Vitamian K antagonists (OACs) are harmful?

 Can we safeguard coronaries from micro calcification?

As Weijs et al.^[1] have described, most patients diagnosed with paroxysmal atrium fibrillation (AF) are currently treated by prescribing life-long use of vtamin K antagonists (VKAs) to prevent thrombo-embolic complications.[2] By applying minimal invasive multislice computed tomography (MSCT) imaging, the authors found a possible adverse treatment effect in patients who were receiving VKAs for relatively longer, showing significant higher levels of calcium in their coronary arteries compared with patients with a shorter time on VKAs. This could have serious consequences for current clinical practice.[2]

 1. Weijs B, Blaauw Y, Rennenberg RJMW, Schurgers LJ et al. Patients using vitamin K antagonists show increased levels of coronary calcification: an observational study in low-risk atrial fibrillation patients. Eur Heart J 2011;32:2555-2562. First published on 20 July 2011. doi:10.1093/eurheartj/ehr226. 

2. Fuster V, Ryden LE,Cannom DS,Crijns HJ et al.. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation). Eur Heart J 2006;27:1979-2030.

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Lower extremities amputaitons are decreasing!

Amputations can be prevented -  amputation rates are decreasing!!!
It is important to know that the methods to reduce amputation and improve the quality of life are measurably effective in some countries such as America. During the last 25 years of our service at our institution in Hyderabad, the amputation rate has come down, but still the patients are coming for advice very late. That means we need to encourage the govt hospital doctors at primary care centers to recognize these problems early and treat the risk factors before they are unmanageable. That is the best way to control the epidemic cardiovascular diseases. Bypasses and balloon angioplasties will help to some extent but the larger populations can be benefited by the identification and modification of the risk factors. It may be worth developing risk modification clinics across the state to address this issue and improve the quality of life. The Aarogyasree scheme is very helpful to the people but it is going to be better if they also spend money for the development of the risk modification clinics.


Temporal Trends and Geographic Variation of Lower-Extremity Amputation in Patients With Peripheral Artery DiseaseResults From U.S. Medicare 2000–2008
W. Schuyler Jones, MD; Manesh R. Patel, MD; David Dai, PhD; Sumeet Subherwal, MD, MBA; Judith Stafford, MS; Sarah Calhoun, BS; Eric D. Peterson, MD, MPH
J Am Coll Cardiol. 2012;60(21):2230-2236. doi:10.1016/j.jacc.2012.08.983
Abstract
Objectives This study sought to characterize temporal trends, patient-specific factors, and geographic variation associated with amputation in patients with lower-extremity peripheral artery disease (LE PAD) during the study period.
Background Amputation represents the end-stage failure for those with LE PAD, and little is known about the rates and geographic variation in the use of LE amputation.
Methods By using data from the Centers for Medicare & Medicaid Services (CMS) from January 1, 2000, to December 31, 2008, we examined national patterns of LE amputation among patients age 65 years or more with PAD. Multivariable logistic regression was used to adjust regional results for other patient demographic and clinical factors.
Results Among 2,730,742 older patients with identified PAD, the overall rate of LE amputation decreased from 7,258 per 100,000 patients with PAD to 5,790 per 100,000 (p < 0.001 for trend). Male sex, black race, diabetes mellitus, and renal disease were all independent predictors of LE amputation. The adjusted odds ratio of LE amputation per year between 2000 and 2008 was 0.95 (95% CI: 0.95–0.95, p < 0.001).
Conclusions From 2000 to 2008, LE amputation rates decreased significantly among patients with PAD. However, there remains significant patient and geographic variation in amputation rates across the United States.

