Blick ins Buch

Pulmonary Embolism (eBook)

Paul D. Stein (Autor)

eBook Download: PDF

2016 | 3. Auflage
John Wiley & Sons (Verlag)
978-1-119-03909-9 (ISBN)

Lese- und Medienproben

Ebook-Leseprobe (PDF)

A must have resource for clinicians and investigators interested in pulmonary embolism and deep venous thrombosis

Highly illustrated with numerous tables and graphs alongside clear concise text
Includes chapters addressing pulmonary embolism (PE) and deep venous thrombosis (DVT) in relation to diseases and disorders such as; chronic heart failure, cancer, diabetes, stroke, chronic obstructive pulmonary disease (COPD) and many more
Discusses the role the different tools offered in imaging for PE, including echocardiography, multidetector computed tomography (CT), single photon emission computed tomography (SPECT), ventilation-perfusion (V-Q) imaging, dual energy CT, and magnetic resonance angiography
Contains 29 new chapters and includes new content on epidemiology of deep venous thrombosis; use of the new anticoagulants (dabigatran, rivaroxaban, and apixaban) for DVT and PE; indications and results with thrombolytic therapy and with vena cava filters; and information and indications for invasive mechanical thrombectomy and thrombolysis
Written by an internationally recognized and respected expert in the field

Paul D. Stein MD,Professor of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA.

Dr. Stein's major research in recent years has been in the field of venous thromboembolism. Dr. Stein initiated the PIOPED II and PIOPED III national collaborative studies and was national principal investigator and chairperson of the steering committees. He has written over 240 articles on venous thromboembolism from among over 560 peer reviewed articles. Dr Stein is a past president of the Laennec Society and of the American College of Chest Physicians. He is Fellow of the American College of Physicians and the American College of Cardiology and a Master Fellow of the American College of Chest Physicians. He is also a Fellow of the American Society of Mechanical Engineers. Fellowship is reserved for those who have made a significant contribution to the field of mechanical engineering. He received the Lifetime Achievement Award from the American Heart Association Midwest Affiliate, the Laureate Award of the American College of Physicians, Michigan Chapter, the Daniel Drake Award from the University of Cincinnati College of Medicine, and the Research Excellence Award from the Michigan State University College of Osteopathic Medicine. Dr. Stein also wrote a book, A Physical and Physiological Basis for the Interpretation of Cardiac Auscultation: Evaluations Based Primarily on Second Sound and Ejection Murmurs.

A must have resource for clinicians and investigators interested in pulmonary embolism and deep venous thrombosis Highly illustrated with numerous tables and graphs alongside clear concise text Includes chapters addressing pulmonary embolism (PE) and deep venous thrombosis (DVT) in relation to diseases and disorders such as; chronic heart failure, cancer, diabetes, stroke, chronic obstructive pulmonary disease (COPD) and many more Discusses the role the different tools offered in imaging for PE, including echocardiography, multidetector computed tomography (CT), single photon emission computed tomography (SPECT), ventilation-perfusion (V-Q) imaging, dual energy CT, and magnetic resonance angiography Contains 29 new chapters and includes new content on epidemiology of deep venous thrombosis; use of the new anticoagulants (dabigatran, rivaroxaban, and apixaban) for DVT and PE; indications and results with thrombolytic therapy and with vena cava filters; and information and indications for invasive mechanical thrombectomy and thrombolysis Written by an internationally recognized and respected expert in the field

Paul D. Stein MD,Professor of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, USA. Dr. Stein's major research in recent years has been in the field of venous thromboembolism. Dr. Stein initiated the PIOPED II and PIOPED III national collaborative studies and was national principal investigator and chairperson of the steering committees. He has written over 240 articles on venous thromboembolism from among over 560 peer reviewed articles. Dr Stein is a past president of the Laennec Society and of the American College of Chest Physicians. He is Fellow of the American College of Physicians and the American College of Cardiology and a Master Fellow of the American College of Chest Physicians. He is also a Fellow of the American Society of Mechanical Engineers. Fellowship is reserved for those who have made a significant contribution to the field of mechanical engineering. He received the Lifetime Achievement Award from the American Heart Association Midwest Affiliate, the Laureate Award of the American College of Physicians, Michigan Chapter, the Daniel Drake Award from the University of Cincinnati College of Medicine, and the Research Excellence Award from the Michigan State University College of Osteopathic Medicine. Dr. Stein also wrote a book, A Physical and Physiological Basis for the Interpretation of Cardiac Auscultation: Evaluations Based Primarily on Second Sound and Ejection Murmurs.

