Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 2.662
Filtrar
1.
J Cardiovasc Pharmacol Ther ; 26(1): 12-24, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32924567

RESUMO

Coronavirus-2019 (COVID-19) predisposes patients to arterial and venous thrombosis commonly complicating the clinical course of hospitalized patients and attributed to the inflammatory state, endothelial dysfunction, platelet activation and blood stasis. This viral coagulopathy may occur despite thromboprophylaxis and raises mortality; the risk appears highest among critically ill inpatients monitored in the intensive care unit. The prevalence of venous thromboembolism in COVID-19 patients has been reported to reach ∼10-35%, while autopsies raise it to nearly 60%. The most common thrombotic complication is pulmonary embolism, which though may occur in the absence of a recognizable deep venous thrombosis and may be due to pulmonary arterial thrombosis rather than embolism, resulting in thrombotic occlusion of small- to mid-sized pulmonary arteries and subsequent infarction of lung parenchyma. This micro-thrombotic pattern seems more specific for COVID-19 and is associated with an intense immuno-inflammatory reaction that results in diffuse occlusive thrombotic micro-angiopathy with alveolar damage and vascular angiogenesis. Furthermore, thrombosis has also been observed in various arterial sites, including coronary, cerebral and peripheral arteries. Biomarkers related to coagulation, platelet activation and inflammation have been suggested as useful diagnostic and prognostic tools for COVID-19-associated coagulopathy; among them, D-dimer remains a key biomarker employed in clinical practice. Various medical societies have issued guidelines or consensus statements regarding thromboprophylaxis and treatment of these thrombotic complications specifically adapted to COVID-19 patients. All these issues are detailed in this review, data from meta-analyses and current guidelines are tabulated, while the relevant mechanisms of this virus-associated coagulopathy are pictorially illustrated.


Assuntos
Anticoagulantes/administração & dosagem , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle , Alarminas/metabolismo , Biomarcadores , Proteínas do Sistema Complemento/biossíntese , Estado Terminal , Citocinas/biossíntese , Produtos de Degradação da Fibrina e do Fibrinogênio/biossíntese , Humanos , Unidades de Terapia Intensiva , Pandemias , Ativação Plaquetária/fisiologia , Embolia Pulmonar/mortalidade , Embolia Pulmonar/prevenção & controle , Tromboembolia Venosa/fisiopatologia
2.
Mol Med ; 26(1): 97, 2020 10 29.
Artigo em Inglês | MEDLINE | ID: mdl-33121429

RESUMO

BACKGROUND: COVID-19 is a viral respiratory disease caused by the severe acute respiratory syndrome-Coronavirus type 2 (SARS-CoV-2). Patients with this disease may be more prone to venous or arterial thrombosis because of the activation of many factors involved in it, including inflammation, platelet activation and endothelial dysfunction. Interferon gamma inducible protein-10 (IP-10), monocyte chemoattractant protein-1 (MCP-1) and macrophage inflammatory protein 1-alpha (MIP1α) are cytokines related to thrombosis. Therefore, this study focused on these three indicators in COVID-19, with the hope to find biomarkers that are associated with patients' outcome. METHODS: This is a retrospective single-center study involving 74 severe and critically ill COVID-19 patients recruited from the ICU department of the Tongji Hospital in Wuhan, China. The patients were divided into two groups: severe patients and critically ill patients. The serum IP-10, MCP-1 and MIP1α level in both groups was detected using the enzyme-linked immunosorbent assay (ELISA) kit. The clinical symptoms, laboratory test results, and the outcome of COVID-19 patients were retrospectively analyzed. RESULTS: The serum IP-10 and MCP-1 level in critically ill patients was significantly higher than that in severe patients (P < 0.001). However, no statistical difference in MIP1α between the two groups was found. The analysis of dynamic changes showed that these indicators remarkably increased in patients with poor prognosis. Since the selected patients were severe or critically ill, no significant difference was observed between survival and death. CONCLUSIONS: IP-10 and MCP-1 are biomarkers associated with the severity of COVID-19 disease and can be related to the risk of death in COVID-19 patients.


Assuntos
Quimiocina CCL2/sangue , Quimiocina CXCL10/sangue , Infecções por Coronavirus/complicações , Síndrome da Liberação de Citocina/complicações , Coagulação Intravascular Disseminada/complicações , Pneumonia Viral/complicações , Embolia Pulmonar/complicações , Insuficiência Respiratória/complicações , Proteínas Adaptadoras de Transdução de Sinal/sangue , Idoso , Betacoronavirus/patogenicidade , Biomarcadores/sangue , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/virologia , Estado Terminal , Síndrome da Liberação de Citocina/diagnóstico , Síndrome da Liberação de Citocina/mortalidade , Síndrome da Liberação de Citocina/virologia , Coagulação Intravascular Disseminada/diagnóstico , Coagulação Intravascular Disseminada/mortalidade , Coagulação Intravascular Disseminada/virologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/mortalidade , Pneumonia Viral/virologia , Prognóstico , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/mortalidade , Embolia Pulmonar/virologia , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/virologia , Estudos Retrospectivos , Índice de Gravidade de Doença , Análise de Sobrevida
3.
Cochrane Database Syst Rev ; 10: CD006212, 2020 10 08.
Artigo em Inglês | MEDLINE | ID: mdl-33027844

