Matriz de evidencia
Factor Xa inhibitors versus vitamin K antagonists for atrial fibrillation
This matrix includes 30 Revisiones Sistemáticas Show Hide

Estudio primario

No clasificado

Oral anticoagulation and antiplatelets in atrial fibrillation patients after myocardial infarction and coronary intervention.

Año 2013
Revista Journal of the American College of Cardiology
Enlaces Pubmed , DOI

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OBJECTIVES:

The purpose of this study was to investigate the risk of thrombosis and bleeding according to multiple antithrombotic treatment regimens in atrial fibrillation (AF) patients after myocardial infarction (MI) or percutaneous coronary intervention (PCI).

BACKGROUND:

The optimal antithrombotic treatment strategy is unresolved in patients with multiple indications.

METHODS:

A total of 12,165 AF patients hospitalized with MI and/or undergoing PCI between 2001 and 2009 were identified by nationwide registries (60.7% male; mean age 75.6 years). Risk of MI/coronary death, ischemic stroke, and bleeding according to antithrombotic treatment regimen was estimated by Cox regression models.

RESULTS:

Within 1 year, MI or coronary death, ischemic stroke, and bleeding events occurred in 2,255 patients (18.5%), 680 (5.6%), and 769 (6.3%), respectively. Relative to triple therapy (oral anticoagulation [OAC] plus aspirin plus clopidogrel), no increased risk of recurrent coronary events was seen for OAC plus clopidogrel (hazard ratio [HR]: 0.69, 95% confidence interval [CI]: 0.48 to 1.00), OAC plus aspirin (HR: 0.96, 95% CI.: 0.77 to 1.19), or aspirin plus clopidogrel (HR: 1.17, 95% CI.: 0.96 to 1.42), but aspirin plus clopidogrel was associated with a higher risk of ischemic stroke (HR: 1.50, 95% CI.: 1.03 to 2.20). Also, OAC plus aspirin and aspirin plus clopidogrel were associated with a significant increased risk of all-cause death (HR: 1.52, 95% CI.: 1.17 to 1.99 and HR.: 1.60, 95% CI.: 1.25 to 2.05, respectively). When compared to triple therapy, bleeding risk was nonsignificantly lower for OAC plus clopidogrel (HR: 0.78, 95% CI.: 0.55 to 1.12) and significantly lower for OAC plus aspirin and aspirin plus clopidogrel.

CONCLUSIONS:

In real-life AF patients with indication for multiple antithrombotic drugs after MI/PCI, OAC and clopidogrel was equal or better on both benefit and safety outcomes compared to triple therapy.

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Estudio primario

No clasificado

Impact of a patient decision aid on care among patients with nonvalvular atrial fibrillation: a cluster randomized trial.

Año 2005
Revista CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne
Enlaces Pubmed , DOI , PMC

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BACKGROUND:

Too few patients with nonvalvular atrial fibrillation (NVAF) receive appropriate antithrombotic therapy. We tested the short-term (primary outcome) and long-term (secondary outcome) effect of a patient decision aid on the appropriateness of antithrombotic therapy among patients with NVAF.

METHODS:

We conducted a cluster randomized trial with blinded outcome assessment involving 434 NVAF patients from 102 community-based primary care practices. Patients in the intervention group received a self-administered booklet and audiotape decision aid tailored to their personal stroke risk profile. Patients in the control group received usual care. The primary outcome measure was change in antithrombotic therapy at 3 months. Appropriateness of therapy was defined using the American College of Chest Physicians (ACCP) recommendations.

RESULTS:

The mean patient age was 72 years, and the median duration of NVAF was 5 years. In the control group, there was a 3% decrease over 3 months in the number of patients receiving therapy appropriate to their risk of stroke (40% [85/215] at baseline v. 37% [79/215] at 3 months). In the intervention group, the number of patients receiving therapy appropriate to their stroke risk increased by 9% (32% [69/219] at baseline v. 41% [89/219] at 3 months). Although the proportion of patients whose therapy met the ACCP treatment recommendations did not differ between study arms at baseline (p = 0.11) or 3 months (p = 0.44), there was a 12% absolute improvement in the number of patients receiving appropriate care in the intervention group compared with the control group at 3 months (p = 0.03). The beneficial effect of the decision aid did not persist (p = 0.44 for differences between study arms after 12 months).

INTERPRETATION:

There was short-term improvement in the appropriateness of antithrombotic care among patients with NVAF who were exposed to a decision aid, but the improvement did not persist.

