1
|
Chessum JE, Shaya SA, Rajab D, Aftabjahani A, Zhou J, Weitz JI, Gross PL, Kim PY. Thrombin-activatable fibrinolysis inhibitor and sex modulate thrombus stability and pulmonary embolism burden in a murine model. J Thromb Haemost 2024; 22:263-270. [PMID: 37751849 DOI: 10.1016/j.jtha.2023.09.016] [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: 04/29/2022] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Thrombin-activatable fibrinolysis inhibitor (TAFI) levels are positively correlated with the risk of thrombosis. The mechanism of how TAFI affects venous thromboembolism (VTE) remains uncertain. In addition, the role of sex on the risk of VTE has also been studied. However, their association also remains unclear. OBJECTIVES To investigate how TAFI and/or sex affect venous thrombus stability and consequent pulmonary embolism (PE). METHODS Ferric chloride-induced thrombi were formed within the femoral veins of male and female wild-type (WT) or TAFI-knockout (Cpb2-/-) mice. Thrombi were imaged over 2 hours using intravital videomicroscopy to quantify embolization and thrombus size over time. Lungs were examined by immunohistochemistry to quantify (a) emboli and (b) fibrin composition of these emboli. RESULTS Embolization events in female mice were higher than in males (7.9-fold in WT and 3.1-fold in Cpb2-/- mice). Although the maximal thrombus sizes were not different across groups, Cpb2-/- mice had thrombi that were, on average, 24% smaller at the end of the 2-hour experiment than WT mice. Loss of TAFI led to a 4.0- and 2.8-fold increase in PE burden in males and females, respectively, while sex had no influence. Pulmonary emboli in Cpb2-/- mice had higher fibrin composition compared with WT mice. CONCLUSION Female mice had less stable venous thrombi than male mice, suggesting a higher risk of PE in females with deep vein thrombosis. Mice lacking TAFI had more thrombus degradation and higher PE burden than WT mice. These results confirm the role of TAFI in venous thrombosis.
Collapse
Affiliation(s)
- James E Chessum
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shana A Shaya
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dana Rajab
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Ali Aftabjahani
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ji Zhou
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Peter L Gross
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Paul Y Kim
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
2
|
Rahmani G, O'Sullivan GJ. Acute and chronic venous occlusion. Br J Radiol 2023; 96:20230242. [PMID: 37750946 PMCID: PMC10607425 DOI: 10.1259/bjr.20230242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/04/2023] [Accepted: 08/04/2023] [Indexed: 09/27/2023] Open
Abstract
This review article provides an overview of acute and chronic venous occlusion, a condition that can cause significant morbidity and mortality if not diagnosed and treated promptly. The article begins with an introduction to the anatomy of the venous system, followed by a discussion of the causes and clinical features of venous occlusion. The diagnostic tools available for the assessment of venous occlusion, including imaging modalities such as ultrasound, CT, and MRI, are then discussed, along with their respective advantages and limitations. The article also covers the treatment options for acute and chronic venous occlusion, including anticoagulant therapy and endovascular interventions. This review aims to provide radiologists with an updated understanding of the pathophysiology, diagnosis, and management of acute and chronic venous occlusion.
Collapse
Affiliation(s)
- George Rahmani
- Department of Interventional Radiology, Galway University Hospitals, Galway, Ireland
| | - Gerard J O'Sullivan
- Department of Interventional Radiology, Galway University Hospitals, Galway, Ireland
| |
Collapse
|
3
|
Truong P, Mazzolai L, Font C, Ciammaichella M, González-Martínez J, Tufano A, Gavín-Sebastián O, Le Mao R, Monreal M, Hugli O. Safety of the pulmonary embolism rule-out criteria rule: Findings from the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry. Acad Emerg Med 2023; 30:935-945. [PMID: 37092646 DOI: 10.1111/acem.14744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/29/2023] [Accepted: 04/20/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND The diagnostic strategy for pulmonary embolism (PE) includes a D-dimer test when PE probability is low or intermediate, but false-positive D-dimer results are frequent and can result in an unnecessary computed tomography pulmonary angiogram. The PE rule-out criteria (PERC) rule excludes PE without D-dimer testing when pretest probability is <15%. The aim of this study was to assess the safety of the PERC rule strategy in patients included in the Registro Informatizado de la Enfermedad TromboEmbolica venosa (RIETE) registry. METHODS This retrospective cohort study used data from the RIETE registry, an ongoing, international prospective registry of patients with objectively confirmed venous thromboembolism. The primary outcome was the failure rate of the PERC strategy, represented by the proportion of PERC-negative (PERC-N) patients with a PE included in the registry. Secondary outcomes were a comparison of the clinical characteristics, treatment strategy, and outcome of PERC-N versus PERC-positive (PERC-P) patients at 3 months. RESULTS From 2001 to 2021, a total of 49,793 patients with acute PE were enrolled in the RIETE registry. We included 48,903 in the final analysis after exclusion of 890 patients with an undetermined PERC status. Only 346 patients were PERC-N with a failure rate of 0.7% (95% confidence interval 0.6%-0.8%). PERC-N patients presented more frequently with chest pain but less often with dyspnea, syncope, or hypotension. They also had subsegmental or segmental PE more frequently, were more often treated with direct oral anticoagulants, and received mechanical or pharmacological thrombolysis less often. In addition, PERC-N patients had a lower incidence of recurrent deep vein thrombosis, major bleeding, and death attributed to PE during the 3-month follow-up. CONCLUSIONS A low failure rate of the PERC rule was observed in the RIETE registry, thus supporting its use to safely identify patients with an unlikely probability of PE.
Collapse
Affiliation(s)
- Perrine Truong
- Department of Emergency Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Lucia Mazzolai
- Department of Angiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Carme Font
- Department of Medical Oncology, Hospital Clínic, Barcelona, Spain
| | | | - José González-Martínez
- Department of Internal Medicine, Hospital Universitari Sant Joan de Déu, Fundació Althaia, Manresa, Barcelona, Spain
| | - Antonella Tufano
- Regional Reference Centre, Federico II University Hospital, Naples, Italy
| | - Olga Gavín-Sebastián
- Department of Haematology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Raphael Le Mao
- Department of Internal Medicine, CHRU Brest, Brest, France
| | - Manuel Monreal
- Faculty of Health Sciences, UCAM-Universidad Católica San Antonio de Murcia, Murcia, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Olivier Hugli
- Department of Emergency Medicine, Lausanne University Hospital, Lausanne, Switzerland
| |
Collapse
|
4
|
Sifuentes AA, Goldar G, Abdul-Aziz AA, Lee R, Shore S. Mechanical Circulatory Support and Critical Care Management of High-Risk Acute Pulmonary Embolism. Interv Cardiol Clin 2023; 12:323-338. [PMID: 37290837 DOI: 10.1016/j.iccl.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Hemodynamically significant pulmonary embolism (PE) remains a widely prevalent, underdiagnosed condition associated with mortality rates as high as 30%. The main driver of poor outcomes is acute right ventricular failure that remains clinically challenging to diagnose and requires critical care management. Treatment of high-risk (or massive) acute PE has traditionally included systemic anticoagulation and thrombolysis. Mechanical circulatory support, including both percutaneous and surgical approaches, are emerging as treatment options for refractory shock due to acute right ventricular failure in the setting of high-risk acute pulmonary embolism.
Collapse
Affiliation(s)
- Aaron A Sifuentes
- University of Michigan Department of Internal Medicine, 1500 East Medical Center Drive, 3116 Taubman Center, SPC 5368, Ann Arbor, MI 48109-5368, USA
| | - Ghazaleh Goldar
- Cleveland Clinic Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, 9500 Euclid Avenue, Mail Code J3-4, Cleveland, OH 44195, USA
| | - Ahmad A Abdul-Aziz
- Inova Heart and Vascular Institute, 3300 Gallows Road, Critical Care Medicine, Falls Church, VA 22042, USA
| | - Ran Lee
- Cleveland Clinic Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, 9500 Euclid Avenue, Mail Code J3-4, Cleveland, OH 44195, USA
| | - Supriya Shore
- University of Michigan Department of Internal Medicine, 1500 East Medical Center Drive, 3116 Taubman Center, SPC 5368, Ann Arbor, MI 48109-5368, USA.
| |
Collapse
|
5
|
Choudry H, Ata F, Ibrahim W, Rana MOR, Ahmad S, Mehmood A, Gill BA, Suheb MK. Saddle pulmonary embolism in the setting of COVID-19 infection: A systematic review of case reports and case series. Open Med (Wars) 2023; 18:20230724. [PMID: 37273918 PMCID: PMC10238810 DOI: 10.1515/med-2023-0724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/02/2023] [Accepted: 05/02/2023] [Indexed: 06/06/2023] Open
Abstract
Saddle pulmonary embolism (SPE) is a rare type of pulmonary embolism that can lead to hemodynamic compromise causing sudden deaths. Due to a dearth of large prospective studies in this area, little is known regarding the epidemiology, and prognosis and factors affecting the latter for COVID-19-associated SPE. We aimed to describe COVID-19-associated SPE and quantify and compare mortality and factors affecting mortality among the cases. We included a total of 25 publications with a total of 35 cases. The average age was 45 ± 16.3 years with 11 females and 24 males. Dyspnoea (82.5%), orthopnoea (43.5%), and cough (43.5%) were the most common symptoms, and obstructive shock was present in five (21.7%) patients. The average reported oxygen (O2) saturation was 85.8% ± 11.9 mm Hg. Hypertension (26.1%), diabetes (21.7%), and deep vein thrombosis (21.7%) were the most commonly reported comorbidities. Right heart strain was recognized in seven (30%) patients on electroencephalogram (S1QIIITIII) and 12 (52.2%) patients on echocardiogram. Anticoagulation, thrombolysis, and percutaneous intervention were tried in 21 (91.3%), 13 (56.5%), and 6 (26.1%) cases, respectively. Despite the aggressive management, 2 of 25 (8.7%) patients died in our smaller case report cohort. We conclude that despite aggressive management modalities, the mortality of SPE remains high in COVID-19.
