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1.
Cochrane Database Syst Rev ; 9: CD005049, 2019 09 04.
Artigo em Inglês | MEDLINE | ID: mdl-31483500

RESUMO

BACKGROUND: Atrial fibrillation is the most frequent sustained arrhythmia. Atrial fibrillation often recurs after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence. This is an update of a review previously published in 2006, 2012 and 2015. OBJECTIVES: To determine the effects of long-term treatment with antiarrhythmic drugs on death, stroke, drug adverse effects and recurrence of atrial fibrillation in people who had recovered sinus rhythm after having atrial fibrillation. SEARCH METHODS: We updated the searches of CENTRAL, MEDLINE and Embase in January 2019, and ClinicalTrials.gov and WHO ICTRP in February 2019. We checked the reference lists of retrieved articles, recent reviews and meta-analyses. SELECTION CRITERIA: Two authors independently selected randomised controlled trials (RCTs) comparing any antiarrhythmic drug with a control (no treatment, placebo, drugs for rate control) or with another antiarrhythmic drug in adults who had atrial fibrillation and in whom sinus rhythm was restored, spontaneously or by any intervention. We excluded postoperative atrial fibrillation. DATA COLLECTION AND ANALYSIS: Two authors independently assessed quality and extracted data. We pooled studies, if appropriate, using Mantel-Haenszel risk ratios (RR), with 95% confidence intervals (CI). All results were calculated at one year of follow-up or the nearest time point. MAIN RESULTS: This update included one new study (100 participants) and excluded one previously included study because of double publication. Finally, we included 59 RCTs comprising 20,981 participants studying quinidine, disopyramide, propafenone, flecainide, metoprolol, amiodarone, dofetilide, dronedarone and sotalol. Overall, mean follow-up was 10.2 months.All-cause mortalityHigh-certainty evidence from five RCTs indicated that treatment with sotalol was associated with a higher all-cause mortality rate compared with placebo or no treatment (RR 2.23, 95% CI 1.03 to 4.81; participants = 1882). The number need to treat for an additional harmful outcome (NNTH) for sotalol was 102 participants treated for one year to have one additional death. Low-certainty evidence from six RCTs suggested that risk of mortality may be higher in people taking quinidine (RR 2.01, 95% CI 0.84 to 4.77; participants = 1646). Moderate-certainty evidence showed increased RR for mortality but with very wide CIs for metoprolol (RR 2.02, 95% CI 0.37 to 11.05, 2 RCTs, participants = 562) and amiodarone (RR 1.66, 95% CI 0.55 to 4.99, 2 RCTs, participants = 444), compared with placebo.We found little or no difference in mortality with dofetilide (RR 0.98, 95% CI 0.76 to 1.27; moderate-certainty evidence) or dronedarone (RR 0.86, 95% CI 0.68 to 1.09; high-certainty evidence) compared to placebo/no treatment. There were few data on mortality for disopyramide, flecainide and propafenone, making impossible a reliable estimation for those drugs.Withdrawals due to adverse eventsAll analysed drugs increased withdrawals due to adverse effects compared to placebo or no treatment (quinidine: RR 1.56, 95% CI 0.87 to 2.78; disopyramide: RR 3.68, 95% CI 0.95 to 14.24; propafenone: RR 1.62, 95% CI 1.07 to 2.46; flecainide: RR 15.41, 95% CI 0.91 to 260.19; metoprolol: RR 3.47, 95% CI 1.48 to 8.15; amiodarone: RR 6.70, 95% CI 1.91 to 23.45; dofetilide: RR 1.77, 95% CI 0.75 to 4.18; dronedarone: RR 1.58, 95% CI 1.34 to 1.85; sotalol: RR 1.95, 95% CI 1.23 to 3.11). Certainty of the evidence for this outcome was low for disopyramide, amiodarone, dofetilide and flecainide; moderate to high for the remaining drugs.ProarrhythmiaVirtually all studied antiarrhythmics showed increased proarrhythmic effects (counting both tachyarrhythmias and bradyarrhythmias attributable to treatment) (quinidine: RR 2.05, 95% CI 0.95 to 4.41; disopyramide: no data; flecainide: RR 4.80, 95% CI 1.30 to 17.77; metoprolol: RR 18.14, 95% CI 2.42 to 135.66; amiodarone: RR 2.22, 95% CI 0.71 to 6.96; dofetilide: RR 5.50, 95% CI 1.33 to 22.76; dronedarone: RR 1.95, 95% CI 0.77 to 4.98; sotalol: RR 3.55, 95% CI 2.16 to 5.83); with the exception of propafenone (RR 1.32, 95% CI 0.39 to 4.47) for which the certainty of evidence was very low and we were uncertain about the effect. Certainty of the evidence for this outcome for the other drugs was moderate to high.StrokeEleven studies reported stroke outcomes with quinidine, disopyramide, flecainide, amiodarone, dronedarone and sotalol. High-certainty evidence from two RCTs suggested that dronedarone may be associated with reduced risk of stroke (RR 0.66, 95% CI 0.47 to 0.95; participants = 5872). This result is attributed to one study dominating the meta-analysis and has yet to be reproduced in other studies. There was no apparent effect on stroke rates with the other antiarrhythmics.Recurrence of atrial fibrillationModerate- to high-certainty evidence, with the exception of disopyramide which was low-certainty evidence, showed that all analysed drugs, including metoprolol, reduced recurrence of atrial fibrillation (quinidine: RR 0.83, 95% CI 0.78 to 0.88; disopyramide: RR 0.77, 95% CI 0.59 to 1.01; propafenone: RR 0.67, 95% CI 0.61 to 0.74; flecainide: RR 0.65, 95% CI 0.55 to 0.77; metoprolol: RR 0.83 95% CI 0.68 to 1.02; amiodarone: RR 0.52, 95% CI 0.46 to 0.58; dofetilide: RR 0.72, 95% CI 0.61 to 0.85; dronedarone: RR 0.85, 95% CI 0.80 to 0.91; sotalol: RR 0.83, 95% CI 0.80 to 0.87). Despite this reduction, atrial fibrillation still recurred in 43% to 67% of people treated with antiarrhythmics. AUTHORS' CONCLUSIONS: There is high-certainty evidence of increased mortality associated with sotalol treatment, and low-certainty evidence suggesting increased mortality with quinidine, when used for maintaining sinus rhythm in people with atrial fibrillation. We found few data on mortality in people taking disopyramide, flecainide and propafenone, so it was not possible to make a reliable estimation of the mortality risk for these drugs. However, we did find moderate-certainty evidence of marked increases in proarrhythmia and adverse effects with flecainide.Overall, there is evidence showing that antiarrhythmic drugs increase adverse events, increase proarrhythmic events and some antiarrhythmics may increase mortality. Conversely, although they reduce recurrences of atrial fibrillation, there is no evidence of any benefit on other clinical outcomes, compared with placebo or no treatment.


