Gene/Protein Disease Symptom Drug Enzyme Compound
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Query: UMLS:C0034065 (pulmonary embolism)
 14,979 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Antiplatelet drugs have been demonstrated to reduce the incidence of myocardial infarction (MI), stroke or vascular death in patients with vascular disease. There are no data suggesting that antiplatelet therapy acts differently in older people than in younger people and recommendations based on randomised clinical trials are probably generalisable to older people. Aspirin (acetylsalicylic acid) has been shown to reduce the incidence of non-fatal MI, nonfatal stroke and vascular death in patients with acute MI, a previous MI, angina pectoris or peripheral occlusive arterial disease (POAD), and to reduce cardiovascular morbidity and mortality in patients with a prior ischaemic stroke or transient ischaemic attack (TIA). It has also been shown to reduce the incidence of thrombus formation after coronary artery bypass graft surgery and percutaneous transluminal angioplasty, and in patients with atrial fibrillation and heart valve replacements. Deep vein thrombosis and pulmonary embolism after surgery are also prevented by aspirin. The available data allows the following recommendations to be made. Aspirin 160 to 325 mg daily should be administered to older men and women without contraindications to aspirin who have acute MI, prior MI, unstable or stable angina pectoris, ischaemic stroke, TIA or POAD, and continued indefinitely to reduce the risk of MI, stroke or vascular death. Aspirin should be started in patients before or immediately after revascularisation, and after heart valve replacement. Older men and women with nonvalvular atrial fibrillation who have contraindications to oral anticoagulant therapy but no contraindications to aspirin should be treated with aspirin 325 mg daily. It is reasonable to treat older men and women without contraindications to aspirin with aspirin 160 to 325 mg daily if they are at high risk for developing new coronary events. The incidence of stroke, MI or vascular death in patients after a stroke or TIA is reduced by ticlopidine. Therefore, ticlopidine 250 mg twice daily may be used in older men and women with a history of stroke or TIA who do not respond to or who cannot tolerate aspirin. Patients at high risk for coronary artery stent thrombosis benefit from combined therapy with aspirin plus ticlopidine. The annual incidence of ischaemic stroke, MI or vascular death was significantly reduced by clopidogrel in the Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE) trial. Therefore, clopidogrel 75 mg daily may be used in older men and women with symptomatic atherosclerosis who do not respond to or who cannot tolerate aspirin to reduce the incidence of ischaemic stroke, MI or vascular death. It should be noted that the acquisition cost for either ticlopidine or clopidogrel is considerably greater than that for aspirin. Most data indicate that the combination of aspirin and dipyridamole is not more effective than aspirin alone in preventing vascular events, and available data do not support the use of sulfinpyrazone in patients with vascular disease.
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PMID:Antiplatelet agents in the prevention of cardiovascular morbidity and mortality in older patients with vascular disease. 1049 69

Older individuals contribute heavily to the percentage of deaths due to myocardial infarction (MI) and stroke. The incidence of venous thromboembolism (VTE) is highest in subjects > 65 years. Prospective intervention trials involving groups of clinically comparable subjects > or = 60 allow the following statements to be made with regard to the use of antithrombotic drugs in the elderly. Antiplatelet agents. To prevent recurrence of ischaemic stroke and MI in stable/unstable angina, MI, TIA/stroke or peripheral arterial disease, aspirin is the drug of choice. Clopidogrel is more effective than aspirin in this respect. Heparin. For the treatment of acute deep venous thrombosis (DVT) and pulmonary embolism (PE), intravenous standard heparin or subcutaneous standard heparin are effective (aPTT 1.5-2.0 times baseline values). As the risk of bleeding increases with age, low-molecular-weight heparins (LMWH) are preferable in the elderly. For the prophylaxis of VTE in general surgery in subjects at low-moderate risk, low-dose heparin or low doses of LMWH are effective. In subjects at high risk, adjusted-dose heparin plus physical devices or high-dose LMWH are recommended. The combination of heparin and aspirin is the standard treatment for unstable angina and non-Q wave MI. LMWH are as active as standard heparin in this indication. Vitamin K antagonists. For the chronic treatment of VTE, warfarin is also the treatment of choice (INR 2.0-3.0) in the elderly, though lower doses are needed due to their hypersensitivity to oral anticoagulants. For the prevention of thromboembolic stroke in patients > 75 with atrial fibrillation, warfarin is the drug of choice. Patients aged 65-75 may receive warfarin or aspirin. Thrombolytic agents. Thrombolytic agents are not recommended for treating DVT in the elderly because of their limited risk/benefit ratio and should be confined to massive PE. In the absence of contraindications, thrombolysis for MI may be considered in the elderly.
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PMID:Antithrombotic drugs for older subjects. Guidelines formulated jointly by the Italian Societies of Haemostasis and Thrombosis (SISET) and of Gerontology and Geriatrics (SIGG). 1138 24

