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1.
Arq Bras Cardiol ; 116(1): 108-116, 2021 01.
Artigo em Inglês, Português | MEDLINE | ID: mdl-33331461

RESUMO

BACKGROUND: In clinical practice, there is evidence of failure to prescribe evidence-based therapies for patients at high cardiovascular risk. However, in Brazil, data on 1-year outcomes of these patients remain insufficient. OBJECTIVES: To describe the use of evidence-based therapies and the occurrence of major cardiovascular outcomes and their major predictors in a 12-month follow-up of a Brazilian multicenter registry of patients at high cardiovascular risk. METHODS: This prospective observational study documented the outpatient clinical practice of managing patients over 45 years of age and of high cardiovascular risk in both primary and secondary prevention. Patients were followed-up for 1 year, and the prescription of evidence-based therapies and the occurrence of major cardiovascular events (myocardial infarction, stroke, cardiac arrest, and cardiovascular death) were assessed. P-values < 0.05 were considered statistically significant. RESULTS: From July 2010 to August 2014, a total of 5076 individuals were enrolled in 48 centers, 91% of the 4975 eligible patients were followed-up in cardiology centers, and 68.6% were in secondary prevention. At 1 year, the concomitant use of antiplatelet agents, statins, and angiotensin-converting enzyme inhibitors reduced from 28.3% to 24.2% (p < 0.001). Major cardiovascular event rate was 5.46%, and the identified predictors were age, patients in secondary prevention, and diabetic nephropathy. CONCLUSIONS: In this large national registry of patients at high cardiovascular risk, risk predictors similar to those of international registries were identified, but medical prescription adherence to evidence-based therapies was inferior and significantly worsened at 1 year. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0).


Assuntos
Doenças Cardiovasculares , Brasil/epidemiologia , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/prevenção & controle , Seguimentos , Humanos , Sistema de Registros , Fatores de Risco
2.
Arq. bras. cardiol ; 115(5 supl.1): 19-19, nov. 2020.
Artigo em Português | LILACS, Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: biblio-1128980

RESUMO

FUNDAMENTO: As arritmias ventriculares (AV) constituem importante causa de orbimortalidade em portadores de cardiopatia estrutural. Apesar dos avanços terapêuticos, o tratamento desta condição continua sendo um desafio na prática clínica. Publicações prévias avaliaram o efeito da denervação simpática renal (DR) no manejo das AVs refratárias ao tratamento medicamentoso e por meio da ablação por cateter. Conduzimos uma revisão sistemática e metanálise para avaliar a eficácia e segurança deste tratamento. Métodos: Uma revisão sistemática da literatura foi realizada para identificar estudos que avaliaram o emprego da DR no tratamento de AVs refratárias. Artigos de revisão e estudos em animais foram excluídos. Os desfechos primários foram a redução do número de AVs (taquicardia ventricular e fibrilação ventricular) e redução do número de terapias pelo cardiodesfibrilador implantável (CDI). Alterações da pressão arterial e de função renal constituíram desfechos secundários de segurança. Resultados: Dez estudos (152 pacientes) foram incluídos na metanálise. No grupo de pacientes submetidos à intervenção, observou-se uma redução no número de AV, ATP, choques e terapias apropriadas pelo CDI de 3,53 eventos/paciente/mês (IC95% = -5,48 a -1,57), 2,86 eventos/paciente/mês (IC95% = -4,09 a -1,63), 2,04 eventos/paciente/mês (IC95% = -2,12 a -1,97) e 2,68 eventos/paciente/mês (IC95% = - 3,58 a -1,78), respectivamente. Complicações periprocedimento ocorreram em apenas 1,23% dos pacientes e não houve alterações significativas nas pressões arteriais sistólica e diastólica (redução de 3,3mmHg, IC95% = -7,1 a 0,4, e de 0,2mmHg IC95%= -3,6 a 4,1, respectivamente). Não se observaram variações significativas na função renal (queda de 0,22mg/dL na creatinina sérica, IC95%= -0,48 a 0,05, e aumento de 2,37 mL/min/1.73m2 na taxa de filtração glomerular, IC95%= -9,98 a 14,71). Conclusões: A denervação simpática renal associou-se a uma redução do número de arritmias ventriculares e terapias apropriadas pelo CDI. O procedimento se mostrou seguro, com poucas complicações e eventos adversos.


Assuntos
Taquicardia Ventricular , Denervação
3.
Rev Bras Ter Intensiva ; 32(3): 354-362, 2020.
Artigo em Português, Inglês | MEDLINE | ID: mdl-33053024

RESUMO

OBJECTIVE: The infection caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads worldwide and is considered a pandemic. The most common manifestation of SARS-CoV-2 infection (coronavirus disease 2019 - COVID-19) is viral pneumonia with varying degrees of respiratory compromise and up to 40% of hospitalized patients might develop acute respiratory distress syndrome. Several clinical trials evaluated the role of corticosteroids in non-COVID-19 acute respiratory distress syndrome with conflicting results. We designed a trial to evaluate the effectiveness of early intravenous dexamethasone administration on the number of days alive and free of mechanical ventilation within 28 days after randomization in adult patients with moderate or severe acute respiratory distress syndrome due to confirmed or probable COVID-19. METHODS: This is a pragmatic, prospective, randomized, stratified, multicenter, open-label, controlled trial including 350 patients with early-onset (less than 48 hours before randomization) moderate or severe acute respiratory distress syndrome, defined by the Berlin criteria, due to COVID-19. Eligible patients will be randomly allocated to either standard treatment plus dexamethasone (Intervention Group) or standard treatment without dexamethasone (Control Group). Patients in the intervention group will receive dexamethasone 20mg intravenous once daily for 5 days, followed by dexamethasone 10mg IV once daily for additional 5 days or until intensive care unit discharge, whichever occurs first. The primary outcome is ventilator-free days within 28 days after randomization, defined as days alive and free from invasive mechanical ventilation. Secondary outcomes are all-cause mortality rates at day 28, evaluation of the clinical status at day 15 assessed with a 6-level ordinal scale, mechanical ventilation duration from randomization to day 28, Sequential Organ Failure Assessment Score evaluation at 48 hours, 72 hours and 7 days and intensive care unit -free days within 28.


