Temporal trends in vena cava filter implantation in public health system inpatients: an 11-year analysis of the largest city in Brazil / Tendência temporal do implante de filtro de veia cava em pacientes internados no SUS em São Paulo: análise de 11 anos da maior cidade do Brasil

Abstract Background Vena cava filter implantation is considered a simple procedure, which can lead to overuse and over-indication. It is nevertheless associated with short and long-term complications. Objectives The goals of this study were to evaluate rates of vena cava filter implantation conducted by Brazil's Unified Public Health System, analyzing in-hospital mortality and migration of patients from other cities seeking medical attention in São Paulo. Methods This study analyzed all vena cava filter procedures conducted from 2008 to 2018 in the city of São Paulo and registered on the public database using a big data system to conduct web scraping of publicly available databases. Results A total of 1324 vena cava filter implantations were analyzed. 60.5% of the patients were female; 61.7% were under 65 years old; 34.07% had registered addresses in other cities or states; and there was a 7.4% in-hospital mortality rate. Conclusions We observed an increase in the rates of use of vena cava filters up to 2010 and a decrease in rates from that year onwards, which coincides with the year that the Food and Drug Administration published a recommendation to better evaluate vena cava filter indications.

Resumo Contexto O implante de filtro de veia cava é considerado um procedimento de baixa complexidade, o que pode resultar em indicação excessiva. No entanto, não é isento de complicações a curto e longo prazo. Objetivos Avaliar as taxas de implantes de filtro de veia cava realizados pelo Sistema Único de Saúde e a origem geográfica e mortalidade intra-hospitalar dos pacientes. Métodos Foi conduzida uma análise em um banco de dados públicos referente às taxas de implantes de filtro de veia cava realizados de 2008 a 2018 na cidade de São Paulo, utilizando o sistema de big data. Resultados Foram analisados 1.324 implantes de filtro de veia cava financiados pelo Sistema Único de Saúde. Identificou-se tendência de aumento da taxa de implantação até 2010 e de redução dos números após esse período. Do total de pacientes, 60,5% eram do sexo feminino; 61,75% tinham menos de 65 anos; e 34,07% possuíam endereço oficial em outra cidade ou estado. A taxa de mortalidade intra-hospitalar foi de 7,4%. Conclusões Observamos aumento das taxas de implante de filtro de veia cava até 2010 e redução das taxas após esse período, o que coincide com o ano em que a organização norte-americana Food and Drug Administration publicou uma recomendação para melhor avaliar as indicações de filtros.

Clinical characteristics of patients with acute pulmonary embolism in high altitude area of Yunnan province in China / 中华心血管病杂志

Objective: To analyze the clinical features of patients with acute pulmonary embolism (APE) living in high altitude area of Yunnan province. Methods: This was a cross-sectional retrospective study. APE patients, hospitalized in our hospital between January 2017 and December 2019, were included. The selected patients were divided into low-risk group, medium-risk group and high-risk group according to risk stratification. The clinical data of patients, including demographic data, the main symptoms, risk factors of APE, heart rate and systolic blood pressure and laboratory testing results (D-dimer, cardiac troponin I (cTNI), N terminal B-type natriuretic peptide (NT-proBNP)) and echocardiography and electrocardiogram examination results, were obtained through the electronic medical record system. The clinical characteristics of selected patients were analyzed. Results: A total of 392 patients, aged (63.5±15.7) years, 224 males (57.14%), were included in this study and there were 59 low-risk, 304 medium-risk and 29 high-risk patients in this cohort. The main clinical manifestations were chest pain (157(40.05%)), dyspnea (107(27.30%)), hemoptysis (55(14.03%)), syncope as the first symptom (20(5.10%)), and only 6 cases (1.53%) presented with the typical "Virchow's triad". Most of the patients were accompanied by atypical chest tightness (223(56.89%)) and cough (208(53.06%)). The main risk factors were venous thrombosis of lower limbs (179(45.66%)), hypertension (138(35.20%)), surgery (63(16.07%)), and chronic obstructive pulmonary disease (COPD) (62(15.82%)). There were 57 cases (14.54%) of coronary heart disease, 57 cases (14.54%) of diabetes, 51 cases (13.01%) of cerebral infarction, 47 cases (12.00%) of advanced age, 15 cases (3.83%) of tumor, 7 cases (1.79%) of activity restriction, 6 cases (1.53%) of pregnancy and 4 cases (1.02%) of hormone use in this cohort. The proportion of lower extremity venous thrombosis was significantly higher in low-risk group than in medium-risk group (P<0.01), COPD was more common in high-risk and medium-risk groups than in low-risk group (P<0.01), hypertension was more common in high-risk group than in medium-and low-risk groups (P<0.01). The proportion of advanced age was significantly higher in medium-risk group than in low-risk group (P<0.01). There were no significant differences in RBC and hemoglobin level between low-, medium-and high-risk groups (P>0.05). The level of D-dimer was significantly higher in high-risk group than in medium-and low-risk groups (P<0.05). Levels of NT-proBNP and cTNI were significantly higher in high-risk group than in medium- and low-risk groups (P<0.05). Increased proportion of cTNI and NT-proBNP was significantly higher in high-risk group than in medium- and low-risk groups (P<0.05). There were 105 (26.79%) patients with pulmonary hypertension (PAH). The incidence of PAH was significantly higher in high-risk group than in low-risk group (P<0.01). There were 104 patients (26.53%) with right ventricular enlargement, and the incidence of right ventricular enlargement was significantly higher in high-risk group than in medium-and low-risk groups (P<0.01). Characteristic changes of electrocardiogram in patient with APE were T-wave inversion of limb leads (98(25.00%)), followed by SⅠQⅢTⅢ (83(21.17%)). Conclusions: The main clinical manifestations of APE in Yunnan high altitude area are chest pain and dyspnea, and syncope is the first symptom in some patients, but the typical "Virchow's triad" is rare. The most common risk factors are lower extremity venous thrombosis, hypertension, and COPD. Clinical symptoms, risk factors and laboratory examination results differ among patients with different risk stratification.

