Cirugia Vascular

#Anticoagulantes orales directos: la opción para #trombosis en cáncer

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Nuevos tratamientos facilitan la prevención del evento trombótico en cáncer, complicación que ensombrece la evolución del paciente.

Infusion pump feeding IV drip into patients arm focus on needle

En un paciente con cáncer, la prioridad es controlar el tumor, ya que es el principal riesgo para su vida. Sin embargo, asociados a la enfermedad hay otra serie de riesgos que también deben vigilarse porque pueden acabar siendo la causa indirecta del fallecimiento. De esta forma, por ejemplo, la enfermedad tromboembólica venosa (ETV) es una de las complicaciones más frecuentes y la segunda causa de muerte prevenible en los pacientes oncológicos.

La última actualización de las guías clínicas para el tratamiento de la trombosis asociada al cáncer señala que el uso de los anticoagulantes orales directos debería ser a partir de ahora el tratamiento de primera línea. “En el estudio en el que hemos participado se ha visto que la trombosis venosa ocurre en el 20% de los pacientes y comprobamos que los nuevos anticoagulantes igualan los resultados de la heparina, que es el actual tratamiento de elección, en la prevención de las complicaciones trombóticas y su gran aportación es que disminuyen de manera muy significativa el riesgo de sangrado, excepto en los tumores gastrointestinales”, explica Amparo Santamaria, hematóloga y jefa de la Unidad de Trombosis del Hospital Universitario Valle de Hebrón, de Barcelona.

Limitar los riesgos

Los tumores producen sustancias procoagulantes que activan la coagulación. La cirugía, la quimioterapia, la colocación de catéteres o la inmovilización prolongada pueden inducir estados de hipercoagulabilidad y la formación de trombos. En algunos cánceres, como el de riñón, ovario, colon o sistema nervioso central (SNC), existe un mayor riesgo. La edad avanzada y el estadio del cáncer también son factores de riesgo que se deben tener en cuenta. Todo esto hace que en los pacientes oncológicos el riesgo de sufrir un evento tromboembólico sea hasta siete veces superior y que un 20% de los pacientes presenten un riesgo alto de hemorragia y de tromboembolismo recurrente.

La hemorragia y el tromboembolismo son siete veces superiores en enfermos oncológicos. También existe mayor riesgo de fibrilación auricular 

“Sin embargo, a pesar de saber todo esto, no se le está dando la importancia que tiene la anticoagulación en estos pacientes. Vemos cada vez más cómo se siguen administrando los mismos tratamientos y hay pacientes que llevan muchos años con heparina cuando sabes que lo que hay que hacer es manejarlos de forma diferente. No existen unidades especializadas en el manejo a largo plazo de estas complicaciones”, señala Santamaria.

Otra de las complicaciones asociadas es la fibrilación auricular, que en los pacientes de cáncer llega a ser de hasta el 4%, el doble de prevalencia que en la población general. “Esto puede deberse al mismo cáncer, que crea problemas en el corazón, pero sobre todo por los nuevos tratamientos contra dianas moleculares que consiguen mejorar la supervivencia, pero que tienen este efecto secundario”, explica la hematóloga, quien además señala cómo hace no mucho tiempo no se veían pacientes de cáncer con fibrilación auricular, una enfermedad que se suele asociar a la edad.

“Al cronificar la enfermedad estamos empezando a ver complicaciones nuevas, como estas fibrilaciones auriculares. Es una buena noticia, entre comillas, porque significa que estamos mejorando la supervivencia, pero que hace necesario que tengamos presentes estas nuevas comorbilidades para que no haya complicaciones con los pacientes”, apunta, e insiste en que con la terapia con anticoagulantes orales directos es posible un manejo seguro y que ayude a reducir muchos de estos riesgos.

“Aunque la primera causa de muerte sigue siendo el cáncer, la segunda es la coagulación. Estamos tratando muy bien al paciente con cáncer, pero estos nuevos fármacos están haciendo que haya un aumento de trombosis y problemas cardiológicos. Por eso, es necesario que el especialista determine cuál es el tratamiento más adecuado y así mejorar el pronóstico a largo plazo y la calidad de vida del paciente”.

No limitar por financiación

Uno de los factores que juegan más a favor de la utilización de los nuevos anticoagulantes directos orales es cómo ayudan en la adherencia terapéutica. “A pesar de que ahora mismo no está financiado por la Seguridad Social, los pacientes prefieren el tratamiento por vía oral. Tras varios meses con heparina muchos de ellos tienen molestias por los pinchazos y pueden saltarse alguna dosis”.

Aunque los pacientes de cáncer suelen ser en general muy cumplidores de sus tratamientos, también es cierto que no se debe olvidar la facilidad de la administración de los fármacos para ayudarles en este sentido. Por eso, la profesional considera que debería insistirse más en que estos nuevos anticoagulantes fueran financiados. “Una vez que se pueda disponer de esta opción, el paso siguiente sería concretar, de forma individualizada, cuál es el mejor tratamiento: o heparina o los nuevos anticoagulantes, en función de la situación de cada paciente. Pero debería quedar claro que su financiación o no por el sistema no debería ser el elemento determinante”, concluye.

 

Nuevas unidades para el control de la oncotrombosis

Las nuevas recomendaciones sobre terapia de la trombosis asociada al cáncer apoyan un enfoque multidisciplinar, de oncólogos y hematólogos, en unidades de Oncotrombosis con un objetivo: mejorar los resultados para los pacientes.

“Los afectados necesitan un manejo más exquisito y de precisión de los anticoagulantes, porque sus tratamientos van cambiando a lo largo de la enfermedad. La experiencia del hematólogo ayudaría en esta medicina más personalizada”, explica Amparo Santamaria, quien pone como ejemplo las unidades creadas en su momento de cardio-oncología para tratar la toxicidad cardiovascular de los tratamientos y los buenos resultados que se están obteniendo.

“El aumento de la supervivencia en cáncer hace necesario un enfoque más a largo plazo y un buen seguimiento por parte de especialistas dentro de estas unidades de onco-trombosis”.

#20 Warning Signs of Poor Blood Circulation in Your System

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Good health depends on a lot of different factors, and a proper blood circulation is one of its main ones. The blood in our bodies is the responsible fluid to take nutrients and oxygen from one spot to another. Helping our body functioning correctly and being balanced. Whenever our blood circulation fails to deliver the proper nutrients to the specific parts of our body, that leads to a diverse range of health issues.

If these issues are left untreated, poor blood circulation can cause severe damage to our heart, brain, liver, limbs, and kidneys. There are many reasons why you may suffer from poor blood circulation. One of the most common ones if atheroscletosis. Which is also known as the hardening of the arteries. As well as peripheral artery disease (also known as PAD).

However, poor blood circulation can also be a result of a variety of health problems. Such as heart diseases, diabetes, blood clots or obesity. An excess of drinking, smoking, and also things like eating disorders or pregnancy can make you extremely vulnerable to this conditions.

If you are aware of the symptoms that show up when your blood circulation isn’t the appropriate, you will be able to control the reason behind it and find a timely treatment. Poor blood circulation can also lead to heart attacks, strokes, or even death. So make sure to check up with your doctor if you experience any of the symptoms listed below in this article. Keeping a healthy blood circulation is key to staying healthy and leading a good lifestyle!

Doctors can process a number of tests on you to find out what is causing your poor blood circulation, thus finding an appropriate solution in a timely manner. So read our article below to find out more about blood circulation.

1.Blood circulation: Swelling of lower extremities

A number of causes can produce swelling on your feet. For example, sitting or standing for a very long period of time in the same position. Or suffering from obesity, malnutrition or PMS (pre-menstrual syndrome). Among others such as high salt intake, ageing, leading a sedentary lifestyle or being pregnant. However, these listed types of swelling are only temporary and do get better within hours.

If the swelling or edema on your feet lasts for a long time, then the reason may relay on poor blood circulation. The explanation for this is that the lack of proper blood circulation make it so that the kidneys are unable to function as they should. By not being able to keep fluids in the blood vessels where they should be. The result of this is the leeching out of fluids which then settle in the surrounding tissues. This leads to swelling. In very severe cases, this poor blood circulation process can cause leg ulcers.

