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1.
Medicine (Baltimore) ; 99(6): e19064, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32028428

RESUMO

BACKGROUND: This meta-analysis is to evaluate the efficacy and safety of bivalirudin in patients with ST-elevation myocardial infarction (STEMI). METHODS: PubMed, Cochrane Library, Embase, CNKI, CBMdisc, and VIP database were searched. Randomized controlled trial (RCT) was selected and the meta-analysis was conducted by RevMan 5.1. The primary efficacy endpoint was the incidence of major adverse cardiovascular events (MACE) and the primary safety endpoint was the incidence of major bleeding. Secondary efficacy endpoints were myocardial infarction (MI), target vessel revascularization (TVR), stent thrombosis (ST), stock, mortality, and thrombocytopenia. The pooled risk ratios (RRs) with the corresponding 95% confidence intervals (CI) were used to assess the efficacy and safety of bivalirudin vs heparin. RESULTS: Seven RCTs met the inclusion criteria, and 16,640 patients were included. We found that bivalirudin associated with lower risk of mortality (RR = 1.05; 95% CI = 0.74-1.49; P = .03; I = 2%), major bleeding (RR = 0.64; 95% CI = 0.54-0.75; P < .00001; I = 70%) and thrombocytopenia (RR = 0.39; 95% CI = 0.25-0.61; P < .0001; I = 0) compared with heparin. However, the use of bivalirudin increase the risk of MI(RR = 1.37; 95% CI = 1.10-1.71; P = .004; I = 25%) and ST(RR = 1.61; 95% CI = 1.05-2.47; P = .03; I = 70%) and has similar risk of MACE (RR = 1.00; 95% CI = 0.90-1.11; P = .97; I = 16%), TVR (RR = 1.43; 95% CI = 0.92-2.22; P = .11; I = 46%) and stock (RR = 1.43; 95% CI = 0.92-2.22; P = .11; I = 46%) compared with heparin used in STEMI patients. CONCLUSION: Bivalirudin associated with lower risk of mortality, major bleeding and thrombocytopenia compared with heparin. However, the use of bivalirudin increase the risk of MI and ST and has similar risk of MACE, TVR and stock compared with heparin used in STEMI patients.


Assuntos
Antitrombinas/uso terapêutico , Doença das Coronárias/cirurgia , Heparina/uso terapêutico , Fragmentos de Peptídeos/uso terapêutico , Intervenção Coronária Percutânea , Heparina/efeitos adversos , Hirudinas/efeitos adversos , Humanos , Fragmentos de Peptídeos/efeitos adversos , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Proteínas Recombinantes/efeitos adversos , Proteínas Recombinantes/uso terapêutico , Trombose/etiologia , Trombose/prevenção & controle , Resultado do Tratamento
2.
Adv Exp Med Biol ; 1232: 39-45, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31893392

RESUMO

Outcome after traumatic brain injury (TBI) is worsened by hemorrhagic shock (HS); however, the existing volume expansion approach with resuscitation fluids (RF) is controversial as it does not adequately alleviate impaired microvascular cerebral blood flow (mCBF). We previously reported that resuscitation fluid with drag reducing polymers (DRP-RF) improves CBF by rheological modulation of hemodynamics. Here, we evaluate the efficacy of DRP-RF, compared to lactated Ringers resuscitation fluid (LR-RF), in reducing cerebral microthrombosis and reperfusion mitochondrial oxidative stress after TBI complicated by HS. Fluid percussion TBI (1.5 ATA, 50 ms) was induced in rats and followed by controlled HS to a mean arterial pressure (MAP) of 40 mmHg. DRP-RF or LR-RF was infused to restore MAP to 60 mmHg for 1 h (pre-hospital period), followed by blood re-infusion to a MAP = 70 mmHg (hospital period). In vivo 2-photon laser scanning microscopy over the parietal cortex was used to monitor microvascular blood flow, nicotinamide adenine dinucleotide (NADH) for tissue oxygen supply and mitochondrial oxidative stress (superoxide by i.v. hydroethidine [HEt], 1 mg/kg) for 4 h after TBI/HS, followed by Dil vascular painting during perfusion-fixation. TBI/HS decreased mCBF resulting in capillary microthrombosis and tissue hypoxia. Microvascular CBF and tissue oxygenation were significantly improved in the DRP-RF compared to the LR-RF treated group (p < 0.05). Reperfusion-induced oxidative stress, reflected by HEt fluorescence, was 32 ± 6% higher in LR-RF vs. DRP-RF (p < 0.05). Post-mortem whole-brain visualization of DiI painted vessels revealed multiple microthromboses in both hemispheres that were 29 ± 3% less in DRP-RF vs. LR-RF group (p < 0.05). Resuscitation after TBI/HS using DRP-RF effectively restores mCBF, reduces hypoxia, microthrombosis formation, and mitochondrial oxidative stress compared to conventional volume expansion with LR-RF.


