Ryan Walsh, MD Department of Emergency Medicine Madigan Army Medical Center

Size: px
Start display at page:

Download "Ryan Walsh, MD Department of Emergency Medicine Madigan Army Medical Center"

Transcription

1 Ryan Walsh, MD Department of Emergency Medicine Madigan Army Medical Center

2 The opinions expressed herein are solely those of the author and do not represent the official views of the Department of Defense or Army Medical Department No financial disclosures

3

4 142,000 ED visits a year for PE 2006: 5% treated as outpatient 2010: 6% treated as outpatient

5 January 2015 study Retrospective cohort of 175 Kaiser Permanente patients with pulmonary embolism 32% were sent home in <24hours

6 Risk of recurrence is greatest in first 2 weeks 2% at 2 weeks 6% at 3 months

7 ICOPER registry: 14-day mortality >20% RIETE registry: 3 month mortality Overall = 8.65% Fatal PE = 1.68% EMPEROR registry: 30 day mortality Overall = 5.4%

8

9 PESI spesi Echocardiography CT Angiography BNP/NT-proBNP Troponin Clinical Judgment

10

11

12 Age >80 History of cancer History of chronic cardiopulmonary disease Heart rate >110 Systolic BP <100 mm Hg O 2 Saturation <90%

13 SCORE 30-DAY MORTALITY 0 1% %

14

15

16 RV dysfunction due to PE = increased mortality RV dysfunction in hemodynamically stable patients does not consistently predict death 2004 Meta-analysis 3395 hypotensive and normotensive patients Subgroup analysis of normotensive patients with RV dysfunction correlated poorly with death (PPV 4-5%)

17 2011 prospective multicenter cohort study of 457 patients RVD is independent predictor for an adverse inhospital outcome Overall Population: HR =3.5 Hemodynamically Stable: HR = Systematic Review of 2288 Normotensive PE pts RVD on CT was associated with increased risk of mortality (OR = 1.8) -LR = LR = 1.27

18 Elevated levels have consistently been associated with an increased risk of death In hemodynamically stable patients; poor markers of death Normal or low levels consistently identify a benign clinical course

19 2007 Meta-Analysis of 1,985 patients Elevated troponin I or T in ~50% of patients with acute PE Elevated troponin concentration were associated with high mortality OR 9.44 in unselected patients OR 5.90 in hemodynamically stable patients Other studies say there is limited prognostic value to elevated troponin in normotensive patients NPV for early mortality is high when Troponin is negative

20

21

22 473 patients Admit if: SBP <100 SP02 <92% Contraindication to LMWH Other significant comorbidities 639 patients Admit if: Hemodynamically unstable Require oxygen Need IV opiods Are high risk for bleeding

23

24

25 92% of outpatients and 95% of inpatients were satisfied with treatment 14% of outpatients would have preferred longer in hospital treatment 29% of inpatients would have preferred outpatient treatment No difference between readmission rates, ED visits, PCM visits

26

27 In Outpatient Treatment Cohort 13 VTE recurrences 3 Major Bleeding events 0 PE related deaths

28

29 Recurrent 90 day VTE Outpatients (1657 pts) 1.7% 1.2% Inpatients (383 pts) Major Bleeding 0.97% 1.0% Mortality 1.9% 0.74%

30

31

32 2014: Review on this topic performed Conclusions: Very low quality evidence Not blinding the outcome assessors Small number of events with wide CI 30 day mortality: RR 0.33, 95% CI 0.01 to day mortality: RR 0.98, 95% CI 0.06 to Small sample size Couldn t verify publication bias

33

34 132 patients randomly assigned Short term mortality (within 10 days) Early vs late discharge: 2.8% vs 0% 63YOF died of UGIB 5 days after discharge (d/c on day 3) 28YOF died of cardiac arrest 5 days after discharge (d/c on day 5) Found to have right atrial thrombus on autopsy Both fell into the low risk categories

35

36 In patients with low risk PE and whose home circumstances are adequate, we suggest early discharge over standard discharge (Grade 2B)

37

38 Outpatient anticoagulation is safe and effective in select patients...

39

40 Outpatient management of PE appears to be safe Determining who can safely be discharged is controversial

41

42 Outpatient management of PE appears to be safe Determining who can safely be discharged is controversial Our literature and many societies support outpatient management There are clinical pathways in use right now

43

44 Kearon et al. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012; 141(2) Yoo et al. Outpatient versus inpatient treatment for acute pulmonary embolism. The Cochrane Collaboration Baglin T. Fifty per cent of patients with pulmonary embolism can be treated as outpatients. J Thromb Haemost 2010; 8: Erkens PMG, Gandara E, Wells P, Shen AY-H, Bose G, Le Gal G, Rodger M, Prins MH, Carrier M. Safety of outpatient treatment in acute pulmonary embolism. J Thromb Haemost 2010; 8: Kovacs MJ, Hawel JD, Rekman JF, Lazo-Langner A. Ambulatory management of pulmonary embolism: a pragmatic evaluation. J Thromb Haemost 2010; 8: Zondag et al. Hestia criteria can discriminate high- from low-risk patients with pulmonary embolism. Eur Respir J 2013; 41: Jimenez et al. Prognostic models for selecting patients with acute pulmonary embolism for initial outpatient therapy. CHEST 2007; 132: Pernot N. Pulmonary embolism management-adult-ambulatory emergency department clinical practice guideline cover sheet. Univ of Wisc Health

45 Squizzato et al. Outpatient treatment and early discharge of symptomatic pulmonary embolism: a systematic review. Eur Respir J 2009; 33: Vinson et al. Timing of discharge follow-up for acute pulmonary embolism: retrospective cohort study. WestJEM. 2015;16: Egan M, Rowland K. Treating pulmonary embolism at home? J Fam Pract. 2012;61: Tapson V. Overview of the treatment, prognosis and follow-up of acute pulmonary embolism in adult patients. UpToDate. Mar Zondag et al. Outpatient versus inpatient treatment in patients with pulmonary embolism: a meta-analysis. Eur Respir J 2013; 42: Zondag et al. Outpatient treatment in patients with acute pulmonary embolism: the Hestia study. Journal of Thrombosis and Haemostasis, 9: Zhou et al. The prognostic value of pulmonary embolism severity index in acute pulmonary embolism: a meta-analysis. Respiratory Research 2012, 13:111.

