DOCSLIB.ORG

Thrombolysis with Reteplase in Acute Pulmonary Embolism

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Thrombolysis with Reteplase in Acute Pulmonary Embolism Indian Heart Journal 71 (2019) 464e467 Contents lists available at ScienceDirect Indian Heart Journal journal homepage: www.elsevier.com/locate/ihj Original Article Thrombolysis with reteplase in acute pulmonary embolism * K.R. Nishanth a, , Ravi S. Math a, Mythri Shankar b, K.S. Ravindranath a, C.N. Manjunath a a Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bengaluru, India b Institute of Nephro Urology, Bengaluru, India article info abstract Article history: Objective: Reteplase (recombinant plasminogen activator) is a mutant of alteplase. It has a longer half-life Received 10 February 2019 than its parent molecule and has shown better vessel patency rates in acute myocardial infarction. In this Accepted 1 September 2019 study, we analyzed the efficacy and safety of reteplase in acute pulmonary embolism (PE). Available online 20 September 2019 Methods: This observational study included patients with high- and intermediate-risk acute PE, presenting within 14 days of symptom onset. The patients were treated with reteplase, which was Keywords: given in two bolus doses of 10 U each, 30 min apart, along with intravenous heparin. Patients Acute pulmonary embolism with hemodynamic compromise (high-risk or massive PE) and normotensive patients with evi- Reteplase Thrombolysis dence of right ventricular (RV) dysfunction (intermediate-risk or submassive PE) on echocardi- ography or computed tomography were included in the study. The efficacy outcomes assessed were in-hospital death and improvement of RV function by echocardiography. The safety out- comes were major bleeding, minor bleeding, and ischemic or hemorrhagic stroke during hospitalization. Results: Of the 40 patients included, 25% were classified as high risk with hemodynamic compromise and 75% were classified as intermediate risk. RV dysfunction was present in all the patients (100%). Concomitant lower extremity deep vein thrombosis was present in 55% of the patients. The mortality rate was 5%. There was significant improvement in RV function and reduction in pulmonary artery systolic pressure and tricuspid regurgitation severity. There was no major bleeding event or stroke, and 7.5% patients had minor extracranial bleeding. Conclusions: Double-bolus reteplase given with heparin is effective in the treatment of high- and in- termediate-risk PE, with minimal risk of bleeding. © 2019 Cardiological Society of India. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1. Introduction resistance with an increase in cardiac output. It has also shown to be superior compared with anticoagulation in intermediate-risk (or e Thrombolytic therapy is an established treatment modality in submassive) PE.2 6 Thrombolytic agents that have been shown to acute high-risk (or massive) pulmonary embolism (PE) with he- be of proven efficacy include streptokinase, urokinase, alteplase, e modynamic instability.1 It effectively resolves thromboembolic and tenecteplase.1,7 10 obstruction and promptly reduces pulmonary artery pressure and Reteplase is a third-generation fibrin-specific recombinant tis- sue plasminogen activator that lacks the finger, epidermal growth factor, and kringle 1 domains.11 The slower clearance resulting from these changes in the molecular structure allows reteplase to be Abbreviations: aPTT, Activated partial tissue thromboplastin time; CT, Computed given as a nonweight-adjusted bolus.12 In patients with acute tomography; DVT, Deep vein thrombosis; ESC, European Society of Cardiology; INR, myocardial infarction (MI), reteplase achieved more rapid and more International normalized ratio; ISTH, International Society on Thrombosis and Hemostasis; MI, Myocardial infarction; STEMI, ST elevation myocardial infarction; complete thrombolysis of