RESUMO
BACKGROUND: Heart failure (HF) is the second most important cardiac risk factor for stroke after atrial fibrillation (AF). Few data are available on mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients with HF. METHODS: The source of data is the multicentre Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS). All AIS patients ≥ 18 years receiving MT were categorised in two groups: HF and no-HF. Baseline clinical and neuroradiological findings on admission were analysed. RESULTS: Of 8924 patients, 642 (7.2%) had HF. Compared to the no-HF group, HF patients had higher prevalence of cardiovascular risk factors. Rate of complete recanalisation (TICI 2b-3) was 76.9% in HF vs 78.1% in no-HF group (p = 0.481). Rate of symptomatic intracerebral haemorrhage at 24-h non-contrast computed tomography (NCCT) was 7.6% in HF vs 8.3% in no-HF patients (p = 0.520). At 3 months, 36.4% of HF patients and 48.2% of no-HF patients (p < 0.001) had mRS 0-2, and mortality was, respectively, 30.7% and 18.5% (p < 0.001). In multivariate logistic regression, HF was independently associated with mortality at 3 months (OR 1.53, 1.24-1.88 95% CI, p < 0.001). In multivariate ordinal regression, HF patients had a probability of transitioning to a higher mRS level of 1.23 (1.05-1.44 95% CI, p = 0.012). The propensity score analysis of two groups matched for age, sex, and NIHSS at admission yielded the same results. CONCLUSION: MT is safe and effective in HF patients with AIS. Patients with HF and AIS suffered from higher 3-month mortality and unfavourable outcome regardless of acute treatments.
Assuntos
Isquemia Encefálica , Procedimentos Endovasculares , Insuficiência Cardíaca , AVC Isquêmico , Acidente Vascular Cerebral , Humanos , AVC Isquêmico/etiologia , Trombectomia/efeitos adversos , Resultado do Tratamento , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/cirurgia , Insuficiência Cardíaca/complicações , Sistema de Registros , Estudos Retrospectivos , Isquemia Encefálica/complicações , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/epidemiologia , Procedimentos Endovasculares/efeitos adversosRESUMO
[Figure: see text].
Assuntos
Antitrombinas/uso terapêutico , Fibrilação Atrial/complicações , Hemorragia Cerebral/induzido quimicamente , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologiaRESUMO
BACKGROUND: Frailty and comorbidity influence the therapeutic approach in everyday clinical practice. The DOACs genericization opens a reflection on their differences from a pharmacological and bioavailability point of view, particularly in elderly frail patients. The aim of this project was to create a national Delphi consensus on the topic of the use of DOACs for atrial fibrillation (AF) in such patients, in light of the genericization of the class. METHODS AND RESULTS: The consensus dealt with 3 main topics: a) efficacy and safety of DOACs in elderly and/or frail patients; b) therapeutic choice in specific frailty scenarios; c) DOACs genericization. 56 cardiologists, two internists and two neurologists from Italy expressed their level of agreement on each statement by using a 5-point Likert scale (1: strongly disagree, 2: disagree, 3: uncertain, 4: agree, 5: strongly agree). A positive consensus was reached if the percentage of agreement (vote 1-2, positive consensus) or disagreement (votes 4-5, negative consensus) was >66%; otherwise, no consensus was reached. Results are displayed accordingly. CONCLUSIONS: After 10 years of everyday clinical management of DOACs for AF, specific elements differentiating a molecule from another, either for efficacy or for safety, are consolidated. However, some uncertainties still exist in particular contexts, such as chronic kidney disease or cancer patients. Clinicians have an unsure attitude towards generic drugs, because clinical practice is lacking as well as a proper knowledge of the topic. Albeit being an alternative, the choice of the generic drug must remain the responsibility of the clinician.
