NEJM â Collection Updates for Anticoagulants/Thromboembolism

CLINICAL PROBLEM-SOLVING: Painful Purple Toes

Thu, 07Â JanÂ 2010 00:00:00 -05:00

A 57-year-old man presented to the emergency department with painful purple toes. On the day of presentation, he had first been seen in another hospital but left against medical advice...

INTERACTIVE MEDICAL CASE: Painful Purple Toes

Thu, 17Â DecÂ 2009 00:00:00 -05:00

A 57-year-old man presented to the emergency department with painful purple toes. He had first noted pain and discoloration in his left great toe 2 weeks earlier. One week before...

ORIGINAL ARTICLE: Dabigatran versus Warfarin in the Treatment of Acute Venous Thromboembolism

Thu, 10Â DecÂ 2009 00:00:00 -05:00

Background: The direct oral thrombin inhibitor dabigatran has a predictable anticoagulant effect and may be an alternative therapy to warfarin for patients who have acute venous thromboembolism.

Methods: In a randomized,...

ORIGINAL ARTICLE: X-Linked Thrombophilia with a Mutant Factor IX (Factor IX Padua)

Thu, 22Â OctÂ 2009 00:00:00 -05:00

We report a case of juvenile thrombophilia associated with a substitution of leucine for arginine at position 338 (R338L) in the factor IX gene (factor IXâR338L). The level of the...

EDITORIAL: Can We Rely on RE-LY?

Brian F. Gage, M.D. — Thu, 17Â SepÂ 2009 00:00:00 -05:00

In patients with atrial fibrillation, warfarin prevents 64% of strokes.1 Thus, warfarin has become the recommended treatment for candidates for anticoagulation therapy who have atrial fibrillation and at least one...

ORIGINAL ARTICLE: Dabigatran versus Warfarin in Patients with Atrial Fibrillation

Thu, 17Â SepÂ 2009 00:00:00 -05:00

Background: Warfarin reduces the risk of stroke in patients with atrial fibrillation but increases the risk of hemorrhage and is difficult to use. Dabigatran is a new oral direct thrombin...

EDITORIAL: Ticagrelor â Is There Need for a New Player in the Antiplatelet-Therapy Field?

Albert SchÃ¶mig, M.D. — Thu, 10Â SepÂ 2009 00:00:00 -05:00

The thienopyridine clopidogrel, which irreversibly blocks the adenosine diphosphate (ADP) receptor P2Y12 on platelets, has become an essential component of therapy in patients with acute coronary syndromes, because it significantly...

ORIGINAL ARTICLE: Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes

Thu, 10Â SepÂ 2009 00:00:00 -05:00

Background: Ticagrelor is an oral, reversible, direct-acting inhibitor of the adenosine diphosphate receptor P2Y12 that has a more rapid onset and more pronounced platelet inhibition than clopidogrel.

Methods: In this multicenter,...

PERSPECTIVE: Weighing Benefits and Risks â The FDA's Review of Prasugrel

Thu, 03Â SepÂ 2009 00:00:00 -05:00

The Food and Drug Administration (FDA) approved prasugrel on July 10, 2009. Developed by Eli Lilly and Daiichi Sankyo, prasugrel is a thienopyridine that inhibits platelet aggregation. It was approved...

PERSPECTIVE: Prasugrel in Clinical Practice

Thu, 03Â SepÂ 2009 00:00:00 -05:00

On July 10, 2009, after an 18-month review, the Food and Drug Administration (FDA) approved the thienopyridine prasugrel for use in patients with unstable angina or myocardial infarction who undergo...

ORIGINAL ARTICLE: Apixaban or Enoxaparin for Thromboprophylaxis after Knee Replacement

Thu, 06Â AugÂ 2009 00:00:00 -05:00

Background: The optimal strategy for thromboprophylaxis after major joint replacement has not been established. Low-molecular-weight heparins such as enoxaparin predominantly target factor Xa but to some extent also inhibit thrombin....

CLINICAL IMPLICATIONS OF BASIC RESEARCH: Platelets, Pyrexia, and Plasmodia

Doron C. Greenbaum, Ph.D., and Garret A. FitzGerald, M.D. — Thu, 30Â JulÂ 2009 00:00:00 -05:00

Platelets have long been known to interact cooperatively with erythrocytes in thrombogenesis, both generally and in patients with sickle cell disease.1 Recently, the molecular mechanisms by which neutrophils can bridge...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 23-2009 â A 13-Year-Old Boy with Headache, Nausea, Seizures, and Hypertension

Thu, 23Â JulÂ 2009 00:00:00 -05:00

A 13-year-old boy was admitted to the hospital because of headache, nausea, seizures, renal failure, and hypertension.

The patient had been well until approximately 3 weeks earlier, when intermittent left-sided headaches...

ORIGINAL ARTICLE: Thrombomodulin Mutations in Atypical HemolyticâUremic Syndrome

Thu, 23Â JulÂ 2009 00:00:00 -05:00

Background: The hemolyticâuremic syndrome consists of the triad of microangiopathic hemolytic anemia, thrombocytopenia, and renal failure. The common form of the syndrome is triggered by infection with Shiga toxinâproducing bacteria...

EDITORIAL: Routine Angioplasty after Fibrinolysis â How Early Should âEarlyâ Be?

Freek W.A. Verheugt, M.D. — Thu, 25Â JunÂ 2009 00:00:00 -05:00

Reperfusion therapy has represented a great leap forward in the management of myocardial infarction with ST-segment elevation. Its goal is early and complete recanalization of the infarct-related artery to salvage...

ORIGINAL ARTICLE: Routine Early Angioplasty after Fibrinolysis for Acute Myocardial Infarction

Thu, 25Â JunÂ 2009 00:00:00 -05:00

Background: Patients with a myocardial infarction with ST-segment elevation who present to hospitals that do not have the capability of performing percutaneous coronary intervention (PCI) often cannot undergo timely primary...

PERSPECTIVE: Left Atrial Appendage Occlusion â Closure or Just the Beginning?

Thu, 18Â JunÂ 2009 00:00:00 -05:00

More than 3 million Americans have atrial fibrillation, which increases their risk of stroke by a factor of 5.12 Patients with atrial fibrillation account for one of every six strokes,...

CLINICAL PRACTICE: Chronic Venous Insufficiency and Varicose Veins

Seshadri Raju, M.D., and Peter NeglÃ©n, M.D., Ph.D. — Thu, 28Â MayÂ 2009 00:00:00 -05:00

A 52-year-old receptionist presents with an ulcer on her ankle that has persisted for a year. The use of narcotic analgesics once or twice a day and elevation of the...

EDITORIAL: Antiplatelet Therapy and Vascular-Access Patency

Charmaine E. Lok, M.D. — Thu, 21Â MayÂ 2009 00:00:00 -05:00

Current predictions estimate that by the year 2020, more than 750,000 people in the United States alone will have end-stage renal disease and over 500,000 will require hemodialysis.1 The success...

ORIGINAL ARTICLE: Effect of Dipyridamole plus Aspirin on Hemodialysis Graft Patency

Thu, 21Â MayÂ 2009 00:00:00 -05:00

Background: Arteriovenous graft stenosis leading to thrombosis is a major cause of complications in patients undergoing hemodialysis. Procedural interventions may restore patency but are costly. Although there is no proven...

EDITORIAL: The ACTIVE Pursuit of Stroke Prevention in Patients with Atrial Fibrillation

Alan S. Go, M.D. — Thu, 14Â MayÂ 2009 00:00:00 -05:00

Approximately 1% of Americans have atrial fibrillation, and the prevalence of this arrhythmia increases sharply with older age (being approximately 10% among persons 80 years of age or older).1 Worldwide...

ORIGINAL ARTICLE: Effect of Clopidogrel Added to Aspirin in Patients with Atrial Fibrillation

The ACTIVE Investigators — Thu, 14Â MayÂ 2009 00:00:00 -05:00

Background: Vitamin K antagonists reduce the risk of stroke in patients with atrial fibrillation but are considered unsuitable in many patients, who usually receive aspirin instead. We investigated the hypothesis...

ORIGINAL ARTICLE: A Randomized Trial of Rosuvastatin in the Prevention of Venous Thromboembolism

Thu, 30Â AprÂ 2009 00:00:00 -05:00

Background: Controversy persists regarding the extent of shared pathways between arterial and venous thrombosis and whether treatments of known efficacy for one disease process have consistent benefits for the other....

IMAGES IN CLINICAL MEDICINE: Prosthetic Mitral Valve with Partial Thrombosis

David T. Schachter, M.D. — Thu, 16Â AprÂ 2009 00:00:00 -05:00

A 63-year-old woman presented for evaluation after 2 weeks of progressive dyspnea. She had a history of dilated cardiomyopathy, and a St. Jude prosthetic valve had been inserted in the...

IMAGES IN CLINICAL MEDICINE: Venous Obstruction of the Thigh

Alberto Caggiati, M.D. and Carlo Catalano, M.D. — Thu, 12Â MarÂ 2009 00:00:00 -05:00

A 56-year-old man presented with a post-thrombotic syndrome of the left leg (involving edema, varicose veins, trophic skin changes, and an ulcer, 5 cm in diameter, of the distal medial...

EDITORIAL: Pharmacogenetics â Tailoring Treatment for the Outliers

Janet Woodcock, M.D., and Lawrence J. Lesko, Ph.D., F.C.P. — Thu, 19Â FebÂ 2009 00:00:00 -05:00

Over the past half century, biomedical science has developed randomized, controlled clinical-trial methods that can distinguish treatment effects from the noise of human variability. Positive results from tests of a...

ORIGINAL ARTICLE: Estimation of the Warfarin Dose with Clinical and Pharmacogenetic Data

The International Warfarin Pharmacogenetics Consortium — Thu, 19Â FebÂ 2009 00:00:00 -05:00

Background: Genetic variability among patients plays an important role in determining the dose of warfarin that should be used when oral anticoagulation is initiated, but practical methods of using genetic...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 5-2009 â A 47-Year-Old Woman with a Rash and Numbness and Pain in the Legs

Thu, 12Â FebÂ 2009 00:00:00 -05:00

Dr. John H. Stone: A 47-year-old woman was seen in the Rheumatology Clinic of this hospital because of numbness and pain in the legs and a rash.

The patient had been...

IMAGES IN CLINICAL MEDICINE: Metallic Mercury Embolism to the Hand

Antonio Carlos de Souza and Adelino Moreira de Carvalho, M.D., M.Sc., Ph.D. — Thu, 29Â JanÂ 2009 00:00:00 -05:00

Severe pain developed in the left hand of a 46-year-old woman after open heart surgery was performed to repair an atrial septal defect. It was initially thought that this pain...

EDITORIAL: Clopidogrel, Genetics, and Drug Responsiveness

Jane E. Freedman, M.D., and Elaine M. Hylek, M.D., M.P.H. — Thu, 22Â JanÂ 2009 00:00:00 -05:00

Despite great progress in the diagnosis and treatment of unstable coronary syndromes, it is estimated that 785,000 Americans will have new acute cardiac events and 470,000 will have recurrent events...

ORIGINAL ARTICLE: Genetic Determinants of Response to Clopidogrel and Cardiovascular Events

Thu, 22Â JanÂ 2009 00:00:00 -05:00

Background: Pharmacogenetic determinants of the response of patients to clopidogrel contribute to variability in the biologic antiplatelet activity of the drug. The effect of these determinants on clinical outcomes after...

ORIGINAL ARTICLE: Cytochrome P-450 Polymorphisms and Response to Clopidogrel

Thu, 22Â JanÂ 2009 00:00:00 -05:00

Background: Clopidogrel requires transformation into an active metabolite by cytochrome P-450 (CYP) enzymes for its antiplatelet effect. The genes encoding CYP enzymes are polymorphic, with common alleles conferring reduced function.

Methods:...

CLINICAL PRACTICE: Acute Pulmonary Embolism

Stavros Konstantinides, M.D. — Thu, 25Â DecÂ 2008 00:00:00 -05:00

A 62-year-old man presented with a 5-day history of progressively worsening dyspnea and orthopnea after returning from a 3-day business trip to the Far East. On physical examination, the heart...

CORRESPONDENCE: Prothrombin Time for Detection of Contaminated Heparins

Susanne Alban, Ph.D. and Susanne LÃ¼hn, Pharm.D. — Thu, 18Â DecÂ 2008 00:00:00 -05:00

To the Editor: The recent âheparin scandalâ resulted from the use of contaminated heparin that caused serious adverse events including death.1 The contaminant was identified as synthetically oversulfated chondroitin sulfate...

