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

The absence of significant symptoms and signs makes the diagnosis of pulmonary embolism difficult. Sensitivity and specificity of laboratory tests, chest X-ray, ECG, echocardiography and venous studies is low. Ventilation-perfusion scanning is also often not diagnostic. The combination of several diagnostic techniques, however, and pulmonary angiography confirm the diagnosis. Heparin remains the standard therapy for patients with stable haemodynamics. Thrombolytic therapy is recommended in haemodynamically compromised patients, since it yields accelerated clot lysis and pulmonary reperfusion. In standard dose regimes streptokinase, urokinase and t-PA are equally efficient. t-PA, however, acts more rapidly than the other agents. So far there is no study to prove that thrombolytic therapy significantly reduces mortality in pulmonary embolism.
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PMID:[Thrombolytic therapy in pulmonary embolism. Indications and therapeutic strategies]. 833 30

The incidence of postoperative deep vein thrombosis (PDVT) after aortic surgery and lower limb revascularisation has not been assessed by a large prospective study. In a prospective randomised trial the effect of a low-molecular-weight heparin fragment, Enoxaparin (ENX) 4200 anti factor Xa IU once daily was compared to that of unfractionated heparin (UFH) 7500 IU twice daily. Two hundred and thirty-three consecutive patients were classified into three groups, aortic or aortoiliac and aneurysmectomy (n = 75), aorto-femoral bypass for atherosclerotic disease (n = 71), and femoropopliteal or femorodistal bypass (n = 87). Patients were analysed for development of deep vein thrombosis by Duplex scanning and, if positive, by venography between the seventh and tenth postoperative day. PDVT was present in 10 patients in the ENX group and in four patients in the UFH group (8.2 and 3.6% respectively, NS). The incidence of PDVT was 8% after aortic or aortoiliac aneurysmectomy, 7% after aortofemoral revascularisation, and 3.4% after femoropopliteal or femorodistal bypass. The overall incidence of PDVT after aortic surgery was 7.5% (95% CI 5.4-9.7). There was no pulmonary embolism. Intra-operative blood loss and postoperative bleeding events did not differ significantly between the ENX and UFH groups. After 1 month follow-up, no clinical event or death could be related to PDVT or pulmonary embolism. In conclusion, in vascular surgery ENX is as safe and effective in the prevention of PDVT as is UFH.
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PMID:A randomised controlled trial of a low-molecular-weight heparin (Enoxaparin) to prevent deep-vein thrombosis in patients undergoing vascular surgery. 840 1

A formal statistical overview of all truly randomised trials was undertaken to determine whether antithrombotic therapy is effective and safe in the early treatment of patients with acute stroke. There were 15 completed randomised controlled trials of the value of early antithrombotic treatment in patients with acute stroke. The regimes tested in acute presumed or confirmed ischaemic stroke were: heparin, 10 trials with 1047 patients: oral anticoagulants, one trial with 51 patients: antiplatelet therapy, three trials with 103 patients. Heparin was tested in one trial with 46 patients with acute haemorrhagic stroke. Outcome measures were deep venous thrombosis (confirmed by I125 scanning or venography), pulmonary embolism, death from all causes, haemorrhagic transformation of cerebral infarction, level of disability in survivors. In patients with acute ischaemic stroke, allocation to heparin was associated with a highly significant 81% (SD 8, 2p < 0.00001) reduction in deep venous thrombosis detected by I125 fibrinogen scanning or venogram. Only three trials systematically identified pulmonary emboli, which occurred in 6/106 (5.7%) allocated control vs 3/132 (2.3%) allocated heparin, a non-significant 58% reduction (SD 45.7, 2p > 0.1). There were relatively few deaths in the trials in patients with presumed ischaemic stroke: 94/485 (19.4%) among patients allocated to the control group vs 79/497 (15.9%) among patients who were allocated heparin. The observed 18% (SD 16) reduction in the odds of death was not statistically significant. The least biased estimated of the effect of treatment on haemorrhagic transformation of the cerebral infarct (HTI) comes from trials where all patients were scanned at the end of treatment, irrespective of clinical deterioration; using this analysis, haemorrhagic transformation occurred in 7/102 (6.9%) control vs 8/106 (7.5%) treated, a non-significant 12% increase (SD 56, 2p > 0.1). These data cannot exclude the possibility that heparin substantially increases the risks of HTI. No data on disability in survivors could be obtained. Early heparin treatment might be associated with substantial reductions in deep venous thrombosis (and probably also pulmonary embolism) and possibly a one fifth reduction in mortality (equivalent to the avoidance of 20-40 early deaths per thousand patients treated.) However, the data were wholly inadequate on safety, particularly on the risk of haemorrhagic transformation of the infarct and on the hazards of heparin therapy in patients with known intracerebral haemorrhage. The trials of oral anticoagulants (15 deaths among 57 patients) and antiplatelet therapy (two deaths among 103 patients) were too small to be informative. Much larger randomized trials-comparing aspirin, heparin and the combination of both drugs against control-in patients with acute ischaemic stroke are justified (and several are now planned or underway).
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PMID:Antithrombotic therapy in acute ischaemic stroke: an overview of the completed randomised trials. 812 24

