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1.
Lancet ; 396(10255): 918-934, 2020 09 26.
Artigo em Inglês | MEDLINE | ID: mdl-32891217

RESUMO

The Sustainable Development Goal (SDG) target 3.4 is to reduce premature mortality from non-communicable diseases (NCDs) by a third by 2030 relative to 2015 levels, and to promote mental health and wellbeing. We used data on cause-specific mortality to characterise the risk and trends in NCD mortality in each country and evaluate combinations of reductions in NCD causes of death that can achieve SDG target 3.4. Among NCDs, ischaemic heart disease is responsible for the highest risk of premature death in more than half of all countries for women, and more than three-quarters for men. However, stroke, other cardiovascular diseases, and some cancers are associated with a similar risk, and in many countries, a higher risk of premature death than ischaemic heart disease. Although premature mortality from NCDs is declining in most countries, for most the pace of change is too slow to achieve SDG target 3.4. To investigate the options available to each country for achieving SDG target 3.4, we considered different scenarios, each representing a combination of fast (annual rate achieved by the tenth best performing percentile of all countries) and average (median of all countries) declines in risk of premature death from NCDs. Pathways analysis shows that every country has options for achieving SDG target 3.4. No country could achieve the target by addressing a single disease. In at least half the countries, achieving the target requires improvements in the rate of decline in at least five causes for women and in at least seven causes for men to the same rate achieved by the tenth best performing percentile of all countries. Tobacco and alcohol control and effective health-system interventions-including hypertension and diabetes treatment; primary and secondary cardiovascular disease prevention in high-risk individuals; low-dose inhaled corticosteroids and bronchodilators for asthma and chronic obstructive pulmonary disease; treatment of acute cardiovascular diseases, diabetes complications, and exacerbations of asthma and chronic obstructive pulmonary disease; and effective cancer screening and treatment-will reduce NCD causes of death necessary to achieve SDG target 3.4 in most countries.


Assuntos
Mortalidade Prematura/tendências , Doenças não Transmissíveis/mortalidade , Desenvolvimento Sustentável , Adulto , Idoso , Doenças Cardiovasculares/mortalidade , Causas de Morte , Doença Crônica , Diabetes Mellitus/mortalidade , Feminino , Humanos , Masculino , Saúde Mental , Pessoa de Meia-Idade , Mortalidade/tendências , Isquemia Miocárdica/mortalidade , Neoplasias/mortalidade , Prevenção Primária , Doenças Respiratórias/mortalidade , Prevenção Secundária , Acidente Vascular Cerebral/mortalidade
2.
Arch Cardiovasc Dis ; 113(8-9): 525-533, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32873521

RESUMO

BACKGROUND: Transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) can be used to detect the presence of left atrial thrombus and left atrial spontaneous echocardiographic contrast (LASEC). AIM: To evaluate the prognostic value of TTE and TOE in predicting stroke and all-cause death at 5-year follow-up in patients with non-valvular atrial fibrillation (NVAF). METHODS: This study included patients hospitalised with electrocardiography-diagnosed NVAF in Saint-Antoine University Hospital, Paris, between July 1998 and December 2011, who underwent TTE and TOE evaluation within 24hours of admission. Cox proportional-hazards models were used to identify predictors of the composite outcome (stroke or all-cause death). RESULTS: During 5 years of follow-up, stroke/death occurred in 185/903 patients (20.5%). By multivariable analysis, independent predictors of stroke/death were CHA2DS2-VASc score (hazard ratio [HR] 1.35, 95% confidence interval [CI] 1.25-1.47; P<0.001), left atrial area>20 cm2 (HR 1.59, 95% CI 1.08-2.35; P=0.018), moderate LASEC (HR 1.72, 95% CI 1.13-2.62; P=0.012) and severe LASEC (HR 2.04, 95% CI 1.16-3.58; P=0.013). Independent protective predictors were dyslipidaemia (HR 0.60, 95% CI 0.43-0.83; P=0.002) and discharge prescription of anti-arrhythmics (HR 0.59, 95% CI 0.40-0.87; P=0.008). Adding LASEC to the CHA2DS2-VASc score modestly improved predictive accuracy and risk classification, with a C index of 0.71 vs. 0.69 (P=0.004). CONCLUSIONS: In this retrospective monocentric study, the presence of moderate/severe LASEC was an independent predictor of stroke/death at 5-year follow-up in patients with NVAF. The inclusion of LASEC in stroke risk scores could modestly improve risk stratification.


Assuntos
Fibrilação Atrial/diagnóstico por imagem , Ecocardiografia Transesofagiana , Átrios do Coração/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Idoso , Idoso de 80 Anos ou mais , Antiarrítmicos/uso terapêutico , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/mortalidade , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/uso terapêutico , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/prevenção & controle , Fatores de Tempo
3.
Medicine (Baltimore) ; 99(38): e22243, 2020 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-32957370

RESUMO

Although obesity is an established risk factor of primary stroke, the association between obesity and post-stroke mortality remains unclear. The aim of this study was to investigate the association between dynamic obesity status and mortality in survivors of their first stroke in China.Of 775 patients with first-ever ischemic stroke included in a longitudinal study, 754 patients were included in this study and categorized into 4 categories of body mass index (BMI) (underweight, normal weight, overweight, and obese) and 2 categories of waist circumference (WC) (normal WC and abdominal obesity) according to standard Chinese criteria. The mortality information and obesity status were obtained via telephone follow-up every 3 months, beginning in 2010 through 2016. Time-dependent Cox proportional hazards models were used to estimate the unadjusted and adjusted hazard ratios (HRs) for the relationship between all-cause mortality and dynamic obesity status.Of 754 patients, 60.87% were male, and the overall mean age was 61.45 years. After adjusting for possible confounders, significant inverse associations were identified between BMI and WC and all-cause mortality. Compared with those with normal BMI or WC, those with abdominal obesity or overweight had a significantly lower risk of all-cause mortality (HR and 95% confidence intervals [CIs]: .521 [.303-.897] and 0.545 [.352-.845], respectively), whereas patients with underweight had the highest risk and those with obesity had lower risk of mortality, though it was not statistically significant (1.241 [.691-2.226] and .486 [.192-1.231], respectively).Overweight and abdominal obesity were paradoxically associated with reduced risk of mortality in patients who survived their first-ever ischemic stroke in China. Future prospective studies must look at evaluating the role of obesity in different stroke subtypes and devise appropriate weight-management strategies for optimal prognoses in secondary prevention in these survivors.


