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1.
Int Heart J ; 62(2): 432-436, 2021 Mar 30.
Artigo em Inglês | MEDLINE | ID: mdl-33731527

RESUMO

Embolic myocardial infarction (MI) caused by infective endocarditis (IE) is rare, but it is increasingly recognized as an important complication. This complication typically occurs in patients with aortic valve endocarditis during the acute phase of the infection. It is also known to have a high mortality rate; however, the best practice for its management is unclear owing to scarce available data. In addition, most cases of embolic acute MI (AMI) caused by IE are indirectly diagnosed with a combination of angiographic examination such as coronary angiography or cardiac computed tomography. Herein, we report a case of fatal embolic ST-elevation MI (STEMI) caused by mitral valve IE during the healed phase, which was clearly proven by the pathology findings.


Assuntos
Embolia/complicações , Endocardite Bacteriana/complicações , Valva Mitral/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/etiologia , Idoso , Angiografia Coronária , Ecocardiografia , Embolia/diagnóstico , Endocardite Bacteriana/diagnóstico , Evolução Fatal , Feminino , Humanos , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico
2.
Angiol Sosud Khir ; 26(3): 9-15, 2020.
Artigo em Russo | MEDLINE | ID: mdl-33063747

RESUMO

Embologenic arterial obstruction remains an extremely important problem of modern medicine. Emboli may affect virtually all arterial vessels of the greater circulation and in some cases arterial emboli may be multiple. The purpose of the present study was to work out a classification of multiple arterial emboli. Analysing the clinical material including over 30 years a total of 1804 patients with embolism of the aorta and major arteries of the limbs made it possible to define the range of the terms used and to submit for discussion a classification describing a situation where emboli affect simultaneously several arteries or occur repeatedly. Both cases involve several emboli migrating from the primary source into the arterial bed, therefore we suggest that all these emboli be called multiple. Simultaneous multiple emboli were classified as combined, multifocal, and layered, with repeated emboli classified as preceding, recurrent, early and remote. Simultaneous emboli were observed in 91 (5%) patients, of these, in 22 - combined, in 49 - multifocal, in 19 - layered, and in 1 case - combined and multifocal. Repeated emboli were revealed at various terms and encountered virtually in each third patient. Overall mortality amongst the patients with embolism of the aorta and arteries of the limbs over 30 years amounted to 13%, having over the last decade decreased to 7.6%. Multiple arterial emboli significantly influenced the outcomes of treatment, with the mortality rate in combined emboli increasing virtually to 50% and that in multifocal and layered emboli exceeding 20% (p<0.05). Early recurrent emboli in the postoperative period were observed in 6.8% of patients, significantly deteriorating the prognosis (mortality - 49.2%). In the remote period, 22.4% of the patients were operated on for recurrent embolism of arteries of the extremities, with more than 25% of the patients having experienced emboli of cerebral or visceral arteries. Recurrent thromboembolic complications played a significant role in the thanatogenesis in each 4th patient.


Assuntos
Arteriopatias Oclusivas , Embolia , Aorta , Arteriopatias Oclusivas/diagnóstico , Artérias/diagnóstico por imagem , Embolia/complicações , Embolia/diagnóstico , Extremidades , Humanos
3.
J Stroke Cerebrovasc Dis ; 29(9): 104934, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807411

RESUMO

BACKGROUND AND PURPOSE: Use of implantable cardiac monitors (ICMs) has increased diagnosis of atrial fibrillation (AF) in cryptogenic stroke (CS) patients. Identifying AF predictors may enhance the yield of AF detection. Recurrent strokes after CS are not well described. We aimed to assess the predictors for AF detection and the characteristics of recurrent strokes in patients after CS. METHODS: We reviewed electronic medical records of CS patients who were admitted between February 2014 and September 2017 and underwent ICM placement with minimum one-year follow-up. Patient demographics, stroke characteristics, pre-defined risk factors as well as recurrent strokes were compared between patients with and without AF detection. RESULTS: 389 patients with median follow-up of 548 days were studied. AF was detected in 102 patients (26.2%). Age (per decade increase, OR 2.10, CI 1.64-2.68, with vs. without AF) and left atrium diameter (per 5 mm increase, OR 1.91, CI 1.33-2.74) were identified as AF predictors. Intracranial large vessel stenosis >50% irrelevant to the index strokes was associated with AF detection within 30 days (OR 0.24, CI 0.09-0.69, >30 vs. <30 days). Recurrent strokes occurred in 14% patients with median follow-up about 2.5 years. Topography of these strokes resembled embolic pattern and was comparable between patients with and without AF. Among recurrent strokes in patients with AF, the median time to AF detection was much shorter (90 vs. 251 days), and the median time to first stroke recurrence was much longer (422 vs. 76 days) in patients whose strokes recurred after AF detection than those before AF detection. CONCLUSIONS: Older age and enlarged left atrium are predictors for AF detection in CS patients. Intracranial atherosclerosis is more prevalent in patients with early AF detection within 30 days. Recurrent strokes follow the embolic pattern, and early AF detection could delay the stroke recurrence.


