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1.
Medicine (Baltimore) ; 98(42): e17628, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31626146

RESUMO

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


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Insuficiência Renal Crônica/complicações , Acidente Vascular Cerebral/prevenção & controle , Terapia Trombolítica/métodos , Fibrilação Atrial/complicações , Humanos , Diálise Renal , Insuficiência Renal Crônica/terapia , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
2.
Wiad Lek ; 72(9 cz 2): 1829-1833, 2019.
Artigo em Polonês | MEDLINE | ID: mdl-31622274

RESUMO

Atrial fibrillation (AF) is the most common cardiac arrhythmia in the adult population. Thromboembolic events are one of the reson of increased mortality in this group of patients. Oral anticoagulation therapy significantly reduces the risk of complications, however every tenth patient has contraindications to this treatment. Percutaneous left atrial appendage occlusion (LAAO) is effective, non-pharmacological method of treatment through elimination the source of thromi. This procedure is dedicated to patients with high risk of thromboembolism events and contraindications to anticoagulation.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/terapia , Tromboembolia/prevenção & controle , Anticoagulantes , Fibrilação Atrial/complicações , Humanos , Terapia Trombolítica
3.
Ideggyogy Sz ; 72(7-8): 241-256, 2019 Jul 30.
Artigo em Inglês | MEDLINE | ID: mdl-31517456

RESUMO

Background and purpose: The aim of this study is to evaluate utility of CHADS2 score to estimate stroke severity and prognosis in patients with ischemic stroke due to non-valvular atrial fibrillation (AF) in addition to evaluate effects of hematologic and echocardiographic findings on stroke severity and prognosis. Methods: This prospective study included 156 ischemic stroke cases due to non-valvular AF in neurology ward of Trakya University Medical School between March 2013-March 2015. National Institute of Health Stroke (NIHS) score was used to evaluate severity of stroke at admission. Carotid and vertebral Doppler ultrasonography findings, brain computed tomography (CT) and magnetic resonance imaging (MRI) of the cases were evaluated. Left atrial diameter and ejection fraction (EF) values were measured. CHADS2 score was calculated. Modified Rankin Scale was used to rate the degree of dependence. Effects of age and sex of the patients, presence of diabetes mellitus (DM), Congestive Heart Failure (CHF), Cerebrovascular Disease (CVD) and C-reactive protein (CRP) levels on CHADS2, NIHS, and mRS were evaluated. Results: In patients with age ≥75, mean NIHS score was 3.3 points and mean mRS score was 1.02 points higher, than in patient below 75 years of age. Compared with the mild risk group, cases in the high risk group had older age, higher serum D-dimer, fibrinogen and CRP levels and lower EF. A positive relation was detected between stroke severity and Hemorrhagic Transformation (HT), previous CVD history, and presence of CHF. A significant association was found between increased stroke severity and Early Neurological Deterioration (END) development. Older age, higher serum fibrinogen, D-dimer, CRP and lower EF values were associated with poor prognosis. History of CVD and presence of CHF were associated with poor prognosis. END development was found to be associated with poor prognosis. In the high-risk group, 30.3% (n = 33) had END. Among those in the high-risk group according to the CHADS2 score, END development rate was found to be significantly higher than in the moderate risk group (p <0.05). There was a strong positive correlation between CHADS2 and NIHS scores. mRS score increased with increasing CHADS2 score and there was a strong correlation between them. Effect of stroke severity on prognosis was assessed and a positive correlation was found between NIHS score and mRS value. Conclusion: Our study demonstrated the importance of CHADS2 score, haemostatic activation and echocardiographic findings to assess stroke severity and prognosis. Knowing factors which affect stroke severity and prognosis in patients with ischemic stroke may be directive to decide primary prevention and stroke management.