RESUMO

BACKGROUND: Pulmonary emboli (PE), or blood clots in the lungs,can be potentially fatal. Anticoagulation is the first line therapy to prevent PE. In some instances anticoagulation fails to prevent more emboli, or cannot be given because the person has a high risk of bleeding. Inferior vena caval filters (VCFs) are metal alloy devices that mechanically trap fragmented emboli from the deep leg veins en route to the pulmonary circulation. Retrievable filters are designed to be introduced and removed percutaneously. Although their deployment seems of theoretical benefit, their clinical efficacy and adverse event profile is unclear. This is the third update of a Cochrane Review first published in 2007. OBJECTIVES: To assess the evidence for the effectiveness and safety of vena caval filters (VCFs) in preventing pulmonary embolism (PE). SEARCH METHODS: For this review update, the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (last searched 10 September 2019) and the Cochrane Register of Controlled Trials (CENTRAL) (2019, Issue 8) via the Cochrane Register of Studies Online. The CIS also searched MEDLINE Ovid, EMBASE Ovid, CINAHL, and AMED (1 January 2017 to 10 September 2019) and trials registries to 10 September 2019. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that examined the efficacy of VCFs in preventing PE. DATA COLLECTION AND ANALYSIS: For this update, studies were assessed and data extracted independently. We assessed study quality with Cochrane's 'Risk of bias' tool and used the GRADE approach to assess the overall certainty of the evidence. The outcomes of interest were PE, mortality, lower limb venous thrombosis, filter-related complications and major bleeding. MAIN RESULTS: We identified four new studies for this update, bringing the total to six included studies involving 1388 participants. The six studies were clinically heterogeneous and we were unable to carry out meta-analysis. Only two studies were considered to be both applicable in current clinical settings and of good methodological quality. One was a randomised open-label trial studying the effect of a retrievable inferior vena caval filter plus anticoagulation versus anticoagulation alone on risk of recurrent pulmonary embolism (PE) in 399 participants over three months. There was no evidence of a difference in the rates of PE, death, lower extremity deep vein thrombosis (DVT), or bleeding at three and six months after the intervention (moderate-certainty evidence). A filter was inserted in 193 people, but could only be successfully retrieved from 153. Minor filter complications were noted at six months. The second clinically relevant study was a randomised open-label trial of 240 participants who had sustained multiple traumatic injuries, allocated to a filter or no filter, three days after injury, in conjunction with anticoagulation and intermittent pneumatic compression. Prophylactic anticoagulation was initiated in both groups when it was thought safe to do so. There was no evidence of a difference in symptomatic PE, death, or lower limb venous thrombosis rates (moderate-certainty evidence). The only major filter complication was that one person required surgical removal of the filter. We are unable to draw any conclusions from the remaining four included studies. One study showed an increased incidence of long-term lower extremity DVT at eight years. Three studies are no longer clinically applicable because they utilised permanent filters which are seldom used now, or they did not use routine prophylactic anticoagulation which is current standard practice. The fourth study compared two filter types and was terminated prematurely as one filter group had a higher rate of thrombosis compared to the other filter type. AUTHORS' CONCLUSIONS: Two of the six identified studies were relevant for current clinical settings. One showed no evidence of a benefit of retrievable filters in acute PE for the outcomes of PE, death, DVT and bleeding during the initial three months in people who can receive anticoagulation (moderate-certainty evidence). The other study did not show any benefit for prophylactic filter insertion in people who sustained multiple traumatic injuries, with respect to symptomatic PE, mortality, or lower extremity venous thrombosis (moderate-certainty evidence). We can draw no firm conclusions regarding filter efficacy in the prevention of PE from the remaining four RCTs identified in this review. Further trials are needed to assess vena caval filter effectiveness and safety, and clinical differences between various filter types.


Assuntos
Embolia Pulmonar/prevenção & controle , Filtros de Veia Cava , Anticoagulantes/uso terapêutico , Terapia Combinada/métodos , Humanos , Dispositivos de Compressão Pneumática Intermitente , Traumatismo Múltiplo/complicações , Embolia Pulmonar/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Recidiva , Filtros de Veia Cava/efeitos adversos , Veia Cava Inferior , Trombose Venosa/complicações
4.
Anesth Analg ; 131(5): 1324-1333, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33079850

