Hundreds of thousands of heart patients would benefit from new type of blood thinning drug to cut their risk of stroke, say UK experts.
Patients with atrial fibrillation (AF), a fast and erratic heartbeat, can reduce their risk by a fifth when taking rivaroxaban rather than the most popular existing treatment, warfarin.
The data comes from a study of 14,000 patients and was presented at the American Heart Association conference.
AF affects around 800,000 UK people.
One in five people over the age of 70 is likely to be diagnosed with an irregular heartbeat, which can lead to blood clots and cause strokes.
This important study adds rivaroxaban to the increasing list of new drugs that seem to be at least as good as warfarin - the current standard therapy to prevent strokes in AF"
End QuoteProfessor Peter WeissbergMedical director of the BHF
Disease prevention
Both rivaroxaban and warfarin work by thinning the blood to reduce the risk of clots.
Patients treated with warfarin are half as likely to have a stroke compared with those taking no treatment or aspirin.
However, the dosage needs to be closely monitored - in some cases once a week. Too high a dose can lead to internal bleeding, which can prove fatal, and too low a dose increases the risk of stroke.
Unlike warfarin, levels of the new drug do not need to be monitored as intently and the necessary dosage is not affected by certain foods or alcohol.
Rivaroxaban is already recommended on the NHS to prevent blood clots in people undergoing hip and knee replacement surgery.
Professor Keith Fox, British Heart Foundation professor of cardiology at the University of Edinburgh, who led the research, said: "Our study showed that rivaroxaban is simpler to administer and patients taking it have fewer strokes and blood clots.
"We now have an effective alternative to warfarin for patients with irregular heart beats and one that reduces complications and is easier to administer."
Professor Peter Weissberg, medical director at the British Heart Foundation, said: "This important study adds rivaroxaban to the increasing list of new drugs that seem to be at least as good as warfarin - the current standard therapy to prevent strokes in AF."
But he said: "The rate at which these new drugs are introduced into routine clinical practice will be determined by the extent to which regulators believe their benefits justify their additional cost."
One new mother, Katie Hide, says post pregnancy support would have helped with her weight management.
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Many women fail to get proper advice on weight management during and after pregnancy, a UK-wide survey suggests.
Some 63% said their midwife had not explained obesity issues such as body mass index during their first antenatal appointment.
The poll of 6,226 women also found that six out of 10 felt pressurised by celebrity culture to lose weight quickly after giving birth.
They were surveyed by the Royal College of Midwives and website Netmums.
Obese, pregnant women run a greater risk of developing conditions such as pre-eclampsia and gestational diabetes.
They are also more likely to experience miscarriages, difficult deliveries, pre-term births and caesarean sections.
The survey found almost half the women who responded were worried about their weight during pregnancy.
But many appeared to be confused about what their correct weight should be, and significant numbers worried unnecessarily that their weight might cause problems giving birth.
As well as missing out on obesity advice during pregnancy, nine out of 10 said that after giving birth they had had no opportunity to discuss their concerns with their midwife.
Overall, 84% said the general advice they received from midwives on weight management was not good.
Nearly three-quarters (73%) of those who responded said the NHS should provide midwife-led antenatal classes specifically to address healthy eating and weight management.
The survey also suggested that lack of care had damaged many mothers' self-esteem. When asked how they felt about their body while pregnant, comments ranged from "disgusting" to "fat, ugly and big".
'Wake-up call'
Sally Russell, a co-founder of Netmums.com, said: "The results from this survey are a wake-up call to midwives to support women better throughout their pregnancy and inform them of their options."
Cathy Warwick, RCM general secretary, said good advice on weight management was vital, both to ensure that women kept as healthy as possible during pregnancy, and to avoid the risks being exaggerated.
But she said midwives did not seem to have enough time to discuss concerns with mothers-to-be.
She called on NHS Trusts to make sure resources were made available to ensure women got the advice and support they needed.
About half of women of childbearing age are either overweight or obese, with levels rising.
The health watchdog, the National Institute for Health and Clinical Excellence put out guidance in July encouraging women in England to attain a healthy weight before they get pregnant.
A Department of Health spokesman said: "We know it's crucial that mothers get the support they need before, during and after birth and we are working with the Royal College of Midwives, the NHS and others to make this happen.
