Analysis of management efficacy in patients with heavy menstrual bleeding associated with antithrombotic therapy / 中华妇产科杂志

Objective: To evaluate different methods' efficacy of controlling acute bleeding and managing long-term menstruation in patients with heavy menstrual bleeding (HMB) associated with antithrombotic therapy. Methods: The clinical data of 22 cases with HMB associated with antithrombotic therapy admitted to Peking University People's Hospital from January 2010 to August 2022 were analyzed, aged 39 years old (26-46 years). Changes in menstrual volume, hemoglobin (Hb), and quality of life were collected after control of acute bleeding and long-term menstrual management. Menstrual volume was assessed by pictorial blood assessment chart (PBAC), and quality of life was assessed by menorrhagia multi-attribute scale (MMAS). Results: (1) Treatment of acute bleeding: of the 22 cases with HMB associated with antithrombotic therapy, 16 cases were treated in our hospital and 6 in other hospital for emergency bleeding; of the 16 cases treated in our hospital, 3 underwent emergency intrauterine Foley catheter balloon compression due to severe bleeding (Hb decreased by 20 to 40 g/L within 12 hours). Of the 22 cases with antithrombotic therapy-related HMB, 15 (including 2 cases with severe bleeding) underwent emergency aspiration or endometrial resection, and intraoperative placement of levonorgestrel-releasing intrauterine system (LNG-IUS) followed by a significant reduction in bleeding volume; 3 cases had controlled acute bleeding after rivaroxaban dose reduction and continued observation; 2 cases were given gonadotropin-releasing hormone agonists to control acute bleeding in other hospital, of which 1 case was temporarily treated with periodic blood transfusion, and the other one patient underwent total hysterectomy; and 2 cases had temporary amenorrhea with oral mifepristone after intrauterine balloon compression or oral norethindrone. (2) Long-term menstrual management: of the 22 cases with antithrombotic therapy-related HMB, 15 had LNG-IUS placement and 12 had LNG-IUS placement for 6 months, and menstrual volume was significantly reduced [PBAC scores were 365.0 (272.5-460.0) vs 25.0 (12.5-37.5), respectively; Z=4.593, P<0.001], Hb was significantly increased [91.5 g/L (71.8-108.2 g/L) vs 128.5 g/L (121.2-142.5 g/L); Z=4.695, P<0.001], and quality of life was significantly improved [MMAS scores were 415.0 (327.5-472.5) vs 580.0 (570.0-580.0), respectively; Z=-3.062, P=0.002] before placement compared with 6 months after placement. Three rivaroxaban dose reduction patients' PBAC scores decreased by 20 to 35 but remained >100, and perceived quality of life did not change significantly. Two cases with temporary amenorrhea treated with oral mifepristone felt significantly improved quality of life, and the MMAS scores increased by 220 and 180, respectively. Conclusion: Intrauterine Foley catheter balloon compression, aspiration or endometrial ablation could be used to control acute bleeding in patients with antithrombotic therapy-related HMB, and LNG-IUS for long-term management could reduce menstrual volume, increase hemoglobin, and improve the quality of life of patients.

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.

Low dosis of alteplase, for ischemic stroke after Enchanted and its determinants, a single center experience / Dosis reducida de alteplase en el accidente cerebrovascular isquémico después del estudio Enchanted y sus determinantes, una experiencia de un solo centro

Abstract Background: Low-dose alteplase (LrtPA) has been shown not to be inferior to the standard-dose (SrtPA) with respect to death/disability. Objective: We aim to evaluate the percentage of patients treated with LrtPA at our center after the ENCHANTED trial and the factors associated with the use of this dosage. Methods: Prospective study in consecutive patients with an acute stroke admitted between June 2016 and November 2018. Results: 160 patients were treated with intravenous thrombolysis, 50% female; mean age 65.4±18.5 years. Of these, 48 patients (30%) received LrtPA. In univariate analysis, LrtPA was associated with patient's age (p=0.000), previous modified Rankin scale scores (mRS) (p<0.000), hypertension (p=0.076), diabetes mellitus (p=0.021), hypercholesterolemia (p=0.19), smoking (p=0.06), atrial fibrillation (p=0.10), history of coronary artery disease (p=0.06), previous treatment with antiplatelet agents (p<0.000), admission International Normalized Ratio-INR (p=0.18), platelet count (p=0.045), leukoaraiosis on neuroimaging (p<0.003), contraindications for thrombolytic treatment (p=0.000) and endovascular treatment (p=0.027). Previous relevant bleedings were determinants for treatment with LrtPA. Final diagnosis on discharge of stroke mimic was significant (p=0.02) for treatment with SrtPA. In multivariate analysis, mRS (OR: 2.21; 95%CI 1.37‒14.19), previous antiplatelet therapy (OR: 11.41; 95%CI 3.98‒32.70), contraindications for thrombolysis (OR: 56.10; 95%CI 8.81‒357.80), leukoaraiosis (OR: 4.41; 95%CI 1.37‒14.10) and diagnosis of SM (OR: 0.22; 95%CI 0.10‒0.40) remained independently associated. Conclusions: Following the ENCHANTED trial, LrtPA was restricted to 30% of our patients. The criteria that clinicians apply are based mostly on clinical variables that may increase the risk of brain or systemic hemorrhage or exclude the patient from treatment with lytic drugs.

