Acute pulmonary embolism in elderly: clinical characteristics and outcome

Differences in clinical and echocardiographic variables and mortality predictors among older patients with pulmonary embolism

BACKGROUND

An increase in short-term mortality can be found among older patients with hemodynamically stable acute pulmonary embolism (APE) who have signs of right ventricular (RV) dysfunction.

AIMS

This study was designed to assess whether any difference exists among clinical, laboratory, electrocardiography and echocardiography parameters between older and younger patients diagnosed with APE.

METHODS

The study sample included a total of 635 patients with confirmed APE who were divided into two groups of older (65 years and older) and younger (younger than 65 years) individuals. Comparisons were performed between these groups in terms of clinical, predisposing factors and laboratory, electrocardiographic and echocardiographic parameters.

RESULTS

Analyses of 295 (46.4%) older and 340 (53.6%) younger patients diagnosed with APE were performed. Female sex, Pulmonary Embolism Severity Index score and baseline creatinine levels were higher in the older group. Also, the frequency of atrial fibrillation, RV outflow tract parasternal long-axis proximal diameter, RV end-diastolic diameter (RV-EDD) basal (apical four-chamber) and RV systolic pressure were significantly greater in older patients with APE. A total of 30 (4.7%) deaths were observed during the in-hospital period [21 (7.1%) older vs 9 (2.6%) younger patients; p < 0.01]. In the multivariate logistic regression analysis, age, white blood cell count (WBC), left ventricular ejection fraction (LVEF), RV-EDD basal and tricuspid annular plane systolic excursion (TAPSE) of less than 16 mm were found to be independently associated with in-hospital mortality.

CONCLUSION

Older patients might experience greater rates of RV dilatation, RV dysfunction and atrial fibrillation during APE. In addition to age; elevated WBC, low LVEF, increased RV-EDD basal and TAPSE of less than 16 mm were independent predictors of mortality among study population.

Prognostic value of microalbuminuria on admission in patients with acute pulmonary embolism

OBJECTIVE

There have been no studies examining the effect of microalbuminuria on outcomes of patients with acute pulmonary embolism (APE). This study aimed to assess the association between microalbuminuria and in-hospital mortality in patients with APE.

METHODS

This retrospective study included all adult patients hospitalized due to APE between June 2015 and May 2018. Blood and urine samples were collected before the diagnostic procedures on admission. Patients were divided into 3 groups according to urinary albumin to creatinine ratio (UACR) levels: normoalbuminuria (<30 mg/g), microalbuminuria (30-299 mg/g), and macroalbuminuria (> 300 mg/g). The primary endpoint of the study was in-hospital mortality.

RESULTS

A total of 154 consecutive patients (mean age 69.8 ± 13.4 years, 51.9% female) were included, and 21 (13.6%) of the patients died during their in-hospital course. The prevalence of normoalbuminuria, microalbuminuria, macroalbuminuria was 70.1%, 23.4%, and 6.5%, respectively. Patients with in-hospital mortality had significantly lower estimated glomerular filtration rate (eGFR), but higher UACR at admission than those patients who survived. As compared with patients with normoalbuminuria, multivariate analyses showed that the patients with microalbuminuria and macroalbuminuria had 2.38-, and 3.48-fold higher risk for in-hospital mortality, respectively (p < 0.001). Multivariate analyses also showed that UACR >102.6 mg/g (OR: 1.76; 95% CI, 0.99-3.16; p = 0.011) was independently associated with in-hospital mortality, while a low eGFR was not associated.

CONCLUSION

Microalbuminuria at admission may allow rapid prediction of prognosis in patients with APE.

The diagnostic value of Red Flags in thoracolumbar pain: a systematic review

PURPOSE

Red Flags (RFs) are signs and symptoms related to the screening of serious underlying pathologies mimicking a musculoskeletal pain. The current literature wonders about the usefulness of RFs, due to high false-positive rates and low diagnostic accuracy. The aims of this systematic review are: (a) to identify and (b) to evaluate the most important RFs that could be found by a health care professional during the assessment of patients with low and upper back pain (named as thoracolumbar pain (TLP)) to screen serious pathologies.

