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Tritschler T, Aujesky D. Venous thromboembolism in the elderly: A narrative review. Thromb Res 2017; 155:140-147. [DOI: 10.1016/j.thromres.2017.05.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 04/30/2017] [Accepted: 05/17/2017] [Indexed: 12/14/2022]
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Harringa JB, Bracken RL, Nagle SK, Schiebler ML, Pulia MS, Svenson JE, Repplinger MD. Negative D-dimer testing excludes pulmonary embolism in non-high risk patients in the emergency department. Emerg Radiol 2017; 24:273-280. [PMID: 28116533 PMCID: PMC5438894 DOI: 10.1007/s10140-017-1478-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 01/06/2017] [Indexed: 01/08/2023]
Abstract
PURPOSE The purpose of this study was to assess the ability of d-dimer testing to obviate the need for cross-sectional imaging for patients at "non-high risk" for pulmonary embolism (PE). METHODS This is a retrospective study of emergency department patients at an academic medical center who underwent cross-sectional imaging (MRA or CTA) to evaluate for PE from 2008 to 2013. The primary outcome was the NPV of d-dimer testing when used in conjunction with clinical decision instruments (CDIs = Wells', Revised Geneva, and Simplified Revised Geneva Scores). The reference standard for PE status included image test results and a 6-month chart review follow-up for venous thromboembolism as a proxy for false negative imaging. Secondary analyses included ROC curves for each CDI and calculation of PE prevalence in each risk stratum. RESULTS Of 459 patients, 41 (8.9%) had PE. None of the 76 patients (16.6%) with negative d-dimer results had PE. Thus, d-dimer testing had 100% sensitivity and NPV, and there were no differences in CDI performance. Similarly, when evaluated independently of d-dimer results, no CDI outperformed the others (areas under the ROC curves ranged 0.53-0.55). There was a significantly higher PE prevalence in the high versus "non-high risk" groups when stratified by the Wells' Score (p = 0.03). CONCLUSIONS Negative d-dimer testing excluded PE in our retrospective cohort. Each CDI had similar NPVs, whether analyzed in conjunction with or independently of d-dimer results. Our results confirm that PE can be safely excluded in patients with "non-high risk" CDI scores and a negative d-dimer.
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Affiliation(s)
- John B Harringa
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 800 University Bay Drive, Suite 310, Mail Code 9123, Madison, WI, 53705, USA
| | - Rebecca L Bracken
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 800 University Bay Drive, Suite 310, Mail Code 9123, Madison, WI, 53705, USA
| | - Scott K Nagle
- Department of Radiology, University of Wisconsin-Madison, Madison, USA
| | - Mark L Schiebler
- Department of Radiology, University of Wisconsin-Madison, Madison, USA
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 800 University Bay Drive, Suite 310, Mail Code 9123, Madison, WI, 53705, USA
| | - James E Svenson
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 800 University Bay Drive, Suite 310, Mail Code 9123, Madison, WI, 53705, USA
| | - Michael D Repplinger
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 800 University Bay Drive, Suite 310, Mail Code 9123, Madison, WI, 53705, USA.
- Department of Radiology, University of Wisconsin-Madison, Madison, USA.
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Enea I, Roncon L, Gulizia MM, Azzarito M, Becattini C, Bongarzoni A, Casazza F, Cuccia C, D’Agostino C, Rugolotto M, Vatrano M, Vinci E, Fenaroli P, Formigli D, Silvestri P, Nardi F, Vedovati MC, Scherillo M. ANMCO Position Paper: the use of non-vitamin K dependent new oral anticoagulant(s) in pulmonary embolism therapy and prevention. Eur Heart J Suppl 2017; 19:D293-D308. [PMID: 28751847 PMCID: PMC5526474 DOI: 10.1093/eurheartj/sux026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The new oral anticoagulants (NOACs) have radically changed the approach to the treatment and prevention of thromboembolic pulmonary embolism. The authors of this position paper face, in succession, issues concerning NOACs, including (i) their mechanism of action, pharmacodynamics, and pharmacokinetics; (ii) the use in the acute phase with the 'double drug single dose' approach or with 'single drug double dose'; (iii) the use in the extended phase with demonstrated efficacy and with low incidence of bleeding events; (iv) the encouraging use of NOACs in particular subgroups of patients such as those with cancer, the ones under- or overweight, with renal insufficiency (creatinine clearance > 30 mL/min), the elderly (>75 years); (v) they propose a possible laboratory clinical pathway for follow-up; and (vi) carry out an examination on the main drug interactions, their potential bleeding risk, and the way to deal with some bleeding complications. The authors conclude that the use of NOACs both in the acute phase and in the extended phase is equally effective to conventional therapy and associated with fewer major bleeding events, which make their use in patients at higher risk of recurrences safer.
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Affiliation(s)
- Iolanda Enea
- Emergency Care Department, S. Anna e S. Sebastiano Hospital, Via G. Tescione, 1. 81100 Casert, Italy
| | - Loris Roncon
- Cardiology Department, S. Maria della Misericordia Hospital, Rovigo, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Garibaldi-Nesima Hospital, Azienda di Rilievo Nazionale e Alta Specializazione “Garibaldi”, Catania, Italy
| | | | - Cecilia Becattini
- Department of Internal and Vascular Medicine, Perugia General Hospital, Perugia, Italy
| | | | | | - Claudio Cuccia
- Cardiology Unit, Poliambulanza Foundation Hospital, Brescia, Italy
| | | | | | - Marco Vatrano
- CCU-Hemodynamics and Interventional Cardiology Department, Civil Pugliese Hospital, Catanzaro, Italy
| | - Eugenio Vinci
- Cardiology-CCU Department, Umberto I Hospital, Siracusa, Italy
| | - Paride Fenaroli
- Nephrology and Dialysis Unit, Salvatore Maugeri Foundation, University of Pavia, Pavia, Italy
| | - Dario Formigli
- Interventional Cardiology-CCU Department, G. Rummo Hospital, Benevento, Italy
| | - Paolo Silvestri
- Interventional Cardiology-CCU Department, G. Rummo Hospital, Benevento, Italy
| | - Federico Nardi
- Cardiology Department, Castelli Hospital, Verbania, Italy
| | - Maria Cristina Vedovati
- Department of Internale and Vascular Medicine, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Marino Scherillo
- Interventional Cardiology-CCU Department, G. Rummo Hospital, Benevento, Italy
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105
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van Es N, Kraaijpoel N, Klok FA, Huisman MV, Den Exter PL, Mos ICM, Galipienzo J, Büller HR, Bossuyt PM. The original and simplified Wells rules and age-adjusted D-dimer testing to rule out pulmonary embolism: an individual patient data meta-analysis. J Thromb Haemost 2017; 15:678-684. [PMID: 28106338 DOI: 10.1111/jth.13630] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Indexed: 12/23/2022]
Abstract
Essentials Evidence for the simplified Wells rule in ruling out acute pulmonary embolism (PE) is scarce. This was a post-hoc analysis on data from 6 studies comprising 7268 patients with suspected PE. The simplified Wells rule combined with age-adjusted D-dimer testing may safely rule out PE. Given its ease of use, the simplified Wells rule is to be preferred over the original Wells rule. SUMMARY Background The Wells score and D-dimer testing can safely rule out pulmonary embolism (PE). A simplification of the Wells score has been proposed to improve clinical applicability, but evidence on its performance is scarce. Objectives To compare the performances of the original and simplified Wells scores alone and in combination with age-adjusted D-dimer testing. Methods Individual patient data from 7268 patients with suspected PE enrolled in six management studies were used to evaluate the discriminatory performances of the original and simplified Wells scores. The efficiency and failure rate of the dichotomized original and simplified scores combined with age-adjusted D-dimer testing were compared by use of a one-stage random effects meta-analysis. Efficiency was defined as the proportion of patients in whom PE could be considered to be excluded on the basis of a 'PE unlikely' Wells score and a negative age-adjusted D-dimer test result. Failure rate was defined as the proportion of patients with symptomatic venous thromboembolism during a 3-month follow-up. Results The discriminatory performances of the original and simplified Wells scores were comparable (c-statistic 0.73 [95% confidence interval (CI) 0.72-0.75] versus 0.72 [95% CI 0.70-0.73]). When combined with age-adjusted D-dimer testing, the original and simplified Wells rules had comparable efficiency (3% [95% CI 25-42%] versus 30% [95% CI 21-40%]) and failure rates (0.9% [95% CI 0.6-1.5%] versus 0.8% [95% CI 0.5-1.3%]). Conclusion The original and simplified Wells rules combined with age-adjusted D-dimer testing have similar performances in ruling out PE. Given its ease of use in clinical practice, the simplified Wells rule is to be preferred.
