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Cimini LA, Luijten D, Barco S, Ghanima W, Jervan Ø, Kahn SR, Konstantinides S, Lachant D, Nakano Y, Ninaber M, van Es J, van Mens T, Vonk Noordegraaf A, Becattini C, Klok FA. Pulmonary perfusion defects or residual vascular obstruction and persistent symptoms after pulmonary embolism: a systematic review and meta-analysis. ERJ Open Res 2024; 10:01010-2023. [PMID: 39076522 PMCID: PMC11284598 DOI: 10.1183/23120541.01010-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/20/2024] [Indexed: 07/31/2024] Open
Abstract
Introduction Up to 50% of pulmonary embolism (PE) patients have perfusion defects or residual vascular obstruction during follow-up despite adequate anticoagulant treatment, and a similar percentage experience chronic functional limitations and/or dyspnoea post-PE. We aimed to evaluate the association between pulmonary perfusion defects or residual vascular obstruction and functional recovery after PE. Methods We performed a systematic review and meta-analysis including studies assessing both the presence of perfusion defects or residual vascular obstruction and functional recovery (i.e. persistent symptoms, quality of life, exercise endurance). An odds ratio was pooled for perfusion defects or residual vascular obstruction and persistent symptoms using a random-effect model. Results 12 studies were included totalling 1888 PE patients; at a median of 6 months after PE (range 2-72 months), 34% had perfusion defects or residual vascular obstruction and 37% reported persistent symptoms. Among patients with perfusion defects or residual vascular obstruction, 48% (95% CI 37-60%, I2=82%) remained symptomatic during follow-up, compared to 34% (95% CI 20-51%, I2=96%) of patients without such defects. Presence of perfusion defects or residual vascular obstruction was associated with persistent symptoms (OR 2.15, 95% CI 1.66-2.78; I2=0%, τ=0). Notably, there was no association between these defects and quality of life or cardiopulmonary exercise test parameters. Conclusion While the odds of having persistent symptoms was higher in patients with perfusion defects or residual vascular obstruction after acute PE, a significant proportion of these patients reported no limitations. A possible causality between perfusion defects or residual vascular obstruction and residual functional limitation therefore remains to be proven.
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Affiliation(s)
- Ludovica Anna Cimini
- Vascular and Emergency Medicine, University of Perugia, Perugia, Italy
- L.A. Cimini and D. Luijten contributed equally and share first authorship
| | - Dieuwke Luijten
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
- L.A. Cimini and D. Luijten contributed equally and share first authorship
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Waleed Ghanima
- Department of Internal Medicine, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - Øyvind Jervan
- Department of Internal Medicine, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Susan R. Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada
- Division of Internal Medicine and Division of Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Daniel Lachant
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Yoshihisa Nakano
- Department of Cardiology, Nagoya University Hospital, Nagoya, Japan
- Department of Public Health and Health Systems, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Maarten Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Josien van Es
- Department of Pulmonology, Amsterdam UMC, Cardiovascular sciences, VU University Amsterdam, Amsterdam, The Netherlands
- Department of Pulmonology, OLVG, Amsterdam, The Netherlands
| | - Thijs van Mens
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam UMC, Cardiovascular sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Cecilia Becattini
- Vascular and Emergency Medicine, University of Perugia, Perugia, Italy
| | - Frederikus A. Klok
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
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Andersson T, Nilsson L, Larsen F, Carlberg B, Söderberg S. Long-term sequelae following acute pulmonary embolism: A nationwide follow-up study regarding the incidence of CTEPH, dyspnea, echocardiographic and V/Q scan abnormalities. Pulm Circ 2023; 13:e12306. [PMID: 37927611 PMCID: PMC10621320 DOI: 10.1002/pul2.12306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/01/2023] [Accepted: 10/22/2023] [Indexed: 11/07/2023] Open
Abstract
We aimed to follow a nationwide cohort of patients with pulmonary embolism (PE) without any exclusions to generate information regarding long-term symptoms, investigational findings and to determine the prevalence of chronic thromboembolic pulmonary hypertension (CTEPH). We hypothesized that this approach would yield generalizable estimates of CTEPH prevalence and incidence. All individuals diagnosed with acute PE in Sweden in 2005 were identified using the National Patient Register. In 2007, survivors were asked to complete a questionnaire regarding current symptoms. Those with dyspnea were referred for further examinations with laboratory tests, electrocardiogram (ECG), and a ventilation/perfusion scan (V/Q scan). If CTEPH was suspected, a referral to the nearest pulmonary arterial hypertension-center was recommended. Of 5793 unique individuals with PE diagnosis in 2005, 3510 were alive at the beginning of 2007. Altogether 53% reported dyspnea at some degree whereof a large proportion had V/Q scans indicating mismatched defects. Further investigation revealed 6 cases of CTEPH and in parallel 18 cases were diagnosed outside this study. The overall prevalence of CTEPH was 0.4% (95% confidence interval [CI]: 0.2%-0.6%) and 0.7% (95% CI: 0.4%-1.0%) among the survivors. The cumulative incidence of CTEPH in the group of patients who underwent a V/Q scan was 1.1% (95% CI: 0.2%-2.0%). There was a high mortality following an acute PE, a high proportion of persistent dyspnea among survivors, whereof several had pathological findings on V/Q scans and echocardiography. Only a minority developed CTEPH, indicating that CTEPH is the tip of the iceberg of post-PE disturbances.
