[Peripartum cardiomyopathy with biventricular failure plus pulmonary thromboembolism and atrial septal defect]. / Miocardiopatía periparto con fallo biventricular más tromboembolismo pulmonar y comunicación interauricular.

This case report examines peripartum cardiomyopathy (PPCM), a rare variant of heart failure with reduced ejection fraction, which manifests at the end of labor or puerperium. The frequency of this pathology varies globally, and its association with risk factors such as genetic disorders, autoimmune diseases, viral infections, suggests a multifactorial etiology. Diagnostic criteria include: Heart failure secondary to left ventricular systolic dysfunction, manifested in the puerperium or at the end of pregnancy and lack of other identifiable causes of heart failure. The case presents a patient with no significant personal pathological history, who, 17 days post cesarean section developed acute symptoms, including abdominal pain, dry cough and dyspnea. Clinical findings revealed hypoxemia, alterations in blood tests and an echocardiogram that confirmed an atrial septal defect. Multidisciplinary management resulted in successful treatment and the patient was discharged without complications. This case highlights the importance of MCPP, a disease with high maternal mortality. The connection between atrial septal defect and PPCM, as well as the involvement of pulmonary thromboembolism.

Actualización del abordaje de la hipertensión pulmonar tromboembólica crónica / Update in the management of chronic thrombo-embolic pulmonary hypertension

La hipertensión pulmonar tromboembólica crónica (HPTEC) es una forma potencialmente curable de hipertensión pulmonar (HP) que aparece hasta en 3% de los pacientes tras una embolia pulmonar (EP). En estos pacientes, la EP no se resuelve, dando paso a coágulos fibróticos organizados, con el desarrollo de HP precapilar debido a la obstrucción proximal de las arterias pulmonares. También puede desarrollarse una microvasculopatía distal que contribuye al aumento de la resistencia vascular pulmonar (RVP). La ecocardiografía transtorácica (ETT) es la exploración que permite establecer la sospecha de HP. La gammagrafía pulmonar de ventilación-perfusión (V/Q) es la herramienta fundamental en el estudio de los pacientes con sospecha de HPTEC; si es normal, prácticamente la descarta. El cateterismo cardiaco derecho es obligatorio para el diagnóstico. La HPTEC se define como la existencia de síntomas, defectos de perfusión residuales e HP precapilar tras un periodo mínimo de tres meses de anticoagulación. La angiografía pulmonar ayuda a determinar la extensión y la accesibilidad quirúrgica de las lesiones tromboembólicas. Las personas con HPTEC son candidatas a anticoagulación indefinida. La endarterectomía pulmonar es el tratamiento de elección, resultando en una mejoría clínica y hemodinámica significativa. Aproximadamente un 25% de los pacientes presentan HP residual postendarterectomía. La angioplastia pulmonar con balón (APB) es una técnica endovascular dirigida a lesiones más distales, de utilidad para sujetos con HPTEC inoperable o HP persistente/recidivante postendarterectomía. Ambos tipos de pacientes también se pueden beneficiar de tratamiento farmacológico para la HP. Las tres terapias constituyen los pilares de la terapia, que ha evolucionado hacia un enfoque multimodal.(AU)

Chronic thrombo-embolic pulmonary hypertension (CTEPH) is a potentially curable form of pulmonary hypertension (PH) that develops in up to 3% of patients after pulmonary embolism (PE). In these patients, PE does not resolve, leading to organized fibrotic clots, with the development of precapillary PH as a result of the proximal obstruction of the pulmonary arteries. In addition, a distal microvasculopathy may also develop, contributing to the increase of pulmonary vascular resistance. Transthoracic echocardiography is the diagnostic tool that allows to establish the suspicion of PH. Ventilation-perfusion lung scintigraphy is the fundamental tool in the study of patients with suspected CTEPH; if it is normal, virtually rules out the diagnosis. Right heart catheterization is mandatory for the diagnosis of these patients. CTEPH is defined as the existence of symptoms, residual perfusion defects and precapillary PH after a minimum period of three months of anticoagulation. Pulmonary angiography helps determine the extent and surgical accessibility of thromboembolic lesions. CTEPH patients are candidates for long-term anticoagulation. Pulmonary endarterectomy is the treatment of choice, resulting in significant clinical and hemodynamic improvement. About 25% of patients have residual PH post-endarterectomy. Balloon pulmonary angioplasty is an endovascular technique that targets more distal lesions, being potentially useful for patients with inoperable CTEPH or persistent/recurrent PH post-endarterectomy. Both types of patients may also benefit from pharmacological treatment for PH. These three therapies are the cornerstone of CTEPH treatment, which has evolved towards a multimodal approach.(AU)

Update in the management of chronic thrombo-embolic pulmonary hypertension. / Actualización del abordaje de la hipertensión pulmonar tromboembólica crónica.