Assuntos
Lesões Encefálicas Traumáticas , Estresse Oxidativo , Polímeros , Ressuscitação , Choque Hemorrágico , Trombose , Animais , Lesões Encefálicas Traumáticas/tratamento farmacológico , Polímeros/uso terapêutico , Ratos , Ressuscitação/métodos , Trombose/prevenção & controle
3.
Medicine (Baltimore) ; 99(2): e18737, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31914090

RESUMO

Portal vein thrombosis (PVT) might impair the prognosis of cirrhotic patients. However, formation of de novo PVT after transjugular intrahepatic portosystemic shunt (TIPS) in cirrhotic patients without preexisting PVT was rarely reported. Moreover, it is not known whether warfarin is efficient in preventing de novo PVT after TIPS. The current study aimed to investigate retrospectively the incidence and location of de novo PVT, and preventive effects of warfarin on de novo PVT after TIPS for cirrhotic patients. Patients who received TIPS placement between March 1, 2015 and March 1, 2016 in our hospital were screened retrospectively. Patients without preexisting PVT before TIPS and those who were followed up for at least 12 months were included. There were 2 groups: 1 group received warfarin (warfarin group) post-TIPS, while another group (control group) did not receive prophylactic drug to prevent PVT. Their baseline characteristics and follow-up data were retrieved. The occurrence of PVT, adverse events due to warfarin, difference in stent patency and clinical complications such as stent dysfunction, hepatic encephalopathy, mortality, liver cancer, variceal bleeding, infection, and liver failure, and results of follow-up biochemical examination were compared. Eighty-three patients without preexisting PVT were included. There were 56 patients in the control group and 27 in the warfarin group. The incidence of PVT in the warfarin group was 14.8% (4/27), whereas the incidence in the control group was 42.9% (24/56, P = .013). The location of de novo PVT was mainly at left portal vein. Adverse events due to warfarin was mostly mild, such as hemorrhinia and gingival hemorrhage. No significant difference regarding to stent patency and clinical complications between the 2 groups was found. At 24-month after-TIPS, for the remaining patients in both groups, the total bilirubin was significantly increased while the red blood cell count was significantly decreased in control group compared with those in warfarin group (P < .05). PVT could commonly occur after TIPS in patients without preexisting PVT. Warfarin could prevent PVT in these patients, and might improve patient's liver function.


Assuntos
Cirrose Hepática/cirurgia , Veia Porta/cirurgia , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Trombose/etiologia , Trombose/prevenção & controle , Varfarina/administração & dosagem , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Varfarina/efeitos adversos
4.
J Oncol Pharm Pract ; 26(1): 74-92, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30917738

RESUMO

The incorporation of L-asparaginase and pegylated asparaginase into pediatric-inspired regimens has conferred a survival advantage in treatment of adults with acute lymphoblastic leukemia. Use of asparaginase products requires careful prevention, monitoring, and management of adverse effects including hypersensitivity, hepatotoxicity, pancreatitis, coagulopathy, and thrombosis. Currently, there is limited published literature to offer guidance on management of these toxicities. At the University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, a standard of practice guideline was created to prevent and manage asparaginase-related adverse events. By sharing our long-term experience with asparaginase products and clinical management of asparaginase-induced toxicities, this article aims to improve patient safety and optimize treatment outcomes.


Assuntos
Antineoplásicos/administração & dosagem , Asparaginase/administração & dosagem , Institutos de Câncer/normas , Gerenciamento Clínico , Monitoramento de Medicamentos/normas , Polietilenoglicóis/administração & dosagem , Guias de Prática Clínica como Assunto/normas , Adulto , Antineoplásicos/efeitos adversos , Asparaginase/efeitos adversos , Pré-Escolar , Relação Dose-Resposta a Droga , Monitoramento de Medicamentos/métodos , Humanos , Polietilenoglicóis/efeitos adversos , Leucemia-Linfoma Linfoblástico de Células Precursoras/tratamento farmacológico , Leucemia-Linfoma Linfoblástico de Células Precursoras/epidemiologia , Trombose/induzido quimicamente , Trombose/epidemiologia , Trombose/prevenção & controle , Resultado do Tratamento
5.
Medicine (Baltimore) ; 98(51): e18446, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31861017