RESUMO

Patients with coronavirus disease 2019 (COVID-19) frequently experience a coagulopathy associated with a high incidence of thrombotic events leading to poor outcomes. Here, biomarkers of coagulation (such as D-dimer, fibrinogen, platelet count), inflammation (such as interleukin-6), and immunity (such as lymphocyte count) as well as clinical scoring systems (such as sequential organ failure assessment [SOFA], International Society on Thrombosis and Hemostasis disseminated intravascular coagulation [ISTH DIC], and sepsis-induced coagulopathy [SIC] score) can be helpful in predicting clinical course, need for hospital resources (such as intensive care unit [ICU] beds, intubation and ventilator therapy, and extracorporeal membrane oxygenation [ECMO]) and patient's outcome in patients with COVID-19. However, therapeutic options are actually limited to unspecific supportive therapy. Whether viscoelastic testing can provide additional value in predicting clinical course, need for hospital resources and patient's outcome or in guiding anticoagulation in COVID-19-associated coagulopathy is still incompletely understood and currently under investigation (eg, in the rotational thromboelastometry analysis and standard coagulation tests in hospitalized patients with COVID-19 [ROHOCO] study). This article summarizes what we know already about COVID-19-associated coagulopathy and-perhaps even more importantly-characterizes important knowledge gaps.


Assuntos
Anti-Inflamatórios/uso terapêutico , Anticoagulantes/uso terapêutico , Betacoronavirus/patogenicidade , Coagulação Sanguínea/efeitos dos fármacos , Infecções por Coronavirus/terapia , Inflamação/terapia , Pneumonia Viral/terapia , Embolia Pulmonar/terapia , Tromboembolia Venosa/terapia , Trombose Venosa/terapia , Anti-Inflamatórios/efeitos adversos , Anticoagulantes/efeitos adversos , Biomarcadores/sangue , Infecções por Coronavirus/sangue , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/virologia , Medicina Baseada em Evidências , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Mortalidade Hospitalar , Interações Hospedeiro-Patógeno , Humanos , Inflamação/sangue , Inflamação/mortalidade , Inflamação/virologia , Mediadores da Inflamação/sangue , Pandemias , Pneumonia Viral/sangue , Pneumonia Viral/mortalidade , Pneumonia Viral/virologia , Prognóstico , Embolia Pulmonar/sangue , Embolia Pulmonar/mortalidade , Embolia Pulmonar/virologia , Fatores de Risco , Tromboembolia Venosa/sangue , Tromboembolia Venosa/mortalidade , Tromboembolia Venosa/virologia , Trombose Venosa/sangue , Trombose Venosa/mortalidade , Trombose Venosa/virologia
6.
PLoS One ; 15(9): e0239801, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32970774

RESUMO

While hospital admissions for myocardial infarction (MI) and pulmonary embolism (PE) are decreased during the COVID-19 pandemic, controversy remains about respective complication and mortality rates. This study evaluated admission rates, complications, and intrahospital mortality for selected life-threatening cardiovascular emergencies (MI, PE, and acute aortic dissection (AAD)) during COVID-19-associated restrictive social measures (RM) in Styria, Austria. By screening a patient information system for International Statistical Classification of Diseases and Related Health Problems (ICD) diagnosis codes covering more than 85% of acute hospital admissions in the state of Styria (~1.24 million inhabitants), we retrospectively identified patients with admission diagnoses for MI (I21, I22), PE (I26), and AAD (I71). Rates of complications such as cardiogenic shock and cardiopulmonary resuscitation, treatment escalations (thrombolysis for PE), and mortality were analyzed by patient chart review during 6 weeks following onset of COVID-19 associated RM, and during respective time frames in the years 2016 to 2019. 1,668 patients were included. Cumulative admissions for MI, PE and AAD decreased (RR 0.77; p<0.001) during RM compared to previous years. In contrast, intrahospital mortality increased by 65% (RR 1.65; p = 0.041), mainly driven by mortality following MI (RR 1.80; p = 0.042). PE patients received more frequently thrombolysis treatment (RR 3.63; p = 0.006), while rates of cardiogenic shock and cardiopulmonary resuscitation remained unchanged. Of 226 patients hospitalized during RM, 81 patients with suspected COVID-19 disease were screened for SARS-CoV-2 infection with only 5 testing positive. Thus, cumulative hospital admissions for cardiovascular emergencies decreased during COVID-19 associated RM while intrahospital mortality increased.


Assuntos
Aneurisma Dissecante/mortalidade , Infecções por Coronavirus/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Infarto do Miocárdio/mortalidade , Pneumonia Viral/epidemiologia , Embolia Pulmonar/mortalidade , Idoso , Idoso de 80 Anos ou mais , Áustria , Betacoronavirus , Serviço Hospitalar de Emergência/tendências , Feminino , Mortalidade Hospitalar/tendências , Hospitalização/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Retrospectivos
7.
Clin Radiol ; 75(11): 804-810, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32829885

RESUMO

Coronavirus disease 2019 (COVID-19) is a newly emerging human infectious disease that has quickly become a worldwide threat to health, mainly causing severe acute respiratory syndrome. In addition to the widely described respiratory syndrome, COVID-19 may cause life-treating complications directly or indirectly related to this infection. Among these, thrombotic complications have emerged as an important issue in patients with COVID-19 infection, particularly in patients in intensive care units. Thrombotic complications due to COVID-19 are likely to occur due to a pro-coagulant pattern encountered in some of these patients or to a progressive endothelial thrombo-inflammatory syndrome causing microvascular disease. In the present authors' experience, from five different hospitals in Italy and the UK, imaging has proved its utility in identifying these COVID-19-related thrombotic complications, with translational clinical relevance. The aim of this review is to illustrate thromboembolic complications directly or indirectly related to COVID-19 disease. Specifically, this review will show complications related to thromboembolism due to a pro-coagulant pattern from those likely related to an endothelial thrombo-inflammatory syndrome.


