Corrigendum to: 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism

Development and validation of a predictive nomogram for lower extremity deep vein thrombosis dislodgement in orthopedic patients

Objective

To analyze the risk factors of lower extremity deep venous thrombosis (DVT) detachment in orthopedic patients, and to establish a risk nomogram prediction model.

Methods

The clinical data of 334 patients with orthopedic DVT admitted to the Third Hospital of Hebei Medical University from January 2020 to July 2021 were retrospectively analyzed. General statistics included gender, age, BMI, thrombus detachment, inferior vena cava filter window type, filter implantation time, medical history, trauma history, operation, use of tourniquet, thrombectomy, anesthesia mode, anesthesia grade, operative position, blood loss during operation, blood transfusion, immobilization, use of anticoagulants, thrombus side, thrombus range, D-dimer content before filter implantation and during removal of inferior vena cava filter. Logistic regression was used to perform univariate and multivariate analysis on the possible factors of thrombosis detachment, screen out independent risk factors, establish a risk nomogram prediction model by variables, and internally verify the predictability and accuracy of the model.

Results

Binary logistic regression analysis showed that Short time window filter (OR = 5.401, 95% CI = 2.338–12.478), lower extremity operation (OR = 3.565, 95% CI = 1.553–8.184), use of tourniquet (OR = 3.871, 95% CI = 1.733–8.651), non-strict immobilization (OR = 3.207, 95% CI = 1.387–7.413), non-standardized anticoagulation (OR = 4.406, 95% CI = 1.868–10.390), distal deep vein thrombosis (OR = 2.212, 95% CI = 1.047–4.671) were independent risk factors for lower extremity DVT detachment in orthopedic patients (P < 0.05). Based on these six factors, a prediction model for the risk of lower extremity DVT detachment in orthopedic patients was established, and the risk prediction ability of the model was verified. The C-index of the nomogram model was 0.870 (95% CI: 0.822–0.919). The results indicate that the risk nomogram model has good accuracy in predicting the loss of deep venous thrombosis in orthopedic patients.

Conclusion

The nomogram risk prediction model based on six clinical factors, including filter window type, operation condition, tourniquet use, braking condition, anticoagulation condition, and thrombosis range, has good predictive performance.

Joint analysis of D-dimer, N-terminal pro b-type natriuretic peptide, and cardiac troponin I on predicting acute pulmonary embolism relapse and mortality

Previous studies on the adverse events of acute pulmonary embolism (APE) were mostly limited to single marker, and short follow-up duration, from hospitalization to up to 30 days. We aimed to predict the long-term prognosis of patients with APE by joint assessment of D-dimer, N-Terminal Pro-Brain Natriuretic Peptide (NT-ProBNP), and troponin I (cTnI). Newly diagnosed patients of APE from January 2011 to December 2015 were recruited from three hospitals. Medical information of the patients was collected retrospectively by reviewing medical records. Adverse events (APE recurrence and all-cause mortality) of all enrolled patients were followed up via telephone. D-dimer > 0.50 mg/L, NT-ProBNP > 500 pg/mL, and cTnI > 0.40 ng/mL were defined as the abnormal. Kaplan–Meier curve was used to compare the cumulative survival rate between patients with different numbers of abnormal markers. Cox proportional hazard regression model was used to further test the association between numbers of abnormal markers and long-term prognosis of patients with APE after adjusting for potential confounding. During follow-up, APE recurrence and all-cause mortality happened in 78 (30.1%) patients. The proportion of APE recurrence and death in one abnormal marker, two abnormal markers, and three abnormal markers groups were 7.69%, 28.21%, and 64.10% respectively. Patients with three abnormal markers had the lowest survival rate than those with one or two abnormal markers (Log-rank test, P < 0.001). After adjustment, patients with two or three abnormal markers had a significantly higher risk of the total adverse event compared to those with one abnormal marker. The hazard ratios (95% confidence interval) were 6.27 (3.24, 12.12) and 10.7 (4.1, 28.0), respectively. Separate analyses for APE recurrence and all-cause death found similar results. A joint test of abnormal D-dimer, NT-ProBNP, and cTnI in APE patients could better predict the long-term risk of APE recurrence and all-cause mortality.

Endovascular therapies for pulmonary embolism

Purpose

The aim of this article is to define the place of new endovascular methods for the management of pulmonary embolisms (PE), on the basis of a multidisciplinary consensus.

