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1.
Clin Appl Thromb Hemost ; 28: 10760296221098717, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35538861

RESUMO

This article seeks to review the current status of treatment and prevention of venous thromboembolic disease (VTE) in cancer patients after the addition of direct oral anticoagulants (DOAC) to the therapeutic arsenal available. The suitability of DOAC use in complex clinical situations, poorly represented in clinical trials, is controversial and difficult for care activity, making the recommendations in clinical practice guidelines the focus of special attention in this area. Recently, several randomized trials have compared low molecular weight heparin (LMWH) to DOAC for the management of CAT. Potential drug interactions with DOACs or the increased risk of bleeding in intraluminal tumors require special precautions, as do metastatic or primary brain disease and comorbid conditions, such as renal or liver failure, which are not suitably represented in pivotal studies. Furthermore, few data are available for situations involving elevated bleeding risk, with thrombocytopenia levels below the inclusion criterion of clinical trials, or recurrence during active anticoagulant therapy. Similarly, it is less clear that patients and physicians accept the presumption that oral DOAC administration is more convenient than subcutaneous LMWH, particularly when drug absorption may be compromised. The non-inclusion or under-representation of patients at higher risk for complications with anticoagulation in randomized clinical trials, makes their use complex in certain situations in health care. This paper provides a practical review of current clinical guideline recommendations regarding LMWH and/ or DOAC to treat and prevent CAT, as well as the most controversial clinical conditions for their use.


Assuntos
Neoplasias , Tromboembolia Venosa , Anticoagulantes , Hemorragia/induzido quimicamente , Hemorragia/prevenção & controle , Heparina de Baixo Peso Molecular , Humanos , Neoplasias/complicações , Neoplasias/tratamento farmacológico , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle
2.
BMJ Open ; 12(5): e058093, 2022 May 09.
Artigo em Inglês | MEDLINE | ID: mdl-35534082

RESUMO

INTRODUCTION: Tranexamic acid (TXA) has become a widely used antifibrinolytic drug for reducing bleeding in surgery. However, adverse events, such as seizures, pulmonary embolism and deep vein thrombosis, limit its application. To date, insufficient attention has been devoted to determining the optimal dosage and administration route of TXA in the field of surgery. Thus, this study uses the network meta-analysis method, relying on its characteristics of combining direct comparison and indirect comparison, to analyse the safety and efficacy of different doses (high, medium, low) of intravenous injection or of topical application of TXA. METHODS AND ANALYSIS: We will search the PubMed, Cochrane Central Register of Controlled Trials, Embase, Web of Science and China National Knowledge Internet databases using a strategy that combines the terms TXA, randomised controlled trials and embolism (or haemorrhage, blood transfusion, seizure, mortality). Two reviewers will independently screen all identified abstracts for eligibility and evaluate the risk-of-bias of the included studies using the Cochrane risk of bias tool for randomised controlled studies. We will conduct a systematic review and network meta-analysis. We plan to investigate heterogeneity by performing subgroup analysis and sensitivity analysis, and we will also consider the dose-response relationship between the optimal dose and a better routine. We will assess the overall certainty of the evidence for each outcome using the Grading Recommendations Assessment, Development and Evaluation approach ETHICS AND DISSEMINATION: No ethics approval will be sought, as no original data will be collected for this review. Findings will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42021281206.


Assuntos
Antifibrinolíticos , Ácido Tranexâmico , Administração Intravenosa , Administração Tópica , Perda Sanguínea Cirúrgica , Transfusão de Sangue , Hemorragia/induzido quimicamente , Humanos , Metanálise como Assunto , Metanálise em Rede , Revisões Sistemáticas como Assunto , Ácido Tranexâmico/efeitos adversos
3.
Gerodontology ; 39(2): 218-221, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35526228

RESUMO

INTRODUCTION: Identifying the causes of accidental oral bleeding can be difficult in patients with dementia. The aim of this study was to highlight the effectiveness of multidisciplinary consultation, which proved extremely useful in investigating the cause of bleeding in this case. CASE PRESENTATION: An 86-year-old woman on anticoagulants who had been admitted to a geriatric facility experienced repeated oral bleeding of unknown cause, initially attributed to periodontitis. CONCLUSION: Along with anticoagulant use, a multidisciplinary consultation attributed the bleeding to the use of a spoon at mealtimes and possible scratching at the wound by the patient with her fingers.


