Emerging issues on comprehensive hemophilia care: preventing, identifying, and monitoring age-related comorbidities.

Life expectancy for persons with hemophilia (PWH) has considerably increased in the last decades as a direct result of the availability of modern therapies to control the clotting defect. Because their life expectancy now matches that of the general population, PWH are experiencing age-related comorbidities, such as, cardiovascular diseases, metabolic syndrome, renal diseases, sexuality issues, malignancies, and neurologic problems, that until recently have been rarely seen in this group of patients. In this article, we present a summary of the current knowledge on the aging PWH along with the clinical approaches that may be integrated into the routine comprehensive care of these patients for preventing, diagnosing, and monitoring age-related comorbidities. In general, patients with and without hemophilia should receive similar care, with close collaboration between the physician treating PWH and the specialty expert treating the comorbid disease.

Safety of dalteparin for the prophylaxis of venous thromboembolism in elderly medical patients with renal insufficiency: a pilot study.

The aim of this prospective cohort study was to determine the incidence of dalteparin bioaccumulation (measured using anti-Xa levels), and bleeding during thromboprophylaxis in elderly patients with renal failure who were admitted to hospital with an acute medical illness. Patients who met the criteria for being at high thromboembolic risk received dalteparin 5,000 IU subcutaneously once daily while the other patients (low risk) received 2,500 IU daily. Thromboprophylaxis was administered for at least 6 days. Anti-Xa activity was determined before the first dalteparin dose and again on day 6, 4 hours after the administration of the dalteparin dose. Bleeding was assessed daily. Compression ultrasonography was performed to identify any deep vein thromboses. There was no evidence of bioaccumulation on day 6 of therapy, irrespective of renal function. No episodes of major bleeding or venous thromboembolism occurred. Larger, randomized studies are warranted to confirm the safety of dalteparin in this patient population.

Does coronary Atherosclerosis Deserve to be Diagnosed earlY in Diabetic patients? The DADDY-D trial. Screening diabetic patients for unknown coronary disease.

OBJECTIVES: To evaluate if screening and treatment of asymptomatic coronary artery disease (CAD) are effective in preventing first cardiac event in diabetics. METHODS: Diabetic patients without known CAD were randomly assigned to undergo a screening for silent myocardial ischemia followed by revascularization or to continue follow-up. The reduction of cardiac death (CD) or nonfatal myocardial infarction (MI) represented the primary aim; secondary aim was the prevention of heart failure (HF). RESULTS: From September 2007 to May 2012, 520 patients (62 years; 104 female) were enrolled. Silent CAD was found in 20 of 262 patients (7.6%), revascularization was performed in 12 (4.6%). After a mean follow-up of 3.6 years 12 events (4.6%) occurred in the study group and 14 (5.4%) in the follow-up (HR=0.849, 95% CI: 0.393-1.827, P=0.678). The occurrence of first HF episode did not differ between groups: 2 (0.8%) in screened and 7 (2.7%) in follow-up (HR=0.273, 95% CI: 0.057-1.314, P=0.083). Subgroup analysis revealed a significantly lower HF episodes among patients with intermediate cardiovascular risk (Log rank P=0.022). Additionally, when CD and MI were analysed within subgroups, a significant lower number of CDs was observed among older than 60 years (P=0.044). CONCLUSION: Screening and revascularization of silent CAD in diabetics, failed to demonstrate a significant reduction in cardiac events and HF episodes. However, our data indicate that further research is warranted in patients older than 60 years and those with an intermediate cardiovascular risk. CLINICALTRIALS.GOV: NCT00547872.

The management of patients who require temporary reversal of vitamin K antagonists for surgery: a practical guide for clinicians.

The management of patients who require temporary interruption of vitamin K antagonists is a common clinical problem, affecting an estimated 400 000 patients per year in Europe and North America. Managing such patients is challenging because of the lack of randomized trials assessing different perioperative anticoagulation management strategies and inconsistent recommendations from consensus groups. Recent non-randomized trials have helped to estimate the risks for arterial thromboembolism and bleeding with bridging anticoagulation involving low-molecular-weight heparin. The objectives of this review are to describe bridging anticoagulation and how it may be used with a short-acting heparin, such as unfractionated heparin or low-molecular-weight heparin, to discuss preoperative patient management, focusing on risk stratification for thromboembolic events and interruption of vitamin K antagonist therapy, and to discuss postoperative patient management, focusing on surgery-related bleeding risk and the resumption of bridging anticoagulation and vitamin K antagonist therapy.