Method and results

Briefly, from the recent literature, for high-risk PE presenting with shock or cardiac arrest, systemic thrombolysis or embolectomy is recommended, while for lowrisk PE, anticoagulation alone is proposed. Normo-tense patients with PE but with biological or imaging signs of right heart dysfunction constitute a group known as “at intermediate risk” for which the therapeutic strategy remains controversial. In fact, some patients may require more aggressive treatment in addition to the anticoagulant treatment, because approximately 10% will decompensate hemodynamically with a high risk of mortality. Systemic thrombolysis may be an option, but with hemorrhagic risks, particularly intra cranial. Various hybrid pharmacomechanical approaches are proposed to maintain the benefits of thrombolysis while reducing its risks, but the overall clinical experience of these different techniques remains limited. Patients with high intermediate and high risk pulmonary embolism should be managed by a multidisciplinary team combining the skills of cardiologists, resuscitators, pneumologists, interventional radiologists and cardiac surgeons. Such a team can determine which intervention – thrombolysis alone or assisted, percutaneous mechanical fragmentation of the thrombus or surgical embolectomy – is best suited to a particular patient.

Conclusions

This consensus document define the place of endovascular thrombectomy based on an appropriate risk stratification of PE.

Two Strategies for the Dosage of Acenocoumarol Co-Administered with Rifampicin in Staphylococcal Prosthetic Valve Endocarditis

According to current European Society of Cardiology guidelines, for staphylococcal prosthetic valve endocarditis, rifampicin should be one of the drugs used. However, there is a concomitant need for vitamin K antagonists in patients with mechanical prostheses. It is widely known that rifampicin interacts with vitamin K antagonists (VKA), and this interaction makes it difficult to maintain the INR (international normalized ratio) value in the therapeutic range. We present two clinical cases of staphylococcal prosthetic valve endocarditis patients. Two different strategies for dealing with adverse drug interactions have been applied. In the first case, the dose of warfarin was up-titrated until the optimal INR value was obtained. In the second case, due to the history of labile INR values, a decision was made to modify the dosage of warfarin, taking into account pharmacological aspects of drug interactions.

The Predictive Value of microRNA-134 and microRNA-1233 for the Early Diagnosis of Acute Exacerbation of Chronic Obstructive Pulmonary Disease with Acute Pulmonary Embolism

Background

The differential diagnosis of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with acute pulmonary embolism (APE) complications are difficult because of the variability of clinical presentations and the shortage of an unfailing screening biomarkers or instruments.

Objective

Aimed to detect and compare the expression of serum microRNAs (miR-1233, miR-134) in AECOPD patients complicated with APE.

Patients/Methods

Blood samples were collected from 52 AECOPD patients (13 patients with APE complications, 39 patients without APE) and 10 patients with stable COPD. Serum miRNAs expression was detected with real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR). The levels of plasma D-dimers were determined by detection with an enzyme-linked immunosorbent assay (ELISA). The receiver-operator characteristic (ROC) curve was used for evaluating the diagnostic accuracy of the studied miRNAs.

Results

According to the Wells score, 42 of the 52 AECOPD patients were unlikely to have APE (≤4 points), whereas the remaining 10 (>4 points) were likely to have APE. There were 4 cases (4/13 30.8%) in the AECOPD combined with APE group with a Wells score of >4 points. The expression levels of miR-1233 and miR-134 in the serum were considerably upregulated in the AECOPD+APE group compared with the AECOPD group and the stable COPD group (P<0.05). The areas under the curve (AUCs) for miR-134 and miR-1233 were, respectively, 0.931 (95% CI 0.863-0.999) (P<0.05) and 0.884 (95% CI 0.79-0.978) (P<0.05) and were higher compared with the AUC for D-dimer of 0.628 (95% CI 0.447-0.809), the AUC for age-adjusted D-dimer of 0.705 (95% CI 0.525-0.885) and the AUC for Wells score of 0.577 (95% CI 0.389-0.765).

Conclusion

Our study indicated that serum miR-1233 and miR-134 have high clinical value in the early diagnosis of AECOPD patients combined with APE, or could be used as potential biomarkers for clinical identification of AECOPD with or without APE complication.

Association between risk stratification for pulmonary embolism and deep vein thrombosis of lower extremities

BACKGROUND

The association of clinical risk factors, in particular deep vein thrombosis (DVT), with risk stratification for pulmonary embolism (PE) remains to be identified. We therefore aimed to establish the relationship between risk stratification of PE patients and DVT of lower extremities.

