Management strategy of antithrombotic therapy in thrombocytopenia patients with atrial fibrillation and atherosclerosis and a literature review / 中国药房

OBJECTIVE To provide reference for the management of antithrombotic therapy in thrombocytopenia patients with atrial fibrillation and atherosclerosis. METHODS The clinical pharmacist participated in the treatment of a thrombocytopenia patient with atrial fibrillation and atherosclerosis， and analyzed the causes of thrombocytopenia according to the patient’s medical history and laboratory examination results. At the same time， the risk of thrombosis-bleeding was evaluated according to the relevant guidelines， and the clinicians were assisted in formulating individual antithrombotic therapy plan and pharmaceutical care plan for the patient. The literature on antithrombotic therapy related to thrombocytopenia was collected and analyzed by retrieving CNKI. RESULTS Thrombocytopenia was considered as primary thrombocytopenia in this patient， and the main risk of bleeding was age ≥65 years old， bleeding tendency， and combined use of antithrombotic drugs. After the clinical pharmacist assessed the risk of thrombosis and bleeding， the clinician was recommended to give full dose of Bemiheparin sodium injection + Dronedarone hydrochloride tablets + Metoprolol succinate sustained-release tablets. In view of thrombocytopenia， the clinician gave Compound zaofan pill， Caffeic acid tablet and Sheng xuexiaoban capsule， but the patient developed diarrhea after the medication. The clinical pharmacist suggested stopping Sheng xuexiaoban capsule， and the clinician adopted the clinical pharmacist’s suggestion. When the patient was discharged from hospital， the clinical pharmacist suggested that the antithrombotic therapy plan for discharge was anticoagulation alone or selective anticoagulation. The clinician chose selective anticoagulation treatment considering that the patient’s current thrombocytopenia， urinary occult blood （+） and fecal occult blood were weakly positive， and ordered the patient to take Metoprolol succinate sustained-release tablets + Atorvastatin calcium tablets at discharge. Literature analysis showed that the causes of thrombocytopenia of patients with thromboembolism mainly included heparin induced-thrombocytopenia， immune thrombocytopenia， etc. All patients were improved after symptomatic treatment. CONCLUSIONS By participating in the management of antithrombotic therapy for the thrombocytopenia patient with atrial fibrillation and atherosclerosis， clinical pharmacists can help effectively control the patient’s condition and ensure the safety and effectiveness of drug use.

Research advances in the study of anticoagulant active molecules / 药学学报

The incidence of thrombosis-induced cardiovascular diseases is increasing worldwide and poses a serious threat to human health. Three factors, slow speed of blood flow, hypercoagulable blood and vascular damage, have been considered to be causes of thrombosis. Antithrombotic drugs have been classified into three categories based on the mechanism of thrombosis, including anticoagulants, platelet inhibitors and fibrinolytics. The coagulation and anticoagulation systems have drawn increasing attention because of the important role they play in the process of thrombosis. Novel compounds with anticoagulant activity are now emerging, alleviating to some extent some of the problems associated with the clinical use of early approved thrombotic drugs, such as high bleeding risk, slow onset of action and narrow therapeutic windows. In this review, we initially describe the mechanisms of coagulation as well as thrombosis. Meanwhile, a wide range of bioactive compounds and potential antithrombotic candidates reported in recent years have been summarized. In addition, the structure-activity relationship of certain compounds has been discussed, expecting to facilitate the development of molecules with anticoagulant biological activity for the treatment of thrombotic diseases.

Diagnosis and treatment recommendations and case study of severe thrombocytopenia caused by tirofiban / 中国输血杂志

