Pharmacological cancer treatment and venous thromboembolism risk.

Risk factors for cancer-associated thrombosis are commonly divided into three categories: patient-, cancer-, and treatment-related factors. Currently, different types of drugs are used in cancer treatment. Chemotherapy has been identified as an independent risk factor for venous thromboembolism (VTE). However, it should be noted, that the risk of VTE is not consistent among all cytotoxic agents. In addition, different supportive care drugs, such as erythropoiesis stimulating agents or granulocyte colony stimulating factors, and hormonotherapy have been associated to an increased risk of VTE. Immunotherapy and molecular-targeted therapies have significantly changed the treatment of cancer over the past decade. The main subtypes include tyrosine-kinase inhibitors, monoclonal antibodies, small molecules, and immunomodulatory agents. The relationship between VTE and targeted therapies remains largely unknown.

Los factores de riesgo para la trombosis asociada al cáncer se suelen dividir en tres categorías: factores relacionados con el paciente, con el cáncer y con el tratamiento. En la actualidad, existen distintos tipos de fármacos que se emplean en el tratamiento del cáncer. La quimioterapia se ha determinado como un factor de riesgo independiente para el desarrollo de la tromboembolia venosa (TEV). No obstante, cabe destacar que el riesgo de padecer TEV no es coherente entre los agentes citotóxicos. Por otra parte, distintos fármacos de tratamiento paliativo, como los agentes estimulantes de la eritropoyesis o factores estimulantes de colonias de granulocitos, se han asociado a un aumento del riesgo de TEV. La inmunoterapia y los tratamientos dirigidos a dianas moleculares han supuesto un cambio significativo en el tratamiento del cáncer en la última década. En los principales subtipos se incluyen los inhibidores de las tirosina-cinasas, anticuerpos monoclonales, fármacos tradicionales y agentes inmunomoduladores. La relación entre la TEV y los tratamientos dirigidos sigue siendo en gran medida desconocida.

Clinical and radiological diagnosis of pulmonary thromboembolism. / Diagnóstico clínico y radiológico de la tromboembolia de pulmón.

Pulmonary thromboembolism has poorly specific clinical symptomatology, which increases the diagnostic suspicion, multiplying the number of patients who will need to undergo imaging tests to confirm the diagnosis. In recent years, pulmonary angiography using multidetector scanners (CT angiography) has been the most widely used imaging test due to its availability and accuracy, which exceeds that of lung ventilation-perfusion (V/Q) scintigraphy. However, CT angiography is not without risks and is also expensive. Its use should therefore be restricting without reducing the diagnostic efficacy, given its enormous prognostic importance and implication. We therefore need to base our approach on previously validated strategies that, taking into account the clinical probability and using highly sensitive diagnostic tests such as D-dimer, will enable us to exclude many patients from undergoing this imaging test. In this article, we review the diagnostic techniques and strategies that are applied for diagnosing pulmonary thromboembolism in hemodynamically stable and unstable outpatients, hospitalised patients, patients with a history of venous thromboembolism and pregnant women.

Home treatment of venous thromboembolism disease. / Tratamiento domiciliario de la enfermedad tromboembólica venosa.

Despite the potential benefits of outpatient care, most patients with pulmonary embolisms are treated in hospitals for fear of possible adverse events. However, there is a wealth of scientific evidence from studies covering more than 4000 outpatients, which has led the current clinical practice guidelines to recommend early discharge or outpatient treatment when a low risk of death or complications has been confirmed, when there are no comorbidities or aggravating processes present to warrant hospitalisation and when appropriate monitoring and treatment are observed. This approach minimises the complications that can arise in hospitals and represents considerable cost savings. When selecting these patients, the use of prognostic tools such as the Pulmonary Embolism Severity Index (PESI), its simplified version (sPESI) and the Hestia Criteria are of paramount importance. Using these tools, the short-term outcomes (30-90days) show low mortality (in general <3%) and a low incidence of other complications (rate of recurrence and major bleeding <2%). Based on the available evidence, outpatient treatment can be considered the most appropriate strategy at this time for most hemodynamically stable patients with pulmonary embolisms.

Algorithm for the diagnosis and follow-up of acute pulmonary embolisms. / Algoritmo para el diagnóstico y el seguimiento de la tromboembolia pulmonar aguda.

The urgent diagnosis of acute pulmonary thromboembolism benefits from the use of evidence-based clinical guidelines that improve patients' prognoses and reduce the unnecessary use of imaging tests. This article explains the diagnostic algorithms for pulmonary thromboembolism most recently published by the relevant scientific societies both for the general population and for special situations, trying to clear up common doubts and analyzing persistent controversies. It also discusses the need to follow up the thromboembolism after anticoagulation treatment, which is not currently recommended in the guidelines.

Impact of a pulmonary embolism response team (PERT) in the prognosis of patients with acute symptomatic pulmonary embolism.