Cover???????????????????????? 1
Title Page?????????????????????????????????? 5
Copyright???????????????????????????????? 6
Dedication?????????????????????????????????? 7
Contents 9
Prologue?????????????????????????????? 13
Preface to the Third Edition?????????????????????????????????????????????????????????????????????? 15
About the companion website???????????????????????????????????????????????????????????????????? 17
Introduction?????????????????????????????????????? 19
Part I Prevalence, risks, and prognosis of pulmonary embolism and deep venous thrombosis 21
Chapter 1 Pulmonary embolism and deep venous thrombosis at autopsy?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 23
Prevalence of pulmonary embolism at autopsy???????????????????????????????????????????????????????????????????????????????????????????????????? 23
Large or fatal PE at autopsy?????????????????????????????????????????????????????????????????????? 23
Small PE at autopsy???????????????????????????????????????????????????? 23
Unsuspected PE at autopsy???????????????????????????????????????????????????????????????? 25
Rate and sequence of organization of thromboemboli?????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 26
Deep venous thrombosis at autopsy???????????????????????????????????????????????????????????????????????????????? 26
Forward thrombosis versus retrograde thrombosis???????????????????????????????????????????????????????????????????????????????????????????????????????????? 30
Collateral veins around occlusions?????????????????????????????????????????????????????????????????????????????????? 30
Thrombophlebitis and phlebothrombosis???????????????????????????????????????????????????????????????????????????????????????? 31
Valve pockets as site of origin of DVT?????????????????????????????????????????????????????????????????????????????????????????? 33
References?????????????????????????????????? 34
Chapter 2 Incidence of pulmonary embolism and deep venous thrombosis in hospitalized patients and in emergency departments?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 36
Pulmonary embolism in hospitals???????????????????????????????????????????????????????????????????????????? 36
Pulmonary embolism in emergency departments???????????????????????????????????????????????????????????????????????????????????????????????????? 36
Deep venous thrombosis in hospitals???????????????????????????????????????????????????????????????????????????????????? 37
Deep venous thrombosis in emergency departments???????????????????????????????????????????????????????????????????????????????????????????????????????????? 39
Vena cava thrombosis?????????????????????????????????????????????????????? 41
References?????????????????????????????????? 41
Chapter 3 Case fatality rate and population mortality rate from pulmonary embolism and deep venous thrombosis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 42
Case fatality rate of patients with pulmonary embolism before early diagnosis by imaging was available?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 42
Case fatality rate of untreated patients with pulmonary embolism in the present era???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 42
Case fatality rate of patients with deep venous thrombosis?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 42
Treated patients with pulmonary embolism compared with treated patients with deep venous thrombosis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 43
Case fatality rate of pulmonary embolism in the present era???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 43
Stable patients with pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????? 44
Unstable patients with pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????? 45
Early death from pulmonary embolism???????????????????????????????????????????????????????????????????????????????????? 45
Case fatality rate attributable to pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 45
Case fatality rate according to age???????????????????????????????????????????????????????????????????????????????????? 47
Population mortality rate from PE???????????????????????????????????????????????????????????????????????????????? 47
References?????????????????????????????????? 48
Chapter 4 Prognosis in acute pulmonary embolism based on right ventricular enlargement and biochemical markers in stable patients???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 49
Right ventricular enlargement and prognosis in stable patients?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 49
Cardiac troponins and prognosis???????????????????????????????????????????????????????????????????????????? 51
Cardiac troponin levels in combination with right ventricular dysfunction or right ventricular dilatation???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 53
Randomized controlled trial: thrombolytic therapy in patients with elevated cardiac troponin and RV dysfunction???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 53
Myoglobin???????????????????????????????? 56
Natriuretic peptides?????????????????????????????????????????????????????? 56
Serum uric acid???????????????????????????????????????????? 57
Creatine kinase isoenzyme MB?????????????????????????????????????????????????????????????????????? 57
Plasma heart-type fatty acid binding protein?????????????????????????????????????????????????????????????????????????????????????????????????????? 58
References?????????????????????????????????? 58
Chapter 5 Prognosis in acute pulmonary embolism based on scoring systems?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 61
Identification of high-risk patients?????????????????????????????????????????????????????????????????????????????????????? 61
Identification of low-risk patients potentially eligible for home treatment of PE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 61
Comparison of outcome in low-risk patients according to scoring system?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 65
Cardiac biomarkers for assessment of low risk???????????????????????????????????????????????????????????????????????????????????????????????????????? 65
References?????????????????????????????????? 65
Chapter 6 Pulmonary embolism following deep venous thrombosis and outcome with untreated pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 67
Pulmonary embolism with untreated deep venous thrombosis?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 67
Pulmonary embolism with treated deep venous thrombosis?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 67
Outcome of untreated patients with PE in the present era of early diagnosis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 68
Recurrent PE in untreated nonmassive PE and negative serial noninvasive leg tests???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 70
References?????????????????????????????????? 70
Chapter 7 Resolution of pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????? 72
Resolution of perfusion lung scans?????????????????????????????????????????????????????????????????????????????????? 72
Resolution of V-Q SPECT???????????????????????????????????????????????????????????? 72
Resolution of conventional pulmonary angiograms???????????????????????????????????????????????????????????????????????????????????????????????????????????? 74
Resolution of CT pulmonary angiograms???????????????????????????????????????????????????????????????????????????????????????? 74
Comparison of vessels???????????????????????????????????????????????????????? 75
Diffusing capacity of the lung for carbon monoxide?????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 76
References?????????????????????????????????? 78
Chapter 8 Upper extremity deep venous thrombosis?????????????????????????????????????????????????????????????????????????????????????????????????????????????? 79
Prevalence of upper extremity DVT???????????????????????????????????????????????????????????????????????????????? 79
Pulmonary embolism with upper extremity DVT???????????????????????????????????????????????????????????????????????????????????????????????????? 80
Post-thrombotic syndrome with upper extremity DVT???????????????????????????????????????????????????????????????????????????????????????????????????????????????? 80
Clinical manifestations of upper extremity DVT?????????????????????????????????????????????????????????????????????????????????????????????????????????? 80
Cancer and upper extremity DVT?????????????????????????????????????????????????????????????????????????? 80
Diagnosis???????????????????????????????? 81
Prophylaxis for prevention of catheter related upper extremity DVT?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 82
Treatment of catheter-related upper extremity DVT???????????????????????????????????????????????????????????????????????????????????????????????????????????????? 82
References?????????????????????????????????? 82
Chapter 9 Thromboembolic disease involving the superior vena cava and brachiocephalic veins???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 84
References?????????????????????????????????? 85
Chapter 10 Venous thromboembolic disease in the four seasons?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 87
Incidence of pulmonary embolism and deep venous thrombosis according to season?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 87
Mortality from pulmonary embolism according to season???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 87
References?????????????????????????????????? 89
Chapter 11 Regional differences in the United States of rates of diagnosis of pulmonary embolism and deep venous thrombosis and mortality from pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 91
Regional rates of diagnosis of pulmonary embolism and deep venous thrombosis?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 91
Regional mortality rates from PE?????????????????????????????????????????????????????????????????????????????? 93
References?????????????????????????????????? 94
Chapter 12 Venous thromboembolism according to age and in the elderly???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 96
Rates of diagnosis and trends in the diagnosis of deep venous thrombosis and pulmonary embolism in the elderly?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 96
Case fatality rate according to age???????????????????????????????????????????????????????????????????????????????????? 97
Diagnosis of acute PE in the elderly?????????????????????????????????????????????????????????????????????????????????????? 97
Predisposing factors according to age???????????????????????????????????????????????????????????????????????????????????????? 98
Syndromes of PE according to age?????????????????????????????????????????????????????????????????????????????? 99
Symptoms according to age???????????????????????????????????????????????????????????????? 99
Signs according to age?????????????????????????????????????????????????????????? 100
Chest radiograph?????????????????????????????????????????????? 100
Combinations of symptoms and signs and radiographic abnormalities???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 100
Acute hemorrhage/infarction syndrome in the elderly???????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 100
Clinical assessment according to age?????????????????????????????????????????????????????????????????????????????????????? 104
The electrocardiogram according to age?????????????????????????????????????????????????????????????????????????????????????????? 104
Blood gases according to age?????????????????????????????????????????????????????????????????????? 104
Use of diagnostic tests in the elderly?????????????????????????????????????????????????????????????????????????????????????????? 105
Antithrombotic prophylaxis and age?????????????????????????????????????????????????????????????????????????????????? 107
Treatment of the elderly?????????????????????????????????????????????????????????????? 108
References?????????????????????????????????? 110
Chapter 13 Pulmonary thromboembolism in infants and children?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 113
Prevalence of pulmonary embolism and deep venous thrombosis in infants, children, and adolescents???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 113
Predisposing factors in children and adolescents?????????????????????????????????????????????????????????????????????????????????????????????????????????????? 113
Pulmonary embolism in pediatric orthopedic patients and pediatric patients with cancer?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 114
Imaging tests in children???????????????????????????????????????????????????????????????? 114
Antithrombotic treatment in infants and children?????????????????????????????????????????????????????????????????????????????????????????????????????????????? 116
References?????????????????????????????????? 116
Chapter 14 Venous thromboembolism in men and women?????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 117
Incidence of pulmonary embolism according to sex?????????????????????????????????????????????????????????????????????????????????????????????????????????????? 117
Incidence of deep venous thrombosis according to sex?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 117
Recurrent venous thromboembolism according to sex???????????????????????????????????????????????????????????????????????????????????????????????????????????????? 117
Use of diagnostic tests according to sex?????????????????????????????????????????????????????????????????????????????????????????????? 118
Sensitivity and specificity of multidetector computed tomography (CT) and of ventilation-perfusion lung scans according to sex?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 118