46 Fesmire et al. Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Suspected Pulmonary Embolism. Ann Emerg Med. 2011;57: Sanchez et al. Echocardiography and pulmonary embolism severity index have independent roles in pulmonary embolism. Eur Respir J 2013; 42: Aujesky et al. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open label, randomised, non-inferiority trial. Lancet 2011; 378: Jimenez et al. Prognostic significance of multidetector CT in normotensive patients with pulmonary embolism: results of the protect study. Thorax 2014;69: Konstantinides et al ESC Guidelines on the diagnosis and management of acute pulmonary embolism. European Heart Journal (2014) 35, McNamara D. Outpatient treatment for pulmonary embolism, blood clots. March 25, Otero et al. Home treatment in pulmonary embolism. Thrombosis Research 126 (2010) e1 e5. Wolde et al. Prognostic value of echocardiographically assessed right ventricular dysfunction in patients with pulmonary embolism. Arch Intern Med. 2004;164:

RISK STRATIFICATION OF PATIENTS WITH ACUTE SYMPTOMATIC PULMONARY EMBOLISM. David Jiménez, MD, PhD, FCCP Ramón y Cajal Hospital, IRYCIS Madrid, Spain

RISK STRATIFICATION OF PATIENTS WITH ACUTE SYMPTOMATIC PULMONARY EMBOLISM. David Jiménez, MD, PhD, FCCP Ramón y Cajal Hospital, IRYCIS Madrid, Spain RISK STRATIFICATION OF PATIENTS WITH ACUTE SYMPTOMATIC PULMONARY EMBOLISM David Jiménez, MD, PhD, FCCP Ramón y Cajal Hospital, IRYCIS Madrid, Spain Potential Conflicts of Interest Financial conflicts of

More information

DECLARATION OF CONFLICT OF INTEREST

DECLARATION OF CONFLICT OF INTEREST DECLARATION OF CONFLICT OF INTEREST IDENTIFYING LOW-RISK PULMONARY EMBOLISM CLINICAL SCORES David Jiménez, MD, PhD Respiratory Department Ramón y Cajal Hospital Madrid, Spain Potential Conflicts of Interest

More information

Acute and long-term treatment of VTE. Cecilia Becattini University of Perugia

Acute and long-term treatment of VTE. Cecilia Becattini University of Perugia Acute and long-term treatment of VTE Cecilia Becattini University of Perugia Acute and long-term treatment of VTE The goals The acute PE phase After the acute phase Treatment for VTE Goals of acute treatment

More information

4/18/2018. Objectives. Background. 1) Compare and contrast the various validated tools for the identification of patients with pulmonary embolism

4/18/2018. Objectives. Background. 1) Compare and contrast the various validated tools for the identification of patients with pulmonary embolism Pulmonary Embolism: Assessment, risk-stratification, and treatment plan for the outpatient management of low-risk patients Presentation by Joshua T. Wood, PharmD/PGY-1 Resident Providence St. Patrick Hospital;

More information

Is it safe to manage pulmonary embolism in Primary Care? Roopen Arya King s College Hospital

Is it safe to manage pulmonary embolism in Primary Care? Roopen Arya King s College Hospital Is it safe to manage pulmonary embolism in Primary Care? Roopen Arya King s College Hospital A few definitions Safe Avoid death, recurrent thrombosis, bleeding Manage Diagnosis + treatment Pulmonary embolism

More information

Updates in venous thromboembolism. Cecilia Becattini University of Perugia

Updates in venous thromboembolism. Cecilia Becattini University of Perugia Updates in venous thromboembolism Cecilia Becattini University of Perugia News for VTE Diagnosis Treatment the acute phase the agents Pulmonary embolism: diagnosis Vein ultrasonography Meta-analysis 15

More information

Acute and long-term treatment of PE. Cecilia Becattini University of Perugia

Acute and long-term treatment of PE. Cecilia Becattini University of Perugia Acute and long-term treatment of PE Cecilia Becattini University of Perugia Acute and long-term treatment of VTE What is the optimal acute phase treatment for the patient? Intravenous thrombolysis One

More information

Massive and Submassive Pulmonary Embolism: 2017 Update and Future Directions

Massive and Submassive Pulmonary Embolism: 2017 Update and Future Directions Massive and Submassive Pulmonary Embolism: 2017 Update and Future Directions Kush R Desai, MD Assistant Professor of Radiology Northwestern University Feinberg School of Medicine Chicago, IL Disclosures

More information

The spectrum of clinical outcome of PE

The spectrum of clinical outcome of PE Practical treatment approach for patients with PE Cecilia Becattini University of Perugia The spectrum of clinical presentation of PE PE-related shock Mild clinical symptoms The spectrum of clinical outcome

More information

Cover Page. The handle holds various files of this Leiden University dissertation

Cover Page. The handle   holds various files of this Leiden University dissertation Cover Page The handle http://hdl.handle.net/1887/40114 holds various files of this Leiden University dissertation Author: Exter, Paul L. den Title: Diagnosis, management and prognosis of symptomatic and

More information

Thrombosis Research 129 (2012) Contents lists available at SciVerse ScienceDirect. Thrombosis Research

Thrombosis Research 129 (2012) Contents lists available at SciVerse ScienceDirect. Thrombosis Research Thrombosis Research 129 (2012) 710 714 Contents lists available at SciVerse ScienceDirect Thrombosis Research journal homepage: www.elsevier.com/locate/thromres Regular Article Does the Pulmonary Embolism

More information

Cover Page. The handle holds various files of this Leiden University dissertation.

