Use of a mobile application for the control of anticoagulation with warfarin: a cluster randomized controlled clinical trial - Ijui/RS/Brazil

Abstract To evaluate the effectiveness of an anticoagulation protocol adapted in a mobile application (appG) for patients using warfarin. This was a cluster randomized controlled clinical trial carried out in basic health centers of Ijui, RS, Brazil, between April and October 2017. The appG was installed on the cell phones of all physicians belonging to the intervention group. Primary outcomes were bleeding and thrombosis, and secondary outcomes were changes in the dose of warfarin, use of new drugs, drug interactions, search for health services, and remaining on the target international normalized ratio. Thirty-three patients belonging to 11 basic health centers were included in this study. From these, 15 patients were in the intervention group which used the appG, and 18 were in the control group. After 6 months, patients in the appG group had fewer bleeding events (7% versus 50%, p-value=0.028) and a lower weekly dose of warfarin (29.3 ± 9.7 mg versus 41.7 ± 12.5 mg, p-value=0.030) when compared to the control group. The anticoagulation protocol adapted in a mobile app reduced bleeding in patients using warfarin.

Avaliação da função renal após a terapia de ressincronização cardíaca / Assessment of renal function after cardiac resynchronization therapy

A síncope é um problema médico comum e, se relacionada a distúrbio da condução atrioventricular (AV), pode indicar o implante de marcapasso definitivo. Por isso, a distinção entre o bloqueio AV devido a doença degenerativa e aquele induzido por aumento do tônus vagal tem importante implicação prognóstica e terapêutica. O mecanismo responsável pela síncope vasovagal é a perda abrupta e transitória da consciência decorrente de hipoperfusão cerebral global e transitória, com início rápido, curta duração e recuperação completa e espontânea. É uma causa comum de síncope e tem bom prognóstico. Em sua forma cardioinibitória, costuma ter como mecanismo a bradicardia sinusal ou a assistolia associada a queda da pressão sanguínea, porém podem ocorrer outras apresentações menos comuns, como o bloqueio AV (BAVT, BAV 2:1 BAV avançado). Descreve-se o caso de uma paciente do sexo feminino, com 54 anos, hipertensa, chagásica (megaesôfago) e vários episódios de síncope no último ano. Foi investigada com eletrocardiograma (BAV 1º grau), ecocardiograma (normal), Holter (BAV 2 grau Mobitz I durante o sono), teste ergométrico (resposta cronotrópica e condução AV normais durante o esforço) e tilt test sensibilizado positivo (BAVT) com manutenção de distúrbios da condução atrioventricular (BAVT, BAV avançado) associados a pré-síncope após retorno a zero grau, quadro que durou 25 minutos. Como parte da investigação, foi submetida a estudo eletrofisiológico com intervalo HV normal. Foi indicado marcapasso definitivo, porém a paciente recusou-se. Retornou após um ano com manutenção do quadro de síncope. Foi então submetida a implante de marcapasso definitivo de dupla-câmara e encontra-se há 15 meses sem sintomas.

Abstract: Syncope is a common medical problem and if related to disorder of atrioventricular (AV) conduction may be indicative of permanent pacemaker implantation. Therefore, the distinction between AV block due to degenerative disease and that induced by increased vagal tone has important prognostic and therapeutic implications. The mechanism responsible for vasovagal syncope is a sudden and transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration, and spontaneous complete recovery. It is a common cause of syncope and has a good prognosis. When cardioinhibitory, usually has as a mechanism of syncope sinus bradycardia or asystole associated to drop in blood pressure, but other less common presentations may occur as AV block (AVB, advanced AVB, AVB 2:1). We describe the case of a female patient, 54 years old, with hypertension, Chagas disease (megaesophagus) and several episodes of syncope in the last year. She was investigated by electrocardiogram (1st degree AVB), echocardiogram (normal), holter (Mobitz I 2nd degree AVB during sleep), exercise testing (normal chronotropic response and AV conduction during exercise) and tilt test (complete AVB) with maintenance of atrioventricular block (complete AVB and advanced AVB) associated with pre-syncope after returning to zero degree. This situation last for 25 minutes. As part of the investigation she underwent electrophysiologic study with normal HV interval. Permanent pacemaker was indicated but the patient refused. After 1 year she returned with maintenance of syncope and then underwent implantation of a permanent dual chamber pacemaker. She is without symptoms in the last 15 months.