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Estudio primario

No clasificado

Use of low molecular weight heparin for prophylaxis and treatment of thromboembolism in pregnancy.

Año 1992
Autores Gillis S , Shushan A , Eldor A
Revista International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics
Enlaces Pubmed

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Low molecular weight heparin (LMWH) preserves the antithrombotic action but not the anticoagulant activity of heparin. LMWH is safe, does not cross the placenta and is administered as a single daily injection. We report our experience with 6 pregnant women given LMWH for treatment or prophylaxis of thromboembolism. The drug was successfully given to 5 women for periods of 6 weeks--6 months and no thromboembolic complications occurred during pregnancy or pueperium. There were no hemorrhagic complications and no excessive bleeding was observed during delivery. The sixth patient relapsed after 6 weeks of therapy. This patient also showed resistance to standard heparin administered intravenously at a very high dose. LMWH should be considered an alternative to standard heparin in pregnant women requiring antithrombotic prophylaxis and therapy.

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Revisión sistemática

No clasificado

Prolonged High-Dose Bivalirudin Infusion Reduces Major Bleeding Without Increasing Stent Thrombosis in Patients Undergoing Primary Percutaneous Coronary Intervention: Novel Insights From an Updated Meta-Analysis.

Año 2016
Revista Journal of the American Heart Association
Enlaces Pubmed , DOI , PMC

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BACKGROUND:

The optimal antithrombotic therapy in patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI) remains a matter of debate. This updated meta-analysis investigated the impact of (1) bivalirudin (with and without prolonged infusion) and (2) prolonged PCI-dose (1.75 mg/hg per hour) bivalirudin infusion compared with conventional antithrombotic therapy on clinical outcomes in patients undergoing primary PCI.

METHODS AND RESULTS:

Eligible randomized trials were searched through MEDLINE, EMBASE, Cochrane database, and proceedings of major congresses. Prespecified outcomes were major bleeding (thrombolysis in myocardial infarction major and Bleeding Academic Research Consortium 3-5), acute stent thrombosis, as well as all-cause and cardiac mortality at 30 days. Six randomized trials (n=17 294) were included. Bivalirudin compared with heparin (+/- glycoprotein-IIb/IIIa inhibitor) was associated with reduction in major bleeding (odds ratio [OR]: 0.65, 95% CI.: 0.48-0.88, P=0.006, derived from all 6 trials), increase in acute stent thrombosis (OR: 2.75, 95% CI.: 1.46-5.18, P=0.002, 5 trials), and lower rate of all-cause mortality (OR: 0.81, 95% CI.: 0.67-0.98, P=0.03, 6 trials) as well as cardiac mortality (OR: 0.69, 95% CI.: 0.55-0.87, P=0.001, 5 trials). The incidence of acute stent thrombosis did not differ between the prolonged PCI-dose bivalirudin and comparator group (OR: 0.81, 95% CI.: 0.27-2.46, P=0.71, 3 trials), whereas the risk of bleeding was reduced despite treatment with high-dose bivalirudin infusion (OR: 0.28, 95% CI.: 0.13-0.60, P=0.001, 3 trials).

CONCLUSIONS:

Bivalirudin (with and without prolonged infusion) compared with conventional antithrombotic therapy in ST-segment-elevation myocardial infarction patients undergoing primary PCI reduces major bleeding and death, but increases the rate of acute stent thrombosis. However, prolonging the bivalirudin infusion at PCI-dose (1.75 mg/kg per hour) for 3 hours eliminates the excess risk of acute stent thrombosis, while maintaining the bleeding benefits.

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Estudio primario

No clasificado

Risk factors, medical therapies and perioperative events in limb salvage surgery: observations from the PREVENT III multicenter trial.

Año 2005
Revista Journal of vascular surgery
Enlaces Pubmed , DOI , PMC

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OBJECTIVES:

Patients who require infrainguinal revascularization for critical limb ischemia (CLI) are at elevated risk for cardiovascular events. The PREVENT III study was a prospective, randomized, multicenter, phase 3 trial of edifoligide for the prevention of vein graft failure in patients with CLI. We examined the baseline characteristics, perioperative medical therapies, and 30-day incidence of major cardiovascular events in the PREVENT III cohort.

METHODS:

Demographics, medical and surgical history, mode of presentation for the index limb, procedural details, and concomitant medications were reviewed for all patients enrolled in PREVENT III (N = 1,404). Major adverse cardiovascular events, including death, myocardial infarction, or cerebrovascular event (stroke or transient ischemic attack) were tabulated. Univariate and multivariate analyses were performed to discern factors that were associated with the utilization of medical therapies and with perioperative events.

