Calidad de la atención en salud en ataque cerebrovascular en un hospital de referencia en Colombia / Quality of health care in stroke in a reference hospital in Colombia

RESUMEN INTRODUCCIÓN: La evaluación de la calidad de la atención del ataque cerebrovascular (ACV) es una prioridad para los sistemas de salud, debido a su relación con la disminución de la discapacidad y la muerte. En este estudio se analizan los marcadores de calidad en ACV en un hospital de referencia en Nariño, Colombia. OBJETIVO: Evaluar los marcadores de calidad de atención en ACV en el Hospital Universitario Departamental de Nariño E. S. E., entre junio del 2018 y diciembre del 2019. Como referencia se comparó con los registros de Colombia en la plataforma RES-Q. MATERIALES Y MÉTODOS: Estudio descriptivo retrospectivo de pacientes con ACV atendidos intrahospitalariamente. La recolección de datos se realizó mediante la plataforma RES-Q, en tanto que el análisis se efectuó por medio de estadísticos descriptivos y frecuencias absolutas y relativas y las diferencias con pruebas analíticas. RESULTADOS: Se evaluaron 457 pacientes con predominio de ACV isquémico y se llevó a cabo trombólisis endovenosa al 7,2% en el 2018 y al 9,2 % en el 2019, el 27,7 % con tiempo puerta aguja menor a 60 minutos en el 2018 y el 42,8 % en el 2019. Entre los marcadores de calidad, se encontró mejoría en realización de NIHSS, evaluación de disfagia en las primeras 24 horas, realización de doppler carotideo en los primeros siete días. En comparación con Colombia, se encontró un porcentaje inferior en trombólisis endovenosa y trombectomía. La mayoría de los indicadores de atención en ACV es similar al promedio nacional. CONCLUSIONES: La mejoría en el cumplimiento de marcadores de calidad en ACV refleja el impacto de programas de atención en ACV. El monitoreo de los parámetros de calidad permite generar programas para fortalecer la atención integral del ataque cerebrovascular en la región.

ABSTRACT INTRODUCTION: The evaluation of the quality of care for Stroke is a priority for health systems, given its relationship with disability and death. In this study, Stroke quality markers are analyzed in stroke in a referral hospital in Narino, Colombia. OBJECTIVE: To evaluate the markers of quality of care in stroke in the Hospital Departamental Universitario de Narino E.S.E between June 2018 and December 2019. As a reference, the outcomes were compared with the Colombian registries on RES-Q platform. MATERIALS AND METHODS: A retrospective descriptive study of patients treated in-hospital with stroke, data collection was performed using the RES-Q platform. The analysis was carried out using descriptive statistics and absolute and relative frequencies and the differences with analytical tests. RESULTS: 457patients were evaluated, with ischemic stroke predominance, endovenous thrombolysis was performed in 7.2 % in 2018, and 9.2 % in 2019, 27.7 % of patients had door to needle time less than 60 minutes in 2018 and 42.8 % in 2019. Among the quality markers evaluated, an improvement was found in the performance of NIHSS, dysphagia evaluation, and carotid doppler performance in ischemic stroke. Compared with Colombian registry, a lower percentage was found in endovenous thrombolysis and thrombectomy. Most of Stroke Care Markers are similar to national average. CONCLUSIONS: The improvement in compliance of standard of Stroke Care Quality Markers reflects the impact of stroke care programs. The monitoring of quality parameters allows the generation of comprehensivestroke care programs in the region.

Experiencia en el manejo del ataque cerebrovascular isquémico en dos centros de tercer nivel de la ciudad de Ibagué (Colombia) entre junio del 2019 y junio del 2020 / Ischemic stroke management - Experience in two third-level hospitals in Ibague (Colombia) from June 2019 to June 2020

RESUMEN INTRODUCCION: El ataque cerebrovascular (ACV) de etiología isquémica es una patología cuya incidencia y mortalidad aumentaron en la última década. Cuando se maneja oportunamente, mediante trombólisis como terapia inicial, mejora su desenlace y funcionalidad. En el departamento del Tolima (Colombia) no hay registros de esta patología y en el país la bibliografía al respecto es limitada. El objetivo de este estudio es evaluar los desenlaces clínicos del manejo agudo con r-tPA en los pacientes que presentaron ACV isquémico en dos instituciones de la ciudad de Ibagué, capital de dicho departamento, entre junio del 2019 y junio del 2020, e identificar los tiempos de atención hospitalaria y las principales variables asociadas con el grupo de pacientes que fallecieron. MATERIALES Y METODOS: Estudio descriptivo de corte transversal del manejo del ACV isquémico con r-tPA, en el que se describen las variables sociodemográficas, la escala NIHSS como evaluación neurológica inicial, los tiempos de atención (inicio-aguja, puerta-tac y puerta-aguja), los desenlaces postoperatorios y el Rankin modificado al egreso. RESULTADOS: Se incluyeron 38 pacientes con una media de 67,37 años, el 60,53 % fueron mujeres. La escala NIHSS al ingreso fue 13,47 puntos (DE 5,24). Los tiempos de atención fueron 183 minutos (DE 72,63) inicio-aguja, 41 minutos (RIQ 17-72) puerta-TAC y 101,50 minutos (RIQ 77 - 137,25) puerta-aguja. La mortalidad fue del 23,68 %. CONCLUSION: La mortalidad y el desenlace funcional del ACV en nuestra población fueron similares a los reportados en la literatura nacional e internacional, sin embargo, es preciso implementar protocolos de atención del infarto cerebral para incrementar el número de pacientes con desenlace favorable, acortando los tiempos de atención en toda la cadena del tratamiento adecuado del infarto cerebral.

