Riesgo de sangrado en pacientes anticoagulados con antagonistas de la vitamina K que reciben antibióticos / Risk of bleeding in anticoagulated patients with vitamin K antagonists who receive antibiotics

Lograr un adecuado nivel de anticoagulación con antagonistas orales de la vitamina K suele ser un desafío frecuente en la práctica clínica, dado que su estrecho rango terapéutico suele verse afectado por diversas interacciones farmacológicas,alimentos y condiciones clínicas. A partir de un caso de un paciente anticoagulado que presenta una hemorragia gastro-intestinal posterior a realizar un tratamiento antibiótico, la autora de este artículo revisó la evidencia sobre el riesgo desangrado secundario a la interacción entre este tipo de anticoagulantes y antibióticos orales. Su conclusión tras realizar una búsqueda bibliográfica y seleccionar la mejor evidencia disponible, es que existe un aumento del riesgo relativo desangrado en pacientes anticoagulados que reciben antibióticos, por lo que deberían evitarse aquellos antibióticos con conocido potencial de interacción. Si ello no fuera posible, se recomienda monitorizar el estado de anticoagulación con dosaje de la razón internacional normatizada (RIN) posterior a la introducción del antibiótico. (AU)

Achieving an adequate level of anticoagulation with oral vitamin K antagonists is often a frequent challenge in clinical practice, given that their narrow therapeutic range is often affected by various drug interactions, food, and clinical conditions. Based on a case of an anticoagulated patient who presented gastrointestinal bleeding after antibiotic treatment, the authorof this article reviewed the evidence on the risk of secondary bleeding due to the interaction between this type of anticoagulants and oral antibiotics. Their conclusion, after performing a literature search and selecting the best available evidence, is that there is an increased relative risk of bleeding in anticoagulated patients receiving antibiotics, so antibiotics with known potential for interaction should be avoided. If it weren't possible, it is recommended to monitor the anticoagulation status with International Normalized Ratio (INR) dosing after the introduction of the antibiotic. (AU)

Thrombolysis in acute pulmonary embolism

SUMMARY OBJECTIVES Acute pulmonary embolism (APE) is an important cause of cardiovascular mortality, due mainly to hemodynamic instability. In these cases, the recommendation is to perform some reperfusion procedure, with systemic thrombolysis being the main therapy used. However, national data evaluating the efficacy and safety of thrombolysis are scarce. METHODS Retrospective analysis of a case series. We included 13 patients diagnosed with high-risk APE and 4 patients with intermediate-high risk from a single-center, who were treated with alteplase 100mg. RESULTS The mean age of the patients was 55 years, most of them female (76.4%). Among the risk factors for VTE were immobilization (41.17%), contraceptive use (35.29%), cancer (17.63%), and previous history of DVT (11.76%). The most frequent clinical manifestations of APE were dyspnea (88.23%), hypoxia (82.35%), hypotension (82.35%), and tachycardia (64.70%). 82.35% of the patients had echocardiographic signs of right ventricular dysfunction, and 52.94% had increased troponin and BNP. Severe bleeding associated with thrombolysis occurred in 17.54% of cases. No patient died due to bleeding. There were 8 deaths from right ventricular failure (47%), 6 in the cases of patients presenting as high-risk APE (35.3%), and 2 in the cases of intermediate-high risk (11.8%). CONCLUSION Thrombolysis in patients with high-risk APE or intermediate-high risk had a severe bleeding rate of 17.6%. However, the high mortality of this population (47%) due to right ventricular failure justifies the use of this therapeutic modality.

