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1.
Clín. investig. arterioscler. (Ed. impr.) ; 32(4): 171-174, jul.-ago. 2020. ilus
Artigo em Inglês | IBECS | ID: ibc-194697

RESUMO

Arterial and venous thromboses are very prevalent diseases and it has been discovered that they share some common pathways, but their presentation in young patients is rare and should raise concern for thrombophilia. Therefore, the case is presented of a 34 year-old female with no prior pertinent history and with no predisposing factors. She was diagnosed with a pulmonary embolism, with an incidental finding of a left ventricular thrombus. A coronary artery thrombosis was also found. The patient met the criteria for a thrombophilia work-up, but the authors would like to express their concern on whether these tests are truly necessary, as they would not have change the patient management


La trombosis arterial y la trombosis venosa son enfermedades altamente prevalentes, y se ha visto que comparten algunas vías en su formación. Sin embargo, su presentación en pacientes jóvenes es rara y debe generar sospechas por trombofilias. Por esto queremos describir el caso de una mujer de 34 años sin antecedentes clínicos pertinentes y sin factores predisponentes que fue diagnosticada de tromboembolismo pulmonar y con hallazgo incidental de un trombo en el ventrículo izquierdo y trombosis de la arteria coronaria. La paciente cumplía criterios para realizar estudios de trombofilia, pero abrimos la discusión de si estos son verdaderamente necesarios, ya que no modificarían el manejo de la paciente


Assuntos
Humanos , Feminino , Adulto , Trombose Coronária/diagnóstico por imagem , Trombofilia/diagnóstico por imagem , Embolia Pulmonar/diagnóstico , Trombose Coronária/diagnóstico , Trombose Coronária/tratamento farmacológico , Trombofilia/tratamento farmacológico , Achados Incidentais , Ecocardiografia/métodos , Cateterismo Cardíaco , Anticoagulantes/uso terapêutico
2.
J Card Surg ; 35(8): 2097-2099, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32652738

RESUMO

Cardiac myxomas are benign primer cardiac tumors of the heart. They can be fatal with a thromboembolic presentation. Myocardial infarction is one of these unusual thromboembolic presentations. We report a patient who presented with cardiac arrest due to ventricular fibrillation related to myocardial infarction. After successful resuscitation, coronary angiography and transthoracic echocardiography were performed. A left atrial mass was observed and interpreted as a possible cause of coronary embolism leading to myocardial infarction. After surgical excision, the pathological examination confirmed myxoma, which was the essential cause of the tendency to arterial embolism.


Assuntos
Trombose Coronária/diagnóstico por imagem , Trombose Coronária/etiologia , Neoplasias Cardíacas/complicações , Mixoma/complicações , Angiografia Coronária , Ecocardiografia , Feminino , Parada Cardíaca/etiologia , Neoplasias Cardíacas/diagnóstico por imagem , Neoplasias Cardíacas/cirurgia , Humanos , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Mixoma/diagnóstico por imagem , Mixoma/cirurgia , Fibrilação Ventricular/etiologia
3.
Rev Cardiovasc Med ; 21(2): 289-295, 2020 06 30.
Artigo em Inglês | MEDLINE | ID: mdl-32706216

RESUMO

Consideration of thrombolysis as first-line reperfusion therapy in patients with COVID-19 and STEMI is recommended by ACC/SCAI guidelines. We describe a patient with COVID-19, who presented with ST-elevation myocardial infarction and was treated with thrombolysis and anticoagulation. He was later found to have a significant persistent thrombus burden requiring thrombectomy and stent placement. Invasive hemodynamics on multiple high-dose pressers revealed a high cardiac output state with low systemic vascular resistance, consistent with distributive rather than cardiogenic shock. Our case illustrates that thrombolytic therapy alone may not be adequate in patients with STEMI and COVID-19, as well as the importance of early invasive hemodynamics in management of shock in patient with STEMI and COVID-19 infection.


