651
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Yang X, Li N, Guo T, Guan X, Tan J, Gao X, Wu Y, Jia L, Gu M, Hua L, Liu H. Comparison of the Effects of Low-Molecular-Weight Heparin and Fondaparinux on Liver Function in Patients With Pulmonary Embolism. J Clin Pharmacol 2020; 60:1671-1678. [PMID: 32639644 DOI: 10.1002/jcph.1686] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/08/2020] [Indexed: 12/12/2022]
Abstract
Hepatotoxicity with low-molecular-weight heparin (LMWH) or fondaparinux is a relatively common adverse reaction. This study assessed the effects of LMWH and fondaparinux on liver function in patients with pulmonary embolism based on a retrospective cohort. As a result, a total of 463 patients with pulmonary embolism and treated with LMWH (enoxaparin sodium or nadroparin calcium) or fondaparinux sodium were included. Liver dysfunction was identified in 79 patients (17.1%), of whom 97.5% had grade 1 drug-induced liver injury (DILI) and 2.5% had grade 2 DILI. The results showed that liver dysfunction usually occurred in the first week after anticoagulant administration, and the liver tests of all patients with liver dysfunction gradually recovered or alleviated at discharge. The multivariable logistic regression analysis indicated that a longer treatment course and hepatitis B surface antigen-positive (HBsAg+) were risk factors for liver dysfunction (P < .05). Moreover, nadroparin calcium had the highest risk of liver dysfunction, approximately 2.2 times (95% confidence interval [CI], 1.1740-4.224; P = .015) that of enoxaparin sodium. In conclusion, nearly one-fifth and 10% of patients prescribed with LMWH or fondaparinux, respectively, for pulmonary embolism had liver dysfunction, mainly with mild liver injury and characterized by self-limited elevated serum transaminase levels. Hence, during the 3 anticoagulant applications, we should pay more attention to the monitoring of liver function in the first week and transit to oral anticoagulants if possible, especially for patients who are HBsAg+ or suffering from other liver diseases.
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Affiliation(s)
- Xu Yang
- Thrombosis Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Nan Li
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, Shenzhen, China
| | - Tingting Guo
- Thrombosis Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoyuan Guan
- Thrombosis Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiangshan Tan
- Thrombosis Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Gao
- Thrombosis Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Wu
- Thrombosis Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Jia
- Thrombosis Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Min Gu
- Thrombosis Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Hua
- Thrombosis Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hong Liu
- Thrombosis Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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652
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Becattini C, Cimini LA. Long term use of anticoagulant therapy for patients with pulmonary embolism. Expert Rev Hematol 2020; 13:709-718. [DOI: 10.1080/17474086.2020.1770589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | - Ludovica Anna Cimini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
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653
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Ly A, Alessandri C, Skripkina E, Meffert A, Clariot S, de Roux Q, Langeron O, Mongardon N. Rescue fibrinolysis in suspected massive pulmonary embolism during SARS-CoV-2 pandemic. Resuscitation 2020; 152:86-88. [PMID: 32445784 PMCID: PMC7238971 DOI: 10.1016/j.resuscitation.2020.05.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 05/13/2020] [Indexed: 01/08/2023]
Affiliation(s)
- André Ly
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France; Univ Paris Est Creteil, Faculté de Santé, F-94010 Créteil, France
| | - Claire Alessandri
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France
| | - Elena Skripkina
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France
| | - Arnaud Meffert
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France
| | - Simon Clariot
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France; Univ Paris Est Creteil, Faculté de Santé, F-94010 Créteil, France
| | - Quentin de Roux
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France; U955-IMRB, Equipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", Inserm, Univ Paris Est Creteil (UPEC), Ecole Nationale Vétérinaire d'Alfort (EnVA), F-94700 Maisons-Alfort, France
| | - Olivier Langeron
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France; Univ Paris Est Creteil, Faculté de Santé, F-94010 Créteil, France
| | - Nicolas Mongardon
- Service d'anesthésie-réanimation chirurgicale, DMU CARE, DHU A-TVB, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, F-94010 Créteil, France; Univ Paris Est Creteil, Faculté de Santé, F-94010 Créteil, France; U955-IMRB, Equipe 03 "Pharmacologie et Technologies pour les Maladies Cardiovasculaires (PROTECT)", Inserm, Univ Paris Est Creteil (UPEC), Ecole Nationale Vétérinaire d'Alfort (EnVA), F-94700 Maisons-Alfort, France; AfterROSC Research Group, F-75014 Paris, France.
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654
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Lachant D, Bach C, Wilson B, Chengazi V, Goldman B, Lachant N, Pietropaoli A, Cameron S, James White R. Clinical and imaging outcomes after intermediate- or high-risk pulmonary embolus. Pulm Circ 2020; 10:2045894020952019. [PMID: 33014336 PMCID: PMC7509735 DOI: 10.1177/2045894020952019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/02/2020] [Indexed: 11/25/2022] Open
Abstract
Long-term outcomes after acute pulmonary embolism vary from complete resolution to chronic thromboembolic pulmonary hypertension (CTEPH). Guidelines after acute pulmonary embolism are generally limited to anticoagulation duration. We assessed patients with estimated prognosis >1 year in our pulmonary hypertension clinic 2-4 months after treatment for intermediate- or high-risk acute pulmonary embolism. At follow-up, ventilation-perfusion scan and echocardiogram were offered. The aim of this study was to assess for recurrent symptomatic disease, residual imaging defects or right ventricular dysfunction, and functional disability after acute management of pulmonary embolism. After treatment for acute intermediate- or high-risk pulmonary embolism, 104 patients followed up in pulmonary hypertension clinic. Of those, 55% of patients had self-reported limitation in activity. No patients had symptomatic recurrence of pulmonary embolism. Forty-eight percent of patients had residual perfusion defects on perfusion imaging, while 91% of patients had either normal or only mildly enlarged right ventricles. We identified heart failure preserved ejection fraction, iron deficiency, and obstructive sleep apnea as significant contributors to breathlessness. Treatment of these conditions was associated with improvement. Surprisingly, we diagnosed CTEPH in nine patients; for some, chronic thrombus may already have been present at the time of index evaluation. Our findings suggest that follow-up in a dedicated pulmonary hypertension clinic 2-4 months after acute intermediate- or high-risk pulmonary embolism may add value to patient care. We identified treatable comorbidities that could be contributing to post-pulmonary embolism syndrome as well as CTEPH.
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Affiliation(s)
- Daniel Lachant
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Christina Bach
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Bennett Wilson
- Division of Pathology, University of Rochester Medical Center, Rochester, NY, USA
| | - Vaseem Chengazi
- Division of Radiology and Nuclear Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Bruce Goldman
- Division of Pathology, University of Rochester Medical Center, Rochester, NY, USA
| | - Neil Lachant
- Division of Hematology at the Wilmont Cancer Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Anthony Pietropaoli
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Scott Cameron
- Division of Cardiology, University of Rochester Medical Center, Rochester, NY, USA
| | - R. James White
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA
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655
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Rech TH, Girardi AM, Gazzana MB. Incidence of pulmonary embolism in patients with COVID-19. Intensive Care Med 2020; 46:1500-1501. [PMID: 32435822 PMCID: PMC7237613 DOI: 10.1007/s00134-020-06081-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Tatiana Helena Rech
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
- Programa de Pós-Graduação Ciências Médicas: Endocrinologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
| | - Adriana Muradás Girardi
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Marcelo Basso Gazzana
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
- Serviço de Pneumologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
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656
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Vinson DR, Bath H, Huang J, Reed ME, Mark DG. Hospitalization Is Less Common in Ambulatory Patients With Acute Pulmonary Embolism Diagnosed Before Emergency Department Referral Than After Arrival. Acad Emerg Med 2020; 27:588-599. [PMID: 32470189 DOI: 10.1111/acem.14034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 04/28/2020] [Accepted: 05/19/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Emergency department (ED) patients with acute pulmonary embolism (PE) may undergo diagnostic pulmonary imaging as an outpatient before referral to the ED for definitive management. This population has not been well characterized. METHODS This retrospective cohort study included ambulatory adults with acute objectively confirmed PE across 21 EDs in an integrated health care system from January 1, 2013, through April 30, 2015. We excluded patients arriving by ambulance. We compared outpatients with diagnostic pulmonary imaging in the 12 hours prior to ED arrival (the clinic-based cohort) with those receiving imaging for PE only after ED arrival. We reported adjusted odds ratio (aOR) with 95% confidence intervals (CIs) for hospitalization, adjusted for race, presyncope or syncope, proximal clot location, and PE Severity Index class. RESULTS Among 2,352 eligible ED patients with acute PE, 344 (14.6%) had a clinic-based diagnosis. This cohort had lower PE Severity Index classification and were less likely to be hospitalized than their counterparts with an ED-based diagnosis: 80.8% vs. 92.0% (p < 0.0001). The inverse association with hospitalization persisted after adjusting for the above patient characteristics with aOR of 0.36 (95% CI = 0.26 to 0.50). CONCLUSION In the study setting, ambulatory outpatients with acute PE are commonly diagnosed before ED arrival. A clinic-based diagnosis of PE identifies ED patients less likely to be hospitalized. Research is needed to identify which patients with a clinic-based PE diagnosis may not require transfer to the ED before home discharge.
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Affiliation(s)
- David R. Vinson
- From The Permanente Medical Group Oakland CA USA
- the Kaiser Permanente Division of Research Oakland CA USA
- the Kaiser Permanente Sacramento Medical Center Sacramento CA USA
| | | | - Jie Huang
- the Kaiser Permanente Division of Research Oakland CA USA
| | - Mary E. Reed
- the Kaiser Permanente Division of Research Oakland CA USA
| | - Dustin G. Mark
- From The Permanente Medical Group Oakland CA USA
- the Kaiser Permanente Division of Research Oakland CA USA
- and the Kaiser Permanente Oakland Medical Center Oakland CA USA
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657
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Timnou Bekouti J, Ravakiniaina Ranaivosoa M, Adossou AC, Diawara A, Camara A, Rambolarimanana M, Lawani P, Ranjatson A, Houeze R, Roynard JL. Cerebral paradoxical embolism associated with patent foramen ovale and idiopathic venous thromboembolism in a 31-year-old patient. Oxf Med Case Reports 2020; 2020:omaa052. [PMID: 32728455 PMCID: PMC7376985 DOI: 10.1093/omcr/omaa052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 01/25/2020] [Accepted: 05/31/2020] [Indexed: 11/23/2022] Open
Abstract
Paradoxical embolism is the passage of venous thrombi into the arterial circulation through a pulmonary or intracardiac shunt. We report the management of a 31-year-old patient who initially presented with chest pain and right brachiofacial paresis. A diagnosis of paradoxical cerebral embolism associated with a spontaneous venous thromboembolism and a patent foramen ovale was made. The patient benefited from thrombolytic therapy and lifelong anticoagulation with good recovery. This case showed that percutaneous closure of a patent foramen ovale needs to be discussed individually.
