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1.
Gac. méd. Méx ; 156(6): 569-579, nov.-dic. 2020. tab, graf
Article in Spanish | LILACS | ID: biblio-1249969

ABSTRACT

Resumen Introducción: México tiene la mortalidad más alta a 30 días por infarto agudo de miocardio (IAM), el cual constituye una de las principales causas de mortalidad en el país: 28 % versus 7.5 % del promedio de los países de la Organización para la Cooperación y el Desarrollo Económicos. Objetivo: Establecer las rutas críticas y las estrategias farmacológicas esenciales interinstitucionales para la atención de los pacientes con IAM en México, independientemente de su condición socioeconómica. Método: Se reunió a un grupo de expertos en diagnóstico y tratamiento de IAM, representantes de las principales instituciones públicas de salud de México, así como las sociedades cardiológicas mexicanas, Cruz Roja Mexicana y representantes de la Sociedad Española de Cardiología, con la finalidad de optimizar las estrategias con base en la mejor evidencia existente. Resultados: Se diseñó una guía de práctica clínica interinstitucional para el diagnóstico temprano y tratamiento oportuno del IAM con elevación del segmento ST, siguiendo el horizonte clínico de la enfermedad, con la propuesta de algoritmos que mejoren el pronóstico de los pacientes que acuden por IAM a los servicios de urgencias. Conclusión: Con la presente guía práctica, el grupo de expertos propone universalizar el diagnóstico y tratamiento en el IAM, independientemente de la condición socioeconómica del paciente.


Abstract Introduction: Mexico has the highest 30-day acute myocardial infarction (AMI) mortality rate: 28% versus 7.5% on average for the OECD countries, and it constitutes one of the main causes of mortality in the country. Objective: To establish critical pathways and essential interinstitutional pharmacological strategies for the care of patients with AMI in Mexico, regardless of their socioeconomic status. Method: A group of experts in AMI diagnosis and treatment, representatives of the main public health institutions in Mexico, as well as the Mexican cardiology societies, the Mexican Red Cross and representatives of the Spanish Society of Cardiology, were brought together in order to optimize strategies based on the best existing evidence. Results: An interinstitutional clinical practice guideline was designed for early diagnosis and timely treatment of AMI with ST elevation, following the clinical horizon of the disease, with the proposal of algorithms that improve the prognosis of patients who attend the emergency services due to an AMI. Conclusion: With these clinical practice guidelines, the group of experts proposes to universalize AMI diagnosis and treatment, regardless of patient socioeconomic status.


Subject(s)
Humans , Consensus , ST Elevation Myocardial Infarction/diagnosis , Societies, Medical , Spain , Biomarkers/blood , Myocardial Reperfusion/methods , Thrombolytic Therapy/methods , Cause of Death , Electrocardiography , Percutaneous Coronary Intervention/methods , ST Elevation Myocardial Infarction/rehabilitation , ST Elevation Myocardial Infarction/blood , Cardiac Rehabilitation , COVID-19/prevention & control , Mexico
2.
Rev. Assoc. Med. Bras. (1992) ; 66(3): 263-267, Mar. 2020. tab, graf
Article in English | SES-SP, LILACS, SES-SP | ID: biblio-1136213

ABSTRACT

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.


Subject(s)
Humans , Male , Female , Adult , Aged , Aged, 80 and over , Young Adult , Pulmonary Embolism/drug therapy , Thrombolytic Therapy/methods , Ventricular Dysfunction, Right/drug therapy , Fibrinolytic Agents/therapeutic use , Antifibrinolytic Agents/therapeutic use , Pulmonary Embolism/complications , Pulmonary Embolism/diagnostic imaging , Acute Disease , Retrospective Studies , Risk Factors , Treatment Outcome , Tissue Plasminogen Activator/therapeutic use , Ventricular Dysfunction, Right/complications , Ventricular Dysfunction, Right/etiology , Ventricular Dysfunction, Right/mortality , Risk Assessment , Fibrinolytic Agents/adverse effects , Hemorrhage/chemically induced , Middle Aged , Antifibrinolytic Agents/adverse effects
3.
Arch. cardiol. Méx ; 90(supl.1): 62-66, may. 2020. tab, graf
Article in Spanish | LILACS | ID: biblio-1152846

ABSTRACT

Resumen Las terapias de reperfusión, tales como intervención coronaria y fibrinólisis, son las principales medidas de atención en pacientes con síndromes coronarios agudos. La angioplastia primaria se considera el estándar de oro, sin embargo, en pacientes con infección por coronavirus 2 del síndrome respiratorio agudo grave (SARS-CoV-2), la estrategia de reperfusión más recomendada es la terapia fibrinolítica, debido al menor tiempo requerido para realizarla y menor exposición al agente infeccioso. Esta pandemia representa una problemática de contagio en el personal de salud, ya que los casos van en aumento a nivel mundial, por lo cual es importante conocer las medidas que se deben seguir a fin de evitar la enfermedad por coronavirus 2019 (COVID-19).