RESUMEN Introducción: Dosis reducidas de trombolitico (LrtPA) podrían no ser inferiores en muerte/discapacidad. Objetivo: Evaluar el porcentaje de pacientes tratados con LrtPA en nuestro centro después del ensayo ENCHANTED, y los factores asociados con el uso de esta dosis. Métodos: Estudio prospectivo de pacientes consecutivos con infarto cerebral ingresados ​entre junio de 2016 y noviembre de 2018. Resultados: 160 pacientes fueron tratados con trombólisis intravenosa, 50% mujeres; edad media 65,4±18,5 años. 48 casos (30%) recibieron LrtPA. En el análisis univariado, LrtPA se asoció con la edad del paciente (p=0,000), escala de Rankin modificadas (mRS) (p<0,000), hipertensión arterial (p=0,076), diabetes mellitus (p=0,021), hipercolesterolemia (p=0,19), tabaquismo (p=0,06), fibrilación auricular (p=0,10), antecedentes de enfermedad coronaria (p=0,06), tratamiento previo con antiplaquetarios (p<0,000), International Normalized Ratio-INR (p=0,18), recuento de plaquetario (p=0,045), leucoaraiosis en neuroimagen (p<0,003), contraindicaciones para el tratamiento trombolítico (p=0,000) y tratamiento endovascular (p=0,027). Las hemorragias previas relevantes fueron determinantes para el tratamiento con LrtPA. El diagnóstico al alta de imitador de accidente cerebrovascular fue significativo (p=0,02) para el tratamiento con dosis estándar. El análisis multivariado demostró que mRS (OR: 2,21; IC95% 1,37‒14,19), tratamiento antiplaquetario previo (OR: 11,41; IC95% 3,98‒32,7), contraindicaciones para trombólisis (OR: 56,1; IC95% 8,81‒357,8), leucoaraiosis (OR: 4,41; IC95% 1,37‒14,1) y un diagnóstico de imitador de accidente cerebrovascular (OR: 0,22; IC95% 0,1‒0,40) fueron asociados con la dosis recibida. Conclusiones: LrtPA está restringido al 30% de nuestros pacientes. Los criterios para tomar esta decisión se basan en variables que podrían aumentar el riesgo de hemorragia cerebral/sistémica o excluir al paciente del tratamiento con fármacos líticos.

Problemas Relacionados à Trombocitopenia em Pacientes com Fibrilação Atrial Concomitante que Necessitam de Prevenção Antitrombótica: Um Estudo de Coorte Retrospectivo / Thrombocytopenia-Related Problems in Patients with Concomitant Atrial Fibrillation Requiring Antithrombotic Prevention: A Retrospective Cohort Study

Resumo Baixas doses de edoxabana e enoxaparina sódica foram objeto de uma comparação retrospectiva implementada com a técnica do escore de propensão a fim de mitigar os efeitos das diferenças nas características clínicas basais de duas coortes e minimizar o risco de viés. Posteriormente, usando um modelo de riscos proporcionais de Cox, avaliou-se a associação de cada tipo de terapia com o risco do composto de morte por todas as causas, acidente vascular cerebral/ataque isquêmico transitório, hospitalizações e ocorrência de sangramentos maiores. Para essa análise, um valor de p < 0,05 foi considerado estatisticamente significante. A terapia com enoxaparina e cirrose hepática como causadora de trombocitopenia estiveram associadas ao aumento do risco do endpoint composto (enoxaparina: hazard ratio (HR): 3,31; IC 95%: 1,54 a 7,13; p = 0,0023; cirrose hepática, HR: 1,04; 95% CI: 1,002 a 1,089; p = 0,0410). Por outro lado, a terapia com edoxabana mostrou-se significativamente associada à diminuição do risco do endpoint composto (HR: 0,071; 95% CI: 0,013 a 0,373; p = 0,0019). Com base nessa análise retrospectiva, o edoxaban em doses baixas seria uma ferramenta farmacológica segura e eficaz para a profilaxia de eventos cardioembólicos em pacientes com FA e trombocitopenia.

