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1.
Vasc Health Risk Manag ; 18: 701-710, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36082196

RESUMO

Introduction: Venous thromboembolism (VTE) is the most preventable complication in hospitalized patients. The main objective of this study was to evaluate the adherence of current clinical practice to the established guidelines at a Palestinian teaching hospital. Methods: This cross-sectional, retrospective, observational study was conducted at a Palestinian Teaching Hospital. The medical records of patients admitted to the medical floor over 18 years of age and hospitalized for longer than 24 hours between January 1 and May 31, 2019, were included. Patients taking anticoagulants with incomplete or duplicated medical records were excluded from the study. A data collection sheet was developed, and clotting and bleeding risks were assessed using the Padua and IMPROVE risk assessment models (scores). The data were analyzed using IBM SPSS (version 25). Results: In total, 408 patients were included in the study, 222 of whom received thromboprophylaxis (54.4%). Of the hospitalized patients, 112 (27.5%) had a high risk of developing VTE (Padua score ≥ 4), and 73 patients were eligible for VTE pharmacological prophylaxis; however, only 44 (60.3%) received the appropriate prophylaxis. In addition, 296 patients had low Padua scores, indicating that pharmacological prophylaxis was not indicated. However, 144 (48.6%) patients received prophylaxis. The mean Padua and IMPROVE risk scores were 2.25 ± 2.08 and 4.44 ± 2.72, respectively. Among the patients, 17.6% had a high risk of bleeding (IMPROVE score ≥ 7). Conclusion: VTE prophylaxis among hospitalized medically ill patients was mostly inappropriate; 80.18% of the patients received inappropriate prophylaxis, and only 60.3% of eligible patients received appropriate prophylaxis. Adapting assessment models or checklists in clinical practice based on clinical guidelines for VTE risk stratification is a practical and effective method to improve VTE prophylaxis management and select the appropriate therapy to prevent toxicity or complication.


Assuntos
Tromboembolia Venosa , Adolescente , Adulto , Anticoagulantes/efeitos adversos , Estudos Transversais , Humanos , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/prevenção & controle
2.
Rev Med Suisse ; 18(794): 1638-1643, 2022 Sep 07.
Artigo em Francês | MEDLINE | ID: mdl-36082382

RESUMO

In cases of severe bleeding on direct oral anticoagulant (DOAC) therapy, several hemostatic agents can be used with varying levels of evidence, including fresh frozen plasma and prothrombin complex concentrates. Recently, we have seen the emergence of specific antidotes to DOAC, such as idarucizumab and andexanet alfa, effective on anti-II and anti-Xa DOAC respectively. These new molecules have shown excellent biological efficacy, hence supporting their use in clinical practice, however they are not routinely used, mainly due to limited availability and high cost. Ciraparantag, an antagonist of DOAC and heparins currently in phase III trials, could become a key molecule in the future considering encouraging preliminary results.


En cas d'hémorragie sévère sous traitement par un anticoagulant oral direct (ACOD), plusieurs agents hémostatiques peuvent être utilisés avec un niveau d'évidence variable, notamment le plasma frais congelé et les concentrés de complexe prothrombinique. Récemment, nous avons vu l'émergence d'antidotes spécifiques aux ACOD, comme l'idarucizumab et l'andexanet alfa, neutralisant les ACOD anti-II et anti-Xa respectivement. Ces nouvelles molécules ont montré une bonne efficacité biologique justifiant leur utilisation en pratique mais leur administration n'est pas encore systématique, en raison notamment d'une disponibilité restreinte et d'un coût élevé. Le ciraparantag, antagoniste des ACOD et des héparines, en cours d'étude de phase III, pourrait devenir une molécule clé à l'avenir au vu de résultats préliminaires encourageants.


