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1.
BMC Pregnancy Childbirth ; 21(1): 108, 2021 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-33546624

RESUMO

BACKGROUND: As pregnancy is a physiological prothrombotic state, pregnant women may be at increased risk of developing coagulopathic and/or thromboembolic complications associated with COVID-19. METHODS: Two biomedical databases were searched between September 2019 and June 2020 for case reports and series of pregnant women with a diagnosis of COVID-19 based either on a positive swab or high clinical suspicion where no swab had been performed. Additional registry cases known to the authors were included. Steps were taken to minimise duplicate patients. Information on coagulopathy based on abnormal coagulation test results or clinical evidence of disseminated intravascular coagulation (DIC), and on arterial or venous thrombosis, were extracted using a standard form. If available, detailed laboratory results and information on maternal outcomes were analysed. RESULTS: One thousand sixty-three women met the inclusion criteria, of which three (0.28, 95% CI 0.0 to 0.6) had arterial and/or venous thrombosis, seven (0.66, 95% CI 0.17 to 1.1) had DIC, and a further three (0.28, 95% CI 0.0 to 0.6) had coagulopathy without meeting the definition of DIC. Five hundred and thirty-seven women (56%) had been reported as having given birth and 426 (40%) as having an ongoing pregnancy. There were 17 (1.6, 95% CI 0.85 to 2.3) maternal deaths in which DIC was reported as a factor in two. CONCLUSIONS: Our data suggests that coagulopathy and thromboembolism are both increased in pregnancies affected by COVID-19. Detection of the former may be useful in the identification of women at risk of deterioration.


Assuntos
/epidemiologia , Coagulação Intravascular Disseminada/epidemiologia , Complicações Cardiovasculares na Gravidez/epidemiologia , Complicações Hematológicas na Gravidez/epidemiologia , Complicações Infecciosas na Gravidez/epidemiologia , Tromboembolia/epidemiologia , Trombose Venosa/epidemiologia , /virologia , Comorbidade , Coagulação Intravascular Disseminada/virologia , Feminino , Humanos , Gravidez , Complicações Cardiovasculares na Gravidez/virologia , Complicações Hematológicas na Gravidez/virologia , Complicações Infecciosas na Gravidez/virologia , Resultado da Gravidez , Tromboembolia/virologia , Trombose Venosa/virologia
2.
Ter Arkh ; 92(9): 15-23, 2020 Oct 14.
Artigo em Russo | MEDLINE | ID: mdl-33346426

RESUMO

AIM: To analyze the frequency of resumption of anticoagulant therapy (ACT) after major and clinically significant bleeding among AF patients who received oral anticoagulants and were observed in the Department of clinical problems of atherothrombosis from 1999 to 2019 within the retro-prospective register Regata-2, and to search for clinical factors associated with recurrence of hemorrhagic complications among patients who resumed anticoagulant therapy after a bleeding episode. MATERIALS AND METHODS: In cohort study of patients with high-risk AF with absolute indications for ACT we enrolled 290 AF patients (130 women and 160 men) aged 32 to 85 years (the average age was 65.188.89 years). During the follow-up period, 92 patients developed hemorrhagic complications, and 73 of them resumed ACT. 35 of the 73 patients who resumed ACT developed a relapse of major/clinically significant bleeding. RESULTS: The frequency of resuming ACT after the first hemorrhagic complication increased over time from 75% in the period from 19992003 to 90% in the period 20152019. We were not able to establish an exact relationship between the presence of concomitant pathology and the decision to resume the ACT after bleeding. The only reliable reason for refusing to resume the ACT was the patients categorical reluctance. Among patients who had recurrent hemorrhagic complications, the total score on the Charleson comorbidity scale was significantly higher (4.232.01vs3.521.43;p=0.0425). Patients with recurrent bleeding were significantly more likely to suffer from CKD with a decrease in GFR less than 60 ml/min/1.73 sq. m, and also had a history of erosive and ulcerative lesions of the gastrointestinal tract. There was also a significant Association of recurrent bleeding with the use of proton pump inhibitors. Subgroups of patients who switched from warfarin to taking direct oral anticoagulants after the first bleeding and subsequent recurrent bleeding did not differ in basic clinical characteristics from patients without bleeding after changing the anticoagulant. According to multiple regression analysis, NSAIDs showed a tendency to develop a relapse of B/C bleeding on the background of direct oral anticoagulants in patients who underwent GO on the background of warfarin therapy (b=0.4524,p=0.0530). CONCLUSION: During the 20-year follow-up, the frequency of all major and clinically significant bleeding was 2.6/100 patients-years, the frequency of first bleeding was 5.86/100 patients-years, while the frequency of repeated hemorrhagic complications was 7.06/100 patients-years. Patients with a high thromboembolic risk should receive anticoagulants, provided that the modifiable risk factors for bleeding are carefully corrected.


