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1.
CMAJ Open ; 10(3): E702-E713, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35918151

RESUMO

BACKGROUND: Assessment of potential geographic variation in quality indicators of atrial fibrillation care may identify opportunities for improvement in the quality of atrial fibrillation care. The objective of this study was to assess for potential geographic variation in the quality of atrial fibrillation care in Alberta, Canada. METHODS: In a population-based cohort of adults (age ≥ 18 yr) with incident nonvalvular atrial fibrillation (NVAF) diagnosed between Apr. 1, 2008, and Mar. 31, 2016, in Alberta, we investigated the variation in national quality indicators of atrial fibrillation care developed by the Canadian Cardiovascular Society. Specifically, we assessed the geographic and temporal variation in the proportion of patients with initiation of oral anticoagulant therapy, persistence with therapy, ischemic stroke and major bleeding outcomes 1 year after atrial fibrillation diagnosis using linked administrative data sets. We defined stroke risk using the CHADS2 score. We assessed geographic variation using small-area variation statistics and geospatial data analysis. RESULTS: Of the 64 093 patients in the study cohort (35 019 men [54.6%] and 29 074 women [45.4%] with a mean age of 69 [standard deviation 15.9] yr), 36 199 were at high risk for stroke and 14 411 were at moderate risk. Within 1 year of NVAF diagnosis, 20 180 patients (55.7%) in the high-risk group and 6448 patients (44.7%) in the moderate-risk group were prescribed anticoagulation. A total of 2187 patients (3.4%) had an ischemic stroke, and 2996 patients (4.7%) experienced a major bleed. There was substantial regional variation observed in initiation of oral anticoagulant therapy but not in the proportion of patients with ischemic stroke or major bleeding. Among the 64 Health Status Areas in Alberta, therapy initiation rates ranged from 22.6% to 71.2% among patients at high stroke risk and from 22.7% to 55.8% among those at moderate stroke risk, with clustering of lower therapy initiation rates in rural northern regions. INTERPRETATION: The rate of initiation of oral anticoagulant therapy among adults with incident atrial fibrillation was less than 60% in patients in whom oral anticoagulant therapy would be considered guideline-appropriate care. The large geographic variation in oral anticoagulant prescribing warrants additional study into patient, provider and health care system factors that contribute to variation and drive disparities in high-quality, equitable atrial fibrillation care.


Assuntos
Fibrilação Atrial , AVC Isquêmico , Acidente Vascular Cerebral , Adulto , Idoso , Alberta/epidemiologia , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/epidemiologia , Feminino , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Masculino , Indicadores de Qualidade em Assistência à Saúde , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento
2.
Vasc Health Risk Manag ; 18: 575-587, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35912018

RESUMO

Purpose: We aimed to determine the incidence of venous thromboembolism among hospitalized patients in Qatar as well as to analyze the adequacy of VTE assessment and prophylaxis in hospitalized patients. Design: Retrospective observational study. Setting: Four hospitals under Hamad Medical Corporation, Qatar. Participants: Patients over the age of 18 who were hospitalized between January 2015 and December 2019 and developed venous thromboembolism during hospitalization or within a month after discharge were included. Results: During the study period, 641,994 individuals were admitted to hospitals. The inclusion criteria were satisfied by 209 of them. The mean age was 51.25 years and 54.5% were males. Hypertension and diabetes mellitus were the most common comorbidities found in the overall group. The incidence of VTE was 32.55 [95% CI 28.4, 37.3] per 100,000 admission per year [0.032%]. The annual incidence was least in 2015 (17.8 per 100,000 admissions) and highest in 2018 (44.4 per 100,000 admissions). Eighty-six subjects had DVT, and 109 had PE, whereas 14 had both. And, 67.5% of the patients developed VTE during admission while, 32.5% developed within 1 month of discharge. Moreover, 22.9% of the patients with PE developed pulmonary embolism after discharge from the hospital. VTE assessment was performed on 64.7% of the patients, and 69.7% received VTE prophylaxis in accordance with guidelines. Conclusion: Although the occurrence of VTE among hospitalized patients in Qatar is low, healthcare providers need additional education and knowledge of VTE assessment and prophylaxis to follow guidelines for all patients at the time of admission. Furthermore, risk assessment for VTE should be done for all patients at the time of discharge to decide on post-discharge prophylaxis so that incidence of VTE after discharge can be minimized. Future studies should focus on patients who developed VTE after discharge from the hospital as well as on various risk factors.


