Oral anticoagulation (OAC) with either new oral anticoagulants (NOACs) or Vitamin-K antagonists (VKAs) is recommended by guidelines for patients with atrial fibrillation (AF) and a moderate to high risk of stroke. Based on a claims-based data set the aim of this study was to quantify the stroke-risk dependent OAC utilization profile of German AF patients and possible causes of OAC under-use. Our claims-based data set was derived from two German statutory health insurance funds for the years 2007-2010. All prevalent AF-patients in the period 2007-2009 were included. The OAC-need in 2010 was assumed whenever a CHADS2- or CHA2DS2-VASC-score was >1 and no factor that disfavored OAC use existed. Causes of OAC under-use were analyzed using multivariate logistic regression. 108,632 AF-prevalent patients met the inclusion criteria. Average age was 75.43 years, average CHA2DS2-VASc-score was 4.38. OAC should have been recommended for 56.1/62.9 % of the patients (regarding factors disfavouring VKA/NOAC use). For 38.88/39.20 % of the patient-days in 2010 we could not observe any coverage by anticoagulants. Dementia of patients (OR 2.656) and general prescription patterns of the treating physician (OR 1.633) were the most important factors increasing the risk of OAC under-use. Patients who had consulted a cardiologist had a lower risk of being under-treated with OAC (OR 0.459). OAC under-use still seems to be one of the major challenges in the real-life treatment of AF patients. Our study confirms that both patient/disease characteristics and treatment environment/general prescribing behaviour of physicians may explain the OAC under-use in AF patients.

Summary: Tobacco consumption is one of the most important risk factors for cardiovascular disease. Despite all efforts to curb any form of smoking, the number of e-cigarette users is still rising more than tabacco smoking decreases. E-cigarettes are often advertised as less harmful than regular cigarettes and helpful for smoking cessation. But e-cigarettes are not risk-free and their use causes vascular damage. There is concern about long-term health risks of e-cigarettes or when non-smokers use them as first nicotine contact. Furthermore, their use for smoking cessation is discussed controversially. To optimize treatment and medical counselling of current smokers and e-cigarette users, we present an evidence-based overview of the most important issues of e-cigarette use from a vascular medicine point of view. The key messages are presented as a position statement of the German Society of Vascular Medicine and endorsed by the European Society of Vascular Medicine.

Venous thromboembolism (VTE) comprises deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT occurs at an incidence of 1/1,000 and risk factors include immobilization, hospitalization, surgery, thrombophilia and positive family history, cancer, pregnancy, and other hormonal effects. Commonly, clinical signs and symptoms for DVT are unreliable, especially in hospitalized patients, but the clinical assessment of the pretest probability, for example, with the Wells score, is an important component in the diagnostic algorithm, where compression ultrasound also plays a central role. Treatment of DVT aims to acutely prevent PE and short-term and long-term VTE recurrence and to avoid the long-term complication of the postthrombotic syndrome (PTS).The immediate, sufficient, and uninterrupted anticoagulation is the most important therapeutic modality in the treatment of DVT and is achieved with subcutaneous LMWH and overlapping use of vitamin K antagonists (VKA) as standard treatment. After the initial anticoagulation, a long-term anticoagulation is used to prevent recurrences. The duration of anticoagulation is determined by balancing the risk of recurrence against the risk for bleeding with VKA and also considering the patient's preference. In patients in whom anticoagulation could be discontinued, aspirin was shown to reduce the risk of VTE recurrence by one third compared to placebo.Novel (non-vitamin K antagonist) oral anticoagulants (NOACs) have been compared to the standard treatment in several large phase 3 trials in patients with VTE. NOACs, which are given at a fixed dose without coagulation monitoring, have been shown to be non-inferior to standard treatment with respect to recurrent VTE, but have consistently shown lower bleeding rates, in particular less intracerebral hemorrhages. Practical issues of NOACs have to be observed, including their label and dosing regimen, their effect on coagulation assays, periprocedural management, and management of bleeding complications.Long-term use of compression stockings has been shown to reduce the PTS in several independent trials and meta-analyses, but new interventional techniques are being introduced in order to further reduce the PTS, particularly in iliac vein thrombosis.Cancer patients suffering from VTE require special attention, as both their bleeding and recurrence risk is increased, and LMWH has been shown to be more effective than VKA. VKA and NOACs should also be avoided in pregnant women suffering from VTE; VKA can cause embryopathy and an increased risk of bleeding both for mother and child. Thus, LMWH is the anticoagulant treatment of choice in pregnant women.Upper-extremity deep vein thrombosis (UEDVT) has a somewhat different pathophysiology and complication rates compared to DVT of the lower extremities. Therefore, diagnostic and therapeutic management of UEDVT may differ from the standard treatment of DVT.

No abstract

No abstract