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Romano KR, Cory JM, Ronco JJ, Legiehn GM, Bone JN, Finlayson GN. Vancouver General Hospital Pulmonary Embolism Response Team (VGH PERT): initial three-year experience. Can J Anaesth 2020; 67:1806-1813. [PMID: 32808096 DOI: 10.1007/s12630-020-01790-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 06/27/2020] [Accepted: 08/02/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE Clinical equipoise exists with the use of novel reperfusion therapies such as catheter-directed thrombolysis in the management of patients presenting to hospital with high risk pulmonary embolism (PE). Therapeutic options rely on clinical presentation, patient factors, physician preference, and institutional availability. We established a Pulmonary Embolism Response Team (PERT) to provide urgent assessment and multidisciplinary care for patients presenting to our institution with high-risk PE. METHODS Data were retrospectively collected from PERT activations between January 2016 and December 2018. Chi square tests were used to determine differences in mortality across the three years of study. Logistic regression was used to evaluate 30- and 90-day mortality and occurrence of major bleeds between those receiving anticoagulation alone (AC) and those receiving advanced reperfusion therapy (ART). RESULTS There were 128 PERT activations over three years, the majority originating from the emergency department. Eighty-five percent of activations were for submassive PE, with 56% of all activations assessed as submassive-high risk. Fifteen patients (12%) presented with massive PE. Advanced reperfusion therapy was used in 29 (23%) patients, of whom 25 (20%) received catheter-directed thrombolysis. There was an increased risk of major bleeding in the ART group compared with in the AC group (odds ratio [OR], 17.9; 95% confidence interval [CI], 4.1 to 125.0; P < 0.001), but no increased risk of mortality at 30 days (OR, 2.1; 95% CI, 0.4 to 9.1; P = 0.3). The 30-day mortality rate was 7.8%. CONCLUSION We describe the first Canadian PERT, a multidisciplinary team aimed at providing urgent individualized care for patients with high-risk PE. Further research is necessary to determine whether a PERT improves clinical outcomes.
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Affiliation(s)
- Kali R Romano
- Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, JPPN 2nd Floor, Room 2449 899 West 12th Ave, Vancouver, BC, V5Z 1M9, Canada.
- Department of Critical Care Medicine, Vancouver General Hospital, Vancouver, BC, Canada.
| | - Julia M Cory
- Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, JPPN 2nd Floor, Room 2449 899 West 12th Ave, Vancouver, BC, V5Z 1M9, Canada
| | - Juan J Ronco
- Department of Critical Care Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | - Gerald M Legiehn
- Division of Interventional Radiology, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Jeffrey N Bone
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Gordon N Finlayson
- Department of Anesthesiology and Perioperative Care, Vancouver General Hospital, JPPN 2nd Floor, Room 2449 899 West 12th Ave, Vancouver, BC, V5Z 1M9, Canada
- Department of Critical Care Medicine, Vancouver General Hospital, Vancouver, BC, Canada
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Gressenberger P, Gary T, Raggam RB, Borenich A, Brodmann M. Significant increase in the incidence of high-risk pulmonary embolism during the COVID-19 shutdown: The pandemic response causes serious collateral consequences. Eur J Intern Med 2020; 82:120-122. [PMID: 33046346 PMCID: PMC7538067 DOI: 10.1016/j.ejim.2020.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/25/2020] [Accepted: 10/05/2020] [Indexed: 01/17/2023]
Affiliation(s)
- Paul Gressenberger
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Austria.
| | - Thomas Gary
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Reinhard B Raggam
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Austria
| | - Andrea Borenich
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Austria
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Austria
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153
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Hobohm L, Becattini C, Ebner M, Lerchbaumer MH, Casazza F, Hasenfuß G, Konstantinides SV, Lankeit M. Definition of tachycardia for risk stratification of pulmonary embolism. Eur J Intern Med 2020; 82:76-82. [PMID: 32843290 DOI: 10.1016/j.ejim.2020.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/19/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Tachycardia is a reliable predictor of adverse outcomes in normotensive patients with acute pulmonary embolism (PE). However, different prognostic relevant heart rate thresholds have been proposed. The aim of the study was to investigate the prognostic performance of different thresholds used for defining tachycardia in normotensive PE patients. METHODS We performed a post-hoc analysis of normotensive patients with confirmed PE consecutively included in a single-centre and a multi-centre registry. An adverse outcome was defined as PE-related death, need for mechanical ventilation, cardiopulmonary resuscitation or administration of catecholamines. RESULTS Of 1567 patients (median age: 72 [IQR, 59-79] years; females: 46.1%) included in the analysis, 78 patients (5.0%) had an in-hospital adverse outcome. The rate of an adverse outcome was higher in patients with a heart rate ≥100 bpm (7.6%) and ≥110 bpm (8.3%) compared to patients with a heart rate <100 bpm (3.0%). A heart rate ≥100 bpm and ≥110 bpm was associated with a 2.7 (95% CI 1.7-4.3) and 2.4-fold (95% CI 1.5-3.7) increased risk for an adverse outcome, respectively. Receiver operating characteristics analysis revealed a similar area under the curve with regard to an adverse outcome for all scores and algorithm (ESC 2019 algorithm, modified FAST and Bova score) if calculated with a heart rate threshold of ≥100 bpm or of ≥110 bpm. CONCLUSIONS Defining tachycardia by a heart rate ≥100 bpm is sufficient for risk stratification of normotensive patients with acute PE. The use of different heart rate thresholds for calculation of scores and algorithm does not appear necessary.
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Affiliation(s)
- Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Centre of the Johannes Gutenberg University Mainz, Germany; Center for Cardiology, Cardiology I, University Medical Centre of the Johannes Gutenberg-University Mainz, Germany
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Italy
| | - Matthias Ebner
- Department of Cardiology and Angiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Germany
| | - Markus H Lerchbaumer
- Department of Radiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Germany
| | - Franco Casazza
- Cardiology Department, San Carlo Borromeo Hospital, Milan, Italy
| | - Gerd Hasenfuß
- Clinic of Cardiology and Pneumology, University Medical Centre Göttingen, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Centre of the Johannes Gutenberg University Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Centre of the Johannes Gutenberg University Mainz, Germany; Clinic of Cardiology and Pneumology, University Medical Centre Göttingen, Germany; Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Germany.
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154
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Abstract
Pregnancy and postpartum represent periods at very high risk of venous thromboembolism disease which appears to extend well beyond the classic 6-8 weeks after childbirth. Pulmonary embolism (PE) is still one of the three leading causes of direct maternal death (MM) in most developed countries. Between 2013 and 2015, 23 maternal deaths were caused by a venous thromboembolic complication (VTE) (20 pulmonary embolism and 3 cerebral thrombophlebitis), representing 8.8 % of maternal deaths and a Maternal Mortality Ratio of 1.0 per 100,000 live births (95 % CI 0.6-1, 4) which is stable over the last 10 years. Regarding the timing of death, 1 death occurred after abortion, 35 % (8/23) during an ongoing pregnancy (including four before 22 WG), and 61 % (14/23) after childbirth. Among the 23 deaths from VTE, 17 % (5/23) occurred outside a healthcare center (home, street). The mean age was 32.3 and 7 women (30 %) were≥35 years old. Six patients were obese (27 %). The preventability rate is 34.8 % (compared to 50 % in 2007-2009 and 2010-2012), The preventability factors involve the inadequacy of care in 34.8 % of cases (8/23), organizational factors in one case (1/23) and a lack of interaction of the patient with the health care system in two cases (2/23). Care was considered non-optimal in 59 % of these deaths. This proportion is higher than the preventability rate because suboptimal care sometimes did not influence the final outcome.
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155
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Predicting Venous Thromboembolic Events in Patients with Coronavirus Disease 2019 Requiring Hospitalization: an Observational Retrospective Study by the COVIDIC Initiative in a Swiss University Hospital. BIOMED RESEARCH INTERNATIONAL 2020; 2020:9126148. [PMID: 33204727 PMCID: PMC7656238 DOI: 10.1155/2020/9126148] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/04/2020] [Accepted: 10/10/2020] [Indexed: 01/08/2023]
Abstract
Background Coronavirus disease 2019 (COVID-19) can result in profound changes in blood coagulation. The aim of the study was to determine the incidence and predictors of venous thromboembolic events (VTE) among patients with COVID-19 requiring hospital admission. Subjects and Methods. We performed a retrospective study at the Lausanne University Hospital with patients admitted because of COVID-19 from February 28 to April 30, 2020. Results Among 443 patients with COVID-19, VTE was diagnosed in 41 patients (9.3%; 27 pulmonary embolisms, 12 deep vein thrombosis, one pulmonary embolism and deep vein thrombosis, one portal vein thrombosis). VTE was diagnosed already upon admission in 14 (34.1%) patients and 27 (65.9%) during hospital stay (18 in ICU and nine in wards outside the ICU). Multivariate analysis revealed D-dimer value > 3,120 ng/ml (P < 0.001; OR 15.8, 95% CI 4.7-52.9) and duration of 8 days or more from COVID-19 symptoms onset to presentation (P 0.020; OR 4.8, 95% CI 1.3-18.3) to be independently associated with VTE upon admission. D-dimer value ≥ 3,000 ng/l combined with a Wells score for PE ≥ 2 was highly specific (sensitivity 57.1%, specificity 91.6%) in detecting VTE upon admission. Development of VTE during hospitalization was independently associated with D-dimer value > 5,611 ng/ml (P < 0.001; OR 6.3, 95% CI 2.4-16.2) and mechanical ventilation (P < 0.001; OR 5.9, 95% CI 2.3-15.1). Conclusions VTE seems to be a common COVID-19 complication upon admission and during hospitalization, especially in ICU. The combination of Wells ≥ 2 score and D − dimer ≥ 3,000 ng/l is a good predictor of VTE at admission.