BACKGROUND: The effect of a pulmonary embolism response team (PERT) in the short-term prognosis of patients with acute symptomatic pulmonary embolism (PE) lacks clarity. We therefore aimed at evaluating the effect of a PERT team on short-term mortality among patients with acute PE. METHODS: We retrospectively reviewed consecutive patients with acute symptomatic PE enrolled in a single-center registry between 2007 and 2022. We used propensity score matching to compare treatment effects for patients with similar predicted probabilities of receiving management by the PERT team. The primary outcome was all-cause mortality within 30 days following the diagnosis of PE. The secondary outcome was 30-day PE-related mortality. RESULTS: Of the 2,902 eligible patients who had acute symptomatic PE, 223 (7.7%; 95% confidence interval [CI], 6.7%-8.7%) were managed by the PERT team. Two hundred and seven patients who were treated by the PERT were matched with 207 patients who were not. Matched pairs did not show a statistically significant lower all-cause (odds ratio [OR], 1.09; 95% CI, 0.63-1.89) or PE-related death (OR, 1.30; 95% CI, 0.47-3.62) for PERT management compared with no PERT management through 30 days after diagnosis of PE. CONCLUSIONS: Our results suggest that multidisciplinary care of patients with acute symptomatic PE by a PERT team is not associated with a significant reduction in short-term all-cause or PE-related mortality.

[Translated article] 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.

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 analysed. Mortality, risk of bleeding and surgical wound complications was also analysed. 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=0.64), DVT (OR=0.72; 95% CI: 0.43-1.20; p=0.21) or PE (OR=1.13; 95% CI: 0.86-1.49; p=0.38) between both groups. No significant differences were found in mortality (p=0.30), bleeding (p=0.22), or complications in the surgical wound (p=0.85) between both groups. These same findings were found in the sub-analysis of only randomised clinical trials (p>0.05). 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.

Pulmonary CT angiography in the first wave of the COVID-19 pandemic: Comparison between patients with and without infection and with a pre-pandemic series.

BACKGROUND AND AIMS: To analyze the diagnostic performance of pulmonary CT angiography and to compare different D-dimer cutoffs for the diagnosis of acute pulmonary embolism in patients with and without SARS-CoV-2 infections. MATERIALS AND METHODS: We retrospectively analysed all consecutive pulmonary CT angiography studies done for suspected pulmonary embolism in a tertiary hospital during two time periods: the first December 2020 through February 2021 and the second December 2017 through February 2018. D-dimer levels were obtained less than 24 h before the pulmonary CT angiography studies. We analysed the sensitivity, specificity, positive and negative predictive values, area under the receiver operating curve (AUC), and pattern of pulmonary embolism for six different values of D-dimer and the extent of the embolism. During the pandemic period, we also analysed whether the patients had COVID-19. RESULTS: After excluding 29 poor-quality studies, 492 studies were analysed; 352 of these were done during the pandemic, 180 in patients with COVID-19 and 172 in patients without COVID-19. The absolute frequency of pulmonary embolism diagnosed was higher during the pandemic period (34 cases during the prior period and 85 during the pandemic; 47 of these patients had COVID-19). No significant differences were found in comparing the AUCs for the D-dimer values. The optimum values calculated for the receiver operating characteristic curves differed between patients with COVID-19 (2200 mcg/l), without COVID-19 (4800 mcg/l), and diagnosed in the prepandemic period (3200 mcg/l). Peripheral distribution of the emboli was more common in patients with COVID-19 (72%) than in those without COVID-19 and than in those diagnosed before the pandemic [OR 6.6, 95% CI: 1.5-24.6, p < 0.05 when compared to central distribution]. CONCLUSIONS: The number of CT angiography studies and the number of pulmonary embolisms diagnosed during the pandemic increased due to SARS-CoV-2 infection. The optimal d-dimer cutoffs and the distribution of the pulmonary embolisms differed between the groups of patients with and without COVID-19.

Sex-related differences in benefits of anticoagulation therapy in elderly patients with atrial fibrillation: a subanalysis of the EMERG-AF study. / Diferencias de sexo en los beneficios de la anticoagulación en pacientes ancianos con fibrilación auricular: un subanálisis del estudio EMERG-AF.

