Extending anticoagulation by 18 months lowers risk of PE recurrence

Anna GarrettThe optimal duration of anticoagulation after a first episode of unprovoked pulmonary embolism is not clear. A recent study examined the benefits of extending warfarin therapy for an additional 18 months (vs. placebo) after an initial six-month treatment period.

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Three hundred seventy-one adult patients who had experienced a first episode of symptomatic unprovoked pulmonary embolism and had been treated initially for six months with a vitamin K antagonist were randomized and followed between July 2007 and September 2014 in 14 French centers.

The primary outcome was the composite of recurrent (VTE) thromboembolism or major bleeding at 18 months after randomization. Secondary outcomes were the composite at 42 months (treatment period plus 24-month follow-up), as well as each component of the composite, and death unrelated to pulmonary embolism or major bleeding, at 18 and 42 months.

During the 18-month treatment period, the primary outcome occurred in six of 184 patients (3.3%) in the warfarin group and in 25 of 187 (13.5%) in the placebo group. Three patients in the warfarin group and 25 patients in the placebo group experienced recurrent VTE. Major bleeding occurred in four patients in the warfarin group and in one patient in the placebo group. During the 42-month follow-up period, rates of recurrent VTE, major bleeding, and unrelated death did not differ between groups.

Source: Couturaud F, Sanchez O, Pernod G, et al. Six months vs. extended oral anticoagulation after a first episode of pulmonary embolism: The PADIS-PE Randomized Clinical Trial. JAMA. 2015;314(1):31–40.

Antidepressant/NSAID combination may increase ICH risk

The combination of antidepressants and nonsteroidal anti-inflammatory drugs (NSAIDs) is linked to an early increased risk for intracranial hemorrhage (ICH), regardless of the type of NSAID or antidepressant, new research shows.

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The retrospective population study analyzed data from the Korean nationwide health insurance database of 4,145,226 people who were treated with antidepressants with and without NSAIDs. In looking at the main outcome measure of time to the first hospital admission with ICH within 30 days of drug use, the investigators found a significantly higher risk for ICH during that 30-day period among patients treated with a combination of antidepressants and NSAIDs compared with those receiving antidepressants without NSAIDs.

There were no significant differences in the increased ICH risk between the antidepressant classes of serotonin-norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, or tricyclic antidepressants.

Although antidepressants and NSAIDs are each known to be associated with increased risk of abnormal gastrointestinal bleeding, neither has been linked independently with an increased risk of ICH. Male sex was the strongest risk factor for a higher hazard ratio for ICH with the combined use of the drugs. However, neither older age nor the use of antithrombotic agents, both well-known risk factors for ICH, was associated with a higher risk for ICH.

Source: Shin J-Y, Park M-J, Lee SH et al. Risk of intracranial hemorrhage in antidepressant users with concurrent use of nonsteroidal anti-inflammatory drugs: Nationwide propensity score matched study. BMJ 2015;351:h3517.

AF frequently undiagnosed in elderly

Atrial fibrillation (AF) is a cause of morbidity and mortality in older patients. In many, an embolic stroke is the first symptom. The risk for embolic events is related to the CHA₂DS₂-VASC score.

Investigators in Sweden sought to determine how many individuals aged 75 and 76 had undiagnosed AF. This age was chosen because all individuals that age have a CHA₂DS²-VASC score of at least 2. Individuals were invited to undergo frequent electrocardiogram (ECG) screening for a two-week period. Of 13,331 invitees, 7,173 underwent screening. Of these, 666 (9.3%) had a known diagnosis of AF, and 517 (78%) of these were on anticoagulation. During the two-week screening, an additional 218 (3.0%) had ECG documentation of AF. Once discovered, 93% agreed to anticoagulation.

Source: Svennberg E, Engdahl J, Al-Khalili F et al. Mass screening for untreated atrial fibrillation: The STROKESTOP study. Circulation 2015. CIRCULATIONAHA.114.014343 published online before print April 24, 2015.