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Query: UMLS:C0038454 (stroke)
 147,016 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Family physicians should be familiar with the acute management of atrial fibrillation and the initiation of chronic therapy for this common arrhythmia. Initial management should include hemodynamic stabilization, rate control, restoration of sinus rhythm, and initiation of antithrombotic therapy. Part II of this two-part article focuses on the prevention of thromboembolic complications using anticoagulation. Heparin is routinely administered before medical or electrical cardioversion. Warfarin is used in patients with persistent atrial fibrillation who are at higher risk for thromboembolic complications because of advanced age, history of coronary artery disease or stroke, or presence of left-sided heart failure. Aspirin is preferred in patients at low risk for thromboembolic complications and patients with a high risk for falls, a history of noncompliance, active bleeding, or poorly controlled hypertension. The recommendations provided in this article are consistent with guidelines published by the American Heart Association and the Agency for Healthcare Research and Quality.
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PMID:Acute management of atrial fibrillation: Part II. Prevention of thromboembolic complications. 1272 47

Many dental patients have medical problems that require the administration of oral anticoagulants to prevent catastrophic or life-threatening thromboembolic events. Examples include patients with medical conditions such as atrial fibrillation, mechanical heart valves, recent pulmonary embolism, stroke, deep vein thrombosis, anticardiolipin syndrome and coronary artery disease. The oral anticoagulant used most commonly in these instances is Coumadin. Stopping the administration of Coumadin to perform routine dental procedures can be life threatening. Many physicians and dentists believe these patients may not have routine dental procedures, including cleanings and uncomplicated extractions, while on Coumadin for fear of serious postoperative bleeding. No scientific evidence exists to support removing these patients from Coumadin to perform routine dental procedures and uncomplicated extractions, provided the patient's level of anticoagulation is within therapeutic range. Science clearly indicates that in the case of routine dental work, including uncomplicated extractions, the risk of a patient on Coumadin having a life-threatening thromboembolic event if the anticoagulant therapy is stopped is three- to five-times greater than the risk of the patient having postoperative bleeding that cannot be controlled with local measures.
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PMID:Stop the nonsense not the anticoagulants: a matter of life and death. 1267 75

Alterations in normal NMDA receptor composition, densities and function have been implicated in the pathophysiology of certain neurological and neuropsychiatric disorders such as Parkinson's Disease, Huntington's Chorea, schizophrenia, alcoholism and stroke. In our first effort to provide PET ligands for the NMDA/glycine site, we reported the synthesis of a novel high affinity glycine site ligand, 3-[2-[(3-methoxyphenylamino)carbonyl]ethenyl]-4,6-dichloroindole-2-carboxylic acid ((3MPICA), Ki = 4.8 +/- 0.9 nM) and the corresponding carbon-11 labeled PET ligand, [11C]3MPICA. We report here the in vivo evaluation of [11C]3MPICA in rats. Biodistribution analysis revealed that [11C]3MPICA exhibited low degree of brain penetration and high blood concentration. The average uptake at two minutes was highest in the cerebellum (0.19 +/- 0.04 %ID/g) and thalamus (0.18 +/- 0.05 %ID/g) and lower in the hippocampus (0.13 +/- 0.03) and frontal cortex (0.11 +/- 0.04 %ID/g). The radioactivity cleared quickly from all brain regions examined. Administration of unlabeled 3MPICA (1 mg/kg, i.v.) revealed at 60 minutes a small general reduction in regional brain radioactivity concentrations in treated animals versus controls, however, the blood radioactivity concentration was also lowered, confounding the assessment of the degree of saturable binding. Warfarin co-administration (100 mg/kg, i.v.) significantly lowered blood activity at 5 minutes post-injection (-27%, P < 0.01) but failed to significantly increase the brain uptake of the radiotracer. In view of these results, and especially considering the low brain penetration of this tracer, [11C]3MPICA does not appear to be a promising PET radiotracer for in vivo use.
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PMID:In vivo evaluation of [11C]-3-[2-[(3-methoxyphenylamino)carbonyl]ethenyl]-4,6-dichloroindole-2-carboxylic acid ([11C]3MPICA) as a PET radiotracer for the glycine site of the NMDA ion channel. 1245 87

