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 Acute treatment of venous thromboembolism

Blood ◽  
2020 ◽  
Vol 135 (5) ◽  
pp. 305-316 ◽  
Author(s):  
Cecilia Becattini ◽  
Giancarlo Agnelli
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Vitamin K ◽  
Acute Pulmonary Embolism ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulant Treatment ◽  
Specific Patient ◽  
Long Term Outcome ◽  
Patient Disposition

Abstract All patients with venous thromboembolism (VTE) should receive anticoagulant treatment in the absence of absolute contraindications. Initial anticoagulant treatment is crucial for reducing mortality, preventing early recurrences, and improving long-term outcome. Treatment and patient disposition should be tailored to the severity of clinical presentation, to comorbidities, and to the potential to receive appropriate care in the outpatient setting. Direct oral anticoagulants (DOACs) used in fixed doses without laboratory monitoring are the agents of choice for the treatment of acute VTE in the majority of patients. In comparison with conventional anticoagulation (parenteral anticoagulants followed by vitamin K antagonists), these agents showed improved safety (relative risk [RR] of major bleeding, 0.61; 95% confidence interval [CI], 0.45-0.83) with a similar risk of recurrence (RR, 0.90; 95% CI, 0.77-1.06). Vitamin K antagonists or low molecular weight heparins are still alternatives to DOACs for the treatment of VTE in specific patient categories such as those with severe renal failure or antiphospholipid syndrome, or cancer, respectively. In addition to therapeutic anticoagulation, probably less than 10% of patients require reperfusion by thrombolysis or interventional treatments; those patients are hemodynamically unstable with acute pulmonary embolism, and a minority of them have proximal limb-threatening deep vein thrombosis (DVT). The choice of treatment should be driven by the combination of evidence from clinical trials and by local expertise. The majority of patients with acute DVT and a proportion of selected hemodynamically stable patients with acute pulmonary embolism can be safely managed as outpatients.

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.

Risk assessment for recurrence and optimal agents for extended treatment of venous thromboembolism

Hematology ◽  
2013 ◽  
Vol 2013 (1) ◽  
pp. 471-477 ◽  
Author(s):  
Giancarlo Agnelli ◽  
Cecilia Becattini
Keyword(s):  
Venous Thromboembolism ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Bleeding Complications ◽  
First Episode ◽  
Anticoagulant Treatment ◽  
Extended Treatment ◽  
Large Phase ◽  
Estimated Risk

Abstract Venous thromboembolism (VTE) has a variable recurrence rate after the discontinuation of anticoagulant treatment. Therefore, the duration of anticoagulation therapy after a first VTE should be tailored to the estimated risk for recurrence. Anticoagulant therapy should be discontinued after the initial 3 to 6 months in those patients who had the first episode in association with temporary risk factors. The duration of anticoagulant therapy in patients who had a first episode of cancer-associated VTE should be reassessed over time based on the persistence of cancer and anticancer therapy. After 3 to 6 months of anticoagulant treatment for VTE, patients with a first unprovoked event and an estimated low risk for bleeding complications should be evaluated for indefinite treatment on an individualized basis. New oral anticoagulants have been evaluated for the extended treatment of VTE. Large phase 3 studies have shown that dabigatran, rivaroxaban, and apixaban are effective and safe in this indication. These agents do not require monitoring for dose adjustment and could make extended treatment more feasible and acceptable to patients.

scholarly journals An incidental finding of testicular seminoma in the context of acute pulmonary embolism: a case report

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Kaitlin J. Mayne ◽  
Emma Lewis ◽  
Lewis Vickers
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Clinical Guidelines ◽  
Acute Pulmonary Embolism ◽  
Incidental Finding ◽  
White Male ◽  
Vena Cava ◽  
Testicular Seminoma ◽  
Computed Tomography Scanning ◽  
The Right

