Heart Disease - Alair Castro - Studies
News on Cardiology continually updated. "The twenty thousand biomedical journals now published are increasing by six to seven per cent a year. To review ten journals in internal medicine, a physician must read about two hundred articles and seventy editorials a month." Phil Manning, M.D. and Lois DeBakey, Ph.D
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Tuesday, April 19, 2011
Wednesday, April 6, 2011
DABIGRATANA
The Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) publicado em setembro 2009 fez com que a Dabigratana fosse liberada pelo FDA agora no início de 2011.
Em 2011 ACCF/AHA/HRS (American College of Cardiology, the American Heart Association and the Heart Rhythm Society)publicou um UPDATE http://circ.ahajournals.org/cgi/reprint/CIR.0b013e31820f14c0v1
com a seguinte recomendação:
CLASSE I: Dabigratana é útil como uma alternativa ao Warfarin para a prevenção de AVC e Tromboembolismo sistêmico em pacientes com FA paroxística e FA permanente com fatores de risco para AVC ou embolização sistêmica que não utilizam prótese valvar cardíaca ou que tenham doença valvar hemodinamicamente significante, Insuficiência renal grave (ClCr < 15 ml/min) ou doença hepática avançada (Nível de evidência B)
Abaixo vou listar como usar DABIGRATANA -
ref: http://www.theheart.org/article/1142899.do
· Paciente em uso de Marevan: Se o INR for menor que 2, iniciar imediatamente Dabigratana.
· Dose:
ClCr > 30 mL/min – 150 mg 2xd
ClCr 15-30 mL/min – 75 mg 2xd
ClCr < ;15 mL/min – não aprovado para uso
· É extremamente recomendado que se use 2 x dia, caso o paciente esqueça uma tomada, poderá tomar a dose com até 6 horas de atraso, caso contrário seguir a prescrição.
· Antes de cirugia eletiva com função renal normal suspender a Dabigratana com 24 horas, se função renal anormal suspender com 48 horas.
· Contra indicado o uso com Rifampicina, ClCr < 15 mL/min e Protese Mecânica.
· Se ocorrer um sangramento - parar a medicação, se for um sangramento abundante pode-se optar pela diálise.
No Brasil já é comercializada a Dabigratana com o nome de Pradaxa® - Boehringer Ingelheim, de largo uso já na ortopedia para prevenir TVP em pacientes submetidos a cirurgias ortopédicas
Sunday, March 13, 2011
VOCÊ É UM FUMANTE ?
1. sim, regularmente (vá para 2)
2. não (vá para 5)
3. ocasionalmente (vá para 3)
2.Em média, quantos cigarros voce fuma por dia? Número:
(vá para 7)
3. Em quantos dias da semana você fuma cigarros?
1. Em 1 dia ou menos
2. Em 2 ou 4 dias
3. Quase todos os dia
4. Em média, quantos cigarros você fuma por dia?
= Número:
5. Alguma vez voce fumou cigarros no passado?
1. Sim (vá para 6)
2. Não (vá para 9)
6. Quando voce parou de fumar cigarros regularmente? Ano:
Se nos últimos 12 meses
1. menos de 1 mês
2. entre 1 e 6 meses
3. entre 6 e 12 meses
7. Qual o número máximo de cigarros que você que você alguma vez já fumou
diariamente por cerca de 1 ano? Número:
8 . Com que idade voce começou a fumar regularmente? Idade:
9. Alguma vez voce fumou charutos ou cigarrilhas?
1. atualmente, fumo regularmente (vá para 10)
2. Não (vá para 11)
3. Atualmente, só ocasionalmente – menos de 1 por dia (vá para 10)
4. Fumei, mas atualmente não (vá para 11)
10. Quantos você fuma por semana? Número:
11. Alguma vez voce fumou cachimbo?
1. atualmente, fumo regularmente (vá para 12)
2. Não (vá para 13)
3. Atualmente, só ocasionalmente – menos de 1 por dia (vá para 12)
4. Fumei, mas atualmente não (vá para 13)
12. Quantas gramas de tabaco (fumo), voce fuma por semana? Gramas:
13. Para ser completada apenas por fumantes ocasionais ou não fumante
(i.e. quando o item 1 é codificado como 2 ou 3)
Por quantas horas, em média cada dia, está você em contacto com outra pessoa que fuma?
