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1.
N Engl J Med ; 382(2): 120-129, 2020 01 09.
Artigo em Inglês | MEDLINE | ID: mdl-31733180

RESUMO

BACKGROUND: Whether the direct factor Xa inhibitor rivaroxaban can prevent thromboembolic events after transcatheter aortic-valve replacement (TAVR) is unclear. METHODS: We randomly assigned 1644 patients without an established indication for oral anticoagulation after successful TAVR to receive rivaroxaban at a dose of 10 mg daily (with aspirin at a dose of 75 to 100 mg daily for the first 3 months) (rivaroxaban group) or aspirin at a dose of 75 to 100 mg daily (with clopidogrel at a dose of 75 mg daily for the first 3 months) (antiplatelet group). The primary efficacy outcome was the composite of death or thromboembolic events. The primary safety outcome was major, disabling, or life-threatening bleeding. The trial was terminated prematurely by the data and safety monitoring board because of safety concerns. RESULTS: After a median of 17 months, death or a first thromboembolic event (intention-to-treat analysis) had occurred in 105 patients in the rivaroxaban group and in 78 patients in the antiplatelet group (incidence rates, 9.8 and 7.2 per 100 person-years, respectively; hazard ratio with rivaroxaban, 1.35; 95% confidence interval [CI], 1.01 to 1.81; P = 0.04). Major, disabling, or life-threatening bleeding (intention-to-treat analysis) had occurred in 46 and 31 patients, respectively (4.3 and 2.8 per 100 person-years; hazard ratio, 1.50; 95% CI, 0.95 to 2.37; P = 0.08). A total of 64 deaths occurred in the rivaroxaban group and 38 in the antiplatelet group (5.8 and 3.4 per 100 person-years, respectively; hazard ratio, 1.69; 95% CI, 1.13 to 2.53). CONCLUSIONS: In patients without an established indication for oral anticoagulation after successful TAVR, a treatment strategy including rivaroxaban at a dose of 10 mg daily was associated with a higher risk of death or thromboembolic complications and a higher risk of bleeding than an antiplatelet-based strategy. (Funded by Bayer and Janssen Pharmaceuticals; GALILEO ClinicalTrials.gov number, NCT02556203.).


Assuntos
Aspirina/uso terapêutico , Clopidogrel/uso terapêutico , Inibidores do Fator Xa/uso terapêutico , Inibidores da Agregação de Plaquetas/uso terapêutico , Rivaroxabana/uso terapêutico , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Aspirina/efeitos adversos , Fibrilação Atrial/tratamento farmacológico , Doenças Cardiovasculares/mortalidade , Clopidogrel/efeitos adversos , Quimioterapia Combinada , Inibidores do Fator Xa/efeitos adversos , Feminino , Próteses Valvulares Cardíacas , Hemorragia/induzido quimicamente , Humanos , Análise de Intenção de Tratamento , Estimativa de Kaplan-Meier , Masculino , Inibidores da Agregação de Plaquetas/efeitos adversos , Rivaroxabana/efeitos adversos , Tromboembolia/mortalidade
2.
N Engl J Med ; 382(2): 130-139, 2020 01 09.
Artigo em Inglês | MEDLINE | ID: mdl-31733182

RESUMO

BACKGROUND: Subclinical leaflet thickening and reduced leaflet motion of bioprosthetic aortic valves have been documented by four-dimensional computed tomography (CT). Whether anticoagulation can reduce these phenomena after transcatheter aortic-valve replacement (TAVR) is not known. METHODS: In a substudy of a large randomized trial, we randomly assigned patients who had undergone successful TAVR and who did not have an indication for long-term anticoagulation to a rivaroxaban-based antithrombotic strategy (rivaroxaban [10 mg] plus aspirin [75 to 100 mg] once daily) or an antiplatelet-based strategy (clopidogrel [75 mg] plus aspirin [75 to 100 mg] once daily). Patients underwent evaluation by four-dimensional CT at a mean (±SD) of 90±15 days after randomization. The primary end point was the percentage of patients with at least one prosthetic valve leaflet with grade 3 or higher motion reduction (i.e., involving >50% of the leaflet). Leaflet thickening was also assessed. RESULTS: A total of 231 patients were enrolled. At least one prosthetic valve leaflet with grade 3 or higher motion reduction was found in 2 of 97 patients (2.1%) who had scans that could be evaluated in the rivaroxaban group, as compared with 11 of 101 (10.9%) in the antiplatelet group (difference, -8.8 percentage points; 95% confidence interval [CI], -16.5 to -1.9; P = 0.01). Thickening of at least one leaflet was observed in 12 of 97 patients (12.4%) in the rivaroxaban group and in 33 of 102 (32.4%) in the antiplatelet group (difference, -20.0 percentage points; 95% CI, -30.9 to -8.5). In the main trial, the risk of death or thromboembolic events and the risk of life-threatening, disabling, or major bleeding were higher with rivaroxaban (hazard ratios of 1.35 and 1.50, respectively). CONCLUSIONS: In a substudy of a trial involving patients without an indication for long-term anticoagulation who had undergone successful TAVR, a rivaroxaban-based antithrombotic strategy was more effective than an antiplatelet-based strategy in preventing subclinical leaflet-motion abnormalities. However, in the main trial, the rivaroxaban-based strategy was associated with a higher risk of death or thromboembolic complications and a higher risk of bleeding than the antiplatelet-based strategy. (Funded by Bayer; GALILEO-4D ClinicalTrials.gov number, NCT02833948.).


Assuntos
Valva Aórtica/fisiopatologia , Aspirina/farmacologia , Clopidogrel/farmacologia , Inibidores do Fator Xa/farmacologia , Próteses Valvulares Cardíacas , Inibidores da Agregação de Plaquetas/farmacologia , Rivaroxabana/farmacologia , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/efeitos dos fármacos , Valva Aórtica/patologia , Aspirina/efeitos adversos , Aspirina/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Doenças Cardiovasculares/mortalidade , Clopidogrel/efeitos adversos , Clopidogrel/uso terapêutico , Quimioterapia Combinada , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/uso terapêutico , Feminino , Tomografia Computadorizada Quadridimensional , Hemorragia/induzido quimicamente , Humanos , Análise de Intenção de Tratamento , Masculino , Inibidores da Agregação de Plaquetas/efeitos adversos , Inibidores da Agregação de Plaquetas/uso terapêutico , Rivaroxabana/efeitos adversos , Rivaroxabana/uso terapêutico , Tromboembolia/etiologia , Tromboembolia/mortalidade
3.
Lakartidningen ; 1162019 Sep 27.
Artigo em Sueco | MEDLINE | ID: mdl-31573669

RESUMO

MM-ARG, the Swedish maternal maternity mortality group within SFOG (Swedish Society of Obstetrics and Gynecology) has, since 2008, surveyed and analysed maternal deaths in Sweden with the aim to find and give feedback on lessons learned to the medical professions.  MM-ARG consists of obstetricians, midwives and anesthetists and the strength of the working model is that the profession itself takes responsibility for the scrutiny.  A summary of 67 known maternal deaths from 2007‒2017 is presented. Direct causes of death are dominated by hypertensive disease/preeclampsia, followed by thromboembolic disease, sepsis and obstetric bleeding. Indirect death, where a known or unknown underlying disease is exacerbated by pregnancy, is dominated by cardiovascular disease. This review shows that the diagnostics and clinical management could be improved. Besides obstetrics/gynecology, maternal mortality affects other specialties and thus holds important lessons to many.


