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PubMed2003

Duplex ultrasonography in patients suspected of postoperative pulmonary embolism following total joint arthroplasty.

Duplex ultrasonography of the deep venous system of the lower extremities is often utilized in the diagnostic evaluation of total hip and knee arthroplasty patients suspected of pulmonary embolism in an attempt to identify the embolic source. A retrospective review of 135 patients who were clinically suspected of pulmonary embolism after 71 total knee arthroplasties and 64 total hip arthroplasties was performed. Of the 35 patients diagnosed with pulmonary embolism, 2 (5.7%) had deep venous thrombosis identified by duplex ultrasonography. The routine use of this imaging modality is not an effective strategy for identifying clinically significant deep venous thrombosis that leads to pulmonary embolism. A negative duplex ultrasound result should not preclude an extensive evaluation for pulmonary thrombosis in symptomatic patients.

Adult↗
PubMed1989

Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis?

To investigate the present status of pulmonary embolism as a cause of death in a general hospital patient population, a 5-year retrospective study of all autopsy reports and associated hospital records was undertaken. Pulmonary embolism was thought to be the cause of death in 239 of 2388 autopsies performed (10%): 15% of these patients were aged less than 60 years and 68% did not have cancer. Of these patients, 83% had deep-vein thrombosis (DVT) in the legs at autopsy, of whom only 19% had symptoms of DVT before death. Only 3% of patients who had DVT at autopsy had undergone an investigation for such before death. Twenty-four per cent of patients who died from pulmonary embolism had undergone surgery a mean of 6.9 days before. Screening tests for DVT should be applied widely in the hospital population.

Adult↗
PubMed1991

Atrial fibrillation as a risk factor for deep venous thrombosis and pulmonary emboli in stroke patients.

In 539 consecutive stroke patients admitted to a rehabilitation department, we studied the possible role of atrial fibrillation as a risk factor for deep venous thrombosis and pulmonary embolism by analyzing a series of relevant clinical data in patients with and without atrial fibrillation and in patients with and without venous thromboembolic complications. Deep venous thrombosis as well as advanced age and cardiac disease were significantly (p less than 0.001) more frequent in patients with atrial fibrillation. However, in a model of simultaneous logistic regression carried out on the presence of absence of venous thromboembolic complications, atrial fibrillation was the only significant risk factor. In view of the morbidity and mortality linked to deep venous thrombosis, our findings argue for preventive anticoagulation therapy in stroke patients suffering from atrial fibrillation and merit further study.

Aged↗
PubMed2005

Selecting an anticoagulant for recurrent venous thromboembolism in cancer.

PURPOSE: The thrombogenicity of newer anticancer agents and the challenges associated with managing cancer patients on warfarin have led to the evaluation of the low-molecular-weight heparins (LMWHs) for primary and secondary prophylaxis in this high-risk patient population. SUMMARY: The first published trial of LMWH in cancer compared three months of warfarin therapy with enoxaparin in cancer patients with proximal deep venous thrombosis (DVT), pulmonary embolism (PE), or both. All patients received four days of enoxaparin 1.5 mg/kg and were then randomized to continue receiving enoxaparin or begin warfarin therapy. Due to inadequate patient enrollment, no statistically significant differences were detected between the two treatment groups. In a similar patient population, the Comparison of Low-Molecular-Weight Heparin versus Oral Anticoagulant Therapy for the Prevention of Recurrent Venous Thromboembolism in Patients with Cancer (CLOT) trial evaluated the use of long-term dalteparin for the prevention of recurrent venous thromboembolism (VTE) in patients with cancer. Cancer patients with proximal DVT, PE, or both were randomized to initial treatment with dalteparin followed by either six months of oral anticoagulant therapy or dalteparin monotherapy. The primary outcome was symptomatic, recurrent VTE, and secondary outcomes were bleeding events and survival time. The cumulative risk of recurrent VTE at six months was reduced from 17% in the oral anticoagulant group to 9% in the dalteparin group, a risk reduction of 52% (p=0.002). No significant differences in bleeding events or overall mortality occurred between the groups. Recent recommendations from the American College of Chest Physicians on the treatment of cancer-associated thrombosis are based in part on data from the CLOT trial and support the use of dalteparin and tinzaparin in the long-term treatment of patients with DVT and cancer. Finally, results of recent trials support the concept that antithrombotic therapy with dalteparin or nadroparin may have an antineoplastic effect, resulting in improved survival time. However, these results require further validation. CONCLUSION: Despite the absence of oncology-specific guidelines for cancer-associated thrombosis, pharmacists now have a number of new tools available for selecting an anticoagulant, including results from several clinical trials with LMWHs and recent reports from national meetings.