A OMS tem trabalhado para normatizar a terminologia e definições de “Fumante”. A terminologia é mencionada abaixo:
Qualquer população pode ser dividida em fumantes e não-fumantes.
A. - Um fumante é qualquer pessoa que até o momento da pesquisa, fuma qualquer tipo de produto de tabaco diariamente ou ocasionalmente
Fumantes podem ser divididos em duas categorias:
1. Fumante diário: aqule que fuma qualquer produto de tabaco pelo menos uma vez ao dia.
2. Fumante ocasional: aquele que fuma, mas não diariamente
Podem ser:
i. redutores – aqueles que fumavam diariamente, mas atualmente, não mais
ii. ocasionais – aqueles que nunca fumaram diariamente, mas que fumaram 100 ou mais cigarros (ou quantidade equivalente de tabaco) e atualmente fumam ocasionalmente
iii. experimentadores – aqueles que fumaram menos de 100 cigarros (ou quantidade equivalente de tabaco) e atualmente fumam ocasionalmente
B. Não-fumantes podem ser divididos em três categorias:
1. Ex fumantes: aqueles que foram fumantes diários mas que atualmente não mais fumam.
2. Nunca fumantes: aqules que ou nunca fumaram ou que nunca fumaram diariamente e que fumaram menos de 100 cigarros (ou quantidade equivalente de tabaco) durante sua vida.
3. Ex fumantes ocasionais: anteriormente, fumantes ocasionais, mas nunca fumantes diários e que fumaram 100 cigarros (ou quantidade equivalente de tabaco) durante sua vida.
Estas definições podem ser usadas para classificar uma população de acordo com o seu estado de fumante durante toda a sua vida. Em particular:
C– Fumantes em algum momento: aqueles que em algum tempo fumaram pelo menos 100 cigarros (ou quantidadeequivalente de tabaco) durante sua vida.
The WHO classification is a general one where all tobacco products are taken into account in the definition of a smoker. In the MONICA Project only cigarette, pipe and cigar smoking are considered. In the MONICA countries other types of tobacco consumption are unknown or at least rare. In addition, in most of the RUAs the proportion of pipe or cigar smokers is small. In MONICA the smoking questionnaire has been mainly directed towards cigarette smoking and therefore gives the best information about it.
RISCO DE SANGRAMENTOS EM PACIENTES ANTICOAGULADOS
Postado anteriormente como se deve usar o escore para medir risco de eventos cerebrais em pacientes portadores de FA, fica a duvida quanto ao risco do paciente desenvolver sangramento se iniciado terapia com anticoagulantes.
HAS-BLED escore traz 9 fatores de risco para sangramento em pacientes usando marevan, cada fator soma 1 ponto na conta final. Quanto maior o número de fatores de risco, maior o risco de sangramento.
Escore maior ou igual a 3: ALTO RISCO
Deixo claro que esses paciente não possuem contra-indicação para terapêutica com anticoagulantes, e o AAS entra na predição de risco de sangramento assim como o Marevan.
Novos anticoagulantes (rivaroxaban, apixaban, dabigatrana) não foram avaliados.
Score if presentHypertension (Systolic ≥ 160mmHg) : 1
Abnormal renal function : 1
Abnormal liver function : 1
Age ≥ 65 years : 1
Stroke in past : 1
Bleeding : 1
Labile INRs : 1
Taking other drugs as well : 1
Alcohol intake at same time : 1
Um escore maior ou igual a 3 indica um aumento do risco de sangramento em um ano sob anticoagulação o que seria suficiente para justificar precaução ou uma avaliação mais freqüente.
