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.

Pacientes pós-AVC com e sem trombólise: análise da deglutição na fase aguda da doença / Post-stroke patients with and without thrombolysis: analysis of deglutition in the acute phase of the disease

RESUMO Objetivo Verificar a frequência e a gravidade de disfagia pós-acidente vascular cerebral isquêmico na fase aguda com e sem trombólise e a associação entre a disfagia e as características demográficas, comprometimentos neurológico e funcional e a realização da trombólise. Método Estudo retrospectivo de análise de prontuário de 94 pacientes pós-acidente vascular cerebral isquêmico na fase aguda, destes, 52 pacientes realizaram trombólise e 42 não receberam o tratamento. Os dados coletados foram: idade, sexo, comorbidades, janela terapêutica para realização da trombólise, nível de consciência, grau de comprometimento neurológico, nível de dependência funcional, avaliação clínica da deglutição. Foram realizadas análise descritiva das variáveis categóricas e contínuas e análise de associação pelo teste Quiquadrado de Pearson, sendo consideradas como associações estatisticamente significantes as que apresentaram valor de p ≤ 0,05. Resultados A frequência de disfagia nos pacientes trombolizados foi de 67,3%. Os pacientes trombolizados apresentaram 4,6 vezes mais chance de apresentarem disfagia do que os pacientes não trombolizados. A gravidade da disfagia não apresentou associação com a realização da trombólise. Houve associação entre a presença de disfagia e a dependência funcional. As características demográficas e o comprometimento neurológico não apresentaram associação com o transtorno da deglutição. Conclusão Os pacientes trombolizados apresentaram maior tendência de desenvolverem disfagia do que os não trombolizados na fase aguda do acidente vascular cerebral, estando a disfagia associada à dependência funcional.

ABSTRACT Purpose To verify the frequency and severity of dysphagia after ischemic stroke with or without thrombolysis in the acute phase; and the association among dysphagia, demographic characteristics, neurological and functional impairments and thrombolysis. Methods A retrospective study of the medical records of 94 patients who suffered from ischemic stroke during the acute phase of the disease. From these, 52 patients received thrombolytic therapy and 42 patients did not receive such therapy. We collected data on age, sex, comorbidities, therapeutic time window of thrombolytic therapy, level of consciousness, degree of neurological impairment, level of functional dependency and clinical swallowing examination. A descriptive analysis included categorical and continuous variables, and an analysis of the association using the Pearson's Chi-Square Test, in which the value of p ≤ 0.05 was considered as a statistically significant association. Results The frequency of dysphagia in the thrombolytic patients was 67.3%, the odds ratio was 4.6 higher than the non-thrombolysed patients. The severity of dysphagia was not associated with thrombolysis. There was an association between the presence of dysphagia and functional dependence. Demographic characteristics and neurological impairment were not associated with dysphagia. Conclusion Thrombolytic patients were more likely to develop dysphagia than non-thrombolysed patients in the acute phase of stroke, with dysphagia associated to functional dependence.

Regional QT Interval Dispersion as an Early Predictor of Reperfusion in Patients with Acute Myocardial Infarction after Fibrinolytic Therapy / A Dispersão do Intervalo QT Regional como Preditor Precoce de Reperfusão em Pacientes com Infarto Agudo do Miocárdio Pós-terapia Fibrinolítica

