CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 4, July/August 2022 192 AFRICA 297–304. 14. Cheung K-S, Leung WK. Gastrointestinal bleeding in patients on novel oral anticoagulants: Risk, prevention and management. Wld J Gastroenterol 2017; 23(11): 1954. 15. Holster IL, Valkhoff VE, Kuipers EJ, Tjwa ET. New oral anticoagulants increase risk for gastrointestinal bleeding: a systematic review and metaanalysis. Gastroenterology 2013; 145(1): 105–112. 16. Schulman S, Kearon C, Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non‐ surgical patients. J Thromb Haemostasis 2005; 3(4): 692–694. 17. Beyer-Westendorf J, Förster K, Pannach S, Ebertz F, Gelbricht V, Thieme C, et al. Rates, management, and outcome of rivaroxaban bleeding in daily care: results from the Dresden NOAC registry. 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Gage BF, Yan Y, Milligan PE, Waterman AD, Culverhouse R, Rich MW, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J 2006; 151(3): 713–719. 23. Jun M, Lix LM, Durand M, Dahl M, Paterson JM, Dormuth CR, et al. Comparative safety of direct oral anticoagulants and warfarin in venous thromboembolism: multicentre, population based, observational study. Br Med J 2017; 359: 4323. 24. Roumia M, Berger P, Evans M, Steinhubl S. Do statins increase bleeding risk in anticoagulated individuals? J Am Coll Cardiol 2015; 65(10S): A1440. 25. Martinez AI, Freeman PR, Moga DC. Statin use and gastrointestinal hemorrhage: a large retrospective cohort study. Am J Cardiovasc Drugs 2019; 19(1): 65–74. 26. Salmoirago-Blotcher E, Hovey KM, Andrews CA, Robinson JG, Johnson KC, Wassertheil-Smoller S, et al. Statin use and risk of haemorrhagic stroke in a community-based cohort of postmenopausal women: an observational study from the Women’s Health Initiative. Br Med J Open 2015; 5(2). 27. McKinney JS, Kostis WJ. Statin therapy and the risk of intracerebral hemorrhage: a meta-analysis of 31 randomized controlled trials. Stroke 2012; 43(8): 2149–2156. 28. The EINSTEIN Investigators. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med 2010; 363(26): 2499–2510. Aspirin link to CVD drop in kidney disease patients confirmed: German analysis Patients with higher-grade chronic kidney disease (CKD) but no established cardiovascular disease who took daily aspirin showed a 43% cut in the rate of adverse cardiovascular events, with no increase in bleeding, compared with placebo during a median 4.6 years of follow up. The finding appears to identify a high-risk population – people with an estimated glomerular filtration rate (eGFR) of less than 60 ml/min/1.73 m2 who averaged 67 years of age – that bucks the now-established advice to not start low-dose aspirin for primary prevention of cardiovascular disease events in people over 59 years. Medscape reports that the latest finding, from a post hoc subgroup analysis of 983 patients with CKD who enrolled in the previously reported TIPS-3 trial, confirms two prior reports of secondary analyses, with the results collectively ‘suggesting that aspirin may moderately reduce the substantial cardiovascular disease risk of people with CKD but no history of cardiovascular disease: primary prevention’, said Dr Johannes Mann on 20 May at the European Renal Association Congress in Paris, France. Bleeding not a problem The rates of major, minor and gastrointestinal bleeds in these patients taking a 75-mg/day dose of aspirin were nearly identical to the rate among the placebo patients, showing that, at this dose and in these patients, ‘bleeding was not a problem’, added Mann, a nephrologist and professor of medicine at the University of Erlangen-Nürnberg in Germany. The ‘bleeding risk may not outweigh the cardiovascular disease benefit in patients with CKD,’ he concluded. The same finding consistently appeared in secondary analyses previously reported from two other controlled trials, the Hypertension Optimal Treatment trial, and the Aspirin in Reducing Events in the Elderly trial. ‘CKD defines, by itself, a high cardiovascular disease risk, and therefore my suggestion is to use aspirin for primary prevention in patients with CKD,’ Mann said. More definitive evidence for this benefit may come in results from about 25 000 people enrolled in the ongoing ATTACK trial, with an anticipated completion date in 2025, he added. The results showed ‘beautiful efficacy in the CKD population’, commented Dr Ronald Gansevoort, a nephrologist and professor of medicine at University Medical Centre Groningen, The Netherlands. continued on page 219…
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