Information

What is the disadvantage of having no anticoagulation after pulmonary embolism?

What is the disadvantage of having no anticoagulation after pulmonary embolism?


We are searching data for your request:

Forums and discussions:
Manuals and reference books:
Data from registers:
Wait the end of the search in all databases.
Upon completion, a link will appear to access the found materials.

Is chronic anticoagulation always given after pulmonary embolism?

What are the risks or disadvantages

  • if anticoagulation is not given?
  • if terminated early?

Not always, however typically it is given for at least a few months. Lack of anticoagulation therapy would greatly heighten the risk of having another PE or related cardiovascular events. At the worst side this could cause death or permanent disability, and PE related deaths are quite common. However this depends on the nature of the PE and risk factors. For example, obesity, cancer and the pill are all risk factors and if these were reduced then it is likely the person wouldn't have another PE despite not being on long term anticoagulation therapy. However, if there is an underlying cause even despite anticoagulation therapy a person may suffer a PE.

The problem with anticoagulation therapy is of course it stops your blood clotting. Thus haemorrhages are more common and also more severe. However in an individual receiving anticoagulation therapy, they typically have increased clotting so this may be balanced out by therapy.

Finally anticoagulation therapy is typically warfarin in the long term. Warfarin interacts with so many drugs including even antibiotics, it is teratogenic and quite sensitive to diet (any changes in Vitamin K will directly affect the effectivity of warfarin) thus frequent monitoring is required. This is annoying for the patient as they have to report for frequent blood tests as well as watch their diet etc.


What is the disadvantage of having no anticoagulation after pulmonary embolism? - Biology

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are forms of venous thromboembolism (VTE). VTE has significant morbidity and mortality for patients in the community and in hospital. Anticoagulation is the mainstay of therapy for VTE. The purpose of anticoagulation is the prevention of recurrent thrombosis, embolization, and death, the risk of which is greatest in the first three to six months following the diagnosis.

Following initial anticoagulation for the first 5 to 10 days, patients with VTE require therapy for a more prolonged period. This topic review will discuss the selection of an anticoagulant, the transition from initial therapy, and the duration and monitoring of long-term anticoagulation. The indications for anticoagulation, an overview of DVT treatment, and details regarding initial and indefinite anticoagulation for patients with VTE are discussed separately. (See "Overview of the treatment of lower extremity deep vein thrombosis (DVT)" and "Venous thromboembolism: Initiation of anticoagulation (first 10 days)" and "Selecting adult patients with lower extremity deep venous thrombosis and pulmonary embolism for indefinite anticoagulation".)

The approach to anticoagulation outlined in this topic is, in general, consistent with strategies outlined by several international societies including The American College of Chest Physicians, The American College of Physicians, The European Society of Cardiology, The European Respiratory Society, The American Society of Hematology, and others [1-4].

For the purposes of discussion in this topic, the following terms apply:

● The term unprovoked deep vein thrombosis (DVT) implies that no identifiable provoking environmental event for DVT is evident [5]. In contrast, a provoked DVT is one that is usually caused by a known event (eg, surgery, hospital admission). VTE events can be provoked by transient major risk factors (ie, major surgery >30 minutes, hospitalization or immobility ≥3 days, caesarian section), transient minor risk factors (minor surgery <30 minutes, hospitalization <3 days, pregnancy, estrogen therapy, reduced mobility ≥3 days) or persistent risk factors. Persistent risk factors include reversible conditions (eg, curable malignancy, inflammatory bowel disease that resolves) and irreversible conditions such as inheritable thrombophilias, chronic heart failure, and metastatic end-stage malignancy. (See "Overview of the causes of venous thrombosis".)


Introduction

For more than 50 years, vitamin K antagonists (eg, warfarin) were the only available oral anticoagulants. It has now been 3 years since the first of the new oral anticoagulants (NOACs), dabigatran etexilate, gained approval for stroke prevention in atrial fibrillation in the United States. This was followed by the approval of rivaroxaban and apixaban for this indication. Rivaroxaban has been approved for thromboprophylaxis after total hip or knee replacement and the initial treatment and secondary prevention of venous thromboembolism (VTE). In other countries, dabigatran etexilate and apixaban were approved for the prevention of VTE after hip and knee replacement. Edoxaban and betrixaban are other oral factor Xa inhibitors in development. Phase 3 trials comparing edoxaban to warfarin for the prevention of stroke and systemic embolism in patients with atrial fibrillation and the treatment of VTE have been completed. Betrixaban is being evaluated in a phase 3 trial versus enoxaparin for the prevention of VTE in medically ill patients undergoing hospitalization.

