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In a randomized trial, 1006 patients with intermediate-risk pulmonary embolism were assigned to tenecteplase or placebo in addition to standard heparin therapy. The tenecteplase group had a lower rate of hemodynamic decompensation but more frequent major hemorrhage and stroke. Acute pulmonary embolism occurs frequently and may cause death or serious disability. 1 Case fatality rates vary widely, 2 , 3 but approximately 10% of all patients with acute pulmonary embolism die within 3 months after the diagnosis. 4 , 5 Acute right ventricular pressure overload at diagnosis is an important determinant of the severity and early clinical outcome of pulmonary embolism. 6 High-risk pulmonary embolism 7 is characterized by overt hemodynamic instability and warrants immediate advanced therapy, including consideration of fibrinolysis. In contrast, for patients presenting without systemic hypotension or hemodynamic compromise, standard anticoagulation is generally considered adequate treatment. 8 However, patients who have acute right ventricular . . .

In the treatment of patients with acute pulmonary embolism, the efficacy of rivaroxaban, a factor Xa inhibitor, was similar to that of traditional anticoagulation therapy. There was less bleeding in the group receiving rivaroxaban, which supports its use in the treatment of this condition. Pulmonary embolism is a common disease, with an estimated annual incidence of 70 cases per 100,000 population. 1 , 2 The condition usually leads to hospitalization and may recur; it can be fatal. 3 For half a century, the standard therapy for most patients with pulmonary embolism has been the administration of heparin, overlapped and followed by a vitamin K antagonist. 4 , 5 This regimen is effective but complex. 5 – 9 Recently developed oral anticoagulants that are directed against factor Xa or thrombin overcome some limitations of standard therapy, including the need for injection and for regular dose adjustments on the basis of laboratory monitoring. . . .

In a trial involving patients with active cancer and venous thromboembolism, extended anticoagulation with reduced-dose apixaban was noninferior to full-dose apixaban for preventing recurrent thromboembolic events.

The challenging clinical dilemma of detecting pulmonary embolism (PE) in suspected patients is encountered in a variety of healthcare settings. We hypothesized that the optimal diagnostic approach to detect these patients in terms of safety and efficiency depends on underlying PE prevalence, case mix, and physician experience, overall reflected by the type of setting where patients are initially assessed. The objective of this study was to assess the capability of ruling out PE by available diagnostic strategies across all possible settings. We performed a literature search (MEDLINE) followed by an individual patient data (IPD) meta-analysis (MA; 23 studies), including patients from self-referral emergency care (n = 12,612), primary healthcare clinics (n = 3,174), referred secondary care (n = 17,052), and hospitalized or nursing home patients (n = 2,410). Multilevel logistic regression was performed to evaluate diagnostic performance of the Wells and revised Geneva rules, both using fixed and adapted D-dimer thresholds to age or pretest probability (PTP), for the YEARS algorithm and for the Pulmonary Embolism Rule-out Criteria (PERC). All strategies were tested separately in each healthcare setting. Following studies done in this field, the primary diagnostic metrices estimated from the models were the \"failure rate\" of each strategy-i.e., the proportion of missed PE among patients categorized as \"PE excluded\" and \"efficiency\"-defined as the proportion of patients categorized as \"PE excluded\" among all patients. In self-referral emergency care, the PERC algorithm excludes PE in 21% of suspected patients at a failure rate of 1.12% (95% confidence interval [CI] 0.74 to 1.70), whereas this increases to 6.01% (4.09 to 8.75) in referred patients to secondary care at an efficiency of 10%. In patients from primary healthcare and those referred to secondary care, strategies adjusting D-dimer to PTP are the most efficient (range: 43% to 62%) at a failure rate ranging between 0.25% and 3.06%, with higher failure rates observed in patients referred to secondary care. For this latter setting, strategies adjusting D-dimer to age are associated with a lower failure rate ranging between 0.65% and 0.81%, yet are also less efficient (range: 33% and 35%). For all strategies, failure rates are highest in hospitalized or nursing home patients, ranging between 1.68% and 5.13%, at an efficiency ranging between 15% and 30%. The main limitation of the primary analyses was that the diagnostic performance of each strategy was compared in different sets of studies since the availability of items used in each diagnostic strategy differed across included studies; however, sensitivity analyses suggested that the findings were robust. The capability of safely and efficiently ruling out PE of available diagnostic strategies differs for different healthcare settings. The findings of this IPD MA help in determining the optimum diagnostic strategies for ruling out PE per healthcare setting, balancing the trade-off between failure rate and efficiency of each strategy.