【Objective】 To investigate the clinical manifestations, diagnosis, differential diagnosis and management strategies of thrombocytopenia caused by tirofiban. 【Methods】 The basic clinical data, platelet count changes and treatment course of 7 patients with acute coronary syndrome who used tirofiban resulting in severe thrombocytopenia during their hospitalization in our hospital from December 2021 to March 2023 were collected, and their individual and common characteristics were analyzed. 【Results】 Platelet counts were in the normal range in all 7 patients on admission. Six of the patients had thrombocytopenia occurring from 3 to 16 hours after tirofiban use, and one patient was detected at 34 h of tirofiban use. Their minimum platelet count ranged from (1-11)×109/L. All 7 cases discontinued tirofiban and other antithrombotic drugs, and the platelet count increased to 50×109/L in 6 patients in 2 to 4 days after stopping the drug and gradually returned to the normal range. During this period, there were no bleeding or acute thrombotic events, and no platelet transfusion was conducted. Five patients resumed antithrombotic therapy when the platelet count returned to (20-50)×109/L, 1 patient underwent elective coronary artery bypass grafting (CABG) surgery when the count rose above 50×109/L. One patient had bleeding manifestations after thrombocytopenia and required limited-duration CABG surgery, so 3 U platelet transfusion and immunoglobulin treatment were performed consecutively. CABG surgery was performed when the platelet count increased to 76×109/L. The differential diagnosis of the cause of thrombocytopenia was performed in all seven patients, and other causes of thrombocytopenia, such as heparin, were excluded. 【Conclusion】 Tirofiban can cause acute severe or extremely severe thrombocytopenia. Routine platelet count testing at 6 hours after medication can prevent serious adverse events by discontinuing tirofiban promptly after thrombocytopenia occurs. At the same time, it is determined whether to perform platelet transfusion based on whether the patient has bleeding and the risk of bleeding, and the timing of resuming antithrombotic treatment is determined based on the recovery of platelet count and the risk of thrombosis.

Pay attention to subsequent arterial ischemic events after intracerebral hemorrhage / 中华神经科杂志

Survivors of intracerebral hemorrhage (ICH) have significantly higher risks of both arterial ischemic events and recurrent ICH after the first event. This uncertainty leaves clinicians with dilemmas about the therapy strategies for the secondary prevention of major vascular events after ICH. Clinicians mainly focus on the prevention of hemorrhage recurrence but overlook the increased risk of ischemic disease after ICH in routine clinical practice. Secondary stroke prevention measures after ICH including antithrombotic and statin treatments remain challenging due to the lack of dedicated studies with strong evidence. Decision-making on stroke prevention requires algorithmic approaches based on the hemorrhagic and ischemic risk stratification. This article systematically reviews the current evidence for the prevention and management of subsequent arterial ischemic events after ICH, aiming to promote further attention and research to address the current controversies and knowledge gap on this topic.

Drug utilization pattern of hospitalized patients with COVID-19 in a tertiary care center

Background: The first COVID-19 case was reported in a Chinese province named Wuhan in December 2019, which later spread to 215 countries worldwide infecting 47.9 crores of people and caused 61.1 lakhs of deaths, until March 2022. In India alone, 4.3 crores were infected and 5.17 lakhs deaths were reported until the above said period. Aims and Objectives: In this study, we analyze the drug utilization pattern of mainline and supportive drugs used in the treatment of COVID-19 patients admitted in a tertiary care center. The role of repurposed drugs in the prescription pattern of COVID-19 patients would also be analyzed. Materials and Methods: The study included all the COVID-19 patients admitted in this institution between April 2021 and June 2021. These included patients were laboratory-confirmed positive cases and must have received medical treatment for a minimum of 3 days in the hospital. Pregnant women and children admitted with COVID-19 infection were not included in this study. All the data for this study were retrospectively extracted from the medical records department of the institution. A total of 420 patients have been admitted in COVID-19 ward between April 2021 and June 2021, out of which 300 case records which fulfilled the above said criteria were selected for further scrutiny. Results: Among 300 patients, there were 192 males (64%) admitted with COVID-19 infection compared to 108 females (36%). Predominant age group of distribution of COVID-19 cases was between 50 and 60 years (42%). One hundred and eighty-eight COVID-19 cases had one or more comorbid conditions along with COVID-19 infection. There were 12 deaths among the selected 300 cases during their hospital stay. The most common combination used in the treatment of COVID-19 was an antibacterial, antiviral, antithrombotic, and an anti-inflammatory drug. About 76% (n = 228) of the admitted COVID-19 patients received this combination along with other supportive or symptomatic treatment during the stay in hospital. About 88% (n = 284) of cases had an antiparasitic drug ivermectin in a daily dose of 12 mg for a period of 5 days. Ivermectin is one among the repurposed drugs used in the treatment of COVID-19 infection. Proton-pump inhibitors such as omeprazole 20 mg twice daily in oral route or pantoprazole 40 mg in parenteral route were the supportive drugs used in most prescriptions. Conclusion: Except the high empirical usage of antibiotics, the remaining frontline drugs for COVID-19 such as antiviral, corticosteroids, and antithrombotics were utilized in an appropriate manner. A high positive clinical outcome observed in this study can be attributed to the expertise gained by the physicians over the period of time in handling the COVID-19 infection.

