Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 3.851
Filtrar
1.
J Cardiothorac Vasc Anesth ; 35(2): 389-397, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32994131

RESUMO

OBJECTIVE: To explore special coagulation characteristics and anticoagulation management in extracorporeal membrane oxygenation (ECMO)-assisted patients with coronavirus disease 2019 (COVID-19). DESIGN: Single-center, retrospective observation of a series of patients. PARTICIPANTS: Laboratory-confirmed severe COVID-19 patients who received venovenous ECMO support from January 20-May 20, 2020. INTERVENTIONS: This study analyzed the anticoagulation management and monitoring strategies, bleeding complications, and thrombotic events during ECMO support. MEASUREMENTS AND MAIN RESULTS: Eight of 667 confirmed COVID-19 patients received venovenous ECMO and had an elevated D-dimer level before and during ECMO support. An ECMO circuit pack (oxygenator and tubing) was replaced a total of 13 times in all 8 patients, and coagulation-related complications included oxygenator thrombosis (7/8), tracheal hemorrhage (5/8), oronasal hemorrhage (3/8), thoracic hemorrhage (3/8), bleeding at puncture sites (4/8), and cannulation site hemorrhage (2/8). CONCLUSIONS: Hypercoagulability and secondary hyperfibrinolysis during ECMO support in COVID-19 patients are common and possibly increase the propensity for thrombotic events and failure of the oxygenator. Currently, there is not enough evidence to support a more aggressive anticoagulation strategy.


Assuntos
Anticoagulantes/uso terapêutico , Oxigenação por Membrana Extracorpórea , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , /diagnóstico por imagem , Cuidados Críticos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Insuficiência Respiratória/diagnóstico por imagem , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia , Estudos Retrospectivos , Trombose/epidemiologia , Tomografia Computadorizada por Raios X , Traqueia/lesões
4.
Medicine (Baltimore) ; 99(48): e23311, 2020 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-33235089

RESUMO

BACKGROUND: The objective of this study was to compare the complications of low-site peritoneal dialysis (PD) catheter placement and traditional open surgery in peritoneal dialysis catheter insertion. METHODS: The following databases were searched from inception to September 6, 2019: PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, and Wanfang. Eligible studies comparing low-site PD catheter placement and traditional open surgery in peritoneal dialysis catheter insertion were included. The data were analyzed using Review Manager Version 5.3. RESULTS: Seven studies were included in the meta-analysis. A total of 504 patients were included in the low-site PD catheter placement group, and 325 patients were included in the traditional open surgery group. Compared with traditional open surgery, low-site PD catheter placement had a lower incidence rate of catheter displacement (odds ratios [OR] 0.11, 95% CI 0.05-0.22, P < .01) and noncatheter displacement dysfunction (OR 0.11, 95% CI 0.04-0.31, P < .01). However, there was no difference between the 2 catheter insertion methods concerning bleeding (OR 0.53, 95% CI 0.23-1.22, P = .13), PD fluid leakage (OR 0.40, 95% CI 0.15-1.10, P = .07), hypogastralgia (OR 0.95, 95% CI 0.32-2.80, P = .93), peritonitis (OR 0.70, 95% CI 0.32-1.54, P = .38), or exit-site and tunnel infections (OR 0.39, 95% CI 0.14-1.03, P = .06). CONCLUSION: Low-site PD catheter placement reduced the risk of catheter displacement and noncatheter displacement dysfunction and did not increase the risk of bleeding, PD fluid leakage, hypogastralgia, peritonitis, or exit site and tunnel infections. Additional large multicenter randomized controlled trials are needed to confirm these conclusions.


Assuntos
Cateterismo/instrumentação , Cateteres de Demora/efeitos adversos , Diálise Peritoneal/efeitos adversos , Diálise Peritoneal/tendências , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Criança , China/epidemiologia , Gerenciamento de Dados , Feminino , Hemorragia/epidemiologia , Hemorragia/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Diálise Peritoneal/métodos , Peritonite/epidemiologia , Peritonite/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Adulto Jovem
5.
PLoS One ; 15(11): e0240859, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33151969

