[Oral Anticoagulation and the Incidence of Stroke Associated with Atrial Fibrillation in Mainland Portugal: A Modelling Study]. / Anticoagulação Oral e Incidência de Acidente Vascular Cerebral Associado a Fibrilhação Auricular em Portugal Continental: Um Estudo de Modelação.

INTRODUCTION: Atrial fibrillation is the most prevalent persistent dysrhythmia, contributing to a significant social and economic burden. The main objective of this study was to evaluate the association between oral anticoagulant use and the incidence of stroke associated with atrial fibrillation, in mainland Portugal. METHODS: The number of episodes of inpatient care with a main diagnosis of stroke and an additional diagnosis of atrial fibrillation, occurring monthly between January 2012 and December 2018, in individuals aged 18 years or over, was extracted from the hospital morbidity database. The number of patients with an atrial fibrillation code documented in this database was used as a proxy for the prevalence of known atrial fibrillation. The number of anticoagulated patients was estimated from total medicine sales of vitamin K antagonists and novel oral anticoagulants (apixaban, dabigatran, edoxaban and rivaroxaban) in mainland Portugal. Descriptive analyses were performed, and seasonal autoregressive integrated moving average (SARIMA) models were built using the R software. RESULTS: The mean number of episodes of stroke per month was 522 (± 57). The number of anticoagulated patients increased gradually from 68 943 to 180 389 per month. The decreasing trend in the number of episodes has been observed since 2016, along with the increased use of new oral anticoagulants compared to vitamin K antagonists. The final model indicated that the increase in oral anticoagulation use between 2012 and 2018, in mainland Portugal, was associated with a decrease in the number of episodes of stroke associated with atrial fibrillation. It was estimated that the shift in the type of anticoagulation used, between 2016 and 2018, was associated with a reduction of 833 episodes of stroke in patients with atrial fibrillation (4.2%). CONCLUSION: The use of oral anticoagulation was associated with a reduced incidence of stroke in patients with atrial fibrillation in mainland Portugal. This reduction was more relevant in the period between 2016 and 2018, and is probably related with the introduction of the novel oral anticoagulants.

Introdução: A fibrilhação auricular é a disritmia persistente mais prevalente, tendo um importante impacto social e económico. O objetivo principal deste estudo foi avaliar a associação entre a utilização de anticoagulantes orais e a incidência de acidente vascular cerebral associado a fibrilhação auricular, em Portugal continental. Métodos: A base de dados de morbilidade hospitalar foi utilizada para a contabilização dos episódios de internamento com um diagnóstico principal de acidente vascular cerebral e um diagnóstico adicional de fibrilhação auricular, ocorridos durante cada mês do período em análise (janeiro de 2012 a dezembro de 2018), em indivíduos com idade igual ou superior a 18 anos. O número de doentes com registo de fibrilhação auricular presentes nesta base de dados foi utilizado como um proxy da prevalência de fibrilhação auricular conhecida. O número de doentes anticoagulados foi estimado a partir das estatísticas das vendas de antagonistas da vitamina K e novos anticoagulantes orais (apixabano, dabigatrano, edoxabano e rivaroxabano) em Portugal continental. Foi realizada uma análise descritiva das variáveis, construindo-se depois modelos auto-regressivos integrados de médias móveis sazonais (seasonal autoregressive integrated moving average, SARIMA), com recurso ao software R. Resultados: Ocorreram, em média, 522 (± 57) episódios de acidente vascular cerebral por mês. Verificou-se um aumento gradual do número de doentes anticoagulados, passando de 68 943 para 180 389, por mês. A tendência decrescente no número de episódios verificou-se a partir de 2016, a par da maior utilização dos novos anticoagulantes orais, comparativamente aos antagonistas da vitamina K. O modelo final estimado indicou que o aumento do consumo de anticoagulação oral entre 2012 e 2018 em Portugal continental foi associado a um decréscimo do número de acidentes vasculares cerebrais associados a fibrilhação auricular. Estimou-se que, entre 2016 e 2018, a mudança no tipo de anticoagulação se associou a uma redução de 833 episódios de acidentes vascular cerebrais em doentes com fibrilhação auricular (4,2%). Conclusão: A anticoagulação oral associou-se à redução da incidência de acidente vascular cerebral em doentes com fibrilhação auricular, em Portugal continental. Esta redução foi mais relevante no período 2016 a 2018, em provável relação com a introdução dos novos anticoagulantes orais.