Fatores de risco para embolia pulmonar em pacientes com COVID-19 anticoagulados na unidade de terapia intensiva submetidos à angiografia por tomografia computadorizada / Pulmonary embolism risk factors for intensive care unit anticoagulated COVID-19 patients undergoing computed tomography angiography

RESUMO Objetivo: Avaliar a incidência de embolia pulmonar, seu relacionamento com os níveis de dímero D e outros possíveis fatores associados, além dos efeitos adversos da anticoagulação e meios de contraste. Métodos: Conduziu-se um estudo de coorte retrospectiva em um hospital público chileno. Foram incluídos os pacientes com idade acima de 18 anos com COVID-19, mecanicamente ventilados na unidade de terapia intensiva, admitidos entre março e junho de 2020. Todos os pacientes receberam tromboprofilaxia com heparina, que foi aumentada até uma dose de anticoagulação com níveis de dímero D acima de 3µg/mL. Resultados: Foram acompanhados 127 pacientes, dos quais 73 foram submetidos à angiografia por tomografia computadorizada (média de idade de 54 ± 12 anos; 49 homens). Sessenta e dois dos 73 pacientes (84,9%) receberam anticoagulação total antes da angiografia por tomografia computadorizada. Além disso, 18 dos 73 pacientes tiveram embolia pulmonar (24,7%). Na comparação entre pacientes com e sem embolia pulmonar, não se observaram diferenças significantes em termos de idade, sexo, obesidade, tabagismo, escores de Wells e Genebra revisado, dímero D ou mortalidade. O uso de anticoagulantes foi similar em ambos os grupos. O número de dias desde o início da anticoagulação até a angiografia por tomografia computadorizada foi significantemente menor no grupo com embolia pulmonar (p = 0,002). Três pacientes tiveram lesão renal aguda após o contraste (4,1%), e um paciente teve sangramento importante. Conclusão: Apesar da anticoagulação, um em cada quatro pacientes com COVID-19 submetidos à ventilação mecânica e avaliados com angiografia por tomografia computadorizada apresentou embolia pulmonar. Com uma maior demora para realização da angiografia por tomografia computadorizada após início de anticoagulação empírica, identificou-se um número significantemente menor de embolias

Abstract Objective: To assess pulmonary embolism incidence, its relationship with D-dimer levels and other possible associated factors in addition to anticoagulation and contrast medium adverse effects. Methods: A retrospective observational cohort study at a Chilean public hospital was performed. Intensive care unit mechanically ventilated COVID-19 patients older than 18 years old between March and June 2020 were included. All patients received heparin thromboprophylaxis, which was increased to the anticoagulation dose with D-dimer greater than 3µg/mL. Results: A total of 127 patients were followed up, of whom 73 underwent pulmonary computed tomography angiography (mean age, 54 ± 12 years; 49 men). Sixty-two of the 73 patients (84.9%) received full anticoagulation before computed tomography angiography. In addition, 18 of the 73 patients had pulmonary embolism (24.7%). When comparing patients with and without pulmonary embolism, no significant differences were observed in age, sex, obesity, smoking, Wells and revised Geneva scores, D-dimer or mortality. Anticoagulant use was similar in both groups. Days from the start of anticoagulation until computed tomography angiography were significantly lower in the pulmonary embolism group (p = 0.002). Three patients presented post contrast-acute kidney injury (4.1%), and one patient had major bleeding. Conclusion: Despite anticoagulation, one in four COVID-19 patients connected to mechanical ventilation and evaluated with pulmonary computed tomography angiography had pulmonary embolism. With a longer the delay in performing computed tomography angiography once empirical anticoagulation was started, significantly less pulmonary embolism was identified.

Incidence, diagnosis, treatment methods, and outcomes of clinically suspected venous thromboembolic disease in patients with COVID-19 in a quaternary hospital in Brazil / Incidência, diagnóstico, métodos terapêuticos e desfechos de eventos tromboembólicos venosos em pacientes com COVID-19 em um hospital quaternário do Brasil

Abstract Background Prothrombotic states have been associated with viral infections and the novel Sars-COV-2 infection has been associated with elevated D-dimer levels, although no causal relation has been clearly established. Objectives This study presents an epidemiological analysis of manifest VTE episodes in a group of patients hospitalized because of COVID-19. Methods Medical records of patients who presented symptomatic deep vein thrombosis and/or pulmonary embolism in concomitance with confirmed COVID-19 were retrospectively studied. Demographic characteristics, prevalence of VTE, site of occurrence, D-dimer variation over time, management, and outcomes were analyzed. Results During the study period, 484 confirmed cases of COVID-19 were admitted, 64 of which displayed VTE symptoms and 13 of which had confirmed symptomatic VTE(2.68% of total sample and 20.31% of symptomatic cases). Most cases (76.92%) occurred in intensive care. On the day attributed to VTE onset, D-dimer levels were over 3,000 ng/mL in 8 (80%) patients, a significant increase from baseline admission levels (p < 0.05). A significant decrease was also observed in D-dimer values at hospital discharge (p < 0.05). All patients received pharmacological thromboprophylaxis and/or anticoagulation as indicated. Two deaths occurred during the study, both patients with severe comorbidities. At the end of our study protocol, nine patients had been discharged and two remained hospitalized, but had no signs of VTE worsening. Conclusions VTE prevalence in hospitalized COVID-19 patients was 2.7%, and higher in intensive care units. Early institution of prophylaxis and immediate full anticoagulation when VTE is diagnosed should be the goals of those who treat this kind of patient.