RESULTS:

Demographics and comorbidities reflected a population with diffuse, advanced atherosclerosis. Perioperative mortality was 2.7%, and major morbidity included myocardial infarction in 4.7% and stroke/transient ischemic attack in 1.4%. Among this population of CLI patients, 33% were not on antiplatelet therapy at study entry, and 24% were not receiving antithrombotics of any type. In addition, 54% of patients were not receiving lipid-lowering therapy, and 52% were not prescribed beta-blocker medications at study entry. On multivariate analysis, race was a significant determinant of antithrombotic utilization, with African-American patients less frequently treated both at baseline and discharge (adjusted odd ratios, 0.5 and 0.6, P < .0001). Antithrombotic and beta-blocker drug usage increased in the overall cohort from baseline (76% and 48%) to discharge (88% and 60%; P < .0001). Patients treated in a university hospital setting were more likely to be prescribed antiplatelet, lipid-lowering, and beta-blocker medications. Advanced age (>75 years), coronary artery disease (prior myocardial infarction or revascularization), and dialysis-dependent renal failure were associated with an increased 30-day risk of death, myocardial infarction, or stroke. Protective effects of beta-blocker and lipid-lowering medications were noted in these defined subgroups.

CONCLUSIONS:

A significant percentage of the population that undergoes surgical revascularization for CLI is not prescribed therapies of proven benefit in reducing cardiovascular events. Utilization of antithrombotics and beta-blockers increases during hospitalization for limb salvage surgery but that of lipid-lowering therapy does not. African-American patients appear to be at greater risk for undertreatment with antithrombotics, and the data suggest that patients undergoing leg bypass surgery in a university hospital setting receive more comprehensive medical treatment of atherosclerosis. Treatment guidelines for medical therapy are needed to standardize care and improve outcomes for patients with CLI.

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Estudio primario

No clasificado

[Treatment of pregnancy related venous thromboembolism].

Año 2009
Autores Mitić G , Povazan L , Lucić AM
Revista Medicinski pregled
Enlaces Pubmed

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INTRODUCTION:

Prevention and treatment of venous thromboembolism during pregnancy are complicated since the use of antithrombotic drugs carries a certain risk to the mother, the fetus or both. Coumarins cross the placental barrier and may be responsible for bleeding, teratogenicity and central nervous system abnormalities. The risk of embriopathy is particularly high between 6 and 12 weeks of gestation.

TREATMENT:

Heparin is the treatment of choice for thrombosis during pregnancy because it is entirely safe for the fetus, unlike oral anticoagulants. The frequency of heparin-induced thrombocytopenia and osteoporosis is significantly lower if LMWH is applied, so this heparin type is preferable to UFH during pregnancy. Treatment of women with VTE during pregnancy, especially those with thrombophilia, requires individualized dosing and duration of antithrombotic therapy.

PERIPARTAL MANAGEMENT:

In order to avoid the peripartum anticoagulant heparin effect and possible bleeding, heparin should be discontinued prior to the delivery and reintroduced after the parturition.

PROPHYLACTIC REGIMEN:

Prophylactic antithrombotic regimen during subsequent pregnancies should also be individualized. The use of low molecular weight heparins is becoming more widespread. They have reliable pharmacokinetics, require less frequent injections than unfractionated heparin and carry a lower risk of treatment complications. LMW heparins are safe and effective and they are replacing UFH as the anticoagulant of choice during pregnancy. Both UFH and LMWH are not secreted into breast milk and can be safely given to nursing mothers. Warfarin does not induce an anticoagulant effect in the breast-fed infant, so it can be safely used in women who require postpartum anticoagulant therapy.

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Estudio primario

No clasificado

[Oral anticoagulation in the very elderly and clinical determinants]. Anticoagulação oral nos muito idosos e seus determinantes clínicos

Año 2012
Revista Revista Portuguesa de Clínica Geral
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OBJECTIVES:

To determine the frequency of anticoagulation in the elderly with 80 or more years old enrolled in USF, analyze factors associated with the institution of this therapy, characterize the subgroup of patients with atrial fibrillation as the score in CHA2DS2VASc HAS-BLED and scales and analyze prescription its antithrombotic. Study design: Cross-sectional analytic study.

SETTING:

Family Health Family Health Unit, Maia, Portugal. Population: Registered users this Family Health Unit with 80 or more years old.