Obesity and deep vein thrombosis

Obesity and Deep vein thrombosis

Obesity is measured as body mass index above 30. The body mass index (BMI) is measured as weight in kilograms divided by the square of height in meter. Obesity is associated with venous thromboembolism (VTE). Body mass index is a marker of excess weight and correlates well with body fat content in adults. Body mass index fails to consider the importance of the distribution of body fat. All measurements of obesity are predictors of the risk for VTE. Positive associations were found between VTE and body weight, body mass index, waist circumference, hip circumference, and total body fat mass (1). The fact is that the fat distribution is not uniform in all the people and so there are different shapes of individuals. Basically obesity is differentiated as central or peripheral depending on the degree of fat accumulation in the central part of the body or extremities. Studies were done to find out the differences in risk associated with these types of fat distribution. The distribution of body fat predicts the risk of arterial thrombotic events, such as coronary heart disease (CHD). Central obesity is a better predictor of CHD than general obesity as measured with BMI.  Central obesity is measured as waist circumference or waist-to-hip ratio. It is important note that peripheral obesity is not a predictor of coronary heart disease. The peripheral obesity is measured as hip circumference (2,3). One study evaluated the association between VTE and central obesity in men and found that a waist circumference >100 cm was associated with a higher risk of VTE than a waist circumference  less than 100 cm (4).It is also important know the benefit of thrombo-prophylaxis in obese people who are undergoing major surgeries such as total knee arthroplasty. In a case-control study, they studied (130, 463) patient with and patients without acute VTE (within 9 days of surgery) and BMI ranging from 17 to 61.  Multivariable logistic regression was used to analyze risk factors for postoperative VTE, adjusted for age and gender. Thromboprophylaxis was LMWH in 284 (48%), warfarin in 189 (32%), both in 55 (10%), and mechanical prophylaxis alone in 120 (20%). Overall, 77% ambulated on day 1 or 2 after surgery. Severe obesity was not a significant independent predictor for VTE and did not modify the beneficial effect of FDA-approved pharmacological thromboprophylaxis. Bilateral TKA and failure to ambulate by the second day after surgery were significant risk factors (5). 

References:

1.   Knut H. Borch, Sigrid K. Brækkan, Ellisiv B. Mathiesen, Inger Njølstad, Tom Wilsgaard, Jan Størmer, and John-Bjarne Hansen. Anthropometric Measures of Obesity and Risk of Venous Thromboembolism: The Tromsø Study. Arterioscler Thromb Vasc Biol. 2010;30:121-12.   

2.   Canoy D, Boekholdt SM, Wareham N, Luben R, Welch A, Bingham S, Buchan I, Day N, Khaw KT. Body fat distribution and risk of coronary heart disease in men and women in the European Prospective Investigation Into Cancer and Nutrition in Norfolk cohort: a population-based prospective study. Circulation. 2007; 116: 2933–2943. 

3.   Yang L, Kuper H, Weiderpass E. Anthropometric characteristics as predictors of coronary heart disease in women. J Intern Med. 2008; 264: 39–49 

4.   Hansson PO, Eriksson H, Welin L, Svardsudd K, Wilhelmsen L. Smoking and abdominal obesity: risk factors for venous thromboembolism among middle-aged men: “the study of men born in 1913.” Arch Intern Med. 1999; 159: 1886–1890.

5.   Sadeghi B, Romano PS, Maynard G, Strater AL, Hensley L, Cerese J, White RH. Mechanical and suboptimal pharmacologic prophylaxis and delayed mobilization but not morbid obesity are associated with venous thromboembolism after total knee arthroplasty: A case-control study. J Hosp Med. 2012 Oct 5. doi: 10.1002/jhm.1962. [Epub ahead of print]

Blood goups and risk of proximal DVT

What is your blood group? if you have  O+  blood group, then you are probably safer than Non-O blood group people !!!

Non-O blood group in people seems to influence the risk of deep vein thrombosis.  In a study on 712 DVT patients, significant thrombotic risk was noted in those with Non O blood group and thrombophilia. In such patients the risk for DVT can be almost 3-fold higher.

Blood Transfus. 2012 Oct 11:1-5. doi: 10.2450/2012.0060-12. [Epub ahead of print]
ABO blood groups and the risk of venous thrombosis in patients with inherited thrombophilia.
Spiezia L, Campello E, Bon M, Tison T, Milan M, Simioni P, Prandoni P.
Although having a non-O blood type is now regarded as a risk factor for venous thromboembolism, the strength of this association is poorly defined, as is its interaction with inherited thrombophilia.
MATERIALS AND METHODS:The prevalence of non-O blood group and inherited thrombophilia (deficiencies of natural anticoagulants, factor V Leiden and prothrombin G20210A mutation) was assessed in a series of 712 consecutive patients with proximal deep vein thrombosis (DVT) of the lower limbs who were referred to our Institution between 2004 and 2010, and in 712 age- and gender-matched healthy volunteers. Odds ratios (OR) of DVT and their 95% confidence intervals (CI) were computed for non-O group and thrombophilia, both separately and in combination.
RESULTS:A non-O blood group was present in 492 cases and 358 controls (OR 2.21; 95% CI, 1.78 to 2.75). A thrombophilic abnormality was present in 237 cases and 105 controls (OR 2.82; 2.18 to 3.66). The combination of non-O group and thrombophilia was present in 152 cases and 51 controls (OR 7.06; 4.85 to 10.28).
DISCUSSION:Having a non-O blood group is associated with an increased risk of proximal DVT of the lower limbs with or without pulmonary embolism. The addition of inherited thrombophilia increases the thrombotic risk conferred by non-O group alone by almost 3-fold.