Da li bi trebalo terapiju antagonistima vitamina K otpočeti prvog dana kod bolesnika sa plućnom embolijom koji nemaju visok rizik?
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.
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.