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Affiliation(s)
| | | | | | - Alpha Diawara
- Department of Neurology, Dax-Côte d'Argent Hospital, Dax, France
| | - Ansoumane Camara
- Department of Neurology, Dax-Côte d'Argent Hospital, Dax, France
| | | | - Pierre Lawani
- Department of Cardiology, Dax-Côte d'Argent Hospital, Dax, France
| | - Alain Ranjatson
- Department of Cardiology, Dax-Côte d'Argent Hospital, Dax, France
| | - Richard Houeze
- Department of Neurology, Dax-Côte d'Argent Hospital, Dax, France
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658
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Klok FA, Couturaud F, Delcroix M, Humbert M. Diagnosis of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. Eur Respir J 2020; 55:13993003.00189-2020. [PMID: 32184319 DOI: 10.1183/13993003.00189-2020] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/03/2020] [Indexed: 02/05/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is the most severe long-term complication of acute pulmonary embolism (PE). Untreated CTEPH is fatal, but, if diagnosed in time, successful surgical (pulmonary endarterectomy), medical (pulmonary hypertension drugs) and/or interventional (balloon pulmonary angioplasty) therapies have been shown to improve clinical outcomes, especially in case of successful pulmonary endarterectomy. Early diagnosis has however been demonstrated to be challenging. Poor awareness of the disease by patients and physicians, high prevalence of the post-PE syndrome (i.e. persistent dyspnoea, functional limitations and/or decreased quality of life following an acute PE diagnosis), lack of clear guideline recommendations as well as inefficient application of diagnostic tests in clinical practice lead to a reported staggering diagnostic delay >1 year. Hence, there is a great need to improve current clinical practice and diagnose CTEPH earlier. In this review, we will focus on the clinical presentation of and risk factors for CTEPH, and provide best practices for PE follow-up programmes from expert centres, based on a clinical case.
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Affiliation(s)
- Fredrikus A Klok
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Francis Couturaud
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Univ Brest, Brest, France
| | - Marion Delcroix
- Dept of Respiratory Diseases, University Hospitals and Respiratory Division, Dept of Chronic Diseases, Metabolism and Aging, KU Leuven - University of Leuven, Leuven, Belgium
| | - Marc Humbert
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France.,Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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659
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Factors Associated With Pulmonary Embolism Among Coronavirus Disease 2019 Acute Respiratory Distress Syndrome: A Multicenter Study Among 375 Patients. Crit Care Explor 2020; 2:e0166. [PMID: 32766562 PMCID: PMC7339309 DOI: 10.1097/cce.0000000000000166] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Risk factors associated with pulmonary embolism in coronavirus disease 2019 acute respiratory distress syndrome patients deserve to be better known. We therefore performed a post hoc analysis from the COronaVirus-Associated DIsease Study (COVADIS) project, a multicenter observational study gathering 21 ICUs from France (n = 12) and Belgium (n = 9). Three-hundred seventy-five consecutive patients with moderate-to-severe acute respiratory distress syndrome and positive coronavirus disease 2019 were included in the study. At day 28, 15% were diagnosed with pulmonary embolism. Known risk factors for pulmonary embolism including cancer, obesity, diabetes, hypertension, and coronary artery disease were not associated with pulmonary embolism. In the multivariate analysis, younger age (< 65 yr) (odds ratio, 2.14; 1.17-4.03), time between onset of symptoms and antiviral administration greater than or equal to 7 days (odds ratio, 2.39; 1.27-4.73), and use of neuromuscular blockers greater than or equal to 7 days (odds ratio, 1.89; 1.05-3.43) were independently associated with pulmonary embolism. These new findings reinforce the need for prospective studies that will determine the predictors of pulmonary embolism among patients with severe coronavirus disease 2019.
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660
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Myc LA, Solanki JN, Barros AJ, Nuradin N, Nevulis MG, Earasi K, Richardson ED, Tsutsui SC, Enfield KB, Teman NR, Haskal ZJ, Mazimba S, Kennedy JLW, Mihalek AD, Sharma AM, Kadl A. Adoption of a dedicated multidisciplinary team is associated with improved survival in acute pulmonary embolism. Respir Res 2020; 21:159. [PMID: 32571318 PMCID: PMC7310489 DOI: 10.1186/s12931-020-01422-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 06/14/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Acute pulmonary embolism remains a significant cause of mortality and morbidity worldwide. Benefit of recently developed multidisciplinary PE response teams (PERT) with higher utilization of advanced therapies has not been established. METHODS To evaluate patient-centered outcomes and cost-effectiveness of a multidisciplinary PERT we performed a retrospective analysis of 554 patients with acute PE at the university of Virginia between July 2014 and June 2015 (pre-PERT era) and between April 2017 through October 2018 (PERT era). Six-month survival, hospital length-of-stay (LOS), type of PE therapy, and in-hospital bleeding were assessed upon collected data. RESULTS 317 consecutive patients were treated for acute PE during an 18-month period following institution of a multidisciplinary PE program; for 120 patients PERT was activated (PA), the remaining 197 patients with acute PE were considered as a separate, contemporary group (NPA). The historical, comparator cohort (PP) was composed of 237 patients. These 3 groups were similar in terms of baseline demographics, comorbidities and risk, as assessed by the Pulmonary Embolism Severity Index (PESI). Patients in the historical cohort demonstrated worsened survival when compared with patients treated during the PERT era. During the PERT era no statistically significant difference in survival was observed in the PA group when compared to the NPA group despite significantly higher severity of illness among PA patients. Hospital LOS was not different in the PA group when compared to either the NPA or PP group. Hospital costs did not differ among the 3 cohorts. 30-day re-admission rates were significantly lower during the PERT era. Rates of advanced therapies were significantly higher during the PERT era (9.1% vs. 2%) and were concentrated in the PA group (21.7% vs. 1.5%) without any significant rise in in-hospital bleeding complications. CONCLUSIONS At our institution, all-cause mortality in patients with acute PE has significantly and durably decreased with the adoption of a PERT program without incurring additional hospital costs or protracting hospital LOS. Our data suggest that the adoption of a multidisciplinary approach at some institutions may provide benefit to select patients with acute PE.
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Affiliation(s)
- Lukasz A Myc
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, USA
| | - Jigna N Solanki
- Department of Medicine, University of Virginia, Charlottesville, USA
| | - Andrew J Barros
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, USA
| | - Nebil Nuradin
- Department of Medicine, University of Virginia, Charlottesville, USA
| | - Matthew G Nevulis
- Department of Medicine, University of Virginia, Charlottesville, USA
| | | | | | - Shawn C Tsutsui
- Department of Medicine, University of Virginia, Charlottesville, USA
| | - Kyle B Enfield
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, USA
| | - Nicholas R Teman
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, USA
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging, Division of Vascular and Interventional Radiology, University of Virginia, Charlottesville, USA
| | - Sula Mazimba
- Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, USA
| | - Jamie L W Kennedy
- Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, USA
| | - Andrew D Mihalek
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, USA
| | - Aditya M Sharma
- Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, USA
| | - Alexandra Kadl
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, USA.
- Department of Pharmacology, University of Virginia, Charlottesville, VA, USA.
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661
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Noordergraaf FA, Alings M. Andexanet Alfa and its Clinical Application. Heart Int 2020; 14:20-23. [PMID: 36277667 PMCID: PMC9524750 DOI: 10.17925/hi.2020.14.1.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/25/2020] [Indexed: 09/06/2024] Open
Abstract
Factor Xa (FXa) inhibitors are widely used for stroke prevention in patients with nonvalvular atrial fibrillation, and for the treatment and prevention of deep venous thrombosis and pulmonary embolism. Compared with warfarin, individual FXa inhibitors are associated with a lower risk of major bleeding. Nevertheless, bleeding remains a feared complication of any anticoagulant therapy. Despite their demonstrated safety, implementation of FXa inhibitors in clinical practice may have been limited by the lack of a specific antidote. Recently, however, the United States Food and Drug Administration and the European Medicines Agency approved andexanet alfa for reversal of anticoagulation in patients treated with rivaroxaban or apixaban who have life-threatening or uncontrolled bleeding. This review will discuss andexanet alfa's mode of action, indication for use and efficacy, with a focus on its appropriate use in clinical practice. Unnecessary usage should be prevented as this may compromise patient safety. Assessment of potentially suitable patients by a multidisciplinary team, use according to the institutional protocol and central storage, all contribute to proper use of andexanet alfa. A practical tool to direct appropriate use of andexanet alfa is proposed.
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Affiliation(s)
| | - Marco Alings
- Department of Cardiology, Amphia Hospital, Breda, Netherlands
- Heart & Lung Division, Utrecht University Medical Center,Utrecht, Netherlands
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662
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Stevenson A, Davis S, Murch N. Pulmonary embolism in acute medicine: a case-based review incorporating latest guidelines in the COVID-19 era. Br J Hosp Med (Lond) 2020; 81:1-12. [PMID: 32589531 DOI: 10.12968/hmed.2020.0300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pulmonary embolism remains an important cause of morbidity and mortality in the UK, particularly following the outbreak of the novel coronavirus 2019 (COVID-19), where those infected have an increased prevalence of venous thromboembolic events. The pathophysiology in COVID-19 patients is thought to relate to a thromboinflammatory state within the pulmonary vasculature, triggered by the infection, but other risk factors such as reduced mobility, prolonged immobilisation and dehydration are likely to contribute. Several societies have released comprehensive guidelines emphasising the importance of risk stratification in patients with acute pulmonary embolism. They advocate the use of clinically validated risk scores in conjunction with biochemical and imaging results. Patients with mild disease can now be managed in the outpatient setting and with newly developed therapies, such as catheter-directed thrombolysis, becoming available in more centres, treatment options for those with more severe disease are also expanding. This article presents four theoretical but realistic cases, each diagnosed with acute pulmonary embolism, but differing in levels of severity. These demonstrate how the guidelines can be applied in a clinical setting, with particular focus on risk stratification and management.