Anticoagulants↗
PubMed2004

Pulmonary embolism and pregnancy.

Pulmonary embolism is a significant cause of morbidity and mortality during pregnancy and the puerperium. The spectrum of venous thromboembolism is difficult to diagnose. Objective diagnostic testing is crucial and should not be delayed. Anticoagulation is the mainstay of therapy for deep vein thrombosis and pulmonary embolism. Most of the literature and practice protocols for the treatment of pregnant women are based on data extrapolated from the nonpregnant population, and more research is needed to improve the understanding of the efficacy and safety of testing and therapy in the pregnant population.

Anticoagulants↗
PubMed1995

Objective tests for the diagnosis of deep leg vein thrombosis.

The concept that deep vein thrombosis and pulmonary embolism are one clinical entity has only recently established itself. Hence, the term venous thromboembolism should be used. The diagnosis of pulmonary embolism has been notoriously difficult, and pulmonary angiography via the reference method has played a prominent role. More recently, the use of less invasive or noninvasive diagnostic tools for patients who have inconclusive lung scan reports has been advocated. This option is based on observations that deep vein thrombosis is present in a substantial number of patients who have proven pulmonary emboli. The authors have reviewed the literature for available data on the use of objective tests for deep vein thrombosis in the management of patients who have clinically suspected pulmonary embolism. Although several clinical studies have shown promising results, no diagnostic strategy has been sufficiently evaluated to warrant the use of such tests for routine clinical practice.

Humans↗
PubMedDate not supplied

Calcaneal fracture with pulmonary embolism.

The primary factors that result in pulmonary embolism are venous stasis, intimal damage and hypercoagulability. Although pulmonary embolism is rare after calcaneal fracture, the possibility should not be overlooked because of the gravity of the consequences. Awareness of the risk factors resulting from the combination of long-term bed rest and immobilization may reduce the occurrence of deep venous thrombosis and pulmonary embolism.

Adult↗
PubMed1976

Risk factors in pulmonary embolism.

The influence of several diseases and conditions upon the prevalence of pulmonary embolism in autopsies performed during a ten year period at the University of Michigan has been analyzed. The major factors contributing to an increase in risk of development of pulmonary embolism include heart disease, certain types of cancer, obesity, acute paraplegia and accidental and operative trauma. These and several other risk factors defined in other studies should be used in a selective program designed to increase the rate of detection of deep venous thrombosis before pulmonary embolism occurs, or alternatively, patients at increased risk should receive prophylactic low dosage heparin therapy during hospitalization.

Adolescent↗
PubMed1997

[The so-called "economy class" syndrome or travel thrombosis].

Thrombosis and pulmonary embolism associated with air travelling is known as "economy class syndrome". However, as it is observed even using other means of transportation, it can generally be described as "traveller's thrombosis". Our own observations include 5 patients with thrombo-embolic disease, which occurred after long-distance travel. In respect to the large number of travellers, the reported incidence of associated thrombosis seems to be remarkably low, and there is no epidemiological evidence about travel and thromboembolic disease. On the other hand, retrospective analysis of patients with manifest thrombosis of any origin reveals in about 5% the circumstances of transportation as possible agent. Anyhow, according to literature the risk of thrombosis could be regarded as quite low. Preventive action during long-distance travelling should be taken into consideration in patients with high risk of thromboembolism.

Aircraft↗
PubMed2000

Thrombosis prophylaxis in the acutely ill medical patient: insights from the prophylaxis in MEDical patients with ENOXaparin (MEDENOX) trial.

