Improving the diagnostic strategy of pulmonary embolism

Pulmonary embolism is a common clinical disorder that is associated with high morbidity and mortality if untreated. In the only randomized study comparing anticoagulant therapy with no treatment in patients with pulmonary embolism, 26% of untreated patients had a fatal embolic event and another 26% developed nonfatal recurrent emboli1. With a course of anticoagulant treatment, the recurrence rate of thromboembolic events decreases to approximately 2% to 9% over 3 to 6 months2, 3. However, anticoagulation always carries a risk for bleeding (annual rate of major bleeding, 7%)4, 5. To avoid unnecessary anticoagulant therapy, it is therefore important to rapidly confirm or exclude pulmonary embolism in patients who present with suspicion of the disorder. Diagnosing or excluding pulmonary embolism on the basis of clinical manifestations alone is difficult because such manifestations are nonspecific6. Approximately 25% of patients with suspected pulmonary embolism have the disease confirmed by objective testing7-9. The goal of the first diagnostic strategies introduced was to confirm rather than exclude the presence of pulmonary emboli. The more recently evaluated diagnostic approaches have focused on identifying patients who probably do not have pulmonary embolism and therefore do not require anticoagulant therapy. Various invasive and noninvasive diagnostic methods have been advocated for excluding the disease. We performed a systematic review of the literature to evaluate diagnostic strategies designed to exclude pulmonary embolism. Our objective was to investigate whether clinical outcome evaluation properly documented the safety of withholding anticoagulant treatment in patients in whom pulmonary embolism was excluded according to a given diagnostic strategy. We assessed the accuracy of the various diagnostic strategies by examining the number of symptomatic thromboembolic events (deep venous thrombosis or pulmonary embolism) that occurred without anticoagulant treatment during a follow-up period of at least 3 months. Studies were grouped according to the number of rounds of diagnostic testing performed before pulmonary embolism was ruled out

Statin use decreases coagulation in users of vitamin K antagonists

Purpose: The purpose of the study is to determine the immediate and long-term effect of statins on coagulation in patients treated with vitamin K antagonists (VKAs). Methods: We selected patients on VKAs of two Dutch anticoagulation clinics who initiated treatment with a statin between 2009 and 2013. Patients who initiated or stopped concomitant drugs that interact with VKAs or were hospitalised during follow-up were excluded. The VKA dosage (mg/day) after statin initiation was compared with the last VKA dosage before the statin was started. Immediate and long-term differences in VKA dosage (at 6 and 12 weeks) were calculated with a paired student t test. Results: Four hund