RESUMO

Thrombosis is one of the serious complications related to prophylactic balloon occlusion of the abdominal aorta (PBOAA). This study aims to retrospectively analyze the efficacy and safety of continuous low-flow infusion of diluted heparin saline to prevent this complication related to PBOAA and further to provide the theory and evidences for using PBOAA.A study was carried out at our hospital from March 2016 to December 2018. Women with pernicious placenta previa (PPP) were treated PBOAA to prevent massive bleeding during CS. According to whether continuous low-flow infusion of diluted heparin saline was used to prevent catheter-related thrombosis or not, they were divided into 2 groups, the test group and the control group. The incidence of thrombosis between the 2 groups was compared and the effective treatment of thrombosis was also discussed. The comparison of nonparametric values was accomplished by using Fisher exact test. Statistical significance was set at P < .05.There were 31 women with PPP who received PBOAA during CS who were included in our study. Six of 19 women in control group (31.6%) developed thrombotic complications, while none of 12 women in test group. There were statistically significant differences in the incidence of thrombosis between the 2 groups (P = .037). There was no statistically significant difference in the amount of estimated blood loss and blood transfusion during CS between the 2 groups, nor was there statistically significant difference in the hospital days after CS (P > .05). All 6 women with thrombotic complications had no positive symptoms and thrombotic sequelae. The managements of thrombus included systemic anticoagulation, catheter-directed thrombolysis, and catheter-directed anticoagulation. One of the 6 women was lost to follow-up, and the thrombus of the other 5 women were completely dissolved. No other adverse outcomes or complications related to PBOAA were observed in all women in this study.Continuous low-flow infusion of diluted heparin saline is a safe procedure when PBOAA is performed for patients with PPP. It can effectively reduce or even avoid thrombosis without increasing intraoperative blood loss during CS for PPP patients.


Assuntos
Anticoagulantes/administração & dosagem , Aorta Abdominal , Oclusão com Balão/efeitos adversos , Heparina/administração & dosagem , Trombose/prevenção & controle , Adulto , Cesárea/efeitos adversos , Feminino , Humanos , Placenta Prévia/etiologia , Gravidez , Estudos Retrospectivos , Trombose/etiologia , Hemorragia Uterina/etiologia , Hemorragia Uterina/prevenção & controle
6.
Transplant Proc ; 51(9): 2986-2990, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31711580

RESUMO

Left ventricular assist device (LVAD) management is very challenging since many adverse events can occur in ongoing patients. Inadequate anticoagulation treatment can lead to life-threatening situations like ischemic stroke or pump thrombosis. The main intention of our study was to investigate if early identification of aspirin nonresponders by using aggregometry can improve anticoagulation management, reducing the risk of pump thrombosis. METHODS: From December 2010 to May 2018, 24 patients were implanted with a HeartMate II (HMII), 6 received a HeartWare HVAD system--full support VAD (HVAD), and 22 received a HeartMate III (HMIII). All patients were maintained with a target INR of 2.0 to 3.0. When the aggregometry test revealed a normal platelet function, 100 mg of aspirin were initiated. Only aspirin nonresponders were early identified by repeating the aggregometry after 7 days of aspirin administration. In acetylsalicylic acid nonresponder patients, 75 mg of clopidogrel was used, and the patients were tested again. Ticlopidine (250 mg) was used when clopidogrel was unsuccessful. RESULTS: Four patients required modification in antiplatelet therapy. Three patients (5%), 2 HVAD and 1 HMII, suffered from pump thrombosis. One patient died as a consequence of a large intracranial hemorrhagic event following thrombolytic treatment. One patient required a pump exchange; in 1 patient, thrombolytic infusion was conducted successfully. CONCLUSION: Reported rates of pump thrombosis at 12 months for patients implanted with commonly used LVADs were 6% to 12% for axial-flow pumps and 8% with centrifugal-flow devices. In our series, the reported 5% overall incidence of pump thrombosis encourages the routine use of an aggregometry test for early identification of aspirin nonresponders.


Assuntos
Aspirina/uso terapêutico , Testes de Coagulação Sanguínea/métodos , Coração Auxiliar/efeitos adversos , Inibidores da Agregação de Plaquetas/uso terapêutico , Trombose/etiologia , Trombose/prevenção & controle , Coagulação Sanguínea/efeitos dos fármacos , Resistência a Medicamentos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Medição de Risco , Trombose/epidemiologia
7.
Clin Biochem ; 74: 54-59, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31669512

RESUMO

BACKGROUND: In order to manage risks of bleeding and thrombosis after some surgical procedures, platelet function is often measured repeatedly over days or weeks using laboratory tests of platelet function. To interpret test results in the perioperative period, it is necessary to understand analytical, biological and between-person variation. METHODS: We collected three separate blood specimens from 16 healthy volunteers on the first study day, and one additional specimen from each volunteer 1, 2, and 3 months later. Arachidonic acid-induced and adenosine diphosphate (ADP)-induced platelet function were measured in duplicate by whole blood impedance aggregometry using Multiplate (ASPI/ADP tests) and VerifyNow (Aspirin Reaction Units [ARU] and P2Y12 Reaction Units [PRU]). The analytical variation (CVA), within-subject variation (CVI), between-subject variation (CVG), index of individuality (II), and reference change values (RCV) were calculated. RESULTS: VerifyNow ARU demonstrated the smallest short-term and long-term variability (CVA, CVI, and CVG ~1%), resulting in short- and long-term RCV values <5%. II was also higher (1.92) for VerifyNow ARU than other platelet function tests. Multiplate ASPI and ADP tests had the highest RCV both short-(19.0% and 25.2%, respectively) and long-term (32.1% and 39.6%, respectively) due to increased CVA (>5%) and CVI (3.9-13.1%). VerifyNow PRU had a lower RCV than Multiplate ADP; but was the only test with II <0.6. CONCLUSIONS: VerifyNow ARU results can be interpreted relative to a fixed cut-off or population-based reference interval; or relative to small changes in an individual's previous values. VerifyNow PRU and Multiplate ASPI and ADP tests should only be interpreted based upon relative change; and can only distinguish relatively large (>23%) changes over several weeks.


