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Introduction: The YEARS algorithm was successfully developed to reduce the number of computed tomography pulmonary angiography (CTPA) investigations in the diagnostic management of patients with suspected pulmonary embolism (PE), although half of patients still needed to be referred for CTPA. We hypothesized that ECG derived ventricular gradient optimized for right ventricular pressure overload (VG-RVPO), an easy to use tool for detecting PE-induced pulmonary hypertension (PH), may further improve the efficiency of the YEARS algorithm.Methods: In this post-hoc analysis of the Years study, ECGs of 479 patients with suspected PE managed according to the YEARS algorithm were available for analysis. The diagnostic performance of VG-RVPO was assessed and likelihood ratios were calculated.Results: PE was diagnosed in 88 patients (18%). In patients with confirmed PE, 34% had an abnormal VG-RVPO versus 24% of those without PE (odds ratio 1.6; 95%CI 0.94-2.6). The mean VG-RVPO was -22 ± 13 and did not differ between the two patient groups (-22 versus -20; mean difference - 2, 95% CI -4.8 to 1.3). The sensitivity of VG-RVPO for PE was 24% (95%CI 34-45), the specificity 76% (95%CI 71-80) and the c-statistic 0.45 (95% CI 0.38-0.51). When combined with the YEARS algorithm, the likelihood ratios of VG-RVPO remained close to 1.0. Ruling out PE in patients with an indication for CTPA based on a normal VG-RVPO would have resulted in 58 missed cases.Conclusions: The VG-RVPO has no diagnostic value for suspected acute PE, either as stand-alone diagnostic test or combined with the YEARS algorithm.Condensed Abstract: This post-hoc analysis of the YEARS study failed to demonstrate incremental diagnostic value of VG-RVPO for acute PE, either as stand-alone diagnostic test or combined with the YEARS algorithm. Nevertheless, the role of VG-RVPO recorded on admission could potentially be valuable in the risk stratification of PE during hospitalization, although this remains to be studied. [ABSTRACT FROM AUTHOR]

Signs and symptoms of acute deep vein thrombosis (DVT) and pulmonary embolism (PE) are notoriously non-specific. Therefore, diagnostic management algorithms have been developed, consisting of a clinical decision rule (CDR), D-dimer testing and an imaging test, that allow safe diagnostic management and the exclusion of VTE in clinical practice. However, several challenges still remain: adherence to the diagnostic algorithms, accurate diagnosis of recurrent VTE and reducing the radiation exposure associated with computed tomography pulmonary angiography for suspected PE. In this clinically oriented review, we will provide an overview of current diagnostic algorithms for suspected DVT and PE and focus on recent advances including strategies to improve adherence to recommended algorithms, age-dependent D-dimer threshold and novel imaging techniques. [ABSTRACT FROM AUTHOR]

Colorectal cancer (CRC) is the third most prevalent cancer type. CRC-patients are at increased risk of venous and arterial thromboembolism (TE), but the magnitude of the risks, their predictors and consequences are not exactly known. We aimed to determine incidence, predictors and prognosis of TE after incident CRC in a large, unselected population. Using data from Statistics Netherlands and the Netherlands Comprehensive Cancer Organization, all incident CRC-patients were identified between 2013 and 2018 plus a sample of 1:2 age- and sex-matched control subjects. Incidence rates and cumulative incidences for TE were estimated. Predictor variables for TE were explored by univariable Cox regression. The association between TE and all-cause mortality was evaluated by multivariable time-dependent Cox regression. 68,238 incident CRC-patients were matched to 136,476 controls. CRC-patients had a 1-year cumulative venous TE (VTE) incidence of 1.93 % (95%CI 1.83–2.04), versus 0.24 % (95%CI 0.21–0.27) in controls (HR 8.85; 95%CI 7.83–9.99). For arterial TE (ATE), this was 2.74 % (95%CI 2.62–2.87) in CRC versus 1.88 % (95%CI 1.81–1.95) in controls (HR 1.57; 95%CI 1.47–1.66). Cancer stage, surgery, chemotherapy and asthma were predictors for VTE, whereas age, prior ATE and Parkinson's disease were predictors for ATE. CRC patients with TE had an increased risk of all-cause mortality (VTE HR; 3.68 (95%CI 3.30–4.10, ATE HR; 3.05 (95%CI 2.75–3.39)) compared with CRC-patients without TE. This Dutch nationwide cohort study adds detailed knowledge on the risk of VTE and ATE, their predictors and prognosis in CRC-patients. These findings may drive TE prophylactic management decisions. • Exact risk and predictors of thromboembolism in colorectal cancer (CRC) is unknown. • Using Dutch nationwide data, 68,238 CRC patients were matched to 136,476 controls. • Venous thromboembolism risk was more prominent on relative scale between cohorts. • Arterial thromboembolism presented a larger absolute risk in CRC versus controls. • Detailed knowledge presented on thrombosis risk, predictors and prognosis in CRC. [ABSTRACT FROM AUTHOR]