Abstract Reperfusion therapy is a measure of care in patients with ST-elevation myocardial infarction (STEMI), which should be performed once we have the diagnosis. Percutaneous coronary intervention is considered the gold standard, however in patients with SARS-CoV-2 infection, the reperfusion strategy is more focused on fibrinolytic therapy due to the shorter time required to perform and less exposure. This pandemic represents a contact problem in health personnel, since cases are increasing worldwide, so it is important to know the measures that must be followed to avoid coronavirus disease (COVID-19).


Subject(s)
Humans , Pneumonia, Viral/prevention & control , Myocardial Reperfusion/methods , Health Personnel , Coronavirus Infections/prevention & control , Pandemics/prevention & control , ST Elevation Myocardial Infarction/therapy , Pneumonia, Viral/epidemiology , Thrombolytic Therapy/methods , Coronavirus Infections/epidemiology , Acute Coronary Syndrome/therapy , Percutaneous Coronary Intervention/methods , COVID-19
4.
CoDAS ; 32(1): e20180229, 2020. tab
Article in Portuguese | LILACS | ID: biblio-1055895

ABSTRACT

RESUMO Objetivo Verificar a frequência e a gravidade de disfagia pós-acidente vascular cerebral isquêmico na fase aguda com e sem trombólise e a associação entre a disfagia e as características demográficas, comprometimentos neurológico e funcional e a realização da trombólise. Método Estudo retrospectivo de análise de prontuário de 94 pacientes pós-acidente vascular cerebral isquêmico na fase aguda, destes, 52 pacientes realizaram trombólise e 42 não receberam o tratamento. Os dados coletados foram: idade, sexo, comorbidades, janela terapêutica para realização da trombólise, nível de consciência, grau de comprometimento neurológico, nível de dependência funcional, avaliação clínica da deglutição. Foram realizadas análise descritiva das variáveis categóricas e contínuas e análise de associação pelo teste Quiquadrado de Pearson, sendo consideradas como associações estatisticamente significantes as que apresentaram valor de p ≤ 0,05. Resultados A frequência de disfagia nos pacientes trombolizados foi de 67,3%. Os pacientes trombolizados apresentaram 4,6 vezes mais chance de apresentarem disfagia do que os pacientes não trombolizados. A gravidade da disfagia não apresentou associação com a realização da trombólise. Houve associação entre a presença de disfagia e a dependência funcional. As características demográficas e o comprometimento neurológico não apresentaram associação com o transtorno da deglutição. Conclusão Os pacientes trombolizados apresentaram maior tendência de desenvolverem disfagia do que os não trombolizados na fase aguda do acidente vascular cerebral, estando a disfagia associada à dependência funcional.


ABSTRACT Purpose To verify the frequency and severity of dysphagia after ischemic stroke with or without thrombolysis in the acute phase; and the association among dysphagia, demographic characteristics, neurological and functional impairments and thrombolysis. Methods A retrospective study of the medical records of 94 patients who suffered from ischemic stroke during the acute phase of the disease. From these, 52 patients received thrombolytic therapy and 42 patients did not receive such therapy. We collected data on age, sex, comorbidities, therapeutic time window of thrombolytic therapy, level of consciousness, degree of neurological impairment, level of functional dependency and clinical swallowing examination. A descriptive analysis included categorical and continuous variables, and an analysis of the association using the Pearson's Chi-Square Test, in which the value of p ≤ 0.05 was considered as a statistically significant association. Results The frequency of dysphagia in the thrombolytic patients was 67.3%, the odds ratio was 4.6 higher than the non-thrombolysed patients. The severity of dysphagia was not associated with thrombolysis. There was an association between the presence of dysphagia and functional dependence. Demographic characteristics and neurological impairment were not associated with dysphagia. Conclusion Thrombolytic patients were more likely to develop dysphagia than non-thrombolysed patients in the acute phase of stroke, with dysphagia associated to functional dependence.


Subject(s)
Humans , Male , Female , Adult , Aged , Aged, 80 and over , Deglutition Disorders/rehabilitation , Thrombolytic Therapy/methods , Stroke/complications , Severity of Illness Index , Deglutition Disorders/diagnosis , Chi-Square Distribution , Retrospective Studies , Risk Factors , Stroke/therapy
6.
Rev. méd. Chile ; 147(7): 932-934, jul. 2019. graf
Article in Spanish | LILACS | ID: biblio-1058624

ABSTRACT

We report an 89-year-old male under oral anticoagulant therapy with a therapeutic international normalized ratio, presenting at the emergency room with right side hemiparesis and aphasia. Neuroimaging was compatible with an acute middle cerebral artery ischemic stroke. Anticoagulation was reverted with the use of four factor prothrombin complex, followed by thrombolysis with alteplase, with a favorable evolution, returning to his basal functional status.