Assuntos
Fibrilação Atrial , Acidente Vascular Cerebral , Tromboembolia , Administração Oral , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/epidemiologia , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Tromboembolia/epidemiologia , Tromboembolia/etiologia , Tromboembolia/prevenção & controle
3.
Pan Afr Med J ; 37: 32, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33209159

RESUMO

Diabetes is considered a risk factor for complications due to COVID-19. In order to clarify this association, we are exploring the characteristics, the clinical signs, the outcomes and death in diabetic patients with COVID-19. In this retrospective observational study we are evaluating the demographic characteristics, the comorbidities of the patients, the clinical signs of the infection, the signs of clinical severity, the biological assessment at admission, the treatment, the outcomes and the deaths of 133 patients with COVID-19, of which 25 (19,4%) had diabetes. In the compared COVID-19 patients, with and without diabetes, the patients with diabetes were older, had higher blood pressure and more cardio-vascular diseases. Severe forms were more present in diabetic patients (56% versus 27.1%). Weight loss was higher in diabetic patients (6kg versus 3kg). Biologically, diabetic patients had higher levels of C-reactive protein (28 versus 5.8mg/l), procalcitonin (0.28 versus 0,13ng/l), ferritin (501 versus 140ng/ml), lactic dehydrogenase (268 versus 226IU/l) and of D. dimer (665 versus 444µg/l). Diabetic patients required more oxygen therapy (60% versus 26.9%), more mechanical ventilation (20% versus 8.3%) and more frequent admission to the intensive care unit (60% versus 27.8%). They presented more thromboembolic complications (12% versus 9%) but there were not significant differences in the other outcomes and in death rates. The excess of morbidity and mortality due to diabetes was still not fully clarified; the role of demographic factors, the interaction of mediations with ACE-2 receptors and the role of co-morbidities will all need to be studied in order to identify the patient at risk profile, i.e. who can develop severe forms of the diseases and more outcomes. The early identification of a possible hyper inflammation could be very valuable. More attention should be paid to patients with COVID-19 with diabetes because they are at a high risk of complications.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Diabetes Mellitus/epidemiologia , Pneumonia Viral/epidemiologia , Fatores Etários , Proteína C-Reativa/análise , Doenças Cardiovasculares/epidemiologia , Infecções por Coronavirus/sangue , Infecções por Coronavirus/complicações , Infecções por Coronavirus/mortalidade , Cuidados Críticos/estatística & dados numéricos , Complicações do Diabetes/sangue , Complicações do Diabetes/epidemiologia , Complicações do Diabetes/mortalidade , Diabetes Mellitus/sangue , Diabetes Mellitus/mortalidade , Ferritinas/sangue , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Hipertensão/epidemiologia , L-Lactato Desidrogenase/sangue , Pessoa de Meia-Idade , Marrocos/epidemiologia , Oxigênio/uso terapêutico , Pandemias , Pneumonia Viral/sangue , Pneumonia Viral/complicações , Pneumonia Viral/mortalidade , Pró-Calcitonina/sangue , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Tromboembolia/epidemiologia
4.
Clin Appl Thromb Hemost ; 26: 1076029620967083, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33074717

RESUMO

Emerging evidence shows that the recent pandemic of coronavirus disease 19 (COVID-19) is characterized by coagulation activation and endothelial dysfunction. This increases the risk of morbidity, mortality and economic loss among COVID-19 patients. Therefore, there was an urgent need to investigate the extent and risk factors of thromboembolism among COVID-19 patients. English-language based databases (PubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and Cochrane library) were exhaustively searched to identify studies related to prevalence of thromboembolism among hospitalized COVID-19 patients. A random-effects model was employed to estimate the pooled prevalence of thromboembolism. The pooled prevalence of thrombotic events was computed using STATA 16.0 software. Heterogeneity analysis was reported using I2. A total of 19 studies with 2,520 patients with COVID-19 were included. The pooled prevalence of thrombotic events of hospitalized patients with COVID-19 was 33% (95% CI: 25-41%, I2 = 97.30%, p < 0.001) with a high degree of heterogeneity across studies. Elevated D-dimer hospitalized in the intensive care unit and being under mechanical ventilation were the most frequently associated factors for the development of thrombotic events. The pooled prevalence of thrombotic events in COVID-19 patients was 33%. The prevalence of thrombotic event is variables on the basis of study design and study centers. Several risk factors such as, elevated D-dimer, hospitalized in the intensive care unit and being under mechanical ventilation, were the most frequently reported risk factors identified. Therefore, healthcare professionals should consider these risk factors to optimally manage thromboembolism in COVID-19 patients.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Pandemias , Pneumonia Viral/complicações , Medição de Risco/métodos , Tromboembolia/epidemiologia , Infecções por Coronavirus/epidemiologia , Saúde Global , Humanos , Pneumonia Viral/epidemiologia , Prevalência , Fatores de Risco , Tromboembolia/etiologia
5.
J Am Coll Cardiol ; 76(18): 2060-2072, 2020 11 03.
Artigo em Inglês | MEDLINE | ID: mdl-33121712

