Interruption of anticoagulant treatment with warfarin or non-vitamin K antagonist oral anticoagulants (NOAC) represents a vulnerable period with an increased risk of thromboembolic events. What is ...the incidence of thromboembolic events in real-life patients with non-valvular atrial fibrillation treated with NOAC who had a discontinuation or cessation of treatment in comparison to patients on continuous treatment?
Registry data from 866 patients with non-valvular atrial fibrillation, aged 74.3 (SD 9.8) years, with an average CHADS2 score of 2.1 (SD 1.2), who were started on dabigatran or rivaroxaban, were analysed for thromboembolic events and survival. Patients who had temporary or permanent discontinuation of NOAC were compared to patients on continuous NOAC treatment.
Among 866 patients started on NOAC, 705 were treated without interruption, 84 patients had temporary interruption (69 because of planned invasive procedures, 10 due to bleeding, 5 for other causes) and 77 had permanent cessation of NOAC treatment. In patients without interruptions, the incidence of thromboembolic events was 1.0 (95% CI 0.4-2.1) per 100 patient-years, while in patients with interruption/cessation the rate of thromboembolic events was 21.6 (95% CI 10.3-45.2) per 100 patient-years, p < 0.001. There was a distinct clustering of thromboembolic events in the first weeks of NOAC discontinuation with the median occurring on day 14 (range 1-37 days) after discontinuation.
Dabigatran and rivaroxaban offered good protection against thromboembolic events during treatment, but interruption of NOAC treatment increased the short-term thromboembolic risk more than 20-fold.
To prevent atherothrombotic events, patients with peripheral arterial disease are typically prescribed antiplatelet therapy (APT). However, some of them receive anticoagulant therapy (ACT) due to ...comorbidities. Our aim was to determine possible differences in the effectiveness and safety of both treatments in patients after endovascular femoropopliteal revascularisation. We retrospectively analysed 1247 patients after successful femoropopliteal revascularisation performed in a single tertiary medical centre and classified them into the ACT or APT group, based on their prescribed treatment. The groups were characterised by descriptive statistics, and their characteristics were adjusted for confounders by propensity score matching. Effectiveness and safety outcomes were assessed within one year after revascularisation. The odds ratio for the composite outcome of all-cause death, PAD exacerbation, and major amputation due to vascular causes with ACT versus APT was 1.21 (95% CI 0.53–2.21; p = 0.484). The odds ratio for major bleeding as defined by the International Society on Thrombosis and Haemostasis with ACT versus APT was 0.77 (95% CI 0.13–3.84; p = 0.251). We found no statistically significant difference in the effectiveness and safety of ACT, when compared to APT in patients with similar cardiovascular risk factors and other baseline characteristics. Further prospective research is warranted.
Supervised exercise training (walking) is recommended in patients with intermittent claudication, both as a means to improve symptoms (walking distance and quality of life QoL) and as a means to ...improve general cardiovascular health (including vascular function and heart rate variability HRV). Our aim was to compare two types of supervised training (moderate-pain and pain-free walking) with comparable intensity based on heart rate, in terms of walking capacity, QoL, vascular function, biomarkers, and HRV in patients with intermittent claudication.
Thirty-six adults with intermittent claudication were randomized to either moderate-pain or pain-free exercise training (36 sessions, two or three times a week) or usual care (no supervised exercise). Initial walking distance and absolute walking distance using treadmill testing, flow-mediated vasodilation and pulse wave velocity using ultrasound, N-terminal pro-B-type natriuretic peptide and fibrinogen levels, HRV, and QoL (36-Item Short Form Health Survey questionnaire) were determined at baseline and after the intervention period.
Twenty-nine patients (mean age, 64 ± 9 years; 72% male) completed the study. Both training programs similarly improved walking capacity. Initial walking distance and absolute walking distance significantly increased with either moderate-pain walking (median, 50 m to 107 m P = .005 and 85 m to 194 m P = .005, respectively) or pain-free walking (median, 53 m to 128 m P = .003 and 92 m to 163 m P = .003, respectively). QoL also similarly improved with both training modalities, whereas only moderate-pain walking was also associated with a statistically significant improvement in the vascular parameters flow-mediated vasodilation (4.4% to 8.0%; P = .002) and pulse wave velocity (6.6 m/s to 6.1 m/s; P = .013). Neither training program was associated with changes in biomarker levels and HRV.
