scholarly journals Management of Anticoagulation and Colonoscopy

2021 ◽  
Author(s):  
Michael O’Donnell ◽  
Seth A. Gross
Keyword(s):  
Cardiovascular Disease ◽  
High Risk ◽  
Antithrombotic Therapy ◽  
Controlled Trial ◽  
Low Risk ◽  
Antithrombotic Agents ◽  
Delayed Hemorrhage ◽  
Risk Patients ◽  
Cold Snare Polypectomy ◽  
Risk Of Hemorrhage

Abstract Purpose of review Patients undergoing colonoscopy frequently require antithrombotic therapy for underlying cardiovascular disease. Antithrombotic therapy increases the risk of bleeding during or after colonoscopy, particularly when more invasive procedures are required. However, the risk of thrombosis—with possibly devastating consequences—is increased if antithrombotic agents are held. This review will highlight existing data on the balance of procedural and patient risk factors to guide endoscopists on the management of periprocedural antithrombotic therapy. Recent findings Diagnostic colonoscopy has long been established to be low risk for hemorrhage even in patients on antithrombotic therapy, while colonoscopy with interventions—including polypectomy—is viewed as high risk requiring interruption of antithrombotic therapy when possible. Recent data, however, has challenged these practices and suggests that a more nuanced perspective may be necessary. For example, a recent randomly controlled trial found no difference in immediate or delayed hemorrhage between patients on dual antiplatelet therapy versus aspirin and placebo after polypectomy. Further, increasing data are emerging to suggest that small polypectomy (< 1 cm) is safe without interruption of anticoagulation with the use of cold snare polypectomy. Summary In patients undergoing colonoscopy, the risk of hemorrhage must be weighed against the risk of thrombosis in patients with cardiovascular disease on antithrombotic agents. In general, low-risk procedures do not require interruption of antithrombotic agents, while high-risk procedures in low-risk patients require holding antithrombotic therapy. High-risk procedures in high-risk patients require individualized decision-making with increasing data helping to support which procedures can safely be performed.

scholarly journals Pre-existing Cardiovascular Disease in United States Population at High Risk for Severe COVID-19 Infection

2020 ◽  
Author(s):  
Adnan I Qureshi
Keyword(s):  
United States ◽  
Risk Factors ◽  
Cardiovascular Disease ◽  
At Risk ◽  
High Risk ◽  
Low Risk ◽  
Chronic Obstructive ◽  
Moderate Risk ◽  
High Risk Patients ◽  
Risk Patients

Background and Purpose There is increasing recognition of a relatively high burden of pre-existing cardiovascular disease in Corona Virus Disease 2019 (COVID 19) infected patients. We determined the burden of pre-existing cardiovascular disease in persons residing in United States (US) who are at risk for severe COVID-19 infection. Methods Age (60 years or greater), presence of chronic obstructive pulmonary disease, diabetes, mellitus, hypertension, and/or malignancy were used to identify persons at risk for admission to intensive care unit, or invasive ventilation, or death with COVID-19 infection. Persons were classified as low risk (no risk factors), moderate risk (1 risk factor), and high risk (two or more risk factors present) using nationally representative sample of US adults from National Health and Nutrition Examination Survey 2017 and 2018 survey. Results Among a total of 5856 participants, 2386 (40.7%) were considered low risk, 1325 (22.6%) moderate risk, and 2145 persons (36.6%) as high risk for severe COVID-19 infection. The proportion of patients who had pre-existing stroke increased from 0.6% to 10.5% in low risk patients to high risk patients (odds ratio [OR]19.9, 95% confidence interval [CI]11.6-34.3). The proportion of who had pre-existing myocardial infection (MI) increased from 0.4% to 10.4% in low risk patients to high risk patients (OR 30.6, 95% CI 15.7-59.8). Conclusions A large proportion of persons in US who are at risk for developing severe COVID 19 infection are expected to have pre-existing cardiovascular disease. Further studies need to identify whether targeted strategies towards cardiovascular diseases can reduce the mortality in COVID-19 infected patients.