Assuntos
Mortalidade Materna , Adolescente , Adulto , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/prevenção & controle , Feminino , Humanos , Morte Materna , Transtornos Mentais/mortalidade , Transtornos Mentais/prevenção & controle , Hemorragia Pós-Parto/mortalidade , Hemorragia Pós-Parto/prevenção & controle , Pré-Eclâmpsia/mortalidade , Pré-Eclâmpsia/prevenção & controle , Gravidez , Complicações na Gravidez/prevenção & controle , Complicações Infecciosas na Gravidez/mortalidade , Complicações Infecciosas na Gravidez/prevenção & controle , Complicações Neoplásicas na Gravidez/mortalidade , Complicações Neoplásicas na Gravidez/prevenção & controle , Qualidade da Assistência à Saúde , Sociedades Médicas , Suicídio/prevenção & controle , Suécia/epidemiologia , Tromboembolia/mortalidade , Tromboembolia/prevenção & controle
4.
Med. intensiva (Madr., Ed. impr.) ; 43(5): 281-289, jun.-jul. 2019. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-183240

RESUMO

Objetivos: Analizar las complicaciones hematológicas y las necesidades transfusionales en niños tratados con oxigenación por membrana extracorpórea (ECMO). Diseño: Estudio retrospectivo. Ámbito: Unidad de cuidados intensivos pediátricos. Pacientes: Niños menores de 18 años tratados con ECMO entre septiembre de 2006 y noviembre de 2015. Intervenciones: Ninguna. Variables de interés: Características clínicas, de la ECMO, anticoagulación, parámetros hematológicos y de coagulación, transfusiones y evolución clínica. Resultados: Se estudiaron 100 pacientes con una mediana de edad de 11 meses. Presentaron sangrado 76; el mediastino fue la localización más frecuente; 39 precisaron revisión quirúrgica. En los primeros 3 días de ECMO, el 97% de los pacientes precisaron transfusión de hematíes (34,4 ml/kg al día), el 94% plaquetas (21,1ml/kg al día) y el 90% plasma (26,6ml/kg al día). Los pacientes posquirúrgicos, con imposibilidad de salida de la circulación extracorpórea, los que presentaron sangrado al inicio de la ECMO, los que precisaron revisión quirúrgica y los que tuvieron canulación transtorácica requirieron mayor volumen de transfusiones. Se produjeron tromboembolias en 14 pacientes y hemólisis en 33. La mortalidad de los niños que presentaron sangrado al inicio de ECMO (57,6%) fue significativamente mayor que la del resto (37,5%) (p = 0,048). Conclusiones: Los niños tratados con ECMO presentan una elevada incidencia de sangrado y precisan un gran volumen de transfusiones. El postoperatorio de cirugía, el sangrado al inicio de la ECMO, la necesidad de revisión quirúrgica, la imposibilidad de salida de la circulación extracorpórea y la canulación transtorácica se asocian a un mayor volumen de transfusiones. Los niños que sangraron al inicio de la ECMO presentaron mayor mortalidad


Objectives: To analyze the hematological complications and need for transfusions in children receiving extracorporeal life support (ECLS). Design: A retrospective study was carried out. Setting: A pediatric intensive care unit. Patients: Children under 18 years of age subjected to ECLS between September 2006 and November 2015. Interventions: None. Variables of interest: Patient and ECLS characteristics, anticoagulation, hematological and coagulation parameters, transfusions and clinical course. Results: A total of 100 patients (94 with heart disease) with a median age of 11 months were studied. Seventy-six patients presented bleeding. The most frequent bleeding point was the mediastinum and 39 patients required revision surgery. In the first 3days, 97% of the patients required blood transfusion (34.4ml/kg per day), 94% platelets (21.1ml/kg per day) and 90% plasma (26.6ml/kg per day). Patients who were in the postoperative period, those who were bleeding at the start of ECLS, those requiring revision surgery, those who could not suspend extracorporeal circulation, and those subjected to transthoracic cannulation required a greater volume of transfusions than the rest of the patients. Thromboembolism occurred in 14 patients and hemolysis in 33 patients. Mortality among the children who were bleeding at the start of ECLS (57.6%) was significantly higher than in the rest of the patients (37.5%) (P=.048). Conclusions: Children subjected to ECLS present high blood product needs. The main factors related to transfusions were the postoperative period, bleeding at the start of ECLS, revision surgery, transthoracic cannulation, and the impossibility of suspending extracorporeal circulation. Children with bleeding suffered greater mortality than the rest of the patients


Assuntos
Humanos , Masculino , Feminino , Lactente , Pré-Escolar , Criança , Adolescente , Oxigenação por Membrana Extracorpórea/métodos , Transfusão de Sangue/tendências , Unidades de Terapia Intensiva Pediátrica , Doenças Hematológicas/sangue , Estudos Retrospectivos , Substitutos Sanguíneos/uso terapêutico , Tromboembolia/mortalidade , Mortalidade Infantil , Hemorragia/complicações , Anticoagulantes , Modelos Logísticos , Hemólise , Doenças Hematológicas/complicações , Doenças Hematológicas/etiologia
5.
Scand Cardiovasc J ; 53(5): 247-254, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31251080

RESUMO

Objectives. To examine the long-term risk of thromboembolism and bleeding in patients with atrial fibrillation comparing patients with and without recent breast cancer in subgroups with or without anticoagulation therapy, respectively. Design. Using nationwide registries, patients with breast cancer from 1998-2015 and subsequent atrial fibrillation within 3 years were stratified on anticoagulation and matched 1:3 on age, sex and comorbidities with atrial fibrillation patients without breast cancer. Risks of thromboembolism and bleeding were estimated by Aalen-Johansen and multivariable cox regression models. Results. Atrial fibrillation patients with and without anticoagulation were matched, respectively (201 and 525 with breast cancer matched with 603 and 1,575 without breast cancer). In patients with CHA2DS2-VASc-score >1 and anticoagulation the three years risks of thromboembolism were 4.2% (95% confidence interval (CI) 1.1-7.3) and 3.2% (CI 1.5-4.9) in patients with and without breast cancer. The risks of bleeding were 5.3% (CI 1.7-8.9) and 5.1% (CI 3.0-7.1), respectively. Breast cancer was associated with a similar risk of thromboembolism in patients with and without anticoagulation, respectively (Hazard ratio (HR) 1.10, CI 0.63-1.92 and HR 1.11, CI 0.82-1.50) and a similar risk of bleeding in patients with and without anticoagulation, respectively (HR 1.01, CI 0.56-1.84 and HR 0.85, CI 0.57-1.27) compared with the matched controls. Conclusions. Breast cancer was not associated with altered risk of thromboembolism or bleeding in patients with atrial fibrillation irrespective of treatment with anticoagulation. Our analyses suggest that atrial fibrillation diagnosed in patients with breast cancer should be considered as primary atrial fibrillation.