Subject(s)
Humans , Male , Aged, 80 and over , Prothrombin/administration & dosage , Thrombolytic Therapy/methods , Amlodipine/adverse effects , Stroke/drug therapy , Infarction, Middle Cerebral Artery/drug therapy , Acenocoumarol/adverse effects , Metformin/adverse effects , Tomography, X-Ray Computed , Amlodipine/administration & dosage , Stroke/etiology , Infarction, Middle Cerebral Artery/etiology , Administration, Intravenous , Acenocoumarol/administration & dosage , Metformin/administration & dosage
7.
Rev. chil. cardiol ; 38(1): 46-53, abr. 2019. tab, graf
Article in Spanish | LILACS | ID: biblio-1003637

ABSTRACT

Resumen En Chile, se han logrado avances importantes en el manejo del Infarto Agudo de Miocardio (IAM) con elevación del segmento ST (IAMCEST). Debido a la mejoría en el diagnóstico precoz y tratamiento, particularmente, con el incremento de la Angioplastía Primaria (APP), hoy están dadas las condiciones para seguir progresando por la vía de la combinación de estrategias de reperfusión y la creación de Redes de Manejo del IAM. El siguiente artículo revisa la evidencia que justifica impulsar dicho avance y se esbozan posibles caminos para lograrlo.


Abstract In Chile, important advances have been made in the management of Acute Myocardial Infarction (MI) with ST segment elevation (STEMI). Due to the progress in early diagnosis and treatment, particularly with the increase in Primary Angioplasty (Primary PCI), nowadays there are conditions to improve early management through the combination of reperfusion strategies and the implementation of MI reperfusion networks. The present article reviews the evidence justifying the promotion of this strategy and outlines possible actions to achieve it.


Subject(s)
Humans , Myocardial Reperfusion/methods , Thrombolytic Therapy/methods , Angioplasty/methods , ST Elevation Myocardial Infarction/therapy , Chile , Endovascular Procedures , Fibrinolytic Agents/therapeutic use , ST Elevation Myocardial Infarction/epidemiology
8.
Arq. bras. cardiol ; 112(1): 20-29, Jan. 2019. tab, graf
Article in English | LILACS | ID: biblio-973836

ABSTRACT

Abstract Background: Patients with ST-elevation acute myocardial infarction attending primary care centers, treated with pharmaco-invasive strategy, are submitted to coronary angiography within 2-24 hours of fibrinolytic treatment. In this context, the knowledge about biomarkers of reperfusion, such as 50% ST-segment resolution is crucial. Objective: To evaluate the performance of QT interval dispersion in addition to other classical criteria, as an early marker of reperfusion after thrombolytic therapy. Methods: Observational study including 104 patients treated with tenecteplase (TNK), referred for a tertiary hospital. Electrocardiographic analysis consisted of measurements of the QT interval and QT dispersion in the 12 leads or in the ST-segment elevation area prior to and 60 minutes after TNK administration. All patients underwent angiography, with determination of TIMI flow and Blush grade in the culprit artery. P-values < 0.05 were considered statistically significant. Results: We found an increase in regional dispersion of the QT interval, corrected for heart rate (regional QTcD) 60 minutes after thrombolysis (p = 0.06) in anterior wall infarction in patients with TIMI flow 3 and Blush grade 3 [T3B3(+)]. When regional QTcD was added to the electrocardiographic criteria for reperfusion (i.e., > 50% ST-segment resolution), the area under the curve increased to 0.87 [(0.78-0.96). 95% IC. p < 0.001] in patients with coronary flow of T3B3(+). In patients with ST-segment resolution >50% and regional QTcD > 13 ms, we found a 93% sensitivity and 71% specificity for reperfusion in T3B3(+), and 6% of patients with successful reperfusion were reclassified. Conclusion: Our data suggest that regional QTcD is a promising non-invasive instrument for detection of reperfusion in the culprit artery 60 minutes after thrombolysis.


Resumo Fundamento: Pacientes com infarto do miocárdico com elevação do segmento-ST atendidos em centros de atendimento primário e tratados de acordo com a estratégia fármaco-invasiva são submetidos à fibrinólise seguida de coronariografia em período de 2-24h. Neste cenário, o conhecimento de marcadores de reperfusão como a redução em 50% do segmento-ST é fundamental. Objetivo: Analisar o desempenho da dispersão do intervalo QT em adição aos critérios clássicos, como marcador precoce de reperfusão pós-terapia trombolítica. Métodos: Estudo observacional com a inclusão de 104 pacientes tratados com tenecteplase (TNKase) e referenciados a hospital de atendimento terciário. A análise dos eletrocardiogramas (ECG) consistiu em mensuração do intervalo QT e sua dispersão nas 12 derivações, e também apenas na região com supradesnivelamento-ST antes e 60min pós-TNKase. A angiografia foi realizada em todos os pacientes com obtenção do fluxo TIMI e Blush da artéria culpada. Foram considerados significantes valores de p < 0,05. Resultados: Observamos aumento da dispersão do intervalo QT, corrigido pela frequência cardíaca, regional (dQTcR) 60min pós-lise (p = 0,006) em infartos de parede anterior nos casos com fluxo TIMI 3 e Blush 3 [T3B3(+)]. Adicionando a dQTcR ao critério ECG (redução do ST > 50%) de reperfusão, a área sob a curva aumentou para 0,87 [(0,78-0,96), IC95%, p < 0,001] em pacientes com fluxo coronário T3B3(+). Nos pacientes com critério de ECG para reperfusão e dQTcR > 13 ms a sensibilidade e especificidade foram 93% e 71%, respectivamente, para reperfusão em T3B3(+), possibilitando reclassificar 6% dos pacientes com sucesso de reperfusão. Conclusão: Os dados sugerem a dQTcR como instrumento promissor na identificação não invasiva de reperfusão na artéria coronária culpada, 60min pós-trombólise.


Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Myocardial Reperfusion/methods , Thrombolytic Therapy/methods , Fibrinolytic Agents/therapeutic use , ST Elevation Myocardial Infarction/drug therapy , Tenecteplase/therapeutic use , Reference Values , Time Factors , Prospective Studies , Reproducibility of Results , ROC Curve , Treatment Outcome , Coronary Angiography/methods , Statistics, Nonparametric , Electrocardiography , Myocardial Perfusion Imaging/methods , ST Elevation Myocardial Infarction/physiopathology , ST Elevation Myocardial Infarction/diagnostic imaging , Tenecteplase/adverse effects
9.
Braz. j. med. biol. res ; 52(2): e7739, 2019. tab, graf
Article in English | LILACS | ID: biblio-984024

ABSTRACT

Alteplase (tPA) intravenous thrombolysis is an effective treatment for acute ischemic stroke (AIS) when administered within 4.5 h of initial stroke symptoms. Here, its safety and efficacy were evaluated among AIS patients with a previous history of cerebral hemorrhage. Patients who arrived at the hospital within 4.5 h of initial stroke symptoms and who were treated with tPA intravenous thrombolysis or conventional therapies were analyzed. The 90-day modified Rankin scale (90-d mRS) was used alongside mortality and incidence of symptomatic intracerebral hemorrhage (SICH) rates to evaluate the curative effect of these therapies. Among 1,694 AIS patients, 805 patients were treated with intravenous thrombolysis, including patients with (n=793) or without (n=12) a history of cerebral hemorrhage, and the rate of incidence of SICH significantly differed between them (8.3 vs 4.3%, P=0.039). No significant difference was found in 90-d mRS measurements (41.7 vs 43.6%, P=0.530) and 90-d mortality rates (8.3 vs 6.5%, P=0.946). A total of 76 AIS patients with a history of cerebral hemorrhage received tPA thrombolytic therapy (n=12) or conventional therapy (n=64), and a significant difference was noted in the 90-d mRS scores between the two groups (41.7 vs 23.4%, P=0.029), while no significant difference was found in SICH measurements (8.3 vs 4.6%, P=0.610) and 90-d mortality rates (8.3 vs 9.4%, P=0.227). A history of cerebral hemorrhage is not an absolute contraindication for thrombolytic therapy; tPA intravenous thrombolysis does not increase SICH measurements and mortality rates in patients with a history of cerebral hemorrhage, and they may benefit from thrombolytic therapy.


Subject(s)
Humans , Male , Female , Middle Aged , Aged , Brain Ischemia/drug therapy , Tissue Plasminogen Activator/administration & dosage , Intracranial Hemorrhages/etiology , Fibrinolytic Agents/administration & dosage , Thrombolytic Therapy/methods , Brain Ischemia/complications , Treatment Outcome , Administration, Intravenous
10.
J. vasc. bras ; 18: e20180107, 2019. tab
Article in Portuguese | LILACS | ID: biblio-1012631

ABSTRACT

O tromboembolismo venoso (TEV), que compreende o espectro de manifestações de trombose venosa profunda e/ou embolia pulmonar, é uma complicação comum, grave e evitável em pacientes hospitalizados. Embora a perda da mobilidade recente ou continuada represente um dos principais fatores de risco relacionados ao desenvolvimento de TEV, não existem critérios claros e uniformes para a definição do conceito de imobilidade. A diversidade dessas descrições dificulta a interpretação e a comparação dos resultados de estudos clínicos randomizados no que se refere à influência dos diferentes níveis de imobilidade na magnitude do risco de TEV e ao papel da deambulação precoce, de forma isolada, na prevenção de tais eventos. O entendimento dessas limitações é mandatório para a utilização e interpretação adequadas das ferramentas de avaliação de risco de TEV, e para a indicação da melhor estratégia de prevenção de trombose em pacientes clínicos hospitalizados. O objetivo deste estudo é revisar as principais evidências da literatura quanto ao papel da deambulação na prevenção do TEV


Venous thromboembolism (VTE) encompasses the spectrum of manifestations of deep venous thrombosis and/or pulmonary embolism and is a common, serious, and preventable complication in hospitalized patients. Although immobility plays an important role in determining VTE risk in medical patients, no clear and uniform criteria exist to guide clinicians in assessing immobility. The variation in the descriptions that do exist makes it difficult to interpret and compare the results of randomized clinical trials with respect to the influence of different levels of immobility on the magnitude of VTE risk and the role that early ambulation as an isolated factor plays in prevention of such events. Understanding these limitations is a prerequisite for the proper use and interpretation of VTE risk assessment tools and for indicating the best strategy for preventing venous thrombosis in hospitalized medical patients. The objective of this study was to review the main evidence reported in the literature on the role of ambulation in prevention of VTE