Length of hospital stay according to sex?????????????????????????????????????????????????????????????????????????????????????????????? 119
Signs and symptoms of pulmonary embolism according to sex???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 119
References?????????????????????????????????? 120
Chapter 15 Pulmonary embolism and deep venous thrombosis in blacks and whites???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 121
Pulmonary embolism in blacks and whites???????????????????????????????????????????????????????????????????????????????????????????? 121
Deep venous thrombosis in blacks and whites???????????????????????????????????????????????????????????????????????????????????????????????????? 121
Complications of pulmonary embolism in blacks and whites?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 122
Mortality from pulmonary embolism in blacks and whites?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 122
Risk factors in blacks and whites???????????????????????????????????????????????????????????????????????????????? 123
Use of diagnostic tests for pulmonary embolism and deep vein thrombosis in blacks and whites?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 123
Length of stay in hospital for pulmonary embolism and deep vein thrombosis in blacks and whites???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 124
References?????????????????????????????????? 124
Chapter 16 Pulmonary thromboembolism in Asians/Pacific Islanders?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 126
Unadjusted population-based rates of diagnosis?????????????????????????????????????????????????????????????????????????????????????????????????????????? 126
Age-adjusted population-based rates of diagnosis?????????????????????????????????????????????????????????????????????????????????????????????????????????????? 126
Incidence in hospitals?????????????????????????????????????????????????????????? 128
Population mortality rates?????????????????????????????????????????????????????????????????? 128
Hemophilic factors?????????????????????????????????????????????????? 129
Venous thromboembolism following orthopedic surgery???????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 131
Sensitivity to warfarin???????????????????????????????????????????????????????????? 131
References?????????????????????????????????? 131
Chapter 17 Pulmonary thromboembolism in American Indians and Alaskan Natives?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 134
References?????????????????????????????????? 135
Chapter 18 Venous thromboembolism in patients with cancer???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 136
Incidence of VTE in women with cancer of the breast???????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 140
Pulmonary embolism as a cause of death in patients who died with cancer???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 140
Inferior vena cava filters in stable patients with PE and cancer?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 141
References?????????????????????????????????? 144
Chapter 19 Venous thromboembolism in patients with heart failure?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 146
Risk factors for venous thromboembolism in patients with heart failure?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 146
Prevalence of VTE in patients with heart failure?????????????????????????????????????????????????????????????????????????????????????????????????????????????? 146
Mortality from PE in patients with heart failure?????????????????????????????????????????????????????????????????????????????????????????????????????????????? 147
Antithrombotic prophylaxis in patients with heart failure???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 148
References?????????????????????????????????? 149
Chapter 20 Obesity as a risk factor in venous thromboembolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 151
Prevalence of pulmonary embolism and deep venous thrombosis in obese hospitalized patients?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 151
Age-dependence of risks of pulmonary embolism and deep venous thrombosis in obese patients?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 151
Definitions of obesity?????????????????????????????????????????????????????????? 153
Mechanism of deep venous thrombosis in obesity?????????????????????????????????????????????????????????????????????????????????????????????????????????? 153
Mortality paradox in obese patients???????????????????????????????????????????????????????????????????????????????????? 153
Bariatric surgery???????????????????????????????????????????????? 154
Oral contraceptives???????????????????????????????????????????????????? 155
References?????????????????????????????????? 155
Chapter 21 Hypertension, smoking, and cholesterol???????????????????????????????????????????????????????????????????????????????????????????????????????????????? 157
Hypertension?????????????????????????????????????? 157
Smoking???????????????????????????? 157
Cholesterol???????????????????????????????????? 157
References?????????????????????????????????? 158
Chapter 22 Overlap of venous and arterial thrombosis risk factors???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 159
Obesity, cigarette smoking, hypertension, age, and coagulation factors?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 159
Stress?????????????????????????? 159
Nutritional factors???????????????????????????????????????????????????? 159
Association of atherosclerosis with deep venous thrombosis?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 159
Statin therapy?????????????????????????????????????????? 160
References?????????????????????????????????? 160
Chapter 23 Venous thromboembolism in patients with ischemic and hemorrhagic stroke?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 161
References?????????????????????????????????? 163
Chapter 24 Paradoxical embolism???????????????????????????????????????????????????????????????????????????? 164
Mechanism of paradoxical embolism???????????????????????????????????????????????????????????????????????????????? 164
Prevalence of patent foramen ovales and evidence of paradoxical embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 164
Percutaneous transvenous closure of patent foramen ovales???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 164
Prevalence of ischemic stroke in patients hospitalized with VTE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 165
Increasing closure rate???????????????????????????????????????????????????????????? 165
References?????????????????????????????????? 165
Chapter 25 Pulmonary embolism and deep venous thrombosis in hospitalized adults with chronic obstructive pulmonary disease?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 167
Prevalence of pulmonary embolism in patients with COPD?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 167
Clinical features of PE in patients with COPD???????????????????????????????????????????????????????????????????????????????????????????????????????? 168
Case fatality rate from pulmonary embolism in patients with COPD?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 170
References?????????????????????????????????? 172
Chapter 26 Pulmonary embolism and deep venous thrombosis in hospitalized patients with asthma???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 174
Speculations related to mechanism of increased VTE in patients with asthma?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 174
References?????????????????????????????????? 175
Chapter 27 Deep venous thrombosis and pulmonary embolism in hospitalized patients with sickle cell disease?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 176
References?????????????????????????????????? 178
Chapter 28 Diabetes mellitus and risk of venous thromboembolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 180
Results from National Hospital Discharge Survey???????????????????????????????????????????????????????????????????????????????????????????????????????????? 180
PE in patients with diabetes mellitus???????????????????????????????????????????????????????????????????????????????????????? 180
DVT in patients with diabetes mellitus?????????????????????????????????????????????????????????????????????????????????????????? 180
VTE in patients with diabetes mellitus?????????????????????????????????????????????????????????????????????????????????????????? 180
Relative risk of VTE in young women compared with young men???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 181
Prior investigations?????????????????????????????????????????????????????? 181
References?????????????????????????????????? 181
Chapter 29 Risk of venous thromboembolism with rheumatoid arthritis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 182
Pulmonary embolism in hospitalized patients with rheumatoid arthritis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 182
Deep venous thrombosis in hospitalized patients with rheumatoid arthritis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 182
Venous thromboembolism in hospitalized patients with rheumatoid arthritis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 182
Venous thromboembolism in patients with rheumatoid arthritis who underwent joint surgery?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 183
References?????????????????????????????????? 183
Chapter 30 Venous thromboembolism with inflammatory bowel disease???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 184
Pulmonary embolism in hospitalized patients with ulcerative colitis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 184
Deep venous thrombosis in hospitalized patients with ulcerative colitis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 184
Venous thromboembolism in hospitalized patients with ulcerative colitis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 184
Pulmonary embolism in hospitalized patients with Crohn's disease?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 185
Deep venous thrombosis in hospitalized patients with Crohn's disease?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 185
Venous thromboembolism in hospitalized patients with Crohn's disease?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 185
References?????????????????????????????????? 185
Chapter 31 Venous thromboembolism with chronic liver disease?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 186
Pulmonary embolism, deep venous thrombosis, and venous thromboembolism in patients with chronic alcoholic liver disease???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 186
Pulmonary embolism, deep venous thrombosis, and venous thromboembolism in patients with chronic nonalcoholic liver disease?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 186
Comparison with hospitalized patients with other medical illnesses?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 187
Prior investigations?????????????????????????????????????????????????????? 187
References?????????????????????????????????? 187
Chapter 32 Nephrotic syndrome???????????????????????????????????????????????????????????????????????? 189
References?????????????????????????????????? 190
Chapter 33 Human immunodeficiency virus infection???????????????????????????????????????????????????????????????????????????????????????????????????????????????? 191
Hypercoagulable state with HIV?????????????????????????????????????????????????????????????????????????? 191
Prior investigations?????????????????????????????????????????????????????? 191
Data from the National Hospital Discharge Survey?????????????????????????????????????????????????????????????????????????????????????????????????????????????? 191
References?????????????????????????????????? 192
Chapter 34 Venous thromboembolism in pregnancy?????????????????????????????????????????????????????????????????????????????????????????????????????????? 194
Twenty-one-year trends in rate of diagnosis of deep venous thrombosis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 194
Trends in DVT according to age?????????????????????????????????????????????????????????????????????????? 194
Pregnancy-associated DVT according to race?????????????????????????????????????????????????????????????????????????????????????????????????? 195
Pregnancy-associated DVT according to mode of delivery?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 195
Twenty-one-year trends in the rate of diagnosis of PE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 196
Diagnosis of DVT during pregnancy???????????????????????????????????????????????????????????????????????????????? 198
Diagnosis of PE during pregnancy?????????????????????????????????????????????????????????????????????????????? 198
Anticoagulant therapy during pregnancy?????????????????????????????????????????????????????????????????????????????????????????? 198
References?????????????????????????????????? 198
Chapter 35 Amniotic fluid embolism?????????????????????????????????????????????????????????????????????????????????? 200
Prevalence of amniotic fluid embolism based on the National Hospital Discharge Survey???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 200
Vaginal delivery compared with cesarean section???????????????????????????????????????????????????????????????????????????????????????????????????????????? 200
References?????????????????????????????????? 201
Chapter 36 Air travel as a risk for pulmonary embolism and deep venous thrombosis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 202
Travel by, car, bus, or train???????????????????????????????????????????????????????????????????????? 202
Air travel?????????????????????????????????? 202
