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Pol Arch Intern Med ; 128(12): 771-778, 2018 12 21.
Artigo em Inglês | MEDLINE | ID: mdl-30575713


Addressing the optimal management approach for patients who are receiving single or dual antiplatelet therapy is a common and sometimes challenging clinical problem, especially for patients with coronary stents who are receiving dual antiplatelet therapy with acetylsalicylic acid (ASA) combined with a P2Y12 inhibitor. Using a case-based format, we summarize the findings of recent clinical trials and key observational studies which help inform best practices for the perioperative antiplatelet management of noncardiac surgery and coronary artery bypass graft surgery. In this review, we explore the evidence to address 3 key questions: What is the minimum duration that a surgery should be delayed after coronary stent implantation? In patients who are receiving single antiplatelet therapy with ASA, how to manage patients who require noncardiac and cardiac surgery? In patients who are receiving dual antiplatelet therapy for a coronary stent, how to manage patients who require noncardiac and cardiac surgery?

Perda Sanguínea Cirúrgica/prevenção & controle , Assistência Perioperatória/métodos , Inibidores da Agregação de Plaquetas/uso terapêutico , Hemorragia Pós-Operatória/prevenção & controle , Monitoramento de Medicamentos/normas , Procedimentos Cirúrgicos Eletivos , Humanos , Fatores de Risco , Tromboembolia/prevenção & controle
Lancet Haematol ; 2(2): e75-81, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26687612


BACKGROUND: Rituximab is commonly used as a treatment for primary immune thrombocytopenia to induce and maintain remission. The benefit of adding rituximab to standard-of-care treatment is uncertain. METHODS: We did a systematic review and meta-analysis of randomised controlled trials assessing the efficacy and safety of rituximab for treatment of adults with primary immune thrombocytopenia. We searched Medline, Embase, and the Cochrane database in duplicate and independently from inception up to July 31, 2014, for relevant studies. Primary outcomes were the proportion of patients achieving a complete platelet count response and a partial platelet count response (as defined in primary studies) that was maintained until the end of follow-up. We also assessed bleeding, infection, and infusion reactions. FINDINGS: Our database search returned 468 abstracts, of which five trials (with total of 463 patients) were eligible for analysis. No patients had splenectomy at the time of enrolment. Median follow-up was 6 months (IQR 6-12). Complete response (>100 × 10(9) platelets per L without rescue therapy) was more common with rituximab than with standard of care (weighted proportions: 46·8% vs 32·5%; relative risk [RR] 1·42, 95% CI 1·13-1·77; p=0·0020). Partial response was not significantly different between groups (57·6% vs 46·7%; RR 1·26, 95% CI 0·95-1·67; p=0·11). Rituximab was not associated with a reduction in bleeding (9·2% vs 5·2%; RR 1·34, 95% CI 0·63-2·87; p=0·44) or an increase in infections (20·1% vs 12·1%; RR 1·40, 95% CI 0·87-2·26; p=0·17). INTERPRETATION: Rituximab can improve complete platelet count responses by 6 months in patients with immune thrombocytopenia. Evidence for sustained responses beyond 6-12 months is limited. Clinicians must consider the goals of treatment before prescribing rituximab. FUNDING: None.

Púrpura Trombocitopênica Idiopática/tratamento farmacológico , Rituximab/uso terapêutico , Padrão de Cuidado , Humanos , Contagem de Plaquetas , Ensaios Clínicos Controlados Aleatórios como Assunto , Indução de Remissão , Resultado do Tratamento
Anesth Analg ; 121(3): 709-15, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26287299


BACKGROUND: The incidence, severity, and duration of postoperative oxygen desaturation in the general surgical population are poorly characterized. We therefore used continuous pulse oximetry to quantify arterial oxygen saturation (SpO2) in a cross-section of patients having noncardiac surgery. METHODS: Oxygen saturation, blinded to clinicians, was recorded at 1-minute intervals in patients >45 years old for up to 48 hours after noncardiac surgery in 1250 patients from Cleveland Clinic Main Campus and 250 patients from the Juravinski Hospital. We determined (1) the cumulative minutes of raw minute-by-minute values below various hypoxemic thresholds; and (2) the contiguous duration of kernel-smoothed (sliding window) values below various hypoxemic thresholds. Finally, we compared our blinded continuous values with saturations recorded during routine nursing care. RESULTS: Eight hundred thirty-three patients had sufficient data for analyses. Twenty-one percent had ≥10 min/h with raw SpO2 values <90% averaged over the entire recording duration; 8% averaged ≥20 min/h <90%; and 8% averaged ≥5 min/h <85%. Prolonged hypoxemic episodes were common, with 37% of patients having at least 1 (smoothed) SpO2 <90% for an hour or more; 11% experienced at least 1 episode lasting ≥6 hours; and 3% had saturations <80% for at least 30 minutes. Clinical hypoxemia, according to nursing records, measured only in Cleveland Clinic patients (n = 594), occurred in 5% of the monitored patients. The nurses missed 90% of smoothed hypoxemic episodes in which saturation was <90% for at least one hour. CONCLUSIONS: Hypoxemia was common and prolonged in hospitalized patients recovering from noncardiac surgery. The SpO2 values recorded in medical records seriously underestimated the severity of postoperative hypoxemia.

