1
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Naoum JJ. Anticoagulation Management Post Pulmonary Embolism. Methodist Debakey Cardiovasc J 2024; 20:27-35. [PMID: 38765210 PMCID: PMC11100539 DOI: 10.14797/mdcvj.1338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/27/2024] [Indexed: 05/21/2024] Open
Abstract
Pulmonary embolus (PE) carries a significant impending morbidity and mortality, especially in intermediate and high-risk patients, and the choice of initial anticoagulation that allows for therapeutic adjustment or manipulation is important. The preferred choice of anticoagulation management includes direct oral anticoagulants. Vitamin K antagonists and low-molecular-weight heparin are preferred in special populations or selected patients such as breastfeeding mothers, those with end-stage renal disease, or obese patients, among others. This article reviews the primary and longer-term considerations for anticoagulation management in patients with PE and highlights special patient populations and risk factor considerations.
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Affiliation(s)
- Joseph J. Naoum
- Houston Methodist Hospital Clear Lake, Nassau Bay, Texas, US
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, US
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2
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Villiger R, Méan M, Stalder O, Limacher A, Rodondi N, Righini M, Aujesky D. Prediction of very early major bleeding risk in acute pulmonary embolism: an independent external validation of the Pulmonary Embolism-Syncope, Anemia, and Renal Dysfunction (PE-SARD) bleeding score. J Thromb Haemost 2023; 21:2884-2893. [PMID: 37149148 DOI: 10.1016/j.jtha.2023.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 03/26/2023] [Accepted: 04/10/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND The Pulmonary Embolism-Syncope, Anemia, and Renal Dysfunction (PE-SARD) bleeding score was derived to predict very early major bleeding (MB) in patients with acute pulmonary embolism (PE). Before adoption into practice, the score requires external validation in different populations. OBJECTIVES We independently validated the PE-SARD score in a prospective multicenter Swiss cohort of 687 patients aged ≥65 years with acute PE. METHODS The PE-SARD score uses 3 variables (syncope, anemia, and renal dysfunction) to classify patients into 3 categories of increasing bleeding risk. The outcomes were very early MB at 7 days (primary) and MB at later time points (secondary). We calculated the PE-SARD score for each patient and classified the proportion of patients as being at low, intermediate, and high risk. To assess discrimination and calibration, we calculated the area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test, respectively. RESULTS The prevalence of MB was 2.0% (14/687) at 7 days and 14.0% (96/687) after a median follow-up of 30 months. The PE-SARD score classified 40.2%, 42.2%, and 17.6% of patients as low, intermediate, and high risk for MB, respectively. The frequency of observed very early MB at 7 days was 1.8% in low-, 2.1% in intermediate-, and 2.5% in high-risk patients. The area under the receiver operating characteristic curve was 0.52 (95% CI, 0.48-0.56) at 7 days and increased to 0.60 (95% CI, 0.56-0.64) at the end of follow-up. Score calibration was adequate (p > .05) over the entire follow-up. CONCLUSION In our independent validation, the PE-SARD score did not accurately predict very early MB and may not be transportable to older patients with PE.
