Paulo de Lara Lavítola

Sangramento durante a anticoagulação oral: alerta sobre um mal maior

BACKGROUNDnBleeding is one of the main concerns in patients undergoing oral anticoagulation therapy.nnnOBJECTIVEnTo investigate the determinant causes of bleeding in patients undergoing oral anticoagulant therapy.nnnMETHODSnA total of 360 patients with atrial fibrillation (AF) undergoing oral anticoagulant (ACo) therapy, with a target INR of 2.0-3.5, were followed prospectively for a period of 48 +/- 7.2 months. The patients were evaluated on average every 30 days and were investigated regarding the presence of associated pathology that could lead to bleeding.nnnRESULTSnA total of 338 patients participated in the present study. Of these, 210 (62.13%) were females. Mitral stenosis was present in 218 patients (64.4%), a mitral biological prosthesis in 64 (18.9%) and mitral valve failure in 56 (16.5%) patients. Bleeding occurred in 65 patients (19.2%), being severe in 7 (10%) patients. In 38/65 patients, a new associated disease was identified, which facilitated bleeding. An associated disease was identified in 100% of the patients with bleeding within the therapeutic range, against 49.05% of associated disease diagnosis in those with an INR > 3.5 (p=0.001).nnnCONCLUSIONnThe diagnosis of a local disease associated to the bleeding was frequent among those patients undergoing oral anticoagulant therapy (58.5%). There was an association between bleeding with an INR within the therapeutic range (INR=2.0-3.5) and the diagnosis of a pathology predisposing to bleeding (p<0.001). It is mandatory to investigate the cause of bleeding in patients undergoing oral anticoagulant therapy, especially if the INR is within the therapeutic range.FUNDAMENTO: Sangramento e uma das grandes preocupacoes em pacientes sob anticoagulacao oral. OBJETIVO: Investigar causas determinantes do sangramento em usuarios de anticoagulante oral. METODOS: Foram acompanhados prospectivamente, por 48 ± 7,2 meses, 360 pacientes com fibrilacao atrial (FA), todos em uso de anticoagulante oral (ACo) com INR-alvo de 2,0-3,5, avaliados em media a cada 30 dias. Os pacientes foram investigados quanto a presenca de patologia associada que levasse a sangramento. RESULTADOS: Participaram deste estudo 338 pacientes. Desses, 210 (62,13%) eram do sexo feminino. A estenose mitral estava presente em 218 pacientes (64,4%), a protese biologica mitral em 64 (18,9%) e a insuficiencia da valva mitral em 56 (16,5%). O sangramento ocorreu em 65 pacientes (19,2%) e de forma grave em 7 (10%). Em 38/65 pacientes (58,5%), identificou-se nova doenca associada, facilitadora do sangramento. Em 100% dos pacientes com sangramento na faixa terapeutica, foi encontrada doenca associada, contra 49,05% de diagnostico de doencas associadas naqueles com INR > 3,5 (p = 0,001). CONCLUSAO: O diagnostico de doenca local associada ao sangramento foi frequente entre os medicados com anticoagulante oral (58,5%). Houve associacao entre sangramento com INR na faixa terapeutica (INR 2,0-3,5) e diagnostico de patologia predisponente a sangramento (p < 0,001). Em pacientes em uso de anticoagulante oral que apresentam sangramento, e mandatoria a investigacao da causa, sobretudo se a INR estiver na faixa terapeutica.

Varfarina ou Aspirina na prevenção de fenômenos embólicos na valvopatia mitral com fibrilação atrial

