Sodium, Blood Pressure, and Cardiovascular Disease: Further Evidence Supporting the American Heart Association Sodium Reduction Recommendations [AHA Presidential Advisory]:
Recent reports of selected observational studies and a meta-analysis have stirred controversy and have become the impetus for calls to abandon recommendations for reduced sodium intake by the US general population. A detailed review of these studies documents substantial methodological concerns that limit the usefulness of these studies in setting, much less reversing, dietary recommendations. Indeed, the evidence base supporting recommendations for reduced sodium intake in the general population remains robust and persuasive. The American Heart Association is committed to improving the health of all Americans through implementation of national goals for health promotion and disease prevention, including its recommendation to reduce dietary sodium intake to <1500 mg/d.
2012. december 10., hétfő
A free online and open-source encyclopedia
A free online and open-source encyclopedia:
The European Association of Cardiovascular Imaging is glad to propose this new knowledge based platform.
WikiEcho, as any other Wiki site, is an open source website and anyone is free to contribute. Covered topics are classified as per the Core Syllabus.
WikiEcho, as any other Wiki site, is an open source website and anyone is free to contribute. Covered topics are classified as per the Core Syllabus.
Topics:
Non-invasive imaging: Echocardiography, MR/CT, Nuclear, Echocardiography (Non-invasive imaging)
Non-invasive imaging: Echocardiography, MR/CT, Nuclear, Echocardiography (Non-invasive imaging)
Medical Director Responsibilities for Outpatient Cardiac Rehabilitation/Secondary Prevention Programs: 2012 Update: A Statement for Health Care Professionals From the American Association of Cardiovascular and Pulmonary Rehabilitation and the American Heart Association [AACVPR/AHA Scientific Statement]
Medical Director Responsibilities for Outpatient Cardiac Rehabilitation/Secondary Prevention Programs: 2012 Update: A Statement for Health Care Professionals From the American Association of Cardiovascular and Pulmonary Rehabilitation and the American Heart Association [AACVPR/AHA Scientific Statement]:
Medical directors of cardiac rehabilitation/secondary prevention (CR/SP) programs are responsible for the safe and effective delivery of high-quality CR/SP services to eligible patients. Yet, the training and resources for CR/SP medical directors are limited. As a result, there appears to be considerable variability throughout CR/SP programs in the United States in the roles, responsibilities, and engagement of CR/SP medical directors. Since the publication of the 2005 scientific statement from the American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation regarding medical director responsibilities for outpatient CR/SP programs, significant changes have occurred. This statement updates the responsibilities of CR/SP medical directors, in view of changes in federal legislation and regulations and changes in health care delivery and clinical practice that impact the roles and responsibilities of CR/SP medical directors.
Medical directors of cardiac rehabilitation/secondary prevention (CR/SP) programs are responsible for the safe and effective delivery of high-quality CR/SP services to eligible patients. Yet, the training and resources for CR/SP medical directors are limited. As a result, there appears to be considerable variability throughout CR/SP programs in the United States in the roles, responsibilities, and engagement of CR/SP medical directors. Since the publication of the 2005 scientific statement from the American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation regarding medical director responsibilities for outpatient CR/SP programs, significant changes have occurred. This statement updates the responsibilities of CR/SP medical directors, in view of changes in federal legislation and regulations and changes in health care delivery and clinical practice that impact the roles and responsibilities of CR/SP medical directors.
New consensus document advises on interpretation of troponin tests
New consensus document advises on interpretation of troponin tests: The American College of Cardiology has released the first comprehensive consensus document covering the clinical considerations involved in ordering and interpreting troponin tests for diagnosing or ruling out MI.
Beyond survival: Recommendations from INTERMACS for assessing function and quality of life with mechanical circulatory support
Beyond survival: Recommendations from INTERMACS for assessing function and quality of life with mechanical circulatory support: Mechanical circulatory support (MCS) therapy has recently undergone more rapid evolution. Initially approved as a bridge to transplantation, MCS was employed primarily for short-term support to allow stabilization of organ function and subsequent transplantation. The advent of smaller continuous-flow pumps, with associated improvements in durability and clinical outcomes, has allowed destination therapy to become a sustainable treatment for advanced heart failure patients ineligible for transplantation. Faced with a horizon of support measured in years rather than months, health-related quality of life (HRQOL) and functional capacity have subsequently become increasingly relevant outcomes. Functional capacity (also referred to as exercise capacity) relates to the ability to perform meaningful physical activity. HRQOL is “the functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient.” Establishing recommendations for assessing HRQOL and functional capacity while on MCS is crucial to more clearly define the benefits of MCS, portray reasonable expectations for patients considering MCS implant, guide development of strategies aimed at enhancing these outcomes, and inform health policy decisions for rational allocation of this costly health resource.
