Review of Medical Therapies for the Management of Pulmonary Embolism

Clinical Profile and Outcomes of Pulmonary Embolism in Central Iran: A Retrospective Cohort Study

BACKGROUND

Pulmonary embolism (PE) is a significant public health concern. This retrospective cohort study examines the clinical profiles and outcomes of patients diagnosed with PE at a medical center in central Iran, aiming to identify mortality predictors during hospitalization and follow-up.

METHODS

Data from 109 patients diagnosed with PE were analyzed, with a median follow-up of 23 months. The collected information included demographic and clinical characteristics, laboratory findings, treatment protocols, and outcomes. Logistic regression and Kaplan-Meier survival analysis were used to identify independent mortality predictors and assess survival impact.

RESULTS

The mean age was 59.2 years (±19.7), with 51.4% male. Common symptoms included dyspnea (86%) and chest pain (53%), with non-massive PE being the most prevalent (63%). Independent mortality predictors identified were age (odds ratio [OR] 1.065 per year, P<0.001), female sex (OR 4.421, P=0.009), and PE severity (OR 0.262, P=0.023). Kaplan-Meier analysis showed reduced survival probabilities in females (P=0.009), those with provoked PE (P=0.002), patients over 65 (P=0.016), and individuals with comorbidities (P=0.018). In-hospital mortality was 10.1%, linked to provoked massive PE, absence of thrombolytic therapy, and reduced left ventricular ejection fraction (LVEF).

CONCLUSION

In this cohort, age, sex, and PE severity were significant mortality predictors, while provoked PE, advanced age, and comorbidities were associated with lower mid-term survival probabilities.

Tailoring oral anticoagulant treatment in the era of multi-drug therapies for PAH and CTEPH

The use of oral anticoagulants in the management of pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) presents distinct therapeutic challenges and benefits. In PAH, the benefits of oral anticoagulation are uncertain, with studies yielding mixed results on their efficacy and safety. Conversely, oral anticoagulants are a cornerstone in the treatment of CTEPH, where their use is consistently recommended to prevent recurrent thromboembolic events. The choice between vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) remains a significant clinical question, as each type presents advantages and potential drawbacks. Furthermore, drug-drug interactions (DDIs) with concomitant PAH and CTEPH treatments complicate anticoagulant management, necessitating careful consideration of individual patient regimens. This review examines the current evidence on oral anticoagulant use in PAH and CTEPH and discusses the implications of DDIs within a context of multi-drug treatments, including targeted drugs in PAH.

Decoding Pulmonary Embolism: Pathophysiology, Diagnosis, and Treatment

Pulmonary Embolism (PE) is a life-threatening condition initiated by the presence of blood clots in the pulmonary arteries, leading to severe morbidity and mortality. Underlying mechanisms involve endothelial dysfunction, including impaired blood flow regulation, a pro-thrombotic state, inflammation, heightened oxidative stress, and altered vascular remodeling. These mechanisms contribute to vascular diseases stemming from PE, such as recurrent thromboembolism, chronic thromboembolic pulmonary hypertension, post-thrombotic syndrome, right heart failure, and cardiogenic shock. Detailing key risk factors and utilizing hemodynamic stability-based categorization, the review aims for precise risk stratification by applying established diagnostic tools and scoring systems. This article explores both conventional and emerging biomarkers as potential diagnostic tools. Additionally, by synthesizing existing knowledge, it provides a comprehensive outlook of the current enhanced PE management and preventive strategies. The conclusion underscores the need for future research to improve diagnostic accuracy and therapeutic effectiveness in PE.

Anticoagulation Management Post Pulmonary Embolism

Pulmonary embolus (PE) carries a significant impending morbidity and mortality, especially in intermediate and high-risk patients, and the choice of initial anticoagulation that allows for therapeutic adjustment or manipulation is important. The preferred choice of anticoagulation management includes direct oral anticoagulants. Vitamin K antagonists and low-molecular-weight heparin are preferred in special populations or selected patients such as breastfeeding mothers, those with end-stage renal disease, or obese patients, among others. This article reviews the primary and longer-term considerations for anticoagulation management in patients with PE and highlights special patient populations and risk factor considerations.