Assuntos
Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Neoplasias da Mama/epidemiologia , Tromboembolia/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Fibrilação Atrial/sangue , Fibrilação Atrial/mortalidade , Neoplasias da Mama/sangue , Neoplasias da Mama/mortalidade , Dinamarca/epidemiologia , Feminino , Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Humanos , Incidência , Pessoa de Meia-Idade , Sistema de Registros , Medição de Risco , Fatores de Risco , Tromboembolia/sangue , Tromboembolia/mortalidade , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
6.
J Cancer Res Ther ; 15(2): 305-311, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30964102

RESUMO

Background: Hepatocellular carcinoma (HCC) with tumor thrombus extending to the inferior vena cava (IVC) and right atrium (RA) is rare, which is generally associated with serial syndromes and poor prognosis. The results of earlier observations revealed that the median survival was 1-5 months after diagnosis for untreated patients. The prognosis was poor with surgery, radiotherapy, transarterial chemoembolization (TACE), and chemotherapy. Methods: A total of 1850 patients received TACE for advanced HCC at our institution from October 2011 to September 2016. Among them, 18 cases presented tumor thrombus extended from hepatic vein to IVC and RA. TACE was performed to deal with the tumor thrombus inside the RA, and angiography was performed for characterizing. The successful rate, survival, safety, and clinical adverse events were retrospectively studied. Results: A total of 56 interventional procedures were conducted for the 18 cases of tumor thrombus extending to IVC and RA. TACE were successfully performed in all patients without significant complications. One case died of pneumonia, and no severe adverse effect was observed in the other 17 cases. The 1- and 3-year overall survival rates were 50% and 16.7%, respectively. The average survival from diagnosis of right atrial tumor thrombus (RATT) was 15.2 months. The blood supply was rich for all RATT. There were seven cases with single-feeding artery and 11 cases with two or three feeding arteries that originated from intra- or extra-hepatic arteries. The extrahepatic artery played a critical role in the blood supply of RATT, including right inferior phrenic artery (8/18), left inferior phrenic artery (1/18), and the left gastric artery (2/18). Conclusion: For HCC with tumor thrombus in the IVC and RA, TACE could safely improve the prognosis of these patients. Searching for multiple feeding arteries are essential for ensuring efficacy. In addition, careful examination and appropriate embolization technique are essential for safety and efficacy. Lipiodol was a safe and ideal agent for the embolization in RATT.


Assuntos
Carcinoma Hepatocelular/complicações , Carcinoma Hepatocelular/terapia , Quimioembolização Terapêutica , Átrios do Coração/patologia , Neoplasias Hepáticas/complicações , Neoplasias Hepáticas/terapia , Tromboembolia/diagnóstico , Tromboembolia/etiologia , Adulto , Idoso , Angiografia/métodos , Carcinoma Hepatocelular/diagnóstico , Carcinoma Hepatocelular/mortalidade , Quimioembolização Terapêutica/métodos , Feminino , Humanos , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/mortalidade , Masculino , Pessoa de Meia-Idade , Prognóstico , Tromboembolia/mortalidade , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento
7.
Eur J Clin Invest ; 49(4): e13078, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30725490

RESUMO

BACKGROUND: Previous studies revealed that patients with Takotsubo syndrome (TTS) have a higher mortality rate than the general population and a comparable mortality to acute coronary syndrome (ACS). Repolarisation abnormalities, namely T-wave amplitude, may provide incremental prognostic information, in addition to traditional risk factors in ACS. This study was performed to determine the short- and long-term prognostic impact of inverted T-waves in TTS patients, as compared to ACS patients. METHODS AND RESULTS: Our institutional database constituted a collective of 138 patients diagnosed with TTS from 2003 to 2017, as well as 532 patients suffering from ACS. Patients with TTS or with ACS (n = 138 per group) were matched for age and sex and assessed retrospectively and prospectively and divided into two groups, TTS with inverted T-waves (n = 123) and ACS with inverted T-waves (n = 80). In-hospital complications such as respiratory failure with the need of respiratory support (60.2% vs 6.3%; P < 0.01), thromboembolic events (13.8% vs 2.5%; P < 0.01) and cardiogenic shock (18.9% vs 8.8%; P = 0.05) were significantly more presented in TTS as compared to ACS patients. Among cardiovascular risk factors diabetes mellitus (23.6% vs 45.0%; P < 0.01) and arterial hypertension (57.7% vs 78.8%; P < 0.01) were more presented in ACS patients as compared to TTS patients. Short-term mortality was similar, however the long-term mortality of 5 years was significantly higher in the TTS group (25.2% vs 7.5%; P < 0.01). In univariate analysis were male gender, EF < 35%, GFR < 60 mL/min, cardiogenic shock, inotropic drugs and history of cancer predictors of 5-year mortality. The multivariate analysis showed only male gender (HR 2.7, 95% CI 1.1-6.5; P = 0.02), GFR < 60 mL/min (HR 2.8, 95% CI 1.2-6.0; P = 0.01) and history of cancer (HR 3.6, 95% CI 1.4-9.3; P < 0.01) as independent predictors of 5-year mortality. CONCLUSION: Rates of long-term mortality were significantly higher in TTS patients showing inverted T-waves compared with patients diagnosed with ACS with inverted T-waves. However, T-inversion was not an independent predictor of 5-year mortality in the multivariate analysis.