2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons
2012. november 30., péntek
2012. október 3., szerda
New EASD/ADA Position Paper Shifts Diabetes Treatment Goals
New EASD/ADA Position Paper Shifts Diabetes Treatment Goals: A new position statement for the treatment of type 2 diabetes takes a much more patient-centered approach compared with the 'one number fits all' target for glycated hemoglobin (HbA1c) used up to now.
Medscape Medical News
Medscape Medical News
2012. október 2., kedd
2012. szeptember 27., csütörtök
Heart failure highlights in 2011
Heart failure highlights in 2011:
Heart failure (HF) remains a major medical problem, and the European Journal of Heart Failure is dedicated to publishing research further investigating its pathophysiology and diagnosis in order to help clinicians alleviate symptoms and improve patient outcomes. 1 This review reports on important studies in the field of HF published in 2011. All research areas are addressed, including experimental studies, biomarkers, clinical trials, arrhythmias, and new insights into the role of device therapy.
Heart failure (HF) remains a major medical problem, and the European Journal of Heart Failure is dedicated to publishing research further investigating its pathophysiology and diagnosis in order to help clinicians alleviate symptoms and improve patient outcomes. 1 This review reports on important studies in the field of HF published in 2011. All research areas are addressed, including experimental studies, biomarkers, clinical trials, arrhythmias, and new insights into the role of device therapy.
2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines [ACCF/AHA Focused Update]
World Health Organization Pulmonary Hypertension Group 2: Pulmonary hypertension due to left heart disease in the adult—a summary statement from the Pulmonary Hypertension Council of the International Society for Heart and Lung Transplantation
World Health Organization Pulmonary Hypertension Group 2: Pulmonary hypertension due to left heart disease in the adult—a summary statement from the Pulmonary Hypertension Council of the International Society for Heart and Lung Transplantation: Pulmonary hypertension associated with left heart disease is the most common form of pulmonary hypertension encountered in clinical practice today. Although frequently a target of therapy, its pathophysiology remains poorly understood and its treatment remains undefined. Pulmonary hypertension in the context of left heart disease is a marker of worse prognosis and disease severity, but whether its primary treatment is beneficial or harmful is unknown. An important step to the future study of this important clinical problem will be to standardize definitions across disciplines to facilitate an evidence base that is interpretable and applicable to clinical practice. In this current statement, we provide an extensive review and interpretation of the current available literature to guide current practice and future investigation. At the request of the Pulmonary Hypertension (PH) Council of the International Society for Heart and Lung Transplantation (ISHLT), a writing group was assembled and tasked to put forth this document as described above. The review process was facilitated through the peer review process of the Journal of Heart and Lung Transplantation and ultimately endorsed by the leadership of the ISHLT PH Council.
Small RNA Biomarkers Come of Age⁎
Small RNA Biomarkers Come of Age⁎: MicroRNAs (miRNAs) are endogenous, 21- to 23-nucleotide- long RNA molecules that post-transcriptionally regulate target genes. miRNAs interact specifically with certain mRNAs by repressing their translation or inducing their degradation (1). Current estimates are that miRNAs thereby regulate the levels of the majority of mammalian proteins (2). Research in recent years has assigned miRNAs a key regulatory role in various physiological processes. Also, a growing number of miRNAs has been implicated in the pathogenesis of several diseases, including cardiac disease (3). With respect to the latter, miRNAs have been implicated in cardiac hypertrophy (4,5), fibrosis (6), and vascular disease (7). Intriguingly, miRNAs also appear to represent valid therapeutic targets, because modulation of their expression in vivo (for example, with antisense RNA molecules) has been shown to effectively modulate cardiovascular disease in various animal models (4,6,8–10). Most recently, miRNAs have received much attention regarding their suitability as biomarkers for disease. Following pioneering work from the cancer field (11,12), also several cardiovascular studies have found marked deregulation of miRNAs in various types of clinical specimens (for review, see ref. 13).