RESUMO OBJETIVOS A embolia pulmonar aguda (EAP) é uma causa importante de mortalidade cardiovascular ao causar instabilidade hemodinâmica. Nesses casos, a recomendação é a realização de algum procedimento de reperfusão, sendo a trombólise sistêmica a principal terapia utilizada. No entanto, dados nacionais avaliando a eficácia e a segurança da trombólise são escassos. MÉTODO Análise retrospectiva de uma série de casos. Foram incluídos 13 pacientes com o diagnóstico de EAP de alto risco e quatro pacientes de risco intermediário-alto, de um único centro, e que foram tratados com alteplase 100 mg. RESULTADOS A média de idade dos pacientes foi 55 anos, sendo a maioria do gênero feminino (76,4%). Dos fatores de risco para TEV, estavam presentes a imobilização (41,17%), o uso de anticonceptivos (35,29%), câncer (17,63%) e história prévia de TVP (11,76%). As manifestações clínicas mais frequentes da EAP foram dispneia (88,23%), hipóxia (82,35%), hipotensão (82,35%) e taquicardia (64,70%); 82,35% dos pacientes apresentaram sinais ecocardiográficos de disfunção ventricular direita e 52,94% apresentaram aumento da troponina e BNP. Sangramento grave associado à trombólise ocorreu em 17,54% dos casos. Nenhum paciente faleceu em decorrência de sangramento. Houve oito mortes por insuficiência ventricular direita (47%): seis nos casos de paciente que se apresentaram como EAP de alto risco (35,3%) e duas nos casos de risco intermediário-alto (11,8%). CONCLUSÃO A trombólise nos pacientes com EAP de alto risco ou risco intermediário-alto apresentou uma taxa de sangramento grave de 17,6%. No entanto, a alta mortalidade dessa população (47%) por insuficiência ventricular direita justifica o uso desta modalidade terapêutica.

Left Atrial Appendage Transcatheter Occlusion with AMPLATZER™ Amulet™ Device: Real Life Data with Mid-Term Follow-Up Results / Oclusão Transcateter do Apêndice Atrial Esquerdo com a Prótese AMPLATZER™ Amulet™: Dados Reais com Resultados de Seguimento de Médio-Prazo

Abstract Background: Left atrial appendage (LAA) occlusion is an alternative therapy for atrial fibrillation patients who have high embolic risk and contraindications to anticoagulant therapy. Objective: To evaluate the feasibility, safety, and mid-term outcomes of percutaneous LAA occlusion, including device-related thrombosis. Methods: Sixty consecutive patients who had undergone percutaneous LAA occlusion with AMPLATZER™ Amulet™ device from September 2015 to March 2018 were enrolled. Patients were followed for 21 ± 15 months (median - 20 months, interquartile range - 9 to 27 months). The postprocedural assessment was done at the 1(st), 6(th), and 12(th) month. Patients were clinically evaluated, and transesophageal echocardiography was performed at each visit. We evaluated the condition of normality of variables using the Kolmogorov-Smirnov test. P-values < 0.05 were statistically significant. Results: The most common indication for the procedure was major bleeding with anticoagulants (n: 53, 88.3%). The procedure was completed successfully in 59 (98.3%) patients. Periprocedural mortality was observed in one patient. Postprocedural antiplatelet treatment was planned as dual or single antiplatelet therapy or low-dose anticoagulant therapy in 52 (88.1%), 2 (3.4%), and 5 (8.5%) patients, respectively. We found no clinically significant cerebrovascular events, device-related thrombus, or embolization in any patient during the follow-up. Two (3.4 %) patients presented significant peri-device leak (>3 mm) at the 1st month evaluation, which disappeared at the 12th month follow-up. Conclusion: We concluded that LAA occlusion using the Amulet™ LAA occluder can be performed with high procedural success and acceptable outcomes.