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Affiliation(s)
- Therese Andersson
- Department of Public Health and Clinical Medicine, Unit of MedicineUmeå UniversityUmeåSweden
| | - Lars Nilsson
- Department of Public Health and Clinical Medicine, Unit of MedicineUmeå UniversityUmeåSweden
| | - Flemming Larsen
- Department of Molecular Medicine and Surgery, Section of Clinical PhysiologyKarolinska InstituteStockholmSweden
- Department of Clinical PhysiologyKarolinska University HospitalStockholmSweden
| | - Bo Carlberg
- Department of Public Health and Clinical Medicine, Unit of MedicineUmeå UniversityUmeåSweden
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, Unit of MedicineUmeå UniversityUmeåSweden
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3
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Lian TY, Cao Y. Prediction of recurrent venous thromboembolism: The writing is on the wall. J Thromb Haemost 2023; 21:1420-1422. [PMID: 37179071 DOI: 10.1016/j.jtha.2023.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Tian-Yu Lian
- Medical Science Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yunshan Cao
- Department of Cardiology, Pulmonary Vascular Disease Center, Gansu Provincial Hospital, Lanzhou, China.
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Kong J, Hardwick A, Jiang SF, Sun K, Vinson DR, McGlothlin DP, Goh CH. CTEPH: A Kaiser Permanente Northern California Experience. Thromb Res 2023; 221:130-136. [PMID: 36566069 DOI: 10.1016/j.thromres.2022.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and life-threatening form of pulmonary hypertension and the only potentially curable form of the World Health Organization Pulmonary Hypertension classes. Thus, the prompt and accurate diagnosis of this condition is imperative. Despite widespread chronic symptoms following acute pulmonary embolism (PE), the condition is rarely considered, and an externally validated inexpensive diagnostic algorithm is lacking. METHODS A long-term, retrospective cohort study was conducted to assess the incidence of CTEPH following acute PE in a real-world study population. Additional data were collected regarding the practice patterns of diagnostic testing and imaging, particularly in patients with persistent or recurrent symptoms. Amongst diagnosed CTEPH patients, previously established risk factors were evaluated for degree of risk and commonly used diagnostic tests (electrocardiogram [ECG] right ventricular hypertrophy [RVH] pattern, B-type natriuretic peptide [BNP] elevations) employed during this period were evaluated and assessed for feasibility as screening tests. The study population was obtained from the MAPLE study cohort, comprised of patients presenting with acute PE in 21 community medical centers across the Kaiser Permanente Northern California system from January 2013 to April 2015. Diagnosis of CTEPH was confirmed via pulmonary vascular imaging (ventilation/perfusion [V/Q] scanning, computed tomography angiography, pulmonary angiography) and diagnostic right heart catheterization (RHC). Probable diagnoses were defined as a combination of suggestive echocardiographic and RHC findings. Additional inclusion criteria included age (≥18 years) with at least 2 years follow up and no previous diagnosis of CTEPH or PE during the prior 30 days. RESULTS There were 1973 patients who met inclusion criteria (mean age 62.4 years). Despite 75 % of patients developing symptoms consistent with CTEPH >3 months following acute PE, only 5.6 % of these symptomatic patients underwent V/Q scanning. There was overall a very low cumulative incidence of CTEPH (2.3 %), which was significantly higher amongst patients with symptoms compared to those without symptoms. When controlled for confounding in the multivariate analysis, only recurrent PE (HR 19.3, P < 0.001) and pulmonary artery systolic pressure >50 mmHg (HR 10.4, P < 0.001) were statistically significant predictors of CTEPH. Of the non-invasive diagnostic tests, ECG criteria for RVH were found to be poorly sensitive (2.6 %), but very specific (98.8 %) for CTEPH. Elevated levels of BNP alone were more sensitive than RVH ECG criteria (76.3 %) but poorly specific (44.4 %). CONCLUSIONS The diagnosis of CTEPH is uncommonly made following acute PE. Despite the frequency of persistent symptoms consistent with CTEPH following acute PE, the appropriate diagnostic work-up is rarely undertaken as evidenced in this cohort. This suggests that CTEPH is underappreciated and rarely considered, likely underestimating the true incidence in this cohort. Future studies are needed to elucidate the true prevalence of CTEPH and further investigate both the optimal diagnostic tools and timing of appropriate screening. These discoveries may help guide future development of diagnostic algorithms that can effectively rule out and accurately identify this potentially curable disease in a timely manner.
