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1.
Isr Med Assoc J ; 23(9): 580-583, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34472234

RESUMO

BACKGROUND: Oral anticoagulants (OAC) reduce the risk for stroke and death from all causes in patients with non-valvular atrial fibrillation (NVAF). OBJECTIVES: To explore adherence rates of OAC among patients with NVAF in long-term use in a real-world setting and to examine patient characteristics associated with good adherence. METHODS: We conducted a population-based cohort study with members of Clalit Health Services, Israel. All patients aged ≥ 30 years with a diagnosis of NVAF before 2016 who were treated with OAC were included. We included patients who filled at least one prescription per year in the three consecutive years 2016-2018. We analyzed all prescriptions that were filled for the medications from 1 January 2017 to 31 December 2017. We considered purchasing of at least nine monthly prescriptions during 2017 as good medication adherence. RESULTS: We identified 26,029 patients with NVAF who were treated with OAC; 10,284 (39.5%) were treated with apixaban, 6321 (24.3%) with warfarin, 6290 (24.1%) with rivaroxaban, and 3134 (12.0%) with dabigatran. Rates of good medication adherence were 88.9% for rivaroxaban, 84.9% for apixaban, 83.6% for dabigatran, and 55.8% for warfarin (P < 0.0001). Advanced age was associated with higher adherence rates (P < 0.001). Socioeconomic status was not associated with medication adherence. Good adherence with OAC was associated with lower low density lipoprotein (LDL) cholesterol and glucose levels. CONCLUSIONS: Adherence rates to OAC in chronic use among patients with chronic NAVF are high. Investing in OAC adherence may have a wider health impact than expected.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Adesão à Medicação , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Estudos de Coortes , Feminino , Humanos , Israel , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/etiologia
7.
Bull World Health Organ ; 99(9): 640-652E, 2021 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-34475601

RESUMO

Objective: To identify gaps in national stroke guidelines that could be bridged to enhance the quality of stroke care services in low- and middle-income countries. Methods: We systematically searched medical databases and websites of medical societies and contacted international organizations. Country-specific guidelines on care and control of stroke in any language published from 2010 to 2020 were eligible for inclusion. We reviewed each included guideline for coverage of four key components of stroke services (surveillance, prevention, acute care and rehabilitation). We also assessed compliance with the eight Institute of Medicine standards for clinical practice guidelines, the ease of implementation of guidelines and plans for dissemination to target audiences. Findings: We reviewed 108 eligible guidelines from 47 countries, including four low-income, 24 middle-income and 19 high-income countries. Globally, fewer of the guidelines covered primary stroke prevention compared with other components of care, with none recommending surveillance. Guidelines on stroke in low- and middle-income countries fell short of the required standards for guideline development; breadth of target audience; coverage of the four components of stroke services; and adaptation to socioeconomic context. Fewer low- and middle-income country guidelines demonstrated transparency than those from high-income countries. Less than a quarter of guidelines encompassed detailed implementation plans and socioeconomic considerations. Conclusion: Guidelines on stroke in low- and middle-income countries need to be developed in conjunction with a wider category of health-care providers and stakeholders, with a full spectrum of translatable, context-appropriate interventions.


Assuntos
Guias como Assunto , Acidente Vascular Cerebral/terapia , Austrália , Isquemia Encefálica , Canadá , Humanos , Acidente Vascular Cerebral/prevenção & controle
8.
Brain Nerve ; 73(9): 975-982, 2021 Sep.
Artigo em Japonês | MEDLINE | ID: mdl-34462368

RESUMO

Antithrombotic therapy is essential for secondary stroke prevention. Clinical practice guidelines recommend anticoagulant and antiplatelet drug administration as first-line therapy for cardioembolic stroke and non-cardioembolic infarction, respectively. Direct oral anticoagulants represent first-choice treatment for cardioembolism secondary to non-valvular atrial fibrillation owing to few hemorrhagic complications associated with this therapy. However, warfarin with optimal control of the international normalized ratio for standardization of prothrombin time is preferred in patients with kidney dysfunction, artificial valve implantation, valvular heart disease, and cardiomyopathy. Antiplatelet drugs, including aspirin, clopidogrel, and cilostazol are used in patients with non-cardioembolic infarction. Dual antiplatelet agents, including aspirin and clopidogrel, are recommended during the acute stage because of the high risk of recurrent ischemic stroke. In contrast, a single antiplatelet drug is recommended during the chronic stage to avoid the risk of intracranial hemorrhage.