Resumo Contexto Os estados pró-trombóticos têm sido associados a infecções virais. A nova infecção pela síndrome respiratória aguda grave do coronavírus 2 (SARS-CoV-2) sabidamente eleva os níveis de D-dímero, embora a relação causal não tenha sido bem estabelecida. Objetivos Este estudo apresenta uma análise epidemiológica de episódios sintomáticos de tromboembolismo em um grupo de pacientes hospitalizados pela doença do novo coronavírus (COVID-19). Métodos Foi realizada uma revisão retrospectiva de prontuários de pacientes internados por COVID-19 que apresentaram trombose venosa profunda e/ou embolia pulmonar sintomáticas. Foram avaliados os dados demográficos, a prevalência de tromboembolismo, a variação do D-dímero ao longo do tempo, o manejo e os desfechos. Resultados Dos 484 casos confirmados de COVID-19 admitidos entre março e julho de 2020, 64 apresentaram sintomas de tromboembolismo, que foram investigados, e 13 tiveram tromboembolismo confirmado (2,68% do total e 20,31% dos sintomáticos). A maioria dos casos ocorreu em regime de terapia intensiva (76,92%). Houve um aumento significativo no número de pacientes com D-dímero acima de 3.000 ng/mL no dia atribuído ao diagnóstico de tromboembolismo com relação aos níveis do momento da admissão (80%, p < 0,05).Uma queda significativa de pacientes nesse limiar também foi observada no momento da alta (p < 0,05). Todos os pacientes receberam tromboprofilaxia ou anticoagulação conforme indicado. Houve dois óbitos na amostra, ambos pacientes com comorbidades severas. Ao fim do protocolo, nove pacientes receberam alta e dois permaneceram hospitalizados, mas sem sinais de piora. Conclusões A prevalência de tromboembolismo em pacientes hospitalizados por COVID-19 foi de 2,7%, sendo mais frequente em regime de terapia intensiva. A instituição precoce de profilaxia e anticoagulação imediata ao diagnóstico é primordial nesse grupo de pacientes.

Utilidad diagnóstica del dímero D cuantitativo / Diagnostic usefulness of quantitative D-dimer

Introducción: El dímero D es un marcador de la generación de trombina y plasmina. Constituye el producto final de la degradación de un trombo rico en fibrina mediada por la acción secuencial de 3 enzimas: trombina, factor FXIIIa y plasmina. Las pruebas disponibles en la actualidad para el diagnóstico del dímero D son variadas y no son uniformes. Objetivo: Analizar las evidencias disponibles sobre la utilidad de diferentes pruebas rápidas de dímero D. Métodos: Se realizó una revisión de la literatura de los últimos diez años, en inglés y español, utilizando motores de búsqueda como Google Académico y Pubmed que permitió el acceso a artículos relacionados en revistas arbitradas. Se agrupó y organizó información sobre las posibles utilidades del dímero D. Desarrollo: La determinación en el laboratorio del dímero D, se usa como prueba rápida y sencilla, posee un lugar definido en los algoritmos de exclusión de la enfermedad tromboembólica venosa, en el diagnóstico de coagulación intravascular diseminada y con aplicación en la predicción de la recidiva de trombosis venosa profunda, en los últimos años. Existen diversos ensayos para la determinación de la concentración plasmática de dímero D que utilizan distintas metodologías, diferentes anticuerpos y sensibilidades. Conclusiones: La determinación de dímero D por los métodos cuantitativos en pacientes con trastornos trombóticos es muy importante para determinar su sensibilidad, y fundamentar el desarrollo del algoritmo diagnóstico de las mencionadas entidades(AU)

Introduction: D-dimer is a marker of thrombin and plasmin generation. It is the final product of the degradation of a fibrin-rich thrombus mediated by the sequential action of three enzymes: thrombin, factor XIIIa and plasmin. The tests currently available for D-dimer diagnosis are varied and not uniform. Objective: Analyze the evidence available about the usefulness of a number of D-dimer rapid tests. Methods: A review was conducted of the literature published in English and Spanish in the last ten years, using search engines such as Google Scholar and PubMed, which allowed access to papers about the topic in peer-reviewed journals. Data about the possible uses of D-dimer were grouped and organized. Discussion: Laboratory D-dimer determination is a rapid and simple test that has occupied a definite place in the exclusion algorithms for venous thromboembolic disease, the diagnosis of disseminated intravascular coagulation, and the prediction of deep venous thrombosis recurrence in recent years. A number of assays are available to determine D-dimer plasma concentration. These are based on different methodologies, antibodies and sensitivity values. Conclusions: D-dimer determination by quantitative methods is very important in patients with thrombotic disorders to determine their sensitivity and substantiate the development of the diagnostic algorithm for the aforementioned conditions(AU)

Determinación del riesgo de tromboembolismo pulmonar y trombosis venosa profunda en pacientes hospitalizados en un servicio de medicina interna / Determination of the risk of lung thromboembolism and deep venous thrombosis in patients hospitalized in an internal medicine service

Objetivo General: Determinar el riesgo de Tromboembolismo pulmonar (TEP) y Trombosis venosa profunda (TVP) en un grupo pacientes con patologías médicas. Métodos: Se realizó un estudio, unicéntrico, descriptivo, longitudinal, en pacientes > 18 años, ingresados por un periodo mayor de 72 horas en el servicio de medicina interna del Hospital Central del IVSS "Dr. Miguel Pérez Carreño", aplicando los modelos de evaluación de riesgos de Padua y Caprini. Resultados: La muestra estuvo representada por 114, el promedio de edad fue de 51 años ± 23, de mayoría femenino con 55 %, el principal diagnóstico de ingreso hospitalario, fue de origen infeccioso con 42,2 %. La escala Padua clasificó como bajo riesgo al 88,6 % y Caprini en alto riesgo al 36,8 %. El primer factor de riesgo fue la edad > 40 años con 82,46 %. El 3,51% de los pacientes presentaron un evento tromboembólico, teniendo positividad en el Dímero D con una media de 733,7 ± 181,3, al igual el eco-doppler venoso y en el caso de TEP, el angiotac pulmonar evidenció trombo de la rama derecha de la arteria pulmonar. Los dos factores de riesgo en este grupo estuvo dado por la edad (>65 años) y tasa de filtración glomerular <90 mL/min/1.73m2. El modelo de evaluación de riesgos de Padua presentó mayor capacidad predictiva (p < 0,05). Conclusión: La presencia de ETEV fue baja, a pesar que la muestra evaluada presentaba factores de riesgo y sin terapia trombo profiláctica, que evidencia la necesidad de evaluar los modelos de riesgos en pacientes con patologías médicas hospitalizados

