Risk Factors Analysis of Thromboembolism in Patients with Lymphoma Chemotherapy / 中国实验血液学杂志

OBJECTIVE@#To evaluate the risk factors affecting thromboembolism in lymphoma patients with chemotherapy.@*METHODS@#Three hundred and four consecutive lymphoma patients treated by chemotherapy between January 2012 and July 2019 were enrolled and retrospectively analyzed, consisting of 111 patients with thromboembolism and 193 without thromboembolism. Univariate analysis was used to compare the clinical characteristics and related laboratory examination between the patients, while multivariate Logistic regression analysis were used to identify the risk factors affecting thromboembolism in lymphoma patients with chemotherapy.@*RESULTS@#Univariate analysis showed that the female, BMI <18.5 or >24, ≥60 years old, with abnormal platelets before chemotherapy, prolonged single hospitalization days and patients at Ann Arbor stage III and IV could increase the incidence of thromboembolism in lymphoma patients treated by chemotherapy. Multivariate Logistic regression analysis showed that abnormal platelet count before chemotherapy, patients at Ann Arbor stage III and IV, and female were all the independent risk factors affecting thromboembolism in lymphoma patients thromboembolism after chemotherapy (P<0.05).@*CONCLUSION@#For lymphoma chemotherapy patients, female, abnormal platelet count before chemotherapy and Ann Arbor stages III and IV show a significantly higher risk for thromboembolism. Thus, preventive anticoagulation therapy is recommended.

Current status of thromboembolism risk assessment in patients hospitalized with non-valvular atrial fibrillation in tertiary hospitals in China / 中华心血管病杂志

Objective: To analyze the current status, trend and predictors of thromboembolism risk assessment in patients hospitalized with non-valvular atrial fibrillation (NVAF) in tertiary hospitals in China. Methods: The study was based on data from the Improving Care for Cardiovascular disease in China (CCC)-Atrial Fibrillation (AF) project. About 10% of the tertiary hospitals in each geographic-economic stratum were recruited. Participating hospitals reported the first 10 to 20 patients with a discharge diagnosis of atrial fibrillation monthly. From February 2015 to December 2019, a total of 49 104 NVAF patients from 151 tertiary hospitals in 30 provinces, municipalities and autonomous regions were enrolled. Clinical data of the patients was collected. The proportion of NVAF patients receiving thromboembolism risk assessment, variations in the proportion between different hospitals, the time trend of the application of thromboembolism risk assessment, and the predictors of the application of thromboembolism risk assessment were analyzed. Results: The age of the NVAF patients was (68.7±12.1) years, 27 709 patients (56.4%) were male. Only 17 251 patients (35.1%) received thromboembolism risk assessment. The proportion varied substantially between hospitals with the lowest value of 0 and the highest value of 100%. Among the hospitals, which enrolled more than 30 patients, no patients received thromboembolism risk assessment in 18.4% (26/141) of the hospitals, more than 50% of the patients received thromboembolism risk assessment in 21.3% (30/141) of the hospitals, and all the patients received thromboembolism risk assessment in only 1 hospital. The proportion of NVAF patients receiving thromboembolism risk assessment was 16.2% (220/1 362) in the first quarter of 2015, and significantly increased to 67.1% (1 054/1 572) in the last quarter of 2019 (P<0.001). Patients' characteristics were associated with the application of thromboembolism risk assessment. The odds of receiving thromboembolism risk assessment was lower in male patients compared to female patients(OR=0.94,95%CI 0.89-0.99), lower in patients with acute coronary syndrome or other cardiovascular diseases compared to those with AF as the primary admission reason (OR=0.59, 95%CI 0.55-0.63, OR=0.52, 95%CI 0.45-0.61, respectively), and lower in patients with paroxysmal, persistent and long-standing/permanent AF compared to those with first detected AF (OR=0.62, 95%CI 0.57-0.67, OR=0.72, 95%CI 0.66-0.79, OR=0.57, 95%CI 0.52-0.64, respectively). The odds was higher in patients with a history of hypertension, heart failure, stroke/TIA, and previous anticoagulant therapy compared to those without the above conditions (OR=1.17, 95%CI 1.11-1.23, OR=1.18, 95%CI 1.07-1.30, OR=1.17, 95%CI 1.08-1.27, OR=1.28, 95%CI 1.19-1.37, respectively) (P all<0.05). Conclusion: Thromboembolism risk assessment was underused in patients hospitalized with NVAF in tertiary hospitals in China, and there were substantial variations between hospitals in the application of thromboembolism risk assessment. The application of thromboembolism risk assessment in tertiary hospitals has been improved in recent years, but there is still plenty of room for future improvement. Patients' characteristics could affect the application of thromboembolism risk assessment in China.

Does total hip arthroplasty provide better outcomes than hemiarthroplasty for the femoral neck fracture? A systematic review and meta-analysis / 中华创伤杂志(英文版)

PURPOSE@#By comparing the outcomes of total hip arthroplasty with hemiarthroplasty in elderly patients with a femoral neck fracture to investigate the one-year mortality, dislocation, infection, reoperation rate, and thromboembolic event.@*METHODS@#The PubMed, EMBASE databases, and Cochrane library were systematically searched from the inception dates to April 1, 2020 for relevant randomized controlled trials in English language using the keywords: "total hip arthroplasty", "hemiarthroplasty" and "femoral neck fracture" to identify systematic reviews and meta-analyses. Two reviewers independently selected articles, extracted data, assessed the quality evidence and risk bias of included trials using the Cochrane Collaboration' stools, and discussed any disagreements. The third reviewer was consulted for any doubts or uncertainty. We derived risk ratios and 95% confidence intervals. Mortality was defined as the primary outcome. Secondary outcomes were other complications, dislocation, infection, reoperation rate, and thromboembolic event.@*RESULTS@#This meta-analysis included 10 studies with 1419 patients, which indicated that there were no significant differences between hemiarthroplasty and total hip arthroplasty in reoperation, infection rate, and thromboembolic event. However, there was a lower mortality and dislocation rate association with total hip arthroplasty at the one-year follow-up.@*CONCLUSION@#Based on our results, we found that total hip arthroplasty was better than hemiarthroplasty for a hip fracture at one-year follow-up.