Abstract Background: Patients with ST-elevation acute myocardial infarction attending primary care centers, treated with pharmaco-invasive strategy, are submitted to coronary angiography within 2-24 hours of fibrinolytic treatment. In this context, the knowledge about biomarkers of reperfusion, such as 50% ST-segment resolution is crucial. Objective: To evaluate the performance of QT interval dispersion in addition to other classical criteria, as an early marker of reperfusion after thrombolytic therapy. Methods: Observational study including 104 patients treated with tenecteplase (TNK), referred for a tertiary hospital. Electrocardiographic analysis consisted of measurements of the QT interval and QT dispersion in the 12 leads or in the ST-segment elevation area prior to and 60 minutes after TNK administration. All patients underwent angiography, with determination of TIMI flow and Blush grade in the culprit artery. P-values < 0.05 were considered statistically significant. Results: We found an increase in regional dispersion of the QT interval, corrected for heart rate (regional QTcD) 60 minutes after thrombolysis (p = 0.06) in anterior wall infarction in patients with TIMI flow 3 and Blush grade 3 [T3B3(+)]. When regional QTcD was added to the electrocardiographic criteria for reperfusion (i.e., > 50% ST-segment resolution), the area under the curve increased to 0.87 [(0.78-0.96). 95% IC. p < 0.001] in patients with coronary flow of T3B3(+). In patients with ST-segment resolution >50% and regional QTcD > 13 ms, we found a 93% sensitivity and 71% specificity for reperfusion in T3B3(+), and 6% of patients with successful reperfusion were reclassified. Conclusion: Our data suggest that regional QTcD is a promising non-invasive instrument for detection of reperfusion in the culprit artery 60 minutes after thrombolysis.

Resumo Fundamento: Pacientes com infarto do miocárdico com elevação do segmento-ST atendidos em centros de atendimento primário e tratados de acordo com a estratégia fármaco-invasiva são submetidos à fibrinólise seguida de coronariografia em período de 2-24h. Neste cenário, o conhecimento de marcadores de reperfusão como a redução em 50% do segmento-ST é fundamental. Objetivo: Analisar o desempenho da dispersão do intervalo QT em adição aos critérios clássicos, como marcador precoce de reperfusão pós-terapia trombolítica. Métodos: Estudo observacional com a inclusão de 104 pacientes tratados com tenecteplase (TNKase) e referenciados a hospital de atendimento terciário. A análise dos eletrocardiogramas (ECG) consistiu em mensuração do intervalo QT e sua dispersão nas 12 derivações, e também apenas na região com supradesnivelamento-ST antes e 60min pós-TNKase. A angiografia foi realizada em todos os pacientes com obtenção do fluxo TIMI e Blush da artéria culpada. Foram considerados significantes valores de p < 0,05. Resultados: Observamos aumento da dispersão do intervalo QT, corrigido pela frequência cardíaca, regional (dQTcR) 60min pós-lise (p = 0,006) em infartos de parede anterior nos casos com fluxo TIMI 3 e Blush 3 [T3B3(+)]. Adicionando a dQTcR ao critério ECG (redução do ST > 50%) de reperfusão, a área sob a curva aumentou para 0,87 [(0,78-0,96), IC95%, p < 0,001] em pacientes com fluxo coronário T3B3(+). Nos pacientes com critério de ECG para reperfusão e dQTcR > 13 ms a sensibilidade e especificidade foram 93% e 71%, respectivamente, para reperfusão em T3B3(+), possibilitando reclassificar 6% dos pacientes com sucesso de reperfusão. Conclusão: Os dados sugerem a dQTcR como instrumento promissor na identificação não invasiva de reperfusão na artéria coronária culpada, 60min pós-trombólise.

The safety and efficacy of tPA intravenous thrombolysis for treating acute ischemic stroke patients with a history of cerebral hemorrhage

Alteplase (tPA) intravenous thrombolysis is an effective treatment for acute ischemic stroke (AIS) when administered within 4.5 h of initial stroke symptoms. Here, its safety and efficacy were evaluated among AIS patients with a previous history of cerebral hemorrhage. Patients who arrived at the hospital within 4.5 h of initial stroke symptoms and who were treated with tPA intravenous thrombolysis or conventional therapies were analyzed. The 90-day modified Rankin scale (90-d mRS) was used alongside mortality and incidence of symptomatic intracerebral hemorrhage (SICH) rates to evaluate the curative effect of these therapies. Among 1,694 AIS patients, 805 patients were treated with intravenous thrombolysis, including patients with (n=793) or without (n=12) a history of cerebral hemorrhage, and the rate of incidence of SICH significantly differed between them (8.3 vs 4.3%, P=0.039). No significant difference was found in 90-d mRS measurements (41.7 vs 43.6%, P=0.530) and 90-d mortality rates (8.3 vs 6.5%, P=0.946). A total of 76 AIS patients with a history of cerebral hemorrhage received tPA thrombolytic therapy (n=12) or conventional therapy (n=64), and a significant difference was noted in the 90-d mRS scores between the two groups (41.7 vs 23.4%, P=0.029), while no significant difference was found in SICH measurements (8.3 vs 4.6%, P=0.610) and 90-d mortality rates (8.3 vs 9.4%, P=0.227). A history of cerebral hemorrhage is not an absolute contraindication for thrombolytic therapy; tPA intravenous thrombolysis does not increase SICH measurements and mortality rates in patients with a history of cerebral hemorrhage, and they may benefit from thrombolytic therapy.

