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In patients on oral anticoagulant (OAC) therapy undergoing percutaneous coronary intervention with stent (PCI), international guidelines endorse the use of direct oral anticoagulants (DOAC) rather than vitamin K antagonists (VKA) and dual antithrombotic therapy (DAT) rather than triple antithrombotic therapy (TAT). Aim of this study was to evaluate contemporary real-world data on antithrombotic regimens and outcome in patients on OAC undergoing PCI with stent. Consecutive patients on OAC undergoing PCI were enrolled in the multicentre, prospective, observational PERSEO registry (NCT03392948). Primary end-point was net adverse clinical events (NACE) with VKA vs DOAC, whereas a secondary pre-specified end-point was NACE with DAT vs TAT both at 1-year follow-up. From February 2018 to February 2022, 1234 consecutive patients were included. The main indication for OAC was atrial fibrillation (86%) and the mean CHA2DS2VASc and HAS-BLED scores were 4±2 and 3.6±1, respectively. Of the 1228 patients discharged alive, 222 (18%) were on VKA and 1006 (82%) on DOAC (p<0.01). DAT was employed in 197 patients whereas TAT in 1028. At follow-up, NACE rate was significantly higher with VKA compared to DOAC (23% vs 16%, p=0.013) and confirmed after propensity score adjustment. TAT and DAT did not differ as regards NACE rate (17% vs 19%, p=0.864) even though, compared to TAT, DAT was associated with less major bleedings (2% vs 5%, p= 0.014), confirmed after propensity score adjustment. In conclusion, in patients on OAC undergoing PCI, DOAC, compared to VKA, was associated with a significantly lower occurrence of NACE and DAT reduced bleedings compared to TAT.
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PURPOSE OF REVIEW: This review provides a concise and complete overview of diagnostic work-up and treatment of venous thromboembolism in pregnancy, with attention to recent research developments and recent applicable guidelines. This may be useful for all the players of the multidisciplinary interaction needed in this disease management, namely cardiologists and gynecological/obstetric teams. RECENT FINDINGS: Venous thromboembolism is, in the developed world, a major cause of maternal morbidity and mortality during pregnancy or early after delivery, with a reported incidence ranging from 0.49 to 2.0 events per 1000 deliveries. It is a particularly challenging issue and there is no common consensus on the major themes of this condition. Diagnostic options, prophylaxis and management, in the antenatal, childbirth and postnatal periods, are carefully analyzed in the light of the most recent published data. Besides, old and recent knowledge must be seen through the clinician's skilled and watchful eyes, deciding on a case-to-case and actively contributing in reducing pregnancy-related morbidity. SUMMARY: Although there is an ongoing debate on various aspects of this condition and there is a paucity of high-quality studies, this review attempts to simplify the complex aspects of joining safety and efficacy in diagnosing and treating a possible two-people life-threatening disease.
