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Singh G, Bamba H, Inban P, Chandrasekaran SH, Priyatha V, John J, Prajjwal P. The prognostic significance of pro-BNP and heart failure in acute pulmonary embolism: A systematic review. Dis Mon 2024:101783. [PMID: 38955637 DOI: 10.1016/j.disamonth.2024.101783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
Pulmonary embolism (PE) is the third most common type of cardiovascular disease and carries a high mortality rate of 30% if left untreated. Although it is commonly known that individuals who suffer heart failure (HF) are more likely to experience a pulmonary embolism, little is known concerning the prognostic relationship between acute PE and HF. This study aims to evaluate the prognostic usefulness of heart failure and pro-BNP in pulmonary embolism cases. A scientific literature search, including PubMed, Medline, and Cochrane reviews, was used to assess and evaluate the most pertinent research that has been published. The findings showed that increased N-terminal brain natriuretic peptide (NT-proBNP) levels could potentially identify pulmonary embolism patients with worse immediate prognoses and were highly predictive of all-cause death. Important prognostic information can be obtained from NT-proBNP and Heart-type Fatty Acid Binding Proteins (H-FABP) when examining individuals with PE. The heart, distal tubular cells of the renal system, and skeletal muscle are where H-FABP is primarily found, with myocardial cells having the highest concentration. Recent studies have indicated that these biomarkers may also help assess the severity of PE and its long-term risk.
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Affiliation(s)
- Gurmehar Singh
- Government Medical College and Hospital, Chandigarh, India
| | - Hyma Bamba
- Government Medical College and Hospital, Chandigarh, India
| | - Pugazhendi Inban
- Internal Medicine, St. Mary's General Hospital and Saint Clare's Health, NY, USA.
| | | | | | - Jobby John
- Dr. Somervell Memorial CSI Medical College and Hospital Karakonam, Trivandrum, India
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2
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Loh TM. Intervention Versus Medical Management of Pulmonary Embolism. Methodist Debakey Cardiovasc J 2024; 20:13-18. [PMID: 38765214 PMCID: PMC11100531 DOI: 10.14797/mdcvj.1351] [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: 01/19/2024] [Accepted: 04/12/2024] [Indexed: 05/21/2024] Open
Abstract
With a multitude of options for pulmonary embolism management, we review the most common diagnostic tools available for assessing risk as well as how each broad risk category is typically treated. Right heart dysfunction is the cornerstone for triage of these patients and should be the focus for decision-making, especially in challenging patients. We aim to provide a modern, clinical perspective for PE management in light of the multitude of intervention options.
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Affiliation(s)
- Thomas M. Loh
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
- Houston Methodist, The Woodlands, Texas, US
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3
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Thangudu P. From Trendelenburg to PERTs: Evolution in the Management of Massive Pulmonary Embolism. Methodist Debakey Cardiovasc J 2024; 20:19-26. [PMID: 38765213 PMCID: PMC11100543 DOI: 10.14797/mdcvj.1345] [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: 01/17/2024] [Accepted: 03/27/2024] [Indexed: 05/21/2024] Open
Abstract
Massive pulmonary embolism (MPE) is a serious condition affecting the pulmonary arteries and is difficult to diagnose, triage, and treat. The American College of Chest Physicians (AHA) and the European Society of Cardiology (ESC) have different classification approaches for PE, with the AHA defining three subtypes and the ESC four. Misdiagnosis is common, leading to delayed or inadequate treatment. The incidence of PE-related death rates has been increasing over the years, and mortality rates vary depending on the subtype of PE, with MPE having the highest mortality rate. The current definition of MPE originated from early surgical embolectomy cases and discussions among experts. However, this definition fails to capture patients at the point of maximal benefit because it is based on late findings of MPE. Pulmonary Embolism Response Teams (PERTs) have emerged as a fundamental shift in the management of MPE, with a focus on high-risk and MPE cases and a goal of rapidly connecting patients with appropriate therapies based on up-to-date evidence. This review highlights the challenges in diagnosing and managing MPE and emphasizes the importance of PERTs and risk stratification scores in improving outcomes for patients with PE.
