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1.
Medicina (B Aires) ; 80 Suppl 4: 1-26, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-32897867

RESUMO

Treating an anticoagulated patient with vitamin K antagonists (VKA) remains a challenge, especially in areas where dicoumarins are still the first drug of choice due to the cost of other oral anticoagulants. Anticoagulation clinics have proven to be the most efficient and safe way to avoid thrombotic and hemorrhagic complications and to keep patients in optimal treatment range. However, they require adequate infrastructure and trained personnel to work properly. In this Argentine consensus we propose a series of guidelines for the effective management of the anticoagulation clinics. The goal is to achieve the excellence in both the clinical healthcare and the hemostasis laboratory for the anticoagulated patient. The criteria developed in the document were agreed upon by a large group of expert specialists in hematology and biochemistry from all over the country. The criteria presented here must always be considered when indicating VKA although they had to be adapted to the unequal reality of each center. Taking these premises into consideration will allow us to optimize the management of the anticoagulated patient with VKA and thus minimize thrombotic and hemorrhagic intercurrences, in order to honor our promise not to harm the patient.


Assuntos
Instituições de Assistência Ambulatorial/organização & administração , Anticoagulantes/uso terapêutico , Fibrinolíticos/uso terapêutico , Guias de Prática Clínica como Assunto , Vitamina K/antagonistas & inibidores , Administração Oral , Instituições de Assistência Ambulatorial/normas , Consenso , Humanos , Coeficiente Internacional Normatizado
2.
Rev. esp. cardiol. (Ed. impr.) ; 73(9): 749-757, sept. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-187648

RESUMO

La pandemia producida por la infección del nuevo coronavirus SARS-CoV-2, que da lugar a una enfermedad altamente contagiosa (COVID-19), ha producido un colapso de los sistemas sanitarios de todo el mundo. Se ha descrito que estos pacientes sufren un estado inflamatorio que condiciona un alto riesgo trombótico. Sin embargo, apenas hay información sobre cómo abordar el riesgo trombótico, la coagulopatía y el tratamiento anticoagulante de estos pacientes. Por otra parte, incluso los pacientes no infectados por COVID-19 sufren una tremenda influencia en su abordaje habitual por la situación sanitaria actual. El objetivo del presente documento, elaborado por el Grupo de Trabajo de Trombosis Cardiovascular de la Sociedad Española de Cardiología, es presentar la información disponible y dar unas pautas sencillas de tratamiento con fármacos antitrombóticos


The new coronavirus SARS-CoV-2, which gives rise to the highly contagious COVID-19 disease, has caused a pandemic that is overwhelming health care systems worldwide. Affected patients have been reported to have a heightened inflammatory state that increases their thrombotic risk. However, there is very scarce information on the management of thrombotic risk, coagulation disorders, and anticoagulant therapy. In addition, the situation has also greatly influenced usual care in patients not infected with COVID-19. This article by the Working Group on Cardiovascular Thrombosis of the Spanish Society of Cardiology aims to summarize the available information and to provide a practical approach to the management of antithrombotic therapy


Assuntos
Humanos , Fibrinolíticos/administração & dosagem , Infecções por Coronavirus/tratamento farmacológico , Vírus da SARS/patogenicidade , Trombose/tratamento farmacológico , Síndrome Respiratória Aguda Grave/tratamento farmacológico , Tromboembolia Venosa/tratamento farmacológico , Transtornos da Coagulação Sanguínea/tratamento farmacológico , Inibidores da Agregação de Plaquetas/administração & dosagem , Trombose/prevenção & controle , Anticoagulantes/administração & dosagem , Heparina de Baixo Peso Molecular/administração & dosagem , Vitamina K/antagonistas & inibidores , Pandemias , Pneumonia Viral/tratamento farmacológico , Transtornos da Coagulação Sanguínea/fisiopatologia , Interações Medicamentosas
3.
No Shinkei Geka ; 48(8): 683-690, 2020 Aug.
Artigo em Japonês | MEDLINE | ID: mdl-32830132

RESUMO

Spontaneous spinal epidural hematoma is a rare disease, and the critical form may mimic cerebral infarction in the acute stage. Consequently, misdiagnosis of a cerebral infarction may result in unnecessary antithrombotic therapy. The present study investigated 19 cases of spontaneous spinal epidural hematoma first diagnosed as cerebral infarctions and treated with antithrombotic therapy. Of these, 16 cases(84.2%)presented with pain in the neck, shoulder, and back on admission, 19 cases(100%)with hemiplegia not including the face, 7 cases(36.8%)with limb sensory disturbance, and all 19 cases(100%)underwent MRI findings for definite diagnosis. After diagnosis, 6 of the 19 cases(31.6%)were treated with recombinant tissue-type plasminogen activator(rt-PA)administration, 13 cases(68.4%)with surgical treatment, and 9 cases(47.4%)were without after effect and showed good progress. MRI is effective in detecting spontaneous spinal epidural hematoma, however, CT is also used for this diagnosis. The most common site of spontaneous spinal epidural hematoma is the cervicothoracic spine junction or thoracolumbar spine junction, but occurrence in the upper cervical vertebra may present with hemiplegia similar to cerebral infarction. Pathognomonic symptoms include pain in the neck, shoulder, and back, however, symptoms such as hemiplegia not including the face, cervical spine, and cervical cord lesion may be important indicators. Although, some cases may not present with pain and sensory disturbance symptoms, therefore an initial misdiagnosis of cerebral infarction may be made and subsequent antithrombotic therapy can result in increased bleeding and serious after-effects. In particular, 4 of the 6 cases(66.7%)treated with hyperacute phase thrombolytic therapy(rt-PA treatment)in this study required surgical treatment, and the time until definite diagnosis was shorter compared with other antithrombotic agents, presumably due to the rapid increase in hematoma. Therefore, the possibility of spinal cord epidural hematoma should be considered before beginning rt-PA therapy with careful examination to confirm the presence of lesions in the cervical spine and cervical cord.


