Author: Maramelia Miranda

Abstract saído do forno, super highlight do congresso da AHA de Chicago, na semana passada… Exemplo claro de como obviedades podem ser jogadas no lixo com simples matemática e estatística.

A Randomised Controlled Trial of Oxygen Therapy in Acute St-segment Elevation Myocardial Infarction: The Air Versus Oxygen in Myocardial Infarction (AVOID) Study

Autores::: Dion Stub et al.

Local::: Australia.

Abstract

Background: Oxygen is commonly administered to patients with ST-elevation myocardial infarction (STEMI) despite previous studies suggesting a possible increase in myocardial injury due to coronary vasoconstriction and heightened oxidative stress.

Methods: We conducted a multicenter, prospective, randomized, controlled trial comparing oxygen (8 L/min) with no supplemental oxygen in patients with STEMI diagnosed on paramedic 12-lead electrocardiogram. Of 638 patients randomized, 441 were confirmed STEMI patients who underwent primary endpoint analysis. The primary endpoint was myocardial infarct size as assessed by cardiac enzymes, troponin (cTnI) and creatine kinase (CK). Secondary endpoints included recurrent myocardial infarction, cardiac arrhythmia and myocardial infarct size assessed by cardiac magnetic resonance (CMR) imaging at 6 months.

Results: There was a significant increase in mean peak CK in the oxygen group compared to the no oxygen group (1948 U/Lvs.1543 U/L; means ratio, 1.27; 95% CI, 1.04 to 1.52; P= 0.01). Mean peak troponin was similar in the oxygen and no oxygen groups (57.4 mcg/L vs. 48.0 mcg/L; ratio, 1.20; 95% confidence interval [CI], 0.92 to 1.56;P=0.18).There was an increase in the rate of recurrent myocardial infarction in the oxygen group compared to the no oxygen group (5.5%vs.0.9%, P=0.006) and an increase in frequency of cardiac arrhythmia (40.4%vs.31.4%; P=0.05). At 6-months the oxygen group had an increase in myocardial infarct size on CMR n=139;20.3grams vs. 13.1grams; P=0.04).

Conclusion: Supplemental oxygen therapy in patients with STEMI but without hypoxia increased early myocardial injury and was associated with larger myocardial infarct size assessed at six months.

Para o coração, faz mal. E para o cérebro?

Mais uma “siglinha” para se decorar… Guardem: É um dos Hot Topics de 2014. 

Critérios clínicos do AVC do tipo ESUS:

• AVCi não-lacunar detectado por TC ou RM (ou seja, características neurorradiológicas de embolia)
• Ausência de estenose / aterosclerose intra ou extracraniana (estenose> 50%) na neuroimagem vascular (AngioTC ou AngioRM), no território do AVC ocorrido
• Ausência de fonte emboligênica de alto risco no ECO TE e Holter de pelo menos 24h de monitoração (Flutter, FA, FEVE < 30%, valvulopatia, etc)
• Nenhuma outra causa possível de AVCi (vasculite, dissecção, espasmo cerebral, etc)

Estou falando grego pra você? Viajou na maionese? Corra. Vá estudar! Hart RG et al. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol 2014.

Determinants of antithrombotic choice for patent foramen ovale in cryptogenic stroke

Autores::: Thaler et al.

Local: Boston, MA; Germany; Girona, Spain; University of Bern; Zurich, Switzerland; Cambridge University, UK; Columbia University, NY; Switzerland; University of Bern, Switzerland; Cleveland, OH.

Revista: Neurology 2014.

Abstract

Efficacy and Safety of Novel Oral Anticoagulants in Patients with Cervical Artery Dissections

Autor: Caprio et al.  Revista: Cerebrovasc Diseases 2014.

Local::: Departments of ^aNeurology and ^bRadiology, Northwestern University, Feinberg School of Medicine, Chicago, Ill., ^cDepartment of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas, Tex., USA

Abstract

Background: American and European guidelines support antiplatelet agents and anticoagulants as reasonable treatments of cervical artery dissection (CAD), though randomized clinical trials are lacking. The utility of novel oral anticoagulants (NOAC), effective in reducing embolic stroke risk in non-valvular atrial fibrillation (NVAF), has not been reported in patients with CAD. We report on the use, safety, and efficacy of NOACs in the treatment of CAD.

Methods: We retrospectively identified patients diagnosed with CAD at a single academic center between January 2010 and August 2013. Patients were categorized by their antithrombotic treatment at hospital discharge with a NOAC (dabigatran, rivaroxaban, or apixaban), traditional anticoagulant (AC: warfarin or treatment dose low-molecular weight heparin), or antiplatelet agent (AP: aspirin, clopidogrel, or aspirin/extended-release dypyridamole). Using appropriate tests, we compared the baseline medical history, presenting clinical symptoms and initial radiographic characteristics among patients in the 3 treatment groups. We then evaluated for the following outcomes: recurrent stroke, vessel recanalization, and bleeding complications. p values <0.05 were considered significant.

