RESUMO
We report the case of a 61-year-old man who presented at the Emergency Department (ED), complaining of sudden-onset dyspnea and chest pain after a long flight from Tokyo to Houston. Considering his clinical stability and sPESI 0, enoxaparin 1â¯mg/kg BID was started for 24â¯h, and the patient was then considered for early discharge with apixaban 10â¯mg BID. Direct-factor Xa inhibition did not improve extensive thrombus burden and right ventricular dysfunction despite D-dimer measurement reduction. Because of the treatment failure, we considered thrombolysis. Currently, recommendations to use thrombolysis in patients under non-vitamin K antagonist oral anticoagulants (NOACs) do not exist. Hence, the one dose of apixaban was stopped, and 12â¯h later, we performed successful thrombolysis. A systematic review from 2007 to 2017 did not identify any cases related to NOACs failure to reduce thrombus burdens in patients with PE and persistent right ventricular dysfunction. We also did not find any evidence of cases that reported strategies for urgent thrombolysis in PE patients on NOACs. To the best of our knowledge, apixaban's failure to reduce thrombus burden, persistent right ventricular dysfunction, and a NOACs-thrombolysis bridge in patients with PE on apixaban has not been previously described. Both the bedside risk stratification and the therapeutic failures should alert clinicians in the ED to the potential limitations of low-molecular-weight heparin, NOACs therapy, and sPESI in the setting of intermediate-high-risk PE.
Assuntos
Dor no Peito/etiologia , Dispneia/etiologia , Inibidores do Fator Xa/uso terapêutico , Embolia Pulmonar/tratamento farmacológico , Pirazóis/uso terapêutico , Piridonas/uso terapêutico , Terapia Trombolítica/métodos , Viagem Aérea , Anticoagulantes/farmacologia , Quimioterapia Combinada , Inibidores do Fator Xa/farmacologia , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/fisiopatologia , Pirazóis/farmacologia , Piridonas/farmacologia , Medição de Risco , Resultado do TratamentoAssuntos
Peptídeo Natriurético Encefálico/sangue , Embolia Pulmonar/sangue , Embolia Pulmonar/complicações , Disfunção Ventricular Direita/sangue , Disfunção Ventricular Direita/complicações , Doença Aguda , Idoso de 80 Anos ou mais , Ecocardiografia , Feminino , Humanos , Medição de Risco , Fatores de Tempo , Disfunção Ventricular Direita/diagnóstico por imagemRESUMO
OBJECTIVE: To correlate the left ventricular parameters obtained with 64-slice Volumetric Computed Tomography (VCT) with those obtained with the reference standard, cardiovascular magnetic resonance (CMR) imaging. METHODS: VCT and a 3.0T MRI scanner were used. Results from both studies were independently evaluated by two cardiologists. A linear correlation and a paired Student's t test were used to analyze the data with a P<0.05 being considered significant. RESULTS: Thirty consecutive patients were evaluated with VCT and CMR. The left ventricular indices for CMR and VCT were, respectively, mass 86.4±25.8 vs. 82.7±27.6g (P=0.31); ESV 45.5±27.8 vs. 48.7±40.4ml (P=.405); EDV 101.3±32.7 vs. 105.1±44.0ml (P=0.475); SV 55.9±16.1 vs. 56.8±15.6ml (P=0.713); LVEF 57.5±13.2% vs. 56.9±12.4% (P=0.630). No differences in intraobserver variability for both methods were found, CT r=0.96, r(2)=0.92 P<0.0001 and MR r=0.96 r(2)=0.93 P<0.0001. There was no significant statistical difference in the presence of artifacts. CONCLUSION: There is a close correlation between CMRI and VCT in the evaluation of LV function. VCT is as useful as 3T CMR, and could be incorporated as another resource for evaluating LV function.
Assuntos
Tomografia Computadorizada de Feixe Cônico , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/fisiopatologia , Imageamento por Ressonância Magnética , Função Ventricular Esquerda/fisiologia , Feminino , Testes de Função Cardíaca/métodos , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
A 34-year-old man was admitted after an episode of aborted sudden cardiac death. The initial investigation including electrocardiogram, chest x-ray, transthoracic echocardiogram, and biomarkers were normal. Although coronary angiography showed nonsevere stenosis, optical coherence tomography revealed severe obstruction in the artery with a layered appearance of the vessel wall; it was consistent with the presence of mural thrombus.