The clinical benefit and cost-effectiveness of routine thromboprophylaxis in surgical patients has been well documented, but use of this approach in general medical patients remains controversial. Following is an overview of major insights from the prophylaxis in Medical patients with Enoxaparin (MEDENOX) trial, which was undertaken to evaluate the efficacy of 2 dosage regimens of the low-molecular-weight heparin enoxaparin for prevention of venous thromboembolism in acutely ill medical patients. MEDENOX was a prospective, double-blind, randomized, placebo-controlled trial, which enrolled 1,102 hospitalized patients from 68 centers in 9 countries. Patients were randomly assigned to receive 40 mg of enoxaparin, 20 mg of enoxaparin, or placebo, given subcutaneously once a day for 6-14 days. The primary outcome was venous thromboembolism (deep-vein thrombosis or pulmonary embolism) between days 1 and 14. At the 40-mg dose, the risk of venous thromboembolism was significantly reduced in patients with heart failure, as well as in patients with other medical illnesses, including respiratory failure, infectious disease, or rheumatic disorders. The incidence of venous thromboembolism was 5.5% in the group that received 40 mg of enoxaparin as compared with 14.9% in the group that received placebo (p <0.001), a benefit that was maintained at 3-month follow-up. There was no significant difference in the incidence of venous thromboembolism between the group that received 20 mg of enoxaparin (15%) and the placebo group. Adverse effects did not significantly differ between the placebo group and either enoxaparin group. This study clearly establishes an effective strategy for lowering the risk of venous thromboembolism in the acutely ill population and provides a framework for future trials in this area.

Aged↗
PubMed2002

Pharmacologic and clinical characteristics of thrombolytic agents.

Arterial and venous thromboembolic events, including myocardial infarction, ischemic stroke, peripheral arterial thrombosis, deep venous thrombosis, and pulmonary embolism are common potentially life-, organ-, and limb-threatening vascular diseases. Anticoagulant therapy is recommended in these settings to prevent further thrombosis pending gradual clearance of the thrombotic occlusion by the endogenous fibrinolytic system. Recognition of the importance of the fibrinolytic system in thrombus resolution has resulted in the development of pharmacologic fibrinolytic (thrombolytic) agents to facilitate rapid restoration of vascular patency. Several plasminogen activator (PA) thrombolytic agents with different pharmacokinetic and pharmacodynamic properties have been developed to treat thrombotic disease. Newer PAs have been developed as "fibrin-specific", bolus-administration drugs to primarily treat acute coronary syndromes. Continuous infusions of these fibrin-specific PAs have become popular for the lysis relatively larger peripheral vascular thromboses. Loss infusion of newer tissue-type plasminogen activator-based PAs may result in an increased risk of bleeding, including intracranial hemorrhage. Currently available data fail to provide compelling evidence that newer PAs offer significantly greater efficacy and safety than well-established agents like urokinase when used to treat peripheral vascular thrombosis.

Fibrinolytic Agents↗
PubMed1991

[Heparin-associated thrombocytopenia, thrombosis and embolism. Side effects of thromboembolism prevention with low molecular weight heparin enoxaparin?].

Heparin-associated thrombocytopenia (HAT) is a rarely described adverse reaction of systemic administration of heparin that may be complicated by thrombosis, embolism and bleeding. Unfractionated heparin as well as low molecular weight heparin may provoke HAT. A case of HAT complicated by thrombosis and pulmonary embolism is described that came about during preventive postoperative anticoagulation with the low molecular weight heparin enoxaparin. Pathogenesis, diagnosis, prophylaxis and therapy of HAT are discussed.

Aged↗
PubMed2006

[Prevention of venous thromboembolism in psychiatry].