Efficacy and safety of antifibrinolytics in oncological surgery: a systematic review and meta-analysis / Eficácia e segurança de antifibrinolíticos em cirurgia oncológica: uma revisão sistemática e metanálise

Abstract Background and objectives: The administration of antifibrinolytics has been shown to be effective in reducing blood loss and the need for transfusions in surgeries. However, few studies have evaluated these drugs in cancer surgery. The objective was to review the efficacy and safety of the treatment with antifibrinolytics in patients who underwent oncologic surgeries. Contents: An electronic bibliographic research was conducted in PubMed, OVID, MEDLINE, EMBASE, EBSCO and in the Cochrane Library data basis in order to identify randomized clinical trials performed in any type of oncologic surgery. The data evaluated were blood loss, need for transfusion and incidence of arteriovenous thromboembolism. Five randomized controlled trials evaluating 838 patients met the inclusion requirements. In the analysis of the incidence of thromboembolic events in the five RCTs, there was no statistically significant difference between the administration of tranexamic acid when compared with the placebo (OR = 0.36, 95% IC: 0.11‒1.19, p= 0.09, I2 = 0%). However, when total estimated blood loss and need for blood transfusion are analyzed, the use of tranexamic acid was associated with a significant reduction over placebo (MD = −135.79, 95% CI: −179.50 to −92.08, p< 0.00001, I2= 68%) and (OR = 0.45, 95% CI: 0.32‒0.65, p< 0.00001, I2= 60%), respectively. Conclusions: This meta-analysis found no evidence that the administration of antifibrinolytics increases the risk of thromboembolic complications in patients submitted to oncologic surgery, and has shown evidence that it is effective in reducing total perioperative blood loss and the need for blood transfusion.

Resumo Justificativa e objetivos: A administração de agentes antifibrinolíticos mostrou ser eficaz para reduzir a perda sanguínea e a necessidade de transfusões em cirurgias. No entanto, poucos estudos avaliaram esses agentes em cirurgias oncológicas. O objetivo foi revisar a eficácia e segurança do tratamento com antifibrinolíticos em pacientes submetidos a cirurgias oncológicas. Conteúdo: Uma pesquisa bibliográfica foi conduzida nos bancos de dados eletrônicos PubMed, OVID, MEDLINE, EMBASE, EBSCO e na Biblioteca Cochrane para identificar ensaios clínicos randomizados feitos em qualquer tipo de cirurgia oncológica. Os dados analisados foram perda sanguínea, necessidade de transfusão e incidência de tromboembolismo arteriovenoso. Cinco ensaios clínicos randomizados que avaliaram 838 pacientes atenderam aos critérios de inclusão. Na análise da incidência de eventos tromboembólicos em cinco ECR, não houve diferença estatisticamente significativa entre a administração do ácido tranexâmico, comparado ao placebo (OR = 0,36, IC 95%: 0,11-1,19, p = 0,09; I2 = 0%). No entanto, quando a perda sanguínea total estimada e a necessidade de transfusão de sangue foram analisadas, o uso do ácido tranexâmico foi associado a uma redução significativa, comparado ao placebo. (DM: -135,79, IC 95%: -179,50 a -92,08, p < 0,00001, I2 = 68%) e (OR = 0,45, IC 95%: 0,32-0,65, p < 0,00001, I2 = 60%), respectivamente. Conclusões: Esta metanálise não encontrou evidências de que a administração de antifibrinolíticos aumente o risco de complicações tromboembólicas em pacientes submetidos à cirurgia oncológica e apresentou evidências de que é eficaz para reduzir a perda sanguínea total no perioperatório e a necessidade de transfusão de sangue.

Diseño de un registro de fibrilación auricular y riesgo embólico en México: CARMEN-AF / Design of an atrial fibrillation and embolic risk registry in Mexico: CARMEN-AF

Resumen: Objetivo: La fibrilación auricular (FA) es una de las arritmias más comunes, y su prevalencia aumenta con la edad. Se asocia con alto riesgo de embolia cerebral. La prevención de dichas tromboembolias se realiza mediante anticoagulantes orales, que en nuestro país parecen estar subutilizados. El Registro CARMEN-AF tiene como objetivo primario determinar cuál es el estado actual de la tromboprofilaxis de la FA no valvular en México. Como objetivo secundario pretende conocer la morbimortalidad asociada a la FA no valvular en por lo menos un año de seguimiento. Métodos: El Registro CARMEN-AF es un estudio observacional, longitudinal, multicéntrico y nacional sobre el empleo de los anticoagulantes orales en pacientes con FA no-valvular que pretende la inclusión de pacientes mayores de 18 años de edad diagnosticados con FA no valvular durante los últimos 6 meses y con al menos un factor de riesgo para desarrollar una tromboembolia de acuerdo con la escala de CHA2DS2-Vasc. Serán recolectados datos demográficos y clínicos en las visitas clínicas habituales a lo largo de un seguimiento de 2 años. El reclutamiento comenzó el 19 de septiembre de 2014 y se prevé la inclusión del último paciente el 18 de septiembre de 2016. Se estima la inclusión de 1,200 pacientes dada la incidencia de FA reportada a nivel mundial y tomando en consideración la población mexicana total. Conclusiones: El registro de FA y riesgo embólico en México (CARMEN-AF) permitirá conocer el estado actual de la tromboprofilaxis en pacientes con FA no valvular y permitirá obtener una panorámica del cumplimiento de las guías nacionales e internacionales de práctica clínica en esta materia.

Abstract: Objective: Atrial fibrillation (AF) is one of the most common arrhythmias, and its prevalence increase with age. It is associated with high risk of stroke. The prevention of such thromboembolism is done with oral anticoagulants, which in our country seem to be underused. CARMEN-AF registry aims primarily to determine the current status of thromboprophylaxis of non-valvular AF in Mexico. A secondary objective is to know the morbidity and mortality associated with non-valvular AF in at least one year of follow-up. Methods: CARMEN-AF registry is an observational, longitudinal, multicenter, and national survey about the use of oral anticoagulants in patients with non-valvular AF. Patients 18 years old or older, diagnosed with AF during the last 6 months, and with at least one risk factor of thromboembolism based in the CHA2DS2-Vasc score are being selected. Demographic and clinical data will be collected during the visits to their usual clinic with a follow-up of 2 years. The recruitment began on September 19, 2014, and the inclusion of the last patient is expected on September 18, 2016. According to the reported incidence of AF globally and taking into account the total Mexican population, the inclusion of 1,200 patients is estimated. Conclusions: The Atrial Fibrillation and Embolic Risk Registry (CARMEN-AF) will reveal the current status of thromboprophylaxis in patients with non-valvular AF, and will allow to get an overview of the national and international clinical practice guidelines accomplishment in this area.