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Affiliation(s)
- N van Es
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - N Kraaijpoel
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - F A Klok
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - M V Huisman
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - P L Den Exter
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - I C M Mos
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - J Galipienzo
- Service of Anesthesiology, MD Anderson Cancer Center, Madrid, Spain
| | - H R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - P M Bossuyt
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Academic Medical Center, Amsterdam, the Netherlands
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106
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Role of Clinical Decision Tools in the Diagnosis of Pulmonary Embolism. AJR Am J Roentgenol 2017; 208:W60-W70. [DOI: 10.2214/ajr.16.17206] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Carrillo Alcaraz A, Martínez AL, Solano FS. Diagnóstico de la embolia pulmonar. El punto de vista del médico clínico. RADIOLOGIA 2017; 59:166-176. [DOI: 10.1016/j.rx.2016.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 10/02/2016] [Accepted: 10/14/2016] [Indexed: 12/27/2022]
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Abstract
Pulmonary embolism (PE) in the pediatric population is relatively rare when compared to adults; however, the incidence is increasing and accurate and timely diagnosis is critical. A high clinical index of suspicion is warranted as PE often goes unrecognized among children leading to misdiagnosis and potentially increased morbidity and mortality. Evidence-based guidelines for the diagnosis, management, and follow-up of children with PE are lacking and current practices are extrapolated from adult data. Treatment options include thrombolysis and anticoagulation with heparins and oral vitamin K antagonists, with newer direct oral anticoagulants currently in clinical trials. Long-term sequelae of PE, although studied in adults, are vastly unknown among children and adolescents. Additional research is needed in order to provide pediatric focused care for patients with acute PE.
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Affiliation(s)
- Ahmar Urooj Zaidi
- Division of Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, United States
| | - Kelley K Hutchins
- Division of Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, United States
| | - Madhvi Rajpurkar
- Division of Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, Detroit, MI, United States
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Abstract
Deep vein thrombosis and pulmonary embolism, collectively referred to as venous thromboembolism, constitute a major global burden of disease. The diagnostic work-up of suspected deep vein thrombosis or pulmonary embolism includes the sequential application of a clinical decision rule and D-dimer testing. Imaging and anticoagulation can be safely withheld in patients who are unlikely to have venous thromboembolism and have a normal D-dimer. All other patients should undergo ultrasonography in case of suspected deep vein thrombosis and CT in case of suspected pulmonary embolism. Direct oral anticoagulants are first-line treatment options for venous thromboembolism because they are associated with a lower risk of bleeding than vitamin K antagonists and are easier to use. Use of thrombolysis should be limited to pulmonary embolism associated with haemodynamic instability. Anticoagulant treatment should be continued for at least 3 months to prevent early recurrences. When venous thromboembolism is unprovoked or secondary to persistent risk factors, extended treatment beyond this period should be considered when the risk of recurrence outweighs the risk of major bleeding.
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Affiliation(s)
- Marcello Di Nisio
- Department of Medical, Oral and Biotechnological Sciences, Gabriele D'Annunzio University, Chieti, Italy; Department of Vascular Medicine, Academic Medical Centre, Amsterdam, Netherlands.
| | - Nick van Es
- Department of Vascular Medicine, Academic Medical Centre, Amsterdam, Netherlands
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Centre, Amsterdam, Netherlands
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110
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Reversal of direct oral anticoagulants in hemophilia treatment: ASH meeting 2015. MEMO 2016; 9:131-135. [PMID: 27752290 PMCID: PMC5045483 DOI: 10.1007/s12254-016-0284-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 08/17/2016] [Indexed: 01/11/2023]
Abstract
During the 57th annual meeting of the American Society of Hematology 2015 in Orlando, Florida, various aspects in the field of hemostaseology were presented. The Choosing Wisely® campaign pointed out the importance of the critical use of diagnostic tools to rule out pulmonary embolism and questioned the relevance of thrombophilia testing in women undergoing routine infertility evaluation. Furthermore, the approval of idarucizumab, a specific antidote for the reversal of the anticoagulant effects of the direct thrombin inhibitor dabigatran, was highlighted. Finally, hemophilia specialists awaited the results of the SIPPET Trial, which were presented for the first time during the plenary session. Replacement therapy of previously untreated hemophilia A patients with plasma-derived factor VIII containing von Willebrand factor resulted in a lower incidence of inhibitors compared with patients treated with recombinant factor VIII.
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111
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Streiff MB, Agnelli G, Connors JM, Crowther M, Eichinger S, Lopes R, McBane RD, Moll S, Ansell J. Guidance for the treatment of deep vein thrombosis and pulmonary embolism. J Thromb Thrombolysis 2016; 41:32-67. [PMID: 26780738 PMCID: PMC4715858 DOI: 10.1007/s11239-015-1317-0] [Citation(s) in RCA: 192] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This guidance document focuses on the diagnosis and treatment of venous thromboembolism (VTE). Efficient, cost effective diagnosis of VTE is facilitated by combining medical history and physical examination with pre-test probability models, D dimer testing and selective use of confirmatory imaging. Clinical prediction rules, biomarkers and imaging can be used to tailor therapy to disease severity. Anticoagulation options for acute VTE include unfractionated heparin, low molecular weight heparin, fondaparinux and the direct oral anticoagulants (DOACs). DOACs are as effective as conventional therapy with LMWH and vitamin K antagonists. Thrombolytic therapy is reserved for massive pulmonary embolism (PE) or extensive deep vein thrombosis (DVT). Inferior vena cava filters are reserved for patients with acute VTE and contraindications to anticoagulation. Retrievable filters are strongly preferred. The possibility of thoracic outlet syndrome and May-Thurner syndrome should be considered in patients with subclavian/axillary and left common iliac vein DVT, respectively in absence of identifiable triggers. The optimal duration of therapy is dictated by the presence of modifiable thrombotic risk factors. Long term anticoagulation should be considered in patients with unprovoked VTE as well as persistent prothrombotic risk factors such as cancer. Short-term therapy is sufficient for most patients with VTE associated with transient situational triggers such as major surgery. Biomarkers such as D dimer and risk assessment models such the Vienna risk prediction model offer the potential to customize VTE therapy for the individual patient. Insufficient data exist to support the integration of bleeding risk models into duration of therapy planning.
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Affiliation(s)
- Michael B Streiff
- Division of Hematology, Department of Medicine and Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Giancarlo Agnelli
- Stroke Unit, Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Mark Crowther
- Departments of Medicine and Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Sabine Eichinger
- Department of Medicine, Medical University of Vienna, Vienna, Austria
| | - Renato Lopes
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Robert D McBane
- Cardiovascular Division, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stephan Moll
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Jack Ansell
- Department of Medicine, Hofstra North Shore/LIJ School of Medicine, Hempstead, NY, USA
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Alabed S, Belci M, Van Middendorp JJ, Al Halabi A, Meagher TM. Thromboembolism in the Sub-Acute Phase of Spinal Cord Injury: A Systematic Review of the Literature. Asian Spine J 2016; 10:972-981. [PMID: 27790330 PMCID: PMC5081337 DOI: 10.4184/asj.2016.10.5.972] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 04/02/2016] [Accepted: 05/03/2016] [Indexed: 11/29/2022] Open
Abstract
To review the evidence of thromboembolism incidence and prophylaxis in the sub-acute phase of spinal cord injury (SCI) 3-6 months post injury. All observational and experimental studies with any length of follow-up and no limitations on language or publication status published up to March 2015 were included. Two review authors independently selected trials for inclusion and extracted data. Outcomes studied were incidence of pulmonary embolism (PE) and deep vein thrombosis (DVT) in the sub-acute phase of SCI. The secondary outcome was type of thromboprophylaxis. Our search identified 4305 references and seven articles that met the inclusion criteria. Five papers reported PE events and three papers reported DVT events in the sub-acute phase of SCI. Studies were heterogeneous in populations, design and outcome reporting, therefore a meta-analysis was not performed. The included studies report a PE incidence of 0.5%-6.0% and DVT incidence of 2.0%-8.0% in the sub-acute phase of SCI. Thromboprophylaxis was poorly reported. Spinal patients continue to have a significant risk of PE and DVT after the acute period of their injury. Clinicians are advised to have a low threshold for suspecting venous thromboembolism in the sub-acute phase of SCI and to continue prophylactic anticoagulation therapy for a longer period of time.
