RESUMEN

OBJECTIVE: Deep vein thrombosis (DVT) is discussed as a source of embolism for cerebral ischemia in the presence of patent foramen ovale (PFO). However, previous studies reported varying rates of DVT in stroke patients, and recommendations for screening are lacking. This study aimed to characterize patients with stroke or transient ischemic attack (TIA) and concomitant PFO and explore the rate of DVT and associated parameters. METHODS: Medical records were screened for patients with stroke or TIA and echocardiographic evidence of PFO. Concomitant DVT was identified according to compression ultrasonography of the lower limbs. A variety of demographic, clinical, and laboratory parameters, the RoPE and Wells scores were compared between patients with and without DVT. RESULTS: Three-hundred-thirty-nine patients (mean age 61.2 ± 15.4 years, 61.1% male) with stroke or TIA and PFO, treated between 01/2015 and 12/2020, were identified. Stroke and TIA patients did not differ for demographic and vascular risk factors. DVT was found in 17 cases out of 217 (7.8%) with compression ultrasonography. DVT was associated with a history of DVT, cancer, previous immobilization, calf compression pain, calf circumference difference, and a few laboratory abnormalities, e.g., increased D-dimer. A multivariate regression model with stepwise backward selection identified the Wells score (odds ratio 35.46, 95%-confidence interval 4.71-519.92) as a significant predictor for DVT. CONCLUSION: DVT is present in a relevant proportion of patients with cerebral ischemia and PFO, which needs to be considered for the individual diagnostic workup. The Wells score seems suitable for guiding additional examinations, i.e., compression ultrasonography.

Asunto(s)

Foramen Oval Permeable , Ataque Isquémico Transitorio , Accidente Cerebrovascular , Trombosis de la Vena , Humanos , Masculino , Femenino , Persona de Mediana Edad , Foramen Oval Permeable/complicaciones , Foramen Oval Permeable/epidemiología , Foramen Oval Permeable/diagnóstico por imagen , Ataque Isquémico Transitorio/epidemiología , Ataque Isquémico Transitorio/diagnóstico por imagen , Ataque Isquémico Transitorio/diagnóstico , Ataque Isquémico Transitorio/complicaciones , Trombosis de la Vena/epidemiología , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/diagnóstico , Trombosis de la Vena/complicaciones , Estudios Retrospectivos , Anciano , Accidente Cerebrovascular/epidemiología , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/diagnóstico , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/etiología , Factores de Riesgo , Adulto

RESUMEN

For the diagnosis of a lower-extremity deep vein thrombosis (LEDVT), venous duplex ultrasound is the method of first choice. If a qualified ultrasonography is not timely available, D-dimer testing, and limited ultrasound protocols (point-of-care ultrasound, POCUS) can contribute to therapeutic decision-making when clinical probability is low. A DOAC-based treatment regimen is preferable to a vitamin K antagonist for both acute therapy and secondary prophylaxis of venous thromboembolism (VTE). Treatment with DOACs is unproblematic up to a body weight (BW) of 120 kg or a body mass index (BMI) of 40 kg/m². Weight restrictions are no longer recommended for apixaban and rivaroxaban, but determination of DOAC trough and peak levels is recommended in the extremely obese and patients after bariatric surgery. In cancer-associated VTE, the direct factor Xa inhibitors are a good and safe alternative to low-molecular weight heparins (LMWH) for many patients; the adherence to oral therapy is also higher. Meaningful initial documentation and structured follow-up after LEDVT and pulmonary embolism (PE) are important in order to make an individualized risk-benefit assessment at the end of the therapy phase with regard to continued pharmacological secondary prophylaxis and to reassess patients' symptoms indicating post-thrombotic syndrome (PTS) or chronic thromboembolic pulmonary hypertension (CTEPH).

Asunto(s)

Tromboembolia Venosa , Trombosis de la Vena , Humanos , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/prevención & control , Heparina de Bajo-Peso-Molecular/uso terapéutico , Anticoagulantes/efectos adversos , Rivaroxabán/uso terapéutico , Trombosis de la Vena/tratamiento farmacológico , Inhibidores del Factor Xa/uso terapéutico

RESUMEN

Despite clear guideline recommendations, only about every second PAD patient is prescribed statins, women less often than men. There is an international consensus that every PAD patient should be treated with statins, as these not only lower lipids but also stabilize plaque, resulting in a prognostic benefit. Limb-related endpoints (MALE) can be reduced by 24% compared to placebo by lowering lipids. The combination of low-dose, high-potency statin with ezetimibe can be equivalent to high-dose statin monotherapy and, with better tolerability, promote therapy adherence. Statin intolerance is observed more frequently in certain risk groups but is very rare overall. Effective alternatives are bempedoic acid and PCSK9 inhibitors. About 20% of the population have severely elevated Lp(a) levels that require risk factor management beyond lipid management. A high Lp(a) concentration is associated with PAD progression as an independent risk factor for all atherosclerosis manifestations. Every adult should have an Lp(a) assessment once in their lifetime.

Asunto(s)

Anticolesterolemiantes , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Enfermedad Arterial Periférica , Masculino , Adulto , Humanos , Femenino , Inhibidores de Hidroximetilglutaril-CoA Reductasas/efectos adversos , Proproteína Convertasa 9 , LDL-Colesterol , Enfermedad Arterial Periférica/tratamiento farmacológico , Anticolesterolemiantes/uso terapéutico , Ezetimiba/efectos adversos

RESUMEN

Cabozantinib and lenvatinib have been approved for the treatment of progressive medullary thyroid cancer and radioiodine-resistant thyroid cancer, respectively. Both phase III trials of cabozantinib and lenvatinib reported that renal adverse events (AEs) rarely occurred. The cabozantinib phase III study reported no AEs related to renal toxicity. In the lenvatinib phase III trial grade 3 (CTCAE), proteinuria (urinary protein ≥3.5 g/24 h) was found in 10.0% of the lenvatinib and 0.0% of the placebo patients. We report a 23-year-old patient with metastatic medullary thyroid cancer who was enrolled in the phase III trial, comparing cabozantinib to placebo and a 67-year-old patient with metastatic, papillary thyroid carcinoma who was undergoing treatment with lenvatinib during his enrollment in the phase III trial. The first patient had a normal kidney function initially, but developed end-stage chronic kidney disease unexpectedly on cabozantinib and additional zoledronate infusion. Whereas the second patient suffered from a dramatic aggravation of his known mild chronic renal insufficiency (KDOQI stage 2) due to long standing hypertension and atherosclerosis during the treatment with lenvatinib. These severe AEs due to anti-VEGF tyrosine kinase inhibitor treatment were unknown so far. In conclusion, these 2 cases argue for increased awareness for the possibility of renal failure as a consequence of anti-VEFG treatment. Predisposing conditions like known mild chronic renal insufficiency with only mild proteinuria and with atherosclerosis or precipitating co-medications like zoledronate infusion need to be accounted for to prevent these severe AEs.