fibrillation (AF) is debated. Usually, in the presence of sinus rhythm at serial ECG recordings, the CHADS2, CHA2DS2VASc, and HAS-BLED scores are adopted to guide decision regarding OAC management.

Areas covered: The safety of OAC cessation in patients without recurrent AF but with historically elevated risk for thromboembolism remains largely unknown. Taking the cue from two clinical cases, we provide an updated summary of the latest evidence regarding how to manage OAC after a successful atrial fibrillation ablation.

Expert commentary: The present clinical perspective suggests that, at least within patients with severely enlarged left atrium, previous cardiac surgery and catheter or surgical AF ablation, especially if repeated, assessment of atrial contractility by transthoracic echocardiography should be performed before discontinuing OAC in patients who maintain sinus rhythm, confirmed by serial ECG or Holter monitorings.     

Antithrombotic strategies after interventional left atrial appendage closure: an update

Introduction: Interventional left atrial appendage occlusion (LAAO) has emerged as a valid alternative to oral anticoagulation (OAC) therapy for the prevention of ischemic stroke and systemic embolism in patients with non-valvular atrial fibrillation (AF).

Areas covered: Antithrombotic therapy following interventional LAAO is critical in balancing the risk of thromboembolism and bleeding during the endothelialization of the implanted devices. In this article, the most recent clinical trials are reviewed and the current real-world antithrombotic strategies following LAAO device implantation are discussed.

Expert commentary: For patients eligible for OAC and receiving a Watchman device, the most solid scientific evidence exists for warfarin plus aspirin for 45 days followed by dual antiplatelet therapy (DAPT) for 6 months and a lifelong aspirin therapy. In real-world most patients are being treated with DAPT for 3–6 months. Alternatively, the Watchman was approved for 3 months of novel OAC (NOAC) therapy in conjunction with aspirin. For all other devices, DAPT for 1–6 months has been used in the vast majority of cases. Considering major bleeding as the predominant complication following LAAO, evidence suggests that short-term DAPT (6 weeks) or single antiplatelet therapy using aspirin may be a viable option.     

The use of a portable three-lead ECG monitor to detect atrial fibrillation in general practice

Objective: To evaluate how well an inexpensive portable three-lead ECG monitor PEM identified patients with atrial fibrillation (AF) compared to a normal 12-lead ECG.

Design: Cross-sectional method comparison study.

Setting: From April 2014 to February 2015, we included patients coming to the general practice clinic “Lægerne Sløjfen”, Aalborg, Denmark for a routine ECG. Patients with severe dementia, mental illness or poor ECG readings were excluded. After oral and written informed consent an ECG and PEM recordings were obtained simultaneously. The PEM recordings were analyzed by two general practitioners (GPs) in training and ECG recordings were evaluated by a senior GP and a cardiologist. Both the PEM and the ECG recordings were analysed blinded.

Subjects: Ninety-three patients were included and four were excluded due to poor ECG readings.

Main outcome measures: The sensitivity and specificity of PEM compared to a standard 12-lead ECG.

Results: Eighty-nine of the 93 (95.7%) patients had ECGs of a satisfactory technical quality and were included in the study. The sensitivity of diagnosing AF by PEM recordings was 86.7% and the specificity was 98.7% when compared to a 12-lead ECG. According to the cardiologist, the misclassification of three PEM recordings were due to interpretation errors and not related to the PEM recording per se.

Conclusions: The inexpensive portable PEM device recording diagnosed AF with a high sensitivity and specificity.

• KEY POINTS

• Simple ECG monitors could be useful to identify atrial fibrillation and thereby lead to a better prevention of stroke.

• The PEM device was easy to use and 95.7% of the recordings were technically acceptable for detecting atrial fibrillation.

• The PEM device has a high sensitivity and specificity in detecting atrial fibrillation compared to a standard 12-lead ECG.

• Further studies should evaluate the clinical usefulness of the PEM device, e.g. to detect intermittent atrial fibrillation.

     

Clinical utility of sympathetic blockade in cardiovascular disease management

Introduction: A dysregulated sympathetic nervous system is a major factor in the development and progression of cardiovascular disease; thus, understanding the mechanism and function of the sympathetic nervous system and appropriately regulating sympathetic activity to treat various cardiovascular diseases are crucial.

Areas covered: This review focused on previous studies in managing hypertension, atrial fibrillation, coronary artery disease, heart failure, and perioperative management with sympathetic blockade. We reviewed both pharmacological and non-pharmacological management.

