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

Pulmonary embolus (PE) after cardiac bypass surgery is an uncommon complication but carries with it high morbidity and mortality. The incidence of deep vein thrombosis (DVT) and PE after cardiac bypass varies depending on postoperative thromboprophylaxis, the presence of indwelling central venous catheters in the lower extremities, and early ambulation. The clinical diagnosis of DVT remains difficult and challenging. Pulmonary embolus is often the first occurring clinical event. The safety and effectiveness of preventative pharmacologic agents, such as subcutaneous unfractionated or fractionated heparin or oral coumadin, remain largely unknown. Heparin-induced thrombocytopenia, generally associated with a high incidence of DVT and PE, occurs in approximately 3.8% of patients who have undergone cardiac surgery and are placed postoperatively on high-dose intravenous unfractionated heparin. Sequential compression devices (SCD) have not been effective in reducing the incidence of DVT in an ambulating cardiac bypass patient when added to routine elastic graded compression stockings (GCS). Very large clinical trials are necessary to prove the effectiveness of pharmacologic or mechanical preventative measures in reducing the incidence of PE after cardiac surgery above the commonly used GCS, early ambulation, and aspirin. In a nonambulating, higher-risk cardiac bypass patient with slow recovery, a more aggressive prophylaxis regimen might be necessary for optimal prevention, although further data are needed to support this hypothesis.
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PMID:Pulmonary embolus after coronary artery bypass surgery: a review of the literature. 1101 12

Initially, patients with deep vein thrombosis (DVT) should be treated with a 5- to 7-day course of heparin or low-molecular-weight heparin (LMWH). They can be administered LMWH as outpatients. Patients with extensive iliofemoral thrombosis, major pulmonary embolism, or concomitant medical illness, and those at high risk for bleeding, should be treated as inpatients. Thrombolytic therapy may be considered for patients with extensive iliofemoral thrombosis if there is no contraindication to the use of thrombolytic drugs. Oral anticoagulants can be started within 24 hours of the initiation of heparin or LMWH. Warfarin is started at a dose of 5 mg, and subsequent doses are given in amounts sufficient to achieve an international normalized ratio of 2.0 to 3.0. Inferior vena caval filters should be considered for patients with overt bleeding or for those at high risk for hemorrhage. Warfarin can be used for secondary prophylaxis in most patients. Patients in whom there are contraindications to the use of oral anticoagulants and patients in whom recurrent venous thromboembolism (VTE) develops while they are receiving therapeutic doses of warfarin can be safely and effectively treated with LMWH. Patients with idiopathic DVT should be treated with anticoagulants for at least 6 months. Those with calf DVT or proximal DVT that complicates surgery or medical illness can be treated with anticoagulants for 6 weeks and 3 months, respectively, provided that there are no ongoing risk factors for recurrent VTE. Oral anticoagulants are teratogenic and should be avoided by patients who are pregnant; unfractionated heparin or LMWH are safe alternatives. Unfractionated heparin, LMWH, and oral anticoagulants can be safely administered to nursing mothers.
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PMID:Deep Vein Thrombosis. 1109 68

Thromboses are a common complication of central venous catheters in cancer patients. This study was performed to analyze retrospectively the treatment and outcome of all patients with venous thromboses related to central venous catheters at a major cancer center. From 1992 through 1995, 319 oncology patients with central venous catheters underwent radionuclide venography (RNV) at the Dana-Farber Cancer Institute for suspected catheter or venous thrombosis. The treatment and outcome of patients found to have venous thromboses were evaluated. Of the 319 patients, 112 were found to have evidence of venous thrombosis. The median age and platelet counts were not significantly different between the patients with and without thromboses. The most common indication for obtaining RNV was difficulty in aspirating or infusing material through the catheter. Patients who had pain or edema, or both, of the neck or upper extremity were more likely to have a venous thrombosis. Regardless of therapeutic intervention, including anticoagulation with heparin or coumadin, or both; line removal or replacement; or a combination thereof, no patients had a major adverse outcome such as pulmonary embolism, compromise of limb, or death. Only 4 patients did not have resolution of their presenting symptoms, all of whom were treated with line replacement. The overall survival of patients with and without thromboses was not significantly different. Either anticoagulation or removal of the central venous catheter (or both) appears to be adequate treatment for catheter-related thrombosis. A prospective trial to evaluate these approaches may be worthwhile so that the use of unnecessary procedures may be avoided in this patient population.
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PMID:The treatment and outcome of cancer patients with thromboses on central venous catheters. 1112 48