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George PM, Barratt SL, Condliffe R, Desai SR, Devaraj A, Forrest I, Gibbons MA, Hart N, Jenkins RG, McAuley DF, Patel BV, Thwaite E, Spencer LG. Respiratory follow-up of patients with COVID-19 pneumonia. Thorax 2020; 75:1009-1016. [PMID: 32839287 PMCID: PMC7447111 DOI: 10.1136/thoraxjnl-2020-215314] [Citation(s) in RCA: 205] [Impact Index Per Article: 51.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/16/2020] [Accepted: 07/03/2020] [Indexed: 01/08/2023]
Abstract
The COVID-19 pandemic has led to an unprecedented surge in hospitalised patients with viral pneumonia. The most severely affected patients are older men, individuals of black and Asian minority ethnicity and those with comorbidities. COVID-19 is also associated with an increased risk of hypercoagulability and venous thromboembolism. The overwhelming majority of patients admitted to hospital have respiratory failure and while most are managed on general wards, a sizeable proportion require intensive care support. The long-term complications of COVID-19 pneumonia are starting to emerge but data from previous coronavirus outbreaks such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) suggest that some patients will experience long-term respiratory complications of the infection. With the pattern of thoracic imaging abnormalities and growing clinical experience, it is envisaged that interstitial lung disease and pulmonary vascular disease are likely to be the most important respiratory complications. There is a need for a unified pathway for the respiratory follow-up of patients with COVID-19 balancing the delivery of high-quality clinical care with stretched National Health Service (NHS) resources. In this guidance document, we provide a suggested structure for the respiratory follow-up of patients with clinicoradiological confirmation of COVID-19 pneumonia. We define two separate algorithms integrating disease severity, likelihood of long-term respiratory complications and functional capacity on discharge. To mitigate NHS pressures, virtual solutions have been embedded within the pathway as has safety netting of patients whose clinical trajectory deviates from the pathway. For all patients, we suggest a holistic package of care to address breathlessness, anxiety, oxygen requirement, palliative care and rehabilitation.
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Affiliation(s)
- Peter M George
- Interstitial Lung Disease Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Shaney L Barratt
- Department of Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
- University of Bristol School of Clinical Science, Bristol, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Sujal R Desai
- Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Anand Devaraj
- Department of Radiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ian Forrest
- Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Michael A Gibbons
- Department of Respiratory Medicine, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK
| | - Nicholas Hart
- Lane Fox Respiratory Service, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - R Gisli Jenkins
- Centre for Respiratory Research, University of Nottingham, Nottingham, UK
| | - Danny F McAuley
- Intensive Care Unit, Queen's University Belfast, Belfast, UK
| | - Brijesh V Patel
- Department of Anaesthetics, Pain Medicine & Intensive Care, Imperial College London, London, UK
| | - Erica Thwaite
- Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Lisa G Spencer
- Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
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O'Shaughnessy F, O'Reilly D, Ní Áinle F. Current opinion and emerging trends on the treatment, diagnosis, and prevention of pregnancy-associated venous thromboembolic disease: a review. Transl Res 2020; 225:20-32. [PMID: 32554071 DOI: 10.1016/j.trsl.2020.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 05/10/2020] [Accepted: 06/09/2020] [Indexed: 12/23/2022]
Abstract
Pregnancy associated venous thromboembolism (PA-VTE) is a leading cause of maternal morbidity and mortality worldwide. Despite the availability of international guidance on the prevention, diagnosis and treatment, practice differs between countries and clinical institutions. The evidence base in this area is limited due to the vulnerable population who are affected, with the majority of guidelines deriving their recommendations from experience in surgical and medical venous thromboembolic disease. This review includes best evidence in PA-VTE management, highlighting specific literature which supports current diagnosis, prevention, and treatment strategies. Additionally, we hope to demonstrate emerging trends in the field through discussion of ongoing trials designed to progress towards evidence-based practice in the context of PA-VTE.
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Affiliation(s)
- Fergal O'Shaughnessy
- Pharmacy Department, Rotunda Hospital, Dublin 1, Ireland; Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland; Department of Haematology, Mater University Hospital, Dublin 7, Ireland
| | - Daniel O'Reilly
- Department of Paediatrics, Children's Health Ireland at Tallaght, Dublin 24, Ireland; SPHERE research group, Conway Institute, University College Dublin, Dublin 4, Ireland; Department of Haematology, Mater University Hospital, Dublin 7, Ireland.
| | - Fionnuala Ní Áinle
- SPHERE research group, Conway Institute, University College Dublin, Dublin 4, Ireland; School of Medicine, University College Dublin, Dublin 4, Ireland; Department of Haematology, Rotunda Hospital, Dublin 1, Ireland; Department of Haematology, Mater University Hospital, Dublin 7, Ireland
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158
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Telemedicine-Based Specialized Care Improves the Outcome of Anticoagulated Individuals with Venous Thromboembolism-Results from the thrombEVAL Study. J Clin Med 2020; 9:jcm9103281. [PMID: 33066188 PMCID: PMC7602093 DOI: 10.3390/jcm9103281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/02/2020] [Accepted: 10/07/2020] [Indexed: 11/17/2022] Open
Abstract
Venous thromboembolism (VTE) is a life-threatening disease with risk of recurrence. Oral anticoagulation (OAC) with vitamin K antagonists (VKA) is effective to prevent thromboembolic recurrence. We aimed to investigate the quality of OAC of VTE patients in regular medical care (RMC) compared to a telemedicine-based coagulation service (CS). The thrombEVAL study (NCT01809015) is a prospective, multi-center study to investigate OAC treatment (recruitment: January 2011-March 2013). Patients were evaluated using clinical visits, computer-assisted personal interviews, self-reported data and laboratory measurements according to standard operating procedures. Overall, 360 patients with VTE from RMC and 254 from CS were included. Time in therapeutic range (TTR) was higher in CS compared to RMC (76.9% (interquartile range [IQR] 63.2-87.1%) vs. 69.5% (52.3-85.6%), p < 0.001). Crude rate of thromboembolic events (rate ratio [RR] 11.33 (95% confidence interval [CI] 1.85-465.26), p = 0.0015), clinically relevant bleeding (RR 6.80 (2.52-25.76), p < 0.001), hospitalizations (RR 2.54 (1.94-3.39), p < 0.001) and mortality under OAC (RR 5.89 (2.40-18.75), p < 0.001) were consistently higher in RMC compared with CS. Patients in RMC had higher risk for primary outcome (clinically relevant bleedings, thromboembolic events and mortality, hazard ratio [HR] 5.39 (95%CI 2.81-10.33), p < 0.0001), mortality (HR 5.54 (2.22-13.84), p = 0.00025), thromboembolic events (HR 6.41 (1.51-27.24), p = 0.012), clinically relevant bleeding (HR 5.31 (1.89-14.89), p = 0.0015) and hospitalization (HR 1.84 (1.34-2.55), p = 0.0002). Benefits of CS care were still observed after adjusting for comorbidities and TTR. In conclusion, anticoagulation quality and outcome of VTE patients undergoing VKA treatment was significantly better in CS than in RMC. Patients treated in CS had lower rates of adverse events, hospitalizations and lower mortality. CS was prognostically relevant, beyond providing advantages of improved international ratio (INR) monitoring.
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159
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Channick CL, Garrison G, Huie TJ, Narewski E, Caplan-Shaw C, Cho J, Rafeq S, Alalawi R, Alashram R, Bailey KL, Carmona EM, Habib N, Kapolka R, Krishnan A, Lammi MR, Peck T, Pennington KM, Rali P, Small BL, Swenson C, Witkin A, Hayes MM. ATS Core Curriculum 2020. Adult Pulmonary Medicine. ATS Sch 2020; 1:416-435. [PMID: 33870311 PMCID: PMC8015759 DOI: 10.34197/ats-scholar.2020-0016re] [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] [Received: 02/06/2020] [Accepted: 08/03/2020] [Indexed: 01/08/2023] Open
Abstract
The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine in a 3- to 4-year recurring cycle of topics. The topics of the 2020 Pulmonary Core Curriculum include pulmonary vascular disease (submassive pulmonary embolism, chronic thromboembolic pulmonary hypertension, and pulmonary hypertension) and pulmonary infections (community-acquired pneumonia, pulmonary nontuberculous mycobacteria, opportunistic infections in immunocompromised hosts, and coronavirus disease [COVID-19]).