Abstract Background Clinical guidelines do not recommend further investigation for occult malignancy in the scenario of unprovoked venous thromboembolism in the absence of additional clinical features suggestive of malignancy. We present the case of a young gentleman with pulmonary embolism who was diagnosed with testicular seminoma despite lack of symptoms or signs suggestive of malignancy. This is a unique case describing a scenario not well documented in existing literature where contravention of clinical guidelines had a potentially advantageous outcome for the patient. Case presentation A 37-year-old white male presented with seemingly unprovoked acute pulmonary embolism with right heart strain. He did not have any predisposing factors for venous thromboembolism and did not have any symptoms or signs suggestive of malignancy. Clinical guidelines do not recommend further investigation to screen for malignancy in this scenario. Despite this, our young, otherwise healthy patient proceeded to computed tomography scanning, resulting in the diagnosis of localized testicular seminoma. Testicular ultrasound described normal-sized testes (despite a discrete lesion in the right testis), suggesting this was not detectable by the patient or clinician on routine examination. The patient was anticoagulated and had an inferior vena cava filter inserted to facilitate orchidectomy followed by adjuvant radiotherapy. Conclusions This case highlights the importance of considering malignancy in seemingly unprovoked venous thromboembolism and the availability of guidelines to direct further investigation. Our patient’s treatment was not in line with clinical guidelines and was considered a “lucky find.”

scholarly journals Osteonecrosis of the Femoral Head in Patients with Hypercoagulability—From Pathophysiology to Therapeutic Implications

2021 ◽  
Vol 22 (13) ◽  
pp. 6801
Author(s):  
Elena Rezus ◽  
Bogdan Ionel Tamba ◽  
Minerva Codruta Badescu ◽  
Diana Popescu ◽  
Ioana Bratoiu ◽  
...  
Keyword(s):  
Femoral Head ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Medical Intervention ◽  
Rapid Progression ◽  
Anticoagulant Treatment ◽  
Early Medical Intervention ◽  
Therapeutic Implications ◽  
Early Stages ◽  
Hereditary Thrombophilia

Osteonecrosis of the femoral head (ONFH) is a debilitating disease with major social and economic impacts. It frequently affects relatively young adults and has a predilection for rapid progression to femoral head collapse and end-stage hip arthritis. If not diagnosed and treated properly in the early stages, ONFH has devastating consequences and leads to mandatory total hip arthroplasty. The pathophysiology of non-traumatic ONFH is very complex and not fully understood. While multiple risk factors have been associated with secondary ONFH, there are still many cases in which a clear etiology cannot be established. Recognition of the prothrombotic state as part of the etiopathogeny of primary ONFH provides an opportunity for early medical intervention, with implications for both prophylaxis and therapy aimed at slowing or stopping the progression of the disease. Hereditary thrombophilia and hypofibrinolysis are associated with thrombotic occlusion of bone vessels. Anticoagulant treatment can change the natural course of the disease and improve patients’ quality of life. The present work focused on highlighting the association between hereditary thrombophilia/hypofibrinolysis states and ONFH, emphasizing the importance of identifying this condition. We have also provided strong arguments to support the efficiency and safety of anticoagulant treatment in the early stages of the disease, encouraging etiological diagnosis and prompt therapeutic intervention. In the era of direct oral anticoagulants, new therapeutic options have become available, enabling better long-term compliance.

scholarly journals Anticoagulant treatment satisfaction with warfarin and direct oral anticoagulants for venous thromboembolism

2021 ◽  
Author(s):  
Margaret C. Fang ◽  
Alan S. Go ◽  
Priya A. Prasad ◽  
Jin-Wen Hsu ◽  
Dongjie Fan ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Treatment Satisfaction ◽  
Clinical Characteristics ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Treatment Options ◽  
Laboratory Monitoring ◽  
Routine Laboratory ◽  
Anticoagulant Treatment ◽  
The Difference