OBJECTIVES: To analyze the long-term benefits and safety of oral anticoagulation therapy prescribed in emergency departments for elderly patients with atrial fibrillation, and to detect any sex-related differences present. MATERIAL AND METHODS: Post-hoc analysis of data compiled by the EMERG-AF group (Spanish acronym for Emergency Department Stroke Prophylaxis and Guidelines Implementation in Atrial Fibrillation). Consecutive patients aged 75 years or older with atrial fibrillation who were treated in 62 EDs were included. We recorded clinical data and anticoagulants prescribed. Patients were followed for 1 year. The main outcome variable was a composite of death, thromboembolism, or major bleeding within 1 year. RESULTS: Data for 690 patients were registered; 386 (55.9%) were women. At discharge, 575 patients (83.3%) were on anticoagulants; therapy was started in the ED for 96 of them. A total of 158 patients (22.9%) had experienced at least 1 component of the main outcome within 1 year: 118 (17.1%) died, 22 (2.7%) had thromboembolic complications, and 34 (4.9%) had major bleeding. After adjustment for main clinical characteristics, hazard ratios (HRs) showed that anticoagulation therapy was associated with a reduction in the composite outcome (HR, 0.372; 95% CI, 0.236-0.587; P .001) but not specifically with major bleeding overall. When data for women were analyzed separately, anticoagulant therapy was again associated with a reduction in the composite outcome (HR, 0.372; 95% CI, 0.236-0.587; P .001) and also with death (HR, 0.281; 95% CI, 0.168-0.469; P .001), even in patients with anticoagulant prescriptions initiated on discharge from the ED. These associations did not reach statistical significance in men. CONCLUSION: ED anticoagulant prescription for elderly patients with atrial fibrillation is safe and contributes to a reduction in mortality. Women in this age group benefited more than men from starting anticoagulation during the acute phase in the ED.

OBJETIVO: Analizar los beneficios y seguridad a largo plazo de la anticoagulación oral (ACO) prescrita en los servicios de urgencias (SU) a pacientes mayores con fibrilación auricular (FA) y las diferencias en función del sexo. METODO: Se trata de un análisis post-hoc del estudio EMERG-AF. Se incluyeron pacientes consecutivos $ 75 años, que consultaron en 62 SU por FA. Se recogieron datos clínicos y ACO. La variable principal estuvo compuesta por muerte, tromboembolia o sangrado mayor en 1 año. RESULTADOS: Se incluyeron 690 pacientes, 386 mujeres (55,9%). Al alta, 575 pacientes (83,3%) estaban con ACO. En 96 de ellos se inició en el SU. Tras 1 año, la variable principal sucedió en 158 pacientes (22,9%): 118 (17,1%) fallecieron, 22 (2,7%) tuvieron una complicación tromboembólica y 34 (4,9%) una hemorragia mayor. Tras ajustar por las principales características clínicas, la ACO se asoció a una reducción en la variable principal (HR: 0,372, IC 95%: 0,236-0,587, p 0,001), pero no se asoció con la hemorragia mayor. En las mujeres, la ACO se asoció con una reducción en la variable principal (HR: 0,372, IC 95%: 0,236-0,587, p 0,001) y una menor mortalidad (HR: 0,281, IC 95%: 0,168-0,469, p 0,001), incluidos pacientes con nueva prescripción y en aquellos dados de alta. Esta asociación no alcanzó significación en los hombres. CONCLUSIONES: La prescripción de ACO en los SU a pacientes mayores con FA es segura y contribuye a reducir la mortalidad. En este grupo etario, las mujeres se benefician más que los hombres de iniciar la ACO en la fase aguda.

Emergency department management of atrial fibrillation: 2023 consensus from the Spanish Society of Emergency Medicine (SEMES), the Spanish Society of Cardiology (SEC), and the Spanish Society of Thrombosis and Hemostasis (SETH). / Manejo de la fibrilación auricular en los servicios de urgencias hospitalarios: actualización a 2023 del consenso de la Sociedad Española de Medicina de Urgencias (SEMES), la Sociedad Española de Cardiología (SEC) y la Sociedad Española de Trombosis y Hemostasia (SETH).

OBJECTIVES: Atrial fibrillation (AF) is the most prevalent sustained arrhythmia managed in emergency departments, and the already high prevalence of this arrhythmia is increasing in Spain. This serious condition associated with increased mortality and morbidity has a negative impact on patient quality of life and the functioning of the health care system. The management of AF requires consideration of diverse clinical variables and a large number of possible therapeutic approaches, justifying action plans to coordinate the work of several medical specialties in the interest of providing appropriate care and optimizing resources. This consensus statement brings together recommendations for emergency department management of AF based on available evidence adapted to special circumstances. The statement was drafted by a multidisciplinary team of specialists from the Spanish Society of Emergency Medicine (SEMES), the Spanish Society of Cardiology (SEC), and the Spanish Society of Thrombosis and Hemostasis (SETH). Strategies for stroke prophylaxis, measures to bring heart rate and heart rhythm under control, and related diagnostic and logistic issues are discussed in detail.

OBJETIVO: La fibrilación auricular (FA) es la arritmia sostenida de mayor prevalencia en los servicios de urgencias (SU), y en España presenta una frecuentación elevada y creciente. Esta arritmia es una enfermedad grave, que incrementa la mortalidad y asocia una relevante morbilidad e impacto en la calidad de vida de los pacientes y en el funcionamiento de los servicios sanitarios. La diversidad de aspectos clínicos a considerar y el elevado número de opciones terapéuticas posibles justifican la implementación de estrategias de actuación coordinadas entre los diversos profesionales implicados, con el fin de incrementar la adecuación del tratamiento y optimizar el uso de recursos. Este documento, realizado por un grupo multidisciplinario de expertos en arritmias cardiacas miembros de la Sociedad Española de Medicina de Urgencias y Emergencias, la Sociedad Española de Cardiología y la Sociedad Española de Trombosis y Hemostasia, recoge las recomendaciones para el manejo de la FA en los SU hospitalarios, basadas en la evidencia disponible y adaptadas a las especiales circunstancias de los mismos. En él se analizan con detalle las estrategias de profilaxis tromboembólica, control de frecuencia y control del ritmo, y los aspectos logísticos y diagnósticos relacionados.

