Preventing DVT and PE in Nonsurgical Patients from the ACCP Guidelines, 9th Ed. The ACCP‘s new 9th edition of their authoritative clinical practice guidelines for prevention and treatment of venous thromboembolism (VTE) were published in February 2012, and we’ll be summarizing the 801-page long document piece by piece. Here we review the section on prophylaxis of [... read more]
Starting and Managing Warfarin/Coumadin for Initial Treatment of DVT/PE from the ACCP Guidelines, 9th Ed. The ACCP’s new 9th edition of their clinical practice guidelines for prevention and treatment of DVT/PE were published in February 2012. Here we review their update on how to start a patient on warfarin (Coumadin) for deep venous thrombosis or pulmonary [... read more]
American College of Chest Physicians (ACCP)’s Guidelines for Diagnosis & Management of DVT / PE, 9th Ed. The ACCP‘s new 9th edition of their authoritative clinical practice guidelines for prevention and treatment of venous thromboembolism (VTE, DVT, PE) were published in February 2012, and we’re summarizing the 801-page long document piece by piece, helping you access the ACCP’s recommendations and [... read more]
For unclear reasons, people receiving chemotherapy for solid tumors are at particularly increased risk for deep venous thrombosis and pulmonary embolism (DVT/PE). Semuloparin is an ultra-low-molecular weight heparin with a long half life of 16-20 hours that (like enoxaparin) is renally excreted. Sanofi, makers of Lovenox, report in the February 16 New England Journal of [... read more]
As we were all taught in med school, long-distance flights, or even a long car trip, greatly increase your risk for deep venous thrombosis and pulmonary embolism … right? (I feel like I’ve answered about 8 board questions featuring this scenario.) The CDC even has a whole page of guidelines detailing the travel-DVT-risk-connection and the [... read more]
Januel et al report findings of a systematic review and meta-analysis to estimate the total incidence of acute symptomatic venous thromboembolism (symptomatic DVT or pulmonary embolism) among patients receiving proper thromboprophylaxis after hip or knee replacements. They came up with rates of 1.1% after knee replacements, and 0.5% after hip replacements. The rate of pulmonary [... read more]
For years, Pharma have been itching to prove a benefit of extended chemoprophylaxis against DVT / PE in medically ill patients after hospital discharge. Three weeks or more of enoxaparin after surgical knee or hip replacement is standard care, since it reduces the high risk of serious venous thromboembolism with a relatively low risk of [... read more]
As you know, the risk for DVT and PE in the ICU are high. How high? Depends on how you count them. Asymptomatic, ultrasound-surveillance-detected DVTs have an incidence of 5-10% during the ICU stay (from the PROTECT trial and a 2005 series), even when patients receive proper thromboprophylaxis. The incidence is even higher (up to 80%) in trauma [... read more]
Daunted by the seeming impossibility of measuring and comparing hospitals on real outcomes (given our primitive state of data collection and heterogeneity in patient populations, among many other challenges), well-meaning bureaucrats and non-profiteering safety advocates like the Institute for Healthcare Improvement have created directives based on surrogate measures in an attempt to standardize and improve [... read more]
Using the Nationwide Inpatient Sample and the national Multiple Cause-of-Death files, Wiener et al found that since the inception of CT-angiography in 1998, the number of CT-PE scans have risen 11-fold, and age-adjusted incidence of pulmonary embolism rose from 62 to 112 per 100,000 (an 81% increase). Over the same period, the mortality rate (presence of PE [... read more]
Moores LK et al. Current Approach to the Diagnosis of Acute Nonmassive Pulmonary Embolism. CHEST 2011;140:509-518. Review. Where is the best area under the curve, or the “overdiagnosis sweet spot?” It seems no approach gets us off the hook as we seek to avoid anticoagulating people without PEs (without missing any, of course): CT-angiography is more sensitive [... read more]
Chronic thromboembolic pulmonary hypertension: concise clinical review. Fedullo P et al. AJRCCM 2011;183:1605-1613. CTEPH review.
Optimal duration of anticoagulation after VTE: Goldhaber SZ, Circulation 2011;123:664-667. FREE FULL TEXT
Dalteparin is a low-molecular weight heparin that, unlike enoxaparin, is safe for people with renal failure. Among 3,746 ICU patients in 6 countries, followed until hospital discharge, there was no difference in the rate of proximal deep venous thrombosis (5.1% vs 5.8%, 1′ endpoint) between once-daily dalteparin and twice-daily UFH, as detected by twice-weekly ultrasounds. [... read more]
A 44-page guideline from the American Heart Association on the management of massive & submassive pulmonary embolism; proximal deep venous thrombosis, and chronic thromboembolic pulmonary hypertension. Circulation 2011;123:1788-1830. FREE FULL TEXT
A handful of people with pulmonary embolism have absolute contraindications to anticoagulation. Authors here describe these as: Any prior intracranial hemorrhage, known structural intracranial cerebrovascular disease (eg, arteriovenous malformation), known malignant intracranial neoplasm, ischemic stroke within 3 months, suspected aortic dissection, active bleeding or bleeding diathesis, recent surgery encroaching on the spinal canal or brain, [... read more]
Did you know that pulmonary embolism causes up to 20% of maternal deaths during pregnancy? The diagnosis is challenging, because pregnant women are often dyspneic, tachycardic, and have leg swelling at baseline. The best test, CT-angiography uses radiation that is, obviously, to be avoided at all costs for its teratogenic effects on the fetus. Ann [... read more]
Acute chest syndrome is a dreaded, dangerous complication of sickle cell disease. Its pathophysiology is complex and poorly understood, but can include high pulmonary artery pressures and vasoconstriction of pulmonary arteries. Although microvascular occlusion by abnormal and viscous sickling blood occurs in the systemic circulation, it’s never been shown to occur in the lungs. Dessap [... read more]
Chronic thromboembolic pulmonary hypertension is a “new” condition (in terms of our recognition and understanding of it), whose true prevalence, natural history, and response to therapies continue to be elucidated. Meanwhile, specialized surgical centers continually make thromboendarterectomy safer, providing definitive cures that are nothing short of miraculous for those affected by this otherwise usually fatal [... read more]
More than 40 small, middling-quality studies (n~80, some randomized) showing inconsistent results as to whether antioxidant therapy with acetylcysteine or other drugs reduces the risk for contrast nephropathy / acute kidney injury after angiography or CT-angiography. A 2008 meta-analysis concluded Mucomyst was helpful, reducing risk of nephropathy by almost 40% vs saline alone. However, the authors noted [... read more]