Assuntos
Fibrilação Atrial , Preparações Farmacêuticas , Acidente Vascular Cerebral , Anticoagulantes/efeitos adversos , Aspirina , Humanos , Inibidores da Agregação Plaquetária/efeitos adversos , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controle , Varfarina
9.
Medicine (Baltimore) ; 100(31): e26846, 2021 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-34397858

RESUMO

ABSTRACT: To estimate National Institutes of Health Stroke Scale (NIHSS) grading of stroke patients with retinal characteristics.A cross-sectional study was conducted in Shenzhen Traditional Chinese Medicine Hospital. Baseline information and retinal photos were collected within 2 weeks of admission. An NIHSS score was measured for each patient by trained doctors. Patients were classified into 0 to 4 score group and 5 to 42 score group for analysis. Three multivariate logistic models, with traditional clinical characteristics alone, with retinal characteristics alone, and with both, were built.For clinical characteristics, hypertension duration is statistically significantly associated with higher NIHSS score (P = .014). Elevated total homocysteine levels had an OR of 0.456 (P = .029). For retinal characteristics, the fractal dimension of the arteriolar network had an OR of 0.245 (P < .001) for the left eyes, and an OR of 0.417 (P = .009) for right eyes. The bifurcation coefficient of the arteriole of the left eyes had an OR of 2.931 (95% CI 1.573-5.46, P = .001), the nipping of the right eyes had an OR of 0.092 (P = .003) showed statistical significance in the model.The area under receiver-operating characteristic curve increased from 0.673, based on the model with clinical characteristics alone, to 0.896 for the model with retinal characteristics alone and increased to 0.931 for the model with both clinical and retinal characteristics combined.Retinal characteristics provided more information than clinical characteristics in estimating NIHSS grading and can provide us with an objective method for stroke severity estimation.


Assuntos
Hipertensão , Vasos Retinianos/diagnóstico por imagem , Prevenção Secundária/métodos , Índice de Gravidade de Doença , Acidente Vascular Cerebral , China/epidemiologia , Estudos Transversais , Feminino , Fatores de Risco de Doenças Cardíacas , Humanos , Hipertensão/diagnóstico , Hipertensão/epidemiologia , Masculino , Microcirculação , Pessoa de Meia-Idade , Modelos Estatísticos , Análise Multivariada , Recidiva , Projetos de Pesquisa , Acidente Vascular Cerebral/classificação , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controle
10.
Nutrients ; 13(8)2021 Jul 26.
Artigo em Inglês | MEDLINE | ID: mdl-34444718

RESUMO

Cardiovascular disease (CVD) and type 2 diabetes (T2D) remain the top disease and mortality burdens worldwide. Oats have been shown to benefit cardiovascular health and improve insulin resistance. However, the evidence linking oat consumption with CVD, T2D and all-cause mortality remains inconclusive. We conducted a comprehensive systematic review and meta-analysis of prospective cohort studies to evaluate the associations between oat consumption and risks of T2D, CVD and all-cause mortality in the general population. Five electronic databases were searched until September, 2020. Study specific relative risks (RR) were meta-analyzed using random effect models. Of 4686 relevant references, we included 9 articles, based on 8 unique studies and 471,157 participants. Comparing oat consumers versus non-consumers, RRs were 0.86 (95% CI 0.72-1.03) for T2D incidence and 0.73 (95% CI 0.5-1.07) for combined CVD incidence. Comparing participants with highest versus lowest oat intake, RRs were 0.78 (95% CI 0.74-0.82) for T2D incidence, 0.81 (95% CI 0.61-1.08) for CHD incidence and 0.79 (95% CI 0.59-1.07) for stroke. For all-cause mortality one study based on three cohorts found RR for men and women were 0.76 (95% CI 0.69-0.85) and 0.78 (95% CI 0.70-0.87), respectively. Most studies (n = 6) were of fair to good quality. This meta-analysis suggests that consumption of oat could reduce the risk for T2D and all-cause mortality, while no significant association was found for CVD. Future studies should address a lack of standardized methods in assessing overall oat intake and type of oat products, and investigate a dose-dependent response of oat products on cardiometabolic outcomes in order to introduce oat as preventive and treatment options for the public.