Development of platelet change characteristics and antithrombotic strategies after transcatheter aortic valve replacement / 中国综合临床

Transcatheter aortic valve implantation (TAVI) is an emerging, minimally invasive surgical procedure for the safe and effective treatment of aortic valve lesions,and with the advancement of medical research and surgical techniques, the population for TAVI is gradually expanding,but, the characteristics of platelet changes after TAVI and the best antithrombotic strategy in the perioperative period are not conclusive. We review the characteristics of platelet changes and related factors after TAVI, and the outcomes of clinical studies related to different antithrombotic treatments in the perioperative period, in order to discuss the individualized antithrombotic strategy after TAVI.

Perioperative antithrombotic therapy in the patient undergoing revision total hip arthroplasty after coronary stent implantation: a case report and literature review / 药学实践杂志

Objective To explore the strategies of perioperative antithrombotic therapy in the patient undergoing revision total hip arthroplasty after coronary stent implantation. Methods The antithrombotic therapy in one patient undergoing revision total hip arthroplasty after coronary stent implantation was analyzed with the review of related literatures. Results The patient developed non-ST segment elevated myocardial infarction due to the stop of aspirin three days before operation and no low molecular weight heparin was used. The antithrombotic treatment and prevention of venous thromboembolism were analyzed. Conclusion Antithrombotic therapy should be selected reasonably in patients undergoing revision total hip arthroplasty after coronary stent implantation.

Early effect of different antithrombotic therapy after coronary endarterectomy combined with coronary artery bypass graft / 中华胸心血管外科杂志

Objective:To investigate the early effect of different antithrombotic therapy in patients with coronary endarterectomy(CE) combined with off-pump coronary artery bypass grafting(OPCABG).Methods:Between January and December 2021, 154 consecutive patients including 120 males and 34 females with the age ranged from 39 to 78 years and an average of(62.6±7.2) years who underwent CE+ OPCABG were evaluated retrospectively. According to the postoperative anticoagulant therapy, patients were divided into two groups: Aspirin+ low molecular weight heparin group(n=81, LMWH group) and Aspirin+ ticagrelor group(n=73, ticagrelor group). The data of both preoperative and postoperative hemoglobin level and blood transfusion after the surgery were collected. The dynamic changes of electrocardiogram and cTnI level were observed within 48 h after the surgery.Results:There was no perioperative death, and all the patients were discharged 5-13 days postoperatively. After the initiation of anticoagulant therapy, the lowest hemoglobin value in the LMWH group and ticagrelor group was(88.3±14.6)g/L vs.(89.5±11.6)g/L( P>0.05), blood transfusion was performed in 8 vs. 5 patients with hemoglobin below 70g/L( P>0.05), peak cTnI within 48 h of surgery was 850.55(410.63, 1 662.63)pg/ml vs. 1 184.60(667.50, 3 169.63)pg/ml( P<0.05), the number of patients with perioperative myocardial infraction within 48h after the surgery confirmed by electrocardiogram was 2(2.5%) vs.2(2.5%), P>0.05. Conclusion:There was no significant difference between the two anticoagulant treatments in preventing perioperative myocardial infarction after CE+ OPCABG surgery. LMWH did not increase the risk of postoperative bleeding compared with ticagrelor. In addition, aspirin+ LMWH reduced the levels of peak TnI within 48 h of surgery, which may be associated with better long-term postoperative outcomes, but further research is needed to confirm this.

Interpretation of the second update to the ninth edition of antithrombotic therapy guidelines for venous thromboembolism disease published by American College of Chest Physicians / 中国胸心血管外科临床杂志

@#Venous thromboembolism (VTE), comprising both deep vein thrombosis and pulmonary embolism, is a chronic illness that contributes significantly to the global burden of disease. The American College of Chest Physicians (ACCP) published the 9th edition of antithrombotic treatment guidelines for VTE (AT9) in 2012, which was first updated in 2016. In October 2021, ACCP published the 2nd update to AT9, which addressed 17 clinical questions related to VTE and presented 29 guidance statements in total. In this paper we interpreted the recommendations proposed in this update of the guidelines.

