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1.
N Engl J Med ; 381(12): 1103-1113, 2019 09 19.
Artigo em Inglês | MEDLINE | ID: mdl-31475793

RESUMO

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


Assuntos
Fibrilação Atrial/tratamento farmacológico , Doença das Coronárias/terapia , Inibidores do Fator Xa/uso terapêutico , Inibidores da Agregação de Plaquetas/uso terapêutico , Rivaroxabana/uso terapêutico , Idoso , Aspirina/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/mortalidade , Ponte de Artéria Coronária , Doença das Coronárias/complicações , Quimioterapia Combinada/efeitos adversos , Inibidores do Fator Xa/efeitos adversos , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/efeitos adversos , Modelos de Riscos Proporcionais , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Rivaroxabana/efeitos adversos
2.
Medicine (Baltimore) ; 98(31): e16568, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31374023

RESUMO

INTRODUCTION: Valvular vegetation is often due to rheumatic heart disease and infective endocarditis. However, multi-arterial embolism can happen in older patients with no history of infection, fever, and cardiac symptoms. We describe a case of multi-organ embolism caused by oscillating aortal valve vegetation. PATIENT CONCERNS: An 80-year-old woman without a history of infection, fever, and heart symptoms showed sudden loss of consciousness and symptoms of a multi-vessel embolism. Magnetic resonance imaging revealed multiple patchy ischemic foci in both cerebral hemispheres in the same time-phase, and echocardiography showed regurgitation in the aortic valve due to an abnormally hypo-hyperechoic mass measuring about 7.7 × 17.2 mm and oscillating aortic valve vegetation, which was induced by cardiac contraction. DIAGNOSIS: Multiple organ cardiac embolisms caused by oscillating aortic valve vegetation. INTERVENTIONS: Anti-platelet, fluid-supplement, and vascular-dilating therapies as well as intravenous diazepam were given to the patient. OUTCOME: The patient died of epileptic attack secondary to the cerebral embolism. CONCLUSIONS: The patient's whole-body multi-vessel ischemic events in nearly the same time-phase should have encouraged us to consider the possibility of cardiogenic embolism and thus early examination and treatment, although she was old with a relatively poor response due to early infection and physical discomfort. Clinicians should be aware that aortic valve vegetation induces generalized multi-organ embolism in the setting of infective endocarditis in order to ensure prompt recognition and treatment of this fatal complication.


Assuntos
Valva Aórtica , Embolia/etiologia , Doenças das Valvas Cardíacas/complicações , Idoso de 80 Anos ou mais , Embolia/terapia , Feminino , Hidratação , Humanos , Imagem por Ressonância Magnética , Inibidores da Agregação de Plaquetas/uso terapêutico , Vasodilatadores/uso terapêutico
3.
Medicine (Baltimore) ; 98(34): e16880, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31441862

RESUMO

INTRODUCTION: Saphenous vein graft (SVG) is the most common conduit used for coronary artery bypass grafting (CABG) surgery. Unfortunately, SVG are associated with poor long-term patency rates; a significant predictor of re-operation rates and survival. As such, medical therapy to prevent SVG narrowing or occlusion is of paramount importance. Aspirin (ASA) monotherapy is the standard of care after CABG, to improve long-term major adverse cardiovascular events (MACE) and graft patency. Benefits of dual antiplatelet therapy (DAPT) have not been well established in all CABG patients. We present a protocol for a network meta-analysis (NMA) comparing the effects of various antiplatelet therapy regimens on SVG patency, mortality, and bleeding among adult patients following CABG. METHODS: We will search CENTRAL, MEDLINE, EMBASE, CINAHL ACPJC, and grey literature sources (AHA, ACC, ESC, and CCC conference proceedings, ISRCTN Register, and WHO ICTRP) for randomized controlled trials (RCTs) which fit our criteria. RCTs that evaluate different antiplatelet regimens at least 3-months after CABG and have any of SVG patency, mortality, MACE, and major bleeding as outcomes will be selected. We will perform title and abstract screening, full-text screening, and data extraction independently and in duplicate. Two independent reviewers will also assess risk of bias (ROB) for each study, as well as evaluate quality of evidence using the GRADE framework. We will use R to perform the NMA and use low-dose ASA as reference within our network. We will report results as odds ratios with confidence intervals for direct comparisons, and credible intervals for indirect or mixed comparisons. We will use the surface under the cumulative ranking curve (SUCRA) to estimate the ranking of interventions. DISCUSSION: Given the limited direct comparison of various antiplatelet regimens, a network approach is ideal to clarify the optimum antiplatelet therapy after CABG. We hope that our NMA will be the largest quantitative synthesis evaluating antiplatelet regimens among patients requiring CABG. It should inform clinicians and guideline developers in selecting the most effective and safest antiplatelet regimen.Systematic Review registration: International Prospective Register for Systematic Reviews (PROSPERO)-CRD42019127695.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Inibidores da Agregação de Plaquetas/uso terapêutico , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/cirurgia , Humanos , Meta-Análise em Rede , Veia Safena/transplante , Revisão Sistemática como Assunto , Resultado do Tratamento
4.
S D Med ; 72(6): 260-266, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31461231