IMAGES IN CLINICAL MEDICINE: Postpartum Venous Thromboembolism

Ronen Zalts, M.D. and Tony Hayek, M.D. — Thu, 18Â DecÂ 2008 00:00:00 -05:00

A previously healthy 34-year-old woman, gravida 7, para 5, presented on postpartum day 14 with severe low back pain, chest pain, dyspnea, and substantial swelling of both legs after an...

ORIGINAL ARTICLE: Outbreak of Adverse Reactions Associated with Contaminated Heparin

Thu, 18Â DecÂ 2008 00:00:00 -05:00

Background: In January 2008, the Centers for Disease Control and Prevention began a nationwide investigation of severe adverse reactions that were first detected in a single hemodialysis facility. Preliminary findings...

ORIGINAL ARTICLE: Thrombolysis during Resuscitation for Out-of-Hospital Cardiac Arrest

Thu, 18Â DecÂ 2008 00:00:00 -05:00

Background: Approximately 70% of persons who have an out-of-hospital cardiac arrest have underlying acute myocardial infarction or pulmonary embolism. Therefore, thrombolysis during cardiopulmonary resuscitation may improve survival.

Methods: In a double-blind,...

CLINICAL PROBLEM-SOLVING: Taken Out of Context

Michael P. Thomas, M.D., and Andrew Wang, M.D. — Thu, 04Â DecÂ 2008 00:00:00 -05:00

A 25-year-old woman with a history of depression, mitral-valve prolapse, and migraine headaches presented to a hospital emergency department with a 3-day history of subjective fever, diffuse arthralgia, and severe...

IMAGES IN CLINICAL MEDICINE: Cavernous Sinus Thrombosis

Ayaz Agayev, M.D. and Sabri Yilmaz, M.D. — Thu, 20Â NovÂ 2008 00:00:00 -05:00

A 34-year-old woman with a 3-year history of systemic lupus erythematosus was admitted to the hospital with sore throat and headache that had lasted for 3 weeks. She had been...

REVIEW ARTICLE: Venous Thromboembolic Disease and Pregnancy

Paul E. Marik, M.D., and Lauren A. Plante, M.D., M.P.H. — Thu, 06Â NovÂ 2008 00:00:00 -05:00

Pulmonary embolism and deep-vein thrombosis are the two components of a single disease called venous thromboembolism. Approximately 30% of apparently isolated episodes of pulmonary embolism are associated with silent deep-vein...

SPECIAL ARTICLE: Cardiovascular Outcomes after a Change in Prescription Policy for Clopidogrel

Thu, 23Â OctÂ 2008 00:00:00 -05:00

Background: Drug-reimbursement policies may have an adverse effect on patient outcomes if they interfere with timely access to efficacious medications for acute medical conditions. Clopidogrel in combination with aspirin is...

EDITORIAL: Thrombolytic Therapy for Acute Stroke â Not a Moment to Lose

Patrick Lyden, M.D. — Thu, 25Â SepÂ 2008 00:00:00 -05:00

Stroke, the most common cause of disability in the world among adults, remains the only neurologic disorder for which physicians are potentially able to completely reverse disabling deficits.1 Thrombolytic therapy,...

ORIGINAL ARTICLE: Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke

Thu, 25Â SepÂ 2008 00:00:00 -05:00

Background: Intravenous thrombolysis with alteplase is the only approved treatment for acute ischemic stroke, but its efficacy and safety when administered more than 3 hours after the onset of symptoms...

EDITORIAL: Stroke Prevention â Insights from Incoherence

David M. Kent, M.D., and David E. Thaler, M.D., Ph.D. — Thu, 18Â SepÂ 2008 00:00:00 -05:00

If clinical trials were sporting contests, then it would be fair to say that low-dose aspirin plus extended-release dipyridamole (Aggrenox) was the clear favorite against clopidogrel going into the Prevention...

ORIGINAL ARTICLE: Aspirin and Extended-Release Dipyridamole versus Clopidogrel for Recurrent Stroke

Thu, 18Â SepÂ 2008 00:00:00 -05:00

Background: Recurrent stroke is a frequent, disabling event after ischemic stroke. This study compared the efficacy and safety of two antiplatelet regimens â aspirin plus extended-release dipyridamole (ASAâERDP) versus clopidogrel.

Methods:...

CLINICAL PROBLEM-SOLVING: Collateral Damage

Thu, 04Â SepÂ 2008 00:00:00 -05:00

A 50-year-old white man presented to the emergency room with an 18-hour history of severe right-sided abdominal and flank pain. The patient had a history of hypothyroidism, autoimmune alopecia, and...

REVIEW ARTICLE: Mechanisms of Thrombus Formation

Bruce Furie, M.D., and Barbara C. Furie, Ph.D. — Thu, 28Â AugÂ 2008 00:00:00 -05:00

Hemostasis is the process that maintains the integrity of a closed, high-pressure circulatory system after vascular damage. Vessel-wall injury and the extravasation of blood from the circulation rapidly initiate events...

IMAGES IN CLINICAL MEDICINE: Infrarenal Aortic Occlusion

Alan T. Hirsch, M.D. and Michael D. Miedema, M.D. — Thu, 14Â AugÂ 2008 00:00:00 -05:00

A 55-year-old woman awoke with an acute onset of bilateral leg numbness and weakness. Initial evaluation and lumbar magnetic resonance imaging, which was performed to assess the patient for disk...

ORIGINAL ARTICLE: Bivalirudin versus Unfractionated Heparin during Percutaneous Coronary Intervention

Thu, 14Â AugÂ 2008 00:00:00 -05:00

Background: Whether bivalirudin is superior to unfractionated heparin in patients with stable or unstable angina who undergo percutaneous coronary intervention (PCI) after pretreatment with clopidogrel is unknown.

Methods: We enrolled 4570...

IMAGES IN CLINICAL MEDICINE: Spontaneous Thrombolysis of an Obstructed Mechanical Aortic Valve

Nicole Wake, B.A. and Akshay S. Desai, M.D. — Thu, 26Â JunÂ 2008 00:00:00 -05:00

A 28-year-old man with idiopathic dilated cardiomyopathy who had had St. Jude aortic- and mitral-valve replacements 3 years earlier presented with decompensated heart failure. The examination was notable for marked...

EDITORIAL: New Anticoagulants â The Path from Discovery to Clinical Practice

Jens Lohrmann, M.D., and Richard C. Becker, M.D. — Thu, 26Â JunÂ 2008 00:00:00 -05:00

For more than half a century, heparin and vitamin K antagonists have defined anticoagulant therapy for the short-term and long-term management, respectively, of thrombotic disorders of the venous system. The...

ORIGINAL ARTICLE: Rivaroxaban versus Enoxaparin for Thromboprophylaxis after Total Knee Arthroplasty

Thu, 26Â JunÂ 2008 00:00:00 -05:00

Background: We investigated the efficacy of rivaroxaban, an orally active direct factor Xa inhibitor, in preventing venous thrombosis after total knee arthroplasty.

Methods: In this randomized, double-blind trial, 2531 patients who...

ORIGINAL ARTICLE: Rivaroxaban versus Enoxaparin for Thromboprophylaxis after Hip Arthroplasty

Thu, 26Â JunÂ 2008 00:00:00 -05:00

Background: This phase 3 trial compared the efficacy and safety of rivaroxaban, an oral direct inhibitor of factor Xa, with those of enoxaparin for extended thromboprophylaxis in patients undergoing total...

IMAGES IN CLINICAL MEDICINE: Central Hemiretinal Arterial Occlusion

Kenneth C. Mathys, M.D. and Seema Garg, M.D., Ph.D. — Thu, 19Â JunÂ 2008 00:00:00 -05:00

A 65-year-old woman with a history of hypertension and cigarette smoking presented with complete loss of vision in the inferior field of the left eye, which she had noticed an...

EDITORIAL: Heparin Comes Clean

Lawrence B. Schwartz, M.D., Ph.D. — Thu, 05Â JunÂ 2008 00:00:00 -05:00

Hypotensive episodes in patients receiving heparin by means of injection, some of which cause death, are voluntarily reported to the Food and Drug Administration (FDA). Many cases occur in medical...

ORIGINAL ARTICLE: Contaminated Heparin Associated with Adverse Clinical Events and Activation of the Contact System

Thu, 05Â JunÂ 2008 00:00:00 -05:00

Background: There is an urgent need to determine whether oversulfated chondroitin sulfate (OSCS), a compound contaminating heparin supplies worldwide, is the cause of the severe anaphylactoid reactions that have occurred...

EDITORIAL: Antithrombotic Therapy to Support Primary PCI

David A. Morrow, M.D., M.P.H. — Thu, 22Â MayÂ 2008 00:00:00 -05:00

The goals of the initial management of ST-segment elevation myocardial infarction include swift restoration of flow within the occluded coronary artery, prevention of early reinfarction, and avoidance of complications of...

EDITORIAL: Does Thrombolytic Therapy Facilitate or Foil Primary PCI?

Jane A. Leopold, M.D. — Thu, 22Â MayÂ 2008 00:00:00 -05:00

Sir Winston Churchill once said, âIt's not enough that we do our best; sometimes we have to do what is required.â Such a sentiment underlies the premise of facilitated percutaneous...

ORIGINAL ARTICLE: Bivalirudin during Primary PCI in Acute Myocardial Infarction

Thu, 22Â MayÂ 2008 00:00:00 -05:00

Background: Treatment with the direct thrombin inhibitor bivalirudin, as compared with heparin plus glycoprotein IIb/IIIa inhibitors, results in similar suppression of ischemia while reducing hemorrhagic complications in patients with stable...

ORIGINAL ARTICLE: Facilitated PCI in Patients with ST-Elevation Myocardial Infarction

Thu, 22Â MayÂ 2008 00:00:00 -05:00

Background: We hypothesized that percutaneous coronary intervention (PCI) preceded by early treatment with abciximab plus half-dose reteplase (combination-facilitated PCI) or with abciximab alone (abciximab-facilitated PCI) would improve outcomes in patients...

EDITORIAL: Intracerebral Hemorrhage â Improving Outcome by Reducing Volume?

Stanley Tuhrim, M.D. — Thu, 15Â MayÂ 2008 00:00:00 -05:00

Intracerebral hemorrhage accounts for 10 to 15% of all strokes. It is the type of stroke with the highest mortality, with a 1-year survival rate of less than 50%.1 Most...

ORIGINAL ARTICLE: Efficacy and Safety of Recombinant Activated Factor VII for Acute Intracerebral Hemorrhage

Thu, 15Â MayÂ 2008 00:00:00 -05:00

Background: Intracerebral hemorrhage is the least treatable form of stroke. We performed this phase 3 trial to confirm a previous study in which recombinant activated factor VII (rFVIIa) reduced growth...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 12-2008 â A Newborn Infant with Intermittent Apnea and Seizures

Thu, 17Â AprÂ 2008 00:00:00 -05:00

A 1-day-old female infant was admitted to the neonatal intensive care unit of this hospital because of intermittent apnea and cyanosis. The day before admission, the patient was born at...

IMAGES IN CLINICAL MEDICINE: Cerebral Embolism of Probable Aortic Origin

Ronald E. Oppenheim, M.D. and Gary J. Felsberg, M.D. — Thu, 10Â AprÂ 2008 00:00:00 -05:00

A 70-year-old woman was hospitalized for intermittent, reversible cerebral ischemia causing weakness of the right side for several days, before resolving. A computed tomographic (CT) scan showed no intracranial abnormalities....

IMAGES IN CLINICAL MEDICINE: Pseudoaneurysm of the Right Internal Thoracic Artery

Nick P. Jenkins, M.B., B.S. and Huon Gray, M.D. — Thu, 10Â AprÂ 2008 00:00:00 -05:00

A 71-year-old woman underwent successful elective mitral annuloplasty and coronary-artery bypass grafting, with a left internal thoracic artery graft to her left anterior descending coronary artery and saphenous-vein grafts to...

ORIGINAL ARTICLE: VEGF Inhibition and Renal Thrombotic Microangiopathy

Thu, 13Â MarÂ 2008 00:00:00 -05:00

The glomerular microvasculature is particularly susceptible to injury in thrombotic microangiopathy, but the mechanisms by which this occurs are unclear. We report the cases of six patients who were treated...