Assuntos
Anticoagulantes , Dabigatrana , Administração Oral , Anticoagulantes/farmacologia , Anticoagulantes/uso terapêutico , Antídotos/uso terapêutico , Dabigatrana/uso terapêutico , Hemorragia/tratamento farmacológico , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Proteínas Recombinantes
3.
Rev Med Suisse ; 18(794): 1671-1676, 2022 Sep 07.
Artigo em Francês | MEDLINE | ID: mdl-36082387

RESUMO

This article reviews the management of transient ischemic attack (TIA) in 2022. There is an important risk of developing a stroke within the first weeks after a TIA and this risk may be significantly reduced with appropriate management. Clinical scores coupled with imaging allow risk stratification. Brain imaging (CT scan and/or MRI) is an essential part of the diagnostic approach and should be performed within 24h. Etiological investigations including vascular and cardiac workup should be scheduled. Therapeutic options include antiplatelet therapy, anticoagulant therapy in case of atrial fibrillation, recanalization in case of symptomatic carotid stenosis, and for all patients a strategy to reduce cardiovascular risk factors.


Cet article passe en revue la prise en charge de l'accident ischémique transitoire (AIT) en 2022. Il existe un risque important de présenter un AVC dans les semaines suivant un AIT qui peut être significativement réduit grâce à une prise en charge adéquate. Les scores cliniques couplés à l'imagerie permettent la stratification du risque. L'imagerie cérébrale constitue une partie indispensable de l'approche diagnostique et doit être réalisée dans les 24 heures. De même, la recherche étiologique incluant un bilan vasculaire et cardiaque est essentielle. Les options thérapeutiques comprennent le traitement antiplaquettaire et anticoagulant en cas de fibrillation auriculaire, une recanalisation lors de sténose carotidienne symptomatique et pour tout patient une stratégie de réduction des facteurs de risque cardiovasculaire.


Assuntos
Fibrilação Atrial , Estenose das Carótidas , Ataque Isquêmico Transitório , Acidente Vascular Cerebral , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/terapia , Humanos , Ataque Isquêmico Transitório/diagnóstico , Ataque Isquêmico Transitório/etiologia , Ataque Isquêmico Transitório/terapia , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/terapia
4.
Ren Fail ; 44(1): 1501-1518, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-36047812

RESUMO

BACKGROUND: A significant proportion of incident and prevalent hemodialysis patients have central venous catheters for vascular access. No consensus is available on the prevention of catheter dysfunction or catheter-related bloodstream infections in patients undergoing hemodialysis by means of catheter lock solutions. METHOD: We reviewed the effects of single and combined anticoagulants with antibacterial catheter lock solutions or other antimicrobials for the prevention of thrombosis or infections in hemodialysis patients. Relative risks with 95% confidence intervals for trials of the same type of catheter locking solution were pooled. SOURCES OF INFORMATION: We included original research articles in English from PubMed, EMBASE, SpringerLink, Elsevier and Ovid using the search terms 'hemodialysis,' 'central venous catheter,' 'locking solution,' 'UFH,' 'low molecular weight heparin,' 'EDTA,' 'citrate,' 'rt-PA,' 'urokinase,' 'gentamicin,' 'vancomycin', 'taurolidine,' 'sodium bicarbonate,' 'hypertonic saline' and 'ethanol' and 'catheter'. FINDINGS: Low-dose heparin lock solution (< 5000 U/ml) can efficiently achieve anticoagulation and will not increase the risk of bleeding. Low-concentration citrate (< 5%) combined with rt-PA can effectively prevent catheter infection and dysfunction. Catheter-related infections may be minimized by choosing the appropriate antibiotic and dose. LIMITATIONS: There is a lack of follow-up validation data for LMWH, EDTA, taurolidine, sodium bicarbonate, ethanol, and other lock solutions. IMPLICATIONS: Since catheterization is common in hemodialysis units, studies on long-term treatment and preventative strategies for catheter dysfunction and catheter-related infection are warranted.


Assuntos
Infecções Relacionadas a Cateter , Cateterismo Venoso Central , Cateteres Venosos Centrais , Antibacterianos/uso terapêutico , Anticoagulantes/uso terapêutico , Infecções Relacionadas a Cateter/microbiologia , Cateteres Venosos Centrais/efeitos adversos , Citratos/efeitos adversos , Ácido Cítrico , Ácido Edético , Heparina/uso terapêutico , Heparina de Baixo Peso Molecular , Humanos , Diálise Renal/efeitos adversos , Bicarbonato de Sódio
5.
BMC Med ; 20(1): 326, 2022 09 02.
Artigo em Inglês | MEDLINE | ID: mdl-36056426

RESUMO

BACKGROUND: Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The 'Atrial fibrillation Better Care' (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. METHODS: From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. RESULTS: Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58-0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52-0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58-0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56-0.98) and composite outcome (aHR: 0.76, 95%CI 0.60-0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. CONCLUSIONS: An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients.


