scholarly journals Risk stratification and management of acute pulmonary embolism

Hematology ◽  
2016 ◽  
Vol 2016 (1) ◽  
pp. 404-412 ◽  
Author(s):  
Cecilia Becattini ◽  
Giancarlo Agnelli
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Clinical Management ◽  
Acute Pulmonary Embolism ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Management Strategies ◽  
Vena Cava ◽  
Low Risk ◽  
Bleeding Complications

Abstract The clinical management of patients with acute pulmonary embolism is rapidly changing over the years. The widening spectrum of clinical management strategies for these patients requires effective tools for risk stratification. Patients at low risk for death could be candidates for home treatment or early discharge. Clinical models with high negative predictive value have been validated that could be used to select patients at low risk for death. In a major study and in several meta-analyses, thrombolysis in hemodynamically stable patients was associated with unacceptably high risk for major bleeding complications or intracranial hemorrhage. Thus, the presence of shock or sustained hypotension continues to be the criterion for the selection of candidates for thrombolytic treatment. Interventional procedures for early revascularization should be reserved to selected patients until further evidence is available. No clinical advantage is expected with the insertion of a vena cava filter in the acute-phase management of patients with acute pulmonary embolism. Direct oral anticoagulants used in fixed doses without laboratory monitoring showed similar efficacy (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.70-1.12) and safety (OR, 0.89; 95% CI, 0.77-1.03) in comparison with conventional anticoagulation in patients with acute pulmonary embolism. Based on these results and on their practicality, direct oral anticoagulants are the agents of choice for the treatment of the majority of patients with acute pulmonary embolism.

scholarly journals Contemporary clinical management of acute pulmonary embolism: the COPE study

2022 ◽  
Author(s):  
Cecilia Becattini ◽  
Giancarlo Agnelli ◽  
Aldo Pietro Maggioni ◽  
Francesco Dentali ◽  
Andrea Fabbri ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Acute Pulmonary Embolism ◽  
Management Strategies ◽  
Treatment Strategies ◽  
Low Risk ◽  
Contemporary Management ◽  
Secondary Study ◽  
European Society Of Cardiology ◽  
Acute Pe

Abstract Background New management, risk stratification and treatment strategies have become available over the last years for patients with acute pulmonary embolism (PE), potentially leading to changes in clinical practice and improvement of patients’ outcome. Methods The COntemporary management of Pulmonary Embolism (COPE) is a prospective, non-interventional, multicentre study in patients with acute PE evaluated at internal medicine, cardiology and emergency departments in Italy. The aim of the COPE study is to assess contemporary management strategies in patients with acute, symptomatic, objectively confirmed PE concerning diagnosis, risk stratification, hospitalization and treatment and to assess rates and predictors of in-hospital and 30-day mortality. The composite of death (either overall or PE-related) or clinical deterioration at 30 days from the diagnosis of PE, major bleeding occurring in hospital and up to 30 days from the diagnosis of PE and adherence to guidelines of the European Society of Cardiology (ESC) are secondary study outcomes. Participation in controlled trials on the management of acute PE is the only exclusion criteria. Expecting a 10–15%, 3% and 0.5% incidence of death for patients with high, intermediate or low-risk PE, respectively, it is estimated that 400 patients with high, 2100 patients with intermediate and 2500 with low-risk PE should be included in the study. This will allow to have about 100 deaths in study patients and will empower assessment of independent predictors of death. Conclusions COPE will provide contemporary data on in-hospital and 30-day mortality of patients with documented PE as well as information on guidelines adherence and its impact on clinical outcomes. Trail registration NCT number: NCT03631810.

scholarly journals Anticoagulant treatment for acute pulmonary embolism: a pathophysiology-based clinical approach

2015 ◽  
Vol 45 (4) ◽  
pp. 1142-1149 ◽  
Author(s):  
Giancarlo Agnelli ◽  
Cecilia Becattini
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Right Ventricular ◽  
Acute Pulmonary Embolism ◽  
Wide Spectrum ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Adverse Outcomes ◽  
Clinical Approach

The management of patients with acute pulmonary embolism is made challenging by its wide spectrum of clinical presentation and outcome, which is mainly related to patient haemodynamic status and right ventricular overload. Mechanical embolic obstruction and neurohumorally mediated pulmonary vasoconstriction are responsible for right ventricular overload. The pathophysiology of acute pulmonary embolism is the basis for risk stratification of patients as being at high, intermediate and low risk of adverse outcomes. This risk stratification has been advocated to tailor clinical management according to the severity of pulmonary embolism.Anticoagulation is the mainstay of the treatment of acute pulmonary embolism. New direct oral anticoagulants, which are easier to use than conventional anticoagulants, have been compared with conventional anticoagulation in five randomised clinical trials including >11 000 patients with pulmonary embolism. Patients at high risk of pulmonary embolism (those with haemodynamic compromise) were excluded from these studies. Direct oral anticoagulants have been shown to be as effective and at least as safe as conventional anticoagulation in patients with pulmonary embolism without haemodynamic compromise, who are the majority of patients with this disease. Whether these agents are appropriate for the acute-phase treatment of patients at intermediate–high risk pulmonary embolism (those with both right ventricle dysfunction and injury) regardless of any risk stratification remains undefined.