Assuntos
Hematoma Epidural Espinal , Infarto Cerebral , Fibrinolíticos , Humanos , Imagem por Ressonância Magnética , Terapia Trombolítica
4.
Am J Cardiol ; 131: 1-6, 2020 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-32732010

RESUMO

There is limited information regarding clinical characteristics and outcomes of patients with SARS-CoV-2 (COVID-19) disease presenting with ST-segment elevation myocardial infarction (STEMI). In this multicenter retrospective study, we reviewed charts of patients admitted with symptomatic COVID-19 infection and STEMI to a total of 4 hospitals spanning Italy, Lithuania, Spain and Iraq from February 1, 2020 to April 15, 2020. A total of 78 patients were included in this study, 49 (63%) of whom were men, with a median age of 65 [58, 71] years, and high comorbidity burden. During hospitalization, 8 (10%) developed acute respiratory distress syndrome, and 14 (18%) required mechanical ventilation. 19 (24%) patients were treated with primary Percutaneous Coronary Intervention (PCI) and 59 (76%) were treated with fibrinolytic therapy. 13 (17%) patients required cardiac resuscitation, and 9 (11%) died. For the 19 patients treated with primary PCI, 8 (42%) required intubation and 8 (42%) required cardiac resuscitation; stent thrombosis occurred in 4 patients (21%). A total of 5 patients (26%) died during hospitalization. 50 (85%) of the 59 patients initially treated with fibrinolytic therapy had successful fibrinolysis. The median time to reperfusion was 27 minutes [20, 34]. Hemorrhagic stroke occurred in 5 patients (9%). Six patients (10%) required invasive mechanical ventilation; 5 (9%) required cardiac resuscitation, and 4 (7%) died. In conclusion, this is the largest case series to-date of COVID-19 positive patients presenting with STEMI and spans 4 countries. We found a high rate of stent thrombosis, indicating a possible need to adapt STEMI management for COVID-19 patients.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Fibrinolíticos/uso terapêutico , Intervenção Coronária Percutânea/métodos , Pneumonia Viral/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Terapia Trombolítica/métodos , Idoso , Angiografia Coronária , Infecções por Coronavirus/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/epidemiologia , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Espanha/epidemiologia , Taxa de Sobrevida/tendências , Resultado do Tratamento
5.
Zhonghua Xin Xue Guan Bing Za Zhi ; 48(6): 472-476, 2020 Jun 24.
Artigo em Chinês | MEDLINE | ID: mdl-32842256

RESUMO

Objective: To evaluate the efficacy and safety of fibrinolysis strategy in patients with acute ST-segment elevation myocardial infarction (STEMI) during the COVID-19 epidemic, and to provide reference value for optimization of fibrinolytic process on the premise of prevention and control of COVID-19 transmission, including self-protection of medical staff. Methods: The efficacy and safety of fibrinolysis were retrospectively analyzed in 7 patients with acute STEM, who hospitalized from February 29, 2020 to April 3, 2020 in the Department of Cardiology, Wuhan Union Hospital of Tongji Medical College, Huazhong University of Science and Technology. To optimize the fibrinolytic process on the premise of prevention and control of COVID-19 transmission, including self-protection of medical staff, a full-time medical team in charge of fibrinolysis under third-grade protection was established. The acute STEMI patients were treated immediately in a fixed and isolated area in emergency department before receiving green channel fibrinolysis. Blood samples for complete blood count, COVID-19 antibody test and nasopharyngeal swab samples for COVID-19 nucleic acid test were made before fibrinolysis, while the chest CT examination was accomplished after fibrinolysis. By comparing differences of time from the first electrocardiogram (ECG) to fibrinolysis before and after the improvement of fibrinolytic process, the effect of optimization of the fibrinolytic process was evaluated. Results: In the present study, seven patients with acute STEMI received fibrinolysis therapy, 6 of them achieved reperfusion and no bleeding was observed in all of the patients. Five out of the 7 patients were hospitalized after fibrinolysis, and the hospitalization days were 19.6 days on average. By following up to April 14, 2020, none of the 7 patients died. The first 2 patients were treated according to the routine medical procedure and the time from the first ECG to fibrinolysis were 201 and 106 minutes, respectively. After the optimization of the fibrinolytic process, the time from the first ECG to fibrinolysis of the last 5 patients were 42, 46, 51, 43 and 54 minutes, respectively,which was significantly shorter than that before optimization. Conclusions: During the COVID-19 epidemic, fibrinolysis in patients with acute STEMI is safe, effective and easy to implement. Therefore, it is recommended as the top priority for the patients with acute STEMI with indications for fibrinolysis. On the premise of prevention and control of COVID-19 transmission, including self-protection of medical staff, the duration of myocardial ischemia can be shortened by optimization of the fibrinolytic process.


