Inmaculada Roldán

Guías de actuación clínica de la Sociedad Española de Cardiología. Recomendaciones para el uso del tratamiento antitrombótico en cardiología

Las indicaciones de los antitromboticos en cardiologia van cambiando a medida que se incorporan nuevas familias de farmacos o se establecen nuevas indicaciones o nuevas dosis para farmacos ya conocidos. El presente documento es una puesta al dia del documento previo publicado en el ano 1994. Para ello se ha hecho una revision exhaustiva de la literatura de los ultimos 15 anos. Siguiendo las pautas de la medicina basada en la evidencia, y con la finalidad de seleccionar las publicaciones relevantes para cada patologia, todas las publicaciones seleccionadas con el MEDLINE, utilizando las palabras clave escogidas para cada apartado, se pasaron por los filtros siguientes: a) se han escogido solamente estudios aleatorizados, controlados, metaanalisis, guias clinicas y articulos de revision; b) seguidamente se consultaron las bases de datos del Best-Evidence y el Cochrane Collaboration, y c) finalmente se han aplicado los criterios de la medici-na basada en la evidencia de validacion, relevancia y aplicabilidad clinica a las evidencias encontradas. Las indicaciones de antiagregacion y/o anticoagulacion se dan para las siguientes patologias: a) profilaxis de la trombosis venosa profunda y del tromboembolismo pulmonar; b) prevencion del tromboembolismo sistemico en el contexto de fibrilacion auricular aislada, fibrilacion auricular con/sin valvulopatia reumatica, en pacientes portadores de protesis valvulares mecanicas y biologicas, y en la miocardiopatia dilatada; c) terapeutica antitrombotica en la enfermedad coronaria y en el intervencionismo coronario, y d) se revisan tambien las interacciones de los dicumarinicos y las indicaciones del control de los diversos farmacos.

Quality of Anticoagulation With Vitamin K Antagonists

Vitamin K antagonists (VKA) have a narrow therapeutic range, and literature analysis reveals poor quality of anticoagulation control. We sought to assess the prevalence of poor anticoagulant control in patients under VKA treatment in the prevention of stroke for atrial fibrillation (AF).

Cardiac involvement in relapsing polychondritis

Relapsing polychondritis is a rare disease characterized by recurrent inflammatory lesions involving cartilaginous structures, the eyes, the ears and the cardiovascular system. Valvar insufficiency represents the most common of the cardiac abnormalities and appears in 8 percent of patients. We describe two patients having relapsing polychondritis with cardiac involvement. One of them required valvar substitution and died 6 months after surgery.

Choice of New Oral Anticoagulant Agents Versus Vitamin K Antagonists in Atrial Fibrillation FANTASIIA Study

Introduction: Atrial fibrillation (AF) is associated with an increased risk of thromboembolic events. Many patients with AF receive chronic anticoagulation, either with vitamin K antagonists (VKAs) or with non-VKA oral anticoagulants (NOACs). We sought to analyze variables associated with prescription of NOAC. Methods: Patients with AF under anticoagulation treatment were prospectively recruited in this observational registry. The sample comprised 1290 patients under chronic anticoagulation for AF, 994 received VKA (77.1%) and 296 NOAC (22.9%). Univariate and multivariate analyses were performed to identify variables associated with use of NOAC. Results: Mean age was 73.8 ± 9.4 years, and 42.5% of the patients were women. The CHA2DS2-VASc score was 0 in 4.9% of the population, 1 in 24.1%, and ≥2 in 71% (median = 4, interquartile range = 2). Variables associated with NOAC treatment were major bleeding (odds ratio [OR] = 3.36; confidence interval [CI] 95%: 1.73-6.51; P < .001), hemorrhagic stroke (OR = 3.19; CI 95% 1.00-10.15, P = .049), university education (OR = 2.44; CI 95%: 1.55-3.84; P < .001), high diastolic blood pressure (OR = 1.02; CI 95%: 1.00-1.03; P = .006), and higher glomerular filtration rate (OR 1.01, CI 95% 1.00-1.01; P = .01). And variables associated with VKA use were history of cancer (OR = 0.46; CI 95%: 0.25-0.85; P = .013) and bradyarrhythmia (OR = 0.40; CI 95% 0.19-0.85; P = .020). Conclusion: Medical and social variables were associated with prescription of NOAC. Major bleeding, hemorrhagic stroke, university education, and higher glomerular filtration rate were more frequent among patients under NOAC. On the contrary, patients with history of cancer or bradyarrhythmias more frequently received VKA.