Assuntos
Trombose Coronária/terapia , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Trombectomia , Terapia Trombolítica/métodos , Anticoagulantes/uso terapêutico , Betacoronavirus , Angiografia Coronária , Trombose Coronária/diagnóstico por imagem , Eletrocardiografia , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem
5.
Medicine (Baltimore) ; 99(26): e20152, 2020 Jun 26.
Artigo em Inglês | MEDLINE | ID: mdl-32590726

RESUMO

No-reflow is an important complication among patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI).A retrospective study of 1658 STEMI patients undergoing direct PCI was performed. Patients were randomly assigned at a 7:3 ratio into development cohort and validation cohort and into no-reflow and normal blood flow groups. Clinical data and laboratory examinations were compared to identify independent risk factors and establish a no-reflow risk scoring system.In the development cohort (n = 1122), 331 (29.5%) had no-reflow. Multivariate analysis showed age ≥ 65 years (OR = 1.766, 95% confidence interval (CI): 1.313-2.376, P < .001), not using angiotonase inhibitor/angiotensin receptor antagonists (OR = 1.454, 95%CI: 1.084-1.951, P = .013), collateral circulation 8 mmol/L (OR = 1.386, 95%CI: 1.007-1.908, P = .045) were related to no-reflow. Receiver operating characteristic (ROC) area under the curve was 0.648 (95%CI: 0.609-0.86). At 0.349 cutoff sensitivity was 42.0%, specificity was 79.3%, positive predictive value (PPV) was 44.7%, negative predictive value (NPV) was 77.4%, P < .001. The resulting risk scoring system was tested in the validation cohort (n = 536), with 30.1% incidence of no-reflow. The area under the ROC curve was 0.637 (95%CI: 0.582-0.692). At a cutoff of 0.349 sensitivity was 53.2% and specificity was 66.7%, PPV was 41.2%, NPV was 76.4%, P < .001.The no-reflow risk scoring system was effective in identifying high-risk patients.


Assuntos
Fenômeno de não Refluxo/epidemiologia , Intervenção Coronária Percutânea , Medição de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Fatores Etários , Glicemia/análise , Estudos de Coortes , Circulação Colateral , Angiografia Coronária , Trombose Coronária/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/epidemiologia , Sensibilidade e Especificidade , Trombectomia
7.
Asian Cardiovasc Thorac Ann ; 28(5): 266-272, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32493040

RESUMO

BACKGROUND: Fibrinolytic therapy is an important reperfusion strategy, especially when primary percutaneous coronary interventions cannot be offered to ST-elevation myocardial infarction patients. Given that failed reperfusion after fibrinolytic therapy is common, it is pragmatic that the predictors, outcomes, and angiographic profiles of patients with failed thrombolysis are carefully scrutinized. METHODS: We prospectively studied clinical variables and outcomes over 30 months in 243 ST-elevation myocardial infarction patients who received fibrinolytics as primary treatment. Logistic regression analysis was used to identify predictors of failed thrombolysis. RESULTS: Failed thrombolysis occurred in 38.68% of patients with a mean window period of 6.58 ± 1.42 h, and 55.32% of patients with failed thrombolysis had Killip class >I on presentation. Risk factors such as diabetes mellitus (55.32%), dyslipidemia (60.64%) and obesity (77.66%) were frequently associated with failed thrombolysis; 73.40% of patients with failed thrombolysis had Thrombolysis in Myocardial Infarction flow grade 0/1 in the infarct-related artery, and 58.51% of such patients needed a rescue percutaneous coronary intervention. The mean Thrombolysis in Myocardial Infarction risk score was 5.46 ± 2.77 in failed thrombolysis patients, with mortality of 4.25% at the 6-month follow-up. CONCLUSION: Non-resolution of presenting symptoms and ST changes on electrocardiography at 90 min served as the earliest indicators of failed thrombolysis, with a significant angiographic correlation. Clinical variables such as delayed presentation (>6 h), dyspnea, Killip class >I, cardiogenic shock, Thrombolysis in Myocardial Infarction score, and conventional risk factors including diabetes mellitus, dyslipidemia, and obesity represented cluster of predictors of failed thrombolysis.


