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(searched for: doi:10.1136/jnnp.37.4.378)
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, Elaine M. Hylek
Journal of the American Heart Association, Volume 7; https://doi.org/10.1161/jaha.117.007338

Abstract:
Vitamin K antagonists (VKAs) were first introduced in the 1920s from studies on the “hemorrhagic” effect of spoiled sweet clover consumption by cattle1 and have evolved ever since to the cornerstone of oral anticoagulation therapy. The most commonly used VKA in the United States is warfarin, while in some European countries acenocoumarol and phenprocoumon are commonly used.2 VKAs exhibit their anticoagulant effect by inhibiting the vitamin K epoxide reductase complex subunit 1 in the liver. This enzyme catalyzes the post‐translational modification of vitamin K–dependent proteins. Inhibition of vitamin K epoxide reductase complex subunit 1 results in impaired synthesis of coagulation factors II (prothrombin), VII, IX, and X as well as of anticoagulant proteins C, S, and Z.3 The primary indications for VKA use are prophylaxis and treatment of venous thromboembolic disease (VTE, which includes deep vein thrombosis and pulmonary embolism) and of thromboembolic complications associated with atrial fibrillation (AF) and/or mechanical cardiac valves.
, Agnese Sembolini, Maurizio Paciaroni
Published: 31 May 2016
Vascular Pharmacology, Volume 84, pp 15-24; https://doi.org/10.1016/j.vph.2016.05.012

The publisher has not yet granted permission to display this abstract.
, A. John Camm
Published: 7 October 2015
EP Europace, Volume 18, pp 6-11; https://doi.org/10.1093/europace/euv288

Abstract:
Patients at thromboembolic risk with non-valvular atrial fibrillation (AF) can now be managed either with a vitamin K antagonist (VKA) or with a fixed dose of a non-VKA oral anticoagulant (NOAC), while patients with valvular AF have been restricted to VKAs on the basis of a potentially higher risk and different mechanism of thrombosis, and the lack of sufficient data on the efficacy of NOACs. The terms ‘non-valvular AF’ and ‘valvular AF’ have not been however consistently defined. ‘Valvular’ AF has included any valvular disorder, including valve replacement and repair. In AF with rheumatic mitral disease, observational studies strongly suggest that VKA treatment is valuable. These patients have not been included in NOAC trials, but there is also no stringent argument to have excluded them. This is at sharp variance from patients with mechanical valves, also excluded from the pivotal Phase III trial comparing warfarin with NOACs, but in whom a single Phase II trial of dabigatran etexilate against VKA treatment was stopped prematurely because of increased rates of thromboembolism as well as increased bleeding associated with dabigatran. Until more data are available, such patients should be therefore managed with VKAs. We here propose an open-label randomized trial of one of the NOACs against the best of treatment available in regions of the world in which rheumatic heart disease is still highly prevalent, aiming at showing the superiority of the NOAC used against current standard treatment.
Laurent Macle, John A. Cairns, , L. Brent Mitchell, , Atul Verma, Clare Atzema, Alan Bell, Stuart Connolly, Jafna L. Cox, et al.
Published: 1 October 2015
Canadian Journal of Cardiology, Volume 31, pp 1207-1218; https://doi.org/10.1016/j.cjca.2015.06.005

The publisher has not yet granted permission to display this abstract.
, Raphael Philippart, , Thierry Bourguignon, , , Dominique Babuty, Anne Bernard
Published: 1 October 2015
Archives of Cardiovascular Diseases, Volume 108, pp 530-539; https://doi.org/10.1016/j.acvd.2015.06.002

