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Arquivos Brasileiros de Cardiologia Apr 2021Myocardial reperfusion is a fundamental part of the treatment for ST elevation myocardial infarction (STEMI) and is responsible for reducing morbidity and mortality in...
BACKGROUND
Myocardial reperfusion is a fundamental part of the treatment for ST elevation myocardial infarction (STEMI) and is responsible for reducing morbidity and mortality in affected patients. However, reperfusion rates are usually lower and mortality rates higher in women compared to men.
OBJECTIVES
To evaluate the prevalence of the use of reperfusion therapies among women and men with STEMI in hospitals where percutaneous coronary intervention (PCI) is available in the state of Sergipe.
METHODS
This is a cross-sectional study that used data from the VICTIM Register. Patients diagnosed with STEMI admitted to the four hospitals (one public and three private) where PCI is available in the state of Sergipe were evaluated, from December 2014 to June 2018. A multivariate analysis with adjusted model using mortality as a dependent variable was made. In all analyses, the level of significance adopted was 5% (p < 0.05).
RESULTS
A total of 878 volunteers with a confirmed diagnosis of STEMI, of which 33.4% were women, were included in the study. Only 53.3% of the patients underwent myocardial reperfusion (134 women versus 334 men). Fibrinolysis was performed only in 2.3% of all patients (1.7% of women versus 2.6% of men; p = 0.422). The rate of primary PCI was lower (44% versus 54.5%; p = 0.003) and hospital mortality was higher (16.1% versus 6.7%; p < 0.001) in women than in men.
CONCLUSION
Women have significantly lower rates of primary PCI and higher hospital mortality. Reperfusion rates were low in both sexes and there was a clear underutilization of thrombolytic agents.
Topics: Brazil; Cross-Sectional Studies; Female; Hospital Mortality; Humans; Male; Myocardial Reperfusion; Percutaneous Coronary Intervention; ST Elevation Myocardial Infarction; Thrombolytic Therapy; Treatment Outcome
PubMed: 33886713
DOI: 10.36660/abc.20190468 -
Journal of Cerebral Blood Flow and... May 2021While the time window for reperfusion after ischemic stroke continues to increase, many patients are not candidates for reperfusion under current guidelines that allow... (Comparative Study)
Comparative Study Review
While the time window for reperfusion after ischemic stroke continues to increase, many patients are not candidates for reperfusion under current guidelines that allow for reperfusion within 24 h after last known well time; however, many case studies report favorable outcomes beyond 24 h after symptom onset for both spontaneous and medically induced recanalization. Furthermore, modern imaging allows for identification of penumbra at extended time points, and reperfusion risk factors and complications are becoming better understood. Taken together, continued urgency exists to better understand the pathophysiologic mechanisms and ideal setting of delayed recanalization beyond 24 h after onset of ischemia.
Topics: Brain; Cerebral Blood Volume; Cerebrovascular Circulation; Child; Combined Modality Therapy; Diffusion Magnetic Resonance Imaging; Female; Fibrinolytic Agents; Humans; Ischemic Stroke; Magnetic Resonance Angiography; Male; Mechanical Thrombolysis; Middle Aged; Reperfusion; Risk Factors; Thrombolytic Therapy; Time Factors; Time-to-Treatment; Tissue Plasminogen Activator; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 33325765
DOI: 10.1177/0271678X20978861 -
CNS Neuroscience & Therapeutics Feb 2024In the field of stroke thrombectomy, ineffective clinical and angiographic reperfusion after successful recanalization has drawn attention. Partial or complete... (Review)
Review
In the field of stroke thrombectomy, ineffective clinical and angiographic reperfusion after successful recanalization has drawn attention. Partial or complete microcirculatory reperfusion failure after the achievement of full patency of a former obstructed large vessel, known as the "no-reflow phenomenon" or "microvascular obstruction," was first reported in the 1960s and was later detected in both experimental models and patients with stroke. The no-reflow phenomenon (NRP) was reported to result from intraluminal occlusions formed by blood components and extraluminal constriction exerted by the surrounding structures of the vessel wall. More recently, an emerging number of clinical studies have estimated the prevalence of the NRP in stroke patients following reperfusion therapy, ranging from 3.3% to 63% depending on its evaluation methods or study population. Studies also demonstrated its detrimental effects on infarction progress and neurological outcomes. In this review, we discuss the research advances, underlying pathogenesis, diagnostic techniques, and management approaches concerning the no-reflow phenomenon in the stroke population to provide a comprehensive understanding of this phenomenon and offer references for future investigations.