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Affiliation(s)
- Jeremy Kong
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA.
| | | | - Sheng-Fang Jiang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Ke Sun
- Department of Internal Medicine, Kaiser Permanente Mid-Atlantic, Gaithersburg, MD
| | - David R Vinson
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA
| | - Dana P McGlothlin
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Choon Hwa Goh
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
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Liu W, Xie S, Liang T, Chang F, Liu M, Zhai Z. Clinical and imaging risk factors for the persistence of thromboembolism following acute pulmonary embolism. Quant Imaging Med Surg 2022; 12:4047-4058. [PMID: 35919067 PMCID: PMC9338360 DOI: 10.21037/qims-21-753] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 05/05/2022] [Indexed: 11/28/2022]
Abstract
Background Predicting the progression of acute pulmonary embolism to chronic pulmonary thromboembolism (CPTE) disease is essential to monitoring and improving the long-term prognosis of pulmonary embolism. We explored the risk factors for chronic persistence of thromboembolism after acute pulmonary embolism. Methods Cases with newly onset acute pulmonary embolism in the China-Japan Friendship Hospital from November 2016 to November 2019 were retrospectively analyzed. The clinical characteristics, serological examination results, and treatment strategies of acute pulmonary embolism patients were obtained through the electronic medical record system (Goodwill E-Health Info Co., Ltd.). Imaging parameters on computed tomography pulmonary angiography (CTPA) images at the onset of the acute pulmonary embolism were measured and counted. Notably, we propose a new parameter based on CTPA images: the ratio of Sd (sum of residual segmental pulmonary artery diameter) to MPAd (the main pulmonary artery diameter) (Sd/MPAd). After 3 months of regular treatment for acute pulmonary embolism, patients were classified into a CPTE group or a non-CPTE group based on the presence of residual embolus. All data were compared between the CPTE group and non-CPTE group. Furthermore, logistic regression analysis was used to investigate risk factors for the progression of acute pulmonary embolism to CPTE. Results A total of 77 cases (male:female = 1:1.26) were included in the study. There were 43 cases (55.84%) in the CPTE group and 34 cases in the non-CPTE group (44.16%). The results of univariate analysis showed that there were statistically significant differences between the 2 groups in risk stratification (χ2=8.043; P=0.005), protein S activity (χ2=5.551; P=0.018), the ratio of sum of residual segmental pulmonary artery diameter to the main pulmonary artery diameter (Sd/MPAd; t=–2.103; P=0.039), Mastora score (U=362.500; P<0.001), and embolus location (χ2=16.969; P<0.001). However, there were no statistically significant differences between the 2 groups in treatment options (P=0.381). According to multivariate logistic-regression analysis, protein S activity <55% (P=0.025), Sd/MPAd ≥1.97 (P=0.011), and an embolus being located in the central pulmonary artery (P<0.001) were independent risk factors for chronic persistence of thromboembolism following acute pulmonary embolism. Conclusions The protein S activity, location of the embolus, and Sd/MPAd on CTPA at the onset of acute pulmonary embolism may suggest the progression of acute pulmonary embolism to CPTE.
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Affiliation(s)
- Weifang Liu
- Department of Radiology, Civil Aviation General Hospital, Beijing, China
| | - Sheng Xie
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Tian Liang
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Feiyan Chang
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Min Liu
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
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Nilsson LT, Andersson T, Larsen F, Lang IM, Liv P, Söderberg S. Dyspnea after pulmonary embolism: a nation-wide population-based case-control study. Pulm Circ 2021; 11:20458940211046831. [PMID: 34616546 PMCID: PMC8488523 DOI: 10.1177/20458940211046831] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/12/2021] [Indexed: 11/15/2022] Open
Abstract
Dyspnea is common after a pulmonary embolism. Often, but not always, the dyspnea can be explained by pre-existing comorbidities, and only rarely by chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH is probably the extreme manifestation of a far more common condition, called the post-pulmonary embolism syndrome. The purpose of this retrospective study was to investigate the prevalence and predictors of dyspnea among Swedish patients that survived a pulmonary embolism, compared to the general population. All Swedish patients diagnosed with an acute pulmonary embolism in 2005 (n = 5793) were identified via the Swedish National Patient Registry. Patients that lived until 2007 (n = 3510) were invited to participate. Of these, 2105 patients responded to a questionnaire about dyspnea and comorbidities. Data from the general population (n = 1905) were acquired from the multinational MONItoring of trends and determinants in CArdiovascular disease health survey, conducted in 2004. Patients with pulmonary embolism had substantially higher prevalences of both exertional dyspnea (53.0% vs. 17.3%, odds ratio (OR): 5.40, 95% confidence intervals (CI): 4.61-6.32) and wake-up dyspnea (12.0% vs. 1.7%, OR: 7.7, 95% CI: 5.28-11.23) compared to control subjects. These differences remained after adjustments and were most pronounced among younger patients. The increased risk for exertional dyspnea and wake-up dyspnea remained after propensity score matching (OR (95% CI): 4.11 (3.14-5.38) and 3.44 (1.95-6.06), respectively). This population-based, nation-wide study demonstrated that self-reported dyspnea was common among patients with previous pulmonary embolism. This finding suggested that a post-pulmonary embolism syndrome might be present, which merits further investigation.