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Affiliation(s)
- Rahel Villiger
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Marie Méan
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | | | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Medicine, Geneva University Hospital (HUG), Geneva, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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3
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Bavalia R, Stals MAM, Mulder FI, Bistervels IM, Coppens M, Faber LM, Hendriks SV, Hofstee HMA, Huisman MV, van der Hulle T, Mairuhu ATA, Kruip MJHA, Middeldorp S, Klok FA, Hutten BA, Holleman F. Use of the National Early Warning Score for predicting deterioration of patients with acute pulmonary embolism: a post-hoc analysis of the YEARS Study. J Accid Emerg Med 2023; 40:61-66. [PMID: 36344240 DOI: 10.1136/emermed-2021-211506] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 10/13/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The Pulmonary Embolism Severity Index (PESI) and the simplified PESI (sPESI) are validated scores for mortality prediction in patients with pulmonary embolism (PE). National Early Warning Score (NEWS) is a general prognostic risk score for multiple clinical settings. We investigated whether the NEWS had a comparable performance with the PESI and sPESI, for predicting intensive care unit (ICU) admission and death in patients with acute PE. METHODS In haemodynamically stable patients with confirmed PE from the YEARS Study (2013-2015), we evaluated the performance of the NEWS, PESI and sPESI for predicting 7-day ICU admission and 30-day mortality. Receiver operating characteristic curves were plotted and the area under the curve (AUC) was calculated. RESULTS Of 352 patients, 12 (3.4%) were admitted to the ICU and 5 (1.4%) died. The AUC of the NEWS for ICU admission was 0.80 (95% CI 0.66 to 0.94) and 0.92 (95% CI 0.82 to 1.00) for 30-day mortality. At a threshold of 3 points, NEWS yielded a sensitivity and specificity of 92% and 53% for ICU admission and 100% and 52% for 30-day mortality. The AUC of the PESI was 0.64 (95% CI 0.48 to 0.79) for ICU admission and 0.94 (95% CI 0.87 to 1.00) for mortality. At a threshold of 66 points, PESI yielded a sensitivity of 75% and a specificity of 38% for ICU admission. For mortality, these were 100% and 37%, respectively. The performance of the sPESI was similar to that of PESI. CONCLUSION In comparison with PESI and sPESI, NEWS adequately predicted 7-day ICU admission as well as 30-day mortality, supporting its potential relevance for clinical practice.
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Affiliation(s)
- Roisin Bavalia
- Vascular Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | | | - Frits I Mulder
- Vascular Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Ingrid M Bistervels
- Vascular Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands.,Internal Medicine, Flevo Hospital, Almere, The Netherlands
| | - Michiel Coppens
- Vascular Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Laura M Faber
- Internal Medicine, Red Cross Hospital, Beverwijk, The Netherlands
| | - Stephan V Hendriks
- Thrombosis and Hemostasis, LUMC, Leiden, The Netherlands.,Internal Medicine, Haga Hospital, Den Haag, The Netherlands
| | | | | | | | | | | | - Saskia Middeldorp
- Vascular Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands.,Internal Medicine & Radboud Institute of Health Sciences, Radboud University Nijmegen Faculty of Medical Sciences, Nijmegen, The Netherlands
| | | | - Barbara A Hutten
- Epidemiology and Data Science, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Frits Holleman
- Internal Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
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4
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Gwozdz AM, de Jong CMM, Fialho LS, Likitabhorn T, Sossi F, Jaber PB, Højen AA, Arcelus JI, Auger WR, Ay C, Barco S, Gazzana MB, Bayley J, Bertoletti L, Cate-Hoek AT, Cohen AT, Connors JM, Galanaud JP, Labropoulos N, Langlois N, Meissner MH, Noble S, Nossent EJ, de León Lovatón PP, Robert-Ebadi H, Rosovsky RP, Smolenaars N, Toshner M, Tromeur C, Wang KL, Westerlund E, de Wit K, Black SA, Klok FA. Development of an international standard set of outcome measures for patients with venous thromboembolism: an International Consortium for Health Outcomes Measurement consensus recommendation. Lancet Haematol 2022; 9:e698-e706. [PMID: 36055334 DOI: 10.1016/s2352-3026(22)00215-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 06/15/2023]
Abstract
The International Consortium for Health Outcomes Measurement assembled an international working group of venous thromboembolism experts and patient representatives to develop a standardised minimum set of outcomes and outcome measurements for integration into clinical practice and potentially research to support clinical decision making and benchmarking of quality of care. 15 core outcomes important to patients and health-care professionals were selected and categorised into four domains: patient-reported outcomes, long term consequences of the disease, disease-specific complications, and treatment-related complications. The outcomes and outcome measures were designed to apply to all patients with venous thromboembolism aged 16 years or older. A measurement tool package was selected for inclusion in the core standard set, with a minimum number of items to be measured at predefined timepoints, which capture all core outcomes. Additional measures can be introduced to the user by a cascade opt-in system that allows for further assessment if required. This set of outcomes and measurement tools will facilitate the implementation of the use of patient-centred outcomes in daily practice.