Chronic thrombo-embolic pulmonary hypertension (CTEPH) is a potentially curable form of pulmonary hypertension (PH) that develops in up to 3% of patients after pulmonary embolism (PE). In these patients, PE does not resolve, leading to organized fibrotic clots, with the development of precapillary PH as a result of the proximal obstruction of the pulmonary arteries. In addition, a distal microvasculopathy may also develop, contributing to the increase of pulmonary vascular resistance. Transthoracic echocardiography is the diagnostic tool that allows to establish the suspicion of PH. Ventilation-perfusion lung scintigraphy is the fundamental tool in the study of patients with suspected CTEPH; if it is normal, virtually rules out the diagnosis. Right heart catheterization is mandatory for the diagnosis of these patients. CTEPH is defined as the existence of symptoms, residual perfusion defects and precapillary PH after a minimum period of three months of anticoagulation. Pulmonary angiography helps determine the extent and surgical accessibility of thromboembolic lesions. CTEPH patients are candidates for long-term anticoagulation. Pulmonary endarterectomy is the treatment of choice, resulting in significant clinical and hemodynamic improvement. About 25% of patients have residual PH post-endarterectomy. Balloon pulmonary angioplasty is an endovascular technique that targets more distal lesions, being potentially useful for patients with inoperable CTEPH or persistent/recurrent PH post-endarterectomy. Both types of patients may also benefit from pharmacological treatment for PH. These three therapies are the cornerstone of CTEPH treatment, which has evolved towards a multimodal approach.

Underuse of reperfusion therapy with systemic thrombolysis in high-risk acute pulmonary embolism in a Portuguese center.

INTRODUCTION: Reperfusion therapy is generally recommended in acute high-risk pulmonary embolism (HR-PE), but several population-based studies report that it is underused. Data on epidemiology, management and outcomes of HR-PE in Portugal are scarce. OBJECTIVE: To determine the reperfusion rate in HR-PE patients, the reasons for non-reperfusion, and how it influences outcomes. METHODS: In this retrospective cohort study of consecutive HR-PE patients admitted to a thromboembolic disease referral center between 2008 and 2018, independent predictors for non-reperfusion were assessed by multivariate logistic regression. PE-related mortality and long-term MACE (cardiovascular mortality, PE recurrence and chronic thromboembolic disease) were calculated according to the Kaplan-Meier method. Differences stratified by reperfusion were assessed using the log-rank test. RESULTS: Of 1955 acute PE patients, 3.8% presented with hemodynamic instability. The overall reperfusion rate was 50%: 35 patients underwent systemic thrombolysis, one received first-line percutaneous embolectomy and one rescue endovascular treatment. Independent predictors of non-reperfusion were: age, with >75 years representing 12 times the risk of non-treatment (OR 11.9, 95% CI 2.7-52.3, p=0.001); absolute contraindication for thrombolysis (31.1%), with recent major surgery and central nervous system disease as the most common reasons (OR 16.7, 95% CI 3.2-87.0, p<0.001); and being hospitalized (OR 7.7, 95% CI 1.4-42.9, p=0.020). At a mean follow-up of 2.5±3.3 years, the survival rate was 33.8%. Although not reaching statistical significance for hospital mortality, mortality in the reperfusion group was significantly lower at 30 days, 12 months and during follow-up (relative risk reduction of death of 64% at 12 months, p=0.013). Similar results were found for MACE. CONCLUSIONS: In this population, the recommended reperfusion therapy was performed in only 50% of patients, with advanced age and absolute contraindications to fibrinolysis being the main predictors of non-reperfusion. In this study, thrombolysis underuse was associated with a significant increase in short- and long-term mortality and events.

Risk of venous thromboembolism in thromboprophylaxis between aspirin and low molecular weight heparins after total hip arthroplasty or total knee arthroplasty: Systematic review and meta-analysis. / Riesgo de tromboembolismo venoso en la tromboprofilaxis entre aspirina y heparinas de bajo peso molecular tras una artroplastia total de cadera o artroplastia total de rodilla. Revisión sistemática y metaanálisis.

INTRODUCTION: The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA). MATERIALS AND METHODS: Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analyzed. Mortality, risk of bleeding and surgical wound complications was also analyzed. RESULTS: 248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR = 0.93; 95% CI: 0.69-1.26; P = .64), DVT (OR = 0.72; 95% CI: 0.43-1.20; P = .21) or PE (OR = 1.13; 95% CI: 0.86-1.49; P = .38) between both groups. No significant differences were found in mortality (P = .30), bleeding (P = .22), or complications in the surgical wound (P = .85) between both groups. These same findings were found in the sub-analysis of only randomized clinical trials (P>.05). CONCLUSIONS: No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis.

Valoración del tromboembolismo pulmonar relacionado con infección SARS-CoV-2 activa en pacientes embarazadas / Assessment of pulmonary embolism related to active SARS-CoV-2 infection in pregnant women

Objetivo Analizar la muestra de pacientes embarazadas a las que se les realizó una gammagrafía de perfusión pulmonar para descartar la sospecha de tromboembolismo pulmonar (TEP) durante el ingreso en nuestro centro por infección aguda por COVID-19. Material y métodos A todas las pacientes (n=5) se les realizó una gammagrafía SPECT con dosis reducida (111MBq) de 99mTc-macroagregados de albúmina. Las imágenes obtenidas se interpretaron comparando los hallazgos con la imagen radiológica según criterios PISAPED. Resultados De las 5 pacientes, tan solo en una se diagnosticó TEP. En 2 pacientes los hallazgos patológicos de la gammagrafía fueron atribuibles a alteraciones radiológicas por neumonía COVID-19, y otras 2 mostraron una perfusión pulmonar normal. Conclusión Dado lo inespecífico de las manifestaciones clínicas y los valores del dímero D dentro de la COVID-19, así como su similitud con los de TEP, la gammagrafía de perfusión pulmonar, por su alta sensibilidad y menor irradiación que la TC, tiene un papel crucial en el despistaje de TEP en estas pacientes. Los resultados obtenidos son de especial relevancia, a pesar del número limitado de pacientes, dada la ausencia de publicaciones científicas en este grupo de pacientes dentro de la situación excepcional por la pandemia de COVID-19 (AU)