Abstract:
SummaryAtrial fibrillation (AF) confers a substantial risk of stroke. Recent trials comparing vitamin K antagonists (VKAs) with non-vitamin K antagonist oral anticoagulants (NOACs) in AF were performed among patients with so-called “non-valvular” AF. The distinction between “valvular” and “non-valvular” AF remains a matter of debate. Currently, “valvular AF” refers to patients with mitral stenosis or artificial heart valves (and valve repair in North American guidelines only), and should be treated with VKAs. Valvular heart diseases, such as mitral regurgitation, aortic stenosis (AS) and aortic insufficiency, do not result in conditions of low flow in the left atrium, and do not apparently increase the risk of thromboembolism brought by AF. Post-hoc analyses suggest that these conditions probably do not make the thromboembolic risk less responsive to NOACs compared with most forms of “non-valvular” AF. The pathogenesis of thrombosis is probably different for blood coming into contact with a mechanical prosthetic valve compared with what occurs in most other forms of AF. This may explain the results of the only trial performed with a NOAC in patients with a mechanical prosthetic valve (only a few of whom had AF), where warfarin was more effective and safer than dabigatran. By contrast, AF in the presence of a bioprosthetic heart valve or after valve repair appears to have a risk of thromboembolism that is not markedly different from other forms of “non-valvular” AF. Obviously, we should no longer consider the classification of AF as “valvular” (or not) for the purpose of defining the aetiology of the arrhythmia, but for the determination of a different risk of thromboembolic events and the need for a specific antithrombotic strategy. As long as there is no better new term or widely accepted definition, “valvular AF” refers to patients with mitral stenosis or artificial heart valves. Patients with “non-valvular AF” may have other types of valvular heart disease. One should emphasize that “non-valvular AF” does not exclude patients with some types of valvular heart disease from therapy with NOACs
, , Phillip J. Schulte, , Bernard J. Gersh, Michael Hanna, , , Rafael Diaz, M. Cecilia Bahit, et al.
Circulation, Volume 132, pp 624-632; https://doi.org/10.1161/circulationaha.114.014807

Abstract:
Background—: Apixaban is approved for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. However, the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial included a substantial number of patients with valvular heart disease and only excluded patients with clinically significant mitral stenosis or mechanical prosthetic heart valves. Methods and Results—: We compared the effect of apixaban and warfarin on rates of stroke or systemic embolism, major bleeding, and death in patients with and without moderate or severe valvular heart disease using Cox proportional hazards modeling. Of the 18 201 patients enrolled in ARISTOTLE, 4808 (26.4%) had a history of moderate or severe valvular heart disease or previous valve surgery. Patients with valvular heart disease had higher rates of stroke or systemic embolism and bleeding than patients without valvular heart disease. There was no evidence of a differential effect of apixaban over warfarin in patients with and without valvular heart disease in reducing stroke and systemic embolism (hazard ratio [HR], 0.70; 95% confidence interval [CI], 0.51–0.97 and HR, 0.84; 95%, CI 0.67–1.04; interaction P =0.38), causing less major bleeding (HR, 0.79; 95% CI, 0.61–1.04 and HR, 0.65; 95% CI, 0.55–0.77; interaction P =0.23), and reducing mortality (HR, 1.01; 95% CI, 0.84–1.22 and HR, 0.84; 95% CI, 0.73–0.96; interaction P =0.10). Conclusions—: More than a quarter of the patients in ARISTOTLE with nonvalvular atrial fibrillation had moderate or severe valvular heart disease. There was no evidence of a differential effect of apixaban over warfarin in reducing stroke or systemic embolism, causing less bleeding, and reducing death in patients with and without valvular heart disease. Clinical Trial Registration—: URL: http://www.clinicaltrials.gov . Unique identifier: NCT00412984.
Laura Harvey, Kenneth K. Liao,
Published: 1 January 2015
The publisher has not yet granted permission to display this abstract.
Kannikar Kongbunkiat, Narongrit Kasemsap, Suporn Travanichakul, Kaewjai Thepsuthammarat, Somsak Tiamkao,
International Journal of Neuroscience, Volume 125, pp 924-928; https://doi.org/10.3109/00207454.2014.986266

Abstract:
To study factors associated with poor outcomes in acute ischemic stroke patients with atrial fibrillation (AF) by using a national database. This study was a retrospective analytical study by retrieving data from the Thailand national database system for universal coverage (UC) health insurance system. All adult patients aged over 18 years who were admitted with acute ischemic stroke during the fiscal years 2004-2012 by the appropriate ICD codes were searched. Eligible patients with AF were categorized as alive or dead during hospital stay. The mortality rate and factors associated with in-hospital mortality were studied. There were 522,699 patients diagnosed as acute stroke; 277,291 patients (53.1%) had acute ischemic stroke. Of those with ischemic stroke, 25,319 patients (9.1%) had AF. The mortality rates of acute ischemic stroke with AF were 14.1% and without AF were 6.2%, (p < 0.001). Significant factors associated with mortality in acute stroke patients with AF by multivariate logistic regression were female gender (adjusted odds ratio; AOR 1.28), co-morbid diseases such as diabetes (AOR 1.28), hypertension (AOR 1.26), rt-PA treatment (AOR 0.55), and stroke complications, such as pneumonia (AOR 2.60), septicemia (AOR 6.50), or gastrointestinal bleeding (AOR 2.16). At the national level, AF caused a higher mortality rate in acute ischemic stroke than in non-AF patients. Gender, co-morbid diseases, rt-PA treatment, and stroke complications were associated with mortality in acute ischemic stroke with AF.
Raffaele De Caterina,
European Heart Journal, Volume 35, pp 3328-3335; https://doi.org/10.1093/eurheartj/ehu352

