Complicaciones tromboembólicas y hemorrágicas en pacientes portadores de prótesis valvulares del corazón en un centro de tercer nivel. ¿Qué hemos aprendido? / Thromboembolic and hemorrhagic complications in patients with prosthetic heart valves at third level care center. What have we learned?

Resumen Antecedentes: El reemplazo valvular por prótesis mecánicas o biológicas implica riesgo de tromboembolismo y complicaciones hemorrágicas. Objetivo: Determinar las complicaciones relacionadas con la terapia de anticoagulación complementaria y la probabilidad de riesgo en pacientes portadores de prótesis valvulares del corazón. Métodos: Se estudiaron 163 pacientes entre 2002 y 2016, portadores de prótesis mecánicas y biológicas, quienes recibieron antagonistas de la vitamina K posterior al egreso hospitalario. La terapia de anticoagulación se categorizó en óptima y no óptima conforme a los valores de INR previos a las complicaciones. Fueron excluidos los pacientes con comorbilidades y otros factores de riesgo de trombosis y/o sangrado. Resultados: a 68.7 % de los pacientes se les colocó prótesis mecánica y a 31.3 %, biológica (p ≤ 0.001); 25.2 % presentó las complicaciones motivo de estudio (p ≤ 0.001), hemorrágicas en 48.8 %, tromboembólicas en 26.8 % y de ambos tipos en 24.4 % (riesgo relativo = 4.229); a 95.1 % de los pacientes con complicaciones se les colocó prótesis mecánica y a 4.9 %, biológica (p = 0.005); 49.7 % presentó INR no óptimo (p ≤ 0.001). Conclusiones: Ante riesgo alto de complicaciones tromboembólicas y hemorrágicas, la elección de las prótesis valvulares, la prevención y el seguimiento son prioridades, principalmente en quienes requieren terapia de anticoagulación.

Abstract Background: Heart valve replacement surgery with mechanical or biological prostheses entails a risk of thromboembolism and bleeding complications. Objective: To determine the complications related to complementary anticoagulation therapy and the probability of risk. Methods: One-hundred and sixty-three patients who underwent heart valve replacement between 2002 and 2016 with either mechanical or biological prostheses, and who received vitamin K antagonists after hospital discharge, were studied. Anticoagulation therapy was categorized into optimal and non-optimal according to INR values prior to the development of complications. Patients with comorbidities and other risk factors for thrombosis and/or bleeding were excluded. Results: In total, 68.7 % of patients received mechanical prostheses, and 31.3 %, biological prostheses (p ≤ 0.001); 25.2 % experienced the complications that motivated the study (p ≤ 0.001), which were hemorrhagic in 48.8 %, thromboembolic in 26.8 %, and of both types in 24.4 % (relative risk = 4.229). Among the patients with complications, 95.1 % received mechanical prostheses, and 4.9 %, biological (p = 0.005); non-optimal INR was identified in 49.7 % (p ≤ 0.001). Conclusions: Given the high risk of thromboembolic and hemorrhagic complications, valve prostheses must be carefully chosen, and care priorities should include prevention and follow-up, especially in those patients who require anticoagulation therapy.

Serious adverse event following immunization and thromboembolic events associated with COVID19 vaccination: An analysis of nationwide causality assessment from India

Background: Vaccines against the COVID-19 pandemic were introduced in late 2020. The present study has been conducted to study the serious Adverse Events Following Immunization (AEFIs) reported for COVID-19 vaccines from India. Methods: Secondary data analysis of the causality assessment reports for the 1112 serious AEFIs published by the Ministry of Health & Family Welfare, Government of India, was conducted. For the current analysis, all the reports published till 29.03.2022 were included. The primary outcome variables analyzed were the consistent causal association and the thromboembolic events. Results: The majority of the serious AEFIs assessed were either coincidental (578, 52%) or vaccine product related (218, 19.6%). All the serious AEFIs were reported among the Covishield (992, 89.2%) and COVAXIN (120, 10.8%) vaccines. Among these, 401 (36.1%) were deaths, and 711 (63.9%) were hospitalized and recovered. On adjusted analysis, females, the younger age group and non-fatal AEFIs showed a statistically significant consistent causal association with COVID-19 vaccination. Thromboembolic events were reported among 209 (18.8%) of the analyzed participants, with a significant association with higher age and case fatality rate. Conclusion: Deaths reported under serious AEFIs were found to have a relatively lower consistent causal relationship with the COVID-19 vaccines than the recovered hospitalizations in India. No consistent causal association was found between the thromboembolic events and the type of COVID-19 vaccine administered in India

Chronic Thromboembolic Pulmonary Hypertension and ChronicThromboembolic Pulmonary Disease / 罕见病研究

Chronic thromboembolic pulmonary hypertension (CTEPH) and chronic thromboembolic pulmonary disease (CTEPD) are diseases that occur after acute pulmonary embolism resulting from residual and organized intra-pulmonary thrombus, with or without pulmonary hypertension(PH). The prognosis of these diseases has been dramatically improved with the continuous progress of treatment and the updated concept of the comprehensive treatment strategy. However, there is a lack of awareness of these diseases among medical practitioners, and a lack of epidemiological data in China, with unknown pathogenesis and non-specific clinical manifestations. Therefore, it is easy to misdiagnosis, underdiagnosis and delay diagnosis in clinical practice. To enhance the understanding of medical personnel, this paper summarizes the definition, epidemiology, pathology, pathogenesis, diagnosis and treatment of CTEPH and CTEPD.

