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Assayag F, Georges JL, Chabay S, Lancien S, Flaujac C, Azarian R, de Villepin EG, Tapiéro S, Livarek B, Koukabi M, Maurizot A. [Home treatment of low-risk pulmonary embolism patients : Efficacy and safety of an outpatient program including the general practitioner]. Ann Cardiol Angeiol (Paris) 2022; 71:245-251. [PMID: 35940966 DOI: 10.1016/j.ancard.2022.06.015] [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: 06/17/2022] [Accepted: 06/29/2022] [Indexed: 06/15/2023]
Abstract
AIM Outpatient treatment (OT) of patients with low-risk pulmonary embolisms (PE) is recommended. A multidisciplinary OT program including the general practitioner (GP) has been implemented at Versailles hospital in 2019. The objectives of the study were to assess the feasibility, safety and acceptability of the program. MATERIAL AND METHODS The feasibility of, and the inclusion criteria for OT were defined from a retrospective cohort study of PE patients carried out in 2018. In the prospective study, consecutive patients consulting in the emergency department between 2019 and 2021 with confirmed PE were eligible for OT if they had sPESI and HESTIA scores equal to 0, normal troponin and NT-pro-BNP levels, and no right ventricular dilation on imaging. PEs associated with COVID were excluded. The OT program included 4 appointments within 3 months, including 2 with the GP. Events (death, recurrence of PE or venous thromboembolism, bleeding, rehospitalisation) were collected at 3-month follow-up. RESULTS In the retrospective study, 19% of the 138 PE patients seen in the emergency department were eligible for OT. No complication occurred at Day 90. In the prospective study, 313 consecutive patients with confirmed PE in the emergency department were included, 66 (21%) were eligible for OT. Overall, 43 patients (14%) received OT (39 eligible) and 27 patients eligible for OT were hospitalised (92% because of pulmonary infarction). At 3-month follow-up, there were no death, no recurrence of thromboembolism, and one patient has been early hospitalised for COVID; 3 female patients treated with rivaroxaban had minor bleeding (heavy menstrual bleeding). The satisfaction rate of general practitioner was 95%. CONCLUSIONS This study confirms the feasibility and safety of our OT program for low-risk EP patients, centered on the general practitioner. It reduces the time spent in the emergency department, reduces hospitalisations and strengthens the city-hospital link for care.
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Affiliation(s)
- Franck Assayag
- Service de cardiologie, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France; Service d'accueil des urgences, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France.
| | - Jean-Louis Georges
- Service de cardiologie, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Simon Chabay
- Unité de Médecine Vasculaire, Service de Cardiologie, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Solène Lancien
- Service d'accueil des urgences, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Claire Flaujac
- Laboratoire de biologie médicale - secteur d'hémostase, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Reza Azarian
- Service de pneumologie, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Eve Galouzeau de Villepin
- Service d'accueil des urgences, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Stéphanie Tapiéro
- Unité de Médecine Vasculaire, Service de Cardiologie, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Bernard Livarek
- Service de cardiologie, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Mehrsa Koukabi
- Service d'accueil des urgences, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
| | - Aurélien Maurizot
- Unité de Médecine Vasculaire, Service de Cardiologie, Centre Hospitalier de Versailles, Hôpital André Mignot, Le Chesnay-Rocquencourt, France
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Ghazvinian R, Elf J, Löfvendahl S, Holst J, Gottsäter A. Outpatient Treatment in Low-Risk Pulmonary Embolism Patients Receiving Direct Acting Oral Anticoagulants Is Associated With Cost Savings. Clin Appl Thromb Hemost 2020; 26:1076029620937352. [PMID: 33259227 PMCID: PMC7711226 DOI: 10.1177/1076029620937352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Direct oral anticoagulants (DOAC) are first line treatment for pulmonary embolism (PE). Treatment of acute PE is traditionally hospital based and associated with high costs. The aims of this study were to evaluate potential cost savings with outpatient DOAC treatment compared to inpatient DOAC treatment in patients with low risk PE. A retrospective study in patients with DOAC treated low risk PE (simplified pulmonary severity index [sPESI] ≤ 1) admitted to 8 hospitals during 2013-2015. Health care costs were compared in 223(44%) patients treated as outpatients and 287(56%) treated in hospital. Total cost per patient was 8293 EUR in the inpatient group, and 2176 EUR in the outpatient group (p < 0.001). Total costs for inpatients were higher (p < 0.001) compared to outpatients in both subgroups with sPESI 0 and 1. In multivariate analysis, type of treatment (in- or outpatient, p = < 0.001) and sPESI group (0 or 1, p = < 0.001) were associated with total cost below or above median, whereas age (p = 0.565) and gender (p = 0.177) was not. Adherence to guidelines recommending outpatient treatment with DOAC in patients with low risk PE enables significant savings.
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Affiliation(s)
- Raein Ghazvinian
- 59568Lund University, Lund, Sweden.,Department of Vascular Diseases, 59564Skåne University Hospital, Malmö, Sweden
| | - Johan Elf
- 59568Lund University, Lund, Sweden.,Department of Vascular Diseases, 59564Skåne University Hospital, Malmö, Sweden
| | - Sofia Löfvendahl
- Health Technology Assesment Skåne, 59564Skåne University Hospital, Lund, Sweden
| | - Jan Holst
- Health Technology Assesment Skåne, 59564Skåne University Hospital, Lund, Sweden
| | - Anders Gottsäter
- 59568Lund University, Lund, Sweden.,Department of Vascular Diseases, 59564Skåne University Hospital, Malmö, Sweden
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Vinson DR, Aujesky D, Geersing GJ, Roy PM. Comprehensive Outpatient Management of Low-Risk Pulmonary Embolism: Can Primary Care Do This? A Narrative Review. Perm J 2020; 24:19.163. [PMID: 32240089 DOI: 10.7812/tpp/19.163] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The evidence for outpatient management of hemodynamically stable, low-risk patients with acute symptomatic pulmonary embolism (PE) is mounting. Guidance in identifying patients who are eligible for outpatient (ambulatory) care is available in the literature and society guidelines. Less is known about who can identify patients eligible for outpatient management and in what clinical practice settings. OBJECTIVE To answer the question, "Can primary care do this?" (provide comprehensive outpatient management of low-risk PE). METHODS We undertook a narrative review of the literature on the outpatient management of acute PE focusing on site of care. We searched the English-language literature in PubMed and Embase from January 1, 1950, through July 15, 2019. RESULTS We identified 26 eligible studies. We found no studies that evaluated comprehensive PE management in a primary care clinic or general practice setting. In 19 studies, the site-of-care decision making occurred in the Emergency Department (or after a short period of supplemental observation) and in 7 studies the decision occurred in a specialty clinic. We discuss the components of care involved in the diagnosis, outpatient eligibility assessment, treatment, and follow-up of ambulatory patients with acute PE. DISCUSSION We see no formal reason why a trained primary care physician could not provide comprehensive care for select patients with low-risk PE. Leading obstacles include lack of ready access to advanced pulmonary imaging and the time constraints of a busy outpatient clinic. CONCLUSION Until studies establish safe parameters of such a practice, the question "Can primary care do this?" must remain open.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group, Oakland, CA.,Kaiser Permanente Division of Research, Oakland, CA.,Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, CA
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, the Netherlands
| | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, UMR (CNRS 6015 - INSERM 1083) Institut Mitovasc, Université d'Angers, France
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4
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Ghazvinian R, Gottsäter A, Elf JL. Efficacy and safety of outpatient treatment with direct oral anticoagulation in pulmonary embolism. J Thromb Thrombolysis 2018; 45:319-324. [PMID: 29305675 PMCID: PMC5818558 DOI: 10.1007/s11239-017-1607-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Anticoagulant treatment of acute pulmonary embolism (PE) has traditionally been hospital-based. The lesser need for monitoring with the increasingly used direct acting oral anticoagulants (DOAC) in comparison to warfarin potentially facilitates outpatient treatment of PE with these drugs. This study aimed to evaluate efficacy and safety of outpatient treatment of PE with DOAC. We extracted data from the Swedish quality registry for patients on oral anticoagulation (AuriculA) for all 245 patients in the southernmost hospital region in Sweden (1.3 million inhabitants) selected for outpatient treatment with of PE with DOAC during 2013-2015. Comorbidites, risk factors, and simplified pulmonary embolism severity index were evaluated at baseline, and death, recurrent venous thromboembolism (VTE), and bleeding was recorded during 6 months of follow-up. Outpatient treatment was defined as discharge from the emergency department within 24 h. During 6 months of follow-up, one patient died during DOAC therapy, the cause of death was unrelated to VTE. No VTE recurrences occured, whereas, one patient experienced major bleeding, and five patients experienced minor bleedings. Outpatient treatment of PE with DOAC is efficient and safe in selected patients.