Assuntos
Anticoagulantes/administração & dosagem , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Embolia Pulmonar/etiologia , Síndrome Respiratória Aguda Grave/complicações , Tromboembolia/tratamento farmacológico , Tromboembolia/etiologia , Adulto , Idoso , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/etiologia , Isquemia Encefálica/mortalidade , Causas de Morte , Doenças Transmissíveis Emergentes/epidemiologia , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/fisiopatologia , Feminino , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/mortalidade , Pneumonia Viral/fisiopatologia , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/mortalidade , Radiografia Torácica/métodos , Síndrome Respiratória Aguda Grave/diagnóstico , Síndrome Respiratória Aguda Grave/mortalidade , Análise de Sobrevida , Tromboembolia/diagnóstico por imagem , Tromboembolia/mortalidade , Tromboplastina/metabolismo , Tomografia Computadorizada por Raios X/métodos
9.
Adv Biol Regul ; 77: 100744, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32773104
10.
Am J Cardiol ; 131: 109-114, 2020 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-32718549

RESUMO

Treatment of submassive (intermediate-risk) pulmonary embolism (PE), defined as hemodynamically stable with right ventricular (RV) dysfunction, showed lower in-hospital all-cause mortality with intravenous thrombolytic therapy than with anticoagulants, but at an increased risk of major bleeding. The present investigation was performed to test whether catheter-directed thrombolysis reduces mortality without increasing bleeding in submassive PE. This was a retrospective cohort study based on administrative data from the Nationwide Inpatient Sample. In 2016, 13,130 patients were hospitalized with PE and acute cor pulmonale, were stable, and treated with catheter-directed thrombolysis in 1,500 (11%) or anticoagulants alone in 11,630 (89%). Mortality was lower with catheter-directed thrombolysis than with anticoagulants in unmatched patients, 35 of 1,500 (2.3%) compared with 755 of 11,630 (6.5%; p <0.0001) and in matched patients, 30 of 1,260 (2.4%) compared with 440 of 6,910 (6.4%; p <0.0001). Time-dependent analysis showed catheter-directed thrombolysis reduced mortality if administered within the first 3 days. Patients with saddle PE treated with anticoagulants had lower mortality than non-saddle PE, 75 of 1,730 (4.3%) compared with 680 of 9,900 (6.9%; p < 0.0001) in unmatched patients and 45 of 1,305 (3.4%) compared with 395 of 5,605 (7.0%; p < 0.0001) in matched patients. Mortality was not lower with inferior vena cava filters either in those who received catheter-directed thrombolysis or those treated with anticoagulants. There were no fatal or nonfatal adverse events associated with catheter-directed thrombolysis. In conclusion, patients with submassive PE appear to have lower in-hospital all-cause mortality with catheter-directed thrombolysis administered within 3 days than with anticoagulants, and risks are low.


Assuntos
Fibrinolíticos/administração & dosagem , Embolia Pulmonar/tratamento farmacológico , Doença Cardiopulmonar/tratamento farmacológico , Terapia Trombolítica/métodos , Doença Aguda , Cateterismo , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/mortalidade , Doença Cardiopulmonar/mortalidade , Estudos Retrospectivos , Estados Unidos
12.
Emergencias ; 32(4): 253-257, 2020.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-32692002