Experiencia en el tratamiento endovascular del accidente cerebrovascular isquémico agudo en un centro chileno / Emergency endovascular management of ischemic stroke: experience in 104 patients

Background: Recently, five randomized controlled trials confirmed the efficacy and safety of endovascular treatment with or without intravenous thrombolysis in acute ischemic stroke with large-vessel occlusion. Aim: To report patients with ischemic stroke treated with endovascular methods. Material and Methods: Retrospective analysis of 104 patients aged 61 ± 15 years (54% males) with ischemic stroke who received endovascular treatment at a single medical center between 2009 and 2017. Results: Sixty one percent were treated with intravenous thrombolysis plus endovascular procedures and 39% with endovascular procedures alone. The median door-to needle time was 61 minutes and door-to femoral puncture was 135 minutes. The median National Institute of Health Stroke Scale (NIHSS) scores on admission, 24 hours later and at discharge were 12,4 and 1 points, respectively. Middle cerebral artery was occluded in 60% of cases. Other frequent localizations where distal carotid artery in 17% and vertebro-basilar artery in 14%. Thrombolysis in cerebral infarction (TICI) scale flow score after the procedure was 3 or 2b in 58% of cases and significantly correlated with NIHSS scores at 24 hours and discharge. Fifty percent of patients had a mRankin score < = 1 and ten patients died (9.6%). Eight percent had a symptomatic intracerebral hemorrhage. Conclusions: The clinical improvement of these patients 24 hours after the procedure and at discharge demonstrate the effectiveness of endovascular treatment in ischemic stroke. The presence neurologists able to interpret multimodal images at the emergency room, the use of local guidelines, the availability of an experienced neuro-interventional team engaged with the workflow and the use of stent retrievers are strongly associated with good outcomes.

Relato de caso sobre comunicação interventricular pós-infarto agudo do miocárdio / Case report on acute postinfarction myocardial interventricular septal rupture

O presente artigo relata dois casos de pacientes, os quais foram admitidos na emergência do Instituto de Moléstias Cardiovasculares (IMC) com dor tipicamente anginosa, caracterizada como dor retroesternal em aperto, com irradiação para a face medial do braço esquerdo e relacionada ao esforço, com melhora no repouso. No exame físico, apresentavam taquicardia e sudorese. O eletrocardiograma evidenciou sinais de isquemia miocárdica em ambos os pacientes. Após as medidas iniciais serem tomadas, um dos pacientes foi submetido à terapia trombolítica e o outro à angioplastia para implantação de stent . Mais tarde, foi identificada a comunicação interventricular (CIV), seguido da necessidade de correção cirúrgica da mesma. Ambos os pacientes evoluíram bem, apesar da alta taxa de mortalidade desta condição

This paper reports two cases of patients who were admitted to the emergency room of the Instituto de Moléstias Cardiovasculares (IMC) with typically anginal pain, characterized by tight retrosternal pain radiating to the inside left arm, related to stress and improving with rest. Physical examination showed tachycardia and excessive sweating. Electrocardiogram showed signs of myocardial ischemia in both patients. After the initial measures were taken, one of the patients received thrombolytic therapy, and the other angioplasty for stent implantation. Later, interventricular septum rupture (IVSR) was identified, followed by the need for surgery to correct it. Both patients recovered well, despite the high mortality rate of this condition