Meta-analysis of the efficacy and safety of tranexamic acid for hemostasis in cancer patients before and during surgery / 中国药房

OBJECTIVE To systematically review the efficacy and safety of tranexamic acid （TXA） for hemostasis in cancer patients before and during surgery， and to provide evidence-based reference for clinical drug use. METHODS Retrieved from PubMed， Embase， the Cochrane Library， CNKI， VIP and Wanfang databases， randomized controlled trials （RCTs） about tranexamic acid （trial group） versus 0.9% Sodium chloride injection， Lactated Ringer’s solution， Compound electrolyte solution or placebo （control group） for cancer surgery were electronically searched from the inception to June 9， 2022. After literature screening and data extraction， the quality of included RCTs were evaluated by bias risk assessment tool recommended by Cochrane system evaluator manual 5.1.0. RevMan 5.3 software was used for meta-analysis or descriptive analysis， sensitivity analysis and publication bias analysis. RESULTS A total of 2 032 patients in 22 RCTs were included for meta-analysis. Results of meta-analysis showed that the blood transfusion rate [RR＝0.59， 95%CI （0.50， 0.69）， P＜0.000 01] and the volume of erythrocyte suspension infusion [MD＝－0.53， 95%CI （－0.92， －0.14）， P＝0.007] in trial group were significantly lower than control group； there was no statistical significance in the incidence of thromboembolic events [RR＝0.44， 95%CI （0.16， 1.17）， P＝0.10] or post-operative mortality [RR＝1.27， 95%CI（0.32，5.08）， P＝0.73] between two groups. Results of descriptive analysis showed that the total blood loss and postoperative drainage volume were still controversial between two groups. The results of sensitivity analysis showed that the results were basically stable. The results of publication bias analysis showed that there was little possibility of publication bias in this study. CONCLUSIONS TXA can significantly decrease the blood transfusion， reduce the volume of erythrocyte suspension infusion， whereas does not increase the incidence of thromboembolic events and post-operative mortality in cancer surgery.

The Use of Ketamine as an Induction Agent for Anesthesia in Pulmonary Thromboendarterectomy Surgery: A Case Series

Pulmonary thromboendarterectomy (PTE) surgery is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (CTEPH). The induction of anesthesia in patients with severe pulmonary hypertension (PHT) can be challenging, with a risk of cardiovascular collapse. The administration of ketamine in patients with PHT is controversial, with some recommendations contraindicating its use. However, ketamine has been used safely in children with severe PHT. We present a retrospective case series of adult patients with severe PHT presenting for PTE surgery, using intravenous ketamine as a co?induction anesthetic agent.

Enfermedad tromboembólica venosa en hemopatías malignas: un enfoque desde la prevención / Venous thromboembolic disease in hematologic malignancies: a preventive approach

Introducción: La enfermedad tromboembólica venosa es una complicación frecuente en las hemopatías malignas, con incidencia similar a la observada en tumores sólidos de alto riesgo trombótico. Objetivo: Describir la influencia de factores de riesgo y biomarcadores de la enfermedad tromboembólica venosa asociada a hemopatías malignas y su aplicación en el diseño de modelos de evaluación de riesgo para la prevención de esta enfermedad. Métodos: Se realizó una revisión exhaustiva en la literatura especializada de artículos publicados sobre la temática a través de las bases de datos: PubMed, SciELO, ScienceDirect, Medline y el motor de búsqueda Google académico. Análisis y síntesis de la información: En pacientes con hemopatías malignas han sido descritos múltiples factores de riesgo para la ocurrencia de eventos tromboembólicos venosos: moleculares, relacionados con el paciente, la enfermedad y el tratamiento, así como biomarcadores de riesgo. Basados en ellos, varias investigaciones han sido desarrolladas para elaborar y validar modelos predictivos de enfermedad tromboembólica venosa que guíen la estratificación del riesgo y el tratamiento profiláctico de esta enfermedad en hemopatías malignas, aunque aún son insuficientes. Enfermedades como los linfomas y el mieloma múltiple tienen más investigaciones en esta área que el resto de las hemopatías malignas. Conclusión: Se necesita diseñar nuevos modelos de riesgo y validar los existentes en un mayor número de casos; así como desarrollar estudios prospectivos en pacientes con riesgo de eventos tromboembólicos y hemopatías malignas, para realizar una estrategia de prevención primaria personalizada con estratificación de la tromboprofilaxis(AU)

Introduction: Venous thromboembolic disease is a frequent complication in hematologic malignancies with incidence similar to that observed in solid tumors with high thrombotic risk. Objective: To describe the influence of risk factors and biomarkers of venous thromboembolic disease associated with hematologic malignancies and their application in the design of risk assessment models for the prevention of this disease. Methods: An exhaustive review was carried out in the specialized literature of articles published on the subject using the following databases: PubMed, SciELO, ScienceDirect, Medline and the academic Google search engine. Analysis and synthesis of the information: Multiple risk factors for the occurrence of venous thromboembolism have been described in patients with hematologic malignancies: patient-related, disease-related, treatment-related and molecular, as well as biomarkers of risk. Based on these, several investigations have been developed to elaborate and validate predictive venous thromboembolism models to guide risk stratification and prophylactic treatment of venous thromboembolic disease in hematologic malignancies, although they are still insufficient. Lymphomas and multiple myeloma have more research in this area than other hematologic malignancies. Conclusion: There is a need to design new risk models and validate existing ones in a larger number of cases, as well as to develop prospective studies in patients at risk of thromboembolic events and hematologic malignancies, to carry out a personalized primary prevention strategy with thromboprophylaxis stratification(AU)