Pregnancy Outcomes in Women With Mechanical Valve Prostheses Using Vitamin K Antagonist Therapy: The Experience of the Salam Centre for Cardiac Surgery in Sudan.

Pregnancy and childbirth on anticoagulants after mechanical heart valve replacement present a high risk of complications for both mother and baby. On top of pregnancy worsening the mother's cardiac function, anticoagulant therapy itself is a crucial problem. A safe and effective anticoagulation regimen for both mother and fetus is not possible. The most effective drugs for preventing valve thrombosis are VKAs, whose dosage needs to be adjusted with frequent INR checks. Moreover, VKAs can have embryopathic and teratogenic action. Patients in follow-up and anticoagulant treatment at the Salam Centre for Cardiac Surgery in Sudan live spread out over a large area where transport to the Center is generally difficult; pregnancy treatment has, therefore, been adapted to the limitations of reality. Pregnancy is discouraged and contraception and therapeutic abortion are recommended, but this guidance frequently goes unheeded. Here we describe maternal and fetal outcomes in 307 consecutive pregnancies recorded by staff at the oral anticoagulant clinic (OAC) from April 2017 to November 2021. Out of 307 pregnancies, there were 15 maternal deaths (4.9%), 24 thrombotic events (7.8%) and 22 major bleedings (7.2%). Fifty pregnancies (16.3%) were terminated by therapeutic abortion. Only 47.6% of pregnancies had good maternal and neonatal outcomes. Data clearly show that, due to the complexity of pregnancy in women with mechanical heart valves and the scarcity of tertiary healthcare services in the area where patients live, maternal mortality is at an unacceptable level and requires a structured, multi-disciplinary intervention.

Influence of using recommended radiological criteria on MDCT-angiography diagnosis of single isolated subsegmental pulmonary embolism.

OBJECTIVES: We assessed the rate of false-positive diagnoses of MDCT-pulmonary angiography (MDCT-A) in patients with single isolated subsegmental pulmonary embolism (SISSPE). METHODS: All patients who underwent MDCT-A between 2006 and 2017 for ruling out acute pulmonary embolism (PE) and received an initial diagnosis of SISSPE were included. The MDCT-A of these patients were reviewed retrospectively by four experienced thoracic radiologists, who applied radiological criteria recommended by the American College of Chest Physicians Antithrombotic Guidelines (ACCP 2016) for the diagnosis of SISSPE. Data extracted from medical records were history of venous thromboembolism (VTE), alternative diagnoses, other diagnostic studies for VTE, anticoagulation, bleeding complications, and VTE over the following 3 months. RESULTS: Of 3839 patients undergoing MDCT-A, PE was found in 1021 (26.6%) and SISSPE in 59 (1.5% overall and 5.8% of all patients with PE). An alternative diagnosis to PE was made on the basis of CT in 33 (55.9%) patients. Forty-one (69.5%) patients received anticoagulants, and major life-threatening bleeding complications occurred in 2, with one death. Recurrent PE was not documented in any patient with SISSPE. In the retrospective assessment of the 59 cases of SISSPE, 21 were negative for PE, with a false-positive rate of 35.6% (21/59); so the percentage of SISSPE cases after the revision was 3.7% of all patients with PE; 11 of these 21 patients received anticoagulation. CONCLUSIONS: Radiologists should be aware of the high rate of false-positives when making the diagnosis of SISSPE on MDCT-A without using strict diagnostic criteria. Misdiagnosis exposes patients to unnecessary anticoagulation. KEY POINTS: • Radiologist should be aware of the high rate of false-positive diagnoses of single isolated subsegmental pulmonary embolism (SISSPE) in MDCT-pulmonary angiography (MDCT-A) performed for ruling out pulmonary embolism. • Misdiagnosis of SISSPE in MDCT-A can be reduced by using strict diagnostic radiological criteria recommended by the American College of Chest Physicians Antithrombotic Guidelines. • Unnecessary anticoagulation therapy with potential severe bleeding complications may result from misdiagnosis of SISSPE.