An easy trick to reduce swelling on your feet and legs is by laying down and raising your legs above heart level. Use some pillows or a higher chair to do so. Relax and apply cold if possible (never directly on the skin, always use towels or blankets to prevent skin burns from ice). If swelling does not reduce within a couple hours, please do consult your doctor. Blood circulation should improve once you’re laying down. But if it doesn’t, it could be a sign of poor blood circulation and needs to be diagnosed

If you also get swelling in other extremities or if your swelling includes discolouring or bruising under your skin make sure to inform your physician about that. Take pictures and write down when it happened and how it happened, if anything triggered it.

2.Blood circulation: Numbness of hands and feet

Numbness of hands and feet can be a consequence of numerous factors. But it can also be a sign of poor blood circulation. Numbness is usually felt in two different ways. The first one being a slight tingling on your extremities. This is reported to feel like little insects or ants walking over your skin. Just like when your hands or feet fall asleep and start waking up again.

The second symptom being what is usually called numbness. A feeling of numbness is when you stop feeling your extremities the way you usually do. When poor blood circulation comes into play, you will have this feeling that your hands and feet are swollen and cannot really feel what you touch. Like if your extremities had fallen asleep and couldn’t really wake up.

In this case, you need to be careful not to hurt yourself when doing normal activities as you won’t have full sensitivity in your hands and feet. Whenever your blood circulation is not at its best, there are several things you can do to help your extremities.

First of all, keep your hands and feet warm. Move them around, clap your hands, walk often. Don’t let your blood circulation get the best of you! If you have to sit or stand in the same position for long at work, make sure to take small breaks. Move around and stretch to help your blood circulation get back to normal. This will also help you get a little extra fitness!

If you do feel like your hands or feet are often feeling numb or tingling, you may want to check with your doctor. Blood circulation issues can be solved easily if treated on time. Just give a quick call to your local doctor if you have any of these symptoms.

3.Blood circulation: Cold hands and feet

Similarly to the above, having cold hands and feet is a symptom of bad blood circulation. It usually goes hand in hand with numbness and tingling, but not always. You may experience them together or separately.

Our blood is what maintains our body temperature. Thus, when having poor blood circulation, your extremities may suffer from a loss of temperature. Your hands and feet are the furthest parts of your body, so it’s normal that they suffer first. Including your fingers and toes. Additionally, blood circulation is what takes the oxygen to the cells around the body. When oxygen levels drop in your cells, this can lower the body’s temperature.

If you feel like your hands and feet are getting too cold, make sure to rub them. Try clapping your hands, jumping, massaging your hands and feet. Moving around will help getting your blood circulation going. However, poor blood circulation is not the only thing that could cause this symptom. A peripheral neuropathy, Raynaud’s syndrome, or even an underactive thyroid are common causes. Make sure to cover your extremities if it is cold outside and to use loosen clothes. This will help with your blood circulation. Additionally, make sure to use the correct size of shoes to tackle the problem on the feet. High heels or open shoes may cause blood circulation issues if used with the wrong size or temperature.

Whatever the cause, it is very important to tackle the problem correctly. Your doctor will be able to diagnose what causes your cold hands and feet. If related to blood circulation, you will get proper treatment. Make sure to bring all your current medications with you and to list any other symptoms that you may feel. Same applies to any other causes whenever needed.

4.Blood circulation: Persistent tiredness and fatigue

Tiredness is a typical symptom of physical effort and can also be linked to numerous drugs. Nonetheless, when consistently feeling weakness and fatigue, the reason may lay on poor blood circulation to various body parts.

Struggling organs will fight to make sure they continue functioning correctly. It even influences the way muscles work. As they are not getting enough nutrients and oxygen.

Alongside weariness and tiredness, a few people may significantly experience the ill effects of shortness of breath, absence of stamina and sore muscles. These are few of the associated symptoms of poor blood circulation related to your system. More reasons for tiredness include excessive drinking (alcohol abuse), uncontrolled intake of caffeine, lack of quality sleep, inactivity, bad dietary patterns, anxiety, grief, depression and stress.

All in all, having proper blood circulation means having good health. As soon as blood circulation is affected, our body will show symptoms to alert us. If you feel like you have any of the ones listed in this article, you really want to contact your doctor. Blood carries the oxygen around our body, and a lack of oxygen in our cells and brain can cause critical issues in the long-term. When caught early enough, it can be cured and controlled without further issues.

However, tiredness and fatigue may also be the symptoms of a list of other diseases. This is also why it is important to always keep your doctor in the loop of what happens within your body. Either by poor blood circulation or any other reason, it is important that you feel energetic and ready to conquer the day at any given time! If that is not how you feel, you definitely need to visit your doctor of choice to check your blood circulation.

5.Blood circulation: Slow healing and weak immune system

A slow blood circulation (also called circulatory system) will directly affect your immune system and general health. Because of poor blood circulation, your body is not receiving the vitamins and minerals that it needs to fight off diseases and infections. As these are not distributed in a timely manner or even in proper amounts. This directly affects the capacity of your body to recognise, diagnose, and fight off pathogens.

Whenever your immune system is weak, you will notice that your body suffers more often from common diseases or takes you longer to heal. You may also notice that you get bruised easily, this is due to blood thinning. Or even that small wounds hurt more and take very long to heal or scar. Your gums may bleed as well as your nose.

To enhance your blood circulation and get your immune system back to work, make sure to incorporate exercise in your every day schedule. Even just 20 minutes of walking, five to seven times a week can make a real difference to your blood circulation and immune system. Additionally, keep a balanced diet so that your body gets all the right nutrients. Make sure that your dishes are colourful and incorporate plenty of leafy greens, veggies, fruits, and proteins. Avoid sugars and processed foods, as well as carbonated sodas.

If after doing all these things you still feel weak and not healing properly, it is necessary that your refer your problems to your doctor. The physician will be able to diagnose whether your issues are related to poor blood circulation or to any other cause. Whatever the reason, make sure to follow the steps your doctor lays down for you and keep a balanced lifestyle with exercise and proper nutrition.

6.Blood circulation: Varicose veins

Varicose veins developing in the legs can be a side effect and also a reason for poor blood circulation. Because of an incorrect blood circulation system, there is a pressure buildup in your legs. This leads to varicose veins just under the first layer of the skin. Veins then become extremely visible, twisted, and swollen.

Varicose veins have a tendency to show up on the lower part of the legs and cause itchiness, irritation, pain, restlessness, heaviness and burning sensations. The presence of protruding veins is obviously a beauty concern for those suffering it and having to show off their legs at work or social events. However, varicose veins are not only caused by poor blood circulation. They are also common symptoms of hereditary diseases, obesity, hormonal changes, jobs that require standing still, the use of birth control pills, and even constipation.

On the off chance that you have varicose veins, it is extremely important to wear pressure stockings to allow for appropriate blood circulation to occur. Additionally, counsel your specialist to decide the correct reason and treatment for your varicose veins. Varicose veins can be treated with non-invasive procedures such as massages, use of compression stockings, and laser. But can also be reduced with injections and surgery.

Additional Information:

Making a few changes in your lifestyle and nutrition will help control, reduce, and prevent the appearance of varicose veins. If the reason behind them is indeed poor blood circulation, your doctor will be able to prescribe proper medication. As well as providing important advises to get your circulatory system in motion again! Always make sure to bring a list of your medications when visiting the doctor and listing any other symptoms you may be suffering from. This will help with the diagnose and get you back on your feet in a timely manner!

7.Blood circulation: Hair loss

Balding with no apparent reason is an unmistakable sign that blood isn’t getting pumped appropriately around your system. The moment your scalp is not receiving the appropriate amount of essential nutrients, you will feel your hair becoming thin and dry. Thus falling out at a higher rate than usual.

When the hair loss issue is related to poor blood circulation, the use of specific shampoos is unnecessary. Instead, it is very important to activate the follicles in your scalp. In order to do so, make sure to wash your hair with your head downwards and massage throughout. This will activate the cells of your scalp and bring more blood circulation to it. Another way to diagnose blood circulation issues is to check your skin and nails. If you get brittle and weak nails, as well as dry skin and hair loss, you are not getting the proper nutrients. Which is usually related to poor blood circulation.

