Pulmonary Embolism / DVT / VTE

Feb 162018
 
Ruling Out PE in the ED: Critical Analysis of the PROPER Trial

By Scott Aberegg, M.D., M.P.H. This post is going to be an in-depth “journal club” style analysis of the PROPER trial. In this week’s JAMA, Freund et al report the results of the PROPER randomized controlled trial of the PERC (pulmonary embolism rule -out criteria) rule for safely excluding pulmonary embolism (PE) in the emergency department (ED) [… read more]

Feb 152018
 
PERC Can Safely Rule Out Pulmonary Embolism in ED Setting

By Salynn Boyles, Contributing Writer, MedPage Today A clinical assessment protocol proved to be as effective as blood testing and CT imaging in the emergency department setting for ruling out pulmonary embolism in very low-risk patients in a newly reported French clinical trial. The crossover cluster-randomized PROPER study was conducted at 14 emergency departments (EDs) in France [… read more]

Dec 222017
 
FDA approves low-dose rivaroxaban for long-term PE/DVT prevention

The long-term management of recurrent venous thromboembolism continues to evolve with the FDA’s approval of once-daily low-dose rivaroxaban, now indicated for patients with recurrent deep venous thrombosis or pulmonary embolism who have completed at least six months of anticoagulation. FDA approved low-dose rivaroxaban based on data from 3,395 patients in the EINSTEIN-CHOICE study. Both 20 [… read more]

Dec 132017
 
Real-world bleeding risks of new anticoagulants similar to warfarin (or lower)

New-generation oral anticoagulants (NOACs) like dabigatran, rivaroxaban, and apixaban all had similar efficacy and bleeding risk compared to warfarin in the randomized trials that led to their FDA approval. That didn’t stop trial lawyers from filing bundles of lawsuits on behalf of patients experiencing hemorrhages after taking NOACs. (The large brand-name pharmaceutical manufacturers advertising new [… read more]

Nov 192017
 
Should intensivists routinely perform bedside echos in suspected PE?

In pulmonary embolism (PE), right ventricular (RV) strain on transthoracic echocardiography increases the likelihood of shock and mortality. One study showed among patients with PE and normal blood pressure, 10% of those with RV strain on echocardiogram developed shock, and 5% died in hospital. Those without RV strain maintained their blood pressure and survived (but important [… read more]

Aug 092017
 
Heparin-Induced Thrombocytopenia (HIT) Review

HIT Overview Heparin-induced thrombocytopenia (HIT) is a dangerous complication of heparin exposure. In HIT, the body creates an autoantibody against the complex of platelet factor 4 bound to heparin. The anti-PF4 autoantibodies can activate platelets and cause life- and limb-threatening thrombosis in arteries and veins. Platelets generally fall by more than 50% five to ten [… read more]

Jun 282017
 

The US Food and Drug Administration (FDA) approved betrixaban (Bevyxxa), a new oral anticoagulant for prevention of venous thromboembolism (VTE) in hospitalized medical patients with risk factors for DVT/PE. With betrixaban, manufacturer Portola will seek to expand a tiny market niche it could immediately dominate: prophylaxis of DVT/PE extending for about a month after hospital [… read more]

May 142017
 
Heparin prophylaxis no help after knee arthroscopy or leg casting (POT-KAST, POT-CAST)

Low molecular weight heparin (LMWH) at preventive doses after arthroscopic knee surgery or leg casting did not prevent venous thromboembolism (DVT or PE), in two Dutch randomized trials. The study helps fill a large gap in knowledge regarding risks and benefits of prophylactic anticoagulation in patients undergoing these procedures. In one (POT-KAST), 1,543 patients received [… read more]

Dec 162016
 
Inferior vena cava filters are overused. What's the harm?

Inferior vena cava filters (IVCF) are placed to prevent deep venous thromboses (DVT) from traveling to the heart and lungs, causing pulmonary embolism (PE). IVC filters’ rationale makes sense, but despite their wide use, the benefits and risks of IVCF remain unclear. With about 50,000 IVC filters placed annually in the U.S., that’s a lot of unclarity. [… read more]

Oct 212016
 
PESIT Investigators: the prevalence of PE in those hospitalized following first syncope

By Jon-Emile S. Kenny [@heart_lung] “The only way to get rid of temptation is to yield to it.” -Oscar Wilde The Case A 76 year old woman without known medical comorbidity is ambulating along 7th avenue, rounding the corner where St. Vincent’s Hospital once operated.  It is an exceptionally humid August afternoon and she has not [… read more]

