S Z Goldhaber

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..In this Seminar, we discuss pulmonary embolism and deep vein thrombosis of the legs...

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..At Brigham and Women's Hospital, VTE after craniotomy for brain tumor is the leading cause of deep vein thrombosis (DVT) and pulmonary embolism (PE) among patients hospitalized for conditions other than VTE...

..When high-risk patients are identified,they can be triaged for urgent or emergent therapy, usually prior to developing overt hypotension and cardiogenic shock...

..We will conclude by posing 10 questions for future research on this topic...

..After hospital discharge, prophylaxis should continue for about a month for patients at high risk of thromboembolism...

..Avenues of investigation currently being evaluated include measurement of d-dimer levels, examination of residual venous thrombosis on ultrasound, and application of risk nomograms...

..The two most common genetic mutations that predispose to VTE are the factor V Leiden and the prothrombin gene. VTE can be precipitated by oral contraceptives, pregnancy, or hormone replacement therapy...

..Fortunately the current tools for risk stratification provide an "early window" for prognostication and can help the coordination of a definitive treatment plan with optimal results...

..Further research will clarify and define more precisely the utility and limitations of echocardiography in the management of pulmonary embolism...

..Our 'new approach' uses advanced treatment strategies in addition to anticoagulation for those pulmonary embolism patients deemed to be at high risk for a poor outcome...

..Among patients with massive DVT or hemodynamically unstable PE, thrombolysis, thrombectomy, and embolectomy (often performed in an interventional angiography laboratory) are being used with increasing skill and improved outcomes...

..With a 3-stage approach consisting of (1) clinical evaluation; (2) nonimaging laboratory tests; and (3) imaging tests, PE can often be quickly detected with a definitive evaluation...

..Once DVT is suspected, a workup can proceed rapidly and accurately to resolve the diagnostic issue...

..Because approximately 3 of every 4 pulmonary embolism and DVT events occur outside the hospital setting, patients should also be assessed for persistent high-risk of VTE at the time of hospital discharge...

..We hypothesized that extended prophylaxis with apixaban would be safe and more effective than short-term prophylaxis with enoxaparin...

..Finally, the availability of low molecular weight heparins broadens our options for pharmacologic management...

..Future clinical trials will require multicenter collaboration and focus on clinically relevant endpoints such as reduction of mortality and recurrent venous thromboembolism...

..Therefore, among hospitalized patients, the development of VTE is thought to occur in the context of omitted prophylaxis...

..6 days) (p = 0.001). Following our study we can conclude that extended 3-month treatment with enoxaparin as monotherapy for symptomatic, acute pulmonary embolism is feasible and warrants further study in a large clinical trial...

..Despite the high rate of recurrent venous thrombosis after discontinuation of anticoagulation, there are currently insufficient data to recommend indefinite warfarin therapy...

..In some but not all studies, men with venous thrombosis had a higher risk of recurrence than women. Information on women with initial hormone-related thrombosis is scant...

..Future studies should focus on ways to improve implementation of prophylaxis in cancer patients and to further define the indications, efficacy, and safety of inferior vena caval filters in this population...

..CONCLUSIONS: Among patients with idiopathic VTE, measurement of D-dimer, but not FVIIIc, might be useful for risk stratification. The efficacy of extended low-intensity warfarin therapy did not vary by biomarker level...

..Our findings identify deficiencies in our current understanding and the prophylaxis of UEDVT and generate hypotheses for future research efforts...

..Hospitalized patients with medical illness are especially susceptible to the development of venous thromboembolism (VTE)...

..Moderate alcohol consumption decreases the risk of coronary heart disease, but its relation to peripheral arterial disease (PAD) is uncertain...

..However, this low-molecular-weight heparin has not been previously evaluated in a randomized controlled trial for treatment of established acute deep venous thrombosis...

..The proportion of patients with major and intracranial bleeding increased from 20.2% and 1.9%, respectively, in the first time period, to 33.3% and 7.8%, respectively, in the second...