ACCF/ACR/AIUM/ASE/ASN/ICAVL/SCAI/SCCT/SIR/SVM/SVS 2012 Appropriate Use Criteria for Peripheral Vascular Ultrasound and Physiological Testing Part I: Arterial Ultrasound and Physiological Testing A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American College of Radiology, American Institute of Ultrasound in Medicine, American Society of Echocardiography, American Society of Nephrology, Intersocietal Commission for the Accreditation of Vascular Laboratories, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery
Thrombo-embolism and antithrombotic therapy for heart failure in sinus rhythm. A Joint Consensus Document from the ESC Heart Failure Association and the ESC Working Group on Thrombosis
Thrombo-embolism and antithrombotic therapy for heart failure in sinus rhythm. A Joint Consensus Document from the ESC Heart Failure Association and the ESC Working Group on Thrombosis:
Chronic heart failure (HF) with either reduced or preserved ejection fraction is common and remains an extremely serious disorder with a high mortality and morbidity. Many complications related to HF can be related to thrombosis. Epidemiological and pathophysiological data also link HF to an increased risk of thrombosis, leading to the clinical consequences of sudden death, stroke, systemic thrombo-embolism, and/or venous thrombo-embolism. This consensus document of the Heart Failure Association (EHFA) of the European Society of Cardiology (ESC) and the ESC Working Group on Thrombosis reviews the published evidence and summarizes ‘best practice’, and puts forward consensus statements that may help to define evidence gaps and assist management decisions in everyday clinical practice. In HF patients with atrial fibrillation, oral anticoagulation is recommended, and the CHA2DS2-VASc and HAS-BLED scores should be used to determine the likely risk–benefit ratio (thrombo-embolism prevention vs. risk of bleeding) of oral anticoagulation. In HF patients with reduced left ventricular ejection fraction who are in sinus rhythm there is no evidence of an overall benefit of vitamin K antagonists (e.g. warfarin) on mortality, with risk of major bleeding. Despite the potential for a reduction in ischaemic stroke, there is currently no compelling reason to use warfarin routinely for these patients. Risk factors associated with increased risk of thrombo-embolic events should be identified and decisions regarding use of anticoagulation individualized. Patient values and preferences are important determinants when balancing the risk of thrombo-embolism against bleeding risk. New oral anticoagulants that offer a different risk–benefit profile compared with warfarin may appear as an attractive therapeutic option, but this would need to be confirmed in clinical trials.
Chronic heart failure (HF) with either reduced or preserved ejection fraction is common and remains an extremely serious disorder with a high mortality and morbidity. Many complications related to HF can be related to thrombosis. Epidemiological and pathophysiological data also link HF to an increased risk of thrombosis, leading to the clinical consequences of sudden death, stroke, systemic thrombo-embolism, and/or venous thrombo-embolism. This consensus document of the Heart Failure Association (EHFA) of the European Society of Cardiology (ESC) and the ESC Working Group on Thrombosis reviews the published evidence and summarizes ‘best practice’, and puts forward consensus statements that may help to define evidence gaps and assist management decisions in everyday clinical practice. In HF patients with atrial fibrillation, oral anticoagulation is recommended, and the CHA2DS2-VASc and HAS-BLED scores should be used to determine the likely risk–benefit ratio (thrombo-embolism prevention vs. risk of bleeding) of oral anticoagulation. In HF patients with reduced left ventricular ejection fraction who are in sinus rhythm there is no evidence of an overall benefit of vitamin K antagonists (e.g. warfarin) on mortality, with risk of major bleeding. Despite the potential for a reduction in ischaemic stroke, there is currently no compelling reason to use warfarin routinely for these patients. Risk factors associated with increased risk of thrombo-embolic events should be identified and decisions regarding use of anticoagulation individualized. Patient values and preferences are important determinants when balancing the risk of thrombo-embolism against bleeding risk. New oral anticoagulants that offer a different risk–benefit profile compared with warfarin may appear as an attractive therapeutic option, but this would need to be confirmed in clinical trials.
