Is dual therapy the correct strategy in frail elderly patients with atrial fibrillation and acute coronary syndrome?

Atrial fibrillation(AF)is a very common arrhythmia in clinical practice.Its incidence and prevalence are age-related and are growing in the last years.Age is a risk factor also for coronary artery disease(CAD),and with the evolution of preventive care,the first event(acute coronary syndrome(ACS)or percutaneous coronary intervention(PCI))takes place at a later age.If elderly patients with AF and CAD undergo ACS or PCI,they have indication to assume triple therapy.Triple therapy(oral anticoagulation(OAC)plus dual antiplatelet therapy(DAPT))exposes patients to high bleeding risk.In the last 10 years,several clinical trials have tested dual therapy(OAC plus single antiplatelet therapy)in AF patients who undergo ACS or elective PCI.WOEST trial has tested warfarin+clopidogrel against triple therapy.PIONEER AF-PCI trial has tested low-dose rivaroxaban+P2Y12 inhibitor or very low-dose rivaroxaban+DAPT against standard triple therapy with warfarin.RE-DUAL PCI trial has tested two doses of dabigatran+P2Y12 inhibitor against standard triple therapy with Warfarin.AUGUSTUS trial has tested apixaban against warfarin both in dual therapy with P2Y12 inhibitor and in triple therapy with a P2Y12 inhibitor and aspirin.ENTRUST-AF PCI,last published study,has tested edoxaban+P2Y12 inhibitor against triple therapy.All these trials show dual therapy reduces significantly bleeding risk than triple therapy.In this paper,we analyze these clinical trials to understand if dual therapy results can be applied to elderly patients and what is probably the better approach in elderly AF patients undergo to ACS or PCI.

Non-invasive stimulation techniques to relieve abdominal/pelvic pain: Is more always better?

Chronic abdominal and pelvic pain is a common condition that has significant impact on quality of life,and causes billions of dollars in direct and indirect costs.Emerging data suggest that transcranial direct current stimulation(t DCS),alone or in combination with transcutaneous electrical nerve stimulation(TENS),could be a promising therapeutic avenue to reduce chronic pain.The encouraging results coming from these studies prompted us to try combining TENS and t DCS in 4 of our patients who suffered from chronic abdominal/pelvic pain and to compare the effect with 5other patients who received TENS alone.Pain intensity was assessed with a visual analog scale before,during and after the stimulation.We observed that there was a slight decrease in pain which was similar in both patient groups(TENS alone and TENS combined with t DCS).These observations suggest that combining TENS and t DCS in patients suffering from chronic pelvic and/or abdominal pain produces no additional benefit,compared to TENS alone.Future studies,looking at the effect of several/consecutive TENS and t DCS sessions should be conducted.

Exercise Blood Pressure Response and Cardiometabolic Risk Factors in Middle Aged Women: A MONET Group Study

Objective: To investigate if an exaggerated peak exercise systolic blood pressure (peak ESBP) is associated with alteration of cardiometabolic risk factors and predict future resting hypertension in middle aged women. Methods: Data analysis was performed in 95 healthy normotensive premeno-pausal women at baseline and 84 after 5-year follow-up (age, 49.9 ± 1.9 years;BMI, 23.3 ± 2.2 kg/m2;resting BP, 117/73 ± 11.8/7.6 mmHg). Blood pressure was measured at rest and during a progressive exercise test on treadmill. Women were divided into two groups according to their peak ESBP <190 mmHg vs. ≥190 mmHg. Other outcome measures were: cardiorespiratory fitness (VO2 peak), body composition, body fat distribution and fasting plasma lipids, glucose and insulin levels. Results: 15% and 27% of women presented an exaggerated peak ESBP response (≥190 mmHg) at baseline and year 5 respectively. Linear mixed model repeated measures analysis revealed higher values of fasting glucose, resting systolic and diastolic BP in women with an exaggerated peak ESBP (≥190 mmHg) compared to women with a peak ESBP (<190 mmHg). No significant difference was observed between the two groups for VO2 peak, body composition and body fat distribution indices and other cardiometabolic risk factors. Finally, baseline peak ESBP was not a significant risk factor for future resting hypertension (OR: 2.96, 95%CI [0.48 - 18.12];P = 0.24). Conclusion: Our results, despite being non significant, are of great interest because in healthy and active premenopausal women, exaggerated peak ESBP is not predictive of future hypertension after 5-year follow-up throughout menopause transition.

Covariates of Disability-Profile Transitions in Older People Living at Home

The objective of this study was to explore the relationship of sociodemographic, clinical, and health-services use-related variables with transitions between disability-based profiles. In a longitudinal study of 1386 people aged 75 and over living in the community at baseline, disabilities were assessed annually for up to four years with the Functional Autonomy Measurement System (SMAF), which generates 14 Iso-SMAF profiles. These profiles are grouped into 4 disability states, which are predominant alterations in instrumental activities of daily living (IADLs), mobility, mental functions as well as severe and mixed disabilities. Continuous-time, multi-state Markov modeling was used to identify the factors associated with transitions made by older people between these states and to institutionalization and death. Greater age and receiving help for ADL were associated with four transitions, while altered cognitive functions and hospitalization were associated with three, all involving more decline or less recovery. From mild IADL profiles, men have a higher risk of transitioning to intermediate predominantly mental profiles, while women are at higher risk of transitioning to intermediate predominantly mobility profiles. Unmet needs are associated with deterioration, from mild IADL to intermediate predominantly mobility profiles. These results help understanding the complex progression of disabilities in older people.

Prognostic relevance of normocytic anemia in elderly patients affected by cardiovascular disease

BACKGROUND Anemia associated with cardiovascular diseases(CVD) is a common condition in older persons. Prevalence and prognostic role of anemia were extensively studied in patients with myocardial infarction(MI) or congestive heart failure(CHF) whereas limited data were available on patients with atrial fibrillation(AF). This study was conducted to assess the clinical prevalence and prognostic relevance of anemia in elderly patients affected by AF and other CVDs.METHODS A total of 866 elderly patients(430 men and 436 women, age: 65-98 years, mean age: 85 ± 10 years) were enrolled.Among these patients, 267 patients had acute non-ST-segment elevation MI(NSTEMI), 176 patients had acute CHF, 194 patients had acute AF and 229 patients were aged-matched healthy persons(CTR). All parameters were measured at the hospital admission and cardiovascular mortality was assessed during twenty-four months of follow-up.RESULTS The prevalence of anemia was higher in NSTEMI, CHF and AF patients compared to CTR subjects(50% vs. 15%, P <0.05), with normocytic anemia being the most prevalent type(90%). Adjusted mortality risk was higher in anemic patient versus non-anemic patient in all the groups of patients [NSTEMI: hazard ratio(HR) = 1.81, 95% CI: 1.06-2.13;CHF: HR = 2.49, 95% CI:1.31-4.75;AF: HR = 1.98, 95% CI: 1.01-3.88]. Decreased hemoglobin levels(P = 0.001) and high reticulocyte index(P = 0.023) were associated with higher mortality in CVD patients.CONCLUSIONS The significant associations between CVD and anemia and the prognostic relevance of anemia for elderly patients with CVD were confirmed in this study. The presence of anemia in AF patients is associated with a two-fold increased mortality risk compared with non-anemic AF patients. Low hemoglobin and high reticulocyte count independently predict mortality in elderly patients with CVD.