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Affiliation(s)
- Pavan Thangudu
- Pulmonary Disease & Critical Care, Memorial Hermann Health System, The Woodlands, Texas, US
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4
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Yuriditsky E. Refining outcome prediction in intermediate-risk pulmonary embolism: The added value of advanced echocardiographic right ventricular assessment. Echocardiography 2024; 41:e15820. [PMID: 38690627 DOI: 10.1111/echo.15820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 05/02/2024] Open
Affiliation(s)
- Eugene Yuriditsky
- Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
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5
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Trammell AW, Ball J. Accumulating Evidence for Reduced-Dose Thrombolysis in Acute Pulmonary Embolism. Crit Care Med 2024; 52:847-850. [PMID: 38619343 DOI: 10.1097/ccm.0000000000006206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Aaron W Trammell
- Pulmonary, Allergy, Critical Care, and Sleep Medicine Division, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jonathan Ball
- General Intensive Care Unit, St George's Hospital, London, United Kingdom
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6
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Bulsara KG, Patel H, Goldstein A, Mathew M. A Rare Case of Argatroban-Induced Anaphylaxis in a Patient With Intermediate-High Risk Pulmonary Embolism. Cureus 2024; 16:e61129. [PMID: 38919225 PMCID: PMC11199000 DOI: 10.7759/cureus.61129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2024] [Indexed: 06/27/2024] Open
Abstract
Heparin-induced thrombocytopenia is a rare and potentially devastating complication of heparin therapy. Patients with an absolute indication for anticoagulation, such as those with significant pulmonary embolism, must be switched to a different anticoagulant, such as argatroban, a direct thrombin inhibitor. We report a case of anaphylaxis to argatroban in a patient who was initially on heparin for intermediate-high risk pulmonary embolism but developed suspected type II heparin-induced thrombocytopenia. This case highlights the significance of recognizing and treating anaphylactic reactions and the diagnostic challenges associated with heparin-induced thrombocytopenia.
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Affiliation(s)
| | - Humail Patel
- Internal Medicine, Northwell Health, New Hyde Park, USA
| | | | - Merlin Mathew
- Internal Medicine, Northwell Health, New Hyde Park, USA
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7
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Miranda CH. Focus on Intermediate-Risk Acute Pulmonary Embolism. Is the Combination of Biomarkers the Solution? Arq Bras Cardiol 2024; 121:e20240075. [PMID: 38695401 PMCID: PMC11081194 DOI: 10.36660/abc.20240075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 02/15/2024] [Accepted: 02/15/2024] [Indexed: 05/12/2024] Open
Affiliation(s)
- Carlos Henrique Miranda
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoDepartamento de Clínica MédicaRibeirão PretoSPBrasilDivisão de Medicina de Emergência, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP – Brasil
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8
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Munshi NH, Truitt TJ, Patton A. An Atypical presentation of pulmonary embolism in a critically ill patient. Radiol Case Rep 2023; 18:2633-2636. [PMID: 37266377 PMCID: PMC10230824 DOI: 10.1016/j.radcr.2023.05.015] [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: 03/21/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 06/03/2023] Open
Abstract
A pulmonary embolism (PE) occurs when a venous thrombotic material from the lower extremities embolizes to the pulmonary vasculature. Common presenting symptoms include shortness of breath and pleuritic chest pain with vital signs demonstrating hypoxia, tachycardia, and tachypnea. In this paper, we describe a unique presentation of a critically ill patient who developed a saddle pulmonary embolism despite being on prophylactic anticoagulation.