scholarly journals Early, real-world experience with direct oral anticoagulants in the treatment of intermediate-high risk acute pulmonary embolism

2017 ◽  
Vol 36 (11) ◽  
pp. 801-806
Author(s):  
Sónia Martins Santos ◽  
Susana Cunha ◽  
Rui Baptista ◽  
Sílvia Monteiro ◽  
Pedro Monteiro ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Real World ◽  
Acute Pulmonary Embolism ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants

scholarly journals CURRENT VIEW ON ANTICOAGULANT AND THROMBOLYTIC TREATMENT OF ACUTE PULMONARY EMBOLISM

2019 ◽  
Vol 9 (5) ◽  
pp. 348-366
Author(s):  
G. G. Taradin ◽  
G. A. Ignatenko ◽  
N. T. Vatutin ◽  
I. V. Kanisheva
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Acute Pulmonary Embolism ◽  
Oral Anticoagulants ◽  
Medical Intervention ◽  
Bleeding Complications ◽  
Current View ◽  
Anticoagulant Treatment ◽  
Thrombolytic Treatment ◽  
Systemic Thrombolysis

The presented review concerns contemporary views on specific aspects of anticoagulant and thrombolytic treatment of venous thromboembolism and mostly of acute pulmonary embolism. Modern classifications of patients with acute pulmonary embolism, based on early mortality risk and severity of thromboembolic event, are reproduced. The importance of multidisciplinary approach to the management of patients with pulmonary embolism with the assistance of cardiologist, intensive care specialist, pulmonologist, thoracic and cardiovascular surgeon, aimed at the management of pulmonary embolism at all stages: from clinical suspicion to the selection and performing of any medical intervention, is emphasized. Anticoagulant treatment with the demonstration of results of major trials, devoted to efficacy and safety evaluation of anticoagulants, is highlighted in details. Moreover, characteristics, basic dosage and dosage scheme of direct (new) oral anticoagulants, including apixaban, rivaroxaban, dabigatran, edoxaban and betrixaban are described in the article. In particular, the management of patients with bleeding complications of anticoagulant treatment and its application in cancer patients, who often have venous thromboembolism, is described. Additionally, modern approaches to systemic thrombolysis with intravenous streptokinase, urokinase and tissue plasminogen activators are presented in this review. The indications, contraindications, results of clinical trials devoted to various regimens of thrombolytic therapy, including treatment of pulmonary embolism by lower doses of fibrinolytic agents, are described.

scholarly journals Outpatient Treatment in Low-Risk Pulmonary Embolism Patients Receiving Direct Acting Oral Anticoagulants Is Associated With Cost Savings

2020 ◽  
Vol 26 ◽  
pp. 107602962093735
Author(s):  
Raein Ghazvinian ◽  
Johan Elf ◽  
Sofia Löfvendahl ◽  
Jan Holst ◽  
Anders Gottsäter
Keyword(s):  
Pulmonary Embolism ◽  
Outpatient Treatment ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Cost Savings ◽  
Severity Index ◽  
Low Risk ◽  
Potential Cost ◽  
Total Cost ◽  
Outpatient Group

Direct oral anticoagulants (DOAC) are first line treatment for pulmonary embolism (PE). Treatment of acute PE is traditionally hospital based and associated with high costs. The aims of this study were to evaluate potential cost savings with outpatient DOAC treatment compared to inpatient DOAC treatment in patients with low risk PE. A retrospective study in patients with DOAC treated low risk PE (simplified pulmonary severity index [sPESI] ≤ 1) admitted to 8 hospitals during 2013-2015. Health care costs were compared in 223(44%) patients treated as outpatients and 287(56%) treated in hospital. Total cost per patient was 8293 EUR in the inpatient group, and 2176 EUR in the outpatient group (p < 0.001). Total costs for inpatients were higher (p < 0.001) compared to outpatients in both subgroups with sPESI 0 and 1. In multivariate analysis, type of treatment (in- or outpatient, p = < 0.001) and sPESI group (0 or 1, p = < 0.001) were associated with total cost below or above median, whereas age (p = 0.565) and gender (p = 0.177) was not. Adherence to guidelines recommending outpatient treatment with DOAC in patients with low risk PE enables significant savings.