the infarct-related artery than alteplase, 13e15 PASP, Pulmonary artery systolic pressure; PE, Pulmonary embolism; RV, Right with no difference in bleeding rates. ventricle; SD, Standard deviation; TAPSE, Tricuspid annular plane systolic excur- Although the efficacy of reteplase in acute MI is known, only few sion; TTE, Transthoracic echocardiography; TR, Tricuspid regurgitation. case reports and case series have reported its utility in high- and * & Corresponding author. Sri Jayadeva Institute of Cardiovascular Sciences intermediate-risk PE.16,17 In this study, we examine the efficacy and Research, Bannerghatta Road, Bengaluru, 560102, India. E-mail address: [email protected] (K.R. Nishanth). safety of reteplase in acute PE. https://doi.org/10.1016/j.ihj.2019.09.011 0019-4832/© 2019 Cardiological Society of India. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). K.R. Nishanth et al. / Indian Heart Journal 71 (2019) 464e467 465 2. Methods 2.4. Statistical analysis 2.1. Study design and patients Descriptive and inferential statistical analyses have been used in this study. The results of continuous measurements are presented This was a prospective observational study conducted at a ter- as mean ± standard deviation (minimumemaximum), and the re- tiary cardiac care center in India between January 2017 and March sults of categorical measurements are presented as number (%). 2018. Significance was assessed at a level of 5%. The Student t-test (two- Patients were included in the study if they met the following tailed, independent) was used to find the significance of improve- criteria: an age of 18 years or older, objectively confirmed acute PE ment in study parameters before and after thrombolysis. The chi- with a symptom duration of 14 days or less, and right ventricular square/Fisher Exact test was used to find the significance of study (RV) dysfunction confirmed by two-dimensional transthoracic parameters on the categorical scale between the different groups. echocardiography (TTE) or computed tomography (CT) of the chest. The Fisher Exact test was used when cell samples were very small. The diagnosis of PE was confirmed by CT of the chest. A p value of <0.05 was considered significant. Data were analyzed Patients were excluded from the study if they had one or more using statistical software SPSS 18.0 and R environment version of the following characteristics: prior intracranial hemorrhage, 3.2.2. known cerebrovascular lesion, intracranial neoplasm, ischemic stroke within 3 months, active bleeding (except menses), known bleeding disorder, major surgery or major trauma within the pre- 3. Results ceding 3 weeks, gastrointestinal bleeding within the preceding 1 month, uncontrolled hypertension, current therapy with an oral 3.1. Patient data anticoagulant, current pregnancy, or lactation. Written informed consent was obtained from all patients before A total of 40 patients received reteplase for acute PE during the thrombolysis. study period. The baseline characteristics of the patients are sum- The choice of the thrombolytic agent was at the discretion of the marized in Table 1. The mean age of the patients was 39.3 ± 12.6 treating physicians. The study protocol was approved by the local years; the oldest patient was 71 years. Dyspnea was the most ethics committee. common symptom at presentation present in 95% patients. The time interval between symptom onset and thrombolysis (window period) was fewer than 3 days in 42.5%, 3e10 days in 37.5%, and 2.2. Drug regimen more than 10 days in 20% of the patients. Concomitant lower ex- tremity deep vein thrombosis confirmed by venous Doppler was Patients diagnosed to have acute PE received an intravenous seen in 55% patients. There was an identifiable provocation factor in bolus of 5000 U of unfractionated heparin and two bolus doses of 10 U of reteplase given 30 min apart. Intravenous heparin infusion or subcutaneous enoxaparin