The American journal of medicine
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Review Meta Analysis
Does warfarin for stroke thromboprophylaxis protect against MI in atrial fibrillation patients?
The Randomized Evaluation of Long-term anticoagulation therapY (RE-LY) study demonstrated a significant increase in myocardial infarction events with dabigatran compared with warfarin, provoking renewed interest in whether vitamin K antagonists are useful drugs for the prevention of myocardial infarction in high-risk patients with atrial fibrillation. Present analyses examined whether there was an increased risk of myocardial infarction associated with non-warfarin anticoagulants (Stroke Prevention with the ORal direct Thrombin Inhibitor ximelagatran compared with warfarin in patients with non-valvular atrial Fibrillation III and IV, RE-LY, Amadeus) or "anticoagulant equivalents" (Atrial fibrillation Clopidogrel Trial with Irbesartan for the prevention of Vascular Events) in patients with atrial fibrillation who are prescribed anticoagulation for stroke thromboprophylaxis. ⋯ Sensitivity analyses, excluding RE-LY, revealed a nonsignificant reduction in myocardial infarctions (relative risk 0.83; 95% CI, 0.62-1.10); an analogous analysis excluding the Atrial fibrillation Clopidogrel Trial with Irbesartan for the prevention of Vascular Events demonstrated a significant reduction in myocardial infarctions (relative risk 0.80; 95% CI, 0.64-1.00). Warfarin might provide a protective effect against myocardial infarction compared with non-warfarin anticoagulants or "anticoagulation equivalents" in patients with atrial fibrillation who are prescribed anticoagulation for stroke thromboprophylaxis.
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Despite their proven mortality and morbidity outcomes benefits, beta-blockers remain substantially underused in patients with cardiac conditions. Reluctance to prescribe beta-blockers may be owing to concerns about tolerability with the traditional drugs in this class. Beta-blockers with vasodilatory properties, such as carvedilol and nebivolol, may overcome the tolerability and metabolic issues associated with traditional beta-blockers. Because endothelial dysfunction, the pathophysiologic hallmark of hypertension, may be heightened in populations with difficult-to-treat hypertension (e.g., elderly patients, African American patients), a vasodilating beta-blocker may be a particularly appropriate choice for these patient groups.
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Atrial fibrillation is associated with substantial mortality and morbidity from stroke and thromboembolism. Despite an efficacious oral anticoagulation therapy (warfarin), atrial fibrillation patients at high risk for stroke are often under-treated. This systematic review compares current treatment practices for stroke prevention in atrial fibrillation with published guidelines. ⋯ This systematic review demonstrates the underuse of oral anticoagulation therapy for real-world atrial fibrillation patients with an elevated risk of stroke, highlighting the need for improved therapies for stroke prevention in atrial fibrillation.
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Editorial Comment Review
A review of clinical guidelines with some thoughts about their utility and appropriate use.
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Dietary supplements occupy a unique niche within the realm of modern medicine. These products are often used by patients at their own discretion, in an unmonitored setting, and without the input of their physicians. Although laws pertaining to dietary supplement labeling prohibit specific claims for the treatment or prevention of disease, these products are widely used as "alternative" or "complementary" therapy. ⋯ Information on dietary supplements in nonmedical literature is typically unreliable, and even in the medical literature, numerous studies have used products that were not well characterized. Although greater attention has recently focused on dietary supplement quality and integrity, complex issues persist and must be addressed when evaluating literature and advising patients. We seek to clarify many of these issues and make practical suggestions for the clinician.