Revista clínica española
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Revista clínica española · Jul 2020
ReviewClinical and radiological diagnosis of pulmonary thromboembolism.
Pulmonary thromboembolism has poorly specific clinical symptomatology, which increases the diagnostic suspicion, multiplying the number of patients who will need to undergo imaging tests to confirm the diagnosis. In recent years, pulmonary angiography using multidetector scanners (CT angiography) has been the most widely used imaging test due to its availability and accuracy, which exceeds that of lung ventilation-perfusion (V/Q) scintigraphy. ⋯ We therefore need to base our approach on previously validated strategies that, taking into account the clinical probability and using highly sensitive diagnostic tests such as D-dimer, will enable us to exclude many patients from undergoing this imaging test. In this article, we review the diagnostic techniques and strategies that are applied for diagnosing pulmonary thromboembolism in hemodynamically stable and unstable outpatients, hospitalised patients, patients with a history of venous thromboembolism and pregnant women.
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The purpose of this guide is to suggest, based on the available clinical evidence, the prevention measures for venous thromboembolism during pregnancy, childbirth and postpartum in expert recommendations and international guidelines. Venous thromboembolism is a cause of maternal death, and it is therefore important to consider those situations in which the risk is greater and for which women should undergo preventive treatment. ⋯ Low-molecular-weight heparin is the treatment of choice for these women. Prophylaxis might be necessary during the antenatal or postnatal period, and the duration and indication will vary depending on the risks and benefits.
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Deep vein thrombosis (DVT) is part of the clinical spectrum of venous thromboembolism disease (VTE), whose estimated annual incidence rate is 1-2 episodes per 1000 individuals and represents the third leading cause of cardiovascular mortality in developed countries. Establishing an accurate diagnosis of DVT is essential for preventing acute complications (such as pulmonary embolism) and chronic complications associated with post-thrombotic syndrome. Currently, there are well-established diagnostic algorithms for lower extremity DVT, which include clinical probability models that help establish the risk of experiencing the disease based on the patients' history, clinical findings, D dimer measurements, fibrin degradation product tests with a high negative predictive value and imaging tests to confirm the diagnosis. ⋯ The consensus is not as clear about the need for a proximal or complete examination of the entire extremity. Other techniques may also be employed, such as magnetic resonance venography and venous phase computed axial tomography, although these should not be a substitute for compression ultrasonography as the initial diagnostic test. There are other special circumstances in which the diagnosis is more problematic and there are no diagnostic algorithms as consolidated, such as DVT during pregnancy, diagnosing rethrombosis and DVT that affects the upper extremities.
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Despite the potential benefits of outpatient care, most patients with pulmonary embolisms are treated in hospitals for fear of possible adverse events. However, there is a wealth of scientific evidence from studies covering more than 4000 outpatients, which has led the current clinical practice guidelines to recommend early discharge or outpatient treatment when a low risk of death or complications has been confirmed, when there are no comorbidities or aggravating processes present to warrant hospitalisation and when appropriate monitoring and treatment are observed. ⋯ Using these tools, the short-term outcomes (30-90days) show low mortality (in general <3%) and a low incidence of other complications (rate of recurrence and major bleeding <2%). Based on the available evidence, outpatient treatment can be considered the most appropriate strategy at this time for most hemodynamically stable patients with pulmonary embolisms.
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Revista clínica española · Jun 2020
ReviewThromboembolism prophylaxis in orthopaedic surgery and trauma.
Thromboembolism prophylaxis is well-established in major orthopaedic surgery (hip and knee arthroplasty and hip fracture surgery), with low-molecular-weight heparins the most often chosen agent. In recent years, however, direct-acting anticoagulants have been gaining ground and can be used in this scenario (except for hip fracture surgery). ⋯ For other orthopaedic procedures (leg surgery below the knee, ankle and foot; knee arthroscopy; arm surgery; and spine surgery), thromboembolism prophylaxis requires individualisation based on the patient's risk factors and the surgery's characteristics, given that the risk of venous thromboembolic disease is minor. In this patient group, the agent of choice is low-molecular-weight heparin, given that direct-acting anticoagulants are not approved for these types of surgery.