Time trends in warfarin-associated hemorrhage.

The annual incidence of warfarin-related bleeding at Brigham and Women's Hospital increased from 0.97/1,000 patient admissions in the first time period (January 1995 to October 1998) to 1.19/1,000 patient admissions in the second time period (November 1998 to August 2002) of this study.

Clinically unrecognized Q-wave myocardial infarction in patients with diabetes mellitus, systemic hypertension, and nephropathy.

During the Irbesartan Diabetic Nephropathy Trial, 1,387 participants with type 2 diabetes mellitus, hypertension, and nephropathy underwent serial electrocardiograms for the identification of Q-wave myocardial infarction (MI). During a mean follow-up of 2.5 years, 14 of 99 first nonfatal MIs in this group were clinically unrecognized, accounting for 14% of all first nonfatal MIs.

Thrombolytic therapy in pulmonary embolism.

Successfully utilized contemporary pulmonary embolism (PE) thrombolysis reverses right heart failure rapidly and safely. This therapeutic approach may lower mortality from PE and reduce morbidity from chronic pulmonary hypertension. PE thrombolysis remains a debatable indication because large clinical trials using survival as an endpoint have not been carried out.

Epidemiology of pulmonary embolism.

The diagnosis of venous thromboembolism (VTE) has notoriously been challenging because the disease often has no specific clinical presentation, can at times be completely asymptomatic, and can masquerade as other illnesses. To further complicate matters, the rules for coding VTE in the presence of other illnesses changed in 1983 so that among patients who died of VTE and other causes, VTE was omitted from the coding. The International Cooperative Pulmonary Embolism Registry enrolled 2454 consecutive pulmonary embolism (PE) patients from 52 participating hospitals in 7 countries.

Warfarin dosing and cytochrome P450 2C9 polymorphisms.

Two cytochrome P450 2C9 (CYP2C9) polymorphisms, CYP2C9*2 and *3, metabolize warfarin inefficiently. We assessed the extent to which these polymorphisms explain very low warfarin dose requirements and hemorrhagic complications after excluding non-genetic determinants of warfarin dosing. In this retrospective observational study, 73 patients with stable warfarin doses for > or =1 month and International Normalized Ratios (INR) of 2.

Right ventricular enlargement on chest computed tomography: prognostic role in acute pulmonary embolism.

Background: We investigated the prognostic role of right ventricular enlargement on multidetector-row chest CT in acute pulmonary embolism (PE).

Methods And Results: We studied 63 patients with CT-confirmed PE who underwent echocardiography within the ensuing 24 hours. Adverse clinical events, defined as 30-day mortality or the need for cardiopulmonary resuscitation, mechanical ventilation, pressors, rescue thrombolysis, or surgical embolectomy, were present in 24 patients.

Spiral computed tomography for acute pulmonary embolism.

There is still considerable debate about the optimal diagnostic imaging modality for acute pulmonary embolism. If imaging is deemed necessary from an initial clinical evaluation such as d-dimer testing, options include nuclear medicine scanning, catheter pulmonary angiography, and spiral CT. In many institutions, spiral CT is becoming established as the first-line imaging test in daily clinical practice.

Pulmonary embolism.

Pulmonary embolism (PE) is a common illness that can cause death and disability. It is difficult to detect because patients present with a wide array of symptoms and signs. The clinical setting can raise suspicion, and certain inherited and acquired risk factors predispose susceptible individuals.

Cost analysis of "bridging therapy" with low-molecular-weight heparin versus unfractionated heparin during temporary interruption of chronic anticoagulation.

Patients on long-term anticoagulation who require interruption of therapy for surgery may receive "bridging therapy" with continuous-infusion unfractionated heparin or low-molecular-weight heparin (LMWH). We estimated the costs of bridging therapy with: (1) LMWH self-administered at home, (2) LMWH administered by a nurse to patients at home, and (3) continuous-infusion unfractionated heparin in the hospital. For surgeries requiring an overnight stay, bridging costs are estimated to be 672, 933, and 3,816 US dollars, respectively, for each of these strategies.