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Affiliation(s)
- Adam M Gwozdz
- Academic Department of Vascular Surgery, Section of Vascular Risk and Surgery, School of Cardiovascular Medicine and Science, Guy's and Saint Thomas' Hospital, King's College London, London, UK; Academic Section of Vascular Surgery, Department of Surgery and Cancer and Department of Vascular Surgery, Imperial College Healthcare NHS Trust, Imperial College London, London, UK
| | - Cindy M M de Jong
- Department of Medicine: Thrombosis and Haemostasis, Leiden University Medical Center, Leiden University, Leiden, Netherlands
| | - Luz Sousa Fialho
- International Consortium for Health Outcomes Measurement, London, UK
| | | | - Frieda Sossi
- International Consortium for Health Outcomes Measurement, London, UK
| | | | - Anette Arbjerg Højen
- Aalborg Thrombosis Research Unit, Department of Cardiology, Aalborg University Hospital, Aalborg University, Aalborg, Denmark
| | - Juan I Arcelus
- Department of Surgery, University of Granada Medical School, University of Granada, Granada, Spain
| | - William R Auger
- Department of Pulmonary Medicine, University of California, San Diego, CA, USA
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Centre for Thrombosis and Haemostasis, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Marcelo B Gazzana
- Department of Pulmonology and Thoracic Surgery, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil; National Association of Private Hospitals, Porto Alegre, Rio Grande do Sul, Brazil
| | - Julie Bayley
- Lincoln Impact Literacy Institute, University of Lincoln, Lincoln, UK
| | - Laurent Bertoletti
- Department of Vascular and Therapeutic Medicine, University Hospital of Saint-Étienne, University of Saint-Étienne, Saint-Étienne, France; CIC-1408, INSERM, University Hospital of Saint-Étienne, University of Saint-Étienne, Saint-Étienne, France; French Clinical Research Infrastructure Network [F-CRIN] INNOvenous thromboembolism, University Hospital of Saint-Étienne, University of Saint-Étienne, Saint-Étienne, France; UMR1059, INSERM, Université Jean-Monnet, Saint-Étienne, France
| | - Arina Ten Cate-Hoek
- Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht University, Maastricht, Netherlands
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and Saint Thomas' Hospital, King's College London, London, UK
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Jean-Philippe Galanaud
- Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada
| | - Nicos Labropoulos
- Division of Vascular Surgery, Department of Surgery, Stony Brook Hospital, Stony Brook, NY, USA
| | - Nicole Langlois
- Department of Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Mark H Meissner
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Esther J Nossent
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Helia Robert-Ebadi
- Division of Angiology and Haemostasis, Geneva University Hospitals, University of Geneva, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Rachel P Rosovsky
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Noa Smolenaars
- Department of Industrial Design, University of Technology Eindhoven, Eindhoven, Netherlands
| | - Mark Toshner
- Heart Lung Research Institute, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Cécile Tromeur
- French Clinical Research Infrastructure Network [F-CRIN] INNOvenous thromboembolism, University Hospital of Saint-Étienne, University of Saint-Étienne, Saint-Étienne, France; Department of Internal Medicine and Pneumology, University Hospital of Brest, Brest, France; Group d'etude de la thrombose de Bretagne Occidentale, Université de Bretagne Occidentale, Brest, France
| | - Kang-Ling Wang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Eli Westerlund
- Department of Clinical Sciences, Karolinska Institutet; Danderyd Hospital, Danderyd, Sweden
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada; Departments of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Stephen A Black
- Academic Department of Vascular Surgery, Section of Vascular Risk and Surgery, School of Cardiovascular Medicine and Science, Guy's and Saint Thomas' Hospital, King's College London, London, UK
| | - Frederikus A Klok
- Department of Medicine: Thrombosis and Haemostasis, Leiden University Medical Center, Leiden University, Leiden, Netherlands.
