Determinants of label non-adherence to non-vitamin K oral anticoagulants in patients with newly diagnosed atrial fibrillation.

Aims: To evaluate the extent and determinants of off-label non-vitamin K oral anticoagulant (NOAC) dosing in newly diagnosed Dutch AF patients. Methods and results: In the DUTCH-AF registry, patients with newly diagnosed AF (<6 months) are prospectively enrolled. Label adherence to NOAC dosing was assessed using the European Medicines Agency labelling. Factors associated with off-label dosing were explored by multivariable logistic regression analyses. From July 2018 to November 2020, 4500 patients were registered. The mean age was 69.6 ± 10.5 years, and 41.5% were female. Of the 3252 patients in which NOAC label adherence could be assessed, underdosing and overdosing were observed in 4.2% and 2.4%, respectively. In 2916 (89.7%) patients with a full-dose NOAC recommendation, 4.6% were underdosed, with a similar distribution between NOACs. Independent determinants (with 95% confidence interval) were higher age [odds ratio (OR): 1.01 per year, 1.01-1.02], lower renal function (OR: 0.96 per ml/min/1.73 m2, 0.92-0.98), lower weight (OR: 0.98 per kg, 0.97-1.00), active malignancy (OR: 2.46, 1.19-5.09), anaemia (OR: 1.73, 1.08-2.76), and concomitant use of antiplatelets (OR: 4.93, 2.57-9.46). In the 336 (10.3%) patients with a reduced dose NOAC recommendation, 22.9% were overdosed, most often with rivaroxaban. Independent determinants were lower age (OR: 0.92 per year, 0.88-0.96) and lower renal function (OR: 0.98 per ml/min/1.73 m2, 0.96-1.00). Conclusion: In newly diagnosed Dutch AF patients, off-label dosing of NOACs was seen in only 6.6% of patients, most often underdosing. In this study, determinants of off-label dosing were age, renal function, weight, anaemia, active malignancy, and concomitant use of antiplatelets.

ICD-implantation guidelines versus clinical practice: a prospective study of out-of-hospital cardiac arrest survivors.

AIMS: The aim of this study was prospectively to compare clinical practice of implantable cardioverter defibrillator (ICD) use with current guidelines in out-of-hospital cardiac arrest (OHCA) survivors. METHODS AND RESULTS: From January 2000 till March 2002, 70 consecutive patients (pts) discharged from 15 hospitals after OHCA, with ventricular fibrillation (VF) as initial rhythm were included. Documentation of diagnosis, left ventricular function, ischaemia, electrophysiological studies (EPS), and decisions regarding ICD implantation were obtained from medical records. An expert committee compared these data with current guidelines. According to these guidelines 18 pts (26%) had an ICD indication and received an ICD while 37 pts (53%) had no indication and did not receive an ICD. In 13 pts without acute myocardial infarction insufficient diagnostic procedures were performed to permit a decision on ICD indication, hence no ICD was implanted. Two pts had an ICD indication but did not receive an ICD. During the follow-up with duration of 25 months (range 12-38 months), two sudden deaths occurred in the group of pts without an ICD. Of the pts with an ICD, 4 pts (22%) were reported to have received one or more shocks for VT/VF. CONCLUSION: In at least 21% of OHCA survivors, insufficient diagnostic procedures concerning the indication for ICD implantation were performed or no ICD was implanted when indicated, despite clear guidelines. In particular, there was no proof of ischaemia prior to revascularization and no confirmation of the absence of ischaemia and EPS thereafter. Clinicians should be guided better in evaluating pts after OHCA concerning the indication for ICD implantation, especially when a transient of reversible condition was present or when treatment was sufficiently established safely to refrain from ICD implantation.

Is fitness training always good for your health?

This case report illustrates the significance of biomechanical forces, such as static exercise as a precipitating factor for plaque rupture resulting in coronary dissection and secondary thrombus formation, as documented by angiography in this particular patient.