Unlike warfarin, which has a narrow therapeutic window and requires individualized dosing based on the international normalized ratio (INR), the NOACs have a wide therapeutic window, thereby facilitating fixed dosing in adults without the need for laboratory monitoring or dose adjustments for body weight. NOACs are renally cleared and lower doses of rivaroxaban and apixaban were used in patients with atrial fibrillation and impaired kidney function (creatinine clearances between 25 and 49 mL/min). In general, the results for the approved indications have been robust, with NOACs being either noninferior or superior to standard treatment regimens. Despite the advantages and potential simplification of anticoagulation afforded by NOACs, their uptake for the approved indications after launch has been less than anticipated in some areas of the United States and other parts of the world. 1

The results of the phase 3 trials of NOACs have been published in peer-reviewed journals and have been the topic of numerous review articles, 2,3 including recent ASH education sessions. 4,5 The issue of whether NOACs or warfarin should be used as frontline agents for stroke prevention in atrial fibrillation has been, and continues to be, vigorously debated 6,7 therefore, the clinical trials will not be reviewed here in detail. This chapter primarily focuses on the pros and cons of the NOACs for the various indications that have gained approval in the United States by the middle of 2013, particularly focusing on real-world concerns related to their effectiveness, safety, and use.


References

  • 1.The Surgeon General's Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism . Rockville, MD : US Dept of Health and Human Services 2008 . Google Scholar
  • 2.

White RH, Zhou H, Romano PS

White RH, Zhou H, Murin S, Harvey D

Schneider D, Lilienfeld DE, Im W

Dowling NF, Austin H, Dilley A, Whitsett C, Evatt BL, Hooper WC

Zakai N, Lutsey P, Folsom A, Cushman M

Heit JA, Beckman MG, Bockenstedt PL, Grant AM, Key NS, Kulkarni R, Manco-Johnson MJ, Moll S, Ortel TL, Philipp CS

James AH, Jamison MG, Brancazio LR, Myers ER

Tang Y, Sampson B, Pack S, Shah K, Yon Um S, Wang D, Wang T, Prinz M

Siddique RM, Siddique MI, Connors AF, Rimm AA

Stein PD, Kayali F, Olson RE

Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Alshab AK, Meyers FA

Aujesky D, Long JA, Fine MJ, Ibrahim SA

Ganz DA, Glynn RJ, Mogun H, Knight EL, Bohn RL, Avorn J

Arnsten JH, Gelfand JM, Singer DE

White RH, Beyth RJ, Zhou H, Romano PS

White RH, Dager WE, Zhou H, Murin S

Bezemer ID, van der Meer FJ, Eikenboom JC, Rosendaal FR, Doggen CJ

Stein PD, Beemath A, Meyers FA, Skaf E, Olson RE

Austin H, Key NS, Benson JM, Lally C, Dowling NF, Whitsett C, Hooper WC

Lutsey PL, Cushman M, Steffen LM, Green D, Barr RG, Herrington D, Ouyang P, Folsom AR


The Risk of VTE and Bleeding with Anticoagulation in Asians

Historically, VTE has been considered a relatively uncommon disease among Asian populations. Some previous studies suggested lower incidences of VTE in Asian population compared with Caucasian population. 15�) Ethnic differences, distinct resource availability, and treatment patterns may have notable implications in the presentation of VTE. In addition, there is a concern that anticoagulation might be associated with a higher risk of bleeding particularly in Asians than in Caucasians. In fact, previous studies have shown markedly higher rates of major bleeding in Asian patients than in non-Asian patients receiving anticoagulation for conditions such as atrial fibrillation. 19,20) Thus, it is important to take a good balance between the risk of thrombosis and bleeding with consideration of the ethnic difference.


Long-term limitations imposed on patients with pulmonary embolism

A multi-centre clinical study, led by Dr. Susan Kahn at the Jewish General Hospital (JGH), determined that nearly half of the patients who suffer a pulmonary embolism (PE) -- a blood clot in the lung -- experience long term limitations to their capacity for physical activity and that this had a negative impact on their quality of life. This research, published in Chest, is the first to demonstrate that PE may have a lasting effect on patients.