Assuntos
Avena , Doenças Cardiovasculares/epidemiologia , Diabetes Mellitus Tipo 2/epidemiologia , Mortalidade , Grãos Integrais , Doenças Cardiovasculares/prevenção & controle , Diabetes Mellitus Tipo 2/prevenção & controle , Feminino , Humanos , Incidência , Masculino , Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controle
11.
Zhonghua Nei Ke Za Zhi ; 60(9): 822-826, 2021 Sep 01.
Artigo em Chinês | MEDLINE | ID: mdl-34445819

RESUMO

To evaluate the efficacy and safety of left atrial appendage occlusion (LAAO) in patients with atrial fibrillation (AF) over 75 years. A total of 82 patients with AF who underwent LAAO successfully in Beijing Anzhen Hospital from March 2014 to March 2019 were divided into two groups according to age: the elderly group (aged>75 years) and the young group (aged ≤75 years). Risk of perioperative complications and incidence of ischemic stroke and major bleeding during follow-up were retrospectively analyzed. The results showed that there were no significant differences in procedure-related ischemic stroke(0 vs.1.6%,P=0.768) and major bleeding (0 vs.1.6%,P=0.768) during perioperative period between the two groups. No complications as death or pericardial tamponade occurred in the two group. During a (25.9±15.9) months period of followed up, ischemic stroke event rate was 3.6/100 person-years in the elderly group and 4.9/100 person-years in the young group, respectively. Major bleeding event rate was 2.5/100 person-years in the elderly group and 0/100 person-years in the young group, respectively. Compared with the expected ones, the relative risk reduction (RRR) of stroke in the elderly group was more profound than that in the young group (32.0% vs. 25.0%), while the risk of major bleeding in the young group was significantly lower than that in the elderly group (RRR 100% vs. 56.9%). Therefore, LAAO might be suitable for stroke prevention in the elderly AF patients.


Assuntos
Apêndice Atrial , Fibrilação Atrial , Acidente Vascular Cerebral , Idoso , Apêndice Atrial/cirurgia , Fibrilação Atrial/complicações , Hemorragia , Humanos , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento
12.
Curr Cardiol Rep ; 23(10): 145, 2021 08 19.
Artigo em Inglês | MEDLINE | ID: mdl-34410542

RESUMO

PURPOSE OF REVIEW: Antiplatelet therapy remains the standard of care in secondary stroke prevention for non-cardioembolic ischemic stroke and transient ischemic attack. We aim to examine the use of antiplatelet agents in secondary prevention through highlighting relevant clinical trials and meta-analyses as well as providing commentary regarding our practice. RECENT FINDINGS: In the POINT and CHANCE trials, dual antiplatelet therapy reduced recurrent stroke compared to aspirin monotherapy. Sub-analyses of these trials suggest that genetic polymorphisms could play a role in diminishing the effectiveness of clopidogrel. Similarly, THALES demonstrated better outcomes with ticagrelor-aspirin combination therapy over aspirin monotherapy. Combination antiplatelet therapy with aspirin and the P2Y12 inhibitors, clopidogrel and ticagrelor, reduced stroke recurrence in those presenting with mild ischemic stroke or high risk TIA. Genetic polymorphisms may play a role in determining the appropriate regimen. Questions remain regarding the optimal duration of combination antiplatelet therapy for various stroke etiologies.