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Affiliation(s)
- R. Ghazvinian
- Division of Vascular Medicine, Skåne University Hospital, Ruth Lundskogs Gata 10, 205 02 Malmö, Sweden
| | - A. Gottsäter
- Division of Vascular Medicine, Skåne University Hospital, Ruth Lundskogs Gata 10, 205 02 Malmö, Sweden
| | - J. L. Elf
- Division of Vascular Medicine, Skåne University Hospital, Ruth Lundskogs Gata 10, 205 02 Malmö, Sweden
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Abstract
BACKGROUND Deep vein thrombosis (DVT) occurs when a blood clot blocks blood flow through a vein, which can occur after surgery, after trauma, or when a person has been immobile for a long time. Clots can dislodge and block blood flow to the lungs (pulmonary embolism (PE)), causing death. DVT and PE are known by the term venous thromboembolism (VTE). Heparin (in the form of unfractionated heparin (UFH)) is a blood-thinning drug used during the first three to five days of DVT treatment. Low molecular weight heparins (LMWHs) allow people with DVT to receive their initial treatment at home instead of in hospital. This is an update of a review first published in 2001 and updated in 2007. OBJECTIVES To compare the incidence and complications of venous thromboembolism (VTE) in patients treated at home versus patients treated with standard in-patient hospital regimens. Secondary objectives included assessment of patient satisfaction and cost-effectiveness of treatment. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (last searched 16 March 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2), and trials registries. We also checked the reference lists of relevant publications. SELECTION CRITERIA Randomised controlled trials (RCTs) examining home versus hospital treatment for DVT, in which DVT was clinically confirmed and was treated with LMWHs or UFH. DATA COLLECTION AND ANALYSIS One review author selected material for inclusion, and another reviewed the selection of trials. Two review authors independently extracted data and assessed included studies for risk of bias. Primary outcomes included combined VTE events (PE and recurrent DVT), gangrene, heparin complications, and death. Secondary outcomes were patient satisfaction and cost implications. We performed meta-analysis using fixed-effect models with risk ratios (RRs) and 95% confidence intervals (CIs) for dichotomous data. MAIN RESULTS We included in this review seven RCTs involving 1839 randomised participants with comparable treatment arms. All seven had fundamental problems including high exclusion rates, partial hospital treatment of many in the home treatment arms, and comparison of UFH in hospital versus LMWH at home. These trials showed that patients treated at home with LMWH were less likely to have recurrence of VTE events than those given hospital treatment with UFH or LMWH (fixed-effect risk ratio (RR) 0.58, 95% confidence interval (CI) 0.39 to 0.86; 6 studies; 1708 participants; P = 0.007; low-quality evidence). No clear difference was seen between groups for major bleeding (RR 0.67, 95% CI 0.33 to 1.36; 6 studies; 1708 participants; P = 0.27; low-quality evidence), minor bleeding (RR 1.29, 95% CI 0.94 to 1.78; 6 studies; 1708 participants; P = 0.11; low-quality evidence), or mortality (RR 0.69, 95% CI 0.44 to 1.09; 6 studies; 1708 participants; P = 0.11; low-quality evidence). The included studies reported no cases of venous gangrene. We could not combine patient satisfaction and quality of life outcomes in meta-analysis owing to heterogeneity of reporting, but two of three studies found evidence that home treatment led to greater improvement in quality of life compared with in-patient treatment at some point during follow-up, and the third study reported that a large number of participants chose to switch from in-patient care to home-based care for social and personal reasons, suggesting it is the patient's preferred option (very low-quality evidence). None of the studies included in this review carried out a full cost-effectiveness analysis. However, a small randomised economic evaluation of the two alternative treatment settings involving 131 participants found that direct costs were higher for those in the in-patient group. These findings were supported by three other studies that reported on their costs (very low-quality evidence).Quality of evidence for data from meta-analyses was low to very low. This was due to risk of bias, as many of the included studies used unclear randomisation techniques, and blinding was a concern for many. Also, indirectness was a concern, as most studies included a large number of participants randomised to the home (LMWH) treatment group who were treated in hospital for some or all of the treatment period. A further issue for some outcomes was heterogeneity that was evident in measurement and reporting of outcomes. AUTHORS' CONCLUSIONS Low-quality evidence suggests that patients treated at home with LMWH are less likely to have recurrence of VTE than those treated in hospital. However, data show no clear differences in major or minor bleeding, nor in mortality (low-quality evidence), indicating that home treatment is no worse than in-patient treatment for these outcomes. Because most healthcare systems are moving towards more LMWH usage in the home setting it is unlikely that additional large trials will be undertaken to compare these treatments. Therefore, home treatment is likely to become the norm, and further research will be directed towards resolving practical issues by devising local guidelines that include clinical prediction rules, developing biomarkers and imaging that can be used to tailor therapy to disease severity, and providing training for community healthcare workers who administer treatment and monitor treatment progress.
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Affiliation(s)
- Richard Othieno
- NHS Lothian, Directorate of Public Health and Health PolicyWaverly Gate2‐4 Waterloo PlaceEdinburghUKEH1 3EG
| | - Emmanuel Okpo
- NHS GrampianPublic Health DirectorateSummerfield House, 2 Eday RoadAberdeenUKAB15 6RE
| | - Rachel Forster
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsEdinburghUKEH8 9AG
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6
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Quezada CA, Zamarro C, Gómez V, Guerassimova I, Nieto R, Barbero E, Chiluiza D, Barrios D, Morillo R, Jiménez D. Clinical gestalt versus prognostic scores for prognostication of patients with acute symptomatic pulmonary embolism. Med Clin (Barc) 2017; 151:136-140. [PMID: 29276010 DOI: 10.1016/j.medcli.2017.11.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 10/08/2017] [Accepted: 11/02/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE To determine the accuracy of clinical gestalt to identify patients with acute symptomatic pulmonary embolism (PE) at low-risk for short-term complications. PATIENTS AND METHODS This study included a total of 154 consecutive patients diagnosed with acute symptomatic PE in a tertiary university hospital. We compared the prognostic accuracy of the Pulmonary Embolism Severity Index (PESI), the simplified PESI (sPESI), and clinical gestalt of 1) 2senior physicians (one with and one without experience in the management of patients with PE), 2) a fourth-year resident of Pneumology, 3) a third-year resident of Pneumology, and 4) a second-year resident of Pneumology. The primary outcome was all-cause mortality during the first month after the diagnosis of PE. RESULTS Thirty-day all-cause mortality was 8.4% (13/154; 8.4%; 95% confidence interval [CI], 4.1-12.8%). The PESI and clinical gestalt classified more patients as low-risk, compared to the sPESI (36.4%, 31.3% y 28.6%, respectively). There were no deaths in the sPESI low-risk category (negative predictive value 100%). Prognostic accuracy increased with increasing experience (84.6 vs. 92.3%; P=.049). CONCLUSIONS The sPESI showed the best accuracy at correctly identifying low-risk patients with acute symptomatic PE. Clinical gestalt is not inferior to standardized clinical prediction rules to prognosticate patients with acute PE.
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Affiliation(s)
| | - Celia Zamarro
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Vicente Gómez
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Ina Guerassimova
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Rosa Nieto
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Esther Barbero
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Diana Chiluiza
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Deisy Barrios
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Raquel Morillo
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - David Jiménez
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España; IRYCIS, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, España; Facultad de Medicina, Universidad de Alcalá, Madrid, España.
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7
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Paes C, Kelly AM. Outpatient Management of Deep Vein Thrombosis: a Model with a Breakdown of the Continuum of Care. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790401100102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives For emergency department (ED) patients with deep venous thrombosis (DVT) treated as outpatients, to determine treatment duration, complications and follow-up arrangements, in particular thrombophilia screening. Methods Explicit, retrospective medical record review of patients with an ED discharge diagnosis of DVT over a three-year period. Data collected included demographics, location of DVT, duration of treatment, complications, hospital admission, mortality, follow-up arrangements and referral for thrombophilia screening. Main outcomes were the duration of treatment, rate of complications and requirement for hospital admission, follow-up arrangements and referral for thrombophilia screening for patients treated as outpatients. Results Two hundred and fourteen patients with DVT were identified, of whom 74 [35%] were treated as outpatients. For this group, the median duration of treatment was eight days. There was one death from advanced neoplasia, two proven pulmonary emboli (PE) [2.7%, 95% CI 0.74–9.3%] and one suspected PE [1.4%, 95% CI 0.24–7.3%]. One patient had a recurrence of DVT within three months [1.4%, 95% CI 0.24–7.3%]. Few patients received specialist follow-up [25/74, 34%]. In 20 cases [27%], thrombophilia screening was neither performed nor recommended, despite no obvious cause for the DVT. Conclusion Outpatient treatment of selected DVT is safe, although there is a small incidence of non-fatal PE. Follow-up and screening arrangements were sub-optimal in the study sample and treatment duration was long. An ambulatory care model with direct physician control is recommended to improve follow-up arrangements, monitor service performance and ensure that the service evolves with new evidence and processes.
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Affiliation(s)
| | - AM Kelly
- Western Hospital, Department of Emergency Medicine, Private Bag, Footscray 3011, Australia
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8
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Roy PM, Moumneh T, Penaloza A, Sanchez O. Outpatient management of pulmonary embolism. Thromb Res 2017; 155:92-100. [DOI: 10.1016/j.thromres.2017.05.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/21/2017] [Accepted: 05/01/2017] [Indexed: 01/17/2023]
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9
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Le P, Martinez KA, Pappas MA, Rothberg MB. A decision model to estimate a risk threshold for venous thromboembolism prophylaxis in hospitalized medical patients. J Thromb Haemost 2017; 15:1132-1141. [PMID: 28371250 PMCID: PMC5712445 DOI: 10.1111/jth.13687] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Indexed: 12/30/2022]
Abstract
Essentials Low risk patients don't require venous thromboembolism (VTE) prophylaxis; low risk is unquantified. We used a Markov model to estimate the risk threshold for VTE prophylaxis in medical inpatients. Prophylaxis was cost-effective for an average medical patient with a VTE risk of ≥ 1.0%. VTE prophylaxis can be personalized based on patient risk and age/life expectancy. SUMMARY Background Venous thromboembolism (VTE) is a common preventable condition in medical inpatients. Thromboprophylaxis is recommended for inpatients who are not at low risk of VTE, but no specific risk threshold for prophylaxis has been defined. Objective To determine a threshold for prophylaxis based on risk of VTE. Patients/Methods We constructed a decision model with a decision-tree following patients for 3 months after hospitalization, and a lifetime Markov model with 3-month cycles. The model tracked symptomatic deep vein thromboses and pulmonary emboli, bleeding events and heparin-induced thrombocytopenia. Long-term complications included recurrent VTE, post-thrombotic syndrome and pulmonary hypertension. For the base case, we considered medical inpatients aged 66 years, having a life expectancy of 13.5 years, VTE risk of 1.4% and bleeding risk of 2.7%. Patients received enoxaparin 40 mg day-1 for prophylaxis. Results Assuming a willingness-to-pay (WTP) threshold of $100 000/ quality-adjusted life year (QALY), prophylaxis was indicated for an average medical inpatient with a VTE risk of ≥ 1.0% up to 3 months after hospitalization. For the average patient, prophylaxis was not indicated when the bleeding risk was > 8.1%, the patient's age was > 73.4 years or the cost of enoxaparin exceeded $60/dose. If VTE risk was < 0.26% or bleeding risk was > 19%, the risks of prophylaxis outweighed benefits. The prophylaxis threshold was relatively insensitive to low-molecular-weight heparin cost and bleeding risk, but very sensitive to patient age and life expectancy. Conclusions The decision to offer prophylaxis should be personalized based on patient VTE risk, age and life expectancy. At a WTP of $100 000/QALY, prophylaxis is not warranted for most patients with a 3-month VTE risk below 1.0%.
