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
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
ReviewSystemic Thrombolytic Therapy for Acute Pulmonary Embolism: Who Is a Candidate?
Pulmonary embolism (PE) is a major cause of both acute and long-term morbidity for a large number of patients worldwide, and massive PE is frequently fatal. Right ventricular (RV) dysfunction is a key determinant of prognosis in the acute phase of PE. Patients with clinically overt RV failure, that is, with cardiogenic shock or persistent hypotension at presentation (acute high-risk PE), are clearly in need of immediate reperfusion treatment with systemic thrombolysis or, alternatively, surgical or catheter-directed techniques. ⋯ Thus, current guidelines agree in proposing a strategy of effective anticoagulation and "watchful waiting" (with initial hemodynamic monitoring notably over the first 48-72 hours) in intermediate-risk PE, with an indication for rescue thrombolysis if signs of hemodynamic decompensation appear. Recently published trials suggest that catheter-directed, ultrasound-assisted, low-dose local fibrinolysis may provide an effective and particularly safe treatment option for some of these patients. Ongoing or planned studies are expected to resolve the controversy on the efficacy and safety or reduced-dose systemic thrombolysis and to address the possible impact of thrombolytic therapy on long-term outcomes after acute PE.
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Semin Respir Crit Care Med · Feb 2017
ReviewRisk Stratification for Proven Acute Pulmonary Embolism: What Information Is Needed?
Classification of risk drives treatment decisions for patients with acute symptomatic pulmonary embolism (PE). High-risk patients with acute symptomatic PE have hemodynamic instability (i.e., shock or hypotension present), and treatment guidelines suggest systemically administered thrombolytic therapy in this setting. Normotensive PE patients at low risk for early complications (low-risk PE) might benefit from treatment at home or early discharge, while normotensive patients with preserved systemic arterial pressure deemed as having a high risk for PE-related adverse clinical events (intermediate-high-risk PE) might benefit from close observation and consideration of escalation of therapy. Prognostic tools (e.g., clinical prognostic scoring systems, imaging testing, and cardiac laboratory biomarkers) assist with the classification of patients into these categories.