MATERIALS AND METHODS

A systematic review of the literature was conducted. Searches were performed on seven databases (Pubmed, Web of Science, Cochrane Library, Pedro, Scielo, CINAHL, and Google Scholar) between March 2019 and June 2020, using a search string which included synonyms of low back pain (LBP), chest pain (CP), differential diagnosis, RF, and serious disease. Only observational studies enrolling patients with LBP or CP were included. Risk of bias was assessed with the Newcastle Ottawa Scale and inter-rater agreement between authors for full-text selection was evaluated with Cohen's Kappa. Where possible the diagnostic accuracy was recorded for sensitivity (Sn), specificity (Sp), and positive/negative likelihood ratio (LR+/LR-).

RESULTS

Forty full-texts were included. Most of the included observational studies were judged as low risk of bias, and Cohen's Kappa was good (=0.78). The identified RFs were: advanced age; neurological signs; history of trauma; malignancy; female gender; corticosteroids use; night pain; unintentional weight loss; bladder or bowel dysfunction; loss of anal sphincter tone; saddle anaesthesia; constant pain; recent infection; family or personal history of heart or pulmonary diseases; dyspnoea; fever; postprandial CP; typical reflux symptoms; haemoptysis; sweating; pain radiated to upper limbs; hypotension; retrosternal pain; exertional pain; diaphoresis; and tachycardia. The diagnostic accuracy of RFs as self-contained screening tool was low, while the combination of multiple RFs showed to increase the probability to identify serious pathologies.

CONCLUSIONS

Despite the use of single RF should not be recommended for the screening process in clinical practice, the combination of multiple RFs to enhance diagnostic accuracy is promising. Moreover, the identified RFs could be a baseline to develop a screening tool for patients with TLP.Implications for rehabilitationDifferential diagnosis and screening for referral are mandatory skills for each healthcare professional in direct access clinical settings, and should be the primary step for an appropriate management of a patient with signs and symptoms mimicking serious pathologies in thoracolumbar region.Clinical reasoning and decision-making processes are essential throughout all phases of a patient's pathway of care. By which, the use of single Red Flag (RF) as a self-contained screening tool should not be recommended. The combination of multiple RFs promises to increase diagnostic accuracy and could grow into an excellent screening tool for thoracolumbar pain.

Survival Benefit of Obese Patients With Pulmonary Embolism

OBJECTIVE

To investigate the impact of obesity and underweight on adverse in-hospital outcomes in pulmonary embolism (PE).

PATIENTS AND METHODS

Patients diagnosed as having PE based on International Statistical Classification of Diseases and Related Health Problems, 10th Revision, German Modification code I26 in the German nationwide inpatient database were stratified for obesity, underweight, and normal weight/overweight (reference group) and compared regarding adverse in-hospital outcomes.

RESULTS

From January 1, 2011, through December 31, 2014, 345,831 inpatients (53.3% females) 18 years and older were included in this analysis; 8.6% were obese and 0.5% were underweight. Obese patients were younger (67.0 vs 73.0 years), were more frequently female (60.2% vs 52.7%), had a lower cancer rate (13.6% vs 20.5%), and were more often treated with systemic thrombolysis (6.4% vs 4.3%) and surgical embolectomy (0.3% vs 0.1%) vs the reference group (P<.001 for all). Overall, 51,226 patients (14.8%) died during in-hospital stay. Obese patients had lower mortality (10.9% vs 15.2%; P<.001) vs the reference group and a reduced odds ratio (OR) for in-hospital mortality (OR, 0.74; 95% CI, 0.71-0.77; P<.001) independent of age, sex, comorbidities, and reperfusion therapies. This survival benefit of obese patients was more pronounced in obesity classes I (OR, 0.56; 95% CI, 0.52-0.60; P<.001) and II (OR, 0.63; 95% CI 0.58-0.69; P<.001). Underweight patients had higher prevalence of cancer and higher mortality rates (OR, 1.15; 95% CI, 1.00-1.31; P=.04).

