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Buus SMØ, Behrndtz AB, Schmitz ML, Hedegaard JN, Cordsen P, Johnsen SP, Phan T, Andersen G, Simonsen CZ. Urban-rural inequalities in IV thrombolysis for acute ischemic stroke: A nationwide study. Eur Stroke J 2024:23969873241244591. [PMID: 38600682 DOI: 10.1177/23969873241244591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024] Open
Abstract
INTRODUCTION Rural residency has been associated with lower reperfusion treatment rates for acute ischemic stroke in many countries. We aimed to explore urban-rural differences in IV thrombolysis rates in a small country with universal health care, and short transport times to stroke units. PATIENTS AND METHODS In this nationwide cohort study, adult ischemic stroke patients registered in the Danish Stroke Registry (DSR) between 2015 and 2020 were included. The exposure was defined by residence rurality. Data from the DSR, Statistics Denmark, and the Danish Health Data Authority, were linked on the individual level using the Civil Registration Number. Adjusted treatment rates were calculated by balancing baseline characteristics using inverse probability of treatment weights. RESULTS Among the included 56,175 patients, prehospital delays were shortest for patients residing in capital municipalities (median 4.7 h), and longest for large town residents (median 7.1 h). Large town residents were predominantly admitted directly to a comprehensive stroke center (98.5%), whereas 30.9% of capital residents were admitted to a hospital with no reperfusion therapy available (non-RT unit). Treatment rates were similar among all non-rural residents (18.5%-18.7%), but slightly lower among rural residents (17.2% [95% CI 16.5-17.8]). After adjusting for age, sex, immigrant status, and educational attainment, rural residents reached treatment rates comparable to capital and large town residents at 18.5% (95% CI 17.7-19.4). DISCUSSION AND CONCLUSION While treatment rates varied minimally by urban-rural residency, substantial differences in median prehospital delay and admission to non-RT units underscored marked urban-rural differences in potential obstacles to reperfusion therapies.
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Affiliation(s)
| | | | | | | | - Pia Cordsen
- Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
| | - Søren Paaske Johnsen
- Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Thanh Phan
- Department of Medicine, School of Clinical Sciences at Monash health, Monash University, Melbourne, VIC, Australia
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Claus Ziegler Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Bernstein RA, Previch L, Caprio FZ. Data Over Dogma in Treatment of Cervical Artery Dissections. Stroke 2024; 55:919-920. [PMID: 38527153 DOI: 10.1161/strokeaha.124.046745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 03/27/2024]
Affiliation(s)
- Richard A Bernstein
- Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, IL
| | - Lauren Previch
- Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, IL
| | - Fan Z Caprio
- Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, IL
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Broderick JP, Mistry EA. Evolution and Future of Stroke Trials. Stroke 2024. [PMID: 38328974 DOI: 10.1161/strokeaha.123.044265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Affiliation(s)
- Joseph P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, OH
| | - Eva A Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, OH
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Poston JN, Brown SP, Ilich A, Ginsburg AS, Herren H, El Kassar N, Jensen CE, Triulzi DJ, Key NS, May S, Gernsheimer TB. Fewer severe infections with tranexamic acid in patients with hematologic malignancies. Res Pract Thromb Haemost 2024; 8:102358. [PMID: 38666065 PMCID: PMC11043644 DOI: 10.1016/j.rpth.2024.102358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/22/2024] [Accepted: 02/13/2024] [Indexed: 04/28/2024] Open
Abstract
Background Tranexamic acid (TXA) is an antifibrinolytic agent that reduces bleeding in a multitude of clinical settings from postpartum hemorrhage to trauma. TXA may have clinical effects unrelated to bleeding; plasminogen, the target of TXA, alters immune responses, and TXA appears to decrease the risk of infection in patients undergoing cardiac surgery, as well as joint arthroplasty. Objectives To address whether TXA alters rates of infection and inflammatory outcomes in patients with hematologic malignancies. Methods We performed a post hoc analysis of outcomes of patients randomized to receive either TXA or placebo in the double-blinded, multicenter American Trial to Evaluate Tranexamic Acid Therapy in Thrombocytopenia (Clinicaltrials.gov identifier: NCT02578901). Results TXA did not change the overall rate of infections, but the rate of severe infections (Common Toxicology Criteria for Adverse Events grade 3+) was lower in patients who received TXA compared with the placebo group. Patients who experienced grade 3+ infections had higher rates of World Health Organization grade 2+ bleeding and red blood cell transfusion requirements than patients who did not experience a grade 3+ infection, irrespective of treatment group. TXA did not impact other inflammatory outcomes such as mucositis, rash, or graft vs host disease. Conclusion Patients with hematologic malignancies who received TXA had less severe infections than those who received placebo with no difference in overall rate of infection or other inflammatory outcomes. Further investigation is needed on the impact of TXA on infections in this population.
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Affiliation(s)
- Jacqueline N. Poston
- Division of Hematology, University of Washington School of Medicine and Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Hematology/Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
- Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Siobhan P. Brown
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Anton Ilich
- Department of Medicine, Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Amy Sarah Ginsburg
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Heather Herren
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Nahed El Kassar
- Division of Blood Diseases and Resources, National Institutes of Health, National Heart, Lung and Blood Institute, Bethesda, Maryland, USA
| | - Christopher E. Jensen
- Department of Medicine, Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Darrell J. Triulzi
- Department of Pathology, Division of Transfusion Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nigel S. Key
- Department of Medicine, Division of Hematology and Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Susanne May
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Terry B. Gernsheimer
- Division of Hematology, University of Washington School of Medicine and Fred Hutchinson Cancer Center, Seattle, Washington, USA
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Allen A, Barnes GD. Direct Oral Anticoagulants Versus Vitamin K Antagonist in Elderly Patients With Atrial Fibrillation: Sometimes Less Is More, but Sometimes More Is More. J Am Heart Assoc 2023; 12:e032127. [PMID: 37929746 PMCID: PMC10727416 DOI: 10.1161/jaha.123.032127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Arthur Allen
- VA Salt Lake City Health Care SystemSalt Lake CityUTUSA
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Eilertsen H, Menon CS, Law ZK, Chen C, Bath PM, Steiner T, Desborough MJ, Sandset EC, Sprigg N, Al-Shahi Salman R. Haemostatic therapies for stroke due to acute, spontaneous intracerebral haemorrhage. Cochrane Database Syst Rev 2023; 10:CD005951. [PMID: 37870112 PMCID: PMC10591281 DOI: 10.1002/14651858.cd005951.pub5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Outcome after acute spontaneous (non-traumatic) intracerebral haemorrhage (ICH) is influenced by haematoma volume. ICH expansion occurs in about 20% of people with acute ICH. Early haemostatic therapy might improve outcome by limiting ICH expansion. This is an update of a Cochrane Review first published in 2006, and last updated in 2018. OBJECTIVES To examine 1. the effects of individual classes of haemostatic therapies, compared with placebo or open control, in adults with acute spontaneous ICH, and 2. the effects of each class of haemostatic therapy according to the use and type of antithrombotic drug before ICH onset. SEARCH METHODS We searched the Cochrane Stroke Trials Register, CENTRAL (2022, Issue 8), MEDLINE Ovid, and Embase Ovid on 12 September 2022. To identify further published, ongoing, and unpublished randomised controlled trials (RCTs), we scanned bibliographies of relevant articles and searched international registers of RCTs in September 2022. SELECTION CRITERIA We included RCTs of any haemostatic intervention (i.e. procoagulant treatments such as clotting factor concentrates, antifibrinolytic drugs, platelet transfusion, or agents to reverse the action of antithrombotic drugs) for acute spontaneous ICH, compared with placebo, open control, or an active comparator. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcome was death/dependence (modified Rankin Scale (mRS) 4 to 6) by day 90. Secondary outcomes were ICH expansion on brain imaging after 24 hours, all serious adverse events, thromboembolic adverse events, death from any cause, quality of life, mood, cognitive function, Barthel Index score, and death or dependence measured on the Extended Glasgow Outcome Scale by day 90. MAIN RESULTS We included 20 RCTs involving 4652 participants: nine RCTs of recombinant activated factor VII (rFVIIa) versus placebo/open control (1549 participants), eight RCTs of antifibrinolytic drugs versus placebo/open control (2866 participants), one RCT of platelet transfusion versus open control (190 participants), and two RCTs of prothrombin complex concentrates (PCC) versus fresh frozen plasma (FFP) (47 participants). Four (20%) RCTs were at low risk of bias in all criteria. For rFVIIa versus placebo/open control for spontaneous ICH with or without surgery there was little to no difference in death/dependence by day 90 (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.74 to 1.05; 7 RCTs, 1454 participants; low-certainty evidence). We found little to no difference in ICH expansion between groups (RR 0.81, 95% CI 0.56 to 1.16; 4 RCTs, 220 participants; low-certainty evidence). There was little to no difference in all serious adverse events and death from any cause between groups (all serious adverse events: RR 0.81, 95% CI 0.30 to 2.22; 2 RCTs, 87 participants; very low-certainty evidence; death from any cause: RR 0.78, 95% CI 0.56 to 1.08; 8 RCTs, 1544 participants; moderate-certainty evidence). For antifibrinolytic drugs versus placebo/open control for spontaneous ICH, there was no difference in death/dependence by day 90 (RR 1.00, 95% CI 0.93 to 1.07; 5 RCTs, 2683 participants; high-certainty evidence). We found a slight reduction in ICH expansion with antifibrinolytic drugs for spontaneous ICH compared to placebo/open control (RR 0.86, 95% CI 0.76 to 0.96; 8 RCTs, 2866 participants; high-certainty evidence). There was little to no difference in all serious adverse events and death from any cause between groups (all serious adverse events: RR 1.02, 95% CI 0.75 to 1.39; 4 RCTs, 2599 participants; high-certainty evidence; death from any cause: RR 1.02, 95% CI 0.89 to 1.18; 8 RCTs, 2866 participants; high-certainty evidence). There was little to no difference in quality of life, mood, or cognitive function (quality of life: mean difference (MD) 0, 95% CI -0.03 to 0.03; 2 RCTs, 2349 participants; mood: MD 0.30, 95% CI -1.98 to 2.57; 2 RCTs, 2349 participants; cognitive function: MD -0.37, 95% CI -1.40 to 0.66; 1 RCTs, 2325 participants; all high-certainty evidence). Platelet transfusion likely increases death/dependence by day 90 compared to open control for antiplatelet-associated ICH (RR 1.29, 95% CI 1.04 to 1.61; 1 RCT, 190 participants; moderate-certainty evidence). We found little to no difference in ICH expansion between groups (RR 1.32, 95% CI 0.91 to 1.92; 1 RCT, 153 participants; moderate-certainty evidence). There was little to no difference in all serious adverse events and death from any cause between groups (all serious adverse events: RR 1.46, 95% CI 0.98 to 2.16; 1 RCT, 190 participants; death from any cause: RR 1.42, 95% CI 0.88 to 2.28; 1 RCT, 190 participants; both moderate-certainty evidence). For PCC versus FFP for anticoagulant-associated ICH, the evidence was very uncertain about the effect on death/dependence by day 90, ICH expansion, all serious adverse events, and death from any cause between groups (death/dependence by day 90: RR 1.21, 95% CI 0.76 to 1.90; 1 RCT, 37 participants; ICH expansion: RR 0.54, 95% CI 0.23 to 1.22; 1 RCT, 36 participants; all serious adverse events: RR 0.27, 95% CI 0.02 to 3.74; 1 RCT, 5 participants; death from any cause: RR 0.49, 95% CI 0.16 to 1.56; 2 RCTs, 42 participants; all very low-certainty evidence). AUTHORS' CONCLUSIONS In this updated Cochrane Review including 20 RCTs involving 4652 participants, rFVIIa likely results in little to no difference in reducing death or dependence after spontaneous ICH with or without surgery; antifibrinolytic drugs result in little to no difference in reducing death or dependence after spontaneous ICH, but result in a slight reduction in ICH expansion within 24 hours; platelet transfusion likely increases death or dependence after antiplatelet-associated ICH; and the evidence is very uncertain about the effect of PCC compared to FFP on death or dependence after anticoagulant-associated ICH. Thirteen RCTs are ongoing and are likely to increase the certainty of the estimates of treatment effect.
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Affiliation(s)
- Helle Eilertsen
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Zhe Kang Law
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Chen Chen
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, Australia
- The George Institute for Global Health, Beijing, China
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Philip M Bath
- Stroke Medicine, University of Nottingham, Nottingham, UK
| | - Thorsten Steiner
- Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Jr Desborough
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Else C Sandset
- Department of Neurology, Oslo University Hospital Ullevål, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Nikola Sprigg
- Stroke Medicine, University of Nottingham, Nottingham, UK
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 91] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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Mahardawi B, Jiaranuchart S, Rochanavibhata S, Arunjaroensuk S, Mattheos N, Pimkhaokham A. The role of hemostatic agents after tooth extractions: A systematic review and meta-analysis. J Am Dent Assoc 2023:S0002-8177(23)00277-5. [PMID: 37367710 DOI: 10.1016/j.adaj.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 04/20/2023] [Accepted: 05/06/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Hemostatic agents are used to control bleeding after tooth extraction and have been compared with conventional measures (that is, sutures or gauze pressure) in several studies. The objective of this systematic review was to evaluate the benefits of topical hemostatic agents for controlling bleeding after tooth extractions, especially in patients receiving antithrombotic therapy. TYPES OF STUDIES REVIEWED The authors conducted a literature search in MEDLINE (PubMed), Scopus, and the Cochrane Central Register of Controlled Trials, including prospective human randomized clinical trials in which researchers compared hemostatic agents with conventional methods and reported the time to achieve hemostasis and postoperative bleeding events. RESULTS Seventeen articles were eligible for inclusion. Hemostatic agents resulted in a significantly shorter time to achieve hemostasis in both healthy patients and patients taking antithrombotic drugs (standardized mean difference, -1.02; 95% CI, -1.70 to -0.35; P = .003 and standardized mean difference, -2.30; 95% CI, -3.20 to -1.39; P < .00001, respectively). Significantly fewer bleeding events were noted when hemostatic agents were used (risk ratio, 0.62; 95% CI, 0.44 to 0.88; P = .007). All forms of hemostatic agents (that is, mouthrinse, gel, hemostatic plug, and gauze soaked with the agent) had better efficacy in reducing the number of postoperative bleeding events than conventional hemostasis measures, except for hemostatic sponges. However, this was based on a small number of studies in each subgroup. CONCLUSIONS The use of hemostatic agents seemed to offer better bleeding control after tooth extractions in patients on antithrombotic drugs than conventional measures. PRACTICAL IMPLICATIONS Findings of this systematic review may help clinicians attain more efficient hemostasis in patients requiring tooth extraction. This systematic review is registered in the PROSPERO database. The registration number is CRD42021256145.
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Abstract
BACKGROUND This is an update of the Cochrane Review last published in 2017. Survivors of stroke due to intracerebral haemorrhage (ICH) are at risk of major adverse cardiovascular events (MACE). Antithrombotic (antiplatelet or anticoagulant) treatments may lower the risk of ischaemic MACE after ICH, but they may increase the risk of bleeding. OBJECTIVES To determine the overall effectiveness and safety of antithrombotic drugs on MACE and its components for people with ICH. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (5 October 2021). We also searched the Cochrane Central Register of Controlled Trials (CENTRAL: the Cochrane Library 2021, Issue 10), MEDLINE Ovid (from 1948 to October 2021) and Embase Ovid (from 1980 to October 2021). The online registries of clinical trials searched were the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (5 October 2021). We screened the reference lists of included randomised controlled trials (RCTs) for additional, potentially relevant RCTs. SELECTION CRITERIA We selected RCTs in which participants with ICH of any age were allocated to a class of antithrombotic treatment as intervention or comparator. DATA COLLECTION AND ANALYSIS In accordance with standard methodological procedures recommended by Cochrane, two review authors assessed each selected RCT for its risk of bias and extracted data independently. The primary outcome was a composite of MACE, and secondary outcomes included death, individual components of the MACE composite, ICH growth, functional status and cognitive status. We estimated effects using the frequency of outcomes that occurred during the entire duration of follow-up and calculated a risk ratio (RR) for each RCT. We grouped RCTs separately for analysis according to 1) the class(es) of antithrombotic treatment used for the intervention and comparator, and 2) the duration of antithrombotic treatment use (short term versus long term). We pooled the intention-to-treat populations of RCTs using a fixed-effect model for meta-analysis, but used a random-effects model if RCTs differed substantially in their design or there was considerable heterogeneity (I2 ≥ 75%) in their results. We applied GRADE to assess the certainty of the evidence. MAIN RESULTS We identified seven new completed RCTs for this update, resulting in the inclusion of a total of nine RCTs based in secondary care, comprising 1491 participants (average age ranged from 61 to 79 years and the proportion of men ranged from 44% to 67%). The proportion of included RCTs at low risk of bias, by category was: random sequence generation (67%), allocation concealment (67%), performance (22%), detection (78%), attrition (89%), and reporting (78%). For starting versus avoiding short-term prophylactic dose anticoagulation after ICH, no RCT reported MACE. The evidence is very uncertain about the effect of starting short-term prophylactic dose anticoagulation on death (RR 1.00, 95% CI 0.59 to 1.70, P = 1.00; 3 RCTs; very low-certainty evidence), venous thromboembolism (RR 0.84, 95% CI 0.51 to 1.37, P = 0.49; 4 RCTs; very low-certainty evidence), ICH (RR 0.24, 95% CI 0.04 to 1.38, P = 0.11; 2 RCTs; very low-certainty evidence), and independent functional status (RR 2.03, 95% CI 0.78 to 5.25, P = 0.15; 1 RCT; very low-certainty evidence) over 90 days. For starting versus avoiding long-term therapeutic dose oral anticoagulation for atrial fibrillation after ICH, starting long-term therapeutic dose oral anticoagulation probably reduces MACE (RR 0.61, 95% CI 0.40 to 0.94, P = 0.02; 3 RCTs; moderate-certainty evidence) and probably reduces all major occlusive vascular events (RR 0.27, 95% CI 0.14 to 0.53, P = 0.0002; 3 RCTs; moderate-certainty evidence), but probably results in little to no difference in