RESUMO

BACKGROUND: Cardiovascular complications, including myocardial infarction, ischemic stroke, and pulmonary embolism, represent an important source of adverse outcomes in coronavirus disease-2019 (COVID-19). OBJECTIVES: To assess the frequency of arterial and venous thromboembolic disease, risk factors, prevention and management patterns, and outcomes in patients with COVID-19, the authors designed a multicenter, observational cohort study. METHODS: We analyzed a retrospective cohort of 1,114 patients with COVID-19 diagnosed through our Mass General Brigham integrated health network. The total cohort was analyzed by site of care: intensive care (n = 170); hospitalized nonintensive care (n = 229); and outpatient (n = 715). The primary study outcome was a composite of adjudicated major arterial or venous thromboembolism. RESULTS: Patients with COVID-19 were 22.3% Hispanic/Latinx and 44.2% non-White. Cardiovascular risk factors of hypertension (35.8%), hyperlipidemia (28.6%), and diabetes (18.0%) were common. Prophylactic anticoagulation was prescribed in 89.4% of patients with COVID-19 in the intensive care cohort and 84.7% of those in the hospitalized nonintensive care setting. Frequencies of major arterial or venous thromboembolism, major cardiovascular adverse events, and symptomatic venous thromboembolism were highest in the intensive care cohort (35.3%, 45.9%, and 27.0 %, respectively) followed by the hospitalized nonintensive care cohort (2.6%, 6.1%, and 2.2%, respectively) and the outpatient cohort (0% for all). CONCLUSIONS: Major arterial or venous thromboembolism, major adverse cardiovascular events, and symptomatic venous thromboembolism occurred with high frequency in patients with COVID-19, especially in the intensive care setting, despite a high utilization rate of thromboprophylaxis.


Assuntos
Anticoagulantes/uso terapêutico , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Sistema de Registros , Tromboembolia/virologia , Adulto , Idoso , Betacoronavirus , Infecções por Coronavirus/mortalidade , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Massachusetts/epidemiologia , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/mortalidade , Estudos Retrospectivos , Fatores de Risco , Tromboembolia/epidemiologia , Tromboembolia/prevenção & controle
6.
Clin Appl Thromb Hemost ; 26: 1076029620960797, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33079569

RESUMO

The incidence of venous thromboembolism (VTE) events in patients with COVID-19 treated with a standard thromboprophylaxis dose of anticoagulants remains high. We conducted a systematic review in order to explore the association between therapeutic-dose anticoagulation and its effect on mortality in patients with COVID-19. A systematic search was carried out using the electronic databases of PubMed, EuropePMC, and the Cochrane Central Database, using specific keywords. All articles that fulfilled the inclusion criteria were included in the qualitative analysis. There were 8 observational studies included in the final qualitative analysis. Quality assessment using the Newcastle-Ottawa Scale (NOS) showed a mean score of 7.5 ± 1.06, indicating moderate to high quality of the studies. Three retrospective cohort studies reported a reduction in the mortality rate, while 6 other studies showed no mortality benefits among patients with COVID-19 treated with therapeutic-dose anticoagulation. There was a slight tendency toward a reduction in the mortality rate among mechanically-ventilated patients with COVID-19 receiving therapeutic-dose anticoagulation. Bleeding events and thrombotic complications among patients receiving therapeutic-dose anticoagulation were reported in 3 studies. Although it is too soon to draw any conclusions, this systematic review draws attention to current evidence regarding the association between therapeutic-dose anticoagulation and its effect on mortality in patients with COVID-19.


Assuntos
Anticoagulantes/administração & dosagem , Betacoronavirus , Coagulação Sanguínea/efeitos dos fármacos , Infecções por Coronavirus/complicações , Pandemias , Pneumonia Viral/complicações , Tromboembolia/prevenção & controle , Infecções por Coronavirus/epidemiologia , Saúde Global , Humanos , Incidência , Pneumonia Viral/epidemiologia , Taxa de Sobrevida/tendências , Tromboembolia/epidemiologia , Tromboembolia/etiologia
7.
Vasc Health Risk Manag ; 16: 437-443, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33116554

RESUMO

Background: Incidence and outcomes of recurrent venous thromboembolism (VTE) in the elderly are still not fully elucidated. The purpose of this study was to determine the incidence and identify the risk factors of VTE recurrence in this population. Methods: A prospective cohort study of a one-year follow-up of 277 patients aged ≥65 years with primary VTE was performed at King Abdulaziz Medical City, a tertiary care teaching hospital in Riyadh, Saudi Arabia. Demographic data, risk factors, and the consequences of VTE (recurrence, bleeding, and mortality) were recorded. Results: Of the 277 VTE patients, 39 (14%) were diagnosed with recurrent VTE over a median follow-up period of 12 months. The cumulative incidence of recurrent VTE was 12.75 per hundred patient-year (95% CI, 8.24-17.36). In multivariate Cox regression, malignancy (hazard ratio [HR], 2.87, 95% CI, 1.32-6.24, p=0.008) and surgery (HR 2.78, 95% CI, 1.36-5.67, p=0.005) were identified as independent risk factors for recurrent VTE. Metformin had a significant independent protection effect (HR, 0.16, 95% CI, 0.08-0.33, p<0.001). During follow-up, two patients in the recurrent VTE group and five patients in the group with no recurrent VTE, all of whom were minor bleeding cases, reported no major bleeding. Seven (18%) patients in the recurrent VTE group and nine (4%) patients in the group with no recurrent VTE died (p<0.001). Conclusion: The findings of this study show that elderly patients with initial VTE have a recurrent rate (14%), with a cumulative incidence rate of 12.75 per hundred patient-year. Malignancy and surgery were the most important clinical risk factors to impact significantly the development of recurrent VTE in our elderly population. Metformin may have a protective effect against recurrent VTE in the elderly population, and a larger study is needed to validate our findings.