Assuntos
Variação Biológica da População/fisiologia , Testes de Função Plaquetária , Difosfato de Adenosina/farmacologia , Ácido Araquidônico/farmacologia , Aspirina/farmacologia , Feminino , Seguimentos , Hemorragia/prevenção & controle , Humanos , Masculino , Distribuição Normal , Agregação Plaquetária/efeitos dos fármacos , Inibidores da Agregação de Plaquetas/farmacologia , Valores de Referência , Trombose/prevenção & controle
8.
High Blood Press Cardiovasc Prev ; 26(5): 413-420, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31617197

RESUMO

INTRODUCTION: Population ageing in developed countries will inevitably increase the need for knee and hip replacement surgery. Over the years, direct oral anticoagulants, such as rivaroxaban, have been widely used for thromboprophylaxis in patients undergoing knee and hip replacement surgery. The study of pharmacogenetic characteristics of rivaroxaban is important for enhancing the effectiveness and safety of rivaroxaban thromboprophylaxis. AIM: Evaluation of CYP3A4, CYP3A5 and ABCB1 gene polymorphisms influence on rivaroxaban pharmacokinetics and prothrombin time dynamics in patients undergoing total hip and knee replacement surgery. METHODS: The study included 78 patients undergoing total hip and knee replacement surgery. The patients received 10 mg of rivaroxaban once a day. Genotyping of polymorphisms ABCB1 rs1045642, ABCB1 rs4148738, CYP3A4 rs35599367 and CYP3A5 rs776746 was performed. Peak steady-state and trough steady-state rivaroxaban concentrations were determined. Prothrombin time was also evaluated. RESULTS: The study revealed the following haplotypes: (1) ABCB1 rs1045642-CYP3A4 rs35599367 and (2) ABCB1 rs4148738-CYP3A4 rs35599367. The analysis of the peak steady-state rivaroxaban concentration between mutant haplotypes and wild haplotypes revealed no significant differences. However, there was a statistically significant average correlation between peak steady-state rivaroxaban concentration and prothrombin time (r = 0.421; r2 = 0.178; p < 0.001). CONCLUSION: No significant difference was identified in peak steady-state rivaroxaban concentration between mutant haplotypes and wild haplotypes. The revealed statistically significant average correlation between the prothrombin time and peak steady-state rivaroxaban concentration is important in clinical practice for assessing the anticoagulant activity of rivaroxaban.


Assuntos
Artroplastia de Quadril , Artroplastia do Joelho , Citocromo P-450 CYP3A/genética , Inibidores do Fator Xa/farmacocinética , Variantes Farmacogenômicos/genética , Rivaroxabana/farmacocinética , Trombose/prevenção & controle , Subfamília B de Transportador de Cassetes de Ligação de ATP/genética , Subfamília B de Transportador de Cassetes de Ligação de ATP/metabolismo , Idoso , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Citocromo P-450 CYP3A/metabolismo , Monitoramento de Medicamentos/métodos , Inibidores do Fator Xa/administração & dosagem , Feminino , Haplótipos , Humanos , Masculino , Pessoa de Meia-Idade , Tempo de Protrombina , Rivaroxabana/administração & dosagem , Trombose/etiologia , Resultado do Tratamento
9.
Khirurgiia (Mosk) ; (10): 75-81, 2019.
Artigo em Russo | MEDLINE | ID: mdl-31626243

RESUMO

Postoperative complications in vascular surgery may be partly provoked by suture material. Analysis of the mechanisms of these complications may be useful for their prevention. Mechanisms of suture-induced thrombosis and neointimal hyperplasia, possible strategies for prevention of postoperative complications including those allowing drug deliveries directly to the vascular anastomosis area are discussed in the article. According to the literature data, heparin is the most optimal drug for modifying suture material and prevention of thrombosis and neointimal hyperplasia. Heparin delivery to the vascular anastomosis site will reduce the risk of thrombosis by inhibiting the activity of thrombin. Complex of heparin and antithrombin III increases inhibitory effect of antithrombin against thrombin. In addition, heparin is able to reduce proliferation of vascular smooth muscle cells through inhibition of the synthesis of extracellular matrix proteases involved in migration and proliferation of cells. Thus, heparin delivery to the vascular injury site may be used to prevent thrombosis and myoproliferative response. Moreover, this strategy prevents complications associated with systemic administration of anticoagulants.