Pharmacological Prophylaxis of Venous Thromboembolism in Terminally Ill Patients: A Need or Futility?

The aim of this case is to clarify the need to maintain the terminally ill oncological patients who have had a thrombotic event in the course of their underlying disease under antithrombotic therapy. This case addresses a 63-year-old man with stage IV gastric antrum adenocarcinoma, completely bed-ridden and anticoagulated with subcutaneous enoxaparin for more than a year, following deep venous thrombosis of the left lower limb. After reviewing the literature, it was found that, for end-of-life patients, anticoagulation seems to have little benefit as the main objective is not the extension of life itself, but rather the preservation of the best quality of life through practices that are well established in the relief of suffering.

O presente caso pretende clarificar qual a verdadeira necessidade de manter sob terapêutica anti-trombótica os doentes oncológicos terminais que tiveram um evento trombótico no decorrer da evolução da sua doença de base. O caso em questão aborda um doente de 63 anos com uma neoplasia do antro gástrico em estadio IV, totalmente acamado, hipocoagulado com enoxaparina subcutânea há mais de um ano, no seguimento de uma trombose venosa profunda no membro inferior esquerdo. Após revisão da literatura, constatou-se que em doentes em fim de vida, a anticoagulação parece ter pouco benefício, visto que o principal objetivo não é o prolongamento da vida, mas sim a preservação da melhor qualidade de vida possível através de práticas cuja evidência no alívio do sofrimento está bem documentada.

Papillary Fibroelastoma in Differential Diagnosis of Left Atrial Appendage Masses.

Papillary fibroelastomas are benign tumors that usually originate from cardiac valves but may have other endocardial origins. We report the cases of 2 patients in whom left atrial appendage masses were initially diagnosed as thrombus. They were treated for embolic stroke and their symptoms resolved; however, their left atrial appendage masses did not regress. After surgery, histologic analysis of the resected masses revealed papillary fibroelastoma in both cases. We discuss the diagnostic and therapeutic dilemmas encountered in patients with papillary fibroelastomas and cardiac masses other than thrombus.

Management of Atrial Fibrillation Following Cardiac Surgery: Observational Study and Development of a Standardized Protocol.

BACKGROUND: Postoperative atrial fibrillation (POAF) is the most common complication occurring after cardiac surgery. Guidelines for the management of this complication are scarce, often resulting in differences in treatment strategy use among patients. OBJECTIVE: To evaluate the management of POAF in a cardiac surgery department, characterize the extent of its variability, and develop a standardized protocol. METHODS: This was an observational retrospective study with data from patients who underwent cardiac surgeries with subsequent POAF between January 1, 2017, and June 1, 2018. We assessed the difference in the proportions of patients whose first POAF episodes were treated with a rate control (RaC) strategy, a rhythm control (RhC) strategy, and both among different hospital units. We also assessed the mean duration of POAF episodes, POAF recurrences, and the management of anticoagulation. RESULTS: Data from 97 patients were included in this study. The POAF management strategy differed significantly among the 3 types of hospital units (P = 0.001). Considering all POAF episodes (including all recurrences), 83 of the 97 patients (85.6%) received amiodarone as part of the RhC strategy. Anticoagulation was used in 58 (59.8%) patients and was suboptimal according to the study criteria in 29.5% of the patients included. Based on these results, a hospital working group developed a standardized protocol for POAF management. CONCLUSIONS AND RELEVANCE: POAF management was heterogeneous at our institution. This article highlights the need for clear practice guidelines based on large prospective studies to provide care according to best practices.

Inhibition of thrombin generation 12 hours after intake of direct oral anticoagulants.

