Serena Granziera

Increasing incidence of non-valvular atrial fibrillation in the UK from 2001 to 2013

Objective To determine whether the incidence of atrial fibrillation (AF) is static or rising in the UK. Design Among the cohort of all individuals aged ≥45 years in the UK Clinical Practice Research Datalink (CPRD) (linked to hospital discharges) we identified incident non-valvular AF cases between 2001 and 2013. Overall and annual AF incidence rates were calculated and standardised to the UK population. Results The cohort of 2.23 million individuals included 91 707 patients with incident AF. The overall standardised AF incidence rate was 6.7 (95% CI 6.7 to 6.8) per 1000 person-years, increasing exponentially with age and higher in men of all ages. There was a small increase in the standardised incidence of AF in the last decade from 5.9 (5.8 to 6.1)/1000 person-years in 2001 to 6.9 (6.8 to 7.1)/1000 person-years in 2013, mostly attributable to subjects aged >80 years with a non-primary hospital discharge diagnosis of AF. Standardised incidence rates of AF among white patients was 8.1 (8.1 to 8.2)/1000 person-years, compared with 5.4 (4.6 to 6.3) for Asians and 4.6 (4.0 to 5.3) for black patients. AF diagnosis was first made in general practice in 39% of incident AF. Conclusions The incidence of AF in the UK has increased gradually in the last decade, with more than 200 000 first-ever non-valvular AF cases expected in 2015. This increase is only partly due to population ageing, though the principal increase has been in the elderly hospitalised for a reason other than AF.

Reasons for and consequences of vitamin K antagonist discontinuation in very elderly patients with non-valvular atrial fibrillation

Essentials Anticoagulation in the elderly is still a challenge and suspension of warfarin is common. This is an observational study reporting reasons and consequences of warfarin suspension. Vascular disease, age, time in therapeutic range, and bleedings are associated with suspension. After suspension for bleeding or frailty, patients remain at high‐risk of death or complications.

Vitamin K antagonists’ use and fracture risk: results from a systematic review and meta‐analysis: reply

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Consequences of warfarin suspension after major bleeding in very elderly patients with non valvular atrial fibrillation

Consequences of warfarin suspension after major bleeding in very elderly patients with non valvular atrial fibrillation -

Minimizing the risk of hemorrhagic stroke during anticoagulant therapy for atrial fibrillation

Introduction: Oral anticoagulation (OAC) is given for ischemic stroke prevention in patients with nonvalvular atrial fibrillation. OAC’s most serious complications are major bleeding and, in particular, hemorrhagic stroke. Together with vitamin K antagonists (VKAs), direct oral anticoagulants (DOAC) are now available which have a more rapid onset/offset of action and more predictable anticoagulant effect. The advent of DOAC has given to the clinician an opportunity to tailor OAC therapy in order to maximize advantages and minimize complications. Areas covered: This review covers data published in literature regarding the risk of hemorrhagic stroke in patients taking OAC. Bleeding risk assessment is discussed and different bleeding risk factors are presented. The paper will also review clinical studies comparing DOAC against standard anticoagulation, in regard to the risk of hemorrhagic stroke. Expert opinion: Bleeding assessment is mandatory in order to select patients at high hemorrhagic risk who will benefit the most from close monitoring. Blood pressure, alcohol intake, concomitant medication and comorbidities should be constantly evaluated and treated accordingly. During VKA therapy, adherence and intensity of anticoagulation must be strictly monitored. DOAC are associated with lower risk of hemorrhagic stroke than VKA. However, periodic hepatic and renal checks as well as careful evaluation of time adherence are necessary to reduce the risk of bleeding.

Full Penetrance of Morgagni-Stewart-Morel Syndrome in a 75-Year-Old Woman: Case Report and Review of the Literature

CONTEXT Morgagni-Stewart-Morel syndrome is defined as the presence of hyperostosis frontalis interna, variably associated with metabolic, endocrine, and neuropsychiatric disorders. The possible cause-effect relationship of these associations remains uncertain. CASE PRESENTATION A 75-year-old woman presented with severe frontal headache and a history of psychotic disorders. On instrumental examination she was found to have extensive frontal hyperostosis and cortical atrophy. These findings, associated to the metabolic and neuropsychiatric pattern of the patient, are consistent with a high penetrance of Morgagni-Stewart-Morel syndrome. EVIDENCE ACQUISITION AND SYNTHESIS In this clinical case seminar, we summarize the current understanding of the association between hyperostosis frontalis interna and Morgagni-Stewart-Morel, based on a MEDLINE search (case reports, original articles, and reviews published between 1928 and 2011) on this topic. Possible pathophysiological mechanisms underlying both the headache and the hyperostosis frontalis interna are discussed. CONCLUSION A case of full penetrance of Morgagni-Stewart-Morel syndrome is reported, presenting many of the clinical features described in the literature. Metabolic and endocrine dysfunctions should be interpreted not only as isolated components of the syndrome, but also as the reason behind its pathogenesis. Endocrine or nutritional disorders may have led to an altered bone metabolism with frontal bone apposition. On the other hand, the severity of our patients neurological and psychiatric symptoms correlates well with the severity of her hyperostosis frontalis interna and the cortical atrophy.

