Depression is a common problem in patients with cardiovascular disease (CVD) and is associated with increased mortality, excess disability, greater health care expenditures, and reduced quality of ...life. Depression is present in 1 of 5 patients with coronary artery disease, peripheral artery disease, and heart failure. Depression complicates the optimal management of CVD by worsening cardiovascular risk factors and decreasing adherence to healthy lifestyles and evidence-based medical therapies. As such, standardized screening pathways for depression in patients with CVD offer the potential for early identification and optimal management of depression to improve health outcomes. Unfortunately, the burden of depression in patients with CVD is under-recognized; as a result, screening and management strategies targeting depression have been poorly implemented in patients with CVD. In this review, the authors discuss a practical approach for the screening and management of depression in patients with CVD.
Oral Anticoagulation in Patients With Liver Disease Qamar, Arman; Vaduganathan, Muthiah; Greenberger, Norton J. ...
Journal of the American College of Cardiology,
05/2018, Letnik:
71, Številka:
19
Journal Article
Recenzirano
Odprti dostop
Patients with liver disease are at increased risks of both thrombotic and bleeding complications. Many have atrial fibrillation (AF) or venous thromboembolism (VTE) necessitating oral anticoagulant ...agents (OACs). Recent evidence has contradicted the assumption that patients with liver disease are “auto-anticoagulated” and thus protected from thrombotic events. Warfarin and non–vitamin K–antagonist OACs have been shown to reduce thrombotic events safely in patients with either AF or VTE. However, patients with liver disease have largely been excluded from trials of OACs. Because all currently approved OACs undergo metabolism in the liver, hepatic dysfunction may cause increased bleeding. Thus, the optimal anticoagulation strategy for patients with AF or VTE who have liver disease remains unclear. This review discusses pharmacokinetic and clinical studies evaluating the efficacy and safety of OACs in patients with liver disease and provides a practical, clinically oriented approach to the management of OAC therapy in this population.
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Patients with active cancer are at an increased risk of arterial and venous thromboembolism (VTE) and bleeding events. Historically, in patients with cancer, low molecular weight heparins have been ...preferred for treatment of VTE, whereas warfarin has been the standard anticoagulant for stroke prevention in patients with atrial fibrillation (AF). More recently, direct oral anticoagulants (DOACs) have been demonstrated to reduce the risk of venous and arterial thromboembolism in large randomized clinical trials of patients with VTE and AF, respectively, thus providing an attractive oral dosing option that does not require routine laboratory monitoring. In this review, we summarize available clinical trial data and guideline recommendations, and outline a practical approach to anticoagulation management of VTE and AF in cancer.
Aims
Trials have tested the safety and efficacy of sodium–glucose co‐transporter 2 inhibitors (SGLT2i) across various disease states. We performed a meta‐analysis of randomized controlled trials ...(RCTs) to estimate the relative and absolute effects of SGLT2i in the prevention of heart failure (HF) events across different risk groups.
Methods and results
We conducted a systematic review and meta‐analysis of large, placebo‐controlled RCTs with >1000 participants evaluating HF hospitalization and the composite of cardiovascular (CV) death or HF hospitalization. Due to varying durations of therapeutic exposure and follow‐up, absolute risk reductions and number needed to treat were calculated based on incidence rates (per 100 patient‐years). Across 71 553 patients enrolled in 10 late‐phase RCTs, SGLT2i reduced the risk of HF hospitalization by 31% hazard ratio (HR) 0.69, 95% confidence interval (CI) 0.64–0.74; I2 = 0% and the composite outcome of CV death or HF hospitalization by 24% (HR 0.76, 95% CI 0.72–0.80; I2 = 1.4%) compared with placebo. The number of patient‐years of treatment exposure needed to prevent one CV death or HF hospitalization ranged from 19–26 (established HF) to 72–125 (chronic kidney disease) to 96–400 (high‐risk type 2 diabetes). In mixed‐effects meta‐regression analyses, the benefits of SGLT2i on HF hospitalizations or the composite outcome (CV death or HF hospitalization) were not influenced by age, sex, or change in intermediate markers (glycated haemoglobin, systolic blood pressure, and body weight) (all P ≥ 0.10).
Conclusion
Despite wide variation in baseline risks and disease states evaluated, SGLT2i demonstrated comparable relative risk reductions in preventing HF events. Patients at highest baseline risk derived the greatest absolute benefits in preventing HF events. These composite estimates may help guide targeted implementation of SGLT2i for the prevention of HF events in type 2 diabetes and chronic kidney disease and in the treatment of HF.
