Evidence from Cochrane systematic reviews for effects of antithrombotic drugs for lower-limb revascularization. A narrative review

ABSTRACT BACKGROUND: Peripheral arterial disease (PAD) is characterized by progressive narrowing of the arterial lumen, resulting from atherosclerotic plaques. Treatment for PAD aims to control atherosclerosis and improve blood flow. Use of antiplatelet agents and anticoagulants has played important roles in helping to prevent occlusions and stenosis. OBJECTIVE: To evaluate the evidence from Cochrane systematic reviews regarding the accuracy, effectiveness and safety of use of anticoagulants and antiplatelets in lower-limb revascularization, in patients with peripheral arterial disease. METHODS: Systematic reviews found through searches in the Cochrane Library were included. Two authors evaluated whether the reviews found were in line with the inclusion criteria for this investigation. A qualitative synthesis of their findings was presented. RESULTS: Three systematic Cochrane reviews were included. Patients who underwent prosthetic bypass surgery probably presented greater benefit from use of antiplatelets, and patients who underwent vein revascularization probably presented greater benefit from use of anticoagulants. Patients who received endovascular treatment benefited from both antiplatelet and anticoagulant treatment. However, the reliability of the results found was impaired because at the time when these reviews were published, there was no mandatory assessment using the GRADE criteria. CONCLUSION: Despite the evidence found, it is necessary for these reviews to be updated in order to evaluate the degree of certainty of the results found.

Impacto da pandemia da COVID-19 sobre o tratamento medicamentoso dos pacientes com doença arterial periférica: um estudo observacional transversal / Impact of the COVID-19 pandemic on drug treatment of patients with peripheral arterial disease: an observational cross-sectional study

Resumo Contexto A pandemia do Coronavírus 2019 (COVID-19) tem afetado negativamente o comportamento da população. Nesse contexto, o impacto da pandemia da COVID-19 no tratamento medicamentoso dos pacientes com doença arterial periférica (DAP) e claudicação intermitente (CI) permanece obscuro. Objetivos Analisar o impacto da pandemia da COVID-19 no tratamento medicamentoso dos pacientes com DAP e CI. Métodos Neste estudo observacional transversal, 136 pacientes com DAP e CI, recrutados do nosso banco de dados, responderam por telefone um questionário envolvendo as seguintes questões: a) cuidados com a COVID-19; b) saúde global; c) tratamento das doenças. Posteriormente, os pacientes foram divididos em dois grupos, de acordo com a dificuldade para a aquisição dos medicamentos (DAM: dificuldade e SDAM: sem dificuldade), para a comparação da saúde global entre os dois grupos. Resultados Dezessete porcento dos pacientes reportaram dificuldades para a aquisição dos medicamentos durante a pandemia. Uma maior prevalência desses pacientes reportou estar mais triste (56,5% versus 24,8%, p < 0,01) e com mais dificuldades para dormir (56,5% versus 24,8%, p < 0,01) em relação aos pacientes do grupo SDAM. Os grupos não apresentaram diferenças para o declínio na capacidade de caminhada, ansiedade, estresse e depressão (p > 0,05). Conclusões Uma maior prevalência de pacientes do grupo DAM reportou estar mais triste e com mais dificuldade para dormir em comparação ao grupo SDAM durante a pandemia da COVID-19.

Abstract Background The Coronavirus 2019 (COVID-19) pandemic has had a negative impact on the population's behavior. In this context, the effect of the COVID-19 pandemic on drug treatment of patients with peripheral arterial disease (PAD) and intermittent claudication (IC) remains unclear. Objectives To analyze the impact of the COVID-19 pandemic on drug treatment of patients with PAD and IC. Methods In this cross-sectional, observational study, 136 patients with PAD and IC were recruited from our database and answered a questionnaire by telephone involving the following questions: a) precautions related to COVID-19; b) general health status; and c) treatment of diseases. Subsequently, patients were divided into two groups according to difficulty in obtaining their drugs (DOD: difficulty obtaining drugs, or NDOD: no difficulty obtaining drugs) and overall health was compared between groups. Results Seventeen percent of patients reported difficulties with obtaining drugs during the pandemic. A higher proportion of these patients reported being sadder (56.5% vs. 24.8%, P < 0.01) and having more difficulty sleeping (56.5% vs. 24.8%, P < 0.01) than of the patients in the NDOD group (P <0.01). The groups did not differ in terms of impairment of walking capability, anxiety, stress, or depression (P> 0.05). Conclusions A higher proportion of patients in the DOD group reported being sadder and having greater difficulty sleeping compared to the NDOD group during the COVID-19 pandemic.

Hipertensão arterial e doença arterial periférica / Hypertension and peripheral arterial disease