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Saúde Global , Guias de Prática Clínica como Assunto , Complicações Cardiovasculares na Gravidez/diagnóstico , Tromboembolia Venosa/diagnóstico , Feminino , Humanos , Período Pós-Parto , Gravidez , Complicações Cardiovasculares na Gravidez/epidemiologia , Complicações Cardiovasculares na Gravidez/prevenção & controle , Complicações Cardiovasculares na Gravidez/terapia , Recidiva , Fatores de Risco , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/prevenção & controle , Tromboembolia Venosa/terapiaRESUMO
In the present study, we tested the hypothesis that chronic treatment with the direct rennin inhibitor aliskiren improves the remodelling of resistance arteries in dTGR (double-transgenic rats). dTGR (5 weeks) were treated with aliskiren (3 mg/kg of body mass per day) or ramipril (1 mg/kg of body mass per day) for 14 days and compared with age-matched vehicle-treated dTGR. BP (blood pressure) was similarly reduced in both aliskiren-treated and ramipril-treated rats compared with control dTGR (167±1 and 169±2 mmHg compared with 197±4 mmHg respectively; P<0.05). The M/L (media-to-lumen) ratio assessed on pressurized preparations was equally reduced in aliskiren-treated and ramipril-treated rats compared with controls (6.3±0.5 and 6.4±0.2% compared with 9.8±0.4% respectively; P<0.05). Endothelium-dependent and -independent relaxations were similar among the groups. L-NAME (N(G)-nitro-L-arginine methyl ester) significantly reduced acetylcholine-induced dilation in drug-treated dTGR. This effect was significantly more prominent in aliskiren-treated rats. eNOS (endothelial NO synthase) expression showed a 2-fold increase only in aliskiren-treated dTGR as compared with controls (P<0.01) and ramipril-treated dTGR (P<0.05). Plasma nitrite, as an index of NO production, was significantly increased in dTGR treated with either aliskiren or ramipril compared with controls. Only aliskiren induced a 2-fold increase in plasma nitrite, which was significantly greater than that induced by ramipril (P<0.05). gp91(phox) expression and ROS (reactive oxygen species) production in aorta were significantly and similarly reduced by both drugs. In conclusion, equieffective hypotensive doses of aliskiren or ramipril reduced the M/L ratio of mesenteric arteries and improved oxidative stress in dTGR. However, only aliskiren increased further NO production in the vasculature. Hence, in dTGR, direct renin inhibition induces favourable effects similar to that induced by ACE (angiotensin-converting enzyme) inhibition in improving vascular remodelling through different mechanisms.
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Amidas/farmacologia , Angiotensinogênio/genética , Fumaratos/farmacologia , Músculo Liso Vascular/efeitos dos fármacos , Renina/antagonistas & inibidores , Renina/genética , Inibidores da Enzima Conversora de Angiotensina/farmacologia , Animais , Aorta/efeitos dos fármacos , Aorta/fisiologia , Pressão Sanguínea/efeitos dos fármacos , Humanos , Técnicas In Vitro , Masculino , Artéria Mesentérica Superior/efeitos dos fármacos , Artéria Mesentérica Superior/fisiologia , Contração Muscular/efeitos dos fármacos , Relaxamento Muscular/efeitos dos fármacos , Músculo Liso Vascular/fisiologia , Óxido Nítrico/metabolismo , Ramipril/farmacologia , Ratos , Ratos Transgênicos , Espécies Reativas de Oxigênio/metabolismo , Resistência VascularRESUMO
AIM: Percutaneous coronary intervention with stent implantation (PCI-S) in patients requiring chronic oral anticoagulant therapy (OAC) is associated with an increased risk of bleeding and ischemic complications. Different randomized studies showed a significant advantage of a double antithrombotic therapy and superiority of direct oral anticoagulant (DOAC) compared with warfarin, but real-world data are limited. Aim is to evaluate the antithrombotic management and clinical outcome of patients with an indication for OAC who undergo PCI-S in a 'real-world' setting. METHODS: The multicentre prospective observational PERSEO (PERcutaneouS coronary intErventions in patients treated with Oral anticoagulant therapy) Registry (ClinicalTrials.gov Identifier: NCT03392948) has been designed to enrol patients requiring OAC treated by PCI-S in 25 Italian centres. A target of at least 1080 patients will be followed for 1âyear and data on thromboembolic and bleeding events and changes in antithrombotic therapy will be registered. The primary end point is a combined measure of efficacy and safety outcome (NACE), including major bleeding events and major adverse cardiac and cerebral events at 1-year follow-up in patients treated with DOAC (and dual or triple antiplatelet therapy) compared with the corresponding strategies with vitamin K antagonists. A secondary prespecified analysis has been defined to evaluate NACE in dual versus triple antithrombotic therapy after hospital discharge at 1-year follow-up. CONCLUSION: The PERSEO Registry will investigate in a 'real world' setting the safety and efficacy of DOAC versus warfarin and dual versus triple antithrombotic therapy in patients with indication for oral anticoagulant therapy who undergo PCI-S.