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Affiliation(s)
- Samer Alabed
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK
- Academic Unit of Radiology, University of Sheffield, Sheffield, UK
| | - Maurizio Belci
- National Spinal Injuries Centre, Stoke Mandeville Hospital, Aylesbury, UK
| | | | - Ahmed Al Halabi
- Department of Vascular Surgery, General Hospital of Celle, Germany
| | - Tom M Meagher
- Radiology Department, Stoke Mandeville Hospital, Aylesbury, UK
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Use of clinical prediction rules and D-dimer tests in the diagnostic management of pregnant patients with suspected acute pulmonary embolism. Blood Rev 2016; 31:31-36. [PMID: 27720446 DOI: 10.1016/j.blre.2016.09.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/16/2016] [Accepted: 09/26/2016] [Indexed: 12/18/2022]
Abstract
Because pregnant women have an increased risk of venous thromboembolism (VTE) and at the same time normal pregnancy is associated with symptoms, mimicking those present in the setting of acute pulmonary embolism (PE), the latter diagnosis is frequently suspected in this patient category. Since imaging tests expose both mother and foetus to ionizing radiation, the ability to rule out PE based on non-radiological diagnostic tests is of paramount importance. However, clinical decision rules have only been scarcely evaluated in the pregnant population with suspected PE, while D-dimer levels lose diagnostic accuracy due to a physiological increase during normal pregnancy. Consequently, clinical guidelines provide contradicting and weak recommendations on this subject and the optimal diagnostic strategy remains highly debated. With this systematic review, we aimed to summarize current evidence on the safety and efficacy of clinical decision rules and biomarkers used in the diagnostic management of suspected acute PE in pregnant patients.
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114
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Voukalis C, Lip GYH, Shantsila E. Non-vitamin K oral anticoagulants versus vitamin K antagonists in the treatment of venous thromboembolic disease. Expert Opin Pharmacother 2016; 17:2033-47. [DOI: 10.1080/14656566.2016.1232393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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115
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Giannitsis E, Mair J, Christersson C, Siegbahn A, Huber K, Jaffe AS, Peacock WF, Plebani M, Thygesen K, Möckel M, Mueller C, Lindahl B. How to use D-dimer in acute cardiovascular care. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:69-80. [PMID: 26450781 DOI: 10.1177/2048872615610870] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
D-dimer testing is important to aid in the exclusion of venous thromboembolic events (VTEs), including deep venous thrombosis and pulmonary embolism, and it may be used to evaluate suspected aortic dissection. D-dimer is produced upon activation of the coagulation system with the generation and subsequent degradation of cross-linked fibrin by plasmin. Many different assays for D-dimer testing are currently used in routine care. However, these tests are neither standardized nor harmonized. Consequently, only clinically validated assays and assay specific decision limits should be used for routine testing. For the exclusion of pulmonary embolism/deep vein thrombosis, age-adjusted cut-offs are recommend. Clinicians must be aware of the validated use of their hospital's D-dimer assay to avoid inappropriate use of this biomarker in routine care.
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Affiliation(s)
| | - Johannes Mair
- 2 Department of Internal Medicine III, Medical University Innsbruck, Austria
| | | | | | - Kurt Huber
- 5 Department of Medicine, Wilhelminen Hospital, Austria
| | | | | | - Mario Plebani
- 8 Department of Laboratory Medicine, University Hospital, Italy
| | | | - Martin Möckel
- 10 Division of Emergency Medicine, Charité-Universitätsmedizin Berlin, Germany
| | | | - Bertil Lindahl
- 12 Department of Medical Sciences, Uppsala University, Sweden
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116
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Khraise WN, Allouh MZ, Hiasat MY, Said RS. Successful Management of Intraoperative Acute Bilateral Pulmonary Embolism in a High Grade Astrocytoma Patient. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:632-6. [PMID: 27578311 PMCID: PMC5013976 DOI: 10.12659/ajcr.898912] [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] [Indexed: 11/30/2022]
Abstract
Patient: Female, 39 Final Diagnosis: Acute bilateral pulmonary embolism Symptoms: Headache • amnesia • seizure • urinary incontinence Medication: — Clinical Procedure: — Specialty: Anesthesiology
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Affiliation(s)
- Wail N Khraise
- Department of Anesthesiology, Faculty of Medicine, Jordan University of Science & Technology, Irbid, Jordan
| | - Mohammed Z Allouh
- Department of Anatomy, Faculty of Medicine, Jordan University of Science & Technology, Irbid, Jordan
| | - Mohammad Y Hiasat
- Division of Neurosurgery, Department of Neuroscience, Faculty of Medicine, Jordan University of Science & Technology, Irbid, Jordan
| | - Raed S Said
- Department of Anatomy, Faculty of Medicine, Jordan University of Science & Technology, Irbid, Jordan
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117
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Tamizifar B, Fereyduni F, Esfahani MA, Kheyri S. Comparing three clinical prediction rules for primarily predicting the 30-day mortality of patients with pulmonary embolism: The "Simplified Revised Geneva Score," the "Original PESI," and the "Simplified PESI". Adv Biomed Res 2016; 5:137. [PMID: 27656606 PMCID: PMC5025907 DOI: 10.4103/2277-9175.187372] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 12/12/2015] [Indexed: 11/05/2022] Open
Abstract
Background: Patients with suspected pulmonary embolism (PE) should be evaluated for the clinical probability of PE using an applicable risk score. The Geneva prognostic score, the PE Severity Index (PESI), and its simplified version (sPESI) are well-known clinical prognostic scores for PE. The purpose of this study was to analyze these clinical scores as prognostic tools. Materials and Methods: A historical cohort study was conducted on patients with acute PE in Al-Zahra Teaching Hospital, Isfahan, Iran, from June 2013 to August 2014. To compare survival in the 1-month follow-up and factor-analyze mortality from the survival graph, Kaplan–Meier, and log-rank logistic regression were applied. Results: Two hundred and twenty four patients were assigned to two “low risk” and “high risk” groups using the three versions of “Simplified PESI, Original PESI, and Simplified Geneva.” They were followed for a period of 1 month after admission. The overall mortality rate within 1 month from diagnosis was about 24% (95% confidence interval, 21.4–27.2). The mortality rate of low risk PE patients was about 4% in the PESI, 17% in the Geneva, and <1% in the simplified PESI scales (P < 0.005). The mortality rate among high risk patients was 33%, 33.5%, and 27.5%, respectively. Conclusions: Among patients with acute PE, the simplified PESI model was able to accurately predict mortality rate for low risk patients. Among high risk patients, however, the difference between the three models in predicting prognosis was not significant.
