Antiaggregation therapy and dental procedures in primary healthcare

Široka uporaba intravaskularnih koronarnih stentova višestruko je povećala broj bolesnika na antiagregacijskoj terapiji acetilsalicilnom kiselinom i klopidogrelom. Uzimajući u obzir povišen rizik krvarenja kod ovih bolesnika raste i (ponekad pretjerana) zabrinutost prilikom planiranja manjih kirurških, pa tako i stomatoloških zahvata. Ista je rezultirala povremenim preuranjenim isključivanjem spomenute terapije što može, mada rijetko, imati i katastrofalne tromboembolijske komplikacije. Cilj ovog članka je iznijeti aktualne preporuke za postupak s bolesnicima na antiagregacijskoj terapiji kod kojih se planiraju stomatološki zahvati u sustavu primarne zdravstvene zaštite.Extensive use of intravascular coronary stents has multiply increased a number of patients receiving antiaggregation therapy with aspirin and clopidogrel. Taking into account an increased risk of bleeding, there is an increasing (sometimes excessive) concern of minor surgical and dental procedures in these patients. This has resulted in occasional premature exclusion of the above therapy, which can, albeit rarely, lead to catastrophic thromboembolic complications. The aim of this article is to present the current recommendations for the management of patients receiving antiaggregation therapy where dental procedures in primary healthcare system are planned

Optimalna medikamentna terapija stabilne angine pektoris.

The pathomorphological substrate of stable angina pectoris differs significantly from that of unstable angina pectoris. Acute coronary syndrome presents with the clinical picture of unstable angina pectoris and myocardial infarction with or without ST-segment elevation, and the invasive approach through percutaneous coronary intervention or surgical myocardial revascularization with optimal medical therapy is indicated. In contrast, stable angina pectoris develops gradually, and many studies have demonstrated that the long-term results (fatal outcomes) do not differ in comparison with the invasive approach. The main prerequisite is the application of optimal medical therapy. It is based on three medications: extended-release nitrates, beta blockers, and calcium antagonists, in addition to other treatment.Patomorfološki supstrat stabilne angine pektoris uvelike se razlikuje od nestabilne angine pektoris. Akutni koronarni sindrom prezentira se slikom nestabilne angine pektoris, infarkta miokarda s elevacijom ili bez elevacije ST segmenta, a indicirani su invazivni pristup perkutanom koronarnom intevencijom ili kirurškom revaskularizacijom miokarda uz optimalnu medikamentnu terapiju. Za razliku od toga stabilna angina pektoris razvija se postupno i brojna su ispitivanja dokazala da se dugoročni rezultati (smrtni ishodi) ne razlikuju s obzirom na invazivni pristup. Osnovni je preduvjet primjena optimalne medikamentne terapije. U osnovi je čini trijas lijekova: nitrata produženog učinka, beta-blokatora i antagonista kalcija, uz drugu terapiju

Terapijski pristup kod akutnog koronarnog sindroma usredotočen na oralnu terapiju