Study of thrombotic complications in COVID-19

Background:In December of 2019, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)began to infect humans in the city of Wuhan and has rapidly become pandemic. Recent clinical trials suggested that COVID-19 related thromboembolic complications are the major cause for increased incidence of morbidity and mortality. We conducted a prospective observational study to evaluate the prevalence of vascular complications due to COVID-19 and to analyse the difference in the inflammatory markers before and after the events.Methods:Prospective observational study, conducted at department of general medicine, Bangalore Medical College, Bangalore Karnataka from 3 months, 01 August2021 to 30 October2020. The incidence of thrombotic events was 70.7% (53/75). The incidence of arterial thromboembolic events was 48%, involving 36 patients of the overall study population. Of these 36 patients, majority of them were suffering from cerebrovascular accident (CVA)accounting for about 12 (16%) of the patients followed by 11 (14.7%) with ischemic heart disease(IHD). About 22.66% (17/75) of patients had developed venous thromboembolic events. Of which, 13 (17.3%) patients had developed deep-vein thrombosis(DVT).Results:We observed that all the inflammatory markers had significantly increased after the onset of thrombotic events. Serum ferritin, lactate dehydrogenase (LDH), interleukin-6 (IL-6)and fibrinogen were almost raised by 50% of the pre-event values. We could not calculate the sensitivity, specificity, positive predictive value and negative predictive value for each parameter as the severity of the disease was widely distributed. Majority of these thrombotic events were observed among the patients aged >60 years and those with comorbid conditions. But there no statistically significant difference observed.Conclusions:We concluded that COVID-19 causes significantly increased surge of inflammatory markers and thereby the significantly increased prevalence of arterial and venous thrombotic events.

Coronary thrombo-embolic events after Covid-19 vaccination- a single centre study

Thrombo-embolic complications after Corona virus disease-19 (COVID-19) vaccination have been previously reported. We aimed to study the coronary thrombo-embolic complications (CTE) after COVID-19 vaccination in a single centre during the initial 3 months of vaccination drive in India. All patients admitted to our hospital between 1st March 2021 and 31st May 2021 with Acute coronary syndrome (ACS) were included. Of the 89 patients [Age 55 (47e64)y, 13f] with ACS and angiographic evidence of coronary thrombus, 37 (42%) had prior vaccination history. The timing from last vaccination dose to index event was <1, 1e2, 2e4 and >4 weeks in 9(24%), 4(11%), 15(41%) and 9 (24%) respectively. ChAdOx1 nCoV-19/AZD1222 (Covishield) was the most used vaccine- 28 (76%), while 9 (24%) had BBV152 (Covaxin). Baseline characteristics were similar in both vaccinated (VG) and non-vaccinated group (NVG), except for symptom to door time [8.5 (5.75e14) vs 14.5 (7.25e24) hrs, p ¼ 0.003]. Thrombocytopenia was not noted in any of the VG patients, while 2 (3.8%) of NVG patient had thrombocytopenia (p ¼ 0.51). The pre- Percutaneous Coronary Intervention (PCI) Thrombolysis in Myocardial Infarction (TIMI) flow was significantly lower [1 (0e3) vs2 (1e3), p ¼ 0.03) and thrombus grade were significantly higher [4 (2.5e5) vs 2 (1e3), p ¼ 0.0005] in VG. The in-hospital (2.7% vs 1.9%, p ¼ 1.0) and 30-day mortality were also similar (5.4% vs 5.8%, p ¼ 1.0). This is the first report of CTE after COVID-19 vaccination during the first 3 months of vaccination drive in India. We need further reports to identify the incidence of this rare but serious adverse events following COVID-19 vaccination.

Prophylaxis of Venous Thromboembolic Disease: Knowledge, Attitudes and Practices of Health Care Personnel in a Hospital Setting in Parakou in 2017

Aims: To describe the knowledge, attitudes and practices of health care personnel regarding venous thromboembolic disease prophylaxis (VTE) in the hospital setting to Parakou in 2017. Study Design: A descriptive cross-sectional study with prospective data collection. Place and Duration of Study: Departments of medicine and medical specialties, Departments of surgery and surgical specialties, Departments of gyneco-obstetrics and intensive care at the Hospital University of Parakou (CHUD-B), in northern Benin, between February 2017 and May 2017. Methodology: We included all health professionals working in these services who consented to participate. The American College of Chest Physicians (ACCP) guidelines for the management of VTE were used as the reference for the assessment of knowledge, attitudes and practices. The evaluation form consisted of two parts, one addressed to physicians and the other to paramedics. The data were analyzed with SPSS 21 software with a significance level of 5% for comparisons. Results: A total of 223 health workers participated in the study. The knowledge level of the health workers was good in 52.47%, attitudes were correct in 37.67% and practices were adequate in 4.32%. Overall, health professionals had a good knowledge-attitude-practice (KAP) score in 5.83% of the cases. Factors significantly associated with a good overall KAP score were practice on medical departments, continuing education of staff, status of doctors, knowledge of VTE guidelines and existence of VTE prevention protocols. Conclusion: Venous thromboembolic disease prophylaxis is moderately known by the health care personnel in Parakou, but attitudes and practices are not satisfactory. This highlights the need for continuous training.

Avaliação da bioequivalência entre duas formulações de rivaroxabana ­ 20 mg comprimido revestido ­ administradas em jejum e pós-prandial em voluntários sadios / Evaluation of bioequivalence between two rivaroxaban formulations ­ coated tablet 20 mg ­ administered under fasting and fed conditions in healthy volunteers

