Desenho de Estudo de um Estudo Observacional Brasileiro sobre o uso de Edoxabana em Pacientes com Fibrilação Atrial (EdoBRA) / Study Design of a Brazilian Observational Study of Edoxaban in Patients with Atrial Fibrillation (EdoBRA)

Resumo Fundamento: Os ensaios clínicos demonstraram a segurança da Edoxabana, um anticoagulante oral não dependente de vitamina K (NOAC), e a sua eficácia na prevenção de acidente vascular cerebral e embolia sistémica em pacientes com fibrilação atrial não valvar (FANV) e também na prevenção e tratamento de tromboembolismo venoso. No entanto, pesquisas adicionais são necessárias para avaliar a segurança e a eficácia da Edoxabana em um cenário real na população brasileira. Objetivo: A fim de compreender os riscos e benefícios do uso da Edoxabana em cenários clínicos de rotina, o estudo EdoBRA está sendo conduzido para obter informações sobre a segurança e eficácia do uso da Edoxabana em pacientes não pré-selecionados com FANV no Brasil. Métodos: O estudo EdoBRA é um estudo multicêntrico, prospectivo e observacional, realizado em 36 centros no Brasil. São elegíveis para este estudo pacientes com FANV, ≥ 18 anos de idade, tratados com Edoxabana disponível comercialmente, que iniciaram o tratamento por pelo menos 14 dias e não mais do que 90 dias antes da data de inclusão no estudo, e que não estão participando de nenhum outro estudo de intervenção. Ao todo, 700 pacientes devem ser inscritos e acompanhados por um ano, com coletas de dados programadas para o período basal e 3, 6 e 12 meses após a inscrição no estudo. O objetivo primário de segurança é o sangramento clinicamente relevante (de acordo com critérios da Sociedade Internacional de Trombose e Hemostasia - ISTH), e o objetivo secundário de eficácia são desfechos cardiovasculares relevantes relacionados à FANV. Conclusão: O estudo observacional EdoBRA gerará informações adicionais relevantes sobre a Edoxabana enquanto NOAC em diversos aspectos do manejo de pacientes no atendimento clínico de rotina, como perfil de segurança e efetividade em pacientes com FANV no Brasil.

Abstract Background: Clinical trials showed the safety of Edoxaban, a non-vitamin K-dependent oral anticoagulant (NOAC), and its efficacy to prevent stroke and systemic embolism in non-valvular atrial fibrillation (NVAF) patients and also to prevent and treat venous thromboembolism. However, additional research is needed to evaluate the safety and effectiveness of Edoxaban in a real-world scenario in the Brazilian population. Objective: In order to understand the risks and benefits of Edoxaban use in routine clinical settings, the EdoBRA study is being conducted to gain insight into the safety and effectiveness of Edoxaban use in non-preselected patients with NVAF in Brazil. Methods: The EdoBRA study is a multicenter, prospective, observational study conducted in 36 sites in Brazil. NVAF patients ≥ 18 years treated with commercially available Edoxaban who initiated treatment for at least 14 days and no longer than 90 days prior to enrollment, and who are not simultaneously participating in any interventional study are eligible for this study. Seven hundred patients are planned to be enrolled and one-year of follow up, with data collections expected at baseline and 3, 6, and 12 months after the study enrollment. The primary safety objective is ISTH Clinically Relevant Bleeding, and the secondary effectiveness objective focuses on relevant cardiovascular outcomes related to NVAF. Conclusion: EdoBRA observational study will generate relevant additional information about NOAC Edoxaban on various aspects of patient management in routine care, such as its safety and effectiveness profile in patients with NVAF in Brazil.

Anticoagulação Crônica em Pacientes com Fibrilação Atrial e COVID-19: Uma Revisão Sistemática e Metanálise / Chronic Anticoagulation in Patients with Atrial Fibrillation and COVID-19: A Systematic Review and Meta-Analysis

Resumo Fundamento: A doença por coronavírus 2019 (COVID-19) está associada à hipercoagulabilidade. Permanece incerto se a anticoagulação contínua para fibrilação atrial (FA) em pacientes que posteriormente contraem COVID-19 melhora os desfechos clínicos. Objetivos: Comparar a anticoagulação oral crônica com ausência de anticoagulação prévia em pacientes com FA que contraíram uma infecção por COVID-19 em relação aos desfechos de mortalidade por todas as causas, mortalidade por COVID-19, admissão em unidade de terapia intensiva (UTI) e hospitalização. Métodos: Buscamos sistematicamente no PubMed, Embase e Cochrane Library estudos elegíveis desde o início até dezembro de 2022. Incluímos estudos que compararam desfechos de COVID-19 em pacientes com e sem anticoagulação crônica prévia para FA. Foram agrupadas razões de risco (RR) com intervalos de confiança (IC) de 95% por meio de um modelo de efeitos aleatórios. O nível de significância foi estabelecido em p < 0,05. As avaliações da qualidade e do risco de viés foram realizadas de acordo com as recomendações da Cochrane. Resultados: Foram identificados 10 estudos abrangendo 1.177.858 pacientes com COVID-19 e FA, dos quais 893.772 (75,9%) estavam em anticoagulação crônica prévia para FA. Em pacientes com COVID-19, a anticoagulação crônica para FA reduziu significativamente a mortalidade por todas as causas (RR 0,75; IC 95% 0,57 a 0,99; p = 0,048; I2 = 89%) e a mortalidade relacionada à COVID-19 (RR 0,76; IC 95% 0,72 a 0,79; p < 0,001; I2 = 0%) quando comparada com a ausência de anticoagulação prévia. Em contrapartida, não houve diferença entre os grupos em relação à hospitalização (RR 1,08; IC 95% 0,82 a 1,41; p = 0,587; I2 = 95%) ou internação em UTI (RR 0,86; IC 95% 0,68 a 1,09; p = 0,216; I2 = 69%). Conclusões: Nesta metanálise, a anticoagulação crônica para pacientes com FA que contraíram COVID-19 foi associada a taxas significativamente mais baixas de mortalidade por todas as causas e mortalidade relacionada à COVID-19 em comparação com a ausência de anticoagulação anterior.