Assuntos
Fibrilação Atrial , Acidente Vascular Cerebral , Anticoagulantes/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/epidemiologia , Humanos , Sistema de Registros , Fatores de Risco , Acidente Vascular Cerebral/complicações
6.
Ann Med ; 54(1): 2411-2419, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-36062815

RESUMO

BACKGROUND: Literature suggests that different risks of mortality could influence physicians in prescribing or not anticoagulants in older patients with atrial fibrillation (AF). The Multidimensional Prognostic Index (MPI) can be considered a tool for the detection of multidimensional frailty. The aim of this cross-sectional study was to evaluate whether prescription patterns of oral anticoagulants exist, based on MPI values. METHODS: Older hospitalised patients (age ≥ 65 years) with non-valvular AF were included across 24 European centres. MPI was calculated using validated and standardised tools derived from a comprehensive geriatric assessment. Other functional and clinical information were collected to calculate indexes specific for haemorrhagic and thromboembolic risk in AF. RESULTS: Altogether, 2,012 participants affected by AF (mean age was 83.2 ± 7.5, range: 65-104 years), with a higher presence of women (57.0%), were included. Overall, 440 took vitamin K antagonists VKAs (22.0%), 667 (33.4%) direct oral anticoagulants (DOACs), whilst 44.6% did not take any anticoagulant treatment. Prescription of anticoagulants was associated with MPI values, with people taking anticoagulants having lower mean MPI values. Anticoagulant therapy was not used in 53.1% of the group with the highest risk of mortality, compared with 32.3% of those in the group with the lowest mortality risk. People with higher scores in MPI were less frequently treated with anticoagulant therapy, after adjusting for several potential confounders. CONCLUSIONS: The EURopean study of Older Subjects with Atrial Fibrillation (EUROSAF) suggested that almost half of the older persons with AF do not receive anticoagulants and that MPI is an important determinant in prescribing or not anticoagulants. Trial Registration: https://clinicaltrials.gov/ct2/show/NCT02973984KEY POINTSAtrial fibrillation is a common condition in older people. The data regarding the use of anticoagulants is mainly derived from randomised controlled trials that do not include a sufficient number of older frail people.Our study suggests that a consistent part of older people affected by atrial fibrillation was not treated with anticoagulants, in particular, older frail patients; however, it is unclear if this choice is supported or not by evidence.The prognostic evaluation through the multidimensional prognostic index could be useful information for the choice in the prescription of anticoagulants in older people affected by atrial fibrillation.


Assuntos
Fibrilação Atrial , Acidente Vascular Cerebral , Administração Oral , Idoso , Idoso de 80 Anos ou mais , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Estudos Transversais , Feminino , Humanos , Prescrições , Prognóstico , Estudos Prospectivos , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle
7.
Sci Rep ; 12(1): 15127, 2022 Sep 06.
Artigo em Inglês | MEDLINE | ID: mdl-36068249

RESUMO

Evidence is mounting that the nature of the lipid bound to the endothelial cell protein C receptor (EPCR) has an impact on its biological roles, as observed in anticoagulation and more recently, in autoimmune disease. Phosphatidylethanolamine and phosphatidylcholine species dominate the EPCR lipid cargo, yet, the extent of diversity in the EPCR-associated lipid repertoire is still unknown and remains to be uncovered. We undertook mass spectrometry analyses to decipher the EPCR lipidome, and identified species not yet described as EPCR ligands, such as phosphatidylinositols and phosphatidylserines. Remarkably, we found further, more structurally divergent lipids classes, represented by ceramides and sphingomyelins, both in less abundant quantities. In support of our mass spectrometry results and previous studies, high-resolution crystal structures of EPCR in three different space groups point to a prevalent diacyl phospholipid moiety in EPCR's pocket but a mobile and ambiguous lipid polar head group. In sum, these studies indicate that EPCR can associate with varied lipid classes, which might impact its properties in anticoagulation and the onset of autoimmune disease.