CONCLUSION

Obesity is associated with decreased in-hospital mortality rates in patients with PE. Although obese patients were more often treated with reperfusion therapies, the survival benefit of obese patients occurred independently of age, sex, comorbidities, and reperfusion treatment.

Obesity paradox in peripheral artery disease

BACKGROUND & AIMS

Previous studies have suggested an obesity survival paradox in patients with peripheral artery disease (PAD). We investigated the influence of obesity and underweight on adverse in-hospital outcomes in PAD.

METHODS

Patients diagnosed with PAD based on ICD-code I70.2 of the German nationwide database were stratified for obesity, underweight and a reference group with normal-weight/over-weight and compared regarding adverse in-hospital outcomes.

RESULTS

Between 01/2005-12/2015, 5,611,484 inpatients (64.8% males) were diagnosed with PAD; of those, 8.9% were coded with obesity and 0.3% with underweight. Obese patients were younger (70 (IQR 63/76) vs. 73 (66/80) years, P < 0.001), more frequently female (36.7% vs. 35.1%, P < 0.001), had less cancer (4.9% vs. 7.9%, P < 0.001) and had less treatment with major amputation (2.6% vs. 3.2%, P < 0.001) compared to the reference group. Overall, 277 876 (5.0%) patients died in-hospital. Obese patients showed lower mortality rate (3.2% vs. 5.1%, P < 0.001) compared to the reference group and reduced risk of in-hospital mortality (OR, 0.617 [95%CI 0.607-0.627], P < 0.001). This "obesity paradox" was demonstrated in obesity classes I (OR, 0.475 [95%CI 0.461-0.490], P < 0.001), II (OR, 0.580 [95%CI 0.557-0.605], P < 0.001), and III (OR, 0.895 [95%CI 0.857-0.934], P < 0.001) and was independent of age, sex and comorbidities. Underweight patients revealed higher in-hospital mortality (6.0% vs. 5.1%, P < 0.001) compared to the reference group (OR, 1.179 [95%CI 1.106-1.257], P < 0.001) and showed higher prevalence of cancer (22.0% vs. 7.9%, P < 0.001).

CONCLUSIONS

Coding for obesity is associated with lower in-hospital mortality in PAD patients relative to those with normal-weight/over-weight. This obesity survival paradox was independent of age, gender and comorbidities and observed for all obesity classes.

Different manifestations of pulmonary embolism in younger compared to older patients: Clinical presentation, prediction rules and long-term outcomes

PURPOSE

Data concerning specific manifestations of pulmonary embolism (PE) among younger patients are scarce. We aimed to evaluate differences in clinical presentation, PE prediction rules, thrombolytic treatment use and PE outcomes in younger (<50 years of age) compared to older patients.

MATERIAL/METHODS

We studied 238 consecutive patients with proven PE who were retrospectively categorized into three PE probability subgroups according to the revised Geneva score (RGS) and Wells score (WS). Duration of follow-up was up to 115 months.

RESULTS

Younger patients accounted for 19.7% of the study cohort. Obesity and smoking were significantly more common, while comorbidities were less common (P<0.05) in the younger patients. According to RGS and WS, younger patients were more often categorized into the low PE probability subgroup and rarely into the high probability subgroup (P<0.05). We found no differences in clinical signs, symptoms, and treatment between the two groups. In-hospital (2% vs. 13%) and long-term (12% vs. 36%) mortality rates were significantly lower in younger patients (P=0.003).

CONCLUSIONS

In younger PE patients, despite differences in predisposing factors and PE probability grading as assessed by RGS and WS, clinical features at admission and treatment were similar compared to the older group. Our findings confirmed lower mortality among younger compared to older patients.

Discharge or admit? Emergency department management of incidental pulmonary embolism in patients with cancer: a retrospective study

BACKGROUND

Hospitalization and early anticoagulation therapy remain standard care for patients who present to the emergency department (ED) with pulmonary embolism (PE). For PEs discovered incidentally, however, optimal therapeutic strategies are less clear-and all the more so when the patient has cancer, which is associated with a hypercoagulable state that exacerbates the threat of PE.