Abstract Background: Coronavirus disease 2019 (COVID-19) is associated with hypercoagulability. It remains uncertain whether ongoing anticoagulation for atrial fibrillation (AF) in patients who later contract COVID-19 improves clinical outcomes. Objectives: To compare chronic oral anticoagulation with no previous anticoagulation in patients with AF who contracted a COVID-19 infection concerning the outcomes of all-cause mortality, COVID-19 mortality, intensive care unit (ICU) admission, and hospitalization. Methods: We systematically searched PubMed, Embase, and Cochrane Library for eligible studies from inception to December 2022. We included studies comparing COVID-19 outcomes in patients with versus without prior chronic anticoagulation for AF. Risk ratios (RR) with 95% confidence intervals (CI) were pooled with a random-effects model. The level of significance was set at p < 0.05. Quality assessment and risk of bias were performed according to Cochrane recommendations. Results: Ten studies comprising 1,177,858 patients with COVID-19 and AF were identified, of whom 893,772 (75.9%) were on prior chronic anticoagulation for AF. In patients with COVID-19, being on chronic anticoagulation for AF significantly reduced all-cause mortality (RR 0.75; 95% CI 0.57 to 0.99; p = 0.048; I2 = 89%) and COVID-19-related mortality (RR 0.76; 95% CI 0.72 to 0.79; p < 0.001; I2 = 0%) when compared with no prior anticoagulation. In contrast, there was no difference between groups regarding hospitalization (RR 1.08; 95% CI 0.82 to 1.41; p = 0.587; I2 = 95%) or ICU admission (RR 0.86; 95% CI 0.68 to 1.09; p = 0.216; I2 = 69%). Conclusions: In this meta-analysis, chronic anticoagulation for patients with AF who contracted COVID-19 was associated with significantly lower rates of all-cause mortality and COVID-19-related mortality as compared with no previous anticoagulation.

Factores asociados a la adherencia al tratamiento en pacientes con anticoagulación oral

Introducción: El tratamiento con anticoagulantes ha demostrado su eficacia en la prevención de complicaciones cardioembólicas; sin embargo, la adherencia probablemente tiene el mayor impacto en la calidad de la anticoagulación. Objetivo: Determinar los factores que influyen en la adherencia al tratamiento anticoagulante y en la estabilidad del índice de estandarización internacional (INR). Métodos: Se realizó un estudio analítico, observacional y prospectivo que se corresponde con un estudio farmacoepidemiológico de utilización de medicamentos (Esquema Terapéutico), en pacientes con diagnóstico de trastornos de la coagulación, en el área de salud del municipio Manzanillo, entre el 1ro de septiembre de 2018 al 1ro de diciembre de 2020. Los datos de la investigación se obtuvieron de una entrevista y su historia clínica. Fueron utilizados el test del Xi-cuadrado (X2), t de Student, ANOVA y Kruskall Wallis, con un valor de p=0,05 durante el procesamiento estadístico. Resultados: Se constató un grado bajo de adherencia farmacoterapéutica en la población estudiada. Las variables sociodemográficas relacionadas con la adherencia terapéutica fueron el sexo, la escolaridad y la ocupación. Existe relación entre los recursos económicos, el conocimiento que tiene el paciente sobre su enfermedad, el cumplimiento del tratamiento no farmacológico y el cumplimiento del tratamiento farmacológico con la adherencia. Las reacciones adversas y la disponibilidad de los medicamentos fueron los factores dependientes del tratamiento relacionados con la adherencia. Las orientaciones del médico al paciente, el seguimiento del paciente y la relación médico-paciente, fueron los factores dependientes del médico. Conclusiones: Las cinco dimensiones de la adherencia terapéutica que plantea la OMS (factores socioeconómicos, relacionados con el paciente, relacionados con la enfermedad, relacionados con el tratamiento y relacionados con el sistema de salud) se asociaron con la adherencia al tratamiento y la estabilidad del índice de estandarización internacional.

Introduction: Anticoagulant therapy has demonstrated efficacy in preventing cardioembolic complications. However, adherence is probably the most important determinant of the quality of anticoagulation. Objective: The aim of this research wasto determine the factors that influence adherence to anticoagulation therapy and the stability of the international normalized ratio (INR). Methods: Between September 1, 2018 and December 1, 2020was conducted an analytical, observational andprospective study, corresponding to a pharmacoepidemiological study of drug utilization (Therapeutic Scheme). The object of this study were patients with a diagnosis of coagulation disorders, in the health area of the municipality of Manzanillo. The research data were obtained through an interview and their clinical history. The Xi-squared test (X2), Student's t-test, ANOVA and Kruskall Wallis were used, with a value of p = 0.05 in statistical processing. Results: As a result, a low level of pharmacotherapeutic adherence was observed in the studied population. The sociodemographic variables associated with adherence were sex, education and occupation. There was an association between economic resources, patients' knowledge of their disease, compliance with nonpharmacological treatment, and compliance with pharmacological treatment and adherence. Also, adverse drug reactions and drug availability were the treatment-related factors associated with adherence. And, physician orientation to the patient, patient follow-up, and physician-patient relationship were the physician-dependent factors. Conclusions: To sump up, the five dimensions of adherence proposedbyWHO (socioeconomic, patient-related, disease-related, treatment-related and health system-related factors) were associated with adherence and stability of the international standardization index.

Introdução: A terapêutica anticoagulante tem-se revelado eficaz na prevenção de complicações cardioembólicas. Objetivo: O objetivo desta investigação foi determinar os factores que influenciam a adesão à terapêutica anticoagulante e a estabilidade do rácio normalizado internacional (INR). Métodos: Um estudo analítico, observacional e prospetivo, correspondente a um estudo farmacoepidemiológico de utilização de medicamentos (Esquema Terapêutico) foi realizado entre 1 de setembro de 2018 e 1 de dezembro de 2020.O objeto deste estudo foram pacientes com diagnóstico de distúrbios de coagulação, da área de saúde do município de Manzanillo. Os dados da pesquisa foram obtidos através de uma entrevista e sua história clínica. Utilizou-se o teste do Xi-quadrado (X2), teste t de Student, ANOVA e Kruskall Wallis, com um valor de p = 0,05 no processamento estatístico. Resultados: Como resultado, observou-se um baixo nível de adesão à farmacoterapia na população estudada. As variáveis sociodemográficas associadas à adesão foram sexo, escolaridade e ocupação. Observou-se associação entre recursos financeiros, conhecimento da doença pelo paciente, adesão ao tratamento não farmacológico e adesão ao tratamento farmacológico e adesão. Além disso, as reacções adversas a medicamentos e a disponibilidade de medicamentos foram os factores relacionados com o tratamento associados à adesão. E a orientação médico-paciente, o acompanhamento do paciente e a relação médico-paciente foram os factores dependentes do médico. Conclusões: Concluindo, as cinco dimensões da adesão propostas pela OMS (factores socioeconómicos, relacionados com o doente, relacionados com a doença, relacionados com o tratamento e relacionados com o sistema de saúde) estiveram associadas à adesão e à estabilidade do índice de normalização internacional.

