Items filtered by date: January 2019

2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation

Circulation

This guideline updates the recommendations on anticoagulation, catheter ablation of atrial fibrillation (AF), management of AF complicating acute coronary syndrome, and includes new recommendations on device detection of AF and weight loss.

 

NIHR Signal: Warfarin and newer anticoagulants equally effective for long-term treatment of blood clots

National Institute for Health Research Signal

Expert commentary is provided for a review of 16 RCTs (n=22,396) which found that all oral anticoagulants regimens reduce the risk of recurrent VTE vs placebo. Ideal regimens for those at higher risk (e.g. thrombophilia), and >1 year treatment still require further investigation.

 

Additional GI bleeding risk with SSRIs in people with declining kidney function: DTB Select

Drug and Therapeutics Bulletin
Summary and context is provided for a cohort study which reported an increased risk of GI bleeding with SSRIs in patients with CKD. Clinicians are advised to review the risks and benefits of SSRIs in this population and consider the need for gastroprotection.

 

 

The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:

http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services

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Association of Aspirin Use for Primary Prevention With Cardiovascular Events and Bleeding Events: A Systematic Review and Meta-analysis

Journal of the American Medical Association

Review of 13 RCTs (n=164,225) found that aspirin use reduced a composite of CV mortality, non-fatal MI/stroke vs no aspirin (57.1 vs 61.4 /10,000 patient-years, HR 0.89, 95% CI 0.84-0.95, NNT 265), however aspirin had an increased risk of major bleeding (1.43, 1.30-1.56, NNH 210).

 

Stroke Outcomes in the Cardiovascular OutcoMes for People using Anticoagulation StrategieS (COMPASS) Trial

Circulation

RCT (n=27,395) found a reduced risk of strokes with rivaroxaban 2.5mg twice daily plus aspirin 100mg daily vs aspirin alone (0.9% per year vs 1.6% per year, HR 0.58, 95% CI 0.44-0.76). The effect of the combination compared with aspirin was consistent across subgroups.

 

 

The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:

http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services

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Revised SPCs: Efient (prasugrel) 5 mg 10 mg film-coated tablets

electronic Medicines compendium

SPCs have been updated to advise a delayed and decreased exposure to oral P2Y12 inhibitors, including prasugrel and active metabolite, has been observed in patients with ACS treated with morphine. This interaction may be related to reduced GI motility and apply to other opioids.

 

Atrial fibrillation and human immunodeficiency virus type‐1 infection: a systematic review: Implications for anticoagulant and antiarrhythmic therapy

British Journal of Clinical Pharmacology

Authors of this narrative review reflect that HIV infection increases the risk of stroke. Choosing antiretrovirals with the lowest drug–drug interaction and with lower impact on the cardiovascular system, and the use of DOACs may help reduce the risk of stroke in this group.

 

 

The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:

http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services

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Thrombolytic therapy for pulmonary embolism

Cochrane Database of Systematic Reviews

Review of 18 RCTs (n=2197) concludes low‐quality evidence shows thrombolytics in addition to heparin reduce death and recurrence of pulmonary embolus following acute pulmonary embolism, compared with heparin alone. The included studies used a variety of thrombolytic drugs.

 

Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases

British Medical Journal

Analysis (n=80 396 matched to 391,494 controls.) found most oral preparations were linked to increased VTE risks. Conjugated equine oestrogens with or without medroxyprogesterone acetate, were linked to highest risks. No increased risk was found for transdermal preparations.

 

Relationship between body mass index and outcomes in patients with atrial fibrillation treated with edoxaban or warfarin in the ENGAGE AF-TIMI 48 trial

European Heart Journal

Review of data from the ENGAGE AF-TIMI 48 trial found that an increased BMI was independently associated with a lower risk of stroke or systemic embolic events (per 5 kg/m2 increase, HR=0.88, p=0.0001), but increased risk of major bleeding (HR 1.06, P = 0.025).

