pulmonary%20thromboembolism
PULMONARY THROMBOEMBOLISM
Pulmonary embolism is the blockage of the blood vessels in the lungs usually due to blood clots from the veins, especially the veins in the legs and pelvis.
Dyspnea, chest pain, syncope or tachypnea (respiratory rate of ≥20/min) occur in most cases of pulmonary embolism.
Pleuritic chest pain with or without dyspnea is one of the most frequent presentations of this disease.
Syncope or shock are the hallmark signs of central pulmonary embolism and usually result in severe hemodynamic repercussions.
Signs of hemodynamic compromise and reduced heart flow are also usually present.

Follow Up

  • Patients w/ acute pulmonary embolism (PE) have a high frequency (20-50%) of symptomatic extension of thrombus &/or recurrent venous thromboembolism (VTE) & therefore require long-term anticoagulant treatment
  • Treatment w/ oral anticoagulant is the preferred method of long-term management of most PE patients
  • Adjusted doses of unfractionated heparin (UFH)  or low-molecular-weight heparin (LMWH) may be indicated for selected patients in whom oral anticoagulants are contraindicated or impractical

Low-molecular-weight Heparin (LMWH)

  • Preferred drug for patients w/ PE & cancer
    • Should be used for the 1st 3-6 months of long-term anticoagulant therapy, then continued as oral therapy indefinitely or until cancer has resolved

Oral Anticoagulant

  • Duration of anticoagulation is dependent on the type of event & the coexistence of prolonged risk factors:
    • PE due to transient or reversible risk factor: Oral anticoagulation is recommended for at least 3 months
    • Unprovoked PE: Oral anticoagulation is recommended for at least 3 months
    • Unprovoked PE (1st episode), w/ low-risk of bleeding & in whom stable anticoagulation can be achieved: Consider long-term oral anticoagulation
    • Unprovoked PE (2nd episode): Long-term treatment is recommended

Risk Factors for Major Bleeding During Anticoagulation

  • Age >75 years
  • Previous gastrointestinal (GI) bleeding
  • Previous noncardioembolic stroke
  • Chronic hepatic & renal disease
  • Concomitant antiplatelet therapy
  • Poor anticoagulant control
  • Suboptimal monitoring of therapy
  • Comorbid illness

Monitoring During Anticoagulation

  • International normalized ratio (INR) should be checked at least weekly during the 1st several weeks of Warfarin therapy
  • If stable, monitor every 2 weeks then every 4 weeks, but not >4 weeks
  • Target INR is 2.5 for most patients & 3.0 for patients w/ recurrent VTE
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