METHODS

We conducted a retrospective review of a historical cohort of patients with cancer and incidental PE who were referred for assessment to the ED in an institution whose standard of care is outpatient treatment of selected patients and use of low-molecular-weight heparin for anticoagulation. Eligible patients had received a diagnosis of incidental PE upon routine contrast enhanced chest CT for cancer staging. Survival data was collected at 30 days and 90 days from the date of ED presentation and at the end of the study.

RESULTS

We identified 193 patients, 135 (70%) of whom were discharged and 58 (30%) of whom were admitted to the hospital. The 30-day survival rate was 92% overall, 99% for the discharged patients and 76% for admitted patients. Almost all (189 patients, 98%) commenced anticoagulation therapy in the ED; 170 (90%) of these received low-molecular-weight heparin. Patients with saddle pulmonary artery incidental PEs were more likely to die within 30 days (43%) than were those with main or lobar (11%), segmental (6%), or subsegmental (5%) incidental PEs. In multivariate analysis, Charlson comorbidity index (age unadjusted), hypoxemia, and incidental PE location (P = 0.004, relative risk 33.5 (95% CI 3.1-357.4, comparing saddle versus subsegmental PE) were significantly associated with 30-day survival. Age, comorbidity, race, cancer stage, tachycardia, hypoxemia, and incidental PE location were significantly associated with hospital admission.

CONCLUSIONS

Selected cancer patients presenting to the ED with incidental PE can be treated with low-molecular-weight heparin anticoagulation and safely discharged. Avoidance of unnecessary hospitalization may decrease in-hospital infections and death, reduce healthcare costs, and improve patient quality of life. Because the natural history and optimal management of this condition is not well described, information supporting the creation of straightforward evidence-based practice guidelines for ED teams treating this specialized patient population is needed.

Vena Caval Filter Utilization and Outcomes in Pulmonary Embolism: Medicare Hospitalizations From 1999 to 2010

BACKGROUND

Inferior vena caval filters (IVCFs) may prevent recurrent pulmonary embolism (PE). Despite uncertainty about their net benefit, patterns of use and outcomes of these devices in contemporary practice are unknown.

OBJECTIVES

The authors determined the trends in utilization rates and outcomes of IVCF placement in patients with PE and explored regional variations in use in the United States.

METHODS

In a national cohort study of all Medicare fee-for-service beneficiaries ≥65 years of age with principal discharge diagnoses of PE between 1999 and 2010, rates of IVCF placement per 100,000 beneficiary-years and per 1,000 patients with PE were determined. The 30-day and 1-year mortality rates after IVCF placement were also investigated.

RESULTS

Among 556,658 patients hospitalized with PE, 94,427 underwent IVCF placement. Between 1999 and 2010, the number of PE hospitalizations with IVCF placement increased from 5,003 to 8,928, representing an increase in the rate per 100,000 beneficiary-years from 19.0 to 32.5 (p < 0.001 for both). As the total number of PE hospitalizations increased (from 31,746 in 1999 to 54,392 in 2010), the rate of IVCF placement per 1,000 PE hospitalizations did not change significantly (from 157.6 to 164.1, p = 0.11). Results were consistent across demographic subgroups, although IVCF use was higher in blacks and patients ≥85 years of age. IVCF utilization varied widely across regions, with the highest rate in the South Atlantic region and the lowest rate in the Mountain region.

CONCLUSIONS

In a period of increasing PE hospitalizations among Medicare fee-for-service beneficiaries, IVCF placement increased as utilization rates in patients with PE remained greater than 15%. Mortality associated with PE hospitalizations is declining, regardless of IVCF use.