Assuntos
Embolia Pulmonar , Tromboembolia Venosa , Adulto , Assistência ao Convalescente , Anticoagulantes/efeitos adversos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/prevenção & controle , Estudos Retrospectivos , Fatores de Risco , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/prevenção & controle
3.
BMC Cardiovasc Disord ; 22(1): 351, 2022 Aug 03.
Artigo em Inglês | MEDLINE | ID: mdl-35922765

RESUMO

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is an antibody-mediated adverse drug reaction characterized by thrombocytopenia and thromboembolism. Herein, we present a case of HIT with subcutaneous hemorrhage after cardiovascular interventional therapy. CASE PRESENTATION: A 74-year-old man was admitted to the hospital for elective atrial fibrillation (AF) catheter ablation and left atrial appendage closure because of intermittent dizziness and palpitations. At presentation, the routine laboratory test results showed no abnormalities. He received subcutaneous enoxaparin for stroke prevention and unfractionated heparin for intraprocedural anticoagulation during coronary angiography and the AF procedure. On the second day after the AF procedure, the patient developed profound thrombocytopenia, moderate anemia, and mild subcutaneous hematoma. Blood tests and imaging examinations excluded acute hemolysis and other active bleeding. A 4Ts score of 5 and markedly positive platelet factor 4 IgG antibody established the diagnosis of HIT. Due to progressive subcutaneous hemorrhage in the thighs that could not be suppressed by pressure dressing, the patient received platelet transfusion and rivaroxaban for anticoagulation. The following days, the patient remained clinically stable from the hemorrhage, and his platelet count recovered. No thrombotic events occurred during hospitalization or follow-up. CONCLUSION: This case emphasizes the significance of suspecting HIT in patients with unexplained rapid thrombocytopenia after frequent heparin exposure. Decision-making regarding alternative anticoagulation and platelet transfusion in HIT with hemorrhage must be based on unique patient characteristics.


Assuntos
Heparina , Trombocitopenia , Idoso , Anticoagulantes/efeitos adversos , Enoxaparina/efeitos adversos , Heparina/efeitos adversos , Humanos , Masculino , Contagem de Plaquetas , Trombocitopenia/induzido quimicamente , Trombocitopenia/diagnóstico , Trombocitopenia/terapia
4.
Anaesthesiologie ; 71(7): 565-576, 2022 Jul.
Artigo em Alemão | MEDLINE | ID: mdl-35925055

RESUMO

Within the approved indications direct oral anticoagulants (DOAC) are increasingly gaining acceptance instead of vitamin K antagonists (VKA). In the last 12 months 5 guidelines relevant to the perioperative management of DOACs have been updated. This article summarizes the current recommendations for the perioperative management of treatment with DOACs. The available substances and their pharmacological properties as well as the possibilities for specific laboratory diagnostics of the effect of DOAC are explained. Special focus is placed on anesthesiologically important aspects of substance-specific preoperative and postoperative intermission intervals, the procedure for neuraxial regional anesthesia and antagonization with specific antidotes in cases of life-threatening bleeding.


Assuntos
Anticoagulantes , Vitamina K , Administração Oral , Anticoagulantes/efeitos adversos , Antídotos/uso terapêutico , Hemorragia/induzido quimicamente , Humanos
5.
Inn Med (Heidelb) ; 63(7): 736-750, 2022 Jul.
Artigo em Alemão | MEDLINE | ID: mdl-35925265

RESUMO

Monitoring of vitamin K antagonist treatment with the international normalized ratio (INR) is obligatory, whereas this only applies to direct oral anticoagulants (DOAC) or low molecular weight heparin in the context of selected clinical scenarios. For DOAC the focus is on the determination of trough and peak plasma levels of the drug but for low molecular weight heparins the focus is on anti-Xa activity. The timing of blood sampling in relation to drug intake is essential for the interpretation of the results. A new-onset thrombocytopenia during hospitalization is common. The cause can frequently be identified based on the classification of the underlying disease, the day of onset and documentation of the dynamics of thrombocytopenia as well as the medication history. The importance of thrombophilia testing following a venous thromboembolism has decreased in the absence of clear therapeutic consequences; however, antiphospholipid antibody syndrome must not be overlooked as both the duration of treatment and the choice of anticoagulant depend on this.