Collapse
Affiliation(s)
- Hassan Choudry
- Department of Respiratory Medicine, University Hospital of Leicester, LeicesterLE1, UK
| | - Fateen Ata
- Department of Endocrinology, Hamad General Hospital, Hammad Medical Corporation, PO BOX 3050, Doha, Qatar
| | - Wanis Ibrahim
- Department of Internal Medicine and Pulmonology, Hammad Medical Corporation, Doha, Qatar
| | - Mohammad Omer Rehman Rana
- Department of Adult Cardiology, Chaudhary Pervaiz Ilahi Institute of Cardiology, Wazirabad, Pakistan
| | - Shoaib Ahmad
- Department of Medicine, Punjab Medical College, Faisalabad, Pakistan
| | - Asim Mehmood
- Respiratory Department, Derriford Hospital, University Hospitals Plymouth, Plymouth, UK
| | - Basir Afzaal Gill
- Intensive Care Unit, Department of Anaesthesia, Jinnah Hospital, Lahore, Pakistan
| | - Mahammed Khan Suheb
- Critical Care Department, St. Luke’s Aurora Hospital, Milwaukee, Wisconsin, USA
| |
Collapse
|
6
|
Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
Collapse
Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| |
Collapse
|
7
|
Ahmed HS. Concerns regarding result analysis and the corresponding risk of pulmonary embolism severity and in-hospital mortality. Eur J Intern Med 2022; 101:116. [PMID: 35382953 PMCID: PMC8976527 DOI: 10.1016/j.ejim.2022.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 03/30/2022] [Indexed: 11/26/2022]
Affiliation(s)
- H Shafeeq Ahmed
- Bangalore Medical College and Research Institute, Bangalore, Karnataka, India.
| |
Collapse
|
8
|
Shaydakov ME, Ting W, Sadek M, Aziz F, Diaz JA, Comerota AJ, Lurie F, Blebea J, Eklöf BG, Lugli M, De Maeseneer MGR, Kakkos SK, Nicolaides A, Heim D, Welch HJ. Extended Anticoagulation for Venous Thromboembolism: A Survey of the American Venous Forum and the European Venous Forum. J Vasc Surg Venous Lymphat Disord 2022; 10:1012-1020.e3. [PMID: 35561974 DOI: 10.1016/j.jvsv.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 03/27/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Extended anticoagulation should always be considered after standard treatment for an unprovoked episode of venous thromboembolism (VTE). It may also be considered in selected patients with provoked VTE. However, evidence-based protocols suggested by some clinical guidelines and risk assessment tools to guide this practice are limited and ambiguous. The goal of this survey research was to analyze current practices in applying extended anticoagulation therapy in patients with VTE among members of the American Venous Forum (AVF) and the European Venous Forum (EVF). METHODS An online survey was created by the AVF Research Committee. The survey consisted of sixteen questions to identify the country of practice, specialty, experience of participating physicians, and their clinical practice patterns in applying extended anticoagulation in VTE patients. The survey was distributed over email to the members of the AVF and EVF. RESULTS A total of 144 practitioners, 48 (33%) AVF members and 96 (66%) EVF members, participated in the survey. The majority of respondents identified themselves as vascular specialists with primary certification in vascular surgery (70%), vascular medicine/angiology (9%), and venous disease/phlebology (3%). Seventy-two percent of participants believe that the risk of VTE recurrence generally overweighs the risk of bleeding in patients with unprovoked VTE. Extended anticoagulation may be utilized by 97% of providers. Different patterns in real world clinical practice were identified. More than half of practitioners estimated VTE recurrence and bleeding risk subjectively. The antithrombotic drugs most commonly used for secondary prophylaxis were rivaroxaban, apixaban, warfarin, dabigatran, and aspirin, in decreasing order of frequency. Among the reasons selected for not considering extended anticoagulation on a regular basis were the lack of specific clinical practice guidelines (24%), the lack of published evidence (9%), and the absence of valid VTE/bleeding risk prediction calculators (8%). Twelve participants (8%) stated that extended anticoagulation was not beneficial for the majority of patients with VTE. Ten participants (7%) indicated that prescribing extended anticoagulation was outside the scope of their specialty. CONCLUSIONS There are different practice patterns in extending anticoagulation beyond the standard treatment in patients with VTE. Major gaps in knowledge remain a serious challenge at least partially explaining inaccuracy and inconsistency in long-term VTE management. Appropriately designed studies are needed to evaluate risk stratification tools when contemporary best medical therapy is used, accurately predict VTE recurrence and its long-term outcomes, and to tailor safe and effective secondary prophylaxis.
Collapse
Affiliation(s)
| | - Windsor Ting
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Faisal Aziz
- Penn State Heart and Vascular Institute, Hershey, PA, USA
| | - Jose A Diaz
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Fedor Lurie
- Jobst Vascular Institute, ProMedica Health System, Toledo, OH, USA; Section of Vascular Surgery, University of Michigan, Ann Arbor, MI, USA
| | - John Blebea
- Central Michigan University College of Medicine, Saginaw, MI, USA
| | | | - Marzia Lugli
- International Center of Deep Venous Surgery, Hesperia Hospital, Modena, Italy
| | | | | | | | - Dominik Heim
- Department of Surgery, Clinic Hohmad, Thun, Switzerland
| | | | | |
Collapse
|
9
|
Factors affecting the recurrence in patients with venous thromboembolism: A retrospective cohort study. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:384-390. [PMID: 34589258 PMCID: PMC8462109 DOI: 10.5606/tgkdc.dergisi.2021.20679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/13/2020] [Indexed: 11/29/2022]
Abstract
Background
The aim of the study was to evaluate the frequency of recurrence and the risk factors for recurrence in patients who were diagnosed with venous thromboembolism.
Methods
Between January 2005 and January 2015, a total of 412 venous thromboembolism patients (164 males, 248 females; mean age: 53.5±16.6 years; range: 19 to 95 years) were retrospectively analyzed. The demographics, underlying risk factors, comorbidities, imaging findings, and treatment data of the patients were recorded.
Results
At least one transient/permanent risk factor was found in 341 (82.7%) of the index events, and the other 71 (17.2%) were idiopathic. Recurrence developed in 76 (18.4%) of the patients. The duration of the treatment in the first event was significantly longer in recurrent cases (p=0.007). The recurrence rate in patients diagnosed with only deep vein thrombosis or patients diagnosed with pulmonary thromboembolism + deep vein thrombosis was significantly higher than the patients diagnosed with only pulmonary thromboembolism (24% vs. 14.2%, respectively; p=0.007). The rate of idiopathic venous thromboembolism was higher in recurrent cases than in non-recurrent cases (26.3% vs. 15.2%, respectively; p=0.028). At the end of the first year, the mean D-dimer levels were higher in recurrent cases (p=0.034). Hereditary risk factors were also higher in recurrent cases (39.5% vs. 19.3%, respectively; p=0.031). There was no significant correlation between recurrence and mortality.
Conclusion
The presence of deep vein thrombosis, idiopathic events, high D-dimer levels at the end of the first year and hereditary risk factors seem to be associated with recurrence.
Collapse
|
10
|
In-Hospital Risks and Management of Deep Venous Thrombosis According to Location of the Thrombus. Am J Med 2021; 134:877-881. [PMID: 33316253 DOI: 10.1016/j.amjmed.2020.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Whether deep venous thrombosis involving the pelvic veins or inferior vena cava is associated with higher in-hospital mortality or higher prevalence of in-hospital pulmonary embolism than proximal or distal lower extremity deep venous thrombosis is not known. METHODS This was a retrospective cohort study based on administrative data from the Nationwide Inpatient Sample, 2016, 2017. Patients hospitalized with a primary diagnosis of deep venous thrombosis at known locations were identified by International Classification of Diseases-10-Clinical Modification codes. RESULTS In-hospital all-cause mortality with deep venous thrombosis involving the inferior vena cava in patients treated only with anticoagulants was 2.2% versus 0.8% with pelvic vein deep venous thrombosis (p<0.0001), 0.7% with proximal deep venous thrombosis (p<0.0001) and 0.2% with distal deep venous thrombosis (p<0.0001). Mortality with anticoagulants was similar with pelvic vein deep venous thrombosis compared with proximal lower extremity deep venous thrombosis, 0.8% versus 0.7% (p=0.39). Lower mortality was shown with pelvic vein deep venous thrombosis treated with thrombolytics than with anticoagulants, 0% versus 0.8% (p<0.0001). In-hospital pulmonary embolism occurred in 11% to 23%, irrespective of the site of deep venous thrombosis. CONCLUSION Patients with deep venous thrombosis involving the inferior vena cava had higher in-hospital mortality than patients with deep venous thrombosis at other locations. Pelvic vein deep venous thrombosis did not result in higher mortality or more in-hospital pulmonary embolism than proximal lower extremity deep venous thrombosis. The incidence of in-hospital pulmonary embolism was considerable with deep venous thrombosis at all sites.
Collapse
|
11
|
Zhang P, Li L, Tian J, Zhang P, Yang K. Statins for the prevention of primary venous thromboembolism. Hippokratia 2021. [DOI: 10.1002/14651858.cd014769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Peng Zhang
- Department of Pediatric Surgery; Nanyang Central Hospital; Nanyang China
| | - Lun Li
- Department of Breast Surgery; The Second Xiangya Hospital, Central South University; Changsha China
| | - JinHui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences; Lanzhou University; Lanzhou City China
| | - Peizhen Zhang
- Maternity and Child-care; Hospital of Lanzhou City; Lanzhou City China
| | - KeHu Yang
- Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province; Lanzhou University; Lanzhou City China
| |
Collapse
|
12
|
Systematic review and meta-analysis of outcomes in patients with suspected pulmonary embolism. Blood Adv 2021; 5:2237-2244. [PMID: 33900385 DOI: 10.1182/bloodadvances.2020002398] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 03/08/2021] [Indexed: 01/14/2023] Open
Abstract
Prompt evaluation and therapeutic intervention of suspected pulmonary embolism (PE) are of paramount importance for improvement in outcomes. We systematically reviewed outcomes in patients with suspected PE, including mortality, incidence of recurrent PE, major bleeding, intracranial hemorrhage, and postthrombotic sequelae. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. We included 22 studies with 15 865 patients. Among patients who were diagnosed with PE and discharged with anticoagulation, 3-month follow-up revealed that all-cause mortality was 5.69% (91/1599; 95% confidence interval [CI], 4.56-6.83), mortality from PE was 1.19% (19/1597; 95% CI, 0.66-1.72), recurrent venous thromboembolism (VTE) occurred in 1.38% (22/1597; 95% CI: 0.81-1.95), and major bleeding occurred in 0.90% (2/221%; 95% CI, 0-2.15). In patients with a low pretest probability (PTP) and negative D-dimer, 3-month follow-up revealed mortality from PE was 0% (0/808) and incidence of VTE was 0.37% (4/1094; 95% CI: 0.007-0.72). In patients with intermediate PTP and negative D-dimer, 3-month follow-up revealed that mortality from PE was 0% (0/2747) and incidence of VTE was 0.46% (14/3015; 95% CI: 0.22-0.71). In patients with high PTP and negative computed tomography (CT) scan, 3-month follow-up revealed mortality from PE was 0% (0/651) and incidence of VTE was 0.84% (11/1302; 95% CI: 0.35-1.34). We further summarize outcomes evaluated by various diagnostic tests and diagnostic pathways (ie, D-dimer followed by CT scan).
Collapse
|
13
|
Systematic review and meta-analysis of outcomes in patients with suspected deep vein thrombosis. Blood Adv 2021; 4:2779-2788. [PMID: 32569377 DOI: 10.1182/bloodadvances.2020001558] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/16/2020] [Indexed: 11/20/2022] Open
Abstract
After deep vein thrombosis (DVT) is diagnosed, prompt evaluation and therapeutic intervention are of paramount importance for improvement in patient-important outcomes. We systematically reviewed patient-important outcomes in patients with suspected DVT, including mortality, incidence of pulmonary embolism (PE) and DVT, major bleeding, intracranial hemorrhage, and postthrombotic sequelae. We searched the Cochrane Central Register of Controlled Trials, Ovid Medline, Embase for eligible studies, references lists of relevant reviews, registered trials, and relevant conference proceedings. Two investigators screened and abstracted data. Nine studies with 5126 patients were included for lower extremity DVT. Three studies with 500 patients were included for upper extremity DVT. Among patients with lower extremity DVT, 0.85% (95% confidence interval [CI], 0% to 2.10%) and 0% developed recurrent DVT and PE, respectively, at 3 months. Among patients with upper extremity DVT, 0.49% (95% CI, 0% to 1.16%) and 1.98% (95% CI, 0.62% to 3.33%) developed recurrent DVT and PE, respectively, at 3 months. No major bleeding events were reported for those anticoagulated, which is lower than in other systematic reviews. For both upper and lower extremity DVT, low pretest probability patients with a negative D-dimer had a comparable incidence of VTE at 3 months (∼1%) as patients with a negative ultrasound (US). At higher pretest probabilities, negative US testing with or without serial US appears to be the safer option. In this review, we summarized the outcomes of patients evaluated by various diagnostic pathways. In most instances, there was significant limitation due to small population size or lack of direct evidence of effects of using a specific pathway. This systematic review was registered at PROSPERO as CRD42018100502.