Assuntos
Doenças Autoimunes , Fosfolipídeos , Anticoagulantes , Fatores de Coagulação Sanguínea , Receptor de Proteína C Endotelial , Humanos , Fosfolipídeos/química , Receptores de Superfície Celular
9.
Kardiologiia ; 62(8): 19-26, 2022 Aug 30.
Artigo em Russo, Inglês | MEDLINE | ID: mdl-36066983

RESUMO

Aim      To evaluate efficacy and safety of the anticoagulant therapy in patients with atrial fibrillation (AF) during a 36-month follow-up after an interventional treatment.Material and methods  This study included 302 patients aged 29 to 81 years with various forms of AF. Catheter ablation (CA) of AF foci was performed for all patients. The patients were divided into 3 groups: group 1 with paroxysmal AF, group 2 with persistent AF, and group 3 with longstanding persistent AF. Two subgroups were isolated in each group, with effective and ineffective CA. Results of the follow-up were analyzed at 12, 24, and 36 months after discharge from the hospital. The follow-up interview recorded complaints of palpitation attacks, effectiveness of administered CA, compliance with the treatment, adverse clinical outcomes, including thromboembolic complications (TEC), bleeding, and hospitalizations.Results Efficacy of the interventional treatment for 36 months was 65.3 % in patients with paroxysmal AF, 59.7 % in patients with persistent AF, and 57.1 % in patients with longstanding persistent AF. Patients with paroxysmal AF and effective CA had no adverse events throughout the same period during the antithrombotic treatment (ATT). In contrast, the group with ineffective ablation had both TEC and hemorrhagic complications during the ATT. In the group with persistent AF and effective CA throughout the follow-up period, TECs were less frequent than in the group of ineffective ablations during the ATT treatment. Patients with longstanding persistent AF and effective CA throughout the follow-up period, had no TECs in contrast to patients with ineffective ablation during the ATT treatment. There were no fatal outcomes in patients with effective procedure.Conclusion      A successful CA procedure for AF provides a significant decrease in the risk of ischemic stroke. Furthermore, the invasive strategy does not increase the risk of major and minor bleedings.


Assuntos
Fibrilação Atrial , Ablação por Cateter , Tromboembolia , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Seguimentos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Tromboembolia/induzido quimicamente , Tromboembolia/prevenção & controle , Resultado do Tratamento
10.
J Med Vasc ; 47(3): 125-132, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36055681

RESUMO

BACKGROUND: Over the past decades, thrombophilia testing in patients with venous thrombo-embolism has increased tremendously. However, the role of inherited thrombophilie in prediction the risk of recurrence remains controversial. Consequently, it is still unclear whether thrombophilia testing influences decisions regarding duration of anticoagulation in clinical practices. The aim of this study was to evaluate the impact if inherited thrombophilia on venous thrombosis treatment decisions and on predicting the risk of recurrence. METHODS: A retrospective longitudinal study (January 2011-Decembre 2016) including 131 patients with confirmed venous thrombo-embolism referred to the hematology laboratory from the internal medicine department for inherited thrombophilia screening was carried out. RESULTS: The mean age patients was 39.4 years and the sex ratio (M/F) was 0.61. Inherited thrombophilia was confirmed in 27.5% of patients. A long term anticoagulation was decided in 46.9% of patients with thrombophilia. There was no significant difference in the duration of anticoagulation between patients with or without thrombophilia. Thrombosis recurrence was recorded in 16 (17%) patients. The 24 years cumulative incidence of recurrence was 19% in patients with thrombophilia and 17% in those without (plog Rank= 0.6). Inherited thrombophilia was not associated with increased risk of recurrence after treatment withdrawal (Hazard ratio=1.31 IC (0.47-3.63); P=0.6). CONCLUSION: In clinical practice, inherited thrombophilia did not influence anticoagulation duration and was not associated with a higher venous thrombosis risk of recurrence. It seems to be less relevant for decision making than presumed.


