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1.
Angiol Sosud Khir ; 25(4): 131-138, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31855210

RESUMO

Presented in the article are the results of surgical management of a patient with an extremely rare pathology - a saccular arterial aneurysm of the cavernous-ophthalmic segment of the left internal carotid artery. We performed multistage open surgical intervention in the following scope: osteoplastic pterional craniotomy on the left, creation of a wide-lumen anastomosis between the left external carotid artery and M2 segment of the left middle cerebral artery with the use of the radial artery, ligation of the cervical portion of the left internal carotid artery and clipping of its supraclinoid portion. The chosen surgical policy made it possible to create sufficient volumetric blood flow through the shunt, comparable to the blood flow through the internal carotid artery, which helped avoid ischaemic stroke after exclusion of the aneurysm from circulation. A conclusion was drawn on efficacy of this method of treatment.


Assuntos
Artéria Carótida Externa/cirurgia , Artéria Carótida Interna/cirurgia , Aneurisma Intracraniano/cirurgia , Artéria Cerebral Média/cirurgia , Anastomose Cirúrgica , Isquemia Encefálica/etiologia , Isquemia Encefálica/prevenção & controle , Humanos , Aneurisma Intracraniano/complicações , Ligadura , Artéria Radial/transplante , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Procedimentos Cirúrgicos Vasculares/métodos
2.
Medicine (Baltimore) ; 98(51): e18225, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31860969

RESUMO

BACKGROUND: Chronic blood transfusions are standard of care for stroke prevention in sickle cell disease but is not cost effective and not without risks. Hydroxyurea has emerged as an option in the prevention of silent stroke in sickle cell disease. OBJECTIVE: To evaluate the role of hydroxyurea in preventing silent strokes in a systematic review by adhering to the Cochrane guidelines. METHODS: PubMed, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials were searched for the related articles. Eligibility criteria included randomized controlled trials (RCTs) comparing the use of hydroxyurea vs blood transfusions and observational studies evaluating the role of hydroxyurea to prevent stroke and silent stroke in patients with sickle cell anemia or sickle cell ß thalassemia. The meta-analysis was conducted using STATA software version 13. RESULTS: We included 10 single arm observational studies with 361 participants, and one RCT study with 60 participants receiving hydroxyurea, respectively. There were no deaths attributed to hydroxyurea. The results revealed that 1% (95% CIs 0.0 to 0.05) of patients receiving hydroxyurea had stroke. 18% (95% CIs 0.03 to 0.4) of the hydroxyurea patients had silent stroke. 24% (95% CIs 0.02 to 0.57) of the hydroxyurea patients had adverse events attributed to hydroxyurea. CONCLUSION: Our findings suggest that hydroxyurea is safe and may prevent silent stroke and stroke in sickle cell disease. More high-quality studies including RCTs are needed.


Assuntos
Anemia Falciforme/complicações , Antidrepanocíticos/uso terapêutico , Hidroxiureia/uso terapêutico , Acidente Vascular Cerebral/prevenção & controle , Anemia Falciforme/tratamento farmacológico , Transfusão de Sangue , Humanos , Acidente Vascular Cerebral/etiologia
3.
Lancet ; 394(10211): 1816-1826, 2019 11 16.
Artigo em Inglês | MEDLINE | ID: mdl-31668726