Subject(s)
Humans , Male , Female , Adult , Patients , Walking , Venous Thromboembolism/prevention & control , Pulmonary Embolism/therapy , Thrombolytic Therapy/methods , Acute Disease/therapy , Risk Factors , Venous Thrombosis/complications , Venous Thrombosis/diagnosis , Mobility Limitation , Patient Safety
11.
Int. j. cardiovasc. sci. (Impr.) ; 31(5)set.-out. 2018. tab
Article in English | LILACS | ID: biblio-914765

ABSTRACT

Background: To reduce mortality of acute myocardial infarction, medical care must be provided within the first hours of the event. Objective: To identify the "front door" to medical care of acute coronary patients and the time elapsed between patients'admission and performance of myocardial reperfusion in the public health system of the city of Joinville, Brazil. Methods: The study was a retrospective analysis of the medical records of 112 consecutive patients diagnosed with acute myocardial infarction by coronary angiography. We identified the place of the first medical contact and calculated the time between admission to this place and admission to the referral hospital, as well as the time until coronary angiography, with or without percutaneous transluminal angioplasty. A descriptive analysis of data was made using mean and standard deviation, and a p < 0.05 was set as statistically significant. Results: Only 16 (14.3%) patients were admitted through the cardiology referral unit. Door-to-angiography time was shorter than 90 minutes in 50 (44.2%) patients and longer than 270 minutes in 39 (34.5%) patients. No statistically significant difference was observed in door-to-angiography time between patients transported directly to the referral hospital and those transferred from other health units (p < 0.240). Considering the time between pain onset and angiography, only 3 (2.9%) patients may have benefited from myocardial reperfusion performed within less than 240 minutes. Conclusion: Management of patients with acute myocardial infarction is not in conformity with current guidelines for the treatment of this condition. The structure of the healthcare system should be urgently modified so that users in need of emergency services receive adequate care in accordance with local conditions


Subject(s)
Humans , Male , Female , Middle Aged , Delivery of Health Care/methods , Failure to Rescue, Health Care , Myocardial Infarction/mortality , Myocardial Infarction/therapy , Therapeutics/methods , Acute Coronary Syndrome/diagnosis , Acute Coronary Syndrome/therapy , Angioplasty/methods , Coronary Angiography/methods , Critical Pathways/trends , Death, Sudden/prevention & control , Diagnostic Imaging/methods , Electrocardiography/methods , Emergency Medical Services/methods , Hospital Care/methods , Myocardial Reperfusion/methods , Retrospective Studies , Statistical Analysis , Thrombolytic Therapy/methods , Unified Health System
12.
Medicina (B.Aires) ; 78(4): 265-271, ago. 2018. ilus, tab
Article in Spanish | LILACS | ID: biblio-954993

ABSTRACT

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.


Subject(s)
Humans , Thrombolytic Therapy/methods , Fibrinolytic Agents/administration & dosage , Prognosis , Pulmonary Embolism/mortality , Pulmonary Embolism/drug therapy , Severity of Illness Index , Thrombolytic Therapy/adverse effects , Fibrinolytic Agents/adverse effects
13.
Rev. Soc. Cardiol. Estado de Säo Paulo ; 28(4): 421-427, out.-dez. 2018. ilus, tab
Article in English, Portuguese | LILACS | ID: biblio-970567

ABSTRACT

Os fibrinolíticos pertencem a uma classe de medicamentos especializada em promover a lise da fibrina e a consequente dissolução do trombo. Esse efeito baseia-se na transformação do plasminogênio em plasmina, potente enzima proteolítica. A sua aplicação nas diferentes síndromes cardiovasculares agudas alterou o curso natural do infarto agudo do miocárdio, da embolia pulmonar e do acidente vascular cerebral isquêmico agudo. Na prática, temos três gerações de fibrinolíticos disponíveis: estreptoquinase, alteplase e tenecteplase, essa última com alta afinidade à fibrina. As complicações hemorrágicas, embora raras, devem ser identificadas e tratadas de forma precoce. Isso se deve aos distúrbios da coagulação, especialmente, queda do fibrinogênio e outros fatores de coagulação, mais predominantes com a estreptoquinase. A correção baseia-se na administração de crioprecipitado e plasma fresco, ricos, respectivamente, em fibrinogênio e fatores de coagulação. A inexperiência ao administrar tais medicamentos e o receio hemorrágico tem sido fator agravante na sobrevida dessas doenças. Campanhas educacionais poderão amenizar tal cenário, especialmente, em centros mais carentes de recursos tecnológicos