Assuntos
Fibrilação Atrial/diagnóstico , Embolia/diagnóstico , Tecnologia de Sensoriamento Remoto/instrumentação , Acidente Vascular Cerebral/diagnóstico , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Diagnóstico Tardio , Registros Eletrônicos de Saúde , Embolia/epidemiologia , Embolia/fisiopatologia , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , North Carolina/epidemiologia , Valor Preditivo dos Testes , Prevalência , Prognóstico , Recidiva , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo
5.
Ann Vasc Surg ; 69: 451.e1-451.e4, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32615205

RESUMO

We present here a case of an uncommon cutaneous manifestation after paclitaxel-coated balloon angioplasty. In this case, the patient underwent drug-coated balloon angioplasty for stenosis of a prior vein bypass graft. The patient subsequently developed extensive cutaneous lesions not confined to a single arterial distribution. This case represents a rare complication related to paclitaxel-eluting balloons and provides a cautionary tale as well as clinical acumen for providers in using such devices in their practice.


Assuntos
Angioplastia com Balão/efeitos adversos , Angioplastia com Balão/instrumentação , Fármacos Cardiovasculares/administração & dosagem , Embolia/etiologia , Oclusão de Enxerto Vascular/terapia , Extremidade Inferior/irrigação sanguínea , Paclitaxel/administração & dosagem , Dispositivos de Acesso Vascular , Analgésicos/uso terapêutico , Embolia/diagnóstico , Embolia/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
6.
BMC Neurol ; 20(1): 229, 2020 Jun 04.
Artigo em Inglês | MEDLINE | ID: mdl-32498705

RESUMO

BACKGROUND: Arterial thoracic outlet syndrome is a rare condition characterized by a subclavian artery pathology associated with a bone abnormality. It is rarely associated with thromboembolic stroke. The mechanism of cerebral embolism associated with thoracic outlet syndrome have rarely been demonstrated. We present here a fully studied case with a high probability of reverse flow embolism. CASE PRESENTATION: A 24-year-old man with a known arterial thoracic outlet syndrome presented with a right cerebral posterior artery brain infarction. An ultrasound examination depicted the compression of the right subclavian artery in the scalene defile with a post stenotic aneurysm and the presence of a floating thrombus in this aneurysm. There was a reverse flow during diastole in this aneurysm. Anticoagulation was carried out with the disappearance of the floating thrombus with no new clinical or brain MRI event. Corrective surgery of this thoracic outlet syndrome was performed one month after stroke. CONCLUSION: Very few cases of stroke in arterial thoracic outlet syndrome have been described with thorough dynamic vascular imaging. To our knowledge, this is the fourth reported case that advocates for a reverse flow embolism mechanism in stroke associated with thoracic outlet syndrome, and the first to realize an extensive ultrasound and doppler workup.