Resumo Fundamento: A oclusão do apêndice atrial esquerdo (AAE) é uma terapia alternativa para pacientes com fibrilação atrial que tenham alto risco embólico e contraindicações à terapia anticoagulante. Objetivo: Avaliar a viabilidade, segurança e resultados de médio prazo da oclusão percutânea do AAE, incluindo a trombose relacionada à prótese. Métodos: Sessenta pacientes consecutivos que foram submetidos à oclusão percutânea do AAE com a prótese AMPLATZER™ Amulet™ de setembro de 2015 a março de 2018 foram incluídos no estudo. Os pacientes foram acompanhados por 21 ± 15 meses (mediana - 20 meses, intervalo interquartílico - 9 a 27 meses). A avaliação pós-procedimento foi feita no 1º, 6º e 12º mês. Os pacientes foram examinados clinicamente e um ecocardiograma transesofágico foi realizado a cada visita. A condição de normalidade das variáveis foi avaliada por meio do teste de Kolmogorov-Smirnov. Os valores de p < 0,05 foram considerados estatisticamente significativos. Resultados: A indicação mais comum para o procedimento foi sangramento significativo com anticoagulantes (n: 53, 88,3%). O procedimento foi concluído com sucesso em 59 (98,3%) pacientes. Mortalidade peri-procedimento ocorreu em um paciente. A tratamento antiplaquetário pós-procedimento foi planejado como terapia antiplaquetária única ou dupla ou terapia anticoagulante de dose baixa em 52 (88,1%), 2 (3,4%) e 5 (8,5%) pacientes, respectivamente. Não foram encontrados eventos cerebrovasculares clinicamente significativos, trombo relacionado à prótese ou embolização nos pacientes durante o seguimento. Dois (3,4%) pacientes apresentaram vazamento peri-prótese significativo (>3 mm) na avaliação do 1º mês, que desapareceu no 12º mês de seguimento. Conclusão: Concluiu-se que a oclusão do AAE com o oclusor de AAE Amulet™ pode ser realizada com grande sucesso e resultados aceitáveis.

Uninterrupted Use of Oral Anticoagulants for the Ablation of Atrial Flutter: A Single Center Cohort of 154 Patients / Uso Ininterrupto de Anticoagulantes Orais na Ablação de Flutter Atrial Istmo-Cavotricuspídeo Dependente: Coorte Unicêntrica de 154 Pacientes

Abstract Background: The uninterrupted use of oral anticoagulation (OAC) with vitamin K antagonists (VKAs) for electrophysiology procedures has been more and more recommended. The clinical practice in our service recommends the continuous use of these drugs for atrial flutter ablation. There is little evidence as to the uninterrupted use of non-vitamin K antagonist oral anticoagulants (NOACs) in this scenario. Objective: To compare the rates of complications related with the uninterrupted use of different types of oral anticoagulants in patients referred to atrial flutter (AFL) ablation. Methods: Historical, single-center cohort of ablation procedures by AFL conducted from November 2012 to April 2016. The primary outcome was the occurrence of hemorrhagic or embolic complication during the procedure. The secondary outcome was the occurrence of stroke or transient ischemic attack (TIA) in follow-up. The statistical significance level was 5%. Results: There were 288 ablations per AFL; 154 were carried out with the uninterrupted use of OAC (57.8% with VKA and 42.2% with NOAC). Mean age was 57 ± 13 years. The rate of hemorrhagic complication during the procedure was 3% in each group (p = NS). The rate of stroke/TIA was, respectively, of 56/1,000 people-year in the VKA group against zero/1,000 people-year in the NOAC group (p = 0.02). Conclusion: In our population there were no hemorrhagic complications regarding the procedure of OAC use uninterruptedly, including NOACs. There was higher occurrence of stroke/TIA in the follow-up of the group of patients undergoing VKAs; however, this difference may not only be a result of the type of OAC used.