METHODS

In this retrospective study, 93 out of 485 PE patients with uncompleted clinical data were excluded, resulting in 392 patients included for analysis. Based on the ESC criteria, 24, 171, and 197 patients were categorized into high (6.1%), intermediate (43.6%), and low risk (50.3%) subgroups, respectively.

RESULTS

DVT was detected in 304 patients (77.6%). The incidence of DVT in patients with high and intermediate risk PE was much lower than in those patients with low risk PE (67.2% vs 87.8%, P < .0001). Further analyses of the 304 patients with DVT showed higher incidence of high and intermediate risk PE in patients with isolated distal DVT than proximal DVT (59.0% vs 39.1%, P = .005), with asymptomatic DVT than symptomatic DVT (63.0% vs 36.8%, P < .0001), and with bilateral DVT than unilateral DVT (54.5% vs 39.9%, P = .03). Stepwise logistic regression showed that symptomatic or asymptomatic DVT was an independent risk factor for risk stratification of PE patients with DVT (0.320, 95% confidence interval, 0.186-0.550).

CONCLUSIONS

Patients with high and intermediate risk PE presented lower incidence of DVT compared with patients with low risk PE. In PE patients with comorbid DVT, asymptomatic DVT is an independent risk factor for high and intermediate risk of PE.

Impella RP in hemodynamically unstable patients with acute pulmonary embolism

Over the last years, different case reports/studies have demonstrated that in patients with acute pulmonary embolism (PE) and refractory shock mechanical circulatory support (MCS) with Impella RP^® (Abiomed, Inc, Danvers, Mass) increases the chances of survival, significantly unloading the right ventricle and improving both the cardiac output and the mean pulmonary artery pressure. We reviewed the medical literature about the use of Impella RP in patients with acute PE and refractory shock using PubMed (MEDLINE), Scopus, Cochrane library, and Google Scholar databases. The final research was conducted in July 2019. The results evidenced that available data are currently scant to definitively assess the real role Impella RP^® in patient with acute PE and refractory shock. However, preliminary data seems to be very promising. Further larger studies are needed to confirm the safety and efficacy of MCS in these patients. A multidisciplinary assessment, using the PERT team, must be performed case by case to determine the need of MCS.

Comparison of urokinase and reteplase thrombolytic treatment in patients with high-risk pulmonary embolism

Thrombolytic treatment is recommended for patients with high-risk pulmonary embolism. The present study compared thrombolytic therapy with urokinase and reteplase. A total of 37 patients presenting with acute high-risk pulmonary embolism at the Intensive Care Unit of Weinan Central Hospital of Shaanxi Province (Weinan, China) between June 2013 and January 2017 were retrospectively analyzed. According to their treatment, these subjects were assigned to the reteplase group (n=16) or the urokinase group (n=21). Systolic blood pressure (SBP), heart rate (HR) and respiratory rate (RR) were recorded prior to, and at 2, 4, 24 and 48 h after thrombolytic therapy. Complications, including bleeding, were closely monitored. Changes in blood gas analysis, troponin-T (TNT), pro-B-type natriuretic peptide (pro-BNP) and D-dimer (D-D) were observed. In the reteplase and urokinase group, 11 and 13 cases exhibited marked improvement, treatment was rated as effective in 4 and 6 cases, and 1 and 2 mortalities occurred, resulting in an overall effective rate of 93.8 and 90.5%, respectively (P>0.05). In the reteplase group, one patient was unsuccessfully resuscitated and died. In the urokinase group, one patient died of gastric hemorrhage after 22 h of thrombolysis, while another patient died of brain failure resuscitation. The treatment improved the SBP in each of the two groups (P<0.05), and this outcome was similar between these two groups (P>0.05). HR and RR were similar prior to and after thrombolytic therapy (P>0.05). In contrast to the urokinase group, TNT was significantly decreased after thrombolyis compared with the baseline in the reteplase group. Complications in the reteplase group were higher, but in contrast to the urokinase group, no life-threatening bleeding occurred. Although reteplase is as effective as urokinase in treating high-risk pulmonary embolism, reteplase may reduce myocardial damage.