Assuntos
Trombose Coronária/tratamento farmacológico , Fibrinolíticos/administração & dosagem , Infarto do Miocárdio/tratamento farmacológico , Terapia Trombolítica , Adulto , Idoso , Angiografia Coronária , Trombose Coronária/diagnóstico por imagem , Trombose Coronária/mortalidade , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico por imagem , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Terapia Trombolítica/efeitos adversos , Terapia Trombolítica/mortalidade , Fatores de Tempo , Falha de Tratamento
10.
Thromb Res ; 191: 9-14, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32353746

RESUMO

BACKGROUND: Few data are available on the rate and characteristics of thromboembolic complications in hospitalized patients with COVID-19. METHODS: We studied consecutive symptomatic patients with laboratory-proven COVID-19 admitted to a university hospital in Milan, Italy (13.02.2020-10.04.2020). The primary outcome was any thromboembolic complication, including venous thromboembolism (VTE), ischemic stroke, and acute coronary syndrome (ACS)/myocardial infarction (MI). Secondary outcome was overt disseminated intravascular coagulation (DIC). RESULTS: We included 388 patients (median age 66 years, 68% men, 16% requiring intensive care [ICU]). Thromboprophylaxis was used in 100% of ICU patients and 75% of those on the general ward. Thromboembolic events occurred in 28 (7.7% of closed cases; 95%CI 5.4%-11.0%), corresponding to a cumulative rate of 21% (27.6% ICU, 6.6% general ward). Half of the thromboembolic events were diagnosed within 24 h of hospital admission. Forty-four patients underwent VTE imaging tests and VTE was confirmed in 16 (36%). Computed tomography pulmonary angiography (CTPA) was performed in 30 patients, corresponding to 7.7% of total, and pulmonary embolism was confirmed in 10 (33% of CTPA). The rate of ischemic stroke and ACS/MI was 2.5% and 1.1%, respectively. Overt DIC was present in 8 (2.2%) patients. CONCLUSIONS: The high number of arterial and, in particular, venous thromboembolic events diagnosed within 24 h of admission and the high rate of positive VTE imaging tests among the few COVID-19 patients tested suggest that there is an urgent need to improve specific VTE diagnostic strategies and investigate the efficacy and safety of thromboprophylaxis in ambulatory COVID-19 patients.


Assuntos
Arteriopatias Oclusivas/etiologia , Infecções por Coronavirus/complicações , Pneumonia Viral/complicações , Trombofilia/etiologia , Tromboembolia Venosa/etiologia , Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/etiologia , Idoso , Idoso de 80 Anos ou mais , Assistência Ambulatorial , Anticoagulantes/uso terapêutico , Arteriopatias Oclusivas/diagnóstico por imagem , Arteriopatias Oclusivas/epidemiologia , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/etiologia , Comorbidade , Trombose Coronária/diagnóstico por imagem , Trombose Coronária/epidemiologia , Trombose Coronária/etiologia , Cuidados Críticos , Coagulação Intravascular Disseminada/epidemiologia , Coagulação Intravascular Disseminada/etiologia , Feminino , Mortalidade Hospitalar , Hospitais de Ensino/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Itália/epidemiologia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pandemias , Admissão do Paciente , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/etiologia , Estudos Retrospectivos , Fatores de Risco , Trombofilia/tratamento farmacológico , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/epidemiologia
11.
BMC Cardiovasc Disord ; 20(1): 153, 2020 03 31.
Artigo em Inglês | MEDLINE | ID: mdl-32234015