Cover Page. The handle   holds various files of this Leiden University dissertation. Cover Page The handle http://hdl.handle.net/1887/20073 holds various files of this Leiden University dissertation. Author: Zondag, Wendy Title: Pulmonary embolism : outpatient treatment and risk stratification

More information

Management of Acute Pulmonary Embolism. Judith Hurdman Consultant Respiratory Physician

Management of Acute Pulmonary Embolism. Judith Hurdman Consultant Respiratory Physician Management of Acute Pulmonary Embolism Judith Hurdman Consultant Respiratory Physician Judith.hurdman@sth.nhs.uk Overview Risk Stratification Who can be managed as an outpatient? To thrombolyse or not

More information

The shock index and the simplified PESI for identification of low-risk patients with acute pulmonary embolism

The shock index and the simplified PESI for identification of low-risk patients with acute pulmonary embolism Eur Respir J 211; 37: 762 766 DOI: 1.1183/931936.711 CopyrightßERS 211 The shock index and the simplified PESI for identification of low-risk patients with acute pulmonary embolism A. Sam*, D. Sánchez*,

More information

Management of Intermediate-Risk Pulmonary Embolism

Management of Intermediate-Risk Pulmonary Embolism Management of Intermediate-Risk Pulmonary Embolism Stavros V. Konstantinides, MD, PhD, FESC Professor, Clinical Trials in Antithrombotic Therapy Center for Thrombosis und Hemostasis, University of Mainz,

More information

PULMONARY EMBOLISM (PE): DIAGNOSIS AND TREATMENT

PULMONARY EMBOLISM (PE): DIAGNOSIS AND TREATMENT PULMONARY EMBOLISM (PE): DIAGNOSIS AND TREATMENT OBJECTIVE: To provide a diagnostic algorithm and treatment options for patients with acute pulmonary embolism (PE). BACKGROUND: Venous thromboembolism (VTE)

More information

Understanding Best Practices in Anticoagulation Therapy in Patients with Venous Thromboembolism. Rajat Deo, MD, MTR

Understanding Best Practices in Anticoagulation Therapy in Patients with Venous Thromboembolism. Rajat Deo, MD, MTR Understanding Best Practices in Anticoagulation Therapy in Patients with Venous Thromboembolism Rajat Deo, MD, MTR Director of Translational Research in Cardiac Arrhythmias Division of Cardiovascular Medicine

More information

With the availability of new treatment

With the availability of new treatment CMAJ Review Managing pulmonary embolism using prognostic models: future concepts for primary care Geert-Jan Geersing Md Phd, Ruud Oudega Md Phd, Arno W. Hoes Md Phd, Karel G.M. Moons Phd With the availability

More information

Pulmonary embolism: Acute management. Cecilia Becattini University of Perugia, Italy

Pulmonary embolism: Acute management. Cecilia Becattini University of Perugia, Italy Pulmonary embolism: Acute management Cecilia Becattini University of Perugia, Italy Acute pulmonary embolism: Acute management Diagnosis Risk stratification Treatment Non-high risk PE: diagnosis 3-mo VTE

More information

Disclosures. Objectives

Disclosures. Objectives BRIGHAM AND WOMEN S HOSPITAL Treatment of Massive and Submassive Pulmonary Embolism Gregory Piazza, MD, MS Assistant Professor of Medicine Harvard Medical School Staff Physician, Cardiovascular Division

More information

Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model

Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model ERJ Express. Published on May 12, 2016 as doi: 10.1183/13993003.00024-2016 ORIGINAL ARTICLE IN PRESS CORRECTED PROOF Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology

More information

Duration of Anticoagulation? Peter Verhamme MD, PhD Department of Cardiovascular Medicine University of Leuven Belgium

Duration of Anticoagulation? Peter Verhamme MD, PhD Department of Cardiovascular Medicine University of Leuven Belgium Duration of Anticoagulation? Peter Verhamme MD, PhD Department of Cardiovascular Medicine University of Leuven Belgium Disclosures Honoraria and research support: Daiichi-Sankyo, Boehringer Ingelheim,

More information

Updates in Management of Pulmonary Embolism (PE) David Ming, MD Duke Hospital Medicine July 24, 2017 Hilton Head, SC

Updates in Management of Pulmonary Embolism (PE) David Ming, MD Duke Hospital Medicine July 24, 2017 Hilton Head, SC Updates in Management of Pulmonary Embolism (PE) David Ming, MD Duke Hospital Medicine July 24, 2017 Hilton Head, SC Objectives Highlight clinical features and presentation of acute PE Analyze strategies

More information

Open Access Original Article

Open Access Original Article Open Access Original Article Prognostic role of simplified Pulmonary Embolism Severity Index and the European Society of Cardiology Prognostic Model in short- and long-term risk stratification in pulmonary

More information

Thrombolysis in PE. Outline. Disclosure. Overview on Pulmonary Embolism. Hot Topics in Emergency Medicine 2012 Midyear Clinical Meeting

Thrombolysis in PE. Outline. Disclosure. Overview on Pulmonary Embolism. Hot Topics in Emergency Medicine 2012 Midyear Clinical Meeting Disclosure Thrombolysis in PE Daniel P. Hays, PharmD, BCPS, FASHP reports no relevant financial relationships. Daniel P. Hays, PharmD, BCPS, FASHP Outline 55 YOF presents to ED with SOB PMH of DVT + noncompliance

More information

Epidemiology. Update on Pulmonary Embolism. Keys to PE Management 5/5/2014. Diagnosis. Risk stratification. Treatment

Epidemiology. Update on Pulmonary Embolism. Keys to PE Management 5/5/2014. Diagnosis. Risk stratification. Treatment Update on Pulmonary Embolism Steven M. Dean, DO, FACP, RPVI Program Director- Vascular Medicine Associate Professor of Internal Medicine Division of Cardiovascular Medicine The Ohio State University Keys

More information

Is Thrombolysis Only for a Crisis?