BACKGROUND: Atrial fibrillation (AF) associated to rheumatic mitral valve disease (RMVD) increases the incidence of thromboembolism (TE), with warfarin being the standard therapy, in spite of difficulties in treatment adherence and therapeutic control. OBJECTIVE: To compare the effectiveness of Aspirin vs Warfarin in TE prevention in patients with AF and RMVD. METHODS: A total of 229 patients (pts) with AF and RMVD were followed in a prospective and randomized study. The first group consisted of 110 pts receiving Aspirin - 200 mg/day (Group Aspirin - GA) and the second group consisted of 119 pts receiving Warfarin at individually-adjusted doses (Group Warfarin - GW). RESULTS: There were 15 embolic events in GA and 24 in GW (p = 0.187), of which 21 presented INR < 2.0. Thus, after excluding patients with inadequate INR, there was a higher number of embolic events in GA than in GW (15 vs 3) (p < 0.0061). The GW showed lower treatment adherence (p = 0.001). Neither group presented episodes of major bleeding. Small bleeding episodes were more frequent in the GW (p < 0.01). Increased serum levels of cholesterol and triglycerides constituted a risk factor for a higher number of thromboembolic events in the studied population, with no difference between the groups. CONCLUSION: In patients presenting RMVD with AF for less than a year and no previous embolism, Aspirin is little effective in preventing TE. Patients with lower-risk mitral valvulopathy (mitral regurgitation and mitral biological prosthesis), especially in cases presenting contraindication to or low adherence to Warfarin, Aspirin use can present some benefit in TE prevention.BACKGROUNDnAtrial fibrillation (AF) associated to rheumatic mitral valve disease (RMVD) increases the incidence of thromboembolism (TE), with warfarin being the standard therapy, in spite of difficulties in treatment adherence and therapeutic control.nnnOBJECTIVEnTo compare the effectiveness of Aspirin vs Warfarin in TE prevention in patients with AF and RMVD.nnnMETHODSnA total of 229 patients (pts) with AF and RMVD were followed in a prospective and randomized study. The first group consisted of 110 pts receiving Aspirin - 200 mg/day (Group Aspirin - GA) and the second group consisted of 119 pts receiving Warfarin at individually-adjusted doses (Group Warfarin - GW).nnnRESULTSnThere were 15 embolic events in GA and 24 in GW (p = 0.187), of which 21 presented INR < 2.0. Thus, after excluding patients with inadequate INR, there was a higher number of embolic events in GA than in GW (15 vs 3) (p < 0.0061). The GW showed lower treatment adherence (p = 0.001). Neither group presented episodes of major bleeding. Small bleeding episodes were more frequent in the GW (p < 0.01). Increased serum levels of cholesterol and triglycerides constituted a risk factor for a higher number of thromboembolic events in the studied population, with no difference between the groups.nnnCONCLUSIONnIn patients presenting RMVD with AF for less than a year and no previous embolism, Aspirin is little effective in preventing TE. Patients with lower-risk mitral valvulopathy (mitral regurgitation and mitral biological prosthesis), especially in cases presenting contraindication to or low adherence to Warfarin, Aspirin use can present some benefit in TE prevention.

Warfarin or Aspirin in embolism prevention in patients with mitral valvulopathy and atrial fibrillation

BACKGROUND: Atrial fibrillation (AF) associated to rheumatic mitral valve disease (RMVD) increases the incidence of thromboembolism (TE), with warfarin being the standard therapy, in spite of difficulties in treatment adherence and therapeutic control. OBJECTIVE: To compare the effectiveness of Aspirin vs Warfarin in TE prevention in patients with AF and RMVD. METHODS: A total of 229 patients (pts) with AF and RMVD were followed in a prospective and randomized study. The first group consisted of 110 pts receiving Aspirin - 200 mg/day (Group Aspirin - GA) and the second group consisted of 119 pts receiving Warfarin at individually-adjusted doses (Group Warfarin - GW). RESULTS: There were 15 embolic events in GA and 24 in GW (p = 0.187), of which 21 presented INR < 2.0. Thus, after excluding patients with inadequate INR, there was a higher number of embolic events in GA than in GW (15 vs 3) (p < 0.0061). The GW showed lower treatment adherence (p = 0.001). Neither group presented episodes of major bleeding. Small bleeding episodes were more frequent in the GW (p < 0.01). Increased serum levels of cholesterol and triglycerides constituted a risk factor for a higher number of thromboembolic events in the studied population, with no difference between the groups. CONCLUSION: In patients presenting RMVD with AF for less than a year and no previous embolism, Aspirin is little effective in preventing TE. Patients with lower-risk mitral valvulopathy (mitral regurgitation and mitral biological prosthesis), especially in cases presenting contraindication to or low adherence to Warfarin, Aspirin use can present some benefit in TE prevention.BACKGROUNDnAtrial fibrillation (AF) associated to rheumatic mitral valve disease (RMVD) increases the incidence of thromboembolism (TE), with warfarin being the standard therapy, in spite of difficulties in treatment adherence and therapeutic control.nnnOBJECTIVEnTo compare the effectiveness of Aspirin vs Warfarin in TE prevention in patients with AF and RMVD.nnnMETHODSnA total of 229 patients (pts) with AF and RMVD were followed in a prospective and randomized study. The first group consisted of 110 pts receiving Aspirin - 200 mg/day (Group Aspirin - GA) and the second group consisted of 119 pts receiving Warfarin at individually-adjusted doses (Group Warfarin - GW).nnnRESULTSnThere were 15 embolic events in GA and 24 in GW (p = 0.187), of which 21 presented INR < 2.0. Thus, after excluding patients with inadequate INR, there was a higher number of embolic events in GA than in GW (15 vs 3) (p < 0.0061). The GW showed lower treatment adherence (p = 0.001). Neither group presented episodes of major bleeding. Small bleeding episodes were more frequent in the GW (p < 0.01). Increased serum levels of cholesterol and triglycerides constituted a risk factor for a higher number of thromboembolic events in the studied population, with no difference between the groups.nnnCONCLUSIONnIn patients presenting RMVD with AF for less than a year and no previous embolism, Aspirin is little effective in preventing TE. Patients with lower-risk mitral valvulopathy (mitral regurgitation and mitral biological prosthesis), especially in cases presenting contraindication to or low adherence to Warfarin, Aspirin use can present some benefit in TE prevention.