Fibrinolytics belong to a class of drugs specialized in promoting lysis of fibrin and consequent dissolution of the thrombus. This effect is based on the conversion of plasminogen into plasmin, a potent proteolytic enzyme. Its application in different acute cardiovascular syndromes has changed the natural course of acute myocardial infarction, pulmonary embolism, and acute ischemic stroke. In practice, three generations of fibrinolytics are available: streptokinase, alteplase, and tenecteplase (the latter having high affinity to fibrin). Hemorrhagic complications, although rare, must be identified and treated early. This is due to coagulation disorders, especially the decrease in fibrinogen and other coagulation factors, more prevalent with streptokinase. Correction is based on the administration of cryoprecipitate and fresh plasma, which are rich in fibrinogen and coagulation factors, respectively. Inexperience in administering these drugs and hemorrhagic fear are aggravating factors of disease progression. Educational programs can mitigate such scenarios, especially in centers that lack technological resources.Inexperience administering such medicines and hemorrhagic fear has been an aggravating factor in the lives of these diseases. Educational campaigns will be able to mitigate such a scenario especially in the most lacking centers of technological resources


Subject(s)
Humans , Male , Female , Adult , Thrombolytic Therapy/methods , Fibrinolytic Agents/therapeutic use , Hemorrhage/complications , Myocardial Infarction/therapy , Pulmonary Embolism , Streptokinase , Blood Coagulation Factors , Cardiovascular Diseases , Reperfusion , Stroke
14.
Rev. Soc. Cardiol. Estado de Säo Paulo ; 28(4): 409-420, out.-dez. 2018. tab, ilus
Article in English, Portuguese | LILACS | ID: biblio-970540

ABSTRACT

As doenças cardiovasculares, especialmente, o infarto agudo do miocárdio, são responsáveis pela primeira causa de óbito em nosso país. Baseando-se em sua fisiopatogenia e nos fatores de risco envolvidos, a taxa de mortalidade, em 30 dias, varia de 3-5% em centros avançados e quase 30% naqueles cujo atendimento não aplicam as diretrizes recomendadas. Tal mudança dependerá de um aprimoramento organizacional com ações educativas para o paciente, profissionais do setor de emergência e plena sintonia com os gestores do sistema de saúde público ou privado. A angioplastia primária é o tratamento padrão-ouro da reperfusão miocárdica, porém, disponível apenas em 15% dos hospitais. Em geral, o setor público carece dessa disponibilidade, sendo a estratégia fármaco-invasivo-terapia fibrinolítica seguida da transferência precoce para angioplastia ­a recomendada. O diagnóstico baseia-se em critérios eletrocardiográficos, porém, nem sempre há médicos habilitados para tal confirmação. Isso retarda o tratamento e compromete bastante os resultados. A disponibilidade da telemedicina ou teleECG permite que profissionais mesmo à distância possam corroborar com o diagnóstico, orientar o tratamento e obter métricas de qualidade e mortalidade. A rápida identificação do paciente com sinais e sintomas de infarto agudo, diagnóstico imediato no ECG e administração do fibrinolítico não devem ultrapassar 20 minutos. São minutos dependentes da prévia organização que salvam vidas! O tratamento fibrinolítico é a realidade para um país com dimensões continentais e sérias limitações logísticas de transporte. Compete aos gestores de saúde disponibilizá-lo a qualquer hora ou momento para o atendimento do paciente infartado


Cardiovascular events, especially acute myocardial infarction, are the main cause of death in our country. In addition to its physiopathogenesis and the involved risk factors, the 30-day mortality rates vary from 3% to 5% in advanced centers and 30% in those where care does not apply the recommended guidelines. Such change will depend on organizational improvement, as well as patient education, professionals in the emergency department, and harmony with agents in the public or private health system. Primary angioplasty is the gold standard treatment for myocardial reperfusion, but is only available in 15% of hospitals. If it is not available in the public sector, a pharmacoinvasive strategy ­ fibrinolytic therapy followed by patient transfer for angioplasty ­ has been recommended. Diagnosis is based on ECG criteria, but there is a shortage of physicians qualified for such confirmation. This delays the treatment and compromises the results. Telemedicine or teleECG allows distant professionals to corroborate with the diagnosis, guide the treatment, and obtain quality and mortality metrics. The rapid identification of patients with signs and symptoms of acute myocardial infarction, immediate diagnosis on ECG, and fibrinolytic administration should not exceed 20 min. They are life-saving minutes dependent on prior organization. Fibrinoly-tic treatment is the reality for a country with continental dimensions and transport logistic limitations. It is the responsibility of health managers to make them available to the care of patients with infarction


Subject(s)
Humans , Male , Female , Myocardial Reperfusion/methods , Thrombolytic Therapy/methods , Myocardial Infarction/therapy , Thrombosis , Cardiovascular Diseases/mortality , Risk Factors , Angioplasty/methods , Coronary Vessels , Drug Therapy/methods , Electrocardiography/methods , Emergencies , Drug-Eluting Stents , Hemodynamics/physiology
15.
Rev. Soc. Cardiol. Estado de Säo Paulo ; 28(3): 267-275, jul.-ago. 2018. tab
Article in English, Portuguese | LILACS | ID: biblio-916465