Objetivo: O objetivo deste trabalho foi avaliar a bioequivalência entre duas formulações de rivaroxabana 20 mg comprimido revestido, sendo a formulação teste produzida por Sanofi Medley, Brasil e a formulação referência (Xarelto®) comercializada por Bayer S/A. Métodos: Os estudos foram conduzidos em voluntários sadios de ambos os sexos e as formulações foram administradas em dose única, sob o estado de jejum e pós-prandial. Cada estudo foi conduzido de maneira independente, sendo ambos do tipo aberto, randomizado e com intervalo (washout) de sete dias entre os períodos. O estudo em jejum foi realizado em quatro períodos, com 48 voluntários, enquanto o pós-prandial foi realizado em dois períodos, com 36 voluntários. Resultados: Na administração em jejum, a razão entre a média geométrica da formulação teste e referência (T/R) de Cmáx foi de 100,77%, com intervalo de confiança de 90% (IC 90%) de 94,24% a 107,76%. Para ASC0-t, a razão T/R foi de 100,65%, com IC 90% de 96,13% a 105,39%. Na administração pós-prandial, a razão T/R de Cmáx foi de 110,63%, com IC 90% de 102,39% a 119,54%. Para ASC0-t, a razão T/R foi de 104,65%, com IC 90% de 98,44% a 109,12%. Conclusões: As formulações teste e referência foram consideradas estatisticamente bioequivalentes em ambas as condições de administração, de acordo com os critérios exigidos pela Agência Nacional de Vigilância Sanitária (Anvisa). A formulação teste foi registrada na Anvisa e disponibilizada para comercialização, contribuindo, assim, para a ampliação da disponibilidade do tratamento para doenças tromboembólicas e para a redução de custos ao paciente e ao Sistema Único de Saúde.

Objective: The objective of the present study was to evaluate the bioequivalence between two formulations of rivaroxaban 20 mg coated tablet, the test formulation being manufactured by Sanofi Medley, Brazil and the reference formulation (Xarelto® ) commercialized by Bayer S/A. Methods: The studies were conducted in healthy volunteers of both sexes and the formulations were administered in a single dose, under fasting and fed conditions. Each study was conducted independently, both being open-label, randomized and with a seven-day interval (washout) between periods. The fasting study was carried out in four periods, with 48 volunteers, while the fed study was carried out in two periods, with 36 volunteers. Results: In the fasting administration, the ratio between.

Morbi-mortalidad de la enfermedad tromboembólica venosa en el Hospital Universitario "Arnaldo Milián Castro" / Morbi-mortality of venous thromboembolic disease at "Arnaldo Milián Castro" University Hospital

Introducción: La enfermedad tromboembólica venosa es un proceso grave y mortal, considerado un problema de salud a escala mundial. Objetivo: Caracterizar la morbi-mortalidad por enfermedad tromboembólica venosa en el Hospital Universitario "Arnaldo Milián Castro". Métodos: Se realizó un estudio descriptivo retrospectivo de corte transversal a una muestra de 290 casos atendidos en el Hospital Universitario "Arnaldo Milián Castro" de Villa Clara, entre febrero de 2014 y febrero de 2016. Las variables fueron: edad, sexo, factores de riesgo, forma de presentación de la enfermedad y tipo de diagnóstico. Resultados: Se observó un predominio del sexo femenino y de los pacientes mayores de 70 años, independientemente del sexo y la inmovilidad como factor de riesgo. La trombosis venosa profunda del sector íleo-femoral fue la forma de presentación más común. El diagnóstico clínico primó, aunque el tromboembolismo pulmonar, como la complicación principal, se diagnosticó por necropsia. La mayor cantidad de trombosis venosa profunda se registró en el Servicio de Angiología, mientras que las muertes por embolia pulmonar predominaron en el Servicio de Terapia Intensiva. El tratamiento médico más utilizado fue la heparina sódica más warfarina; el profiláctico se realizó solo en el 24,7 por ciento de los casos. La heparina sódica se utilizó más en los servicios de Terapia Intensiva. Conclusiones: La enfermedad tromboembólica venosa fue la principal causa de muerte prevenible en el hospital, lo que sugiere que la profilaxis antitrombótica debe resultar una práctica esencial en los pacientes hospitalizados(AU)

Introduction: Venous thromboembolic disease is a serious and fatal process considered a health problem on a global scale. Objective: Characterize morbidity and mortality due to venous thromboembolic disease at "Arnaldo Milián Castro" University Hospital. Methods: A retrospective descriptive cross-sectional study was conducted on a sample of 290 cases treated at "Arnaldo Milián Castro" University Hospital in Villa Clara between February 2014 and February 2016. The variables were: age, sex, risk factors, form of presentation of the disease and type of diagnosis. Results: A predominance of the female sex and patients over 70 years of age was observed, regardless of sex and immobility as risk factors. Deep vein thrombosis of the ileus-femoral sector was the most common form of presentation. Clinical diagnosis prevailed, although pulmonary thromboembolism, as the main complication, was diagnosed by necropsy. The highest amount of deep vein thrombosis was recorded in the Angiology Service, while deaths from pulmonary embolism predominated in the Intensive Care Service. The most commonly used medical treatment was sodium heparin plus warfarin; prophylaxis was performed only in 24.7 percent of cases. Sodium heparin was more used in Intensive Care services. Conclusions: Venous thromboembolic disease was the leading cause of preventable death in the hospital, suggesting that antithrombotic prophylaxis should be an essential practice in hospitalized patients.

Pulmonary Hypertension Registry of Kerala, India (PRO-KERALA): One-year outcomes

Background: Short term outcomes of patients with pulmonary hypertension are not available from low and middle-income countries including India. Methods: We conducted a prospective study of 2003 patients with pulmonary hypertension, from 50 centres (PROKERALA) in Kerala, who were followed up for one year. Pulmonary hypertension (PH) was mainly diagnosed on the basis of Doppler echocardiography. The primary outcome was a composite endpoint of all-cause death and hospital admission for heart failure. All cause hospitalisation events constituted the secondary outcome. Results: Mean age of study population was 56 ± 16 years. Group 1 and Group 2 PH categories constituted 21.2% and 59% of the study population, respectively. Nearly two-thirds (65%) of the study participants had functional class II symptoms. 31% of Group 1 PH patients were on specific vasodilator drugs.In total, 83 patients (4.1%) died during the one-year follow-up period. Further, 1235 re-hospitalisation events (61.7%) were reported. In the multivariate model, baseline NYHA class III/IV (OR 1.87, 95% C.I. 1.35e2.56), use of calcium channel blockers (OR 0.18, 95% C.I. 0.04e0.77), vasodilator therapy (OR 0.5, 95% C.I. 0.28e0.87) and antiplatelet agents (OR 1.80, 95% C.I. 1.29e2.51) were associated with primary composite outcome at one-year (p < 0.05). Conclusion: In the PROKERALA registry, annual mortality rate was 4%. More than half of the patients reported re-hospitalisation events on follow up. Uptake of guideline directed therapies were suboptima