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Affiliation(s)
- Colleen L. Channick
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology, and Allergy, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Garth Garrison
- Division of Pulmonary Disease and Critical Care Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Tristan J. Huie
- Division of Pulmonary Sciences and Critical Care Medicine, Anschutz Medical Campus, University of Colorado, Aurora, Colorado
| | - Erin Narewski
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Caralee Caplan-Shaw
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, New York University, New York, New York
| | - Josalyn Cho
- Division of Pulmonary, Critical Care, and Occupational Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Samaan Rafeq
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, New York University, New York, New York
| | - Raed Alalawi
- Division of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine, University of Arizona, Phoenix, Phoenix, Arizona
| | - Rami Alashram
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Kristina L. Bailey
- Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Nebraska Medical Center, University of Nebraska, Omaha, Nebraska
| | - Eva M. Carmona
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Naomi Habib
- Division of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine, University of Arizona, Phoenix, Phoenix, Arizona
| | - Rebecca Kapolka
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University, Atlanta, Georgia
| | - Amita Krishnan
- Section of Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University Health Sciences Center, Louisiana State University, New Orleans, Louisiana
| | - Matthew R. Lammi
- Section of Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University Health Sciences Center, Louisiana State University, New Orleans, Louisiana
| | - Tyler Peck
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Kelly M. Pennington
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Bronwyn L. Small
- Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Nebraska Medical Center, University of Nebraska, Omaha, Nebraska
| | - Colin Swenson
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University, Atlanta, Georgia
| | - Alison Witkin
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Margaret M. Hayes
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center–Harvard Medical School, Harvard University, Boston, Massachusetts
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160
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Quezada A, Jiménez D. Duración de la anticoagulación tras una tromboembolia de pulmón: una decisión no siempre sencilla. Arch Bronconeumol 2020; 56:617-618. [DOI: 10.1016/j.arbres.2019.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 10/31/2019] [Accepted: 11/04/2019] [Indexed: 11/26/2022]
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161
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Abstract
Purpose of the Review Point-of-care ultrasound using small ultrasound devices has expanded beyond emergency and critical care medicine to many other subspecialties. Awareness of the strengths and limitations of the technology and knowledge of the appropriate settings and common indications for point-of-care ultrasound is important. Recent Findings Point-of-care ultrasound is widely embraced as an extension of the physical exam and is employed in acute care and medical education settings. Echocardiography laboratories involved in education must individualize training to the intended scope of practice of the user. Advances in artificial intelligence may assist in image acquisition and interpretation by novice users. Summary Point-of-care ultrasound is widely available in a variety of clinical settings. The field has advanced substantially in the past 2 decades and will likely continue to expand with advancement in technology, reduced cost, and improved opportunities to assist new users.
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Affiliation(s)
- Linda Lee
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, 5758 S. Maryland Ave., MC 9067, Chicago, IL, 60637, USA
| | - Jeanne M DeCara
- Department of Medicine, Section of Cardiology, University of Chicago Medicine, 5758 S. Maryland Ave., MC 9067, Chicago, IL, 60637, USA.
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162
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Affiliation(s)
- Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, ul. borowa 14/18, ECZ-Otwock, Otwock, Poland
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163
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Zuily S, Cohen H, Isenberg D, Woller SC, Crowther M, Dufrost V, Wahl D, Doré CJ, Cuker A, Carrier M, Pengo V, Devreese KMJ. Use of direct oral anticoagulants in patients with thrombotic antiphospholipid syndrome: Guidance from the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. J Thromb Haemost 2020; 18:2126-2137. [PMID: 32881337 DOI: 10.1111/jth.14935] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/20/2020] [Accepted: 05/18/2020] [Indexed: 01/17/2023]
Abstract
Clarity and guidance is required with regard to the use of direct oral anticoagulants in antiphospholipid syndrome (APS) patients, within the confines of the recent European Medicines Agency recommendations, discrepant recommendations in other international guidelines and the limited evidence base. To address this, the Lupus Anticoagulant/Antiphospholipid Antibodies Scientific and Standardization Committee (SSC) chair and co-chairs together with SSC Control of Anticoagulation members propose guidance for healthcare professionals to help them manage APS patients. Uncertainty in this field will be addressed. This guidance will also serve as a call and focus for research.
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Affiliation(s)
- Stéphane Zuily
- Division of Vascular Medicine and Regional Competence Centre for Rare Vascular and Systemic Autoimmune Diseases, Nancy Academic Hospital, Nancy, France
- Inserm UMR_S 1116, Lorraine University, Nancy, France
| | - Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - David Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Murray, UT, USA
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Virginie Dufrost
- Division of Vascular Medicine and Regional Competence Centre for Rare Vascular and Systemic Autoimmune Diseases, Nancy Academic Hospital, Nancy, France
- Inserm UMR_S 1116, Lorraine University, Nancy, France
| | - Denis Wahl
- Division of Vascular Medicine and Regional Competence Centre for Rare Vascular and Systemic Autoimmune Diseases, Nancy Academic Hospital, Nancy, France
- Inserm UMR_S 1116, Lorraine University, Nancy, France
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Vittorio Pengo
- Cardiology Clinic, Department of Cardiac-Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Diagnostic Sciences, Ghent University Hospital, Ghent, Belgium
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164
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Acceptance of a potential major bleeding among patients with venous thromboembolism on long-term oral anticoagulation: the knowledge of the disease and therapy matters. Thromb Res 2020; 193:116-121. [DOI: 10.1016/j.thromres.2020.05.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 05/15/2020] [Accepted: 05/25/2020] [Indexed: 12/22/2022]
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165
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Konstantinides S, Meyer G. Management of acute pulmonary embolism 2019: what is new in the updated European guidelines? Intern Emerg Med 2020; 15:957-966. [PMID: 32458205 PMCID: PMC7467952 DOI: 10.1007/s11739-020-02340-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 04/08/2020] [Indexed: 12/11/2022]
Abstract
Pulmonary embolism (PE) is the third most frequent acute cardiovascular syndrome. Annual PE incidence and PE-related mortality rates rise exponentially with age, and consequently, the disease burden imposed by PE on the society continues to rise as the population ages worldwide. Recently published landmark trials provided the basis for new or changed recommendations included in the 2019 update of the European Society of Cardiology Guidelines (developed in cooperation with the European Respiratory Society). Refinements in diagnostic algorithms were proposed and validated, increasing the specificity of pre-test clinical probability and D-dimer testing, and thus helping to avoid unnecessary pulmonary angiograms. Improved diagnostic strategies were also successfully tested in pregnant women with suspected PE. Non-vitamin K antagonist oral anticoagulants (NOACs) are now the preferred agents for treating the majority of patients with PE, both in the acute phase (with or without a brief lead-in period of parenteral heparin or fondaparinux) and over the long term. Primary reperfusion is reserved for haemodynamically unstable patients. Besides, the 2019 Guidelines endorse multidisciplinary teams for coordinating the acute-phase management of high-risk and (in selected cases) intermediate-risk PE. For normotensive patients, physicians are advised to include the assessment of the right ventricle on top of clinical severity scores in further risk stratification, especially if early discharge of the patient is envisaged. Further important updates include guidance (1) on extended anticoagulation after PE, taking into account the improved safety profile of NOACs; and (2) on the overall care and follow-up of patients who have suffered PE, with the aim to prevent, detect and treat late sequelae of venous thromboembolism.
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Affiliation(s)
- Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Langenbeckstrasse 1, Bldg. 403, 55131 Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Komotini, Greece
| | - Guy Meyer
- Respiratory Medicine Department, Hôpital Européen Georges Pompidou, APHP, Paris, France
- Université Paris Descartes, 75006 Paris, France
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166
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Albertsen IE, Nielsen PB. How to optimize the value of administrative venous thromboembolism codes. Thromb Res 2020; 194:195-196. [PMID: 32788117 DOI: 10.1016/j.thromres.2020.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Ida Ehlers Albertsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark..
| | - Peter Brønnum Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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167
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Rivera-Lebron BN, Rali PM, Tapson VF. The PERT Concept: A Step-by-Step Approach to Managing Pulmonary Embolism. Chest 2020; 159:347-355. [PMID: 32758561 DOI: 10.1016/j.chest.2020.07.065] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/30/2020] [Accepted: 07/16/2020] [Indexed: 11/28/2022] Open
Abstract
Pulmonary embolism (PE) is a major source of morbidity and mortality. The presentation of acute PE varies, ranging from few or no symptoms to sudden death. Patient outcome depends on how well the right ventricle can sustain the increased afterload caused by the embolic burden. Careful risk stratification is critical, and the PE response team (PERT) concept offers a rapid and multidisciplinary approach. Anticoagulation is essential unless contraindicated; thrombolysis, surgical embolectomy, and catheter-directed approaches are also available. Clinical consensus statements have been published that offer a guide to PE management, but areas remain for which the evidence is inadequate. Although the management of low-risk and high-risk patients is more straightforward, optimal management of intermediate-risk patients remains controversial. In this document, we offer a case-based approach to PE management, beginning with diagnosis and risk stratification, followed by therapeutic alternatives, and finishing with follow-up care.