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5
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Yoo HH, Nunes-Nogueira VS, Fortes Villas Boas PJ, Broderick C. Outpatient versus inpatient treatment for acute pulmonary embolism. Cochrane Database Syst Rev 2022; 5:CD010019. [PMID: 35511086 PMCID: PMC9070407 DOI: 10.1002/14651858.cd010019.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is a common life-threatening cardiovascular condition, with an incidence of 23 to 69 new cases per 100,000 people each year. For selected low-risk patients with acute PE, outpatient treatment might provide several advantages over traditional inpatient treatment, such as reduction of hospitalisations, substantial cost savings, and improvements in health-related quality of life. This is an update of an earlier Cochrane Review. OBJECTIVES To assess the effects of outpatient versus inpatient treatment in low-risk patients with acute PE. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 31 May 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) of outpatient versus inpatient treatment of adults (aged 18 years and over) diagnosed with low-risk acute PE. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were short- and long-term all-cause mortality. Secondary outcomes were bleeding, adverse effects, recurrence of PE, and patient satisfaction. We used GRADE to assess certainty of evidence for each outcome. MAIN RESULTS We did not identify any new studies for this update. We included a total of two RCTs involving 453 participants. Both trials discharged participants randomised to the outpatient group within 36 hours of initial triage, and both followed participants for 90 days. One study compared the same treatment regimens in both outpatient and inpatient groups, and the other study used different treatment regimens. There was no clear difference in treatment effect for the outcomes of mortality at 30 days (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.01 to 7.98; 2 studies, 453 participants; low-certainty evidence), mortality at 90 days (RR 0.98, 95% CI 0.06 to 15.58; 2 studies, 451 participants; low-certainty evidence), major bleeding at 14 days (RR 4.91, 95% CI 0.24 to 101.57; 2 studies, 445 participants; low-certainty evidence) and at 90 days (RR 6.88, 95% CI 0.36 to 132.14; 2 studies, 445 participants; low-certainty evidence), minor bleeding (RR 1.08, 95% CI 0.07 to 16.79; 1 study, 106 participants; low-certainty evidence), recurrent PE within 90 days (RR 2.95, 95% CI 0.12 to 71.85; 2 studies, 445 participants; low-certainty evidence), and patient satisfaction (RR 0.97, 95% CI 0.90 to 1.04; 2 studies, 444 participants; moderate-certainty evidence). We downgraded the certainty of the evidence because the CIs were wide and included treatment effects in both directions, the sample sizes and numbers of events were small, and it was not possible to determine the effect of missing data or the presence of publication bias. The included studies did not assess PE-related mortality or adverse effects, such as haemodynamic instability, or adherence to treatment. AUTHORS' CONCLUSIONS Currently, only low-certainty evidence is available from two published randomised controlled trials on outpatient versus inpatient treatment in low-risk patients with acute PE. The studies did not provide evidence of any clear difference between the interventions in overall mortality, bleeding, or recurrence of PE.
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Affiliation(s)
- Hugo Hb Yoo
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University-UNESP, Botucatu, Brazil
| | - Vania Santos Nunes-Nogueira
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University-UNESP, Botucatu, Brazil
| | - Paulo J Fortes Villas Boas
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University-UNESP, Botucatu, Brazil
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6
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Kabrhel C, Vinson DR, Mitchell AM, Rosovsky RP, Chang AM, Hernandez‐Nino J, Wolf SJ. A clinical decision framework to guide the outpatient treatment of emergency department patients diagnosed with acute pulmonary embolism or deep vein thrombosis: Results from a multidisciplinary consensus panel. J Am Coll Emerg Physicians Open 2021; 2:e12588. [PMID: 34950930 PMCID: PMC8673564 DOI: 10.1002/emp2.12588] [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: 08/26/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
The outpatient treatment of select emergency department patients with acute pulmonary embolism (PE) or deep vein thrombosis (DVT) has been shown to be safe, cost effective and associated with high patient satisfaction. Despite this, outpatient PE and DVT treatment remains uncommon. To address this, the American College of Emergency Physicians assembled a multidisciplinary team of content experts to provide evidence-based recommendations and practical advice to help clinicians safely treat patients with low-risk PE and DVT without hospitalization. The emergency clinician must stratify the patient's risk of clinical decompensation due to their PE or DVT as well as their risk of bleeding due to anticoagulation. The clinician must also select and start an anticoagulant and ensure that the patient has access to the medication in a timely manner. Reliable follow-up is critical, and the patient must also be educated about signs or symptoms that should prompt a return to the emergency department. To facilitate access to these recommendations, the consensus panel also created 2 web-based "point-of-care tools."