Evolución del protocolo de trombolisis endovenosa en ataque cerebrovascular isquémico agudo / Intravenous thrombolysis for acute ischemic stroke. A four years' experience in a Chilean public hospital

Background: Intravenous thrombolysis (IVT) with alteplase (tissue plasminogen activator) is the standard pharmacological treatment in acute ischemic stroke (AIS), reducing disability in patients. Aim: To report the results a thrombolysis protocol during four years in a regional public hospital. Material and Methods: Data from 106 consecutive patients aged 68 ± 13 years (57% men) who were treated with IVT, from May 2012 until April 2016, was analyzed. Results: The median door-to-needle time was 80 minutes (interquartile range = 57-113). The median National Institute of Health Stroke Scale (NIHSS) scores on admission and at discharge were was 11.5 and 5 points respectively. At discharge, 27% of hospitalized patients had a favorable outcome (n = 99), defined as having 0 to 1 points in the modified Rankin scale. Symptomatic intracerebral hemorrhage and mortality rates were 5.7 and 13.1%, respectively. The thrombolysis rate rose from 0.7% in 2012 to 6% in 2016. Conclusions: The implementation of 24/7 neurology shifts in the Emergency Department allowed us to increase the amount and quality of IVT in our hospital, as measured by the rate of thrombolysis and by process indicators such as door-to-needle time.

Trombolisis intravenosa en accidente cerebro vascular isquémico agudo en un hospital público de Chile: análisis prospectivo de 54 casos / Intravenous thrombolysis for ischemic stroke: experience in 54 patients

Background: Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) reduces disability in patients with ischemic stroke. However, its implementation in Chilean public general hospitals has been slow and faces some difficulties. Aim: To analyze the results of an intravenous thrombolysis protocol implementation in a public general hospital. Material and Methods: During a lapse of 28 months a standardized protocol for intravenous thrombolysis implemented in the emergency room of a public hospital, was prospectively evaluated. Fifty four patients with ischemic stroke were treated and assessed three months later as outpatients. Results: At three months of follow-up, 66.4% of patients subjected to thrombolysis had a favorable evolution, defined as having 0 to 1 points in the modified Rankin scale. Intracerebral hemorrhage rate was 11.1%, including 5.5% of symptomatic intracerebral hemorrhage. Four percent of patients had systemic bleeding complications after thrombolysis. The mortality rate was 14.8%. Conclusions: The success rates, mortality, and complications rate were comparable to the results obtained in international studies, despite of the absence of a stroke unit to manage stroke and its complications.

Increased neutrophil-to-lymphocyte ratio predicts persistent coronary no-flow after wire insertion in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

OBJECTIVES: Acute ST-segment elevation myocardial infarction patients presenting persistent no-flow after wire insertion have a lower survival rate despite successful mechanical intervention. The neutrophil-to-lymphocyte ratio has been associated with increased mortality and worse clinical outcomes in ST-segment elevation myocardial infarction. We hypothesized that an elevated neutrophil-to-lymphocyte ratio would also be associated with a persistent Thrombolysis In Myocardial Infarction flow grade of 0 after wire insertion in patients undergoing primary percutaneous coronary intervention. METHODS: A total of 644 patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention within 12 hours of symptom onset were included in our study. Blood samples were drawn immediately upon hospital admission. The patients were divided into 3 groups according to their Thrombolysis In Myocardial Infarction flow grade: Thrombolysis In Myocardial Infarction flow grade 0 after wire insertion, Thrombolysis In Myocardial Infarction flow grade 1-3 after wire insertion and Thrombolysis In Myocardial Infarction flow grade 1-3 at baseline. RESULTS: The neutrophil-to-lymphocyte ratio was significantly higher in the group with Thrombolysis In Myocardial Infarction flow grade 0 after wire insertion compared with the group with Thrombolysis In Myocardial Infarction flow grade 1-3 after wire insertion and the group with Thrombolysis In Myocardial Infarction flow grade 1-3 at baseline. The group with Thrombolysis In Myocardial Infarction flow grade 0 after wire insertion also had a significantly higher in-hospital mortality rate. Persistent coronary no-flow after wire insertion was independently associated with the neutrophil-to-lymphocyte ratio. CONCLUSIONS: An increased neutrophil-to-lymphocyte ratio on admission is significantly associated with persistent coronary no-flow after wire insertion in patients with ST-segment ...