Long-term follow-up studies have consistently demonstrated that after an episode of acute pulmonary embolism (PE), half of patients report functional limitations and/or decreased quality of life up to many years after the acute event. Incomplete thrombus resolution occurs in one-fourth to one-third of patients. Further, pulmonary artery pressure and right ventricular function remain abnormal despite adequate anticoagulant treatment in 10–30% of patients, and 0.5–4% is diagnosed with chronic thromboembolic pulmonary hypertension (CTEPH) which represents the most severe long term complication of acute PE. From these numbers, it seems that CTEPH itself is the extreme manifestation of a much more common phenomenon of permanent changes in pulmonary artery flow, pulmonary gas exchange and/or cardiac function caused by the acute PE and associated with dyspnea and decreased exercise capacity, which in analogy to post-thrombotic syndrome after deep vein thrombosis could be referred to as the post-pulmonary embolism syndrome. The acknowledgement of this syndrome would both be relevant for daily clinical practice and also provide a concept that aids in further understanding of the pathophysiology of CTEPH. In this clinically oriented review, we discuss the established associations and hypotheses between the process of thrombus resolution or persistence, lasting hemodynamic changes following acute PE as well as the consequences of a PE diagnosis on long-term physical performance and quality of life. [ABSTRACT FROM AUTHOR]

Abstract: The long-term clinical course of acute pulmonary embolism (PE) is complicated by high rates of serious adverse events, both before and after cessation of anticoagulant therapy. These adverse events include recurrent venous thromboembolism, chronic thromboembolic pulmonary hypertension, arterial thrombotic events and increased risk of death, all compared to patients without thromboembolic disease. Several pharmacological options are available that may beneficially influence patients' prognosis. Nonetheless, because of insufficient knowledge of the benefit-to-harm ratio of these pharmacological agents, unambiguous recommendations are scarcely available. This review will cover the epidemiological aspects of the various possible complications in the long-term clinical course of acute PE as well as the latest evidence on preventive strategies. In addition, the unresolved issues regarding frequency, duration and focus of medical follow-up after acute PE are discussed. [Copyright &y& Elsevier]

Introduction Among patients with clinically suspected pulmonary embolism (PE), imaging and anticoagulant treatment can be safely withheld in approximately one-third of patients based on the combination of a “PE unlikely” Wells score and a D-dimer below the age-adjusted threshold. The clinical utility of this diagnostic approach in cancer patients is less clear. Aim To evaluate the efficiency and failure rate of the original and simplified Wells rules in combination with age-adjusted D-dimer testing in patients with active cancer. Materials and Methods Individual patient data were used from 6 large prospective studies in which the diagnostic management of PE was guided by the original Wells rule and D-dimer testing. Study physicians classified patients as having active cancer if they had new, recurrent, or progressive cancer (excluding basal-cell or squamous-cell skin carcinoma), or cancer requiring treatment in the last 6 months. We evaluated the dichotomous Wells rule and its simplified version (Table). The efficiency of the algorithm was defined as the proportion of patients with a “PE unlikely” Wells score and a negative age-adjusted D-dimer, defined by a D-dimer below the threshold of a patient’s age times 10 μg/L in patients aged ≥ 51 years. A diagnostic failure was defined as a patient with a “PE unlikely” Wells score and negative age-adjusted D-dimer who had symptomatic venous thromboembolism during 3 months follow-up. A one-stage random effects meta-analysis was performed to estimate the efficiency and failure. Results The dataset comprised 938 patients with active cancer with a mean age of 63 years. The most frequent cancer types were breast (13%), gastrointestinal tract (11%), and lung (8%). The type of cancer was not specified in 42%. The pooled PE prevalence was 29% (95% CI 25-32). PE could be excluded in 122 patients based on a “PE unlikely” Wells score and a negative age-adjusted D-dimer (efficiency 13%; 95% CI 11-15). Two of 122 patients were diagnosed with non-fatal symptomatic venous thromboembolism during follow-up (failure rate 1.5%; 95% CI 0.13-14.8). The simplified Wells score in combination with a negative age-adjusted D-dimer had an efficiency of 3.9% (95% CI 2.0-7.6) and a failure rate of 2.4% (95% CI 0.3-15). Table Original and simplified Wells scores and classifications Wells score items Original Wells score Points Simplified Wells score Points Alternative diagnosis less likely than PE + 3 + 1 Clinical signs and symptoms of DVT + 3 + 1 Previous DVT or PE + 1.5 + 1 Tachycardia + 1.5 + 1 Immobilization or surgery < 4 weeks + 1.5 + 1 Active cancer + 1 + 1 Haemoptsysis + 1 + 1 Wells rule classification Wells rule Simplified Wells rule PE unlikely ≤ 4 ≤ 1 PE likely > 4 > 1 Conclusions Among cancer patients with clinically suspected PE, imaging and anticoagulant treatment can be withheld in 1 out of every 8 patients by the original Wells rule and age-adjusted D-dimer testing. The simplified Wells rule was neither efficient nor safe in this population. [ABSTRACT FROM AUTHOR]

• DDIs between DOACs and anticancer drugs are complex and occur frequently in cancer patients undergoing DOAC therapy. • The majority of DDIs between DOACs and anticancer drugs are based solely on literature and lack adequate monitoring. • Prescribers generally do not respond to both generated and solely literature-based DDIs. • Patients experiencing DDIs, as well as those not experiencing them, exhibit thrombosis, major bleeding, and mortality. • The potential clinical consequences of these DDIs remain unknown and require further research. [ABSTRACT FROM AUTHOR]