AHA Statement Addresses Severe Manifestations of VTE

A scientific statement from the American Heart As­sociation provides guidance for the management of the more severe forms of venous thromboembolism.

The statement focuses on three areas: massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pul­monary hypertension. “The goal is to provide practi­cal advice to enable the busy clinician to optimize the management of patients with these severe manifesta­tions of [venous thromboembolism],” said the writing committee, cochaired by Dr. Michael R. Jaff and Dr. M. Sean McMurtry (Circulation 2011 Mar. 21 [doi:10.1161/CIR.0b013e318214914f]).« http://www.theheart.org/article/1200965.do»

<[stk -1]>In an interview, Dr. McMurtry noted that because these disease areas have less data to support manage­ment strategies than do other areas of cardiovascular medicine, most of the recommendations in the docu­ment are class II (“it is reasonable” or “may be consid­ered”) with level of evidence B or C (limited populations evaluated). “The authors hope that this document will inspire more research into these conditions,” said Dr. McMurtry of the University of Alberta, Edmonton.<[etk]>

<[stk -3]>The document begins by defining “massive,” “sub­massive,” and “low-risk” pulmonary embolism (PE), and provides data for the various techniques used to identify patients at increased risk for adverse short-term outcomes in acute PE. <[etk]>

Beyond initial heparin anticoagulation therapy, the use of fibrinolytic drugs is reasonable for patients with massive acute PE and an acceptable risk of bleeding complications, the statement said. It may also be con­sidered for patients with submassive acute PE judged to have clinical evidence of an adverse prognosis (new hemodynamic instability, worsening respiratory insuf­ficiency, severe right ventricle [RV] dysfunction, or major myocardial necrosis) and a low risk of bleeding.

Fibrinolysis is not recommended for patients with low-risk PE, or submassive PE with minor RV dys­function, minor myocardial necrosis, and no clinical worsening. Fibrinolysis is also not recommended for undifferentiated cardiac arrest, wrote Dr. McMurtry and Dr. Jaff of Harvard Medical School, and coauthors.

In addition, recommendations are provided for oth­er areas in which data are sparse and optimal manage­ment is unclear, including catheter-based therapies. Transcatheter procedures can be performed as an al­ternative to thrombolysis when there are contraindi­cations or when emergency surgical thrombectomy is unavailable or contraindicated. Catheter interventions can also be performed when thrombolysis has failed to improve hemodynamics in the acute setting.

Hybrid therapy that includes both catheter-based clot fragmentation and local thrombolysis is an emerging strategy, the committee noted.

Adult patients with any confirmed acute PE who have contraindications to anticoagulation or have active bleeding should receive an inferior vena cava (IVC) fil­ter. Further specific guidance is given for the type of fil­ter and for monitoring.

<[stk -1]>Iliofemoral Deep Vein Thrombosis (IVDVT) refers to complete or partial thrombosis of any part of the iliac vein or the common femoral vein, with or without in­volvement of other lower-extremity veins or the IVC. Under this heading, the document addresses the use of initial coagulant therapy, long-term anticoagulant ther­apy, compression therapy, IVC filters, and thrombore­ductive strategies, including systemic, catheter-directed, percutaneous mechanical, and pharmacomechanical thrombolysis. Surgical venous thrombectomy is also dis­cussed as an alternative method of thrombus removal. <[etk]>

«qc'er: pls fact check these next 2 grafs»<[stk -2]>“Reasonable” angiopathy and stenting options for older adolescents and adults include the use of percuta­neous transluminal venous angioplasty and stent place­ment in the iliac vein to treat obstructive lesions after catheter-directed thrombolysis (CDT), pharmacome­chanical CDT (PCDT), or surgical venous thrombecto­my, and placement of iliac vein stents to reduce postthrombotic symptoms and heal venous ulcers in pa­tients with advanced postthrombotic symptoms and il­iac vein obstruction. “For obstructive iliac vein lesions that extend into the common femoral vein, caudal ex­tension of stents into the common femoral vein is rea­sonable if unavoidable.” Guidelines regarding subsequent therapeutic anticoagulation are also provided. <[etk]>

The authors noted that “the use of percutaneous transluminal venous angioplasty in children may be rea­sonable, but this practice has not been well studied and may be associated with a greater risk of vasospasm.”