BACKGROUND: The residual antithrombotic activity 12 hours after intake of direct oral anticoagulants (DOACs) is of clinical relevance in the setting of bleeding or urgent surgery. OBJECTIVE: To evaluate the effects of DOACs on thrombin generation 12 hours after DOAC intake in comparison to baseline and a healthy control group. METHODS: Eighty patients were recruited, 20 patients for each approved DOAC: apixaban, edoxaban, rivaroxaban, and dabigatran. The patients were either to be put on anticoagulation for the first time or had stopped taking oral anticoagulation for at least 48 hours. Blood plasma was sampled before (baseline) and 12 hours after starting DOAC for quantification of drug levels and thrombin generation assayed using an automated system (ST Genesia). Sixty-one blood donors served as control group. RESULTS: The factor Xa inhibitors significantly increased lag time (137%-219%) and reduced thrombin peak (47%-76%) and velocity index (17%-44%) after 12 hours compared to baseline. Dabigatran showed prolongation of lag time to 133% and time to peak to 119%. All patients had residual antithrombotic activity, with reduced thrombin generation parameters 12 hours after DOAC intake compared to baseline and to the healthy control group. This effect remained significant in patients with low residual DOAC plasma levels <50 ng/mL. CONCLUSION: Thrombin generation remains reduced 12 hours after DOAC intake. While thrombin peak is particularly modified by factor Xa inhibitors, all DOACs prolong the lag time and time to thrombin peak. In the setting of bleeding or urgent surgery, the automated thrombin generation assay may assist in decision making and antidote administration.

Safety of Catheter Ablation of Atrial Fibrillation Under Uninterrupted Rivaroxaban Use / Segurança da Ablação por Cateter de Fibrilação Atrial sob Uso Ininterrupto de Rivaroxabana

Abstract Background: Atrial fibrillation (AF) ablation under uninterrupted warfarin use is safe and recommended by experts. However, there is some controversy regarding direct-acting oral anticoagulants for the same purpose. Objective: To evaluate the safety of AF ablation under uninterrupted anticoagulation with rivaroxaban. Methods: A series of 130 patients underwent AF radiofrequency ablation under uninterrupted rivaroxaban use (RIV group) and was compared to a control group of 110 patients under uninterrupted warfarin use (WFR group) and therapeutic International Normalized Ratio (INR). We analyzed death, rates of thromboembolic events, major and minor bleedings, activated clotting time (ACT) levels, and heparin dose in the procedure. The ablation protocol basically consisted of circumferential isolation of the pulmonary veins guided by electroanatomic mapping. It was adopted a statistical significance of 5%. Results: The clinical characteristics of the groups were similar, and the paroxysmal AF was the most frequent type (63% and 59%, RIV and WFR groups). A thromboembolic event occurred in the RIV group. There were 3 patients with major bleeding (RIV = 1 and WFR = 2; p = 0.5); no deaths. Basal INR was higher in the WFR group (2.5 vs. 1.2 ± 0.02; p < 0.0001), with similar basal ACT levels (123.7 ± 3 vs. 118 ± 4; p= 0, 34). A higher dose of venous heparin was used in the RIV group (9,414 ± 199 vs. 6,019 ± 185 IU; p < 0.0001) to maintain similar mean ACT levels during the procedure (350 ± 3 vs. 348.9 ± 4; p = 0.79). Conclusion: In the study population, AF ablation under uninterrupted rivaroxaban showed a safety profile that was equivalent to uninterrupted warfarin use with therapeutic INR.

