Venous thrombosis and pulmonary embolism. Their prevention by oral anticoagulants.
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Anticoagulants↗
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Results for “PULMONARY EMBOLISM AND THROMBOSIS”
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Evaluation of plasma D-dimer in the diagnosis and in the course of fibrinolytic therapy of deep vein thrombosis and pulmonary embolism.
Blood samples were obtained from patients with deep venous thrombosis (DVT) or pulmonary embolism (PE) after angiographic confirmation as well as during fibrinolytic therapy with streptokinase. Plasma cross-linked fibrin degradation products were measured by a quantitative enzyme-linked immunoassay that recognizes the D-Dimer epitope. 24 patients with PE showed elevated D-Dimer levels (median; 25%-, 75%-quartile) (3,250 ng/ml; 1,270 ng/ml, 6,940 ng/ml) as well as 38 patients presenting with DVT (2,330 ng/ml; 1,760 ng/ml, 3,980 ng/ml). The sensitivity for the diagnosis of PE was 92%, for diagnosis of DVT 89% resp. 100%, depending on the cut-off limit. The D-Dimer level showed a correlation (r = 0.64) to the angiographically documented severity of PE quantified by the Miller's score, in contrast to DVT, where no such correlation could be found. During fibrinolytic therapy median levels rose from 3,020 ng/ml to 63,000 ng/ml within 8 hours and then fell within 6 days to 2,930 ng/ml. 10 patients with PE showed a good correlation (r = 0.72) between the reduction of Miller's score within 72 hours and D-Dimer 24 hours after the onset of therapy. In 17 patients with fibrinolytic treatment of DVT no correlation between D-Dimer and clot lysis could be found. These findings indicate that D-Dimer can provide additional information in the diagnostic procedure of suspected PE. During fibrinolytic therapy of PE with streptokinase, D-Dimer could serve as an early prognostic parameter of successful thrombolysis.
Biomarkers↗
Diagnosis of deep venous thrombosis and pulmonary embolism.
Diagnostic evaluation in the patient with suspected deep vein thrombosis (DVT) and pulmonary embolism (PE) includes a clear correlation between clinical probability, test selection and test interpretation. Real-time B-mode ultrasound with color Doppler remains the imaging technique of choice in suspected DVT. The ventilation/perfusion (V/Q) lung scan is the preferred diagnostic modality in suspected PE. The D-dimer assay may be useful in excluding PA. New diagnostic techniques, including spiral computerized tomography may further modify the diagnostic algorithm.
Humans↗
Deep venous thrombosis and pulmonary embolism in trauma patients: an overstatement of the problem?
Deep venous thrombosis (DVT) and pulmonary embolism (PE) affect high-risk trauma patients (HRTP). Accurate incidence and clinical importance of DVT and PE in HRPT may be overstated. We performed a ten-year retrospective analysis of HRTP of the Pennsylvania Trauma Outcome Study. High-risk factors (HRF) included pelvic fracture (PFx), lower extremity fracture (LEFx), severe head injury (CHI) (AIS - head > or =3), and spinal cord injury. HRF alone or in combination, age, Injury Severity Score (ISS), and Glasgow Coma Score (GCS) were examined for association with DVT/PE. A total of 73,419 HRTP were included: 1377 (1.9%) had DVT, 365 (0.5%) had PE. The incidence of DVT in level I trauma centers was 2.2 per cent and was 1.5 per cent in level II centers. The lowest incidence of DVT was 1.3 per cent for isolated LEFx; highest was 5.4% for combined PFx, LEFx, and CHI. Variables associated with DVT included age, ISS, and GCS (all P < 0.001). In logistic regression analysis, only ISS was consistently predictive for DVT and PE. Though increased during the past decade, the overall incidence of DVT in HRTP remains below 3 per cent. Only the combination of multiple injuries or an ISS >30 result in DVT incidence of > or =5 per cent. We believe that current guidelines for screening for DVT may need to be reevaluated.
Adolescent↗
[Deep-vein thrombosis and pulmonary embolism due to air travel].
In recent years, the association between air travel and the incidence of deep-vein thrombosis or pulmonary embolism has become clearer. Epidemiologic studies reveal an increased relative risk of thromboembolism after flights of more than 8 hours and especially in subjects at higher risk for this disease, due, for example, to congenital thrombophilia or the use of oral contraceptives. However, the absolute risk of deep-vein thrombosis or pulmonary embolism after prolonged air travel is very small. Studies have shown that a combination of factors present during prolonged air travel may account for increased activation of coagulation. There is no definitive proof that elastic stockings are effective in reducing the incidence of clinically relevant thromboembolism during air travel. Acetylsalicylic acid is not effective in the prevention of thrombosis during air travel and may be dangerous. Prophylactic subcutaneous low molecular weight heparin may be effective to prevent air travel-associated thrombosis. However, pending more solid evidence, this strategy should only be used cautiously, e.g. only in patients with a high risk of thrombosis who are planning a long flight.