Even though hair loss is usually encountered in men, women can also suffer from it when it comes from poor blood circulation. Other factors causing baldness are stress, excessive smoking, aging, hormonal imbalance, nutritional deficiencies, thyroids, anemia, chronic illnesses, and genetic factors among many.

If you notice that your hair is falling off faster than usual, it is getting thinner and the ends are split, check your skin and nails. If they’re dry and brittle, then get an appointment with your doctor. After running a few tests you will be able to have a proper diagnose of the causes for your hair loss and start treatment straight away. Make sure to tell your doctor if you noticed any other symptoms and bring with you your most recent blood tests and list of current medication as to avoid any interactions.

8.Blood circulation: Erectile dysfunction

Blood is the reason why most of our organs work the way they do. When there is poor blood circulation, many things will stop working or will work from time to time. This includes the reproductive organs. A poor blood circulation can cause erectile dysfunction in men. This issue is represented by consistent problems in sustaining and even achieving an erection even though the subject feels aroused.

Erectile dysfunction (also known as ED) is also frequently associated with atherosclerosis. This is another very important reason to leave any embarrassment behind and to contact your doctor as soon as this becomes a recurrent problem. Due to erectile dysfunction being caused by physical and not emotional issues, it can be treated if diagnosed correctly.

Whenever visiting your doctor, make sure to take with you not only a list of your current medications and illnesses. But also a detailed list of the dates and times erectile dysfunction has happened to you. This will help the doctor diagnose the reasons behind erectile dysfunction and help you correct it as soon as possible. Once the issue is solved, either blood circulation or atherosclerosis, you will be able to achieve and sustain proper erections, thus returning to a satisfactory sexual life with your partner.

Do not feel ashamed or afraid to talk about this. Many men suffer from erectile dysfunction and the only way to solve the issue is talking to a physician. Keeping it a secret will only add to your stress and anxiety and make the problem not only physical but also psychological. Leading to a more complicated treatment. Make sure to talk about it with your physician and also with your partner as to get the proper support and treatment, you will soon be happy again!

9.Blood circulation: Cyanosis or skin discolouring

On the off chance that your skin or lips turn blue, it unmistakably shows low blood oxygen levels due to poor blood circulation. This issue is otherwise called cyanosis or skin discolouring.

When your blood circulation is normal, your skin will look its natural shade and organs will look either pink or red. However, whenever your blood circulation levels drop, your skin and organs will turn of a greyish color. Some part of your body will turn blue instead, similar to a bruising color. These parts are: fingers, toes, nails, eyes, gums, and lips.

Blue skin is also an early sign of heart disease in babies. It is very important that if you ever get or see someone getting blue or extremely discoloured skin, that you call a doctor or emergency services. Cyanosis can be the indication of something going extremely wrong with your heart and blood circulation so it needs to be treated as soon as possible.

Family history, current medications, and a list of all the symptoms that you have felt is what the doctor needs to diagnose you and treat you correctly. Make sure to take them with you when you attend your next appointment or the emergency room at your nearest hospital. Congenital heart diseases are a major factor for skin discolouring so it is very important to have the above with you when seeing a doctor. Take a friend or relative with you in case you need to be administered medication that may make you dizzy or hospitalised for the time being. Don’t worry, this can be treated, but it is important to catch it on time. Do not wait for the next time it happens, go as soon as occurs the first time. Better safe than sorry, even more when talking blood circulation!

10.Blood circulation: Heaviness in the chest

Our heart is the main and most important organ in your body. Its function is to pump blood around, thus being the manager of blood circulation as we know it.But in order to pump blood correctly, it also needs to receive blood correctly. If your arteries are not bringing enough blood back to your heart, it will cause heaviness and tightness.

The pain will not be constant, it will come and go. This pain is usually known as andina pectoris or angina. However, pain and heaviness in your chest can also be a symptom of atherosclerosis in your arteries. In addition, this same pain can also represent heartburn, muscle spasms, acidity, stomach ulcers, indigestion, or upper respiratory infections.

Because of its nature, it is important that chest pain is treated as soon as possible. Either one of the reasons above can lead to serious heart damage as well as many other organs. Please make sure to check with your physician as soon as possible.

11. Reduced cognitive function

When you think of blood, you do not always think of the brain. The first thing that generally comes to mind is the heart along with its accompanying veins and arteries. This is correct, and technically blood does not go into the brain. There is even something called the Blood-Brain Barrier which is specifically designed to keep blood out of the brain.

While blood does not enter the brain, the brain does need the things that get carried by the blood. This includes oxygen and nutrients to name but a few. Therefore, the brain, like every other part of the body, requires sufficient blood flow if it is to operate correctly. When this blood flow has been decreased, then there will certainly be problems.

Many symptoms of poor circulation are a lot more intuitive than reduced cognitive function. But, if a person has problems remembering things, or possibly they feel a bit mentally foggy, then they could be suffering from reduced or poor circulation. A diagnosis of this kind can only be made if the person displays other symptoms, but it is completely advisable to take it very seriously if the cognitive function is impaired.

A person cannot survive without their brain and if poor circulation is left untreated, the brain will not only suffer in the short-term. If the brain is left without proper blood flow for too long, then the cells will start to die. Unlike other cells in your body, brain cells don’t regenerate properly. Once they have been damaged, the chances of them recovering are incredibly slim. Your mother may have told you that you only get one set of eyes, but you also get one brain.

12. Digestive irregularities

This is another system that one doesn’t usually associate with blood flow. When you think of your digestive system as a whole, you think of food and the waste matter that is created once this food has been broken down. But, consider for a second how this system works. It is a very active system that requires a reliable source of blood, and it needs this blood constantly. No part of the digestive system can be left without blood for any period.

If there is a case where circulation is reduced, then there will be disruptions to digestion. These disruptions can be of many different kinds as the digestive system is quite complex and is made up of many different parts. The noticeable digestive problem that could result from poor circulation is a pain in the abdomen. The abdomen houses the digestive system, so clearly this is the area that would hurt if something goes amiss. This pain may be localized, or it could be a pain that spreads through the general area.

The other problem which could arise is related to the stool. You can tell a lot about the health of a person by looking at their stool. In the case of poor circulation, there is a multitude of things that could go wrong with one’s stool. A person could experience very uncomfortable bouts of diarrhea, or they could even be very constipated.

The type of issue that one is having with their stool is almost irrelevant. The point is, if there has been a drastic change in a person’s bowel movements, then they could very well be suffering from poor circulation.

13. Systemic cramping and pain

There is not a single person on this planet who has not experienced muscle pain at some point or other. There is muscle pain that results from exercise. Then there is the pain that accompanies an injury. Most people also know what it is like to have stiff joints. Granted, this is generally more felt by the elderly, but on the whole, people are quite aware of the concept. The same can be said for cramping. People sleep in awkward positions and pull their backs out all the time. The one thing that all these types of aches and pains have in common is that the people suffering from them can generally pinpoint the root of the problem.

They know that they may have pushed their workout too far, or possibly the sat in an awkward position for too long. If, however, a person has muscle pain or joint cramping and they have no clue why they are feeling that way, then the problem could be poor circulation.

The concept is quite simple, and muscles need blood to function. They need oxygen, and they need nutrients. If they do not get these things, then they will stop working properly. If this wasn’t bad enough, not only will the muscles stop working, they will also start to hurt. This pain will generally result from the stiffness and cramping that will arise when the muscles do not get enough blood.

There will also be pain that will be associated with the reheating of the hands and feet which have become cold due to inadequate blood flow. This pain will be more throbbing than stabbing, but it will be pain none the less.

14. Ulcers on the legs

This condition is not one that is very well known. People may know about ulcers when they think of their mouths as mouth ulcers are relatively common. But, it is possible to get ulcers elsewhere on one’s body. In particular, these ulcers can appear on one’s legs. First, let us have a look at what would happen to the blood in the legs if circulation was decreased.

When blood circulation has been impaired or reduced, what happens is that the blood starts pooling in the veins. This does not necessarily occur in the arteries as the blood here is pumping out the heart and isn’t as affected by gravity. But, the blood in the veins has to try and work against gravity to make its way back up to the heart.