Collapse
|
14
|
A novel rationale for targeting FXI: Insights from the hemostatic microRNA targetome for emerging anticoagulant strategies. Pharmacol Ther 2021; 218:107676. [DOI: 10.1016/j.pharmthera.2020.107676] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023]
|
15
|
Marchetti AA, Davila BO, Oddi FM, Ippoliti A. Pulmonary embolism: Successful treatment of floating thrombus in SFJ after vena cava filter insertion and surgical thrombectomy. JRSM Cardiovasc Dis 2020; 9:2048004020976256. [PMID: 33294173 PMCID: PMC7708661 DOI: 10.1177/2048004020976256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 11/16/2022] Open
Abstract
The floating venous thrombus in the common femoral vein has a high potential risk for pulmonary embolization. Clinical treatments, using anticoagulants or fibrinolytic, open thrombectomies, or thrombectomies by endovascular devices have all been used. Our case describe an obese patient affected by floating thrombus coming from GSV and diving in common femoral vein successful treated by combined both temporary vena cava insertion and open surgical thrombectomy.
Collapse
Affiliation(s)
- Andrea Ascoli Marchetti
- Vascular Surgery Unit, Biomedicine and Prevention Department, University of Rome, Rome, Italy
| | | | - Fabio Massimo Oddi
- Vascular Surgery Unit, Biomedicine and Prevention Department, University of Rome, Rome, Italy
| | - Arnaldo Ippoliti
- Vascular Surgery Unit, Biomedicine and Prevention Department, University of Rome, Rome, Italy
| |
Collapse
|
16
|
Abstract
BACKGROUND Pulmonary emboli (PE), or blood clots in the lungs,can be potentially fatal. Anticoagulation is the first line therapy to prevent PE. In some instances anticoagulation fails to prevent more emboli, or cannot be given because the person has a high risk of bleeding. Inferior vena caval filters (VCFs) are metal alloy devices that mechanically trap fragmented emboli from the deep leg veins en route to the pulmonary circulation. Retrievable filters are designed to be introduced and removed percutaneously. Although their deployment seems of theoretical benefit, their clinical efficacy and adverse event profile is unclear. This is the third update of a Cochrane Review first published in 2007. OBJECTIVES To assess the evidence for the effectiveness and safety of vena caval filters (VCFs) in preventing pulmonary embolism (PE). SEARCH METHODS For this review update, the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (last searched 10 September 2019) and the Cochrane Register of Controlled Trials (CENTRAL) (2019, Issue 8) via the Cochrane Register of Studies Online. The CIS also searched MEDLINE Ovid, EMBASE Ovid, CINAHL, and AMED (1 January 2017 to 10 September 2019) and trials registries to 10 September 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that examined the efficacy of VCFs in preventing PE. DATA COLLECTION AND ANALYSIS For this update, studies were assessed and data extracted independently. We assessed study quality with Cochrane's 'Risk of bias' tool and used the GRADE approach to assess the overall certainty of the evidence. The outcomes of interest were PE, mortality, lower limb venous thrombosis, filter-related complications and major bleeding. MAIN RESULTS We identified four new studies for this update, bringing the total to six included studies involving 1388 participants. The six studies were clinically heterogeneous and we were unable to carry out meta-analysis. Only two studies were considered to be both applicable in current clinical settings and of good methodological quality. One was a randomised open-label trial studying the effect of a retrievable inferior vena caval filter plus anticoagulation versus anticoagulation alone on risk of recurrent pulmonary embolism (PE) in 399 participants over three months. There was no evidence of a difference in the rates of PE, death, lower extremity deep vein thrombosis (DVT), or bleeding at three and six months after the intervention (moderate-certainty evidence). A filter was inserted in 193 people, but could only be successfully retrieved from 153. Minor filter complications were noted at six months. The second clinically relevant study was a randomised open-label trial of 240 participants who had sustained multiple traumatic injuries, allocated to a filter or no filter, three days after injury, in conjunction with anticoagulation and intermittent pneumatic compression. Prophylactic anticoagulation was initiated in both groups when it was thought safe to do so. There was no evidence of a difference in symptomatic PE, death, or lower limb venous thrombosis rates (moderate-certainty evidence). The only major filter complication was that one person required surgical removal of the filter. We are unable to draw any conclusions from the remaining four included studies. One study showed an increased incidence of long-term lower extremity DVT at eight years. Three studies are no longer clinically applicable because they utilised permanent filters which are seldom used now, or they did not use routine prophylactic anticoagulation which is current standard practice. The fourth study compared two filter types and was terminated prematurely as one filter group had a higher rate of thrombosis compared to the other filter type. AUTHORS' CONCLUSIONS Two of the six identified studies were relevant for current clinical settings. One showed no evidence of a benefit of retrievable filters in acute PE for the outcomes of PE, death, DVT and bleeding during the initial three months in people who can receive anticoagulation (moderate-certainty evidence). The other study did not show any benefit for prophylactic filter insertion in people who sustained multiple traumatic injuries, with respect to symptomatic PE, mortality, or lower extremity venous thrombosis (moderate-certainty evidence). We can draw no firm conclusions regarding filter efficacy in the prevention of PE from the remaining four RCTs identified in this review. Further trials are needed to assess vena caval filter effectiveness and safety, and clinical differences between various filter types.
Collapse
Affiliation(s)
- Tim Young
- Department of Medicine, Gold Coast University Hospital, Southport, Australia
| | - Krishna Bajee Sriram
- Department of Respiratory Medicine, Gold Coast University Hospital, Southport, Australia
| |
Collapse
|
17
|
Obaid M, El-Menyar A, Asim M, Al-Thani H. Prevalence and Outcomes of Thrombophilia in Patients with Acute Pulmonary Embolism. Vasc Health Risk Manag 2020; 16:75-85. [PMID: 32214817 PMCID: PMC7082538 DOI: 10.2147/vhrm.s241649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 02/21/2020] [Indexed: 11/23/2022] Open
Abstract
Background We aimed to study the prevalence and outcomes of thrombophilia in acute pulmonary embolism. Methods A retrospective observational study was conducted to include patients with a radiologically confirmed diagnosis of PE screened for thrombophilia from May 2011 to February 2015. Data included patients’ demographics; clinical presentation, risk factors, laboratory investigations, management, and outcome were analyzed and compared in patients with and without thrombophilia. Results A total of 227 cases of PE were included in the study, of which 108 (47.6%) had thrombophilia. The most frequent coagulopathic abnormality included deficiency of protein S, protein C, and antithrombin III and hyperhomocysteinemia. Only seven out of 79 patients were found to have factor V Leiden. PE patients diagnosed with thrombophilia were 10 years younger in age and peaked in the age range 30–39 years. Prior history of DVT (p=0.001) and PE (p=0.001) were the main significant risk factors in the thrombophilia group. The frequency of different risk categories of clinical probability scores did not differ significantly among those with and without thrombophilia. Pulmonary hypertension was a common complication in the thrombophilia group (P=0.009). Medications used included warfarin (74.7%), enoxaparin (73.9%), and heparin (55.4%). The overall mortality rate was 8.4%, and was non-significantly higher in the non-thrombophilia group. Conclusion Deficiencies of protein S, protein C, and antithrombin III are the leading causes of thrombophilic defects. Patients with hereditary thrombophilia are at increased risk of acute PE, particularly among young individuals. Therefore, early detection of thrombophilic defects together with other unprovoked risk factors could reduce the risk of recurrent VTE.
Collapse
Affiliation(s)
- Munzir Obaid
- Department of Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | - Ayman El-Menyar
- Department of Surgery, Clinical Research, Trauma and Vascular Surgery Section, HGH, Doha, Qatar.,Department of Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
| | - Mohammad Asim
- Department of Surgery, Clinical Research, Trauma and Vascular Surgery Section, HGH, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Hamad General Hospital (HGH), Doha, Qatar
| |
Collapse
|
18
|
Kim J, Kim HJ, Park S, Kim DK, Kim TH. Predictive Factors of Deep Vein Thrombosis in Gynecologic Cancer Survivors with Lower Extremity Edema: A Single-Center and Retrospective Study. Healthcare (Basel) 2020; 8:healthcare8010048. [PMID: 32120824 PMCID: PMC7151164 DOI: 10.3390/healthcare8010048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/15/2020] [Accepted: 02/25/2020] [Indexed: 11/25/2022] Open
Abstract
This study was conducted to examine predictive factors of deep vein thrombosis (DVT) in gynecologic cancer survivors with lower extremity edema (LEE). In the current single-center, retrospective study, there was a total of 315 eligible patients, including 80 patients with DVT and 235 without DVT. They were therefore divided into two groups: the DVT group (n = 80) and the non-DVT group (n = 235). Then, baseline and clinical characteristics of the patients were compared between the two groups. In our study, distant organ metastasis, advanced stage, lymphadectomy, and amount of intraoperative blood loss had a positive predictive value for the occurrence of DVT in gynecologic cancer survivors presenting LEE. In conclusion, our results indicate that it is necessary to consider the possibility of LEE arising from DVT in gynecologic cancer survivors with advanced-stage cancer, distant organ metastasis, lymphadectomy, and intraoperative blood loss over 1500 mL.
Collapse
Affiliation(s)
- Jungin Kim
- Department of Rehabilitation Medicine, Konkuk University Chungju Hospital, Chungju 27478, Korea; (J.K.); (S.P.); (D.K.K.)
| | - Hyun-Jun Kim
- Department of Obstetrics & Gynecology, School of Medicine, Konkuk University, Chungju 27478, Korea;
- Research Institute of Medical Science, Konkuk University School of Medicine, Seoul 05029, Korea
| | - Seunghun Park
- Department of Rehabilitation Medicine, Konkuk University Chungju Hospital, Chungju 27478, Korea; (J.K.); (S.P.); (D.K.K.)
| | - Dong Kyu Kim
- Department of Rehabilitation Medicine, Konkuk University Chungju Hospital, Chungju 27478, Korea; (J.K.); (S.P.); (D.K.K.)
| | - Tae Hee Kim
- Department of Rehabilitation Medicine, Konkuk University Chungju Hospital, Chungju 27478, Korea; (J.K.); (S.P.); (D.K.K.)
- Correspondence: ; Tel.: +82-43-840-8890; Fax: +82-43-840-8968
| |
Collapse
|
19
|
Hajouli S. Massive Fatal Pulmonary Embolism While on Therapeutic Heparin Drip. J Investig Med High Impact Case Rep 2020; 8:2324709620914787. [PMID: 32208868 PMCID: PMC7099618 DOI: 10.1177/2324709620914787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Venous thromboembolism (VTE) includes deep venous thrombosis (DVT) and pulmonary embolism (PE). In this article, we present a case of a patient with an acute DVT who was treated with a therapeutic heparin drip, then developed syncope while in the hospital and found to have massive bilateral PEs. This case aims to arouse the medical staff’s awareness of the VTE diagnosis even if the patient is fully anticoagulated. We review the indications for DVT hospitalization, heparin infusion monitoring, risk factors for developing PE from DVT, mechanisms of developing PE from DVT while on therapeutic anticoagulation, and signs and treatment of massive PE.