Abstract:
Despite the same electrophysiological abnormality, the risk of stroke and systemic embolism in atrial fibrillation (AF) ranges from 20%/year and can be assessed by simple clinical risk factors.1 This has led to the gradual adoption of vitamin K antagonist (VKA) oral anticoagulation as a preventive strategy for most patients with AF, unless clearly identifiable to be at very-low risk.2,3 The recent availability of non-VKA oral anticoagulants (NOACs) is likely to increase the number of AF patients treated with these drugs for stroke prevention in the future. In some such patients, atrial appendage occlusion devices are now also a viable alternative.3
Published: 1 January 2014
Abstract:
Valvular heart disease (VHD) is frequently associated with neurologic complications; cerebral embolism is the most common of these since thrombus formation results from the abnormalities in the valvular surfaces or from the anatomic and physiologic changes associated with valve dysfunction, such as atrial or ventricular enlargement, intracardiac thrombi, and cardiac dysrhythmias. Prosthetic heart valves, particularly mechanical valves, are very thrombogenic, which explains the high risk of thromboembolism and the need for anticoagulation for the prevention of embolism. Infective endocarditis is a disease process with protean manifestations that include not only cerebral embolism but also intracranial hemorrhage, mycotic aneurysms, and systemic manifestations such as fever and encephalopathy. Other neurologic complications include nonbacterial thrombotic endocarditis, a process associated with systemic diseases such as cancer and systemic lupus erythematosus. For many of these conditions, anticoagulation is the mainstay of treatment to prevent cerebral embolism, therefore it is the potential complications of anticoagulation that can explain other neurologic complications in patients with VHD. The prevention and management of these complications requires an understanding of their natural history in order to balance the risks posed by valvular disease itself against the risks and benefits associated with treatment.
Ryan R. Schupbach, John M. Bousum,
Pharmacy Practice, Volume 11, pp 30-37; https://doi.org/10.4321/s1886-36552013000100006

