The American journal of medicine
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Vitamin K antagonists (VKA) are the most widely used anticoagulants, and bridging is commonly administered during periprocedural VKA interruption. Given the unclear benefits and risks of periprocedural bridging in patients with previous venous thromboembolism, we aimed to assess recurrent venous thromboembolism and bleeding outcomes with and without bridging in this population. ⋯ Periprocedural bridging increases the risk of bleeding compared with VKA interruption without bridging, without a significant difference in periprocedural venous thromboembolism rates.
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The risks of thromboembolic and hemorrhagic events in patients with atrial fibrillation both increase with age; therefore, net clinical benefit analyses of anticoagulant treatments in the elderly population are crucial to guide treatment. We evaluated the 1-year clinical outcomes with non-vitamin-K antagonist and vitamin K antagonist oral anticoagulants (NOACs vs VKAs) in elderly (≥75 years) patients with atrial fibrillation in a prospective registry setting. ⋯ Our real-world data indicate that, compared with VKAs, NOAC use is associated with a better net clinical benefit in elderly patients with atrial fibrillation, primarily due to lower rates of major bleeding. Major bleeding with NOACs was numerically lower also in higher-risk patients with low BMI or age ≥85 years.
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Heart failure with preserved ejection fraction (HFpEF) is increasing in prevalence and has no guideline-recommended therapy, related in part to a lack of mechanism. Traditionally, HFpEF was thought to be secondary to afterload overload due to systemic hypertension; however, accumulating evidence suggests that HFpEF continues to worsen despite adequate control of blood pressure. ⋯ Further, the most prevalent clinical phenotype (eg older women with multiple comorbidities) of patients with HFpEF resembles those with coronary microvascular dysfunction, albeit older. In this review, we provide in-depth insight about this emerging HFpEF paradigm, discuss potential therapeutic implications of this pathophysiology, and summarize some important knowledge gaps.
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Discharges against medical advice are common among inpatients in the United States. The impact of discharge against medical advice on readmission rates and subsequent hospitalization outcomes is uncertain. We sought to ascertain the effect of discharge against medical advice on 30-day readmission rates and outcomes of readmission. ⋯ Discharge against medical advice is associated with over twice the odds of all-cause unplanned 30-day readmission compared with routine discharge. There is large hospital-level variation in rates of discharge against medical advice. Interventions to reduce discharges against medical advice, particularly at hospitals with high rates of such discharges, may reduce the overall readmission burden in this challenging and high-risk patient population.