RESUMO

BACKGROUND: Uncertainty remains about the optimal monotherapy for hypertension, with current guidelines recommending any primary agent among the first-line drug classes thiazide or thiazide-like diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, dihydropyridine calcium channel blockers, and non-dihydropyridine calcium channel blockers, in the absence of comorbid indications. Randomised trials have not further refined this choice. METHODS: We developed a comprehensive framework for real-world evidence that enables comparative effectiveness and safety evaluation across many drugs and outcomes from observational data encompassing millions of patients, while minimising inherent bias. Using this framework, we did a systematic, large-scale study under a new-user cohort design to estimate the relative risks of three primary (acute myocardial infarction, hospitalisation for heart failure, and stroke) and six secondary effectiveness and 46 safety outcomes comparing all first-line classes across a global network of six administrative claims and three electronic health record databases. The framework addressed residual confounding, publication bias, and p-hacking using large-scale propensity adjustment, a large set of control outcomes, and full disclosure of hypotheses tested. FINDINGS: Using 4·9 million patients, we generated 22 000 calibrated, propensity-score-adjusted hazard ratios (HRs) comparing all classes and outcomes across databases. Most estimates revealed no effectiveness differences between classes; however, thiazide or thiazide-like diuretics showed better primary effectiveness than angiotensin-converting enzyme inhibitors: acute myocardial infarction (HR 0·84, 95% CI 0·75-0·95), hospitalisation for heart failure (0·83, 0·74-0·95), and stroke (0·83, 0·74-0·95) risk while on initial treatment. Safety profiles also favoured thiazide or thiazide-like diuretics over angiotensin-converting enzyme inhibitors. The non-dihydropyridine calcium channel blockers were significantly inferior to the other four classes. INTERPRETATION: This comprehensive framework introduces a new way of doing observational health-care science at scale. The approach supports equivalence between drug classes for initiating monotherapy for hypertension-in keeping with current guidelines, with the exception of thiazide or thiazide-like diuretics superiority to angiotensin-converting enzyme inhibitors and the inferiority of non-dihydropyridine calcium channel blockers. FUNDING: US National Science Foundation, US National Institutes of Health, Janssen Research & Development, IQVIA, South Korean Ministry of Health & Welfare, Australian National Health and Medical Research Council.


Assuntos
Anti-Hipertensivos/uso terapêutico , Hipertensão/tratamento farmacológico , Adolescente , Adulto , Idoso , Antagonistas de Receptores de Angiotensina/efeitos adversos , Antagonistas de Receptores de Angiotensina/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anti-Hipertensivos/efeitos adversos , Bloqueadores dos Canais de Cálcio/efeitos adversos , Bloqueadores dos Canais de Cálcio/uso terapêutico , Criança , Estudos de Coortes , Pesquisa Comparativa da Efetividade/métodos , Bases de Dados Factuais , Diuréticos/efeitos adversos , Diuréticos/uso terapêutico , Medicina Baseada em Evidências/métodos , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/prevenção & controle , Humanos , Hipertensão/complicações , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Infarto do Miocárdio/prevenção & controle , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Adulto Jovem
4.
Rev Lat Am Enfermagem ; 27: e3197, 2019 Oct 14.
Artigo em Português, Inglês, Espanhol | MEDLINE | ID: mdl-31618390

RESUMO

OBJECTIVE: to analyze the in-hospital complications of prolonged hospital stay in patients with ischemic stroke or transient ischemic attack, admitted to the stroke unit of a tertiary hospital. METHOD: this is an evaluative correlational study. All first-ever ischemic stroke or transient ischemic attack patients admitted were retrospectively analyzed. During hospital stay, the predictors of long-term hospitalization considered were: 1) clinical complications (pneumonia, urinary tract infection, pressure damage and deep vein thrombosis), and 2) neurological complications (malignant ischemic stroke and symptomatic hemorrhagic transformation). RESULTS: 353 patients were discharged in the study period. Mean age was 64.1±13.7 years old and 186 (52.6%) were men. The mean time of hospital stay was 13.7±14.3 days. Pneumonia (25.3±28.8 days, p<0.001), urinary tract infection (32.9±45.2 days, p<0.001) and malignant stroke (29.1±21.4 days, p<0.001) increased significantly the length of hospital stay compared to patients without any complications (11.2±7.1 days). CONCLUSION: this study showed that three complications delayed hospital discharge in patients admitted in a stroke unit, two preventable ones: pneumonia and urinary tract infection. More intense measures to avoid them should be included in the performance indicators to reduce the length of hospital stay in stroke units.


Assuntos
Hospitalização/estatística & dados numéricos , Ataque Isquêmico Transitório/prevenção & controle , Tempo de Internação/estatística & dados numéricos , Acidente Vascular Cerebral/prevenção & controle , Fatores Etários , Idoso , Correlação de Dados , Complicações do Diabetes/complicações , Feminino , Humanos , Hipertensão/complicações , Ataque Isquêmico Transitório/complicações , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Pneumonia/complicações , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/complicações , Reabilitação do Acidente Vascular Cerebral/estatística & dados numéricos , Centros de Atenção Terciária/estatística & dados numéricos , Infecções Urinárias/complicações
5.
Life Sci ; 237: 116915, 2019 Nov 15.
Artigo em Inglês | MEDLINE | ID: mdl-31610207