The Correlation Between the D-Dimer Values and Anatomical Distribution of Pulmonary Embolism

Background

Pulmonary Embolism (PE) represents a life-threatening medical emergency that, given the serious complications, requires urgent application of anticoagulant therapy. In addition to other factors that are taken into account when choosing a therapy for treatment of PE, the anatomical distribution of thrombi is also considered-whether it is a central, lobar, segmental or subsegmental PE. D-dimer is an intermediate product of degradation of fibrin molecules and its values in the plasma are increased in the case of PE, but also in other diseases.

Objective

To determine whether there is a difference in D-dimer values in subjects with different anatomical distribution of PE.

Methods

The study included 100 subjects with diagnosed PE by using MSCT and/or V/P SPECT and with measured values of D-dimer.

Results

Out of 100 subjects, PE was not diagnosed in 37 subjects, while 63 subjects PE was diagnosed. All subjects with diagnosed PE were divided into 3 groups regarding the anatomical localization of thrombus: lobar, segmental or subsegmental. Average D-dimer values were calculated for all 3 groups. Statistical analysis showed that there was no significant difference in D-dimer values between subjects with different anatomical distribution of PE.

Conclusion

There is no significant difference in D-dimer values between subjects with different anatomical distribution od PE-lobar, segmental and subsegmental PE.

Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application

Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.

Recent Developments in Blood-Compatible Superhydrophobic Surfaces

Superhydrophobic surfaces, as indicated in the name, are highly hydrophobic and readily repel water. With contact angles greater than 150° and sliding angles less than 10°, water droplets flow easily and hardly wet these surfaces. Superhydrophobic materials and coatings have been drawing increasing attention in medical fields, especially on account of their promising applications in blood-contacting devices. Superhydrophobicity controls the interactions of cells with the surfaces and facilitates the flowing of blood or plasma without damaging blood cells. The antibiofouling effect of superhydrophobic surfaces resists adhesion of organic substances, including blood components and microorganisms. These attributes are critical to medical applications such as filter membranes, prosthetic heart valves, extracorporeal circuit tubing, and indwelling catheters. Researchers have developed various methods to fabricate blood-compatible or biocompatible superhydrophobic surfaces using different materials. In addition to being hydrophobic, these surfaces can also be antihemolytic, antithrombotic, antibacterial, and antibiofouling, making them ideal for clinical applications. In this review, the authors summarize recent developments of blood-compatible superhydrophobic surfaces, with a focus on methods and materials. The expectation of this review is that it will support the biomedical research field by providing current trends as well as future directions.

Trauma-induced pulmonary thromboembolism: What's update?

Trauma-induced pulmonary thromboembolism is the second leading cause of death in severe trauma patients. Primary fibrinolytic hyperactivity combined with hemorrhage and consequential hypercoagulability in severe trauma patients create a huge challenge for clinicians. It is crucial to ensure a safe anticoagulant therapy for trauma patients, but a series of clinical issues need to be answered first, for example, what are the risk factors for traumatic venous thromboembolism? How to assess and determine the status of coagulation dysfunction of patients? When is the optimal timing to initiate pharmacologic prophylaxis for venous thromboembolism? What types of prophylactic agents should be used? How to manage the anticoagulation-related hemorrhage and to determine the optimal timing of restarting chemoprophylaxis? The present review attempts to answer the above questions.

Direct (New) Oral Anticoagulants (DOACs): Drawbacks, Bleeding and Reversal

BACKGROUND AND OBJECTIVE

Direct (new) Oral Anticoagulants (DOACs) have emerged as a contemporary and promising option in the treatment of thromboses and VTE, while protecting the coagulation cascade against untoward bleeding events. They are used in the management and prophylaxis of Venous Thromboembolism (VTE) and other thrombotic diseases. The most prominent complication of these agents is bleeding. These agents have similar or lower rates of major intracranial hemorrhages, while they had a higher risk of major gastrointestinal bleeding when compared to warfarin. This manuscript is aimed to revise and update the literature findings to outline the side effects of DOACs in various clinical scenarios.