Assuntos
Anticoagulantes , Demência , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Demência/complicações , Feminino , Hemorragia/induzido quimicamente , Humanos , Estudos Retrospectivos
4.
Pharmacol Res Perspect ; 10(3): e00956, 2022 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-35505637

RESUMO

The anticoagulant application is an effective treatment modality for cardiovascular diseases such as coronary heart disease, unstable angina pectoris, and myocardial infarction. In this study, the antithrombotic effect of recombinant neorudin (EPR-hirudin, EH) was evaluated using a canine model of coronary artery thrombosis. A canine model with platelet thrombosis in the left circumferent branch of the coronary artery was designed using Folt's method, and the anti-thrombus activity of EH was investigated. Femoral administration of EH intravenously had a significant dose-dependent inhibitory effect on canine coronary artery thrombosis and the effective rates were 66.7% (p < .05), 83.3% (p < .05), and 100% (p < .01) after injection of 0.3, 1.0, and 3.0 mg/kg EH, respectively. Furthermore, EH demonstrated lower bleeding, with shorter bleeding time and less bleeding loss than low molecular weight heparin (LMWH). Under the similar effect intensity of EH and LMWH (85 IU/kg), the bleeding time of the EH group at 30 min was shorter, and the blood loss at 30-120 min was less than that of LMWH (p < .05 and p < .05-.001, respectively). EH had a significant dose-dependent inhibitory effect in the dose range of 0.3-3.0 mg/kg on the coronary artery thrombosis and lower bleeding side effects than LMWH with a similar antithrombosis effect.


Assuntos
Trombose Coronária , Infarto do Miocárdio , Animais , Trombose Coronária/tratamento farmacológico , Vasos Coronários , Cães , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Heparina de Baixo Peso Molecular/uso terapêutico , Infarto do Miocárdio/tratamento farmacológico
5.
J Invasive Cardiol ; 34(5): E348-E355, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35501111

RESUMO

BACKGROUND: Left atrial appendage occlusion (LAAO) is recommended for patients with atrial fibrillation at increased stroke risk, where effective long-term oral anticoagulation (OAC) is not feasible. In order to assess long-term safety of LAAO with aspirin monotherapy or no therapy, we aimed to report on patients with the Watchman LAAO device (Boston Scientific) once postimplantation intensified antiplatelet or anticoagulation therapy is discontinued. METHODS: A total of 1025 patients scheduled for elective LAAO therapy prospectively consented for participation in the EWOLUTION registry; 1005 patients received a successful implant and were followed for 2 years. We identified 766 patients in EWOLUTION on single-antiplatelet therapy (SAPT; n = 639) or no therapy (n = 127) for ≥1 year following LAAO. RESULTS: Three to 6 months after LAAO, 766 patients were switched to SAPT or no therapy and were followed for at least 1 year until the study's conclusion or with events while on SAPT/ no therapy; mean time on SAPT/no therapy was 536.56 ± 177.59 days. Patients experienced 1.4 ischemic strokes per 100 patient years (PY) despite a CHA2DS2-VASC score of 4.3 ± 1.6. Major nonprocedural bleeding rates were low, with 1.3 major bleeds per 100 PY with a mean HAS-BLED score of 2.2 ± 1.2. Furthermore, the ischemic stroke rate in the SAPT/no-therapy subgroup was similar to the whole EWOLUTION collective and high-risk subgroups; the bleeding rate was even lower. When analyzed separately, strokes (2.1/100 PY) and bleedings (1.4/100 PY) of the no-therapy subgroup were similar to patients on SAPT (strokes 0.7/100 PY [P=.70]; bleedings 1.4/100 PY [P=.90]). CONCLUSIONS: Outcome data of patients on SAPT/no therapy for ≥1 year following Watchman implantation in the EWOLUTION registry suggest the efficacy and safety of LAAO.


Assuntos
Apêndice Atrial , Fibrilação Atrial , Acidente Vascular Cerebral , Anticoagulantes/efeitos adversos , Apêndice Atrial/cirurgia , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Hemorragia/prevenção & controle , Humanos , Sistema de Registros , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento
8.
J Invasive Cardiol ; 34(5): E363-E368, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35451995