RESUMO

BACKGROUND: Studies have not demonstrated consistent outcomes following thrombus aspiration in Primary Percutaneous Coronary Intervention (PPCI). We investigated the relationship between thrombus aspiration and microvascular obstruction as measured using Index of Microcirculatory Resistance (IMR) immediately following PPCI and Left Ventricle Function Improvement measured using Global Longitudinal Strain (GLS) six months following PPCI. Our aim is to determine microvascular obstruction and left ventricle function improvement six months following thrombus aspiration during PPCI. METHODS: This was a single-center, observational, prospective non-randomized study involving 45 patients with thrombus score 4-5 (defined as high thrombus burden) and Thrombolysis in Myocardial Infarction (TIMI) flow of 0-2 who subsequently underwent PPCI. Thrombus aspiration was conducted based on physician discretion. The IMR was measured immediately following the procedure. All patients underwent echocardiography to measure GLS at 24 h, 3 months and 6 months following PPCI. RESULTS: Thirty-three (73%) patients underwent thrombus aspiration during PPCI and twelve (27%) patients underwent the conventional PPCI. No significant difference in IMR was found between the group that underwent thrombus aspiration and the group that underwent conventional PCI (51.9 ± 41.5 vs 47.1 ± 35.6 p = 0.723). TIMI flow after PPCI was worse in thrombus aspiration group (OR 5.2 [1.2-23.2], p = 0.041). There was no difference in GLS between two groups at 6-month follow-up (- 13.0 ± 3.4 vs - 12.8 ± 4.6, p = 0.912). CONCLUSION: This study indicates no benefit of thrombus aspiration during PPCI in reducing either microvascular obstruction or left ventricular function at 6-month follow-up for patients with high thrombus burden. Nevertheless, further studies are required before definite conclusions can be made.


Assuntos
Síndrome Coronariana Aguda/terapia , Circulação Coronária , Trombose Coronária/terapia , Microcirculação , Intervenção Coronária Percutânea , Trombectomia , Resistência Vascular , Função Ventricular Esquerda , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/fisiopatologia , Trombose Coronária/diagnóstico por imagem , Trombose Coronária/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Estudos Prospectivos , Recuperação de Função Fisiológica , Sucção , Trombectomia/efeitos adversos , Fatores de Tempo , Resultado do Tratamento
12.
Circ Cardiovasc Interv ; 13(4): e008603, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32279567

RESUMO

BACKGROUND: High bleeding risk (HBR) patients undergoing percutaneous coronary intervention have been widely excluded from randomized device registration trials. The LF study (LEADERS FREE) reported superior outcomes of HBR patients receiving 30-day dual antiplatelet therapy after percutaneous coronary intervention with a polymer-free drug-coated stent (DCS). LFII was designed to assess the reproducibility and generalizability of the benefits of DCS observed in LF to inform the US Food and Drug Administration in a device registration decision. METHODS: LFII was a single-arm study using HBR inclusion/exclusion criteria and 30-day dual antiplatelet therapy after percutaneous coronary intervention with DCS, identical to LF. The 365-day rates of the primary effectiveness (clinically indicated target lesion revascularization) and safety (composite cardiac death and myocardial infarction) end points were reported using a propensity-stratified analysis compared with the LF bare metal stent arm patients as controls. RESULTS: A total of 1203 LFII patients were enrolled with an average 1.7 HBR criteria per patient, including 60.7% >75 years of age, 34.1% on anticoagulants, and 14.7% with renal failure. Propensity-adjusted 365-day clinically indicated target lesion revascularization was significantly lower with DCS (7.2% versus 9.2%; hazard ratio, 0.72 [95% CI, 0.52-0.98]; P=0.0338 for superiority), as was the primary safety (cardiac death and myocardial infarction) composite (9.3% versus 12.4%; hazard ratio, 0.72 [95% CI, 0.55-0.94]; P=0.0150 for superiority). Stent thrombosis rates were 2.0% DCS and 2.2% bare metal stent. Major bleeding at 1 year occurred in 7.2% DCS patients and 7.2% bare metal stent. CONCLUSIONS: LFII reproduces the results of the DCS arm of LF in an independent, predominantly North American cohort of HBR patients.


Assuntos
Síndrome Coronariana Aguda/terapia , Doença da Artéria Coronariana/terapia , Trombose Coronária/prevenção & controle , Stents Farmacológicos , Intervenção Coronária Percutânea/instrumentação , Inibidores da Agregação de Plaquetas/administração & dosagem , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Síndrome Coronariana Aguda/diagnóstico por imagem , Síndrome Coronariana Aguda/mortalidade , Idoso , Idoso de 80 Anos ou mais , Canadá , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Trombose Coronária/diagnóstico por imagem , Trombose Coronária/mortalidade , Esquema de Medicação , Terapia Antiplaquetária Dupla , Europa (Continente) , Feminino , Hemorragia/induzido quimicamente , Humanos , Masculino , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Inibidores da Agregação de Plaquetas/efeitos adversos , Desenho de Prótese , Recidiva , Medição de Risco , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
15.
BMC Cardiovasc Disord ; 20(1): 146, 2020 03 24.
Artigo em Inglês | MEDLINE | ID: mdl-32204697

