Endovascular treatment of aneurisms: Pre,intra and post operative management

The most frequent risk in endovascular aneurysm treatment is thromboembolic complications. Thus adjuvant pharmaceuticals are largely focused on preventing and treating these latter. Additionally symptomatic treatment of subarachnoid hemorrhage (SAH) and treatments to avoid vasospasm will enter into play in cases of ruptured aneurisms.     

Inherited risk factors for thrombophilia in children with nephrotic syndrome

A hereditary tendency to venous thrombosis rarely results in a spontaneous thrombotic episode before puberty. The acquired hypercoagulability associated with nephrotic syndrome (NS) could, however, coincide with underlying inherited thrombophilia, thereby resulting in a thrombotic event. In order to determine the contribution of inherited prothrombotic conditions to thrombosis in children with NS, we analysed DNA from a cohort of patients with NS for the common genetic risk factors of vascular disease. We evaluated 53 children with NS and 41 paediatric controls for prevalence of the factor V mutation Arg506→Gln (factor V Leiden), the prothrombin variant (20210G→A), and homozigosity for Ala677→Val in the methylenetetrahydrofolate reductase gene (MTHFR). Eight thrombo-embolic events were identified in 6 out of 53 (11%) children. Three thrombotic events occurred during NS activity and were associated with systemic infections in two and an arterial puncture in one. An inherited risk factor was identified in seven children, all without thrombosis (two heterozygous for the prothrombin variant and five homozygous for the MTHFR-T). None of the studied inherited risk factors were identified among those with thrombosis. Conclusions These data suggest that inherited thrombophilia is not a strong risk factor for the development of non recurrent thrombosis in children with NS. Received: 21 October 1997 / Accepted in revised form: 12 April 1998     

Should we abandon the common practice of withholding oral anticoagulation in paroxysmal atrial fibrillation?

AIMS: To assess the relation between the atrial fibrillation (AF) subtype and thrombo-embolic events. METHODS AND RESULTS: The observational Euro Heart Survey on AF (2003-04) enrolled 1509 paroxysmal, 1109 persistent, and 1515 permanent AF patients, according to the 2001 American College of Cardiology, American Heart Association, and the European Society of Cardiology guidelines definitions. A 1 year follow-up was performed. Permanent AF patients had at baseline a worse stroke risk profile than paroxysmal and persistent AF patients. In paroxysmal AF, the risk for stroke, any thrombo-embolism, major bleeding and the combined endpoint of cardiovascular mortality, any thrombo-embolism, and major bleeding was comparable with persistent and permanent AF, in both univariable and multivariable analyses. Compared with AF patients without stroke, patients suffering from a stroke had a comparable frequency and duration of AF attacks, but tended to have a worse stroke risk profile at baseline. During 1 year following cardioversion, paroxysmal AF patients had a higher risk for stroke (P = 0.029) and any thrombo-embolism (P = 0.001) than persistent AF patients. CONCLUSION: In the Euro Heart Survey, paroxysmal AF had a comparable risk for thrombo-embolic events as persistent and permanent AF. This observation strengthens the guideline recommendation not to consider the clinical AF subtype when deciding on anticoagulation.     

非瓣膜病心房颤动患者抗凝治疗现状与指南差距分析

目的：了解心房颤动抗凝治疗的现状、影响因素及其与指南推荐的差距。方法：调查2011年1月-2011年6月在本院住院的109例非瓣膜病心房颤动患者的血栓栓塞危险因素、抗凝药物使用情况,采用logistic回归分析法分析影响抗凝治疗的相关因素。结果：具有抗凝指征且无抗凝禁忌证的患者102例,仅12.7%的患者接受华法林治疗,年龄≥75岁、患者对抗凝治疗的选择是影响抗凝治疗的主要因素。结论：本院抗凝治疗的现状与指南推荐差距明显。     

Complications of endovascular treatment of cerebral aneurysms

The number of neuroendovascular treatments of both ruptured and unruptured aneurysms has increased substantially in the last two decades. Complications of endovascular treatments of cerebral aneurysms are rare but can potentially lead to acute worsening of the neurological status, to new neurological deficits or death. Some of the possible complications, such as vascular access site complications or systemic side effects associated with contrast medium (e.g. contrast medium allergy, contrast induced nephropathy) can also be encountered in diagnostic angiography. The most common complications of endovascular treatment of cerebral aneurysms are related to acute thromboembolic events and perforation of the aneurysm. Overall, the reported rate of thromboembolic complications ranges between 4.7% and 12.5% while the rate of intraprocedural rupture of cerebral aneurysms is about 0.7% in patients with unruptured aneurysms and about 4.1% in patients with previously ruptured aneurysms.     

