Efficacy and Safety of Direct Oral Anticoagulants (DOACs) Versus Warfarin in Atrial Fibrillation Patients with Prior Stroke: a Systematic Review and Meta-analysis.

BACKGROUND: The purpose of this meta-analysis was to compare efficacy and safety of direct oral anticoagulants (DOACs) to warfarin for secondary stroke prevention among adult patients with atrial fibrillation and prior stroke. METHODS: Major repositories were screened for randomized controlled trials (RCTs), RCT subgroups, and observational studies (OBSs, divided in claims and non-claims). Occurrences of ischemic stroke or transient ischemic attack, systemic embolism, all-cause mortality, intracranial hemorrhage (ICH), and major bleeding were outcomes of interest. Hazard ratios (HRs) and their confidence intervals (95%CIs) were pooled using random-effects models for each study design. Claims studies were analyzed separately from non-claims, while RCT subgroups were grouped with OBSs (non-claims) as the randomization was broken. RESULTS: Of 8647 articles, 20 were included (one RCT, six RCT subgroups, nine claims, and four non-claims). Comparing DOACs to warfarin, pooled HRs (95%CI) were consistently in favor of DOACs although some did not reach statistical significance: for ischemic stroke, 0.84 (0.66-1.07) in claims; 0.90 (0.77-1.06) in non-claims and RCT subgroups; for systemic embolism, 0.77 (0.62-0.96) in claims; 0.86 (0.77-0.96) in non-claims and RCT subgroups; for all-cause mortality, 0.57 (0.33-0.99) in claims; 0.87 (0.79-0.96) in non-claims and RCT subgroups; for ICH, 0.72 (0.39-1.33) in claims; 0.51 (0.38-0.67) in non-claims and RCT subgroups; and for major bleeding, 0.86 (0.71-1.03) in claims; 0.90 (0.76-1.08) for non-claims and RCT subgroups. CONCLUSION: DOACs were associated with better efficacy and safety profiles than warfarin in atrial fibrillation patients with prior stroke, more specifically a lower risk of systemic embolism, all-cause mortality, and ICH.

Peripheral vascular manifestation in patients receiving an amphetamine analog: A case series.

Amphetamine and its related derivatives and analogues (ADRA) are highly addictive central nervous system stimulants that are used commonly in the treatment of attention-deficit/hyperactivity disorder and narcolepsy. These medications are associated with many side effects but reports of peripheral arterial manifestations associated with ADRA usage are scarce. We retrospectively reviewed the records of 16 patients (median age 37 years (IQR 31-47), 13 females) referred to a single tertiary referral service while receiving ADRA. Follow-up was available for a median of 3 years (IQR 3-4.5). The most common presentation (62.5%) was mild vasospastic symptoms involving the upper, lower or both extremities. Six patients developed severe manifestations including tissue loss and the need for lower extremity amputation. Most patients (75%) refused to stop the medication during follow-up. Underlying rheumatologic disorders were found in 25% of the patients, and the presence of rheumatologic disease seemed to be associated with more severe vascular manifestations. In conclusion, it is important to search for ADRA usage as part of the differential diagnosis of digital ischemia.

Presentation, treatment, and outcomes in patients with spontaneous isolated celiac and superior mesenteric artery dissection.

Spontaneous isolated celiac or superior mesenteric artery (SMA) dissection (SICMAD) is a rare clinical entity. Not much is known about the natural history and appropriate treatment. We retrospectively queried a prospectively collected institutional radiology database for all patients diagnosed with SICMAD from 1990 to 2017. We identified 42 arteries in 40 patients (83.3% male), mean age 54.8 ± 10.9 years, consisting of 24 celiac arteries and 18 SMA. SMA lesions were longer than celiac lesions (5.15 ± 3.81 vs 2.38 ± 1.40 cm, p = 0.008). Thirty-one patients had follow-up; mean follow-up was 4.9 ± 4.8 years. Morphologic improvement was seen in 20 (48%) arteries. Sakamoto IV lesions were more likely to remodel (OR: 11.26, 95% CI: 1.13, 588.26, p = 0.039), and Sakamoto II lesions less likely to remodel (OR: 0, 95% CI: 0.00, 0.93, p = 0.05). Patients received an average of 2.35 scans during follow-up. Symptom resolution occurred in all symptomatic patients, and 16% of patients had recurrence of symptoms. Follow-up CT scans revealed a stable arterial diameter for the majority of patients. In conclusion, the majority of patients with SICMAD improve with medical therapy alone. Aneurysmal dilatation is uncommon.

Culture Negative Infective Endocarditis Atypically Diagnosed From Mycotic Cerebral Aneurysm.

Cerebral mycotic aneurysms (CMA) are a rare consequence of infective endocarditis (IE). We report a case of a 75-year-old left-handed male with comorbidities who was admitted to our facility with left-sided weakness, dysarthria, and left-sided facial droop. Initial computed tomography of the head without contrast and angiography of the head showed acute hemorrhage in the paramedian right frontal lobe with extension into the right lateral ventricle, occlusion of the left intracranial internal carotid artery, and an associated 0.3 cm aneurysm involving the distal right anterior cerebral artery. C-reactive protein and erythrocyte sedimentation rate were elevated but blood cultures showed no growth for more than five days. The patient underwent a two-vessel cerebral angiogram, primary coil embolization of the aneurysm, and selective catheterization of the left common carotid artery, right internal carotid artery, and right anterior cerebral artery. Transesophageal echocardiography showed an echogenic, highly mobile structure attached to the aortic valve suggestive of vegetation. The patient was subsequently started on a vancomycin regimen and stably discharged for further outpatient follow-up. This case highlights an uncommon presentation of CMA and the retroactive diagnosis of IE.