scholarly journals Early, real-world experience with direct oral anticoagulants in the treatment of intermediate-high risk acute pulmonary embolism

2017 ◽  
Vol 36 (11) ◽  
pp. 801-806 ◽  
Author(s):  
Sónia Martins Santos ◽  
Susana Cunha ◽  
Rui Baptista ◽  
Sílvia Monteiro ◽  
Pedro Monteiro ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Real World ◽  
Acute Pulmonary Embolism ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants

148 Acute Pulmonary Embolism Patients With Low Risk Stratification Scores but Concerning CTPE Findings

2020 ◽  
Vol 76 (4) ◽  
pp. S57-S58
Author(s):  
W.J. Schaeffer ◽  
K.A. Grace ◽  
J.A. Cranford ◽  
K.E. Kocher ◽  
G.D. Barnes ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Acute Pulmonary Embolism ◽  
Low Risk

scholarly journals Developments in the management and treatment of pulmonary embolism

2015 ◽  
Vol 24 (137) ◽  
pp. 484-497 ◽  
Author(s):  
Rachel Limbrey ◽  
Luke Howard
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Primary Care Providers ◽  
Similar Efficacy ◽  
Individual Risk ◽  
Care Providers ◽  
Outpatient Services ◽  
Risk Patients

Pulmonary embolism (PE) is a serious and costly disease for patients and healthcare systems. Guidelines emphasise the importance of differentiating between patients who are at high risk of mortality (those with shock and/or hypotension), who may be candidates for thrombolytic therapy or surgery, and those with less severe presentations. Recent clinical studies and guidelines have focused particularly on risk stratification of intermediate-risk patients. Although the use of thrombolysis has been investigated in these patients, anticoagulation remains the standard treatment approach. Individual risk stratification directs initial treatment. Rates of recurrence differ between subgroups of patients with PE; therefore, a review of provoking factors, along with the risks of morbidity and bleeding, guides the duration of ongoing anticoagulation. The direct oral anticoagulants have shown similar efficacy and, in some cases, reduced major bleeding compared with standard approaches for acute treatment. They also offer the potential to reduce the burden on patients and outpatient services in the post-hospital phase. Rivaroxaban, dabigatran and apixaban have been shown to reduce the risk of recurrent venous thromboembolism versus placebo, when given for >12 months. Patients receiving direct oral anticoagulants do not require regular coagulation monitoring, but follow-up, ideally in a specialist PE clinic in consultation with primary care providers, is recommended.

scholarly journals Outpatient treatment in low-risk pulmonary embolism patients receiving direct acting oral anticoagulants is associated with cost savings.

2020 ◽  
Author(s):  
Raein Ghazvinian ◽  
Johan Elf ◽  
Anders Gottsäter ◽  
Sofie Löfvendahl ◽  
Jan Holst
Keyword(s):  
Pulmonary Embolism ◽  
Outpatient Treatment ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Cost Savings ◽  
Low Risk ◽  
Potential Cost ◽  
Multicenter Cohort Study ◽  
Total Cost ◽  
Outpatient Group

Abstract Background Direct oral anticoagulants (DOAC) are first line treatment for pulmonary embolism (PE). Treatment of acute PE is traditionally hospital based and associated with high costs, in spite of recent guidelines suggesting outpatient treatment for low-risk patients. The aims of this study were to evaluate potential cost savings with outpatient DOAC treatment of patients with low risk PE compared to DOAC treatment of low risk PE patients in hospital. Methods A retrospective comparatory multicenter cohort study in patients with low risk PE (simplified pulmonary severity index [sPESI]) ≤ 1 admitted to the eight hospitals in Sweden´s southernmost healthcare region during 2013-2015, and treated with DOAC. Local criteria guiding outpatient treatment had been used, and sPESI was calculated retrospectively. Health care costs were analysed in the 223 (44%) patients treated as outpatients and the 287 (56%) treated in hospital. Results Total cost per patient was 7334 EUR in the inpatient group, and 2088 EUR in the outpatient group (p<0.001). In multivariate analysis, type of treatment (in- or outpatient, p=<0.001) and sPESI group (0 or 1, p=<0.001) were significantly associated with total cost below or above median, whereas age (p=0.565) and gender (p=0.177) was not. Total cost for inpatients was higher (p<0.001) compared to outpatients in subgroups with sPESI 0 and 1. Conclusion Better adherence to current guidelines recommending outpatient treatment with DOAC in patients with low risk PE would potentially lead to significant savings in healthcare expenditure.

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