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ΕΠΙΣΤΗΜΟΝΙΚΑ ΚΙ … ΑΛΛΑ”από τον Ομ. Καθηγητή, Ιωάννη Γουδέβενο, 15.10.2024 – Οξεία Πνευμονική Εμβολή

Ioυλία (CEO UniPharm) αντε και Πρόεδρος Δημοκρατίας!!!

Bραβεία NOBEL  σχετικά με τη καρδιολογία έχουν απονεμηθεί για τη συσκευή καταγραφής ΗΚΓ(1924  Willem Einthoven), Καρδιακός Καθετηριασμός(1956 André Frédéric Cournand, Werner Forssmann, Dickinson W. Richards),  Ασπιρίνη(1982 Τζον Βέιν), LDL υποδοχείς ( Joseph L. Goldstein ,Michael S. Brown 1985), Β αποκλειστές (James Black 1988).

Συνάδελφοι-Συναδέλφισσες

Για την Ενδοσκοπική καρδιοχειρουργική το Endoscopic Cardiac Surgeons Club ( J. Zacharias, A. Pitsis, M. Glauber, M. Solinas, J. Kempfert, M. Castillo-Sang, H. Balkhy, Patrick Perier) δεν τα παρουσίασαν τόσο ρόδινα όσο ο Α. Πάνου στο τελευταίο cardiology news. Lancet Published online October 1, 2024

Την τιμητική της έχει η Οξεία Πνευμονική Εμβολή με δύο δημοσιεύσεις. Η πρώτη Circulation. 2024;150:1140–1150 είναι consensus του  Pulmonary Embolism Research Collaborative(PERC) με σκοπούς1) to identify the current major evidence gaps that must be closed to better inform care providers and reduce variations in PE care (2) to identify what data capture will be necessary to close those gaps and (3) to develop consensus about a set of core set of data elements to be captured in routine care in all patients treated for PE.

Η δεύτερη  JACC. 2024;84:1561–1577 συγκρίνει τις διεθνείς guidelines με βασικό πρόβλημα ότι έχουν εκδοθεί σε διαφορετικά χρονικά διαστήματα.

To  ενδιαφέρον από ελληνικής πλευράς είναι ότι στη συγγραφική ομάδα της πρώτης συ συμμετέχει ο Stavros V. Konstantinides  και της  δεύτερης ο George Giannakoulas.

Key points από τη δεύτερη δημοσίευση
100% συμφωνία στα παρακάτω:

  • Anticoagulation’s role as the mainstay therapy for all patients without contraindication
  • The use of inferior vena cava filters in patients with acute venous thromboembolism who have contraindication to anticoagulation
  • Identification of low-risk PE
  • The use of risk scores and D-dimer to rule out PE in patients with low/intermediate pretest probability
  • The need for systematic fibrinolysis in hemodynamically unstable PE
  • 1.Most current guidelines emphasize initial patient assessment using validated pretest probability scores( Wells’ or Geneva). All recommend D-dimer testing to exclude acute PE in non–high pretest probability cases. ESC/ERS and PERT suggest using an age-adjusted or probability-adapted D-dimer cutoff. NICE and ASH suggest using age-adjusted cutoff for patients aged >50 years. ASH, NICE, and PERT suggest using the PE Rule-out Criteria (PERC) in patients with low pretest probability. ESC/ERS does not incorporate PERC criteria, noting that the evidence for its use is limited.
  • 2.There is variation in imaging recommendations for diagnosis. ESC/ERS, NICE, and PERT recommend CTPA as first-line for acute PE diagnosis. ASH recommends using V/Q lung scans over CTPA to reduce radiation exposure when this can be done rapidly and interpreted expertly.
  • 3.During pregnancy, ESC/ERS  assert that the diagnosis of PE should be considered in the presence of high pretest probability (Geneva score) or intermediate/low probability with a positive D-dimer test. They recommend CTPA for further diagnosis imaging, using a low-dose radiation protocol. ESC/ERS  suggest the use of customized strategies, such as a modified YEARS algorithm, to limit the use of CTPAs. ASH suggests using V/Q scanning as the primary imaging modality in pregnant patients being evaluated for acute PE.
  • 4.To diagnose RV dysfunction, the ESC/ERS  suggest use of a comprehensive echo with RV/LV diameter ratio of ≥1.0 and TAPSE  <16 mm. They also suggest using a CTPA RV/LV ≥1.0 to define RV dysfunction. The AHA has similar RV/LV ratio criteria for both echo and CTPA, while the PERT document does not endorse specific definitions. CHEST, ASH, and NICE do not provide specific recommendations for assessment of RV dysfunction.
  • 5.The use of validated prognostic scores (PE Severity Index [PESI], simplified PESI) is endorsed by ESC/ERS, PERT, and ASH. ESC/ERS and CHEST also recommend assessing RV size and function to identify low-risk patients with acute PE.
  • 6.AHA and ASH recommend diagnosing intermediate-risk PE when RV dysfunction or strain are detected, while ESC/ERS and PERT further subdivide this group into intermediate-low and intermediate-high risk categories based on the combined imaging and cardiac troponin abnormalities.
  • 7.Home-based care and early discharge for low-risk acute PE patients is supported by ESC/ERS, CHEST, NICE, and ASH guidelines. ESC/ERS and ASH suggest using clinical scores (e.g., PESI, simplified PESI, Hestia criteria). CHEST suggests the use of DOAC) medications to facilitate home-based care.