"Obesity can have serious consequences for mothers and babies. Women need information, education and support at every opportunity.
"Health visitors have a key role in making sure that all mothers and babies get advice about what to eat, exercise and lifestyle. We are committed to recruiting an extra 4,200 health visitors who will be able to give professional support to women and we are currently exploring with the profession how best to achieve this."
In 2009 there were 26,678 full-time equivalent midwives in the UK.
BBC News website readers have been sending us their thoughts on this story. Here is a selection of their comments.
Isn't this a case of how to handle the horse once it's bolted? I was obese and got pregnant. My midwife did mention my BMI and explained that it put me at higher risk, so I would therefore need more scans throughout my term. She didn't bang on about my weight presumably because I couldn't diet by that stage. Is it right that a midwife starts to point fingers and say that mothers are the cause of so many potential problems during their first appointment? In this time, they are supposed to be developing a rapport with the patient so they can also find out other things such as cases of domestic violence, or history of depression. Kathryn, Chester, Cheshire
Yes, there are opportunities to go through this information at a later time, but at the booking-in appointment it isn't always possible."
End QuoteVicky, Midwife, Peterborough
I am currently 37 weeks pregnant and have received no specific advice from my midwife about weight gain/post-pregnancy weight loss. However, there is plenty of advice given in publications produced and provided by the NHS as part of the process. I have the opportunity to ask questions of my midwife, but haven't felt the need. There are lots of resources accessible freely on the internet and in libraries on healthy diets generally, but specifically in pregnancy. Clair, Watford
I have had no help with weight, since becoming pregnant for the second time. After having my first child I had no help from either my midwife or GP about my weight, I noticed they are too busy trying to promote breastfeeding. Maybe they are just way too busy to be able to sit and talk to you about anything because of the amount of people they have to see. Tanya, Birmingham
I'm 13 weeks pregnant with twins. I have found most of the information I need from surfing the web. Most people have internet access now, so with the ever over-stretched NHS, this is a godsend. Helen L, Weymouth, Dorset
Shouldn't healthy eating be your first choice whether you are pregnant or not? Does everyone in this country need to be spoon fed the obvious? Simon Stringer, Barnstaple, Devon
I am a first-time mum-to-be at 37 weeks pregnant. I'm also included in the high-risk category of being obese during pregnancy, with a BMI of over 30. From your article, I appear to be one of the lucky ones and was able to discuss my weight issues with my midwife, so much so that I was referred to an NHS dietician. As a result I've managed to avoid putting on less than half the weight that the average pregnant woman can put on. C Hunter, Isle of Skye
I spent the first six months of my pregnancy in Spain and the final three in the UK, and gave birth here. I have always had a healthy BMI. In Spain my weight was carefully monitored. At one point I was urged to take extreme care, as I had put on a couple of kilos "too quickly". I spent the next month or so eating exceptionally healthily with no sugary or salty snacks at all. Pips, Norwich, Norfolk
I'm a midwife and the first appointment that we have with a pregnant lady is one hour long. In that hour, we have to gain information about their obstetric history, their medical history, their social history, explain scans and blood tests, take some blood if the lady consents, explain the plan of care, refer the lady for her ongoing care and fill out various other paperwork as well as arranging the next appointment. While we do take their BMI index, it often isn't the right time for some women to have their obesity pointed out by a midwife, especially if they have an unexpected pregnancy. Yes, there are opportunities to go through this information at a later time, but at the booking-in appointment it isn't always possible. Vicky, Peterborough
I was asked about how much I weighed at my booking appointment, but have not actually been weighed once throughout my pregnancy or been asked for my weight. I am now in my third trimester. Anke Twigg-Flesner, Gloucestershire
It makes me angry that midwives are being blamed for the failings of women. Why is it a midwives responsibility to give advice about weight loss? If you are overweight before you get pregnant and have done nothing about it, when you become pregnant you can transfer the responsibility onto yet another health professional. Having had weight issues myself and lost a significant amount of weight, it is each individual's responsibility to control what you are putting in your mouth. Alison Martin, Manchester
I am a dietician and also currently pregnant. I feel that midwives are not best placed to provide weight-loss advise and this should be a problem that is dealt with prior to women becoming pregnant. Dieticians are the nutrition experts and should routinely meet newly pregnant women to warn them of the risks of weight gain during pregnancy. Sasha Watkins, London
I am not at all surprised by this. The midwives at the hospital were fantastic but the ones in the community were over-stretched and gave next to no support during my pregnancy. I asked about the size of my bump due to comments. I am a size 8-10 and they said my bump was normal. This was incorrect as I had a 10lb 2oz baby by emergency caesarean section. With the current cuts no more money will be given to improve this though. Sarah, Stratford Upon Avon
Women with high job strain have a 40% increased risk of cardiovascular disease compared with those in less demanding posts, a US study suggests.
