05 Sep 12

Risk stratification and treatment strategy of pulmonary embolism

Posted in Venous thromboembolism at 0:20 by Laci

By A Penaloza, P M Roy, J Kline

Curr Opin Crit Care 2012;18:318-325

Pulmonary embolism remains one of the leading causes of cardiovascular mortality. The wide range of reported mortality rates reflects heterogeneity in comorbidity and severity of pulmonary embolism. Optimizing risk stratification to prognose pulmonary embolism patients appears to be important to improve management, treatment and clinical outcome.

Recent findings
Hemodynamic status is the most important short-term prognostic factor. High-risk pulmonary embolism or massive pulmonary embolism is defined by the patient response more than the clot size: patients with circulatory shock including sustained hypotension should receive thrombolytic therapy in absence of contraindications. Nonmassive or normotensive pulmonary embolism can be further stratified using clinical features, imaging (echocardiography, computed tomography) and biomarkers (troponins, natriuretic peptides): low-risk pulmonary embolism, evaluated by clinical model (Pulmonary Embolism Severity Index; PESI) can potentially be treated as outpatients; and intermediate-risk pulmonary embolism, which can be further stratified into less-severe and more-severe intermediate risk. The last may benefit from intensive clinical surveillance but the risk–benefit ratio for thrombolysis has been inadequately quantified to make any strong recommendation. New anticoagulants may transform traditional pulmonary embolism treatment.

Summary
Optimizing risk stratification of patients with normotensive pulmonary embolism before they develop overt hemodynamic instability is the challenge of current pulmonary embolism management. Treatment strategy has to integrate this risk stratification and new anticoagulants arrival.

17 Sep 11

Long-haul air travel before major surgery: a prescription for thromboembolism?

Posted in Venous thromboembolism at 19:37 by Laci

By O Gajic, D Warner, P Decker, R Rana, D Bourke and J Sprung

Mayo Clin Proc. June 2005 80(6):728-731

To investigate the incidence of postoperative venous thromboembolism (VTE) in patients who had flown long distances before major surgery.

Patients and methods
Using the Mayo Clinic computerized patient database, we identified patients who had flown more than 5000 km before major surgery (travelers) and had experienced an episode of clinically significant VTE within 28 days after surgery. Individual medical records were reviewed for the diagnosis of VTE, pertinent risk factors, and outcome. We compared the incidence of VTE in travelers to the incidence of VTE in patients from North America (nontravelers) undergoing similar surgical procedures.

Results
Eleven patients met our criteria for long-haul air travel and clinically significant VTE within 28 days after surgery. Compared with nontravelers undergoing similar surgical procedures, long-haul travelers had a higher incidence of VTE (4.9% vs 0.15%; P<.001). Compared with nontravelers who developed VTE, travelers were younger (P=.006), developed VTE earlier in the postoperative course (P=.01), had higher American Society of Anesthesiologists physical status classification (P=.02), and had higher prevalence of smoking (P=.007). Of the 11 travelers with VTE, 10 were of Middle Eastern origin.

Conclusion
Prolonged air travel before major surgery significantly increases the risk of perioperative VTE. Such patients should receive more intensive VTE prophylactic measures during the flight and throughout the perioperative period.

24 Feb 10

Venous thromboembolism – reducing the risk

Posted in Anesthesia, Pre-operatie evaluation, Venous thromboembolism at 12:17 by Laci

NICE clinical guideline CG92

This guidance is about the care and treatment of people who are at risk of developing deep vein thrombosis (DVT) while in hospital in the NHS in England and Wales.

The advice in the NICE guideline covers the care and treatment that should be offered to all adults (aged 18 and over) who are admitted to hospital as inpatients (including those admitted for day-case procedures).

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22 Jan 09

Natriuretic peptides in acute pulmonary embolism

Posted in BNP, Venous thromboembolism at 0:26 by Laci

By R Cavallazzi, A Nair, T Vasu and P E Marik

Intensive Care Med 2008:34;2147-2156

Patients with pulmonary embolism (PE) have a high risk of death, and it is important to recognize factors associated with higher mortality. Recently, several biomarkers have been studied for risk stratification in patients with PE.

Objectives
Evaluate the available evidence on (a) the accuracy of brain natriuretic peptide (BNP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) for the diagnosis of right ventricular dysfunction and (b) their value as a prognostic factor of all-cause in-hospital or short-term mortality in patients with PE.

Data sources
MEDLINE, Embase, and citation review of relevant primary and review articles.
Selection criteria  We selected studies evaluating the accuracy of BNP or NT-proBNP for the diagnosis of right ventricular dysfunction. We also selected studies that reported data on BNP or NT-proBNP as a predictor of short-term mortality in patients with PE.

Results
Sixteen studies met our inclusion criteria. The pooled diagnostic odds ratio for the diagnosis of right ventricular dysfunction in pulmonary embolism was 39.45 (95% CI; 15.54ñ100.12) and 24.73 (95% CI 2.02ñ302.37) for BNP and NT-proBNP, respectively. The pooled odds ratio for all-cause in-hospital or short-term mortality was 6 (95% CI 1.31±27.43; p: 0.021) and 16.12 (95% CI 3.1±83.68; p: 0.001) for BNP (cutoff: 100 pg/ml) and NT-proBNP (cutoff: 600 ng/L), respectively.

Conclusion
The results of this meta-analysis indicate that BNP and NT-proBNP are associated with the diagnosis of right ventricular dysfunction (RVD) in patients with an acute PE and are significant predictors of all-cause in-hospital or short-term mortality in these patients.

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