Medical Management Of Pulmonary Embolism

2018 ◽  
Author(s):  
Aaron B Waxman ◽  
Andrew J Schissler
Keyword(s):  
Pulmonary Embolism ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Pregnant Patient ◽  
Reperfusion Therapy ◽  
Medical Attention ◽  
Medium Risk ◽  
Evidenced Based ◽  
Acute Pe

Acute pulmonary embolism (PE) can be fatal and requires prompt medical attention. This chapter reviews the treatment of acute PE, including a detailed report of the acute- and long-term management of high-risk (“massive”), medium-risk (“submassive”), and low-risk thrombi. It summarizes the reperfusion therapies available in hemodynamically unstable patients with massive PEs such as thrombolysis, embolectomy, and percutaneous catheter-directed treatment. There is further in-depth examination of the various anticoagulants available including parenteral therapies, vitamin K antagonists, and direct oral anticoagulants. Recommendations on the treatment duration are discussed. Other considerations are described, including how management changes in the pregnant patient with acute PE, when venous filters should be considered and whether to initiate treatment before confirming a diagnosis. Overall this chapter serves as an excellent evidenced-based guide to better manage the various presentations of acute PE.   This review contains 3 figures, 5 tables and 47 references Key Words: anticoagulation, embolectomy, PE, pulmonary embolism, reperfusion therapy, thrombolysis, treatment

scholarly journals Novel Anticoagulant Treatment for Pulmonary Embolism with Direct Oral Anticoagulants Phase 3 Trials and Clinical Practice

2018 ◽  
Vol 35 (02) ◽  
pp. 83-91 ◽  
Author(s):  
Liselotte van der Pol ◽  
Albert Mairuhu ◽  
Christophe Leroyer ◽  
Francis Couturaud ◽  
Menno Huisman ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Clinical Practice ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Similar Efficacy ◽  
Ease Of Use ◽  
Therapeutic Management ◽  
Published Data ◽  
Phase 3

AbstractAnticoagulant therapy is the cornerstone of therapeutic management in acute venous thromboembolism (VTE), consisting of pulmonary embolism and deep vein thrombosis. Direct oral anticoagulants (DOACs) have become the standard of care because of their good safety profile and ease of use in clinical practice. Indeed, phase 3 randomized trials (AMPLIFY, EINSTEIN, RECOVER, and HOKUSAI studies) showed that DOACs provided a similar efficacy and a better safety than conventional treatment with parenteral heparin with overlapping loading dose of vitamin K antagonists in acute VTE therapeutic management. The results of published data from real-world registries confirm the safety and efficacy of DOACs demonstrated in the phase 3 trials.

P6464Acute pulmonary embolism in Argentina. CONAREC XX registry

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
I M Cigalini ◽  
C E Scatularo ◽  
J C C Jauregui ◽  
J I Ortego ◽  
D Cornejo ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Hospital Mortality ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Hemodynamic Instability ◽  
Low Risk ◽  
P Value ◽  
Acute Pe

Abstract Background Pulmonary embolism (PE) represents the third cause of cardiovascular death and one of the leading causes of preventable in-hospital mortality. However, there is lack of information about this entity in our country. Purpose To describe baseline characteristics, in-hospital evolution and treatments among patients (P) admitted for acute PE in Argentina. Methods A prospective multicentric registry of P with acute PE was conducted in 75 academic centers between October 2016 and November 2017. Conventional analysis was used for descriptive and comparative statistics, with a p value <0.05 considered as significant. Cross audit was performed at 20% of participating centers. Results We included 684 consecutive P with an average age of 63,8 years (SD 16,8), with slight majority of female sex (57%). PE was the reason for admission in 484 (71%) of the cases; 68% of those others who developed PE as a complication during hospital stay were under adequate venous thromboembolism prophylaxis. The most frequent predisposing factors were obesity (34%), recent hospitalization (34%), transient rest (30%) and active cancer (22%). Multislice computed tomography was the diagnostic method of choice (81%). An echocardiogram was performed in 625 P (91%), showing right ventricular dilatation or dysfunction in 41% and 35% of the cases, respectively. After initial diagnosis, P were stratified as low risk (24%), intermediate-low risk (34%), intermediate-high risk (27%) and high risk (15%). Anticoagulation was indicated in 661 (97%), mainly with low-molecular-weight heparins (LMWH) (59%) as initial strategy. Reperfusion with either thrombolytics or mechanical therapies was performed in 91 (13%) cases. However, only 50 of the 102 P who presented with hemodynamic instability received any reperfusion therapy (49%). Overall in-hospital mortality was 12%, mainly related to PE (51%), with significant differences according to risk stratification (p<0,01) (Figure 1). 579 out of 601 survivors received anticoagulants at discharge: 60% vitamin K antagonists, 21% LMWH and 19% direct oral anticoagulants (49% Rivaroxaban, 34% Apixaban and 17% Dabigatran). Mortality according risk stratification Conclusions PE presents with high in-hospital mortality in our setting mainly due to the embolic event. This finding could be related to a low use of reperfusion therapies in P with hemodynamic instability, reflecting low adherence to guideline recommendations even in academic centers. This issue should be taken into consideration to improve PE prognosis in Argentina.