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Affiliation(s)
- Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular EmergenciesMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - David R. Vinson
- Department of Emergency Medicine, Kaiser Permanente Division of Research and the CREST Network, Oakland, CAKaiser Permanente Roseville Medical CenterRosevilleCaliforniaUSA
| | - Alice Marina Mitchell
- Department of Emergency Medicine, Richard L. Roudebush VAMCIndiana University School of MedicineIndianapolisIndianaUSA
| | - Rachel P. Rosovsky
- Division of HematologyDepartment of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Anna Marie Chang
- Department of Emergency MedicineThomas Jefferson University HospitalsPhiladelphiaPennsylvaniaUSA
| | | | - Stephen J. Wolf
- Department of Emergency MedicineDenver Health and University of Colorado School of MedicineDenverColoradoUSA
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7
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Hobohm L, Lankeit M. [Pulmonary Embolism]. Pneumologie 2021; 75:800-818. [PMID: 34662916 DOI: 10.1055/a-1029-9937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pulmonary embolism (PE) is a life-threatening disease and the third most frequent cardiovascular cause of death after stroke and myocardial infarction. The annual incidence is increasing (in Germany from 85 cases per 100000 population in the year 2005 to 109 cases per 100000 population in the year 2015). The individual risk for PE-related complications and death increases with the number of comorbidities and severity of right ventricular dysfunction. Using clinical, laboratory and imaging parameters, patients with PE can be stratified to four risk classes (high, intermediate-high, intermediate-low and low risk). This risk stratification has concrete therapeutic consequences ranging from out-of-hospital treatment of low-risk patients to reperfusion treatment of (intermediate)-high-risk patients. For haemodynamically unstable patients, treatment decision should preferably be made in interdisciplinary "Pulmonary Embolism Response Teams" (PERT). Due to their comparable efficacy and preferable safety profile compared to vitamin-K antagonists (VKAs), non-vitamin K-dependent oral anticoagulants (NOACs) are increasingly considered the treatment of choice for initial and prolonged anticoagulation of patients with pulmonary embolism. Use of low molecular weight heparins (LMWHs) is recommended for PE patients with cancer; however, recent studies indicate that treatment with factor Xa-inhibitors may be effective and safe (in patients without gastrointestinal cancer). Only prolonged anticoagulation (in reduced dosage) will ensure reduction of VTE recurrence and should thus be considered for all patients with unprovoked events.
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8
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Hendriks SV, Hout WBVD, van Bemmel T, Bistervels IM, Eijsvogel M, Faber LM, Hofstee HMA, van der Hulle T, Iglesias Del Sol A, Kruip MJHA, Mairuhu ATA, Middeldorp S, Nijkeuter M, Huisman MV, Klok FA. Home Treatment Compared to Initial Hospitalization in Normotensive Patients with Acute Pulmonary Embolism in the Netherlands: A Cost Analysis. Thromb Haemost 2021; 122:427-433. [PMID: 34041736 DOI: 10.1055/a-1518-1847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Venous thromboembolism constitutes substantial health care costs amounting to approximately 60 million euros per year in the Netherlands. Compared with initial hospitalization, home treatment of pulmonary embolism (PE) is associated with a cost reduction. An accurate estimation of cost savings per patient treated at home is currently lacking. AIM The aim of this study was to compare health care utilization and costs during the first 3 months after a PE diagnosis in patients who are treated at home versus those who are initially hospitalized. METHODS Patient-level data of the YEARS cohort study, including 383 normotensive patients diagnosed with PE, were used to estimate the proportion of patients treated at home, mean hospitalization duration in those who were hospitalized, and rates of PE-related readmissions and complications. To correct for baseline differences within the two groups, regression analyses was performed. The primary outcome was the average total health care costs during a 3-month follow-up period for patients initially treated at home or in hospital. RESULTS Mean hospitalization duration for the initial treatment was 0.69 days for those treated initially at home (n = 181) and 4.3 days for those initially treated in hospital (n = 202). Total average costs per hospitalized patient were €3,209 and €1,512 per patient treated at home. The adjusted mean difference was €1,483 (95% confidence interval: €1,181-1,784). CONCLUSION Home treatment of hemodynamically stable patients with acute PE was associated with an estimated net cost reduction of €1,483 per patient. This difference underlines the advantage of triage-based home treatment of these patients.