ABSTRACT

O acidente vascular cerebral (AVC) é a maior causa de incapacidade em todo mundo, e atualmente é também considerado como a segunda maior causa de morte no Brasil. O AVC isquêmico é o subtipo mais comum e pode ser subdividido etiologicamente em car-dioembólico, aterosclerótico de grandes ou pequenas artérias (lacunas), criptogênico ou de outras etiologias. Dependendo da etiologia encontrada, a profilaxia secundária de novos eventos deve ser feita através de medicações antitrombóticas específicas. Portanto, investigar adequadamente a etiologia do evento vascular isquêmico é fundamental para a instituição da profilaxia secundária apropriada. A terapia antitrombótica pós-AVC isquêmico evoluiu consideravelmente na última década. Especificamente para pacientes com AVC e fibrilação atrial, a incorporação de anticoagulantes de ação direta à prática clínica representa um grande avanço, já que tais medicações são mais eficazes e seguras para o tratamento de pacientes de alto risco. No presente artigo, discutiremos o uso de antitrombóticos em pacientes com AVC em diferentes momentos pós-icto vascular e nas distintas etiologias possíveis


Stroke is the leading cause of disability worldwide, and is currently also considered the second leading cause of death in Brazil. Ischemic stroke is the most common subtype and can be subdivided etiologically into cardioembolic, atherosclerotic (large artery atherosclero-sis or small vessel disease-lacunae), cryptogenic or strokes of other etiologies. Depending on the etiology, secondary prophylaxis of new events should be undertaken with specific antithrombotic medications. Therefore, a thorough investigation of ischemic vascular event etiology is essential for the introduction of appropriate secondary prophylaxis. Antithrombotic therapy after ischemic stroke has evolved considerably in the last decade. The incorporation of direct-acting anticoagulants into clinical practice represents a major advance, particularly for stroke and atrial fibrillation patients, since such medications are safer and more effective for the treatment of high-risk patients. In this article, we will discuss the use of antithrombo-tics in stroke patients at different post-stroke stages and in the distinct possible etiologies


Subject(s)
Humans , Male , Female , Thrombolytic Therapy/methods , Stroke/etiology , Stroke/physiopathology , Disease Prevention , Platelet Aggregation Inhibitors/therapeutic use , Cerebral Infarction/diagnosis , Aspirin/therapeutic use , Risk Factors , Diabetes Mellitus , Secondary Prevention/methods , Sedentary Behavior , Rivaroxaban/therapeutic use , Hypertension , Anticoagulants/therapeutic use
16.
Rev. Soc. Cardiol. Estado de Säo Paulo ; 28(3): 286-290, jul.-ago. 2018. tab
Article in English, Portuguese | LILACS | ID: biblio-916534

ABSTRACT

A fibrilação atrial (FA) é a arritmia cardíaca mais comum na população com uma prevalência de 1-2%, além disso, está associada a um risco, aproximadamente cinco vezes maior de acidente vascular cerebral do que na população em geral. A anticoagulação é a melhor maneira de prevenir os eventos tromboembólicos. A varfarina é utilizada há décadas como uma droga segura e eficaz, desde que rigorosamente controlada. Nos últimos anos, foram desenvolvidas novas classes de anticoagulantes orais: inibidores diretos da trombina e inibidores do fator Xa, conhecidos como anticoagulantes orais de ação direta (DOACs). Tanto a cardioversão elétrica quanto a cardioversão farmacológica estão associadas a um maior risco de eventos tromboembólicos durante o primeiro mês após o procedimento (5-7%). No entanto, com a utilização de nticoagulantes essa taxa é inferior a 1%. No presente artigo, faremos uma revisão das principais evidências científicas relacionadas ao uso da dabigatrana, rivaroxabana, apixabana e edoxabana durante a cardioversão e uma abordagem prática com o manejo antitrombótico em diferentes cenários clínicos (cardioversão em pacientes com uso prévio de DOACs, cardioversão em pacientes com FA com duração maior ou menor que 48 horas sem anticoagulação)


Atrial fibrillation (AF) is the most common cardiac arrhythmia in clinical practice with a prevalence of 1-2%, and is associated with an almost 5-fold increase in the risk of stroke compared to the general population. Anticoagulation is the best way to prevent thromboembolic events. Warfarin has been used for decades as a safe and effective drug, provided it is strictly controlled. In recent years, new classes of oral anticoagulants have been developed: direct thrombin inhibitors and factor Xa inhibitors, known as direct oral anticoagulants (DOACs). Both electrical and pharmacological cardioversion are associated with an increased risk of thromboembolic events during the first month after the procedure (5-7%). However, with the use of anticoagulants, this rate is less than 1%. In this article, we will review the main scientific evidence related to the use of dabigatran, rivaroxaban, apixaban and edoxaban during cardioversion and a practical approach with antithrombotic management in different clinical scenarios (cardioversion of patients in previous use of DOACs, cardioversion of patients not using oral anticoagulants with episodes of AF longer or shorter than 48 h)


Subject(s)
Humans , Male , Female , Arrhythmias, Cardiac , Atrial Fibrillation , Electric Countershock , Emergencies , Intensive Care Units , Anticoagulants/therapeutic use , Thromboembolism/therapy , Warfarin/adverse effects , Warfarin/therapeutic use , Heparin/adverse effects , Heparin/therapeutic use , Factor Xa , Thrombolytic Therapy/methods , Prevalence , Review , Stroke/complications , Rivaroxaban/therapeutic use , Hemorrhage
17.
Rev. méd. Chile ; 146(6): 708-716, jun. 2018. tab, graf
Article in Spanish | LILACS | ID: biblio-961451