death (RR 1.05, 95% CI 0.62 to 1.78, P = 0.86; 3 RCTs; moderate-certainty evidence), probably increases intracranial haemorrhage (RR 2.43, 95% CI 0.88 to 6.73, P = 0.09; 3 RCTs; moderate-certainty evidence), and may result in little to no difference in independent functional status (RR 0.98, 95% CI 0.78 to 1.24, P = 0.87; 2 RCTs; low-certainty evidence) over one to three years. For starting versus avoiding long-term antiplatelet therapy after ICH, the evidence is uncertain about the effects of starting long-term antiplatelet therapy on MACE (RR 0.89, 95% CI 0.64 to 1.22, P = 0.46; 1 RCT; moderate-certainty evidence), death (RR 1.08, 95% CI 0.76 to 1.53, P = 0.66; 1 RCT; moderate-certainty evidence), all major occlusive vascular events (RR 1.03, 95% CI 0.68 to 1.55, P = 0.90; 1 RCT; moderate-certainty evidence), ICH (RR 0.52, 95% CI 0.27 to 1.03, P = 0.06; 1 RCT; moderate-certainty evidence) and independent functional status (RR 0.95, 95% CI 0.77 to 1.18, P = 0.67; 1 RCT; moderate-certainty evidence) over a median follow-up of two years. For adults within 180 days of non-cardioembolic ischaemic stroke or transient ischaemic attack and a clinical history of prior ICH, there was no evidence of an effect of long-term cilostazol compared to aspirin on MACE (RR 1.33, 95% CI 0.74 to 2.40, P = 0.34; subgroup of 1 RCT; low-certainty evidence), death (RR 1.65, 95% CI 0.55 to 4.91, P = 0.37; subgroup of 1 RCT; low-certainty evidence), or ICH (RR 1.29, 95% CI 0.35 to 4.69, P = 0.70; subgroup of 1 RCT; low-certainty evidence) over a median follow-up of 1.8 years; all major occlusive vascular events and functional status were not reported. AUTHORS' CONCLUSIONS We did not identify beneficial or hazardous effects of short-term prophylactic dose parenteral anticoagulation and long-term oral antiplatelet therapy after ICH on important outcomes. Although there was a significant reduction in MACE and all major occlusive vascular events after long-term treatment with therapeutic dose oral anticoagulation for atrial fibrillation after ICH, the pooled estimates were imprecise, the certainty of evidence was only moderate, and effects on other important outcomes were uncertain. Large RCTs with a low risk of bias are required to resolve the ongoing dilemmas about antithrombotic treatment after ICH.
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Affiliation(s)
| | - Chen Chen
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, Australia
- The George Institute for Global Health, Beijing, China
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Ole Morten Rønning
- Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Craig S Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- The George Institute China at Peking University Health Science Center, Beijing, China
| | - Graeme J Hankey
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
- Perron Institute for Neurological and Translational Science, Perth, Australia
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11
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Lehr A, Guichet P, Garimella B, Krolikowski K, Amoroso N, Sista A, Brosnahan SB. Impact of Time to Intervention on Catheter-Directed Therapy for Pulmonary Embolism. Crit Care Explor 2023; 5:e0828. [PMID: 36699257 DOI: 10.1097/CCE.0000000000000828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Cather-directed therapies (CDTs) are an evolving therapeutic option for patients with intermediate-risk pulmonary embolism (PE). Although many techniques have been studied, there is limited evidence for the impact of timing of intervention on patient outcomes. Our objective was to assess the association between time to CDT in patients presenting with PE on patient-related outcomes such as length of stay (LOS) and mortality. DESIGN Retrospective cohort study. SETTING Single academic center. PATIENTS We identified patients for which the PE response team had been activated from January 2014 to October 2021. Patients were split into two cohorts depending on whether they went to CDT less than 24 hours from admission (early) versus greater than 24 hours (late). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data on demographics, timing of interventions, pulmonary hemodynamics, and outcomes were collected. Sixty-four patients were included in analysis. Thirty-nine (63.8%) underwent their procedure less than 24 hours from admission, whereas 25 (36.2%) underwent the procedure after 24 hours. The time from admission to CDT was 15.9 hours (9.1-20.3 hr) in the early group versus 33.4 (27.9-41) in the late group (p ≤ 0.001). There was a greater decrease in pulmonary artery systolic pressure after intervention in the early cohort (14 mm Hg [6-20 mm Hg] vs 6 mm Hg [1-10 mm Hg]; p = 0.022). Patients who received earlier intervention were found to have shorter hospital LOS (4 vs 7 d; p = 0.038) and ICU LOS (3 vs 5 d; p = 0.004). There was no difference in inhospital mortality between the groups (17.9% vs 12%; p = 0.523). CONCLUSIONS Patients who underwent CDT within 24 hours of admission were more likely to have shorter hospital and ICU LOS. The magnitude of change in LOS between the two cohorts was not fully explained by the difference in time to CDT. There were modest improvements in pulmonary hemodynamics in the patients who underwent CDT earlier.
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12
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Mohan A, Komakula S, Murali S, Anand P, Shah D, Vishnu VY, Pandit AK, Agarwal A, Vibha D, Singh MB, Padma Srivastava MV, Bhatia R. Biosimilar Tenecteplase Versus Alteplase in Acute Ischemic Stroke: A Real World Study. Ann Indian Acad Neurol 2023; 26:54-58. [PMID: 37034051 PMCID: PMC10081554 DOI: 10.4103/aian.aian_754_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 11/15/2022] [Accepted: 11/17/2022] [Indexed: 01/06/2023] Open
Abstract
Background and Purpose There is an unmet need for a more effective thrombolytic agent in acute ischemic stroke (AIS) management. Various studies and meta-analysis suggest tenecteplase (TNK) as non-inferior over alteplase (rTPA). The present single-center study compares biosimilar TNK and rTPA in a tertiary care setting. Methods Data of patients who presented with AIS and underwent intravenous thrombolysis (IVT) were recruited retrospectively from January 2018 to July 2021. Primary efficacy outcome was a modified Rankin score (mRS) at 90 days dichotomized at < = 2. Qualitative and quantitative variables were assessed using Chi-square test and Student's t-test, respectively. Results A total of 160 patients, 103 in the rTPA and 57 in TNK group, were analyzed. The baseline characteristics were well matched apart from hypertension. Large artery atherosclerosis was the most frequent subtype of stroke among the two groups. Good functional outcome was seen in 47.92% of patients TNK and 64.77% of patients in rTPA group (p = 0.069). No difference was seen in the rates of any ICH (p = 0.29) and mortality at 3 months (p = 0.32) among the two groups. Conclusion This present study observed no difference in the efficacy and safety between biosimilar TNK and rTPA. Our findings are in concordance with published trials showing equivalence between the two molecules.
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Affiliation(s)
- Ayush Mohan
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Snigdha Komakula
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Suhas Murali
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Pooja Anand
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Dyuti Shah
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - VY Vishnu
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Awadh Kishor Pandit
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Ayush Agarwal
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Deepti Vibha
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Mamta Bhushan Singh
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - MV Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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13
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Zayed NE, El Fakharany K, Mehriz Naguib Abozaid M. Intrapleural Instillation of Sodium Bicarbonate versus Urokinase in Management of Complicated Pleural Effusion: A Comparative Cohort Study. Int J Gen Med 2022; 15:8705-8713. [PMID: 36575733 PMCID: PMC9790168 DOI: 10.2147/ijgm.s388488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Aim The main target is evacuation; however, with evidence about the value of intrapleural instillation of different fibrinolytic agents still under evaluation, our aim was comparing the effectiveness and safety of intrapleural instillation of sodium bicarbonate (NaHCO3) in comparison with urokinase in patients with infected pleural effusion. Methods Our prospective cohort study included 40 patients with complicated empyema; the diagnosis was based on analysis of aspirated fluid in association with radiological and bacteriological culture. The patients were subjected to instillation of two different fibrinolytic agents; the first one was NaHCO3, the second was urokinase. Results The commonest underlying chest infection that was visualized by CT was pneumonia 70%. Nearly half of cases had community-acquired infection (45%), and more than half of them (55%) had anaerobic infection, and only five cases had TB pleural effusion based on ADA-positive, tuberculin skin test in addition to Abram's needles closed biopsy. The rate of repeated therapeutic thoracentesis success in each group was 85%; 80% in NaHCO3 group, and 90% in urokinase group, both of them was significantly equal, P=0.37. Moreover, the frequency of complications in all patients was less than 13%, hence hemothorax and iatrogenic pneumothorax was 12.5%, and only 10% of cases were admitted in ICU after the maneuver, with insignificant difference in between the groups. However, looking at the smaller rate of RTT failure of NaHCO3 or urokinase, the logistic regression model showed that RTT-NaHCO3 was insignificantly related to failure in both unadjusted and adjusted models, P=0.37 and 0.32, respectively, and only smoking habits increase the likelihood of failure 9-fold (OR=8.9, P=0.04) with respect to age, sex, and treatment methods. Conclusion The efficacy of repeated therapeutic thoracentesis (RTT) with intrapleural instillation of NaHCO3 was effective and safe, the same as urokinase, with consideration that NaHCO3 was much more available and affordable than urokinase.