Assuntos
Tromboembolia/epidemiologia , Fatores Etários , Idoso , Feminino , Humanos , Incidência , Masculino , Estudos Prospectivos , Recidiva , Medição de Risco , Fatores de Risco , Arábia Saudita/epidemiologia , Tromboembolia/diagnóstico , Tromboembolia/mortalidade , Fatores de Tempo
8.
PLoS One ; 15(9): e0238387, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32870937

RESUMO

OBJECTIVE: Anticoagulation (AC) is a critical topic in perioperative and post-bleeding management. Nevertheless, there is a lack of data about the safe, judicious use of prophylactic and therapeutic anticoagulation with regard to risk factors and the cause and modality of brain tissue damage as well as unfavorable outcomes such as postoperative hemorrhage (PH) and thromboembolic events (TE) in neurosurgical patients. We therefore present retrospective data on perioperative anticoagulation in meningioma surgery. METHODS: Data of 286 patients undergoing meningioma surgery between 2006 and 2018 were analyzed. We followed up on anticoagulation management, doses and time points of first application, laboratory values, and adverse events such as PH and TE. Pre-existing medication and hemostatic conditions were evaluated. The time course of patients was measured as overall survival, readmission within 30 days after surgery, as well as Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS). Statistical analysis was performed using multivariate regression. RESULTS: We carried out AC with Fraxiparin and, starting in 2015, Tinzaparin in weight-adapted recommended prophylactic doses. Delayed (216 ± 228h) AC was associated with a significantly increased rate of TE (p = 0.026). Early (29 ± 21.9h) prophylactic AC, on the other hand, did not increase the risk of PH. We identified additional risk factors for PH, such as blood pressure maxima, steroid treatment, and increased white blood cell count. Patients' outcome was affected more adversely by TE than PH (+3 points in modified Rankin Scale in TE vs. +1 point in PH, p = 0.001). CONCLUSION: Early prophylactic AC is not associated with an increased rate of PH. The risks of TE seem to outweigh those of PH. Early postoperative prophylactic AC in patients undergoing intracranial meningioma resection should be considered.


Assuntos
Anticoagulantes/efeitos adversos , Hemorragias Intracranianas/etiologia , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Idoso , Anticoagulantes/administração & dosagem , Esquema de Medicação , Feminino , Alemanha/epidemiologia , Humanos , Hemorragias Intracranianas/epidemiologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/efeitos adversos , Hemorragia Pós-Operatória/epidemiologia , Hemorragia Pós-Operatória/etiologia , Estudos Retrospectivos , Fatores de Risco , Tromboembolia/epidemiologia , Tromboembolia/etiologia
9.
Intern Emerg Med ; 15(8): 1533-1544, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32910363

RESUMO

Infection with SARS-CoV-2 is becoming the leading cause of death in most countries during the 2020 pandemic. The objective of this study is to assess the association between COVID-19 and cause-specific death. The design is retrospective cohort study. We included data from inpatients diagnosed with COVID-19 between March 18 and April 21, 2020, who died during their hospital stay. Demographic, clinical and management data were collected. Causes of death were ascertained by review of medical records. The sample included 128 individuals. The median age was 84 (IQR 75-89), 57% were men. In 109 patients, the death was caused by SARS-CoV-2 infection, whereas in 19 (14.8%, 95 CI 10-22%), the infection acted only as a precipitating factor to decompensate other pathologies. This second group of patients was older (88y vs 82, p < 0.001). In age-adjusted analysis, they had a greater likelihood of heart failure (OR 3.61 95% CI 1.15-11.32), dependency in activities of daily living (OR 12.07 95% CI 1.40-103.86), frailty (OR 8.73 95% CI 1.37-55.46). The presence of X-ray infiltrates was uncommon (OR 0.07, 95% CI 0.02-0.25). A higher percentage of patient deaths from causes unrelated to COVID-19 complications occurred during the two first weeks of the pandemic. Fifteen percent of patients with COVID-19 infection died from decompensation of other pathologies and the cause of death was unrelated to COVID-19 severe complications. Most of these patients had more comorbidities and were frail and elderly. These findings can partially explain the excess mortality in older people.


Assuntos
Causas de Morte/tendências , Infecções por Coronavirus/mortalidade , Pandemias/estatística & dados numéricos , Pneumonia Viral/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Infecções por Coronavirus/complicações , Infecções por Coronavirus/epidemiologia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/complicações , Pneumonia Viral/epidemiologia , Insuficiência Respiratória/complicações , Insuficiência Respiratória/epidemiologia , Estudos Retrospectivos , Espanha/epidemiologia , Estatísticas não Paramétricas , Tromboembolia/complicações , Tromboembolia/epidemiologia
10.
Emerg Med J ; 37(10): 630-636, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32948623