Difficult withdrawal of an inferior vena cava filter: Technical considerations and associated variables.

OBJECTIVE: To analyse the efficacy of the procedure for withdrawing an inferior vena cava (IVC) filter and the clinical and radiological factors associated with difficult withdrawal. MATERIAL AND METHODS: This retrospective observational study included patients who underwent IVC filter withdrawal at a single centre between May 2015 and May 2021. We recorded demographic, clinical, procedural, and radiological variables: type of IVC filter, angle with the IVC > 15°, hook against the wall, and legs embedded in the IVC wall > 3 mm. The efficacy variables were fluoroscopy time, success of IVC filter withdrawal, and number of attempts to withdraw the filter. The safety variables were complications, surgical removal, and mortality. The main variable was difficult withdrawal, defined as more than 5 min fluoroscopy or more than 1 attempt at withdrawal. RESULTS: A total of 109 patients were included; withdrawal was considered difficult in 54 (49.5%). Three radiological variables were more common in the difficult withdrawal group: hook against the wall (33.3% vs. 9.1%; p = 0.027), embedded legs (20.4% vs. 3.6%; p = 0.008), and >45 days since IVC filter placement (51.9% vs. 25.5%; p = 0.006). These variables remained significant in the subgroup of patients with OptEase IVC filters; however, in the group of patients with Celect IVC filters, only the inclination of the IVC filter >15 ° was significantly associated with difficult withdrawal (25% vs 0%; p = 0.029). CONCLUSION: Difficult withdrawal was associated with time from IVC placement, embedded legs, and contact between the hook and the wall. The analysis of the subgroups of patients with different types of IVC filters found that these variables remained significant in those with OptEase filters; however, in those with cone-shaped devices (Celect), the inclination of the IVC filter >15° was significantly associated with difficult withdrawal.

Pulmonary embolism rule-out decision-making tools for patients aged 35 years or younger in hospital emergency departments: a post-hoc analysis of performance in 3 prospective cohorts. / Capacidad de diferentes reglas de decisión clínica para descartar tromboembolismo pulmonar en pacientes de 35 o menos años atendidos en servicios de urgencias: análisis post-hoc de tres cohortes prospectivas.

OBJECTIVES: To assess the performance of the Pulmonary Embolism Rule-out Criteria (PERC) and the age-modified PERC-35 tool in hospital emergency departments (EDs) for evaluating patients aged 35 years or younger. A secondary aim was to assess other decision-making criteria. MATERIAL AND METHODS: Post-hoc analysis of 3 European cohort studies. We included data for patients aged 35 years or younger suspected of PE who were followed for 3 months. The safety and efficacy of applying the PERC and PERC-35 were assessed with the diagnostic error rate (failure to detect PE) and the proportion of patients in whom a diagnosis of PE was ruled out. We also assessed the safety and efficacy of applying the YEARS and PEGeD criteria. RESULTS: Data for 1235 patients aged 35 years or younger were analyzed. Twenty-two (1.8%; 95% CI, 1.2%-2.7%) PE cases were diagnosed at 3 months. Six (1.0%; 95% CI, 0.5%-2.2%) and 5 (0.9%; 95% CI, 0.4%-2.1%) PE cases were not diagnosed by the PERC and PERC-35 tools, respectively. These tools allowed PE to be ruled out in 591 (48.2%; 95% CI, 45.4%-51.0%) and 554 (46.2%; 95% CI, 43.4%-49.0%) cases, respectively. The error rates of the YEARS and PEGeD criteria, respectively, were 0.4% (95% CI, 0.1%-1.1%) and 0.5% (95% CI, 0.2%-1.2%); their efficacy was similar. CONCLUSION: The safety and efficacy profiles of the PERC and PERC-35 algorithms were similar in patients aged 35 years or younger. However, the large confidence intervals we report do not allow us to confirm the safety of using the tools in patients in this age group.