ABSTRACT INTRODUCTION: Ischemic stroke is a growing disease in the last decade, increasing both its incidence and its mortality. However, timely thrombolysis management as initial therapy can improve both disease progression as well as an individual's functionality. In Tolima, there are no registries of this disease and in Colombia in general, the literature is limited. The objective of this study is to investigate the clinical outcomes of the acute management of ischemic stroke using r-tPA as well as identifying in-hospital treatment times, at two institutions in Ibague between 2019 and 2020. METHODS AND MATERIALS: Using a cross-sectional descriptive study, we describe the management of ischemic stroke using r-tPA, describing sociodemographic variables, NIHSS scale as the initial neurological evaluation, in-hospital treatment times (symptoms-to-needle, door-to-TAC, door-to-needle), the clinical outcomes, and lastly the modified Rankin score upon discharge. RESULTS: We included 38 patients with median age of 67,37 years, 60,53 % were females. The initial average NIHSS scale upon admission was 13,47 (DE 5,24). In-hospital attention time averages were: symptoms-to-needle 183 minutes (DE 72,63), door-to-CAT 41 minutes (RIQ 17-72), and door-to-needle 101,50 minutes (RIQ 77-137,25). Overall the rate of mortality was 23,68 %. CONCLUSIONS: Mortality and functionality outcomes of the stroke population observed was similar to previously reported, both nationally and internationally. However, protocols should be implemented for the timely ischemic stroke management to improve the number of patients with favorable outcomes, by reducing the in-hospital attention times in all areas of the management chain.

Uso y resultados de la fibrinolisis intravenosa en una unidad cerebrovascular / Use and results of intravenous fibrinolysis in a stroke unit

Resumen La fibrinólisis intravenosa con activador del plasminógeno tisular recombinante (rTPA) y la utilización de unidades cerradas, demostraron disminuir sustancialmente la morbimortalidad en pacientes con accidente cerebrovascular isquémico (ACVi). Sin embargo, los datos publicados en Argentina son escasos. Describimos la experiencia en la utilización de fibrinólisis en pacientes con ACVi agudo antes y después de la implementación de una unidad cerebrovascular (UCV) en un Centro Integral de Neurología Vascular de la Ciudad de Buenos Aires durante 17 años. Se realizó un análisis retrospectivo de pacientes consecutivos tratados con rTPA entre enero 2003 y diciembre 2019. Se evaluaron tiempos de tratamiento, de internación, complicaciones post tratamiento y discapacidad a 3 meses. Para su análisis se evaluaron los períodos pre y post apertura de la UCV, período 1 (P1 de 2003-2011) y P2 (2012 -2019). Se realizó fibrinolisis intravenosa en 182 pacientes. La apertura de UCV resultó en aumento del porcentaje de fibrinólisis sobre el total de los ACVi ingresados (4% en P1 vs. 10% en P2, p < 0.001), acortamiento del tiempo puerta-aguja (75 minutos en P1 vs. 53 minutos en P2, p < 0.00001) y mayor proporción de pacientes tratados dentro de los 60 minutos del ingreso hospitalario (36% en P1 vs. 76% en P2, p < 0.00001). Además, hubo reducción de la mediana de internación de 9 días en P1 a 5 días en P2 (p < 0.00001). En conclusión, la UCV parece optimizar la utilización de fibrinólisis en el ACVi agudo, aumentando el porcentaje de pacientes tratados, reduciendo el tiempo puerta-aguja y disminuyendo el de internación.

Abstract Intravenous fibrinolysis with recombinant tissue plasminogen activator (rTPA) and use of stroke units improve morbidity and mortality in patients with acute ischemic stroke (AIS). However, data published in Argentina are scarce. We describe the experience in the use of fibrinolysis in patients with acute ischemic stroke (AIS) before and after the implementation of a stroke unit in a Comprehensive Stroke Center in Buenos Aires during the last 17 years. Retrospective analysis of consecutive patients treated with rTPA between January 2003 and December 2019. Treatment times, hospitalization time, post-treatment complications and disability at 3 months were evaluated. For the analysis, the pre and post opening periods of the stroke unit were evaluated, Period 1 (P1, from 2003 to 2011) and Period 2 (P2, from 2012 to 2019). Intravenous fibrinolysis was performed in 182 patients. Opening of the stroke unit resulted in an increase in the percentage of fibrinolysis over the total number of admitted strokes (4% in P1 vs. 10% in P2, p < 0.001), shortening of the door-to-needle time (75 minutes in P1 vs. 53 minutes in P2, p < 0.00001) and higher proportion of patients treated within 60 minutes of hospital admission (36% in P1 vs. 76% in P2, p < 0.00001). In addition, there was a reduction in the median hospital stay from 9 days in P1 to 5 days in P2 (p < 0.00001). In conclusion, stroke units seem to optimize the use of fibrinolysis in acute stroke, increasing the percentage of patients treated, reducing door-to-needle time, and reducing hospitalization time.