Early Experience of Novel Oral Anticoagulants in Catheter Ablation for Atrial Fibrillation: Efficacy and Safety Comparison to Warfarin

PURPOSE: Compared with warfarin, novel oral anticoagulants (NOACs) are convenient to use, although they require a blanking period immediately before radiofrequency catheter ablation for atrial fibrillation (AF). We compared NOACs and uninterrupted warfarin in the peri-procedural period of AF ablation. MATERIALS AND METHODS: We compared 141 patients treated with peri-procedural NOACs (72% men; 58+/-11 years old; 71% with paroxysmal AF) and 281 age-, sex-, AF type-, and history of stroke-matched patients treated with uninterrupted warfarin. NOACs were stopped 24 hours before the procedure and restarted on the same procedure day after hemostasis was achieved. RESULTS: We found no difference in the CHA2DS2-VASc (p=0.376) and HAS-BLED scores (p=0.175) between the groups. The preprocedural anticoagulation duration was significantly shorter in the NOAC group (76.3+/-110.7 days) than in the warfarin group (274.7+/-582.7 days, p<0.001). The intra-procedural total heparin requirement was higher (p<0.001), although mean activated clotting time was shorter (350.0+/-25.0 s vs. 367.4+/-42.9 s, p<0.001), in the NOAC group than in the warfarin group. There was no significant difference in thromboembolic events (1.4% vs. 0%, p=0.111) or major bleeding (1.4% vs. 3.9%, p=0.235) between the NOAC and warfarin groups. Minor stroke occurred in two cases within 10 hours of the procedure (underlying CHA2DS2-VASc scores 0 and 1) in the NOAC group. CONCLUSION: Pre-procedural anticoagulation duration was shorter and intra-procedural heparin requirement was higher with NOAC than with uninterrupted warfarin during AF ablation. Although the peri-procedural thromboembolism and bleeding incidences did not differ, minor stroke occurred in two cases in the NOAC group.

Pressure bandage over venous conduit harvesting site causing compartment syndrome in a patient with intra-aortic balloon pump: An unusual cause.

Intra Aortic Balloon Pump (IABP) is conventionally used to support coronary perfusion and weaning from cardiopulmonary bypass. IABP in situ has its own share of complications. We present a case where a patient on IABP support who had reduced peripheral pulsations of the ipsilateral limb and was initially misdiagnosed as IABP catheter associated thromboembolism. A negative embolectomy ruled out the same. Further looking for the cause of reduction of ipsilateral pulses it was found that the tight compressive bandage at saphenous vein conduit harvesting site had led to development of compartment syndrome (CS).

Long-term Prognosis of Paroxysmal Atrial Fibrillation and Predictors for Progression to Persistnt or Chronic Atrial Fibrillation in the Korean Population

Little is known about the long-term prognosis of or predictors for the different clinical types of atrial fibrillation (AF) in Korean populations. The aim of this study was to validate a risk stratification to assess the probability of AF progression from paroxysmal AF (PAF) to persistent AF (PeAF) or permanent AF. A total of 434 patients with PAF were consecutively enrolled (mean age; 71.7 +/- 10.7 yr, 60.6% male). PeAF was defined as episodes that are sustained > 7 days and not self-terminating, while permanent AF was defined as an ongoing long-term episode. Atrial arrhythmia during follow-up was defined as atrial premature complex, atrial tachycardia, and atrial flutter. During a mean follow-up of 72.7 +/- 58.3 months, 168 patients (38.7%) with PAF progressed to PeAF or permanent AF. The mean annual AF progression was 10.7% per year. In univariate analysis, age at diagnosis, body mass index, atrial arrhythmia during follow-up, left ventricular ejection fraction, concentric left ventricular hypertrophy, left atrial diameter (LAD), and severe mitral regurgitation (MR) were significantly associated with AF progression. In multivariate analysis, age at diagnosis (P = 0.009), atrial arrhythmia during follow-up (P = 0.015), LAD (P = 0.002) and MR grade (P = 0.026) were independent risk factors for AF progression. Patients with younger age at diagnosis, atrial arrhythmia during follow-up, larger left atrial chamber size, and severe MR grade are more likely to progress to PeAF or permanent AF, suggesting more intensive medical therapy with close clinical follow-up would be required in those patients.

Control perioperatorio de la anticoagulación con antagonistas de la vitamina K en cirugía electiva

Los pacientes anticoagulados crónicamente que son sometidos a cirugías electivas requieren la suspensión temporaria de los antagonistas de vitamina K. El objetivo del presente trabajo fue evaluar la incidencia de eventos tromboembólicos y hemorrágicos en pacientes anticoagulados sometidos a un procedimiento invasivo, aplicando un protocolo de manejo de anticoagulación en el perioperatorio. Se realizó un estudio descriptivo, con datos obtenidos de manera prospectiva, donde se incluyeron mayores de 18 años que ingresaron para la realización de una cirugía electiva. Recibieron sustitución con enoxaparina aquellos con fibrilación auricular(FA) de moderado y alto riesgo de evento tromboembólico, pacientes con reemplazo con válvula cardíaca mecánica(VCM) de moderado y alto riesgo de evento tromboembólico y con tromboembolismo venoso(TEV) de alto riesgo de evento tromboembólico. Se evaluaron los eventos embólicos y hemorrágicos en el perioperatorio. Setenta y ocho recibieron sustitución con enoxaparina en el perioperatorio, edad promedio de 69.4 ± 11.9 años. Veintiocho tenían FA (36.4%), 12 TEV (15.6%) y 37 VCM (48.1%). En el postoperatorio hubo un evento embólico (1.6%) y 12 eventos hemorrágicos (15.4%) de los cuales 10 fueron menores (12.8%) y 2mayores (2.6%). La seguridad de la sustitución con enoxaparina aún es cuestionable, y se deberán esperar estudios aleatorizados, comparando diferentes estrategias de sustitución con heparinas versus la suspensión del tratamiento anticoagulante en el período perioperatorio para una conclusión definitiva.

