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Journal of the American College of... Jan 2020The term embolic stroke of undetermined source (ESUS) was introduced in 2014 to describe patients with a nonlacunar ischemic stroke and no convincing etiology. The terms... (Review)
Review
The term embolic stroke of undetermined source (ESUS) was introduced in 2014 to describe patients with a nonlacunar ischemic stroke and no convincing etiology. The terms ESUS and cryptogenic stroke are not synonyms, as the latter also includes patients with multiple stroke etiologies or incomplete diagnostic work-up. ESUS involves approximately 17% of all ischemic stroke patients, and these patients are typically younger with mild strokes and an annual rate of stroke recurrence of 4% to 5%. It was hypothesized that oral anticoagulation may decrease the risk of stroke recurrence in ESUS, which was tested in 2 large randomized controlled trials: the NAVIGATE ESUS (Rivaroxaban Versus Aspirin in Secondary Prevention of Stroke and Prevention of Systemic Embolism in Patients With Recent Embolic Stroke of Undetermined Source) and the RE-SPECT ESUS (Dabigatran Etexilate for Secondary Stroke Prevention in Patients With Embolic Stroke of Undetermined Source). The present review discusses the trials of anticoagulation in patients with ESUS, suggests potential explanations for their neutral results, and highlights the rationale that supports ongoing and future research in this population aiming to reduce the associated risk for stroke recurrence.
Topics: Anticoagulants; Clinical Trials as Topic; Embolism; Humans; Platelet Aggregation Inhibitors; Stroke
PubMed: 31976872
DOI: 10.1016/j.jacc.2019.11.024 -
Thrombosis Research Jun 2021Pulmonary infarction results from occlusion of the distal pulmonary arteries leading to ischemia, hemorrhage and ultimately necrosis of the lung parenchyma. It is most... (Review)
Review
Pulmonary infarction results from occlusion of the distal pulmonary arteries leading to ischemia, hemorrhage and ultimately necrosis of the lung parenchyma. It is most commonly caused by acute pulmonary embolism (PE), with a reported incidence of around 30%. Following an occlusion of the pulmonary artery, the bronchial arteries are recruited as primary source of perfusion of the pulmonary capillaries. The relatively higher blood pressure in the bronchial circulation causes an increase in the capillary blood flow, leading to extravasation of erythrocytes (i.e. alveolar hemorrhage). If this hemorrhage cannot be resorbed, it results in tissue necrosis and infarction. Different definitions of pulmonary infarction are used in literature (clinical, radiological and histological), although the diagnosis is nowadays mostly based on radiological characteristics. Notably, the infarcted area is only replaced by a fibrotic scar over a period of months. Hence and formally, the diagnosis of pulmonary infarction cannot be confirmed upon diagnosis of acute PE. Little is known of the impact and relevance of pulmonary infarction in acute PE, and whether specific management strategies should be applied to prevent and/or treat complications such as pain, pneumonia or post-PE syndrome. In this review we will summarize current knowledge on the pathophysiology, epidemiology, diagnosis and prognosis of pulmonary infarction in the setting of acute PE. We highlight the need for dedicated studies to overcome the current knowledge gaps.
Topics: Acute Disease; Humans; Lung; Pulmonary Artery; Pulmonary Embolism; Pulmonary Infarction
PubMed: 33862471
DOI: 10.1016/j.thromres.2021.03.022 -
Indian Heart Journal 2023Acute pulmonary embolism (PE) can present with non-specific signs and symptoms and thus the diagnosis and management might not be as straightforward. This review... (Review)
Review
Acute pulmonary embolism (PE) can present with non-specific signs and symptoms and thus the diagnosis and management might not be as straightforward. This review outlines the new PE management guidelines in the Indian context. The exact prevalence in the Indian population is not well defined; despite recent studies suggesting an increasing trend in the Asian population. A delay in treatment can be fatal, especially in massive PE. The nuances associated with stratification and management have led to heterogeneity in acute PE management. The purpose of the review is. 1: To highlight the principles of stratification, diagnosis and management of acute PE with a special attention towards the Indian population. 2: To aid patient selection for newer catheter based therapies. To conclude, formulation of pulmonary embolism guidelines in the Indian setting is required underlying the role of further research in this area.