Determinantes del tiempo puerta-aguja en trombolisis endovenosa en el infarto cerebral, experiencia de un centro

Background: Intravenous thrombolysis (IT) in acute ischemic stroke (AIS) is time dependent. The time elapsed from hospital admission to the thrombolytic bolus is named door to needle time (DNT) and is recommend to be of less than 60 min. Aim: To describe the DNT in our center and determine those factors associated with a DNT longer than 60 min. Material and Methods: Prospective analysis of patients treated with IT at a private hospital between June 2016 and June 2019. The percentage of patients with DNT exceeding 60 min, and the causes for this delay were evaluated. Results: IT was used in 205 patients. DNT was 43.6 ± 23.8 min. Forty patients (19.5% (95% CI, 14.4-25.7), had a DNT longer than 60 min. Uni-varied analysis demonstrated that AIS with infratentorial symptomatology (ITS), was significantly associated with DNTs exceeding 60 min. A history of hypertension, a higher NIH Stroke Scale score, the presence of an hyperdense sign in brain tomography (p = 0.001) and the need for endovascular therapy (p = 0.019), were associated with DNT shorter than 60 min. Multivariate analysis ratified the relationship between ITS and DNT longer than 60 min (Odds ratio: 3.19, 95% confidence intervals 1.26-8). Conclusions: The individual elements that correlated with a DNT longer than 60 min were the failure to detect the AIS during triage and doubts about its diagnosis.

Informe diário de evidências COVID-19: busca realizada em 8 de julho de 2020 / Daily evidence report COVID-19: search conducted on July 8, 2020

O Informe Diário de Evidências é uma produção do Ministério da Saúde que tem como objetivo acompanhar diariamente as publicações científicas sobre tratamento farmacológico e vacinas para a COVID-19. Dessa forma, são realizadas buscas estruturadas em bases de dados biomédicas, referentes ao dia anterior desse informe. Não são incluídos estudos pré-clínicos (in vitro, in vivo, in silico). A frequência dos estudos é demonstrada de acordo com a sua classificação metodológica (revisões sistemáticas, ensaios clínicos randomizados, coortes, entre outros). Para cada estudo é apresentado um resumo com avaliação da qualidade metodológica. Essa avaliação tem por finalidade identificar o grau de certeza/confiança ou o risco de viés de cada estudo. Para tal, são utilizadas ferramentas já validadas e consagradas na literatura científica, na área de saúde baseada em evidências. Cabe ressaltar que o documento tem caráter informativo e não representa uma recomendação oficial do Ministério da Saúde sobre a temática. Foram encontrados 16 artigos e 11 protocolos.

Informe diário de evidências COVID-19: busca realizada em 22 de maio de 2020 / COVID-19 daily evidence report: search conducted on May 22, 2020

O Informe Diário de Evidências é uma produção do Ministério da Saúde que tem como objetivo acompanhar diariamente as publicações científicas sobre tratamento farmacológico e vacinas para a COVID-19. Dessa forma, são realizadas buscas estruturadas em bases de dados biomédicas, referente ao dia anterior desse informe. Não são incluídos estudos pré-clínicos (in vitro, in vivo, in silico). A frequência dos estudos é demonstrada de acordo com a sua classificação metodológica (revisões sistemáticas, ensaios clínicos randomizados, coortes, entre outros). Para cada estudo é apresentado um resumo com avaliação da qualidade metodológica. Essa avaliação tem por finalidade identificar o grau de certeza/confiança ou o risco de viés de cada estudo. Para tal, são utilizadas ferramentas já validadas e consagradas na literatura científica, na área de saúde baseada em evidências. Cabe ressaltar que o documento tem caráter informativo e não representa uma recomendação oficial do Ministério da Saúde sobre a temática. Foram encontrados 21 artigos e 13 protocolos.

Informe diário de evidências COVID-19: busca realizada entre 24 e 26 de abril de 2020 / COVID-19 daily evidence report: search conducted between April 24 and 26, 2020

Essa é uma produção do Departamento de Ciência e Tecnologia (Decit) da Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde (SCTIE) do Ministério da Saúde (Decit/SCTIE/MS), que tem como missão promover a ciência e tecnologia e o uso de evidências científicas para a tomada de decisão do SUS, tendo como principal atribuição o incentivo ao desenvolvimento de pesquisas em saúde no Brasil, de modo a direcionar os investimentos realizados em pesquisa pelo Governo Federal às necessidades de saúde pública. Informar sobre as principais evidências científicas descritas na literatura internacional sobre tratamento farmacológico para a COVID-19. Além de resumir cada estudo identificado, o informe apresenta também uma avaliação da qualidade metodológica e a quantidade de artigos publicados, de acordo com a sua classificação metodológica (revisões sistemáticas, ensaios clínicos randomizados, entre outros). Foram encontrados 25 artigos e 47 protocolos.