RESUMO

BACKGROUND: In bioresorbable vascular scaffolds (BVSs), there is some concern about a possible increase in the rate of scaffold thromboses (ScTs). Although several characteristics similarly contribute to the development of both early and late ScTs, there are also clearly different pathomechanisms between the two time-dependent types of thromboses, especially with BVSs. CASE PRESENTATION: We recently experienced a very rare case of a 69-year-old man who had recurrent early and late ScTs with somewhat differing pathomechanisms as assessed by optical coherence tomography (OCT). For the late ScT, OCT identified a scaffold dismantling in the same place that a peri-strut low intensity area (PLIA) was observed in the previous OCT finding. CONCLUSION: We report the management of an ScT in a case with findings such as a heterogeneous a BVS degradation, peri-strut low intensity area (PLIA), intraluminal scaffold dismantling, and under-sizing and/or stent malapposition observed in OCT.


Assuntos
Implantes Absorvíveis , Angioplastia Coronária com Balão/instrumentação , Angiografia Coronária , Doença da Artéria Coronariana/terapia , Trombose Coronária/diagnóstico por imagem , Stents , Tomografia de Coerência Óptica , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Doença da Artéria Coronariana/diagnóstico por imagem , Trombose Coronária/etiologia , Trombose Coronária/terapia , Humanos , Masculino , Valor Preditivo dos Testes , Recidiva , Fatores de Tempo , Resultado do Tratamento
17.
BMC Cardiovasc Disord ; 20(1): 125, 2020 03 11.
Artigo em Inglês | MEDLINE | ID: mdl-32160856

RESUMO

BACKGROUND: Although the presence of thrombus in patients with ST-elevation myocardial infarction (STEMI) has been linked to adverse outcomes, routine thrombus aspiration has not been proven effective. A potential explanation is that these patients should be risk-stratified. Traditional clinical, laboratory and angiographic parameters used in clinical trials have been proven inadequate to classify patients. Aspirated thrombotic material characteristics might be an additional important parameter that has not yet been addressed. In this report, we aim to describe a methodological analysis of thrombus aspirated from coronary arteries during primary PCI using micro-Computed Τomography (micro-CT). These data will be combined with traditional factors to develop a risk-stratification system with high discriminative power for these patients. METHODS: Eighty-seven patients with STEMI undergoing thrombus aspiration in AHEPA University Hospital, Greece, will be enrolled in the study. The first patient was enrolled in June 2018. After being aspirated, thrombi are preserved in formalin and their volume and density are calculated with micro-CT. Micro-CT allows us to create 3D models of thrombi from a series of x-ray projection images. These models are further analyzed to find the volume and density of extracted thrombi and to assess potential differences in their structure. Association of these variables with clinical parameters and angiographic outcomes will be explored. DISCUSSION: QUEST-STEMI is-to our knowledge-the first study of volumetric coronary thrombus assessment by micro-CT. This method could be used in larger, clinically-oriented trials to help stratify patients with thrombus burden according to their risk for adverse outcomes. TRIAL REGISTRATION: QUEST-STEMI trial ClinicalTrials.gov number: NCT03429608 Date of registration: February 12, 2018. The study was prospectively registered (registered prior to enrollment of the first participant).