Resumo Fundamento: O uso ininterrupto de anticoagulação oral (ACO) com antagonistas da vitamina K (AVKs) para procedimentos de eletrofisiologia está sendo cada vez mais recomendado. A prática clínica em nosso serviço é de uso continuado dessas drogas para ablação de flutter atrial. Existem poucas evidências quanto ao uso ininterrupto dos anticoagulantes orais não antagonistas da vitamina K (NOACs) nesse cenário. Objetivos: Comparar as taxas de complicações relacionadas ao uso ininterrupto de diferentes tipos de anticoagulantes orais em pacientes referidos para ablação por flutter atrial (FLA). Métodos: Coorte histórica e unicêntrica dos procedimentos de ablação por FLA realizados no período de novembro de 2012 a abril de 2016. O desfecho primário foi o de ocorrência de complicação hemorrágica ou embólica durante o procedimento. O desfecho secundário foi o de ocorrência de acidente vascular cerebral (AVC) ou acidente isquêmico transitório (AIT) no acompanhamento. O nível de significância estatística adotado foi de 5%. Resultados: Foram incluídas 288 ablações por FLA; 154 foram feitas com uso ininterrupto de ACO (57,8% com AVK e 42,2% com NOAC). A idade média foi de 57 ± 13 anos. A taxa de complicação hemorrágica durante o procedimento foi de 3% em cada grupo (p = NS). A taxa de AVC/AIT foi, respectivamente, de 56/1.000-pessoas-ano no grupo AVK contra zero/1.000-pessoas-ano no grupo NOAC (p = 0,02). Conclusão: Em nossa população não ocorreram complicações hemorrágicas relacionadas ao procedimento com uso de ACO de forma ininterrupta, incluindo NOACs. Houve maior ocorrência de AVC/AIT no seguimento no grupo de pacientes em uso de AVK, contudo essa diferença pode não ser decorrente apenas do tipo de ACO em uso.

Evaluación de la estrategia de terapia antitrombótica posterior al cambio valvular aórtico con válvulas biológicas en pacientes de bajo riesgo trombótico / Evaluation of the antithrombotic strategy in low thrombotic risk patients who underwent aortic valve replacement with a bioprosthesis

Resumen De acuerdo a las guías actuales, aún es materia de debate el uso de anticoagulación en los primeros 3 meses en pacientes de bajo riesgo trombótico sometidos a cambio valvular aórtico con prótesis biológicas. En base a la evidencia actual, la aspirina a dosis bajas es razonable como alternativa a los antagonistas de la vitamina K (AVK) durante el posquirúrgico temprano en pacientes con prótesis biológicas en posición aórtica. Se comparó la incidencia de complicaciones trombóticas o hemorrágicas de acuerdo a la estrategia de terapia antitrombótica en los pacientes de bajo riesgo trombótico sometidos a cambio valvular aórtico con válvulas biológicas en el Instituto Nacional de Cardiología Ignacio Chávez. La hipótesis: la aspirina como monoterapia antitrombótica tiene un efecto benéfico comparado con los AVK. Se estudiaron los pacientes de bajo riesgo trombótico sometidos a cambio valvular aórtico con válvulas biológicas en el Instituto Nacional de Cardiología Ignacio Chávez. Se incluyeron los pacientes operados del año 2011 al 2015. Se identificó en el seguimiento a un año la presencia de complicaciones trombóticas o hemorrágicas y si se manejaron con cualquiera de las siguientes: aspirina únicamente, AVK solo y la combinación aspirina más AVK. Se analizaron 231 pacientes. Solo se presentó una complicación hemorrágica en un paciente tratado con AVK. No hubo complicaciones trombóticas. No se presentaron complicaciones trombóticas en pacientes que no recibieron anticoagulación oral formal durante los primeros 3 meses posquirúrgicos, lo que indica que es seguro el uso de aspirina como monoterapia en estos pacientes de bajo riesgo trombótico.