Assuntos
Betacoronavirus , Infecções por Coronavirus , Fibrinolíticos/uso terapêutico , Pandemias , Pneumonia Viral , Infarto do Miocárdio com Supradesnível do Segmento ST , Infecções por Coronavirus/epidemiologia , Epidemias , Humanos , Pneumonia Viral/epidemiologia , Estudos Retrospectivos , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Terapia Trombolítica , Fatores de Tempo , Resultado do Tratamento
6.
Tohoku J Exp Med ; 251(4): 327-336, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32788506

RESUMO

After the first cases of COVID-19 appeared in Wuhan, China at the end of 2019, the disease quickly become a pandemic that has seriously affected the economic and health systems in more than 200 countries and territories around the world. Although most patients have mild symptoms or are even asymptomatic, there are patients who can develop serious complications such as acute respiratory distress syndrome or venous thromboembolism requiring mechanical ventilation and intensive care. Hence, it is important to identify patients with a higher risk of complications in a timely manner. Thus, the objective of this paper is to review the hematological laboratory parameters that consistently are altered in COVID-19 and to identify their relationship with the severity of the disease. According to 11 selected reports, the frequency of patients aged > 65 years is higher among subjects severely affected or deceased; likewise, males predominantly suffer from comorbidities such as hypertension, diabetes or obesity. Retrospective studies have identified alterations in various hematological and inflammatory parameters as part of the host's response to infection and a secondary increased risk of different thrombotic events. Among these altered parameters, D-dimer, C-reactive protein, and interleukin-6 have been tested as prognostic biomarkers due to their close relationship with the severity of the disease. Actually, they can reliably indicate the use of antithrombotic therapy at prophylactic or therapeutic doses (mainly D-dimer), as has already been established in those patients who, after an individualized assessment, appear to be at high risk for thrombotic events.


Assuntos
Anticoagulantes/uso terapêutico , Betacoronavirus , Transtornos da Coagulação Sanguínea/etiologia , Infecções por Coronavirus/sangue , Fibrinolíticos/uso terapêutico , Pandemias , Pneumonia Viral/sangue , Fatores Etários , Betacoronavirus/patogenicidade , Betacoronavirus/fisiologia , Biomarcadores , Transtornos da Coagulação Sanguínea/tratamento farmacológico , Transtornos da Coagulação Sanguínea/prevenção & controle , Testes de Coagulação Sanguínea , Comorbidade , Infecções por Coronavirus/complicações , Infecções por Coronavirus/epidemiologia , Gerenciamento Clínico , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Hemofilia A/complicações , Humanos , Inflamação , Interleucina-6/sangue , Pneumonia Viral/complicações , Pneumonia Viral/epidemiologia , Prognóstico , Risco , Trombofilia/diagnóstico , Trombofilia/tratamento farmacológico , Trombofilia/etiologia , Trombose/etiologia , Trombose/prevenção & controle
7.
Medicine (Baltimore) ; 99(30): e21366, 2020 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-32791743

RESUMO

The utility of endovascular thrombectomy for acute occlusion of the distal intracranial artery (A2/A3/M2/M3/P2/P3) is unclear, and aspiration and stent thrombectomy are associated with risk of bleeding. We analyzed patients with acute occlusion of the distal intracranial artery to assess the safety and efficacy of microcatheter-based tirofiban infusion.We retrospectively reviewed data of the endovascular thrombectomy registry of our center between January 2018 and June 2019. Patients with distal intracranial artery occlusion who underwent endovascular thrombectomy with microcatheter-based infusion of tirofiban were recruited.Of 13 patients included, 1 presented with anterior cerebral artery occlusion, 2 with posterior cerebral artery occlusion, 2 with posterior inferior cerebellar artery occlusion, and 7 with middle cerebral artery M2 occlusion. The mean National Institute of Health Stroke scale score was 10.1 (3-19). Three patients (23.1%) underwent bridging treatment of intravenous thrombolysis with recombinant plasminogen activator and endovascular thrombectomy. The arithmetic mean onset-to-recanalization time was 696.3 minutes (140-1440) and average operating time was 47.1 minutes (30-80). After treatment, 10 patients (76.9%) underwent revascularization. No operative complications were observed in any case. All patients underwent angiography and were reviewed 7 to 14 days after surgery. Imaging revealed significant improvements in recanalization compared with the immediate postoperative period, with no reoccurrence of occlusion. The mean modified Rankin scale score at the 3-month follow-up was 0.54 (0-2).Microcatheter-based infusion of bolus-dose tirofiban can result in safe and effective recanalization of acute occlusion of the distal artery in the case of a relatively light thrombotic load.