Aerospace Medicine↗
A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study.
A community-wide study was conducted in 16 short-stay hospitals in metropolitan Worcester, Mass, to examine the incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism in patients hospitalized between July 1, 1985, and December 31, 1986. The average annual incidence of deep vein thrombosis alone was 48 per 100,000, while the incidence of pulmonary embolism with or without deep vein thrombosis was 23 per 100,000. The incidence rates of deep vein thrombosis and pulmonary embolism increased exponentially with age. The in-hospital case-fatality rate of venous thromboembolism was 12%. Among patients discharged from the hospital, the long-term case-fatality rates were 19%, 25%, and 30% at 1, 2, and 3 years after hospital discharge. Extrapolation of the data from this population-based study suggests that there are approximately 170,000 new cases of clinically recognized venous thromboembolism in patients treated in short-stay hospitals in the United States each year, and 99,000 hospitalizations for recurrent disease. Because of the silent nature of this disease and the low rate of autopsy in the United States, the total incidence, prevalence, and mortality rates of venous thromboembolism remain elusive.
Adolescent↗
Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial.
BACKGROUND: Previous trials of antiplatelet therapy for the prevention of venous thromboembolism have individually been inconclusive, but a meta-analysis of their results indicated reductions in the risks of deep-vein thrombosis and of pulmonary embolism in various high-risk groups. The aim of this large randomised placebo-controlled trial was to confirm or refute these apparent benefits. METHODS: During 1992-1998, 148 hospitals in Australia, New Zealand, South Africa, Sweden and the UK randomised 13,356 patients undergoing surgery for hip fracture, and 22 hospitals in New Zealand randomised a further 4088 patients undergoing elective arthroplasty. Study treatment was 160 mg daily aspirin or placebo, started preoperatively and continued for 35 days. Patients received any other thromboprophylaxis thought necessary. Follow-up was of mortality and of in-hospital morbidity up to day 35. FINDINGS: Among the patients with hip fracture, allocation to aspirin produced proportional reductions in pulmonary embolism of 43% (95% CI 18-60; p=0.002) and in symptomatic deep-vein thrombosis of 29% (3-48; p=0.03). Pulmonary embolism or deep-vein thrombosis was confirmed in 105 (1.6%) of 6679 patients assigned aspirin compared with 165 (2.5%) of 6677 assigned placebo, which represents an absolute reduction of 9 (SE 2) per 1000 and a proportional reduction of 36% (19-50; p=0.0003). Similar proportional effects were seen in all major subgroups, including patients receiving subcutaneous heparin. Aspirin prevented 4 (1) fatal pulmonary emboli per 1000 patients (18 aspirin-group vs 43 placebo-group deaths), representing a proportional reduction of 58% (27-76; p=0.002), with no apparent effect on deaths from any other vascular cause (hazard ratio 1.04 [95% CI 0.86-1.26]) or non-vascular cause (1.01 [0.84-1.23]). Deaths due to bleeding were few (13 aspirin vs 15 placebo), but there was an excess of 6 (3) postoperative transfused bleeding episodes per 1000 patients assigned aspirin (p=0.04). Among elective-arthroplasty patients, rates of venous thromboembolism were lower, but the proportional effects of aspirin were compatible with those among patients with hip fracture. INTERPRETATION: These results, along with those of the previous meta-analysis, show that aspirin reduces the risk of pulmonary embolism and deep-vein thrombosis by at least a third throughout a period of increased risk. Hence, there is now good evidence for considering aspirin routinely in a wide range of surgical and medical groups at high risk of venous thromboembolism.
Aged↗
Deep vein thrombosis and pulmonary embolism in the perioperative patient.
Approximately 500,000 cases of deep vein thrombosis (DVT) and pulmonary embolism (PE) occur in the United States each year. Of those patients who suffer a massive PE, 70% die within the first hour of symptom onset. Thus, early and aggressive intervention is essential. Clinical evaluation of patients is key in assessing clot risk and is aided by a variety of screening devices, with venography as the gold standard. Patients who undergo hip and knee arthroplasty are at highest risk for DVT and PE. However, appropriate prophylaxis can reduce the incidence significantly. Although standard low-dose heparin is considered to be ineffective, positive experience with the administration of the low-molecular weight heparin (LMWH) enoxaparin, because of the speed of its efficacy in postoperative patients at high risk for DVT, has been reported. The dosage of enoxaparin is weight-adjusted and is sometimes combined with warfarin. Tools for risk-factor assessment and suggested prophylactic regimens for patients undergoing total hip and knee replacement are presented.