RESUMO

Antiplatelet agents are the mainstay of treatment for patients with acute coronary syndrome (ACS) or stable ischemic heart disease (SIHD). The most commonly used antiplatelet agents are aspirin and clopidogrel. Newer agents such as ticagrelor are becoming more commonplace as new studies have shown more cardiovascular benefits with these group of medications. The duration of use of these agents in setting of stable disease versus ACS is variable. We have tried to delineate the usage and duration of these agents in patients with the history of ACS or SIHD in numerous medical conditions. We have delved into available guidelines from American College of Cardiology/American Heart Association, Society of Thoracic Surgeons, and American College of Gastroenterology for our review article.


Assuntos
Síndrome Coronariana Aguda , Doença da Artéria Coronariana , Isquemia Miocárdica , Inibidores da Agregação de Plaquetas/uso terapêutico , Aspirina/uso terapêutico , Doença da Artéria Coronariana/tratamento farmacológico , Humanos
6.
Stud Health Technol Inform ; 262: 110-113, 2019 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-31349278

RESUMO

A 'Rapid Recommendation' has been produced by the GRADE group, in collaboration with MAGIC and BMJ, in response to an RCT showing Dual Anti-Platelet Therapy (DAPT) is superior to Aspirin alone for patients who had suffered acute high risk transient ischaemic attack or minor ischaemic stroke. The interactive MAGIC decision aid that accompanies each Rapid Recommendation is the main route to their clinical implementation. It can facilitate preference-sensitive person-centred care, but only if a Multi-Criteria Decision Analysis-based decision support tool is added. A demonstration version of such an add-on to the MAGIC aid, divested of recommendations, is available online. Exploring the results of different preference inputs into the tool raises questions about the strong recommendation for DAPT.


Assuntos
Isquemia Encefálica , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Isquemia Encefálica/tratamento farmacológico , Clopidogrel , Humanos , Ataque Isquêmico Transitório/tratamento farmacológico , Assistência Centrada no Paciente , Inibidores da Agregação de Plaquetas/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico
7.
Lancet ; 393(10186): 2155-2167, 2019 05 25.
Artigo em Inglês | MEDLINE | ID: mdl-31226053

RESUMO

Aspirin is one of the most frequently used drugs worldwide and is generally considered effective for the secondary prevention of cardiovascular disease. By contrast, the role of aspirin in primary prevention of cardiovascular disease is controversial. Early trials evaluating aspirin for primary prevention, done before the turn of the millennium, suggested reductions in myocardial infarction and stroke (although not mortality), and an increased risk of bleeding. In an effort to balance the risks and benefits of aspirin, international guidelines on primary prevention of cardiovascular disease have typically recommended aspirin only when a substantial 10-year risk of cardiovascular events exists. However, in 2018, three large randomised clinical trials of aspirin for the primary prevention of cardiovascular disease showed little or no benefit and have even suggested net harm. In this narrative Review, we reappraise the role of aspirin in primary prevention of cardiovascular disease, contextualising data from historical and contemporary trials.


Assuntos
Aspirina/uso terapêutico , Doenças Cardiovasculares/prevenção & controle , Inibidores de Ciclo-Oxigenase/uso terapêutico , Inibidores da Agregação de Plaquetas/uso terapêutico , Adulto , Idoso , Idoso de 80 Anos ou mais , Aspirina/farmacologia , Ensaios Clínicos como Assunto , Inibidores de Ciclo-Oxigenase/farmacologia , Angiopatias Diabéticas/prevenção & controle , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/farmacologia , Prevenção Primária , Fatores Sexuais
8.
JAMA ; 321(24): 2414-2427, 2019 06 25.
Artigo em Inglês | MEDLINE | ID: mdl-31237644