RESUMO

Common causes of death in COVID-19 due to SARS-CoV-2 include thromboembolic disease, cytokine storm and adult respiratory distress syndrome (ARDS). Our aim was to develop a system for early detection of disease pattern in the emergency department (ED) that would enhance opportunities for personalised accelerated care to prevent disease progression. A single Trust's COVID-19 response control command was established, and a reporting team with bioinformaticians was deployed to develop a real-time traffic light system to support clinical and operational teams. An attempt was made to identify predictive elements for thromboembolism, cytokine storm and ARDS based on physiological measurements and blood tests, and to communicate to clinicians managing the patient, initially via single consultants. The input variables were age, sex, and first recorded blood pressure, respiratory rate, temperature, heart rate, indices of oxygenation and C-reactive protein. Early admissions were used to refine the predictors used in the traffic lights. Of 923 consecutive patients who tested COVID-19 positive, 592 (64%) flagged at risk for thromboembolism, 241/923 (26%) for cytokine storm and 361/923 (39%) for ARDS. Thromboembolism and cytokine storm flags were met in the ED for 342 (37.1%) patients. Of the 318 (34.5%) patients receiving thromboembolism flags, 49 (5.3% of all patients) were for suspected thromboembolism, 103 (11.1%) were high-risk and 166 (18.0%) were medium-risk. Of the 89 (9.6%) who received a cytokine storm flag from the ED, 18 (2.0% of all patients) were for suspected cytokine storm, 13 (1.4%) were high-risk and 58 (6.3%) were medium-risk. Males were more likely to receive a specific traffic light flag. In conclusion, ED predictors were used to identify high proportions of COVID-19 admissions at risk of clinical deterioration due to severity of disease, enabling accelerated care targeted to those more likely to benefit. Larger prospective studies are encouraged.


Assuntos
Infecções por Coronavirus/terapia , Etiquetas de Emergência Médica/tendências , Serviço Hospitalar de Emergência/estatística & dados numéricos , Mortalidade Hospitalar/tendências , Equipe de Assistência ao Paciente/organização & administração , Pneumonia Viral/terapia , Tromboembolia/diagnóstico , Adulto , Fatores Etários , Idoso , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Progressão da Doença , Feminino , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Seleção de Pacientes , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Medicina de Precisão/estatística & dados numéricos , Medição de Risco , Índice de Gravidade de Doença , Fatores Sexuais , Tromboembolia/epidemiologia , Tromboembolia/terapia , Reino Unido
12.
Intern Med ; 59(15): 1819-1826, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32741891

RESUMO

Objective Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary hypertension caused by persistent thromboemboli of the pulmonary arteries, and one of its etiological factors may be inflammation. Sleep disordered breathing (SDB) is reportedly an important complication of pulmonary hypertension. However, the association between SDB and inflammation in CTEPH has been undefined. This prospective observational study analyzed the association between the severity of SDB, pulmonary hemodynamic parameters and the systemic inflammation level in patients with CTEPH. Methods CTEPH patients admitted for a right heart catheter (RHC) examination were consecutively enrolled from November 2017 to June 2019 at the pulmonary hypertension center in Chiba University Hospital. Patients with idiopathic pulmonary arterial hypertension (IPAH) were also enrolled as a control group. All patients underwent a sleep study using a WatchPAT 200 during admission. Results The CTEPH patients showed worse nocturnal hypoxemia, oxygen desaturation index (ODI), and apnea-hypopnea index than the IPAH patients. Among these factors, only the nocturnal mean percutaneous oxygen saturation (SpO2) was negatively correlated with the pulmonary hemodynamic parameters. The circulating tumor necrosis factor-alpha (TNF-α) level was also high in the CTEPH group, and a multivariate analysis showed that the nocturnal mean SpO2 was the most important predictive factor for a high TNF-α level. Conclusion We showed that CTEPH patients had high serum TNF-α levels and that the nocturnal mean SpO2 was a predictive factor for serum TNF-α levels. Further investigations focused on nocturnal hypoxemia and the TNF-α level may provide novel insight into the etiology and new therapeutic strategies for CTEPH.


Assuntos
Hipertensão Pulmonar/epidemiologia , Hipóxia/epidemiologia , Síndromes da Apneia do Sono/epidemiologia , Fator de Necrose Tumoral alfa/sangue , Adulto , Idoso , Doença Crônica , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Polissonografia , Estudos Prospectivos , Artéria Pulmonar/fisiopatologia , Tromboembolia/epidemiologia
13.
Value Health ; 23(7): 862-869, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32762987

RESUMO

OBJECTIVE: To assess patient preferences for benefits and risks in hemophilia A treatment. METHODS: A systematic literature search and pretest interviews were conducted to determine the most patient-relevant endpoints in terms of effects, risks, and administration of hemophilia A treatments. A Best-Worst Scaling (BWS; Case 3 or multiprofile case) approach was applied in a structured questionnaire. Patients were surveyed by interviewers in a computer-assisted personal interview. Treatments in the choice scenarios comprised bleeding frequency per year, application type, risk of thromboembolic event risk, and inhibitor development. Each respondent answered 13 choice tasks, including 1 dominant task, comparing 3 treatment profiles. Data were analyzed using a mixed logit model (random-parameters logit). RESULTS: Data from 57 patients were used. The attributes "bleeding frequency per year" and "inhibitor development" had the greatest impact on respondents' choice decisions. Patients disliked being at risk of inhibitor development more than being at risk of thromboembolic events. The type of application, whether intravenous or subcutaneous, was of less importance for patients. There was a significant preference variation for all attributes. CONCLUSIONS: Patients value low frequency of bleeding per year and low risk of development of inhibitors the most. An increase of risk and frequency would significantly decrease the impact on choice decisions. The type of application does not seem to influence the choice decision very much compared with the other attributes. Regarding preference heterogeneity, further analysis is needed to identify subgroups among patients and their characteristics. This may help to adapt individually patient-tailored treatment alternatives for hemophilia A patients.