We have utilized epidemiological data to address three questions in patients with cancer and venous thromboembolism (VTE): (1) What is the risk for occult cancer in patients with idiopathic versus secondary VTE? (2) What is the risk for thrombosis in patients with cancer (vs. noncancer patients)? (3) What is the risk of recurrent VTE in cancer patients with an initial episode of VTE compared to noncancer patients? The risk for a new cancer diagnosis within 6-12 months of the diagnosis of idiopathic VTE (including pulmonary embolism) is well supported by retrospective analyses of large numbers of unselected patients, population-based retrospective cohort analyses from large registries and prospective studies. The odds ratios for these studies are in the range of 4- to 7-fold increased risk. In surgical patients with known cancer the odds ratio for an episode of postoperative VTE is approximately 2, when compared to a control group of noncancer patients subjected to the same procedures. A similar odds ratio of approximately 2 exists for the relative risk for recurrence of VTE in the first 3 months after an initial episode in cancer patients treated with heparin and warfarin (Coumadin) compared to noncancer patients. Therefore, patients with idiopathic VTE are at increased risk for occult cancer and cancer patients are at increased risk for VTE. Appropriate studies are underway to determine the best strategies for anticoagulant management of these patients.
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PMID:Epidemiology of thrombosis in cancer. 1154 71

Pulmonary embolism is the most common cause of maternal death during pregnancy and the puerperium in the industrialized world. The risk of venous thromboembolism (VTE) in pregnancy is 0.05%-1.8%, 6 times greater than in the non-pregnant state. The risk is increased in women over 35 years and those with obesity, previous VTE, operative delivery, or underlying thrombophilia. Women presenting with recurrent miscarriages, preeclampsia, intrauterine growth restriction, abruptio placentae, or stillbirth (all associated with microvascular thrombosis in placental blood vessels) have high incidence (65%) of thrombophilia. About 70% of the women who present with VTE during pregnancy are carriers of hereditary or acquired thrombophilia. Treatment of women with VTE during pregnancy, and especially those with thrombophilia, requires individualized dosing and duration of antithrombotic therapy and the formulation of thromboprophylactic strategies for future pregnancies. Warfarin is contraindicated during the first trimester due to fetotoxicity; unfractionated heparin (UFH) is associated with practical disadvantages and the risk of heparin-induced thrombocytopenia (HIT) and osteoporosis with long-term use. Low molecular weight heparins (LMWHs) are convenient to use, do not cross the placenta, carry a lower risk of HIT and osteoporosis, and are safe and effective. LMWHs are replacing UFH as the anticoagulant of choice during pregnancy and improve pregnancy outcome in women with a history of obstetric complications and confirmed thrombophilia.
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PMID:Thrombophilia and its treatment in pregnancy. 1171 85

Many dental patients have medical problems that require the administration of oral anticoagulants to prevent catastrophic or life-threatening thromboembolic events. Examples include patients with medical conditions such as atrial fibrillation, mechanical heart valves, recent pulmonary embolism, stroke, deep vein thrombosis, anticardiolipin syndrome and coronary artery disease. The oral anticoagulant used most commonly in these instances is Coumadin. Stopping the administration of Coumadin to perform routine dental procedures can be life threatening. Many physicians and dentists believe these patients may not have routine dental procedures, including cleanings and uncomplicated extractions, while on Coumadin for fear of serious postoperative bleeding. No scientific evidence exists to support removing these patients from Coumadin to perform routine dental procedures and uncomplicated extractions, provided the patient's level of anticoagulation is within therapeutic range. Science clearly indicates that in the case of routine dental work, including uncomplicated extractions, the risk of a patient on Coumadin having a life-threatening thromboembolic event if the anticoagulant therapy is stopped is three- to five-times greater than the risk of the patient having postoperative bleeding that cannot be controlled with local measures.
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PMID:Stop the nonsense not the anticoagulants: a matter of life and death. 1267 75