When the circulatory system has been impaired then this blood pool, especially in the legs, which then creates a hospitable environment for ulcers. It is more likely for these to develop on one’s legs, but it is possible for them to appear in other parts of the body. Another reason why a person with bad circulation is prone to ulcers is that of how bad circulation affects a person immune system.

If blood is not flowing correctly, then a person’s immune system is compromised. When this happens, then it will take longer for them to heal which is another thing that will contribute to the development of ulcers. This symptom of poor circulation is one of the more visible ones as an ulcer on the legs or feet of a person is incredibly hard to miss. There are also not many other conditions which will result in this kind of skin condition.

15. Inability to perform strenuous tasks

The secret to living a healthy and happy life is no real secret. There is no mystery here, and there is no real debate. There may be people out there who would want to argue the finer points, points like whether it is healthier to be vegetarian or whether humans need meat to survive. These points will be discussed until the end of the earth. But at the core of each argument is that to be healthy a person needs to do a few simple things.

They need to eat healthy food that is not overly processed, and that is not loaded with chemicals. Added to this diet is exercise. A person who is not exercising is a person who is certainly not healthy. Now, this is all well and good, but what about the people who physically cannot exercise.

Put aside fitness levels for a moment and think about what it must be like to not even be able to walk up a flight of stairs without getting severely out of breath. Or trying to lift something heavy and not be able to move it an inch. This is a very real reality for people with poor circulation. They may not even know that this is why they are unable to perform specific physical tasks. They might think that they are unfit and that they need to try harder.

The reason why people with bad circulation are less physically capable is that their muscles are not getting enough blood and not at the correct speed. Their heart is also taking the strain as it is forced to pump harder to try to get the blood to where it needs to go.

 

16. Unexplained weight loss

These days everyone is obsessed with their weight. People go to the gyms on mass. They spend thousands on diet products and are always on the lookout for the next best thing that will make them thin without having to put in too much effort. This is the society we live in. The thinner, the better. It is for this reason, that if a person suddenly loses weight, they would not blink an eye.

They would more likely be thanking their lucky stars rather than sitting back and trying to figure out what is happening. But, and there is no argument here if a person loses weight and they can find no explanation for it they should not just brush it under the rug. This person needs to take a moment to try and figure out what has changed in their lifestyle. Are they more stressed than usual or possibly they have changed their diet? Maybe they have started a new medication?

If they can find absolutely no reason for this weight loss and they have a few of the other symptoms on this list, then the culprit could be poor blood circulation. Poor circulation does not necessarily affect one’s weight directly, and it is more of a secondary consequence. When a person’s blood is not getting appropriately circulated, they are more inclined to have a decreased appetite, after an extended enough period, this will lead to weight loss. There is also the case of malabsorption. If the digestive system is not getting the correct blood flow, then it does not operate properly. Food is not broken down and absorbed correctly, also leading to weight loss over time.

17. High blood pressure

Blood pressure is a bit of an odd physiological value. It is not one that is widely understood by those who do not work in the medical field. People know about their heart. They know that it beats and on the whole, they can find their pulse if they need to. Barring this, they can feel their heartbeat if they are paying enough attention. But heart rate is only one part of the equation. There is the speed at which the heart pumps blood around the body, and then there is the actual pressure that is created when the heart pumps this blood.

It is almost counter intuitive, but when the body is experiencing poor circulation, a person will have increased blood pressure. This is because the heart has to work harder to pump blood throughout the body. If blood is pooling in one’s limbs and muscles then when the heart tries to beat as normal, it is trying to fit more blood into a space that already has blood.

On the surface, a slight increase in blood pressure may not seem that dangerous. This is only somewhat true. The body is designed to handle periods of high blood pressure. The heart and blood vessels will not be immediately affected if blood pressure increases. There are times when it is normal to have elevated blood pressure. The problem here would involve the timeframe.

High blood pressure in the short-term will not necessarily cause long-term damage. But, if this high blood pressure persists for too long, then the body will start taking the strain. This damage will not only be limited to the heart and blood vessels, but even organs like the kidneys will begin to falter if blood pressure remains high for too long.

18. A decrease in libido

Sex is very much a part of life. It is arguably one of the most critical aspects of the human experience. There are some who may even argue that it controls the world. If this is, in fact, the case, then it would be because sex is a huge motivator for many people. This number is not one that can be tested, but it is safe to say that a lot of us, maybe even all of us, make a lot of our decisions with sex in mind. Considering how important sex is in our lives, it is odd that we are so reluctant to talk about it.

While we may have made quite a bit of progress in this arena over the last couple of years, we are not almost nearly where we need to be. We need to be able to talk about sex not only for our mental health but our physical health as well. The reason for this is because sex is important as it is quite a reliable indicator of one’s overall health.

When using this as a health indicator, doctors will look at not only the reproductive organs themselves but also at a person libido. Libido is made up of a couple of components. There are quite a few hormones involved which are made in the brain and the organs themselves, and then there are the organs which contribute in their way to one’s libido. When it comes to poor circulation, if these organs do not get the correct supply of blood then they will not work in the way that they should.

This applies to both men and women and will manifest itself in a decreased libido. There will also be other dysfunctions in this area including irregular menstrual cycles for women and decreased fertility and functionality in men.

19. Dark rings underneath your eyes

Sleep is incredibly important. A person can go longer without food then they can without sleep. When a person sleeps, their body recharges, and it heals. If a person does not get enough sleep, the effects are incredibly visible. Symptoms of sleep deprivation range from mood disturbances to a decreased immune system. There is also the appearance of little bags and dark rings underneath the eyes.

While these bags and rings may not be attractive, they are temporary. But, if you have dark rings underneath your eyes that won’t go away even though you are getting the correct amount of sleep. Then there may be other factors that should be considered. One of these being bad circulation. There are certain items on this list which are more secondary consequences of poor circulation as opposed to a direct result.

When it comes to dark rings underneath the eyes, these appear because blood is not moving the way it should. Instead, it is pooling in that area and not being circulated by the natural mechanisms in place. As mentioned, there are other causes for these dark rings other than poor circulation. But, there is a very easy way to check whether circulation is the culprit.

The way to do this is to press down on the rings while looking in the mirror. If the rings subtly clear up for a few seconds and then darken up again, then the problem is poor circulation. This little at home test should tell you whether you are having circulation issues, but it will not tell you the extent of the problem. A doctor can only do this after further testing.

20. Brittle nails

When one thinks of their health, they do not generally look to their nails as indicators. Many people do not even look after their nails, so they wouldn’t even actually know if something is wrong with them. Sure, smokers may look at the discoloration and think that maybe their health is taking a beating, but this isn’t even an internal consequence and is only due to the nicotine in cigarettes.

While nails may not be the gold standard when it comes to testing one’s health, they can be good indicators if you know what to look for. The first thing that needs to be considered is the quality of the nail. Are the strong or are they brittle? Do they chip and break very easily or are they thick and hard to cut? If the nails are brittle, then there could be a circulation problem that exists. The reason for this is that nails, like every other part of the body, needs nutrients to grow.

If circulation is weak, then these areas will not be getting enough nutrients and they will, therefore, be weak and will not grow properly. Another way that nails can indicate the quality of circulation is by looking at the nail beds themselves. If you press down on them until they turn white and then release, look at how long it takes for them to go pink again. If this seems like it is taking too long, then there could be a prevailing circulatory problem.

When it comes too poor circulation, there are many symptoms which can be sought out simply because bad circulation will affect the entire body. By looking at one’s nails, you will not be able to make a full diagnosis, but it will give you a pretty good idea on the state of one’s blood circulation.

How to Improve Blood Circulation

• Add physical exercise to your daily routine.

• Stress can be one of the affecting causes of poor blood circulation. Practice meditation, mindfulness, and yoga to control your stress levels.

• Massage your body using warm olive oil and some drops of rosemary essential oil. Use it on your extremities such as hands, fingers, feet, and toes. As well as legs and arms.

• Try contrast hydrotherapy (jumping from hot to icy water and viceversa) to improve your blood circulation.

• Posture is a leading factor to blood circulation, either good or bad. Talk to a professional to make sure that you sit, walk, and stand properly.

• Caffeine is also not good for blood circulation as it causes anxiety. Change it for green tea or herbal teas in general.