Assuntos
Comportamento de Escolha , Tomada de Decisões , Hemofilia A/terapia , Preferência do Paciente , Hemofilia A/fisiopatologia , Humanos , Inquéritos e Questionários , Tromboembolia/epidemiologia
14.
Arch Cardiovasc Dis ; 113(10): 642-651, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32712202

RESUMO

Major thromboembolic complications in patients with atrial fibrillation, secondary to thromboembolism from the left atrium or the left atrial appendage, are a major concern because of their burden of disabling stroke and mortality. To date, non-vitamin K antagonist oral anticoagulants (NOACs) are considered the first-line strategy in most patients with atrial fibrillation receiving chronic anticoagulation, as they have major advantages compared with vitamin K antagonists, including minimization of intracranial bleeding risk. Although several studies and post-hoc analyses have provided initial data on the use of NOACs in patients with documented atrial and/or left atrial appendage thrombosis, the benefit of NOACs in these patients has not been fully elucidated. In this review, we reappraise current evidence supporting the use of NOACs in patients with established atrial and/or left atrial appendage thrombosis, discussing potential mechanisms favouring the use of a NOAC-based strategy in this special setting.


Assuntos
Antitrombinas/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/administração & dosagem , Acidente Vascular Cerebral/prevenção & controle , Tromboembolia/prevenção & controle , Trombose/tratamento farmacológico , Administração Oral , Antitrombinas/efeitos adversos , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Medicina Baseada em Evidências , Inibidores do Fator Xa/efeitos adversos , Hemorragia/induzido quimicamente , Humanos , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/fisiopatologia , Tromboembolia/epidemiologia , Tromboembolia/fisiopatologia , Trombose/epidemiologia , Trombose/fisiopatologia , Resultado do Tratamento
15.
J Thromb Thrombolysis ; 50(4): 799-808, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32696172

RESUMO

A common and potent consideration has recently entered the landscape of the novel coronavirus disease of 2019 (COVID-19): venous thromboembolism (VTE). COVID-19 has been associated to a distinctive related coagulopathy that shows unique characteristics. The research community has risen to the challenges posed by this « evolving COVID-19 coagulopathy ¼ and has made unprecedented efforts to promptly address its distinct characteristics. In such difficult time, both national and international societies of thrombosis and hemostasis released prompt and timely responses to guide recognition and management of COVID-19-related coagulopathy. However, latest guidelines released by the international Society on Thrombosis and Haemostasis (ISTH) on May 27, 2020, followed the American College of Chest Physicians (CHEST) on June 2, 2020 showed some discrepancies regarding thromboprophylaxis use. In this forum article, we would like to offer an updated focus on thromboprophylaxis with current incidence of VTE in ICU and non-ICU patients according to recent published studies; highlight the main differences regarding ISTH and CHEST guidelines; summarize and describe which are the key ongoing RCTs testing different anticoagulation strategies in patients with COVID-19; and finally set a proposal for COVID-19 coagulopathy specific risk factors and dedicated trials.


Assuntos
Anticoagulantes/administração & dosagem , Coagulação Sanguínea/efeitos dos fármacos , Infecções por Coronavirus/terapia , Fibrinolíticos/administração & dosagem , Pneumonia Viral/terapia , Tromboembolia/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Betacoronavirus/patogenicidade , Infecções por Coronavirus/sangue , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/virologia , Feminino , Fibrinolíticos/efeitos adversos , Interações Hospedeiro-Patógeno , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/sangue , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , Fatores de Risco , Tromboembolia/sangue , Tromboembolia/epidemiologia , Tromboembolia/virologia , Resultado do Tratamento
16.
Aliment Pharmacol Ther ; 52(4): 646-654, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32657466

