RESUMO
AIM: The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS: A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE: Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
Assuntos
American Heart Association , Extremidade Inferior , Doença Arterial Periférica , Humanos , Doença Arterial Periférica/terapia , Doença Arterial Periférica/diagnóstico , Extremidade Inferior/irrigação sanguínea , Estados Unidos , Cardiologia/normasRESUMO
AIM: The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS: A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE: Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
Assuntos
American Heart Association , Extremidade Inferior , Doença Arterial Periférica , Humanos , Doença Arterial Periférica/terapia , Doença Arterial Periférica/diagnóstico , Extremidade Inferior/irrigação sanguínea , Estados Unidos , Cardiologia/normas , Sociedades Médicas/normasRESUMO
Venous thromboembolism (VTE) is a common vascular condition. New medications are available to prevent hospital-associated VTE. Strategies are being studied to increase appropriate diagnostic testing utilization. Management of deep vein thrombosis (DVT) and pulmonary embolism (PE) has evolved with the advent of new anticoagulant options and catheter-directed intervention. In light of this, providers are commonly challenged with the decision regarding inpatient versus outpatient management. Which patients require long-term (> 3 months) anticoagulation is challenging and multiple clinical prediction models may be used to help determine the risk-benefit ratio in each patient. The management of VTE is an ongoing area of research and is rapidly evolving.
Assuntos
Anticoagulantes/administração & dosagem , Fibrinolíticos/administração & dosagem , Terapia Trombolítica/métodos , Tromboembolia Venosa/tratamento farmacológico , Anticoagulantes/efeitos adversos , Tomada de Decisão Clínica , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Seleção de Pacientes , Recidiva , Medição de Risco , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Tromboembolia Venosa/sangue , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/epidemiologiaRESUMO
Management of intermediate and high risk acute pulmonary embolism (PE) is challenging. The role of multidisciplinary teams for the care of these patients is emerging. Herein, we report our experience with a pulmonary embolism response team (PERT). We conducted a retrospective chart review on all patients admitted to the Cleveland Clinic main campus who required activation of the (PERT) from October 1, 2014 to September 1, 2016. We extracted data pertaining to clinical presentation, bleeding complications, and pre- and post-discharge imaging. Patients were classified as low, intermediate or high risk PE. Descriptive and continuous variables were collected and analyzed. There were 134 PERT activations. PE was confirmed by CT-PA in 118 patients. Fifteen (13%) patients were classified as low risk, 80 (68%) intermediate risk PE and 23 (19%) high risk PE. Fourteen (12%) patients were treated with catheter directed rtPA, 6 (5%) received full dose (100 mg rtPA), 16 (13%) received systemic half-dose (50 mg rtPA), 6 (5%) underwent a surgical embolectomy and 4 (3%) underwent mechanical thrombectomy. 65 (55%) patients received anticoagulation only, and 8 (7%) patients were managed conservatively without any anticoagulation or advanced therapy. 11 (9%) patients died while during the hospitalization. Fourteen patients had major bleeding events. There were no bleeding events among patients who received systemic low dose or full dose rtPA. A multidisciplinary approach to cases of intermediate risk and high risk PE can be implemented successfully. We saw a relatively low rate of bleeding events with use of rtPA.