scholarly journals Modern position of anticoagulants in acute pulmonary embolism: achievements, limitations, prospects

2019 ◽  
Vol 27 (1) ◽  
pp. 93-106 ◽  
Author(s):  
Yuliya V. Terekhovskaya ◽  
Viktor G. Okorokov ◽  
Natal`ya N. Nikulina
Keyword(s):  
Pulmonary Embolism ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Evidence Base ◽  
Sufficient Evidence ◽  
Aim Analysis ◽  
The Russian Federation ◽  
Choice Of Therapy

Pulmonary embolism (PE) is the third most common cardiovascular disease after myocardial infarction and stroke, and one of the leading causes of death in Europe. Aim. Analysis of the modern scientific base concerning the possibilities and limitations of use of anticoagulant therapy (ACT) at different stages of medical care in PE depending on risk stratification. The article reflects the position of modern Clinical guidelines, the results of recent studies and some controversial and unresolved issues of the ACT for PE. Conclusion. Currently, a sufficient evidence base has been obtained in favor of the fact that the ACT increases the survival rate of patients with past PE even taking into account an increase in the frequency of hemorrhagic complications; the choice of therapy schemes for PE is based on the stratification of the risk of patients; the schemes of the ACT for the acute period, for the subsequent prevention of relapses of PE are developed, the evidence of the expediency of its further prolongation (a study of rivaroxaban at a dose of 10 mg for prolonged therapy) is obtained. Use of direct oral anticoagulants (DOAC) in patients with past PE has a more optimal efficacy/safety profile compared to vitamin K antagonists (VCA). However, not all the issues of the ACT for PE are solved, therefore the prospects for the study and application of the ACT in PE include: reasonability of obtaining substantiated data on use of DOAC after thrombolysis, in patients with reduced renal function, with antiphospholipid syndrome, with neoplastic diseases, and also for determination of exact periods of extended therapy. It is necessary to search for additional prognostic factors for PE, to study and register specific antidotes for DOAC (currently in the Russian Federation a specific antidote to dabigatran Idarucizumab-registered); to increase the share of DOAC in the ACT as drugs with a proven best profile efficacy/safety compared to VCA.

scholarly journals Do women with venous thromboembolism bleed more than men during anticoagulation? Data from the real-life, prospective START-Register

2021 ◽  
Vol 12 ◽  
pp. 204209862110629
Author(s):  
Gualtiero Palareti ◽  
Cristina Legnani ◽  
Emilia Antonucci ◽  
Benilde Cosmi ◽  
Anna Falanga ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Vaginal Bleeding ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Hormonal Contraception ◽  
Real Life ◽  
Renal Diseases ◽  
Bleeding Events ◽  
Risk Of Bleeding