Assuntos
Síndrome Coronariana Aguda/mortalidade , Arritmias Cardíacas/mortalidade , Cardiomiopatia de Takotsubo/mortalidade , Síndrome Coronariana Aguda/complicações , Idoso , Arritmias Cardíacas/complicações , Eletrocardiografia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Prognóstico , Estudos Retrospectivos , Cardiomiopatia de Takotsubo/complicações , Tromboembolia/etiologia , Tromboembolia/mortalidade
8.
Ann Thorac Surg ; 107(4): 1181-1186, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30365959

RESUMO

BACKGROUND: Thromboembolic events (TEs) are common adverse events with continuous-flow left ventricular assist devices (LVADs). Left atrial appendage occlusion (LAAO) is commonly performed at the time of a cardiac operation. The effect of LAAO on TEs in LVAD patients remains unknown. METHODS: All patients receiving a first LVAD implantation between January 2013 and January 2014 were reviewed. TEs included device thrombosis and ischemic cerebrovascular accidents. The incidence of TEs with respect to LAAO was evaluated using Kaplan-Meier and Cox proportional hazards analyses. RESULTS: The analysis included 102 patients, 36 of whom received LAAO and 66 did not. LAAO patients were an average age of 60 years, and 69.4% were men. Non-LAAO patients were an average age of 59.3 years, and 71.2% were men. There were no significant differences in characteristics other than history of coronary artery bypass grafting (8.3% of LAAO vs 44% of non-LAAO, p = 0.0005). Preoperative atrial fibrillation was present in 19 LAAO patients (52.7%) and in 36 non-LAAO patients (54.5%; p = 1.0). Patients were monitored for a median of 306 days. TEs occurred in 3 LAAO patients (1 device thrombosis and 2 cerebrovascular accidents) compared with 15 non-LAAO patients (5 device thromboses and 11 cerebrovascular accidents, p = 0.049). In a Cox hazards analysis including age, sex, hypertension, and atrial fibrillation, LAAO demonstrated a decreased risk of TE (hazard ratio, 0.27; 95% confidence interval, 0.08 to 0.95; p = 0.04). CONCLUSIONS: In patients undergoing LVAD implantation, LAAO is associated with reduced TEs, and this effect may be independent of atrial fibrillation. A prospective randomized study to examine the efficacy LAAO in prevention of TE is needed to confirm these findings.


Assuntos
Apêndice Atrial/cirurgia , Causas de Morte , Coração Auxiliar/efeitos adversos , Tromboembolia/prevenção & controle , Centros Médicos Acadêmicos , Fatores Etários , Idoso , Apêndice Atrial/patologia , Fibrilação Atrial/cirurgia , Estudos de Coortes , Falha de Equipamento , Feminino , Seguimentos , Humanos , Illinois , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/prevenção & controle , Modelos de Riscos Proporcionais , Valores de Referência , Estudos Retrospectivos , Medição de Risco , Fatores Sexuais , Análise de Sobrevida , Tromboembolia/etiologia , Tromboembolia/mortalidade , Resultado do Tratamento
9.
Vasc Med ; 24(1): 41-49, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30105938

RESUMO

Lower extremity arterial thromboembolism is associated with significant morbidity and mortality. We sought to establish temporal trends in the incidence, management and outcomes of lower extremity arterial thromboembolism within the Veterans Affairs Healthcare System (VAHS). We identified patients admitted to VAHS between 2003 and 2014 with a primary diagnosis of lower extremity arterial thromboembolism. Medical and procedural management were ascertained from pharmaceutical and administrative data. Subsequent rates of major adverse limb events (MALE), major adverse cardiovascular events (MACE), and mortality were calculated using Cox proportional hazards models. From 2003 to 2014, there were 10,636 patients hospitalized for lower extremity thromboembolism across 140 facilities, of which 8474 patients had adequate comorbid information for analysis. Age-adjusted incidence decreased from 7.98 per 100,000 patients (95% CI: 7.28-8.75) in 2003 to 3.54 (95% CI: 3.14-3.99) in 2014. On average, the likelihood of receiving anti-platelet or anti-thrombotic therapy increased 2.3% (95% CI: 1.2-3.4%) per year during this time period and the likelihood of undergoing endovascular revascularization increased 4.0% (95% CI: 2.7-5.4%) per year. Clinical outcomes remained constant over time, with similar rates of MALE, MACE and mortality at 1 year after adjustment. In conclusion, the incidence of lower extremity arterial thromboembolism is decreasing, with increasing utilization of anti-thrombotic therapies and endovascular revascularization among those with this condition. Despite this evolution in management, patients with lower extremity thromboembolism continue to experience high rates of amputation and death within a year of the index event.


Assuntos
Arteriopatias Oclusivas/terapia , Procedimentos Endovasculares/tendências , Fibrinolíticos/uso terapêutico , Hospitalização/tendências , Extremidade Inferior/irrigação sanguínea , Inibidores da Agregação de Plaquetas/uso terapêutico , Tromboembolia/terapia , Saúde dos Veteranos/tendências , Idoso , Amputação/tendências , Arteriopatias Oclusivas/diagnóstico , Arteriopatias Oclusivas/mortalidade , Feminino , Humanos , Incidência , Salvamento de Membro/tendências , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Fatores de Risco , Tromboembolia/diagnóstico , Tromboembolia/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , United States Department of Veterans Affairs
10.
Rev. inf. cient ; 98(4): 458-468, 2019. tabs
Artigo em Espanhol | LILACS | ID: biblio-1023817

RESUMO

Introducción: la prescripción de fármacos inhibidores de la vitamina K exige el control del efecto anticoagulante. Objetivo: caracterizar a los pacientes con antecedentes de tratamiento con warfarina sódica al momento del ingreso en la unidad de terapia intensiva del Hospital General Docente Dr Agostinho Neto durante el periodo 2016- 2018. Método: se realizó estudio analítico, retrospectivo y longitudinal. Se estudiaron 54 pacientes con las características señaladas, que se agruparon en un grupo control (n=16) con anticoagulación adecuada y un grupo estudio (n=38) también con anticoagulación adecuada. Se estudiaron variables sociodemográficas, clínicas y de laboratorio. Resultados: Un total de 16 pacientes presentó nivel adecuado de anticoagulación y en, 38, nivel de anticoagulación fue inadecuado. La warfarina sódica se indicó más en pacientes con prótesis valvular cardiaca mecánica (20,0 por ciento), y en estos fue más común la anticoagulación inadecuada. Los factores más relacionados con la anticoagulación adecuada fueron la supervisión médica frecuente (p=0,0000), que no usaron fármacos que interfieran con la acción del fármaco (p=0,0000) y el cumplimiento del tratamiento (p=0,0000). En 22 pacientes se presentaron complicaciones hemorrágicas y la más común fue la hemorragia cerebral y, 16, presentaron complicaciones tromboembólicas y la más frecuente fue el embolismo cerebral. Fallecieron 3 pacientes por complicaciones hemorrágicas y 9 por complicaciones tromboembólicas. En 21 pacientes la indicación del fármaco fue inapropiada. Conclusiones: se revela la necesidad del control de la adecuada adherencia terapéutica del paciente pues el inadecuado efecto anticoagulante genera complicaciones que pueden determinar la muerte del paciente(AU)