Topics: Humans; No-Reflow Phenomenon; Microcirculation; Stroke; Thrombectomy; Reperfusion; Treatment Outcome
PubMed: 38358074
DOI: 10.1111/cns.14631 -
Neurotherapeutics : the Journal of the... Apr 2023Racial and ethnic inequities in stroke care are ubiquitous. Acute reperfusion therapies, i.e., IV thrombolysis (IVT) and mechanical thrombectomy (MT), are central to... (Review)
Review
Racial and ethnic inequities in stroke care are ubiquitous. Acute reperfusion therapies, i.e., IV thrombolysis (IVT) and mechanical thrombectomy (MT), are central to acute stroke care and are highly efficacious at preventing death and disability after stroke. Disparities in the use of IVT and MT in the USA are pervasive and contribute to worse outcomes among racial and ethnic minority individuals with ischemic stroke. A meticulous understanding of disparities and underlying root causes is necessary in order to develop targeted mitigation strategies with lasting effects. This review details racial and ethnic disparities in the use of IVT and MT after stroke and highlights inequities in the underlying process measures as well as the contributing root causes. Furthermore, this review spotlights the systemic and structural inequities that contribute to race-based differences in the use of IVT and MT, including geographic and regional differences and differences based on neighborhood, zip code, and hospital type. In addition, recent promising trends suggesting improvements in racial and ethnic IVT and MT disparities and potential approaches for future solutions to achieve equity in stroke care are briefly discussed.
Topics: Humans; Thrombectomy; Ethnicity; Brain Ischemia; Treatment Outcome; Minority Groups; Stroke; Reperfusion
PubMed: 37219714
DOI: 10.1007/s13311-023-01388-y -
Journal of the American Heart... Feb 2019See Editorial by Cenko et al.
See Editorial by Cenko et al.
Topics: Female; Heart; Humans; Male; Myocardial Infarction; Myocardial Reperfusion; Thrombolytic Therapy
PubMed: 30767600
DOI: 10.1161/JAHA.118.011835 -
European Journal of Neurology Jul 2022Reperfusion therapy is the mainstay of treatment for acute ischaemic stroke (AIS); however, little is known about the use of reperfusion therapy and time delay amongst...
BACKGROUND AND PURPOSE
Reperfusion therapy is the mainstay of treatment for acute ischaemic stroke (AIS); however, little is known about the use of reperfusion therapy and time delay amongst immigrants.
METHODS
This is a Danish nationwide register-based cohort study of patients with AIS aged ≥18 years (n = 49,817) recruited from 2009 to 2018. Use of reperfusion therapy (intravenous thrombolysis and/or mechanical thrombectomy) and time delay between immigrants and Danish-born residents were compared using multivariable logistics and quantile regression.
RESULTS
Overall, 10,649 (39.8%) Danish-born residents and 452 (39.0%) immigrants with AIS were treated with reperfusion therapy in patients arriving <4.5 h following stroke onset. Compared with Danish-born residents, immigrants had lower odds of receiving reperfusion therapy after adjustment for prehospital delay, age, sex, stroke severity, sociodemographic factors and comorbidities (adjusted odds ratio 0.67; 95% confidence interval 0.49-0.92, p = 0.01). The lowest odds were observed amongst immigrants originating from Poland and non-Western countries. Similarly, immigrants had a longer prehospital delay than Danish-born residents in the fully adjusted model in patients arriving <4.5 h after stroke onset (15 min; 95% confidence interval 4-26 min, p = 0.03). No evidence was found that system delay and clinical outcome differed between immigrants and Danish-born residents in patients eligible for reperfusion therapy after adjustment for sociodemographic factors and comorbidities.
CONCLUSION
Immigration status was significantly associated with lower chances of receiving reperfusion therapy and there may be differences in patient delay between immigrants and Danish-born residents in patients arriving to a stroke unit <4.5 h after stroke onset.
Topics: Adolescent; Adult; Brain Ischemia; Cohort Studies; Denmark; Emigration and Immigration; Humans; Ischemic Stroke; Reperfusion; Stroke; Treatment Outcome
PubMed: 35212085
DOI: 10.1111/ene.15303 -
Arquivos de Neuro-psiquiatria Dec 2023Over the last three decades, stroke care has undergone significant transformations mainly driven by the introduction of reperfusion therapy and the organization of... (Review)
Review
Over the last three decades, stroke care has undergone significant transformations mainly driven by the introduction of reperfusion therapy and the organization of systems of care. Patients receiving treatment through a well-structured stroke service have a much higher chance of favorable outcomes, thereby decreasing both disability and mortality. In this article, we reviewed the scientific evidence for stroke reperfusion therapy, including thrombolysis and thrombectomy, and its implementation in the public health system in Brazil.