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Affiliation(s)
- Niveen E Zayed
- Department of Chest Disease, Faculty of Medicine, Zagazig University, Zagazig City, Egypt,Correspondence: Niveen E Zayed, Chest Department, Zagazig University, Faculty of Medicine, Sharkia Government, Zagazig City, 44519, Egypt, Tel +201024831444, Email ;
| | - Karim El Fakharany
- Department of Cardiothoracic Surgery, Faculty of Medicine, Zagazig University, Zagazig City, Egypt
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14
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Zhu A, Rajendram P, Tseng E, Coutts SB, Yu AYX. Alteplase or tenecteplase for thrombolysis in ischemic stroke: An illustrated review. Res Pract Thromb Haemost 2022; 6:e12795. [PMID: 36186106 PMCID: PMC9487449 DOI: 10.1002/rth2.12795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/21/2022] [Accepted: 07/22/2022] [Indexed: 11/09/2022] Open
Abstract
Intravenous thrombolysis is a standard of care treatment for patients with acute ischemic stroke. Tissue plasminogen activator (tPA) has been the main thrombolytic agent used since the publication of the seminal National Institutes of Neurological Disorders and Stroke trial in 1995. There is now mounting evidence to support the routine use of Tenecteplase (TNK) to treat acute ischemic stroke. TNK is a genetically modified tPA with higher fibrin specificity, longer half‐life, and reduced systemic coagulopathy. In this illustrated review, we compare the indications, doses, mechanisms of action, efficacy and safety of TNK and tPA. We provide an overview of published clinical trials studying TNK in acute ischemic stroke, including dose‐escalation studies and head‐to‐head comparisons with tPA. Finally, we summarize current acute stroke guideline recommendations and suggest treatment algorithms to manage the two main complications of intravenous thrombolysis: symptomatic intracerebral hemorrhage and angioedema.
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Affiliation(s)
- Annie Zhu
- Department of Medicine (Neurology) University of Toronto, Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Phavalan Rajendram
- Department of Medicine (Neurology) University of Toronto, Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | - Eric Tseng
- Department of Medicine (Hematology) University of Toronto, Unity Health Toronto Toronto Ontario Canada
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, Radiology and Community Health Sciences Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary Calgary Alberta Canada
| | - Amy Y X Yu
- Department of Medicine (Neurology) University of Toronto, Sunnybrook Health Sciences Centre Toronto Ontario Canada
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15
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Angkananard T, Issarasenarak P, Teerawattananon P, Kosulawath M, Samrejphol V, Okanurak K. Medical students' confidence and competence with prescribing in ST-elevation myocardial infarction: a mixed-methods study. Int J Med Educ 2022; 13:187-197. [PMID: 35909350 PMCID: PMC9911138 DOI: 10.5116/ijme.62c2.c33c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 07/04/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To explore factors associated with prescribing confidence and competence of final-year medical students for prescribing antiplatelet and fibrinolytic agents in ST-segment elevation myocardial infarction (STEMI). METHODS The study was conducted among final-year medical students with a triangular convergent mixed-methods approach. First, an online survey was conducted using a voluntary sampling method with concurrent in-depth interviews performed. The survey data was analysed using descriptive statistics and paired t-tests, while survey factors were compared using the chi-squared or Fisher's exact test. The interview data were coded and analysed thematically. The relations between the qualitative and quantitative findings were finally described. RESULTS Totally 92 validly replied to the questionnaire, and 20 participated in the interviews. The quantitative analysis indicated that they had high competence in the diagnosis of STEMI and prescribing antiplatelet and fibrinolytic agents. The mean confidence score of prescribing for both was medium and was significantly lower in fibrinolytic agents. (M=3.3, SD=1.1 vs. M=2.8, SD=1.0, t(91)=5.39, p<0.01). Their experience, knowledge, and mentoring were accounted for, considering the prescribing confidence factors in both approaches. Besides, providing guidelines and standing orders were derived from the interview data. CONCLUSIONS This study has demonstrated that final-year medical students have a high ability to diagnose and prescribe essential medications in STEMI but tend to have low confidence in prescribing fibrinolytic agents. Experiential learning, mentorship and providing guidelines can help them, especially in emergency settings to prescribe confidently and safely. Further multicenter studies on undergraduate and graduate medical students' confidence and perspective of prescribing are required, especially for high-alert medications.
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Affiliation(s)
- Teeranan Angkananard
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, HRH Princess Maha Chakri Sirind-horn Medical Center, Srinakharinwirot University, Nakhon Nayok, Thailand
| | - Panida Issarasenarak
- Medical student of Faculty of Medicine, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot Uni-versity, Nakhon Nayok, Thailand
| | - Pawita Teerawattananon
- Medical student of Faculty of Medicine, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot Uni-versity, Nakhon Nayok, Thailand
| | - Maneekarn Kosulawath
- Medical student of Faculty of Medicine, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot Uni-versity, Nakhon Nayok, Thailand
| | - Varunrut Samrejphol
- Medical student of Faculty of Medicine, HRH Princess Maha Chakri Sirindhorn Medical Center, Srinakharinwirot Uni-versity, Nakhon Nayok, Thailand
| | - Kamolnetr Okanurak
- Department of Social and Environmental Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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16
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Barrett R, Hodgkinson J. Impact of the COVID-19 pandemic on cardiovascular heart disease medication use: time-series analysis of England's prescription data during the COVID-19 pandemic (January 2019 to October 2020). Ther Adv Cardiovasc Dis 2022; 16:17539447221137170. [PMID: 36420815 PMCID: PMC9702971 DOI: 10.1177/17539447221137170] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 10/19/2022] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Management of high blood pressure (BP) typically requires adherence to medication regimes. However, it is known that the COVID-19 pandemic both interrupted access to some routine prescriptions and changed some patient health behaviours. AIM This study, therefore, retrospectively investigated prescription reimbursement of cardiovascular (CVD) medicines as a proxy measure for patient adherence and access to medicines during the pandemic. METHODS A cohort study of all primary care patients in England prescribed CVD medicines. The exposure was to the global pandemic. Prescriptions were compared before and after the pandemic's onset. Statistical variation was the outcome of interest. RESULTS Descriptive statistics show changes to monthly prescriptions, with wide confidence intervals indicating varying underlying practice. Analysis of variance reveals statistically significant differences for bendroflumethiazide, potassium-sparing diuretics, nicorandil, ezetimibe, ivabradine, ranolazine, colesevelam and midodrine. After the pandemic began (March-October 2020), negative parameters are observed for ACE inhibitors, beta-blockers, calcium channel blockers, statins, antiplatelet, antithrombotics, ARBs, loop diuretics, doxazosin, bendroflumethiazide, nitrates and indapamide, indicating decelerating monthly prescription items (statistically significant declines of calcium channel blockers, antithrombotic, adrenoreceptor blockers and diuretics) of CVD medicines within the general population. Many data points are not statistically significant, but fluctuations remain clinically important for the large population of patients taking these medications. CONCLUSION A concerning decline in uptake of CVD therapies for chronic heart disease was observed. Accessible screening and treatment alongside financial relief on prescription levies are needed. A video abstract is (4 min 51 s) available: https://bit.ly/39gvEHi.