Investigation of Proposed Mechanisms of Chemotherapy-Induced Venous Thromboembolism

Venous thromboembolism (VTE) during chemotherapy is common, with 7% mortality in metastatic breast cancer (MBC). In a prospective cohort study of patients with breast cancer, we investigated whether vascular endothelial cell activation (VECA), and whether apoptosis, is the cause of chemotherapy-induced VTE. Methods: Serum markers of VECA, E-selectin (E-sel), vascular cell adhesion molecule 1 (VCAM-1) and d-dimer (fibrin degradation and hypercoagulability marker) were measured prechemotherapy and at 1, 4, and 8 days following chemotherapy. Clinical deep vein thrombosis (DVT) or pulmonary embolism and occult DVT detected by duplex ultrasound imaging were recorded as VTE-positive (VTE+). In patients with MBC, hypercoagulable response to chemotherapy was compared between patients with and without cancer progression. Development of VTE and cancer progression was assessed 3 months following starting chemotherapy. Results: Of the 134 patients, 10 (7.5%) developed VTE (6 [17%] of 36 MBC receiving palliation, 0 of 11 receiving neoadjuvant to downsize tumor, and 4 [5%] of 87 early breast cancer receiving adjuvant chemotherapy, P = .06). Levels of E-sel and VCAM-1 decreased in response to chemotherapy ( P < .001) in both VTE+ and patients not developing VTE (VTE−). However, decrease in VECA markers was similar in VTE+ and VTE− patients, implying this is not the cause of VTE. In patients with MBC following chemotherapy, d-dimer (geometric mean) increased by 36% in the 21 patients with MBC responding to chemotherapy but steadily decreased by 11% in the 15 who progressed (day 4, P < .01), implying patients with tumor response (apoptosis) had an early hypercoagulable response. Conclusions: During chemotherapy for breast cancer, VECA is induced; however, this is not the primary mechanism for VTE. Chemotherapy-induced apoptosis may enhance hypercoagulability and initiate VTE.

A comparison of patients diagnosed with pulmonary embolism who are ≥65 years with patients <65 years

Recent studies have highlighted differences in how older patients respond to high-risk pulmonary embolism (PE) and treatment. However, guidelines for PE risk stratification and treatment are not based on age, and data are lacking for older patients. We characterized the impact of age on clinical features, risk stratification, treatment, and outcomes in a sample of patients with PE in the emergency department. We performed an observational cohort study of 547 consecutive patients with PE in the emergency department from 2005 to 2011 in an urban tertiary hospital. We used bivariate proportions and multivariable logistic regression to compare clinical presentation, risk category, treatment, and outcomes in patients ≥65 years with those <65 years. The mean age was 58 ± 17 years, 276 (50%) were women, and 210 (38%) were ≥65 years. PE was more severe in patients ≥65 years (massive 14% vs 5%, submassive 48% vs 25%, and low risk 38% vs 70%, p <0.0001), with submassive PE being the most common presentation in patients ≥65 years. However, subanalysis removing natriuretic peptides from the definition of submassive PE negated this finding. Treatment with parenteral anticoagulation (88% vs 90%, p = 0.32), thrombolytic therapy (5% vs 4%, p = 0.87), and inferior vena cava filter (4% vs 4%, p = 0.73) were similar among age groups. Patients ≥65 years had higher 30-day mortality (11% vs 3%, p <0.001). In conclusion, patients ≥65 years present with more severe PE and have higher mortality, although treatment patterns were similar to younger patients. Age-specific guideline definitions of submassive PE may better identify high-risk patients.

Relative risk of pulmonary embolism in the very elderly compared with the elderly

BACKGROUND

Pulmonary embolism (PE) can be an acute, life-threatening emergency, and studies suggest that advanced age is a risk factor for this condition. However, the literature is scarce regarding PE in patients above the age of 90 years. This study examined the relative risk for PE in the very elderly (>90 years) compared with that in the elderly (80-89 years).

METHODS

A retrospective study was performed examining very elderly patients diagnosed with PE in the Department of Internal Medicine at the University Hospital Homburg/Saar in Germany between 2004 and 2012. Elderly patients (aged 80-89 years) diagnosed with PE served as controls. PE was confirmed by contrast-enhanced chest computed tomography or ventilation perfusion scintigraphy in both groups. A total of 2230 patients were examined for PE in this study. Of these, 15 (0.67%) in the study group and 197 (8.83%) in the control group underwent further evaluation for PE.

