International journal of clinical practice
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Int. J. Clin. Pract. · Jul 2015
ReviewSubclinical hypothyroidism: a historical view and shifting prevalence.
Accurate diagnosis and treatment of subclinical hypothyroidism (SCH) is challenging in clinical practice because of differing upper limits of normal (ULN) for thyroid-stimulating hormone (TSH). This review summarises the various definitions of SCH and their impact on reported SCH prevalence. ⋯ Given the variable definition of SCH based on an inconsistent ULN for TSH, it is currently difficult to ascertain the true prevalence of SCH and to correctly label and treat patients with SCH; use of age-adjusted definitions may be considered when assessing prevalence. A diagnosis of SCH does not necessarily merit treatment, especially if TSH elevations are transient (i.e. not persistent for > 3-6 months) and the patient lacks other risk factors for developing overt hypothyroidism.
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Int. J. Clin. Pract. · Jul 2015
ReviewStroke prevention with rivaroxaban in higher-risk populations with atrial fibrillation.
Atrial fibrillation (AF), the most common cardiac arrhythmia, is a major risk factor for stroke. Rivaroxaban, an oral factor Xa inhibitor, is approved for the prevention of stroke in patients with non-valvular AF. In the pivotal phase III trial ROCKET AF, rivaroxaban demonstrated non-inferiority compared with warfarin for reducing the risk of stroke or systemic embolism (SE) in patients with AF (intention-to-treat analysis), without an increased risk of major bleeding. Superior efficacy vs. warfarin was achieved while patients were on study medication. Other direct oral factor Xa inhibitors have completed phase III clinical trials in this indication. Compared with warfarin, apixaban (in the ARISTOTLE trial) and edoxaban (in the ENGAGE-AF trial) were shown to be superior or non-inferior, respectively, for reduction in stroke or SE risk in patients with AF. Baseline stroke risk, as indicated by CHADS2 scores, was lower in patients in the ARISTOTLE and ENGAGE-AF trials than in ROCKET AF. ⋯ These subgroup analyses demonstrate that the treatment effect for rivaroxaban vs. warfarin is broadly consistent across a wide range of patient groups, with respect to both efficacy and safety.