Collapse
Affiliation(s)
- Said Hajouli
- Hospital Medicine Department, Logan Regional Medical Center, Logan, WV, USA
| |
Collapse
|
20
|
A Caprini Risk Score-Based Cost-Effectiveness Analysis of Enoxaparin for the Thromboprophylaxis of Patients After Nonorthopedic Surgery in a Chinese Healthcare Setting. Clin Drug Investig 2019; 40:161-171. [PMID: 31773492 DOI: 10.1007/s40261-019-00876-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is an important cause of post-surgery morbidity and mortality. However, it is unclear whether thromboprophylaxis with the low-molecular-weight heparin (LMWH) enoxaparin after non-orthopedic surgery could balance the cost and clinical outcomes or not. OBJECTIVES The purpose of this research was to evaluate the cost-effectiveness of enoxaparin for the universal prophylaxis of VTE and associated long-term complications in patients after non-orthopedic surgery compared with no prevention in a Chinese healthcare setting. METHODS A decision model, which included both acute VTE and long-term complications, was developed to assess the economic outcomes of the two strategies for patients after non-orthopedic surgery. Quality-adjusted life years (QALYs) and direct medical costs were measured over a 5-year horizon. Incremental cost-effectiveness ratios (ICERs) were calculated. RESULTS Compared with no prevention, patients under enoxaparin treatment with Caprini risk scores of 3-4, 5-6, 7-8, and ≥ 9 increased by 0.012, 0.017, 0.034, and 0.102 in QALYs, respectively. The results were either that ICERs of thromboprophylaxis with enoxaparin over no prevention were lower than the thresholds or that thromboprophylaxis with enoxaparin was dominant. For patients with a Caprini risk score ≥ 9, thromboprophylaxis with enoxaparin is dominant across the whole drug use duration range. The sensitivity analysis confirmed the results. CONCLUSIONS As the first analysis evaluating the economic outcomes of enoxaparin in patients undergoing general non-orthopedic surgery, this study suggests that thromboprophylaxis with enoxaparin is highly cost-effective compared with no prevention in patients with Caprini risk score ≥ 3.
Collapse
|
21
|
Couturaud F, Girard P, Laporte S, Sanchez O. [What duration of anticoagulant treatment for PE/proximal DVT?]. Rev Mal Respir 2019; 38 Suppl 1:e99-e112. [PMID: 31711819 DOI: 10.1016/j.rmr.2019.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- F Couturaud
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; EA3878-GETBO, CIC Inserm1412, département de médecine interne et pneumologie, centre hospitalo-universitaire de Brest, université de Bretagne occidentale, 29200 Brest, France
| | - P Girard
- Institut du thorax-Curie-Montsouris, l'institut mutualiste Montsouris, 75014 Paris, France
| | - S Laporte
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; SAINBOIS U1059 équipe DVH, Unité de recherche clinique, Inserm, innovation, pharmacologie, CHU de Saint-Étienne, université Jean-Monnet, université de Lyon, hôpital du Nord, 42000 Saint-Étienne, France
| | - O Sanchez
- F-CRIN INNOVTE, 42055 Saint-Étienne cedex 2, France; Service de pneumologie et soins intensifs, université de Paris, AH-HP, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France; Innovations thérapeutiques en hémostase, Inserm UMRS 1140, 75006 Paris, France.
| | | |
Collapse
|
22
|
Computed tomography pulmonary angiography for acute pulmonary embolism: prediction of adverse outcomes and 90-day mortality in a single test. Pol J Radiol 2019; 84:e436-e446. [PMID: 31969963 PMCID: PMC6964354 DOI: 10.5114/pjr.2019.89896] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 10/01/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose Pulmonary embolism (PE) is a potentially fatal cardiopulmonary disease; therefore, rapid risk stratification is necessary to make decisions of appropriate management strategies. The aim of this study was to assess various computed tomography (CT) findings in order to find new prognostic factors of adverse outcome and mortality. Material and methods The study enrolled 104 patients with acute PE. Based on their outcome, patients were categorised into four groups. Comorbidities such as ischaemic heart disease were obtained from their medical records. Patients CT angiography were reviewed for recording variables such as main pulmonary artery diameter and right ventricle (RV)/left ventricle (LV) ratio. Patient deaths up to three months since diagnosis of PE had been registered. Logistic regression analysis was performed to find predictors. Results Based on multiple logistic regression, RV/LV ratio, LV diameter, and right-sided pulmonary infarction are predictors of mortality in 30 days. An RV/LV ratio of 1.19 could successfully discriminate patients who died within 30 days and those who did not. Conclusions RV/LV ratio, LV diameter, right-sided pulmonary infarction, assessed with helical CT, can help predict 30-day mortality.
Collapse
|
23
|
Becattini C, Giustozzi M, Cerdà P, Cimini LA, Riera-Mestre A, Agnelli G. Risk of recurrent venous thromboembolism after acute pulmonary embolism: Role of residual pulmonary obstruction and persistent right ventricular dysfunction. A meta-analysis. J Thromb Haemost 2019; 17:1217-1228. [PMID: 31063646 DOI: 10.1111/jth.14477] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 05/01/2019] [Indexed: 08/31/2023]
Abstract
Essentials Debated is the role of residual pulmonary obstruction (RPO) in predicting venous thromboembolism. Whether right ventricular dysfunction (RVD) predicts recurrent venous thromboembolism is unknown. 15 studies on RPO and 4 on RVD and venous thromboembolism were included in this meta-analysis. RPO is a predictor of recurrent venous thromboembolism when assessed by perfusion lung scan. RVD after acute pulmonary embolism is not associated with recurrent venous thromboembolism. BACKGROUND There is conflicting evidence regarding the role of residual pulmonary obstruction (RPO) or persistent right ventricular dysfunction (RVD) after pulmonary embolism (PE) as a predictor of recurrent venous thromboembolism (VTE). The aim of this study was to assess whether RPO or persistent RVD after PE is associated with recurrent VTE. METHODS MEDLINE and EMBASE were searched through December 2018. Studies reporting on (a) RPO either on computed tomography (CT) angiography or perfusion lung scan, or RVD on echocardiography or CT angiography, after therapeutic anticoagulation for the acute PE, and (b) recurrent VTE, were included in this meta-analysis. RESULTS RPO was associated with an increased risk of recurrent VTE (16 studies; 3472 patients; odds ratio [OR] 2.22; 95% confidence interval [CI] 1.61-3.05; I2 = 26%); the association was statistically significant for lung scan-detected RPO (11 studies; 2916 patients; OR 2.21; 95% CI 1.63-3.01) but not for CT angiography-detected RPO (five studies; 556 patients; OR 2.56; 95% CI 0.82-7.94). No significant association was found between persistent RVD and recurrent VTE (four studies; 852 patients; OR 1.62; 95% CI 0.63-4.17). CONCLUSIONS RPO is a predictor of recurrent VTE after a first acute PE, mainly when assessed by perfusion lung scan.
Collapse
Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Michela Giustozzi
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Pau Cerdà
- Internal Medicine, Hospital Universitari Bellvitge-IDIBELL, Barcelona, Spain
| | - Ludovica A Cimini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Antoni Riera-Mestre
- Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| |
Collapse
|
24
|
Lahham S, Fox JC, Thompson M, Nakornchai T, Alruwaili B, Doman G, Lee SM, Shafi A, Shniter I, Valdes V, Zhang L. Tricuspid annular plane of systolic excursion to prognosticate acute pulmonary symptomatic embolism (TAPSEPAPSE study). JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:695-702. [PMID: 30182486 PMCID: PMC6628892 DOI: 10.1002/jum.14753] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/06/2018] [Accepted: 06/08/2018] [Indexed: 05/05/2023]
Abstract
INTRODUCTION The imaging standard for evaluation of acute pulmonary embolism (PE) includes a computed tomography pulmonary angiogram. Ultrasonography has shown promise in obtaining the tricuspid annular plane systolic excursion (TAPSE) measurements, which may be of clinical importance in patients with acute PE. The objective of this study is to evaluate the diagnostic capability of TAPSE measurements for patients with suspicion for acute PE. METHODS We prospectively enrolled patients who came to the emergency department with suspicion of acute PE. Each patient underwent a point-of-care sonogram where a TAPSE measurement was obtained, followed by computed tomography pulmonary angiogram. Based on the computed tomography pulmonary angiogram findings, patients were grouped into 3 categories: no acute PE, clinically insignificant acute PE, or clinically significant acute PE. RESULTS We enrolled 87 patients in this study. Twenty-three (26.4%) of these patients were diagnosed with PE. Of patients with PE, 15 (65%) were found to have a clinically significant acute PE. Analysis of mean TAPSE measurements between patients with clinically significant acute PE and those with insignificant or no PE was 15.2 mm and 22.7 mm, respectively (P ≤ .0001). Following receiver operating characteristic curve analysis, optimum TAPSE measurement to identify clinically significant acute PE is 18.2 mm. A cutoff TAPSE measurement of 15.2 mm shows a sensitivity of 53.3% (95% confidence interval, 26.7%-80%) and a specificity of 100% (95% confidence interval, 100%-100%) for the diagnosis of a clinically significant PE. CONCLUSIONS Our data suggest that TAPSE measurements less than 15.2 mm have a high specificity for identifying clinically significant acute PE.
Collapse
Affiliation(s)
- Shadi Lahham
- University of California, Irvine, Department of Emergency Medicine, Orange, CA
| | - John C Fox
- University of California, Irvine, Department of Emergency Medicine, Orange, CA
| | - Maxwell Thompson
- University of California, Irvine, Department of Emergency Medicine, Orange, CA
| | | | - Badriah Alruwaili
- University of California, Irvine, Department of Emergency Medicine, Orange, CA
| | - Ghadeer Doman
- University of California, Irvine, Department of Emergency Medicine, Orange, CA
| | - Shannon May Lee
- University of California, Irvine, Department of Emergency Medicine, Orange, CA
| | - Amal Shafi
- University of California, Irvine, Department of Emergency Medicine, Orange, CA
| | - Inna Shniter
- University of California, Irvine, Department of Emergency Medicine, Orange, CA
| | - Victoria Valdes
- University of California, Irvine, Department of Emergency Medicine, Orange, CA
| | - Lishi Zhang
- University of California, Irvine, Department of Statistical Analysis, Institute for Clinical and Translational Sciences, Irvine, CA
| |
Collapse
|
25
|
Couturaud F, Pernod G, Presles E, Duhamel E, Jego P, Provost K, Pan-Petesch B, Sollier CBD, Tromeur C, Hoffmann C, Bressollette L, Lorillon P, Girard P, Le Moigne E, Le Hir A, Guégan M, Laporte S, Mismetti P, Lacut K, Bosson JL, Bertoletti L, Sanchez O, Meyer G, Leroyer C, Mottier D. Six months versus two years of oral anticoagulation after a first episode of unprovoked deep-vein thrombosis. The PADIS-DVT randomized clinical trial. Haematologica 2019; 104:1493-1501. [PMID: 30606789 PMCID: PMC6601089 DOI: 10.3324/haematol.2018.210971] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 01/02/2019] [Indexed: 11/09/2022] Open
Abstract
The optimal duration of anticoagulation after a first episode of unprovoked deep-vein thrombosis is uncertain. We aimed to assess the benefits and risks of an additional 18 months of treatment with warfarin versus placebo, after an initial 6 months of anticoagulation for a first unprovoked proximal deep-vein thrombosis. We conducted a multicenter, randomized, double-blind, controlled trial comparing an additional 18 months of warfarin with placebo in patients with a unprovoked proximal deep-vein thrombosis initially treated for 6 months (treatment period: 18 months; follow up after treatment period: 24 months). The primary outcome was the composite of recurrent venous thromboembolism or major bleeding at 18 months. Secondary outcomes were the composite at 42 months, as well as each component of the composite, and death unrelated to pulmonary embolism or major bleeding, at 18 and 42 months. All outcomes were centrally adjudicated. A total of 104 patients, enrolled between July 2007 and October 2013 were analyzed on an intention-to-treat basis; no patient was lost to follow-up. During the 18-month treatment period, the primary outcome occurred in none of the 50 patients in the warfarin group and in 16 out of 54 patients (cumulative risk, 29.6%) in the placebo group (hazard ratio, 0.03; 95% confidence interval: 0.01 to 0.09; P<0.001). During the entire 42-month study period, the composite outcome occurred in 14 patients (cumulative risk, 36.8%) in the warfarin group and 17 patients (cumulative risk, 31.5%) in the placebo group (hazard ratio, 0.72; 95% confidence interval: 0.35-1.46). In conclusion, after a first unprovoked proximal deep-vein thrombosis initially treated for 6 months, an additional 18 months of warfarin therapy reduced the composite of recurrent venous thrombosis and major bleeding compared to placebo. However, this benefit was not maintained after stopping anticoagulation. Clinical registration: this trial was registered at www.clinicaltrials.gov as #NCT00740493.