Resumo Fundamento: A ablação de fibrilação atrial (FA) sob uso ininterrupto de varfarina é segura e recomendada por especialistas. Entretanto, há controvérsia quanto aos anticoagulantes orais de ação direta para o mesmo fim. Objetivo: Avaliar a segurança em realizar ablação de FA sob anticoagulação ininterrupta com rivaroxabana. Métodos: Uma série de 130 pacientes foi submetida à ablação com radiofrequência da FA sob uso ininterrupto de rivaroxabana (grupo RIV) e comparada a um grupo-controle de 110 pacientes que a fizeram sob uso ininterrupto de varfarina (grupo VRF) e relação normatizada internacional (RNI) terapêutica. Analisamos morte, taxas de eventos tromboembólicos, de sangramentos maiores e menores, níveis do tempo de coagulação ativado (TCA) e dose de heparina no procedimento. O protocolo da ablação consistiu basicamente em isolamento circunferencial das veias pulmonares guiado por mapeamento eletroanatômico. Significância estatística de 5% foi adotada. Resultados: As características clínicas dos grupos foram semelhantes e a FA paroxística mais frequente (63% e 59%, grupos RIV e VRF). Um evento tromboembólico ocorreu no grupo RIV. Foram três pacientes com sangramentos maiores (RIV = 1 e VRF = 2; p = 0,5); nenhum óbito. A RNI basal foi maior no grupo VRF (2,5 vs. 1,2 ± 0,02; p < 0,0001), com níveis de TCA basal semelhantes (123,7 ± 3 vs. 118 ± 4; p = 0,34). Maior dose de heparina venosa foi utilizada no grupo RIV (9.414 ± 199 vs. 6.019 ± 185 UI; p < 0,0001) para manter níveis médios de TCA semelhantes durante o procedimento (350 ± 3 vs. 348,9 ± 4; p = 0,79). Conclusão: Na população estudada, a ablação de FA sob rivaroxabana ininterrupta teve segurança equivalente à varfarina ininterrupta, com RNI terapêutica.

Left Atrial Appendage Transcatheter Occlusion with AMPLATZER™ Amulet™ Device: Real Life Data with Mid-Term Follow-Up Results / Oclusão Transcateter do Apêndice Atrial Esquerdo com a Prótese AMPLATZER™ Amulet™: Dados Reais com Resultados de Seguimento de Médio-Prazo

Abstract Background: Left atrial appendage (LAA) occlusion is an alternative therapy for atrial fibrillation patients who have high embolic risk and contraindications to anticoagulant therapy. Objective: To evaluate the feasibility, safety, and mid-term outcomes of percutaneous LAA occlusion, including device-related thrombosis. Methods: Sixty consecutive patients who had undergone percutaneous LAA occlusion with AMPLATZER™ Amulet™ device from September 2015 to March 2018 were enrolled. Patients were followed for 21 ± 15 months (median - 20 months, interquartile range - 9 to 27 months). The postprocedural assessment was done at the 1(st), 6(th), and 12(th) month. Patients were clinically evaluated, and transesophageal echocardiography was performed at each visit. We evaluated the condition of normality of variables using the Kolmogorov-Smirnov test. P-values < 0.05 were statistically significant. Results: The most common indication for the procedure was major bleeding with anticoagulants (n: 53, 88.3%). The procedure was completed successfully in 59 (98.3%) patients. Periprocedural mortality was observed in one patient. Postprocedural antiplatelet treatment was planned as dual or single antiplatelet therapy or low-dose anticoagulant therapy in 52 (88.1%), 2 (3.4%), and 5 (8.5%) patients, respectively. We found no clinically significant cerebrovascular events, device-related thrombus, or embolization in any patient during the follow-up. Two (3.4 %) patients presented significant peri-device leak (>3 mm) at the 1st month evaluation, which disappeared at the 12th month follow-up. Conclusion: We concluded that LAA occlusion using the Amulet™ LAA occluder can be performed with high procedural success and acceptable outcomes.

