The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in Asia and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701).
Natriuretic peptides were discovered in 50–70s of the XX century. BNP was more diagnostically and prognostically significant, as it is secreted directly into the ventricles of the heart. The studies demonstrated a high predictive value of increasing the level of BNP in acute decompensation of heart failure and in patients with chronic heart failure in a study of Val-HeFT. It was demonstrated that monitoring the level of NT-proBNP can be used for the selection of optimal therapy, affect the course and outcome of the disease, and reduce the cost of treatment. The next step in learning BNP was to undertake attempts of their use in the therapy of heart failure. Long-term therapy BNP (drug nesiritide) improved left ventricular remodelling in patients with stable heart failure. Currently the definition of the levels of BNP and NT-proBNP is used for the diagnosis and management of patients with heart failure.
ВведениеОтечественные и зарубежные кардиологи разделяют мнение о том, что без адекватной антикоагулянтной те-рапии у больных с фибрилляцией предсердий (ФП) не-возможно снизить частоту такого тяжелейшего и по-тенциально фатального осложнения, как кардиоэм-болический инсульт.Вне зависимости от формы ФП (пароксизмальная, персистирующая, постоянная) при наличии 1 и более факторов риска, включенных в шкалу CHA 2 DS 2 -VASc, пациентам с ФП необходима неопределенно долгая те-рапия либо антагонистами витамина К (АВК), либо но-выми пероральными антикоагулянтами (НПА). Только в случае категорического нежелания пациентов при-нимать вышеуказанные препараты можно рассмотреть вопрос о назначении комбинации аспирин+клопидо-грел, либо, что гораздо менее эффективно, о моноте-рапии аспирином [1,2]. Новые пероральные антикоагулянтыДовольно много публикаций в последнее время было посвящено вопросам эффективности терапии НПА. К числу зарегистрированных и рекомендован-ных для профилактики инсультов и системных эмбо-лий у пациентов с ФП неклапанной этиологии из груп-пы НПА, являющихся реальной альтернативой вар-фарину, сейчас относятся прямой ингибитор тромбина дабигатран (RE-LY), а также пероральные ингибито-ры Ха фактора ривароксабан (ROCKET-AF) и апикса-бан (ARISTOTLE, AVERROES) [3][4][5]. К числу их основ-ных преимуществ следует отнести как минимум не меньшую, а для некоторых препаратов и большую эф-фективность при аналогичной или лучшей безопас-ности в сравнении со стандартной терапией варфа-рином. Этот аспект представляется особенно важным, поскольку, по данным литературы, около 40-60% па-циентов не получают антикоагулянтной терапии из-за страха развития тяжелых геморрагических осложне-ний на фоне приема варфарина -либо пациентов, либо их лечащих врачей. В то же время, медицинское сообщество выглядит довольно растерянным, когда за-дается вопросом: какой из НПА лучше? В отсутствие возможности получить результаты исследований с пря-мым сравнением данных препаратов (пожалуй, за ис-ключением данных регистров, но их интерпретацию также следует проводить с осторожностью), мы можем оперировать только статистическими выкладками в ре-зультате непрямых сравнений [6]. Не всегда такой под-ход можно признать адекватным хотя бы потому, что в вышеупомянутые исследования включались паци-енты с различным сердечно-сосудистым риском, трактовка конечных точек также была неодинако-вой. Тем не менее, тем, что допускает хотя бы саму воз-можность подобных сравнений, является факт, что во всех исследованиях в качестве препарата сравнения выступал варфарин.Перед проведением сопоставления скажем не-сколько слов о представителях класса новых перо-ральных антикоагулянтов и исследованиях, в которых они изучались. Сведения об авторах:Сулимов Виталий Андреевич -д.м.н., профессор, зав. кафедрой Проводится непрямое статистическое сравнение представителей класса новых пероральных антикоагулянтов с особым акцентом на их безопасности. Пероральный ингибитор Ха фактора апиксабан на данный момент может рассматриваться как препарат с очень хорошим профилем безопасно...