Sonotrombolisis en el ataque cerebrovascular isquémico: once años de experiencia en Clínica Alemana de Santiago / Sonothrombolysis for acute ischemic stroke

Background: Sonothrombolysis (ST) is an emerging modality for the treatment of stroke. Aim: To assess the feasibility to perform ST in a Chilean hospital. Material and Methods: Patients attended at a private clinic with an acute ischemic stroke, between September 2002 and May 2013 and eligible for endovenous thrombolysis, were studied with a transcranial Doppler (Spencer PMD 100 or 150®). Those with an adequate sonographic window and a demonstrated arterial occlusion were monitored continuously with transcranial Doppler at the site of worst residual flow following the CLOTBUST study protocol. Results: One thousand twenty six patients were studied, of whom 136 received intravenous thrombolysis (rt-PA) and 61, aged 66 ± 18 years (59% males), were subjected to ST (7% of total). Their median National Institutes of Health Stroke Scale score was 14, the lapse from symptom onset to rt-PA was 127 minutes (43-223). Middle cerebral artery (MCA) occlusion was found in 88.5% of patients. Complete recanalization was achieved in 44.3% of patients. Sixty percent had Modified Rankin Scale of 0 to 2 at 3 months (95% confidence intervals (CI) 48.1 to 72). Case fatality was 9.8% and asymptomatic intracranial hemorrhage occurred in 9.8% (95% CI: 4.3 to 20.2). Conclusions: ST can be carried out in a complex medical center and is safe.

Treatment of ischemic stroke with r-tPA: implementation challenges in a tertiary hospital in Brazil / Tratamento do acidente vascular cerebral isquêmico com r-tPA: o desafio da implantação em um hospital terciário no Brasil

Purpose: This paper presents the initial experience with thrombolysis for acute ischaemic stroke at Hospital de Base do Distrito Federal (HBDF), Brazil, and the difficulties associated with the implementation of this treatment. Method: A retrospective study was performed using the medical records of all patients with acute stroke who were treated with intravenous alteplase in our department, between May 2011 and April 2012. Results: The thrombolytic therapy was administered to 32 patients. The mean time between the ictus and the start of stroke therapy start was 195 (60-270) minutes. Sixteen patients demonstrated a significant clinical improvement (decrease in National Institute Health Stroke Scale [NIHSS] score≥4 points in 24 hours); 6 patients were discharged with an NIHSS score of 0 and 2 demonstrated haemorrhagic transformation. Conclusions: The results of our study are similar to those reported in the literature, although we have been dealing with difficulties, such as the lack of a stroke unit. .

Introdução: O objetivo deste trabalho é apresentar a experiência inicial em trombólise para o acidente vascular encefálico isquêmico (AVC) no Hospital de Base do Distrito Federal (HBDF) e as dificuldades encontradas na implementação do serviço. Método: Foi realizado estudo retrospectivo através da análise de prontuário de todos os pacientes submetidos à terapia trombolítica no período de maio de 2011 a abril de 2012. Resultados: A terapia trombolítica foi administrada a 32 pacientes. O tempo médio do ictus até o início da terapia foi de 195 (60-270) minutos. Dezesseis pacientes apresentaram uma melhora clínica significativa (queda do National Institute Health Stroke Scale [NIHSS] maior ou igual a 4 pontos em 24 horas). Seis pacientes receberam alta com NIHSS 0. Dois pacientes apresentaram transformação hemorrágica. Conclusão: Apesar das dificuldades encontradas, como a ausência de uma Unidade de AVC, o desfecho da nossa série é semelhante aos resultados descritos na literatura. .

