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Management of massive and nonmassive pulmonary embolism.

Arch Med Sci. 2012 Dec 20;8(6):957-69

Authors: Sekhri V, Mehta N, Rawat N, Lehrman SG, Aronow WS

Abstract
Massive pulmonary embolism (PE) is characterized by systemic hypotension (defined as a systolic arterial pressure < 90 mm Hg or a drop in systolic arterial pressure of at least 40 mm Hg for at least 15 min which is not caused by new onset arrhythmias) or shock (manifested by evidence of tissue hypoperfusion and hypoxia, including an altered level of consciousness, oliguria, or cool, clammy extremities). Massive pulmonary embolism has a high mortality rate despite advances in diagnosis and therapy. A subgroup of patients with nonmassive PE who are hemodynamically stable but with right ventricular (RV) dysfunction or hypokinesis confirmed by echocardiography is classified as submassive PE. Their prognosis is different from that of others with non-massive PE and normal RV function. This article attempts to review the evidence-based risk stratification, diagnosis, initial stabilization, and management of massive and nonmassive pulmonary embolism.

PMID: 23319967 [PubMed]

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Aspirin for the Prophylaxis of Venous Thromboembolic Events in Orthopedic Surgery Patients: A Comparison of the AAOS and ACCP Guidelines with Review of the Evidence.

Ann Pharmacother. 2013 Jan;47(1):63-74

Authors: Stewart DW, Freshour JE

Abstract
BACKGROUND: The American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have both developed evidence-based guidelines to prevent venous thromboembolism (VTE) in high-risk orthopedic surgery patients. Recent changes to these documents have brought them into agreement as to the inclusion of aspirin as an appropriate option for VTE prophylaxis in this patient population.
OBJECTIVE: To evaluate the appropriateness of aspirin to prevent VTE in high-risk orthopedic surgery patients.
DATA SOURCES: Guidelines published by the AAOS in 2011 and the ACCP in 2012 were compared regarding their recommendations on the use of aspirin for the prevention of VTE. A literature search was also conducted to identify clinical trials that evaluated the use of aspirin for the prevention of VTE in this patient population. Search terms included the MeSH terms venous thromboembolism; venous thrombosis; pulmonary embolism; aspirin; arthroplasty, replacement, knee; arthroplasty, replacement, hip; and hip fractures/surgery.
STUDY SELECTION AND DATA EXTRACTION: Any study that evaluated aspirin, even in combination with another method of prophylaxis (such as pneumatic compression devices), and had been published during or after 1985 was included.
DATA SYNTHESIS: Randomized controlled trials, meta-analyses, and other large pooled and retrospective reviews have failed to consistently arrive at similar conclusions regarding the efficacy and safety of aspirin as an option for VTE prophylaxis in patients undergoing total knee arthroplasty (TKA), total hip arthroplasty (THA), or hip fracture surgery (HFS). Disagreements in the appropriateness of surrogate markers for safety and efficacy have resulted in differing recommendations from the ACCP and AAOS. The primary argument lies in the appropriateness of deep vein thrombosis as a surrogate marker for more serious outcomes such as pulmonary emboli.
CONCLUSIONS: Recent changes to both the ACCP and AAOS guidelines are in agreement for those who choose to use aspirin for chemoprophylaxis of VTE. Current surgical care improvement project measures do not include aspirin as an appropriate sole option for the prevention of VTE, but in patients undergoing elective TKA or who have a contraindication to pharmacologic prophylaxis and undergo a THA or HFS, aspirin in conjunction with compression devices as part of a multimodal approach would meet these measures. Data do not support the hypothesis that aspirin is less likely to cause adverse bleeding events than more potent anticoagulants.

PMID: 23324504 [PubMed - in process]

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Rivaroxaban: an oral factor xa inhibitor.

Clin Ther. 2013 Jan;35(1):4-27

Authors: Thomas TF, Ganetsky V, Spinler SA

Abstract
BACKGROUND: Currently available anticoagulants utilized for venous thromboembolism (VTE) treatment and prevention and stroke prevention in patients with atrial fibrillation (AF) have proven effectiveness but are not optimally utilized because of barriers such as the need for subcutaneous administration and requisite routine laboratory monitoring. Rivaroxaban, a novel oral Xa inhibitor, is an alternative to standard therapies utilized for VTE prevention after elective orthopedic surgery, primary and secondary stroke prevention in nonvalvular AF, VTE treatment after an acute VTE event, and secondary prevention after the acute coronary syndromes (ACS).
OBJECTIVE: This article reviews the pharmacology, efficacy, and tolerability of rivaroxaban for VTE prophylaxis in post-orthopedic surgery and medically ill patients, stroke prevention in nonvalvular AF, adjunctive therapy in patients with ACS, and VTE treatment.
METHODS: International Pharmaceutical Abstracts and EMBASE were searched for English-only clinical trials and reviews published between 1970 and March 15, 2012. PubMed was searched for articles published between 1970 and June 30, 2012. Additional trials and reviews were identified from the citations of published articles.
RESULTS: Eighty-nine publications were identified: 10 clinical trials and 1 meta-analysis were used to obtain efficacy and tolerability data, and 1 analysis of pooled data from the clinical trials was included; 17 pharmacokinetic, pharmacodynamic, and drug-drug interaction studies were included; and 5 cost-analyses were reviewed. These data showed rivaroxaban to be noninferior to enoxaparin for thromboprophylaxis of VTE after total knee and total hip replacement surgery. It was also shown to be noninferior to vitamin K antagonist therapy for primary and recurrent stroke prevention in nonvalvular AF as well as for the treatment of VTE after an acute deep vein thrombosis or pulmonary embolism. It also showed benefit in lowering the risk for major adverse cardiovascular events after ACS. Differences in major bleeding rates were not statistically significant between rivaroxaban and comparators across the various studies, with the exception of ACS, in which there were higher rates of non-coronary artery bypass graft surgery related bleeding and intracranial hemorrhage.
CONCLUSIONS: Based on the findings of the studies reported in this review, rivaroxaban is an effective option for the prevention of VTE after orthopedic surgery, stroke prevention for nonvalvular AF, and treatment of VTE. At this time, rivaroxaban cannot be recommended for secondary risk reduction after ACS because of the increased bleeding risk.

PMID: 23328267 [PubMed - in process]

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Procalcitonin in Acute Exacerbations of Interstitial Pneumonia: Another Tool in the Toolbox?

Respirology. 2013 Jan 22;

Authors: Nambiar AM

Abstract
Interstitial lung diseases (sometimes also referred to as interstitial pneumonias, or IPs) comprise a heterogeneous group of diffuse parenchymal lung diseases that are associated with identifiable causes (such as collagen vascular diseases (CVD-ILD), like rheumatoid arthritis and scleroderma, or chronic hypersensitivity pneumonitis) and unidentified etiologies (idiopathic interstitial pneumonias, IIP, the most common of which is idiopathic pulmonary fibrosis, or IPF). During their slowly progressive decline, many IPF patients may suddenly experience an acute worsening of their disease. In the absence of an identifiable cause such as infection, heart failure, or pulmonary embolism, these sudden deteriorations have been defined as acute exacerbations and are associated with a significantly increased risk of morbidity and mortality.

PMID: 23336530 [PubMed - as supplied by publisher]