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

In the acute stage of stroke, fibrinolytics are beneficial for up to 3, and in some patients up to 6, hours. If fibrinolytics are contraindicated, aspirin should be given. Heparin is dangerous due to the threat of intra- and extracranial hemorrhage. For secondary prevention, anticoagulants are indicated. When hypercholesterolemia is present, statins should be given.
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PMID:[Advances in therapy and prevention of ischemic myocardial infarct]. 941 88

Fibrinolytic therapy substantially reduces mortality from acute myocardial infarction. Patient selection is, however, important. The patient must present within 12 hours of the onset of ischaemic symptoms, have definite ECG changes of ST elevation or left bundle branch block and no contraindications. The major contraindications are those for risk of an intracerebral bleed, recent stroke, intracranial tumour or risk of a major systemic bleed. Age and hypertension are not contraindications but may modify the regimen used. Heparin is required with recombinant tissue plasminogen activator but is optional with streptokinase. The recent COBALT trial suggests that the accelerated weight related t-PA regimen given over 90 minutes is more satisfactory than double bolus t-PA. However, in patients under 75 years of age, the two regimens were equivalent. For patients suffering acute myocardial infarction, practitioners should now individualise choice of therapy, rather than give the same cocktail to all patients. The choice of regimen will depend on the cardiac risk, the stroke risk, the bleeding risk and the cost.
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PMID:The current status of thrombolytic therapy. 944 5

To define the clinical characteristics, prognosis and treatment of myocardial infarction (MI) in the elderly, we retrospectively compared the files of 101 patients aged > or = 75 years (mean: 82 +/- 4 years) and of 120 others aged < or = 65 years (mean: 55 +/- 4.7 years). The figures corresponding to younger patients are presented in brackets. The elderly group included 60.4% women (5%: p < 0.001), 58.9% hypertensive subjects (38.3%: p = 0.005); 30.4% diabetics (11.7%: p = 0.0013) and 12.6% smokers (66.1%: p < 0.001); 20.8% of the elderly had a history of MI (10%: p = 0.002), 15.8% of arteriopathy of the lower limbs (8.3%: p = 0.001) and 6.9% of cerebrovascular accident (1.7%: p = 0.02). Elderly patients were admitted after an average of 26.6 hours (10.4 hours: p < 0.001). Only 56.4% (79.2%) reported typical MI pain, 22.8% (7.5%) had a painless form, 31.8% (4.2%) an initial left ventricular failure, 21.8% (7.5%) a global cardiac dysfunction and 20.8% (4.2%) a cardiogenic shock (p < 0.001 for all comparisons). 63.4% had an anterior MI (40.8%: p < 0.001), 40.6% a Q-form (29.6%: p = NS) and 22.2% an atrial fibrillation (0.8%: p < 0.001). Serum myoglobin and total CK concentrations were significantly lower in elderly subjects. 20.8% of them received beta-blockers (86.7%), 43.6% aspirin (80%), 14.6% oral anticoagulant (56.7%), but 63.4% were given diuretics (25.2%) and 31.7% digitalis alkaloids and positive inotropic drugs (6.7%) (p < 0.001 for all these comparisons). Heparin, nitrates, calcium channel blockers, ACE inhibitors and antiarrhythmics were prescribed as often regardless of age. Only 10 elderly patients (9.9%) were treated with thrombolytics (77: 65%: p < 0.001); 6 (5.9%) underwent coronary angiography (43: 35.8%: p < 0.001), 2 (2%) angioplasty (11: 9.2%) and one (1%) coronary bypass surgery (12: 10%). 35 elderly patients (34.7%) died while in hospital (5: 4.2%), 22 suddenly, 10 in cardiogenic shock and 3 due to arrhythmias. 38 cases (37.8%) of heart failure (21: 17.5%), 21 (20.8%) recurrences of coronary insufficiency (8: 6.7%) and 11 (10.9%) mechanical complications of MI (4: 3.3%) were also observed (p < 0.001 for all these comparisons). Due to lack of sufficient data, we could not define the status of the surviving patients discharged from hospital. The wider use of thrombolytics, angiography and angioplasty (coronary bypass surgery still having a heavy mortality and morbidity) is probably the best way to improve the prognosis of MI in the elderly.
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PMID:[Myocardial infarction in the elderly. Comparison between 2 groups of patients over 75 and under 65 years of age]. 953 67