Anti-coagulated patients who undergo elective surgery require temporary interruption of vitamin K antagonists. The aim of this study was to evaluate the incidence of thromboembolic events and bleeding complications in anti-coagulated patients undergoing elective invasive procedures by using an institutional management protocol. This was a descriptive study with prospective follow-up that included patients over 18 year old anti-coagulated with vitamin K antagonists, undergoing elective surgery. Those with atrial fibrillation (AF) at moderate and high risk of thromboembolic events, with mechanical heart valve (MCV) at moderate and high risk of thromboembolic events, and patients' venous thromboembolism (VTE) at high risk of thromboembolic events received bridging therapy with enoxaparin. Embolic and bleeding events in the pre-operative period were recorded. Seventy- eight received bridging, mean age 69.4 ± 11.9 years. Twenty-eight had AF (36.4 %), 12 had VTE (15.6 %) and 37 had MCV (48.1 %). Postoperatively, 1 embolic event (1.6 %) and 12 bleeding events (15.4 %) were documented, of which 10 were minor (12.8 %) and 2 major (2.6 %). The safety of bridging therapy is still under debate, and we should await the result of randomized studies comparing different strategies of bridging vs. interruption of anticoagulant therapy in the pre-operative period prior to reaching a definitive conclusion.

Safety and Efficacy of Switching Anticoagulation to Aspirin Three Months after Successful Radiofrequency Catheter Ablation of Atrial Fibrillation

PURPOSE: Although current guidelines recommend continuing the same antithrombotic strategy regardless of rhythm control after radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF), anticoagulation has a risk of major bleeding. We evaluated the safety of switching warfarin to aspirin in patients with successful AF ablation. MATERIALS AND METHODS: Among 721 patients who underwent RFCA of AF, 608 patients (age, 57.3+/-10.9 years; 77.0% male, 75.5% paroxysmal AF) who had no evidence of AF recurrence at 3 months post-RFCA were included. We compared the thromboembolic and hemorrhagic events in patients for whom warfarin was switched to aspirin (ASA group; n=296) and patients who were kept on warfarin therapy (W group; n=312). RESULTS: There were no significant differences in CHA2DS2-VASc or HAS-BLED scores between the groups. In 30 patients in the ASA group and 37 patients in W group, AF recurred and warfarin was restarted or maintained during the 18.0+/-12.2 months of follow-up. There were no significant differences in thromboembolic (0.3% vs. 1.0%, p=0.342) and major bleeding incidences (0.7% vs. 0.6%, p=0.958) between ASA and W groups during the follow-up period. In the 259 patients with a CHA2DS2-VASc score > or =2, there were no significant differences in thromboembolism (0.8% and 2.2%, p=0.380) or major bleeding incidences (0.8% and 1.4%, p=0.640) between ASA and W groups. CONCLUSION: Switching warfarin to aspirin 3 months after successful RFCA of AF could be as safe and efficacious as long-term anticoagulation even in patients with CHA2DS2-VASc score > or =2. However, strict rhythm monitoring cannot be overemphasized.

Tratamiento quirúrgico de la enfermedad valvular cardiaca de predominio izquierdo, en un hospital de referencia nacional de Lima, Perú / Surgical treatment for left-sided heart valve disease in a national reference hospital in Lima, Peru

Objetivos. Describir las características preoperatorias, intraoperatorias y posoperatorias de los pacientes con enfermedad valvular cardiaca de predominio izquierdo (EVCPI) tratados en un servicio de cirugía de tórax y cardiovascular de un hospital de referencia nacional; así como describir la ocurrencia de eventos tromboembólicos y hemorrágicos en estos pacientes. Materiales y métodos. Se realizó un estudio longitudinal retrospectivo en el que se incluyeron 185 pacientes operados entre 1999 y 2006 en el Hospital Nacional Dos de Mayo (Lima, Perú). Los pacientes fueron divididos en cuatro grupos: con comisurotomía mitral; con reemplazo valvular aórtico; con reemplazo valvular mitral y con doble reemplazo valvular. Se empleó la prueba t de student, la prueba chi cuadrado, el análisis de varianza y la prueba de Bonferroni. El análisis de supervivencia tomó en cuenta los eventos tromboembolicos y hemorrágicos serios y se fijó un tiempo de seguimiento de seis años. Resultados. El tiempo de enfermedad promedio fue 4,6 años. La etiología más frecuente fue enfermedad reumática valvular (74,6%). La mortalidad hospitalaria fue 3,8%, siendo la causa de muerte más frecuente el síndrome de bajo gasto cardiaco con falla multiorgánica asociada. La incidencia de eventos isquémicos (trombosis o embolización) en pacientes que tuvieron reemplazo valvular a largo plazo (más de 6 meses) fue 3,2%, y de eventos hemorrágicos fue 4,3%. Conclusiones. Los resultados del tratamiento quirúrgico de EVCPI en el Perú son favorables. La tasa de complicaciones y mortalidad hospitalaria, así como los eventos tromboembólicos y hemorrágicos a largo plazo son comparables con los reportados en la literatura mundial.

Objectives. To describe the preoperative, intraoperative and postoperative characteristics of patients with left-sided heart valve disease treated in the thoracic and cardiovascular surgery service of a national reference hospital; as well as to describe the occurrence of thromboembolic and bleeding events in these patients. Materials and methods. A retrospective longitudinal study was carried out, which included 185 patients who underwert surgery between 1999 and 2006 at the Hospital Nacional Dos de Mayo (Lima, Peru). The patients were divided into 4 groups: patients with mitral commissurotomy; with aortic valve replacement; with mitral valve replacement and with double valve replacement. T-student test, Chi-square test, analysis of variance and Bonferroni test were used. The survival analysis took into account the severe thromboembolic and bleeding events and a follow-up period of 7 years was set. Results. The average durations of disease was 4.6 years. The most frequent etiology was rheumatic valve disease (74.6%). Hospital mortality was 3.8%, the most frequent cause of death was low cardiac output syndrome associated to multiple organ failure. The incidence of ischemic events (thrombosis or embolization) in patients who had a long-term valve replacement (more than 6 months) was 3.2%, and the incidence of bleeding events was 4.3%. Conclusions. The results of surgical treatment for left-sided heart valve disease in Peru are favorable. The rate of complications and hospital mortality rate, as well as the long-term thromboembolic and bleeding events are comparable to those reported in the world literature.