Trials of prophylactic agents???????????????????????????????????????????????????????????????????????? 203
Recommendations???????????????????????????????????????????? 203
References?????????????????????????????????? 204
Chapter 37 Estrogen-containing oral contraceptives and venous thromboembolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 205
Risks of venous thromboembolism in users of estrogen-containing oral contraceptives???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 205
Risk of venous thromboembolism in relation to dose?????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 205
Relative risk of venous thromboembolism in relation to dose???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 205
Relative risk according to duration of use?????????????????????????????????????????????????????????????????????????????????????????????????? 205
Estrogen-containing oral contraceptives in combination with smoking???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 206
Estrogen-containing oral contraceptives and obesity???????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 206
Estrogen-containing oral contraceptives and postoperative venous thromboembolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 206
Estrogen-containing oral contraceptives and factor V Leiden mutation?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 206
Modifications of coagulation proteins in with oral contraceptives???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 207
Role of progesterone?????????????????????????????????????????????????????? 207
Hormone replacement therapy and risk of venous thrombosis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 207
References?????????????????????????????????? 208
Chapter 38 Estrogen and testosterone in men???????????????????????????????????????????????????????????????????????????????????????????????????? 210
Thrombotic risk of estrogen and relation to dose?????????????????????????????????????????????????????????????????????????????????????????????????????????????? 210
Transdermal administration of estrogen compared with oral administration?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 210
Effect of estrogen on coagulation proteins?????????????????????????????????????????????????????????????????????????????????????????????????? 210
Testosterone?????????????????????????????????????? 210
References?????????????????????????????????? 211
Chapter 39 Tamoxifen?????????????????????????????????????????????????????? 212
Superficial venous thrombosis in women receiving tamoxifen for treatment or prevention of breast cancer???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 212
Deep venous thrombosis in women receiving tamoxifen for treatment or prevention of breast cancer?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 212
Pulmonary embolism in women receiving tamoxifen for treatment or prevention of breast cancer?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 212
Venous thromboembolism in women receiving tamoxifen for treatment or prevention of breast cancer?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 212
Factor V Leiden mutation and venous thromboembolism in women receiving tamoxifen for treatment of breast cancer???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 213
Tampoxifen in men receiving tamoxifen for treatment of breast cancer?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 214
Tampoxifen in men receiving tamoxifen for treatment of infertility?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 214
References?????????????????????????????????? 214
Chapter 40 Venous thromboembolism following bariatric surgery???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 216
Antithrombotic prophylaxis?????????????????????????????????????????????????????????????????? 216
Number of bariatric surgical procedures performed???????????????????????????????????????????????????????????????????????????????????????????????????????????????? 216
Deep venous thrombosis with bariatric surgery???????????????????????????????????????????????????????????????????????????????????????????????????????? 216
Pulmonary embolism with bariatric surgery???????????????????????????????????????????????????????????????????????????????????????????????? 219
Venous thromboembolism with bariatric surgery???????????????????????????????????????????????????????????????????????????????????????????????????????? 219
Vena cava filters with bariatric surgery?????????????????????????????????????????????????????????????????????????????????????????????? 219
References?????????????????????????????????? 220
Chapter 41 Hypercoagulable syndrome???????????????????????????????????????????????????????????????????????????????????? 222
Inherited thrombophilia???????????????????????????????????????????????????????????? 222
Antithrombin III deficiency???????????????????????????????????????????????????????????????????? 222
Protein C deficiency?????????????????????????????????????????????????????? 222
Protein S deficiency?????????????????????????????????????????????????????? 223
Factor V Leiden???????????????????????????????????????????? 225
Prothrombin G20210A mutation?????????????????????????????????????????????????????????????????????? 225
Elevated factor VIII levels???????????????????????????????????????????????????????????????????? 225
Elevated factor XI levels???????????????????????????????????????????????????????????????? 226
Heparin cofactor II deficiency?????????????????????????????????????????????????????????????????????????? 226
Inherited dysfibrinogenemias?????????????????????????????????????????????????????????????????????? 226
Disorders of plasmin generation???????????????????????????????????????????????????????????????????????????? 226
Hyperhomocysteinemia?????????????????????????????????????????????????????? 226
Sticky platelet syndrome?????????????????????????????????????????????????????????????? 226
Acquired thrombophilia?????????????????????????????????????????????????????????? 226
Malignancy?????????????????????????????????? 228
Diagnostic approach to patients suspected of thrombophilia?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 228
References?????????????????????????????????? 228
Part II Diagnosis of deep venous thrombosis 231
Chapter 42 Deep venous thrombosis of the lower extremities: clinical evaluation???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 233
References?????????????????????????????????? 236
Chapter 43 Clinical scoring system for assessment of deep venous thrombosis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 238
Scoring systems for deep venous thrombosis?????????????????????????????????????????????????????????????????????????????????????????????????? 238
References?????????????????????????????????? 239
Chapter 44 Clinical probability score plus single negative ultrasound for exclusion of deep venous thrombosis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 241
Outcome in outpatients with clinical assessment and negative compression ultrasound???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 241
References?????????????????????????????????? 241
Chapter 45 D-dimer for the exclusion of acute deep venous thrombosis?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 243
References?????????????????????????????????? 248
Chapter 46 D-dimer combined with clinical probability assessment for exclusion of acute deep venous thrombosis?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 252
References?????????????????????????????????? 253
Chapter 47 D-dimer and single negative compression ultrasound for exclusion of deep venous thrombosis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 254
References?????????????????????????????????? 254
Chapter 48 Contrast venography?????????????????????????????????????????????????????????????????????????? 255
Method of contrast venography???????????????????????????????????????????????????????????????????????? 255
Diagnostic criteria???????????????????????????????????????????????????? 255
Complications with low-osmolar, nonionic contrast material?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 256
Adequacy of visualization with clinical venograms???????????????????????????????????????????????????????????????????????????????????????????????????????????????? 256
Correlation of contrast venography with I-125 fibrinogen uptake???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 256
Correlation of postmortem contrast venography with dissection???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 256
References?????????????????????????????????? 256
Chapter 49 Compression ultrasound for the diagnosis of deep venous thrombosis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 258
Equipment preference?????????????????????????????????????????????????????? 258
Diagnostic criteria for acute DVT???????????????????????????????????????????????????????????????????????????????? 259
Accuracy of compression ultrasound?????????????????????????????????????????????????????????????????????????????????? 259
Comparison of compression ultrasound and CT venous phase imaging for DVT?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 262
References?????????????????????????????????? 263
Chapter 50 Impedance plethysmography and fibrinogen uptake tests for diagnosis of deep venous thrombosis?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 265
Impedance plethysmography???????????????????????????????????????????????????????????????? 265
Fibrinogen uptake test?????????????????????????????????????????????????????????? 266
References?????????????????????????????????? 266
Chapter 51 Ascending CT venography and venous phase CT venography for diagnosis of deep venous thrombosis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 268
Ascending CT venography compared with conventional contrast venography?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 268
Methods of ascending CT venography?????????????????????????????????????????????????????????????????????????????????? 268
Complications of ascending CT venography?????????????????????????????????????????????????????????????????????????????????????????????? 268
Methods of venous phase CT venography???????????????????????????????????????????????????????????????????????????????????????? 268
Diagnostic criteria for DVT on venous phase CT venography???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 269
Validity of CT venous phase venography in patients with suspected acute pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 269
Increased sensitivity for venous thromboembolism using venous phase CT venography in patients with suspected acute PE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 270
Discontinuous images for venous phase CT venography???????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 271
Recommendations regarding venous phase CT venography?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 271
References?????????????????????????????????? 271
Chapter 52 Magnetic resonance venography for diagnosis of deep venous thrombosis?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 273
MR venography without contrast material???????????????????????????????????????????????????????????????????????????????????????????? 273
Gd-MR venography of the lower extremities???????????????????????????????????????????????????????????????????????????????????????????????? 273
Delayed-enhanced MR venography of the veins of the thighs???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 273
Gd-MR venography: diagnostic criteria for acute DVT???????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 274
Venous phase MR venography in combination with MR pulmonary angiography???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 274
Gd-MR venography of the upper extremities and central veins???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 275
Complications???????????????????????????????????????? 275
Direct thrombus imaging with MR imaging???????????????????????????????????????????????????????????????????????????????????????????? 276
References?????????????????????????????????? 276
Chapter 53 P-selectin and microparticles to predict deep venous thrombosis?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 278
References?????????????????????????????????? 278
Part III Diagnosis of acute pulmonary embolism 281
Chapter 54 Clinical characteristics of patients with no prior cardiopulmonary disease???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 283
Predisposing factors?????????????????????????????????????????????????????? 284
Syndromes of acute PE???????????????????????????????????????????????????????? 285
Symptoms of acute PE?????????????????????????????????????????????????????? 285
Signs of acute PE???????????????????????????????????????????????? 285
Combinations of signs and symptoms?????????????????????????????????????????????????????????????????????????????????? 288
Clinical assessment???????????????????????????????????????????????????? 289
References?????????????????????????????????? 289
Chapter 55 Relation of right-sided pressures to clinical characteristics of patients with no prior cardiopulmonary disease?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 290
Chapter 56 The history and physical examination in all patients irrespective of prior cardiopulmonary disease???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 293
Predisposing factors?????????????????????????????????????????????????????? 293
Syndromes of acute PE???????????????????????????????????????????????????????? 293
Symptoms of acute PE?????????????????????????????????????????????????????? 293
Signs of acute PE???????????????????????????????????????????????? 294
Combinations of signs and symptoms?????????????????????????????????????????????????????????????????????????????????? 295