Aim To analyze the sample of pregnant patients who underwent pulmonary perfusion scintigraphy to rule out the pulmonary embolism (PE) suspicion during the acute COVID-19 infection hospitalization period in our hospital. Material and methods SPECT scintigraphy with a reduced dose (111MBq) of 99mTc-macroaggregated albumin was performed in all of the patients (n=5). The obtained images were interpreted by comparing the findings with the radiological images according to the PISAPED criteria. Results Only one of the 5 patients was diagnosed with PE. Two patients obtained pathological findings of the scintigraphy attributable to radiological alterations due to COVID-19 pneumonia, and the other 2 had normal pulmonary perfussion. Conclusion Given the non-specific features of the clinical manifestations and D-dimer values in COVID-19, as well as their similarity to those of PE, the pulmonary perfusion scintigraphy plays a crucial role in the screening of PE in these patients due to its high sensitivity and lower irradiation compared to CT. Despite the limited number of patients, the results obtained have special relevance related to the absence of scientific publications on this group of patients within the context of COVID-19 pandemic exceptional situation (AU)

Treatment of intracardiac thrombi using ultra-slow low-dose thrombolytic therapy: A case report.

A 57-year-old male with previously known severe primary mitral regurgitation was admitted to the intensive care unit (ICU) due to massive venous thromboembolism, associated with right ventricular dysfunction and two large mobile right atrial thrombi. Due to deterioration in his clinical condition despite standard treatment with unfractionated heparin, it was decided to use an ultra-slow low-dose thrombolysis protocol, which consisted of a 24-hour infusion of 24 mg of alteplase at a rate of 1 mg per hour, without initial bolus. The treatment was continued for 48 consecutive hours, with clinical improvement and resolution of the intracardiac thrombi and no complications. One month after ICU admission, successful mitral valve repair surgery was conducted. This case demonstrates that ultra-slow low-dose thrombolysis is a valid bailout treatment option in patients with large intracardiac thrombi refractory to the standard approach.

Anticoagulación en enfermedad renal crónica G4-5 en una red de hospitales de Bogotá

Contexto: la anticoagulación en pacientes con enfermedad renal crónica es un reto terapéutico debido a que la evidencia médica es escasa y los beneficios son discutibles, además, el riesgo de sangrado en estos pacientes es mayor. Objetivo: describir los pacientes con enfermedad renal G4-5 que recibieron terapia anticoagulante oral durante por lo menos tres meses en la Subred Centro Oriente de Bogotá. Metodología: estudio analítico de pacientes con enfermedad renal crónica G4-5 en un hospital de referencia entre enero del 2018 y diciembre del 2021, en el cual se analizaron variables sociodemográficas, clínicas y se realizó una regresión logística sobre los anticoagulantes y la frecuencia de eventos (hemorrágicos o embólicos). Resultados: se evaluó a 75 pacientes con diagnóstico de enfermedad renal crónica G4-5 anticoagulados, donde el anticoagulante más usado fue warfarina (76 %), seguido de apixabán (16 %) y rivaroxabán (8 %). El sangrado mayor se presentó con warfarina (8,47 %), apixabán (10%) y rivaroxabán (16,6 %). No se encontraron diferencias significativas entre el sangrado mayor con warfarina (OR: 2,8; IC 95 %: 0,46-16,9; p = 0,262) y rivaroxabán (OR: 1,86; IC 95 %: 0,18-18,7; p = 0,596), además, el sangrado no mayor y clínicamente relevante fue del 28,9 % con warfarina. Solo se presentó una complicación trombótica en un paciente que recibió rivaroxabán. Conclusiones: en los pacientes con enfermedad renal G4-5 que recibieron warfarina y los anticoagulantes orales directos no se encontraron diferencias significativas en cuanto a la presentación de sangrado mayor y no mayor, clínicamente relevantes.

Background: Anticoagulation in patients with chronic kidney disease is a therapeutic challenge since the medical evidence is scarce and the benefits are debatable since the risk of bleeding in these patients is greater. Purpose: To describe patients with G4-5 kidney disease who received oral anticoagulant therapy for at least 3 months in the central-eastern subnetwork of Bogotá. Methodology: Analytical study of patients with G4-5 chronic kidney disease, in a reference hospital between January 2018 and December 2021, in which sociodemographic and clinical variables were analyzed, and a logistic regression was performed on anticoagulants and the frequency of events (hemorrhagic or embolic). Results: 75 anticoagulated patients diagnosed with G4-5 chronic kidney disease were evaluated. The most commonly used anticoagulant was warfarin (76%), apixaban (16%), and rivaroxaban (8%). Major bleeding occurred with warfarin (8.47%), apixaban (10%), and rivaroxaban (16.6%). There are no significant differences between major bleeding with warfarin (OR: 2.8; 95% CI: 0.46;16.9; p= 0.262), and rivaroxaban (OR: 1.86; 95% CI: 0.18;18.7; p=0.596). Clinically relevant non-major bleeding was 28.9% with warfarin. A thrombotic complication only occurred in one patient who received rivaroxaban. Conclusions: In patients with G4-5 kidney disease who received warfarin and direct oral anticoagulants, no significant differences were found in terms of the presentation of clinically relevant major and non-major bleeding.