Assuntos
Trombocitopenia , Trombofilia , Anticoagulantes/efeitos adversos , Heparina de Baixo Peso Molecular , Humanos , Trombocitopenia/diagnóstico , Trombofilia/diagnóstico , Vitamina K
6.
BMC Cardiovasc Disord ; 22(1): 349, 2022 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-35918658

RESUMO

BACKGROUND: Percutaneous left atrial appendage occlusion (LAAO) represents an alternative stroke prevention method in patients with atrial fibrillation and an increased bleeding risk, chronic kidney disease or contraindications to oral anticoagulants. Aim of our study was to evaluate the feasibility and safety of percutaneous LAAO in high-risk, frail patients having undergone transcatheter aortic valve implantation (TAVI). METHODS: Thirty-one patients having undergone TAVI and scheduled for LAAO were prospectively included in our study. RESULTS: Implantation was successful in 29 of 31 cases (93.5%).There were no patients that developed a major acute cardiovascular event, stroke, or device dislocation/embolization. There was a single case of major bleeding (3.2%) and 3 cases of acute kidney injury (9.7%). At 3 months, no patients experienced a stroke, one patient had a device-related thrombus (3.4%), one patient showed a significant peri-device leak, and one patient had a persistent iatrogenic atrial septal defect. CONCLUSIONS: Our study shows that percutaneous LAAO may represent a feasible alternative strategy for stroke prevention, that can be safely performed in high-risk, multimorbid patients with high bleeding risk or contraindications to oral anticoagulation.


Assuntos
Apêndice Atrial , Fibrilação Atrial , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Apêndice Atrial/diagnóstico por imagem , Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Fibrilação Atrial/terapia , Idoso Fragilizado , Humanos , Octogenários , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Substituição da Valva Aórtica Transcateter/efeitos adversos , Resultado do Tratamento
8.
BMJ ; 378: e070022, 2022 07 04.
Artigo em Inglês | MEDLINE | ID: mdl-35788047

RESUMO

OBJECTIVE: To assess the benefits and harms of different types and doses of anticoagulant drugs for the prevention of venous thromboembolism in patients who are acutely ill and admitted to hospital. DESIGN: Systematic review and network meta-analysis. DATA SOURCES: Cochrane CENTRAL, PubMed/Medline, Embase, Web of Science, clinical trial registries, and national health authority databases. The search was last updated on 16 November 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Published and unpublished randomised controlled trials that evaluated low or intermediate dose low-molecular-weight heparin, low or intermediate dose unfractionated heparin, direct oral anticoagulants, pentasaccharides, placebo, or no intervention for the prevention of venous thromboembolism in acutely ill adult patients in hospital. MAIN OUTCOME MEASURES: Random effects, bayesian network meta-analyses used four co-primary outcomes: all cause mortality, symptomatic venous thromboembolism, major bleeding, and serious adverse events at or closest timing to 90 days. Risk of bias was also assessed using the Cochrane risk-of-bias 2.0 tool. The quality of evidence was graded using the Confidence in Network Meta-Analysis framework. RESULTS: 44 randomised controlled trials that randomly assigned 90 095 participants were included in the main analysis. Evidence of low to moderate quality suggested none of the interventions reduced all cause mortality compared with placebo. Pentasaccharides (odds ratio 0.32, 95% credible interval 0.08 to 1.07), intermediate dose low-molecular-weight heparin (0.66, 0.46 to 0.93), direct oral anticoagulants (0.68, 0.33 to 1.34), and intermediate dose unfractionated heparin (0.71, 0.43 to 1.19) were most likely to reduce symptomatic venous thromboembolism (very low to low quality evidence). Intermediate dose unfractionated heparin (2.63, 1.00 to 6.21) and direct oral anticoagulants (2.31, 0.82 to 6.47) were most likely to increase major bleeding (low to moderate quality evidence). No conclusive differences were noted between interventions regarding serious adverse events (very low to low quality evidence). When compared with no intervention instead of placebo, all active interventions did more favourably with regard to risk of venous thromboembolism and mortality, and less favourably with regard to risk of major bleeding. The results were robust in prespecified sensitivity and subgroup analyses. CONCLUSIONS: Low-molecular-weight heparin in an intermediate dose appears to confer the best balance of benefits and harms for prevention of venous thromboembolism. Unfractionated heparin, in particular the intermediate dose, and direct oral anticoagulants had the least favourable profile. A systematic discrepancy was noted in intervention effects that depended on whether placebo or no intervention was the reference treatment. Main limitations of this study include the quality of the evidence, which was generally low to moderate due to imprecision and within-study bias, and statistical inconsistency, which was addressed post hoc. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020173088.


