Lucia Filippi

The value of 64-detector row computed tomography for the exclusion of pulmonary embolism

Recently, a diagnostic strategy using a clinical decision rule, D-dimer testing and spiral computed tomography (CT) was found to be effective in the evaluation of patients with clinically suspected pulmonary embolism (PE). However, the rate of venous thromboembolic complications in the three-month follow-up of patients with negative CT was still substantial and included fatal events. It was the objective to evaluate the safety of withholding anticoagulants after a normal 64-detector row CT (64-DCT) scan from a cohort of patients with suspected PE. A total of 545 consecutive patients with clinically suspected first episode of PE and either likely pre-test probability of PE (using the simplified Wells score) or unlikely pre-test probability in combination with a positive D-dimer underwent a 64-DCT. 64-DCT scanning was inconclusive in nine patients (1.6%), confirmed the presence of PE in 169 (31%), and ruled out the diagnosis in the remaining 367. During the three-month follow-up of the 367 patients one developed symptomatic distal deep-vein thrombosis (0.27%; 95%CI, 0.0 to 1.51%) and none developed PE (0 %; 95%CI, 0 to 1.0%). We conclude that 64-DCT scanning has the potential to safely exclude the presence of PE virtually in all patients presenting with clinical suspicion of this clinical disorder.

Unexpectedly High Recanalization Rate in Patients with Pulmonary Embolism Treated with Anticoagulants Alone

The rate of residual thrombosis, defined as the long-term persistence of thrombotic material in the pulmonary artery tree after pulmonary embolism (PE), is uncertain. Although a systematic review reported low recanalization rates (43% at 6 mo) (1), most studies used perfusion or ventilation–perfusion lung scanning or older generation computed tomography (CT) scanners. In a prospective study we determined the rate of residual thrombosis in a cohort of consecutive patients with acute PE as detected by 64-row multidetector CT (MDCT), treated with anticoagulants alone and reassessed 6 months later with the same high-technology procedure.

Impact of residual pulmonary obstruction on the long-term outcome of patients with pulmonary embolism

The impact of residual pulmonary obstruction on the outcome of patients with pulmonary embolism is uncertain. We recruited 647 consecutive symptomatic patients with a first episode of pulmonary embolism, with or without concomitant deep venous thrombosis. They received conventional anticoagulation, were assessed for residual pulmonary obstruction through perfusion lung scanning after 6 months and then were followed up for up to 3 years. Recurrent venous thromboembolism and chronic thromboembolic pulmonary hypertension were assessed according to widely accepted criteria. Residual pulmonary obstruction was detected in 324 patients (50.1%, 95% CI 46.2–54.0%). Patients with residual pulmonary obstruction were more likely to be older and to have an unprovoked episode. After a 3-year follow-up, recurrent venous thromboembolism and/or chronic thromboembolic pulmonary hypertension developed in 34 out of the 324 patients (10.5%) with residual pulmonary obstruction and in 15 out of the 323 patients (4.6%) without residual pulmonary obstruction, leading to an adjusted hazard ratio of 2.26 (95% CI 1.23–4.16). Residual pulmonary obstruction, as detected with perfusion lung scanning at 6 months after a first episode of pulmonary embolism, is an independent predictor of recurrent venous thromboembolism and/or chronic thromboembolic pulmonary hypertension. Residual pulmonary obstruction after PE is an independent predictive factor of VTE recurrences and/or CTEPH http://ow.ly/XK49308SDTd

An international survey on isolated subsegmental pulmonary embolism.

The large and growing number of radiological examinations performed for several thoracic diseases with multidetector-row CT (MDCT) scanners are leading to a marked increase in newly diagnosed isolated (i.e. without a concomitant diagnosis of deep venous thrombosis) subsegmental PE (I-SSPE), often incidentally identified. A diagnosis of SSPE may account for up to 12% of positive CT scans performed for suspected PE, whereas the proportion of incidental PE in patients undergoing chest CT varies from 1.5% to over 4% [1–3]. Whether MDCT findings of SSPE show true emboli or something else (artifacts?in situ thrombosis?) is still an unresolved issue and studies directly comparing the findings of the most recent MDCT scanners with those of pulmonary angiography are lacking. However, a number of indirect criteria could help radiologists to exclude false positive diagnoses (e.g. lack of concomitant atelectasis, pleural effusion or interstitial disease). The prognostic value of these findings is still undefined, especially in asymptomatic patients, and evenmore so it is unclear whether affected patients should be treated, with which drugs, at what dosage and how long. As the achievement of high-quality randomized clinical trials on I-SSPE is likely to be unrealistic, we decided to explore this topic through an inquiry on the current perception of the problem among physicians practicing in several European countries.We submitted a questionnaire to attendees of medical conferences and members of both Italian thrombosis research program networks and of the Registro Informatizado de Pacientes con Enfermedad Tromboembolica (RIETE), an international registry on venous thromboembolism (VTE) collecting data from 14 countries. The questionnaire was a list of multiple-choice questions with additional freely fillable lines of text if more detailed comments were needed, without any presentation of clinical cases and inquiring whether an I-SSPE requires treatment, which factors should influence the clinical decisions, which drugs should be used, at what dosage and how long, whether the identification of I-SSPE should prompt the search for a thrombophilic defect and/or an underlying malignancy. The definition adopted of ISPPE was that of a diagnosis, by MDCT scanning and confirmed by the radiologist, of a single ormultiple pulmonary sub-segmental emboli not associated with the concomitant presence of both segmental emboli and thrombosis in the peripheral venous circulation, identified primarily but not exclusively by an ultrasound examination. The survey focused on the symptomatic or asymptomatic clinical presentations of I-SPPE episodes and the incidental nature of some episodes could have been considered by physicians among the factors that influenced their clinical decisions. The survey was conducted either on-line, on a dedicated internet portal of our Department or manually on paper forms; several invitations to complete the on-line questionnaire were sent out via e-mail and paper copies of the questionnaire were distributed among attendees of major scientific