"Our clinical experience told us that some patients who'd had a pulmonary embolism suffered from shortness of breath and chronic fatigue long after the PE had been treated and resolved," explained Dr. Kahn, who is founder and director of the Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC) at the JGH, and an epidemiologist at the Lady Davis Institute at the JGH. "Our study revealed that 47% of participants showed a significant reduction in their physical stamina."

One-hundred patients were followed over the course of a year following treatment for PE. They answered quality of life questionnaires and participated in a number of physiological tests to measure their cardiopulmonary functions. All of the participants were generally healthy when they experienced their PE, so it was surprising that nearly half performed below 80% of their predicted peak oxygen uptake (a standard measure for cardiopulmonary exercise testing) one year later. These patients also scored lower in variables used to measure quality of life.

"One of the tests we use is to see how far a patient can walk in six minutes, which is a basic measure of mobility and stamina. When someone is limited in performing this test, it is really something that is interfering with their normal day-to-day functioning," said Dr. Kahn, a Professor of Medicine at McGill University, who is recognized as a world leader in research and treating patients with venous thromboembolism (VTE).

The underlying cause of the PE did not seem to be a predictor of whether a person may experience long-term repercussions. The study did reveal that men were three times more likely to have adverse effects, younger patients fared worse, as did more overweight patients and smokers.

Though further study is required, the outcome of this research suggests that patients with PE may benefit from some form of exercise rehabilitation as part of their recovery.


Effect of post-filter anticoagulation on mortality in patients with cancer-associated pulmonary embolism

Malignancy is associated with an increased risk of venous thromboembolism. Inferior vena cava filters are a viable alternative when anticoagulation is infeasible because of the risk of bleeding. Although the current guidelines recommend that all patients with a vena cava filter be treated with anticoagulation treatment when the risk of bleeding is reduced, studies concerning the role of concomitant anticoagulation after vena cava filter insertion in high-risk patients are scarce. Since many cancer patients suffer from a high risk of hemorrhagic complications, we aimed to determine the effect of post-filter anticoagulation on mortality in patients with a malignant solid tumor.

Methods

A retrospective cohort study of patients with pulmonary embolism was performed between January 2010 and May 2016. Patients with a solid tumor and vena cava filter inserted because of pulmonary embolism were included. Using Cox proportional hazards model, the prognostic effect of clinical variables was analyzed.

Results

A total of 180 patients were analyzed, with 143 patients receiving and 37 patients not receiving post-filter anticoagulation treatment. Mortality was not significantly different between the two groups. The presence of metastatic cancer and that of pancreatobiliary cancer were significant risk factors for mortality. However, post-filter anticoagulation did not show significant effect on mortality regardless of the stage of cancer.

Conclusion

In patients with cancer-associated pulmonary embolism, the effect of post-filter anticoagulation on mortality may not be critical, especially in patients with a short life expectancy.


Benefit of extending anticoagulation therapy lost after discontinuation of therapy

Among patients with a first episode of pulmonary embolism (the obstruction of the pulmonary artery or a branch of it leading to the lungs by a blood clot) who received 6 months of anticoagulant treatment, an additional 18 months of treatment with warfarin reduced the risk of additional blood clots and major bleeding, however, the benefit was not maintained after discontinuation of anticoagulation therapy, according to a study in the July 7 issue of JAMA.

When anticoagulant therapy is stopped after 3 to 6 months of treatment, patients with a first episode of unprovoked (no major risk factor) venous thromboembolism (blood clot within a vein) have a much higher risk of recurrence than those with venous thromboembolism provoked by a transient risk factor (e.g., surgery). In this high-risk population, extending anticoagulation beyond 3 to 6 months is associated with a reduction in the risk of recurrence as long as treatment is continued. However, whether this benefit is maintained thereafter has been uncertain because most previous studies did not include follow-up of patients after discontinuation of treatment, according to background information in the article.

Francis Couturaud, M.D., Ph.D., of the Universite de Bretagne Occidentale, Brest, France, and colleagues conducted a study that included 371 adult patients who had experienced a first episode of symptomatic unprovoked pulmonary embolism (i.e., with no major risk factor for a blood clot) and had been treated initially for 6 uninterrupted months with a vitamin K antagonist. The patients were randomly assigned to warfarin or placebo for 18 months median follow-up was 24 months. The trial was conducted at 14 French centers.