Assuntos
Isquemia Encefálica , Ataque Isquêmico Transitório , AVC Isquêmico , Acidente Vascular Cerebral , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/prevenção & controle , Quimioterapia Combinada , Humanos , Ataque Isquêmico Transitório/tratamento farmacológico , Inibidores da Agregação Plaquetária/uso terapêutico , Prevenção Secundária , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controle
13.
Prog Cardiovasc Dis ; 66: 92-100, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34332665

RESUMO

Stroke is a major driver of increased morbidity and mortality in patients with non-valvular atrial fibrillation (NVAF). While systemic oral anticoagulation (OAC) continues to be the mainstay for stroke reduction therapy in patients with NVAF, several barriers prevent the sustained long-term use of OAC, including increased risk of bleeding, non-compliance, cost, drug-drug interactions, and the need for ongoing laboratory testing. Given the need for continued stroke reduction therapies in patients who are intolerant of or non-compliant with OAC, percutaneous left atrial appendage (LAA) occlusion (LAAO) has emerged as a nonpharmacologic alternative to OAC. The development of percutaneous LAAO techniques is based on data suggesting that more than 90% of thrombi in patients with NVAF originate in the LAA. Two percutaneous LAAO devices are currently in widespread clinical use: Watchman (United States and Europe) and the Amplatzer type of devices (Europe); randomized trial data exist only for the Watchman device. Multiple randomized and nonrandomized trials and registries have demonstrated the safety and effectiveness of LAAO in patients who are suitable for short-term anticoagulation using a variety of post-procedural antithrombotic strategies. Ongoing randomized clinical trials on LAAO are focused on OAC-ineligible patients to compare efficacy of LAAO devices against a multitude of antithrombotic options. This review aims to discuss the rationale and evidence for LAAO and post procedural antithrombotic strategies and opportunities for research examination. In addition, we discuss the need for continued investigation of LAAO in populations not well represented in clinical trials or registries, including women, older patients, and underrepresented racial and ethnic groups.


Assuntos
Apêndice Atrial/fisiopatologia , Fibrilação Atrial/terapia , Cateterismo Cardíaco/instrumentação , Fibrinolíticos/uso terapêutico , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral/prevenção & controle , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Fibrilação Atrial/fisiopatologia , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/mortalidade , Tomada de Decisão Clínica , Fibrinolíticos/efeitos adversos , Humanos , Seleção de Pacientes , Desenho de Prótese , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Resultado do Tratamento
14.
Kardiologiia ; 61(6): 79-87, 2021 Jul 01.
Artigo em Russo | MEDLINE | ID: mdl-34311691

RESUMO

Senile patients with atrial fibrillation (AF) are at a higher risk of thromboembolism and hemorrhage than younger patients. Three direct oral anticoagulants (DOAC), apixaban, dabigatran, and rivaroxaban, are registered in the Russian Federation and are extensively used for prevention of stroke in patients with AF. The DOAC treatment of older patients requires considering peculiarities of these patients, clinical situation and properties of individual drugs to achieve the balance of efficiency and safety and a comprehensive protection. According to studies of real clinical practice DOAC may have advantages over warfarin (reduced risk of fractures, diabetes mellitus, and dementia). Compliance with and constancy of the DOAC treatment are important for its efficiency, particularly in senile age. Results of clinical trials and real clinical practice studies have confirmed that rivaroxaban may provide a comprehensive protection for a senile patient with AF due to favorable indexes of efficiency and safety, beneficial effect on the risk of coronary events and impairment оf renal function, whereas once a day dosing of rivaroxaban improves the compliance with this treatment and its constancy.