Assuntos
Fibrinolíticos/administração & dosagem , Doenças Arteriais Intracranianas/terapia , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/métodos , Tirofibana/administração & dosagem , Idoso , Angiografia por Tomografia Computadorizada , Feminino , Humanos , Doenças Arteriais Intracranianas/complicações , Doenças Arteriais Intracranianas/diagnóstico por imagem , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia
8.
BMJ ; 370: m2177, 2020 08 05.
Artigo em Inglês | MEDLINE | ID: mdl-32759284

RESUMO

Pulmonary embolism is a common and potentially fatal cardiovascular disorder that must be promptly diagnosed and treated. The diagnosis, risk assessment, and management of pulmonary embolism have evolved with a better understanding of efficient use of diagnostic and therapeutic options. The use of either clinical probability adjusted or age adjusted D-dimer interpretation has led to a reduction in diagnostic imaging to exclude pulmonary embolism. Direct oral anticoagulation therapies are safe, effective, and convenient treatments for most patients with acute venous thromboembolism, with a lower risk of bleeding than vitamin K antagonists. These oral therapeutic options have opened up opportunities for safe outpatient management of pulmonary embolism in selected patients. Recent clinical trials exploring the use of systemic thrombolysis in intermediate to high risk pulmonary embolism suggest that this therapy should be reserved for patients with evidence of hemodynamic compromise. The role of low dose systemic or catheter directed thrombolysis in other patient subgroups is uncertain. After a diagnosis of pulmonary embolism, all patients should be assessed for risk of recurrent venous thromboembolism to guide duration of anticoagulation. Patients with a venous thromboembolism associated with a strong, transient, provoking risk factor can safely discontinue anticoagulation after three months of treatment. Patients with an ongoing strong risk factor, such as cancer, or unprovoked events are at increased risk of recurrent events and should be considered for extended treatment. The use of a risk prediction score can help to identify patients with unprovoked venous thromboembolism who can benefit from extended duration therapy. Despite major advances in the management of pulmonary embolism, up to half of patients report chronic functional limitations. Such patients should be screened for chronic thromboembolic pulmonary hypertension, but only a small proportion will have this as the explanation of their symptoms. In the remaining patients, future studies are needed to understand the pathophysiology and explore interventions to improve quality of life.


Assuntos
Anticoagulantes/uso terapêutico , Neoplasias/complicações , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/terapia , Administração Oral , Anticoagulantes/efeitos adversos , Angiografia por Tomografia Computadorizada , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Fibrinolíticos/uso terapêutico , Humanos , Imagem de Perfusão , Gravidez , Complicações Cardiovasculares na Gravidez/tratamento farmacológico , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/etiologia , Recidiva , Medição de Risco , Fatores de Risco , Filtros de Veia Cava , Tromboembolia Venosa/tratamento farmacológico
9.
Lancet Haematol ; 7(8): e613-e623, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32735839

RESUMO

Lifelong anticoagulation with warfarin or alternative vitamin K antagonist is the standard anticoagulant treatment for thrombotic antiphospholipid syndrome. Anticoagulant-refractory thrombotic antiphospholipid syndrome can be broadly defined as breakthrough thrombosis while on standard oral anticoagulation treatment and its management is a major challenge given the serious nature of the thrombotic disease observed, which has become refractory to oral anticoagulation. The factors (genetic and cellular) that cause anticoagulant-refractory thrombotic antiphospholipid syndrome are now better understood. However, efforts to use this greater understanding have not yet transformed the capacity to treat it successfully in many patients. In this Viewpoint, we review the factors that are likely to be contributing to the cause of this syndrome and consider how they might be modified or inhibited. We also discuss management, including general strategies to minimise thrombotic risk, intensification of anticoagulation, addition of an antiplatelet agent, adjunctive treatment for thrombosis, immunomodulatory therapy, complement inhibition, vascular options, and future potential therapeutic targets.


Assuntos
Anticoagulantes/farmacologia , Síndrome Antifosfolipídica/terapia , Resistência a Medicamentos/efeitos dos fármacos , Fibrinolíticos/uso terapêutico , Inibidores da Agregação de Plaquetas/uso terapêutico , Terapia Trombolítica , Trombose/prevenção & controle , Síndrome Antifosfolipídica/patologia , Humanos , Trombose/patologia
10.
Brasília; s.n; 15 jul.2020.
Não convencional em Português | LILACS, BRISA/RedTESA, PIE | ID: biblio-1117674

RESUMO

O Informe Diário de Evidências é uma produção do Ministério da Saúde que tem como objetivo acompanhar diariamente as publicações científicas sobre tratamento farmacológico e vacinas para a COVID-19. Dessa forma, são realizadas buscas estruturadas em bases de dados biomédicas, referentes ao dia anterior desse informe. Não são incluídos estudos pré-clínicos (in vitro, in vivo, in silico). A frequência dos estudos é demonstrada de acordo com a sua classificação metodológica (revisões sistemáticas, ensaios clínicos randomizados, coortes, entre outros). Para cada estudo é apresentado um resumo com avaliação da qualidade metodológica. Essa avaliação tem por finalidade identificar o grau de certeza/confiança ou o risco de viés de cada estudo. Para tal, são utilizadas ferramentas já validadas e consagradas na literatura científica, na área de saúde baseada em evidências. Cabe ressaltar que o documento tem caráter informativo e não representa uma recomendação oficial do Ministério da Saúde sobre a temática. Foram encontrados 14 artigos e 6 protocolos.