Eficácia e segurança de Riociguate comparado ao placebo e a medicamentos disponíveis no sus para tratamento de hipertensão pulmonar tromboembólica crônica: revisão rápida de evidências / Effectiveness and safety of Riociguate compared to placebo and drugs available in brazilian public health for treatment of chronic thromboembolic pulmonary hypertension: rapid response review of evidence

Tecnologia: Riociguate e outros medicamentos de controle da hipertensão pulmonar. Indicação: Tratamento de Hipertensão Pulmonar Tomboembólica Crônica (HPTEC). Pergunta: Há superioridade em eficácia e segurança do riociguate, comparado a medicamentos disponíveis no SUS, no tratamento de HPTEC inoperável ou operada com hipertensão pulmonar residual? Métodos: Revisão rápida de evidências (overview) de revisões sistemáticas, com levantamento bibliográfico realizado na base de dados PUBMED, utilizando estratégia estruturada de busca. A qualidade metodológica das revisões sistemáticas foi avaliada com AMSTAR-2 (Assessing the Methodological Quality of Systematic Reviews). Resultados: Foram selecionadas 4 e incluídas 2 revisões sistemáticas. Conclusão: Comparado ao placebo, em tratamento de curto prazo de HPTEC, riociguate melhora a tolerância ao exercício, aumenta a chance de melhora da classificação funcional e tem similar risco de eventos adversos sérios, porém não reduz a mortalidade. Treprostinil tem efeitos similares a riociguate. Entretanto, ambrisentana, bosentana, macitentana ou sildenafila não diferem do placebo no tratamento de HPTEC

Technology: Riociguat and other drugs to control pulmonary hypertension. Indication: Treatment of chronic thromboembolic pulmonary hypertension (CTEPH). Question: Is riociguat more effective and safe than other drugs available in the Brazilian Public Health System for the treatment of inoperable or recurrent CTEPH? Methods: Rapid review of evidence (overview) from systematic reviews, with a bibliographic search in the PUBMED database, using a structured strategy. The methodological quality of systematic reviews was assessed with AMSTAR-2 (Methodological Quality Assessment of Systematic Reviews). Results: Four systematic reviews were selected and two included in this study. Conclusion: Compared to placebo, in the short-term treatment of CTEPH, riociguat improves exercise tolerance, increases the chance of improving functional classification, and has a similar risk of serious adverse events, but does not reduce mortality. Treprostinil has similar effects to riociguat. However, ambrisentan, bosentan, macitentan or sildenafil do not differ from placebo in the treatment of CTEPH

Clinical study on the changes of left ventricular function and recovery after pulmonary endarterectomy in patients with chronic thromboembolic pulmonary hypertension / 中华超声影像学杂志

Objective:To assess the configuration and systolic function of the left ventricle in patients with chronic thromboembolic pulmonary hypertension (CTEPH) by routine ultrasound, two-dimensional speckle tracking imaging and three-dimensional echocardiography, and to observe the recovery after pulmonary endarterectomy (PEA).Methods:The patients who were diagnosed with CTEPH, underwent PEA and had no left heart disease were enrolled as the CTEPH group ( n=30) in the China-Japan Friendship Hospital from November 2016 and June 2021. The right heart catheterization data before and after surgery were recorded. In the meantime, gender- and age-matched healthy individuals who sought for physical examination during the same period were included as the control group ( n=23). Echocardiography findings before and after PEA were comparatively analyzed and compared between the two groups, including left ventricular end-diastolic diameter (LVEDd), right and left ventricular cross-section ratio (RVd/LVd), left ventricular global longitudinal strain (LVGLS), left ventricular end-diastolic/systolic volume index (LVEDVi/LVESVi), left ventricular ejection fraction (LVEF) and left ventricular stroke volume (LVSV). Associations between the mean pulmonary arterial pressure (mPAP)/pulmonary vascular resistance (PVR) and left ventricular function were discussed. Results:When compared with the control group, the LVEDd, LVEDVi, LVESVi, LVSV, LVGLS and the mitral early to late diastolic flow velocity ratio (E/A) in the CTEPH group were lower (all P<0.05). There were no significant differences between the two groups regarding LVEF, cardiac output (CO), and cardiac index (CI) (all P>0.05). There were no statistical differences of the left ventricular volume and LVSV between PEA group and the control group (both P>0.05), while the LVGLS and E/A remained lower (both P<0.05). Correlation analysis showed negative associations between mPAP and LVSV as well as E/A ( r=-0.490, -0.455; both P<0.05). Conclusions:There are changes in left ventricular configuration with abnormal filling pattern and potential systolic dysfunction in CTEPH patients. The PEA surgery could lead to recovery of the left ventricular configuration and volume, but the filling pattern and LVGLS at follow-up can not recover completely.