Assuntos
Isquemia Encefálica/mortalidade , Obesidade/epidemiologia , Acidente Vascular Cerebral/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/prevenção & controle , China/epidemiologia , Comorbidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/terapia , Prevalência , Estudos Prospectivos , Fatores de Risco , Prevenção Secundária , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/prevenção & controle , Sobreviventes , Circunferência da Cintura , Adulto Jovem
4.
Vasc Health Risk Manag ; 16: 285-297, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32764949

RESUMO

Purpose: To ascertain the most appropriate treatment for chronic, stable, coronary artery disease (CAD) in patients submitted to elective coronary angiography. Patients and Methods: A total of 814 patients included in the prospective cohort study were referred for elective coronary angiography and were followed up on average for 6±1.9 years. Main outcomes were all-cause death, cardiovascular death, non-fatal myocardial infarction (MI) and stroke and late revascularization and their combinations as major adverse cardiac and cerebral events (MACCE): MACCE-1 included cardiovascular death, nonfatal MI, and stroke; MACCE-2 was MACCE-1 plus late revascularization. Survival curves and adjusted Cox proportional hazard models were used to explore the association between the type of treatment and outcomes. Results: All-cause death was lower in participants submitted to percutaneous coronary intervention (PCI) (0.41, 0.16-1.03, P=0.057) compared to medical treatment (MT). Coronary-artery bypass grafting (CABG) had an overall trend for poorer outcomes: cardiovascular death 2.53 (0.42-15.10), combined cardiovascular death, nonfatal MI, and stroke 2.15 (0.73-6.31) and these events plus late revascularization (2.17, 0.86-5.49). The corresponding numbers for PCI were 0.27 (0.05-1.43) for cardiovascular death, 0.77 (0.32-1.84) for combined cardiovascular death, nonfatal MI, and stroke and 2.35 (1.16-4.77) with the addition of late revascularization. These trends were not influenced by baseline blood pressure, left ventricular ejection fraction and previous MI. Patients with diabetes mellitus had a significantly higher risk of recurrent revascularization when submitted to PCI than CABG. Conclusion: Patients with confirmed CAD in elective coronary angiography do not have a better prognosis when submitted to CABG comparatively to medical treatment. Patients treated with PCI had a trend for the lower incidence of combined cardiovascular events, at the expense of additional revascularization procedures. Patients without significant CAD had a similar prognosis than CAD patients treated with medical therapy.


Assuntos
Fármacos Cardiovasculares/uso terapêutico , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/terapia , Procedimentos Endovasculares , Intervenção Coronária Percutânea , Idoso , Fármacos Cardiovasculares/efeitos adversos , Causas de Morte , Doença Crônica , Doença da Artéria Coronariana/mortalidade , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/prevenção & controle , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Valor Preditivo dos Testes , Estudos Prospectivos , Encaminhamento e Consulta , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/prevenção & controle , Fatores de Tempo , Resultado do Tratamento
5.
BMC Infect Dis ; 20(1): 583, 2020 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-32762676

RESUMO

BACKGROUND: Dengue fever is endemic and a leading health problem in Sri Lanka. Increased incidence of concurrent bacteremia in patients with dengue infection is a recognized complication. However, Staphylococcal endocarditis following dengue fever is uncommon. Quadricuspid aortic valve (QAV) is a rare congenital anomaly and few cases of infective endocarditis have been reported in QAV. CASE PRESENTATION: A 32-year-old Sri Lankan male presented to the National Hospital of Sri Lanka with recurrence of fever and acute left hemiplegia following an uncomplicated recovery of dengue fever. He was diagnosed to have Staphylococcal infective endocarditis of quadricuspid aortic valve, with septic emboli to brain and spleen. He was managed with intravenous vancomycin initially, however, due to inadequate response, intravenous linezolid was added. He developed rhabdomyolysis with very high creatine phosphokinase leading to acute kidney injury, which settled with the cessation of linezolid. The patient succumbed to his illness despite aggressive antimicrobial therapy and maximum supportive care while being assessed for aortic valve replacement. CONCLUSIONS: This case illustrates three clinical issues that a clinician should be aware of. Firstly, the possibility of a serious secondary bacterial infection as a cause for recurrence of fever following dengue infection. Secondly, this case highlights the importance of identifying QAV as a cause for complicated infective endocarditis of increased severity. The report also denotes the value of being vigilant of linezolid induced rhabdomyolysis which had a causal relationship with the commencement of the drug and its cessation.


Assuntos
Valva Aórtica/anormalidades , Dengue/complicações , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/etiologia , Doenças das Valvas Cardíacas/diagnóstico , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/etiologia , Staphylococcus aureus/isolamento & purificação , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/mortalidade , Adulto , Antibacterianos/farmacologia , Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Hemocultura , Dengue/tratamento farmacológico , Dengue/virologia , Vírus da Dengue , Endocardite Bacteriana/tratamento farmacológico , Evolução Fatal , Febre/tratamento farmacológico , Humanos , Linezolida/farmacologia , Linezolida/uso terapêutico , Masculino , Rabdomiólise/induzido quimicamente , Rabdomiólise/complicações , Infecções Estafilocócicas/tratamento farmacológico , Infecções Estafilocócicas/microbiologia , Acidente Vascular Cerebral/mortalidade
6.
PLoS One ; 15(8): e0237107, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32745121