Assuntos
Trombose , Tromboembolia Venosa , Anticoagulantes/efeitos adversos , Teorema de Bayes , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Heparina/efeitos adversos , Heparina de Baixo Peso Molecular/efeitos adversos , Hospitais , Humanos , Metanálise em Rede , Ensaios Clínicos Controlados Aleatórios como Assunto , Trombose/tratamento farmacológico , Tromboembolia Venosa/tratamento farmacológico
9.
Clin Appl Thromb Hemost ; 28: 10760296221110568, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35792949

RESUMO

Purpose: To assess costs and healthcare resource utilization (HCRU) associated with the use of idarucizumab for the reversal of dabigatran and andexanet alfa for the reversal of direct oral Factor Xa inhibitors. Methods: This retrospective study utilizing Premier Healthcare Database (PHD) included patients aged ≥18 years on direct oral anticoagulants (DOACs) who experienced life-threatening bleeds, discharged from the hospital during 5/1/2018-6/30/2019, and received idarucizumab or andexanet alfa. Inverse of treatment probability weighting (IPTW) method was used to balance patient and clinical characteristics between treatment cohorts. Results: Idarucizumab patients were older than andexanet alfa patients (median age 81 vs 77 years; p < 0.001), and less likely to experience intracranial hemorrhage (ICH) (37.1%vs 73.8%; p = 0.001). After IPTW adjustment, idarucizumab patients incurred lower mean total hospital costs ($30,413 ± $33,028 vs $44,477 ± $30,036; p < 0.001),and mean intensive care unit (ICU) cost ($25,114 ± $30,433 vs $43,484 ± $29,335; p < 0.001). Conclusions: Anticoagulant reversal therapy with idarucizumab was associated with significantly lower adjusted mean total hospital and ICU costs compared with andexanet alfa. However, a higher prevalence of ICH bleeds was noted in the andexanet alfa group. Trial Registration: Not applicable.


Assuntos
Reversão da Anticoagulação , Hemorragia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticorpos Monoclonais Humanizados , Anticoagulantes/efeitos adversos , Fator Xa , Inibidores do Fator Xa , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/tratamento farmacológico , Aceitação pelo Paciente de Cuidados de Saúde , Proteínas Recombinantes , Estudos Retrospectivos
10.
Biomed Res Int ; 2022: 4611383, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35845939