Assuntos
Tromboembolia Venosa , Trombose Venosa , Adulto , Anticoagulantes/uso terapêutico , Humanos , Estudos Longitudinais , Estudos Retrospectivos , Fatores de Risco , Trombofilia , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/epidemiologia , Trombose Venosa/etiologia
11.
J Am Heart Assoc ; 11(17): e024970, 2022 Sep 06.
Artigo em Inglês | MEDLINE | ID: mdl-36056729

RESUMO

Background We investigated the predictors related to major bleeding events during treatment with edoxaban 15 mg in patients aged ≥80 years with nonvalvular atrial fibrillation and high bleeding risk, for whom standard oral anticoagulants are inappropriate, focusing on standard laboratory tests related to bleeding. Methods and Results This was a prespecified subanalysis of the on-treatment analysis set of the ELDERCARE-AF (Edoxaban Low-Dose for Elder Care Atrial Fibrillation Patients) trial. Major bleeding was the primary safety end point. The event rates were calculated according to prespecified characteristics at baseline. A total of 984 Japanese patients were randomly assigned to edoxaban 15 mg or placebo (n=492, each). During the study period, 20 and 11 major bleeding events occurred in the edoxaban and placebo groups, respectively. The adjusted analysis revealed that hemoglobin <12.3 g/dL (adjusted hazard ratio [aHR], 3.57 [95% CI, 1.10-11.55]) and prothrombin time ≥12.7 seconds; (aHR, 2.89 [95% CI, 1.05-8.02]) independently predicted major bleeding, while creatinine clearance <30 mL/min showed a tendency towards an increase in major bleeding (aHR, 2.68; 95% CI, 0.96-7.46). In patients treated with edoxaban lacking these 3 risk factors, no major bleeding occurred; major bleeding event rates increased with each risk factor. Patients with 3 risk factors were significantly more likely to have a major bleeding event at 11.05%/year (HR, 7.15 [95% CI, 1.92-26.71]). Conclusions In elderly patients with nonvalvular atrial fibrillation with high bleeding risk, baseline hemoglobin <12.3 g/dL, prothrombin time ≥12.7 seconds, and creatinine clearance <30 mL/min may predict major bleeding during treatment with edoxaban 15 mg. Registration URL: ELDERCARE-AF https://www.clinicaltrials.gov; Unique number: NCT02801669.


Assuntos
Fibrilação Atrial , Acidente Vascular Cerebral , Idoso , Anticoagulantes/uso terapêutico , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Creatinina , Método Duplo-Cego , Inibidores do Fator Xa , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Piridinas , Acidente Vascular Cerebral/etiologia , Tiazóis , Varfarina
13.
BMC Nephrol ; 23(1): 305, 2022 09 05.
Artigo em Inglês | MEDLINE | ID: mdl-36064370

RESUMO

BACKGROUND: Nephrotic syndrome (NS) is associated with increased risk of thromboembolic events (TE) adding to the morbidity and mortality. International guidelines recommend prophylactic anticoagulation in patients with NS and high risk of TE, but no studies have identified the optimal type of anticoagulation in NS. We aimed to assess the effectiveness and safety of direct oral anticoagulant (DOAC) by analyzing the thromboembolic and bleeding events in NS patients prescribed DOAC as primary prophylaxis to prevent TE or as treatment for TE occurring in relation to NS. METHODS: We performed a single-center, retrospective study including patients with NS, a plasma albumin less than 25 g/L and prophylactic anticoagulation treatment with DOAC at the Department of Renal Medicine at Aarhus University Hospital, Denmark from July 2016 to June 2021. Patients treated with DOAC as thromboprophylaxis for other indications than NS were excluded. Baseline characteristics and outcomes, including TE, bleeding and other adverse effects associated with DOAC were obtained from medical records. RESULTS: We identified 268 patients treated with DOAC of which 21 patients with NS were included in the study. Nineteen patients were prescribed DOAC as thromboprophylaxis and two patients received DOAC due to previous TE, which was considered associated with the NS. The type of DOAC prescribed was apixaban (n = 10) and rivaroxaban (n = 11). No patients experienced TE during DOAC treatment, while five patients had a minor bleeding episode. Patients who experienced bleeding episodes were older (median 62 vs 51 years), more often female (80%) and had been on DOAC for a longer period (204 days vs 47 days). Neither the HAS-BLED score nor GN-risk-score predicted the risk of minor bleedings in this population. CONCLUSIONS: In this case series, no new TE and only minor bleeding complications were observed among adult NS patients treated with DOAC.