OBJETIVO: Evaluar la capacidad de la regla PERC (Pulmonary Embolism Rule-out Criteria) y la regla modificada por edad (PERC-35) para descartar tromboembolia pulmonar (TEP) en servicios de urgencias hospitalarios (SUH) en pacientes 35 años. El objetivo secundario fue analizar otras reglas de decisión clínica. METODO: Análisis post-hoc de 3 estudios de cohorte europeos (PROPER, PERCEPIC y MODIGLIANI). Se incluyeron pacientes 35 años con sospecha de TEP en SUH y con seguimiento a 3 meses. La seguridad y eficacia de PERC y PERC-35 se evaluaron con su tasa de error -no detectar TEP- y la proporción de pacientes con diagnóstico de TEP descartado. Se evaluó la seguridad y eficacia de las reglas YEARS y PEGeD. RESULTADOS: Se analizaron 1.235 pacientes 35 años. Hubo 22 (1,8%, IC 95%: 1,2-2,7) TEP diagnosticados a los 3 meses. Hubo 6 (1,0%, IC 95%: 0,5-2,2) y 5 (0,9%, IC 95%: 0,4-2,1) TEP no diagnosticados con las reglas PERC y PERC-35 respectivamente. Estas reglas permitieron descartar TEP en 591 (48,2%, IC 95%: 45,4- 51,0) y 554 (46,2%, IC 95%: 43,4- 49,0) respectivamente. La tasa de error de YEARS y PEGeD fue del 0,4% (IC 95%: 0,1- 1,1) y 0,5% (IC 95%: 0,2-1,2), con una eficacia similar. CONCLUSIONES: En pacientes 35 años, las reglas PERC y PERC-35 mostraron perfiles de seguridad y eficacia similares. Sin embargo, el amplio intervalo de confianza comunicado en este estudio no permite confirmar su seguridad.

Multidisciplinary Consensus for the Management of Pulmonary Thromboembolism. / Consenso multidisciplinar para el manejo de la tromboembolia de pulmón.

We have updated recommendations on 12 controversial topics that were published in the 2013 National Consensus on the diagnosis, risk stratification and treatment of patients with pulmonary embolism (PE). A comprehensive review of the literature was performed for each topic, and each recommendation was evaluated in two teleconferences. For diagnosis, we recommend against using the Pulmonary Embolism Rule Out Criteria (PERC) rule as the only test to rule out PE, and we recommend using a D-dimer cutoff adjusted to age to rule out PE. We suggest using computed tomography pulmonary angiogram as the imaging test of choice for the majority of patients with suspected PE. We recommend using direct oral anticoagulants (over vitamin K antagonists) for the vast majority of patients with acute PE, and we suggest using anticoagulation for patients with isolated subsegmental PE. We recommend against inserting an inferior cava filter for the majority of patients with PE, and we recommend using full-dose systemic thrombolytic therapy for PE patients requiring reperfusion. The decision to stop anticoagulants at 3 months or to treat indefinitely mainly depends on the presence (or absence) and type of risk factor for venous thromboembolism, and we recommend against thrombophilia testing to decide duration of anticoagulation. Finally, we suggest against extensive screening for occult cancer in patients with PE.

Prognostic Significance of Findings on CTPA Supporting an Alternative Diagnosis to PE Among Patients Hospitalized for an Exacerbation of COPD: Predefined Subanalysis of the SLICE Trial. / Significado pronóstico de los diagnósticos alternativos a la TEP hallados en la tomografía computarizada de tórax de pacientes ingresados por agudización de EPOC: subanálisis predefinido del ensayo SLICE.

BACKGROUND: Among patients hospitalized for an exacerbation of chronic obstructive pulmonary disease (COPD), the SLICE trial showed that the addition of an active diagnostic strategy for pulmonary embolism (PE) to usual care compared with usual care alone did not improve a composite set of health outcomes. The objective of this subanalysis was to determine the frequency and prognostic significance of findings on computed tomography pulmonary angiogram (CTPA) supporting an alternative diagnosis to PE. METHODS: We analyzed all patients randomized to the intervention in the SLICE trial who received a CTPA that did not show PE. We used multivariable logistic regression to assess the independent association between findings supporting an alternative diagnosis to PE and a composite of readmission for COPD or death within 90 days after randomization. RESULTS: Among the 746 patients who were randomized, this subanalysis included 175 patients in the intervention group who received a CTPA that did not show PE. Eighty-four (48.0%) patients had acute bronchial infection, 13 (7.4%) had lung cancer, 10 (5.7%) had congestive heart failure, 8 (4.6%), 18 (10.3%) had other diagnoses, and 42 (24.0%) had a normal CTPA. In multivariable analysis, findings supporting an alternative diagnosis to PE were not significantly associated with the primary outcome (odds ratio: 0.64; 95% confidence interval: 0.30-1.38; P=0.26). CONCLUSIONS: Among patients hospitalized for an exacerbation of COPD, CTPA identified an alternative diagnosis in 76% of the patients. However, specific management of these patients was not associated with improved outcomes within 90 days after randomization.

Predictors of use of direct oral anticoagulants in acute pulmonary embolism.

