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Query: UMLS:C0034065 (pulmonary embolism)
 14,979 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism, represents a significant source of morbidity and mortality. It is readily diagnosed with noninvasive modalities when there is a clinical suspicion. Most patients presenting with signs and symptoms of DVT have well-known risk factors, such as a history of VTE, malignancy, recent illness, or immobilization. A subset of individuals with idiopathic VTE have no readily identifiable risk factors. Therapeutic anticoagulation is the cornerstone of management in all patients with VTE. Adjunctive measures, such as thrombolysis and the use of vena cava filters, are indicated in select cases. The ideal duration of anticoagulation is unknown, but is often maintained long-term in patients with acquired or inherited thrombophilia. Warfarin is the only oral anticoagulant approved by the US Food and Drug Administration. Warfarin carries a substantial annual risk of bleeding complications, requires ongoing monitoring, and has extensive drug-drug interactions, which are causes for concern in patients requiring long-term anticoagulation. Alternative oral anticoagulants, such as direct thrombin inhibitors and factor Xa inhibitors, are subjects of active research in alternative agents for oral anticoagulation, and have been recently approved for prophylaxis in Canada and the European Union.
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PMID:Venous thromboembolism: a clinical review. 2020 56

Venous thromboembolic disease, including deep vein thrombosis and pulmonary embolism, is a cause of significant mortality and morbidity. For several decades, anticoagulant options for the treatment and prevention of thrombosis have been limited mainly to agents such as unfractionated heparin and oral vitamin K antagonists, such as warfarin. Although these therapies have proven benefits, they also have important limitations that result in their underuse in routine clinical practice. A variety of novel anticoagulants with improved pharmacologic and clinical profiles are in development, offering benefits over traditional therapies. Specifically, progress has been made in the development of small molecule factor Xa inhibitors and thrombin inhibitors. With their potentially consistent and predictable clinical profile, oral formulation, and decreased need for coagulation monitoring, these new agents will likely increase the use and duration of anticoagulation treatment in thromboembolic disorders and reduce the burden associated with long-term management.
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PMID:Novel oral anticoagulants in development: Dabigatran, Rivaroxaban, and Apixaban. 2053 13

Prevention of venous thromboembolism (VTE) is essential in neurological patients. Little is known about the optimal duration, efficacy, and safety of prolonged off-label use of low-molecular-weight heparin (LMWH). We enrolled n = 1176 early neurological rehabilitation cases in a retrospective study. In most cases (n = 1151, 97.9%), 4000 anti-Xa (activated coagulation factor X [factor Xa]) units enoxaparin were administered, only 25 received 2000 units for approximately 2 months (mean of 57.5 days). In 969 cases, enoxaparin was administered for more than 2 weeks. Incidence of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) were 0.43% (n = 5) and 1.11% (n = 13), respectively. Hemorrhages during enoxaparin therapy were more frequent. Bleeding occurred in 1.96% (n = 23) of cases, mainly gastrointestinal, urinary tract, and vitreous body bleeding. In short-term (up to 2 weeks) treatment, bleeding and VTE were more frequent than in long-term treatment. Results from this study suggest that prolonged enoxaparin thromboprophylaxis in neurological rehabilitation is safe and effective.
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PMID:Prolonged thromboprophylaxis with enoxaparin in early neurological rehabilitation. 2054 51

Edoxaban is a new oral direct factor Xa inhibitor. The purpose of this study was to evaluate the efficacy and safety of different doses of edoxaban for the prevention of venous thromboembolism (VTE) in patients undergoing elective total hip replacement. A total of 903 patients were randomised to oral edoxaban 15, 30, 60 or 90 mg once daily or subcutaneous dalteparin once daily (initial dose 2,500 IU, subsequent doses 5,000 IU). Both drugs were begun 6-8 hours postoperatively and continued for 7-10 days, when bilateral venography was performed. The primary efficacy endpoint was the incidence of total VTE, which included proximal and/or distal deep-vein thrombosis (DVT) by venography or symptomatic, objectively confirmed DVT or pulmonary embolism during the treatment period. The primary safety outcome was the incidence of the composite of major and clinically relevant non-major bleeding. All venograms and bleeding events were reviewed by a central independent adjudication committee blinded as to treatment allocation. Of the 903 patients randomised, 776 were evaluable for the primary efficacy analysis. The incidences of VTE were 28.2%, 21.2%, 15.2%, and 10.6% in patients receiving edoxaban 15, 30, 60 and 90 mg, respectively, compared with 43.8% in the dalteparin group (p<0.005 ). There was a statistically significant (p<0.001) dose-response for efficacy across the edoxaban dose groups for total VTE and for major VTE. The incidence of clinically relevant bleeding was low and similar across the groups. Oral edoxaban once daily is effective for preventing VTE after total hip replacement.
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PMID:Oral direct factor Xa inhibition with edoxaban for thromboprophylaxis after elective total hip replacement. A randomised double-blind dose-response study. 2058 17