AHA/ASA statement calls stroke a cardiac risk equivalent
AHA/ASA statement calls stroke a cardiac risk equivalent: A new AHA/ASA scientific statement says ischemic-stroke patients are a high-risk group for further atherosclerotic coronary events and that stroke should be included in risk models.
AHA guidance on genetics and CVD
AHA guidance on genetics and CVD: The American Heart Association has issued a new policy statement on the use of genetic information in cardiovascular medicine and research, making recommendations on everything from the legality of patenting genes with significance to cardiovascular disease to the role of genetic testing and genetic-variant genotyping for cardiovascular risk prediction.
ESC issues position paper on new anticoagulants
ESC issues position paper on new anticoagulants: The ESC's Working Group on Thrombosis is enthusiastic about the new drugs in AF, but it is not so impressed with their use in ACS.
Cardiology Secrets 3rd Edition
Cardiology Secrets 3rd Edition: Revised and updated, Cardiology Secrets, 3rd Edition has the answers. Comprehensive, yet easy to read, Dr. Levine presents all the latest advances in the diagnosis and treatment of heart conditions in this popular Secret Series volume. A two-color page layout, portable size, and a list of the “Top 100 Secrets” in cardiology help you better Click here to Download this Book Free
ACCF/AHA/HFSA 2011 Survey Results: Current Staffing Profile of Heart Failure Programs, Including Programs That Perform Heart Transplant and Mechanical Circulatory Support Device Implantation: A Report of the ACCF Heart Failure and Transplant Committee, AHA Heart Failure and Transplantation Committee, and Heart Failure Society of America [ACCF/AHA/HFSA Data and Survey Report]
ACCF/AHA/HFSA 2011 Survey Results: Current Staffing Profile of Heart Failure Programs, Including Programs That Perform Heart Transplant and Mechanical Circulatory Support Device Implantation: A Report of the ACCF Heart Failure and Transplant Committee, AHA Heart Failure and Transplantation Committee, and Heart Failure Society of America [ACCF/AHA/HFSA Data and Survey Report]: Objectives—
There have been no published recommendations about staffing needs for a heart failure (HF) clinic or an office setting focused on heart transplant. The goal of this survey was to understand the current staffing environment of HF, transplant, and mechanical circulatory support device (MCSD) programs in the United States and abroad. This report identifies current staffing patterns but does not endorse a particular staffing model.
Methods—
An online survey, jointly sponsored by the American College of Cardiology Foundation (ACCF), American Heart Association (AHA), and the Heart Failure Society of America (HFSA), was sent to the members of all 3 organizations who had identified themselves as interested in HF, heart transplant, or both, between March 12, 2009, and May 12, 2009.
Results—
The overall response rate to the 1823 e-mail surveys was 23%. There were 257 unique practices in the United States (81% of total sites) and 58 international sites (19%); approximately 30% of centers were in a cardiovascular group practice and 30% in a medical school hospital setting. The large majority of practices delivered HF care in both an inpatient and outpatient environment, and slightly more centers were implanting MCSDs (47%) than performing cardiac transplantation (39%). Most practices (43%) were small, with <4 staff members, or small- to medium-sized (34%), with 4 to 10 staff members, with only 23% being medium (11–20 staff) or large programs (>20 staff). On average, a US HF practice cared for 1641 outpatients annually. An average HF program with transplant performed 10 transplants. Although larger programs were able to perform more transplants and see more outpatient HF visits, their clinician staffing volume tended to double for approximately every 500 to 700 additional HF visits annually. The average staffing utilization was 2.65 physician full-time equivalents (FTEs), 2.21 nonphysician practitioner (nurse practitioner or physician assistant) FTEs, and 2.61 nurse coordinator FTEs annually.
Conclusions—
The HF patient population is growing in number in the United States and internationally, and the clinicians who provide the highly skilled and time-consuming care to this population are under intense scrutiny as a result of focused quality improvement initiatives and reduced financial resources. Staffing guidelines should be developed to ensure that an adequate number of qualified professionals are hired for a given practice volume. These survey results are an initial step in developing such standards.