Assuntos
Fibrilação Atrial/complicações , Ecocardiografia , Insuficiência Cardíaca/complicações , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/epidemiologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Idoso , Fibrilação Atrial/sangue , Humanos , Ataque Isquêmico Transitório/etiologia , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/etiologia
4.
Adv Gerontol ; 32(3): 415-421, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31512429

RESUMO

Aged patients with atrial fibrillation (AF) are at high risk of both thromboembolic and haemorrhagic complications of disease and of its treatment. A study was provided to assess the role of D-dimer plasma level as a marker of thrombosis in aged patients with AF having no clinical signs of active thrombosis depending on used treatment strategy and quantitative thrombotic and haemorrhagic risk of AF. The results show that D-dimer plasma levels correlate with scores of thromboembolic and haemorrhagic risks in group on antiplatelet agents but not anticoagulants, with the difference in D-dimer level driven by subgroup on CHA2DS2-VASc score ≥5. High D-dimer level was associated with in-hospital mortality and rhythm of AF at the moment of blood sample collection. Therefore, an accuracy of risk prognosis of fatal complications of AF for elderly patients may be increased by using the laboratory markers of thrombus formation such as D-dimer and by using the obtained results to guide an antithrombotic therapy.


Assuntos
Fibrilação Atrial , Biomarcadores , Produtos de Degradação da Fibrina e do Fibrinogênio , Trombose , Idoso , Fibrilação Atrial/complicações , Biomarcadores/sangue , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Fatores de Risco , Trombose/diagnóstico , Trombose/etiologia
5.
N Engl J Med ; 381(12): 1103-1113, 2019 09 19.
Artigo em Inglês | MEDLINE | ID: mdl-31475793

RESUMO

BACKGROUND: There are limited data from randomized trials evaluating the use of antithrombotic therapy in patients with atrial fibrillation and stable coronary artery disease. METHODS: In a multicenter, open-label trial conducted in Japan, we randomly assigned 2236 patients with atrial fibrillation who had undergone percutaneous coronary intervention (PCI) or coronary-artery bypass grafting (CABG) more than 1 year earlier or who had angiographically confirmed coronary artery disease not requiring revascularization to receive monotherapy with rivaroxaban (a non-vitamin K antagonist oral anticoagulant) or combination therapy with rivaroxaban plus a single antiplatelet agent. The primary efficacy end point was a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, or death from any cause; this end point was analyzed for noninferiority with a noninferiority margin of 1.46. The primary safety end point was major bleeding, according to the criteria of the International Society on Thrombosis and Hemostasis; this end point was analyzed for superiority. RESULTS: The trial was stopped early because of increased mortality in the combination-therapy group. Rivaroxaban monotherapy was noninferior to combination therapy for the primary efficacy end point, with event rates of 4.14% and 5.75% per patient-year, respectively (hazard ratio, 0.72; 95% confidence interval [CI], 0.55 to 0.95; P<0.001 for noninferiority). Rivaroxaban monotherapy was superior to combination therapy for the primary safety end point, with event rates of 1.62% and 2.76% per patient-year, respectively (hazard ratio, 0.59; 95% CI, 0.39 to 0.89; P = 0.01 for superiority). CONCLUSIONS: As antithrombotic therapy, rivaroxaban monotherapy was noninferior to combination therapy for efficacy and superior for safety in patients with atrial fibrillation and stable coronary artery disease. (Funded by the Japan Cardiovascular Research Foundation; AFIRE UMIN Clinical Trials Registry number, UMIN000016612; and ClinicalTrials.gov number, NCT02642419.).


Assuntos
Fibrilação Atrial/tratamento farmacológico , Doença das Coronárias/terapia , Inibidores do Fator Xa/uso terapêutico , Inibidores da Agregação de Plaquetas/uso terapêutico , Rivaroxabana/uso terapêutico , Idoso , Aspirina/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/mortalidade , Ponte de Artéria Coronária , Doença das Coronárias/complicações , Quimioterapia Combinada/efeitos adversos , Inibidores do Fator Xa/efeitos adversos , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/efeitos adversos , Modelos de Riscos Proporcionais , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Rivaroxabana/efeitos adversos
6.
Lancet ; 394(10206): 1335-1343, 2019 Oct 12.
Artigo em Inglês | MEDLINE | ID: mdl-31492505