RESUMO

OBJECTIVES: To analyze clinical, laboratory, and radiologic findings and final health outcomes in patients with pulmonary embolism and coronavirus disease 2019 (COVID-19). To compare them to findings and outcomes in patients with pulmonary embolism without COVID-19. MATERIAL AND METHODS: Multicenter, observational, retrospective study in 4 Spanish hospital emergency departments (EDs) from January 15 to April 15, 2020. Cases were located by reviewing all ED requests for pulmonary computed tomography angiography (CTA) procedures. Clinical, laboratory, and radiologic findings; medical histories and comorbidity; risk factors; and outcomes were compared between the 2 groups of patients (with or without COVID-19). RESULTS: A total of 399 CTAs were ordered; 88 pulmonary embolisms were diagnosed, 28 of them (32%) in patients with COVID-19. This group had more men, and a history of thromboembolic disease was more common. We found no between-group differences in clinical presentation, laboratory, or radiologic findings; nor were there differences in final outcomes. In-hospital mortality was 7% (2 cases) in patients with COVID-19 and 17% (10 cases) in patients without the virus (odds ratio for death in patients with pulmonary embolism and COVID-19, 0.38; 95% CI, 0.08-1.89). CONCLUSION: We found no clinically important differences in the clinical, laboratory, or radiologic findings between patients with or without COVID-19 who were treated for pulmonary embolism in our hospital EDs. Final outcomes also did not differ.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Embolia Pulmonar/diagnóstico por imagem , Idoso , Comorbidade , Angiografia por Tomografia Computadorizada/estatística & dados numéricos , Infecções por Coronavirus/sangue , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/mortalidade , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Intubação Intratraqueal , Tempo de Internação , Masculino , Razão de Chances , Pandemias , Pneumonia Viral/sangue , Pneumonia Viral/diagnóstico , Pneumonia Viral/mortalidade , Embolia Pulmonar/sangue , Embolia Pulmonar/etiologia , Embolia Pulmonar/mortalidade , Estudos Retrospectivos , Fatores de Risco , Espanha/epidemiologia
13.
Am J Cardiol ; 128: 54-59, 2020 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32650924

RESUMO

To conduct a systematic review and meta-analysis evaluating the safety and effectiveness of inferior vena cava filter (IVCF) placement in the setting of massive and submassive pulmonary embolism (PE), Pubmed and Cochrane Library were queried to identify all clinical studies evaluating IVCF placement in patients with massive and submassive PE from database establishment to December 2019. The rate of recurrent PE, PE-related mortality, adverse events, IVCF type, additional treatment intervention, DVT status, and follow-up length were retrieved. Recurrent PE, mortality, and complication rates were pooled. Meta-analysis was performed to compare mortality rates between groups with and without IVCF placement. Subgroup analysis was performed based on whether catheter-directed therapy was used for PE intervention. Fifteen observational studies with a total of 232 patients who received IVCF for submassive or massive PE were included. The pooled overall recurrent symptomatic PE and mortality rates were 1.4% and 5.5%, respectively. A lower mortality rate among patients with IVCF was observed than those without (6.8% vs 26.3%; odds ratio [OR] 0.275 [95% confidence interval] 0.090 to 0.839], I2 = 30.6%, p = 0.023). Patients who received concurrent catheter-directed therapy demonstrated a lower recurrent PE (0% vs 2.8%) and mortality rate (3.4% vs 7.8%) than those who did not. The cumulative IVCF-related complication rate was 0.63%. In conclusion, based on a limited amount of low-quality evidence, IVCF placement is associated with low recurrent PE and PE-related mortality rates among patients with massive and submassive PE, suggestive of a potential clinical benefit in this scenario. Prospectively designed studies are warranted to confirm these findings.


Assuntos
Embolia Pulmonar/terapia , Filtros de Veia Cava , Anticoagulantes/uso terapêutico , Humanos , Hipotensão/fisiopatologia , Trombólise Mecânica , Mortalidade , Embolia Pulmonar/mortalidade , Embolia Pulmonar/fisiopatologia , Recidiva , Índice de Gravidade de Doença , Trombectomia , Terapia Trombolítica , Disfunção Ventricular Direita/fisiopatologia
14.
J Stroke Cerebrovasc Dis ; 29(8): 104958, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32689605

RESUMO

BACKGROUND AND OBJECTIVE: Patients with intracerebral hemorrhage are susceptible to venous thromboembolism, but the relationship between venous thromboembolism and outcome is largely unknown. We aim to investigate the association of in-hospital venous thromboembolism with functional outcome in patients with intracerebral hemorrhage. METHODS: From September 2014 through August 2016, we conducted a hospital-based, prospective study by consecutively recruiting eligible patients with first-ever acute spontaneous intracerebral hemorrhage. In-hospital venous thromboembolism was defined as observation of pulmonary embolism or deep vein thrombosis during initial hospitalization. The primary end point was death or disability (modified Rankin Scale 3 to 6) at discharge, 3-month and 1-year follow-up. Logistic analysis was conducted to evaluate the association of venous thromboembolism and poor functional outcome. RESULTS: Among 637 participants included in the analysis, the prevalence of venous thromboembolism was 22.6%. After adjusting for confounding factors, venous thromboembolism was independently associated with death or disability at discharge (odds ratio 2.09, 95% confidence interval 1.12-3.85), 3-month follow-up (2.00 [1.12-3.54]) and 1-year follow-up (2.00 [1.14-3.49]). Venous thromboembolism was also an independent indicator of disability (modified Rankin Scale 3-5) among ICH survivors, with odds ratios ranging from 1.93 to 2.08 (all P<0.05). The relationship was stronger in patients with hematoma volume <10 ml (3.24 [1.11-9.46]) and ≥30 ml (2.57 [1.03-6.44]) (P for interaction=0.002) at 1-year follow-up. The results were confirmed by sensitivity analysis. CONCLUSION: In-hospital venous thromboembolism was independently associated with poor outcome at discharge, 3-month and 1-year in patients with intracerebral hemorrhage.