RESUMO

Objective: To observe the safety and efficacy of warfarin and rivaroxaban in anticoagulation therapy in patients with atrial fibrillation (AF). Methods: A total of 96 patients with AF treated in our hospital from June 2019 to February 2021 were enrolled in this study. According to the different modes of drug administration, the patients were divided into the warfarin group and rivaroxaban group. Demographic and clinical data such as age, body weight, and previous drug use were collected. The blood routine, liver and kidney function, blood coagulation routine, and cardiac color ultrasound were accessed. The valvular atrial fibrillation and anticoagulant taboos were excluded, and the risk of embolism and bleeding was evaluated. Among them, 48 patients in the warfarin group were given warfarin once a day, and the international ratio (INR) was used to adjust the dose, and the INR was controlled between 2.0 and 3.0. In contrast, 48 patients in the rivaroxaban group received a fixed dose of rivaroxaban 20 mg or 15 mg once a day. After administration, regular telephone or outpatient follow-up was given once a month, to monitor patients' drug compliance and ask if there was bleeding, and to detect blood routine, urine routine, fecal routine+occult blood, and liver and kidney function. In addition, at the beginning of 3, 6, and 12 months of follow-up, each patient was given cardiac color Doppler ultrasound, peripheral vascular color ultrasound, and brain CT to determine whether there were mural thrombosis, stroke, and peripheral arterial thromboembolism. The INR attainment rate, coagulation index, thromboembolism, bleeding, and adverse reactions were compared between the two groups. Results: There was no significant difference in serum Dmurd and NT-proBNP levels between the two groups before treatment and 3, 6, and 9 months after treatment. There was no significant difference in the number of venous embolism, pulmonary embolism, cerebral embolism, and total embolism between the two groups (P > 0.05). There was no significant difference in the number of mild, moderate, and severe bleeding between the two groups (P > 0.05), but the total number of bleeding in the rivaroxaban group was lower than that in the warfarin group (P < 0.05). During the treatment, side effects such as nausea and vomiting, elevated transaminase, glutamyl transpeptidase, and diarrhea occurred between the two groups, and there was no significant difference in the number of adverse reactions between the two groups (P > 0.05). Conclusion: Compared with warfarin, rivaroxaban anticoagulant therapy has the same advantage in tolerance and prevention of thromboembolism in patients with AF, but rivaroxaban can effectively reduce the risk of bleeding in patients with AF.


Assuntos
Fibrilação Atrial , Embolia , Acidente Vascular Cerebral , Tromboembolia , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Estudos de Coortes , Embolia/tratamento farmacológico , Inibidores do Fator Xa/uso terapêutico , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Humanos , Rivaroxabana/efeitos adversos , Acidente Vascular Cerebral/tratamento farmacológico , Tromboembolia/tratamento farmacológico , Tromboembolia/prevenção & controle , Resultado do Tratamento , Varfarina/efeitos adversos
11.
Brain Nerve ; 74(7): 905-909, 2022 Jul.
Artigo em Japonês | MEDLINE | ID: mdl-35860939

RESUMO

Thrombosis with thrombocytopenia syndrome (TTS) induced by the coronavirus disease 2019 vaccine is characterized by thrombocytopenia and thrombosis. Positivity for the anti-platelet factor 4-antibody is related to TTS pathophysiology, similar to heparin-induced thrombocytopenia. Although TTS is very rare, with an incidence of almost 1/100,000 cases, physicians need to keep in mind this adverse reaction that can lead to serious symptoms and death. Prompt treatment should be initiated in cases of suspected TTS.


Assuntos
Vacinas contra COVID-19 , COVID-19 , Trombocitopenia , Trombose , Anticoagulantes/efeitos adversos , COVID-19/prevenção & controle , Vacinas contra COVID-19/efeitos adversos , Heparina/efeitos adversos , Humanos , Trombocitopenia/induzido quimicamente , Trombocitopenia/diagnóstico , Trombose/induzido quimicamente
15.
J Am Heart Assoc ; 11(14): e025723, 2022 Jul 19.
Artigo em Inglês | MEDLINE | ID: mdl-35861836

RESUMO

Background Diltiazem, a moderate cytochrome P450 3A4 isozyme/P-glycoprotein inhibitor, may potentiate the bleeding risk of direct oral anticoagulants (DOACs) through pharmacokinetic interactions. We evaluated the association between concomitant use of diltiazem with DOACs and bleeding among patients with atrial fibrillation, across varying degrees of kidney function. Methods and Results We identified 4544 patients with atrial fibrillation who were initiated on rivaroxaban (n=1583), apixaban (n=2373), or dabigatran (n=588), between 2010 and 2019 in Geisinger Health, with a mean age of 72 years and an estimated glomerular filtration rate of 70 mL/min per 1.73 m2. At the time of DOAC initiation, 15% patients were taking diltiazem and an additional 5% were initiated on diltiazem during follow-up. Among DOAC users, using diltiazem concurrently (versus DOAC alone) was associated with an increased risk of any bleeding-related hospitalization (unadjusted risk difference, 2.4; 95% CI, 0.6-4.2 events per 100 person-years; adjusted hazard ratio, 1.56, 95% CI, 1.15-2.12), as well as major bleeding (unadjusted risk difference, 1.4 [95% CI, 0.1-2.6 events per 100 person-years]; adjusted hazard ratio, 1.84 [95% CI, 1.18-2.85]). Increased risk of any/major bleeding with diltiazem was observed in both patients with and without CKD (estimated glomerular filtration rate <60 mL/min per 1.73 m2) (P for interaction=0.524 and 0.629, respectively). Among 13 179 warfarin users (the negative control), concomitant diltiazem use was not associated with bleeding. Conclusions Concomitant use of diltiazem with DOACs was associated with a higher bleeding risk in patients with atrial fibrillation, consistently in both subgroups of chronic kidney disease and non-chronic kidney disease. For DOAC users, concomitant diltiazem should be prescribed only when the benefit outweighs the risk, with close monitoring for signs of bleeding.