In the light of some new information based on clinical evidence, current therapeutic approach to patients with acute coronary syndrome especially focusing on oral therapy is being considered. The initial stage of treatment does not differ greatly among patients with unstable angina pectoris (UA), non-ST-elevation myocardial infarction (NSTEMI), or ST-elevation myocardial infarction (STEMI). It is necessary to simultaneously resolve a series of problems within the first twenty minutes upon admission, i.e. risk assessment, selection of treatment strategy (conservative, invasive), relief of ischemic pain, determination of hemodynamic status and elimination of any undesired complications (hypertension, tachycardia, heart failure), and administration of antithrombotic therapy. Patients suffering from STEMI require reperfusion treatment, and the method of choice is primary percutaneous coronary intervention (PCI) where available. Fibrinolytic reperfusion therapy is limited exclusively to STEMI within the first three hours from the onset of pain. Unlike this, in patients suffering from UA/NSTEMI it is necessary to make risk assessment in the early stage of disease, and thus select the patients that will certainly benefit from invasive treatment through PCI. For pain relief, the patient should be immediately administered nitroglycerin along with oxygen. Beta-blockers that are reasonably used in the initial stage of treatment during the first 24 hours, if not contraindicated, are still underused. Clopidogrel becomes an obligatory drug not only in patients having undergone PCI, but also in those treated conservatively following fibrinolysis.U svjetlu nekih novih podataka zasnovanih na kliničkim dokazima razmatra se terapijski pristup bolesnicima s akutnim koronarnim sindromom koji se osobito oslanja na oralnu terapiju. U početnoj fazi liječenja nema većih razlika u pristupu bolesnicima s nestabilnom pektoralnom anginom, infarktom miokarda bez povišenja ST segmenta (NSTEMI) ili infarktom miokarda s povišenjem ST segmenta (STEMI). Istodobno treba razriješiti niz problema unutar prvih dvadesetak minuta od prijma bolesnika: procjenu rizika, odabir strategije liječenja (konzervativno, invazivno), ublažavanje ishemijske boli, određivanje hemodinamskog statusa i uklanjanje neželjenih komplikacija (hipertenzija, tahikardija, srčano zatajenje), te davanje antitrombotske terapije. Bolesnici koji imaju STEMI zahtijevaju liječenje reperfuzijom, a metoda izbora je primarna perkutana koronarna intervencija (PCI) tamo gdje je dostupna. Fibrinolitička reperfuzijska terapija je ograničena isključivo na STEMI unutar prva tri sata od nastupa boli. Za razliku od toga, kod bolesnika s nestabilnom pektoralnom anginom/NSTEMI treba procijeniti rizik u ranom stadiju bolesti te tako odabrati one bolesnike kod kojih će invazivno liječenje pomoću PCI zasigurno biti korisno. Uz kisik bolesniku treba smjesta dati nitroglicerin radi ublažavanja boli. Primjena beta blokatora je razumna u početnoj fazi liječenja tijekom prva 24 sata, ako nisu kontraindicirani, no oni se još uvijek nedostatno primjenjuju. Klopidogrel postaje obvezatan lijek ne samo u bolesnika podvrgnutih PCI, nego isto tako u bolesnika koji se liječe konzervativno nakon fibrinolize

Poremećaji metabolizma glukoze u bolesnika s akutnim koronarnim sindromom

Glucose metabolism disorders in acutely ill patients include oscillations in plasma glucose concentration outside the range of reference values. These disorders include both hyperglycemia and hypoglycemia, regardless of previous diagnosis of diabetes in a particular patient. Hyperglycemia is frequent in acute patients due to the increased release of stress hormones such as catecholamines and cortisol, but also as an effect of a cascade of proinflammatory cytokines in emergencies such as acute coronary syndrome, pulmonary edema, pulmonary embolism, injuries, severe infections and sepsis. Hyperglycemia occurs often even in patients in whom diabetes was not previously diagnosed, and in diabetic patients requirement for hypoglycemic medication may be temporarily increased. Hyperglycemia in cardiac emergencies is associated with more frequent adverse major cardiovascular events and worse prognosis. Hypoglycemia occurs seldom in these patients, its origin is almost always iatrogenic, and it worsens the patient’s prognosis even more than moderate hyperglycemia. Good regulation of glycemia is necessary in the management of these patients; therefore plasma glucose determination and close monitoring are obligatory, and therapy with short acting insulin should be introduced if plasma glucose concentration exceeds 10 mmol/L, regardless of the risk of hypoglycemia. It is also useful to determine the acid-base status and blood or urine ketones.Poremećaji metabolizma glukoze u akutnih bolesnika uključuju poremećaje poput hiperglikemije i hipoglikemije, odnosno odstupanja koncentracija glukoze u plazmi izvan referentnih raspona. Pritom je nevažno boluje li bolesnik od ranije dijagnosticirane šećerne bolesti. Hiperglikemija je česta kod ovakvih bolesnika zbog prolazno povišenih koncentracija kateholamina i kortizola, kao i niza proupalnih citokina, a može se javiti kod bolesti poput akutnog koronarnog sindroma, plućnog edema, plućne embolije, povreda, te teških infekcija i sepsa. Često se javlja kod bolesnika bez šećerne bolesti, kod dijabetičara može zahtijevati prolazno povišenje doza antidijabetičnih lijekova. Hipoglikemija se javlja mnogo rjeđe, po svom postanku je gotovo uvijek jatrogena. Hiperglikemija i hipoglikemija pogoršavaju prognozu akutnih bolesnika, te je u bolničkim uvjetima praćenje razine glukoze u krvi obvezno, uz uvođenje terapije kratkodjelujućim inzulinom kod hiperglikemije iznad 10 mmol/L. Dodatne informacije pruža određivanje acidobaznog statusa i ketona