RESUMO

AIMS: The objective of the study was to determine whether ß-caryophyllene (BCP) exerts a neuroprotective effect in cerebral ischemia-reperfusion (I/R) injury by inhibiting microglial activation and modulating their polarization via the TLR4 pathway. MAIN METHODS: Wild-type (WT) and TLR4 knockout (KO) C57BL/6J mice were subjected to cerebral I/R injury and neurologic dysfunction, cerebral infarct volume, brain edema, microglia activation and polarization, and TLR4 expression were determined. In vitro, primary microglia were stimulated with LPS and IFN-γ or IL-4 to induce polarization of microglia toward M1 or M2 phenotypes. KEY FINDINGS: BCP reduced cerebral infarct volume, brain edema, and neurologic deficits in WT mice after I/R. The optimal dose of BCP, 72 mg/kg body weight, inhibited microglial activation and reduced the secretion of proinflammatory cytokines interleukin (IL)-1ß, tumor necrosis factor (TNF)-α, and IL-6 by microglia of WT mice. BCP inhibited the level of TLR4 in WT mice, and partially reduced neurologic deficits, infarct volume, and brain edema in TLR4 KO mice. Importantly, BCP reduced the number of activated M1-type microglia and increased the number of M2-type microglia in the ipsilateral cortex of both WT and TLR4 KO mice. In vitro, BCP decreased the secretion of proinflammatory cytokines induced by LPS plus IFN-γ, downregulated the level of TLR4 protein, and polarized microglia towards the M2 phenotype. SIGNIFICANCES: The decrease in TLR4 activity mediated, at least in part, the anti-inflammatory effects of BCP and its ability to shift microglia polarization from the M1 to M2 phenotype.


Assuntos
Isquemia Encefálica/prevenção & controle , Macrófagos/efeitos dos fármacos , Microglia/efeitos dos fármacos , Fármacos Neuroprotetores/farmacologia , Sesquiterpenos/farmacologia , Acidente Vascular Cerebral/prevenção & controle , Receptor 4 Toll-Like/fisiologia , Animais , Anti-Inflamatórios não Esteroides/farmacologia , Isquemia Encefálica/metabolismo , Isquemia Encefálica/patologia , Ativação de Macrófagos/efeitos dos fármacos , Macrófagos/imunologia , Macrófagos/metabolismo , Macrófagos/patologia , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Camundongos Knockout , Microglia/imunologia , Microglia/metabolismo , Microglia/patologia , Acidente Vascular Cerebral/metabolismo , Acidente Vascular Cerebral/patologia
6.
Bratisl Lek Listy ; 120(10): 764-768, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31663352

RESUMO

OBJECTIVES: To investigate real-world data on warfarinisation rates and results in the elderly patients with atrial fibrillation (AF). BACKGROUND: AF is the most frequent arrhythmia in the elderlies with considerable risk of devastating stroke-related consequences. Guidelines prefer non-vitamin K antagonist oral anticoagulants (NOAC) to warfarin for thromboprophylaxis. Nevertheless, warfarin is still widely used, even if it is challenging, especially in polymorbid elderlies, to achieve the therapeutic international normalised ratio (INR). There are only scarce real-world data on INR in warfarinised elderly AF patients. METHODS: The study was based on multicentric observational Slovak audit of atrial fibrillation in seniors (SAFIS) performed on 4,252 hospitalised AF patients aged over 64 years (mean age 80.9 yrs.). INR data from warfarinised patients were analysed (955 at admission and 870 at discharge). RESULTS: At hospital admission and discharge, the warfarin medication rates were 22.6 % and 23.5 %, respectively, INR lower than 2 was present in 41.8 % and 30.6 % of patients, respectively, and INR higher than 3 was in 27.0 % and 7.7 %, respectively and altogether, 68.8 % and 38.3 % of warfarinised patients, respectively, were out of therapeutic range. CONCLUSION: Warfarin is still frequently used in the elderlies with AF, but the success rates are unsatisfactory in a huge number of patients. It is urgent to improve seniors' access to NOAC (Fig. 2, Ref. 34).