Sep 172015
 
Overdiagnosis of pulmonary embolism on CT-angiogram by radiologists may be widespread

Contrasted CT-angiography of the chest, often called a “PE protocol CT,” has dramatically improved the diagnosis of pulmonary embolism. When used in conjunction with validated clinical decision tools like modified Wells criteria, CT-angiography is highly sensitive (good at detecting PE when it’s there and ruling it out when it’s not) and specific (generating few false-positive [… read more]

Aug 272015
 
Limited cancer screening seems appropriate after unprovoked PE

Cancers can cause pulmonary embolism, and an unprovoked PE may signal an undiscovered cancer lurking in the body. In older studies, as many as 1 in 10 patients with unprovoked PE were diagnosed with cancer within a year. (The current terminology is that a PE is provoked if associated with a known cancer or another provoking factor, but [… read more]

Aug 252015
 
Dabigatran-induced bleeding: antidote (idarucizumab) on the way

New oral anticoagulants like dabigatran, apixaban and rivaroxaban have advantages over warfarin: not requiring regular monitoring for efficacy; faster onset of action; shorter half-lives. Unlike warfarin, they’ve had the significant disadvantage of having no proven antidote for the bleeding that inevitably occurs when any anticoagulant is given to thousands of people. [lawsuits] Boehringer Ingelheim, makers [… read more]

Jul 172015
 
Recurrent PE risk after long-term warfarin therapy remains high (PADIS-PE)

Not long ago, doctors were taught that 6 months of anticoagulation was plenty for patients with unprovoked pulmonary embolism. That standard was never based on long-term outcomes studies. And as longer-range data started to come in — gulp — it was clear that large numbers of people treated with 6-month warfarin courses after unprovoked PE [… read more]

Jul 172015
 
Bridging anticoagulation for procedures after DVT/PE: usually, more harm than help?

“Bridging” anticoagulation — usually, interrupting chronic warfarin therapy, starting injectable or intravenous heparin, stopping just before an invasive procedure, restarting heparin and warfarin after, then stopping heparin — is a cumbersome and common practice in medicine. A new paper in JAMA Internal Medicine suggests that for most patients taking anticoagulation after deep venous thrombosis (DVT) [… read more]

Jul 022015
 
Direct thrombin inhibitors associated with heart attack risk in multiple trials

Direct thrombin inhibitors (DTIs) are anticoagulants (blood thinners) most often used as alternatives to heparin and warfarin. DTIs are approved by the FDA for prevention and treatment of venous thromboembolism (deep venous thrombosis and pulmonary embolism) and to prevent blood clots in people with atrial fibrillation. But multiple randomized trials suggest these widely used anticoagulants might cause heart [… read more]

Mar 132015
 
ICU Physiology in 1,000 Words: Right Ventricular Afterload (Part 1 of 2)

ICU Physiology in 1,000 Words: The Right Ventricular Afterload (Part 1 of 2) By Jon-Emile S. Kenny M.D. With my trusted-resident – Dr. Lina Miyakawa – at my side we watched as our patient could not maintain his oxygen saturation above 82%. The patient had terrible aspiration pneumonia superimposed upon horrendous methamphetamine-related pulmonary arterial hypertension [… read more]

Dec 192014
 
Age-adjusted D-dimer to rule out PE: coming of age?

Put a CT scanner in every U.S. emergency department, add the non-specific signs and symptoms of pulmonary embolism, stir in its potential lethality and morbidity, and line up a few thousand lawyers on the sidelines ready to capitalize on any missed diagnoses, and it’s no wonder that the use of CT-angiograms to rule out pulmonary embolism has risen 11-fold [… read more]

Sep 052014
 
New 2014 Pulmonary Hypertension guidelines released

The American College of Chest Physicians (unaffiliated with PulmCCM) published its new consensus guidelines in August 2014 for the drug treatment of pulmonary arterial hypertension (PAH). They’re free to view on the Chest website, and well worth a look. Remember that pulmonary arterial hypertension (PAH) is but one small subset (“Group 1”) of the much larger [… read more]

Aug 162014
 
Which cancer patients need prophylaxis for DVT and pulmonary embolism?

People with cancer have the highest rates of deep venous thrombosis (DVT) and pulmonary embolism (PE). However, the risk of venous thromboembolism varies widely by cancer type and between patients. Daily anticoagulant use can reduce the risk of DVT and pulmonary embolism, but at a cost of increased bleeding risk, patient inconvenience and discomfort, and cost. [… read more]