Karam Ayoub

Perioperative Heparin Bridging in Atrial Fibrillation Patients Requiring Temporary Interruption of Anticoagulation: Evidence from Meta-analysis.

BACKGROUND Patients with atrial fibrillation (AF) often require temporary interruption of warfarin for an elective operation or invasive procedure. However, the safety and efficacy of periprocedural bridging anticoagulation with unfractionated heparin (UH) or low-molecular-weight heparin (LMWH) are still unclear. We evaluated the safety of periprocedural heparin bridging in AF patients requiring temporary interruption of oral anticoagulation. METHODS We searched the literature for trials that compared heparin bridging with no bridging in AF patients for whom warfarin was temporarily interrupted. The incidence of all-cause mortality, thromboembolism, and major and all bleeding was included, and meta-analysis was performed. RESULTS A total of 13,808 patients with AF were included in 4 observational studies, 1 randomized trial, and 1 subgroup analysis of a randomized trial. The mean CHADS2 score for the no heparin bridging group was 2.49 and that for the heparin bridging group was 2.34. At 30 days and up to 3 months, when compared to the heparin bridging group, the no bridging group did not have any significant difference in mortality (odds ratio [OR], 1.29; 95% confidence interval [CI], .15-11.52; P = .82) or cerebrovascular accidents (OR, .93; 95% CI, .34-2.51; P = .88), but the no bridging group had significantly less major bleeding (OR, .41; 95% CI, .24-.68; P = .0006). CONCLUSION Among AF patients with intermediate CHADS2 scores who are anticoagulated with warfarin and who required temporary interruption of warfarin for an elective surgery or procedure, periprocedural bridging with UH or LMWH was associated with a higher rate of major bleeding with no significant difference in mortality or CVA.

Immunity, Inflammation, and Oxidative Stress in Heart Failure: Emerging Molecular Targets

PurposeHeart failure (HF) remains a major cause of morbidity and mortality worldwide. Although various therapies developed over the last two decades have shown improved long term outcomes in patients with established HF, there has been little progress in preventing the adverse cardiac remodeling that initiates HF. To fill the gap in treatment, current research efforts are focused on understanding novel mechanisms and signaling pathways. Immune activation, inflammation, oxidative stress, alterations in mitochondrial bioenergetics, and autophagy have been postulated as important pathophysiological events in this process. An improved understanding of these complex processes could facilitate a therapeutic shift toward molecular targets that can potentially alter the course of HF.MethodsIn this review, we address the role of immunity, inflammation, and oxidative stress as well as other novel emerging concepts in the pathophysiology of HF that may have therapeutic implications.ConclusionBased on the experimental and clinical studies presented here, we anticipate that a better understanding of the pathophysiology of HF will open the door for new therapeutic targets. A one-size-fits-all approach may not be appropriate for all patients with HF, and further clinical trials utilizing molecular targeting in HF may result in improved outcomes.

ANTIPLATELET AND ANTITHROMBOTIC THERAPY IN ATRIAL FIBRILLATION PATIENTS IN THE SETTING OF ACUTE CORONARY SYNDROME AND/OR AFTER PERCUTANEOUS CORONARY INTERVENTION: EVIDENCE FROM META-ANALYSIS

Atrial fibrillation (AF) patients presenting with acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI) are very challenging to manage. Studies have proposed different treatment regimens including dual antiplatelet therapy (DAPT: Aspirin and Clopidogrel) and triple therapy (

A Computerized Order Set Entry (CPOE) for Vancomycin Dosing Results in Improved Clinical Outcomes in Adult Patients Treated at an Academic Medical Center

Background. Appropriate vancomycin dosing is important to ensure adequate bactericidal activity. The purpose of this study was to evaluate the impact of a CPOE on the achievement of early therapeutic vancomycin trough levels and clinical outcomes among adult patients admitted to surgical/medical wards and critical care units at the University of Arkansas for Medical Sciences who received treatment for at least 2 days.

PERCUTANEOUS CORONARY INTERVENTION WITH HALF DOSE FIBRINOLYSIS VERSUS PRIMARY PERCUTANEOUS CORONARY INTERVENTION IN ST ELEVATION MYOCARDIAL INFARCTION: EVIDENCE FROM A META-ANALYSIS

A strategy of pre-hospital administration of Half Dose Fibrinolysis followed by urgent percutaneous coronary intervention (HDF-PCI) on arrival to hospital has been evaluated in a growing number of studies as a possible solution for delays to primary PCI (PPCI). We searched online databases up to

Duration of Triple Therapy: A Clinical Question Remains Unanswered.

1 The article fails to mention the average duration of dual vs triple therapy. Duration of triple therapy is important information, vital for clinical decision making. 2 Certain important patients’ characteristics are missing including CHADS2, CHADSVASC, and HASBLED scores in each of the included studies. The outcome may be different if we stratify patients based on the aforementioned scores. 3 This meta-analysis included 16 studies; each has patients with various indications for oral anticoagulants. In few of these studies, the percentage of patients with atrial fibrillation was 100%, while others had as low as 40%. What were the other indications for oral anticoagulation? Different diseases have different pathological consequences, and treatment may differ significantly. 4 There are few other studies that meet the authors’ inclusion criteria but were not included in this metaanalysis2,3. We ask the authors why they were not included and will their inclusion change any of the outcomes reported.

Letter by Ayoub Regarding Article, “Prospective Randomized Trial of Moderately Strenuous Aerobic Exercise After an Implantable Cardioverter Defibrillator”

I read with great interest the study published by Dougherty et al1 demonstrating that moderately strenuous exercise significantly improved cardiovascular performance in persons with an implantable cardioverter-defibrillator. I commend the authors for their efforts. I believe the following issues should be clarified. First, the usual …

Antithrombotic and Antiplatelet Therapy in Patients Requiring Oral Anticoagulation After Percutaneous Coronary Intervention.

adequate response to aspirin. Subgroup analysis revealed that aspirin-resistant patients with body mass index >30 kg/m tend to have a higher occurrence of MACCEs relative to aspirinsensitive patients (18% vs 5%, p 1⁄4 0.05). Our findings suggest that further sufficiently powered studies are needed to define optimal APT management. Evaluation of APT effect on both bleeding and adverse ischemic events should be based on platelet function assessment with subsequent distinction of patients with high residual platelet activity, thus proclivity to ischemic events, or enhanced platelet inhibition, thus proclivity to excessive bleeding. For patients who underwent CABG, individually tailored APT administration management, based on platelet function testing, can help reduce both bleeding and ischemic events. Such an approach requires further studies to provide precise and comprehensive view on the relation between APT administration management and both, bleeding and ischemic events, through achieved platelet inhibition quantified by platelet function tests. One of the major drawbacks of our randomized controlled trial was that platelet inhibitory response to clopidogrel was not assessed in the DAPT group. The negligible rate of clopidogrel resistance certainly requires the assessment of platelet ADP receptor activity while on clopidogrel therapy. That a patient is treated by the DAPT does not necessarily mean that patient has achieved adequate platelet inhibition. According to our findings, there is wide interindividual variability in inherent ADP receptor activity. In contrast, the effect of clopidogrel or any other ADP receptor blocker depends on (1) baseline-inherent ADP receptor activity and (2) platelet inhibitory response to the ADP receptor blocker. Considering wide variability in inherent platelet ADP receptor activity and wide variability in platelet inhibitory response to ADP receptor blockers, we should not be surprised by negative studies evaluating the role of DAPT. It seems that the “one-size-fits-all” concept of APT administration is outdated, and further development of personalized APT management based on platelet function testing is desirable.