Assuntos
Infecções por Coronavirus/tratamento farmacológico , Dexametasona/administração & dosagem , Glucocorticoides/administração & dosagem , Pneumonia Viral/tratamento farmacológico , /tratamento farmacológico , Adulto , Infecções por Coronavirus/fisiopatologia , Humanos , Unidades de Terapia Intensiva , Escores de Disfunção Orgânica , Pandemias , Pneumonia Viral/fisiopatologia , Estudos Prospectivos , Respiração Artificial , Fatores de Tempo
4.
Rev Bras Ter Intensiva ; 32(3): 337-347, 2020.
Artigo em Português, Inglês | MEDLINE | ID: mdl-32965395

RESUMO

INTRODUCTION: Pro-inflammatory markers play a significant role in the disease severity of patients with COVID-19. Thus, anti-inflammatory therapies are attractive agents for potentially combating the uncontrolled inflammatory cascade in these patients. We designed a trial testing tocilizumab versus standard of care intending to improve the outcomes by inhibiting interleukin-6, an important inflammatory mediator in COVID-19. METHODS AND ANALYSIS: This open-label multicentre randomized controlled trial will compare clinical outcomes of tocilizumab plus standard of care versus standard of care alone in patients with moderate to severe COVID-19. Two of the following four criteria are required for protocol enrolment: D-dimer > 1,000ng/mL; C reactive protein > 5mg/dL, ferritin > 300mg/dL, and lactate dehydrogenase > upper limit of normal. The primary objective will be to compare the clinical status on day 15, as measured by a 7-point ordinal scale applied in COVID-19 trials worldwide. The primary endpoint will be assessed by an ordinal logistic regression assuming proportional odds ratios adjusted for stratification variables (age and sex). ETHICS AND DISSEMINATION: The TOCIBRAS protocol was approved by local and central (national) ethical committees in Brazil following current national and international guidelines/directives. Each participating center had the study protocol approved by their institutional review boards before initiating protocol enrolment. The data derived from this trial will be published regardless of the results. If proven active, this strategy could alleviate the consequences of the inflammatory response in COVID-19 patients and improve their clinical outcomes.


Assuntos
Anti-Inflamatórios/uso terapêutico , Anticorpos Monoclonais Humanizados/uso terapêutico , Infecções por Coronavirus/tratamento farmacológico , Pneumonia Viral/tratamento farmacológico , Anti-Inflamatórios/farmacologia , Anticorpos Monoclonais Humanizados/farmacologia , Brasil , Infecções por Coronavirus/fisiopatologia , Humanos , Interleucina-6/antagonistas & inibidores , Pandemias , Pneumonia Viral/fisiopatologia , Índice de Gravidade de Doença
5.
Rev. bras. ter. intensiva ; 32(3): 354-362, jul.-set. 2020. tab, graf
Artigo em Português | LILACS-Express | LILACS | ID: biblio-1138502

RESUMO

RESUMO Objetivo: A infecção causada pelo coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2) disseminou-se por todo o mundo e foi categorizada como pandemia. As manifestações mais comuns da infecção pelo SARS-CoV-2 (doença pelo coronavírus 2019 - COVID-19) se referem a uma pneumonia viral com graus variáveis de comprometimento respiratório e até 40% dos pacientes hospitalizados, que podem desenvolver uma síndrome do desconforto respiratório agudo. Diferentes ensaios clínicos avaliaram o papel dos corticosteroides na síndrome do desconforto respiratório agudo não relacionada com COVID-19, obtendo resultados conflitantes. Delineamos o presente estudo para avaliar a eficácia da administração endovenosa precoce de dexametasona no número de dias vivo e sem ventilação mecânica nos 28 dias após a randomização, em pacientes adultos com quadro moderado ou grave de síndrome do desconforto respiratório agudo causada por COVID-19 provável ou confirmada. Métodos: Este é um ensaio pragmático, prospectivo, randomizado, estratificado, multicêntrico, aberto e controlado que incluirá 350 pacientes com quadro inicial (menos de 48 horas antes da randomização) de síndrome do desconforto respiratório agudo moderada ou grave, definida segundo os critérios de Berlim, causada por COVID-19. Os pacientes elegíveis serão alocados de forma aleatória para tratamento padrão mais dexametasona (Grupo Intervenção) ou tratamento padrão sem dexametasona (Grupo Controle). Os pacientes no Grupo Intervenção receberão dexametasona 20mg por via endovenosa uma vez ao dia, por 5 dias, e, a seguir, dexametasona por via endovenosa 10mg ao dia por mais 5 dias, ou até receber alta da unidade de terapia intensiva, o que ocorrer antes. O desfecho primário será o número de dias livres de ventilação mecânica nos 28 dias após a randomização, definido como o número de dias vivo e livres de ventilação mecânica invasiva. Os desfechos secundários serão a taxa de mortalidade por todas as causas no dia 28, a condição clínica no dia 15 avaliada com utilização de uma escala ordinal de seis níveis, a duração da ventilação mecânica desde a randomização até o dia 28, a avaliação com o Sequential Organ Failure Assessment Score após 48 horas, 72 horas e 7 dias, e o número de dias fora da unidade de terapia intensiva nos 28 dias após a randomização.