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Fibrilação Atrial , Doença da Artéria Coronariana , Intervenção Coronária Percutânea , Administração Oral , Anticoagulantes , Fibrilação Atrial/tratamento farmacológico , Doença da Artéria Coronariana/tratamento farmacológico , Doença da Artéria Coronariana/terapia , Quimioterapia Combinada , Fibrinolíticos/uso terapêutico , Hemorragia/etiologia , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Inibidores da Agregação Plaquetária , Sistema de Registros , Stents , Vitamina K , VarfarinaRESUMO
Objectives: The UEFA 2020 European Football Championship held in multiple cities across Europe from June 11 to July 11, 2021, was won by Italy, providing an opportunity to examine the relationship between emotional stress and the incidence of acute cardiovascular events (ACE). Methods and results: Cardiovascular hospitalizations in the Cardiac Care Units of 49 hospital networks in Italy were assessed by emergency physicians during the UEFA Euro 2020 Football Championship. We compared the events that occurred during matches involving Italy with events that occurred during the remaining days of the championship as the control period. ACE was assessed in 1,235 patients. ACE during the UEFA Euro 2020 Football Championship semifinal and final, the most stressful matches ended with penalties and victory of the Italian team, were assessed. A significant increase in the incidence of Takotsubo Syndrome (TTS) by a factor of 11.41 (1.6-495.1, P < 0.003), as compared with the control period, was demonstrated during the semifinal and final, whereas no differences were found in the incidence of ACS [IRR 0.93(0.74-1.18), P = 0.57]. No differences in the incidence of ACS [IRR 0.98 (0.87-1.11; P = 0.80)] or TTS [IRR 1.66(0.80-3.4), P = 0.14] were found in the entire period including all matches of the UEFA Euro 2020 compared to the control period. Conclusions: The data of this national registry demonstrated an association between the semifinal and final of UEFA Euro 2020 and TTS suggesting that it can be triggered by also positive emotions such as the victory in the European Football Championship finals.
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BACKGROUND: Different tools and devices are effective to reduce operator radiation exposure at thorax level during percutaneous coronary procedures, but the operator radiation dose received at pelvic region still remains high. Our aim was to evaluate the efficacy of under-the-table adjunctive shields to reduce operator radiation exposure during percutaneous coronary procedures Methods and Results: The EXTRA-RAD study (Extended Protective Shield Under Table to Reduce Operator Radiation Dose in Percutaneous Coronary Procedures) is a prospective, single-center, randomized study. Patients who underwent transradial coronary procedures were randomized into 2 groups: group 1 (standard arrangement) and group 2 (adjunctive anti-rx shield under the angiographic table). In group 2, a further randomization was performed to compare 2 different under-the-table shields (a small curtain and a drape). A total of 205 procedures (122 diagnostic coronary angiographies and 83 percutaneous coronary interventions) performed in 157 patients by 4 different operators were included without significant differences in clinical and procedural characteristics between groups. The use of adjunctive shields was associated with lower radiation dose compared with no shield at pelvic region (42 µSv [14-98] in group 1, 13 µSv [5-27] in group 2; P<0.0001) and also at thorax level (4 µSv [1-13] in group 1, 2 µSv [1-4] in group 2; P=0.001). The reduction in dose was observed in all the operators. No significant differences were observed in pelvic dose using the 2 different shields ( P=0.183). CONCLUSIONS: The use of adjunctive anti-rx shields under the angiographic table during transradial coronary procedures is associated with a significant lower radiation dose to operators at pelvic and thorax level. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03259126.