Informe diário de evidências COVID-19: busca realizada em 23 de abril de 2020 / COVID-19 daily evidence report: search conducted on April 23, 2020

Essa é uma produção do Departamento de Ciência e Tecnologia (Decit) da Secretaria de Ciência, Tecnologia, Inovação e Insumos Estratégicos em Saúde (SCTIE) do Ministério da Saúde (Decit/SCTIE/MS), que tem como missão promover a ciência e tecnologia e o uso de evidências científicas para a tomada de decisão do SUS, tendo como principal atribuição o incentivo ao desenvolvimento de pesquisas em saúde no Brasil, de modo a direcionar os investimentos realizados em pesquisa pelo Governo Federal às necessidades de saúde pública. Informar sobre as principais evidências científicas descritas na literatura internacional sobre tratamento farmacológico para a COVID-19. Além de resumir cada estudo identificado, o informe apresenta também uma avaliação da qualidade metodológica e a quantidade de artigos publicados, de acordo com a sua classificação metodológica (revisões sistemáticas, ensaios clínicos randomizados, entre outros). Foram encontrados 14 artigos.

Thrombolysis in acute pulmonary embolism

SUMMARY OBJECTIVES Acute pulmonary embolism (APE) is an important cause of cardiovascular mortality, due mainly to hemodynamic instability. In these cases, the recommendation is to perform some reperfusion procedure, with systemic thrombolysis being the main therapy used. However, national data evaluating the efficacy and safety of thrombolysis are scarce. METHODS Retrospective analysis of a case series. We included 13 patients diagnosed with high-risk APE and 4 patients with intermediate-high risk from a single-center, who were treated with alteplase 100mg. RESULTS The mean age of the patients was 55 years, most of them female (76.4%). Among the risk factors for VTE were immobilization (41.17%), contraceptive use (35.29%), cancer (17.63%), and previous history of DVT (11.76%). The most frequent clinical manifestations of APE were dyspnea (88.23%), hypoxia (82.35%), hypotension (82.35%), and tachycardia (64.70%). 82.35% of the patients had echocardiographic signs of right ventricular dysfunction, and 52.94% had increased troponin and BNP. Severe bleeding associated with thrombolysis occurred in 17.54% of cases. No patient died due to bleeding. There were 8 deaths from right ventricular failure (47%), 6 in the cases of patients presenting as high-risk APE (35.3%), and 2 in the cases of intermediate-high risk (11.8%). CONCLUSION Thrombolysis in patients with high-risk APE or intermediate-high risk had a severe bleeding rate of 17.6%. However, the high mortality of this population (47%) due to right ventricular failure justifies the use of this therapeutic modality.

RESUMO OBJETIVOS A embolia pulmonar aguda (EAP) é uma causa importante de mortalidade cardiovascular ao causar instabilidade hemodinâmica. Nesses casos, a recomendação é a realização de algum procedimento de reperfusão, sendo a trombólise sistêmica a principal terapia utilizada. No entanto, dados nacionais avaliando a eficácia e a segurança da trombólise são escassos. MÉTODO Análise retrospectiva de uma série de casos. Foram incluídos 13 pacientes com o diagnóstico de EAP de alto risco e quatro pacientes de risco intermediário-alto, de um único centro, e que foram tratados com alteplase 100 mg. RESULTADOS A média de idade dos pacientes foi 55 anos, sendo a maioria do gênero feminino (76,4%). Dos fatores de risco para TEV, estavam presentes a imobilização (41,17%), o uso de anticonceptivos (35,29%), câncer (17,63%) e história prévia de TVP (11,76%). As manifestações clínicas mais frequentes da EAP foram dispneia (88,23%), hipóxia (82,35%), hipotensão (82,35%) e taquicardia (64,70%); 82,35% dos pacientes apresentaram sinais ecocardiográficos de disfunção ventricular direita e 52,94% apresentaram aumento da troponina e BNP. Sangramento grave associado à trombólise ocorreu em 17,54% dos casos. Nenhum paciente faleceu em decorrência de sangramento. Houve oito mortes por insuficiência ventricular direita (47%): seis nos casos de paciente que se apresentaram como EAP de alto risco (35,3%) e duas nos casos de risco intermediário-alto (11,8%). CONCLUSÃO A trombólise nos pacientes com EAP de alto risco ou risco intermediário-alto apresentou uma taxa de sangramento grave de 17,6%. No entanto, a alta mortalidade dessa população (47%) por insuficiência ventricular direita justifica o uso desta modalidade terapêutica.

Recent progress in developing of thrombolytic agents for ischemic stroke / 生物工程学报

Ischemic stroke is a major health crisis causing high mortality and morbidity. The key treatment relies on the rapid intervention to dissolve thrombus, to reduce bleeding side effect and re-canalize clotted blood vessels using clot lysis drugs. Tissue plasminogen activator (tPA) is the only FDA-approved drug for ischemic stroke, but it has many limitations in clinical use. In recent years, the development of thrombolytic drugs and treatment strategies based on tPA has been progressed rapidly. Here we review the recent progress in this field, including the contributions from us and others, to promote the future development of novel thrombolytic drugs.