Algorithms↗
Heparin requirements in pulmonary embolism and venous thrombosis: a prospective study.
To investigate the relationship between the clinical diagnosis of thromboembolic disease and heparin requirements for anticoagulation, we prospectively studied 31 patients suspected to have either deep vein thrombosis or pulmonary embolism. Six had the diagnosis of pulmonary embolism confirmed by a combination of ventilation and perfusion scans with pulmonary angiography, eight had venograms showing deep vein thrombosis, seven had diseases which mimicked pulmonary embolism, and ten had normal venograms. These four diagnostic groups were not significantly different with respect to heparin requirements during the first 24 hours of therapy (mean +/- S.D. = 426 +/- 105, 507 +/- 105, 434 +/-79, and 457 +/- 46 units/kg per 24 hours, respectively). Patients with pulmonary embolism and deep vein thrombosis did not differ significantly with respect to heparin requirements (UNITS/kg per 24 hours) on the second (386 +/- 108 vs. 439 +/- 127), third (415 +/- 136 vs. 464 +/- 130), and fourth (374 +/- 104 vs. 418 +/- 127) days of therapy. Our data suggest that the clinical diagnosis does not affect the dose of heparin necessary to anticoagulate patients with pulmonary embolism and deep vein thrombosis.
Adult↗
Deep venous thrombosis and pulmonary embolism as a complication of bed rest for low back pain.
A case of bilateral lower extremity deep venous thrombosis and pulmonary embolism as a complication of bed rest prescribed for an acute low back pain episode is presented. A 29-year-old woman with low back pain was prescribed more than 2 weeks of bed rest, during which she developed progressive bilateral lower extremity complaints that were ascribed to nerve root irritation. Her symptoms were initially treated with physical therapy and epidural steroid injections. A Doppler examination and ventilation-perfusion scan revealed extensive deep venous thromboses and mismatches consistent with pulmonary embolism. This case illustrates an unusual extraspinal source of lower extremity symptoms associated with low back pain and further supports the role of early mobilization in the treatment of back pain.
Acute Disease↗
Non-traumatic thoracic emergencies: CT venography in an integrated diagnostic strategy of acute pulmonary embolism and venous thrombosis.
Deep venous thrombosis and pulmonary embolism are the two aspects of venous thrombo-embolism. Investigation of lower limb veins has been part of various diagnostic algorithms in the past 15 years. Recently, the combination of CT venography (CTV) of lower limbs and abdominal veins together with CT angiography of the pulmonary arteries has allowed a complete examination of venous thrombo-embolism in one session. The technical aspects, imaging findings, venous anatomy on CT, interpretative pitfalls, results and advantages of CT venography are reviewed.
Acute Disease↗
Heparin therapy, deep-vein thrombosis and pulmonary embolism after intracerebral hemorrhage.
A prospective randomized pilot study of subcutaneous low-dose heparin in the prevention of deep-vein thrombosis and pulmonary embolism was carried out in patients admitted to hospital after intracerebral hemorrhage. A high incidence of deep-vein thrombosis and lung embolism was detected by phleboscintigraphy and lung perfusion scintigraphy, respectively. There was no significant reduction of deep-vein thrombosis and pulmonary embolism in the therapy group. Heparin did not increase the risk of rebleeding.
Cerebral Hemorrhage↗
Prevention of venous thrombosis and pulmonary embolism in injured patients.
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Biomedical Research↗
[Present state of guidelines for perioperative management of deep vein thrombosis and pulmonary embolism in Japan].
To clarify the present state of local institutional guideline for perioperative deep thrombosis and pulmonary embolism in individual hospitals, a questionnaire was sent to anesthesia departments in Japan. According to the replies, 82 hospitals have original guidelines. Forty of them reported the contents of their guidelines. However, 37 hospitals have some problems regarding their guidelines. Cost for these perioperative managements and application of spinal or epidural anesthesia for heparinized patients appears to be commonly recognized as pending questions in their guideline. It seems to be difficult to make a stereotyped standard guideline in Japan because each local guideline has a specific strategy according to their situations. However, it is needless to say that a further nationwide survey and collaboration, and governmental support for these diseases would be required.
Anesthesia Department, Hospital↗
Heparin therapy for venous thrombosis and pulmonary embolism.