Is the ORBIT Bleeding Risk Score Superior to the HAS-BLED Score in Anticoagulated Atrial Fibrillation Patients?

BACKGROUNDnSeveral bleeding risk scores have been validated in patients with atrial fibrillation (AF). The ORBIT score has been recently proposed as a simple score with the best ability to predict major bleeding. The present study aimed to test the hypothesis that the ORBIT score was superior to the HAS-BLED score for predicting major bleeding and death in real world anticoagulated AF patients.nnnMETHODSANDRESULTSnWe analyzed the predictive performance for bleeding and death of 406 AF patients who underwent 571 electrical cardioversion procedures and 1,276 patients with permanent/persistent AF from the FANTASIIA registry. In the cardioversion population, 21 patients had major bleeding events and 26 patients died. The predictive performance for major bleeding of HAS-BLED and ORBIT were not significantly different (c-statistics 0.77 (95% CI 0.66-0.88) and 0.82 (95% CI 0.77-0.93), respectively; P=0.080). For the FANTASIIA population, 46 patients had major bleeding events and 50 patients died. The predictive performances for major bleeding of HAS-BLED and ORBIT were not significantly different (c-statistics 0.63 (95% CI 0.56-0.71) and 0.70 (95% CI 0.62-0.77), respectively; P=0.116). For death, the predictive performances of HAS-BLED and ORBIT were not significantly different in both populations. The ORBIT score categorized most patients as low risk.nnnCONCLUSIONSnDespite the original claims in its derivation paper, the ORBIT score was not superior to HAS-BLED for predicting major bleeding and death in a real world oral anticoagulated AF population. (Circ J 2016; 80: 2102-2108).

Satisfaction With Medical Care in Patients With Atrial Fibrillation Treated With Vitamin K Antagonists Versus New Oral Anticoagulants

1. Kim NH, Delcroix M, Jenkins DP, Channick R, Dartevelle P, Jansa P, et al. Chronic Thromboembolic Pulmonary Hypertension. J Am Coll Cardiol. 2013; 62:D92–9. 2. Dı́az B, del Pozo R, López-Gude MJ, Alonso S, Velázquez MT, Ruiz-Cano MJ, et al. Tratamiento quirúrgico versus médico en la hipertensión pulmonar tromboembólica crónica: ? Cuál es la mejor opción terapéutica? Rev Esp Cardiol. 2014;67 Supl 1:887. 3. Feinstein JA, Goldhaber SZ, Lock JE, Ferndandes SM, Landzberg MJ. Balloon pulmonary angioplasty for treatment of chronic thromboembolic pulmonary hypertension. Circulation. 2001;103:10–3. 4. Mizoguchi H, Ogawa A, Munemasa M, Mikouchi H, Ito H, Matsubara H. Refined balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension. Circ Cardiovasc Interv. 2012;5:748–55. 5. Lang IM, Madani M. Update on chronic thromboembolic pulmonary hypertension. Circulation. 2014;130:508–18.