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Affiliation(s)
- Ravina Barrett
- School of Applied Sciences, University of
Brighton, Cockcroft Building, Lewes Road, Moulsecoomb, Brighton BN2 4GJ,
UK
| | - James Hodgkinson
- Murray Learning Centre, Institute of Applied
Health Research, College of Medical and Dental Sciences, University of
Birmingham, Birmingham, UK
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17
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Hijazi Z, Alexander JH, Li Z, Wojdyla DM, Mehran R, Granger CB, Parkhomenko A, Bahit MC, Windecker S, Aronson R, Berwanger O, Halvorsen S, de Waha-Thiele S, Sinnaeve P, Darius H, Storey RF, Lopes RD. Apixaban or Vitamin K Antagonists and Aspirin or Placebo According to Kidney Function in Patients With Atrial Fibrillation After Acute Coronary Syndrome or Percutaneous Coronary Intervention: Insights From the AUGUSTUS Trial. Circulation 2021; 143:1215-1223. [PMID: 33461308 DOI: 10.1161/circulationaha.120.051020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the AUGUSTUS trial (An Open-Label, 2×2 Factorial, Randomized Controlled, Clinical Trial to Evaluate the Safety of Apixaban Versus Vitamin K Antagonist and Aspirin Versus Aspirin Placebo in Patients With Atrial Fibrillation and Acute Coronary Syndrome or Percutaneous Coronary Intervention), apixaban resulted in less bleeding and fewer hospitalizations than vitamin K antagonists, and aspirin caused more bleeding than placebo in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention treated with a P2Y12 inhibitor. We evaluated the risk-benefit balance of antithrombotic therapy according to kidney function. METHODS In 4456 patients, the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) formula was used to calculate baseline estimated glomerular filtration rate (eGFR). The effect of apixaban versus vitamin K antagonists and aspirin versus placebo was assessed across kidney function categories by using Cox models. The primary outcome was International Society on Thrombosis and Haemostasis major or clinically relevant nonmajor bleeding. Secondary outcomes included death or hospitalization and ischemic events (death, stroke, myocardial infarction, stent thrombosis [definite or probable], or urgent revascularization). Creatinine clearance <30 mL/min was an exclusion criterion in the AUGUSTUS trial. RESULTS Overall, 30%, 52%, and 19% had an eGFR of >80, >50 to 80, and 30 to 50 mL·min-1·1.73 m-2, respectively. At the 6-month follow-up, a total of 543 primary outcomes of bleeding, 1125 death or hospitalizations, and 282 ischemic events occurred. Compared with vitamin K antagonists, patients assigned apixaban had lower rates for all 3 outcomes across most eGFR categories without significant interaction. The absolute risk reduction with apixaban was most pronounced in those with an eGFR of 30 to 50 mL·min-1·1.73 m-2 for bleeding events with rates of 13.1% versus 21.3% (hazard ratio, 0.59; 95% CI, 0.41-0.84). Patients assigned aspirin had a higher risk of bleeding in all eGFR categories with an even greater increase among those with eGFR >80 mL·min-1·1.73 m-2: 16.6% versus 5.6% (hazard ratio, 3.22; 95% CI, 2.19-4.74; P for interaction=0.007). The risk of death or hospitalization and ischemic events were comparable to aspirin and placebo across eGFR categories with hazard ratios ranging from 0.97 (95% CI, 0.76-1.23) to 1.28 (95% CI, 1.02-1.59) and from 0.75 (95% CI, 0.48-1.17) to 1.34 (95% CI, 0.81-2.22), respectively. CONCLUSIONS The safety and efficacy of apixaban was consistent irrespective of kidney function, compared with warfarin, and in accordance with the overall trial results. The risk of bleeding with aspirin was consistently higher across all kidney function categories. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02415400.
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Affiliation(s)
- Ziad Hijazi
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Sweden (Z.H.)
| | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.H.A., Z.L., D.M.W., C.B.G., R.D.L.)
| | - Zhuokai Li
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.H.A., Z.L., D.M.W., C.B.G., R.D.L.)
| | - Daniel M Wojdyla
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.H.A., Z.L., D.M.W., C.B.G., R.D.L.)
| | - Roxana Mehran
- Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, and Cardiovascular Research Foundation, New York, NY (R.M.)
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.H.A., Z.L., D.M.W., C.B.G., R.D.L.)
| | | | - M Cecilia Bahit
- Instituto de Neurología Cognitiva (INECO) Neurociencias Oroño, Fundación INECO, Rosario, Argentina (M.C.B.)
| | - Stephan Windecker
- Bern University Hospital, Inselspital, University of Bern, Switzerland (S.W.)
| | | | | | | | - Suzanne de Waha-Thiele
- University Heart Centre Lübeck, University Hospital Schleswig-Holstein, Germany (S.dW.-T.).,German Center for Cardiovascular Research (DZHK), Lübeck (S.dW.-T.)
| | - Peter Sinnaeve
- University Hospitals Leuven, University of Leuven, Belgium (P.S.)
| | - Harald Darius
- Vivantes Neukoelln Medical Center, Berlin, Germany (H.D.)
| | - Robert F Storey
- Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, United Kingdom (R.F.S.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (J.H.A., Z.L., D.M.W., C.B.G., R.D.L.)
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Abstract
An imbalance in oxygen supply to cardiac tissues or formation of thrombus leads to deleterious results like pulmonary embolism, coronary heart disease and acute cardiac failure. The formation of thrombus requires clinical encounter with fibrinolytic agents including streptokinase, urokinase or tissue plasminogen activator. Irrespective to urokinase and tissue plasminogen activator, streptokinase is still a significant agent in treatment of cardiovascular diseases. Streptokinase, being so economical, has an important value in treating cardiac diseases in developing countries. This review paper will provide the maximum information to enlighten all the pros and cons of streptokinase up till now. It has been concluded that recent advances in structural/synthetic biology improved SK with enhanced half-life and least antigenicity. Such enzyme preparations would be the best thrombolytic agents.
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Affiliation(s)
- Muhammad A Zia
- Enzyme Biotechnology Laboratory, Department of Biochemistry, University of Agriculture, Faisalabad-38040,Pakistan
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19
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Tomasello A, Hernandez D, Gramegna LL, Aixut S, Barranco Pons R, Jansen O, Zawadzki M, Lopez-Rueda A, Parra-Fariñas C, Piñana C, Dinia L, Arikan F, Rovira A. Early experience with a novel net temporary bridging device (Cascade) to assist endovascular coil embolization of intracranial aneurysms. J Neurosurg 2020; 134:591-599. [PMID: 31978881 DOI: 10.3171/2019.11.jns192477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 11/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to evaluate the effectiveness and safety of a new noncompletely occlusive net-assisted remodeling technique in which the Cascade net device is used for temporary bridging of intracranial aneurysms. METHODS Between July 2018 and May 2019, patients underwent coil embolization with the Cascade net device within 4 centers in Europe. Analysis of angiographic (modified Raymond-Roy classification [MRRC]) and clinical outcomes data was conducted immediately following treatment and at the 6-month follow-up. RESULTS Fifteen patients were included in the study (mean age 58 ± 13 years, 11/15 [73.3%] female). Ten patients had unruptured aneurysms, and 5 presented with ruptured aneurysms with acute subarachnoid hemorrhage. The mean aneurysm dome length was 6.27 ± 2.33 mm and the mean neck width was 3.64 ± 1.19 mm. Immediately postprocedure, MRRC type I (complete obliteration) was achieved in 11 patients (73.3%), whereas a type II (residual neck) was achieved in 4 patients (26.7%). Follow-up examination was performed in 7/15 patients and showed stabilization of aneurysm closure with no thromboembolic complications and only 1 patient with an increased MRRC score (from I to II) due to coil compression. CONCLUSIONS Initial experience shows that the use of a new noncompletely occlusive net-assisted remodeling technique with the Cascade net device may be safe and effective for endovascular coil embolization of intracranial aneurysms.
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Affiliation(s)
- Alejandro Tomasello
- 1Interventional Neuroradiology Section, Department of Radiology, Vall d'Hebron University Hospital, Barcelona
- 2Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Barcelona, Spain
| | - David Hernandez
- 1Interventional Neuroradiology Section, Department of Radiology, Vall d'Hebron University Hospital, Barcelona
- 2Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Laura Ludovica Gramegna
- 2Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Barcelona, Spain
- 3IRCCS Istituto delle Scienze Neurologiche di Bologna, Italy
| | - Sonia Aixut
- 4Department of Neuroradiology, Hospital Universitari de Bellvitge de Llobregat, Barcelona, Spain
| | - Roger Barranco Pons
- 4Department of Neuroradiology, Hospital Universitari de Bellvitge de Llobregat, Barcelona, Spain
| | - Olav Jansen
- 5Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Michal Zawadzki
- 6Division of Interventional Neuroradiology, Department of Radiology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | | | - Carmen Parra-Fariñas
- 2Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Carlos Piñana
- 1Interventional Neuroradiology Section, Department of Radiology, Vall d'Hebron University Hospital, Barcelona
| | - Lavinia Dinia
- 1Interventional Neuroradiology Section, Department of Radiology, Vall d'Hebron University Hospital, Barcelona
- 2Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Fuat Arikan
- 8Department of Neurosurgery, Vall d'Hebron University Hospital, and Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d'Hebron Research Institute, Barcelona; and
| | - Alex Rovira
- 2Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Barcelona, Spain
- 9Section of Neuroradiology and Magnetic Resonance Unit, Vall d'Hebron University Hospital, Barcelona, Spain
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20
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Knijnik L, Rivera M, Blumer V, Cardoso R, Fernandes A, Fernandes G, Ferreira T, Romano JG, Lambrakos LK, Cohen MG. Prevention of Stroke in Atrial Fibrillation After Coronary Stenting. Stroke 2019; 50:2125-2132. [PMID: 31303150 DOI: 10.1161/strokeaha.119.026078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- The optimal antithrombotic strategy to balance thromboembolic and bleeding events, especially acute stroke, for patients with atrial fibrillation following coronary stenting remains a matter of debate. We conducted a network meta-analysis to identify the antithrombotic regimen associated with the lowest rate of bleeding and thromboembolic events in atrial fibrillation after coronary stenting. Methods- PubMed, Scopus, and Cochrane Central were searched for randomized controlled trials and observational studies of patients with atrial fibrillation after coronary stenting. The outcomes of interest were stroke, myocardial infarction, major adverse cardiac events, mortality, and major bleeding. A network meta-analysis was performed comparing the available antithrombotic regimens in the literature. Results- Three randomized and 15 observational studies were included, with a total of 23 478 participants. Median follow-up was 2 years. Network meta-analysis demonstrated that vitamin K antagonist plus single antiplatelet therapy or direct-acting oral anticoagulant plus single antiplatelet therapy were the most effective regimens in preventing stroke. Direct-acting oral anticoagulant regimens were associated with lower major bleeding rates than vitamin K antagonist regimens. Regimens with dual antiplatelet therapy were associated with lower rates of myocardial infarction. Vitamin K antagonist plus dual antiplatelet therapy was associated with a lower mortality and low-dose direct-acting oral anticoagulants with decreased major cardiovascular adverse events. Conclusions- Direct-acting oral anticoagulant regimens were associated with less major bleeding and major cardiovascular adverse events, but vitamin K antagonists were associated with decreased mortality and stroke. These results suggest that the decision of antithrombotic therapy in patients with atrial fibrillation after percutaneous coronary intervention needs to be individualized.