Hipóxia/diagnóstico , Oximetria/tendências , Complicações Pós-Operatórias/diagnóstico , Idoso , Estudos Transversais , Feminino , Humanos , Hipóxia/sangue , Masculino , Pessoa de Meia-Idade , Oximetria/métodos , Complicações Pós-Operatórias/sangue , Estudos Prospectivos , Método Simples-Cego
Chest ; 144(6): 1848-1856, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-23928727


BACKGROUND: It is unclear how to appropriately manage discontinuation and resumption of antiplatelet therapy in patients with coronary stents who need noncardiac surgery. We undertook a systematic review of the literature to identify practice guideline statements regarding antiplatelet therapy in patients with coronary stents undergoing noncardiac surgery. METHODS: We used six search strategies to identify practice guideline statements that comment on perioperative antiplatelet management for patients with coronary stents undergoing noncardiac surgery. Two independent reviewers assessed study eligibility, abstracted data, and completed quality assessment. RESULTS: We identified 11 practice guidelines that met the eligibility criteria; these were included in the review. These guidelines advised that elective noncardiac surgery be delayed for at least 4 weeks after bare-metal stent implantation and at least 6 months after drug-eluting stent implantation. For elective surgery, all guidelines advised continuing acetylsalicylic acid (ASA) therapy whenever possible. If interruption of antiplatelet therapy was required, four guidelines advised to discontinue ASA/clopidogrel at least 5 days before surgery, while two guidelines advised to discontinue 7 to 10 days before surgery. Five guidelines provided varying guidance for the use of perioperative bridging during antiplatelet therapy interruption. CONCLUSIONS: Most current recommendations are based on expert opinion. This review highlights the need for well-designed prospective studies to identify optimal management strategies in patients with coronary stents who are on antiplatelet therapy and who need noncardiac surgery.

Doença da Artéria Coronariana/tratamento farmacológico , Procedimentos Cirúrgicos Eletivos , Assistência Perioperatória , Inibidores da Agregação de Plaquetas/uso terapêutico , Guias de Prática Clínica como Assunto , Stents , Aspirina/uso terapêutico , Clopidogrel , Hemorragia/prevenção & controle , Humanos , Metais , Tromboembolia/prevenção & controle , Ticlopidina/análogos & derivados , Ticlopidina/uso terapêutico , Fatores de Tempo , Suspensão de Tratamento
Pol Arch Med Wewn ; 123(11): 617-22, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-24466582


The novel oral anticoagulant drugs, comprising dabigatran, rivaroxaban, and apixaban, have emerged as compelling alternatives to vitamin K antagonists for stroke prevention in atrial fibrillation, and low­molecular­weight heparin for thromboprophylaxis following hip and knee arthroplasty. Rivaroxaban has also been approved for treatment of venous thromboembolism. However, the role of these drugs for the management of patients with an acute coronary syndrome (ACS) is less certain. The purpose of this review was to summarize the randomized trials evaluating novel oral anticoagulants in patients with an ACS and consider the reasons why these drugs have not been incorporated into routine clinical practice. In addition, the situation involving rivaroxaban, which has been approved for use in patients with an acute coronary syndrome in Europe but not in North America, is discussed.

Síndrome Coronariana Aguda/tratamento farmacológico , Anticoagulantes/administração & dosagem , Fibrilação Atrial/prevenção & controle , Síndrome Coronariana Aguda/complicações , Administração Oral , Fibrilação Atrial/etiologia , Benzimidazóis/administração & dosagem , Ensaios Clínicos como Assunto , Dabigatrana , Humanos , Morfolinas/administração & dosagem , Pirazóis/administração & dosagem , Piridonas/administração & dosagem , Rivaroxabana , Tiofenos/administração & dosagem , beta-Alanina/administração & dosagem , beta-Alanina/análogos & derivados
Semin Thromb Hemost ; 38(7): 652-60, 2012 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-23034826


Patients receiving anticoagulant or antiplatelet therapy who require noncardiac surgery represent a common yet challenging clinical problem. Clinicians must balance the risk of thromboembolic and major adverse cardiovascular events that are associated with interrupting these therapies, against the risk of bleeding from continuing these drugs in the perioperative period. Identifying patients at highest risk for such complications requires particular attention to the role of bridging therapy and the optimal timing and duration of drug withdrawal and resumption with surgery. Patients with coronary stents represent a population that requires specific considerations, due to the added risk and significant mortality associated with perioperative stent thrombosis. Minimizing this risk is dependent on several patient- and stent-specific factors. This review provides clinicians with a summary of the available evidence to facilitate a practical approach to the management of these patients while highlighting the need for continued research in this field.

Anticoagulantes/administração & dosagem , Inibidores da Agregação de Plaquetas/administração & dosagem , Procedimentos Cirúrgicos Operatórios/métodos , Anticoagulantes/efeitos adversos , Prática Clínica Baseada em Evidências , Humanos , Assistência Perioperatória , Inibidores da Agregação de Plaquetas/efeitos adversos , Varfarina/administração & dosagem , Varfarina/efeitos adversos