The risk of post-polypectomy bleeding among patients receiving antithrombotic agents: A prospective observational study

ABSTRACT BACKGROUND: In July 2012, the Japan Gastroenterological Endoscopy Society updated their guidelines for gastroenterological endoscopy in patients receiving antithrombotic therapy. Colonoscopic polypectomy procedures are associated with a high risk of bleeding. OBJECTIVES: The present study evaluated the safety of colonoscopic polypectomy procedures in terms of bleeding, among patients receiving antithrombotic therapy. DESIGN AND SETTING: Prospective observational study conducted in a tertiary-level public cardiovascular hospital in Istanbul, Turkey. METHODS: Colonoscopic polypectomies carried out in a single endoscopy unit between July 2018 and July 2019 were evaluated prospectively. The patients' data, including age, gender, comorbidities, whether antithrombotic drug use was ceased or whether patients were switched to bridging therapy, polyp size, polyp type, polyp location, histopathology, resection methods (hot snare, cold snare or forceps) and complications relating to the procedures were recorded. RESULTS: The study was completed with 94 patients who underwent a total of 167 polypectomy procedures. As per the advice of the physicians who prescribed antithrombotic medications, 108 polypectomy procedures were performed on 60 patients without discontinuing medication and 59 polypectomy procedures were performed on 34 patients after discontinuing medication. The age, gender distribution and rate of bleeding did not differ significantly between the patients whose medication was discontinued and those whose medication was continued (P > 0.05). CONCLUSION: This study found that the colonoscopic polypectomy procedure without discontinuation of antithrombotic medication did not increase the risk of bleeding. This procedure can be safely performed by experienced endoscopists in patients with an international normalized ratio (INR) below 2.5.

Estudio comparativo entre enoxaparina y ácido acetilsalicílico en profilaxis antitrombótica para pacientes sometidos a artroplastía total de rodilla / Comparative study between enoxaparin and salicylic acetyl acid in antithrombotic prophylaxis for patients undergoing total knee arthroplasty

Resumen: Introducción: Aún existe controversia en cuanto a la tromboprofilaxis para la disminución de la enfermedad tromboembólica en la cirugía ortopédica mayor. Objetivo: Responder la siguiente pregunta: ¿existe diferencia en la efectividad y seguridad en el manejo antitrombótico de pacientes con un régimen tradicional de enoxaparina contra ácido acetilsalicílico? Material y métodos: Las cirugías se llevaron a cabo por tres cirujanos, se aleatorizó la muestra y los pacientes fueron sometidos a los criterios del estudio. Evaluamos eficacia y seguridad así como la necesidad de reingreso y variables secundarias como infección, infarto agudo de miocardio, enfermedad vascular cerebral y muerte con un seguimiento de 90 días. Resultados: El total de la muestra fue de 402 pacientes, 214 en el grupo de enoxaparina y 188 en el de aspirina. Se presentaron cinco casos (1.24%) con enfermedad tromboembólica, tres (1.4%) enoxaparina y dos (1.06%) aspirina sin diferencia significativa (p = 0.23). En cuanto a seguridad, el sangrado mayor fue cero en ambos grupos, presentándose sangrado menor en siete pacientes (1.74%), cuatro (1.86%) fueron del grupo enoxaparina y tres (1.59%) del grupo aspirina sin diferencias significativas (p = 0.82). Los resultados secundarios mostraron cinco (1.24%) infecciones de herida quirúrgica superficiales y un IAM en los primeros 30 días del procedimiento en el grupo de enoxaparina. Conclusión: La aspirina como monoterapia es segura y eficaz en profilaxis antitrombótica en pacientes operados de artroplastía total de rodilla.

Abstract: Introduction: There is still controversy regarding thrombo-prophylaxis for the reduction of thromboembolic disease in major orthopedic surgery. Objective: To answer the following question: is there a difference in the effectiveness and safety in the antithrombotic management of patients with a traditional regimen of enoxaparin against acetyl salicylic acid? Material and methods: The surgeries were performed by 3 surgeons; the sample was randomized and the patients were subjected to the study criteria. We evaluated efficacy and safety as well as the need for readmission and secondary variables such as infection, acute myocardial infarction (AMI), cerebral vascular disease and death with a follow-up of 90 days. Results: The total sample was 402 patients; 214 in the enoxaparin group and 188 in the aspirin group. There were 5 cases (1.24%) with thromboembolic disease, 3 (1.4%) enoxaparin and 2 (1.06%) aspirin without significant difference (p = 0.23). In terms of safety, major bleeding was zero in both groups, with minor bleeding in 7 patients (1.74%), 4 (1.86%) were from the enoxaparin group and 3 (1.59%) from the aspirin group without significant differences (p = 0.82). Secondary outcomes showed 5 (1.24%) superficial surgical wound infections and one AMI in the first 30 days of the procedure in the enoxaparin group. Conclusion: Aspirin as monotherapy is safe, effective in antithrombotic prophylaxis in patients operated on total knee arthroplasty.