Assuntos
Hemorragia Cerebral/epidemiologia , Embolia Pulmonar/epidemiologia , Tromboembolia Venosa/epidemiologia , Trombose Venosa/epidemiologia , Idoso , Pequim/epidemiologia , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/mortalidade , Hemorragia Cerebral/terapia , Avaliação da Deficiência , Feminino , Mortalidade Hospitalar , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Estudos Prospectivos , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/mortalidade , Embolia Pulmonar/terapia , Medição de Risco , Fatores de Risco , Fatores de Tempo , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/mortalidade , Tromboembolia Venosa/terapia , Trombose Venosa/diagnóstico , Trombose Venosa/mortalidade , Trombose Venosa/terapia
15.
J Mol Cell Cardiol ; 146: 32-40, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32681845

RESUMO

SARS-CoV-2 causes a phenotype of pneumonia with diverse manifestation, which is termed as coronavirus disease 2019 (COVID-19). An impressive high transmission rate allows COVID-19 conferring enormous challenge for clinicians worldwide, and developing to a pandemic level. Combined with a series of complications, a part of COVID-19 patients progress into severe cases, which critically contributes to the risk of fatality. To date, coagulopathy has been found as a prominent feature of COVID-19 and severe coagulation dysfunction may be associated with poor prognosis. Coagulopathy in COVID-19 may predispose patients to hypercoagulability-related disorders including thrombosis and even fatal vascular events. Inflammatory storm, uncontrolled inflammation-mediated endothelial injury and renin angiotensin system (RAS) dysregulation are the potential mechanisms. Ongoing efforts made to develop promising therapies provide several potential strategies for hypercoagulability in COVID-19. In this review, we introduce the clinical features of coagulation and the increased vascular thrombotic risk conferred by coagulopathy according to present reports about COVID-19. The potential underlying mechanisms and emerging therapeutic avenues are discussed, emphasizing an urgent need for effective interventions.


Assuntos
Anticoagulantes/uso terapêutico , Betacoronavirus/patogenicidade , Infecções por Coronavirus/complicações , Síndrome da Liberação de Citocina/complicações , Coagulação Intravascular Disseminada/complicações , Pneumonia Viral/complicações , Embolia Pulmonar/complicações , Insuficiência Respiratória/complicações , Doença Aguda , Betacoronavirus/imunologia , Biomarcadores/sangue , Plaquetas/efeitos dos fármacos , Plaquetas/patologia , Plaquetas/virologia , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/virologia , Síndrome da Liberação de Citocina/tratamento farmacológico , Síndrome da Liberação de Citocina/mortalidade , Síndrome da Liberação de Citocina/virologia , Coagulação Intravascular Disseminada/tratamento farmacológico , Coagulação Intravascular Disseminada/mortalidade , Coagulação Intravascular Disseminada/virologia , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Heparina/uso terapêutico , Interações Hospedeiro-Patógeno/imunologia , Humanos , Pulmão/irrigação sanguínea , Pulmão/efeitos dos fármacos , Pulmão/patologia , Pulmão/virologia , Pandemias , Tempo de Tromboplastina Parcial , Pneumonia Viral/tratamento farmacológico , Pneumonia Viral/mortalidade , Pneumonia Viral/virologia , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/mortalidade , Embolia Pulmonar/virologia , Insuficiência Respiratória/tratamento farmacológico , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/virologia , Análise de Sobrevida
16.
J Card Surg ; 35(7): 1531-1538, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32598529

RESUMO

BACKGROUND: Surgical pulmonary embolectomy (SPE) has been around since the early days of cardiac surgery. But with the increase in thrombolytic and intervention options, indications of SPE have been limited. Literature suggests that risk stratification has been a key step in getting good results. We are analyzing serum lactate levels for risk stratification in massive and submassive pulmonary embolism (PE). METHODS: This study is a retrospective analysis of 82 cases that underwent SPE between January 1997 and January 2020. Patients were divided into two groups stratified by venous serum lactate levels on the first admission (Group I: normolactatemia <2 mmol/L, Group II: hyperlactatemia, >2 mmol/L). Primary endpoints were all-cause in-hospital mortality and secondary endpoints were cardiopulmonary bypass time, extracorporeal membrane oxygenator (ECMO) insertion, low cardiac output, blood product use, and right ventricular functions in the follow-up. RESULTS: Our study had an overall follow-up of 23 years with a median of 3.18 years. Overall, the in-hospital mortality rate was 8.54%. Group II had a higher mortality rate (P = .015) and morbidity incidences like cardiopulmonary bypass time (P = .008), ECMO insertion (P = .036), and open chest after surgery (P = .015). Although 5-year survival was better in group I a compared to group II (81%, 95% CI, 69%-93% vs 65%, 95% CI, 46%-84%), the log rank test showed no statistical survival difference among both groups on long-term follow-up. CONCLUSIONS: Long term survival after SPE is good and these results can further be improved by proper PE risk stratification. Alongside computed tomography and echocardiography, the importance of biomarkers like serum lactate can be explored in the PE management algorithm.