O risco é o risco de hemorragia intracraniana, hemorragia exigindo hospitalização ou uma queda da hemoglobina > 2g / L ou um episódio de hemorragia que requer transfusão.
Em um artigo recente validando este escore, diabetes e disfunção ventricular esquerda foram identificados como fatores de risco para hemorragia.
(http://www.ncbi.nlm.nih.gov/pubmed/21111555).
Friday, March 4, 2011
Aperfeiçoamento da estratificação de risco para tromboembolismo na fibrilação atrial utilizando uma nova abordagem (CHA2DS2-VASC)
risco, enquanto no Framingham 48,3% estavam nesta faixa de risco. Pela análise (estatística C), o valor preditivo para TE é modesto em todos os esquemas propostos. O esquema de Birmingham 2009 foi um pouco melhor (estatística C = 0,606) do que o CHADS2 (estatística C=0,586). Aqueles classificados como de baixo risco pelo Birmingham 2009 e pelo esquema do guideline de NICE 2006 eram verdadeiramente de baixo risco, sem eventos tromboembólicos registrados, enquanto estes eventos ocorreram em 1,4% dos pacientes de baixo risco pelo CHADS2. Além disso, enquanto o grupo de risco intermediário teve uma taxa de eventos em torno de 3% no CHADS2, o mesmo grupo pelo esquema de Birmingham 2009 teve apenas 1 caso (0,6%). Quando expressado em um sistema de pontuação, esse novo esquema também mostrou um aumento na taxa de TE com o aumento progressivo da pontuação e aqueles com pontuação de zero (ou seja, baixo risco) não tiveram eventos tromboembólicos.
Autor: Dra. Luciana Sacilotto Referência: Gregory Y. H. Lip, Robby Nieuwlaat, Ron Pisters, Deirdre A. Lane and Harry J. G. M. Crijns. Refining Clinical Risk Stratification for Predicting Stroke and Thromboembolism in Atrial Fibrillation Using a Novel Risk Factor-Based approach. The Euro Heart Survey on Atrial Fibrillation. CHEST 2010; 137(2):263–272
MÉDICOS X MÉDICOS COM IPHONES
Sem falar nos Tablets, que chegaram pra ficar, Steve Jobs lançou ontem a segunda geração - o Ipad 2.
Considero ferramenta indispensável para o estudante de medicina e para o médico atual.
Fica o link para o blog de um colega, o Guilherme Aquino, que já acompanho há algum tempo.
ECHOTALK
Blog sério, de gente experiente que traz ferramentas para uma cardiologia mais eficiente.
Monday, October 5, 2009
New ASCOT Analysis: Beta Blockers Not Beneficial in Hypertensives With Tachycardia
The study was published in the September 22, 2009 issue of the Journal of the American College of Cardiology.
The findings mean that "there is no reason to believe that beta blockers should be used earlier on in the treatment of hypertension on the basis of heart rate," lead author Dr Neil R Poulter (Imperial College London, UK) told heartwire . He said many cardiologists have had "a hindbrain belief" that "if there is a touch of tachycardia, beta blockers are the right drugs to use in hypertension management." But prior to this analysis, there had been no data from randomized controlled trials available to assess the impact of this advice on patient outcomes, he noted.
"We thought, if it's true that a touch of tachycardia should push you toward beta blockers, we'd be able to see that in ASCOT," Poulter added. Noting that the ASCOT-BPLA study–-reported in 2005--confirmed the superiority of an amlodipine-based regimen over an atenolol-based regimen, "we looked to see whether, if you started with tachycardia, was that still the case?" he noted. "The bottom line is, yes, it is. Pulse rate should not be the determinant of what drugs you use in hypertension."