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Affiliation(s)
- Lars T. Nilsson
- Department of Public Health and Clinical Medicine, Unit of Medicine, Umeå University, Umeå, Sweden
| | - Therese Andersson
- Department of Public Health and Clinical Medicine, Unit of Medicine, Umeå University, Umeå, Sweden
| | - Flemming Larsen
- Department of Molecular Medicine and Surgery, Section of Clinical Physiology, Karolinska Institute and Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Irene M. Lang
- Department of Internal Medicine II, Division of Cardiology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Per Liv
- Department of Public Health and Clinical Medicine, Section of Sustainable Health, Umeå University, Umeå, Sweden
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, Unit of Medicine, Umeå University, Umeå, Sweden
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Aranda C, Gonzalez P, Gagliardi L, Peralta L, Jimenez A. Prognostic factors of clot resolution on follow-up computed tomography angiography and recurrence after a first acute pulmonary embolism. THE CLINICAL RESPIRATORY JOURNAL 2021; 15:949-955. [PMID: 33960121 DOI: 10.1111/crj.13386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 09/23/2020] [Accepted: 04/12/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Recent studies seem to confirm the relationship between residual pulmonary obstruction (RPO) in pulmonary embolism (PE) and risk of recurrent thrombosis and chronic thromboembolic pulmonary hypertension (CTEPH). However, the prognostic factors associated with PE resolution on follow-up computed tomography angiography (CTA) are not clear. OBJECTIVES To determine the prognostic factors of resolution of PE diagnosed and monitored by CTA and the impact of RPO on late complications. METHODS We retrospectively analyzed 241 patients with PE who had undergone a 12-month follow-up and CT scan evaluation at 6 months. Factors related to resolution and the impact of RPO on the outcome were analyzed. RESULTS Resolution was achieved in 74.3% of all cases after 6 months of treatment. Absence of chronic obstructive pulmonary disease (COPD) (OR, 3.22 [1.35-7.71]; p = 0.009), provoked PE (OR, 2.02 [1.08-3.79]; p = 0.028), early initiation of treatment (<7 days) (OR, 2.42 [1.22-4.78]; p = 0.011), and degree of obstruction caused by the initial PE as indicated by a Qanadli score lower than 16 (OR, 2.12 [1.03-4.37]; p = 0.043) were associated with complete resolution. RPO was associated with recurrent PE as well as the combined endpoint consisting of recurrent VTE and/or CTEPH (4.67 [95% CI, 1.26-17.26]; p = 0.02) and (OR 6.4 [95% CI, 1.9-21.2]; p < 0.005), respectively. CONCLUSIONS Resolution of PE is associated with a lower risk of recurrent thrombosis. Earlier initiation of treatment improves prognosis as measured by resolution on follow-up CTA.
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Affiliation(s)
- Carlos Aranda
- Internal Medicine Department, Hospital Universitario Infanta Elena, Valdemoro, Spain
| | - Paula Gonzalez
- Internal Medicine Department, Hospital Universitario Infanta Elena, Valdemoro, Spain
| | - Lidia Gagliardi
- Internal Medicine Department, Hospital Universitario Infanta Elena, Valdemoro, Spain
| | - Luisa Peralta
- Emergencies Department, Hospital Universitario Rey Juan Carlos, Móstoles, Spain
| | - Angel Jimenez
- Internal Medicine Department, Hospital Universitario Infanta Elena, Valdemoro, Spain
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Predicting the Risk of Recurrent Venous Thromboembolism: Current Challenges and Future Opportunities. J Clin Med 2020; 9:jcm9051582. [PMID: 32456008 PMCID: PMC7290951 DOI: 10.3390/jcm9051582] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/13/2020] [Accepted: 05/19/2020] [Indexed: 12/11/2022] Open
Abstract
Acute venous thromboembolism (VTE) is a commonly diagnosed condition and requires treatment with anticoagulation to reduce the risk of embolisation as well as recurrent venous thrombotic events. In many cases, cessation of anticoagulation is associated with an unacceptably high risk of recurrent VTE, precipitating the use of indefinite anticoagulation. In contrast, however, continuing anticoagulation is associated with increased major bleeding events. As a consequence, it is essential to accurately predict the subgroup of patients who have the highest probability of experiencing recurrent VTE, so that treatment can be appropriately tailored to each individual. To this end, the development of clinical prediction models has aided in calculating the risk of recurrent thrombotic events; however, there are several limitations with regards to routine use for all patients with acute VTE. More recently, focus has shifted towards the utility of novel biomarkers in the understanding of disease pathogenesis as well as their application in predicting recurrent VTE. Below, we review the current strategies used to predict the development of recurrent VTE, with emphasis on the application of several promising novel biomarkers in this field.
