Μακροχρόνια παρακολούθηση ασθενών με πνευμονική εμβολή Ευφροσύνη Δ. Μάναλη Λέκτορας Β Πανεπιστημιακή Πνευμονολογική Κλινική ΓΝΑ «Αττικόν» Εθνικό και Καποδιστριακό Πανεπιστήμιο Αθηνών
Existing guidelines recommend therapeutic anticoagulation for all patients with acute pulmonary embolism (PE) for at least three months. PL den Exter, et al. Blood Reviews 2013; 27: 185-192
Konstantinides S, et al. Eur Heart J 2012; 33(24): 3014-3022
These guidelines however do not provide a clear recommendation on the frequency and duration of medical follow-up. Generally, this latter ends at the moment of anticoagulant cessation, despite current insight that the long-term clinical course of acute PE is frequently complicated by several thrombotic and non-thrombotic adverse events
It has even been shown that half of the patients with acute PE suffer from at least one major complication within four years after initial diagnosis Klok FA, et al. Am J Respir Crit Care Med 2010; 181: 501-506
This represents a relative increase in risk of death of 12.6-fold for our study cohort s youngest quintile compared with the general population. For the oldest quintile, the relative risk increase was 1.9-fold.
It is important to note that the increased mortality in this population could not be solely assigned to baseline comorbidity. In 351 patients with a Charlson Comorbidity Index score of 0 at baseline (ie, no comorbidities), there were 44 (13%) deaths post-discharge, of which 19 (43%) were cardiovascular (3 due to recurrent PE, 6 to myocardial infarction, 4 to heart failure, 2 to cardiac-related causes, and 4 to stroke) and 4 (9%) were due to malignancy.
However, further research in this field and controlled clinical trials are warranted before recommendations can be established which risk factors should be therapeutically targeted to prevent ATE in the years following a PE diagnosis. Whereas there are well-developed guidelines for the long-term follow-up of patients with coronary disease and heart failure, current guidelines do not recommend the long-term follow-up of patients post-pe. The current study shows that this is unsupportable for any age group, including those in the youngest quintile and those without baseline comorbidities.
Recurrent venous thromboembolism Venous thrombosis is a common disease with a yearly incidence of around one case per 1000 person-years. In a third of patients deep venous thrombosis is complicated by embolization of the clot into the lungs Venous thrombosis is a chronic disease that often recurs. In unselected cohorts of patients with venous thrombosis, the risk of recurrence after 5 years is 20 25%, and is higher than 25% in patients with unprovoked venous thrombosis Lancet 2010; 376: 2032-2039 Recurrent PE is associated with a considerable case-fatality rate of 5.0% 14%
Kearon C, et al. Circulation 2004; 110: I10-I18
Abnormalities that are associated with an increased risk of venous thrombosis, and that are detectable with laboratory techniques, can be established in more than 50% of patients with a first unprovoked venous thrombosis. Recurrent venous thrombosis can only be prevented by indefinite anticoagulation treatment, which confers a substantial risk of haemorrhage.
Lip GYH, et al. Europace 2011; 13: 723-746
A third of patients with recurrent unprovoked venous thrombosis have a normal test result. A negative finding from thrombophilia testing could therefore result in a false sense of safety for patients. Lancet 2010; 376: 2032-2039
The rate of symptomatic VTE in patients with cancer who have been hospitalized approaches 5%. VTE, especially when unprovoked, may herald an impending diagnosis of cancer in a subset of patients without known malignancy.
In patients with venous thromboembolism (VTE), 15 20% will have prevalent cancer when VTE is diagnosed In patients with a first VTE and without prevalent cancer, the risk for new cancer is about 1 2% per year, appears to be uniform over time, and is higher in patients with unprovoked VTE and those with advanced age.
The risk of recurrent VTE is 3-fold higher in patients with cancer who experience an initial venous thromboembolic event in comparison with patients who do not have cancer and develop VTE Mortality after hospital discharge is nearly double among patients with cancer who subsequently developed VTE in comparison with those who do not
Because patients who have cancer with VTE have an increased risk of recurrent VTE, the 2012 American College of Chest Physicians Evidence- Based Clinical Practice Guidelines on Antithrombotic Therapy for VTE Disease recommend extended-duration anticoagulant therapy over time-limited anticoagulation in patients with active cancer, especially if the risk of bleeding is not elevated. Because patients with cancer who are receiving anticoagulation for VTE treatment have at least a 2-fold increased risk of major bleeding in comparison with patients without cancer who are receiving anticoagulant therapy for VTE, patients with cancer who are receiving extended-duration anticoagulation for secondary prevention should be monitored closely for bleeding
Chronic thromboembolic pulmonary hypertension Incomplete thromboembolic resolution after PE may result in the development of CTEPH, which is characterized by intraluminal thrombus organization to endothelialized residua resulting in fibrous stenosis or complete obliteration of the pulmonary arteries Also, for reasons still unidentified, 25 40% of patients with established CTEPH lack a prior history of symptomatic PE or DVT
Bonderman D, et al. Eur Respir J 2009; 33: 325-331
N Engl J Med 2004;350:2257-64.
Acta Radiol 2012 53: 728
CHEST 2009; 136:1202 1210
For example, from the time of diagnosis to the 6-month follow-up, the percentage of patients treated with standard anticoagulation with manifest RV hypokinesis decreased from 20% to 7%, and this same end point among patients treated with heparin and alteplase decreased from 57% to 6%. Symptom-based, selective monitoring may be an insensitive screening measure for the identification of patients with tricuspid regurgitation suggestive of high right-side heart pressures. Only 9 of 39 patients who manifested an increase in RVSP admitted to dyspnea at rest (NYHA score, 4) at the 6-month follow-up, but 10 more patients admitted to shortness of breath every day with walking.
Survival without intervention is poor In one study, the 5-year survival rate in patients with CTEPH was 30% when the mean pulmonary artery pressure was >40 mm Hg and 10% when it was >50 mm Hg
Further recommendations for post thrombotic syndrome
Further recommendations for drug interactions
Further recommendations for hematological monitoring
importance of patient information and education relating to lifestyle issues while on anticoagulation, when receiving dental treatment and during pregnancy
CHEST 2012; 141(2)(Suppl):e691S e736s
The term clinical vigilance refers to patient and physician alertness to the signs and symptoms of VTE and awareness of the need for timely and appropriate objective investigation of women with symptoms suspicious of DVT or PE. A family history of VTE refers to DVT or PE in a first-degree relative
Long term follow-up for patients with pulmonary embolism Recommendations Optimization of treatment Optimization of duration of treatment Evaluation for major bleeding complications Laboratory monitoring and screening Regular follow-up for cardiovascular disease Regular follow-up for chronic thromboembolic pulmonary hypertension Screening for cancer Special recommendation for VTE complicating pregnancy Everyday lifestyle issues Good patient-health care provider communication Increased clinical vigilance
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