Abstract Objective: The infection caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads worldwide and is considered a pandemic. The most common manifestation of SARS-CoV-2 infection (coronavirus disease 2019 - COVID-19) is viral pneumonia with varying degrees of respiratory compromise and up to 40% of hospitalized patients might develop acute respiratory distress syndrome. Several clinical trials evaluated the role of corticosteroids in non-COVID-19 acute respiratory distress syndrome with conflicting results. We designed a trial to evaluate the effectiveness of early intravenous dexamethasone administration on the number of days alive and free of mechanical ventilation within 28 days after randomization in adult patients with moderate or severe acute respiratory distress syndrome due to confirmed or probable COVID-19. Methods: This is a pragmatic, prospective, randomized, stratified, multicenter, open-label, controlled trial including 350 patients with early-onset (less than 48 hours before randomization) moderate or severe acute respiratory distress syndrome, defined by the Berlin criteria, due to COVID-19. Eligible patients will be randomly allocated to either standard treatment plus dexamethasone (Intervention Group) or standard treatment without dexamethasone (Control Group). Patients in the intervention group will receive dexamethasone 20mg intravenous once daily for 5 days, followed by dexamethasone 10mg IV once daily for additional 5 days or until intensive care unit discharge, whichever occurs first. The primary outcome is ventilator-free days within 28 days after randomization, defined as days alive and free from invasive mechanical ventilation. Secondary outcomes are all-cause mortality rates at day 28, evaluation of the clinical status at day 15 assessed with a 6-level ordinal scale, mechanical ventilation duration from randomization to day 28, Sequential Organ Failure Assessment Score evaluation at 48 hours, 72 hours and 7 days and intensive care unit -free days within 28.

6.
Rev. bras. ter. intensiva ; 32(3): 337-347, jul.-set. 2020. tab, graf
Artigo em Português | LILACS-Express | LILACS | ID: biblio-1138506

RESUMO

RESUMO Introdução: Os marcadores pró-inflamatórios desempenham papel importante na severidade de pacientes com COVID-19. Assim, terapêuticas anti-inflamatórias são agentes interessantes para potencialmente combater a cascata inflamatória descontrolada em tais pacientes. Delineamos um ensaio para testar tocilizumabe em comparação com o tratamento padrão, tendo como objetivo melhorar os desfechos por meio da inibição da interleucina 6, um importante mediador inflamatório na COVID-19. Métodos e análises: Este será um estudo aberto multicêntrico, randomizado e controlado, que comparará os desfechos de pacientes tratados com tocilizumabe mais tratamento padrão com o tratamento padrão isoladamente em pacientes com COVID-19 moderada a grave. Como critérios de inclusão, serão exigidos dois dos quatro critérios a seguir: dosagens de dímero D acima de 1.000ng/mL, proteína C-reativa acima de 5mg/dL, ferritina acima de 300mg/dL e desidrogenase lática acima do limite superior do normal. O objetivo primário será comparar a condição clínica no dia 15, conforme avaliação por meio de escala ordinal de 7 pontos aplicada nos estudos de COVID-19 em todo o mundo. O desfecho primário será avaliado por regressão logística ordinal assumindo razões de propensão proporcionais ajustadas pelas variáveis de estratificação (idade e sexo). Ética e disseminação: O TOCIBRAS foi aprovado pelos comitês de ética locais e central (nacional) do Brasil em conformidade com as atuais diretrizes e orientações nacionais e internacionais. Cada centro participante obteve aprovação do estudo por parte de seu comitê de ética em pesquisa, antes de iniciar as inscrições no protocolo. Os dados derivados deste ensaio serão publicados independentemente de seus resultados. Se tiver sua efetividade comprovada, esta estratégia terapêutica poderá aliviar as consequências da resposta inflamatória na COVID-19 e melhorar os resultados clínicos.


ABSTRACT Introduction: Pro-inflammatory markers play a significant role in the disease severity of patients with COVID-19. Thus, anti-inflammatory therapies are attractive agents for potentially combating the uncontrolled inflammatory cascade in these patients. We designed a trial testing tocilizumab versus standard of care intending to improve the outcomes by inhibiting interleukin-6, an important inflammatory mediator in COVID-19. Methods and analysis: This open-label multicentre randomized controlled trial will compare clinical outcomes of tocilizumab plus standard of care versus standard of care alone in patients with moderate to severe COVID-19. Two of the following four criteria are required for protocol enrolment: D-dimer > 1,000ng/mL; C reactive protein > 5mg/dL, ferritin > 300mg/dL, and lactate dehydrogenase > upper limit of normal. The primary objective will be to compare the clinical status on day 15, as measured by a 7-point ordinal scale applied in COVID-19 trials worldwide. The primary endpoint will be assessed by an ordinal logistic regression assuming proportional odds ratios adjusted for stratification variables (age and sex). Ethics and dissemination: The TOCIBRAS protocol was approved by local and central (national) ethical committees in Brazil following current national and international guidelines/directives. Each participating center had the study protocol approved by their institutional review boards before initiating protocol enrolment. The data derived from this trial will be published regardless of the results. If proven active, this strategy could alleviate the consequences of the inflammatory response in COVID-19 patients and improve their clinical outcomes.