Collapse
Affiliation(s)
- Francis Couturaud
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
| | - Gilles Pernod
- Département de Médecine Vasculaire, CHU de Grenoble, Université de Grenoble 1, F-CRIN INNOVTE, Grenoble
| | - Emilie Presles
- Unité de Recherche Clinique, Innovation et Pharmacologie, CHU de Saint-Etienne, and INSERM U1059 SAINBIOSE, Université Jean Monnet, F-CRIN INNOVTE, Saint-Etienne
| | - Elisabeth Duhamel
- Service de Médecine Interne, Centre Hospitalier Général de Saint-Brieuc, F-CRIN INNOVTE, Saint-Brieuc
| | - Patrick Jego
- Service de Médecine Interne, CHU de Rennes, Université de Rennes 1, Rennes
| | - Karine Provost
- Service de Cardiologie, Centre Hospitalier Général de Lannion, Lannion
| | | | - Claire Bal Dit Sollier
- Clinique des Anticoagulants d'Ile de France (C.R.E.A.T.I.F.), CHU de Lariboisière, Paris
| | - Cécile Tromeur
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
| | - Clément Hoffmann
- Service d'Echo-Doppler Vasculaire, and EA 3878, CIC INSERM 1412, CHU de Brest, Université de Bretagne Occidentale, F-CRIN INNOVTE, Brest
| | - Luc Bressollette
- Service d'Echo-Doppler Vasculaire, and EA 3878, CIC INSERM 1412, CHU de Brest, Université de Bretagne Occidentale, F-CRIN INNOVTE, Brest
| | - Philippe Lorillon
- Pharmacie Centrale, CHU de Brest, Université de Bretagne Occidentale, Brest
| | - Philippe Girard
- Département Thoracique, Institut Mutualiste Montsouris, F-CRIN INNOVTE, Paris
| | - Emmanuelle Le Moigne
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
| | - Aurelia Le Hir
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
| | - Marie Guégan
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
| | - Silvy Laporte
- Unité de Recherche Clinique, Innovation et Pharmacologie, CHU de Saint-Etienne, and INSERM U1059 SAINBIOSE, Université Jean Monnet, F-CRIN INNOVTE, Saint-Etienne
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, Unité de Pharmacologie Clinique, CIC1408, CHU de Saint-Etienne, and INSERM U1059 SAINBIOSE, Université Jean Monnet, F-CRIN INNOVTE, Saint-Etienne
| | - Karine Lacut
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
| | - Jean-Luc Bosson
- CIC and UMR CNRS 5525, CHU de Grenoble, Université de Grenoble 1, Grenoble, France
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, Unité de Pharmacologie Clinique, CIC1408, CHU de Saint-Etienne, and INSERM U1059 SAINBIOSE, Université Jean Monnet, F-CRIN INNOVTE, Saint-Etienne
| | - Oliver Sanchez
- CIC and UMR CNRS 5525, CHU de Grenoble, Université de Grenoble 1, Grenoble, France
| | - Guy Meyer
- CIC and UMR CNRS 5525, CHU de Grenoble, Université de Grenoble 1, Grenoble, France
| | - Christophe Leroyer
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
| | - Dominique Mottier
- Départementde Médecine Interne et Pneumologie, CHU de Brest, Université de Bretagne Occidentale, EA 3878, CIC INSERM 1412, F-CRIN INNOVTE, Brest
| | | |
Collapse
|
26
|
High prevalence of deep vein thrombosis in elderly hip fracture patients with delayed hospital admission. Eur J Trauma Emerg Surg 2018; 46:913-917. [PMID: 30523360 DOI: 10.1007/s00068-018-1059-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 12/04/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Deep vein thrombosis (DVT) is a common complication in hip fracture patients, associated with significant morbidity and mortality. Research has focused on postoperative DVT, with scant reports on preoperative prevalence. The aim of this study was to describe the prevalence of preoperative DVT in patients accessing medical care ≥ 48 h after a hip fracture. METHODS We included elderly patients admitted ≥ 48 h after sustaining a hip fracture, between September 2015 and October 2017. Patients with a previous episode of DVT, undergoing anticoagulation therapy, with pathologic fractures or undergoing cancer treatment were excluded. Of 273 patients, 59 were admitted at least 48 h after the fracture. DVT screening by Doppler ultrasound of both lower extremities was carried upon hospital admission. We recorded age, sex, Charlson comorbidity index and ASA score, fracture type, time since injury, time from admission to surgery and total length of hospital stay. RESULTS We studied 41 patients, 79 (± 10.34) years old. The delay from injury to admission was 120 h (48-696 h). Seven patients (17.1%) had a DVT upon admission. There were no significant differences between patients with and without DVT, regarding time from admission to surgery or the total length of the hospital stay. CONCLUSIONS The prevalence of DVT in patients admitted ≥ 48 h after a hip fracture was 17.1%. The diagnosis and management of DVT did not increase time to surgery or hospital stay. Our results suggest routine screening for DVT in patients consulting emergency services ≥ 48 h after injury.
Collapse
|
27
|
van der Wall SJ, van der Pol LM, Ende-Verhaar YM, Cannegieter SC, Schulman S, Prandoni P, Rodger M, Huisman MV, Klok FA. Fatal recurrent VTE after anticoagulant treatment for unprovoked VTE: a systematic review. Eur Respir Rev 2018; 27:27/150/180094. [DOI: 10.1183/16000617.0094-2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 10/22/2018] [Indexed: 12/23/2022] Open
Abstract
Current guidelines recommend long-term anticoagulant therapy in patients with unprovoked venous thromboembolism (VTE). The risk of fatal recurrent VTE after treatment discontinuation (versus that of fatal bleeding during anticoagulation) is of particular relevance in the decision to continue or stop anticoagulation after the first 3 months. Our primary aim was to provide a point-estimate of the yearly rate of fatal recurrent VTE and VTE case-fatality rate in patients with unprovoked VTE after anticoagulation cessation. Data were extracted from both randomised controlled trials and observational studies published before May 1, 2017. The pooled fatality rates were calculated using a random-effects model. 18 studies with low-to-moderate bias were included in the primary analysis, totalling 6758 patients with a median (range) follow-up duration of 2.2 (1–5) years. After anticoagulation cessation, the weighted pooled rate of VTE recurrence was 6.3 (95% CI 5.4–7.3) per 100 patient-years and the weighted pooled rate of fatal recurrent VTE was 0.17 (95% CI 0.047–0.33) per 100 patient-years, for a case-fatality rate of 2.6% (95% CI 0.86–5.0). These numbers are a solid benchmark for comparison to the risks associated with long-term anticoagulation treatment for the decision on the optimal duration of treatment of patients with unprovoked VTE.
Collapse
|
28
|
Abram SGF, Judge A, Beard DJ, Price AJ. Adverse outcomes after arthroscopic partial meniscectomy: a study of 700 000 procedures in the national Hospital Episode Statistics database for England. Lancet 2018; 392:2194-2202. [PMID: 30262336 PMCID: PMC6238020 DOI: 10.1016/s0140-6736(18)31771-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/22/2018] [Accepted: 07/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Arthroscopic partial meniscectomy is one of the most common orthopaedic procedures worldwide. Clinical trial evidence published in the past 6 years, however, has raised questions about the effectiveness of the procedure in some patient groups. In view of concerns about potential overuse, we aimed to establish the true risk of serious complications after arthroscopic partial meniscectomy. METHODS We analysed national Hospital Episode Statistics data for all arthroscopic partial meniscectomies done in England between April 1, 1997, and March 31, 2017. Simultaneous or staged (within 6 months) bilateral cases were excluded. We identified complications occurring in the 90 days after the index procedure. The primary outcome was the occurrence of at least one serious complication within 90 days, which was defined as either myocardial infarction, stroke, pulmonary embolism, infection requiring surgery, fasciotomy, neurovascular injury, or death. Logistic regression modelling was used to identify factors associated with complications and, when possible, risk was compared with general population data. FINDINGS During the study period 1 088 782 arthroscopic partial meniscectomies were done, 699 965 of which were eligible for analysis. Within 90 days, serious complications occurred in 2218 (0·317% [95% CI 0·304-0·330]) cases, including 546 pulmonary embolisms (0·078% [95% CI 0·072-0·085]) and 944 infections necessitating further surgery (0·135% [95% CI 0·126-0·144]). Increasing age (adjusted odds ratio [OR] 1·247 per decade [95% CI 1·208-1·288) and modified Charlson comorbidity index (adjusted OR 1·860 per 10 units [95% CI 1·708-2·042]) were associated with an increased risk of serious complications. Female sex was associated with a reduced risk of serious complications (adjusted OR 0·640 [95% CI 0·580-0·705). The risk of mortality fell over time (adjusted OR 0·965 per year [95% CI 0·937-0·994]). Mortality, myocardial infarction, and stroke occurred less frequently in the study cohort than in the general population. The risks of infection and pulmonary embolism did not change during the study, and were significantly higher in the study cohort than in the general population. For every 1390 (95% CI 1272-1532) fewer knee arthroscopies done, one pulmonary embolism could be prevented. For every 749 (95% CI 704-801) fewer procedures done, one native knee joint infection could be prevented. INTERPRETATION Overall, the risk associated with undergoing arthroscopic partial meniscectomy was low. However, some rare but serious complications (including pulmonary embolism and infection) are associated with the procedure, and the risks have not fallen with time. In view of uncertainty about the effectiveness of arthroscopic partial meniscectomy, an appreciation of relative risks is crucial for patients and clinicians. Our data provide a basis for decision making and consent. FUNDING UK National Institute for Health Research.