was started 6 h after administration of Table 1 Baseline characteristics of the study patients. the second bolus dose of reteplase. The heparin infusion rate was 1000 U per hour, and the rate was subsequently adjusted to Characteristics maintain the activated partial thromboplastin time (aPTT) at 2.0 to Sex, no. (%) 2.5 times the upper limit of normal. aPTT measurements were Male 29 (72.5) taken at 6-hour intervals. Enoxaparin was administered subcuta- Female 11 (27.5) Mean age, yrs 39.3 ± 12.6 neously at a dose of 1 mg/kg twice daily. Overlapping oral antico- Symptoms, no. (%) agulant therapy with warfarin was initiated on day 2 after Dyspnea 38 (95) thrombolysis, and the dosage was adjusted to maintain an inter- Syncope 5 (12.5) national normalized ratio of 2.0e3.0. Fatigue 3 (7.5) Chest pain 6 (15) Window period, no. (%) < 3 days 17 (42.5) 2.3. Outcome assessment 3e10 days 15 (37.5) >10 days 8 (20.0) After thrombolysis, the patients were evaluated upto the end of Blood pressure, no. (%) hospital stay and earlier if any clinical deterioration occurred. TTE < 90 mm Hg 10 (25) > was performed to assess RV function and pulmonary artery systolic 90 mm Hg 30 (75) e Lower extremity DVT, no. (%) 22 (55) pressure (PASP) 12 24 h after administration of reteplase and RV systolic dysfunction, no. (%) 40 (100) before discharge and earlier in case if any clinical deterioration. Mean PASP, mm Hg 64.5 ± 12.9 Efficacy of thrombolysis was assessed in terms of in-hospital death Severity of tricuspid regurgitation, no. (%) and persistent RV dysfunction with elevated PASP at discharge. The Mild 11 (27.5) Moderate 25 (62.5) tricuspid annular plane systolic excursion (TAPSE) value of <17 mm 18 Severe 4 (10) measured
Load more

Recommended publications
  • Spontaneous Epidural Hematoma of the Cervical Spine Following Thrombolysis in a Patient with STEMI—Two Medical Specialties Facing a Rare Dilemma
    Published online: 2019-12-05 THIEME Case Report 191 Spontaneous Epidural Hematoma of the Cervical Spine Following Thrombolysis in a Patient with STEMI—Two Medical Specialties Facing a Rare Dilemma Anastasios Tsarouchas1 Dimitrios Mouselimis1 Constantinos Bakogiannis1 Grigorios Gkasdaris2 George Dimitriadis3 Dimitrios Zioutas4 Christodoulos E. Papadopoulos1 13rd Cardiology Department, Hippokrateio University Hospital, Address for correspondence Grigorios Gkasdaris, MD, Department Aristotle University of Thessaloniki, Thessaloniki, Greece of Neurosurgery, KAT General Hospital of Attica, Athens 145 61, 2Department of Neurosurgery, KAT General Hospital of Attica, Greece (e-mail: [email protected]). Athens, Greece 3General Hospital of Katerini, Katerini, Greece 4St. Luke’s Hospital, Thessaloniki, Greece J Neurosci Rural Pract 2020;11:191–195 Abstract Spontaneous spinal epidural hematoma (SSEH) is a rare, albeit well-documented complication following thrombolysis treatment in ST elevation myocardial infarction (STEMI). A SSEH usually manifests with cervical pain and neurologic deficits and may require surgical intervention. In this case report, we present the first reported SSEH to occur following thrombolysis with reteplase. In this case, the SSEH manifested with cervical pain shortly after the patient emerged from his rescue percutaneous coronary intervention (PCI). Although magnetic resonance imaging reported spinal cord com- Keywords pression, the lack of neurologic symptoms prompted the treating clinicians to delay ► spinal epidural surgery. A dangerous dilemma emerged, as the usual antithrombotic regimen that hematoma was necessary to avoid stent thrombosis post-PCI, was also likely to exacerbate the ► spontaneous spinal bleeding. As a compromise, the patient only received aspirin as a single antiplatelet epidural hematoma therapy. Ultimately, the patient responded well to conservative treatment, with the ► cervical spine hematoma stabilizing a week later, without residual neurologic deficits.