These findings "reinforce the UK guidelines that state that, in primary prevention, beta blockers should be kept to a much later stage of intervention," Poulter says.
No Attenuation of Amlodipine Superiority on Basis of Heart Rate
The ASCOT trial enrolled 19 257 hypertensive patients with at least three other cardiovascular risk factors from 650 general practices in the UK, Ireland, and the Nordic countries. The results showed that an antihypertensive strategy based on amlodipine, with perindopril added as required, significantly reduced all-cause mortality and other cardiovascular end points, including stroke, compared with an atenolol-based strategy, with the diuretic bendroflumethiazide added as required.
In this new subgroup analysis, patients with atrial fibrillation or taking rate-limiting antihypertensive drugs at baseline were excluded. The potential attenuation of the treatment effect with higher baseline heart rate on total cardiovascular events and procedures (TCVP) was assessed via an interaction term. Secondary analyses evaluated coronary and stroke outcomes.
There were 12 759 of the ASCOT patients included and 1966 total cardiovascular events and procedures. At the final visit, mean heart-rate reduction from baseline was 12.0 and 1.3 beats per minute in the atenolol- and amlodipine-based groups, respectively. There was a reduction in total cardiovascular events and procedures in those allocated to amlodipine-based therapy compared with those on atenolol-based therapy (unadjusted hazard ratio 0.81; p<0.001).
Until further notice, beta blockers should not come up the pecking order on the basis of pulse rate.
This benefit was unattenuated at higher heart rates (interaction p value=0.82). Similar results were obtained for coronary and total stroke outcomes.
"These analyses provide no evidence that atenolol-based therapy is superior to amlodipine-based therapy for patients with hypertension uncomplicated by coronary heart disease across the wide range of baseline heart rates observed in the ASCOT database," say Poulter et al.
"Pending further information--which could perhaps be gleaned from other studies such as [Losartan Intervention for Endpoint Reduction in Hypertension] LIFE--beta-blocker–based therapies are not appropriate to select as initial therapy for hypertension on the basis of a higher heart rate unless congestive heart failure and/or symptomatic ischemic heart disease coexist," they conclude.
Results Apply to All Beta Blockers, Until Further Notice
Poulter added to heartwire that "some cardiologists will say that if we hadn’t used atenolol the results would have been different: 'If you'd used my favorite "olol," ' for example, and I say, 'Prove it!' "
He believes that beta blockers "are not all the same, they do have different effects on all sorts of things," but "there is no evidence of heterogeneity in terms of cardiovascular outcomes," he maintains.
"Until further notice, beta blockers should not come up the pecking order on the basis of pulse rate."
Poulter has served as a consultant to and received travel expenses, payment for speaking at meetings, or funding for research from one or more pharmaceutical companies marketing BP-lowering or lipid-lowering drugs. Poulter has also previously received financial support from Pfizer to cover administrative and staffing costs of the ASCOT study and travel or accommodation expenses or both incurred by attending relevant meetings. Disclosures for the coauthors are listed in the paper.
References
Poulter NR, Dobson JE, Sever PS, et al. Baseline heart rate, antihypertensive treatment, and prevention of cardiovascular outcomes in ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial). J Am Coll Cardiol 2009; 54:1154-1161.
Thursday, March 13, 2008
Gmail - MedWire Cardiology News - 13 March 2008
Plausible role for CAPON gene in QRT variationResearchers have shown cardiac expression and biologic effects of the CAPON protein, supporting its potential influence on QT interval variation in human populations.http://www.medwire-news.md/38/73666/Cardiology_News/Plausible_role_for_CAPON_gene_in_QRT_variation.html
Implantable pressure monitor fails to reduce HF-related eventsUse of an implantable continuous hemodynamic monitor to guide optimal medical management of patients with heart failure failed to significantly reduce rates of HF-related events, report researchers.http://www.medwire-news.md/38/73667/Cardiology_News/Implantable_pressure_monitor_fails_to_reduce_HF-related_events.html
No evidence of link between bisphosphonates and AF, flutterScientists have found no evidence to suggest that use of bisphosphonates increases the risk for atrial fibrillation and flutter.http://www.medwire-news.md/38/73668/Cardiology_News/No_evidence_of_link_between_bisphosphonates_and_AF,_flutter.html
Wednesday, March 12, 2008
Migraine Intervention With STARFlex Technology (MIST)
Posted: 3/10/2008
Writer: Anthony A. Bavry, M.D., M.P.H.