Estrategias de antiagregación plaquetaria en síndromes coronarios agudos / Antiplatelet Strategies in Acute Coronary Syndromes

RESUMEN Los pacientes que presentan síndrome coronario agudo se benefician de la utilización de antiagregantes plaquetarios para reducir la recurrencia de eventos isquémicos. Durante mucho tiempo estuvimos acostumbrados a indicar una combinación fija de aspirina más un inhibidor del receptor P2Y12 por un tiempo estricto. Sin embargo, la complejidad de los pacientes y de los procedimientos que en ellos se realizan nos obligan, como médicos, a buscar las mejores combinaciones posibles, tanto en lo referido al tipo de fármacos utilizados como a la duración del tratamiento, con el fin de lograr el mejor equilibrio entre protección isquémica y riesgo hemorrágico. En los últimos años, múltiples estudios llevados a cabo en esta línea han mostrado que diferentes estrategias pueden beneficiar a nuestros pacientes en distintos escenarios. En la siguiente revisión brindamos una descripción general de los conocimientos actuales sobre el tratamiento con antiagregantes plaquetarios, junto con algunas sugerencias sobre su manejo.

ABSTRACT Patients with acute coronary syndrome benefit from the use of antiplatelet agents to reduce the recurrence of ischemic events. For a long time, we have been used to indicating a fixed combination of aspirin plus a P2Y12 receptor inhibitor during a strict period of time. However, the complexity of patients and procedures force us, as physicians, to seek the best possible combinations, both of the type of drugs used as treatment duration, in order to achieve the best balance between ischemic protection and bleeding risk. In recent years, numerous studies carried out in this regard have shown that different strategies may benefit our patients in different settings. In the following review we provide an overview of the current knowledge about antiplatelet therapies, along with some suggestions on their management.

Discovery and identification of quality markers of Sparganii Rhizoma based on zebrafish thrombosis model / 中草药·英文版

Objective: The aim of the present study was to determine the quality marker (Q-Markers) of Sparganii Rhizoma against thrombus through an integration of investigations on its antithrombotic effect, content determination and spectrum-effect correlation analysis. Methods: Based on the concept of Q-Marker, Sparganii Rhizoma was investigated for the identification of chemical component. The pharmacological effects on arachidonic acid-induced thrombosis in zebrafish were also investigated. The material basis in ethanol extract was determined by HPLC-UV. Furthermore, the potential Q-Markers were analyzed and predicted according to the effect-chemical correlation analysis. Finally, the anti-thrombotic Q-Markers were verified through the anti-thrombotic test of monomer components. Results: The model of thrombosis zebrafish was established with larvae exposed to 100 µmol/L arachidonic acid for 1 h. Nine ingredients in Sparganii Rhizoma were identified as 5-hydroxymethylfurfural, vanillic acid, ferulic acid, p-hydroxybenzaldehyde, p-hydroxybenzoic acid, vanillin, protocatechuic acid, p-coumaric acid and isoferulic acid. According to the determination effect of zebrafish thrombosis model and HPLC content analysis results, all the other contents present positive correlation except 5-hydroxymethylfurfural, and the P values of three representative potential Q-Markers (ferulic acid, protocatechuic acid and p-coumaric acid) were 0.002, 0.001 and 0.026, respectively. Conclusion: Sparganii Rhizoma showed a dose-dependent effect on the recovery of reducing cardiac red blood cell on zebrafish model. Three phenolic acids (ferulic acid, protocatechuic acid and p-coumaric acid) were proved to possess the anti-thrombotic effects which could be regarded as the potential Q-Markers for quality assessment of Sparganii Rhizoma.

Safety and feasibility of bridging with low molecular weight heparin in patients scheduled for percutaneous nephrolithotomy undergoing long-term antithrombotic therapy / 中华泌尿外科杂志