RESUMO

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


Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/uso terapêutico , Fibrinolíticos/uso terapêutico , Intervenção Coronária Percutânea , Piridinas/uso terapêutico , Tiazóis/uso terapêutico , Vitamina K/antagonistas & inibidores , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/cirurgia , Idoso , Fibrilação Atrial/complicações , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/uso terapêutico , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Stents , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
7.
Zhejiang Da Xue Xue Bao Yi Xue Ban ; 48(3): 254-259, 2019 May 25.
Artigo em Chinês | MEDLINE | ID: mdl-31496156

RESUMO

OBJECTIVE: To investigate the association of atrial fibrillation (AF) with hemorrhagic transformation (HT) in patients with ischemic stroke treated by intravenous thrombolysis. METHODS: Clinical data of 3272 patients treated by intravenous thrombolysis from 71 hospitals in Zhejiang Province during June 2017 and December 2018 were retrospectively reviewed. Intracranial HT was defined as intracranial hemorrhage suggested by imaging examination 24 hours after intravenous thrombolysis. Patients were dichotomized into HT group (n=533) and non-HT group (n=2739). The association of AF and HT was analyzed by univariate analysis and binary logistic regression. RESULTS: Compared with the non-HT group, the HT group were older, had longer onset to needle time (ONT), higher baseline National Institute of Health Stroke Scale (NIHSS) score, higher baseline glucose level, and higher AF rate (P<0.05 or P<0.01). Binary logistic regression analysis revealed that AF was independently associated with HT (OR=2.527, 95%CI:2.030-3.146, P<0.01). CONCLUSIONS: AF is independently associated with the occurrence of HT in ischemic stroke patients treated with intravenous thrombolysis.


Assuntos
Fibrilação Atrial , Isquemia Encefálica , Acidente Vascular Cerebral , Antifibrinolíticos/efeitos adversos , Antifibrinolíticos/farmacologia , Fibrilação Atrial/complicações , Isquemia Encefálica/complicações , Isquemia Encefálica/tratamento farmacológico , Humanos , Estudos Retrospectivos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/efeitos adversos , Resultado do Tratamento
8.
Med Clin North Am ; 103(5): 847-862, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31378330

RESUMO

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


Assuntos
Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Ensaios Clínicos como Assunto , Humanos , Guias de Prática Clínica como Assunto , Acidente Vascular Cerebral/etiologia , Varfarina/administração & dosagem , Varfarina/efeitos adversos
9.
Medicine (Baltimore) ; 98(31): e16560, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31374021

RESUMO

BACKGROUND: Patients with atrial fibrillation (AF) have a higher risk of fatal complications (e.g., stroke). This investigation was performed as an observational retrospective cohort study includes 137 patients (age 61 ±â€Š15; 34.3% women) with a primary diagnosis of AF (paroxysmal, persistent, and permanent). METHODS: We collected information about the drug therapy, comorbidities and survival of AF patients and determined their congestive heart failure, hypertension, age, diabetes mellitus, prior stroke or TIA or thromboembolism, vascular disease, age, sex category (CHA2DS2-VASc) scores. Statistical analysis identified patients with high CHA2DS2-VASc scores and defined the predictive value of individual parameters, or their combination, with regards to the outcomes of stroke and mortality. RESULTS: CHA2DS2-VASc scores identified 43.8% of the patients as low to intermediate risk (score 0-1) and 56.2% of the patients as high risk (score ≥2). Increasing CHA2DS2-VASc scores were not only accompanied by an increase in the incidence of stroke (Ptrend < .001) but also by an increase in the 3 to 5 years mortality (P = .005). Comparison of anticoagulation and anti-aggregation treatment between the 3 groups of AF did not show any significant statistical difference. Highly significant predictors of death were the CHA2DS2-VASc score (OR 1.71, 95% CI 1.10-2.67, P < .017) as well as other risk factors not included in the CHA2DS2-VASc score such as valvular heart disease (OR 5.04, 95% CI 1.10-23.10, P = .037), hyperlipidemia (OR 4.82, 95% CI 1.03-22.63, P = .046) and chronic renal failure (OR 14.21, 95% CI 2.41-83.91, P = .003). The type of AF type did not affect survival (P = .158) nor the incidence of stroke (P = .466). Patients with paroxysmal AF were linked to significantly lower frequencies of ischemic heart disease (P < .0001), vascular disease (P = .002), diabetes mellitus (P = .047), valvular heart disease (P = .03) and heart failure/left ventricular dysfunction (P = .015). CONCLUSION: The CHA2DS2-VASc score correctly predicted the patients at high-risk for 3 to 5 years mortality and confirmed its significant predictive value in the patients with AF.