..7% in clinical trials up to approximately 3.0% in a large registry...

..33). Reconstructed 4-chamber views on chest CT provide noninvasive imaging of right ventricular enlargement and permit dynamic assessment of the right ventricular response to thrombolysis and embolectomy in patients with acute PE...

..To describe the circumstances surrounding deep vein thrombosis among pregnant or postpartum patients enrolled in a large multicenter registry...

..Supplementation with vitamin E may antagonize vitamin K in healthy adults, but it is unclear whether intake of vitamin E decreases the risk of venous thromboembolism (VTE)...

..Future studies should focus on devising mechanisms to improve implementation of prophylaxis and investigate the long-term safety and efficacy of IVC filters in surgical patients...

..43 to 0.81; P=0.001). CONCLUSIONS: The institution of a computer-alert program increased physicians' use of prophylaxis and markedly reduced the rates of deep-vein thrombosis and pulmonary embolism among hospitalized patients at risk...

..Rapid, noninvasive, and accurate prognostic assessment with an inexpensive cardiac biomarker is an appealing approach for patients with acute pulmonary embolism (PE)...

..99) and in elderly (1.1% vs 0.7%; P=.12) patients. CONCLUSION: Our findings suggest that a fixed low dose of dalteparin sodium of 5000 U/d is effective and safe in preventing VTE in obese and elderly hospitalized medical patients...

..Short-term aspirin therapy can lower the risk for venous thromboembolism (VTE) in high-risk patients, but whether the long-term use of low-dose aspirin reduces risk in healthy adults is uncertain...

..The patients who received low-molecular-weight heparin had a shorter length of stay and decreased postoperative costs compared with the control subjects receiving unfractionated heparin...

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..In conclusion, LMWH has the potential to offer several short- and long-term cost advantages compared with warfarin, mostly due to lower test costs associated with prophylaxis and reduced complication rates...

..5 mg/kg once daily versus enoxaparin 1.0 mg/kg twice daily as a bridge to warfarin in outpatients with acute venous thromboembolism...

..Counterintuitively, thrombolysis did not reduce mortality or recurrent PE at 90 days. The observed reduction in mortality from IVC filters requires further investigation...

..32 bleeds/100 patient-years of coverage. Of the 12 bleeding events, 5 (42%) were intracranial hemorrhages. The average hospitalization cost per patient was dollar 15,988, and the average length of hospitalization was 6.0 days...

..CONCLUSION: Among patients with pulmonary embolism who present with a systolic arterial pressure greater than or equal to 90 mm Hg, echocardiographic RV hypokinesis is an independent predictor of early death...

..Patients with elevated troponin and right ventricular enlargement are at significantly greater risk for death after PE than patients with only 1 or with neither adverse prognostic marker...

..To review the incidence and outcome of clinically significant venous thromboembolism (VTE) following gynecologic surgery in a population receiving provider-specified prophylaxis...

..Recognition of potential causes of excessive anticoagulation and the use of self-monitoring by patients may improve the efficacy and safety of long-term warfarin administration...

..4 to 1,410.9, p < 0.001), cancer (OR 16.0, 95% CI 3.2 to 80, p = 0.004), diabetes mellitus (OR 9.6, 95% CI 1.7 to 54, p = 0.010), and elevated international normalized ratio before fibrinolysis (OR 5.8, 95% CI 1.5 to 22, p = 0.012)...

..The purpose of our study was to assess the utility of performing routine pelvic and lower extremity CT venography (CTV) along with pulmonary CT angiography (CTA) in all patients evaluated for pulmonary embolism...

..Patients with chronic obstructive pulmonary disease (COPD) are at increased risk for venous thromboembolism (VTE). We analyzed a large US deep vein thrombosis (DVT) registry to explore the profile of patients with COPD and VTE...

..By paying more attention to normal D-dimer results, fewer chest CT scans and lung scans will be required, and improvements may be realized in diagnostic efficiency and cost reduction...

..Our contemporary approach to pulmonary embolectomy no longer confines this operation to a treatment of last resort reserved for clinically desperate circumstances...