Bleeding during oral anticoagulant therapy: warning against a greater hazard

BACKGROUNDnBleeding is one of the main concerns in patients undergoing oral anticoagulation therapy.nnnOBJECTIVEnTo investigate the determinant causes of bleeding in patients undergoing oral anticoagulant therapy.nnnMETHODSnA total of 360 patients with atrial fibrillation (AF) undergoing oral anticoagulant (ACo) therapy, with a target INR of 2.0-3.5, were followed prospectively for a period of 48 +/- 7.2 months. The patients were evaluated on average every 30 days and were investigated regarding the presence of associated pathology that could lead to bleeding.nnnRESULTSnA total of 338 patients participated in the present study. Of these, 210 (62.13%) were females. Mitral stenosis was present in 218 patients (64.4%), a mitral biological prosthesis in 64 (18.9%) and mitral valve failure in 56 (16.5%) patients. Bleeding occurred in 65 patients (19.2%), being severe in 7 (10%) patients. In 38/65 patients, a new associated disease was identified, which facilitated bleeding. An associated disease was identified in 100% of the patients with bleeding within the therapeutic range, against 49.05% of associated disease diagnosis in those with an INR > 3.5 (p=0.001).nnnCONCLUSIONnThe diagnosis of a local disease associated to the bleeding was frequent among those patients undergoing oral anticoagulant therapy (58.5%). There was an association between bleeding with an INR within the therapeutic range (INR=2.0-3.5) and the diagnosis of a pathology predisposing to bleeding (p<0.001). It is mandatory to investigate the cause of bleeding in patients undergoing oral anticoagulant therapy, especially if the INR is within the therapeutic range.FUNDAMENTO: Sangramento e uma das grandes preocupacoes em pacientes sob anticoagulacao oral. OBJETIVO: Investigar causas determinantes do sangramento em usuarios de anticoagulante oral. METODOS: Foram acompanhados prospectivamente, por 48 ± 7,2 meses, 360 pacientes com fibrilacao atrial (FA), todos em uso de anticoagulante oral (ACo) com INR-alvo de 2,0-3,5, avaliados em media a cada 30 dias. Os pacientes foram investigados quanto a presenca de patologia associada que levasse a sangramento. RESULTADOS: Participaram deste estudo 338 pacientes. Desses, 210 (62,13%) eram do sexo feminino. A estenose mitral estava presente em 218 pacientes (64,4%), a protese biologica mitral em 64 (18,9%) e a insuficiencia da valva mitral em 56 (16,5%). O sangramento ocorreu em 65 pacientes (19,2%) e de forma grave em 7 (10%). Em 38/65 pacientes (58,5%), identificou-se nova doenca associada, facilitadora do sangramento. Em 100% dos pacientes com sangramento na faixa terapeutica, foi encontrada doenca associada, contra 49,05% de diagnostico de doencas associadas naqueles com INR > 3,5 (p = 0,001). CONCLUSAO: O diagnostico de doenca local associada ao sangramento foi frequente entre os medicados com anticoagulante oral (58,5%). Houve associacao entre sangramento com INR na faixa terapeutica (INR 2,0-3,5) e diagnostico de patologia predisponente a sangramento (p < 0,001). Em pacientes em uso de anticoagulante oral que apresentam sangramento, e mandatoria a investigacao da causa, sobretudo se a INR estiver na faixa terapeutica.