After randomization, 4 patients were lost to follow-up, all after month 18, and 1 withdrew due to an adverse event. During the 18-month treatment period, the primary outcome (the composite of recurrent venous thromboembolism or major bleeding at 18 months after randomization) occurred in 6 of 184 patients (3 percent) in the warfarin group and in 25 of 187 patients (13.5 percent) in the placebo group, resulting in a relative risk reduction of 78 percent in favor of warfarin. This result was driven by a reduction in the risk of recurrent venous thromboembolism, with the risk of bleeding increasing to a minimal extent.

This benefit of anticoagulation was lost after anticoagulation was discontinued. During the 42-month entire study period (including the study treatment and follow-up periods), the composite outcome occurred in 33 patients (21 percent) in the warfarin group and in 42 (24 percent) in the placebo group. Rates of recurrent venous thromboembolism, major bleeding, and unrelated death did not differ between groups.

The authors note that their results suggest that patients such as those who participated in this study require long-term secondary prevention measures. "Whether these should include systematic treatment with vitamin K antagonists, new anticoagulants or aspirin, or be tailored according to patient risk factors needs further investigation."

(doi:10.1001/jama.2015.7046 Available pre-embargo to the media at http://media. jamanetwork. com)

Editor's Note: The study was supported by grants from the Programme Hospitalier de Recherche Clinique (French Department of Health), and the sponsor was the University Hospital of Brest. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

Please Note: There is related content in this issue of JAMA on this topic. These articles, along with a podcast, are available to the media at http://media. jamanetwork. com.

Long-term vs Short-term Therapy With Vitamin K Antagonists for Symptomatic Venous Thromboembolism

Computed Tomographic Pulmonary Angiography for Pulmonary Embolism

Edoxaban (Savaysa) - The Fourth New Oral Anticoagulant

Treatment Duration for Pulmonary Embolism

Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.


Introduction

Roughly 5-10% of patients with renal masses have venous tumor thrombus [1,2] and tumor thrombus level has been shown to correlate with survival [3] as well as higher rates of adverse events [4]. Higher levels of tumor thrombus [5] often require liver mobilization and possible cardiac bypass [6]. With increased inferior vena cava (IVC) manipulation, the risk of emboli increases and different techniques to ensure tumor control have been reported with good results [7]. IVC filters have been utilized in an attempt to prevent pulmonary embolism (PE), but are not recommended due to the potential for caval thrombosis, provided the patient does not have active tumor embolus [2]. The patient we present had suspected tumor emboli, given her worsening chest CT despite appropriate anticoagulation. Cardiothoracic surgery was consulted preoperatively and was present during the operation. Intraoperatively, the patient demonstrated signs of PE expansion prior to liver mobilization and significant IVC manipulation. As such, the decision to use the AngioVac system (Vortex Medical, Norwell, MA) was made in an attempt to prevent further PE.


Discussion

In an observational cohort of higher-risk PE patients, DOAC therapy in morbidly obese patients was not associated with an increased risk of recurrent VTE compared to warfarin anticoagulation therapy within 6 months of management of acute PE, and these higher-risk patients had similar recovery of right ventricle function on DOAC therapy as those treated with warfarin (even among morbidly obese patients). This work is strengthened by the rigorous follow-up and imaging acquisition in almost all patients regardless of symptoms.

Fixed-dose DOAC therapies have greatly simplified management of acute PE by preventing recurrent VTE without the need for laboratory monitoring and the associated effort to make warfarin dose adjustments. For patients, the “real-world” rates of bleeding are low [19], and there is relatively little concern for drug–diet or drug–drug interactions [20]. The initial concern about using fixed-dose DOAC therapy in morbid obesity was understandable. Both unfractionated and low-molecular weight heparin are weight-based drugs, and vitamin K antagonist doses are typically higher in morbid obesity [8]. Theoretically, it would make sense that morbidly obese patients would require higher doses of DOAC therapy based on a fixed dose diluted in a larger volume of distribution, but limited pharmacokinetic and pharmacodynamic studies evaluating DOAC in morbid obesity suggest weight does not influence dosing [21–25]. Furthermore, there is no clear relationship between drug levels and clinical outcomes like VTE recurrence or bleeding [3–6]. No therapeutic range of Xa inhibition is established for DOAC. Given the difficulty in achieving therapeutic levels with warfarin [8], having a simplified option could decrease recurrent events.

