Non-vitamin K antagonist oral anticoagulants in the treatment of coronary and peripheral atherosclerosis.

Oral anticoagulants (OACs) are widely used for prevention of systemic thromboembolism, including the reduction of the risk of stroke in patients with atrial fibrillation (AF) and prosthetic heart valves. There is also an increasing population of patients who require not only OACs, but also double antiplatelet therapy (DAPT). A typical example is a patient with AF and stable coronary artery disease or acute coronary syndrome (ACS), treated by percutaneous coronary intervention. In recent years, with the introduction of NOACs, triple or dual therapy has become safer. Regardless of these indications for the use of NOACs, rivaroxaban at a reduced dose has proved to efficiently reduce the risk of further thrombotic events when added to DAPT in patients who have suffered an ACS. However, such therapy increases the incidence of bleeding complications. Interesting was also the potential impact of the pleiotropic mechanism of action of non-vitamin K antagonist oral anticoagulants (NOACs) through protease­activated receptors 1 and 2, present on the platelets and many other cells, and changing the course of arterial atherosclerosis. The COMPASS trial has shown that in the group treated with rivaroxaban combined with aspirin, the primary outcome (cardiovascular death, stroke, and myocardial infarction) occurred significantly less frequently than in the group treated only with aspirin. However, a significantly higher number of bleedings was observed. In the subgroup of patients with peripheral artery disease, a significant reduction of the incidence of amputations was shown. The outcomes of the COMPASS trial might be a breakthrough in the treatment of coronary and peripheral atherosclerosis.

Local and general anaesthesia do not influence outcome of transfemoral aortic valve implantation.

BACKGROUND: There is great variability for the type of anaesthesia used during TAVI, with no clear consensus coming from comparative studies or guidelines. We sought to detect regional differences in the anaesthetic management of patients undergoing transcatheter aortic valve implantation (TAVI) in Europe and to evaluate the relationship between type of anaesthesia and in-hospital and 1 year outcome. METHODS: Between January 2011 and May 2012 the Sentinel European TAVI Pilot Registry enrolled 2807 patients treated via a transfemoral approach using either local (LA-group, 1095 patients, 39%) or general anaesthesia (GA-group, 1712 patients, 61%). RESULTS: A wide variation in LA use was evident amongst the 10 participating countries. The use of LA has increased over time (from a mean of 37.5% of procedures in the first year, to 57% in last 6 months, p<0.01). MI, major stroke as well as in-hospital death rate (7.0% LA vs 5.3% GA, p=0.053) had a similar incidence between groups, confirmed in multivariate regression analysis after adjusting for confounders. Dividing our population in tertiles according to the Log-EuroSCORE we found similar mortality under LA, whilst mortality was higher in the highest risk tertile under GA. Survival at 1 year, compared by Kaplan-Meier analysis, was similar between groups (log-rank: p=0.1505). CONCLUSIONS: Selection of anaesthesia appears to be more influenced by national practice and operator preference than patient characteristics. In the absence of an observed difference in outcomes for either approach, there is no compelling argument to suggest that operators and centres should change their anaesthetic practice.