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1.
J Stroke Cerebrovasc Dis ; 28(11): 104305, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31405791

RESUMO

BACKGROUND: Intravenous recombinant tissue plasminogen activator (rt-PA) has become a common treatment for acute ischemic stroke and has highly time-dependent benefits. We aimed to clarify temporal trends regarding the frequency and characteristics of patients receiving rt-PA and explore factors associated with door-to-needle time (DNT) in Japanese emergency hospitals. METHODS: Consecutive patients who received intravenous rt-PA for acute ischemic stroke from October 2005 to December 2015 were retrospectively registered from 4 hospitals. Temporal trends in the frequency and characteristics of patients receiving rt-PA and factors associated with DNT were investigated. RESULTS: A total of 750 patients, including 688 (420 men, median 75 years old) with out-of-hospital stroke, were registered. The frequency of patients receiving intravenous rt-PA for acute ischemic stroke continuously increased from 1.8% in 2005 to 9.5% in 2015. The proportion of patients who were elderly or had prestroke disability increased over time, while pretreatment stroke severity declined. The DNT gradually decreased (median 105 minutes in 2005, 61 minutes in 2015). According to multivariate regression analysis with correction for multiple comparisons, activation of a code stroke system (standardized partial regression coefficient (ß) -.50, P < .001, q < .001), onset-to-door time (ß -.15, P < .001, q < .001), pretreatment with antithrombotic agents (ß .12, P < .001, q = .001), and year of treatment (ß .11, P = .007, q = .011) were associated with DNT. CONCLUSIONS: Intravenous rt-PA was widely adopted in Japanese emergency hospitals. Characteristics of patients receiving intravenous rt-PA have changed over the past decade. Several factors, including the year of treatment, were associated with DNT, which has shortened over time.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Serviço Hospitalar de Emergência/tendências , Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/tendências , Tempo para o Tratamento/tendências , Ativador de Plasminogênio Tecidual/administração & dosagem , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Japão , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
2.
Emerg Med Pract ; 21(Suppl 6): 1-22, 2019 06 15.
Artigo em Inglês | MEDLINE | ID: mdl-31233301

RESUMO

This review examines the evidence and indications for the use of intravenous thrombolysis in the treatment of acute ischemic stroke.


Assuntos
Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Administração Intravenosa , Definição da Elegibilidade/métodos , Humanos , Terapia Trombolítica/tendências
3.
Emerg Med Pract ; 21(Suppl 6): 23-52, 2019 06 15.
Artigo em Inglês | MEDLINE | ID: mdl-31233302

RESUMO

This review discusses the current evidence for endovascular therapy in the treatment of acute ischemic stroke and explores the indications for its use. Imaging studies and procedural techniques for endovascular therapy are also discussed.


Assuntos
Procedimentos Endovasculares/métodos , Acidente Vascular Cerebral/tratamento farmacológico , Serviço Hospitalar de Emergência/organização & administração , Procedimentos Endovasculares/tendências , Humanos , Terapia Trombolítica/métodos , Terapia Trombolítica/tendências
4.
J Clin Neurosci ; 66: 45-50, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31153752

RESUMO

BACKGROUND: Endovascular treatment (ET) has been proved as safety and effective in acute ischemic stroke. However, early reocclusion is an inevitable complication following ET. There is uncertainty effect of early antiplatelet therapy on outcomes in patients with acute ischemic stroke undergoing endovascular treatment. METHODS: We searched major databases for articles published from 2011 to 2019 in the present study. Safety outcomes were any intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage (sICH) and mortality. Efficacy outcomes were recanalization rate and follow-up functional outcome. Review Manager 5.3 and Stata Software Package 14.0 were used to perform the meta-analysis. RESULTS: Seven studies with a total of 1251 patients were included. A total of 451 (36.1%) patients were administrated by antiplatelet agent following ET. Meta-analysis suggested that early antiplatelet did not increase the risk for ICH (OR 1.15; 95% CI 0.56-2.37; P = 0.70), sICH (OR 1.29; 95% CI 0.79-2.09; P = 0.31) and mortality (OR 0.71; 95% CI 0.45-1.12; P = 0.14). There was no association between antiplatelet therapy and recanalization rate (OR 1.03; 95% CI 0.73-1.46; P = 0.30) or functional outcome (OR 0.97; 95% CI 0.55-1.69; P = 0.90). Sensitivity analysis indicated tirofiban did not associated with any ICH and mortality, nor improve the recanalization rate and functional outcome in patients receiving ET or mechanical thrombectomy (all p > 0.05). CONCLUSIONS: Early antiplatelet therapy may be safe in acute ischemic stroke patients, further studies are needed to confirm the efficacy.