Abstract:
Anticoagulation patient self-testing (PST) represents an alternative approach to warfarin monitoring by enabling patients to use coagulometers to test their international normalized ratio (INR) values. PST offers several advantages that potentially improve warfarin management. To describe implementation and associated performance of a PST demonstration program at an Indian Health Service (IHS) facility. A non-consecutive case series analysis of patients from a pharmacy-managed PST demonstration program was performed at an IHS facility in Oklahoma between July 2008 and February 2009. Mean time in therapeutic range (TTR) for the seven patients showed a small, absolute increase during the twelve weeks of PST compared to the twelve weeks prior to PST. Four of the seven patients had an increase in TTR during the twelve week course of PST compared to their baseline TTR. Three of four patients with increased TTR in the final eight week period of PST achieved a TTR of 100%. Of the three patients who experienced a decrease in TTR after initiating self-testing, two initially presented with a TTR of 100% prior to PST and one patient had a TTR of 100% for the final eight weeks of PST. The two patients not achieving a TTR of 100% during the twelve week PST period demonstrated an increase in TTR following the first four weeks of PST. Although anticoagulation guidelines now emphasize patient self-management (PSM) only, optimal PST remains an integral process in PSM delivery. In the patients studied, the results of this analysis suggest that PST at the IHS facility provided a convenient, alternative method for management of chronic warfarin therapy for qualified patients. More than half of the patients demonstrated improvement in TTR. Although there is a learning curve immediately following PST initiation, the mean TTR for the entire PST period increased modestly when compared to the time period prior to PST.
, Kenneth Liao
Published: 4 January 2013
The publisher has not yet granted permission to display this abstract.
, Jack C. Sun, , Fraser D. Rubens, Kevin H. Teoh
Published: 29 February 2012
Abstract:
Antithrombotic therapy in valvular disease is important to mitigate thromboembolism, but the hemorrhagic risk imposed must be considered. The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. In rheumatic mitral disease, we recommend vitamin K antagonist (VKA) therapy when the left atrial diameter is > 55 mm (Grade 2C) or when complicated by left atrial thrombus (Grade 1A). In candidates for percutaneous mitral valvotomy with left atrial thrombus, we recommend VKA therapy until thrombus resolution, and we recommend abandoning valvotomy if the thrombus fails to resolve (Grade 1A). In patients with patent foramen ovale (PFO) and stroke or transient ischemic attack, we recommend initial aspirin therapy (Grade 1B) and suggest substitution of VKA if recurrence (Grade 2C). In patients with cryptogenic stroke and DVT and a PFO, we recommend VKA therapy for 3 months (Grade 1B) and consideration of PFO closure (Grade 2C). We recommend against the use of anticoagulant (Grade 1C) and antiplatelet therapy (Grade 1B) for native valve endocarditis. We suggest holding VKA therapy until the patient is stabilized without neurologic complications for infective endocarditis of a prosthetic valve (Grade 2C). In the first 3 months after bioprosthetic valve implantation, we recommend aspirin for aortic valves (Grade 2C), the addition of clopidogrel to aspirin if the aortic valve is transcatheter (Grade 2C), and VKA therapy with a target international normalized ratio (INR) of 2.5 for mitral valves (Grade 2C). After 3 months, we suggest aspirin therapy (Grade 2C). We recommend early bridging of mechanical valve patients to VKA therapy with unfractionated heparin (DVT dosing) or low-molecular-weight heparin (Grade 2C). We recommend long-term VKA therapy for all mechanical valves (Grade 1B): target INR 2.5 for aortic (Grade 1B) and 3.0 for mitral or double valve (Grade 2C). In patients with mechanical valves at low bleeding risk, we suggest the addition of low-dose aspirin (50-100 mg/d) (Grade 1B). In valve repair patients, we suggest aspirin therapy (Grade 2C). In patients with thrombosed prosthetic valve, we recommend fibrinolysis for right-sided valves and left-sided valves with thrombus area < 0.8 cm(2) (Grade 2C). For patients with left-sided prosthetic valve thrombosis and thrombus area ≥ 0.8 cm(2), we recommend early surgery (Grade 2C). These antithrombotic guidelines provide recommendations based on the optimal balance of thrombotic and hemorrhagic risk.
Larry B. Goldstein,
Revista Española de Cardiología (English Edition), Volume 64, pp 319-327; https://doi.org/10.1016/j.rec.2010.12.010

The publisher has not yet granted permission to display this abstract.
Larry B. Goldstein,
Published: 30 April 2011
Revista Española de Cardiología, Volume 64, pp 319-327; https://doi.org/10.1016/j.recesp.2010.12.004

Abstract:
Strokes resulting from cardiac diseases, and cardiac abnormalities associated with neuromuscular disorders are examples of the many points of contact between neurology and cardiology. Approximately 20-30% of strokes are related to cardiac diseases, including atrial fibrillation, congestive heart failure, bacterial endocarditis, rheumatic and nonrheumatic valvular diseases, acute myocardial infarction with left ventricular thrombus, and cardiomyopathies associated with muscular dystrophies, among others. Strokes can also occur in the setting of cardiac interventions such as cardiac catheterization and coronary artery bypass procedures. Treatment to prevent recurrent stroke in any of these settings depends on the underlying etiology. Whereas anticoagulation with vitamin K antagonists is proven to be superior to acetylsalicylic acid for stroke prevention in atrial fibrillation, the superiority of anticoagulants has not been conclusively established for stroke associated with congestive heart failure and is contraindicated in those with infective endocarditis. Ongoing trials are evaluating management strategies in patients with atrial level shunts due to patent foramen ovale. Cardiomyopathies and conduction abnormalities are part of the spectrum of many neuromuscular disorders including mitochondrial disorders and muscular dystrophies. Cardiologists and neurologists share responsibility for caring for patients with or at risk for cardiogenic strokes, and for screening and managing the heart disease associated with neuromuscular disorders.
M. Àngels Font, Jerzy Krupinski,
Published: 1 January 2011
Stroke Research and Treatment, Volume 2011, pp 1-23; https://doi.org/10.4061/2011/607852