Assuntos
Humanos , Pneumonia Viral/tratamento farmacológico , Infecções por Coronavirus/tratamento farmacológico , Betacoronavirus/efeitos dos fármacos , Sistema Renina-Angiotensina , Avaliação da Tecnologia Biomédica , Omeprazol/uso terapêutico , Dexametasona/uso terapêutico , Oxigenação por Membrana Extracorpórea/instrumentação , Efeito de Coortes , Enoxaparina/uso terapêutico , Peptidil Dipeptidase A/uso terapêutico , Ritonavir/uso terapêutico , Proteína Antagonista do Receptor de Interleucina 1/uso terapêutico , Lopinavir/uso terapêutico , Fibrinolíticos/uso terapêutico , Esomeprazol/uso terapêutico , Darunavir/uso terapêutico , Rituximab/uso terapêutico , Pantoprazol/uso terapêutico , Hidroxicloroquina/uso terapêutico , Anticoagulantes/uso terapêutico
11.
Brasília; s.n; 8 jul. 2020.
Não convencional em Português | LILACS, BRISA/RedTESA, PIE | ID: biblio-1117634

RESUMO

O Informe Diário de Evidências é uma produção do Ministério da Saúde que tem como objetivo acompanhar diariamente as publicações científicas sobre tratamento farmacológico e vacinas para a COVID-19. Dessa forma, são realizadas buscas estruturadas em bases de dados biomédicas, referentes ao dia anterior desse informe. Não são incluídos estudos pré-clínicos (in vitro, in vivo, in silico). A frequência dos estudos é demonstrada de acordo com a sua classificação metodológica (revisões sistemáticas, ensaios clínicos randomizados, coortes, entre outros). Para cada estudo é apresentado um resumo com avaliação da qualidade metodológica. Essa avaliação tem por finalidade identificar o grau de certeza/confiança ou o risco de viés de cada estudo. Para tal, são utilizadas ferramentas já validadas e consagradas na literatura científica, na área de saúde baseada em evidências. Cabe ressaltar que o documento tem caráter informativo e não representa uma recomendação oficial do Ministério da Saúde sobre a temática. Foram encontrados 16 artigos e 11 protocolos.


Assuntos
Humanos , Pneumonia Viral/tratamento farmacológico , Infecções por Coronavirus/tratamento farmacológico , Betacoronavirus/efeitos dos fármacos , Antivirais/uso terapêutico , Avaliação da Tecnologia Biomédica , Imunoglobulinas/uso terapêutico , Vacinas/uso terapêutico , Cloroquina/uso terapêutico , Colchicina/uso terapêutico , Estudos Transversais/instrumentação , Estudos de Coortes , Interferon-alfa/uso terapêutico , Ativador de Plasminogênio Tecidual/uso terapêutico , Corticosteroides/uso terapêutico , Azitromicina/uso terapêutico , Ritonavir/uso terapêutico , Lopinavir/uso terapêutico , Fibrinolíticos/uso terapêutico , Hidroxicloroquina/uso terapêutico , Antibacterianos/uso terapêutico
12.
Eur Rev Med Pharmacol Sci ; 24(13): 7494-7496, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32706089

RESUMO

Although most patients with coronavirus disease 2019 (COVID-19) have a good prognosis, in some cases, the disease progresses rapidly, and the mortality rate is high. Some evidence suggests that infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) produces a 'cytokine storm', which is related to acute respiratory distress syndrome or multi-organ dysfunction leading to physiological deterioration and death. It is important to highlight the state of hypercoagulability that can be triggered, involving microvascular thrombosis and vascular occlusive events, which are relevant to such poor outcomes. At present, no specific antiviral drug or vaccine is available for SARS-CoV-2 infection, and current research is aimed at preventing and mitigating damage to the target organs, mainly the lungs. In seeking therapies for patients with COVID-19, immunomodulators, cytokine antagonists and early anti-coagulation therapies have been tested in attempts to reduce the mortality rate. Pentoxifylline, a non-specific phosphodiesterase inhibitor widely used to improve the rheological properties of blood, has beneficial anti-inflammatory properties and can significantly reduce the serum levels of pro-inflammatory cytokines such as interleukin (IL)-6, IL-1, tumour necrosis factor-alpha, C-reactive protein and other immunoregulators. It has also been found to exert anti-thrombotic, antioxidant and anti-fibrogenic actions. These properties could help to prevent or mitigate the inflammatory response and hypercoagulability that develop with SARS-CoV-2 infection, decreasing multi-organ dysfunction manifesting primarily as acute lung injury.


Assuntos
Antivirais/farmacologia , Betacoronavirus/efeitos dos fármacos , Infecções por Coronavirus/tratamento farmacológico , Pneumonia Viral/tratamento farmacológico , Anti-Inflamatórios/farmacologia , Antioxidantes/farmacologia , Fibrinolíticos/farmacologia , Humanos , Testes de Sensibilidade Microbiana , Pandemias , Pentoxifilina/farmacologia
13.
Zhejiang Da Xue Xue Bao Yi Xue Ban ; 49(1): 131-136, 2020 May 25.
Artigo em Chinês | MEDLINE | ID: mdl-32621412

RESUMO

Stenting for iliac vein stenosis or compression has become a common therapeutic approach in recent years. The antithrombotic therapy after the stent deployment, however, reaches no consensus. Medications strategies and patients' prognoses differ in non-thrombotic, acute thrombotic and chronic thrombotic these three circumstances. Non-thrombotic patients usually possess satisfactory stent patency whatever antithrombotic therapy is used. Anticoagulant is the basic medication for acute thrombotic patients, benefits from additional antiplatelet drug remains to be clarified. In terms of chronic thrombotic patients, their prognoses are unsatisfactory under all antithrombotic therapies. In this review, we outlined the recent progress of antithrombotic therapy after iliac vein stenting, aiming to provide feasible medication plans for each circumstance.


