Seminars in respiratory and critical care medicine
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Low molecular weight heparins (LMWHs) and vitamin K antagonists make up the cornerstone of therapy for patients with venous thromboembolism (VTE) but have drawbacks making their use difficult in daily practice. Current research focuses on the development of new anticoagulant drugs that could be administered orally at a fixed dose, with fewer food and drug interactions and no need for monitoring or dose adjustment. Several new drugs are tested in noninferiority trials, either as a single-drug approach treatment (e.g., rivaroxaban or apixaban), or after an initial course of LMWH (e.g., dabigatran or edoxaban). ⋯ To what extent new anticoagulant drugs will change clinical practice is not yet well defined. They may facilitate outpatient management of VTE. They might also improve the risk-benefit balance of prolonged anticoagulation and therefore modify the optimal duration of anticoagulation in VTE patients.
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Risk stratification of patients with pulmonary embolism represents an important step and may help to guide initial therapeutic management. Pulmonary embolism can be stratified into several groups, with different risk of early death or complications based on the presence of several risk factors. High-risk pulmonary embolism is defined by shock or peripheral signs of hypoperfusion. ⋯ Lastly, patients with normotensive pulmonary embolism and without right ventricular dysfunction or myocardial injury have a low risk of death and complications. These patients may be candidates for home treatment. Several scores combining these risk factors have been described.
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Immediate intense anticoagulation with parenteral anticoagulants (heparin or fondaparinux) followed by vitamin K antagonists is the current standard therapy for deep vein thrombosis (DVT) or nonmassive pulmonary embolism. In the future, new oral anticoagulants may replace not only vitamin K antagonists but also initial parenteral anticoagulation. ⋯ Global markers of coagulation, particularly D-dimer, may discriminate low- and high-risk patients. Models that combine clinical characteristics and laboratory markers further improve prediction of the recurrence risk in individual patients, but these models await validation before they can be applied in routine care.
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Semin Respir Crit Care Med · Apr 2012
Review Comparative StudySerial limited versus single complete compression ultrasonography for the diagnosis of lower extremity deep vein thrombosis.
The diagnostic approach to deep vein thrombosis (DVT) has evolved during the last 3 decades. Contrast venography has been replaced by noninvasive tests. Compression ultrasonography (CUS) is currently the most widely used diagnostic test. ⋯ The main limitation of proximal CUS is the need to repeat the test once in patients with initial negative findings. Conversely, complete CUS detects many distal DVTs for which systematic anticoagulation therapy is debatable and exposes patients to potentially unnecessary anticoagulation. Incorporation of D-dimer testing and clinical pretest probability assessment in the diagnostic algorithm is beneficial because it allows excluding DVT without the need for diagnostic imaging in about a third of patients.
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An increasing body of evidence suggests the likelihood of a link between venous and arterial thrombosis. The two vascular complications share several risk factors, such as age, obesity, smoking, diabetes mellitus, blood hypertension, hypertriglyceridemia, and metabolic syndrome. ⋯ We, therefore, speculate the two vascular complications are simultaneously triggered by biological stimuli responsible for activating coagulation and inflammatory pathways in both the arterial and the venous system. Future studies are needed to clarify the nature of this association, to assess its extent, and to evaluate its implications for clinical practice.