• Alcohol intake must be reduced to a minimum.

• Smoking is bad either actively or passively, so we advise to quit smoking and to stay away from secondhand smoke.

• Add nuts, black pepper, cayenne pepper, seeds, onion, garlic, and ginger to your diet to boost your metabolism and blood circulation.

• Proper shoes are key to keep your legs and feet healthy and to help with blood circulation.

#Actualités de la #cardiologie interventionnelle

Postado em

Olivier VARENNE, Hôpital Cochin, Paris

Un dossier réalisé avec la collaboration d’Olivier Varenne, Hôpital Cochin, Paris.

Quelles sont les causes de FFR sub-optimale après déploiement d’un stent ?

La FFR était utilisée pour évaluer le résultat du stenting. Une valeur FFR < 0,90 a été montrée comme étant associée à plus d’événements cardiovasculaires dans le suivi clinique après stenting.
Ce travail étudiait par OCT les causes associées à une FFR < 0,90 et éventuellement visait à améliorer cette valeur.
Les résultats de cette étude montrent une FFR optimale observée chez 40 % des patients (n = 14) et < 0,90 chez 60 % (n = 21). Chez 61,9 % de ces patients avec FFR < 0,90, le stent était mal déployé. Une optimisation par angioplastie complémentaire permettait d’améliorer la FFR finale (0,80 ± 0,02 à 0,88 ± 0,01 ; p = 0,008). Malgré un bon résultat angiographique, le résultat fonctionnel demeurait sub-optimal chez 60 % des patients évalués par la mesure de la FFR, principalement à cause d’un mauvais déploiement du stent.
L’utilisation de l’OCT permet d’améliorer la valeur finale de la FFR.

Wolfrum M et al. Eurointerv 2018 ; 14 (12) : e1324-31.

Durabilité à long terme des prothèses valvulaires après TAVI

La durabilité des substituts valvulaires utilisés lors des interventions de TAVI reste une préoccupation clinique, en particulier depuis le développement des indications chez des patients à risque intermédiaire.
Ce travail décrit l’incidence des dégénérescences valvulaires entre 5 et 10 ans après la procédure de TAVI. Tous les patients traités par TAVI au Royaume-Uni entre 2007 et 2011 ont été inclus dans un registre national (United Kingdom Transcatheter Aortic Valve Implantation registry). Ce travail comprend les données des patients qui avaient une échographie cardiaque au moins 5 ans après TAVI.
Au total, 241 patients (79,3 ans, 46 % de femmes) avec un suivi médian de 5,8 ans ont été étudiés. Parmi eux 149 patients (64 %) ont été traités par valve autoexpansible et 80 (34,7 %) par valve sur ballon. Le gradient transaortique maximal durant le suivi était plus bas qu’en postprocédure (17,1 vs 19,1 mmHg ; p = 0,002). Il y avait plus de patients avec insuffisance aortique minime ou absente (47,5 % vs 33 %) durant le suivi. Il y a eu 1 seul cas de dégénérescence sévère (0,4 %) 5 ans après l’implantation (insuffisance aortique sévère) et 21 cas de dégénérescence modérée (8,7 %) entre 4,9 et 8,6 ans due à une insuffisance aortique (57 %) ou une sténose aortique (43 %).
Le suivi à moyen/long terme des valves aortiques implantées au cours des procédures de TAVI apparaît donc bon avec une incidence de dégénérescence sévère inférieure à 1 %. Il faut également noter que dans ce registre, 91 % des patients restent indemnes de dégénérescence entre 5 et 10 ans après TAVI.

Blackman DJ et al. J Am Coll Cardiol 2019 ; 73 : 537-45.

Cicatrisation à 1 et 2 mois de l’angioplastie avec stents BuMA™ Supreme ou XIENCE

Le but de cette étude était de comparer la cicatrisation dans les stents XIENCE et dans les nouveaux stents BuMA™ (stents cobalt chrome au sirolimus et polymère résorbable), par OCT à 1 et 2 mois de leur implantation.
L’étude PIONEER II OCT est une étude randomisée multicentrique avec deux cohortes. Les patients de la cohorte 1 avait un OCT à 1 mois (BuMA™ : 16 patients, XIENCE : 15 patients), ceux de la cohorte 2 un OCT à 2 mois (BuMA™ : 21 patients, XIENCE : 23 patients).
Le critère principal, le pourcentage de mailles de stents recouvertes à 1 mois était supérieur dans le groupe BuMA™ (83,8 ± 10,4 % vs 73,0 ± 17,5 % ; psup < 0,037). Dans la cohorte 2, le BuMA™ était non inférieur au XIENCE (80,3 ± 18,3 % vs 73,3 ± 21,3 %). Les scores de cicatrisation étaient meilleurs pour le BuMATM dans la cohorte 1 (32,36 ± 21,59 vs 54,88 ± 34,65 ; p = 0,027), mais pas dans la cohorte 2 (39,86 ± 37,77 vs 53,75 ± 42,84 ; p = 0,25).
Le stent BuMA™ semble avoir une couverture de mailles plus rapide que le XIENCE mais cette différence ne s’observe plus à 2 mois.

Asano T et al. Eurointervention 2018 ; 14 (12) : e1306-15.

Durabilité des substituts valvulaires aortiques après TAVI ou chirurgie

Le but de l’étude NOTION (Nordic Aortic Valve Intervention) était de comparer la durabilité des substituts valvulaires aortiques au cours des remplacements valvulaires chirurgicaux et par TAVI.
Les patients avec sténose aortique ont été randomisés pour être traités par TAVI (n = 139) ou chirurgie (n = 135). Une dégénérescence valvulaire était définie par un gradient transvalvulaire ≥ 20 mmHg, ou une augmentation du gradient moyen de plus de 10 mmHg après le 3e mois ou par une insuffisance aortique intraprothétique après la procédure.
À 6 ans, les taux de mortalité étaient similaires entre les deux techniques (42 ,5 % vs 37,7 % ; p = 0,58). Le taux de dégénérescence était plus important après chirurgie (24,0 % vs 4,8 % ; p < 0,001). Il n’y avait pas de différence en termes d’endocardite (5,9 % vs 5,8 % ; p = 0,95).
Le résultat principal de cette étude est que la dégénérescence valvulaire semble plus fréquente après chirurgie de remplacement aortique qu’après TAVI. Ces données demandent bien évidemment confirmation avec un plus grand nombre de patients inclus.

Søndergaard L et al. J Am Coll Cardiol 2019 ; 73 : 546-53.

Thrombose de valve précoce et tardive après TAVI

La fréquence de survenue d’une thrombose valvulaire après TAVI et ses conséquences cliniques demeurent mal définies.
Dans ce registre multicentrique, OCEAN TAVI, 485 patients ayant bénéficié d’un scanner post-TAVI ont été analysés à 3 jours, 6 mois, 1 an, 2 ans et 3 ans après la procédure. La thrombose de valve était définie comme un épaississement hypodense avec diminution de la mobilité valvulaire. Les patients ne recevaient pas de traitement anticoagulant en cas de détection de thrombose valvulaire. Une thrombose précoce était retrouvée chez 9,3 % des patients. Le gradient moyen à la sortie de l’hôpital était plus haut chez les patients présentant une thrombose valvulaire précoce. Les autres paramètres associés à la thrombose précoce en cas de valve déployée sur ballon étaient une sténose aortique à bas flux et bas gradient, un mismatch important, et une valve de 29 mm. Il n’y avait pas de facteur prédictif en cas de valve autoexpansive.
Les taux de décès, AVC ou insuffisance cardiaque entraînant une hospitalisation à 2 ans étaient de 10,7 % et 16,9 % chez les patients avec et sans thrombose de valve respectivement (p = 0,63).
Une thrombose valvulaire non anticoagulée en post-TAVI ne modifie pas le risque global de MACE.

Yanagisawa R et al. Circ Cardiovasc Interv 2019 ; 12 : e007349.