Assuntos
Isquemia Encefálica/terapia , Procedimentos Endovasculares/tendências , Inibidores da Agregação de Plaquetas/uso terapêutico , Prevenção Secundária/tendências , Acidente Vascular Cerebral/terapia , Isquemia Encefálica/diagnóstico , Procedimentos Endovasculares/efeitos adversos , Humanos , Hemorragias Intracranianas/induzido quimicamente , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/etiologia , Inibidores da Agregação de Plaquetas/efeitos adversos , Acidente Vascular Cerebral/diagnóstico , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/tendências , Tirofibana/efeitos adversos , Tirofibana/uso terapêutico , Resultado do Tratamento
5.
J Stroke Cerebrovasc Dis ; 28(8): 2255-2261, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31153762

RESUMO

OBJECTIVE: We sought to characterize the US nationwide temporal trends in recanalization therapy utilization for ischemic stroke among patients with and without cancer. METHODS: We identified all acute ischemic stroke (AIS) hospitalizations in the National Inpatient Sample from January 1, 1998 to September 30, 2015. The primary exposure was solid or hematologic cancer. The primary outcome was use of intravenous thrombolysis. The secondary outcome was use of endovascular therapy (EVT). RESULTS: Among 9,508,804 AIS hospitalizations, 503,510 (5.3%) involved cancer patients. Intravenous thrombolysis use among ischemic stroke patients with cancer increased from .01% (95% confidence interval [CI], .00%-.02%) in 1998 to 4.91% (95% CI, 4.33%-5.48%) in 2015, whereas intravenous thrombolysis use among ischemic stroke patients without cancer increased from .02% (95% CI, .01%-.02%) in 1998 to 7.22% (95% CI, 6.98%-7.45%) in 2015. The demographic- and comorbidity-adjusted odds ratio/year of receiving intravenous thrombolysis was similar in patients with cancer (1.21; 95% CI, 1.20-1.23) versus those without (1.20; 95% CI, 1.19-1.21). EVT use among ischemic stroke patients with cancer increased from .05% (95% CI, .02%-.07%) in 2006 to 1.90% (95% CI, 1.49%-2.31%) in 2015, whereas EVT use among ischemic stroke patients without cancer increased from .09% (95% CI, .00%-.18%) in 2006 to 1.88% (95% CI, 1.68%-2.09%) in 2015. CONCLUSIONS: Among 9.5 million AIS hospitalizations, patients with cancer received intravenous thrombolysis about two thirds as often as patients without cancer. This difference persisted over time despite increased utilization in both groups. EVT utilization was similar between cancer and non-cancer AIS patients.


Assuntos
Isquemia Encefálica/terapia , Procedimentos Endovasculares/tendências , Fibrinolíticos/administração & dosagem , Disparidades em Assistência à Saúde/tendências , Neoplasias/epidemiologia , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/tendências , Administração Intravenosa , Idoso , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Comorbidade , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Feminino , Fibrinolíticos/efeitos adversos , Hospitalização/tendências , Humanos , Masculino , Neoplasias/diagnóstico , Neoplasias/terapia , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
6.
J Vasc Interv Radiol ; 30(6): 801-806, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31040058