We report on clinical experiences with a low molecular weight heparin (Enoxaparin). Altogether 2339 patients undergoing gynecologic surgery received 20 or 40 mg Enoxaparin once a day beginning 2 hours before surgery. The dose was chosen depending on an assessment of the individual risk factors for each patient. No deep venous thrombosis and no pulmonary embolism were observed. Major intra- or postoperative bleeding was rare (0.3%). We considered these results as favorable. However, early physical therapy and mobilisation of the patients may present an important factor. Most importantly, dose adjustment according to individual risk assessment appears to be a very effective concept with respect to clinical management in gynecologic surgery.
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PMID:[General perioperative prevention of thromboembolism in gynecology with low-molecular weight heparin: clinical experiences with enoxaparin over 7 years]. 853 94

The objective was to retrospectively study the initiation of anticoagulant therapy in inpatients of the two major teaching hospitals in Tasmania, Australia. The medical records of a random sample of patients with an admission diagnosis of deep venous thrombosis (DVT) or pulmonary embolism (PE) during the period February 1992 to June 1994 were studied, to examine therapeutic issues including (i) the time taken after commencing heparin to achieve a therapeutic activated partial thromboplastin time (APTT), (ii) when warfarin was commenced, (iii) the time taken after commencing warfarin to achieve a therapeutic International Normalized Ratio (INR), and (iv) the degree of anticoagulant control at the time of discharge from hospital. The medical records of 99 patients (median age: 65 years and range: 16-93 years; 52 females) were studied. Heparin was generally commenced within 4 h of admission to hospital. The median duration of heparin therapy was 5 days (range: 2-26 days). The median number of APTTs performed per patient was 6 (range: 1-24), with most results (60%) being below the optimum range. Warfarin was commenced from day 1 of hospitalization in only 34% of patients. The INR was within the therapeutic range in only 29% of cases when heparin was ceased. The median time taken to achieve a therapeutic INR after starting warfarin was 3 days (range: 1-15 days).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Review of the initiation of anticoagulant therapy. 855 86

To evaluate the effects of the short-term, high-dose sodium heparin therapy on biochemical markers of bone metabolism, we studied 20 patients (11 males and 9 females) with pulmonary embolism, treated with sodium heparin (daily dose range: 40,000-45,000 I.U. by continuous i.v. infusion). Heparin therapy lasted 5-7 days, after which patients received warfarin over 12 months. Eleven patients (6 males and 5 females) with ischaemic stroke, treated with i.v. glycerol and pentoxifilline, were used as controls. Before and after therapy serum and urinary markers of bone metabolism were evaluated; in 12 heparin-treated pts., the parameters were also evaluated 4 months after discontinuation of warfarin therapy. After heparin therapy a significant reduction vs. basal value was observed in levels of serum osteocalcin (ng/ml;mean + SEM): 3.32 & 0.19 vs. 2.05 + 0.21; p < 0.001. In the 12 patients evaluated 4 months after discontinuation of warfarin therapy, serum osteocalcin levels returned to basal value: 3.41 + 0.12 ng/ml (p:n.s.). No significant changes of the examined parameters were observed in controls. In conclusion, our data seem to indicate an effect of i.v. short-term heparin therapy on bone metabolism. This effect seems to be characterized by an inhibition of osteoblast function as suggested by the reduction of serum osteocalcin levels.
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PMID:Effects of short-term, high dose, heparin therapy on biochemical markers of bone metabolism. 860 85