scholarly journals Protocol for a multinational risk-stratified randomised controlled trial in paediatric Crohn’s disease: methotrexate versus azathioprine or adalimumab for maintaining remission in patients at low or high risk for aggressive disease course

BMJ Open ◽  
2020 ◽  
Vol 10 (7) ◽  
pp. e034892
Author(s):  
Rachel E Harris ◽  
Marina Aloi ◽  
Lissy de Ridder ◽  
Nicholas M Croft ◽  
Sibylle Koletzko ◽  
...  
Keyword(s):  
High Risk ◽  
Randomised Controlled Trial ◽  
Controlled Trial ◽  
Risk Groups ◽  
Low Risk ◽  
High Risk Patients ◽  
Link Type ◽  
Risk Patients ◽  
Randomised Controlled ◽  
Paediatric Crohn’S Disease

IntroductionImmunomodulators such as thiopurines (azathioprine (AZA)/6-mercaptopurine (6MP)), methotrexate (MTX) and biologics such as adalimumab (ADA) are well established for maintenance of remission within paediatric Crohn’s disease (CD). It remains unclear, however, which maintenance medication should be used first line in specific patient groups.AimsTo compare the efficacy of maintenance therapies in newly diagnosed CD based on stratification into high and low-risk groups for severe CD evolution; MTX versus AZA/6MP in low-risk and MTX versus ADA in high-risk patients. Primary end point: sustained remission at 12 months (weighted paediatric CD activity index ≤12.5 and C reactive protein ≤1.5 fold upper limit) without relapse or ongoing requirement for exclusive enteral nutrition (EEN)/steroids 12 weeks after treatment initiation.Methods and analysisREDUCE-RISK in CD is an international multicentre open-label prospective randomised controlled trial funded by EU within the Horizon2020 framework (grant number 668023). Eligible patients (aged 6–17 years, new-onset disease receiving steroids or EEN for induction of remission for luminal ± perianal CD are stratified into low and high-risk groups based on phenotype and response to induction therapy. Participants are randomised to one of two treatment arms within their risk group: low-risk patients to weekly subcutaneous MTX or daily oral AZA/6MP, and high-risk patients to weekly subcutaneous MTX or fortnightly ADA. Patients are followed up for 12 months at prespecified intervals. Electronic case report forms are completed prospectively. The study aims to recruit 312 participants (176 low risk; 136 high risk).Ethics and disseminationClinicalTrials.gov Identifier: (NCT02852694), authorisation and approval from local ethics committees have been obtained prior to recruitment. Individual informed consent will be obtained prior to participation in the study. Results will be published in a peer-reviewed journal with open access.Trial registration numberNCT02852694; Pre-results.

Five-year treat-to-target outcomes after methotrexate induction therapy with or without other csDMARDs and temporary glucocorticoids for rheumatoid arthritis in the CareRA trial

2021 ◽  
pp. annrheumdis-2020-219825
Author(s):  
Veerle Stouten ◽  
René Westhovens ◽  
Sofia Pazmino ◽  
Diederik De Cock ◽  
Kristien Van der Elst ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
High Risk ◽  
Disease Activity ◽  
Controlled Trial ◽  
Health Assessment ◽  
Low Risk ◽  
Treat To Target ◽  
Longitudinal Models ◽  
High Risk Patients ◽  
Risk Patients