Assuntos
Fibrilação Atrial/complicações , Projetos de Pesquisa/normas , Medição de Risco/métodos , Acidente Vascular Cerebral/mortalidade , Fatores Etários , Idoso , Fibrilação Atrial/mortalidade , Estudos de Coortes , Diabetes Mellitus/classificação , Feminino , Insuficiência Cardíaca/classificação , Insuficiência Cardíaca/complicações , Humanos , Hipertensão/classificação , Hipertensão/complicações , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/fisiopatologia , Tromboembolia/classificação , Tromboembolia/complicações
10.
Int Heart J ; 60(5): 1192-1195, 2019 Sep 27.
Artigo em Inglês | MEDLINE | ID: mdl-31447464

RESUMO

Here we report two young patients with atrial fibrillation/atrial flutter complicated with cardiogenic cerebral embolism. Electrophysiological study revealed a large area of low-voltage zone or area of electric silence in both sides of the atrium during restoration of sinus rhythm, and the echocardiogram showed loss of mechanical function of the atrium. The electrical-mechanical dysfunction of the atrium was considered to be the cause of embolic event in this type of patient who was "very low" stroke risk atrial fibrillation or atrial flutter. The idiopathic, fibrotic atrial cardiomyopathy may be underlying in these patients.


Assuntos
Fibrilação Atrial/complicações , Flutter Atrial/complicações , Ablação por Cateter/métodos , Eletrocardiografia/métodos , Acidente Vascular Cerebral/etiologia , Adulto , Fatores Etários , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Flutter Atrial/diagnóstico , Flutter Atrial/cirurgia , Mapeamento Potencial de Superfície Corporal/métodos , China , Feminino , Seguimentos , Humanos , Masculino , Doenças Raras , Medição de Risco , Amostragem , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia
11.
Lakartidningen ; 1162019 Aug 13.
Artigo em Sueco | MEDLINE | ID: mdl-31408188

RESUMO

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


Assuntos
Fibrilação Atrial/complicações , Desfibriladores Implantáveis , Marca-Passo Artificial , Acidente Vascular Cerebral/etiologia , Taquicardia/complicações , Anticoagulantes/administração & dosagem , Anticoagulantes/uso terapêutico , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Feminino , Humanos , Masculino , Guias de Prática Clínica como Assunto , Fatores de Risco , Acidente Vascular Cerebral/prevenção & controle , Taquicardia/diagnóstico , Taquicardia/tratamento farmacológico
12.
Unfallchirurg ; 122(8): 633-645, 2019 Aug.
Artigo em Alemão | MEDLINE | ID: mdl-31367841

RESUMO

As the population gets older the prevalence of atrial fibrillation and venous thromboembolism also increases. Therefore, more patients require anticoagulation and currently direct oral anticoagulants (DOAC), such as dabigatran etexilate, apixaban, rivaroxaban and edoxaban are preferred to vitamin K antagonists (VKA), mainly because of the more favorable risk-benefit profile with respect to bleeding. Older patients in particular frequently present at the accident and emergency department due to falls and an increased risk of fractures. The perioperative management of these patients who are treated with DOACs is a challenge in the clinical routine and needs special consideration. This article discusses these issues in an interdisciplinary approach and develops strategies for the perioperative management of patients treated with DOACs and undergoing trauma or orthopedic surgery.