Assuntos
Trombose Coronária/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Microtomografia por Raio-X , Trombose Coronária/terapia , Grécia , Humanos , Intervenção Coronária Percutânea , Valor Preditivo dos Testes , Estudos Prospectivos , Projetos de Pesquisa , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Índice de Gravidade de Doença , Sucção , Trombectomia
18.
In Vivo ; 34(2): 745-756, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32111780

RESUMO

BACKGROUND/AIM: Spontaneous recanalization of coronary thrombus (SRCT) is a rare in vivo appearance, with a nonspecific angiographic aspect. The aim of this study was to investigate the importance of optical coherence tomography (OCT) use for SRCT identification, characterization of pathogenic mechanisms and optimal treatment. PATIENTS AND METHODS: We retrospectively analyzed all patients with angiographic suspicion of SRCT who underwent coronary angiography for suspected coronary artery disease and afterward investigated by OCT imaging. RESULTS: We identified 28 cases with angiographic suspicion of SCRT (0.41% of CA) and confirmed it in 4 patients (0.05% of CA). OCT provided insight about the underlying SRCT mechanism: possible complicated atherosclerotic plaques in two cases and, respectively, spontaneous coronary artery dissection in other two cases. OCT provided accurate lesion assessment and offered optimal PCI materials selection. CONCLUSION: Besides providing the diagnosis, OCT also improved characterization of SRCT pathogenic mechanisms, in the four confirmed SRCT cases, supporting the role of coronary wall in situ complications, namely dissection of an atherosclerotic plaque or spontaneous dissection of a normal coronary wall.


Assuntos
Angiografia Coronária/métodos , Trombose Coronária/diagnóstico , Anomalias dos Vasos Coronários/diagnóstico , Tomografia de Coerência Óptica/métodos , Doenças Vasculares/congênito , Adulto , Idoso , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/diagnóstico por imagem , Trombose Coronária/diagnóstico por imagem , Anomalias dos Vasos Coronários/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Doenças Vasculares/diagnóstico , Doenças Vasculares/diagnóstico por imagem
19.
Circ Cardiovasc Interv ; 13(4): e008226, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32216472

RESUMO

BACKGROUND: Whether the underlying risk of bleeding influences the associations between patterns of dual antiplatelet therapy (DAPT) cessation and adverse events after percutaneous coronary intervention is unknown. METHODS: Patients enrolled in the prospective, international, multicenter PARIS registry (Patterns of Non-Adherence to Anti-Platelet Regimens in Stented Patients) were categorized according to their risk of bleeding using the PARIS bleeding risk score. We evaluated the incidence, patterns, and association between modes of DAPT cessation and outcomes across bleeding risk groups. Modes of DAPT cessations were defined as physician-guided DAPT discontinuation, brief interruption (<14 days) or disruption for bleeding, or noncompliance. The primary end point of interest was major adverse cardiac events, defined as the composite of cardiac death, myocardial infarction, or definite-probable stent thrombosis. RESULTS: From a total of 5018 patients, 513 (10.2%) were classified as high, 2058 (41.0%) as intermediate, and 2447 (48.8%) as low risk for bleeding. High bleeding risk (HBR) patients were older and had greater prevalence of comorbidities. Compared with non-HBR, HBR patients had higher rates of both ischemic and bleeding events. The cumulative incidence of DAPT cessation was higher in HBR patients, mostly driven by physician-guided discontinuation and disruption. Of note, DAPT disruption occurred in 17.7%, 10.4%, and 7.8% at 1 year and 22.0%, 15.1%, and 12.0% at 2 years (P<0.0001) in high, intermediate, and low bleeding risk groups, respectively. Physician-guided DAPT discontinuation was not associated with increased risk of major adverse cardiac events in both HBR and non-HBR patients, while DAPT disruption was associated with an increased risk of major adverse cardiac events across all bleeding risk groups. There was no interaction between bleeding risk status and clinical outcomes for any cessation mode. CONCLUSIONS: Patients at HBR remain at higher risk of adverse events. Disruption of DAPT is associated with an increased risk of major adverse cardiac events irrespective of the underlying bleeding risk. Physician-guided discontinuation of DAPT appears to be safe, irrespective of HBR.