Assuntos
Equipe de Assistência ao Paciente/normas , Embolia Pulmonar/terapia , Adulto , Idoso , Anticoagulantes/uso terapêutico , Gerenciamento Clínico , Embolectomia , Hemorragia/induzido quimicamente , Hemorragia/etiologia , Humanos , Pessoa de Meia-Idade , Embolia Pulmonar/complicações , Estudos Retrospectivos , Medição de Risco , Trombectomia , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/uso terapêuticoAssuntos
Dor Abdominal/etiologia , Hipóxia/etiologia , Perna (Membro)/irrigação sanguínea , Embolia Pulmonar/diagnóstico , Trombose Venosa/diagnóstico , Idoso , Eletrocardiografia , Serviço Hospitalar de Emergência , Humanos , Masculino , Embolia Pulmonar/complicações , Pulso Arterial , Tomografia Computadorizada por Raios X , Trombose Venosa/complicaçõesRESUMO
BACKGROUND: We present a case series of upper extremity fibromuscular dysplasia (UE FMD) consisting of 22 patients from two tertiary referral centers focusing on clinical presentation, diagnostic findings, and interventional outcomes. FMD is a noninflammatory, nonatherosclerotic arteriopathy that has a predisposition for middle-aged women. Involvement of the UE is thought to be rare. Patients with UE FMD can present with claudication or ischemia, or they can be incidentally diagnosed. The treatment approach is dictated by clinical presentation. METHODS: Data were collected of patients with UE FMD evaluated at two centers. Demographic data, presenting UE symptoms, UE arteries involved, FMD type, diagnostic method, physical examination findings, management, and outcomes were included. RESULTS: Twenty-two patients (29 limbs) were diagnosed with UE FMD. The brachial artery was most commonly involved (89.7% of affected limbs). More than half of limbs (n = 15 of 29 limbs [51.7%]) were asymptomatic, and of those who presented with symptoms, the most common symptoms were ischemic fingers or hand (31% of all affected limbs) and hand or arm claudication (27.6% of all affected limbs). UE FMD was noted on catheter angiography in 58.6% (n = 17 of 29 limbs), duplex ultrasound in 41.4% (n = 12 of 29 limbs), and computed tomography angiography in 27.6% (n = 8 of 29 limbs). Of the symptomatic limbs (n = 14), the majority were treated solely with medical therapy as the first intervention (57.1%). For symptomatic limbs treated with vascular intervention (n = 5), angioplasty was most commonly performed. Only 4 of the 14 limbs (28.6%) had complete symptomatic relief after the initial first intervention, in which 2 limbs were treated with medical therapy, 1 limb underwent angioplasty, and 1 limb had resolution of symptoms despite deferment of any therapy. Of the 10 limbs with residual symptoms after the first intervention, 6 limbs underwent a second intervention: angioplasty in 2 limbs initially treated medically (33.3%), surgical bypass in 2 limbs initially treated with angioplasty, surgical bypass in 1 limb initially treated with medical therapy, and sympathectomy in 1 limb (16.7%) initially treated with angioplasty. Both surgical bypass and angioplasty as secondary interventions resulted in complete symptom relief. CONCLUSIONS: Presenting symptoms for patients with UE FMD vary in severity from asymptomatic disease to digital ischemia. More than half of symptomatic limbs eventually require at least one invasive intervention for complete relief of symptoms.
Assuntos
Angioplastia , Fármacos Cardiovasculares/uso terapêutico , Displasia Fibromuscular/diagnóstico , Displasia Fibromuscular/terapia , Isquemia/diagnóstico , Isquemia/terapia , Extremidade Superior/irrigação sanguínea , Enxerto Vascular , Adolescente , Adulto , Idoso , Angioplastia/efeitos adversos , Doenças Assintomáticas , Fármacos Cardiovasculares/efeitos adversos , Criança , Pré-Escolar , Angiografia por Tomografia Computadorizada , Displasia Fibromuscular/complicações , Displasia Fibromuscular/fisiopatologia , Humanos , Isquemia/etiologia , Isquemia/fisiopatologia , Pessoa de Meia-Idade , Ohio , Exame Físico , Valor Preditivo dos Testes , Estudos Retrospectivos , Índice de Gravidade de Doença , Centros de Atenção Terciária , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Dupla , Enxerto Vascular/efeitos adversos , Virginia , Adulto JovemRESUMO
Pulmonary embolism (PE) is a common thrombotic event that is variable in its presentation. Depending on the patients' risk for mortality, guidelines provide several treatment strategies including thrombolysis, catheter-directed therapies, pulmonary embolectomy, anticoagulation, and inferior vena cava filters. However, there is considerable disagreement between guidelines regarding the optimal treatment strategy for patients, particularly for those with intermediate-risk PE. In order to provide rapid and individualized care, PE response teams (PERT) have been developed. These teams consist of members from different specialties with a particular interest in PE, varying technical skills, and clinical experience, thereby allowing for a multidisciplinary approach. PERT allows for consensus decision making, and for rapid intervention in patients whose conditions worsen. In this review, we provide an overview of treatment guidelines for PE, and of results from recent clinical trials involving patients with submassive PE. In addition, we discuss an outline of our approach and use of PERT.