Assuntos
Infarto da Artéria Cerebral Posterior/diagnóstico , Acidente Vascular Cerebral/diagnóstico , Síndrome do Desfiladeiro Torácico/complicações , Constrição Patológica/patologia , Embolia/diagnóstico , Humanos , Embolia Intracraniana/patologia , Masculino , Artéria Subclávia , Tromboembolia/diagnóstico , Ultrassonografia , Adulto Jovem
7.
Cardiovasc Ther ; 2020: 2683740, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32405322

RESUMO

Background: We performed a network meta-analysis (NMA) comparing the efficacy (stroke or systemic embolism) and safety (major bleeding) among different non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) and renal impairment, with the aim of recommending the proper drug and the dose based on renal function. Methods: We searched PubMed, EMBASE, Web of Science, and Cochrane Library with the items "dabigatran, edoxaban, apixaban, rivaroxaban, warfarin, and atrial fibrillation" through August 2019. NMA was analyzed with R (version 3.5.1, R Foundation for Statistical Computing) with the packages gemtc recalling JAGS (version 4.3.0) for the efficacy and safety of each drug with regard to different levels of renal function. NetMetaXL (version 1.6.1) and winBUGS (version 1.4.3) were used to obtain the cumulative ranking curve (SUCRA) of each drug. Result: In patients with normal renal function, dabigatran150 was ranked as the most effective drug (SUCRA 0.90), followed by dabigatran110 (SUCRA 0.68), apixaban (SUCRA 0.66), and rivaroxaban (SUCRA 0.59). With regard to the safety for preventing major bleeding, there was high probability that edoxaban30 (SUCRA 0.99) ranked first, compared to dabigatran110 (SUCRA 0.78) and edoxaban60 (SUCRA 0.66). For patients with mild renal impairment, with respect to the most effective drug for preventing stroke or systemic embolism, edoxaban60 ranked first (SUCRA 0.98), in comparison with dabigatran150 (SUCRA 0.74) and apixaban (SUCRA 0.64). Possibility of ranking first for the safest drug was edoxaban30 (SUCRA 0.99), followed by dabigatran110 (SUCRA 0.70) and apixaban (SUCRA 0.69). In patients with moderate renal function, dabigatran150 (SUCRA 0.95) ranked as the most effective drug in comparison with apixaban (SUCRA 0.66). Dabigatran110 (SUCRA 0.53), rivaroxaban (SUCRA 0.51), and edoxaban60 (SUCRA 0.50) had the similar probability of ranking third. When referred to the safest drug, probability of ranking first for preventing major bleeding was edoxaban30 (SUCRA 0.98), followed by apixaban (SUCRA 0.85) and edoxaban60 (SUCRA 0.64). Conclusion: In patients with AF and renal impairment and for patients with normal renal function, dabigatran 110 mg (bid) might have a better effect on the clinical results. And it does not coincide with patients taking dabigatran 110 mg with dose reduction for other factors including aged ≥75 years, renal impairment (CrCL 30-50 mL/min), gastritis, esophagitis, or gastroesophageal reflux, receiving concomitant verapamil, and so on. For patients with mild renal impairment, apixaban 5 mg (bid) would be a better choice for preventing stroke or systemic embolism and major bleeding, while apixaban 5 mg (bid) and edoxaban 60 mg (qd) were recommended for patients with moderate renal impairment. However, considering the fact of no RCTs for the head-to-head comparison, caution should be exercised over selecting each of NOACs for patients.


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Embolia/prevenção & controle , Taxa de Filtração Glomerular , Nefropatias/fisiopatologia , Rim/fisiopatologia , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Idoso , Anticoagulantes/efeitos adversos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Tomada de Decisão Clínica , Embolia/diagnóstico , Embolia/epidemiologia , Feminino , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Nefropatias/diagnóstico , Nefropatias/epidemiologia , Masculino , Metanálise em Rede , Seleção de Pacientes , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Resultado do Tratamento
8.
J Clin Neurosci ; 77: 222-224, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32409214

RESUMO

Fibrocartilaginous embolism (FCE) is a rare and probably under diagnosed cause of spinal cord infarction presumably due to acute embolization of nucleus pulposus fragments into the spinal circulation. Concomitant cerebral involvement is much rarer and often asymptomatic. Although the definitive diagnosis is histologic, certain criteria have been proposed to support the diagnosis in living patients, such as absence of vascular risk factors, acute onset or antecedent of valsalva maneuver before the episode and the exclusion of potential differential diagnoses. A 56 years-old patient, without any medical history was referred for sudden back pain while carrying heavy load at work. Clinical examination showed a Brown-Sequard syndrome. Brain and spine MRI disclosed spinal cord infarction at the C4-C5 level associated with brain infarctions involving exclusively the vertebrobasilar circulation. The exhaustive etiological assessment was normal. In our case, the acute symptoms onset, the clinical and imaging data and lack of evidence for other plausible diagnoses in the setting of a valsalva-like maneuver are highly suggestive of FCE diagnosis.