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Affiliation(s)
| | - Sarah Davis
- Acute Medicine Department, Royal Free Hospital, London, UK
| | - Nick Murch
- Acute Medicine Department, Royal Free Hospital, London, UK
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663
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Konstantinides SV. The optimal imaging test for diagnosis of acute pulmonary embolism: a second chance for lung scintigraphy? Eur Respir J 2020; 55:55/6/2001426. [PMID: 32527854 DOI: 10.1183/13993003.01426-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany .,Dept of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
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664
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Hansen SL, de Nijs R, Mortensen J, Berg RMG. Ventilation-perfusion SPECT versus CTPA in young adult females with suspected pulmonary embolism. Eur Respir J 2020; 55:55/6/2000448. [PMID: 32527852 DOI: 10.1183/13993003.00448-2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/15/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Sofie Lindskov Hansen
- Dept of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Robin de Nijs
- Dept of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Jann Mortensen
- Dept of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark.,Dept of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Dept of Medicine, The National Hospital, Torshavn, Faroe Islands
| | - Ronan M G Berg
- Dept of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark .,Dept of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Centre for Physical Activity Research, Rigshospitalet, Copenhagen, Denmark
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665
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Glise Sandblad K, Jern S, Åberg M, Robertson J, Torén K, Lindgren M, Adiels M, Hansson PO, Rosengren A. Obesity in adolescent men increases the risk of venous thromboembolism in adult life. J Intern Med 2020; 287:734-745. [PMID: 32338406 DOI: 10.1111/joim.13044] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND As the population of obese and severely obese young adults grows, it is becoming increasingly important to recognize the long-term risks associated with adolescent obesity. OBJECTIVES This study aimed to determine the association between body mass index (BMI) in young men at enlistment for military service and later risk of venous thromboembolism (VTE). METHODS Nationwide register-based prospective cohort study of men enlisting 1969 to 2005, followed through the Swedish National Patient and Cause of Death registries. We identified 1 639 838 men (mean age, 18.3 years) free of prior venous thromboembolism, of whom 29 342 were obese (BMI 30 to <35 kg m-2 ) and 7236 severely obese (BMI ≥ 35 kg m-2 ). The participants were followed until a first registered diagnosis of VTE. RESULTS During a median follow-up of 28 years (interquartile interval, 20 to 36 years), 11 395 cases of deep vein thrombosis and 7270 cases of pulmonary embolism were recorded. Compared with men with a BMI of 18.5 to <20 kg m-2 , men with higher BMI in young adulthood showed an incrementally increasing risk of VTE that was moderately but significantly increased already at normal BMI levels. Adolescent obese men with a BMI of 30 to 35 kg m-2 had an adjusted hazard ratio of 2.93 (95% confidence interval, 2.65 to 3.24) for VTE. Severely obese men with a BMI of ≥35 kg m-2 had a hazard ratio of 4.95 (95% confidence interval, 4.16 to 5.90). CONCLUSIONS Men who were obese or severely obese in young adulthood had a marked increase in risk of VTE.
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Affiliation(s)
- K Glise Sandblad
- From the, Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - S Jern
- The Wallenberg Laboratory for Cardiovascular Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Åberg
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - J Robertson
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - K Torén
- Occupational and Environmental Medicine, School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Lindgren
- From the, Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - M Adiels
- Centre for Applied Biostatistics, Occupational and Environmental Medicine, University of Gothenburg, Gothenburg, Sweden
| | - P O Hansson
- From the, Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - A Rosengren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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666
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Decreased size of the left anterior descending coronary artery is an independent predictor of deterioration in non-high-risk patients with acute pulmonary embolism. J Thromb Thrombolysis 2020; 51:168-175. [PMID: 32436009 DOI: 10.1007/s11239-020-02136-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
To evaluate the efficacy of measuring left coronary artery size to predict deterioration in non-high-risk acute pulmonary embolism (PE) patients. This retrospective study enrolled non-high-risk acute PE patients from January 2011 to December 2019. Patient deterioration was defined as the occurrence of adverse events within 30 days of hospital admission. Patients with adverse events were sex- and age-matched to patients without adverse events. Risk stratification was performed. Cross-sectional areas (CSAs) of the left main and left anterior descending (LAD) coronary artery inlets were measured. The main pulmonary artery (MPA) inlet and outlet and MPA LAD plane, which adjoined the LAD in the MPA, were reconstructed. CSAs, perimeters, and hydraulic diameters were measured to evaluate MPA size and deformation. Cardiac volume was also measured. Quantitative parameters were divided into tertiles. After adjustment by risk stratification, univariate and multivariate analyses were performed. Correlations between different parameters were analysed. Seventy-three patients with adverse events were matched to 73 patients without adverse events. The results of the univariate and multivariate analyses revealed that LAD inlet CSAs (middle and high) predicted adverse events (odds ratio: 0.28 and 0.07, 95% confidence interval: 0.10-0.77 and 0.02-0.22, p = 0.013 and < 0.0001). LAD inlet CSA was strongly and negatively correlated with MPA LAD hydraulic diameter and CSA (correlation coefficients: - 0.643 and - 0.604, p < 0.001). LAD inlet CSA measurement would facilitate adverse event prediction in non-high-risk acute PE patients on the basis of risk stratification. The dilated MPA may involve the decrease in LAD inlet CSA.
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667
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Vasiltseva OY, Vorozhtsova IN, Bukhovets IL, Gulyaev VM, Vitt KN, Karpov RS. [Typical errors pulmonary artery verification on the example of a clinical case]. TERAPEVT ARKH 2020; 92:80-83. [PMID: 32598703 DOI: 10.26442/00403660.2020.04.000516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Indexed: 11/22/2022]
Abstract
The difficulties of verification of pulmonary embolism (PE) are well known and have not been overcome to date, despite significant progress in approaches to managing patients with this pathology over the past 1015 years. Due to the nonspecific clinical picture, cases of a long and difficult journey to this diagnosis are not exclusive. In large studies have shown that the most frequent symptom of pulmonary embolism shortness of breath. However, it is not always associated with doctors of different specialties with the need to exclude this diagnosis, purposefully collect anamnesis, identify risk factors. Modern low-dose oral contraceptives are considered quite prosperous in terms of the development of thrombotic complications and cause a slight (1020%) increase in fibrinogen concentration, factors VII, VIII and X, as well as a decrease in the content of active protein S by 1020%. But in the case of the presence of diseases and conditions that increase the risk of venous embolism, this effect may be sufficient for the realization of life-threatening pulmonary embolism. In this regard, it is important to provide a combined effect on the prognosis of the pathology of the patients and the chosen method of contraception.
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Affiliation(s)
| | - I N Vorozhtsova
- Tomsk National Research Medical Center.,Siberian State Medical University
| | | | | | - K N Vitt
- Tomsk National Research Medical Center
| | - R S Karpov
- Tomsk National Research Medical Center.,Siberian State Medical University
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668
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McCormack T, Harrisingh MC, Horner D, Bewley S. Venous thromboembolism in adults: summary of updated NICE guidance on diagnosis, management, and thrombophilia testing. BMJ 2020; 369:m1565. [PMID: 32430311 DOI: 10.1136/bmj.m1565] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Terry McCormack
- Institute of Clinical and Applied Health Research, Hull York Medical School, Hull, UK
| | | | - Daniel Horner
- Salford Royal NHS Foundation Trust, Stott Lane, Salford, UK
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Susan Bewley
- Division of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
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669
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De Gregorio MA, Guirola JA, Urbano J, Díaz-Lorenzo I, Muñoz JJ, Villacastin E, Lopez-Medina A, Figueredo AL, Guerrero J, Sierre S, Blazquez Sanchez J, Kuo WT, Jimenez D. Spanish multicenter real - life registry of retrievable vena cava filters (REFiVeC). CVIR Endovasc 2020; 3:26. [PMID: 32419040 PMCID: PMC7231811 DOI: 10.1186/s42155-020-00114-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 03/17/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND The treatment of venous thromboembolic disease the treatment of choice is systemic anticoagulation. However, the interruption of the inferior vena cava with filters has been recommended when anticoagulation fails or there is a contraindication. Due to the rising inferior vena cava filter (IVCF) complications, physicians are encouraged to retrieve them when there is no longer recommended. In daily practice, it may be a difficult close follow-up of these patients. In this study, the primary objective was to evaluate the IVCF retrieval rate of all implanted filters in a Spanish registry. Secondary objectives were to analyze the causes of failed retrieval, procedure-related complications, and outcomes at a 12-month follow-up. RESULTS Three hundred fifty-six vena cava filters were implanted in 355 patients. The types of filter were: Gunther Tulip (Cook Medical) 160 (44.9%), Optease (Cordis) 77 (21.6%), Celect (Cook Medical) 49 (13, 7%), Aegisy (Lifetech Scientific) 33 (9.2%), Option ELITE (Argon Medical devices) 16 (4.4%), Denali filter (BD Bard) 11 (3.08%), ALN filter (ALN) 10 (2.8%). Removal was achieved in 274/356 (76,9%). eighty-two (23,1%) IVCF were not retrieved due to the following: 41 (11,5%) patients required ongoing filtration, 24 IVCF (6,7%) patients died before retrieval, and 17 (4,7%) impossibility of retrieval because of a tilted and embedded filter apex. There were no major complications observed. CONCLUSIONS The global retrieval rate of IVCF was achieved in 76.9%, and the adjusted retrieval rate was of 94.15% with no major complications. IVCF tilting was associated with failure of filter removal in less than 5% of cases. This study demonstrates that the retrieval procedure of IVCF is controlled by the clinician and not by the interventional radiologist.
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Affiliation(s)
| | - Jose A. Guirola
- Hospital Universitario Lozano Blesa, Universidad de Zaragoza, Zaragoza, Spain
| | | | | | | | | | | | | | - Javier Guerrero
- Grupo Investigación Técnicas Mínimamente Invasivas (GITMI), Zaragoza, Spain
| | - Sergio Sierre
- Hospital Universitario Austral, Buenos Aires, Argentina
| | | | - William T. Kuo
- Department of Radiology, Stanford University Medical Center, Stanford, CA USA
| | - David Jimenez
- Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain
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670
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Tal S, Spectre G, Kornowski R, Perl L. Venous Thromboembolism Complicated with COVID-19: What Do We Know So Far? Acta Haematol 2020; 143:417-424. [PMID: 32396903 PMCID: PMC7270063 DOI: 10.1159/000508233] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/27/2020] [Indexed: 01/08/2023]
Abstract
Coronavirus disease (COVID-19) is caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is responsible for the ongoing 2019-2020 pandemic. Venous thromboembolism (VTE), a frequent cardiovascular and/or respiratory complication among hospitalized patients, is one of the known sequelae of the illness. Hospitalized COVID-19 patients are often elderly, immobile, and show signs of coagulopathy. Therefore, it is reasonable to assume a high incidence of VTE among these patients. Presently, the incidence of VTE is estimated at around 25% of patients hospitalized in the intensive care unit for COVID-19 even under anticoagulant treatment at prophylactic doses. In this review, we discuss present knowledge of the topic, the unique challenges of diagnosis and treatment of VTE, as well as some of the potential mechanisms of increased risk for VTE during the illness. Understanding the true impact of VTE on patients with COVID-19 will potentially improve our ability to reach a timely diagnosis and initiate proper treatment, mitigating the risk for this susceptible population during a complicated disease.