ORIGINAL ARTICLE: Genetic Determinants of Response to Warfarin during Initial Anticoagulation

Thu, 06Â MarÂ 2008 00:00:00 -05:00

Background: Genetic variants of the enzyme that metabolizes warfarin, cytochrome P-450 2C9 (CYP2C9), and of a key pharmacologic target of warfarin, vitamin K epoxide reductase (VKORC1), contribute to differences in...

EDITORIAL: Pharmacogenomics â Ready for Prime Time?

Susan B. Shurin, M.D., and Elizabeth G. Nabel, M.D. — Thu, 06Â MarÂ 2008 00:00:00 -05:00

Pharmacogenomics is receiving a great deal of attention in scientific circles and, increasingly, in the popular press because of the promise of personalized medicine. Short of being able to cure...

REVIEW ARTICLE: Acute Pulmonary Embolism

Victor F. Tapson, M.D. — Thu, 06Â MarÂ 2008 00:00:00 -05:00

Pulmonary embolism, most commonly originating from deep venous thrombosis of the legs, ranges from asymptomatic, incidentally discovered emboli to massive embolism causing immediate death. Chronic sequelae of venous thromboembolism (deep...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 7-2008 â A 17-Year-Old Girl with Chest Pain and Hemoptysis

Thu, 28Â FebÂ 2008 00:00:00 -05:00

Dr. Mary Shannon Fracchia (Pediatrics): A 17-year-old girl was transferred to this hospital because of chest pain and hemoptysis. She had been well except for mild asthma until 4 months...

IMAGES IN CLINICAL MEDICINE: Retinal Arteriolar Cholesterol Emboli

Michael Colucciello, M.D. — Thu, 21Â FebÂ 2008 00:00:00 -05:00

A 59-year-old man with a medical history of hypertension, hyperlipidemia, and coronary artery disease presented with transient, painless visual obscuration in the left eye, and he was referred for retinal...

EDITORIAL: Improving Reperfusion in Patients with Myocardial Infarction

George W. Vetrovec, M.D. — Thu, 07Â FebÂ 2008 00:00:00 -05:00

A little over 50 years ago, my father had a heart attack. He was driven to the hospital by friends after having âindigestionâ for 2 days. He spent 2 weeks...

ORIGINAL ARTICLE: Thrombus Aspiration during Primary Percutaneous Coronary Intervention

Thu, 07Â FebÂ 2008 00:00:00 -05:00

Background: Primary percutaneous coronary intervention (PCI) is effective in opening the infarct-related artery in patients with myocardial infarction with ST-segment elevation. However, the embolization of atherothrombotic debris induces microvascular obstruction...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 2-2008 â A 38-Year-Old Woman with Postpartum Visual Loss, Shortness of Breath, and Renal Failure

Thu, 17Â JanÂ 2008 00:00:00 -05:00

Dr. Esperance A. Schaefer (Medicine): A 38-year-old woman was admitted to the hospital, because of blurred vision and shortness of breath, 2 weeks after a cesarean section had been performed...

IMAGES IN CLINICAL MEDICINE: Retiform Purpura

Dan Lipsker, M.D., Ph.D. and Fady Kara, M.D. — Thu, 10Â JanÂ 2008 00:00:00 -05:00

A rapidly spreading, painful rash and confusion developed in a 46-year-old male patient with a history of chronic alcoholism. On physical examination, he was febrile and hypotensive and had a...

IMAGES IN CLINICAL MEDICINE: Dissecting Aneurysm of the Posterior Cerebral Artery

Dimitri Renard, M.D. and Didier Milhaud, M.D. — Thu, 13Â DecÂ 2007 00:00:00 -05:00

A 43-year-old man presented with acute-onset hemianesthesia involving the right arm, the right leg, and the right side of the face. Six weeks earlier, he had a moderate occipital headache...

IMAGES IN CLINICAL MEDICINE: Occlusion and Reperfusion of the Middle Cerebral Artery

Ronan Ryan, A.F.R.C.S.I. and David P. Brophy, F.F.R.R.C.S.I. — Thu, 13Â DecÂ 2007 00:00:00 -05:00

A 65-year-old woman with chronic atrial fibrillation was admitted for an elective exchange of an implanted defibrillator for idiopathic dilated cardiomyopathy. To facilitate this procedure, warfarin was withheld for 5...

REVIEW ARTICLE: Platelet Activation and Atherothrombosis

Giovanni DavÃ¬, M.D., and Carlo Patrono, M.D. — Thu, 13Â DecÂ 2007 00:00:00 -05:00

Platelets are essential for primary hemostasis and repair of the endothelium, but they also play a key role in the development of acute coronary syndromes and contribute to cerebrovascular events....

EDITORIAL: Intensifying Platelet Inhibition â Navigating between Scylla and Charybdis

Deepak L. Bhatt, M.D. — Thu, 15Â NovÂ 2007 00:00:00 -05:00

In Greek mythology, Scylla was a ferocious beast and Charybdis was a monstrous whirlpool. The wily Odysseus successfully navigated between these two dangers by steering closer to Scylla, though he...

ORIGINAL ARTICLE: Prasugrel versus Clopidogrel in Patients with Acute Coronary Syndromes

Thu, 15Â NovÂ 2007 00:00:00 -05:00

Background: Dual-antiplatelet therapy with aspirin and a thienopyridine is a cornerstone of treatment to prevent thrombotic complications of acute coronary syndromes and percutaneous coronary intervention.

Methods: To compare prasugrel, a new...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 28-2007 â A 68-Year-Old Man with Syncope

Thu, 13Â SepÂ 2007 00:00:00 -05:00

A 68-year-old man was admitted to this hospital because of a syncopal episode, followed by hemiparesis and altered mental status.

The patient was in his usual state of health until the...

ORIGINAL ARTICLE: Extended Prophylaxis of Venous Thromboembolism with Idraparinux

The van Gogh Investigators — Thu, 13Â SepÂ 2007 00:00:00 -05:00

Background: The extended use of vitamin K antagonists for prophylaxis against venous thromboembolism is often constrained by riskâbenefit limitations and inconvenience. We evaluated the efficacy and safety of a 6-month...

ORIGINAL ARTICLE: Idraparinux versus Standard Therapy for Venous Thromboembolic Disease

The van Gogh Investigators — Thu, 13Â SepÂ 2007 00:00:00 -05:00

Background: Venous thromboembolism is treated with unfractionated heparin or low-molecular-weight heparin, followed by a vitamin K antagonist. We investigated the potential use of idraparinux, a long-acting inhibitor of activated factor...

REVIEW ARTICLE: Drug-Induced Immune Thrombocytopenia

Richard H. Aster, M.D., and Daniel W. Bougie, Ph.D. — Thu, 09Â AugÂ 2007 00:00:00 -05:00

Drug-induced thrombocytopenia can be caused by dozens, perhaps hundreds, of medications. Because thrombocytopenia can have many other causes, the diagnosis of drug-induced thrombocytopenia can easily be overlooked. On occasion, outpatients...

ORIGINAL ARTICLE: Partial Thrombosis of the False Lumen in Patients with Acute Type B Aortic Dissection

Thu, 26Â JulÂ 2007 00:00:00 -05:00

Background: Patency or thrombosis of the false lumen in type B acute aortic dissection has been found to predict outcomes. The prognostic implications of partial thrombosis of the false lumen...

EDITORIAL: Atherothrombosis â Wave Goodbye to Combined Anticoagulation and Antiplatelet Therapy?

Emile R. Mohler III, M.D. — Thu, 19Â JulÂ 2007 00:00:00 -05:00

Atherothrombosis describes the occurrence of both atherosclerosis and thrombosis in an artery, a common feature of peripheral arterial disease.1 It is estimated that 1 in 16 U.S. residents who were...

ORIGINAL ARTICLE: Oral Anticoagulant and Antiplatelet Therapy and Peripheral Arterial Disease

The Warfarin Antiplatelet Vascular Evaluation Trial Investigators — Thu, 19Â JulÂ 2007 00:00:00 -05:00

Background: Atherosclerotic peripheral arterial disease is associated with an increased risk of myocardial infarction, stroke, and death from cardiovascular causes. Antiplatelet drugs reduce this risk, but the role of oral...

CLINICAL PROBLEM-SOLVING: A Sinister Development â A 35-year-old woman presented to the emergency department with a 2-day history of progressive swelling and pain in her left leg, without antecedent trauma

Thu, 05Â JulÂ 2007 00:00:00 -05:00

A 35-year-old woman presented to the emergency department with a 2-day history of progressive swelling and pain in her left leg, without antecedent trauma. Her pain worsened acutely during the...

CLINICAL PRACTICE: Superior Vena Cava Syndrome with Malignant Causes

Thu, 03Â MayÂ 2007 00:00:00 -05:00

A 58-year-old man presents with a 2-week history of progressive dyspnea on exertion, neck swelling, decreased appetite, and fatigue. There is no history of syncope or dysphagia. He smoked cigarettes...

CLINICAL PRACTICE: Prophylaxis for Thromboembolism in Hospitalized Medical Patients

Charles W. Francis, M.D. — Thu, 05Â AprÂ 2007 00:00:00 -05:00

A 62-year-old man is admitted with fever, cough, and dyspnea. He is weak, appears to be dehydrated, and has purulent sputum. His temperature is 39.2Â°C, respirations 22, and blood pressure...

IMAGES IN CLINICAL MEDICINE: Calcified Left Atrial Thrombus

Joseph M. Pappachan, M.D. and Benjamin C. Bino, M.D. — Thu, 08Â MarÂ 2007 00:00:00 -05:00

A 21-year-old woman with a history of rheumatic fever at 7 years of age presented with left-sided weakness. A large ischemic infarction involving the territory of the right middle cerebral...

PERSPECTIVE: Drug-Induced Immune-Mediated Thrombocytopenia â From Purpura to Thrombosis

Thu, 01Â MarÂ 2007 00:00:00 -05:00

In 1949, Ackroyd reported the abrupt onset of severe thrombocytopenia and purpura in patients receiving the sedative allylisopropylacetylcarbamide (Sedormid).1 All the patients had taken Sedormid previously and had become sensitized...

IMAGES IN CLINICAL MEDICINE: Central Retinal Artery Occlusion

Kayvan Arashvand, M.D. — Thu, 22Â FebÂ 2007 00:00:00 -05:00

A 76-year-old man with hypertension presented with a sudden, painless, and profound loss of vision in the right eye. Visual acuity was light perception only in the affected eye, with...

PERSPECTIVE: Debating the Risks of Drug-Eluting Stents

Thu, 25Â JanÂ 2007 00:00:00 -05:00

Last September, a firestorm was ignited over drug-eluting stents when data were released showing an increase in the risk of late stent thrombosis. In response, the Food and Drug Administration...

IMAGES IN CLINICAL MEDICINE: Phlegmasia Cerulea Dolens

Kalleen Barham, M.D. and Tina Shah, M.D. — Thu, 18Â JanÂ 2007 00:00:00 -05:00

An 85-year-old woman with newly diagnosed metastatic nonâsmall-cell lung cancer was admitted for pain control. Two days after admission, bluish discoloration of the left great toe was noted. Doppler ultrasonography...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 1-2007 â A 40-Year-Old Woman with Epistaxis, Hematemesis, and Altered Mental Status

Thu, 11Â JanÂ 2007 00:00:00 -05:00

Dr. Amy Jo Chien (Medicine): A 40-year-old woman was admitted to the emergency department of this hospital because of the sudden onset of headache, loss of consciousness, and coagulopathy.

The patient...

EDITORIAL: Reducing the Door-to-Balloon Time for Myocardial Infarction with ST-Segment Elevation

Mauro Moscucci, M.D., and Kim A. Eagle, M.D. — Thu, 30Â NovÂ 2006 00:00:00 -05:00

It has been 27 years since the initial report of successful reperfusion of occluded coronary arteries with thrombolytic therapy in patients with acute myocardial infarction,1 and 20 years since the...

SPECIAL ARTICLE: Strategies for Reducing the Door-to-Balloon Time in Acute Myocardial Infarction

Thu, 30Â NovÂ 2006 00:00:00 -05:00

Background: Prompt reperfusion treatment is essential for patients who have myocardial infarction with ST-segment elevation. Guidelines recommend that the interval between arrival at the hospital and intracoronary balloon inflation (door-to-balloon...