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Affiliation(s)
- Stephan V Hendriks
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Wilbert B van den Hout
- Department of Biomedical Data Science-Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas van Bemmel
- Department of Internal Medicine, Gelre Hospital, Apeldoorn, The Netherlands
| | - Ingrid M Bistervels
- Department of Internal Medicine, Flevoziekenhuis, Almere, The Netherlands.,Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Michiel Eijsvogel
- Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Laura M Faber
- Department of Internal Medicine, Rode Kruis Hospital, Beverwijk, The Netherlands
| | - Herman M A Hofstee
- Department of Internal Medicine, Haaglanden Medisch Centrum, The Hague, The Netherlands
| | - Tom van der Hulle
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mathilde Nijkeuter
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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9
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van Dam LF, Kroft LJM, Huisman MV, Ninaber MK, Klok FA. Computed Tomography Pulmonary Perfusion for Prediction of Short-Term Clinical Outcome in Acute Pulmonary Embolism. TH OPEN 2021; 5:e66-e72. [PMID: 33585787 PMCID: PMC7875679 DOI: 10.1055/s-0041-1723782] [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: 11/10/2020] [Accepted: 12/18/2020] [Indexed: 11/18/2022] Open
Abstract
Background
Computed tomography pulmonary angiography (CTPA) is the imaging modality of choice for the diagnosis of acute pulmonary embolism (PE). With computed tomography pulmonary perfusion (CTPP) additional information on lung perfusion can be assessed, but its value in PE risk stratification is unknown. We aimed to evaluate the correlation between CTPP-assessed perfusion defect score (PDS) and clinical presentation and its predictive value for adverse short-term outcome of acute PE.
Patients and Methods
This was an exploratory, observational study in 100 hemodynamically stable patients with CTPA-confirmed acute PE in whom CTPP was performed as part of routine clinical practice. We calculated the difference between the mean PDS in patients with versus without chest pain, dyspnea, and hemoptysis and 7-day adverse outcome. Multivariable logistic regression analysis and likelihood-ratio test were used to assess the added predictive value of PDS to CTPA parameters of right ventricle dysfunction and total thrombus load, for intensive care unit admission, reperfusion therapy and PE-related death.
Results
We found no correlation between PDS and clinical symptoms. PDS was correlated to reperfusion therapy (
n
= 4 with 16% higher PDS, 95% confidence interval [CI]: 3.5–28%) and PE-related mortality (
n
= 2 with 22% higher PDS, 95% CI: 4.9–38). Moreover, PDS had an added predictive value to CTPA assessment for PE-related mortality (from Chi-square 14 to 19,
p
= 0.02).
Conclusion
CTPP-assessed PDS was not correlated to clinical presentation of acute PE. However, PDS was correlated to reperfusion therapy and PE-related mortality and had an added predictive value to CTPA-reading for PE-related mortality; this added value needs to be demonstrated in larger studies.
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Affiliation(s)
- Lisette F van Dam
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Klok FA, Huisman MV. When I treat a patient with acute pulmonary embolism at home. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:190-194. [PMID: 33275689 PMCID: PMC7727561 DOI: 10.1182/hematology.2020000106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Home treatment is feasible and safe in selected patients with acute pulmonary embolism (PE) and is associated with a considerable reduction in health care costs. When establishing a PE outpatient pathway, 2 major decisions must be made. The first one concerns the selection of patients for home treatment. The second one involves dedicated outpatient follow-up including sufficient patient education and facilities for specialized follow-up visits. Current evidence points toward the use of either the Hestia criteria or Pulmonary Embolism Severity Index with/without assessment of the right ventricular function to select patients for home treatment, depending on local preferences. Results from ongoing trials are expected to enforce current guideline recommendations on home treatment and pave the way for more broad application of this elegant and cost-effective management option for patients with acute PE.