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Affiliation(s)
- Belinda N Rivera-Lebron
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Parth M Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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168
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Araszkiewicz A, Kurzyna M, Kopeć G, Roik M, Darocha S, Pietrasik A, Puślecki M, Biederman A, Przybylski R, Stępniewski J, Furdal M, Mularek-Kubzdela T, Pruszczyk P, Torbicki A. Expert opinion on the creating and operating of the regional Pulmonary Embolism Response Teams (PERT). Polish PERT Initiative. Cardiol J 2020; 26:623-632. [PMID: 31970735 DOI: 10.5603/cj.2019.0127] [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: 11/30/2019] [Revised: 01/11/2020] [Accepted: 01/14/2020] [Indexed: 01/20/2023] Open
Abstract
Pulmonary Embolism Response Team (PERT) is a multidisciplinary team established to stratify risk and choose optimal treatment in patients with acute pulmonary embolism (PE). Established for the first time at Massachusetts General Hospital in 2013, PERT is based on a concept combining a Rapid Response Team and a Heart Team. The growing role of PERTs in making individual therapeutic decisions is identified, especially in hemodynamically unstable patients with contraindications to thrombolysis or with co-morbidities, as well as in patients with intermediate-high risk in whom a therapeutic decision may be difficult. The purpose of this document is to define the standards of PERT under Polish conditions, based on the experience of teams already operating in Poland, which formed an agreement called the Polish PERT Initiative. The goals of Polish PERT Initiative are: improving the treatment of patients with PE at local, regional and national levels, gathering, assessing and sharing data on the effectiveness of PE treatment (including various types of catheter-directed therapy), education on optimal treatment of PE, creating expert documents and supporting scientific research, as well as cooperation with other communities and scientific societies.
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Affiliation(s)
- Aleksander Araszkiewicz
- 1st Department of Cardiology, University of Medical Sciences,Poznan, Poland, Dluga 1/2, 61-848 Poznan, Poland.
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology European Health Centre Otwock, Medical Centre for Postgraduate Education, Otwock, Poland
| | - Grzegorz Kopeć
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Marek Roik
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Poland, Poland
| | - Szymon Darocha
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology European Health Centre Otwock, Medical Centre for Postgraduate Education, Otwock, Poland
| | - Arkadiusz Pietrasik
- Department and Faculty of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Mateusz Puślecki
- Department of Medical Rescue and Department of Cardiac Surgery and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Roman Przybylski
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Jakub Stępniewski
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Michał Furdal
- Department of Cardiology, Provincial Specialist Hospital, Wroclaw, Poland
| | - Tatiana Mularek-Kubzdela
- 1st Department of Cardiology, University of Medical Sciences,Poznan, Poland, Dluga 1/2, 61-848 Poznan, Poland
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Poland, Poland
| | - Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology European Health Centre Otwock, Medical Centre for Postgraduate Education, Otwock, Poland
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169
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Gupta R. Reappraising Thrombolytic Therapy and Risk Stratification for Acute Pulmonary Embolism: Where Does Hypoxemia Fit In? Am J Med Sci 2020; 360:107-108. [DOI: 10.1016/j.amjms.2020.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 04/23/2020] [Indexed: 11/26/2022]
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170
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Qanadli SD, Gudmundsson L, Rotzinger DC. Catheter-directed thrombolysis in COVID-19 pneumonia with acute PE: Thinking beyond the guidelines. Thromb Res 2020; 192:9-11. [PMID: 32416366 PMCID: PMC7205661 DOI: 10.1016/j.thromres.2020.05.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 01/16/2023]
Abstract
•Patients having COVID-19 pneumonia are at risk of venous thromboembolism. •Prophylaxis versus anticoagulation for severely ill patients is currently debated. •No specific guidelines for the management of severe pulmonary embolism exist. •Endovascular pulmonary embolism therapy may play a critical role in severe COVID-19.
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Affiliation(s)
- S D Qanadli
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland.
| | - L Gudmundsson
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - D C Rotzinger
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
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171
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Xiong W, Du H, Ding W, Sun J, Xu M, Guo X. The association between pulmonary embolism and the cancer-related genomic alterations in patients with NSCLC. Respir Res 2020; 21:185. [PMID: 32677947 PMCID: PMC7364644 DOI: 10.1186/s12931-020-01437-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 06/29/2020] [Indexed: 12/21/2022] Open
Abstract
To date, the association between the acute pulmonary embolism (PE) and the currently existing cancer-related genomic alterations in patients with non-small cell lung cancer (NSCLC) has been understudied. We reviewed patients with a confirmed histopathological diagnosis of NSCLC who underwent computed tomography pulmonary angiography (CTPA) and molecular tests including ALK, ROS1, EGFR, BRAF V600E as well as PD-L1 during the diagnosis of NSCLC, to explore the association between the genomic alterations and PE. The results showed that, for the patients with positive results of genomic alterations, the proportion of positive ALK (13.6%vs8.5%, P<0.001) and PD-L1 (24.7%vs19.9%, P = 0.001) in PE group were more than those in Non-PE group. The patients with positive ALK and PD-L1 had the most (19.0%) and second most (15.4%) incidence of PE among all the patients being studied. A multivariate Logistic regression analysis showed that the positive ALK [1.685(1.065-2.215)(P<0.001)] and PD-L1[1.798(1.137-2.201)(P<0.001)] were correlated with the occurrence of PE. The positive results of ALK and PD-L1 genomic alterations may indicate an increased risk of pulmonary embolism in patients with NSCLC.
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Affiliation(s)
- Wei Xiong
- Department of Respiratory Medicine, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092, Yangpu District, China.
| | - He Du
- Department of Oncology, Shanghai Pulmonary Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Wei Ding
- Department of Pulmonary and Critical Care Medicine, Punan Hospital, Pudong New District, Shanghai, China
| | - Jinyuan Sun
- Department of Respiratory Medicine, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092, Yangpu District, China
| | - Mei Xu
- Department of General Practice, North Bund Community Health Center, Shanghai, Hongkou District, China.
| | - Xuejun Guo
- Department of Respiratory Medicine, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, No. 1665, Kongjiang Road, Shanghai, 200092, Yangpu District, China.
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172
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Havranek S, Fingrova Z, Ambroz D, Jansa P, Kuchar J, Dusik M, Lindner J, Kunstyr J, Aschermann M, Linhart A. Atrial fibrillation and atrial tachycardia in patients with chronic thromboembolic pulmonary hypertension treated with pulmonary endarterectomy. Eur Heart J Suppl 2020; 22:F30-F37. [PMID: 32694951 PMCID: PMC7361671 DOI: 10.1093/eurheartj/suaa096] [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] [Indexed: 01/30/2023]
Abstract
Atrial fibrillation (AF) and atrial tachycardia (AT) are frequently observed in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who were treated with pulmonary endarterectomy (PEA). Their prevalence and impact on prognosis of patients are not known. We analysed the prevalence of AF/AT and the clinical outcome in 197 patients with CTEPH treated with PEA (median age 62; interquartile range 53–68 years; 62% males). The prevalence of AF/AT was 29% (57 patients). Compared to patients without arrhythmia, the subjects with AF/AT were older [60 (50–67) vs. 62 (57–70) years], manifested an increased size of the left atrium [39 (35–44) vs. 45 (40–50) mm], had a reduced 6-min walking distance [411 (321–506) vs. 340 (254–460) m], and higher pulmonary artery systolic pressure after PEA [38 (30–47) vs. 45 (38–71) mmHg], all results with P-value <0.05. During the follow-up with a median 4.2 (1.6–6.3) years, 45 (23%) patients died. In a multivariate Cox regression model only the male gender [hazard ratio (HR) 2.27, 95% confidence interval (CI) 1.15–4.50], a reduced 6-min walking distance (HR 3.67, 95% CI 1.74–7.73), and an increased New York Heart Association class (HR 8.56, 95% CI 4.17–17.60) were associated with mortality (P < 0.05). The prevalence of AF/AT in patients with CTEPH treated with PEA is high. Arrhythmias are associated with reduced functional capacity but not with mortality.