On the Way to a Better Use of Anticoagulants in Nonvalvular Atrial Fibrillation. Proposed Amendment to the Therapeutic Positioning Report UT/V4/23122013

Atrial fibrillation (AF) is the most common type of cardiac arrhythmia. It is associated with an increased morbidity and mortality, in particular due to a higher thrombo-embolic risk. The clinical benefits of anticoagulant therapy have been demonstrated repeatedly, with a marked reduction in thrombo-embolic events and mortality. However, there are several inherent limitations in vitamin K antagonist (VKA) therapy: variability in the effect (related to clinical and genetic factors), drug interactions and interaction with certain foods, need for frequent routine monitoring, etc. Patients with poor anticoagulation control with a VKA, estimated using the time in therapeutic range (TTR), have a higher probability of complications, both thrombo-embolic and hemorrhagic. Likewise, a labile international normalized ratio (INR) is associated with an increased bleeding risk. In fact, labile INR is one of the variables included in the HAS-BLED score for major bleeding risk, which is recommended in the current European guidelines on AF. Recent studies carried out in Spain found that anticoagulation control was suboptimal in approximately 40% of patients receiving VKAs; this percentage could be higher in patients starting VKA anticoagulant therapy. Regarding the novel oral anticoagulants (NOACs), also known as direct-acting oral anticoagulants (DOACs), various pivotal clinical studies have shown a benefit in the primary efficacy endpoint as well as a clear safety benefit, finding a reduction in the rate of intracranial hemorrhage. Use of NOACs has been approved by the European and Spanish regulatory agencies. However, the Spanish regulatory approval includes several restrictions for use, which are reflected in the therapeutic positioning report UT/V4/ 23122013, and, in addition, requires authorization for their prescription. Patients who cannot attend for blood monitoring of VKAs and patients with a high bleeding risk, high thrombotic risk, or poor anticoagulation control are clear candidates for NOACs. However, the need for authorization is a bureaucratic

Oral anticoagulation in octogenarians with atrial fibrillation

BACKGROUNDnVitamin K antagonists (VKAs) are still largely employed, even in nonvalvular atrial fibrillation (AF). Our aim was to study the clinical profile of octogenarians treated with oral anticoagulation and to study the effect of age on the quality of VKAs anticoagulation.nnnMETHODSnData are from a prospective national registry in an adult Spanish population of nonvalvular AF. We included 1637 patients who had been receiving VKAs for at least 6months before enrolment.nnnRESULTSnMean age was 73.8±9.4years. Patients aged >80years (N=429) had a high risk profile with higher risk of stroke and bleeding than younger patients; CHA2DS2-VASc (Cardiac failure, Hypertension, Age>74, Diabetes, Stroke, Vascular disease, Age 65-74years, and Sex category) 4.5±1.3 vs. 3.5±1.6, p<0.001, HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (>64years), Drugs/alcohol concomitantly) 2.4±0.9 vs. 1.9±1.1, p<0.001. Creatinine clearance was lower in octogenarians than in younger patients (54.3±16.1ml/min vs. 69.5±23.7ml/min, p<0.001) and severe renal disease with creatinine clearance <30ml/min was more frequent in octogenarians (5.2% vs. 2.2%, p<0.001). In patients treated with VKAs (N=1637), the international normalized ratio values of the 6months previous to enrollment were similar in all age quartiles, as was the time in the therapeutic range.nnnCONCLUSIONnIn this large registry octogenarians with nonvalvular AF had high risk of stroke and bleeding and frequent renal disease. VKAs anticoagulation quality was similar in octogenarians and in younger patients.

Perioperative and Periprocedural Management of Antithrombotic Therapy: Consensus Document of SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT and AEU

During the last few years, the number of patients receiving anticoagulant and antiplatelet therapy has increased worldwide. Since this is a chronic treatment, patients receiving it can be expected to need some kind of surgery or intervention during their lifetime that may require treatment discontinuation. The decision to withdraw antithrombotic therapy depends on the patients thrombotic risk versus hemorrhagic risk. Assessment of both factors will show the precise management of anticoagulant and antiplatelet therapy in these scenarios. The aim of this consensus document, coordinated by the Cardiovascular Thrombosis Working Group of the Spanish Society of Cardiology, and endorsed by most of the Spanish scientific societies of clinical specialities that may play a role in the patient-health care process during the perioperative or periprocedural period, is to recommend some simple and practical guidelines with a view to homogenizing daily clinical practice.