Aspirin and recurrent venous thromboembolism in patients with symptomatic atherosclerosis: retrospective cohort study

thesis by platelets: historical and new perspectives. J Thromb Haemost 2009; 7: 241–6. 11 Massberg S, Konrad I, Schurzinger K, Lorenz M, Schneider S, Zohlnhoefer D, Hoppe K, Schiemann M, Kennerknecht E, Sauer S, Schulz C, Kerstan S, Rudelius M, Seidl S, Sorge F, Langer H, Peluso M, Goyal P, Vestweber D, Emambokus NR, et al. Platelets secrete stromal cell-derived factor 1{alpha} and recruit bone marrow-derived progenitor cells to arterial thrombi in vivo. J ExpMed 2006; 203: 1221– 33. 12 Stellos K, Langer H, Daub K, Schoenberger T, Gauss A, Geisler T, Bigalke B, Mueller I, Schumm M, Schaefer I, Seizer P, Kraemer BF, Siegel-Axel D, May AE, Lindemann S, Gawaz M. Platelet-derived stromal cell-derived factor-1 regulates adhesion and promotes differentiation of human CD34+ cells to endothelial progenitor cells. Circulation 2008; 117: 206–15.

What are the pharmacotherapy options for treating venous thromboembolism in cancer patients

Introduction: Venous thromboembolism (VTE) is a frequent complication in patients with malignancies. The treatment of VTE disorders in cancer patients remains a difficult clinical task. Areas covered: Current evidence on the most appropriate initial and long-term treatment of cancer patients with VTE was addressed, as was the management of recurrent VTE despite anticoagulation, the management of incidentally detected isolated pulmonary embolism (PE), the potential role of the novel direct oral anticoagulants and the impact of low-molecular-weight heparin (LMWH) on cancer evolution. Expert opinion: LMWHs are the cornerstone of VTE treatment in cancer patients. The intensity and duration of treatment are dependent on several factors that need to be individually evaluated. The novel oral anticoagulants should be investigated more carefully before being routinely implemented in the treatment of cancer-associated VTE. Incidentally detected isolated sub-segmental PE is unlikely to require systematic full-dose anticoagulation. Evidence favoring an impact of LMWH on survival in cancer patients is weak.

ANMCO Position Paper: Long-term follow-up of patients with pulmonary thromboembolism

Abstract Venous thromboembolism (VTE), including pulmonary embolism and deep venous thrombosis, is the third most common cause of cardiovascular death. The management of the acute phase of VTE has already been described in several guidelines. However, the management of the follow-up (FU) of these patients has been poorly defined. This consensus document, created by the Italian cardiologists, wants to clarify this issue using the currently available evidence in VTE. Clinical and instrumental data acquired during the acute phase of the disease are the cornerstone for planning the FU. Acquired or congenital thrombophilic disorders could be identified in apparently unprovoked VTE during the FU. In other cases, an occult cancer could be discovered after a VTE. The main targets of the post-acute management are to prevent recurrence of VTE and to identify the patients who can develop a chronic thromboembolic pulmonary hypertension. Knowledge of pathophysiology and therapeutic approaches is fundamental to decide the most appropriate long-term treatment. Moreover, prognostic stratification during the FU should be constantly updated on the basis of the new evidence acquired. Currently, the cornerstone of VTE treatment is represented by both the oral and the parenteral anticoagulation. Novel oral anticoagulants should be an interesting alternative in the long-term treatment.

Position paper ANMCO: Raccomandazioni per il follow-up del paziente con tromboembolia polmonare

: Venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism, is the third most common cause of cardiovascular death. The management of the acute phase of VTE is well described in several papers and guidelines, whereas the management of the follow-up of the patients affected from VTE is less defined. This position paper of the Italian Association of Hospital Cardiologists (ANMCO) tries to fill the gap using currently available evidence and the opinion of the experts to suggest the most useful way to manage patients in the chronic phase.The clinical and laboratory tests acquired during the acute phase of the disease drives the decision of the following period. Acquired or congenital thrombophilic factors may be identified to explain an apparently not provoked VTE. In some patients, a not yet clinically evident cancer could be the trigger of VTE and this could lead to a different strategy. The main target of the post-acute management is to prevent relapse of the disease and to identify those patients who could worsen or develop chronic thromboembolic pulmonary hypertension. The knowledge of the etiopathogenetic ground is important to address the therapeutic approach, choosing the best antithrombotic strategy and deciding how long therapy should last. During the follow-up period, prognostic stratification should be updated on the basis of new evidences eventually acquired.Treatment of VTE is mainly based on oral or parenteral anticoagulation. Oral direct inhibitors of coagulation represent an interesting new therapy for the acute and extended period of treatment.