AbstractTreatment options for patients with venous thromboembolism (VTE) include warfarin and direct oral anticoagulants (DOACs). Although DOACs are easier to administer than warfarin and do not require routine laboratory monitoring, few studies have directly assessed whether patients are more satisfied with DOACs. We surveyed adults from two large integrated health systems taking DOACs or warfarin for incident VTE occurring between January 1, 2015 and June 30, 2018. Treatment satisfaction was assessed using the validated Anti-Clot Treatment Scale (ACTS), divided into the ACTS Burdens and ACTS Benefits scores; higher scores indicate greater satisfaction. Mean treatment satisfaction was compared using multivariable linear regression, adjusting for patient demographic and clinical characteristics. The effect size of the difference in means was calculated using a Cohen’s d (0.20 is considered a small effect and ≥ 0.80 is considered large). We surveyed 2217 patients, 969 taking DOACs and 1248 taking warfarin at the time of survey. Thirty-one point five percent of the cohort was aged ≥ 75 years and 43.1% were women. DOAC users were on average more satisfied with anticoagulant treatment, with higher adjusted mean ACTS Burdens (50.18 v. 48.01, p < 0.0001) and ACTS Benefits scores (10.21 v. 9.84, p = 0.046) for DOACs vs. warfarin, respectively. The magnitude of the difference was small (Cohen’s d of 0.29 for ACTS Burdens and 0.12 for ACTS Benefits). Patients taking DOACs for venous thromboembolism were on average more satisfied with anticoagulant treatment than were warfarin users, although the magnitude of the difference was small.

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

Trends in risk stratification, in-hospital management and mortality of patients with acute pulmonary embolism: an analysis from China pUlmonary thromboembolism REgistry Study (CURES)

2021 ◽  
pp. 2002963
Author(s):  
Zhenguo Zhai ◽  
Dingyi Wang ◽  
Jieping Lei ◽  
Yuanhua Yang ◽  
Xiaomao Xu ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Hospital Mortality ◽  
Acute Pulmonary Embolism ◽  
Severity Index ◽  
Disease Diagnosis ◽  
Initial Therapy ◽  
European Respiratory Society ◽  
Systemic Thrombolysis ◽  
All Cause Mortality

BackgroundSimilar trends of management and in-hospital mortality of acute pulmonary embolism (PE) have been reported in European and American populations. However, these tendencies were not clear in Asian countries.ObjectivesWe retrospectively analyzed the trends of risk stratification, management and in-hospital mortality for patients with acute PE through a multicenter registry in China (CURES).MethodsAdult patients with acute symptomatic PE were included between 2009 and 2015. Trends in disease diagnosis, treatment and death in hospital were fully analyzed. Risk stratification was retrospectively classified by hemodynamical status and the simplified Pulmonary Embolism Severity Index (sPESI) score according to the 2014 European Society of Cardiology/European Respiratory Society guidelines.ResultsAmong overall 7438 patients, the proportions with high (hemodynamically instability), intermediate (sPESI≥1) and low (sPESI=0) risk were 4.2%, 67.1% and 28.7%, respectively. Computed tomographic pulmonary angiography was the widely employed diagnostic approach (87.6%) and anticoagulation was the frequently adopted initial therapy (83.7%). Between 2009 and 2015, a significant decline was observed for all-cause mortality (from 3.1% to 1.3%, adjusted Pfor trend=0.0003), with a concomitant reduction in use of initial systemic thrombolysis (from 14.8% to 5.0%, Pfor trend<0.0001). The common predictors for all-cause mortality shared by hemodynamically stable and unstable patients were co-existing cancer, older age, and impaired renal function.ConclusionsThe considerable reduction of mortality over years was accompanied by changes of initial treatment. These findings highlight the importance of risk stratification-guided management throughout the nation.

scholarly journals Clinical Outcomes of Multiple Myeloma Patients Treated with Direct Oral Anticoagulants for Immunomodulatory Drug Associated Venous Thromboembolism