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Affiliation(s)
- P Le
- Center for Value-based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - K A Martinez
- Center for Value-based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - M A Pappas
- Center for Value-based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - M B Rothberg
- Center for Value-based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
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10
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A new prognostic strategy for adult patients with acute pulmonary embolism eligible for outpatient therapy. J Thromb Thrombolysis 2017; 43:326-332. [PMID: 27822904 DOI: 10.1007/s11239-016-1451-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We sought to derive a parsimonious predictive model to identify a subgroup of patients that will experience a low number of adverse events within 14 days of the diagnosis of pulmonary embolism. Retrospective cohort study of adult patients with acute pulmonary embolism at the Ottawa Hospital between 2007 and 2012. Primary outcome was defined as the composite of all-cause mortality, recurrent venous thromboembolism and major bleeding within 14 days. Multivariate logistic regression models were fit to model the occurrence of the primary outcome so as to guide either outpatient therapy or early discharge after initial admission. Calibration and discrimination were assessed in both the derivation and internal validation cohorts. 1143 patients were included, of whom 42% were treated as outpatients. At pulmonary embolism diagnosis, final score to predict the primary outcome included age, malignancy, intravenous drug or oxygen requirement and systolic blood pressure <90 mmHg, with an area under the curve (AUC) of 0.79 (95% CI 0.73-0.84) and 0.82 (95% CI 0.75-0.89) in the derivation and validation cohorts respectively. Conversely, final score to predict primary outcome after initial admission included age, malignancy, intravenous drug requirement and systolic blood pressure <90 mmHg (AUC: 0.70 (95% CI 0.64-0.76) and 0.72 (95% CI 0.66-0.79) in the derivation and validation cohorts). We have developed two simple clinical scores that may identify patients with pulmonary embolism at low risk of clinically meaningful outcomes during the first 14 days of follow up.
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Abstract
Direct oral anticoagulants (DOACs) can be quantified using methods that can be performed in any clinical or research laboratory using manual or automated instrument platforms. Dabigatran etexilate, the oral direct thrombin inhibitor, can be quantified by drug-calibrated clot or chromogenic-based assays using either thrombin or ecarin as substrates. Oral direct anti-Xa inhibitors, such as rivaroxaban, apixaban, and edoxaban, can be quantified with drug-calibrated anti-Xa kits or reagents as typically used for measuring heparins (unfractionated, low molecular weight, or pentasaccharides).
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Affiliation(s)
- Robert C Gosselin
- Department of Pathology and Laboratory Medicine, Davis Health System, University of California, 4400 V Street, Sacramento, CA, 95817, USA.
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, University of Namur, Namur, Belgium
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Rabinovich E, Bartholomew JR, Wilks ML, Tripp BL, McCrae KR, Khorana AA. Centralizing care of cancer-associated thromboembolism: The Cleveland Clinic experience. Thromb Res 2016; 147:102-103. [DOI: 10.1016/j.thromres.2016.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 09/29/2016] [Accepted: 10/02/2016] [Indexed: 11/27/2022]
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Saric M, Armour AC, Arnaout MS, Chaudhry FA, Grimm RA, Kronzon I, Landeck BF, Maganti K, Michelena HI, Tolstrup K. Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism. J Am Soc Echocardiogr 2016; 29:1-42. [PMID: 26765302 DOI: 10.1016/j.echo.2015.09.011] [Citation(s) in RCA: 225] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Embolism from the heart or the thoracic aorta often leads to clinically significant morbidity and mortality due to transient ischemic attack, stroke or occlusion of peripheral arteries. Transthoracic and transesophageal echocardiography are the key diagnostic modalities for evaluation, diagnosis, and management of stroke, systemic and pulmonary embolism. This document provides comprehensive American Society of Echocardiography guidelines on the use of echocardiography for evaluation of cardiac sources of embolism. It describes general mechanisms of stroke and systemic embolism; the specific role of cardiac and aortic sources in stroke, and systemic and pulmonary embolism; the role of echocardiography in evaluation, diagnosis, and management of cardiac and aortic sources of emboli including the incremental value of contrast and 3D echocardiography; and a brief description of alternative imaging techniques and their role in the evaluation of cardiac sources of emboli. Specific guidelines are provided for each category of embolic sources including the left atrium and left atrial appendage, left ventricle, heart valves, cardiac tumors, and thoracic aorta. In addition, there are recommendation regarding pulmonary embolism, and embolism related to cardiovascular surgery and percutaneous procedures. The guidelines also include a dedicated section on cardiac sources of embolism in pediatric populations.
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Affiliation(s)
- Muhamed Saric
- New York University Langone Medical Center, New York, New York
| | | | - M Samir Arnaout
- American University of Beirut Medical Center, Beirut, Lebanon
| | - Farooq A Chaudhry
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Richard A Grimm
- Learner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | | | | | | | - Kirsten Tolstrup
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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Dalen JE, Dalen JE. Unnecessary Hospitalizations for Pulmonary Embolism: Impact on US Health Care Costs. Am J Med 2016; 129:899-900. [PMID: 27143322 DOI: 10.1016/j.amjmed.2016.03.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 03/25/2016] [Indexed: 11/24/2022]
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15
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McGuire M, Dobesh PP. Therapeutic Update on the Prevention and Treatment of Venous Thromboembolism. J Pharm Pract 2016. [DOI: 10.1177/0897190004271779] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Venous thromboembolism (VTE) is a common condition that increases in incidence with age and risk factors. Therapies for VTE are aimed at either preventing the disease in high-risk individuals or treating patients who have developed VTE. Assessing risk and aggressively using the recommended therapies is primacy in preventing VTE in surgical and medical patients. Risk of VTE in medical patients has become more defined in recent years, and prophylaxis in this group can prevent scores of iatrogenic VTE. Treatment of VTE has evolved in the past decade from a condition that required hospitalization for 5 to 7 days to a disease state that can be conveniently and safely treated on an outpatient basis, largely due to the advent of low-molecular-weight heparins and patient self-directed treatment.
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Affiliation(s)
- Mike McGuire
- Kos Pharmaceuticals, 125 West Third Avenue, Conshohocken, Pennsylvania 19428
| | - Paul P. Dobesh
- Division of Pharmacy Practice, St. Louis College of Pharmacy, St. Louis, Missouri, St. Luke's Hospital, Chesterfield, Missouri
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Smith SB, Geske JB, Kathuria P, Cuttica M, Schimmel DR, Courtney DM, Waterer GW, Wunderink RG. Analysis of National Trends in Admissions for Pulmonary Embolism. Chest 2016; 150:35-45. [PMID: 26905364 DOI: 10.1016/j.chest.2016.02.638] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 02/03/2016] [Accepted: 02/05/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) remains a significant cause of hospital admission and health-care costs. Estimates of PE incidence came from the 1990s, and data are limited to describe trends in hospital admissions for PE over the past decade. METHODS We analyzed Nationwide Inpatient Sample data from 1993 to 2012 to identify patients admitted with PE. We included admissions with International Classification of Diseases, 9th revision, codes listing PE as the principal diagnosis as well as admissions with PE listed secondary to principal diagnoses of respiratory failure or DVT. Massive PE was defined by mechanical ventilation, vasopressors, or nonseptic shock. Outcomes included hospital lengths of stay, adjusted charges, and all-cause hospital mortality. Linear regression was used to analyze changes over time. RESULTS Admissions for PE increased from 23 per 100,000 in 1993 to 65 per 100,000 in 2012 (P < .001). The percent of admissions meeting criteria for massive PE decreased (5.3% to 4.4%, P = .002), but the absolute number of admissions for massive PE increased (from 1.5 to 2.8 per 100,000, P < .001). Median length of stay decreased from 8 (interquartile range [IQR], 6-11) to 4 (IQR, 3-6) days (P < .001). Adjusted hospital charges increased from $16,475 (IQR, $10,748-$26,211) in 1993 to $25,728 (IQR, $15,505-$44,493) in 2012 (P < .001). All-cause hospital mortality decreased from 7.1% to 3.2% (P < .001), but population-adjusted deaths during admission for PE increased from 1.6 to 2.1 per 100,000 (P < .001). CONCLUSIONS Total admissions and hospital charges for PE have increased over the past two decades. However, the population-adjusted admission rate has increased disproportionately to the incidence of patients with severe PE. We hypothesize that these findings reflect a concerning national movement toward more admissions of less severe PE.