Dyspnea, hypoxia, and normal chest radiograph???????????????????????????????????????????????????????????????????????????????????????????????????????? 295
References?????????????????????????????????? 297
Chapter 57 Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 298
Predisposing factors?????????????????????????????????????????????????????? 298
Symptoms?????????????????????????????? 299
Signs???????????????????????? 299
Combinations of signs and symptoms?????????????????????????????????????????????????????????????????????????????????? 299
Clinical assessment???????????????????????????????????????????????????? 299
Electrocardiographic manifestations???????????????????????????????????????????????????????????????????????????????????? 300
Plain chest radiograph?????????????????????????????????????????????????????????? 300
Pulmonary artery pressure, PaO2, PaCO2, and pH?????????????????????????????????????????????????????????????????????????????????????????????????????????? 301
Ventilation-perfusion lung scan???????????????????????????????????????????????????????????????????????????? 301
Pulmonary infarction syndrome compared with isolated dyspnea syndrome???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 301
Circulatory collapse syndrome???????????????????????????????????????????????????????????????????????? 302
References?????????????????????????????????? 303
Chapter 58 Clinical assessment in the critically ill?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 304
Ventilatory support, intensive care units, hypoxemic not on ventilatory support???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 304
Ventilation-perfusion lung scans?????????????????????????????????????????????????????????????????????????????? 305
References?????????????????????????????????? 305
Chapter 59 The electrocardiogram?????????????????????????????????????????????????????????????????????????????? 307
Definitions???????????????????????????????????? 307
Prevalence of electrocardiographic abnormalities in PE?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 307
Duration of electrocardiographic abnormalities?????????????????????????????????????????????????????????????????????????????????????????????????????????? 312
Relation of electrocardiograpic abnormalities to severity of PE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 313
Mechanism of electrocardiographic abnormalities???????????????????????????????????????????????????????????????????????????????????????????????????????????? 315
Relation of electrocardiographic changes to right ventricular dilatation?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 317
Electrocardiogram in pneumonia?????????????????????????????????????????????????????????????????????????? 318
References?????????????????????????????????? 319
Chapter 60 The plain chest radiograph???????????????????????????????????????????????????????????????????????????????????????? 321
Radiographic signs of pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????? 321
Radiographic findings with acute PE and no prior cardiopulmonary?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 321
Sensitivity of findings in relation false-positives???????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 321
Pleural effusion?????????????????????????????????????????????? 323
Vascular signs?????????????????????????????????????????? 323
Elevated hemidiaphragm, infiltrates, and other common findings?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 323
Radiographic abnormalities related to pulmonary artery mean pressure?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 324
Radiographic abnormalities, related PaO2?????????????????????????????????????????????????????????????????????????????????????????????? 324
References?????????????????????????????????? 325
Chapter 61 Arterial blood gases and the alveolar-arterial oxygen difference in acute pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 326
Arterial blood gases?????????????????????????????????????????????????????? 326
Alveolar-arterial oxygen difference???????????????????????????????????????????????????????????????????????????????????? 326
Alveolar-arterial oxygen difference in all patients with PE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 330
Alveolar-arterial oxygen difference in patients with no prior cardiopulmonary disease???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 330
Alveolar-arterial oxygen difference in patients with no prior PE or prior DVT???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 330
Relation of alveolar-arterial oxygen difference to the PaO2???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 331
Relation of alveolar-arterial oxygen difference to pulmonary pressure and to the ventilation-perfusion lung scan?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 331
Blood gases in combination with the alveolar-arterial oxygen difference???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 332
References?????????????????????????????????? 333
Chapter 62 Fever in acute pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????? 334
References?????????????????????????????????? 335
Chapter 63 Leukocytosis in acute pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 337
References?????????????????????????????????? 338
Chapter 64 Alveolar dead-space in the diagnosis of pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 339
Calculation???????????????????????????????????? 339
Sensitivity and specificity???????????????????????????????????????????????????????????????????? 339
Alveolar dead-space fraction for exclusion of PE?????????????????????????????????????????????????????????????????????????????????????????????????????????????? 340
References?????????????????????????????????? 340
Chapter 65 Empirical assessment and clinical models for diagnosis of acute pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 342
Wells model???????????????????????????????????? 342
Geneva system???????????????????????????????????????? 342
Pisa clinical model???????????????????????????????????????????????????? 344
Pulmonary embolism rule-out criteria?????????????????????????????????????????????????????????????????????????????????????? 344
References?????????????????????????????????? 345
Chapter 66 Prognostic models for pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 347
Pulmonary embolism severity index (PESI)?????????????????????????????????????????????????????????????????????????????????????????????? 347
Simplified pulmonary embolism severity index score (simplified PESI score)?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 347
Multimarker model for prognosis in normotensive patients with acute pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 348
Prediction rule to identify low-risk patients with pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 348
Clinical prediction rule for adverse events following acute PE (Geneva score)???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 349
Clinical prediction rule for short-term risk of adverse events following acute PE (Spanish score)???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 349
Outcome model for short-term adverse events in normotensive outpatients???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 349
Prognostic model for low-risk patients with acute PE and active cancer?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 349
Qualitative exclusion criteria for early discharge?????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 350
Multivariate model to predict mortality from acute PE with cancer (POMPE-C tool)?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 350
Prognosis based on quantification of the angiographic severity (CT angiography PE index)?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 350
Prognostic value of D-dimer levels in stable patients with PE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 350
D-dimer levels and risk of recurrent venous thromboembolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 350
References?????????????????????????????????? 351
Chapter 67 D-dimer for the exclusion of acute pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 353
ELISA (enzyme-linked immunosorbent assay) and quantitative rapid ELISA: most sensitive?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 353
Description of D-dimer tests?????????????????????????????????????????????????????????????????????? 353
D-dimer as a stand-alone test???????????????????????????????????????????????????????????????????????? 353
Causes of D-dimer elevation in hospitalized patients?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 358
D-dimer in pregnancy?????????????????????????????????????????????????????? 358
D-dimer and age???????????????????????????????????????????? 358
D-dimer and race?????????????????????????????????????????????? 358
D-dimer level, likelihood of PE, and severity of PE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 358
Decreasing D-dimer levels with time after the onset of symptoms???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 358
Decreasing D-dimer levels with anticoagulant therapy?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 359
Abnormal D-dimer in patients who do not have PE in the emergency department???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 359
Prognostic value of high levels of D-dimer in stable patients with PE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 360
References?????????????????????????????????? 360
Chapter 68 D-dimer combined with clinical probability for exclusion of acute pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 364
Negative rapid ELISA or latex agglutination assay in combination with a low- or moderate-probability clinical assessment?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 364
Pretest and posttest probability with clinical assessment and negative D-dimer?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 364
Outcome with clinical assessment and negative D-dimer assays?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 366
Proportion of patients with suspected PE who have a negative D-dimer and low, moderate, or unlikely clinical assessment???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 366
Reference???????????????????????????????? 366
Chapter 69 D-dimer in combination with amino-terminal pro-B-type natriuretic peptide for exclusion of acute pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 367
References?????????????????????????????????? 367
Chapter 70 Tissue plasminogen activator, plasminogen activator inhibitor-1, and thrombin-antithrombin III complexes in the exclusion of acute pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 368
Tissue plasminogen activator for exclusion of pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 368
Plasminogen activator inhibitor type-1 for exclusion of pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 368
Thrombin-antithrombin III complexes for exclusion of pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 368
References?????????????????????????????????? 369
Chapter 71 Echocardiogram in the diagnosis of acute pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 370
Visualization of emboli within the right atrium, right ventricle, or pulmonary artery???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 370
Right ventricular enlargement or dysfunction as an aid to diagnosis of pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 370
Echocardiogram plus venous ultrasound for diagnosis of pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 370
Right ventricular enlargement or dysfunction in patients with massive PE or unstable patients with PE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 370
References?????????????????????????????????? 372
Chapter 72 Trends in the use of diagnostic imaging in patients hospitalized with acute pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 374
Availability of imaging tests???????????????????????????????????????????????????????????????????????? 374
Trends in imaging???????????????????????????????????????????????? 374
References?????????????????????????????????? 375
Chapter 73 Techniques of perfusion and ventilation imaging?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 376
Ventilation scans???????????????????????????????????????????????? 376
Perfusion imaging???????????????????????????????????????????????? 378
Single photon emission computed tomographic lung scan (SPECT)???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 379
References?????????????????????????????????? 379
Chapter 74 Ventilation-perfusion lung scan criteria for interpretation prior to the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED)?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 381
Diagnostic criteria for PE?????????????????????????????????????????????????????????????????? 382
References?????????????????????????????????? 384
Chapter 75 Observations from PIOPED: ventilation-perfusion lung scans alone and in combination with clinical assessment???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 385
Clinical assessment in combination with lung scans?????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 391
References?????????????????????????????????? 391
Chapter 76 Ventilation-perfusion lung scans according to complexity of lung disease???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 392
References?????????????????????????????????? 393
Chapter 77 Perfusion lung scans alone in acute pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 394
Perfusion scans alone in PIOPED???????????????????????????????????????????????????????????????????????????? 394