Assuntos
Antitrombinas/administração & dosagem , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Tromboembolia Venosa/prevenção & controle , Ferimentos e Lesões/cirurgia , Administração Oral , Fibrilação Atrial/complicações , Humanos , Assistência Perioperatória , Tromboembolia Venosa/etiologia , Ferimentos e Lesões/complicações
13.
Medicine (Baltimore) ; 98(26): e16194, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31261559

RESUMO

BACKGROUND: Atrial fibrillation (AF) is increasingly prevalent in chronic kidney disease (CKD) patients. The efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) in AF and CKD patients remains unknown. This systematic review and meta-analysis will mainly assess net clinical benefit (NCB) property of NOACs versus warfarin in patients with AF and CKD by a pooled-analysis. METHODS: We will search Medline, Embase, Cochrane Library, and Clinical Trials.gov Website comprehensively for eligible randomized controlled trials that report the efficacy and safety outcomes according to renal function of NOACs. Relative risks and their 95% confidence intervals will be calculated using fixed- and random-effects models. Subgroup, sensitivity, and regression analyses will be performed to evaluate intertrial heterogeneity and bias of the results. NCB that balance stroke/systemic embolism (SSE) and major bleeding will be calculated using Singer's method. RESULTS: This systemic review and meta-analysis will evaluate the NCB of NOACs versus warfarin via SSE, major bleeding and all-cause death in patients with CKD. CONCLUSIONS: This study will provide new evidence for clinical profile of NOACs on SSE, major bleeding, all-cause death, and NCB in CKD patients. PROSPERO REGISTRATION NUMBER: CRD42019116940.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Metanálise como Assunto , Insuficiência Renal Crônica/tratamento farmacológico , Revisão Sistemática como Assunto , Administração Oral , Anticoagulantes/efeitos adversos , Anticoagulantes/farmacologia , Fibrilação Atrial/complicações , Humanos , Insuficiência Renal Crônica/complicações , Projetos de Pesquisa , Varfarina/efeitos adversos , Varfarina/uso terapêutico
14.
Int Heart J ; 60(4): 822-829, 2019 Jul 27.
Artigo em Inglês | MEDLINE | ID: mdl-31257338

RESUMO

Atrial fibrillation (AF) is an independent risk factor for intracranial hemorrhage in patients receiving recombinant-tissue-type plasminogen activator (rt-PA) thrombolytic therapy. Research showed that patients with acute ischemic stroke (AIS) could benefit from multimode computed-tomography- (CT-) guided intravenous thrombolysis over 4.5 hours. The medical data of patients with AIS in our center were retrospectively reviewed, and the data of the multimode CT-guided thrombolytic therapy or nonthrombolytic therapy within different time windows (3-9 hours) were evaluated. 134 AIS cases were selected successfully and divided into three groups: patients with AF treated by rt-PA (AF rt-PA), patients with AF not treated by rt-PA (AF non-rt-PA), and patients without AF treated by rt-PA (non-AF rt-PA). After correcting for the baseline NIH Stroke Scale (NIHSS), sex, age, and hypertension data, the comparison results showed that the NIHSS improved significantly at hospital discharge for rt-PA-treated patients (n = 47) compared to non-rt-PA-treated patients with AIS (n = 31) with AF (P = 0.0156). The NIHSS evaluation at 90 days of follow-up also improved in rt-PA-treated patients (P = 0.0157). The NIHSS at hospital discharge was higher in AF rt-PA-treated patients compared to non-AF rt-PA-treated patients (P = 0.0167) after correction; the difference was not statistically significant at 90 days of follow-up (P = 0.091). Our research showed that the neural function improved after 3-9 hours of thrombolytic therapy with rt-PA in patients with AIS and AF. If there is no thrombolytic taboo, the patients could benefit from the thrombolytic therapy, although the onset time window has been extended to 9 hours.


