Publication: Fibrilación auricular en pacientes con enfermedad tromboembólica venosa: evolución y validación de escalas de riesgo de ictus y de sangrado
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2017-09-13
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Universidad Complutense de Madrid
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Abstract
La fibrilación auricular (FA) es la arritmia más frecuente en la población, con una incidencia en aumento y la enfermedad tromboembólica venosa (ETV) es la tercera causa de mortalidad cardiovascular. En ambas situaciones la anticoagulación farmacológica es la piedra angular del tratamiento por el protagonismo en las manifestaciones clínicas del trombo venoso y del generado en las aurículas, de características similares al venoso. El tratamiento anticoagulante es eficaz en la FA en la profilaxis del ictus, y en la ETV en la progresión de la trombosis, prevención de complicaciones y de recurrencia , pero tiene en el sangrado mayor su principal efecto secundario, que limita y condiciona su uso. La FA y la ETV parecen asociarse con frecuencia, con posible relación causal entre ellas en algunos casos, y los pacientes con ETV y FA pueden constituir una subpoblación con características clínicas y evolutivas diferentes a las de los pacientes que solo presentan ETV. La FA puede condicionar un peor pronóstico considerado como mortalidad a 3-12 meses y como riesgo de recurrencia de ETV, de ictus y de hemorragia debido a factores de riesgo vascular y comorbilidad mas frecuentes y por ser un posible marcador de severidad de la ETV. El tipo de tratamiento antitrombótico que se utiliza en la FA y en la ETV es el mismo, ya que se trata en ambos casos de trombos con características de trombo venoso, para los que son de elección los fármacos anticoagulantes, bien sean anticoagulantes orales AVK o los nuevos ACODs, con escaso o ausente papel para los fármacos antiplaquetarios. Las heparinas , fundamentalmente las heparinas de bajo peso molecular (HBPM) son de eficacia indiscutible al inicio de la anticoagulación y parecen útiles en el tratamiento a largo plazo en los casos de ETV en los que se indican por diversos motivos, principalmente por la presencia de cáncer activo, donde la mayoría de las guías recomiendan HBPM. En los casos donde además de ETV existe FA se considera habitualmente que la HBPM protege del ictus al paciente pero no hay constancia de su eficacia, ya que no ha sido evaluada...
Atrial fibrillation (AF) is the most common arrhythmia in the general population, and its incidence is increasing. Venous thromboembolic disease (VTD) is the third most common cause of cardiovascular mortality. In both cases, anticoagulant drugs are the cornerstone of treatment because of the role of venous thrombi and atrial thrombi (which are venous-like) as clinical manifestations. Anticoagulant agents have proven efficacious as prophylaxis of stroke in patients with AF. They are also efficacious in the progression of thrombosis, prevention of complications, and prevention of recurrences in patients with VTD. However, their major adverse effect is bleeding, which limits and affects administration. The criteria used to prolong anticoagulant therapy after a specific period of time in VTD differ from those applied in AF. In VTD, the recommendation is for 3 months of anticoagulant therapy in patients who have experienced venous thromboembolic events as a result of transient risk factors and for long-term therapy or therapy with an indefinite duration in patients who experience events with no apparent cause (idiopathic events) and in patients with active cancer. Current guidelines on AF recommend anticoagulant therapy in patients with paroxysmal or permanent AF and a moderate-to-high risk of ischemic stroke, after taking into account the risk of bleeding. Guidelines recommend predicting the risk of stroke using the scores obtained on the CHADS2 and CHA2S2-VASc and the risk of bleeding using the HASBLED. AF and VTD often co-occur, with a possible causal relationship in some cases. Patients with both AF and VTD make up a subpopulation whose clinical characteristics and outcome are different from those of patients with VTD only. The presence of AF could indicate a poorer prognosis (ie, death at 3-12 months and risk of recurrence of VTD, stroke, and bleeding) owing to more frequent associated vascular risk factors and comorbid conditions and to the role of AF as a potential marker of the severity of VTD...
Atrial fibrillation (AF) is the most common arrhythmia in the general population, and its incidence is increasing. Venous thromboembolic disease (VTD) is the third most common cause of cardiovascular mortality. In both cases, anticoagulant drugs are the cornerstone of treatment because of the role of venous thrombi and atrial thrombi (which are venous-like) as clinical manifestations. Anticoagulant agents have proven efficacious as prophylaxis of stroke in patients with AF. They are also efficacious in the progression of thrombosis, prevention of complications, and prevention of recurrences in patients with VTD. However, their major adverse effect is bleeding, which limits and affects administration. The criteria used to prolong anticoagulant therapy after a specific period of time in VTD differ from those applied in AF. In VTD, the recommendation is for 3 months of anticoagulant therapy in patients who have experienced venous thromboembolic events as a result of transient risk factors and for long-term therapy or therapy with an indefinite duration in patients who experience events with no apparent cause (idiopathic events) and in patients with active cancer. Current guidelines on AF recommend anticoagulant therapy in patients with paroxysmal or permanent AF and a moderate-to-high risk of ischemic stroke, after taking into account the risk of bleeding. Guidelines recommend predicting the risk of stroke using the scores obtained on the CHADS2 and CHA2S2-VASc and the risk of bleeding using the HASBLED. AF and VTD often co-occur, with a possible causal relationship in some cases. Patients with both AF and VTD make up a subpopulation whose clinical characteristics and outcome are different from those of patients with VTD only. The presence of AF could indicate a poorer prognosis (ie, death at 3-12 months and risk of recurrence of VTD, stroke, and bleeding) owing to more frequent associated vascular risk factors and comorbid conditions and to the role of AF as a potential marker of the severity of VTD...
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Tesis inédita de la Universidad Complutense de Madrid, Facultad de Medicina, Departamento de Medicina, leída el 02-02-2016