Assuntos
Embolectomia/métodos , Lactatos/sangue , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/cirurgia , Medição de Risco/métodos , Adolescente , Adulto , Idoso , Biomarcadores/sangue , Ponte Cardiopulmonar , Embolectomia/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Embolia Pulmonar/mortalidade , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
17.
Ann Intern Med ; 173(4): 268-277, 2020 08 18.
Artigo em Inglês | MEDLINE | ID: mdl-32374815

RESUMO

BACKGROUND: The new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused more than 210 000 deaths worldwide. However, little is known about the causes of death and the virus's pathologic features. OBJECTIVE: To validate and compare clinical findings with data from medical autopsy, virtual autopsy, and virologic tests. DESIGN: Prospective cohort study. SETTING: Autopsies performed at a single academic medical center, as mandated by the German federal state of Hamburg for patients dying with a polymerase chain reaction-confirmed diagnosis of COVID-19. PATIENTS: The first 12 consecutive COVID-19-positive deaths. MEASUREMENTS: Complete autopsy, including postmortem computed tomography and histopathologic and virologic analysis, was performed. Clinical data and medical course were evaluated. RESULTS: Median patient age was 73 years (range, 52 to 87 years), 75% of patients were male, and death occurred in the hospital (n = 10) or outpatient sector (n = 2). Coronary heart disease and asthma or chronic obstructive pulmonary disease were the most common comorbid conditions (50% and 25%, respectively). Autopsy revealed deep venous thrombosis in 7 of 12 patients (58%) in whom venous thromboembolism was not suspected before death; pulmonary embolism was the direct cause of death in 4 patients. Postmortem computed tomography revealed reticular infiltration of the lungs with severe bilateral, dense consolidation, whereas histomorphologically diffuse alveolar damage was seen in 8 patients. In all patients, SARS-CoV-2 RNA was detected in the lung at high concentrations; viremia in 6 of 10 and 5 of 12 patients demonstrated high viral RNA titers in the liver, kidney, or heart. LIMITATION: Limited sample size. CONCLUSION: The high incidence of thromboembolic events suggests an important role of COVID-19-induced coagulopathy. Further studies are needed to investigate the molecular mechanism and overall clinical incidence of COVID-19-related death, as well as possible therapeutic interventions to reduce it. PRIMARY FUNDING SOURCE: University Medical Center Hamburg-Eppendorf.


Assuntos
Autopsia/métodos , Infecções por Coronavirus/mortalidade , Pneumonia Viral/mortalidade , Embolia Pulmonar/mortalidade , Tromboembolia Venosa/mortalidade , Idoso , Idoso de 80 Anos ou mais , Betacoronavirus , Causas de Morte , Feminino , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Prospectivos , Tomografia Computadorizada por Raios X
18.
Intensive Care Med ; 46(6): 1089-1098, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32367170

RESUMO

PURPOSE: Little evidence of increased thrombotic risk is available in COVID-19 patients. Our purpose was to assess thrombotic risk in severe forms of SARS-CoV-2 infection. METHODS: All patients referred to 4 intensive care units (ICUs) from two centers of a French tertiary hospital for acute respiratory distress syndrome (ARDS) due to COVID-19 between March 3rd and 31st 2020 were included. Medical history, symptoms, biological data and imaging were prospectively collected. Propensity score matching was performed to analyze the occurrence of thromboembolic events between non-COVID-19 ARDS and COVID-19 ARDS patients. RESULTS: 150 COVID-19 patients were included (122 men, median age 63 [53; 71] years, SAPSII 49 [37; 64] points). Sixty-four clinically relevant thrombotic complications were diagnosed in 150 patients, mainly pulmonary embolisms (16.7%). 28/29 patients (96.6%) receiving continuous renal replacement therapy experienced circuit clotting. Three thrombotic occlusions (in 2 patients) of centrifugal pump occurred in 12 patients (8%) supported by ECMO. Most patients (> 95%) had elevated D-dimer and fibrinogen. No patient developed disseminated intravascular coagulation. Von Willebrand (vWF) activity, vWF antigen and FVIII were considerably increased, and 50/57 tested patients (87.7%) had positive lupus anticoagulant. Comparison with non-COVID-19 ARDS patients (n = 145) confirmed that COVID-19 ARDS patients (n = 77) developed significantly more thrombotic complications, mainly pulmonary embolisms (11.7 vs. 2.1%, p < 0.008). Coagulation parameters significantly differed between the two groups. CONCLUSION: Despite anticoagulation, a high number of patients with ARDS secondary to COVID-19 developed life-threatening thrombotic complications. Higher anticoagulation targets than in usual critically ill patients should therefore probably be suggested.