Abstract According to current guidelines, in patients without additional risk factors who have undergone aortic valve replacement with a bioprosthesis, anticoagulation in the first 3 months after surgery is still a matter of debate. According to current evidence, aspirin in low doses is a reasonable alternative to vitamin K antagonists (VKA). A comparison is made between the incidence of thrombotic and haemorrhagic complications in patients with low thrombotic risk who underwent aortic valve replacement with a bioprosthesis in the National Institute of Cardiology of Ignacio Chávez of Mexico. The hypothesis: aspirin as monotherapy has a beneficial effect compared to VKA. The studied patients were the low thrombotic risk patients who underwent aortic valve replacement with a bioprosthesis in the National Institute of Cardiology of Ignacio Chávez of Mexico from 2011 to 2015. The groups studied were: aspirin only, VKA only, and the combination of VKA plus aspirin. The patients were retrospectively followed-up for 12 months, and the thrombotic and haemorrhagic complications were documented. Of the 231 patients included in the study, only one patient in the VKA only group presented with a haemorrhagic complication. No thrombotic complications were observed. In the present study no thrombotic complications were observed in patients who did not receive anticoagulation in the first 3 months after an aortic valve replacement with a bioprosthesis after a follow up period of 12 months. This suggests that the use of aspirin only is safe during this period.

Uso de terapia antiagregante dual luego de angioplastía coronaria: duración, frecuencia de sangramientos y validación de scores de riesgo de hemorragia en una cohorte chilena / Dual anti platelet therapy post PTCA: duration, bleeding risk and validation of scores for predicting risk of bleeding in a Chilean population

Resumen: Introducción: La terapia antiagregante dual (TAD) con aspirina más clopidogrel o ticagrelor es fundamental para prevenir trombosis de stent y nuevos eventos cardiovasculares (CV) en pacientes sometidos a angioplastía coronaria (AC). Sin embargo, TAD se asocia a un riesgo aumentado de hemorragias, en particular cuando su uso se prolonga. Recientemente se han creado puntajes (DAPT, PRECISE-DAPT) que buscan estimar el riesgo de sangrado en pacientes con TAD por tiempo prolongado, los que quisimos evaluar en nuestra población. Métodos: Se utilizó la base de datos prospectiva de Prevención Cardiovascular del Hospital Clínico U. Católica, seleccionando pacientes sometidos a AC el año 2015. Se realizó una encuesta telefónica estandarizada para identificar episodios de sangrado definidos según clasificación ISTH, tiempo de uso de TAD y nuevos eventos CV. Se calcularon los puntajes DAPT y PRECISE-DAPT. Se usó pruebas de t de Student, test exacto de Fisher y curva ROC, según correspondiese, considerando significativa una p<0,05. Resultados: Se incluyeron 227 pacientes (edad 64,2±12,3 años, 22,5% mujeres), de los cuales el 69,6% eran hipertensos, 28,6% diabéticos, 26,9% fumadores y 5,3% insuficientes renales crónicos. En el 63% de los pacientes la AC fue por síndrome coronario agudo, se implantaron 1,4±0,7 stents/paciente y el 37% de los pacientes recibió sólo stents metálicos. Al momento de la encuesta, el seguimiento fue de 26±3 meses. Se registró un tiempo promedio de duración de TAD de 12,6±7,4 meses, con 99,1% de los pacientes recibiendo aspirina, 93,4% clopidogrel, 6,6% ticagrelor y 9,3% anticoagulantes orales. Hubo 35 (15,4%) nuevos eventos CV (revascularización 14, infarto 12, accidente cerebrovascular 2 y muerte 7) y 31 (13,6%) episodios de sangrados (criterio ISTH). De acuerdo con el criterio TIMI de sangrado se registraron 5 (2,2%) episodios graves, 9 (3,9%) leves y 17 (7,4%) menores. En 10 (4,4%) pacientes se modificó la TAD debido al sangrado. PRECISE-DAPT se asoció de manera significativa a los episodios de sangrado (p<0,01); tener un puntaje de alto riesgo (>25) aumentó más de 3 veces el riesgo de sangrado (OR 3,1 IC 1,4-7,1, p<0,01) y una curva ROC estableció que en la población estudiada el mejor punto de corte fue de 18 puntos (C-statistic 0,69) (Figuras 1A y B). El uso de TACO aumentó el riesgo (OR 3,4 IC 1,2-9,5, p=0,02). Si bien miden distintos parámetros, los puntajes de riesgo DAPT y PRECISE-DAPT se correlacionaron significativamente en nuestra cohorte (p<0,01). Conclusiones: En esta cohorte de la vida real se demuestra que la ocurrencia de sangramientos es un evento frecuente en pacientes con TAD, similar a la tasa de nuevos eventos CV, y por tanto debe ser un factor relevante a considerar al momento de la AC y la selección de la TAD. El puntaje PRECISE-DAPT es una herramienta útil para predecir sangrados, aunque nuestros resultados sugieren que en población chilena los valores de corte pueden ser algo menores que lo previamente publicado .

