Acil Serviste Trombolitik Uygulanan Hastaların Özellikleri

Yıl 2023, , 51 - 55, 28.02.2023

Ahmet Tolga Eraslan , Fatih Selvi , Cihan Bedel , Muhammed Baltacıoğlu , Günay Yıldız

https://doi.org/10.54005/geneltip.1200029

Öz

Amaç: Arteriyel veya venöz tromboembolizm günümüzde sık görülen hastalıklardan birisi olup; iskemik inme, pulmoner emboli ve miyokart infarktüsü gibi mortalite ve morbiditesi yüksek patolojiler ile ilişkilidir. Fibrinolitik tedavi bu hastalıklarda hayat kurtarıcı en önemli tedavidir. Bu çalışmada fibrinolitik tedavi almış hastaların demografik verileri ile takip süreçlerini değerlendirmeyi amaçladık.
Gereç ve Yöntem: 1 Ocak 2018 – 1 Temmuz 2021 tarihleri arasında acil servise başvuran ve fibrinolitik tedavi alan hastalar geriye dönük olarak bu çalışmaya dahil edildi. Çalışma hastalarının yaş, cinsiyet, fibrinolitik uygulama nedeni, vital bulguları, laboratuvar tetkikleri, ek hastalıkları, kullandığı ilaçlar, hastalığa yönelik aldığı ek tedaviler, tedavilerin komplikasyonları, mortalite ve 6 aylık süreçte benzer tanılı başvuruları kaydedildi.
Bulgular: Toplamda 277 hasta çalışmaya dahil edildi. Çalışmada acil serviste en sık tPA uygulama nedeni iskemik inmeydi (n=252; %91). tPA uygulanan hastalarda en sık görülen komplikasyon %11,9 ile intrakraniyal kanama, en sık uygulanan kurtarıcı tedavi ise trombektomiydi (n=34, %12,4). Hastaların en sık kullandığı ilaç %56 (n=155) ile anti-hipertansifler olup, anti-hipertansifleri %36,5 (n=101) ile anti-agreganlar, %30 (n=83) ile anti-diyabetikler, %24,5 (n=68) ile anti-aritmik ilaçlar takip etmekteydi. Yapılan tek değişkenli analizde, tPA uygulaması sonrası kanama meydana gelen ve gelmeyen hastalar arasında anti-agregan kullanımı (n=21, %53,8 vs n=80, %33,6; p=0,01), sistolik kan basıncı (160 mmHg, IQR: 138-190 vs 150 mmHg 130-169; p=0,02) ve diyastolik kan basıncı (90 mmHg, IQR: 75-100 vs 83 mmHg, IQR: 72-94; p=0,03) açısından anlamlı fark vardı. Çok değişkenli analizde ise post-tPA kanama ile ilişkili bağımsız değişken olarak sadece anti-agregan kullanımı saptandı.
Sonuç: Bizim çalışmamızın sonuçlarına göre, acil servisimizde en sık tPA verilme endikasyonu iskemik inmedir. tPA verilen hastalarda en sık yandaş hastalık hipertansiyon olup, en sık kullanılan ilaç antihipertansifler ve antiagreganlardır. İntrakraniyal kanama tPA verilen hasta grubunda en sık görülen komplikasyon olup, sistolik ve diyastolik kan basıncı ile antiagregan kullanımı tPA kullanımı sonrası kanamalarla ilişkilidir.