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Affiliation(s)
- Sean B Smith
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL.
| | - Jeffrey B Geske
- Division of Cardiovascular Disease, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Parul Kathuria
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Michael Cuttica
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Daniel R Schimmel
- Division of Cardiovascular Disease, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - D Mark Courtney
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Grant W Waterer
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL; University of Western Australia, Perth, Australia
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Ceresetto JM. Venous thromboembolism in Latin America: a review and guide to diagnosis and treatment for primary care. Clinics (Sao Paulo) 2016; 71:36-46. [PMID: 26872082 PMCID: PMC4732387 DOI: 10.6061/clinics/2016(01)07] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 11/10/2015] [Accepted: 11/10/2015] [Indexed: 12/31/2022] Open
Abstract
There are various region-specific challenges to the diagnosis and effective treatment of venous thromboembolism in Latin America. Clear guidance for physicians and patient education could improve adherence to existing guidelines. This review examines available information on the burden of pulmonary embolism and deep vein thrombosis in Latin America and the regional issues surrounding the diagnosis and treatment of pulmonary embolism and deep vein thrombosis. Potential barriers to appropriate care, as well as treatment options and limitations on their use, are discussed. Finally, an algorithmic approach to the diagnosis and treatment of venous thromboembolism in ambulatory patients is proposed and care pathways for patients with pulmonary embolism and deep vein thrombosis are outlined for primary care providers in Latin America.
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Prandoni P. The Treatment of Venous Thromboembolism in Patients with Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:123-135. [DOI: 10.1007/5584_2016_111] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Meyer G, Planquette B, Sanchez O. Pulmonary embolism: whom to discharge and whom to thrombolyze? J Thromb Haemost 2015; 13 Suppl 1:S252-8. [PMID: 26149032 DOI: 10.1111/jth.12944] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Patients with pulmonary embolism can be divided in two groups according to their risk of death or major complication: a small group of high-risk patients defined by the presence of systemic hypotension or cardiogenic shock and a large group of normotensive patients. Among normotensive patients, further risk stratification, based on clinical grounds alone or on the combination of clinical data, biomarkers, and imaging tests, allows selection of low-risk patients and intermediate-risk patients. The safety of outpatient treatment for low-risk patients has been established mainly on the basis of retrospective and prospective cohorts using different selection tools. In most studies, about 50% of the patients have been safely treated at home. Although thrombolytic therapy has a favorable benefit to risk profile in patients with high-risk pulmonary embolism, the risk of major and especially intracranial bleeding outweighs the benefits in terms of hemodynamic decompensation in patients with intermediate-risk pulmonary embolism.
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Affiliation(s)
- G Meyer
- Service de Pneumologie, Hôpital Européen Georges Pompidou, APHP, Paris, France
- Sorbonne Paris Cité, INSERM UMRS 970, CIC 1418, Université Paris Descartes, Paris, France
- GIRC Thrombose, Paris, France
| | - B Planquette
- Service de Pneumologie, Hôpital Européen Georges Pompidou, APHP, Paris, France
- Sorbonne Paris Cité, INSERM UMRS 970, CIC 1418, Université Paris Descartes, Paris, France
- GIRC Thrombose, Paris, France
| | - O Sanchez
- Service de Pneumologie, Hôpital Européen Georges Pompidou, APHP, Paris, France
- Sorbonne Paris Cité, INSERM UMRS 970, CIC 1418, Université Paris Descartes, Paris, France
- GIRC Thrombose, Paris, France
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Clinical outcomes and patient satisfaction of a pharmacist-managed, emergency department–based outpatient treatment program for venous thromboembolic disease. CAN J EMERG MED 2015; 10:10-7. [PMID: 18226313 DOI: 10.1017/s1481803500009957] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACTObjective:The purpose of this study was to evaluate the efficacy, safety and patient satisfaction outcomes of our pharmacist-managed, emergency department (ED)–based outpatient treatment program for venous thromboembolism (VTE) disease.Methods:We conducted a prospective cohort study of all patients who were enrolled in the Vancouver General Hospital (VGH) outpatient VTE treatment program over a 7-year period (1999–2006). Efficacy outcomes include recurrent VTE events at 3 and 6 months following discharge from the program. Safety evaluation included major and minor bleeding complications and the development of thrombocytopenia during the acute phase of therapy. Patient satisfaction was assessed using an 18-question patient satisfaction survey, which was mailed to all patients following discharge from the program.Results:Overall, 305 patients were included in the study. Of the 260 evaluable patients, 2 patients (0.8%, 95% confidence interval [CI] 0.2–2.7) experienced a recurrent VTE at 3 months and 5 patients (1.9%, 95% CI 0.8–4.4) had a recurrence at 6 months. One patient (0.3%, 95% CI 0.1–1.8) experienced a major bleeding complication. Seven patients (2.3%, 95% CI 1.1–4.7) experienced a minor bleeding complication and no patient developed thrombocytopenia. Overall, 96.1% were comfortable having their condition treated as an outpatient and 85.7% felt it was more convenient to return to hospital daily for medications and assessment than to be admitted to hospital. Finally, 96.9% of respondents were very satisfied or satisfied with the treatment they received in the outpatient program, and 96.1% would enroll again if future treatment was indicated.Conclusion:Our pharmacist-managed, ED-based outpatient treatment program for VTE disease is safe, effective and achieves a high level of patient satisfaction.
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Huang W, Goldberg RJ, Cohen AT, Anderson FA, Kiefe CI, Gore JM, Spencer FA. Declining Long-term Risk of Adverse Events after First-time Community-presenting Venous Thromboembolism: The Population-based Worcester VTE Study (1999 to 2009). Thromb Res 2015; 135:1100-6. [PMID: 25921936 DOI: 10.1016/j.thromres.2015.04.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Revised: 04/02/2015] [Accepted: 04/06/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Contemporary trends in health-care delivery are shifting the management of venous thromboembolism (VTE) events (deep vein thrombosis [DVT] and/or pulmonary embolism [PE]) from the hospital to the community, which may have implications for its prevention, treatment, and outcomes. MATERIALS AND METHODS Population-based surveillance study monitoring trends in clinical epidemiology among residents of the Worcester, Massachusetts, metropolitan statistical area (WMSA) diagnosed with an acute VTE in all 12 WMSA hospitals. Patients were followed for up to 3 years after their index event. Total of 2334 WMSA residents diagnosed with first-time community-presenting VTE (occurring in an ambulatory setting or diagnosed within 24 hours of hospitalization) from 1999 through 2009. RESULTS While PE patients were consistently admitted to the hospital for treatment over time, the proportion diagnosed with DVT-alone admitted to the hospital decreased from 67% in 1999 to 37% in 2009 (p value for trend <0.001). Among hospitalized patients, the mean length of stay decreased from 5.6 to 4.8 days (p value for trend <0.001). Between 1999 and 2009, treatment of VTE shifted from warfarin and unfractionated heparin towards use of low-molecular-weight heparins and newer anticoagulants; also, 3-year cumulative event rates decreased for all-cause mortality (41-26%), major bleeding (12-6%), and recurrent VTE (17-9%). CONCLUSIONS A decade of change in VTE management was accompanied by improved long-term outcomes. However, rates of adverse events remained fairly high in our population-based surveillance study, implying that new risk-assessment tools to identify individuals at increased risk for developing major adverse outcomes over the long term are needed.
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Affiliation(s)
- W Huang
- Center for Outcomes Research, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA.
| | - R J Goldberg
- Department of Quantitative Health Science, University of Massachusetts Medical School, Worcester, MA, USA
| | - A T Cohen
- Haematological Medicine, Guy's and St Thomas' Hospitals, King's College, London, UK
| | - F A Anderson
- Center for Outcomes Research, Department of Surgery, University of Massachusetts Medical School, Worcester, MA, USA
| | - C I Kiefe
- Department of Quantitative Health Science, University of Massachusetts Medical School, Worcester, MA, USA
| | - J M Gore
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - F A Spencer
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Falconieri L, Thomson L, Oettinger G, Pugliese R, Palladino M, Galanis T, Merli G. Facilitating anticoagulation for safer transitions: preliminary outcomes from an emergency department deep vein thrombosis discharge program. Hosp Pract (1995) 2015; 42:16-45. [PMID: 25502127 DOI: 10.3810/hp.2014.10.1140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Patients presenting to the emergency department (ED) with an acute uncomplicated deep vein thrombosis (DVT) may be eligible for outpatient treatment. This study aims to establish a transition of care program in the ED for patients with DVT presenting with an acute uncomplicated DVT. METHODS This article specifies the transition of care program for DVT patients in the ED. Data was collected on patients admitted and discharged from the ED who had an acute DVT both prior to the initiation of facilitating anticoagulation for safer transitions (FAST) and after initiation of FAST. Follow-up phone calls were made to patients discharged from the ED after the initiation of FAST, and data were collected on follow-up appointments, anticoagulation adherence, readmission rates, and patient satisfaction. RESULTS The FAST program has been successfully implemented. By the 30-day follow-up phone call, 100% of patients had attended a follow-up appointment. The average time to the follow-up appointment post-discharge was 4.4 days (range, 1-7 days). None of the patients at the 3- to 5-day follow-up phone call and 30-day phone call had any issues taking their anticoagulant, and none reported side effects of significant bleeding. One patient was re-admitted after discharge with a pulmonary embolism. Patient satisfaction has also been very high with the program, with all patients indicating at the 30-day phone call that they would recommend the program to a friend or family member. The educational components of this program also improved the discharge process for this population compared with patients discharged prior to the initiation of FAST. CONCLUSION The FAST program is an example of a successful transition-of-care program for discharging DVT patients from the ED. Reassessment and improvements to the program are underway to ensure it remains current, sustainable, and provider friendly.