ObjectivesTo compare outcomes of different treatment schedules from the care in early rheumatoid arthritis (CareRA) trial over 5 years.MethodsPatients with RA completing the 2-year CareRA randomised controlled trial were eligible for the 3-year observational CareRA-plus study. 5-year outcomes after randomisation to initial methotrexate (MTX) monotherapy with glucocorticoid bridging (COBRA-Slim) were compared with MTX step-up without glucocorticoids or conventional synthetic disease-modifying antirheumatic drug (DMARD) combinations with glucocorticoid bridging, per prognostic patient group. Disease activity (Disease Activity Score based on 28 joints calculated with C reactive protein (DAS28-CRP)) and functionality (Health Assessment Questionnaire (HAQ)) were compared between treatment arms using longitudinal models; safety and drug use were detailed.ResultsOf 322 eligible patients, 252 (78%) entered CareRA-plus, of which 203 (81%) completed the study. Treatments for high-risk patients resulted in comparable DAS28-CRP (p=0.539) and HAQ scores over 5 years (p=0.374). Low-risk patients starting COBRA-Slim had lower DAS28-CRP (p<0.001) and HAQ scores (p=0.041) than those starting only on MTX. At study completion, 114/203 (56%) patients never had their original DMARD therapy intensified, with comparable rates between all treatments. Safety was comparable between treatments in high-risk patients. In low-risk patients, there were 18 adverse events in 10 COBRA-Slim and 36 in 17 patients treated with initial MTX monotherapy (p=0.048). Over 5 years, 22% of patients initiated biologics, 25% took glucocorticoids for >3 months and 17% for >6 months outside the bridging period.ConclusionsAll intensive treatments with glucocorticoids bridging demonstrated excellent 5 year outcomes. Initiating COBRA-Slim was comparably effective as more complex treatments for high-risk patients with early RA and more effective than initial MTX monotherapy for low-risk patients with limited need for biologics and chronic glucocorticoid use.

scholarly journals 30-DAY READMISSION IN PATIENTS WITH CARDIOVASCULAR DISEASE: DO PATIENTS KNOW THEIR RISK BEFORE DISCHARGE?

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S901-S901
Author(s):  
Hanzhang Xu ◽  
Heather R Farmer ◽  
Bradi Granger ◽  
Matthew Dupre
Keyword(s):  
Cardiovascular Disease ◽  
Older Adults ◽  
High Risk ◽  
Perceived Risk ◽  
The United States ◽  
Low Risk ◽  
Logistic Regression Models ◽  
Self Rated Health ◽  
Risk Patients ◽  
Heart Center

Abstract Cardiovascular disease (CVD) is the leading cause of disability and death in the United States, and older adults with CVD are at a high risk of readmission after discharge. This study examined whether patients’ perceived risk of readmission at discharge was associated with actual 30-day readmissions in patients with CVD. A standardized survey and electronic health records (EHR) were used to collect sociodemographic, psychosocial, behavioral, and clinical data on patients admitted to the Duke Heart Center (n=730). Prior to discharge, patients were asked their perceived likelihood of returning to the hospital for an unplanned/emergency visit within 30-days. Logistic regression models were used to examine all-cause 30-day readmission among patients who perceived low versus high readmission risk. Nearly 1-in-3 patients (31.4%) perceived high-risk of readmission at the time of discharge. Life stressors, poor self-rated health, and ADL limitations were associated with perceptions of high-risk. Patients who perceived high-risk had significantly higher subsequent readmissions compared with low-risk (23.3% vs. 15.6% p=0.016). Among patients who perceived low-risk of readmission, those who were widowed, had inadequate health literacy, and reported difficulty accessing care exhibited a higher likelihood of being readmitted. In those perceiving a high-risk, nonwhites and those with poor self-rated health, difficulty accessing care, and prior hospitalizations in the past year were significantly more likely to be readmitted. These findings have important implications for identifying CVD patients at high risk of readmission within 30 days after discharge, particularly older adults who may lack adequate resources (e.g., social support, literacy, access to care).

scholarly journals Echocardiography and EuroSCORE II for the stratification of low-gradient severe aortic stenosis and preserved left ventricular ejection fraction

2021 ◽  
Author(s):  
Yan Fan ◽  
Hong Shen ◽  
Brandon Stacey ◽  
David Zhao ◽  
Robert J. Applegate ◽  
...  
Keyword(s):  
High Risk ◽  
Left Ventricular Ejection Fraction ◽  
Risk Group ◽  
Severe Aortic Stenosis ◽  
Left Ventricular ◽  
High Risk Group ◽  
Low Risk ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Risk Patients

