Carlos Ibarra-Perez

Prevalence and Prevention of Deep Venous Thrombosis of the Lower Extremities in High-Risk Pulmonary Patients

Information is lacking about the prevalence of, and the best method of pre venting deep venous thrombosis (DVT) of the lower extremities in patients forty years or older with pulmonary disease that keeps them in bed for three consecu tive days or more and who are thus at high risk of developing DVT or pulmo nary embolism (PE). In this study, 192 high-risk patients, aged forty to ninety-two, received 125I fibrinogen and had daily radioactive scans, venous Doppler, and strain gauge plethysmography. Four preventive methods were used until patients became ambulatory: graded compression stockings (GCS) in 39, elastic bandages (EB) in 33, subcutaneous administration of 5,000 USP units of heparin (HEP) bid in 39, and oral administration of 0.5 g of acetylsalicyclic acid (ASA) bid in 35. Results were compared with those in 46 patients in a control group (CG). Twelve patients in CG, none in GCS, 4 in EB, 1 in HEP, and 2 in ASA developed DVT proved by contrast venography. There was a statistically significant difference between GCS and CG (P < 0.0003), HEP and CG (P < 0.0022), and ASA and CG (P < 0.0148) but not between EB and CG (P > 0.10); no significant differences were found between any pair of prophy laxis groups. The significant differences could not be attributed to differences in age, sex, or length of stay in bed. PE occurred in 3 patients in CG and 1 in EB. Hemorrhagic complications occurred in 7 patients in HEP and 4 in ASA, re quiring exclusion of 2 patients and 1 patient, respectively, from the study. GCS, HEP, and ASA are effective methods of preventing DVT in high-risk pulmonary patients, in whom the disease is highly prevalent (26%). Effectiveness, invasive ness, simplicity of use, side effects, and price should be considered in choosing among them.

High dose and short-term streptokinase infusion in patients with pulmonary embolism: prospective with seven-year follow-up trial.

AbstractBackground: High dose and short-term streptokinase infusion has proved to improve survival among few patients with pulmonary embolism and cardiogenic shock, without increasing hemorrhagic complications. However its efficacy and safety in terms of long follow-up and in major number of patients requires to be established.nMethods: Patients with pulmonary embolism proved through high probability V/Q lung scan, suggestive echocardiogram, or deep venous thrombosis were enrolled. All were assigned to receive 1,500,000 IU in one-hour streptokinase infusion. The primary end point was efficacy and safety of streptokinase regimen in terms of pulmonary arterial hypertension, right ventricular dysfunction, perfusion abnormalities, recurrence, mortality and hemorrhagic complications. In long-term follow-up, we assessed functional class, recurrence, chronic pulmonary arterial hypertension, postthrombotic-syndrome and mortality.nResults: A total of 40 consecutive patients (47.3±15.3 years of age) with large or massive pulmonary embolism were enrolled. In 35 patients high dose and short-term streptokinase regimen reversed acute pulmonary arterial hypertension, clinical and echocardiographic evidence of right ventricular dysfunction and improved pulmonary perfusion without increasing hemorrhagic complications. In acute phase 5 patients died, necropsy study performed in 4 patients showed massive pulmonary embolism and right ventricular myocardial infarction, without significant coronary arterial obstruction. Risk factors for mortality and recurrence were: right ventricular global hypokinesis (p<0.0001), 6 hours or over between onset symptoms and streptokinase regimen (p=0.02), severe systolic pulmonary arterial hypertension (p=0.001) right ventricular hypokinesis (p=0.001), hypoxemia (p=0.02) and right ventricular acute myocardial infarction (p<0.0001). Right ventricular hypokinesis (p=0.02) was the only independent risk factor for recurrence. In a seven-year follow-up of the original 35 patients who survived in acute phase, 2 patients were lost and 33 are alive, in functional class I, without recurrence or chronic pulmonary arterial hypertension.nConclusions: Our report indicates that among properly selected high-risk PE patients, short-term streptokinase infusion is effective and safe.

Single-Dose Sublingual Nifedipine as the Only Treatment in Hypertensive Urgencies and Emergencies

One hundred and eighteen patients with hypertensive urgencies and emer gencies and diastolic blood pressure (DBP) at least 120 mm Hg by the cuff method were seen at the Emergency Care Department; none had received calcium chan nel blockers during the previous twelve hours. Patients with DBP of 120 to 139 mm Hg received 10 mg of sublingual nifedi pine; patients with left ventricular hypertrophy or failure, renal disease, hyper tensive encephalopathy, angina, papilledema, or a DBP over 140 mm Hg received 20 mg of the drug. The criterion for control was the achievement of a DBP of 100 mm Hg or less within sixty minutes of receiving sublingual nifedipine and maintenance of the effect until discharge. Control was achieved in all patients; a sixty-three-year-old man died of a brain hemorrhage after pulmonary edema and a DBP of 210 had been controlled; the other 117 were discharged to their attending physicians, either as outpatients or to a hospital ward. No patient developed hypotension, clinical or electrocardio graphic signs of myocardial ischemia, or clinical signs of neurologic dysfunction. Practical, fast, safe, and dependable control of hypertensive urgencies and emergencies has made sublingual nifedipine the treatment of choice of such pa tients in the Emergency Care Department.

The Dressler syndrome after pulmonary embolism.

A study was conducted in 14 patients with pericardial syndrome after pulmonary embolism. The role of right ventricular myocardial injury and noncardiogenic pulmonary edema in this syndrome is considered and its existence is established.

Short-term efficacy and safety of a single five-milligram dose of oral nifedipine in uncontrolled essential systemic hypertension

Abstract Nifedipine has been extensively and successfully used for the treatment of various hypertensive syndromes in doses of ≥10 mg 1 ; such doses have a harmful potential, at least in the elderly. 1–8 As there are only scant reports about the use of smaller doses of nifedipine, 9,10 we undertook this clinical study to test the effectiveness and safety of a single 5-mg dose of oral nifedipine in patients admitted to our Emergency Care Department with uncontrolled moderate to severe hypertension. Only patients with essential hypertension were treated if the diagnosis had been present for ≥1 year and, if previously normotensive under medical treatment, they had a gradual elevation of the diastolic blood pressure (BP) to values from 110 to 129 mm Hg. Excluded were patients with coexisting valvular heart disease or acute myocardial infarction, those who were pregnant or who were receiving calcium antagonists within the previous 12 hours, or those with hypertensive urgencies and emergencies.