Resveratrol attenuates chronic pulmonary embolism-related endothelial cell injury by modulating oxidative stress, inflammation, and autophagy

Abstract Objectives: Due to Pulmonary Artery Endothelial Cell (PAEC) dysfunction, Pulmonary Hypertension (PH) persists even after the Pulmonary Embolism (PE) has been relieved. However, the mechanism behind this remains unclear. Method: Here, the authors incubated Human PAECs (HPAECs) with thrombin to simulate the process of arterial thrombosis. Results: CCK8 results showed a decrease in the viability of HPAECs after thrombin incubation. In addition, the expression of Tissue Factor (TF), Monocyte Chemoattractant Protein 1 (MCP-1), VCAM-1, ICAM-1, cleaved cas-pase 3, cleaved caspase 9, and Bax protein were all increased after thrombin incubation, while Bcl-2 was decreased. The effects of 3-MA treatment further suggested that autophagy might mediate the partial protective effects of Resveratrol on HPAECs. To observe the effects of Resveratrol in vivo, the authors established a Chronic Thromboembolic Pulmonary Hypertension (CTEPH) model by repeatedly injecting autologous blood clots into a rat's left jugular vein. The results exhibited that Mean Pulmonary Arterial Pressure (mPAP) and vessel Wall Area/ Total Area (WA/TA) ratio were both decreased after Resveratrol treatment. Moreover, Resveratrol could reduce the concentration and activity of TF, vWF, P-selectin, and promote these Superoxide Dismutase (SOD) in plasma. Western blot analysis of inflammation, platelet activation, autophagy, and apoptosis-associated proteins in pulmonary artery tissue validated the results in PHAECs. Conclusions: These findings suggested that reduced autophagy, increased oxidative stress, increased platelet activation, and increased inflammation were involved in CTEPH-induced HPAEC dysfunction and the development of PH, while Resveratrol could improve PAEC dysfunction and PH.

Profilaxis farmacológica para la prevención de la enfermedad tromboembólica en paciente con enfermedad cerebrovascular / Pharmacological prophylaxis for the prevention of thromboembolic disease in patients with cerebrovascular disease

INTRODUCCIÓN: La enfermedad cerebrovascular es un conjunto de alteraciones atribuidas a lesiones agudas y focales en el sistema nervioso central, en su mayoría secundaria a aterosclerosis DESARROLLO: En la prevención de la enfermedad cerebrovascular, existen dos grandes grupos farmacológicos, los antitromboticos y los anti plaquetarios, los cuales impactan en la calidad de vida de estos pacientes mejorando el pronóstico de los mismos. CONCLUSIONES: La enfermedad cerebrovascular comparte factores de riesgo de enfermedad tromboembólica, por lo que se recomienda iniciar profilaxis.

INTRODUCTION: Cerebrovascular disease is a group of alterations attributed to acute and focal lesions in the central nervous system, mostly secondary to atherosclerosis. DEVELOPMENT: In the prevention of cerebrovascular disease, there are two major pharmacological groups, antithrombotics and antiplatelet drugs. , which impact the quality of life of these patients, improving their prognosis. CONCLUSIONS: Cerebrovascular disease shares risk factors for thromboembolic disease, so it is recommended to start prophylaxis.

El impacto de CoViD-19 en la hipertensión arterial pulmonar

La enfermedad por coronavirus 2019 (CoViD-19) está causada por el virus del síndrome respiratorio agudo severo por coronavirus 2 (SARS-CoV-2), siendo particularmente perjudicial para los pacientes con enfermedad cardiovascular subyacente, y provocando una causa de morbilidad y mortalidad significativas en todo el mundo. Este virus lleva a una neumopatía, al tiempo que causa lesiones agudas de miocardio y daño crónico al sistema cardiovascular. Como consecuencia del daño del parénquima pulmonar y de la circulación pulmonar alterada, puede desarrollarse hipertensión pulmonar (HP), con su respectiva consecuencia. La fisiopatología de este tipo de HP es compleja y multifactorial, considerándose factores potenciales para las alteraciones de la circulación pulmonar. En estudios recientes, la prevalencia evidenciada de HP en pacientes con CoViD-19 es de alrededor del 12%, pero su evolución aún no está clara. La pandemia de CoViD-19 ha tenido un impacto significativo en todos los aspectos de la HP, desde el diagnóstico y manejo hasta la observación de un mayor riesgo de muerte en pacientes con hipertensión arterial pulmonar (HAP). En una encuesta de 77 centros de atención médica integral de HAP, la incidencia de infección por CoViD-19 fue de 2,1 casos por cada 1000 pacientes con HAP, similar a la incidencia de infección por CoViD-19 en la población general. Si bien, esta pandemia ha alterado el estándar de atención médica de rutina y de manejo agudo, particularmente, en aquellos pacientes con HAP, los riesgos asociados con CoViD-19 son significativos, presentándose nuevos desafíos en el cuidado de pacientes con HP. Dado que los pacientes con HAP han demostrado tener peores resultados en el ámbito de esta pandemia, es esencial trabajar de manera proactiva para disminuir el riesgo de infección por CoViD-19, mientras se continúa brindando un alto nivel de atención médica. El impacto de CoViD-19 en la prestación de atención médica y en la sociedad en general requirió que se establecieran nuevos protocolos para el tratamiento de HAP para disminuir el riesgo de exposición o transmisión de CoViD-19. De manera similar, ha habido una disminución en las pruebas de pacientes estables. Actualmente, la forma en que brindamos la atención médica se evidencia en un aumento de las visitas de telemedicina, una menor exposición a los entornos de atención médica para los pacientes y los profesionales de la salud, ayudando a nuestra necesidad continua de brindar servicios a los pacientes dentro del entorno de CoViD-19 y adaptándonos a una forma diferente de interactuar, ampliando nuestra comprensión de la mejor manera de cuidar a nuestros pacientes.