Assuntos
Encéfalo/irrigação sanguínea , Doenças das Cartilagens/complicações , Embolia/complicações , Infarto/etiologia , Medula Espinal/irrigação sanguínea , Síndrome de Brown-Séquard/etiologia , Doenças das Cartilagens/diagnóstico , Doenças das Cartilagens/patologia , Diagnóstico Diferencial , Embolia/diagnóstico , Embolia/patologia , Humanos , Infarto/diagnóstico , Infarto/patologia , Imagem por Ressonância Magnética/efeitos adversos , Masculino , Pessoa de Meia-Idade , Medula Espinal/patologia
11.
Rev. esp. cir. ortop. traumatol. (Ed. impr.) ; 64(2): 130-133, mar.-abr. 2020. ilus
Artigo em Espanhol | IBECS | ID: ibc-196242

RESUMO

La lesión vascular arterial asociada a la luxación anterior de hombro es una complicación rara, pero potencialmente devastadora, a menudo en el contexto de traumatismos de alta energía o heridas penetrantes. Se trata de una urgencia médica que puede llegar a comprometer la viabilidad y funcionalidad del miembro, incluso la vida del paciente si no es identificada precozmente y tratada de forma adecuada. Sin embargo, su diagnóstico puede ser difícil, pues precisa un alto índice de sospecha. La presencia de una trombosis de la arteria axilar con una luxación de hombro por un mecanismo de baja energía es extraordinariamente poco frecuente, especialmente cuando se presenta de forma subaguda con embolismo en la arteria radial


Arterial vascular injury associated with anterior dislocation of the shoulder is a rare but potentially devastating complication, often seen in the context of high-energy trauma or penetrating injury. It is a medical emergency that can compromise both the viability and functionality of the limb, as well as the patient's life if it is not identified early and treated properly. However, its diagnosis can be difficult, since it requires a high index of suspicion. The presence of an axillary artery thrombosis after shoulder dislocation resulting from low-energy trauma is extremely rare, even more so with subacute clinical presentation associated with embolism to the radial artery


Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Artéria Axilar/lesões , Embolia/diagnóstico , Artéria Radial , Luxação do Ombro/complicações , Trombose/diagnóstico , Lesões do Sistema Vascular/diagnóstico , Artéria Axilar/diagnóstico por imagem , Artéria Axilar/cirurgia , Embolia/etiologia , Embolia/cirurgia , Artéria Radial/diagnóstico por imagem , Artéria Radial/cirurgia , Trombose/etiologia , Trombose/cirurgia , Lesões do Sistema Vascular/etiologia , Lesões do Sistema Vascular/cirurgia
12.
Stroke ; 51(4): 1294-1296, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32078473

RESUMO

Background and Purpose- Compared with other causes of ischemic stroke, the mechanism of action of embolic stroke of undetermined source (ESUS) remains unclear, with previous literature suggesting that ESUS may be due to an undetected cardioembolic source. This study aimed to improve our understanding of the pathophysiology of ESUS through current knowledge of sleep disorders. Methods- Patients were included in this study if they sustained an ischemic stroke and completed either polysomnography or a home sleep apnea test. Strokes were classified into 1 of 6 mechanisms and were compared with the presence of sleep disorders (ie, obstructive sleep apnea, periodic limb movements, and abnormalities in sleep architecture). Results- There was a significant relationship between obstructive sleep apnea and cardioembolic stroke mechanism compared with the other stroke mechanisms (P=0.018). There was no significant relationship between obstructive sleep apnea and ESUS (P=0.585). Patients with ESUS were significantly more likely to have an elevated periodic limb movement index (P=0.037) and prolonged sleep onset latency (P=0.0166) compared with patients with other causes of stroke. Conclusions- ESUS was not associated with markers of cardioembolic stroke such as obstructive sleep apnea. There was a significant relationship between ESUS and elevated periodic limb movements and impaired sleep architecture, which suggests that ESUS may have a multifactorial underlying pathophysiology.


