For patients with venous thromboembolism (VTE), prediction of bleeding is relevant throughout the course of treatment, although the means and goal of this prediction differ between the subsequent ...stages of treatment: treatment initiation, hospital discharge, 3-month follow-up, and long-term follow-up. Even in the absence of fully established risk prediction schemes and outcome studies using a prediction scheme for treatment decisions, the present evidence supports screening for and targeting of modifiable risk factors for major bleeding, as well as the application of decision rules to identify patients at low risk of bleeding complications, in whom long-term anticoagulant treatment is likely safe. Moving forward, prediction tools need to be incorporated in well-designed randomized controlled trials aiming to establish optimal treatment duration in patients at high risk of recurrent VTE. Moreover, the benefit of their longitudinal assessment rather than application as stand-alone baseline assessments should be studied, because changes in bleeding risk over time likely constitute the best predictor of major bleeding. We provide the state-of-the-art of assessing and managing bleeding risk in patients with acute VTE and highlight a practical approach for daily practice illustrated by 2 case scenarios.
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Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism, either symptomatic or not. The occlusion of proximal pulmonary arteries by fibrotic ...intravascular material, in combination with a secondary microvasculopathy of vessels less than 500 µm, leads to increased pulmonary vascular resistance and progressive right heart failure. The mechanism responsible for the transformation of red clots into fibrotic material remnants has not yet been elucidated. In patients with pulmonary hypertension, the diagnosis is suspected when a ventilation/perfusion lung scan shows mismatched perfusion defects and confirmed by right heart catheterisation and vascular imaging. Today, in addition to lifelong anticoagulation, treatment modalities include surgery, angioplasty and medical treatment according to the localisation and characteristics of the lesions.This Statement outlines a review of the literature and current practice concerning diagnosis and management of CTEPH. It covers the definitions, diagnosis, epidemiology, follow up after acute pulmonary embolism, pathophysiology, treatment by pulmonary endarterectomy, balloon pulmonary angioplasty, drugs and their combination, rehabilitation and new lines of research in CTEPH.It represents the first collaboration of the European Respiratory Society (ERS), the International CTEPH Association (ICA) and the European Reference Network (ERN)-Lung in the pulmonary hypertension domain. The Statement summarises current knowledge but does not make formal recommendations for clinical practice.
Abstract The post-Pulmonary Embolism (post-PE) syndrome is being increasingly recognized as a long-term consequence of PE. Its most severe manifestation, chronic thromboembolic pulmonary hypertension ...(CTEPH), affects a small proportion of PE survivors. However, many more with less severe post-PE syndrome have reduced quality of life and functional capacity. The pathophysiology is incompletely understood, but involves unresolved pulmonary artery thrombus, right ventricular damage, and abnormal gas exchange. Treatment has only been established for CTEPH, and further studies are required to determine if novel treatment and/or preventative strategies can reduce the incidence of this entity.
Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, most attention has focused on containing transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and ...addressing the surge of critically ill patients in acute care settings. Indeed, as of 29 April 2020, over 3 million confirmed cases have been accounted for globally 1. In the coming weeks and months, emphasis will gradually involve also post-acute care of COVID-19 survivors. It is anticipated that COVID-19 may have a major impact on physical, cognitive, mental and social health status, also in patients with mild disease presentation 2. Previous outbreaks of coronaviruses have been associated with persistent pulmonary function impairment, muscle weakness, pain, fatigue, depression, anxiety, vocational problems, and reduced quality of life to various degrees 3–5.
An ordinal tool is proposed to measure the full spectrum of functional outcomes following COVID-19. This “Post-COVID-19 Functional Status (PCFS) scale” can be used for tracking functional status over time as well as for research purposes.
https://bit.ly/3cofGaa
The incidence of chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE) is relevant for management decisions but is currently unknown.We performed a meta-analysis of ...studies including consecutive PE patients followed for CTEPH. Study cohorts were predefined as "all comers", "survivors" or "survivors without major comorbidities". CTEPH incidences were calculated using random effects models.We selected 16 studies totalling 4047 PE patients who were mostly followed up for >2-years. In 1186 all comers (two studies), the pooled CTEPH incidence was 0.56% (95% CI 0.1-1.0). In 999 survivors (four studies) CTEPH incidence was 3.2% (95% CI 2.0-4.4). In 1775 survivors without major comorbidities (nine studies), CTEPH incidence was 2.8% (95% CI 1.5-4.1). Both recurrent venous thromboembolism and unprovoked PE were significantly associated with a higher risk of CTEPH, with odds ratios of 3.2 (95% CI 1.7-5.9) and 4.1 (95% CI 2.1-8.2) respectively. The pooled CTEPH incidence in 12 studies that did not use right heart catheterisation as the diagnostic standard was 6.3% (95% CI 4.1-8.4).The 0.56% incidence in the all-comer group probably provides the best reflection of the incidence of CTEPH after PE on the population level. The ∼3% incidences in the survivor categories may be more relevant for daily clinical practice. Studies that assessed CTEPH diagnosis by tests other than right heart catheterisation provide overestimated CTEPH incidences.
The main objectives of therapeutic trials in venous thromboembolism (VTE) are to prevent recurrent VTE, major bleeding and death. While these outcomes are indeed highly relevant, they are also rare ...and do not fully capture the overall functional outcome of VTE patients. Importantly, functional limitations after VTE are prevalent after both deep vein thrombosis and pulmonary embolism occurring in up to 50% of patients. These post-VTE syndromes are associated with a decreased quality of life, higher risk of depressive disorders, unemployment and increased utilization of healthcare resources. Because of the major impact of functional limitations on individual patients and society as a whole, development of tools able to capture functional outcomes in clinical trials are urgently needed. We anticipate that a standardized post-VTE functional status scale will aid in demarcating effective and ineffective VTE therapies on functional outcomes in trials with appropriately powered sample sizes, as well as pave the road for value-based healthcare. The scale that we have in mind covers the entire spectrum of functional outcomes ranging from no symptoms to death. Moreover, it focuses on both limitations in usual activity as well as changes in lifestyle. The scale is not meant to replace current diagnostic or prognostic scores for post-VTE syndromes, but to be used as an outcome measure to evaluate the overall consequences of VTE on functional status. This review is a call for action to the VTE community to join forces and support further development of the proposed scale, a process of which we summarize the necessary steps.
•Functional limitations after venous thromboembolism (VTE) are prevalent.•Validated tools to measure post-VTE functional limitations are unavailable.•We propose derivation of an ordinal standardized post-VTE functional status scale.
Management of incidental pulmonary embolism Klok, Frederikus A; Huisman, Menno V
European respiratory journal/The European respiratory journal,
06/2017, Letnik:
49, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Incidental pulmonary embolism (PE) is a frequent finding on routine computed tomography (CT) scans of the chest, occurring in 1.1% of coronary CT scans and 3.6% of oncological CT scans. Despite this ...high frequency, optimal management of incidental PE has not been addressed in clinical trials and remains the subject of debate. Although these CT scans have not been performed with a dedicated PE protocol and have suboptimal contrast enhancement, diagnosis of incidental PE has been shown to be accurate up to the segmental and subsegmental arteries. The embolic load in incidental PE is lower than that in symptomatic PE. Even so, observational studies suggest that the natural course of incidental PE is similar to that of symptomatic PE with regard to the risk of recurrent venous thrombotic disease and mortality. Interestingly, the increased use of more advanced CT technology has coincided with an increase in the rate of incidental subsegmental PE, as is the case for symptomatic subsegmental PE. Although clinical trials are lacking, and observational data are limited to cancer-associated incidental PE, the consensus is that the management of incidental PE is identical to that of symptomatic PE, including the choice of optimal drug class, outpatient treatment and total duration of treatment.
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