Traitement par angioplastie des occlusions coronaires chroniques

Les techniques de revascularisation coronaire permettent un haut taux de succès y compris dans les occlusions coronaires chroniques (CTO) les plus compliquées. Cependant, l’évaluation de l’angioplastie dans les CTO demeure surtout le fait de registres.
L’étude de non-infériorité DECISION-CTO a inclus des patients avec au moins une occlusion chronique et les a randomisés entre angioplastie et traitement médical. Les patients ayant d’autres lésions pouvaient être traités par angioplastie. Le critère principal d’évaluation, était un critère composite (décès, infarctus du myocarde, AVC ou tout type de revascularisation). L’étude a été interrompue avant l’inclusion des 1 284 patients prévus. Entre mars 2010 et septembre 2016, seuls 834 patients ont été inclus et traités par angioplastie (n = 417) ou traitement médical seul (n = 398). Le taux de cross over des patients du groupe traitement médical était de 19,6 % dans les 3 jours suivants la randomisation.
Le taux de succès de l’angioplastie était de 91 %. Durant le suivi de 4 ans, il n’y avait pas de différence dans le critère principal d’évaluation entre les patients avec angioplastie et ceux sans (22,3 % vs 22,4 % ; p = 0,86).
L’angioplastie des CTO apparaît faisable et sûre mais sans impact fort sur les critères évalués. L’étude est cependant limitée par une faible puissance et un taux élevé de cross over.

Lee SW et al. Circulation 2019 ; doi.org/10.1161/CIRCULATIONAHA.118.031313.

Comparaison entre valves autoexpansibles et valves déployées sur ballon dans les TAVI

Le but de ce travail était de comparer les résultats cliniques après TAVI par prothèse autoexpansible ou prothèse délivrée par ballon.
Dans ce méta-registre (Collaboration CENTER), les données de deux registres individuels ont été poolées. Le critère principal était la mortalité ou le risque d’AVC à 30 jours. Les valves étaient de plus catégorisées comme ancienne ou nouvelle génération. Le total des 12 381 patients ont été traités par valves autoexpansibles (n = 6 142) ou valves déployées par ballon (n = 6 239). L’âge moyen des patients était de 81 ± 7 ans et le score STS-PROM médian de 6,5 %
À 30 jours, la mortalité n’était pas différente dans les deux groupes 6,2 % vs 5,3 % ; p = 0,10. Un AVC était moins fréquent en cas de valve déployée sur ballon (1,9 % vs 2,6 % ; p = 0,03). Les valves autoexpansibles étaient associées à un triplement du risque de stimulateur cardiaque (7,8 % vs 20,3 % ; p < 0,001). Les nouvelles valves délivrées sur ballon étaient associées à plus de saignements majeurs (4,8 % vs 2,1 % ; p < 0,001).

Vlastra W et al. Eur Heart J 2019 ; 40 (5) : 456-65.

STEMI : efficacité des DES avec polymère résorbable

Les résultats à long terme des stents actifs avec polymère résorbable au biolimus (BES) versus stents nus ont été rapportés dans l’étude randomisée COMFORTABLE (1 157 patients ; BES : n = 575 et BMS : n = 582).
Une imagerie endocoronaire (IVUS ou OCT) était réalisée à l’implantation des stents et à 13 mois chez 103 patients. À 5 ans, les BES étaient associés à une réduction du risque de MACE (RR : 0,56 ; IC 95 % : 0,39-0,79 ; p = 0,001], principalement due à une réduction du risque de réinfarctus dans le vaisseau traité (RR : 0,44 ; IC 95 % : 0,22-0 ,87 ; p = 0,02) et des revascularisations (RR : 0,41 ; IC 95 % : 0,25- 0,66 ; p < 0,001). Les thromboses de stents (2,2 % et 3,9 %) et les thromboses de stents très tardives (1,3 % vs 1,6 % ; p = 0,77) n’étaient pas différentes entre les groupes.
La fréquence de mailles malapposées était similaire dans les deux groupes (BES : 0,08 % vs BMS : 0,02 % ; p = 0,10) mais les mailles non recouvertes étaient plus fréquentes dans les BES (2,1 % vs0,15 % ; p < 0,001).
Dans le STEMI, l’utilisation de stents BES comparativement aux BMS est associée à une réduction des MACE à 5 ans. À 13 mois, la cicatrisation dans les deux types de stents est voisine.

Räber L et al. Eur Heart J 2019 ; doi: 10.1093/eurheartj/ehz074.

Essai randomisé comparant deux types de sondes de FFR : essai COMET

Cette étude visait à comparer deux des sondes de mesure de la FFR disponibles sur le marché en comparant les mesures obtenues de façon simultanée.
Des mesures pairées ont été réalisées chez les 106 patients randomisés en trois groupes selon les sondes de FFR utilisées (BS : Boston Scientific et SJ : St Jude/Abbott), dans l’évaluation de sténoses intermédiaires (BS/BS, SJ/SJ ou SJ/BS). Après égalisation des pressions, des paires de mesures étaient réalisées au maximum de l’hyperhémie (BS/BS n = 90 ; SJ/SJ n = 90 ; SJ/ BS n = 108) et au retrait du cathéter (drift ; BS n = 105 ; SJ n = 103)).
Les moyennes des différences (DS) entre les paires de mesures étaient similaires : BS/BS = 0,0016 (0,023) ; SJ/SJ = 0,002 (0,03) ; SJ/BS = 0,0013 (0,028). Le drift était similaire entre les deux types de sondes : BS = 0,02 (0,01-0,05) ; SJ = 0,02 (0,01-0,04) ; p = 0,14.
Il n’a donc pas été retrouvé de différences entre les deux guides de mesure de la FFR, les guides St Jude/Abbott et les guides COMET de Boston Scientific.

Stables R et al. Eurointervention 2019 ; 14 (15) : e1578-84.

Traitement antithrombotique après SCA ou angioplastie coronaire chez les patients en FA

L’essai factoriel 2 x 2, AUGUSTUS, a randomisé 4 614 patients en fibrillation atriale (FA) lors d’un SCA ou après angioplastie coronaire entre apixaban/AVK et aspirine/placebo en plus d’un inhibiteur P2Y12 et cela pendant 6 mois.
Le critère principal comprenait les saignements majeurs ou non majeurs mais cliniquement significatifs.
Les saignements ont été observés chez 10,5 % des patients sous apixaban et 14,7 % de ceux sous AVK (HR : 0,69 ; IC95 % : 0,58-0,81 ; p < 0,001), et chez 16,1 % des patients sous aspirine et 9,0 % sous placebo (HR : 1,89 ; IC 95 % : 1,59-2,24 ; p < 0,001). De plus, les patients sous apixaban avaient une plus faible incidence de décès ou d’hospitalisations que ceux sous AVK (23,5 % vs 27,4 % ; p = 0,002) et autant d’événements ischémiques. Les patients sous aspirine avaient une incidence de décès et d’hospitalisations et d’événements ischémiques similaires à ceux sous placebo.
Cette étude montre que chez les patients sous anti-P2Y12 en fibrillation atriale avec un SCA ou une angioplastie coronaire récents, un traitement antithrombotique à base d’apixaban sans aspirine fait moins saigner et conduit à moins d’hospitalisations sans augmenter le risque ischémique.

Lopes RD et al. NEJM 2019 ; doi: 10.1056/NEJMoa1817083.


“Publié dans Cath’Lab

#Conduite à tenir devant un #phénomène de Raynaud

Postado em

Jean-Benoît MONFORT, service de dermatologie, médecine vasculaire et allergologie, Hôpital Tenon, Paris

Les acrosyndromes sont un motif de consultation très fréquent. Un interrogatoire et un examen physique minutieux sont indispensables afin de bien classer l’acrosyndrome et de prescrire un bilan paraclinique et un traitement adapté.

Un acrosyndrome vasculaire est défini par des manifestations des extrémités d’origine vasomotrice. Tout acrosyndrome n’est pas d’origine vasculaire. Ainsi, devant des manifestations des extrémités, le clinicien devra éliminer une origine neurologique (paresthésies d’une polyneuropathie périphérique), rhumatologique (syndrome du canal carpien, algoneurodystrophie).

Les acrosyndromes vasculaires sont classés selon leur évolution :
• paroxystiques : phénomène de Raynaud, érythermalgie ;
• permanents : engelures, acrocyanose, acrorhigose, acrocholose, syndrome de l’orteil bleu, hématome digital spontané.

Nous traiterons ici du phénomène de Raynaud.

