2 Minute Medicine Rewind October 23, 2017

Dual Antithrombotic Therapy with Dabigatran after PCI in Atrial Fibrillation

Patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI) typically receive warfarin and two antiplatelet drugs as part of the current standard of care. However, studies have shown that this approach is associated with an increased risk of major bleeding. In this multicenter randomized controlled trial, 2725 patients with atrial fibrillation undergoing PCI were randomized to receive triple therapy with warfarin, aspirin and either clopidogrel or ticagrelor, or dual therapy with dabigatran (110 mg twice daily or 150 mg twice daily) and either clopidogrel or ticagrelor, to investigate whether dual therapy is clinically inferior and associated with a reduced incidence of bleeding. Patients were followed for major or clinically relevant bleeding events, as well as a composite efficacy end point that included unplanned revascularization, death, or thromboembolic events. Researchers found that patients in the 110 mg dual therapy group were significantly less likely to experience bleeding events (HR 0.52, 95% CI 0.42 to 0.63, p<0.001 for noninferiority and superiority). Patients in the 150 mg dual therapy group were also significantly less likely to experience bleeding events when compared to the triple therapy group (HR 0.52, 95% CI 0.42 to 0.63, p<0.001 for noninferiority and superiority). The incidence of the composite efficacy end point was not significantly different between the two groups (HR 1.04, 95% CI 0.84 to 1.29, p=0.005 for noninferiority). As such, the investigators concluded that dual therapy does not increase the risk of thromboembolic events and, in fact, results in fewer bleeding events as compared to triple therapy in patients with atrial fibrillation that have undergone PCI.

Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France

Elderly patients account for 10-20% of all intensive care unit (ICU) admissions. Currently, there is a lack of consensus on the role of ICU triage in elderly patients, and whether programs that increase ICU admission rates among critically ill elderly patients have a beneficial effect on long-term outcomes. This multicenter randomized controlled trial aimed to investigate whether systematic ICU admission for elderly patients, as compared to standard practice, has an effect on the primary end point of 6-month mortality. Critically ill patients age 75 years and older with preserved functional status, lack of cancer, and absence of cachexia (n=3037) were randomized either to a program that promoted systematic ICU admission or to follow standard practice. With adjustment for patient characteristics at baseline, researchers found that the systematic ICU admission group had a significantly higher ICU admission rate (RR 1.68, 95% CI 1.54 to1.82). However, there was no significant difference in 6-month mortality rate (RR 1.05, 95% CI 0.96 to1.14). There was, however, a significantly increased risk of in-hospital death. Quality of life and functional status were not significantly different between the groups. Investigators therefore concluded that a program to promote systematic ICU admission does not reduce 6-month mortality.

Comparative Safety of Direct Oral Anticoagulants and Warfarin in Venous Thromboembolism: Multicenter, Population Based, Observational Study

Venous thromboembolism (VTE) is relatively common, with one case occurring per 1000 people each year. It is also the third leading cause of vascular-related death. In this retrospective cohort study, 59,525 patients with a new diagnosis of VTE and prescription for a direct oral anticoagulant (DOAC) or warfarin were followed up study to compare these treatments in terms of their effects of on the primary end points of major bleeding and all-cause mortality within 90 days. Researchers found that there was no significant difference between the two groups with respect to all-cause mortality, (HR 0.99, 95% CI 0.84 to 1.16). Results also showed a similar risk of bleeding between the two treatment groups (HR 0.92, 95% CI 0.82 to 1.03). The results were independent of the treatment location, age, gender, and presence or absence of chronic kidney disease. Investigators therefore concluded that in patients receiving treatment for VTE, DOACs are not associated with an increased risk of bleeding or all-cause mortality within 90 days when compared to warfarin.

Oral Human Papillomavirus Infection: Differences in Prevalence Between Sexes and Concordance with Genital Human Papillomavirus Infection, NHANES 2011 to 2014

There is currently limited data on the concurrence of oral and genital human papilloma virus (HPV) infection in men, as well as prevalence differences between men and women. This national survey aimed to determine the prevalence of oral HPV in men and women in the US, as well as the association between oral and genital HPV in men. Participants age 18 to 69 years enrolled in the National Health and Nutritional Exam Survey (NHANES) underwent a penile or vaginal swab, as well as an oral rinse. These samples were evaluated utilizing polymerase chain reaction (PCR), as well as type-specific hybridization. Researchers found that the prevalence of oral HPV infection was 3.2% (95% CI 2.7% to 3.8%) in women and 11.5% (95% CI 9.8% to 13.1%) in men. Of men with genital HPV, 19.3% also had oral HPV, as compared to 4.4% in men who did not have genital infection. In addition, samples showed that oral HPV with high-risk strains was more prevalent in men. Risk factors for infection with high-oral HPV included current marijuana use (p<0.001), smoking more than 20 cigarettes per day (p=0.011), self-report of more than 16 oral or genital sexual partners, and African-American race. Investigators concluded that HPV infection is common among men and that genital HPV infection is a risk factor for oral HPV infection. This has important implications in efforts to prevent oropharyngeal squamous cell carcinoma, a potential sequelae of HPV.

Association of Blood Transfusion From Female Donors With and Without a History of Pregnancy With Mortality Among Male and Female Transfusion Recipients

Transfusion-related acute lung injury (TRALI) is the most common cause of mortality related to blood transfusions. This has been shown to occur more often with transfusions from female donors. This retrospective cohort study aimed to investigate the relationship between red blood cell transfusion from women with and without a history of pregnancy and all-cause mortality rate in recipients. Transfusions with red blood cells from all men, all women without a history of pregnancy, or all women with a history of pregnancy were given to 31,118 patients from 2005 to 2015. Researchers found that male recipients had a significantly higher incidence of all-cause mortality at 101 deaths per 1000 person-years when receiving transfusion from women with a history of pregnancy, as compared to an incidence of 80 deaths per 1000 person-years when receiving transfusion from males (HR 1.13, 95% CI 1.01 to 1.26). However, there was no significant difference in mortality rates for men who received transfusions from females without a history of pregnancy and men who received transfusions from males (HR 0.93, 95% CI 0.81 to 1.06).  In female recipients, there was no significant difference between mortality rates among those who received transfusions from female donors with a history of pregnancy and male donors (HR 0.99, 95% CI 0.87 to 1.13). Finally, females who received transfusions from females without a history of pregnancy did not have a significantly increased incidence of mortality as compared to male donors (HR 1.01, 95% CI 0.88 to 1.15). Investigators concluded that male recipients had an increased risk of all-cause mortality when receiving blood transfusions from women with a history of pregnancy as compared to males and suggested that further research is needed to determine clinical significance and the mechanism underlying this association.

Image: PD

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