Results: Of the 149 included patients (mean age 43.4 years; 63.1% female; 70.5% vertebral artery CAD), 39 (26.2%), 70 (47.0%), and 40 (26.8%) were treated with a NOAC, AC, and AP, respectively. More patients with severe stenosis or occlusion were treated with NOAC than with AC or AP (61.8 vs. 60.0 vs. 22.5%, p = 0.002). Other baseline clinical and radiographic findings, including the presence of acute infarction and hematoma, did not differ between the 3 treatment groups. One hundred and thirty-five (90.6%) patients had clinical follow-up (median time 7.5 months) and 125 (83.9%) had radiographic follow-up (median time 5 months) information. There were 2 recurrent strokes in the NOAC group and 1 in each of the AC and AP groups (p = 0.822). There were more major hemorrhagic events in the AC group (11.4%) compared to the NOAC (0.0%) and AP (2.5%) groups (p = 0.034). Three patients treated with NOAC and none treated with AC or AP had a worsened degree of stenosis on follow-up imaging (8.6 vs. 0.0 vs. 0.0%, p = 0.019).

Conclusion: Compared to traditional anticoagulants for CAD, treatment with NOACs is associated with similar rates of recurrent stroke, fewer hemorrhagic complications, but greater rates of radiographic worsening. These data suggest that NOACs may be a reasonable alternative in the management of CAD. Prospective validation of these findings is needed.

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Depois comento.

Notícia boa para nossos queridos amigos intervencionistas!!!!!

Foram apresentados no Congresso Mundial de AVC, em Istambul, novos dados do estudo IMS III, que avaliou rTPA endovenoso (sistêmico) versus rTPA e terapia endovascular combinada no AVCi agudo, e os resultados iniciais do estudo MR CLEAN (Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands).

Em relação ao IMS-III, os pesquisadores observaram que, na análise de follow-up de 12 meses, embora os pacientes com AVCi mais leves ficaram melhores do que os mais graves, a evidência foi de que, ao contrário do grupo mais leve, a terapia endovascular fez diferença (favoravelmente) no subgrupo de pacientes com AVCi mais severo, quando comparados com a terapia de primeira linha – rTPA EV sozinho.  Lembro aqui que AVCi moderado foi definido pelo trial como NIH de 8-19, e severo > ou igual a 20.

Até então, os dados do IMS-III que tínhamos eram os publicados na NEJM em 2013, que tinha jogado 5476 baldes de água fria na terapia endovascular –> este paper mostrou similaridade dos tratamentos quando medidos desfechos em 90 dias, motivo inclusive de sua interrupção por futilidade.

A melhora ao longo do tempo até a visita de 12m foi de 8% no grupo de AVCi mais grave, versus 2% no grupo moderado.

O “odds ratio” para o efeito do tratamento chegar ao escore de mRS de 0 a 2 foi de 0,95 no subgrupo de AVCi moderado, e 2,37 no grupo severo, isso já ajustadas variáveis como escala de NIH, tempo de início dos sintomas e idade.

Tabela. Desfechos favoráveis em 12 meses (mRS de 0 a 2)

Ou seja, aparentemente, parece haver uma maior diferença, uma melhora maior, mais “tardia”, em relação aos AVCis mais graves que recebem rTPA e terapia endovascular??? Seria isso?! Fiquei algo confusa com estes números. Preciso “digerir” melhor…

Depois volto com os dados do MR CLEAN…

Neurorradiologia ressurgindo das cinzas!!!!! 

Vamos chamar mais os caras!!!!!

Agora não são somente leituras… Vivemos a era dos Downloads… Baixamos tudo que podemos: textos, artigos, apps, programas, PDFs, livros, fotos, arquivos em geral… Enchemos nossos pendrives, nossos HDs, e muitas vezes nem temos tempo de ler, de ver tudo. Essa é a parte ruim, tempo pra ler… Tempo para fuçar o que temos nas mídias…  🙂

Universidades em Perigo. Por Paulo Alcântara Gomes, para o Blog do Noblat. Leiam.

2013 AHA/ASA CV Risk Calculator. App disponível nas principais plataformas, para cálculo de risco cardiovascular.

Meschia et al. Executive Summary: Guidelines for the Primary Prevention of Stroke. A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2014.  Atenção para várias novas recomendações do documento. Vejam tabela no final do artigo.

Abigail Moore. This Is Your Brain on Drugs. Artigo mais enviado desta semana, do NY Times.

Burnett et al. A Simple Text-Messaging Intervention Is Associated With Improved Door-to-Needle Times for Acute Ischemic Stroke. Stroke 2014. Uma medida simples, mas de impacto…

Blumenthal et al. Innovation in Health Care Leadership. NEJM 2014. Na verdade, este material trata-se de uma mesa redonda, um vídeo com os participantes da mesa discutindo inovação na área de Saúde.