Topics: Humans; Thrombolytic Therapy; Pulmonary Embolism; Acute Disease; Treatment Outcome; Fibrinolytic Agents
PubMed: 37207830
DOI: 10.1016/j.ihj.2023.05.007 -
The Israel Medical Association Journal... Mar 2022Pulmonary embolism (PE) is very common in cancer patients and is a marker of increased mortality in these patients. Treatment is associated with increased rates of... (Review)
Review
Pulmonary embolism (PE) is very common in cancer patients and is a marker of increased mortality in these patients. Treatment is associated with increased rates of recurrent thrombosis and bleeding and has undergone significant change in the last years with the increasing use of direct oral anticoagulants. Diagnosis of PE and risk stratification is possible with minor changes to existing risk scores. Thrombolytic therapy should be considered in appropriate patients.
Topics: Anticoagulants; Hemorrhage; Humans; Neoplasms; Pulmonary Embolism; Thrombolytic Therapy
PubMed: 35347932
DOI: No ID Found -
Clinics in Chest Medicine Mar 2021Chronic thromboembolic pulmonary hypertension (CTEPH) and chronic thromboembolic pulmonary vascular disease (CTED) are rare manifestations of venous thromboembolism.... (Review)
Review
Chronic thromboembolic pulmonary hypertension (CTEPH) and chronic thromboembolic pulmonary vascular disease (CTED) are rare manifestations of venous thromboembolism. Presumably, CTEPH and CTED are variants of the same pathophysiological mechanism. CTEPH and CTED can be near-cured by pulmonary endarterectomy, balloon pulmonary angioplasty, and medical treatment with Riociguat or subcutaneous treprostinil, which are the approved drugs.
Topics: Chronic Disease; Humans; Hypertension, Pulmonary; Pulmonary Embolism; Venous Thromboembolism
PubMed: 33541619
DOI: 10.1016/j.ccm.2020.11.014 -
Deutsches Arzteblatt International Sep 2021Physicians from many different specialties see patients suffering from acute pulmonary embolism (PE), which has an incidence of 39-115 cases per 100 000 persons per... (Review)
Review
BACKGROUND
Physicians from many different specialties see patients suffering from acute pulmonary embolism (PE), which has an incidence of 39-115 cases per 100 000 persons per year. Because PE can be life-threatening, a rapid, targeted response is essential.
METHODS
This review is based on pertinent publications retrieved by a selective literature search of international databases, with particular attention to current guidelines and expert opinions.
RESULTS
Whenever PE is suspected, clinical assessment tools must be applied for risk stratification and diagnostic evaluation. The PERC (Pulmonary Embolism Rule-out Criteria) and the YEARS algorithm lead to more effective diagnosis. For hemodynamically unstable patients, bedside echocardiography is of high value and enables risk stratification. New oral anticoagulants have fewer hemorrhagic complications than vitamin K antagonists and are not inferior to them with respect to the risk of recurrent PE (hazard ratio 0.84-1.09). The duration of anticoagulation is set according to the risk of recurrence. Systemic thrombolysis is recommended for patients with a high-risk PE, in whom it significantly reduces mortality (odds ratio 0.53, number needed to treat 59). Surgical or interventional techniques can be considered if thrombolysis is contraindicated or unsuccessful.
CONCLUSION
Newly introduced diagnostic aids and algorithms simplify the diagnosis and treatment of acute PE while continuing to assure a high degree of patient safety.
Topics: Acute Disease; Anticoagulants; Echocardiography; Fibrinolytic Agents; Humans; Pulmonary Embolism
PubMed: 34857082
DOI: 10.3238/arztebl.m2021.0226 -
JAMA Network Open Nov 2022Amniotic fluid embolism (AFE) is an uncommon pregnancy complication but is associated with high maternal mortality. Because of the rarity of AFE, associated risks...