    [Show full text]
  • Full Prescribing Information for - Active Internal Bleeding (4) RETAVASE
    HIGHLIGHTS OF PRESCRIBING INFORMATION CONTRAINDICATIONS These highlights do not include all the information needed to use • Do not use in patients with: RETAVASE safely and effectively. See full prescribing information for - Active internal bleeding (4) RETAVASE. - Recent stroke (4) - Recent intracranial or intraspinal surgery or serious head trauma (4) RETAVASE (reteplase) for injection, for intravenous use - Intracranial neoplasm, arteriovenous malformation, or aneurysm (4) Initial U.S. Approval: 1996 - Known bleeding diathesis (4) - Severe uncontrolled hypertension (4) INDICATIONS AND USAGE RETAVASE is a tissue plasminogen activator (tPA) indicated for treatment of WARNINGS AND PRECAUTIONS acute ST-elevation myocardial infarction (STEMI) to reduce the risk of death • Increases the risk of bleeding. Avoid intramuscular injections. (5.1) and heart failure. (1) • Hypersensitivity (5.2) • Cholesterol embolism (5.3) Limitation of Use: The risk of stroke may outweigh the benefit produced by thrombolytic therapy in patients whose STEMI puts them at low risk for death ADVERSE REACTIONS or heart failure. (1) The most common adverse reaction (>5%) is bleeding. (6.1) DOSAGE AND ADMINISTRATION To report SUSPECTED ADVERSE REACTIONS, contact Chiesi USA, • Two 10 unit intravenous injections, each administered over 2 minutes, Inc. at 1-888-661-9260 or FDA at 1-800-FDA-1088 or 30 minutes apart. (2.1) www.fda.gov/medwatch. • No other medication should be injected or infused simultaneously via the same intravenous line or added to the injection solution. (2.1) USE IN SPECIFIC POPULATIONS • Pediatric Use: Safety and effectiveness have not been established. (8.4) DOSAGE FORMS AND STRENGTHS For Injection: 10 units as a lyophilized powder in single-use vials for Revised: 10/2020 reconstitution co-packaged with Sterile Water for Injection, USP in 10 mL prefilled syringe.
    [Show full text]
  • Dosing and Administration Guide for RETAVASE® (Reteplase) for Injection1
    RETAVASE® (reteplase) is a recombinant plasminogen activator which catalyzes the cleavage of endogenous plasminogen to generate plasmin. Plasmin degrades the fibrin matrix of the thrombus, exerting its thrombolytic action. Dosing and administration guide for RETAVASE® (reteplase) for injection1 RETAVASE is a tissue plasminogen activator (tPA) with the convenience of fixed dosing for your fibrinolytic needs in acute STEMI Administration with zero dose calculations As soon as possible after the 30 minutes later, administer onset of STEMI, administer 10 units 30min a second dose of 10 units intravenously over 2 minutes. intravenously. Each single-use vial contains 10 units of RETAVASE as lyophilized powder. Reconstitute RETAVASE immediately before administration using only the co-packaged Sterile Water for Injection, USP (see instructions on back). Indication and Usage Important Safety Information RETAVASE is a tissue plasminogen activator (tPA) Heparin and RETAVASE are incompatible. Do not administer indicated for treatment of acute ST-elevation RETAVASE through an intravenous line containing heparin. myocardial infarction (STEMI) to reduce the risk of death and heart failure. The most common adverse reaction (>5%) is bleeding. Limitation of Use: The risk of stroke may outweigh Please see Full Important Safety the benefit produced by thrombolytic therapy in Information on back. patients whose STEMI puts them at low risk for death or heart failure. Reconstitution instructions for RETAVASE® (reteplase) — the only fixed-dose fibrinolytic for acute STEMI1 Indication and Usage STEP 1 STEP 2 RETAVASE is a tissue plasminogen activator (tPA) indicated Uncap Clean vial for treatment of acute ST-elevation myocardial infarction spike, vial membrane (STEMI) to reduce the risk of death and heart failure.
