Pulmonary embolism treatment

It is indicated in the prophylaxis and treatment of deep vein thrombosis in major surgery and pulmonary embolism, treatment of atrial fibrillation with embolisation, prophylaxis and treatment of peripheral arterial embolism. 

Thrombolytic Enzymes. Although atherosclerosis and the accompanying vascular wall defects are ultimately responsible for such diseases as acute pulmonary embolism, arterial occlusion, and myocardial infarction, the lack of blood flow caused by a fibrin clot directly results in tissue injury and in the clinical symptoms of these devastating diseases (54). Thrombolytic enzyme therapy removes the fibrin clot by dissolution, and has shown promise in the treatment of a number of thrombo-occlusive diseases (60). 

Indications for treatment with streptokinase include acute occlusion of arteries, deep vein thrombosis, and pulmonary embolism. Streptokinase therapy in coronary thrombosis, which is the usual cause of myocardial infarction (54,71,72), has proved to be valuable. In this frequently fatal condition, the enzyme is adrninistered intravenously at a dose of 1.5 million units over 60 min, or given by intracoronary infusion at a 20,000- to 50,000-unit bolus dose followed by 2000 to 4000 units/min for 60 min therapy must be instituted as soon as practicable after the diagnosis of heart attack is made. For deep vein thrombosis, pulmonary embolism, or arterial occlusion, streptokinase is infused at a loading dose of 250,000 units given over 30 min, followed by a maintenance dose of 100,000 units over a 60-min period. 

Therapeutically t-PA and urokinase are the most important drugs for fibrinolytic therapy (myocardial infarction, stroke, massive pulmonary embolism). This treatment is associated with an enhanced risk of bleeding complications. 

Streptokinase is administered by intravenous or intra-arterial infusion in the treatment of thrombo-embolic disorders, e g. pulmonary embolism, deep-vein thrombosis and arterial occlusiorrs. It is also used in acute myocardial irtfarclioa... 

In stroke patients presenting to the ED, the first goal of treatment is immediate cardiac and respiratory stabilization. The systemic blood pressure is most often elevated in the setting of an acute stroke as the result of a catecholamine surge, and if the patient is hypotensive, the clinician should consider a concomitant cardiac process, such as myocardial infarction (MI), congestive heart failure (CHF), or pulmonary embolism (PE). 

Pulmonary embolism most commonly develops in patients with risk factors for VTE (Table 7-2) during or following a hospitalization. While many patients will have symptoms of DVT prior to developing a PE, many do not. Patients may die suddenly before effective treatment can be initiated. 

FIGURE 7-11. Treatment of venous thromboembolism. LMWH, low-molecular-weight heparin PE, pulmonary embolism SBP, systolic blood pressure UFH, unfractionated heparin VTE, venous thromboembolism. (Reproduced from Haines ST, Zeolla M, Witt DM. Venous thromboembolism. In DiPiro JT, Talbert RL, Yee GC, et al, (eds.) Pharmacotherapy A Pathophysiologic Approach. 6th ed. New York McGraw-Hill 2005 398, with permission.)... 

FIGURE 14-2. Treatment of venous thromboembolism (VTE). (LMWH, low-molecular-weight heparin PE, pulmonary embolism SBP, systolic blood pressure UFH, unfractionated heparin.)... 

Tamoxifen users present also a doubling incidence of deep venous thrombosis (DVT) and pulmonary embolism (PE) (118 vs. 62 cases). This increase is similar to that seen with HRT. There are some aspects of this side effect that should be commented on to improve the management of women eligible for tamoxifen treatment and at risk for DVT (Goldhaber 2005). In the subanalysis of the Italian study (Decensi et al. 2005), the venous thromboembolism definition included DVT, PE, and superficial phlebitis. Most of the VTE that the authors reported were, in fact, cases of superficial phlebitis, whereas the admitted definition of venous thromboembolism excludes this entity. Such conceptual differences, together with differences in age and background characteristics between the four studies, can explain the diversity in the incidences observed. 