RESUMO

PURPOSE: To evaluate changes in the use of catheter-directed therapy (CDT) for pulmonary embolism (PE) treatment with attention to primary operator specialty in the Medicare population. METHODS: Using a 5% national sample of Medicare claims data from 2004 to 2016, all claims associated with PE were identified. The annual volume of 2 billable CDT services-arterial mechanical thrombectomy and transcatheter arterial infusion for thrombolysis-were determined to evaluate changes in CDT use and primary CDT operator specialty over time. RESULTS: The total number of CDT procedures increased over the course of the study period, representing 0.457 and 5.057 service counts per 100,000 Medicare beneficiaries in 2004 and 2016, respectively. The proportion of PEs treated with CDT increased 10-fold from 2004 to 2016, increasing from 0.1% to 1.0%. Interventional radiologists performed most CDT therapies each year, with the exception of 2010 when vascular surgeons performed more. In 2016, interventional radiologists performed 3.54 CDT services for PE per 100,000 Medicare beneficiaries, which was 70% of total CDT for PE procedures, followed by interventional cardiologists and vascular surgeons performing 0.92 services (18%) and 0.60 services (12%), respectively. CONCLUSIONS: CDT is an increasingly used treatment for PE, with a 10-fold increase from 2004 to 2016. Interventional radiologists are the dominant providers of these services, followed by interventional cardiologists and vascular surgeons.


Assuntos
Cateterismo/tendências , Procedimentos Endovasculares/tendências , Medicare/tendências , Padrões de Prática Médica/tendências , Embolia Pulmonar/terapia , Radiologistas/tendências , Trombectomia/tendências , Terapia Trombolítica/tendências , Demandas Administrativas em Assistência à Saúde , Cardiologistas/tendências , Cateterismo/efeitos adversos , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Humanos , Embolia Pulmonar/diagnóstico por imagem , Estudos Retrospectivos , Cirurgiões/tendências , Trombectomia/efeitos adversos , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
8.
J Stroke Cerebrovasc Dis ; 28(6): 1440-1447, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30952531

RESUMO

BACKGROUND AND PURPOSE: 15% of cerebral venous thrombosis (CVT) patients have poor outcomes despite anticoagulation. Uncontrolled studies suggest that endovascular approaches may benefit such patients. In this study, we analyze Nationwide Inpatient Sample (NIS) data to evaluate the safety and efficacy of endovascular therapy (ET) versus medical management in CVT. We also examined the yearly trends of ET utilization in the United States. METHODS: International Classification of Diseases, Ninth Revision, Clinical Modification codes were utilized to identify CVT patients who received ET. To make the data nationally representative, weights were applied per NIS recommendations. Since ET was not randomly assigned to patients and was likely to be influenced by disease severity, propensity score weighting methods were utilized to correct for this treatment selection bias. Outcome variables included in-hospital mortality and discharge disposition. To determine if our primary outcomes were associated with ET, we used weighted multivariable logistic regression analyses. RESULTS: Of the 49,952 estimated CVT cases, 48,704 (97%) received medical management and 1248 (3%) received ET (mechanical thrombectomy [MT] alone, N = 269 [21%], MT ± thrombolysis, N = 297 [24%], and thrombolysis alone, N = 682 [55%]). Patients who received ET were older with more CVT associated complications including venous infarct, intracranial hemorrhage, coma, seizure, and cerebral edema. There was a significant yearly rise in the use of ET, with a trend favoring MT versus thrombolysis alone. ET was independently associated with an increased risk of death (odds ratio 1.96, 95% confidence interval 1.15-3.32). CONCLUSIONS: Patients receiving ET experienced higher mortality after adjusting for age and CVT associated complications. Large, well designed prospective randomized trials are warranted for further evaluation of the safety and efficacy of ETs.


Assuntos
Procedimentos Endovasculares/tendências , Pacientes Internados , Trombose Intracraniana/terapia , Padrões de Prática Médica/tendências , Trombectomia/tendências , Terapia Trombolítica/tendências , Trombose Venosa/terapia , Adulto , Idoso , Fármacos Cardiovasculares/uso terapêutico , Bases de Dados Factuais , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , Humanos , Trombose Intracraniana/diagnóstico por imagem , Trombose Intracraniana/mortalidade , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/mortalidade
9.
Stroke ; 50(5): 1149-1155, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30943884