Abstracts: Background: Dual antiplatelet therapy (DAT) with aspirin plus clopidogrel or ticagrelor is essential for the prevention of stent thrombosis and new cardiovascular events in patients undergoing PCI. However, DAT is associated with an increased risk of bleeding, more so when it is used for prolonged time periods. Scores (DAPT, PRECISE-DAPT) developed to predict bleeding risk were evaluated in this study. Method: The prospective Cardiovascular Prevention database at Catholic University Hospital was used to select patients who underwent PCI followed by DAT during 2015. By phone contact information on bleeding episodes - according to the ISTH classification -, new cardiovascular events and DAT duration were collected. DAPT and PRECISE- DAPT scores were calculated. Student's t test, Fisher exact test and ROC analysis were used. Significance was established at p< 0.05. Results: 277 patients were included (age 64.2±12.3 y-o, 22.5% women). Hypertension was present in 66.9%, diabetes in 28.6%, smoking habit in 26.9% and renal failure in 5.3%. The indication for PCI was acute coronary syndrome in 63%, 1.4±0.7 stents per patient were implanted and 37% of patients received bare metal stents exclusively. Follow-up extended for 26±3 months. DAT was active for 12.6±7.4 months and 9.3% of patients received oral anticoagulant therapy. There were 35 (15.4%) new cardiovascular events (14 revascularizations, 12 myocardial infarctions, 2 CVA and 7 deaths). Conversely, there were 31 (13.6%) bleeding episodes. According to the TIMI classification, bleeding episodes were severe in 2.2%, mild in 3.9% and minor in 7.4%. In 4% of patients DAT was modified due to bleeding. PRECISE-DAPT score was significantly associated to bleeding episodes (p<0.01). A high score (>25) was associated with a 3-fold risk of bleeding (OR 3.1, CI 1.4-7.1 (p<0.01). Through ROC analysis the best PRECISE-DAPT cutting point in this cohort was 18 (C=0.69). The use of oral anticoagulation increased bleeding risk (OR 3.4 CI 1.2 - 9.5, p=0.02). DAPT and PRECISE-DAPT were significantly correlated (p<0.01). Conclusion: Bleeding is a frequent complication of DAT, similar to the risk of new cardiovascular events. PRECISE-DAPT score is useful to estimate the risk of bleeding, although this study suggests that in the studied population the cutting point may be somewhat lower than previously published.

Efectividad y seguridad del tratamiento anticoagulante con acenocumarol en fibrilación auricular no valvular / Effectiveness and safety of oral anticoagulation treatment with acenocoumarol in non-valvular atrial fibrillation