Both moderate-pain and pain-free training modalities were safe and similarly improved walking capacity and health-related QoL. Conversely, vascular function improvements were associated with only moderate-pain walking.
Background. Patients with peripheral arterial disease (PAD) are routinely prescribed antiplatelet treatment (APT) after revascularisation. An exception are patients who receive anticoagulant ...treatment (ACT) due to comorbidity. We set out to determine possible differences in the effectiveness and safety between ACT and APT in patients who underwent endovascular revascularisation of the lower limb arteries.
Methods. In a single-centre retrospective study, we analysed the data of 1,587 consecutive patients with PAD who underwent successful endovascular revascularisation of the lower limb arteries due to disabling intermittent claudication or chronic critical limb ischemia in a 5-year period. Patients were divided in the ACT and APT group based on their prescribed treatment. After balancing both groups' baseline characteristics and cardiovascular risk factors with propensity score matching (PSM), we compared the effectiveness and safety of both treatment regimens in the first year afterrevascularisation.
Results. Compared to patients with APT, patients with ACT were older, more often reported arterial hypertension, diabetes, chronic kidney disease, congestive heart failure, ischaemic heart disease, and a history of stroke or transient ischaemic attack. After PSM, the odds ratio (OR) for an effective outcome with ACT versus APT was 0.78 (95% CI 0.39–1.59; p=0.502), while the OR for a safe outcome with ACT versus APT was 4.12 (95% CI 0.82–20.73; p=0.085).
Conclusions. Patients who required ACT were older, had more cardiovascular risk factors, and more advanced PAD than patients with APT. After matching, we found no statistically significant difference in the effectiveness and safety of both treatment regimens.
Adults with repaired tetralogy of Fallot (ToF) have impaired exercise capacity, vascular and cardiac autonomic function, and quality of life (QoL). Specific effects of high-intensity interval or ...moderate continuous exercise training on these parameters in adults with repaired ToF remain unknown.
Thirty adults with repaired ToF were randomized to either high-intensity interval, moderate intensity continuous training (36 sessions, 2–3 times a week) or usual care (no supervised exercise). Exercise capacity, flow-mediated vasodilation, pulse wave velocity, NT-proBNP and fibrinogen levels, heart rate variability and recovery, and QoL (SF-36 questionnaire) were determined at baseline and after the intervention period. Twenty-seven patients (mean age 39±9years, 63% females, 9 from each group) completed this pilot study. Both training groups improved in at least some parameters of cardiovascular health compared to no exercise. Interval–but not continuous–training improved VO2peak (21.2 to 22.9ml/kg/min, p=0.004), flow-mediated vasodilation (8.4 to 12.9%, p=0.019), pulse wave velocity (5.4 to 4.8m/s, p=0.028), NT-proBNP (202 to 190ng/L, p=0.032) and fibrinogen levels (2.67 to 2.46g/L, p=0.018). Conversely, continuous–but not interval–training improved heart rate variability (low-frequency domain, 0.32 to 0.22, p=0.039), heart rate recovery after 2min post-exercise (40 to 47 beats, p=0.023) and mental domain of SF-36 (87 to 95, p=0.028).
Both interval and continuous exercise training modalities were safe. Interval training seems more efficacious in improving exercise capacity, vascular function, NT-proBNP and fibrinogen levels, while continuous training seems more efficacious in improving cardiac autonomic function and QoL. (Clinicaltrials.gov, NCT02643810).
Cardiovascular rehabilitation (CR) improves aerobic capacity and quality of life in patients after myocardial infarction (MI). The aim was to examine the associations between exercise capacity ...improvement and different clinically relevant cardiovascular events.