Assuntos
Suturas/efeitos adversos , Trombose/prevenção & controle , Doenças Vasculares/prevenção & controle , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Anticoagulantes/administração & dosagem , Heparina/administração & dosagem , Humanos , Hiperplasia/etiologia , Hiperplasia/patologia , Hiperplasia/prevenção & controle , Neointima/patologia , Trombose/etiologia , Doenças Vasculares/etiologia
10.
BMJ ; 367: l5476, 2019 Oct 10.
Artigo em Inglês | MEDLINE | ID: mdl-31601578

RESUMO

OBJECTIVE: To assess the effects of different oral antithrombotic drugs that prevent saphenous vein graft failure in patients undergoing coronary artery bypass graft surgery. DESIGN: Systematic review and network meta-analysis. DATA SOURCES: Medline, Embase, Web of Science, CINAHL, and the Cochrane Library from inception to 25 January 2019. ELIGIBILITY CRITERIA: for selecting studies Randomised controlled trials of participants (aged ≥18) who received oral antithrombotic drugs (antiplatelets or anticoagulants) to prevent saphenous vein graft failure after coronary artery bypass graft surgery. MAIN OUTCOME MEASURES: The primary efficacy endpoint was saphenous vein graft failure and the primary safety endpoint was major bleeding. Secondary endpoints were myocardial infarction and death. RESULTS: This review identified 3266 citations, and 21 articles that related to 20 randomised controlled trials were included in the network meta-analysis. These 20 trials comprised 4803 participants and investigated nine different interventions (eight active and one placebo). Moderate certainty evidence supports the use of dual antiplatelet therapy with either aspirin plus ticagrelor (odds ratio 0.50, 95% confidence interval 0.31 to 0.79, number needed to treat 10) or aspirin plus clopidogrel (0.60, 0.42 to 0.86, 19) to reduce saphenous vein graft failure when compared with aspirin monotherapy. The study found no strong evidence of differences in major bleeding, myocardial infarction, and death among different antithrombotic therapies. The possibility of intransitivity could not be ruled out; however, between-trial heterogeneity and incoherence were low in all included analyses. Sensitivity analysis using per graft data did not change the effect estimates. CONCLUSIONS: The results of this network meta-analysis suggest an important absolute benefit of adding ticagrelor or clopidogrel to aspirin to prevent saphenous vein graft failure after coronary artery bypass graft surgery. Dual antiplatelet therapy after surgery should be tailored to the patient by balancing the safety and efficacy profile of the drug intervention against important patient outcomes. STUDY REGISTRATION: PROSPERO registration number CRD42017065678.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Fibrinolíticos/uso terapêutico , Inibidores da Agregação de Plaquetas/uso terapêutico , Trombose/prevenção & controle , Humanos , Meta-Análise em Rede , Ensaios Clínicos Controlados Aleatórios como Assunto
11.
Expert Opin Drug Saf ; 18(12): 1171-1189, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31623473

RESUMO

Introduction: Potent platelet inhibition reduces the risk of thrombotic complications including myocardial infarction and death in patients with acute coronary syndrome (ACS). Targeting different pathways involved in thrombotic processes have synergistic effects and more effectively counteract thrombosis both in the acute and long-term following an ACS. Unavoidably, more potent platelet inhibition increases the risk of bleeding. In light of the adverse prognostic implications associated with bleeding, including increased mortality, safety aspects with antiplatelet therapy have gained increased importance.Areas covered: This review aims at describing the safety of different antiplatelet agents, particularly with regards to the risk of bleeding complications, used in the management of ACS patients. New bleeding reduction strategies to enhance the safety of antiplatelet therapy are also reviewed.Expert opinion: The final goal of a well-structured antiplatelet treatment strategy is that of tackling the spectrum of ischemic risk without compromising patient safety. A simple mnemonic rule for guiding therapeutic decisions in this complex clinical scenario can be summarized with the acronym 'ABC', meaning the sequential process of assessing, balancing and customizing treatment strategies in individual patients on the tradeoff between bleeding and ischemic risk. This approach is recommended for maximizing the ischemic benefits, while preserving safety, with the use of antiplatelet therapy.


Assuntos
Síndrome Coronariana Aguda/tratamento farmacológico , Hemorragia/induzido quimicamente , Inibidores da Agregação de Plaquetas/efeitos adversos , Síndrome Coronariana Aguda/complicações , Hemorragia/epidemiologia , Hemorragia/prevenção & controle , Humanos , Inibidores da Agregação de Plaquetas/administração & dosagem , Trombose/etiologia , Trombose/prevenção & controle
12.
J Cardiovasc Surg (Torino) ; 60(5): 624-632, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31486613