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Affiliation(s)
- Babak Tamizifar
- Department of Internal medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farid Fereyduni
- Department of Internal medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Morteza Abdar Esfahani
- Department of Internal medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeed Kheyri
- Department of Internal medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
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119
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Evaluation of the new simple and objective clinical decision rule “I-DVT” in patients with clinically suspected acute deep vein thrombosis. Thromb Res 2016; 141:112-8. [DOI: 10.1016/j.thromres.2016.03.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 02/18/2016] [Accepted: 03/12/2016] [Indexed: 11/17/2022]
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Current standings in diagnostic management of acute venous thromboembolism: Still rough around the edges. Blood Rev 2016; 30:21-6. [DOI: 10.1016/j.blre.2015.07.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 07/09/2015] [Accepted: 07/09/2015] [Indexed: 01/26/2023]
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van der Hulle T, Dronkers CEA, Klok FA, Huisman MV. Recent developments in the diagnosis and treatment of pulmonary embolism. J Intern Med 2016; 279:16-29. [PMID: 26286356 DOI: 10.1111/joim.12404] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Due to the nonspecific symptoms of the condition, a diagnosis of acute pulmonary embolism (PE) is frequently considered. However, PE will only be confirmed in 10-20% of patients. Because the imaging test of choice, computed tomography pulmonary angiography (CTPA), is costly and associated with radiation exposure and other complications, a validated diagnostic algorithm consisting of a clinical decision rule and D-dimer test should be used to safely exclude PE in 20-30% of patients without the need for CTPA. Recently, the age-adjusted D-dimer threshold has been validated, and this has increased the proportion of patients at older age in whom PE can be excluded without CTPA. Initial therapeutic management of PE depends on the risk of short-term PE-related mortality. Haemodynamically unstable patients should be closely monitored and receive thrombolytic therapy unless contraindicated because of an unacceptably high bleeding risk, whereas patients with low-risk PE may be safely discharged early from hospital or receive only outpatient treatment. The PESI score and Hestia decision rule are available to select patients in whom early discharge or outpatient treatment will be safe, although the safety of these strategies should be confirmed in additional studies. Standard PE therapy consists of low molecular weight heparin (LMWH) followed by vitamin K antagonists (VKAs). Recently, several nonvitamin K-dependent oral anticoagulants have been shown to be as effective as LMWH/VKAs, and maybe safer. Determining the optimal duration of treatment for a first unprovoked PE remains a challenge, although clinical prediction rules for estimating the risk of recurrence of venous thromboembolism and anticoagulation-associated haemorrhage are under investigation. Using these prediction rules may lead to both more standardized and more individualized long-term treatment of PE.
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Affiliation(s)
- T van der Hulle
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - C E A Dronkers
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Salla E, Dimakakos EP, Tsagkouli S, Giozos I, Charpidou A, Kainis E, Syrigos KN. Venous Thromboembolism in Patients Diagnosed With Lung Cancer. Angiology 2015; 67:709-24. [PMID: 26553057 DOI: 10.1177/0003319715614945] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Considering the high prevalence of lung cancer, our purpose was to summarize the existing literature to identify the several factors that contribute to the increased risk of venous thromboembolism (VTE) in patients with lung cancer and to analyze the current recommendations for thromboprophylaxis and treatment of VTE in those patients. METHODS We searched the Medline and EMBASE databases from February 1985 to February 2014 to identify retrospective and prospective randomized controlled studies that investigate one or more risk factors for VTEs in patients with lung cancer. RESULTS A VTE is a major complication for patients diagnosed with lung cancer. The risk factors for VTE events in patients with lung cancer consist of cancer-related (histological type and stage of cancer), treatment-related (surgery, chemotherapy, angiogenic agents, and supportive care agents), and patient-related factors (comorbidities, immobility, performance status, and prior thrombosis). Low-molecular-weight heparins are recommended for long-term treatment of cancer-associated thrombosis. Duration of anticoagulant therapy beyond 6 months should be based on individual clinical evaluation. Thromboprophylaxis for patients with lung cancer during hospitalization and immediate postoperative period is well established. CONCLUSIONS Efforts to assess thrombotic risk in patients with lung cancer may improve therapeutic and preventive strategies in the future, with final goal to minimize the burden and consequences of thrombotic events in patients with lung cancer.
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Affiliation(s)
- E Salla
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - Evangelos P Dimakakos
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - S Tsagkouli
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - I Giozos
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - A Charpidou
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - E Kainis
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - K N Syrigos
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece Yale School of Medicine, New Haven, CT, USA
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Ostovan MA, Ghaffari S, Pourafkari L, Dehghani P, Hajizadeh R, Nadiri M, Ghaffari MR. Modification of Simplified Pulmonary Embolism Severity Index and its Prognostic Value in Patients with Acute Pulmonary Embolism. Heart Lung Circ 2015; 25:184-90. [PMID: 26481399 DOI: 10.1016/j.hlc.2015.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 07/16/2015] [Accepted: 08/17/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Various risk stratification systems have been used to predict the clinical outcome of patients with pulmonary embolism (PE). In this study we present a modification of the simplified Pulmonary Embolism Severity Index (S-PESI) score and evaluate its accuracy in predicting the outcome of these patients. MATERIALS AND METHODS Patients older than 18 years with documented PE were enrolled in this study. S-PESI was calculated in all patients. We added electrocardiographic evidence of right ventricular strain as a new criteria and replaced the O2 saturation of <90% in S-PESI score with PaO2 /PaCO2 ratio obtained from the arterial blood gas analysis as two newly modified criteria to define a modified form of S-PESI system (modified s-PESI). Patients were followed for about one year in outpatient clinics. Any deaths attributable to PE or for unknown reasons were considered as PE related. We defined Major Adverse Cardio-Pulmonary Events (MACPE) as sum of one-year mortality, need for thrombolysis and mechanical ventilation during index hospitalisation. RESULTS Among 300 enrolled patients, in-hospital mortality occurred in 38 (12.7%) and one-year mortality in 73 (24.3%) patients. Considering a cut-off point of 3, modified s-PESI score had a lower sensitivity (49.3% vs. 89%) and higher specificity (79.4% vs. 37.7%) than S-PESI to predict one-year mortality. Area Under Curve (AUC) to predict MACPE was significantly higher for modified s-PESI (0.692 vs 0.730, P=0.012). CONCLUSION The modified s-PESI is superior to S-PESI in predicting one-year outcome in patients with PE and can be used for more accurate risk stratification of these patients.
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Affiliation(s)
| | - Samad Ghaffari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Leili Pourafkari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Pooyan Dehghani
- Cardiology Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Hajizadeh
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Nadiri
- Pulmonology Department, Imam Reza Hospital, Tabriz, Iran
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Hendriksen JMT, Geersing GJ, Lucassen WAM, Erkens PMG, Stoffers HEJH, van Weert HCPM, Büller HR, Hoes AW, Moons KGM. Diagnostic prediction models for suspected pulmonary embolism: systematic review and independent external validation in primary care. BMJ 2015; 351:h4438. [PMID: 26349907 PMCID: PMC4561760 DOI: 10.1136/bmj.h4438] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To validate all diagnostic prediction models for ruling out pulmonary embolism that are easily applicable in primary care. DESIGN Systematic review followed by independent external validation study to assess transportability of retrieved models to primary care medicine. SETTING 300 general practices in the Netherlands. PARTICIPANTS Individual patient dataset of 598 patients with suspected acute pulmonary embolism in primary care. MAIN OUTCOME MEASURES Discriminative ability of all models retrieved by systematic literature search, assessed by calculation and comparison of C statistics. After stratification into groups with high and low probability of pulmonary embolism according to pre-specified model cut-offs combined with qualitative D-dimer test, sensitivity, specificity, efficiency (overall proportion of patients with low probability of pulmonary embolism), and failure rate (proportion of pulmonary embolism cases in group of patients with low probability) were calculated for all models. RESULTS Ten published prediction models for the diagnosis of pulmonary embolism were found. Five of these models could be validated in the primary care dataset: the original Wells, modified Wells, simplified Wells, revised Geneva, and simplified revised Geneva models. Discriminative ability was comparable for all models (range of C statistic 0.75-0.80). Sensitivity ranged from 88% (simplified revised Geneva) to 96% (simplified Wells) and specificity from 48% (revised Geneva) to 53% (simplified revised Geneva). Efficiency of all models was between 43% and 48%. Differences were observed between failure rates, especially between the simplified Wells and the simplified revised Geneva models (failure rates 1.2% (95% confidence interval 0.2% to 3.3%) and 3.1% (1.4% to 5.9%), respectively; absolute difference -1.98% (-3.33% to -0.74%)). Irrespective of the diagnostic prediction model used, three patients were incorrectly classified as having low probability of pulmonary embolism; pulmonary embolism was diagnosed only after referral to secondary care. CONCLUSIONS Five diagnostic pulmonary embolism prediction models that are easily applicable in primary care were validated in this setting. Whereas efficiency was comparable for all rules, the Wells rules gave the best performance in terms of lower failure rates.