This was a registry-based study of post-MI patients, referred to CR. All patients were submitted to exercise testing before and after CR (36 sessions, 2-3 times/week, and combined exercise). Patients were divided into two groups, based on the difference in exercise capacity before and after the CR programme with the cut-off of two metabolic equivalents (METs) improvement. We assessed the correlation between the extent of exercise capacity improvement and the following cardiovascular events: major adverse cardiac events (MACE), cardiovascular-related hospitalizations, and unplanned coronary angiography. A total of 499 patients were included (mean age 56 ± 10 years, 20% women). Both groups significantly improved in terms of exercise capacity, natriuretic peptide levels, resting heart rate, and resting diastolic pressure; however, lipid status significantly improved only in patients with ≥2 METs difference in exercise capacity. A total of 13.4% patients suffered MACE (median follow-up 858 days); 21.8% were hospitalized for cardiovascular reasons (median follow-up 791 days); and 19.8% had at least one unplanned coronary angiography (median follow-up 791 days). Exercise capacity improvement of ≥2 METs was associated with lower rates of MACE, cardiovascular hospitalizations, and unplanned coronary angiography in all examined univariate and multivariate models.
This study has shown that exercise improvement of ≥2 METs is associated with a significant decrease in MACE, cardiac hospitalizations, and unplanned coronary angiography.
Measurement of some haemostatic factors and products formed during activation of haemostasis seems to be promising in the determination of hypercoagulability.
The fibrinolytic variables euglobulin ...clot lysis time, tissue-type plasminogen activator, plasminogen activator inhibitor-1 and the haemostasis activation markers prothrombin fragment 1+2, thrombin-antithrombin complex and D-dimer were determined in 101 apparently healthy men and women aged 20-92 years (58+/-18 years, mean+/-SD) to establish variability due to several demographic, behavioural and metabolic factors.
None of the fibrinolytic variables were affected by smoking, while tissue-type plasminogen activator antigen was significantly lower in women compared to men. Multiple regression analysis revealed several independent associations between tissue-type plasminogen activator, plasminogen activator inhibitor, body mass index and lipid levels, describing up to 40% of the variance in fibrinolytic variables. For haemostasis activation markers, no gender difference or effect of smoking was observed. Only D-dimer was independently associated with age. The haemostasis activation markers determined proved to be extremely sensitive to blood sampling procedure and were significantly higher in samples obtained by an untrained nurse compared to a trained nurse.
Fibrinolytic variables are predominantly modulated by age, body mass index and blood lipids, while haemostasis activation markers are mainly un-influenced by these factors.
Thrombophilia is considered to increase the risk of venous thrombosis (VT) due to hemostasis activation. To determine the level of hemostasis activation in thrombophilic subjects with or without a ...history of VT, hemostasis activation markers prothrombin fragment 1 and 2 (F1+2), thrombin—antithrombin complex (TAT), and cross-linked fibrin degradation products (D-dimer) were measured in 94 subjects with (patients) and 101 subjects without a history of VT (controls). A total of 34.8% of patients and 14.8% of controls (P = .002) had at least 1 thrombophilic defect (protein C deficiency, activated protein C APC resistance, presence of lupus anticoagulants, or prothrombin G20210A polymorphism). The subjects were divided into 4 subgroups: patients with (TF+ patients) and without (TF− patients) thrombophilia, and controls with (TF+ controls) and without (TF− controls) thrombophilia. Hemostasis activation was comparable between all patients and controls (TAT: 2.1 vs 2.6 µg/L; F1+2: 1.0 vs 0.9 nmol/L; D-dimer: 36 vs 37 µg/L, respectively) and between TF+ and TF− patients. However, TF+ controls had a significantly higher prevalence of increased hemostasis activation markers compared with TF− controls (TAT > 4.4 µg/L, 38.4 vs 7.3%; F1+2 > 1.1 nmol/L, 53.8 vs 22.0%; D-dimer > 78 µg/L, 30.7 vs 8.8% of subjects, respectively; all P < .05). After stratification for thrombophilic defects, hemostasis activation was associated with APC resistance in controls and with protein C deficiency in patients. To conclude, thrombophilia was associated with hemostasis activation in controls. We assumed that, in patients, the differences in hemostasis activation between subjects with or without thrombophilia were blurred due to undetermined and unidentified thrombophilic defects.
In the article diagnostic and therapeutic recommendations for treatment of patients with suspected deep vein thrombosis are presented. All recommendations are graduated according to evidence and ...general agreement.
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