Abstract Low-dose edoxaban and enoxaparin sodium have been the subject of a retrospective comparison implemented with the propensity score technique in order to mitigate the effects of the differences in the basal clinical features of two cohorts and minimize the risk of bias. Subsequently, using a Cox proportional-hazards model, the association of each type of therapy with the risk of the composite of all-cause death, stroke/transient ischemic attack, hospitalizations and major bleeding events was assessed. For this analysis, a p-value < 0.05 was considered statistically significant. Therapy with enoxaparin and liver cirrhosis as causing thrombocytopenia were associated with increased risk of the composite endpoint (enoxaparin: hazard ratio (HR): 3.31; 95% CI: 1.54 to 7.13; p = 0.0023; liver cirrhosis, HR: 1.04; 95% CI: 1.002 to 1.089; p = 0.0410). Conversely, edoxaban therapy was significantly associated with decreased risk of the composite endpoint (HR: 0.071; 95% CI: 0.013 to 0.373; p = 0.0019). Based on this retrospective analysis, edoxaban at low doses would appear as an effective and safe pharmacological tool for the prophylaxis of cardioembolic events in patients with AF and thrombocytopenia.

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.

Fibrinolíticos en tromboembolismo de pulmón: Nuevas alternativas para una indicación controvertida / Fibrinolytics in lung thromboembolism. New alternatives for a controversial prescription

El uso de fibrinolíticos en el tromboembolismo de pulmón (TEP) es un tema de debate que ha sufrido idas y venidas desde su primera descripción en la década del 60. Esta terapia que puede liberar rápidamente la obstrucción mecánica en la arteria pulmonar, tiene la limitante del alto riesgo hemorrágico. Justamente por la incidencia prohibitiva de sangrado mayor y cerebral, y por la falta de beneficio en la supervivencia, es que solo está indicado el uso de fibrinolíticos sistémicos en el reducido número de pacientes con TEP grave y descompensación hemodinámica. En el TEP de moderado riesgo, aun con sufrimiento del ventículo derecho (VD), no están indicados. En los últimos años ha surgido la alternativa de combinar bajas dosis de fibrinolíticos liberados localmente en la arteria pulmonar mediante un catéter que puede adjuntarse o no a ultrasonidos en el sitio de la trombosis. Esta forma de administrar los trombolíticos permite corregir la hipertensión pulmonar aguda y liberar el trombo prácticamente sin sangrados mayores o del SNC. Los estudios publicados son muy alentadores, pero la evidencia aún es muy escasa, se requiere un laboratorio de hemodinamia disponible en todo momento y no está exento de riesgos, con un costo considerable. Por el momento solo un reducido número de pacientes con TEP moderado y parámetros de mal pronóstico parece tener indicación para esta alternativa.

The use of fibrinolytics in lung thromboembolism (PTE) is a subject under debate since its first description in the 1960s. This therapy, which can rapidly resolve the mechanical obstruction in the pulmonary artery, has the limiting of a high hemorrhagic risk. Precisely because of the prohibitive incidence of major and cerebral bleeding and the lack of benefit in survival, the use of systemic thrombolytics is only indicated in the small number of patients with severe PE and hemodynamic instability. In moderate-risk PE, even with right ventricular (RV) dysfunction, they are not indicated. In recent years, an alternative has arisen, by combining low doses of fibrinolytics released locally into the pulmonary artery through a catheter that may, or may not, be attached to ultrasound at the site of thrombosis. This way of administering thrombolytics can correct acute pulmonary hypertension and eliminate the thrombus without major or CNS bleeds. Although the published studies are very encouraging, the evidence is still poor, a laboratory of hemodynamics is required at all times and this procedure is not free of risks, with a considerable cost. At the moment, only a small number of patients with moderate PE and poor prognosis seem to have an indication for this new alternative.