A hipertensão arterial é o fator mais potente no desenvolvimento da doença vascular aterosclerótica e um fator de risco importante para a doença arterial periférica (DAP) e suas complicações. A DAP é resultante do bloqueio das artérias que fornecem sangue aos membros inferiores, em geral secundário à aterosclerose. Destaca-se o aumento de casos de pacientes com DAP, juntamente com o crescimento da expectativa de vida, variando quantitativamente conforme o sexo e a comorbidade já em curso, tais como: hipertensão, diabetes, tabagismo; dislipidemia, idade, dentre outros. A maioria dos pacientes com DAP são assintomáticos ou não apresenta o sintoma mais presente: claudicação intermitente, mas quando sintomáticos estes podem referir dor, desconforto, queimação ou câimbra em membros inferiores. Para diagnóstico da DAP encontra-se como mais referenciado o índice tornozelo-braquial (ITB) com Doppler, mas também formas de se identificar a doença, por meio da angiotomografia, angioressonância magnética, arteriografia por punção direta, além do exame físico minuncioso, este sim imprescindível. A redução da pressão arterial sistólica (PAS) reduz eventos cardiovasculares e a meta atual para tratamento na DAP é de PA ≤ 140×90 mmHg (em diabéticos, considerar PA diastólica ≤ 85 mmHg). A terapia anti-hipertensiva deve ser administrada a pacientes com hipertensão e DAP para reduzir o risco de IM, AVC, insuficiência cardíaca e morte cardiovascular. O uso de inibidores da enzima conversora da angiotensina (IECA) ou bloqueadores dos receptores da angiotensina (BRA) são eficazes neste propósito e são drogas de escolha na hipertensão. Não há contra indicação aos betabloqueadores nestes pacientes. A cessação do tabagismo, exercícios, terapia com estatinas, terapia antiplaquetária com aspirina ou clopidogrel e, possivelmente, cilostazol em pacientes sem história de insuficiência cardíaca controlam parte dos fatores de risco, auxiliando assim a continuidade da assistência ao paciente com DAP quando da necessidade de angioplastia com stent, uso de balão arterial, cirurgia de by-pass, além da revascularização endovascular

Arterial hypertension is the most potent factor in the development of atherosclerotic vascular disease and an important risk factor for peripheral arterial disease (PAD) and its complications. PAD results from the blockage of the arteries that supply blood to the lower limbs, usually secondary to atherosclerosis. The increase in cases of patients with PAD stands out, together with the increase in life expectancy, varying quantitatively according to sex and comorbidity already underway, such as: hypertension, diabetes, smoking; dyslipidemia, age, among others. Most patients with PAD are asymptomatic or do not have the most common symptom: intermittent claudication, but when symptomatic they may report pain, discomfort, burning or cramps in the lower limbs. For the diagnosis of PAD, the ankle-brachial index (ABI) with Doppler is the most referenced, but also ways to identify the disease, through angiotomography, magnetic resonance angiography, arteriography by direct puncture, in addition to detailed physical examination. The reduction in systolic blood pressure (SBP) reduces cardiovascular events and the current target for treatment in PAD is BP ≤ 140 × 90 mmHg (in diabetics, consider diastolic BP ≤ 85 mmHg). Antihypertensive therapy should be administered to patients with hypertension and PAD to reduce the risk of MI, stroke, heart failure and cardiovascular death. The use of angiotensin-converting enzyme (ACEI) inhibitors or angiotensin receptor blockers (BRA) are effective in this regard and are drugs of choice in hypertension. There is no contraindication to beta-blockers in these patients. Smoking cessation, exercise, statin therapy, antiplatelet therapy with aspirin or clopidogrel and, possibly, cilostazol in patients without a history of heart failure control part of the risk factors, thus helping the continuity of assistance to patients with PAD when the need for stent angioplasty, use of an arterial balloon, bypass surgery, in addition to endovascular revascularization.

Respuesta al tratamiento con Heberprot-P® según la severidad de la enfermedad arterial periférica / Response to treatment with Heberprot-P® depending on the severity of the peripheral arterial disease

Introducción: El pie diabético es uno de los problemas más grave en la medicina contemporánea que aún no se ha resuelto. Actualmente el Heberprot-P ® constituye una alternativa terapéutica para su solución. Objetivos: Identificar en los pacientes con úlcera de pie diabético el grado de severidad de la enfermedad arterial periférica en función del índice tobillo/brazo y determinar la respuesta al tratamiento con Heberprot-P® según el grado de severidad de la enfermedad arterial periférica. Métodos: Estudio retrospectivo, descriptivo de corte transversal en 156 pacientes diabéticos ingresados entre junio de 2010 a diciembre de 2011 en el Instituto Nacional de Angiología y Cirugía Vascular por presentar una úlcera de pie diabético y recibieron tratamiento con Heberprot-P ®. Las variables estudiadas fueron: sexo, edad, tipo de diabetes y tiempo de evolución de la misma, grado de severidad de la enfermedad arterial periférica según los valores del índice tobillo-brazo, y el porcentaje de granulación a las ocho semanas de tratamiento. Resultados: Se observó una mayor proporción de pacientes con un grado de severidad normal los cuales tuvieron el 92,8 por ciento de respuesta al tratamiento. El 33,3 por ciento de no respuesta presentaba un grado severo de enfermedad arterial periférica. Conclusión: Los pacientes con un grado severo de enfermedad arterial periférica o valores bajos del índice de presiones tobillo-brazo no tienen una respuesta favorable a la administración del Heberprot-P®(AU)

Introduction: Heberprot-P® presently represents a therapeutic alternative for this illness. Objective: To determine the response to Heberprot-P ® treatment in patients with diabetic foot ulcers, depending on the level of severity of the peripheral arterial disease. Methods: Retrospective, descriptive and cross-sectional study of 156 patients with diabetic foot ulcers, who were admitted to the National Institute of Angiology and Vascular Surgery from June 2010 through December 2011. They were treated with Heberprot-P ® during hospitalization. The studied variables were sex, age, type of diabetes and time of progression, level of severity of the peripheral arterial disease according to the ankle-brachial pressure indexes, and the percentage of granulation after eight-week treatment. Results: The proportion of patients with normal level of disease was higher, 92.8 percent of whom positively responded to treatment whereas 7.2 percent did not. Among the patients with severe peripheral arterial disease, 33.3 percent showed no response to this treatment. Conclusion: The patients with severe peripheral arterial disease or low ankle-brachial pressure index do not show favorable response to the administration of Heberprot-P®(AU)