Pulmonary embolism is a common disease associated with high mortality. Death due to pulmonary embolism occurs mainly before hospital admission or in the first hours of the hospital stay. Prompt diagnosis and prognostic stratification and more intensive treatment in patients with estimated high risk for adverse outcomes have the potential to reduce mortality due to pulmonary embolism. Significant advances have recently been made in the risk stratification for adverse outcomes in patients with pulmonary embolism and normal blood pressure. In these patients, right ventricle overload assessed by echocardiography and probably by helical computerized tomography is a predictor of in-hospital mortality. Serum troponin is rapidly available in the emergency room, and has a critical role in the management of patients with acute coronary syndromes. The role of serum troponin in patients with pulmonary embolism has been explored recently: it seems to be marginal in diagnosis while it can significantly contribute to prognostic stratification. Elevated serum levels of troponins are associated with right ventricular overload and adverse in-hospital outcomes in patients with pulmonary embolism and normal blood pressure.
Clinical management of acute pulmonary embolism has changed over the years based on new evidence on diagnosis, prognostic stratification and treatment. The increasing availability of computed tomography angiography has made the diagnosis faster and accurate, although with some concern on radiation exposure and potential for overdiagnosis. The efficacy and safety of simple-to-use oral anticoagulant agents acting as selective direct inhibitors of coagulation certainly offer considerable benefits to the patients. However, the appropriate use of these agents is necessary to maintain an optimal risk-benefit ratio. This paper reports answers to ten frequently asked questions in the management of patients with suspected or proven acute pulmonary embolism.
The association between cancer and venous thromboembolism (VTE) is well established [1]. Indeed, up to 20 % of cancer patients have a symptomatic VTE, which is recognized to be one of the leading causes of death in these patients [2]. Patients with cancer are heterogeneous concerning the risk for VTE. Some solid malignancies including pancreatic, lung, colon-rectum, ovarian, and brain cancer are associated with a particularly high risk for VTE. A risk assessment score for VTE, known as Khorana score, was validated for cancer patients treated with chemotherapy in order to identify high risk patients [2]. Among cancer patients receiving chemotherapy, rates of VTE seem to be particularly high in those receiving cisplatin or carboplatin-based chemotherapy as well as gemcitabine [3]. We designed a modified Khorana risk assessment score (the Protecht score) by adding platinum or gemcitabine-based chemotherapy to the predictive variables already taken into account in the Khorana score.
The aim of this study in patients with acute posterior ischaemic stroke (PS) and atrial fibrillation (AF) was to evaluate (1) the risks of recurrent ischaemic event and severe bleeding and (2) these risks in relation with oral anticoagulant therapy (OAT) and its timing. Patients with PS were prospectively included; the outcome events of these patients were compared with those of patients with anterior stroke (AS) which were taken from previous registries. The primary outcome was the composite of stroke recurrence, transient ischaemic attack, symptomatic systemic embolism, symptomatic cerebral bleeding and major extracranial bleeding occurring within 90 days from acute stroke. A total of 2470 patients were available for the analysis: 473 (19.1%) with PS and 1997 (80.9%) with AS. Over 90 days, 213 (8.6%) primary outcome events were recorded: 175 (8.7%) in patients with AS and 38 (8.0%) in those with PS. In patients who initiated OAT within 2 days, the primary outcome occurred in 5 out of 95 patients (5.3%) with PS compared to 21 out of 373 patients (4.3%) with AS (OR 1.07; 95% CI 0.39-2.94). In patients who initiated OAT between days 3 and 7, the primary outcome occurred in 3 out of 103 patients (2.9%) with PS compared to 26 out of 490 patients (5.3%) with AS (OR 0.54; 95% CI 0.16-1.80). our findings suggest that, when deciding the time to initiate oral anticoagulation, the location of stroke, either anterior or posterior, does not predict the risk of outcome events. Patients with PS or AS and AF appear to have similar risks of ischaemic or haemorrhagic events at 90 days with no difference concerning the timing of initiation of OAT.
Summary In patients with acute stroke and atrial fibrillation (AF), the risk of early recurrence has been reported to range between 0.1% and 1.3% per day. Anticoagulants are the most effective therapy for the prevention of recurrent ischaemic stroke in these patients, but randomised clinical trials have failed to produce any evidence supporting the administration of heparin within 48 hours from stroke onset as it has been associated with a non-significant reduction in the recurrence of ischaemic stroke, no substantial reduction in death and disability, and an increase in intracranial bleeding. As early haemorrhagic transformation is a major concern in the acute phase of stroke patients with AF, determining the optimal time to start anticoagulant therapy is essential. This review which focuses on the epidemiology of recurrent ischaemic stroke and haemorrhagic transformation in patients with acute ischaemic stroke and AF, proposes a model for decision making on optimal timing for initiating anticoagulation, based on currently available evidence.