Cerebral air embolism (CAE) is a rare, life-threatening condition often caused by iatrogenic procedures. Despite numerous case reports, there are limited systematic reviews, with insufficient data integration for clinical application. This study aims to analyze procedure-related CAEs, focusing on clinical characteristics, diagnostic methods, and outcomes. A systematic review and single-patient analysis were conducted using PubMed, Embase, and Cochrane (2015–2024), supplemented by one institutional case. Descriptive statistics examined demographics, presentation, diagnostics, and outcomes. Kruskal-Wallis and Fisher’s exact tests compared clinical differences across procedures, while univariable logistic regression identified mortality risk factors. The study analysed 132 patients (65.2 % male, median age 68), with minimally invasive pulmonary interventions being the most common procedure (24.2 %). Motor dysfunction (78 %) and altered consciousness (42.4 %) were the most frequent symptoms. Post-treatment, 63.1 % of motor and sensory symptoms resolved, with high recovery rates for visual (93 %) and language impairments (69 %). The mortality rate was 30.5 %. In logistic regression, cranial nerve symptoms, coma, cardiac angiography, and intervention were associated with increased mortality, while motor deficit and hyperbaric oxygen therapy were protective factors (p < 0.05). Our study synthesized smaller studies to establish a clinically relevant CAE profile, emphasizing neurological patterns, diagnostic methods, and outcomes across procedures. Motor deficits and altered consciousness were the most common presentations, while cranial nerve dysfunction, coma, and cardiac angiography and interventions were significant mortality predictors. These findings offer valuable insights for early CAE identification and management, improving overall patient outcomes. •Systematic review identifies key clinical patterns and mortality predictors in CAE.•Motor dysfunction and altered consciousness are the most common CAE presentations.•Cranial nerve dysfunction, coma, and cardiac angiography increase CAE mortality risk.•Hyperbaric oxygen therapy significantly reduces mortality in CAE cases.

After atrial fibrillation ablation, left atrial appendage closure was associated with a lower risk of bleeding than oral anticoagulation and was noninferior to oral anticoagulation with respect to clinical outcomes at 36 months.

Due to the bleeding risk of full-dose systemic thrombolysis and the lack of major trials focusing on the clinical benefits of catheter-directed treatment, heparin antiocoagulation remains the standard of care for patients with intermediate-high-risk pulmonary embolism (PE). The Higher-Risk Pulmonary Embolism Thrombolysis (HI-PEITHO) study (ClinicalTrials.gov Identifier: NCT04790370) is a multinational multicenter randomized controlled parallel-group comparison trial. Patients with: (1) confirmed acute PE; (2) evidence of right ventricular (RV) dysfunction on imaging; (3) a positive cardiac troponin test; and (4) clinical criteria indicating an elevated risk of early death or imminent hemodynamic collapse, will be randomized 1:1 to treatment with a standardized protocol of ultrasound-facilitated catheter-directed thrombolysis plus anticoagulation, vs anticoagulation alone. The primary outcome is a composite of PE-related mortality, cardiorespiratory decompensation or collapse, or non-fatal symptomatic and objectively confirmed PE recurrence, within 7 days of randomization. Further assessments cover, apart from bleeding complications, a broad spectrum of functional and patient-reported outcomes including quality of life indicators, functional status and the utilization of health care resources over a 12-month follow-up period. The trial plans to include 406 patients, but the adaptive design permits a sample size increase depending on the results of the predefined interim analysis. As of May 11, 2022, 27 subjects have been enrolled. The trial is funded by Boston Scientific Corporation and through collaborative research agreements with University of Mainz and The PERT Consortium. Regardless of the outcome, HI-PEITHO will establish the first-line treatment in intermediate-high risk PE patients with imminent hemodynamic collapse. The trial is expected to inform international guidelines and set the standard for evaluation of catheter-directed reperfusion options in the future.

In a randomized trial involving patients who had a first stroke from an embolus of unknown source, rivaroxaban at a daily dose of 15 mg did not result in a lower incidence of recurrent stroke than aspirin at a dose of 100 mg. Bleeding rates were higher with rivaroxaban.

In a large trial, the estimated incidence of stroke, systemic embolism, hemorrhage, or death was 2.8 percentage points lower to 0.5 percentage points higher with early than with later use of direct oral anticoagulants.

A randomized trial of the factor XIa inhibitor asundexian was stopped early owing to a higher incidence of stroke or systemic embolism than with apixaban therapy among patients with atrial fibrillation.