Introduction: the prescription of vitamin K inhibitor drugs requires control of the anticoagulant effect. Objective: to characterize patients with a history of treatment with warfarin sodium at the time of admission to the intensive care unit of the General Teaching Hospital Dr Agostinho Neto during the 2016-2018 period. Method: an analytical, retrospective and longitudinal study was carried out. 54 patients with the characteristics indicated were studied, which were grouped in a control group (n=16) with adequate anticoagulation and a study group (n=38) also with adequate anticoagulation. Sociodemographic, clinical and laboratory variables were studied. Results: A total of 16 patients presented adequate level of anticoagulation and, in 38, level of anticoagulation was inadequate. Sodium warfarin was indicated more in patients with mechanical cardiac valve prostheses (20.0per cent), and inadequate anticoagulation was more common in these. The factors most related to adequate anticoagulation were frequent medical supervision (p=0.0000), who did not use drugs that interfere with the action of the drug (p=0.0000) and treatment compliance (p=0.0000). In 22 patients there were hemorrhagic complications and the most common was cerebral hemorrhage and, 16, they presented thromboembolic complications and the most frequent was cerebral embolism. Three patients died from bleeding complications and 9 from thromboembolic complications. In 21 patients the indication of the drug was inappropriate. Conclusions: the need to control the adequate therapeutic adherence of the patient is revealed because the inadequate anticoagulant effect generates complications that can determine the death of the patient(AU)


Introdução: a prescrição de medicamentos inibidores da vitamina K requer controle do efeito anticoagulante. Objetivo: caracterizar pacientes com histórico de tratamento com varfarina sódica no momento da admissão na unidade de terapia intensiva do Hospital Geral de Ensino Dr Agostinho Neto no período 2016-2018.Método: estudo analítico, retrospectivo e longitudinal. Foram estudados 54 pacientes com as características indicadas, os quais foram agrupados em um grupo controle (n=16) com anticoagulação adequada e um grupo estudo (n=38) também com anticoagulação adequada. Foram estudadas variáveis sociodemográficas, clínicas e laboratoriais. Resultados: Um total de 16pacientes apresentou nível adequado de anticoagulação e, em 38, o nível de anticoagulação foi inadequado. A varfarina sódica foi mais indicada em pacientes com próteses valvares cardíacas mecânicas (20,0 por cento), sendo a anticoagulação inadequada mais comum. Os fatores mais relacionados à anticoagulação adequada foram a supervisão médica frequente (p=0,0000), que não utilizou medicamentos que interferem na ação do medicamento (p=0,0000) e adesão ao tratamento (p=0,0000) Em 22 pacientes houve complicações hemorrágicas e a mais comum foi hemorragia cerebral; 16 apresentaram complicações tromboembólicas e a mais frequente foi embolia cerebral. Três pacientes morreram por complicações hemorrágicas e 9 por complicações tromboembólicas. Em 21 pacientes, a indicação do medicamento foi inadequada. Conclusões: a necessidade de controlar a aderência terapêutica adequada do paciente é revelada, pois o efeito anticoagulante inadequado gera complicações que podem determinar a morte do paciente(AU)


Assuntos
Humanos , Vitamina K/antagonistas & inibidores , Varfarina/administração & dosagem , Anticoagulantes/efeitos adversos , Tromboembolia/mortalidade , Hemorragia Cerebral/mortalidade , Estudos Retrospectivos , Estudos Longitudinais
11.
PLoS One ; 13(11): e0207943, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30481212

RESUMO

BACKGROUND AND AIMS: With the intention to gain support for the hypothesis that incident ischemic complications of atherosclerotic disease involve a stochastic aspect, we performed a histological, qualitative evaluation of the epidemiology of coronary atherosclerotic disease in a cohort of aortic valve donors. PATIENTS AND METHODS: Donors (n = 695, median age 54, range 11-65 years) were dichotomized into a non-cardiovascular (non-CVD) and a cardiovascular disease death (CVD) group. Consecutive 5 mm proximal left coronary artery segments were Movat stained, and the atherosclerotic burden for each segment was graded (revised AHA-classification). RESULTS: Non-CVD and CVD groups showed steep increase of atherosclerosis severity beyond the age of 40, resulting in an endemic presence of advanced atherosclerosis in men over 40 and women over 50 years. In fact, only 19% of the non-CVD and 6% of the CVD donors over 40 years were classified with a normal LCA or a so called non-progressive lesion type. Fibrous calcified plaques (FCP), the consolidated remnants of earlier ruptured lesions, dominated in both non-CVD and CVD donors. Estimates of the atherosclerosis burden (i.e. average lesion grade, proportion of FCPs, and average number of FCPs per cross-section) were all higher in the CVD group (p<1.10-16, p<0.0001, and p<0.05, respectively). CONCLUSIONS: Dominance of consolidated FCP lesions in males over 40 and females over 50 years, show that plaque ruptures in the left coronary artery are common. However, the majority of these ruptures remain asymptomatic. This implies that the atherosclerotic process is repetitive. A relative difference in disease burden between CVD and non-CVD donors supports the concept that complications of atherosclerotic disease involve a stochastic element.


Assuntos
Doença da Artéria Coronariana/patologia , Placa Aterosclerótica/parasitologia , Tromboembolia/patologia , Adolescente , Adulto , Idoso , Valva Aórtica/transplante , Criança , Estudos de Coortes , Doença da Artéria Coronariana/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Placa Aterosclerótica/mortalidade , Placa Aterosclerótica/patologia , Processos Estocásticos , Tromboembolia/mortalidade , Doadores de Tecidos , Adulto Jovem
12.
Rev Fac Cien Med Univ Nac Cordoba ; 75(2): 119-127, 2018 06 11.
Artigo em Inglês | MEDLINE | ID: mdl-30273535

RESUMO

BACKGROUND: In high-risk patients, common prophylaxis may be insufficient to prevent thromboembolic events after orthopaedic procedures. In this scenario, a retrievable vena cava filter (VCF) could be considered as an alternative, although it's use remains controversial. Therefore, we asked: (1) what is the overall mechanical complication rate associated with the use of retrievable VCFs in orthopaedic surgery?, (2) what is the association with thromboembolic disease (TED) recurrence, post-thrombotic syndrome and/or major bleeding according to different surgical characteristics?, (3) What is the overall mortality rate attributed to VCF use? METHODS: We retrospectively analyzed a cohort of 68 patients who underwent orthopaedic surgery with a previous diagnosis of TED, in whom a retrievable VCF was placed. Permanent filters were excluded. We studied the filter's mechanical complications and considered as possible outcomes death and 3 hematologic complications: TED recurrence, post-thrombotic syndrome and major bleeding. To estimate association with risk factors, we subclassified surgeries into 5 groups: 1, arthroplasty/non-arthroplasty; 2, primary/revision; 3, elective/urgent; 4, oncologic/non-oncologic; 5, preoperative/postoperative filter. RESULTS: Mechanical complications were 16% and required a filter revision. Sixty-four percent of the revised VCFs developed a mechanical failure and could not be retrieved. Overall prevalence of TED recurrence, post-thrombotic syndrome and hemorrhage was 33%, 15% and 4.5%, respectively. Spinal surgeries were a risk factor for developing TED recurrences.  Only 4% of patients died of a TED recurrence. CONCLUSIONS: Orthopaedic procedures had a high risk of mechanical and hematologic complications after using a retrievable VCF. However, mortality was low due to these complications.


