SeminarPulmonary embolism and deep vein thrombosis
Introduction
Deep vein thrombosis and pulmonary embolism constitute venous thromboembolism. Deep vein thrombosis occurs most often in the legs, but can form in the veins of the arms,1 and in the mesenteric and cerebral veins. We focus on deep vein thrombosis of the legs and pulmonary embolism. Although these disorders are part of the same syndrome, important differences in epidemiology, diagnosis, and treatment exist between them.
Section snippets
Epidemiology
In population-based studies, no consensus exists about whether the incidence of venous thromboembolism varies according to sex. In a Norwegian study,2 the incidence of all first events of venous thromboembolism was 1·43 per 1000 person-years, and was slightly higher in women than in men. In a Swedish study,3 incidence was equal for both sexes. In a community-based study,4 incidence was higher for men than for women (1·14 per 1000 patient-years vs 1·05 per 1000 patient years). In the
Clinical probability assessment
Diagnosis of deep vein thrombosis and pulmonary embolism is dependent on several, mainly non-invasive, diagnostic techniques that should be used sequentially. Because use of a validated diagnostic work-up is associated with a substantially diminished risk of complications,27 implementation of such standardised approaches is highly recommended. Massive pulmonary embolism should be diagnosed quickly; its clinical features include shock or haemodynamic instability. Clinical probability assessment
Prognostic stratification of patients with pulmonary embolism
Patients with pulmonary embolism should be stratified according to prognosis.54 The Pulmonary Embolism Severity Index55 and its simplified version56 allow such stratification on a clinical basis (table 3). Several therapeutic implications exist for patients with pulmonary embolism: (1) high-risk patients (who represent about 5% of all symptomatic patients, with about a 15% short-term mortality) should be treated aggressively with thrombolytic drugs or surgical or catheter embolectomy;57 (2)
Prevention
Findings from rigorous clinical trials have shown the effectiveness and safety of pharmacological prevention with low, fixed doses of anticoagulant drugs (panel 2). For patients undergoing orthopaedic surgery—eg, total hip or knee replacement—novel oral anticoagulant drugs have been approved for thromboprophylaxis and are available instead of warfarin, heparins, and fondaparinux. Mechanical prophylactic measures, including graduated compression stockings and intermittent pneumatic compression
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