IMPORTANCE
Amniotic fluid embolism (AFE) is an uncommon pregnancy complication but is associated with high maternal mortality. Because of the rarity of AFE, associated risks factors and maternal outcomes have been relatively understudied.
OBJECTIVE
To examine the clinical, pregnancy, and delivery characteristics and the maternal outcomes related to AFE in a recent period in the US.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective cohort study examined hospital deliveries from January 1, 2016, to December 31, 2019, from the Healthcare Cost and Utilization Project's National Inpatient Sample.
MAIN OUTCOMES AND MEASURES
The primary outcome was clinical, pregnancy, and delivery characteristics of AFE, assessed with a multivariable binary logistic regression model. The coprimary outcome was failure to rescue, defined as maternal mortality after AFE. Associations with other severe maternal morbidity indicators and failure to rescue per clinical and pregnancy characteristics were also assessed.
RESULTS
A total of 14 684 135 deliveries were examined, with AFE diagnosed in 880 women, corresponding to an incidence rate of 6.0 per 100 000 deliveries. The cohort-level median patient age was 29 years (IQR, 25-33 years). In a multivariable analysis, (1) patient factors of older age, Asian and Black race, Western US region, pregestational hypertension, asthma, illicit substance use, and grand multiparity; (2) pregnancy factors of placental accreta spectrum (PAS), placental abruption, uterine rupture, polyhydramnios, chorioamnionitis, preeclampsia, fetal growth restriction, and fetal demise; and (3) delivery factors of early gestational age, cervical ripening, cesarean delivery, operative delivery, and manual removal were associated with AFE. Among these characteristics, PAS had the largest association with AFE (adjusted odds ratio [aOR], 10.01; 95% CI, 7.03-14.24). When stratified by the PAS subtypes, more severe forms of PAS had a greater association with AFE (aOR for increta and percreta, 17.35; 95% CI, 10.21-28.48; and aOR for accreta, 7.62; 95% CI, 4.83-12.01). Patients who had AFE were more likely to have coagulopathy (aOR, 24.68; 95% CI, 19.38-31.44), cardiac arrest (aOR, 24.56; 95% CI, 17.84-33.81), and adult respiratory distress syndrome (aOR, 10.72; 95% CI, 8.09-14.20). The failure-to-rescue rate after AFE was 17.0% overall. However, the failure-to-rescue rate exceeded 30% when AFE co-occurred with other severe maternal morbidity indicators: 45.8% for AFE, cardiac arrest, and coagulopathy; 43.2% for AFE, shock, and cardiac rhythm conversion; and 38.6% for AFE, cardiac arrest, coagulopathy, and shock. The failure-to-rescue rate after AFE also exceeded 30% when AFE occurred in the setting of placental pathology: 42.9% for AFE and PAS and 31.3% for AFE and placental abruption.
CONCLUSIONS AND RELEVANCE
This contemporaneous, national-level analysis validated previously known risk factors for AFE and confirmed the dismal outcomes of pregnancy complicated by AFE. The association between PAS and AFE, which was not previously reported, warrants further investigation.
Topics: Humans; Adult; Female; Pregnancy; Embolism, Amniotic Fluid; Maternal Mortality; Retrospective Studies; Abruptio Placentae; Placenta; Parity; Heart Arrest
PubMed: 36399343
DOI: 10.1001/jamanetworkopen.2022.42842 -
Medicina (Kaunas, Lithuania) Aug 2022Pulmonary embolism (PE) can have a wide range of hemodynamic effects, from asymptomatic to a life-threatening medical emergency. Pulmonary embolism (PE) is associated... (Review)
Review
Pulmonary embolism (PE) can have a wide range of hemodynamic effects, from asymptomatic to a life-threatening medical emergency. Pulmonary embolism (PE) is associated with high mortality and requires careful risk stratification for individualized management. PE is divided into three risk categories: low risk, intermediate-risk, and high risk. In terms of initial therapeutic choice and long-term management, intermediate-risk (or submassive) PE remains the most challenging subtype. The definitions, classifications, risk stratification, and management options of intermediate-risk PE are discussed in this review.