An arterial aneurysm is defined as a focal dilation of a blood vessel with respect to the original artery. The risk of abdominal aortic aneurysms (AAAs) increases dramatically in the presence of the ...following factors: age older than 60 years, smoking, hypertension and Caucasian ethnicity. The likelihood that an aneurysm will rupture is influenced by the aneurysm size, expansion rate, continued smoking and persistent hypertension. The majority of AAAs are asymptomatic and are detected as an incidental finding on ultrasonography, abdominal computed tomography or magnetic resonance imaging performed for other purposes. It can also present with abdominal pain or complications such as thrombosis, embolization and rupture. Approximately 30% of asymptomatic AAAs are discovered as a pulsatile abdominal mass on routine physical examination. Abdominal ultrasonography is considered the screening modality of choice for detecting AAAs because of its high sensitivity and specificity, as well as its safety and relatively lower cost. The decision to screen for AAAs is challenging. The United States Preventive Services Task Force recommended that men between the age of 65 to 75 years who have ever smoked should be screened at least once for AAAs by abdominal ultrasonography. Management options for patients with an asymptomatic AAA include reduction of risk factors such as smoking, hypertension and dyslipidemia; medical therapy with beta-blockers; watchful waiting; endovascular stenting; and surgical repair depending on the size and expansion rate of the aneurysm and underlying comorbidities.
Current status of data on cangrelor Qamar, Arman; Bhatt, Deepak L
Pharmacology & therapeutics (Oxford),
03/2016, Letnik:
159
Journal Article
Recenzirano
P2Y12 receptor inhibition in addition to aspirin is the cornerstone of treatment in patients with acute coronary syndromes (ACS) and those undergoing percutaneous coronary intervention (PCI). Despite ...advances in contemporary antithrombotic therapy, periprocedural thrombotic complications such as myocardial infarction and stent thrombosis remain a major concern in patients treated with PCI. Current practice guidelines recommend treatment with a P2Y12 receptor inhibitor as early as possible in patients with ACS. Existing oral P2Y12 receptors inhibitors (clopidogrel, prasugrel, or ticagrelor) have several limitations such as delayed onset and offset of action, interindividual variation, and only oral availability. Cangrelor, an intravenous, fast-onset, direct-acting P2Y12 receptor inhibitor offers potent platelet inhibition that is rapidly reversible. In large randomized trials, cangrelor has shown substantial reduction in ischemic events with no increase in severe bleeding compared with clopidogrel among patients undergoing PCI. Cangrelor is approved as an adjunct to PCI to reduce the risk of periprocedural MI, repeat coronary revascularization, and stent thrombosis in patients who have not been pretreated with a P2Y12 receptor inhibitor and are not receiving a glycoprotein IIb/IIIa inhibitor. This review aims at providing a comprehensive analysis of the current evidence pertaining to the role of cangrelor in contemporary practice.
Aims: Of patients with atrial fibrillation (AF), approximately 10% undergo percutaneous coronary intervention (PCI). We studied the safety and efficacy of dual vs. triple antithrombotic therapy (DAT ...vs. TAT) in this population.
Methods and results: A systematic review and meta-analysis was conducted using PubMed, Embase, EBSCO, Cochrane database of systematic reviews, Web of Science, and relevant meeting abstracts for Phase 3, randomized trials that compared DAT vs. TAT in patients with AF following PCI. Four trials including 5317 patients were included, of whom 3039 (57%) received DAT. Compared with the TAT arm, Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding showed a reduction by 47% in the DAT arm 4.3% vs. 9.0%; hazard ratio (HR) 0.53, 95% credible interval (CrI) 0.36–0.85, I 2 = 42.9%. In addition, there was no difference in the trial-defined major adverse cardiac events (MACE) (10.4% vs. 10.0%, HR 0.85, 95% CrI 0.48–1.29, I 2 = 58.4%), or in individual outcomes of all-cause mortality, cardiac death, myocardial infarction, stent thrombosis, or stroke between the two arms.
Conclusion: Compared with TAT, DAT shows a reduction in TIMI major or minor bleeding by 47% with comparable outcomes of MACE. Our findings support the concept that DAT may be a better option than TAT in many patients with AF following PCI.
Antiplatelet therapy is key for preventing thrombotic events after transient ischemic attack or ischemic stroke. Although the role of aspirin is well established, there is emerging evidence for the ...role of short-term dual antiplatelet therapy (DAPT) in preventing recurrent stroke.
We conducted a systematic review and study-level meta-analyses of randomized controlled trials comparing outcomes of early initiation of short-term DAPT (aspirin+P2Y12 inhibitor for up to 3 months) versus aspirin alone in patients with acute stroke or transient ischemic attack. Primary efficacy outcome was risk of recurrent stroke and primary safety outcome was incidence of major bleeding. Secondary outcomes studied were risk of any ischemic stroke, hemorrhagic stroke, major adverse cardiovascular events, and all-cause death. Pooled risk ratios (RRs) and CIs were calculated using a random-effects model.
Four trials with a total of 21 459 patients were included. As compared to aspirin alone, DAPT had a lower risk of recurrent stroke (RR, 0.76 95% CI, 0.68–0.83; P<0.001; I2=0%) but a higher risk of major bleeding events (RR, 2.22 95% CI, 1.14–4.34, P=0.02, I2=46.5%). Patients receiving DAPT had a lower risk of major adverse cardiovascular events (RR, 0.76 95% CI, 0.69–0.84, P<0.001, I2=0%) and recurrent ischemic events (RR, 0.74 95% CI, 0.67–0.82, P<0.001, I2=0%).
As compared to aspirin alone, short-term DAPT within 24 hours of high-risk transient ischemic attack or mild-moderate ischemic stroke reduces the risk of recurrent stroke at the expense of higher risk of major bleeding.
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