RESUMO

Background and Purpose- There are limited data on intravenous thrombolysis treatment in patients with ischemic stroke who have received prophylactic doses of low molecular weight heparins (LMWHs). We aimed to evaluate the safety and outcomes of intravenous thrombolysis treatment in stroke patients taking thromboprophylactic doses of LMWH. Methods- We analyzed 109 291patients treated with intravenous thrombolysis, recorded in the Safe Implementation of Treatments in Stroke International Thrombolysis Register between 2003 and 2017 not taking oral anticoagulants or therapeutic doses of heparin at stroke onset. One thousand four hundred eleven patients (1.3%) were on prophylactic LMWH for deep venous thrombosis prevention. Outcome measures were symptomatic intracerebral hemorrhage, parenchymal hematoma, death within 7 days and 3 months, and functional dependency at 3 months. Results- Patients on LMWH were older, had more severe strokes, more prestroke disability, and comorbidities than patients without LMWH. There was no significant increase in adjusted odds ratios (aOR) for symptomatic intracerebral hemorrhage (aOR, 1.02 [95% CI, 0.48-2.17] as per Safe Implementation of Treatments in Stroke -MOST, aOR, 0.95 [0.59-1.53] per ECASS II]), nor for 7-day mortality (aOR, 1.14 [0.82-1.59]), in the prophylactic LMWH group. The LMWH group had a higher aOR for 3-month mortality (aOR, 1.94 [1.49-2.53]) and functional dependency, aOR, 1.44 (1.10-1.90). Propensity score analysis matching patients on baseline characteristics removed differences between groups on all outcomes except 3-month mortality. Conclusions- Intravenous thrombolysis in patients with acute ischemic stroke on treatment with prophylactic doses of LMWH at stroke onset is not associated with an increased risk of symptomatic intracerebral hemorrhage or early death.


Assuntos
Anticoagulantes/administração & dosagem , Heparina de Baixo Peso Molecular/administração & dosagem , Profilaxia Pré-Exposição/métodos , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Administração Intravenosa , Idoso , Feminino , Humanos , Masculino , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Terapia Trombolítica/mortalidade , Terapia Trombolítica/tendências , Resultado do Tratamento
10.
J Stroke Cerebrovasc Dis ; 28(5): 1362-1370, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30846245

RESUMO

BACKGROUND AND PURPOSE: Emergent evaluation of inpatients with suspected acute ischemic stroke faces difficulty of symptoms recognition, false alarms, and high rate of contraindications to reperfusion therapies. We aim to assess the clinical characteristics and therapeutic interventions implemented in patients evaluated though the in-hospital Stroke Alert Protocol. METHODS: We analyzed 4 years-worth of Stroke Alert cases at a university hospital. Demographics, clinical presentation, final diagnosis, and acute interventions were compared between inpatients and those presenting to the emergency department. FINDINGS: A total of 1965 Stroke Alert cases were included: 959 (48.8%) were acute cerebrovascular events and 1006 (51.2%) were noncerebrovascular. Hospitalized patients accounted for 489 (24.9%) of Stroke Alerts and patients in the emergency department for 1476 (75.1%). Inpatients were more likely to present with nonfocal neurological deficits (46.2% versus 32.4%, P < .0001) and be diagnosed with noncerebrovascular disorders (62.4% versus 47.5%, P < .0001). Acute interventions other than thrombolysis were delivered in 77.1% of in-hospital cases. Compared to the emergency department, inpatients were more commonly managed with rectification of metabolic abnormalities (21.5% versus 13.7%, P < .001), suspension or pharmacological reversal of drugs (11% versus 3.7%, P < .001), and initiation of respiratory support (13.5% versus 9.3%, P = .01). Inpatients with acute ischemic stroke received intravenous thrombolysis less frequently (4.9% versus 23.9%, P < .001), but the endovascular treatment rate was comparable (9.8% versus 10.3%) to the emergency department. CONCLUSION: Nonfocal neurological deficits and noncerebrovascular disorders are commonly encountered during in-hospital Stroke Alerts. In the inpatient setting, intravenous thrombolysis is rarely delivered while other time-sensitive therapeutic interventions are frequently implemented.


