Professional Documents
Culture Documents
Univille - Universidade de Joinville, Joinville SC, Brasil: 1Neurologista, Mestre em Medicina Interna; 2Estudantes Medicina, Univille;
3
Neurologista, Coordenadora Unidade de AVC - Hospital Municipal So Jos; 4Cardiologista, Mestre em Medicina Interna, Hospital
Dona Helena.
Recebido 20 Janeiro 2004, recebido na forma final 3 Maio 2004. Aceito 1 Julho 2004.
Dr. Norberto L. Cabral - Clnica Neurolgica de Joinville - Rua Plcido O. Oliveira, 1244/47 - 89202-451 Joinville SC - Brasil. E-mail:
cabral@neurologica.com.br
1017
1018
RESULTADOS
Em um perodo de 10 meses de estudo, 167 pacientes internaram com AVC isqumico ou hemorrgico. Destes, 26 pacientes (15,7%) eram portadores de fibrilao atrial crnica no valvular (FANV).
Foram excludos da amostra 4 pacientes com hematoma intracerebral e FANV. Nenhum destes pacientes
estava em uso de warfarina. A amostra final elegvel
foi de 22 pacientes. A maioria era do sexo masculino
(60,8%) e a idade mdia foi 71,6 anos para os homens e 71,1 anos para as mulheres.
A Tabela 1 mostra o perfil scio-econmico e os
fatores de risco e dos pacientes. A maioria possua
Tabela 1. Perfil demogrfico e scio-econmico e fatores de risco dos 22 pacientes portadores de FANV
internados com AVC isqumico agudo.
Homens
n
Distribuio sexo
Idade mdia
Renda familiar
< 1 SM
1-3 SM
3-10 SM
> 10SM
Escolaridade
Analfabeto
Primrio
Secundrio
Tercirio
Fatores de risco
AVC prvio
ICC
AIT prvio
Hipertenso arterial
Infarto agudo miocrdio
Diabetes melitus
Tabagismo
Alcoolismo
Cncer
13
Mulheres
%
51
%
49
71,6
71,1
5
8
-
2
5
2
-
4
8
1
3
6
-
7
3
4
13
4
6
9
1
31,8
13,6
18,1
59
18
27
41
4,5
-
3
1
1
9
2
2
13,6
4,5
4,5
41
9,1
9,1
-
SM, salrio mnimo; n, nmero de pacientes; AVC, acidente cerebrovascular; ICC, insuficincia cardaca congestiva;
AIT, ataque isqumico transitrio.
1019
Conhecimento prvio
da FA
Consulta prvia a
Cardiologista
N0 de visitas
uma
duas
+ duas
Mulheres
Total
9,1
18,2
27,3
36,3
31,8
15
68,1
6
2
27,2
9,1
5
1
1
22,7
4,5
4,5
5
7
3
22,7
31,7
13,6
9%
54%
36%
81%
54%
27%
9%
54%
36%
-91%
63%
54%
AVC, acidente cerebrovascular; FA, atrial crnica; FC, freqncia cardaca; INR, ndice normatizado de
INR: ndice normatizado de anticoagulao; FR, fator de risco.
lantes em pacientes portadores de FANV, mas somente 54% deles consideravam-nas aplicveis para pacientes do servio pblico.
DISCUSSO
As dificuldades para a prescrio de anticoagulantes podem ser potencialmente identificadas no
mdico, no paciente e no sistema de sade7. Inmeras pesquisas confrontando a conduta terica e prticas a respeito do tema tm sido publicadas7,9,12,17,18.
Em uma delas, Beyth e colaboradores, analisaram
1020
1021
4. Benjamin EJ, Wolf PA, D Agostino RB, Silbershatz H, Kannel WB, Levy
D. Impact of atrial fibrillation on the risk of death: the Framingham Heart
Study. Circulation 1998:98:946-952.
5. Cabral NL,Longo ALL,Moro CHC,Amaral CH,Kiss HC.Epidemiologia
dos acidentes cerebrovasculares em Joinville, Brasil. Arq Neuropsiquiatr
1997;55:357-363.
6. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation: a major contributor
of stroke in the elderly: the Framingham Study. Arch Intern Med
1987;147:1561-1564.