Calidad de atención en el manejo de enfermedad cerebrovascular isquémica aguda posterior a la iniciativa angels / Acute ischemic cerebrovascular disease management quality of care following the adoption of the angels initiative

Introducción: el ataque cerebrovascular (ACV) es común a nivel mundial, una de cada cuatro personas puede presentarlo a lo largo de la vida. Constituye la segunda causa de muerte y la tercera principal de discapacidad. Es importante la atención integral para lograr un impacto en la calidad de vida. Objetivo: determinar la calidad de atención en el manejo del ACV isquémico agudo de los pacientes que consultaron al servicio de neurología en los Hospitales de San José e Infantil Universitario de San José, Bogotá DC, entre enero 1/2019 y enero 1/2020. Metodología: estudio descriptivo de corte transversal. El criterio de inclusión fue pacientes mayores de 18 años con diagnóstico de ACV isquémico. La información se recolectó de las historias clínicas, se empleó estadística descriptiva para analizar los datos. Resultados: se incluyeron 411 pacientes, 88,8% sin alteración del estado de conciencia, 26,4% ingresaron antes de las 4,5 horas de ventana para trombólisis, se realizaron procedimientos de recanalización endovenosa a 11,4%. El tiempo puerta aguja tuvo una mediana de 37,2 minutos comparado con la mediana nacional de tiempo que fue 56,5 min según lo registrado en la plataforma ResQ. El 72% recibió terapia antiagregante y estatina 88.8%. Discusión y conclusiones: al identificar los síntomas es importante ser estrictos en el tiempo de atención y la implementación de plataformas para óptimos planes de atención. Se requieren campañas masivas de educación, así como que planes de mejora institucionales.

Introduction: cerebrovascular attack (CVA) is common worldwide. One in four people may have a stroke during their lifetime. It is the second leading cause of death and the third leading cause of disability. Thus, it is important to provide integrated care to achieve an impact on quality of life. Objective: to determine ischemic CVA management quality of care among patients seen at the neurology service of the San José and Infantil Universitario de San José hospitals in Bogotá DC, between January 1/2019 and January 1/2020. Methodology: a descriptive, cross-sectional study. The inclusion criteria included patients over 18 years of age diagnosed with ischemic CVA. Information was collected from clinical records. Data was analyzed using descriptive statistics. Results: 411 patients were included; 88.8% had an altered state of consciousness, 26.4% were admitted within the 4.5-hour window for thrombolysis; 11.4% underwent intravenous reperfusion procedures. Door-to-needle time: median was 37.2 minutes versus the national media of 56.5 min according to the ResQ records platform; 72% received anti-platelet therapy and 88.8% received statins. Discussion and conclusions: the establishment of a strict time to care and the implementation of platforms to improve care plans, is essential. Massive education campaigns are required, as well as, institutional improvement plans.

Manejo odontológico del paciente en tratamiento de anticoagulante oral sometido a cirugía oral: una revisión narrativa / Stomatological management of anticoagulated patients undergoing oral surgery: a narrative review

Resumen Los pacientes que se encuentran bajo tratamiento de anticoagulantes orales, presentan alteraciones en distintas etapas de la hemostasia, lo que conlleva a tener implicancias y consideraciones médico/quirúrgicas durante su atención. En la actualidad, no existe un consenso en relación con el manejo odontológico de estos pacientes que serán sometidos a procedimientos quirúrgicos, llevando a protocolos clínicos que siguen diversas posturas, como la de disminuir la ingesta farmacológica del anticoagulante, sustituir con heparina y la de mantener el tratamiento bajo control. Objetivo Establecer el manejo estomatológico del paciente que se encuentra en tratamiento de anticoagulante oral mediante una revisión profunda de la literatura Materiales y método Se realizó una búsqueda de revisión bibliográfica manualmente de artículos indexados a las bases de datos de PUBMED y EBSCO que correspondiesen a las palabras "cirugía bucal", "anticoagulantes", "atención dental" y "hemorragia oral". En cuanto a los criterios de inclusión, se consideraron revisiones bibliográficas, estudios observacionales, ensayos clínicos, guías, revisiones sistemáticas y metaanálisis publicados entre noviembre de 2005 y 2022, en idiomas inglés o español. Conclusiones Existen múltiples protocolos para la atención del paciente anticoagulado que será sometido bajo procedimiento de cirugía oral menor. Es importante considerar el anticoagulante utilizado, motivo, control de este, el procedimiento a realizar en el paciente y medidas hemostáticas tanto intra como postoperatorias por realizar, tras analizar lo anterior, se advierte que disminuir la ingesta del fármaco para realizar el procedimiento, puede ser más perjudicial al paciente como al clínico, por lo tanto se sugiere mantener el tratamiento antitrombótico y realizar un correcto manejo médico/quirúrgico.

Abstract Patients undertaking oral anticoagulant treatment may experience alterations in different stages of hemostasis, which lead to medical/surgical implications and considerations during their care. Currently, there is no consensus regarding the dental management of these patients, as they go through surgical procedures. This leads to clinical protocols that follow numerous approaches, such as reducing the pharmacological intake of the anticoagulant, replacing it with heparin, and maintaining the controlled treatment. Objective: To establish the stomatological management of the patient undergoing oral anticoagulant treatment through an in depth review of the literature. Materials and Method: A manual bibliographic review search of articles indexed to the PUBMED and EBSCO databases corresponding to the words "oral surgery", "oral bleeding", "anticoagulants" and "dental management" was performed. Regarding the inclusion criteria: bibliographic reviews, observational studies, clinical trials, guidelines, systematic reviews, and meta-analyses published between November 2005 and 2022, in English or Spanish, were considered. Conclusion: There are multiple protocols for the care of the anticoagulated patient who will undergo a minor oral surgery procedure. It is important to reflect on the anticoagulant used, the reason for it, its supervision, the surgical procedure that will be undertaken by the patient, and both intraoperative and postoperative hemostatic measures to be implemented. After analyzing the above, it is noted that reducing the intake of the drug to perform the surgical procedure may be harmful to the patient and to the clinician, therefore it is suggested to maintain the antithrombotic treatment and carry out a correct medical/surgical management.