Assessment of pulmonary embolism related to active SARS-CoV-2 infection in pregnant women.

AIM: To analyze a sample of pregnant patients who underwent pulmonary perfusion scintigraphy to rule out suspicion of pulmonary embolism (PE) during the acute COVID-19 infection hospitalization period in our hospital. MATERIAL AND METHODS: SPECT scintigraphy with a reduced dose (111MBq) of 99mTc-macroaggregated albumin was performed in all the patients (n=5). The images obtained were interpreted by comparing the findings with the radiological images according to the PISAPED criteria. RESULTS: Only one of the 5 patients was diagnosed with PE. Two patients showed pathological scintigraphy findings attributable to radiological alterations due to COVID-19 pneumonia, and the other two had normal pulmonary perfusion. CONCLUSION: Given the non-specific features of the clinical manifestations and d-dimer values ​​in COVID-19, as well as their similarity to those of PE, pulmonary perfusion scintigraphy plays a crucial role in the screening of PE in these patients due to its high sensitivity and lower irradiation compared to CT. Despite the limited number of patients, the results obtained have special relevance due to the absence of scientific publications in this group of patients within the exceptional context of the COVID-19 pandemic.

Tromboembolismo pulmonar como posible reacción adversa a Quetiapina Reporte de caso / Pulmonary thromboembolism as a possible adverse reaction to Quetiapine Case report

Resumen Algunos estudios sugieren que existe una relación entre el uso de antipsicóticos y el riesgo de tromboembolismo venoso (TEV) y embolia pulmonar (EP). Sin embargo, los resultados siguen sin ser concluyentes. Se trata del caso de un Masculino de 23 años con antecedentes de Esquizofrenia y Depresión tratado quetiapina 800 mg, el cual es encontrado muerto en la cama de un hotel. En la necropsia sin lesiones traumáticas visibles, hallazgos histológicos de tromboembolismo pulmonar masivo con infartos pulmonares secundarios. Laboratorio de Toxicología detectó la presencia de quetiapina, no se detectó alcohol o drogas de abusos. Mediante el Algoritmo De Karch & Lasagna Modificado el tromboembolismo pulmonar fue una reacción adversa con una probabilidad de relación causal posible. Se han informado muchos casos de muerte súbita causada por EP con la exposición a antipsicóticos, pero la relación de su uso y el riesgo de TEV y EP sigue siendo controvertida.

Abstract Some studies suggest a relationship between antipsychotic use and the risk of venous thromboembolism (VTE) and pulmonary embolism (PE). However, the results remain inconclusive. This is the case of a 23-year-old male with a history of schizophrenia and depression treated with quetiapine 800 mg, who was found dead in a hotel bed. At necropsy with no visible traumatic lesions, histological findings of massive pulmonary thromboembolism with secondary pulmonary infarcts. Toxicology laboratory detected the presence of quetiapine, no alcohol or drugs of abuse were detected. Using the Modified Karch & Lasagna Algorithm, pulmonary thromboembolism was an adverse reaction with a probable causal relationship. Many cases of sudden death caused by PE have been reported with exposure to antipsychotics, but the relationship of their use and the risk of VTE and PE remains controversial.

Trombosis venosa profunda masiva en gestante: la importancia de individualizar el plan de acción / Massive deep vein thrombosis in pregnant women: The importance of individualizing the action plan

El tromboembolismo venoso (TEV), incluida la trombosis venosa profunda (TVP) y la embolia pulmonar (TEP) es una afección potencialmente letal y a tener en cuenta en mujeres embarazadas, donde la situación es favorecida por los cambios fisiológicos característicos de la gestación, el parto y el puerperio. El manejo de esta patología en este tipo de pacientes está basado en la anticoagulación, con los beneficios e inconvenientes que ello implica. Presentamos el caso de una mujer embarazada con TVP masiva e intentamos arrojar luz sobre temas como son la vía de parto (vaginal vs. cesárea) o el manejo del tratamiento (heparina de bajo peso molecular [HBPM] vs. heparina no fraccionada [HNF]) de cara a obtener la situación más segura para la paciente.(AU)

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a potentially lethal condition to be taken into account in pregnant women, where the situation is favored by the characteristic physiological changes of the pregnancy, childbirth and the puerperium. The management of this pathology in this type of patient is based on anticoagulation, with the benefits and drawbacks that this implies. We present the case of a pregnant woman with massive DVT and the issues are discussed, such as the method of delivery (vaginal vs. cesarean section) or the management of treatment (LMWH vs. UFH) in order to obtain the safest situation for the patient.(AU)

Massive deep vein thrombosis in pregnant women: The importance of individualizing the action plan.

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a potentially lethal condition to be taken into account in pregnant women, where the situation is favored by the characteristic physiological changes of the pregnancy, childbirth and the puerperium. The management of this pathology in this type of patient is based on anticoagulation, with the benefits and drawbacks that this implies. We present the case of a pregnant woman with massive DVT and the issues are discussed, such as the method of delivery (vaginal vs. cesarean section) or the management of treatment (LMWH vs. UFH) in order to obtain the safest situation for the patient.