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Affiliation(s)
- Leonardo Knijnik
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Manuel Rivera
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO (M.R.)
| | - Vanessa Blumer
- Cardiovascular Division, Duke University Hospital, Durham, NC (V.B.)
| | - Rhanderson Cardoso
- Division of Cardiology, Johns Hopkins Medical Institutions, Baltimore, MD (R.C.)
| | - Amanda Fernandes
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Gilson Fernandes
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Tanira Ferreira
- From the Department of Internal Medicine (L.K., A.F., G.F., T.F.), University of Miami Miller School of Medicine, FL
| | - Jose G Romano
- Department of Neurology (J.G.R.), University of Miami Miller School of Medicine, FL
| | - Litsa K Lambrakos
- Cardiovascular Division, Department of Medicine (L.K.L., M.G.C.), University of Miami Miller School of Medicine, FL
| | - Mauricio G Cohen
- Cardiovascular Division, Department of Medicine (L.K.L., M.G.C.), University of Miami Miller School of Medicine, FL
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Abstract
Thrombolytic treatment accelerates the dissolution of thrombus in acute pulmonary thromboembolism (PTE) and is potentially a lifesaving treatment. High-risk PTE is the clearest indication for this therapy, and its use in intermediate-risk cases is still controversial. A PTE response team may enable a rapid and effective determination of risk and treatment in these controversial clinical cases. Approved thrombolytic agents for the PTE treatment are streptokinase, urokinase, and alteplase. Currently, the most widely used agent is alteplase. It has a short infusion time (2 h) and a rapid effect. Newer, unapproved agents for the PTE treatment are tenecteplase and reteplase. The active resolution of thrombus via thrombolytic agents improves rapidly pulmonary perfusion, hemodynamic defect, gas exchange, and right ventricular dysfunction. However, it is important to determine appropriate candidates carefully, to prevent hemorrhage, which is the most important side effect of these drugs. Catheter-directed thrombolysis seems to be an alternative in patients not eligible for systemic thrombolytic therapy.
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Affiliation(s)
- Elif Yilmazel Ucar
- Department of Pulmonary Diseases, Ataturk University School of Medicine, Erzurum, Turkey
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22
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Campi TR, George S, Villacís D, Ward-Peterson M, Barengo NC, Zevallos JC. Effect of charted mental illness on reperfusion therapy in hospitalized patients with an acute myocardial infarction in Florida. Medicine (Baltimore) 2017; 96:e7788. [PMID: 28834883 PMCID: PMC5572005 DOI: 10.1097/md.0000000000007788] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Patients with mental illness carry risk factors that predispose them to excess cardiovascular mortality from an acute myocardial infarction (AMI) compared to the general population. The aim of this study was to determine if patients with AMI and charted mental illness (CMI) received less reperfusion therapy following an AMI, compared to AMI patients without CMI in a recent sample population from Florida.A secondary analysis of data was conducted using the Florida Agency for Health Care Administration (FL-AHCA) hospital discharge registry. Adults hospitalized with an AMI from 01/01/2010 to 12/31/2015 were included for the analysis. The dependent variable was administration of reperfusion therapy (thrombolytic, percutaneous coronary intervention [PCI], and coronary artery bypass graft [CABG]), and the independent variable was the presence of CMI (depression, schizophrenia, and bipolar disorder). Multivariate logistic regression models were used to test the association controlling for age, gender, ethnicity, race, health insurance, and comorbidities.The database included 61,614 adults (31.3% women) hospitalized with AMI in Florida. The CMI population comprised of 1036 patients (1.7%) who were on average 5 years younger than non-CMI (60.2 ±12.8 versus 65.2 ±14.1; P < .001). Compared with patients without CMI, patients with CMI had higher proportions of women, governmental health insurance holders, and those with more comorbidities. The adjusted odds ratio indicated that patients with CMI were 30% less likely to receive reperfusion therapy compared with those without CMI (OR = 0.7; 95% CI = 0.6-0.8). Within the AMI population including those with and without CMI, women were 23% less likely to receive therapy than men; blacks were 26% less likely to receive reperfusion therapy than whites; and those holding government health insurances were between 20% and 40% less likely to receive reperfusion therapy than those with private health insurance.Patients with AMI and CMI were statistically significantly less likely to receive reperfusion therapy compared with patients without CMI. These findings highlight the need to implement AMI management care aimed to reduce disparities among medically vulnerable patients (those with CMI, women, blacks, and those with governmental health insurance).
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Affiliation(s)
- Thomas R. Campi
- American University of Antigua College of Medicine, Coolidge, Antigua and Barbuda
| | - Sharon George
- American University of Antigua College of Medicine, Coolidge, Antigua and Barbuda
| | - Diego Villacís
- Universidad de las Américas, Facultad de Medicina, Quito, Ecuador
| | - Melissa Ward-Peterson
- Department of Medical and Population Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Noël C. Barengo
- Department of Medical and Population Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Juan C. Zevallos
- Department of Medical and Population Health Sciences Research, Herbert Wertheim College of Medicine, Florida International University, Miami, FL
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23
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Abstract
BACKGROUND Venous leg ulcers are common, chronic wounds caused by venous diseases, with a high recurrence rate and heavy disease burden. Compression therapy (bandages or stockings) is the first choice treatment for venous leg ulcers. However, when ulcers remain unhealed, medication can also be used with or without compression therapy. Sulodexide, a highly purified glycosaminoglycan (a naturally occurring molecule) has antithrombotic and profibrinolytic properties (it reduces the formation of blood clots) as well as anti-inflammatory effects. Sulodexide has been studied as a potential treatment for venous leg ulcers. OBJECTIVES To assess the efficacy and safety of sulodexide for treating venous leg ulcers. SEARCH METHODS In July 2015 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; Chinese Biomedical Literature Database (CBM); China National Knowledge Infrastructure Database (CNKI); Wan Fang and VIP. We also searched clinical trials registries to identify ongoing studies, as well as references listed in relevant publications. There were no restrictions based on date of publication, language or study setting. SELECTION CRITERIA Randomised controlled trials (RCTs) involving people with a diagnosis of venous leg ulcers which compared sulodexide with placebo or any other drug therapy (such as pentoxifylline, flavonoids, aspirin), with or without compression therapy. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. The authors independently selected studies, extracted data and assessed risk of bias. We pooled data to present the risk ratio (RR) with 95% confidence interval (CI), or presented a narrative summary. We assessed overall evidence quality according to the GRADE approach. MAIN RESULTS We included four RCTs with a total of 463 participants (aged 42 years to 93 years); one report was only available as a published abstract.Meta-analysis of three RCTs suggests an increase in the proportion of ulcers completely healed with sulodexide as an adjuvant to local treatment (including wound care and compression therapy) compared with local treatment alone (rate of complete healing with sulodexide 49.4% compared with 29.8% with local treatment alone; RR 1.66; 95% CI 1.30 to 2.12). This evidence for sulodexide increasing the rate of complete healing is low quality due to risk of bias. It is unclear whether sulodexide is associated with any increase in adverse events (4.4% with sulodexide versus 3.1% with no sulodexide; RR 1.44; 95% CI 0.48 to 4.34). The evidence for adverse events is very low quality, downgraded twice for risk of bias and once for imprecision. AUTHORS' CONCLUSIONS Sulodexide may increase the healing of venous ulcers, when used alongside local wound care, however the evidence is only low quality and the conclusion is likely to be affected by new research. It is not clear whether sulodexide is associated with adverse effects. The standard dosage, route and frequency of sulodexide reported in the trials was unclear. Further rigorous, adequately powered RCTs examining the effects of sulodexide on healing, ulcer recurrence, quality of life and costs are necessary.