DVT Prevention: what is happening in the "real world"?

Pulmonary embolism (PE) and deep venous thrombosis (DVT) remain major problems in medicine that receive less attention from healthcare professionals and the public than either coronary artery disease or acute myocardial infarction. Furthermore, strategies proven to minimize the frequency of PE and DVT are not widely employed on a consistent and effective basis. The problem is widespread and affects patients in acute care hospitals, rehabilitation hospitals, and skilled nursing facilities, as well as high-risk individuals at home.

A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis.

We enrolled 5,451 patients with ultrasound-confirmed deep vein thrombosis (DVT), including 2,892 women and 2,559 men, from 183 United States sites in our prospective registry. The 5 most frequent co-morbidities were hypertension (50%), surgery within 3 months (38%), immobility within 30 days (34%), cancer (32%), and obesity (27%). Of the 2,726 patients who had their DVT diagnosed while in the hospital, only 1,147 (42%) received prophylaxis within 30 days before diagnosis.

Comparison of efficacy, safety, and cost of low-molecular-weight heparin with continuous-infusion unfractionated heparin for initiation of anticoagulation after mechanical prosthetic valve implantation.

We compared the efficacy, safety, and impact on postoperative hospital length of stay and inpatient hospital costs of low-molecular-weight heparin with that of unfractionated heparin as a "bridge" to achieving therapeutic levels of anticoagulation with warfarin in patients with newly implanted prosthetic heart valves. The patients who received low-molecular-weight heparin had a shorter length of stay and decreased postoperative costs compared with the control subjects receiving unfractionated heparin.

Trace element risk assessment: essentiality vs. toxicity.

Risk assessment of essential trace elements examines high intakes resulting in toxicity and low intakes resulting in nutritional deficiencies. This paper analyzes the risk assessments carried out by several U.S.

Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry.

Objectives: This study was designed to investigate the prevalence and prognostic significance of right heart thrombi (RHTh) in pulmonary embolism.

Background: Most reports about patients with RHTh are small case series. We analyzed data referring to RHTh among 2,454 consecutive pulmonary embolism patients enrolled in the International Cooperative Pulmonary Embolism Registry.

Enoxaparin monotherapy without oral anticoagulation to treat acute symptomatic pulmonary embolism.

Conventional anticoagulation for symptomatic pulmonary embolism consists of continuous intravenous unfractionated heparin as a "bridge" to oral anticoagulation. This strategy requires 5 days or more of intravenous heparin while oral vitamin K antagonists gradually achieve a therapeutic effect. Oral vitamin K antagonists require frequent blood testing to optimize dosing, and their interactions with other medications and foods make regulation difficult.

Prognostic role of brain natriuretic peptide in acute pulmonary embolism.

Background: Rapid, noninvasive, and accurate prognostic assessment with an inexpensive cardiac biomarker is an appealing approach for patients with acute pulmonary embolism (PE).

Methods And Results: We measured at the time of admission the plasma level of plasma brain natriuretic peptide (BNP) to determine its utility in prognosticating the clinical course of 73 consecutive patients with acute PE. We used a prespecified BNP cut-off level (<90 pg/mL) for the prediction of the absence of a major adverse cardiovascular event, defined as any of the following: death, cardiopulmonary resuscitation, mechanical ventilation, or use of pressors, thrombolysis, catheter fragmentation, or surgical embolectomy.

Rationale and design of a clinical trial of a low-molecular-weight heparin in preventing clinically important venous thromboembolism in medical patients: the prospective evaluation of dalteparin efficacy for prevention of venous thromboembolism in immobilized patients trial (the PREVENT study).

The utility of low-molecular-weight heparin (LMWH) in the prophylaxis of venous thromboembolic disease has been examined using the surrogate endpoint of venographically identified thrombi. The largest portion of these thrombi were asymptomatic calf-vein thrombi. The clinical relevance of this observation is a matter of debate.