Assuntos
Antiarrítmicos/uso terapêutico , Fibrilação Atrial/prevenção & controle , Cardioversão Elétrica , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Prevenção Secundária
2.
BMJ Open ; 9(3): e025224, 2019 03 30.
Artigo em Inglês | MEDLINE | ID: mdl-30928940

RESUMO

OBJECTIVES: Healthcare professionals are expected to firmly ground their practice in sound evidence. That implies that they know and use evidence-based medicine (EBM). In this study, our aim was to know how often health professionals actually made use of EBM in their daily practice. DESIGN: A questionnaire survey of healthcare professionals. PARTICIPANTS: Healthcare professionals who attended six university postgraduate courses. 226 answered the questionnaire (144 physicians, 64 nurses and 24 pharmacists; response rate 63.3%). SETTING: 56.5% of respondents worked in hospitals (mostly non-teaching), 25.0% in nursing homes and 10.2% in primary care. All participants were French-speaking and lived in France or Switzerland. MEASURES: Declared degree of knowledge and use of EBM, use of EBM-related information sources. RESULTS: Overall, 14.2% of respondents declared to use EBM regularly in their daily practice and 15.6% declared to use EBM only occasionally. The remaining respondents declared they: knew about EBM but did not use it (33.1%), had just heard about EBM (31.9%) or did not know what EBM is (4.0%). Concerning the use of EBM-related information sources, 83.4% declared to use at least monthly (or more often) clinical guidelines, 47.1% PubMed, 21.3% the Cochrane Library and 6.4% other medical databases.Fewer pharmacists (12%) declared to use EBM in their practice than nurses (22%) or doctors (36%). No difference appeared when analysed by gender, work setting or years after graduation. The most frequent obstacles perceived for the practice of EBM were: lack of general knowledge about EBM, lack of skills for critical appraisal and lack of time. CONCLUSIONS: Only a minority of health professionals-with differences between physicians, nurses and pharmacists-declare to regularly use EBM in their professional practice. A larger proportion appears to be interested in EBM but seems to be deterred by their lack of knowledge, skills and personal time.