RESULTS

After performing a radiological examination, 11 (73.3%, including six [54.55%] women) of the 15 study patients (mean age 91.6 ± 1.67 years) and 148 (75.1%, including 93 [62.84%] women) of the 197 controls (mean age 84.0 ± 2.59 years) were confirmed to have PE. There was a significantly lower proportion of the very elderly enrolled in the study (P < 0.001). There were no significant differences in clinical presentation, cardiovascular risk factors, electrocardiograms, blood gas analyses, radiological diagnoses, or acute comorbidities between the groups. However, the very elderly were more likely to experience minor bleeding in the extremities (P = 0.016) and to have more chronic diseases (P < 0.001). An increased relative risk of PE was not detected in the very elderly (relative risk 0.98, P = 0.88). Furthermore, D-dimer, troponin T, and high-sensitive troponin T levels had limited predictive value for PE in the very elderly. There were no significant differences in the number of hospital admissions, intensive care or ward treatments, or duration of hospitalization.

CONCLUSION

The relative risk for PE in the very elderly is not higher than that in the elderly.

The Impact of Age on the Delay in Diagnosis in Patients With Acute Pulmonary Embolism

It has been speculated that the atypical clinical presentation of acute pulmonary embolism (PE) in older patients leads to a late diagnosis and therefore contributes to a worse prognosis. Therefore, we prospectively evaluated the delay in diagnosis and its relation to the in-hospital mortality in 202 patients with acute PE. Patients >65 years presented more often with hypoxia ( P = .017) and with a history of syncope ( P = .046). Delay in diagnosis was not statistically different in both age groups. Older age was significantly associated with an increased risk for in-hospital mortality (OR 4.36, 95% CI 0.93-20.37, P = .043), whereas the delay in diagnosis was not associated with an increase of in-hospital mortality. We therefore conclude that the clinical presentation of acute PE in older patients cannot be considered as a risk factor for late diagnosis and is not responsible for their higher in-hospital death rate.

Diagnostic accuracy of point-of-care testing for acute coronary syndromes, heart failure and thromboembolic events in primary care: a cluster-randomised controlled trial

Background

Evidence of the clinical benefit of 3-in-1 point-of-care testing (POCT) for cardiac troponin T (cTnT), N-terminal pro-brain natriuretic peptide (NT-proBNP) and D-dimer in cardiovascular risk stratification at primary care level for diagnosing acute coronary syndromes (ACS), heart failure (HF) and thromboembolic events (TE) is very limited. The aim of this study is to analyse the diagnostic accuracy of POCT in primary care.

Methods

Prospective multicentre controlled trial cluster-randomised to POCT-assisted diagnosis and conventional diagnosis (controls). Men and women presenting in 68 primary care practices in Zurich County (Switzerland) with chest pain or symptoms of dyspnoea or TE were consecutively included after baseline consultation and working diagnosis. A follow-up visit including confirmed diagnosis was performed to determine the accuracy of the working diagnosis, and comparison of working diagnosis accuracy between the two groups.

Results

The 218 POCT patients and 151 conventional diagnosis controls were mostly similar in characteristics, symptoms and pre-existing diagnoses, but differed in working diagnosis frequencies. However, the follow-up visit showed no statistical intergroup difference in confirmed diagnosis frequencies. Working diagnoses overall were significantly more correct in the POCT group (75.7% vs 59.6%, p = 0.002), as were the working diagnoses of ACS/HF/TE (69.8% vs 45.2%, p = 0.002). All three biomarker tests showed good sensitivity and specificity.

Conclusion

POCT confers substantial benefit in primary care by correctly diagnosing significantly more patients.

Trial registration

DRKS: DRKS00000709

Pulmonary embolism in the elderly: a review on clinical, instrumental and laboratory presentation

Objective

Diagnosis of pulmonary embolism (PE) remains difficult and is often missed in the elderly due to nonspecific and atypical presentation. Diagnostic algorithms able to rule out PE and validated in young adult patients may have reduced applicability in elderly patients, which increases the number of diagnostic tools use and costs. The aim of the present study was to analyze the reported clinical presentation of PE in patients aged 65 and more.