7.
Am Heart J ; 227: 100-106, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32730905

RESUMO

BACKGROUND: New antithrombotic strategies that reduce primary thrombosis and restenosis might improve vascular outcomes in patients with peripheral artery disease (PAD) undergoing arterial angioplasty. The study objective is to evaluate the potential benefit of apixaban plus aspirin compared with standard of care dual antiplatelet therapy (DAPT) in reducing thrombotic restenosis and artery re-occlusion in patients undergoing endovascular infrapopliteal revascularization. STUDY DESIGN: This multicenter, parallel-group, prospective, randomized, open-label, blinded-endpoint adjudication, proof-of-concept, exploratory trial aims to randomize 200 patients 72 hours after successful infrapopliteal angioplasty for critical limb ischemia (CLI). Patients will be randomly assigned in a 1:1 ratio to receive oral apixaban (2.5 mg twice daily) plus aspirin (100 mg once daily) for 12 months or clopidogrel (75 mg daily) for at least 3 months on a background of aspirin (100 mg once daily) for 12 months. The primary endpoint is the composite of target lesion revascularization (TLR), major amputation, or restenosis/occlusion (RAS) in addition to major adverse cardiovascular events - MACE (myocardial infarction, stroke or cardiovascular death) at 12 months. The primary safety endpoint is the composite of major bleeding or clinically relevant non-major bleeding at 12 months. SUMMARY: This study will evaluate the efficacy and safety of apixaban 2.5 mg twice daily plus aspirin compared with DAPT (clopidogrel plus aspirin) in patients with CLI undergoing endovascular infrapopliteal revascularization and might prove the concept of an alternative antithrombotic regimen for these patients to be tested in a future large randomized clinical trial.


Assuntos
Angioplastia , Aspirina/uso terapêutico , Clopidogrel/uso terapêutico , Isquemia/cirurgia , Perna (Membro)/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Inibidores da Agregação de Plaquetas/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Pirazóis/uso terapêutico , Piridonas/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Trombose/prevenção & controle , Angioplastia/métodos , Estado Terminal , Inibidores do Fator Xa , Humanos , Estudos Multicêntricos como Assunto , Artéria Poplítea , Estudo de Prova de Conceito , Estudos Prospectivos
8.
Clin Appl Thromb Hemost ; 26: 1076029620936350, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32649232
9.
Clinics (Sao Paulo) ; 74: e663, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31644664

RESUMO

OBJECTIVE: To develop and validate a questionnaire to assess the knowledge of mechanical ventilation among final-year medical students in Brazil. METHODS: A cross-sectional study conducted between October 2015 and October 2017 involving 554 medical students was carried out to develop a questionnaire for assessing knowledge on mechanical ventilation. Reproducibility was evaluated with the intraclass correlation coefficient, internal consistency was evaluated with Cronbach's alpha, and construct validation was evaluated with a tetrachoric exploratory factor analysis. To compare the means of the competences among the same type of assessment tool, the nonparametric Friedman test was used, and the identification of the differences was obtained with Dunn-Bonferroni tests. RESULTS: The final version of the questionnaire contained 19 questions. The instrument presented a clarity index of 8.94±0.83. The value of the intraclass correlation coefficient was 0.929, and Cronbach's alpha was 0.831. The factor analysis revealed five factors associated with knowledge areas regarding mechanical ventilation. The final score among participants was 24.05%. CONCLUSION: The instrument has a satisfactory clarity index and adequate psychometric properties and can be used to assess the knowledge of mechanical ventilation among final-year medical students in Brazil.


Assuntos
Avaliação Educacional , Medicina de Emergência/educação , Respiração Artificial , Estudantes de Medicina , Inquéritos e Questionários/normas , Adulto , Brasil , Estudos Transversais , Medicina de Emergência/normas , Análise Fatorial , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Internato e Residência , Masculino , Reprodutibilidade dos Testes
10.
Am J Cardiol ; 123(1): 69-74, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-30539748

RESUMO

In 2015, 3 independent meta-analyses raised concerns about digoxin therapy being associated with an increased mortality risk in patients with atrial fibrillation (AF) and with heart failure (HF). Although several other studies have been published since then fostering these safety issues, the most recent 2016 European guidelines for AF still recommend this therapy as a class I indication. We performed an updated systematic review and random-effect meta-analysis on publications up to March 2018 reporting data on digoxin associated mortality in subjects with AF or HF. Based on the adjusted survival data of all identified 37 trials comprising a total of 825,061 patients, digoxin use was associated with an increased relative risk of all-cause mortality (hazard ratio [HR] 1.17, 95% confidence interval [CI] 1.05 to 1.29, p <0.01). Treatment with digoxin was associated with an increased mortality risk in the subgroup of patients with AF (n = 627,620, HR 1.23, 95% CI, 1.17 to 1.30, p <0.01), and in the subgroup of patients with HF (n = 197,441, HR 1.11, 95% CI, 1.06 to 1.16, p<0.01). A sensitivity analysis of studies reporting data on new digoxin users (n = 41,687) demonstrated an even higher risk for all-cause mortality compared with patients not receiving cardiac glycosides (HR 1.47, 95% CI, 1.15 to 1.88, p <0.01). In conclusion, this updated meta-analysis confirms that digoxin use is associated with increased mortality in patients with AF or HF.