Description
The goal of this trial was to evaluate closure of patent foramen ovale (PFO) compared with a sham procedure in patients with refractory migraine headache.
Hypothesis
Closure of a PFO with the STARFlex device will be more effective in reducing migraine headache.
Drugs/Procedures Used
After general anesthesia, patients underwent transesophageal echocardiography to assess the interatrial septal anatomy. Patients were then randomized to PFO closure (n = 74) or a sham procedure that consisted of a skin incision (n = 73).
Concomitant Medications
Patients received aspirin (300 mg) and clopidogrel (300 mg) 24 hours prior to the procedure and for 90 days after the procedure at a dose of 75 mg daily for both medications. Patients continued any prophylactic medication that they were on at the start of the trial.
Principal Findings
Of the migraine patients referred for potential study enrollment, a right-to-left shunt from a moderate-to-large PFO was documented by transthoracic echocardiography in 38%. Any type of shunt, including atrial septal defect, was present in 60%. The mean number of migraine attacks in the 30 days prior to the procedure was 4.82 in the closure group and 4.51 in the sham group. No PFO was identifiable in 7% of the closure group. Residual moderate-to-large right-to-left shunt was present in four patients at 6 months. There were more serious procedural-related adverse events in the closure group (atrial fibrillation, n = 2; pericardial tamponade, n = 2; retroperitoneal hemorrhage, n = 1; and chest pain, n = 2).
Three patients in each group reported migraine cessation (p = 1.0). Similarly, for closure versus sham, there was no difference in any of the secondary endpoints; frequency of migraine attacks per month (3.23 vs. 3.52, p = 0.14), total MIDAS headache score (17 vs. 18, p = 0.88), or headache days per 3 months (18 vs. 21, p = 0.79).
No difference in treatment effect was noted, regardless of whether a residual shunt was present at follow-up. Two patient outliers accounted for one-third of the study headache burden. When these patients were removed from analysis, there was a reduction of 2.2 headache days per month in the closure group versus 1.3 days per month in the sham group (p = 0.027).
Interpretation
This was the first randomized sham-controlled trial to study the effect of PFO closure in patients with refractory migraine. An important finding was that among migraine patients referred for analysis, some type of right-to-left shunt was documented in 60% (in 38% due to PFO). The primary outcome, cessation of migraine, occurred in three patients in each group. Secondary outcomes such as frequency of migraines and headache scores were also similar between the two groups.When the two patient outliers were excluded from analysis, a difference was noted in the reduction of headache days favoring PFO closure; however, this finding should only be hypothesis generating since it was a post-hoc analysis.
Failure to detect a difference between treatment groups may have been at least partly explained by lack of adequate power. It is unknown if a longer duration of follow-up to allow for more complete healing of the defect would have also been beneficial. Additionally, patients continued prophylactic medications throughout the trial, which may have made it more difficult for the PFO device to show benefit. Additional trials on the topic are forthcoming.
References:
Dowson A, Mullen MJ, Peatfield R, et al. Migraine Intervention With STARFlex Technology (MIST) Trial. A Prospective, Multicenter, Double-Blind, Sham-Controlled Trial to Evaluate the Effectiveness of Patent Foramen Ovale Closure With STARFlex Septal Repair Implant to Resolve Refractory Migraine Headache. Circulation 2008;Mar 3:[Epub ahead of print].