RESUMO

BACKGROUND: Gastrointestinal bleeding (GIB) frequently occurs following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) with the prescription of P2Y12 inhibiting antiplatelet agents. Compared with clopidogrel, the newer P2Y12 inhibitors lower major adverse cardiac events with similar or possibly higher major bleeding events. The comparative GIB rates of these medications remain poorly understood. AIM: To compare GIB rates associated with clopidogrel, prasugrel and ticagrelor using national medical and pharmacy claims data from privately insured and Medicare Advantage enrollees . METHODS: Propensity score and inverse probability treatment weighting were used to balance baseline characteristics among treatment groups. The 1-year GIB risk was calculated using weighted Cox proportional hazard models and expressed as hazard ratios (HR) with 95% confidence intervals (CI) and number needed to harm (NNH). RESULTS: We identified 37 019 patients with ACS (non-ST elevation ACS [NSTE-ACS] and ST-elevation myocardial infarction [STEMI]) within 14 days of a PCI (mean age 63 years and 70% male). Clopidogrel prescription was most common (69%) with prasugrel (16%) and ticagrelor (14%) prescribed less frequently. When compared with clopidogrel, ticagrelor was associated with a 34% risk reduction (HR 0.66; 95% CI: 0.54-0.81) in GIB overall and with NSTE-ACS, and a 37% GIB risk reduction (HR 0.63; 95% CI: 0.42-0.93) in STEMI patients. When compared with clopidogrel, prasugrel was associated with a 21% risk reduction (HR 0.79; 95% CI: 0.64-0.97) overall, a 36% GIB risk reduction (HR 0.64; 95% CI: 0.49-0.85) in STEMI patients but no reduction of GIB risk in NSTE-ACS patients. CONCLUSIONS: In the first year following PCI, ticagrelor or prasugrel are associated with fewer GIB events than clopidogrel.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/cirurgia , Clopidogrel/efeitos adversos , Hemorragia Gastrointestinal/induzido quimicamente , Intervenção Coronária Percutânea , Cloridrato de Prasugrel/efeitos adversos , Ticagrelor/efeitos adversos , Síndrome Coronariana Aguda/epidemiologia , Idoso , Clopidogrel/uso terapêutico , Estudos de Coortes , Feminino , Hemorragia Gastrointestinal/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/efeitos adversos , Complicações Pós-Operatórias/induzido quimicamente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Cloridrato de Prasugrel/uso terapêutico , Estudos Retrospectivos , Tromboembolia/epidemiologia , Tromboembolia/prevenção & controle , Ticagrelor/uso terapêutico , Resultado do Tratamento , Estados Unidos/epidemiologia
17.
Reprod Biomed Online ; 41(3): 361-364, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32660814

RESUMO

The COVID-19 pandemic has significantly increased mortality in many countries, with the number of infected cases increasing exponentially worldwide. One of the main determining factors of the poor prognosis in these patients is the development of coagulopathy. Moreover, it is well known that assisted reproductive technology procedures confer a risk of thromboembolic complications. This commentary analyses specific aspects coexisting between the thrombotic risk described during virus infection and that reported in the context of assisted reproduction treatments. Based on known pathophysiological aspects of virus infection and of ovarian stimulation, there are common elements that deserve to be taken into account. In the present context, any risk of hyperstimulation should be avoided. Gonadotrophin-releasing hormone agonist triggering should be mandatory in high-responder patients and/or those with COVID-19 infection. In both cases, the cycle should be segmented. A proposal is made for the use of prophylactic low molecular weight heparin not only in those cases in which oocyte retrieval has been performed, but also in those in which cancellation has been decided. In addition, endometrial preparation for frozen-thawed embryo transfers should use the transdermal route in order to minimize the higher thrombotic risk associated with the oral route.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Técnicas de Reprodução Assistida/efeitos adversos , Tromboembolia/epidemiologia , Tromboembolia/virologia , Transferência Embrionária/métodos , Feminino , Heparina de Baixo Peso Molecular/administração & dosagem , Humanos , Recuperação de Oócitos , Síndrome de Hiperestimulação Ovariana/complicações , Síndrome de Hiperestimulação Ovariana/prevenção & controle , Síndrome de Hiperestimulação Ovariana/virologia , Indução da Ovulação/efeitos adversos , Pandemias , Gravidez , Fatores de Risco , Tromboembolia/prevenção & controle
18.
Am J Cardiol ; 129: 71-78, 2020 08 15.
Artigo em Inglês | MEDLINE | ID: mdl-32605717

RESUMO

Controversy persists regarding the advisability of anticoagulation for the early period after biological surgical aortic valve replacement (AVR). We aim to examine the impact of various antithrombotic regimens on outcomes in a large cohort of biological AVR patients. Records of 1,111 consecutive adult patients who underwent surgical biological AVR at our institution between 2013 and 2017 were reviewed. Outcomes included stroke, bleeding, and death at 3 and 12 months. Treatment regimens included (1) no therapy, (2) anticoagulants (warfarin or Factor Xa inhibitors), (2) antiplateles (various), and (4) anticoagulants + antiplatelets. Kaplan-Meier analysis was used to track outcomes, and Cox-proportional hazards regression models were conducted to analyze effects of different therapies on adverse events. At 3 months, thromboembolic events were low and not significantly different between the no therapy group (2.2%) and anticoagulation (2.8%) or anticoagulation + antiplatelet (3.6%) or all groups (3.7%). The antiplatelet group was just significantly lower, at 2.2%. However, this was driven by non-stroke cardiovascular events in patients with coronary artery disease. The incidence of death at 3 months was low and not significantly different between all groups. At 12 months, there were no thromboembolic benefits between groups, but bleeding events were significantly higher in the anticoagulation group (no therapy (1.4%), anticoagulation (8.4%), antiplatelet (4.5%), anticoagulation + antiplatelet (7.9%)). In conclusion, none of the antithrombotic regimens showed benefits in stroke or survival at 3 or 12 months after biological AVR. Anticoagulation increased bleeding events. Routine anticoagulation after biological AVR appears to be unnecessary and potentially harmful.


