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Query: UMLS:C0011849 (diabetes)
 277,896 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Atrial fibrillation(AF) is a common arrhythmia that is an important independent risk factor for stroke. The overall risk of stroke in AF patients averages about 5%/y, but with wide variation depending on the presence of coexistent thromboembolic risk factors, which include increasing age, history of hypertension, previous stroke or transient ischemic attack(TIA), and diabetes. AF patients with prior stroke or TIA are at highest risk(about 12%/y). Adjusted-dose warfarin(target INR 2.0-3.0) is highly efficacious for preventing stroke in AF patients, and is safe for selected patients. Aspirin has a modest effect on reducing stroke. Warfarin is recommended for high-risk AF patients who can safely receive it. Aspirin may be indicated for those with a low stroke risk and for those who cannot receive warfarin.
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PMID:[Antithrombotic therapy for stroke prevention in patients with atrial fibrillation]. 1087 60

Atrial fibrillation (AF) affects 5% of people older than 65 years. Among patients with AF, the risk of stroke averages about 5% per year. The risk of stroke increases cumulatively with increasing age, previous transient ischaemic attack or stroke, hypertension, diabetes, impaired left ventricular function and a large left atrium. Management aims to identify and treat the underlying cause, control the ventricular rate, restore and maintain sinus rhythm, and minimise the risk of stroke. Warfarin reduces the risk of stroke by about two-thirds, and aspirin by about one-fifth. The risk of anticoagulant-associated haemorrhage increases with serious concomitant disease, and with poorly controlled hypertension and poorly controlled anticoagulation. All patients with chronic AF should be considered for oral anticoagulant therapy, and the decision based on the balance between the risks of thromboembolism and bleeding. The recommended INR (international normalised ratio) is 2.0-3.0. Treating 1,000 "average" AF patients (ie, those with a 5% per year risk of stroke) with warfarin prevents about 30 strokes and causes at least two episodes of major haemorrhage each year. Treating 1,000
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PMID:Non-valvular atrial fibrillation and stroke prevention. National Blood Pressure Advisory Committee of the National Heart Foundation. 1128 Jun 95

Nonvalvular atrial fibrillation (NVAF) is frequently seen in elderly people and has become a main cause of cardioembolic stroke. The efficacy of anticoagulation for primary prevention of stroke or transient ischaemic attacks (TIAs) in patients with NVAF has been established by prospective, randomised and controlled trials. Warfarin decreased the frequency of all strokes by 68% and the rate of the combined outcome of stroke, systemic embolism or death by 48%. Anticoagulation with warfarin using international normalised ratios (INRs) ranging from 2.0 to 3.0 is recommended for patients with NVAF, who have any of the risk factors identified by the Atrial Fibrillation Investigators (AFI) [previous stroke or TIA, history of hypertension, diabetes mellitus, advanced age (> or = 65 years old), congestive heart failure and coronary artery disease], the American College of Chest Physicians (ACCP) [increased age (> 75 years old), prior stroke, hypertension and heart failure], or the Stroke Prevention in Atrial Fibrillation (SPAF) investigators [women > 75 years old, prior stroke, systolic blood pressure > 160mm Hg, recent heart failure, and fractional shortening < 25% on echocardiography]. For the secondary prevention of stroke, the efficacy of adjusted-dose warfarin therapy has been demonstrated by 2 major randomised trials. SPAF III (INR 2.0 to 3.0) demonstrated a lower incidence of ischaemic stroke or systemic embolism (3.4 %/year) compared with low fixed-dose warfarin plus aspirin (acetylsalicylic acid) [11.9%]. The European Atrial Fibrillation Trial [EAFT] (INR 2.5 to 4.0) showed a lower incidence of all stroke (4.0 %/year) with adjusted-dose warfarin compared with placebo (12.0 %/year). The incidence of major bleeding in the adjusted-dose warfarin group in SPAF III and EAFT was 2.4 and 2.8 %/year, respectively. EAFT incidence rates for the occurrence of a first ischaemic or haemorrhagic complication analysed by INR range indicated that the rate was lowest at INRs of 2.0 to 2.9, and higher with INRs of 3.0 to 3.9. Therefore, the optimal intensity of anticoagulation for prevention of recurrent stroke seems to be an INR of between 2.0 and 3.0, as for primary prevention. Retrospective and prospective studies from Japan reported that in the elderly, haemorrhagic complications occur frequently with INRs above 2.6 and major ischaemic events cannot be prevented at INRs below 1.6. Therefore, an INR target between 1.6 and 2.6 may be an alternative for secondary prevention of stroke in elderly patients with NVAF who have a potential risk of bleeding, to avoid both major ischaemic and haemorrhagic events. Antiplatelets may be administered in patients who are unable to manage taking warfarin properly or who have a high risk of falling and subsequently sustaining a head injury, although the efficacy of antiplatelets for secondary prevention of stroke in NVAF has not yet been established.
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PMID:Secondary prevention of stroke in patients with nonvalvular atrial fibrillation: optimal intensity of anticoagulation. 1152 34