4.
Presse Med ; 48(2): 120-126, 2019 Feb.
Artigo em Francês | MEDLINE | ID: mdl-30853293

RESUMO

The multidimensional, multiprofessional gerontological evaluation helps identify geriatric syndromes and situations of fragility. This is a first step to establish a plan of care and assistance, to reduce the risk of falls, hospitalization, entry into institutions and to prevent a decline in independence. Older people with cardiovascular disease such as heart failure are at very high risk of repeated hospitalizations, with an average of 45% of patients re-hospitalized in the year following all-cause hospitalization. In the context of heart failure, frailty is an independent risk factor for mortality within 30 days of leaving hospital. Screening for frailty before transcatheter aortic valve implantation (TAVI) or interventional rhythmic procedure is a determining factor in decision-making for benefit in terms of survival and quality of life in elderly patients. Vascular diseases by their cerebral complications represent the first cause of mortality and the first cause of loss of functional independence in the subjects of more than 65 years. Vascular disease is a risk factor for cognitive impairment in the elderly.


Assuntos
Doenças Cardiovasculares/complicações , Avaliação da Deficiência , Avaliação Geriátrica , Idoso de 80 Anos ou mais , Disfunção Cognitiva/diagnóstico , Depressão/diagnóstico , Idoso Fragilizado , Insuficiência Cardíaca/complicações , Humanos , Readmissão do Paciente , Doenças Vasculares Periféricas/complicações
5.
Presse Med ; 48(2): 134-142, 2019 Feb.
Artigo em Francês | MEDLINE | ID: mdl-30728099

RESUMO

Hypotension and especially very low diastolic blood pressure could be an at-risk situation in very old and frail patients and in those with coronary heart disease. Chronic hypotension in people with heart failure is an indicator of poor prognosis and hinders the management of therapy. Orthostatic hypotension is a decrease in blood pressure>20mmHg for systolic and/or>10mmHg for diastolic within 3minutes after transition from supine to upright. Orthostatic hypotension may be symptomatic or not. The search for orthostatic hypotension is part of the clinical examination of elderly patients with hypertension, falling, diabetes and or polymedication. First intention treatment aims to correct modifiable modifying factors and to limit the circulatory consequences of orthostatism by elastic venous compression.


Assuntos
Hipotensão Ortostática/etiologia , Hipotensão Ortostática/prevenção & controle , Hipotensão/etiologia , Hipotensão/prevenção & controle , Acidentes por Quedas/prevenção & controle , Idoso , Insuficiência Cardíaca/complicações , Humanos , Hipotensão Ortostática/diagnóstico , Hipovolemia/complicações , Hipovolemia/terapia , Postura , Prognóstico , Síncope/etiologia , Síncope/prevenção & controle
6.
Presse Med ; 48(2): 143-153, 2019 Feb.
Artigo em Francês | MEDLINE | ID: mdl-30799151

RESUMO

Heart failure (HF) is a clinical syndrome that associates clinical signs in people over 80 years of age, an increase in natriuretic peptides and abnormal cardiac structures that result from cardiac aging in many cases. The most common symptoms are grouped according to the acronym "EPOF" (shortness of breath, weight gain, edema, fatigue). Over the age of 80, comorbidities must be taken into account. The incidence and prevalence of HF significantly increases with age and makes HF the most common reason for hospitalization for people over 80, and an important health expense. The management of HF, necessarily multidisciplinary with a geriatric evaluation, has improved over time due to effective targeted treatment, but mortality, hospitalization and readmission rates remain high. Therapeutic education and patient follow-up for treatment optimization are needed.


Assuntos
Envelhecimento/fisiologia , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/fisiopatologia , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Fármacos Cardiovasculares/uso terapêutico , Ensaios Clínicos como Assunto , Coração/fisiopatologia , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/terapia , Hospitalização , Humanos , Peptídeo Natriurético Encefálico/sangue , Educação de Pacientes como Assunto , Fragmentos de Peptídeos/sangue , Prognóstico
7.
Presse Med ; 48(2): 154-164, 2019 Feb.
Artigo em Francês | MEDLINE | ID: mdl-30528147

RESUMO

Vitamin-K antagonists (VKA) have been the standard for oral anticoagulation. However, they carry several problems in older patients: frequent bleeding complications, complex management, risk of interactions with multiple drugs. Two classes of direct oral anticoagulants (DOA) are currently available in France: (a) direct thrombin inhibitors: dabigatran; and (b) direct factor Xa inhibitors: rivaroxaban, apixaban and others. Their management is easier: quickly effective after administration, they are given at fixed doses and do not need regular laboratory monitoring. Several randomized trials have shown that DOA are non-inferior to VKA for treating venous thromboembolic disease (prophylactic or curative treatment) and atrial fibrillation (prevention of associated embolisms). DOA might be also effective for long-term treatment of coronary disease, in some cases. No trial has specifically studied older patients. In the context of atrial fibrillation, subgroup analysis show similar results between patients above and below 75-years-old. Lower doses of dabigatran and apixaban should be used in many older people. All DOA are eliminated at least partly by kidneys. Their dose must be reduced in moderate renal failure (filtration glomerular rate (FGR) 30 to 50mL/min) and they are contraindicated in older patients with severe renal failure (FGR<30mL/min). DOA also have other problems: (a) important drug interactions are still possible, (b) the clinical application of specific coagulation tests need to be defined, (c) their safety in some subgroups of elderly patients, very different from patients included in clinical trials, is not known.