Metabolični sindrom i ishod u bolesnika s akutnim infarktom miokarda

The impact of the metabolic syndrome/insulin resistance syndrome (MS/IR S) on the severity and prognosis of acute ST elevation myocardial infarction (STEMI ) treated with primary percutaneous coronary intervention (PCI) was assessed using the American Association of Clinical Endocrinologists and American College of Endocrinology (AACE/ACE) definition from 2003. A total of 385 patients having suffered acute STEMI and treated with primary PCI over a two-year period were divided into two groups (with and without MS/IR S) and compared according to the parameters of severity (clinical, laboratory, echocardiography, coronary angiography parameters and complications) and prognosis using major adverse cardiovascular events (MACE) during the six-month follow-up of acute STEMI . In comparison with control group, the MS/IR S group of patients had worse or similar results of almost all study parameters of severity (hospital days 6.5 vs. 6.5, cardiogenic shock 2.9% vs. 2.6%, cardiac arrest 6.8% vs. 5.2%, reinfarction 0.5 vs. 1.6%) and prognosis (total MACE 30.7 vs. 30.7%), however, none of the differences reached statistical significance. It is concluded that the unexpected lack of such differences in MS/IR S could be due to the absence of waist-to-hip ratio in the definition and other open questions in metabolic syndrome in general.Istraživao se utjecaj metaboličnog sindroma/sindroma inzulinske rezistencije (MS/SIR ) koristeći definiciju American Association of Clinical Endocrinologists i American College of Endocrinology (AACE/ACE) iz 2003. na težinu i prognozu akutnog infarkta miokarda s elevacijom ST spojnice (STEMI ) liječenog primarnom perkutanom intervencijom (pPCI). Ukupno 395 bolesnika koji su preboljeli akutni STEMI i bili liječeni pomoću pPCI u dvogodišnjem razdoblju podijeljeno je u dvije skupine (s MS/SIR i bez njih) i uspoređeno prema parametrima težine (klinički, laboratorijski, ehokardiografski, koronarografski, komplikacije) i prognoze koristeći velike neželjene kardiovaskularne događaje (MACE) tijekom šestomjesečnog praćenja akutnog STEMI . Skupina bolesnika s MS/SIR u usporedbi s kontrolnom skupinom imala je uglavnom lošije ili jednake rezultate težine (dani u bolnici 6,5:6,5, kardiogeni šok 2,9%:2,6%, srčani zastoj 6,8%:5,2%, reinfarkt 0,5%:1,6%) i prognoze (ukupno MACE 30,7%:30,7%), no niti jedna od razlika nije dosegla statističku značajnost. Zaključuje se kako bi izostanak takvih očekivanih razlika u MS/SIR mogao biti posljedica isključenja omjera struka i kukova iz ove definicije i ostalih otvorenih pitanja u metaboličnom sindromu uopće