EDITORIAL: Research Replication

Jeffrey M. Drazen, M.D. — Thu, 23Â NovÂ 2006 00:00:00 -05:00

In January 2006, we published an article by Mangano and colleagues1 that reported the results of an observational study of antifibrinolytic agents to control bleeding in cardiac surgery. The data...

EDITORIAL: Accounting for ACUITY

John A. Bittl, M.D. — Thu, 23Â NovÂ 2006 00:00:00 -05:00

The treatment of patients with acute coronary syndromes is straightforward in principle but complex in practice. With the increase in referrals of moderate- or high-risk patients for invasive cardiac procedures...

ORIGINAL ARTICLE: Bivalirudin for Patients with Acute Coronary Syndromes

Thu, 23Â NovÂ 2006 00:00:00 -05:00

Background: Current guidelines for patients with moderate- or high-risk acute coronary syndromes recommend an early invasive approach with concomitant antithrombotic therapy, including aspirin, clopidogrel, unfractionated or low-molecular-weight heparin, and glycoprotein...

EDITORIAL: Treatment of In-Stent Restenosis â Back to the Future?

Thu, 16Â NovÂ 2006 00:00:00 -05:00

Percutaneous transluminal coronary angioplasty has become the most frequently used method for myocardial revascularization.1 The use of uncoated coronary-artery stents during percutaneous intervention has decreased the incidence of acute complications...

ORIGINAL ARTICLE: Treatment of Coronary In-Stent Restenosis with a Paclitaxel-Coated Balloon Catheter

Thu, 16Â NovÂ 2006 00:00:00 -05:00

Background: Treatment of coronary in-stent restenosis is hampered by a high incidence of recurrent in-stent restenosis. We assessed the efficacy and safety of a paclitaxel-coated balloon in this setting.

Methods: We...

IMAGES IN CLINICAL MEDICINE: Vascular Occlusion after Intraarterial Cocaine Injection

Mark C. Stover, M.D. and Jeanmarie Perrone, M.D. — Thu, 09Â NovÂ 2006 00:00:00 -05:00

A 54-year-old man with a history of parenteral substance abuse, hepatitis C virus infection, and poor peripheral venous access presented to the emergency department with a history of progressive pain,...

PERSPECTIVE: Trading Restenosis for Thrombosis? New Questions about Drug-Eluting Stents

Thu, 09Â NovÂ 2006 00:00:00 -05:00

In September, at the World Cardiology Congress in Barcelona, Donald Baim, a cardiologist who is the new chief medical and scientific officer of Boston Scientific, was talking to a reporter...

ORIGINAL ARTICLE: -Dimer Testing to Determine the Duration of Anticoagulation Therapy

Thu, 26Â OctÂ 2006 00:00:00 -05:00

Background: The optimal duration of oral anticoagulation in patients with idiopathic venous thromboembolism is uncertain. Testing of d-dimer levels may play a role in the assessment of the need for...

IMAGES IN CLINICAL MEDICINE: Rasmussen's Aneurysm

Michel M. van den Heuvel, M.D., Ph.D. and Jacques J. van Rensburg, M.D. — Thu, 19Â OctÂ 2006 00:00:00 -05:00

A 54-year-old man presented with a 3-month history of hemoptysis of approximately 50 ml per day. He had a remote history of pulmonary tuberculosis. On the second hospital day, he...

IMAGES IN CLINICAL MEDICINE: Arteriovenous Fistula on CT Angiography

Marc Laureys, M.D. — Thu, 05Â OctÂ 2006 00:00:00 -05:00

A 62-year-old man with diabetes and end-stage renal disease, for which an arteriovenous fistula had been placed in the left arm 11 months earlier for hemodialysis, presented with a possible...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 29-2006 â A 43-Year-Old Woman with Painful Nodules on the Fingertips, Shortness of Breath, and Fatigue

Thu, 21Â SepÂ 2006 00:00:00 -05:00

Dr. Tessa Cigler (Cancer Center): A 43-year-old woman was admitted to this hospital because of painful nodules on the fingertips, shortness of breath, and fatigue.

Systemic lupus erythematosus (SLE) had been...

EDITORIAL: Risk of Bleeding after Elective Percutaneous Coronary Intervention

William W. O'Neill, M.D. — Thu, 07Â SepÂ 2006 00:00:00 -05:00

About 2.2 million percutaneous coronary interventions (PCIs) were performed worldwide in 2004 (Mead D: personal communication). Success rates of more than 97%, mortality rates of less than 0.5%, and rates...

ORIGINAL ARTICLE: Enoxaparin versus Unfractionated Heparin in Elective Percutaneous Coronary Intervention

Thu, 07Â SepÂ 2006 00:00:00 -05:00

Background: Despite its limitations, unfractionated heparin has been the standard anticoagulant used during percutaneous coronary intervention (PCI). Several small studies have suggested that intravenous enoxaparin may be a safe and...

IMAGES IN CLINICAL MEDICINE: Ocular Bleeding Due to Anticoagulation

Latha G. Stead, M.D. and Kurtis A. Judson, M.D. — Thu, 24Â AugÂ 2006 00:00:00 -05:00

An 83-year-old woman with a history of hypertension, glaucoma, and atrial fibrillation, who had a pacemaker and was receiving warfarin, woke up with a sensation of pain in the right...

CLINICAL PRACTICE: Heparin-Induced Thrombocytopenia

Gowthami M. Arepally, M.D., and Thomas L. Ortel, M.D., Ph.D. — Thu, 24Â AugÂ 2006 00:00:00 -05:00

A 63-year-old man with coronary artery disease who has recently undergone bypass surgery presents with dyspnea. Findings on physical examination are unremarkable. Laboratory testing reveals a platelet count of 86,000...

REVIEW ARTICLE: Chronic Venous Disease

Thu, 03Â AugÂ 2006 00:00:00 -05:00

Chronic venous disease of the lower limbs is manifested by a range of signs, the most obvious of which are varicose veins and venous ulcers. However, the signs also include...

EDITORIAL: Accuracy or Outcome in Suspected Pulmonary Embolism

Arnaud Perrier, M.D., and Henri Bounameaux, M.D. — Thu, 01Â JunÂ 2006 00:00:00 -05:00

Sixteen years ago, the results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED) study1 were published. That large-scale, multicenter trial definitively established the diagnostic characteristics of ventilationâperfusion scintigraphy of...

CLINICAL PROBLEM-SOLVING: Thinking outside the Box

Ramin Farzaneh-Far, M.D., Talya Schwarzberg, M.D., and Stuart B. Mushlin, M.D. — Thu, 01Â JunÂ 2006 00:00:00 -05:00

A 35-year-old man with advanced acquired immunodefiency syndrome (AIDS) presented to the emergency department after a witnessed syncopal event. He had noted light-headedness after walking from the bathroom to his...

ORIGINAL ARTICLE: Multidetector Computed Tomography for Acute Pulmonary Embolism

Thu, 01Â JunÂ 2006 00:00:00 -05:00

Background: The accuracy of multidetector computed tomographic angiography (CTA) for the diagnosis of acute pulmonary embolism has not been determined conclusively.

Methods: The Prospective Investigation of Pulmonary Embolism Diagnosis II trial...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 16-2006 â A 72-Year-Old Woman Admitted to the Emergency Department because of a Sudden Change in Mental Status

Stephen H. Thomas, M.D., M.P.H., Lee H. Schwamm, M.D., and Michael H. Lev, M.D. — Thu, 25Â MayÂ 2006 00:00:00 -05:00

Dr. Emily Senecal (Emergency Medicine): A 72-year-old left-handed woman was transported by helicopter from her home to the emergency department of this hospital because of a sudden change in mental...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 15-2006 â A 46-Year-Old Woman with Sudden Onset of Abdominal Distention

Thu, 18Â MayÂ 2006 00:00:00 -05:00

Dr. Patrick S. Yachimski (Gastrointestinal Unit): A 46-year-old woman was admitted to this hospital because of rapidly increasing abdominal girth. She had been well until five weeks earlier, when increasing...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 14-2006 â A 25-Year-Old Woman with Anemia and Iron Overload

Eyal C. Attar, M.D., and Robert P. Hasserjian, M.D. — Thu, 11Â MayÂ 2006 00:00:00 -05:00

A 25-year-old woman was seen in the hematology clinic at this hospital because of anemia and laboratory evidence of increased iron stores.

The patient had been admitted to another hospital one...

EDITORIAL: The Charisma of Subgroups and the Subgroups of CHARISMA

Marc A. Pfeffer, M.D., Ph.D., and John A. Jarcho, M.D. — Thu, 20Â AprÂ 2006 00:00:00 -05:00

Antiplatelet therapy with aspirin, an irreversible inhibitor of platelet cyclooxygenase, has earned its rightful place as a cornerstone of treatment for reducing cardiovascular events in patients with established vascular disease.12...

ORIGINAL ARTICLE: Clopidogrel and Aspirin versus Aspirin Alone for the Prevention of Atherothrombotic Events

Thu, 20Â AprÂ 2006 00:00:00 -05:00

Background: Dual antiplatelet therapy with clopidogrel plus low-dose aspirin has not been studied in a broad population of patients at high risk for atherothrombotic events.

Methods: We randomly assigned 15,603 patients...

EDITORIAL: Therapy for Patients with Acute Coronary Syndromes â New Opportunities

Raymond J. Gibbons, M.D., and Valentin Fuster, M.D., Ph.D. — Thu, 06Â AprÂ 2006 00:00:00 -05:00

Acute coronary syndromes, defined as myocardial infarction with ST-segment elevation, myocardial infarction without ST-segment elevation, and unstable angina, share a common pathophysiology: atherosclerotic plaque rupture, erosion, or both with superimposed...

ORIGINAL ARTICLE: Role of COL4A1 in Small-Vessel Disease and Hemorrhagic Stroke

Thu, 06Â AprÂ 2006 00:00:00 -05:00

Small-vessel diseases of the brain underlie 20 to 30 percent of ischemic strokes and a larger proportion of intracerebral hemorrhages. In this report, we show that a mutation in the...

ORIGINAL ARTICLE: Enoxaparin versus Unfractionated Heparin with Fibrinolysis for ST-Elevation Myocardial Infarction

Thu, 06Â AprÂ 2006 00:00:00 -05:00

Background: Unfractionated heparin is often used as adjunctive therapy with fibrinolysis in patients with ST-elevation myocardial infarction. We compared a low-molecular-weight heparin, enoxaparin, with unfractionated heparin for this purpose.

Methods: We...

ORIGINAL ARTICLE: Comparison of Fondaparinux and Enoxaparin in Acute Coronary Syndromes

Thu, 06Â AprÂ 2006 00:00:00 -05:00

Background: The combined use of anticoagulants, antiplatelet agents, and invasive coronary procedures reduces ischemic coronary events but also increases bleeding in patients with acute coronary syndromes. We therefore assessed whether...

PERSPECTIVE: Small Vessels, Big Problems

Thu, 06Â AprÂ 2006 00:00:00 -05:00

The impressive gains in stroke prevention and treatment seen over the past decade have not been evenly distributed across all types of stroke. Most advances have pertained to the approximately...

IMAGES IN CLINICAL MEDICINE: Bilateral Renal-Vein Thrombosis Associated with the Nephrotic Syndrome

Surat Phonsombat, M.D. and Marshall L. Stoller, M.D. — Thu, 30Â MarÂ 2006 00:00:00 -05:00

A 61-year-old woman whose medical history was notable for hypertension and type 2 diabetes reported a two-day history of increasing dull pain in the right flank and nonbloody, bilious vomiting....

IMAGES IN CLINICAL MEDICINE: Malignant Obstruction of the Superior Vena Cava

Ronak S. Kanani, M.D. and Douglas E. Drachman, M.D. — Thu, 23Â FebÂ 2006 00:00:00 -05:00

A 75-year-old man with a substantial smoking history and stage IV nonâsmall-cell carcinoma of the lung presented with progressive symptoms of cough, hoarseness, and swelling of the face and arms....

ORIGINAL ARTICLE: Effect of Haplotypes on Transcriptional Regulation and Warfarin Dose

Thu, 02Â JunÂ 2005 00:00:00 -05:00

Background: The management of warfarin therapy is complicated by a wide variation among patients in drug response. Variants in the gene encoding vitamin K epoxide reductase complex 1 (VKORC1) may...

ORIGINAL ARTICLE: Amiodarone versus Sotalol for Atrial Fibrillation

Thu, 05Â MayÂ 2005 00:00:00 -05:00

Background: The optimal pharmacologic means to restore and maintain sinus rhythm in patients with atrial fibrillation remains controversial.