Change in right ventricular function in an American cocker spaniel with acute pulmonary thromboembolism

A 12-year-old neutered female American cocker spaniel weighing 9.9 kg was presented for evaluation with a 2-day history of dyspnea and anorexia. Echocardiography revealed severe pulmonary hypertension (estimated systolic pulmonary arterial pressure, 93.4 mmHg) with right heart enlargement, pulmonary arterial dilation, and right ventricular dysfunction. The dilation of left heart and congenital cardiac shunt were not observed. Pulmonary thromboembolism (PTE) was confirmed by computed tomographic angiography. After treatment with antiplatelet and anticoagulant, the clinical sign and the echocardiographic abnormality of right heart were improved. These echocardiographic findings are not specific for PTE, but it can be useful as a rule-in test for PTE when other causes of pulmonary hypertension are excluded and a monitor of therapeutic efficacy.

Update on Thrombolytic Therapy in Acute Pulmonary Thromboembolism

Thrombolytic treatment accelerates the dissolution of thrombus in acute pulmonary thromboembolism (PTE) and is potentially a lifesaving treatment. High-risk PTE is the clearest indication for this therapy, and its use in intermediate-risk cases is still controversial. A PTE response team may enable a rapid and effective determination of risk and treatment in these controversial clinical cases. Approved thrombolytic agents for the PTE treatment are streptokinase, urokinase, and alteplase. Currently, the most widely used agent is alteplase. It has a short infusion time (2 h) and a rapid effect. Newer, unapproved agents for the PTE treatment are tenecteplase and reteplase. The active resolution of thrombus via thrombolytic agents improves rapidly pulmonary perfusion, hemodynamic defect, gas exchange, and right ventricular dysfunction. However, it is important to determine appropriate candidates carefully, to prevent hemorrhage, which is the most important side effect of these drugs. Catheter-directed thrombolysis seems to be an alternative in patients not eligible for systemic thrombolytic therapy.

Atrial fibrillation, an obscured cause of pulmonary embolism can be revealed by adding to Wells criteria

Among the various clinical scoring methods used for the prediagnosis of pulmonary embolism (PE), Wells criteria is the most common. It relies on the findings and story of deep venous thrombosis (DVT), PE and malignancy. It is known that atrial fibrillation (AF) is a risk factor for PE like as DVT or malignancy. We aimed to evaluate the possibility of diagnosing more patients with PE by including AF in the Wells criteria. This prospective study included 250 patients admitted to the emergency department with PE findings. Wells scoring and Wells scoring with AF were performed for each patient. Out of 250 patients, 165 patients were diagnosed as PE. Wells score was >4 in 61.8% of patients with PE and 28.2% of patients without PE. Out of false negative 63 patients with PE, 21 of them had AF. According to Wells scoring with AF the score of 148 (89.7%) patients with PE diagnosis was ≥3, whereas the score of 45 (52.9%) patients without PE was ≥3. AF was detected in 15.8% of patients with PE. The sensitivity of Wells score with AF was significantly higher than that of the Wells score (p<0.001). As a result, when AF, which is one of an important PE cause such as DVT and malignancy, was added to the Wells criteria, an additional correct PE estimate was obtained in 46 patients. We recommend using Wells score with AF since prediagnosing more PE is more valuable than having some false negative PE predictions.

Reliability of Platelet Indices for Diagnosing Pulmonary Embolism; a Brief Report

Introduction:

Early diagnosis of pulmonary thromboembolism (PTE) is crucial in clinical medicine. Many para-clinical measurements are used to diagnose PTE.

Objective:

The present study was conducted to evaluate platelet indices in terms of diagnosing PTE.

Methods:

The present case-control study was conducted between May 2015 to July 2016 with 173 patients suspected of PTE in the emergency wards of Shahid Madani Hospital and Imam Reza Hospital affiliated to Tabriz University of Medical Sciences, Iran. The patients’ platelet indices were checked upon admission and they were evaluated in terms of diagnosing PTE. Platelet indices included mean platelet volume (MPV), platelet distribution width (PDW) and plateletcrit (PL-CR). PTE was diagnosed in 125 out of the 173 patients. Platelet indices were also compared between two groups.

Results:

No statistically significant differences were observed between the two groups in term of demographic variables (p>0.05). MPV was found to be 10.38±8.59 in the case group and 9.46±1.11 in the controls (p>0.05). PDW was also found to be 12.86±5.57 in the case group and 12.32±2.48 in the controls (p>0.05). Moreover, PL-CR was found to be 22.59±7.32 in the case group and 21.97±8.16 in the controls (p>0.05).

Conclusion:

According to the obtained results, platelet indices do not increase in PTE. They cannot be therefore used to diagnose PTE in suspected patients.