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Affiliation(s)
- Bin Wu
- West China Hospital, Sichuan UniversityDepartment of PharmacyNo.37,Guoxue LaneChengduSichuanChina610041
| | - Jing Lu
- West China Hospital, Sichuan UniversityDepartment of PharmacyNo.37,Guoxue LaneChengduSichuanChina610041
| | - Ming Yang
- West China Hospital, Sichuan UniversityCenter of Geriatrics and GerontologyNo. 37, Guo Xue LaneChengduSichuanChina610041
| | - Ting Xu
- West China Hospital, Sichuan UniversityDepartment of PharmacyNo.37,Guoxue LaneChengduSichuanChina610041
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Lindsberg PJ, Caso V. Desmoteplase After Ischemic Stroke in Patients With Occlusion or High-Grade Stenosis in Major Cerebral Arteries. Stroke 2016; 47:901-3. [PMID: 26846865 DOI: 10.1161/strokeaha.115.011495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 01/11/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Perttu J Lindsberg
- From the Research Programs, Molecular Neurology, Biomedicum Helsinki, and Clinical Neurosciences, Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland (P.J.L.); and Stroke Unit, Department of Internal and Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy (V.C.).
| | - Valeria Caso
- From the Research Programs, Molecular Neurology, Biomedicum Helsinki, and Clinical Neurosciences, Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland (P.J.L.); and Stroke Unit, Department of Internal and Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy (V.C.)
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25
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Absar S, Gupta N, Nahar K, Ahsan F. Engineering of plasminogen activators for targeting to thrombus and heightening thrombolytic efficacy. J Thromb Haemost 2015; 13:1545-56. [PMID: 26074048 DOI: 10.1111/jth.13033] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 05/29/2015] [Indexed: 01/02/2023]
Abstract
Thrombotic occlusion of the coronary artery, which triggers acute myocardial infarction, is one of the major causes of death in the USA. Currently, arterial occlusions are treated with intravenous plasminogen activators (PAs), which dissolve the clot by activating plasminogen. However, PAs indiscriminately generate plasmin, which depletes critical clotting factors (fibrinogen, factor V, and factor VIII), precipitates a lytic state in the blood, and produces bleeding complications in a large patient population. PAs have been extensively investigated to achieve thrombus specificity, to attenuate the bleeding risk, and to widen their clinical applications. In this review, we discuss various strategies that have been pursued since the beginning of thrombolytic therapy. We review the biotechnological approaches that have been used to develop mutant and chimeric PAs for thrombus selectivity, including the use of specific antibodies for targeting thrombi. We discuss particulate carrier-based systems and triggered-release concepts. We propose new hypotheses and strategies to spur future studies in this research arena. Overall, we describe the approaches and accomplishments in the development of patient-friendly and workable delivery systems for thrombolytic drugs.
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Affiliation(s)
- S Absar
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - N Gupta
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - K Nahar
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX, USA
| | - F Ahsan
- Department of Pharmaceutical Sciences, School of Pharmacy, Texas Tech University Health Sciences Center, Amarillo, TX, USA
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26
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Abstract
BACKGROUND Mailuoning is widely used in the treatment of acute ischaemic stroke in China. Animal experimental studies and clinical pharmacological research indicate that mailuoning might improve blood circulation, prevent ischaemic injury, and protect heart and brain tissue. This review was last published in 2009. As new data have become available, it is necessary to reassess the evidence from randomised controlled trials. OBJECTIVES To determine the effects and safety of mailuoning agents (injection or oral liquid) in the treatment of people with acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (May 2014), the Cochrane Central Register of Controlled Trials (CENTRAL;2014, Issue 4), MEDLINE (1966 to May 2014), Embase (1980 to May 2014), AMED (1985 to May 2014), the Chinese Stroke Trials Register (June 2014), the China Biological Medicine Database (CBM-disc; 1979 to June 2014), China Science and Technology Journal database (CSTJ; 1979 to June 2014), Wanfang Data Chinese databases (1979 to June 2014), and the China National Knowledge Infrastructure (1979 to June 2014). We searched clinical trials and research registers, handsearched 10 Chinese journals including relevant conference proceedings, scanned reference lists, and contacted the pharmaceutical company that manufactures mailuoning. We also attempted to contact trial authors to obtain further data. SELECTION CRITERIA Randomised controlled trials comparing mailuoning with placebo or mailuoning plus other treatment compared with that other treatment in people with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, assessed trial quality, and extracted data. MAIN RESULTS We included 21 trials, involving 1746 participants, in this update; six trials were new. The included trials did not report the numbers of dead and dependent participants at the end of at least three months' follow-up. Of the 12 trials that reported adverse events, five events occurred in two trials. There was no significant difference between the treatment group and the control group. We assessed 20 trials to be of a poor quality: When analysing these trials together, mailuoning was associated with a significant increase in the number of participants with an improved neurological deficit (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.23 to 0.42) and showed a significant improvement of neurological deficit with the European Stroke Scale (ESS) (mean difference (MD) (fixed) 8.29, 95% CI 3.44 to 13.15). One placebo-controlled trial, assessed to be of a better methodological quality, failed to show a significant improvement of neurological deficit at the end of three months' follow-up (MD (fixed) 2.49, 95% CI -1.45 to 6.43) or in quality of life. One trial, which reported cognitive function using the Montreal Cognitive Assessment as a continuous scale, showed a significant improvement of cognitive function (MD (fixed) 2.68, 95% CI 1.82 to 3.54). Two trials assessed activities of daily life: One trial showed a significant improvement, but the other did not. AUTHORS' CONCLUSIONS This review did not provide sufficient evidence to support the routine use of mailuoning for the treatment of people with acute ischaemic stroke. High-quality large-scale randomised controlled trials are needed to confirm the efficacy of mailuoning.
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Affiliation(s)
- Weimin Yang
- First Affiliated Hospital of Zhengzhou UniversityDepartment of NeurologyNo. 1, Jianshe Road EastZhengzhouHenan ProvinceChina450052
| | - Zhaobo Shi
- First Affiliated Hospital of Zhengzhou UniversityDepartment of NeurologyNo. 1, Jianshe Road EastZhengzhouHenan ProvinceChina450052
| | - Hong‐Qi Yang
- Henan Provincial People's Hospital of Zhengzhou UniversityDepartment of NeurologyZhengzhouChina450003
| | - Junfang Teng
- First Affiliated Hospital of Zhengzhou UniversityDepartment of NeurologyNo. 1, Jianshe Road EastZhengzhouHenan ProvinceChina450052
| | - Jun Zhao
- First Affiliated Hospital of Zhengzhou UniversityDepartment of NeurologyNo. 1, Jianshe Road EastZhengzhouHenan ProvinceChina450052
| | - Guoliang Xiang
- First Affiliated Hospital of Zhengzhou UniversityDepartment of NeurologyNo. 1, Jianshe Road EastZhengzhouHenan ProvinceChina450052
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27
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Abstract
BACKGROUND Early thrombolysis for individuals experiencing a myocardial infarction is associated with better mortality and morbidity outcomes. While traditionally thrombolysis is given in hospital, pre-hospital thrombolysis is proposed as an effective intervention to save time and reduce mortality and morbidity in individuals with ST-elevation myocardial infarction (STEMI). Despite some evidence that pre-hospital thrombolysis may be delivered safely, there is a paucity of controlled trial data to indicate whether the timing of delivery can be effective in reducing key clinical outcomes. OBJECTIVES To assess the morbidity and mortality of pre-hospital versus in-hospital thrombolysis for STEMI. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE (OVID), two citation indexes on Web of Science (Thomson Reuters) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for randomised controlled trials and grey literature published up to June 2014. We also searched the reference lists of articles identified, clinical trial registries and unpublished thesis sources. We did not contact pharmaceutical companies for any relevant published or unpublished articles. We applied no language, date or publication restrictions. The Cochrane Heart Group conducted the primary electronic search. SELECTION CRITERIA We included randomised controlled trials of pre-hospital versus in-hospital thrombolysis in adults with ST-elevation myocardial infarction diagnosed by a healthcare provider. DATA COLLECTION AND ANALYSIS Two authors independently screened eligible studies for inclusion and carried out data extraction and 'Risk of bias' assessments, resolving any disagreement by consulting a third author. We contacted authors of potentially suitable studies if we required missing or additional information. We collected efficacy and adverse effect data from the trials. MAIN RESULTS We included three trials involving 538 participants. We found low quality of evidence indicating uncertainty whether pre-hopsital thrombolysis reduces all-cause mortality in individuals with STEMI compared to in-hospital thrombolysis (risk ratio 0.73, 95% confidence interval 0.37 to 1.41). We found high-quality evidence (two trials, 438 participants) that pre-hospital thrombolysis reduced the time to receipt of thrombolytic treatment compared with in-hospital thrombolysis. For adverse events, we found moderate-quality evidence that the occurrence of bleeding events was similar between participants receiving in-hospital or pre-hospital thrombolysis (two trials, 438 participants), and low-quality evidence that the occurrence of ventricular fibrillation (two trials, 178 participants), stroke (one trial, 78 participants) and allergic reactions (one trial, 100 participants) was also similar between participants receiving in-hospital or pre-hospital thrombolysis. We considered the included studies to have an overall unclear/high risk of bias. AUTHORS' CONCLUSIONS Pre-hospital thrombolysis reduces time to treatment, based on studies conducted in higher income countries. In settings where it can be safely and correctly administered by trained staff, pre-hospital thrombolysis may be an appropriate intervention. Pre-hospital thrombolysis has the potential to reduce the burden of STEMI in lower- and middle-income countries, especially in individuals who have limited access to in-hospital thrombolysis or percutaneous coronary interventions. We found no randomised controlled trials evaluating the efficacy of pre-hospital thrombolysis for STEMI in lower- and middle-income countries. Large high-quality multicentre randomised controlled trials implemented in resource-constrained countries will provide additional evidence for the efficacy and safety of this intervention. Local policy makers should consider their local health infrastructure and population distribution needs. These considerations should be taken into account when developing clinical guidelines for pre-hospital thrombolysis.
