03 Dec 08

Thrombolytic therapy and mortality in patients with acute pulmonary embolism

Posted in Venous thromboembolism at 0:11 by Laci

By SA Ibrahim, RA Stone, DS Obrosky, M Geng, MJ Fine, D Aujesky

Arch Intern Med 2008;168:2183-2190

In the management of acute pulmonary embolism, the prevalence of thrombolytic therapy is uncertain, and its benefits compared with standard anticoagulation remain a subject of debate.

Methods
This analysis included 15 116 patient discharges with a primary diagnosis of pulmonary embolism from 186 acute care hospitals in Pennsylvania (January 2000 to November 2002). We compared propensity score–adjusted mortality between patients who received thrombolysis and those who did not, using logistic regression to model mortality within 30 days of presentation and Poisson regression to model in-hospital mortality.

Results
Of the 15 116 patient discharges, only 356 (2.4%) received thrombolytic therapy. The overall 30-day mortality rate for patients who received thrombolytic therapy was 17.4% compared with 8.6% for those who did not. The corresponding in-hospital mortality rates were 19.6 and 8.3, respectively, per 1000 person-days. However, mortality risk associated with thrombolysis varied with the propensity to receive thrombolysis: the odds ratios of 30-day mortality were 2.8 (P = .007), 3.9 (P < .001), 1.8 (P = .09), 1.0 (P = .98), and 0.7 (P = .30) for patients in the lowest to the highest quintiles of the propensity score distribution who received thrombolysis. A similar pattern was observed in the risk ratios for in-hospital death.

Conclusions
In this large sample of patients hospitalized for acute pulmonary embolism, thrombolytic therapy was used infrequently. Risk of in-hospital and 30-day mortality appears to be elevated for patients who were unlikely candidates for this therapy based on characteristics at presentation, but not for patients with a relatively high predicted probability of receiving thrombolysis.

07 Sep 08

Prognostic value of brain natriuretic peptide in acute pulmonary embolism

Posted in BNP, Venous thromboembolism at 19:27 by Laci

By G Coutancel, O Le Page, T Lo and M Hamon

Critical Care 2008;12:R109

The relationship between brain natriuretic peptide (BNP) increase in acute pulmonary embolism (PE) and the increase in mortality and morbidity has frequently been suggested in small studies but its global prognostic performance remains largely undefined. We performed a systematic review and meta-analysis of data to examine the prognostic value of elevated BNP for short term all-cause mortality and serious adverse events.

Methods
The authors reviewed PubMed, BioMedCentral, and the Cochrane database and conducted a manual review of article bibliographies. Using a prespecified search strategy, we included a study if it used BNP or N-Terminal Pro-Brain Natriuretic Peptide (NT-pro BNP) biomarkers as a diagnostic test in patients with documented pulmonary embolism and if it reported death, the primary endpoint of the meta-analysis, in relation to BNP testing. Studies were excluded if they were performed in patients without certitude of PE or in a subset of patients with cardiogenic shock. Twelve relevant studies involving a total of 868 patients with acute PE at baseline were included in the meta-analysis using a random-effects model.

Results
Elevated BNP levels were significantly associated with short-term all-cause mortality (odds ratio [OR], 6.57; 95% confidence interval (CI), 3.11 to 13.91), with death resulting from pulmonary embolism (OR, 6.10; 95% CI, 2.58 to 14.25), and with serious adverse events (OR, 7.47; 95% CI, 4.20 to 13.15). The corresponding positive and negative predictive values for death were 14% (95%, 11 to 18) and 99% (95% CI, 97 to 100), respectively.

Conclusions
This meta-analysis indicates that while elevated BNP levels can help to identify patients with acute pulmonary embolism at high risk of death and adverse outcome events, the high negative predictive value of normal BNP levels is certainly more useful for clinicians to select patients with a likely uneventful follow-up.