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controle , Tromboembolia Venosa/prevenção & controle , Varfarina/uso terapêutico , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Humanos
7.
Medicine (Baltimore) ; 98(42): e17628, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31626146

RESUMO

BACKGROUND: The role of anticoagulation therapy for stroke prevention in older atrial fibrillation (AF) patients with chronic kidney disease (CKD) remains unclear. Therefore, we conducted a meta-analysis to explore the efficacy and safety of anticoagulation therapy in this population. METHODS: The Cochrane Library, PubMed, and Embase databases were systematically searched for studies reporting the effect of anticoagulation therapy in older patients with AF and CKD. The risk ratios (RRs) and 95% confidence intervals (CIs) were regarded as the risk estimates. A random-effects model selected was to evaluate the treatment outcomes. The presentations were based on the Preferred Reporting Items for reporting systematic reviews and meta-analyses statement. RESULTS: A total of 7 studies with 24,794 older patients with AF and CKD were included. The follow-up of the included studies ranged from 0.9 to 9.0 years. In older patients with no dialysis, compared with nonanticoagulants, anticoagulants reduced the risk of all-cause death (RR 0.66, 95% CI 0.54-0.79), but had comparable risks of ischemic stroke/transient ischemic attack (TIA, RR 0.91, 95% CI 0.46-1.79) and bleeding (RR 1.17, 95% CI 0.86-1.60). In older patients with dialysis, compared with nonanticoagulants, anticoagulants increased the risk of bleeding (RR 1.37, 95% CI 1.09-1.74), but had similar risks of ischemic stroke/TIA (RR 1.18, 95% CI 0.88-1.58) and death (RR 0.87, 95% CI 0.60-1.27). CONCLUSION: Compared with nonanticoagulation, anticoagulation therapy is associated with a reduced risk of death in older AF patients with nondialysis, but an increased risk of bleeding in older patients with dialysis.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Insuficiência Renal Crônica/complicações , Acidente Vascular Cerebral/prevenção & controle , Terapia Trombolítica/métodos , Fibrilação Atrial/complicações , Humanos , Diálise Renal , Insuficiência Renal Crônica/terapia , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
10.
Nervenarzt ; 90(10): 995-1004, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31560112

RESUMO

Over the past decade innovations regarding antithrombotic treatment for secondary stroke prevention have been particularly dominated by the non-vitamin K dependent anticoagulants in patients with cardioembolic stroke; however, several studies investigating other important aspects have also recently been published. This update focuses on new trials on intensified antiplatelet therapy in the early phase of (mild) stroke and transient ischemic attacks (TIA) as well as studies on secondary prevention in patients with embolic stroke of undetermined source (ESUS). Data from these studies are critically reviewed to demonstrate strategies for clinical implementation.


Assuntos
Isquemia Encefálica , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Anticoagulantes/uso terapêutico , Isquemia Encefálica/prevenção & controle , Fibrinolíticos/uso terapêutico , Humanos , Ataque Isquêmico Transitório/prevenção & controle , Inibidores da Agregação de Plaquetas/uso terapêutico , Prevenção Secundária , Acidente Vascular Cerebral/prevenção & controle
11.
Lancet ; 394(10206): 1335-1343, 2019 Oct 12.
Artigo em Inglês | MEDLINE | ID: mdl-31492505