Incidental pulmonary embolism. Incidence, clinical-radiological features and survival / Tromboembolismo pulmonar incidental. Incidencia, manifestaciones clínico-radiológicas y supervivencia

Objetive: To describe the incidence and features of incidental pulmonary embolism (IPE) and survival of all patients with IPE from January 2012 to December 2014. Rationale: The prevalence of IPE accounts for 1–10% of all pulmonary embolisms (PE). Methods: All radiological reports of computed tomography with intravenous contrast in which the IPE was not suspected were evaluated. The numerical data are expressed by mean and standard deviation (SD); Survival by the Kaplan–Meier analysis and the Log Rank test. Results: We reviewed 7508 reports, detecting 44 patients with IPE (0.6%). Men 64%, age 68 years, pack-year 25, oncological disease 73%, chemotherapy last month before IPE 82%. The predominant histological strain was adenocarcinoma (60%) and epidermoid (20%). The origin of the most common tumor was bronchogenic (27%) and colorectal (14%). The distribution according to the PESI index was mainly I (71%) and II (21%). They received anticoagulation 54%. The location of thrombi was bilateral in 32%. Around 70% were located in main and lobar arteries. Overall survival at one year was more than 70%, being higher in anticoagulated patients (log rank <0.05). Conclusions: The incidence of IPE is low, predominantly in oncological patients. Adenocarcinoma is the predominant strain. Most of them have a low severity index. Survival is higher in anticoagulated patients and higher than in the case of published non-incidental PE.(AU)

Objetivo: Describir la incidencia, características y supervivencia de todos los pacientes con TEPI desde Enero de 2012 hasta Diciembre de 2014. Justificación: La prevalencia de tromboembolismo pulmonar incidental (TEPI) ocurre en el 1–10% de todos los tromboembolismos pulmonares (TEP). Método: Todos los informes radiológicos de tomografía computerizada con contraste intravenoso en los cuales el TEP no era sospechado fueron evaluados. Los resultados numéricos fueron expresados mediante media y desviación estándar; Supervivencia por KaplanMeier y test de LogRank. Resultado: Revisamos 7508 informes detectando 44 pacientes con TEPI (0.6%). Hombres 64%, edad 68 años, índice paquetes-año 25, enfermedad oncológica 73%, quimioterapia el mes previo al TEPI 82%. La estirpe histológica predominante fue adenocarcinoma (60%) y epidermoide (20%). El origen del tumor más frecuente fue broncogénico (27%) y colorrectal (14%). La distribución teniendo en cuenta la escala PESI fue predominantemente I (71%) y II (21%). Recibieron anticoagulación el 54%. La localización del trombo fue bilateral en el 32%. En torno al 70% fueron localizados en arterias principales y lobares. La supervivencia global al año fue mayor del 70%, siendo mayor en pacientes anticoagulados (log rank <0.05). Conclusiones: La incidencia de TEPI es baja, predominantemente en pacientes oncológicos. La mayoría presentaron bajo índice de severidad. La supervivencia es mayor en pacientes anticoagulados y mayor que la publicada para embolismos pulmonares no incidentales.(AU)

Utilidad diagnóstica del dímero-D en el tromboembolismo pulmonar de pacientes COVID-19 / DiagnosticutilityofD-dimerin pulmonarythromboembolism in COVID-19 patients

Resumen Introducción: El aumento de la concentración de dímero-D en pacientes COVID-19 se ha asociado a mayor gravedad y peor pronóstico; sin embargo, su rol en predecir el diagnóstico de tromboembolismo pulmonar (TEP), aún es incierto. Objetivo: Evaluar la utilidad del dímero-D plasmático en el diagnóstico de TEP en pacientes con COVID-19. Pacientes y Métodos: Estudio observacional analítico. Se incluyó a pacientes COVID-19 que tenían una angiotomografía computada de tórax (AngioTAC). Se registraron datos clínicos, niveles plasmáticos de dímero-D de ingreso y previo al momento de realizar la AngioTAC. Se identificó la presencia o ausencia de TEP. Resultados: Se incluyeron 163 pacientes; 37(23%) presentaron TEP. Al comparar la serie de pacientes con TEP versus sin TEP, no se encontraron diferencias significativas en características clínicas, ni mortalidad. Hubo diferencias significativas en el nivel plasmático del dímero-D previo a realizar la AngioTAC (3.929 versus 1.912 μg/L; p = 0,005). El área bajo la curva ROC del dímero-D para TEPfue de 0,65. El mejor punto de corte del dímero-D fue de 2.000 μg/L, con una baja sensibilidad y valor predictivo positivo. El valor de corte con el mejor valor predictivo negativo (VPN)fue de 900 μg/L (96%), el cual fue mejor que la estrategia de corte de dímero D ajustado por edad (VPN 90%). Conclusión: La capacidad discriminativa del dímero D para diagnosticar TEP fue baja. En cambio, el dímero D mantiene un alto valor predictivo negativo para descartar TEP, el cual es mayor al valor descrito clásicamente en los pacientes no COVID.