In todays medicine, anticoagulant drugs like heparin and coumadin derivatives have become indispensable for the treatment of thrombo-embolic diseases. Heparin, consisting of long poly-sulfated polysaccharide chains of variable length and sequences is mostly derived from porcine mucosa. Its bioavailability by other than the parenteral way of administration is almost negligible. Therefore, with only few exceptions, it is almost exclusively applied in hospitalized patients (short-term therapy) or to bridge 2 phases of treatment with oral anticoagulant drugs. Today, besides the conventional high-molecular weight heparins, new fractionated heparins are gaining more and more attention. They offer the advantage of a more reliable resorption from the subcutaneous tissue and thus warrant reliable plasma levels. In many recent randomized trials of deep vein thrombosis and pulmonary embolism, those fractionated heparins have proven to successfully substitute for intravenously applied, aPTT-controlled unfractionated heparin. It remains however open, whether this also translates into the prevention of arterial thrombo-embolic diseases. Heparin may not pass through the placental barrier nor into the milk and is regarded non-teratogenic. Therefore, it may be regarded the ideal anticoagulant for pregnant women and lactating mothers. Those women, however, still carry the heparin-associated risk of bleeding and osteoporosis. In comparison: Coumadin derivatives interfere with the carboxylation of the clotting factors II, VII, IX, and X as well as proteins C and S. By inhibiting the synthesis of these proteins they shift the haemostatic balance to a lower level. In addition, they are almost completely bioavailable by the enteral pathway. They are, therefore, regarded the drugs of choice for long-term anticoagulant therapy in patients at particular thromboembolic risk. For their therapeutic range, being extremely narrow, meticulous drug monitoring by repeated INR-measurements as well as a reliable compliance of the patient to drug intake and dietary restrictions are mandatory to exclude phases with over- or under-anticoagulation. Above all, coumadin therapy is characterized by numerous drug interactions. Thus, whenever the basal medication is changed, for whatever reason, more intense care must be laid to drug monitoring, and the intervals for INR determinations must transiently be shortened. Coumadin derivatives do pass through the placental barrier and in minor amounts also into the milk of breast feeding mothers. Furthermore, they are highly teratogenic. If taken during pregnancy, malformations of the central nervous system are reported to occur in some 10% to 30% of the infants. Thus during pregnancy and in the lactation period, coumadin therapy should be avoided. Bleeding episodes of different severity are the most frequent adverse effects of anticoagulant therapy, no matter whether heparin or coumadin is given. There is a direct relation between the intensity of anticoagulant therapy and the frequency of bleeds. Luckily, most bleeding episodes do not create major therapeutic problems. In case of severe bleeds, however, the anticoagulant therapy must immediately be suspended. In case of coumadin therapy the immediate administration of 4 packs of PPSB (prothrombin-complex-concentrates) or FFP (fresh-frozen-plasma) with concomitant low doses of heparin is additionally advised. Allopecia diffusa, urticartia and allergic reactions are known side effects of anticoagulant therapy. Patients on long-term heparin may also suffer from severe osteoporosis. On the other hand, heparin treatment raises the hazzards of a HAT-Syndrome (heparin-associated thrombocytopenia) (estimated frequency 0.01% to 0.1% of treated patients), giving rise to severe and life-threatening thrombo-embolic side effects predominantly in the arterial tree. In these cases, heparin must be suspended despite those severe thrombo-embolic episodes.
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PMID:-Anticoagulant drugs-. 864 76

Venous thrombo-embolic disease is the most common cause of maternal death during pregnancy. Haemodynamic, anatomical and biological changes support the notion that normal pregnancy in a prethrombotic state. But thrombotic events remain unusual episodes. A pre-thrombotic disease has to be investigated in such cases. Accurate diagnosis of deep vein thrombosis or pulmonary embolism is imperative, using non-invasive approaches. Heparin is the anticoagulant of choice to treat objective thrombosis. Thrombo-embolism prophylaxis using compression stockings and heparin has to be discussed in hypercoagulable disorders.
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PMID:[Venous thromboembolic disease and pregnancy]. 876 77

Venous thrombosis and pulmonary embolism are the two faces of thromboembolic disease. In over 90% of cases, the initial treatment of the pulmonary embolism is anticoagulant therapy, the necessity and efficacy of which were demonstrated over 30 years ago with a reduction of mortality of 25 to 6%. Intravenous heparin relayed rapidly (1st to 3rd day) is still the conventional treatment protocol. Heparin therapy adapted to the result of the activated cephalin time (two to three times the control value) and oral vitamin K antagonists with a dosage adapted to keep the International Normalized Ratio between 2 and 3 is the safest and most effective treatment to date. The efficacy is shown by the low rate of recurrency, about 5% under anticoagulant therapy, lethal recurrence being very rare (less than 1%), and safety is attested by the low rate of severe bleeding complications (3 to 5%). The introduction of low molecular weight heparin and the excellent results observed in the treatment of deep vein thrombosis will probably lead to rapid extension of its indications to mild or moderate but haemodynamically well-tolerated pulmonary embolism. Hirudine and heparinoids will probably be the next step in the treatment of pulmonary embolism.
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PMID:[Anticoagulant therapy in pulmonary embolism]. 881 36

Prevention offers the best approach to limiting morbidity and mortality from deep vein thrombosis and pulmonary embolism in obstetric patients. The use of anticoagulant drugs during pregnancy, however, can be problematic, from the maternal or the fetal point of view. Deciding on the best management is further limited by the lack of controlled clinical trials in the obstetric setting. From the data available, it can be recommended that anticoagulant prophylaxis should be targeted at groups of patients at high risk of thrombosis during pregnancy and the puerperium. Heparin is the agent of choice in most situations during pregnancy for the prophylaxis of venous thrombosis, while warfarin is still the most effective agent for the prevention of systemic embolism from artificial cardiac valves. Prophylactic measures against venous thrombosis are probably underused in the puerperium. Controlled clinical studies are urgently required to optimize prophylaxis of venous thromboembolism associated with pregnancy, and large studies may be more feasible in the puerperium when the incidence of thromboembolism is highest.
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PMID:Thrombosis and embolism. 884 59


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