 

Inhaled Tranexamic Acid for Hemoptysis Treatment

Chest

RCT (n=47) found that resolution of hemoptysis within 5 days of admission was observed in more tranexamic acid (TXA) treated vs placebo (96% vs 50%; p< 0.0005). TXA patients also had a shorter hospital stay and required fewer interventional procedures.

 

Effect of Low-Dose Intracoronary Alteplase During Primary Percutaneous Coronary Intervention on Microvascular Obstruction in Patients With Acute Myocardial Infarction: A Randomized Clinical Trial

Journal of the American Medical Association

RCT (n=195) was stopped early due to futility. Among patients with acute STEMI presenting within 6 hours of symptoms, adjunctive low-dose intracoronary alteplase given during the primary percutaneous intervention did not reduce microvascular obstruction vs placebo.

 

Pro‐coagulant haemostatic factors for the prevention and treatment of bleeding in people without haemophilia

Cochrane Database of Systematic Reviews

Review of 31 RCTs (n=2392) found that paucity of good‐quality evidence precludes the drawing of conclusions for clinical practice. Sample sizes of future RCTs would need to be greatly increased to detect a reduction in mortality or thromboembolic events between treatment arms.

 

Uterotonic agents for preventing postpartum haemorrhage: a network meta‐analysis

Cochrane Database of Systematic Reviews

Analysis (196 trials; n=135,559; 7 uterotonic agents) found all agents were generally effective vs. placebo or no treatment. Some oxytocin (OX) combination regimens may have some additional desirable effects vs current standard OX but are linked to significant side effects.

 

Tranexamic acid for patients with nasal haemorrhage (epistaxis)

Cochrane Database of Systematic Reviews

Review of 6 RCTs (n=692) found moderate‐quality evidence that there is probably a reduction in the risk of re‐bleeding with use of either oral or topical tranexamic acid in addition to usual care in adults with epistaxis, compared to placebo with usual care.

 

The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:

http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services

 

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NIHR Signal: People leaving hospital after medical illness do not benefit from extended clot reducing treatment

National Institute for Health Research Signal

Commentary is provided of trial which found continued use of rivaroxaban offered very small reduction in VTE risk, but also slightly increased risk of major bleeding (neither statistically significant). Trial was terminated because of lower than expected number of clots.

 

Efficacy and safety of reduced-dose non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: a meta-analysis of randomized controlled trials

European Heart Journal

Data from phase 3 trials found that, irrespective of direct oral anticoagulant (DOAC) used, rates of stroke or systemic embolism and major bleeding were higher in those eligible for reduced-dose DOACs than in those eligible for full-dose DOACs (2.70% vs 1.60% and 4.35% vs 2.87%).

 

When is it appropriate to stop non-vitamin K antagonist oral anticoagulants before catheter ablation of atrial fibrillation? A multicentre prospective randomized study

European Heart Journal

Open label RCT (n=326) found a higher intra-procedural heparin requirement with 24-hour skipped DOACs vs single dose skipped and uninterrupted regimens (p<0.001) though the incidence of major bleeding up to 1 month after ablation did not differ.

 

Association of Parenteral Anticoagulation Therapy With Outcomes in Chinese Patients Undergoing Percutaneous Coronary Intervention for Non–ST-Segment Elevation Acute Coronary Syndrome

JAMA Internal Medicine

Chinese cohort study (n=6,804) found that parenteral anticoagulant therapy did not reduce the incidence of in-hospital death, or rate of myocardial infarction vs those that did not receive it. Bleeding was more frequent with anticoagulation (2.5% vs 1.0%, p<0.001).

 

Human coagulation factor X for hereditary factor X deficiency (all ages)

NHS England

NHS England will not routinely commission human coagulation factor X for people of all ages with hereditary factor X deficiency who need long term prophylaxis owing to insufficient published evidence.

 

 

 

The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:

http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services

 

 

 

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