RESUMO

BACKGROUND: Dual-antiplatelet treatment (DAPT) has conventionally been prescribed for 1 year after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation. Recent evidence suggests that a duration of only 6 months may be equally safe and effective when using contemporary DES options. OBJECTIVE: The aim of this study was to assess clinical outcomes in patients treated with the BioMatrix biodegradable-polymer coated biolimus-eluting stent (BP-BES; Biosensors International) who received only 6 months of DAPT. METHODS: This prospective "all-comers" registry enrolled 2038 patients in France. Following PCI, DAPT was started for a recommended period of 6 months. Patients were followed up at 6 and 24 months. The primary endpoint of major adverse cardiac and cerebrovascular event (MACCE) was a composite of all-cause death, cerebrovascular accidents, non-fatal myocardial infarction, or clinically driven target-vessel revascularization. Secondary endpoints included stent thrombosis (ST) and major bleeding (MB). RESULTS: The mean age of the study population was 67 ± 10.5 years and 77% of patients were male. Follow-up data were available in 96.9% and 95.3% of patients at 6 and 24 months, respectively. At 6 months, the incidences of MACCE, ST, and MB were 3.1%, 0.3%, and 0.4%, respectively. At 24 months, 21.2% of patients were still on DAPT and the cumulative incidences of MACCE, ST, and MB were 9.7%, 0.54%, and 0.79%, respectively. CONCLUSIONS: In this unselected population of patients undergoing PCI with a BP-BES, a 6-month duration of DAPT after implantation is safe and effective.


Assuntos
Doença da Artéria Coronariana , Stents Farmacológicos , Intervenção Coronária Percutânea , Idoso , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/cirurgia , Stents Farmacológicos/efeitos adversos , Feminino , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Inibidores da Agregação Plaquetária/uso terapêutico , Polímeros , Estudos Prospectivos , Sistema de Registros , Sirolimo/efeitos adversos , Resultado do Tratamento
9.
J Interv Cardiol ; 2022: 9609970, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35418809

RESUMO

Objectives: To investigate the safety and clinical efficacy of tirofiban during primary percutaneous coronary interventions (pPCI). Background: Gp IIb/IIIa inhibitors (GPI) use during pPCI has declined over years, mainly for the increased hemorrhagic risk associated to their use and for the availability of potent, fast-acting oral antiplatelet drugs. However, several pharmacodynamic studies showed suboptimal platelet inhibition with P2Y12-blockers, such as prasugrel or ticagrelor. Methods: Patients with ST-segment elevation myocardial infarction (STEMI) undergoing pPCI were prospectively enrolled in a multicenter registry conducted in high-volume centers in Italy. All patients received intraprocedural tirofiban. The primary safety endpoint was the occurrence of in-hospital bleedings according to the Bleeding Academic Research Consortium definition. In-hospital major adverse coronary events (MACE, defined as death, reinfarction, stent thrombosis, and target vessel revascularization), final TIMI flow, myocardial blush grade, and ST-segment resolution were also evaluated. Results: A total of 472 patients (mean age 61 ± 11 years, 83% males) were enrolled in 16 Italian centers from October 2015 to June 2018. Mean basal thrombus grade score was 3.47 ± 1.25. PCI was performed by transradial approach in 88% of patients. We observed a very low rate of 30 days BARC bleedings (2.1%) and MACE (0.8%). Complete (>70%) ST-segment resolution was observed in 67% of patients. Conclusions: In the FASTER registry, the use of tirofiban during primary PCI, performed with a transradial approach in most cases, in patients with high thrombus burden was associated with high rates of complete ST-segment resolution and low rates of in-hospital bleeding and MACE.


Assuntos
Intervenção Coronária Percutânea , Trombose , Idoso , Feminino , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Inibidores da Agregação Plaquetária/efeitos adversos , Sistema de Registros , Reperfusão , Trombose/etiologia , Tirofibana/efeitos adversos , Resultado do Tratamento , Tirosina/efeitos adversos
10.
Thromb Res ; 213: 195-202, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35398728

RESUMO

BACKGROUND: Dual antiplatelet therapy (DAPT) prevents ischemic events in patients with acute coronary syndrome (ACS), but is associated with increased risk of bleeding events. Symmetric dimethylarginine (SDMA) is one of nitric oxide (NO)-related pathway metabolites and stands as a promising biomarker of early chronic kidney disease (CKD) and cardiovascular diseases (CVDs). OBJECTIVES: Our study evaluated the role of SDMA in predicting bleeding events in patients after ACS treated with DAPT. METHODS: We compared plasma concentrations of NO-related pathway metabolites in patients with ACS (n = 291) and investigated the prognostic value of SDMA as a bleeding predictor during 1-year follow-up. We measured the metabolites concentration using ultra performance liquid chromatography. Platelet reactivity was determined using impedance aggregometry. RESULTS: Patients with the highest quartile (4th) of SDMA concentration had significantly lower platelet aggregation compared to those in the 1st-3rd quartiles of SDMA, based on ADP + PGE1-, AA-, and ADP-induced platelet reactivity tests (p = 0.0004, p = 0.002, p = 0.014, respectively). Patients with major or minor bleeding events had significantly higher concentrations of SDMA as compared to those without bleeding events or to those with minimal bleeding events (p = 0.019, p = 0.019, respectively). CONCLUSION: Higher SDMA concentration is associated with lower platelet reactivity and is associated with major and minor bleeding events in patients with ACS on DAPT. Therefore, SDMA stands as a potential biomarker for individualization of duration and potency of antiplatelet therapies in the ACS population at high risk of bleeding complications.