Impact of aspirin use in the incidence of thromboembolic events after bioprosthesis replacement in patients with rheumatic disease / Impacto da aspirina na incidência de eventos tromboembólicos após implante de bioprótese valvar cardíaca na doença reumática crônica

INTRODUCTION: There is still much debate regarding the kind of antithrombotic therapy in the immediate postoperative period of bioprosthesis replacement (first three months). Thus, the authors consider relevant to determine the contemporary incidence of thromboembolic events in rheumatic patients early after implantation of aortic and mitral bioprosthesis replacement (first 90 days in the post-operative period) and perform a comparison between isolated Aspirin uses versus no-antiplatelet therapy, in this same context. METHODS: Between the period of January 2010 to July 2012, all consecutive rheumatic patients, with basal sinus rhythm, who performed mitral and aortic valve replacement with bioprosthesis (pericardial bovine), were included in this prospective cohort study, 184 patients in total. The primary endpoint evaluated were the rate of embolic events. RESULTS: In the first 30 days, there were three cerebral ischemic events among patients treated in Aspirin group (5.2%) compared with two events in patients without Aspirin therapy (1.7%), HR = 3.18; 95% CI 0.5 to 19.6; P=0.33. Between 31 and 90 days postoperatively, no patient had a primary outcome. The embolism-free survival, bleeding events and the overall survival were not statistically significant between the aspirin and no-antiplatelet groups. CONCLUSION: In conclusion, in this prospective cohort of rheumatic patients, we found a low and very rare incidence rate of embolic events during the first 90 days postoperative period in mitral and isolated aortic position, respectively. The use of aspirin did not significantly reduce the rate of thromboembolism.

INTRODUÇÃO: Ainda existem controvérsias em relação à melhor estratégia de terapia antitrombótica nos três meses iniciais de pós-operatório de implante de bioprótese valvar cardíaca. Assim, os autores consideram relevante determinar a incidência contemporânea de episódios de isquemia cerebral nos meses iniciais (primeiros 90 dias de pós-operatório), e realizar uma comparação entre a aspirina isolada versus a não terapia antiplaquetária no mesmo contexto. MÉTODOS: Entre o período de janeiro de 2010 a julho de 2012, consecutivamente todos pacientes reumáticos com ritmo sinusal basal, que realizaram a substituição da valva mitral, e ou aórtica, por bioprótese (pericárdio bovino), foram incluídos neste estudo de coorte prospectivo, totalizando 184 pacientes. O desfecho primário avaliado foi a ocorrência de eventos embólicos. RESULTADOS: Nos primeiros 30 dias, três (5,2%) eventos isquêmicos cerebrais foram observados em pacientes do grupo aspirina, em comparação com dois (1,7%) eventos em pacientes sem terapia aspirina, RR = 3,18, 95% IC 0,5-19,6; P=0,33. Entre 31 e 90 dias do pós-operatório, nenhum paciente apresentou episódios de embolia cerebral ou periférica. A sobrevida livre de eventos embólicos, sangramentos e a sobrevida geral não foram estatisticamente significativas entre os grupos aspirina e não-aspirina. CONCLUSÃO: Constatou-se baixa incidência de eventos embólicos durante os primeiros 90 dias de pós-operatório de troca valvar por bioprótese envolvendo a posição mitral, e uma ainda menor para mesma situação para troca aórtica isolada. O uso da aspirina não influenciou de maneira significativa na redução de episódios tromboembólicos.

Estudo transversal das estratégias de tratamento clínico na fibrilação atrial / Cross-sectional study of treatment strategies on atrial fibrillation / Estudio transversal de las estrategias de tratamiento clínico en la fibrilación atrial

FUNDAMENTO: A despeito de elevada prevalência e importância clínica da Fibrilação Atrial (FA), não existem até o momento publicações brasileiras informando o perfil clínico e a estratégia de tratamento (controle de ritmo vs. controle de frequência cardíaca) mais utilizada nesse universo de pacientes. OBJETIVO: Avaliar a estratégia de tratamento mais empregada na FA em ambulatório especializado no manejo dessa doença. Secundariamente, procurou-se descrever o perfil clínico dessa população. MÉTODOS: Estudo transversal que avaliou sequencialmente, em 167 portadores de FA, a estratégia de tratamento mais empregada, bem como o perfil clínico desses pacientes. Utilizou-se questionário padronizado para coleta de dados. A análise estatística foi realizada por meio do software SPSS® versão 13.0. RESULTADOS: Nessa população de alto risco para eventos tromboembólicos (61% com score CHADS2 > 2), em que 54% dos indivíduos apresentavam fibrilação atrial paroxística ou persistente, 96,6% utilizavam antagonistas da vitamina K ou AAS, e 76,6% faziam uso de betabloqueador (81,2% frequência x 58,8% ritmo, p < 0,05); a estratégia de controle de frequência foi a mais empregada (79,5% x 20,5%, p < 0,001). Houve uma tendência estatística a maior agrupamento de pacientes com disfunção ventricular (15,2% x 2,9%; p = 0,06), CHADS2 > 2 (60,5% x 39,5%; p = 0,07) e valvopatias (25,8% x 11,8%; p = 0,08) no segmento de controle da frequência. CONCLUSÃO: Nessa população de alto risco para eventos tromboembólicos, a estratégia de controle de frequência cardíaca foi a mais empregada.