Topics: Humans; Ischemic Stroke; Brain Ischemia; Stroke; Thrombectomy; Thrombolytic Therapy; Reperfusion; Treatment Outcome
PubMed: 38157871
DOI: 10.1055/s-0043-1777721 -
American Heart Journal Nov 2015More than 20 years of misconceptions derailed acceptance of reperfusion therapy for acute myocardial infarction (AMI). Cardiologists abandoned reperfusion for AMI using... (Review)
Review
More than 20 years of misconceptions derailed acceptance of reperfusion therapy for acute myocardial infarction (AMI). Cardiologists abandoned reperfusion for AMI using fibrinolytic therapy, explored in 1958, because they no longer attributed myocardial infarction to coronary thrombosis. Emergent aortocoronary bypass surgery, pioneered in 1968, remained controversial because of the misconception that hemorrhage into reperfused myocardium would result in infarct extension. Attempts to limit infarct size by pharmacotherapy without reperfusion dominated research in the 1970s. Myocardial necrosis was assumed to progress slowly, in a lateral direction. At least 18 hours was believed to be available for myocardial salvage. Afterload reduction and improvement of the microcirculation, but not reperfusion, were thought to provide the benefit of streptokinase therapy. Finally, coronary vasospasm was hypothesized to be the central mechanism in the pathogenesis of AMI. These misconceptions unraveled in the late 1970s. Myocardial necrosis was shown to progress in a transmural direction, as a "wave front," beginning with the subendocardium. Reperfusion within 6 hours salvaged a subepicardial ischemic zone in experimental animals. Acute angiography provided in vivo evidence of the high incidence of total coronary occlusion in the first hours of AMI. In 1978, early reperfusion by transluminal recanalization was shown to be feasible. The pathogenetic role of coronary thrombosis was definitively established in 1979 by demonstrating that intracoronary streptokinase rapidly restored flow in occluded infarct-related arteries, in contrast to intracoronary nitroglycerine which rarely did. The modern reperfusion era had dawned.
Topics: Humans; Myocardial Infarction; Myocardial Reperfusion
PubMed: 26542507
DOI: 10.1016/j.ahj.2015.08.005 -
BMC Neurology Jan 2018Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with... (Review)
Review
Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with acute ischemic stroke (AIS). In this paper, we present an extensive overview of intravenous and endovascular reperfusion strategies, recent advances in AIS neurointervention, limitations of various treatment paradigms, and provide insights on imaging-guided reperfusion therapies. A roadmap for imaging guided reperfusion treatment workflow in AIS is also proposed. Both systemic thrombolysis and endovascular treatment have been incorporated into the standard of care in stroke therapy. Further research on advanced imaging-based approaches to select appropriate patients, may widen the time-window for patient selection and would contribute immensely to early thrombolytic strategies, better recanalization rates, and improved clinical outcomes.
Topics: Brain Ischemia; Endovascular Procedures; Fibrinolytic Agents; Humans; Patient Selection; Reperfusion; Stroke; Thrombolytic Therapy; Treatment Outcome
PubMed: 29338750
DOI: 10.1186/s12883-017-1007-y -
Annals of Clinical and Translational... Jun 2023Intracranial arterial calcification (IAC) is a risk factor of ischemic stroke. However, the relationship between IAC patterns and clinical outcome of ischemic stroke...
OBJECTIVE
Intracranial arterial calcification (IAC) is a risk factor of ischemic stroke. However, the relationship between IAC patterns and clinical outcome of ischemic stroke remains controversial. We aimed to investigate the correlation between IAC patterns and the effects of reperfusion therapy among acute stroke patients.
METHODS
Consecutive acute ischemic stroke patients who underwent reperfusion therapy were included. IAC was categorized as intimal or medial. Based on its involvement, IAC was further classified as diffuse or focal. Neurologic dysfunction was assessed by the National Institute of Health stroke scale (NIHSS). Clinical outcome including favorable neurologic outcome (FNO) and early neurologic deterioration (END) were assessed.
RESULTS
Of 130 patients, 117 had IAC. Intimal IAC was identified in 74.6% of patients and medial IAC was present in 64.6% of patients. Diffuse IAC was present in 31.5% of patients. All diffuse IACs were medial pattern. Diffuse IAC was associated with higher baseline NIHSS (p = 0.011) and less FNO (p = 0.047). Compared with patients with focal or single diffuse IAC, patients with multiple diffuse IAC had higher baseline NIHSS (p = 0.002) and less FNO (p = 0.024). Multivariable linear regression (p < 0.001) and logistic regression (p = 0.027) suggested that multiple diffuse IAC was associated with higher baseline NIHSS and less FNO. No significant association was found between END and different IAC patterns.
INTERPRETATION
Multiple diffuse medial IAC may predict severer neurologic dysfunction and less favorable neurologic outcome after reperfusion therapy in acute stroke patients.
Topics: Humans; Brain Ischemia; Ischemic Stroke; Stroke; Risk Factors; Reperfusion
PubMed: 37088543
DOI: 10.1002/acn3.51780