Translational research : the journal of laboratory and clinical medicine
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Venous thromboembolism (VTE) is a common disorder associated with substantial morbidity and mortality. It may be encountered by clinicians in virtually all medical specialties and healthcare settings. A large number of clinical practice guidelines (CPGs) on VTE have been published in recent years to support clinicians in delivering high-quality care for the prevention, diagnosis, and management of VTE. ⋯ These elements enhance the transparency and trustworthiness of CPGs and set them apart from other types of clinical guidance documents. The objectives of this narrative review are to summarize methods used to develop CPGs and to provide guidance to end-users on how to interpret recommendations and apply them in clinical practice. While much of the content of this review applies to CPGs in general, irrespective of disease focus, a number of examples specific to VTE are included.
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The use of fibrinolytic agents in acute pulmonary embolism (PE), first described over 50 years ago, hastens the resolution of RV stain, leading to earlier hemodynamic improvement. However, this benefit comes at the increased risk of bleeding. The strongest indication for fibrinolysis is in high-risk PE, or that characterized by sustained hypotension, while its use in patients with intermediate-risk PE remains controversial. ⋯ The efficacy of fibrinolysis often varies significantly between patients, which may be at least partially explained by several factors found to promote resistance to fibrinolysis. Ultimately, treatment decisions should carefully weigh the risks and benefits of the individual clinical scenario at hand, including the overall severity, the patient's bleeding risk, and the presence of factors known to promote resistance to fibrinolysis. This review aims to further explore the use of fibrinolytic agents in the treatment of PE including specific indications, outcomes, and special considerations.
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Antiphospholipid syndrome is one of the more common acquired causes of hypercoagulability. Its major presentations are thrombotic (arterial, venous, or microvascular) and pregnancy morbidity (miscarriages, late intrauterine fetal demise, and severe pre-eclampsia). Classification criteria include 3 different antiphospholipid antibodies: lupus anticoagulant, anticardiolipin, and anti-beta 2 glycoprotein I. Management includes both preventive strategies (low-dose aspirin, hydroxychloroquine) and long-term anticoagulation after thrombosis.
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Endogenous and exogenous hormones have significant effects on coagulation and may tip the hemostatic balance toward thrombosis. The endogenous hormonal changes in pregnancy and polycystic ovary syndrome, and exogenous hormonal contraception, menopause replacement, and transgender cross-hormone replacement may increase thromboembolism risk. Using the lowest effective dose is critical for prevention, but once thrombosis occurs, anticoagulation may be required, in some, long term. We review the relative risk of thrombosis in these conditions, risk factors, and anticoagulation treatment and prevention. Implementation of lowest effective hormonal therapies, thrombosis reduction strategies, and current anticoagulation management are critical for optimal patient outcomes.
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Cancer-associated thrombosis is a leading cause of non-cancer death in cancer patients and is comprised of both arterial and venous thromboembolism (VTE). There are multiple risk factors for developing VTE, including cancer type, stage, treatment, and other medical comorbidities, which suggests that the etiology of thrombosis is multifactorial. ⋯ Although risk models exist for primary and recurrent VTE, additional predictors are needed to improve model performance and discrimination of high-risk patients. This review will outline the diverse mechanisms driving thrombosis in cancer patients, as well as provide an overview of biomarkers studied in thrombosis risk and important considerations when selecting candidate biomarkers.