RESUMO

The real-world status of proton pump inhibitor (PPI) use in patients with atrial fibrillation (AF) receiving antithrombotic treatment is largely unknown. The All Nippon AF In the Elderly (ANAFIE) Registry, a prospective, multicenter, observational study, aimed to determine treatment patterns, risk factors, and outcomes among elderly (aged ≥75 years) Japanese non-valvular AF (NVAF) patients in the real-world clinical setting. The present subanalysis of the ANAFIE Registry determined the PPI prescription status of 32,490 elderly Japanese NVAF patients. Patients were stratified by PPI use (PPI+) or no PPI use (PPI-). Risk scores for stroke (CHADS2, CHA2DS2-VASc) and bleeding (HAS-BLED), anticoagulant use, time in therapeutic range (TTR) for warfarin, and anticoagulant/antiplatelet combination use were evaluated. PPIs were used in 11,981 (36.9%) patients. Compared with the PPI- group, the PPI+ group included a greater proportion of female patients (45.2% vs 41.3%; P <0.0001) and had significantly higher CHADS2, CHA2DS2-VASc, and HAS-BLED scores (P <0.0001 for each) as well as higher prevalences of several comorbidities. In the PPI+ group, 54.6% of patients did not have gastrointestinal (GI) disorders and were likely prescribed a PPI to prevent GI bleeding events. Most of the patients with a GI disorder in the PPI+ group had reflux esophagitis. Compared with patients not receiving anticoagulants, a significantly higher proportion of patients receiving anticoagulants received PPIs. For patients receiving anticoagulants, antiplatelet drugs, and both drugs, rates of PPI use were 34.1%, 44.1%, and 53.5%, respectively (P <0.01). Although the rate of PPI use was the highest for NVAF patients receiving both antiplatelet and anticoagulants, no clear differences were observed in the anticoagulants used. These data suggest that PPIs were actively prescribed in high-risk cases and may have been used to prevent GI bleeding among elderly NVAF patients receiving antithrombotic drugs. Trial registration: UMIN000024006.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores da Bomba de Prótons/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Estudos de Coortes , Quimioterapia Combinada , Feminino , Hemorragia/epidemiologia , Hemorragia/etiologia , Hemorragia/prevenção & controle , Humanos , Japão/epidemiologia , Masculino , Inibidores da Agregação de Plaquetas/administração & dosagem , Inibidores da Agregação de Plaquetas/efeitos adversos , Inibidores da Agregação de Plaquetas/uso terapêutico , Estudos Prospectivos , Inibidores da Bomba de Prótons/administração & dosagem , Sistema de Registros , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
6.
Int Heart J ; 61(6): 1204-1211, 2020 Nov 28.
Artigo em Inglês | MEDLINE | ID: mdl-33191346

RESUMO

The risk of thromboembolic events is significantly increased among patients with heart failure, even in those without atrial fibrillation. However, it is still unclear whether patients with heart failure and sinus rhythm can benefit from prophylactic anticoagulant therapy.This was a retrospective review of the pathophysiological mechanisms, epidemiological studies, and clinical trials on anticoagulation in patients with heart failure and sinus rhythm.Some subgroup analyses of clinical trials found that prophylactic anticoagulant therapy could reduce the incidence of stroke in patients with heart failure and sinus rhythm, and the risk of bleeding was significantly increased. Regarding the incidence of primary endpoint outcomes, all results from clinical trials were negative.Prophylactic anticoagulation did not improve the clinical outcome in patients with heart failure and sinus rhythm.


Assuntos
Anticoagulantes/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controle , Tromboembolia/prevenção & controle , Inibidores do Fator Xa/uso terapêutico , Insuficiência Cardíaca/sangue , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/fisiopatologia , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/fisiopatologia , Tromboembolia/sangue , Tromboembolia/epidemiologia , Tromboembolia/fisiopatologia
7.
Int Heart J ; 61(6): 1165-1173, 2020 Nov 28.
Artigo em Inglês | MEDLINE | ID: mdl-33191353

RESUMO

Direct oral anticoagulants (DOACs) are sometimes prescribed at off-label under-doses for patients who have undergone ablation for atrial fibrillation (AF). This practice may be an attempt to balance the risk of bleeding against that of stroke or AF recurrence.We examined outcomes of 1163 patients who continued use of a DOAC after ablation. The patients were enrolled in a large (3530 patients) multicenter registry in Japan. The study patients were classified as 749 (64.4%) appropriate standard-dose DOAC users, 216 (18.6%) off-label under-dose DOAC users, and 198 (17.0%) appropriate low-dose DOAC users.Age and CHA2DS2-VASc scores differed significantly between DOAC dosing regimens, with patients given an appropriate standard-dose being significantly younger (63.3 ± 9.4 versus 64.8 ± 9.5 versus 73.2 ± 6.8 years, P < 0.0001) and lower (2.1 ± 1.5 versus 2.4 ± 1.6 versus 3.4 ± 1.4, P < 0.0001) than those given an off-label under-dose or an appropriate low-dose. During the median 19.0-month follow-up period, the AF recurrence rate was similar between the appropriate standard-dose and off-label under-dose groups but relatively low in the appropriate low-dose group (42.5% versus 41.2% versus 35.4%, P = 0.08). Annualized rates of thromboembolic events, major bleeding, and death from any cause were 0.47%, 0.70%, and 0.23% in the off-label under-dose group, while those rates were 0.74%, 0.73%, and 0.65% in the appropriate standard-dose, and 1.58%, 2.12%, and 1.57% in the appropriate low-dose groups.In conclusion, the clinical adverse event rates for patients on an off-label under-dose DOAC regimen after ablation, predicated on careful patient evaluations, was not high as seen with that of patients on a standard DOAC dosing regimen.