Background: Venous thromboembolism (VTE) is a frequent and serious disease that requires immediate and long-term anticoagulant treatment, which is inevitably associated with a risk of bleeding complications. Some studies, though not all, reported a higher risk of bleeding in female patients treated with either old anticoagulants [vitamin k antagonists (VKAs)] or recent anticoagulants [direct oral anticoagulants (DOACs)]. Furthermore, analyses of clinical trials reported an abnormal vaginal bleeding in women of reproductive age treated with DOACs. This study aimed at comparing the risk of bleeding in an inception cohort of VTE women and men included in a prospective observational registry. Methods: Baseline characteristics and bleeding events occurring during anticoagulation in patients of both sexes, included in the START-Register after a first VTE, were analyzed. Results: In all, 1298 women were compared with 1290 men. Women were older and more often had renal diseases; their index events were often provoked (often by hormonal contraception and pregnancy), and more frequently presented as isolated pulmonary embolism (PE). The rate of bleeding was similar in women (2.9% patient-years) and men (2.1% patient-years), though it was higher when uterine bleeds were included (3.5% patient-years, p = 0.0141). More bleeds occurred in VKA- than DOAC-treated patients (6.4% versus 2.6%, respectively; p = 0.0013). At multivariate analysis, age ⩾ 75 years was associated with higher prevalence of bleeds. Conclusion: The occurrence of bleeding was not different between women and men during anticoagulation after VTE. Only after inclusion of vaginal/uterine bleeds, the rate of bleeding was higher in women. The incidence of bleeding was higher in women treated with VKAs. Plain Language Summary The risk of bleeding in women anticoagulated for deep vein thrombosis or pulmonary embolism is not higher than that in men, except for vaginal bleeding Background: The occurrence of a venous thromboembolic event (VTE, including deep vein thrombosis and pulmonary embolism) necessarily requires a period of at least 3–6 months of treatment with anticoagulant drugs [either vitamin k antagonists (VKA) or, more recently, direct oral anticoagulants (DOACs)]. Anticoagulation therapy, however, is associated with a risk of bleeding that is influenced by several factors. Sex is one of these factors as some authors have hypothesized that women are at higher risk than men. Furthermore, some studies have recently found more vaginal bleeding in VTE women treated with a DOAC compared with those who received VKAs. Methods: The present study aimed to compare the frequency of bleeds occurring in women and in men who were treated with DOACs or VKAs for a first VTE event and followed in real-life conditions. Since the beginning of their anticoagulant treatment, the patients were included in a prospective, multicenter, observational registry (the START-Register), and bleeding events were recorded. Results: A total of 1298 women were compared with 1290 men. Women were older and more often were affected by renal diseases; their VTE events were often associated with risk factors (especially hormonal contraception and pregnancy) and presented as isolated pulmonary embolism. The rate of all bleeding events (including major, non-major but clinically relevant, and minor bleeds) was higher in women (3.5% patient-years) than in men (2.1% patient-years, p = 0.0141); however, the difference was no longer statistically significant after exclusion of uterine bleeds (2.9% patient years). More bleeding occurred in women receiving VKA as anticoagulant drug compared with those treated with a DOAC (6.4% versus 2.6%, respectively; p = 0.0013). At multivariate analysis, age ⩾ 75 years was associated with higher prevalence of bleeds. Conclusion: In conclusion, we found that in real-life conditions, the rate of bleeding events occurring during anticoagulation after a VTE episode is not higher in women than in men. Only after inclusion of vaginal bleeds, the rate of bleeding was higher in women. More bleeds (including vaginal bleeding) occurred in women treated with VKA than DOACs.

scholarly journals Late Pulmonary Embolism after COVID-19 Pneumonia despite Adequate Rivaroxaban Treatment

2020 ◽  
Author(s):  
Giuseppe Di Tano ◽  
Luigi Moschini ◽  
Marco Loffi ◽  
Gianluca Galeazzi ◽  
Sophie Testa ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Acute Infection ◽  
Chronic Atrial Fibrillation ◽  
Drug Plasma ◽  
Thrombotic Complications ◽  
Underlying Mechanisms ◽  
Drug Plasma Levels

Introduction: SARS-CoV-2 infection may predispose patients to thrombotic disease. Patients with COVID-19 pneumonia who are receiving non-vitamin K antagonists or direct oral anticoagulants for chronic disease are usually switched to heparin treatment during hospitalization. However, information about the most appropriate antithrombotic therapy after the acute infection phase is lacking. Case Description: We report the case of a patient with chronic atrial fibrillation who was recently hospitalized for severe COVID-19 pneumonia. Four weeks after discharge he experienced an episode of an acute pulmonary embolism while on rivaroxaban therapy with adequate drug plasma levels, and in the absence of strong predisposing risk factors. Conclusion: This case highlights the risk of thrombotic complications after COVID-19 infection, raises some concern about their underlying mechanisms, and supports the use of effective anti-thrombotic therapy.

