Calidad de la anticoagulación oral con antagonistas de la vitamina K: papel del tiempo en rango terapéutico como variable pronóstica de eventos adversos en la fibrilación auricular.

Los Antagonistas de la Vitamina K (AVK) han demostrado ser altamente efectivos reduciendo el ictus y la mortalidad en la fibrilación auricular (FA). Sin embargo, no están exentos de inconvenientes que hacen que su seguridad y efectividad estén determinadas por el adecuado control de los niveles de anticoagulación, reflejado en el tiempo en rango terapéutico (TRT) del Índice Normalizado Internacional (INR) 2,0-3,0. Objetivos: Investigar la asociación del TRT y el cambio en el TRT durante 6 meses (es decir, ΔTRT) con el riesgo de mortalidad y “eventos clínicamente significativos”; analizar la tasa de cese de anticoagulación oral y los factores que predisponen dicho cese, así como su relación con los resultados clínicos adversos; y comparar cuatro esquemas validados de riesgo de sangrado (HAS-BLED, ATRIA, ORBIT y HEMORR2HAGES) para comprobar si la capacidad predictiva y utilidad clínica de ATRIA, ORBIT y HEMORR2HAGES podría mejorar añadiendo el criterio “INR lábil (TRT <65%)”. Métodos: Estudio de carácter observacional, con seguimiento longitudinal prospectivo en único centro (Hospital General Universitario Morales Meseguer). Del 1 de mayo de 2007 al 1 de diciembre de 2007 se reclutaron, consecutivamente, pacientes con FA permanente o paroxística que se encontraran en tratamiento estable con acenocumarol (INR 2,0-3,0) durante al menos los 6 meses previos. Se excluyeron pacientes con válvulas reumáticas o protésicas, síndrome coronario agudo, ictus, angina inestable, hospitalización o intervención quirúrgica en los 6 meses anteriores. A los 6 meses del inicio del estudio se calculó el TRT. Se registraron todos los eventos clínicos durante 6,5 años (RIQ 4,3-7,9). Resultados: Se incluyeron 1361 pacientes (48,7% varones, edad mediana 76 años [RIQ 71-81]). Durante el seguimiento, se produjeron 130 ictus isquémicos, 250 episodios de sangrado mayor y 551 muertes. A los 6 meses, la mediana de ΔTTR fue del 20% (RIQ 0-34). Durante los primeros 6 meses de seguimiento, 34 (4,16%/año) pacientes fallecieron y 61 (7,47%/año) sufrieron eventos clínicamente significativos, siendo la mediana de ΔTRT significativamente superior en estos pacientes. En consecuencia, el riesgo de mortalidad (HR 1,02, IC 95% 1,01-1,04; p=0,003) y de eventos clínicamente significativos (HR 1,01, IC 95% 1,00-1,03; p=0,028) aumentó por punto de disminución del TRT. Durante el seguimiento, el 10% de los pacientes cesó anticoagulación oral. El abandono de la anticoagulación se asoció con el riesgo de mortalidad (p=0,034), eventos cardiovasculares adversos (p=0,043) e ictus isquémico (p=0,009). La edad ≥80 años (p<0,001), la enfermedad coronaria previa (p=0,005) y el desarrollo de algunas comorbilidades asociadas con mayor riesgo hemorrágico, demostraron ser predictoras independientes del cese de anticoagulación oral. De las 250 hemorragias mayores producidas, el 65,2% ocurrió en la categoría de “alto riesgo” HAS-BLED y el 82,4% en la categoría de “medio/alto riesgo” HEMORR2HAGES. Solo el 29,6% y 34% de las hemorragias mayores ocurrieron en las categorías de “medio/alto riesgo” de ATRIA y ORBIT. Todas las escalas predijeron el sangrado mayor, con estadísticos c de 0,625 (p<0,001) para HAS-BLED, y 0,545 (p=0,004), 0,565 (p<0,001) y 0,547 (p=0,007) para ATRIA, ORBIT y HEMORR2HAGES, respectivamente. La comparación de las curvas ROC y el índice de mejoría de la reclasificación confirmaron que HAS-BLED era la escala con el mejor rendimiento predictivo. Tras añadir la baja calidad de la anticoagulación (TRT <65%) a ATRIA, ORBIT y HEMORR2HAGES, la capacidad predictiva y de discriminación de estas escalas se aumentó, mostrando mejoras significativas en el estadístico c, la sensibilidad, reclasificación y beneficio neto. Conclusiones: En pacientes con FA anticoagulados con AVKs, tanto el TRT como el ΔTRT, son factores de riesgo independientes para la mortalidad y los eventos clínicamente significativos. Este riesgo aumenta con cada punto de deterioro del TRT. Por otro lado, el cese de la anticoagulación oral se asocia de manera independientemente con el riesgo de ictus isquémico, eventos cardiovasculares adversos y mortalidad. Los eventos hemorrágicos y algunas variables relacionadas con un mayor riesgo de sangrado causan la mayoría de los ceses de anticoagulación oral. Finalmente, la escala HAS-BLED muestra actualmente la mejor capacidad predictiva de hemorragia mayor. La adición del TRT <65% a las escalas ATRIA, ORBIT y HEMORR2HAGES mejora su valor predictivo de hemorragia mayor, su utilidad clínica y su beneficio neto en comparación con las escalas originales.EnfermeríaMedicin