Collapse
Affiliation(s)
- Simon G F Abram
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK; Musculoskeletal Research Unit, University of Bristol, Bristol, UK
| | - David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Andrew J Price
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
29
|
Dzudovic J, Dzudovic B, Subota V, Antunovic M, Stavric M, Subotic B, Obradovic S. Differences between activities of coagulation factors after one month of therapy with different direct oral anticoagulant in pulmonary embolism patients. J Clin Pharm Ther 2018; 44:236-242. [DOI: 10.1111/jcpt.12776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 09/24/2018] [Accepted: 10/15/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Jelena Dzudovic
- Clinic for Cardiology and Emergency Internal Medicine; Military Medical Academy; Belgrade Serbia
| | - Boris Dzudovic
- Clinic for Cardiology and Emergency Internal Medicine; Military Medical Academy; Belgrade Serbia
| | - Vesna Subota
- Institute for Medical Biochemistry; Military Medical Academy; Belgrade Serbia
| | - Marko Antunovic
- National Poison Control Center; Military Medical Academy; Belgrade Serbia
| | - Milena Stavric
- Institute for Medical Biochemistry; Military Medical Academy; Belgrade Serbia
| | - Bojana Subotic
- Clinic for Cardiology and Emergency Internal Medicine; Military Medical Academy; Belgrade Serbia
| | - Slobodan Obradovic
- Clinic for Cardiology and Emergency Internal Medicine; Military Medical Academy; Belgrade Serbia
| |
Collapse
|
30
|
Obi A, Wakefield T. The Management of Venous Thromboembolic Disease: New Trends in Anticoagulant Therapy. Adv Surg 2018; 52:43-56. [PMID: 30098620 DOI: 10.1016/j.yasu.2018.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Andrea Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, 5372 Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA.
| | - Thomas Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, 5463 Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA
| |
Collapse
|
31
|
Venous Thromboembolism Secondary to Adult-Onset Still’s Disease: a Case Report. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2018. [DOI: 10.2478/jce-2018-0009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Abstract
A 56-year-old man presented to the emergency department with pain, swelling, and restricted mobility of the left lower limb and shortness of breath on exertion in the previous 3 days. Seven months prior to this presentation, he had been diagnosed with adult-onset Still’s disease based on the Yamuguchi criteria, after excluding the presence of any other disease. The patient had been treated with prednisolone and methotrexate. Subsequent investigations revealed that he developed bilateral deep venous thrombosis and bilateral pulmonary emboli. This case emphasizes that adult-onset Still’s disease can be a rare but life-threatening cause of venous thromboembolism.
Collapse
|
32
|
Elmi G, Pizzini AM, Silingardi M. The secondary prevention of venous thromboembolism: Towards an individual therapeutic strategy. Vascular 2018; 26:670-682. [PMID: 29966487 DOI: 10.1177/1708538118776896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
After the anticoagulant withdrawal, a substantial proportion of patients with venous thromboembolism will develop recurrent events. Whether to consider an extended treatment depends on the risk of recurrence and bleeding risk. The assessment of the individual risk profile remains a difficult task. Several basal and post-basal factors modulate the risk of recurrence and may help clinicians to select patients who can benefit from the extended therapy. During the year 2017, new evidence regarding the post-basal factors was provided by the Morgagni and Scope studies. Another interesting novelty was the VTE-BLEED score, the first bleeding risk score that obtained the external validation in venous thromboembolism setting. In secondary prevention, the use of direct oral anticoagulants is growing instead of vitamin K antagonist. Even at lower doses, direct oral anticoagulants showed to be effective and safe, to reduce all-cause mortality and seemed to be superior to placebo for the composite outcome of fatal bleeding and fatal recurrence. After the recently published Einstein-Choice trial, the role of aspirin has become truly marginal as rivaroxaban 10 mg showed a bleeding risk similar to aspirin 100 mg but a greater effectiveness reducing the relative risk of recurrence by about 70%. Another option for secondary prevention could be sulodexide, with a lower protective effect than direct oral anticoagulants but an interesting safety profile. In conclusion, in our opinion, an individual strategy taking into account the risk of recurrence, bleeding risk, therapeutic options and patient preferences is the most appropriate approach to secondary prevention of venous thromboembolism.
Collapse
Affiliation(s)
- Giovanna Elmi
- Internal Medicine A Unit, Medical Department, Maggiore Hospital, Largo Nigrisoli Bologna, Italy
| | - Attilia M Pizzini
- Internal Medicine A Unit, Medical Department, Maggiore Hospital, Largo Nigrisoli Bologna, Italy
| | - Mauro Silingardi
- Internal Medicine A Unit, Medical Department, Maggiore Hospital, Largo Nigrisoli Bologna, Italy
| |
Collapse
|
33
|
Mampuya FK, Steinberg WJ, Raubenheimer JE. Risk factors and HIV infection among patients diagnosed with deep vein thrombosis at a regional/tertiary hospital in Kimberley, South Africa. S Afr Fam Pract (2004) 2018. [DOI: 10.1080/20786190.2018.1432135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- FK Mampuya
- Faculty of Health Sciences, Department of Family Medicine, University of the Free Sate , Bloemfontein, South Africa
| | - WJ Steinberg
- Faculty of Health Sciences, Department of Family Medicine, University of the Free Sate , Bloemfontein, South Africa
| | - JE Raubenheimer
- Faculty of Health Sciences, Department of Biostatistics, University of the Free Sate , Bloemfontein, South Africa
| |
Collapse
|
34
|
Wormer KC, Jangda AA, El Sayed FA, Stewart KI, Mumford SL, Segars JH. Is thromboprophylaxis cost effective in ovarian hyperstimulation syndrome: A systematic review and cost analysis. Eur J Obstet Gynecol Reprod Biol 2018; 224:117-124. [PMID: 29602141 PMCID: PMC5973799 DOI: 10.1016/j.ejogrb.2018.03.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/13/2018] [Accepted: 03/17/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND The majority of serious thromboembolic events occurring in assisted reproductive technologies (ART) are in women with ovarian hyperstimulation syndrome (OHSS). OBJECTIVES The purpose of this study was to present a thorough review and cost analysis regarding the use of venous thromboembolism (VTE) prophylaxis in OHSS to inform clinical management. DATA SOURCES Databases used were Pubmed and Embase, in addition to checking reference lists of retrieved articles (inception to November 2017). METHODS The systematic search strategy identified 365 titles and abstracts. Articles included in the qualitative synthesis had identified venous thrombosis incidence rates or ratios. A separate search for the cost model was conducted recognizing all associated complications of VTE. The decision tree was modeled to best fit the patient population and a sensitivity analysis was performed over a range of variables. RESULTS The cost of VTE event per OHSS patient not on prophylaxis was €5940 (range €3405 to €38,727), versus €4134 (€2705 to €23,192) per event per patient on prophylaxis, amounting to a saving of (€19 to €23,192) per VTE per patient. Sensitivity analysis found VTE prophyaxis to be cost effective if the incidence of VTE in the OHSS population was greater than 2.79%. Prophylactic therapy was cost effective through 16 weeks of treatment. LIMITATIONS OHSS is infrequent and hence, the incidence of VTE in patients with OHSS is low; therefore, the data used to inform the incidence of VTE in OHSS in the model carry some uncertainty. Further, low molecular weight heparin (LMWH) has side effects therefore individualization of care must be considered. CONCLUSIONS With the increasing incidence of infertility and requirement for ART, thromboembolism in OHSS poses a major health threat for patients. VTE prophylaxis using enoxaparin was cost effective in patients with severe OHSS over a wide range of costs and incidences. Prophylaxis was also cost effective through the completion of the first trimester of pregnancy.
Collapse
Affiliation(s)
| | | | - Farah A El Sayed
- Faculty of Medicine, American University of Beirut Medical Center, Riad El Solh, Beirut, Lebanon
| | - Katherine I Stewart
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21287, United States
| | - Sunni L Mumford
- Epidemiology Branch, Eunice Kennedy Shriver, National Institute of Child Health and Human Development, National Institutes of Health, 6100 Executive Blvd, Bethesda, MD, 20892, United States
| | - James H Segars
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21287, United States.
| |
Collapse
|
35
|
Cohen DM, Winter M, Lindenauer PK, Walkey AJ. Echocardiogram in the Evaluation of Hemodynamically Stable Acute Pulmonary Embolism: National Practices and Clinical Outcomes. Ann Am Thorac Soc 2018; 15:581-588. [PMID: 29298088 PMCID: PMC5955052 DOI: 10.1513/annalsats.201707-577oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 01/03/2018] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Societal guideline recommendations vary with regard to the role of routine trans-thoracic echocardiography to screen for right ventricular strain in patients with hemodynamically stable acute pulmonary embolism. OBJECTIVE To characterize national patterns in use of early trans-thoracic echocardiography for the evaluation of patients with hemodynamically stable acute pulmonary embolism and determine associations between trans-thoracic echocardiography use and patient outcomes. METHODS Retrospective cohort study using Premier, Inc. database of approximately 20% of patients hospitalized in the United States with hemodynamically stable acute pulmonary embolism between 2008 and 2011. Multivariable, risk-adjusted hierarchical regression models were used to evaluate hospital variation in use of trans-thoracic echocardiography for pulmonary embolism and associations between hospital trans-thoracic echocardiography rates and patient outcomes. Patient-level trans-thoracic echocardiography exposure was used in sensitivity analyses. RESULTS We identified 64,037 patients (mean age, 61.7 years; 54% women; 68% white) hospitalized at 363 U.S. hospitals. Trans-thoracic echocardiography rates for hemodynamically stable acute pulmonary embolism varied widely among hospitals (median trans-thoracic echocardiography rate, 41.4%; range, 0-89%; interquartile range, 32.7-51.7%). Hospital rates of trans-thoracic echocardiography were not associated with significant differences in risk-adjusted mortality (trans-thoracic echocardiography rate quartile 4 vs. quartile 1: odds ratio, 0.88; 95% confidence interval, 0.69-1.13) or use of thrombolytics (odds ratio, 1.28; 95% confidence interval, 0.84-1.96), but rates of intensive care unit admission (odds ratio, 1.57; 95% confidence interval, 1.18-2.07), hospital length of stay (relative risk, 1.08; 95% confidence interval, 1.03-1.15), and costs (relative risk, 1.15; 95% confidence interval, 1.07-1.23) were significantly higher at hospitals with high trans-thoracic echocardiography rates. Analyses of patient-level trans-thoracic echocardiography exposure produced similar results, except with higher rates of thrombolysis (odds ratio, 5.58; 95% confidence interval, 4.40-7.09) and bleeding (odds ratio, 1.37; 95% confidence interval, 1.24-1.51) among patients receiving trans-thoracic echocardiography. CONCLUSIONS Trans-thoracic echocardiography use in the evaluation of patients with hemodynamically stable acute pulmonary embolism varied widely between hospitals. Hospitals with high rates of pulmonary embolism-associated trans-thoracic echocardiography use did not achieve different patient mortality outcomes but had higher resource use and costs. Our findings support the 2016 American College of Chest Physicians guidelines for management of pulmonary embolism, which recommend selective, rather than routine, use of trans-thoracic echocardiography to risk stratify patients with hemodynamically stable pulmonary embolism.
Collapse
Affiliation(s)
| | - Michael Winter
- Department of Statistics, Boston University School of Public Health, Boston, Massachusetts
| | - Peter K. Lindenauer
- Department of Medicine and
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School–Baystate, Springfield, Massachusetts; and
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Allan J. Walkey
- Division of Pulmonary and Critical Care Medicine and
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, Massachusetts
| |
Collapse
|
36
|
Ruiz-Artacho P, Piñera P, Antolin A, Casal JR, Sanchez M, Suero C, Merlo M, Carriel J, Genis M, Jimenez S. Therapeutic approach for patients with venous thromboembolism attended in emergency departments during routine clinical practice: the EDITH study. J Comp Eff Res 2018; 7:319-330. [DOI: 10.2217/cer-2017-0061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To analyze treatment at discharge/follow-up of patients diagnosed with venous thromboembolism (VTE) in the emergency department (ED). Materials & methods: Ambispective study (50 Spanish centers) of consecutive patients (October–December 2014) with VTE diagnosed in ED. Results: VTE was diagnosed in 775 patients (295 pulmonary embolism [PE] without deep vein thrombosis [DVT], 389 DVT without PE and 91 PE + DVT); 95.5% received anticoagulants (90.7% low-molecular-weight heparin [LMWH], 4% LMWH + vitamin K antagonists and <1% direct oral anticoagulants). Overall, 23.3% were discharged from ED and 74.5% hospitalized (98.6% with PE and 50.4% with DVT). After discharge/90/180 days, 43.6/21.0/13.5% were taking LMWH, with similar rates in nononcologic patients. Conclusion: There is a poor adherence to international guidelines in management of VTE patients in Spain.