An elderly lady developed an epidural hematoma following combined spinal-epidural anesthesia with a local anesthetic-opioid mixture for a vaginal hysterectomy. This occurred in association with the use of prophylactic subcutaneously administered unfractionated heparin. She had diabetes, hypertension and had previously undergone coronary artery bypass surgery and right carotid endarterectomy. Warfarin and aspirin were discontinued 2 weeks before the surgery. Postoperatively, an atypical presentation of backache, bilateral sensory loss and left lower limb monoplegia ensued. The initial clinical impression was of a cerebrovascular accident. Magnetic resonance imaging, however, revealed an extensive epidural hematoma that necessitated decompression laminectomy. Progression to paraparesis occurred but the patient gradually regained much of her functionality over the next 2 years.
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PMID:Postoperative epidural hematoma or cerebrovascular accident? A dilemma in differential diagnosis. 1194 75

Atrial fibrillation is a common arrhythmic disorder which is becoming increasingly prevalent among the elderly. Atrial fibrillation is an independent risk factor for ischaemic stroke. Patients with hypertension, heart failure, diabetes, age older than 65 years, previous thromboembolisms, left atrial enlargement and left ventricular dysfunction have an increased risk. Coumarins (with a target international normalised ratio (INR) of 2.0 to 3.0) are the treatment of first choice in patients with atrial fibrillation. In young patients without additional risk factors, acetyl salicylic acid provides sufficient protection. The management of anticoagulant therapy during electric cardioversion in the acute phase of an ischaemic stroke and during elective surgical interventions, is still a subject of clinical research.
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PMID:[Anticoagulant treatment of patients with atrial fibrillations: dependent on age and other risk factors for thromboembolism]. 1262 83

Systemic embolism is a frequent cause of stroke. At the beginning of the last decade by introduction of transesophageal echocardiography and other imaging techniques atheromatosis of the aortic arch has been recognized as an important source of embolism. Formerly in the pre-TEE era, this entity was included into cryptogenic strokes. Aortic atheromas are found in about one quarter of patients presenting with embolic events. The severity of atherosclerosis graded by TEE correlates with the risk for future embolism, especially if mobile lesions or superimposed thrombi are present. Independent of plaque extension, patients with unstable plaques characterized by echo-lucency, inhomogenity, lacking of calcifications, ulceration, mobile parts and concomitant spontaneous echo contrast within the aorta have a higher risk for embolic events. However, the diagnosis of aortic atheromatosis is mostly established if an embolic event has already occurred. Therefore, it is important to identify patients at risk, especially before they undergo interventions with manipulation at the aorta like coronary bypass surgery. Risk factors are age above 70, diabetes mellitus, hyperlipidemia, arterial hypertension, aortic calcifications on standard chest X-ray, elevated serum levels of C-reactive protein, other inflammatory markers, and an activated coagulation. Randomized studies for treatment of patients with severe aortic atheromatosis are not yet existing. Warfarin has been shown to prevent stroke in patients with mobile atheromas and superimposed thrombi, but there are case reports about aggravation of cholesterol embolism under warfarin treatment. It is concluded from other atherosclerotic manifestations that plaque stabilizing treatment with statins and ACE inhibitors is also beneficial.
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PMID:Atheromatous disease of the thoracic aorta and systemic embolism. Clinical picture and therapeutic challenge. 1474 Feb 36

Diabetes mellitus patients after aorto-coronary bypass operation constitute a patient cohort at largely increased risk for secondary coronary events. Antiplatelet agents and antithrombotic agents are applied for secondary prevention. Up to now, secondary prevention has not been addressed specifically in the cohort of diabetic patients after bypass operation. Hence therapeutic recommendations are derived from the global cohort of CAD patients and based on risk assessment rather than on specific data. Since diabetic patients after myocardial infarction are at particularly high risk, combined therapy with clopidogrel and ASS may be considered even with restricted resources in the health system. Oral anticoagulation with coumadin constitutes an effective alternative to dual anti-platelet therapy. Under specific conditions (ventricular aneurysms, EF < 30%, or certain conditions in coronary anatomy) oral anticoagulants should be considered more liberally than currently.
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PMID:[Postoperative antithrombotic treatment in diabetic patients]. 1659 54