Perfusion scans interpreted with chest radiograph???????????????????????????????????????????????????????????????????????????????????????????????????????????????? 395
References?????????????????????????????????? 396
Chapter 78 Probability interpretation of ventilation-perfusion lung scans in relation to the largest pulmonary arterial branches in which pulmonary embolism is observed?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 397
References?????????????????????????????????? 398
Chapter 79 Revised criteria for evaluation of lung scans recommended by nuclear physicians in PIOPED?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 399
References?????????????????????????????????? 402
Chapter 80 Criteria for very-low-probability interpretation of ventilation-perfusion lung scans???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 403
Nonsegmental perfusion abnormalities?????????????????????????????????????????????????????????????????????????????????????? 404
Perfusion defect smaller than radiographic defect???????????????????????????????????????????????????????????????????????????????????????????????????????????????? 404
Matched ventilation-perfusion abnormality in two or three zones of a single lung?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 404
One to three small perfusion defects?????????????????????????????????????????????????????????????????????????????????????? 405
Triple matched defects in the upper or middle lung zones?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 405
Stripe sign???????????????????????????????????? 405
Pleural effusion?????????????????????????????????????????????? 407
Prospective evaluation of very low probability ventilation-perfusion lung scan interpretation in PIOPED II?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 407
Very-low-probability ventilation-perfusion scan in combination with a low-probability clinical assessment???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 407
References?????????????????????????????????? 407
Chapter 81 Probability assessment based on the number of mismatched segmental equivalent perfusion defects?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 409
Number of mismatched segmental equivalent defects and stratification according to prior cardiopulmonary disease???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 409
References?????????????????????????????????? 412
Chapter 82 Probability assessment based on the number of mismatched vascular defects and stratification according to prior cardiopulmonary disease?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 413
References?????????????????????????????????? 418
Chapter 83 The addition of clinical assessment to stratification according to prior cardiopulmonary disease further optimizes the interpretation of ventilation-perfusion lung scans?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 419
Patients with no prior cardiopulmonary disease?????????????????????????????????????????????????????????????????????????????????????????????????????????? 419
Patients with prior cardiopulmonary disease???????????????????????????????????????????????????????????????????????????????????????????????????? 422
References?????????????????????????????????? 424
Chapter 84 Pulmonary scintigraphy scans since PIOPED?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 425
Advances since PIOPED???????????????????????????????????????????????????????? 425
Evaluation of V-Q scans according to modified PIOPED criteria in mostly outpatients???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 426
Outcome with low-probability interpretations of V-Q lung scans?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 426
Outcome with trinary interpretation of V-Q lung scans???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 426
Exclusion of PE with planar perfusion lung scans interpreted with the chest radiograph using trinary interpretation???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 426
Outcome with V-Q SPECT?????????????????????????????????????????????????????????? 427
Outcome with perfusion SPECT?????????????????????????????????????????????????????????????????????? 427
References?????????????????????????????????? 427
Chapter 85 Single photon emission computed tomographic (SPECT) lung scans???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 430
Guidelines for use of V-Q SPECT???????????????????????????????????????????????????????????????????????????? 430
Guidelines for interpretation of V-Q SPECT?????????????????????????????????????????????????????????????????????????????????????????????????? 430
Radiation dose of SPECT compared with multidetector CT perfusion SPECT?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 433
Ventilation SPECT???????????????????????????????????????????????? 433
Ventilation/perfusion SPECT???????????????????????????????????????????????????????????????????? 434
V-Q SPECT using multidetector CT angiography as reference standard?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 434
V-Q SPECT using composite reference standards???????????????????????????????????????????????????????????????????????????????????????????????????????? 434
V-Q SPECT compared with planar V-Q scintigraphy???????????????????????????????????????????????????????????????????????????????????????????????????????????? 434
V-Q SPECT combined with low-dose noncontrast enhanced CT?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 439
Perfusion SPECT combined with low-dose noncontrast enhanced CT plus planar ventilation scintigraphy compared with dual-energy CT?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 439
Perfusion SPECT???????????????????????????????????????????? 439
Perfusion SPECT combined with low-dose noncontrast enhanced CT compared with planar V-Q???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 439
Perfusion SPECT combined with low-dose noncontrast enhanced CT compared with V-Q SPECT combined with low-dose noncontrast enhanced CT???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 439
Outcome after negative V-Q SPECT or Q/SPECT???????????????????????????????????????????????????????????????????????????????????????????????????? 439
References?????????????????????????????????? 441
Chapter 86 SPECT with radiolabeled markers?????????????????????????????????????????????????????????????????????????????????????????????????? 444
Radiolabeled antibody fragments that bind to the D-dimer?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 444
99mTc-apcitide?????????????????????????????????????????? 444
References?????????????????????????????????? 444
Chapter 87 Standard and augmented techniques in pulmonary angiography???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 445
Historical development of pulmonary angiography???????????????????????????????????????????????????????????????????????????????????????????????????????????? 445
Angiographic technique?????????????????????????????????????????????????????????? 446
Pulmonary cineangiography, balloon-occlusion cineangiography, and pulmonary wedge arteriography???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 447
Interpretation of pulmonary DSA???????????????????????????????????????????????????????????????????????????? 447
Quality of pulmonary angiography?????????????????????????????????????????????????????????????????????????????? 447
Outcome in patients with normal pulmonary angiograms?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 447
Reader agreement?????????????????????????????????????????????? 448
Digital subtraction pulmonary angiography: peripheral injection???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 449
References?????????????????????????????????? 451
Chapter 88 Subsegmental pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????? 453
Pulmonary embolism in branches < 1 mm diameter??????????????????????????????????????????????????????????????????????????????????????????????????????????
Isolated subsegmental pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????? 453
Incidental subsegmental pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????? 453
Diagnosis by pulmonary wedge angiography?????????????????????????????????????????????????????????????????????????????????????????????? 454
Computed tomographic angiography?????????????????????????????????????????????????????????????????????????????? 454
Outcome of untreated patients with isolated subsegmental PE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 454
Management?????????????????????????????????? 454
References?????????????????????????????????? 456
Chapter 89 Quantification of pulmonary embolism by conventional and CT angiography?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 458
CT angiography index?????????????????????????????????????????????????????? 458
Angiographic index: Walsh index???????????????????????????????????????????????????????????????????????????? 458
Subjective evaluation???????????????????????????????????????????????????????? 459
Miller index?????????????????????????????????????? 459
References?????????????????????????????????? 459
Chapter 90 Complications of pulmonary angiography???????????????????????????????????????????????????????????????????????????????????????????????????????????????? 460
Major complications???????????????????????????????????????????????????? 461
Nonmajor or minor complications???????????????????????????????????????????????????????????????????????????? 462
Relation of complications to clinical characteristics???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 462
References?????????????????????????????????? 463
Chapter 91 Contrast-enhanced spiral CT for the diagnosis of acute pulmonary embolism before the Prospective Investigation of Pulmonary Embolism Diagnosis II?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 464
Diagnostic accuracy, Tier 1 studies???????????????????????????????????????????????????????????????????????????????????? 465
Tier 2 investigations???????????????????????????????????????????????????????? 467
CT in combination with clinical assessment?????????????????????????????????????????????????????????????????????????????????????????????????? 467
Single-slice CT in combination with venous phase imaging of the veins of the pelvis and lower extremities???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 467
Outcome studies with single-slice and 2-slice CT?????????????????????????????????????????????????????????????????????????????????????????????????????????????? 467
Outcome studies with 4-slice and 16-slice CT?????????????????????????????????????????????????????????????????????????????????????????????????????? 472
Effect of age on sensitivity and specificity of single-slice CT angiography???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 472
References?????????????????????????????????? 472
Chapter 92 Methods of PIOPED II???????????????????????????????????????????????????????????????????????????? 476
CT angiography and CT venography?????????????????????????????????????????????????????????????????????????????? 478
Venous phase spiral CT of the veins of the lower extremities?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 479
Procedures to minimize potential risks?????????????????????????????????????????????????????????????????????????????????????????? 479
Time interval for imaging???????????????????????????????????????????????????????????????? 480
V-Q lung scans: technique???????????????????????????????????????????????????????????????? 480
Lung scan interpretation?????????????????????????????????????????????????????????????? 481
References?????????????????????????????????? 483
Chapter 93 Multidetector spiral CT of the chest for acute pulmonary embolism: results of the PIOPED II trial?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 485
Sensitivity, specificity, likelihood ratios, and predictive values of CTA???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 485
Positive predictive value according to largest pulmonary artery branch with PE?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 485
Sensitivity, specificity, likelihood ratios, and predictive values of CT pulmonary angiography with CT venography???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 485
CTA and CTA/CTV results and clinical assessment???????????????????????????????????????????????????????????????????????????????????????????????????????????? 486
Location of venous thrombi?????????????????????????????????????????????????????????????????? 489
Sensitivity analysis?????????????????????????????????????????????????????? 489
Complications???????????????????????????????????????? 489
References?????????????????????????????????? 490
Chapter 94 Multidetector CT pulmonary angiography since PIOPED II???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 491
The new diagnostic reference standard???????????????????????????????????????????????????????????????????????????????????????? 491
Evolution of technology???????????????????????????????????????????????????????????? 491
Scanners with > 16 detectors preferred for evaluation of PE????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????
False positive rate according to clinical probability and D-dimer???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 491
Validity of a negative multidetector CT angiogram???????????????????????????????????????????????????????????????????????????????????????????????????????????????? 491
Diagnostic yield of CT angiography?????????????????????????????????????????????????????????????????????????????????? 491
Evaluation for acute chest pain and "triple rule-out" test?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 492
Dual-energy CT angiography?????????????????????????????????????????????????????????????????? 492
Ancillary findings on CT angiograms???????????????????????????????????????????????????????????????????????????????????? 494