RESUMO

Importance: Very short mandatory dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with a drug-eluting stent may be an attractive option. Objective: To test the hypothesis of noninferiority of 1 month of DAPT compared with standard 12 months of DAPT for a composite end point of cardiovascular and bleeding events. Design, Setting, and Participants: Multicenter, open-label, randomized clinical trial enrolling 3045 patients who underwent PCI at 90 hospitals in Japan from December 2015 through December 2017. Final 1-year clinical follow-up was completed in January 2019. Interventions: Patients were randomized either to 1 month of DAPT followed by clopidogrel monotherapy (n=1523) or to 12 months of DAPT with aspirin and clopidogrel (n=1522). Main Outcomes and Measures: The primary end point was a composite of cardiovascular death, myocardial infarction (MI), ischemic or hemorrhagic stroke, definite stent thrombosis, or major or minor bleeding at 12 months, with a relative noninferiority margin of 50%. The major secondary cardiovascular end point was a composite of cardiovascular death, MI, ischemic or hemorrhagic stroke, or definite stent thrombosis and the major secondary bleeding end point was major or minor bleeding. Results: Among 3045 patients randomized, 36 withdrew consent; of 3009 remaining, 2974 (99%) completed the trial. One-month DAPT was both noninferior and superior to 12-month DAPT for the primary end point, occurring in 2.36% with 1-month DAPT and 3.70% with 12-month DAPT (absolute difference, -1.34% [95% CI, -2.57% to -0.11%]; hazard ratio [HR], 0.64 [95% CI, 0.42-0.98]), meeting criteria for noninferiority (P < .001) and for superiority (P = .04). The major secondary cardiovascular end point occurred in 1.96% with 1-month DAPT and 2.51% with 12-month DAPT (absolute difference, -0.55% [95% CI, -1.62% to 0.52%]; HR, 0.79 [95% CI, 0.49-1.29]), meeting criteria for noninferiority (P = .005) but not for superiority (P = .34). The major secondary bleeding end point occurred in 0.41% with 1-month DAPT and 1.54% with 12-month DAPT (absolute difference, -1.13% [95% CI, -1.84% to -0.42%]; HR, 0.26 [95% CI, 0.11-0.64]; P = .004 for superiority). Conclusions and Relevance: Among patients undergoing PCI, 1 month of DAPT followed by clopidogrel monotherapy, compared with 12 months of DAPT with aspirin and clopidogrel, resulted in a significantly lower rate of a composite of cardiovascular and bleeding events, meeting criteria for both noninferiority and superiority. These findings suggest that a shorter duration of DAPT may provide benefit, although given study limitations, additional research is needed in other populations. Trial Registration: ClinicalTrials.gov Identifier: NCT02619760.


Assuntos
Aspirina/uso terapêutico , Clopidogrel/uso terapêutico , Stents Farmacológicos , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/uso terapêutico , Cloridrato de Prasugrel/uso terapêutico , Idoso , Aspirina/efeitos adversos , Clopidogrel/efeitos adversos , Esquema de Medicação , Quimioterapia Combinada , Feminino , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Cloridrato de Prasugrel/efeitos adversos , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico
9.
BMJ ; 365: l2222, 2019 06 28.
Artigo em Inglês | MEDLINE | ID: mdl-31253632

RESUMO

OBJECTIVE: To evaluate the efficacy and safety of standard term (12 months) or long term (>12 months) dual antiplatelet therapy (DAPT) versus short term (<6 months) DAPT after percutaneous coronary intervention (PCI) with drug-eluting stent (DES). DESIGN: Systematic review and network meta-analysis. DATA SOURCES: Relevant studies published between June 1983 and April 2018 from Medline, Embase, Cochrane Library for clinical trials, PubMed, Web of Science, ClinicalTrials.gov, and Clinicaltrialsregister.eu. REVIEW METHODS: Randomised controlled trials comparing two of the three durations of DAPT (short term, standard term, and long term) after PCI with DES were included. The primary study outcomes were cardiac or non-cardiac death, all cause mortality, myocardial infarction, stent thrombosis, and all bleeding events. RESULTS: 17 studies (n=46 864) were included. Compared with short term DAPT, network meta-analysis showed that long term DAPT resulted in higher rates of major bleeding (odds ratio 1.78, 95% confidence interval 1.27 to 2.49) and non-cardiac death (1.63, 1.03 to 2.59); standard term DAPT was associated with higher rates of any bleeding (1.39, 1.01 to 1.92). No noticeable difference was observed in other primary endpoints. The sensitivity analysis revealed that the risks of non-cardiac death and bleeding were further increased for ≥18 months of DAPT compared with short term or standard term DAPT. In the subgroup analysis, long term DAPT led to higher all cause mortality than short term DAPT in patients implanted with newer-generation DES (1.99, 1.04 to 3.81); short term DAPT presented similar efficacy and safety to standard term DAPT with acute coronary syndrome (ACS) presentation and newer-generation DES placement. The heterogeneity of pooled trials was low, providing more confidence in the interpretation of results. CONCLUSIONS: In patients with all clinical presentations, compared with short term DAPT (clopidogrel), long term DAPT led to higher rates of major bleeding and non-cardiac death, and standard term DAPT was associated with an increased risk of any bleeding. For patients with ACS, short term DAPT presented similar efficacy and safety with standard term DAPT. For patients implanted with newer-generation DES, long term DAPT resulted in more all cause mortality than short term DAPT. Although the optimal duration of DAPT should take personal ischaemic and bleeding risks into account, this study suggested short term DAPT could be considered for most patients after PCI with DES, combining evidence from both direct and indirect comparisons. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018099519.