Assuntos
Fibrilação Atrial , Insuficiência Renal Crônica , Acidente Vascular Cerebral , Administração Oral , Idoso , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Dabigatrana/uso terapêutico , Diltiazem/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Insuficiência Renal Crônica/complicações , Estudos Retrospectivos , Rivaroxabana/uso terapêutico , Acidente Vascular Cerebral/diagnóstico
16.
Ned Tijdschr Geneeskd ; 1662022 Jul 06.
Artigo em Holandês | MEDLINE | ID: mdl-35899745

RESUMO

Hospitalization and surgery are associated with an increased risk of deep vein thrombosis and pulmonary embolism. Low molecular weight heparins (LMWH) are effective in venous thromboembolism (VTE) prevention and have been the treatment of choice during many years. In recent years direct oral anticoagulants (DOAC's) have also been approved for VTE prevention in patients undergoing elective orthopedic surgery. Randomized controlled clinical trials (RCT's) on the use of DOAC's for VTE prevention in non-orthopedic surgery are scarce, whereas RCT's on DOACs in acute ill medical patients do not favor its use. Although DOAC's have a similar efficacy compared with LMWH, their use is associated with an increased risk of major bleeding. As a result, in primary VTE prevention the role of DOAC's will probably remain limited to patients with a very low bleeding risk and a high thrombotic risk in whom an oral drug is preferred.


Assuntos
Embolia Pulmonar , Tromboembolia Venosa , Anticoagulantes/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Heparina de Baixo Peso Molecular/efeitos adversos , Humanos , Embolia Pulmonar/complicações , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/prevenção & controle
17.
Artigo em Inglês | MEDLINE | ID: mdl-35894799

RESUMO

Thoracic computed tomography angiography revealed a filling defect with an internal air density in the lower lobar branch of the left pulmonary artery accompanied by pleural fluid, in a patient who applied with sudden onset chest pain and dyspnoea. The filling defect remained stable after anticoagulant treatment. No progression or complications were observed in 5-year follow-up. In pulmonary embolism that does not resolve despite adequate treatment, non-thrombotic sources, particularly foreign body, should be considered.


Assuntos
Embolia Pulmonar , Angiografia/métodos , Anticoagulantes/efeitos adversos , Seguimentos , Humanos , Artéria Pulmonar/diagnóstico por imagem , Embolia Pulmonar/complicações , Embolia Pulmonar/etiologia
18.
Cochrane Database Syst Rev ; 7: CD003186, 2022 07 28.
Artigo em Inglês | MEDLINE | ID: mdl-35900898