Assuntos
Fibrilação Atrial , Técnica Delphi , Medicamentos Genéricos , Idoso Fragilizado , Humanos , Idoso , Fibrilação Atrial/tratamento farmacológico , Medicamentos Genéricos/uso terapêutico , Inibidores do Fator Xa/uso terapêutico , Inibidores do Fator Xa/administração & dosagem , Feminino , Masculino , Idoso de 80 Anos ou mais , Consenso , Itália/epidemiologia , Acidente Vascular CerebralRESUMO
Embolic stroke of undetermined source (ESUS) is a new clinical entity which requires an accurate diagnostic work-up. The involvement of the cardiologist in this challenge is of paramount importance as in many cases an occult cardioembolic source is detectable. In the absence of subclinical atrial fibrillation detectable by prolonged ECG monitoring, potential causes of ESUS include atrial cardiomyopathy, left ventricular dysfunction or heart failure, aortic plaques and patent foramen ovale. The assessment of a causal relationship between these cardiac abnormalities and ESUS is often a difficult challenge and the randomized clinical trials performed so far failed to demonstrate a superiority of direct oral anticoagulants (DOAC) over aspirin. In selected individual patients with heart failure in sinus rhythm with high CHA2DS2-VASc score, or aortic plaques with thrombotic component, oral anticoagulation with DOAC might be considered even in the absence of evidence from randomized clinical trials.
Assuntos
Fibrilação Atrial , Cardiologistas , AVC Embólico , Insuficiência Cardíaca , Acidente Vascular Cerebral , Humanos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , AVC Embólico/complicações , AVC Embólico/tratamento farmacológico , Aspirina/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Insuficiência Cardíaca/tratamento farmacológico , Fatores de RiscoRESUMO
The search for silent atrial tachyarrhythmias remains one of the cornerstones in patients suffering from embolic stroke of undetermined source. We report the case of a 76-year-old female patient suffering from recurrence of ischemic stroke, adequately selected based on the presence of predictors of atrial fibrillation (AF), to perform prolonged ECG monitoring. This recording allowed to document long-lasting AF triggered by atrial tachycardia. It was also possible to demonstrate a direct correlation between AF and new cerebral stroke.
Assuntos
Fibrilação Atrial , AVC Embólico , AVC Isquêmico , Acidente Vascular Cerebral , Taquicardia Supraventricular , Feminino , Humanos , Idoso , Fibrilação Atrial/complicações , Fatores de Risco , Eletrocardiografia , Acidente Vascular Cerebral/etiologiaRESUMO
The etiological diagnosis of ischemic stroke is crucial for secondary prevention, but often complex for the patients' cardiovascular comorbidities, each of which may cause a stroke. We report the case of an 84-year-old patient with severe left ventricular systolic dysfunction due to dilated cardiomyopathy and implantable cardioverter-defibrillator in primary prevention, hospitalized for atherothrombotic ischemic stroke treated conservatively and later by carotid thromboendarterectomy for ulcerated plaque of the right internal carotid artery. A week after discharge, an embolic ischemic stroke occurred due to thrombosis of the left atrial appendage in absence of atrial fibrillation. A careful analysis of the patient's cardiovascular risk factors, clinical signs and neuroimages allowed for the etiological diagnosis of both cerebral ischemic events. The case is also peculiar because of left atrial appendage thrombus formation in the context of severe left ventricular systolic dysfunction in absence of atrial fibrillation. In the same patient, the recurrent stroke was not due to the same cause and, owing to the complexity of the differential diagnosis, a multidisciplinary neurological and cardiological approach is pivotal for the management of these patients.
Assuntos
Fibrilação Atrial , Cardiologia , AVC Isquêmico , Acidente Vascular Cerebral , Humanos , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Acidente Vascular Cerebral/etiologia , CoraçãoRESUMO
The clinical benefit of LDL cholesterol (LDL-C) lowering for cardiovascular disease prevention is well documented. This paper from the Italian Study Group on Atherosclerosis, Thrombosis and Vascular Biology summarizes current recommendations for treatment of hypercholesterolemia, barriers to lipid-lowering therapy implementation and tips to overcome them, as well as available evidence on the efficacy and safety of bempedoic acid. We also report an updated therapeutic algorithm for pharmacological LDL-C lowering in view of the introduction of bempedoic acid in clinical practice.