Resumo Fundamento: A oclusão do apêndice atrial esquerdo (AAE) é uma terapia alternativa para pacientes com fibrilação atrial que tenham alto risco embólico e contraindicações à terapia anticoagulante. Objetivo: Avaliar a viabilidade, segurança e resultados de médio prazo da oclusão percutânea do AAE, incluindo a trombose relacionada à prótese. Métodos: Sessenta pacientes consecutivos que foram submetidos à oclusão percutânea do AAE com a prótese AMPLATZER™ Amulet™ de setembro de 2015 a março de 2018 foram incluídos no estudo. Os pacientes foram acompanhados por 21 ± 15 meses (mediana - 20 meses, intervalo interquartílico - 9 a 27 meses). A avaliação pós-procedimento foi feita no 1º, 6º e 12º mês. Os pacientes foram examinados clinicamente e um ecocardiograma transesofágico foi realizado a cada visita. A condição de normalidade das variáveis foi avaliada por meio do teste de Kolmogorov-Smirnov. Os valores de p < 0,05 foram considerados estatisticamente significativos. Resultados: A indicação mais comum para o procedimento foi sangramento significativo com anticoagulantes (n: 53, 88,3%). O procedimento foi concluído com sucesso em 59 (98,3%) pacientes. Mortalidade peri-procedimento ocorreu em um paciente. A tratamento antiplaquetário pós-procedimento foi planejado como terapia antiplaquetária única ou dupla ou terapia anticoagulante de dose baixa em 52 (88,1%), 2 (3,4%) e 5 (8,5%) pacientes, respectivamente. Não foram encontrados eventos cerebrovasculares clinicamente significativos, trombo relacionado à prótese ou embolização nos pacientes durante o seguimento. Dois (3,4%) pacientes apresentaram vazamento peri-prótese significativo (>3 mm) na avaliação do 1º mês, que desapareceu no 12º mês de seguimento. Conclusão: Concluiu-se que a oclusão do AAE com o oclusor de AAE Amulet™ pode ser realizada com grande sucesso e resultados aceitáveis.

Tratamiento anticoagulante de la fibrilación auricular: usos y hábitos de los cardiólogos / Anticoagulant treatment of atrial fibrillation: uses and habits of cardiologists

RESUMEN Introducción: El tratamiento anticoagulante (TACO) es uno de los pilares en la prevención del accidente cerebrovascular. Objetivos: Conocer los hábitos de inicio del TACO, las dificultades en su continuidad y la incorporación de nuevos anticoagulantes orales (NAO). Analizar las conductas médicas. Material y Métodos: Encuesta cerrada a 107 cardiólogos. Resultados: En el inicio del TACO, el 52,3% adoptó una decisión con el paciente. Fueron reconocidos diversos inconvenientes para su continuidad y el 85% eligió al costo como la dificultad para incorporar NAO. En pacientes de alto riesgo y FA de tiempo incierto, el 83,2% eligió TACO y control de frecuencia cardíaca. En pacientes de bajo riesgo con FA paroxística, el 54,2% optó por el seguimiento. En pacientes con alto riesgo embolígeno y de sangrado, el 75,7% decidió TACO. Conclusiones: Se observó una tendencia a dar participación al paciente en el inicio del TACO y múltiples dificultades para sostenerlo. El precio de los NAO condiciona su uso. Las conductas médicas fueron concordantes con lo que indican las guías.

SUMMARY Introduction: The anticoagulant treatment (ACOT) is one of the pillars in the prevention of stroke. Objectives: To know the habits of initiation of ACOT, difficulties in its continuity, incorporation of new anticoagulants (NOA), and analyze medical behaviors. Material and Methods: Survey closed to 107 cardiologists. Results: At the beginning of ACOT, 52.3% cardiologists adopted a decision with the patient, several inconveniences were recognized for its continuity, and 85% chose the economic cost as a difficulty to incorporate NOA. In High risk and AF of uncertain time: 83.2% cardiologists chose ACOT and frequency control. In Low risk with paroxysmal AF: 54.2% opted for follow-up. In High risk embolism and bleeding: 75.7% decided ACOT. Conclusions: A tendency to involve the patient at the beginning of ACOT, and multiple difficulties to sustain it was observed. The use of NAO is conditioned by economic cost. The medical behaviors were consistent with the guidelines.

The risk of major bleeding in patients with suspected heparin-induced thrombocytopenia.