Assuntos
Fibrilação Atrial/complicações , Isquemia Encefálica/tratamento farmacológico , Tomografia Computadorizada Multidetectores/métodos , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Doença Aguda , Administração Intravenosa , Idoso , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiologia , Feminino , Fibrinolíticos/administração & dosagem , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
15.
Int Heart J ; 60(4): 849-853, 2019 Jul 27.
Artigo em Inglês | MEDLINE | ID: mdl-31308325

RESUMO

The diagnostic performance of 320-detector cardiac computed tomography (CCT) for the detection of thrombi in the left atrial appendage (LAA), relative to transesophageal echocardiography (TEE) as the gold standard, has not yet been evaluated. A total of 91 consecutive patients who were scheduled to undergo pulmonary vein isolation and underwent TEE and CCT were enrolled in this study. Delayed scanning on CCT was performed following early scanning, at 60 seconds after the start of the contrast injection. The radiation dose was estimated for both scans. The early scans showed a contrast medium filling defect (FD) in the LAA in 27 patients, whereas the delayed scans showed an FD in the LAA in six patients. Of these, five patients were confirmed to have a thrombus in the LAA by TEE. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 100, 74.4, 18.5, 100, and 75.8% for early scanning and 100, 98.8, 83.3, 100, and 98.9% for delayed scanning, respectively. The area under the curve for the detection of a thrombus in the LAA on the delayed scans was significantly larger than that for the detection on the early scans (0.99 versus 0.87, P < 0.001). The estimated median radiation doses for the early and delayed scans were 2.86 and 0.42 mSv, respectively. Addition of delayed scanning to early scanning improved the diagnostic performance for the detection of a thrombus in the LAA and may obviate unnecessary TEE, with minimal additional radiation exposure.


Assuntos
Apêndice Atrial/diagnóstico por imagem , Cardiopatias/diagnóstico , Tomografia Computadorizada Multidetectores/métodos , Trombose/diagnóstico , Idoso , Fibrilação Atrial/complicações , Ecocardiografia Transesofagiana , Feminino , Humanos , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Trombose/etiologia
16.
Khirurgiia (Mosk) ; (7): 52-57, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31355815

RESUMO

OBJECTIVE: To compare incidence of thromboembolic and hemorrhagic complications in patients with atrial fibrillation (AF) undergoing elective surgery on different schemes of perioperative anticoagulant therapy (ACT). MATERIAL AND METHODS: There were 86 patients (56 (65.1%) men and 30 (34.9%) women, mean age was 69 (64; 78) years) with non-valvular AF who underwent elective interventions. Forty (46.5%) patients underwent abdominal surgery, 34 (39.5%) - cardiovascular procedures, 12 (14.0%) patients underwent surgery for malignant diseases. We have analyzed incidence of thromboembolic and hemorrhagic events and compliance of perioperative ACT modes with current international guidelines. RESULTS: Thromboembolic and hemorrhagic events developed in 14 (16.3%) patients. Thromboembolic complications were noted in 6 (7.0%) patients, hemorrhagic events - in 8 (9.3%) cases. Maximum complication rate was observed in case of bridge-therapy (n=12, 20.0%). Cancellation of ACT was followed by 2 (9.5%) complications, bridge-therapy - by 4 (6.7%) thromboembolic complications. Hemorrhagic events were 2 times more common in case of this therapy (n=8, 13.3%). It was found that ESC guidelines for perioperative ACT were applied in less than half of patients (41, 47.7% patients with AF undergoing elective surgery). Half of complications (8 out of 16) occurred if unapproved modes of ACT were used (including 7 cases of bridge-therapy was not necessary). The causes of these complications were inadequate assessment of perioperative risk of thromboembolic and hemorrhagic events; unreasonable administration of bridge therapy. CONCLUSION: An unambiguous clinical effect of bridge therapy has not been confirmed in patients with high risk of thromboembolic complications. Cancer patients have higher risk of complications compared with others. These events occur mainly due to non-compliance with clinical guidelines and insufficient prevention of thromboembolic events.