Faire le diagnostic de phénomène de Raynaud

Le phénomène de Raynaud (PR) est l’acrosyndrome vasculaire de loin le plus fréquent (10 % des femmes et 2-3 % des hommes). Il prédomine nettement chez la femme. Le diagnostic se fait lors de l’interrogatoire. En effet, il n’y a généralement aucune manifestation clinique lors de la consultation. Il est la conséquence d’un vasospasme brutal de la microcirculation, déclenché par l’exposition au froid. Il se manifeste par trois phases :
 la phase syncopale (blanche) : les doigts deviennent brutalement blancs, avec généralement une bonne délimitation (figure 1). Cette phase dure quelques minutes à quelques heures selon l’étiologie. Une diminution de la sensibilité (sensation de « doigts morts ») est très souvent observée.


Figure 1. Phénomène de Raynaud (phase syncopale).

• la phase asphyxique (bleue) : elle est la conséquence d’une stase veinulaire. Les doigts sont bleus, cyanosés. Elle dure quelques minutes.
• la phase hyperhémique (rouge) : lors du réchauffement des doigts, une vasodilatation réflexe se produit. Elle dure quelques minutes, les doigts sont rouges avec une sensation de brûlure.

Seule la phase syncopale est obligatoire pour retenir le diagnostic de PR, les deux autres peuvent manquer à l’interrogatoire. Leur absence ne doit pas faire remettre en cause le diagnostic. En revanche, il existe des PR atypiques, où seule la phase asphyxique est présente. Il ne faut pas confondre cette situation avec une simple acrocyanose. Le caractère paroxystique et transitoire est en faveur du PR. La topographie du PR concerne essentiellement les doigts, parfois les orteils. Les autres localisations (oreilles, nez, etc.) sont exceptionnelles.

Rechercher des arguments cliniques pour une cause secondaire

Devant un PR, l’objectif principal est d’éliminer une cause secondaire. On distingue le PR primitif (ancienne maladie de Raynaud), idiopathique et toujours bénin, du PR secondaire. Le PR primitif touche essentiellement la jeune femme, mince. Un caractère familial est souvent retrouvé à l’interrogatoire. Les manifestations cliniques sont bilatérales, grossièrement symétriques et disparaissent l’été. Les pouces sont classiquement épargnés. Le retentissement sur la qualité de vie est généralement peu important. Il n’y a jamais de troubles trophiques. La présence d’atypies doit impérativement faire suspecter une cause secondaire (encadré).

Les causes de PR secondaire sont extrêmement nombreuses (tableau). L’interrogatoire doit donc être le plus complet possible, de même que l’examen clinique. Celui-ci insistera sur l’examen vasculaire (pouls, manœuvre d’Allen), cutané (sclérodactylie, troubles trophiques) et général. La manœuvre d’Allen recherche une thrombose de l’artère radiale ou cubitale. En exerçant une pression manuelle sur les deux artères, la main blanchit. Le clinicien lève ensuite la pression sur une des artères , devant normalement entraîner une recoloration de la main (< 3 secondes). Si ce n’est pas le cas, la manœuvre est positive et doit faire rechercher une obstruction de l’artère.

Prescrire un bilan étiologique adapté

À la fin de l’examen clinique, 3 situations sont possibles.

Le PR est bilatéral, l’examen clinique normal

Chez une jeune femme, le PR est bilatéral, l’examen clinique normal avec une forte suspicion de PR primitif. Deux examens paracliniques sont indispensables : le dosage des anticorps antinucléaires (AAN) et un examen capillaroscopique. Les recommandations françaises sont extrêmement claires sur ce sujet : il ne faut plus voir de jeune femme avec un PR sans un bilan paraclinique ! Celui-ci sera normal dans la majorité des cas. Il est justifié par le fait qu’une étiologie de PR doit impérativement être éliminée : la sclérodermie systémique (ScS). En effet, dans cette maladie, le PR est quasi-constant (> 98 %) et surtout très précoce, bien avant les manifestations viscérales. En revanche, à ce stade, il n’est pas nécessaire de prescrire d’autres examens complémentaires en 1reintention.

Le PR est bilatéral mais suspect

Un dosage d’AAN et une capillaroscopie sont indiqués. Il n’y a cependant pas d’autres examens systématiques recommandés. Ils devront être prescrits selon les données de l’examen clinique.

Le PR est unilatéral

Il s’agit obligatoirement d’une cause secondaire, surtout locorégionale. En plus du dosage des AAN et de la capillaroscopie, un écho-Doppler artériel devra être effectué pour rechercher une artériopathie d’origine athéromateuse, inflammatoire (maladie de Takayasu) ou traumatique (anévrisme de l’artère ulnaire). Les autres examens complémentaires se discutent selon l’examen clinique.

Que faire si le PR semble primitif mais qu’un examen est anormal ?

• Les AAN sont positifs de façon isolée : il faut rechercher la spécificité des AAN (anticentromères, anti-ECT et anti-ADN natif). À noter que 10 % de la population générale a des AAN faiblement positifs. Une hypothyroïdie auto-immune doit être recherchée, elle est fréquemment responsable de la positivité des AAN.

• La capillaroscopie met en évidence une microangiopathie non spécifique (figure 2) : un contrôle à 6 mois doit être effectué. Un tel résultat peut s’observer dans un PR primitif, ou de façon précoce lors d’un PR secondaire.

• La capillaroscopie met en évidence une microangiopathie spécifique (mégacapillaires et/ou plages avasculaires, figure 3) : cas exceptionnel. Un tel résultat est pathologique, les AAN seront dans la majorité des cas positifs et l’examen clinique souvent anormal.


Figure 2. Capillaroscopie non spécifique.

Figure 3. Microangiopathie spécifique (mégacapillaires, diminution de la densité capillaire).

Que faire si le PR est suspect mais les examens normaux ?

Il n’y a pas de recommandations officielles sur la conduite à tenir. Certains critères de « PR suspect » doivent alerter plus que d’autres, notamment la présence de troubles trophiques. Il faut impérativement s’acharner à éliminer une cause secondaire, sans effrayer le patient ni prescrire d’innombrables examens complémentaires.

Un bilan biologique simple peut être prescrit afin d’éliminer un syndrome myéloprolifératif et de rechercher un syndrome inflammatoire biologique. Le dosage des anticorps anti-ARN polymérase III recherche des arguments pour une ScS associée à un cancer. Chez l’homme, un risque de cancer doit être éliminé. Nous prescrivons un scanner thoraco-abdominopelvien dans un premier temps. Un examen ORL avec nasofibroscopie est effectué chez les patients fumeurs. Si malgré cela les examens sont toujours normaux, une surveillance clinique ± paraclinique est indispensable.

À propos de l’hypothyroïdie

L’hypothyroïdie est une cause de PR rapportée dans de nombreux traités de médecine. Elle est en fait plus souvent associée à un PR primitif que réellement une cause de PR (terrain identique : jeune femme dans les 2 cas et les 2 pathologies sont très fréquentes). Ainsi, il n’est plus recommandé de doser systématiquement la TSH. Le dosage peut être utile devant des AAN positifs sans spécificité, situation fréquente lors d’une hypothyroïdie d’Hashimoto. En cas de de TSH anormale, le clinicien ne doit pas se contenter de ce résultat devant un PR suspect, une autre étiologie doit impérativement être recherchée.

Traitement

Dans le cas du PR primitif, de simples mesures symptomatiques sont généralement suffisantes : arrêt du tabac, protection contre le froid (pas seulement au niveau des mains !). Exceptionnellement, un inhibiteur calcique peut être prescrit pendant la saison froide si le retentissement sur la qualité de vie est important. L’arrêt d’un médicament vasoconstricteur n’est pas systématique : la balance bénéfice-risque doit être évaluée.
Lors d’un PR secondaire, le traitement de la cause peut parfois permettre une amélioration, voire une disparition de celui-ci. Cependant, ce n’est pas suffisant dans la majorité des cas. Le traitement de première ligne repose sur les inhibiteurs calciques. Les données de la lit térature sont les plus riches con cernant la nifédipine (Adalate®). Dans notre expérience, le diltiazem (Tildiem®) est souvent mieux toléré. Une faible dose est initialement prescrite, puis augmentée selon l’efficacité et la tolérance. En cas de grossesse, seule la nicardipine (Loxen®) peut être utilisée. Elle est parfois mal tolérée (céphalées, hypotension orthostatique, œdèmes des membres inférieurs).