Introduction: Increased D-dimer concentration in COVID-19 patients has been associated with greater severity and worse prognosis; however its role in predicting the diagnosis of pulmonary thromboembolism (PTE), is still uncertain. Objective: To evaluate the usefulness of plasma D-dimer in the diagnosis of PTE in patients with COVID-19. Method: Analytical observational study. COVID-19 patients who had a chest computed tomography angiography (CTA) were included. Clinical data, Ddimer plasma levels on admission and prior to CTA were recorded. The presence or absence of PTE was identified. Results: 163 patients were included, 37 (23%) presented PTE. After comparing the series of patients with PTE versus the series without PTE, no significant differences were found in clinical characteristics or mortality. There were significant differences in the plasma level of D-dimer prior to performing CTA (3,929 μg/L versus. 1,912 μg/L; p = 0.005). The area under the D-dimer ROC curve for PTEprediction was 0.65. The best D-dimer cutoffpoint was 2.000μg/L, with a low sensitivity and positivepredictive value. The cutoff value with the best negativepredictive value (NPV) was 900 μg/L (96%), which was better than the age-adjusted D-dimer cutoff strategy (NPV 90%). Conclusion: The discriminative ability of D-dimer to diagnose PTE was low. In contrast, D-dimer maintains a high negative predictive value to rule out PTE, which is higher than the value classically described in non-COVID patients.

Cardiac complications in a geriatric population hospitalized with COVID-19: The OCTA-COVID cohort.

PURPOSE: The geriatric population is especially vulnerable to coronavirus disease (COVID-19) and its potential complications. We sought to analyze the incidence of cardiological complications in an elderly population hospitalized for COVID-19. METHODS: A prospective observational longitudinal that included patients ≥75 years of age with diagnosis of COVID-19 admitted to the Geriatric Department from March to May 2020. Epidemiological, geriatric, clinical and laboratory test variables were collected. Cardiovascular events, including de novo atrial fibrillation (AF), acute coronary syndrome (ACS), congestive heart failure (CHF), pulmonary embolism and in-hospital death, were documented. A follow-up was carried out at 12 months through a telephone interview as well as using electronic medical records, collecting cardiac events and mortality. RESULTS: 305 patients were included; 190 (62.3%) were female, with median age of 87 years (interquartile range (82-91)). More than half of the patients had a history of cardiac disease, with AF being the most common and affecting 85 (27.9%) patients. During hospitalization, 112 (36.7%) patients died. Eighty-nine (29.2%) patients presented cardiac complications. Acute heart failure was the most prevalent (46; 15.1%), followed by new-onset AF (20; 6.5%), pulmonary embolism (17; 5.6%), and ACS (5; 1.6%). Patients with cardiac complications had a longer hospital stay (p<0.001). During follow-up, 29 (15.1%) died, and 40 (20.8%) patients had a cardiovascular event being CHF the most prevalent complication (16.7%). CONCLUSION: The incidence of cardiovascular complications in geriatric patients is high and is associated with a longer hospital stay. CHF was the most frequent event, followed by AF.

Hipertensión pulmonar en Enfermedad de Graves Basedow. Discusión de un caso y puesta al día / Pulmonary Hypertension in Graves-Basedow Disease. Discussion of one case and Update

Resumen Se presenta una paciente con Enfermedad de Graves Basedow que desarrolla signos clínicos de hipertiroidismo, trastornos de coa gulación, hepáticos e hipertensión pulmonar que mejora con el tratamiento de la enfermedad. Se revisan los potenciales mecanismos fisiopatológicos implicados.

Abstract Patient with Graves-Basedow disease who develops clinical signs of hyperthyroidism, coagulation and liver disorders, and pulmonary hypertension. The patient gets better with the treatment for this disease. Review of potential physiopathological mechanisms involved.

Cardiac complications in a geriatric population hospitalized with COVID-19: The OCTA-COVID cohort / Complicaciones cardiacas en una población geritrica hospitalizada por COVID-19: La cohorte OCTA-COVID

Purpose: The geriatric population is especially vulnerable to coronavirus disease (COVID-19) and its potential complications. We sought to analyze the incidence of cardiological complications in an elderly population hospitalized for COVID-19.Methods: A prospective observational longitudinal that included patients ≥75 years of age with diagnosis of COVID-19 admitted to the Geriatric Department from March to May 2020. Epidemiological, geriatric, clinical and laboratory test variables were collected. Cardiovascular events, including de novo atrial fibrillation (AF), acute coronary syndrome (ACS), congestive heart failure (CHF), pulmonary embolism and in-hospital death, were documented. A follow-up was carried out at 12 months through a telephone interview as well as using electronic medical records, collecting cardiac events and mortality.Results:305 patients were included; 190 (62.3%) were female, with median age of 87 years (interquartile range (82–91)). More than half of the patients had a history of cardiac disease, with AF being the most common and affecting 85 (27.9%) patients. During hospitalization, 112 (36.7%) patients died. Eighty-nine (29.2%) patients presented cardiac complications. Acute heart failure was the most prevalent (46; 15.1%), followed by new-onset AF (20; 6.5%), pulmonary embolism (17; 5.6%), and ACS (5; 1.6%). Patients with cardiac complications had a longer hospital stay (p<0.001). During follow-up, 29 (15.1%) died, and 40 (20.8%) patients had a cardiovascular event being CHF the most prevalent complication (16.7%). (AU)