Assuntos
Anticoagulantes/efeitos adversos , Fibrilação Atrial/tratamento farmacológico , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Hemorragia/prevenção & controle , Tromboembolia/prevenção & controle , Idoso , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Feminino , Fidelidade a Diretrizes , Hemorragia/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Tromboembolia/etiologia
17.
Ther Adv Cardiovasc Dis ; 13: 1753944719860676, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31319783

RESUMO

BACKGROUND: The role of cancer-specific factors for ischemic stroke and mortality in patients with cancer and atrial fibrillation (AF) is unknown. We evaluated the utility of a previously validated risk tool for venous thromboembolism (VTE) in cancer outpatients [Khorana score (KS)] in predicting stroke and mortality in cancer patients with AF. METHODS: We conducted a retrospective cohort study of patients with cancer and AF at the Cleveland Clinic from 2008 to 2014. Outcomes, CHADS2, CHA2DS2-VASc, and KS scores were calculated from date of cancer diagnosis. Prognostic factors were identified with Fine and Gray regression (for stroke) or Cox proportional hazards analysis (for mortality). RESULTS: The study population comprised 1181 patients. Genitourinary (19%), lung (18%), and gastrointestinal (13%) were the most frequent cancers. Overall, 67% had CHADS2 ⩾ 2, 57% had an intermediate KS (1-2), and 7% high KS (⩾3). Median follow up was 26.5 months (range 0.03-76). At a median of 8.2 months (range 0-61), 45 patients (3.8%) developed a stroke and 418 (35%) died. In multivariable analysis a high KS (HR 4.5, 95% CI 3.2-6.3, p < 0.001) was associated with a quadruple risk of death and every point increase in CHADS2 score had a 20% increased risk of death (HR 1.19, 95% CI 1.1-1.2, p < 0.001). The addition of KS did not improve risk stratification for ischemic stroke to CHADS2. CONCLUSION: In patients with cancer and AF, CHADS2 and CHA2DS2-VASc but not KS were predictive of ischemic stroke. A high KS represented a unique predictor of mortality beyond traditional risk scores.


Assuntos
Fibrilação Atrial/complicações , Isquemia Encefálica/etiologia , Técnicas de Apoio para a Decisão , Neoplasias/complicações , Acidente Vascular Cerebral/etiologia , Tromboembolia Venosa/etiologia , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/mortalidade , Registros Eletrônicos de Saúde , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/diagnóstico , Neoplasias/mortalidade , Ohio , Valor Preditivo dos Testes , Prognóstico , Sistema de Registros , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/mortalidade
18.
BMC Neurol ; 19(1): 148, 2019 Jul 03.
Artigo em Inglês | MEDLINE | ID: mdl-31269910

RESUMO

BACKGROUND: Almost 40% of stroke patients have a poor outcome at 3 months after the index event. Predictors for stroke outcome in the early acute phase may help to tailor stroke treatment. Infection and inflammation are considered to influence stroke outcome. METHODS: In a prospective multicenter study in Germany and Spain, including 486 patients with acute ischemic stroke, we used multivariable regression analysis to investigate the association of poor outcome with monocytic HLA-DR (mHLA-DR) expression, interleukin 6 (IL-6), interleukin 10 (IL-10), tumor necrosis factor alpha (TNF-alpha) and lipopolysaccharide-binding protein (LBP) as markers for immunodepression, inflammation and infection. Outcome was assessed at 3 months after stroke via a structured telephone interview using the modified Rankin Scale (mRS). Poor outcome was defined as a mRS score of 3 or higher which included death. Furthermore, a time-to-event analysis for death within 3 months was performed. RESULTS: Three-month outcome data was available for 391 patients. Female sex, older age, diabetes mellitus, atrial fibrillation, stroke-associated pneumonia (SAP) and higher National Institute of Health Stroke Scale (NIHSS) score as well as lower mHLA-DR levels, higher IL-6 and LBP-levels at day 1 were associated with poor outcome at 3 months in bivariate analysis. Furthermore, multivariable analysis revealed that lower mHLA-DR expression was associated with poor outcome. Female sex, older age, atrial fibrillation, SAP, higher NIHSS score, lower mHLA-DR expression and higher IL-6 levels were associated with shorter survival time in bivariate analysis. In multivariable analysis, SAP and higher IL-6 levels on day 1 were associated with shorter survival time. CONCLUSIONS: SAP, lower mHLA-DR-expression and higher IL-6 levels on day one are associated with poor outcome and shorter survival time at 3 months after stroke onset. TRIAL REGISTRATION: www.clinicaltrials.gov, NCT01079728 , March 3, 2010.