Assuntos
Fibrilação Atrial/terapia , Ablação por Cateter , Inibidores do Fator Xa/administração & dosagem , Hemorragia/induzido quimicamente , Acidente Vascular Cerebral/prevenção & controle , Tromboembolia/prevenção & controle , Idoso , Fibrilação Atrial/complicações , Feminino , Hemorragia/epidemiologia , Humanos , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Mortalidade , Uso Off-Label , Cuidados Pós-Operatórios , Recidiva , Sistema de Registros , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Tromboembolia/epidemiologia , Tromboembolia/etiologia
8.
PLoS One ; 15(10): e0240489, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33035259

RESUMO

INTRODUCTION: Although the direct oral anticoagulant rivaroxaban is recommended for stroke prevention in patients with non-valvular atrial fibrillation based on Phase III clinical trials, there is still a need for additional safety data from everyday clinical practice. The ROSE study was initiated to collect further information on the safety and utilisation of rivaroxaban in a broader range of patient groups in routine clinical practice. METHODS AND RESULTS: The ROSE study was conducted in hospitals in England and Wales. Consenting adults with non-valvular atrial fibrillation newly started on rivaroxaban were eligible and followed up for 12 weeks. Data was derived through secondary use of medical records. The primary outcome was major bleeding within gastrointestinal, urogenital and intracranial sites. A total of 4846 patients were enrolled in the study September 2013 to January 2016, 965 of which were treated with rivaroxaban for non-valvular atrial fibrillation. The median age in the rivaroxaban non-valvular atrial fibrillation cohort was 76 years, 53.6% were male. The median HAS-BLED score was 2 and the median CHA2DS2-VASc score was 4. The risk of major bleeding within each of the primary sites of gastrointestinal, urogenital and intracranial during the 12 week observation period was low (0.2%; n = 2). The risk of major bleeding in all sites was 1.0% (n = 10) at a rate of 5.5 events per 100 patient years. CONCLUSION: In terms of the primary outcome risk of major bleeding within gastrointestinal, urogenital and intracranial sites during the 12 week observation period, the risk estimates in the non-valvular atrial fibrillation rivaroxaban user population were low (<1%), and consistent with risk estimated from clinical trial data and in routine clinical practice.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/efeitos adversos , Hemorragia/epidemiologia , Rivaroxabana/efeitos adversos , Acidente Vascular Cerebral/prevenção & controle , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Inglaterra/epidemiologia , Inibidores do Fator Xa/administração & dosagem , Feminino , Hemorragia/induzido quimicamente , Humanos , Incidência , Masculino , Rivaroxabana/administração & dosagem , Atenção Secundária à Saúde , País de Gales/epidemiologia
9.
JAMA ; 324(16): 1629-1639, 2020 10 27.
Artigo em Inglês | MEDLINE | ID: mdl-33095849

RESUMO

Importance: Although current guidelines suggest the use of regional citrate anticoagulation (which involves the addition of a citrate solution to the blood before the filter of the extracorporeal dialysis circuit) as first-line treatment for continuous kidney replacement therapy in critically ill patients, the evidence for this recommendation is based on few clinical trials and meta-analyses. Objective: To determine the effect of regional citrate anticoagulation, compared with systemic heparin anticoagulation, on filter life span and mortality. Design, Setting, and Participants: A parallel-group, randomized multicenter clinical trial in 26 centers across Germany was conducted between March 2016 and December 2018 (final date of follow-up, January 21, 2020). The trial was terminated early after 596 critically ill patients with severe acute kidney injury or clinical indications for initiation of kidney replacement therapy had been enrolled. Interventions: Patients were randomized to receive either regional citrate anticoagulation (n = 300), which consisted of a target ionized calcium level of 1.0 to 1.40 mg/dL, or systemic heparin anticoagulation (n = 296), which consisted of a target activated partial thromboplastin time of 45 to 60 seconds, for continuous kidney replacement therapy. Main Outcomes and Measures: Coprimary outcomes were filter life span and 90-day mortality. Secondary end points included bleeding complications and new infections. Results: Among 638 patients randomized, 596 (93.4%) (mean age, 67.5 years; 183 [30.7%] women) completed the trial. In the regional citrate group vs systemic heparin group, median filter life span was 47 hours (interquartile range [IQR], 19-70 hours) vs 26 hours (IQR, 12-51 hours) (difference, 15 hours [95% CI, 11 to 20 hours]; P < .001). Ninety-day all-cause mortality occurred in 150 of 300 patients vs 156 of 296 patients (Kaplan-Meier estimator percentages, 51.2% vs 53.6%; unadjusted difference, -2.4% [95% CI, -10.5% to 5.8%]; unadjusted hazard ratio, 0.91 [95% CI, 0.72 to 1.13]; unadjusted P = .38; adjusted difference, -6.1% [95% CI, -12.6% to 0.4%]; primary adjusted hazard ratio, 0.79 [95% CI, 0.63 to 1.004]; primary adjusted P = .054). Of 38 prespecified secondary end points, 34 showed no significant difference. Compared with the systemic heparin group, the regional citrate group had significantly fewer bleeding complications (15/300 [5.1%] vs 49/296 [16.9%]; difference, -11.8% [95% CI, -16.8% to -6.8%]; P < .001) and significantly more new infections (204/300 [68.0%] vs 164/296 [55.4%]; difference, 12.6% [95% CI, 4.9% to 20.3%]; P = .002). Conclusions and Relevance: Among critically ill patients with acute kidney injury receiving continuous kidney replacement therapy, anticoagulation with regional citrate, compared with systemic heparin anticoagulation, resulted in significantly longer filter life span. The trial was terminated early and was therefore underpowered to reach conclusions about the effect of anticoagulation strategy on mortality. Trial Registration: ClinicalTrials.gov Identifier: NCT02669589.