Can a Trained Radiology Technician Do Arterial Obstruction Quantification in Patients With Acute Pulmonary Embolism?

Objectives: To assess interobserver variability between a trained radiology technician (RT) and an experienced radiologist in arterial obstruction quantification using the Qanadli obstruction index (QOI), in patients diagnosed with acute pulmonary embolism (APE) at CT pulmonary angiography (CTPA).

Materials and Methods: A RT and a radiologist independently reviewed CTPAs of 97 consecutive, prospectively enrolled patients with APE, and calculated the QOI. They classified patients into three risk categories: high for QOI ≥40%, intermediate for QOI 20–37.5%, low for QOI <20%. Interobserver variability was investigated for QOI as a continuous variable and as a categorical variable (high, intermediate, and low-risk groups).

Results: Mean QOI (±SD) was 39.5 ± 24.3% and 38.6 ± 18.9% for the RT and the radiologist, respectively. The mean QOI was not statistically different between the RT and the radiologist (p = 0.502), and the interobserver agreement was excellent (ICC = 0.905). The RT classified 54 patients (55.7%) as high, 17 (17.53%) as intermediate, and 26 (26.8%) as low risk. The radiologist classified 55 patients (56.7%) as high, 22 (22.7%) as intermediate, and 20 (20.6%) as low risk. The interrater agreement for risk stratification was excellent (weighted kappa = 0.844).

Conclusion: Once the diagnosis of APE was established, an adequately trained RT achieved an accuracy comparable to that of an experienced radiologist regarding QOI calculation and risk assessment.

Clinical effects of antiplatelet drugs and statins on D-dimer levels

BACKGROUND

Acute pulmonary embolism may be ruled out by combining nonhigh clinical probability and a normal D-dimer level. Both antiplatelet drugs and HMG-CoA reductase inhibitors (statins) have been associated with effects on thrombus formation, potentially influencing D-dimer levels in this setting, leading to a higher rate of false-negative tests. Therefore, we determined whether D-dimer levels in patients with suspected pulmonary embolism are affected by concomitant use of antiplatelet drugs and/or statins and evaluated whether the effect of antiplatelet drugs or statins might affect diagnostic accuracy.

MATERIALS AND METHODS

We performed a posthoc analysis in the YEARS diagnostic study, comparing age- and sex-adjusted D-dimer levels among users of antiplatelet drugs, statins and nonusers. We then reclassified patients within the YEARS algorithm by developing a model in which we adjusted D-dimer cut-offs for statin use and evaluated diagnostic accuracy.

RESULTS

We included 156 statins users, 147 antiplatelet drugs users and 726 nonusers of either drugs, all with suspected pulmonary embolism. Use of antiplatelet drugs did not have a significant effect, whereas statin use was associated with 15% decrease in D-dimer levels (95% CI, -28% to -0.6%). An algorithm with lower D-dimer thresholds in statin users yielded lower specificity (0.42 compared to 0.33) with no difference in false-negative tests.

CONCLUSIONS

We conclude that use of statins but not of antiplatelet agents is associated with a modest decrease in D-dimer levels. Adjusting D-dimer cut-offs for statin use did, however, not result in a safer diagnostic strategy in our cohort.

Clinical Update. Clinical Presentations of Pulmonary Embolism in the Emergency Department

Pulmonary embolism (PE) is one of the most severe conditions encountered in the emergency department (ED) and one of the leading causes of cardiovascular morbidity and mortality, especially in patients presenting with hemodynamic instability, right ventricular dysfunction, or necessitating cardiopulmonary resuscitation. The early recognition and treatment of PE is essential, as many studies demonstrated that mortality rates drop significantly if adequate therapy is administered from the early stages. The aim of this update is to summarize the various patterns of PE presentations in the ED.

Utilization of bedside ultrasound in the diagnosis and management of massive pulmonary embolism: a case report

The prompt diagnosis and treatment of massive pulmonary embolism is a well-known challenge for physicians. We report a case of a 61-year-old hemodynamically unstable man who presented to the emergency department with complaints of acute dyspnea. After performing a focused history and physical, we used bedside ultrasound to diagnose significant right heart strain, which suggested massive bilateral pulmonary embolisms. This diagnosis was further supported by the visualization of deep venous thrombosis in the left lower extremity. The patient was treated with IV tissue plasminogen activator in the emergency department and survived to discharge in his usual state of health.