Assuntos
Fibrilação Atrial , Acidente Vascular Cerebral , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Dabigatrana/uso terapêutico , Humanos , Piridonas/efeitos adversos , Gestão de Riscos , Rivaroxabana/efeitos adversos , Federação Russa , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
17.
Mayo Clin Proc ; 96(7): 1845-1860, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34218859

RESUMO

OBJECTIVE: To evaluate the effects of female sex on in-hospital outcomes and to provide estimates for sex-specific prediction models of adverse outcomes following left atrial appendage closure (LAAC). PATIENTS AND METHODS: Cohort-based observational study querying the National Inpatient Sample database between October 1, 2015, and December 31, 2017. Demographics, baseline characteristics, and comorbidities were assessed with the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index score (ECS), and CHA2DS2-VASc score. The primary outcome was in-hospital major adverse events (MAEs) defined as the composite of bleeding, vascular, cardiac complications, post-procedural stroke, and acute kidney injury. The associations of the CCI, ECS, and CHA2DS2-VASc score with in-hospital MAE were examined using logistic regression models for women and men, respectively. RESULTS: A total of 3294 hospitalizations were identified, of which 1313 (40%) involved women and 1981 (60%) involved men. Women were older (76.3±7.7 vs 75.2±8.4 years, P<.001), had a higher CHA2DS2-VASc score (4.9±1.4 vs 3.9±1.4, P<.001) but showed lower CCI and ECS compared with men (2.1±1.9 vs 2.3±1.9, P=.01; and 9.3±5.9 vs 9.9±5.7, P=.002, respectively). The primary composite outcome occurred in 4.6% of patients and was higher in women compared with men (women 5.6% vs men 4.0%, P=.04), and this was mainly driven by the occurrence of cardiac complications (2.4% vs 1.2%, P=.01). In women, older age, higher median income, and higher CCI (adjusted odds ratio [aOR], 1.32; 95% confidence interval [CI], 1.21 to 1.44; P<.001), ECS (aOR, 1.04; 95% CI, 1.02 to 1.07; P=.002), and CHA2DS2-VASc score (aOR, 1.24; 95% CI, 1.10 to 1.39; P<.001) were associated with increased risk of in-hospital MAE. In men, non-White race/ethnicity, lower median income, and higher ECS (aOR, 1.06; 95% CI, 1.04 to 1.09; P<.001) were associated with increased risk of in-hospital MAE. CONCLUSION: Women had higher rates of in-hospital adverse events following LAAC than men did. Women with older age and higher median income, CCI, ECS, and CHA2DS2-VASc scores were associated with in-hospital adverse events, whereas men with non-White race/ethnicity, lower median income, and higher ECS were more likely to experience adverse events. Further research is warranted to identify sex-specific, racial/ethnic, and socioeconomic pathways during the patient selection process to minimize complications in patients undergoing LAAC.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial , Procedimentos Cirúrgicos Cardíacos , Hospitalização/estatística & dados numéricos , Complicações Pós-Operatórias , Implantação de Prótese/instrumentação , Acidente Vascular Cerebral , Idoso , Fibrilação Atrial/complicações , Fibrilação Atrial/cirurgia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Regras de Decisão Clínica , Feminino , Humanos , Masculino , Avaliação de Resultados em Cuidados de Saúde , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Prognóstico , Risco Ajustado/métodos , Medição de Risco/métodos , Dispositivo para Oclusão Septal , Fatores Sexuais , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
18.
Nutrients ; 13(6)2021 Jun 08.
Artigo em Inglês | MEDLINE | ID: mdl-34201106

RESUMO

Ischemic stroke (IS) is still among the leading causes of death and disability worldwide. The pathogenic mechanisms beyond its development are several and are complex and this is the main reason why a functional therapy is still missed. The beneficial effects of natural compounds against cardiovascular diseases and IS have been investigated for a long time. In this article, we reviewed the association between the most studied polyphenols and stroke protection in terms of prevention, effect on acute phase, and rehabilitation. We described experimental and epidemiological studies reporting the role of flavonols, phenolic acid, and stilbens on ischemic mechanisms leading to stroke. We analyzed the principal animal models used to evaluate the impact of these micronutrients to cerebral blood flow and to molecular pathways involved in oxidative stress and inflammation modulation, such as sirtuins. We reported the most significant clinical trials demonstrated as the persistent use of polyphenols is clinically relevant in terms of the reduction of vascular risk factors for IS, such as Atrial Fibrillation. Interestingly, different kinds of polyphenols provide brain protection by activating different pathways and mechanisms, like inducing antithrombotic effect, such as Honokiol. For this reason, we discussed an appropriate integrative use of them as a possible therapeutic alternative against stroke.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/prevenção & controle , Polifenóis/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controle , Animais , Isquemia Encefálica/complicações , Isquemia Encefálica/fisiopatologia , Modelos Animais de Doenças , Humanos , Estresse Oxidativo/efeitos dos fármacos , Polifenóis/farmacologia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/fisiopatologia , Reabilitação do Acidente Vascular Cerebral
19.
BMJ Open ; 11(7): e045929, 2021 07 20.
Artigo em Inglês | MEDLINE | ID: mdl-34285006

