Sažetak
Uvod. Protokoli i smernice poboljšavaju rezultate naše kliničke prakse. Ponekad postoje razlike između preporuka o istoj temi, ali obično te razlike nisu toliko važne. U vezi sa početkom primene antagonista vitamina K (VKA) kod bolesnika sa plućnom tromboembolijom (PTE), postoji globalni konsenzus (prisutan u svim savremenim smernicama) da bi to trebalo da bude na dan prijema ili dan kasnije. Međutim, postoje situacije u kojima davanje VKA od prvog (ili drugog) dana hospitalizacije može, zapravo, komplikovati tretman. Prikaz bolesnika. Kao ilustracija, naša 71-godišnja bolesnica, sa drugom neprovociranom PTE srednjeg rizika, je dobila heparin male molekulske težine (LMVH) + VKA od drugog dana hospitalizacije. Zbog izostanka poboljšanja simptoma, saturacije kiseonikom i D dimera nakon 9 dana, kompjuterizovana tomografski pulmonarna angiografija (CTPA) je ponovljena i nalaz je potvrdio minimalan napredak. Bolesnica je već postigla ciljni internacionalni normalizovani odnos (INR) i to je komplikovalo prelazak na fibrinolitičku terapiju. Zaključak. Korekcija terapijskog pristupa u lečenju PTE može biti potrebna čak i kad se lečenje sprovodi u skladu sa savremenim preporukama. Predlaže se odlaganje primene VKA od prvog (ili drugog) dana hospitalizacije (kao što se preporučuje u svim raspoloživim vodičima za bolesnike sa PTE koji nisu na visokom riziku), dok se ne postigne kliničko poboljšanje.
Ključne reči
Array
Array
Array
Array
Reference
Becattini C, Agnelli G, Lankeit M, Masotti L, Pruszczyk P, Casaz-za F, et al. Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model. Eur Respir J 2016; 48(3): 780‒6
Sista AK, Klok FA. Late outcomes of pulmonary embolism: The post-PE syndrome. Thromb Res 2018; 164: 157‒62.
Konstantinides SV, Barco S. Prevention of early complications and late consequences after acute pulmonary embolism: Focus on reperfusion techniques. Thromb Res 2018; 164: 163‒9
Bova C, Sanchez O, Prandoni P, Lankeit M, Konstantinides S, Van-ni S, et al. Identification of intermediate-risk patients with acute symptomatic pulmonary embolism. Eur Respir J 2014; 44(3): 694‒703.
Hobohm L, Hellenkamp K, Hasenfuß G, Münzel T, Konstantinides S, Lankeit M. Comparison of risk assessment strategies for not-high-risk pulmonary embolism. Eur Respir J 2016; 47(4): 1170‒8.
Goldhaber SZ. Thrombolytic therapy for patients with pulmo-nary embolism who are hemodynamically stable but have right ventricular dysfunction: pro. Arch Intern Med 2005; 165(19): 2197‒9.
Martin C, Sobolewski K, Bridgeman P, Boutsikaris D. Systemic Thrombolysis for Pulmonary Embolism: A Review. P T 2016; 41(12): 770‒5.
NICE pathways. Treating venous thromboembolism. 2016. Available from: http://pathways.nice.org.uk/pathways/venous-thromboembolism on 2/11/2018.
Streiff MB, Agnelli G, Connors JM, Crowther M, Eichinger S, Lopes R, et al. Guidance for the treatment of deep vein thrombosis and pulmonary embolism. J Thromb Thrombolysis 2016; 41(1): 32‒67.
Arepally GM. Heparin-induced thrombocytopenia. Blood 2017; 129(21): 2864‒72.
Kosuge M, Ebina T, Hibi K, Tsukahara K, Iwahashi N, Gohbara M, et al. Differences in negative T waves among acute coro-nary syndrome, acute pulmonary embolism, and Takotsubo cardiomyopathy. Eur Heart J Acute Cardiovasc Care 2012; 1(4): 349‒57.
Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, et al. American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscita-tion; American Heart Association Council on Peripheral Vas-cular Disease; American Heart Association Council on Arteri-osclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmo-nary hypertension: a scientific statement from the American Heart Association. Circulation 2011; 123(16): 1788‒830.