Accesos vasculares para hemodiálisis: la fístula arteriovenosa como primera opción

MedicinaEnfermerí

Morbimortality in hemodialysis according to the vascular access. A literature review

Objetivos: Examinar mediante revisión bibliográfica la morbilidad y mortalidad asociada al acceso vascular, analizar la tendencia actual del tipo de acceso en las unidades de Hemodiálisis españolas, determinar las causas que influyen en su elección y mostrar la importancia de la fístula arteriovenosa como acceso vascular. Metodología: Se ha diseñado un estudio descriptivo transversal mediante una revisión de la literatura científica comprendida entre los años 2008 y 2014. Resultados: Los estudios revisados ponen de manifiesto que en comparación con la fístula arteriovenosa, los catéteres venosos centrales tiene un mayor riesgo relativo de muerte y una comorbilidad más grave y que ésta aumenta con el tiempo. Existe además una relación inversamente proporcional entre la probabilidad de iniciar hemodiálisis mediante un acceso vascular permanente y el tiempo transcurrido entre la remisión del paciente y la evaluación por el cirujano, así como entre la evaluación por el cirujano y la construcción del acceso vascular. Conclusiones: La fístula arteriovenosa ha demostrado ser el acceso vascular más seguro y duradero y por ello el acceso vascular por excelencia. En los últimos años no ha sido posible alcanzar los objetivos planteados en las guías en lo relativo a la prevalencia e incidencia del acceso vascular. La alta morbimortalidad asociada al inicio en hemodiálisis con un catéter venoso central hace necesaria la reducción del uso de éstos. La causa de su actual exceso es multifactorial, por ello es necesario actuar simultáneamente desde varios niveles siendo crucial derivar al paciente con tiempo suficiente para permitir la realización de la fístula arteriovenosa.Objectives: To examine by literature review the morbidity and mortality associated with vascular access, analyze current trends in the type of access of Spanish hemodialysis units, determine the factors that influence their choice and show the importance of the arteriovenous fistula as vascular access. Methodology: We have designed a cross-sectional study by reviewing the scientific literature between 2008 and 2014. Results: The reviewed studies show that compared with arteriovenous fistula, central venous catheters have a higher relative risk of death and more severe comorbidity that increases with time. There is also an inverse relationship between the probability of starting dialysis with a permanent vascular access and the time from patient referral to assessment by the surgeon, as well as from the evaluation by the surgeon to the construction of vascular access. Conclusions: The arteriovenous fistula has proved the most reliable and durable vascular access being by this reason the vascular access for excellence. In recent years it has not been possible to achieve the goals outlined in the guidelines with regard to the prevalence and incidence of vascular access. The high morbidity associated with the initiation in hemodialysis with a central venous catheter requires the reduction of their use. The cause of current excess is multifactorial, so it is necessary to act simultaneously at various levels being crucial to refer the patient on time to allow the completion time of the arteriovenous fistula