Methods: In this double-blind, placebo-controlled trial, we randomly assigned 665 patients who were...

EDITORIAL: Multislice Computed Tomography for Pulmonary Embolism â A Technological Marvel

Samuel Z. Goldhaber, M.D. — Thu, 28Â AprÂ 2005 00:00:00 -05:00

Rapid and accurate diagnosis of pulmonary embolism will improve survival and quality of life because treatment decreases mortality and the likelihood that thromboembolic pulmonary hypertension or the post-thrombotic syndrome will...

REVIEW ARTICLE: Thrombosis of the Cerebral Veins and Sinuses

Jan Stam, M.D., Ph.D. — Thu, 28Â AprÂ 2005 00:00:00 -05:00

05042828.xml Thrombosis of the cerebral veins and sinuses is a distinct cerebrovascular disorder that, unlike arterial stroke, most often affects young adults and children. The symptoms and clinical course...

ORIGINAL ARTICLE: Multidetector-Row Computed Tomography in Suspected Pulmonary Embolism

Thu, 28Â AprÂ 2005 00:00:00 -05:00

Background: Single-detectorârow computed tomography (CT) has a low sensitivity for pulmonary embolism and must be combined with venous-compression ultrasonography of the lower limbs. We evaluated whether the use of D-dimer...

IMAGES IN CLINICAL MEDICINE: An Unusual Case of Pulmonary Embolism

Tom Routledge, M.R.C.S. and David Jenkins, F.R.C.S. — Thu, 14Â AprÂ 2005 00:00:00 -05:00

A 33-year-old woman had dyspnea for six months, with intermittent fever. She was admitted to the hospital with worsening dyspnea, hypoxia, and patchy bilateral pulmonary consolidations. Computed tomography showed large,...

EDITORIAL: Warfarin, Aspirin, and Intracranial Vascular Disease

Walter J. Koroshetz, M.D. — Thu, 31Â MarÂ 2005 00:00:00 -05:00

The WarfarinâAspirin Symptomatic Intracranial Disease (WASID) Trial, funded by the National Institute of Neurological Disorders and Stroke and reported by Chimowitz et al.1 in this issue of the Journal, was...

ORIGINAL ARTICLE: Comparison of Warfarin and Aspirin for Symptomatic Intracranial Arterial Stenosis

Thu, 31Â MarÂ 2005 00:00:00 -05:00

Background: Atherosclerotic intracranial arterial stenosis is an important cause of stroke. Warfarin is commonly used in preference to aspirin for this disorder, but these therapies have not been compared in...

ORIGINAL ARTICLE: Electronic Alerts to Prevent Venous Thromboembolism among Hospitalized Patients

Thu, 10Â MarÂ 2005 00:00:00 -05:00

Background: Prophylaxis against deep-vein thrombosis in hospitalized patients remains underused. We hypothesized that the use of a computer-alert program to encourage prophylaxis might reduce the frequency of deep-vein thrombosis among...

EDITORIAL: Electronic Medical Alerts â So Simple, So Complex

Pierre Durieux, M.D., M.P.H. — Thu, 10Â MarÂ 2005 00:00:00 -05:00

One of the most consistent findings in health research is the gap between evidence and practice. It is estimated that the care received by 30 to 40 percent of patients...

IMAGES IN CLINICAL MEDICINE: Mondor's Disease

Jorge Soler-GonzÃ¡lez, M.D. and M.C. Ruiz, M.D. — Thu, 10Â MarÂ 2005 00:00:00 -05:00

A 32-year-old woman presented with a three-day history of tenderness and swelling of the left breast. Physical examination revealed a subcutaneous fibrous lesion that was linear and cordlike. The patient...

IMAGES IN CLINICAL MEDICINE: Fatal Free-Floating Left Atrial Thrombus

TamÃ¡s TornÃ³czky, M.D., Ph.D. and Zeno Ajtay, M.D. — Thu, 30Â DecÂ 2004 00:00:00 -05:00

A 68-year-old woman who had been resuscitated after cardiac arrest was admitted because of chest pain. The electrocardiogram showed atrial fibrillation and ST-segment elevation in leads II, III, and aVF,...

ORIGINAL ARTICLE: Ultrasound-Enhanced Systemic Thrombolysis for Acute Ischemic Stroke

Thu, 18Â NovÂ 2004 00:00:00 -05:00

Background: Transcranial Doppler ultrasonography that is aimed at residual obstructive intracranial blood flow may help expose thrombi to tissue plasminogen activator (t-PA). Our objective was to determine whether ultrasonography can...

PERSPECTIVE: Ultrasound Energy and the Dissolution of Thrombus

Joseph F. Polak, M.D., M.P.H. — Thu, 18Â NovÂ 2004 00:00:00 -05:00

In this issue of the Journal, Alexandrov et al. (pages 2170â2178) introduce practicing physicians to a new and exciting use of diagnostic ultrasonography. The authors show that ultrasound energy, used...

PERSPECTIVE: Triggering Myocardial Infarction

Peter H. Stone, M.D. — Thu, 21Â OctÂ 2004 00:00:00 -05:00

Enormous progress made during the past few decades has dramatically enhanced our understanding of the pathobiology and pathophysiology responsible for acute myocardial infarction. Investigations in vascular biology have elucidated the...

REVIEW ARTICLE: Pulmonary Arterial Hypertension

Harrison W. Farber, M.D., and Joseph Loscalzo, M.D., Ph.D. — Thu, 14Â OctÂ 2004 00:00:00 -05:00

Pulmonary hypertension is usually classified as primary (idiopathic) or secondary.1 It is now clear, however, that there are conditions within the category of secondary pulmonary hypertension that resemble primary pulmonary...

PERSPECTIVE: Cardiopulmonary Bypass after 50 Years

L. Henry Edmunds, M.D. — Thu, 14Â OctÂ 2004 00:00:00 -05:00

A little more than 50 years ago, a hole inside a human heart was closed, with a machine maintaining life while the surgery was done. Within the next two years,...

PERSPECTIVE: Problems with Drug-Eluting Coronary Stents â The FDA Perspective

Neal I. Muni, M.D., M.S.P.H., and Thomas P. Gross, M.D., M.P.H. — Thu, 14Â OctÂ 2004 00:00:00 -05:00

The introduction of drug-eluting coronary stents in the United States has rapidly and profoundly affected the field of interventional cardiology. Met with widespread anticipation by the clinical community, drug-eluting stents...

EDITORIAL: Stenting for Carotid-Artery Stenosis

Richard P. Cambria, M.D. — Thu, 07Â OctÂ 2004 00:00:00 -05:00

In the context of his original description of the pathoanatomical relationship of plaque at the carotid bifurcation to ipsilateral hemispheric stroke, C. Miller Fisher predicted that âone day surgeons might...

ORIGINAL ARTICLE: Protected Carotid-Artery Stenting versus Endarterectomy in High-Risk Patients

Thu, 07Â OctÂ 2004 00:00:00 -05:00

Background: 04100728.xml 04100728.xml 04100728.xml Carotid endarterectomy is more effective than medical management in the prevention of stroke in patients with severe symptomatic or asymptomatic atherosclerotic carotid-artery stenosis. Stenting with the...

ORIGINAL ARTICLE: Elevated Plasma Factor VIII and D-Dimer Levels as Predictors of Poor Outcomes of Thrombosis in Children

Thu, 09Â SepÂ 2004 00:00:00 -05:00

Background: Elevated levels of plasma factor VIII and D-dimer predict recurrent venous thromboembolism in adults. We sought to determine whether an elevation of factor VIII, D-dimer, or both at diagnosis...

PERSPECTIVE: Factor VIII, D-Dimer, and Thromboembolism in Children

Ulrike Nowak-GÃ¶ttl, M.D., and Andrea Kosch, M.D. — Thu, 09Â SepÂ 2004 00:00:00 -05:00

Symptomatic venous and arterial thromboses are being diagnosed with increasing frequency in neonates, infants, and children. Because of the special properties of the hemostatic system in children, thrombotic manifestations are...

CLINICAL PRACTICE: Treatment of Deep-Vein Thrombosis

Shannon M. Bates, M.D.C.M., and Jeffrey S. Ginsberg, M.D. — Thu, 15Â JulÂ 2004 00:00:00 -05:00

A 52-year-old-woman with no history of venous thromboembolism presents with a four-day history of discomfort in her left calf. Proximal deep-vein thrombosis is diagnosed by compression ultrasonography. How should her...

ORIGINAL ARTICLE: Mannose-Binding Lectin Variant Alleles and the Risk of Arterial Thrombosis in Systemic Lupus Erythematosus

Thu, 15Â JulÂ 2004 00:00:00 -05:00

Background: Cardiovascular disease is an important complication in patients with systemic lupus erythematosus (SLE). Variant alleles of the mannose-binding lectin gene are associated with SLE as well as with severe...

CLINICAL PROBLEM-SOLVING: A Twist of Fate?

Michael D. Christian, M.D., and Allan S. Detsky, M.D., Ph.D. — Thu, 01Â JulÂ 2004 00:00:00 -05:00

A 39-year-old Sri Lankan male physiotherapist presented to an emergency department in Toronto with a three-day history of headache, chills, diarrhea, nausea, vomiting, and neck stiffness. He reported having had...

EDITORIAL: Mars or Venus â Is Sex a Risk Factor for Recurrent Venous Thromboembolism?

C. Gregory Elliott, M.D., and Lewis J. Rubin, M.D. — Thu, 17Â JunÂ 2004 00:00:00 -05:00

In 1856 Rudolph Virchow identified three primary risk factors â commonly called Virchow's triad â for venous thromboembolism: venous stasis, hypercoagulability, and endothelial injury.1 Other risk factors have since been...

ORIGINAL ARTICLE: The Risk of Recurrent Venous Thromboembolism in Men and Women

Thu, 17Â JunÂ 2004 00:00:00 -05:00

Background: Whether a patient's sex is associated with the risk of recurrent venous thromboembolism is unknown.

Methods: We studied 826 patients for an average of 36 months after a first episode...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 17-2004 â A 42-Year-Old Woman with Cardiac Arrest Several Weeks after an Ankle Fracture

Thu, 27Â MayÂ 2004 00:00:00 -05:00

Dr. Vicki E. Noble (Emergency Medicine): A 42-year-old woman was admitted to the emergency department of this hospital after cardiac arrest with pulseless electrical activity.

Approximately two weeks before admission,...

ORIGINAL ARTICLE: Incidence of Chronic Thromboembolic Pulmonary Hypertension after Pulmonary Embolism

Thu, 27Â MayÂ 2004 00:00:00 -05:00

Background: Chronic thromboembolic pulmonary hypertension (CTPH) is associated with considerable morbidity and mortality. Its incidence after pulmonary embolism and associated risk factors are not well documented.

Methods: We conducted a prospective,...

PERSPECTIVE: Chronic Thromboembolic Pulmonary Hypertension â Not So Rare after All

Irene M. Lang, M.D. — Thu, 27Â MayÂ 2004 00:00:00 -05:00

Chronic thromboembolic pulmonary hypertension (CTPH) is believed to result from single or recurrent pulmonary thromboemboli arising from sites of venous thrombosis. The occurrence of CTPH after a diagnosis of acute...

REVIEW ARTICLE: Thrombocytosis

Andrew I. Schafer, M.D. — Thu, 18Â MarÂ 2004 00:00:00 -05:00

Thrombocytosis is typically discovered as an incidental laboratory abnormality when the complete blood count is obtained for some unrelated reason. When found, however, it creates an important diagnostic challenge. Thrombocytosis...

CLINICAL PROBLEM-SOLVING: Occam's Razor versus Saint's Triad

Thu, 05Â FebÂ 2004 00:00:00 -05:00

A 60-year-old woman with a history of radiologically confirmed seronegative rheumatoid arthritis presented to the emergency department with a 10-day history of worsening dyspnea on exertion, nonproductive cough, and subjective...

EDITORIAL: Antiplatelet Therapy for Ischemic Heart Disease

Richard A. Lange, M.D., and L. David Hillis, M.D. — Thu, 15Â JanÂ 2004 00:00:00 -05:00

Rupture or injury of an atherosclerotic coronary arterial plaque â as occurs spontaneously in patients with an acute coronary syndrome or as the result of a percutaneous coronary intervention â...