Assuntos
Clopidogrel/uso terapêutico , Stents Farmacológicos/normas , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/uso terapêutico , Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/cirurgia , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Hemorragia/mortalidade , Humanos , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/mortalidade , Inibidores da Agregação de Plaquetas/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Trombose/epidemiologia , Trombose/mortalidade
10.
BMJ ; 365: l2211, 2019 06 06.
Artigo em Inglês | MEDLINE | ID: mdl-31171523

RESUMO

OBJECTIVE: To test the hypothesis that ticagrelor plus aspirin is safe and superior to clopidogrel plus aspirin for reducing high platelet reactivity at 90 days and stroke recurrence in patients with minor stroke or transient ischaemic attack, particularly in carriers of the CYP2C19 loss-of-function allele and patients with large artery atherosclerosis. DESIGN: Open label, blinded endpoint, randomised controlled phase II trial. SETTING: Prospective studies conducted at 26 centres in China, August 2015 to March 2017. PARTICIPANTS: 675 patients with acute minor stroke or transient ischaemic attack. INTERVENTION: Ticagrelor (180 mg loading dose, 90 mg twice daily thereafter) or clopidogrel (300 mg loading dose, 75 mg daily thereafter) on a background of aspirin (100 mg daily for the first 21 days) within 24 hours of symptom onset. MAIN OUTCOME MEASURES: Primary outcome was the proportion of patients with high platelet reactivity at 90 days. High platelet reactivity was defined as P2Y12 reaction units of more than 208. Secondary outcomes included high platelet reactivity at 90 days (7 days either way) in patients carrying genetic variants that would affect clopidogrel metabolism, and any stroke (ischaemic or haemorrhagic) recurrence at 90 days (7 days either way), six months, and one year. RESULTS: At 90 days, high platelet reactivity occurred in 35 (12.5%) of 280 patients in the ticagrelor/aspirin group and 86 (29.7%) of 290 patients in the clopidogrel/aspirin group (risk ratio 0.40; 95% confidence interval 0.28 to 0.56; P<0.001), and in 10.8% versus 35.4% (0.31; 0.18 to 0.49; P<0.001) of patients carrying CYP2C19 loss-of-function alleles. Stroke occurred in 21 (6.3%) of 336 patients in the ticagrelor/aspirin group and 30 (8.8%) of 339 patients in the clopidogrel/aspirin group (hazard ratio 0.70; 95% confidence interval 0.40 to 1.22; P=0.20). Patients with large artery atherosclerosis in the ticagrelor/aspirin group had a lower stroke recurrence at 90 days than those in the clopidogrel/aspirin group (6.0% v 13.1%; hazard ratio 0.45, 95% confidence interval 0.20 to 0.98; P=0.04). No difference was seen in the rates of major or minor haemorrhagic events between the ticagrelor/aspirin and clopidogrel/aspirin groups (4.8% v 3.5%; P=0.42). CONCLUSION: Patients with minor stroke or transient ischaemic attack who are treated with ticagrelor plus aspirin have a lower proportion of high platelet reactivity than those who are treated with clopidogrel plus aspirin, particularly for those who are carriers of the CYP2C19 loss-of-function allele. The results of this study should be evaluated further in large scale, phase III trials and in different populations. TRIAL REGISTRATION: Clinicaltrials.gov NCT02506140.


Assuntos
Aspirina/uso terapêutico , Clopidogrel/uso terapêutico , Ataque Isquêmico Transitório/tratamento farmacológico , Ativação Plaquetária/efeitos dos fármacos , Inibidores da Agregação de Plaquetas/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Ticagrelor/uso terapêutico , Adulto , Idoso , Plaquetas/efeitos dos fármacos , China , Quimioterapia Combinada , Feminino , Humanos , Ataque Isquêmico Transitório/fisiopatologia , Masculino , Pessoa de Meia-Idade , Ativação Plaquetária/fisiologia , Estudos Prospectivos , Acidente Vascular Cerebral/fisiopatologia , Resultado do Tratamento
11.
Sultan Qaboos Univ Med J ; 19(1): e63-e67, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31198598

RESUMO

Massive hyphaema presentation after a laser iridotomy is very rare. We report a 63-year-old man with ischaemic heart disease on dual antiplatelet therapy (aspirin plus ticagrelor) who was diagnosed as a primary angle-closure suspect and was to undergo a neodymium-doped yttrium aluminium garnet laser iridotomy at Centro Oftalmológico Virgilio Galvis, Floridablanca, Colombia in 2016. While performing the iridotomy in the left eye, active bleeding occurred that finally filled approximately 75% of the anterior chamber. Intraocular pressure (IOP) increased to 62 mmHg. Mannitol and a topical dorzolamide/timolol were used to control the increase in IOP. The hyphaema slowly resolved over the following week without sequelae. This case revealed that massive hyphaema can complicate laser iridotomy in patients on dual antiplatelet therapy, although this is rare. Therefore, if patients are taking aspirin and ticagrelor, it would be advisable to stop the second medication if possible. In addition, sequential application of photocoagulation and photodisruption lasers might diminish the risk of significant bleeding.