Long-Term Stroke Risk Prediction in Patients With Atrial Fibrillation:Comparison of the ABC-Stroke and CHA2DS2-VASc Scores

Background The ABC ‐stroke score (age, biomarkers [N‐terminal fragment B‐type natriuretic peptide, high‐sensitivity troponin], and clinical history [prior stroke/transient ischemic attack]) was proposed to predict stroke in atrial fibrillation ( AF ). This score was derived/validated in 2 clinical trial cohorts in which patients with AF were highly selected and carefully followed‐up. However, the median follow‐up was 1.9 years in the trial cohort; therefore, its long‐term predictive performance remains uncertain. This study aimed to compare the long‐term predictive performances of the ABC ‐stroke and CHA 2 DS 2 ‐ VAS c (cardiac failure or dysfunction, hypertension, age ≥75 [doubled], diabetes mellitus, stroke [doubled]—vascular disease, age 65 to 74 years and sex category [female]) scores in a cohort of anticoagulated patients with AF. Methods and Results We recruited 1125 consecutive patients with AF who were stable on vitamin K antagonists and followed‐up for a median of 6.5 years. ABC ‐stroke and CHA 2 DS 2 ‐ VAS c (cardiac failure or dysfunction, hypertension, age ≥75 [doubled], diabetes mellitus, stroke [doubled]—vascular disease, age 65 to 74 years and sex category [female]) scores were calculated and compared. Median CHA 2 DS 2 ‐ VAS c and ABC ‐stroke scores were 4 (interquartile range 3–5) and 9.1 (interquartile range 7.3–11.3), respectively. There were 114 ischemic strokes (1.55% per year) at 6.5 years. The C‐index of ABC ‐stroke at 3.5 years was significantly higher than CHA 2 DS 2 ‐ VAS c (0.663 versus 0.600, P =0.046), but both C‐indexes were nonsignificantly different at 6.5 years. Integrated discrimination improvement showed a small improvement (&lt;2%) in sensitivity at 3.5 and 6.5 years with ABC ‐stroke. For ABC ‐stroke, net reclassification improvement was nonsignificantly different at 3.5 years, and showed a negative reclassification at 6.5 years compared with CHA 2 DS 2 ‐ VAS c. Decision curve analyses did not show a marked improvement in clinical usefulness of the ABC ‐stroke score over the CHA 2 DS 2 ‐ VAS c score. Conclusions In anticoagulated patients with AF followed‐up over a long‐term period, the novel ABC ‐stroke score does not offer significantly better predictive performance compared with the CHA 2 DS 2 ‐ VAS c score. </jats:sec

Does von Willebrand factor improve the predictive ability of current risk stratification scores in patients with atrial fibrillation?

Von Willebrand factor (vWF) is a biomarker of endothelial dysfunction. We investigated its role on prognosis in anticoagulated atrial fibrillation (AF) patients and determined whether its addition to clinical risk stratification schemes improved event-risk prediction. Consecutive outpatients with non-valvular AF were recruited and rates of thrombotic/cardiovascular events, major bleeding and mortality were recorded. The effect of vWF on prognosis was calculated using a Cox regression model. Improvements in predictive accuracy over current scores were determined by calculating the integrated discrimination improvement (IDI), net reclassification improvement (NRI), comparison of receiver-operator characteristic (ROC) curves and Decision Curve Analysis (DCA). 1215 patients (49% males, age 76 (71–81) years) were included. Follow-up was almost 7 years. Significant associations were found between vWF and cardiovascular events, stroke, mortality and bleeding. Based on IDI and NRI, addition of vWF to CHA(2)DS(2)-VASc statistically improved its predictive value, but c-indexes were not significantly different. For major bleeding, the addition of vWF to HAS-BLED improved the c-index but not IDI or NRI. DCA showed minimal net benefit. vWF acts as a simple prognostic biomarker in AF and, whilst its addition to current scores statistically improves prediction for some endpoints, absolute changes and impact on clinical decision-making are marginal