7. Bungard TJ, Ghali WA, Teo KK, Maclister FA, Tsuyuki RT. Why do patients with atrial fibrillation not receive warfarin? Arch Intern Med
2000;160:41-46.
8. Sudlow M, Thomson R, Thwaites B, Rodgers H,Kenny RA. Prevalence
of atrial fibrillation and eligibility for anticoagulation in the community.
Lancet 1998;352:1167-171.
9. Connolly SW, Stuart J. Preventing stroke in atrial fibrillation: why are
so many eligible patients not receiving anticoagulation therapy?
CMAJ.1999;161:533-534.
10. Roderick E, Cox J. Non-valvular atrial fibrillation. Br Gen Pract
1997;47:660-661.
11. Thomson R, Mcelroy H, Sudlow M. Guidelines on anticoagulant treatment in atrial fibrillation in Great Britain: variation and implications
for treatment. BMJ 1996;316:509-513.
12. Gottlieb LK, Salem-Schatz S. Anticoagulation in atrial fibrillation: does
efficacy in clinical trials translate into effectiveness in practice? Arch
Intern Med 1994;154:1945-1953.
13. National Institute of Neurological Disorders and Stroke ad Hoc
Committee. Classification of cerebrovascular diseases III. Stroke
1990;21:637-676.
14. Adams HP Jr, Bendixen BH, Kappelle LJ, et al, and the TOAST
Investigators. Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial. Stroke 1993;24:35-41.
15. Kalra L, Yu G, Perez I, Lakhani A, Donaldson N. Prospective cohort study
to determine if trial efficacy of anticoagulation for stroke prevention
in atrial fibrillation translates into clinical effectiveness. BMJ
2000;320:1236-1239.
16. Cabral NL, Moro C HC, Silva GR, Scola RH, Werneck LC. Unidade de
AVC em Joinville: ensaio clnico randomizado. Arq Neuropsiatr
2003;61:188-193.
17. Fuster V, Ryden LE, Asinger RW, et al. ACC/AHA/ESC guidelines for
the management of patients with atrial fibrillation: executive summary.
J Am Coll Cardiol 2001;38:1231-1266.
18. Beyth RJ, Antani MR, Covinsky KE, et al. Why isnt warfarin prescribed
to patients with nonrheumatic atrial fibrillation? J Gen Intern Med
1996;11:721-728.
19. Fitzmaurice DA. Its still not clear whether results in secondary care
translate to primary care. In replly to: anticoagulation to prevent stroke
atrial fibrilation BMJ 2000;321:1156.
20. Chang HJ, Bell JR, Devoo KJW, Wasson JH. Physician variation in anticoagulation patients. Arch Intern Med, 1990;150:81-84.
21. Landefeld CS, Goldman L. Major bleeding in outpatients treated with
warfarin: Incidence and prediction by factors know at the start of
outpatient therapy. The Am J Med, 1989;87:144-152.
22. Wyse,DG, Waldo AL,DiMarco JP, et al. A comparison of rate control and
rhythm control in patients with atrial fibrillation. N Engl J Med
2002;347:1825-1833.
23. Belleli G, Bianchetti A, Trabucchi M. Lets strip the King: eligibility not
safety is the problem of anticoagulation for stroke prevention in the
elderly patients with atrial fibrillation. Arch Intern Med 2002;162:1067.
24. Petty GW, Brown RD Jr, Whisnant JP, et al. Frequency of major
complications of aspirin, warfarin and intravenous heparin for secondary
stroke prevention: a population based study. Ann Intern Med
1999;5:130:14-22.
25. Rodger H, Sudlow M, Dobson R, Kenny RA, Thonson RG. Warfarin anticoagulation in primary care: a regional survey of present practice
and clinicians views Br J Gen Pract 1997:47:309-310.
26. Kutner M, Nixon G, Silverstone F. Physicians` attitudes toward oral anticoagulants and antiplatelet agents for stroke prevention in elderly patients with atrial fibrillation. Arch Intern Med 1991;151:1950-1953.
27. Secretaria Estadual de Sade de Santa Catarina.Sem data. Populao
estimada segundo idade e sexo.IBGE: Censo demogrfico 2000.