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Direct oral anticoagulants: unique properties and practical approaches to management
Since 2009, four direct oral anticoagulants (DOACs) have been introduced for treatment of venous thromboembolism and stroke prevention in non-valvular atrial fibrillation. While they are currently first-line therapy for a majority of patients, there are a number of clinical situations where warfarin is preferable. In both randomised trials and real-world populations, use of DOACs significantly reduces the risk of intracranial haemorrhage as compared with warfarin. While drug-specific reversal agents are currently only available for dabigatran, andexanet alpha is pending approval for reversal of factor Xa inhibitors, reduci...
Source: Heart - September 26, 2016 Category: Cardiology Authors: Barnes, G. D., Kurtz, B. Tags: Review articles Reviews Source Type: research

Histology of debris captured by a cerebral protection system during transcatheter valve-in-valve implantation
Conclusions Transcatheter VIV procedures were associated with the release of particulate debris into the cerebral circulation in all patients. The type of debris suggests that debris originates predominantly from arterial and valvular passage of the THV.
Source: Heart - September 12, 2016 Category: Cardiology Authors: Schmidt, T., Schlüter, M., Alessandrini, H., Akdag, O., Schewel, D., Schewel, J., Thielsen, T., Kreidel, F., Bader, R., Romero, M., Ladich, E., Virmani, R., Schäfer, U., Kuck, K.-H., Frerker, C. Tags: Aortic and vascular disease Source Type: research

Non-vitamin K antagonist oral anticoagulants (NOACs) for the management of venous thromboembolism
Learning objectives Understand the importance of venous thrombosis in cardiovascular medicine. Appreciate the mode of action of different oral anticoagulants. Recall the uses, risks and benefits of each non-vitamin K antagonist oral anticoagulants. Introduction Thrombosis is the common pathophysiology responsible for ischaemic heart disease, ischaemic stroke and venous thromboembolism (VTE), and a major contributor to the global disease burden.1 This effect is markedly more pronounced by considering the view that cancer is also a thrombotic disease.2 3 Cardiovascular disease (CVD, manifesting as acute coronary syndromes, m...
Source: Heart - June 5, 2016 Category: Cardiology Authors: Blann, A. D., Lip, G. Y. H. Tags: Education in Heart, Drugs: cardiovascular system, Acute coronary syndromes, Venous thromboembolism, Epidemiology Source Type: research

Safety and efficacy of ticagrelor and clopidogrel in primary percutaneous coronary intervention
Conclusions In the subset of patients with STEMI treated with primary PCI, ticagrelor compared with clopidogrel was safe, and efficacy outcomes were consistent with the overall PLATO trial. Trial registration number NCT00391872; Results.
Source: Heart - March 22, 2016 Category: Cardiology Authors: Velders, M. A., Abtan, J., Angiolillo, D. J., Ardissino, D., Harrington, R. A., Hellkamp, A., Himmelmann, A., Husted, S., Katus, H. A., Meier, B., Schulte, P. J., Storey, R. F., Wallentin, L., Gabriel Steg, P., James, S. K., on behalf of the PLATO Investi Tags: Drugs: cardiovascular system, Interventional cardiology, Acute coronary syndromes, Percutaneous intervention, Venous thromboembolism Coronary artery disease Source Type: research

Cochrane corner: oral hormone therapy and cardiovascular outcomes in post-menopausal women
Introduction Hormone therapy (HT) is commonly prescribed for the relief of climacteric symptoms in post-menopausal women; 54% (620490) of women enrolled in the Million Women Study1 in the UK (mean age 56 years) have tried it and 31% (358252) use it. Observational studies have shown oral HT is associated with lower rates of cardiovascular disease in post-menopausal women2; however randomised controlled trials (RCTs) have presented mixed results. The 2002 publication of the Women's Health Initiative I (WHI I) reported an association between combined oestrogen and progestin use and increased rates of both coronary heart...
Source: Heart - December 11, 2015 Category: Cardiology Authors: Boardman, H., Hartley, L., Eisinga, A., Main, C., Figuls, M. R. I. Tags: Drugs: cardiovascular system, Cochrane Corner, Acute coronary syndromes, Venous thromboembolism, Epidemiology Editorials Source Type: research