RESUMO

OBJECTIVE: In this study we aimed to estimate the effect of diabetes, educational level and income on the risk of mortality and cardiovascular events in primary care patients with hypertension. METHODS: We followed 62,557 individuals with hypertension diagnosed 2001-2008, in the Swedish Primary Care Cardiovascular Database. Study outcomes were death, myocardial infarction, and ischemic stroke, assessed using national registers until 2012. Cox regression models were used to estimate adjusted hazard ratios of outcomes according to diabetes status, educational level, and income. RESULTS: During follow-up, 13,231 individuals died, 9981 were diagnosed with diabetes, 4431 with myocardial infarction, and 4433 with ischemic stroke. Hazard ratios (95% confidence intervals) for diabetes versus no diabetes: mortality 1.57 (1.50-1.65), myocardial infarction 1.24 (1.14-1.34), and ischemic stroke 1.17 (1.07-1.27). Hazard ratios for diabetes and ≤9 years of school versus no diabetes and >12 years of school: mortality 1.56 (1.41-1.73), myocardial infarction 1.36 (1.17-1.59), and ischemic stroke 1.27 (1.08-1.50). Hazard ratios for diabetes and income in the lowest fifth group versus no diabetes and income in the highest fifth group: mortality 3.82 (3.36-4.34), myocardial infarction 2.00 (1.66-2.42), and ischemic stroke 1.91 (1.58-2.31). CONCLUSIONS: Diabetes combined with low income was associated with substantial excess risk of mortality, myocardial infarction and ischemic stroke among primary care patients with hypertension.


Assuntos
Diabetes Mellitus/epidemiologia , Cardiopatias/epidemiologia , Hipertensão/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Escolaridade , Feminino , Cardiopatias/mortalidade , Humanos , Hipertensão/mortalidade , Renda/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/mortalidade , Suécia
7.
Cochrane Database Syst Rev ; 8: CD013066, 2020 08 29.
Artigo em Inglês | MEDLINE | ID: mdl-32860632

RESUMO

BACKGROUND: Stroke is one of the leading causes of long-lasting disability and mortality and its global burden has increased in the past two decades. Several therapies have been proposed for the recovery from, and treatment of, ischemic stroke. One of them is citicoline. This review assessed the benefits and harms of citicoline for treating patients with acute ischemic stroke. OBJECTIVES: To assess the clinical benefits and harms of citicoline compared with placebo or any other control for treating people with acute ischemic stroke. SEARCH METHODS: We searched in the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS until 29 January 2020. We searched the World Health Organization Clinical Trials Search Portal and ClinicalTrials.gov. Additionally, we also reviewed reference lists of the retrieved publications and review articles, and searched the websites of the US Food and Drug Administration (FDA) and European Medicines Agency (EMA). SELECTION CRITERIA: We included randomized controlled trials (RCTs) in any setting including participants with acute ischemic stroke. Trials were eligible for inclusion if they compared citicoline versus placebo or no intervention. DATA COLLECTION AND ANALYSIS: We selected RCTs, assessed the risk of bias in seven domains, and extracted data by duplicate. Our primary outcomes of interest were all-cause mortality and the degree of disability or dependence in daily activities at 90 days. We estimated risk ratios (RRs) for dichotomous outcomes. We measured statistical heterogeneity using the I² statistic. We conducted our analyses using the fixed-effect and random-effects model meta-analyses. We assessed the overall quality of evidence for six pre-specified outcomes using the GRADE approach. MAIN RESULTS: We identified 10 RCTs including 4281 participants. In all these trials, citicoline was given either orally, intravenously, or a combination of both compared with placebo or standard care therapy. Citicoline doses ranged between 500 mg and 2000 mg per day. We assessed all the included trials as having high risk of bias. Drug companies sponsored six trials. A pooled analysis of eight trials indicates there may be little or no difference in all-cause mortality comparing citicoline with placebo (17.3% versus 18.5%; RR 0.94, 95% CI 0.83 to 1.07; I² = 0%; low-quality evidence due to risk of bias). Four trials found no difference in the proportion of patients with disability or dependence in daily activities according to the Rankin scale comparing citicoline with placebo (21.72% versus 19.23%; RR 1.11, 95% CI 0.97 to 1.26; I² = 1%; low-quality evidence due to risk of bias). Meta-analysis of three trials indicates there may be little or no difference in serious cardiovascular adverse events comparing citicoline with placebo (8.83% versus 7.77%; RR 1.04, 95% CI 0.84 to 1.29; I² = 0%; low-quality evidence due to risk of bias). Overall, either serious or non-serious adverse events - central nervous system, gastrointestinal, musculoskeletal, etc. - were poorly reported and harms may have been underestimated. Four trials assessing functional recovery with the Barthel Index at a cut-off point of 95 points or more did not find differences comparing citicoline with placebo (32.78% versus 30.70%; RR 1.03, 95% CI 0.94 to 1.13; I² = 24%; low-quality evidence due to risk of bias). There were no differences in neurological function (National Institutes of Health Stroke Scale at a cut-off point of ≤ 1 points) comparing citicoline with placebo according to five trials (24.31% versus 22.44%; RR 1.08, 95% CI 0.96 to 1.21; I² = 27%, low-quality evidence due to risk of bias). A pre-planned Trial Sequential Analysis suggested that no more trials may be needed for the primary outcomes but no trial provided information on quality of life. AUTHORS' CONCLUSIONS: This review assessed the clinical benefits and harms of citicoline compared with placebo or any other standard treatment for people with acute ischemic stroke. The findings of the review suggest there may be little to no difference between citicoline and its controls regarding all-cause mortality, disability or dependence in daily activities, severe adverse events, functional recovery and the assessment of the neurological function, based on low-certainty evidence. None of the included trials assessed quality of life and the safety profile of citicoline remains unknown. The available evidence is of low quality due to either limitations in the design or execution of the trials.


