Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Feb 2017
ReviewCatheter-Based Approaches for the Treatment of Acute Pulmonary Embolism.
Except when contraindicated, anticoagulation should be initiated when pulmonary embolism (PE) is strongly suspected and the bleeding risk is perceived to be low, even if the evaluation has not been completed. Low-risk patients with acute PE are simply continued on anticoagulation. Severely ill patients with high-risk (massive) PE require aggressive therapy, and if the bleeding risk is acceptable, systemic thrombolysis should be considered. ⋯ In spite of this, intermediate-risk (submassive) PE comprises a fairly broad clinical spectrum so that there is not a solid evidence base permitting a consistent algorithm for clinicians to follow. Thus, for several decades, thromboembolism basic scientists, clinical trialists, and clinicians have worked toward a lower risk solution for treatment of patients with more than simply low-risk PE. Catheter-based therapy, consisting of various devices and techniques, with or without low-dose thrombolytic therapy, offers one potential solution and continues to evolve.
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Semin Respir Crit Care Med · Feb 2017
The Novel Oral Anticoagulants for Acute Venous Thromboembolism: Is Warfarin Dead?
The direct oral anticoagulants (DOACs) have been compared with parenteral anticoagulants and vitamin K antagonists (VKAs) for the treatment of venous thromboembolism (VTE) in several robust studies. DOACs have shown similar efficacy in preventing recurrent VTE and significant reductions in critical site (intracranial) bleeding, fatal bleeding, major and nonmajor bleeding. Warfarin and other VKAs are not dead as treatment modalities for VTE. ⋯ Hence, guidelines are now recommending DOACs in preference to VKAs. In this article, we consider where DOACs are indicated, where there is growing evidence for use, where we have little evidence for use, and finally where there is no evidence for use and where they, thus, should not be used. We have included recommendations and examples of our own practice which may not be applicable to all settings.
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Semin Respir Crit Care Med · Feb 2017
ReviewAcute Pulmonary Embolism after Discharge: Duration of Therapy and Follow-up Testing.
Pulmonary embolism (PE) is a frequent cause of death and serious disability with a risk extending far beyond the acute phase of the disease. Anticoagulant treatment reduces the risk for death and recurrent VTE after a first PE. The optimal duration of anticoagulation after a first episode of PE remains controversial and should be made on an individual basis, balancing the estimated risk for recurrence without anticoagulant treatment against bleeding risk under anticoagulation. ⋯ If the favorable safety profile of direct oral anticoagulants from clinical trials would be confirmed in real-life, extension of anticoagulation could be reconsidered in large proportions of patients after an unprovoked PE. The most feared late sequela of PE is chronic thromboembolic pulmonary hypertension. Although there has been progress in both the diagnosis and management of this disease in recent years, further data are needed to provide recommendations regarding long-term follow-up after PE.
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Semin Respir Crit Care Med · Feb 2017
ReviewInferior Vena Cava Filters: When to Place and When to Remove.
Pulmonary embolism (PE) is a common and feared result of deep vein thrombosis. While anticoagulation is the mainstay of management, interruption of flow of thrombus from leg veins to the pulmonary circulation is frequently desired either in lieu of or in addition to anticoagulation. Inferior vena cava filters have become frequently used to prevent PE despite a paucity of evidence for efficacy and increasing concerns about the long-term complications of indwelling filters.
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Semin Respir Crit Care Med · Feb 2017
ReviewThe Pulmonary Embolism Response Team: What Is the Ideal Model?
Treatment of patients with intermediate- and high-risk pulmonary embolism (PE) is a controversial area. Many therapeutic options exist, and deciding on appropriate treatment can be difficult. ⋯ The goal of a PERT is to have a single multidisciplinary team of experts in thromboembolic disease, who can respond rapidly to patients with acute PE, and offer consultation with the full spectrum of therapeutic options. PERT teams were modeled after rapid response teams and are meant to generate a prompt, patient-specific plan for patients with PE without having to consult multiple individual specialists.