Anticoagulation with heparin has a valuable place in prevention and management of deep venous thrombosis. However, the benefit of heparin in acute ischemic stroke and transient ischemic attack remains unclear despite its widespread use for these indications. Heparin also carries several risks, including unpredictable anticoagulation effects, bleeding, and thrombocytopenia. Low-molecular-weight heparins (LMWHs) and heparinoids have several advantages over heparin, such as higher bioavailability, more predictable anticoagulant effects, and less interaction with platelets. Heparin, LMWHs, and heparinoids have been studied in acute ischemic stroke with variable results. Of three recent, large, controlled clinical trials, only one documented a net benefit of treatment. Fewer patients treated with an LMWH within 48 hours of stroke were dead or disabled at 6 months compared with placebo-treated patients. The largest randomized clinical trial of heparin in acute stroke (the International Stroke Trial) showed that heparin was associated with a significant excess in bleeding complications but no clinical benefit at 6 months. Interim analysis of the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) study also showed an excess number of bleeding complications in the treated group without a corresponding benefit on stroke outcome at 3 months. Therefore, although heparin, LMWHs, and heparinoids continue to be used in the management of patients with acute ischemic stroke, their value in recurrent stroke prevention and in the treatment of stroke-in-progress remains unsettled. Ongoing studies may help to clarify the use of LMWHs and heparinoids in these patients.
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PMID:Heparin and heparinoids in stroke. 974 37

Stroke is a very common medical emergency that, until recently, had no specific treatment. Following the results of several major trials (including 2 'mega-trials'), aspirin (acetylsalicylic acid) can be recommended for the majority of patients with acute ischaemic stroke. While the benefit of aspirin is only modest, i.e. an increase of 11 per 1000 long term independent survivors, the public health benefit in the world will be substantial as this treatment could be given to millions of patients with acute ischaemic stroke each year. Heparin is associated with a reduction in early recurrent ischaemic stroke, but there is no net benefit because of a similar sized excess of recurrent haemorrhagic stroke (even for those in atrial fibrillation). Thrombolytic therapy has not been so widely tested and the results of the small trials to date have yielded conflicting results. The only positive publication to date (comprised of 2 related trials) evaluated the recombinant tissue plasminogen activator alteplase, but such treatment is probably only indicated for highly selected patients. Further trials are almost certainly required and it would be unwise to change clinical practice based on the current evidence. No other stroke treatments have been shown to be beneficial, and much larger trials will be required to confirm or refute possible moderate benefits of treatment. A well organised stroke service and participation in clinical trials will improve the future care of patients with acute ischaemic stroke.
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PMID:Drug therapy for acute ischaemic stroke: risks versus benefits. 982 50

Stroke is a neurological emergency that makes immediate hospitalization mandatory. Basic medical management includes maintenance of arterial blood pressure at an adequately high level, provision of an optimal supply of oxygen, and correction of hyperglycemia, hyperthermia and hypovolemia. Systemic thrombolytic therapy with rt-PA can be applied only within the first three hours after onset of symptoms and when hemorrhage has been excluded by a cranial CT scan. Heparin and aspirin have no proven therapeutic action, and are used only for early secondary prophylaxis.
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PMID:[Acute therapy of stroke]. 1008 33

Cerebral and myocardial infarctions share common aspects of pathobiochemistry. The central problem is the oxygen supply of the infarcted region. To maintain this supply, H.E.L.P.-apheresis (Heparin-mediated Extracorporeal LDL/Fibrinogen Precipitation) has already proven beneficial in the prevention and therapy of myocardial infarction. Since H.E.L.P.-apheresis can lower significantly plasma viscosity and erythrocyte aggregation without reducing the oxygen transport capacity, patients with cerebral infarction (stroke) may also benefit from our experiences in myocardial ischemia. The system is designed to remove selectively plasma fibrinogen, LDL-cholesterol and lipoprotein(a) from blood circulation, simultaneously. The removal of the plasma compounds is achieved by extracorporeal precipitation with heparin at low pH. Excess heparin is completely removed by an adsorber before the plasma is given back to the patient. H.E.L.P.-apheresis has proved to be safe in patients with coronary heart disease and allows a controlled reduction of thrombogenic plasma compounds. It is therefore hoped to be effective also in patients with acute ischemic stroke.
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PMID:Heparin-mediated extracorporeal LDL/fibrinogen precipitation--H.E.L.P.--in coronary and cerebral ischemia. 1049 46