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Affiliation(s)
- Michael McCaul
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesFrancie van Zyl Drive, Tygerberg, 7505, ParowCape TownSouth Africa7505
| | - Andrit Lourens
- Faculty of Medicine and Health Science, Stellenbosch UniversityDivision of Emergency Medicine, Department of Interdisciplinary Health SciencesPO Box 19063TygerbergCape TownSouth Africa7505
| | - Tamara Kredo
- South African Medical Research CouncilSouth African Cochrane CentrePO Box 19070TygerbergCape TownSouth Africa7505
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28
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Abstract
BACKGROUND Worldwide, streptokinase remains the most used thrombolytic agent for the treatment of myocardial infarction. Recombinant streptokinase, from E. coli, is increasingly used in developing countries as a biosimilar of native streptokinase; however, potency assignments relative to the WHO International Standard (IS) are highly variable with potentially dangerous consequences. A proportion of recombinant streptokinase appears to be incompletely processed, retaining the amino-terminal methionine engineered for intracellular expression. OBJECTIVES To investigate and quantify the impact of an amino-terminal methionine on streptokinase activity. METHODS Mature native streptokinase (rSK) was cloned and a novel variant constructed to include an amino-terminal methionine (rSK-Met) that is not susceptible to processing during expression. Potencies of rSK and rSK-Met were determined relative to the WHO IS using a chromogenic solution (European Pharmacopoeia) assay, and fibrin-based assays. RESULTS In the chromogenic solution assay there was no measurable difference between rSK and rSK-Met activities. In the fibrin-based methods, however, potency estimates for rSK-Met were greatly reduced compared with rSK, and fibrinolytic activity for rSK-Met was shown to increase over time with methionine aminopeptidase treatment. This apparent difference in activity and fibrin selectivity was consistent with potency estimates for several different batches of commercial recombinant streptokinase products also tested; consequently, different potencies would be assigned to therapeutic recombinant streptokinase products depending on the degree of amino-terminal methionine processing, and on the pharmacopoeial assay method used, affecting the dosage patients receive. This has serious health implications and provides an example of the danger in the unregulated clinical use of biosimilars.
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Affiliation(s)
- C Thelwell
- Biotherapeutics, Haemostasis Section, National Institute for Biological Standards and Control, South Mimms, EN6 3QG, UK
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29
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Barekatain A, Rasekh A, Massumi A. Exclusion of the left atrial appendage to prevent stroke in cases of atrial fibrillation. Tex Heart Inst J 2012; 39:535-537. [PMID: 22949772 PMCID: PMC3423289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Armin Barekatain
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, USA
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30
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Ganjehei L, Wilson JM. Anticoagulants for stroke prevention in nonvalvular atrial fibrillation: new agents and an updated understanding. Tex Heart Inst J 2012; 39:517-25. [PMID: 22949768 PMCID: PMC3423272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Leila Ganjehei
- Department of Adult Cardiology, Texas Heart Institute at St. Luke's Episcopal Hospital, Houston, Texas 77030, USA
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31
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Abstract
Empyema thoracis can produce significant morbidity in children if inadequately treated. Correct evaluation of the stage of the disease, the clinical condition of the child and proper assessment of the response to conservative treatment is crucial in deciding the mode of further surgical intervention. This ranges from intercostal chest tube drainage and video-assisted thoracoscopic surgery to open decortication. Surgical decortication becomes mandatory in neglected cases; it gives very gratifying results ameliorating the disease rapidly and is well tolerated by young patients. This article reviews the current literature and discusses the important considerations while managing these patients. Indications for surgery are highlighted, based on our large experience at a tertiary care center.
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Affiliation(s)
- Prema Menon
- Department of Pediatric Surgery, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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32
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Abstract
BACKGROUND Impaired placentation can cause some of the most important obstetrical complications such as pre-eclampsia and intrauterine growth restriction and has been linked to increased fetal morbidity and mortality. The failure to undergo physiological trophoblastic vascular changes is reflected by the high impedance to the blood flow at the level of the uterine arteries. Doppler ultrasound study of utero-placental blood vessels, using waveform indices or notching, may help to identify the 'at-risk' women in the first and second trimester of pregnancy, such that interventions might be used to reduce maternal and fetal morbidity and/or mortality. OBJECTIVES To assess the effects on pregnancy outcome, and obstetric practice, of routine utero-placental Doppler ultrasound in first and second trimester of pregnancy in pregnant women at high and low risk of hypertensive complications. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2010) and the reference lists of identified studies. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of Doppler ultrasound for the investigation of utero-placental vessel waveforms in first and second trimester compared with no Doppler ultrasound. We have excluded studies where uterine vessels have been assessed together with fetal and umbilical vessels. DATA COLLECTION AND ANALYSIS Two authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. We checked data entry. MAIN RESULTS We found two studies involving 4993 participants. The methodological quality of the trials was good. Both studies included women at low risk for hypertensive disorders, with Doppler ultrasound of the uterine arteries performed in the second trimester of pregnancy. In both studies, pathological finding of uterine arteries was followed by low-dose aspirin administration.We identified no difference in short-term maternal and fetal clinical outcomes.We identified no randomised studies assessing the utero-placental vessels in the first trimester or in women at high risk for hypertensive disorders. AUTHORS' CONCLUSIONS Present evidence failed to show any benefit to either the baby or the mother when utero-placental Doppler ultrasound was used in the second trimester of pregnancy in women at low risk for hypertensive disorders. Nevertheless, this evidence cannot be considered conclusive with only two studies included. There were no randomised studies in the first trimester, or in women at high risk. More research is needed to investigate whether the use of utero-placental Doppler ultrasound may improve pregnancy outcome.
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Affiliation(s)
- Tamara Stampalija
- Children's Hospital "V. Buzzi"Department of Obstetrics and GynaecologyVia Castelvetro 32MilanoItaly20154
| | - Gillian ML Gyte
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, School of Reproductive and Developmental Medicine, Division of Perinatal and Reproductive MedicineFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Zarko Alfirevic
- The University of LiverpoolSchool of Reproductive and Developmental Medicine, Division of Perinatal and Reproductive MedicineFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Armstrong PW. Contemporary therapy of acute ST-elevation myocardial infarction. Tex Heart Inst J 2009; 36:273-281. [PMID: 19693298 PMCID: PMC2720296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Paul W Armstrong
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Alberta T6G 2H7, Canada.
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Stadius ML. After thrombolytic therapy: angiography, angioplasty, or surgery? Tex Heart Inst J 1990; 17:165-72. [PMID: 15227167 PMCID: PMC324913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Thrombolytic therapy has been found to improve the prognosis of selected patients with acute myocardial infarction. Many investigators advocate that combined emergency coronary angiography and percutaneous transluminal coronary angioplasty be performed immediately after thrombolytic therapy. Emergency angiography documents the anatomic extent of coronary artery disease, shows whether reperfusion has occurred, and indicates whether emergency angioplasty is necessary. In this setting, emergency catheterization without angioplasty is associated with relatively little additional risk. However, a number of prospective trials have compared emergency angioplasty to more conservative treatment strategies, and emergency angioplasty has been not found to offer any advantage in terms of improved prognosis or preservation of left ventricular function. Therefore, it is probable that most patients with evolving Q-wave myocardial infarction are best treated with conservative strategies after initial thrombolytic therapy, although there may still be a role for emergency angioplasty in a relatively small subset who present with evolving myocardial infarction and severely depressed left ventricular function. Emergency coronary artery bypass surgery also appears to have a limited role in patients treated with thrombolytic therapy. Nevertheless, in occasional patients with a poor prognosis at hospital presentation, in whom thrombolytic therapy and emergency angioplasty have failed or are contraindicated, prompt emergency coronary artery bypass grafting may salvage the ischemic myocardium and improve the prognosis.
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Affiliation(s)
- M L Stadius
- The Division of Cardiology, Stanford University School of Medicine, Stanford, California, USA
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