Assuntos
Fibrinolíticos , Veia Ilíaca , Stents , Constrição Patológica/tratamento farmacológico , Constrição Patológica/cirurgia , Fibrinolíticos/uso terapêutico , Humanos , Veia Ilíaca/cirurgia , Resultado do Tratamento , Grau de Desobstrução Vascular
14.
Clin Appl Thromb Hemost ; 26: 1076029620938149, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32677459

RESUMO

The novel coronavirus infection (COVID-19) is caused by the new coronavirus SARS-CoV-2 and is characterized by an exaggerated inflammatory response that can lead to severe manifestations such as adult respiratory syndrome, sepsis, coagulopathy, and death in a proportion of patients. Among other factors and direct viral effects, the increase in the vasoconstrictor angiotensin II, the decrease in the vasodilator angiotensin, and the sepsis-induced release of cytokines can trigger a coagulopathy in COVID-19. A coagulopathy has been reported in up to 50% of patients with severe COVID-19 manifestations. An increase in d-dimer is the most significant change in coagulation parameters in severe COVID-19 patients, and progressively increasing values can be used as a prognostic parameter indicating a worse outcome. Limited data suggest a high incidence of deep vein thrombosis and pulmonary embolism in up to 40% of patients, despite the use of a standard dose of low-molecular-weight heparin (LMWH) in most cases. In addition, pulmonary microvascular thrombosis has been reported and may play a role in progressive lung failure. Prophylactic LMWH has been recommended by the International Society on Thrombosis and Haemostasis (ISTH) and the American Society of Hematology (ASH), but the best effective dosage is uncertain. Adapted to the individual risk of thrombosis and the d-dimer value, higher doses can be considered, especially since bleeding events in COVID-19 are rare. Besides the anticoagulant effect of LMWH, nonanticoagulant properties such as the reduction in interleukin 6 release have been shown to improve the complex picture of coagulopathy in patients with COVID-19.


Assuntos
Anticoagulantes/uso terapêutico , Betacoronavirus , Infecções por Coronavirus/complicações , Pandemias , Pneumonia Viral/complicações , Trombofilia/etiologia , Trombose/prevenção & controle , Angiotensina II/metabolismo , Arteriopatias Oclusivas/sangue , Arteriopatias Oclusivas/epidemiologia , Arteriopatias Oclusivas/etiologia , Infecções por Coronavirus/sangue , Infecções por Coronavirus/epidemiologia , Síndrome da Liberação de Citocina/sangue , Síndrome da Liberação de Citocina/etiologia , Surtos de Doenças , Coagulação Intravascular Disseminada/etiologia , Coagulação Intravascular Disseminada/prevenção & controle , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Fibrinolíticos/uso terapêutico , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Incidência , Inflamação , Pneumonia Viral/sangue , Pneumonia Viral/epidemiologia , Prognóstico , Embolia Pulmonar/etiologia , Embolia Pulmonar/prevenção & controle , Risco , Sepse/sangue , Sepse/complicações , Síndrome Respiratória Aguda Grave/sangue , Síndrome Respiratória Aguda Grave/complicações , Síndrome Respiratória Aguda Grave/epidemiologia , Trombofilia/sangue , Trombofilia/tratamento farmacológico , Trombose/sangue , Trombose/epidemiologia , Trombose/etiologia , Microangiopatias Trombóticas/etiologia , Microangiopatias Trombóticas/prevenção & controle , Ativador de Plasminogênio Tecidual/uso terapêutico
15.
JAMA ; 324(3): 279-290, 2020 07 21.
Artigo em Inglês | MEDLINE | ID: mdl-32692391