Expert commentary: Chronic sympathetic nervous system activation is related to several cardiovascular diseases mediated by various pathways. Advancement in measuring sympathetic activity makes visualizing noninvasively and evaluating the activation level even in single fibers possible. Evidence suggests that sympathetic blockade still has a role in managing hypertension and controlling the heart rate in atrial fibrillation. For ischemic heart disease, beta-adrenergic receptor antagonists have been considered a milestone drug to control symptoms and prevent long-term adverse effects, although its clinical implication has become less potent in the era of successful revascularization. Owing to pathologic involvement of sympathetic nervous system activation in heart failure progression, sympathetic blockade has proved its value in improving the clinical course of patients with heart failure.     

The effect on the patient flow in a local health care after implementing reverse triage in a primary care emergency department: a longitudinal follow-up study

Objective: Reverse triage means that patients who are not considered to be in need of medical services are not placed on the doctor’s list in an emergency department (ED) but are sent, after face-to-face evaluation by a triage nurse, to a more appropriate health care unit. It is not known how an abrupt application of such reverse triage in a combined primary care ED alters the demand for doctors’ services in collaborative parts of the health care system.

Design: An observational study.

Setting: Register-based retrospective quasi-experimental longitudinal follow-up study based on a before–after setting in a Finnish city.

Subjects: Patients who consulted different doctors in a local health care unit.

Main outcome measures: Numbers of monthly visits to different doctor groups in public and private primary care, and numbers of monthly referrals to secondary care ED from different sources of primary care were recorded before and after abrupt implementation of the reverse triage.

Results: The beginning of reverse triage decreased the number of patient visits to a primary ED doctor without increasing mortality. Simultaneously, there was an increase in doctor visits in the adjacent secondary care ED and local private sector. The number of patients who came to secondary care ED without a referral or with a referral from the private sector increased.

Conclusions: The data suggested that the reverse triage causes redistribution of the use of doctors’ services rather than a true decrease in the use of these services.     

Adenosine triphosphate/adenosine guided pulmonary vein isolation does not improve the outcomes of ablation: a meta-analysis of randomized controlled trials

Background: Successful pulmonary vein isolation (PVI) is the most reliable predictor of success after ablation in patients with atrial fibrillation (AF). Adenosine triphosphate (ATP) unmasks the dormant conduction and can be used to improve the effectiveness of PVI. The impact of ATP guided PVI on clinical outcomes is discordant in various randomized controlled trials (RCTs).

Objectives: To delineate the incremental benefit of ATP during PVI in patients with AF through a meta-analysis.

Methods and results: Database searches through January 2017 identified 5 RCTs (enrolling 2839 patients) comparing ATP guided PVI versus standard PVI (non-ATP). Four trials exclusively studied paroxysmal AF while one trial included both paroxysmal and non-paroxysmal AF patients. Baseline characteristics, dose of adenosine and ablation strategies were clearly identified among all the trials. The risk ratio (RR) for AF episodes lasting >30 s after 3-month blanking period was calculated with random effects meta-analysis and showed no difference at a median follow up of 12 months [RR: 1.02, 95 % Confidence interval (CI): 0.85 to 1.25; p = 0.82]. Similarly, the number of repeat ablation was similar in both groups [RR: 1.02, 95 % CI: 0.63, 1.56; p = 0.98].

Conclusions: ATP guided PVI does not decrease the recurrence of AF or the need for repeat ablation at 12 months.     

Adjunctive ablation strategies improve the efficacy of pulmonary vein isolation in non-paroxysmal atrial fibrillation: a systematic review and meta-analysis

Background: Pulmonary vein (PV) isolation (PVI) has suboptimal outcomes in patients with non-paroxysmal atrial fibrillation (AF). Adjunctive strategies employed to ablate non-PV triggers have shown favorable outcomes.

Aims: To delineate the incremental benefit of adjunctive ablation in patients with non-paroxysmal AF through a meta-analysis.

Methods and results: Database searches through August 2016 identified five non-randomized and seven randomized controlled trials (enrolling 1694 patients). The adjunctive strategies employed for non-PV ablation included focal impulse and rotor modulation; empirical linear lines, ablation of complex fractionated atrial electrograms and ganglionated plexi. The risk ratio (RR) for AF recurrence, calculated with random effects meta-analysis showed a 36% reduction of AF recurrence at a median follow up of 12 months (RR: 0.64, 95% Confidence interval: 0.48 to 0.85; p = 0.003). The benefits persisted during longer follow up when assessed in subgroup analysis.

Conclusions: Addition of adjunctive ablation to PVI improves outcomes.     

Factors associated with self-rated health in primary care

Background: Self-rated health (SRH) measures one’s current general health and is a widely used health indicator. Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships are suspected to influence SRH, but studies in primary health care settings are sparse.