Assuntos
Citidina Difosfato Colina/uso terapêutico , Nootrópicos/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Atividades Cotidianas , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Viés , Isquemia Encefálica/complicações , Causas de Morte , Citidina Difosfato Colina/efeitos adversos , Humanos , Pessoa de Meia-Idade , Nootrópicos/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Recuperação de Função Fisiológica , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade
8.
J Stroke Cerebrovasc Dis ; 29(9): 104938, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807412

RESUMO

BACKGROUND AND PURPOSE: The novel severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), now named coronavirus disease 2019 (COVID-19), may change the risk of stroke through an enhanced systemic inflammatory response, hypercoagulable state, and endothelial damage in the cerebrovascular system. Moreover, due to the current pandemic, some countries have prioritized health resources towards COVID-19 management, making it more challenging to appropriately care for other potentially disabling and fatal diseases such as stroke. The aim of this study is to identify and describe changes in stroke epidemiological trends before, during, and after the COVID-19 pandemic. METHODS: This is an international, multicenter, hospital-based study on stroke incidence and outcomes during the COVID-19 pandemic. We will describe patterns in stroke management, stroke hospitalization rate, and stroke severity, subtype (ischemic/hemorrhagic), and outcomes (including in-hospital mortality) in 2020 during COVID-19 pandemic, comparing them with the corresponding data from 2018 and 2019, and subsequently 2021. We will also use an interrupted time series (ITS) analysis to assess the change in stroke hospitalization rates before, during, and after COVID-19, in each participating center. CONCLUSION: The proposed study will potentially enable us to better understand the changes in stroke care protocols, differential hospitalization rate, and severity of stroke, as it pertains to the COVID-19 pandemic. Ultimately, this will help guide clinical-based policies surrounding COVID-19 and other similar global pandemics to ensure that management of cerebrovascular comorbidity is appropriately prioritized during the global crisis. It will also guide public health guidelines for at-risk populations to reduce risks of complications from such comorbidities.


Assuntos
Betacoronavirus/patogenicidade , Infecções por Coronavirus/epidemiologia , Hospitalização/tendências , Pneumonia Viral/epidemiologia , Padrões de Prática Médica/tendências , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/terapia , Comorbidade , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/virologia , Disparidades em Assistência à Saúde/tendências , Mortalidade Hospitalar/tendências , Interações Hospedeiro-Patógeno , Humanos , Incidência , Análise de Séries Temporais Interrompida , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/mortalidade , Pneumonia Viral/virologia , Estudos Prospectivos , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
9.
Eur J Vasc Endovasc Surg ; 60(4): 502-508, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32732140

RESUMO

OBJECTIVE: Composite measures may better objectify hospital performance than individual outcome measures (IOM). Textbook outcome (TO) is an outcome measure achieved for an individual patient when all undesirable outcomes are absent. The aim of this study was to assess TO as an additional outcome measure to evaluate quality of care in symptomatic patients treated by carotid endarterectomy (CEA). METHODS: All symptomatic patients treated by CEA in 2018, registered in the Dutch Audit for Carotid Interventions, were included. TO was defined as a composite of the absence of 30 day mortality, neurological events (any stroke or transient ischaemic attack [TIA]), cranial nerve deficit, haemorrhage, 30 day readmission, prolonged length of stay (LOS; > 5 days) and any other surgical complication. Multivariable logistic regression was used to identify covariables associated with achieving TO, which were used for casemix adjustment for hospital comparison. For each hospital, an observed vs. expected number of events ratio (O/E ratio) was calculated and plotted in a funnel plot with 95% control limits. RESULTS: In total, 70.7% of patients had a desired outcome within 30 days after CEA and therefore achieved TO. Prolonged LOS was the most common parameter (85%) and mortality the least common (1.1%) for not achieving TO. Covariates associated with achieving TO were younger age, the absence of pulmonary comorbidity, higher haemoglobin levels, and TIA as index event. In the case mix adjusted funnel plot, the O/E ratios between hospitals ranged between 0.63 and 1.27, with two hospitals revealing a statistically significantly lower rate of TO (with O/E ratios of 0.63 and 0.66). CONCLUSION: In the Netherlands, most patients treated by CEA achieve TO. Variation between hospitals in achieving TO might imply differences in performance. TO may be used as an additive to the pre-existing IOM, especially in surgical care with low baseline risk such as CEA.


Assuntos
Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/normas , Avaliação de Processos e Resultados em Cuidados de Saúde/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Idoso , Idoso de 80 Anos ou mais , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Doenças dos Nervos Cranianos/epidemiologia , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/mortalidade , Feminino , Disparidades em Assistência à Saúde/normas , Humanos , Ataque Isquêmico Transitório/epidemiologia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Readmissão do Paciente , Hemorragia Pós-Operatória/epidemiologia , Sistema de Registros , Fatores de Risco , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Resultado do Tratamento
10.
PLoS One ; 15(8): e0238312, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32857820

RESUMO

BACKGROUND: We aimed to investigate the correlation between the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), platelet-to-neutrophil ratio (PNR), platelet-to-white blood cell ratio (PWR) and 90-day mortality in patients with acute ischemic stroke (AIS). METHODS: We retrospectively included 633 patients with AIS from January 2017 to May 2018. The correlation between each indicator and the degree of neurologic deficit was assessed. Kaplan-Meier survival curves based on blood cell ratios were used to analyze the 90-day survival rate of patients with AIS. RESULTS: A total of 663 patients with AIS were enrolled, of which 24 (3.6%) experienced recurrence and 13 (2.0%) died. NLR>3.23 (odds ratio; OR = 2.236; 95% confidence interval [CI], 1.472-3.397; P<0.001), PNR<31.14 (OR = 0.471; 95% CI, 0.297-0.749; P = 0.001), and PWR<20.62 (OR = 0.498; 95% CI, 0.309-0.800; P = 0.004) were associated with an unfavorable 90-day prognosis. NLR>3.23, PWR<20.62, and PNR<31.14 were associated with an increased risk of 90-day mortality. CONCLUSION: PNR, PWR, and NLR were associated with the 90-day mortality of patients with AIS. Patients with high NLRs or low PWRs and PNRs may have a greater risk of mortality than other patients. These clinical indicators may help clinicians judge unfavorable prognosis early and implement the appropriate interventions.