Assuntos
Antiarrítmicos/efeitos adversos , Fibrilação Atrial/mortalidade , Digoxina/efeitos adversos , Insuficiência Cardíaca/mortalidade , Humanos , Análise de Sobrevida
11.
Clinics ; 74: e663, 2019. tab, graf
Artigo em Inglês | LILACS-Express | LILACS | ID: biblio-1039557

RESUMO

OBJECTIVE: To develop and validate a questionnaire to assess the knowledge of mechanical ventilation among final-year medical students in Brazil. METHODS: A cross-sectional study conducted between October 2015 and October 2017 involving 554 medical students was carried out to develop a questionnaire for assessing knowledge on mechanical ventilation. Reproducibility was evaluated with the intraclass correlation coefficient, internal consistency was evaluated with Cronbach's alpha, and construct validation was evaluated with a tetrachoric exploratory factor analysis. To compare the means of the competences among the same type of assessment tool, the nonparametric Friedman test was used, and the identification of the differences was obtained with Dunn-Bonferroni tests. RESULTS: The final version of the questionnaire contained 19 questions. The instrument presented a clarity index of 8.94±0.83. The value of the intraclass correlation coefficient was 0.929, and Cronbach's alpha was 0.831. The factor analysis revealed five factors associated with knowledge areas regarding mechanical ventilation. The final score among participants was 24.05%. CONCLUSION: The instrument has a satisfactory clarity index and adequate psychometric properties and can be used to assess the knowledge of mechanical ventilation among final-year medical students in Brazil.

12.
Artigo em Português | LILACS | ID: biblio-916465

RESUMO

O acidente vascular cerebral (AVC) é a maior causa de incapacidade em todo mundo, e atualmente é também considerado como a segunda maior causa de morte no Brasil. O AVC isquêmico é o subtipo mais comum e pode ser subdividido etiologicamente em car-dioembólico, aterosclerótico de grandes ou pequenas artérias (lacunas), criptogênico ou de outras etiologias. Dependendo da etiologia encontrada, a profilaxia secundária de novos eventos deve ser feita através de medicações antitrombóticas específicas. Portanto, investigar adequadamente a etiologia do evento vascular isquêmico é fundamental para a instituição da profilaxia secundária apropriada. A terapia antitrombótica pós-AVC isquêmico evoluiu consideravelmente na última década. Especificamente para pacientes com AVC e fibrilação atrial, a incorporação de anticoagulantes de ação direta à prática clínica representa um grande avanço, já que tais medicações são mais eficazes e seguras para o tratamento de pacientes de alto risco. No presente artigo, discutiremos o uso de antitrombóticos em pacientes com AVC em diferentes momentos pós-icto vascular e nas distintas etiologias possíveis


Stroke is the leading cause of disability worldwide, and is currently also considered the second leading cause of death in Brazil. Ischemic stroke is the most common subtype and can be subdivided etiologically into cardioembolic, atherosclerotic (large artery atherosclero-sis or small vessel disease-lacunae), cryptogenic or strokes of other etiologies. Depending on the etiology, secondary prophylaxis of new events should be undertaken with specific antithrombotic medications. Therefore, a thorough investigation of ischemic vascular event etiology is essential for the introduction of appropriate secondary prophylaxis. Antithrombotic therapy after ischemic stroke has evolved considerably in the last decade. The incorporation of direct-acting anticoagulants into clinical practice represents a major advance, particularly for stroke and atrial fibrillation patients, since such medications are safer and more effective for the treatment of high-risk patients. In this article, we will discuss the use of antithrombo-tics in stroke patients at different post-stroke stages and in the distinct possible etiologies


Assuntos
Humanos , Masculino , Feminino , Prevenção de Doenças , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/métodos , Anticoagulantes/uso terapêutico , Aspirina/uso terapêutico , Infarto Cerebral/diagnóstico , Diabetes Mellitus , Hipertensão , Inibidores da Agregação de Plaquetas/uso terapêutico , Fatores de Risco , Rivaroxabana/uso terapêutico , Prevenção Secundária/métodos , Comportamento Sedentário
13.
Artigo em Português | LILACS | ID: biblio-916534

RESUMO

A fibrilação atrial (FA) é a arritmia cardíaca mais comum na população com uma prevalência de 1-2%, além disso, está associada a um risco, aproximadamente cinco vezes maior de acidente vascular cerebral do que na população em geral. A anticoagulação é a melhor maneira de prevenir os eventos tromboembólicos. A varfarina é utilizada há décadas como uma droga segura e eficaz, desde que rigorosamente controlada. Nos últimos anos, foram desenvolvidas novas classes de anticoagulantes orais: inibidores diretos da trombina e inibidores do fator Xa, conhecidos como anticoagulantes orais de ação direta (DOACs). Tanto a cardioversão elétrica quanto a cardioversão farmacológica estão associadas a um maior risco de eventos tromboembólicos durante o primeiro mês após o procedimento (5-7%). No entanto, com a utilização de nticoagulantes essa taxa é inferior a 1%. No presente artigo, faremos uma revisão das principais evidências científicas relacionadas ao uso da dabigatrana, rivaroxabana, apixabana e edoxabana durante a cardioversão e uma abordagem prática com o manejo antitrombótico em diferentes cenários clínicos (cardioversão em pacientes com uso prévio de DOACs, cardioversão em pacientes com FA com duração maior ou menor que 48 horas sem anticoagulação)


Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice with a prevalence of 1-2%, and is associated with an almost 5-fold increase in the risk of stroke compared to the general population. Anticoagulation is the best way to prevent thromboembolic events. Warfarin has been used for decades as a safe and effective drug, provided it is strictly controlled. In recent years, new classes of oral anticoagulants have been developed: direct thrombin inhibitors and factor Xa inhibitors, known as direct oral anticoagulants (DOACs). Both electrical and pharmacological cardioversion are associated with an increased risk of thromboembolic events during the first month after the procedure (5-7%). However, with the use of anticoagulants, this rate is less than 1%. In this article, we will review the main scientific evidence related to the use of dabigatran, rivaroxaban, apixaban and edoxaban during cardioversion and a practical approach with antithrombotic management in different clinical scenarios (cardioversion of patients in previous use of DOACs, cardioversion of patients not using oral anticoagulants with episodes of AF longer or shorter than 48 h)


Assuntos
Humanos , Masculino , Feminino , Anticoagulantes/uso terapêutico , Arritmias Cardíacas , Fibrilação Atrial , Cardioversão Elétrica , Emergências , Unidades de Terapia Intensiva , Fator Xa , Hemorragia , Heparina/efeitos adversos , Heparina/uso terapêutico , Prevalência , Revisão , Rivaroxabana/uso terapêutico , Acidente Vascular Cerebral/complicações , Tromboembolia/terapia , Terapia Trombolítica/métodos , Varfarina/efeitos adversos , Varfarina/uso terapêutico
14.
Medicine (Baltimore) ; 97(24): e11094, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29901625

RESUMO

INTRODUCTION: The prevalence of metabolic syndrome (MetS) and MetS-related stroke is set to increase dramatically in coming decades. MetS is a complex disease that includes endothelial dysfunction, insulin resistance, diabetes, hypertension, ectopic obesity, and dyslipidaemia and an increased risk of cardiovascular events. One function of high-density lipoprotein (HDL) cholesterol (HDL-C) is the cholesterol-efflux pathway, which is the pathway where cholesterol is removed from macrophages within the arterial walls back into the bloodstream and out to the liver. As one of the key functions of HDL, their hypothesis was that if they could measure HDL-C-efflux capacity, they would have a better handle on the role of HDL in atherosclerosis. However, there are no systematic analyses or well-conducted meta-analyses to evaluate the relationship between HDL-C functionality and MetS. The aim of this study is to examine this association of HDL-C functionality with MetS in different ages and sex. METHODS AND ANALYSIS: The update systematic review and meta-analysis will be conducted using published studies that will be identified from electronic databases (i.e., PubMed, EMBASE, Web of Science, and Google Scholar). Studies that examined the association between HDL-C functionality and MetS; focused on cohort, case-control, and cross-sectional studies; were conducted among in adults aged 40 to 70 years; provided sufficient data for calculating odds ratio or relative risk with a 95% confidence interval; were published as original articles written in English or other languages; and have been published until January 2018 will be included. Study selection, data collection, quality assessment, and statistical syntheses will be conducted based on discussions among investigators. ETHICS AND DISSEMINATION: Ethics approval was not required for this study because it was based on published studies. The results and findings of this study will be submitted and published in a scientific peer-reviewed journal. TRIAL REGISTRATION NUMBER: PROSPERO (CRD42018083465).


Assuntos
HDL-Colesterol/sangue , Síndrome Metabólica/etiologia , Adulto , Idoso , Feminino , Humanos , Masculino , Síndrome Metabólica/epidemiologia , Síndrome Metabólica/mortalidade , Pessoa de Meia-Idade , Fatores de Risco , Revisões Sistemáticas como Assunto
15.
Int J Cardiol ; 267: 13-15, 2018 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-29861104

RESUMO

BACKGROUND: The National Cardiovascular Data Registry (NCDR®) Database is commonly used for quality-improvement initiatives in North America, but little is known about the application of this tool in other regions of the world. METHODS: All consecutive patients admitted due to myocardial infarction (MI) and/or undergoing percutaneous coronary intervention (PCI) from January 2012 until December 2015 in a Brazilian private cardiovascular hospital were included respectively in ACTION REGISTRY®-GWTG™ and CathPCI Registry®. Meetings including all hospital staff were performed quarterly to discuss every NCDR® report. Quality improvement initiatives were developed based on the reports which were also used for evaluation of changes after the interventions. The following indicators were considered a priority 1) Door-to-ECG and door-to-balloon (D2B) times; 2) PCI appropriateness; 3) length of stay; 4) delivery of guideline-based medication. Changes in the quality of care with respect to the over time were assessed using linear and logistic regression for continuous and binary outcomes, respectively. RESULTS: A total of 1.382 patients were included in the ACTION REGISTRY®-GWTG™ and 3.179 patients in the CathPCI Registry®. In the ACTION registry, the overall AMI performance composite of quality indicators improved along the 4 years from 95.0% to 99.6% (p for trend <0.001). The percentage of appropriate/uncertain PCI in acute and elective scenario increased along the years from 91.1% and 70.9% to 96.6% and 84.7%, respectively (p for trend <0.001). CONCLUSION: The present novel experience using the NCDR® registries as benchmarks to guide quality-improvement programs in an international site was associated with improvement in quality indicators.