The treatment and prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE) in pregnant patients is challenging for several reasons. Coumarins can cause embryopathy and other adverse effects in the fetus. Although unfractionated heparin and low-molecular-weight heparins, the cornerstones of initial therapy, are safe for the fetus, they can have significant maternal side effects, including osteoporosis and thrombocytopenia. Because they must be given parenterally, long-term administration is inconvenient. Further, although low-molecular-weight heparins probably cause less maternal osteoporosis and thrombocytopenia than unfractionated heparin, the appropriate dosing regimens for prevention and treatment of thrombosis during pregnancy have not been established. In addition, there is a paucity of reliable information on the incidence of venous thromboembolism and the risk of recurrent thrombosis during pregnancy. This paper briefly reviews the areas of controversy and provides recommendations for the treatment and prophylaxis of acute deep vein thrombosis and pulmonary embolism in pregnant patients.
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PMID:Treatment and prophylaxis of venous thromboembolism during pregnancy. 1259 Sep 44

Incidence data on thromboembolism in patients with heart failure (which may include stroke, peripheral embolism, pulmonary embolism) are limited but provide a general population range from 1-5 cases per 1000 each year, increasing with age to more than 30 cases per 1000 each year among people aged 75 years or older. However, the incidence of thromboembolism varied depending very much on what was being investigated in each of these studies. Data from subgroup analysis of the larger heart failure trials would seem to support this incidence data, although there is very little true epidemiological data and no randomised, controlled trial has been designed to specifically investigate thromboembolism in patients with heart failure. The pathophysiology of heart failure is complex. There are many well recognised factors which are associated with thrombosis in heart failure patients, such as vascular abnormalities, increased coagulability and impaired blood flow. In the past 50 years many studies have been performed to investigate if oral anticoagulation is of benefit for the prevention of thromboembolism in patients with heart failure. The use of warfarin therapy for heart failure patients has been a controversial subject. Warfarin does have a role to play in patients with myocardial infarction and those with atrial fibrillation. Furthermore, in patients with congestive heart failure secondary to coronary artery disease, warfarin reduces the occurrence of nonfatal myocardial infarction and, therefore, may reduce the chances of progression to heart failure. It has also been shown that warfarin reduces the risk of thromboembolic strokes in patients recovering from myocardial infarction. At present, there is a lack of randomised data, and the incidence of bleeding complications in patients with heart failure has caused a decrease in the use of oral anticoagulants for the prevention of thrombosis. This review summarises the incidence, potential mechanism and therapeutic approaches for management of thromboembolism in heart failure.
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PMID:Blood coagulation in patients with chronic heart failure: evidence for hypercoagulable state and potential for pharmacological intervention. 1265 54

Purple toes syndrome is an extremely uncommon, nonhemorrhagic, cutaneous complication associated with warfarin therapy. It is characterized by the sudden appearance of bilateral, painful, purple lesions on the toes and sides of the feet that blanch with pressure. The syndrome usually develops 3-8 weeks after the start of warfarin therapy. A 47-year-old man with a history of purple toes syndrome that resolved after discontinuing warfarin--prescribed for a deep vein thrombosis (DVT) in his right lower leg--experienced an acute, proximal DVT in his other leg. Warfarin again was prescribed; 1 week later, purple toes syndrome developed in that extremity. Warfarin therapy again was discontinued, and intravenous unfractionated heparin was started; the patient's clinical picture indicated a possible pulmonary embolism, and laboratory analysis suggested antiphospholipid syndrome. The patient's toe pain resolved, but the purple discoloration persisted. Follow-up laboratory analysis confirmed antiphospholipid syndrome, and warfarin was restarted with close monitoring. No further complications occurred with long-term therapy. Although a rare complication of therapy, clinicians should monitor for the development of purple toes syndrome in patients taking warfarin.
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PMID:Purple toes syndrome associated with warfarin therapy in a patient with antiphospholipid syndrome. 1274 43

A 24-year-old man known to have a double outlet right ventricle, status post-modified Fontan procedure at age 10, taking coumadin after having a stroke one year prior, presented with a massive pulmonary embolism and hemodynamic instability. Locally delivered tPA was unsuccessful, and the pulmonary artery thrombus was finally removed with a thrombectomy catheter (Angiojet thrombectomy); the patient recovered soon thereafter. This is the first report of the successful use of a thrombectomy catheter in a patient with pulmonary emboli and an occluded Fontan conduit.
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PMID:A pulmonary embolism treated with the Angiojet technique in a patient with double outlet right ventricle. 1469 24


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