Materials and Methods

Prospective and retrospective English language studies dealing with the clinical, instrumental and laboratory aspects of PE in patients more than 65 and published after January 1987 and indexed in MEDLINE using keywords as pulmonary embolism, elderly, old, venous thromboembolism (VTE) in the title, abstract or text, were reviewed.

Results

Dyspnea (range 59%–91.5%), tachypnea (46%–74%), tachycardia (29%–76%), and chest pain (26%–57%) represented the most common clinical symptoms and signs. Bed rest was the most frequent risk factor for VTE (15%–67%); deep vein thrombosis was detected in 15%–50% of cases. Sinus tachycardia, right bundle branch block, and ST-T abnormalities were the most frequent ECG findings. Abnormalities of chest X-ray varied (less than 50% in one-half of the studies and more than 70% in the other one-half). Arterial blood gas analysis revealed severe hypoxemia and mild hypocapnia as the main findings. D-Dimer was higher than cut-off in 100% of patients in 75% of studies. Clinical usefulness of D-Dimer measurement decreases with age, although the strategies based on D-Dimer seem to be cost-effective at least until 80 years.

Conclusion

Despite limitations due to pooling data of heterogeneous studies, our review could contribute to the knowledge of the presentation of PE in the elderly with its diagnostic difficulties. A diagnostic strategy based on reviewed data is proposed.

Primary Prevention of Venous Thromboembolism in Long-Term Care: Identifying and Managing the Risk

Venous thromboembolism (VTE) is a significant, but underestimated, cause of morbidity and mortality in long-term care settings. VTE risk increases significantly with age and is further increased by comorbidities common to this group; however, advancing age and limited mobility alone are insufficient to warrant pharmacological prophylaxis. Recognizing those at increased VTE risk during an acute illness is crucial for appropriate and timely prophylaxis. Warfarin is used for the long-term secondary prevention of VTE, whereas unfractionated and low-molecular-weight heparins are used for primary prophylaxis. The elderly are at increased risk for bleeding complications, because of the high frequency of comorbidities and comedications. Attention to dosing is recommended for those with severely impaired renal function, low body weight, or perceived to be at high bleeding risk. This review addresses the role of risk assessment in the decision of when to provide prophylaxis to an individual in long-term care and highlights key management issues for those prescribed prophylaxis.

The impact of an aging population on the diagnosis of pulmonary embolism: comparison of young and elderly patients

The influence of age on predisposing factors, diagnostic tests, and clinical presentation of pulmonary embolism was evaluated in 582 subjects with suspected pulmonary embolism (180 aged <65 years; 402 aged > or =65 years) consecutively enrolled at the Emergency Department. Pulmonary embolism was confirmed in 40% of patients, 75% of those were aged >65 years. Age was directly related to the diagnosis, and the observed probability was higher than the expected probability in the 70 to 79 year subgroup. Score at the Cumulative Illness Rating Scale significantly increased as a function of both age and pulmonary embolism. Dyspnea, syncope, jugular distension, and history of previous venous thromboembolism were more frequently observed in elderly patients. In-hospital mortality rate among the elderly and younger patients was 2% and 0.2%, respectively. The authors conclude that age > or =65 years and high comorbidity are risk factors for pulmonary embolism.

Predictive indicators of deep venous thrombosis and pulmonary arterial thromboembolism in 54 subjects after total knee arthroplasty using multislice computed tomography in logistic regression models

PURPOSE

To determine predictors of deep venous thrombosis (DVT) in the lower extremities and pulmonary arterial thromboembolism (PE) after total knee arthroplasty (TKA), we evaluated the incidence of these events using multislice computed tomography (CT).

METHODS

54 subjects (10 males, 53-81 years old, the first consecutive 25 receiving anticoagulant therapy) underwent enhanced multislice CT (MSCT) before and one week after TKA.