They have an 88% raised risk of a heart attack, and more chance of strokes and damage requiring coronary artery bypass surgery, researchers said.
Researchers from Boston's Brigham and Women's Hospital followed 17,415 healthy women for more than 10 years.
The study was presented to the American Heart Association.
Job strain, a form of psychological stress, is defined as having a demanding job that provides limited opportunity for decision making or to use one's creative or individual skills.
The researchers also found job insecurity was also associated with risk factors for cardiovascular disease, such as high blood pressure and obesity - but not directly with poor cardiovascular health.
Stress can trigger the release of hormones such as adrenaline and cortisol, which at persistently high levels are thought to damage the cardiovascular system.
It can also raise inflammation levels which are thought to destabilise the fatty plaques which build up in the blood vessels and can cause circulatory problems.
Experts are concerned that heart disease can be overlooked in women, as it is often mistakenly thought of as a male problem.
Women may have less common symptoms, such as back pain, burning in the chest, abdominal discomfort, nausea, or fatigue, which makes diagnosis more difficult.
They are also less likely to seek medical help, and tend to present late in the process of their disease.
Researcher Dr Michelle Albert said the study suggested job stress had both a short and long-term effect on cardiovascular health.
She also said it was crucial for employers to monitor job stress, and take action to try to alleviate it.
"Job stress results in absenteeism, sickness, and disability, which can reduce productivity and competitiveness," she said.
Previous research has tended to focus on the impact of job stress on men.
Some critics believe it is not stress that causes heart problems - but the unhealthy behaviour, such as smoking and drinking, that some people adopt to try to cope with stress.
Ellen Mason, a senior cardiac nurse at the British Heart Foundation, said the exact mechanism by which stress could change the body's chemistry to raise the risk of heart disease had still to be pinned down.
But she said there was a growing body of research to suggest that it did have a damaging effect on the lining of the arteries.
Too many people are dying in hospitals and care homes, and not at home the way they want to, says a report from Demos.
Of the 500,000 people who die each year in the UK, the think tank found only 18% die at home, yet 60% of people surveyed would like to.
Investing in community-based end of life care would also save the NHS money in the long term, the report says.
The Department of Health is reviewing funding for England. Services in the rest of the UK are funded locally.
The report, entitled Dying for Change predicts that by 2030 more people will die in hospital (65%) and fewer people will die at home (just one in 10 people).
In 10 years, Demos predicts that 20% of people will die in care homes, a figure currently at 17%.
Yet a poll of 2,127 people carried out as part of the report shows that two in three people would prefer to die at home, surrounded by family and friends.
People are dying over a longer period, losing first their memory and then their physical capacities..."
End QuoteCharles LeadbetterDemos
This equates to more than 190,000 people dying in hospital each year when they would rather be at home.
Not everyone who dies in hospital knows they are going to, but many do.
Two in five people who die in hospital do not have curable conditions and most people will be ill for six years before they die.
It is estimated that 20% of hospital beds are currently taken up with caring for people who are dying.
Funding injection
The report says that investing �500m more a year would allow more of these people to die at home or with support in the community.
Setting up new places for people to die close to home, training volunteers to support the terminally ill, a 24-hour nursing support service and an "end of life telephone help line" are all suggestions the report makes on how this money could be spent.
It also proposes setting up a national "hospice at home" service to help support people dying at home.
Demos claims that making this investment would result in fewer and shorter hospital admissions, helping the NHS save money in the long term.
At present, around �20bn of NHS services is spent on end-of-life care.
This is forecast to rise to �25bn in 2030.
Charles Leadbeater, co-author of the Dying for Change report said: "It's not just that we're living longer; part of this means that people are dying over a longer period, losing first their memory and then their physical capacities in stages.