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Affiliation(s)
- Stepan Havranek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, 1st Faculty of Medicine, Charles University, U Nemocnice 2, Prague 128 08, Czech Republic
| | - Zdenka Fingrova
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, 1st Faculty of Medicine, Charles University, U Nemocnice 2, Prague 128 08, Czech Republic
| | - David Ambroz
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, 1st Faculty of Medicine, Charles University, U Nemocnice 2, Prague 128 08, Czech Republic
| | - Pavel Jansa
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, 1st Faculty of Medicine, Charles University, U Nemocnice 2, Prague 128 08, Czech Republic
| | - Jan Kuchar
- Regional Hospital in Tabor, Kpt. Jarose 2000, Tabor 390 03, Czech Republic
| | - Milan Dusik
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, 1st Faculty of Medicine, Charles University, U Nemocnice 2, Prague 128 08, Czech Republic
| | - Jaroslav Lindner
- 2nd Department of Surgery - Department of Cardiovascular Surgery, General Univesity Hospital in Prague, 1st Faculty of Medicine, Charles University, U Nemocnice 2, Prague 128 08, Czech Republic
| | - Jan Kunstyr
- Department of Anesthesiology, Resuscitation and Intensive Medicine, General Univesity Hospital in Prague, 1st Faculty of Medicine, Charles University, U Nemocnice 2, Prague 128 08, Czech Republic
| | - Michael Aschermann
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, 1st Faculty of Medicine, Charles University, U Nemocnice 2, Prague 128 08, Czech Republic
| | - Ales Linhart
- 2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, 1st Faculty of Medicine, Charles University, U Nemocnice 2, Prague 128 08, Czech Republic
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173
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Sabatino J, De Rosa S, Polimeni A, Sorrentino S, Indolfi C. Direct Oral Anticoagulants in Patients With Active Cancer: A Systematic Review and Meta-Analysis. JACC: CARDIOONCOLOGY 2020; 2:428-440. [PMID: 34396250 PMCID: PMC8352218 DOI: 10.1016/j.jaccao.2020.06.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 01/08/2023]
Abstract
Background Many patients with cancer have a hypercoagulable state and an increased risk of developing venous thromboembolism (VTE), arterial occlusion, and pulmonary emboli. Patients with cancer may also have an increased risk of bleeding with anticoagulant treatment. Recent trials have reported that direct oral anticoagulants (DOACs) are noninferior to the low-molecular-weight heparin, dalteparin, in preventing VTE, but have a higher bleeding rate. Objectives This study compared the efficacy and risks of DOACs versus dalteparin in patients with cancer-related VTEs across all randomized controlled trials (RCTs). Methods This study performed a systematic analysis of RCTs published in PubMed, SCOPUS, and Google Scholar from September 1, 2007 through March 31, 2020 that reported clinical outcomes of treatment with DOACs versus dalteparin in patients with cancer with acute VTE. Two investigators independently performed study selection and data extraction. Extracted data were recorded and exported to statistical software for all analyses (OpenMetaAnalyst). Results This study included 4 randomized trials (N = 2,907). Compared with DOACs, dalteparin was associated with higher VTE recurrence (risk ratio [RR]: 1.55; 95% confidence interval [CI]: 1.19 to 2.03; p = 0.001), whereas clinically relevant nonmajor bleeding (CRNMB) was significantly less frequent with dalteparin than that with DOACs (RR: 0.68; 95% CI: 0.54 to 0.86; p = 0.001). The risk of CRNMB was largely observed with patients with gastrointestinal malignancies. No significant differences were observed in major bleeding (RR: 0.74; 95% CI: 0.52 to 1.06; p = 0.11). Conclusions DOACs were noninferior to dalteparin in preventing VTE recurrence in patients with cancer without a significantly increased risk of major bleeding. However, DOACs were associated with higher rates of CRNMB compared with dalteparin, primarily in patients with gastrointestinal malignancies.
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Key Words
- CI, confidence interval
- CRNMB, clinically relevant nonmajor bleeding
- DOAC, direct oral anticoagulant
- DOACs
- DVT, deep vein thrombosis
- GI, gastrointestinal
- LMWH, low-molecular-weight heparin
- PE, pulmonary embolism
- RCT, randomized controlled trial
- RR, risk ratio
- VKA, vitamin K antagonist
- VTE, venous thromboembolism
- cancer
- direct oral anticoagulants
- hypercoagulable state
- venous thromboembolism
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Affiliation(s)
- Jolanda Sabatino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Alberto Polimeni
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
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174
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Nishimoto Y, Yamashita Y, Morimoto T, Saga S, Amano H, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Izumi T, Tada T, Chen PM, Murata K, Tsuyuki Y, Sasa T, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Yoshikawa Y, Shiomi H, Kato T, Makiyama T, Ono K, Sato Y, Kimura T. Predictive ability of modified Ottawa score for recurrence in patients with cancer-associated venous thromboembolism: From the COMMAND VTE Registry. Thromb Res 2020; 191:66-75. [DOI: 10.1016/j.thromres.2020.04.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/18/2020] [Accepted: 04/29/2020] [Indexed: 12/21/2022]
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175
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Robert-Ebadi H, Righini M. The 2019 ESC guidelines on pulmonary embolism: some further insights. Eur J Intern Med 2020; 77:6-8. [PMID: 32446816 DOI: 10.1016/j.ejim.2020.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 04/28/2020] [Accepted: 05/04/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
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176
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An international survey of clinicians regarding their management of venous thromboembolism following the initial 3-6 months of anticoagulation. J Thromb Thrombolysis 2020; 51:17-24. [PMID: 32592081 DOI: 10.1007/s11239-020-02193-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
After an initial treatment period for venous thromboembolism (VTE), indefinite anticoagulation may be considered, depending upon individual risks. The aim of the study was to determine if there is consensus amongst clinicians that manage VTE regarding which patients require 3-6 months versus indefinite anticoagulation. The importance of VTE site and severity in decision making was also evaluated. An international survey of clinicians involved in VTE management was undertaken. Respondents were asked about long-term treatment of six patients that had completed 3-6 months initial anticoagulation. These included four cases of VTE not associated with a major reversible risk factor and two control cases; one unprovoked VTE and one VTE associated with a major reversible risk factor. For consensus, there was a pre-defined equivalence boundary whereby at least 70% of clinicians had to decide either to stop or consider indefinite anticoagulation for each case. 351 responses were collected. In the control cases, there was a ≥ 95% consensus on long-term management (stop versus indefinite anticoagulation). In three of the four test cases, there was no consensus about duration of anticoagulation. In case 3, 78% (99% confidence interval 73-84%) would stop anticoagulation after 3-6 months. When analysed by grade or specialty of doctor, a lack of consensus remained. Opinion on whether site or severity of VTE influenced decision making was variable. For patients with unprovoked VTE or VTE associated with a major transient risk factor there is treatment consensus. For the remainder, there is a lack consensus regarding the need for indefinite anticoagulation.
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177
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Hendriks SV, Klok FA, Stenger WJE, Mairuhu ATA, Eikenboom J, Fogteloo J, Huisman MV. Effectiveness and Safety of Apixaban for Treatment of Venous Thromboembolism in Daily Practice. TH OPEN 2020; 4:e119-e126. [PMID: 32607465 PMCID: PMC7314657 DOI: 10.1055/s-0040-1713683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/25/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction Phase 3 trials have shown comparable efficacy of direct oral anticoagulants (DOACs) and vitamin K antagonists in patients with acute venous thromboembolism (VTE), with less major bleeding events in patients randomized to DOAC treatment. With DOACs being increasingly used in clinical practice, evaluation of the DOACs in daily practice-based conditions is needed to confirm their safety and effectiveness. The aim of this study is to evaluate the effectiveness and safety of apixaban in VTE patients in daily practice. Methods In this retrospective cohort study, consecutive patients diagnosed with VTE in two Dutch hospitals (Leiden University Medical Center, Leiden and Haga Teaching Hospital, The Hague) were identified based on administrative codes. We assessed recurrent VTE, major bleeding and mortality during a 3-month follow-up period in those treated with apixaban. Results Of 671 consecutive VTE patients treated with apixaban, 371 presented with acute pulmonary embolism (PE) and 300 patients with deep-vein thrombosis. During 3 months treatment, 2 patients had a recurrent VTE (0.3%; 95% confidence interval [CI]: 0.08-1.1), 12 patients had major bleeding (1.8%; 95% CI: 1.0-3.2), and 11 patients died (1.6%; 95% CI: 0.9-2.9), of which one patient with recurrent PE and one because of a intracerebral bleeding. Conclusion In this daily practice-based cohort, apixaban yielded a low incidence of recurrent VTE, comparable to the phase 3 AMPLIFY study patients. The incidence of major bleeding was higher than in the AMPLIFY-study patients, reflecting the importance of daily practice evaluation and the fact that results from phase III clinical studies cannot be directly extrapolated toward daily practice.
