[Bridging anticoagulation in patients receiving vitamin K antagonists : Current status]. / Überbrückende Antikoagulation bei Patienten unter Vitamin-K-Antagonisten : Eine Bestandsaufnahme.

Approximately 30% of patients receiving oral anticoagulation using vitamin K antagonists (VKA) require surgery within 2 years. In this context, a clinical decision on the need and the mode of a peri-interventional bridging with heparin is needed. While a few years ago, bridging was almost considered a standard of care, recent study results triggered a discussion on which patients will need bridging at all. Revisiting the currently available recommendations and study results the conclusion can be drawn that the indications for bridging with heparin must nowadays be taken more narrowly and considering the individual patient risk of bleeding and thromboembolism. Bridging with heparin is only needed in patients with a very high risk of thromboembolism. This overview aims to give guidance for a risk-adapted peri-interventional approach to management of patients with a need for long-term anticoagulation using VKA.

[The conspicuous leg]. / Das auffällige Bein.

Symptoms of the leg or of both legs, may indicate a need for evaluation and/or treatment, which must be clarified urgently or even as an emergency situation. Among the diseases which must be considered from a vascular viewpoint are critical limb ischemia, suspicion of deep leg vein thrombosis and special forms of venous insufficiency. With respect to infections erysipelas and the syndrome of infected diabetic foot must be considered as well as peripheral and central leg paresis as orthopedic and neurological disorders, respectively. The current review summarizes the main clinical features of these diseases. Criteria are discussed as to which require the particular capabilities of a hospital and which patients can be managed in an outpatient setting.

[Abnormal laboratory results : Plausibility, reliability, and implications]. / Auffällige Laborwerte : Plausibilität, Aussagekraft und Konsequenzen.

In outpatient care or the emergency room laboratory tests oftentimes provide the first clues to the medical condition that made the patient seek medical help. Quite commonly, rapid medical decisions are required in these situations. Therefore, laboratory results must be evaluated immediately and interpreted within the broader context of the patient's presentation. During this process test results must be checked for plausibility, their positive and/or negative predictive values for the individual patient must be considered, and finally, the potential clinical implications need to be assessed. The latter in particular is of the utmost importance. This article discusses several laboratory tests commonly ordered for emergency patients and provides some guidance on their relevance in the decision to refer an outpatient to an emergency room or for inpatient care, or whether a patient can be safely diagnosed in the outpatient setting.

[Bridging anticoagulation in patients receiving vitamin K antagonists : Current status]. / Überbrückende Antikoagulation bei Patienten unter Vitamin-K-Antagonisten : Eine Bestandsaufnahme.

Approximately 30% of patients receiving oral anticoagulation using vitamin K antagonists (VKA) require surgery within 2 years. In this context, a clinical decision on the need and the mode of a peri-interventional bridging with heparin is needed. While a few years ago, bridging was almost considered a standard of care, recent study results triggered a discussion on which patients will need bridging at all. Revisiting the currently available recommendations and study results the conclusion can be drawn that the indications for bridging with heparin must nowadays be taken more narrowly and considering the individual patient risk of bleeding and thromboembolism. Bridging with heparin is only needed in patients with a very high risk of thromboembolism. This overview aims to give guidance for a risk-adapted peri-interventional approach to management of patients with a need for long-term anticoagulation using VKA.

[Imaging representation of peripheral veins]. / Bildgebende Darstellung peripherer Venen.

Several techniques are available for imaging of the venous system of the legs and pelvic region. In cases of suspected deep leg vein thrombosis B­mode compression ultrasound is applied. Its accuracy is sufficient to either confirm or exclude the diagnosis with certainty. For examination of the iliac veins, however, flow information has to be added by pulsed wave (PW) Doppler or color Doppler sonography. In cases of suspected arm vein thrombosis, ultrasound is also the method of choice. The more proximal or the central parts of the venous system, i. e. brachiocephalic veins or the superior and inferior vena cava can be visualized by cross-sectional imaging procedures. Computed tomography (CT) angiography accurately shows the vessel lumen and magnetic resonance imaging (MRI) provides more details of the surrounding soft tissue. The use of classical contrast medium phlebography is nowadays restricted to interventions on proximal or central parts of the venous system. In addition, venous imaging is required in the field of chronic venous insufficiency. For both differential diagnostics and choice of treatment options, e. g. for varicose veins, the mainstay is venous ultrasound.

[Imaging of vessels supplying the brain]. / Bildgebende Darstellung hirnversorgender Gefäße.