Comparison of different types of endovascular mechanical embolectomy in acute ischemic stroke

SUMMARY Background: To compare the treatment efficacy of different types of endovascular mechanical embolectomy in acute ischemic stroke (AIS). Material and Methods: A total of 89 patients with AIS were selected in our hospital from January 2014 to January 2016 and divided into tPA group (n=27), tPA+Trevo group (n=30) and tPA+Solitaire FR group (n=32) for different treatments. Treatment effectiveness was evaluated using NIHSS and mRS system. The NIHSS score, vascular recanalization rate and postoperative complications were compared among groups. Results: The NIHSS score of the tPA group was significantly lower than that of other two groups at 1 d after the operation (p < 0.05), but it was significantly higher than that of other two groups at 3 d and 3 w after the operation (p < 0.05). After the treatment, no significant difference in NIHSS score was found between the tPA+Trevo and tPA Solitaire FR groups. The revascularization rate was significantly higher, but the mortality rate in 90 d was significantly lower in the tPA+Trevo and tPA+Solitaire FR groups than that in the tPA group (p < 0.05), and no significant difference was found between the tPA+Trevo and tPA+Solitaire FR groups. The incidence rate of symptomatic intracranial hemorrhage was significantly lower in the tPA+Solitaire FR group than that in tPA+Trevo group (p < 0.05) or tPA group (p < 0.01). Significantly more patients with mRS no higher than 2 points were found in the tPA+Trevo and tPA+Solitaire FR groups than those in tPA group (p < 0.05), and no significant difference was found between the tPA+Trevo and tPA+Solitaire FR groups. Conclusion: TPA+Solitaire FR is a type of thrombectomy that is superior to tPA and tPA+Trevo in the treatment of patients with AIS.

RESUMO OBJETIVO Comparar a eficácia do tratamento de diferentes tipos de embolectomia mecânica endovascular em acidente vascular cerebral isquêmico agudo (AIS). MATERIAL E MÉTODOS Um total de 89 pacientes com AIS foi selecionado em nosso hospital de janeiro de 2014 a janeiro de 2016, e os pacientes foram divididos em: grupo tPA (n = 27), tPA + grupo Trevo (n = 30) e grupo tPA + Solitaire FR (n = 32) para diferentes tratamentos. A eficácia do tratamento foi avaliada usando NIHSS e sistema mRS. Escore NIHSS, taxa de recanalização vascular e complicações pós-operatórias foram comparados entre os grupos. RESULTADOS A pontuação NIHSS do grupo tPA foi significativamente menor do que a dos outros dois grupos em um dia após a operação (p < 0,05), mas foi significativamente maior do que nos outros dois grupos em três dias e três semanas após a operação (p < 0,05). Após o tratamento, não houve diferença significativa no escore NIHSS entre o grupo tPA + Trevo e o grupo tPA Solitaire FR. A taxa de revascularização foi significativamente maior, mas a taxa de mortalidade em 90 dias foi significativamente menor nos grupos tPA + Trevo e tPA + Solitaire FR do que no grupo tPA (p < 0,05) e não houve diferença significativa entre os grupos tPA + Trevo e tPA + Solitaire FR. A taxa de incidência de hemorragia intracraniana sintomática foi significativamente menor no grupo tPA + Solitaire FR do que no grupo tPA + Trevo (p < 0,05) ou no grupo tPA (p < 0,01). Significativamente mais pacientes com mRS não maiores que 2 pontos foram encontrados no grupo tPA + Trevo e tPA + Solitaire FR do que no grupo tPA (p < 0,05), e nenhuma diferença significativa foi encontrada entre os grupos tPA + Trevo e tPA + Solitaire FR. Conclusão O tPA + Solitaire FR é um tipo de trombectomia superior ao tPA e tPA + Trevo no tratamento de pacientes com EIA.

Endovascular thrombectomy for the treatment of acute ischemic stroke / Tratamento endovascular do acidente vascular isquêmico agudo

ABSTRACT Few patients benefit from the current standard treatment for acute ischemic stroke (AIS), encouraging the development of new treatments. Objective To systematically review the literature on the efficacy and/or safety of endovascular thrombectomy in AIS compared to standard treatment and to identify ongoing randomized controlled trials (RCTs). Method Searches for RCTs were performed in Medline/Embase, and for ongoing trials: International Clinical Trial Registry Platform, Clinicaltrials.gov and ISRCTN registry (to June 15th, 2015). Results From the eight published RCTs, five showed the superiority of treatment that includes thrombectomy compared to standard care alone. From the 13 ongoing RCTs, 3 have been halted, one has not started, one has unknown status and eight will end between 2016 - 2020. Conclusion Evidence favours a combination of the standard therapy with endovascular thrombectomy. The selection criteria however limit the number of people who can benefit. Further studies are needed to prove its cost-effectiveness.