    [Show full text]
  • Best Evidence for Antithrombotic Agent Reversal in Bleeding
    3/16/2021 1 JAMES H. PAXTON, MD • DIRECTOR OF CLINICAL RESEARCH • DETROIT RECEIVING HOSPITAL (DRH), DEPARTMENT OF EMERGENCY MEDICINE, WAYNE STATE UNIVERSITY • ATTENDING PHYSICIAN • SINAI-GRACE HOSPITAL (SGH) • DETROIT RECEIVING HOSPITAL (DRH) 2 1 3/16/2021 DISCLOSURES • FUNDED RESEARCH SPONSORED BY: TELEFLEX INC, 410 MEDICAL, HOSPI CORP. 3 OBJECTIVES •AT THE CONCLUSION OF THIS LECTURE, THE LEARNER WILL: • RECOGNIZE COMMON ANTITHROMBOTIC MEDICATIONS ASSOCIATED WITH BLEEDING EMERGENCIES • BE ABLE TO EXPLAIN THE MECHANISMS OF ACTION FOR COMMON ANTITHROMBOTIC MEDICATIONS • UNDERSTAND THE EVIDENCE FOR RAPID REVERSAL OF ANTITHROMBOTIC MEDICATIONS, INCLUDING CONTROVERSIES AND BEST PRACTICES HAVE FEWER NIGHTMARES ABOUT SCENES LIKE THE ONE ON THE NEXT SLIDE? 4 2 3/16/2021 BLEEDING IS BAD 5 WHEN TO REVERSE? • WHEN RISK OF BLEEDING OUTWEIGHS RISK OF REVERSAL: • INTRACRANIAL HEMORRHAGE (ICH) • OTHER CNS HEMATOMA (E.G., INTRAOCULAR, SPINAL) • EXSANGUINATING GASTROINTESTINAL (GI) BLEED • UNCONTROLLED RETROPERITONEAL BLEED • HEMORRHAGE INTO EXTREMITY WITH COMPARTMENT SYNDROME • CONSIDER IN POSTERIOR EPISTAXIS, HEMOTHORAX, PERICARDIAL TAMPONADE 6 3 3/16/2021 ANTITHROMBOTIC AGENTS •ANTI-PLATELET DRUGS •ANTI-COAGULANTS •FIBRINOLYTICS 7 THROMBOGENESIS • Primary component in arterial thrombosis (“white clot”) • Target for antiplatelet drugs • Primary component in venous thrombosis (“red clot”) • Aggregated platelets + • Target for anticoagulants fibrin mesh • Target for fibrinolytics 8 4 3/16/2021 PLATELET AGGREGATION Antiplatelet Drugs Mechanism Aspirin*
    [Show full text]
  • In Vivo Effects of Contrast Media on Coronary Thrombolysis
    View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector 1102 JACC Vol. 32, No. 4 October 1998:1102–8 In Vivo Effects of Contrast Media on Coronary Thrombolysis SORIN PISLARU, MD, PHD,*† CRISTINA PISLARU, MD,* MONIKA SZILARD, MD,* JEF ARNOUT, PHD,‡ FRANS VAN DE WERF, MD, PHD, FACC* Leuven, Belgium and Bucharest, Romania Objectives. The aim of the present study was to evaluate the associated with longer reperfusion delays (time to optimal reper- influence of radiographic contrast media (CM) on alteplase- fusion: 67 6 48 min and 65 6 49 min, respectively, vs. 21 6 11 min induced coronary thrombolysis. after placebo; p < 0.05) and shorter periods of coronary perfusion Background. Contrast media inhibit fibrinolysis in vitro and (optimal perfusion time: 21 6 26 min and 21 6 28 min, respec- interact with endothelial cells, platelets and the coagulation tively, vs. 58 6 40 min after placebo; p < 0.05). No significant system. The in vivo effects of CM on thrombolysis are not known. differences were observed between groups with regard to activated Methods. Occlusive coronary artery thrombosis was induced in partial thromboplastin times, circulating thrombin-antithrombin 4 groups of 10 dogs by the copper coil technique. After 70 min of III complex concentrations and fibrinogen. occlusion the dogs were randomized to intracoronary injection of Conclusions. In this animal model administration of iohexol 2 2mlkg 1 of either saline, a low-osmolar ionic CM (ioxaglate), a and amidotrizoate before thrombolysis significantly delayed low-osmolar nonionic CM (iohexol) or a high-osmolar ionic CM reperfusion.
