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The results of the Commander HF trial about the effects of low dose Rivaroxaban in combination with antiplatelet therapy on the combined endpoint of death, myocardial infarction and stroke in heart failure patients with sinus rhythm were published in the NEJM in October 2018. The drug failed to improve overall cardiovascular outcome. Mehra et al. report now the results of a post hoc analysis of these patients. Patients were most at risk for stroke or TIA after an episode of worsening heart failure. Rivaroxaban 2.5 mg b.i.d. was effective in reducing the neurological endpoint of all-cause stroke or TIA by 32% compared to placebo (1.29 events vs. 1.90 per 100 patients-years; adjusted HR 0.68, 95%CI 0.49-0.94). Fatal bleeding was not more frequent in the rivaroxaban group compared to the patients on placebo. Of note, nearly half of all strokes were either disabling (16%) or fatal (31%). Low dose Rivaroxaban seems to safely attenuate the risk of stroke in TIA after a recent episode of worsening heart failure.
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In this Canadian study from Conen et al., new atrial fibrillation within 30 days after surgery increased the stroke incidence 1 year after surgery from 1.54 (in patients without perioperative atrial fibrillation) to 5.58 events per 100 patients. The adjusted HR was 3.43 (95%CI 2.0-5.90). The occurrence of perioperative atrial fibrillation identified a group of patients at high risk for future cardiovascular events. Perioperative atrial fibrillation may be more than just a consequence of perioperative stress and inflammation, it could also be a first manifestation of chronic atrial fibrillation, unmasked by a surgical event. Definitively further research is needed in this respect, including what strategy is best for reducing the risks of an adverse event after an episode of perioperative atrial fibrillation
Stoke can hit anyone, even a only fifty year old four-time olmypic champion like Michael Johnson who did not smoke, ate healthy, was still fit and had no family history of premature cardiovascular disease. This article in an English Newspaper points out how challenging (physically and mentally) the process can be of accepting such a hit, especially for a champion and “alpha male”. Raising awareness for early recognition of this potentially devastating event remains important, as of course all preventive measures.
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