BACKGROUND: Despite the high prevalence and clinical importance of atrial fibrillation (AF), there is no Brazilian study about the clinical profile of patients with AF and the most used treatment strategy (heart rhythm control vs. heart rate control) for them. OBJECTIVE: To assess the most used treatment strategy for AF in an outpatient clinic specialized in the management of that disease. In addition, the clinical profile of the population studied was provided. METHODS: Cross-sectional study assessing sequentially, in 167 patients with AF, the most used treatment strategy, as well as their clinical profile. A standardized form was used for data collection. The statistical analysis was performed by using the SPSS® software, version 13.0. RESULTS: In that population at high risk for thromboembolic events (61% had CHADS2 > 2), 54% of the patients had paroxysmal or persistent AF, 96.6% used vitamin K antagonists or acetylsalicylic acid, and 76.6% used beta-blocker (heart rate, 81.2% x heart rhythm, 58.8%; p < 0.05). Heart rate control was the most used treatment strategy (79.5% x 20.5%; p < 0.001). A statistical tendency towards more patients with ventricular dysfunction (15.2% x 2.9%; p = 0.06), CHADS2 > 2 (60.5% x 39.5%; p = 0.07) and heart valve diseases (25.8% x 11.8%; p = 0.08) was observed in the heart rate control group. CONCLUSION: In that population at high risk for thromboembolic events, the heart rate control strategy was the most used.

FUNDAMENTO: A despecho de la elevada prevalencia y importancia clínica de la Fibrilación Atrial (FA), no existen hasta el momento publicaciones brasileñas informando el perfil clínico y la estrategia de tratamiento (control de ritmo vs. control de frecuencia cardíaca) más utilizada en ese universo de pacientes. OBJETIVO: Evaluar la estrategia de tratamiento más empleada en la FA en ambulatorio especializado en el manejo de esa enfermedad. Secundariamente, se buscó describir el perfil clínico de esa población. MÉTODOS: Estudio transversal que evaluó secuencialmente, en 167 portadores de FA, la estrategia de tratamiento más empleada, así como el perfil clínico de esos pacientes. Se utilizó cuestionario estandarizado para recolección de datos. El análisis estadístico fue realizado por medio del software SPSS® versión 13.0. RESULTADOS: En esa población de alto riesgo para eventos tromboembólicos (61% con escore CHADS2 > 2), en que 54% de los individuos presentaban fibrilación atrial paroxística o persistente, 96,6% utilizaban antagonistas de la vitamina K o AAS, y 76,6% hacían uso de betabloqueante (81,2% frecuencia x 58,8% ritmo, p < 0,05); la estrategia de control de frecuencia fue la más empleada (79,5% x 20,5%, p < 0,001). Hubo una tendencia estadística la mayor agrupamiento de pacientes con disfunción ventricular (15,2% x 2,9%; p = 0,06), CHADS2 > 2 (60,5% x 39,5%; p = 0,07) y valvulopatías (25,8% x 11,8%; p = 0,08) en el segmento de control de la frecuencia. CONCLUSION: En esa población de alto riesgo para eventos tromboembólicos, la estrategia de control de frecuencia cardíaca fue la más empleada.

Frecuencia de fibrilación auricular y tratamiento con anticoagulantes orales en pacientes con marcapasos definitivo / Atrial fibrillation prevalence and treatment with oral anticoagulation in patients with permanent pacemakers

La fibrilación auricular (FA) es el factor de riesgo más importante para eventos tromboembólicos (ETE). El objetivo del presente estudio fue determinar la prevalencia de FA en pacientes con marcapasos definitivo (MCD), el porcentaje de anticoagulación y la prevalencia de ETE. El objetivo secundario fue determinar el nivel de conocimiento relacionado con las indicaciones de anticoagulación oral (AO) en pacientes con FA. Estudio descriptivo y retrospectivo de una serie consecutiva de pacientes. Se evaluaron factores de riesgo cardiovascular, motivos de indicación del MCD, antecedentes de FA, ETE y régimen de anticoagulación. Para determinar las potenciales causas de no AO, se realizó una encuesta a todos los médicos que habitualmente derivan sus pacientes a nuestro servicio. De 934 pacientes, el 26% (244) presentó FA, con una tasa de AO del 34%. El 77,3% presentaban un score CHADS2 ³2, solo el 2% presentó contraindicaciones para AO y la prevalencia de ETE fue del 9%. El 63% de los médicos contestó la encuesta. El 41% conocían el score CHADS2, el 33% pudo describir los parámetros clínicos que evalúa y un 23% respondieron correctamente el puntaje necesario para indicar AO. Se detectó una baja tasa de anticoagulación oral en pacientes con FA y MCD, con una elevada prevalencia de ETE y un sorprendente desconocimiento por parte de los médicos tratantes de las recomendaciones actuales de tratamiento.

Atrial Fibrillation (AF) is the most important risk factor for stroke and thromboembolic events (TE). The aims of this study were to determine the prevalence of AF among patients with permanent pacemakers (PPM), the percentage of anticoagulated patients and the prevalence on TE in this population. The secondary purpose was to determine the “level of knowledge” about indications of anticoagulation for AF patients. This was a descriptive and retrospective study on a consecutive series of patients referred for PPM implantation. Cardiovascular risk factors, indications for pacing, prior history of AF, TE and anticoagulation indication were analyzed. In order to determine possible causes for not indicating anticoagulation, an electronic survey was sent to all doctors that usually refer patients for PPM implant and follow-up to our clinic. Among 934 patients, 26% (244) presented AF of which 34% were anticoagulated. 77, 3% presented a CHADS2 score of ³2 while only 2% had absolute contraindication for anticoagulation. The prevalence of TE was 9%. More than 60% of the doctors answered the survey. More than 40% acknowledged the CHADS2 score but only 33% were able to recognize all variables included in the score and 23% were able to determine when to indicate anticoagulation properly. A low anticoagulation rate was detected among patients with AF and PPM with a high prevalence of TE and stroke. An extremely low adherence to international guidelines was detected among doctors that usually deal with this sort of patients.