Is Thrombolysis Only for a Crisis? Is Thrombolysis Only for a Crisis? December 19, 2017 Is Thrombolysis Only for a Crisis? Indications for Thrombolytic Therapy in Patients with Acute Pulmonary Embolism Case Scenario A 28 year old woman

More information

Case. Case. Management of Pulmonary Embolism in the ICU

Case. Case. Management of Pulmonary Embolism in the ICU Management of Pulmonary Embolism in the ICU Todd M Bull, M.D. Associate Professor of Medicine Division of Pulmonary Sciences and Critical Care Medicine Pulmonary Hypertension Center University of Colorado

More information

Venous thromboembolism (VTE) is a common. Changes in PESI scores predict mortality in intermediate-risk patients with acute pulmonary embolism

Venous thromboembolism (VTE) is a common. Changes in PESI scores predict mortality in intermediate-risk patients with acute pulmonary embolism Eur Respir J 2013; 41: 354 359 DOI: 10.1183/09031936.00225011 CopyrightßERS 2013 Changes in PESI scores predict mortality in intermediate-risk patients with acute pulmonary embolism Lisa Moores*, Celia

More information

Optimal Management of Intermediate-Risk Pulmonary Embolism

Optimal Management of Intermediate-Risk Pulmonary Embolism Optimal Management of Intermediate-Risk Pulmonary Embolism Stavros V. Konstantinides, MD, PhD, FESC Professor, Clinical Trials in Antithrombotic Therapy Center for Thrombosis und Hemostasis, University

More information

Impaired renal function predicts short term prognosis in patients with acute pulmonary embolism

Impaired renal function predicts short term prognosis in patients with acute pulmonary embolism Impaired renal function predicts short term prognosis in patients with acute pulmonary embolism Kostrubiec Maciej, Łabyk Andrzej, Pedowska-Włoszek Jusyna, Pacho Szymon, Jankowski Krzysztof, Koczaj-Bremer

More information

Chapter 1. Introduction

Chapter 1. Introduction Chapter 1 Introduction Introduction 9 Even though the first reports on venous thromboembolism date back to the 13 th century and the mechanism of acute pulmonary embolism (PE) was unraveled almost 150

More information

UC SF. Division of General Internal Medicine UNIVERSITY OF CALIFORNIA SAN FRANCISCO, DIVISION OF HOSPITAL MEDICINE

UC SF. Division of General Internal Medicine UNIVERSITY OF CALIFORNIA SAN FRANCISCO, DIVISION OF HOSPITAL MEDICINE Updates in the Management of Venous Thromboembolism Margaret C. Fang, MD, MPH Associate Professor of Medicine UCSF Division of Hospital Medicine Medical Director, Anticoagulation Clinic Venous Thromboembolism

More information

Canadian Society of Internal Medicine Annual Meeting 2016 Montreal, QC

Canadian Society of Internal Medicine Annual Meeting 2016 Montreal, QC Canadian Society of Internal Medicine Annual Meeting 2016 Montreal, QC 1 st workshop: update to VTE guidelines in 2016 2 nd workshop: VTE controversies + new horizons André Roussin MD, FRCP, CSPQ CHUM

More information

Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (2012) NICE guideline CG144

Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (2012) NICE guideline CG144 Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (2012) NICE guideline CG144 Appendix A: Summary of new evidence from Summary of evidence from previous year Diagnosis Diagnostic

More information

Understanding thrombosis in venous thromboembolism. João Morais Head of Cardiology Division and Research Centre Leiria Hospital Centre Portugal

Understanding thrombosis in venous thromboembolism. João Morais Head of Cardiology Division and Research Centre Leiria Hospital Centre Portugal Understanding thrombosis in venous thromboembolism João Morais Head of Cardiology Division and Research Centre Leiria Hospital Centre Portugal Disclosures João Morais On the last year JM received honoraria

More information

Challenges in the management of acute pulmonary embolism

Challenges in the management of acute pulmonary embolism Challenges in the management of acute pulmonary embolism Case: A pregnant woman presenting with clinical suspicion of acute venous thromboembolism: Appropriate diagnostic and therapeutic strategy in pregnancy.

More information

Cover Page. The handle holds various files of this Leiden University dissertation

Cover Page. The handle   holds various files of this Leiden University dissertation Cover Page The handle http://hdl.handle.net/1887/40114 holds various files of this Leiden University dissertation Author: Exter, Paul L. den Title: Diagnosis, management and prognosis of symptomatic and

More information

Epidemiology of Pulmonary Embolism (PE)

Epidemiology of Pulmonary Embolism (PE) Why Treat Submassive PE Abstract: Massive Pulmonary Embolism (PE) requires immediate lifesaving intervention for the patient. For the submassive PE patient, characterized by presence of right ventricular

More information

Identification of intermediate-risk patients with acute symptomatic pulmonary embolism

Identification of intermediate-risk patients with acute symptomatic pulmonary embolism ORIGINAL ARTICLE PULMONARY VASCULAR DISEASES Identification of intermediate-risk patients with acute symptomatic pulmonary embolism Carlo Bova 1, Olivier Sanchez 2,3, Paolo Prandoni 4, Mareike Lankeit

More information

The Pulmonary Embolism Severity Index in Predicting the Prognosis of Patients With Pulmonary Embolism

The Pulmonary Embolism Severity Index in Predicting the Prognosis of Patients With Pulmonary Embolism ORIGINAL ARTICLE DOI: 10.3904/kjim.2009.24.2.123 The Pulmonary Embolism Severity Index in Predicting the Prognosis of Patients With Pulmonary Embolism Won-Ho Choi 1, Sung Uk Kwon 1,2, Yoon Jung Jwa 1,

More information

Μακροχρόνια παρακολούθηση ασθενών με πνευμονική εμβολή

Μακροχρόνια παρακολούθηση ασθενών με πνευμονική εμβολή Μακροχρόνια παρακολούθηση ασθενών με πνευμονική εμβολή Ευφροσύνη Δ. Μάναλη Λέκτορας Β Πανεπιστημιακή Πνευμονολογική Κλινική ΓΝΑ «Αττικόν» Εθνικό και Καποδιστριακό Πανεπιστήμιο Αθηνών Existing guidelines

More information

Timing of NT-pro-BNP sampling for predicting adverse outcome after acute pulmonary embolism

Timing of NT-pro-BNP sampling for predicting adverse outcome after acute pulmonary embolism 7 Frederikus A. Klok Noortje van der Bijl Inge C.M. Mos Albert de Roos Lucia J. M. Kroft Menno V. Huisman Timing of NT-pro-BNP sampling for predicting adverse outcome after acute pulmonary embolism Letter

More information

EXTENDING VTE PROPHYLAXIS IN ACUTELY ILL MEDICAL PATIENTS

EXTENDING VTE PROPHYLAXIS IN ACUTELY ILL MEDICAL PATIENTS EXTENDING VTE PROPHYLAXIS IN ACUTELY ILL MEDICAL PATIENTS Samuel Z. Goldhaber, MD Director, VTE Research Group Cardiovascular Division Brigham and Women s Hospital Professor of Medicine Harvard Medical

More information

Diagnosis and Treatment of Pulmonary Embolism: High-Tech versus Low- Tech, which way to go?