Collapse
Affiliation(s)
- Pedro Ruiz-Artacho
- Emergency Department, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Pascual Piñera
- Emergency Department, Hospital Reina Sofía, Murcia, Spain
| | - Albert Antolin
- Emergency Department, Hospital Clínic, Grupo UPP, Área 1 IDIBAPS, Barcelona, Spain
| | | | - Marta Sanchez
- Emergency Department, Hospital Central de Asturias, Oviedo, Spain
| | - Coral Suero
- Emergency Department, Hospital de la Axarquia, Málaga, Spain
| | - Marta Merlo
- Emergency Department, Hospital de Getafe, Madrid, Spain
| | - Jorge Carriel
- Emergency Department, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Mar Genis
- Medical Department, Bayer Hispania, S.L. Avda. Baix Llobregat 3-5, 08970 Sant Joan Despí, Spain
| | - Sonia Jimenez
- Emergency Department, Hospital Clínic, Grupo UPP, Área 1 IDIBAPS, Barcelona, Spain
| |
Collapse
|
37
|
Elder M, Blank N, Kaki A, Alraies MC, Grines CL, Kajy M, Hasan R, Mohamad T, Schreiber T. Mechanical circulatory support for acute right ventricular failure in the setting of pulmonary embolism. J Interv Cardiol 2018. [PMID: 29514403 DOI: 10.1111/joic.12503] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Right ventricular (RV) failure due to pulmonary embolism (PE) increases morbidity and mortality and contributes to prolonged hospital length of stay and higher costs of care. RV mechanical circulatory support (MCS) including Impella RP devices have been increasingly used in hemodynamically compromised PE patients who are refractory to intravascular volume expansion and inotropic therapy. However, effectiveness and safety of Impella RP, in hemodynamically unstable PE patients is unknown. METHODS We included consecutive patients who presented to Detroit Medical Center between November 3, 2015 and October 2, 2017 with acute PE and had evidence of hemodynamic compromise indicating Impella RP. RESULTS Total of five cases were identified. All patients met the shock definition due to massive or submassive PE and therefore received Impella RP on admission. Cardiac index was improved from mean of 1.69/min/m2, (0.88-2.15 L/min/m2 ), to 2.5 L/min/m2 (range 1.88-3.4), after 24 h of treatment. Similarly, mean heart rate reduced to 92 beats per minute (79-105), and mean systolic blood pressure increased to 140 mmHg (115-179). No significant changes were found in renal function, hemoglobin and platelets level during device use. One patient experienced hemoglobin drop from 13.7 to 7.3 g/dL but did not require blood transfusion. All patients survived to discharge. CONCLUSION In patients with PE and RV shock, Impella RP device resulted in immediate hemodynamic benefit with reversal of shock and favorable survival to discharge.
Collapse
Affiliation(s)
- Mahir Elder
- Wayne State University School of Medicine, Detroit Medical Center Heart Hospital, Detroit, Michigan
| | - Nimrod Blank
- Wayne State University School of Medicine, Detroit Medical Center Heart Hospital, Detroit, Michigan
| | - Amir Kaki
- Wayne State University School of Medicine, Detroit Medical Center Heart Hospital, Detroit, Michigan
| | - M Chadi Alraies
- Wayne State University School of Medicine, Detroit Medical Center Heart Hospital, Detroit, Michigan
| | - Cindy L Grines
- Zucker School of Medicine at Hofstra Northwell Health, Northshore University Hospital, Manhasset, New York
| | - Marvin Kajy
- Wayne State University School of Medicine, Detroit Medical Center Heart Hospital, Detroit, Michigan
| | | | - Tamam Mohamad
- Wayne State University School of Medicine, Detroit Medical Center Heart Hospital, Detroit, Michigan
| | - Theodore Schreiber
- Wayne State University School of Medicine, Detroit Medical Center Heart Hospital, Detroit, Michigan
| |
Collapse
|
38
|
Abstract
Anticoagulation pharmacy has been dramatically altered with US Food and Drug Administration (FDA) approval of 5 direct oral anticoagulants, 1 novel reversal agent and, a second designated for fast-track approval. Trial data surrounding current trends in anticoagulant choice for VTE, reversal, and bridging are constantly redefining practice. Extended therapy for unprovoked VTE has expanded to include low-dose direct oral anticoagulants, aspirin, and the use of the HERDOO2 system to identify women who can stop anticoagulant therapy without increased risk of recurrent VTE. Trends in thromboprophylaxis include extended duration low-dose direct oral anticoagulants to prevent VTE in high-risk patients.
Collapse
Affiliation(s)
- Margaret Smith
- General Surgery Residency, Department of Surgery, University of Michigan, 2207 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA
| | - Glenn Wakam
- General Surgery Residency, Department of Surgery, University of Michigan, 2207 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA
| | - Thomas Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, 5463 Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA
| | - Andrea Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, 5372 Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA.
| |
Collapse
|
39
|
Tromeur C, Sanchez O, Presles E, Pernod G, Bertoletti L, Jego P, Duhamel E, Provost K, Parent F, Robin P, Deloire L, Leven F, Mingant F, Bressollette L, Le Roux PY, Salaun PY, Nonent M, Pan-Petesch B, Planquette B, Girard P, Lacut K, Melac S, Mismetti P, Laporte S, Meyer G, Mottier D, Leroyer C, Couturaud F. Risk factors for recurrent venous thromboembolism after unprovoked pulmonary embolism: the PADIS-PE randomised trial. Eur Respir J 2018; 51:51/1/1701202. [DOI: 10.1183/13993003.01202-2017] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 10/04/2017] [Indexed: 11/05/2022]
Abstract
We aimed to identify risk factors for recurrent venous thromboembolism (VTE) after unprovoked pulmonary embolism.Analyses were based on the double-blind randomised PADIS-PE trial, which included 371 patients with a first unprovoked pulmonary embolism initially treated during 6 months who were randomised to receive an additional 18 months of warfarin or placebo and followed up for 2 years after study treatment discontinuation. All patients had ventilation/perfusion lung scan at inclusion (i.e. at 6 months of anticoagulation).During a median follow-up of 41 months, recurrent VTE occurred in 67 out of 371 patients (6.8 events per 100 person-years). In main multivariate analysis, the hazard ratio for recurrence was 3.65 (95% CI 1.33–9.99) for age 50–65 years, 4.70 (95% CI 1.78–12.40) for age >65 years, 2.06 (95% CI 1.14–3.72) for patients with pulmonary vascular obstruction index (PVOI) ≥5% at 6 months and 2.38 (95% CI 1.15–4.89) for patients with antiphospholipid antibodies. When considering that PVOI at 6 months would not be available in practice, PVOI ≥40% at pulmonary embolism diagnosis (present in 40% of patients) was also associated with a 2-fold increased risk of recurrence.After a first unprovoked pulmonary embolism, age, PVOI at pulmonary embolism diagnosis or after 6 months of anticoagulation and antiphospholipid antibodies were found to be independent predictors for recurrence.
Collapse
|
40
|
Mañas E, Barbero E, Chiluiza D, García A, Morillo R, Barrios D, Martínez-García MÁ, Albalat A, Cano I, Jiménez D. Impact of obstructive sleep apnea on cardiovascular outcomes in patients with acute symptomatic pulmonary embolism: Rationale and methodology for the POPE study. Clin Cardiol 2017; 40:1182-1188. [PMID: 29247523 DOI: 10.1002/clc.22834] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 09/29/2017] [Accepted: 10/04/2017] [Indexed: 01/07/2023] Open
Abstract
In normotensive patients with acute symptomatic pulmonary embolism (PE), the effect of undiagnosed obstructive sleep apnea (OSA) on cardiovascular (CV) outcomes lacks clarity. The Prognostic Significance of Obstructive Sleep Apnea in Patients With Acute Symptomatic Pulmonary Embolism (POPE) study is a multicenter, observational study designed to prospectively assess the prognostic significance of concomitant OSA in hemodynamically stable outpatients with acute symptomatic PE. Adult patients with acute stable PE are eligible. Recruited patients undergo an overnight sleep study using a level III portable diagnostic device within 7 days (and preferably within 48 hours) of diagnosis of PE. The sleep tracings are analyzed by a certified sleep technologist and audited by a sleep physician, both of whom are blinded to other study data. The patients are divided into 2 groups based on apnea-hypopnea index (AHI): OSA (AHI ≥15) and non-OSA (AHI <15) groups. The study uses a composite of PE-related death, CV death, clinical deterioration requiring an escalation of treatment, or nonfatal CV events (recurrent venous thromboembolism, acute myocardial infarction, or stroke) within 30 days after the diagnosis of PE as the primary outcome. The projected sample size of 225 patients will provide 80% power to test the hypothesis that OSA will increase the primary outcome from 7% in the non-OSA group to 20% in the OSA group, with α ≤0.05. The trial results will be important to understand the burden and CV effects of OSA in PE patients.
Collapse
Affiliation(s)
- Eva Mañas
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Esther Barbero
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Diana Chiluiza
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Aldara García
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Deisy Barrios
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | | | - Alicia Albalat
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Irene Cano
- Respiratory Department, Hospital de Getafe, Madrid, Spain
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | | |
Collapse
|
41
|
Alfonso A, Jiménez D, Capitán CF, Prandoni P, Wells PS, Vidal G, Barillari G, Monreal M, Lecumberri R. Dynamics of case-fatalilty rates of recurrent thromboembolism and major bleeding in patients treated for venous thromboembolism. Thromb Haemost 2017; 110:834-43. [DOI: 10.1160/th13-02-0132] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 05/21/2013] [Indexed: 12/31/2022]
Abstract
SummaryIn patients with venous thromboembolism (VTE), assessment of the risk of fatal recurrent VTE and fatal bleeding during anticoagulation may help to guide intensity and duration of therapy. We aimed to provide estimates of the case-fatality rate (CFR) of recurrent VTE and major bleeding during anticoagulation in a ‘real life’ population, and to assess these outcomes according to the initial presentation of VTE and its etiology. The study included 41,826 patients with confirmed VTE from the RIETE registry who received different durations of anticoagulation (mean 7.8 ± 0.6 months). During 27,110 patient-years, the CFR was 12.1% (95% CI, 10.2–14.2) for recurrent VTE, and 19.7% (95% CI, 17.4–22.1) for major bleeding. During the first three months of anticoagulant therapy, the CFR of recurrent VTE was 16.1% (95% CI, 13.6–18.9), compared to 2.0% (95% CI, 0–4.2) beyond this period. The CFR of bleeding was 20.2% (95% CI, 17.5–23.1) during the first three months, compared to 18.2% (95% CI, 14.0–23.2) beyond this period. The CFR of recurrent VTE was higher in patients initially presenting with PE (18.5%; 95% CI, 15.3–22.1) than in those with DVT (6.3%; 95% CI, 4.5–8.6), and in patients with provoked VTE (16.3%; 95% CI, 13.6–19.4) than in those with unprovoked VTE (5.5%; 95% CI, 3.5–8.0). In conclusion, the CFR of recurrent VTE decreased over time during anticoagulation, while the CFR of major bleeding remained stable. The CFR of recurrent VTE was higher in patients initially presenting with PE and in those with provoked VTE.