Assuntos
Procedimentos Ortopédicos/efeitos adversos , Complicações Pós-Operatórias , Tromboembolia/complicações , Filtros de Veia Cava/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Remoção de Dispositivo , Feminino , Lesões do Quadril/complicações , Lesões do Quadril/mortalidade , Lesões do Quadril/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Ortopédicos/mortalidade , Complicações Pós-Operatórias/mortalidade , Falha de Prótese/efeitos adversos , Recidiva , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Tromboembolia/mortalidade , Tromboembolia/prevenção & controle , Filtros de Veia Cava/estatística & dados numéricos
13.
Clin Cardiol ; 41(11): 1480-1486, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30294784

RESUMO

INTRODUCTION: A large number of older people receive pacemakers each year but broad population-based studies that describe complications following pacemaker implantation in this population are lacking. METHODS: We conducted a retrospective cohort study using data from the Australian Government Department of Veterans' Affairs database. The cohort consisted of patients who received a pacemaker from 2005 to 2014. The outcomes were subsequent rehospitalizations for infections, procedure-related complications, thromboembolism, cardiovascular events (heart failure, myocardial infarction, and atrial fibrillation), and reoperation of pacemaker, and mortality. RESULTS: There were 10 883 pacemakers recipients, the median age was 86 years (interquartile range 83-89), 61% were males, and 74% received a dual-chamber pacemaker. Within 90 days postdischarge, rehospitalizations were occasioned by pacemaker infection in 0.5%, device-related complications in 1.5%, cerebral infarction in 0.7%, and heart failure in 6% of single-chamber pacemaker recipients. In dual-chamber pacemaker recipients rehospitalizations were occasioned by pacemaker infection in 0.4%, septicemia in 0.4%, device-related complications in 1.2%, cerebral infarction in 0.3%, and heart failure in 3%. Rehospitalizations for pacemaker adjustment occurred in 1.5% of patients. The 90-day postdischarge mortality was 5% and 3% in patients with single- and dual-chamber pacemaker, respectively. CONCLUSION: Rehospitalizations for infection, procedure-related complications, or thromboembolism occurred in 1% to 2% of patients within 90 days postdischarge, while 10% of single chamber and 7% of dual-chamber recipients experienced a rehospitalization for a cardiovascular event.


Assuntos
Arritmias Cardíacas/terapia , Estimulação Cardíaca Artificial/efeitos adversos , Estimulação Cardíaca Artificial/mortalidade , Marca-Passo Artificial , Readmissão do Paciente , Complicações Pós-Operatórias/mortalidade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/fisiopatologia , Austrália , Comorbidade , Bases de Dados Factuais , Falha de Equipamento , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Fatores de Risco , Tromboembolia/mortalidade , Tromboembolia/terapia , Fatores de Tempo , Resultado do Tratamento
14.
Thromb Haemost ; 118(11): 1875-1884, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30296815

RESUMO

Patients with cancer are at risk of developing venous and arterial thromboembolism (VTE and ATE). Elevated platelet-to-lymphocyte (PLR) and neutrophil-to-lymphocyte ratios (NLR) have been suggested as potential biomarkers for cancer-associated chronic inflammation, VTE and mortality. We investigated the association between PLR and NLR with VTE, ATE and mortality in patients with cancer. Within a prospective cohort study, we followed-up patients with newly diagnosed or progressing cancer for objectively confirmed, symptomatic VTE, ATE and death. Fine and Gray competing-risk regression was used to model the risk of VTE and ATE. Overall survival was analysed with Kaplan-Meier estimators. From 2003 to 2013, 1,469 patients with solid cancer (median age: 61 years; 47.3% female) were recruited and followed for 2 years. Overall, 128 (8.7%) patients developed VTE, 41 (2.8%) ATE and 643 (43.8%) patients died. The sub-distribution hazard ratios (SHRs) for VTE per doubling of PLR and NLR were 1.0 (95% confidence interval [CI]: 0.8-1.3, p = 0.899) and 1.2 (1.0-1.4, p = 0.059), respectively. For ATE, the SHR per doubling of PLR and NLR were 1.0 (0.7-1.5, p = 0.940) and 1.2 (0.9-1.6, p = 0.191), respectively. A higher PLR (hazard ratio [HR] per doubling = 1.5, 1.4-1.7, p < 0.001) and a higher NLR (HR per doubling = 1.5, 1.4-1.7, p < 0.001) were associated with an increased risk of mortality after adjusting for age, sex and cancer stage. There was no statistically significant association between NLR and VTE occurrence in patients with cancer. Neither PLR nor NLR were associated with the risk of ATE. Both elevated PLR and NLR were independently associated with a twofold increased risk of mortality.


Assuntos
Plaquetas/patologia , Linfócitos/patologia , Neoplasias/patologia , Neutrófilos/patologia , Tromboembolia/patologia , Biomarcadores/metabolismo , Contagem de Células , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/epidemiologia , Neoplasias/mortalidade , Prognóstico , Estudos Prospectivos , Risco , Análise de Sobrevida , Tromboembolia/epidemiologia , Tromboembolia/mortalidade
15.
J Heart Lung Transplant ; 37(10): 1207-1217, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30195832