References?????????????????????????????????? 494
Chapter 95 Outcome studies of pulmonary embolism versus accuracy?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 496
References?????????????????????????????????? 497
Chapter 96 Contrast-induced nephropathy???????????????????????????????????????????????????????????????????????????????????????????? 498
Radiocontrast nephropathy in PIOPED I and PIOPED II???????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 498
Nonionic contrast material?????????????????????????????????????????????????????????????????? 498
Iso-osmolar contrast material???????????????????????????????????????????????????????????????????????? 498
Hydration???????????????????????????????? 498
Nonsteroidal anti-inflammatory drugs and dipyridamole???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 499
Metformin???????????????????????????????? 499
Acetylcysteine (Mucomist)???????????????????????????????????????????????????????????????? 499
Fendolopam?????????????????????????????????? 499
Postprocedural hemodialysis and periprocedural hemofiltration???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 499
References?????????????????????????????????? 499
Chapter 97 Radiation exposure and risk?????????????????????????????????????????????????????????????????????????????????????????? 501
Effective (whole body) dose with posterior-anterior and lateral chest radiograph?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 502
Effective (whole body) dose with CT pulmonary angiography???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 502
Breast doses with CT pulmonary angiography and V-Q SPECT?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 502
Dual-energy CT pulmonary angiography?????????????????????????????????????????????????????????????????????????????????????? 502
Effective (whole body) dose with conventional digital subtraction angiography???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 502
Effective (whole body) dose with CT venous phase venography???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 502
Effective dose with a perfusion lung scan???????????????????????????????????????????????????????????????????????????????????????????????? 503
Radiation dose of perfusion SPECT and ventilation-perfusion SPECT???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 503
Background radiation and allowable yearly effective dose in radiation workers???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 504
Risks of cancer with radiation?????????????????????????????????????????????????????????????????????????? 504
Breast cancer with radiation?????????????????????????????????????????????????????????????????????? 504
Cell damage from radiation?????????????????????????????????????????????????????????????????? 505
Genetic effects???????????????????????????????????????????? 505
Fetal exposure?????????????????????????????????????????? 505
References?????????????????????????????????? 505
Chapter 98 Magnetic resonance angiography for the diagnosis of acute pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 508
Contrast-enhanced MR angiography for acute PE???????????????????????????????????????????????????????????????????????????????????????????????????????? 508
Gd-MR venous phase imaging?????????????????????????????????????????????????????????????????? 509
Complications???????????????????????????????????????? 509
MR angiography without contrast material?????????????????????????????????????????????????????????????????????????????????????????????? 513
MR perfusion imaging?????????????????????????????????????????????????????? 513
References?????????????????????????????????? 514
Chapter 99 Serial noninvasive leg tests in patients with suspected pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 517
Outcome of patients with suspected PE who had negative serial impedance plethysmograms?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 517
Outcome of patients with suspected PE and negative serial venous ultrasound examinations?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 517
References?????????????????????????????????? 518
The ancient history of deep venous thrombosis and pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 29
References?????????????????????????????????? 29
Chapter 100 Diagnosis of pulmonary embolism in the coronary care unit???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 519
Predisposing factors?????????????????????????????????????????????????????? 519
Symptoms?????????????????????????????? 519
Signs???????????????????????? 520
Dyspnea and tachypnea???????????????????????????????????????????????????????? 520
Objective clinical assessment???????????????????????????????????????????????????????????????????????? 520
PaO2 and alveolar-arterial oxygen gradient?????????????????????????????????????????????????????????????????????????????????????????????????? 520
Electrocardiogram???????????????????????????????????????????????? 520
Chest radiograph?????????????????????????????????????????????? 520
Cardiac troponin and brain natriuretic peptides???????????????????????????????????????????????????????????????????????????????????????????????????????????? 520
D-dimer???????????????????????????? 520
CT angiography and CT venography?????????????????????????????????????????????????????????????????????????????? 521
Optional pathways???????????????????????????????????????????????? 521
Ventilation-perfusion lung scans?????????????????????????????????????????????????????????????????????????????? 521
Echocardiography?????????????????????????????????????????????? 521
Patients in extremis?????????????????????????????????????????????????????? 521
References?????????????????????????????????? 521
Chapter 101 Silent pulmonary embolism with deep venous thrombosis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 524
Prevalence of silent pulmonary embolism with deep venous thrombosis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 524
Severity of silent PE???????????????????????????????????????????????????????? 524
Recurrent PE with silent PE???????????????????????????????????????????????????????????????????? 524
Routine screening???????????????????????????????????????????????? 524
References?????????????????????????????????? 527
Chapter 102 Fat embolism syndrome???????????????????????????????????????????????????????????????????????????????? 529
Clinical description?????????????????????????????????????????????????????? 529
Mortality???????????????????????????????? 529
Prevalence?????????????????????????????????? 529
Prevalence according to fracture?????????????????????????????????????????????????????????????????????????????? 529
Prevalence in nonorthopedic patients?????????????????????????????????????????????????????????????????????????????????????? 532
Gender and age?????????????????????????????????????????? 532
Prior investigations?????????????????????????????????????????????????????? 532
References?????????????????????????????????? 532
Chapter 103 Diagnostic approach to acute pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 534
Exclusion of PE by clinical assessment with D-dimer???????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 534
Venous phase CT venography?????????????????????????????????????????????????????????????????? 534
Validity of a negative multidetector CT angiogram???????????????????????????????????????????????????????????????????????????????????????????????????????????????? 534
Importance of discordance between results of CT angiography and clinical probability?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 535
Venous ultrasound???????????????????????????????????????????????? 535
Ventilation-perfusion lung scans since PIOPED???????????????????????????????????????????????????????????????????????????????????????????????????????? 535
Perfusion lung scans with normal or nearly normal chest radiograph?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 536
Single photon emission computed tomography (SPECT)?????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 536
Patients with allergy to iodinated contrast material?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 536
Patients with impaired renal function???????????????????????????????????????????????????????????????????????????????????????? 536
Women of reproductive age???????????????????????????????????????????????????????????????? 536
Pregnant patients???????????????????????????????????????????????? 536
Patients in extremis?????????????????????????????????????????????????????? 537
Lung ultrasound???????????????????????????????????????????? 537
References?????????????????????????????????? 537
Part IV Prevention and treatment of deep venous thrombosis and pulmonary embolism 539
Chapter 104 Warfarin and other vitamin K antagonists?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 541
International normalized ratio?????????????????????????????????????????????????????????????????????????? 541
Optimal INR level???????????????????????????????????????????????? 541
Administration?????????????????????????????????????????? 543
Anticoagulation clinics???????????????????????????????????????????????????????????? 543
Computerized monitoring???????????????????????????????????????????????????????????? 543
Patient self-management???????????????????????????????????????????????????????????? 543
Stability of INR with vitamin K supplementation???????????????????????????????????????????????????????????????????????????????????????????????????????????? 543
Warfarin resistance???????????????????????????????????????????????????? 544
Genotype-guided dosing?????????????????????????????????????????????????????????? 544
Drug and dietary interactions???????????????????????????????????????????????????????????????????????? 544
Major and fatal bleeding?????????????????????????????????????????????????????????????? 544
Scores for prediction of major bleeding???????????????????????????????????????????????????????????????????????????????????????????? 544
Score for prediction of fatal bleeding?????????????????????????????????????????????????????????????????????????????????????????? 545
Reversal of high INR?????????????????????????????????????????????????????? 545
Nonhemorrhagic complications of warfarin?????????????????????????????????????????????????????????????????????????????????????????????? 546
References?????????????????????????????????? 546
Chapter 105 Unfractionated heparin, low-molecular-weight heparin, heparinoid, and pentasaccharide???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 549
Unfractionated heparin?????????????????????????????????????????????????????????? 549
Low-molecular-weight heparin?????????????????????????????????????????????????????????????????????? 551
Heparinoid?????????????????????????????????? 553
Pentasaccharide???????????????????????????????????????????? 553
References?????????????????????????????????? 554
Chapter 106 Parenteral inhibitors of factors Va, VIIIa, tissue factor, and thrombin???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 558
Factor Va and VIIIa inhibitors?????????????????????????????????????????????????????????????????????????? 558
Direct thrombin inhibitors?????????????????????????????????????????????????????????????????? 558
References?????????????????????????????????? 561
Chapter 107 Novel oral anticoagulants???????????????????????????????????????????????????????????????????????????????????????? 563
Approved novel oral anticoagulants and indications?????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 563
Mechanism of action of direct factor Xa inhibitors and direct thrombin inhibitor?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 563
Novel oral anticoagulants for prophylaxis following hip or knee replacement???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 563
Bleeding with novel oral anticoagulants during treatment of DVT and PE?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 563
Effectiveness of novel oral anticoagulants for treatment of DVT, PE, or VTE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 563
Outcome with novel oral anticoagulants in "real world" clinical practice?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 567
Outcome of extended treatment with novel oral anticoagulants?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 567
Pharmacology?????????????????????????????????????? 568
References?????????????????????????????????? 569
Chapter 108 Aspirin for venous thromboembolism?????????????????????????????????????????????????????????????????????????????????????????????????????????? 570
Aspirin for prophylaxis following major orthopedic surgery?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 570
Aspirin for prevention of recurrent venous thromboembolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 570
Major bleeding with aspirin for prevention of recurrent venous thromboembolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 571
Possible mechanism for effectiveness of aspirin in reducing recurrent venous thromboembolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 571
References?????????????????????????????????? 571
Chapter 109 Immediate therapeutic levels of heparin in relation to timing of recurrent events???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 573
References?????????????????????????????????? 575
Chapter 110 Intermittent pneumatic compression?????????????????????????????????????????????????????????????????????????????????????????????????????????? 576
Mechanism of action???????????????????????????????????????????????????? 576
Intermittent pneumatic compression after general surgery?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 576
Intermittent pneumatic compression after orthopedic surgery???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 576