Daniel MW, Nathan PC, Scott K, Terri S, Jack EA. Guidance for the practical management of warfarin therapy in the treatment of venous thromboembolism. J Thromb Thrombolysis 2016; 41: 187–205.
Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, et al. Task Force for the Diagnosis and Manage-ment of Acute Pulmonary Embolism of the European Society of Cardiology. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35(43): 3033‒69.
Kaczyńska A, Kostrubiec M, Pacho R, Kunikowska J, Pruszczyk P. Elevated D-dimer concentration identifies patients with in-complete recanalization of pulmonary artery thromboemboli despite 6 months anticoagulation after the first episode of acute pulmonary embolism. Thromb Res 2008; 122(1): 21‒5.
Klein A, Shepshelovich D, Spectre G, Goldvaser H, Raanani P, Gafter-Gvili A. Screening for occult cancer in idiopathic ve-nous thromboembolism - Systemic review and meta-analysis. Eur J Intern Med 2017; 42: 74‒80.
Jara-Palomares L, Otero R, Jimenez D, Carrier M, Tzoran I, Bren-ner B, et al. RIETE Investigators. Development of a Risk Pre-diction Score for Occult Cancer in Patients With VTE. Chest 2017; 151(3): 564‒71.
Khorana AA, Carrier M, Garcia DA, Lee AY. Guidance for the prevention and treatment of cancer-associated venous throm-boembolism. J Thromb Thrombolysis 2016; 41(1): 81‒91.
Ensor J, Riley RD, Moore D, Snell KI, Bayliss S, Fitzmaurice D. Systematic review of prognostic models for recurrent venous thromboembolism (VTE) post-treatment of first unprovoked VTE. BMJ Open 2016; 6(5): e011190.
Eichinger S, Heinze G, Jandeck LM, Kyrle PA. Risk assessment of recurrence in patients with unprovoked deep vein throm-bosis or pulmonary embolism: the Vienna prediction model. Circulation 2010; 121(14): 1630–6.
van Es N, Wells PS, Carrier M. Bleeding risk in patients with unprovoked venous thromboembolism: A critical appraisal of clinical prediction scores. Thromb Res 2017; 152: 52‒60.
Wells PS, Forgie MA, Simms M, Greene A, Touchie D, Lewis G, et al. The Outpatient Bleeding Risk Index: validation of a tool for predicting bleeding rates in patients treated for deep ve-nous thrombosis and pulmonary embolism. Arch Intern Med 2003; 163(8): 917–20.
Long B, Koyfman A. Best Clinical Practice: Controversies in Outpatient Management of Acute Pulmonary Embolism. J Emerg Med 2017; 52(5): 668‒79.
Obradović S, Džudović B, Rusović S, Vraneš D, Subotić B, Ratković N, et al. Strategy of pulmonary thromboembolism treatment. Srce i krvni sudovi 2016; 35(51): 37‒9. (Serbian)
Mohsen S, Curt B, Laura S, Farnoosh R, Mahshid M. “MOPETT” Investigators Moderate Pulmonary Embolism Treated With Thrombolysis (from the “MOPETT” Trial). Am J Cardiol 2013; 111(2): 273‒7.
Wang C, Zhai Z, Yang Y, Wu Q, Cheng Z, Liang L, et al. China Venous Thromboembolism (VTE) Study Group. Efficacy and safety of low dose recombinant tissue-type plasminogen acti-vator for the treatment of acute pulmonary thromboembo-lism: a randomized, multicenter, controlled trial. Chest 2010; 137(2): 254‒62.
Sharifi, M, Bay C, Schwartz F, Skrocki L. Safe-Dose Thrombo-lysis Plus Rivaroxaban for Moderate and Severe Pulmonary Embolism: Drip, Drug, and Discharge. Clin Cardiol 2014; 37(2): 78–82.
Koracevic GP. Time to individualize duration of parenteral anti-coagulation in pulmonary thromboembolism? Am J Emerg Med 2012; 30(6): 1004‒6.