Introducción: La población geriátrica es especialmente vulnerable a la enfermedad por coronavirus (COVID-19) y sus posibles complicaciones. Nos propusimos analizar la incidencia de complicaciones cardiológicas en una población anciana hospitalizada por COVID-19.Métodos: Estudio longitudinal observacional prospectivo que incluyó a pacientes≥75 años con diagnóstico de COVID-19 ingresados en el Servicio de Geriatría de marzo a mayo de 2020. Se recogieron variables epidemiológicas, geriátricas, clínicas y de laboratorio. Se documentaron eventos cardiovasculares, que incluyen fibrilación auricular (FA) de novo, síndrome coronario agudo, insuficiencia cardíaca congestiva, embolia pulmonar y muerte intrahospitalaria. Se realizó un seguimiento a los 12 meses, mediante entrevista telefónica y accediendo a la historia clínica electrónica, recogiendo eventos cardíacos y mortalidad.Resultados: Se incluyeron 305 pacientes; 190 (62,3%) eran mujeres, con una mediana de edad de 87 años (rango intercuartílico: 82-91). Más de la mitad de los pacientes tenían antecedentes de enfermedad cardíaca, siendo la FA la más frecuente y afectando a 85 (27,9%) pacientes. Durante la hospitalización fallecieron 112 (36,7%) pacientes. Ochenta y nueve (29,2%) pacientes presentaron complicaciones cardíacas. La insuficiencia cardíaca congestiva aguda fue la más prevalente (46; 15,1%), seguida de la FA de nueva aparición (20; 6,5%), la embolia pulmonar (17; 5,6%) y el síndrome coronario agudo (5; 1,6%). Los pacientes con complicaciones cardíacas tuvieron una estancia hospitalaria más prolongada (p<0,001). Durante el seguimiento fallecieron 29 pacientes (15,1%) y 40 (20,8%) presentaron un evento cardiovascular, siendo la insuficiencia cardíaca congestiva la complicación más prevalente (16,7%). (AU)

Doble vena cava inferior y enfermedad tromboembólica / Double inferior vena cava and thromboembolic disease

La doble vena cava inferior (DVCI) es una anomalía congénita poco frecuente, pero con grandes implicaciones clínicas en la planificación quirúrgica y el intraoperatorio de cirugías en las que se aborda el retroperitoneo, así como en la enfermedad tromboembólica.En la siguiente revisión se presenta el caso de una paciente de noventa años con enfermedad tromboembólica y doble vena cava inferior.

Double inferior vena cava (DIVC) is a rare congenital anomaly, but with great clinical implications, both in the surgical and intraoperative planning of surgeries where the retroperitoneum is approached, as well as in thromboembolic disease.In the following report and review, a case of a 90-year-old patient with thromboembolic disease and DIVC is presented.

Profilaxia do tromboembolismo venoso nas cirurgias ortopédicas / Venous thromboprophylaxis in orthopedic surgeries

A trombose venosa profunda (TVP) e o tromboembolismo pulmonar (TEP) são as principais manifestações clínicas do tromboembolismo venoso (TEV). O TEV é uma complicação comum e potencialmente grave das cirurgias ortopédicas, uma vez que pode levar à limitação funcional e morte pós-operatória. O uso da tromboprofilaxia reduz acentuadamente a incidência de TEV relacionado às intervenções ortopédicas, e seu uso é recomendado por diversas diretrizes. Entretanto, a indicação e o tipo de tromboprofilaxia para algumas intervenções ortopédicas, assim como o uso de ferramentas de predição de risco, ainda não estão bem estabelecidos e constituem pontos de debate. Os objetivos deste trabalho foram identificar os fatores de risco para TEV e suas interações nas cirurgias ortopédicas e avaliar a aplicabilidade do escore de risco de Caprini na predição de TEV em pacientes ortopédicos. Além disso, devido à escassez de conhecimento e recomendações sobre tromboprofilaxia nas intervenções ortopédicas de tornozelo e pé, realizaram-se uma revisão narrativa e uma enquete internacional sobre o assunto. Para analisar a interação de fatores de risco de TEV e a aplicabilidade preditiva do escore de Caprini nas cirurgias ortopédicas, foram utilizados os dados do Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis (MEGA), um estudo caso-controle holandês de base populacional cujo desfecho de interesse é o TEV. Neste, 263 indivíduos que tiveram TEV e 94 controles foram submetidos à cirurgia ortopédica. O risco de TEV foi maior nos primeiros 30 dias após a cirurgia [odds ratio ajustada (ORadj) 17,5; intervalo de confiança (IC) 95%, 9,2-33,4] e manteve-se aumentado até 90 dias (ORadj 11,5; IC 95%, 7,3-17,7). Houve interação entre cirurgia ortopédica e mutação fator V Leiden (ORadj 17,5; IC 95%, 4,1-73,6), tipo de sangue não-O (ORadj 11,2; 95% IC, 3,4-34,0) e níveis séricos de fator VIII maiores que 150 mg/dl (ORadj 18,6; IC, 7,4-46,9). Quanto ao escore de Caprini, foram avaliados 357 indivíduos com TEV submetidos à cirurgia ortopédica. Um total de 20,9% dos casos e 41,5% dos controles foram classificados no grupo de menor risco (Caprini < 5 pontos). Pacientes com um escore de Caprini maior que 11 pontos tiveram um risco de TEV seis vezes maior (OR 6,3; IC 95%, 1,7-22,9), e pacientes com um escore de 9 a 10 tiveram um risco três vezes maior (OR 3,5; IC 95% 1,2-10,3). A área sob a curva (AUC) do escore de Caprini foi de 0,64, evidenciando uma discriminação de predição de TEV moderada. Na enquete internacional sobre tromboprofilaxia de pé e tornozelo, 693 cirurgiões ortopédicos de pé e tornozelo de 49 países participaram. Aproximadamente 50% informaram prescrever tromboprofilaxia durante a imobilização do paciente. Quando utilizada, as escolhas preferidas em ordem decrescente foram ácido acetilsalicílico (AAS), heparina de baixo peso molecular (HBPM) e anticoagulantes orais diretos. AAS e HBPM foram predominantemente prescritos na América do Norte e Europa, respectivamente. TVP prévia, imobilidade, obesidade e trombofilia hereditária foram considerados os principais fatores de risco indicativos do uso de tromboprofilaxia. Concluiu-se que: houve risco aumentado de TEV e interação entre os fatores de risco fator V Leiden, níveis elevados de fator VIII e grupo sanguíneo não- O com cirurgia ortopédica; o escore de Caprini é uma ferramenta que pode auxiliar os cirurgiões ortopédicos a classificarem o risco de TEV no pós-operatório, embora seu desempenho preditivo discriminativo tenha sido moderado; apesar de a maioria dos cirurgiões ortopédicos de tornozelo e pé considerarem que a tromboprofilaxia está indicada para cirurgias de tornozelo e pé (principalmente na presença de fatores de risco como TVP prévia, imobilidade, obesidade e trombofilia hereditária), a prescrição, o tipo e a duração apresentam grande discrepância intercontinental. Assim, este trabalho contribui para a identificação de pacientes sob alto risco de TEV, ponto estratégico para o uso individualizado e seguro da tromboprofilaxia como ferramenta para redução do risco de TEV relacionado às cirurgias ortopédicas.