Predictors of in-hospital mortality in patients with ST-segment elevation myocardial infarction undergoing pharmacoinvasive treatment

OBJECTIVES: To identify predictors of in-hospital mortality in patients with acute myocardial infarction undergoing pharmacoinvasive treatment. METHODS: This was an observational, prospective study that included 398 patients admitted to a tertiary center for percutaneous coronary intervention within 3 to 24 hours after thrombolysis with tenecteplase. ClinicalTrials.gov: NCT01791764 RESULTS: The overall in-hospital mortality rate was 5.8%. Compared with patients who survived, patients who died were more likely to be older, have higher rates of diabetes and chronic renal failure, have a lower left ventricular ejection fraction, and demonstrate more evidence of heart failure (Killip class III or IV). Patients who died had significantly lower rates of successful thrombolysis (39% vs. 68%; p = 0.005) and final myocardial blush grade 3 (13.0% vs. 61.9%; p<0.0001). Based on the multivariate analysis, the Global Registry of Acute Coronary Events score (odds ratio 1.05, 95% confidence interval (CI) 1.02-1.09; p = 0.001), left ventricular ejection fraction (odds ratio 0.9, 95% CI 0.89-0.97; p = 0.001), and final myocardial blush grade of 0-2 (odds ratio 8.85, 95% CI 1.34-58.57; p = 0.02) were independent predictors of mortality. CONCLUSIONS: In this prospective study that evaluated patients with ST-segment elevation myocardial infarction treated by a pharmacoinvasive strategy, the in-hospital mortality rate was 5.8%. The Global Registry of Acute Coronary Events score, left ventricular ejection fraction, and myocardial blush were independent predictors of mortality in this high-risk group of acute coronary syndrome patients. .

Hipertensão arterial e acidente vascular encéfalico / Stroke and hypertension

O Acidente Vascular Encefàlico (AVE) é um dos principais problemas de saúde pública na atualidade sendo a hipertensão arterial o mais importante fator de risco modificável, tanto para o AVE isquêmico quanto hemorrágico, devido a seu risco relativo e, principalmente, pela sua elevada prevalência na população mundial. O benefício do tratamento com anti-hipertensivos é observado em todas as faixas etárias e é maior dependendo da redução da pressão arterial, e pode continuar mesmo após serem atingidos os níveis basais pré-estabelecidos. A escolha do anti-hipertensivo ideal para cada paciente deve levar em consideração as propriedades farmacológicas, mecanismos de ação e as características individuais de cada paciente. A elevação da pressão arterial observada na fase aguda do AVE isquêmico é frequente e transitória, mesmo em pacientes previamente normotensos. Nos pacientes com AVE isquêmico agudo candidatos à terapia trombolítica intravenosa, a pressão arterial não controlada contribui para aumentar o risco de hemorragia sintomática após a recanalização arterial. Níveis elevados de pressão arterial estão associados a um prognóstico desfavorável nos pacientes com hematoma intraparenquimatoso cerebral. A expansão do hematoma é, frequentemente, demonstrada na fase precoce e pode estar relacionada ao aumento da pressão arterial e ao prognóstico desfavorável. O AVE e os eventos isquêmicos transitórios são apenas parte do espectro das doenças cerebro-vasculares presentes em indivíduos hipertensos. Este espectro inclui as doenças vasculares assintomáticas ou oligosintomáticas resultantes da hipertensão arterial, onde apresentam uma evolução clínica progressiva e crônica.