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Affiliation(s)
- Shir Tal
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Galia Spectre
- Hematology Department, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leor Perl
- Cardiology Department, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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671
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Al Dandan O, Hassan A, Alnasr A, Al Gadeeb M, AbuAlola H, Alshahwan S, Al Shammari M, Alzaki A. The use of clinical decision rules for pulmonary embolism in the emergency department: a retrospective study. Int J Emerg Med 2020; 13:23. [PMID: 32393324 PMCID: PMC7216540 DOI: 10.1186/s12245-020-00281-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/23/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is a common and life-threatening medical condition with non-specific clinical presentation. Computed tomography pulmonary angiography (CT-PA) has been the diagnostic modality of choice, but its use is not without risks. Clinical decision rules have been established for the use of diagnostic modalities for patients with suspected PE. This study aims to assess the adherence of physicians to the diagnostic algorithms and rules. METHODS A retrospective observational study examining the utilization of CT-PA in the Emergency Department of King Fahd Hospital of Imam Abdulrahman Bin Faisal University for patients with suspected PE from May 2016 to December 2019. The electronic health records were used to collect the data, including background demographic data, clinical presentation, triage vital signs, D-dimer level (if ordered), risk factors for PE, and the CT-PA findings. The Wells score and pulmonary embolism rule-out (PERC) criteria were calculated retrospectively without knowledge of the results of D-dimer and the CT-PA. RESULTS The study involved a total of 353 patients (125 men and 228 women) with a mean age of 46.7 ± 18.4 years. Overall, 200 patients (56.7%) were classified into the "PE unlikely" group and 153 patients (43.3%) in the "PE likely" group as per Wells criteria. Out of all the CT-PA, 119 CT-PA (33.7%) were requested without D-dimer assay (n = 114) or with normal D-dimer level (n = 5) despite being in the "PE unlikely" group. Only 49 patients had negative PERC criteria, of which three patients had PE. CONCLUSIONS The study revealed that approximately one-third of all CT-PA requests were not adhering to the clinical decision rules with a significant underutilization of D-dimer assay in such patients. To reduce overutilization of imaging, planned interventions to promote the adherence to the current guidelines seem imperative.
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Affiliation(s)
- Omran Al Dandan
- Department of Radiology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Ali Hassan
- Department of Radiology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Afnan Alnasr
- Department of Radiology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Mohammed Al Gadeeb
- Department of Radiology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Hossain AbuAlola
- Department of Radiology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Sarah Alshahwan
- Department of Radiology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Malak Al Shammari
- Department of Family and Community Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Alaa Alzaki
- Department of Internal Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
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672
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Hobohm L, Anušić T, Konstantinides SV, Barco S. Ambulatory treatment of low-risk pulmonary embolism in fragile patients: a subgroup analysis of the multinational Home Treatment of Pulmonary Embolism (HoT-PE) Trial. Eur Respir J 2020; 56:13993003.00663-2020. [DOI: 10.1183/13993003.00663-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 04/29/2020] [Indexed: 11/05/2022]
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673
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Gerges M, Yacoub M. Chronic thromboembolic pulmonary hypertension - still evolving. Glob Cardiol Sci Pract 2020; 2020:e202011. [PMID: 33150155 PMCID: PMC7590968 DOI: 10.21542/gcsp.2020.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is one of the leading causes of severe pulmonary hypertension (PH). The disease is still underdiagnosed, and the true prevalence is unknown. CTEPH is characterized by intraluminal non-resolving thrombus organization and fibrous stenosis, or complete obliteration of pulmonary arteries, promoted by progressive remodeling of the pulmonary vasculature. One consequence of this is an increase in pulmonary vascular resistance and pressure, resulting in PH and progressive right heart failure, leading to death if left untreated. Endovascular disobliteration by pulmonary endarterectomy (PEA) is the preferred treatment for CTEPH patients. PEA surgery is the only technique that can potentially cure CTEPH disease, especially in patients with fresh or organized thrombi of the proximal branches of pulmonary arteries. However, not all patients are eligible for PEA surgery. Recent research has provided evidence suggesting balloon pulmonary angioplasty (BPA) and targeted medical therapy as additional promising available treatments options for inoperable CTEPH and recurrent/persistent PH after PEA surgery. Studies on BPA have shown it to improve pulmonary hemodynamics, symptoms, exercise capacity and RV function in inoperable CTEPH. Subsequently, BPA has developed into an essential component of the modern era of CTEPH treatment. Large randomized controlled trials have demonstrated varying significant improvements with targeted medical therapy in technically inoperable CTEPH patients. Thus, treatment of CTEPH requires a comprehensive multidisciplinary assessment, including an experienced PEA surgeon, PH specialist, BPA interventionist and CTEPH-trained radiologist at expert centers. In this comprehensive review, we address the latest developments in the fast-evolving field of CTEPH. These include advancements in imaging modalities and developments in operative and interventional techniques, which have widened the range of patients who may benefit from these procedures. The efficacy and safety of targeted medical therapies in CTEPH patients are also discussed. As the treatment options for CTEPH improve, hybrid management involving multiple treatments in the same patient may become a viable option in the near future.
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Affiliation(s)
- Mario Gerges
- Department of Internal Medicine II, Division of Cardiology, General Hospital Vienna, Medical University of Vienna, Vienna, Austria
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674
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Vinson DR, Engelhart DC, Bahl D, Othieno AA, Abraham AS, Huang J, Reed ME, Swanson WP, Clague VA, Cotton DM, Krauss WC, Mark DG. Presyncope Is Associated with Intensive Care Unit Admission in Emergency Department Patients with Acute Pulmonary Embolism. West J Emerg Med 2020; 21:703-713. [PMID: 32421523 PMCID: PMC7234693 DOI: 10.5811/westjem.2020.2.45028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/04/2020] [Accepted: 02/12/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Syncope is common among emergency department (ED) patients with acute pulmonary embolism (PE) and indicates a higher acuity and worse prognosis than in patients without syncope. Whether presyncope carries the same prognostic implications has not been established. We compared incidence of intensive care unit (ICU) admission in three groups of ED PE patients: those with presyncope; syncope; and neither. METHODS This retrospective cohort study included all adults with acute, objectively confirmed PE in 21 community EDs from January 2013-April 2015. We combined electronic health record extraction with manual chart abstraction. We used chi-square test for univariate comparisons and performed multivariate analysis to evaluate associations between presyncope or syncope and ICU admission from the ED, reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS Among 2996 PE patients, 82 (2.7%) had presyncope and 109 (3.6%) had syncope. ICU admission was similar between groups (presyncope 18.3% vs syncope 25.7%) and different than their non-syncope counterparts (either 22.5% vs neither 4.7%; p<0.0001). On multivariate analysis, both presyncope and syncope were independently associated with ICU admission, controlling for demographics, higher-risk PE Severity Index (PESI) class, ventilatory support, proximal clot location, and submassive and massive PE classification: presyncope, aOR 2.79 (95% CI, 1.40, 5.56); syncope, aOR 4.44 (95% CI 2.52, 7.80). These associations were only minimally affected when excluding massive PE from the model. There was no significant interaction between either syncope or presyncope and PESI, submassive or massive classification in predicting ICU admission. CONCLUSION Presyncope appears to carry similar strength of association with ICU admission as syncope in ED patients with acute PE. If this is confirmed, clinicians evaluating patients with acute PE may benefit from including presyncope in their calculus of risk assessment and site-of-care decision-making.
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Affiliation(s)
- David R. Vinson
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Division of Research, Oakland, California
- Kaiser Permanente Sacramento Medical Center, Department of Emergency Medicine, Sacramento, California
| | | | - Disha Bahl
- St. George’s University, School of Medicine, Grenada, West Indies
| | - Alisha A. Othieno
- University of California, Davis, School of Medicine, Sacramento, California
| | - Ashley S. Abraham
- University of California, Davis, School of Medicine, Sacramento, California
| | - Jie Huang
- Kaiser Permanente Division of Research, Oakland, California
| | - Mary E. Reed
- Kaiser Permanente Division of Research, Oakland, California
| | - William P. Swanson
- University of California, Davis, School of Medicine, Sacramento, California
- Kaiser Permanente San Diego Medical Center, Department of Emergency Medicine, San Diego, California
| | - Victoria A. Clague
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente San Rafael Medical Center, Department of Radiology, San Rafael, California
| | - Dale M. Cotton
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente South Sacramento Medical Center, Department of Emergency Medicine, Sacramento, California
| | - William C. Krauss
- Kaiser Permanente San Diego Medical Center, Department of Emergency Medicine, San Diego, California
| | - Dustin G. Mark
- The Permanente Medical Group, Oakland, California
- Kaiser Permanente Division of Research, Oakland, California
- Kaiser Permanente Oakland Medical Center, Department of Emergency Medicine, Oakland, California
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675
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L'Angiocola PD, Donati R. Cardiac Masses in Echocardiography: A Pragmatic Review. J Cardiovasc Echogr 2020; 30:5-14. [PMID: 32766100 PMCID: PMC7307625 DOI: 10.4103/jcecho.jcecho_2_20] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 02/18/2020] [Accepted: 02/25/2020] [Indexed: 01/07/2023] Open
Abstract
Transthoracic echocardiography is a useful diagnostic technique for the identification of intracardiac and extracardiac masses, which can evaluate morphologic properties of the masses such as their location, attachment, shape, size, mobility, and possible hemodynamic-related implications. Apart from physiological variants and structural normal mimickers, echocardiography can detect principal intracardiac masses such as neoplasms, thrombi, vegetation, and extracardiac masses such as metastatic lesions. Moreover, transesophageal echocardiography can provide further details and provide higher accuracy in case a deeper examination of the mass is needed. This review will focus on the systematic evaluation of intra-/extracardiac masses including epidemiology and morphological and echocardiographic features, providing practical and technical tips to health-care professionals to achieve correct identification of the masses. General data on cardiac masses were extracted via PubMed/MEDLINE search engine from indexed reviews, original studies, and clinical case reports. The echocardiographic features of cardiac masses were reviewed according to the most relevant international cardiology and echocardiography scientific societies' position statements.