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Affiliation(s)
- Stephan V Hendriks
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Department of Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilhelmina J E Stenger
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Albert T A Mairuhu
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Department of Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Jeroen Eikenboom
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaap Fogteloo
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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178
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Montes Santiago J, Argibay Filgueira AB. Home treatment of venous thromboembolism disease. Rev Clin Esp 2020; 220:S0014-2565(20)30130-2. [PMID: 32560918 DOI: 10.1016/j.rce.2020.03.008] [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: 01/15/2020] [Revised: 03/08/2020] [Accepted: 03/24/2020] [Indexed: 11/30/2022]
Abstract
Despite the potential benefits of outpatient care, most patients with pulmonary embolisms are treated in hospitals for fear of possible adverse events. However, there is a wealth of scientific evidence from studies covering more than 4000 outpatients, which has led the current clinical practice guidelines to recommend early discharge or outpatient treatment when a low risk of death or complications has been confirmed, when there are no comorbidities or aggravating processes present to warrant hospitalisation and when appropriate monitoring and treatment are observed. This approach minimises the complications that can arise in hospitals and represents considerable cost savings. When selecting these patients, the use of prognostic tools such as the Pulmonary Embolism Severity Index (PESI), its simplified version (sPESI) and the Hestia Criteria are of paramount importance. Using these tools, the short-term outcomes (30-90days) show low mortality (in general <3%) and a low incidence of other complications (rate of recurrence and major bleeding <2%). Based on the available evidence, outpatient treatment can be considered the most appropriate strategy at this time for most hemodynamically stable patients with pulmonary embolisms.
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Affiliation(s)
- J Montes Santiago
- Departamento de Medicina Interna, Complejo Hospital Universitario, Vigo, Pontevedra, España.
| | - A B Argibay Filgueira
- Departamento de Medicina Interna, Complejo Hospital Universitario, Vigo, Pontevedra, España
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179
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Venoarterial extracorporeal membrane oxygenation is an effective management strategy for massive pulmonary embolism patients. J Vasc Surg Venous Lymphat Disord 2020; 9:307-314. [PMID: 32505687 DOI: 10.1016/j.jvsv.2020.04.033] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/15/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Treatment of massive pulmonary embolism (MPE) is controversial, with mortality rates ranging from 25% to 65%. Patients commonly present with profound shock or cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used as a form of acute cardiopulmonary support in critically ill patients. We reviewed our institution's pulmonary embolism response team experience using VA-ECMO for patients presenting with advanced shock and/or cardiac arrest from MPE. METHODS From March 2017 to July 2019 we retrospectively reviewed 17 consecutive patients at our institution with MPE who were placed on VA-ECMO for initial hemodynamic stabilization. RESULTS The mean patient age and body mass index was 55.8 years and 31.8, respectively. Ten of 17 patients (59%) required cardiopulmonary resuscitation before or during VA-ECMO cannulation. All patients had evidence of profound shock with a mean initial lactate of 8.95 mmol/L, a mean pH of 7.10, and a mean serum creatinine of 1.78 mg/dL. Seventeen of 17 cannulations (100%) were performed percutaneously, with 41% (n = 7) of patients placed on VA-ECMO while awake and using local analgesia. Five of 17 patients (29%) required reperfusion cannulas, with 0% incidence of limb loss. Overall survival was 13 of 17 patients (76%), with causes of death resulting from anoxic brain injury (n = 2), septic shock (n = 1), and cardiopulmonary resuscitation-induced hemorrhage from liver laceration (n = 1). In survivors, 12 of 13 patients (92%) were discharged without evidence of neurologic insult. The median duration of the VA-ECMO run for survivors was 86 hours (range, 45-218 hours). In survivors, the median length of time from ECMO cannulation to lactate clearance (<2.0 mmol/L) was 10 hours and the median length of time from ECMO cannulation to freedom from vasopressors was 6 hours. Three of 13 patients (23%) required concomitant percutaneous thrombectomy and catheter-directed thrombolysis to address persistent right heart dysfunction, with the remaining survivors (77%) receiving VA-ECMO and anticoagulation alone as definitive therapy for their MPE. The median intensive care and hospital length of stay for survivors was 9 and 13 days, respectively. CONCLUSIONS VA-ECMO was effective at salvaging highly unstable patients with MPE. Survivors had rapid reversal of multiple organ failure with ECMO as their primary therapy. The majority of survivors required ECMO and anticoagulation alone for definitive therapy of their MPE.
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180
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Comentarios a la guía ESC 2019 sobre embolia pulmonar aguda. Rev Esp Cardiol (Engl Ed) 2020. [DOI: 10.1016/j.recesp.2019.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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181
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Comments on the 2019 ESC guidelines on acute pulmonary embolism. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2020; 73:452-456. [PMID: 32349911 DOI: 10.1016/j.rec.2019.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 12/18/2019] [Indexed: 06/11/2023]
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182
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Akel T, Qaqa F, Abuarqoub A, Shamoon F. Pulmonary embolism: A complication of COVID 19 infection. Thromb Res 2020; 193:79-82. [PMID: 32526545 PMCID: PMC7247481 DOI: 10.1016/j.thromres.2020.05.033] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 12/13/2022]
Abstract
The Coronavirus Disease 2019 (COVID 19) has been reported in almost every country in the world. Although a large proportion of infected individuals develop only mild symptoms or are asymptomatic, the spectrum of the disease among others has been widely variable in severity. Additionally, many infected individuals were found to have coagulation markers abnormalities. This is especially true among those progressing to severe pneumonia and multi-organ failure. While the incidence of venous thromboembolic (VTE) disease has been recently noted to be elevated among critically ill patients, the incidence among ambulatory and non-critically ill patients is not yet clearly defined. Herein, we present six patients who didn't have any hypercoagulable risk factors yet presented with pulmonary embolism in association with COVID 19 infection. Furthermore, we discuss the possible underlying mechanisms of hypercoagulability and highlight the possibility of underdiagnosing pulmonary embolism in the setting of overlapping symptoms, decreased utilization of imaging secondary to associated risks, and increased turnover times. In addition, we emphasize the role of extended thromboprophylaxis in discharged patients.
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Affiliation(s)
- Tamer Akel
- Department of Cardiology, St. Joseph's University Medical Center, 703 Main St., Paterson, NJ 07503, United States of America.
| | - Firas Qaqa
- Department of Cardiology, St. Joseph's University Medical Center, 703 Main St., Paterson, NJ 07503, United States of America
| | - Ahmad Abuarqoub
- Department of Cardiology, St. Joseph's University Medical Center, 703 Main St., Paterson, NJ 07503, United States of America
| | - Fayez Shamoon
- Department of Cardiology, St. Joseph's University Medical Center, 703 Main St., Paterson, NJ 07503, United States of America
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183
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New Insights into the Use of Direct Oral Anticoagulants in Non-high Risk Thrombotic APS Patients: Literature Review and Subgroup Analysis from a Meta-analysis. Curr Rheumatol Rep 2020; 22:25. [DOI: 10.1007/s11926-020-00901-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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184
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Bartholomew JR. Pulmonary Embolism in the Intensive Care Unit: Therapy in Subpopulations. Crit Care Clin 2020; 36:547-560. [PMID: 32473698 DOI: 10.1016/j.ccc.2020.03.001] [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: 10/24/2022]
Abstract
The optimal management of a submassive or massive pulmonary embolism (PE) during pregnancy is unclear because of a lack of large clinical trials. Evaluation of the patient who may be a candidate for more aggressive therapy includes the use of biomarkers and echocardiogram for risk stratification. PE Response teams (PERTs) have gained increasing acceptance by the medical community and are being implemented in hospitals in the United States and worldwide. PERTs bring together a team of specialists from different disciplines to enhance decision-making in the patient with acute submassive and massive PE.
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Affiliation(s)
- John R Bartholomew
- Vascular Medicine, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue J3-5, Cleveland, OH 44195, USA.
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185
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Acute Pulmonary Embolism. Crit Care Med 2020; 48:769-770. [DOI: 10.1097/ccm.0000000000004297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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186
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187
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Ramírez P, Otero R, Barberà JA. Pulmonary chronic thromboembolic disease. Arch Bronconeumol 2020; 56:314-321. [PMID: 35373741 DOI: 10.1016/j.arbr.2020.03.007] [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: 04/29/2019] [Accepted: 10/21/2019] [Indexed: 06/14/2023]
Abstract
Persistent thrombotic lesions are common in patients with pulmonary embolism. These lesions occur on a clinical spectrum, ranging from an asymptomatic course with complete functional recovery to chronic thromboembolic pulmonary hypertension. The concept of chronic thromboembolic disease has emerged in recent years to describe a subgroup of patients with persistent thrombotic lesions who have symptoms on exertion and pulmonary vascular dysfunction, but no pulmonary hypertension at rest. The prevalence of this entity is unknown and the criteria for diagnosing it are not defined. The aim of this article is to analyze post-pulmonary embolism sequelae and review existing evidence on chronic thromboembolic disease, with special emphasis on its diagnosis and therapeutic approach.