Collapse
|
42
|
Cenci C, Antonucci E, Grifoni E, Arcangeli C, Prisco D, Abbate R, Miniati M, Poli D. Risk of recurrence in patients with pulmonary embolism: Predictive role of D-dimer and of residual perfusion defects on lung scintigraphy. Thromb Haemost 2017. [DOI: 10.1160/th12-07-0534] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
SummaryThe stratification of recurrence risk after a first episode of venous thromboembolism (VTE) is an important topic of research, especially in patients with pulmonary embolism (PE). Elevated D-dimer levels and residual vein obstruction (RVO) at compression ultrasonography have been studied as predictors of recurrence after withdrawing oral anticoagulant treatment (OAT). It is still unknown if residual perfusion defects (PD) on lung scintigraphy are related to recurrent PE. In the present study, we evaluated the association of PD with PE recurrence. The relationship between PD, elevated D-dimer levels, and RVO was also investigated. We prospectively followed 236 consecutive patients who survived a first episode of objectively confirmed PE, with or without deep-vein thrombosis. After at least three months of OAT, treatment was withdrawn in 139 patients. D-dimer levels were evaluated at one month of OAT withdrawal, RVO was measured, and perfusion lung scan (P-scan) was performed to evaluate PD. During follow-up, 20 patients experienced a recurrent episode of VTE. Elevated D-dimer levels were significantly associated with VTE recurrence, (p=0.003). RVO was present in 22% of the patients with recurrence and in 7.5% of those without (p=0.07). No significant association was found between PD >10% and VTE recurrence, D-dimer, or RVO. In conclusion, we confirmed the positive predictive value of elevated D-dimer levels for recurrent VTE. Residual PD on lung scintigraphy are neither predictive of recurrence nor related to D-dimer levels or RVO.
Collapse
|
43
|
Holdsworth MT, Welch SM, Borrego M, Spyropoulos AC, Mahan CE. Long-term attack rates, as compared with incidence rates, may provide improved cost-estimates in venous thromboembolism. A reply to S. D. Grosse. Thromb Haemost 2017. [DOI: 10.1160/th11-11-0802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
44
|
Moutzouris JP, Chow V, Chung T, Curnow J, Kritharides L, Chwan Ng AC. Acute pulmonary embolism during warfarin therapy and long-term risk of recurrent fatal pulmonary embolism. Thromb Haemost 2017; 110:523-33. [DOI: 10.1160/th13-04-0288] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 05/17/2013] [Indexed: 11/05/2022]
Abstract
SummaryThe clinical characteristics and long-term outcomes of patients presenting with acute pulmonary embolism (PE) during treatment with warfarin have not been described. Clinical details of all patients admitted to a tertiary institution from 2000-2007 with acute PE were retrieved retrospectively, baseline warfarin status and the international normalised ratio (INR) were recorded, and their outcomes tracked using a statewide death registry. Of 923 patients with clearly documented warfarin status included in this study, 83 (9%) were taking warfarin. Mean (± standard deviation) day-1 INR of those taking warfarin was 2.3 ± 0.9, with 67% of patients therapeutically anti-coagulated (INR ≥2.0) at presentation (49 patients with INR <2.5 and 34 with INR ≥2.5). Patients taking warfarin on admission were more likely to have heart failure, atrial fibrillation and valvular heart disease, with similar prevalence of malignancy and ischaemic heart disease, compared to patients not on warfarin. Total mortality of the cohort (mean follow-up 4.0 ± 2.5 years) was 31.6% (in-hospital mortality 1.5%), and was similar between warfarin and no warfarin groups. There was however a greater than four-fold increased risk of post-discharge death due to recurrent PE for the patients taking warfarin on admission (hazard ratio [HR] 4.43, 95% confidence interval [CI] 1.36-14.42, p=0.01). Among patients taking warfarin on admission, day-1 INR <2.5 significantly increased long-term all-cause mortality compared to INR ≥2.5 (adjusted HR 2.51, 95% CI 1.08-5.86, p=0.03). In conclusion, patients presenting with PE during treatment with warfarin have an increased risk of death from recurrent PE. Admission INR appears to have independent long-term prognostic importance in these patients.
Collapse
|
45
|
Tsuru M, Sata M, Tanaka M, Umeyama H, Kodera Y, Shiwa M, Aoyagi N, Yasuda K, Matsuoka K, Fukuda T, Yamana H, Nagata K. Retrospective Proteomic Analysis of a Novel, Cancer Metastasis-Promoting RGD-Containing Peptide. Transl Oncol 2017; 10:998-1007. [PMID: 29096248 PMCID: PMC5671418 DOI: 10.1016/j.tranon.2017.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 10/02/2017] [Accepted: 10/05/2017] [Indexed: 12/28/2022] Open
Abstract
Patients who undergo surgical extirpation of a primary liver carcinoma followed by radiotherapy and chemotherapy leading to complete remission are nevertheless known to develop cancerous metastases 3-10 years later. We retrospectively examined the blood sera collected over 8 years from 30 patients who developed bone metastases after the complete remission of liver cancer to identify serum proteins showing differential expression compared to patients without remission. We detected a novel RGD (Arg-Gly-Asp)-containing peptide derived from the C-terminal portion of fibrinogen in the sera of metastatic patients that appeared to control the EMT (epithelial-mesenchymal transition) of cancer cells, in a process associated with miR-199a-3p. The RGD peptide enhanced new blood vessel growth and increased vascular endothelial growth factor levels when introduced into fertilized chicken eggs. The purpose of this study was to enable early detection of metastatic cancer cells using the novel RGD peptide as a biomarker, and thereby develop new drugs for the treatment of metastatic cancer.
Collapse
Affiliation(s)
- Michiyo Tsuru
- Clinical Proteomics and Gene Therapy Laboratory, Kurume University, Kurume, Japan; Research Center for Innovative Cancer Therapy, Kurume University, Kurume, Japan; Department of Orthopedic Surgery, Kurume University School of Medicine, Kurume, Japan.
| | - Michio Sata
- Research Center for Innovative Cancer Therapy, Kurume University, Kurume, Japan; Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Maki Tanaka
- Department of Surgery, Kurume General Hospital, Kurume, Japan
| | - Hideaki Umeyama
- Department of Biological Science, Chuo University, Tokyo, Japan
| | - Yoshio Kodera
- Department of Physics, School of Science, Kitasato University, Kanagawa, Japan
| | - Mieko Shiwa
- Life Science Division, Bio-Rad Laboratories K.K., Tokyo, Japan
| | - Norikazu Aoyagi
- Life Science Division, Bio-Rad Laboratories K.K., Tokyo, Japan
| | | | - Kei Matsuoka
- Research Center for Innovative Cancer Therapy, Kurume University, Kurume, Japan; Department of Urology, Kurume University, Kurume, Japan
| | - Takaaki Fukuda
- Center for Rheumatology, Kurume University School of Medicine, Kurume, Japan
| | - Hideaki Yamana
- Research Center for Innovative Cancer Therapy, Kurume University, Kurume, Japan; Center for Multidisciplinary Treatment of Cancer, Kurume University School of Medicine, Kurume, Japan
| | - Kensei Nagata
- Clinical Proteomics and Gene Therapy Laboratory, Kurume University, Kurume, Japan; Research Center for Innovative Cancer Therapy, Kurume University, Kurume, Japan; Department of Orthopedic Surgery, Kurume University School of Medicine, Kurume, Japan
| |
Collapse
|
46
|
Bernardi E, Camporese G. Diagnosis of deep-vein thrombosis. Thromb Res 2017; 163:201-206. [PMID: 29050648 DOI: 10.1016/j.thromres.2017.10.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 09/17/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
Abstract
The diagnostic approach to suspected symptomatic deep-vein thrombosis of the lower extremities is usually based on non-invasive methods, including the estimation of clinical probability, the measurement of D-dimer levels, and ultrasonography. The present review discusses the evidence available from the literature about the management of the first episode of suspected deep-vein-thrombosis.
Collapse
Affiliation(s)
- Enrico Bernardi
- Emergency Unit, Department of Critical Care, aULSS2 "Marca Trevigana", distretto di Pieve di Soligo, via Brigata Bisagno, 4, 31015 Conegliano, Treviso, Italy.
| | - Giuseppe Camporese
- Unit of Angiology, Department of Cardiac, Thoracic and Vascular Sciences, University Hospital of Padua, via Giustiniani, 2, 35128 Padova, Italy.
| |
Collapse
|
47
|
Palareti G. Optimal long-term pharmacological treatment of patients with venous thromboembolism that was unprovoked or associated with weak risk factors. Expert Rev Hematol 2017; 10:921-931. [PMID: 28803491 DOI: 10.1080/17474086.2017.1366851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Unprovoked venous thromboembolism (VTE) tend to recur. Many factors, patient- or event-related, influence the individual risk of recurrence. After initial and long-term (usually for 3-6 months) anticoagulant therapy, extended anticoagulation has been recommended in patients at high risk of recurrence, provided they do not have a high risk of bleeding. Areas covered: The effect of different risk factors on the risk of recurrence is discussed, as well as risk factors for bleeding. The estimation of individual balance between these two risks is crucial to decide which can be the best treatment duration in single patients. The use of direct oral anticoagulants, with likely less risk of bleeding, may influence the balance. D-dimer assessment during and after anticoagulation is stopped is also commented for its role to help identifying the individual risk of recurrence. Expert commentary: All patients with a first VTE should be reconsidered after the initial 3-6 months of treatment. Anticoagulation can then be stopped or continued in relation to low or very high risk of recurrence, respectively. Serial D-dimer assessment during the first 2 or 3 months after anticoagulation is stopped is useful in patients with uncertain risk evaluation (especially after unprovoked events).
Collapse
|
48
|
Karmakar B. Impact of health utility after thrombotic complications following total hip and knee arthroplasty. ANZ J Surg 2017; 87:820-824. [PMID: 28759944 DOI: 10.1111/ans.14122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 03/21/2017] [Accepted: 05/28/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Medical complications and preexisting conditions frequently place the surgeon in the unenviable position of choosing between the serious and potentially life-threatening effects of thrombosis, or the issue of bleeding and surgical site complications. The aim of this research was to determine if health utility could be a consideration before choosing to therapeutically anticoagulate in the hip and knee arthroplasty patient. METHODS The quantitative risks and effectiveness of treatment options for venous thromboembolism, atrial fibrillation, acute coronary syndromes, ischaemic stroke and mechanical heart valves were evaluated from previously published data. Previously calculated health utility values were obtained from published studies for both thrombotic events and anticoagulant-related complications at the site of arthroplasty. An impact score was generated through a multiplication of 1 - utility with the rate of the event occurring. RESULTS Impact scores associated with revision surgery and deep infection at the arthroplasty site following anticoagulation are higher compared to impact scores in subsets of non-treated venous thromboembolism, low CHADS2 (congestive heart failure, hypertension, age >75, diabetes (1 point each), stroke/transient ischaemic attack (2 points)) atrial fibrillation and potentially some acute coronary syndrome patients. Some anticoagulation strategies in mechanical heart valves are of definite overall patient value due to the significant complications otherwise. CONCLUSION Objective calculation of both the benefit and risks of anticoagulation in the post-operative patient is significantly altered by including the effect on patient's quality of life utility value. Therapeutic anticoagulation in some common situations is probable to be of more detriment than benefit when considering health utility.
Collapse
Affiliation(s)
- Bikram Karmakar
- Department of Orthopaedics, John Hunter Hospital, Newcastle, New South Wales, Australia
| |
Collapse
|
49
|
Quel traitement anticoagulant au décours d’une embolie pulmonaire. Presse Med 2017; 46:728-738. [DOI: 10.1016/j.lpm.2017.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 06/27/2017] [Indexed: 01/22/2023] Open
|
50
|
|