Assuntos
Hifema/etiologia , Iridectomia/efeitos adversos , Inibidores da Agregação de Plaquetas/uso terapêutico , Aspirina/uso terapêutico , Colômbia , Glaucoma de Ângulo Fechado/complicações , Glaucoma de Ângulo Fechado/cirurgia , Humanos , Iridectomia/métodos , Terapia a Laser/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Ticagrelor/uso terapêutico
12.
J Stroke Cerebrovasc Dis ; 28(8): 2098-2108, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31160219

RESUMO

Sneddon syndrome (SS) is an episodic or chronic, slowly progressive disorder and characterized by generalized livedo racemosa (patchy, violaceous, skin discoloration) and recurrent cerebrovascular events. The histopathology of skin and brain is remarkable for a noninflammatory thrombotic vasculopathy involving medium- and small-sized dermal and cerebral arteries, respectively. Approximately 80% of the SS patients are women with a median age of diagnosis at 40 years. However, the onset of the disease during childhood have been reported. Etiopathogenesis of SS is unknown with 2 primary mechanisms proposed - autoimmune/inflammatory versus thrombophilia. SS is primarily classified as antiphospholipid positive or negative type. Neurological manifestations usually occur in 3 phases: (1) prodromal symptoms such as headaches, dizziness, and vertigo, (2) recurrent strokes, and (3) early onset dementia. Livedo racemosa precedes the onset of recurrent strokes by more than 10 years, but in many instances, the significance of the skin lesion is recognized only after the appearance of the stroke. The involvement of the heart valves, systolic labile hypertension, and retinal changes are also commonly associated with this syndrome. Treatment of SS is primarily based on anecdotal reports. Antiplatelet and antithrombotic agents are used for secondary stroke prophylaxis, and a recent study showed a relatively lower stroke recurrence rate with the universal use of antiplatelet/antithrombotic agents. Routine use of anti-inflammatory or immunosuppressive therapies is controversial. Neuropsychiatric prognosis of SS is relatively poor with predominant deficits in the concentration, attention, visual perception, and visuospatial skills.


Assuntos
Artérias Cerebrais/patologia , Livedo Reticular/etiologia , Pele/irrigação sanguínea , Síndrome de Sneddon/complicações , Acidente Vascular Cerebral/etiologia , Anti-Inflamatórios/uso terapêutico , Artérias Cerebrais/efeitos dos fármacos , Fibrinolíticos/uso terapêutico , Humanos , Imunossupressores/uso terapêutico , Livedo Reticular/patologia , Livedo Reticular/fisiopatologia , Livedo Reticular/prevenção & controle , Inibidores da Agregação de Plaquetas/uso terapêutico , Recidiva , Fatores de Risco , Síndrome de Sneddon/tratamento farmacológico , Síndrome de Sneddon/patologia , Síndrome de Sneddon/fisiopatologia , Acidente Vascular Cerebral/patologia , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento
13.
J Stroke Cerebrovasc Dis ; 28(8): 2302-2310, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31174954

RESUMO

BACKGROUND: Aggregation of platelets is a trigger for additional development of larger thrombi. This study aimed to identify factors that may affect platelet aggregability and their role in clinical outcomes in acute ischemic stroke. METHODS: Consecutive acute ischemic stroke patients (n = 352) who were transferred within 24 hours after its onset were enrolled. Peripheral venous blood was sampled to measure platelet aggregability and other parameters. RESULTS: Mean values of spontaneous small-sized platelet aggregates and collagen- or adenosine diphosphate (ADP)-induced large-sized aggregates were elevated in acute ischemic stroke. In atherothrombotic stroke (n = 178), collagen and ADP-induced large-sized aggregates were positively correlated with HbA1c, respectively. High incidence of the modified Rankin Scales (mRS) 5-6 at discharge was associated with diabetes complication (odds ratio [OR] 8.77, 95% confidence interval [CI] 1.32-57.56). The proportion of patients who were functionally independent (the mRS 0-2) at discharge was lower in the middle tertile of collagen and ADP-induced large-sized aggregates than their low tertile (OR 2.46, 95% CI 1.09-5.58; OR 2.43, 95% CI 1.05-5.59, respectively). Prestroke administration of aspirin recovered the proportion of independence at discharge (OR 0.25, 95% CI 0.06-0.99), and ameliorated incidence of the mRS 5-6. On logistic regression analysis, diabetes, HbA1c, collagen-induced large-sized aggregates, and prestroke administration of aspirin remained independent predictors of clinical outcomes in atherothrombotic stroke. In cardioembolic and lacunar stroke, no relations with clinical outcomes were found. CONCLUSIONS: High plasma level of HbA1c is involved in enhanced platelet aggregability in acute atherothrombotic stroke patients, and prestroke administration of aspirin may be beneficial to clinical outcomes.