Assuntos
Isquemia Encefálica/epidemiologia , Embolia/epidemiologia , Transtornos do Sono-Vigília/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Embolia/diagnóstico , Embolia/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos do Sono-Vigília/diagnóstico , Transtornos do Sono-Vigília/fisiopatologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia
14.
J Am Coll Cardiol ; 75(3): 333-340, 2020 01 28.
Artigo em Inglês | MEDLINE | ID: mdl-31976872

RESUMO

The term embolic stroke of undetermined source (ESUS) was introduced in 2014 to describe patients with a nonlacunar ischemic stroke and no convincing etiology. The terms ESUS and cryptogenic stroke are not synonyms, as the latter also includes patients with multiple stroke etiologies or incomplete diagnostic work-up. ESUS involves approximately 17% of all ischemic stroke patients, and these patients are typically younger with mild strokes and an annual rate of stroke recurrence of 4% to 5%. It was hypothesized that oral anticoagulation may decrease the risk of stroke recurrence in ESUS, which was tested in 2 large randomized controlled trials: the NAVIGATE ESUS (Rivaroxaban Versus Aspirin in Secondary Prevention of Stroke and Prevention of Systemic Embolism in Patients With Recent Embolic Stroke of Undetermined Source) and the RE-SPECT ESUS (Dabigatran Etexilate for Secondary Stroke Prevention in Patients With Embolic Stroke of Undetermined Source). The present review discusses the trials of anticoagulation in patients with ESUS, suggests potential explanations for their neutral results, and highlights the rationale that supports ongoing and future research in this population aiming to reduce the associated risk for stroke recurrence.


Assuntos
Embolia/diagnóstico , Embolia/terapia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Anticoagulantes/uso terapêutico , Ensaios Clínicos como Assunto/métodos , Embolia/epidemiologia , Humanos , Inibidores da Agregação de Plaquetas/uso terapêutico , Acidente Vascular Cerebral/fisiopatologia
15.
Eur Heart J Cardiovasc Pharmacother ; 6(2): 75-85, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-31942972

RESUMO

AIMS: The aim of this study was to compare the risk of stroke or systemic embolism (SE) and major bleeding in patients with atrial fibrillation (AF) using dabigatran, rivaroxaban, and apixaban in routine clinical practice. METHODS AND RESULTS: Using nationwide registries in Norway from January 2013 to December 2017, we established a cohort of 52 476 new users of non-vitamin K antagonist oral anticoagulants (NOACs) with AF. Users of individual NOACs were matched 1:1 on the propensity score to create three pairwise-matched cohorts: dabigatran vs. rivaroxaban (20 504 patients), dabigatran vs. apixaban (20 826 patients), and rivaroxaban vs. apixaban (27 398 patients). Hazard ratios (HRs) for the risk of stroke or SE and major bleeding were estimated. In the propensity-matched comparisons of the risk of stroke or SE, the HRs were 0.88 [95% confidence interval (CI) 0.76-1.02] for dabigatran vs. rivaroxaban, 0.88 (95% CI 0.75-1.02) for dabigatran vs. apixaban, and 1.00 (95% CI 0.89-1.14) for apixaban vs. rivaroxaban. For the risk of major bleeding, the HRs were 0.75 (95% CI 0.64-0.88) for dabigatran vs. rivaroxaban, 1.03 (95% CI 0.85-1.24) for dabigatran vs. apixaban, and 0.79 (95% CI 0.68-0.91) for apixaban vs. rivaroxaban. CONCLUSION: In this nationwide study of patients with AF in Norway, we found no statistically significant differences in risk of stroke or SE in propensity-matched comparisons between dabigatran, rivaroxaban, and apixaban. However, dabigatran and apixaban were both associated with significantly lower risk of major bleeding compared with rivaroxaban.