Abstract:
Embolism of cardiac origin accounts for about 20% of ischemic strokes. Nonvalvular atrial fibrillation is the most frequent cause of cardioembolic stroke. Approximately 1% of population is affected by atrial fibrillation, and its prevalence is growing with ageing in the modern world. Strokes due to cardioembolism are in general severe and prone to early recurrence and have a higher long-term risk of recurrence and mortality. Despite its enormous preventive potential, continuous oral anticoagulation is prescribed for less than half of patients with atrial fibrillation who have risk factors for cardioembolism and no contraindications for anticoagulation. Available evidence does not support routine immediate anticoagulation of acute cardioembolic stroke. Anticoagulation therapy's associated risk of hemorrhage and monitoring requirements have encouraged the investigation of alternative therapies for individuals with atrial fibrillation. New anticoagulants being tested for prevention of stroke are low-molecular-weight heparins (LMWH), unfractionated heparin, factor Xa inhibitors, or direct thrombin inhibitors like dabigatran etexilate and rivaroxaban. The later exhibit stable pharmacokinetics obviating the need for coagulation monitoring or dose titration, and they lack clinically significant food or drug interaction. Moreover, they offer another potential that includes fixed dosing, oral administration, and rapid onset of action. There are several concerns regarding potential harm, including an increased risk for hepatotoxicity, clinically significant bleeding, and acute coronary events. Therefore, additional trials and postmarketing surveillance will be needed.
Ranjit John, Kenneth K. Liao
Published: 29 May 2009
The publisher has not yet granted permission to display this abstract.
, Antonio Salvador, Javier Zumalde, Jose A. Iriarte, Jesús Berjón, Eduardo Alegría, Carlos Almería, Ramón Bover, Dionisio Herrera, Cristina Fernández
European Heart Journal, Volume 27, pp 960-967; https://doi.org/10.1093/eurheartj/ehi667

Abstract:
Aims The randomized NASPEAF study included non-valvular with prior embolism and mitral stenosis patients in the same group. This is a sub-study to specially focus on the antithrombotic therapy in mitral stenosis. Methods and results We analysed 311 patients with mitral stenosis, compared with 175 non-valvular atrial fibrillation patients with prior embolism, stratified by a history of previous embolism and assigned to anticoagulant therapy [target international normalized ratio (INR)=2.0–3.0] or combined antiplatelet plus moderate intensity anticoagulant therapy. Median follow-up was 2.9 years. Outcomes were fatal and non-fatal embolism, stroke and myocardial infarction, sudden death, and death from bleeding. Combined therapy in mitral stenosis patients, compared with anticoagulant alone therapy, reduced the risk of vascular events by 58.3%. During equal therapy, the outcome annual rates were essentially the same in non-valvular and valvular patients [hazard ratio 0.90 (95% confidence interval 0.37–2.16), P=0.81]. During anticoagulant alone therapy, the annual event rate in mitral stenosis patients without prior embolism was low (2.5%) and it was very high in patients with prior embolism (6.6%). Conclusion Combined therapy was effective in mitral stenosis patients. Prior embolism patients are not efficiently protected with anticoagulant alone therapy for an INR of 2.0–3.0.
George W. Petty, Bijoy K. Khandheria, Jack P. Whisnant, JoRean D. Sicks, W. Michael O'fallon, David O. Wiebers
Published: 31 August 2005
Mayo Clinic Proceedings, Volume 80, pp 1001-1008; https://doi.org/10.4065/80.8.1001