There have been no published recommendations about staffing needs for a heart failure (HF) clinic or an office setting focused on heart transplant. The goal of this survey was to understand the current staffing environment of HF, transplant, and mechanical circulatory support device (MCSD) programs in the United States and abroad. This report identifies current staffing patterns but does not endorse a particular staffing model.
Methods—
An online survey, jointly sponsored by the American College of Cardiology Foundation (ACCF), American Heart Association (AHA), and the Heart Failure Society of America (HFSA), was sent to the members of all 3 organizations who had identified themselves as interested in HF, heart transplant, or both, between March 12, 2009, and May 12, 2009.
Results—
The overall response rate to the 1823 e-mail surveys was 23%. There were 257 unique practices in the United States (81% of total sites) and 58 international sites (19%); approximately 30% of centers were in a cardiovascular group practice and 30% in a medical school hospital setting. The large majority of practices delivered HF care in both an inpatient and outpatient environment, and slightly more centers were implanting MCSDs (47%) than performing cardiac transplantation (39%). Most practices (43%) were small, with <4 staff members, or small- to medium-sized (34%), with 4 to 10 staff members, with only 23% being medium (11–20 staff) or large programs (>20 staff). On average, a US HF practice cared for 1641 outpatients annually. An average HF program with transplant performed 10 transplants. Although larger programs were able to perform more transplants and see more outpatient HF visits, their clinician staffing volume tended to double for approximately every 500 to 700 additional HF visits annually. The average staffing utilization was 2.65 physician full-time equivalents (FTEs), 2.21 nonphysician practitioner (nurse practitioner or physician assistant) FTEs, and 2.61 nurse coordinator FTEs annually.
Conclusions—
The HF patient population is growing in number in the United States and internationally, and the clinicians who provide the highly skilled and time-consuming care to this population are under intense scrutiny as a result of focused quality improvement initiatives and reduced financial resources. Staffing guidelines should be developed to ensure that an adequate number of qualified professionals are hired for a given practice volume. These survey results are an initial step in developing such standards.
Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation
Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation:
The European Society of Cardiology heart failure guidelines firmly recommend regular physical activity and structured exercise training (ET), but this recommendation is still poorly implemented in daily clinical practice outside specialized centres and in the real world of heart failure clinics. In reality, exercise intolerance can be successfully tackled by applying ET. We need to encourage the mindset that breathlessness may be evidence of signalling between the periphery and central haemodynamic performance and regular physical activity may ultimately bring about favourable changes in myocardial function, symptoms, functional capacity, and increased hospitalization-free life span and probably survival. In this position paper, we provide practical advice for the application of exercise in heart failure and how to overcome traditional barriers, based on the current scientific and clinical knowledge supporting the beneficial effect of this intervention.
The European Society of Cardiology heart failure guidelines firmly recommend regular physical activity and structured exercise training (ET), but this recommendation is still poorly implemented in daily clinical practice outside specialized centres and in the real world of heart failure clinics. In reality, exercise intolerance can be successfully tackled by applying ET. We need to encourage the mindset that breathlessness may be evidence of signalling between the periphery and central haemodynamic performance and regular physical activity may ultimately bring about favourable changes in myocardial function, symptoms, functional capacity, and increased hospitalization-free life span and probably survival. In this position paper, we provide practical advice for the application of exercise in heart failure and how to overcome traditional barriers, based on the current scientific and clinical knowledge supporting the beneficial effect of this intervention.
2012. augusztus 8., szerda
2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update) A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
2012. július 27., péntek
2012. május 16., szerda
Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation
Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation:
The European Society of Cardiology heart failure guidelines firmly recommend regular physical activity and structured exercise training (ET), but this recommendation is still poorly implemented in daily clinical practice outside specialized centres and in the real world of heart failure clinics. In reality, exercise intolerance can be successfully tackled by applying ET. We need to encourage the mindset that breathlessness may be evidence of signalling between the periphery and central haemodynamic performance and regular physical activity may ultimately bring about favourable changes in myocardial function, symptoms, functional capacity, and increased hospitalization-free life span and probably survival. In this position paper, we provide practical advice for the application of exercise in heart failure and how to overcome traditional barriers, based on the current scientific and clinical knowledge supporting the beneficial effect of this intervention.