Assuntos
Isquemia Encefálica/sangue , Isquemia Encefálica/mortalidade , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Contagem de Células Sanguíneas , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Adulto Jovem
11.
Stroke ; 51(9): 2674-2682, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32755348

RESUMO

BACKGROUND AND PURPOSE: No studies have reported the effect of the coronavirus disease 2019 (COVID-19) epidemic on patients with preexisting stroke. We aim to study the clinical course of COVID-19 patients with preexisting stroke and to investigate death-related risk factors. METHODS: We consecutively included 651 adult inpatients with COVID-19 from the Central Hospital of Wuhan between January 2 and February 15, 2020. Data on the demography, comorbidities, clinical manifestations, laboratory findings, treatments, complications, and outcomes (ie, discharged or death) of the participants were extracted from electronic medical records and compared between patients with and without preexisting stroke. The association between risk factors and mortality was estimated using a Cox proportional hazards regression model for stroke patients infected with severe acute respiratory syndrome coronavirus 2. RESULTS: Of the 651 patients with COVID-19, 49 with preexisting stroke tended to be elderly, male, had more underlying comorbidities and greater severity of illness, prolonged length of hospital stay, and greater hospitalization expenses than those without preexisting stroke. Cox regression analysis indicated that the patients with stroke had a higher risk of developing critical pneumonia (adjusted hazard ratio, 2.01 [95% CI, 1.27-3.16]) and subsequent mortality (adjusted hazard ratio, 1.73 [95% CI, 1.00-2.98]) than the patients without stroke. Among the 49 stroke patients, older age and higher score of Glasgow Coma Scale or Sequential Organ Failure Assessment were independent risk factors associated with in-hospital mortality. CONCLUSIONS: Preexisting stroke patients infected with severe acute respiratory syndrome coronavirus 2 were readily predisposed to death, providing an important message to individuals and health care workers that preventive measures must be implemented to protect and reduce transmission in stroke patients in this COVID-19 crisis.


Assuntos
Infecções por Coronavirus/complicações , Infecções por Coronavirus/mortalidade , Pneumonia Viral/complicações , Pneumonia Viral/mortalidade , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/mortalidade , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , China/epidemiologia , Comorbidade , Infecções por Coronavirus/terapia , Progressão da Doença , Registros Eletrônicos de Saúde , Feminino , Escala de Coma de Glasgow , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/epidemiologia , Insuficiência de Múltiplos Órgãos/etiologia , Pandemias , Pneumonia/etiologia , Pneumonia Viral/terapia , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Acidente Vascular Cerebral/terapia , Resultado do Tratamento
12.
Medicine (Baltimore) ; 99(29): e21236, 2020 Jul 17.
Artigo em Inglês | MEDLINE | ID: mdl-32702900

RESUMO

Sulphonylureas (SUs) subclasses have different risks of all-cause mortality, acute myocardial infarction (AMI), and stroke. Therefore, we assessed these risks in patients with type 2 diabetes mellitus administered gliclazide, glimepiride, or metformin monotherapy with retrospective cohort study design. Total 195,235 subjects were included in the study who were ≥20 years' old and prescribed monotherapy for at least 1 year as a first-line therapy for incident diabetes from January 01, 2009 to December 31, 2013 in the National Health Insurance Service Claim data. Incidence and hazard ratios (HRs) of all-cause mortality, AMI, and stroke were compared with glimepiride monotherapy as a reference. Gliclazide monotherapy increased all-cause mortality compared with glimepiride monotherapy. However, the gliclazide and glimepiride groups showed no difference in AMI and stroke incidences. In line with previous studies, metformin monotherapy showed significant clinical benefits in reducing risks of all-cause mortality, AMI, and stroke compared with glimepiride. This population-based cohort study suggested that gliclazide increases risks of all-cause mortality and has similar risk of AMI and stroke with gliclazide monotherapy in Korean.


Assuntos
Diabetes Mellitus Tipo 2/tratamento farmacológico , Gliclazida/efeitos adversos , Hipoglicemiantes/efeitos adversos , Infarto do Miocárdio/induzido quimicamente , Acidente Vascular Cerebral/induzido quimicamente , Compostos de Sulfonilureia/efeitos adversos , Adulto , Idoso , Grupo com Ancestrais do Continente Asiático , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , República da Coreia , Fatores de Risco , Acidente Vascular Cerebral/mortalidade
13.
Lancet ; 396(10244): 129-142, 2020 07 11.
Artigo em Inglês | MEDLINE | ID: mdl-32653056

RESUMO

Stroke is a major cause of death and disability globally. Diagnosis depends on clinical features and brain imaging to differentiate between ischaemic stroke and intracerebral haemorrhage. Non-contrast CT can exclude haemorrhage, but the addition of CT perfusion imaging and angiography allows a positive diagnosis of ischaemic stroke versus mimics and can identify a large vessel occlusion target for endovascular thrombectomy. Management of ischaemic stroke has greatly advanced, with rapid reperfusion by use of intravenous thrombolysis and endovascular thrombectomy shown to reduce disability. These therapies can now be applied in selected patients who present late to medical care if there is imaging evidence of salvageable brain tissue. Both haemostatic agents and surgical interventions are investigational for intracerebral haemorrhage. Prevention of recurrent stroke requires an understanding of the mechanism of stroke to target interventions, such as carotid endarterectomy, anticoagulation for atrial fibrillation, and patent foramen ovale closure. However, interventions such as lowering blood pressure, smoking cessation, and lifestyle optimisation are common to all stroke subtypes.