Topics: Humans; Pulmonary Embolism; Risk Assessment
PubMed: 36143863
DOI: 10.3390/medicina58091186 -
Annals of Internal Medicine Nov 2022Although apixaban and rivaroxaban are commonly used in patients with atrial fibrillation (AF) and valvular heart disease (VHD), there is limited evidence comparing the 2... (Clinical Trial)
Clinical Trial
BACKGROUND
Although apixaban and rivaroxaban are commonly used in patients with atrial fibrillation (AF) and valvular heart disease (VHD), there is limited evidence comparing the 2 drugs in these patients.
OBJECTIVE
To emulate a target trial of effectiveness and safety of apixaban and rivaroxaban in patients with AF and VHD.
DESIGN
New-user, active comparator, cohort study design.
SETTING
Commercial health insurance database from 1 January 2013 to 31 December 2020.
PATIENTS
New users of apixaban or rivaroxaban who had a diagnosis of AF and VHD before initiation of anticoagulant therapy.
MEASUREMENTS
The primary effectiveness outcome was a composite of ischemic stroke or systemic embolism. The primary safety outcome was a composite of gastrointestinal or intracranial bleeding. Cox proportional hazards regression with a robust variance estimator was used to estimate hazard ratios (HRs) and 95% CIs.
RESULTS
When compared with rivaroxaban in a propensity score-matched cohort of 19 894 patients (9947 receiving each drug), apixaban was associated with a lower rate of ischemic stroke or systemic embolism (HR, 0.57 [95% CI, 0.40 to 0.80]) and bleeding (HR, 0.51 [CI, 0.41 to 0.62]). The absolute reduction in the probability of stroke or systemic embolism with apixaban compared with rivaroxaban was 0.0026 within 6 months and 0.011 within 1 year of treatment initiation. The absolute reduction in the probability of bleeding events with apixaban compared with rivaroxaban was 0.012 within 6 months and 0.019 within 1 year of treatment initiation.
LIMITATION
Short follow-up time and inability to ascertain some types of VHD.
CONCLUSION
In this study of patients with AF and VHD, patients receiving apixaban had a lower risk for ischemic stroke or systemic embolism and for bleeding when compared with those receiving rivaroxaban.
PRIMARY FUNDING SOURCE
National Institutes of Health.
Topics: Humans; Anticoagulants; Atrial Fibrillation; Cohort Studies; Embolism; Heart Valve Diseases; Hemorrhage; Ischemic Stroke; Rivaroxaban; Stroke
PubMed: 36252244
DOI: 10.7326/M22-0318 -
Australian Journal of General Practice Sep 2022Pulmonary embolism (PE) remains a common problem and can present with nonspecific symptoms and signs. Anticoagulation is the mainstay of management, the duration of...
BACKGROUND
Pulmonary embolism (PE) remains a common problem and can present with nonspecific symptoms and signs. Anticoagulation is the mainstay of management, the duration of which often depends on the clinical circumstances of the PE.
OBJECTIVE
The aim of this article is to review the epidemiology, clinical presentation, diagnosis, management and long-term complications of PE.
DISCUSSION
The incidence of PE appears to be increasing worldwide. Common risk factors include recent surgery, trauma, malignancy and oestrogen exposure. Diagnosis relies on a combination of clinical findings, laboratory tests and radiological imaging, often incorporating clinical prediction tools. Objectively confirmed PE requires anticoagulation, usually with a direct oral anticoagulant (DOAC), of at least three months' duration, but indefinite anticoagulation is being considered increasingly because of the heightened risk for recurrence following anticoagulation cessation, and overall safety of DOACs. Chronic thromboembolic pulmonary hypertension is rare but associated with significant morbidity and mortality.
Topics: Anticoagulants; Humans; Incidence; Pulmonary Embolism; Risk Factors
PubMed: 36045622
DOI: 10.31128/AJGP-05-22-6440