Non-valvular atrial fibrillation (AF) is the most common cardiac arrhythmia in the clinical setting. AF increases both the risk and severity of strokes, and is associated with substantial morbidity and mortality. Despite the clear net clinical benefit of oral anticoagulants (OACs) in patients with AF at risk for stroke, major bleeding events, especially intracranial bleeds, may be devastating. In the last decade, four new OACs have been approved for stroke prevention in patients with AF and are at least as effective as warfarin with better bleeding profiles. These new agents have changed and simplified our approach to stroke prevention because the threshold for initiation of OACs is lowered. An important clinical practice shift is the initial identification of "low-risk" patients who do not need antithrombotic therapy, with low-risk comprising CHA2DS2-VASc {Congestive heart failure, Hypertension, Age > or =75 years (double), Diabetes mellitus, previous Stroke/transient ischemic attack/thromboembolism (double), Vascular disease, Age 65-74 years, and female gender (score of 0 for males and 1 for female)}. Subsequent to this step, effective stroke prevention consisting of OACs can be offered to patients with one or more stroke risk factors. Apart from stroke risk, another consideration is bleeding risk assessment, with a focus on the use of the validated HAS-BLED {Hypertension, Abnormal renal/liver function, Stroke, Bleeding history, Labile international normalized ratio (INR), Elderly (age >65 years), drugs or alcohol concomitantly} score. A high HAS-BLED score can flag patients potentially at risk for bleeding, and alert clinicians to the need for careful review and follow up, and the need to consider potentially correctable bleeding risk factors that include uncontrolled hypertension, labile INRs, concomitant aspirin use, and alcohol excess.
Aged ; Anticoagulants ; Arrhythmias, Cardiac ; Aspirin ; Atrial Fibrillation* ; Diabetes Mellitus ; Female ; Follow-Up Studies ; Heart Failure ; Hemorrhage* ; Humans ; Hypertension ; International Normalized Ratio ; Male ; Mortality ; Risk Assessment ; Risk Factors ; Stroke* ; Vascular Diseases ; Warfarin

Oxidative stress is prevalent among infertile men and is a significant cause of sperm DNA damage. Since sperm DNA damage may reduce embryo quality and increase miscarriage rates, it is possible that untreated sperm oxidative stress may impair in vitro fertilization (IVF) live birth rates. Given that the antioxidant Menevit is reported to reduce sperm DNA damage, it was hypothesized that men's consumption of this supplement may alter IVF outcomes. Therefore, a retrospective cohort study was conducted analyzing outcomes for couples undergoing their first fresh embryo transfer. Men were classified as controls if they were taking no supplements, health conscious controls if taking "general health" supplements, or Menevit users. Men with karyotype abnormalities, or cycles using donated, frozen and surgically extracted sperm were excluded. Among the final study cohort of 657 men, live birth rates were significantly higher in Menevit users than controls (multivariate adjusted odds ratio [OR]: 1.57, 95% confidence interval [CI]: 1.01-2.45, P= 0.046), but not between controls taking no supplements and those using general health supplements, thereby suggesting that potential health conscious behavior in supplement users is unlikely responsible for the superior outcomes in Menevit users. Interestingly, in a post hoc sensitivity analysis, live birth rates among Menevit users were statistically superior to controls for lean men (OR: 2.73, 95% CI: 1.18-6.28; P= 0.019), not their overweight/obese counterparts (OR: 1.29, 95% CI: 0.75-2.22, P = 0.37). The results of this large cohort study therefore support a positive association between men's use of the Menevit antioxidant during IVF treatment and live birth rates, especially in lean individuals.