Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is the most frequent sustained arrhythmia. After restoration of normal sinus rhythm, the recurrence rate of AF is high. Antiarrhythmic drugs have been widely used to prevent recurrence, but the effect of these drugs on mortality and other clinical outcomes is unclear. OBJECTIVES: To determine, in patients who recovered sinus rhythm after AF, the effect of long-term treatment with antiarrhythmic drugs on death, stroke and embolism, adverse effects, pro-arrhythmia and recurrence of AF. If several antiarrhythmics were effective our secondary aim was to compare them. SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Libary (Issue 2, 2005), MEDLINE (1950 to May 2005) and EMBASE (1966 to May 2005) were searched. The reference lists of retrieved articles, recent reviews and meta-analyses were checked. No language restrictions were applied. SELECTION CRITERIA: Two independent reviewers selected randomised controlled trials comparing any antiarrhythmic with a control (no treatment, placebo or drugs for rate control) or with another antiarrhythmic, in adults who had AF and in whom sinus rhythm was restored. Post-operative AF was excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed quality and extracted data, on an intention-to-treat basis. Disagreements were resolved by discussion. Studies were pooled, if appropriate, using Peto odds ratio (OR). MAIN RESULTS: 45 studies met inclusion criteria, comprising 12,559 patients. All results were calculated at 1 year of follow-up. Class IA drugs (disopyramide, quinidine) were associated with increased mortality compared with controls (OR 2.39, 95% confidence interval (CI) 1.03 to 5.59, P = 0.04, number needed to harm (NNH) 109, 95% CI 34 to 4985). Other antiarrhythmics did not modify mortality. Several class IA (disopyramide, quinidine), IC (flecainide, propafenone) and III (amiodarone, dofetilide, dronedarone, sotalol) drugs significantly reduced recurrence of AF (OR 0.19 to 0.60, number needed to treat 2 to 9), but all increased withdrawals due to adverse affects (NNH 17 to 36) and all but amiodarone and propafenone increased pro-arrhythmia (NNH 17 to 119). AUTHORS' CONCLUSIONS: Several class IA, IC and III drugs are effective in maintaining sinus rhythm but increase adverse events, including pro-arrhythmia, and disopyramide and quinidine are associated with increased mortality. Any benefit on clinically relevant outcomes (embolisms, heart failure, mortality) remains to be established.

Bleeding risk of antiplatelet drugs compared with oral anticoagulants in older patients with atrial fibrillation: a systematic review and meta-analysis.

Essentials Hemorrhagic risk of antiplatelet drugs is generally thought to be lower than anticoagulants. We systematically reviewed trials comparing antiplatelet and anticoagulant drugs in older patients. Overall, the risk of major bleeding was similar with antiplatelet and with anticoagulant drugs. In elderly patients, risks and benefits of antiplatelet drugs should be carefully weighted. SUMMARY: Background The hemorrhagic risk of antiplatelet drugs in older patients could be higher than is usually assumed. Objective To compare the bleeding risk of antiplatelet drugs and oral anticoagulants in elderly patients. Methods We carried out a systematic review and meta-analysis. We searched PubMed, EMBASE and the Cochrane Library up to January 2016 for randomized and non-randomized controlled trials (RCTs) and parallel cohorts comparing antiplatelet drugs and oral anticoagulants in patients aged 65 years or older. Two independent authors assessed studies for inclusion. The pooled relative risk (RR) of major bleeding was estimated using a random model. Results Seven RCTs (4550 patients) and four cohort studies (38 649 patients) met the inclusion criteria. The risk of major bleeding when on aspirin or clopidogrel was equal to that when on warfarin in RCTs (RR, 1.01; 95% confidence interval (95% CI), 0.69-1.48; moderate-quality evidence), lower than when on warfarin in non-randomized cohort studies (RR, 0.87; 95% CI, 0.77-0.99; low-quality evidence) and not different when all studies were combined (RR, 0.86; 95% CI, 0.73-1.01). Bleeding of any severity (RR, 0.70; 95% CI, 0.57-0.86) and intracranial bleeding (RR, 0.46; 95% CI, 0.30-0.73) were less frequent with antiplatelet drugs than with warfarin. All-cause mortality was similar (RR, 0.99). Subgroup analysis suggested that major bleeding might be higher with warfarin than with aspirin in patients over 80 years old. Conclusion Elderly patients treated with aspirin or clopidogrel suffer less any-severity bleeding but have a risk of major bleeding similar to that of oral anticoagulants, with the exception of intracranial bleeding.

