Risk of arterial cardiovascular events in patients after pulmonary embolism

Blood ◽  
2009 ◽  
Vol 114 (8) ◽  
pp. 1484-1488 ◽  
Author(s):  
Frederikus A. Klok ◽  
Inge C.M. Mos ◽  
Lisette Broek ◽  
Jouke T. Tamsma ◽  
Frits R. Rosendaal ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thrombosis ◽  
Vitamin K ◽  
Cardiovascular Events ◽  
Vitamin K Antagonists ◽  
Baseline Risk ◽  
Start Date ◽  
Risk Characteristics ◽  
The Moment ◽  
And Control

Abstract Studies have reported inconsistent evidence for an association between venous thrombosis and arterial cardiovascular events. We further studied the association between both diseases by comparing the occurrence of cardiovascular events in patients diagnosed with acute pulmonary embolism (PE) contrasted to patients with comparable baseline risk characteristics (patients in whom PE was clinically suspected but ruled out). Included were 259 patients with provoked PE, 95 patients with unprovoked PE, and 334 control patients without PE. Patients diagnosed with PE were treated with vitamin K antagonists for 6 months. Median follow-up was 4.2 years. Sixty-three arterial cardiovascular events were registered (incidence, 5.1/100 patient-years). Adjusted hazard ratio was not different between patients with all-cause PE and control patients (1.39, 95% confidence interval [CI], 0.83-2.3) but increased for patients with unprovoked PE versus both patients with provoked PE and control patients without PE (2.18; 95% CI, 1.1-4.5; and 2.62; 95% CI, 1.4-4.9, respectively). This effect was confirmed after redefining the study start date to the moment the vitamin K antagonists were discontinued. Our study underlines the association between unprovoked venous thrombosis and arterial cardiovascular events; however, risk differences between patients with provoked PE and patients in whom PE was clinically suspected but ruled out could not be demonstrated.

Idiopathic venous thrombosis

2006 ◽  
Vol 26 (01) ◽  
pp. 52-54 ◽  
Author(s):  
P. A. Kyrle
Keyword(s):  
Chronic Disease ◽  
Venous Thrombosis ◽  
Vitamin K ◽  
Clinical Benefit ◽  
Plasma Levels ◽  
Vitamin K Antagonists ◽  
Antithrombin Deficiency ◽  
Optimal Duration ◽  
Risk Of Treatment

SummaryVenous thrombosis is a chronic disease with a recurrence rate of approximately 30% within 5-8 years. The optimal duration of secondary thromboprophylaxis in these patients entails balancing the risk of recurrence against the risk of treatment-associated bleeding. There is agreement that patients with a first idiopathic venous thrombosis should receive vitamin K antagonists for at least 3-6 months. Convincing trials showing a clinical benefit in terms of morbidity or mortality with respect to expansion of anticoagulation beyond 6 months are lacking. Nevertheless, some subgroups of patients with venous thrombosis may benefit from indefinite anticoagulation. Thus, patients with antithrombin deficiency, combined or homozygous defects, more than one unprovoked episode of thrombosis, the lupus anticoagulant or high factor VIII plasma levels are good candidates for long-term prevention.

scholarly journals Influenza vaccination and risk for cardiovascular events: a nationwide self-controlled case series study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Abhijit Sen ◽  
Inger Johanne Bakken ◽  
Ragna Elise Støre Govatsmark ◽  
Torunn Varmdal ◽  
Kaare Harald Bønaa ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Influenza Vaccination ◽  
Lower Risk ◽  
Cardiovascular Events ◽  
Case Series ◽  
Baseline Risk ◽  
Inverse Association ◽  
Relative Risks ◽  
Case Series Study ◽  
Cardiovascular Medications