Reliability and Validity of a Stress Scale in Public Employees from Murcia (Spain)

Stress is common in all work environments. Technostress and the difficulty of separating the family arena from the work environment are some of the new and emerging risks faced by companies, employees and society in general. Most of the available instruments for measuring stress in workers have been focused on education professionals and healthcare workers. Therefore, it is necessary to validate simple and friendly-use tools to detect stress levels in public workers. The aim of this study was to determine the internal consistency of an adapted version of the Student Stress Inventory-Stress Manifestations (SSI-SM) for public employees and to determine if high-stress levels are related to personal and work-related factors. A cross-sectional and descriptive study was conducted from October 2016 to February 2019 including 468 Spanish public workers based in Murcia. An adapted version of the SSI-SM was administered and data on personal and work-related factors were collected. Results showed that all of the factors had Cronbach’s α over 0.700, and no items need to be deleted due to correlations with the factor exceeding 0.300. Factor 1, “Self-concept”, has a Cronbach’s α of 0.868, with values of 15.62 ± 4.99; factor 2, “Sociability”, Cronbach’s α: 0.853, with mean values of 13.33 ± 4.17; factor 3, “Somatization”, Cronbach’s α: 0.704, mean value of 5.35 ± 1.90 and: factor 4, “Uncertainty”, Cronbach’s α: 0.746, with a mean value of 8.19 ± 2.51. In conclusion, the internal consistency of the adapted SSI-SM for public employees with different work positions and shifts has been validated and determined. This study provides a useful tool for the early detection of stress in public employees and may be potentially useful for preventing the harmful consequences of stres

Estimated absolute effects on efficacy and safety outcomes of using non-vitamin K antagonist oral anticoagulants in 'real-world' atrial fibrillation patients:A comparison with optimally acenocoumarol anticoagulated patients

Background Non-vitamin K antagonist oral anticoagulants (NOACs) have been proposed as an alternative to vitamin K antagonists (VKA) for atrial fibrillation (AF) patients. Some studies have proposed that well-managed warfarin therapy is still a valid alternative as efficacious as NOACs but the potential impact and absolute effect of NOACs in “real world” optimally management of VKA AF patients is unknown. Purpose To estimate the potential absolute benefit in clinical outcome rates if the optimally anticoagulated “real-world” AF patients with acenocoumarol had been treated with NOACs. Methods We included 1361 patients stable on acenocoumarol with a time in therapeutic range of 100% for the previous 6 months and 6.5 years of follow-up. The estimation of clinical events avoided was calculated applying absolute risk reductions, relative risk reductions and hazard ratios from the pivotal clinical trials, relative to acenocoumarol. Results Compared to acenocoumarol, the highest estimated event reduction for stroke was seen with dabigatran 150 mg, with an estimated reduction of 0.53%/year. For major bleeding, the highest estimated reduction was seen with apixaban (0.88%/year). For mortality, the largest estimated reduction was with dabigatran 150 mg (0.75%/year). In net clinical outcome, apixaban had the estimated highest reduction (1.23%/year). All NOACs showed significantly lower rates for intracranial haemorrhage. Conclusion In optimally acenocoumarol anticoagulated AF patients, estimated reductions in stroke, bleeding and net clinical outcomes with various NOACs are evident. NOACs would potentially show an improvement even among optimally VKA AF patients