Stroke is a major public health condition today and hypertension is the most important modifiable risk factor for ischemic and hemorrhagic stroke due to the relative risk and especially for its high prevalence in the population. the treatment benefit using antihypertensive drugs in observed in all age groups and is greater depending on the blood pressure reduction and may continue even after reaching basal blood pressure levels. The choice of the antihypertensive medication must take into consideration the pharmacological properties, mechanisms of action and individual features of each patient. Increasing blood pressure levels is observed during the acute phase of the ischemic stroke and often is transient even in previously normotensive patients. In those patients with acute ischemic stroke and candidates to IV thrombolytic therapy, uncontrolled blood pressure contributes to increasing the risk of symptomatic hemorrhage after arterial recanalization. Elevated blood pressure levels are associated with poor prognosis in stroke patients with cerebral hematoma. The Hematoma expansion in aften demonstrated in the early stage and may be related to increased blood pressure and unfavorable outcome. Stroke and transient ischemic attacks are just part of the spectrum of cerebrovascular diseases related to hypertension. This spectrum may include asymptomatic and oligosymptomatic strokes resulting from hypertension which show a progressive and chronic clinical course.

Intravenous thrombolysis is more effective in ischemic cardioembolic strokes than in non-cardioembolic? / A trombólise endovenosa é mais eficaz nos acidentes vasculares cerebrais isquêmicos cardioembólicos do que nos não cardioembólicos?

It was suggested that intravenous thrombolysis (IT) leads to larger extent recanalization in cardioembolic stroke. In this work we assess if this has beneficial clinical traduction. METHOD: We evaluated 177 patients undergoing IT, which were categorized into cardioembolic (CE) and non-cardioembolic (NCE). National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale were compared. RESULTS: The mean age was 67.4±12.01 and 53.8 percent were male. The mean NIHSS was: 14 (admission), 9 (24 h) and 6 (discharge), similar in subgroups. The difference between NIHSS at admission and 24 hours was 4.17±4.92 (CE: 4.08±4.71; NCE: 4.27±5.17, p=0.900) and at admission and discharge there was an average difference of 6.74±5.58 (CE: 6.97±5.68; NCE: 6.49±5.49, p=0.622). The mRS at discharge and 3 months was not significantly different by subtype, although individuals whose event was NCE are more independent at 3 months. CONCLUSION: Ours findings argue against a specific paper of IT in CE. It can result from heterogeneity of NCE group.

Alguns estudos sugerem que a trombólise endovenosa (TE) conduz a melhor recanalização nos acidentes vasculares cerebrais isquêmicos (AVCI) cardioembólicos. Neste trabalho questionamos se isto terá tradução em benefício clínico. MÉTODO: Avaliamos 177 doentes submetidos a TE, os quais foram categorizados como cardioembólicos (CE) e não cardioembólicos (NCE). Compararam-se a National Institutes of Health Stroke Scale (NIHSS) e escala de Rankin modificada. RESULTADOS: A idade média foi 67,4±12,01 e 53,8 por cento eram homens. NIHSS média foi: 14 (admissão), 9 (24 h), 6 (alta), semelhante nos subgrupos. A diferença entre NIHSS à admissão e 24 h foi de 4,17±4,92 (CE: 4,08±4,71; NCE: 4,27±5,17, p=0,900) e entre a admissão e a alta de 6,74±5,58 (CE: 6,97±5,68; NCE: 6,49±5,49, p=0,622). A classificação na mRS não foi significativamente diferente nos subgrupos (alta e 3 meses), mas os doentes com eventos NCE estavam mais independentes aos 3 meses. CONCLUSÃO: Os nossos resultados não documentam um papel específico da TE nos CE, o que pode resultar da heterogeneidade do grupo NCE.

Terapia de reperfusión en infarto agudo al miocardio: Comparación entre trombolisis endovenosa y angioplastía coronaria / Angioplasty compared to thrombolysis as the initial reperfusion therapy in acute myocardial infarction

Background: Primary angioplasty is superior to intravenous thrombolysis as reperfusion therapy for acute myocardial infarction. Aim: To compare the results of available reperfusion strategies for initial management of acute myocardial infarction during hospitalization and 5 years follow up. Patients and Methods: Historical cohort study from a prospective registry of patients admitted with acute myocardial infarction to our center. Patients treated with primary angioplasty were identified and were then matched by age, sex and date of event with patients treated with throm-bolysis. The clinical outcomes were compared including hospitalization and 5-years follow-up. Results: From March 1993 to August 2001, 98 patients were treated with primary angioplasty and matched with 98 thrombolyzed patients. The groups were comparable. Compared to thrombolysis, angioplasty had a higher success rate (68 and 91% respectively), resulted in less complications and reduced mortality (11 and 2% respectively), required less revascularization procedures and shorter hospital stay (17 and 13 days, respectively). During the follow-up of survivors, no differences in events or additional mortality were detected at 1 or 5years. Conclusions: Primary angioplasty is superior as treatment in terms of achieving success and reducing mortality during hospitalization. Evolution after hospitalization is independent of initial therapy.