..02-1.34) was the only independent predictor of massive DVT. Thrombus propagation from the femoropopliteal system cannot be reliably predicted using demographic or clinical characteristics...

..Future studies should expand on our observations to determine whether prophylaxis with proton pump inhibitors is warranted...

..CONCLUSIONS: Serial INRs are poor predictors of hemorrhagic events. There appears to be only a brief warning period during which a slightly elevated INR predicts an imminent bleeding event...

..217). In patients with acute symptomatic PE, extended enoxaparin monotherapy is feasible and warrants further investigation in a large clinical trial...

..To investigate risk factors for pulmonary embolism in women...

..Diagnosis can present a challenge because typical deep-vein thrombosis symptoms may be absent. Fewer than 50% of elderly patients with deep-vein thrombosis had received any venous thromboembolism prophylaxis...

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..Our goals were to determine which strategy demonstrated the best adherence in terms of timing and frequency of dose administration, and to determine reasons for ordered heparin not being administered...

..Increasing BMI has a strong, linear association with the development of PE in women. Clinicians should consider BMI when assessing the risk of PE in their patients...

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..These VTE complications would be reduced by more than half with universal thromboprophylaxis. Further efforts should focus on improving VTE prophylaxis utilisation...

..However, research suggests that subjective gestalt performs similarly to the CPES, and the influence of the subjective question on the predictive value of the CPES is not clear...

..When patients present with dyspnea, hepatojugular reflux, and peripheral edema refractory to diuretics, constrictive cardiac physiology should be considered in the differential diagnosis, even in the absence of parietal pericardium...

..2% of patients required medical intervention and 1.5% needed prolonged hospitalization. Medication errors frequently occur with anticoagulant therapy in hospitalized patients...

..69). These results should provide clinicians with increased warfarin dosing options in patients presenting with acute venous thromboembolism...

..For surgeries requiring an overnight stay, bridging costs are estimated to be 672, 933, and 3,816 US dollars, respectively, for each of these strategies...

..04). In two large, prospective cohorts, ABO blood type was significantly associated with the risk of idiopathic and non-idiopathic PE, with even greater risk for idiopathic PE among current and past smokers with non-O blood type...

..Prospective controlled trials need to be conducted to determine the optimal strategy to reduce the frequency of HIT...

..Of the 2,726 patients who had their DVT diagnosed while in the hospital, only 1,147 (42%) received prophylaxis within 30 days before diagnosis...

..Many of these patients may have warranted less invasive methods of venous thromboembolism prophylaxis. Improved physician education regarding mechanical and pharmacologic prophylaxis alternatives might reduce the use of IVCFs...

..Instead, a predefined cut-off range for high INR values generated by POC instruments should mandate confirmatory testing with central laboratory instrumentation...

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..In conclusion, despite having fewer comorbid conditions, orthopedic patients with deep vein thrombosis remain particularly vulnerable to calf deep vein thrombosis. Rates of venous thromboembolism prophylaxis were inadequate...

..The number of VTE-related events would be halved with universal thromboprophylaxis. Further efforts focused on improving VTE prevention strategies in hospitalised medical patients are warranted...

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..In this review article, we discuss decision support strategies for improving VTE prevention during hospitalization and at the time of discharge...

..Fondaparinux warrants further evaluation in patients with HIT or suspected HIT. In the meantime, its off-label use may exceed its use for FDA-approved indications...

..0 and 3.0. However, for long-term management, no therapeutic agent has shown an acceptable benefit-to-risk ratio...

..The present study evaluated the effects of an electronic alert to the responsible physician in a cohort of hospitalized high-risk patients not receiving VTE prophylaxis...

..We examined the value of CTA to identify the presence of ischemia, as determined by stress perfusion imaging, using integrated positron emission tomography (PET)-CT imaging...

..The purpose of this study was to evaluate the efficiency and reproducibility of a single-breath-hold time-resolved 3D MR angiographic technique in the diagnosis of pulmonary embolism...