Comparison of Outcomes after Device Closure and Medication Alone in Patients with Patent Foramen Ovale and Cryptogenic Stroke in Korean Population

PURPOSE: To compare the effectiveness of device closure and medical therapy in prevention of recurrent embolic event in the Korean population with cryptogenic stroke and patent foramen ovale (PFO). MATERIALS AND METHODS: Consecutive 164 patients (men: 126 patients, mean age: 48.1 years, closure group: 72 patients, medical group: 92 patients) were enrolled. The primary end point was a composite of death, stroke, transient ischemic attack (TIA), or peripheral embolism. RESULTS: Baseline characteristics were similar in the two groups, except age, which was higher in the medical group (45.3±9.8 vs. 50.2±6.1, p<0.0001), and risk of paradoxical embolism score, which was higher in the closure group (6.2±1.6 vs. 5.7±1.3, p=0.026). On echocardiography, large right-to-left shunt (81.9% vs. 63.0%, p=0.009) and shunt at rest/septal hypermobility (61.1% vs. 23.9%, p<0.0001) were more common in the closure group. The device was successfully implanted in 71 (98.6%) patients. The primary end point occurred in 2 patients (2 TIA, 2.8%) in the closure group and in 2 (1 death, 1 stroke, 2.2%) in the medical group. Event-free survival rate did not differ between the two groups. CONCLUSION: Compared to medical therapy, device closure of PFO in patients with cryptogenic stroke did not show difference in reduction of recurrent embolic events in the real world's setting. However, considering high risk of echocardiographic findings in the closure group, further investigation of the role of PFO closure in the Asian population is needed.

Activador del plasminógeno tisular recombinante en el manejo de trombos cardiacos en recién nacidos / Recombinant tissue plasminogen activator for the management of intracardiac thrombi in newborns

Introducción: La incidencia de trombos cardíacos en recién nacidos (RN) ha aumentado con el uso de catéteres venosos centrales. La trombólisis con activador del plasminógeno tisular recombinante (rTPA) se ha utilizado como alternativa a la heparina en trombos gigantes con riesgo vital y de embolización. Nuestro objetivo fue describir la respuesta y las complicaciones relacionadas con el uso del rTPA en el manejo de trombos cardíacos con riesgo vital en RN. Pacientes y método: Estudio retrospectivo de 8 RN, 7 prematuros, con trombos cardíacos en los cuales se utilizó rTPA. Se analizó la edad gestacional y al diagnóstico, peso, sexo, enfermedades asociadas, hemograma, niveles de fibrinógeno, dímero D, tiempo parcial de tromboplastina activada y de protrombina, antes y al término de la infusión de rTPA. El diagnóstico del trombo se realizó por ecocardiografía doppler. La indicación de rTPA fue trombo mayor de 10 mm o que ocupara más del 50% de la cavidad donde se localizaba; aumento del tamaño a pesar del tratamiento con heparina, aspecto fragmentado y lobulado con riesgo embólico pulmonar o sistémico o que comprometiera la función valvular o cardíaca. Resultados: Cuatro hombres; peso promedio de 1.580 g. La principal enfermedad fue la sepsis (7/8), se usó catéter venoso central en todos, la vena cava superior fue la localización más frecuente, con tiempo promedio de instalación previo al diagnóstico de 12 días. En 7/8 RN los trombos se ubicaron en la aurícula derecha, con un tamaño entre 7 a 20 mm. Tres pacientes recibieron heparina de bajo peso molecular previo al uso de rTPA, se realizaron entre uno a 5 ciclos con rTPA. En 4 pacientes se logró resolución completa del trombo a los 3,5 días en promedio. No hubo embolia ni fallecidos. Cuatro pacientes presentaron hemorragia intracraneana grado I, sin secuelas en el seguimiento. Conclusión: Este estudio constituye la primera serie de neonatos tratados con rTPA en Chile, lográndose la resolución completa del trombo en un 50% de los RN y parcial en el resto, permitiendo con ello disminuir el riesgo vital secundario a este proceso patológico.