Assuntos
Anticoagulantes/administração & dosagem , Embolectomia/métodos , Medicina de Precisão/métodos , Embolia Pulmonar , Filtros de Veia Cava , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/terapiaRESUMO
OPINION STATEMENT: Fibromuscular dysplasia (FMD) is an arteriopathy of unknown etiology which has traditionally been associated with secondary hypertension; however, it has garnered increased attention in the cardiology field in the recent years because of its potential association with spontaneous coronary artery dissection. Cardiologists should be aware that FMD is a polyvascular disease which can affect any arterial bed and can result in morbid conditions such as chronic headaches, pulsatile tinnitus, stroke from cervical artery dissection, and renal infarction from renal artery dissection and has also been associated with increased prevalence of arterial aneurysm, including brain aneurysm. For these reasons, some experts recommend panvascular imaging from head-to-pelvis upon diagnosis for screening purposes and targeted imaging surveillance after diagnosis. When necessary, endovascular intervention with angioplasty alone is the preferred modality, though there are still situations which require surgical intervention. Patients with FMD may benefit from a multispecialty team approach for optimal treatment.
Assuntos
Migração de Corpo Estranho/etiologia , Hipertensão Renovascular/etiologia , Doença Iatrogênica , Obstrução da Artéria Renal/etiologia , Artéria Renal , Filtros de Veia Cava/efeitos adversos , Adulto , Angiografia Digital , Remoção de Dispositivo , Feminino , Migração de Corpo Estranho/diagnóstico por imagem , Migração de Corpo Estranho/cirurgia , Humanos , Hipertensão Renovascular/diagnóstico , Hipertensão Renovascular/cirurgia , Angiografia por Ressonância Magnética , Valor Preditivo dos Testes , Procedimentos de Cirurgia Plástica , Artéria Renal/diagnóstico por imagem , Artéria Renal/cirurgia , Obstrução da Artéria Renal/diagnóstico por imagem , Obstrução da Artéria Renal/cirurgia , Ultrassonografia de IntervençãoRESUMO
INTRODUCTION: K201, a 1,4-benzodiazepine derivative, acts on multiple cardiac ion channels and the ryanodine receptor. We tested whether administration of M-II, the main metabolite of K201, would terminate induced atrial flutter (AFL) or atrial fibrillation (AF) in the canine sterile pericarditis model. METHODS: In 6 dogs, electrophysiologic studies were performed at baseline and after drug administration, measuring atrial effective refractory period (AERP), and conduction time from 3 sites during pacing at cycle lengths (400, 300, and 200 milliseconds) on postoperative days 1-4. In 12 induced episodes of sustained AF/AFL (2/10, respectively), M-II was administered intravenously to test efficacy. Five of the AFL episodes were studied in the open chest state during simultaneous multisite atrial mapping. RESULTS: M-II terminated 2/2 AF and 8/10 AFL episodes, prolonged AERP (P < 0.05), significantly increased atrial pacing capture thresholds but did not significantly change atrial conduction time. AFL CL prolongation was largely explained by prolonged conduction in an area of slow conduction in the reentrant circuit. AFL terminated with block in the area of slow conduction. CONCLUSIONS: M-II was very effective in terminating AFL/AF in the canine sterile pericarditis model. AFL terminated due to block in the area of slow conduction of the reentrant circuit.
Assuntos
Antiarrítmicos/farmacologia , Fibrilação Atrial/tratamento farmacológico , Flutter Atrial/tratamento farmacológico , Sistema de Condução Cardíaco/efeitos dos fármacos , Pericardite/complicações , Tiazepinas/farmacologia , Tiazolidinedionas/farmacologia , Animais , Antiarrítmicos/metabolismo , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/etiologia , Fibrilação Atrial/fisiopatologia , Flutter Atrial/diagnóstico , Flutter Atrial/etiologia , Flutter Atrial/fisiopatologia , Biotransformação , Estimulação Cardíaca Artificial , Modelos Animais de Doenças , Cães , Eletrocardiografia , Técnicas Eletrofisiológicas Cardíacas , Sistema de Condução Cardíaco/fisiopatologia , Tiazepinas/metabolismo , Tiazolidinedionas/metabolismo , Fatores de TempoRESUMO
Patients with chronic inflammatory diseases are at increased risk for heart failure due to ischemic heart disease and other causes including heart failure with preserved ejection fraction. Using rheumatoid arthritis and treated HIV infection as two prototypical examples, we review the epidemiology and potential therapies to prevent heart failure in these populations. Particular focus is given to anti-inflammatory therapies including statins and biologic disease modifying drugs. There is also limited evidence for lifestyle changes and blockade of the renin-angiotensin-aldosterone system. We conclude by proposing how a strategy for heart failure prevention, such as the model tested in the Screening To Prevent Heart Failure (STOP-HF) trial, may be adapted to chronic inflammatory disease.