Informe de un caso clínico con síndrome de Paget-Schroetter

Introducción: El síndrome de Paget-Schroetter (SPS) es una trombosis venosa profunda primaria del complejo venoso subclavio-axilar que ocurre después del uso repetitivo y extenuante de los hombros y los brazos. Muestra una incidencia de 1 por 100 000 personas al año. Se informa con mayor frecuencia en atletas jóvenes. Objetivo: Presentar un caso inusual de síndrome de Paget-Schroetter en un individuo joven no deportista. Caso clínico: Varón militar activo de 24 años de edad, sin antecedentes patológicos personales, que ingresó con inflamación del miembro superior izquierdo de 24 horas de evolución. Presentó una trombosis de la vena cefálica izquierda después de un esfuerzo físico de carga y descarga. Tras descartar trastornos secundarios de hipercoagulabilidad se le diagnosticó un SPS. Se le informó de la opción de intervención quirúrgica, pero la rechazó. El diagnóstico fue confirmado con ecografía Doppler y tratado con anticoagulación endovenosa al inicio y luego por vía oral durante 6 meses. Durante el seguimiento no se evidenció trombosis crónica de la vena cefálica izquierda ni formación de intervalo de colaterales vasculares. Conclusiones: El SPS es una condición clínica que necesita un alto índice de sospecha y un diagnóstico oportuno, por tanto, los médicos deben estar atentos a esta rara entidad para su reconocimiento temprano y derivación oportuna a cirugía vascular.

Introduction: Paget-Schroetter syndrome (PSS) is a primary deep vein thrombosis of the subclavian-axillary venous complex that occurs after repetitive and strenuous use of the shoulders and arms. It shows an incidence of 1 per 100,000 people per year. It is reported more frequently in young athletes. Objective: To present an unusual case of Paget-Schroetter syndrome in a young non-athlete individual. Clinical case: 24-year-old active military man with no personal pathological history is presented, who was admitted with inflammation of the left upper limb of 24 hours of evolution. He presented a thrombosis of the left cephalic vein after a physical effort of loading and unloading. After ruling out secondary hypercoagulability disorders, he was diagnosed with SPS. He was informed of the option of surgical intervention, but he declined it. The diagnosis was confirmed with Doppler ultrasound and treated with intravenous anticoagulation at the beginning, and then orally for 6 months. During the follow-up of the patient, there was no evidence of chronic thrombosis of the left cephalic vein or interval formation of vascular collaterals. Conclusions: SPS is a clinical condition that requires a high index of suspicion and prompt diagnosis, therefore, physicians must be attentive to this rare entity for early recognition and timely referral to vascular surgery.

Risk of bias assessment of clinical trials referenced in the technical notes on direct-acting oral anticoagulants available on e-NatJus / Avaliação do risco de viés dos ensaios clínicos referenciados nas notas técnicas sobre os anticoagulantes orais diretos disponíveis no e-NatJus

Objective: Assess and classify the risks of bias in the clinical trials (CTs) that make up the technical notes (TNs) referring to direct-acting oral anticoagulants (DOAC) requests. Methods: The TNs related to the DOAC requests of apixaban, dabigatran, edoxaban, and rivaroxaban were selected on the e-NatJus website and, after excluding duplicate references, an analysis of the CT used for their writing was carried out. The CT risk of bias (low, high, or uncertain bias) was assessed using the Cochrane Risk of Bias tool, and the results were added to Review Manager 5.4. Results: 181 TNs were selected, 236 articles were analyzed and after applying the inclusion criteria, 28 CTs were analyzed in full. None of the CTs were free of bias. Most CTs, 71% (20/28), had a low risk of bias regarding attrition bias and reporting bias. In contrast, 61% (17/28) of the studies did not control for selection, performance, and detection bias, as they present uncertainties and a high risk of bias. In addition, it was observed that 21% (6/28) of the CTs had a high risk of bias for conflict of interest. Conclusion: The biases present in the CT cited as a reference for the TN referring to the DOAC request are significant and compromise their quality (AU).

Objetivo: Avaliar e classificar os riscos de vieses dos ensaios clínicos (EC) que compõem as NTs referentes à solicitação dos DOAC. Métodos: As NTs relacionadas à solicitação dos DOAC apixabana, dabigatrana, edoxabana e rivaroxabana foram selecionadas no website e-NatJus e, após exclusão das referências duplicadas, foi realizada uma análise dos EC utilizados para a redação das mesmas. O risco de viés dos EC (baixo, alto ou viés incerto) foi avaliado utilizando a ferramenta Cochrane Risk of Bias e os resultados foram adicionados no Review Manager 5.4. Resultados: Foram selecionadas 181 NTs, analisados 236 artigos e após aplicação dos critérios de inclusão, resultou em 28 EC analisados na íntegra. Nenhum dos EC ficou isento de viés. A maioria dos EC, 71% (20/28), apresentou baixo risco de viés em relação ao viés de atrito e viés de relato. Por outro lado, 61% (17/28) dos estudos não controlaram o viés de seleção, performance e detecção, uma vez que apresentam incertezas e alto risco de viés. Além disso, foi observado que 21% (6/28) dos EC apresentaram alto risco de viés para conflito de interesses. Conclusão: Os vieses presentes nos EC citados como referência das NT referentes a solicitação dos DOAC são significativos e comprometem a sua qualidade (AU).

Comparing follow-up of patients with vitamin K antagonists in a health center: pre- and post-COVID-19 pandemic / Comparação do seguimento de doentes hipocoagulados com antagonistas da vitamina K numa unidade de saúde: pré e pós pandemia COVID-19

Introduction and objectives: During the COVID-19 pandemic, the follow-up of patients treated with vitamin K antagonists (VKAs) may have been affected. This study aims to compare how these patients were monitored pre- and post-COVID-19 pandemic and understand the impact of non-face-to-face appointments on their follow-up. Methods: We conducted a retrospective cohort study in a Portuguese Health Center. The study included patients treated with VKAs and followed at the Health Center for international normalized ratio (INR) monitoring between March 2019 and March 2021. Data collected: sex, age, type of VKA; INR; date of INR assessment, type of appointment (face-to-face or phone/e-mail). Rosendaal's method was used to calculate pre-COVID-19 and post-COVID-19 time in therapeutic range (TTR). Good TTR control was defined if values ≥ 70%. Results: 44 patients were included. The mean TTR in the pre-COVID-19 period was 64.55% (95% CI: 58.10 - 71.00%). The post-COVID-19 mean was slightly higher (+ 2.26%), 66.81% (95% CI: 59.66 - 73.97%), but the difference was not statistically significant (p = 0.576). The use of non-face-to-face appointments did not contribute to worsening post-pandemic TTR, show-ing no lower follow-up than during pre-pandemic period in which all contacts were face-to-face [CI (95%) -0.397 - 0.196 for a reference range -0.489 - 0.693]. Conclusions: The TTR value in both periods was similar and lower than the value defined for effective hypocoagulation. The use of non-face-to-face consultation in the post-COVID-19 period does not seem to have influenced the quality of hypocoagulation (AU).