METHODS

A narrative review of currently published studies was performed. Online database searches were performed for clinical trials published before July 2021, on the efficacy and adverse effects attributed to the anticoagulant treatment, especially DOACs. A literature search via electronic databases was carried out, beginning with the usage of the agents in the Western Languages papers. The search terms initially included direct (new) oral anticoagulants, dabigatran, rivaroxaban, apixaban, edoxaban, idarucizumab, andexanet, prothrombin complex concentrates, and fresh frozen plasma. Papers were examined for methodological soundness before being included.

RESULTS

Severe bleeding episodes require aggressive interventions for successful management. Therefore, bleeding should be evaluated in special regard to the location and rate of hemorrhage, and total volume of blood loss. Patient's age, weight and organ dysfunctions (e.g., kidney/liver failure or chronic respiratory diseases) directly affect the clinical course of overdose.

CONCLUSION

Management recommendations for hemorrhage associated with DOAC use vary, depending on the class of the culprit agent (direct thrombin inhibitor vs. FXa inhibitor), the clinical status of the patient (mild/ moderate vs. severe/life-threatening), and capabilities of the institution. Specific reversal agents (i.e., idarucizumab and andexanet alfa) can be used if available, while prothrombin complex concentrates, fresh frozen plasma and/ or tranexamic acid can also be employed as nonspecific replacement agents in the management of DOAC-related bleeding diathesis.

An Update of the Efficacy and Comparative Characteristics of Direct (New) Oral Anticoagulants (DOACs)

Direct (New-generation) Oral Anticoagulants (DOACs) have emerged as effective agents which are used in place of vitamin-K antagonists in treatment and prophylaxis of Venous Thromboembolism (VTE), atrial fibrillation and other thrombotic diseases. Among them, the FIIa- direct thrombin inhibitor dabigatran and FXa inhibitors (rivaroxaban, apixaban, edoxaban) are the most broadly used. Anticoagulant dosing may differ under special considerations. The patients' physiological reserves, organ functional status and failures should be taken into account in clinical decision-making processes. The advantages and drawbacks of each specific agent should be weighed with special regard to metabolism, pharmacokinetics and pharmacodynamics, along with the efficiency of the agents in different indications. This article aims to review the most recent literature to highlight the usage and efficacy of the agents in different clinical conditions.

Application of pulmonary rehabilitation in patients with pulmonary embolism (Review)

As a common clinical emergency, pulmonary embolism (PE) is the third most fatal cardiovascular disease worldwide. Although current sophisticated medical technology has considerably improved the prognosis of patients with PE, they remain at risk of developing long-term complications such as post-PE syndrome. Pulmonary rehabilitation is of great value for patients with chronic lung diseases since it can improve their quality of life while also relieving clinical symptoms. Rehabilitation therapy has been demonstrated to improve recovery and prognosis of patients with PE. Due to short implementation time and the small number of studies, its effectiveness and safety in PE warrant further investigation. The present review focused on elucidating PE pathogenesis, post-PE syndrome and the clinical application of pulmonary rehabilitation in patients with PE.

In situ Pulmonary Artery Thrombosis: A Previously Overlooked Disease

Pulmonary thromboembolism (PTE) is the third leading cause of death in cardiovascular diseases. PTE is believed to be caused by thrombi detached from deep veins of lower extremities. The thrombi travel with systemic circulation to the lung and block pulmonary arteries, leading to sudden disruption of hemodynamics and blood gas exchange. However, this concept has recently been challenged by accumulating evidence demonstrating that de novo thrombosis may be formed in pulmonary arteries without deep venous thrombosis. On the other hand, chronic thromboembolic pulmonary hypertension (CTEPH), a subtype of pulmonary hypertension, could have different pathogenesis than traditional PTE. Therefore, this article summarized and compared the risk factors, the common and specific pathogenic mechanisms underlying PTE, in situ pulmonary artery thrombosis, and CTEPH at molecular and cellular levels, and suggested the therapeutic strategies to these diseases, aiming to facilitate understanding of pathogenesis, differential diagnosis, and precision therapeutics of the three pulmonary artery thrombotic diseases.