Lege Artis Medicinae

[New treatment option for oral anticoagulation in the prevention of cardiogenic stroke - Focus on the RE-LY trial]

SZAPÁRY László

MARCH 20, 2011

Lege Artis Medicinae - 2011;21(03)

[Atrial fibrillation (AF) represents the most common cause of cardioembolic stroke. The prevalence of AF increases with age and affects 10% of elderly people. AF-related stroke is usually severe and has a high mortality. The risk of stroke can be estimated on the basis of risk factors accompanying AF and age. Patients with one of the highest risk are those with AF and previous TIA or stroke. Efficient prevention is achieved by chronic anticoagulation therapy. In clinical practice, the use of vitamin K antagonists (VKA) has been the only option. The use of these agents is limited for a number of reasons, and clinicians are especially reluctant to use them in elderly patients at high risk of stroke. Consequently, of the patients with AF for whom anticoagulant therapy is indicated, only about 50-60% receives such therapy, and only half of the treated patients achieves target INR values. More than 50 years after the introduction of warfarin, data of trials with the new direct thrombin inhibitor dabigatran have been published in the past few years. In this paper, we review the results of the phase III, international RE-LY trial, published in 2009, which evaluated the preventive efficacy dabigatran etexilate in patients with AF compared with warfarin at a therapeutic dose. On the basis of the results, dabigatran used at a dose of 2×110mg daily provides the same protection as warfarin, whereas at a dose of 2×150mg it provides a signiificantly more efficient protection from AF-associated stroke and systemic embolism. In addition to its excellent preventive effect, dabigatran tretament results in a significant decrease in the risk of intracranial haemorrhages, and of other major haemorrhages. On the basis of the results, dabigatran will probably change the current treatment paradigm in the stroke prevention in patients with AF, and its introduction can substantially increase the number of patients treated efficiently and safely.]

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[INTRODUCTION - Although the introduction of stents has dramatically improved the efficiency of percutaneous coronary interventions, a new complication, the stent thrombosis has appeared. Owing to intensive research, the incidence of this previously common complication is currently 1%. Because of the high mortality and morbidity, it is important to find more and more predictors, which might help to further reduce the incidence. CASE REPORT - Our elderly male patient presented with acute anterior myocardial infarct. Stent implantation of the left anterior descendent branch was performed using coronarography, with no complications. After five days without any symptoms, ST elevation recurred and subacute stent thrombosis was deteceted. Because of the laboratory results showing thrombocytosis, we performed JAK2 V617F screening, with a positive result. Prolonged heparin therapy, platelet aggegation inhibition at a transiently elevated dose and hydroxyurea treatment because of the myeloproliferativ malignancy were used. At the follow-up visit, the patient did not report any complaints, and cell counts for all three myeloid cell lines were in the normal range. CONCLUSION - The thrombogenic feature of the classic myeloproliferative disorders is well-known, and JAK2 V617F mutations further increase the risk. In our departement, screeing for such genetic alteration was performed in patients with stent thrombosis and a platelet count higher than 450 G/l. Two of the three cases had positive results. Supported by the literature, we think that the hematologic disease lead to the thrombotic complication in our patients. In our opinion, the JAK2 V617F is a potential risk factor of stent thrombosis.]

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[Introduction - Decreased activity of natural anticoagulants (antithrombin-III, protein C, protein S) rarely causes cerebral ischaemia, however it can be found frequently in acute phase of ischaemic stroke. The authors’ aim was to investigate whether the decreased activity of natural anticoagulants is accompanied by worsening of symptoms in ischaemic stroke. Patients and method - Sixty-eight acute ischaemic stroke patients were investigated. Severity of symptoms were assessed and followed by the NIH Stroke Scale. Antithrombin- III, protein C, protein S activities, and concentration of C-reactive protein (CRP) were measured within 48 hours after onset of ischaemic stroke. Results - Progressing stroke was found in 29% of patients. Decreased activity of at least one natural anticoagulant proteins was present in 31% of patients. Progression of stroke symptoms occured in 76% of patients with decreased natural anticoagulant activity, while this proportion was only 9% in those with normal natural coagulation inhibitor protein activity (p<0.01). Progressing stroke was also more frequent in patients with elevated CRP value (60%) than in those with normal CRP level (11%; p<0.05). Decreased activity of natural anticoagulants was more frequent in patients with elevated CRP concentration compared with patients with normal CRP. Conclusion - The results demonstrate the importance of decreased activity of natural anticoagulants in acute phase of ischaemic stroke. This abnormality was present in about 1/3 of stroke patients. The decreased activity of natural coagulant inhibitor proteins may play an important role in development of progressing stroke thus indicating unfavourable outcome.]

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[Examination of cardio-vascular risk factors in the priority of atrial fibrillation]

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