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Affiliation(s)
- Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Menno V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Hendriks SV, Klok FA, den Exter PL, Eijsvogel M, Faber LM, Hofstee HMA, Iglesias Del Sol A, Kroft LJM, Mairuhu ATA, Huisman MV. Right Ventricle-to-Left Ventricle Diameter Ratio Measurement Seems to Have No Role in Low-Risk Patients with Pulmonary Embolism Treated at Home Triaged by Hestia Criteria. Am J Respir Crit Care Med 2020; 202:138-141. [PMID: 32203673 DOI: 10.1164/rccm.202002-0267le] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Stephan V Hendriks
- Leiden University Medical CenterLeiden, the Netherlands.,Haga Teaching HospitalThe Hague, the Netherlands
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Hendriks SV, den Exter PL, Zondag W, Brouwer R, Eijsvogel M, Grootenboers MJ, Faber LM, Heller-Baan R, Hofstee HMA, Iglesias del Sol A, Kruip MJHA, Mairuhu ATA, Melissant CF, Peltenburg HG, van de Ree MA, Serné EH, Huisman MV, Klok FA. Reasons for Hospitalization of Patients with Acute Pulmonary Embolism Based on the Hestia Decision Rule. Thromb Haemost 2020; 120:1217-1220. [DOI: 10.1055/s-0040-1713170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Background The Hestia criteria can be used to select pulmonary embolism (PE) patients for outpatient treatment. The subjective Hestia criterion “medical/social reason for admission” allows the treating physician to consider any patient-specific circumstances in the final management decision. It is unknown how often and why this criterion is scored.
Methods This is a patient-level post hoc analysis of the combined Hestia and Vesta studies. The main outcomes were the frequency of all scored Hestia items in hospitalized patients and the explicit reason for scoring the subjective criterion. Hemodynamic parameters and computed tomography-assessed right ventricular (RV)/left ventricular (LV) ratio of those only awarded with the subjective criterion were compared with patients treated at home.
Results From the 1,166 patients screened, data were available for all 600 who were hospitalized. Most were hospitalized to receive oxygen therapy (45%); 227 (38%) were only awarded with the subjective criterion, of whom 51 because of “intermediate to intermediate-high risk PE.” Compared with patients with intermediate risk PE (RV/LV ratio > 1.0) treated at home (179/566, 32%), hospitalized patients with only the subjective criterion had a higher mean RV/LV ratio (mean difference +0.30, 95% confidence interval [CI] 0.19–0.41) and a higher heart rate (+18/min, 95% CI 10–25). No relevant differences were observed for other hemodynamic parameters.
Conclusion The most frequent reason for hospital admission was oxygen therapy. In the decision to award the subjective criterion as sole argument for admission, the severity of the RV overload and resulting hemodynamic response of the patient was taken into account rather than just abnormal RV/LV ratio.
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Affiliation(s)
- Stephan V. Hendriks
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Paul L. den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wendy Zondag
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Rolf Brouwer
- Department of Internal Medicine, Reinier de Graaff Gasthuis, Delft, The Netherlands
| | - Michiel Eijsvogel
- Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Laura M. Faber
- Department of Pulmonary Medicine, Rode Kruis Hospital, Beverwijk, The Netherlands
| | - Roxanne Heller-Baan
- Department of Pulmonary Medicine, Ikazia Hospital, Rotterdam, The Netherlands
| | - Herman M. A. Hofstee
- Department of Internal Medicine, Haaglanden Medical Center, The Hague, The Netherlands
| | | | - Marieke J. H. A. Kruip
- Department of Haematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Albert T. A. Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | | | - Henny G. Peltenburg
- Department of Internal Medicine, Groene Hart Hospital, Gouda, The Netherlands
| | | | - Erik H. Serné
- Department of Internal Medicine, VU Medical Center, Amsterdam, The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Hendriks SV, Bavalia R, van Bemmel T, Bistervels IM, Eijsvogel M, Faber LM, Fogteloo J, Hofstee HMA, van der Hulle T, Iglesias Del Sol A, Kruip MJHA, Mairuhu ATA, Middeldorp S, Nijkeuter M, Huisman MV, Klok FA. Current practice patterns of outpatient management of acute pulmonary embolism: A post-hoc analysis of the YEARS study. Thromb Res 2020; 193:60-65. [PMID: 32521336 DOI: 10.1016/j.thromres.2020.05.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/30/2020] [Accepted: 05/25/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Studies have shown the safety of home treatment of patients with pulmonary embolism (PE) at low risk of adverse events. Management studies focusing on home treatment have suggested that 30% to 55% of acute PE patients could be treated at home, based on the HESTIA criteria, but data from day-to-day clinical practice are largely unavailable. AIM To determine current practice patterns of home treatment of acute PE in the Netherlands. METHOD We performed a post-hoc analysis of the YEARS study. The main outcomes were the proportion of patients who were discharged <24 h and reasons for admission if treated in hospital. Further, we compared the 3-month incidence of PE-related unscheduled readmissions between patients treated at home and in hospital. RESULTS Of the 404 outpatients with PE included in this post-hoc analysis of the YEARS study, 184 (46%) were treated at home. The median duration of admission of the hospitalized patients was 3.0 days. The rate of PE-related readmissions of patients treated at home was 9.7% versus 8.6% for hospitalized patients (crude hazard ratio 1.1 (95% CI 0.57-2.1)). The 3-month incidence of any adverse event was 3.8% in those treated at home (2 recurrent VTE, 3 major bleedings and two deaths) compared to 10% in the hospitalized patients (3 recurrent VTE, 6 major bleedings and fourteen deaths). CONCLUSIONS In the YEARS study, 46% of patients with PE were treated at home with low incidence of adverse events. PE-related readmission rates were not different between patients treated at home or in hospital.