Assuntos
Anticoagulantes/uso terapêutico , Antitrombinas/uso terapêutico , Inibidores do Fator Xa/uso terapêutico , Tromboembolia/prevenção & controle , Síndrome Coronariana Aguda/prevenção & controle , Idoso , Anticoagulantes/farmacologia , Antitrombinas/farmacologia , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Contraindicações de Medicamentos , Relação Dose-Resposta a Droga , Interações de Medicamentos , Inibidores do Fator Xa/farmacologia , Próteses Valvulares Cardíacas , Hemorragia/induzido quimicamente , Humanos , Insuficiência Renal Crônica/complicações , Fatores de Risco , Prevenção Secundária , Acidente Vascular Cerebral/prevenção & controle , Tromboembolia/tratamento farmacológico , Vitamina K/antagonistas & inibidores , Varfarina/farmacologia , Varfarina/uso terapêutico
8.
Front Neurol ; 9: 910, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30420830

RESUMO

Manual dexterity measures can be useful for early detection of age-related functional decline and for prediction of cognitive decline. However, what aspects of sensorimotor function to assess remains unclear. Manual dexterity markers should be able to separate impairments related to cognitive decline from those related to healthy aging. In this pilot study, we aimed to compare manual dexterity components in patients diagnosed with cognitive decline (mean age: 84 years, N = 11) and in age comparable cognitively intact elderly subjects (mean age: 78 years, N = 11). In order to separate impairments due to healthy aging from deficits due to cognitive decline we also included two groups of healthy young adults (mean age: 26 years, N = 10) and middle-aged adults (mean age: 41 years, N = 8). A comprehensive quantitative evaluation of manual dexterity was performed using three tasks: (i) visuomotor force tracking, (ii) isochronous single finger tapping with auditory cues, and (iii) visuomotor multi-finger tapping. Results showed a highly significant increase in force tracking error with increasing age. Subjects with cognitive decline had increased finger tapping variability and reduced ability to select the correct tapping fingers in the multi-finger tapping task compared to cognitively intact elderly subjects. Cognitively intact elderly subjects and those with cognitive decline had prolonged force release and reduced independence of finger movements compared to young adults and middle-aged adults. The findings suggest two different patterns of impaired manual dexterity: one related to cognitive decline and another related to healthy aging. Manual dexterity tasks requiring updating of performance, in accordance with (temporal or spatial) task rules maintained in short-term memory, are particularly affected in cognitive decline. Conversely, tasks requiring online matching of motor output to sensory cues were affected by age, not by cognitive status. Remarkably, no motor impairments were detected in patients with cognitive decline using clinical scales of hand function. The findings may have consequences for the development of manual dexterity markers of cognitive decline.

9.
PLoS One ; 13(2): e0193034, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29474380

RESUMO

BACKGROUND: Factors associated with delirium among community-dwelling older adults have been poorly studied. Our aim was to describe the prevalence of predisposing and precipitating factors for delirium among patients admitted for delirium and to assess whether these factors were appropriately recognized at the first patient assessment at hospital. METHODS: Consecutive community-dwelling individuals admitted to three geriatric acute care units with a confirmed initial diagnosis of delirium were prospectively included. An independent investigator recorded, using a predefined form, any acute medical condition considered by the attending geriatrician to be a precipitating factor, at the first patient assessment and at the end of his stay in acute care. RESULTS: A total of 208 patients were included, 80.0% had a pre-existing cognitive or neurological disorder, or both. The most frequent precipitating factor found were infections (49.0% of all patients, mainly lung and urinary tract infections), followed by drugs (30.8%), dehydration (26.4%) and electrolytic disturbances (18.7%, mostly hyponatremia). 91% of patients had a cerebral imagery, but acute neurological conditions were found in only 18.3%. Fewer precipitating factors were found at first than at final assessment (1.4 (95%CI 1.3-1.6) versus 1.9 (95%CI 1.8-2.0) respectively, p<0.001). This difference was significant for all main categories of precipitating factors. CONCLUSIONS: Infections, followed by drugs and hydro-electrolytic disorders seem to be the most frequent precipitating factors for delirium in community-dwelling elderly individuals. Early diagnostic and management of precipitating factors in these patients should be improved, as a significant number of them are missed at the initial assessment.