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Dentali F, Di Micco G, Giorgi Pierfranceschi M, Gussoni G, Barillari G, Amitrano M, Fontanella A, Lodigiani C, Guida A, Visonà A, Monreal M, Di Micco P. Rate and duration of hospitalization for deep vein thrombosis and pulmonary embolism in real-world clinical practice. Ann Med 2015; 47:546-54. [PMID: 26422329 DOI: 10.3109/07853890.2015.1085127] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Current guidelines recommend initial treatment with anticoagulants at home in patients with acute deep vein thrombosis (DVT) and in patients with low-risk pulmonary embolism (PE) with adequate home circumstances. However, most of the patients with acute venous thromboembolism (VTE) are currently hospitalized regardless of their risk of short-term complications. AIM OF THE STUDY To assess the proportion of outpatients with acute VTE initially treated in hospitals, to assess the mean duration of hospitalization, and to identify predictors for in-hospital or home treatment. METHODS Data of Italian patients enrolled in the RIETE registry from January 2006 to December 2013 were included. RESULTS Altogether 766 PE and 1,452 isolated DVT were included. Among PE patients, mean PESI score was 84 points (SD 35), and 56% of patients had a low-risk PESI score (<85). In all, 53.7% of DVT and 17.0% of PE were entirely treated at home, and 38.2% of DVT patients and 19.9% of PE patients were hospitalized for ≤5 days. On multivariate analysis, low PESI score was not independently associated with the hospitalization of PE patients. CONCLUSIONS One in every two patients with DVT and five in every six with PE are still hospitalized.
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Affiliation(s)
- Francesco Dentali
- a Department of Internal Medicine , Università dell'Insubria , Varese , Italy
| | - Gianluca Di Micco
- b Department of Cardiology , Ospedale Fatebenefratelli , Napoli , Italy
| | | | | | | | - Maria Amitrano
- f Department of Angiology , AO Moscati , Avellino , Italy
| | - Andrea Fontanella
- g Department of Internal Medicine , Ospedale Fatebenefratelli , Napoli , Italy
| | - Corrado Lodigiani
- h Thrombosis Center, IRCCS Istituto Clinico Humanitas , Milano , Italy
| | - Anna Guida
- i Critical Care Department , AOU S. Giovanni e Ruggi , Salerno , Italy
| | | | - Manuel Monreal
- k Department of Internal Medicine , Hospital Universitari Germans Trias i Pujol , Badalona , Spain
| | - Pierpaolo Di Micco
- g Department of Internal Medicine , Ospedale Fatebenefratelli , Napoli , Italy
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Vigneau C, Le Stum S, Isnard-Bagnis C, Choukroun G, Lemeur Y, Kamar N, Oger E. QuiPO : qui administre les EPO en prédialyse ? Nephrol Ther 2014; 10:507-11. [DOI: 10.1016/j.nephro.2014.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 06/04/2014] [Accepted: 06/04/2014] [Indexed: 01/24/2023]
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Secular trends in occurrence of acute venous thromboembolism: the Worcester VTE study (1985-2009). Am J Med 2014; 127:829-39.e5. [PMID: 24813864 PMCID: PMC4161646 DOI: 10.1016/j.amjmed.2014.03.041] [Citation(s) in RCA: 187] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 03/07/2014] [Accepted: 03/21/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND The clinical epidemiology of venous thromboembolism has changed recently because of advances in identification, prophylaxis, and treatment. We sought to describe secular trends in the occurrence of venous thromboembolism among residents of the Worcester, Massachusetts, metropolitan statistical area. METHODS Population-based methods were used to monitor trends in event rates of first-time or recurrent venous thromboembolism in 5025 Worcester, Massachusetts, metropolitan statistical area residents who were diagnosed with acute pulmonary embolism or lower-extremity deep vein thrombosis during 9 annual periods between 1985 and 2009. Medical records were reviewed by abstractors and validated by clinicians. RESULTS Age- and sex-adjusted annual event rates for first-time venous thromboembolism increased from 73 (95% confidence interval [CI], 64-82) per 100,000 in 1985/1986 to 133 (CI, 122-143) in 2009, primarily because of an increase in pulmonary embolism. The rate of recurrent venous thromboembolism decreased from 39 (CI, 32-45) in 1985/1986 to 19 (CI, 15-23) in 2003, and then increased to 35 (CI, 29-40) in 2009. There was an increasing trend in using noninvasive diagnostic testing, with approximately half of tests being invasive in 1985/1986 and almost all noninvasive by 2009. CONCLUSIONS Despite advances in identification, prophylaxis, and treatment between 1985 and 2009, the annual event rate of venous thromboembolism has increased and remains high. Although these increases partially may be due to increased sensitivity of diagnostic methods, especially for pulmonary embolism, they also may imply that current prevention and treatment strategies are less than optimal.
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Choubey AK, Dora CP, Bhatt TD, Gill MS, Suresh S. Development and evaluation of PEGylated Enoxaparin: A novel approach for enhanced anti-Xa activity. Bioorg Chem 2014; 54:1-6. [DOI: 10.1016/j.bioorg.2014.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/26/2014] [Accepted: 03/03/2014] [Indexed: 11/25/2022]
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Prandoni P, Piovella C, Filippi L, Vedovetto V, Dalla Valle F, Piccioli A. What are the pharmacotherapy options for treating venous thromboembolism in cancer patients? Expert Opin Pharmacother 2014; 15:799-807. [PMID: 24548179 DOI: 10.1517/14656566.2014.889685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a frequent complication in patients with malignancies. The treatment of VTE disorders in cancer patients remains a difficult clinical task. AREAS COVERED Current evidence on the most appropriate initial and long-term treatment of cancer patients with VTE was addressed, as was the management of recurrent VTE despite anticoagulation, the management of incidentally detected isolated pulmonary embolism (PE), the potential role of the novel direct oral anticoagulants and the impact of low-molecular-weight heparin (LMWH) on cancer evolution. EXPERT OPINION LMWHs are the cornerstone of VTE treatment in cancer patients. The intensity and duration of treatment are dependent on several factors that need to be individually evaluated. The novel oral anticoagulants should be investigated more carefully before being routinely implemented in the treatment of cancer-associated VTE. Incidentally detected isolated sub-segmental PE is unlikely to require systematic full-dose anticoagulation. Evidence favoring an impact of LMWH on survival in cancer patients is weak.
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Affiliation(s)
- Paolo Prandoni
- University of Padua, Department of Medicine, Clinica Medica 2, Vascular Medicine Unit , Via Giustiniani 2, 35128 - Padua , Italy +39 049 8212656 ; +39 049 8218731 ;
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Piran S, Le Gal G, Wells PS, Gandara E, Righini M, Rodger MA, Carrier M. Outpatient treatment of symptomatic pulmonary embolism: A systematic review and meta-analysis. Thromb Res 2013; 132:515-9. [DOI: 10.1016/j.thromres.2013.08.012] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 07/22/2013] [Accepted: 08/13/2013] [Indexed: 10/26/2022]
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Taylor RA, Davis J, Liu R, Gupta V, Dziura J, Moore CL. Point-of-Care Focused Cardiac Ultrasound for Prediction of Pulmonary Embolism Adverse Outcomes. J Emerg Med 2013; 45:392-9. [DOI: 10.1016/j.jemermed.2013.04.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Revised: 03/18/2013] [Accepted: 04/24/2013] [Indexed: 10/26/2022]
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Chandra R, Melino G, Thomas M, Lawrence MJ, Hunter RA, Moore J. Is extended thromboprophylaxis necessary in elective colorectal cancer surgery? ANZ J Surg 2013; 83:968-72. [DOI: 10.1111/ans.12244] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Raaj Chandra
- Department of Colorectal Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Giovanni Melino
- Department of Colorectal Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Michelle Thomas
- Department of Colorectal Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Matthew J. Lawrence
- Department of Colorectal Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - R. Andrew Hunter
- Department of Colorectal Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - James Moore
- Department of Colorectal Surgery; Royal Adelaide Hospital; Adelaide South Australia Australia
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Ahn S, Lim KS, Lee YS, Lee JL. Validation of the clinical prediction rule for recurrent venous thromboembolism in cancer patients: the Ottawa score. Support Care Cancer 2013; 21:2309-13. [PMID: 23525939 DOI: 10.1007/s00520-013-1792-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Accepted: 03/14/2013] [Indexed: 12/13/2022]
Abstract
PURPOSE Recently, a clinical prediction rule for recurrent venous thromboembolism (VTE) in cancer patients, named Ottawa score, was derived to individualize treatments with different intensities. It is composed of four variables including sex, primary tumor site, tumor stage, and prior history of VTE. The objective of this study was to validate the Ottawa score in an independent patient population in a tertiary hospital in Korea. METHODS Medical records of consecutive adult patients (>18 years) with active malignancy and newly diagnosed VTE from January 1, 2006 to December 31, 2010 were analyzed. Using the same definition of predictor variables in the original derivation study, patients were divided into low (score ≤ 0) and high (score ≥ 1) risk groups for recurrent VTE, and their actual recurrence rate were analyzed. RESULTS Of the 546 patients with newly diagnosed VTE, 99 (18.1 %) had recurrent VTE during the follow-up period. In the low-risk group, 34 (13.2 %) had recurrence, compared to 65 (22.4 %) in the high-risk group. Ottawa score's performance showed 66 % sensitivity, 50 % specificity, 22 % positive predictive value, and 87 % negative predictive value in our validation cohort. CONCLUSION We were not able to accurately ascertain the relevance of the Ottawa score in our validation cohort. Future validation studies, including a more diverse patient population with different cancer predominance, are warranted.
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Affiliation(s)
- Shin Ahn
- Department of Emergency Medicine, Cancer Emergency Room, Asan Medical Center, University of Ulsan, College of Medicine, 388-1, Pungnap-dong, Songpa-gu, Seoul, 138-736, South Korea.