Nowadays, several technically validated modalities are available for imaging both the extracranial and intracranial segments of arteries supplying blood to the brain. In the acute stroke setting, computed tomography (CT) angiography is of utmost importance because it provides the key diagnostic criteria indicative for the use of catheter-based recanalization techniques. Ultrasound imaging of extracranial arteries is most suitable for detecting an underlying stenosis of the internal carotid artery (ICA) in patients with stroke, transient ischemic attacks (TIA), retinal vessel occlusion and amaurosis fugax. Ultrasound imaging enables measurement of the methodologically most reliable criteria for grading stenosis of the ICA, which defines the indications for revascularization procedures in this territory. Magnetic resonance imaging (MRI) in the cross-sectional mode is of greatest value in confirming or excluding an arterial dissection even in short arterial segments, whereas MR angiography generates a more global view of the cerebral circulation. In most cases classical digital subtraction angiography (DSA) is no longer needed for diagnostic purposes only. Conversely, it is an indispensable component of any interventional approach and thus of growing importance. Ultrasound imaging is not indicated for the clarification of vertigo or syncope. In addition, there is no evidence that ultrasound screening of the ICA adds any value to the care of asymptomatic persons.

[Vertigo and syncope: a clinically oriented introduction to the problem]. / Schwindel und Synkope: Eine klinisch orientierte Hinführung zum Problem.

Vertigo and syncope are frequently occurring clinical presentations in the physician's practice as well as in the emergency room. Therefore, many physicians and institutions have formulated diagnostic protocols that they follow when a patient with vertigo or syncope presents. This kind of blanket routine may lead to over-diagnosis in many cases, as well as to under-diagnosis in some. The purpose of the following article is to show that a well-focused history based on clear cut concepts of disease and a sound pathophysiological understanding will guide the physician precisely through the diagnostic process in both clinical presentations and will help to avoid manifold diagnostic procedures. Finally, a description of the most frequent pitfalls of the diagnostic work-up is given, along with measures to avoid these.

[Dyspnea. Profile of the most important diagnostic tests]. / Dyspnoe. Profile der wichtigsten diagnostischen Tests.

The diagnostic pathway for the evaluation of patients with dyspnea requires a thorough history taking and physical examination. Based on the results of these basic steps a broad variety of additional diagnostic tests are available. Each test can contribute valuable information when correctly indicated and performed. Among these are electrocardiography (ECG), laboratory parameters, X-ray examination, echocardiography, spirometry and whole body plethysmography and finally spiroergometry. This article presents a focused review of what each of these diagnostic modalities can contribute to the diagnostic process for dyspnea.

[Non-cardiac and non-pulmonary causes of dyspnea]. / Nichtkardiale und nichtpulmonale Ursachen der Dyspnoe.

In addition to cardiac and pulmonary diseases there is a broad variety of different underlying causes of dyspnea. The spectrum includes the different forms of anemia, all causes of upper airway obstructions, neuromuscular diseases and psychopathological disorders. This article gives a brief review of the entire spectrum by providing information about differential diagnostics as well as the main therapeutic principles. A field of growing interest is dyspnea in the context of palliative care.

[Importance of thrombophilia screening]. / Stellenwert des Thrombophilie-Screenings.

Thrombophilia testing denotes a test battery for inherited or acquired features associated with a tendency for clot formation. Currently, it is being used in a frequency and to an extent which is not supported by evidence. In order to protect patients from unnecessary worry and stigmatization, but also for reasons of cost effectiveness, thrombophilia testing should be reduced to a very small number of medically justifiable indications which are outlined in this review.Those indications include the following: secondary prevention of venous thromboembolism in patients from a thrombophilic family, i.e., with two or more first degree relatives with venous thromboembolism (VTE), or patients with suspected antiphospholipid syndrome; women prior to oral contraception or planning to become pregnant if they had no prior VTE but have one or more first-degree relatives with VTE-provided they are willing to follow the consequences of positive test results; women with recurrent miscarriage. The inappropriate indications are discussed as well.The test panel for inherited thrombophilias includes deficiencies of antithrombin, protein C and protein S, factor V Leiden and prothrombin 20210 mutation. Patients with suspicion of antiphospholipid syndrome have to be tested for lupus anticoagulans, anti-cardiolipin antibodies, and anti-ß2-glycoprotein I-antibodies. It is important to do the blood sampling at an appropriate point in time.

[Leg swelling]. / Das geschwollene Bein.

Leg swelling is an extremely frequent symptom with a broad variety of largely differing causes. The most important mechanisms behind the symptom include venous and lymphatic pathology, volume overload, increased capillary permeability, and lowered oncotic pressure. Therefore, the most frequent diseases associated with leg swelling are deep vein thrombosis and chronic venous insufficiency, primary or secondary lymphedema, cardiac failure, hypoproteinemia due to liver or renal failure, idiopathic cyclic edema, and drug-induced edema. Lipedema as a misnomer represents an important differential diagnosis. History and physical examination, when based on a sound knowledge of the diseases of interest, enable a conclusive diagnosis in most cases. Additional test are required in only a minority of patients. The present review discusses pathophysiology and clinical features of the most prevalent types of leg swelling. Finally, a brief guide to differential diagnosis is given.