Assuntos
Serviço Hospitalar de Emergência/tendências , Procedimentos Endovasculares/tendências , Pacientes Internados , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/tendências , Idoso , Chicago , Tratamento Farmacológico/tendências , Feminino , Hospitais Universitários/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica/tendências , Terapia Respiratória/tendências , Estudos Retrospectivos , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
11.
Pract Neurol ; 19(4): 326-331, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30872357

RESUMO

Current national guidelines advocate intravenous thrombolysis to treat patients with acute ischaemic stroke presenting within 4.5 hours from symptom onset, and thrombectomy for patients with anterior circulation ischaemic stroke from large vessel occlusion presenting within 6 hours from onset. However, a substantial group of patients presents with acute ischaemic stroke beyond these time windows or has an unknown time of onset. Recent studies are set to revolutionise treatment for these patients. Using MRI diffusion/FLAIR (fluid-attenuated inversion recovery) mismatch, it is possible to identify patients within 4.5 hours from onset and safely deliver thrombolysis. Using CT perfusion imaging, it is possible to identify subjects with a middle cerebral artery syndrome who have an extensive area of ischaemic brain but as yet have only a small area of infarction who may benefit from urgent thrombectomy in up to 24 hours. Here, we highlight the recent advances in late window stroke treatment and their potential contribution to clinical practice.


Assuntos
Imagem de Difusão por Ressonância Magnética/tendências , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/tendências , Tempo para o Tratamento/tendências , Tomografia Computadorizada por Raios X/tendências , Imagem de Difusão por Ressonância Magnética/métodos , Gerenciamento Clínico , Humanos , Terapia Trombolítica/métodos , Tomografia Computadorizada por Raios X/métodos
12.
Eur J Radiol ; 112: 214-221, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30777213

RESUMO

After being staggered by numerous negative trials in 2013, the interventional stroke community saw four years of vindication for mechanical thrombectomy showing efficacy and safety, even beyond a hopeful 6-8 hour window out to 24 h. A landmark set of five trials in 2015 provided a foundation upon which years of incremental follow-ups, meta-analyses and new breakthroughs would be built. With optimized devices for thrombectomy and image analysis, the neurointerventional community has turned to workflow and systemization in this new era of acute ischemic stroke treatment. The aim of this review is to chronicle the evidence in the epoch of positive trials, synthesize ancillary studies to these, and discuss the imminent challenges that remain.


Assuntos
Isquemia Encefálica/terapia , Trombólise Mecânica/tendências , Acidente Vascular Cerebral/terapia , Anestesia/métodos , Procedimentos Endovasculares/métodos , Previsões , Humanos , Trombólise Mecânica/métodos , Terapia Trombolítica/métodos , Terapia Trombolítica/tendências , Fluxo de Trabalho
13.
J Stroke Cerebrovasc Dis ; 28(5): 1243-1251, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30745230

RESUMO

OBJECTIVE: To explore a 5-year comparison of disparities in intravenous t-PA (IV t-PA) use among acute ischemic stroke (AIS) patients based on race, gender, age, ethnic origin, hospital status, and geographic location. METHODS: We extracted patients' demographic information and hospital characteristics for 2010 and 2014 from the New York Statewide Planning and Research Cooperative System (SPARCS). We compared disparities in IV t-PA use among AIS patients in 2010 to that in 2014 to estimate temporal trends. Multiple logistic regression was performed to compare disparities based on demographic variables, hospital designation, and geographic location. RESULTS: Overall, there was approximately a 2% increase in IV t-PA from 2010 to 2014. Blacks were 15% less likely to receive IV t-PA compared to Whites in 2014, but in 2010, there was no difference. Patients aged 62-73 had lower odds of receiving IV t-PA than age group ≤61 in both 2010 and 2014. Designated stroke centers in the Lower New York State region were associated with reduced odds of IV t-PA use in 2010 while those located in the Upper New York State region were associated with increased odds of IV t-PA use in both 2010 and 2014, compared to their respective nondesignated counterparts. Gender, ethnic origin, and insurance status were not associated with IV t-PA utilization in both 2010 and 2014. CONCLUSION: Overall IV t-PA utilization among AIS patients increased between 2010 and 2014. However, there are evident disparities in IV t-PA use based on patient's race, age, hospital geography, and stroke designation status.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Acesso aos Serviços de Saúde/tendências , Disparidades em Assistência à Saúde/tendências , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/tendências , Administração Intravenosa , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etnologia , Grupos de Populações Continentais , Bases de Dados Factuais , Feminino , Disparidades em Assistência à Saúde/etnologia , Humanos , Masculino , Pessoa de Meia-Idade , New York/epidemiologia , Fatores Sexuais , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etnologia , Fatores de Tempo , Resultado do Tratamento
14.
Angiology ; 70(4): 352-360, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30176735