Assuntos
Aterosclerose , Doenças Cardiovasculares , Inibidores de Hidroximetilglutaril-CoA Redutases , Trombose , Humanos , LDL-Colesterol , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/prevenção & controle , Consenso , Fatores de Risco , Ácidos Graxos , Aterosclerose/diagnóstico , Aterosclerose/tratamento farmacológico , Aterosclerose/prevenção & controle , Trombose/tratamento farmacológico , Trombose/prevenção & controle , Biologia , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêuticoRESUMO
Antithrombotic therapy, in particular oral anticoagulation, is associated with an increased risk of bleeding. During anticoagulant treatment bleedings may also be caused by occult cancer, allowing its early diagnosis. The use of direct oral anticoagulants is associated with a lower risk of bleeding compared to vitamin K antagonists, but in the presence of a cancer lesion the risk of bleeding is not inferior. Atrial fibrillation patients with gastrointestinal bleeding during warfarin therapy are 6 times more likely to be diagnosed with cancer than patients without bleeding. In patients with hematuria, the probability of cancer is almost triple if treated with warfarin. With all the four direct oral anticoagulants newly colon cancer diagnoses have been reported in association with bleedings in phase III randomized clinical trials. In the real world, a 4.5% incidence of newly diagnosed cancer has been reported, mainly in the early stage and preceded by a bleeding event. Gastrointestinal bleeding is associated with a 13 times higher risk of newly diagnosed gastrointestinal cancer, genitourinary bleeding with a 18 times higher risk of newly diagnosed genitourinary cancer, and bronchopulmonary bleeding with a 15 times higher risk of newly diagnosed lung cancer. In the presence of bleeding during oral anticoagulant therapy, a diagnostic screening is warranted in order to detect occult cancer. An adverse event such as bleeding can become a favorable opportunity.
Assuntos
Fibrilação Atrial , Neoplasias , Administração Oral , Anticoagulantes , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/epidemiologia , Detecção Precoce de Câncer , Hemorragia Gastrointestinal/induzido quimicamente , Humanos , Neoplasias/complicações , Neoplasias/tratamento farmacológicoRESUMO
Cardiovascular diseases are still the main cause of death among women despite the improvements in treatment and prognosis achieved in the last 30 years of research. The determinant factors and causes have not been completely identified but the role of "gender" is now recognized. It is well known that women tend to develop cardiovascular disease at an older age than men, and have a high probability of manifesting atypical symptoms not often recognized. Other factors may also co-exist in women, which may favor the onset of specific cardiac diseases such as those with a sex-specific etiology (differential effects of estrogens, pregnancy pathologies, etc.) and those with a different gender expression of specific and prevalent risk factors, inflammatory and autoimmune diseases and cancer. Whether the gender differences observed in cardiovascular outcomes are influenced by real biological differences remains a matter of debate.This ANMCO position paper aims at providing the state of the research on this topic, with particular attention to the diagnostic aspects and to care organization.
Assuntos
Doenças Cardiovasculares , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Estrogênios , Feminino , Humanos , Masculino , Prognóstico , Fatores de Risco , Fatores SexuaisRESUMO
BACKGROUND: Neurogenic pulmonary oedema (NPO) and Takotsubo cardiomyopathy are rare complications of ischaemic stroke. They are considered to be due to an excess catecholamine release after sympathetic nervous stimulation following stroke onset. Among the different types of Takotsubo cardiomyopathy, apical ballooning is recognized as the typical form, but three atypical patterns have been described (midventricular, basal, and focal) which are more commonly observed in patients with neurological disorders. CASE SUMMARY: A 78-year-old woman was treated with intravenous alteplase and underwent mechanical thrombectomy for ischaemic stroke. During the procedure, her respiratory condition quickly worsened requiring invasive mechanical ventilation because of a wide and persistent reduction of the inspiratory oxygen fraction/arterial partial oxygen pressure ratio. Transthoracic echocardiography revealed moderate left ventricular systolic dysfunction with akinesis of the septal-apical and inferior-apical segments. Coronary angiography excluded obstructive lesions and/or evidence of acute plaque rupture. Ventriculography confirmed akinesis/dyskinesis of the inferior segment of the left ventricular apex associated with normal kinesis of the remaining segments. Chest X-ray revealed an infiltrative shadow on both lungs. After 24 h from NPO onset, her respiratory function improved and she was finally discharged on Day 7 without neurological defects. Left ventricular systolic dysfunction was reversible and ejection fraction normalized in 3 months. DISCUSSION: It is a very rare case of simultaneous NPO and Takotsubo cardiomyopathy following ischaemic stroke. Moreover, it is unique in that it is the first observation of NPO associated with an atypical pattern of Takotsubo cardiomyopathy, which is more frequent in patients with neurological disorders. A rapid recognition and treatment are essential for patient survival.