RESUMO

Importance: Perioperative cardiovascular complications occur in 3% of hospitalizations for noncardiac surgery in the US. This review summarizes evidence regarding cardiovascular risk assessment prior to noncardiac surgery. Observations: Preoperative cardiovascular risk assessment requires a focused history and physical examination to identify signs and symptoms of ischemic heart disease, heart failure, and severe valvular disease. Risk calculators, such as the Revised Cardiac Risk Index, identify individuals with low risk (<1%) and higher risk (≥1%) for perioperative major adverse cardiovascular events during the surgical hospital admission or within 30 days of surgery. Cardiovascular testing is rarely indicated in patients at low risk for major adverse cardiovascular events. Stress testing may be considered in patients at higher risk (determined by the inability to climb ≥2 flights of stairs, which is <4 metabolic equivalent tasks) if the results from the testing would change the perioperative medical, anesthesia, or surgical approaches. Routine coronary revascularization does not reduce perioperative risk and should not be performed without specific indications independent of planned surgery. Routine perioperative use of low-dose aspirin (100 mg/d) does not decrease cardiovascular events but does increase surgical bleeding. Statins are associated with fewer postoperative cardiovascular complications and lower mortality (1.8% vs 2.3% without statin use; P < .001) in observational studies, and should be considered preoperatively in patients with atherosclerotic cardiovascular disease undergoing vascular surgery. High-dose ß-blockers (eg, 100 mg of metoprolol succinate) administered 2 to 4 hours prior to surgery are associated with a higher risk of stroke (1.0% vs 0.5% without ß-blocker use; P = .005) and mortality (3.1% vs 2.3% without ß-blocker use; P = .03) and should not be routinely used. There is a greater risk of perioperative myocardial infarction and major adverse cardiovascular events in adults aged 75 years or older (9.5% vs 4.8% for younger adults; P < .001) and in patients with coronary stents (8.9% vs 1.5% for those without stents; P < .001) and these patients warrant careful preoperative consideration. Conclusions and Relevance: Comprehensive history, physical examination, and assessment of functional capacity during daily life should be performed prior to noncardiac surgery to assess cardiovascular risk. Cardiovascular testing is rarely indicated in patients with a low risk of major adverse cardiovascular events, but may be useful in patients with poor functional capacity (<4 metabolic equivalent tasks) undergoing high-risk surgery if test results would change therapy independent of the planned surgery. Perioperative medical therapy should be prescribed based on patient-specific risk.


Assuntos
Doenças Cardiovasculares/etiologia , Complicações Pós-Operatórias/etiologia , Medição de Risco/métodos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Antagonistas Adrenérgicos beta/administração & dosagem , Antagonistas Adrenérgicos beta/efeitos adversos , Fatores Etários , Idoso , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Biomarcadores/sangue , Angiografia Coronária , Ecocardiografia Transesofagiana , Eletrocardiografia/métodos , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Insuficiência Cardíaca/diagnóstico , Doenças das Valvas Cardíacas/diagnóstico , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/etiologia , Isquemia Miocárdica/diagnóstico , Revascularização Miocárdica , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Stents/efeitos adversos , Acidente Vascular Cerebral/induzido quimicamente , Fatores de Tempo , Estados Unidos/epidemiologia
17.
Clin Appl Thromb Hemost ; 26: 1076029620936776, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32687449

RESUMO

COVID-19 has proven to be particularly challenging given the complex pathogenesis of SARS-CoV-2. Early data have demonstrated how the host response to this novel coronavirus leads to the proliferation of pro-inflammatory cytokines, massive endothelial damage, and generalized vascular manifestations. While SARS-CoV-2 primarily targets the upper and lower respiratory tract, other organ systems are also affected. SARS-CoV-2 relies on 2 host cell receptors for successful attachment: angiotensin-converting enzyme 2 and transmembrane protease serine 2. Clinicopathologic reports have demonstrated associations between severe COVID-19 and viral coagulopathy, resulting in pulmonary embolism; venous, arterial, and microvascular thrombosis; lung endothelial injury; and associated thrombotic complications leading to acute respiratory distress syndrome. Viral coagulopathy is not novel given similar observations with SARS classic, including the consumption of platelets, generation of thrombin, and increased fibrin degradation product exhibiting overt disseminated intravascular coagulation-like syndrome. The specific mechanism(s) behind the thrombotic complications in COVID-19 patients has yet to be fully understood. Parenteral anticoagulants, such as heparin and low-molecular-weights heparins, are widely used in the management of COVID-19 patients. Beyond the primary (anticoagulant) effects of these agents, they may exhibit antiviral, anti-inflammatory, and cytoprotective effects. Direct oral anticoagulants and antiplatelet agents are also useful in the management of these patients. Tissue plasminogen activator and other fibrinolytic modalities may also be helpful in the overall management. Catheter-directed thrombolysis can be used in patients developing pulmonary embolism. Further investigations are required to understand the molecular and cellular mechanisms involved in the pathogenesis of COVID-19-associated thrombotic complications.


Assuntos
Betacoronavirus/patogenicidade , Infecções por Coronavirus/complicações , Pandemias , Pneumonia Viral/complicações , Trombofilia/etiologia , Bloqueadores do Receptor Tipo 1 de Angiotensina II/farmacologia , Bloqueadores do Receptor Tipo 1 de Angiotensina II/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/farmacologia , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anticoagulantes/uso terapêutico , Arteriopatias Oclusivas/etiologia , Arteriopatias Oclusivas/fisiopatologia , Arteriopatias Oclusivas/virologia , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/prevenção & controle , Cateterismo de Swan-Ganz , Terapia Combinada , Infecções por Coronavirus/sangue , Infecções por Coronavirus/tratamento farmacológico , Endotélio Vascular/fisiopatologia , Endotélio Vascular/virologia , Fibrinolíticos/uso terapêutico , Humanos , Oxigenação Hiperbárica , Inibidores da Agregação de Plaquetas/uso terapêutico , Pneumonia Viral/sangue , Pneumonia Viral/tratamento farmacológico , Embolia Pulmonar/etiologia , Embolia Pulmonar/terapia , Embolia Pulmonar/virologia , Síndrome do Desconforto Respiratório do Adulto/etiologia , Terapia Trombolítica/instrumentação , Terapia Trombolítica/métodos , Trombofilia/fisiopatologia , Trombofilia/terapia , Trombose Venosa/etiologia , Trombose Venosa/fisiopatologia , Trombose Venosa/virologia , Internalização do Vírus/efeitos dos fármacos
18.
J Am Geriatr Soc ; 68(8): 1647-1652, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32633418