20 Jul 08

Prevention of venous thromboembolism

Posted in Venous thromboembolism at 16:50 by Laci

American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)
By W H Geerts, D Bergqvist, G F Pineo, J A Heit, C M Samama et al

Chest 2008:133:381S-453S

This article discusses the prevention of venous thromboembolism (VTE) and is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do or do not outweigh risks, burden, and costs. Grade 2 suggestions imply that individual patient values may lead to different choices (for a full discussion of the grading, see the “Grades of Recommendation” chapter by Guyatt et al). Among the key recommendations in this chapter are the following: we recommend that every hospital develop a formal strategy that addresses the prevention of VTE (Grade 1A). We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A), and we recommend that mechanical methods of thromboprophylaxis be used primarily for patients at high bleeding risk (Grade 1A) or possibly as an adjunct to anticoagulant thromboprophylaxis (Grade 2A).

For patients undergoing major general surgery, we recommend thromboprophylaxis with a low-molecular-weight heparin (LMWH), low-dose unfractionated heparin (LDUH), or fondaparinux (each Grade 1A). We recommend routine thromboprophylaxis for all patients undergoing major gynecologic surgery or major, open urologic procedures (Grade 1A for both groups), with LMWH, LDUH, fondaparinux, or intermittent pneumatic compression (IPC).

For patients undergoing elective hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or a vitamin K antagonist (VKA); international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0 (each Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1B), a VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 1B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty or HFS receive thromboprophylaxis for a minimum of 10 days (Grade 1A); for hip arthroplasty and HFS, we recommend continuing thromboprophylaxis > 10 days and up to 35 days (Grade 1A). We recommend that all major trauma and all spinal cord injury (SCI) patients receive thromboprophylaxis (Grade 1A). In patients admitted to hospital with an acute medical illness, we recommend thromboprophylaxis with LMWH, LDUH, or fondaparinux (each Grade 1A). We recommend that, on admission to the ICU, all patients be assessed for their risk of VTE, and that most receive thromboprophylaxis (Grade 1A).

19 Jul 08

The perioperative management of antithrombotic therapy

Posted in Venous thromboembolism at 18:36 by Laci

American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)
By J D Douketis, P B Berger, A S Dunn, A K Jaffer, A C Spyropoulos et al

Chest. 2008;133:299S-339

This article discusses the perioperative management of antithrombotic therapy and is part of the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). The primary objectives of this article are the following: (1) to address the perioperative management of patients who are receiving vitamin K antagonists (VKAs) or antiplatelet drugs, such as aspirin and clopidogrel, and require an elective surgical or other invasive procedures; and (2) to address the perioperative use of bridging anticoagulation, typically with low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH). A secondary objective is to address the perioperative management of such patients who require urgent surgery. The recommendations in this article incorporate the grading system that is discussed in this supplement (Guyatt G et al, CHEST 2008; 133:123S–131S). Briefly, Grade 1 recommendations are considered strong and indicate that the benefits do (or do not) outweigh risks, burden, and costs, whereas Grade 2 recommendations are referred to as suggestions and imply that individual patient values may lead to different management choices.

The key recommendations in this article include the following: in patients with a mechanical heart valve or atrial fibrillation or venous thromboembolism (VTE) at high risk for thromboembolism, we recommend bridging anticoagulation with therapeutic-dose subcutaneous (SC) LMWH or IV UFH over no bridging during temporary interruption of VKA therapy (Grade 1C); in patients with a mechanical heart valve or atrial fibrillation or VTE at moderate risk for thromboembolism, we suggest bridging anticoagulation with therapeutic-dose SC LMWH, therapeutic-dose IV UFH, or low-dose SC LMWH over no bridging during temporary interruption of VKA therapy (Grade 2C); in patients with a mechanical heart valve or atrial fibrillation or VTE at low risk for thromboembolism, we suggest low-dose SC LMWH or no bridging over bridging with therapeutic-dose SC LMWH or IV UFH (Grade 2C).

In patients with a bare metal coronary stent who require surgery within 6 weeks of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C); in patients with a drug-eluting coronary stent who require surgery within 12 months of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C).

In patients who are undergoing minor dental procedures and are receiving VKAs, we recommend continuing VKAs around the time of the procedure and coadministering an oral prohemostatic agent (Grade 1B); in patients who are undergoing minor dermatologic procedures and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C); in patients who are undergoing cataract removal and are receiving VKAs, we recommend continuing VKAs around the time of the procedure (Grade 1C).

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