Assuntos
Delírio/etiologia , Idoso de 80 Anos ou mais , Delírio/diagnóstico , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/complicações , Feminino , Hospitalização , Humanos , Vida Independente , Infecção/complicações , Masculino , Paris , Fatores Desencadeantes , Estudos Prospectivos , Desequilíbrio Hidroeletrolítico/complicações
11.
Cochrane Database Syst Rev ; (3): CD005049, 2015 Mar 28.
Artigo em Inglês | MEDLINE | ID: mdl-25820938

RESUMO

BACKGROUND: Atrial fibrillation is the most frequent sustained arrhythmia. Atrial fibrillation frequently recurs after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence, but the effect of these drugs on mortality and other clinical outcomes is unclear. This is an update of a review previously published in 2008 and 2012. OBJECTIVES: To determine in patients who have recovered sinus rhythm after having atrial fibrillation, the effects of long-term treatment with antiarrhythmic drugs on death, stroke, embolism, drug adverse effects and recurrence of atrial fibrillation. SEARCH METHODS: We updated the searches of CENTRAL in The Cochrane Library (2013, Issue 12 of 12), MEDLINE (to January 2014) and EMBASE (to January 2014). The reference lists of retrieved articles, recent reviews and meta-analyses were checked. SELECTION CRITERIA: Two independent authors selected randomised controlled trials comparing any antiarrhythmic drug with a control (no treatment, placebo, drugs for rate control) or with another antiarrhythmic drug in adults who had atrial fibrillation and in whom sinus rhythm was restored. Post-operative atrial fibrillation was excluded. DATA COLLECTION AND ANALYSIS: Two authors independently assessed quality and extracted data. Studies were pooled, if appropriate, using Peto odds ratio (OR). All results were calculated at one year of follow-up. MAIN RESULTS: In this update three new studies, with 534 patients, were included making a total of 59 included studies comprising 21,305 patients. All included studies were randomised controlled trials. Allocation concealment was adequate in 17 trials, it was unclear in the remaining 42 trials. Risk of bias was assessed in all domains only in the trials included in this update.Compared with controls, class IA drugs quinidine and disopyramide (OR 2.39, 95% confidence interval (95% CI) 1.03 to 5.59, number needed to treat to harm (NNTH) 109, 95% CI 34 to 4985) and sotalol (OR 2.23, 95% CI 1.1 to 4.50, NNTH 169, 95% CI 60 to 2068) were associated with increased all-cause mortality. Other antiarrhythmics did not seem to modify mortality, but our data could be underpowered to detect mild increases in mortality for several of the drugs studied.Several class IA (disopyramide, quinidine), IC (flecainide, propafenone) and III (amiodarone, dofetilide, dronedarone, sotalol) drugs significantly reduced recurrence of atrial fibrillation (OR 0.19 to 0.70, number needed to treat to beneft (NNTB) 3 to 16). Beta-blockers (metoprolol) also significantly reduced atrial fibrillation recurrences (OR 0.62, 95% CI 0.44 to 0.88, NNTB 9).All analysed drugs increased withdrawals due to adverse affects and all but amiodarone, dronedarone and propafenone increased pro-arrhythmia. Only 11 trials reported data on stroke. None of them found any significant difference with the exception of a single trial than found less strokes in the group treated with dronedarone compared to placebo. This finding was not confirmed in others studies on dronedarone.We could not analyse heart failure and use of anticoagulation because few original studies reported on these measures. AUTHORS' CONCLUSIONS: Several class IA, IC and III drugs, as well as class II drugs (beta-blockers), are moderately effective in maintaining sinus rhythm after conversion of atrial fibrillation. However, they increase adverse events, including pro-arrhythmia, and some of them (disopyramide, quinidine and sotalol) may increase mortality. Possible benefits on clinically relevant outcomes (stroke, embolism, heart failure) remain to be established.


Assuntos
Antiarrítmicos/uso terapêutico , Fibrilação Atrial/terapia , Cardioversão Elétrica , Adolescente , Adulto , Antiarrítmicos/efeitos adversos , Fibrilação Atrial/mortalidade , Fibrilação Atrial/prevenção & controle , Causas de Morte , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Prevenção Secundária , Acidente Vascular Cerebral/induzido quimicamente
12.
Geriatr Psychol Neuropsychiatr Vieil ; 13 Suppl 2: 15-20, 2015 Sep.
Artigo em Francês | MEDLINE | ID: mdl-26967927

RESUMO

Herpes zoster (HZ) infection is a common condition in the elderly. Immunosuppression involving cellular immunity favors its occurrence. The pain is the most frequent complications of HZ. It occurs in about 30% of people aged over 70 years. The virological diagnosis of typical HZ is not useful, and the diagnosis is mainly based on clinical data. Skin care is essential to limit cutaneous damage. Antiviral drugs will reduce the risk of post-herpetic neuralgia, if they are early prescribed within 72 hours after the rash onset. Analgesia is essential and should be conducted in relation evolution. Vaccination is the most effective way to prevent the occurrence of HZ complications in the elderly, in particular post-herpetic neuralgia.