The section on chronic thromboembolic pulmonary hypertension (CTEPH) outlines the classification, risk factors, clinical presentation, diagnosis, and treatment with pulmonary endarterectomy and medical therapies. The condition is a syndrome of dyspnea, fatigue, and exercise intolerance caused by proximal thromboem­bolic obstruction and distal remodeling of the pul­monary circulation that leads to elevated pulmonary artery pressure and progressive RV failure.

Patients with unexplained dyspnea, exercise intoler­ance, or clinical evidence of right-sided heart failure, with or without a prior history of symptomatic venous thromboembolism, should be evaluated for CTEPH, and it is reasonable to evaluate patients with an echocar­diogram 6 weeks after an acute pulmonary embolism to screen for persistent pulmonary hypertension that may predict the development of CTEPH.

Patients with objectively proven CTEPH should be promptly evaluated for pulmonary endarterectomy, even if symptoms are mild, and receive indefinite ther­apeutic anticoagulation in the absence of contraindi­cations, they advised.

I have checked the following facts in my story: (Please initial each.)

 lf MET    drug names and dosages -

 lf MET    lab test values and their units -

lf MET     whether nos. are correct and add up, and whether percentages based on those nos. are correct -

lf MET     citation (e.g., JAMA 2008;299:785-92) -

 lf MET    investigators’ names and affiliations -

 lf MET     all other proper names (e.g., clinical trials; geographic, company, and test names) –..

 lf MET    investigators' conflicts of interest and sponsor of study – 

Dr. McMurtry reported no relavant disclosures.

********* UNDERSET  1  LINES *********

A scientific statement from the American Heart As­sociation provides guidance for the management of the more severe forms of venous thromboembolism.

The statement focuses on three areas: massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pul­monary hypertension. “The goal is to provide practi­cal advice to enable the busy clinician to optimize the management of patients with these severe manifesta­tions of [venous thromboembolism],” said the writing committee, cochaired by Dr. Michael R. Jaff and Dr. M. Sean McMurtry (Circulation 2011 Mar. 21 [doi:10.1161/CIR.0b013e318214914f]).« http://www.theheart.org/article/1200965.do»

<[stk -1]>In an interview, Dr. McMurtry noted that because these disease areas have less data to support manage­ment strategies than do other areas of cardiovascular medicine, most of the recommendations in the docu­ment are class II (“it is reasonable” or “may be consid­ered”) with level of evidence B or C (limited populations evaluated). “The authors hope that this document will inspire more research into these conditions,” said Dr. McMurtry of the University of Alberta, Edmonton.<[etk]>

<[stk -3]>The document begins by defining “massive,” “sub­massive,” and “low-risk” pulmonary embolism (PE), and provides data for the various techniques used to identify patients at increased risk for adverse short-term outcomes in acute PE. <[etk]>

Beyond initial heparin anticoagulation therapy, the use of fibrinolytic drugs is reasonable for patients with massive acute PE and an acceptable risk of bleeding complications, the statement said. It may also be con­sidered for patients with submassive acute PE judged to have clinical evidence of an adverse prognosis (new hemodynamic instability, worsening respiratory insuf­ficiency, severe right ventricle [RV] dysfunction, or major myocardial necrosis) and a low risk of bleeding.

Fibrinolysis is not recommended for patients with low-risk PE, or submassive PE with minor RV dys­function, minor myocardial necrosis, and no clinical worsening. Fibrinolysis is also not recommended for undifferentiated cardiac arrest, wrote Dr. McMurtry and Dr. Jaff of Harvard Medical School, and coauthors.

In addition, recommendations are provided for oth­er areas in which data are sparse and optimal manage­ment is unclear, including catheter-based therapies. Transcatheter procedures can be performed as an al­ternative to thrombolysis when there are contraindi­cations or when emergency surgical thrombectomy is unavailable or contraindicated. Catheter interventions can also be performed when thrombolysis has failed to improve hemodynamics in the acute setting.

Hybrid therapy that includes both catheter-based clot fragmentation and local thrombolysis is an emerging strategy, the committee noted.

Adult patients with any confirmed acute PE who have contraindications to anticoagulation or have active bleeding should receive an inferior vena cava (IVC) fil­ter. Further specific guidance is given for the type of fil­ter and for monitoring.