Assuntos
Lesão Renal Aguda/terapia , Anticoagulantes/administração & dosagem , Ácido Cítrico/administração & dosagem , Terapia de Substituição Renal Contínua/instrumentação , Heparina/administração & dosagem , Lesão Renal Aguda/sangue , Lesão Renal Aguda/mortalidade , Idoso , Anticoagulantes/efeitos adversos , Cálcio/sangue , Ácido Cítrico/efeitos adversos , Terapia de Substituição Renal Contínua/mortalidade , Estado Terminal , Término Precoce de Ensaios Clínicos , Feminino , Filtração/instrumentação , Alemanha , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Heparina/efeitos adversos , Humanos , Infecções/epidemiologia , Estimativa de Kaplan-Meier , Masculino , Tempo de Tromboplastina Parcial , Modelos de Riscos Proporcionais , Fatores de Tempo
10.
Can J Surg ; 63(5): E422-E430, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33009903

RESUMO

BACKGROUND: Failure to rapidly identify bleeding in trauma patients leads to substantial morbidity and mortality. We aimed to develop and validate a simple bedside score for identifying bleeding patients requiring escalation of care beyond initial resuscitation. METHODS: We included patients with major blunt or penetrating trauma, defined as those with an Injury Severity Score greater than 12 or requiring trauma team activation, at The Ottawa Hospital from September 2014 to September 2017. We used logistic regression for derivation. The primary outcome was a composite of the need for massive transfusion, embolization or surgery for hemostasis. We prespecified clinical, laboratory and imaging predictors using findings from our prior systematic review and survey of Canadian traumatologists. We used an AIC-based stepdown procedure based on the Akaike information criterion and regression coefficients to create a 5-variable score for bedside application. We used bootstrap internal validation to assess optimism-corrected performance. RESULTS: We included 890 patients, of whom 133 required a major intervention. The main model comprised systolic blood pressure, clinical examination findings suggestive of hemorrhage, lactate level, focused assessment with sonography in trauma (FAST) and computed tomographic imaging. The C statistic was 0.95, optimism-corrected to 0.94. A simplified Canadian Bleeding (CAN-BLEED) score was devised. A score cut-off of 2 points yielded sensitivity of 97.7% (95% confidence interval [CI] 93.6 to 99.5) and specificity 73.2% (95% CI 69.9 to 76.3). An alternative version that included mechanism of injury rather than CT had lower discriminative ability (C statistic = 0.89). CONCLUSION: A simple yet promising bleeding score is proposed to identify highrisk patients in need of major intervention for traumatic bleeding and determine the appropriateness of early transfer to specialized trauma centres. Further research is needed to evaluate the performance of the score in other settings, define interrater reliability and evaluate the potential for reduction of time to intervention.


Assuntos
Hemorragia/diagnóstico , Modelos Biológicos , Triagem/métodos , Ferimentos não Penetrantes/complicações , Ferimentos Penetrantes/complicações , Adulto , Transfusão de Sangue/estatística & dados numéricos , Canadá/epidemiologia , Tomada de Decisão Clínica , Embolização Terapêutica/estatística & dados numéricos , Feminino , Hemorragia/epidemiologia , Hemorragia/etiologia , Hemorragia/terapia , Hemostasia Cirúrgica/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Transferência de Pacientes/estatística & dados numéricos , Estudos Prospectivos , Reprodutibilidade dos Testes , Medição de Risco/métodos , Centros de Traumatologia/estatística & dados numéricos , Ferimentos não Penetrantes/terapia , Ferimentos Penetrantes/terapia
11.
J Vasc Interv Radiol ; 31(12): 2106-2112, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33023806

RESUMO

This study aimed to better define the safety and efficacy of transjugular renal biopsy (TJRB) based on published studies. Seventeen published articles were included (1,321 biopsies). Complications were classified as major if they resulted in blood transfusion or additional invasive procedures. All other bleeding complications were considered minor. Diagnostic tissue was obtained in 1,193 procedures (90.3%). The total incidence of bleeding complications among 15 articles with complete data was 202 of 892 procedures (22.6%): 162 (18.2%) minor and 40 (4.5 %) major. These results show that TJRB is a feasible procedure for obtaining renal tissue for diagnosis and that most complications are self-limiting.


