CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 6, November/December 2022 290 AFRICA The use of a direct-acting oral anticoagulants for anticoagulation of mechanical prosthetic valves is contra-indicated. A landmark phase 2 study of dabigatran versus warfarin in 252 patients with mechanical prosthetic mitral or aortic valves was stopped early due to excess thromboembolic and bleeding complications in the dabigatran arm. For this reason, novel oral anticoagulants are not recommended as an alternative to warfarin in mechanical prosthetic valves.5 The clinical decision-making in the pregnant patient with a mechanical prosthetic valve remains challenging. Each case is to be considered on an individual level, with consultation and buy-in from both the patient and clinician in a suitably resourced environment. References 1. Van Hagen IM, Roos-Hesselink JW, Ruys TP, Merz WM, Goland S, Gabriel H, et al. Pregnancy in women with a mechanical heart valve: data of the European Society of Cardiology Registry of Pregnancy and Cardiac Disease (ROPAC). Circulation 2015; 132: 132–142. 2. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143(5): e35–e71. 3. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy. The TaskForce for theManagement of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Endorsed by: the International Society of Gender Medicine (IGM), the German Institute of Gender in Medicine (DGesGM), the European Society of Anaesthesiology (ESA), and the European Society of Gynecology (ESG). Eur Heart J 2018; 39: 3165–3241. 4. Ebrahim I, Bryer A, Cohen K, Mouton JP, Msemburi W, Blockman M. Poor anticoagulation control in patients taking warfarin at a tertiary and district-level prothrombin clinic in Cape Town, South Africa. S Afr Med J 2018; 108(6): 490–494. 5. Eikelboom JW, Connolly S, Breuckmann M, Granger C, Kappetein A, Mack M, et al. for the RE-ALIGN Investigators. Dabigatran versus warfarin in patients with mechanical heart valves. N Eng J Med 2013; 369: 1206–1214. Systemic corticosteroids a potential treatment for heart failure: Spanish study Intravenous corticosteroids did not hurt people with acute heart failure (HF), and could be a potential treatment for those with more inflammation, according to a hypothesisgenerating study based on Spain’s Epidemiology of Acute Heart Failure in the Emergency Departments (EAHFE) registry. Whereas acuteHFpatients receiving corticosteroid therapy in the emergency department (ED) saw no improvement in all-cause mortality at 30 days, there was a trend of more favourable point estimates for survival in those with elevated C-reactive protein (CRP) levels. Medpage Today reports that potential for an association between corticosteroid therapy and better outcomes was observed among people with the most inflammation, defined as CRP > 40 mg/l – findings that were nevertheless statistically non-significant based on the available data: • All-cause mortality at 30 days: 11.8% with corticosteroids vs 19.4% without (HR 0.56, 95% CI 0.20–1.55) • Post-discharge ED revisit at 30 days: 42.3 vs 43.8% (HR 0.92, 95% CI 0.52–1.62) • In-hospital all-cause mortality: 8.8 vs 13.4% (HR 0.61, 95% CI 0.17–2.14). ‘The present analysis suggests that corticosteroids might have the potential to improve outcomes in acute HF patients with inflammatory activation,’ wrote study authors Dr Gad Cotter of Momentum Research in Chapel Hill, North Carolina, and colleagues in ESC Heart Failure. Inflammation has been linked to HF, though antiinflammatory therapies have failed in chronic HF, the researchers said, citing the failures of infliximab and etanercept in the older ATTACH and RENEWAL studies, respectively. ‘Although corticosteroids have been classically viewed as anti-inflammatory agents, they can cause sodium and water retention, potentially leading to worsening of HF. However, it has been reported that the administration of corticosteroids to patients with severe acute HF produced a potent diuretic effect and improved fluid overload and renal function,’ said the investigators. ‘Added to previous studies of potentially improved diuresis, the [present] results suggest that future randomised trials on anti-inflammatory therapy are needed to assess potential benefit in patients with the highest degree of inflammation,’ Cotter and co-authors said. EAHFE was a registry that included 45 Spanish EDs from 2007 to 2018. For the present analysis, the investigators included 1 109 people (median age of 81.2 years, 45% of whom were men) with NT-proBNP > 300 pg/ml and CRP > 5 mg/l in the ED. The team excluded people taking chronic systemic corticosteroids and those who had had acute HF triggered by an infection. Of the study cohort, 10.9% of patients received at least one IV bolus corticosteroid treatment. This group tended to have higher systolic blood pressure, lower room air oxygen saturation, and were more likely to have cerebrovascular disease, peripheral artery disease, chronic obstructive pulmonary disease and dementia. Their index acute HF episode was more commonly triggered by hypertensive crisis, compared with non-corticosteroid users. The retrospective study was limited by the potential for confounding, a relatively small sample of corticosteroid users, and a lack of details regarding dose and duration of treatment in the database, Cotter and colleagues acknowledged. Source: MedicalBrief 2022
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