Warfarin causes extensive vascular calcification leading to increased systolic blood pressure and pulse pressure in rats, may be associated with increased valvular and coronary calcifications in man, and possibly worsens hypertension in high-risk patients, particularly in those with diabetes mellitus or uncontrolled hypertension. The authors evaluated blood pressure and intensity of antihypertensive therapy over 36 months in a cohort of 58 patients with diabetes and hypertension on warfarin and 58 control subjects with diabetes and hypertension not on warfarin. The results demonstrate that warfarin therapy at conventional doses does not increase systolic blood pressure or pulse pressure in patients with diabetes and hypertension.
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PMID:Effects of warfarin on blood pressure in men with diabetes and hypertension--a longitudinal study. 1739 67

Recurrent ischemic stroke and transient ischemic attack are common problems in primary care, with stroke survivors averaging 10 outpatient visits per year. Risk factors such as hypertension, diabetes, and hypercholesterolemia should be evaluated during each office visit. Attention should be given to lifestyle modification including management of obesity, smoking cessation, reduction in alcohol consumption, and promotion of physical activity. The choice of an antiplatelet agent (e.g., aspirin, ticlopidine, clopidogrel, dipyridamole) or the anticoagulant warfarin is based on the safety, tolerability, effectiveness, and price of each agent. Aspirin is a common first choice for prevention of recurrent stroke, but the combination of dipyridamole and aspirin should be considered for many patients because of its superior effectiveness in two clinical trials. Clopidogrel is recommended for patients with aspirin intolerance or allergy, or for those who cannot tolerate dipyridamole. Warfarin and the combination of aspirin and clopidogrel should not be used in the prevention of ischemic stroke. Carotid endarterectomy is appropriate for select patients; carotid stenting was recently shown to be less effective and less safe than endarterectomy.
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PMID:Prevention of recurrent ischemic stroke. 1770 38

Nephropathy is one of the most common and severe complications of diabetes mellitus. The mechanism of diabetic nephropathy, however, remains incompletely understood. To elucidate the mechanism of diabetic nephropathy, we focus on the role of a vitamin K-dependent growth factor, growth arrest-specific gene 6 (Gas6), and its receptor Axl in the pathogenesis of diabetic nephropathy. We used streptozotocin (STZ)-induced diabetic rats and mice as a model of diabetic nephropathy and examined the role of Gas6 and Axl in the development of diabetic nephropathy. We also studied signaling mechanisms involved in mesangial hypertrophy characteristic of the early phase of diabetic nephropathy in vitro. After 12 weeks of STZ injection, the glomerular expression of Gas6 and Axl was increased along with the phosphorylation of Akt, p70 S6 kinase, and 4E-BP-1. Administration of warfarin, which inactivates Gas6, inhibited mesangial and glomerular hypertrophy and the increase in albuminuria in STZ-rats. Warfarin treatment also inhibited the phosphorylation of Akt, p70 S6 kinase, and 4E-BP-1. To demonstrate the specific role of Gas6, we showed that these findings were recapitulated in STZ-induced Gas6-knockout mice and confirmed the role of Gas6 in the development of diabetic nephropathy in vivo. In vitro stimulation of mesangial cells with Gas6 resulted in mesangial cell hypertrophy. Stimulation of the cells with 25 mmol/l of glucose increased the expression of Gas6/Axl and mesangial cell size compared with that with 5.6 mmol/l of glucose. LY294002 and rapamycin blocked Gas6-induced activation of the Akt/mTOR pathway and mesangial hypertrophy. Thus, we have found a novel mechanism of glomerular hypertrophy through the Gas6/Axl-mediated pathway in the development of diabetic nephropathy, where the Akt/mTOR pathway is a key signaling cascade in Gas6-mediated mesangial and glomerular hypertrophy. Inhibition of the Gas6/Axl pathway in diabetic patients might be beneficial to slow down the progression of diabetic nephropathy.
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PMID:Role of growth arrest-specific gene 6 in diabetic nephropathy. 1837 1


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