Current cardiology reports
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To review the clinical evidence underlying the efficacy and safety of the use of direct oral anticoagulants (DOACs) for the treatment of patients with valvular atrial fibrillation (AF). ⋯ The recent focused update to the 2014 AHA/ACC/HRS Atrial Fibrillation Guidelines defines valvular AF as AF in the setting of moderate-to-severe mitral stenosis (MS) and/or in the presence of a mechanical heart valve. Landmark clinical trials of DOACs in patients with AF systematically excluded these patient populations. However, there are trial data in both animals and humans regarding the use of DOACs in patients with MS and in those with mechanical heart valves. Based on sub-analyses and meta-analyses of clinical trial data in patients with AF, the use of DOACs in valvular AF is not recommended. Patients with moderate-to-severe MS or a mechanical heart valve and AF should be anticoagulated with dose-adjusted warfarin. DOACs are reasonable alternatives to warfarin in patients with AF and other types of valvular disease, including mild MS and bioprosthetic valves.
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To review the current evidence supporting the use of endovascular thrombectomy (EVT) for the treatment of acute ischemic stroke (AIS) due to anterior circulation large vessel occlusion (LVO). ⋯ Recent advances in AIS management by EVT have led to significant reduction in morbidity and mortality in selected patients with LVO within the anterior circulation. Until recently, use of EVT was strictly based on time criteria, within 4.5 to 12 h of symptom onset with many patients presenting with "wake-up" stroke who were not considered for EVT. The positive results of the DAWN and DEFUSE-3 trials have shown benefit in extending the therapeutic window for EVT to 24 and 16 h, respectively, after last known normal (LKN) time in the setting of large ischemic penumbra. These trials represent a paradigm shift in contemporary treatment of AIS, changing from a purely time-based decision to treat to an individualized decision based on clinical and radiographic findings of salvageable tissue. Overall, acute stroke management has evolved considerably over the years from intravenous thrombolysis to include EVT, with paralleled improvements in patient selection and thrombectomy devices. Since the results of the DAWN and DEFUSE-3, EVT is now considered the standard of care in select patients with anterior circulation LVO up to 24 h from LKN time. Despite these developments, post-stroke disability remains pervasive and further studies are warranted in establishing the role of EVT in posterior circulation and distal vessel occlusions, with need for development of new and effective techniques for revascularization of small vessels.
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Tobacco continues to kill about 0.48 million Americans per year and there are currently 34.3 million smokers in the USA. As a consequence of the First Surgeon General's Report on Tobacco in 1964, tobacco control interventions on part of the government led to a significant decline in conventional tobacco product usage over the last few decades. However, more recently, a new entity in the form of electronic cigarettes has risen rapidly and has exposed a younger population to a plethora of dangerous consequences. ⋯ On the other hand, several studies have reported that e-cigarettes significantly reduce an existing smoker's risk of being exposed to toxic tobacco smoke constituents that are normally present in cigarette smoke. This leads to the conclusions that e-cigarettes can be a tool for smoking cessation for current smokers. Public policy must take a multi-dimensional approach to balance these two extremes.
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Interventional cardiology and in particular the field of renal denervation is subject to constant change. This review provides an up to date overview of renal denervation trials and an outlook on what to expect in the future. ⋯ After the sham-controlled SYMPLICITY HTN-3 trial dampened the euphoria following early renal denervation trials, the recently published results of the sham-controlled SPYRAL HTN and RADIANCE HTN trials provided proof-of-principle for the blood pressure-lowering efficacy of renal denervation. However, these studies underline the major issue of patients' non-adherence to antihypertensive medication as well as the need for reliable patient- and procedure-related predictors of response. The second generation of sham-controlled renal denervation trials provided proof of principle for the blood pressure-lowering efficacy of RDN. However, larger trials have to assess long-term safety and efficacy.
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When treating patients with diabetes mellitus (DM), the benefits of antiplatelet therapy in preventing cardiovascular disease must be weighed against an increased risk of bleeding. Recent trials have sought to determine both the optimal anti-platelet regimen for patients with DM, and who specifically requires medication among the DM population. This paper will review recent trials and evidence recommending the use of antiplatelet therapy in the prevention of cardiovascular disease in patients with diabetes. ⋯ Seven notable trials assessed the effectiveness of antiplatelet therapy in the DM population. The ASCEND trial concluded 100 mg aspirin/day reduced rates of serious vascular events (OR 0.88, p < 0.01) but also increased rates of major bleeding events (OR 1.29, p < 0.01). The DAPT study revealed a longer dual antiplatelet regimen (30 months vs. 18 months) after coronary stent placement was more effective in reducing rates of stent thrombosis (0.5% vs. 1.1%, p = 0.06) and rates of myocardial infarction (3.5% vs. 4.8%, p = 0.06). DECLARE DIABETES showed that adding cilostazol to dual antiplatelet therapy after a coronary stent procedure reduced rates of in-stent and in-segment late loss and increased rates of revascularization (p < 0.04). In PEGASUS-TIMI, daily ticagrelor demonstrated reduced rates of major adverse cardiovascular and cerebrovascular events (OR 0.84, p < 0.04). The DAVID trial compared daily picotamide with daily aspirin therapy, finding reduced mortality rates in the picotamide group (OR 0.55, p < 0.05). Lastly, ACUITY found bivalirudin monotherapy resulted in lower rates of major bleeding events when compared to a glycoprotein IIb/IIa inhibitor and heparin or bivalirudin combination regimen (p < 0.01). Dual antiplatelet therapy guidelines still typically revolve around aspirin, but an increasing number of studies have demonstrated other drugs that may have a role in preventing atherosclerotic cardiovascular disease while decreasing the risk of major bleeding. Overall, it is wise to weigh the cardiovascular risk of a DM patient before prescribing antiplatelet medication. More research is necessary to determine a universal drug or combination of drugs that is safe and effective for DM patients.