METHODS:

A data collection was performed of electronic processes in a random sample of 266 users. Were recorded age and gender of the user, prescribing oral anticoagulants and antiplatelet agents, possible medical reasons and contraindications to anticoagulation, and associated cardiovascular pathologies, last tension-registration and body mass index.

RESULTS:

The frequency of anticoagulation was 6.8% (95% CI.: 3.7 to 9.8%). The analysis of factors associated with anticoagulation, stand out with statistically significant values ​​diagnoses of atrial fibrillation / atrial flutter, pulmonary embolism, peripheral arterial disease, heart failure and acute myocardial infarction. Of the 31 users with atrial fibrillation, 35.5% were anticoagulated, 9.7% were anticoagulated and antiagregados, 45.2% were antiagregados and 9.7% had not prescribed antithrombotic therapeutic. Users with this arrhythmia had, according to the thrombotic risk scale, to anticoagulation.

CONCLUSIONS:

The prevalence of anticoagulation among the very elderly users of this health unit is high. Atrial fibrillation is the likely reason for anticoagulation of most users. Many of the individuals with this arrhythmia was under antithrombotic therapy, but the percentage of anticoagulated users was lower than expected, according to the weighting of thrombotic and bleeding risk scores.

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Estudio primario

No clasificado

Direct Factor Xa Inhibitor YM150 for Prevention of Stroke in Subjects With Non-Valvular Atrial Fibrillation

Año 2007
Autores Astellas Pharma Inc
Registro de estudios clinicaltrials.gov
Enlaces ClinicalTrials.gov

Este artículo está incluido en 1 Revisión sistemática Revisiones sistemáticas (1 referencia)

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To evaluate the safety and tolerability of YM150 in subjects with non-valvular atrial fibrillation (NVAF)and to obtain information on pharmacokinetics and pharmacodynamics (anti-thrombotic potential) in the target population

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Revisión sistemática

No clasificado

Vocal cord paralysis secondary to spontaneous internal carotid dissection: case report and systematic review of the literature.

Año 2013
Revista Journal of otolaryngology - head & neck surgery = Le Journal d'oto-rhino-laryngologie et de chirurgie cervico-faciale
Enlaces Pubmed , DOI , PMC

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OBJECTIVES:

To present a rare case of unilateral vocal cord paralysis (VCP) secondary to spontaneous internal carotid artery dissection and to perform a literature review.

CASE REPORT:

A 35-year-old male presented to the emergency department with acute onset hoarseness and dysphagia. History, physical exam and laryngoscopy revealed left sided VCP without obvious cause. Magnetic Resonance Imaging (MRI) demonstrated a left internal carotid artery dissection of unknown etiology. Neurovascular surgery was consulted and treatment with aspirin was initiated. The dysphagia and hoarseness resolved in 12 weeks with long-term neurosurgery follow-up as the management plan.

METHODS:

Systematic literature review was conducted by 3 independent reviewers. Since 1988 only 9 cases of VCP due to internal carotid artery dissection have been reported. These were reviewed for: demographics, diagnostic method, treatment and vocal cord function.

RESULTS:

7 patients had unilateral while 2 had bilateral VCP. MRI was used for diagnosis in 7 cases and 5 cases utilized a type of angiography. All received antithrombotic treatment with 5 out of the 9 patients experiencing vocal cord recovery in an average of 7.2 weeks.

CONCLUSION:

MRI is crucial in the work-up of idiopathic VCP. If an ipsilateral internal carotid artery dissection is found, antithrombotic treatment is initiated with an expectation that vocal cord mobility is likely to return.

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Estudio primario

No clasificado

Contra: “Anti-platelet therapy is an alternative to oral anticoagulation for atrial fibrillation”

Año 2009
Revista Thromb Haemost
Enlaces

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Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. Its prevalence increases with age, from less than 0.1% per year in those under 40 years old to 10% per year in people ≥80 years (1–3). The risk of stroke associated with AF is in the range of 1.9% to 18% per year, depending on associated stroke risk factors. Thus, prevention of thromboembolism should be considered in all patients with AF or atrial flutter (AFl). Estimating the risk of stroke for an individual patient is a crucial step for the decision to provide the correct currently available antithrombotic strategy (1–3). Certain schemes for stratification of stroke risk can be used to identify patients who will benefit more from antiplatelet or anticoagulant agents. Still, individual risk for thromboembolism or bleeding varies over time, so the need for anticoagulation must be reevaluated periodically and the antithrombotic strategy might periodically change (3).

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