    [Show full text]
  • Use of Antithrombotic Medications in the Presence of Neuraxial Anesthesia
    Guideline: Use of Antithrombotic Medications In The Presence of Neuraxial Anesthesia Use of Antithrombotic Medications In The Presence of Neuraxial Anesthesia Purpose of Guidelines: To establish appropriate administration and timing of antithrombotic medications before, during, and after the use of neuraxial anesthesia to minimize the risk of bleeding. Definitions: Neuraxial Anesthesia = Delivery of anesthetic medication requiring placement of catheters or needles into the epidural or spinal space Antithrombotic Medications = Anticoagulant, antiplatelet, and thrombolytic medications Background1-3: Spinal (or epidural) hematomas are a rare but catastrophic complication of neuraxial anesthesia. The risk of hematoma development is increased in the presence of antithrombotic medication. Patients undergoing neuraxial anesthesia must have the risks of bleeding from neuraxial interventions balanced with the underlying and ongoing risk of thromboembolism necessitating anticoagulation. Recommendations for the management of specific antithrombotics in patients undergoing neuraxial anesthesia are provided in the following Tables: o Table 1. Management of Intravenous and Subcutaneous Anticoagulation Therapy in Patients Undergoing Neuraxial Anesthesia o Table 2. Management of ORAL Anticoagulation Therapy in Patients Undergoing Neuraxial Anesthesia o Table 3. Management of ORAL and Intravenous Antiplatelet and Thrombolytic Therapy in Patients Undergoing Neuraxial Anesthesia Workflow if a Contradicted Medication is Prescribed: Providers will have
    [Show full text]
  • Update in Standard of Care for Venous Thromboembolism from the June 2012 Supplement to CHEST and 2017 AC Forum
    Update in Standard of Care for Venous Thromboembolism from the June 2012 supplement to CHEST and 2017 AC Forum Sharyl Magnuson, MD Adjunct Faculty, Pacific University School for PA Studies former Associate Medical Director, Lovelace Clinical Thrombosis Center Member THSNA Disclosures • Nothing to disclose from pharmaceutical sources of income. • I have been an Investigator on many Pharmaceutical sponsored Clinical trials, last more than 7 years ago. • I have been a promotional speaker in the past for Xarelto, last more than 2 years ago. Scope of the Problem • “On average, one American dies of a blood clot every 6 minutes” 100,000/year. National Blood Clot Alliance • The precise number of people affected by DVT/PE is unknown, although as many as 900,000 people could be affected (1 to 2 per 1,000) each year in the United States. • Estimates suggest that 60,000-100,000 Americans die of DVT/PE (also called venous thromboembolism). • 10 to 30% of people will die within one month of Clot diagnosis. • Sudden death is the first symptom in about one-quarter (25%) of people who have a PE. • Among people who have had a DVT, one-half will have long-term complications (post-thrombotic syndrome) such as swelling, pain, discoloration, and scaling in the affected limb. • One-third (about 33%) of people with DVT/PE will have a recurrence within 10 years. • Cdc.gov Best Resource • MAQI2 version 1.7, the Michigan Anticoagulation Quality Improvement Initiative, a consortium of AC clinics and experts across MI, produced this 65pg Quick Reference using updated review literature.
