It is unclear whether improvements in the detection/treatment of peripheral artery disease (PAD) affect overall survival and morbidity. We undertook a systematic review to describe survival and morbidity in contemporary PAD cohorts.Electronic databases were searched for randomised and observational studies reporting mortality/morbidity events between 1 May 2003 and 31 December, 2017 in patients with PAD, diagnosed by intermittent claudication (IC), critical limb ischaemia (CLI), or an ankle brachial index (ABI) < 0.9. Pooled event rates for all-cause and cardiovascular (CV) mortality, non-fatal myocardial infarction (MI), non-fatal stroke, major CV events (MACE; non-fatal MI/stroke, CV death), and major amputation were calculated per 1000 person-years.124 eligible studies were identified (570,856 patients; 855,894 person-years of follow-up). Statin use was reported in 67% of the overall cohort and antiplatelet use in 79%. Pooled event rates for all-cause and CV mortality, MI, stroke, MACE, and major amputation were 113, 39, 20, 12, 71, and 70 per 1000 person-years, respectively. Compared with patients with an ABI <0.9, the presence of CLI was associated with increased rates of all-cause and CV mortality, MI, MACE, and major amputation. Event rates for stroke were similar between patients with an ABI <0.9 and CLI.Our data show PAD patients have a high risk of all-cause and CV mortality, and imply the risk of stroke or MI is at least equivalent to the risk in patients with coronary artery disease. Moreover, our data underline the need for improved treatments to attenuate CV risk in PAD patients.
Abstract Prognostic assessment in patients with acute venous thromboembolism is essential to drive clinical management in terms of disposition for hospitalization or home treatment, and revascularization strategies or anticoagulation alone. In these patients, single predictors, combinations of predictors, or prognostic models can be used for prognostic assessment. Overall, the risk for short-term death is about tenfold higher after acute pulmonary embolism than after acute deep vein thrombosis. Localization of thrombosis (proximal or distal) and comorbidities are the main predictors of prognosis in patients with deep vein thrombosis. In patients with pulmonary embolism, prognostic assessment includes the evaluation of clinical features, findings at imaging (computed tomography angiography, echocardiography, and/or ultrasonography of the lower limbs), or biomarkers of right ventricular dysfunction or injury. The presence of shock or sustained hypotension is the main criterion for the identification of high-risk patients. Clinical models with high negative predictive value have been validated to identify patients at low risk for short-term death. Whether the assessment of right ventricular dysfunction in these patients can further improve the negative predictive value of clinical models remains to be defined. Right ventricular dysfunction as assessed by echocardiography or computed tomography angiography as well as right ventricular damage by troponin levels are associated with an about twofold increase in the risk for short-term death in intermediate risk patients. However, prognostic assessment in these patients requires further improvement before it can be used to drive decisions on treatment.
The management of patients with acute pulmonary embolism is made challenging by its wide spectrum of clinical presentation and outcome, which is mainly related to patient haemodynamic status and right ventricular overload. Mechanical embolic obstruction and neurohumorally mediated pulmonary vasoconstriction are responsible for right ventricular overload. The pathophysiology of acute pulmonary embolism is the basis for risk stratification of patients as being at high, intermediate and low risk of adverse outcomes. This risk stratification has been advocated to tailor clinical management according to the severity of pulmonary embolism. Anticoagulation is the mainstay of the treatment of acute pulmonary embolism. New direct oral anticoagulants, which are easier to use than conventional anticoagulants, have been compared with conventional anticoagulation in five randomised clinical trials including >11 000 patients with pulmonary embolism. Patients at high risk of pulmonary embolism (those with haemodynamic compromise) were excluded from these studies. Direct oral anticoagulants have been shown to be as effective and at least as safe as conventional anticoagulation in patients with pulmonary embolism without haemodynamic compromise, who are the majority of patients with this disease. Whether these agents are appropriate for the acute-phase treatment of patients at intermediate–high risk pulmonary embolism (those with both right ventricle dysfunction and injury) regardless of any risk stratification remains undefined.
Cerebral veins contain about 70% of the total cerebral blood volume, but cerebral venous thrombosis (CVT) occurs about a thousand times less often than arterial stroke. CVT affects mostly young adults and children, and in about one quarter of cases the cause remains unknown. Written by international experts, this publication is dealing with epidemi