Assuntos
Fibrilação Atrial , Síndrome Nefrótica , Tromboembolia Venosa , Administração Oral , Adulto , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Feminino , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Síndrome Nefrótica/induzido quimicamente , Síndrome Nefrótica/complicações , Síndrome Nefrótica/tratamento farmacológico , Estudos Retrospectivos , Tromboembolia Venosa/induzido quimicamente , Tromboembolia Venosa/complicações , Tromboembolia Venosa/tratamento farmacológico
14.
Aust J Gen Pract ; 51(9): 667-671, 2022 09.
Artigo em Inglês | MEDLINE | ID: mdl-36045622

RESUMO

BACKGROUND: Pulmonary embolism (PE) remains a common problem and can present with nonspecific symptoms and signs. Anticoagulation is the mainstay of management, the duration of which often depends on the clinical circumstances of the PE. OBJECTIVE: The aim of this article is to review the epidemiology, clinical presentation, diagnosis, management and long-term complications of PE. DISCUSSION: The incidence of PE appears to be increasing worldwide. Common risk factors include recent surgery, trauma, malignancy and oestrogen exposure. Diagnosis relies on a combination of clinical findings, laboratory tests and radiological imaging, often incorporating clinical prediction tools. Objectively confirmed PE requires anticoagulation, usually with a direct oral anticoagulant (DOAC), of at least three months' duration, but indefinite anticoagulation is being considered increasingly because of the heightened risk for recurrence following anticoagulation cessation, and overall safety of DOACs. Chronic thromboembolic pulmonary hypertension is rare but associated with significant morbidity and mortality.


Assuntos
Embolia Pulmonar , Anticoagulantes/uso terapêutico , Humanos , Incidência , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/etiologia , Fatores de Risco
15.
PLoS One ; 17(9): e0265998, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36048754

RESUMO

BACKGROUND: We investigated differences in risk of stroke, with all-cause mortality as a competing risk, in people newly diagnosed with atrial fibrillation (AF) who were commenced on either direct oral anticoagulants (DOACs) or warfarin treatment. METHODS AND RESULTS: We conducted a retrospective cohort study of the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) database (a network of 500 English general practices). We compared long term exposure to DOAC (n = 5,168) and warfarin (n = 7,451) in new cases of AF not previously treated with oral anticoagulants. Analyses included: survival analysis, estimating cause specific hazard ratios (CSHR), Fine-Gray analysis for factors affecting cumulative incidence of events occurring over time and a cumulative risk regression with time varying effects.We found no difference in CSHR between stroke 1.08 (0.72-1.63, p = 0.69) and all-cause mortality 0.93 (0.81-1.08, p = 0.37), or between the anticoagulant groups. Fine-Gray analysis produced similar results 1.07 (0.71-1.6 p = 0.75) for stroke and 0.93 (0.8-1.07, p = 0.3) mortality. The cumulative risk of mortality with DOAC was significantly elevated in early follow-up (67 days), with cumulative risk decreasing until 1,537 days and all-cause mortality risk significantly decreased coefficient estimate:: -0.23 (-0.38-0.01, p = 0.001); which persisted over seven years of follow-up. CONCLUSIONS: In this large, contemporary, real world primary care study with longer follow-up, we found no overall difference in the hazard of stroke between warfarin and DOAC treatment for AF. However, there was a significant time-varying effect between anti-coagulant regimen on all-cause mortality, with DOACs showing better survival. This is a key methodological observation for future follow-up studies, and reassuring for patients and health care professionals for longer duration of therapy.


