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
ReviewThrombophilic Evaluation in Patients with Acute Pulmonary Embolism.
Patients with acute pulmonary embolism (PE) are often tested for thrombophilias, which are hereditary and acquired conditions that predispose to thrombosis. If a hereditary condition is identified, then testing is often performed on members of the patient's family. Testing for these conditions can be complex, as the presence of acute thrombosis and antithrombotic therapies can make the results of many tests unreliable. ⋯ Clinicians should carefully consider the relevant risks and benefits before testing patients for thrombophilia. When performed, testing should be timed correctly and care should be taken to properly interpret results. New models that incorporate multiple genetic and clinical markers may improve the utility of testing, but these await further research.
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Semin Respir Crit Care Med · Feb 2017
ReviewThe Pulmonary Embolism Response Team: What Is the Ideal Model?
Treatment of patients with intermediate- and high-risk pulmonary embolism (PE) is a controversial area. Many therapeutic options exist, and deciding on appropriate treatment can be difficult. ⋯ The goal of a PERT is to have a single multidisciplinary team of experts in thromboembolic disease, who can respond rapidly to patients with acute PE, and offer consultation with the full spectrum of therapeutic options. PERT teams were modeled after rapid response teams and are meant to generate a prompt, patient-specific plan for patients with PE without having to consult multiple individual specialists.
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Semin Respir Crit Care Med · Feb 2017
Echocardiography in the Risk Assessment of Acute Pulmonary Embolism.
Acute pulmonary embolism (PE) is a major cause of morbidity and mortality and is classified as massive (high risk), submassive (intermediate risk), or nonmassive (low risk) based on the hemodynamic status and clinical characteristics of the patient. At this time, the management of patients with submassive PE remains controversial and approaches for improving risk assessment are critical. ⋯ Because of their reproducibility and objective nature, quantitative RV echocardiographic assessments have been gaining importance in the assessment of acute PE. Current limitations to the use of echocardiography for risk assessment in acute PE are the lack of normative values for RV parameters, the absence of standardization of measurements across different ultrasound platforms, and the heterogeneity of the performance of echocardiographic examinations and reports across centers.
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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.