RESUMO

BACKGROUND: We aimed to assess the safety of edoxaban in combination with P2Y12 inhibition in patients with atrial fibrillation who had percutaneous coronary intervention (PCI). METHODS: ENTRUST-AF PCI was a randomised, multicentre, open-label, non-inferiority phase 3b trial with masked outcome evaluation, done at 186 sites in 18 countries. Patients had atrial fibrillation requiring oral anticoagulation, were aged at least 18 years, and had a successful PCI for stable coronary artery disease or acute coronary syndrome. Participants were randomly assigned (1:1) from 4 h to 5 days after PCI using concealed, stratified, and blocked web-based central randomisation to either edoxaban (60 mg once daily) plus a P2Y12 inhibitor for 12 months or a vitamin K antagonist (VKA) in combination with a P2Y12 inhibitor and aspirin (100 mg once daily, for 1-12 months). The edoxaban dose was reduced to 30 mg per day if one or more factors (creatinine clearance 15-50 mL/min, bodyweight ≤60 kg, or concomitant use of specified potent P-glycoprotein inhibitors) were present. The primary endpoint was a composite of major or clinically relevant non-major (CRNM) bleeding within 12 months. The primary analysis was done in the intention-to-treat population and safety was assessed in all patients who received at least one dose of their assigned study drug. This trial is registered with ClinicalTrials.gov, NCT02866175, is closed to new participants, and follow-up is completed. FINDINGS: From Feb 24, 2017, through May 7, 2018, 1506 patients were enrolled and randomly assigned to the edoxaban regimen (n=751) or VKA regimen (n=755). Median time from PCI to randomisation was 45·1 h (IQR 22·2-76·2). Major or CRNM bleeding events occurred in 128 (17%) of 751 patients (annualised event rate 20·7%) with the edoxaban regimen and 152 (20%) of 755 patients (annualised event rate 25·6%) patients with the VKA regimen; hazard ratio 0·83 (95% CI 0·65-1·05; p=0·0010 for non-inferiority, margin hazard ratio 1·20; p=0·1154 for superiority). INTERPRETATION: In patients with atrial fibrillation who had PCI, the edoxaban-based regimen was non-inferior for bleeding compared with the VKA-based regimen, without significant differences in ischaemic events. FUNDING: Daiichi Sankyo.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/uso terapêutico , Fibrinolíticos/uso terapêutico , Intervenção Coronária Percutânea , Piridinas/uso terapêutico , Tiazóis/uso terapêutico , Vitamina K/antagonistas & inibidores , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/cirurgia , Idoso , Fibrilação Atrial/complicações , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/uso terapêutico , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Stents , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
12.
N Engl J Med ; 381(16): 1524-1534, 2019 10 17.
Artigo em Inglês | MEDLINE | ID: mdl-31475799

RESUMO

BACKGROUND: The relative merits of ticagrelor as compared with prasugrel in patients with acute coronary syndromes for whom invasive evaluation is planned are uncertain. METHODS: In this multicenter, randomized, open-label trial, we randomly assigned patients who presented with acute coronary syndromes and for whom invasive evaluation was planned to receive either ticagrelor or prasugrel. The primary end point was the composite of death, myocardial infarction, or stroke at 1 year. A major secondary end point (the safety end point) was bleeding. RESULTS: A total of 4018 patients underwent randomization. A primary end-point event occurred in 184 of 2012 patients (9.3%) in the ticagrelor group and in 137 of 2006 patients (6.9%) in the prasugrel group (hazard ratio, 1.36; 95% confidence interval [CI], 1.09 to 1.70; P = 0.006). The respective incidences of the individual components of the primary end point in the ticagrelor group and the prasugrel group were as follows: death, 4.5% and 3.7%; myocardial infarction, 4.8% and 3.0%; and stroke, 1.1% and 1.0%. Definite or probable stent thrombosis occurred in 1.3% of patients assigned to ticagrelor and 1.0% of patients assigned to prasugrel, and definite stent thrombosis occurred in 1.1% and 0.6%, respectively. Major bleeding (as defined by the Bleeding Academic Research Consortium scale) was observed in 5.4% of patients in the ticagrelor group and in 4.8% of patients in the prasugrel group (hazard ratio, 1.12; 95% CI, 0.83 to 1.51; P = 0.46). CONCLUSIONS: Among patients who presented with acute coronary syndromes with or without ST-segment elevation, the incidence of death, myocardial infarction, or stroke was significantly lower among those who received prasugrel than among those who received ticagrelor, and the incidence of major bleeding was not significantly different between the two groups. (Funded by the German Center for Cardiovascular Research and Deutsches Herzzentrum München; ISAR-REACT 5 ClinicalTrials.gov number, NCT01944800.).


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Cloridrato de Prasugrel/uso terapêutico , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Ticagrelor/uso terapêutico , Síndrome Coronariana Aguda/mortalidade , Síndrome Coronariana Aguda/terapia , Idoso , Trombose Coronária/epidemiologia , Feminino , Hemorragia/induzido quimicamente , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/prevenção & controle , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/efeitos adversos , Cloridrato de Prasugrel/efeitos adversos , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Stents , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Ticagrelor/efeitos adversos
13.
N Engl J Med ; 381(14): 1309-1320, 2019 Oct 03.
Artigo em Inglês | MEDLINE | ID: mdl-31475798

