Volume 120, Issue 10, Supplement 2 , Page S1, October 2007
Introduction
Article Outline
Pulmonary embolism (PE) remains a major challenge in medicine. Historically, any type of physician may be called on to diagnose and manage PE. Frustratingly, mortality rates may approach 30% in medical patients with untreated PE. With rapid identification and appropriate therapy, however, mortality is dramatically reduced.1 Early and accurate diagnosis of this potentially fatal condition is therefore of the utmost importance.
Although much has been written on risk assessment, less attention has been given to the recent technologic advances that enable quick and accurate diagnosis of PE. Pulmonary angiography has long been held to be the “gold standard” for definitive diagnosis, yet newer modalities have emerged to challenge this assumption. Recently, computed tomographic pulmonary angiography with or without imaging of the lower extremities has all but replaced traditional angiography. In the first article of this supplement to The American Journal of Medicine, Drs. Seth Clemens and Kenneth V. Leeper review the evidence on the relative accuracies and limitations of these newer modalities, concluding with how they fit into an algorithm for first-line evaluation of PE.
Additionally, this supplement focuses on several areas of active controversy. The ease of introduction of inferior vena cava filters and the advent of retrievable devices have led to their expanded use. Yet, according to current evidence-based guidelines, they are recommended only for patients with proven venous thromboembolism (VTE) and an absolute contraindication for anticoagulation, a complication of anticoagulation, or recurrent VTE despite adequate anticoagulation.2 Dr. Mark A. Crowther reviews the limited evidence currently available on these devices.
Although outpatient management of patients with deep vein thrombosis is becoming more widely accepted, outpatient treatment of persons with PE remains an area of uncertainty. Yet, new data are emerging to show that outpatient treatment may be feasible for selected patients who are deemed to be at low risk based on careful risk stratification. Following an overview of the pathogenesis and epidemiology of PE, Drs. Teresa L. Carman and Amjad AlMahameed discuss risk stratification and the available evidence, benefits, and therapeutic options pertaining to outpatient management of these patients.
Thromboembolic disease is now the leading cause of maternal death in the United States.3 Pregnant women are at increased risk of thrombosis both during pregnancy and postpartum, due to a relative hypercoagulable state that is thought to have evolved to protect them from hemorrhage. Anticoagulation in these patients is challenging, requiring consideration of both maternal and fetal issues. After a review of risk factors for thrombosis in pregnancy and indications for VTE prophylaxis, Dr. Andra H. James discusses options for prophylaxis, initiation of anticoagulation, and diagnosis and management of VTE in pregnancy, as well as management at parturition and postpartum.
Finally, in today’s world of third-party payers and managed care medicine, pharmacoeconomics is assuming an ever-increasing role. The economic burden posed by VTE is considerable, and pharmacoeconomic analyses have become a useful tool for helping clinicians select appropriate therapy from among similarly effective and safe therapies. In the last article of this supplement, I discuss factors that may affect the relative costs of different approaches to treatment and review recent clinical and pharmacoeconomic data comparing fondaparinux with enoxaparin.
We hope that readers will find the articles in this supplement both thought provoking and useful as a guide for detection and management of an important condition that is potentially devastating, yet treatable if detected in a timely manner.
References
- The clinical course of pulmonary embolism. N Engl J Med. 1992;326:1240–1245
- . Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(suppl 3):401S–428S
- Pregnancy-related mortality surveillance—United States, 1991–1999. MMWR Surveill Summ. 2003;52:1–8
Statement of conflict of interest: Andrew F. Shorr, MD, MPH, reports no conflict of interest with the sponsor of this supplement article or products discussed in this article.
PII: S0002-9343(07)00665-1
doi:10.1016/j.amjmed.2007.07.013
© 2007 Elsevier Inc. All rights reserved.
Volume 120, Issue 10, Supplement 2 , Page S1, October 2007
