[Anticoagulant treatment in patients with non-valvular atrial fibrillation and chronic anemia: still a grey area]. / Il trattamento anticoagulante nei pazienti con fibrillazione atriale non valvolare e anemia cronica: ancora zone grigie.

Anemia has been associated with a higher risk of major bleeding among atrial fibrillation patients on oral anticoagulation and is therefore included in most bleeding risk scores. In contrast, much less evidence exists regarding the association between anemia and stroke risk in atrial fibrillation patients. The purpose of this review was to re-evaluate the efficacy and safety of anticoagulant treatment, in particular of new oral anticoagulants, in patients with non-valvular atrial fibrillation and chronic anemia. Five observational studies were found in the literature that specifically investigated this issue; the results can be synthetized as follows: (i) the progressive decrease in hemoglobin level was associated with an increased incidence of major hemorrhages, already evident in mild anemia and very high in more severe anemia (hemoglobin level <~10 g/dl), up to >10% per year. In contrast, the association between anemia and stroke risk appears to be weak; (ii) warfarin seems to be effective in stroke prevention in patients with mild anemia, with a moderate increase in major hemorrhages, whereas it seems to be ineffective and associated with a high incidence of hemorrhagic complications in patients with more severe anemia; (iii) new oral anticoagulants, in particular apixaban, seem to induce a lower incidence of major hemorrhages in comparison with warfarin in patients with both mild and severe anemia. However, when hemoglobin level is <~10 g/dl, the incidence of major hemorrhages remains high, also in patients treated with the new anticoagulants. These data suggest that in patients with atrial fibrillation and mild anemia, anticoagulant treatment appears to be effective, but requires close monitoring during follow-up, whereas in patients with more severe anemia the choice of whether or not to prescribe an anticoagulant treatment should be made on a case by case basis, considering the thromboembolic risk, the etiology of chronic anemia and the history and general condition of the patient. New oral anticoagulants should be preferred to warfarin.

Are women really more affected by vasovagal syncope than men?

It is commonly reported that vasovagal syncope (VVS) is more frequent in women. Presently, this issue has never been investigated. The purpose of this review was to evaluate, through an extensive review of the literature, whether women are really more affected by VVS than men. The gender distribution was investigated in individuals with classical and nonclassical VVS. The database PubMed was searched using the terms 'syncope', 'vasovagal syncope', 'neurally mediated syncope' and 'tilt testing'. Twelve studies dealing with classical and 75 with nonclassical VVS were eligible. In the individuals with classical (N = 1861) and nonclassical VVS (N = 9696), a trend towards a greater percentage of women emerged (P = 0.14 and 0.07, respectively). In the total population with VVS (N = 11 557), the percentage of women was significantly higher than that of men (58 versus 42%, P = 0.03). Most of the individuals were young or middle-aged. In 84% of the studies, the percentage of women was greater than that of men. A separate analysis was carried out in older VVS patients (≥60 years) and only two studies were eligible to be evaluated. Considering that almost all the studies were carried out in the western nations, where the number of men and women is almost superimposable until the age of 65 years and a bias by gender has never been reported in the management of VVS, these data strongly suggest that young and middle-aged women are more affected by VVS than their male counterparts. At present, data are too scant to draw a definitive conclusion in older VVS patients.