"If we put in the right kind of supports for people to cope at home, many tens of thousands of people could have a chance of achieving what they want at the end of life; to be close to their family and friends, to find a sense of meaning in death."
Care services minister Paul Burstow said the government wanted to ensure that the care people receive at the end of life is "compassionate, appropriate and gives people choices in where they die and how they are cared for".
"Identifying people approaching the end of life and advance care planning is an essential part of this," he said.
"We are consulting on extending patient choice and want to move towards a national choice offer that supports those who wish to die at home."
David Prailll, chief executive of the charity Help the Hospices, said the report would help to stimulate public debate.
"It also makes some very interesting suggestions about specific practical steps that could be taken at a national level and these merit deeper investigation."
"Seventy per cent of hospice care takes place in people's homes and a growing number of hospices - already over two-thirds - provide support to care homes to make sure residents get the palliative care they need," he said.
BBC News website readers have been sending in their reaction. Here is a selection of comments:
My husband was terminally ill with Angio Sarcoma at Guy's Hospital in August 2004. The doctor came to tell him that the cancer has spread to his other lung too. My husband said he would like to go home and yet the doctor made me feel that it would be more suitable if he stayed in the hospital. I did not understand why it would be more suitable for him to stay there. He died four days later. He was so sedated that he died without us getting a chance to say goodbye to him. I still keep worrying that I let him down by not insisting on him coming home. I still have not got over the way he died. It was so impersonal. Ranjna, London
My father died at home several years ago, which was his wish. He had been in and out of hospital and spent time in a local hospice, but it was at home where he wanted to be, and where my mother could best care for him. The GP was superb, there was a district nurse visiting regularly to help us prepare for his death, and although desperately sad for the family, it was what he and my mother wanted, and they were at peace with that. Penny, Dorset
I lost my mum and although she was totally dependant on me in the last years of her life, when it came to the end she died in hospital. I suppose because I couldn't bear to be alone when she died, not knowing if I was doing everything to make her going as painless as possible. I know in my heart that she would have forgiven me taking her in hospital but it is so hard for the loved ones to make that decision. We all, in an ideal world, would like to just go to sleep in our own bed at the end but real life isn't like that. Daisy, Reading
My mother died today in a care home. In her last few weeks she has needed continuous care and kindness to keep her clean, as she was incontinent. A hoist was needed to raise her weak body and a special bed was used to prevent bed sores and aid her in being fed. It is a nice idea that we should all die where we want to but life is not like that. My mother would also not have wanted to die in a care home but as it happens she had dementia and didn't know where she was. She had the very best of care, the bedroom was equivalent to her bedroom at home, so what is wrong with that? People would not get 24 hour care if they stayed in their own homes and the expense would be enormous if they privately hired a 24 hour a day carer. Christine, Portsmouth
I work for the NHS and it is very frustrating that patients can't die at home because of the paperwork. Sometimes it is also very dependent on your postcode. If your GP is in one PCT and you live in the next borough, you are not entitled to services as they do not receive from that borough. I speak from experience as I have recently had battles with two PCT's in getting services so that my patient could die at home. One solution given to me was that the patient changes his GP, but this is not always suitable when you have been with a particular GP and have built a relationship. As a health care professional I try very hard to give my patients the choice of dying at home. Suki, Harrow
My mum passed away only a couple of months ago and it was her wish to die in hospital. She was terrified of dying at home for many reasons. I have to say that the hospital was superb and cared for her wonderfully and I can also say she died feeling safe. Whilst many people do wish to die at home, it should be realised that many people feel safer in a medical situation, where there are nurses and doctors around to make them comfortable. Rob, Lancashire
My mother was able to die at home but only because of my persistence. She had a major stroke on 18 June and was in hospital for four days. She had signed a "Living Will" five years before and we knew her wishes, so she was not being artificially fed but just kept comfortable. When she indicated her wish to go home, the hospital made it appear an impossibility. Luckily I have friends in the NHS and was able to take their advice and through the "Fast Track for the terminally ill" was able to get her home within 24 hours. She had 36 hours in her own bedroom before dying. Jinny, Wales
Recently-bereaved people have heart rhythm changes which may make some of them more vulnerable to health problems, say researchers.
The University of Sydney study, released at a US heart conference, monitored the hearts of 78 bereaved spouses and parents.