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Affiliation(s)
- Stephan V Hendriks
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands.
| | - Roisin Bavalia
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Thomas van Bemmel
- Department of Internal Medicine, Gelre Hospital, Apeldoorn, the Netherlands
| | - Ingrid M Bistervels
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Department of Internal Medicine, Flevoziekenhuis, Almere, the Netherlands
| | - Michiel Eijsvogel
- Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Laura M Faber
- Department of Pulmonary Medicine, Rode Kruis Hospital, Beverwijk, the Netherlands
| | - Jaap Fogteloo
- Department of Acute Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Herman M A Hofstee
- Department of Internal Medicine, HMC Westeinde/Bronono, The Hague, the Netherlands
| | - Tom van der Hulle
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Marieke J H A Kruip
- Department of Haematology, Erasmus University Medical center, Rotterdam, the Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Mathilde Nijkeuter
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Calais C, Mercier G, Meusy A, Le Collen L, Kahn SR, Quéré I, Galanaud JP. Pulmonary embolism home treatment: What GP want? Thromb Res 2020; 187:180-185. [DOI: 10.1016/j.thromres.2020.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 12/23/2019] [Accepted: 01/14/2020] [Indexed: 11/27/2022]
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Home treatment of patients with cancer-associated venous thromboembolism - An evaluation of daily practice. Thromb Res 2019; 184:122-128. [PMID: 31731069 DOI: 10.1016/j.thromres.2019.10.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/25/2019] [Accepted: 10/31/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND Home treatment of cancer-associated venous thromboembolism (VTE) is challenging due to the high risk of adverse events. While home treatment is quite agreeable to cancer patients, studies evaluating the safety of VTE home treatment in this setting are largely unavailable. METHODS This was an observational study in patients with cancer-associated VTE. The main outcomes were the proportion of patients treated at home (hospital discharge <24 h after diagnosis) and the 3-month incidence of VTE-related adverse events (major bleeding, recurrent VTE and/or suspected VTE-related mortality) in patients managed in hospital versus at home. RESULTS A total of 183 outpatients were diagnosed with cancer-associated VTE: 69 had deep vein thrombosis (DVT) and 114 had pulmonary embolism (PE ± DVT). Of those, 120 (66%) were treated at home; this was 83% for patients with DVT and 55% for patients with PE (±DVT). The 3-month incidence of any VTE-related adverse event was 13% in those treated at home versus 19% in the hospitalized patients (HR 0.48; 95%CI 0.22-1.1), independent of initial presentation as PE or DVT. All-cause 3-month mortality occurred in 33 patients treated as inpatient (54%) compared to 29 patients treated at home (24%; crude HR 3.1 95%CI 1.9-5.0). CONCLUSIONS Two-third of patients with cancer-associated VTE - including PE - were selected to start anticoagulant treatment at home. Cancer-associated VTE is associated with high rates of VTE-related adverse events independent of initial in hospital or home treatment. However, home treatment may be a good option for selected patients with cancer-associated DVT or PE.
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