Bilateral pulmonary emboli in a competitive gymnast

Sport and Venous Thromboembolism

BACKGROUND

The occurrence of venous thromboembolisms (VTE) in association with sporting activity has been described but not yet systematically explored. The aim of this study was to determine the sites at which VTE occur in athletes, the accompanying features, and the special features of the symptoms and diagnosis, so that physicians can take the findings into consideration.

METHODS

A search of the literature in the databases PubMed, Web of Science, and Cochrane in accordance with the PRISMA criteria, together with a search of Google Scholar up to 29 February 2020.

RESULTS

No observational studies were identified. A total of 154 case descriptions were evaluated: 89 on upper-extremity deep vein thrombosis (DVT), 53 on lower-extremity DVT, and 12 on pulmonary embolisms with no evidence of thrombosis. Ninety-five percent of the upper-extremity DVT involved the region of the subclavian/axillary vein. Thoracic outlet syndrome (38%), hereditary thrombophilia/a family history of VTE (16%), intensive training (12%), and the use of oral contraceptives (7%) were identified as accompanying features. The upper-extremity DVT occurred mainly in male strength athletes and ball sports players. The lower-extremity DVT were located in the lower leg/knee (30%), the thigh (19 %), or occurred in combination in the lower leg-to-pelvis region (30 %). The features accompanying lower-extremity DVT were hereditary thrombophilia/a family history of VTE (30%), trauma (25%), immobilization (21%), and the use of oral contraceptives (11%). The lower-extremity DVT were found in endurance sports and ball sports. The symptoms may be obscured by sport-specific symptoms/trauma, and diagnosis is often delayed. Early D-dimer determination is useful and is complemented by diagnostic imaging.

CONCLUSION

VTE are found in association with sports. The background factors, the sites of VTE, the types of sports involved, and the accompanying features are all important to know. The symptoms may be obscured, and it may be difficult to reach the correct diagnosis. The possible presence of DVT must be borne in mind.

Non-vitamin K antagonist oral anticoagulants and sport

Physical activity is worldwide recommended for its benefits on cardiovascular system. There is an increasing number of people of all ages that approach sport activity both as leisure time physical activity and as competitive sport. It is always more frequent the request even from older subjects and cardiac patients to be allowed to practice physical activity. Some problems could arise when these subjects present or develop pathologic conditions that require specific pharmacological treatment, in particular an anticoagulation therapy. This review focalizes on the management of oral anticoagulant therapy (OAT) in patients practicing sport activity, especially due to atrial fibrillation and deep vein thrombosis, which represent two highly prevalent conditions, particularly with increasing age. Official recommendations in this field may appear limiting for patients, forbidding in the majority of cases sports at risk of trauma and consequent bleeding. These recommendations still resent the heritage of the "traditional" management of OAT, mainly represented by vitamin-K antagonists (VKAs). The non-vitamin K antagonist oral anticoagulants, with their more favorable pharmacokinetic-pharmacodynamic profile compare to VKAs, may now represent an opportunity to modify the approach to sport activity in patients with an indication to OAT. This review of the literature deals with possible strategies to overcome the present limitations for OAT subjects willing to pursue a healthy lifestyle, that include sport activity, minimizing at the same time their risk of bleeding.

Sixteen-year-old athlete with chest pain and shortness of breath due to pulmonary emboli

BACKGROUND

Pulmonary embolism (PE) is a life-threatening condition that is extremely uncommon in the healthy pediatric population.

OBJECTIVE

Because pediatric PE is rarely on the Emergency Physician's differential diagnosis, with this case we hope to increase the clinical suspicion for PE in children who present to the Emergency Department (ED).

CASE REPORT

This is a case of bilateral pulmonary embolism in a 16-year-old basketball player whose only risk factor is oral contraceptive medication. Initial vital signs demonstrated a temperature of 37.1°C (98.8°F), blood pressure 124/74 mm Hg, heart rate 74 beats/min, respiratory rate 16 breaths/min, and oxygen saturation 100% on room air. Subsequent vital signs, physical examination, chest radiograph, electrocardiogram, and laboratory assessments were all within normal limits. Using clinician gestalt in combination with the patient's Wells score of 0, a D-dimer was obtained and returned at 1916 ng/mL. The computed tomography scan with PE protocol detected a total of seven pulmonary emboli bilaterally. The patient was anticoagulated with Lovenox (Sanofi US, Bridgewater, NJ) in the ED and admitted to the pediatric intensive care unit. Complete thrombophilia work-up was negative. The patient was discharged with Lovenox and was transitioned to warfarin.

CONCLUSIONS

Emergency Physicians may be inclined to discharge a pediatric patient at low pre-test probability for PE with outpatient follow-up if the work-up is non-contributory. But the current adult PE clinical criteria are not as sensitive or specific in the pediatric population. This case demonstrates that the clinician's gestalt should play a major role in combination with the Wells score and PERC (pulmonary embolism rule-out criteria) rule to exclude PE until clinical decision rules specific for the pediatric population are established.