Diagnosis and Treatment of Pulmonary Embolism: High-Tech versus Low- Tech, which way to go? Diagnosis and Treatment of Pulmonary Embolism: High-Tech versus Low- Tech, which way to go? Philip S. Wells MD, FRCPC, MSc Professor Chair and Chief, Department of Medicine, University of Ottawa DISCLOSURE

More information

ACR Appropriateness Criteria Suspected Lower Extremity Deep Vein Thrombosis EVIDENCE TABLE

ACR Appropriateness Criteria Suspected Lower Extremity Deep Vein Thrombosis EVIDENCE TABLE . Fowkes FJ, Price JF, Fowkes FG. Incidence of diagnosed deep vein thrombosis in the general population: systematic review. Eur J Vasc Endovasc Surg 003; 5():-5.. Hamper UM, DeJong MR, Scoutt LM. Ultrasound

More information

Cover Page. The handle holds various files of this Leiden University dissertation

Cover Page. The handle   holds various files of this Leiden University dissertation Cover Page The handle http://hdl.handle.net/1887/40114 holds various files of this Leiden University dissertation Author: Exter, Paul L. den Title: Diagnosis, management and prognosis of symptomatic and

More information

Hestia criteria can discriminate high from low risk patients with pulmonary embolism

Hestia criteria can discriminate high from low risk patients with pulmonary embolism ERJ Express. Published on July 12, 2012 as doi: 10.1183/09031936.00030412 Hestia criteria can discriminate high from low risk patients with pulmonary embolism Running head: Pulmonary embolism treating

More information

A VENOUS THROMBOEMBOLISM (VTE) TOWN HALL: Answering Your Top Questions on Treatment and Secondary Prevention

A VENOUS THROMBOEMBOLISM (VTE) TOWN HALL: Answering Your Top Questions on Treatment and Secondary Prevention A VENOUS THROMBOEMBOLISM (VTE) TOWN HALL: Answering Your Top Questions on Treatment and Secondary Prevention This handout is a supplemental resource to an educational video activity released on Medscape

More information

New Guidance in AT10 Clive Kearon, MD, PhD,

New Guidance in AT10 Clive Kearon, MD, PhD, New Guidance in AT10 Clive Kearon, MD, PhD, Professor, Department of Medicine, McMaster University; Program Director, McMaster Clinical Investigator Program, McMaster University Head, Clinical Thromboembolism

More information

RECOMMENDATIONS FOR THE MANAGEMENT OF MASSIVE AND SUBMASSIVE PULMONARY EMBOLISM IN ADULT PATIENTS.

RECOMMENDATIONS FOR THE MANAGEMENT OF MASSIVE AND SUBMASSIVE PULMONARY EMBOLISM IN ADULT PATIENTS. RECOMMENDATIONS FOR THE MANAGEMENT OF MASSIVE AND SUBMASSIVE PULMONARY EMBOLISM IN ADULT PATIENTS. Target Audience: Physicians managing adult patients with massive and submassive pulmonary emboli in the

More information

PE service. 65 years old lady. What would you do next? Risk stratification. What would you do next? Regional College Lecture PE Management

PE service. 65 years old lady. What would you do next? Risk stratification. What would you do next? Regional College Lecture PE Management PE service Regional College Lecture PE Management Update in medicine (Eastern) Cambridge 29 th June 2017 Dr Rachel M Limbrey DM FRCP University Hospital Southampton NHS Foundation Trust Ambulatory acute

More information

Chapter 3. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism

Chapter 3. Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism Chapter 3 Simplification of the revised Geneva score for assessing clinical probability of pulmonary embolism F.A. Klok, I.C.M. Mos, M. Nijkeuter, M. Righini, A. Perrier, G. Le Gal and M.V. Huisman Arch

More information

Underuse of risk assessment and overuse of CTPA in patients with suspected pulmonary thromboembolism

Underuse of risk assessment and overuse of CTPA in patients with suspected pulmonary thromboembolism Underuse of risk assessment and overuse of CTPA in patients with suspected pulmonary thromboembolism Michael Perera Advanced Trainee in General and Acute Medicine Leena Aggarwal Director, Medical Assessment

More information

What is New in Acute Pulmonary Embolism? Interventional Treatment. Prof. Nils Kucher University Hospital Bern Switzerland

What is New in Acute Pulmonary Embolism? Interventional Treatment. Prof. Nils Kucher University Hospital Bern Switzerland What is New in Acute Pulmonary Embolism? Interventional Treatment Prof. Nils Kucher University Hospital Bern Switzerland nils.kucher@insel.ch Disclosure of Interest Dr. Kucher received research grants

More information

Heart Health ESC Guidelines on the diagnosis and management of acute pulmonary embolism

Heart Health ESC Guidelines on the diagnosis and management of acute pulmonary embolism Heart Health Open Access Received: Oct 22, 2014 Accepted: Dec 01, 2014 Published: Dec 05, 2014 http://dx.doi.org/10.14437/hhoa-1-105 Review Jiri Widimsky, Heart Health Open Access 2014, 1:1 2014 ESC Guidelines

More information

Cancer Associated Thrombosis: six months and beyond. Farzana Haque Hull York Medical School