Assuntos
Vacina contra Herpes Zoster , Herpes Zoster/prevenção & controle , Herpes Zoster/psicologia , Neuralgia Pós-Herpética/imunologia , Neuralgia Pós-Herpética/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Feminino , Herpes Zoster/complicações , Herpes Zoster/epidemiologia , Humanos , Imunização , Masculino , Pessoa de Meia-Idade , Neuralgia Pós-Herpética/epidemiologia , Dor/etiologia
13.
Cochrane Database Syst Rev ; (9): CD002751, 2013 Sep 20.
Artigo em Inglês | MEDLINE | ID: mdl-24052483

RESUMO

BACKGROUND: Active compression-decompression cardiopulmonary resuscitation (ACDR CPR) uses a hand-held suction device, applied mid-sternum, to compress the chest then actively decompress the chest after each compression. Randomised controlled trials testing this device have shown discordant results. OBJECTIVES: To determine the effect of active chest compression-decompression CPR compared to standard chest compression CPR on mortality and neurological function in adults with cardiac arrest treated either in-hospital or out-of-hospital. SEARCH METHODS: We updated the searches of CENTRAL in The Cochrane Library (Issue 12 of 12, 2012), MEDLINE (OVID, 1946 to January week 1 2013), and EMBASE (OVID, 1980 to week 1 2013) on 14 January 2013. We checked the reference list of retrieved articles, contacted experts in the field, and searched ClinicalTrials.gov. SELECTION CRITERIA: All randomised or quasi-randomised studies comparing active compression-decompression with standard manual chest compression in adults with a cardiac arrest who received cardiopulmonary resuscitation by a trained medical or paramedical team. DATA COLLECTION AND ANALYSIS: We independently extracted data on an intention-to-treat basis. When needed, we contacted the authors of the primary studies. If appropriate, we cumulated studies and pooled relative risk (RR) estimates. We predefined subgroup analyses according to setting (out-of-hospital or in-hospital) and attending team composition (with physician or paramedic only). MAIN RESULTS: In this update, 27 new related publications were found, but they did not all fulfil inclusion criteria or concerned participants already reported in previous publications. In the end, we included 10 trials in this review: Eight were in out-of-hospital settings; one was set in-hospital only; and one had both in-hospital and out-of-hospital components. Allocation concealment was adequate in four studies. The two in-hospital studies were different in quality and size (773 and 53 participants). Both found no differences between ACDR CPR and STR in any outcome.Out-of-hospital trials cumulated 4162 participants. There were no differences between ACDR CPR and STR for mortality either immediately (RR 0.98, 95% confidence interval (CI) 0.94 to 1.03) or at hospital discharge (RR 0.99, 95% CI 0.98 to 1.01). The pooled RR of neurological impairment of any severity was 1.71 (95% CI 0.90 to 3.25), with a non-significant trend to more frequent severe neurological damage in survivors of ACDR CPR (RR 3.11, 95% CI 0.98 to 9.83). However, assessment of neurological outcome was limited, and few participants had neurological damage.There was no difference between ACDR CPR and STR with regard to complications such as rib or sternal fractures, pneumothorax, or haemothorax (RR 1.09, 95% CI 0.86 to 1.38). Skin trauma and ecchymosis were more frequent with ACDR CPR. AUTHORS' CONCLUSIONS: Active chest compression-decompression in people with cardiac arrest is not associated with any clear benefit.


Assuntos
Reanimação Cardiopulmonar/métodos , Parada Cardíaca/terapia , Adulto , Reanimação Cardiopulmonar/instrumentação , Serviços Médicos de Emergência , Massagem Cardíaca/instrumentação , Massagem Cardíaca/métodos , Humanos , Parada Cardíaca Extra-Hospitalar/terapia , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
14.
Presse Med ; 42(2): 187-96, 2013 Feb.
Artigo em Francês | MEDLINE | ID: mdl-23312927