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Affiliation(s)
- Janneke M T Hendriksen
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands
| | - Geert-Jan Geersing
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands
| | - Wim A M Lucassen
- Department of General Practice, Academic Medical Center, Amsterdam, Netherlands
| | - Petra M G Erkens
- Department of Family Medicine, CAHPRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
| | - Henri E J H Stoffers
- Department of Family Medicine, CAHPRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands
| | | | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, Netherlands
| | - Arno W Hoes
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands
| | - Karel G M Moons
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3508 GA Utrecht, Netherlands
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Gbolahan OB, Stankowski-Drengler TJ, Ibraheem A, Engel JM, Onitilo AA. Management of chemotherapy-induced thromboembolism in breast cancer. BREAST CANCER MANAGEMENT 2015. [DOI: 10.2217/bmt.15.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Thromboembolic events are common in cancer patients and, apart from contributing to significant morbidity, are regarded as the second leading cause of death in this population. Breast cancer patients are considered low risk for venous thromboembolism; however, the presence of advanced disease and use of chemotherapy and/or other adjunct treatments significantly raises this risk by altering the balance of pro- and anti-coagulant proteins. Low molecular weight heparin is central to the management of venous thromboembolism in this context, whether for prophylaxis, acute management or prevention of recurrences. Risk stratification models need to be incorporated to guide decision making where available.
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Affiliation(s)
- Olumide B Gbolahan
- Morehouse school of Medicine, 720 Westview Drive SW, Atlanta, GA 30310, USA
| | | | - Abiola Ibraheem
- Morehouse school of Medicine, 720 Westview Drive SW, Atlanta, GA 30310, USA
| | - Jessica M Engel
- Marshfield Clinic Cancer Care at St Michael's, Stevens Point, WI, USA
| | - Adedayo A Onitilo
- Oncology/Hematology Department, Marshfield Clinic Weston Center, Weston, WI, USA
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Limbrey R, Howard L. Developments in the management and treatment of pulmonary embolism. Eur Respir Rev 2015; 24:484-97. [PMID: 26324810 PMCID: PMC9487690 DOI: 10.1183/16000617.00006614] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 11/13/2014] [Indexed: 01/24/2023] Open
Abstract
Pulmonary embolism (PE) is a serious and costly disease for patients and healthcare systems. Guidelines emphasise the importance of differentiating between patients who are at high risk of mortality (those with shock and/or hypotension), who may be candidates for thrombolytic therapy or surgery, and those with less severe presentations. Recent clinical studies and guidelines have focused particularly on risk stratification of intermediate-risk patients. Although the use of thrombolysis has been investigated in these patients, anticoagulation remains the standard treatment approach. Individual risk stratification directs initial treatment. Rates of recurrence differ between subgroups of patients with PE; therefore, a review of provoking factors, along with the risks of morbidity and bleeding, guides the duration of ongoing anticoagulation. The direct oral anticoagulants have shown similar efficacy and, in some cases, reduced major bleeding compared with standard approaches for acute treatment. They also offer the potential to reduce the burden on patients and outpatient services in the post-hospital phase. Rivaroxaban, dabigatran and apixaban have been shown to reduce the risk of recurrent venous thromboembolism versus placebo, when given for >12 months. Patients receiving direct oral anticoagulants do not require regular coagulation monitoring, but follow-up, ideally in a specialist PE clinic in consultation with primary care providers, is recommended.
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Affiliation(s)
- Rachel Limbrey
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Luke Howard
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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127
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Abstract
Pulmonary embolism (PE) is a common diagnosis in critical care. Depending on the severity of clot burden, the clinical picture ranges from nearly asymptomatic to cardiovascular collapse. The signs and symptoms of PE are nonspecific. The clinician must have a high index of suspicion to make the diagnosis. PE is risk stratified into 3 categories: low-risk, submassive, and massive. Submassive PE remains the most challenging with regard to initial and long-term management. Little consensus exists as to the appropriate tests for risk stratification and therapy. This article reviews the current literature and a suggested approach to these patients.
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Affiliation(s)
- Laurence W Busse
- Section of Critical Care Medicine, Department of Medicine, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA.
| | - Jason S Vourlekis
- Section of Critical Care Medicine, Department of Medicine, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA
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128
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Emergency Evaluation for Pulmonary Embolism, Part 2: Diagnostic Approach. J Emerg Med 2015; 49:104-17. [DOI: 10.1016/j.jemermed.2014.12.041] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/17/2014] [Accepted: 12/21/2014] [Indexed: 12/14/2022]
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129
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Ma Y, Yan S, Zhou L, Yuan DT. Competitive assessments of pulmonary embolism: Noninvasiveness versus the golden standard. Vascular 2015; 24:217-24. [PMID: 26038123 DOI: 10.1177/1708538115589893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diagnosis of suspected pulmonary embolism (PE) is crucial as undiagnosed and over-diagnosis can both lead to serious consequences. Contemporary diagnostic approach of PE is a sequential combination assessment beginning with clinical assessment, validated with D-dimer measurement and confirmed with pulmonary angiography or imaging. Since the invasive pulmonary angiography is risky and costly, imaging is a warranted tool in the diagnosis procedure. CT pulmonary angiography is a less-invasive method with general availability, studies provide favorable evidences for CT pulmonary angiography as a stand-alone test for excluding PE, and it has become the first choice of tests in emergency department for suspected PE in most centers. Ventilation/perfusion single-photon emission CT signifies a new era in nuclear medicine. It has excellent sensitivity and specificity, fast procedure, low radiation exposure, few complications and contradictions. Besides, MR angiography is another possible and promising approach for diagnosis of suspected PE with much safer contrast agents than CT and no ionizing radiation. With wide availability and less invasive effects, imaging becomes a firsthand tool to obtain optimal accuracy in the diagnosis work up in clinic nowadays. This review summarizes the current methods in diagnosing PE and the update of imaging assessments of the disease.
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Affiliation(s)
- Yuxia Ma
- Division of Internal Medicine, Cangzhou Central Hospital, Cangzhou,China
| | - Shi Yan
- Department of Emergency, The Affiliated Huai'an Hospital of Xuzhou Medical College and The Second People's Hospital of Huai'an, Huai'an, China
| | - Lin Zhou
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Dong-Tang Yuan
- Department of Orthopedics, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, China
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Polo Friz H, Molteni M, Del Sorbo D, Pasciuti L, Crippa M, Villa G, Meloni DF, Primitz L, Galli A, Rognoni M, Cavalieri d'Oro L, Arpaia G, Cimminiello C. Mortality at 30 and 90 days in elderly patients with pulmonary embolism: a retrospective cohort study. Intern Emerg Med 2015; 10:431-6. [PMID: 25539955 DOI: 10.1007/s11739-014-1179-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 12/15/2014] [Indexed: 01/07/2023]
Abstract
Pulmonary Embolism (PE) incidence increases with age. Data on mortality and prognosis in elderly patients with suspected PE are lacking. (1) To assess 30- and 90-day mortality in subjects with PE from an elderly population seen in the emergency department (ED); (2) to test the prognostic accuracy of a simplified Pulmonary Embolism Severity Index (sPESI) coupled to a highly sensitive cardiac Troponin T (hs-cTnT) level. A retrospective cohort study was performed, including patients evaluated in the ED of Vimercate Hospital for clinically suspected PE from 2010 to 2012. Study population: n = 470, 63.4% women, mean age ± SD 73.06 ± 16.0 years, 40% aged ≥80 and 77.7% ≥65 years old, confirmed PE: 22.6% (106 cases). Within 30 and 90 days, mortality among patients with confirmed PE was 14.2% (8.8-22.0) and 20.8% (16.5-41.7). In subjects aged ≥80 years, 30-day mortality was 18.9% among patients with confirmed PE, and 12.6% among those with PE excluded (p = 0.317). Ninety-day mortality rates were 29.7 and 19.9%, respectively (p = 0.193). In patients with confirmed PE, Negative Predictive Value of sPESI was 94.1% (80.3-99.3) for 30 days and 88.2% (72.3-96.7) for 90-day mortality. Adding the hs-cTnT level to sPESI did not improve its performance. (1) In an elderly population referring to the ED with clinically suspected PE, mortality was high both in subjects with and without confirmed PE; (2) the ability of sPESI and hs-cTnT to predict PE mortality seems to be lower than reported in studies based on data from younger populations. Better risk stratification tools will be necessary to improve clinical management in this setting.