RESUMO

BACKGROUND: Patients with stable coronary artery disease and diabetes mellitus who have not had a myocardial infarction or stroke are at high risk for cardiovascular events. Whether adding ticagrelor to aspirin improves outcomes in this population is unclear. METHODS: In this randomized, double-blind trial, we assigned patients who were 50 years of age or older and who had stable coronary artery disease and type 2 diabetes mellitus to receive either ticagrelor plus aspirin or placebo plus aspirin. Patients with previous myocardial infarction or stroke were excluded. The primary efficacy outcome was a composite of cardiovascular death, myocardial infarction, or stroke. The primary safety outcome was major bleeding as defined by the Thrombolysis in Myocardial Infarction (TIMI) criteria. RESULTS: A total of 19,220 patients underwent randomization. The median follow-up was 39.9 months. Permanent treatment discontinuation was more frequent with ticagrelor than placebo (34.5% vs. 25.4%). The incidence of ischemic cardiovascular events (the primary efficacy outcome) was lower in the ticagrelor group than in the placebo group (7.7% vs. 8.5%; hazard ratio, 0.90; 95% confidence interval [CI], 0.81 to 0.99; P = 0.04), whereas the incidence of TIMI major bleeding was higher (2.2% vs. 1.0%; hazard ratio, 2.32; 95% CI, 1.82 to 2.94; P<0.001), as was the incidence of intracranial hemorrhage (0.7% vs. 0.5%; hazard ratio, 1.71; 95% CI, 1.18 to 2.48; P = 0.005). There was no significant difference in the incidence of fatal bleeding (0.2% vs. 0.1%; hazard ratio, 1.90; 95% CI, 0.87 to 4.15; P = 0.11). The incidence of an exploratory composite outcome of irreversible harm (death from any cause, myocardial infarction, stroke, fatal bleeding, or intracranial hemorrhage) was similar in the ticagrelor group and the placebo group (10.1% vs. 10.8%; hazard ratio, 0.93; 95% CI, 0.86 to 1.02). CONCLUSIONS: In patients with stable coronary artery disease and diabetes without a history of myocardial infarction or stroke, those who received ticagrelor plus aspirin had a lower incidence of ischemic cardiovascular events but a higher incidence of major bleeding than those who received placebo plus aspirin. (Funded by AstraZeneca; THEMIS ClinicalTrials.gov number, NCT01991795.).


Assuntos
Aspirina/uso terapêutico , Doença da Artéria Coronariana/tratamento farmacológico , Diabetes Mellitus Tipo 2/tratamento farmacológico , Inibidores da Agregação de Plaquetas/uso terapêutico , Ticagrelor/uso terapêutico , Idoso , Aspirina/efeitos adversos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/mortalidade , Método Duplo-Cego , Quimioterapia Combinada/efeitos adversos , Feminino , Seguimentos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Hemorragia/mortalidade , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/prevenção & controle , Inibidores da Agregação de Plaquetas/efeitos adversos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Ticagrelor/efeitos adversos , Resultado do Tratamento
14.
Lakartidningen ; 1162019 Aug 13.
Artigo em Sueco | MEDLINE | ID: mdl-31408188

RESUMO

Atrial high rate episodes (AHRE) are frequently detected in patients with pacemakers or implantable cardioverter defibrillators. AHRE episodes ≥5 minutes are associated with increased risk of ischemic stroke. There is no clear temporal relationship between AHRE and ischemic stroke, therefore atrial arrhythmia could be suspected to at least in part be a risk marker and not solely a direct cause of stroke. No results have been published on the effect of anticoagulation in patients with AHRE, but several studies are in progress. The European Heart Rhythm Association (EHRA) recommends anticoagulation for patients with AHRE ≥5.5 hours per day and a CHA2DS2-VASc score of ≥2 (≥3 in females). Anticoagulation may be considered for CHA2DS2-VASc scores of 1 (2 in females). In patients with several risk factors anticoagulation should be considered also in cases with shorter duration of AHRE.