General Objective: To determine the risk of pulmonary thromboembolism (PET) and deep vein thrombosis (DVT) in a group of patients with medical pathologies. Methods: A longitudinal, descriptive, single-center study was conducted in patients > 18 years, admitted for a period of more than 72 hours in the internal medicine service of the Central Hospital of the IVSS "Dr. Miguel Pérez Carreño", applying the Padua and Caprini risk assessment models. Results: The sample was represented by 114, the average age was 51 years ± 23, mostly female with 55 %, the main diagnosis of hospital admission, was of infectious origin with 42,2 %. The Padua scale classified 88,6 % as low risk and Caprini as high risk 36.8 %. The first risk factor was age > 40 years with 82,46 %. 3,51% of the patients presented a thromboembolic event, having a D-Dimer positivity with a mean of 733,7 ± 181,3, like venous echo-Doppler and, in the case of PET, pulmonary angiotac showed thrombus of the right branch of the pulmonary artery. The two risk factors for this group were given by age (> 65 years) and glomerular filtration rate <90 mL / min / 1.73m2. The Padua risk assessment model showed greater predictive capacity (p < 0.05). Conclusion: The presence of VTE was low, despite the fact that the sample evaluated presented risk factors and without thromboprophylactic therapy, which shows the need to evaluate the risk models in patients with hospitalized medical conditions

Incidence and morphological characteristics of the reversed halo sign in patients with acute pulmonary embolism and pulmonary infarction undergoing computed tomography angiography of the pulmonary arteries / Incidência e características morfológicas do sinal do halo invertido em pacientes com tromboembolismo pulmonar agudo e infarto pulmonar submetidos a angiotomografia de artérias pulmonares

ABSTRACT Objective: To determine the incidence of the reversed halo sign (RHS) in patients with pulmonary infarction (PI) due to acute pulmonary embolism (PE), detected by computed tomography angiography (CTA) of the pulmonary arteries, and to describe the main morphological features of the RHS. Methods: We evaluated 993 CTA scans, stratified by the risk of PE, performed between January of 2010 and December of 2014. Although PE was detected in 164 scans (16.5%), three of those scans were excluded because of respiratory motion artifacts. Of the remaining 161 scans, 75 (46.6%) showed lesions consistent with PI, totaling 86 lesions. Among those lesions, the RHS was seen in 33 (38.4%, in 29 patients). Results: Among the 29 patients with scans showing lesions characteristic of PI with the RHS, 25 (86.2%) had a single lesion and 4 (13.8%) had two, totaling 33 lesions. In all cases, the RHS was in a subpleural location. To standardize the analysis, all images were interpreted in the axial plane. Among those 33 lesions, the RHS was in the right lower lobe in 17 (51.5%), in the left lower lobe in 10 (30.3%), in the lingula in 5 (15.2%), and in the right upper lobe in 1 (3.0%). Among those same 33 lesions, areas of low attenuation were seen in 29 (87.9%). The RHS was oval in 24 (72.7%) of the cases and round in 9 (27.3%). Pleural effusion was seen in 21 (72.4%) of the 29 patients with PI and the RHS. Conclusions: A diagnosis of PE should be considered when there are findings such as those described here, even in patients with nonspecific clinical symptoms.

RESUMO Objetivo: Verificar a incidência do sinal do halo invertido (SHI) associado a infartos pulmonares (IP) relacionados ao tromboembolismo pulmonar (TEP) agudo, identificado por angiotomografia (angio-TC) de artérias pulmonares, e demonstrar as principais características morfológicas do SHI. Métodos: Foram avaliadas 993 angio-TCs, após estratificação de risco clínico para TEP entre janeiro de 2010 e dezembro de 2014. TEP foi encontrado em 164 pacientes (16,5%), sendo que três exames foram descartados devido a artefatos de movimentação respiratória. Dos 161 exames restantes, em 75 (46,6%) foram identificadas imagens compatíveis com IP, totalizando 86 lesões; o SHI foi observado em 33 (38,4% dos pacientes) dessas lesões. Resultados: Dos 29 pacientes com lesões características de IP com o SHI, 25 pacientes (86,2%) apresentavam lesão única e 4 (13,8%), lesão dupla. Todas as imagens compatíveis com SHI eram de localização subpleural. Para padronizar a análise, todas as imagens foram interpretadas no plano axial. Em relação à distribuição lobar das 33 lesões, o SHI estava localizado no lobo inferior direito, em 17 (51,5%); no lobo inferior esquerdo, em 10 (30,3%); na língula, em 5 (15,2%) e no lobo superior direito, em 1 (3,0%). Áreas de baixa atenuação no interior dos IPs com o SHI foram observadas em 29 das 33 lesões (87,9%). O SHI apresentava formato ovalado em 24 (72,7%) dos casos e formato arredondado, em 9 (27,3%). Derrame pleural foi encontrado associado aos IP com o SHI em 21 pacientes (72,4%). Conclusões: O achado de imagens com essas características, mesmo em pacientes com sintomatologia inespecífica, deve alertar para a possibilidade do diagnóstico de TEP.

Validation of the Pulmonary Embolism Severity Index for risk stratification after acute pulmonary embolism in a cohort of patients in Brazil / Validação do Pulmonary Embolism Severity Index para a estratificação de risco após tromboembolia pulmonar aguda em uma coorte no Brasil