Assuntos
Antitrombinas/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Dabigatrana/administração & dosagem , Embolia/prevenção & controle , Inibidores do Fator Xa/administração & dosagem , Pirazóis/administração & dosagem , Piridonas/administração & dosagem , Rivaroxabana/administração & dosagem , Acidente Vascular Cerebral/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Antitrombinas/efeitos adversos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Dabigatrana/efeitos adversos , Bases de Dados Factuais , Embolia/diagnóstico , Embolia/epidemiologia , Inibidores do Fator Xa/efeitos adversos , Feminino , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Noruega/epidemiologia , Segurança do Paciente , Pirazóis/efeitos adversos , Piridonas/efeitos adversos , Sistema de Registros , Medição de Risco , Fatores de Risco , Rivaroxabana/efeitos adversos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Resultado do Tratamento
16.
J Stroke Cerebrovasc Dis ; 29(2): 104446, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31837921

RESUMO

OBJECTIVE: In population-based studies asymptomatic retinal emboli occur in .32%-2.9% of people. Retinal artery occlusion (RAO) may occur concurrently with cerebral stroke but the frequency is unknown. No study has examined how commonly retinal emboli occur in the acute stroke population. We aimed to assess the prevalence of retinal emboli and RAO at the time of carotid territory ischemic stroke. METHODS: Patients were enrolled prospectively after onset of symptoms consistent with the diagnosis of carotid territory ischemic stroke. Every participant underwent pharmacologic dilation of both pupils and bedside funduscopic examination. Emboli were classified as cholesterol, calcific, platelet/fibrin, or other and categorized by the side of occurrence. Stroke was classified as atheroembolic, cardioembolic, embolic stroke of undetermined source, lacunar, or other. Acute RAO was diagnosed by direct visualization of ischemic retinal whitening. RESULTS: Sixty-five patients were enrolled with a mean age of 59.2 years; 23 were female (35.4%). Eleven of 65 subjects (16.9%) had retinal emboli visible on funduscopy; all were cholesterol emboli except a single platelet/fibrin embolus in a patient with atheroembolic source. Six patients (9%) had acute RAO and no RAO was seen in the lacunar or undetermined source subgroups. CONCLUSIONS: Retinal emboli occurred more than 10 times more frequently in the acute stroke patient than in large population-based studies. RAOs also occurred concurrently with ischemic stroke. Although emboli were seen in patients with atheroembolic and cardioembolic sources, all patients with carotid disease had emboli in the ipsilateral eye. Future studies are required to determine if the presence of retinal emboli or RAO may help elucidate an etiology in patients suffering from embolic stroke of undetermined source.


Assuntos
Isquemia Encefálica/epidemiologia , Embolia/epidemiologia , Oclusão da Artéria Retiniana/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas , Isquemia Encefálica/diagnóstico , Embolia/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oregon/epidemiologia , Projetos Piloto , Prevalência , Estudos Prospectivos , Oclusão da Artéria Retiniana/diagnóstico , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Adulto Jovem
17.
Arterioscler Thromb Vasc Biol ; 40(1): 279-287, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31766870

RESUMO

OBJECTIVE: Takotsubo syndrome (TTS) is characterized by acute left ventricular dysfunction, which can contribute to intraventricular thrombus and embolism. Still, prevalence and clinical impact of thrombus formation and embolic events on outcome of TTS patients remain unclear. This study aimed to investigate clinical features and outcomes of patients with and without intraventricular thrombus or embolism. Additionally, factors associated with thrombus formation or embolism, as well as predictors for mortality, were identified. Approach and Results: TTS patients enrolled in the International Takotsubo Registry at 28 centers in Australia, Europe, and the United States were dichotomized according to the occurrence/absence of intraventricular thrombus or embolism. Patients with intraventricular thrombus or embolism were defined as the ThrombEmb group. Of 1676 TTS patients, 56 (3.3%) patients developed intraventricular thrombus and/or embolism following TTS diagnosis (median time interval, 2.0 days [range, 0-38 days]). Patients in the ThrombEmb group had a different clinical profile including lower left ventricular ejection fraction, higher prevalence of the apical type, elevated levels of troponin and inflammatory markers, and higher prevalence of vascular disease. In a Firth bias-reduced penalized-likelihood logistic regression model apical type, left ventricular ejection fraction ≤30%, previous vascular disease, and a white blood cell count on admission >10×103 cells/µL emerged as independent predictors for thrombus formation or embolism. CONCLUSIONS: Intraventricular thrombus or embolism occur in 3.3% of patients in the acute phase of TTS. A simple risk score including clinical parameters associated with intraventricular thrombus formation or embolism identifies patients at increased risk. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01947621.