ORIGINAL ARTICLE: A Clinical Trial of Abciximab in Elective Percutaneous Coronary Intervention after Pretreatment with Clopidogrel

Thu, 15Â JanÂ 2004 00:00:00 -05:00

Background: Whether the glycoprotein IIb/IIIa inhibitor abciximab is beneficial in patients undergoing elective percutaneous coronary intervention after pretreatment with clopidogrel is unknown.

Methods: We enrolled 2159 patients with coronary artery disease...

PERSPECTIVE: Daily Aspirin â Only Half the Answer

Jerry Spivak, M.D. — Thu, 08Â JanÂ 2004 00:00:00 -05:00

Polycythemia vera is a chronic clonal hematopoieticâstem-cell disorder of unknown cause characterized by autonomous bone marrow function. Among the long-term consequences of this unregulated hematopoiesis are the extramedullary production of...

ORIGINAL ARTICLE: Efficacy and Safety of Low-Dose Aspirin in Polycythemia Vera

Thu, 08Â JanÂ 2004 00:00:00 -05:00

Background: The use of aspirin for the prevention of thrombotic complications in polycythemia vera is controversial.

Methods: We enrolled 518 patients with polycythemia vera, no clear indication for aspirin treatment, and...

IMAGES IN CLINICAL MEDICINE: Peripheral Embolism from an Aortic-Arch Atheroma

James Sangyop Lee, M.D. and P.A.N. Chandraratna, M.D. — Thu, 11Â DecÂ 2003 00:00:00 -05:00

A 62-year-old man presented with a one-month history of pain in the toes of both feet and in the left fourth fingertip. Examination revealed gangrene of the fingertip and all...

REVIEW ARTICLE: ST-Segment Elevation in Conditions Other Than Acute Myocardial Infarction

Kyuhyun Wang, M.D., Richard W. Asinger, M.D., and Henry J.L. Marriott, M.D. — Thu, 27Â NovÂ 2003 00:00:00 -05:00

Acute myocardial infarction resulting from an occlusive thrombus is recognized on an electrocardiogram by ST-segment elevation.1 Early reperfusion therapy has proved beneficial in such infarctions.234 The earlier the reperfusion, the...

EDITORIAL: Treating Thrombosis in the 21st Century

Sandor S. Shapiro, M.D. — Thu, 30Â OctÂ 2003 00:00:00 -05:00

The seemingly magical transmutation of shed blood into a solid has fascinated inquisitive observers for millennia. Hippocrates, in De Carnibus, and Aristotle, in Meteorology, postulated that the phenomenon was due...

ORIGINAL ARTICLE: Secondary Prevention of Venous Thromboembolism with the Oral Direct Thrombin Inhibitor Ximelagatran

Thu, 30Â OctÂ 2003 00:00:00 -05:00

Background: For many patients with venous thromboembolism, secondary prevention with vitamin K antagonists is not extended beyond six months, since the risk of recurrence may be outweighed by the risk...

ORIGINAL ARTICLE: Comparison of Ximelagatran with Warfarin for the Prevention of Venous Thromboembolism after Total Knee Replacement

Thu, 30Â OctÂ 2003 00:00:00 -05:00

Background: In a previous study of the prevention of venous thromboembolism after total knee replacement, the efficacy of ximelagatran, an oral direct thrombin inhibitor that does not require monitoring of...

ORIGINAL ARTICLE: Subcutaneous Fondaparinux versus Intravenous Unfractionated Heparin in the Initial Treatment of Pulmonary Embolism

The Matisse Investigators — Thu, 30Â OctÂ 2003 00:00:00 -05:00

Background: The standard initial treatment of hemodynamically stable patients with pulmonary embolism is intravenous unfractionated heparin, requiring laboratory monitoring and hospitalization.

Methods: We conducted a randomized, open-label trial involving 2213 patients...

CLINICAL PRACTICE: The Evaluation of Suspected Pulmonary Embolism

Peter F. Fedullo, M.D., and Victor F. Tapson, M.D. — Thu, 25Â SepÂ 2003 00:00:00 -05:00

An otherwise healthy 51-year-old woman presents to her physician with pleuritic right posterior chest pain, without dyspnea or hemoptysis. Her temperature is 38.2Â°C, and her pulse is 102 beats per...

ORIGINAL ARTICLE: Evaluation of D-Dimer in the Diagnosis of Suspected Deep-Vein Thrombosis

Thu, 25Â SepÂ 2003 00:00:00 -05:00

Background: Several diagnostic strategies using ultrasound imaging, measurement of D-dimer, and assessment of clinical probability of disease have proved safe in patients with suspected deep-vein thrombosis, but they have not...

PERSPECTIVE: D-Dimer in Venous Thromboembolism

Paula Bockenstedt, M.D. — Thu, 25Â SepÂ 2003 00:00:00 -05:00

Venous thromboembolism is an important medical problem, with an estimated incidence in the United States of 100,000 to 300,000 cases per year. Of patients presenting with symptoms suggestive of deep...

EDITORIAL: Treatment of the Antiphospholipid Syndrome

Michael D. Lockshin, M.D., and Doruk Erkan, M.D. — Thu, 18Â SepÂ 2003 00:00:00 -05:00

Two decades after the presence of anticardiolipin antibodies and a syndrome of spontaneous thrombosis and fetal death were linked,1 and after the publication of approximately 3500 reports in which the...

ORIGINAL ARTICLE: A Comparison of Two Intensities of Warfarin for the Prevention of Recurrent Thrombosis in Patients with the Antiphospholipid Antibody Syndrome

Thu, 18Â SepÂ 2003 00:00:00 -05:00

Background: Many patients with the antiphospholipid antibody syndrome and recurrent thrombosis receive doses of warfarin adjusted to achieve an international normalized ratio (INR) of more than 3.0. However, there are...

ORIGINAL ARTICLE: Effect of Intensity of Oral Anticoagulation on Stroke Severity and Mortality in Atrial Fibrillation

Thu, 11Â SepÂ 2003 00:00:00 -05:00

Background: The incidence of stroke in patients with atrial fibrillation is greatly reduced by oral anticoagulation, with the full effect seen at international normalized ratio (INR) values of 2.0 or...

PERSPECTIVE: Atrial Fibrillation and Stroke Prevention

Robert G. Hart, M.D. — Thu, 11Â SepÂ 2003 00:00:00 -05:00

Atrial fibrillation is a common cardiac arrhythmia whose most serious clinical consequence is stroke. Described in pathological studies in the 1940s, uncoordinated atrial contractions result in sluggish blood flow and...

EDITORIAL: Primary Angioplasty for Acute Myocardial Infarction â Is It Worth the Wait?

Alice K. Jacobs, M.D. — Thu, 21Â AugÂ 2003 00:00:00 -05:00

Nearly two decades after clinical trials established that fibrinolytic therapy for acute myocardial infarction preserves left ventricular function and reduces mortality, there is evidence that mechanical reperfusion therapy is superior...

ORIGINAL ARTICLE: A Comparison of Coronary Angioplasty with Fibrinolytic Therapy in Acute Myocardial Infarction

Thu, 21Â AugÂ 2003 00:00:00 -05:00

Background: For the treatment of myocardial infarction with ST-segment elevation, primary angioplasty is considered superior to fibrinolysis for patients who are admitted to hospitals with angioplasty facilities. Whether this benefit...

EDITORIAL: Secondary Prophylaxis with Warfarin for Venous Thromboembolism

Harry R. BÃ¼ller, M.D., and Martin H. Prins, M.D. — Thu, 14Â AugÂ 2003 00:00:00 -05:00

There are two phases in the treatment of patients with symptomatic venous thromboembolism: initial treatment and secondary prophylaxis. Initial therapy usually consists of either subcutaneous low-molecular-weight heparin or intravenous unfractionated...

CLINICAL PRACTICE: Care of Patients Receiving Long-Term Anticoagulant Therapy

Sam Schulman, M.D. — Thu, 14Â AugÂ 2003 00:00:00 -05:00

A 75-year-old man with diabetes mellitus is found to have chronic atrial fibrillation, and warfarin therapy is begun for the prevention of thromboembolic stroke. How should the anticoagulant therapy be...

ORIGINAL ARTICLE: Comparison of Low-Intensity Warfarin Therapy with Conventional-Intensity Warfarin Therapy for Long-Term Prevention of Recurrent Venous Thromboembolism

Thu, 14Â AugÂ 2003 00:00:00 -05:00

Background: Warfarin is very effective in preventing recurrent venous thromboembolism but is also associated with a substantial risk of bleeding. After three months of conventional warfarin therapy, a lower dose...

ORIGINAL ARTICLE: Low-Molecular-Weight Heparin versus a Coumarin for the Prevention of Recurrent Venous Thromboembolism in Patients with Cancer

Thu, 10Â JulÂ 2003 00:00:00 -05:00

Background: Patients with cancer have a substantial risk of recurrent thrombosis despite the use of oral anticoagulant therapy. We compared the efficacy of a low-molecular-weight heparin with that of an...

PERSPECTIVE: Cancer-Associated Thrombosis

Rodger L. Bick, M.D., Ph.D. — Thu, 10Â JulÂ 2003 00:00:00 -05:00

Thrombosis was identified as a complication of cancer by Trousseau in 1865, and the combination of the two conditions is still often called Trousseau's syndrome. Arterial and, more commonly, venous...

EDITORIAL: Warfarin for Venous Thromboembolism â Walking the Dosing Tightrope

Andrew I. Schafer, M.D. — Thu, 10Â AprÂ 2003 00:00:00 -05:00

Venous thromboembolism encompasses deep venous thrombosis and pulmonary embolism, which represent different manifestations of the same disease process. Indeed, most patients in whom symptoms of either condition develop will simultaneously...

IMAGES IN CLINICAL MEDICINE: Hematoma of the Rectus Sheath

David R. Gutknecht, M.D. — Thu, 10Â AprÂ 2003 00:00:00 -05:00

A 79-year-old woman who was taking warfarin and enoxaparin because of deep venous thrombosis reported abdominal pain after coughing. On physical examination, a mass was felt in the left side...

ORIGINAL ARTICLE: An Association between Atherosclerosis and Venous Thrombosis

Thu, 10Â AprÂ 2003 00:00:00 -05:00

Background: In about a third of patients with venous thromboembolism, the cause of the disorder is unexplained. In patients with atherosclerosis, activation of both platelets and blood coagulation and an...

ORIGINAL ARTICLE: Long-Term, Low-Intensity Warfarin Therapy for the Prevention of Recurrent Venous Thromboembolism

Thu, 10Â AprÂ 2003 00:00:00 -05:00

Background: Standard therapy to prevent recurrent venous thromboembolism includes 3 to 12 months of treatment with full-dose warfarin with a target international normalized ratio (INR) between 2.0 and 3.0. However,...

EDITORIAL: CD40 Ligand â Assessing Risk Instead of Damage?

Jane E. Freedman, M.D. — Thu, 20Â MarÂ 2003 00:00:00 -05:00

Platelet activation is central to the formation of thrombus, which precipitates most unstable coronary syndromes. The angiographic severity of coronary stenoses may not predict the occurrence of acute cardiac events,...

ORIGINAL ARTICLE: Soluble CD40 Ligand in Acute Coronary Syndromes

Thu, 20Â MarÂ 2003 00:00:00 -05:00

Background: CD40 ligand is expressed on platelets and released from them on activation. We investigated the predictive value of soluble CD40 ligand as a marker for clinical outcome and the...

REVIEW ARTICLE: Exercise Training for Claudication

Thu, 12Â DecÂ 2002 00:00:00 -05:00

Peripheral arterial disease, a manifestation of systemic atherosclerosis, affects approximately 8 million to 10 million people in the United States, with an age-adjusted prevalence of 12 percent that increases to...

CLINICAL PROBLEM-SOLVING: The Unusual Suspect

Thu, 05Â DecÂ 2002 00:00:00 -05:00

A previously healthy 17-year-old boy awoke with left-sided pleuritic chest pain. He also noticed mild dyspnea on exertion during track-and-field practice but reported no sputum production, fever, chills, or recent...

IMAGES IN CLINICAL MEDICINE: Floating Left Atrial Thrombus

John R. Doty, M.D and Donald B. Doty, M.D. — Thu, 07Â NovÂ 2002 00:00:00 -05:00

Figure 1. A 71-year-old woman with a one-year history of dyspnea on exertion presented to the emergency department with worsening shortness of breath. Physical examination demonstrated rapid atrial fibrillation and...

EDITORIAL: Aspirin with Bypass Surgery â From Taboo to New Standard of Care

Thu, 24Â OctÂ 2002 00:00:00 -05:00

Until a few years ago, we did not understand the pivotal role of platelets in orchestrating the process of inflammation. The discovery in 1998 that CD40 ligand is shed from...

ORIGINAL ARTICLE: Aspirin and Mortality from Coronary Bypass Surgery

Thu, 24Â OctÂ 2002 00:00:00 -05:00

Background: There is no therapy known to reduce the risk of complications or death after coronary bypass surgery. Because platelet activation constitutes a pivotal mechanism for injury in patients with...

IMAGES IN CLINICAL MEDICINE: Thrombolysis of a Massive Pulmonary Embolism

Neil P. Fam, M.D. and Atul Verma, M.D. — Thu, 10Â OctÂ 2002 00:00:00 -05:00

Figure 1. A 52-year-old man with chronic left bundle-branch block presented with exertional syncope but no chest pain, palpitations, or dyspnea. His blood pressure was 95/60 mm Hg, and examination...

ORIGINAL ARTICLE: Heparin plus Alteplase Compared with Heparin Alone in Patients with Submassive Pulmonary Embolism

Thu, 10Â OctÂ 2002 00:00:00 -05:00

Background: The use of thrombolytic agents in the treatment of hemodynamically stable patients with acute submassive pulmonary embolism remains controversial.

Methods: We conducted a study of patients with acute pulmonary embolism...

PERSPECTIVE: Thrombolysis for Pulmonary Embolism

Thu, 10Â OctÂ 2002 00:00:00 -05:00

The primary therapy for acute pulmonary embolism is anticoagulation with heparin and warfarin to prevent additional thromboembolism. Traditional teaching relegates the use of thrombolysis to the rare situation in which...

IMAGES IN CLINICAL MEDICINE: Massive Right Atrial Thrombus

Nick Dobrilovic, M.D. and Creighton B. Wright, M.D. — Thu, 03Â OctÂ 2002 00:00:00 -05:00

Figure 1. An 80-year-old woman presented to the emergency department soon after the onset of shortness of breath. Computed tomography of the chest (Panel A) revealed a pulmonary embolism and...

ORIGINAL ARTICLE: Warfarin, Aspirin, or Both after Myocardial Infarction

Thu, 26Â SepÂ 2002 00:00:00 -05:00

Background: The role of antithrombotic therapy in secondary prevention after myocardial infarction is well established. Although the available literature suggests that warfarin is superior to aspirin, aspirin is currently the...

CLINICAL IMPLICATIONS OF BASIC RESEARCH: COX Inhibitors and Thromboregulation

Thu, 26Â SepÂ 2002 00:00:00 -05:00

From a historical perspective, there is perhaps no more interesting therapeutic saga than that of aspirin, which began as a folk remedy, distilled from willow bark, and became a lifesaving...

EDITORIAL: Antithrombotic Therapy after Myocardial Infarction

Thu, 26Â SepÂ 2002 00:00:00 -05:00

Despite encouraging trends over the past three decades, coronary heart disease remains the leading cause of death in the United States and other industrialized countries. Recent data from the National...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 29-2002 â A 17-Year-Old Boy with Acute Mitral Regurgitation and Pulmonary Edema

Bradley J. Bloom and R. Neal Smith — Thu, 19Â SepÂ 2002 00:00:00 -05:00

A 17-year-old boy was admitted to the hospital because of acute mitral regurgitation and pulmonary edema.

The patient had received a diagnosis of juvenile spondyloarthropathy two years earlier. He had intermittent...

ORIGINAL ARTICLE: Use of the Low-Molecular-Weight Heparin Reviparin to Prevent Deep-Vein Thrombosis after Leg Injury Requiring Immobilization

Michael R. Lassen, M.D., Lars C. Borris, M.D., and Roumen L. Nakov, M.D., Ph.D. — Thu, 05Â SepÂ 2002 00:00:00 -05:00

Background: Deep-vein thrombosis is a well-recognized complication after trauma to the legs and subsequent immobilization, but there are no generally accepted approaches to preventing this complication.

Methods: 02090524.xml We performed a...

EDITORIAL: Clotting and Hemorrhage in the Placenta â A Delicate Balance

Thu, 04Â JulÂ 2002 00:00:00 -05:00

Increased susceptibility to deep-vein thrombosis is a well-known facet of pregnancy and the puerperium, with the greatest risk occurring during the puerperium. It remains unclear, however, whether a genetically determined...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 16-2002 â A 41-Year-Old Woman with Global Headache and an Intracranial Mass

David E. Thaler and Matthew P. Frosch — Thu, 23Â MayÂ 2002 00:00:00 -05:00

A 41-year-old woman was admitted to the hospital because of an intracranial mass.

The patient had been in excellent health until one week earlier, when a global headache developed, accompanied by...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 15-2002 â A 53-Year-Old Man with a Myocardial Infarct and Thromboses after Coronary-Artery Bypass Grafting

William C. Aird and Eugene J. Mark — Thu, 16Â MayÂ 2002 00:00:00 -05:00

A 53-year-old man was admitted to the hospital because of a myocardial infarction.

The patient had been well until three months earlier, when he began to have increasingly severe exertional dyspnea,...

ORIGINAL ARTICLE: Tissue Plasminogen Activator in Cardiac Arrest with Pulseless Electrical Activity

Thu, 16Â MayÂ 2002 00:00:00 -05:00

Background: Coronary thrombosis and pulmonary thromboembolism are common causes of cardiac arrest. We assessed whether the administration of tissue plasminogen activator (t-PA) during cardiopulmonary resuscitation would benefit patients with cardiac...

EDITORIAL: Detection and Management of Small Aortic Aneurysms

Thu, 09Â MayÂ 2002 00:00:00 -05:00

Abdominal aortic aneurysms arise through a chronic degenerative process that produces localized weakening of the aortic wall. They have a natural history characterized by progressive expansion and eventual rupture.1 Population-based...

CLINICAL PRACTICE: Aspirin for Primary Prevention of Coronary Events

Michael S. Lauer, M.D. — Thu, 09Â MayÂ 2002 00:00:00 -05:00

A 45-year-old man with a strong family history of premature heart disease has no symptoms of coronary disease and has a normal electrocardiogram. A fasting lipid analysis reveals a total...

IMAGES IN CLINICAL MEDICINE: Left Ventricular Thrombus

Sanjay Gupta, M.D. and Ronald A. Kahn, M.D. — Thu, 02Â MayÂ 2002 00:00:00 -05:00

Figure 1. A 45-year-old man with a history of constrictive pericarditis underwent an uncomplicated pericardiectomy. Perioperative transesophageal echocardiography did not reveal any intraventricular masses. Three days after discharge, he presented...

ORIGINAL ARTICLE: Duration of Prophylaxis against Venous Thromboembolism with Enoxaparin after Surgery for Cancer

Thu, 28Â MarÂ 2002 00:00:00 -05:00

Background: Abdominal surgery for cancer carries a high risk of venous thromboembolism, but the optimal duration of postoperative thromboprophylaxis is unknown.

Methods: We conducted a double-blind, multicenter trial in which patients...

ORIGINAL ARTICLE: Comparison of Angioplasty with Stenting, with or without Abciximab, in Acute Myocardial Infarction

Thu, 28Â MarÂ 2002 00:00:00 -05:00

Background: 02032824.xml As compared with thrombolytic therapy, primary percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction reduces the rates of death, reinfarction, and stroke, but recurrent ischemia, restenosis, and...

REVIEW ARTICLE: The Antiphospholipid Syndrome

Jerrold S. Levine, M.D., D. Ware Branch, M.D., and Joyce Rauch, Ph.D. — Thu, 07Â MarÂ 2002 00:00:00 -05:00

Antiphospholipid antibodies are a family of autoantibodies that exhibit a broad range of target specificities and affinities, all recognizing various combinations of phospholipids, phospholipid-binding proteins, or both. The term âantiphospholipid...

REVIEW ARTICLE: Mesenteric Venous Thrombosis

Shaji Kumar, M.D., Michael G. Sarr, M.D., and Patrick S. Kamath, M.D. — Thu, 06Â DecÂ 2001 00:00:00 -05:00

Mesenteric venous thrombosis was recognized as a cause of intestinal gangrene more than a century ago by Elliot,1 but Warren and Eberhard2 were the first to characterize mesenteric venous thrombosis...

EDITORIAL: Oral Anticoagulant Therapy for the Prevention of Stroke

Thu, 15Â NovÂ 2001 00:00:00 -05:00

This year in the United States, 450,000 people will have a first ischemic stroke.123 For these patients (including those receiving thrombolytic therapy), the primary therapeutic goals will be rehabilitation and...

REVIEW ARTICLE: Chronic Thromboembolic Pulmonary Hypertension

Thu, 15Â NovÂ 2001 00:00:00 -05:00

Thromboembolic obstruction of the major pulmonary arteries due to unresolved pulmonary embolism is a potentially correctable cause of pulmonary hypertension. Chronic thromboembolic pulmonary hypertension of sufficient severity to warrant surgical...

ORIGINAL ARTICLE: A Comparison of Warfarin and Aspirin for the Prevention of Recurrent Ischemic Stroke

Thu, 15Â NovÂ 2001 00:00:00 -05:00

Background: Despite the use of antiplatelet agents, usually aspirin, in patients who have had an ischemic stroke, there is still a substantial rate of recurrence. Therefore, we investigated whether warfarin,...

EDITORIAL: Choosing a Parenteral Anticoagulant Agent

Thu, 01Â NovÂ 2001 00:00:00 -05:00

For decades, if a patient required a parenteral anticoagulant agent, the choice was simple: unfractionated heparin was the only such agent available. Unfractionated heparin has a long track record of...

IMAGES IN CLINICAL MEDICINE: Pulmonary Embolism

Peter E. Sokolove, M.D. and Steven R. Offerman, M.D. — Thu, 01Â NovÂ 2001 00:00:00 -05:00

Figure 1. A 67-year-old man presented to the emergency department with a five-day history of nonproductive cough and progressive dyspnea and a one-day history of right-sided pleuritic chest pain. Four...

ORIGINAL ARTICLE: Fondaparinux Compared with Enoxaparin for the Prevention of Venous Thromboembolism after Elective Major Knee Surgery

Thu, 01Â NovÂ 2001 00:00:00 -05:00

Background: Despite thromboprophylaxis, major knee surgery carries a high risk of venous thromboembolism. Fondaparinux, the first of a new class of synthetic antithrombotic agents, may reduce this risk.

Methods: In a...

ORIGINAL ARTICLE: Fondaparinux Compared with Enoxaparin for the Prevention of Venous Thromboembolism after Hip-Fracture Surgery

Thu, 01Â NovÂ 2001 00:00:00 -05:00

Background: Surgery for hip fracture carries a high risk of venous thromboembolism, despite the use of current thromboprophylactic treatments. Fondaparinux, a synthetic pentasaccharide, is a new antithrombotic agent that may...

EDITORIAL: Air Travel and Venous Thromboembolism â Is the Evidence In?

Thu, 13Â SepÂ 2001 00:00:00 -05:00

These three headlines from the general press highlight a growing concern: Is air travel, especially over long distances, associated with an increased risk of venous thromboembolism?

In 1954, Homans1 reported on...

IMAGES IN CLINICAL MEDICINE: Paradoxical Embolus

Frandics P. Chan, M.D., Ph.D. and Timothy R. Jones, M.D. — Thu, 13Â SepÂ 2001 00:00:00 -05:00

Figure 1. An 18-year-old woman who had flown from England to the United States presented to the emergency room with shortness of breath and numbness of the right arm. She...

ORIGINAL ARTICLE: Severe Pulmonary Embolism Associated with Air Travel

Thu, 13Â SepÂ 2001 00:00:00 -05:00

Background: Air travel is believed to be a risk factor for pulmonary embolism, but the relation between pulmonary embolism and distance flown has not been documented. The aim of this...

ORIGINAL ARTICLE: Three Months versus One Year of Oral Anticoagulant Therapy for Idiopathic Deep Venous Thrombosis

Thu, 19Â JulÂ 2001 00:00:00 -05:00

Background: In patients with idiopathic deep venous thrombosis, continuing anticoagulant therapy beyond three months is associated with a reduced incidence of recurrent thrombosis during the period of therapy. Whether this...