ABSTRACT Objective: To validate the Pulmonary Embolism Severity Index (PESI), which was developed for risk stratification after acute pulmonary embolism (PE), for use in Brazil. Methods: This was a single-center retrospective study involving patients admitted to the emergency department with acute PE. The original and simplified versions of the PESI were calculated using hospital admission data from medical records. The outcome measure was the overall 30-day mortality rate. Results: We included 123 patients. The mean age was 57 ± 17 years, and there was a predominance of females, who accounted for 60% of the cohort. There were 28 deaths, translating to an overall 30-day mortality rate of 23%. In the cluster analysis by risk class, overall 30-day mortality was 2.40% for classes I-II, compared with 20.00% for classes III-IV-V (relative risk [RR] = 5.9; 95% CI: 1.88-18.51; p = 0.0002). When we calculated overall 30-day mortality using the simplified version (0 points vs. ≥ 1 point), we found it to be 3.25% for 0 points and 19.51% for ≥ 1 point (RR = 2.38; 95% CI: 0.89-6.38; p = 0.06). Using the original version, a survival analysis showed that risk classes I and II presented similar Kaplan-Meier curves (p = 0.59), as did risk classes III, IV, and V (p = 0.25). However, the curve of the clusters based on the original version, showed significantly higher mortality in the III-IV-V classes than in the I-II classes (RR = 7.63; 95% CI: 2.29-25.21; p = 0.0001). The cluster analysis based on the original version showed a greater area under the ROC curve than did the analysis based on the simplified version (0.70; 95% CI: 0.62-0.77 vs. 0.60; 95% CI: 0.51-0.67; p = 0.05). Conclusions: The PESI adequately predicted the prognosis after acute PE in this sample of the population of Brazil. The cluster analysis based on the original version is the most appropriate analysis in this setting.

RESUMO Objetivo: Pulmonary Embolism Severity Index (PESI) foi desenvolvido para a estratificação de risco após tromboembolia pulmonar (TEP) aguda. Nosso objetivo foi validá-lo para uso no Brasil. Métodos: Estudo retrospectivo unicêntrico incluindo pacientes com TEP admitidos numa unidade de emergência. O PESI (versão original e simplificada) foi calculado utilizando-se dados dos prontuários na admissão hospitalar. O desfecho analisado foi mortalidade geral em 30 dias (MG30). Resultados: Foram incluídos 123 pacientes, com média de idade de 57 ± 17 anos, predomínio do sexo feminino (60%) e MG30 de 28 óbitos (23%). Na análise agrupada, a MG30 (classes I-II vs. III-IV-V) foi de 2,40% vs. 20,00% (risco relativo [RR] = 5,9; IC95%: 1,88-18,51; p = 0,0002). A MG30 na versão simplificada (0 vs. ≥ 1 ponto) foi de 3,25% vs. 19,51% (RR = 2,38; IC95%: 0,89-6,38; p = 0,06). A análise da sobrevida mostrou que as curvas de Kaplan-Meier foram semelhantes nas classes I e II (p = 0,59) e entre as classes III, IV e V (p = 0,25). A curva da versão original agrupada mostrou que a MG30 foi significativamente maior no grupo III-IV-V que no grupo I-II (RR = 7,63; IC95%: 2,29-25,21; p = 0,0001). A análise agrupada da versão original mostrou área sob a curva ROC maior que a da versão simplificada (0,70; IC95%: 0,62-0,77 vs. 0,60; IC95%: 0,51-0,67; p = 0,05). Conclusões: O PESI mensurou adequadamente o prognóstico de MG30 após TEP aguda nesta amostra da população brasileira. A utilização da versão original agrupada foi a mais adequada nesse cenário.

Venous thromboembolism in Latin America: a review and guide to diagnosis and treatment for primary care

There are various region-specific challenges to the diagnosis and effective treatment of venous thromboembolism in Latin America. Clear guidance for physicians and patient education could improve adherence to existing guidelines. This review examines available information on the burden of pulmonary embolism and deep vein thrombosis in Latin America and the regional issues surrounding the diagnosis and treatment of pulmonary embolism and deep vein thrombosis. Potential barriers to appropriate care, as well as treatment options and limitations on their use, are discussed. Finally, an algorithmic approach to the diagnosis and treatment of venous thromboembolism in ambulatory patients is proposed and care pathways for patients with pulmonary embolism and deep vein thrombosis are outlined for primary care providers in Latin America.

Embolia pulmonar grasa: Presentación de un caso / Pulmonary fat embolism. Case report

La embolia grasa (EG) es una obstrucción de los vasos sanguíneos por glóbulos de grasa. Ha sido descrita en la circulación pulmonar con una gran variedad de asociaciones, pero las más comunes e importantes se dan con fracturas de huesos largos y daño de tejido blando debido a traumatismo grave. Por su parte, el síndrome de embolia grasa (SEG) es una manifestación poco frecuente, aunque grave, del fenómeno de embolia grasa, que se caracteriza clínicamente por la tríada disnea, petequias y confusión mental. La razón de la discrepancia entre la presencia de embolia grasa y el desarrollo del síndrome no es clara. Presentamos el caso de un hombre de 41 años que, inmediatamente después del trauma, presentó en la tomografía computada (TC) inicial defectos de llenado de atenuación grasa dentro de las arterias pulmonares. Estos fueron interpretados como múltiples embolias grasas macroscópicas. Los valores de atenuación de la tomografía computada multidetector (TCMD) de las embolias pulmonares deben examinarse cuidadosamente en el contexto de un traumatismo agudo o después de procedimientos ortopédicos, debido a la complicación rara pero potencialmente fatal del SEG. En los centros de trauma, la TCMD es una herramienta esencial para hacer el diagnóstico de la embolia grasa macroscópica, así como también para descartar otras causas de hipoxia, como la embolia pulmonar trombótica. La reconstrucción de cortes finos debe utilizarse para la evaluación detallada de la vasculatura pulmonar.

Fat embolism (FE) may be defined as the blockage of blood vessels by fat globules. Pulmonary fat embolisms are reported to be associated with a wide variety of conditions, with the most common and important ones being with long bone fractures and soft tissue damage due to severe trauma. Fat embolism syndrome (FES) is a rare but serious manifestation of the fat embolism phenomenon, characterized clinically by a triad of dyspnea, petechiae, and mental confusión. The discrepancy between the presence of a fat embolism and the development of fat embolism syndrome is unclear. The case is presented of a 41 year-old mate who, on the initial trauma CT sean, presented with filling defeets of fat attenuation within the pulmonary arteries. Those were interpreted as múltiple macroscopic fat emboli. The CT attenuation valúes of pulmonary embolism should be carefully examined in the setting of acute trauma or after orthopedic procedures, as the rare but potentially fatal complicaron of FES may result. In trauma centers, multidetectorcomputed tomography is an essential tool to make the diagnosis of macroscopic fat embolism, and to exelude other causes of hypoxia, such as thrombotic pulmonary embolism. These reconstructions should be used for detailed evaluation of the pulmonary vasculature.