Assuntos
Síndrome Coronariana Aguda , Intervenção Coronária Percutânea , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/tratamento farmacológico , Difosfato de Adenosina , Arginina/análogos & derivados , Biomarcadores , Feminino , Hemorragia/induzido quimicamente , Humanos , Masculino , Intervenção Coronária Percutânea/efeitos adversos , Inibidores da Agregação Plaquetária/efeitos adversos
11.
J Assoc Physicians India ; 70(4): 11-12, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35443390

RESUMO

Dual antiplatelet treatment (DAPT) is the cornerstone of the management and prophylaxis of acute coronary syndrome (ACS). However, the associated risk of bleeding with the usage of DAPT and risk of thrombosis with stoppage of the drug makes it a challenging task to take appropriate decisions regarding the choice and duration of DAPT. The present study is aimed to tackle these challenges and to analyze whether prolonged dual antiplatelet therapy carries more risk of bleeding or a higher risk of thrombosis is present with discontinuation of the same. MATERIAL: In this study, a total of 235 cases of confirmed myocardial infarction, unstable angina, or those who underwent percutaneous intervention were included. After 1 year, the number of patients on DAPT, the type of antiplatelets they were using were observed, their ischemic risk was calculated using DAPT score, and bleeding risk was calculated using PRECISE-DAPT score. Bleeding events were assessed using BARC classification. OBSERVATION: Out of 235 patients, the majority of the patients were males (78.7%). Only 7.2% of the patients had bleeding since the start of the drugs. The majority (5% out of 7.2%) of bleeding episodes were clinically insignificant. 163 (69%) patients were on Dual antiplatelet therapy after 1 year. Out of which 115 were appropriately taking DAPT as per their DAPT score. Patients with high bleeding risk (PRECISE DAPT score ≥25) were 89, out of which 38 (53.2%) patients were taking SAPT, appropriate for their bleeding risk. While 112 (68.7%) were taking prolonged DAPT, appropriate for PRECISE-DAPT risk. CONCLUSION: The majority of patients remained on DAPT following discharge for more than 1 year after ACS. This suggests that treating physicians prioritizes ischemic risk reduction over bleeding risk in patients with ACS, according to the patient's risk profile.


Assuntos
Síndrome Coronariana Aguda , Intervenção Coronária Percutânea , Trombose , Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/etiologia , Quimioterapia Combinada , Feminino , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Hemorragia/epidemiologia , Humanos , Masculino , Intervenção Coronária Percutânea/efeitos adversos , Inibidores da Agregação Plaquetária/efeitos adversos , Fatores de Risco , Trombose/etiologia , Resultado do Tratamento
12.
J Assoc Physicians India ; 70(4): 11-12, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35443396

RESUMO

Although anti-thrombotic therapy is known to reduce embolic episodes leading to various ischemic events in patients with atrial fibrillation, it is strongly underused even in developed countries. MATERIAL: In an observational study, total 141 diagnosed cases of atrial fibrillation more than 18 years of age were studied from a period of 1st September 2019 to 31st August 2021. Detailed history, physical examination and relevant investigations were carried out. Guideline adherence was assessed as per prescription by treating physician in compliance with anti-thrombotic recommendations for stroke prevention in atrial fibrillation according to CHA2DS2-VASc score. Statistical analysis was done by STATA, version 10.1,2011. OBSERVATION: Among the 141 cases studied, mean age was 46.85±19.47 years with slight female preponderance (M:F = 1:1.27). Breathlessness was the most common presenting complaint (74.47%) followed by palpitations (69.5%) and pedal edema (55.3%). Rheumatic heart disease was the commonest etiology (40.4%) followed by hypertension (21.27%) and ischemic heart disease (17%). In non-valvular atrial fibrillation the mean CHA2DS2- VASc score was 2.74±1.99. Out of 141 patients, all 141 were indicated for anti-thrombotic therapy. Among these 141 patients, 129 (91.49%) were prescribed anti-thrombotic therapy, of which 105(81.39%) received oral anticoagulants, 36(27.91%) received anti-platelets while 12(9.30%) received both aspirin and oral anti-coagulant. The remaining 12 (8.51) patients who weren't prescribed anti-thrombotic therapy despite being indicated had high risk of bleeding (HAS-BLED score>3). Warfarin was prescribed to 94.28% patients while acitrom was used in 5.72% patients among those who received oral anti-coagulants. CONCLUSION: Although anti-thrombotic therapy was thought to be sub-optimally used, we see a trend in its increasing use. This study shows that the treatment guidelines for the stroke prevention in atrial fibrillation were followed in 91.49% patients by the treating physician in this part of India (Central India). Also there was no use of Newer/Novel oral anti-coagulants (NOACs) among those prescribed.