Abstract Background US and European guidelines diverge on whether to vaccinate adults who are not at high risk for cardiovascular events against influenza. Here, we investigated the associations between influenza vaccination and risk for acute myocardial infarction, stroke and pulmonary embolism during the 2009 pandemic in Norway, when vaccination was recommended to all adults. Methods Using national registers, we studied all vaccinated Norwegian individuals who suffered AMI, stroke, or pulmonary embolism from May 1, 2009 through September 30, 2010. We defined higher-risk individuals as those using anti-diabetic, anti-obesity, anti-thrombotic, pulmonary or cardiovascular medications (i.e. individuals to whom vaccination was routinely recommended); all other individuals were regarded as having lower-risk. We estimated incidence rate ratios with 95% CI using conditional Poisson regression in the pre-defined risk periods up to 180 days following vaccination compared to an unexposed time-period, with adjustment for season or daily temperature. Results Overall, we observed lower risk for cardiovascular events following influenza vaccination. When stratified by baseline risk, we observed lower risk across all three outcomes in association with vaccination among higher-risk individuals. In this subgroup, relative risks were 0.72 (0.59–0.88) for AMI, 0.77 (0.59–0.99) for stroke, and 0.73 (0.45–1.19) for pulmonary embolism in the period 1–14 days following vaccination when compared to the background period. These associations remained essentially the same up to 180 days after vaccination. In contrast, the corresponding relative risks among subjects not using medications were 4.19 (2.69–6.52), 1.73 (0.91–3.31) and 2.35 (0.78–7.06). Conclusion In this nationwide study, influenza vaccination was associated with overall cardiovascular benefit. This benefit was concentrated among those at higher cardiovascular risk as defined by medication use. In contrast, our results demonstrate no comparable inverse association with thrombosis-related cardiovascular events following vaccination among those free of cardiovascular medications at baseline. These results may inform the risk–benefit balance for universal influenza vaccination.

Management of pulmonary embolism in patients with cancer

ESC CardioMed ◽  
2018 ◽  
pp. 2790-2794
Author(s):  
Cihan Ay ◽  
Florian Posch
Keyword(s):  
Pulmonary Embolism ◽  
Vitamin K ◽  
Meta Analysis ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Standard Of Care ◽  
Current Standard ◽  
Patients With Cancer ◽  
High Index Of Suspicion ◽  
Excessive Anticoagulation

Pulmonary embolism (PE) is a frequent complication in patients with cancer. Clinicians have to maintain a high index of suspicion to reduce the large proportion of PEs that remain undiagnosed in the cancer population. Thrombolysis is not a standard treatment for haemodynamically unstable patients with cancer-associated PE because the risk of haemorrhage can be excessive. Anticoagulation with a low-molecular-weight heparin (LMWH) for at least 6 months is the current standard of care for the treatment of cancer-associated PE, while vitamin K antagonists are a reasonable second choice for patients with contraindications against LMWH or a strong preference towards an oral agent. Although an indirect network meta-analysis suggests that non-vitamin K-dependent oral anticoagulants may be comparably efficacious and safe as LMWH for treating PE in cancer patients, these agents cannot be recommended as a standard first-line treatment at this time because a head-to-head comparison to the standard of care has not yet been reported. Anticoagulation beyond 6 months is an emerging concept; however, the patient population that may benefit from this intervention still needs to be defined. Guidance statements facilitate the management of challenging patients with brain metastases, unsuspected PE, thrombocytopenia, and recurrent PE.

scholarly journals Time to therapeutic range (TtTR), anticoagulation control, and cardiovascular events in vitamin K antagonists–naive patients with atrial fibrillation

2018 ◽  
Vol 200 ◽  
pp. 32-36 ◽  
Author(s):  
Daniele Pastori ◽  
Pasquale Pignatelli ◽  
Francesco Cribari ◽  
Roberto Carnevale ◽  
Mirella Saliola ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Therapeutic Range ◽  
Cardiovascular Events ◽  
Vitamin K Antagonists ◽  
Anticoagulation Control

Enoxaparin monotherapy without oral anticoagulation to treat acute symptomatic pulmonary embolism

2003 ◽  
Vol 89 (06) ◽  
pp. 953-958 ◽  
Author(s):  
Joshua Beckman ◽  
Kelly Dunn ◽  
Arthur Sasahara ◽  
Samuel Goldhaber
Keyword(s):  
Pulmonary Embolism ◽  
Unfractionated Heparin ◽  
Vitamin K ◽  
Oral Anticoagulation ◽  
Standard Therapy ◽  
Vitamin K Antagonists ◽  
Hospital Length Of Stay ◽  
Hemorrhagic Complication ◽  
Oral Vitamin ◽  
Symptomatic Pulmonary Embolism