Objective:To investigate the safety and efficacy of low molecular weight heparin (LMWH) bridging program in the perioperative period of mini-percutaneous nephrolithotomy (mPCNL) for long-term antithrombotic patients.Methods:The clinical data of 50 patients who received long-term antithrombotic therapy with mPCNL in Sun Yat-sen Memorial Hospital from January 2013 to December 2017 were retrospectively analyzed. Perioperative anticoagulation plans were drawn up after discussion with an internist. Patients with high thrombosis risk were bridged with LMWH during the perioperative period. Resumed LMWH anticoagulation within 48 hours after surgery. Patients with low or medium thrombosis risk directly discontinued anticoagulation one week before surgery. Preoperative anticoagulation was resumed within 48 hours after removing the nephrostomy tube in all patients. We analyzed the general information before surgery, data during surgery, postoperative hemoglobin changes and stone-free rate (SRF) of all cases. 21 patients were treated with LMWH bridging (bridging group), and 29 patients were directly discontinued with anticoagulant drugs (non-bridging group). There was no statistical difference between the two groups in age [(59.7±7.1) vs. (52.4±10.4)years] , gender [(male/female), 14/7 vs. 19/10], BMI [ (24.3±3.9) kg/m 2 vs. (24.7±5.1) kg/m 2], S. T.O.N.E. score (7.4±1.1 vs. 6.9±1.0), stone surface area [ 314.0(31.4-1 130.4) mm 2 vs. 282.5(64.7-866.0) mm 2], the number of calculi involved in calyces (6/15 vs. 13/16) and stone-related surgical history [ 34% (7/21) vs. 24% (7/29) ]. Results:In the bridging group, 18 patients (86%) performed single-channel mPCNL, 3 patients (14%) underwent dual-channel mPCNL, and the operation time was 80 (35-180) min. In the non-bridging group, 27 patients (93%) underwent single-channel mPCNL, 2 patients (7%) performed dual-channel mPCNL, and the operation time was 80 (30-60) min. The mean changes in hemoglobin in the bridging group and the non-bridging group was 18 (-2 -66) g/L and 14 (-25-64) g/L, respectively ( P = 0.073). The average postoperative hospital stay in the bridging group was (8.6 ± 3.5) days, and the non-bridging group was (7.1 ± 2.3) days ( P= 0.057). Two patients in each group received blood transfusion, and no patients received interventional embolization. The SRF of bridging group and non-bridging group was 81.0% (17/21) vs. 75.9% (22/29) ( P = 0.67) 1 month after the operation. During the perioperative period, no patients had thrombotic complications. Conclusions:When mPCNL was required for long-term antithrombotic treatment patients, the use of LWMH alternatives during the perioperative period did not increase bleeding related complications.

Rapid Enrichment and Activity Research of Antithrombotic Proteins from Pheretima vulgaris / 中国实验方剂学杂志

Objective:A strong antithrombotic protein component， named PvQ， was purified and enriched from total protein of <italic>Pheretima vulgaris</italic>，<italic> </italic>a<italic> </italic>traditional Chinese medicine. Moreover， we evaluated its fibrinolytic and anticoagulant activity， and expected to provide reference for the research on antithrombotic substances of Pheretima. Method:A rapid <italic>in</italic> <italic>vitro</italic> activity-oriented separation combined with the AKTA-Pure protein purification system conducted on <italic>P. vulgaris</italic>. Meanwhile， the fibrinolytic and anticoagulant activities of PvQ were measured by fibrin plate method and fibrinogen-thrombin time （Fibg-TT） method. And the <italic>in vitro</italic> thrombolysis assay was used for evaluating the lysis ability of PvQ to thrombus. Then the stability of PvQ was also analyzed for its anticoagulant activity at different pH and temperature. Result:The PvQ was successfully enriched and its activity was determined to have significant fibrinolytic and anticoagulant activities. And the result of <italic>in vitro</italic> thrombolysis assay revealed that PvQ could hydrolyze more than 80% of thrombus after 5 h of incubation at 37 ℃. In addition， the changes of temperature and pH had significant effects on antithrombotic activity， and this study showed that PvQ was rapidly inactivated at ≥60 ℃ or in acidic conditions （pH<7）. While， the activity of PvQ was unaffected or less affected at ≤50 ℃ and under alkaline conditions. Conclusion:A feasible preparation method of PvQ is established， and it can affect fibrin and fibrinogen at the same time， thus exerting a dual fibrinolytic effect and possessing significant fibrinolytic and anticoagulant activities. It provides a scientific interpretation for the treatment of thrombotic diseases by PvQ and a reference for the development of antithrombotic protein products of Pheretima.

Infarto agudo de miocardio en pacientes convalecientes de neumonía por COVID-19 / Acute myocardial infarction in patients recovering from COVID-19 pneumonia

Resumen El compromiso coronario en la infección COVID-19 se presenta habitualmente como infarto agudo de miocardio (IAM) tipo 2, debido al aumento del consumo y reducción del aporte de oxígeno, y menos frecuentemente como IAM tipo 1, con supradesnivel del ST. Se cree que estos últimos pueden tener relación con la trombogenicidad de la infección. Se presentan dos casos de varones de mediana edad, con pocos o sin factores de riesgo cardiovasculares, que luego de 10 días de internación por neumonía debida a COVID-19 con buena evolución, presentaron IAM con supradesnivel del ST en fase de convalecencia, al día siguiente del alta hospitalaria y de la suspensión de enoxaparina profiláctica. Ambos fueron tratados mediante angioplastia directa con stent farmacológico. Se discute cuál debiera ser el tratamiento al alta del IAM, si agregar anticoagulación a la doble antiagregación plaquetaria y también considerar algún tratamiento antitrombótico profiláctico al alta de neumonía por COVID-19 en ciertos pacientes.