RESUMO

Circadian rhythms have been identified in multiple physiological processes that may affect cardiovascular diseases, yet little is known about the impact of circadian rhythm on acute ST-segment elevation myocardial infarction (STEMI) onset and outcomes in the Middle East. The relationship between time of symptom onset during the 24-hour circadian cycle and prehospital delays and in-hospital death was assessed in 2909 patients with STEMI presenting in 6 Arabian Gulf countries. A sinusoidal smoothing function was used to show the average circadian trends. There was a significant association between time of symptom onset and the circadian cycle. The STEMIs were more frequent during the late morning and early afternoon hours ( P < .001). Patients with pain onset from 0.00 to 5:59 had median prehospital delays of 150 minutes versus 90 minutes from 6:00 to 11:59 and 12:00 to 17:59, respectively ( P < .001). Although there was no significant difference in mortality between the 4 groups ( P = .230), there was a significant association between time of symptom onset as sinusoidal function and in-hospital mortality ( P = .032). Patients with STEMI in the Middle East have significant circadian patterns in symptoms onset, prehospital delay, and timeliness of reperfusion. A circadian rhythm of in-hospital mortality was found over the 24-hour clock of symptom onset time.


Assuntos
Fármacos Cardiovasculares/administração & dosagem , Ritmo Circadiano , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Terapia Trombolítica , Tempo para o Tratamento , Adulto , Idoso , Fármacos Cardiovasculares/efeitos adversos , Esquema de Medicação , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Oriente Médio/epidemiologia , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Intervenção Coronária Percutânea/tendências , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Terapia Trombolítica/tendências , Fatores de Tempo , Tempo para o Tratamento/tendências , Resultado do Tratamento
15.
Neurotox Res ; 35(2): 441-450, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30328586

RESUMO

Little is known about the prognostic value of the estimated glomerular filtration rate (eGFR) and the effect of dynamic changes in the eGFR on mortality in acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT). We aim to investigate the association between the eGFR and dynamic changes in the eGFR after IVT with all-cause mortality in AIS patients. A total of 391 AIS patients treated with IVT between May 2010 and May 2017 were included in the final analysis. Serum creatinine was measured at admission and within 24 h after IVT. The main outcomes included 3-month all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE). During the 3-month follow-up, 37 (9.5%) patients died from all causes. Mortality was associated with a reduced eGFR at admission (adjusted hazard ratio (HR), 4.17; 95% confidence interval (CI), 1.50-11.58; P trend = 0.016) and within 24 h after IVT (adjusted HR, 5.88; 95% CI, 1.41-24.52; P trend = 0.009). Mortality was negatively correlated with increased eGFR after IVT (adjusted HR, 0.70; 95% CI, 0.51-0.96; P trend = 0.027). Additionally, a reduced eGFR after IVT was also associated with increased risk of MACCE (adjusted HR, 3.64; 95% CI, 1.41-9.39; P trend = 0.009). Using a multivariable Cox regression model with restricted cubic splines, we observed an L-shaped association between the eGFR and 3-month all-cause mortality and MACCE and observed a linear association between dynamic changes in the eGFR and 3-month all-cause mortality. A reduced eGFR and dynamic decreases in the eGFR after IVT independently predict 3-month all-cause mortality in AIS patients.