Cochrane corner: vitamin K for improved anticoagulation control in patients receiving warfarin
There has been a substantial increase in the use of oral anticoagulants, notably in the ageing population. This is primarily driven by the use of warfarin in people with atrial fibrillation (AF) in order to reduce the risks of thromboembolic events such as stroke.1 In elderly patients with AF, warfarin use has been shown to reduce the relative risk of stroke by >50% compared with aspirin alone.2 Warfarin is also used to treat patients with deep vein thrombosis, mechanical heart valve replacement, cardioversion, cardiomyopathy and antiphospholipid syndrome.1 The clinical benefits of warfarin must also be balanced with po...
Source: Heart - October 11, 2015 Category: Cardiology Authors: Mahtani, K. R., Nunan, D., Heneghan, C. Tags: Drugs: cardiovascular system, Cochrane Corner, Venous thromboembolism, Epidemiology Editorials Source Type: research

Prevalence of cerebral and pulmonary thrombosis in patients with cyanotic congenital heart disease
Conclusions Patients with CCHD have a prevalence of both cerebral and pulmonary thrombosis of around 30%–40%, which is much higher than that reported previously. Furthermore, there is a large discrepancy between clinical history and imaging findings, suggesting a high prevalence of silent thrombotic events. Neither erythrocytosis nor haemostatic abnormalities were associated with the prevalence of thrombosis in patients with CCHD. Trial registration number http://www.cvk.sum.dk/CVK/Home/English.aspx (H-KF-2006-4068).
Source: Heart - September 10, 2015 Category: Cardiology Authors: Jensen, A. S., Idorn, L., Thomsen, C., von der Recke, P., Mortensen, J., Sorensen, K. E., Thilen, U., Nagy, E., Kofoed, K. F., Ostrowski, S. R., Sondergaard, L. Tags: Congenital heart disease in adult patients, Editor's choice, Congenital heart disease, Drugs: cardiovascular system, Venous thromboembolism Source Type: research

Atrial flutter and thromboembolic risk: a systematic review
This study performs an up to date systematic review of the literature to investigate the association between atrial flutter and thromboembolic events. Articles were found by MEDLINE, EMBASE search and a manual search of references list in included articles. International guidelines, meta-analyses, reviews, case reports, studies reporting thromboembolic events in relation to ablation, or cardioversion procedures, echocardiography, and observational studies were found eligible in this review. A total of 52 articles were included in this review. During cardioversion, thromboembolic event rates varied from 0% to 6% with a foll...
Source: Heart - August 25, 2015 Category: Cardiology Authors: Vadmann, H., Nielsen, P. B., Hjortshoj, S. P., Riahi, S., Rasmussen, L. H., Lip, G. Y. H., Larsen, T. B. Tags: Review articles Reviews Source Type: research

Not all thromboembolism comes from the left atrial appendage in atrial fibrillation
Atrial fibrillation (AF) confers a substantial risk of stroke and thromboembolism, which is effectively reduced by oral anticoagulation (OAC), whether as a vitamin K antagonist (VKA, eg, warfarin) or one of non-VKA oral anticoagulants (NOACs). With the use of OACs, the risk of bleeding remains a problem associated with these agents. Thus, a clinical dilemma remains in the optimal management of patients with AF who are at high risk of stroke but have a history of bleeding. Among patients with non-valvular AF, over 90% of the thrombus is formed in the left atrial appendage (LAA).1 Thus, the exclusion of LAA could greatly dec...
Source: Heart - May 12, 2015 Category: Cardiology Authors: Senoo, K., Lip, G. Y. H. Tags: Drugs: cardiovascular system, Heart failure, Hypertension, Epidemiology Editorials Source Type: research

Left atrial appendage occlusion
Left atrial appendage (LAA) occlusion for stroke and thromboembolism prevention in patients with atrial fibrillation (AF) represents a significant advancement in the field of cardiovascular disease. Prevention and avoidance of the devastating consequences of thromboembolic complications from AF continues to be central in the management of these patients. The role of LAA as a nidus for thrombus formation is well documented. Multiple approaches to exclude the LAA from the circulation either percutaneously or surgically have been described and are undergoing testing. Although pharmacological therapy for stroke prevention rema...
Source: Heart - May 12, 2015 Category: Cardiology Authors: Alli, O., Holmes, D. Tags: Review articles Reviews Source Type: research