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4964-4964 ◽  
Author(s):  
Zachary Crowther ◽  
Jamie Doyle ◽  
Stanford Taylor ◽  
Nadia Ali
Keyword(s):  
Multiple Myeloma ◽  
Venous Thromboembolism ◽  
Clinical Outcomes ◽  
Chart Review ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Direct Result ◽  
Bleeding Complications ◽  
Bleeding Events ◽  
Growing Body

Introduction: Venous thromboembolism (VTE) is a common complication in multiple myeloma (MM) patients for several reasons; hematologic malignancy itself is a VTE risk factor and standard of care immunomodulatory drugs (IMiDs) in combination with dexamethasone (Dex) increase the risk further. This combination therapy has a mean VTE incidence of 21.5% in studies that did not use thromboprophylaxis and is recommended for all patients on IMiDs, although the optimal thromboprophylactic regimen remains uncertain. In clinical practice, aspirin (ASA) is commonly prescribed for VTE prophylaxis due to the ease of use. Despite this, the incidence of VTE remains between 7-14%. There is a growing body of literature supporting the efficacy and safety of direct oral anticoagulants (DOACs) for the treatment of VTE in cancer populations. We wanted to assess the incidence of VTE despite ASA prophylaxis at our institution and to further characterize the role of DOACs in the MM population. To do this, we performed a chart review of all MM patients who had been treated with lenalidomide and a DOAC, assessing for VTE development and patient outcomes. Methods: We conducted a retrospective chart review of patients with the diagnosis of MM treated with lenalidomide therapy at Fox Chase Cancer Center at Temple University Hospital or Cottman Avenue after Jan 1st, 2015 to July 2019. Eligible patients were identified through electronic medical record data mining for patients that had been diagnosed with MM, had been prescribed lenalidomide, had been taking ASA while on lenalidomide, and switched to rivaroxaban, edoxaban or apixaban. For comparison, the number of patients treated with lenalidomide and ASA who did not switch to a DOAC were also identified. Patient charts were reviewed for VTE development and bleeding complications after DOAC administration. Results: 132 patients were identified who had a diagnosis of MM and had been prescribed lenalidomide between Jan 1, 2015 and July 31, 2019. These patients were also prescribed aspirin except for three who were already on a DOAC prior to starting lenalidomide. Of the total 132 patients, only 17 were prescribed a DOAC. Six of the patients were on DOACs for reasons other than VTE (atrial fibrillation N=4, atrial flutter N=1, marantic endocarditis N=1). Eleven patients were started on DOACs for VTE; incidence of 8.3% in our myeloma population. However three of these VTEs occurred within one month of high dose melphalan chemotherapy and autologous stem cell rescue. These three patients had been off lenalidomide for over one month prior to VTE. Eight of the 17 patients with VTE developed clots in the setting of active MM and concurrent therapy with IMiD/Dex, independent of hospitalizations or other provoking factors. This is an incidence of 6.0% for VTE directly attributed to therapy. Six patients were on lenalidomide and Dex, while two patients developed VTE while on pomalidomide and Dex. No patients on lenalidomide experienced recurrent VTEs after being switched to therapeutic dose DOAC. One patient on pomalidomide/Dex did experience recurrent VTE. We examined all 17 patients who were on DOACs, 16 of which had been on IMiD and DOACs concurrently. Three had minor bleeding events which all resolved spontaneously. One patient had a major bleeding event, which was a fatal ruptured cerebral aneurysm while on a DOAC and ASA concurrently. Conclusion: The incidence of VTE in our patient population receiving IMiD/Dex while on ASA prophylaxis therapy was similar to what has been previously reported in the literature. We examined the clinical outcomes of 16 patients treated with IMiDs and DOACs concurrently and found few bleeding events. The one major bleed was likely precipitated by malignant hypertension and not a direct result of being on a DOAC. Taken together these results further support the growing body of evidence that DOACs are effective and safe treatments for VTE in cancer patients, including MM. Moving forward, our clinical experience with treatment dose DOACs supports the use of prophylactic dose DOACs to potentially further reduce the incidence of VTE in this high-risk population. Disclosures No relevant conflicts of interest to declare.

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