Introdução e objetivos: Durante a pandemia COVID-19 o acompanhamento de doentes medicados com antagonistas da vitamina K (AVKs) pode ter sido afetado. Este estudo pretende comparar a forma como estes doentes foram monitorizados antes e depois da pandemia COVID-19 e compreender o impacto da consulta não presencial no seu seguimento. Métodos: Estudo de coorte retrospetivo num Centro de Saúde em Portugal. O estudo incluiu doentes tratados com AVKs e seguidos no Centro de Saúde para monitorização do International Normalized Ratio(INR) entre março de 2019 e março de 2021. Dados recolhidos: sexo, idade, tipo de AVK; INR; data da avaliação do INR, tipo de consulta (presencial ou por telefone/e-mail). Foi utilizado o método de interpolação linear de Rosendaal para calcular o tempo em intervalo terapêutico (TTR) pré- e pós-COVID-19. Foi definido um bom controle se valores de TTR ≥ 70%. Resultados: Foram incluídos 44 doentes. A média de TTR no período pré-COVID-19 foi de 64,55% (95% IC: 58,10 - 71,00%). A média pós-COVID-19 foi ligeiramente superior (+ 2,26%), 66,81% (95% IC: 59,66 - 73,97%), mas a diferença não foi estatisticamente significativa (p = 0,576). A utilização da consulta não presencial não contribuiu para o agravamento do TTR no período pós-pandemia, não mostrando um seguimento inferior ao do período pré-pandemia em que todos os contatos foram presenciais [IC (95%) -0,397 - 0,196 para um intervalo de referência -0,489 - 0,693]. Conclusões: O valor de TTR em ambos os períodos foi semelhante e inferior ao valor definido para hipocoagulação eficaz. A utilização da consulta não presencial no período pós-COVID-19 não parece ter influenciado a qualidade da hipocoagulação (AU).

Manejo perioperatorio de medicación anticoagulante y antiagregante antiplaquetaria en radiología intervencionista / Perioperative management of anticoagulants and antiplatelets agents in interventional radiology

Resumen El número de personas en tratamiento con fármacos anticoagulantes o antiplaquetarios está en crecimiento constante debido al aumento de la supervivencia de los pacientes con fibrilación auricular, válvulas cardiacas mecánicas o que han sufrido un evento isquémico o trombótico agudo. Cuando estos pacientes necesitan un procedimiento radiológico intervencionista que acarrea riesgo de sangrado, es necesario analizar el riesgo trombótico del paciente al interrumpir la medicación frente al riesgo hemorrágico del procedimiento para tomar la decisión más adecuada en cada caso. Por tanto, es una decisión individualizada y supone un desafío para los/as radiólogos/as que realicen estas técnicas. Nuestro objetivo en esta revisión es mostrar las recomendaciones actuales sobre el manejo perioperatorio de la medicación anticoagulante y antiplaquetaria, adaptada al intervencionismo radiológico.

Abstract The number of people treated with anticoagulant or antiplatelet agents is constantly growing due to the increased survival of patients with atrial fibrillation, mechanical cardiac valves or who have suffered an acute thrombotic or ischemic event. When these patients need an interventional radiological procedure that carries a risk of bleeding, it is necessary to analyze the thrombotic risk of the patient when interrupting the medication against the hemorrhagic risk of the procedure, to make the most appropriate decision in each case. Therefore, it is an individualized decision, and it is a challenge for radiologists who perform these techniques. Our goal in this review is to update the current recommendations on the perioperative management of anticoagulant and antiplatelet agents, adapted to the radiological interventionism.

Outcomes of recurrent stroke in patients with atrial fibrillation according to presumed etiology / Desfecho de AVC recorrente em pacientes com fibrilação atrial de acordo com etiologia presumida

Abstract Background Atrial fibrillation (AF) is a potent risk factor for stroke. The presence of competing etiologies can modify disease outcomes and demand different treatment strategies. Objective The primary purpose of the study was to examine the differences in outcomes for patients with AF admitted with a recurrent stroke, stratified according to the presumed etiology of the stroke. Methods We analyzed AF patients admitted for a recurrent ischemic stroke in an academic comprehensive stroke center. Recurrent strokes were categorized as "Cardioembolic", meaning AF without any competing mechanism, versus "Undetermined" etiology due to competing mechanisms. We used logistic regression to test the association between recurrent stroke etiology and favorable outcome (discharge home), after accounting for important covariates. Results We included 230 patients, with a mean age 76.9 (SD ± 11.3), 52.2% male, median National Institute of Health Stroke Scale (NIHSS) score of 7 (IQR 2-16). Patients with cardioembolic stroke (65.2%) had higher median NIHSS 8.5 (3-18) versus 3 (1-8) and were more likely to be treated with reperfusion therapies. The favorable outcome was reached by 64 patients (27.8%), and in-hospital mortality was 15.2% overall. After adjustment, there was no difference in outcome between patients with cardioembolic versus undetermined stroke etiology (odds ratio for discharge home: 1.41; 95% CI: 0.65-3.15). Conclusions In this single-center sample of AF patients with history of stroke, there was no difference in discharge outcomes between those with cardioembolic and those with undetermined stroke etiology. This question warrants examination in larger samples to better understand the importance of the stroke mechanism and secondary prophylaxis.

Resumo Antecedentes Fibrilação atrial (FA) é um fator de risco importante para AVC. A presença de mecanismos concorrentes para o AVC pode modificar o desfecho e demandar estratégias de tratamento diferentes. Objetivo O objetivo primário do estudo foi examinar diferenças no desfecho de pacientes com FA admitidos por um AVC recorrente, sendo estratificados de acordo com a etiologia presumida do AVC. Métodos Nós analisamos pacientes com FA admitidos por conta de AVC recorrente em um centro acadêmico terciário de AVC. Os casos de AVC recorrentes foram classificados como "Cardioembólicos", sendo FA sem outros mecanismos alternativos, versus aqueles de etiologia "Indeterminada" por conta de mecanismos concorrentes. Foi usada regressão logística para testar a associação entre a etiologia do AVC recorrente e desfecho favorável (alta direto para casa) após controle para covariáveis importantes. Resultados Nós incluímos 230 pacientes, com uma idade média 76,9 anos (DP ± 11.3), 52.2% homens, com um escore mediano do National Institute of Health Stroke Scale (NIHSS) de 7 (IIQ 2-16). Pacientes com AVC cardioembólicos (65,2%) tiveram um escore de NIHSS mediano mais alto 8,5 (3-18) versus 3 (1-8), e com maior chance de tratamento com terapias de reperfusão. O desfecho favorável ocorreu em 64 pacientes (27,8%) e a mortalidade institucional foi de 15,2% no total. Após ajustes, não encontramos diferença no desfecho entre pacientes com AVC cardioembólico versus AVC de etiologia indeterminada (odds ratio para alta para casa: 1,41; 95% IC: 0,65-3,15). Conclusões Nessa amostra de pacientes com FA e história de AVC recorrente de centro único, não houve diferença no desfecho de alta entre aqueles com AVC cardioembólico e aqueles com etiologia indeterminada. Essa questão deve ser examinada em amostras maiores para melhor compreender a importância do mecanismo do AVC e a profilaxia secundária.