Varfarina o aspirina en la prevención de fenómenos embólicos en la valvopatía mitral con fibrilación atrial

BACKGROUND: Atrial fibrillation (AF) associated to rheumatic mitral valve disease (RMVD) increases the incidence of thromboembolism (TE), with warfarin being the standard therapy, in spite of difficulties in treatment adherence and therapeutic control. OBJECTIVE: To compare the effectiveness of Aspirin vs Warfarin in TE prevention in patients with AF and RMVD. METHODS: A total of 229 patients (pts) with AF and RMVD were followed in a prospective and randomized study. The first group consisted of 110 pts receiving Aspirin - 200 mg/day (Group Aspirin - GA) and the second group consisted of 119 pts receiving Warfarin at individually-adjusted doses (Group Warfarin - GW). RESULTS: There were 15 embolic events in GA and 24 in GW (p = 0.187), of which 21 presented INR < 2.0. Thus, after excluding patients with inadequate INR, there was a higher number of embolic events in GA than in GW (15 vs 3) (p < 0.0061). The GW showed lower treatment adherence (p = 0.001). Neither group presented episodes of major bleeding. Small bleeding episodes were more frequent in the GW (p < 0.01). Increased serum levels of cholesterol and triglycerides constituted a risk factor for a higher number of thromboembolic events in the studied population, with no difference between the groups. CONCLUSION: In patients presenting RMVD with AF for less than a year and no previous embolism, Aspirin is little effective in preventing TE. Patients with lower-risk mitral valvulopathy (mitral regurgitation and mitral biological prosthesis), especially in cases presenting contraindication to or low adherence to Warfarin, Aspirin use can present some benefit in TE prevention.BACKGROUNDnAtrial fibrillation (AF) associated to rheumatic mitral valve disease (RMVD) increases the incidence of thromboembolism (TE), with warfarin being the standard therapy, in spite of difficulties in treatment adherence and therapeutic control.nnnOBJECTIVEnTo compare the effectiveness of Aspirin vs Warfarin in TE prevention in patients with AF and RMVD.nnnMETHODSnA total of 229 patients (pts) with AF and RMVD were followed in a prospective and randomized study. The first group consisted of 110 pts receiving Aspirin - 200 mg/day (Group Aspirin - GA) and the second group consisted of 119 pts receiving Warfarin at individually-adjusted doses (Group Warfarin - GW).nnnRESULTSnThere were 15 embolic events in GA and 24 in GW (p = 0.187), of which 21 presented INR < 2.0. Thus, after excluding patients with inadequate INR, there was a higher number of embolic events in GA than in GW (15 vs 3) (p < 0.0061). The GW showed lower treatment adherence (p = 0.001). Neither group presented episodes of major bleeding. Small bleeding episodes were more frequent in the GW (p < 0.01). Increased serum levels of cholesterol and triglycerides constituted a risk factor for a higher number of thromboembolic events in the studied population, with no difference between the groups.nnnCONCLUSIONnIn patients presenting RMVD with AF for less than a year and no previous embolism, Aspirin is little effective in preventing TE. Patients with lower-risk mitral valvulopathy (mitral regurgitation and mitral biological prosthesis), especially in cases presenting contraindication to or low adherence to Warfarin, Aspirin use can present some benefit in TE prevention.

