Stroke prophylaxis in atrial fibrillation: who gets it and who does not? Report from the Stockholm Cohort-study on Atrial Fibrillation (SCAF-study).

AIMS: Underuse of warfarin for stroke prophylaxis in atrial fibrillation (AF) is extensive and represents a major problem in clinical practice. To identify factors associated with warfarin treatment in eligible AF patients. METHODS AND RESULTS: The study population consisted of all Swedish resident AF patients at the Stockholm South General Hospital during 2002 (n=2796). Medical records were examined and complemented by data from the Swedish National Hospital Discharge Register. Sixty-eight percent of the patients (1898/2796) had indications, and no apparent contraindications for warfarin treatment. Of these 54% (1029/1898) got warfarin. Factors favouring warfarin treatment after adjustment for other factors were history of ischaemic stroke, an implanted pacemaker, treatment in a cardiology rather than internal medicine ward and valvular defect. Factors associated with a reduced likelihood of warfarin treatment were paroxysmal type of AF and age >80 years. Important risk factors for stroke in AF like heart failure, hypertension, and diabetes did not increase the chances of warfarin treatment. CONCLUSION: Risk stratification using known risk factors of stroke seems to affect warfarin treatment only to a minor degree in clinical practice. Undertreatment was particularly common in patients with paroxysmal AF and in patients aged >80 years and calls for improved clinical routines in accordance with international guidelines.     

Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines

Cholecystectomy has been widely performed in the treatment of acute cholecystitis, and laparoscopic cholecystectomy has been increasingly adopted as the method of surgery over the past 15 years. Despite the success of laparoscopic cholecystectomy as an elective treatment for symptomatic gallstones, acute cholecystitis was initially considered a contraindication for laparoscopic cholecystectomy. The reasons for it being considered a contraindication were the technical difficulty of performing it in acute cholecystitis and the development of complications, including bile duct injury, bowel injury, and hepatic injury. However, laparoscopic cholecystectomy is now accepted as being safe for acute cholecystitis, when surgeons who are expert at the laparoscopic technique perform it. Laparoscopic cholecystectomy has been found to be superior to open cholecystectomy as a treatment for acute cholecystitis because of a lower incidence of complications, shorter length of postoperative hospital stay, quicker recuperation, and earlier return to work. However, laparoscopic cholecystectomy for acute cholecystitis has not become routine, because the timing and approach to the surgical management in patients with acute cholecystitis is still a matter of controversy. These Guidelines describe the timing of and the optimal surgical treatment of acute cholecystitis in a question-and-answer format.     

A prospective multicenter study of factors associated with hospital admission among adults with acute asthma

PURPOSE: We sought to determine patient characteristics associated with hospital admission after emergency treatment for asthma, and whether disposition guidelines are followed. SUBJECTS AND METHODS: We performed a prospective multicenter cohort study involving 64 emergency departments in the United States and Canada. Consecutive adult patients with asthma exacerbations were interviewed, and their charts were reviewed using standardized protocols. Telephone follow-up at 2 weeks determined relapse. RESULTS: Of 1805 patients, 363 (20%; 95% confidence interval [CI]: 18% to 22%) were hospitalized. Among patients with severe exacerbations (final peak flow <50% of predicted), 122 (49%; 95% CI: 43% to 55%) were hospitalized. Admission was associated with final peak flow, female sex, nonwhite race, severity of chronic illness, and severity of exacerbation. Admission predictors were similar regardless of hospital funding, region, or size. Among patients with mild or moderate exacerbations of asthma (peak flow >or=50% predicted), the likelihood of admission was associated significantly with the number of predefined risk factors for death from asthma. Of patients who were discharged from the emergency department, 62 (5%; 95% CI: 4% to 6%) relapsed within 72 hours. Relapse was not associated with final peak flow (P = 0.39). CONCLUSION: Associations between patient characteristics and disposition were similar across sites. Despite guidelines to the contrary, half of patients with final peak flow <50% were discharged. After emergency department treatment and discharge, short-term relapse was uncommon among patients with asthma, suggesting that strict peak flow cutoffs may be unnecessary if risk factors in patients with mild or moderate exacerbations are considered.     

Pregnancy and aortic root growth in the Marfan syndrome: a prospective study.