AbstractThe purpose of this study was to explore the utility of echocardiography and the EuroSCORE II in stratifying patients with low-gradient severe aortic stenosis (LG SAS) and preserved left ventricular ejection fraction (LVEF ≥ 50%) with or without aortic valve intervention (AVI). The study included 323 patients with LG SAS (aortic valve area ≤ 1.0 cm2 and mean pressure gradient < 40 mmHg). Patients were divided into two groups: a high-risk group (EuroSCORE II ≥ 4%, n = 115) and a low-risk group (EuroSCORE II < 4%, n = 208). Echocardiographic and clinical characteristics were analyzed. All-cause mortality was used as a clinical outcome during mean follow-up of 2 ± 1.3 years. Two-year cumulative survival was significantly lower in the high-risk group than the low-risk patients (62.3% vs. 81.7%, p = 0.001). AVI tended to reduce mortality in the high-risk patients (70% vs. 59%; p = 0.065). It did not significantly reduce mortality in the low-risk patients (82.8% with AVI vs. 81.2%, p = 0.68). Multivariable analysis identified heart failure, renal dysfunction and stroke volume index (SVi) as independent predictors for mortality. The study suggested that individualization of AVI based on risk stratification could be considered in a patient with LG SAS and preserved LVEF.

scholarly journals Very similar cardiometabolic profile in the moderate and high cardiovascular risk classes: a population-based study

2021 ◽  
Vol 28 (Supplement_1) ◽  
Author(s):  
M Chlabicz ◽  
J Jamolkowski ◽  
W Laguna ◽  
P Sowa ◽  
M Paniczko ◽  
...  
Keyword(s):  
Insulin Resistance ◽  
Cardiovascular Disease ◽  
Cardiovascular Risk ◽  
High Risk ◽  
Population Based ◽  
Low Risk ◽  
Public Institution ◽  
Population Based Study ◽  
The Metabolic Syndrome ◽  
Cardiometabolic Profile

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Medical University of Bialystok, Poland Background Cardiovascular disease (CVD) is a major, worldwide problem and remain the dominant cause of premature mortality in the word. Simultaneously the metabolic syndrome is a growing problem. The aim of this study was to investigate the cardiometabolic profile among cardiovascular risk classes, and to estimate CV risk using various calculators. Methods The longitudinal, population-based study, was conducted in 2017-2020. A total of 931 individuals aged 20-79 were included. Anthropometric and biochemical profiles were measured according to a standardized protocols. The study population was divided into CV risk classes according to the latest recommendation. Comparisons variables between subgroups were conducted using Dwass-Steele-Critchlow-Fligner test. To estimate CV risk were used: the  Systematic Coronary Risk Estimation system, Framingham Risk Score and LIFEtime-perspective model for individualizing CardioVascular Disease prevention strategies in apparently healthy people (LIFE-CVD). Results The mean age was 49.1± 15.5 years, 43.2% were male. Percentages of low-risk, moderate-risk, high-risk and very-high CV risk were 46.1%, 22.8%, 13.5%, 17.6%, respectively. Most of the analyzed anthropometric, body composition and laboratory parameters did not differ between the moderate and high CV risk participants, whereas the low risk group differed significantly. In the moderate and high-risk groups, abdominal distribution of adipose tissue dominated with significantly elevated parameters of insulin resistance. Interestingly, estimating lifetime risk of myocardial infarction, stroke or CV death using LIFE-CVD calculator yielded similar results in moderate and high CV risk classes. Conclusion The participants belonging to moderate and high CV risk classes have a very similar unfavorable cardiometabolic profile which may result in the similar lifetime CV risk. This may imply the need for more aggressive pharmacological and non-pharmacological management of CV risk factors in the moderate CV risk population. It would be advisable to consider combining the moderate and high risk classes into one high CV risk class, or it may be worth adding one of the parameters of abdominal fat distribution to the CV risk calculators as an expression of increased insulin resistance. Abstract Figure 1.

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