Successful treatment with rivaroxaban of an extended deep vein thrombosis complicated by pulmonary embolism in a patient with familial antithrombin III deficiency: a case report.

BACKGROUND: Patients with low levels of antithrombin III (AT III) are at an increased risk of developing arteriovenous thromboembolic disease. CASE SUMMARY: We report a case of a 28-year-old woman who presented with a 1-week history of spontaneous right calf pain and swelling. A heterozygous AT III deficiency, phenotypically expressed as deep vein thrombosis, was reported in the patient's mother and sister. Blood workup revealed residual AT III activity at 58% with normal protein C and protein S levels. Computed tomographic angiography (CTA) revealed subsegmental bilateral pulmonary embolism (PE) and deep vein thrombosis in the right leg extending into the inferior vena cava up to the confluence of the left renal vein. Placement of an inferior vena cava filter was not considered. Given the patient's haemodynamic stability, anticoagulant therapy with 15 mg of rivaroxaban twice a day was initiated instead. Echocardiography after 10 days of treatment revealed complete resolution of the thrombus located in the inferior vena cava, while CTA revealed complete resolution of the PE. DISCUSSION: Patients with AT III deficiency are likely to be heparin-resistant and will require higher heparin doses or the administration of AT III replacement therapy for the treatment of thrombosis, both of which are associated with an increased risk for haemorrhagic complications. Direct factor Xa inhibition by rivaroxaban provided an alternative mechanism for anticoagulation, which was found to be particularly useful in this patient with familial AT III deficiency, deep vein thrombosis, and PE.

The effect of physical exercise on endothelial function.

Endothelium is essential for maintenance of health of the vessel wall and for the local regulation of vascular tone and structure and haemostasis. Regular physical exercise, which is known to promote a favourable cardiovascular state, may improve endothelial function via several mechanisms. Indeed, it augments blood flow and laminar shear stress, resulting in increased nitric oxide production and bioavailability. In this regard, the beneficial effects of training on endothelial function can be mediated in a number of ways, including synthesis of molecular mediators, changes in neurohormonal release and oxidant/antioxidant balance. On the other hand, physical exercise can also elicit systemic molecular pathways connected with angiogenesis and chronic anti-inflammatory action with consequent modification of the endothelial function. However, its benefit depends on the type and intensity of training performed. While strenuous exercise increases oxidative metabolism and produces a pro-oxidant environment, only regular moderate physical activity promotes an antioxidant state and preserves endothelial function. Thus, exercise may have a beneficial effect on the development of cardiovascular disease through preserving endothelial function.

Surgical bleeding after pre-operative unfractionated heparin and low molecular weight heparin for coronary bypass surgery.

BACKGROUND AND OBJECTIVES: Since the impairment of platelet function may cause excess peri-operative bleeding, pre-operative discontinuation of aspirin and heparin bridging are common for cardiac surgery. We evaluated the impact of pre-operative administration of enoxaparin and unfractionated heparin (UFH) on coagulation parameters and peri-operative bleeding in patients undergoing elective coronary artery bypass grafting (CABG) surgery after discontinuation of aspirin. DESIGN AND METHODS: Forty-three patients with three-vessel coronary artery disease undergoing elective CABG surgery discontinued aspirin and were randomized to receive either UFH 180 UI/Kg x 2/day s.c. or enoxaparin 100 UI/Kg x 2/day s.c. until 12 h before surgery (median pre-operative treatment 8 days, range 6-12 days). Surgery was performed as usual with UFH. Neither UFH nor any low molecular weight heparin was given in the immediate post-operative period. The effects of UFH and enoxaparin were monitored by the activated partial thromboplastin time (aPTT) and the Enox-test (sensitive to factor Xa inhibition) using a Rapidpoint Coagulation Analyzer. aPTT and factor Xa activity were also measured by standard methods. Peri-operative bleeding and the nadirs of hemoglobin concentration, hematocrit and platelet count were monitored post-operatively. RESULTS: Patients in the two groups were similar for number of bypasses, on-pump time, total surgery time, and time from the last heparin administration. Coagulation parameters increased significantly and similarly at 30 min and 6 h with both treatments, but returned within the normal range at 12 h. Hemoglobin, hematocrit and platelet counts significantly decreased to the same extent after CABG and re-normalized at the same time. Transfusional requirements of blood and plasma units were similar in the two groups. INTERPRETATION AND CONCLUSIONS: From the kinetics of coagulation parameters and the evaluation of bleeding, enoxaparin is a safe alternative to UFH as a bridging therapy to CABG after discontinuation of aspirin.

Aspirin overprescription in primary cardiovascular prevention.

INTRODUCTION: Aspirin overprescription is of some concern, especially in still-healthy individuals, and estimates of the magnitude of this problem are lacking. We evaluated the inappropriateness of aspirin prescription by primary care physicians in primary cardiovascular prevention. MATERIALS AND METHODS: Out of 20,599 patients screened by 16 primary care physicians in the Abruzzi region, central Italy, 400 patients were on treatment with aspirin for primary prevention. For each such patient, the absolute cardiovascular and coronary risks were assessed according to the Italian Cardiovascular Risk Chart for Primary Prevention and the European Society of Cardiology Coronary Risk Chart, respectively. Patients with a cardiovascular and/or coronary risk <1.0 event/100 patients/year were considered as treated inappropriately (aspirin overprescription), on the basis of previous literature. RESULTS: Overall, as many as 12% and 18% of patients had a cardiovascular and/or coronary risk <1.0 event/100 patients/year according to the European and the Italian charts, respectively, and therefore were defined as treated inappropriately. Patients with and without inappropriate treatment were similar with respect to smoking habits, family history and body max index. However, inappropriately treated patients had significantly lower levels of blood pressure and total cholesterol, and were more likely to be female, younger and non-diabetic than patients appropriately treated. CONCLUSIONS: A non-negligible proportion-up to 18%-of subjects in primary prevention is currently more likely to derive harm than benefit from inappropriate aspirin use. A wider use of Cardiovascular Risk Charts should guide primary care physicians in prescribing aspirin for primary prevention.