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Affiliation(s)
| | - Roberto Donati
- Department of Cardiology, Giovan Battista Grassi Hospital, Rome, Italy
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676
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Pulmonary perfusion by iodine subtraction maps CT angiography in acute pulmonary embolism: comparison with pulmonary perfusion SPECT (PASEP trial). Eur Radiol 2020; 30:4857-4864. [PMID: 32279113 DOI: 10.1007/s00330-020-06836-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/03/2020] [Accepted: 03/25/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To assess the diagnostic accuracy of iodine map computed tomography pulmonary angiography (CTPA), for segment-based evaluation of lung perfusion in patients with acute pulmonary embolism (PE), using perfusion single-photon emission CT (SPECT) imaging as a reference standard. METHODS Thirty participants who have been diagnosed with acute pulmonary embolism on CTPA underwent perfusion SPECT/CT within 24 h. Perfusion SPECT and iodine map were independently interpreted by 2 nuclear medicine physicians and 2 radiologists. For both modalities, each segment was classified as normoperfused or hypoperfused, as defined by a perfusion defect of more than 25% of a segment. The primary end point was the diagnostic accuracy (sensitivity and specificity) of iodine map for segment-based evaluation of lung perfusion, using perfusion SPECT imaging as a reference standard. Following blinded interpretation, a retrospective explanatory analysis was performed to determine potential causes of misinterpretation. RESULTS The median time between CTPA with iodine maps and perfusion SPECT was 14 h (range 2-23 h). A total of 597 segments were analyzed. Sensitivity and specificity of iodine maps with CTPA for the detection of segmental perfusion defects were 231/284 = 81.3% (95% CI 76.4 to 85.4%) and 247/313 = 78.9% (95% CI 74.1 to 83.1%), respectively. In retrospect, false results were explained in 48.7%. CONCLUSION Iodine map CTPA showed promising results for the assessment of pulmonary perfusion in patients with acute PE, with sensitivity of 81.3% and specificity of 78.9%, respectively. Recognition of typical pitfalls such as atelectasis, fissures, or beam-hardening artifacts may further improve the accuracy of the test. KEY POINTS • Sensitivity and specificity of iodine subtraction maps for the detection of segmental perfusion defects were 81.3% (95% CI 76.4 to 85.4%) and 78.9% (95% CI 74.1 to 83.1%), respectively. • Recognition of typical pitfalls such as atelectasis, fissures, or beam-hardening artifacts may further improve the diagnostic accuracy of the test.
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677
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McCabe C, Dimopoulos K, Pitcher A, Orchard E, Price LC, Kempny A, Wort SJ. Chronic thromboembolic disease following pulmonary embolism: time for a fresh look at old clot. Eur Respir J 2020; 55:55/4/1901934. [DOI: 10.1183/13993003.01934-2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 01/24/2020] [Indexed: 01/16/2023]
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Konstantinides SV. Chronic thromboembolic disease following pulmonary embolism: more work ahead. Eur Respir J 2020; 55:55/4/2000229. [PMID: 32245774 DOI: 10.1183/13993003.00229-2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/03/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany .,Dept of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
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679
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Cernera G, Di Minno A, Amato F, Elce A, Liguori R, Bruzzese D, Di Lullo AM, Castaldo G, Zarrilli F, Comegna M. Molecular Analysis of Prothrombotic Gene Variants in Venous Thrombosis: A Potential Role for Sex and Thrombotic Localization. J Clin Med 2020; 9:jcm9041008. [PMID: 32252449 PMCID: PMC7231221 DOI: 10.3390/jcm9041008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/01/2020] [Indexed: 01/07/2023] Open
Abstract
Background: Requests to test for thrombophilia in the clinical context are often not evidence-based. Aim: To define the role of a series of prothrombotic gene variants in a large population of patients with different venous thromboembolic diseases. Methods: We studied Factor V Leiden (FVL), FVR2, FII G20210A, Methylenetetrahydrofolate reductase (MTHFR) C677T and A1298C, beta-fibrinogen -455 G>A, FXIII V34L, and HPA-1 L33P variants and PAI-1 4G/5G alleles in 343 male and female patients with deep vein thrombosis (DVT), 164 with pulmonary embolism (PE), 126 with superficial vein thrombosis (SVT), 118 with portal vein thrombosis (PVT), 75 with cerebral vein thrombosis (CVT) and 119 with retinal vein thrombosis (RVT), and compared them with the corresponding variants and alleles in 430 subjects from the general population. Results: About 40% of patients with DVT, PE and SVT had at least one prothrombotic gene variant, such as FVL, FVR2 and FII G20210A, and a statistically significant association with the event was found in males with a history of PE. In patients with a history of PVT or CVT, the FII G20210A variant was more frequent, particularly in females. In contrast, a poor association was found between RVT and prothrombotic risk factors, confirming that local vascular factors have a key role in this thrombotic event. Conclusions: Only FVL, FVR2 and FII G20210A are related to vein thrombotic disease. Other gene variants, often requested for testing in the clinical context, do not differ significantly between cases and controls. Evidence of a sex difference for some variants, once confirmed in larger populations, may help to promote sex-specific prevention of such diseases.
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Affiliation(s)
- Gustavo Cernera
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, 80131 Naples, Italy; (G.C.); (F.A.); (R.L.); (G.C.); (M.C.)
- CEINGE-Biotecnologie avanzate, 80131 Naples, Italy; (A.D.M.); (A.E.); (A.M.D.L.)
| | - Alessandro Di Minno
- CEINGE-Biotecnologie avanzate, 80131 Naples, Italy; (A.D.M.); (A.E.); (A.M.D.L.)
- Dipartimento di Farmacia, Università di Napoli Federico II, 80131 Naples, Italy
| | - Felice Amato
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, 80131 Naples, Italy; (G.C.); (F.A.); (R.L.); (G.C.); (M.C.)
- CEINGE-Biotecnologie avanzate, 80131 Naples, Italy; (A.D.M.); (A.E.); (A.M.D.L.)
| | - Ausilia Elce
- CEINGE-Biotecnologie avanzate, 80131 Naples, Italy; (A.D.M.); (A.E.); (A.M.D.L.)
- Università Telematica Pegaso, 80143 Naples, Italy
| | - Renato Liguori
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, 80131 Naples, Italy; (G.C.); (F.A.); (R.L.); (G.C.); (M.C.)
- CEINGE-Biotecnologie avanzate, 80131 Naples, Italy; (A.D.M.); (A.E.); (A.M.D.L.)
| | - Dario Bruzzese
- Dipartimento di Sanità Pubblica, Università di Napoli Federico II, 80131 Naples, Italy;
| | - Antonella Miriam Di Lullo
- CEINGE-Biotecnologie avanzate, 80131 Naples, Italy; (A.D.M.); (A.E.); (A.M.D.L.)
- Dipartimento di Neuroscienze e Scienze Riproduttive ed Odontostomatologiche, Università di Napoli Federico II, 80131 Naples, Italy
| | - Giuseppe Castaldo
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, 80131 Naples, Italy; (G.C.); (F.A.); (R.L.); (G.C.); (M.C.)
- CEINGE-Biotecnologie avanzate, 80131 Naples, Italy; (A.D.M.); (A.E.); (A.M.D.L.)
| | - Federica Zarrilli
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, 80131 Naples, Italy; (G.C.); (F.A.); (R.L.); (G.C.); (M.C.)
- CEINGE-Biotecnologie avanzate, 80131 Naples, Italy; (A.D.M.); (A.E.); (A.M.D.L.)
- Correspondence: ; Tel.: +39-081-373-7860
| | - Marika Comegna
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università di Napoli Federico II, 80131 Naples, Italy; (G.C.); (F.A.); (R.L.); (G.C.); (M.C.)
- CEINGE-Biotecnologie avanzate, 80131 Naples, Italy; (A.D.M.); (A.E.); (A.M.D.L.)
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Citro R, Prota C, Resciniti E, Radano I, Posteraro A, Fava A, Monte IP. Thrombotic Risk in Cancer Patients: Diagnosis and Management of Venous Thromboembolism. J Cardiovasc Echogr 2020; 30:S38-S44. [PMID: 32566465 PMCID: PMC7293865 DOI: 10.4103/jcecho.jcecho_63_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 11/28/2019] [Accepted: 12/05/2019] [Indexed: 12/20/2022] Open
Abstract
Venous thromboembolism (VTE) represents a major health problem, especially in cancer patients, who experience a significantly higher incidence of both deep vein thrombosis and pulmonary embolism compared to the general population. Indeed, patients with cancer have a prothrombotic state resulting in both increased expression of procoagulants and suppression of fibrinolytic activity. In addition, VTE increases the morbidity and mortality of these patients. For all these reasons, the prevention and treatment of VTE in cancer setting represent major challenges in daily practice. In general, low-molecular-weight heparin monotherapy is the standard of care for the management of cancer-associated VTE, as Vitamin K antagonists are less effective in this setting. Direct oral anticoagulants offer a potentially promising treatment option for cancer patients with VTE, since recent studies demonstrated their efficacy and safety also in this peculiar setting.
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Affiliation(s)
- Rodolfo Citro
- Heart Department, University Hospital “San Giovanni di Dio e Ruggi d'Aragona”, Salerno, Italy
| | - Costantina Prota
- Heart Department, University Hospital “San Giovanni di Dio e Ruggi d'Aragona”, Salerno, Italy
| | | | - Ilaria Radano
- Heart Department, University Hospital “San Giovanni di Dio e Ruggi d'Aragona”, Salerno, Italy
| | | | - Antonella Fava
- Cardiology Department, University Hospital “Città della Salute e della Scienza di Torino”, Molinette Hospital, Turin, Italy
| | - Ines Paola Monte
- Cardiology Department Echocardiography Laboratory, Department of Cardiothoracic and Vascular, Policlinico “Vittorio Emanuele”, Catania University, Catania, Italy
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681
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Koraćević G, Stojanović M, Petrović S, Simić D, Sakač D, Vlajković M, Stevic M, Kocić M, Đorđević M, Koraćević M. CUSHING'S SYNDROME, A RISK FACTOR FOR VENOUS THROMBOEMBOLISM IS A CANDIDATE FOR GUIDELINES. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2020; 16:123-128. [PMID: 33029226 PMCID: PMC7535883 DOI: 10.4183/aeb.2020.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The present paper aims to review important contemporary information about VTE risk in endogenous and exogenous CS, as a substantial discrepancy exists between the results of a recent meta-analysis confirming the increased risk for VTE and the absence of CS in VTE guidelines. METHODS An extensive search of relevant databases (e.g. PubMed, Google Scholar, and Scopus) was performed in order to establish the interconnectedness of the following terms: Cushing's syndrome, venous thromboembolism, deep vein thrombosis, pulmonary embolism. RESULTS The analysis demonstrated that patients with CS have about ten times the risk for VTE, particularly during the first year following the diagnosis of CS. Oral glucocorticoid users (with iatrogenic CS) have a 3-fold increase in risk of VTE in comparison with non-users. The most recent 2019 meta-analysis encompassed 7142 patients with endogenous CS (including Cushing's disease) undergoing transsphenoidal surgery or adrenalectomy, and their risk of unprovoked VTE was almost 18 times higher in comparison with a healthy population. CONCLUSION Over the past 50 years considerable evidence of increased VTE risk in CS has been accumulated. It pertains to both endogenous and exogenous type of CS and has been confirmed in the vast majority, if not all the available studies, including meta-analyses. Nevertheless, official CS guidelines make no mention of CS as a VTE risk factor, even though it is important that not only physicians who treat CS, but also physicians who manage patients with suspected VTE be aware of increased VTE risk.