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Becattini C, Giustozzi M, Cerdà P, Cimini LA, Riera-Mestre A, Agnelli G. Risk of recurrent venous thromboembolism after acute pulmonary embolism: Role of residual pulmonary obstruction and persistent right ventricular dysfunction. A meta-analysis. J Thromb Haemost 2019; 17:1217-1228. [PMID: 31063646 DOI: 10.1111/jth.14477] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 05/01/2019] [Indexed: 08/31/2023]
Abstract
Essentials Debated is the role of residual pulmonary obstruction (RPO) in predicting venous thromboembolism. Whether right ventricular dysfunction (RVD) predicts recurrent venous thromboembolism is unknown. 15 studies on RPO and 4 on RVD and venous thromboembolism were included in this meta-analysis. RPO is a predictor of recurrent venous thromboembolism when assessed by perfusion lung scan. RVD after acute pulmonary embolism is not associated with recurrent venous thromboembolism. BACKGROUND There is conflicting evidence regarding the role of residual pulmonary obstruction (RPO) or persistent right ventricular dysfunction (RVD) after pulmonary embolism (PE) as a predictor of recurrent venous thromboembolism (VTE). The aim of this study was to assess whether RPO or persistent RVD after PE is associated with recurrent VTE. METHODS MEDLINE and EMBASE were searched through December 2018. Studies reporting on (a) RPO either on computed tomography (CT) angiography or perfusion lung scan, or RVD on echocardiography or CT angiography, after therapeutic anticoagulation for the acute PE, and (b) recurrent VTE, were included in this meta-analysis. RESULTS RPO was associated with an increased risk of recurrent VTE (16 studies; 3472 patients; odds ratio [OR] 2.22; 95% confidence interval [CI] 1.61-3.05; I2 = 26%); the association was statistically significant for lung scan-detected RPO (11 studies; 2916 patients; OR 2.21; 95% CI 1.63-3.01) but not for CT angiography-detected RPO (five studies; 556 patients; OR 2.56; 95% CI 0.82-7.94). No significant association was found between persistent RVD and recurrent VTE (four studies; 852 patients; OR 1.62; 95% CI 0.63-4.17). CONCLUSIONS RPO is a predictor of recurrent VTE after a first acute PE, mainly when assessed by perfusion lung scan.
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Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Michela Giustozzi
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Pau Cerdà
- Internal Medicine, Hospital Universitari Bellvitge-IDIBELL, Barcelona, Spain
| | - Ludovica A Cimini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Antoni Riera-Mestre
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
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Zhang Y, Liu H, Zhang Y, Wu Q, Zhang Y, Zhang J, Zhou X, Jiao H, Fan F, Xue Q, Wang X, Zhong Z. Efficacy evaluation of reteplase in a novel canine acute pulmonary thromboembolism model developed by minimally invasive surgery and digital subtraction angiography. Drug Des Devel Ther 2018; 12:3717-3730. [PMID: 30464403 PMCID: PMC6219412 DOI: 10.2147/dddt.s180151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Purpose In order to evaluate the thrombolytic effects of reteplase in pulmonary thromboembolism (PTE), we developed a novel canine PTE model. The efficacy of reteplase against PTE in comparison to alteplase was clarified for the first time, and this PTE model could be further applied to studies of novel thrombolytic therapies. Patients and methods Twenty-four dogs were divided into four groups: sham operation, vehicle, alteplase, and reteplase. Autologous thrombi/saline were injected into the pulmonary artery, and thrombolytic agents were administrated. Thrombus formation and dissolution were monitored by real-time digital subtraction angiography (DSA), and pulmonary pressures were measured simultaneously. Blood coagulation, blood gas, hematology, and histopathologic examinations were used as subsidiary methods. Results The canine PTE model was established with a significant decrease of blood flow and ~75% blocking area. Administration of reteplase (0.6 mg/kg) resulted in effective thrombus dissolution with a recovery of over 80% blood flow, as effective as alteplase (1.6 mg/kg). Correspondingly, the elevated pulmonary systolic, diastolic, and mean arterial pressures declined to the normal level. Blood coagulation was changed by reteplase, with a dramatic elongation of prothrombin time, activated partial thromboplastin time, and thrombin time, even longer than alteplase. In contrast to the vehicle group, no obvious pathological changes were found in the two thrombolytic groups. Hematological, blood biochemical, and blood gas results also indicated that reteplase had no adverse reactions in this PTE model. Conclusion Reteplase proved to be an effective and safe therapy for PTE for the first time, and a small dosage of reteplase exerted an efficacy comparable to the routine dosage of alteplase. Our findings indicated the potential of reteplase as clinical treatment against PTE. This technically innovative, stability- and validity-proved canine PTE model developed by minimally invasive surgery and DSA resembled major clinical features. This may further facilitate our understanding of thrombotic disorders and development of prophylactic and therapeutic approaches.