Assuntos
Encéfalo/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/prevenção & controle , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Amilose/uso terapêutico , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/prevenção & controle , Encéfalo/irrigação sanguínea , Encéfalo/patologia , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/fisiopatologia , Isquemia Encefálica/cirurgia , Hemorragia Cerebral/complicações , Hemorragia Cerebral/tratamento farmacológico , Hemorragia Cerebral/fisiopatologia , Hemorragia Cerebral/cirurgia , Angiografia por Tomografia Computadorizada/métodos , Intervenção Médica Precoce/métodos , Endarterectomia das Carótidas/métodos , Procedimentos Endovasculares/métodos , Forame Oval Patente/cirurgia , Humanos , Pessoa de Meia-Idade , Seleção de Pacientes , Imagem de Perfusão/métodos , Polímeros/uso terapêutico , Recidiva , Acidente Vascular Cerebral/epidemiologia , Succinatos/uso terapêutico , Trombectomia/métodos , Terapia Trombolítica/métodos , Tomografia Computadorizada por Raios X/métodos
14.
PLoS Med ; 17(7): e1003146, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32673305

RESUMO

BACKGROUND: Atrial fibrillation (AF) is underdiagnosed and especially undertreated in China. We aimed to investigate the prevalence of unknown and untreated AF in community residents (≥65 years old) and to determine whether an education intervention could improve oral anticoagulant (OAC) prescription. METHODS AND FINDINGS: We performed a single-time point screening for AF with a handheld single-lead electrocardiography (ECG) in Chinese residents (≥65 years old) in 5 community health centers in Shanghai from April to September 2017. Disease education and advice on referral to specialist clinics for OAC treatment were provided to all patients with actionable AF (newly detected or undertreated known AF) at the time of screening, and education was reinforced at 1 month. Follow-up occurred at 12 months. In total, 4,531 participants were screened (response rate 94.7%, mean age 71.6 ± 6.3 years, 44% male). Overall AF prevalence was 4.0% (known AF 3.5% [n = 161], new AF 0.5% [n = 22]). The 183 patients with AF were older (p < 0.001), taller (p = 0.02), and more likely to be male (p = 0.01), and they had a higher prevalence of cardiovascular disease than those without AF (p < 0.001). In total, 85% (155/183) of patients were recommended for OAC treatment by the established guidelines (CHA2DS2-VASc ≥ 2 for men; ≥ 3 for women). OAC prescription rate for known AF was 20% (28/138), and actionable AF constituted 2.8% of all those screened. At the 12-month follow-up in 103 patients (81% complete), despite disease education and advice on specialist referral, only 17 attended specialist clinics, and 4 were prescribed OAC. Of those not attending specialist clinics, 71 chose instead to attend community health centers or secondary hospital clinics, with none prescribed OAC, and 15 had no review. Of the 17 patients with new AF and a class 1 recommendation for OAC, only 3 attended a specialist clinic, and none were prescribed OAC. Of the 28 AF patients taking OAC at baseline, OAC was no longer taken in 4. Ischemic stroke (n = 2) or death (n = 3) occurred in 5/126 (4%), with none receiving OAC. As screening was performed at a single time point, some paroxysmal AF cases may have been missed; thus, the rate of new AF may be underestimated. CONCLUSIONS: We demonstrated a noticeable gap in AF detection and treatment in community-based elderly Chinese: actionable AF constituted a high proportion of those screened. Disease education and advice on specialist referral are insufficient to close the gap. Before more frequent or intensive screening for unknown AF could be recommended in China, greater efforts must be made to increase appropriate OAC therapy in known AF to prevent AF-related stroke.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/terapia , Administração Oral , Idoso , Anticoagulantes/administração & dosagem , Fibrilação Atrial/epidemiologia , China/epidemiologia , Centros Comunitários de Saúde , Estudos Transversais , Eletrocardiografia , Feminino , Seguimentos , Humanos , Masculino , Programas de Rastreamento , Prevalência , Estudos Prospectivos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Varfarina/administração & dosagem , Varfarina/uso terapêutico
15.
BMJ ; 370: m2297, 2020 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-32669282

RESUMO

OBJECTIVE: To evaluate the associations between prediabetes and the risk of all cause mortality and incident cardiovascular disease in the general population and in patients with a history of atherosclerotic cardiovascular disease. DESIGN: Updated meta-analysis. DATA SOURCES: Electronic databases (PubMed, Embase, and Google Scholar) up to 25 April 2020. REVIEW METHODS: Prospective cohort studies or post hoc analysis of clinical trials were included for analysis if they reported adjusted relative risks, odds ratios, or hazard ratios of all cause mortality or cardiovascular disease for prediabetes compared with normoglycaemia. Data were extracted independently by two investigators. Random effects models were used to calculate the relative risks and 95% confidence intervals. The primary outcomes were all cause mortality and composite cardiovascular disease. The secondary outcomes were the risk of coronary heart disease and stroke. RESULTS: A total of 129 studies were included, involving 10 069 955 individuals for analysis. In the general population, prediabetes was associated with an increased risk of all cause mortality (relative risk 1.13, 95% confidence interval 1.10 to 1.17), composite cardiovascular disease (1.15, 1.11 to 1.18), coronary heart disease (1.16, 1.11 to 1.21), and stroke (1.14, 1.08 to 1.20) in a median follow-up time of 9.8 years. Compared with normoglycaemia, the absolute risk difference in prediabetes for all cause mortality, composite cardiovascular disease, coronary heart disease, and stroke was 7.36 (95% confidence interval 9.59 to 12.51), 8.75 (6.41 to 10.49), 6.59 (4.53 to 8.65), and 3.68 (2.10 to 5.26) per 10 000 person years, respectively. Impaired glucose tolerance carried a higher risk of all cause mortality, coronary heart disease, and stroke than impaired fasting glucose. In patients with atherosclerotic cardiovascular disease, prediabetes was associated with an increased risk of all cause mortality (relative risk 1.36, 95% confidence interval 1.21 to 1.54), composite cardiovascular disease (1.37, 1.23 to 1.53), and coronary heart disease (1.15, 1.02 to 1.29) in a median follow-up time of 3.2 years, but no difference was seen for the risk of stroke (1.05, 0.81 to 1.36). Compared with normoglycaemia, in patients with atherosclerotic cardiovascular disease, the absolute risk difference in prediabetes for all cause mortality, composite cardiovascular disease, coronary heart disease, and stroke was 66.19 (95% confidence interval 38.60 to 99.25), 189.77 (117.97 to 271.84), 40.62 (5.42 to 78.53), and 8.54 (32.43 to 61.45) per 10 000 person years, respectively. No significant heterogeneity was found for the risk of all outcomes seen for the different definitions of prediabetes in patients with atherosclerotic cardiovascular disease (all P>0.10). CONCLUSIONS: Results indicated that prediabetes was associated with an increased risk of all cause mortality and cardiovascular disease in the general population and in patients with atherosclerotic cardiovascular disease. Screening and appropriate management of prediabetes might contribute to primary and secondary prevention of cardiovascular disease.