RESUMO Poucos pacientes se beneficiam do atual tratamento para o acidente vascular cerebral isquêmico agudo (AVCIA), incentivando o desenvolvimento de novos tratamentos. Objetivo Revisão sistemática da literatura sobre a eficácia e/ou segurança da trombectomia endovascular (TE) em AVCIA comparado com tratamento padrão (TP) e identificar ensaios clínicos randomizados controlados (ECR) atualmente em andamento. Método Buscas por ECRs foram conduzidas no Medline,Embase, International Clinical Trial Registry Platform, Clinicaltrials.gov e no ISRCTN registry (to June 15th, 2015). Resultados Oito ECRs publicados foram identificados, dos quais cinco mostraram superioridade do tratamento com trombectomia comparado ao TP. Dos 13 ERCs registrados, 3 foram suspensos, um não iniciou, um temstatus desconhecido e oito encerrarão recrutamento entre 2016 e 2020. Conclusão A evidência favorece a combinação do TP com a TE em relação ao TP somente. Os critérios de inclusão limitam o número daqueles que poderiam se beneficiar. Mais estudos são necessários para demonstrar o custo-efetividade desta intervenção.

Activador del plasminógeno tisular recombinante en el manejo de trombos cardiacos en recién nacidos / Recombinant tissue plasminogen activator for the management of intracardiac thrombi in newborns

Introducción: La incidencia de trombos cardíacos en recién nacidos (RN) ha aumentado con el uso de catéteres venosos centrales. La trombólisis con activador del plasminógeno tisular recombinante (rTPA) se ha utilizado como alternativa a la heparina en trombos gigantes con riesgo vital y de embolización. Nuestro objetivo fue describir la respuesta y las complicaciones relacionadas con el uso del rTPA en el manejo de trombos cardíacos con riesgo vital en RN. Pacientes y método: Estudio retrospectivo de 8 RN, 7 prematuros, con trombos cardíacos en los cuales se utilizó rTPA. Se analizó la edad gestacional y al diagnóstico, peso, sexo, enfermedades asociadas, hemograma, niveles de fibrinógeno, dímero D, tiempo parcial de tromboplastina activada y de protrombina, antes y al término de la infusión de rTPA. El diagnóstico del trombo se realizó por ecocardiografía doppler. La indicación de rTPA fue trombo mayor de 10 mm o que ocupara más del 50% de la cavidad donde se localizaba; aumento del tamaño a pesar del tratamiento con heparina, aspecto fragmentado y lobulado con riesgo embólico pulmonar o sistémico o que comprometiera la función valvular o cardíaca. Resultados: Cuatro hombres; peso promedio de 1.580 g. La principal enfermedad fue la sepsis (7/8), se usó catéter venoso central en todos, la vena cava superior fue la localización más frecuente, con tiempo promedio de instalación previo al diagnóstico de 12 días. En 7/8 RN los trombos se ubicaron en la aurícula derecha, con un tamaño entre 7 a 20 mm. Tres pacientes recibieron heparina de bajo peso molecular previo al uso de rTPA, se realizaron entre uno a 5 ciclos con rTPA. En 4 pacientes se logró resolución completa del trombo a los 3,5 días en promedio. No hubo embolia ni fallecidos. Cuatro pacientes presentaron hemorragia intracraneana grado I, sin secuelas en el seguimiento. Conclusión: Este estudio constituye la primera serie de neonatos tratados con rTPA en Chile, lográndose la resolución completa del trombo en un 50% de los RN y parcial en el resto, permitiendo con ello disminuir el riesgo vital secundario a este proceso patológico.

Introduction: The incidence of cardiac thrombi in newborns has increased with the use of central venous catheters. Thrombolysis with recombinant tissue plasminogen activator (rTPA) has been used as an alternative to heparin in life threatening giant thrombus and embolization. The aim of this study is to describe the response and complications related to the use of rTPA in the management of life- threatening cardiac thrombi in newborns. Patients and method: The medical records of 8 newborn were reviewed in a retrospective study, of whom 7 were preterm with cardiac thrombi, and rTPA was used in all of them. Results: The patients included 4 males with a mean weight of 1580 gr. The principal pathology was sepsis (7/8), all of them used venous central catheter. The superior vena cava was the most frequent location, with a mean time of installation before the diagnosis of 12 days. RN 7/8 thrombi were located in the right atrium with a size between 7 to 20 mm. Three patients received low molecular weight heparin prior to using rTPA. They received between 1 to 5 cycles with rTPA. In 4 patients complete resolution of the thrombus was achieved in a mean of 3.5 days. Four patients had intracranial haemorrhage grade I, without sequelae at follow-up. There were no deaths or embolism. Conclusion: This study is the first series of infants treated with rTPA in Chile, and where its use has quickly achieved complete resolution of the thrombus in 50% of cases, and partially in the others, thus reducing the secondary life-threatening risk of this disease.