Anahtar Kelimeler

fibrinolitik tedavi, inme, pulmoner emboli, intrakaniyal kanama

Characteristics of Patients Administrated Thrombolytics in the Emergency Department

Öz

Objective: Arterial and venous thromboembolism is one of the most prevalent diseases and related to ischemic stroke, pulmonary embolism, and myocardial infarction leading to mortality or morbidity. Fibrinolytic therapy is the most profound lifesaving therapy in these diseases. We aimed to evaluate the demographic features and post- tissue plasminogen activator (tPA) period of patients administered fibrinolytic in the emergency department (ED).
Materials and Methods: This retrospective study was conducted with patients instituted fibrinolytic therapy in the ED between January 2018 and July 2021. Age and gender of the patients, vital signs, laboratory tests, comorbidities, drugs used, lifesaving therapies secondary to the present pathology, tPA complications, mortality and similar presentations within the six months period were recorded to the study form.
Results: A total of 277 patients were included into the study. Ischemic stroke was the most prevalent disease entailing the institution of tPA (n=252; 91%). The study patients mostly used antihypertensives (n=155, 56%), followed by anti-aggregants (n=101, 36.5%). Intracranial hemorrhage (11.9%) was the most frequent complication secondary to tPA and the study patients had mostly undergone thrombectomy as a lifesaving therapy (n=34, 12.4%). The univariate analysis revealed that antiaggregant usage (n=21, 53.8% vs n=80, 33.6%; p=0.01), systolic blood pressure (160 mmHg, IQR: 138-190 vs 150 mmHg 130-169; p=0.02) and diastolic blood pressure (90 mmHg, IQR: 75-100 vs 83 mmHg, IQR: 72-94; p=0.03) differ between the patients with and without a post-tPA hemorrhage.
Conclusion: According to the results of this study, ischemic stroke is the main pathology related to tPA administration in ED. Hypertension was the most seen comorbidity in study patients, mostly using anti-hypertensive and anti-aggregants. Intracranial hemorrhage was the most prevalent complication owing to tPA use, and systolic and diastolic blood pressures and anti-aggregant use pertain to post-tPA hemorrhages.