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Affiliation(s)
- Yinbing Zhang
- Laboratory of Nonhuman Primate Disease Modeling Research, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China, , .,Sichuan Kangcheng Biomed Co., Ltd., Chengdu, China, ,
| | - Haifeng Liu
- Angde Biotech Pharmaceutical Co., Ltd., Liaocheng, China
| | - Yingqian Zhang
- Department of Physiology, Southwest Medical University, Luzhou, China
| | - Qiong Wu
- Laboratory of Nonhuman Primate Disease Modeling Research, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China, ,
| | - Yanyan Zhang
- Laboratory of Nonhuman Primate Disease Modeling Research, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China, , .,Sichuan Kangcheng Biomed Co., Ltd., Chengdu, China, ,
| | - Jie Zhang
- Laboratory of Nonhuman Primate Disease Modeling Research, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China, , .,Sichuan Kangcheng Biomed Co., Ltd., Chengdu, China, ,
| | - Xiangshan Zhou
- Angde Biotech Pharmaceutical Co., Ltd., Liaocheng, China
| | - He Jiao
- Department of Interventional therapy, West China Hospital, Sichuan University, Chengdu, China
| | - Feng Fan
- Department of Neurointervention, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qi Xue
- Food and Drug Administration of Shibei District Government, Qingdao, China
| | - Xin Wang
- Laboratory of Nonhuman Primate Disease Modeling Research, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China, , .,Sichuan Kangcheng Biomed Co., Ltd., Chengdu, China, ,
| | - Zhihui Zhong
- Laboratory of Nonhuman Primate Disease Modeling Research, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu, China, , .,Sichuan Kangcheng Biomed Co., Ltd., Chengdu, China, ,
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11
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Elmi G, Pizzini AM, Silingardi M. The secondary prevention of venous thromboembolism: Towards an individual therapeutic strategy. Vascular 2018; 26:670-682. [PMID: 29966487 DOI: 10.1177/1708538118776896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
After the anticoagulant withdrawal, a substantial proportion of patients with venous thromboembolism will develop recurrent events. Whether to consider an extended treatment depends on the risk of recurrence and bleeding risk. The assessment of the individual risk profile remains a difficult task. Several basal and post-basal factors modulate the risk of recurrence and may help clinicians to select patients who can benefit from the extended therapy. During the year 2017, new evidence regarding the post-basal factors was provided by the Morgagni and Scope studies. Another interesting novelty was the VTE-BLEED score, the first bleeding risk score that obtained the external validation in venous thromboembolism setting. In secondary prevention, the use of direct oral anticoagulants is growing instead of vitamin K antagonist. Even at lower doses, direct oral anticoagulants showed to be effective and safe, to reduce all-cause mortality and seemed to be superior to placebo for the composite outcome of fatal bleeding and fatal recurrence. After the recently published Einstein-Choice trial, the role of aspirin has become truly marginal as rivaroxaban 10 mg showed a bleeding risk similar to aspirin 100 mg but a greater effectiveness reducing the relative risk of recurrence by about 70%. Another option for secondary prevention could be sulodexide, with a lower protective effect than direct oral anticoagulants but an interesting safety profile. In conclusion, in our opinion, an individual strategy taking into account the risk of recurrence, bleeding risk, therapeutic options and patient preferences is the most appropriate approach to secondary prevention of venous thromboembolism.
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Affiliation(s)
- Giovanna Elmi
- Internal Medicine A Unit, Medical Department, Maggiore Hospital, Largo Nigrisoli Bologna, Italy
| | - Attilia M Pizzini
- Internal Medicine A Unit, Medical Department, Maggiore Hospital, Largo Nigrisoli Bologna, Italy
| | - Mauro Silingardi
- Internal Medicine A Unit, Medical Department, Maggiore Hospital, Largo Nigrisoli Bologna, Italy
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12
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Barco S, Konstantinides S, Huisman MV, Klok FA. Diagnosis of recurrent venous thromboembolism. Thromb Res 2018; 163:229-235. [DOI: 10.1016/j.thromres.2017.05.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/11/2017] [Accepted: 05/25/2017] [Indexed: 12/19/2022]
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13
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Barbar S, Milan M, Campello E, Spiezia L, Piovella C, Pesavento R, Prandoni P. Optimal duration of anticoagulation. Thromb Haemost 2017; 113:1210-5. [DOI: 10.1160/th14-04-0396] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 06/24/2014] [Indexed: 11/05/2022]
Abstract
SummaryOnce anticoagulation is stopped, the risk of recurrent venous thromboembolism (VTE) over years after a first episode is consistently around 30%. This risk is higher in patients with unprovoked than in those with (transient) provoked VTE, and among the latter in patients with medical than in those with surgical risk factors. Baseline parameters that have been found to be related to the risk of recurrent VTE are the proximal location of deep-vein thrombosis, obesity, old age, male sex and non-0 blood group, whereas the role of inherited thrombophilia is controversial. The persistence of residual vein thrombosis at ultrasound assessment has consistently been shown to increase the risk, as do persistently high values of D-dimer and the early development of the post-thrombotic syndrome. Although the latest international guidelines suggest indefinite anticoagulation for most patients with the first episode of unprovoked VTE, strategies that incorporate the assessment of residual vein thrombosis and D-dimer have the potential to identify subjects in whom anticoagulation can be safely discontinued. Moreover, new opportunities are offered by a few emerging anti-Xa and anti-IIa oral compounds, which are likely to induce fewer haemorrhagic complications than vitamin K antagonists while preserving the same effectiveness; and by low-dose aspirin, which has the potential to prevent the occurrence of both venous and arterial thrombotic events.