Treatment of ischemic stroke with r-tPA: implementation challenges in a tertiary hospital in Brazil / Tratamento do acidente vascular cerebral isquêmico com r-tPA: o desafio da implantação em um hospital terciário no Brasil

Purpose: This paper presents the initial experience with thrombolysis for acute ischaemic stroke at Hospital de Base do Distrito Federal (HBDF), Brazil, and the difficulties associated with the implementation of this treatment. Method: A retrospective study was performed using the medical records of all patients with acute stroke who were treated with intravenous alteplase in our department, between May 2011 and April 2012. Results: The thrombolytic therapy was administered to 32 patients. The mean time between the ictus and the start of stroke therapy start was 195 (60-270) minutes. Sixteen patients demonstrated a significant clinical improvement (decrease in National Institute Health Stroke Scale [NIHSS] score≥4 points in 24 hours); 6 patients were discharged with an NIHSS score of 0 and 2 demonstrated haemorrhagic transformation. Conclusions: The results of our study are similar to those reported in the literature, although we have been dealing with difficulties, such as the lack of a stroke unit. .

Introdução: O objetivo deste trabalho é apresentar a experiência inicial em trombólise para o acidente vascular encefálico isquêmico (AVC) no Hospital de Base do Distrito Federal (HBDF) e as dificuldades encontradas na implementação do serviço. Método: Foi realizado estudo retrospectivo através da análise de prontuário de todos os pacientes submetidos à terapia trombolítica no período de maio de 2011 a abril de 2012. Resultados: A terapia trombolítica foi administrada a 32 pacientes. O tempo médio do ictus até o início da terapia foi de 195 (60-270) minutos. Dezesseis pacientes apresentaram uma melhora clínica significativa (queda do National Institute Health Stroke Scale [NIHSS] maior ou igual a 4 pontos em 24 horas). Seis pacientes receberam alta com NIHSS 0. Dois pacientes apresentaram transformação hemorrágica. Conclusão: Apesar das dificuldades encontradas, como a ausência de uma Unidade de AVC, o desfecho da nossa série é semelhante aos resultados descritos na literatura. .

Predictive factors for anterior chamber fibrin formation after vitreoretinal surgery / Fatores preditivos para formação de fibrina na câmara anterior após cirurgia vitreorretiniana

Purpose: The aim of this study was to investigate possible predictive factors related to anterior chamber fibrin formation after vitreoretinal surgery in a large series of patients. Methods: The data of 185 eyes of 185 patients submitted to vitreoretinal surgery was reviewed. The following variables were evaluated: the postoperatively presence of fibrin, age, diabetes mellitus, the vitrectomy system gauge (20, 23 or 25 gauge), the type of vitreous substitute, the influence of prior surgical procedures and the combination with cataract extraction. To evaluate predictive factors for anterior chamber fibrin formation, univariate analysis was performed. A multivariate stepwise logistic regression model was adjusted to investigate factors associated with fibrin formation (p<0.05). Results: Fibrinoid anterior chamber reaction was found in 12 (6.4%) patients. For multivariate logistic regression analysis, balanced salt solution (BSS), the chance of fibrin occurrence was 5 times greater (odds ratio 4.83, CI 95% 1.302 - 17.892; p=0.019), while combination with phacoemulsification increased the chance of fibrin formation by 20 times (odds ratio 20, CI 95% 2.480 - 161.347; p=0.005). No significant difference was found regarding other variables. Conclusion: Anterior chamber fibrin formation is an unwanted complication after vitreoretinal surgery. Factors such as combined performance of phacoemulsification and the use of balanced salt solution as a vitreous substitute may predispose the occurrence of this complication. .

Objetivo: Avaliar os possíveis fatores relacionados à formação de fibrina na câmara anterior após cirurgia vitreorretiniana em uma grande série de casos. Métodos: Foi realizado um estudo retrospectivo, observacional, caso-controle, onde os dados de 185 olhos de 185 pacientes submetidos à cirurgia vitreorretiniana foram avaliados. Os seguintes dados foram analisados: presença ou não de fibrina na câmara anterior na primeira semana de pós-operatório, idade, presença ou não de diabetes mellitus, calibre do sistema de vitrectomia utilizado (20,23 ou 25 gauge), substituto vítreo, a influência de cirurgias oftalmológicas prévias e a realização de cirurgia de catarata combinada. Para avaliação dos fatores preditivos para formação de fibrina, a análise univariada foi realizada. O modelo de regressão logística multivariada foi utilizado para investigar os fatores associados com a formação de fibrina (p<0,05). Resultados: A presença de fibrina na câmara anterior foi encontrada em 12 (6,4%) pacientes. Pela análise de regressão logística multivariada, o uso de solução salina balanceada (BSS) como substituto vítreo, a chance da presença de fibrina foi 5 vezes maior (odds ratio 4,83, IC 95% 1,302 - 17,892; p=0,019), enquanto que a realização de cirurgia facoemulsificação combinada aumentou a chance de formação de fibrina 20 vezes (odds ratio 20, IC 95% 2,480 - 161,347; p=0,005). Nenhuma diferença estatisticamente significativa foi encontrada para as outras variáveis. Conclusão: A formação de fibrina na câmara é uma complicação indesejada após cirurgia vitreorretiniana. Fatores como realização de cirurgia de facoemulsificação combinada e ...