Anahtar Kelimeler

fibrinolytic therapy, stroke, pulmonary embolus, intracranial hemorrhage

Kaynakça

• 1- GBD 2016 Stroke Collaborators. Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019 May;18(5):439-458. doi: 10.1016/S1474-4422(19)30034-1.
• 2- Konstantinides SV. Trends in incidence versus case fatality rates of pulmonary embolism: Good news or bad news? Thromb Haemost. 2016 Jan;115(2):233-5. doi: 10.1160/TH15-10-0832. Epub 2015 Dec 3. PMID: 26632213.
• 3- Khan F, Tritschler T, Kahn SR, Rodger MA. Venous thromboembolism. The lancet. 2021 Jul 3;398(10294):64-77.
• 4- Hao Q, Dong BR, Yue J, Wu T, Liu GJ. Thrombolytic therapy for pulmonary embolism. Cochrane Database Syst Rev. 2018;12(12):CD004437. doi: 10.1002/14651858.CD004437.pub5. Update in: Cochrane Database Syst Rev. 2021 Apr 15;4:CD004437.
• 5- Igneri LA, Hammer JM. Systemic Thrombolytic Therapy for Massive and Submassive Pulmonary Embolism. J Pharm Pract. 2020;33(1):74-89. doi: 10.1177/0897190018767769. Epub 2018 Apr 19. PMID: 29673293.
• 6- Au A, Hsu P, McClure M, Cabrera G, Kalivoda EJ. Serial Point-of-care Echocardiography Performed by an Emergency Physician to Guide Thrombolytic Management of Massive Pulmonary Embolism. Cureus. 2020;12(4).
• 7- Aslaner MA, Necmi B. İkinci basamak bir acil serviste trombolitik tedavi deneyimi. Pamukkale Medical Journal.2019:12: 309-314.
• 8- Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E, et al. Effect of treatment delay, age, and stroke severity on the effects of intravenous thrombolysis with alteplase for acute ischaemic stroke: a meta-analysis of individual patient data from randomised trials. Lancet. 2014;384(9958):1929-35. doi: 10.1016/S0140-6736(14)60584-5.
• 9- Kleindorfer DO, Khoury J, Moomaw CJ, Alwell K, Woo D, Flaherty ML, et al. Stroke incidence is decreasing in whites but not in blacks: a population-based estimate of temporal trends in stroke incidence from the Greater Cincinnati/Northern Kentucky Stroke Study. Stroke. 2010;41(7):1326-31. doi: 10.1161/STROKEAHA.109.575043.
• 10- Anderson CS, Huang Y, Lindley RI, Chen X, Arima H, Chen G, et al. Intensive blood pressure reduction with intravenous thrombolysis therapy for acute ischaemic stroke (ENCHANTED): an international, randomised, open-label, blinded-endpoint, phase 3 trial. Lancet. 2019;393(10174):877-888. doi: 10.1016/S0140-6736(19)30038-8. 11- Liu H, Zheng H, Cao Y, Pan Y, Wang D, Zhang R, et al. Low- versus Standard-Dose Intravenous Tissue-Type Plasminogen Activator for Acute Ischemic Stroke: An Updated Meta-Analysis. J Stroke Cerebrovasc Dis. 2018 Apr;27(4):988-997. doi: 10.1016/j.jstrokecerebrovasdis.2017.11.005.
• 12- Gilliland C, Shah J, Martin JG, Miller MJ. Acute Limb Ischemia. Tech Vasc Interv Radiol. 2017;20(4):274-280.
• 13- Vivien D. Can the benefits of rtPA treatment for stroke be improved? Rev Neurol (Paris) 2017;173(9):566- 571.
• 14- The NINDS t-PA Stroke Study Group. Intracerebral hemorrhage after intravenous t-PA therapy for ischemic stroke. Stroke. 1997;28(11):2109-18. doi: 10.1161/01.str.28.11.2109. PMID: 9368550.
• 15- Tong X, George MG, Yang Q, Gillespie C. Predictors of in-hospital death and symptomatic intracranial hemorrhage in patients with acute ischemic stroke treated with thrombolytic therapy: Paul Coverdell Acute Stroke Registry 2008-2012. Int J Stroke. 2014;9(6):728-34.
• 16- Tsivgoulis G, Frey JL, Flaster M, Sharma VK, Lao AY, Hoover SL, et al. Pre-tissue plasminogen activator blood pressure levels and risk of symptomatic intracerebral hemorrhage. Stroke. 2009;40(11):3631-4.
• 17- Ahmed N, Wahlgren N, Brainin M, Castillo J, Ford GA, Kaste M, et al. Relationship of blood pressure, antihypertensive therapy, and outcome in ischemic stroke treated with intravenous thrombolysis: retrospective analysis from Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). Stroke. 2009;40(7):2442-9.
• 18- Berge E, Cohen G, Lindley RI, Sandercock P, Wardlaw JM, Sandset EC, et al. Effects of Blood Pressure and Blood Pressure-Lowering Treatment During the First 24 Hours Among Patients in the Third International Stroke Trial of Thrombolytic Treatment for Acute Ischemic Stroke. Stroke. 2015;46(12):3362-9.
• 19- Cucchiara B, Kasner SE, Tanne D, Levine SR, Demchuk A, Messe SR, et al. Factors associated with intracerebral hemorrhage after thrombolytic therapy for ischemic stroke: pooled analysis of placebo data from the Stroke-Acute Ischemic NXY Treatment (SAINT) I and SAINT II Trials. Stroke. 2009;40(9):3067-72.
• 20- Larrue V, von Kummer R, Müller A, Bluhmki E. Risk factors for severe hemorrhagic transformation in ischemic stroke patients treated with recombinant tissue plasminogen activator: a secondary analysis of the European-Australasian Acute Stroke Study (ECASS II). Stroke. 2001;32(2):438-41.
• 21- Tanne D, Kasner SE, Demchuk AM, Koren-Morag N, Hanson S, Grond M, et al. Markers of increased risk of intracerebral hemorrhage after intravenous recombinant tissue plasminogen activator therapy for acute ischemic stroke in clinical practice: the Multicenter rt-PA Stroke Survey. Circulation. 2002;105(14):1679-85.