<[stk -1]>Iliofemoral Deep Vein Thrombosis (IVDVT) refers to complete or partial thrombosis of any part of the iliac vein or the common femoral vein, with or without in­volvement of other lower-extremity veins or the IVC. Under this heading, the document addresses the use of initial coagulant therapy, long-term anticoagulant ther­apy, compression therapy, IVC filters, and thrombore­ductive strategies, including systemic, catheter-directed, percutaneous mechanical, and pharmacomechanical thrombolysis. Surgical venous thrombectomy is also dis­cussed as an alternative method of thrombus removal. <[etk]>

«qc'er: pls fact check these next 2 grafs»<[stk -2]>“Reasonable” angiopathy and stenting options for older adolescents and adults include the use of percuta­neous transluminal venous angioplasty and stent place­ment in the iliac vein to treat obstructive lesions after catheter-directed thrombolysis (CDT), pharmacome­chanical CDT (PCDT), or surgical venous thrombecto­my, and placement of iliac vein stents to reduce postthrombotic symptoms and heal venous ulcers in pa­tients with advanced postthrombotic symptoms and il­iac vein obstruction. “For obstructive iliac vein lesions that extend into the common femoral vein, caudal ex­tension of stents into the common femoral vein is rea­sonable if unavoidable.” Guidelines regarding subsequent therapeutic anticoagulation are also provided. <[etk]>

The authors noted that “the use of percutaneous transluminal venous angioplasty in children may be rea­sonable, but this practice has not been well studied and may be associated with a greater risk of vasospasm.”

The section on chronic thromboembolic pulmonary hypertension (CTEPH) outlines the classification, risk factors, clinical presentation, diagnosis, and treatment with pulmonary endarterectomy and medical therapies. The condition is a syndrome of dyspnea, fatigue, and exercise intolerance caused by proximal thromboem­bolic obstruction and distal remodeling of the pul­monary circulation that leads to elevated pulmonary artery pressure and progressive RV failure.

Patients with unexplained dyspnea, exercise intoler­ance, or clinical evidence of right-sided heart failure, with or without a prior history of symptomatic venous thromboembolism, should be evaluated for CTEPH, and it is reasonable to evaluate patients with an echocar­diogram 6 weeks after an acute pulmonary embolism to screen for persistent pulmonary hypertension that may predict the development of CTEPH.

Patients with objectively proven CTEPH should be promptly evaluated for pulmonary endarterectomy, even if symptoms are mild, and receive indefinite ther­apeutic anticoagulation in the absence of contraindi­cations, they advised.

I have checked the following facts in my story: (Please initial each.)

 lf MET    drug names and dosages -

 lf MET    lab test values and their units -

lf MET     whether nos. are correct and add up, and whether percentages based on those nos. are correct -

lf MET     citation (e.g., JAMA 2008;299:785-92) -

 lf MET    investigators’ names and affiliations -

 lf MET     all other proper names (e.g., clinical trials; geographic, company, and test names) –..

 lf MET    investigators' conflicts of interest and sponsor of study – 

Dr. McMurtry reported no relavant disclosures.

********* UNDERSET  1  LINES *********

A scientific statement from the American Heart As­sociation provides guidance for the management of the more severe forms of venous thromboembolism.

The statement focuses on three areas: massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pul­monary hypertension. “The goal is to provide practi­cal advice to enable the busy clinician to optimize the management of patients with these severe manifesta­tions of [venous thromboembolism],” said the writing committee, cochaired by Dr. Michael R. Jaff and Dr. M. Sean McMurtry (Circulation 2011 Mar. 21 [doi:10.1161/CIR.0b013e318214914f]).« http://www.theheart.org/article/1200965.do»

<[stk -1]>In an interview, Dr. McMurtry noted that because these disease areas have less data to support manage­ment strategies than do other areas of cardiovascular medicine, most of the recommendations in the docu­ment are class II (“it is reasonable” or “may be consid­ered”) with level of evidence B or C (limited populations evaluated). “The authors hope that this document will inspire more research into these conditions,” said Dr. McMurtry of the University of Alberta, Edmonton.<[etk]>

<[stk -3]>The document begins by defining “massive,” “sub­massive,” and “low-risk” pulmonary embolism (PE), and provides data for the various techniques used to identify patients at increased risk for adverse short-term outcomes in acute PE. <[etk]>

Beyond initial heparin anticoagulation therapy, the use of fibrinolytic drugs is reasonable for patients with massive acute PE and an acceptable risk of bleeding complications, the statement said. It may also be con­sidered for patients with submassive acute PE judged to have clinical evidence of an adverse prognosis (new hemodynamic instability, worsening respiratory insuf­ficiency, severe right ventricle [RV] dysfunction, or major myocardial necrosis) and a low risk of bleeding.