RESUMO

INTRODUCTION: Cardiovascular diseases (CVDs) are the leading causes of death and disability worldwide. Reducing dietary salt consumption is a potentially cost-effective way to reduce blood pressure and the burden of CVD. To date, economic evidence has focused on sodium reduction in food industry or processed food with blood pressure as the primary outcome. This study protocol describes the planned within-trial economic evaluation of a low-sodium salt substitute intervention designed to reduce the risk of stroke in China. METHODS AND ANALYSES: The economic evaluation will be conducted alongside the Salt Substitute and Stroke Study: a 5-year large scale, cluster randomised controlled trial. The outcomes of interest are quality of life measured using the EuroQol-5-Dimensions and major adverse cardiovascular events. Costs will be estimated from a healthcare system perspective and will be sought from the routinely collected data available within the New Rural Cooperative Medical Scheme. Cost-effectiveness and cost-utility analyses will be conducted, resulting in the incremental cost-effectiveness ratio expressed as cost per cardiovascular event averted and cost per quality-adjusted life year gained, respectively. ETHICS AND DISSEMINATION: The trial received ethics approval from the University of Sydney Ethics Committee (2013/888) and Peking University Institutional Review Board (IRB00001052-13069). Informed consent was obtained from each study participant. Findings of the economic evaluation will be published in a peer-reviewed journal and presented at international conferences. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT02092090).


Assuntos
Qualidade de Vida , Acidente Vascular Cerebral , China , Análise Custo-Benefício , Humanos , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Acidente Vascular Cerebral/prevenção & controle
20.
Herz ; 46(4): 323-328, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34223913

RESUMO

Anticoagulation in patients with atrial fibrillation (AF) should be guided by considerations of the risk of thromboembolism, stroke, and bleeding as well as the patient's preference. Well-recognized scores have been developed to help the clinician in daily risk assessment, but there are several special patient populations for whom scores are not developed or validated. Furthermore, these patients were not adequately represented in the pivotal randomized trials for non-vitamin K antagonist oral anticoagulants (NOACs). In patients with cancer, the intrinsic hypercoagulable state has to be balanced against an increased risk of bleeding, and a dynamic concept should be applied, taking into account the cancer type, current disease state, therapeutic strategy, and patient-related factors, with NOACs playing an increasingly larger role. In women with planned pregnancy or already pregnant, NOACs should be avoided. However, accidental exposure during pregnancy should not lead to recommendations for pregnancy termination in view of current observational data. Whether patients on dialysis with AF benefit from anticoagulation at all is questionable. But if the decision for anticoagulation is made, NOACs may contribute to a more favorable risk-benefit profile than vitamin- K antagonists. Finally, patients on the ward deserve special considerations regarding periprocedural management of anticoagulation. Although for the majority of procedures a short discontinuation of oral anticoagulation seems appropriate, there are some low-bleeding-risk procedures that do not require cessation. The aim of the present review is to discuss the major particularities of these four patient subgroups and thus to facilitate the clinical decision-making.


Assuntos
Fibrilação Atrial , Acidente Vascular Cerebral , Tromboembolia , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Feminino , Humanos , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Tromboembolia/etiologia , Tromboembolia/prevenção & controle
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