Circulation: Clinical Summaries
Original Research Put Into Perspective for the Practicing Clinician
- Sex Differences in the Rate, Timing, and Principal Diagnoses of 30-Day Readmissions in Younger Patients with Acute Myocardial Infarction
- Perioperative Management of Dabigatran: A Prospective Cohort Study
- Association of Discharge Aspirin Dose With Outcomes After Acute Myocardial Infarction: Insights From the Treatment with ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome (TRANSLATE-ACS) Study
- Endovascular Versus External Targeted Temperature Management for Patients With Out-of-Hospital Cardiac Arrest: A Randomized, Controlled Study
- Efficacy and Harms of Direct Oral Anticoagulants in the Elderly for Stroke Prevention in Atrial Fibrillation and Secondary Prevention of Venous Thromboembolism: Systematic Review and Meta-Analysis
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Sex Differences in the Rate, Timing, and Principal Diagnoses of 30-Day Readmissions in Younger Patients with Acute Myocardial Infarction
For the first time, results of the present study demonstrate that younger women (<65 years) are at higher risk for 30-day readmission following acute myocardial infarction than similarly aged men, an association that persists even after extensive adjustment for confounders and is consistent across all strata of age. The readmission risk is highest for both sexes on days 2 to 4 after discharge from acute myocardial infarction, and it declines thereafter. The primary readmission diagnoses are diverse for both sexes, but women are more likely to present with noncardiac diagnoses than men. Moving forward, healthcare providers need to be cognizant of the higher risk for readmission among younger women following acute myocardial infarction. Research efforts need to be directed toward identifying risk factors and opportunities in care that differ between women and men and that may mediate the observed disparities in the risk of readmission, to inform effective interventions. See p 158.
Perioperative Management of Dabigatran: A Prospective Cohort Study
The timing of stopping and resuming dabigatran for surgery is heterogeneous, and the role of bridging with heparin is debated. In this prospective cohort study, 541 patients treated with dabigatran for atrial fibrillation were managed for elective invasive procedures or surgery using a specific protocol. The last dose was 24, 48, or 96 hours before the surgery or procedure, depending on renal function and bleeding risk of the procedure. Resumption was timed according to the complexity of the surgery and consequences of a bleeding complication. Despite the absence of heparin bridging unless oral intake postoperatively was delayed, there was only 1 transient ischemic attack and there were no major thromboembolic events. The risk of major bleeding during 30 days of follow-up was 1.8%, which is at the lower end of what previous studies with dabigatran or with warfarin have shown. Our protocol was followed in terms of the correct day of stopping and resuming dabigatran in 89% and 77%, respectively. We recommend that local protocols for perioperative management of dabigatran be established to avoid premature stopping of dabigatran, which may increase the risk of thromboembolism, and to refrain from routine bridging with heparin, which increases the risk of bleeding. See p 167.
Association of Discharge Aspirin Dose With Outcomes After Acute Myocardial Infarction: Insights From the Treatment with ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome (TRANSLATE-ACS) Study
Aspirin has been a mainstay therapy for patients with coronary artery disease for decades, yet the optimal maintenance dose after percutaneous coronary intervention has been a matter of significant debate. The American Heart Association/American College of Cardiology revised the current recommendation to change the maintenance aspirin dose from high to low dose based on limited data from clinical trial and observational studies. We examined data from 10 213 patients with myocardial infarction in the Treatment with ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome (TRANSLATE-ACS) study who underwent percutaneous coronary intervention and were discharged on dual-antiplatelet therapy at 228 hospitals in the United States. Despite changes in guideline recommendations, we continued to observe marked variation in discharge aspirin dosing, with more frequent use of high-dose (325 mg) aspirin in contemporary practice in the United States. Although it is commonly prescribed, we found that high-dose aspirin was not associated with a lower risk of major adverse cardiac events during follow-up. In contrast, high-dose aspirin was associated with an increased risk of minor bleeding events in comparison with low-dose aspirin (81 mg). The results noted were consistent regardless of age, sex, baseline home aspirin use, and discharge adenosine diphosphate receptor inhibitors. Collectively, our observational results support current guidelines for recommending low-dose aspirin as the preferred maintenance dose following percutaneous coronary intervention in the setting of myocardial infarction. See p 174.
Endovascular Versus External Targeted Temperature Management for Patients With Out-of-Hospital Cardiac Arrest: A Randomized, Controlled Study
Based on a large, randomized, controlled trial, the Clinical and Economical Interest of Endovascular Cooling in the Management of Cardiac Arrest (ICEREA) study is the first to evaluate the clinical differences between 2 different in-hospital cooling strategies after cardiac arrest by comparing advanced invasive and basic external methods. The main finding is that no major clinical difference, that is, survival with favorable neurological outcome, was found at 1 month. However, a trend at 3 months was observed in favor of the advanced endovascular device compared with basic surface cooling, possibly related to more strictly controlled targeted temperature management in the advanced cooling group. The ICEREA study provides new rationale for considering advanced methods of targeted temperature management after cardiac arrest instead of basic conventional cooling. Despite a higher rate of minor, but not major, side effects with the invasive method, a significant decrease in the workload of intensive care unit nurses was found in the advanced endovascular group. This effect was observed both for the cumulated time spent by nurses on patients’ specific targeted temperature management interventions and for the overall nurses’ workload measured during the entire period of the targeted temperature management. See p 182.
Efficacy and Harms of Direct Oral Anticoagulants in the Elderly for Stroke Prevention in Atrial Fibrillation and Secondary Prevention of Venous Thromboembolism: Systematic Review and Meta-Analysis
Elderly patients are at a higher risk of developing atrial fibrillation and venous thromboembolism and are frequently prescribed anticoagulant therapy. Historically, vitamin K antagonists (VKA) were prescribed, but the direct oral anticoagulants (DOACs) dabigatran, apixaban, rivaroxaban, and edoxaban now provide alternatives to clinicians. This study presents the first comprehensive evaluation of the use of DOACs in the elderly. We found DOACs to be at least as effective as VKA in managing the thrombotic risks in atrial fibrillation and acute venous thromboembolism. However, bleeding risks with DOACs were different than with VKA. Dabigatran, apixaban, and rivaroxaban provided a protective effect in comparison with VKA against intracranial bleeding in the elderly. This was consistent with the benefit seen across all ages. Dabigatran, however, was associated with a higher risk of gastrointestinal bleeding than VKA in the elderly; this risk was also evident across all ages but with the higher (150 mg) dose only. Full interpretation of bleeding outcomes in the elderly was limited by accessible trial data (particularly for apixaban, rivaroxaban, and edoxaban), the low numbers of bleeding events, and the lack of data characterizing the older age groups. Our study has added to the current evidence for the prescribing safety of DOACs, in particular, relating to bleeding risks. The results have most significance for prescribers of DOACs in elderly populations who may be at a higher risk of bleeding from concomitant comorbidities and medications. Better availability of unpublished trial data and more research is needed to further elucidate risks and understand the optimal use of DOACs in the elderly. See p 194.
- © 2015 American Heart Association, Inc.
- Perioperative Management of Dabigatran: A Prospective Cohort Study
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