Assuntos
Embolia/etiologia , Sistema de Registros , Medição de Risco/métodos , Cardiomiopatia de Takotsubo/complicações , Trombose/etiologia , Idoso , Austrália/epidemiologia , Angiografia Coronária , Eletrocardiografia , Embolia/diagnóstico , Embolia/epidemiologia , Europa (Continente)/epidemiologia , Feminino , Seguimentos , Cardiopatias/diagnóstico , Cardiopatias/epidemiologia , Cardiopatias/etiologia , Ventrículos do Coração , Humanos , Incidência , Imagem Cinética por Ressonância Magnética , Masculino , Ventriculografia com Radionuclídeos , Fatores de Risco , Taxa de Sobrevida/tendências , Cardiomiopatia de Takotsubo/diagnóstico , Trombose/diagnóstico , Trombose/epidemiologia , Fatores de Tempo , Estados Unidos/epidemiologia
18.
J Stroke Cerebrovasc Dis ; 29(3): 104527, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31810724

RESUMO

BACKGROUND: Troponin is a marker of cardiac ischemia and is elevated in about 30% of stroke patients. We investigated if the elevation of troponin during an acute stroke code is associated with a cardioembolic source. METHODS: We performed a retrospective chart review of patients evaluated for acute strokes from July 2014 to March 2018. Patients included in the study were all given intravenous alteplase, had blood drawn for troponins during the acute stroke code and had confirmation of a new stroke on neuroimaging during hospitalization. Patients who were on dialysis or had a glomerular filtration rate of less than or equal to 40 ml/minutes on initial laboratory evaluation were excluded. Stroke etiology was classified into noncardioembolic (NCE) and cardioembolic (CE), according to Trial of Org 10172 in Acute Stroke Treatment criteria. The NCE group was compared with the CE group with respect to troponin levels. Troponin was considered as a dichotomous categorical variable, with a cut-off point at greater than or equal to.05 ng/ml. RESULTS: 144 patients met the inclusion criteria. In our cohort, 40.74% of patients in the CE group had troponin levels of greater than or equal to .05 ng/mL compared to 12.22% in NCE group. A troponin level of greater than or equal to.05 ng/ml obtained during a stroke code showed a significant difference between cardioembolic and noncardioembolic strokes (OR, 4.94; 95% CI, 2.15-11.35; P < .001), with high specificity (87.78%) but low sensitivity (40.74%) to exclude noncardioembolic stroke. CONCLUSIONS: A troponin level of greater than or equal to .05 ng/ml obtained during a stroke code showed a significant difference between CE and NCE strokes. This finding may have implications for clinical workup, and patients with admission troponin levels of greater than or equal to .05 ng/mL may need further clinical investigations to look for a cardioembolic source. A troponin level of greater than or equal to .05 ng/ml may prompt a more thorough search for a cardioembolic source in cases in which such a source is not identified on initial evaluation.


Assuntos
Embolia/sangue , Cardiopatias/sangue , Acidente Vascular Cerebral/sangue , Troponina/sangue , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Embolia/complicações , Embolia/diagnóstico , Feminino , Fibrinolíticos/administração & dosagem , Cardiopatias/complicações , Cardiopatias/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/etiologia , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/administração & dosagem , Regulação para Cima
19.
Heart Vessels ; 35(3): 399-408, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31492970