RESUMO

INTRODUCTION: Recently transcatheter aortic valve replacement (TAVR) has emerged as a feasible alternative for traditional surgical aortic valve replacement (SAVR) in patients with intermediate to high risk. There is currently no clear consensus regarding the optimal antiplatelet strategy after TAVR. The primary objective of this updated meta-analyses was to compare the outcomes of dual antiplatelet therapy (DAPT) versus single antiplatelet therapy (SAPT) following TAVR. EVIDENCE ACQUISITION: A meta-analysis of eligible studies of patients undergoing TAVR which reported our outcomes of postoperative DAPT in comparison with SAPT, was carried out. The outcomes included the all-cause mortality, stroke, major/life-threatening bleeding, myocardial infarction and a composite endpoint of mortality, stroke, bleeding and myocardial infarction. EVIDENCE SYNTHESIS: Three randomized controlled trials (RCTs, N.=421) and 5 observational studies (N.=6683) were included in this updated meta-analysis. All-cause mortality was comparable between the two groups (OR 1.13 [95% CI: 0.70-1.81], P=0.619). Besides, DAPT resulted in an augmented risk of major/life-threatening bleeding (OR 2.45 [95% CI: 1.08-5.59], P=0.032). No statistically significant difference was found between the two groups in the rates of stroke (OR 0.83 [95% CI: 0.62-1.10], P=0.212) and myocardial infarction (OR 1.17 [95% CI: 0.47-2.91], P=0.728). And DAPT led to an increased rate of the composite endpoint (OR 2.39 [95% CI: 1.63-3.50], P<0.0001). CONCLUSIONSː The updated meta-analysis presents the evidence that post-TAVR DAPT increases bleeding events, with no benefit in survival and ischemic events, in comparison with SAPT. Nevertheless, it is currently difficult to evaluate by a meta-analysis the effectiveness of DAPT versus SAPT to prevent the valve thrombosis resulting in leaflet dysfunction, due to a limited number of existing publications. Additional RCTs are needed to determine the optimal antiplatelet strategy after TAVR.


Assuntos
Estenose da Valva Aórtica/cirurgia , Valva Aórtica/cirurgia , Inibidores da Agregação de Plaquetas/administração & dosagem , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/mortalidade , Esquema de Medicação , Quimioterapia Combinada , Feminino , Hemorragia/induzido quimicamente , Hemorragia/mortalidade , Humanos , Masculino , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/prevenção & controle , Inibidores da Agregação de Plaquetas/efeitos adversos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/prevenção & controle , Trombose/mortalidade , Trombose/prevenção & controle , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento
14.
Pediatr Cardiol ; 40(7): 1523-1529, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31375852

RESUMO

Acute femoral artery occlusion is common in pediatric patients following cardiac catheterization. A variety of means are utilized to assess lower extremity (LE) perfusion and arterial patency following cardiac catheterization including palpation of pulses, pulse oximetry, subjective assessment of lower extremity color and temperature, and ultrasound. We sought to evaluate the utility of Near-Infrared Spectroscopy (NIRS) to monitor LE perfusion in pediatric patients undergoing cardiac catheterization. INVOS pediatric sensors were placed on bilateral LE in all pediatric patients ≤ 40 kg undergoing cardiac catheterization. Data were recorded continuously from the start of the procedure until 4-6 h after completion of the procedure. NIRS readings were compared between the accessed versus non-accessed LE at baseline before start of case, time of vascular access, arterial sheath exchange when applicable, sheath withdrawal, and Safeguard application, deflation, and removal. 133 patients underwent 152 catheterizations with mean age 2.4 ± 2.3 years and mean weight 12.4 ± 13.2 kg. NIRS oximetry readings were significantly decreased in the LE with arterial access compared to non-accessed LE from time of sheath insertion until removal of the pressure assist device post procedure. A greater difference was noted in smaller patients. NIRS oximetry readings did not correlate with subjective assessment of lower extremity perfusion after arterial sheaths were removed. One patient had pulse loss 4 h post procedure with a decrease in oximetry readings noted at this point on review. Weight-based heparin protocol was initiated, and a gradual improvement in oximetry readings was noted over the next 5 h. Vascular ultrasound 12 h later showed no evidence of arterial thrombus. NIRS may be helpful in identifying patients who are risk for developing arterial thrombus post cardiac catheterization and for monitoring response to therapy; however, further study in these patients is warranted.