Assuntos
Biópsia , Nefropatias/patologia , Rim/patologia , Biópsia/efeitos adversos , Feminino , Hemorragia/epidemiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco
12.
N Engl J Med ; 383(15): 1447-1457, 2020 10 08.
Artigo em Inglês | MEDLINE | ID: mdl-32865376

RESUMO

BACKGROUND: The effect of single as compared with dual antiplatelet treatment on bleeding and thromboembolic events after transcatheter aortic-valve implantation (TAVI) in patients who do not have an indication for long-term anticoagulation has not been well studied. METHODS: In a randomized, controlled trial, we assigned a subgroup of patients who were undergoing TAVI and did not have an indication for long-term anticoagulation, in a 1:1 ratio, to receive aspirin alone or aspirin plus clopidogrel for 3 months. The two primary outcomes were all bleeding (including minor, major, and life-threatening or disabling bleeding) and non-procedure-related bleeding over a period of 12 months. Most bleeding at the TAVI puncture site was counted as non-procedure-related. The two secondary outcomes were a composite of death from cardiovascular causes, non-procedure-related bleeding, stroke, or myocardial infarction (secondary composite 1) and a composite of death from cardiovascular causes, ischemic stroke, or myocardial infarction (secondary composite 2) at 1 year, with both outcomes tested sequentially for noninferiority (noninferiority margin, 7.5 percentage points) and superiority. RESULTS: A total of 331 patients were assigned to receive aspirin alone and 334 were assigned to receive aspirin plus clopidogrel. A bleeding event occurred in 50 patients (15.1%) receiving aspirin alone and in 89 (26.6%) receiving aspirin plus clopidogrel (risk ratio, 0.57; 95% confidence interval [CI], 0.42 to 0.77; P = 0.001). Non-procedure-related bleeding occurred in 50 patients (15.1%) and 83 patients (24.9%), respectively (risk ratio, 0.61; 95% CI, 0.44 to 0.83; P = 0.005). A secondary composite 1 event occurred in 76 patients (23.0%) receiving aspirin alone and in 104 (31.1%) receiving aspirin plus clopidogrel (difference, -8.2 percentage points; 95% CI for noninferiority, -14.9 to -1.5; P<0.001; risk ratio, 0.74; 95% CI for superiority, 0.57 to 0.95; P = 0.04). A secondary composite 2 event occurred in 32 patients (9.7%) and 33 patients (9.9%), respectively (difference, -0.2 percentage points; 95% CI for noninferiority, -4.7 to 4.3; P = 0.004; risk ratio, 0.98; 95% CI for superiority, 0.62 to 1.55; P = 0.93). A total of 44 patients (13.3%) and 32 (9.6%), respectively, received oral anticoagulation during the trial. CONCLUSIONS: Among patients undergoing TAVI who did not have an indication for oral anticoagulation, the incidence of bleeding and the composite of bleeding or thromboembolic events at 1 year were significantly less frequent with aspirin than with aspirin plus clopidogrel administered for 3 months. (Funded by the Netherlands Organization for Health Research and Development; POPular TAVI EU Clinical Trials Register number, 2013-003125-28; ClinicalTrials.gov number, NCT02247128.).


Assuntos
Aspirina/uso terapêutico , Clopidogrel/uso terapêutico , Hemorragia/induzido quimicamente , Inibidores da Agregação de Plaquetas/uso terapêutico , Trombose/prevenção & controle , Substituição da Valva Aórtica Transcateter , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Aspirina/efeitos adversos , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/mortalidade , Clopidogrel/efeitos adversos , Quimioterapia Combinada , Feminino , Hemorragia/epidemiologia , Humanos , Incidência , Masculino , Inibidores da Agregação de Plaquetas/efeitos adversos , Período Pós-Operatório , Trombose/epidemiologia
13.
Ann Hematol ; 99(12): 2763-2771, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32918114

RESUMO

The current standard of care treatment for severe hemophilia A and B (SHA and SHB) is the prophylactic intravenous replacement of coagulation factor VIII or IX (FVIII/FIX) to prevent spontaneous bleeding. Persons with hemophilia without prophylactic treatment receive therapy in case of bleeding, i.e., on demand. To assess treatment patterns, utilization of products, and bleeding outcomes in a real-world cohort of persons with SHA and SHB, defined as FVIII or FIX activity < 1%, data was retrospectively collected from hemophilia-specific patient diaries used for home treatment, medical records, and entries into the Austrian Hemophilia Registry from the year 2012 to 2017. Fifty-three male persons with SHA (n = 47) and SHB (n = 6) were included; 26 with SHA and 5 with SHB were on prophylaxis, 8 and 1 switched therapy regimen, and 13 and 0 received on-demand therapy. Persons on prophylaxis used a mean factor FVIII or FIX dose of 71.7 and 40.1 IU/kg/week. Median (IQR) annualized bleeding rates (ABR) in SHA were 28.0 (23.4-31.3) in the on-demand, 4.9 (1.6-13.5) in the prophylaxis group, and 3.0 (2.0-6.8) in the prophylactic group of SHB. Three persons with SHA had zero bleeds during the observation period. On-demand therapy and hepatitis B and C were associated with higher ABR but not age, weight, and HIV positivity. Bleeding rates and the proportion of on-demand therapy in persons with hemophilia were high in our real-world cohort. Further improvement is needed, which might be facilitated with the advent of factor products with extended half-life or non-factor therapies.