P5585Determinants of the use of direct oral anticoagulants in acute pulmonary thromboembolism in argentina

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M I Bernal ◽  
C E Scatularo ◽  
I M Cigalini ◽  
J C C Jauregui ◽  
J I Ortego ◽  
...  
Keyword(s):  
Heart Failure ◽  
Health Insurance ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Health Coverage ◽  
History Of ◽  
Lower Severity ◽  
Ischemic Attack ◽  
Acute Pe

Abstract Background In the last decade, direct oral anticoagulants (DOACs) were incorporated as an alternative for anticoagulation in patients with venous thromboembolism. Although they have a better pharmacologic profile than vitamin K antagonists (VKAs), the use of these drugs is not massive. Purpose Assess the rate of use of DOACs in acute pulmonary embolism (PE) patients (P) in Argentina and analyze the determinants of their use. Methods Based on a registry of 684 P admitted for acute PE in 75 academic centers between October 2016 and November 2017, we performed an analysis of DOACs prescription at discharge. A conventional statistical analysis was performed, to assess the differences between the P that received DOACs or other anticoagulants using univariate and multivariate models. Results 579 of 601 P who survived were discharged with anticoagulant treatment: 348 (60%) received VKA; 108 (19%) received DOACs (49% Rivaroxaban, 34% Apixaban, 17% Dabigatran) and 123 (21%) received low molecular weight heparins. Patients who received DOACs had lower severity of PE and less risk of bleeding. The main baseline characteristics are described in table 1. Also, those patients who received DOACs at discharge had fewer in-hospital complications (heart failure, infections or bleeding; all p<0.05). In the multivariate analysis, health insurance (OR 7.45, 95% CI: 1.74–31.9, p<0.01) was an independent predictor of DOACs prescription at discharge. The history of previous heart failure (OR 0.19, 95% CI: 0.04–0.84, p=0.03) or oncologic disease (OR 0.49; 95% CI: 0.27–0.89; p=0.02) were inversely and independent predictors for DOACs prescription. Variable DOACs Other anticoagulants P OR CI (95%) Male sex 51 (47.2%) 196 (41.6%) 0.29 – – Age 64.3±17.6 63.3±16.6 0.61 – – Health insurance 106 (98.1%) 402 (85.4%) 0.01 9.1 (2.2–37.7) CKD without dialysis 2 (1.9%) 34 (7.3%) 0.06 0.24 (0.06–1.03) Heart failure 2 (1.9%) 55 (11.7%) 0.01 0.14 (0.03–0.59) Oncology disease 16 (14.8%) 127 (27%) 0.01 0.47 (0.27–0.83) Previous anticoagulation 3 (2.8%) 44 (9.3%) 0.03 0.28 (0.08–0.91) sPESI 1±1.12 1.28±1.11 0.02 0.78 (0.64–0.96) RIETE 1.71±1.17 2.05±1.33 0.02 0.81 (0.68–0.97) CKD: Chronic kidney disease; TIA: Transient ischemic attack. Conclusions The rate of use of DOACs in survivors of an acute PE in Argentina was 19%, and this P present lower clinical risk, fewer co-morbidities and greater access to health coverage.

scholarly journals Initial and Long-Term Treatment of Pulmonary Embolism: Current Approach and Future Perspectives

2018 ◽  
Vol 38 (02) ◽  
pp. 75-86
Author(s):  
Walter Ageno ◽  
Marco Donadini
Keyword(s):  
Pulmonary Embolism ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Right Ventricular Dysfunction ◽  
Current Approach ◽  
Duration Of Treatment ◽  
Onset Of Action ◽  
Long Term Treatment ◽  
Risk Patients

AbstractPulmonary embolism is associated with variable risk of early mortality, ranging from less than 1% to more than 15%. Risk stratification, based on clinical variables and signs of right ventricular dysfunction, is crucial to decide the best management and treatment strategy. Home therapy may be an option for low-risk patients, whereas patients at intermediate risk need to be hospitalized and some of them, at intermediate high risk, may require more intensive monitoring to early detect signs of haemodynamic decompensation. The initial treatment is based on anticoagulants with rapid onset of action, either parenteral (heparin/fondaparinux) or oral (direct oral anticoagulants, DOACs). Thereafter, DOACs (or, if contraindicated, vitamin K antagonists) needs to be continued for at least 3 months. Beyond this period, an individual re-evaluation of the risk-to-benefit ratio of anticoagulation should be performed, based on several factors, including the type of index event, age, sex, D-dimer and residual venous obstruction. Possibly safer strategies can be offered to higher risk patients requiring extended duration of treatment, including the DOACs apixaban and rivaroxaban at reduced dose.