Relationship between polycythemia and in-hospital mortality in chronic obstructive pulmonary disease patients with low-risk pulmonary embolism

BACKGROUNDS

Pulmonary embolism (PE) is frequent in subjects with chronic obstructive pulmonary disease (COPD) and associated with high mortality. This multi-center retrospective study was performed to investigate if secondary polycythemia is associated with in-hospital mortality in COPD patients with low-risk PE.

METHODS

We identified COPD patients with proven PE between October, 2005 and October, 2015. Patients in risk classes III-V on the basis of the PESI score were excluded. We extracted demographic, clinical and laboratory information at the time of admission from medical records. All subjects were followed until hospital discharge to identify all-cause mortality.

RESULTS

We enrolled 629 consecutive patients with COPD and PE at low risk: 132 of them (21.0%) with and 497 (79.0%) without secondary polycythemia. Compared with those without polycythemia, the polycythemia group had significantly lower forced expiratory volume in one second (FEV₁) level (0.9±0.3 vs. 1.4±0.5, P=0.000), lower PaO₂ and SpO₂ as well as higher PaCO₂ (P=0.03, P=0.03 and P=0.000, respectively). COPD patients with polycythemia had a higher proportion of arrhythmia in electrocardiogram (ECG) (49.5% vs. 35.7%, P=0.02), a longer hospital duration time (15.3±10.1 vs. 9.7±9.1, P=0.001), a higher mechanical ventilation rate (noninvasive and invasive, 51.7% vs. 30.3%, P=0.04 and 31.0% vs. 7.9%, P=0.04, respectively), and a higher in-hospital mortality (12.1% vs. 6.6%, P=0.04). Multivariate logistic regression analysis revealed that polycythemia was associated with mortality in COPD patients with low-risk PE (adjusted OR 1.11; 95% CI, 1.04-1.66).

CONCLUSIONS

Polycythemia is an independent risk factor for all-cause in-hospital mortality in COPD patients with PE at low risk.

Fibrinolysis for Acute Care of Pulmonary Embolism in the Intermediate Risk Patient

Controversy over the role of fibrinolysis in patients with intermediate-risk pulmonary embolism (PE) has persisted because of the lack of adequately sized trials. The PEITHO study now allows a more precise estimate of the risk to benefit ratio of fibrinolysis in these patients. This trial enrolled patients with intermediate-risk PE who were randomized to receive heparin with either tenecteplase or placebo. Fibrinolysis was associated with a significant reduction in the combined end-point of death or hemodynamic decompensation, but also with a significant increase in the risk of major bleeding. The primary efficacy end-point occurred in 2.6 % of the patients in the tenecteplase group and in 5.6 % of the patients in the placebo group (OR, 0.44; 95 % CI, 0.23 to 0.87), conversely, major extracranial bleeding occurred in 6.3 % and 1.2 % in the tenecteplase and placebo groups, respectively (OR, 5.55; 95 % CI, 2.3 to 13.39) and stroke occurred in 2.4 % and in 0.2 % of the patients in the tenecteplase group and in the placebo group, respectively (OR, 12.10; 95 % CI, 1.57 to 93.39). No difference was observed for the risk of death alone and the risk of full-dose thrombolytic therapy outweighs its benefit in patients with intermediate-risk PE. Recent meta-analyses suggest that fibrinolysis may be associated with a slight reduction in overall mortality offset by an increase in major bleeding. Two pilot studies suggest that a reduced dose of fibrinolysis may produce significant hemodynamic improvement with a low risk of major bleeding. These options need to be evaluated in larger studies including patients with a higher risk of adverse outcome than those included in the PEITHO study.

[Enoxaparin is a low-molecular-weight heparin with a complex chemical structure and various non-anticoagulant properties]

The paper discusses the non-anticoagulant properties of unfractionated heparin and enoxaparin and their relation to their chemical structures. It is emphasized that enoxaparin has multiple, often interrelated, non-anticoagulant effects that can complement its antithrombotic activity and enhance the efficiency of therapy in patients receiving the drug for various indications. The realization of these effects requires the complex structure with the standard distribution of molecular weight (Mw) (average Mw, about 4500 Da, as well as Mw of less than 2000 Da (<20%), 2000 to 8000 Da (>68%), and more than 8000 Da (<18%), and with the standard content of 1.6-anhidro rings (15-25%), which is determined by the source of raw materials and by the production technology of the original drug and cannot be fully reproduced when designing its bioanalogues.