RESUMO

BACKGROUND: Limited data exist describing impact of body mass index (BMI) on post‒left ventricular assist device (post-LVAD) outcomes. We sought to define the relationship between body mass index (BMI) and adverse events (AEs) after LVAD implantation by examining the ISHLT Mechanically Assisted Circulatory Support (IMACS) registry. METHODS: Patients implanted with a contemporary continuous flow (CF)-LVAD were stratified into 4 groups using pre-operative BMI: underweight (UW; BMI ≤18.5 kg/m2); non-obese (NO; BMI >18.5 to <30 kg/m2); obese (OB; BMI ≥30 to <40 kg/m2); and morbidly obese (MO; BMI ≥40 kg/m2). Freedom from AEs was evaluated using the Kaplan-Meier method and risk factors for development of first AE were identified using multiphase parametric hazard modeling. AEs included infection, thromboembolic events, bleeding, device malfunction, and neurologic dysfunction. RESULTS: Between 2013 and 2015, a total of 9,408 patients underwent implantation of a CF-LVAD, which consisted of 368 (4%) UW, 5,719 (61%) NO, 2,770 (29%) OB, and 444 (5%) MO patients. Survival among the 4 BMI cohorts was similar at 2years (70.8% to 75.8%, p = 0.24). MO patients were less likely to be free from a non‒VAD-related infection (p < 0.0001) or device-related infection (p = 0.0014) at 2years (50.3%, 70.7%) when compared with OB (58.3%, 78.7%), NO (65.2%, 81.4%), and UW (68.9%, 77.4%) patients. UW (81.5%) and NO (81.3%) patients were more likely to be free from device malfunction at 2years when compared with OB (78.3%) and MO (72.6%) (p = 0.0006). Thromboembolic events were rare and more common in the UW cohort (p = 0.026). CONCLUSIONS: Although BMI was not correlated with 2-year mortality, an increased rate of infectious and device-related AEs was noted in OB and MO LVAD patients. In a group with few options for transplant, the event morbidity in obese patients can be expected to impact morbidity with longer support durations.


Assuntos
Índice de Massa Corporal , Coração Auxiliar/efeitos adversos , Complicações Pós-Operatórias/etiologia , Sistema de Registros , Disfunção Ventricular Esquerda/cirurgia , Causas de Morte , Estudos de Coortes , Humanos , Estimativa de Kaplan-Meier , Funções Verossimilhança , Complicações Pós-Operatórias/mortalidade , Modelos de Riscos Proporcionais , Fatores de Risco , Taxa de Sobrevida , Tromboembolia/etiologia , Tromboembolia/mortalidade , Estados Unidos , Disfunção Ventricular Esquerda/mortalidade
16.
Int Heart J ; 59(5): 1047-1051, 2018 Sep 26.
Artigo em Inglês | MEDLINE | ID: mdl-30101854

RESUMO

Recently, long-term outcomes of pre-capillary pulmonary hypertension (PH) have been improved, whereas morbidity and mortality are still high because of right-sided heart failure (HF). Right-sided HF is closely related to right ventricular (RV) function and hemodynamics such as RV stroke work index (RVSWI). However, the association between RVSWI and long-term outcomes in pre-capillary PH has not been well investigated. The aims of this study were to compare clinical characteristics between low RVSWI and high RVSWI and to investigate the association between low RVSWI and long-term outcomes in patients with pre-capillary PH. We included patients admitted to diagnose and evaluate PH by right heart catheterization between 2007 and 2015. Patients with pre-capillary PH were divided into two groups according to the median value of RVSWI (low RVSWI group: RVSWI < 19.7 g・m/m2/beat; high RVSWI group: RVSWI ≥ 19.7 g・m/m2/beat). Kaplan-Meier survival curves were applied to investigate whether the low RVSWI were associated with HF death or HF readmission in patients with pre-capillary PH. A total of 36 patients with pre-capillary PH who were diagnosed as pulmonary arterial hypertension (PAH) or chronic thromboembolic PH (CTEPH) were allocated into the low RVSWI group (n = 18) and high RVSWI group (n = 18). The event-free survival rate was significantly lower in the low RVSWI group as compared with the high RVSWI group (P = 0.02). In conclusion, lower RVSWI was significantly associated with HF death or HF readmission in patients with PAH or CTEPH.


Assuntos
Hipertensão Pulmonar/fisiopatologia , Volume Sistólico/fisiologia , Tromboembolia/fisiopatologia , Função Ventricular Direita/fisiologia , Adulto , Idoso , Cateterismo Cardíaco/métodos , Feminino , Seguimentos , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Hemodinâmica , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/mortalidade , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Pressão Propulsora Pulmonar/fisiologia , Análise de Sobrevida , Tromboembolia/diagnóstico , Tromboembolia/mortalidade
17.
Am J Cardiol ; 122(4): 597-603, 2018 08 15.
Artigo em Inglês | MEDLINE | ID: mdl-29970238

RESUMO

Research is conflicting whether kidney function should be incorporated in thromboembolism risk prediction. Our published data showed that the CHA2DS2-VASc score predicts thromboembolism and mortality in those without atrial fibrillation. We used the Rochester Epidemiology Project medical records system to retrospectively evaluate whether adding renal impairment (1 point) to the CHA2DS2-VASc score (-R) enhances the score's prediction of mortality, thromboembolism, and atrial fibrillation in patients without atrial fibrillation. We identified patients that had an implantable cardiac monitoring device placed from January 1, 2004 to December 31, 2013, which was defined as the start date. Follow-up was through March 7, 2016. An implantable device was required to discern the absence of atrial fibrillation. Renal impairment was defined as chronic kidney disease stage 3 or greater. The population (n = 1,606) had a mean age of 69.8 years and median follow-up of 4.8 years. Baseline renal impairment was predictive of mortality (hazard ratio [HR] 2.06, 95% confidence interval [CI] 1.64 to 2.60, p <0.001), thromboembolism (HR 1.34, 95% CI 0.96 to 1.87, p = 0.09), and atrial fibrillation (HR 1.31, 95% CI 0.98 to 1.74, p = 0.07). Lower glomerular filtration rate correlated significantly with mortality. Increasing CHA2DS2-VASc-R score correlated significantly with mortality, thromboembolism, and incident atrial fibrillation. The addition of renal impairment to the CHA2DS2-VASc score improved the C-statistics for thromboembolism and survival from 0.72 to 0.73 (p = 0.01) and 0.70 to 0.72 (p <0.001). Adding renal impairment to the CHA2DS2-VASc score improves the score's prediction of thromboembolism and mortality in a population without atrial fibrillation, although the incremental benefit appears mild.