This article affects the problems of using NOAC in the most defenseless groups of patients with atrial fibrillation: those who have high bleeding and high thromboembolic risk and elderly. The focus is on comparison of effectiveness and safety of NOACs based on randomized clinical trials (RCT) and real-world data (RWD). The possible reasons for the different interpretation of the data of the RCT and the RWD are shown. Use of NOAC in reduced doses prescribing according to RCT and RWD are shown. Our own 13-month observation of patients 75 years and older with very high thromboembolic risk (CHA 2 DS 2-VASc-4,5 points) on rivaroxaban therapy are presented. Good efficacy and safety of full and reduced doses of rivaroxaban were demonstrated: only 2 episodes of small bleedings and no large bleedings (ISTH criteria) were detected as well as no thromboembolic events. Thus, even difficult patients with AF and comorbidity may be safely and effectively treated with NOACs taking into consideration integrated approach and correction of modifiable risk factors.
The article presents a clinical observation of the left atrial appendage thrombosis in a 51-year-old female patient with a paroxysmal form of nonvalvular atrial fibrillation which occurred despite long-term anticoagulant therapy with apixaban in a full dose (5 mg b.i.d.), and the patient’s management. The patient was admitted with recurrent symptomatic paroxysm for more than 48 hours, because of which, in accordance with the recommendations, transesophageal echocardiography was performed before an emergency rhythm restoration. Thrombus in the left atrial appendage 0.5×1.03 cm in size was detected. It was decided to refrain from the immediate restoration of the rhythm due to the very high risk of thromboembolic complications. In connection with the categorical refusal of the patient from warfarin, it was decided to replace apixaban with another direct oral anticoagulant – dabigatran 150 mg bid for a period of 4 weeks followed by performing a control transesophageal echocardiographic study. As a result, no thrombus was found on control echocardiography. The particularity of this observation is concomitant hypertrophic cardiomyopathy and diabetes mellitus type 1 in this patient.
The literature review discusses approaches to the treatment of patients with chronic heart failure and preserved ejection fraction (EF>50) – HFpEF. The impact of various groups of drugs on the prognosis and quality of life of patients in this cohort was assessed based on the results of randomized trials, systematic reviews and meta-analyses, clinical recommendations of recent years. To date, only sodium-glucose cotransporter-2 inhibitors unequivocally improve the quality of life and prognosis of patients with HFpEF. Angiotensin receptor – neprilysin inhibitors and mineralocorticoid receptor antagonists are effective in terms of prognosis and quality of life only in patients with HFpEF in combination with resistant hypertension. In patients with sinus rhythm, heart rate > 70 beats/min and concomitant coronary artery disease, a combination of bisoprolol and ivabradine may be considered. Diuretics are recommended for patients with HFpEF when there are signs of congestion and signs of decompensation. Other groups of drugs do not significantly affect the quality of life and prognosis of patients with HFpEF and can be prescribed to such patients only as part of planned therapy for the treatment of other concomitant cardiovascular diseases.
Atrial fibrillation (AF) is one of the most common heart rhythm disorders in the population. Researchers revealed a direct relationship between their incidence and a patient's age long ago. One of the most challenging issues of clinical practice in patients with AF is anticoagulant therapy used in the so-called very elderly patients aged 75 years and older when age itself is a risk factor for developing both thromboembolic and hemorrhagic events due to anticoagulants, regardless of the mechanism of action of the latter. However, scientific data regarding the treatment and prevention of thromboembolic events in elderly and senile patients with AF are very scarce and often uninformative. The data from the EURObservational Research Programme-Atrial Fibrillation Registry Pilot Phase (EORP-AF Pilot) and the randomized clinical studies RELY, ROCKET AF, ARISTOTLE, and AVERROES were analyzed to identify the most safe and most effective anticoagulant for elderly patients (over 75 years). Relying on the analyses of literature data, the authors propose an algorithm based on clinical characteristics for choosing the anticoagulant for patients older than 75 years.
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