Abstract Coronary involvement in COVID-19 infection usually presents as type 2 acute myocardial infarction (AMI), due to increased 0 consumption and reduction of oxygen supply, and less frequently as type 1 (STEMI). In that cases, thrombogenicity of the infection may contribute to acute coronary occlusion. We present 2 cases of middle-aged men, with few or none cardiovascular risk factors, who were in hospital during 10 days because pneumonia due to COVID-19 with good evolution. In the convalescent phase, one day after hospital discharge, and enoxaparin suspension, they went back to hospital because STEMI. Both were treated by direct angioplasty using pharmacologic stent. Discussion is related to treatment of AMI at discharge, if anticoagulation should be added to double antiplatelet therapy, and if any prophylactic antithrombotic treatment should be considered at discharge from COVID-19 pneumonia in some patients.

SBA 2020: Regional anesthesia guideline for using anticoagulants update / SBA 2020: Atualização na diretriz da anestesia regional em uso de anticoagulantes

Abstract The development of protocols to prevent perioperative Venous Thromboembolism (VTE) and the introduction of increasingly potent antithrombotic drugs have resulted in concerns of increased risk of neuraxial bleeding. Since the Brazilian Society of Anesthesiology 2014 guideline, new oral anticoagulant drugs were approved by international regulating agencies, and by ANVISA. Societies and organizations that try to approach concerns through guidelines have presented conflicting perioperative management recommendations. As a response to these issues and to the need for a more rational approach, managements were updated in the present narrative review, and guideline statements made. They were projected to encourage safe and quality patient care, but cannot assure specific results. Like any clinical guide recommendation, they are subject to review as knowledge grows, on specific complications, for example. The objective was to assess safety aspects of regional analgesia and anesthesia in patients using antithrombotic drugs, such as: possible technique-associated complications; spinal hematoma-associated risk factors, prevention strategies, diagnosis and treatment; safe interval for discontinuing and reinitiating medication after regional blockade.

Resumo Os padrões evolutivos para a prevenção do tromboembolismo venoso perioperatório e a introdução de medicações antitrombóticas cada vez mais potentes resultaram em preocupações com o aumento do risco de sangramento neuroaxial. Após o consenso da Sociedade Brasileira de Anestesiologia em 2014, novos medicamentos anticoagulantes orais foram aprovados pelas instituições reguladoras internacionais, assim como pela ANVISA. As sociedades que buscam abordar o manejo perioperatório desses fármacos apresentam recomendações conflitantes. Em resposta a essas questões e à necessidade de uma abordagem mais racional, as condutas foram atualizadas nesta revisão narrativa e feitas declarações de consenso. Elas foram projetadas para encorajar a assistência ao paciente de forma segura e de qualidade, mas não podem garantir um resultado específico. Tal como acontece com qualquer recomendação de orientação clínica, estas estão sujeitas a revisão com o conhecimento de avanços específicos de complicações. O objetivo foi avaliar aspectos da segurança em anestesia e analgesia regional em pacientes em uso de medicações antitrombóticas, tais como: possíveis complicações decorrentes da técnica; fatores de risco associados ao hematoma espinhal, estratégias de prevenção, diagnóstico e tratamento; intervalo seguro para suspensão e reinício da medicação após o bloqueio regional.

Tromboprofilaxis durante el embarazo / Thromboprophylaxis during pregnancy

Resumen Introducción. En mujeres, el riesgo de desarrollar enfermedad tromboembólica venosa (ETV) es 5 a 6 veces mayor durante el embarazo, riesgo que puede aumentar considerablemente si existen antecedentes personales o familiares de otros estados protrombóticos. La ETV es una de las principales causas de morbimortalidad en esta población, por lo que para evaluar la pertinencia de usar tromboprofilaxis, ya sea farmacológica o no farmacológica, es necesario reconocer oportunamente los factores de riesgo clínico asociados a esta condición. Objetivo. Describir el uso de pruebas de tamizaje de estados protrombóticos y de la tromboprofilaxis farmacológica y no farmacológica para prevenir la ETV durante la gestación, durante el parto y durante el puerperio. Materiales y métodos. Se realizó una revisión de la literatura en Embase, ClinicalKey, ScienceDirect, Access Medicine, Scopus, ProQuest, PubMed y LILACS. Se buscaron estudios sobre trombofilia y tromboprofilaxis en el embarazo publicados entre enero de 2004 y marzo de 2018 en inglés y en español. Resultados. En la búsqueda inicial se identificaron 126 artículos, de los cuales 52 cumplieron los criterios de inclusión. La mayoría de estudios correspondió a revisiones narrativas (n = 15), revisiones sistemáticas (n=8) y guías de práctica clínica (n=6). Conclusión. Se recomienda el uso de pruebas de tamizaje de estados protrombóticos durante la gestación, el parto y el puerperio, ya que la identificación oportuna de la ETV permite disminuir las tasas de morbimortalidad en esta población mediante la implementación de medidas tromboprofilácticas, sean o no farmacológicas.