Assuntos
Anticoagulantes/uso terapêutico , Betacoronavirus/patogenicidade , Infecções por Coronavirus/fisiopatologia , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Pneumonia Viral/fisiopatologia , Embolia Pulmonar/fisiopatologia , Síndrome Respiratória Aguda Grave/fisiopatologia , Trombose/fisiopatologia , Idoso , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/terapia , Estado Terminal , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , França/epidemiologia , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/mortalidade , Pneumonia Viral/terapia , Pontuação de Propensão , Estudos Prospectivos , Embolia Pulmonar/complicações , Embolia Pulmonar/mortalidade , Embolia Pulmonar/virologia , Síndrome Respiratória Aguda Grave/complicações , Síndrome Respiratória Aguda Grave/mortalidade , Síndrome Respiratória Aguda Grave/virologia , Trombose/etiologia , Trombose/mortalidade , Trombose/virologia
19.
Ann Emerg Med ; 76(4): 527-541, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32461009

RESUMO

STUDY OBJECTIVE: Syncope is a presenting symptom in 10% to 20% of patients with pulmonary embolism. We perform a meta-analysis to clarify the prognostic value of syncope on short-term mortality in pulmonary embolism patients and its association with hemodynamic instability. METHODS: PubMed, EMBASE, and the Cochrane Library were searched up until January 7, 2020. Studies reporting inhospital or 30-day mortality of adults with pulmonary embolism with and without syncope were included. Quality of included studies was evaluated with the Quality in Prognosis Studies tool. Meta-analysis was conducted to derive pooled odds ratios (ORs) and risk differences for the relation of syncope with mortality and hemodynamic instability. To study the influence of hemodynamic instability on the association between syncope and mortality, meta-regression was performed. RESULTS: Search and selection resulted in 26 studies, of which 20 were pooled, involving 9,419 of 335,120 patients (3%) with syncope. Syncope was associated with higher mortality (OR 1.82; 95% confidence interval [CI] 1.14 to 2.90; I2 88%; risk difference 4% [95% CI 1% to 8%]) and higher prevalence of hemodynamic instability (OR 4.36; 95% CI 2.27 to 8.37; I2 93%; risk difference 12% [95% CI 7% to 18%]). OR for mortality in patients with pulmonary embolism with syncope versus without it was higher in the presence of a larger difference in hemodynamic instability between groups (coefficient 0.05; 95% CI 0.01 to 0.09). CONCLUSION: The association between syncope and short-term mortality in patients with pulmonary embolism is explained by a difference in hemodynamic instability. This emphasizes the importance of risk stratification by hemodynamic status in pulmonary embolism patients with and without syncope.


Assuntos
Mortalidade , Prognóstico , Embolia Pulmonar/complicações , Síncope/diagnóstico , Humanos , Razão de Chances , Embolia Pulmonar/mortalidade , Medição de Risco/métodos , Medição de Risco/normas , Síncope/etiologia , Síncope/mortalidade
20.
Swiss Med Wkly ; 150: w20293, 2020 05 18.
Artigo em Inglês | MEDLINE | ID: mdl-32459857

RESUMO

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) as a global phenomenon has presented clinicians around the world with multiple challenges. Thromboembolic events are recognised complications of viral infection, but the diagnosis of an acute pulmonary thrombotic complication in the context of coronavirus disease 2019 (COVID-19) can be challenging because of the similarities of presentation, logistical considerations of diagnosis in a patient isolated for infection control reasons and the effects of cognitive errors in diagnostic reasoning. We present the case of a patient who was diagnosed with a pulmonary thrombotic complication during inpatient care for COVID-19. The haemostasis parameters we observed, including increased levels of von Willebrand factor and factor VIII, point towards a relevant involvement of endothelial cells in patients with severe COVID-19. We suggest that it is possible to hypothesise a spectrum of secondarily acquired, prothrombotic coagulopathy mediated by the endothelial interaction with SARS-CoV-2 as a cause of mortality in a subset of patients with a complicated clinical course of COVID-19. We support the recommendation of thromboembolic chemoprophylaxis for inpatients with COVID-19 as a very minimum in the absence of strict contraindications, while recognising that pulmonary thrombotic complications can occur under standard thromboprophylaxis. We suggest that higher, possibly therapeutic levels of anticoagulation might be mandatory for a further subset of patients with COVID-19 where a discrepant evolution of C-reactive protein and D-dimer is observed. Therapeutic levels of anticoagulation are obligatory where new evidence of a macrovascular thrombotic complication has been documented. More research to delineate the macro- and microvascular thrombotic complications of COVID-19, and the therapeutic implications for this patient group is required.


Assuntos
Betacoronavirus , Infecções por Coronavirus/sangue , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Pneumonia Viral/sangue , Embolia Pulmonar/virologia , Infecções por Coronavirus/complicações , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/complicações , Pneumonia Viral/mortalidade , Pneumonia Viral/fisiopatologia , Embolia Pulmonar/mortalidade , Embolia Pulmonar/fisiopatologia , Embolia Pulmonar/terapia
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA