Pulmonary Embolus— Unusual Presentations and Diagnostic Dilemma
- Mon, 12/15/08 - 10:55am
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Pages 15 - 16
To the Editor:
Thank you for your report of a pulmonary embolism case in the October 2008 issue of Clinical Geriatrics.1 I’ll bet we are all missing lots of pulmonary emboli (PEs). I wonder what to do with all of my patients who are immobilized from old strokes or multiple sclerosis. Should they be on prophylactic anticoagulation chronically? I’ll keep your case in mind. You also taught me about McConnell’s sign. If the case patient didn’t have contraindications, I’m sure she may have been offered tissue plasminogen activator because of this sign, despite her normal hemodynamics. The syncope was a sign that her hemodynamics were abnormal, at least transiently.
Why was the patient switched from warfarin to subcutaneous heparin? I had to do the same for a patient with poorly controlled Crohn’s disease who had suffered deep vein thrombosis and femoral artery thrombus. After 2 years of subcutaneous heparin, her bones had turned to dust. She broke her hip just rolling over in bed. This was in the 1980s. As far as I know, enoxaparin and fondaparinux do not cause osteoporosis with long-term use.
Anonymous
Reference
1. Doraiswamy VA, Hegde V, Kleist PC. Pulmonary embolus—Unusual presentations and diagnostic dilemma. Clinical Geriatrics 2008;16(10):25-28.
1. Raskob GE, Comerota AJ, Kearon C, et al. Anti-thrombotic therapy for venous thromboembolic disease: American College of Chest Physicians (ACCP) Evidence-Based Clinical Practice Guide-lines (8th Edition) [published correction appears in Chest 2008; 134(4):892]. Chest 2008;133(6 Suppl):454S-545S.
2. Monreal M, Lafoz E, Olive A, et al. Comparison of subcutaneous unfractionated heparin with a low molecular weight heparin (Fragmin) in patients with venous thromboembolism and contraindications to coumarin. Thromb Haemost 1994;71:7-11.
3. Palareti G, Cosmi B, Legnani C, et al; PROLONG Investigators. D-dimer testing to determine the duration of anticoagulation therapy [published correction appears in N Engl J Med 2006;355(26):2797]. N Engl J Med 2006;355(17): 1780-1789.
4. Ost D, Tepper J, Mihara H, et al. Duration of anticoagulation following venous thromboembolism: A meta-analysis. JAMA 2005;294:706-715.
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