    [Show full text]
  • Summary of Product Characteristics, Labelling and Package Leaflet
    SUMMARY OF PRODUCT CHARACTERISTICS, LABELLING AND PACKAGE LEAFLET 1 SUMMARY OF PRODUCT CHARACTERISTICS 2 1. NAME OF THE MEDICINAL PRODUCT LOVENOX (and associated names) 12,000 IU (120 mg)/0.8 mL solution for injection in pre-filled syringes LOVENOX (and associated names) 15,000 IU (150 mg)/1 mL solution for injection in pre-filled syringes [To be completed nationally] 2. QUALITATIVE AND QUANTITATIVE COMPOSITION 12,000 IU (120 mg) / 0.8 mL Each pre-filled syringe contains enoxaparin sodium 12,000 IU anti-Xa activity (equivalent to 120 mg) in 0.8 mL water for injections. 15,000 IU (150 mg) /1 mL Each pre-filled syringe contains enoxaparin sodium 15,000 IU anti-Xa activity (equivalent to 150 mg) in 1.0 mL water for injections. For the full list of excipients, see section 6.1. Enoxaparin sodium is a biological substance obtained by alkaline depolymerization of heparin benzyl ester derived from porcine intestinal mucosa. 3. PHARMACEUTICAL FORM Solution for injection in prefilled syringes. Clear, colourless to yellowish solution, pH-value 5.5–7.5 4. CLINICAL PARTICULARS 4.1 Therapeutic indications LOVENOX (and associated names) is indicated in adults for: - Prophylaxis of venous thromboembolic disease in moderate and high risk surgical patients, in particular those undergoing orthopaedic or general surgery including cancer surgery. - Prophylaxis of venous thromboembolic disease in medical patients with an acute illness (such as acute heart failure, respiratory insufficiency, severe infections or rheumatic diseases) and reduced mobility at increased risk of venous thromboembolism. - Treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), excluding PE likely to require thrombolytic therapy or surgery.
    [Show full text]
  • Venothrombotic Events: the Subtle Killer Disclosure Statement
    Venothrombotic Events: The Subtle Killer Disclosure Statement No financial or professional conflicts to report Learner Objectives • Review risk factors, symptoms and subgroups of VTE • Recognize medications utilized to treat VTE, indications and contraindications • Utilize most current evidence-based guidelines for prevention and duration of treatment therapy [email protected] 708-216-4541 Pulmonary Embolism • Thrombosis (VTE) that originates in the venous system and embolizes to the pulmonary arterial circulation – DVT in veins of leg above the knee (>90%) – DVT elsewhere (pelvic, arm, calf veins, etc.) – Cardiac thrombi • Air embolism. • Fat embolism. Epidemiology • Third most common acute cardiovascular disease – After coronary ischemia and stroke – Rate is 98 (nonfatal) and 107 (fatal) events per 100,000 persons in USA (650,000 yr) – Over 300,000 hospitalizations and 50,000 deaths per year • Mortality increases with age and male sex • 40% (idiopathic PE's) have increased incidence of developing overt cancer • 10-20% of persons with PE have genetic thrombophilic disorders • Patients with PE are at increased risk (>1.5X) of death within 6 months of diagnosis Definitions Massive PE Submassive PE Minor/Nonmassive PE High risk Moderate/intermediate risk Low risk • Sustained hypotension (systolic • Systemically normotensive • Systemically normotensive BP <90 mmHg for 15 min) (systolic BP 90 mmHg) (systolic BP 90 mmHg) • Inotropic support • RV dysfunction • No RV dysfunction • Pulseless • Myocardial necrosis • No myocardial necrosis • Persistent profound bradycardia (HR <40 bpm with signs or symptoms of shock) RV dysfunction • RV/LV ratio > 0.9 or RV systolic dysfunction on echo • RV/LV ratio > 0.9 on CT • Elevation of BNP (>90 pg/mL) • Elevation of NTpro-BNP (>500 pg/mL) • ECG changes: • new complete or incomplete RBBB • anteroseptal ST elevation or depression • anteroseptal T-wave inversion Jaff et al.
    [Show full text]
  • Stembook 2018.Pdf
    The use of stems in the selection of International Nonproprietary Names (INN) for pharmaceutical substances FORMER DOCUMENT NUMBER: WHO/PHARM S/NOM 15 WHO/EMP/RHT/TSN/2018.1 © World Health Organization 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. Suggested citation. The use of stems in the selection of International Nonproprietary Names (INN) for pharmaceutical substances. Geneva: World Health Organization; 2018 (WHO/EMP/RHT/TSN/2018.1). Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data.