Introduction: The incidence of cardiac thrombi in newborns has increased with the use of central venous catheters. Thrombolysis with recombinant tissue plasminogen activator (rTPA) has been used as an alternative to heparin in life threatening giant thrombus and embolization. The aim of this study is to describe the response and complications related to the use of rTPA in the management of life- threatening cardiac thrombi in newborns. Patients and method: The medical records of 8 newborn were reviewed in a retrospective study, of whom 7 were preterm with cardiac thrombi, and rTPA was used in all of them. Results: The patients included 4 males with a mean weight of 1580 gr. The principal pathology was sepsis (7/8), all of them used venous central catheter. The superior vena cava was the most frequent location, with a mean time of installation before the diagnosis of 12 days. RN 7/8 thrombi were located in the right atrium with a size between 7 to 20 mm. Three patients received low molecular weight heparin prior to using rTPA. They received between 1 to 5 cycles with rTPA. In 4 patients complete resolution of the thrombus was achieved in a mean of 3.5 days. Four patients had intracranial haemorrhage grade I, without sequelae at follow-up. There were no deaths or embolism. Conclusion: This study is the first series of infants treated with rTPA in Chile, and where its use has quickly achieved complete resolution of the thrombus in 50% of cases, and partially in the others, thus reducing the secondary life-threatening risk of this disease.

Oral surgery in patients under antithrombotic therapy / Cirugía bucal en pacientes con terapia antitrombótica: revisión narrativa

Population aging and the increasing rates of cardiovascular diseases have raised the number of patients receiving antithrombotic therapy in elective or emergency dental care, including surgical procedures. The aim of this article is to review the evidence and clinical guidelines for management of patients on antithrombotic therapy published in the past five years. TheAmerican Antithrombotic Therapy Guideline - 2012 - generally recommends not to suspend antiplatelet or anticoagulant treatment in dental procedures since they are considered to have low bleeding risk and easy resolution. In the dental field, there is ample published evidence regarding oral surgical procedure management, especially by maxillofacial surgeons, showing a low number of complications associated with extractions or other minor oral surgical procedures without suspending antithrombotic drugs and only taking some minimum safeguards, such as healing by first intention or the use of some local hemostatic agents. In general, patients under chronic antithrombotic therapy should keep their medication when undergoing low and medium complexity dental procedures, since complications are minor and easy to handle. Due to interactions between them, particular care should be taken with patients using more than one drug...

El envejecimiento poblacional y el aumento patologías cardiovasculares ha aumentado la cantidad de pacientes bajo terapia antitrombótica que reciben atención dental electiva o de urgencia, incluidos los procedimientos quirúrgico. El objetivo de este artículo es revisar la evidencia y las guías clínicas publicadas en los últimos 5 anos respecto al manejo odontológico de pacientesbajo terapia antitrombótica. La guía clínica americana de terapia antitrombótica del ano 2012 recomienda en general no suspender la terapia antiplaquetaria ni anticoagulante, en los procedimientos dentales ya que son considerados como de bajo riesgo de sangrado y de fácil resolución. En el área odontológica existe amplia evidencia publicada respecto al manejo de procedimientos quirúrgicos bucales, especialmente por cirujanos maxilofaciales, que ha demostrado la baja cantidad de complicaciones asociadas a exodoncias u otras cirugías menores de la cavidad bucal; sin la necesidad de suspender los medicamentos antitrombóticos y tomando algunos resguardos mínimos como la cicatrización por primera intención o el uso de algunos agentes hemostáticos locales. En términos generales los pacientes bajo terapia antitrombótica crónica deben mantener sus medicamentos cuando son sometidos a procedimientos dentales de baja y mediana complejidad, ya que las complicaciones son menores y de sencillo manejo. Se debe poner especialatención en pacientes con más de un medicamento, por las interacciones entre ellos...

Ultrasound-Guided Fine Needle Aspiration of Thyroid Nodules: A Consensus Statement by the Korean Society of Thyroid Radiology

Ultrasound (US)-guided fine needle aspiration (US-FNA) has played a crucial role in managing patients with thyroid nodules, owing to its safety and accuracy. However, even with US guidance, nondiagnostic sampling and infrequent complications still occur after FNA. Accordingly, the Task Force on US-FNA of the Korean Society of Thyroid Radiology has provided consensus recommendations for the US-FNA technique and related issues to improve diagnostic yield. These detailed procedures are based on a comprehensive analysis of the current literature and from the consensus of experts.