Coronavirus disease 2019 (CoViD-19) causes severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), being particularly harmful for patients with underlying cardiovascular disease, and causing a cause of significant morbidity and mortality throughout the world. This virus leads to lung disease, while causing acute myocardial injury and chronic damage to the cardiovascular system. As a consequence of the damage to the lung parenchyma and altered pulmonary circulation, pulmonary hypertension (PH) can develop, with its respective consequence. The pathophysiology of this type of PH is complex and multifactorial, considering potential factors for alterations in pulmonary circulation. In recent studies, the evidenced prevalence of PH in patients with CoViD-19 is around 12%, but its evolution is not yet clear. The CoViD-19 pandemic has had a significant impact on all aspects of PH, from diagnosis and management to observing an increased risk of death in patients with pulmonary arterial hypertension (PAH). In a survey of 77 comprehensive PAH healthcare centers, the incidence of CoViD-19 infection was 2.1 cases per 1,000 PAH patients, similar to the incidence of CoViD-19 infection in the general population. Although this pandemic has altered the standard of routine medical care and acute management, particularly in those patients with PAH, the risks associated with CoViD-19 are significant, presenting new challenges in the care of patients with PH. Since PAH patients have been shown to have worse outcomes in the setting of this pandemic, it is essential to work proactively to decrease the risk of CoViD-19 infection, while continuing to provide a high level of medical care. The impact of CoViD-19 on the provision of health care and on society in general required that new protocols be established for the treatment of PAH to reduce the risk of exposure or transmission of CoViD-19. Similarly, there has been a decline in stable patient testing. Currently, the way we provide healthcare is evidenced by an increase in telemedicine visits, less exposure to healthcare settings for patients and healthcare professionals, aiding our continued need to provide services to patients. patients within the CoViD-19 environment and adapting to a different way of interacting, broadening our understanding of the best way to care for our patients

A doença coronavírus 2019 (CoViD-19) causa síndrome respiratória aguda grave coronavírus 2 (SARS-CoV-2), sendo particularmente prejudicial para pacientes com doença cardiovascular subjacente e causando uma importante morbidade e mortalidade em todo o mundo. Este vírus leva à doença pulmonar, enquanto causa lesão aguda do miocárdio e dano crônico ao sistema cardiovascular. Como consequência do dano ao parênquima pulmonar e da circulação pulmonar alterada, pode ocorrer hipertensão pulmonar (HP), com suas respectivas consequências. A fisiopatologia desse tipo de HP é complexa e multifatorial, considerando fatores potenciais para alterações da circulação pulmonar. Em estudos recentes, a prevalência de HP evidenciada em pacientes com CoViD-19 gira em torno de 12%, mas sua evolução ainda não está clara. A pandemia CoViD-19 teve um impacto significativo em todos os aspectos da HP, desde o diagnóstico e tratamento até a observação de um risco aumentado de morte em pacientes com hipertensão arterial pulmonar (HAP). Em uma pesquisa com 77 centros de saúde com HAP abrangentes, a incidência de infecção por CoViD-19 foi de 2,1 casos por 1.000 pacientes com HAP, semelhante à incidência de infecção por CoViD-19 na população em geral. Embora essa pandemia tenha alterado o padrão de cuidados médicos de rotina e tratamento agudo, particularmente em pacientes com HAP, os riscos associados ao CoViD-19 são significativos, apresentando novos desafios no cuidado de pacientes com HP. Como os pacientes com HAP demonstraram ter resultados piores no cenário dessa pandemia, é essencial trabalhar proativamente para diminuir o risco de infecção por CoViD-19, enquanto continua a fornecer um alto nível de cuidados médicos. O impacto do CoViD-19 na prestação de cuidados de saúde e na sociedade em geral exigiu o estabelecimento de novos protocolos para o tratamento da HAP para reduzir o risco de exposição ou transmissão do CoViD-19. Da mesma forma, houve um declínio nos testes de pacientes estáveis. Atualmente, a forma como prestamos serviços de saúde é evidenciada por um aumento nas visitas de telemedicina, menos exposição aos ambientes de saúde para pacientes e profissionais de saúde, auxiliando nossa necessidade contínua de fornecer serviços aos pacientes. Pacientes dentro do ambiente CoViD-19 e adaptando-se de uma maneira diferente de interagir, ampliando nosso entendimento sobre a melhor forma de cuidar de nossos pacientes.

Enfermedad Tromboembólica Venosa en el período grávido puerperal. Diagnóstico, tratamiento y profilaxis / Venous Thromboembolic Disease in the puerperal gravid period. Diagnosis, treatment and prophylaxis / Doença tromboembólica venosa no período gravídico puerperal. Diagnóstico, tratamento e profilaxia

Resumen: El embarazo y puerperio son situaciones asociadas fisiológicamente con un marcado aumento del riesgo de enfermedad tromboembólica venosa. El riesgo se estima entre 7 a 10 veces superior que en mujeres de igual edad y 15-35 veces superior que la población control, durante el puerperio y hasta la sexta semana post-parto. Los factores de riesgo son distintos durante el período prenatal y post-parto. Los métodos diagnósticos incluyen radiografía, angio-tomografía de tórax y centellograma pulmonar ventilación-perfusión, ecodoppler venoso y venografía por resonancia nuclear magnética. El tratamiento supone un desafío que va desde la elección de la droga anticoagulante, los cambios en la farmacocinética durante el embarazo, entre otros. Se presentan algoritmos diagnósticos y terapéuticos.

Abstract: Pregnancy and the puerperium are physiologically associated with a markedly increased risk of venous thromboembolic disease. The risk is estimated between 7 to 10 times higher than in women of the same age and 15-35 times higher than the control population, during the puerperium and up to the sixth week postpartum. Risk factors are different during the prenatal and postpartum period. Diagnostic methods include radiography, chest angio-tomography and ventilation-perfusion lung scintigraphy, venous Doppler ultrasound, and magnetic resonance venography. Treatment involves a challenge that ranges from the choice of anticoagulant drug, changes in pharmacokinetics during pregnancy, among others. Diagnostic and therapeutic algorithms are presented.