Perspectiva neurológica en la elección del anticoagulante oral directo para la prevención del accidente cerebrovascular en fibrilación auricular / Neurological perspective in the choice of direct oral an ticoagulants for prevention of stroke in atrial fibrillation

Resumen La fibrilación auricular no valvular (FA) es la arritmia con potencial embolígeno más prevalente y una de las principales y crecientes causas de accidente cerebrovas cular isquémico (ACVi). El principal objetivo del uso de la anticoagulación en pacientes con FA es la prevención del ACVi. Hasta hace poco tiempo, la anticoagulación con antagonistas de la vitamina K (AVKs) era la única opción disponible. Los anticoagulantes orales directos (DOACs) como el inhibidor directo de la trombina, dabigatrán, o los inhibidores directos del factor Xa, rivaroxabán, apixa bán y edoxabán, tienen un perfil de efectividad/seguridad más favorable en comparación con los AVKs. No existen estudios que comparen la efectividad de los DOACs entre sí. La elección del DOAC depende de múltiples factores específicos del paciente, preferencias del médico, costos y accesibilidad. Entre 1-2% de los pacientes correctamente tratados con un DOAC intercurre con un ACVi cada año. La posibilidad de contar con un agente reversor debería ser tenida en cuenta al momento de la elección del DOAC, especialmente por el riesgo residual de ocurrencia de ACVi. En la actualidad, en nuestro país solo el dabigatrán cuenta con un agente reversor disponible y lo convierte en el único DOAC que no contraindica el uso de trombolisis intraveno sa con rtPA. Esta situación debería ser considerada en el momento de la elección del DOAC para la prevención de eventos tromboembólicos en pacientes con FA.

Abstract Non-valvular atrial fibrillation (AF) is the most preva lent arrhythmia with high embolic potential, and one of the main and growing causes of stroke. The main objec tive of anticoagulation in patients with AF is prevention of stroke. Until recently, anticoagulation with vitamin K antagonists (VKAs) was the only available option. Direct oral anticoagulants (DOACs), such as the direct thrombin inhibitor dabigatran, or the direct factor Xa inhibitors rivaroxaban, apixaban, and edoxaban, have a more favor able effectiveness/safety profile compared to VKAs. There are no studies comparing the efficacy of DOACs with each other. The choice of a DOAC arose from patient car achterictis, physician preferences, cost, and accessibility. Between 1-2% of patients correctly treated with a DOAC experience a stroke each year. The possibility of having a reversal agent should be taken into account when choos ing a DOAC, especially due to the residual risk of stroke occurrences even under DOACs. Currently, in our country only dabigatran has a reversing agent available, making it the only DOAC that does not contraindicate the use of intravenous thrombolysis. This should be taken into account when choosing the DOAC for the prevention of thromboembolic events in patients with AF.

Relato de caso de intoxicación con superwarfarinas: un desafío terapéutico

La intoxicación humana por rodenticidas anticoagulantes de acción prolongada, conocidos como superwarfarinas, provoca coagulopatía de prolongado manejo. Presentamos el caso de un hombre de 42 años que ingirió una dosis tóxica de rodenticida en un intento suicida, evolucionando con epistaxis, INR de 11,6 y necesidad de hospitalización. Durante 7 días se realizaron controles seriados de pruebas de coagulación, con optimización de diferentes dosis de suplementación de Vitamina K. El caso destaca la potencia y vida media prolongada (aproximadamente 6 semanas) de este tipo de anticoagulantes, hecho que requiere un control clínico regular y una adherencia al tratamiento satisfactoria.

Human intoxication by long-acting anticoagulant rodenticides, known as superwarfarins, causes coagulopathy that is difficult to manage. We present the case of a 42-year-old man who ingested a toxic dose of rodenticide in a suicide attempt, evolving with epistaxis, INR of 11.6, and needing hospitalization. For seven days, serial controls of coagulation tests were carried out, with optimization of different doses of Vitamin K supplementation. The case highlights this type of anticoagulant's potency and prolonged half-life (approximately six weeks), which requires regular clinical control and satisfactory treatment adherence.

Anticoagulación en enfermedad renal crónica G4-5 en una red de hospitales de Bogotá

Contexto: la anticoagulación en pacientes con enfermedad renal crónica es un reto terapéutico debido a que la evidencia médica es escasa y los beneficios son discutibles, además, el riesgo de sangrado en estos pacientes es mayor. Objetivo: describir los pacientes con enfermedad renal G4-5 que recibieron terapia anticoagulante oral durante por lo menos tres meses en la Subred Centro Oriente de Bogotá. Metodología: estudio analítico de pacientes con enfermedad renal crónica G4-5 en un hospital de referencia entre enero del 2018 y diciembre del 2021, en el cual se analizaron variables sociodemográficas, clínicas y se realizó una regresión logística sobre los anticoagulantes y la frecuencia de eventos (hemorrágicos o embólicos). Resultados: se evaluó a 75 pacientes con diagnóstico de enfermedad renal crónica G4-5 anticoagulados, donde el anticoagulante más usado fue warfarina (76 %), seguido de apixabán (16 %) y rivaroxabán (8 %). El sangrado mayor se presentó con warfarina (8,47 %), apixabán (10%) y rivaroxabán (16,6 %). No se encontraron diferencias significativas entre el sangrado mayor con warfarina (OR: 2,8; IC 95 %: 0,46-16,9; p = 0,262) y rivaroxabán (OR: 1,86; IC 95 %: 0,18-18,7; p = 0,596), además, el sangrado no mayor y clínicamente relevante fue del 28,9 % con warfarina. Solo se presentó una complicación trombótica en un paciente que recibió rivaroxabán. Conclusiones: en los pacientes con enfermedad renal G4-5 que recibieron warfarina y los anticoagulantes orales directos no se encontraron diferencias significativas en cuanto a la presentación de sangrado mayor y no mayor, clínicamente relevantes.