Assuntos
Fibrilação Atrial/complicações , Desfibriladores Implantáveis , Marca-Passo Artificial , Acidente Vascular Cerebral/etiologia , Taquicardia/complicações , Anticoagulantes/administração & dosagem , Anticoagulantes/uso terapêutico , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Feminino , Humanos , Masculino , Guias de Prática Clínica como Assunto , Fatores de Risco , Acidente Vascular Cerebral/prevenção & controle , Taquicardia/diagnóstico , Taquicardia/tratamento farmacológico
15.
Med Clin North Am ; 103(5): 847-862, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31378330

RESUMO

Oral anticoagulation significantly reduces the risk of stroke in patients with atrial fibrillation (AF), and the decision to initiate therapy is based on assessing the patient's yearly risk of stroke. Although warfarin remains the drug of choice in patients with AF and artificial mechanical valves, the novel anticoagulation agents are becoming the drug of choice for all other patients with AF, because of their efficacy, safety, and ease of use. This article summarizes the current evidence for stroke prevention in AF, including valvular AF, subclinical AF, AF in patients with renal insufficiency, as well as stroke prevention around AF cardioversion.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Ensaios Clínicos como Assunto , Humanos , Guias de Prática Clínica como Assunto , Acidente Vascular Cerebral/etiologia , Varfarina/administração & dosagem , Varfarina/efeitos adversos
16.
Arch Cardiovasc Dis ; 112(8-9): 532-542, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31378692

RESUMO

BACKGROUND: Unlike previous randomized clinical trials (RCTs), recent trials and meta-analyses have shown that transcatheter closure of patent foramen ovale (PFO) reduces stroke recurrence risk in young and middle-aged adults with an otherwise unexplained PFO-associated ischaemic stroke. AIM: To produce an expert consensus on the role of transcatheter PFO closure and antithrombotic drugs for secondary stroke prevention in patients with PFO-associated ischaemic stroke. METHODS: Five neurologists and five cardiologists with extensive experience in the relevant field were nominated by the French Neurovascular Society and the French Society of Cardiology to make recommendations based on evidence from RCTs and meta-analyses. RESULTS: The experts recommend that any decision concerning treatment of patients with PFO-associated ischaemic stroke should be taken after neurological and cardiological evaluation, bringing together the necessary neurovascular, echocardiography and interventional cardiology expertise. Transcatheter PFO closure is recommended in patients fulfilling all the following criteria: age 16-60 years; recent (≤6 months) ischaemic stroke; PFO associated with atrial septal aneurysm (>10mm) or with a right-to-left shunt>20 microbubbles or with a diameter≥2mm; PFO felt to be the most likely cause of stroke after thorough aetiological evaluation by a stroke specialist. Long-term oral anticoagulation may be considered in the event of contraindication to or patient refusal of PFO closure, in the absence of a high bleeding risk. After PFO closure, dual anti-platelet therapy with aspirin (75mg/day) and clopidogrel (75mg/day) is recommended for 3 months, followed by monotherapy with aspirin or clopidogrel for≥5 years. CONCLUSIONS: Although a big step forward that will benefit many patients has been taken with recent trials, many questions remain unanswered. Pending results from further studies, decision-making regarding management of patients with PFO-associated ischaemic stroke should be based on a close coordination between neurologists/stroke specialists and cardiologists.


Assuntos
Isquemia Encefálica/prevenção & controle , Cateterismo Cardíaco/normas , Cardiologia/normas , Forame Oval Patente/terapia , Prevenção Secundária/normas , Acidente Vascular Cerebral/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Consenso , Feminino , Forame Oval Patente/diagnóstico , Forame Oval Patente/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Medição de Risco , Fatores de Risco , Dispositivo para Oclusão Septal/normas , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Resultado do Tratamento , Adulto Jovem
18.
Artigo em Russo | MEDLINE | ID: mdl-31464291