Assuntos
Doenças Cardiovasculares/mortalidade , Doença das Coronárias/mortalidade , Estado Pré-Diabético/complicações , Acidente Vascular Cerebral/mortalidade , Idoso , Aterosclerose/complicações , Aterosclerose/epidemiologia , Aterosclerose/mortalidade , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/patologia , Doenças Cardiovasculares/prevenção & controle , Estudos de Casos e Controles , Ensaios Clínicos como Assunto , Doença das Coronárias/epidemiologia , Feminino , Humanos , Incidência , Masculino , Programas de Rastreamento/métodos , Programas de Rastreamento/normas , Pessoa de Meia-Idade , Estudos Observacionais como Assunto , Estado Pré-Diabético/epidemiologia , Risco , Fatores de Risco , Prevenção Secundária/métodos , Acidente Vascular Cerebral/epidemiologia
17.
Artigo em Inglês | MEDLINE | ID: mdl-32609257

RESUMO

Age, sex and presence of comorbidities are risk factors associated with COVID-19. Hypertension, diabetes and heart disease are the most common comorbidities in patients with COVID-19. The objective of this study was to estimate the prevalence of patients with comorbidities who died of COVID-19 in Brazil. Searches of data were carried out on the official pages of the 26 State health departments and the federal district. The random-effect method was used to calculate the prevalence of patients with comorbidities who died. From the beginning of the pandemic in Brazil until May 20, 2020, 276,703 cases of COVID-19 were notified in Brazil, 6.4% died, 58.6% of whom were male. The prevalence of comorbidities among deaths was 83% (95% CI: 79 - 87), with heart disease and diabetes being the most prevalent. To our knowledge, this study represents the first large analysis of cases of patients with confirmed COVID-19 in Brazil. There is a high prevalence of comorbidities (83%) among patients who died from COVID-19 in Brazil, with heart disease being the most prevalent. This is important considering the possible secondary effects produced by drugs such as hydroxychloroquine.


Assuntos
Betacoronavirus , Infecções por Coronavirus/mortalidade , Cardiopatias/mortalidade , Pandemias/estatística & dados numéricos , Pneumonia Viral/mortalidade , Brasil/epidemiologia , Doença Crônica , Comorbidade , Diabetes Mellitus/mortalidade , Feminino , Humanos , Hipertensão/mortalidade , Doenças do Sistema Imunitário/mortalidade , Unidades de Terapia Intensiva/estatística & dados numéricos , Nefropatias/mortalidade , Pneumopatias/mortalidade , Masculino , Obesidade/mortalidade , Pneumonia/mortalidade , Prevalência , Fatores de Risco , Distribuição por Sexo , Fatores Sexuais , Acidente Vascular Cerebral/mortalidade
18.
Neurology ; 95(4): e362-e373, 2020 07 28.
Artigo em Inglês | MEDLINE | ID: mdl-32601121

RESUMO

OBJECTIVE: To evaluate whether pretreatment with metformin (MET) is associated with less stroke severity and better outcome after IV thrombolysis (IVT), we analyzed a cohort of 1,919 patients with stroke with type 2 diabetes mellitus in a multicenter exploratory analysis. METHODS: Data from patients with diabetes and ischemic stroke treated with IVT were collected within the European Thrombolysis in Ischemic Stroke Patients (TRISP) collaboration. We applied propensity score matching (PSM) to obtain balanced baseline characteristics of patients treated with and without MET. RESULTS: Of 1,919 patients with stroke with type 2 diabetes who underwent IVT, 757 (39%) had received MET before stroke (MET+), whereas 1,162 (61%) had not (MET-). MET+ patients were younger with a male preponderance. Hypercholesterolemia and pretreatment with statins, antiplatelets, or antihypertensives were more common in the MET+ group. After PSM, the 2 groups were well balanced with respect to demographic and clinical aspects. Stroke severity on admission (NIH Stroke Scale 10.0 ± 6.7 vs 11.3 ± 6.5), 3-month degree of independence on modified Rankin Scale (2 [interquartile range (IQR) 1.0-4.0] vs 3 [IQR 1.0-4.0]), as well as mortality (12.5% vs 18%) were significantly lower in the MET+ group. The frequency of symptomatic intracerebral hemorrhages did not differ between groups. HbA1c levels were well-balanced between the groups. CONCLUSIONS: Patients with stroke and diabetes on treatment with MET receiving IVT had less severe strokes on admission and a better functional outcome at 3 months. This suggests a protective effect of MET resulting in less severe strokes as well as beneficial thrombolysis outcome.


Assuntos
Hipoglicemiantes/uso terapêutico , Metformina/uso terapêutico , Recuperação de Função Fisiológica/efeitos dos fármacos , Acidente Vascular Cerebral , Idoso , Diabetes Mellitus Tipo 2/tratamento farmacológico , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/métodos
19.
J Thromb Thrombolysis ; 50(3): 587-595, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32661757