Assuntos
Fibrinolíticos/administração & dosagem , Taxa de Filtração Glomerular/fisiologia , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/mortalidade , Terapia Trombolítica/mortalidade , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/tratamento farmacológico , Isquemia Encefálica/mortalidade , Isquemia Encefálica/fisiopatologia , Feminino , Taxa de Filtração Glomerular/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Valor Preditivo dos Testes , Sistema de Registros , Acidente Vascular Cerebral/fisiopatologia , Terapia Trombolítica/tendências , Resultado do Tratamento
16.
J Emerg Med ; 56(3): 258-266, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30528709

RESUMO

BACKGROUND: In the past three years, there have been several major studies published on the use of endovascular therapy (EVT) in large vessel occlusion (LVO) acute ischemic stroke. With multiple publications in such a short amount of time, it is difficult to keep up with the evolving landscape of ischemic stroke therapy. OBJECTIVE: This narrative review discusses recent randomized controlled trials evaluating EVT and its effects on acute ischemic stroke management. DISCUSSION: Ischemic stroke is the most common type of stroke overall, and recanalization is the predominant focus in stroke therapy to improve outcomes. Treatment first focused on systemic thrombolysis for ischemic stroke, followed by studies evaluating the use of thrombolysis with EVT. Early research did not find a benefit to EVT; however, recent studies using current devices and with narrow selection criteria demonstrate significant benefit to EVT in LVOs. In patients with LVOs and perfusion mismatches, reperfusion rates are higher with EVT compared with systemic thrombolysis alone. Recognition of patients with small infarct cores and large areas of ischemic but salvageable brain tissue up to 24 h after symptom onset stresses the need for advanced imaging to recognize the target group. CONCLUSIONS: EVT technology for acute ischemic stroke has now become more efficient, minimizing complications and improving the efficacy of EVT. Several viable interventions for a small subgroup of patients with ischemic stroke up to 24 h after symptoms onset can significantly improve patient outcomes.


Assuntos
Arteriopatias Oclusivas/terapia , Procedimentos Endovasculares/normas , Acidente Vascular Cerebral/terapia , Arteriopatias Oclusivas/tratamento farmacológico , Procedimentos Endovasculares/métodos , Humanos , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/métodos , Terapia Trombolítica/normas , Terapia Trombolítica/tendências , Resultado do Tratamento
17.
Vascular ; 27(1): 71-77, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30193552

RESUMO

OBJECTIVE: Acute limb ischemia is a common vascular emergency requiring immediate intervention. Thrombolysis has been widely utilized for acute limb ischemia; the purpose of this study is to analyze contemporary trends, outcomes and complications of thrombolysis for acute limb ischemia. METHODS: Patients were identified from the Nationwide Inpatient Sample (2003-2013) using ICD-9. Patients undergoing emergency thrombolysis for acute limb ischemia were evaluated. Three groups were analyzed: thrombolysis alone, thrombolysis and endovascular procedure (T+ENDO), and failed thrombolysis requiring open surgery (T+OPEN). RESULTS: A total of 162,240 patients with acute limb ischemia were estimated: 33,615 patients (20.7%) underwent thrombolysis as the initial treatment. Mean age was 66.2 ± 34.9 years with 54% male. The utilization of thrombolysis increased significantly during the study period (16.8-24.2%, p < 0.0001). The most common group was thrombolysis and endovascular procedure (40.7%), followed by thrombolysis alone (34.1%), and T+OPEN (25.2%). Thrombolysis and endovascular procedure increased significantly over time (31.6-47.8%, p < 0.0001) whereas thrombolysis alone and T+OPEN significantly decreased (39.6-28.6% and 28.7-23.6%, respectively, p < 0.0001). Overall mortality was 4.9%; thrombolysis and endovascular procedure compared to thrombolysis alone and T-OPEN had a lower mortality rate (3.2% vs. 6.1% and 5.9%, p < 0001). The overall stroke rate was 1.9%; thrombolysis alone had the highest stroke rate (3.0%, p < 0.0001) with thrombolysis and endovascular procedure the lowest (1.2%) and T+OPEN 1.7%. The highest amputation rate was T+OPEN (11.6%, p < 0.001) compared to thrombolysis and endovascular procedure (5.1%) and thrombolysis alone (5.3%). T+OPEN had the highest incidence of cardiac (5.5%), respiratory (7.3%) and renal complications (12.5%), pneumonia (4.0%), and fasciotomy (16.8%) (all p < 0.0001). CONCLUSION: Thrombolysis remains an effective treatment for acute limb ischemia with increased utilization over time. There was a significant increase in thrombolysis and endovascular procedure leading to improved outcomes. Thrombolysis alone carried the highest mortality and stroke rate, with T+OPEN associated with the highest amputation and complications. Although thrombolysis is effective, 25% of patients required an open procedure suggesting that patient selection for thrombolysis first instead of open surgery continues to be a clinical challenge.