RESUMO

BACKGROUND/OBJECTIVES: Nursing home (NH) residents are a vulnerable population, susceptible to respiratory disease outbreaks such as coronavirus disease 2019 (COVID-19). Poor outcome in COVID-19 is at least partly attributed to hypercoagulability, resulting in a high incidence of thromboembolic complications. It is unknown whether commonly used antithrombotic therapies may protect the vulnerable NH population with COVID-19 against mortality. This study aimed to investigate whether the use of oral antithrombotic therapy (OAT) was associated with a lower mortality in NH residents with COVID-19. DESIGN: A retrospective case series. SETTING: Fourteen NH facilities from the NH organization Envida, Maastricht, the Netherlands PARTICIPANTS: A total of 101 NH residents with COVID-19 were enrolled. MEASUREMENTS: The primary outcome was all-cause mortality. The association between age, sex, comorbidity, OAT, and mortality was assessed using logistic regression analysis. RESULTS: Overall mortality was 47.5% in NH residents from 14 NH facilities. Age, comorbidity, and medication use were comparable among NH residents who survived and who died. OAT was associated with a lower mortality in NH residents with COVID-19 in the univariable analysis (odds ratio (OR) = 0.89; 95% confidence interval (CI) = 0.41-1.95). However, additional adjustments for sex, age, and comorbidity attenuated this difference. Mortality in males was higher compared with female residents (OR = 3.96; 95% CI = 1.62-9.65). Male residents who died were younger compared with female residents (82.2 (standard deviation (SD) = 6.3) vs 89.1 (SD = 6.8) years; P < .001). CONCLUSION: NH residents in the 14 facilities we studied were severely affected by the COVID-19 pandemic, with a mortality of 47.5%. Male NH residents with COVID-19 had worse outcomes than females. We did not find evidence for any protection against mortality by OAT, necessitating further research into strategies to mitigate poor outcome of COVID-19 in vulnerable NH populations. J Am Geriatr Soc 68:1647-1652, 2020.


Assuntos
Betacoronavirus , Infecções por Coronavirus/mortalidade , Fibrinolíticos/uso terapêutico , Pneumonia Viral/mortalidade , Tromboembolia/mortalidade , Idoso , Idoso de 80 Anos ou mais , Infecções por Coronavirus/complicações , Infecções por Coronavirus/tratamento farmacológico , Feminino , Instituição de Longa Permanência para Idosos , Humanos , Incidência , Masculino , Países Baixos/epidemiologia , Casas de Saúde , Razão de Chances , Pandemias , Pneumonia Viral/complicações , Pneumonia Viral/tratamento farmacológico , Estudos Retrospectivos , Fatores Sexuais , Tromboembolia/tratamento farmacológico , Tromboembolia/virologia
19.
J Assoc Physicians India ; 68(6): 32-34, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32610877

RESUMO

About 36% to 57% of bacterial pneumonias develop parapneumonic effusion. When the chest tube is correctly positioned as evidenced by postero-anterior and lateral chest radiographs and there is a significant amount of pleural fluid, the major reasons for failed drainage are multiple pleural space loculations or tube obstruction by thick and viscous fluid. The various modalities of treatment available for loculated pleural effusion are: saline flushes, placing one or more catheters in loculi under image guidance, video assisted thoracoscopic surgery (VATS), standard thoracotomy with drainage of empyema and decortication. The first two modalities are not so effective in improving drainage. The last two surgical modalities are more invasive, not easily available and, if available, are not affordable by majority of patients in the developing countries like India. The fibrinolytic agents, if used early in loculated pleural effusions, break loculations and early pleural peel thereby facilitating pleural space drainage.


Assuntos
Empiema Pleural/tratamento farmacológico , Derrame Pleural , Drenagem , Fibrinolíticos/uso terapêutico , Humanos , Índia , Terapia Trombolítica
20.
Stud Health Technol Inform ; 272: 421-424, 2020 Jun 26.
Artigo em Inglês | MEDLINE | ID: mdl-32604692

RESUMO

The aim of this study was to evaluate accessibility of stroke patients to optimal healthcare technology in Greece. Methods: The study population consisted of 313 first ever stroke patients derived from the "Stroke Units Necessity for Patients, SUN4P" registry. Descriptive statistics were used, to present patients' characteristics and resources utilization Results: The vast majority of patients (91.7%) conducted a CT scan during the acute phase (within the first 24hours). Almost, (65%) were admitted to wards of Internal Medicine Departments, whereas only 21% of patients were admitted to a Stroke Unit. Of note, a total of 6.9% of ischemic stroke patients received intravenous thrombolytic therapy with recombinant tissue plasminogen activator (rtPA). Conclusions: Preliminary results from SUN4P underline the urgent necessity for the re-organization of acute stroke care in Greece, as rates of admissions to stroke units and rtPA treatment during the acute phase are currently below optimal.


Assuntos
Acidente Vascular Cerebral , Pessoal Administrativo , Isquemia Encefálica , Fibrinolíticos , Grécia , Humanos , Terapia Trombolítica , Ativador de Plasminogênio Tecidual , Resultado do Tratamento
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