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Connolly GC, Francis CW. Cancer-associated thrombosis. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2013; 2013:684-691. [PMID: 24319253 DOI: 10.1182/asheducation-2013.1.684] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Cancer-associated thrombosis accounts for almost one-fifth of all cases of venous thromboembolism (VTE) and is a leading cause of death, morbidity, delays in care, and increased costs. Our understanding of risk factors for cancer-associated thrombosis has expanded in recent years, and investigators have begun to use biomarkers and clinical prediction models to identify those cancer patients at greatest risk for VTE. The Khorana Risk Model, which is based on easily obtained biomarkers and clinical factors, has now been validated in several studies. Recent clinical trials of prophylaxis and treatment of VTE in cancer patients are reviewed here. In addition, consensus guidelines and expert opinion regarding management of VTE in specific challenging situations are presented.
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Affiliation(s)
- Gregory C Connolly
- 1James P. Wilmot Cancer Center and Department of Medicine, University of Rochester, Rochester, NY
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Wells P, Anderson D. The diagnosis and treatment of venous thromboembolism. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2013; 2013:457-463. [PMID: 24319219 DOI: 10.1182/asheducation-2013.1.457] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Venous thromboembolism (VTE) is a common condition that can lead to complications such as postphlebitic syndrome, chronic pulmonary artery hypertension, and death. The approach to the diagnosis of has evolved over the years and an algorithm strategy combining pretest probability, D-dimer testing, and diagnostic imaging now allows for safe, convenient, and cost-effective investigation of patients. Patients with low pretest probability and a negative D-dimer can have VTE excluded without the need for imaging. The mainstay of treatment of VTE is anticoagulation, whereas interventions such as thrombolysis and inferior vena cava filters are reserved for special situations. Low-molecular-weight heparin has allowed for outpatient management of most patients with deep vein thrombosis at a considerable cost savings to the health care system. Patients with malignancy-associated VTE benefit from decreased recurrent rates if treated with long-term low-molecular-weight heparin. The development of new oral anticoagulants further simplifies treatment. The duration of anticoagulation is primarily influenced by underlying cause of the VTE (whether provoked or not) and consideration of the risk for major hemorrhage. Testing for genetic and acquired thrombophilia may provide insight as to the cause of a first idiopathic deep vein thrombosis, but the evidence linking most thrombophilias to an increased risk of recurrent thrombosis is limited.
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Affiliation(s)
- Philip Wells
- 1Department of Medicine, University of Ottawa and the Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, ON; and
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Squizzato A. New prospective for the management of low-risk pulmonary embolism: prognostic assessment, early discharge, and single-drug therapy with new oral anticoagulants. SCIENTIFICA 2012; 2012:502378. [PMID: 24278706 PMCID: PMC3820448 DOI: 10.6064/2012/502378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 11/05/2012] [Indexed: 06/02/2023]
Abstract
Patients with pulmonary embolism (PE) can be stratified into two different prognostic categories, based on the presence or absence of shock or sustained arterial hypotension. Some patients with normotensive PE have a low risk of early mortality, defined as <1% at 30 days or during hospital stay. In this paper, we will discuss the new prospective for the optimal management of low-risk PE: prognostic assessment, early discharge, and single-drug therapy with new oral anticoagulants. Several parameters have been proposed and investigated to identify low-risk PE: clinical prediction rules, imaging tests, and laboratory markers of right ventricular dysfunction or injury. Moreover, outpatient management has been suggested for low-risk PE: it may lead to a decrease in unnecessary hospitalizations, acquired infections, death, and costs and to an improvement in health-related quality of life. Finally, the main characteristics of new oral anticoagulant drugs and the most recent published data on phase III trials on PE suggest that the single-drug therapy is a possible suitable option. Oral administration, predictable anticoagulant responses, and few drug-drug interactions of direct thrombin and factor Xa inhibitors may further simplify PE home therapy avoiding administration of low-molecular-weight heparin.
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Affiliation(s)
- Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
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McCabe A, Hassan T, Doyle M, McCann B. Identification of patients with low-risk pulmonary embolism suitable for outpatient treatment using the pulmonary embolism severity index (PESI). Ir J Med Sci 2012. [PMID: 23188547 DOI: 10.1007/s11845-012-0878-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is increasing evidence that outpatient treatment of patients with low-risk stable pulmonary embolism (PE) is safe, effective and potentially reduces costs. It is not clear how many patients presenting to an Irish Emergency Department (ED) are potentially suitable for outpatient management. AIMS To identify how many patients presenting to our ED over a 1-year period who were diagnosed with acute PE are potentially suitable for outpatient treatment. METHODS A retrospective observational study was conducted over a 1-year period. Clinical notes for patients who had a positive computed tomographic pulmonary angiogram (CTPA) within 24 h of presentation to the ED were examined to risk stratify the patients according to the pulmonary embolism severity index (PESI). RESULTS Forty-seven patients who presented to our ED were diagnosed with a PE. Clinical notes were missing for 3 cases, and 44 cases were analysed further. The mean age was 64.3 (±16.8 SD) years and 24 (54.5 %, 95 % CI 40-68.3 %) were males. Six patients (13.6 %, 95 % CI 6.4-26.7 %) had a background of cancer. Fifteen cases (34.1 %, 95 % CI 21.9-48.7 %) were deemed to be low risk as they were categorised as PESI risk class I or II. Our study found that 61/420 (14.5 %, 95 % CI 11.5-18.2) of CTPAs done were positive for PE. CONCLUSION This study suggests that a significant percentage of patients diagnosed with acute PE are low risk as per PESI and therefore potentially suitable for outpatient management.
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Affiliation(s)
- A McCabe
- Emergency Department, Waterford Regional Hospital, Dunmore East Road, Waterford, Ireland.
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Can Selected Patients With Newly Diagnosed Pulmonary Embolism Be Safely Treated Without Hospitalization? A Systematic Review. Ann Emerg Med 2012; 60:651-662.e4. [DOI: 10.1016/j.annemergmed.2012.05.041] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 05/25/2012] [Accepted: 05/31/2012] [Indexed: 11/22/2022]
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Daley MJ, Lat I. Clinical controversies in thrombolytic therapy for the management of acute pulmonary embolism. Pharmacotherapy 2012; 32:158-72. [PMID: 22392425 DOI: 10.1002/phar.1051] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Acute pulmonary embolism is a common complication in hospitalized patients, spanning multiple patient populations and crossing various therapeutic disciplines. Due to the heterogeneous clinical manifestations, the selection of management strategies for patients with acute pulmonary embolism is a challenge for clinicians, and a nuanced understanding of the relevant literature is required. Previous studies that evaluated thrombolytic therapy in patients with acute pulmonary embolism are limited and controversial. Thus, we sought to identify the clinical controversies related to thrombolytic therapy in acute pulmonary embolism and reviewed the recent literature that impacts clinical practice. To apply these controversies into daily clinical practice and decision making, we provide an overview of risk stratification and assessment of pulmonary embolism. Specific areas of controversies that are discussed relate to the impact of thrombolytic therapy on outcomes, specifically in submassive pulmonary embolism, including mortality, composite primary end points, and intensive care unit length of stay. Other controversies relate to the impact of the patient's sex on outcomes, the most safe and effective thrombolytic dose, optimal administration techniques including infusion duration or concurrent anticoagulation, and therapeutic strategies when thrombolytic therapy is unsuccessful. Despite published guidelines and review articles, select aspects of thrombolytic therapy for the management of pulmonary embolism remain controversial; therefore, clinical practice varies from institution to institution and from practitioner to practitioner. When making decisions about the role of thrombolytic therapy in patients with pulmonary embolism, clinicians must be knowledgeable about areas with limited evidence and the therapy's associated risks. In every situation, practitioners must consider the trajectory of the patient's status and the ability to intervene in an appropriate time frame.
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Affiliation(s)
- Mitchell J Daley
- Department of Pharmacy, University Medical Center Brackenridge, Seton Family of Hospitals, Austin, Texas 78703, USA.
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Louzada ML, Carrier M, Lazo-Langner A, Dao V, Kovacs MJ, Ramsay TO, Rodger MA, Zhang J, Lee AYY, Meyer G, Wells PS. Development of a clinical prediction rule for risk stratification of recurrent venous thromboembolism in patients with cancer-associated venous thromboembolism. Circulation 2012; 126:448-54. [PMID: 22679142 DOI: 10.1161/circulationaha.111.051920] [Citation(s) in RCA: 143] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Long-term low-molecular-weight heparin (LMWH) is the current standard for treatment of venous thromboembolism (VTE) in cancer patients. Whether treatment strategies should vary according to individual risk of VTE recurrence remains unknown. We performed a retrospective cohort study and a validation study in patients with cancer-associated VTE to derive a clinical prediction rule that stratifies VTE recurrence risk. METHODS AND RESULTS The cohort study of 543 patients determined the model with the best classification performance included 4 independent predictors (sex, primary tumor site, stage, and prior VTE) with 100% sensitivity, a wide separation of recurrence rates, 98.1% negative predictive value, and a negative likelihood ratio of 0.16. In this model, the score sum ranged between -3 and 3 score points. Patients with a score ≤ 0 had low risk (≤ 4.5%) for recurrence and patients with a score >1 had a high risk (≥ 19%) for VTE recurrence. Subsequently, we applied and validated the rule in an independent set of 819 patients from 2 randomized, controlled trials comparing low-molecular-weight heparin to coumarin treatment in cancer patients. CONCLUSIONS By identifying VTE recurrence risk in cancer patients with VTE, we may be able to tailor treatment, improving clinical outcomes while minimizing costs.