RESUMO
BACKGROUND: Antithrombotic/anticoagulation effects of direct oral anticoagulants (DOACs) are dose-dependent. However, recent observations suggest that administering lower dose DOACs may better protect against all-cause mortality. We investigated whether, in patients with established atherosclerosis, DOAC dose selection would affect the risk of all-cause mortality. METHODS: We performed a structured literature research for controlled trials allowing random assignment to a lower dose DOAC, a higher dose DOAC, or control therapy in patients with established atherosclerosis. Pooled risk ratios (RRs) of all-cause mortality in lower and higher dose DOACs versus control therapy were estimated using a random-effect model. RESULTS: Atherosclerosis manifested as acute coronary syndrome (n=17,220), stable coronary (CAD) and/or peripheral artery disease (PAD) (n=27,395) or CAD associated with atrial fibrillation (n=4,510). Antithrombotic doses of rivaroxaban (2.5 mg or 5.0 mg BID) or dabigatran (50 mg, 75 mg, 110 mg, or 150 mg, BID) were tested in three trials versus single or dual antiplatelet control therapy, whereas anticoagulation doses of edoxaban (30 mg or 60 OD) were tested versus warfarin in one trial. Compared to control, patients receiving lower dose (RR 0.80, 95% CI 0.73-0.89, p<0.0001, I²=0%), but not those receiving higher dose DOACs (RR 0.95, 95% CI 0.87-1.05, p=0.3074, I²=0%), had a significant reduction of all-cause mortality. Benefit from lower dose DOACs remained after sensitivity analysis or direct comparison with higher dose DOACs (RR 0.84, 95% CI 0.76-0.93, p=0.0009, I²=0%). CONCLUSIONS: Within antithrombotic/anticoagulation regimens of DOAC administration, selection of lower dose appears to protect from all-cause mortality in patients with established atherosclerosis.
Assuntos
Aterosclerose , Fibrilação Atrial , Acidente Vascular Cerebral , Administração Oral , Anticoagulantes/uso terapêutico , Aterosclerose/tratamento farmacológico , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Dabigatrana/uso terapêutico , Hemorragia , Humanos , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controle , Varfarina/uso terapêuticoRESUMO
BACKGROUND: Most studies of amyloidotic cardiomyopathy consider as a single entity the 3 main systemic cardiac amyloidoses: acquired monoclonal immunoglobulin light-chain (AL); hereditary, mutated transthyretin-related (ATTRm); and wild-type transthyretin-related (ATTRwt). In this study, we compared the diagnostic/clinical profiles of these 3 types of systemic cardiac amyloidosis. METHODS AND RESULTS: We conducted a longitudinal study of 233 patients with clear-cut diagnosis by type of cardiac amyloidosis (AL, n=157; ATTRm, n=61; ATTRwt, n=15) at 2 large Italian centers providing coordinated amyloidosis diagnosis/management facilities since 1990. Average age at diagnosis was higher in AL than in ATTRm patients; all ATTRwt patients except 1 were elderly men. At diagnosis, mean left ventricular wall thickness was higher in ATTRwt than in ATTRm and AL. Left ventricular ejection fraction was moderately depressed in ATTRwt but not in AL or ATTRm. ATTRm patients less often displayed low QRS voltage (25% versus 60% in AL; P<0.0001) or low voltage-to-mass ratio (1.1+/-0.5 versus 0.9+/-0.5; P<0.0001). AL patients appeared to have greater hemodynamic impairment. On multivariate analysis, ATTRm was a strongly favorable predictor of survival, and ATTRwt predicted freedom from major cardiac events. CONCLUSIONS: AL, ATTRm, and ATTRwt should be considered 3 different cardiac diseases, probably characterized by different pathophysiological substrates and courses. Awareness of the diversity underlying the cardiac amyloidosis label is important on several levels, ranging from disease classification to diagnosis and clinical management.