Severe Bleeding and Perforation Are Rare Complications of Endoscopic Ultrasound-Guided Fine Needle Aspiration for Pancreatic Masses: An Analysis of 3,090 Patients from 212 Hospitals

BACKGROUND/AIMS: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is useful for the pathological diagnosis of pancreatic masses, but patients are susceptible to severe bleeding and perforation. Because the incidence and severity of these complications have not been fully evaluated. METHODS: We aimed to evaluate severe bleeding and perforation after EUS-FNA for pancreatic masses using large-scale data derived from a Japanese nationwide administrative database. RESULTS: In total, 3,090 consecutive patients from 212 low- to high-volume hospitals were analyzed. Severe bleeding requiring transfusion or endoscopic treatment occurred in seven patients (0.23%), and no perforation was observed. No patient mortality was recorded within 30 days of EUS-FNA. The rate of severe bleeding in low-volume hospitals was significantly higher than that in medium- and high-volume hospitals (0.48% vs 0.10%, p=0.045). CONCLUSIONS: Severe bleeding and perforation following EUS-FNA for pancreatic masses are rare, and the procedure is safe.

Aortic intramural hematoma after thrombolysis in a patient with acute massive pulmonary embolism

No abstract available.

Hemorragia por dicumarínicos: Incidencia, factores de riesgo y comparación con los nuevos anticoagulantes orales / Bleeding during anti-vitamin K treatment: Incidence, risk factors and comparison with the new oral anticoagulants

La hemorragia es la complicación principal de los anticoagulantes orales, dicumarínicos o los nuevos agentes anti-Factor Xa y antitrombínicos. Se analizan los distintos factores de riesgo asociados a sangrado con los agentes clásicos y su vinculación probable con los nuevos fármacos. Se compara la incidencia de sangrado mayor en fibrilación auricular y en tromboembolismo venoso por ambos grupos de antitrombóticos. Además de las propiedades intrínsecas de los agentes clásicos y de los nuevos, serán las características de los pacientes y el correcto empleo terapéutico, los factores que impacten en la incidencia de sangrado en su uso diario, más allá de los datos publicados en los estudios clínicos.

Bleeding is the main complication of oral anticoagulants, anti-vitamin K or new drugs such as anti-factor Xa or anti-thrombin agents. Risk factors associated with bleeding during warfarin therapy are discussed. For the new drugs no published data is available yet. Comparative frequencies of major bleeding during anticoagulation in atrial fibrillation and venous thromboembolism are shown. Beyond the intrinsic properties of the classic and new agents, patients characteristics and co-morbidities and an appropriate management of the antithrombotic therapy will be the factors associated with bleeding incidence in real life.

Frequency and predictors of symptomatic intracranial hemorrhage after intravenous thrombolysis for acute ischemic stroke in a Brazilian public hospital

OBJECTIVE: Scarce data are available on the occurrence of symptomatic intracranial hemorrhage related to intravenous thrombolysis for acute stroke in South America. We aimed to address the frequency and clinical predictors of symptomatic intracranial hemorrhage after stroke thrombolysis at our tertiary emergency unit in Brazil. METHOD: We reviewed the clinical and radiological data of 117 consecutive acute ischemic stroke patients treated with intravenous thrombolysis in our hospital between May 2001 and April 2010. We compared our results with those of the Safe Implementation of Thrombolysis in Stroke registry. Univariate and multiple regression analyses were performed to identify factors associated with symptomatic intracranial transformation. RESULTS: In total, 113 cases from the initial sample were analyzed. The median National Institutes of Health Stroke Scale score was 16 (interquartile range: 10-20). The median onset-to-treatment time was 188 minutes (interquartile range: 155-227). There were seven symptomatic intracranial hemorrhages (6.2%; Safe Implementation of Thrombolysis in Stroke registry: 4.9%; p = 0.505). In the univariate analysis, current statin treatment and elevated National Institute of Health Stroke Scale scores were related to symptomatic intracranial hemorrhage. After the multivariate analysis, current statin treatment was the only factor independently associated with symptomatic intracranial hemorrhage. CONCLUSIONS: In this series of Brazilian patients with severe strokes treated with intravenous thrombolysis in a public university hospital at a late treatment window, we found no increase in the rate of symptomatic intracranial hemorrhage. Additional studies are necessary to clarify the possible association between statins and the risk of symptomatic intracranial hemorrhage after stroke thrombolysis.