RESUMO

BACKGROUND: The main complications of elevated systemic blood pressure (BP), coronary heart disease, ischaemic stroke, and peripheral vascular disease, are related to thrombosis rather than haemorrhage. Therefore, it is important to investigate if antithrombotic therapy may be useful in preventing thrombosis-related complications in patients with elevated BP. OBJECTIVES: To conduct a systematic review of the role of antiplatelet therapy and anticoagulation in patients with elevated BP, including elevations in systolic or diastolic BP alone or together. To assess the effects of antiplatelet agents on total deaths or major thrombotic events or both in these patients versus placebo or other active treatment. To assess the effects of oral anticoagulants on total deaths or major thromboembolic events or both in these patients versus placebo or other active treatment. SEARCH METHODS: The Cochrane Hypertension Information Specialist searched the following databases for randomised controlled trials (RCTs) up to January 2021: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 12), Ovid MEDLINE (from 1946), and Ovid Embase (from 1974). The World Health Organization International Clinical Trials Registry Platform and the US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) were searched for ongoing trials.  SELECTION CRITERIA: RCTs in patients with elevated BP were included if they were ≥ 3 months in duration and compared antithrombotic therapy with control or other active treatment. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data for inclusion criteria, our prespecified outcomes, and sources of bias. They assessed the risks and benefits of antiplatelet agents and anticoagulants by calculating odds ratios (OR), accompanied by the 95% confidence intervals (CI). They assessed risks of bias and applied GRADE criteria.  MAIN RESULTS: Six trials (61,015 patients) met the inclusion criteria and were included in this review. Four trials were primary prevention (41,695 patients; HOT, JPAD, JPPP, and TPT), and two secondary prevention (19,320 patients, CAPRIE and Huynh). Four trials (HOT, JPAD, JPPP, and TPT) were placebo-controlled and two studies (CAPRIE and Huynh) included active comparators. Four studies compared acetylsalicylic acid (ASA) versus placebo and found no evidence of a difference for all-cause mortality (OR 0.97, 95% CI 0.87 to 1.08; 3 studies, 35,794 participants; low-certainty evidence). We found no evidence of a difference for cardiovascular mortality (OR 0.98, 95% CI 0.82 to 1.17; 3 studies, 35,794 participants; low-certainty evidence). ASA reduced the risk of all non-fatal cardiovascular events (OR 0.63, 95% CI 0.45 to 0.87; 1 study (missing data in 3 studies), 2540 participants; low-certainty evidence) and the risk of all cardiovascular events (OR 0.86, 95% CI 0.77 to 0.96; 3 studies, 35,794 participants; low-certainty evidence). ASA increased the risk of major bleeding events (OR 1.77, 95% CI 1.34 to 2.32; 2 studies, 21,330 participants; high-certainty evidence). One study (CAPRIE; ASA versus clopidogrel) included patients diagnosed with hypertension (mean age 62.5 years, 72% males, 95% Caucasians, mean follow-up: 1.91 years). It showed no evidence of a difference for all-cause mortality (OR 1.02, 95% CI 0.91 to 1.15; 1 study, 19,143 participants; high-certainty evidence) and for cardiovascular mortality (OR 1.08, 95% CI 0.94 to 1.26; 1 study, 19,143 participants; high-certainty evidence). ASA probably reduced the risk of non-fatal cardiovascular events (OR 1.10, 95% CI 1.00 to 1.22; 1 study, 19,143 participants; high-certainty evidence) and the risk of all cardiovascular events (OR 1.08, 95% CI 1.00 to 1.17; 1 study, 19,143 participants; high-certainty evidence) when compared to clopidogrel. Clopidogrel increased the risk of major bleeding events when compared to ASA (OR 1.35, 95% CI 1.14 to 1.61; 1 study, 19,143 participants; high-certainty evidence). In one study (Huynh; ASA verus warfarin) patients with unstable angina or non-ST-segment elevation myocardial infarction, with prior coronary artery bypass grafting (CABG) were included (mean age 68 years, 79.8% males, mean follow-up: 1.1 year). There was no evidence of a difference for all-cause mortality (OR 0.98, 95% CI 0.06 to 16.12; 1 study, 91 participants; low-certainty evidence). Cardiovascular mortality, non-fatal cardiovascular events, and all cardiovascular events were not available. There was no evidence of a difference for major bleeding events (OR 0.13, 95% CI 0.01 to 2.60; 1 study, 91 participants; low-certainty evidence).  AUTHORS' CONCLUSIONS: There is no evidence that antiplatelet therapy modifies mortality in patients with elevated BP for primary prevention. ASA reduced the risk of cardiovascular events and increased the risk of major bleeding events.  Antiplatelet therapy with ASA probably reduces the risk of non-fatal and all cardiovascular events when compared to clopidogrel. Clopidogrel increases the risk of major bleeding events compared to ASA in patients with elevated BP for secondary prevention.  There is no evidence that warfarin modifies mortality in patients with elevated BP for secondary prevention.  The benefits and harms of the newer drugs glycoprotein IIb/IIIa inhibitors, clopidogrel, prasugrel, ticagrelor, and non-vitamin K antagonist oral anticoagulants for patients with high BP have not been studied in clinical trials. Further RCTs of antithrombotic therapy including newer agents and complete documentation of all benefits and harms are required in patients with elevated BP.