Embolização arterial recorrente: aorta torácica, fonte embolígena pouco frequente: relato de caso / Recurrent arterial embolization: thoracic aortic, embolic source less frequent: case report

JUSTIFICATIVA E OBJETIVOS: O tromboembolismo ainda hoje é um desafio médico, sendo muitas vezes de difícil diagnóstico e tratamento. Além disso, a trombose sobre placa ateromatosa em aorta torácica é uma condição incomum, porém com complicações graves. O objetivo deste estudo foi relatar um caso de embolização arterial recorrente de fonte embolígena de localização menos frequente, com atualização da literatura. RELATO DO CASO: Paciente do sexo feminino, 56 anos, com histórico de oclusão arterial aguda no membro superior esquerdo, em duas ocasiões distintas, submetida à embolectomia, com melhora clínica. Durante o segundo episódio, evoluiu com isquemia cerebral e óbito. Nos antecedentes, era portadora de hipotireoidismo e desenvolveu diabetes mellitus, quadro que surgiu clinicamente um ano antes do óbito. CONCLUSÃO: A incidência de trombose da aorta torácica é muito baixa e o diagnóstico clínico está relacionado com eventos embólicos. Na investigação de quadros de embolia arterial, na maioria das vezes o coração é o órgão investigado ou os vasos periféricos.No caso desta paciente, o aspecto extremamente incomum foi a localização peculiar da lesão - óstio da artéria subcláviaesquerda - que somente poderia ser avaliada com acurácia por angiografia ou ecocardiograma transesofágico.

BACKGROUND AND OBJECTIVES: Thromboembolism is still a medical challenge, and diagnosis and treatment are often difficult to proceed. In addition, thrombosis on atheromatous plaque in the thoracic aorta is uncommon but with serious complications.The aim of this study was to report a case of arterialembolization recurrent from uncommon embolic source location, with an update of literature. CASE REPORT: Female patient, 56 years of age, with history ofacute arterial occlusion of the left arm on two separate occasions, underwent embolectomy, presenting clinical improvement. Duringthe second episode, the patient developed cerebral ischemia and death. Prior to this, the patient presented hypothyroidism and diabetes mellitus, clinical picture that emerged a year beforedeath. CONCLUSION: The incidence of thrombosis of the thoracic aorta is very low and the clinical diagnosis is related to embolic events. In the research frame of arterial embolism, in most cases the heart is the main organ investigated or peripheral vessels. Forthis patient, the most unusual aspect was the peculiar location ofthe lesion - the ostium of the left subclavian artery - could onlybe accurately assessed by angiography or transesophageal echocardiography.

Varfarina ou Aspirina na prevenção de fenômenos embólicos na valvopatia mitral com fibrilação atrial / Warfarin or Aspirin in embolism prevention in patients with mitral valvulopathy and atrial fibrillation / Varfarina o aspirina en la prevención de fenómenos embólicos en la valvopatía mitral con fibrilación atrial

FUNDAMENTO: A fibrilação atrial (FA) associada à doença valvar mitral reumatismal (DVMR) aumenta a incidência de tromboembolismo (TE), sendo a Varfarina a medicação padrão, apesar das dificuldades na adesão e no controle terapêutico. OBJETIVO: Comparar a eficácia da Aspirina contra a Varfarina na prevenção do TE em pacientes com FA e DVMR. MÉTODOS: Acompanhamos 229 pacientes (pts), portadores de FA e DVMR, em estudo prospectivo e randomizado. 110 pts receberam Aspirina 200 mg/dia, compondo o Grupo A (GA), e 119, a Varfarina, em doses ajustáveis individualmente, compondo o Grupo V (GV). RESULTADOS: Ocorreram 15 eventos embólicos no GA e 24 no GV (p = 0,187), dos quais 21 com o INR menor que 2,0. Assim, excluindo os pacientes com INR inadequado, houve maior número de eventos embólicos no GA (15 vs 3) (p < 0,0061). Houve menor adesão ao tratamento no GV (p = 0,001). Não houve sangramentos maiores em ambos os grupos. Pequenos sangramentos foram mais frequentes no GV (p < 0,01). O nível sérico de colesterol e triglicérides aumentados constituiu fator de risco para maior número de eventos tromboembólicos na população estudada, não havendo diferença entre os grupos. CONCLUSÃO: Na DVMR com FA há menos de um ano e sem embolia prévia, a Aspirina é uma opção pouco eficaz na prevenção do TE. Nos portadores de valvopatia mitral com menor risco (insuficiência mitral e prótese biológica mitral), sobretudo se houver contraindicação ou baixa aderência à Varfarina, a Aspirina pode ter algum benefício na prevenção do TE.

BACKGROUND: Atrial fibrillation (AF) associated to rheumatic mitral valve disease (RMVD) increases the incidence of thromboembolism (TE), with warfarin being the standard therapy, in spite of difficulties in treatment adherence and therapeutic control. OBJECTIVE: To compare the effectiveness of Aspirin vs Warfarin in TE prevention in patients with AF and RMVD. METHODS: A total of 229 patients (pts) with AF and RMVD were followed in a prospective and randomized study. The first group consisted of 110 pts receiving Aspirin - 200 mg/day (Group Aspirin - GA) and the second group consisted of 119 pts receiving Warfarin at individually-adjusted doses (Group Warfarin - GW). RESULTS: There were 15 embolic events in GA and 24 in GW (p = 0.187), of which 21 presented INR < 2.0. Thus, after excluding patients with inadequate INR, there was a higher number of embolic events in GA than in GW (15 vs 3) (p < 0.0061). The GW showed lower treatment adherence (p = 0.001). Neither group presented episodes of major bleeding. Small bleeding episodes were more frequent in the GW (p < 0.01). Increased serum levels of cholesterol and triglycerides constituted a risk factor for a higher number of thromboembolic events in the studied population, with no difference between the groups. CONCLUSION: In patients presenting RMVD with AF for less than a year and no previous embolism, Aspirin is little effective in preventing TE. Patients with lower-risk mitral valvulopathy (mitral regurgitation and mitral biological prosthesis), especially in cases presenting contraindication to or low adherence to Warfarin, Aspirin use can present some benefit in TE prevention.