Intravenous heparin is the initial treatment of choice for most patients with acute pulmonary embolism or proximal deep vein thrombosis. The primary objective of initial heparin therapy in such patients is to prevent recurrent venous thromboembolism. The efficacy of intravenous heparin for this purpose has been established by randomized clinical trials in patients with pulmonary embolism, and more recently, in patients with proximal vein thrombosis. Heparin is given as an initial intravenous bolus of 5000 units, followed by a maintenance dose of 30,000-40,000 units per 24 h by continuous intravenous infusion. A recent randomized trial in patients with proximal vein thrombosis indicates that failure to achieve an adequate anticoagulant response (APTT greater than 1.5 times control) is associated with a high risk (25%) of recurrent venous thromboembolism. Intravenous heparin administered in doses that prolong the activated partial thromboplastin time (APTT) to 1.5 or more times the control value is highly effective, and associated with a low frequency (2%) of recurrent venous thromboembolism. Heparin is continued for 7-10 days, overlapped with warfarin sodium during the last 4-5 days. Multiple randomized clinical trials indicate that this approach is highly effective. An alternative approach is to commence heparin and oral anticoagulants together at the time of diagnosis, and to discontinue heparin on the fourth or fifth day. A recent randomized trial in patients with submassive venous thrombosis or pulmonary embolism suggests that 4-5 days of initial heparin therapy is effective and safe, but this approach must be evaluated by further randomized trials before it is recommended for patients with extensive proximal vein thrombosis.(ABSTRACT TRUNCATED AT 250 WORDS)
Heparin↗
Customizing our approach in deep vein thrombosis and pulmonary embolism treatment: overview of our clinical experience.
Until recently, the management of established deep vein thrombosis (DVT) and pulmonary embolism remained largely unchanged and unchallenged. Treatment comprised an initial intravenous bolus of unfractionated heparin (UFH), followed by dose-adjusted intravenous UFH for 5-7 days, and oral warfarin for three months. UFH is traditionally administered in hospital, and monitoring and dose adjustment remain essential features of both UFH and warfarin treatment, making therapy both costly and inconvenient. Recent clinical trials have shown that subcutaneous UFH, or low-molecular-weight heparins (LMWHs), administered subcutaneously at a weight-adjusted fixed dose, are at least as effective as standard UFH given intravenously in the treatment of DVT. The feasibility of initial treatment of DVT at home in selected patients, with associated cost-savings and improved convenience have also been demonstrated with LMWHs. Clinical trials are currently investigating the potential value of LMWHs in the treatment of pulmonary embolism and as an alternative to warfarin in secondary prevention of DVT. The role of newer anticoagulants, such as recombinant hirudin, in initial treatment of DVT, and of thrombolysis in the management of pulmonary embolism remain to be defined.
Disease Management↗
[Mechanical recanalization of venous thrombosis and pulmonary embolism with the Clotbuster thrombectomy system in a 12-year-old boy].
The treatment of patients with deep vein thrombosis and pulmonary embolism with contraindications for a thrombolytic therapy is a therapeutic challenge. We report on a 12 year old patient who was treated for large cell lymphoma according to NHL-BFM 95: Block AA protocol. During his therapy, he developed a thrombosis of his right femoral vein and pulmonary embolism affecting the left segments 4, 5, 8, and 9. Because of cerebral metastasis a fibrinolytic therapy was contraindicated. Therefore, we performed a mechanical thrombectomy using the Amplatz thrombectomy device. The postinterventional scintigraphy showed a markedly improved pulmonary perfusion; dopplersonography 4 months postinterventionally showed a patent right femoral vein.
Angiography↗
Deep venous thrombosis and pulmonary embolism following physical restraint.
OBJECTIVE: We describe a case of deep venous thrombosis (DVT) and pulmonary embolism (PE) following the use of physical restraint in a patient with a diagnosis of acute delusional psychotic disorder. METHOD: A new case report of DVT and PE associated with prolonged physical restraint is presented. The literature on physical restraint, DVT, and PE was reviewed using a search of Medline and Psychinfo from 1966 to the present. RESULTS: Four other reported cases of DVT and PE were found in association with physically restrained patients. CONCLUSION: Risk of DVT and PE in association with immobilization during physical restraint may occur in spite of no pre-existing risk factors. Medical guidelines for the prevention of thrombosis following physical restraint are presented. Despite the absence of controlled trials of treatment effectiveness, the catastrophic outcome of DVT and PE warrants early and vigorous intervention in patients undergoing physical restraint.
Acute Disease↗