[Anticoagulation use in older patients with atrial fibrillation in a cardio-geriatric unit]. / Utilisation des anticoagulants chez les patients âgés atteints de fibrillation atriale dans un service de cardiogériatrie.

OBJECTIVE: Older people with atrial fibrillation (AF) have an increased embolic risk but they are less frequently treated with anticoagulants. We wanted to assess our current practice in a specialized service. PATIENTS AND METHODS: Prospective observational study including all patients older than 75 years admitted during 3 months in a cardio-geriatric unit. Patients' embolic risk (CHADS2 score), hemorrhagic risk (HAS-BLED score), anti-thrombotic treatment at arrival and any modification afterwards, were analyzed. RESULTS: Thirty-four patients were included (mean age: 85 years). AF was known in 28 patients, of whom 20 were under anticoagulant therapy at their admission (10 fluindione, 9 warfarine, 1 dabigatran), 4 received aspirin and 4 no anti-thrombotic treatment. Only the treatment of one of these patients was modified, replacing aspirin by warfarin. AF was newly diagnosed in 6 patients, of whom anticoagulation were initiated in 4 patients (3 warfarine, 1 fluindione). Finally, 9 patients (26%) left the hospital without anticoagulant treatment. Reasons given by their attending doctors were: advanced dementia (4 patients), estimated excessive hemorrhagic risk (4), and estimated low embolic risk (1). There was a clear trend to initiate anticoagulation more frequently in patients with a newly diagnosed AF (P=0.09) CONCLUSIONS: A substantial proportion of older patients with AF do not receive anticoagulant therapy, even after having been admitted to a specialized service. Advanced dementia and hemorrhagic risk are the reasons most frequently given for that.

Wrist Actigraphy: A Simple Way to Record Motor Activity in Elderly Patients with Dementia and Apathy or Aberrant Motor Behavior.

INTRODUCTION: In dementia, behavioral psychological symptoms are frequent and variable. OBJECTIVE: To assess the value of wrist actigraphy as a measure of disorder in motor behavior especially apathy, aberrant motor behavior, agitation and anxiety. METHODS: Cross sectional observational study of consecutive patients older than 75 years admitted to an intermediate care unit of a geriatric hospital ward during a two-year period. Psycho behavioral symptoms and cognitive status were assessed using the NPI scale and MMSE and diagnosis of dementia was done using DSMIV criteria. A wrist actigraph was worn for 10 days to record motor activity, sleep time and number of periods of sleep. RESULTS: 183 patients were included. Among patients with dementia, a significant decrease in motor activity was recorded in those with apathy from 9h to 12h and 18h to 21h (p <0.05) and in those with anxiety from 21h to 24h (p <0.05). Aberrant motor behavior in dementia was associated with a significant increase in motor activity from 21h to 24h (p <0.01). Agitation was not associated with a significant differences in motor activity. CONCLUSIONS: Wrist actigraphy can be used to record motor activity in elderly patients with dementia especially in those with apathy and aberrant motor behavior.

Active chest compression-decompression for cardiopulmonary resuscitation.

BACKGROUND: Active compression-decompression cardiopulmonary resuscitation (ACDR CPR) uses a hand-held suction device, applied mid sternum, to compress the chest then actively decompress the chest after each compression. Randomised controlled trials on use of active compression decompression cardiopulmonary resuscitation have results which are discordant. OBJECTIVES: To determine clinical effects and safety of active compression-decompression cardiopulmonary resuscitation compared with standard manual cardiopulmonary resuscitation (STR). SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE. Last search was conducted in January 2004. We checked the reference list of retrieved articles and contacted enterprises manufacturing the active decompression devices. SELECTION CRITERIA: All randomised or quasi-randomised studies comparing active compression-decompression cardiopulmonary resuscitation compared with standard manual cardiopulmonary resuscitation in adults with a cardiac arrest who received cardiopulmonary resuscitation by a trained medical or paramedical team. DATA COLLECTION AND ANALYSIS: Data were independently extracted. All data were analysed on an intention-to-treat basis. The authors of the primary studies were contacted for more information when needed. Studies were cumulated, if appropriate, and pooled relative risk (RR) estimated. Subgroup analysis according to setting (out of hospital or in hospital) and attending team composition (with physician or paramedic only) were predefined. MAIN RESULTS: Ten trials were included: eight were in out-of-hospital settings, one set in-hospital only and one had both in-hospital and out-of-hospital components. Allocation concealment was adequate in 4 trials. The two in-hospital studies were very different in quality (A and C) and size (773 and 53 patients). Both found no differences between ACDR CPR and STR in any outcome. Trials conducted in out-of-hospital settings cumulated 4162 patients. There were no differences between ACDR CPR and STR for mortality either immediately (RR 0.98 [95% CI 0.94 - 1.03]) or at hospital discharge (RR 0.99 [95% CI 0.98 - 1.01]). The pooled RR of neurological impairment, any severity, was 1.71 [95% CI 0.90 - 3.25], with a non-significant trend to more frequent severe neurological damage in survivors of ACDR CPR (RR 3.11 [95% CI 0.98 - 9.83]). However, assessment of neurological outcome was limited and there were few patients with neurological damage. There was no difference between ACDR CPR and STR with regard complications such as rib or sternal fractures, pneumothorax or hemothorax (RR 1.09 [95% CI 0.86 - 1.38]). Skin trauma and ecchymosis were more frequent with ACDR CPR. REVIEWERS' CONCLUSIONS: Active chest compression-decompression in patients with cardiac arrest is not associated with clear benefit.