In CEA, the total cost and the total benefits, measured in terms of an efficacy parameter, associated with two or more treatment pathways are added, and the increment is calculated. The incremental costs are then compared (in a ratio) with incremental outcomes (as measured in physical or natural emits). Physical and natural units can include both intermediate (surrogate) clinical endpoints (e.g. millimetres of mercury blood pressure reduction, changes in FEVi) or final endpoints (e.g. deaths averted or life-years gained). In a study that assessed the cost per deaths due to pulmonary embolism averted, Hull and associates reported that subcutaneous administration of... 

Prophylaxis and treatment Prophylaxis and treatment of venous thrombosis and its extension pulmonary embolism peripheral arterial embolism atrial fibrillation with embolization. 

Fondaparinux is a synthetic pentasaccharide. It is used for the prevention of deep vein thrombosis in patients who have had orthopedic surgery as well as for the treatment of deep vein thrombosis and pulmonary embolism. 

Treatment of venous thrombosis, pulmonary embolism, peripheral arterial embolism, atrial fibrillation with embolism Intermittently Initially, 10,000 units, then 50-70 units/kg (5000-10,000 units) q4 6h. IV Infusion Loading dose 80 units/kg, then 18 units/kg/hr, with adjustments based on aPTT. Range 10-30 units/kg/hr. 

Contraindications Concomitant coumarin-type therapy when used in the treatment of breast cancer in high-risk women, history of deep vein thrombosis or pulmonary embolism in high-risk women... 

Another example of a serious adverse effect that can surface through close systematic monitoring is the association of clozapine treatment with venous thromboembolytic complications (514, 515). Six cases of pulmonary embolism and six cases of venous thrombosis were reported to the Swedish Adverse-Reaction... 

Pulmonary embolism Approximately 12 hours after an ECT treatment, a patient became hypotensive and later died of a suspected pulmonary embolism. 

The goal in the treatment of deep venous thrombosis and pulmonary embolism is the prevention of recurrent, fatal embolism. 

Fondaparinux is a chemically synthesized pentasaccharide that mimics the antithrombin-binding site of heparin and LMWH. Its molecular size (1728Da) is too small to bind to thrombin molecules while it is bound to antithrombin, Therefore, it is a pure anti-Xa inhibitor. It binds very little to platelets, proteins, or endothelium and is excreted in the urine, It does not form a complex with PF4 or other positively charged molecules. It is not neutralizable by protamine sulfate, Recent clinical trials have resulted in FDA approval for prophylaxis of deep vein thrombosis in orthopedic surgery, It has been shown to be effective and safe for the treatment of pulmonary embolism (20,21) and ACS (non-ST-elevation Ml) (OASIS 5—Michelangelo Trial) (17). 

Barritt DW, Jordan SC. Anticoagulant drugs in the treatment of pulmonary embolism. A controlled trial. Lancet I960 I 1309- 1312. 

The Matisse Investigators. Subcutaneous fondaparinux versus intravenous unfractionated heparin in the initial treatment of pulmonary embolism. N EnglJ Med 2003 349 1695-1702. 

UFH anticoagulation is routinely used during vascular and cardiac surgery, for the prophylaxis and treatment of DVT for the prevention of pulmonary embolism in surgical patients, and in patients with atrial fibrillation and recent embolization (6). 

Urokinase is intended for intravenous use only and indicated for the treatment of pulmonary embolism, coronary artery thrombosis, and intravenous catheter clearance. Typical dosages in peripheral arterial disease consist of an infusion at a rate ranging from 60,000 lU/hr to 240,000 lU/hr infused directly into the thrombus. 

Alteplase was the first commercially available recombinant tissue-type plasminogen activator (rt-PA) (25), It has a plasma half-life of less than five minutes and is metabolized by the liver, This agent was initially hailed as fibrin-specific unlike its precursors (urokinase and streptokinase). It was thought that this would result in a better safety profile, but this has not been born out in either the coronary or the peripheral experience, where actually there may be a higher bleeding risk as infusion time increases. Alteplase is currently indicated for use in the treatment of myocardial infarction, acute ischemic stroke, and pulmonary embolism. 

Goldhaber SZ, Kessler CM, Heit J, et al. Randomized controlled trial of recombinant tissue plasminogen activator versus urokinase in the treatment of acute pulmonary embolism. Lancet 1988 2 293-298. 

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