Seminars in respiratory and critical care medicine
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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 Contrast venography has been replaced by noninvasive tests.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.
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Semin Respir Crit Care Med · Apr 2012
Inherited and acquired risk factors for venous thromboembolism.
Venous thrombosis, or venous thromboembolism, comprises deep vein thrombosis with or without symptomatic pulmonary embolus. The development of symptomatic venous thrombosis is highly dependent on gene-environment interaction. In most instances this interaction results in hypercoagulability (the intermediate phenotype) sufficient to result in intraluminal clot formation (the disease phenotype). ⋯ However, the risk differs between patients. Duration of anticoagulation (lifelong or not) should be made with reference to whether an episode of thrombosis was provoked and the presence of other risk factors. The results of testing for heritable thrombophilia rarely influence duration of treatment.