ABSTRACT

Background: Recently, five randomized controlled trials confirmed the efficacy and safety of endovascular treatment with or without intravenous thrombolysis in acute ischemic stroke with large-vessel occlusion. Aim: To report patients with ischemic stroke treated with endovascular methods. Material and Methods: Retrospective analysis of 104 patients aged 61 ± 15 years (54% males) with ischemic stroke who received endovascular treatment at a single medical center between 2009 and 2017. Results: Sixty one percent were treated with intravenous thrombolysis plus endovascular procedures and 39% with endovascular procedures alone. The median door-to needle time was 61 minutes and door-to femoral puncture was 135 minutes. The median National Institute of Health Stroke Scale (NIHSS) scores on admission, 24 hours later and at discharge were 12,4 and 1 points, respectively. Middle cerebral artery was occluded in 60% of cases. Other frequent localizations where distal carotid artery in 17% and vertebro-basilar artery in 14%. Thrombolysis in cerebral infarction (TICI) scale flow score after the procedure was 3 or 2b in 58% of cases and significantly correlated with NIHSS scores at 24 hours and discharge. Fifty percent of patients had a mRankin score < = 1 and ten patients died (9.6%). Eight percent had a symptomatic intracerebral hemorrhage. Conclusions: The clinical improvement of these patients 24 hours after the procedure and at discharge demonstrate the effectiveness of endovascular treatment in ischemic stroke. The presence neurologists able to interpret multimodal images at the emergency room, the use of local guidelines, the availability of an experienced neuro-interventional team engaged with the workflow and the use of stent retrievers are strongly associated with good outcomes.


Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Aged, 80 and over , Young Adult , Thrombolytic Therapy/methods , Brain Ischemia/therapy , Stroke/therapy , Endovascular Procedures/methods , Time Factors , Severity of Illness Index , Brain Ischemia/diagnostic imaging , Retrospective Studies , Analysis of Variance , Treatment Outcome , Statistics, Nonparametric , Stroke/diagnostic imaging , Time-to-Treatment
18.
Rev. cuba. oftalmol ; 31(1): 72-81, ene.-mar. 2018.
Article in Spanish | LILACS | ID: biblio-960632

ABSTRACT

La oclusión de la arteria central de la retina es considerada una urgencia oftalmológica con mal pronóstico visual, a pesar de los métodos convencionales de tratamiento. Los recientes avances en neurorradiología permiten realizar un cateterismo selectivo en la arteria oftálmica e inyectar un agente fibrinolítico cerca del lugar de la obstrucción. Esta intervención podría ser efectiva en ciertos tipos de oclusiones y se han obtenido resultados prometedores en pacientes con oclusiones de la arteria central de la retina. Se realizaron búsquedas en diferentes publicaciones relacionadas con la especialidad en los últimos 10 años en bases de datos de revistas líderes de Oftalmología, con el objetivo de mostrar la trombolisis intrarterial como opción de tratamiento para la oclusión de la arteria central de la retina. La baja incidencia de esta enfermedad, además de que los pacientes acuden a consulta con frecuencia fuera del periodo de ventana, son justificantes por las que no se recogen respuestas definitivas, lo que se suma a la heterogenicidad de tratamiento coadyuvante empleado en los diferentes centros y al uso de fibrinolíticos y de dosis variados. Se requieren ensayos clínicos aleatorizados que permitan determinar su superioridad frente a las medidas convencionales, el grado de beneficio en contraposición al riesgo de eventos adversos y el tipo de pacientes que son candidatos a esta medida terapéutica que se avecina de manera prometedora para mejorar el pronóstico visual de estos pacientes(AU)


The occlusion of the retina central artery is considered an ophthalmological emergency with poor visual prognosis, despite conventional treatment methods. Recent advances in neuroradiology allow a selective catheterization in the ophthalmic artery and inject a fibrinolytic agent near the site of the obstruction. This intervention could be effective in certain types of occlusions and promising results have been obtained in patients with Central Retina Artery occlusions. We searched different publications related to the specialty, using the database of leading journals of ophthalmology, in the last 10 years; with the objective of showing intra-arterial thrombolysis as an option of treatment for the Retinal Central Artery Occlusion. The low incidence of this disease, together with the fact that patients frequently visit outside the window period, are justifying why no definitive answers are collected, which adds to the heterogeneity of coadjutant treatment used in the different centers, controversial window period and use of fibrinolytics and varied doses. Randomized clinical trials are required to determine its superiority to conventional measures, the degree of benefit as opposed to the risk of adverse events and the type of patients that are candidates for this therapeutic approach that is promising to improve the visual prognosis of these patients(AU)


Subject(s)
Humans , Retinal Artery Occlusion/therapy , Thrombolytic Therapy/methods , Databases, Bibliographic/statistics & numerical data , Validation Study
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