Assuntos
Cateterismo Cardíaco/efeitos adversos , Extremidade Inferior/irrigação sanguínea , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Arteriopatias Oclusivas/diagnóstico , Encéfalo/irrigação sanguínea , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Oximetria/métodos , Trombose/etiologia , Trombose/prevenção & controle , Ultrassonografia Doppler
15.
Lupus ; 28(10): 1181-1188, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31345117

RESUMO

Antiphospholipid syndrome an autoimmune disease characterized by thrombosis and/or pregnancy morbidity alongside the presence of antiphospholipid antibodies (aPL). This review evaluates primary and secondary thromboprophylaxis in patients with aPL and thrombotic events. In primary thromboprophylaxis a risk-stratified approach is needed based on aPL, comorbidity with other autoimmune conditions and cardiovascular vascular risk factors. In primary thromboprophylaxis, the efficacy of low-dose aspirin is debatable and requires better-designed controlled studies. So far warfarin has not been shown to improve venous and/or arterial thrombosis incidence in aPL carriers and instead increased safety concerns. The benefit of hydroxychloroquine is inconclusive despite promising data, requiring large, controlled trials. For secondary thromboprophylaxis warfarin seems to be the best option with potential in renal transplant recipients and better efficacy at high intensity, although maintenance of target international normalized ratio needs careful monitoring. Aspirin has not shown to be beneficial, and data on rivaroxaban are limited and contradictory. Despite all data being informative, there are limitations that need to be addressed with robust clinical trials.


Assuntos
Anticoagulantes/administração & dosagem , Síndrome Antifosfolipídica/complicações , Trombose/prevenção & controle , Anticorpos Antifosfolipídeos/imunologia , Síndrome Antifosfolipídica/imunologia , Doenças Autoimunes/complicações , Humanos , Coeficiente Internacional Normatizado , Fatores de Risco , Trombose/etiologia
16.
Cancer Treat Res ; 179: 37-54, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31317479

RESUMO

For over 100 years, a link has been recognized between thrombosis and cancer. However, whether this was a causal or correlational relationship was debated. It is now well established that cancer and thrombosis are mechanistically related in intricate ways and can directly fuel each other. Here, we present an historical perspective of platelets and how their physiological function in hemostasis can contribute to tumor development and metastasis. This emerging field has garnered great interest as aspirin therapy has been proposed as a prevention strategy for some malignancies. We highlight the advances that have been made, presenting platelets as a key component that supports many of the hallmarks of cancer that have been described and conclude with future directions and studies that are needed to clarify the role of platelets in cancer and solidify platelet modulating therapies within oncology.


Assuntos
Plaquetas/fisiologia , Hemostasia/fisiologia , Neoplasias/fisiopatologia , Trombose/fisiopatologia , Plaquetas/efeitos dos fármacos , Hemostasia/efeitos dos fármacos , Humanos , Neoplasias/complicações , Neoplasias/prevenção & controle , Trombose/etiologia , Trombose/prevenção & controle
17.
Cancer Treat Res ; 179: 55-68, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31317480

RESUMO

Cancer and its treatments are commonly complicated by venous thromboembolism (VTE), but there is a substantial variation in risk between individual cancer patients. The risk of VTE in cancer patients is influenced by multiple risk factors including primary site of cancer, stage, comorbidities, use of specific antineoplastic agents. Several biomarkers have been associated with subsequent VTE including D-dimer and tissue factor, although no single risk factor or biomarker accurately is predictive of VTE on its own. The risk of VTE is best predicted by a validated risk assessment score. Cancer patients at risk of VTE benefit from thromboprophylaxis, supported by evidence in the setting of hospitalization for acute medical illness and surgery, and emerging data from two large randomized trials in the outpatient setting. This chapter focuses on approaches to identifying risk of VTE and approaches to reducing this risk with appropriate thromboprophylaxis.


Assuntos
Neoplasias/complicações , Tromboembolia Venosa/prevenção & controle , Anticoagulantes/uso terapêutico , Quimioprevenção , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Trombose/etiologia , Trombose/prevenção & controle , Tromboembolia Venosa/etiologia
18.
Cancer Treat Res ; 179: 87-101, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31317482

RESUMO

Cancer patients have an increased risk of thrombosis. The development of cancer thrombosis is dependent on a number of factors including cancer type, stage, various biologic markers, and the use of central venous catheters. In addition, cancer treatment itself may increase thrombotic risk. Tamoxifen increases the risk of venous thromboembolism (VTE) by two- to sevenfold, while an impact on risk of arterial thrombosis is uncertain. Immunomodulatory imide drugs (IMiDs) such as thalidomide and lenalidomide increase the risk of VTE in patients with multiple myeloma (MM) by about 10-40% when given in combination with glucocorticoids or other chemotherapy agents; the risk of VTE in MM patients treated with IMiD-containing regimens necessitates that such patients receive thromboprophylaxis with aspirin, low-molecular-weight heparin, or warfarin. Among cytotoxic chemotherapy agents, cisplatin, and to a lesser extent fluorouracil, has been described in association with thrombosis. L-asparaginase in treatment of acute lymphoblastic leukemia is significantly associated with increased thrombosis particularly affecting the CNS, which may be due to acquired antithrombin deficiency; at some centers, plasma infusions or antithrombin replacement is used to mitigate this. Bevacizumab, an inhibitor of vascular endothelial growth factor, increases arterial and possibly venous thrombotic risk, although the literature is conflicting about the latter. Supportive care agents in cancer care, such as erythropoiesis-stimulating agents, granulocyte colony stimulating factor, and steroids, also have some impact on thrombosis. This review summarizes the mechanisms by which these and other therapies modulate thrombotic risks and how such risks may be managed.