Rivaroxaban is a small-molecule, direct factor Xa inhibitor that is under investigation for the prevention and treatment of venous and arterial thrombosis. To date, oral anticoagulants have been limited largely to vitamin K antagonists. Despite their remarkable benefits, vitamin K antagonists are limited by their narrow therapeutic window, the existence of multiple food and drug interactions, and the need for frequent monitoring and dose-adjustment. Rivaroxaban represents a potentially attractive alternative to warfarin, as it could enable simplified once-daily dosing, requires no therapeutic monitoring, and has a lower potential for drug interactions. At present, the safety and efficacy of rivaroxaban for the prophylaxis and treatment of venous thromboembolism has been evaluated in phase-II and phase-III trials involving over 24,000 patients. Rivaroxaban is also being evaluated for the treatment of pulmonary embolism, secondary prevention after acute coronary syndromes, and the prevention of stroke and non-central nervous system embolism in patients with non-valvular atrial fibrillation. The need for new oral anticoagulants, the development and pharmacology of rivaroxaban, results of completed studies of rivaroxaban, and details of ongoing phase-II and phase-III trials with rivaroxaban are the subjects of this chapter.
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PMID:Oral direct factor Xa inhibitors, with special emphasis on rivaroxaban. 2061 18

The clinical presentation of pulmonary embolism (PE) varies widely, ranging from only limited symptoms to severe cardiogenic shock. Treatment of PE comprises initial therapy--with low-molecular-weight heparin (LMWH), fondaparinux, or unfractionated heparin--and long-term treatment, most commonly with vitamin-K antagonists (VKAs). Methods of risk stratification, to determine whether a patient will benefit from thrombolysis, are currently under investigation. However, at present, insufficient evidence exists that hemodynamically stable patients who demonstrate echocardiographic right ventricular strain (submassive PE) benefit from thrombolysis. By contrast, thrombolysis is a widely accepted treatment strategy for patients with hemodynamic shock (massive PE). The duration of VKA treatment is commonly 3-12 months and depends on the type of PE and on the balance between the risks of recurrent PE, major bleeding, and the patient's preference. In patients with a malignancy, treatment with LMWH during the first 6 months after diagnosis of PE is recommended. Several new oral anticoagulants, such as factor IIa and factor Xa inhibitors, are now being investigated. For prevention of recurrent PE in situations where anticoagulation is contraindicated, a temporary inferior vena cava filter might be useful. Some patients with PE can be safely treated at home, but few outcome studies in this setting have been published.
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PMID:Acute pulmonary embolism. Part 2: treatment. 2084 79

The 'pill in the pocket' concept is an established therapy for atrial fibrillation. The current guidelines for the management of patients with ST-elevation myocardial infarction endorse the concept that faster time to reperfusion is associated with important reductions in morbidity and mortality. The mechanical reperfusion and outcome of these patients is significantly supported by dual antiplatelet therapy. There is no data comparing the effect of early self-application by the patient ('pill in the pocket') versus application by the emergency doctor of dual antiplatelet therapy and a factor Xa inhibitor in case of severe chest pain. In patients with a high risk of developing an acute coronary syndrome and previously selected by a cardiologist, early self-application of dual antiplatelet therapy and a factor Xa inhibitor (e.g. fondaparinux) immediately after calling the emergency doctor might be of significance in cases of acute coronary syndrome or pulmonary embolism. In particular, in less developed areas where it might take a long time for the emergency doctor to arrive, this 'pill in the pocket' concept may be significant.
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PMID:The 'chest pain kit' study: A 'pill in the pocket' concept to improve the pre-hospital therapy of acute coronary syndrome. 2086 88