Assuntos
Isquemia Encefálica/imunologia , Antígenos HLA-DR/sangue , Interleucina-6/sangue , Pneumonia/etiologia , Acidente Vascular Cerebral/imunologia , Proteínas da Fase Aguda , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/complicações , Biomarcadores/sangue , Isquemia Encefálica/sangue , Isquemia Encefálica/complicações , Isquemia Encefálica/mortalidade , Proteínas de Transporte/sangue , Diabetes Mellitus , Feminino , Alemanha , Humanos , Tolerância Imunológica , Inflamação/complicações , Interleucina-10/sangue , Masculino , Glicoproteínas de Membrana/sangue , Pessoa de Meia-Idade , Pneumonia/mortalidade , Estudos Prospectivos , Espanha , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/mortalidade , Fatores de Tempo , Fator de Necrose Tumoral alfa/sangue
19.
BMC Neurol ; 19(1): 152, 2019 Jul 05.
Artigo em Inglês | MEDLINE | ID: mdl-31277605

RESUMO

BACKGROUND: Simultaneous cerebral and myocardial infarction is called cardiocerebral infarction (CCI), and is rarely encountered. Because of the narrow time window and complex pathophysiology, CCI is challenging to immediately diagnose and treat. CASE PRESENTATION: A 73-year-old woman suddenly developed right hemiplegia and severe aphasia. Twelve-lead electrocardiography showed tachycardic atrial fibrillation without any significant ST-T change. Magnetic resonance imaging revealed a proximal middle cerebral artery occlusion. She was immediately treated with alteplase at the dosage approved for ischemic stroke followed by mechanical thrombectomy as bridging therapy, and complete recanalization was achieved. Aphasia improved and she began to complain of chest pain, and reported that she had experienced chest discomfort just prior to right limb weakness. Coronary angiography showed a partial filling defect in the right coronary artery with rapid and adequate distal flow, for which percutaneous coronary intervention was not required. Alteplase was suggested to have effectively resolved the coronary emboli. The occlusions of the cerebral and coronary arteries were assumed to have occurred nearly simultaneously and cardiogenic embolism due to atrial fibrillation was considered as the most likely etiology. CONCLUSIONS: As seen in the present case, CCI may benefit from immediate treatment with intravenous tissue plasminogen activator (IV-tPA). Although which of percutaneous coronary intervention or cerebral thrombectomy should be performed first remains unclear, we must decide whether to rescue the brain or heart first in each patient within a limited window of time. This dilemma has recently become evident in this era with mechanical thrombectomy strongly established as an effective intervention for acute ischemic stroke. Close cooperation between stroke physicians and cardiologists is becoming more important.


Assuntos
Infarto da Artéria Cerebral Média/complicações , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto do Miocárdio/complicações , Infarto do Miocárdio/diagnóstico por imagem , Administração Intravenosa , Idoso , Fibrilação Atrial/complicações , Doença da Artéria Coronariana/complicações , Imagem de Difusão por Ressonância Magnética , Eletrocardiografia , Procedimentos Endovasculares , Feminino , Fibrinolíticos/uso terapêutico , Coração , Humanos , Infarto da Artéria Cerebral Média/terapia , Trombectomia , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
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