AIMS: In women with Marfan syndrome pregnancy presents an increased risk of dilatation, dissection, and rupture of the aorta. The aim of this study was to investigate the influence of pregnancy on growth of the aortic root. METHODS AND RESULTS: Between 1993 and 2004 127 women with Marfan syndrome were prospectively followed; 61 women had one or more children; in 23 women, 33 pregnancies could be followed prospectively for aortic dimensions. Only one woman had suffered an aortic complication, a type A dissection (limited to the ascending aorta), before pregnancy. Out of 66 childless women a comparison group of 22 women was selected and individually matched. Mean initial aortic root diameter just before pregnancy was 37+/-5 mm (range 25-45). Before, during, and after pregnancy the overall individual aortic root diameter change (in 31 pregnancies) was not significant (P=0.77). Only the woman with a previous type A dissection developed an aortic complication (type B dissection) during her second pregnancy. No cardiac complications occurred in the other 22 women during their pregnancies. During a median follow-up of 6.4 years, no significant difference in growth of the aortic root was observed between the pregnancy group and the matched childless group (0.28 vs. 0.19 mm/year, P=0.08, respectively). CONCLUSION: Pregnancy in women with Marfan syndrome seems to be relatively safe up to an aortic root diameter of 45 mm, at least as far as our observed diameter range of 25-45 mm is concerned.     

Combination therapy in hypertension: an Asia-Pacific consensus viewpoint

Hypertension incurs a significant healthcare burden in Asia-Pacific countries, which have suboptimal rates of blood pressure (BP) treatment and control. A consensus meeting of hypertension experts from the Asia-Pacific region convened in Hanoi, Vietnam, in April 2013. The principal objectives were to discuss the growing problem of hypertension in the Asia-Pacific region, and to develop consensus recommendations to promote standards of care across the region. A particular focus was recommendations for combination therapy, since it is known that most patients with hypertension will require two or more antihypertensive drugs to achieve BP control, and also that combinations of drugs with complementary mechanisms of action achieve BP targets more effectively than monotherapy. The expert panel reviewed guidelines for hypertension management from the USA and Europe, as well as individual Asia-Pacific countries, and devised a treatment matrix/guide, in which they propose the preferred combination therapy regimens for patients with hypertension, both with and without compelling indications. This report summarizes key recommendations from the group, including recommended antihypertensive combinations for specific patient populations. These strategies generally entail initiating therapy with free drug combinations, starting with the lowest available dosage, followed by treatment with single-pill combinations once the BP target has been achieved. A single reference for the whole Asia-Pacific region may contribute to increased consistency of treatment and greater proportions of patients achieving BP control, and hence reducing hypertension-related morbidity and mortality.     

Treating According to Asthma Control : Does it Work in Real Life?

Control-based asthma management has been incorporated in asthma guidelines for many years. This article reviews the evidence for its utility in adults, describes its strengths and limitations in real life, and proposes areas for further research, particularly about incorporation of future risk and identification of patients for whom phenotype-guided treatment would be effective and efficient. The strengths of control-based management include its simplicity and feasibility for primary care, and its limitations include the nonspecific nature of asthma symptoms, the complex role of β(2)-agonist use, barriers to stepping down treatment, and the underlying assumptions about asthma pathophysiology and treatment responses.     

State of secondary prevention in Czech coronary patients in the EUROASPIRE IV study

IntroductionThe main objectives of cardiovascular prevention are to maintain risk factor management through lifestyle changes and use of cardioprotective medicines to reduce morbidity and mortality, and to improve quality of life.ObjectivesTo determine, in patients with coronary heart disease (CHD), whether the treatment goals as defined by the current European guidelines on secondary prevention are implemented in clinical practice.MethodsA total of 650 consecutive patients, men and women aged ≤80 years when hospitalized for any of the following first or recurrent discharge diagnoses or treatments for CHD were retrospectively identified from hospital records: (i) coronary artery bypass grafting (CABG), (ii) percutaneous transluminal coronary angioplasty (PTCA), (iii) acute myocardial infarction (AMI), and (iv) acute myocardial ischemia. The starting date for identification was not less than 6 months and not more than 3 years prior to the expected date of the study interview. Data collection was based on a review of medical records and the interview.ResultsIn total, 493 respondents were interviewed. Among them, 17% were smokers, 42% were obese, 86% were overweight or obese, 69% had central obesity, 71% had low physical activity, 75% had raised blood pressure (≥130/80 mmHg, according to the 2007 guidelines), 39% had elevated LDL-cholesterol (≥2.5 mmol/l), and 48% had overt diabetes (declared diabetes treatment or fasting glucose >7.0 mmol/l). At interview, 92% of patients were treated with aspirin or other antiplatelets, 85% with beta-blockers, 82% with ACE inhibitors or angiotensin receptor blockers (ARBs), and 93% with statins. Only a minority of the patients followed the non-pharmacologic secondary prevention recommendations.ConclusionAmong coronary patients, prevalence of overweight, obesity, and diabetes increased. Although pharmacotherapy is used in a majority of secondary prevention in patients, the recommended levels of blood pressure, lipid, and glucose metabolism are largely not achieved. Also, implementation of non-pharmacologic interventions of lifestyle factors remains unsatisfactory.