Assuntos
Amiloidose/diagnóstico por imagem , Amiloidose/mortalidade , Cardiomiopatias/diagnóstico por imagem , Cardiomiopatias/mortalidade , Ecocardiografia , Adulto , Idoso , Amiloidose/genética , Pressão Sanguínea , Cardiomiopatias/genética , Progressão da Doença , Eletrocardiografia , Feminino , Seguimentos , Humanos , Cadeias Leves de Imunoglobulina/sangue , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Miocárdio/patologia , Miócitos Cardíacos/patologia , Mutação Puntual , Pré-Albumina/genética , Pressão Propulsora Pulmonar , Fatores de Risco , Análise de SobrevidaRESUMO
BACKGROUND: The ongoing prospective, single-arm, observational, phase 4 ETNA-AF Europe study is collecting real-world data about the safety and, secondarily, the effectiveness and therapeutic adherence of newly prescribed edoxaban for non-valvular atrial fibrillation in Europe. METHODS: At the end of enrollment in 2018, 13 980 subjects were included, of whom 3509 were Italian. Of them, 3341 (95.2%) had follow-up data available at 1 year. RESULTS: Their mean age was 75 ± 9.3 years, with 56.9% being ≥75 years old. The CHA2DS2-VASc score was ≥4 in 1380 (41.3%) patients. Overall, 662 patients (19.7%) were judged as "frail" by the investigators. Edoxaban 30 mg/day was given to 1048 (31.4%) subjects, who were older with more comorbidities and a lower estimated creatinine clearance than those prescribed the 60 mg/day dose. Overall, the rates of bleeding and thromboembolic events were low: major bleeding was 1.63%/year, intracranial hemorrhage 0.16%/year, stroke or systemic embolism 0.50%/year and all-cause mortality 3.72%/year. Rates were higher in subjects ≥75 years or with a CHA2DS2-VASc score ≥4 and in frail individuals. Remarkably, there was a trend for no increase in intracranial bleeding with more advanced age. CONCLUSIONS: These findings confirm the favorable safety and effectiveness profile of edoxaban in atrial fibrillation patients in routine clinical care in Italy.
Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/administração & dosagem , Adesão à Medicação , Piridinas/administração & dosagem , Tiazóis/administração & dosagem , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Relação Dose-Resposta a Droga , Inibidores do Fator Xa/efeitos adversos , Feminino , Seguimentos , Hemorragia/induzido quimicamente , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Piridinas/efeitos adversos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Tiazóis/efeitos adversos , Tromboembolia/etiologia , Tromboembolia/prevenção & controleRESUMO
The introduction of direct oral anticoagulants (DOACs) has been the main therapeutic revolution in the last 20 years. Four molecules have been approved for the thromboembolic prophylaxis in patients with non-valvular atrial fibrillation (AF). After the publication of phase 3 clinical trials, many studies evaluating DOAC safety and efficacy in daily clinical practice have been published. Edoxaban is the latest DOAC available on the market, based on the results of the ENGAGE AF-TIMI 48 trial. The phase 4 ETNA-AF (Edoxaban Treatment in Routine Clinical Practice for Patients With Non-Valvular Atrial Fibrillation) observational study was designed with the aim to confirm the results of the pivotal clinical trial in routine care in unselected patients with AF. This registry involved several sites and enrolled a large population in Europe and in Italy (13 980 and 3512 patients, respectively). The broad spectrum of patients will allow to have an overview of the characteristics of the AF population and to make a comparison with previous national registries and between different European realities.
Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/administração & dosagem , Piridinas/administração & dosagem , Tiazóis/administração & dosagem , Tromboembolia/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Europa (Continente) , Feminino , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Tromboembolia/etiologiaRESUMO
In patients with coronavirus disease 2019 (COVID-19), the prevalence of pre-existing cardiovascular diseases is elevated. Moreover, various features, also including pro-thrombotic status, further predispose these patients to increased risk of ischemic cardiovascular events. Thus, the identification of optimal antithrombotic strategies in terms of the risk-benefit ratio and outcome improvement in this setting is crucial. However, debated issues on antithrombotic therapies in patients with COVID-19 are multiple and relevant. In this article, we provide ten questions and answers on risk stratification and antiplatelet/anticoagulant treatments in patients at risk of/with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection based on the scientific evidence gathered during the pandemic.