Efectos adversos de la terapia antitrombótica en reemplazos articulares / Adverse effects of antithrombotic therapy in arthroplasty surgery

Introducción: la enfermedad tromboembólica es la complicación más frecuente en el reemplazo total de rodilla y/o cadera. Sin profilaxis, la incidencia de la enfermedad tromboembólica en los pacientes sometidos a estas cirugías se incrementa hasta en un 50% y en el 90% de los pacientes con embolia pulmonar sintomática los coágulos provienen de las extremidades inferiores. Materiales y métodos: se diseñó un estudio tipo serie de casos con los pacientes a los que se les realizó reemplazo total de cadera o rodilla primario en el Centro Médico Imbanaco de Cali entre junio de 2009 y junio de 2010, y a quienes se les medicó como profilaxis antitrombótica clexane o rivaroxaban en un esquema extendido por 30 días. Resultados: se seleccionaron 251 pacientes, de los cuales 9 (3,6%) presentaron efectos adversos, siendo los más frecuentes las flictenas y la equimosis de la zona operatoria, con 4 pacientes. Dos pacientes presentaron infección del sitio operatorio, 2 tuvieron intolerancia al medicamento y 1 presentó necrosis grasa de la zona operatoria. Se encontraron 6 eventos adversos en pacientes medicados con clexane y 3 en pacientes que recibieron rivaroxaban. Todos los pacientes con eventos adversos eran obesos. Discusión: el porcentaje y tipo de eventos adversos fue similar a lo reportado en la literatura mundial. Es necesario realizar un trabajo con un tamaño de muestra mayor y un diseño que permita establecer factores de riesgo para la presentación de eventos adversos con el uso de rivaroxaban o clexane como medicamentos antitrombóticos.

Validação de um escore para predição de eventos hemorrágicos em síndromes coronarianas agudas / Validation of a score for predicting bleeding events during acute coronary syndromes / Validación de un escore para predicción de eventos hemorrágicos en síndromes coronarios agudos

FUNDAMENTO: Sangramento é uma complicação grave em pacientes tratados para síndromes coronarianas agudas (SCA) com antitrombóticos e terapias invasivas. Consequentemente, o benefício dessas terapias deve ser analisado contra os potenciais riscos de complicações hemorrágicas. Desta forma, a determinação de um escore para estimar o risco individual de sangramento pode representar uma importante ferramenta na tomada de decisões clínicas. OBJETIVO: Criar e validar um escore de risco de sangramento para pacientes com SCA. MÉTODOS: Foram utilizados preditores independentes de sangramento relatados pelo Registro GRACE. Variáveis com odds ratio (OR) > 2,5 nesse Registro somaram 3 pontos (histórico anterior de sangramento), OR=1,5-2,4 somaram 2 pontos (clearance de creatinina< 30 ml/min, sexo feminino) e aquelas com OR < 1,5 somaram 1 ponto (clearance entre 30 e 60 ml/min, a cada 10 anos de idade > 30, infra ou supra-desnivelamento do segmento ST, doença arterial periférica e fumo). O escore foi validado em uma coorte de 383 indivíduos com SCA. Sangramento hospitalar foi definido como queda de hematócrito > 10 por cento, transfusão de sangue > 2 unidades, sangramento intracerebral ou sangramento fatal. RESULTADOS: A incidência de eventos hemorrágicos foi de 3,1 por cento e a estatística-C do escore foi 0,66 (IC95 por cento = 0,52-0,80), indicando capacidade preditiva para esses eventos. Aqueles com escore > 7 apresentaram 6 por cento de incidência de sangramento, comparados com 1,9 por cento se o escore era < 7 (RR=3,2; IC95 por cento=1,04-9,9; p=0,03). Houve uma interação entre um escore > 7 e um maior risco imposto pelo tratamento com Clopidogrel (p=0,02), bloqueadores IIb/IIIa (p=0,06) e revascularização cirúrgica (p < 0,001). CONCLUSÃO: O escore discrimina o risco de sangramento e é potencialmente útil na tomada de decisão clínica em SCA.