Atrial fibrillation is a common arrhythmic disorder which is becoming increasingly prevalent among the elderly. Atrial fibrillation is an independent risk factor for ischaemic stroke. Patients with hypertension, heart failure, diabetes, age older than 65 years, previous thromboembolisms, left atrial enlargement and left ventricular dysfunction have an increased risk. Coumarins (with a target international normalised ratio (INR) of 2.0 to 3.0) are the treatment of first choice in patients with atrial fibrillation. In young patients without additional risk factors, acetyl salicylic acid provides sufficient protection. The management of anticoagulant therapy during electric cardioversion in the acute phase of an ischaemic stroke and during elective surgical interventions, is still a subject of clinical research.
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PMID:[Anticoagulant treatment of patients with atrial fibrillations: dependent on age and other risk factors for thromboembolism]. 1262 83

Causes of stroke in children include congenital heart malformations, sickle cell disease, infections, and metabolic disorders. Up to 80% of children with ischemic stroke have cerebrovascular disease, and case control studies demonstrate an association of ischemic stroke in children with hereditary prothrombotic risk factors. There have been no randomized, clinical trials for primary prevention, short-term treatment, or secondary prevention of pediatric ischemic stroke. Treatment recommendations are based on small case series or case reports, and have mainly been adapted from adult stroke studies. Antiplatelet agents (e.g. aspirin [acetylsalicylic acid]) and heparins (e.g. low molecular weight heparin), have been used on an individual patient basis. Warfarin is administered in children with cardioembolic stroke, arterial dissection, or persistent hypercoagulable states. Alteplase has been used in a few patients within 3 hours of the onset of symptoms. In each patient treated the benefit of anticoagulation has to be weighed up against the individual bleeding risk.
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PMID:Antithrombotic drug treatment of pediatric patients with ischemic stroke. 1260 81

Aspirin is the drug of choice in most patients with acute stroke, if thrombolysis is contraindicated. Heparin is only used in acute stroke due to cerebral venous thrombosis, extracranial carotid or vertebral artery dissection and cardiac emboli with high risk of recurrence. In the prevention of recurrent stroke in patients with a noncardioembolic ischemic stroke antiplatelet agents are used. Aspirin is the first-line agent. Clopidogrel or a combination aspirin/dipyridamol are recommended for patients with several risk factors or recurrent cerebrovascular events. Warfarin has demonstrated a clear efficacy in stroke prevention in patients with atrial fibrillation, cerebral venous thrombosis and antiphospholipid antibody syndrome. Other, less well established possible indications for warfarin in the secondary prevention of stroke are symptomatic intracranial artery stenosis, large aortic atheroma, extracranial carotid or vertebral artery dissection and patent foramen ovale.
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PMID:[Anticoagulation and antiaggregation in neurological patients]. 1263 76

Incidence data on thromboembolism in patients with heart failure (which may include stroke, peripheral embolism, pulmonary embolism) are limited but provide a general population range from 1-5 cases per 1000 each year, increasing with age to more than 30 cases per 1000 each year among people aged 75 years or older. However, the incidence of thromboembolism varied depending very much on what was being investigated in each of these studies. Data from subgroup analysis of the larger heart failure trials would seem to support this incidence data, although there is very little true epidemiological data and no randomised, controlled trial has been designed to specifically investigate thromboembolism in patients with heart failure. The pathophysiology of heart failure is complex. There are many well recognised factors which are associated with thrombosis in heart failure patients, such as vascular abnormalities, increased coagulability and impaired blood flow. In the past 50 years many studies have been performed to investigate if oral anticoagulation is of benefit for the prevention of thromboembolism in patients with heart failure. The use of warfarin therapy for heart failure patients has been a controversial subject. Warfarin does have a role to play in patients with myocardial infarction and those with atrial fibrillation. Furthermore, in patients with congestive heart failure secondary to coronary artery disease, warfarin reduces the occurrence of nonfatal myocardial infarction and, therefore, may reduce the chances of progression to heart failure. It has also been shown that warfarin reduces the risk of thromboembolic strokes in patients recovering from myocardial infarction. At present, there is a lack of randomised data, and the incidence of bleeding complications in patients with heart failure has caused a decrease in the use of oral anticoagulants for the prevention of thrombosis. This review summarises the incidence, potential mechanism and therapeutic approaches for management of thromboembolism in heart failure.
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PMID:Blood coagulation in patients with chronic heart failure: evidence for hypercoagulable state and potential for pharmacological intervention. 1265 54