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Affiliation(s)
- G. Koraćević
- Clinical Centre Niš - Department for Cardiovascular Diseases, Novi Sad Serbia
- Clinical Centre Niš - University of Niš, Faculty of Medicine, Novi Sad Serbia
| | - M. Stojanović
- Clinical Centre Niš - Institute for Treatment and Rehabilitation, Niška Banja, Novi Sad Serbia
| | - S. Petrović
- Clinical Centre Niš - Department of Radiology, Novi Sad Serbia
- Clinical Centre Niš - University of Niš, Faculty of Medicine, Novi Sad Serbia
| | - D. Simić
- Clinical Centre Niš - Clinical Center of Serbia - Division of Cardiology, Novi Sad Serbia
- Clinical Centre Niš - University of Belgrade Faculty of Medicine, Beograd, Novi Sad Serbia
| | - D. Sakač
- Clinical Centre Niš - Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Vojvodina, Novi Sad Serbia
- Clinical Centre Niš - University of Novi Sad Medical Faculty, Novi Sad Serbia
| | - M. Vlajković
- Clinical Centre Niš - Department of Nuclear Medicine, Novi Sad Serbia
- Clinical Centre Niš - University of Niš, Faculty of Medicine, Novi Sad Serbia
| | - M. Stevic
- Clinical Centre Niš - Center of Nuclear Medicine, Novi Sad Serbia
- Clinical Centre Niš - University of Niš, Faculty of Medicine, Novi Sad Serbia
| | - M. Kocić
- Clinical Centre Niš - Department of Rehabilitation, Novi Sad Serbia
- Clinical Centre Niš - University of Niš, Faculty of Medicine, Novi Sad Serbia
| | - M. Đorđević
- Clinical Centre Niš - Health Centre Jagodina - Emergency Medical Service, Novi Sad Serbia
| | - M. Koraćević
- Clinical Centre Niš - University of Niš, Faculty of Medicine, Novi Sad Serbia
- Clinical Centre Niš - University of Nis - Innovation Centre, Niš, Novi Sad Serbia
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682
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Pompilio G, Integlia D, Raffetto J, Palareti G. Comparative Efficacy and Safety of Sulodexide and Other Extended Anticoagulation Treatments for Prevention of Recurrent Venous Thromboembolism: A Bayesian Network Meta-analysis. TH OPEN 2020; 4:e80-e93. [PMID: 32355907 PMCID: PMC7188513 DOI: 10.1055/s-0040-1709731] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/12/2020] [Indexed: 02/07/2023] Open
Abstract
Objective This network meta-analysis (NMA) assesses the clinical comparative efficacy and safety of sulodexide versus direct-acting oral anticoagulants (DOACs), vitamin K antagonist (VKA), and aspirin in patients with an unprovoked venous thromboembolism (VTE). Methods We conducted a literature search in MEDLINE, Embase, and Cochrane Library using both randomized controlled trials (RCTs) and observational studies. Reduction in recurrent deep venous thrombosis (r-DVT), pulmonary embolism (PE), major bleeding (MB), clinically relevant nonmajor bleeding (CRNMB) were the primary efficacy and safety outcomes. Other secondary end points were also included. We performed a fixed, random effects, and hierarchical models Bayesian NMA for each outcome. Results We identified 18 RCTs and seven observational studies. Random models showed sulodexide is the best treatment compared with DOACs, VKA, and aspirin at reducing the risk of CRNMB, for preventing death from any cause, and VTE/PE/myocardial infarction (MI)/stroke with 0.47, 0.81, and 0.65 probabilities, respectively. In the random model sulodexide was the best treatment for reducing the risk of MB with a 0.50 probability and hierarchical model that confirmed favorable results. Random and hierarchical models showed sulodexide and DOACs to be the best treatments for reducing PE risk. Sulodexide was more effective than aspirin for reducing r-DVT with 0.12 and less of 0.0001 probabilities, respectively. Conclusion Sulodexide is more effective for reducing MB and CRNMB, for preventing deaths from any cause, and from VTE/PE/MI/stroke, than other treatments, for both random and hierarchical models. Sulodexide showed to be more effective than aspirin in reducing the risk of r-DVT and PE. Sulodexide's reduction in bleeding while protecting from recurrent DVT risk makes this therapeutic option an important alternative for extended anticoagulation treatment.
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Affiliation(s)
| | | | - Joseph Raffetto
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
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683
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Ząbczyk M, Natorska J, Janion-Sadowska A, Malinowski KP, Janion M, Undas A. Elevated Lactate Levels in Acute Pulmonary Embolism Are Associated with Prothrombotic Fibrin Clot Properties: Contribution of NETs Formation. J Clin Med 2020; 9:E953. [PMID: 32235490 PMCID: PMC7231195 DOI: 10.3390/jcm9040953] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/24/2020] [Accepted: 03/27/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Elevated plasma lactate levels correlate with high mortality rate in acute pulmonary embolism (PE) patients. We hypothesized that elevated lactate levels correlate with prothrombotic fibrin clot properties and enhanced neutrophil extracellular trap (NET) formation in acute PE. METHODS As many as 126 normotensive acute PE patients (aged 58 ± 14 years) were enrolled. Plasma fibrin clot permeability (Ks), clot lysis time (CLT), endogenous thrombin potential (ETP), citrullinated histone H3 (citH3), and plasminogen activator inhibitor-1 antigen (PAI-1), together with plasma L-lactate levels were evaluated on admission. RESULTS Lactate levels ≥2 mM were found in 70 (55.6%) patients in whom we observed 29% higher neutrophil count and 45% elevated plasma citH3 levels. Elevated lactate levels were associated with more prothrombotic fibrin properties as reflected by 11% reduced Ks, 13% longer CLT, along with 11% increased ETP. Lactate levels were positively associated with plasma citH3 concentrations, ETP, CLT, and PAI-1 (p < 0.05). An increase of lactate levels by 1 mM leading to the prolongation of CLT by 8.82 minutes was shown in the linear regression. CONCLUSIONS Our findings suggest a new mechanism contributing to a negative impact of elevated lactate levels on prognosis in acute PE patients, in particular hypofibrinolysis, associated with enhanced NET formation.
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Affiliation(s)
- Michał Ząbczyk
- Institute of Cardiology, Jagiellonian University Medical College, 31-202 Krakow, Poland; (M.Z.); (J.N.)
- John Paul II Hospital, 31-202 Krakow, Poland
| | - Joanna Natorska
- Institute of Cardiology, Jagiellonian University Medical College, 31-202 Krakow, Poland; (M.Z.); (J.N.)
- John Paul II Hospital, 31-202 Krakow, Poland
| | - Agnieszka Janion-Sadowska
- The Faculty of Medicine and Health Sciences, The Jan Kochanowski University, 25-317 Kielce, Poland; (A.J.-S.); (M.J.)
| | - Krzysztof P. Malinowski
- Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, 31-126 Krakow, Poland;
| | - Marianna Janion
- The Faculty of Medicine and Health Sciences, The Jan Kochanowski University, 25-317 Kielce, Poland; (A.J.-S.); (M.J.)
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, 31-202 Krakow, Poland; (M.Z.); (J.N.)
- John Paul II Hospital, 31-202 Krakow, Poland
- The Faculty of Medicine and Health Sciences, The Jan Kochanowski University, 25-317 Kielce, Poland; (A.J.-S.); (M.J.)
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684
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Boon GJAM, Barco S, Bertoletti L, Ghanima W, Huisman MV, Kahn SR, Noble S, Prandoni P, Rosovsky RP, Sista AK, Siegerink B, Klok FA. Measuring functional limitations after venous thromboembolism: Optimization of the Post-VTE Functional Status (PVFS) Scale. Thromb Res 2020; 190:45-51. [PMID: 32298840 DOI: 10.1016/j.thromres.2020.03.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION We recently proposed a scale for assessment of patient-relevant functional limitations following an episode of venous thromboembolism (VTE). Further development of this post-VTE functional status (PVFS) scale is still needed. METHODS Guided by the input of VTE experts and patients, we refined the PVFS scale and its accompanying manual, and attempted to acquire broad consensus on its use. RESULTS A Delphi analysis was performed involving 53 international VTE experts with diverse scientific and clinical backgrounds. In this process, the number of scale grades of the originally proposed PVFS scale was reduced and descriptions of the grades were improved. After these changes, a consensus was reached on the number/definitions of the grades, and method/timing of the scale assessment. The relevance and potential impact of the scale was confirmed in three focus groups totaling 18 VTE patients, who suggested additional changes to the manual, but not to the scale itself. Using the improved manual, the κ-statistics between PVFS scale self-reporting and its assessment via the structured interview was 0.75 (95%CI 0.58-1.0), and 1.0 (95%CI 0.83-1.0) between independent raters of the recorded interview of 16 focus groups members. CONCLUSION We improved the PVFS scale and demonstrated broad consensus on its relevance, optimal grades, and methods of assessing among international VTE experts and patients. The interobserver agreement of scale grade assignment was shown to be good-to-excellent. The PVFS scale may become an important outcome measure of functional impairment for quality of patient care and in future VTE trials.
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Affiliation(s)
- G J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany; Clinic of Angiology, University Hospital of Zurich, Zurich, Switzerland
| | - L Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Étienne, Saint-Étienne, France; INSERM UMR 1059 and CIC 1408, Université Jean-Monnet, Saint-Étienne, France
| | - W Ghanima
- Department of Oncology, Østfold Hospital Trust, Kalnes, Norway; Department Medicine and Research, Østfold Hospital Trust, Kalnes, Norway
| | - M V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - S R Kahn
- Division of Clinical Epidemiology, Department of Medicine, Jewish General Hospital, Montreal, QC, Canada
| | - S Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - P Prandoni
- Arianna Foundation on Anticoagulation, Bologna, Italy
| | - R P Rosovsky
- Department of Medicine, Hematology/Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - A K Sista
- Department of Radiology, New York University School of Medicine, New York, NY, United States
| | - B Siegerink
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.