Objective: To examine the associations between patients’ self-rated health and their sleep problems, somatic health complaints, and unmet needs in interpersonal relationships.

Design: We collected data via questionnaires for this cross-sectional study from general practice.

Setting: Primary health care in Norway.

Subjects: 1302 consecutive patients participated.

Main outcome measures: The questionnaire included a single question about SRH, the Bergen Insomnia Scale (BIS), five questions on somatic health complaints, and three questions from the Basic Psychological Needs Scale (BPNS) pertaining to the relationships domain. We analyzed our data using ordinal logistic regression models.

Results: Our response rate was 74%. The prevalence of fair/poor SRH was 26%, with no gender differences. We revealed a significant association between increasing age and reduced SRH. The study showed that sleep problems and somatic health complaints were strongly associated with SRH, and unmet needs in relationships were also significantly and independently associated with reduced SRH in a full model analysis.

Conclusion: Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH. These factors are all modifiable and could be managed both within and outside a primary care setting in order to improve SRH.

• Key Points

• There was a high prevalence of reduced SRH in clinical general practice

• Sleep problems, somatic health complaints, and unmet needs in interpersonal relationships were all associated with reduced SRH

• These predictors are all modifiable with a potential to improve SRH

     

Atrial cardiopathy: a mechanism of cryptogenic stroke

Introduction: Cryptogenic stroke accounts for approximately 30% of all ischemic strokes. Recently, atrial cardiopathy diagnosed by the presence of one of its serum, imaging, or electrocardiogram biomarkers has been shown to be associated with ischemic stroke, particularly of embolic subtypes.

Areas covered: This paper aims to summarize data on occult atrial fibrillation and stroke, provide an overview on mechanisms, such as inflammation and fibrosis, of stroke in atrial cardiopathy, critically review data on biomarkers of atrial cardiopathy and their association with stroke, and suggest therapeutic implications, including directions for future research.

Expert commentary: Atrial cardiopathy may constitute one of the mechanisms in cryptogenic stroke, and patients with evidence of atrial cardiopathy constitute a group of patients in whom clinical trials are warranted to test anticoagulation versus antiplatelet therapy to reduce stroke recurrence risk. In addition, more studies are needed to determine the degree of overlap between these atrial cardiopathy biomarkers and which one is more useful in predicting the risk of stroke and response to anticoagulation therapy.     

Resolution of cannabis hyperemesis syndrome with topical capsaicin in the emergency department: a case series

Background: Cannabinoid hyperemesis syndrome (CHS) is characterized by symptoms of cyclic abdominal pain, nausea, and vomiting in the setting of prolonged cannabis use. The transient receptor potential vanilloid 1 (TRPV1) receptor may be involved in this syndrome. Topical capsaicin is a proposed treatment for CHS; it binds TRPV1 with high specificity, impairing substance P signaling in the area postrema and nucleus tractus solitarius via overstimulation of TRPV1. This may explain its apparent antiemetic effect in this syndrome.

Purpose: We describe a series of thirteen cases of suspected cannabis hyperemesis syndrome treated with capsaicin in the emergency departments of two academic medical centers.

Methods: A query of the electronic health record at both centers identified thirteen patients with documented daily cannabis use and symptoms consistent with CHS who were administered topical capsaicin cream for symptom management.

Results: All 13 patients experienced symptom relief after administration of capsaicin cream.

Conclusion: Topical capsaicin was associated with improvement in symptoms of CHS after other treatments failed.     

Serum osmolal gap in clinical practice: usefulness and limitations

Background: Although serum osmolal gap can be a useful diagnostic tool, clinicians are not familiar with its use in clinical practice.

Objectives: The review presents in a series of questions-answers and under a clinical point of view the current data regarding the use of osmolal gap.

Discussion: The definition and the best formula used for the calculation of osmolal gap, the main causes of increased osmolal gap with or without increased anion gap metabolic acidosis, as well as the role of concurrent lactic acidosis or ketoacidosis are presented under a clinical point of view.

Conclusions: The calculation of osmolal gap is crucial in the differential diagnosis of many patients presenting in emergency departments with possible drug or substance overdose as well as in comatose hospitalized patients.     

Hybrid and surgical procedures for the treatment of persistent and longstanding persistent atrial fibrillation

Introduction: Atrial fibrillation (AF) is the most common cardiac arrhythmia. The incidence of AF increases with age and is associated with increased stroke, heart failure and mortality. Persistent and long standing persistent AF is difficult to treat and often refractory to medical therapy and catheter ablation.