SummaryConventional anticoagulation for symptomatic pulmonary embolism consists of continuous intravenous unfractionated heparin as a “bridge” to oral anticoagulation. This strategy requires 5 days or more of intravenous heparin while oral vitamin K antagonists gradually achieve a therapeutic effect. Oral vitamin K antagonists require frequent blood testing to optimize dosing, and their interactions with other medications and foods make regulation difficult. Therefore we tested a different approach to therapy: long-term enoxaparin monotherapy.We randomized 60 symptomatic pulmonary embolism patients in a 2:1 ratio to 90 days of enoxaparin as monotherapy without warfarin (N=40) or to intravenous unfractionated heparin as a “bridge” to warfarin, target INR 2.0-3.0 (N=20). Enoxaparin patients received 1 mg/kg twice daily for 14 days during the acute phase followed by randomized assignment during the chronic phase to 1.0 mg/kg vs. 1.5 mg/kg once daily.In an intention-to-treat analysis, 3 of the 40 enoxaparin patients developed recurrent venous thromboembolism compared with 0 of 20 standard therapy patients (p = 0.54). One of the 40 enoxaparin patients had a major hemorrhagic complication compared with 2 of the 20 standard therapy patients (p = 0.26). Median hospital length of stay was shorter with enoxaparin compared to standard therapy (4 vs. 6 days) (p = 0.001). Following our study we can conclude that extended 3-month treatment with enoxaparin as monotherapy for symptomatic, acute pulmonary embolism is feasible and warrants further study in a large clinical trial.

scholarly journals Cost-Effectiveness of Dabigatran Compared to Vitamin-K Antagonists for the Treatment of Deep Venous Thrombosis in the Netherlands Using Real-World Data

PLoS ONE ◽  
2015 ◽  
Vol 10 (8) ◽  
pp. e0135054 ◽  
Author(s):  
Merlijn W. J. van Leent ◽  
Jelena Stevanović ◽  
Frank G. Jansman ◽  
Maarten J. Beinema ◽  
Jacobus R. B. J. Brouwers ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
The Netherlands ◽  
Venous Thrombosis ◽  
Deep Venous Thrombosis ◽  
Vitamin K ◽  
Real World ◽  
Vitamin K Antagonists ◽  
Real World Data ◽  
World Data

scholarly journals Risk of cerebral haemorrhage in patients treated with antithrombotic drugs. Focus on new oral anticoaguants

2011 ◽  
Vol 2 (1S) ◽  
pp. 77
Author(s):  
Giancarlo Agnelli
Keyword(s):  
Clinical Practice ◽  
Vitamin K ◽  
Cardiovascular Events ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Cerebral Haemorrhage ◽  
Antithrombotic Drugs ◽  
Thromboembolic Risk ◽  
Prevention And Treatment ◽  
Antithrombotic Efficacy

Antithrombotic drugs represent one of the leading pharmacological category used in clinical practice, especially in cardiovascular setting. Their demonstrated antithrombotic efficacy has been fundamental in the improvement of the management of many diseases related to athero-thrombotic or thromboembolic risk in prevention and treatment of cardiovascular events. Nonetheless, they are also associated with a not negligible haemorrhagic risk. Among these risks, intracranial bleeding represents the most feared, and should be kept in mind, prevented when possible and adequately managed when occurs. In this article the intracranial haemorrhagic risk associated to drugs vitamin K antagonists and new oral anticoagulants is reviewed.

scholarly journals Risk of cerebral haemorrhage in patients treated with antithrombotic drugs. Focus on new oral anticoaguants

2011 ◽  
Vol 2 (1S) ◽  
pp. 77-86
Author(s):  
Giancarlo Agnelli
Keyword(s):  
Clinical Practice ◽  
Vitamin K ◽  
Cardiovascular Events ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Cerebral Haemorrhage ◽  
Antithrombotic Drugs ◽  
Thromboembolic Risk ◽  
Prevention And Treatment ◽  
Antithrombotic Efficacy

Antithrombotic drugs represent one of the leading pharmacological category used in clinical practice, especially in cardiovascular setting. Their demonstrated antithrombotic efficacy has been fundamental in the improvement of the management of many diseases related to athero-thrombotic or thromboembolic risk in prevention and treatment of cardiovascular events. Nonetheless, they are also associated with a not negligible haemorrhagic risk. Among these risks, intracranial bleeding represents the most feared, and should be kept in mind, prevented when possible and adequately managed when occurs. In this article the intracranial haemorrhagic risk associated to drugs vitamin K antagonists and new oral anticoagulants is reviewed.