Our understanding of the pathogenesis of congestive heart failure (CHF) has improved remarkably in recent years. However, despite better knowledge and novel pharmaceutical strategies, this disease is still one of the most brutal killers in the Western world. The pathophysiology of CHF is complex, and much of our comprehension revolves strictly around the neurohormonal and mechanical mechanisms involved. It has been suggested that CHF is associated with altered hemostasis, but whether a prothrombotic state contributes to the pathogenesis and progression of the disease is still not well known. The purpose of this review article is to discuss our current knowledge of platelet activation in patients with CHF and the potential role of antiplatelet agents in preventing these hemostatic abnormalities. Clopidogrel is an established medication that reduces the incidence of stroke, myocardial ischemia, or vascular death. It is currently the drug of choice in the prophylaxis of subacute stent thrombosis and postischemic stroke treatment. Promising results of the most resent trials (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events [CAPRIE] and Clopidogrel in Unstable angina to prevent Recurrent Events [CURE]) may expand future indications of this ADP receptor antagonist for prevention of thrombotic complications in the CHF population. Currently conducted clinical trials (Warfarin and Antiplatelet Therapy in Chronic Heart Failure [WATCH] and Plavix Use for Treatment of Congestive Heart Failure [PLUTO-CHF] should clarify the role of clopidogrel in these patients.
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PMID:Platelet activation in patients with congestive heart failure: do we have enough evidence to consider clopidogrel? 1266 Jun 60

The anticoagulant, warfarin, and the antiplatelet agent, aspirin, have been shown to have similar benefits after myocardial infarction. As these agents have different mechanisms of action, the beneficial effects of warfarin and aspirin may be additive after myocardial infarction. In the Warfarin, Aspirin, Reinfarction Study (WARIS II), the main outcome was a composite of death, non-fatal reinfarction or thromboembolic stroke, whichever came first over 4 years. Compared to aspirin alone (160 mg/day), the risk reduction was 19% (p = 0.03) with warfarin alone (INR of 2.8 IU) and 29% (p = 0.001) with the combination of aspirin and warfarin (aspirin, 75 mg/day; warfarin, INR of 2.2 IU). This difference in the first event with warfarin alone or the combination, represented a reduction in reinfarction and thromboembolic stroke rather than death. For reinfarction, compared to aspirin alone (117 of 1206), there was a reduction with warfarin alone (90 of 1216) and a further reduction with the combination (69 of 1208). For thromboembolic stroke, compared to aspirin (32 of 1206), there were similar reductions with warfarin and the combination. There were more major and minor bleeding in the warfarin groups than the aspirin group, with major bleeding occurring in 8, 33 and 28 patients taking aspirin, warfarin and aspirin and warfarin, respectively. In conclusion, as compared with aspirin alone, therapy with moderate-intensity warfarin combined with aspirin and high-intensity warfarin alone, resulted in a reduced risk of reinfarction and ischemic stroke but a higher risk of bleeding.
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PMID:Warfarin and aspirin give more benefit than aspirin alone but also more bleeding after myocardial infarction. 1266 21

Atrial fibrillation predisposes to left atrial thrombus formation and carries a sixfold increased risk for stroke. Antithrombotic therapies are the mainstay for stroke prevention. The National Institute of Neurological Disorders and Stroke-sponsored Stroke Prevention in Atrial Fibrillation (SPAF) studies assessed the value of warfarin, aspirin, and their combination for preventing stroke in six multicenter trials involving 3950 participants. This review presents the major results and implications, which offer unique perspectives on antithrombotic therapies for stroke prevention in atrial fibrillation. Warfarin and aspirin reduce stroke. Anticoagulation substantially benefits high-risk patients with atrial fibrillation, while many younger patients with atrial fibrillation have a low stroke rate when given aspirin. Pathogenetic and transesophageal echocardiographic correlations shed light on mechanisms by which antithrombotic agents prevent stroke. Warfarin inhibits formation of atrial appendage thrombi and markedly reduces cardioembolic strokes, while aspirin primarily prevents smaller, noncardioembolic strokes. The SPAF III stroke risk stratification scheme has been validated for identifying patients with high versus moderate versus low risk for stroke. Women with atrial fibrillation benefit from anticoagulation significantly more than men do. Many elderly patients with recurrent paroxysmal atrial fibrillation have high rates of stroke. Antithrombotic prophylaxis should be individualized on the basis of the estimated risk for stroke during aspirin therapy and the risk for bleeding during anticoagulation. Overall, nearly one third of patients with atrial fibrillation are low risk and should be treated with aspirin, and about one third are high risk and should receive warfarin if it can be given safely. For patients at moderate risk for stroke, patient preferences and access to reliable anticoagulation monitoring are particularly relevant.
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PMID:Lessons from the Stroke Prevention in Atrial Fibrillation trials. 1275 55


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