They beat faster on average than unaffected volunteers, with more common periods of very rapid heart rates.
A UK specialist recommended check-ups for those with-existing heart problems.
It is known that the trauma of bereavement can mean an increased risk of heart attacks and strokes in the months immediately following the death of a close relative.
The Australian team asked people whose relative had died in hospital two weeks earlier to wear heart monitors 24 hours a day to try to reveal any underlying changes which might be contributing to this.
Some bereaved, especially those already at increased cardiovascular risk, might benefit from medical review"
End QuoteDr Thomas BuckleyUniversity of Sydney
They found that the average heart rate following bereavement was 75 beats per minute, compared to 70.7 in unaffected volunteers.
However, this was accompanied by twice the normal number of periods where the heartbeat accelerated to higher than normal levels, called tachycardia.
This alone does not cause serious heart problems - rapid heartbeats can be a normal by-product of stress and anxiety.
Lead researcher Dr Thomas Buckley said that it might, however, be enough to trigger an attack in someone with pre-existing heart disease.
"While the focus at the time of bereavement is naturally directed toward the deceased person, the health and welfare of bereaved survivors should also be of concern," he said.
"Some bereaved, especially those already at increased cardiovascular risk, might benefit from medical review, and they should seek medical assistance for any possible cardiac symptoms."
Return to normal
The study found that, six months after bereavement, heart rhythms had returned to normal.
Dr Richard Stein, from New York University School of Medicine, said that the study was an "important first step" to understanding how bereavement could affect health.
He said that, wherever possible, the bereaved should try to take moderate exercise and seek out social support.
He said: "Understanding that this is a high risk time, perhaps paying a visit to your doctor, having your blood pressure taken, looking for other illness problems, is an important thing to do.
"In the context of grieving it's hard to do that, but the tragedy of a death of a loved one would be an even greater tragedy if it preceded your own serious illness."
Psychiatrist Dr Colin Murray Parkes, an advisor to bereavement charity CRUSE, said that it was important for bereaved people not to panic if they felt an increased heart rate.
He said: "An increased heart rate can be a perfectly normal response to the anxiety of being bereaved.
"If you are worried, then consult your doctor, but not with the assumption that anything is wrong.
"If you have pre-existing heart disease, then you may well benefit from a check-up at the time."
Further research is needed to confirm and quantify its benefits and to establish just which patients are likely to benefit. "
End QuoteProfessor Peter WeissbergBritish Heart Foundation
At the moment it is recommended that if there is no sign of consciousness three days after re-warming, then doctors should consider ending life support.
'Alert and conscious'
However, the evidence from the two US studies may put this in question.
One, from a Baltimore hospital, looked at 47 patients, and found that, after three days, none of the patients given hypothermia were alert and conscious, although by day seven, 33% had woken up.
Another from Minnesota hospitals examined 66 cases, and found a handful in which recovery began after the three day mark - one patient awoke after more than 10 days.
It suggested that continuing life support after three days could mean 10% more people surviving with little or no noticeable brain damage.
The third, a larger study of 298 patients receiving hypothermia treatment at a variety of hospitals, also concluded that there was a wide degree of variation in the time it took such patients to start recovering.
In the UK, while some hospitals have introduced therapeutic hypothermia on an experimental basis, it is yet to be accepted as standard practice.
Professor Peter Weissberg from the British Heart Foundation, said: "Therapeutic hypothermia for patients who have suffered a cardiac arrest is being considered at some hospitals in the UK, but further research is needed to confirm and quantify its benefits and to establish just which patients are likely to benefit from its use before it can be adopted as a routine therapy."
Dr John Griffiths is an intensive care specialist at the John Radcliffe Hospital in Oxford, one of those which uses the technique on some patients.
He said that there had been suggestions for the technique to be offered as standard practice in some cases.
He said it was still regarded with some caution, with no certainty that it could improve the outcome for many patients, either in terms of pure survival, or reducing the amount of brain damage they suffered.
He said: "We have to make sure that it fits with the way that patients are treated at UK centres."
One example was the concern that cooling could actually contribute to heart rhythm problems, a potential issue if the patient is being taken immediately into the operating theatre.
"There are lots of unresolved questions - who should do it, when it should be done, how it should be done and where should it be done?" he added.
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