Fibrinolysis is not recommended for patients with low-risk PE, or submassive PE with minor RV dys­function, minor myocardial necrosis, and no clinical worsening. Fibrinolysis is also not recommended for undifferentiated cardiac arrest, wrote Dr. McMurtry and Dr. Jaff of Harvard Medical School, and coauthors.

In addition, recommendations are provided for oth­er areas in which data are sparse and optimal manage­ment is unclear, including catheter-based therapies. Transcatheter procedures can be performed as an al­ternative to thrombolysis when there are contraindi­cations or when emergency surgical thrombectomy is unavailable or contraindicated. Catheter interventions can also be performed when thrombolysis has failed to improve hemodynamics in the acute setting.

Hybrid therapy that includes both catheter-based clot fragmentation and local thrombolysis is an emerging strategy, the committee noted.

Adult patients with any confirmed acute PE who have contraindications to anticoagulation or have active bleeding should receive an inferior vena cava (IVC) fil­ter. Further specific guidance is given for the type of fil­ter and for monitoring.

<[stk -1]>Iliofemoral Deep Vein Thrombosis (IVDVT) refers to complete or partial thrombosis of any part of the iliac vein or the common femoral vein, with or without in­volvement of other lower-extremity veins or the IVC. Under this heading, the document addresses the use of initial coagulant therapy, long-term anticoagulant ther­apy, compression therapy, IVC filters, and thrombore­ductive strategies, including systemic, catheter-directed, percutaneous mechanical, and pharmacomechanical thrombolysis. Surgical venous thrombectomy is also dis­cussed as an alternative method of thrombus removal. <[etk]>

«qc'er: pls fact check these next 2 grafs»<[stk -2]>“Reasonable” angiopathy and stenting options for older adolescents and adults include the use of percuta­neous transluminal venous angioplasty and stent place­ment in the iliac vein to treat obstructive lesions after catheter-directed thrombolysis (CDT), pharmacome­chanical CDT (PCDT), or surgical venous thrombecto­my, and placement of iliac vein stents to reduce postthrombotic symptoms and heal venous ulcers in pa­tients with advanced postthrombotic symptoms and il­iac vein obstruction. “For obstructive iliac vein lesions that extend into the common femoral vein, caudal ex­tension of stents into the common femoral vein is rea­sonable if unavoidable.” Guidelines regarding subsequent therapeutic anticoagulation are also provided. <[etk]>

The authors noted that “the use of percutaneous transluminal venous angioplasty in children may be rea­sonable, but this practice has not been well studied and may be associated with a greater risk of vasospasm.”

The section on chronic thromboembolic pulmonary hypertension (CTEPH) outlines the classification, risk factors, clinical presentation, diagnosis, and treatment with pulmonary endarterectomy and medical therapies. The condition is a syndrome of dyspnea, fatigue, and exercise intolerance caused by proximal thromboem­bolic obstruction and distal remodeling of the pul­monary circulation that leads to elevated pulmonary artery pressure and progressive RV failure.

Patients with unexplained dyspnea, exercise intoler­ance, or clinical evidence of right-sided heart failure, with or without a prior history of symptomatic venous thromboembolism, should be evaluated for CTEPH, and it is reasonable to evaluate patients with an echocar­diogram 6 weeks after an acute pulmonary embolism to screen for persistent pulmonary hypertension that may predict the development of CTEPH.

Patients with objectively proven CTEPH should be promptly evaluated for pulmonary endarterectomy, even if symptoms are mild, and receive indefinite ther­apeutic anticoagulation in the absence of contraindi­cations, they advised.

I have checked the following facts in my story: (Please initial each.)

 lf MET    drug names and dosages -

 lf MET    lab test values and their units -

lf MET     whether nos. are correct and add up, and whether percentages based on those nos. are correct -

lf MET     citation (e.g., JAMA 2008;299:785-92) -

 lf MET    investigators’ names and affiliations -

 lf MET     all other proper names (e.g., clinical trials; geographic, company, and test names) –..

 lf MET    investigators' conflicts of interest and sponsor of study – 

Dr. McMurtry reported no relavant disclosures.

********* UNDERSET  1  LINES *********