Assuntos
Fibrilação Atrial , Acidente Vascular Cerebral , Administração Oral , Adulto , Idoso , Anticoagulantes , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Feminino , Hemorragia/induzido quimicamente , Humanos , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/prevenção & controle , Centros de Atenção Terciária
13.
BMJ ; 377: e069590, 2022 04 06.
Artigo em Inglês | MEDLINE | ID: mdl-35387772

RESUMO

OBJECTIVE: To quantify the risk of deep vein thrombosis, pulmonary embolism, and bleeding after covid-19. DESIGN: Self-controlled case series and matched cohort study. SETTING: National registries in Sweden. PARTICIPANTS: 1 057 174 people who tested positive for SARS-CoV-2 between 1 February 2020 and 25 May 2021 in Sweden, matched on age, sex, and county of residence to 4 076 342 control participants. MAIN OUTCOMES MEASURES: Self-controlled case series and conditional Poisson regression were used to determine the incidence rate ratio and risk ratio with corresponding 95% confidence intervals for a first deep vein thrombosis, pulmonary embolism, or bleeding event. In the self-controlled case series, the incidence rate ratios for first time outcomes after covid-19 were determined using set time intervals and the spline model. The risk ratios for first time and all events were determined during days 1-30 after covid-19 or index date using the matched cohort study, and adjusting for potential confounders (comorbidities, cancer, surgery, long term anticoagulation treatment, previous venous thromboembolism, or previous bleeding event). RESULTS: Compared with the control period, incidence rate ratios were significantly increased 70 days after covid-19 for deep vein thrombosis, 110 days for pulmonary embolism, and 60 days for bleeding. In particular, incidence rate ratios for a first pulmonary embolism were 36.17 (95% confidence interval 31.55 to 41.47) during the first week after covid-19 and 46.40 (40.61 to 53.02) during the second week. Incidence rate ratios during days 1-30 after covid-19 were 5.90 (5.12 to 6.80) for deep vein thrombosis, 31.59 (27.99 to 35.63) for pulmonary embolism, and 2.48 (2.30 to 2.68) for bleeding. Similarly, the risk ratios during days 1-30 after covid-19 were 4.98 (4.96 to 5.01) for deep vein thrombosis, 33.05 (32.8 to 33.3) for pulmonary embolism, and 1.88 (1.71 to 2.07) for bleeding, after adjusting for the effect of potential confounders. The rate ratios were highest in patients with critical covid-19 and highest during the first pandemic wave in Sweden compared with the second and third waves. In the same period, the absolute risk among patients with covid-19 was 0.039% (401 events) for deep vein thrombosis, 0.17% (1761 events) for pulmonary embolism, and 0.101% (1002 events) for bleeding. CONCLUSIONS: The findings of this study suggest that covid-19 is a risk factor for deep vein thrombosis, pulmonary embolism, and bleeding. These results could impact recommendations on diagnostic and prophylactic strategies against venous thromboembolism after covid-19.


Assuntos
COVID-19 , Embolia Pulmonar , Tromboembolia Venosa , Trombose Venosa , Anticoagulantes/efeitos adversos , COVID-19/complicações , COVID-19/epidemiologia , Estudos de Coortes , Hemorragia/induzido quimicamente , Hemorragia/etiologia , Humanos , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/etiologia , Embolia Pulmonar/prevenção & controle , Fatores de Risco , SARS-CoV-2 , Tromboembolia Venosa/induzido quimicamente , Trombose Venosa/induzido quimicamente , Trombose Venosa/etiologia
14.
JACC Cardiovasc Interv ; 15(8): 861-872, 2022 04 25.
Artigo em Inglês | MEDLINE | ID: mdl-35367170