Assuntos
Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Infarto do Miocárdio , Intervenção Coronária Percutânea , Melhoria de Qualidade/organização & administração , Indicadores de Qualidade em Assistência à Saúde/normas , Idoso , Brasil/epidemiologia , Feminino , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Medição de Risco , Fatores de Risco , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos
16.
Medicine (Baltimore) ; 97(17): e0273, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29702973

RESUMO

BACKGROUND: Atherosclerosis is now widely recognized as a multifactorial disease with outcomes that arise from complex factors such as plaque components, blood flow, and inflammation. Epicardial adipose tissue (EAT) is a metabolically active fat depot, abundant in proinflammatory cytokines, and has been correlated with the extent and severity of carotid artery disease (CD). The locations most frequently affected by carotid atherosclerosis are the proximal internal carotid artery (ie, the origin) and the common carotid artery bifurcation. Progression of atheromatous plaque at the carotid bifurcation results in luminal narrowing, often accompanied by ulceration. However, there are no systematic analyses or well-conducted meta-analyses to evaluate the relationship between EAT and CD. The aim of this study is to examine this association of EAT with CD in different ages and sex. METHODS: This systematic review and meta-analysis will be conducted using published studies that will be identified from electronic databases (ie, PubMed, EMBASE, Web of Science, and Google Scholar. Studies that (1) examined the association between EAT and CD, (2) focus on cohort, case-control and cross-sectional studies, (3) will conducted among in adults aged 40 to 70 years, (4) provided sufficient data for calculating ORs or relative risk with a 95% CI, (5) will published as original articles written in English or other languages, and (6) have been published until January 2018 will be included. Study selection, data collection, quality assessment and statistical syntheses will be conducted based on discussions among investigators. RESULTS: We propose the current protocol to evaluate the evaluation of EAT with ED. CONCLUSION: This systematic review will not need ethical approval, because it does not involve human beings. The results and findings of this study will be submitted and published in a scientific peer-reviewed journal. ETHICS AND DISSEMINATION: Ethics approval was not required for this study because it was based on published studies. The results and findings of this study will be submitted and published in a scientific peer-reviewed journal. TRIAL REGISTRATION NUMBER: PROSPERO (CRD42018083458).


Assuntos
Tecido Adiposo/patologia , Doenças das Artérias Carótidas/patologia , Pericárdio/patologia , Adulto , Fatores Etários , Idoso , Estudos Transversais , Feminino , Humanos , Mediadores da Inflamação/metabolismo , Masculino , Pessoa de Meia-Idade , Placa Aterosclerótica/patologia , Projetos de Pesquisa , Fatores de Risco , Fatores Sexuais , Revisões Sistemáticas como Assunto
17.
Medicine (Baltimore) ; 97(16): e0387, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29668593

RESUMO

BACKGROUND: The prevalence of metabolic syndrome (MetS) and MetS-related stroke is set to increase dramatically in coming decades. MetS is a complex disease that includes endothelial dysfunction, insulin resistance, diabetes, hypertension, ectopic obesity, and dyslipidaemia, and an increased risk of cardiovascular events. However, there are no systematic analyses, or well-conducted meta-analyses to evaluate the relationship between epicardial adipose tissue (EAT) and (MetS). The aim of this study is to examine this association of EAT with MetS in different ages and sex. METHODS: The update systematic review, and meta-analysis will be conducted using published studies that will be identified from electronic databases (ie, PubMed, EMBASE, Web of Science, and Google Scholar. Studies that firstly, examined the association between EAT and MetS, secondly, focus on cohort, case-control, and cross-sectional studies, thirdly, were conducted among in adults aged between 40 and 70 years, fourth, provided sufficient data for calculating ORs or relative risk with a 95% CI, fifth, were published as original articles written in English or other languages, and sixth, have been published until January year 2018 will be included. Study selection, data collection, quality assessment, and statistical syntheses will be conducted based on discussions among investigators. RESULTS: Ethics approval was not required for this study because it was based on published studies. The results and findings of this study will be submitted and published in a scientific peer-reviewed journal. This study will provide a high quality synthesis on the association of EAT and MetS. CONCLUSION: This systematic review will provide evidence to assess whether there is a strong association of EAT and MetS, and its components.


Assuntos
Tecido Adiposo/patologia , Síndrome Metabólica/patologia , Pericárdio/patologia , Humanos , Projetos de Pesquisa
18.
Medicine (Baltimore) ; 97(15): e0116, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29642140

RESUMO

BACKGROUND: Patients with HIV have been found to suffer from lipid abnormalities, including elevated levels of total and LDL-cholesterol as well as triglyceride levels. Abnormal lipid levels are associated with an increased risk of developing cardiovascular diseases, which are significant causes of mortality among the general population. Therefore, the objective of the current study is to conduct a systematic review with network meta-analysis to compare the effects of statins classes on HIV patients. METHODS: Randomized clinical trials (RCTs) and observational studies published in English up to 31 December 2017, and which include direct and/or indirect evidence, will be included. Studies will be retrieved by searching four electronic databases and cross-referencing. Dual selection and abstraction of data will occur. The primary outcome will all-cause mortality, new event of acute myocardial infarction, stroke (hemorrhagic and ischemic), hospitalization for acute coronary syndrome and urgent revascularization procedures and cardiovascular mortality. Secondary outcomes will be assessment of the differences in change of total cholesterol (TC), low-density lipoprotein (LDL-C), apolipoprotein B (ApoB), high density lipoprotein (HDL-C). Risk of bias will be assessed using the Cochrane Risk of Bias assessment instrument for RCTs and the Strengthening the Reporting of Observational Studies in Epidemiology instrument for observational studies. Network meta-analysis will be performed using multivariate random-effects meta-regression models. The surface under the cumulative ranking curve will be used to provide a hierarchy of statins that reduce cardiovascular mortality in HIV patients. A revised version of the Cochrane Risk of Bias tool (RoB 2.0) will be used to assess the risk of bias in eligible RCTs. Results will be synthesized and analyzed using network meta-analysis (NMA). Overall strength of the evidence and publication bias will be evaluated. Subgroup and sensitivity analysis will also be performed. RESULTS AND CONCLUSION: Ethics approval was not required for this study because it was based on published studies. The results and findings of this study will be submitted and published in a scientific peer-reviewed journal. The evidence will determine which combination of interventions are most promising for current practice and further investigation. TRIAL REGISTRATION NUMBER: PROSPERO (CRD42017072996).