Abstract:
To estimate the rates and predictors of survival and recurrence among residents of Olmsted County, Minnesota, who received an Initial diagnosis based on 2-dimensional color Doppler echocardiography of moderate or severe mitral or aortic stenosis or regurgitation and who experienced a first ischemic stroke, transient ischemic attack (TIA), or amaurosis fugax. At the Mayo Clinic in Rochester, Minn, we used the resources of the Rochester Epidemiology Project to identify Individuals who met the criteria for inclusion in the study and to verify exclusion criteria. The study included all residents of Olmsted County, Minnesota, who experienced a first Ischemic stroke, TIA, or amaurosis fugax within 30 days of or subsequent to receiving a first-time 2-dimensional color Doppler echocardlography-based diagnosis of moderate or severe mitral or aortic stenosis or regurgitation between January 1, 1985, and December 31, 1992. The Kaplan-Meier product-limit method was used to estimate the rates of subsequent stroke and death after the ischemic stroke, TIA, or amaurosis fugax. The Cox proportional hazards model was used to assess the effect of several potential risk factors on subsequent stroke occurrence and death. For the 125 patients in the study, the Kaplan-Meier estimates of the risk of death and the risk of stroke at 2-year follow-up were 38.6% (95% confidence interval [CI], 29.9%-47.5%) and 18.5% (95% CI, 10.0%-27.0%), respectively. Compared with the general population, death rates were significantly Increased (standardized mortality ratio = 1.75; 95% CI, 1.38-2.19; P < .001) but rates of subsequent stroke occurrence were not (standardized morbidity ratio = 1.20; 95% CI, 0.75-1.84; P = .40). After adjustment for age, sex, and cardiac comorbidity, neither the type nor severity of valvular heart disease was an independent determinant of survival or subsequent stroke occurrence. Patients with mitral or aortic valvular heart disease who experience Ischemic stroke, TIA, or amaurosis fugax have Increased rates of death, but not recurrent stroke, compared with expected rates. Other cardiovascular risk factors are more important determinants of survival In these patients than the type or echocardiographic severity of the valvular heart disease.
Robert P. Gallegos, R. Morton Bolman, R. Morton Bolman Iii
Published: 1 January 2005
The publisher has not yet granted permission to display this abstract.
Louis R. Caplan, Werner Hacke
Published: 1 January 2003
The publisher has not yet granted permission to display this abstract.
Richard C. Becker
Journal of Thrombosis and Thrombolysis, Volume 12, pp 41-52; https://doi.org/10.1023/a:1012786410881

The publisher has not yet granted permission to display this abstract.
Deeb N. Salem, Denise Hartnett Daudelin, Herbert J. Levine, Stephen G. Pauker, , Joshua Riff
Published: 1 January 2001
Chest, Volume 119, pp 207S-219S; https://doi.org/10.1378/chest.119.1_suppl.207s

George W. Petty, Bijoy K. Khandheria, Jack P. Whisnant, JoRean D. Sicks, W. Michael O’Fallon, David O. Wiebers
Published: 1 November 2000
Stroke, Volume 31, pp 2628-2635; https://doi.org/10.1161/01.str.31.11.2628

Abstract:
Background and Purpose —There is little population-based information on cerebrovascular events and survival among valvular heart disease patients. We used the Kaplan-Meier product-limit method and the Cox proportional hazards model to determine rates and predictors of cerebrovascular events and death among valve disease patients. Methods —This population-based historical cohort study in Olmsted County, Minnesota, reviewed residents with a first echocardiographic diagnosis of mitral stenosis (n=19), mitral regurgitation (n=528), aortic stenosis (n=140), and aortic regurgitation (n=106) between 1985 and 1992. Results —During 2694 person-years of follow-up, 98 patients developed cerebrovascular events and 356 died. Compared with expected numbers, these observations are significantly elevated, with standardized morbidity ratio of 3.2 (95% CI, 2.6 to 3.8) and 2.5 (95% CI, 2.2 to 2.7), respectively. Independent predictors of cerebrovascular events were age, atrial fibrillation, and severe aortic stenosis. The risk ratio of severe aortic stenosis was 3.5 (95% CI, 1.4 to 8.6), with atrial fibrillation conferring greater risk at younger age. Predictors of death were age, sex, cerebrovascular events, ischemic heart disease, and congestive heart failure, the greatest risk being among those with both congestive heart failure and cerebrovascular events (risk ratio=8.8; 95% CI, 5.8 to 13.4). Valve disease type and severity were not independent determinants of death. Conclusions —The risk of cerebrovascular events and death among patients with valve disease remains high. Age, atrial fibrillation, and severe aortic stenosis are independent predictors of cerebrovascular events, and age, sex, cerebrovascular events, congestive heart failure, and ischemic heart disease are independent predictors of death in these patients.
G. Galindo, R. Peiró, A. Plana, M.A. Navarro, J. Berdié, J. Morató
Published: 1 January 2000
Atención Primaria, Volume 26, pp 293-297; https://doi.org/10.1016/s0212-6567(00)78667-7

Abstract:
Evaluar la adecuación de la profilaxis de la enfermedad tromboembólica en los pacientes diagnosticados de cardiopatía.
Deeb N. Salem, Herbert J. Levine, Stephen G. Pauker, , Denise Hartnett Daudelin
Published: 1 November 1998
Chest, Volume 114, pp 590S-601S; https://doi.org/10.1378/chest.114.5_supplement.590s

Charles J. Bruce, Rick A. Nishimura
Published: 1 August 1998
Cardiology Clinics, Volume 16, pp 375-403; https://doi.org/10.1016/s0733-8651(05)70021-7