Areas covered: This article reviews the historical development of the surgical Cox-MAZE procedure and current hybrid and minimally invasive surgical approaches for the treatment of persistent and long standing persistent AF. The role of concomitant pulmonary vein isolation and left atrial appendage (LAA) exclusion will also be reviewed.

Expert commentary: An ablation pattern emulating the Cox-Maze surgical procedure is commonly needed to obtain maintenance of sinus rhythm in patients with persistent and long standing persistent atrial fibrillation. Minimally invasive bilateral thorascopic surgical procedures can achieve a similar Cox-Maze lesion set, but are associated with increased adverse events compared to catheter ablation. Future prospective randomized studies are required to confirm whether the recently developed hybrid subxyphoid epicardial/endocardial procedure and percutaneous LAA ligation and catheter ablation are indeed as effective as surgical options with less adverse events.     

Focal activation patterns: breaking new grounds in the pathophysiology of atrial fibrillation

Introduction: High-resolution atrial mapping studies have provided novel insights in the pathophysiology of atrial fibrillation (AF) in the last few years. Increasing attention is being drawn to the so-called focal activation patterns (FAPs); however, there is no consensus on criteria to identify and characterize these patterns.

Areas covered: In this expert review, an overview of definitions and criteria used to examine FAPs obtained from atrial mapping studies is provided and studies reporting on the underlying mechanisms are discussed.

Expert commentary: High-resolution cardiac mapping has revealed the importance of FAPs in the pathophysiology of AF. There is increasing evidence supporting the concept of endo-epicardial (E-E) asynchrony enabling transmural conduction of electrical waves resulting in FAPs. Uniform reports of FAPs in future studies are needed to provide more knowledge on its clinical importance.     

A systematic review to determine the optimal type and dosage of land-based exercises for treating knee osteoarthritis

Background: Exercise has been acknowledged as an effective non-pharmacological intervention for osteoarthritis. Consensus regarding the type of exercise i.e., aerobic or resistance, weight bearing or non-weight bearing, and dosage i.e., frequency, loading, duration, or intensity, is yet to be reached.

Objective: The purpose of this review was to address two questions: (1) is there a difference in clinical outcomes between different exercise programmes; and (2) what is the optimal dosage of exercises for people with knee osteoarthritis.

Methods: A systematic review was conducted. A study of published (AMED, CINAHL, MEDLINE, EMBASE, PubMed, and the Cochrane Library) and unpublished literature (WHO International Clinical Trials Registry Platform, current controlled trials and the United States National Institute of Health Trials Registry, and Open Grey) was undertaken in January 2013. Studies assessing the clinical outcomes of different types and dosages of exercise for people with osteoarthritis of the knee were included. Methodological quality was assessed using the critical appraisal skills programme (CASP) randomized controlled trial (RCT) appraisal tool.

Results: Ten studies assessing 958 knees from 916 participants were included. Exercise significantly improved pain and function for people with knee osteoarthritis. There was no significant difference in outcomes for different types of exercise i.e., aerobic versus resistance, weight bearing versus non-weight bearing. There was no significant difference in respect to the intensity of exercise i.e., high- versus lower-intensity resistance or aerobic exercises. The quality of the literature was moderate to high.

Conclusions: While exercise appears to improve symptoms and optimize function for people with knee osteoarthritis, the optimal form and dosage of exercise remains unknown.

Funding: None.

PROSPERO Registration Number: CRD42012002811.     

Rethinking physiotherapy for patients with fibromyalgia - lessons learnt from qualitative studies

Background: Fibromyalgia (FM) is characterized by chronic, widespread musculoskeletal pain, extensive fatigue and an array of other symptoms. Cure is not expected, and patients have to learn to live with the illness. During the last years several studies have examined how it is like to live with FM from a patient’s point of view. These findings may help physiotherapists to better understand the challenges faced by patients.

Objective: To describe what it is like for patients to live with FM and discuss how this may inform physiotherapy practice.

Design: A systematic literature search of qualitative studies up till May 2016 was conducted, and 93 papers were read. The focus was on patients’ experiences of symptoms and how they managed everyday life.

Results: Incomprehensible, unpredictable symptoms of FM intrude and disturb everyday life. The body is constantly monitored by patients on a day-to-day basis according to fluctuations in pain and energy levels, and habits and routines of daily life are adapted to these shifts. With other words, the connection between body, self and daily life is ruptured. In contrast, those having recovered from FM had found out what they could tolerate during a day and had spent long time in rebuiding a life worth living.

Conclusion: The present paper presents an argument that living with FM calls for a rather complex personal healing process that should be recognized and supported by physiotherapists.     