Diagnosis of an aortic valvular lesion
From the question on page 719 Clinical introduction A 59-year-old woman with hypertension presented with right-sided weakness and vision loss. Her vital signs were normal; cardiopulmonary exam was significant for a systolic and diastolic murmur. MRI of the brain showed multiple chronic bilateral infarctions, and Doppler ultrasound revealed acute left lower extremity deep vein thrombosis. Transthoracic echocardiography (TTE) to determine cardioembolic source of stroke was significant only for severe aortic valve regurgitation. To assess for cardiac vegetations, transoesophageal echocardiography (TEE) was performed (figure 1...
Source: Heart - April 9, 2015 Category: Cardiology Authors: Elboudwarej, O., Wei, J., Siegel, R. Tags: Drugs: cardiovascular system, Echocardiography, Image challenges, Hypertension, Venous thromboembolism, Aortic valve disease, Clinical diagnostic tests Source Type: research

Do risk factors for cardiovascular disease also increase the risk of frailty?
Frailty is a clinical syndrome characterised by multisystem impairment which decreases physiological reserve and increases the vulnerability to stressors. In patients with cardiovascular disease, frailty is a strong independent predictor of reduced life expectancy, prolonged hospitalisation and complications from surgery and other interventions.1 For these reasons there has been an increasing interest in the role of more systematic evaluation for frailty in elderly patients considered for major cardiovascular interventions.2 In their published Heart paper, Ramsay and colleagues3 provide a different perspective on the links...
Source: Heart - March 25, 2015 Category: Cardiology Authors: Stewart, R. Tags: Drugs: cardiovascular system, Hypertension, Acute coronary syndromes, Epidemiology, Tobacco use Editorials Source Type: research

Cardiovascular highlights from non-cardiology journals
Dual Antiplatelet Therapy Beyond 1-year after Percutaneous Coronary Interventions for Stable Coronary Artery Disease Results in Harm The benefit of extended dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is uncertain. The ARTIC-Interruption Trial examined discontinuation of DAPT at 1-year after PCI vs continuation for an additional 6–18 months. The study randomized patients 1-year after PCI to continuation (N=635) or interruption (N=624) groups, and examined the primary composite endpoint of death, myocardial infarction, stent thrombosis, stroke, or urgent revascularization over a med...
Source: Heart - January 14, 2015 Category: Cardiology Authors: Bradley, S. M. Tags: Journal scan Source Type: research

Combined anticoagulation and antiplatelet therapy in AF patients: why do we not follow guidelines?
While current European guidelines recommend oral anticoagulation treatment over antiplatelet therapy for the prevention of ischaemic stroke in patients with non-valvular atrial fibrillation (AF) with a 64% stroke risk reduction by warfarin treatment versus placebo and a 39% risk reduction versus aspirin,1 single or dual antiplatelet therapy is the guideline recommended first-line treatment strategy for patients with peripheral and/or coronary artery disease with and without intervention to prevent recurrences and major adverse cardiac events.2–7 Antiplatelet therapy is also recommended in patients with ischaemic stro...
Source: Heart - September 23, 2014 Category: Cardiology Authors: Brandes, A. Tags: Drugs: cardiovascular system, Acute coronary syndromes, Venous thromboembolism Editorials Source Type: research

Prediction of stroke in patients without atrial fibrillation using the CHADS2 and CHA2DS2-VASc scores: a justification for more widespread thromboprophylaxis?
The CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, previous stroke/transient ischaemic attack (TIA) (double)) and more recently, the CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years (double score), diabetes mellitus, previous stroke/TIA (double score), vascular disease, age 65–74 years, sex category (female)) scores are validated clinical prediction tools commonly used to estimate the stroke risk in atrial fibrillation (AF) patients. More recently, the focus has been on initially identifying those patients at ‘low risk’ (ie, CHA2DS...
Source: Heart - September 9, 2014 Category: Cardiology Authors: Senoo, K., Lip, G. Y. H. Tags: Drugs: cardiovascular system, Heart failure, Hypertension, Epidemiology, Diabetes, Metabolic disorders Editorials Source Type: research

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