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Affiliation(s)
- Nirali H. Munshi
- Edward Via College of Osteopathic Medicine, 2265 Kraft Dr SW, Blacksburg, VA 24060, USA
| | - Terrance J. Truitt
- Sentara Halifax Regional Hospital, Pulmonology Associates of Southside Virginia, South Boston, VA, USA
| | - Alexander Patton
- Department of Internal Medicine, Sentara Halifax Regional Hospital, South Boston, VA, USA
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9
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Cahan N, Klang E, Marom EM, Soffer S, Barash Y, Burshtein E, Konen E, Greenspan H. Multimodal fusion models for pulmonary embolism mortality prediction. Sci Rep 2023; 13:7544. [PMID: 37160926 PMCID: PMC10170065 DOI: 10.1038/s41598-023-34303-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/27/2023] [Indexed: 05/11/2023] Open
Abstract
Pulmonary embolism (PE) is a common, life threatening cardiovascular emergency. Risk stratification is one of the core principles of acute PE management and determines the choice of diagnostic and therapeutic strategies. In routine clinical practice, clinicians rely on the patient's electronic health record (EHR) to provide a context for their medical imaging interpretation. Most deep learning models for radiology applications only consider pixel-value information without the clinical context. Only a few integrate both clinical and imaging data. In this work, we develop and compare multimodal fusion models that can utilize multimodal data by combining both volumetric pixel data and clinical patient data for automatic risk stratification of PE. Our best performing model is an intermediate fusion model that incorporates both bilinear attention and TabNet, and can be trained in an end-to-end manner. The results show that multimodality boosts performance by up to 14% with an area under the curve (AUC) of 0.96 for assessing PE severity, with a sensitivity of 90% and specificity of 94%, thus pointing to the value of using multimodal data to automatically assess PE severity.
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Affiliation(s)
- Noa Cahan
- Department of Biomedical Engineering, Tel-Aviv University, Tel Aviv, Israel.
| | - Eyal Klang
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel affiliated with the Tel Aviv University, Tel Aviv, Israel
| | - Edith M Marom
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel affiliated with the Tel Aviv University, Tel Aviv, Israel
| | - Shelly Soffer
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel affiliated with the Tel Aviv University, Tel Aviv, Israel
| | - Yiftach Barash
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel affiliated with the Tel Aviv University, Tel Aviv, Israel
| | - Evyatar Burshtein
- Department of Biomedical Engineering, Tel-Aviv University, Tel Aviv, Israel
| | - Eli Konen
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel affiliated with the Tel Aviv University, Tel Aviv, Israel
| | - Hayit Greenspan
- Department of Biomedical Engineering, Tel-Aviv University, Tel Aviv, Israel.
- Biomedical Engineering and Imaging Institute, Radiology Dept., Icahn School of Medicine at Mount Sinai, New York, United States.
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10
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Shamaki GR, Soji-Ayoade D, Adedokun SD, Kesiena O, Favour M, Bolaji O, Ezeh EO, Okoh N, Sadiq AA, Baldawi H, Davis A, Bob-Manuel T. Endovascular Venous Interventions - A State-of-the-Art Review. Curr Probl Cardiol 2023; 48:101534. [PMID: 36481393 DOI: 10.1016/j.cpcardiol.2022.101534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
Venous vascular diseases are an important clinical entity estimated to affect several million people worldwide. Deep vein thrombosis (DVT) is a common venous disease with a population variable prevalence of 122 to 160 persons per 100,000 per year, whereas pulmonary embolism (PE) affects up to 60 to 70 per 100 000 and carries much higher mortality. Chronic venous diseases, which cause symptoms like leg swelling, heaviness, pain, and discomfort, are most prevalent in the elderly and significantly impact their quality of life. Some estimate that chronic vascular diseases account for up to 2% of healthcare budgets in Western countries. Treating venous vascular disease includes using systemic anticoagulation and interventional therapies in some patient subsets. In this comprehensive review, we discuss endovascular treatment modalities in the management of venous vascular diseases.