Assuntos
Fator IX/administração & dosagem , Fator VIII/administração & dosagem , Hemofilia A/tratamento farmacológico , Hemofilia B/tratamento farmacológico , Hemorragia/tratamento farmacológico , Índice de Gravidade de Doença , Adulto , Áustria/epidemiologia , Estudos de Coortes , Hemofilia A/diagnóstico , Hemofilia A/epidemiologia , Hemofilia B/diagnóstico , Hemofilia B/epidemiologia , Hemorragia/diagnóstico , Hemorragia/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
14.
Am J Cardiol ; 134: 83-90, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-32892987

RESUMO

The optimal antiplatelet strategy after left atrial appendage (LAA) occlusion able to protect from device-related thrombosis, paying the lowest price in terms of bleeding increase, is unclear. In a real-world, observational study we performed a head-to-head comparison of single versus dual antiplatelet therapy (SAPT vs DAPT) in patients who underwent LAA occlusion. We included 610 consecutive patients, stratified according to the type of post-procedural antiplatelet therapy (280 on SAPT and 330 on DAPT). Primary outcome measure was the incidence of the net composite end point including Bleeding Academic Research Consortium classification 3-5 bleeding, major adverse cardiovascular events or device-related thrombosis at 1-year follow-up. The use of SAPT compared with DAPT was associated with similar incidence of the primary net composite end point (9.3% vs 12.7% p = 0.22), with an adjusted hazard ratio (HR) of 0.69, 95% confidence interval 0.41 to 1.15; p = 0.15) at multivariate analysis. However, SAPT significantly reduced Bleeding Academic Research Consortium classification 3-5 bleeding (2.9% vs 6.7%, p = 0.038; adjusted HR 0.37, 0.16 to 0.88; p = 0.024). The occurrence of ischemic events (major adverse cardiovascular events or device-related thrombosis) was not significantly different between the 2treatment strategies (7.8% vs 7.4%; adjusted HR 1.34, 0.70 to 2.55; p = 0.38). In patients who underwent LAA occlusion, post-procedural use of SAPT instead of DAPT was associated with reduction of bleeding complications, with no significant increase in the risk of thrombotic events. These hypothesis-generating findings should be confirmed in a specific, randomized study.


Assuntos
Apêndice Atrial/cirurgia , Fibrilação Atrial/cirurgia , Terapia Antiplaquetária Dupla/estatística & dados numéricos , Hemorragia/epidemiologia , Inibidores da Agregação de Plaquetas/uso terapêutico , Implantação de Prótese , Acidente Vascular Cerebral/prevenção & controle , Trombose/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Aspirina/uso terapêutico , Fibrilação Atrial/complicações , Doenças Cardiovasculares/mortalidade , Clopidogrel/uso terapêutico , Embolia/etiologia , Embolia/prevenção & controle , Feminino , Humanos , Masculino , Modelos de Riscos Proporcionais , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral/etiologia
15.
Am J Cardiol ; 134: 74-82, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-32900468

RESUMO

Data regarding the associations of anemia (hemoglobin level <13.0 g/dl in men and <12.0 g/dl in women) with clinical outcomes in patients with atrial fibrillation (AF) remains scarce. This study sought to investigate the associations of anemia with the incidences of stroke or systemic embolism, major bleeding, heart failure (HF) hospitalization, and all-cause mortality including its causes, using the data from a Japanese community-based survey, the Fushimi AF Registry. A total of 4,169 AF patients were divided into the 3 groups, based on the baseline hemoglobin level: no (n = 2,622), mild (11.0 to <13.0 g/dl for men and <12.0 g/dl for women; n = 880), and moderate/severe anemia (<11.0 g/dl; n = 667). During a median follow-up of 1,464 days, the incidences of major bleeding, HF hospitalization, and mortality increased with higher rates of cardiac death, in accordance with anemic severity. On multivariate analyses, the higher risk of moderate/severe anemia, relative to no anemia, for major bleeding remained statistically significant (hazard ratio [HR]: 2.00, 95% confidential interval [CI]: 1.48 to 2.72). The risks of those with anemia, relative to no anemia, for HF hospitalization (mild; HR: 1.87, 95% CI: 1.51 to 2.31, and moderate/severe; HR: 2.02, 95% CI: 1.59 to 2.57) as well as for mortality (mild; HR: 1.80, 95% CI: 1.50 to 2.16, and moderate/severe; HR: 2.95, 95% CI: 2.45 to 3.55) were also higher, but not for stroke/systemic embolism. These relations were consistent, regardless of the use of oral anticoagulants. In conclusion, anemia was associated with higher risks of HF hospitalization, mortality, and major bleeding in AF patients.