Assuntos
Aspirina/uso terapêutico , Plaquetas/efeitos dos fármacos , Isquemia Encefálica/tratamento farmacológico , Diabetes Mellitus/sangue , Hemoglobina A Glicada/metabolismo , Inibidores da Agregação de Plaquetas/uso terapêutico , Agregação Plaquetária/efeitos dos fármacos , Testes de Função Plaquetária/métodos , Acidente Vascular Cerebral/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Aspirina/efeitos adversos , Biomarcadores/sangue , Plaquetas/metabolismo , Isquemia Encefálica/sangue , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Comorbidade , Estudos Transversais , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/epidemiologia , Avaliação da Deficiência , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Valor Preditivo dos Testes , Recuperação de Função Fisiológica , Fatores de Risco , Acidente Vascular Cerebral/sangue , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Resultado do Tratamento , Regulação para Cima
14.
JAMA ; 321(24): 2428-2437, 2019 06 25.
Artigo em Inglês | MEDLINE | ID: mdl-31237645

RESUMO

Importance: Data on P2Y12 inhibitor monotherapy after short-duration dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention are limited. Objective: To determine whether P2Y12 inhibitor monotherapy after 3 months of DAPT is noninferior to 12 months of DAPT in patients undergoing PCI. Design, Setting, and Participants: The SMART-CHOICE trial was an open-label, noninferiority, randomized study that was conducted in 33 hospitals in Korea and included 2993 patients undergoing PCI with drug-eluting stents. Enrollment began March 18, 2014, and follow-up was completed July 19, 2018. Interventions: Patients were randomly assigned to receive aspirin plus a P2Y12 inhibitor for 3 months and thereafter P2Y12 inhibitor alone (n = 1495) or DAPT for 12 months (n = 1498). Main Outcomes and Measures: The primary end point was major adverse cardiac and cerebrovascular events (a composite of all-cause death, myocardial infarction, or stroke) at 12 months after the index procedure. Secondary end points included the components of the primary end point and bleeding defined as Bleeding Academic Research Consortium type 2 to 5. The noninferiority margin was 1.8%. Results: Among 2993 patients who were randomized (mean age, 64 years; 795 women [26.6%]), 2912 (97.3%) completed the trial. Adherence to the study protocol was 79.3% of the P2Y12 inhibitor monotherapy group and 95.2% of the DAPT group. At 12 months, major adverse cardiac and cerebrovascular events occurred in 42 patients in the P2Y12 inhibitor monotherapy group and in 36 patients in the DAPT group (2.9% vs 2.5%; difference, 0.4% [1-sided 95% CI, -∞% to 1.3%]; P = .007 for noninferiority). There were no significant differences in all-cause death (21 [1.4%] vs 18 [1.2%]; hazard ratio [HR], 1.18; 95% CI, 0.63-2.21; P = .61), myocardial infarction (11 [0.8%] vs 17 [1.2%]; HR, 0.66; 95% CI, 0.31-1.40; P = .28), or stroke (11 [0.8%] vs 5 [0.3%]; HR, 2.23; 95% CI, 0.78-6.43; P = .14) between the 2 groups. The rate of bleeding was significantly lower in the P2Y12 inhibitor monotherapy group than in the DAPT group (2.0% vs 3.4%; HR, 0.58; 95% CI, 0.36-0.92; P = .02). Conclusions and Relevance: Among patients undergoing percutaneous coronary intervention, P2Y12 inhibitor monotherapy after 3 months of DAPT compared with prolonged DAPT resulted in noninferior rates of major adverse cardiac and cerebrovascular events. Because of limitations in the study population and adherence, further research is needed in other populations. Trial Registration: ClinicalTrials.gov Identifier: NCT02079194.