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Affiliation(s)
| | | | | | - Onoriode Kesiena
- Department of Internal Medicine, Piedmont Athens Regional Medical Center, Athens, GA
| | - Markson Favour
- Department of Internal Medicine, Lincoln Medical Centre Bronx, NY
| | - Olayiwola Bolaji
- Department of Internal Medicine, University of Maryland Capital Region Medical Center, Largo, MD
| | | | - Nelson Okoh
- Department of Internal Medicine, Rutgers Community Hospital West Toms Rivers, NJ
| | | | - Harith Baldawi
- Department of Internal Medicine, Ochsner Clinic Foundation, Orleans, LA
| | - Arthur Davis
- Department of Internal Medicine, Ochsner Clinic Foundation, Orleans, LA
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11
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Keller K, Schmitt VH, Sagoschen I, Münzel T, Espinola-Klein C, Hobohm L. CRB-65 for Risk Stratification and Prediction of Prognosis in Pulmonary Embolism. J Clin Med 2023; 12:jcm12041264. [PMID: 36835800 PMCID: PMC9961795 DOI: 10.3390/jcm12041264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/29/2023] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is accompanied by high morbidity and mortality. The search for simple and easily assessable risk stratification scores with favourable effectiveness is still ongoing, and prognostic performance of the CRB-65 score in PE might promising. METHODS The German nationwide inpatient sample was used for this study. All patient cases of patients with PE in Germany 2005-2020 were included and stratified for CRB-65 risk class: low-risk group (CRB-65-score 0 points) vs. high-risk group (CRB-65-score ≥1 points). RESULTS Overall, 1,373,145 patient cases of patients with PE (76.6% aged ≥65 years, 47.0% females) were included. Among these, 1,051,244 patient cases (76.6%) were classified as high-risk according to CRB-65 score (≥1 points). The majority of high-risk patients according to CRB-65 score were females (55.8%). Additionally, high-risk patients according to CRB-65 score showed an aggravated comorbidity profile with increased Charlson comorbidity index (5.0 [IQR 4.0-7.0] vs. 2.0 [0.0-3.0], p < 0.001). In-hospital case fatality (19.0% vs. 3.4%, p < 0.001) and MACCE (22.4% vs. 5.1%, p < 0.001) occurred distinctly more often in PE patients of the high-risk group according to CRB-65 score (≥1 points) compared to the low-risk group (= 0 points). The CRB-65 high-risk class was independently associated with in-hospital death (OR 5.53 [95%CI 5.40-5.65], p < 0.001) as well as MACCE (OR 4.31 [95%CI 4.23-4.40], p < 0.001). CONCLUSIONS Risk stratification with CRB-65 score was helpful for identifying PE patients being at higher risk of adverse in-hospital events. The high-risk class according to CRB-65 score (≥1 points) was independently associated with a 5.5-fold increased occurrence of in-hospital death.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
- Correspondence:
| | - Volker H. Schmitt
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Ingo Sagoschen
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Christine Espinola-Klein
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
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12
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Bulman JC, Weinstein JL. Invited Commentary: Importance of a Multidisciplinary Approach to Pulmonary Embolism in the Era of Catheter-directed Therapies. Radiographics 2022; 42:E186-E187. [PMID: 36190875 DOI: 10.1148/rg.220174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Julie C Bulman
- From the Department of Radiology, Beth Israel Deaconess Medical Center, Deaconess Road, Boston, MA 02215
| | - Jeffrey L Weinstein
- From the Department of Radiology, Beth Israel Deaconess Medical Center, Deaconess Road, Boston, MA 02215
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13
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Lasica R, Asanin M, Djukanovic L, Radovanovic N, Savic L, Polovina M, Stankovic S, Ristic A, Zdravkovic M, Lasica A, Kravic J, Perunicic J. Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application. Pharmaceuticals (Basel) 2022; 15:ph15091146. [PMID: 36145366 PMCID: PMC9501350 DOI: 10.3390/ph15091146] [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: 08/04/2022] [Revised: 09/03/2022] [Accepted: 09/06/2022] [Indexed: 11/24/2022] Open
Abstract
Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.
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Affiliation(s)
- Ratko Lasica
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Correspondence:
| | - Milika Asanin
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lazar Djukanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nebojsa Radovanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lidija Savic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marija Polovina
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Sanja Stankovic
- Center for Medical Biochemistry, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Arsen Ristic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | | | | | - Jelena Kravic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Jovan Perunicic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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