Lorsque l’inhibiteur calcique n’est pas suffisant, il est poursuivi et un traitement de 2e ligne doit être instauré. Cette situation concerne quasi-exclusivement les ScS, où le PR peut être sévère et très invalidant.
Plusieurs traitements sont possibles :
– iloprost (Ilomédine®). Il est, dans notre expérience, le traitement le plus efficace mais un des plus lourds. Il s’administre par voie intraveineuse à la seringue électrique pendant 6 h par jour, 5 jours consécutifs. Les effets indésirables sont fréquents mais peu sévères : céphalées, flushs, hypotension artérielle ;
– inhibiteurs de la PDE5 : sildénafil (Revatio®). Il peut s’utiliser en cas d’efficacité insuffisante des inhibiteurs calciques ;
– fluoxétine : elle peut être une alternative thérapeutique. Le niveau de preuve est cependant faible ;
– le bosentan (Tracleer®), antagoniste des récepteurs de l’endothéline, n’est pas indiqué en cas de PR secondaire isolé.

D’autres traitements ont été étudiés avec un faible niveau de preuve : injection palmaire de graisse autologue. Un programme hospitalier de recherche clinique est actuellement en cours pour l’évaluation d’injections palmaires de toxine botulique pour la ScS car des cas cliniques ont été rapportés dans la littérature avec efficacité.

Conclusion

Le phénomène de Raynaud est une pathologie très fréquente. Le diagnostic est aisé avec un interrogatoire bien mené. Un bilan est toujours justifié, même si celui-ci sera normal dans la grande majorité des cas. En cas de PR suspect, il est impératif d’éliminer une sclérodermie systémique chez la femme et un cancer chez l’homme.


“Publié dans Dermatologie Pratique

Références

Cliquez sur les références et accédez aux Abstracts sur

Bakst R et al. Raynaud’s phenomenon: pathogenesis and management. J Am Acad Dermatol 2008 ; 59 (4) : 633-53. Rechercher l’abstract
Pistorius MA, Carpentier PH ; le groupe de travail « Microcirculation » de la Société française de médecine vasculaire. Minimal work-up for Raynaud syndrome: a consensus report. Microcirculation Working Group of the French Vascular Medicine Society. J Mal Rechercher l’abstract
Rirash F et al. Calcium channel blockers for primary and secondary Raynaud’s phenomenon. Cochrane Database Sys t Rev 2017 ; 12 : CD000467. Rechercher l’abstract
Senet P. Diagnosis of vascular acrosyndromes. Ann Dermatol Venereol 2015 ; 142 (8-9) : 513-8. Rechercher l’abstract
Wigley FM, Flavahan NA. Raynaud’s phenomenon. N Engl J Med 2016 ; 375 (6) : 556-65. Rechercher l’abstract

#Risk of major #haemorrhage after #clopidogrel with #aspirin

Postado em Atualizado em

    •  Univadis Medical News

A new analysis in JAMA Neurology suggests that treatment with clopidogrel plus aspirin after transient ischaemic attack (TIA) or minor acute ischaemic stroke (AIS) increases the risk of major haemorrhage over aspirin alone, although the risk is low.

Researchers performed a secondary analysis of the Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial which randomised patients in 269 sites worldwide to receive clopidogrel (600 mg loading dose on day one, followed by 75 mg daily for days 2-90) or placebo. All patients also received open-label aspirin 50-325 mg/d.

In the as-treated analyses (4,819 patients), major haemorrhage occurred in 21 patients receiving clopidogrel plus aspirin and six receiving aspirin alone (hazard ratio [HR] 3.57; 95% CI 1.44-8.85; number needed to harm, 159). There were four fatal haemorrhages—three in the clopidogrel plus aspirin group and one in the aspirin alone groupand there were seven intracranial haemorrhages: five in the clopidogrel plus aspirin group and two in the aspirin plus placebo group. The most common location of major haemorrhages was the gastrointestinal tract.

The authors estimated that for every 1,000 patients treated, adding clopidogrel might prevent about 15 major ischaemic events and cause five more major haemorrhages.

#Colesterol baixo associado a maior risco de AVC hemorrágico

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Fonte de imagem: Harvard Health – Harvard University

As mulheres que apresentam índices de colesterol LDL (mau colesterol) muito baixos (de 70 mg/dl ou menos) poderão correr um risco mais elevado de acidente vascular cerebral (AVC) hemorrágico do que as mulheres com níveis mais elevados (de 100 a 130 mg/dl), anunciou um estudo.

Os AVC hemorrágicos são muito menos prevalentes do que os AVC isquémicos. São também mais difíceis de tratar e mais suscetíveis de serem fatais. As mulheres apresentam geralmente um maior risco de AVC do que os homens.

O estudo que foi conduzido por Pamela Rist e colegas, do Hospital Brigham and Women’s, em Boston, EUA, contou com a participação de 27.937 mulheres com 45 anos de idade ou mais.

No início do estudo, as mulheres foram submetidas a medições de colesterol total, colesterol LDL, colesterol HDL (bom colesterol) e triglicerídeos. Os investigadores analisaram também os processos clínicos das mulheres para identificarem casos de AVC hemorrágico.

As participantes foram seguidas durante uma média de 19 anos. Ao longo do período de acompanhamento 137 mulheres sofreram um AVC hemorrágico.

Foi observado que nove em 1.069 mulheres com colesterol LDL de 70 mg/dl ou inferior, equivalente a 0,8%, sofreram um AVC hemorrágico contra 40 em 10.067 mulheres com colesterol de 100 a 130 mg/dl. Após ajustes a vários fatores que poderiam afetar o risco de AVC como idade, fumar e hipertensão, a equipa apurou que as mulheres com colesterol LDL muito baixo eram 2,2 vezes mais propensas a sofrerem um AVC hemorrágico.

Relativamente a triglicerídeos, 34 mulheres (0,6%) em 5.714 com índices em jejum de 74 mg/dl ou menos tiveram um AVC hemorrágico contra 29 (0,4%) em 7.989 mulheres com índices superiores a 156 mg/dl em jejum.

Não foram detetadas diferenças em relação ao colesterol total e ao colesterol HDL.

#Consumo elevado de proteína animal pode causar morte prematura em homens

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Fonte de imagem: Shape Singapore

Um novo estudo demonstrou que uma alimentação rica em proteína animal e carne em particular, não favorece a saúde.

Conduzido por uma equipa de investigadores da Universidade do Leste da Finlândia, o estudo apurou que os homens que privilegiavam uma alimentação rica em proteínas de origem animal apresentavam um risco mais elevado de morte prematura do que os homens que seguiam um regime alimentar equilibrado em termos de fontes animais e vegetais de proteína.

Para o estudo, os investigadores recrutaram 2.641 homens finlandeses que tinham entre 42 e 60 anos de idade no período de recrutamento, que foi entre 1984 e 1989. Os índices de mortalidade nos participantes foram estudados ao longo de cerca de 20 anos de acompanhamento.

Foi observado que os homens cujas principais fontes de proteína eram animais corriam um risco 23% mais elevado de morte, durante o período de acompanhamento, do que os que seguiam um regime mais equilibrado de carne e plantas na sua alimentação.

O consumo elevado de carne demonstrou ser mais nocivo. Os homens que comiam mais de 200 gr. de carne por dia corriam um risco 23% mais elevado de morte do que os que consumiam menos de 100 gr. por dia. A carne consumida era principalmente vermelha.

O estudo apurou ainda que, de forma geral, o consumo elevado de proteínas foi associado a um maior risco de morte em homens diagnosticados com diabetes de tipo 2, cancro ou doença cardiovascular no início do estudo. Esta associação não foi observada em homens sem aqueles tipos de doenças.

Estudos anteriores tinham sugerido que o consumo elevado de proteína animal, especialmente carnes processadas como salsichas, fiambre e salames, estava associado a um maior risco de morte. Contudo, os efeitos da proteína e de diferentes fontes de proteína continuam por especificar.