Although unfractionated heparin is widely used for thrombin inhibition in the management of unstable coronary artery disease, clinical and experimental evidence suggests that it is suboptimal. Recent pharmaceutical strategies to improve upon unfractionated heparin's efficacy profile have centered on the development of 2 major classifications of thrombin inhibition medications: the naturally occurring leech protein hirudin (and synthetic analogs) and low-molecular-weight (LMW) heparins. In the Organisation to Assess Strategies for Ischaemic Syndromes-2 (OASIS-2) trial, hirudin was demonstrably more effective than heparin in diminishing rates of death, myocardial infarction (MI), and angina at both 72 hours and 7 days after unstable coronary artery disease index events, with risk ratios on the order of 0.8. Similarly, in the Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events (ESSENCE) study, the LMW heparin enoxaparin emerged superior to unfractionated heparin in attenuating rates of unstable coronary artery disease at 14 days, 30 days, and 1 year. On the other hand, findings involving other LMW heparins (dalteparin sodium, Fragmin, and fraxaparin) are equivocal. Although the Fragmin During Instability in Coronary Artery Disease (FRISC) study demonstrated statistically significant superiority of this LMW heparin over aspirin/placebo in driving down death/MI/revascularization rates, the Fragmin in Unstable Coronary Artery Disease (FRIC) trial showed no such superiority, but had wide confidence intervals. Similarly, the Fraxaparin Versus Unfractionated Heparin in Acute Coronary Syndromes (FRAXIS) trial with fraxaparin failed to show superiority over unfractionated heparin. The favorable efficacy findings associated with hirudin and enoxaparin regimens, compared with unfractionated heparin, accrued without significant increases in the incidences of life-threatening bleeding events (e.g., hemorrhagic stroke), but did include more frequent lesser bleeding events. In summary, both hirudin and enoxaparin have demonstrated clinically important improvements in outcome compared with standard treatments in unstable coronary artery disease.
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PMID:Implications of the Organization to Assess Strategies for Ischemic Syndromes-2 (OASIS-2) study and the results in the context of other trials. 1050 40

Therapeutical trials in the acute phase of stroke have showed a moderate benefit of administration of aspirin in prevention of death or recurrent cerebral events. This benefit was obtained despite a small increase in systemic and cerebral haemorrhages. Heparin used at high dosage, without any control of coagulation test, induces an excess of cerebral and systemic haemorrhage which overset its benefit in prevention of recurrent cerebral events. Similar results have been observed with heparinoid and nadroparine used at high dosage. The only benefit of anticoagulation is the prevention of total and fatal pulmonary embolism which has been observed in all recent studies. The antithrombotic treatment which offers the best ratio benefit-risk in the acute phase of stroke is aspirin at a minimum dosage of 160 mg by day and, if risk factors are present, heparin at an adequate dosage to prevent venous thrombo-embolism. Explicative studies are required to explore the potential benefit of heparin in patients with a high risk of recurrent cerebral ischemic events.
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PMID:[Anti-platelet and anticoagulant therapy in acute cerebral ischemia]. 1052 44

Hospitalized nonsurgical patients are at risk of developing venous thromboembolic disease (VTED) but, in contrast to surgical patients, only a limited number of prevention trials have been performed. Guidelines for optimal prophylaxis, particularly with respect to low molecular weight heparins (LMWHs), are not definitive. The Fifth American College of Chest Physicians' (ACCP) Consensus on Antithrombotic Therapy makes limited recommendations on the use of LMWH in patients. Recommendations are made for ischemic stroke and general medical patients, but there are insufficient clinical trial data to produce firm recommendations on the use of LMWHs in acute myocardial infarction, pregnancy, and cancer patients. Patients with acute ischemic stroke are at high risk for VTED. The ACCP Consensus recommends employing either low-dose UFH or LMWH. A recent comparison between enoxaparin and UFH revealed an incidence of thromboembolic events in 20% of patients randomized to enoxaparin, compared with 35% in the UFH-treated group. Although the ACCP Consensus states that both low-dose unfractionated heparin (UFH) and LMWH provide effective prophylaxis in general medical patients, particularly those with congestive heart failure and/or pulmonary infections, no specific LMWH or dose is specified. The recently completed Thromboembolism Prevention in Cardiopulmonary Diseases with Enoxaparin (PRINCE) trial compared once-daily enoxaparin with three times daily UFH. Enoxaparin was at least as effective as UFH in reducing the risk of thromboembolic events by 19%. In high-risk pre-defined subgroups with heart failure, enoxaparin was significantly more effective. It is not possible to recommend a specific LMWH for prophylaxis in medical patients, but the recent position adopted by the United States Food and Drug Administration and the World Health Organization that LMWHs are noninterchangeable drugs suggests that thromboprophylaxis guidelines should be strengthened to reflect the level of evidence for each individual LMWH.
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PMID:Low molecular weight heparins in the prevention of venous thromboembolism in nonsurgical patients. 1054 24


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