Social disparities in diabetes care: a general population study in Denmark

Objective: We investigated the association between socioeconomic factors and the attainment of treatment goals and pharmacotherapy in patients with type 2 diabetes in Denmark.

Design: A cross-sectional population study.

Setting: The municipality of Naestved, Denmark.

Subjects: We studied 907 patients with type 2 diabetes identified from a random sample of 21,205 Danish citizens.

Main outcome measures: The proportion of patients who were not achieving goals for diabetes care based on their HbA_1c, LDL-cholesterol, blood pressure, and lifestyle, and the proportion of patients who were treated with antihypertensive and cholesterol- and glucose-lowering medication.

Methods: We investigated the association of the socioeconomic factors such as age, gender, education, occupation, income, and civil status and attainment of treatment goals and pharmacotherapy in logistic regression analyses. We investigated effect modification of cardiovascular disease and kidney disease.

Results: Middle age (40–65 years), low education level (i.e. basic schooling), and low household income (i.e. less than 21,400 € per year) were associated with nonattainment of goals for diabetes care. The association of socioeconomic factors with attainment of individual treatment goals varied. Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure. Socioeconomic factors were not associated with treatment goals for hyperglycemia. Socioeconomic factors were inconsistently associated with pharmacotherapy. There was no difference in contacts to general practitioners according to SES.

Conclusions: In a country with free access to health care, the socioeconomic factors such as middle age, low education, and low income were associated with nonattainment of goals for diabetes care.

• KEY POINTS

• Middle age, low education, and low income were associated with nonattainment of goals for diabetes care, especially for lifestyle goals.

• Patients with low socioeconomic status were more often obese, physically inactive, smoking, and had elevated blood pressure.

• Association of socioeconomic factors with pharmacotherapy was inconsistent.

     

Association between continuity of care in Swedish primary care and emergency services utilisation: a population-based cross-sectional study

Objective: The primary objective of this study was to determine the association between longitudinal continuity of care (CoC) in Swedish primary care (PC) and emergency services (ES) utilisation.

Study design: A cross-sectional analysis of longitudinal population data. Setting. PC centres, out-of-hours PC facilities and emergency departments (EDs) in Blekinge County in southern Sweden. Subjects: People of all ages who lived in Blekinge County and who had made two or more visits per year to a general practitioner (GP) during office hours from 1 January 2012 to 31 December 2014.

Main outcome measure: ES utilisation.

Results: Eight-thousand one-hundred and eighty-five people were included in the study. CoC was quantified using three different indices—Usual Provider of Care index (UPC), Continuity of Care index (CoCI), and Sequential Continuity index (SECON). The CoC that the PC centres could offer their enrolled patients varied significantly between the different centres, ranging from 0.23–0.57 for UPC, 0.12–0.43 for CoCI, and 0.25–0.52 for SECON. Association between the three CoC indices and ES utilisation was computed as an incidence rate ratio which ranged between 0.50 and 0.59.

Conclusion: Longitudinal CoC was shown to have a negative association with ES utilisation. The association was significant and of a magnitude that implies clinical relevance. Computed incidence rate ratios suggest that patients with the lowest CoC had twice as many ES visits compared to patients with the highest CoC.     

Subacute effects of cervicothoracic spinal thrust/non-thrust in addition to shoulder manual therapy plus exercise intervention in individuals with subacromial impingement syndrome: a prospective,randomized controlled clinical trial pilot study

Objectives: To determine the subacute effects of cervicothoracic spinal thrust/non-thrust in addition to shoulder non-thrust plus exercise in patients with subacromial pathology.

Methods: This was a randomized, single blinded controlled trial pilot study. This trial was registered at ClinicalTrials.gov (NCT01753271) and reported according to Consolidated Standards of Reporting Trials requirements. Patients were randomly assigned to either shoulder treatment plus cervicothoracic spinal thrust/non-thrust or shoulder treatment-only group. Primary outcomes were average pain intensity (Numeric Pain Rating Scale) and physical function (Shoulder Pain and Disability Index) at 2 weeks, 4 weeks, and patient discharge.

Results: 18 patients, mean age 43.1(15.8) years satisfied the eligibility criteria and were analyzed for follow-up data. Both groups showed statistically significant improvements in both pain and function at 2 weeks, 4 weeks, and discharge. The between-group differences for changes in pain or physical function were not significant at any time point.

Discussion: The addition of cervicothoracic spinal thrust/non-thrust to the shoulder treatment-only group did not significantly alter improvement in pain or function in patients with subacromial pathology. Both approaches appeared to provide an equally notable benefit. Both groups improved on all outcomes and met the criteria for clinical relevance for both pain and function.

Level of Evidence: 2b.