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Affiliation(s)
- Hernan Polo Friz
- Internal Medicine, Medical Department, Vimercate Hospital, Via Santi Cosma e Damiano, 10, 20871, Vimercate, MB, Italy,
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131
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Kline JA, Kabrhel C. Emergency Evaluation for Pulmonary Embolism, Part 1: Clinical Factors that Increase Risk. J Emerg Med 2015; 48:771-80. [DOI: 10.1016/j.jemermed.2014.12.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 12/17/2014] [Accepted: 12/21/2014] [Indexed: 12/14/2022]
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132
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Coleman DM, Obi A, Henke PK. Update in venous thromboembolism pathophysiology, diagnosis, and treatment for surgical patients. Curr Probl Surg 2015; 52:233-59. [PMID: 26071037 DOI: 10.1067/j.cpsurg.2015.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 04/20/2015] [Indexed: 11/22/2022]
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133
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Is It Time to Raise the Bar? Age-Adjusted D-dimer Cutoff Levels for Excluding Pulmonary Embolism. Ann Emerg Med 2014; 64:678-83. [DOI: 10.1016/j.annemergmed.2014.07.450] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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134
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Sivananthan G, Halin NJ, Estes JM, Alessi-Chinetti JM, Polak JF. Value of complete full-length lower extremity sonography in patients undergoing computed tomographic pulmonary angiography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:2137-2143. [PMID: 25425370 DOI: 10.7863/ultra.33.12.2137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To evaluate the diagnostic yield of complete lower extremity venous sonography for diagnosing deep venous thrombosis (DVT) in patients undergoing computed tomographic (CT) pulmonary angiography for suspected pulmonary embolism (PE). METHODS We retrospectively reviewed all cases of lower extremity venous sonography and CT pulmonary angiography performed within 1 day of each other (n = 147) in a tertiary care center. Indications for the studies performed, angiographic findings, sonographic findings, age, sex, inpatient/outpatient status, lower extremity symptoms, and treatment status were recorded. Prevalence rates and patient characteristics were compared by χ(2) and Fisher exact probability tests where appropriate. Multivariable logistic regression with acute PE as the outcome was performed for age, sex, interval between angiography and sonography, indication for angiography, inpatient/outpatient status, and venous sonographic findings. RESULTS The prevalence of PE (23.8%) was similar to the prevalence of DVT (27.9%). Angiographic findings were not associated with the interval between angiography and sonography or inpatient/outpatient status. Acute DVT was more likely (P = .0009) when angiographic findings were positive (51.4%), but DVT prevalence was still substantial (20.5%) in patients with negative angiographic findings. Lower extremity symptoms were not associated with DVT in cases with negative angiographic findings (P = .48). Eighteen of the 23 patients with acute DVT and negative angiographic findings were treated. CONCLUSIONS There is a high rate of DVT in a population undergoing CT pulmonary angiography for suspected PE even when PE is not diagnosed. Our data apply to a tertiary care institution, suggest a surveillance bias, and favor the utility of venous sonography in this population.
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Affiliation(s)
- Gajan Sivananthan
- Departments of Radiology (G.S., N.J.H., J.F.P.) and Vascular Surgery (J.M.E., J.M.A.-C.), Tufts Medical Center, Boston, Massachusetts USA.
| | - Neil J Halin
- Departments of Radiology (G.S., N.J.H., J.F.P.) and Vascular Surgery (J.M.E., J.M.A.-C.), Tufts Medical Center, Boston, Massachusetts USA
| | - James M Estes
- Departments of Radiology (G.S., N.J.H., J.F.P.) and Vascular Surgery (J.M.E., J.M.A.-C.), Tufts Medical Center, Boston, Massachusetts USA
| | - Jean M Alessi-Chinetti
- Departments of Radiology (G.S., N.J.H., J.F.P.) and Vascular Surgery (J.M.E., J.M.A.-C.), Tufts Medical Center, Boston, Massachusetts USA
| | - Joseph F Polak
- Departments of Radiology (G.S., N.J.H., J.F.P.) and Vascular Surgery (J.M.E., J.M.A.-C.), Tufts Medical Center, Boston, Massachusetts USA
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135
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Konstantinides SV, Torbicki A. Management of pulmonary embolism: recent evidence and the new European guidelines. Eur Respir J 2014; 44:1385-90. [DOI: 10.1183/09031936.00180414] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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136
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Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JSR, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk Noordegraaf A, Zamorano JL, Zompatori M. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35:3033-69, 3069a-3069k. [PMID: 25173341 DOI: 10.1093/eurheartj/ehu283] [Citation(s) in RCA: 1850] [Impact Index Per Article: 185.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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137
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Diagnostic accuracy of computed tomography pulmonary angiography with reduced radiation and contrast material dose: a prospective randomized clinical trial. Invest Radiol 2014; 49:201-8. [PMID: 24473367 DOI: 10.1097/rli.0000000000000016] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The objective of the study was to test the diagnostic performance of low-dose computed tomography pulmonary angiography (CTPA) at peak tube voltage of 80 kVp with both reduced radiation and reduced contrast material (CM) dose. MATERIALS AND METHODS In this single-center, single-blinded prospective randomized trial, 501 patients with body weights of less than 100 kg with suspected acute pulmonary embolism (PE) were assigned to normal-dose CTPA (100-kVp tube energy and 100-mL CM, 255 patients) and low-dose CTPA (80-kVp tube energy and 75-mL CM, 246 patients). Primary end points were evidence of PE in CTPA and accuracy of CTPA on a composite reference standard. Results were compared by calculating the odds ratio with the 95% confidence interval. RESULTS The reference diagnosis was equivocal in 20 of the 501 patients. Diagnosis of CTPA was correct in 240 patients and incorrect in 5 in the normal-dose group. Computed tomography pulmonary angiography was correct in 230 patients and incorrect in 6 in the low-dose group (odds ratio, 1.25; 95% confidence interval, 0.38-4.16; P = 0.77). Sensitivity was 96.9% and 100% and specificity was 98.1% and 97.1% in the normal-dose and low-dose groups, respectively. No PE or PE-related death occurred during the 90-day follow-up. The size-specific dose estimates were 30% lower at 80 kVp (4.8 ± 1.0 mGy) compared with that at 100 kVp (6.8 ± 1.2 mGy; P < 0.001). CONCLUSIONS The accuracy of low-dose CTPA at 80 kVp with a 30% reduced radiation dose and a 25% lower CM volume is not significantly different from that of normal-dose CTPA at 100 kVp in detecting acute PE in patients weighing less than 100 kg.