RESUMO

OBJECTIVES: The aim of this study was to investigate the effects of rivaroxaban on left ventricle thromboprophylaxis in patients with anterior ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Anterior STEMI is associated with an increased risk of left ventricular thrombus (LVT) formation. The contemporary role of prophylactic rivaroxaban therapy remains unclear. METHODS: We randomly assigned 279 patients with anterior STEMI who had undergone primary percutaneous coronary intervention to receive, in a 1:1 ratio, low-dose rivaroxaban (2.5 mg twice daily for 30 days) and dual antiplatelet therapy (DAPT) or only DAPT. The primary efficacy outcome was the LVT formation within 30 days. Net clinical adverse events were assessed at 30 days and 180 days, including all-cause mortality, LVT, systemic embolism, rehospitalization for cardiovascular events, and bleeding. RESULTS: The addition of low-dose rivaroxaban to DAPT reduced LVT formation within 30 days compared with only DAPT (0.7% vs 8.6%; HR: 0.08; 95% CI: 0.01-0.62; P = 0.015; P < 0.001 for superiority). Net clinical adverse events were lower within 30 days in the rivaroxaban group versus those in the only DAPT group and remained relatively low throughout the follow-up period. There were no significant differences in bleeding events between the 2 groups in 30 days and 180 days. However, 1 case of intracranial hemorrhage (major bleeding) occurred in the rivaroxaban group within 30 days. CONCLUSIONS: Our results supported that the short-duration addition of low-dose rivaroxaban to DAPT could prevent LVT formation in patients with anterior STEMI following primary percutaneous coronary intervention. A larger multiple-institution study is necessary to determine the generalizability.


Assuntos
Rivaroxabana , Infarto do Miocárdio com Supradesnível do Segmento ST , Trombose , Terapia Antiplaquetária Dupla/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Intervenção Coronária Percutânea , Inibidores da Agregação Plaquetária/efeitos adversos , Rivaroxabana/efeitos adversos , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Trombose/epidemiologia , Trombose/prevenção & controle , Resultado do Tratamento
15.
Circulation ; 145(19): 1471-1479, 2022 May 10.
Artigo em Inglês | MEDLINE | ID: mdl-35389229

RESUMO

BACKGROUND: Extended thromboprophylaxis has not been widely implemented in acutely ill medical patients because of bleeding concerns. The MAGELLAN (Multicenter, Randomized, Parallel Group Efficacy and Safety Study for the Prevention of Venous Thromboembolism in Hospitalized Medically Ill Patients Comparing Rivaroxaban With Enoxaparin) and MARINER (Medically Ill Patient Assessment of Rivaroxaban Versus Placebo in Reducing Post-Discharge Venous Thrombo-Embolism Risk) trials evaluated whether rivaroxaban compared with enoxaparin or placebo could prevent venous thromboembolism without increased bleeding. We hypothesized that patients with major bleeding but not those with nonmajor clinically relevant bleeding would be at an increased risk of all-cause mortality (ACM). METHODS: We evaluated all bleeding events in patients taking at least 1 dose of study drug and their association with ACM in 4 mutually exclusive groups: (1) no bleeding, or first event was (2) nonmajor clinically relevant bleeding, (3) major bleeding, or (4) trivial bleeding. Using a Cox proportional hazards model adjusted for differences in baseline characteristics associated with ACM, we assessed the risk of ACM after such events. RESULTS: Compared with patients with no bleeding, the risk of ACM for patients with nonmajor clinically relevant bleeding was not increased in MARINER (hazard ratio, 0.43; P=0.235) but was increased in MAGELLAN (hazard ratio, 1.74; P=0.021). Major bleeding was associated with a higher incidence of ACM in both studies, whereas trivial bleeding was not associated with ACM in either study. CONCLUSIONS: Patients with major bleeding had an increased risk of ACM, whereas nonmajor clinically relevant bleeding was not consistently associated with an increased risk of death. These results inform the risk-benefit calculus of extended thromboprophylaxis in medically ill patients. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: MAGELLAN, NCT00571649. URL: https://www. CLINICALTRIALS: gov; Unique identifier: MARINER, NCT02111564.


