Anticoagulation in patients with nonvalvular atrial fibrillation

Abstract

Letters } CorrespondanceAnticoagulation in patients with nonvalvular atrial fibrillation D r Murray B. Trusler's letter in the April 2023 issue of Canadian Family Physician 1 concerned teambased care to improve time in therapeutic range with the use of warfarin. He documents how the use of ancillary personnel and new technologies can successfully ease the burden of anticoagulation monitoring in primary care. While the newer direct oral anticoagulants (DOACs) can obviate this burden, these drugs are often inaccessible to those of lower income in our increasingly inequitable society.Dr Trusler goes on to say that DOACs have failed to reduce the incidence of stroke and systemic embolism compared with warfarin. He cites a Canadian retrospective cohort study by Durand et al 2 as evidence. What is not mentioned is that the same study found an association with reduced major bleeding, intracranial hemorrhage (ICH), and all-cause mortality with DOAC use. In fact, if we consider the much higher level of evidence shown in meta-analyses of randomized controlled trials, DOACs have been associated with reductions in stroke, ICH, fatal bleeding, and all-cause mortality compared with warfarin. 3,4 Only gastrointestinal bleeding was increased, while ICH, a devastating cause of death and disability, was reduced by more than 50%. 5 The 2020 Canadian Cardiovascular Society guidelines recommend DOACs for anticoagulation in nonvalvular atrial fibrillation and, additionally, switching to these agents from warfarin wherever possible. 6 An approach to use of these guidelines appears in the same issue of the journal. 7 Those who must continue taking warfarin will, of course, greatly benefit from a team-based approach to monitoring.-N. John Bosomworth MD CCFP FCFP Vancouver, BC

Association of central obesity with retinal neurodegeneration: Cross‐sectional and longitudinal evidence from two countries

“…Although high BMI is touted as a red flag for adverse health in public health guidelines, WHR is often overlooked, despite being more sensitive than BMI for obesity and metabolic disease-related outcomes [42,43]. The present study and other reports highlight the fact that people with normal weight and central obesity are at elevated risks of complications that are traditionally associated with people with BMI values classified as obesity [44].…”

Acute vestibular neuritis may provoke atrial fibrillation

“…43 Exercise appears to be protective against AF at moderate levels, but a precipitant of AF when intense. 44 Increased vagal tone disrupting sympathetic-parasympathetic balance appears implicated in the development of AF with exercise and conditions such as OSA. 45,46 Brain infarction and haemorrhage affecting the insulaespecially on the rightare associated with arrhythmias including AF, potentially via sympathetic discharges from the damaged insula.…”

Effectiveness of combined use of targeted pressure energy, radiofrequency, and high‐intensity focused electromagnetic fields to improve skin quality and appearance of fat and muscle tissue in different body parts

“…Emsculpt Neo (HIFEM+RF) treats the underlying muscle and subcutaneous fat and Emtone (TPE+RF) treatment is for the skin and fat pockets in the treatment area. Moreover, the therapy is highly versatile, producing distinguishable results in thighs, saddlebags, abdomen, and upper arms, which are all problematic areas when it comes to fat distribution and deposition 26,27 . This easily administered therapy offers a convenient alternative to subjects, requiring no physical exertion or demanding routine whatsoever.…”