BISAP-O y APACHE-O: utilidad en la predicción de severidad en la pancreatitis aguda según la clasificación modificada de Atlanta / BISAP-O y APACHE-O: utility in predicting severity in acute pancreatitis in modified Atlanta classification

Objetivo: Valorar los puntajes BISAP y APACHE II en predecir severidad según la clasificación Atlanta 2012 y determinar si el factor obesidad añadido a dichos puntajes mejora su predicción. Material y métodos: Se realizó un estudio prospectivo entre enero de 2013 y abril de 2014 de todos los pacientes con pancreatitis aguda según la nueva clasificación Atlanta 2012. Se confeccionó curvas ROC para los puntajes BISAP, BISAP-O, APACHE-II y APACHE-O y se seleccionó puntos de corte apropiados con los que se calculó la sensibilidad, especificidad, VPP, VPN, RPP y la RPN. Resultados: Se estudió a 334 pacientes. El 65,27% presentó sobrepeso u obesidad. La etiología fue biliar en el 86,53%. Sólo 8,38% presentó pancreatitis severa y 1,5% falleció. Las áreas bajo la curva ROC y puntos de corte seleccionados fueron: BISAP: 0,8725, 2; BISAP-O: 0,8246, 3; APACHE-II: 0,8547, 5; APACHE-O: 0,8531, 6. Con dichos puntos de corte la sensibilidad, especificidad, VPP, VPN, RPP y la RPN fueron: BISAP: 60,71%, 91,83%, 40,48%, 96,23%, 7,43, 0,43; BISAP-O: 60,71%, 86,93%, 29,82%, 96,03%, 4,76, 0,45; APACHE-II: 85,71%, 76,14%, 24,74%, 98,31%, 3,6, 0,19; APACHE-O: 82,14%, 79,41%, 26,74%, 97,98%, 4, 0,22. Conclusiones: Los sistemas BISAP, BISAP-O, APACHE-II, y APACHE-O pueden usarse para identificar a los pacientes con bajo riesgo de severidad en razón de su alto VPN, sin embargo su uso debe ser prudente considerando que la RPP y RPN no alcanza niveles óptimos, indicando que su valor en la predicción de severidad es limitado. Por otro lado el añadir el factor obesidad no mejoró su capacidad predictiva.

Objective: To assess the BISAP and APACHE II scores in predicting severity according to the 2012 Atlanta classification and whether the obesity factor added to these scores improves prediction. Material and methods: A prospective study between January 2013 and April 2014 including all patients with acute pancreatitis was performed according to the new Atlanta 2012 classification. ROC curves were fabricated for BISAP, BISAP-O, APACHE-II scores and Apache O and appropriate cutoffs were selected to the sensitivity, specificity, PPV, NPV, RPP and RPN. Results: We studied 334 patients. 65.27% were overweighted or obese. The biliar etiology was 86.53%. Only 8.38% had severe pancreatitis and 1.5% died. Areas under the ROC curve and cut points selected were: BISAP: 0.8725, 2; BISAP-O: 0.8246, 3; APACHE-II: 0.8547, 5; APACHE-O: 0.8531, 6. Using these cutoffs the sensitivity, specificity, PPV, NPV, RPP and RPN were BISAP: 60.71%, 91.83%, 40.48%, 96.23 %, 7.43, 0.43; BISAP-O: 60.71%, 86.93%, 29.82%, 96.03%, 4.76, 0.45; APACHE-II: 85.71%, 76.14%, 24.74%, 98.31%, 3.6, 0.19; APACHE-O: 82.14%, 79.41%, 26.74%, 97.98%, 4, 0.22. Conclusions: BISAP, BISAP-O, APACHE-II and APACHE-O systems can be used to identify patients at low risk of severity because of its high NPV, however their use should be cautious considering that the RPP and RPN do not reach optimal levels indicating that their value in predicting severity is limited. On the other hand adding the obesity factor did not improve their predictive ability.

Incidence of pulmonary embolism during COPD exacerbation / Incidência de embolia pulmonar durante exacerbação da DPOC

OBJECTIVE: Because pulmonary embolism (PE) and COPD exacerbation have similar presentations and symptoms, PE can be overlooked in COPD patients. Our objective was to determine the prevalence of PE during COPD exacerbation and to describe the clinical aspects in COPD patients diagnosed with PE. METHODS: This was a prospective study conducted at a university hospital in the city of Ankara, Turkey. We included all COPD patients who were hospitalized due to acute exacerbation of COPD between May of 2011 and May of 2013. All patients underwent clinical risk assessment, arterial blood gas analysis, chest CT angiography, and Doppler ultrasonography of the lower extremities. In addition, we measured D-dimer levels and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels. RESULTS: We included 172 patients with COPD. The prevalence of PE was 29.1%. The patients with pleuritic chest pain, lower limb asymmetry, and high NT-pro-BNP levels were more likely to develop PE, as were those who were obese or immobile. Obesity and lower limb asymmetry were independent predictors of PE during COPD exacerbation (OR = 4.97; 95% CI, 1.775-13.931 and OR = 2.329; 95% CI, 1.127-7.105, respectively). CONCLUSIONS: The prevalence of PE in patients with COPD exacerbation was higher than expected. The association between PE and COPD exacerbation should be considered, especially in patients who are immobile or obese. .