Assuntos
Hipertensão , Tromboembolia , Trombose , Idoso , Anticoagulantes/efeitos adversos , Aspirina/uso terapêutico , Clopidogrel/uso terapêutico , Fibrinolíticos/uso terapêutico , Hemorragia/induzido quimicamente , Humanos , Hipertensão/induzido quimicamente , Pessoa de Meia-Idade , Inibidores da Agregação Plaquetária/efeitos adversos , Tromboembolia/etiologia , Trombose/prevenção & controle , Varfarina/uso terapêutico
19.
PLoS One ; 17(7): e0272140, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35901007

RESUMO

BACKGROUND: Triple antithrombotic therapy, including dual antiplatelet therapy and oral anticoagulant (OAC), is recommended for a short-term period after percutaneous coronary intervention (PCI) in patients requiring anticoagulation therapy. The purpose of this study was to compare in-hospital clinical outcomes between low-dose prasugrel (3.75 mg/day) and clopidogrel, as part of triple antithrombotic therapy, using a large database in Japan. METHODS: Patients with ischemic heart disease who underwent PCI between January 2015 and December 2019, and were prescribed triple therapy with aspirin, a P2Y12 inhibitor (clopidogrel or low-dose prasugrel), and OAC (direct oral anticoagulant: DOAC or vitamin K antagonist: VKA), were selected from the Diagnosis Procedure Combination database. The primary outcome was in-hospital mortality. The secondary outcomes were myocardial infarction, ischemic stroke, bleeding stroke, gastrointestinal bleeding, and blood transfusion. RESULTS: Overall, 5,777 patients were eligible in this analysis. The patients were divided into 4 subgroups according to the type of P2Y12 inhibitor and OAC: clopidogrel/DOAC (n = 1,628), clopidogrel/VKA (n = 1,334), prasugrel/DOAC (n = 1,607), and prasugrel/VKA (n = 1,208). There was no significant difference in the incidence of death and gastrointestinal bleeding among the 4 subgroups. The prasugrel/DOAC group had significantly lower incidence of MI (OR 0.566, 95% CI 0.348-0.921). The incidence of ischemic stroke was significantly lower in the prasugrel/DOAC group (OR 0.701, 95% CI 0.502-0.979), and significantly higher in the clopidogrel/VKA group (OR 1.680, 95% CI 1.273-2.216). Need for blood transfusion was less frequent in the prasugrel/DOAC group (OR 0.729, 95% CI 0.598-0.890), and more frequent in both the clopidogrel/VKA group (OR 1.424, 95% CI 1.187-1.708) and the prasugrel/VKA group (OR 1.633, 95% CI 1.367-1.950). CONCLUSIONS: Combination of low-dose prasugrel and DOAC was associated with lower incidence of MI, ischemic stroke, and blood transfusion. Low-dose prasugrel may be feasible as part of triple therapy in patients undergoing PCI.


Assuntos
AVC Isquêmico , Intervenção Coronária Percutânea , Anticoagulantes/efeitos adversos , Clopidogrel , Quimioterapia Combinada , Fibrinolíticos/uso terapêutico , Hemorragia Gastrointestinal/etiologia , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação Plaquetária/efeitos adversos , Cloridrato de Prasugrel/efeitos adversos , Resultado do Tratamento
20.
Ann Intern Med ; 175(7): JC74, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-35785542

RESUMO

SOURCE CITATION: Abraham NS, Barkun AN, Sauer BG, et al. American College of Gastroenterology-Canadian Association of Gastroenterology clinical practice guideline: management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. Am J Gastroenterol. 2022;117:542-58. 35297395.


Assuntos
Anticoagulantes , Hemorragia Gastrointestinal , Anticoagulantes/efeitos adversos , Canadá , Hemorragia Gastrointestinal/prevenção & controle , Humanos
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