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685
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Lio KU, Jiménez D, Moores L, Rali P. Clinical conundrum: concomitant high-risk pulmonary embolism and acute ischemic stroke. Emerg Radiol 2020; 27:433-439. [PMID: 32211984 DOI: 10.1007/s10140-020-01772-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/13/2020] [Indexed: 01/01/2023]
Abstract
High-risk PE can be complicated by the presence of a patent foramen ovale (PFO), which can lead to paradoxical systemic embolization, including cerebral embolism ultimately leading to acute ischemic stroke (AIS). Acute management is challenging given the competing benefits and risks of systemic thrombolysis. Herein, we aim to provide a review of clinical presentations, diagnostic findings, and treatment and outcome from the available literature, with the hopes of providing insight into treatment options. We followed the guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic literature search using PubMed/MEDLINE database, Cochrane Library, and Google Scholar for all reported cases/case series of concomitant high-risk PE and paradoxical ischemic stroke was conducted from inception to July 2019. Twenty-nine cases from 27 articles (26 single case reports, 1 case series of 3 patients) were included. There were 10 men and 19 women, ranging in age from 29 to 81 years (mean 56.1 ± 13.5 years). PFO was diagnosed in 89.7% of patients, mostly by transesophageal echocardiography. Treatment modalities included systemic thrombolysis (40%), anticoagulation alone (36%), surgical thrombectomy (16%), and percutaneous thrombectomy (8%). Overall mortality rate was 31%. Patients receiving thrombolysis and surgical thrombectomy had the most favorable outcome. Survival to discharge was 90% (9 out of 10), 100% (5 out of 5), and 50% (4 out of 8) in the systemic thrombolysis, surgical thrombectomy, and anticoagulation alone groups respectively. In the setting of combined high-risk PE and ischemic stroke, PFO can be detected in 90% of published cases. Thrombolysis and surgical thrombectomy seem to be effective management, but further studies are needed for validation.
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Affiliation(s)
- Ka U Lio
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcala, Madrid, Spain
| | - Lisa Moores
- Department of Medicine, F. Edward Hebert School of Medicine, The Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School Of Medicine, Temple University Hospital, Philadelphia, PA, USA.
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686
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Chen C, Millar FR, Jones A. Outpatient management of pulmonary emboli: when to ambulate. Br J Hosp Med (Lond) 2020; 81:1-10. [PMID: 32239990 DOI: 10.12968/hmed.2019.0370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pulmonary embolism is a potentially fatal consequence of venous thromboembolism and constitutes a significant proportion of the acute medical take. Standard management has previously required admission of all patients presenting with acute pulmonary embolism for initiation of anticoagulation and initial investigations. However, clinical trial data have demonstrated the feasibility and safety of managing a subset of patients with low-risk pulmonary embolism in the outpatient setting and this has since been reflected in national guidelines. This article provides a practical overview for general physicians with regards to identifying patients with low-risk pulmonary embolism, and when and how to manage these patients on an outpatient basis.
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Affiliation(s)
- Cheng Chen
- Department of Respiratory Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Fraser R Millar
- CRUK Edinburgh Centre, University of Edinburgh, Edinburgh, UK
| | - Anne Jones
- Department of Respiratory Medicine, Western General Hospital, Edinburgh, Edinburgh, UK
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687
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Vinson DR, Aujesky D, Geersing GJ, Roy PM. Comprehensive Outpatient Management of Low-Risk Pulmonary Embolism: Can Primary Care Do This? A Narrative Review. Perm J 2020; 24:19.163. [PMID: 32240089 DOI: 10.7812/tpp/19.163] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The evidence for outpatient management of hemodynamically stable, low-risk patients with acute symptomatic pulmonary embolism (PE) is mounting. Guidance in identifying patients who are eligible for outpatient (ambulatory) care is available in the literature and society guidelines. Less is known about who can identify patients eligible for outpatient management and in what clinical practice settings. OBJECTIVE To answer the question, "Can primary care do this?" (provide comprehensive outpatient management of low-risk PE). METHODS We undertook a narrative review of the literature on the outpatient management of acute PE focusing on site of care. We searched the English-language literature in PubMed and Embase from January 1, 1950, through July 15, 2019. RESULTS We identified 26 eligible studies. We found no studies that evaluated comprehensive PE management in a primary care clinic or general practice setting. In 19 studies, the site-of-care decision making occurred in the Emergency Department (or after a short period of supplemental observation) and in 7 studies the decision occurred in a specialty clinic. We discuss the components of care involved in the diagnosis, outpatient eligibility assessment, treatment, and follow-up of ambulatory patients with acute PE. DISCUSSION We see no formal reason why a trained primary care physician could not provide comprehensive care for select patients with low-risk PE. Leading obstacles include lack of ready access to advanced pulmonary imaging and the time constraints of a busy outpatient clinic. CONCLUSION Until studies establish safe parameters of such a practice, the question "Can primary care do this?" must remain open.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA.,Kaiser Permanente Division of Research, Oakland, CA.,Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, CA
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, UMR (CNRS 6015 - INSERM 1083) Institut Mitovasc, Université d'Angers, France
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688
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Millington S, Lawson A, Rajiv K. Making the change through acute medical team education: Inpatient risk assessment of stable pulmonary embolism cases at high risk of deterioration. Clin Med (Lond) 2020; 20:s95. [DOI: 10.7861/clinmed.20-2-s95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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689
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Cohen SL, Feizullayeva C, McCandlish JA, Sanelli PC, McGinn T, Brenner B, Spyropoulos AC. Comparison of international societal guidelines for the diagnosis of suspected pulmonary embolism during pregnancy. LANCET HAEMATOLOGY 2020; 7:e247-e258. [PMID: 32109405 DOI: 10.1016/s2352-3026(19)30250-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/13/2019] [Accepted: 11/18/2019] [Indexed: 10/24/2022]
Abstract
Pregnancy-associated pulmonary embolism is one of the leading causes of maternal mortality. Diagnosis of pulmonary embolism in pregnancy is challenging, with symptoms of pulmonary embolism mimicking those of pregnancy. Several key components such as clinical prediction tools, risk stratification, laboratory tests, and imaging widely used for diagnosis of pulmonary embolism in the non-pregnant population show limitations for diagnosis in pregnancy. Further, because of the difficulty of studying pregnant patients, high-quality research evaluating the performance of these diagnostic components in pregnancy is scarce. Seven international medical society guidelines present clinical diagnostic pathways for evaluation of pulmonary embolism in pregnancy that show conflicting recommendations on the use of these diagnostic components. This Review assesses all key components of diagnostic clinical pathways recommended by guidelines for evaluation of pulmonary embolism in pregnancy, reviews current evidence, compares the guideline recommendations with respect to each key component, and provides our preferred diagnostic pathway. It provides the guidelines and available data needed for informed decision making to diagnose pulmonary embolism in pregnancy.
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Affiliation(s)
- Stuart L Cohen
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA.
| | - Chinara Feizullayeva
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - John A McCandlish
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA; Georgia Institute of Technology, Atlanta, GA, USA
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research, Department of Radiology, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Thomas McGinn
- Department of Medicine, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Benjamin Brenner
- Institute of Hematology, Rambam Health Care Campus and Technion, Israel Institute of Technology, Haifa, Israel; Department of Obstetrics and Gynaecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health, Manhasset, NY, USA; Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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690
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Ricci F, De Innocentiis C, Verrengia E, Ceriello L, Mantini C, Pietrangelo C, Irsuti F, Gabriele S, D'Alleva A, Khanji MY, Aung N, Renda G, Cameli M, Petersen SE, Cesare ED, Gallina S. The Role of Multimodality Cardiovascular Imaging in Peripartum Cardiomyopathy. Front Cardiovasc Med 2020; 7:4. [PMID: 32133371 PMCID: PMC7041418 DOI: 10.3389/fcvm.2020.00004] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/13/2020] [Indexed: 11/16/2022] Open
Abstract
The burden of pregnancy-related heart disease has dramatically increased over the last decades due to the increasing age at first pregnancy and higher prevalence of cardiovascular risk factors such as diabetes, hypertension, and obesity. Pregnancy is associated with physiological changes in the cardiovascular system, including hemodynamic, metabolic, and hormonal adaptations to meet the increased metabolic demands of the mother and fetus. It has been postulated that pregnancy may act as a cardiovascular stress test to identify women at high risk for heart disease, where the inability to adequately adapt to the physiologic stress of pregnancy may reveal the presence of genetic susceptibility to cardiovascular disease or accelerate the phenotypic expression of both inherited and acquired heart diseases, such as peripartum cardiomyopathy (PPCM). PPCM is a rare and incompletely understood clinical condition. Despite recent advances in the understanding of its pathogenesis, PPCM is not attributable to a well-defined pathological mechanism, and therefore, its diagnosis still relies on the exclusion of overlapping dilated phenotypes. Cardiac imaging plays a key role in any peripartum woman with signs and symptoms of heart failure in establishing the diagnosis, ruling out life-threatening complications, guiding therapy and conveying prognostic information. Echocardiography represents the first-line imaging technique, given its robust diagnostic yield and its favorable cost-effectiveness. Cardiovascular magnetic resonance is a biologically safe high-throughput modality that allows accurate morpho-functional assessment of the cardiovascular system in addition to the unique asset of myocardial tissue characterization as a pivotal piece of information in the pathophysiological puzzle of PPCM. In this review, we will highlight current evidence on the role of multimodality imaging in the differential diagnosis, prognostic assessment, and understanding of the pathophysiological basis of PPCM.