Assuntos
Taxa de Filtração Glomerular/fisiologia , Monitorização Fisiológica/métodos , Insuficiência Renal Crônica/fisiopatologia , Medição de Risco/métodos , Tromboembolia/diagnóstico , Idoso , Fibrilação Atrial , Feminino , Seguimentos , Humanos , Masculino , Minnesota/epidemiologia , Prognóstico , Insuficiência Renal Crônica/complicações , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Tromboembolia/etiologia , Tromboembolia/mortalidade , Fatores de Tempo
18.
Cardiovasc Pathol ; 35: 23-28, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29747049

RESUMO

BACKGROUND: The risk of thromboembolic events is increased in patients with heart failure (HF); however, few studies have reported thromboembolic findings in HF patients who have undergone autopsy. METHODS AND RESULTS: We reviewed 1457 autopsies (January 2000/July 2006) and selected 595 patients with HF. We studied the occurrence of thromboembolic events in patients' autopsy reports. Mean age was 61.8±15.9 years; 376 (63.2%) were men and 219 (36.8%) women; left ventricular ejection fraction was 42.1±18.7%. HF etiologies were coronary artery disease in 235 (39.5%) patients, valvular disease in 121 (20.3%), and Chagas' disease in 81 (13.6%). The main cause of death was progressive HF in 253 (42.5%) patients, infections in 112 (18.8%), myocardial infarction in 86 (14.5%), and pulmonary embolism in 81 (13.6%). Altogether, 233 patients (39.2%) suffered 374 thromboembolic events. A thromboembolic event was considered the direct cause of death in 93 (24.9%) patients and related to death in 158 (42.2%). The most frequent thromboembolism was pulmonary embolism in 135 (36.1%) patients; in 81 events (60%), it was considered the cause of death. When we compared clinical characteristics of patients, sex (OR=1.511, CI 95% 1.066-2.143, P=.021) and Chagas disease (OR=2.362, CI 95% 1.424-3.918, P=.001) were independently associated with the occurrence of thromboembolisms. CONCLUSIONS: Thromboembolic events are frequent in patients with heart failure revealed at autopsy, and are frequently associated with the death process. Our findings warrant a high degree of suspicion for these occurrences, especially during the care of more susceptible populations, such as women and Chagas patients.


Assuntos
Insuficiência Cardíaca/patologia , Tromboembolia/patologia , Idoso , Autopsia , Causas de Morte , Cardiomiopatia Chagásica/mortalidade , Cardiomiopatia Chagásica/patologia , Feminino , Insuficiência Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/patologia , Razão de Chances , Embolia Pulmonar/mortalidade , Embolia Pulmonar/patologia , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Tromboembolia/mortalidade
19.
J Stroke Cerebrovasc Dis ; 27(9): e206-e211, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29779882

RESUMO

BACKGROUND: The risk of complications from thromboembolism is increased for patients with malignancy. Cancer-associated stroke is also a serious issue with regard to the management of patients with cancer because stroke incidence often causes disabilities that affect daily life and cancer treatment strategy. METHODS: Between March 2011 and September 2017, 328 patients with acute ischemic stroke were registered to our hospital. RESULTS: Of these patients, 26 (7.9%) had a cancer-associated stroke diagnosis, namely, Trousseau syndrome. After ischemic stroke onset, malignancy treatment was changed to palliative treatment for 11 patients. Eighteen patients died 1 year after ischemic stroke onset, and 15 of these patients underwent cancer treatment according to the best supportive care policy. Of those who died, 8 underwent anticoagulation therapy. We described the clinical courses of 3 cases among 26 cases with Trousseau syndrome. Two cases took direct oral anticoagulants (DOACs) due to cancer-associated venous thromboembolism before stroke onset, and there has been no stroke recurrence with subcutaneous unfractionated heparin. In the third case, when cancer activity was suppressed, we changed DOACs from subcutaneous unfractionated heparin and continued DOACs without thromboembolic events. CONCLUSIONS: There is insufficient evidence regarding cases for which DOACs would be suitable for the prevention of thromboembolism and regarding its long-term efficacy and safety in patients with cancer. As it stands, heparin treatment, which has multifaceted antithrombotic actions, may be suitable for cancer-associated stroke prevention.


Assuntos
Anticoagulantes/administração & dosagem , Isquemia Encefálica/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Heparina/administração & dosagem , Neoplasias/química , Acidente Vascular Cerebral/tratamento farmacológico , Tromboembolia/tratamento farmacológico , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/efeitos adversos , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/etiologia , Isquemia Encefálica/mortalidade , Imagem de Difusão por Ressonância Magnética , Feminino , Fibrinolíticos/efeitos adversos , Heparina/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/diagnóstico , Neoplasias/mortalidade , Neoplasias/terapia , Recidiva , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Tromboembolia/diagnóstico , Tromboembolia/etiologia , Tromboembolia/mortalidade , Fatores de Tempo , Resultado do Tratamento
20.
Haematologica ; 103(9): 1549-1556, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29794142

RESUMO

In contrast to venous thromboembolism, little is known about arterial thromboembolism in patients with cancer. The aim of this study was to quantify the risk and explore clinical risk factors of arterial thromboembolism in patients with cancer, and investigate its potential impact on mortality. Patients with newly-diagnosed cancer or progression of disease after remission were included in a prospective observational cohort study and followed for two years. Between October 2003 and October 2013, 1880 patients (54.3% male; median age 61 years) were included. During a median follow up of 723 days, 48 (2.6%) patients developed arterial thromboembolism [20 (41.7%) myocardial infarction, 16 (33.3%) stroke and 12 (25.0%) peripheral arterial events], 157 (8.4%) developed venous thromboembolism, and 754 (40.1%) patients died. The cumulative 3-, 6-, 12-, and 24-month risks of arterial thromboembolism were 0.9%, 1.1%, 1.7%, and 2.6%, respectively. Male sex (subdistribution hazard ratio=2.9, 95%CI: 1.5-5.6; P=0.002), age (subdistribution hazard ratio per 10 year increase=1.5, 1.2-1.7; P<0.001), hypertension (3.1, 1.7-5.5; P<0.001), smoking (2.0, 1.1-3.7; P=0.022), lung cancer (2.3, 1.2-4.2; P=0.009), and kidney cancer (3.8, 1.4-10.5; P=0.012) were associated with a higher arterial thromboembolism risk. Furthermore, the occurrence of arterial thromboembolism was associated with a 3.2-fold increased risk of all-cause mortality (hazard ratio=3.2, 95%CI: 2.2-4.8; P<0.001). Arterial thromboembolism is a less common complication in patients with cancer than venous thromboembolism. The risk of arterial thromboembolism is high in patients with lung and kidney cancer. Patients with cancer who develop arterial thromboembolism are at a 3-fold increased risk of mortality.


Assuntos
Neoplasias/complicações , Neoplasias/mortalidade , Tromboembolia/etiologia , Tromboembolia/mortalidade , Idoso , Áustria/epidemiologia , Comorbidade , Progressão da Doença , Feminino , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Neoplasias/diagnóstico , Neoplasias/epidemiologia , Avaliação de Resultados da Assistência ao Paciente , Prognóstico , Sistema de Registros , Medição de Risco , Fatores de Risco , Tromboembolia/diagnóstico , Tromboembolia/epidemiologia
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