scholarly journals Applied Nanotechnologies in Anticoagulant Therapy: From Anticoagulants to Coagulation Test Performance of Drug Delivery Systems

Applied Nano ◽  
2021 ◽  
Vol 2 (2) ◽  
pp. 98-117
Author(s):  
Yuri B. G. Patriota ◽  
Luíse L. Chaves ◽  
Evren H. Gocke ◽  
Patricia Severino ◽  
Mônica F. R. Soares ◽  
...  
Keyword(s):  
Drug Delivery ◽  
Anticoagulant Therapy ◽  
Test Performance ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Delivery Systems ◽  
Reversal Agent ◽  
Laboratory Assessment ◽  
Administration Routes

Heparin-based delivery systems have been explored to improve their therapeutic efficacy and to reduce toxicity for different administration routes. Regardless of the applied drug delivery system (DDS), the evaluation of anticoagulant performance is instrumental for the development of a suitable DDS. The understanding of the range of anticoagulant assays, together with their key applications and limitations, is essential both within the context of scientific research and for clinical usage. This review provides an overview of the current anticoagulant therapy and discusses the advantages and limitations of currently available anticoagulant assays. We also discuss studies involving low-molecular-weight heparin (LMWH)-based nanocarriers with emphasis on their anticoagulation performance. Conventional anticoagulants have been used for decades for the treatment of many diseases. Direct oral anticoagulants have overcome some limitations of heparins and vitamin K antagonists. However, the lack of an accurate laboratory assessment, as well as the lack of a factor “xaban” (Xa) inhibitor reversal agent, remains a major problem associated with these anticoagulants. LMWHs represent anticoagulant agents with noteworthy efficacy and safety, and they have been explored to improve their outcomes with various nanocarriers through several administration routes. The main problems related to LMWHs have been surmounted, and improved efficiency may be achieved through the use of DDSs.

scholarly journals Computed Tomography Pulmonary Perfusion for Prediction of Short-Term Clinical Outcome in Acute Pulmonary Embolism

TH Open ◽  
2021 ◽  
Vol 05 (01) ◽  
pp. e66-e72
Author(s):  
Lisette F. van Dam ◽  
Lucia J. M. Kroft ◽  
Menno V. Huisman ◽  
Maarten K. Ninaber ◽  
Frederikus A. Klok
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Predictive Value ◽  
Acute Pulmonary Embolism ◽  
Clinical Presentation ◽  
Reperfusion Therapy ◽  
Pulmonary Perfusion ◽  
Short Term ◽  
Acute Pe ◽  
Related Mortality

Abstract Background Computed tomography pulmonary angiography (CTPA) is the imaging modality of choice for the diagnosis of acute pulmonary embolism (PE). With computed tomography pulmonary perfusion (CTPP) additional information on lung perfusion can be assessed, but its value in PE risk stratification is unknown. We aimed to evaluate the correlation between CTPP-assessed perfusion defect score (PDS) and clinical presentation and its predictive value for adverse short-term outcome of acute PE. Patients and Methods This was an exploratory, observational study in 100 hemodynamically stable patients with CTPA-confirmed acute PE in whom CTPP was performed as part of routine clinical practice. We calculated the difference between the mean PDS in patients with versus without chest pain, dyspnea, and hemoptysis and 7-day adverse outcome. Multivariable logistic regression analysis and likelihood-ratio test were used to assess the added predictive value of PDS to CTPA parameters of right ventricle dysfunction and total thrombus load, for intensive care unit admission, reperfusion therapy and PE-related death. Results We found no correlation between PDS and clinical symptoms. PDS was correlated to reperfusion therapy (n = 4 with 16% higher PDS, 95% confidence interval [CI]: 3.5–28%) and PE-related mortality (n = 2 with 22% higher PDS, 95% CI: 4.9–38). Moreover, PDS had an added predictive value to CTPA assessment for PE-related mortality (from Chi-square 14 to 19, p = 0.02). Conclusion CTPP-assessed PDS was not correlated to clinical presentation of acute PE. However, PDS was correlated to reperfusion therapy and PE-related mortality and had an added predictive value to CTPA-reading for PE-related mortality; this added value needs to be demonstrated in larger studies.

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