8.Multidisciplinary PE response teams are recommended by ESC/ERS and PERT. However, these guidelines do not specify which subspecialties are required. ASH acknowledges the growing use of PE response teams along with the lack of high-quality evidence demonstrating improved outcomes.

9.ESC/ERS recommend initial anticoagulation wιth  UFH) in patients with suspected high-risk PE. ESC/ERS, PERT, and NICE recommend UFH for hemodynamically unstable PE if advanced therapies (e.g., thrombus extraction, fibrinolysis, or surgery) are being considered. However, recent evidence has demonstrated that fixed-dose LMWH) is associated with a lower incidence of recurrent VTE) and major hemorrhage when compared to UFH.

10.In patients with non–GI cancer and PE who do not require UFH, CHEST and NICE recommend the use of a DOAC over LMWH. ESC/ERS and ASH recommend either DOAC or LMWH. CHEST recommends apixaban or LMWH in patients with luminal GI malignancy. ESC/ERS recommends LMWH in pregnant patients with acute PE.

11.ESC/ERS suggest that a modest fluid challenge is reasonable in patients with low central venous pressure, guided by invasive monitoring, ultrasound, or clinical monitoring. The guidelines do not discuss the use of a diuretic in normotensive patients with intermediate-risk PE. A universal definition of shock in acute PE is lacking.

12.All guidelines recommend fibrinolysis in patients with high-risk PE. All  recommend avoiding routine use of systemic fibrinolysis in intermediate-high risk (submissive) PE due to the risk of major hemorrhage (especially intracranial hemorrhage).

13.All guidelines suggest the use of catheter-directed interventions as a rescue treatment following failure of systemic thrombolysis or in individuals with high bleeding risk. NICE suggests that catheter-based embolectomy should be used within the confines of research protocols due to the lack of clinical trial data.

14.The most widely agreed-upon indication for inferior vena cava filter placement across all guidelines is for patients with an acute PE and an absolute contraindication to systemic anticoagulation. Other scenarios have marked heterogeneity in guideline recommendations.

15.ESC/ERS and PERT recommend a follow-up visit 3-6 months after hospital discharge. ESC/ERS, AHA, and PERT support the use of noninvasive imaging (e.g., echocardiography, 6-minute walk tests, cardiopulmonary exercise testing) to evaluate for the presence of pulmonary hypertension, especially in patients with persistent dyspnea or impaired exercise tolerance >3 months after an acute PE. ESC/ERS, PERT, and AHA recommend referral to a pulmonary hypertension center for further management.

16.ESC/ERS, ASH, and CHEST recommend ≥3 months of therapeutic anticoagulation for primary treatment of acute PE. ESC/ERS recommend extended anticoagulation beyond 3 months for patients with persistent or minor transient risk factors. ASH recommends stopping anticoagulation after primary treatment for patients with transient provoking risk factors. ESC/ERS and CHEST suggest DOAC dose reduction for extended-duration treatment (secondary prevention), while ASH suggests either full-dose or reduced dose in this phase.

 Και ένα κύριο ερώτημα που παραμένει είναι πιο το επίπεδο της φυσικής δραστηριότητας μετά  το οξύ συμβάν( what do we do after this acute phase for people who are still having lingering symptoms? How do we guide them to get back to their routine?).

Oι ακόλουθες εικόνες είναι από σεμινάριο στο ESC 24: Top ten pitfalls in echoFabian Knebel,Berlin,

?forshortening

..,ότι καταλάβατε

Το συμβάν είναι σπάνιο αλλά συγκλονιστικό. Ημών των καρδιολόγων  μας προκαλεί και μεγάλη απογοήτευση λόγω  αποτυχίας της πρόληψης.  Ετσι η καθημερινότητά για άλλη μια φορά μας προσγειώνει στη σκληρή πραγματικότητα.

Τα τελευταία 20 χρόνια(2002-22) θάνατοι σε αθλητές κολεγίων στις ΗΠΑ. Απo τους 1102 οι αιφνίδιοι καρδιακοί ήταν  143(13%). PeteK BJ. Circulation.  2024;149: 80-90

ΟΙ καρδιακές αιτίες  Other: 1 each of long QT , complications of congenital heart disease, idiopathic LVH)/possible sickle cell trait, Kawasaki disease,  after heart transplant, and SCD  in individual with pacemaker for idiopathic AV block.AC arrhythmogenic cardiomyopathy, AN-SUD, autopsy-negative sudden unexplained death

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