Active chest compression-decompression for cardiopulmonary resuscitation.

BACKGROUND: Active compression-decompression cardiopulmonary resuscitation (ACD CPR) uses a hand-held suction device, applied mid sternum, to compress the chest then actively decompress the chest after each compression. Randomised controlled trials on use of active compression decompression cardiopulmonary resuscitation have results which are discordant. OBJECTIVES: To determine clinical effects and safety of active compression-decompression cardiopulmonary resuscitation compared with standard manual cardiopulmonary resuscitation (STR). SEARCH STRATEGY: We searched the Cochrane Heart Group Specialised register (April 2001), the Cochrane library, MEDLINE and EMBASE. We checked the reference list of retrieved articles and contacted enterprises manufacturing the active decompression devices. SELECTION CRITERIA: All randomized or quasi-randomized studies comparing active compression-decompression cardiopulmonary resuscitation compared with standard manual cardiopulmonary resuscitation in adults with a cardiac arrest who received cardiopulmonary resuscitation by a trained medical or paramedical team. DATA COLLECTION AND ANALYSIS: Data were independently extracted. All data were analysed on an intention-to-treat basis. The authors of the primary studies were contacted for more information when needed. Studies were cumulated, if appropriate, and pooled relative risk (RR) estimated. Subgroup analysis according to setting (out of hospital or in hospital) and attending team composition (with physician or paramedic only) were predefined. MAIN RESULTS: Twelve trials were included: 10 were in out-of-hospital settings, one set in-hospital only and one had both in-hospital and out-of-hospital components. Allocation concealment was adequate in 4 trials. The two in-hospital studies were very different in quality (A and C) and size (773 and 53 patients). Both found no differences between ACD CPR and STR in any outcome. Trials conducted in out-of-hospital settings cumulated 4162 patients. There were no differences between ACD CPR and STR for mortality either immediately (RR 0.98 [95% CI 0.94 - 1.03]) or at hospital discharge (RR 0.99 [95% CI 0.98 - 1.01]). The pooled RR of neurological impairment, any severity, was 1.71 [95% CI 0.90 - 3.25], with a non-significant trend to more frequent severe neurological damage in survivors of ACD CPR (RR 3.11 [95% CI 0.98 - 9.83]). However, assessment of neurological outcome was limited and there were few patients with neurological damage. There was no difference between ACD CPR and STR with regard complications such as rib or sternal fractures, pneumothorax or hemothorax (RR 1.09 [95% CI 0.86 - 1.38]). Skin trauma and ecchymosis were more frequent with ACD CPR. REVIEWER'S CONCLUSIONS: Active chest compression-decompression in patients with cardiac arrest is not associated with clear benefit.

Active chest compression-decompression for cardiopulmonary resuscitation.