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Affiliation(s)
- Purificación Ramírez
- Servicio de Neumología, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | - Remedios Otero
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío-Instituto de Biomedicina de Sevilla (IBiS); CSIC; Universidad de Sevilla, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Joan Albert Barberà
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Servicio de Neumología y Alergia Respiratoria, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS); Universidad de Barcelona, Barcelona, Spain.
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188
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Physical activity and respiratory symptoms after pulmonary embolism. A longitudinal observational study. Thromb Res 2020; 189:55-60. [DOI: 10.1016/j.thromres.2020.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 01/23/2023]
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189
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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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190
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Hempel D, Michels G. [Sonography in intensive care and emergency medicine : A new training concept]. Med Klin Intensivmed Notfmed 2020; 116:301-306. [PMID: 32318820 DOI: 10.1007/s00063-020-00688-x] [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: 11/13/2019] [Revised: 03/02/2020] [Accepted: 03/26/2020] [Indexed: 01/20/2023]
Abstract
Structured sonography training in internal medicine intensive care and emergency medicine (SIN) comprises two levels and was proposed by three national societies in Germany (DGIIN, DGK and DEGUM). The curriculum consists of a basic level (SIN-I) and an expert level (SIN-II) which are consecutive levels teaching both theoretical and hands-on skills using a symptom-based approach. Competency is assessed using written, oral and practical structured assessments at the end of each level. The goal is to implement national and international recommendations regarding the use of point-of-care ultrasound into clinical practice.
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Affiliation(s)
- D Hempel
- Zentrale Notaufnahme und Aufnahmestation, Universitätsklinik Magdeburg, Magdeburg, Deutschland
| | - G Michels
- Klinik für Akut- und Notfallmedizin, St.-Antonius-Hospital Eschweiler, Dechant-Deckers-Straße 8, 52249, Eschweiler, Deutschland.
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191
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Siddappa Malleshappa SK, Valecha GK, Mehta T, Patel S, Giri S, Smith RE, Parikh RA, Mehta K. Thirty-day readmissions due to Venous thromboembolism in patients discharged with syncope. PLoS One 2020; 15:e0230859. [PMID: 32282801 PMCID: PMC7153877 DOI: 10.1371/journal.pone.0230859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 03/10/2020] [Indexed: 12/14/2022] Open
Abstract
A recent study found that approximately 1 in every 6 patients hospitalized for the 1st episode of syncope had an underlying pulmonary embolism (PE). As current guidelines do not strongly emphasize evaluation for PE in the workup of syncope, we hypothesize that there might be a higher rate of 30-day readmission due to untreated venous thromboembolism (VTE). The objective of this study is to measure the 30-day readmission rate due to VTE and identify predictors of 30-day readmission with VTE among syncope patients. We identified patients admitted with syncope with ICD9 diagnoses code 780.2 in the Nationwide Readmission Database (NRD-2013), Healthcare Cost and Utilization Project (HCUP). The 30-day readmission rate was calculated using methods described by HCUP. Logistic-regression was used to identify predictors of 30-day readmission with VTE. Discharge weights provided by HCUP were used to generate national estimates. In 2013, NRD included 207,339 eligible patients admitted with syncope. The prevalence rates of PE and DVT were 1.1% and 1.4%, respectively. At least one syncope associated condition was present in 60.9% of the patients. Among the patients who were not diagnosed with VTE during index admission for syncope (N = 188,015), 30-day readmission rate with VTE was 0.5% (0.2% with PE and 0.4% with DVT). In conclusion, low prevalence of VTE in patients with syncope and extremely low 30-day readmission rate with VTE argues against missed diagnoses of VTE in index admission for syncope. These results warrant further studies to determine clinical impact of work up for PE in syncope patients without risk factors.
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Affiliation(s)
| | - Gautam K. Valecha
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, United States of America
| | - Tapan Mehta
- Department of Neurology, University of Minnesota, Minneapolis, MN, United States of America
| | - Smit Patel
- Division of Neurology, University of Connecticut, Hartford, CT, United States of America
| | - Smith Giri
- Division of Hematology-Oncology, Yale New Haven Hospital, New Haven, CT, United States of America
| | - Roy E. Smith
- Division of Hematology-Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Rahul A. Parikh
- Division of Hematology-Oncology, University of Kansas Medical Center, Kansas City, KS, United States of America
| | - Kathan Mehta
- Division of Hematology-Oncology, University of Kansas Medical Center, Kansas City, KS, United States of America
- * E-mail:
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192
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Haramati A, Haramati LB. Imaging of Chronic Thromboembolic Disease. Lung 2020; 198:245-255. [PMID: 32166427 DOI: 10.1007/s00408-020-00344-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 02/28/2020] [Indexed: 12/19/2022]
Abstract
Acute pulmonary embolism (PE) is a leading cause of cardiovascular morbidity. The most common long-term complication of acute PE is chronic thromboembolic disease, a heterogenous entity which ranges from asymptomatic imaging sequelae to persistent symptoms. Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease that can develop in this population and represents the only treatable type of pulmonary hypertension. Recognition of the characteristic findings of chronic pulmonary embolism and CTEPH provides not only diagnostic information, but is also crucial for guiding therapy. The present state-of-the-art review focuses on the multimodality imaging features of chronic pulmonary embolism. Detailed description and illustrations of relevant imaging findings will be demonstrated for ventilation/perfusion (V/Q) scan, CT scan and Dual-Energy CT and MRI and features that distinguish chronic PE from common imaging mimics.
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Affiliation(s)
- Adina Haramati
- Department of Radiology, Northwell Health, Manhasset, NY, USA.
| | - Linda B Haramati
- Departments of Radiology and Internal Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
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193
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Rolving N, Brocki BC, Bloch-Nielsen JR, Larsen TB, Jensen FL, Mikkelsen HR, Ravn P, Frost L. Effect of a Physiotherapist-Guided Home-Based Exercise Intervention on Physical Capacity and Patient-Reported Outcomes Among Patients With Acute Pulmonary Embolism: A Randomized Clinical Trial. JAMA Netw Open 2020; 3:e200064. [PMID: 32108888 PMCID: PMC7049077 DOI: 10.1001/jamanetworkopen.2020.0064] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
IMPORTANCE Survivors of acute pulmonary embolism (PE) experience long-term negative physical and mental consequences, but the effects of rehabilitation on outcomes among these patients have not been investigated. OBJECTIVE To investigate the effect of a rehabilitation intervention, comprising an 8-week home-based exercise program and nurse consultations, on physical capacity and patient-reported outcomes among patients with acute PE. DESIGN, SETTING, AND PARTICIPANTS This multicenter randomized clinical superiority trial was conducted at 4 regional hospitals and 1 university hospital in Denmark. The 140 consecutively included participants had been diagnosed with an acute PE between April 2016 and February 2018 and had 6 months of follow-up. An intention-to-treat analysis was conducted. INTERVENTION Patients in the control group received a brief nurse consultation, while patients in the exercise group participated in an 8-week home-based exercise program in addition to receiving nurse consultations. MAIN OUTCOMES AND MEASURES The primary outcome was the Incremental Shuttle Walk Test, and secondary outcomes were the Pulmonary Embolism Quality of Life and the EuroQol-5 Dimensions-3 Levels questionnaires, self-reported number of sick-leave days, and self-reported use of psychotropic drugs. RESULTS A total of 140 patients (90 [64.3%] men) were included, with a mean (SD) age of 61 (11) years. Of 70 participants (50.0%) randomized to each group, 69 participants (49.3%) received the intervention and 68 (48.6%) received the control intervention. Both groups achieved improvements in all outcomes (eg, mean [SD] improvement on Incremental Shuttle Walk Test: control group, 78 (127) m; intervention group, 104 [106] m; median [interquartile range] improvement on Pulmonary Embolism Quality of Life: control group, -17 [-22 to -11] points; intervention group, -20 [-24 to -15] points). Between-group differences were nonsignificant. The mean differences between the intervention group and the control group were 25 m (95% CI, -20 to 70 m; P = .27) on the Incremental Shuttle Walk Test, 3.0 points (95% CI, -3.7 to 9.9 points; P = .39) on the Pulmonary Embolism Quality of Life questionnaire, and 0.017 point (95% CI, -0.032 to 0.065 point; P = .50) on the EuroQol-5 Dimensions-3 Levels questionnaire. Of the 27 patients in the intervention group on sick leave at baseline, 24 (88.9%) reported fit-for-duty at the 6-month follow-up, and of 18 patients in the control group on sick leave, 17 (94.4%) reported fit-for-duty at the 6-month follow up. The between-group risk difference was not significant (5.5 points; P = .49). CONCLUSIONS AND RELEVANCE An 8-week rehabilitation intervention with exercise added to nurse consultations did not show significantly better outcomes than nurse consultations alone. However, because of a ceiling effect on the primary outcome of physical capacity and an inclusion of patients with a low comorbidity burden and low PE disease severity, definitive conclusions could not be drawn. Initiating an exercise intervention shortly after pulmonary embolism was safe and without adverse events. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02684721.