The current consensus guidelines from ISTH [7] and the European Society of Cardiology [26] both caution against using DOAC therapy for patients with a BMI>40 kg·m −2 if DOACs are used, these documents recommend measuring anti-Xa activity despite the fact that no therapeutic range has been established. The American Society of Hematology does not address morbid obesity in their 2018 VTE guidelines [27]. Papers being published today still caution against DOAC use in morbidly obese patients owing to the lack of clinical data, with calls for prospective trials to be completed before DOAC use can be recommended in this population [28–30]. However, at least one meta-analysis found no reduction in efficacy in the registration trials when looking at obese versus non-obese patients [31]. To the best of our knowledge, there are no active clinical trials evaluating DOAC therapy for VTE in morbid obesity (clinicaltrials.gov, October 2020).

The majority of patients included in the original DOAC clinical trials were low-risk VTE and not obese. However, it is important to note that neither BMI nor weight was an exclusionary criterion in the registration trials. A meta-analysis determined that 20% of participants in the registration trials were “high body weight” at randomisation (either >100 kg or >90 kg) [31]. None of the registration trials reported event rates specifically in morbid obesity, but they did report no differences in recurrent events in the high body weight groups treated with DOAC versus conventional therapy [3–6].

Recurrent VTE events often occur within 3–6 months at a rate of 4%–8% [32, 33] and typically present in a similar manner as the index event [34, 35]. With obesity being a risk factor for initial [11–13] and recurrent [14] VTE, if effective anticoagulation was not provided, the observed VTE recurrence rate would likely be much higher than the reported baseline of ∼4%–8%. We did not observe an elevated recurrence rate in our cohort. There is evolving retrospective data on the efficacy of DOAC therapy in morbid obesity. K ushnir et al. [36] used single-centre chart review and determined a 2% risk for recurrent VTE in 366 morbidly obese (BMI>40 kg·m −2 ) patients with any DOAC-treated VTE event. Using two US claims databases, S pyropoulos et al. [37] found a similar rate of risk of recurrent thrombotic events in morbid obesity. Although both studies relied on coding, their findings are real-world evidence that DOACs are effective in morbid obesity. We do not know if some of their recurrent VTE could have been unrecognised CTEPH or chronic clot.

We complement these larger studies with rigorous clinical follow-up and detailed chart review including echocardiogram, V/Q scan and RHC. We did not observe any recurrent PE within the first year in any patient, regardless of weight group or type of anticoagulation. We were able to differentiate CTEPH from recurrent PE. Furthermore, we did not observe any difference in the resolution of thrombotic disease on perfusion lung scanning, and DOAC-treated patients were just as likely to achieve right ventricle recovery (an indirect measure that the pulmonary circulation is no longer obstructed) after higher-risk PE. Our numbers are small, but DOACs did not appear to leave patients at higher risk for CTEPH. None of the registration clinical trials reported rates of CTEPH development, and given the large numbers of patients involved, CTEPH would be expected in some patients. Our data strengthen a growing body of literature supporting the clinical efficacy of DOAC therapy in morbid obesity because none of the previously reported studies detailed follow-up data on imaging and physiological recovery.

There are limitations to our study. We have data on a small number of morbidly obese patients on DOAC therapy that took 2 years to collect. However, given that this is a high-risk group, DOAC failure with recurrent events should have been observed. Our data are observational and anticoagulation was chosen based on the preference of the discharging attending physician and patient. Peak and trough drug concentrations were not measured, and we have no measurements of anti-Xa levels. We only included patients who had an intermediate- or high-risk PE. We did not include atrial fibrillation in our analysis and therefore our results may not be applicable to patients with BMI>40 kg·m −2 and atrial fibrillation.

In conclusion, we found that DOAC therapy does not put patients with morbid obesity at higher risk for recurrent VTE after intermediate- or high-risk PE compared to warfarin anticoagulation we observed similar outcomes in obese and non-obese patients. Perfusion lung scanning did not suggest a difference in the rate of thrombus resolution, and echocardiography suggested similar rates of right ventricular recovery regardless of anticoagulation choice. In patients with PE, we believe that the available evidence makes DOAC therapy a reasonable option even in morbid obesity we propose prospective clinical trials to address this directly.


Watch the video: 10 Τρομακτικά Μυστικά Ομορφιάς Των Πιο Όμορφων Γυναικών Της Ιστορίας (June 2022).


Comments:

  1. Emesto

    It's a pity that I can't speak now - I'm late for the meeting. I will be released - I will definitely express my opinion

  2. Cunningham

    I hope they come to the correct decision.



Write a message