Assuntos
Anticoagulantes/farmacologia , Anticoagulantes/uso terapêutico , COVID-19/complicações , Trombose/etiologia , Trombose/prevenção & controle , Fatores Etários , Anti-Inflamatórios não Esteroides/farmacologia , Anticoagulantes/administração & dosagem , Anticoagulantes/classificação , Antivirais/farmacologia , Fibrilação Atrial/tratamento farmacológico , Quimioprevenção/efeitos adversos , Quimioprevenção/métodos , Coagulação Intravascular Disseminada/tratamento farmacológico , Interações Medicamentosas , Humanos , Itália , Pandemias , Fatores de Risco , Gestão de Riscos , SARS-CoV-2 , Índice de Gravidade de Doença , Fatores Sexuais , Trombose/tratamento farmacológico , Trombose/fisiopatologiaRESUMO
Given the high prevalence of preexisting cardiovascular diseases and the increased incidence of adverse cardiovascular events in patients hospitalized for SARS-CoV-2 infection, the identification of optimal antithrombotic approaches in terms of risk/benefit ratio and outcome improvement appears crucial in this setting. In the present position paper we collected current evidence from the literature to provide practical recommendations on the management of antithrombotic therapies (antiplatelet and anticoagulant) in various clinical contexts prevalent during the SARS-CoV-2 outbreak: in-home management of oral anticoagulant therapy; interactions between drugs used in the SARS-CoV-2 infection and antithrombotic agents; in-hospital management of antithrombotic therapies; diagnosis, risk stratification and treatment of in-hospital thrombotic complications.
Assuntos
Aterosclerose/tratamento farmacológico , Aterosclerose/epidemiologia , Infecções por Coronavirus/epidemiologia , Surtos de Doenças/estatística & dados numéricos , Fibrinolíticos/uso terapêutico , Pneumonia Viral/epidemiologia , Trombose/tratamento farmacológico , Aterosclerose/diagnóstico , Betacoronavirus , COVID-19 , Comorbidade , Infecções por Coronavirus/diagnóstico , Medicina Baseada em Evidências , Feminino , Humanos , Incidência , Itália , Masculino , Pandemias , Pneumonia Viral/diagnóstico , Guias de Prática Clínica como Assunto , Medição de Risco , SARS-CoV-2 , Trombose/diagnóstico , Trombose/epidemiologia , Resultado do TratamentoRESUMO
Heart-brain interactions are represented by the association of cerebral ischemia with coronary artery disease, cardioembolic cerebral ischemia, and cardiovascular complications due to brain damage. As atherosclerosis is a systemic inflammatory disease, in patients with transient ischemic attack, stroke or asymptomatic carotid artery disease, a previous myocardial infarction, angina or an asymptomatic coronary artery disease are often associated and a correlation between the carotid atherosclerosis and coronary artery disease severity has been reported. Furthermore, the long-term prognosis of patients with stroke is strongly affected by coronary events. At the same time, the prevalence of concomitant cerebrovascular disease is common in patients with coronary artery disease. Other cardiovascular diseases, including left atrial and left atrial appendage thrombosis in atrial fibrillation, thrombi in the left ventricle in acute and chronic coronary artery disease and dilated cardiomyopathies, infective endocarditis with vegetations, cardiac valve prosthesis thrombosis, cardiac tumors, mitral and aortic valve calcifications, aortic plaques and patent foramen ovale, are associated with cardioembolic events. Finally, acute ischemic or hemorrhagic cerebral events, epileptic seizures, cerebral traumas, and brain tumors can be associated with electrocardiographic abnormalities, catecholaminergic myocardial damage, or arrhythmias.