Deep vein thrombosis (DVT) and pulmonary embolism are the main clinical manifestations of venous thromboembolism (VTE). VTE is a common and potentially serious complication of orthopedic surgeries, as it can lead to functional limitation and postoperative death. The use of thromboprophylaxis markedly reduces the incidence of VTE related to orthopedic interventions, and its use is recommended by several guidelines. However, the indication and type of thromboprophylaxis for some orthopedic interventions, as well as the use of risk prediction tools are still not well established and is debatable. The objectives of this study were to identify risk factors for VTE and their interactions in orthopedic surgeries and to evaluate the applicability of the Caprini risk score in predicting VTE in orthopedic patients. In addition, due to the lack of knowledge and recommendations on thromboprophylaxis in foot and ankle surgeries, a narrative review and an international survey on the subject were carried out. Data from the MEGA Study (Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis) which is a Dutch population-based case-control study whose outcome of interest is VTE were used. A total of 263 subjects who had VTE and 94 controls underwent orthopedic surgery. The risk of VTE was the highest in the first 30 days after surgery (adjusted odds ratio [ORadj] 17.5; 95% CI [confidence interval], 9.2-33.4) and remained increased up to 90 days (ORadj, 11.5; 95% CI, 7.3- 17.7). There was interaction between orthopedic surgery and factor V Leiden mutation (ORadj 17.5, 95%CI 4.1-73.6), non-O blood type (ORadj 11.2; 95%CI 3.4-34.0) and factor VIII plasma levels greater than 150 mg/dl (ORadj 18.6; CI 7.4-46.9). To assess the applicability of the Caprini Score, 357 individuals with VTE undergoing orthopedic surgery in the MEGA were evaluated. A total of 20.9% of cases and 41.5% of controls were classified in the lowest risk group (Caprini <5 points). Patients with a Caprini score greater than 11 points had a six-fold increased risk of VTE (OR 6.3, 95% CI 1.7- 22.9) and patients with a score of 9-10 had about three-fold increased risk (OR 3.5, 95% CI 1.2-10.3). The area under curve for the Caprini score was 0.64, evidencing a moderate VTE prediction discrimination. In the international survey on foot and ankle thromboprophylaxis, 693 orthopedic foot and ankle surgeons from 49 countries participated. Approximately 50% reported prescribing thromboprophylaxis during patient immobilization that, when used, the preferred choice, in descending order, was acetylsalicylic acid (ASA), low molecular weight heparin (LMWH) and direct oral anticoagulants. ASA and LMWH were predominantly prescribed in North America and Europe, respectively. Previous DVT, immobility, obesity and hereditary thrombophilia were considered the main risk factors indicative of the use of thromboprophylaxis. It is concluded that there was increased risk of VTE and interaction between factor V Leiden, high plasma levels of factor VIII or non-O blood group and orthopedic surgery; that the Caprini score is a tool that can help orthopedic surgeons to classify the risk of postoperative VTE, although its discriminative predictive performance was moderate and that although most ankle and foot orthopedic surgeons consider that thromboprophylaxis is indicated for ankle and foot surgeries (especially in the presence of risk factors such as previous DVT, immobility, obesity and hereditary thrombophilia), the prescription, type and duration present a large intercontinental discrepancy. Thus, this work contributed to the identification of patients at high risk of VTE, a strategic point for the individualized and safe use of thromboprophylaxis as a tool to reduce the risk of VTE related to orthopedic surgeries.