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Akwaa F, Spyropoulos AC. The potential of target-specific oral anticoagulants for the acute and long-term treatment of venous thromboembolism. Curr Med Res Opin 2014; 30:2179-90. [PMID: 25105309 DOI: 10.1185/03007995.2014.951425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) comprises both deep vein thrombosis and pulmonary embolism. VTE is a leading cause of morbidity and mortality worldwide and its increasing incidence and prevalence are a major health concern. The primary medical objective during the acute phase of VTE treatment is to prevent thrombus extension and embolization. Extended treatment aims to prevent or minimize long-term complications, such as recurrent VTE, post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension. SCOPE Anticoagulant therapy has been the mainstay of treatment for VTE and traditionally involves initial therapy with heparin, overlapping with and followed by a vitamin K antagonist. Although effective, standard heparin/vitamin K antagonist therapy has several limitations that can be overcome by more recently developed target-specific oral anticoagulants (TSOACs). These agents have predictable pharmacokinetics, a rapid onset of action and few drug-drug or drug-food interactions. Furthermore, TSOACs offer convenient anticoagulation without the need for routine coagulation monitoring and dose adjustment. FINDINGS The efficacy and safety data from phase III clinical trials support the use of TSOACs for VTE treatment, including in special patient populations. Risk-stratification tools and strategies have been developed to assist physicians in managing anticoagulation treatment. CONCLUSIONS Rivaroxaban is the first TSOAC to gain widespread approval for the treatment of acute deep vein thrombosis and pulmonary embolism and the long-term prevention of recurrent VTE as monotherapy. Dabigatran has also been approved for this indication recently. TSOACs, especially as monotherapy, represent a paradigm shift in clinical practice for the management of patients with VTE.
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Affiliation(s)
- Frank Akwaa
- School of Medicine, University of Rochester , Rochester, NY , USA
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139
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Akpinar EE, Hoşgün D, Akpinar S, Ataç GK, Doğanay B, Gülhan M. Incidence of pulmonary embolism during COPD exacerbation. ACTA ACUST UNITED AC 2014; 40:38-45. [PMID: 24626268 PMCID: PMC4075911 DOI: 10.1590/s1806-37132014000100006] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 12/05/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Because pulmonary embolism (PE) and COPD exacerbation have similar presentations and symptoms, PE can be overlooked in COPD patients. Our objective was to determine the prevalence of PE during COPD exacerbation and to describe the clinical aspects in COPD patients diagnosed with PE. METHODS This was a prospective study conducted at a university hospital in the city of Ankara, Turkey. We included all COPD patients who were hospitalized due to acute exacerbation of COPD between May of 2011 and May of 2013. All patients underwent clinical risk assessment, arterial blood gas analysis, chest CT angiography, and Doppler ultrasonography of the lower extremities. In addition, we measured D-dimer levels and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels. RESULTS We included 172 patients with COPD. The prevalence of PE was 29.1%. The patients with pleuritic chest pain, lower limb asymmetry, and high NT-pro-BNP levels were more likely to develop PE, as were those who were obese or immobile. Obesity and lower limb asymmetry were independent predictors of PE during COPD exacerbation (OR = 4.97; 95% CI, 1.775-13.931 and OR = 2.329; 95% CI, 1.127-7.105, respectively). CONCLUSIONS The prevalence of PE in patients with COPD exacerbation was higher than expected. The association between PE and COPD exacerbation should be considered, especially in patients who are immobile or obese.
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Affiliation(s)
- Evrim Eylem Akpinar
- Ufuk University School of Medicine, Department of Chest Diseases, Ankara, Turkey, MD. Department of Chest Diseases, Ufuk University School of Medicine, Ankara, Turkey
| | - Derya Hoşgün
- Ufuk University, School of Medicine, Department of Chest Diseases, Ankara, Turkey, MD. Department of Chest Diseases, Ufuk University School of Medicine, Ankara, Turkey
| | - Serdar Akpinar
- Chest Surgery Training Hospital, Ankara, Turkey, MD. Atatürk Chest Diseases and Chest Surgery Training Hospital, Ankara, Turkey
| | - Gökçe Kaan Ataç
- Ufuk University, School of Medicine, Department of Radiology, Ankara, Turkey, MD. Department of Radiology, Ufuk University School of Medicine, Ankara, Turkey
| | - Beyza Doğanay
- Ankara University, School of Medicine, Department of Biostatistics, Ankara, Turkey, PhD. Department of Biostatistics, Ankara University School of Medicine, Ankara, Turkey
| | - Meral Gülhan
- Ufuk University, School of Medicine, Department of Chest Diseases, Ankara, Turkey, Chief. Department of Chest Diseases School of Medicine, Ufuk University, Ankara, Turkey
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Megyeri B, Christe A, Schindera ST, Horkay E, Sikula J, Cullmann JL, Kollar J, Heverhagen JT, Szucs-Farkas Z. Accuracy of computed tomography angiography in the detection of pulmonary embolism in patients with high body weight. Eur J Intern Med 2014; 25:724-30. [PMID: 25179677 DOI: 10.1016/j.ejim.2014.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 04/29/2014] [Accepted: 07/14/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND The accuracy of CT pulmonary angiography (CTPA) in detecting or excluding pulmonary embolism has not yet been assessed in patients with high body weight (BW). METHODS This retrospective study involved CTPAs of 114 patients weighing 75-99 kg and those of 123 consecutive patients weighing 100-150 kg. Three independent blinded radiologists analyzed all examinations in randomized order. Readers' data on pulmonary emboli were compared with a composite reference standard, comprising clinical probability, reference CTPA result, additional imaging when performed and 90-day follow-up. Results in both BW groups and in two body mass index (BMI) groups (BMI <30 kg/m(2) and BMI ≥ 30 kg/m(2), i.e., non-obese and obese patients) were compared. RESULTS The prevalence of pulmonary embolism was not significantly different in the BW groups (P=1.0). The reference CTPA result was positive in 23 of 114 patients in the 75-99 kg group and in 25 of 123 patients in the ≥ 100 kg group, respectively (odds ratio, 0.991; 95% confidence interval, 0.501 to 1.957; P=1.0). No pulmonary embolism-related death or venous thromboembolism occurred during follow-up. The mean accuracy of three readers was 91.5% in the 75-99 kg group and 89.9% in the ≥ 100 kg group (odds ratio, 1.207; 95% confidence interval, 0.451 to 3.255; P=0.495), and 89.9% in non-obese patients and 91.2% in obese patients (odds ratio, 0.853; 95% confidence interval, 0.317 to 2.319; P=0.816). CONCLUSION The diagnostic accuracy of CTPA in patients weighing 75-99 kg or 100-150 kg proved not to be significantly different.
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Affiliation(s)
- Boglarka Megyeri
- Department of Anaesthesiology and Intensive Care, University of Debrecen, Clinical Centre, Nagyerdei krt. 98, Debrecen H-4012, Hungary.
| | - Andreas Christe
- University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University Hospital Bern, Freiburgstrasse 10, Bern CH-3010, Switzerland
| | - Sebastian T Schindera
- Department of Radiology, University Hospital Basel, Petersgraben 4, Basel, CH-4031, Switzerland
| | - Edit Horkay
- Department of Radiology, University of Debrecen, Clinical Centre, Nagyerdei krt. 98, Debrecen H-4012, Hungary
| | - Judit Sikula
- Department of Radiology, University of Debrecen, Clinical Centre, Nagyerdei krt. 98, Debrecen H-4012, Hungary
| | - Jennifer L Cullmann
- University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University Hospital Bern, Freiburgstrasse 10, Bern CH-3010, Switzerland
| | - Jozsef Kollar
- Department of Radiology, University of Debrecen, Clinical Centre, Nagyerdei krt. 98, Debrecen H-4012, Hungary
| | - Johannes T Heverhagen
- University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University Hospital Bern, Freiburgstrasse 10, Bern CH-3010, Switzerland
| | - Zsolt Szucs-Farkas
- University Institute of Diagnostic, Interventional and Paediatric Radiology, Inselspital, University Hospital Bern, Freiburgstrasse 10, Bern CH-3010, Switzerland; Institute of Radiology, Hospital Centre of Biel, Vogelsang 84, Biel/Bienne CH-2501, Switzerland
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Abstract
BACKGROUND Pulmonary embolism (PE) can be a life-threatening emergency. Accurate diagnostic techniques and patient-specific management strategies are necessary to ensure favorable clinical outcomes. METHODS Relevant guidelines, articles, reviews, and abstracts were identified using a narrative approach in PubMed/MEDLINE, Google Scholar, clinicaltrials.gov and nice.org.uk. English-language articles published in 2000-2014 were initially identified using the search terms: novel OAC, pulmonary embolism, venous thromboembolism, diagnosis, treatment, rivaroxaban, apixaban, dabigatran, and edoxaban. The initial literature search was supported by a 'snowballing' style literature search, and relevant articles were included based on a professional judgment of relevance. SCOPE We discuss the diagnosis of PE and the categorization of risk for subgroups, which may assist with making treatment decisions. We review current guidance on acute and long-term treatment, possible limitations of traditional anticoagulant therapy, and the development of direct oral anticoagulants, which may significantly alter the management of patients with PE. Finally, we discuss special considerations in high-risk and hard-to-treat subpopulations that may benefit from the improved benefit-risk profile offered by these newer agents. CONCLUSIONS The direct oral anticoagulants may overcome several of the limitations associated with traditional anticoagulant therapy, potentially improving the standard of care for PE patients, including high-risk and hard-to-manage subgroups.