OBJETIVO: Visto que a embolia pulmonar (EP) e a exacerbação da DPOC têm apresentação e sintomas comuns, o diagnóstico de EP pode ser negligenciado nesses pacientes. Nosso objetivo foi determinar a prevalência de EP durante a exacerbação da DPOC e descrever os aspectos clínicos em portadores de DPOC diagnosticados com EP. MÉTODOS: Estudo prospectivo conduzido em um hospital universitário na cidade de Ancara, Turquia. Entre maio de 2011 e maio de 2013, todos os pacientes hospitalizados por exacerbação aguda da DPOC foram incluídos no estudo. Todos os pacientes foram submetidos a avaliação de risco clínico, gasometria arterial, angiotomografia de tórax e ultrassonografia Doppler de membros inferiores. Além disso, foram medidos os níveis de dímero-D e de N-terminal pro-brain natriuretic peptide (NT-pro-BNP). RESULTADOS: Foram incluídos 172 pacientes com DPOC. A prevalência de EP foi de 29,1 %. Os pacientes com DPOC e dor torácica pleurítica, assimetria de membros inferiores e altos níveis de NT-pro-BNP, assim como aqueles que estavam obesos ou imobilizados, apresentavam maior probabilidade de desenvolver EP. Obesidade e assimetria de membros inferiores foram preditores independentes de EP nos pacientes com exacerbação da DPOC (OR = 4,97; IC95%, 1,775-13,931 e OR = 2,329; IC95% CI, 1,127-7,105, respectivamente). CONCLUSÕES: A prevalência de EP em pacientes com exacerbação da DPOC foi maior que a esperada. A associação entre EP e exacerbação da DPOC deve ser considerada nesses pacientes, especialmente naqueles imobilizados ou obesos. .

Does thromboprophylaxis prevent venous thromboembolism after major orthopedic surgery? / A tromboprofilaxia evita o tromboembolismo venoso após cirurgia ortopédica de grande porte?

OBJECTIVE: Pulmonary embolism (PE) is an important complication of major orthopedic surgery. The aim of this study was to evaluate the incidence of venous thromboembolism (VTE) and factors influencing the development of VTE in patients undergoing major orthopedic surgery in a university hospital. METHODS: Patients who underwent major orthopedic surgery (hip arthroplasty, knee arthroplasty, or femur fracture repair) between February of 2006 and June of 2012 were retrospectively included in the study. The incidences of PE and deep vein thrombosis (DVT) were evaluated, as were the factors influencing their development, such as type of operation, age, and comorbidities. RESULTS: We reviewed the medical records of 1,306 patients. The proportions of knee arthroplasty, hip arthroplasty, and femur fracture repair were 63.4%, 29.9%, and 6.7%, respectively. The cumulative incidence of PE and DVT in patients undergoing major orthopedic surgery was 1.99% and 2.22%, respectively. Most of the patients presented with PE and DVT (61.5% and 72.4%, respectively) within the first 72 h after surgery. Patients undergoing femur fracture repair, those aged ≥ 65 years, and bedridden patients were at a higher risk for developing VTE. CONCLUSIONS: Our results show that VTE was a significant complication of major orthopedic surgery, despite the use of thromboprophylaxis. Clinicians should be aware of VTE, especially during the perioperative period and in bedridden, elderly patients (≥ 65 years of age). .

OBJETIVO: A embolia pulmonar (EP) é uma complicação importante de cirurgia ortopédica de grande porte. Este estudo visou avaliar a incidência de tromboembolismo venoso (TEV) e os fatores que influenciam o desenvolvimento de TEV em pacientes submetidos a cirurgia ortopédica de grande porte em um hospital universitário. MÉTODOS: Pacientes submetidos a cirurgia ortopédica de grande porte (artroplastia de quadril, artroplastia do joelho ou reparação de fratura de fêmur) entre fevereiro de 2006 e junho de 2012 foram incluídos retrospectivamente no estudo. As incidências de EP e de trombose venosa profunda (TVP) foram avaliadas, assim como os fatores que influenciaram sua ocorrência, tais como o tipo de cirurgia, idade e comorbidades. RESULTADOS: Foram revisados os prontuários médicos de 1.306 pacientes. As proporções de artroplastia do joelho, artroplastia de quadril e reparação de fratura de fêmur foram, respectivamente, de 63,4%, 29,9% e 6,7%. A incidência cumulativa de EP e TVP nos pacientes submetidos a cirurgia ortopédica de grande porte foi, respectivamente, de 1,99% e 2,22%. A maioria dos pacientes apresentou EP e TVP (61,5% e 72,4 %, respectivamente) nas primeiras 72 h após a cirurgia. Pacientes submetidos à reparação de fratura de fêmur, aqueles com idade ≥ 65 anos, e pacientes acamados tinham um risco maior de desenvolver TVP. CONCLUSÕES: Nossos resultados demonstram que o TEV foi uma complicação importante de cirurgia ortopédica de grande porte, apesar da utilização de tromboprofilaxia. Os médicos clínicos devem estar alerta para a ocorrência ...

Incidence of Deep Vein Thrombosis after Spinal Cord Injury in Korean Patients at Acute Rehabilitation Unit

Deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE) remain significant causes of morbidity, mortality in patients with spinal cord injury (SCI). Since incidence of DVT after SCI in Korean population has not been much studied, we retrospectively analyzed the medical records of 185 SCI patients admitted for acute rehabilitation unit to investigate the incidence of DVT. Color Doppler ultrasonography was performed to screen for the occurrence of DVT at the time of initial presentation to acute rehabilitation unit. Primary study outcome was the incidence of DVT. Possible risk factors for DVT including the epidemiologic characteristics, completeness of motor paralysis, cause of injury, spasticity, surgery, and active cancer were analyzed. The incidence of DVT after SCI was 27.6%. In multiple logistic regression analysis, absence of spasticity was a significant independent risk factor (P<0.05) for occurrence of DVT. Symptomatic pulmonary embolism was evident in 7 patients without an episode of sudden death. Therefore, it is concluded that the incidence of DVT after SCI in Korean patients is comparable with that in Western populations. This result suggests that pharmacologic thromboprophylaxis should be considered in Korean patients with SCI.