Compliance in use of intermittent pneumatic compression devices???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 577
References?????????????????????????????????? 577
Chapter 111 Graduated compression stockings???????????????????????????????????????????????????????????????????????????????????????????????????? 579
Mechanism of action???????????????????????????????????????????????????? 579
Elastic compression stockings and deep venous thrombosis after general surgery?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 579
Elastic compression stockings and deep venous thrombosis in medical patients?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 580
Elastic compression stockings and deep venous thrombosis after orthopedic surgery???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 580
Elastic compression stockings and deep venous thrombosis after long-distance air travel???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 581
Compression stockings and post-thrombotic syndrome?????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 581
References?????????????????????????????????? 581
Chapter 112 Ankle exercise and venous blood velocity?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 583
References?????????????????????????????????? 584
Chapter 113 Thrombolytic therapy for deep venous thrombosis???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 585
Systemic thrombolytic therapy???????????????????????????????????????????????????????????????????????? 585
Locoregional thrombolytic therapy???????????????????????????????????????????????????????????????????????????????? 587
Catheter-directed thrombolytic therapy?????????????????????????????????????????????????????????????????????????????????????????? 587
References?????????????????????????????????? 588
Chapter 114 Mechanical and ultrasonic enhancement of catheter-directed thrombolytic therapy for deep venous thrombosis?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 590
Rheolytic systems???????????????????????????????????????????????? 590
Ultrasound?????????????????????????????????? 590
References?????????????????????????????????? 591
Chapter 115 Thrombolytic therapy for treatment of acute pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 592
History of thrombolytic therapy for acute pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 592
Mechanism of action???????????????????????????????????????????????????? 592
FDA-approved regimens and unapproved regimens???????????????????????????????????????????????????????????????????????????????????????????????????????? 592
Infusion directly into the pulmonary artery???????????????????????????????????????????????????????????????????????????????????????????????????? 592
Resolution?????????????????????????????????? 594
Resolution of functional abnormalities?????????????????????????????????????????????????????????????????????????????????????????? 594
Mortality???????????????????????????????? 595
Recurrent PE?????????????????????????????????????? 599
Major bleeding with thrombolytic therapy?????????????????????????????????????????????????????????????????????????????????????????????? 600
Major bleeding with "safe dose" rt-PA???????????????????????????????????????????????????????????????????????????????????????? 601
Predictors of major bleeding with thrombolytic therapy?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 602
Intracranial hemorrhage???????????????????????????????????????????????????????????? 602
Diagnostic tests before thrombolytic therapy?????????????????????????????????????????????????????????????????????????????????????????????????????? 603
Thrombolytic therapy for patients with massive PE who are being resuscitated from cardiopulmonary arrest?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 603
References?????????????????????????????????? 604
Chapter 116 Catheter-tip embolectomy in the management of acute massive pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 607
Aspiration thrombectomy???????????????????????????????????????????????????????????? 607
Fragmentation with standard angiographic catheters?????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 607
Fragmentation with catheter-tip device?????????????????????????????????????????????????????????????????????????????????????????? 608
Rheolytic technique???????????????????????????????????????????????????? 608
Fragmentation, embolectomy, and catheter thrombolysis (PERFECT registry)?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 610
Ultrasound-accelerated thrombolysis???????????????????????????????????????????????????????????????????????????????????? 611
American College of Chest Physicians recommendations?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 612
References?????????????????????????????????? 612
Chapter 117 Vena cava filters???????????????????????????????????????????????????????????????????????? 615
History of venous interruption?????????????????????????????????????????????????????????????????????????? 615
Permanent and retrievable vena cava filters???????????????????????????????????????????????????????????????????????????????????????????????????? 615
Use of vena cava filters?????????????????????????????????????????????????????????????? 615
Complications of permanent vena cava filters?????????????????????????????????????????????????????????????????????????????????????????????????????? 617
Complications of retrievable vena cava filters?????????????????????????????????????????????????????????????????????????????????????????????????????????? 618
Failure to attempt to remove retrievable vena cava filters?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 620
Vena cava filters for prophylaxis???????????????????????????????????????????????????????????????????????????????? 621
Vena cava filters for deep venous thrombosis?????????????????????????????????????????????????????????????????????????????????????????????????????? 621
Vena cava filters in stable patients with acute pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 621
Vena cava filters in stable patients according to age???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 622
Trends in case fatality rate in stable low-risk patients with PE with and without IVC filters???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 624
Stable patients who received thrombolytic therapy???????????????????????????????????????????????????????????????????????????????????????????????????????????????? 624
Stable patients who underwent pulmonary embolectomy???????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 624
Stable patients with chronic obstructive pulmonary disease?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 625
Stable patients with cancer???????????????????????????????????????????????????????????????????? 625
Prevention du Risque d'Embolie Pulmonaire par Interruption Cave2 (PREPIC2) Study?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 625
Vena cava filters in unstable patients with acute pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 626
Unstable patients undergoing pulmonary embolectomy?????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 627
Trends in the case fatality rate in unstable patients with PE with and without IVC filters?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 628
Use of vena cava filters according to stability in patients with pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 628
Indications for IVC filters???????????????????????????????????????????????????????????????????? 628
References?????????????????????????????????? 629
Chapter 118 Withholding treatment of patients with acute pulmonary embolism who have a high risk of bleeding provided and negative serial noninvasive leg tests???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 633
References?????????????????????????????????? 634
Chapter 119 Home treatment of deep venous thrombosis?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 635
Cautious approach to early discharge with DVT???????????????????????????????????????????????????????????????????????????????????????????????????????? 635
Home treatment of DVT, 2007-2012?????????????????????????????????????????????????????????????????????????????? 635
Home treatment according to comorbid conditions???????????????????????????????????????????????????????????????????????????????????????????????????????????? 636
Home treatment according to age???????????????????????????????????????????????????????????????????????????? 636
Decreasing length of hospital stay and increased rate of early discharge with DVT???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 636
Cultural differences regarding home treatment of DVT?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 636
Charges for emergency department visits and hospitalization???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 637
Recommendations for home treatment of DVT???????????????????????????????????????????????????????????????????????????????????????????????? 638
References?????????????????????????????????? 638
Chapter 120 Home treatment of acute pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 640
Decreasing length of hospital stay and increasing rate of early discharge in patients with PE???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 640
Outpatient treatment of PE in the United States???????????????????????????????????????????????????????????????????????????????????????????????????????????? 640
Outcome of outpatient treatment of pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 640
Recommendations for home treatment of pulmonary embolism?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 642
References?????????????????????????????????? 642
Chapter 121 Pulmonary embolectomy???????????????????????????????????????????????????????????????????????????????? 644
Observations from case series???????????????????????????????????????????????????????????????????????? 644
Average mortality from pulmonary embolectomy throughout the United States???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 644
Pulmonary embolectomy in unstable patients?????????????????????????????????????????????????????????????????????????????????????????????????? 647
Pulmonary embolectomy in stable patients?????????????????????????????????????????????????????????????????????????????????????????????? 647
Patients with primary diagnosis of pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 647
Patients with a primary diagnosis of pulmonary embolism and none of the comorbid conditions listed in the Charlson Index?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 647
Age and pulmonary embolectomy???????????????????????????????????????????????????????????????????????? 649
References?????????????????????????????????? 650
Chapter 122 Chronic thromboembolic pulmonary hypertension and pulmonary thromboendarterectomy???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 652
Prevalence of chronic thromboembolic pulmonary hypertension???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 652
Prevalence after acute pulmonary embolism???????????????????????????????????????????????????????????????????????????????????????????????? 652
Clinical manifestations and pathophysiology???????????????????????????????????????????????????????????????????????????????????????????????????? 652
Diagnosis???????????????????????????????? 652
Pulmonary thromboendarterectomy???????????????????????????????????????????????????????????????????????????? 654
Medical therapy???????????????????????????????????????????? 654
American College of Chest Physicians 2012 recommendations???????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 655
References?????????????????????????????????? 655
Chapter 123 Prevention and treatment of deep venous thrombosis and acute pulmonary embolism: American College of Chest Physicians Guidelines?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 657
Management of anticoagulant therapy???????????????????????????????????????????????????????????????????????????????????? 657
Management of high INR with vitamin K antagonist?????????????????????????????????????????????????????????????????????????????????????????????????????????????? 658
Prevention of VTE in nonsurgical patients???????????????????????????????????????????????????????????????????????????????????????????????? 658
Prevention of VTE in nonorthopedic surgical patients?????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? 659
Prevention of VTE in orthopedic surgery patients?????????????????????????????????????????????????????????????????????????????????????????????????????????????? 660
Antithrombotic therapy for VTE disease?????????????????????????????????????????????????????????????????????????????????????????? 660
References?????????????????????????????????? 662
Index???????????????????????? 665
EULA 689

Erscheint lt. Verlag	5.4.2016
Sprache	englisch
Themenwelt	Medizin / Pharmazie ► Allgemeines / Lexika
	Medizinische Fachgebiete ► Innere Medizin ► Kardiologie / Angiologie
	Medizinische Fachgebiete ► Innere Medizin ► Pneumologie
Schlagworte	acute pulmonary embolism • Anticoagulants • Cardiovascular Disease • Deep venous thrombosis • DVT • KardiovaskulÃ¤re Erkrankung • KardiovaskulÃ¤re Erkrankungen • Kardiovaskuläre Erkrankung • Kardiovaskuläre Erkrankungen • Lungenembolie • Medical Science • Medizin • Medizin des Atmungssystems • Paul D. Stein • PE • Pulmonary embolism • Radiologie • Radiologie u. Bildgebende Verfahren • Radiology & Imaging • Respiratory Medicine • Thrombectomy • Thrombolytic therapy • vena cava filters • Venous Thromboembolism • VTE
ISBN-10	1-119-03909-6 / 1119039096
ISBN-13	978-1-119-03909-9 / 9781119039099

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