[Extended anticoagulant treatment of venous thromboembolic disease with direct oral anticoagulants]. / Tratamiento anticoagulante extendido de la enfermedad tromboembólica venosa con anticoagulantes orales directos.

Direct oral anticoagulants have demonstrated efficacy and safety in the treatment of venous thromboembolic disease. A review is presented of the results of direct oral anticoagulants in the published clinical trials of extended anticoagulant treatment (after the first 3-6 months of treatment) of venous thromboembolic disease.

Low-molecular-weight heparins in patients with atrial fibrillation. / Heparinas de bajo peso molecular en pacientes con fibrilación auricular.

In clinical practice, low-molecular-weight heparins are used relatively frequently in patients with atrial fibrillation to prevent embolic events. In this article, it is revised the available evidence in the following clinical situations: rapid onset of anticoagulation, bridging therapy (replacing long-term oral anticoagulant therapy around an invasive procedure) and transesophageal echocardiography-guided cardioversion.

Giant cell arteritis: diagnosis and treatment. / Arteritis de células gigantes: diagnóstico y tratamiento.

Giant cell arteritis is the most common primary systemic vasculitis in adults. The condition is granulomatous arteritis of large and medium vessels, which occurs almost exclusively in patients aged 50 years or more. This article reviews the diagnosis and treatment of the disease.

[New oral anticoagulants in the treatment of venous thromboembolic disease]. / Nuevos anticoagulantes orales en el tratamiento de la enfermedad tromboembólica venosa.

Rivaroxaban is a direct inhibitor of activated factor X, and dabigatran is a direct inhibitor of thrombin. These new oral anticoagulants have demonstrated to be effective and safe in clinical trials on the treatment of venous thromboembolic disease (deep vein thrombosis and pulmonary thromboembolism).

[Should dabigatran or vitamin K antagonists be used in prevention of stroke in patients with atrial fibrillation?]. / ¿Dabigatrán o antagonistas de la vitamina K en la prevención de ictus en pacientes con fibrilación auricular?

Patients with atrial fibrillation (AF) at risk of stroke are not always anticoagulated with vitamin K antagonists (VKA) despite lack of contraindication. Dabigatran, an oral direct thrombin inhibitor, is a new option with proven safety and effectiveness in these patients. The advantages of dabigatran are its more predictable response, obviating coagulation monitoring and possible lower frequency of bleedings. Its drawbacks are cost, lack of antidote and long-term data, frequency of dyspepsia and the twice daily dosage.

[Cancer in patients with venous thromboembolic disease]. / Cáncer en pacientes con enfermedad tromboembólica venosa.

OBJECTIVE: To study the characteristics of patients with venous thromboembolic disease (VTD) and cancer in our area. METHODS: Prospective observational study of all patients diagnosed by objective methods of VTD in the only hospital in a rural area from November 2002 to April 2005. RESULTS: Ninety-four patients were diagnosed of VTD. The median age was 71.9 years (range 35-94 years), and 52 (55.3%) were women. The median follow-up with anticoagulant therapy was 7.1 months (range 0-29 months). Seventeen patients (18.1%) had cancer. Eleven cases (64.7%) had an adenocarcinoma, and 7 (41.2%) had distant metastases. Two (2.5%) of 79 cases without prior cancer were diagnosed of cancer after the diagnosis of VTD. The frequency of adverse events (death, major hemorrhage and thromboembolic recurrence) was higher in patients with cancer (64.7 vs. 9.1%, p < 0.001). CONCLUSIONS: Almost one fifth of patients with VTD in our area had cancer, more frequently an adenocarcinoma. Cancer is infrequently diagnosed after the diagnosis of VTD. Cancer in VTD is associated to a poor prognosis, with a remarkable frequency of adverse events.

["Natural" treatments of hypercholesterolemia]. / Tratamientos "naturales" de la hipercolesterolemia.

In this article we briefly review the evidence on the effect of different "natural" products on cholesterolemia. Plant stanols and sterols reduce cholesterol intestinal absorption and decrease total and LDL cholesterol by approximately 10%. Polycosanol is a mixture of saturated alcohols that seem to inhibit cholesterol hepatic synthesis and decrease total and LDL cholesterol by up to 25%. The effects on the cholestorolemia of soy and soluble fiber are modest.

[Venous thromboembolic disease in a rural area of Southern Extremadura (Spain)]. / Enfermedad tromboembólica venosa en un área ruraldel sur de Extremadura (España).