RESUMO

AIM: To perform a pharmacoeconomic analysis of the most frequently prescribed neuroprotective medicines for treating patients with mild ischemic stroke in the acute and early rehabilitation periods in the Russian Federation. MATERIAL AND METHODS: Three medical technologies were compared: ethylmethylhydroxypyridine succinate (mexidol), inosine + nicotinamide + riboflavin + succinic acid (cytoflavin) and a deproteinized hemoderivate of the blood of calves (actovegin). Cost minimization analysis, budget impact analysis and sensitivity analysis were performed based on the indirect comparison results. RESULTS: Efficacy analysis shows that mentioned above medicines have the same efficacy: mean difference mexidol is 0,2 (CI min 0,25; max 0,65), cytoflavin - 0,61 (CI min 0,23; max 0,99), actovegin 0,2 (CI min 0,18; max 0,22). The cost minimization analysis for the Russian Federation shows that mexidol therapy is associated with the lowest costs, while savings are observed both in the evaluation of total costs and separate components: intravenous ampoules and tablet forms. The savings in comparison with cytoflavin and actovegin are 231 RUB and 12,872 RUB, respectively. These savings will be enough to treat five patients with ischemic stroke (IS) with mexidol. Moreover, oral mexidol therapy is cheaper than the same dosage forms of cytoflavin and actovegin by 481 RUB and 3,164 RUB, respectively. This is an advantage for the treatment of population at the outpatient stage. Budget impact analysis has shown that the budget for the medicines for treating IS at the current distribution between treatment regimens, is estimated at 1.99 BN RUB. The increase in the proportion of patients receiving mexidol by 10% reduces total costs to 1.75 BN RUB, which is 240 M RUB less than current costs. With these savings 85 thousand patients with IS could be treated. The sensitivity analysis reveals that the result of the cost minimization analysis and the budget impact analysis remain stable when both the amount of the population and the cost of 1 mg of mexidol vary from -10% to + 10%. CONCLUSIONS: Mexidol has the same efficacy as alternatives. However mexidol is superior to cytoflavin and actovegin in terms of cost minimization analysis. The savings from one course of alternatives will cover costs of treatment of five patients with IS using mexidol. The increase in the proportion of patients receiving mexidol is associated with savings, which allows us to consider mexidol therapy of mild IS as budget-saving in the Russian Federation.


Assuntos
Isquemia Encefálica , Farmacoeconomia , Fármacos Neuroprotetores , Acidente Vascular Cerebral , Animais , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/prevenção & controle , Bovinos , Humanos , Fármacos Neuroprotetores/economia , Fármacos Neuroprotetores/uso terapêutico , Federação Russa , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controle
19.
Stud Health Technol Inform ; 264: 916-919, 2019 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-31438057

RESUMO

The habits and lifestyles are the fundamental factors in the control of cardiovascular risk. Patients who have had a cerebrovascular accident (CVA) have a high risk of having a new event with similar characteristics. The exponentially growing success, penetration and adherence of the new communication technologies, based on applications (APPs), allows to use them to obtain information and influence the risk factors. We propose that empowering patients in their disease can make a more efficient management of it. For this reason, we designed and developed a system which integrates a mobile application and a web application. This system also makes use of peripheral devices to monitor patients and allow the automatic acquisition of information to enable the characterization of this kind of patients in relation to habits and lifestyle. At the same time, the system can also empower these patients with their disease to do secondary prevention.


Assuntos
Aplicativos Móveis , Acidente Vascular Cerebral , Hábitos , Humanos , Fatores de Risco , Prevenção Secundária , Acidente Vascular Cerebral/prevenção & controle
20.
Int J Clin Pharmacol Ther ; 57(9): 458-463, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31347488

RESUMO

BACKGROUND: Oral anticoagulation is efficient to prevent ischemic stroke in atrial fibrillation (AF), but in very old patients, physicians always remain cautious to use anticoagulants concerning the bleeding risk. This research aims to investigate the current situation of oral anticoagulation therapy in very old (≥ 80 years) AF patients. MATERIALS AND METHODS: We carried out a cross-sectional study in an urban area in China from 2014 to 2016. Characteristics of the very old patients (age ≥ 80 years) and the younger patients (age < 80 years) were compared. Logistic analysis was used to estimate the association between oral anticoagulation therapy and CHA2DS2-VASc score. RESULTS: A total of 1,000 AF patients were enrolled; 306 were very old patients, and 694 were younger patients. In the very old group, 48.0% were women, and the average age was 84.12 ± 3.62 years. In the younger group, 35.3% were women, and the average age was 66.92 ± 9.02 years. CHA2DS2-VASc score was 2.8 ± 1.7 in the younger group and 4.5 ± 1.5 in the very old group (p < 0.001). The proportion of oral anticoagulation was low in patients with AF (31.8%) and even lower in very old patients compared to younger patients (24.5 vs. 35.0%, p = 0.004). Moreover, oral anticoagulation therapy was strongly associated with CHA2DS2-VASc scores only in the younger group, but not in the very old group, which means the very old patients were not treated with oral anticoagulation according to their elevated CHA2DS2-VASc scores. CONCLUSION: Anticoagulants were underused in AF patients, particularly in very old patients. Evidence is accumulating that the very old patients could still benefit from anticoagulants so that physicians should not exclude such patients from anticoagulation only because of their older age.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial , Acidente Vascular Cerebral/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , China , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco
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