Assuntos
Rivaroxabana , Tromboembolia Venosa , Assistência ao Convalescente , Anticoagulantes/efeitos adversos , Enoxaparina/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/complicações , Humanos , Alta do Paciente , Rivaroxabana/efeitos adversos , Tromboembolia Venosa/epidemiologia
16.
Am Fam Physician ; 105(4): 377-385, 2022 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-35426644

RESUMO

Venous thromboembolism (VTE) recurrence rates are three times higher in patients with chronic or no risk factors compared with those who have transient risk factors after stopping anticoagulation therapy. In patients with unprovoked VTE, age-appropriate screening is sufficient evaluation for occult malignancy. Thrombophilia evaluation should be considered only in selected patients because routine evaluation has not been shown to improve outcomes. Patients with VTE should receive three months of anticoagulation therapy. The context of the initial VTE, risk of bleeding and recurrence, and patient preference should be considered when determining whether to continue treatment beyond the initial three months. There is growing evidence regarding the use of risk assessment models to determine risk of recurrence, but this has not been incorporated into guidelines. All pregnant patients with a prior VTE should receive postpartum prophylaxis for six weeks. Antepartum prophylaxis should be used in pregnant people with a history of unprovoked or hormonally induced VTE. High-risk patients undergoing surgery may require extended VTE prophylaxis postoperatively.


Assuntos
Tromboembolia Venosa , Anticoagulantes/uso terapêutico , Feminino , Hemorragia/induzido quimicamente , Humanos , Gravidez , Recidiva , Medição de Risco , Fatores de Risco , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle
17.
Am J Nurs ; 122(5): 49, 2022 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-35447654

RESUMO

According to this study: Among patients younger than 21 years of age who have provoked venous thromboembolism, anticoagulant therapy for six weeks compared with three months met noninferiority criteria based on the trade-off between recurrent venous thromboembolism risk and bleeding risk.


Assuntos
Tromboembolia Venosa , Anticoagulantes/efeitos adversos , Criança , Hemorragia/induzido quimicamente , Hemorragia/tratamento farmacológico , Humanos , Recém-Nascido , Recidiva , Tromboembolia Venosa/tratamento farmacológico
18.
Ther Adv Cardiovasc Dis ; 16: 17539447221093963, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35481366

RESUMO

AIMS: Oral anticoagulation with direct oral anticoagulants (DOAC) could provide an alternative to vitamin K antagonists (VKA) for patients with atrial fibrillation (AF) undergoing bioprosthetic heart valve replacement or valve repair. METHODS AND RESULTS: The aim of this meta-analysis was to review the safety and efficacy of DOAC in patients with surgical implanted bioprosthetic heart valves or valve repairs and AF including data from six clinical trials with a total of 1,857 patients. The efficacy and safety data of DOAC and VKA were pooled to perform random-effects meta-analyses using the Mantel-Haenszel method with pooled risk ratios (RR) and 95% confidence interval (CI). A trial sequential analysis (TSA) was performed to assess statistical robustness. Death caused by cardiovascular cause or thromboembolic events were comparable (RR 0.67, 95% CI: 0.42-1.08; p = 0.10) as DOAC significantly reduced the risk for major bleeding (RR 0.55, 95% CI: 0.35-0.88; p = 0.01) and thromboembolic stroke or systemic embolism rates (RR 0.54, 95% CI: 0.32-0.90; p = 0.02). Rates for intracranial bleeding and hemorrhagic stroke (RR 0.27, 95% CI: 0.07-0.99; p = 0.05) show a trend toward fewer events in the DOAC group. Outcomes for major or minor bleeding events and all-cause mortality were comparable for DOAC and VKA. CONCLUSION: Cumulative data analysis reveals that DOAC may provide an effective and safe alternative to VKA in patients with AF after surgically implanted bioprosthetic heart valves or repair with AF. Within a relatively heterogeneous study population, this meta-analysis shows a risk reduction of major bleedings and thromboembolic stroke or systemic embolisms for DOAC.


Assuntos
Fibrilação Atrial , Acidente Vascular Cerebral , Tromboembolia , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Hemorragia/induzido quimicamente , Humanos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Tromboembolia/etiologia , Tromboembolia/prevenção & controle
19.
JAMA ; 327(16): 1577-1584, 2022 04 26.
Artigo em Inglês | MEDLINE | ID: mdl-35471505