RESUMO

Vitamin-K antagonists (VKA) are the current standard for oral anticoagulation. However, they carry several problems in older patients: frequent bleeding complications, complex management, risk of interactions with multiple drugs. Two new classes of oral anticoagulants (NOA) are now available: direct thrombin inhibitors (dabigatran); and direct factor Xa inhibitors (rivaroxaban, apixaban) and others. Their management is easier: quickly effective after administration, they are given at fixed doses and do not need regular laboratory monitoring. Several randomized trials have shown that NOA are non-inferior to heparins and VKA for treating venous thromboembolic disease (prophylactic or curative treatment) and atrial fibrillation (prevention of associated embolisms). NOA are also being studied for long-term treatment after acute coronary syndromes. Data regarding older people is still sparse. No trial has specifically studied older patients. In the context of atrial fibrillation, subgroup analysis show similar results between patients above and below 75 years old, except for dabigatran which seems to carry more bleeding complications in people older than 75 years, specially with the highest dose employed. All NOA are eliminated at least partly by kidneys. Their dose must be reduced in moderate renal failure (filtration glomerular rate (FGR) 30 to 50 ml/min) and they are contra-indicated in severe renal failure (FGR<30 ml/min). Doses of dabigatran and apixaban should be reduced in older people too. NOA also have other unresolved problems: drug interactions are still possible, specific coagulation test to assess them must be developed, and no specific antidote is currently available in case of hemorrhagic complication.


Assuntos
Idoso , Anticoagulantes/uso terapêutico , Transtornos da Coagulação Sanguínea/terapia , Hematologia/tendências , 4-Hidroxicumarinas/administração & dosagem , 4-Hidroxicumarinas/efeitos adversos , 4-Hidroxicumarinas/uso terapêutico , Administração Oral , Idade de Início , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Transtornos da Coagulação Sanguínea/induzido quimicamente , Transtornos da Coagulação Sanguínea/epidemiologia , Humanos , Indenos/administração & dosagem , Indenos/efeitos adversos , Indenos/uso terapêutico , Medição de Risco , Vitamina K/administração & dosagem , Vitamina K/efeitos adversos , Vitamina K/antagonistas & inibidores , Vitamina K/uso terapêutico
16.
Presse Med ; 42(2): 171-80, 2013 Feb.
Artigo em Francês | MEDLINE | ID: mdl-23332403

RESUMO

Clinicians must be aware that aging can lead to changes in the pharmacokinetics and pharmacodynamics of many drugs. Drug distribution may be modified with aging secondarily to the decrease of serum albumin and to modifications of body composition (increase in the proportion of fat mass and decrease of lean mass). Hepatic metabolism of several drugs is reduced with age, especially drugs which depend of hepatic blood flow or P450 cytochroms. The incidence of renal failure increase largely with age. Glomerular filtration rate should be systematically estimated in older patients and, when needed, the doses of those drugs having significant renal elimination should be adjusted. In older patients, changes in the response to drugs can also develop, concerning specially the central nervous system (increased sensibility to any neurological effect of drugs), the cardiovascular system and the renal management of water and electrolytes. In many cases, the pharmacological changes associated to age are mild and requires no dose adjustment. However, many drugs should be adapted depending on the individual situation of each patient, particularly his renal function and nutritional state. Finally, some drugs should be avoided in older patients because of a bad effectiveness/tolerance ratio compared to alternatives.


Assuntos
Envelhecimento/fisiologia , Farmacologia Clínica/métodos , Idoso , Idoso de 80 Anos ou mais , Envelhecimento/metabolismo , Disponibilidade Biológica , Composição Corporal/fisiologia , Humanos , Inativação Metabólica/fisiologia , Fígado/efeitos dos fármacos , Fígado/metabolismo , Farmacologia Clínica/normas , Medicamentos sob Prescrição/farmacocinética , Distribuição Tecidual
17.
Presse Med ; 42(2): 181-6, 2013 Feb.
Artigo em Francês | MEDLINE | ID: mdl-23332893

RESUMO

Iatrogenic agitation is frequently drug-induced in the elderly. The management of the iatrogenic agitation is based on: a detailed analysis of the patient's medications, stopping non-essential drugs, prescribing drugs to the lowest and effective dose possible. This management of the iatrogenic agitation is also based on: adjustment of drugs according to renal function and limitation of polypharmacy. Special attention is necessary when prescribing treatments for patients with cognitive impairment.


Assuntos
Idoso , Doença Iatrogênica , Agitação Psicomotora , Idoso de 80 Anos ou mais , Analgésicos Opioides/efeitos adversos , Antagonistas Colinérgicos/efeitos adversos , Humanos , Doença Iatrogênica/epidemiologia , Prevalência , Agitação Psicomotora/epidemiologia , Agitação Psicomotora/etiologia , Agitação Psicomotora/terapia , Psicotrópicos/efeitos adversos
18.
Cochrane Database Syst Rev ; (5): CD005049, 2012 May 16.
Artigo em Inglês | MEDLINE | ID: mdl-22592700