Assuntos
Doença da Artéria Coronariana/terapia , Trombose Coronária/prevenção & controle , Terapia Antiplaquetária Dupla/efeitos adversos , Hemorragia/induzido quimicamente , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/efeitos adversos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Trombose Coronária/diagnóstico por imagem , Trombose Coronária/mortalidade , Feminino , Hemorragia/mortalidade , Humanos , Incidência , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Intervenção Coronária Percutânea/mortalidade , Inibidores da Agregação de Plaquetas/administração & dosagem , Prevalência , Estudos Prospectivos , Sistema de Registros , Medição de Risco , Fatores de Risco , Stents , Fatores de Tempo , Resultado do Tratamento
20.
JACC Cardiovasc Interv ; 13(5): 606-617, 2020 03 09.
Artigo em Inglês | MEDLINE | ID: mdl-32139218

RESUMO

OBJECTIVES: The aim of this study was to develop a risk score integrating cytochrome P450 2C19 loss-of-function genotypes with clinical risk factors influencing clopidogrel response that would allow the identification with more precision of subjects at risk for high platelet reactivity (HPR) and adverse clinical outcomes. BACKGROUND: Clopidogrel is the most broadly used platelet P2Y12 inhibitor. However, a considerable number of patients achieve inadequate platelet inhibition, with persistent HPR, an established marker of increased thrombotic risk, underscoring the need for tools to help identify these subjects. Although carriers of loss-of-function alleles of the cytochrome P450 2C19 enzyme have reduced clopidogrel metabolism leading to increased rates of HPR and thrombotic complications, this explains only a fraction of the pharmacodynamic response to clopidogrel, and a number of clinical factors have also been shown to have contributing roles. METHODS: Three prospective and independent studies were used to: 1) develop a risk score integrating genetic and clinical factors to identify patients with HPR while on clopidogrel; 2) investigate the external validity of the risk score; and 3) define clinical outcomes associated with the risk score in a cohort of patients with myocardial infarction treated with clopidogrel. RESULTS: A risk score ABCD-GENE (Age, Body Mass Index, Chronic Kidney Disease, Diabetes Mellitus, and Genotyping) was developed incorporating 5 independent predictors of HPR: 4 clinical (age >75 years, body mass index >30 kg/m2, chronic kidney disease [glomerular filtration rate <60 ml/min], and diabetes mellitus) and 1 genetic (cytochrome P450 2C19 loss-of-function alleles). The C-statistics for the score as an integer variable were 0.71 (95% confidence interval [CI]: 0.68 to 0.75) and 0.64 (95% CI: 0.60 to 0.67) in the pharmacodynamic derivation and validation cohorts, respectively. A cutoff score ≥10 was associated with the best sensitivity and specificity to identify HPR status. The C-statistics for the score were 0.67 (95% CI: 0.64 to 0.71) for all-cause death and 0.66 (95% CI: 0.63 to 0.69) for the composite of all-cause death, stroke, or myocardial infarction at 1 year. Using multiple models for adjustment, the ABCD-GENE score consistently and independently correlated with all-cause death, as well as with the composite of all-cause death, stroke, or myocardial infarction, both as a continuous variable and by using the cutoff of ≥10. The score did not predict bleeding. CONCLUSIONS: The ABCD-GENE score is a simple tool to identify patients with HPR on clopidogrel and who are at increased risk for adverse ischemic events, including mortality, following an acute myocardial infarction. In patients with a high ABCD-GENE score, long-term oral P2Y12 inhibitors other than clopidogrel should be considered.


Assuntos
Regras de Decisão Clínica , Clopidogrel/uso terapêutico , Trombose Coronária/prevenção & controle , Resistência a Medicamentos , Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/uso terapêutico , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Fatores Etários , Idoso , Índice de Massa Corporal , Clopidogrel/efeitos adversos , Clopidogrel/farmacocinética , Trombose Coronária/diagnóstico por imagem , Trombose Coronária/etiologia , Trombose Coronária/mortalidade , Citocromo P-450 CYP2C19/genética , Citocromo P-450 CYP2C19/metabolismo , Bases de Dados Factuais , Diabetes Mellitus/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Obesidade/complicações , Obesidade/diagnóstico , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Variantes Farmacogenômicos , Inibidores da Agregação de Plaquetas/efeitos adversos , Inibidores da Agregação de Plaquetas/farmacocinética , Valor Preditivo dos Testes , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Antagonistas do Receptor Purinérgico P2Y/farmacocinética , Ensaios Clínicos Controlados Aleatórios como Assunto , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/diagnóstico , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
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