Assuntos
Doenças Cardiovasculares/prevenção & controle , Dislipidemias , Infecções por HIV , Inibidores de Hidroximetilglutaril-CoA Redutases/farmacologia , Adulto , Dislipidemias/complicações , Dislipidemias/tratamento farmacológico , Infecções por HIV/complicações , Infecções por HIV/terapia , Humanos , Conduta do Tratamento Medicamentoso , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa , Revisões Sistemáticas como Assunto
19.
Medicine (Baltimore) ; 97(15): e9862, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29642227

RESUMO

INTRODUCTION: The metabolic syndrome is composed of several cardiovascular risk factors and has a high prevalence throughout the world. However, there are no systematic analyses or well-conducted meta-analyses to evaluate the relationship between metabolic syndrome and stroke. The aim of this study is to examine this association of metabolic syndrome with stroke in different ages and sex. METHODS AND ANALYSIS: The update systematic review and meta-analysis will be conducted using published studies that will be identified from electronic databases (i.e., PubMed, EMBASE, Web of Science, and Google Scholar. Studies that examined the association between metabolic syndrome and stroke, had a longitudinal or prospective cohort design, were conducted among in adults aged 40 to 70 years, provided sufficient data for calculating ORs or relative risk with a 95% CI, were published as original articles written in English or other languages, and have been published until December 2017 will be included. Study selection, data collection, quality assessment, and statistical syntheses will be conducted based on discussions among investigators. ETHICS AND DISSEMINATION: Ethics approval was not required for this study because it was based on published studies. The results and findings of this study will be submitted and published in a scientific peer-reviewed journal. The findings from this study could be useful for assessing metabolic syndrome risk factors in stroke, and determining approaches for prevention of stroke in the future.


Assuntos
Síndrome Metabólica/diagnóstico , Síndrome Metabólica/epidemiologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Adulto , Fatores Etários , Idoso , Estudos de Coortes , Estudos Transversais , Feminino , Humanos , Masculino , Síndrome Metabólica/complicações , Pessoa de Meia-Idade , Risco , Fatores Sexuais , Estatística como Assunto , Acidente Vascular Cerebral/etiologia , Revisões Sistemáticas como Assunto
20.
JAMA ; 319(13): 1331-1340, 2018 04 03.
Artigo em Inglês | MEDLINE | ID: mdl-29525821

RESUMO

Importance: The effects of loading doses of statins on clinical outcomes in patients with acute coronary syndrome (ACS) and planned invasive management remain uncertain. Objective: To determine if periprocedural loading doses of atorvastatin decrease 30-day major adverse cardiovascular events (MACE) in patients with ACS and planned invasive management. Design, Setting, and Participants: Multicenter, double-blind, placebo-controlled, randomized clinical trial conducted at 53 sites in Brazil among 4191 patients with ACS evaluated with coronary angiography to proceed with a percutaneous coronary intervention (PCI) if anatomically feasible. Enrollment occurred between April 18, 2012, and October 6, 2017. Final follow-up for 30-day outcomes was on November 6, 2017. Interventions: Patients were randomized to receive 2 loading doses of 80 mg of atorvastatin (n = 2087) or matching placebo (n = 2104) before and 24 hours after a planned PCI. All patients received 40 mg of atorvastatin for 30 days starting 24 hours after the second dose of study medication. Main Outcomes and Measures: The primary outcome was MACE, defined as a composite of all-cause mortality, myocardial infarction, stroke, and unplanned coronary revascularization through 30 days. Results: Among the 4191 patients (mean age, 61.8 [SD, 11.5] years; 1085 women [25.9%]) enrolled, 4163 (99.3%) completed 30-day follow-up. A total of 2710 (64.7%) underwent PCI, 333 (8%) underwent coronary artery bypass graft surgery, and 1144 (27.3%) had exclusively medical management. At 30 days, 130 patients in the atorvastatin group (6.2%) and 149 in the placebo group (7.1%) had a MACE (absolute difference, 0.85% [95% CI, -0.70% to 2.41%]; hazard ratio, 0.88; 95% CI, 0.69-1.11; P = .27). No cases of hepatic failure were reported; 3 cases of rhabdomyolysis were reported in the placebo group (0.1%) and 0 in the atorvastatin group. Conclusions and Relevance: Among patients with ACS and planned invasive management with PCI, periprocedural loading doses of atorvastatin did not reduce the rate of MACE at 30 days. These findings do not support the routine use of loading doses of atorvastatin among unselected patients with ACS and intended invasive management. Trial Registration: clinicaltrials.gov Identifier: NCT01448642.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Atorvastatina/administração & dosagem , Doenças Cardiovasculares/prevenção & controle , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Intervenção Coronária Percutânea , Síndrome Coronariana Aguda/terapia , Idoso , Atorvastatina/efeitos adversos , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/mortalidade , Método Duplo-Cego , Feminino , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/efeitos adversos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia
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