Background: Vitamin K antagonists significantly decrease the incidence of stroke but increase the risk of bleeding. Aim: To assess the effectiveness and risk of bleeding of vitamin K antagonists in non-valvular atrial fibrillation. Material and Methods: Retrospective cohort study of 524 patients, 236 women (45%) and 288 men (55%) with non-valvular atrial fibrillation (NVAF) admitted to the oral anticoagulation treatment (OAT) clinic at four public hospitals, between 2009 and 2012. They were followed until March 2013, measuring the quality of OAT, ischemic and bleeding events. Results: The mean follow-up was 26.1 months, with 1,154.7 person-years of follow-up accrued. The percentage of time in therapeutic range (TTR) was 35.2 ± 18%; this was deemed to represent the quality of OAT. The cumulative incidence of ischemic events, either stroke or systemic embolism, was 2.25/100 person-years, being greater in patients with previous embolism (Risk ratio 5.21, 95% confidence intervals 2.31- 11.73, p < 0.01). The cumulative incidence of major bleeding events-extracranial and intracraneal-was 4.08/100 person-years. The main site of extracranial major bleeding was the gastrointestinal tract (32%). Conclusions: In our clinical practice, the effectiveness of OAT with acenocoumarol in NVAF patients is similar to that published abroad. However, the incidence of bleeding complications is higher. The quality of the OAT measured by the TTR was lower than abroad.

Tratamiento anticoagulante oral en pacientes sometidos a remplazo valvular en un hospital general de Antofagasta, Chile / Oral anticoagulant treatment (OAT) in patients with cardiac valve replacement at a general hospital in Antofagasta, Chile

Introduccion: La atención de pacientes con reemplazo valvular cardíaco constituye una actividad importante en cardiología. Si bien el recambio valvular representa una alternativa terapéutica eficaz para el manejo de esta patología, muchos pacientes requieren de tratamiento anticoagulante oral (TACO) para lograr mayor sobrevida. Objetivos: Describir los resultados terapéuticos obtenidos en un cohorte de pacientes sometidos a recambio valvular, controlados en el Hospital Regional de Antofagasta. Resultados: Se identificaron 180 pacientes con reemplazo valvular de los cuales 135 cumplieron criterios de inclusión. Hubo 76 mujeres (56,3%), 59 hombres (43,7%); la edad global promedio fue 62 años (28-90), 59 años (30-90) en las mujeres y 64 (36-81) en los hombres. La válvula intervenida fue la aórtica en 69 pacientes (51,1%), mitral en 60 (44,5%), aórtica y mitral en 5 (3,7%), y tricúspide en 1 paciente (0,7%). No hubo casos de recambio valvular pulmonar. Se instalaron 122 válvulas mecánicas (90,4%) y 13 válvulas biológicas (9,6%). El INR promedio fue 2,64 (1,11-5,47). Según válvula intervenida el INR promedio fue: mitral 2,50 (1,11-4,89), aórtica: 2,75 (1,19-5,47), mitral y aórtica: 2,65 (1,28-3,74), y tricúspide: 1,87. Del total de cirugías valvulares, 77 (57,03%) se encontraron dentro del rango terapéutico deseado: (mitral 33/60, Aórtica 43/69 mitral y aórtica 0/5, Tricúspide: 0/1). 58 pacientes (42,97%) se encontraron fuera del rango terapéutico deseado. Conclusion: Los resultados obtenidos en nuestro centro se encuentran por debajo de las recomendaciones nacionales. La dificultad por obtener mejores resultados refuerza el uso de prótesis biológicas y la implementación óptima de un policlínico de tratamiento anticoagulante (TACO).

Background: Care of patients with cardiac valve replacement often includes the need for anticoagulation which prevents complications that may decrease survival rate. Aim: to describe the experience with OAT in a cohort of patients with cardiac valve replacement at the Regional Hospital in Antofagasta Results: 135 out of 180 patients fulfilled inclusion criteria. There were 76 females (56.3%) and 59 males (43.7%), with a mean of 62 years old (28-90), 59 (30-90) in females and 64 (36-81) in males. The valve replaced was the aortic in 69 patients (51.1%), the mitral in 60 (44.5%), both the aortic and the mitral valve in 5 (3.7%). Only 1 patients had a tricuspid valve replaced. 122 mechanical valves (90.4%) and 13 biological valves (9.6%) were implanted. The overall mean INR was 2.64 (1.11 - 5.47). The mean INR value according to the valve replaced was: mitral valve 2.5 (1,11-4,89), aortic valve 2.75 (1.195.47) and mitral plus aortic valve 2.65 (1.28-3.74). Overall, 58 patients were found to be outside the therapeutic target. Conclusion: These results are less satisfactory than those proposed by national guidelines. The anticoagulant clinic must be optimized and more biological rather than mechanical valves should be used for cardiac valve replacement.