The hospitalized patients of the psychiatric wards represent a risk group for the development of venous thromboembolism. Apart from sedative administration, total movement reduction, bad life style and daily routine and increased body weight, there is negative impact of dehydration, prolonged hospitalization and sometimes immobilisation in consequence of mechanical restraints. A large amount of patients are treated with antipsychotics that have a series of adverse effects. Depending of the drug used, the most frequent of them are somnolence, fatigue, extrapyramidal syndrome, hypotension, hepatotoxicity, increased body weight, prolongation of the QT interval of the ECG with a risk of ventricular arrhythmias, hematopoietic disorders, lipid or glycide metabolism disorders or hyperprolactinemia. Another potential adverse effect of these drugs is the heightened risk of venous thromboembolism development (deep vein thrombosis and/or pulmonary embolism). There is the risk of a pathological blood clotting event in psychiatric patients, especially those treated with antipsychotics. Although it is not high, it can have fatal consequences when combined with a relatively frequent pulmonary embolism and difficult diagnostics of thromboembolism. An algorithm for thromboembolism prevention has been developed. It involves important general risk factors of venous thrombosis (VTE history, immobilisation, malignancy, age over 75 years etc.) and also markers (physical restraints, dehydration, obesity, antipsychotics use) that can participate in the pathogenesis of venous thrombosis in the hospitalized psychiatric patients with limited motility. The authors believe that this prophylaxis is indicated, safe, effective and that it improves the quality of life at relatively low costs.

Anticoagulants↗
PubMed2003

[Anticoagulation in patients with venous thromboembolism].

Deep venous thrombosis and pulmonary embolism are considered to be two variants of one disease--'venous thromboembolism'. Pathogenesis, therapy and prognosis of these both entities are very similar and therefore the term 'venous thromboembolism' has been used in recent literature. The cornerstone of therapy is anticoagulation and initially consists of heparin for at least five days. Because of pharmacokinetic advantages low molecular weight heparins are the therapy of choice. They are as efficient and save as unfractionated heparins and allow weight-adapted dosing with daily subcutaneous injections in most patients. Low molecular weight heparins do not require regularly laboratory monitoring with few exceptions, e.g. renal failure. Therefore outpatient treatment of deep venous thrombosis is possible in most patients. Although there are promising data about outpatient treatment of pulmonary embolism, this is still being studied and can not be recommended outside clinical trials. Introduction of coumarin therapy for venous thromboembolism should be started on day 1 of diagnosis, keeping the total duration of heparin therapy at no more than five days and therefore minimizing the incidence of heparin-induced thrombocytopenia. Evidence from multiple studies indicates that effective coumarin therapy in venous thromboembolism is usually reflected by an INR of 2.0 to 3.0. In patients with massive and hemodynamically relevant thromboembolism alternative therapeutic approaches such as thrombolytic therapy, thrombectomy or insertion of intravenous filters may be useful. Adequately fit compression stockings can reduce the risk of post-thrombotic syndrome after deep venous thrombosis.

Anticoagulants↗
PubMed2004

Right-sided heart thromboembolism and pulmonary embolism.

We report a patient with an evidence of bilateral calf deep vein thrombosis, hemodynamically significant pulmonary embolism, and echocardiographic evidence of right heart thromboemboli with "popcorn" appearance. She responded well to thrombolytics and low molecular weight heparin with resolution of symptoms and improvement of echocardiographic abnormalities.

Aged↗
PubMed2004

Venous protocols, techniques, and interpretations of the upper and lower extremities.

Deep venous thrombosis and pulmonary embolism are common problems and frequently included in the differential diagnosis of patients presenting to the emergency department and in the acute care setting. Clinical signs and symptoms of these entities are nonspecific and it is important to perform objective testing to confirm the diagnosis and initiate proper therapy. Compression ultrasonography is the diagnostic procedure of choice for the investigation of patients with suspected deep venous thrombosis. This article reviews the clinical indications, diagnostic techniques, and interpretation of compression ultrasound to assess deep venous thrombosis in the upper and lower extremities and to evaluate the role of compression ultrasonography in the assessment of patients with suspected pulmonary embolism.

Diagnostic Imaging↗
PubMed1987

The week-old hip fracture: indication for prophylactic use of a vena cava filter? Report of two cases.

Occasional patients will present a week or more after sustaining a hip fracture. Though these patients are at high risk for asymptomatic deep venous thrombosis and pulmonary embolism, anticoagulation may be contraindicated prior to surgery. Two recent cases involving such a situation are reported. In the first, the patient sustained a fatal intraoperative pulmonary embolism. In the second, a transvenous Greenfield vena caval filter was placed prior to surgery. An extremely high suspicion of asymptomatic deep venous thrombosis is necessary when evaluating a patient whose hip fracture has been untreated for a week or more. If studies demonstrate a deep venous thrombosis preoperatively, placement of an inferior vena caval filter may be indicated.

Aged↗

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