RESUMO

Importance: Cardiovascular disease (CVD) is the leading cause of mortality in the US, accounting for more than 1 in 4 deaths. Each year, an estimated 605 000 people in the US have a first myocardial infarction and an estimated 610 000 experience a first stroke. Objective: To update its 2016 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review on the effectiveness of aspirin to reduce the risk of CVD events (myocardial infarction and stroke), cardiovascular mortality, and all-cause mortality in persons without a history of CVD. The systematic review also investigated the effect of aspirin use on colorectal cancer (CRC) incidence and mortality in primary CVD prevention populations, as well as the harms (particularly bleeding) associated with aspirin use. The USPSTF also commissioned a microsimulation modeling study to assess the net balance of benefits and harms from aspirin use for primary prevention of CVD and CRC, stratified by age, sex, and CVD risk level. Population: Adults 40 years or older without signs or symptoms of CVD or known CVD (including history of myocardial infarction or stroke) who are not at increased risk for bleeding (eg, no history of gastrointestinal ulcers, recent bleeding, other medical conditions, or use of medications that increase bleeding risk). Evidence Assessment: The USPSTF concludes with moderate certainty that aspirin use for the primary prevention of CVD events in adults aged 40 to 59 years who have a 10% or greater 10-year CVD risk has a small net benefit. The USPSTF concludes with moderate certainty that initiating aspirin use for the primary prevention of CVD events in adults 60 years or older has no net benefit. Recommendation: The decision to initiate low-dose aspirin use for the primary prevention of CVD in adults aged 40 to 59 years who have a 10% or greater 10-year CVD risk should be an individual one. Evidence indicates that the net benefit of aspirin use in this group is small. Persons who are not at increased risk for bleeding and are willing to take low-dose aspirin daily are more likely to benefit. (C recommendation) The USPSTF recommends against initiating low-dose aspirin use for the primary prevention of CVD in adults 60 years or older. (D recommendation).


Assuntos
Aspirina , Doenças Cardiovasculares , Adulto , Aspirina/efeitos adversos , Aspirina/uso terapêutico , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/prevenção & controle , Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/prevenção & controle , Simulação por Computador , Hemorragia/induzido quimicamente , Humanos , Pessoa de Meia-Idade , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/prevenção & controle , Prevenção Primária , Medição de Risco , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controle
20.
JAMA ; 327(16): 1585-1597, 2022 04 26.
Artigo em Inglês | MEDLINE | ID: mdl-35471507

RESUMO

Importance: Low-dose aspirin is used for primary cardiovascular disease prevention and may have benefits for colorectal cancer prevention. Objective: To review the benefits and harms of aspirin in primary cardiovascular disease prevention and colorectal cancer prevention to inform the US Preventive Services Task Force. Data Sources: MEDLINE, PubMed, Embase, and the Cochrane Central Register of Controlled Trials through January 2021; literature surveillance through January 21, 2022. Study Selection: English-language randomized clinical trials (RCTs) of low-dose aspirin (≤100 mg/d) compared with placebo or no intervention in primary prevention populations. Data Extraction and Synthesis: Single extraction, verified by a second reviewer. Quantitative synthesis using Peto fixed-effects meta-analysis. Main Outcomes and Measures: Cardiovascular disease events and mortality, all-cause mortality, colorectal cancer incidence and mortality, major bleeding, and hemorrhagic stroke. Results: Eleven RCTs (N = 134 470) and 1 pilot trial (N = 400) of low-dose aspirin for primary cardiovascular disease prevention were included. Low-dose aspirin was associated with a significant decrease in major cardiovascular disease events (odds ratio [OR], 0.90 [95% CI, 0.85-0.95]; 11 RCTs [n = 134 470]; I2 = 0%; range in absolute effects, -2.5% to 0.1%). Results for individual cardiovascular disease outcomes were significant, with similar magnitude of benefit. Aspirin was not significantly associated with reductions in cardiovascular disease mortality or all-cause mortality. There was limited trial evidence on benefits for colorectal cancer, with the findings highly variable by length of follow-up and statistically significant only when considering long-term observational follow-up beyond randomized trial periods. Low-dose aspirin was associated with significant increases in total major bleeding (OR, 1.44 [95% CI, 1.32-1.57]; 10 RCTs [n = 133 194]; I2 = 4.7%; range in absolute effects, 0.1% to 1.0%) and in site-specific bleeding, with similar magnitude. Conclusions and Relevance: Low-dose aspirin was associated with small absolute risk reductions in major cardiovascular disease events and small absolute increases in major bleeding. Colorectal cancer results were less robust and highly variable.


Assuntos
Aspirina , Doenças Cardiovasculares , Neoplasias Colorretais , Aspirina/efeitos adversos , Aspirina/uso terapêutico , Doenças Cardiovasculares/prevenção & controle , Neoplasias Colorretais/prevenção & controle , Hemorragia/induzido quimicamente , Humanos , Prevenção Primária , Ensaios Clínicos Controlados Aleatórios como Assunto
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