Assuntos
Antineoplásicos/efeitos adversos , Neoplasias/tratamento farmacológico , Trombose/tratamento farmacológico , Anticoagulantes/uso terapêutico , Antineoplásicos/uso terapêutico , Humanos , Neoplasias/complicações , Fatores de Risco , Trombose/etiologia , Trombose/prevenção & controle , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle
19.
J Orthop Surg Res ; 14(1): 214, 2019 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-31307499

RESUMO

BACKGROUND: Questions remain, mainly concerning whether tranexamic acid (TXA) is truly safe since all available trials were underpowered to identify clinically important differences. The objective of this study is to evaluate the safety of TXA by using a novel technique-thromboelastography (TEG). METHODS: A retrospective review was conducted on 359 consecutive patients who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) and received multiple-dose or single-dose of TXA at a tertiary academic center. TEG parameters, TEG coagulation status, conventional coagulation test parameters, and incidence of thrombotic events were used for safety evaluation. RESULTS: Compared with single-dose cohort, patients who received multiple-dose of TXA had consistent statistically significant shortened R times on post-operative day 1 (POD1) and POD3 in both THA (POD1: 4.06 ± 0.71 s versus 4.45 ± 1.28 s, P = 0.011; POD3: 4.36 ± 0.83 s versus 5.12 ± 1.64 s, P < 0.0001) and TKA (POD1: 3.90 ± 0.73 s versus 4.29 ± 0.92 s, P = 0.011; POD3: 4.24 ± 0.94 s versus 4.65 ± 1.07 s, P = 0.023), while the K, α-angle, and MA values were similar during the perioperative period. TEG coagulation status analysis indicated that patients were significantly (P = 0.003) more likely with hypercoagulable status during the course of multiple-dose TXA. Conventional coagulation test parameters were similar. Only one patient developed calf vein thrombosis in the multiple-dose cohort. CONCLUSIONS: Multiple-dose of TXA was associated with aggravated hypercoagulable state when compared with single-dose of TXA, but this prothrombotic state does not provoke thrombosis when combined with appropriate anticoagulant therapy. Therefore, multiple-dose of TXA remains safe and could be recommended for clinical practice. Potential benefits and possible risks should be trade-off when considering increasing the dosage and frequency of TXA on the present basis. TRIAL REGISTRATION: ChiCTR1800015422 .


Assuntos
Antifibrinolíticos/administração & dosagem , Artroplastia de Quadril/tendências , Artroplastia do Joelho/tendências , Tromboelastografia/métodos , Ácido Tranexâmico/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/administração & dosagem , Antifibrinolíticos/efeitos adversos , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Estudos de Coortes , Relação Dose-Resposta a Droga , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Trombose/induzido quimicamente , Trombose/prevenção & controle , Ácido Tranexâmico/efeitos adversos
20.
World Neurosurg ; 129: e695-e699, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31279757

RESUMO

BACKGROUND: An appropriate time (5-7 days) of discontinuation of low-dose acetylsalicylic acid (ASA) in patients undergoing surgery for chronic subdural hematoma (CSDH) is recommended. However, patient clinical deterioration often does not allow to wait the recommended time for surgery. Clear guidelines regarding the perioperative management of patients with ASA therapy are still lacking. The aim of this study is to compare the surgical outcome, complications, and mortality of patients suffering from CSDHs who underwent urgent surgery or before and after 5 days of discontinuation of low-dose ASA. METHODS: A retrospective 3-center study included patients treated for CSDH taking low-dose ASA. Aspirin was discontinued on hospital admission. Based on the timing of discontinuation, we classified patients in 3 groups: urgent (surgery at admission), surgery within 5 days, and surgery 5 days after discontinuation. Surgery consisted of minicraniotomy or burr holes. Variables analyzed were age, comorbidities, modified Rankin Scale, complications, rebleedings, and mortality. Outcome measures were acute rebleeding requiring surgery, recurrence, mortality, complications, and clinical conditions. The χ2 test and the Fisher exact test were used to compare variables. Logistic regression analysis was used for defining the impact on outcome measures. RESULTS: We enrolled 164 patients. After aspirin discontinuation, patients underwent surgery: on admission (69 cases [42.1%]), within 5 days (59 patients [36%]), and after 5 days (36 cases [22%]). No correlation was observed between time of discontinuation and outcome measures, including having a worse clinical outcome. CONCLUSIONS: Our data showed that the time of discontinuation of ASA does not influence outcome.


Assuntos
Aspirina/uso terapêutico , Hematoma Subdural Crônico/cirurgia , Inibidores da Agregação de Plaquetas/uso terapêutico , Trombose/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Aspirina/administração & dosagem , Feminino , Humanos , Masculino , Inibidores da Agregação de Plaquetas/administração & dosagem , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Suspensão de Tratamento
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