Background: Anticoagulation in patients with chronic kidney disease is a therapeutic challenge since the medical evidence is scarce and the benefits are debatable since the risk of bleeding in these patients is greater. Purpose: To describe patients with G4-5 kidney disease who received oral anticoagulant therapy for at least 3 months in the central-eastern subnetwork of Bogotá. Methodology: Analytical study of patients with G4-5 chronic kidney disease, in a reference hospital between January 2018 and December 2021, in which sociodemographic and clinical variables were analyzed, and a logistic regression was performed on anticoagulants and the frequency of events (hemorrhagic or embolic). Results: 75 anticoagulated patients diagnosed with G4-5 chronic kidney disease were evaluated. The most commonly used anticoagulant was warfarin (76%), apixaban (16%), and rivaroxaban (8%). Major bleeding occurred with warfarin (8.47%), apixaban (10%), and rivaroxaban (16.6%). There are no significant differences between major bleeding with warfarin (OR: 2.8; 95% CI: 0.46;16.9; p= 0.262), and rivaroxaban (OR: 1.86; 95% CI: 0.18;18.7; p=0.596). Clinically relevant non-major bleeding was 28.9% with warfarin. A thrombotic complication only occurred in one patient who received rivaroxaban. Conclusions: In patients with G4-5 kidney disease who received warfarin and direct oral anticoagulants, no significant differences were found in terms of the presentation of clinically relevant major and non-major bleeding.

Describing the Oral Health of Warfarin Users. A Short Report

Aim: To describe the burden of oral diseases and of self-reported periodontal disease of patients under Oral Anticoagulation Therapy (OAT) with warfarin. Methods: A cross-sectional study was conducted. Validated questionnaires assessed self-reported periodontal disease and demographic variables. After calibration (Kappa > 0.80), an examiner evaluated dental caries and the need for dental prostheses. Statistical analysis involved proportions and measures of central tendency. Results: The sample consisted of 158 individuals, with a mean age of 58.8 years (SD = 12.1), of which 62.7% of the participants were women. The average DMFT (Decayed, Missing, and Filled Teeth) index was 22.9 (SD = 7.6), with the missing component being the highest (Mean = 16.23). The use of maxillary prosthesis (53.2%) was higher than mandibular (32.3%). The need for mandibular prosthesis reached 66.5%. The percentage of participants that referred gum disease, tooth migration, and tooth mobility was 29.6%, 37.4%, and 30.4%, respectively. Conclusions: The burden of oral diseases among individuals undergoing OAT is worrisome.

Objetivo: Describir la carga de enfermedades bucales y la enfermedad periodontal autorreportada de pacientes en tratamiento con anticoagulación oral con warfarina. Métodos: Se realizó un estudio transversal. Los cuestionarios validados evaluaron la enfermedad periodontal autoinformada y las variables demográficas. Después de la calibración (Kappa> 0.80), un examinador evaluó la caries dental y la necesidad de prótesis dentales. El análisis estadístico involucró proporciones y medidas de tendencia central. Resultados: La muestra estuvo formada por 158 individuos, con una edad media de 58.8 años (DE = 12.1), de los cuales el 62.7% de los participantes eran mujeres. El índice CPOD promedio fue de 22.9 (DE = 7.6), siendo el componente perdido el que más contribuyó al índice (Media = 16.23). El uso de prótesis maxilar (53.2%) fue mayor que el de prótesis mandibular (32.3%). La necesidad de prótesis mandibular alcanzó el 66.5%. El porcentaje de participantes que informaron enfermedad de las encías, migración de los dientes y movilidad de los dientes fue del 29.6%, 37.4% y 30.4%, respectivamente. Conclusiones: Las enfermedades bucales y la necesidad de rehabilitación oral entre los individuos sometidos a anticoagulación oral con warfarina fue motivo de preocupación.

Hematoma de la vaina de los rectos abdominales en el curso de la COVID-19

Introducción: El hematoma espontáneo de la pared abdominal constituye una entidad clínica poco frecuente en la práctica médica. En el contexto de la COVID-19 el hematoma intraabdominal se presentó como complicación de la terapéutica impuesta y no fue tomado en consideración al realizar el diagnóstico diferencial del dolor abdominal e hipotensión arterial. Objetivo: Reportar la aparición de hematoma de la vaina de los rectos abdominales como complicación del empleo de anticoagulantes en el curso del tratamiento de la COVID-19. Caso clínico: Se presenta una paciente de 71 años de edad con la COVID-19 que se encontraba con tratamiento anticoagulante y comenzó con dolor abdominal agudo, con ecografía abdominal que no fue concluyente, se realizó laparotomía y se encontró gran hematoma en el espacio de Retzius. Evolucionó favorablemente y es dada de alta a los 7 días. Conclusiones: El diagnóstico transoperatorio conjuntamente con el drenaje del hematoma y la fluidoterapia oportuna permitió una evolución favorable y la recuperación de la paciente.

Introduction: Spontaneous abdominal wall hematoma is a rare clinical entity in medical practice. In the context of COVID-19, intra-abdominal hematoma presented as a complication of the imposed therapy and was not taken into consideration when making the differential diagnosis of abdominal pain and arterial hypotension. Objective: To report the appearance of rectus abdominis sheath hematoma as a complication of the use of anticoagulants in the course of COVID-19 treatment. Clinical case: A 71-year-old patient with COVID-19 is presented who was receiving anticoagulant treatment and began with acute abdominal pain, with abdominal ultrasound that was inconclusive, laparotomy was performed and a large hematoma was found in the abdominal Retzius space. She evolved favourably and is discharged after 7 days. Conclusions: The trans-operative diagnosis together with the drainage of the hematoma and the opportune fluid therapy allowed a favourable evolution and the recovery of the patient.

Factores de riesgo cardiometabólico y tratamiento antitrombótico en población mexicana con fibrilación auricular e insuficiencia cardiaca con fracción de expulsión reducida / Cardiometabolic risk factors and antithrombotic treatment in a Mexican population with atrial fibrillation and heart failure with reduced ejection fraction

Resumen Introducción: La insuficiencia cardiaca en pacientes con fibrilación auricular no valvular (FANV) es de dos a tres veces más frecuente que en individuos sin FANV. Objetivo: Identificar los factores de riesgo cardiometabólico (FRCM) y el tratamiento antitrombótico de pacientes con FANV e insuficiencia cardiaca con fracción de expulsión reducida (IC-FEr), y determinar si existen diferencias conforme al sexo. Métodos: En forma global y de acuerdo con el sexo se analizaron FRCM, riesgo protrombótico, riesgo de sangrado y terapia antitrombótica. Resultados: De 1423 pacientes con FANV, 336 tuvieron IC-FEr. Las mujeres promediaron mayor edad que los hombres. No hubo diferencia entre los sexos respecto al tipo de FANV o uso de anticoagulantes orales directos. La hipertensión arterial sistémica fue más frecuente en mujeres. Un 3.6 % de los pacientes reportó antecedente de ataque isquémico transitorio y 10 % de evento vascular cerebral, sin diferencias en cuanto al sexo. El porcentaje de hombres con riesgo embólico elevado fue mayor, pero sin tratamiento antitrombótico, en comparación con las mujeres. Conclusiones: Se encontraron diferencias significativas de acuerdo con el sexo en pacientes con FANV e IC-FEr, tanto en FRCM y algunas comorbilidades, como en el tratamiento antitrombótico de acuerdo con el riesgo embólico y de sangrado.