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Affiliation(s)
- Nanna Rolving
- Diagnostic Center, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Barbara C. Brocki
- Department of Occupational Therapy and Physiotherapy, Aalborg University Hospital, Aalborg, Denmark
| | | | - Torben B. Larsen
- Thrombosis and Drug Research Unit, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Frank L. Jensen
- Department of Physical and Occupational Therapy, Regional Hospital Herning, Herning, Denmark
| | - Hanne R. Mikkelsen
- Diagnostic Center, Department of Cardiology, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Pernille Ravn
- Diagnostic Center, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Lars Frost
- Diagnostic Center, Department of Cardiology, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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194
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Vedovati MC, Giustozzi M, Franco L. Beyond the guidelines: Novelties, changes and unsolved issues from the 2019 ESC guidelines on pulmonary embolism. Eur J Intern Med 2020; 72:1-4. [PMID: 31744660 DOI: 10.1016/j.ejim.2019.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 11/01/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Maria Cristina Vedovati
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy.
| | - Michela Giustozzi
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - Laura Franco
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
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195
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Heiss C, Pitcher A, Belch JJF, De Carlo M, Reinecke H, Baumgartner I, Mazzolai L, Aboyans V. The year in cardiology: aorta and peripheral circulation. Eur Heart J 2020; 41:501-508b. [DOI: 10.1093/eurheartj/ehz939] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/29/2019] [Accepted: 12/11/2019] [Indexed: 02/07/2023] Open
Abstract
Abstract
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Affiliation(s)
- Christian Heiss
- Department of Clinical and Experimental Medicine, University of Surrey, Stag Hill 14AY04, Guildford GU2 7XH, UK
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill RH1 5RH, UK
| | - Alex Pitcher
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - Jill J F Belch
- The Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital and Medical School, Ninewells Hospital, Dundee DD1 9SY, UK
| | - Marco De Carlo
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, via Paradisa 2, 56100 Pisa, Italy
| | - Holger Reinecke
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Albert Schweitzer Campus 1, A1, 48149 Muenster, Germany
| | - Iris Baumgartner
- Clinical and Interventional Angiology, Swiss Cardiovascular Center Bern, Insel Group AG, University Hospital Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Lucia Mazzolai
- Division of Angiology, Department of Heart and Vessel, Lausanne University Hospital, Ch du Mont-Paisible 18, Lausanne 1011, Switzerland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, 2, Martin Luther King Ave., 87042 Limoges, France
- Inserm 1094, Limoges School of Medicine, Ave Dr. Marcland, 87025 Limoges, France
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196
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Bikdeli B, Jiménez D. Atrial fibrillation in the course of pulmonary embolism: just a little smoke, or fuel to the fire? J Intern Med 2020; 287:114-116. [PMID: 31637791 DOI: 10.1111/joim.12999] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 10/17/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA.,Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, CT, USA.,Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Madrid, Spain.,Medicine Department, Universidad de Alcala, IRYCIS, Madrid, Spain
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Takeshima M, Ishikawa H, Umeta Y, Kudoh M, Umakoshi A, Yoshizawa K, Ito Y, Hosoya T, Tsutsui K, Ohta H, Mishima K. Prevalence of Asymptomatic Venous Thromboembolism in Depressive Inpatients. Neuropsychiatr Dis Treat 2020; 16:579-587. [PMID: 32161463 PMCID: PMC7049756 DOI: 10.2147/ndt.s243308] [Citation(s) in RCA: 7] [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: 12/21/2019] [Accepted: 02/20/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE While depression has been recognized as a risk factor for venous thromboembolism (VTE), the prevalence of VTE in depressed inpatients has never been investigated. The aim of this study was thus to examine VTE prevalence and factors associated with VTE in depressed inpatients. PATIENTS AND METHODS We conducted a retrospective cross-sectional study of consecutive depressed inpatients (n = 94) from January 1, 2018, to June 30, 2019, at the psychiatry department of Akita University Hospital. As part of our clinical routine, depressed inpatients were screened for VTE using D-dimer, and patients who screened positive underwent enhanced CT to examine VTE. A variety of data was extracted from medical records, including, amongst others, age, sex, body mass index, diagnoses of psychiatric disorders, total scores on the 17-item Hamilton Depression Rating Scale, duration of current depressive episode, daily dosages of antidepressants and antipsychotics, catatonia, and physical restraint. RESULTS VTE was detected in 8.5% of depressed inpatients. There were no significant differences between VTE-positive and VTE-negative inpatients regarding any of the considered factors. CONCLUSION Our analysis shows a VTE prevalence of 8.5% in depressed inpatients, higher than that of 2.3% reported in a previous study in hospitalized patients with psychiatric disorders including depression. This emphasizes the importance of VTE screening for depressive inpatients.
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Affiliation(s)
- Masahiro Takeshima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita 010-8543, Japan
| | - Hiroyasu Ishikawa
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita 010-8543, Japan
| | - Yoshiaki Umeta
- Department of Psychiatry, Omagari City Hospital, Akita 014-0067, Japan
| | - Mizuki Kudoh
- Department of Neuropsychiatry, Nakadori Rehabilitation Hospital, Akita 010-0001, Japan
| | - Akise Umakoshi
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita 010-8543, Japan
| | | | - Yu Ito
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita 010-8543, Japan
| | - Tomoko Hosoya
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita 010-8543, Japan
| | - Ko Tsutsui
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita 010-8543, Japan
| | - Hidenobu Ohta
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita 010-8543, Japan
| | - Kazuo Mishima
- Department of Neuropsychiatry, Akita University Graduate School of Medicine, Akita 010-8543, Japan
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Hussein L, Rehman MA, Sajid R, Annajjar F, Al-Janabi T. Bedside ultrasound in cardiac standstill: a clinical review. Ultrasound J 2019; 11:35. [PMID: 31889224 PMCID: PMC6937355 DOI: 10.1186/s13089-019-0150-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 12/23/2019] [Indexed: 01/11/2023] Open
Abstract
Patients with cardiac arrest present as a relatively frequent occurrence in the Emergency Department. Despite the advances in our understanding of the pathophysiology of cardiac arrest, managing the condition remains a stressful endeavor and currently implemented interventions, while beneficial, are still associated with a disappointingly low survivability. The majority of modern Advanced Life Support algorithms employ a standardized approach to best resuscitate the 'crashed' patient. However, management during resuscitation often encourages a 'one-size-fits-all' policy for most patients, with lesser attention drawn towards causality of the disease and factors that could alter resuscitative care. Life support providers are also often challenged by the limited bedside predictors of survival to guide the course and duration of resuscitation. Over the recent decades, point-of-care ultrasonography (PoCUS) has been gradually proving itself as a useful adjunct that could potentially bridge the gap in the recognition and evaluation of precipitants and end-points in resuscitation, thereby facilitating an improved approach to resuscitation of the arrested patient. Point-of-care ultrasound applications in the critical care field have tremendously evolved over the past four decades. Today, bedside ultrasound is a fundamental tool that is quick, safe, inexpensive and reproducible. Not only can it provide the physician with critical information on reversible causes of arrest, but it can also be used to predict survival. Of note is its utility in predicting worse survival outcomes in patients with cardiac standstill, i.e., no cardiac activity witnessed with ultrasound. Unfortunately, despite the increasing evidence surrounding ultrasound use in arrest, bedside ultrasound is still largely underutilized during the resuscitation process. This article reviews the current literature on cardiac standstill and the application of bedside ultrasound in cardiac arrests.
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Affiliation(s)
| | | | - Ruhina Sajid
- Mediclinic Hospital, Dubai, United Arab Emirates
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199
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Bikdeli B, Carrier M, Bates SM. Subsegmental pulmonary embolism: May not be a killer but indicates significant risk. Thromb Res 2019; 185:180-182. [PMID: 31796210 DOI: 10.1016/j.thromres.2019.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA; Yale/YNHH Center for Outcomes Research & Evaluation, New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA.
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, ON, Canada; Ottawa Hospital, General Campus, ON, Canada
| | - Shannon M Bates
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
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200
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Affiliation(s)
- Hazem Lashin
- Adult Critical Care Unit, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom
| | - Rosalba Spiritoso
- Adult Critical Care Unit, Barts Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom
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