Prevalence of oral anticoagulation in atrial fibrillation

OBJECTIVES: Atrial fibrillation is the most common sustained arrhythmia and is associated with poor outcomes, including stroke. The ability of anticoagulation therapy to reduce the risk of stroke has been well established; however, the prevalence of anticoagulation therapy use in the Public Health System is unknown. The aim of this study is to evaluate both the prevalence of anticoagulation therapy among patients with atrial fibrillation and the indications for the treatment. METHODS: In this cross-sectional study, we included consecutive patients who had atrial fibrillation documented by an electrocardiogram performed between September 2011 and March 2012 at a university hospital of the Public Health System. The variables analyzed included the risk of a thromboembolic event and/or bleeding, the use of antiplatelet or anticoagulation therapy, the location where the electrocardiogram report was initially reviewed and the specialty of the physician who initially reviewed it. RESULTS: We included 162 patients (mean age 68.9 years, 56% men). Hypertension (90.1%), heart failure (53.4%) and stroke (38.9%) were the most prevalent diseases found. Only 50.6% of the patients knew that they had atrial fibrillation. Regarding the use of therapy, only 37.6% of patients classified as high risk according to the CHADS2 scores and 35.5% according to the CHA2DS2VASc used oral anticoagulation. A presumptive diagnosis of heart failure and the fact that the electrocardiogram was evaluated by a cardiologist were the only independent predictors of the use of anticoagulants. CONCLUSIONS: Our study found a low prevalence of oral anticoagulation therapy among patients with atrial fibrillation and an indication for stroke prophylaxis for the use of this therapy, including among those with high CHADS2 and CHA2DS2VASc scores. .

Oclusão percutânea da auriculeta esquerda em pacientes com fibrilação atrial: uma alternativa à terapia anticoagulante / Percutaneous occlusion of the left auricular appendage in patients with atrial fibrillation: an alternative to anticoagulation therapy

O risco de fenômenos tromboembólicos aumenta em pacientes com fibrilação atrial. Recomenda-se que pacientes com CHADS2 ≥2 sejam mantidos em uso deanticoagulantes indefinidamente. A auriculeta esquerda é o local onde mais frequentemente são encontradostrombos. Por isso, sua exclusão pode reduzir o risco de acidentes embólicos. Neste artigo, discute-se a utilizaçãode novos dispositivos para oclusão da auriculeta por via percutânea.

Cistitis crónica hemorrágica por ciclofosfamida en dermatomiositis refractaria a tratamiento esteroidal / Chronic hemorrhagic cystitis induced by cyclophosphamide in dermatomyositis refractory to corticosteroid treatment

Se describe el caso de una niña de 14 años que a la edad de 7 años consultó por debilidad muscular de grupos proximales y compromiso cutáneo característico de dermatomiositis, confirmada con concentraciones altas de creatinfosfokinasa sérica y alteraciones características en la electromiografía y biopsia muscular. Debido a falta de respuesta a dosis altas de prednisona se le dio ciclofosfamida oral 0,8 mg.kg.día (25 mg.m*), que debió suspenderse a las dieciséis semanas por cistitis hemorrágica, cambiándose el tratamiento a azatioprina por 2 años, después de lo cual hubo remisión completa de la enfermedad. Fue estudiada a los 13 años por hematuria microscópica persistente, demostrándose cistitis crónica mediante cistoscopía y biopsia vesical. Se destaca la presencia de esta complicación con dosis y tiempo total de tratamiento menores a los descritos en la literatura