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Affiliation(s)
- Robert J Walter
- Walter Reed National Military Medical Center , Bethesda, MD , USA
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Käberich A, Wärntges S, Konstantinides S. Risk-adapted management of acute pulmonary embolism: recent evidence, new guidelines. Rambam Maimonides Med J 2014; 5:e0040. [PMID: 25386356 PMCID: PMC4222429 DOI: 10.5041/rmmj.10174] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Venous thromboembolism (VTE), the third most frequent acute cardiovascular syndrome, may cause life-threatening complications and imposes a substantial socio-economic burden. During the past years, several landmark trials paved the way towards novel strategies in acute and long-term management of patients with acute pulmonary embolism (PE). Risk stratification is increasingly recognized as a cornerstone for an adequate diagnostic and therapeutic management of the highly heterogeneous population of patients with acute PE. Recently published European Guidelines emphasize the importance of clinical prediction rules in combination with imaging procedures (assessment of right ventricular function) and laboratory biomarkers (indicative of myocardial stress or injury) for identification of normotensive PE patients at intermediate risk for an adverse short-term outcome. In this patient group, systemic full-dose thrombolysis was associated with a significantly increased risk of intracranial bleeding, a complication which discourages its clinical application unless hemodynamic decompensation occurs. A large-scale clinical trial program evaluating new oral anticoagulants in the initial and long-term treatment of venous thromboembolism showed at least comparable efficacy and presumably increased safety of these drugs compared to the current standard treatment. Research is continuing on catheter-directed, ultrasound-assisted, local, low-dose thrombolysis in the management of intermediate-risk PE.
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Affiliation(s)
- Anja Käberich
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Simone Wärntges
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany ; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
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143
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Pollack CV. The use of oral anticoagulants for the treatment of venous thromboembolic events in an ED. Am J Emerg Med 2014; 32:1526-33. [PMID: 25315880 DOI: 10.1016/j.ajem.2014.08.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 08/26/2014] [Accepted: 08/28/2014] [Indexed: 12/01/2022] Open
Abstract
Venous thromboembolism (VTE) is a disease spectrum that ranges from deep vein thrombosis (DVT) to pulmonary embolism (PE). Rapid diagnosis and treatment of VTE by emergency care providers are critical for decreasing patient mortality, morbidity, and the incidence of recurrent events. Recent American College of Chest Physicians guidelines recommend initial treatment with unfractionated heparin, low-molecular weight heparin, or fondaparinux overlapped with warfarin for a minimum of 5 days for the treatment of VTE in most cases. Warfarin monotherapy is thereafter continued for 3, 6, or 12 months. These guidelines were published before the approval of target-specific oral anticoagulants (TSOACs), and they have yet to be updated to reflect these new treatment options. For some patients, TSOACs, which act by directly inhibiting factor IIa or factor Xa, may provide safer, more convenient alternatives to warfarin. Their advantages include ease of use, reduced monitoring requirements, and lower bleeding risk than traditional therapy. Additionally, clinical trials have established noninferiority of TSOACs to warfarin for the prevention of recurrent VTE. These trials have demonstrated that TSOACs exhibit similar or lower bleeding rates, particularly intracranial bleeding rates compared with warfarin. Anticoagulation therapy with TSOACs may allow early discharge or outpatient management options for low-risk patients with DVT and PE. This review addresses the importance of early diagnosis and treatment of VTE, outcomes of VTE risk assessment, key efficacy and safety data from phase 3 clinical trials for the various TSOACs for the treatment of DVT and PE, and the corresponding considerations for clinical practice.
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Affiliation(s)
- Charles V Pollack
- Department of Emergency Medicine, Pennsylvania Hospital, University of Pennsylvania
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144
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145
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Kirschner JM, Kline JA. Is It Time to Raise the Bar? Age-Adjusted D-dimer Cutoff Levels to Exclude Pulmonary Embolism. Ann Emerg Med 2014; 64:86-7. [DOI: 10.1016/j.annemergmed.2014.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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146
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147
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Lindner G, Funk GC, Pfortmueller CA, Leichtle AB, Fiedler GM, Schwarz C, Exadaktylos AK, Puig S. D-dimer to rule out pulmonary embolism in renal insufficiency. Am J Med 2014; 127:343-7. [PMID: 24355353 DOI: 10.1016/j.amjmed.2013.12.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 12/03/2013] [Accepted: 12/03/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND D-dimer levels are often elevated in renal insufficiency. The diagnostic accuracy of D-dimer to rule out pulmonary embolism in patients with renal insufficiency is unclear. METHODS We evaluated the data of patients presenting to our Emergency Department and receiving computed tomography angiography to rule out pulmonary embolism with measurement of D-dimer and creatinine. Glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration formula. RESULTS There were 1305 patients included; 1067 (82%) had an estimated glomerular filtration rate (eGFR) exceeding 60 mL/min, 209 (16%) 30-60 mL/min, and 29 (2%) <30 mL/min. One hundred fifty-two patients (12%) had D-dimer below 500 μg/L. eGFR (R = -0.1122) correlated significantly with D-dimer (P <.0001). One hundred sixty-nine patients (13%) were found to have pulmonary embolism. Sensitivity of D-dimer for patients with an eGFR >60 mL/min was 96% (confidence interval [CI], 0.93-0.99) and 100% (CI, 100-100) for those with 30-60 mL/min, while specificity decreased significantly with impaired renal function. Area under the curve of the receiver operating characteristic for D-dimer was 0.734 in patients with an eGFR of >60 mL/min, and 0.673 for 30-60 mL/min. CONCLUSIONS D-dimer levels were elevated in patients with an eGFR <60 mL/min, but proved to be highly sensitive for the exclusion of pulmonary embolism. However, because almost all patients with impaired renal function had elevated D-dimer irrespective of the presence of pulmonary embolism, studies should be performed to determine renal function-adjusted D-dimer cutoffs.
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Affiliation(s)
- Gregor Lindner
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Switzerland; Department of Internal Medicine, Inselspital, University Hospital Bern, Switzerland.
| | - Georg-Christian Funk
- Department of Respiratory and Critical Care Medicine, Otto Wagner Hospital Vienna and Ludwig Boltzmann Institute for COPD and Respiratory Epidemiology, Vienna, Austria
| | - Carmen A Pfortmueller
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Switzerland; Department of Internal Medicine, Inselspital, University Hospital Bern, Switzerland
| | - Alexander B Leichtle
- Center for Laboratory Medicine, Inselspital, University Hospital Bern, Switzerland
| | - Georg M Fiedler
- Center for Laboratory Medicine, Inselspital, University Hospital Bern, Switzerland
| | | | | | - Stefan Puig
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University Hospital Bern, Switzerland
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Cohen A, Le Heuzey JY. Anticoagulants : stratification du risque en pathologie vasculaire. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2014. [DOI: 10.1016/s1878-6480(14)71479-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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149
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Diagnostic et traitement de la maladie thromboembolique veineuse en 2013. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2014. [DOI: 10.1016/s1878-6480(14)71482-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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150
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