(J Clin Hypertens. 2005;7:598-604)

BACKGROUND: Ventilator-associated pneumonia (VAP) is a nosocomial infection of multifactorial etiology and has a negative influence on cardiovascular surgery (CVS) outcomes. OBJECTIVES: Determine the effect of toothbrushing plus 0.12% chlorhexidine gluconate oral rinse in preventing VAP after CVS. METHODS: In a quasi-experimental study, patients undergoing heart surgery were enrolled in a protocol for controlling dental biofilm by proper oral hygiene (toothbrushing) and oral rinses with 0.12% chlorhexidine gluconate (Group 1), and they were compared with a historical control group (Group 2), which included patients who underwent cardiac surgery be-

The results of our study indicate that oxidative drug-metabolizing capacity is increased in surgical patients maintained on hypocaloric peripheral parenteral nutrition. Clinicians should be conscious of the potential of this effect for altering the efficacy or toxicity of many therapeutic agents.

Introduction: Oral anticoagulants (OAC) are under-utilised in atrial fibrillation (AF). Even patients prescribed an OAC may stop taking the drug soon after treatment initiation, particularly with Vitamin K Antagonists (VKA). The Non-VKA OAC (NOAC) drugs offer greater ease of use, and persistence is likely to be higher. Aim: To determine persistence on treatment in the first year after inception of NOACs and VKA in incident AF in real-world clinical practice. Methods: We studied 24,467 OAC-naïve patients with incident non-valvular AF diagnosed between Jan 2011-Feb 2014, mean age 73.9 ± 12.5, 45.6% female, in a very large UK primary care database (Clinical Practice Research Datalink, CRPD), with full linkage to medication use. Follow up was for a mean of 1.2 ± 0.9 years. The proportion of OAC initiation in the 90 days after first-time AF and of those remaining on OAC one year after initiation were estimated using competing risk survival analyses censoring for use of alternative OAC. Results: NOAC drugs prescribed included Rivaroxaban, Dabigatran and Apixaban. Overall, 12,579 (51.4%) were commenced on an OAC: 11,888 on VKA and 691 on NOAC, within 90 days after incident AF. Amongst all OAC users, the proportion taking NOAC increased from 0.3% in 2011 to 12.3% in 2014. Persistence, defined as the proportion still taking the OAC after one year, declined over the 12 months to 54.3% for VKA and 80.7% for NOAC (Table). Persistence was significantly greater for NOAC than VKA at all time points. Conclusions: There is a progressive fall in VKA use amongst OAC naïve patients with AF in real-world practice to only 54% at 1 year. This contributes to under-utilisation of anticoagulation in AF and would result in an increased rate of stroke. Persistence was significantly improved with NOACs compared to VKA, and this factor alone could lead to reduced stroke burden with increasing uptake of the NOACs.

Introduction: Quality and duration of anticoagulation reflected by high proportion of Time in Therapeutic INR range (TTR) is associated with reduced thrombo-embolic and bleeding events in atrial fibrillation (AF). SAMeTT2R2, a novel score incorporating age, sex, ethnicity, smoking, co-morbidities, and interacting drugs, predicts inadequate anticoagulation control (TTR <0.6) after commencing Vitamin K Antagonist (VKA) for AF, with scores ≥2 suggested as a cut-off to predict inadequate control. Aims: To determine whether SAMeTT2R2 score ≥2 at VKA inception is associated with an increased stroke risk in real-world practice. Methods: A cohort of VKA-naïve patients with incident non-valvular AF between 2001 - 2010 was formed from a large UK primary care database (Clinical Practice Research Datalink, CPRD) with linkage to hospital discharges, and death registry. SAMeTT2R2 score was calculated in a subset of 4468 in whom VKA treatment was initiated within 90 days of AF diagnosis, and scores 0-1, ≥2 were related to 3-year stroke incidence. Competing risk analysis accounting for death was performed to compare the risk of stroke between the two groups in an intention-to-treat analysis. Results: Of 4468 patients with incident AF commenced on VKA (mean age 70.7, 41.2% female), 3422 (76.6%) had a SAMeTT2R2 score of 0-1, and 1046 (23.4%) a score of ≥2. During 3-years 138 patients had a stroke and 58 of these occurred in the year following AF. Cumulative risk estimates for stroke in patients with scores ≥2 compared to 0-1 were significantly increased at 1, 2 and 3 years (log rank test, p<0.01)(Figure). The proportion with TTR≥0.6 was 37.1% for scores ≥2 compared to 44.1% for scores 0-1 (p<0.01). Conclusions: SAMeTT2R2 scores ≥2 predict increased stroke risk in the 3 years following incident AF in patients commenced on VKA treatment. These findings suggest that patients with high SAMeTT2R2 scores may require intensified anticoagulation control or use of oral non-VKA anticoagulants.