Assuntos
Fibrilação Atrial , Acidente Vascular Cerebral , Administração Oral , Anticoagulantes/efeitos adversos , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Seguimentos , Hemorragia/epidemiologia , Humanos , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Varfarina/efeitos adversos
17.
Brain Behav ; 12(9): e2756, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-36050910

RESUMO

BACKGROUND: Perimesencephalic and nonperimesencephalic nonaneurysmal subarachnoid hemorrhage (PM-naSAH and NPM-naSAH) have a different bleeding pattern and clinical course. The etiology and risk factors for PM-naSAH and NPM-naSAH are unclear. The objective of this study was to compare risk factors and triggering events between PM-naSAH and NPM-naSAH. METHODS: We reviewed retrospectively all patients (n = 3475) who had undergone cerebral digital subtraction angiography between 2003 and 2020 at our tertiary hospital. Of these, 119 patients had 6-vessel angiography negative subarachnoid hemorrhage (47 (39%) PM-naSAH and 72 (61%) NPM-naSAH) and accurate information about the triggering event was available in 42 (89%) PM-NASAH and 64 (89%) NPM-naSAH patients. RESULTS: PM-naSAH were younger compared to NPM-naSAH (mean age [SD]; 55.3 [11.1] years vs. 59.6 [12.2] years, p = .045. PM-naSAH was triggered during the physical exertion in 79% of patients and 16% of patients with NPM-naSAH (relative risk 5.4; 95% CI, 2.9-10.1, p < .0001). There were no significant difference in sex, smoking, alcohol abuse, hypertension, diabetes, hyperlipidemia, or anticoagulation/antithrombotic usage between PM-naSAH and NMP-naSAH, p > .05. CONCLUSION: Physical exertion was a triggering factor in most of the PM-naSAH cases and the risk was five times greater than in NMP-naSAH. More studies are needed to confirm our results and to study pathophysiology of PM-naSAH and NPM-naSAH.


Assuntos
Hemorragia Subaracnóidea , Anticoagulantes , Criança , Fibrinolíticos , Humanos , Esforço Físico , Estudos Retrospectivos , Fatores de Risco , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/epidemiologia , Hemorragia Subaracnóidea/etiologia
18.
Thromb Res ; 218: 151-156, 2022 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-36054979

RESUMO

BACKGROUND: Coagulation dysfunction represents a serious complication in patients during the COVID-19 infection, while fulminant thrombotic complications emerge as critical issues in individuals with severe COVID-19. In addition to a severe clinical presentation, comorbidities and age significantly contribute to the development of thrombotic complications in this disease. However, there is very little data on association of congenital thrombophilia and thrombotic events in the setting of COVID-19. Our study aimed to evaluate the risk of COVID-19 associated thrombosis in patients with congenital thrombophilia. METHODS: This prospective, case-control study included patients with confirmed COVID-19 infection, followed 6 months post-confirmation. The final outcome was a symptomatic thrombotic event. In total, 90 COVID-19 patients, 30 with known congenital thrombophilia and 60 patients without thrombophilia within the period July 2020-November 2021, were included in the study. Evaluation of hemostatic parameters including FVIII activity and D-dimer was performed for all patients at 1 month, 3 months and 6 months post-COVID-19 diagnosis. RESULTS: Symptomatic thrombotic events were observed in 7 out of 30 (23 %) COVID-19 patients with thrombophilia, and 12 out of 60 (20 %) without thrombophilia, P = 0.715. In addition, the two patient groups had comparable localization of thrombotic events, time to thrombotic event, effect of antithrombotic treatment and changes in FVIII activity, while D-dimer level were significantly increased in patients without thrombophilia. CONCLUSION: Our findings suggest that patients with congenital thrombophilia, irrespective of their age, a mild clinical picture and absence of comorbidities, should receive anticoagulant prophylaxis, adjusted based on the specific genetic defect.


Assuntos
COVID-19 , Hemostáticos , Trombofilia , Trombose , Anticoagulantes/uso terapêutico , COVID-19/complicações , Teste para COVID-19 , Estudos de Casos e Controles , Fibrinolíticos/uso terapêutico , Hemostáticos/uso terapêutico , Humanos , Estudos Prospectivos , Medição de Risco , Trombofilia/complicações , Trombose/tratamento farmacológico
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