Abstract:
Changes in the evaluation and management of patients with mitral stenosis have occurred over the past two decades.12 In the past, cardiac catheterization provided the clinician with important hemodynamic information about the severity of obstruction across the mitral valve and its effect on the pulmonary circulation. This role has been superseded by two-dimensional and Doppler echocardiography, which now provide a noninvasive method for the complete evaluation of a patient with mitral stenosis. The catheterization laboratory today plays a therapeutic role with the development of percutaneous mitral balloon valvotomy, an accepted form of therapy for selected patients with mitral stenosis. With the excellent results achieved by this catheter-based therapy, recommendations for earlier intervention in properly selected patients with mitral stenosis have been proposed to prevent the long-term sequelae of chronic mitral stenosis.
, Geoffrey Harris, John Gelman, T.Eng Gan, Richard W Harper, Joseph J Smolich
Published: 1 February 1997
The American Journal of Cardiology, Volume 79, pp 339-343; https://doi.org/10.1016/s0002-9149(96)00758-8

Uichi Ikeda, Keiji Yamamoto, Kazuyuki Shimada
Published: 1 January 1997
Clinical Cardiology, Volume 20, pp 7-10; https://doi.org/10.1002/clc.4960200104

The publisher has not yet granted permission to display this abstract.
Keiji Yamamoto, Uichi Ikeda, Yoshitane Seino, Hideaki Mito, Hideyuki Fujikawa, Hiromichi Sekiguchi, Kazuyuki Shimada
Journal of the American College of Cardiology, Volume 25, pp 107-112; https://doi.org/10.1016/0735-1097(94)00322-h

Abstract:
Objectives. This study investigated the hemostatic status of the right and left atria in patients with mitral stenosis.Background. Systemic thromboembolism is a serious major complication in patients with mitral stenosis. However, the pathogenesis of thromboembolism in mitral stenosis is not fully understood.Methods. We determined the plasma levels of biochemical markers for platelet activity (platelet factor 4 and beta-thromboglobulin) and status of thrombin generation (fibrinopeptide A and thrombin—antithrombin III complex) and fibrinolysis (D-dimer and plasmin—alpha2-plasmin inhibitor complex) in specimens of blood obtained from the peripheral vein and right and left atria of 12 consecutive patients with mitral stenosis who were undergoing percutaneous mitral valvuloplasty.Results. Plasma levels of platelet factor 4, beta-thromboglobulin, D-dimer and plasmin—alpha2-plasmin inhibitor complex in the patients did not differ significantly between the right and left atria, whereas levels of fibrinopeptide A and thrombin-antithrombin III complex in the left atrium were significantly higher than those in the right atrium (fibrinopeptide A in the left and right atria 19.35 ± 4.64 and 6.31 ± 0.75 ng/ml [mean ± SE], respectively, p < 0.02; thrombin-antithrombin III complex in the left and right atria 11.45 ± 2.29 and 3.98 ± 0.60 ng/ml, respectively, p < 0.01). Levels of fibrinopeptide A and thrombin-antithrombin III complex in the left atrium did not correlate with mean transmitral gradient, dimension of the left atrium or reciprocal of the mitral valve area. Peripheral blood plasma levels of von Willebrand factor antigen were significantly higher in the patients than in an age-matched control group of normal subjects (168 ± 25% and 99 ± 7%, respectively, p < 0.05) but showed no difference in the peripheral blood and right and left atria of the patients.Conclusions. The coagulation system is activated in the left atrium of patients with mitral stenosis even during anticoagulation
Rainer J. Zotz, Uwe Pinnau, Sabine Genth, Raimund Erbel, Jürgen Meyer
Published: 1 July 1994
Clinical Cardiology, Volume 17, pp 375-382; https://doi.org/10.1002/clc.4960170707

The publisher has not yet granted permission to display this abstract.
P Scheinberg
Stroke, Volume 25, pp 1290-1294; https://doi.org/10.1161/01.str.25.6.1290