Nutritional and global indexes of progression in dementia: a 12-month prospective study.

Background: To assess the influence of body mass index (BMI) on the progression of dementia. Methods: Sixty elderly outpatients with untreated dementia followed for 12 months. All patients underwent clinical, cognitive, functional, and nutritional assessment at the baseline and after 12 months. Patients were divided into 2 groups by baseline BMI (< or ≥25 kg/m2). Results: Participants with a baseline BMI ≥25 kg/m2 had significantly higher Mini-Mental State Examination (MMSE) scores (21 ± 5.1 vs 15.9 ± 5.5; P < .001), while clinical dementia rating (CDR) and multidimensional prognostic index (MPI) scores were similar in the 2 groups. After 12 months, the MMSE score decreased significantly in both groups compared to the baseline, while the CDR and MPI scores increased significantly for patients with a baseline BMI <25 kg/m2. Conclusion: A BMI cutoff of 25 kg/m2 could be useful for identifying frail patients with dementia who will experience a more rapid global impairment, which could be assessed adequately using multidimensional evaluation tools.

The Novel Oral Anticoagulants for Acute Venous Thromboembolism: Is Warfarin Dead?

Abstract The direct oral anticoagulants (DOACs) have been compared with parenteral anticoagulants and vitamin K antagonists (VKAs) for the treatment of venous thromboembolism (VTE) in several robust studies. DOACs have shown similar efficacy in preventing recurrent VTE and significant reductions in critical site (intracranial) bleeding, fatal bleeding, major and nonmajor bleeding. Warfarin and other VKAs are not dead as treatment modalities for VTE. A better way to describe the current situation is to use a boxing expression, “down but not out.” VKAs and parenteral anticoagulants still have a role to play in the management of VTE in several clinical settings. In indications where DOACs can be used, VKAs should not, as the safety profile of VKAs is considerably worse than DOACs. Hence, guidelines are now recommending DOACs in preference to VKAs. In this article, we consider where DOACs are indicated, where there is growing evidence for use, where we have little evidence for use, and finally where there is no evidence for use and where they, thus, should not be used. We have included recommendations and examples of our own practice which may not be applicable to all settings.

Excellence, quality and limitations of the NICE venous thromboembolism score tool: how can it be improved?

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Aspirin Versus Low-Molecular-Weight Heparin After Total Hip Arthroplasty

TO THE EDITOR: In a multicenter randomized trial involving 786 patients having elective total hip replacement in Canada during a 3-year period, Anderson and colleagues (1) observed how, after 10 days of dalteparin therapy, 28 days of oral aspirin prophylaxis was noninferior to 28 days of dalteparin therapy for preventing venous thromboembolism (VTE). These results are very interesting to clinicians involved in elective hip surgery, particularly because some guidelines consider aspirin to be effective despite the single large randomized trial (2) quoted in the guidelines from the American College of Chest Physicians (3) that showed no effect of aspirin in this setting. We believe that the data from Anderson and colleagues’ trial cannot be considered as definitive as the conclusions indicated. The randomization in this relatively small trial did not result in a satisfactory distribution of important risk factors. Despite the authors’ assurance of the similarity of baseline characteristics of the 2 groups, we can see several important differences. The 3 strongest risk factors for VTE—history of deep venous thrombosis or pulmonary embolism (8 vs. 5 cases; 2.0% vs. 1.3%), active cancer in the past 5 years (13 vs. 8 cases; 3.3% vs. 2.1%), and surgery in the past 6 months (16 vs. 10 cases; 4.0% vs. 2.6%)— occurred more frequently in the dalteparin group. Furthermore, the most important risk factor for bleeding (previous major bleeding) also occurred more frequently in the dalteparin group (6 vs. 2 cases; 1.5% vs. 0.5%). With these being the principal risk factors for deep venous thrombosis and bleeding, we believe that the results should be interpreted with caution. It is also important to emphasize that the sample size is significantly smaller than those of trials in a similar setting (4, 5). As a result, the number of thromboembolic events in the 2 groups is small and chance-related findings cannot be excluded. We agree with Anderson and colleagues that the generalizability of the findings is probably questionable given the recent availability of novel oral anticoagulants for VTE prophylaxis after hip replacement (5). It would now be of major interest to outline a welldesigned randomized, controlled trial comparing aspirin with a novel oral anticoagulant. In conclusion, we believe that this article adds useful information on the role of aspirin in the orthopedic setting; however, the results need to be considered in the context of the unbalanced baseline risks and confirmed by new larger trials. Until this happens, the weak guidelines from the American College of Chest Physicians (3), based on evidence that shows little or no effect of aspirin in total hip replacement recipients, should not be given more attention or credibility.