Cancer Associated Thrombosis: six months and beyond. Farzana Haque Hull York Medical School Cancer Associated Thrombosis: six months and beyond Farzana Haque Hull York Medical School Disclosure I have no disclosure The Challenge of Anticoagulation in Patients with Venous Thromboembolism and Cancer

More information

Results from RE-COVER RE-COVER II RE-MEDY RE-SONATE EXECUTIVE SUMMARY

Results from RE-COVER RE-COVER II RE-MEDY RE-SONATE EXECUTIVE SUMMARY Assessment of the safety and efficacy of dabigatran etexilate (Pradaxa ) in the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and the prevention of recurrent DVT and PE Results from

More information

PREVENTION AND TREATMENT OF VENOUS THROMBOEMBOLISM

PREVENTION AND TREATMENT OF VENOUS THROMBOEMBOLISM PREVENTION AND TREATMENT OF VENOUS THROMBOEMBOLISM International Consensus Statement 2013 Guidelines According to Scientific Evidence Developed under the auspices of the: Cardiovascular Disease Educational

More information

Epidemiology: Incidence VTE: Mortality Morbidity Risk Factors: Acute Chronic : Genetic

Epidemiology: Incidence VTE: Mortality  Morbidity Risk Factors: Acute Chronic : Genetic Submassive PE Pulmonary Embolism Epidemiology: Incidence VTE: 100-200/100,000 = 3rd most frequent cardiovascular disease Symptomatic DVT complicated by PE = 40-50% Sudden fatal PE = 34% Intermediate-risk

More information

Focus: l embolia polmonare Per quanto la terapia anticoagulante orale? Giulia Magnani 27 Gennaio, 2018

Focus: l embolia polmonare Per quanto la terapia anticoagulante orale? Giulia Magnani 27 Gennaio, 2018 Focus: l embolia polmonare Per quanto la terapia anticoagulante orale? Giulia Magnani 27 Gennaio, 2018 NO DISCLOSURE Pulmonary Embolism Venous thromboembolism (VT) is the third most common cause of cardiovascular

More information

PE Pathway. The charts are listed as follows:

PE Pathway. The charts are listed as follows: PE Pathway This document comprises 6 simple flow charts to assist clinicians in the investigation and treatment of suspected or confirmed Acute Pulmonary Emboli. The pathway has been put together using

More information

Catheter-directed Thrombolysis for Pulmonary Embolism

Catheter-directed Thrombolysis for Pulmonary Embolism Catheter-directed Thrombolysis for Pulmonary Embolism Is It Good Advice to Lyse? Texas Society of Health-System Pharmacists April 7, 2018 Rebecca L. Attridge, PharmD, MSc, BCPS Associate Professor, University

More information

ORIGINAL INVESTIGATION. Thrombolytic Therapy and Mortality in Patients With Acute Pulmonary Embolism

ORIGINAL INVESTIGATION. Thrombolytic Therapy and Mortality in Patients With Acute Pulmonary Embolism ORIGINAL INVESTIGATION Thrombolytic Therapy and in Patients With Acute Pulmonary Embolism Said A. Ibrahim, MD, MPH; Roslyn A. Stone, PhD; D. Scott Obrosky, MSc; Ming Geng, MSc; Michael J. Fine, MD, MSc;

More information

ORIGINAL INVESTIGATION

ORIGINAL INVESTIGATION ORIGINAL INVESTIGATION Prognostic Role of Echocardiography Among Patients With Acute Pulmonary Embolism and a Systolic Arterial Pressure of 90 mm Hg or Higher Nils Kucher, MD; Elisa Rossi, BS; Marisa De

More information

VTE General Background

VTE General Background VTE General Background VTE incidence is about 1:1000 persons annually >250,000 admissions for VTE annually >100,000 people die of PE annually >90% of PE s arise from lower limb DVT 50% of DVT at diagnosis

More information

Citation for published version (APA): Douma, R. A. (2010). Pulmonary embolism: advances in diagnosis and prognosis

Citation for published version (APA): Douma, R. A. (2010). Pulmonary embolism: advances in diagnosis and prognosis UvA-DARE (Digital Academic Repository) Pulmonary embolism: advances in diagnosis and prognosis Douma, R.A. Link to publication Citation for published version (APA): Douma, R. A. (2010). Pulmonary embolism:

More information

Recent advances in the management of pulmonary embolism. Kodati Rakesh SR Pulmonary medicine

Recent advances in the management of pulmonary embolism. Kodati Rakesh SR Pulmonary medicine Recent advances in the management of pulmonary embolism Kodati Rakesh SR Pulmonary medicine Clinical decision rules & D dimer Outpatient anticoagulation Thrombolysis Anticoagulation Catheter directed therapies

More information

S (18) doi: /j.ajem Reference: YAJEM 57346

S (18) doi: /j.ajem Reference: YAJEM 57346 Accepted Manuscript A portrait of patients who die in-hospital from acute pulmonary embolism Hesham R. Omar, Mehdi Mirsaeidi, Bishoy Abraham, Garett Enten, Devanand Mangar, Enrico M. Camporesi PII: S0735-6757(18)30172-4

More information

Pulmonary Embolectomy:

Pulmonary Embolectomy: Pulmonary Embolectomy: Recommendation for early surgical intervention Tomas A. Salerno, M.D. Professor of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital Epidemiology

More information

ORIGINAL INVESTIGATION. Thrombolysis vs Heparin in the Treatment of Pulmonary Embolism

ORIGINAL INVESTIGATION. Thrombolysis vs Heparin in the Treatment of Pulmonary Embolism Thrombolysis vs Heparin in the Treatment of Pulmonary Embolism A Clinical Outcome Based Meta-analysis ORIGINAL INVESTIGATION Giancarlo Agnelli, MD; Cecilia Becattini, MD; Timo Kirschstein, MD Background:

More information

SAFETY OF A PULMONARY EMBOLISM AMBULATORY TREATMENT PROGRAM

SAFETY OF A PULMONARY EMBOLISM AMBULATORY TREATMENT PROGRAM SAFETY OF A PULMONARY EMBOLISM AMBULATORY TREATMENT PROGRAM Mahir M. Hamad 1, MD, FRCP, Elrasheed A. Ellidir 1, MD, MRCP, Charlotte Routh 1, MD, MRCP, Siraj O. Wali 2, FACP, FCCP, and Vincent M. Connolly