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Angiografia Coronária , Exposição Ocupacional/prevenção & controle , Saúde Ocupacional , Mesas Cirúrgicas , Intervenção Coronária Percutânea , Doses de Radiação , Exposição à Radiação/prevenção & controle , Proteção Radiológica/instrumentação , Radiografia Intervencionista , Campos Cirúrgicos , Idoso , Angiografia Coronária/efeitos adversos , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Exposição Ocupacional/efeitos adversos , Intervenção Coronária Percutânea/efeitos adversos , Estudos Prospectivos , Exposição à Radiação/efeitos adversos , Radiografia Intervencionista/efeitos adversos , Medição de Risco , Fatores de Risco , Cidade de RomaRESUMO
In women with hypertrophic cardiomyopathy (HCM), pregnancy prompts major changes in hemodynamic and cardiac autonomic function that may precipitate heart failure (HF) or increase the risk of cardiac arrhythmia. We report the clinical follow-up of two patients with non-obstructive HCM implanted with a cardioverter defibrillator (ICD) allowing for continuous analysis of heart rate (HR), heart rate variability (HRV) and cardiac arrhythmia throughout the entire course of pregnancy. Both patients experienced increased HR and decreased HRV from the early stages of pregnancy, which persisted until delivery. Premature ventricular contractions (PVCs) and runs of non-sustained ventricular tachycardia (NSVT) reached a peak in the second and third trimesters, concurrent with sympathetic hyperactivity. In one patient with baseline NYHA class II HF symptoms, increased PVCs and NSVT were consistent with the deterioration of HF, supporting the decision to bring the delivery forward. While both patients experienced a persistent increase in sympathetic tone and ventricular ectopic activity, no life-threatening arrhythmias were documented. During pregnancy, patients with hypertrophic cardiomyopathy develop progressive neuroautonomic imbalance, prompting an increase in non-sustained ventricular arrhythmia. This enhanced arrhythmia burden warrants close follow-up and rhythm assessment during the third trimester, especially in women who have heart failure symptoms before pregnancy. Implantable cardioverter defibrillators provide a continuous analysis of heart rate variability and arrhythmia burden that supports therapeutic decision-making during follow-up.
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Arritmias Cardíacas/terapia , Desfibriladores Implantáveis , Complicações Cardiovasculares na Gravidez/terapia , Adulto , Arritmias Cardíacas/etiologia , Sistema Nervoso Autônomo/fisiopatologia , Cardiomiopatia Hipertrófica/complicações , Cardiomiopatia Hipertrófica/fisiopatologia , Feminino , Frequência Cardíaca , Humanos , Gravidez , Complicações Cardiovasculares na Gravidez/etiologiaRESUMO
BACKGROUND: As benefits of revascularization in non-ST elevation acute coronary syndromes (NSTEACSs) in the elderly are still unproven, we sought to assess the association between invasive or conservative management of NSTEACS and short-, mid- and long-term mortality or composite outcome of all-cause mortality and myocardial infarction in a cohort of consecutive elderly patients. METHODS AND RESULTS: Consecutive NSTEACS patients older than 75 years discharged between 2006 and 2010 from a single intensive cardiac care unit, and managed with invasive or conservative strategy according to available guidelines were retrospectively surveyed. By multivariate regression and sensitivity analysis, crude and adjusted mortality and composite outcome were estimated at prespecified time points of short-term (in-hospital or 30 days mortality), mid-term (T1: 31 days to 6 months), and long-term (T2: 31 days to 12 months). A total of 453 patients (median age 80 years, 47% men) were evaluated; 301 (66.5%) underwent invasive treatment. Invasive was associated with significantly lower risk of short- [odds ratio (OR) 0.28, 95% confidence interval (CI) 0.12-0.67, Pâ=â0.004], mid- (OR 0.33, 95% CI 0.16-0.67, Pâ=â0.003) and long-term mortality (OR 0.34, 95% CI 0.20-0.58, Pâ<â.0001). Invasive strategy was also associated with nonsignificant lower short- (OR 0.55, 95% CI 0.28-1.07, Pâ=â0.077), and highly significant lower mid- (OR 0.52, 95% CI 0.34-0.81, Pâ=â0.003) and long-term adjusted cumulative composite outcome rate (OR 0.68, 95% CI 0.46-0.98, Pâ=â0.004). CONCLUSION: In NSTEACS elderly patients, invasive strategy is independently associated with lower short-, mid- and long-term mortality and composite outcome.
