Background: Venous thromboembolism (VTE) occurs frequently in patient with cancer. Treatment in this group entails a number of challenges including a higher rate of thrombosis recurrence and a higher risk of bleeding. Standard therapy in 2018 for both symptomatic and asymptomatic VTE is with low-molecular-weight heparin (LMWH) based on this study. Prior to 2003, patients were treated with warfarin after bridging with either unfractionated or LMWH. This approach requires frequent monitoring due to unpredictable anticoagulation levels associated with drug interactions, malnutrition and vomiting. Due to these issues, treatment with LMWH alone may be both more efficacious as well as preferred by patients. Read more →
Tag Archive for: Pulmonary Embolism
Background: Venous thromboembolism (VTE) occurs frequently in patient with cancer. Treatment in this group entails a number of challenges including a higher rate of thrombosis recurrence and a higher risk of bleeding. Standard therapy at this time for both symptomatic and asymptomatic VTE is with low-molecular-weight heparin (LMWH) based on results from the CLOT trial (Lee 2003). In non-cancer patients, new oral anticoagulants (NOACs) like rivaroxaban have been shown to be effective in treatment without increasing bleeding events. The NOACs also add ease of use for the patient. Though these agents are frequently used in the treatment of cancer-associated VTE, there is a dearth of evidence supporting this practice. Read more →
Background: Previously, I had given a talk on the use of thrombolytics in submassive PE in 2016. This year, I had the privilege of speaking at ACOEP 2017 again with an update on the critical pulmonary embolism patient. This post will serve as a reference for that talk.
There are many ways to classify pulmonary embolism, but the best clinical definition would depend on the hemodynamic consequences. For example, massive pulmonary embolism can be defined as systemic hypotension (SBP < 90 mmHg or a drop in SBP of at least 40mmHg for at least 15 min) or shock (tissue hypoperfusion, hypoxia, altered mental status, oliguria, or cool clammy extremities.) There is a second subset of patients that also warrant discussion; submassive pulmonary embolism. These patients are defined as lack of systemic hypotension (<90mmHg), but have right ventricular dysfunction/hypokinesis. RV dysfunction tells us that there is severe pulmonary artery obstruction and impending hemodynamic failure. Read more →
Background: The clinical diagnosis of pulmonary embolism (PE) can be challenging given its variable presentation, requiring dependence on objective testing. Decision instruments such as PERC and the Wells’ score help stratify patients to low or high probability, enabling focused use of CT pulmonary angiography (CTPA) for diagnosis. However, despite these algorithms, there is evidence of increasing use of CTPA along with diminishing diagnostic rate (less than 10%). This combination results in the overdiagnosis of subsegmental PEs, unnecessary exposure to radiation, false positive results and the potential for contrast-induced nephropathy. The YEARS study aims to present a simplified algorithm for evaluation with a two-tiered D-dimer threshold to reduce the numbers of CTPA in all age groups. Read more →
Background: The simplified PE Severity Index (sPESI) is one of several validated prognostic tools for acute pulmonary embolism (PE). The European Society of Cardiology recommended the use of the sPESI to risk-stratify patients with acute PE into low risk (sPESI=0) and non-low risk (sPESI≥1) in order to guide treatment and disposition (Konstantinides 2014). Systematic reviews and meta-analyses have found that outpatient management of low-risk PE patients with standard therapy is safe, effective, and cost-effective (Aujesky 2011, Zondag 2013, Kahler 2015).
Standard practice in the United States for treatment of acute PE over the last decade has been a parenteral agent (e.g. enoxaparin, fondaparinux) overlapping with a vitamin K antagonist (VKA) (e.g. warfarin). However, a paradigm shift has been brewing over recent years. Direct oral anticoagulants (DOACs) have demonstrated efficacy as initial and long-term treatment of PE compared to standard therapy in various trials (EINSTEIN-PE 2012, RE-COVER 2014, AMPLIFY 2013, Hosukai-VTE 2013). The EINSTEIN-PE study found that rivaroxaban was noninferior to enoxaparin/VKA for the treatment of recurrent venous thromboembolism (VTE) without increased risk of bleeding. Rivaroxaban and other DOACs are approved for treatment of VTE in the European Union, but use in the United States of DOACs for ED treatment of PE is more limited. Read more →