Immediately from the ACCP Pulmonary medication Board overview 2009 direction, this article covers each subject in a concise, easy-to-use structure. Use as a self-study source to arrange for the pulmonary drugs subspecialty board exam.
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There is no evidence that longer (but finite) initial courses of therapy (such as 6, 12, or 18 months) are more effective than 3 months because the recurrence rates upon discontinuation of therapy are identical. In patients with continuing risk factors (such as active malignancy) and patients who have had a documented recurrent event, long-term (perhaps lifelong) therapy is recommended. Thrombolytic Therapy Thrombolytic therapy is approved for the treatment of proximal DVT and massive PE. These agents dissolve thrombi by activating plasminogen into plasmin.
A randomized trial found that the use of an inferior vena cava filter reduced the rate of PE, had no effect on mortality, and was associated with a greater risk of recurrent DVT. These devices are being used more frequently, especially now that many can be safely retrieved after several months. However, the approved indications remain few, as follows: absolute contraindication to anticoagulation; life-threatening bleeding while receiving anticoagulation; and documented recurrent VTE while receiving therapeutic anticoagulation.
The two validated rules are shown in Table 3. It should be emphasized that the tool or approach used is less important than the idea that the clinical pretest probability of disease must be determined in each patient before further testing. As noted in the section on “DVT,” moderately to highly sensitive ddimer assays have a sensitivity of 96 to 98% in patients with suspected PE, which is sufficient to rule out the disease in those patients with an unlikely pretest probability. In patients with a high pretest probability, imaging studies should be performed instead of the d-dimer assay.