INTRODUCTION: In the last decade, direct oral anticoagulants (DOACs) have been incorporated as an anticoagulation tool in patients with acute pulmonary thromboembolism (PTE). Although they have a better pharmacological profile than vitamin K antagonists (VKA), the use of these drugs is not massive. The objective of this study was to evaluate the use of DOACs in patients with acute PE and to detect determinants of its use. METHODOLOGY: Prespecified analysis of the CONAREC XX registry that included patients with acute PE in 64 centers in Argentina. An analysis was performed to detect predictors of DOAC prescription at discharge. RESULTS: 579 patients who received anticoagulation at hospital discharge were analyzed: 60% received VKA, 21% heparin and 19% DOAC (of them, 49% Rivaroxaban, 34% Apixaban, and 17% Dabigatran). Patients receiving DOACs had less severe PE, lower risk of bleeding, and fewer in-hospital complications. At 30-day follow-up, there were no differences in all-cause mortality or bleeding. Health coverage by social insurance (OR 7.45, CI 95% 1.74-31.9, p < 0.01) or by private coverage (OR 10.5, CI 95% 2.4-45.9, p < 0.01) were independent predictors of DOAC prescription at discharge, and history of heart failure (OR 0.19, 95% CI 0.04-0.84, p = 0.028) and oncological disease (OR 0.49, 95% CI 0.27-0.89; p = 0.02) were predictors not prescribe them. CONCLUSIONS: One in five survivors of acute PE received DOACs at hospital discharge in Argentina, and this was determined by clinical and economic variables.

INTRODUCCIÓN: En la última década los anticoagulantes orales directos (ACOD) se incorporaron como herramienta para la anticoagulación en pacientes con tromboembolia pulmonar (TEP) aguda. Aunque tienen un mejor perfil farmacológico que los antagonistas de la vitamina K (AVK), el uso de estos fármacos no es masivo. El objetivo del presente trabajo fue evaluar el uso de ACOD en pacientes con TEP aguda y detectar determinantes de su indicación. METODOLOGÍA: Análisis preespecificado del registro CONAREC XX que incorporó pacientes con TEP aguda en 64 centros de Argentina. Se realizó un análisis para detectar predictores de prescripción de ACOD al alta. RESULTADOS: Se analizaron 579 pacientes que recibieron anticoagulación al alta hospitalaria: el 60% recibió AVK, el 21% heparinas y el 19% ACOD (de ellos, un 49% rivaroxabán, un 34% apixabán y un 17% dabigatrán). Los pacientes que recibieron ACOD tenían TEP de menor gravedad, menor riesgo de hemorragia y menos complicaciones intrahospitalarias. En el seguimiento a 30 días no hubo diferencias en mortalidad por todas las causas o sangrados. La cobertura de salud por un seguro social (odds ratio [OR] 7.45; intervalo de confianza del 95% [IC 95%]: 1.74-31.9; p < 0.01) o por cobertura privada (OR 10.5; IC 95%: 2.4-45.9; p < 0.01) fueron predictores independientes de la prescripción de ACOD al alta, y el antecedente de insuficiencia cardiaca (OR 0.19; IC 95%: 0.04-0.84; p = 0.028) y de enfermedad oncológica (OR 0.49; IC 95%: 0.27-0.89; p = 0.02) fueron predictores de no prescribirlos. CONCLUSIONES: Uno de cada cinco supervivientes de TEP aguda recibió ACOD al egreso hospitalario en Argentina, y esto fue determinado por variables clínicas y económicas.

[Aspiration thrombectomy for acute pulmonary embolism with an intermediate-high risk]. / Trombectomía mecánica en la tromboembolia pulmonar aguda de riesgo intermedio-alto.

INTRODUCTION AND PURPOSE: The treatment of acute pulmonary embolism (PE) with an intermediate-high risk of mortality at 30 days is still not well defined, recommending the latest clinical guidelines of the European Society of Cardiology 2019 exclusively anticoagulant treatment, reducing the indication for mechanical thrombectomy to high-risk patients or intermediate-high risk patients with poor hemodynamic evolution. Our purpose is to determine the safety and efficacy of aspiration thrombectomy in intermediate-high risk patients with PE and to analyze possible differences in these results between hemodynamically unstable patients (massive PE) and hemodynamically stable patients (submassive PE). METHODS: We analyzed all patients who underwent aspiration thrombectomy for PE at our tertiary university hospital during a 34-month period. We compared echocardiographic parameters (right ventricular diameter, tricuspid plane annular plane systolic excursion (TAPSE), S' wave, and pulmonary hypertension), respiratory parameters (PaO2/FiO2 ratio), and clinical parameters recorded before and 24h after the procedure. We also analyzed bleeding complications and mortality. RESULTS: In the 42 patients included (16 with massive PE and 26 with submassive PE), aspiration thrombectomy resulted in significant improvements in right ventricular diameter, TAPSE, S' wave, andPaO2/FiO2 ratio. Of the 8 patients administered fibrinolysis, 4 developed bleeding complications. Only one direct complication of the procedure was observed (pulmonary artery rupture). Eight patients died in the acute phase. CONCLUSIONS: Aspiration thrombectomy for PE is safe and effective, significantly improving respiratory and hemodynamic parameters in the first 24h after the procedure with a low rate of complications compared to fibrinolysis.

Case report: cerebral thromboembolism in an unconscious COVID-19 patient in intensive care.