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14
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Pesavento R, Filippi L, Palla A, Visonà A, Bova C, Marzolo M, Porro F, Villalta S, Ciammaichella M, Bucherini E, Nante G, Battistelli S, Muiesan ML, Beltramello G, Prisco D, Casazza F, Ageno W, Palareti G, Quintavalla R, Monti S, Mumoli N, Zanatta N, Cappelli R, Cattaneo M, Moretti V, Corà F, Bazzan M, Ghirarduzzi A, Frigo AC, Miniati M, Prandoni P. Impact of residual pulmonary obstruction on the long-term outcome of patients with pulmonary embolism. Eur Respir J 2017; 49:49/5/1601980. [PMID: 28546279 DOI: 10.1183/13993003.01980-2016] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 02/07/2017] [Indexed: 01/08/2023]
Abstract
The impact of residual pulmonary obstruction on the outcome of patients with pulmonary embolism is uncertain.We recruited 647 consecutive symptomatic patients with a first episode of pulmonary embolism, with or without concomitant deep venous thrombosis. They received conventional anticoagulation, were assessed for residual pulmonary obstruction through perfusion lung scanning after 6 months and then were followed up for up to 3 years. Recurrent venous thromboembolism and chronic thromboembolic pulmonary hypertension were assessed according to widely accepted criteria.Residual pulmonary obstruction was detected in 324 patients (50.1%, 95% CI 46.2-54.0%). Patients with residual pulmonary obstruction were more likely to be older and to have an unprovoked episode. After a 3-year follow-up, recurrent venous thromboembolism and/or chronic thromboembolic pulmonary hypertension developed in 34 out of the 324 patients (10.5%) with residual pulmonary obstruction and in 15 out of the 323 patients (4.6%) without residual pulmonary obstruction, leading to an adjusted hazard ratio of 2.26 (95% CI 1.23-4.16).Residual pulmonary obstruction, as detected with perfusion lung scanning at 6 months after a first episode of pulmonary embolism, is an independent predictor of recurrent venous thromboembolism and/or chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
| | - Lucia Filippi
- Dept of Internal Medicine, University of Padua, Padua, Italy
| | - Antonio Palla
- Cardio-thoracic Dept, Cisanello Hospital, University of Pisa, Pisa, Italy
| | - Adriana Visonà
- Dept of Internal and Vascular Medicine, Angiology Unit, Civic Hospital, Castelfranco Veneto, Italy
| | - Carlo Bova
- Dept of Internal Medicine, University Hospital of Cosenza, Cosenza, Italy
| | - Marco Marzolo
- UOC Medicina Interna, UOS Angiologia Medica, Civic Hospital, Rovigo, Italy
| | - Fernando Porro
- UOC Pronto Soccorso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sabina Villalta
- UOC Medicina Interna I, Ca' Foncello Hospital, Treviso, Italy
| | | | - Eugenio Bucherini
- UOS di Angiologia e Medicina Vascolare, Civic Hospital of Faenza, Faenza, Italy
| | - Giovanni Nante
- Dept of Internal Medicine, University of Padua, Padua, Italy
| | - Sandra Battistelli
- Department of Medicine, Surgery and Neuroscience, University Hospital of Siena, Siena, Italy
| | | | | | - Domenico Prisco
- Dept of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Franco Casazza
- UO Cardiologia Clinica, San Carlo Borromeo Hospital, Milan, Italy
| | - Walter Ageno
- Dept of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Gualtiero Palareti
- Angiology and Blood Coagulation, University Hospital of Bologna, Bologna, Italy
| | - Roberto Quintavalla
- UOC Medicina Interna ad indirizzo Angiologico e Coagulativo, University Hospital of Parma, Parma, Italy
| | - Simonetta Monti
- Istituto di Fisiologia Clinica del CNR e Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Nicola Mumoli
- Dept of Internal Medicine, Livorno Hospital, Livorno, Italy
| | - Nello Zanatta
- Dept of Internal Medicine, Civic Hospital of Conegliano, Conegliano, Italy
| | | | - Marco Cattaneo
- Medicina III, Ospedale San Paolo, ASST Santi Paolo e Carlo, Dipartimento di Scienze della Salute, University of Milan, Milan, Italy
| | - Valentino Moretti
- AAS3 Alto Friuli Collinare, Medio Friuli, San Daniele del Friuli, Italy
| | - Francesco Corà
- UOS Emergenza Medica, Pronto Soccorso Generale, Civic Hospital of Vicenza, Vicenza, Italy
| | - Mario Bazzan
- UOSD di Ematologia e Malattie Trombotiche CMID, Ospedale San Giovanni Bosco, Torino Emergenza Nord, Turin, Italy
| | - Angelo Ghirarduzzi
- Dipartimento Medicina Interna e Specialità Mediche, Medicina II, Angiologia, Arcispedale S. Maria Nuova, IRCCS, Reggio Emilia, Italy