Assuntos
Isquemia Encefálica/patologia , Doenças Cardiovasculares/fisiopatologia , Acidente Vascular Cerebral/patologia , Isquemia Encefálica/epidemiologia , Doenças Cardiovasculares/complicações , Humanos , Embolia Intracraniana/etiologia , Prognóstico , Acidente Vascular Cerebral/epidemiologiaRESUMO
To investigate associations between gender and myocardial involvement in systemic amyloidosis, we reviewed all patients presenting between 1994 and September 2006 in our institutional network (100 AL and 98 familial transthyretin-related amyloidosis (ATTR) patients, plus 12 elderly men with senile systemic amyloidosis). We focused on echocardiographic descriptors of myocardial involvement (height-indexed mean left ventricular (LV) wall thickness, LV mass index), and baseline LV function. Among familial ATTR patients, female prevalence was lower within the highest tertile of either echocardiographic indicator of myocardial involvement. Gender was independently associated with height-indexed mean LV wall thickness (as were gene mutations). Female prevalence appeared rather similar across the different neurological stages. Within the subgroup of familial ATTR patients with amyloidotic cardiomyopathy, women tended to display a considerably less severe morphological and functional echocardiographic profile. We explored the possible role of female sex hormones by considering menopausal status: women in the highest tertile of mean LV wall thickness index were more often postmenopausal than those in the other two tertiles and had a much higher ( approximately 15 years) mean age; analogous age-related associations were not observable for men. In conclusion, these findings raise the hypothesis that some biological characteristic associated with female gender protects against myocardial involvement in familial ATTR.
Assuntos
Amiloidose/complicações , Cardiomiopatias/etiologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Amiloidose/diagnóstico por imagem , Amiloidose/epidemiologia , Amiloidose/metabolismo , Cardiomiopatias/diagnóstico por imagem , Cardiomiopatias/epidemiologia , Cardiomiopatias/metabolismo , Ecocardiografia , Feminino , Hormônios Esteroides Gonadais/metabolismo , Ventrículos do Coração/diagnóstico por imagem , Humanos , Masculino , Menopausa/metabolismo , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores SexuaisRESUMO
Advances in cancer therapy have led to a significant improvement of survival in most types of malignancies over the past few decades. As a result, there is a growing population of cancer survivors, expected to reach 18 million people in 2030 in the US and a similar number in Europe. Interestingly, cancer survivor studies have shown that although about half of these patients eventually die of cancer, one third of them actually die of cardiovascular disease. Arrhythmias represent a significant part of cardiovascular complications and atrial fibrillation is the main arrhythmia occurring in cancer patients.Antithrombotic therapy is a challenge: the optimal international normalized ratio (INR) level in patients on therapy with vitamin K antagonists is achieved in only 12% of them; in these patients, direct oral anticoagulants seem to be effective and safe for the prevention of stroke and systemic embolic events compared to warfarin and have similar risk of major bleeding. Among the trials, ENGAGE AF-TIMI 48 provides more data on the efficacy and safety of edoxaban in cancer patients.
Assuntos
Fibrilação Atrial/tratamento farmacológico , Neoplasias/complicações , Piridinas/administração & dosagem , Tiazóis/administração & dosagem , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Anticoagulantes/farmacologia , Fibrilação Atrial/complicações , Fibrilação Atrial/etiologia , Sobreviventes de Câncer , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Embolia/etiologia , Embolia/prevenção & controle , Inibidores do Fator Xa/administração & dosagem , Inibidores do Fator Xa/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Coeficiente Internacional Normatizado , Piridinas/efeitos adversos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Tiazóis/efeitos adversos , Varfarina/administração & dosagem , Varfarina/efeitos adversosRESUMO
The management of antithrombotic therapy in patients on oral anticoagulation (OAC) for atrial fibrillation (AF) undergoing percutaneous coronary intervention with stent (PCI) is currently addressed by expert consensus documents and official Guidelines. No specific data, nor management suggestions, are available for OAC patients undergoing PCI in whom the indication for OAC is venous thromboembolism (VTE). In this article, the available evidence on VTE patients undergoing PCI, as obtained from studies where patients with various indications for PCI were included, is evaluated, and an algorithm for the management of antithrombotic therapy in this unique population is proposed.