Thrombolytic Therapy Complemented by ECMO: Successful Treatment for A Case of Massive Pulmonary Thromboembolism with Hemodynamic Collapse

Pulmonary thromboembolism (PTE) is a common clinical condition related to significant mortality. Furthermore, patients with PTE presenting with right heart thrombus show higher mortality due to rapid hemodynamic deterioration. But the optimal treatment of massive PTE is controversial although various methods have been developed and improved. Here, we presented a case of 56-yr-old woman with massive PTE showing hemodynamic collapse, who was successfully treated with extracorporeal membrane oxygenation (ECMO) adjunct to thrombolytic therapy even without thrombectomy. ECMO was useful for resuscitation and stabilization of the cardiopulmonary function. In conclusion, thrombolytic therapy complemented by ECMO may be an effective treatment option for acute massive PTE with hemodynamic instability.

Predictors of in-hospital mortality in patients with ST-segment elevation myocardial infarction undergoing pharmacoinvasive treatment

OBJECTIVES: To identify predictors of in-hospital mortality in patients with acute myocardial infarction undergoing pharmacoinvasive treatment. METHODS: This was an observational, prospective study that included 398 patients admitted to a tertiary center for percutaneous coronary intervention within 3 to 24 hours after thrombolysis with tenecteplase. ClinicalTrials.gov: NCT01791764 RESULTS: The overall in-hospital mortality rate was 5.8%. Compared with patients who survived, patients who died were more likely to be older, have higher rates of diabetes and chronic renal failure, have a lower left ventricular ejection fraction, and demonstrate more evidence of heart failure (Killip class III or IV). Patients who died had significantly lower rates of successful thrombolysis (39% vs. 68%; p = 0.005) and final myocardial blush grade 3 (13.0% vs. 61.9%; p<0.0001). Based on the multivariate analysis, the Global Registry of Acute Coronary Events score (odds ratio 1.05, 95% confidence interval (CI) 1.02-1.09; p = 0.001), left ventricular ejection fraction (odds ratio 0.9, 95% CI 0.89-0.97; p = 0.001), and final myocardial blush grade of 0-2 (odds ratio 8.85, 95% CI 1.34-58.57; p = 0.02) were independent predictors of mortality. CONCLUSIONS: In this prospective study that evaluated patients with ST-segment elevation myocardial infarction treated by a pharmacoinvasive strategy, the in-hospital mortality rate was 5.8%. The Global Registry of Acute Coronary Events score, left ventricular ejection fraction, and myocardial blush were independent predictors of mortality in this high-risk group of acute coronary syndrome patients. .

Clinical Retrospective and Prospective Evaluation of Efficacy and Safety of Reteplase in STEMI Patients.

Reteplase is a third-generation recombinant form of t- PA (tissue plasminogen activator). A phase–III prospective, multi-centric trial and retrospective, post-marketing surveillance (PMS) of reteplase have been conducted to evaluate the efficacy and safety of reteplase in patients with ST segment Elevation Myocardial Infarction (STEMI). Phase-III trial was a prospective, multi-centric, open-label study conducted across 15 centers in India. 80 patients out of 83 screened were enrolled in the study. Patients with STEMI admitted to an intensive care unit in a hospital within 6 hours of onset of symptoms and meeting all eligibility criteria were enrolled in the study. Each patient received a total dose of 20 units of reteplase. The dose was given as two 10 unit intravenous injections each over two minutes, no more than 30 minutes apart. The primary objective of the study was to evaluate the all cause mortality rate at 30 days post-dosing in patients with STEMI following treatment with reteplase. Safety assessment was based on treatment emergent adverse events, physical examinations, vital signs, ECGs, echocardiography and safety laboratory tests. A Post Marketing Surveillance (PMS) following the marketing approval in India was undertaken to assess the safety profile of reteplase in patients with STEMI and/or recent left bundle branch block. Reteplase was administered as two bolus injections of 10 units each. Each bolus was administered as a slow intravenous injection over 2 minutes. Total 204 patients’ data has been considered for the analysis in present post-marketing study. The results of both these studies are discussed. In both these studies, reteplase efficacy and safety were well established in treatment of patients with ST segment elevation Myocardial Infarction (STEMI).

A razão do uso de rtPA na trombólise do AVE isquêmico / The reason for the use rtPA of thrombolysis in ischemic stroke

As doenças cerebrovasculares são atualmente a maior causa de morte no Brasil e uma das três maiores causas de incapacidade permanente. A reabertura de uma artéria ocluída com rtPA em 4,5h mostrou-se extremamente eficaz no tratamento. Muitas outras substâncias ainda prometem estudos mais consistentes, e outras já foram descartadas através de trabalhos anteriores. O presente trabalho disserta sobre todos os mais relevantes estudos que acabaram levando ao uso do rtPA como medicação de eleição para o tratamento, em detrimento de outras substâncias que não vingaram porque não eram factíveis ou porque os trabalhos deixaram a desejar.

Cerebrovascular diseases are currently the leading cause of death in Brazil and one of the three maior causes of permanent disability. The reopening of an occluded artery with rtPA in 4.5 hours has shown to be an extremely effective treatment. Many other substances are also showing promise, and others have been dismissed by previous papers. This paper discusses the most relevant studies that eventually led to the use of rtPA as the treatment of choice to the detriment of substances which have either proven ineffective or impractical, or because of inconsistent or superficial research.