Assuntos
Anemia/epidemiologia , Fibrilação Atrial/epidemiologia , Embolia/epidemiologia , Insuficiência Cardíaca , Hemorragia/epidemiologia , Hospitalização/estatística & dados numéricos , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Anemia/metabolismo , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Causas de Morte , Embolia/etiologia , Embolia/prevenção & controle , Feminino , Hemoglobinas/metabolismo , Humanos , Incidência , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Mortalidade , Análise Multivariada , Modelos de Riscos Proporcionais , Sistema de Registros , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
16.
AJR Am J Roentgenol ; 215(5): 1279-1285, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32901565

RESUMO

OBJECTIVE. This study evaluates the prevalence of an abnormal international normalized ratio (INR) and platelet count before image-guided percutaneous needle biopsies over a 10-year period, comparing data from patients with and those without known conditions predisposing to coagulopathy. MATERIALS AND METHODS. A review of electronic medical records identified patients who were scheduled for a biopsy in a single institution's radiology department for the period of 2007-2016. The following information was recorded: demographic data, patient history of conditions that predispose to bleeding (e.g., liver disease, anticoagulant therapy, history of coagulopathy), and INR and platelet values within 30 days before biopsy. Data were stratified by biopsies that were performed versus those that were cancelled. RESULTS. Over 10 years, 3864 percutaneous biopsies were performed, and 6371 were cancelled. Approximately half of the biopsies (48.2%) were performed in patients without a predisposing condition; of those patients, 0.8% and 0.1% had an INR greater than 1.5 and greater than 1.8, respectively, and 0.4% had a platelet count of 50,000/µL or less (≤ 50 × 109/L). In patients with no known predisposing condition, 0.6% and 0.0% of biopsies cancelled were in patients who had an INR greater than 1.5 and greater than 1.8, respectively, and 0.1% of biopsies cancelled were in patients who had a platelet count of 50,000/µL or less. Ordering prebiopsy testing of patients with no predisposing conditions for the 1864 percutaneous biopsies performed over the 10-year study period resulted in more than $850,000 in laboratory-related health care costs. Our results suggest that the cost of identifying one abnormal INR is nearly $700,000. CONCLUSION. For patients without any known bleeding risks who are scheduled to undergo image-guided percutaneous biopsies, identifying an abnormal INR or abnormal platelet count is rare. Eliminating this testing in patients without predisposing conditions has the potential to create savings in costs and time for both physicians and patients.


Assuntos
Transtornos da Coagulação Sanguínea/diagnóstico , Coeficiente Internacional Normatizado , Contagem de Plaquetas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia por Agulha/efeitos adversos , Biópsia por Agulha/métodos , Feminino , Hemorragia/epidemiologia , Hemorragia/prevenção & controle , Humanos , Biópsia Guiada por Imagem/efeitos adversos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Período Pré-Operatório , Estudos Retrospectivos , Medição de Risco , Adulto Jovem
17.
Yonsei Med J ; 61(9): 741-749, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32882758

RESUMO

PURPOSE: Non-vitamin K antagonist oral anticoagulants (NOACs) are widely used in patients with atrial fibrillation (AF) because of their effectiveness in preventing stroke and their better safety, compared with warfarin. However, there are concerns for an increased risk of bleeding associated with concomitant use of non-steroidal anti-inflammatory drugs (NSAIDs) or selective serotonin reuptake inhibitors (SSRIs) with NOACs. In this study, we aimed to evaluate the risk of bleeding events in individuals taking concomitant NSAIDs or SSRIs with NOACs after being diagnosed with AF. MATERIALS AND METHODS: A nested case-control analysis to assess the safety of NSAIDs and SSRIs among NOAC users with AF was performed using data from Korean National Health Insurance Service from January 2012 to December 2017. Among patients who were newly prescribed NOACs, 1233 cases hospitalized for bleeding events were selected, and 24660 controls were determined. RESULTS: The risk of bleeding events was higher in patients receiving concomitant NSAIDs [adjusted odds ratio (aOR) 1.41; 95% confidence interval (CI) 1.24-1.61] or SSRIs (aOR 1.92; 95% CI 1.52-2.42) with NOACs, compared to no use of either drug, respectively. The risk of upper gastrointestinal bleeding was higher in patients receiving concomitant NSAIDs or SSRIs without proton pump inhibitors (PPIs) (NSAIDs: aOR 2.47; 95% CI 1.26-4.83, SSRI: aOR 10.8; 95% CI 2.41-2.48) compared to no use. CONCLUSION: When NSAIDs or SSRIs are required for NOAC users with AF, physicians need to monitor bleeding events and consider the use of PPIs, especially for combined use of both drugs or when initiating NOACs treatment.