Older individuals (subjects aged >65 years) largely contribute to the percentage deaths due to myocardial infarction (MI) and stroke. The incidence of venous thromboembolism (VTE) is also higher >65 years old patients. However, the risk of bleeding complications in patients on antithrombotic drugs increases with age and with clinical conditions, as cognitive/psychiatric diseases, traumas, hypertension, poor compliance with medications, common in the elderly. Thus the risk-benefit ratio of antithrombotics should be carefully evaluated in older individuals. To prevent the risk and the recurrence of ischemic stroke and MI in the older patients with stable/ unstable angina, MI, TIA/stroke or peripheral arterial disease, antiplatelet drugs are of choice. Aspirin is the most widely used antiplatelet drug. Clopidogrel is safer and more effective than aspirin in this respect. The combination of heparin and aspirin is the treatment of choice for unstable angina and non-Q wave MI, also in the elderly. Low molecular weight heparins (LMWHs) proved to be as effective as standard heparin in this indication. In the absence of contraindications, thrombolysis for treatment of acute MI may be considered in the elderly. For the treatment of acute venous thromboembolism (VTE), intravenous standard heparin, subcutaneous standard heparin or LMWHs are effective. Because of the limited risk/benefit ratio, thrombolytic agents are not recommended for treating deep vein thrombosis (DVT) in the elderly. They should be limited to young patients and to patients with massive pulmonary embolism (PE). For chronic treatment of VTE, warfarin is the treatment of choice (INR 2.0-3.0), also in the elderly. Because of hypersensitivity to oral anticoagulants, lower dosages of warfarin are needed in the old patient. As to prophylaxis of VTE in surgery, in subjects at low-moderate risk, or in medical patients, low-dose heparin or low-dose LMWHs are effective. As to prophylaxis of VTE in surgery in subjects at high risk, adjusted-dose heparin or high-dose LMWHs are recommended. Finally, as to prevention of stroke in patients older than 75 with atrial fibrillation (AF), warfarin is of choice.
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PMID:The use of antithrombotic drugs in older people. 1185 Jun 11

In the last few years three new oral anticoagulants-Dabigatran, Rivaroxaban and Apixaban and two new antiplatelet agents Prasugrel and Ticagrelor have been approved for use. Dabigatran, Rivaroxaban and Apixaban have been approved for the prevention of stroke and systemic embolism in non valvular Atrial Fibrillation in the United States. Rivaroxaban is also approved for the prevention and treatment of venous thromboembolism, including pulmonary embolism. These drugs have been shown to be non-inferior to Warfarin. These drugs do not need monitoring and have lesser drug interactions compared to Warfarin. The newer antiplatelet agents Prasugrel and Ticagrelor are more potent than Clopidogrel and are more effective in patients with CYP2 C19 enzyme deficiency. Both of these drugs are approved in acute coronary syndrome and Prasugrel is approved only in acute coronary syndrome with percutaneous coronary intervention.
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PMID:Review of newer anticoagulants and anti-platelet agents in acute coronary syndrome and cardiovascular diseases. 2385 19

About 80% of strokes are ischaemic. Approximately 12% of patients die within 3 months following stroke, and another 20% are institutionalised or become highly dependent. In early 2013, what is the harm-benefit balance of antithrombotic treatments used in the acute phase of ischaemic stroke? To answer this question, we reviewed the available data using the standard Prescrire methodology. Clinical trials of aspirin in the acute phase of ischaemic stroke consist mainly of two randomised trials including a total of 40 541 patients. After 1 to 6 months, 13 deaths or sequelae resulting in dependence are prevented when 1000 patients are treated with aspirin during the acute phase. Aspirin increases the risk of symptomatic intracranial haemorrhage when it is introduced less than 24 hours after treatment with alteplase. Abciximab, an injectable antiplatelet agent, showed no tangible clinical benefit in 5 randomised placebo-controlled trials in a total of 1275 patients. Clopidogrel and prasugrel, two other antiplatelet agents, have not been evaluated in this setting. However, in case of allergy to aspirin, clopidogrel is a useful alternative in other situations associated with a risk of arterial ischaemia. In a randomised trial including 458 patients, cilostazol and aspirin were similarly effective after 3 months of follow-up, but cilostazol caused cardiac arrhythmias. Ticlopidine has too many adverse effects to consider it a useful drug. Anticoagulant therapy during the acute phase of stroke has an unfavourable harm-benefit balance, including in patients with stroke secondary to cardiac embolism. Low-molecular-weight heparin reduces the risk of pulmonary embolism but has no impact on overall mortality. The aim of thrombolysis is to unclog the affected artery. Intravenous alteplase administration is the best-assessed thrombolytic method. Twelve randomised trials have compared intravenous thrombolysis with alteplase versus no thrombolytic therapy in 7012 patients. Among patients treated within 3 hours after stroke onset, 41% survived without sequelae after alteplase administration, versus 32% in the absence of thrombolysis; alteplase had no statistically significant impact on mortality at the end of follow-up. Efficacy appeared to be similar in patients over 80 years old.The harm-benefit balance may also be favourable when thrombolysis is started more than 3 hours after stroke onset, but when it is initiated more than 4.5 hours after stroke onset, it increases mortality. Four randomised trials showed that intra-arterial thrombolysis with urokinase or pro-urokinase had a beneficial effect, versus no thrombolysis, in a total of 356 patients. In a randomised trial including 362 patients, intra-arterial thrombolysis did not have a better harm-benefit balance than intravenous thrombolysis. Among the various physical and mechanical methods used to remove or dissolve clots, the best-evaluated is ultrasound plus intravenous alteplase thrombolysis; initial results with this procedure warrant further clinical trials. Rapid intervention and patient selection are both crucial in optimising the harm-benefit balance of intravenous alteplase thrombolysis. This treatment should only be used when management begins within the first hours following stroke symptom onset, and when there are no risk factors for bleeding, especially intracranial bleeding. For other patients, aspirin is the only antithrombotic drug known to reduce, albeit only slightly, the risk of death and sequelae following ischaemic stroke.
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PMID:Antithrombotic drugs and ischaemic stroke. 2442 42