The Clot Thickens: COVID-19-Related ST-Elevation Myocardial Infarction in the Setting of Recent Boosters.

The coronavirus disease of 2019 (COVID-19) has an array of pathological effects that continue to be discovered. Vaccines against COVID-19 have quickly emerged as our main tool. However, the thrombotic risk of both the virus and the vaccine is yet to be established, let alone together. In this case report, we present a case involving a recently diagnosed COVID-19 patient who developed an ST-elevated myocardial infarction (STEMI) after receiving his booster shot. Our aim is to highlight the standard of treatment outcomes in COVID-19-associated clots, familiarize ourselves with the complexity of the clot burden in a COVID-19-associated STEMI, and illustrate the potential role of the cumulative pro-thrombotic effects of a recent COVID-19 booster with a concomitant symptomatic COVID-19 infection.

COVID-19-Associated Superior Mesenteric Artery Thrombosis and Acute Intestinal Ischemia.

The prothrombotic nature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been well-established since the start of the global coronavirus disease 2019 (COVID-19) pandemic. Mesenteric artery thrombosis and acute mesenteric ischemia are, on their own, rare occurrences and often present with fatal gastrointestinal (GI) pathologies requiring quick identification and intervention by the clinician to improve clinical outcomes. SARS-CoV-2 infection can present with acute GI pathologies and warrants further investigation regarding anticoagulation therapy in COVID-19 positive patients. We report on a 64-year-old woman infected with SARS-CoV-2 who presented with superior mesenteric artery thrombosis and acute intestinal ischemia.

Effects of an Intensive Discharge Intervention on Medication Adherence, Glycemic Control, and Readmission Rates in Patients With Type 2 Diabetes.

OBJECTIVES: Patients with diabetes are at particularly high risk for adverse outcomes after hospitalization. The goals of this study were to design, implement, and evaluate a multipronged transitional care intervention among hospitalized patients with diabetes. METHODS: We randomly assigned inpatients likely to be discharged home on insulin to an intensive transitional care intervention or usual care. The primary outcome was 90-day postdischarge insulin adherence, using prescription refill information to calculate a medication possession ratio. Unadjusted analyses were conducted using Wilcoxon rank sum; adjusted analyses used multivariable linear regression and weighted propensity scoring methods, with general estimating equations to account for clustering by admitting physician. RESULTS: One hundred eighty patients participated. The mean (SD) medication possession ratio to all insulin types was 84.5% (22.6) among intervention and 76.4% (25.1) among usual care patients (difference = 8.1, 95% confidence interval = -1.0 to 17.2, P = 0.06), with a smaller difference for adherence to all medications (86.3% versus 82.0%). A1c levels decreased in both groups but was larger in the intervention arm (1.09 and 0.11, respectively) (difference = -0.98, 95% confidence interval = -2.03 to -0.07, P = 0.04). Differences between study arms were not significant for rates of hypoglycemic episodes, 30-day readmissions, or emergency department visits. In adjusted/clustered analyses, the difference in A1c reduction remained statistically significant, whereas differences in all other outcomes remained nonsignificant. CONCLUSIONS: The intervention was associated with improvements in glycemic control, with nonsignificant trends toward greater medication adherence. Further research is needed to optimize and successfully implement interventions to improve patient safety and health outcomes during care transitions.

Quality of life in patients with symptomatic multivessel coronary artery disease: a comparative post hoc analyses of medical, angioplasty or surgical strategies-MASS II trial.

OBJECTIVE: We evaluated the impact of Coronary Artery Bypass Graft Surgery (CABG), Percutaneous Coronary Intervention (PCI) or Medical Therapy (MT) on self-perceived quality of life among patients with stable Coronary Artery Disease (CAD). BACKGROUND: The Medicine, Angioplasty and Surgery Study (MASS-II) implemented initial policies of CABG, PCI or continued medical treatment in patients who allow assessment of mid-term health consequences. METHODS: A total of 542 patients were randomly assigned to CABG (175), to PCI (180) and to MT (187). The short form 36 (SF-36) self-administered quality of life (QoL) questionnaires were applied at baseline, 6 months and 12 months later. RESULTS: All the three therapeutic strategies presented significant improvement in all dimensions of the SF-36 during the follow-up (p<0.0001). However, the CABG group was the one that had significantly greater improvement in physical and social functioning, vitality and general health when compared to MT and PCI. Also, men had the best QoL at the beginning of the treatment when compared to women, with a progressive improvement after 6 and 12 months. CONCLUSIONS: The quality of life was better in both CABG and PCI groups compared to MT after 1 year of follow-up. However, the patients submitted to CABG were the ones that presented the greater and progressive improvement of QoL. Also, men presented better QoL at the beginning and after treatment when compared to women.

Aspectos clínicos, angiográficos e anatomopatológicos das artérias e das anastomoses coronárias na segunda revascularização miocárdica / Clinic-angiographic and anatomo-pathologic aspects of arteries and coronary anastomoses in the 2nd. myocardial revascularization

O surgimento de sintomatologia anginosa, infarto agudo do miocárdio ou óbito em pacientes portadores de doença arterial coronária (DAC), submetidos previamente à cirurgia de revascularização do miocárdico (RM), tem sido atribuído ao desenvolvimento de doença aterosclerótica nas artérias ou veias correspondentes ou, então, às associações desses vasos.Neste estudo se buscou analisar os aspectos clínicos, angiográficos e anatomopatológico das artérias e dos enxertos coronários em pacientes que foram submetidos à segunda RM. Selecionaram-se 51 pacientes consecutivos com idade média de 59±8 anos, sendo 46 do sexo masculino, e com intervalo entre as operações de 8±3,5 anos.Os dados clínicos mostraram 74.