More information

Acute Pulmonary Embolism and Deep Vein Thrombosis. Barbara LeVarge MD Beth Israel Deaconess Medical Center Pulmonary Hypertension Center COPYRIGHT

Acute Pulmonary Embolism and Deep Vein Thrombosis. Barbara LeVarge MD Beth Israel Deaconess Medical Center Pulmonary Hypertension Center COPYRIGHT Acute Pulmonary Embolism and Deep Vein Thrombosis Barbara LeVarge MD Beth Israel Deaconess Medical Center Pulmonary Hypertension Center Acute PE and DVT No disclosures. Acute PE and DVT Learning objectives

More information

Duration of Anticoagulant Therapy. Linda R. Kelly PharmD, PhC, CACP September 17, 2016

Duration of Anticoagulant Therapy. Linda R. Kelly PharmD, PhC, CACP September 17, 2016 Duration of Anticoagulant Therapy Linda R. Kelly PharmD, PhC, CACP September 17, 2016 Conflicts of Interest No conflicts of interest to report Objectives At the end of the program participants will be

More information

Single-Center, Retrospective, Observational Analysis of Patients with Submassive Pulmonary Embolism (PE) Receiving Catheter- Directed Thrombolysis

Single-Center, Retrospective, Observational Analysis of Patients with Submassive Pulmonary Embolism (PE) Receiving Catheter- Directed Thrombolysis Single-Center, Retrospective, Observational Analysis of Patients with Submassive Pulmonary Embolism (PE) Receiving Catheter- Directed Thrombolysis John A. Phillips, M.D. OhioHealth Heart and Vascular Physicians

More information

Recurrence risk after anticoagulant treatment of limited duration for late, second venous thromboembolism

Recurrence risk after anticoagulant treatment of limited duration for late, second venous thromboembolism ARTICLES Coagulation & its Disorders Recurrence risk after anticoagulant treatment of limited duration for late, second venous thromboembolism Tom van der Hulle, Melanie Tan, Paul L. den Exter, Mark J.G.

More information

10/26/2016. Disclosures 2016 ACOI Annual Convention and Scientific Sessions. Learning Objectives

10/26/2016. Disclosures 2016 ACOI Annual Convention and Scientific Sessions. Learning Objectives AMERICAN COLLEGE OF OSTEOPATHIC INTERNIST PULMONARY EMBOLISM & RELATED STUFF Timothy J. Barreiro, DO, MPH, FCCP, FACP, FACOI Section Chair, Pulmonary & Critical Care Medicine Associate Professor of Internal

More information

Adjustments in the diagnostic work-up, treatment and prognosis of pulmonary embolism van Es, Josien

Adjustments in the diagnostic work-up, treatment and prognosis of pulmonary embolism van Es, Josien UvA-DARE (Digital Academic Repository) Adjustments in the diagnostic work-up, treatment and prognosis of pulmonary embolism van Es, Josien Link to publication Citation for published version (APA): van

More information

Treatment of venous thromboembolism: focus on patient characteristics and bleeding complications Brekelmans, M.P.A.

Treatment of venous thromboembolism: focus on patient characteristics and bleeding complications Brekelmans, M.P.A. UvA-DARE (Digital Academic Repository) Treatment of venous thromboembolism: focus on patient characteristics and bleeding complications Brekelmans, M.P.A. Link to publication Citation for published version

More information

Venous Thrombosis. Magnitude of the Problem. DVT 2 Million PE 600,000. Death 60,000. Estimated Cost of VTE Care $1.5 Billion/year.

Venous Thrombosis. Magnitude of the Problem. DVT 2 Million PE 600,000. Death 60,000. Estimated Cost of VTE Care $1.5 Billion/year. Venous Thrombosis Magnitude of the Problem DVT 2 Million Postthrombotic Syndrome 800,000 PE 600,000 Death 60,000 Silent PE 1 Million Pulmonary Hypertension 30,000 Estimated Cost of VTE Care $1.5 Billion/year

More information

Management of Massive and Sub-Massive Pulmonary Embolism

Management of Massive and Sub-Massive Pulmonary Embolism Management of Massive and Sub-Massive Pulmonary Embolism M. Montero-Baker, MD L Leon Jr., MD, RVT, FACS Tucson Medical Center Vascular and Endovascular Surgery Section CASE PRESENTATION 54 YEAR- OLD CAUCASIAN

More information

PREVENTION AND TREATMENT OF VENOUS THROMBOEMBOLISM

PREVENTION AND TREATMENT OF VENOUS THROMBOEMBOLISM PREVENTION AND TREATMENT OF VENOUS THROMBOEMBOLISM International Consensus Statement 2013 Guidelines According to Scientific Evidence Developed under the auspices of the: Cardiovascular Disease Educational

More information

Pulmonary Embolism. Pulmonary Embolism. Pulmonary Embolism. PE - Clinical

Pulmonary Embolism. Pulmonary Embolism. Pulmonary Embolism. PE - Clinical Pulmonary embolus - a practical approach to investigation and treatment Sam Janes Wellcome Senior Fellow and Respiratory Physician, University College London Background Diagnosis Treatment Common: 50 cases

More information

Cover Page. The handle holds various files of this Leiden University dissertation.

