ABSTRACT
Background: Antithrombotic therapy (ATT) in patients with infective endocarditis (IE) is challenging. Objectives: The authors evaluated the impact of anticoagulant and antiplatelet therapy on clinical endpoints in IE patients. Methods: We performed a systematic review and meta-analysis comparing IE patients with prior and/or ongoing use of ATT vs those without any ATT during IE course. Primary outcome was reported in-hospital cerebrovascular events. Secondary outcomes were in-hospital mortality, intracranial hemorrhage (ICH), systemic thromboembolism (ST), and mortality within 6 months. Results: Twelve studies, with a total of 12,151 patients, were included. The primary endpoint was not different comparing 10,115 IE patients with or without prior anticoagulation (OR: 1.10; 95% CI: 0.56-2.17; P = 0.77) or comparing 838 IE patients with or without prior antiplatelet (OR: 0.90; 95% CI: 0.61-1.33; P = 0.61). In-hospital mortality was lower in IE patients with prior anticoagulation compared to those without (OR: 0.74; 95% CI: 0.57-0.96; P = 0.03). There was no difference in reported ICH rates between patients with or without prior anticoagulation (OR: 0.54; 95% CI: 0.27-1.09; P = 0.09) or between patients with or without prior antiplatelet (OR: 0.35; 95% CI: 0.11-1.10; P = 0.07). The rate of ST was lower in IE patients with prior antiplatelet therapy compared to those without (OR: 0.53; 95% CI: 0.38-0.72; P < 0.01). Conclusions: ATT in IE patients was not associated with higher frequency of cerebrovascular events or ICH. Moreover, we found that the use of anticoagulation was associated with decreased in-hospital mortality and the use of antiplatelets was associated with decreased ST. Due to the limitations of this study, these results should be interpreted cautiously showing the necessity of a randomized setup.
ABSTRACT
La fibrilación auricular (FA) afecta a más de dos millones de personas en Estados Unidos y se calcula que afectará a más de tres millones para el año 2020. Se caracteriza por la presencia en el electrocardiograma de ondas rápidas e irregulares sobre la línea de base, que varían de tamaño, morfología y tiempo. Es particularmente frecuente en los ancianos. Se produce por múltiples circuitos de microrreentrada que salen de la aurícula, colisionan, se extinguen y reaparecen; es necesaria una masa critica de tejido auricular para sostener un mínimo de circuitos que permitan perpetuar la arritmia. Dos estudios recientes permiten concluir que la terapia dirigida solamente al control de la respuesta ventricular es igualmente efectiva para el control del ritmo cardíaco, lo que desvirtúa la conducta de intentar restablecer el ritmo sinusal en todos los pacientes con FA.Una de las complicaciones más severas de la FA son los eventos tromboembólicos sistémicos que se presentan principalmente al sistema nervioso central; a la FA se le atribuye ser el factor causal en el 15 por ciento de todos los casos y en el 30 por ciento de los que ocurren en personas mayores de 80 años. Se revisan y analizan diferentes estudios de prevención tanto primaria como secundaria en pacientes con FA no valvular, los cuales sustentan las recomendaciones de consensos internacionales para su tratamiento basado en anticoagulación o antiagregación
The number of people with atrial fibrillation (AF) in the United States has been projected to increase from the current 2.2 million to 3 million in 2020. It is characterized by the presence of rapid and irregular waves on the base line that vary in size, shape and timing. It is particularly frequent in the elderly. In AF multiple, small microreentrant circuits are constantly arising in the atria, colliding, being extinguished, and arising again; a critical mass of atrial tissue is required to sustain the minimal number of simultaneous circuits necessary for the perpetuation of the arrhythmia. Two recent studies permit to conclude that the rhythm control strategy offers no survival advantage over the rate control strategy, and there are potential advantages, such as the lower risk of adverse drug effects, with the rate control strategy. One of the most severe complications of AF are the thromboembolic events mainly to the central nervous system. AF is an important independent risk factor for the embolic stroke, responsible for as many as 15% of strokes and for 30% in the group 80 to 89 years old. We analyzed different primary and secondary prevention studies in patients with non-valvular FA, which support the recommendations of guidelines developed by the American College of Cardiology, the American Heart Association, the European Society of Cardiology and ACCP.