RESUMO

Direct oral anticoagulants (DOACs), such as rivaroxaban, reduce the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation (NVAF). However, it is still unclear whether the stroke reduction benefit outweighs the bleeding risk in elderly Japanese patients with NVAF. The Xarelto Post-Authorization Safety and Effectiveness Study in Japanese Patients with Atrial Fibrillation (XAPASS) was a real-world, prospective observational, post-marketing surveillance study on the safety and effectiveness of rivaroxaban in Japanese clinical practice. This sub-analysis evaluated the clinical outcomes of elderly patients aged ≥ 75 years. At the 1-year follow-up, there were 4,685 (48.91%) and 4,893 (51.09%) patients aged ≥ 75 and < 75 years, respectively. Safety and effectiveness outcomes were compared between patients aged ≥ 75 years and those aged < 75 years, and among 3 elderly sub-populations (age ranges: 75-79, 80-84, and ≥ 85 years). Patients aged ≥ 75 years had higher rates of major bleeding [2.22 vs. 1.35 events per 100 patient-years, hazard ratio (HR) 1.63, 95% confidence interval (CI) 1.17-2.28] and composite of stroke (ischemic or hemorrhagic)/non-central nervous system (non-CNS) systemic embolism (SE)/myocardial infarction (MI) (2.41 vs. 1.21 events per 100 patient-years, HR 1.97, 95% CI 1.40-2.77) compared to patients aged < 75 years. Intracranial hemorrhage rates were < 1 event per 100 patient-years in both groups (0.85 vs. 0.59 events per 100 patient-years, HR 1.43, 95% CI 0.85-2.40). Kaplan-Meier curves of major bleeding and stroke/non-CNS SE/MI showed that no significant differences of cumulative event rates were identified among the 3 elderly sub-populations. Stepwise Cox regression analyses revealed that creatinine clearance (CrCl) (<50 mL/min), hepatic impairment, and hypertension were specific predictors for major bleeding and no specific predictors were found for stroke/non-CNS SE/MI in patients aged ≥ 75 years. In conclusion, safety and effectiveness event rates were higher in patients aged ≥ 75 years compared with those aged < 75 years, yet, no distinct differences were observed among the 3 elderly sub-populations.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Embolia/prevenção & controle , Inibidores do Fator Xa/administração & dosagem , Rivaroxabana/administração & dosagem , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Embolia/diagnóstico , Embolia/epidemiologia , Inibidores do Fator Xa/efeitos adversos , Feminino , Hemorragia/induzido quimicamente , Humanos , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Vigilância de Produtos Comercializados , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Rivaroxabana/efeitos adversos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Resultado do Tratamento
20.
BMJ Open ; 9(12): e031716, 2019 12 09.
Artigo em Inglês | MEDLINE | ID: mdl-31822542

RESUMO

INTRODUCTION: So far there is no uniform, commonly accepted diagnostic and therapeutic algorithm for patients with embolic stroke of undetermined source (ESUS). Recent clinical trials on secondary stroke prevention in ESUS did not support the use of oral anticoagulation. As ESUS comprises heterogeneous subgroups including a wide age-range, concomitant patent foramen ovale (PFO), and variable probability for atrial fibrillation (AF), an individualised approach is urgently needed. This prospective registry study aims to provide initial data towards an individual, structured diagnostic and therapeutic approach in ESUS patients. METHODS AND ANALYSIS: The open-label, investigator-initiated, prospective, single-centre, observational registry study (Catch-up-ESUS) started in 01/2018. Consecutive ESUS patients ≥18 years who give informed consent are included and will be followed up for 3 years. Stratified by age <60 or ≥60 years, the patients are processed following a standardised diagnostic and treatment algorithm with an interdisciplinary design involving neurologists and cardiologists. Depending on the strata, patients receive a transesophageal echocardiogram; all patients receive an implantable cardiac monitor. Patients <60 years with PFO and without evidence of concomitant AF are planned for PFO closure within 6 months after stroke. The current diagnostic and therapeutic workup of ESUS patients requires improvement by both standardisation and a more individualised approach. Catch-up-ESUS will provide important data with respect to AF detection and PFO closure and will estimate stratified stroke recurrence rates after ESUS. ETHICS AND DISSEMINATION: The study has been approved by the responsible ethics committee at the Ludwig Maximilian University, Munich, Germany (project number 17-685). Catch-Up-ESUS is conducted in accordance with the Declaration of Helsinki. All patients will have to give written informed consent or, if unable to give consent themselves, their legal guardian will have to provide written informed consent for their participation. The first observation period of the registry study is 1 year, followed by the first publication of the results including follow-up of the patients. Further publications will be considered according the predefined individual follow-up dates of the stroke patients up to 36 months. TRIAL REGISTRATION NUMBER: Clinicaltrialsregister.gov registry (NCT03820375).


Assuntos
Embolia/diagnóstico , Embolia/terapia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Fibrilação Atrial/complicações , Eletrocardiografia , Forame Oval Patente/complicações , Alemanha , Humanos , Estudos Observacionais como Assunto , Estudos Prospectivos , Sistema de Registros , Projetos de Pesquisa , Fatores de Risco
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