Abstract Introduction: The risk of developing venous thromboembolism (VTE) in women is 5 to 6 times higher during pregnancy. In addition, this risk can be significantly higher if the patient has a history or family history of hypercoagulate states. VTE is a leading cause of morbidity and mortality in this population, so in order to assess if it is appropriate to use thromboprophylaxis during pregnancy, whether pharmacological or non-pharmacological, it is necessary to timely recognize the clinical risk factors associated with this condition. Objective: To describe the use, on the one hand, of screening tests for hypercoagulate states and, on the other, of pharmacological and non-pharmacological thromboprophylaxis to prevent the development of VTE during pregnancy, labor and the puerperium Materials and methods: A literature review was conducted in the Embase, ClinicalKey, ScienceDirect, Acces Medicine, Scopus, ProQuest, PubMed and LILACS databases. The search included studies on thrombophilia and thrombophylaxis during pregnancy published in English or Spanish between January 2004 and March 2018. Results: After completing the initial search, 126 studies were identified, of which 52 met the inclusion criteria. Most studies were narrative reviews (n = 15), systematic reviews (n = 8) and clinical practice guidelines (n=6). Conclusion: The use of screening tests for hypercoagulate states during pregnancy, labor and the puerperium is recommended, since the timely identification of VTE will allow the reduction of morbidity and mortality rates in this population through the implementation of thromboprophylactic measures, whether they are pharmacological or non-pharmacological.

Incidence of thrombophilia in patients with recurrent pregnancy loss

Background: Approximately 1-3% of women of reproductive age suffer from recurrent pregnancy loss. Objective of this study was to evaluate the association between recurrent pregnancy loss and thrombophilia.Methods: This is a descriptive study, involving retrospective analysis of patients with recurrent pregnancy losses. Patients with recurrent pregnancy loss in whom associated morbidity factors were excluded underwent screening for both acquired and inherited thrombophilia.Results: A total of 20 patients were screened for acquired and inherited thrombophilia with recurrent pregnancy loss. Thrombophilia was diagnosed in 70% cases. Out of which, anticardiolipin antibodies was found positive in 57% of patients, protein C 7% and protein S deficiency was observed in 35% cases.Conclusions: Thrombophilias are associated with recurrent pregnancy loss. Patients in whom other associated morbid factors are excluded, should be offered screening for thrombophilia. Multidisciplinary management involving hematologist is vital for management.

Strategies of diagnosis and treatment of symptomatic spontaneous isolated superior mesenteric artery dissection / 中国介入影像与治疗学

Objective: To explore the strategies of diagnosis and treatment of symptomatic spontaneous isolated mesenteric artery dissection (SSIMAD). Methods: Data of 44 patients with SSIMAD were retrospectively reviewed, and the strategies of diagnosis and treatment as well as follow-up results were analyzed. Results: Among 44 SSIMAD patients, abdominal pain was the initial symptoms in 39 cases, accompanied by nausea and vomiting in 27 cases. Twenty-eight patients underwent nonsurgical treatment (antithrombotic therapy and expectant treatment), while 13 underwent intraluminal interventional therapy and 3 underwent open surgery. Two cases after nonsurgical treatments and 1 case after surgery were lost. Totally 41 patients were followed up for (32.42±6.67)months. During follow up periods, positive remodeling and negative remodeling were observed in 21 and 5 cases among 25 patients after nonsurgical treatment, while in 10 and 5 cases among 15 patients after intraluminal interventional therapy or open surgery. Conclusion: For acute stage SSIMAD, nonsurgical treatment should be the first-line regimen. Endovascular intervention is safe and feasible if conservative management (≥7 days) fails to relieve persistent abdominal pain symptoms. When peritonitis is present, surgical treatment should be promptly performed.