| | - Anna Chiara Frigo
- Dept of Cardiac Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Massimo Miniati
- Dept of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Paolo Prandoni
- Dept of Cardiac Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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15
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Algoritmo para el diagnóstico y el seguimiento de la tromboembolia pulmonar aguda. RADIOLOGIA 2017; 59:75-87. [DOI: 10.1016/j.rx.2016.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 10/04/2016] [Accepted: 10/26/2016] [Indexed: 01/24/2023]
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16
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The post-PE syndrome: a new concept for chronic complications of pulmonary embolism. Blood Rev 2014; 28:221-6. [DOI: 10.1016/j.blre.2014.07.003] [Citation(s) in RCA: 211] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 04/21/2014] [Accepted: 07/14/2014] [Indexed: 02/07/2023]
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17
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Lami D, Cellai AP, Antonucci E, Fiorillo C, Becatti M, Grifoni E, Cenci C, Marcucci R, Mannini L, Miniati M, Abbate R, Prisco D. Residual perfusion defects in patients with pulmonary embolism are related to impaired fibrinolytic capacity. Thromb Res 2014; 134:737-41. [DOI: 10.1016/j.thromres.2014.07.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 07/04/2014] [Accepted: 07/10/2014] [Indexed: 10/25/2022]
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18
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Prandoni P, Barbar S, Milan M, Vedovetto V, Pesavento R. The risk of recurrent thromboembolic disorders in patients with unprovoked venous thromboembolism: new scenarios and opportunities. Eur J Intern Med 2014; 25:25-30. [PMID: 24120221 DOI: 10.1016/j.ejim.2013.09.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 09/10/2013] [Indexed: 10/26/2022]
Abstract
The risk of recurrent thromboembolic disorders in the 10-year period following an episode of unprovoked venous thromboembolism (VTE) ranges between 30 and 50%, the rate being higher in patients with primary deep venous thrombosis (DVT) than in those with primary pulmonary embolism (PE). The clinical presentation with primary PE increases by more than three times the risk of a new PE episode over that with isolated DVT. Baseline parameters that increase this risk are the proximal location of DVT, obesity, old age and male sex, whereas the role of thrombophilia is controversial. An increasing role is played by post-baseline parameters such as the ultrasound assessment of residual vein thrombosis and the determination of D-dimer. While the latest international guidelines suggest indefinite anticoagulation for most patients with the first episode of unprovoked VTE, new scenarios are being offered by the identification of risk stratification models and by strategies that have the potential to help identify patients in whom anticoagulation can be safely discontinued, such as those that incorporate the assessment of D-dimer and residual vein thrombosis. New opportunities are being offered by low-dose aspirin, which has recently been reported to decrease by more than 30% the risk of recurrent events without increasing the bleeding risk; and especially by a few emerging anti-Xa and anti-IIa oral compounds, which are likely to induce fewer haemorrhagic complications than vitamin K antagonists while preserving at least the same effectiveness, do not require laboratory monitoring, and can be used immediately after the thrombotic episode.
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Affiliation(s)
- Paolo Prandoni
- Department of Medicine, Thromboembolism Unit, University of Padua, Italy.
| | - Sofia Barbar
- Department of Medicine, Thromboembolism Unit, University of Padua, Italy
| | - Marta Milan
- Department of Medicine, Thromboembolism Unit, University of Padua, Italy
| | | | - Raffaele Pesavento
- Department of Medicine, Thromboembolism Unit, University of Padua, Italy
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19
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Golpe R, Pérez-de-Llano LA, Castro-Añón O. Prognostic value of the Charlson comorbidity index in pulmonary embolism. ACTA ACUST UNITED AC 2013; 85:438. [PMID: 23485768 DOI: 10.1159/000346982] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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