BACKGROUND: The presence of a hypercoagulable disorder such as heparin-induced thrombocytopenia (HIT) may protect against anticoagulant-associated bleeding. OBJECTIVES: To determine the incidence of major bleeding in patients with suspected HIT. METHODS: We performed a retrospective analysis of 310 patients suspected of having HIT from the Hospital of the University of Pennsylvania and an affiliated community hospital. We compared the cumulative incidence of major bleeding following suspicion for HIT by ultimate HIT status (HIT+ or HIT-) and exposure to an alternative anticoagulant (Tx+ or Tx-). Secondary outcomes included the incidence of new/progressive thrombosis and 30-day mortality. RESULTS: The incidence of major bleeding was high in the HIT+Tx+, HIT- Tx+, and HIT-Tx- groups (35.7%, 44.0%, and 37.3%, respectively). The time to first major bleeding event did not differ between groups (P = .24). Factors associated with increased risk of major bleeding included intensive care unit admission (HR 2.24, 95% CI 1.44-3.47), platelet count < 25 × 109 /L (HR 2.13, 1.10-4.12), and renal dysfunction (HR 1.56, 1.06-2.27); 35.7% of HIT+Tx+, 13.8% HIT-Tx+, and 9.3% of HIT-Tx- patients experienced new or progressive thrombosis. Mortality was similar among the three groups (26.2% HIT+Tx+, 34.5% HIT-Tx+, and 26.7% of HIT-Tx- [P = .34]). CONCLUSIONS: Among patients with suspected HIT, major bleeding was common regardless of HIT status. Contrary to our hypothesis, HIT+ patients were not protected from major bleeding. A better understanding of bleeding risk is needed to inform management decisions in patients with suspected HIT.

Trombosis venosa de sitio inusual: síndrome de Paget-Schroetter / Venous thrombosis of unusual site: Paget-Schroetter syndrome

RESUMEN Fundamento: la enfermedad tromboembólica venosa es una enfermedad clínica frecuente, asociada a múltiples factores de riesgo ya identificados. Existen presentaciones con localizaciones atípicas, como lo es la trombosis en miembro superior. Al ser su etiología en el 30 % de los casos la hipertrofia de músculos de la cintura escapular (síndrome de Paget-Schroetter), el cual siempre deberá ser sospechado en pacientes sanos que realicen actividades deportivas de máximo esfuerzo donde tanto el tratamiento farmacológico como quirúrgico ofrecerán una adecuada alternativa terapéutica. Objetivo: presentar un paciente joven con trombosis venosa de sitio inusual en miembro superior. Presentación del caso: se presenta el caso de un paciente joven de 20 años sano, deportista de alto rendimiento, quien acude a consulta por cuadro subagudo de signos inflamatorios y circulación colateral en miembro superior izquierdo, con posterior confirmación de trombosis venosa de sitio inusual, se descartan causas comunes, trombofilias y luego se confirma la hipertrofia de músculos escalenos como evento precipitante. Dada la duración del cuadro en su inicio es manejado con anticoagulación e intervenido de forma quirúrgica con adecuada respuesta. Conclusiones: la presencia de trombosis venosa de sitio inusual en miembro superior en pacientes jóvenes, sanos y deportistas obliga a sospechar el síndrome de Paget-Schroetter como principal causa, al permitir un adecuado manejo y pronóstico.

ABSTRACT Background: venous thromboembolic disease is a frequent clinical illness, associated with multiple risk factors already identified. There are presentations with atypical locations such as thrombosis in the upper limb. The etiology in the 30% of cases is the hypertrophy of the scapular waist muscles (Paget-Schroetter syndrome), which should always be suspected in healthy patients that practice sports to their maximum level, where both pharmacological and surgical treatment will offer an adequate alternative. Objective: to present a young patient with venous thrombosis of unusual site in the upper limb. Presentation of the case: we present the case of a 20-year-old healthy patient, previously a high-performance athlete, who went to consultation for a sub-acute symptomps of inflammatory signs and collateral circulation in the left upper limb, with subsequent confirmation of unusual site venous thrombosis. The common etiologies are ruled out and, finally, scalene hypertrophy known as Paget-Schroetter syndrome is confirmed. Given the duration of the symptoms, the anticoagulation is initially handled and subsequently he is surgically treated with an adequate response. Conclusions: the presence of unusual site venous thrombosis in upper limb in young, healthy and athletic patients forces us to be suspicious about the Paget-Schroetter syndrome as the main etiology allowing the correct handling and prognosis.