OBJECTIVE: To study the characteristics of the venous thromboembolic disease (VTD) in a rural area of Southern Extremadura (Spain). MATERIAL AND METHODS: Prospective observational study of all patients diagnosed by objective methods of VTD in the only hospital in our area from November 2002 to November 2004. RESULTS: Seventy-six patients were diagnosed of VTD: 35 (46.1%) with pulmonary thromboembolism and 41 (53.9%) with isolated deep vein thrombosis (DVT). The median age was 72.4 years (range 35-94 years), 51 (67.1%) were older than 70 years, and 43 (56.6%) were women. The annual incidence of VTD was 0.63 per 1,000 persons (0.74 per 1,000 persons in women and 0.54 per 1,000 persons in men). Thirty-seven patients (48.7%) had "idiopathic" VTD. After a median follow-up of 5.5 months with anticoagulant therapy, 13 patients (17.1%) had dead. Comorbidity and non "idiopathic" VTD were significantly more frequent in the dead patients. Three patients (3.9%) presented probable recurrence, and all of them died. There were 4 cases (5.3%) of non-fatal severe hemorrhage. Nine patients with isolated DVT did not require hospitalization, and there was no event in the follow-up. CONCLUSIONS: The incidence of VTD may be lower in our area than in other geographical areas. VTD affects more frequently to elderly and women, and almost half of cases are "idiopathic". The mortality is high, and it is related to the existence of comorbidity and non "idiopathic" VTD. The recurrences and the severe hemorrhages are not exceptional during the anticoagulant therapy. The ambulatory treatment of isolated DVT may be an option in selected patients.

[Outcome of patients with suspected pulmonary thromboembolism and low probability ventilation/perfusion lung scan who receive no long-term anticoagulation]. / Evolución de los pacientes con sospecha de tromboembolismo pulmonar y gammagrafía pulmonar de ventilación/perfusión de baja probabilidad que no son anticoagulados a largo plazo.

OBJECTIVE: To know in our area the security of no long-term anticoagulation in patients with suspected pulmonary thromboembolism (PTE) and a low probability ventilation/perfusion (V/Q) lung scan. MATERIAL AND METHODS: Retrospective review of a series of consecutive outpatients with suspected PTE and a low probability V/Q lung scan, according to the modified PIOPED criteria, who receive no long-term anticoagulation. RESULTS: Among 38 patients with a low probability V/Q lung scan, 31 (81.6%) did not receive long-term anticoagulation. The median age was 69.1 years (range 26-88 years), and 19 (61.3%) were female. The clinical probability of PTE was moderate in 27 patients (87.1%). Twenty-two patients (71%) had a venous lower extremities echography-doppler negative for deep vein thrombosis (DVT). The median follow-up was 6.3 months (range 3-12 months). There was one case (3.2%; 95% confidence interval, 0.1-16.7%) with demonstrated PTE and DVT, and there was no death. CONCLUSION: No long-term anticoagulation in outpatients with a moderate clinical probability of PTE, a low probability V/Q lung scan and a venous lower extremities echography-doppler negative for DVT may be secure in our area.

[Troponin I in patients with pulmonary thromboembolism]. / Troponina I en pacientes con tromboembolismo pulmonar.

OBJECTIVE: To study the frequency in patients with pulmonary thromboembolism (PTE) of an elevated troponin I and the associated characteristics. MATERIAL AND METHODS: Prospective study of 29 consecutive patients with PTE. RESULTS: Troponin I was determined in 22 patients. The median age was 78.1 years. Ten (45.5%) had an elevated troponin I, with a median level of 1 ng/ml (range 0.7-3.1 ng/ml). The diagnostic delay was lower in patients with an elevated troponin I (2 +/- 1.7 vs. 5.9 +/- 5.6 days, p = 0.04). Three (30%) of 10 patients with an elevated troponin I had midthoracic pain. Patients with an elevated troponin I had a higher frequency of arterial hypotension (40 vs. 16.7%), respiratory failure (70 vs. 58.3%) and electrocardiographic overload right heart data (50% vs. 33.3%), although without reaching statistical significance. CONCLUSIONS: A slightly elevated troponin I is frequent in patients with PTE. The early diagnosis may increase the frequency of an elevated troponin I. The coexistence of an elevated troponin I and midthoracic pain may simulate an acute coronary syndrome. In patients with PTE, an elevated troponin I may associate to some severity criteria such as arterial hypotension, respiratory failure and electrocardiographic overload right heart data.

Diffuse large B cell lymphoma in a patient with hypocomplementemic urticarial vasculitis.

Hypocomplementemic urticarial vasculitis (HUV) is known to be associated with malignancies. Urticarial vasculitis has been linked to lymphomas, but to our knowledge, the association of HUV and non-Hodgkin lymphoma has not been described so far. A patient with HUV who developed 10 years later a diffuse large B cell lymphoma is reported here.