Assuntos
Aspirina/uso terapêutico , Clopidogrel/uso terapêutico , Stents Farmacológicos , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/uso terapêutico , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Idoso , Aspirina/efeitos adversos , Clopidogrel/efeitos adversos , Esquema de Medicação , Quimioterapia Combinada , Feminino , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/efeitos adversos , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos
15.
Zh Nevrol Psikhiatr Im S S Korsakova ; 119(3. Vyp. 2): 76-82, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31184628

RESUMO

To study rheological properties of blood in patients with acute ischemic stroke treated with mexidol. MATERIAL AND METHODS: Sixty patients with acute stroke, including 32 patients who received mexidol (500 mg/IV/20 days) and 28 people who received magnesium sulfate (2000 mg/IV/20 days) were examined. The control group included 20 people without a cardiovascular pathology. Blood rheology (viscosity of whole blood, plasma viscosity, hematocrit, aggregation and deformability of erythrocytes, fibrinogen level) was evaluated in patients three times: for the first 12 hours, 3-5 days and 18-20 days after hospitalization. RESULTS: Hyperviscosity syndrome was observed in all patients with stroke. A significant decrease in blood viscosity was found in patients treated with mexidol: in the 3-5th day at low shear rates and in the 18-20th day at 3-100 s-1 shear rates. Significant differences in hematocrit (p=0.026) and fibrinogen levels (p=0.017) in patients treated with different drugs were found in the 18-20th day of the disease. Higher erythrocyte deformability index was recorded in patients treated with mexidol in the 3-5th day at shear rates of 90 and 890 s-1, in the 18-20th day at shear rates of 90-360 s-1. CONCLUSION: The study confirms the impact of mexidol on the fluidity of blood during the acute cerebral ischemia and shows its efficacy in reducing blood viscosity, decreasing the level of hematocrit and fibrinogen, increasing the deformability of erythrocytes.


Assuntos
Isquemia Encefálica , Picolinas , Inibidores da Agregação de Plaquetas , Acidente Vascular Cerebral , Viscosidade Sanguínea , Agregação Eritrocítica , Deformação Eritrocítica , Humanos , Picolinas/uso terapêutico , Inibidores da Agregação de Plaquetas/uso terapêutico , Fluxo Sanguíneo Regional/efeitos dos fármacos , Reologia , Acidente Vascular Cerebral/tratamento farmacológico
16.
Int. j. cardiovasc. sci. (Impr.) ; 32(3): 297-301, may.-june. 2019. ilus
Artigo em Inglês | LILACS | ID: biblio-1006182

RESUMO

Uterine leiomyoma and coronary artery disease are two common diseases in women. However, the association of uterine bleeding caused by leiomyoma with unstable coronary syndrome is not frequent. Here we describe a case of a patient with active vaginal bleeding and unstable angina who underwent a unique approach by performing percutaneous procedures. The report demonstrates that new interventional options can be used to control active bleeding in patients in need of coronary angioplasty


Assuntos
Humanos , Feminino , Adulto , Hemorragia Uterina/complicações , Mulheres , Stents , Angioplastia , Inibidores da Agregação de Plaquetas/uso terapêutico , Angioplastia Coronária com Balão/métodos , Embolização Terapêutica/métodos , Leiomioma
17.
Medicine (Baltimore) ; 98(18): e15437, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31045810

RESUMO

RATIONALE: Cranial arterial air embolism is a rare but potentially fatal complication after computed tomography (CT)-guided pulmonary interventions. PATIENT CONCERNS: A 64-year-old man was diagnosed with a pulmonary nodule (diameter: approximately 1 cm) in the right lower lobe. The patient developed convulsions after CT-guided hook-wire localization. DIAGNOSIS: Cranial CT revealed arborizing/linearly distributed gas in the territory of the right middle cerebral artery. INTERVENTIONS: The patient was administered hyperbaric oxygen, antiplatelet aggregation therapy, and dehydration treatment. OUTCOMES: Clinical death occurred 55 hours after air embolism. LESSONS: Systemic air embolism is a serious complication of lung puncture. Clinicians should improve their understanding of this complication and remain vigilant against air embolism.


Assuntos
Doenças Arteriais Cerebrais/etiologia , Embolia Aérea/etiologia , Radiografia Intervencionista/efeitos adversos , Nódulo Pulmonar Solitário/cirurgia , Doenças Arteriais Cerebrais/terapia , Embolia Aérea/terapia , Humanos , Oxigenação Hiperbárica/métodos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/uso terapêutico , Radiografia Intervencionista/métodos
18.
J Stroke Cerebrovasc Dis ; 28(7): 1886-1890, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31078387

RESUMO

OBJECTIVE: To summarize the characteristics of and therapeutic options for cancer patients whose treatments may be vasotoxic and cause intracranial arterial stenotic disease and stroke. METHODS: We describe 3 patients with symptomatic cerebrovascular pathology that were being actively treated for cancer. RESULTS: Two of the patients were being treated with tyrosine kinase inhibitors (TKIs); and the third was being treated with 2 monoclonal antibodies, one of which was targeting an endothelial growth factor. These agents have been associated with vascular adverse events. Surgical revascularization was done in the first 2 patients, as they were suffering from cerebral ischemia. The third patient had suffered a significant brain hemorrhage, and therapeutic options were limited. In the first 2 patients, treatments also included antiplatelet agents and stopping/changing the TKI. In one of these patients we demonstrated regression of arterial stenosis after changing the TKI. CONCLUSIONS: Possibilities for treatment in this population, beyond the usual medical and surgical administrations, may include stopping or changing cancer drugs that may be related to the development of arterial pathology. Collaboration with oncologists is essential in this subset of patients. While aware of the potential for vascular toxicity, oncologists are often not fully appreciative of the fact that their therapeutic agents can cause stroke.