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Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/cirurgia , Ponte de Artéria Coronária/efeitos adversos , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/cirurgia , Intervenção Coronária Percutânea/efeitos adversos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Angiografia Coronária , Feminino , Humanos , Itália , Masculino , Análise Multivariada , Análise de Regressão , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoAssuntos
Angioplastia com Balão/instrumentação , Tronco Braquiocefálico/lesões , Cateterismo Periférico/efeitos adversos , Estenose Coronária/terapia , Edema/terapia , Hematoma/terapia , Lesões do Pescoço/terapia , Infarto do Miocárdio sem Supradesnível do Segmento ST/terapia , Intervenção Coronária Percutânea , Artéria Radial , Stents , Lesões do Sistema Vascular/terapia , Idoso de 80 Anos ou mais , Tronco Braquiocefálico/diagnóstico por imagem , Estenose Coronária/diagnóstico por imagem , Edema/diagnóstico por imagem , Edema/etiologia , Feminino , Hematoma/diagnóstico por imagem , Hematoma/etiologia , Humanos , Lesões do Pescoço/diagnóstico por imagem , Lesões do Pescoço/etiologia , Infarto do Miocárdio sem Supradesnível do Segmento ST/diagnóstico por imagem , Artéria Radial/diagnóstico por imagem , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/etiologiaRESUMO
We aimed to revise the increasingly accruing data about the association between anti-tyrosinkinase, "targeted" cancer drugs and the development of arterial thrombotic events or acute coronary syndromes. Further insights into the involved pathophysiologic mechanisms, and into the clinical implications are overviewed. Antiangiogenesis has become a mainstream of cancer therapy, leading to development of a specific class of drugs. Besides, a "wider" angiogenesis network made up of several growth factors, can be recognized as target of a higher number of compounds. Their widespread use has been progressively favored over conventional chemotherapy, because of their better safety/efficacy profile, even allowing a prolonged administration. However, there is a growing awareness of an association between these useful drugs and serious cardiovascular side effects including myocardial infarction, stroke, heart failure and cardiovascular death, in addition to the known relation with the most frequent hypertension onset. Observational studies indeed report that combined cardiovascular events may reach figures of 20-40%, and, for their management, several monitoring, diagnostic and therapeutic regimens have been suggested. On the basis of the available data we recommend an active screening program for acute coronary syndromes in the "at risk" period, immediately after the beginning of the "targeted" drug therapy, and during the whole administration time. Likewise, a mandatory cardiological specialistic evaluation is warranted to plan a schedule of follow-up evaluations for diagnostics, including ECG, echocardiogram, and multimarker evaluation. An appropriate treatment with antiplatelet or anticoagulant drugs, endothelial protective agents or cardiovascular interventions is similarly advised.
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Síndrome Coronariana Aguda/induzido quimicamente , Inibidores da Angiogênese/administração & dosagem , Antineoplásicos/efeitos adversos , Cardiologia/normas , Oncologia/normas , Papel do Médico , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/epidemiologia , Inibidores da Angiogênese/efeitos adversos , Animais , Antineoplásicos/administração & dosagem , Cardiologia/métodos , Humanos , Peptídeos e Proteínas de Sinalização Intercelular/metabolismo , Oncologia/métodos , Neoplasias/tratamento farmacológico , Neoplasias/epidemiologia , Inibidores da Agregação Plaquetária/administração & dosagem , Inibidores da Agregação Plaquetária/efeitos adversosRESUMO
Essential hypertension is characterized by increased peripheral vascular resistance to blood flow. The endothelium is a crucial regulator of vascular tone. Its function is impaired in patients with hypertension, with reduced vasodilation, increased vascular tone associated with a proinflammatory and prothrombotic state. Low-grade inflammation localized in vascular tissue is therefore recognized as an important contributor to the pathophysiology of hypertension, to the initiation and progression of atherosclerosis as well as to the development of cardiovascular diseases.