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Editorial - August 2022

Dear Members,

In this newsletter and European Journal of Cardiovascular Pharmacotherapy, we focus on different aspects of atrial fibrillation (AF),1–3 but we also report treatment of Coronavirus disease 2019 (COVID-19) infections in addition to a report on the challenge of medicating older people.

Data from epidemiological cohorts support the role of obesity as an independent risk factor for AF.4,5 In a meta-analysis, Dr. Thangjui and co-workers from the United States have assessed the efficacy and safety of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) in morbidly obese patients with AF. They found that obese patients with AF who used DOACs had lower risk of stroke and similar major bleeding risk compared with non-obese patients. In the obese group of patients, use of a DOAC was not statistically different from use of a VKA in reducing stroke, but major bleeding risk was lower in the DOAC group.

Patients with liver disease, concomitant with AF, carry a significantly higher risk for all clinical outcomes.6,7 Dr. Chen from Germany report that DOACs seem to be associated with better clinical outcome than VKAs in patients with mild to moderate liver disease in this study.

In a Danish registry study,8–10 Dr. Binning and co-workers aimed to evaluate the risk of discontinuing treatment with DOACs among patients with atrial fibrillation AF according to cohabitation status and gender. They concluded that male gender and living alone were associated with a higher risk of DOAC discontinuation among patients with AF.

Dronedarone reduces the risk of AF recurrence in patients with AF.11,12 However, in patients with chronic kidney disease (CKD) use of antiarrhythmic drugs (AADs) is a challenge. Vanos et al. concluded that dronedarone is an effective AAD in patients with AF/AFL and cardiovascular (CV) risk factors across a wide range of renal functions.

There are still concerns about the safety of digoxin therapy in AF.13–15 Dr. Lip and co-workers concluded that poor outcomes related to the use of digoxin over beta-blocker therapy in terms of excess mortality and reduced quality of life are secondary to the presence of risk factors other than digoxin per se.

In a review paper, Dr. Capodanno and Dr. Angiolillo provide an updated appraisal of the currently available evidence on the use of various oral antithrombotic agents for the prevention of IS and TIA.

COVID-19 is caused by infection with severe acute respiratory syndrome coronavirus-2. COVID-19 is characterized by striking dysregulation of the immune system, with evidence of hyperinflammation, an impaired induction of interferons, and delayed adaptive immune responses.16–18 In a current opinion paper, Dr Sascha Goonewardena and co-workers discuss the immune-modulating and known pharmacologic properties of low-dose naltrexone.

Dr. Wu and co-workers from China have investigated the effects of neuraminidase inhibitors (NIs) on COVID-19 in a retrospective study consisting of 3267 COVID-19 patients. The NI treatment lowered the mortality rate and the critically ill conversion rate compared with those in the non-NI group when applying the multivariate Cox model for adjusting imbalanced confounding factors.

Population ageing has resulted in an increasing number of older people living with chronic diseases (multimorbidity) requiring five or more medications daily (polypharmacy).19–21 Ageing produces important changes in the CV system and represents the most potent single CV risk factor. In a review paper by the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy, Tamargo et al. analyse the main challenges confronting healthcare professionals when prescribing in older people with CVD, multimorbidity, and polypharmacy.

Recently, several studies highlighted potential safety issues, i.e. photosensitizing effects, associated with the use of thiazide diuretics and reported an increased risk of several types of skin cancer.22 In a review paper, Dr. Götzinger and co-workers from Germany provide an overview of the prevalence, clinical manifestation, and management of adverse photoinduced skin reactions caused by frequently used CV drugs and to assess their potential relevance for skin cancer development.

On behalf of the Working Group Nucleus,
Alexander Niessner, Chairperson 2020–2022 and
Anne Grete Semb, Communication Coordinator 2020–2022


Retrieve other WG news


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  2. Agewall S. Atrial fibrillation in registries. Eur Heart J Cardiovasc Pharmacother 2021;7:1–2.
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  4. Javed S, Gupta D, Lip GYH. Obesity and atrial fibrillation: making inroads through fat. Eur Heart J Cardiovasc Pharmacother 2021;7:59–67.
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  13. Kapelios CJ, Lund LH, Benson L, Dahlström U, Rosano GMC, Hauptman PJ, Savarese G. Digoxin use in contemporary heart failure with reduced ejection fraction: an analysis from the Swedish Heart Failure Registry. Eur Heart J Cardiovasc Pharmacother 2021:pvab079. doi:10.1093/ehjcvp/pvab079. Google ScholarWorldCat
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  15. Bugiardini R, Cenko E, Yoon J, van der Schaar M, Kedev S, Gale CP, Vasiljevic Z, Bergami M, Miličić D, Zdravkovic M, Krljanac G, Badimon L, Manfrini O. Concerns about the use of digoxin in acute coronary syndromes. Eur Heart J Cardiovasc Pharmacother 2021:pvab055. doi: 10.1093/ehjcvp/pvab055.
  16. Ortega-Paz, L, Galli M, Capodanno D, Franchi F, Rollini F, Bikdeli B, Mehran R, Montalescot G, Gibson CM, Lopes RD, Andreotti F, Angiolillo DJ. Safety and efficacy of different prophylactic anticoagulation dosing regimens in critically and non-critically ill patients with COVID-19: a systematic review and meta-analysis of randomized controlled trials. Eur Heart J Cardiovasc Pharmacother 2021:pvab070. doi: 10.1093/ehjcvp/pvab070.
  17. Canonico ME, Siciliano R, Scudiero F, Sanna GD, Parodi G. The tug-of-war between coagulopathy and anticoagulant agents in patients with COVID-19. Eur Heart J Cardiovasc Pharmacother 2020;6:262–264.
  18. Kunal S, Ish P, Sakthivel P, Malhotra N, Gupta K. The emerging threat of multisystem inflammatory syndrome in adults (MIS-A) in COVID-19: a systematic review. Heart Lung 2022;54:7–18.
  19. Lip GYH, Keshishian A, Kang A, Dhamane AD, Luo X, Klem C, Rosenblatt L, Mardekian J, Jiang J, Yuce H, Deitelzweig S. Effectiveness and safety of oral anticoagulants among non-valvular atrial fibrillation patients with polypharmacy. Eur Heart J Cardiovasc Pharmacother 2021;7:405–414.
  20. Vanassche T, Verhamme P, Anand SS, Shestakovska O, Leong DP, Fox KAA, Bhatt DL, Avezum A, Alings M, Aboyans V, Maggioni AP, Widimsky P, Muehlhofer E, Berkowitz SD, Yusuf S, Connolly SJ, Eikelboom JW, Bosch J. Low-dose rivaroxaban plus aspirin in patients with polypharmacy and multimorbidity: an analysis from the COMPASS trial. Eur Heart J Cardiovasc Pharmacother 2021:pvab050. doi: 10.1093/ehjcvp/pvab050.
  21. Kaski JC, Tamargo J, Savarese G. Cardiovascular pharmacotherapy in older people: challenges posed by cardiovascular drug prescription in the elderly. Eur Heart J Cardiovasc Pharmacother 2020;6:277–279.
  22. Pedersen SA, Johannesdottir Schmidt SA, Hölmich LR, Friis S, Pottegård A, Gaist D. Hydrochlorothiazide use and risk for Merkel cell carcinoma and malignant adnexal skin tumors: a nationwide case-control study. JAAD 2019;80:460–465.