Although the severity of coronavirus disease 2019 (COVID-19) being more frequently related to acute respiratory distress syndrome and acute cardiac and renal injuries, thromboembolic events have been increasingly reported. Acute respiratory distress syndrome due to SARS-CoV-2 (Severe Acute Respiratory Syndrome - Corona Virus 2) often requires intensive care follow-up. As well as respiratory failure, the SARS-CoV-2 may cause central nervous system (CNS) involvement. The pandemic has raised many challenges in managing critically ill older adults, a population preferentially killed by COVID-19. The mortality and morbidity rates are extremely high in critically ill patients with COVID-19. Recent studies have reported the potential development of a hypercoagulable state in COVID-19. Viral infections and hypoxia may cause these state. It is increasingly reported that thromboembolic events are associated with a poor prognosis. Due to these thromboembolic complications, COVID-19 patients often have neurological symptoms. These symptoms may not be observed in intensive care patients who are sedated. We report one case who was sedated COVID-19 pneumonia and who was later diagnosed with cerebral venous thrombosis with cranial imaging when he could not awaken even though sedation was discontinued. Since COVID-19 causes intense thrombotic susceptibility due to cytokine storm, cerebrovascular thromboembolic complications associated with COVID-19 infection should be considered first and foremost for unconsciousness ventilated patients. Severe and potentially cerebral thrombosis may prolong the patient´s stay in intensive care.

Guidelines for prophylaxis and anti-thrombotic treatment for patients with COVID-19. Consensus of the Latin American Cooperative Group on Hemostasis and Thrombosis (CLAHT) / Guía de profilaxia y tratamiento antitrombótico para pacientes con COVID-19. Consenso del Grupo Cooperativo Latinoamericano en Hemostasia y Trombosis (CLAHT)

Coagulopathy and thrombosis associated with coronavirus disease 2019 (COVID-19) represent a major issue in the management of this disease. In the past months, clinical studies have demonstrated that COVID-19 patients present with a particular hypercoagulable state, in which a markedly increased D-dimer concomitant with increased levels of fibrinogen are observed. This hypercoagulable state leads to an increased risk of thrombosis, which seems to be higher among those patients with critical symptoms of COVID-19. The best therapeutic approach to prevent thrombotic events in COVID-19 has not been determined yet and several questions regarding thromboprophylaxis therapy, such as the time to initiate anticoagulation, type of anticoagulant and dose regimen, have emerged among physicians. To address these concerns, several medical societies have published position papers to provide the opinion of thrombosis experts on the management of coagulopathy and thrombosis associated with COVID-19. In line with this, the Latin America Cooperative Group of Hemostasis and Thrombosis (Grupo CLAHT) has constituted a panel of experts in thrombosis and hemostasis to discuss the available data on this topic. The aim of this review is to summarize the current evidence regarding hemostatic impairment and thrombotic risk in COVID-19 and to provide a carefully revised opinion of Latin American experts on the thromboprophylaxis and management of thrombotic events and coagulopathy in patients with suspected COVID-19.

La coagulopatía y la trombosis asociadas a la enfermedad por coronavirus 2019 (COVID-19) representan un problema importante en el manejo de esta enfermedad. Los estudios clínicos de los últimos meses han demostrado que los pacientes con COVID-19 presentan un estado de hipercoagulabilidad particular, en el que se observa un aumento notable del dímero D concomitante con niveles elevados de fibrinógeno. El estado de hipercoagulabilidad conduce a un mayor riesgo de trombosis, que parece ser mayor entre aquellos pacientes con síntomas críticos de COVID-19. El mejor enfoque terapéutico para prevenir los eventos trombóticos en esta nueva enfermedad aún no se ha determinado y han surgido varias preguntas con respecto a la tromboprofilaxia, como el momento adecuado para iniciar la anticoagulación, el tipo de anticoagulante y el régimen de dosis. Para abordar estas preocupaciones, varias sociedades médicas han publicado artículos de posición para brindar la opinión de expertos en trombosis sobre el manejo de la coagulopatía y trombosis asociadas a COVID-19. Grupo Cooperativo Latinoamericano de Hemostasia y Trombosis (Grupo CLAHT) ha convocado a un panel de expertos en trombosis y hemostasia para discutir los datos disponibles sobre este tema. El objetivo de esta revisión es resumir la evidencia actual con respecto al deterioro hemostático y el riesgo trombótico en el COVID-19 y proporcionar una opinión cuidadosamente revisada de los expertos latinoamericanos sobre la tromboprofilaxis y el manejo de eventos trombóticos y coagulopatía en pacientes con sospecha de COVID-19.

Prevalence of pulmonary thromboembolism in patients undergoing abdominopelvic surgery with respiratory distress.