Assuntos
Anti-Inflamatórios não Esteroides/uso terapêutico , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Hemorragia Gastrointestinal/prevenção & controle , Hemorragia/prevenção & controle , Inibidores de Captação de Serotonina/uso terapêutico , Acidente Vascular Cerebral/prevenção & controle , Varfarina/uso terapêutico , Administração Oral , Idoso , Anti-Inflamatórios não Esteroides/efeitos adversos , Fibrilação Atrial/complicações , Estudos de Casos e Controles , Feminino , Hemorragia Gastrointestinal/complicações , Hemorragia/epidemiologia , Humanos , Pessoa de Meia-Idade , Inibidores de Captação de Serotonina/efeitos adversos , Acidente Vascular Cerebral/etiologia
18.
Nat Med ; 26(10): 1609-1615, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32747830

RESUMO

Understanding the pathophysiology of SARS-CoV-2 infection is critical for therapeutic and public health strategies. Viral-host interactions can guide discovery of disease regulators, and protein structure function analysis points to several immune pathways, including complement and coagulation, as targets of coronaviruses. To determine whether conditions associated with dysregulated complement or coagulation systems impact disease, we performed a retrospective observational study and found that history of macular degeneration (a proxy for complement-activation disorders) and history of coagulation disorders (thrombocytopenia, thrombosis and hemorrhage) are risk factors for SARS-CoV-2-associated morbidity and mortality-effects that are independent of age, sex or history of smoking. Transcriptional profiling of nasopharyngeal swabs demonstrated that in addition to type-I interferon and interleukin-6-dependent inflammatory responses, infection results in robust engagement of the complement and coagulation pathways. Finally, in a candidate-driven genetic association study of severe SARS-CoV-2 disease, we identified putative complement and coagulation-associated loci including missense, eQTL and sQTL variants of critical complement and coagulation regulators. In addition to providing evidence that complement function modulates SARS-CoV-2 infection outcome, the data point to putative transcriptional genetic markers of susceptibility. The results highlight the value of using a multimodal analytical approach to reveal determinants and predictors of immunity, susceptibility and clinical outcome associated with infection.


Assuntos
Ativação do Complemento/imunologia , Infecções por Coronavirus/mortalidade , Hemorragia/epidemiologia , Degeneração Macular/epidemiologia , Pneumonia Viral/mortalidade , Trombocitopenia/epidemiologia , Trombose/epidemiologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Betacoronavirus , Coagulação Sanguínea/genética , Transtornos da Coagulação Sanguínea/epidemiologia , Ativação do Complemento/genética , Infecções por Coronavirus/sangue , Infecções por Coronavirus/genética , Infecções por Coronavirus/imunologia , Diabetes Mellitus Tipo 2/epidemiologia , Feminino , Expressão Gênica , Hemorragia/sangue , Hemorragia/imunologia , Doenças da Deficiência Hereditária de Complemento/epidemiologia , Doenças da Deficiência Hereditária de Complemento/imunologia , Humanos , Hipertensão/epidemiologia , Intubação Intratraqueal , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Obesidade/epidemiologia , Pandemias , Pneumonia Viral/sangue , Pneumonia Viral/genética , Pneumonia Viral/imunologia , Modelos de Riscos Proporcionais , Respiração Artificial , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Trombocitopenia/sangue , Trombose/sangue
20.
Ann Hematol ; 99(10): 2323-2328, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32808105

RESUMO

Infection with SARS-CoV-2 (COVID-19) can cause prothrombotic complications. We aim to study the frequency of thrombotic complications and impact of anticoagulation on outcomes in hospitalized patients. We conducted a retrospective chart review of 921 consecutive patients admitted to our hospital with COVID-19. Patients were divided into four groups depending on whether they were on anticoagulation prior to admission, started anticoagulation during the admission, received prophylactic anticoagulation, or did not receive any anticoagulation. At the time of analysis, 325 patients (35.3%) had died, while 544 patients (59%) had been discharged resulting in inpatient mortality of 37.3%. Male sex, age > 65 years, and high D-dimer at admission were associated with higher mortality. Sixteen patients (1.7%) had venous thromboembolism confirmed with imaging, 11 patients had a stroke, and 2 patients developed limb ischemia. Treatment with therapeutic anticoagulation was associated with improved inpatient mortality compared with prophylactic anticoagulation alone (63% vs 86.2%, p < 0.0001) in patients requiring mechanical ventilation. Other outcomes such as rates of liberation from mechanical ventilation and duration of mechanical ventilation were not significantly impacted by the type of anticoagulation.


Assuntos
Anticoagulantes/uso terapêutico , Betacoronavirus , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Trombose/prevenção & controle , Trombose/virologia , Grupo com Ancestrais do Continente Africano , Idoso , Anticoagulantes/administração & dosagem , Infecções por Coronavirus/terapia , Feminino , Hemorragia/epidemiologia , Hispano-Americanos , Hospitais Comunitários , Hospitais Urbanos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Pandemias , Pneumonia Viral/terapia , Respiração Artificial , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Trombose/epidemiologia , Resultado do Tratamento , Tromboembolia Venosa/epidemiologia
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA