To assess the optimal duration of anticoagulation after a first episode of unprovoked pulmonary embolism, Couturaud and colleagues randomly assigned 371 patients to receive an additional 18 months’ treatment with warfarin or placebo after completion of 6 months’ treatment with a vitamin K antagonist. The authors report that compared with placebo, extended treatment with warfarin reduced the risk of recurrent venous thromboembolism or major bleeding during the 18- month treatment period—a benefit not maintained when anticoagulation therapy was discontinued.
Related Articles 1, 2, 3, and Patient Page
Author Audio Interview and Continuing Medical Education
Cognitive impairment after stroke is a major contributor to disability among stroke survivors. In a prospective study that enrolled 23 572 participants aged 45 years or older who were not cognitively impaired, Levine and colleagues assessed change in cognitive function associated with incident stroke—experienced by 515 participants. The authors found that incident stroke was associated with an acute decline in cognitive function and accelerated and persistent cognitive decline over 6 years’ follow-up. In an Editorial, Gorelick and Nyenhuis discuss the association of stroke with cognitive decline.
Author Video Interview and Continuing Medical Education
In an analysis of individual participant data from the Emerging Risk Factors Collaboration (91 cohorts; 689 300 participants; 128 843 deaths) and the UK Biobank (499 808 participants; 7995 deaths), Danesh and colleagues assessed the association of cardiometabolic multimorbidity—a history of 2 or more of the following: diabetes mellitus, stroke, myocardial infarction—with all-cause mortality and reductions in life expectancy. Among the investigators’ findings was that mortality risks associated with a history of diabetes, stroke, or myocardial were similar. Any combination of these conditions was associated with a multiplicative mortality risk, with life expectancy substantially lower among individuals with cardiometabolic multimorbidity.
Dashti and colleagues investigated the association of hormonal factors—including age at menarche, first and last live birth, and menopause; number of live births; and exogenous hormone use—with risk of endometrial cancer in 1128 women with a mismatch repair gene mutation (Lynch syndrome). The authors report some endogenous and exogenous hormonal factors—similar to those observed in a general population— were associated with a lower risk of endometrial cancer in women with a mismatch repair gene mutation.
This JAMA Clinical Evidence Synopsis by Middeldorp and Hutten summarizes an updated Cochrane review of 11 clinical trials (3716 patients total) that compared long-term vs short-term duration vitamin K antagonist therapy for patients with acute venous thromboembolism. (VTE). The review found that compared with short-term therapy, long-term vitamin K antagonist therapy was associated with a reduced risk of recurrent VTE and an increased risk of major bleeding, but no difference in mortality.
This JAMA Diagnostic Test Interpretation article by Le Gal and colleagues considers the case of a 67-year-old man who presented with a 3-day history of dyspnea on exertion, increased anxiety, and new onset pleuritic chest pain. He had no history of cancer or venous thrombosis. His pretest probability of pulmonary embolism (PE) was considered “likely.” Computed tomography (CT) pulmonary angiography was performed. How would you interpret the results? What would you do next?
Related Article 1 and Patient Page
This Medical Letter on Drugs and Therapeutics article provides information about edoxaban, a third oral direct factor Xa inhibitor, approved for treatment of venous thromboembolism and for prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Important adverse effects, drug interactions, and dosage adjustments are summarized.
Highlights. JAMA. 2015;314(1):3-5. doi:10.1001/jama.2014.11837