Assuntos
Anticorpos Monoclonais/efeitos adversos , Antineoplásicos Imunológicos/efeitos adversos , Arteriopatias Oclusivas/terapia , Doenças Arteriais Cerebrais/terapia , Artérias Cerebrais/cirurgia , Revascularização Cerebral/métodos , Inibidores de Proteínas Quinases/efeitos adversos , Idoso de 80 Anos ou mais , Arteriopatias Oclusivas/induzido quimicamente , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/fisiopatologia , Angiografia Cerebral/métodos , Doenças Arteriais Cerebrais/induzido quimicamente , Doenças Arteriais Cerebrais/diagnóstico por imagem , Doenças Arteriais Cerebrais/fisiopatologia , Artérias Cerebrais/diagnóstico por imagem , Artérias Cerebrais/efeitos dos fármacos , Artérias Cerebrais/fisiopatologia , Circulação Cerebrovascular , Angiografia por Tomografia Computadorizada , Tratamento Conservador , Constrição Patológica , Substituição de Medicamentos , Evolução Fatal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Imagem de Perfusão/métodos , Inibidores da Agregação de Plaquetas/uso terapêutico , Resultado do Tratamento , Grau de Desobstrução Vascular
19.
J Stroke Cerebrovasc Dis ; 28(7): e102-e103, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31036340

RESUMO

Akinetopsia is a quite rare symptom. Two types of akinetopsia have been reported: one is cinematographic vision, and the other is invisibility of moving objects. These symptoms are thought to occur due to dysfunction of the MT/V5 area at the occipitoparietal region. I herein describe a 54-year-old man who collided with a car parked on the left side of the road while driving. He complained that the parked car looked to be moving forwards and he could not stop his car when he noticed that it was parked. Magnetic resonance imaging disclosed the fresh infarction on the right temporoparietal region involving the MT/V5 area. His symptom during driving was considered cinematographic vision and it was the cause of the traffic accident. Akinetopsia resulted in illusory kinetopsia on driving and the traffic accident.


Assuntos
Acidentes de Trânsito , Condução de Veículo , Infarto Cerebral/complicações , Ilusões , Percepção de Movimento , Transtornos da Percepção/etiologia , Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/tratamento farmacológico , Infarto Cerebral/psicologia , Humanos , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Transtornos da Percepção/diagnóstico , Transtornos da Percepção/psicologia , Inibidores da Agregação de Plaquetas/uso terapêutico
20.
J Stroke Cerebrovasc Dis ; 28(7): e95-e97, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31053373

RESUMO

Mobile plaque in the innominate artery is extremely rare and difficult to diagnose, especially in its acute stage. Its diagnosis is often delayed in many cases, resulting in delayed treatment and poor prognosis. Herein, we report the case of a 69-year-old patient with multiple cerebral infarction only in the right internal carotid artery and vertebrobasilar territories. No embolic sources were found until arterial ultrasonography detected a large balloon-like mobile plaque in the IA. Mobile plaque consisted of high-and low-echoic components and showed balloon-like plaque. Despite sufficient antiplatelet therapy, recurrence of cerebral embolism could not be prevented. IA replacement was eventually performed by cardiac surgeons. Pathological examinations showed that organized mobile plaque could have existed previously and acute thrombi, generated after the atheromatous plaque rupture caused by the mechanical burden of organized mobile plaque, could expand along with the organized mobile plaque and caused balloon-like plaque and related with repeated embolism. The IA should be explored immediately in cases of repetitive right-sided cerebral embolisms to prevent further recurrence.


Assuntos
Tronco Braquiocefálico/diagnóstico por imagem , Tronco Braquiocefálico/patologia , Infarto Cerebral/etiologia , Embolia Intracraniana/etiologia , Doença Arterial Periférica/diagnóstico por imagem , Doença Arterial Periférica/patologia , Placa Aterosclerótica , Ultrassonografia de Intervenção , Idoso , Biópsia , Implante de Prótese Vascular , Tronco Braquiocefálico/cirurgia , Infarto Cerebral/diagnóstico por imagem , Imagem de Difusão por Ressonância Magnética , Humanos , Embolia Intracraniana/diagnóstico por imagem , Masculino , Doença Arterial Periférica/complicações , Doença Arterial Periférica/terapia , Inibidores da Agregação de Plaquetas/uso terapêutico , Valor Preditivo dos Testes , Recidiva , Resultado do Tratamento
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