Post-operative use of heparin increases morbidity of pacemaker implantation.

AIMS: The objective of this study is to characterize the incidence of peri-operative severe adverse events (AEs) related to the post-operative use of heparin in patients undergoing pacemaker surgery. METHODS AND RESULTS: We retrospectively compared the outcome of 38 patients with mechanical valves (MVs) and 76 patients with atrial fibrillation (AF) with control cases matched for gender, age, and surgical details. Heparin was systematically used post-operatively in MV patients, but left to clinical judgment in AF patients. The relative risk for severe haemorrhagic AEs was 11 (CI 1.5-81.1, P < 0.01) in the MV group when compared with matched controls and 8 (CI 1.0-62.5, P < 0.05) in the AF group. Overall, the relative risk of heparin use in the post-operative period was 14 (CI 1.88-104, P = 0.0006) and the post-operative stay was prolonged from 7 days in this group when compared with control cases (P < 0.0001).The variables associated with haemorrhage were the delay to restart heparin after surgery and the presence of an MV. CONCLUSION: Post-operative use of heparin increases morbidity of pacemaker implantation. A different approach to management of these patients is possible.     

Low-dose oral anticoagulation in patients with mechanical heart valve prostheses: final report from the early self-management anticoagulation trial II.

AIMS: In mechanical heart valve recipients, low-dose international normalized ratio (INR) self-management of oral anticoagulants can reduce the risk of developing thrombo-embolic events and improve long-term survival compared with INR control by a general practitioner. Here, we present data on the safety of low-dose INR self-management. METHODS AND RESULTS: In a prospective, randomized multi-centre trial, 1346 patients with a target INR range of 2.5-4.5 and 1327 patients with a target INR range of 1.8-2.8 for aortic valve recipients and an INR range of 2.5-3.5 for mitral or double valve recipients were followed up for 24 months. The incidence of thrombo-embolic events that required hospital admission was 0.37 and 0.19% per patient year in the conventional and low-dose groups, respectively (P = 0.79). No thrombo-embolic events occurred in the subgroups of patients with mitral or double valve replacement. The incidence of bleeding events that required hospital admission was 1.52 and 1.42%, respectively (P = 0.69). In the majority of patients with bleeding events, INR values were < 3.0. Mortality rate did not differ between the study groups. CONCLUSION: Data demonstrate that low-dose INR self-management does not increase the risk of thrombo-embolic events compared with conventional dose INR self-management. Even in patients with low INR target range, the risk of bleeding events is still higher than the risk of thrombo-embolism.     

Atrial fibrillation in the elderly

This review discusses atrial fibrillation according to the guidelines of Brazilian Society of Cardiac Arrhythmias and the Brazilian Cardiogeriatrics Guidelines. We stress the thromboembolic burden of atrial fibrillation and discuss how to prevent it as well as the best way to conduct cases of atrial fibrillatios in the elderly, reverting the arrhythmia to sinus rhythm, or the option of heart rate control. The new methods to treat atrial fibrillation, such as radiofrequency ablation, new oral direct thrombin inhibitors and Xa factor inhibitors, as well as new antiarrhythmic drugs, are depicted.     

非瓣膜病心房颤动患者抗凝治疗现状与指南差距分析

目的：了解心房颤动抗凝治疗的现状、影响因素及其与指南推荐的差距。方法：调查2011年1月-2011年6月在本院住院的109例非瓣膜病心房颤动患者的血栓栓塞危险因素、抗凝药物使用情况，采用logistic回归分析法分析影响抗凝治疗的相关因素。结果：具有抗凝指征且无抗凝禁忌证的患者102例，仅12.7%的患者接受华法林治疗，年龄≥75岁、患者对抗凝治疗的选择是影响抗凝治疗的主要因素。结论：本院抗凝治疗的现状与指南推荐差距明显。