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Affiliation(s)
- Martha L Louzada
- Department of Medicine, Division of Hematology, University of Western Ontario, 800-E3637 Commissioners Rd E, London, ON, Canada, N6A 5W9.
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Radhakrishna G, Berridge D. Cancer-related venous thromboembolic disease: current management and areas of uncertainty. Phlebology 2012; 27 Suppl 2:53-60. [PMID: 22457305 DOI: 10.1258/phleb.2012.012s34] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The relationship between cancer and venothromboembolic events is a complex, multifactorial process which is still not fully understood and therefore the use of current generic guidelines may be inadequate. Current management of cancer-related VTE may be suboptimal because of the lack of cancer-specific studies into the role of primary prophylaxis in both ambulant and non-ambulant cancer patients. Further research into developing cancer-specific risk assessment tools and the choice, dose and duration of prophylaxis is required. The management of confirmed symptomatic VTE in cancer patients is outlined but certain controversies remain. Areas for further research include the management of asymptomatic unsuspected VTE events, recurrent VTE events on treatment and the role of IVC filters and other treatment options are required. This paper attempts to cover some of the recent developments and areas of uncertainty surrounding the management of cancer-related VTE.
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Affiliation(s)
- G Radhakrishna
- St James's Institute of Oncology, St James's University Hospital, Beckett Street, Leeds, UK
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Barra S, Paiva L, Providência R, Fernandes A, Nascimento J, Marques AL. LR-PED rule: low risk pulmonary embolism decision rule - a new decision score for low risk pulmonary embolism. Thromb Res 2012; 130:327-33. [PMID: 22465039 DOI: 10.1016/j.thromres.2012.03.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2012] [Revised: 03/06/2012] [Accepted: 03/12/2012] [Indexed: 11/18/2022]
Abstract
INTRODUCTION When accurately diagnosed, non-massive Pulmonary embolism (PE) has a low mortality rate. However, some patients initially considered to be low risk show progressive deterioration. This research aims at developing a preliminary score that allows detection of low risk patients potentially eligible for outpatient treatment. MATERIALS AND METHODS Retrospective cohort study involving 142 asymptomatic/mildly symptomatic and hemodynamically stable patients with PE and no clinical/echocardiographic signs of right ventricular dysfunction. Collected data: risk factors, analytic/gasometric parameters, admission echocardiogram, thoracic CT angiography. Patients followed for 6months. Primary endpoint: 1-month all-cause mortality. Secondary endpoints: Intrahospital and 6-month all-cause mortality. A score designed for identification of very low risk patients eligible for outpatient treatment was developed and its prognostic accuracy compared to that of the Geneva and simplified PESI models. RESULTS A score for predicting 1-month mortality (Low Risk Pulmonary Embolism Decision [LR-PED] rule) was obtained using Binary Logistic Regression, including: age, atrial fibrillation at admission, previous heart failure, admission heart rate, creatinine, glycaemia, troponin I and C-reactive protein at admission. ROC curve analysis assessed its overall accuracy for predicting 1-month, intrahospital and 6-month mortality (AUC=0.756, 0.763 and 0.854, respectively). Compared to Geneva and simplified PESI, the LR-PED rule showed higher sensitivity and negative predictive value for the detection of the lowest risk patients. The net reclassification improvement index revealed significant successful upward risk reclassification by the LR-PED model of patients reaching primary or secondary outcomes. CONCLUSIONS LR-PED rule seems more attractive than Geneva or simplified PESI in its ability to identify patients at very low mortality risk who would be potentially eligible for outpatient treatment. Prospective validation of this score in larger cohorts is mandatory before its potential implementation.
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Affiliation(s)
- Sérgio Barra
- Cardiology Department, Coimbra Hospital and University Centre, Coimbra, Portugal.
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Rodríguez-Cerrillo M, Poza-Montoro A, Fernandez-Diaz E, Iñurrieta-Romero A, Matesanz-David M. Home treatment of patients with acute cholecystitis. Eur J Intern Med 2012; 23:e10-3. [PMID: 22153541 DOI: 10.1016/j.ejim.2011.07.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 07/01/2011] [Accepted: 07/22/2011] [Indexed: 12/07/2022]
Abstract
BACKGROUND Patients with acute cholecystitis are treated in Hospital. The aim of the study was to analyze the security and efficacy of treating not-operated-on patients with acute cholecystitis in Hospital in the Home (HIH). METHODS Prospective study from January 2010 to May 2011 including all patients diagnosed with acute cholecystitis, not operated on and without comorbidities admitted to HIH Unit from the Emergency Department Short Stay Unit and Observation Unit. Patients were treated with ertapenem for at least one week. Intravenous treatment was followed by oral therapy to complete 14 days of antibiotic treatment. Patient characteristics, clinical course, need for return to hospital during admission to HIH, and admission to hospital in the month after discharge from HIH are analyzed. RESULTS 25 patients were included. Mean age was 59 years (34-82). Upon arrival to the Emergency Department, all patients suffered abdominal pain, 60% had fever, and 32% vomiting. 48% of patients had a leukocyte count over 13,000 cells/μl. All patients had cholelithiasis and a distended gallbladder. 56% showed thickening of the gallbladder wall. Fluid accumulation around the gallbladder was noted in 16% of the cases. Murphy's sign proved positive in 44%. All patients showed a favorable course. No patient required hospital readmission during stay in HIH or in the month after discharge. All patients expressed their satisfaction with treatment at home. CONCLUSIONS Patients with acute cholecystitis and without comorbidities can be safely and effectively treated in HIH after a short monitoring period in hospital.
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Chan CM, Woods CJ, Shorr AF. Comparing the pulmonary embolism severity index and the prognosis in pulmonary embolism scores as risk stratification tools. J Hosp Med 2012; 7:22-7. [PMID: 22042764 DOI: 10.1002/jhm.932] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2010] [Revised: 03/16/2011] [Accepted: 03/21/2011] [Indexed: 11/06/2022]
Abstract
BACKGROUND Multiple risk stratification scoring systems exist to forecast outcomes in patients with acute pulmonary embolism (PE). OBJECTIVE We evaluated the comparative validity of the PE severity index (PESI) and the prognosis in pulmonary embolism (PREP) scores to predict mortality in acute PE. DESIGN Retrospective observational cohort study. SETTING Washington Hospital Center, Washington, DC. PATIENTS Consecutive adults (aged >18 years) diagnosed with acute PE. INTERVENTION The PESI and PREP scores were calculated. MEASUREMENTS Raw PESI scores were segregated into risk class (I-V) and then dichotomized into low (I-II) versus high (III-V) risk groups; the raw PREP scores were divided into low (0-7) versus high (>7) risk groups. The primary endpoint was 30-day and 90-day mortality. We determined the negative predictive value and computed the area under the receiver operating characteristics (AUROC) curves to compare the ability of these scoring tools. RESULTS The cohort consisted of 302 subjects. Thirty-day mortality was 3.0%, and 4.0% died within 90 days. The PESI and the PREP performed similarly (PESI AUROC: 0.858 [95% confidence interval (CI), 0.773-0.943] vs 0.719 [95% CI, 0.563-0.875] for PREP). Segregating these scores into risk categories did not affect their discriminatory power (AUROC: 0.684 [95% CI, 0.559-0.810] for PESI and 0.790 [95% CI, 0.679-0.903] for PREP). The negative predictive value for death of being classified as low risk by the PESI or PREP was 100% and 99%, respectively. CONCLUSIONS The PREP score performed comparably to the PESI score for identifying PE patients at low risk for short-term and intermediate-term mortality.
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Affiliation(s)
- Chee M Chan
- Pulmonary and Critical Care Medicine, Washington Hospital Center, Washington DC.
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Dutta S, Chattopadhayay S, Dasgupta C, Sarkar S. Low molecular weight heparin: a practical approach in deep venous thrombosis in palliative care. Indian J Palliat Care 2011; 17:143-5. [PMID: 21976855 PMCID: PMC3183604 DOI: 10.4103/0973-1075.84536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction: Deep vein thrombosis (DVT) is one of the many cause of pain in advance cases of carcinoma cervix. The most widely used agent for combating DVT is unfractionated heparin. Aims: Aims of this study is to see the efficacy of the use of low molecular weight (LMW) haparin and its practical utility in palliative care settings. Materials and Methods: Twelve cases of established DVT received enoxaparin at 40 mg/m with warfarin. Results: There was 70% resolution of limb swelling in seven cases. Out of remaining four cases took two months to resolve and one case did not resolve completely. Conclusions: LMV heparin is effective in palliative care setting and also has added advantage of subcutaneous route of administration.