Prevalência e preditores de embolia pulmonar em pacientes com insuficiência cardíaca agudamente descompensada / Prevalence and predictors of pulmonary embolism in patients with acutely decompensated heart failure

FUNDAMENTO: Não existe descrição da prevalência de Embolia Pulmonar (EP) em pacientes internados por quadro clássico de Insuficiência Cardíaca descompensada (IC). OBJETIVO: Em pacientes internados por IC, (1) descrever a prevalência de EP, e (2) avaliar a acurácia diagnóstica dos Escores de Wells e de Genebra. MÉTODOS: Pacientes internados primariamente por IC realizaram sistematicamente cintilografia pulmonar de ventilação/perfusão, sendo EP definida por laudo de alta probabilidade. Para fins de interpretação, definimos baixa probabilidade clínica de EP como prevalência < 5 por cento, de acordo com dados da literatura. No cálculo do tamanho amostral, 49 pacientes seriam necessários para fornecer um intervalo de confiança 95 por cento com ± 10 por cento de precisão, estimando uma prevalência a priori de 15 por cento. RESULTADOS: Em 51 pacientes estudados, seis apresentaram cintilografia de alta probabilidade, resultando em prevalência de 12 por cento (95 por cento IC = 5 por cento - 23 por cento). Os Escores de Wells e de Genebra apresentaram área abaixo da curva ROC de 0,53 (95 por cento IC = 0,27 - 0,80; p = 0,80) e 0,43 (95 por cento IC = 0,13 - 0,73; p = 0,56), respectivamente, indicando ausência de acurácia para o diagnóstico de EP. Alternativamente, variáveis relacionadas à IC mostraram tendência a associação com EP e um modelo exploratório formado por esse tipo de variável apresentou acurácia diagnóstica para EP (ROC = 0,81; 95 por cento IC = 0,66 - 0,96; p = 0,01). CONCLUSÃO: (1) A despeito da ausência de suspeita primária, pacientes internados com IC possuem probabilidade clínica intermediária de EP concomitante; (2) Os escores usualmente utilizados para estimar a probabilidade clínica de EP não se aplicam à população com IC e futuros modelos preditores devem contemplar variáveis relacionadas a esta síndrome.

BACKGROUND: The prevalence of pulmonary embolism (PE) has not been reported in patients hospitalized due to classical findings of decompensated heart failure (HF). OBJECTIVE: To describe the prevalence of PE and to assess the diagnostic accuracy of the Wells and Geneva scores in patients hospitalized due to HF. METHODS: Patients hospitalized primarily due to HF underwent systematic ventilation-perfusion lung scan, and PE was defined by a result of high probability. Aiming at interpreting, low clinical probability of PE was defined as prevalence < 5 percent, according to the literature. When calculating the sample size, 49 patients were required to provide a 95 percent confidence interval with ±10 percent accuracy, estimating an a priori prevalence of 15 percent. RESULTS: Of 51 patients studied, six had a high probability of PE on lung scan, resulting in 12 percent prevalence (95 percent CI = 5 percent - 23 percent). The Wells and Geneva scores had an area under the ROC curve of 0.53 (95 percent CI = 0.27 - 0.80; p = 0.80) and 0.43 (95 percent CI = 0.13 - 0.73; p = 0.56), respectively, indicating lack of accuracy for the diagnosis of PE. Alternatively, variables related to HF showed a tendency towards association with PE, and an exploratory model formed by that type of variable showed diagnostic accuracy for PE (ROC = 0.81; 95 percent CI = 0.66 - 0.96; p = 0.01). CONCLUSION: (1) Despite the lack of primary suspicion, patients admitted with HF have intermediate clinical probability of concomitant PE; (2) the scores usually used to estimate the clinical probability of PE do not apply to the population with HF, and future predictive models should consider variables related to that syndrome.

Hipertensão pulmonar no tromboembolismo pulmonar crônico / Pulmonary hypertension in chronic thromboembolic

A hipertensão arterial pulmonar secundaria ao tromboembolismo pulmonar crônico tem emergido como uma das principais causas de hipertensão pulmonar grave. A doença resulta de uma obstrução dos vasos pulmonares por trombos organizados causando estenose fibrosa ou a oclusão completa das artérias pulmonares. Embolia pulmonar, como um único episódio ou episódios recorrentes parece ser evento inicial, seguido de progressivo remodelamento do leito vascular pulmonar e hipertensão pulmonar progressiva e insuficiência cardíaca direita e pobre prognóstico. A utilização de métodos de imagem incluindo o mapeamento de ventilação-perfusão, tomografia computadorizada e angiografia pulmonar são fundamental na avaliação de pacientes com hipertensão pulmonar tromboembólica. O tratamento de escolha para pacientes sintomáticos com hipertensão pulmonar secundária ao tromboembolismo pulmonar crônico é a desobstrução vascular pulmonar através da tromboendarterectomia pulmonar. Experiência com esta cirurgia está bem documentada e excelentes resultados podem ser alcançados para a maioria dos pacientes considerados candidatos adequados ao tratamento cirúrgico.

Optimal duration of anticoagulation in patients with venous thromboembolism.

The risk of recurrent venous thromboembolism (VTE) approaches 40 per cent of all patients after 10 yr of follow up. This risk is higher in patients with permanent risk factors of thrombosis such as active cancer, prolonged immobilization from medical diseases, and antiphospholipid syndrome; in carriers of several thrombophilic abnormalities, including deficiencies of natural anticoagulants; and in patients with unprovoked presentation. Patients with permanent risk factors of thrombosis should receive indefinite anticoagulation, consisting of subtherapeutic doses of low molecular weight heparin in cancer patients, and oral anticoagulants in all other conditions. Patients whose VTE is triggered by major surgery or trauma should be offered three months of anticoagulation. Patients with unprovoked VTE, including carriers of thrombophilia, and those whose thrombotic event is associated with minor risk factors (such as hormonal treatment, minor injuries, long travel) should receive at least three months of anticoagulation. The decision as to go on or discontinue anticoagulation after this period should be individually tailored and balanced against the haemorrhagic risk. Post-baseline variables, such as the D-dimer determination and the ultrasound assessment of residual thrombosis can help identify those patients in whom anticoagulation can be safely discontinued. As a few emerging anti-Xa and anti-IIa compounds seem to induce fewer haemorrhagic complications than conventional anticoagulation, while preserving at least the same effectiveness, these have the potential to open new scenarios for decisions regarding the duration of anticoagulation in patients with VTE.