This multicentre dose-finding study compared TAK-442, an oral factor Xa inhibitor, with enoxaparin for thromboprophylaxis after knee arthroplasty. In this parallel group study, patients were randomised to oral TAK-442 (40 or 80 mg once-daily [QD] or 10, 20, 40, or 80 mg twice-daily [BID] started 6-8 hours postoperatively), which was blinded as to dose, or to open-label subcutaneous enoxaparin (30 mg BID starting 12-24 hours postoperatively) for 10 days. Treatments were continued until bilateral venography was performed (maximum of 14 days). The primary efficacy endpoint was the composite of any deep-vein thrombosis, non-fatal pulmonary embolism or all-cause mortality, while the primary safety endpoint was major bleeding. Of 1,038 patients randomised who received at least one dose of study drug, 949 completed the study and 730 (76.9%) were evaluable for the primary efficacy analysis. Recruitment into the 10 and 20 mg BID dose groups was stopped early because the incidences of the primary efficacy endpoint were significantly higher than that with enoxaparin. The primary efficacy endpoint occurred in 22.0% of patients given enoxaparin and in 39.0%, 38.4%, 23.5%, 21.4%, 26.8%, and 14.3% of those receiving TAK-442 10 mg BID, 20 mg BID, 40 mg QD, 40 mg BID, 80 mg QD, and 80 mg BID, respectively. The incidences of major and clinically relevant non-major bleeding with TAK-442 were not dose-dependent or different from that with enoxaparin. All TAK-442 doses except 10 and 20 mg BID displayed similar efficacy and safety profiles to enoxaparin.
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PMID:A dose-finding study with TAK-442, an oral factor Xa inhibitor, in patients undergoing elective total knee replacement surgery. 2088 98

Venous thromboembolism (VTE) is a spectrum of diseases that includes deep vein thrombosis (DVT) and pulmonary embolism (PE). Anticoagulant treatment is the mainstay of therapy for VTE. Unfractionated heparin (UFH) or low molecular weight heparin (LMWH) followed by vitamin K antagonists have been the treatment of choice for most patients with VTE, with the aim to prevent thrombus extension or embolization and recurrent VTE. Fondaparinux, a selective, indirect, parenteral factor Xa inhibitor, is now also approved for the initial treatment of VTE and represents an important alternative to UFH or LMWH. Secondary prevention of VTE with vitamin K antagonists is usually prescribed for a minimum of three months, with the duration of treatment based on the presence or absence of major identifiable risk factors for the index event. Patients with permanent risk factors or patients with recurrent DVT or PE require life long secondary prevention. Over the last years, new oral anticoagulant agents have been developed and are now undergoing extensive clinical evaluation in several settings, including the treatment of VTE. New oral anticoagulants include selective, direct thrombin inhibitors, such as dabigatran etexilate, and selective, direct factor Xa inhibitos, such as rivaroxaban, apixaban or edoxaban. All these drugs are admistered at fixed daily doses and do not require laboratory monitoring. The positive results of the first completed clinical trials suggest that a new era in the management of VTE is about to begin.
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PMID:Recent advances in the management of venous thromboembolism. 2112 Jan 57

Anticoagulation for thromboembolic disease and bleeding, the main complication of anticoagulation therapy, are uncommon but are potentially life- or limb-threatening conditions that may present in the pediatric emergency department. Thromboembolic disease in children usually occurs as a complication of vascular access, primarily in children with congenital heart disease or cancer. However, complications of anticoagulation therapy used in the treatment of venous thromboembolism, pulmonary embolism, and blocked central venous catheter; arterial thromboembolism, including arterial ischemic stroke, Kawasaki disease, and after cardiac surgery, may warrant a visit to n the pediatric emergency department. Anticoagulation therapy may take the form of unfractionated heparin, low-molecular weight heparin, vitamin K antagonists, acetylsalicylic acid, or thrombolytic therapy. Monitoring anticoagulation therapy in children is very important and follows adult guidelines. Anticoagulant dosing may be adjusted based on activated partial thromboplastin time, anti-factor Xa level, and international normalized ratio.
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PMID:Anticoagulation therapy: indications, monitoring, and complications. 2120 60


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