Assuntos
Fibrinolíticos/administração & dosagem , Isquemia/tratamento farmacológico , Extremidade Inferior/irrigação sanguínea , Terapia Trombolítica/tendências , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Amputação/tendências , Tomada de Decisão Clínica , Terapia Combinada , Conversão para Cirurgia Aberta/tendências , Bases de Dados Factuais , Procedimentos Endovasculares/tendências , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Isquemia/diagnóstico por imagem , Isquemia/mortalidade , Isquemia/cirurgia , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Padrões de Prática Médica/tendências , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Adulto Jovem
19.
Ned Tijdschr Geneeskd ; 1622018 11 30.
Artigo em Holandês | MEDLINE | ID: mdl-30570931

RESUMO

In the Netherlands, a well-organized network of anticoagulation centres has been managing anticoagulation with vitamin K antagonists for the last 60-70 years. The introduction of direct oral anticoagulant (DOAC) therapy has made treatment much more straightforward and it can now be managed by a general physician or a nurse specialized in cardiovascular risk management. The involvement of the current anticoagulation centres in anticoagulation therapy will accordingly become smaller over time, as more patients will be treated with DOACs, and anticoagulation centres in their present form may no longer be needed.


Assuntos
Instituições de Assistência Ambulatorial/tendências , Anticoagulantes/uso terapêutico , Fibrinolíticos/uso terapêutico , Terapia Trombolítica/tendências , Administração Oral , Humanos , Países Baixos
20.
Catheter Cardiovasc Interv ; 92(7): E425-E432, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-30269436

RESUMO

BACKGROUND: Pharmacologic reperfusion therapy is a recommended and effective strategy in patients with ST-elevation myocardial infarction (STEMI) when percutaneous coronary intervention (PCI) is not available. This study investigates temporal trends and outcomes of fibrinolytic therapy (FT) in elderly patients with STEMI. METHODS: Using the Nationwide Inpatient Sample database, we extracted patients ≥80 years a primary diagnosis of STEMI admitted between 2010 and 2014. Using ICD codes, we identified patients who underwent FT. We performed temporal trend analysis, then compared characteristics and inpatient outcomes in the FT group versus no-FT group. Our primary outcome of interest was hemorrhagic stroke (HS). We also assessed the impact of HS on mortality and discharge to skilled nursing facility (SNF). RESULTS: Of the 917,307 patients with STEMI, 16.1% (n = 147,874) were aged 80 or older. Primary PCI was performed in 46.2%, 2.4% underwent FT, and 51.3% had neither pharmacologic nor mechanical revascularization. The rate of FT increased (1.9%-2.4%) in a nonlinear trend over the five years of the study. The FT group was eight times more likely to suffer HS (P < 0.001). FT was an independent predictor of HS (OR 7.90, 95% CI 4.36-14.30; P < 0.001), whether they underwent PCI or not. HS was an independent predictor of mortality and SNF discharge. CONCLUSION: FT in patients 80 years or older presenting with STEMI was associated with an eight-fold increase in HS and no associated mortality advantage, both with or without PCI. These data underscore the increased risk of FT in the elderly.


Assuntos
Infarto do Miocárdio com Supradesnível do Segmento ST/tratamento farmacológico , Terapia Trombolítica/tendências , Fatores Etários , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Incidência , Pacientes Internados , Hemorragias Intracranianas/epidemiologia , Masculino , Alta do Paciente/tendências , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Instituições de Cuidados Especializados de Enfermagem/tendências , Acidente Vascular Cerebral/epidemiologia , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
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