Assuntos
Anticoagulantes/uso terapêutico , Estenose da Valva Aórtica/cirurgia , Bioprótese , Próteses Valvulares Cardíacas , Hemorragia/epidemiologia , Inibidores da Agregação de Plaquetas/uso terapêutico , Acidente Vascular Cerebral/epidemiologia , Tromboembolia/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/anormalidades , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/complicações , Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/complicações , Aspirina/uso terapêutico , Fibrilação Atrial/complicações , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/tratamento farmacológico , Inibidores do Fator Xa/uso terapêutico , Feminino , Doenças das Valvas Cardíacas/complicações , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca , Hemorragia/induzido quimicamente , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Mortalidade , Cuidados Pós-Operatórios , Modelos de Riscos Proporcionais , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Varfarina/uso terapêutico , Adulto Jovem
19.
J Cardiovasc Pharmacol Ther ; 25(6): 564-569, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32602356

RESUMO

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is frequently present in patients with mitral regurgitation (MR). Currently, there is a lack of real-world evidence specifically addressing the clinical performance of direct oral anticoagulants (DOACs) in patients with AF and concomitant MR. Therefore, the aim of the present study was to assess the efficacy and safety profile of DOACs therapy in patients with AF and MR. METHODS: Data for this study were sourced from the Atrial Fibrillation Research Database in the Department of Cardiology at Monaldi Hospital. The database was queried for AF patients with MR who were prescribed DOACs therapy. The primary safety outcome was defined as the annual incidence rate of major bleeding events and the primary effectiveness outcome as the annual incidence rate of all events classified as ischemic stroke, transient ischemic attacks, and systemic embolisms. RESULTS: Consecutive AF patients with concomitant mild to severe MR who received DOACs therapy (n = 259) were included. Patients were dichotomized in 2 groups according to MR severity: a mild-to-moderate group (MR 1-2+; n = 151) and a moderate-to-severe group (MR 3-4+; n = 108). The incidence rate of major bleedings was significantly higher in MR 3-4+ group (3.92%) compared with the MR 1-2+ group (1.18%; hazard ratio [HR]: 3.2; 95% CI: 1.4-7.3; P = .0059). The incidence rate of thromboembolic events between MR 3-4+ group (0.66%) and MR 1-2+ group (0.62%) was not significantly different (HR: 0.75; P = .823). CONCLUSIONS: In the present study, there was no difference in the efficacy profile of DOACs between AF patients with mild-to-moderate and moderate-to-severe MR. Considering the increased bleeding risk, a close and careful follow-up should be warranted for patients with moderate-to-severe MR.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Inibidores do Fator Xa/administração & dosagem , Insuficiência da Valva Mitral/tratamento farmacológico , Tromboembolia/prevenção & controle , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Bases de Dados Factuais , Inibidores do Fator Xa/efeitos adversos , Feminino , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Incidência , Ataque Isquêmico Transitório/epidemiologia , Ataque Isquêmico Transitório/prevenção & controle , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/epidemiologia , Insuficiência da Valva Mitral/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Tromboembolia/diagnóstico , Tromboembolia/epidemiologia , Fatores de Tempo , Resultado do Tratamento
20.
Cardiovasc Drugs Ther ; 34(5): 689-696, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32710129

RESUMO

PURPOSE: To date, clinical data on real-world treatment practices in Japanese patients with atrial fibrillation (AF) after bioprosthetic valve (BPV) replacement are needed. We conducted a large-scale, prospective, multicenter study to understand the actual usage of antithrombotic therapy and the incidence of thromboembolic and bleeding events in these patients, and to eliminate the clinical data gap between Japan and Western countries. METHODS: This was an observational study, in patients who had undergone BPV replacement and had a confirmed diagnosis of AF, with no mandated interventions. We report the baseline demographic and clinical data for the 899 evaluable patients at the end of the enrollment period. RESULTS: Overall, 45.7% of patients were male; the mean age was 80.3 years; AF was paroxysmal, persistent, or permanent in 36.9%, 34.6%, and 28.5% of patients, respectively. Mean risk scores for stroke and bleeding were 2.5 (CHADS2), 4.1 (CHA2DS2-VASc), and 2.5 (HAS-BLED). Many patients (76.2%) had comorbid hypertension and 54.8% had heart failure. Most BPVs (65.5%) were positioned in the aortic valve. Warfarin-based therapy, direct oral anticoagulant (DOAC)-based therapy, and antiplatelet therapy (without warfarin and DOAC) were administered to 55.0%, 29.3%, and 9.7% of patients, respectively. CONCLUSION: Patients enrolled into this study are typical of the wider Japanese AF/BPV population in terms of age and clinical history. Future data accruing from the observational period will contribute to future treatment recommendations and guide therapeutic decisions in patients with BPV and AF. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: UMIN000034485.


Assuntos
Fibrilação Atrial/tratamento farmacológico , Bioprótese , Fibrinolíticos/uso terapêutico , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/instrumentação , Próteses Valvulares Cardíacas , Tromboembolia/prevenção & controle , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Feminino , Fibrinolíticos/efeitos adversos , Doenças das Valvas Cardíacas/diagnóstico , Doenças das Valvas Cardíacas/epidemiologia , Implante de Prótese de Valva Cardíaca/efeitos adversos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Incidência , Japão/epidemiologia , Masculino , Estudos Prospectivos , Desenho de Prótese , Sistema de Registros , Projetos de Pesquisa , Fatores de Risco , Tromboembolia/diagnóstico , Tromboembolia/epidemiologia , Fatores de Tempo , Resultado do Tratamento
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