    [Show full text]
  • Protocol for Non-Interventional Studies Based on Existing Data TITLE PAGE Document Number: C30445781-01
    ABCD Protocol for non-interventional studies based on existing data TITLE PAGE Document Number: c30445781-01 BI Study Number: 1237-0090 BI Investigational Stiolto® Respimat® Product(s): The Role of Inhaler Device in the Treatment Persistence with Dual Title: Bronchodilators in Patients with COPD Protocol version 1.0 identifier: Date of last version of N/A protocol: PASS: No EU PAS register Study not registered number: Olodaterol and Tiotropium Bromide (ATC R03AL06) Active substance: Umeclidinium and Vilanterol (ATC R03AL03) Medicinal product: Stiolto® Respimat®; Anoro® Ellipta® Product reference: N/A Procedure number: N/A Joint PASS: No The primary objective of the study is to use US data to determine relative persistence between Olodaterol/Tiotropium Bromide delivered with the Respimat soft mist inhaler and Umeclidinium/Vilanterol delivered with the Ellipta dry powder inhaler using a 1:2 propensity score matched analysis. The secondary objectives of the study are as follows: Research question and - Characterize new users of Olodaterol/Tiotropium Bromide objectives: and Umeclidinium/Vilanterol in terms of demographics, medication use, comorbidities, and other variables, before and after propensity score matching. - Determine the incidence rate and proportion of patients discontinuing or switching among new users of Olodaterol/Tiotropium Bromide and Umeclidinium/ Vilanterol. - Determine the relative rate and proportion of patients discontinuing between Olodaterol/ Tiotropium Bromide and 001-MCG-102_RD-02 (1.0) / Saved on: 22 Oct 2015 Boehringer Ingelheim Page 2 of 69 Protocol for non-interventional studies based on existing data BI Study Number 1237-0090 c30445781-01 Proprietary confidential information © 2019 Boehringer Ingelheim International GmbH or one or more of its affiliated companies Umeclidinium/Vilanterol.
    [Show full text]
  • Life Threatening Massive Pulmonary Embolism Treated with Reteplase: a Case Report
    Case reports Life Threatening Massive Pulmonary Embolism Treated with Reteplase: A Case Report C. THERON, D. C. LAIDLOW Department of Anaesthesia and Intensive Care, Lakeland Health, Rotorua, NEW ZEALAND ABSTRACT We describe a case of sudden and severe pulseless electrical activity in a 30 year old woman which was managed successfully with reteplase and heparin one day following an anterior cruciate ligament repair. The presentation of a sudden collapse with ECG findings of S1Q3T3, early precordial lead ST depression and partial right bundle branch block were indicative of an acute pulmonary embolus. The cardiopulmonary collapse necessitated rapid treatment in the absence of confirmatory investigations. Reteplase (10 U stat followed by 10 U at 30 minutes) led to a dramatic improvement in the cardiovascular status of the patient. One day following the cardiac arrest the patient was extubated and responding normally. A spiral CT performed later confirmed multiple small embolic defects in the lower pulmonary arteries of both lower lung zones. This case highlights the utility of reteplase in the management of an acute pulmonary embolism and in an emergency, recent surgery is not necessarily a contraindication to its use. (Critical Care and Resuscitation 2000; 2: 278-281) Key words: Acute pulmonary embolism, reteplase, pulseless electrical activity, shock For more than 30 years thrombolytic agents have The hospital mortality rate in patients with massive been used to dissolve or reduce thromboembolism and PE and shock is high.6 We report the successful use of improve the circulation in patients with acute pulmonary reteplase in the management of a patient who suffered embolism (PE).1 Numerous studies have been conducted an acute cardiovascular collapse due to a massive PE.
    [Show full text]