Sangrado durante la anticoagulación oral: alerta sobre un mal mayor

BACKGROUNDnBleeding is one of the main concerns in patients undergoing oral anticoagulation therapy.nnnOBJECTIVEnTo investigate the determinant causes of bleeding in patients undergoing oral anticoagulant therapy.nnnMETHODSnA total of 360 patients with atrial fibrillation (AF) undergoing oral anticoagulant (ACo) therapy, with a target INR of 2.0-3.5, were followed prospectively for a period of 48 +/- 7.2 months. The patients were evaluated on average every 30 days and were investigated regarding the presence of associated pathology that could lead to bleeding.nnnRESULTSnA total of 338 patients participated in the present study. Of these, 210 (62.13%) were females. Mitral stenosis was present in 218 patients (64.4%), a mitral biological prosthesis in 64 (18.9%) and mitral valve failure in 56 (16.5%) patients. Bleeding occurred in 65 patients (19.2%), being severe in 7 (10%) patients. In 38/65 patients, a new associated disease was identified, which facilitated bleeding. An associated disease was identified in 100% of the patients with bleeding within the therapeutic range, against 49.05% of associated disease diagnosis in those with an INR > 3.5 (p=0.001).nnnCONCLUSIONnThe diagnosis of a local disease associated to the bleeding was frequent among those patients undergoing oral anticoagulant therapy (58.5%). There was an association between bleeding with an INR within the therapeutic range (INR=2.0-3.5) and the diagnosis of a pathology predisposing to bleeding (p<0.001). It is mandatory to investigate the cause of bleeding in patients undergoing oral anticoagulant therapy, especially if the INR is within the therapeutic range.FUNDAMENTO: Sangramento e uma das grandes preocupacoes em pacientes sob anticoagulacao oral. OBJETIVO: Investigar causas determinantes do sangramento em usuarios de anticoagulante oral. METODOS: Foram acompanhados prospectivamente, por 48 ± 7,2 meses, 360 pacientes com fibrilacao atrial (FA), todos em uso de anticoagulante oral (ACo) com INR-alvo de 2,0-3,5, avaliados em media a cada 30 dias. Os pacientes foram investigados quanto a presenca de patologia associada que levasse a sangramento. RESULTADOS: Participaram deste estudo 338 pacientes. Desses, 210 (62,13%) eram do sexo feminino. A estenose mitral estava presente em 218 pacientes (64,4%), a protese biologica mitral em 64 (18,9%) e a insuficiencia da valva mitral em 56 (16,5%). O sangramento ocorreu em 65 pacientes (19,2%) e de forma grave em 7 (10%). Em 38/65 pacientes (58,5%), identificou-se nova doenca associada, facilitadora do sangramento. Em 100% dos pacientes com sangramento na faixa terapeutica, foi encontrada doenca associada, contra 49,05% de diagnostico de doencas associadas naqueles com INR > 3,5 (p = 0,001). CONCLUSAO: O diagnostico de doenca local associada ao sangramento foi frequente entre os medicados com anticoagulante oral (58,5%). Houve associacao entre sangramento com INR na faixa terapeutica (INR 2,0-3,5) e diagnostico de patologia predisponente a sangramento (p < 0,001). Em pacientes em uso de anticoagulante oral que apresentam sangramento, e mandatoria a investigacao da causa, sobretudo se a INR estiver na faixa terapeutica.

Mini-sternotomy for the treatment of aortic valve lesions

OBJECTIVEnTo compare inverted-L mini-sternotomy performed above the sternal furcula with conventional sternotomy in patients with aortic valve diseases who undergo surgical treatment.nnnMETHODSnWe operated upon 30 patients who had aortic valve lesions that had clinical and hemodynamic findings. All patients underwent inverted-L sternotomy, which extended from above the manubrium of the sternum to the 3rd right intercostal space, without opening the pleural cavity. Their ages ranged from 32 to 76 years, and 18 were males and 12 were females. We used negative pressure in a venous 1/4-inch cannula, and the patients were maintained in Trendelemburgs position. Twenty-seven patients received bioprostheses with diameters ranging from 23 to 29mm. Three patients underwent only removal of the calcifications of the aortic valve leaflets and aortic commissurotomy.nnnRESULTSnThe mean duration of anoxic cardiac arrest was 63.11min. Access was considered good in all patients. One death was due to pulmonary and renal problems not related to the incision. All patients had a better recovery in the intensive care unit, got out of bed sooner, coughed more easily, and performed prophylactic physiotherapeutic maneuvers for respiratory problems more easily and with less pain in the incision. Early ambulation was more easily carried out by all patients.nnnCONCLUSIONnMini-sternotomy proved to be better than the conventional sternotomy because it provided more comfort for the patients in the early postoperative period, with less pain and greater desire for early ambulation and all its inherent advantages.