RESUMO

Acute ischemic stroke (AIS) is a life-threatening complication of coronavirus disease 2019 (COVID-19) infection. Increasing reports suggest an association between COVID-19 and AIS, although the underlying mechanism remains uncertain. We performed a systematic review to characterize the clinical characteristics, neuroimaging findings, and outcomes of AIS in COVID-19 patients. A literature search was performed in PubMed and Embase using a suitable keyword search strategy from 1st December 2019 to 29th May 2020. All studies reporting AIS occurrence in COVID-19 patients were included. A total of 39 studies comprising 135 patients were studied. The pooled incidence of AIS in COVID-19 patients from observational studies was 1.2% (54/4466) with a mean age of 63.4 ± 13.1 years. The mean duration of AIS from COVID-19 symptoms onset was 10 ± 8 days, and the mean NIHSS score was 19 ± 8. Laboratory investigations revealed an elevated mean D-dimer (9.2 ± 14.8 mg/L) and fibrinogen (5.8 ± 2.0 g/L). Antiphospholipid antibodies were detected in a significant number of cases. The majority of AIS neuroimaging patterns observed was large vessel thrombosis, embolism or stenosis (62.1%, 64/103), followed by multiple vascular territory (26.2%, 27/103). A high mortality rate was reported (38.0%, 49/129). We report the pooled incidence of AIS in COVID-19 patients to be 1.2%, with a high mortality rate. Elevated D-dimer, fibrinogen and the presence of antiphospholipid antibodies appear to be prominent in COVID-19 patients with concomitant AIS, but further mechanistic studies are required to elucidate their role in pathogenesis.


Assuntos
Betacoronavirus/patogenicidade , Isquemia Encefálica/epidemiologia , Infecções por Coronavirus/epidemiologia , Pneumonia Viral/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Idoso , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Isquemia Encefálica/virologia , Causas de Morte , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/virologia , Feminino , Interações Hospedeiro-Patógeno , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Estudos Observacionais como Assunto , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/mortalidade , Pneumonia Viral/virologia , Prevalência , Prognóstico , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/virologia , Fatores de Tempo
20.
Cochrane Database Syst Rev ; 7: CD007026, 2020 07 14.
Artigo em Inglês | MEDLINE | ID: mdl-32662068

RESUMO

BACKGROUND: Cerebrolysin is a mixture of low-molecular-weight peptides and amino acids derived from porcine brain that has potential neuroprotective properties. It is widely used in the treatment of acute ischaemic stroke in Russia, Eastern Europe, China, and other Asian and post-Soviet countries. This is an update of a review first published in 2010 and last updated in 2017. OBJECTIVES: To assess the benefits and harms of Cerebrolysin for treating acute ischaemic stroke. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, Web of Science Core Collection, with Science Citation Index, LILACS, OpenGrey, and a number of Russian databases in October 2019. We also searched reference lists, ongoing trials registers, and conference proceedings. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing Cerebrolysin, started within 48 hours of stroke onset and continued for any length of time, with placebo or no treatment in people with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS: Two review authors independently applied the inclusion criteria, assessed trial quality and risk of bias, extracted data, and applied GRADE criteria to the evidence. MAIN RESULTS: Seven RCTs (1601 participants) met the inclusion criteria of the review. In this update we re-evaluated risk of bias through identification, examination, and evaluation of study protocols and judged it to be low, unclear, or high across studies: unclear for all domains in one study, and unclear for selective outcome reporting across all studies; low for blinding of participants and personnel in four studies and unclear in the remaining three; low for blinding of outcome assessors in three studies and unclear in four studies. We judged risk of bias to be low in two studies and unclear in the remaining five studies for generation of allocation sequence; low in one study and unclear in six studies for allocation concealment; and low in one study, unclear in one study, and high in the remaining five studies for incomplete outcome data. The manufacturer of Cerebrolysin supported four multicentre studies, either totally, or by providing Cerebrolysin and placebo, randomisation codes, research grants, or statisticians. We judged three studies to be at high risk of other bias and the remaining four studies to be at unclear risk of other bias. All-cause death: we extracted data from six trials (1517 participants). Cerebrolysin probably results in little to no difference in all-cause death: risk ratio (RR) 0.90, 95% confidence interval (CI) 0.61 to 1.32 (6 trials, 1517 participants, moderate-quality evidence). None of the included trials reported on poor functional outcome defined as death or dependence at the end of the follow-up period or early death (within two weeks of stroke onset), or time to restoration of capacity for work and quality of life. Only one trial clearly reported on the cause of death: cerebral infarct (four in the Cerebrolysin and two in the placebo group), heart failure (two in the Cerebrolysin and one in the placebo group), pulmonary embolism (two in the placebo group), and pneumonia (one in the placebo group). Serious adverse events (SAEs): Cerebrolysin probably results in little to no difference in the total number of people with SAEs (RR 1.15, 95% CI 0.81 to 1.65, 4 RCTs, 1435 participants, moderate-quality evidence). This comprised fatal SAEs (RR 0.90, 95% CI 0.59 to 1.38) and an increase in the total number of people with non-fatal SAEs (RR 2.15, 95% CI 1.01 to 4.55, P = 0.047, 4 trials, 1435 participants, moderate-quality evidence). In the subgroup of dosing schedule 30 mL for 10 days (cumulative dose 300 mL), the increase was more prominent: RR 2.86, 95% CI 1.23 to 6.66, P = 0.01 (2 trials, 1189 participants). Total number of people with adverse events: four trials reported on this outcome. Cerebrolysin may result in little to no difference in the total number of people with adverse events: RR 0.97, 95% CI 0.85 to 1.10, P = 0.90, 4 trials, 1435 participants, low-quality evidence. Non-death attrition: evidence from six trials involving 1517 participants suggests that Cerebrolysin results in little to no difference in non-death attrition, with 96 out of 764 Cerebrolysin-treated participants and 117 out of 753 placebo-treated participants being lost to follow-up for reasons other than death (very low-quality evidence). AUTHORS' CONCLUSIONS: Moderate-quality evidence indicates that Cerebrolysin probably has little or no beneficial effect on preventing all-cause death in acute ischaemic stroke, or on the total number of people with serious adverse events. Moderate-quality evidence also indicates a potential increase in non-fatal serious adverse events with Cerebrolysin use.


Assuntos
Aminoácidos/uso terapêutico , Fármacos Neuroprotetores/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Doença Aguda , Aminoácidos/efeitos adversos , Viés , Isquemia Encefálica/complicações , Causas de Morte , Humanos , Fármacos Neuroprotetores/efeitos adversos , Pacientes Desistentes do Tratamento/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade
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