BACKGROUND: Active compression-decompression cardiopulmonary resuscitation (ACDR CPR) uses a hand-held suction device, applied mid sternum, to compress the chest then actively decompress the chest after each compression. Randomised controlled trials on use of active compression decompression cardiopulmonary resuscitation have results which are discordant. OBJECTIVES: To determine clinical effects and safety of active compression-decompression cardiopulmonary resuscitation compared with standard manual cardiopulmonary resuscitation (STR). SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (May 2002), MEDLINE and EMBASE. We checked the reference list of retrieved articles and contacted enterprises manufacturing the active decompression devices. SELECTION CRITERIA: All randomised or quasi-randomised studies comparing active compression-decompression cardiopulmonary resuscitation compared with standard manual cardiopulmonary resuscitation in adults with a cardiac arrest who received cardiopulmonary resuscitation by a trained medical or paramedical team. DATA COLLECTION AND ANALYSIS: Data were independently extracted. All data were analysed on an intention-to-treat basis. The authors of the primary studies were contacted for more information when needed. Studies were cumulated, if appropriate, and pooled relative risk (RR) estimated. Subgroup analysis according to setting (out of hospital or in hospital) and attending team composition (with physician or paramedic only) were predefined. MAIN RESULTS: Twelve trials were included: 10 were in out-of-hospital settings, one set in-hospital only and one had both in-hospital and out-of-hospital components. Allocation concealment was adequate in 4 trials. The two in-hospital studies were very different in quality (A and C) and size (773 and 53 patients). Both found no differences between ACDR CPR and STR in any outcome. Trials conducted in out-of-hospital settings cumulated 4162 patients. There were no differences between ACDR CPR and STR for mortality either immediately (RR 0.98 [95% CI 0.94 - 1.03]) or at hospital discharge (RR 0.99 [95% CI 0.98 - 1.01]). The pooled RR of neurological impairment, any severity, was 1.71 [95% CI 0.90 - 3.25], with a non-significant trend to more frequent severe neurological damage in survivors of ACDR CPR (RR 3.11 [95% CI 0.98 - 9.83]). However, assessment of neurological outcome was limited and there were few patients with neurological damage. There was no difference between ACDR CPR and STR with regard complications such as rib or sternal fractures, pneumothorax or hemothorax (RR 1.09 [95% CI 0.86 - 1.38]). Skin trauma and ecchymosis were more frequent with ACDR CPR. REVIEWER'S CONCLUSIONS: Active chest compression-decompression in patients with cardiac arrest is not associated with clear benefit.

[Intravascular lymphomatosis. Report of a case and brief review of the disease]. / Linfomatosis intravascular. Presentación de un caso y breve revisión de la entidad.

Intravascular lymphomatosis (IL), previously called "malignant angioendotheliomatosis", is a rare neoplastic disease in which mononuclear cells, of demonstrated lymphoid origin, proliferate in small blood vessels lumen. Any organ may be involved, standing out general status affectation, skin and central nervous system (CNS) because their frequency. A case of this disease is reported, who presented general impairment with prolonged fever, abdominal pain and cutaneous arborescent telangiectasias as the most significant clinical data. It become fatal in a short time. It was clinically considered to be a sepsis and diagnosis was only obtained in post-mortem study. This study revealed multiple organ infiltration by this neoplasm, with the notable exception of CNS. Immunohistochemical study confirmed the lymphoid origin of neoplastic cells. The main characteristics of IL are reviewed.

Description of liver disease in a cohort of HIV/HBV coinfected patients.

BACKGROUND: Factors associated with advanced liver disease have been incompletely explored in HIV/HBV coinfected patients. OBJECTIVES: To describe liver-related morbidity, mortality, and related risk factors, in HIV/HBV coinfected patients. STUDY DESIGN: We followed-up 107 consecutive HIV/HBV coinfected patients. Clinical, biological and virological data were collected every 3 months. Liver-related mortality and a composite score were used to define advanced liver disease. RESULTS: The patients were mainly sub-Saharan Africans (61%) or Europeans (33%). Forty-four percent of patients had liver biopsy, 78% of patients received lamivudine. Advanced liver disease (ALD) was diagnosed in 19/107 patients during follow-up (mean 4.8 years): 10 extensive fibrosis, 5 cirrhosis, 3 hepatocellular carcinoma resulting from cirrhosis, and 1 fulminant hepatitis following lamivudine withdrawal. Eleven patients died, 4 from HBV-related liver disease. In univariate analysis, male gender, mean HIV and HBV viral loads, and raised AST/ALT transaminases were associated with increased risk of ALD. The strongest associations, in a multivariate model, were mean AST transaminase and cumulated time receiving lamivudine, with a favourable effect. 39% of patients with increased mean AST presented with ALD, versus 7% when normal mean AST (Relative Risk 5.5). CONCLUSIONS: During HIV/HBV coinfection, transaminase levels are strongly associated with ALD. Normal mean AST has a high negative predictive value, contrary to previously reported data in HIV/HCV patients.