[Treatment of deep vein thrombosis and pulmonary embolism]. / Therapie der Beinvenenthrombose und der Lungenembolie.

Deep vein thrombosis and pulmonary embolism may be considered as different manifestations of the same disease: venous thromboembolism. Under the condition of entirely stable hemodynamics, treatment follows exactly the same principles. The phase of initial therapy has a duration of 5-10 days and has remained so far a domain of parenteral anticoagulants (low molecular weight heparin, fondaparinux). The phase of early maintenance therapy is instituted with an overlap and has a duration of 3-6 months; vitamin K antagonists with a target INR of 2.0-3.0 are the standard. Patients with a high risk of recurrence and a low risk of bleeding will enter a phase of prolonged or even indefinite maintenance therapy. Again, vitamin K antagonists with a target INR of 2.0-3.0 are the standard. A target INR of 1.5-2.0 may be considered an alternative for patients in whom a very stable anticoagulation with less frequent INR testing is desirable. Clear recommendations can be made for venous thromboembolism treatment in pregnancy, in the post partum and lactation periods, as well as for patients with severe renal impairment. New anticoagulants (thrombin inhibitors, factor Xa inhibitors) have made significant progress in their clinical development and will soon become available as an alternative for all three phases of therapy.

[Bridging, interruption and switching of anticoagulants in trauma surgery]. / Überbrückung, Pausieren und Wechsel von Antikoagulanzien in der Unfallchirurgie.

Patients under long-term administration of vitamin K antagonists may require temporary interruption of anticoagulation therapy for invasive procedures or trauma surgery. Due to the long half-life of these substances bridging therapy with anticoagulants having a shorter half-life may become necessary. In this situation the risk of bleeding due to the intervention and the risk of thromboembolism due the underlying disease must be assessed. Low molecular weight heparins (LMWHs) are considered to be the medication of choice for bridging anticoagulation, mainly due to practical reasons and as they do not require coagulation monitoring and dose adjustment out of hospital treatment is feasible. Low molecular weight heparins are not authorized for the indication of bridging anticoagulation, however, on the basis of recent studies on large patient cohorts, the evidence of efficacy and safety is significantly better for LMWHs than for unfractionated heparin. New oral anticoagulants will soon become available for stroke prevention in patients with atrial fibrillation and for treatment of venous thromboembolism. Due to the shorter half-lives these compounds will no longer require bridging anticoagulation. However, the trauma surgeon should be familiar with the dosing regimens for different indications in order to adequately decide about the preoperative cessation and the perioperative pause of these anticoagulants.

[Diagnostics in venous thrombosis and pulmonary embolism]. / Diagnostik der venösen Thrombose und Lungenembolie.

Deep vein thrombosis and pulmonary embolism (venous thromboembolism) have a prevalence as high as 1-2/1000/year. Timely diagnosis and therapy prevent or reduce the acute life threatening and the long term disabling complications. Due to the variability in its signs and symptoms, venous thromboembolism should frequently be considered as a differential diagnosis. When doing so, only one in five or six suspected cases actually will have the disease. A low estimate of the clinical probability in conjunction with a negative D-Dimer test may rule out the diagnosis in 40-50% of cases. All other patients need imaging procedures. Current standard of care for deep vein thrombosis is venous ultrasound of the leg, for pulmonary embolism it is CT pulmonary angiography. Sensitivity and specificity of both methods are high enough to allow for a definitive diagnosis. Diagnostic challenges remain the suspicion of relapsing disease and venous thromboembolism in pregnancy.

[The patient with pulmonary embolism or vascular emergency requiring intensive care]. / Der intensivpflichtige Patient mit Lungenembolie oder arteriellem Gefässnotfall.

Acute pulmonary embolism requires ICU management only for patients with hemodynamic instability who need artificial ventilation, or for hemodynamically stable patients with significant right ventricular dysfunction. For both patient groups, echocardiography is the most relevant diagnostic method. The main therapeutic consideration is on systemic thrombolysis. It is indicated in almost all patients with hemodynamic instability but only in selected cases of right ventricular dysfunction. All other patients receive standard anticoagulation only. A second vascular emergency scenario is type 2 heparin-induced thrombocytopeniae (HIT II) which may cause venous as well as arterial complications. Alternative anticoagulation has to be established from the first moment of clinical suspicion. It has to be continued in a therapeutic dosage if HIT II is confirmed, and has to be stopped if the diagnosis is refuted. The latter case is by far more frequent. Regarding arterial occlusions (acute limb ischemia, acral gangrene, iatrogenic vascular trauma) hints are given for the management in the setting of intensive care.