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Affiliation(s)
- Samrat Dutta
- Department of Radiotherapy, Medical College and Hospital, Kolkata, India
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Aujesky D, Roy PM, Verschuren F, Righini M, Osterwalder J, Egloff M, Renaud B, Verhamme P, Stone RA, Legall C, Sanchez O, Pugh NA, N'gako A, Cornuz J, Hugli O, Beer HJ, Perrier A, Fine MJ, Yealy DM. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet 2011; 378:41-8. [PMID: 21703676 DOI: 10.1016/s0140-6736(11)60824-6] [Citation(s) in RCA: 390] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although practice guidelines recommend outpatient care for selected, haemodynamically stable patients with pulmonary embolism, most treatment is presently inpatient based. We aimed to assess non-inferiority of outpatient care compared with inpatient care. METHODS We undertook an open-label, randomised non-inferiority trial at 19 emergency departments in Switzerland, France, Belgium, and the USA. We randomly assigned patients with acute, symptomatic pulmonary embolism and a low risk of death (pulmonary embolism severity index risk classes I or II) with a computer-generated randomisation sequence (blocks of 2-4) in a 1:1 ratio to initial outpatient (ie, discharged from hospital ≤24 h after randomisation) or inpatient treatment with subcutaneous enoxaparin (≥5 days) followed by oral anticoagulation (≥90 days). The primary outcome was symptomatic, recurrent venous thromboembolism within 90 days; safety outcomes included major bleeding within 14 or 90 days and mortality within 90 days. We used a non-inferiority margin of 4% for a difference between inpatient and outpatient groups. We included all enrolled patients in the primary analysis, excluding those lost to follow-up. This trial is registered with ClinicalTrials.gov, number NCT00425542. FINDINGS Between February, 2007, and June, 2010, we enrolled 344 eligible patients. In the primary analysis, one (0·6%) of 171 outpatients developed recurrent venous thromboembolism within 90 days compared with none of 168 inpatients (95% upper confidence limit [UCL] 2·7%; p=0·011). Only one (0·6%) patient in each treatment group died within 90 days (95% UCL 2·1%; p=0·005), and two (1·2%) of 171 outpatients and no inpatients had major bleeding within 14 days (95% UCL 3·6%; p=0·031). By 90 days, three (1·8%) outpatients but no inpatients had developed major bleeding (95% UCL 4·5%; p=0·086). Mean length of stay was 0·5 days (SD 1·0) for outpatients and 3·9 days (SD 3·1) for inpatients. INTERPRETATION In selected low-risk patients with pulmonary embolism, outpatient care can safely and effectively be used in place of inpatient care. FUNDING Swiss National Science Foundation, Programme Hospitalier de Recherche Clinique, and the US National Heart, Lung, and Blood Institute. Sanofi-Aventis provided free drug supply in the participating European centres.
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Oliveira SS, Oliveira FS, Gaitani CM, Marchetti JM. Microparticles as a Strategy for Low-Molecular-Weight Heparin Delivery. J Pharm Sci 2011; 100:1783-92. [DOI: 10.1002/jps.22412] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2010] [Revised: 09/16/2010] [Accepted: 12/27/2010] [Indexed: 11/12/2022]
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Hariharan P, Takayesu JK, Kabrhel C. Association between the Pulmonary Embolism Severity Index (PESI) and short-term clinical deterioration. Thromb Haemost 2011; 105:706-11. [PMID: 21225095 DOI: 10.1160/th10-09-0577] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 12/10/2010] [Indexed: 11/05/2022]
Abstract
The Pulmonary Embolism Severity Index (PESI) has been shown to predict 30 and 90 day mortality after PE. However, whether the PESI predicts patients who will be free of clinically adverse outcomes during a typical hospitalisation is not known. Retrospective analysis of Emergency Department patients with PE from May 2006 to April 2008. We compiled demographics, data to calculate the PESI and a composite outcome. Patients were considered to have a negative PESI if they were in category I or II (≤85 points). Patients were considered to have the composite outcome if, within five days of diagnosis, they: A) had recurrent PE; B) developed a new cardiac dysrhythmia; C) required advanced cardiac life support; D) required respiratory support; E) required vasopressors; F) received thrombolysis; G) had major bleeding; H) returned to the ED; I) died. We enrolled 245 patients with PE. Of these, 115 (47%) were male, 204 (83%) were white. The mean age was 57 ± 17 years. The PESI identified 109 (44%) as low risk and 136 (56%) as high risk. Sixty-one (26%) patients had the outcome, of whom nine (14%) were characterised as low risk by the PESI. Test characteristics were: sensitivity 86% (95% confidence interval [CI]: 75%-93%), specificity 55% (95% CI: 47%-62%), NPV 63% (95% CI: 55%-70%), PPV 40% (95% CI: 31%-49%), LR(+) 1.9 (95% CI: 1.57-2.30) and LR(-) 0.26 (95% CI: 0.14-0.48). Of the patients who had an adverse clinical event or required a hospital-based intervention within the first five days after PE diagnosis, 14% were categorised by the PESI as safe for discharge [corrected] .
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Affiliation(s)
- Praveen Hariharan
- Department of Medicine, Internal Medicine Residency Program, Boston University Medical Center, Boston, Massachusetts, USA
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Modest response in translation to home management of deep venous thrombosis. Am J Med 2010; 123:1107-13. [PMID: 20961524 DOI: 10.1016/j.amjmed.2010.07.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Revised: 07/06/2010] [Accepted: 07/07/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND years may elapse between the publication of results of rigorous randomized trials and changes in clinical practice. It is not often that a definitive time interval can be identified that shows the time taken for published clinical trials to affect clinical practice. In the present study, we track the timelines of evidence for home treatment of deep venous thrombosis and its eventual impact on hospitalizations and early discharge. METHODS the number of patients discharged from short-stay hospitals throughout the United States between 1979 and 2006 with a principal diagnosis of deep venous thrombosis and the proportion discharged in ≤ 2 days was determined from The National Hospital Discharge Survey. We also attempted to identify all published articles that reported home treatment of deep venous thrombosis in unselected populations. RESULTS eleven years after demonstration of the safety and efficacy of home treatment, there was only a 21% decrease in the population-based incidence of hospitalizations of patients with a principal diagnosis of deep venous thrombosis. The proportion of patients with a principal diagnosis of deep venous thrombosis who were discharged in ≤ 2 days began to increase prominently after the 1996 publication of trials showing the safety and efficacy of home treatment, and continued to increase through 2006. However, the proportion discharged early remained modest (21% to 25%). CONCLUSIONS whether the slow implementation of home treatment reflects a cautious approach accompanied by a gradual testing of shortened hospitalization for deep venous thrombosis or other factors is uncertain.
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Bai S, Ahsan F. Inhalable Liposomes of Low Molecular Weight Heparin for the Treatment of Venous Thromboembolism. J Pharm Sci 2010; 99:4554-64. [DOI: 10.1002/jps.22160] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Maestre A, Sánchez R, Rosa V, Aujesky D, Lorenzo A, Barillari G, Monreal M. Clinical characteristics and outcome of inpatients versus outpatients with venous thromboembolism: findings from the RIETE Registry. Eur J Intern Med 2010; 21:377-82. [PMID: 20816588 DOI: 10.1016/j.ejim.2010.07.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Revised: 07/02/2010] [Accepted: 07/06/2010] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with venous thromboembolism (VTE) treated with anticoagulants are at risk of death from pulmonary embolism (PE) and/or bleeding. However, whether patients who develop VTE in hospital have a higher complication rate than those who develop VTE in an outpatient setting is unclear. PATIENTS AND METHODS RIETE is an ongoing, prospective registry of consecutive patients with acute, objectively confirmed, symptomatic VTE. We compared the 3-month incidence of fatal PE and fatal bleeding in patients in whom the VTE had developed while in hospital for another medical condition (inpatients) with those who presented to the emergency ward because of VTE (outpatients). RESULTS Up to April 2008, 22,133 patients with acute VTE were enrolled: 10,461 (47%) presented with PE, 11,672 with deep vein thrombosis. Overall, 6445 (29%) were inpatients. During the study period, those who developed VTE as inpatients had a significantly higher incidence of fatal PE (2.1% vs. 1.5%; odds ratio: 1.4; 95% CI: 1.1-1.7), overall death (7.0% vs. 5.4%; odds ratio: 1.3; 95% CI: 1.2-1.5), and major bleeding (2.9% vs. 2.1%; odds ratio: 1.4; 95% CI: 1.1-1.6) than outpatients. The incidence of fatal bleeding was not significantly increased (0.7% vs. 0.5%; odds ratio: 1.2; 95% CI: 0.9-1.8). In multivariable analysis, inpatient status was significantly associated with a higher risk for fatal PE (odds ratio: 1.3; 95% CI: 1.1-1.7). CONCLUSIONS VTE occurring in hospitalized patients carries a significantly higher risk for death of PE than in outpatients, underscoring the importance of VTE prevention strategies in the hospital setting.
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Affiliation(s)
- Ana Maestre
- Department of Internal Medicine, Hospital Universitario de Elche, Elche, Alicante, Spain
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Spencer FA, Goldberg RJ, Lessard D, Reed G, Emery C, Gore JM, Pacifico L, Weitz JI. Factors associated with adverse outcomes in outpatients presenting with pulmonary embolism: the Worcester Venous Thromboembolism Study. Circ Cardiovasc Qual Outcomes 2010; 3:390-4. [PMID: 20606125 DOI: 10.1161/circoutcomes.110.937441] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Data from clinical trials suggest that short-term mortality in outpatients presenting with pulmonary embolism (PE) is low and that outpatient therapy may be appropriate. However, subjects enrolled in these studies may not be representative of patients seen in the community setting. METHODS AND RESULTS The medical records of residents from Worcester, Mass, with International Classification of Disease, Ninth Edition, codes consistent with potential venous thromboembolism during 1999, 2001, and 2003 were independently validated and reviewed by trained abstractors. A total of 305 patients presented with PE from the outpatient setting. The rates of recurrent PE, major bleeding, mortality, or occurrence of any 1 of these end points at 90 days were 1.4%, 9.5%, 11.1%, and 20.1%, respectively. Patients with a history of congestive heart failure, recent intensive care unit discharge, cancer, severe infection, systolic blood pressure <100 mm Hg, and male sex were at increased risk for the composite end point. CONCLUSIONS In the present population-based study, morbidity and mortality after outpatient PE were much higher than what was observed in clinical studies. Our findings raise questions about broad-based outpatient treatment of PE in the community setting. In our study, comorbid conditions and recent illness were important determinants of adverse outcomes, suggesting that these variables should be carefully considered before embarking on outpatient therapy of PE.
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Affiliation(s)
- Frederick A Spencer
- Department of Medicine, McMaster University Medical Center, and Thrombosis and Atherosclerosis Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
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