Resumo: A gravidez e o puerpério estão fisiologicamente associados a um risco acentuadamente aumentado de doença tromboembólica venosa. O risco é estimado entre 7 a 10 vezes maior do que em mulheres da mesma idade e 15 a 35 vezes maior do que na população controle, durante o puerpério e até a sexta semana pós-parto. Os fatores de risco são diferentes durante o período pré-natal e pós-parto. Os métodos de diagnóstico incluem radiografia, angiotomografia de tórax e cintilografia pulmonar de ventilação-perfusão, ultrassom Doppler venoso e venografia por ressonância magnética nuclear. O tratamento envolve um desafio que vai desde a escolha do anticoagulante, mudanças na farmacocinética durante a gravidez, entre outros. Algoritmos diagnósticos e terapêuticos são apresentados.

Factores influyentes en la muerte por tromboembolismo pulmonar / Influencing factors in death due to pulmonary embolism / Fatores que influenciam na morte devido a embolia pulmonar

RESUMEN Introducción: el tromboembolismo pulmonar (TEP) significa la consecuencia más grave de un evento primario. Requiere alto índice de análisis de probabilidad clínica basada en la evaluación de los factores de riesgos presentes. Objetivo: identificar los factores pronósticos de muerte en los pacientes con tromboembolismo pulmonar. Métodos: se realizó estudio analítico de casos y testigoscon78enfermos porTEP(26 casos y 52 testigos). Resultados: edad media 57.3 años, predominio no significativo en el sexo femenino de 53,7 % p>0,05 y en grupo de edades ≤60 años 55,1 %, p˃0,05. La letalidad fue 30,5 % sin predominio de género. Diabetes mellitus, síndrome metabólico y trombosis venosa profunda, mostraron asociación significativa a la muerte. El modelo de regresión logística demostró que hipertensión pulmonar OR ajustado 7,1 IC 95 % (2,5- 9,2) p=0,01 y disfunción ventricular derecha OR ajustado 5,5 IC 95 % (2,0-8,6) p=0,00 mostraron una relación independiente con la probabilidad de morir. Conclusiones: disfunción ventricular derecha e hipertensión pulmonar se identificaron como factores pronósticos de muerte por TEP. Los resultados probados nos permiten estratificar al paciente constituyendo una base sólida para ulteriores estudios predictivos.

ABSTRACT Introduction: pulmonary thromboembolism (PE) is the most serious consequence of a primary event. It requires a high rate of clinical probability analysis based on the evaluation of the risk factors present. Objective: to identify prognostic factors for death in patients with pulmonary embolism. Methods: an analytical study of cases and controls was carried out with 78 patients with PE (26 cases and 52 controls). Results: mean age 57.3 years, non-significant predominance in the female sex of 53.7% p> 0.05 and in the age group ≤60 years 55.1%, p˃0.05. The fatality was 30.5% without gender predominance. Diabetes mellitus, metabolic syndrome and deep vein thrombosis showed a significant association with death. The logistic regression model showed that pulmonary hypertension adjusted OR 7.1 95% CI (2.5- 9.2) p = 0.01 and right ventricular dysfunction adjusted OR 5.5 95% CI (2.0-8, 6) p = 0.00 showed an independent relationship with the probability of dying. Conclusions: right ventricular dysfunction and pulmonary hypertension were identified as prognostic factors for death due to PE. The proven results allow us to stratify the patient, constituting a solid base for further predictive studies.

RESUMO Introdução: o tromboembolismo pulmonar (EP) é a consequência mais grave de um evento primário. Requeruma alta taxa de análise de probabilidade clínica baseada na avaliação dos fatores de risco presentes. Objetivo: identificar fatores prognósticos para óbito em pacientes com embolia pulmonar. Métodos: foi realizado um estudo analítico de casos e controles com 78 pacientes com PE (26 casos e 52 controles). Resultados: média de idade 57,3 anos, predominância não significativa no sexo feminino de 53,7% p> 0,05 e na faixa etária ≤60 anos 55,1%, p˃0,05. A letalidade foi de 30,5% sempre domínio de gênero. Diabetes mellitus, síndrome metabólica e trombose venosa profunda mostraram associação significativa com óbito. O modelo de regressão logística mostrou que hipertensão pulmonar ajustada OR 7,1 IC95% (2,5-9,2) p = 0,01 e disfunção ventricular direita ajustada OR 5,5 IC95% (2,0-8,6) p = 0,00 mostraram uma relação independente com a probabilidade de moribundo. Conclusões: disfunção ventricular direita e hipertensão pulmonar foram identificadas como fatores prognósticos para óbito por EP. Os resultados comprovados permitem estratificar o paciente, constituindo uma base sólida para futuros estudos preditivos.

Propuesta para manejo de la coagulopatía asociada a la COVID-19 en adultos / A proposal for the management of COVID-19-induced coagulopathy in adults

Resumen La infección por coronavirus 2 del síndrome respiratorio agudo grave (SARS-CoV-2) es la causante de la pandemia de enfermedad por coronavirus 2019 (COVID-19), con un índice de letalidad alto. La mayoría de los pacientes graves desarrollan un tipo especial de coagulopatía no descrito hasta ahora y la cual se considera ahora la principal causa de muerte. Por esta razón, el tratamiento anticoagulante se ha convertido en una de las piedras angulares del tratamiento de esta infección. Sin embargo, la velocidad con la que se genera la evidencia respecto al uso de anticoagulantes es muy rápida y, en ocasiones difícil de interpretar y contradictoria. Luego de hacer una revisión extensa de la literatura publicada, se hace esta propuesta para el uso del tratamiento anticoagulante tomando en cuenta los recursos disponibles en México.

Abstract Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is the cause of the coronavirus disease 2019 (COVID-19) pandemic, which has a high case fatality rate. Most severely ill patients develop a special type of coagulopathy that had not been described before and that is now considered the main cause of death. For this reason, anticoagulant treatment has become one of the cornerstones of the treatment of this infection. However, the rate at which the evidence regarding the use of anticoagulants is generated is quite fast, and sometimes it is difficult to interpret and conflicting. After having performed an extensive review of the published literature, this proposal for the use of anticoagulant treatment is made, taking into account available resources in Mexico.