FUNDAMENTO: La fibrilación atrial (FA) asociada a la enfermedad valvar mitral reumática (DVMR) aumenta la incidencia de tromboembolismo (TE), siendo la Varfarina la medicación estándar, a pesar de las dificultades en la adhesión y en el control terapéutico. OBJETIVO: Comparar la eficacia de la Aspirina contra la Varfarina en la prevención del TE en pacientes con FA y DVMR. Métodos: Controlamos 229 pacientes (pts), portadores de FA y DVMR, en estudio prospectivo y randomizado. 110 pts recibieron Aspirina 200 mg/día, componiendo el Grupo A (GA), y 119, la Varfarina, en dosis ajustables individualmente, componiendo el Grupo V (GV). RESULTADOS: Ocurrieron 15 eventos embólicos en el GA y 24 en el GV (p = 0,187), de los cuales 21 con el INR menor que 2,0. Así, excluyendo los pacientes con INR inadecuado, hubo mayor número de eventos embólicos en el GA (15 vs. 3) (p < 0,0061). Hubo menor adhesión al tratamiento en el GV (p = 0,001). No hubo sangrados mayores en ambos grupos. Pequeños sangrados fueron más frecuentes en el GV (p < 0,01). El nivel sérico de colesterol y triglicéridos aumentados constituyó factor de riesgo para mayor número de eventos tromboembólicos en la población estudiada, no habiendo diferencia entre los grupos. CONCLUSIÓN: En la DVMR con FA hace menos de un año y sin embolia previa, la Aspirina es una opción poco eficaz en la prevención del TE. En los portadores de valvopatía mitral con menor riesgo (insuficiencia mitral y prótesis biológica mitral), sobre todo se hubiese contraindicación o baja adherencia a la Varfarina, la Aspirina puede tener algún beneficio en la prevención del TE.

Anticoagulação oral em portadores de próteses valvares cardíacas mecânicas: experiência de dez anos / Oral anticoagulation in carriers of mechanical heart valve prostheses: experience of ten years

INTRODUÇÃO: Dados da literatura sugerem que as taxas de tromboembolismo e sangramento em pacientes com próteses valvares cardíacas mecânicas podem ser muito reduzidas se a terapia anticoagulante for otimizada. OBJETIVOS: Avaliar a ocorrência de complicações em portadores de próteses valvares cardíacas mecânicas submetidos à terapêutica anticoagulante, otimizada por meio de ambulatório especializado. MÉTODOS: Estudou-se a ocorrência de complicações ao longo de 10 anos em 261 pacientes com próteses valvares cardíacas mecânicas, anticoagulados e acompanhados em ambulatório especializado. Esses pacientes foram divididos em dois grupos conforme porcentual de consultas com tempo de protrombina (RNI) dentro do intervalo desejado: G1-0 por cento a 50,00 por cento e G2-50,01 por cento a 100 por cento das consultas. Foram avaliadas as ocorrências de complicações tromboembólicas e hemorrágicas na sua totalidade, ou subdivididas em maiores e menores, de acordo com a gravidade. Os resultados estão apresentados sob forma de estudo atuarial e de frequência linearizada de ocorrência de eventos. RESULTADOS: O estudo atuarial mostrou que, ao longo do tempo, no grupo G2 (com 50,01 por cento a 100 por cento das consultas com a RNI no intervalo desejado) maior número de pacientes esteve livre da ocorrência de qualquer tipo de evento, de eventos hemorrágicos menores ou da elevação exacerbada da RNI. As frequências linearizadas de ocorrência, em todos os tipos eventos, também foram menores nos pacientes do grupo G2. CONCLUSÕES: O tempo de permanência dentro do intervalo de anticoagulação desejado está diretamente relacionado com a ocorrência de complicações. Entretanto, mesmo com acompanhamento otimizado por meio de ambulatório especializado, apenas cerca de um terço dos pacientes apresentaram nível de anticoagulação adequado em mais da metade das consultas.

BACKGROUND: Published data suggest that rates of thromboembolism and bleeding, in patients with mechanical heart valve prostheses, can be very small by optimizing current anticoagulant therapy. OBJECTIVE: To evaluate the occurrence of complications in patients with mechanical heart valve prostheses undergoing anticoagulant therapy optimized through specialized clinics. METHODS: We studied the occurrence of complications over 10 years in 261 anticoagulated patients with mechanical heart valve prostheses, followed in specialized clinics. These patients were divided into two groups according to percentage of queries with prothrombin time (INR) within the desired range: G1-0 percent to 50.00 percent and G2-50.01 percent to 100 percent of appointments. We evaluated the occurrence of thromboembolic and bleeding complications in their entirety or subdivided into major and minor, according to gravity. The results are presented in an actuarial study and frequency of occurrence of linear events. RESULTS: The actuarial study showed that, over time, more G2 (with 50.01 percent to 100 percent of the consultations with INR in desired range) more patients were free of the occurrence of any event, of minor bleeding events or the marked increase of RNI. The linearized frequency of occurrence in all types events, were also lower in group G2. CONCLUSIONS: The period of time that patients that remain within the desired anticoagulation interval has directly relations with occurrence of complications. Even with careful follow-up at a specialized outpatient unit, only approximately one third of the patients showed an adequate anticoagulation level in more than half of the consultations.

Evaluación prospectiva de la venografía mediante angioTC en el diagnóstico de enfermedad tromboembólica / Diagnostic yield of CT pulmonary angiography and venography for thromboembolic disease

Background: CT pulmonary angiography is the diagnostic procedure of choice for non-massive pulmonary embolism. Aim: To assess the diagnostic yield for thromboembolic disease of CT pulmonary angiography and venography using a 64- slice multidetector tomography. Material and Methods: Prospective study of patients with a clinical suspicion of thromboembolic disease, subjected to CT pulmonary angiography and venography. The presence and location of pulmonary thromboembolism, of isolated or concomitant deep venous thrombosis and of other significant radiological findings, were registered. Results: A 64-MDCT scanner was performed to 893 patients and thromboembolic disease was demonstrated in 240. Pulmonary thromboembolism was diagnosed in 218 patients. It was concomitant with deep venous thrombosis in 79 patients (36 percent) and isolated in the rest. Thirty fve of the 218 patients with pulmonary thromboembolism had radiological evidence of right ventricular overload. Twenty two patients (10 percent) had an isolated deep venous thrombosis. In 65 patients with pulmonary thromboembolism (30 percent) a possibly new or old malignant lesion, was observed. Seventy one of 653 patients without evidence of thromboembolic disease had potentially pathological findings on CT. Conclusions: The combined use of CT pulmonary arteriography and venography using a 64 MDCT scanner increases the diagnostic yield of the procedure for thromboembolic disease. It also allows the diagnosis of other related conditions, specially malignant tumors.