Cover Page. The handle   holds various files of this Leiden University dissertation. Cover Page The handle http://hdl.handle.net/1887/21764 holds various files of this Leiden University dissertation. Author: Mos, Inge Christina Maria Title: A more granular view on pulmonary embolism Issue

More information

Mark H. Meissner, MD Peter Gloviczki Professor of Venous & Lymphatic Disorders University of Washington School of Medicine

Mark H. Meissner, MD Peter Gloviczki Professor of Venous & Lymphatic Disorders University of Washington School of Medicine Pulmonary Embolism Response Teams Not So Fast Early Interventions is a House of Cards Mark H. Meissner, MD Peter Gloviczki Professor of Venous & Lymphatic Disorders University of Washington School of Medicine

More information

DOACs in CAT. Fellow: Shweta Jain, MD Faculty Discussant: David Garcia, MD

DOACs in CAT. Fellow: Shweta Jain, MD Faculty Discussant: David Garcia, MD DOACs in CAT Fellow: Shweta Jain, MD Faculty Discussant: David Garcia, MD Case 65 year old post menopausal female Left breast lesion Oct 2015 Biopsy Invasive ductal carcinoma Lumpectomy with SNB- pt1cno

More information

Θεραπεία και Πρόληψη Θρομβώσεων και Πνευμονικών Εμβολών Τι μάθαμε το 2017; Τι περιμένουμε το 2018;

Θεραπεία και Πρόληψη Θρομβώσεων και Πνευμονικών Εμβολών Τι μάθαμε το 2017; Τι περιμένουμε το 2018; Θεραπεία και Πρόληψη Θρομβώσεων και Πνευμονικών Εμβολών Τι μάθαμε το 2017; Τι περιμένουμε το 2018; Stavros V. Konstantinides, MD, PhD, FESC Professor of Cardiology Democritus University of Thrace, Greece

More information

Supplementary Online Content

Supplementary Online Content Supplementary Online Content Mismetti P, Laporte S, Pellerin O, Ennezat P-V, Couturaud F, Elias A, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs anticoagulation alone

More information

Usefulness of Clinical Pre-test Scores for a Correct Diagnostic Pathway in Patients with Suspected Pulmonary Embolism in Emergency Room

Usefulness of Clinical Pre-test Scores for a Correct Diagnostic Pathway in Patients with Suspected Pulmonary Embolism in Emergency Room Send Orders for Reprints to reprints@benthamscience.net The Open Emergency Medicine Journal, 2013, 5, (Suppl 1: M-4) 19-24 19 Open Access Usefulness of Clinical Pre-test Scores for a Correct Diagnostic

More information

Cover Page. The handle holds various files of this Leiden University dissertation.

Cover Page. The handle  holds various files of this Leiden University dissertation. Cover Page The handle http://hdl.handle.net/1887/21764 holds various files of this Leiden University dissertation. Author: Mos, Inge Christina Maria Title: A more granular view on pulmonary embolism Issue

More information

Screening for CETPH after acute pulmonary embolism: is it needed? Menno V. Huisman Department of Vascular Medicine LUMC Leiden

Screening for CETPH after acute pulmonary embolism: is it needed? Menno V. Huisman Department of Vascular Medicine LUMC Leiden Screening for CETPH after acute pulmonary embolism: is it needed? Menno V. Huisman Department of Vascular Medicine LUMC Leiden m.v.huisman@lumc.nl Background CETPH Chronic Thrombo Embolic Pulmonary Hypertension

More information

Duration of Therapy for Venous Thromboembolism

Duration of Therapy for Venous Thromboembolism Duration of Therapy for Venous Thromboembolism Michael B Streiff, MD FACP Associate Professor of Medicine and Pathology Medical Director, Johns Hopkins Anticoagulation Service Chairman, VTE Guideline Committee

More information

Inferior Venacaval Filters Valuable vs. Dangerous Valuable Annie Kulungowski. Department of Surgery Grand Rounds March 24, 2008

Inferior Venacaval Filters Valuable vs. Dangerous Valuable Annie Kulungowski. Department of Surgery Grand Rounds March 24, 2008 Inferior Venacaval Filters Valuable vs. Dangerous Valuable Annie Kulungowski Department of Surgery Grand Rounds March 24, 2008 History of Vena Cava Filters Virchow-1846-Proposes PE originate from veins

More information

Age-adjusted hstnt cut-off value for risk stratification of pulmonary embolism

Age-adjusted hstnt cut-off value for risk stratification of pulmonary embolism ERJ Express. Published on January 22, 2015 as doi: 10.1183/09031936.00174514 ORIGINAL ARTICLE IN PRESS CORRECTED PROOF Age-adjusted hstnt for risk stratification of pulmonary embolism Anja Kaeberich 1,

More information

Treatment of cancer-associated venous thromboembolism by new oral anticoagulants: a meta-analysis

Treatment of cancer-associated venous thromboembolism by new oral anticoagulants: a meta-analysis Original Article Page of 9 Treatment of cancer-associated venous thromboembolism by new oral anticoagulants: a meta-analysis Satyanarayana R. Vaidya, Sonu Gupta, Santhosh R. Devarapally, Department of

More information

A 50-year-old woman with syncope

A 50-year-old woman with syncope Hira Shahzad 1, Ali Bin Sarwar Zubairi 2 1 Medical College, Aga Khan University Hospital, Karachi 2 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan Ali Bin Sarwar Zubairi Associate

More information

Obesity, renal failure, HIT: which anticoagulant to use?

Obesity, renal failure, HIT: which anticoagulant to use? Obesity, renal failure, HIT: which anticoagulant to use? Mark Crowther with thanks to Dr David Garcia and others. This Photo by Unknown Author is licensed under CC BY-SA 1 2 Drug choices The DOACs have

More information

The Evidence Base for Treating Acute DVT

The Evidence Base for Treating Acute DVT The Evidence Base for Treating Acute DVT Mr Chung Sim Lim Consultant Vascular Surgeon and Honorary Lecturer Royal Free London NHS Foundation Trust and University College London NIHR UCLH Biomedical Research

More information

Critical Review Form Therapy

Critical Review Form Therapy Critical Review Form Therapy Alteplase versus heparin in acute pulmonary embolism: randomised trial assessing right-ventricular function and pulmonary perfusion Lancet 1993; 341:501-511 Objective: To determine

More information

The effects of cause of death classification on prognostic assessment of patients with pulmonary embolism

The effects of cause of death classification on prognostic assessment of patients with pulmonary embolism Journal of Thrombosis and Haemostasis, 9: 2201 2207 DOI: 10.1111/j.1538-7836.2011.04490.x ORIGINAL ARTICLE The effects of cause of death classification on prognostic assessment of patients with pulmonary

More information