scholarly journals Unexpected acute pulmonary embolism in an old COVID-19 patient with warfarin overdose: a case report

2021 ◽  
Vol 5 (6) ◽  
Author(s):  
Maxime Coutrot ◽  
Maxime Delrue ◽  
Bérangère S Joly ◽  
Virginie Siguret
Keyword(s):  
Pulmonary Embolism ◽  
Case Report ◽  
Vitamin K ◽  
Vitamin K Antagonists ◽  
International Normalized Ratio ◽  
Heparin Therapy ◽  
High Incidence ◽  
Severe Epistaxis ◽  
Repeated Administrations ◽  
Concurrent Medication

Abstract Background Severe acute respiratory syndrome coronavirus 2 disease is strongly associated with a high incidence of thrombotic events. Anticoagulation could be a cornerstone in successfully managing severe forms of coronavirus disease 2019 (COVID-19). However, optimal anticoagulant dosing in elderly patients is challenging because of high risk of both thrombosis and bleeding. Case summary We present here the case of an 89-year-old patient receiving warfarin for atrial fibrillation and valvular heart disease, admitted to the intensive care unit for respiratory failure due to COVID-19. The patient presented with a severe epistaxis associated with warfarin overdose [international normalized ratio (INR) > 10]. After a successful initial reversal using vitamin K per os, INR values greatly fluctuated up to 10, requiring repeated administrations of vitamin K. Despite starting low-molecular-weight heparin therapy at therapeutic dose as soon as INR value was below 2.0, the patient further developed an acute bilateral and proximal pulmonary embolism concomitantly with a sharp D-dimer increase. The combination of azithromycin intake, a known inhibitor of CYP2C9, with the presence of CYP2C9*2 and −1639G>A VKORC1, two variants associated with warfarin hypersensitivity, have likely contributed to explain the warfarin overdose and the difficulty to reverse warfarin effect in this patient. Discussion This case report illustrates the complexity of COVID-19 pathophysiology and its management for physicians, especially in patients receiving vitamin K antagonists (VKAs). Infection, concurrent medication use, and pharmacogenetic factors involved in VKA metabolism and pharmacodynamics may lead to a loss of control of anticoagulation. Pulmonary embolism should still be considered in COVID-19 patients even with effective or overdosed anticoagulant therapy.

An Assay of the Antithrombotic Action of Warfarin: Its Correlation with the Inhibition of Stasis Thrombosis in Rabbits

1978 ◽  
Vol 40 (02) ◽  
pp. 486-498 ◽  
Author(s):  
Stanford Wessler ◽  
Sanford N Gitel ◽  
Harry Bank ◽  
Uri Martinowitz ◽  
Ronald C Stephenson
Keyword(s):  
Venous Thrombosis ◽  
Vitamin K ◽  
Inhibitory Activity ◽  
Reaction Rate ◽  
Antithrombin Iii ◽  
Factor Ix ◽  
Factor X ◽  
Similar Increase ◽  
Antithrombotic Effect ◽  
And Control

SummaryNo assay of the antithrombotic action of warfarin has been available. Experiments were performed to determine whether Xa inhibitory activity - the reaction rate between activated factor X (Xa) and antithrombin III - could serve this function. 105 warfarin-treated patients demonstrated a significant 18% increase in Xa inhibitory activity compared to 51 controls, p <0.001, without any correlation between this activity and the prothrombin times in the treated patients. A similar increase in Xa inhibitory activity was obtained in rabbits treated with 2 mg of warfarin per day compared to control animals, p <0.001. Employing an assay which routinely produced venous thrombosis after clotting proteases were infused into warfarin-treated and control rabbits, three observations were made. 1. The extent of stasis thrombosis induced by injection of thrombin, Xa or activated factor IX, was significantly reduced in warfarin-treated rabbits compared to control animals, independent of alteration in the four established vitamin K-dependent zymogens. 2. In the rabbit, significant changes in prothrombin times and prothrombin and factor X activities preceded by 5 days both the increase in Xa inhibitory activity and the antithrombotic effect which became significant on the sixth day. 3. The correlation between Xa inhibitory activity of warfarin-treated rabbits and the extent of stasis thrombosis induced by Xa was significant, p<0.05. Xa inhibitory activity is one measure of the antithrombotic action of warfarin.

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