BACKGROUND: Bleeding is a major complication in patients treated for acute coronary syndromes (ACS) with antithrombotic and invasive therapies. Consequently, the benefit of such therapies should be balanced against the potential risk of hemorrhagic complications. Therefore, a score to estimate individual risk of bleeding might represent an important tool in clinical decision-making. OBJECTIVE: This study aims to create and validate a bleeding risk score for patients with ACS. METHODS: Independent predictors of bleeding reported by the GRACE Registry were utilized. Variables with odds ratio (OR) > 2.5 in that Registry added 3 points (previous history of bleeding), OR = 1.5-2.4 added 2 points (creatinine clearance < 30 ml/min, female gender) and those with OR < 1.5 added 1 point (clearance between 30 and 60 ml/min, each 10 years of age>30, ST-deviation, peripheral artery disease and smoking). The score was validated in a cohort of 383 individuals with ACS. In-hospital bleeding was defined as hematocrit fall > 10 percent, blood transfusion > 2 units, intracerebral bleeding or fatal bleeding. RESULTS: The incidence of bleeding events was 3.1 percent and the score's C-statistics was 0.66 (95 percent CI = 0.52-0.80), indicating a predictive ability towards these events. Those with a score > 7 had 6 percent incidence of bleeding, compared with 1.9 percent if the score was < 7 (RR = 3.2; 95 percentCI = 1.04-9.9; p = 0.03). There was an interaction between a score > 7 and greater risk imposed by treatment with Clopidogrel (p = 0.02), IIb/IIIa blockers (p = 0.06) and surgical revascularization (p < 0.001). CONCLUSION: The score discriminates bleeding risk and is potentially useful in clinical decision-making during ACS.

FUNDAMENTO: Sangrado es una complicación grave en pacientes tratados por síndromes coronarios agudos (SCA) con antitrombóticos y terapias invasivas. Consecuentemente, el beneficio de esas terapias debe ser analizado contra los potenciales riesgos de complicaciones hemorrágicas. De esta forma, la determinación de un escore para estimar el riesgo individual de sangrado puede representar una importante herramienta en la toma de decisiones clínicas. OBJETIVO: Crear y validar un escore de riesgo de sangrado para pacientes con SCA. MÉTODOS: Fueron utilizados predictores independientes de sangrado relatados por el Registro GRACE. Variables con odds ratio (OR) > 2,5 en ese Registro sumaron 3 puntos (histórico anterior de sangrado), OR=1,5-2,4 sumaron 2 puntos (clearance de creatinina < 30 ml/min, sexo femenino) y aquellas con OR < 1,5 sumaron 1 punto (clearance = 30-60 ml/min, a cada 10 años de edad > 30, infra o supra-desnivel del segmento ST, enfermedad arterial periférica y tabaco). El escore fue validado en una cohorte de 383 individuos con SCA. Sangrado intrahospitalario fue definido como caída de hematocrito > 10 por ciento, transfusión de sangre > 2 unidades, sangrado intracerebral o sangrado fatal. RESULTADOS: La incidencia de eventos hemorrágicos fue de 3,1 por ciento y la estadística-C del escore fue 0,66 (IC95 por ciento = 0,52-0,80), indicando capacidad predictiva para esos eventos. Aquellos con escore > 7 presentaron 6 por ciento de incidencia de sangrado, comparados con 1,9 por ciento si el escore era < 7 (RR=3,2; IC95 por ciento=1,04-9,9; P=0,03). Hubo una interacción entre un escore > 7 y un mayor riesgo impuesto por el tratamiento con Clopidogrel (P=0,02), bloqueadores IIb/IIIa (P=0,06) y revascularización quirúrgica (P<0,001). CONCLUSIÓN: El escore discrimina el riesgo de sangrado y es potencialmente útil en la toma de decisión clínica en SCA.

Management of nonvalvular atrial fibrillation : A comprehensive approach.

Atrial fibrillation is the most common arrhythmia in clinical practice, may coexist with conditions common to both cardiovascular and noncardiovascular diseases and is associated with considerable morbidity and mortality. Atrial fibrillation is often asymptomatic and diagnosed only when it has caused a potentially serious complication, such as an ischemic stroke. When atrial fibrillation has been identified, 2 objectives have to be addressed - the antiarrhythmic therapy based on rate control or rhythm control, and prevention of thromboembolism. A rhythm or rate control strategy can be chosen indifferently because they have comparable efficacy for the outcome measure of mortality, but the antithrombotic therapy is ever mandatory. The risk of stroke increases cumulatively with increasing age, previous transient ischemic attack or stroke, hypertension, diabetes mellitus, impaired left ventricular function and heart failure. Warfarin reduces the risk of stroke by about two thirds; and aspirin, by about one fifth, but its use must be weighted with the risk of bleeding. The risk of anticoagulant-associated hemorrhage increases with age, the presence of serious concomitant diseases, with poorly controlled hypertension and poorly controlled anticoagulation.