RESUMO

BACKGROUND: Atrial fibrillation (AF) is the most frequent sustained arrhythmia. AF recurs frequently after restoration of normal sinus rhythm. Antiarrhythmic drugs have been widely used to prevent recurrence, but the effect of these drugs on mortality and other clinical outcomes is unclear. OBJECTIVES: To determine, in patients who recovered sinus rhythm after AF, the effect of long-term treatment with antiarrhythmic drugs on death, stroke and embolism, adverse effects, pro-arrhythmia, and recurrence of AF. SEARCH METHODS: We updated the searches of CENTRAL on The Cochrane Libary (Issue 1 of 4, 2010), MEDLINE (1950 to February 2010) and EMBASE (1966 to February 2010). The reference lists of retrieved articles, recent reviews and meta-analyses were checked. SELECTION CRITERIA: Two independent reviewers selected randomised controlled trials comparing any antiarrhythmic with a control (no treatment, placebo or drugs for rate control) or with another antiarrhythmic, in adults who had AF and in whom sinus rhythm was restored. Post-operative AF was excluded. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed quality and extracted data. Studies were pooled, if appropriate, using Peto odds ratio (OR). All results were calculated at one year of follow-up. MAIN RESULTS: In this update, 11 new studies met inclusion criteria, making a total of 56 included studies, comprising 20,771 patients. Compared with controls, class IA drugs quinidine and disopyramide (OR 2.39, 95% confidence interval (95%CI) 1.03 to 5.59, number needed to harm (NNH) 109, 95%CI 34 to 4985) and sotalol (OR 2.47, 95%CI 1.2 to 5.05, NNH 166, 95%CI 61 to 1159) were associated with increased all-cause mortality. Other antiarrhythmics did not seem to modify mortality.Several class IA (disopyramide, quinidine), IC (flecainide, propafenone) and III (amiodarone, dofetilide, dronedarone, sotalol) drugs significantly reduced recurrence of AF (OR 0.19 to 0.70, number needed to treat (NNT) 3 to 16). Beta-blockers (metoprolol) also reduced significantly AF recurrence (OR 0.62, 95% CI 0.44 to 0.88, NNT 9).All analysed drugs increased withdrawals due to adverse affects and all but amiodarone, dronedarone and propafenone increased pro-arrhythmia. We could not analyse other outcomes because few original studies reported them. AUTHORS' CONCLUSIONS: Several class IA, IC and III drugs, as well as class II (beta-blockers), are moderately effective in maintaining sinus rhythm after conversion of atrial fibrillation. However, they increase adverse events, including pro-arrhythmia, and some of them (disopyramide, quinidine and sotalol) may increase mortality. Possible benefits on clinically relevant outcomes (stroke, embolisms, heart failure) remain to be established.


Assuntos
Antiarrítmicos/uso terapêutico , Fibrilação Atrial/terapia , Cardioversão Elétrica , Fibrilação Atrial/mortalidade , Fibrilação Atrial/prevenção & controle , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Prevenção Secundária
19.
Int J Cardiol ; 155(1): 102-9, 2012 Feb 23.
Artigo em Inglês | MEDLINE | ID: mdl-21126785

RESUMO

BACKGROUND: Atrial fibrillation (AF) is more frequent with age but it is not clear whether, and how, older age should influence therapeutic choice. METHODS: We developed a Markov decision analytic model simulating the long term effectiveness of 4 therapeutic strategies (rate control (RateC) or rhythm control (RhythmC) using amiodarone, each combined with aspirin or warfarin) in two hypothetical cohorts of patients with persistent AF, 60 and 80 years old at baseline. Two different base risks of stroke, low and moderate/high, were analysed. Outcomes studied were: predicted mortality, quality-adjusted years (QALYs), stroke, and disability. Time horizon was 10 years. RESULTS: All results applied similarly to patients 60 and 80 years old at baseline. RateC + warfarin obtained in all cases the lowest predicted mortality (0.5% to 3.9% absolute reduction). RateC + warfarin also gained the more cumulated QALYs in patients at moderate/high risk of stroke, but RateC + aspirin obtained better results in QALYs in patients at low risk of stroke. Differences between strategies in terms of QALYs were limited (0.07 to 0.25 QALY of difference). Sensitivity analysis identified four variables, the same in younger and in older patients, that could change which strategy was optimal: impact on quality of life provoked by AF and by warfarin treatment, baseline risk of stroke and risk of major bleeding on warfarin. CONCLUSIONS: No important difference in the decision making between patients 60 and 80 years old was found. Several individual variables influenced the optimal choice of long term treatment of AF, but not age by itself.


Assuntos
Fibrilação Atrial/terapia , Técnicas de Apoio para a Decisão , Cadeias de Markov , Idoso , Idoso de 80 Anos ou mais , Aspirina/uso terapêutico , Fibrilação Atrial/fisiopatologia , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do Tratamento , Varfarina/uso terapêutico
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