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Affiliation(s)
- Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy.,Department of Clinical Sciences, Lund University, Clinical Research Center, Malmö, Sweden.,Casa di Cura Villa Serena, Città Sant'Angelo, Pescara, Italy
| | - Carlo De Innocentiis
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Elvira Verrengia
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Laura Ceriello
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Carla Pietrangelo
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Flaviano Irsuti
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Stefano Gabriele
- Hypertension and Related Diseases Center, AOU-University of Sassari, Sassari, Italy
| | - Alberto D'Alleva
- Cardiac Intensive Care and Interventional Cardiology Unit, Santo Spirito Hospital, Pescara, Italy
| | - Mohammed Y Khanji
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, London, United Kingdom.,Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Nay Aung
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, London, United Kingdom.,Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Matteo Cameli
- Department of Life, Health and Environmental Science, University of L'Aquila, L'Aquila, Italy
| | - Steffen E Petersen
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University of London, London, United Kingdom.,Barts Heart Centre, St. Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ernesto Di Cesare
- Department of Life, Health and Environmental Science, University of L'Aquila, L'Aquila, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University, Chieti, Italy
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691
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Meyer G, Planquette B. Incidental venous thromboembolism, detected by chance, but still venous thromboembolism. Eur Respir J 2020; 55:55/2/2000028. [PMID: 32029648 DOI: 10.1183/13993003.00028-2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 01/15/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Guy Meyer
- Division of Respiratory Disease, APHP Centre, Université Paris Descartes, Université de Paris, Paris, France
| | - Benjamin Planquette
- Division of Respiratory Disease, APHP Centre, Université Paris Descartes, Université de Paris, Paris, France
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692
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Yoo HHB, Nunes‐Nogueira VS, Fortes Villas Boas PJ. Anticoagulant treatment for subsegmental pulmonary embolism. Cochrane Database Syst Rev 2020; 2:CD010222. [PMID: 32030721 PMCID: PMC7004894 DOI: 10.1002/14651858.cd010222.pub4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute pulmonary embolism (PE) is a common cause of death, accounting for 50,000 to 200,000 deaths annually. It is the third most common cause of mortality among the cardiovascular diseases, after coronary artery disease and stroke. The advent of multi-detector computed tomographic pulmonary angiography (CTPA) has allowed better assessment of PE regarding visualisation of the peripheral pulmonary arteries, increasing its rate of diagnosis. More cases of peripheral PEs, such as isolated subsegmental PE (SSPE) and incidental PE, have thereby been identified. These two conditions are usually found in patients with few or none of the classic PE symptoms such as haemoptysis or pleuritic pain, acute dyspnoea or circulatory collapse. However, in patients with reduced cardiopulmonary reserve, classic PE symptoms can be found with isolated SSPEs. Incidental SSPE is found casually in asymptomatic patients, usually by diagnostic imaging performed for other reasons (for example routine CT for cancer staging in oncology patients). Traditionally, all PEs are anticoagulated in a similar manner independent of their location, or number and size of the thrombi. It has been suggested that many patients with SSPE may be treated without benefit, increasing adverse events by a possible unnecessary use of anticoagulants. Patients with isolated SSPE, or incidental PE, may have a more benign clinical presentation compared to those with proximal PEs. However, the clinical significance in patients, and their prognosis, needs to be studied to evaluate whether anticoagulation therapy is required. This is the second update of the Cochrane systematic review published in 2014. OBJECTIVES To assess the effectiveness and safety of anticoagulation therapy versus control in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 November 2019. We also undertook reference checking to identify additional studies. SELECTION CRITERIA We included randomised controlled trials of anticoagulation therapy versus control in patients with SSPE or incidental SSPE. DATA COLLECTION AND ANALYSIS Two review authors inspected all citations identified to ensure reliable assessment. If relevant studies were identified, we planned for two review authors to independently extract data and to assess the methodological quality of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We did not identify any studies that met the inclusion criteria. AUTHORS' CONCLUSIONS There is no evidence from randomised controlled trials to assess the effectiveness and safety of anticoagulation therapy versus control in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE. Well-conducted research is required before informed practice decisions can be made.
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Affiliation(s)
- Hugo HB Yoo
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Vania Santos Nunes‐Nogueira
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Paulo J Fortes Villas Boas
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
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693
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Aday AW, Beckman JA. Pulmonary Embolism and Unfractionated Heparin: Time to End the Roller Coaster Ride. Acad Emerg Med 2020; 27:176-178. [PMID: 31625222 PMCID: PMC7018537 DOI: 10.1111/acem.13871] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Aaron W. Aday
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joshua A. Beckman
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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694
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Meyer G, Konstantinides S. Should oral anticoagulation be discontinued after 3 months in the setting of a first high-risk pulmonary embolism secondary to a major transient/reversible risk factor? Eur Respir J 2020; 55:55/1/1902323. [PMID: 32001500 DOI: 10.1183/13993003.02323-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 12/10/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Guy Meyer
- Division of respiratory disease, APHP Centre; Université Paris Descartes; Université de Paris, Paris, France
| | - Stavros Konstantinides
- Center for Thrombosis and Haemostasis, University Medical Centre Mainz, Mainz, Germany.,Dept of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
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695
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Torres PPTES, Mançano AD, Zanetti G, Hochhegger B, Aurione ACV, Rabahi MF, Marchiori E. Multimodal indirect imaging signs of pulmonary embolism. Br J Radiol 2020; 93:20190635. [PMID: 31944831 DOI: 10.1259/bjr.20190635] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The clinical diagnosis of pulmonary embolism is often difficult, as symptoms range from syncope and chest pain to shock and sudden death. Adding complexity to this picture, some patients with non-diagnosed pulmonary embolism may undergo unenhanced imaging examinations for a number of reasons, including the prevention of contrast medium-related nephrotoxicity, anaphylactic/anaphylactoid reactions and nephrogenic systemic fibrosis, as well as due to patients' refusal or lack of venous access. In this context, radiologists' awareness and recognition of indirect signs are cornerstones in the diagnosis of pulmonary embolism. This article describes the indirect signs of pulmonary embolism on chest X-ray, unenhanced CT, and MRI.
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Affiliation(s)
| | - Alexandre Dias Mançano
- Department of Radiology, RA Radiologia - Sabin Medicina Diagnóstica, Taguatinga (DF), Brazil
| | - Gláucia Zanetti
- Department of Radiology, Rio de Janeiro Federal University, Rio de Janeiro, Brazil
| | - Bruno Hochhegger
- Department of Radiology, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | | | | | - Edson Marchiori
- Department of Radiology, Rio de Janeiro Federal University, Rio de Janeiro, Brazil
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696
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Recent trends in use of inferior vena caval filters in US older adults with acute pulmonary embolism. Thromb Res 2020; 186:78-79. [PMID: 31901644 DOI: 10.1016/j.thromres.2019.12.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/19/2019] [Accepted: 12/24/2019] [Indexed: 11/22/2022]
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697
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Ciurzynski M, Domienik-Karłowicz J, Jaguszewski M, Pruszczyk P. COVID-19 and its implication for venous thromboembolism. Cardiol J 2020; 27:481-484. [PMID: 33165897 PMCID: PMC8078986 DOI: 10.5603/cj.2020.0153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/12/2020] [Accepted: 08/26/2020] [Indexed: 06/11/2023] Open
Affiliation(s)
- Michał Ciurzynski
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Poland
| | | | - Miłosz Jaguszewski
- First Department of Cardiology, Medical University of Gdansk, Gdańsk, Poland
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Poland
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698
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Slabbynck H, Clukers J, Galdermans D. Should oral anticoagulation be discontinued after 3 months in the setting of a first high-risk pulmonary embolism secondary to a major transient/reversible risk factor? Eur Respir J 2020; 55:55/1/1902028. [DOI: 10.1183/13993003.02028-2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 10/27/2019] [Indexed: 11/05/2022]
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699
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Tomić M. The current place of direct oral anticoagulants in the prevention/treatment of venous thromboembolism. ARHIV ZA FARMACIJU 2020. [DOI: 10.5937/arhfarm2005284t] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Venous thromboembolism (VTE; includes deep venous thrombosis, DVT, and pulmonary embolism, PE) represents the third most common acute cardiovascular syndrome. Contemporary VTE management comprises primary prevention in high-risk patients, treatment of established VTE, and prevention of its recurrence (secondary prevention). Anticoagulants are the basis of VTE pharmacological prophylaxis and treatment. For several decades, parenteral (heparin and low-molecular-weight heparins, LMWHs) and oral anticoagulants (vitamin K antagonists, VKAs) have been the cornerstone of VTE prevention/treatment. The introduction of direct oral anticoagulants (DOACs: thrombin inhibitor dabigatran and Xa inhibitors rivaroxaban, apixaban, edoxaban, and betrixaban) markedly improved the management of VTE by overcoming many disadvantages of conventional anticoagulants. For primary VTE prevention in patients after total hip/knee arthroplasty, rivaroxaban, apixaban, and dabigatran are preferred over LMWHs, due to comparable efficacy and safety, but favourable acceptability (avoided everyday injections). In other high-risk populations (other surgical patients, acutely ill medical patients), LMWHs are still the recommended option. Betrixaban is currently the only DOAC approved for VTE prophylaxis in medically ill patients during and after hospitalization. For acute VTE treatment and secondary prevention, DOACs (rivaroxaban, apixaban, edoxaban, and dabigatran) are recommended as the first-line therapy in the general population. DOACs proved to be similarly effective but safer than VKAs. In some specific populations, DOACs also seem to be advantageous over conventional treatment (patients with renal impairment, elderly, long-term secondary prevention in cancer patients). Currently, there is no data from randomized head-to-head comparative studies between the DOAC classes or representatives so the choice is made mainly according to patient characteristics and pharmacokinetic properties of the drug.
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700
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Chen J, Lin J, Wu D, Guo X, Li X, Shi S. Optimal Mean Arterial Pressure Within 24 Hours of Admission for Patients With Intermediate-Risk and High-Risk Pulmonary Embolism. Clin Appl Thromb Hemost 2020; 26:1076029620933944. [PMID: 32551849 PMCID: PMC7427015 DOI: 10.1177/1076029620933944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We aimed to determine whether the average mean arterial pressure (aMAP) in the first 24 hours of hospital admission is useful in predicting short-term outcomes of patients with intermediate- and high-risk pulmonary embolism (PE). We conducted a single-center retrospective study. From May 2012 to April 2019, 122 patients with intermediate- and high-risk PE were included. The primary outcome was in-hospital mortality. The secondary outcome was adverse events. Receiver operating characteristic (ROC) curves and cutoff values for aMAP predicting in-hospital death were computed. According to cutoff values, we categorized 5 groups defined as follows: group 1: aMAP < 70 mm Hg; group 2: 70 mm Hg ≤ aMAP < 80 mm Hg; group 3: 80 mm Hg ≤ aMAP < 90 mm Hg; group 4: 90 mm Hg ≤ aMAP <100 mm Hg; and group 5: aMAP ≥ 100 mm Hg. Cox regression models were calculated to investigate associations between aMAP and in-hospital death. In the study group of 122 patients, 15 (12.30%) patients died in the hospital due to PE. The ROC analysis for MAP predicting in-hospital death revealed an area under the curve of 0.729 with a cutoff value of 79.4 mm Hg. Cox regression models showed a significant association between in-hospital death and aMAP group 1 (ref), aMAP group 2 (odds ratio [OR] = 1.680, 95% CI: 0.020-140.335), aMAP group 3 (OR = 0.003, 95% CI: 0.0001-0.343), aMAP group 4 (OR = 0.006, 95% CI: 0.0001-1.671), and aMAP group 5 (OR = 0.003, 95% CI: 0.0001-9.744). In particular, those with an aMAP of 80 to 90 mm Hg had minimum adverse events. The optimal range of MAP for patients with intermediate- and high-risk PE may be 80 to 90 mm Hg.
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Affiliation(s)
- Jialong Chen
- Shengli Clinical Medical College of Fujian Medical University, China
| | - Jing Lin
- Shengli Clinical Medical College of Fujian Medical University, China
| | - Danshen Wu
- Medical Intensive Care Unit of Fujian Provincial Hospital, China
| | - Xiaolan Guo
- Shengli Clinical Medical College of Fujian Medical University, China
| | - XiuHua Li
- Shengli Clinical Medical College of Fujian Medical University, China
| | - Songjing Shi
- Shengli Clinical Medical College of Fujian Medical University, China.,Medical Intensive Care Unit of Fujian Provincial Hospital, China
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