OBJECTIVE: To determine the prevalence of pulmonary thromboembolism (PET) and identify it's risk factors in patients operated on a scheduled basis, in the general surgery service from the High Specialty Medical Unit Hospital de Especialidades de Puebla, of the Mexican Social Security Institute. METHOD: Descriptive, retrospective and cross sectional study of 52 patients' records with PET and pulmonary angiotomography whose indication was respiratory distress; from 2612 operated patients from November 2015 to March 2018, the sampling was not probabilistic. The statistics was descriptive, with measures of central tendency and dispersion. Fisher test, and Rho Spearman were used. RESULTS: There were association between the development of PET and trans-surgical time (p = 0.018), with the D Dimer (p = 0.014), there was correlation between PET and Wells scale (p=0.001) and blood transfusion (p=0.044). Age, gender, body mass index, preoperative diagnosis, thromboprophylaxis, blood transfusion and surgical approach were not risk factors. CONCLUSION: The prevalence of postoperative PET in patients with respiratory distress after surgical procedure is 5.7% and the mortality is 33.3%.

OBJETIVO: Determinar la prevalencia de la tromboembolia pulmonar (TEP) e identificar sus factores de riesgo en los pacientes intervenidos en el servicio de cirugía general de manera programada de la Unidad Médica de Alta Especialidad Hospital de Especialidades de Puebla, del Instituto Mexicano del Seguro Social. MÉTODO: Estudio descriptivo, retrospectivo y transversal de 52 expedientes de pacientes con TEP y angiotomografía pulmonar cuya indicación fue la dificultad respiratoria, de 2612 pacientes operados de noviembre de 2015 a marzo de 2018. El muestreo fue no probabilístico. La estadística fue descriptiva, con medidas de tendencia central y de dispersión. Se utilizó prueba de Fisher para riesgo y Rho de Spearman. RESULTADOS: Hubo asociación entre el desarrollo de TEP y el tiempo transquirúrgico (p = 0.018), y con el dímero D (p = 0.014); hubo correlación entre la TEP y con la escala de Wells (p = 0.001) y con la transfusión de hemoderivados (p = 0.044). La edad, el sexo, el índice de masa corporal, el diagnóstico preoperatorio, la tromboprofilaxis, la transfusión de hemoderivados y el abordaje quirúrgico no fueron factores de riesgo. CONCLUSIÓN: La prevalencia de TEP posquirúrgica en pacientes que cursan con dificultad respiratoria después del procedimiento quirúrgico es del 5.7% y la mortalidad es del 33.3%.

Need for Transthoracic Echocardiogram in Patients with Low-Risk Pulmonary Thromboembolism: A Systematic Review and Meta-Analysis. / Necesidad de una ecocardiografía transtorácica en pacientes con tromboembolia de pulmón de riesgo bajo: revisión sistemática y metanálisis.

INTRODUCTION: It is unclear whether low-risk patients with acute symptomatic pulmonary embolism (PE) should undergo echocardiogram. METHODS: We performed a meta-analysis of studies that enrolled patients with acute low-risk PE to assess the prognostic value of echocardiographic diagnosis of right ventricular (RV) dysfunction for the primary outcome of short-term all-cause mortality, and the secondary outcome of short-term PE-related mortality. We used a random-effects model to pool study results, a Begg rank correlation method to evaluate for publication bias, and I2 testing to assess heterogeneity. RESULTS: The meta-analysis included a total of 11 studies 1,868 patients with low-risk PE. Ten of the 447 (2.2%; 1.1%-4.1%) low-risk patients with echocardiographic RV dysfunction died soon after the diagnosis of PE compared with 10 of 1,421 (0.7%; 0.3-1.3%) patients without RV dysfunction. RV dysfunction was not significantly associated with short-term all-cause mortality (odds ratio 2.0; 95% confidence interval, 0.8-5.1, p=.14; I2=8%). RV dysfunction was significantly associated with short-term PE-related mortality (odds ratio 5.2; 95% confidence interval, 1.7-16, p <.01; I2=0%). CONCLUSIONS: In patients with low-risk PE, echocardiographic RV dysfunction is not associated with all-cause mortality, but identifies patients with an increased risk for short-term PE-related mortality.

Participation of pulmonary embolism response teams during the perioperative period.

La tromboembolia pulmonar aguda representa una causa frecuente de morbimortalidad cardiovascular, sólo rebasada por los síndromes coronarios agudos y la enfermedad cerebrovascular. El inicio y la intervención de un equipo multidisciplinario de respuesta rápida en la tromboembolia pulmonar son imperantes para mejorar el pronóstico y reducir al mínimo las posibles secuelas en el subgrupo de pacientes más graves. En este artículo de revisión se describe y revisa de manera general el papel actual y potencial que tienen dichos equipos de respuesta rápida, con un enfoque particular en el perioperatorio.Acute pulmonary embolism represents a frequent cause of cardiovascular morbidity and mortality, only exceeded by acute coronary syndromes and cerebrovascular disease. The start-up and implementation of a designated pulmonary embolism response team is necessary to improve prognosis and minimize long-term sequelae in the subgroup of patients with significant pulmonary embolism. Herein, we describe and discuss an overview of the current and potential role of pulmonary embolism response teams, with a focus on the perioperative period.