Abstract Introduction: Heart failure in patients with non-valvular atrial fibrillation (NVAF) is two to three times more common than in individuals without NVAF. Objective: To identify cardiometabolic risk factors (CMRF) and antithrombotic treatment in patients with NVAF and heart failure with reduced ejection fraction (HFrEF), and to determine if there were differences according to gender. Methods: CMRF, pro-thrombotic risk, bleeding risk, and antithrombotic therapy were globally analyzed and according to gender. Results: Out of 1,423 patients with NVAF, 336 had HFrEF. On average, females were older than males. There was no difference between genders with regard to the type of NVAF or direct oral anticoagulants use. Hypertension was more common in women. History of transient ischemic attack was reported in 3.6% of the patients and cerebrovascular event in 10%, without differences in terms of gender. The percentage of men with elevated embolic risk was higher, but without antithrombotic treatment, in comparison with women. Conclusions: Significant differences were found according to gender in patients with NVAF and HFrEF, both in CMRF and some comorbidities, as well as in antithrombotic treatment according to embolic and bleeding risk.

Plantar vein thrombosis: an uncommon cause of plantar foot pain / Trombose venosa plantar: uma causa incomum de dor em região plantar

INTRODUCTION: Plantar vein thrombosis is a rare condition that can lead to pain, edema, and walking difficulties. It presents a series of predisposing factors, such as recent surgeries, the use of oral contraceptives, and local trauma, among others. Imaging tests are essential for the right diagnosis, and ultrasonography is the modality of choice. As for treatment, there is no consensus in the literature. REPORT: Case of a 30-year-old patient who sought emergency medical care complaining of sudden severe pain in the plantar region of her right foot with walking difficulties. On physical examination, hyperalgesia was observed in the plantar region, irradiating to the calf, associated with swelling. Color Doppler imaging identified an acute thrombus in the medial plantar vein. Rivaroxaban was initially prescribed and replaced by acetylsalicylic acid after three months. The treatment was effective, and the patient was discharged after 11 months. CONCLUSION: Plantar vein thrombosis is a rare condition and has a wide range of differential diagnoses so physicians must maintain a high level of clinical suspicion. To improve diagnosis and treatment, it would be necessary to include plantar veins in the investigation protocols of patients suspected of having Deep Venous Thrombosis, besides additional clinical research for improving treatment.

INTRODUÇÃO: A trombose de veias plantares é uma condição rara que pode cursar com dor, edema e dificuldade na deambulação. Apresenta uma série de fatores predisponentes, como cirurgias recentes, uso de anticoncepcional oral, trauma local, entre outros. A realização de exame de imagem é essencial para o diagnóstico, sendo a ultrassonografia a modalidade de escolha. Quanto ao tratamento, não há consenso na literatura. RELATO: Relatamos o caso de uma paciente de 30 anos que procurou atendimento médico de urgência com queixa de dor de forte intensidade, súbita, em região plantar do pé direito com dificuldade de deambulação. Ao exame físico, observou-se hiperalgesia em região plantar com irradiação para panturrilha, associada a empastamento da mesma. O ecodoppler colorido identificou trombo agudo em veia plantar medial. Optou-se pela prescrição de rivaroxabana, a qual foi substituída por ácido acetilsalicílico após três meses. A paciente evoluiu bem e recebeu alta do tratamento após 11 meses. CONCLUSÃO: A trombose de veias plantares é rara e tem uma alta gama de diagnósticos diferenciais, de forma que o profissional médico deve manter um alto nível de suspeição clínica. Para aperfeiçoar seu diagnóstico e tratamento, seria necessária a inclusão das veias plantares aos protocolos de investigação de pacientes com suspeita de Trombose Venosa Profunda, e pesquisas clínicas que elucidassem os melhores métodos terapêuticos.

Successful use of rivaroxaban achieving therapeutic anti-factor xa levels in a morbidly obese patient with acute intermediate-high risk pulmonary embolism / Uso bem-sucedido de rivaroxabana com níveis terapêuticos de antifator xa em paciente com obesidade mórbida e embolia pulmonar aguda de risco intermediário-alto

Abstract Direct oral anticoagulants (DOACs) have become the standard of care for acute and long-term therapy for venous thromboembolism (VTE) due to their efficacy and safety profiles. The 2021 International Society on Thrombosis and Haemostasis guidelines recommend using standard DOAC dosages in patients with BMI >40 kg/m2 or weight >120 kg. Use of DOACs remains uncertain in morbidly obese patients with VTE, including acute PE. A morbidly obese woman in her 30s who presented with acute worsening of dyspnea was diagnosed with acute intermediate-high risk acute pulmonary embolism and concomitant proximal deep vein thrombosis, constituting a clinically challenging scenario for treating her with rivaroxaban. Standard doses of rivaroxaban for acute and extended phase treatment of venous thromboembolism in individuals with morbid obesity at BMI>70 kg/m2 may be effective, and safe.

Resumo Devido à sua eficácia e aos seus perfis de segurança, os anticoagulantes orais diretos (DOACs) tornaram-se o padrão de cuidado para a terapia aguda e de longo prazo de tromboembolismo venoso (TEV). As diretrizes da Sociedade Internacional de Trombose e Hemostasia de 2021 recomendam o uso de dosagens padrão de DOACs em pacientes com índice de massa corporal (IMC) > 40 kg/m2 ou peso > 120 kg. O uso de DOACs em pacientes com obesidade mórbida e TEV, incluindo embolia pulmonar aguda, ainda não foi esclarecido. Uma mulher com obesidade mórbida na faixa dos 30 anos que apresentou piora aguda da dispneia foi diagnosticada com embolia pulmonar aguda de risco intermediário-alto e trombose venosa profunda proximal concomitante, com o cenário clínico desafiador de tratá-la com rivaroxabana. Doses padrão de rivaroxabana para tratamento e recorrência de tromboembolismo venoso em indivíduos com obesidade mórbida e IMC > 70 kg/m2 podem ser eficazes e seguras.