The European Society of Cardiology heart failure guidelines firmly recommend regular physical activity and structured exercise training (ET), but this recommendation is still poorly implemented in daily clinical practice outside specialized centres and in the real world of heart failure clinics. In reality, exercise intolerance can be successfully tackled by applying ET. We need to encourage the mindset that breathlessness may be evidence of signalling between the periphery and central haemodynamic performance and regular physical activity may ultimately bring about favourable changes in myocardial function, symptoms, functional capacity, and increased hospitalization-free life span and probably survival. In this position paper, we provide practical advice for the application of exercise in heart failure and how to overcome traditional barriers, based on the current scientific and clinical knowledge supporting the beneficial effect of this intervention.
2012. május 12., szombat
2012. április 25., szerda
2012. április 10., kedd
New Oral Anticoagulants in Atrial Fibrillation and Acute Coronary Syndromes: ESC Working Group on Thrombosis--Task Force on Anticoagulants in Heart Disease Position Paper
New Oral Anticoagulants in Atrial Fibrillation and Acute Coronary Syndromes: ESC Working Group on Thrombosis--Task Force on Anticoagulants in Heart Disease Position Paper:
Until recently, vitamin K antagonists were the only available oral anticoagulants, but with numerous limitations that prompted the introduction of new oral anticoagulants targeting the single coagulation enzymes thrombin (dabigatran) or factor Xa (apixaban, rivaroxaban, and edoxaban) and given in fixed doses without coagulation monitoring. Here we review the pharmacology and the results of clinical trials with these new agents in stroke prevention in atrial fibrillation and secondary prevention after acute coronary syndromes, providing perspectives on their future incorporation into clinical practice. In phase III trials in atrial fibrillation, compared with warfarin, dabigatran etexilate 150 mg B.I.D. reduced the rates of stroke/systemic embolism without any difference in major bleeding; dabigatran etexilate 110 mg B.I.D. had similar efficacy with decreased bleeding; apixaban 5 mg B.I.D. reduced stroke, systemic embolism, and mortality as well as major bleeding; and rivaroxaban 20 mg Q.D. was noninferior to warfarin for stroke and systemic embolism without a difference in major bleeding. All these agents reduced intracranial hemorrhage. Edoxaban is currently being evaluated in a further large phase III trial. Apixaban and rivaroxaban were evaluated in phase III trials for prevention of recurrent ischemia in patients with acute coronary syndromes who were mostly receiving dual antiplatelet therapy, with conflicting results on efficacy but consistent results for increased major bleeding. Overall, the new oral anticoagulants are poised to replace vitamin K antagonists for many patients with atrial fibrillation and may have a role after acute coronary syndromes. Although convenient to administer and manage, they present challenges that need to be addressed.
Until recently, vitamin K antagonists were the only available oral anticoagulants, but with numerous limitations that prompted the introduction of new oral anticoagulants targeting the single coagulation enzymes thrombin (dabigatran) or factor Xa (apixaban, rivaroxaban, and edoxaban) and given in fixed doses without coagulation monitoring. Here we review the pharmacology and the results of clinical trials with these new agents in stroke prevention in atrial fibrillation and secondary prevention after acute coronary syndromes, providing perspectives on their future incorporation into clinical practice. In phase III trials in atrial fibrillation, compared with warfarin, dabigatran etexilate 150 mg B.I.D. reduced the rates of stroke/systemic embolism without any difference in major bleeding; dabigatran etexilate 110 mg B.I.D. had similar efficacy with decreased bleeding; apixaban 5 mg B.I.D. reduced stroke, systemic embolism, and mortality as well as major bleeding; and rivaroxaban 20 mg Q.D. was noninferior to warfarin for stroke and systemic embolism without a difference in major bleeding. All these agents reduced intracranial hemorrhage. Edoxaban is currently being evaluated in a further large phase III trial. Apixaban and rivaroxaban were evaluated in phase III trials for prevention of recurrent ischemia in patients with acute coronary syndromes who were mostly receiving dual antiplatelet therapy, with conflicting results on efficacy but consistent results for increased major bleeding. Overall, the new oral anticoagulants are poised to replace vitamin K antagonists for many patients with atrial fibrillation and may have a role after acute coronary syndromes. Although convenient to administer and manage, they present challenges that need to be addressed.
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