Trends in utilization of warfarin and direct oral anticoagulants in older adult patients with atrial fibrillation.

PURPOSE: Results of a study to determine trends in oral anticoagulant (OAC) use and OAC switching in patients with atrial fibrillation (AF) or atrial flutter are presented. METHODS: Warfarin has been the most prescribed anticoagulant in patients with AF for decades. Since 2010, several direct OACs (DOACs) have gained U.S. marketing approval for stroke prevention in AF or atrial flutter. A cross-sectional longitudinal analysis was conducted using healthcare and prescription claims databases to characterize OAC use and rates of OAC and DOAC switching during the period 2008-14 in cohorts of Medicare beneficiaries 65 years of age or older with AF or atrial flutter. RESULTS: Overall, 66% of patients with AF or atrial flutter were receiving OACs during the study period. The prevalence of warfarin use decreased from 69.8% in 2008 to 42.2% in 2014. This decrease in warfarin use was paralleled by an increase in dabigatran use, which rose from 1.3% in 2010 to 12.1% in 2011 and then declined to 7.6% in 2014. The prevalence of rivaroxaban use increased from 0.13% in 2011 to 13.87% in 2014. Among anticoagulated patients, an average of 6% annually were switched from one OAC to another. CONCLUSION: Overall OAC utilization in patients with AF or atrial flutter remained steady over the study period. Beginning in 2010, a gradual decrease in use of warfarin was paralleled by an increase in use of DOACs.

Anticoagulation for stroke prevention in elderly patients with non-valvular atrial fibrillation: what are the obstacles?

The elderly with atrial fibrillation are more prone to stroke. Oral anticoagulants such as warfarin are effective in the prevention of atrial fibrillation-associated stroke and systemic embolism. The CHADS2 or CHA2D2-VASc score and HAS-BLED score were developed to stratify stroke risk associated with atrial fibrillation and bleeding risk in a patient with atrial fibrillation, respectively, to facilitate the decision for and safe use of oral anticoagulant. Nonetheless, the decision for anticoagulation is not straightforward and the elderly with non-valvular atrial fibrillation are often precluded from anticoagulant prescription. Advanced age and disadvantages associated with the elderly such as fall, comorbidities, cognitive impairment, and polypharmacy contribute to the over-concern of physicians about bleeding risk. Various treatment options such as low-intensity warfarin and aspirin plus clopidogrel have been suggested but are inferior to dose-adjusted warfarin. Novel oral anticoagulants with promising efficacy and convenience hold great appeal. Optimal management of underlying medical conditions and modifiable stroke risk factors, together with intervention to improve the safe use of oral anticoagulants, are useful.

Efficacy of Oral Anticoagulation in Stroke Prevention among Sinus-Rhythm Patients Who Lack Left Atrial Mechanical Contraction after Cryoablation.

The customary recommendation is that oral anticoagulation be withdrawn a few months after cryoablation for atrial fibrillation, independently of left atrial mechanical contraction in patients in sinus rhythm. Recently, a 5-fold increase in stroke has been described in sinus-rhythm patients who lack atrial mechanical contraction. One aim of this study was to evaluate the efficacy of oral anticoagulation in preventing postoperative stroke in such patients. This prospective study divided 154 sinus-rhythm patients into 2 groups, depending on the presence (108 patients) or absence (46 patients) of left atrial mechanical contraction at 6 months after surgery, and monitored them annually for 5 years. Those without left atrial contraction were maintained on acenocumarol. The primary endpoint was the occurrence of ischemic stroke. The median follow-up period was 29 ± 16 months; 4 patients (2.5%), all belonging to the group with preserved atrial contraction, had ischemic stroke; the group of patients without left atrial contraction had no episodes of stroke during follow-up. Logistic binary regression analyses showed no evidence of factors independently predictive of stroke. Among anticoagulated patients in sinus rhythm without left atrial contraction, we found the incidence of stroke to be zero. In a small, nonrandomized group such as this, we cannot discount the element of chance, yet we suggest that maintaining anticoagulation might lower the incidence of stroke in this population.