Abstract:
To comply with governmental requirements regarding the validity of therapeutic modalities and for medico-legal purposes, it is important to distinguish between what has been scientifically proven and what is anecdotal in the prevention and management of stroke. This review summarizes the evidence for many of the modalities used to prevent stroke in high-risk patients, including antiplatelet drugs, anticoagulants, and endarterectomy, and the limitations of each. Controversial therapeutic modalities for which no scientific proof exists, such as anticoagulation of progressing stroke, are also discussed. The term "standard of care" should apply to modalities proven to be effective by scientifically controlled studies, not because they are used by many physicians. Treatment of acute stroke is still disappointing despite the development of many promising pharmacological strategies in experimental animals. An important part of the reason may be that the window of therapeutic opportunity is much shorter than the usual entry time of patients in most clinical trials. This logistic problem merits serious attention. Numerous controlled, randomized, multiple-center clinical trials have demonstrated that the efficacy or lack thereof of various therapies directed at preventing or treating stroke can be determined and that anecdotal data may be misleading and harmful. At the least we should be aware of what we know and what we do not.
Herbert J. Levine, Stephen G. Pauker, Edwin W. Salzman, , Stephen G. Banker
Published: 1 October 1992
Chest, Volume 102, pp 434S-444S; https://doi.org/10.1378/chest.102.4_supplement.434s

The publisher has not yet granted permission to display this abstract.
Andreas Laupacis, Gregory Albers, Marvin Dunn, William Feinberg
Published: 1 October 1992
Chest, Volume 102, pp 426S-433S; https://doi.org/10.1378/chest.102.4_supplement.426s

Michael D. Freedman
The Journal of Clinical Pharmacology, Volume 32, pp 196-209; https://doi.org/10.1002/j.1552-4604.1992.tb03827.x

Abstract:
Discovered early in this century consequent to investigations of a bovine hemorrhagic disease, the oral anticoagulants inhibit a post translational modification required for various hepatically derived serine proteases to become active. These include Factors II, V, VII and X. Through their effect on Proteins S and C, the extrinsic pathway is also effected. While most of these agents exist as optically active enantiomers, with differing kinetics and pharmacologic profiles, they are generally administered in the clinic as racemic mixtures. Over the last 45 years, various studies have sought to better evaluate the role of the oral anticoagulation in both prevention and treatment of various types of thrombo‐occlusive and ‐embolic disease. Such exercises have allowed us to better understand the pathophysiology of those diseases as well as to better characterize the pre‐thrombotic state.
A. T. Marcel Gosselink, Harry J. G. M. Crijns, Kong I. Lie
Published: 1 January 1992
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Wieslaw J. Oczkowski, Alexander G.G. Turpie
Baillière's Clinical Haematology, Volume 3, pp 781-813; https://doi.org/10.1016/s0950-3536(05)80028-9

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J R Stratton
Published: 1 August 1989
Western Journal of Medicine, Volume 151, pp 172-9

Abstract:
This discussion was selected from the weekly Grand Rounds in the Department of Medicine, University of Washington School of Medicine, Seattle. Taken from a transcription, it has been edited by Drs Paul G. Ramsey, Associate Professor of Medicine, and Philip J. Fialkow, Professor and Chair of the Department of Medicine.
Herbert J. Levine, Stephen G. Pauker, Edwin W. Salzman
Published: 1 February 1989
Chest, Volume 95, pp 98S-106S; https://doi.org/10.1378/chest.95.2_supplement.98s

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Marvin Dunn, James Alexander, Regis de Silva, Frank Hildner
Published: 1 February 1989
Chest, Volume 95, pp 118S-127S; https://doi.org/10.1378/chest.95.2_supplement.118s

H. Yamanouchi, H. Nagura, Y. Ohkawa, Y. Sakurai, S. Kuzuhara, K. Kuramoto, H. Shimada, Y. Toyokura
Published: 1 September 1988
Journal of Neurology, Volume 235, pp 407-410; https://doi.org/10.1007/bf00314482

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James H. Chesebro, Philip C. Adams,
Journal of the American College of Cardiology, Volume 8, pp 41B-56B; https://doi.org/10.1016/s0735-1097(86)80006-7

Abstract:
Indications and the type of antithrombotic therapy for the prevention of thromboembolism in patients with valvular heart disease, mechanical prosthetic heart valves and bioprosthetic heart valves are discussed. The evidence for these clinical recommendations is described and graded into five levels. The indications for anticoagulation in patients with valvular heart disease are chronic or paroxysmal atrial fibrillation, sinus rhythm with a very large left atrium, severe left ventricular dysfunction or presence of heart failure or a history of previous thromboembolism. Anticoagulant therapy is administered to prolong the prothrombin time to 1.5 to 2.0 times control, using rabbit brain thromboplastin (standardized international normalized ratio = 3.0 to 4.5).
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