RESULTS

DVT, PE, and both were detected in twelve, twelve, and three subjects, respectively, one week after TKA. Hemoglobin and alveolar-arterial oxygen gradient (AaDO2) on the day after TKA, and total amount of operative bleeding (TAOB) were significantly higher in subjects with DVT or PE (P<0.05). In a logistic model for predicting DVT or PE, hemoglobin and AaDO2 levels on the day after TKA and TAOB were associated with an increased incidence of DVT or PE (relative risks 3.51, 1.19 and 1.01 (P<0.05), respectively). From box and whisker plots, we speculated the significant border to predict DVT or PE as 10.5 g/dl for hemoglobin, 34 Torr for AaDO2, and 1280 ml for TAOB. These factors also predicted DVT or PE (relative risks 5.08 (hemoglobin more than 10.5), 6.25 (AaDO2 more than 34 Torr), and 4.95 (TAOB more than 1280 ml) (P<0.05)).

CONCLUSIONS

The incidence of DVT or PE one week after TKA was 39% by MSCT. High levels of TAOB, hemoglobin and AaDO2 on the day after TKA may be predictive indicators of DVT or PE one week after TKA.

Management of venous thromboembolism in the elderly

In this review the authors discuss the use of oral and parenteral anticoagulants for the prevention and treatment of venous thromboembolism (VTE) in the elderly. The use of anticoagulant agents in VTE prophylaxis and treatment in the elderly is complicated by an increase with age in the presence of multiple risk factors and co-morbidities that may increase the risk of both VTE and bleeding. Age itself is identified as an independent risk factor for thromboembolism. VTE is underdiagnosed in the elderly population, and routine prophylaxis frequently falls short of the levels required according to level of risk. Although appropriate anticoagulation of at-risk patients offers a means of reducing the significant VTE burden in this population, concerns have been raised over the use of anticoagulants in a patient group in whom multiple risk factors are common. Bleeding in the elderly can be exacerbated by reduced renal clearance and hypersensitivity to oral anticoagulants that may lead to over-anticoagulation. Although bleeding due to anticoagulant therapy is a serious issue in the elderly, it is often overemphasized, given the therapeutic value otherwise observed in treating this patient group. Warfarin is still used in VTE prophylaxis after orthopaedic surgery and for long-term VTE treatment. Unfractionated and low-molecular-weight heparins (LMWHs) have been shown to be safe and effective in the prophylaxis of VTE, and are now being shown to be as effective as warfarin in the initial and long-term treatment of VTE. LMWHs confer the advantage over unfractionated heparin of subcutaneous once-daily administration with no requirement for laboratory monitoring of their anticoagulant effect, which allows for the convenience of outpatient therapy. New anticoagulants that may be of potential benefit in this patient population include fondaparinux sodium, but clinical experience of this drug in the elderly remains limited.

The role of low-molecular-weight heparins as supportive care therapy in cancer-associated thrombosis

Venous thromboembolism (VTE) is a common complication of malignant disease, affecting approximately 1 in 200 cancer patients. Oncology nurses are instrumental in identifying patients with cancer at high risk of venous thromboembolism. Risk factors include: stage of disease, chemotherapy, the patient's degree of immobility, a history of recent surgery, and the presence of a central venous catheter. The treatment of venous thromboembolism in patients with cancer usually involves a sequential combination of unfractionated heparin or low-molecular-weight heparin (LMWH), followed by oral warfarin or LMWH. LMWHs are an alternative to warfarin for secondary prophylaxis and long-term treatment. LMWH is given by subcutaneous injection, does not require hospitalization for administration or routine laboratory monitoring. Recent clinical trial results have shown that LMWH use is associated with improved survival in cancer patients with relatively good prognoses. Patients receiving any anticoagulant therapy should be monitored for signs of pulmonary embolism or bleeding and intravenous sites (if present) should be monitored for oozing. Appropriate patient selection, a carefully constructed treatment plan, extensive patient education, and regular patient contact are integral elements for the nursing care of patients with cancer-associated thrombosis treated in the outpatient setting.