Experiencia de trombolisis sistematizada en infarto cerebral agudo en un hospital público de Chile / Thrombolysis for acute ischemic stroke with recombinant tissue plasminogen activator in a Chilean public hospital

Background: The only accepted treatment for acute ischemic stroke is thrombolysis with recombinant tissue plasminogen activator (t-PA). It was implemented in Chile in 1996, although its use was mainly restricted in Chile to private clinics. Recently, at year 2009, we have implemented this treatment in a public hospital. Aim: To describe the results of treatment of acute ischemic stroke with t-PA in a public hospital in Chile. Material and Methods: Prospective analysis of all eligible patients with acute ischemic stroke that were admitted within 4 hours of its onset and had no contraindications for thrombolysis. Results: In an eight months period, a total of 19 intravenous thrombolyses were performed in 12 males and seven females aged 28 to 79 years old. The mean lapse between onset of symptoms and onset of thrombolysis was 190 ± 57 min. Results were favorable, according to Rankin and National Institute of Health Stroke scales. Ninety days after treatment, 63 percent of patients had minimal or absent disability, 26 percent had moderate disability and only one (5 percent) had severe disability. One patient had a clinically not significant intracranial hemorrhage and one patient died six days after thrombolysis. Conclusions: These results indicate that thrombolysis can be successfully implemented in Chilean public hospitals. The limitations for its use in this setting are mostly administrative.

Cerebral microbleeds and intravenous thrombolysis: case report / Micro-hemorragias cerebrais e trombólise endovenosa: relato de caso

Intravenous thrombolysis is an important procedure that has significant impact on ischemic stroke prognosis. However, intracranial hemorrhage (ICH) is a feared complication of this procedure. It has been suggested that cerebral microbleeds (CMBs) may increase the risk of ICH after thrombolysis. We report on a 69 years-old woman with multiple CMBs submitted to intravenous thrombolysis without complications.

A trombólise endovenosa é um procedimento importante que tem impacto significativo sobre o prognóstico de pacientes com acidente vascular cerebral isquêmico. Contudo, a hemorragia intracraniana (HIC) é complicação temida deste procedimento. Foi sugerido que micro-hemorragias cerebrais (MHC) aumentem o risco de HIC após trombólise. Relatamos o caso de mulher de 69 anos com múltiplas MHCs submetida a trombólise endovenosa sem complicações.

Revascularización de accesos vasculares para hemodiálisis crónica: resultados inmediatos y seguimiento a mediano plazo / Revascularization of vascular accesses for chronica hemodialysis

La hemodiálisis, uno de los tratamientos supletorios de la insuficiencia renal crónica, implica la depuración sanguínea periódica, a través de un acceso vascular (AV). La principal complicación de los AV son la estenosis y la obstrucción. El objetivo del presente trabajo es presentar nuestra experiencia en el tratamiento percutáneo de las disfunciones de los AV. Entre enero de 1993 y julio de 1995, se trataron por angioplastia (ATP), trombolisis (T-LIS) y trongoaspiración (T-ASP), 34 pacientes con insuficiencia en sus AV para hemodiálisis crónica. De éstos, 19 eran portadores de estenosis y 15 con oclusión del AV. El tratamiento percutáneo de las disfunciones de los AV es el procedimiento de elección ya que ofrece muy buenos resultados. Realizado precozmente, en etapa de estenosis, ofrece mejores resultados que aquellos con oclusión, mejorando significativamente su sobrevida