REVIEW ARTICLE: Medical Treatment of Peripheral Arterial Disease and Claudication

William R. Hiatt, M.D. — Thu, 24Â MayÂ 2001 00:00:00 -05:00

Peripheral arterial disease, which is caused by atherosclerotic occlusion of the arteries to the legs, is an important manifestation of systemic atherosclerosis. The age-adjusted prevalence of peripheral arterial disease is...

REVIEW ARTICLE: Oral Contraceptives and the Risk of Venous Thrombosis

Thu, 17Â MayÂ 2001 00:00:00 -05:00

In the early 1960s, shortly after the introduction of oral contraceptives, the first case reports appeared describing venous thrombosis and pulmonary emboli in women using this method of birth control....

EDITORIAL: Strategies for Cardioversion of Atrial Fibrillation â Time for a Change?

Thu, 10Â MayÂ 2001 00:00:00 -05:00

Dating back to the 17th-century observation that cinchona bark could correct an irregular heartbeat in patients with malaria,1 cardioversion of atrial fibrillation is one of the oldest therapies in cardiovascular...

ORIGINAL ARTICLE: Use of Transesophageal Echocardiography to Guide Cardioversion in Patients with Atrial Fibrillation

Thu, 10Â MayÂ 2001 00:00:00 -05:00

Background: The conventional treatment strategy for patients with atrial fibrillation who are to undergo electrical cardioversion is to prescribe warfarin for anticoagulation for three weeks before cardioversion. It has been...

ORIGINAL ARTICLE: Temporal Aspects of Heparin-Induced Thrombocytopenia

Theodore E. Warkentin, M.D., and John G. Kelton, M.D. — Thu, 26Â AprÂ 2001 00:00:00 -05:00

Background: Heparin-induced thrombocytopenia is a relatively common antibody-mediated drug reaction. We studied the temporal relation between previous or current heparin therapy and the onset of heparin-induced thrombocytopenia.

Methods: We examined the...

REVIEW ARTICLE: Genetic Susceptibility to Venous Thrombosis

Uri Seligsohn, M.D., and Aharon Lubetsky, M.D. — Thu, 19Â AprÂ 2001 00:00:00 -05:00

The annual incidence of venous thrombosis, one of the leading causes of mortality and morbidity, increases from 1 per 100,000 during childhood to 1 per 100 in old age.1 In...

IMAGES IN CLINICAL MEDICINE: Superficial Thrombophlebitis

Michael A. Lucia, M.D. and E. Wesley Ely, M.D., M.P.H. — Thu, 19Â AprÂ 2001 00:00:00 -05:00

Figure 1. A 56-year-old woman began to have pain and redness of the left leg the day after a six-hour car ride. Two days later she was found to have...

EDITORIAL: Aging and the Public Health Effects of Dementia

Thu, 12Â AprÂ 2001 00:00:00 -05:00

Dementia, and Alzheimer's disease in particular, is one of the principal causes of disability and decreased quality of life among the elderly and a leading obstacle to successful aging.12 In...

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 11-2001 â Rapidly Progressive Renal Failure in a 35-Year-Old Woman with Systemic Lupus Erythematosus

Cecil H.Coggins, Robert T. McCluskey — Thu, 12Â AprÂ 2001 00:00:00 -05:00

A 35-year-old woman was admitted to the hospital because of rapidly worsening renal failure.

Twelve years before admission, she had received a diagnosis of systemic lupus erythematosus, manifested by Raynaud's syndrome,...

ORIGINAL ARTICLE: Effects of a Low-Molecular-Weight Heparin on Thrombus Regression and Recurrent Thromboembolism in Patients with Deep-Vein Thrombosis

Thu, 01Â MarÂ 2001 00:00:00 -05:00

Background: Low-molecular-weight heparins are frequently used to treat venous thromboembolism, but optimal dosing regimens and clinical outcomes need further definition.

Methods: In this multicenter, open-label study with blinded adjudication of end...

ORIGINAL ARTICLE: A Synthetic Pentasaccharide for the Prevention of Deep-Vein Thrombosis after Total Hip Replacement

Thu, 01Â MarÂ 2001 00:00:00 -05:00

Background: Venous thromboembolism is a frequent complication of total hip replacement. The pentasaccharide Org31540/SR90107A, a highly selective, indirect inhibitor of activated factor X, is the first of a new class...

IMAGES IN CLINICAL MEDICINE: Psoas Hematoma

Charles Cuvelier, M.D. — Thu, 01Â FebÂ 2001 00:00:00 -05:00

Figure 1. An 83-year-old woman who was taking acenocoumarol because of a previous pulmonary embolism presented with tiredness, a limp, and extensive bruising of both legs. Two weeks earlier, she...

IMAGES IN CLINICAL MEDICINE: Retroperitoneal Hemorrhage

Alfred Lindner, M.D. and Stephan Zierz, M.D. — Thu, 01Â FebÂ 2001 00:00:00 -05:00

Figure 1. A 54-year-old man presented with severe pain in the right side of the groin that radiated to the calf and anteromedial thigh of the right leg, causing him...

ORIGINAL ARTICLE: Prognosis of Cancers Associated with Venous Thromboembolism

Thu, 21Â DecÂ 2000 00:00:00 -05:00

Background: Little is known about the prognosis of cancer discovered during or after an episode of venous thromboembolism.

Methods: We linked the Danish National Registry of Patients, the Danish Cancer Registry,...

ORIGINAL ARTICLE: Predictors of Rehospitalization for Symptomatic Venous Thromboembolism after Total Hip Arthroplasty

Thu, 14Â DecÂ 2000 00:00:00 -05:00

Background: Recent studies have shown that symptomatic venous thromboembolism after total hip arthroplasty most commonly develops after the patient is discharged from the hospital. Risk factors associated with these symptomatic...

ORIGINAL ARTICLE: Safety of Withholding Heparin in Pregnant Women with a History of Venous Thromboembolism

Thu, 16Â NovÂ 2000 00:00:00 -05:00

Background: Women with a history of venous thromboembolism may be at increased risk for venous thromboembolic events during pregnancy. In these women, the decision to give or withhold heparin in...

ORIGINAL ARTICLE: Mutations in Coagulation Factors in Women with Unexplained Late Fetal Loss

Thu, 05Â OctÂ 2000 00:00:00 -05:00

Background: The Factor V Leiden and prothrombin-gene mutations are independent risk factors for venous thrombosis; it is debated whether a mutation in the gene encoding methylenetetrahydrofolate reductase, an enzyme involved...

ORIGINAL ARTICLE: Polymorphisms in the Factor VII Gene and the Risk of Myocardial Infarction in Patients with Coronary Artery Disease

Thu, 14Â SepÂ 2000 00:00:00 -05:00

Background: High plasma levels of coagulation factor VII have been suggested to be predictors of death due to coronary artery disease. Since polymorphisms in the factor VII gene contribute to...

IMAGES IN CLINICAL MEDICINE: Renal-Vein Thrombosis

Gerald J. Matthews, M.D. and Suelyn Hall, M.D. — Thu, 07Â SepÂ 2000 00:00:00 -05:00

Figure 1. A 42-year-old man with a history of non-insulin-dependent diabetes presented with acute right-flank pain. He was afebrile, and an examination revealed tenderness of the right upper quadrant. The...

IMAGES IN CLINICAL MEDICINE: Spontaneous Duodenal Hematoma during Oral Anticoagulation

Pierre HÃ¶sli, M.D. and Marc Schapira, M.D. — Thu, 17Â AugÂ 2000 00:00:00 -05:00

Figure 1. A 62-year-old man presented with abdominal pain and nausea. On examination, his abdomen was distended and diffusely tender. He had been receiving oral anticoagulants for more than two...

ORIGINAL ARTICLE: High Plasma Levels of Factor VIII and the Risk of Recurrent Venous Thromboembolism

Thu, 17Â AugÂ 2000 00:00:00 -05:00

Background: A high plasma level of factor VIII is a risk factor for venous thromboembolism. We evaluated the risk of a recurrence of thrombosis after an initial episode of spontaneous...

ORIGINAL ARTICLE: Coronary Stenting plus Platelet Glycoprotein IIb/IIIa Blockade Compared with Tissue Plasminogen Activator in Acute Myocardial Infarction

Thu, 10Â AugÂ 2000 00:00:00 -05:00

Background: Prevention of myocardial damage is the main goal of all reperfusion therapies in patients with acute myocardial infarction. The relative efficacy of various reperfusion strategies is under intensive investigation....

EDITORIAL: Warfarin for Cancer Prevention

Thu, 29Â JunÂ 2000 00:00:00 -05:00

Recently reported large series have provided clear evidence of an association between idiopathic thromboembolism and the development of cancer. The standardized incidence ratio for all cancers is as high as...

ORIGINAL ARTICLE: Incidence of Cancer after Prophylaxis with Warfarin against Recurrent Venous Thromboembolism

Thu, 29Â JunÂ 2000 00:00:00 -05:00

Background: The length of time after an episode of venous thromboembolism during which the risk of newly diagnosed cancer is increased is not known, and whether vitamin K antagonists have...

CLINICAL IMPLICATIONS OF BASIC RESEARCH: Blockade of Adhesion of Sickle Cells to Endothelium by Monoclonal Antibodies

Thu, 22Â JunÂ 2000 00:00:00 -05:00

Red cells that contain sickle hemoglobin tend to acquire an abnormal, sickled shape when their mutant hemoglobin polymerizes as a result of low oxygen tension. In the classic view of...

EDITORIAL: Thrombotic Thrombocytopenic Purpura and Clopidogrel â A Need for New Approaches to Drug Safety

Thu, 15Â JunÂ 2000 00:00:00 -05:00

In this issue of the Journal, Bennett et al. describe 11 cases of thrombotic thrombocytopenic purpura that occurred in patients during or shortly after they received clopidogrel.1 The evidence linking...

REVIEW ARTICLE: Plasminogen-Activator Inhibitor Type 1 and Coronary Artery Disease

Hans P. Kohler, M.D., and Peter J. Grant, M.D. — Thu, 15Â JunÂ 2000 00:00:00 -05:00

The development of coronary artery disease, and specifically myocardial infarction, involves hyperplasia of arterial smooth muscle, the development of fatty streaks, atheroma formation, plaque rupture, and ultimately thrombus formation and...

ORIGINAL ARTICLE: Thrombotic Thrombocytopenic Purpura Associated with Clopidogrel

Thu, 15Â JunÂ 2000 00:00:00 -05:00

Background: The antiplatelet drug clopidogrel is a new thienopyridine derivative whose mechanism of action and chemical structure are similar to those of ticlopidine. The estimated incidence of ticlopidine-associated thrombotic thrombocytopenic...

ORIGINAL ARTICLE: Long-Term Treatment with a Platelet Glycoprotein-Receptor Antagonist after Percutaneous Coronary Revascularization

Thu, 04Â MayÂ 2000 00:00:00 -05:00

Background: When administered intravenously at the time of percutaneous coronary revascularization, glycoprotein IIb/IIIa receptor antagonists decrease the incidence of death and nonfatal myocardial infarction and the need for urgent revascularization....

IMAGES IN CLINICAL MEDICINE: Retroperitoneal Hemorrhage

David J. Kastan, M.D. and Thomas H. Burke, R.T. — Thu, 09Â MarÂ 2000 00:00:00 -05:00

Figure 1. Left flank pain and hypotension developed in a 62-year-old woman during treatment with intravenous heparin (900 U per hour) and warfarin (7.5 mg per day) for deep venous...

ORIGINAL ARTICLE: High Levels of Coagulation Factor XI as a Risk Factor for Venous Thrombosis

Thu, 09Â MarÂ 2000 00:00:00 -05:00

Background: Factor XI, a component of the intrinsic pathway of coagulation, contributes to the generation of thrombin, which is involved in both the formation of fibrin and protection against fibrinolysis....

EDITORIAL: The Challenge of Thrombophilia in MaternalâFetal Medicine

Thu, 10Â FebÂ 2000 00:00:00 -05:00

Twenty years ago we did not have a problem with thrombophilia as a cause of venous thromboembolism in pregnant and postpartum women, or rather, we did not know we had...

ORIGINAL ARTICLE: Prothrombin and Factor V Mutations in Women with a History of Thrombosis during Pregnancy and the Puerperium

Thu, 10Â FebÂ 2000 00:00:00 -05:00

Background: Venous thromboembolism is a leading cause of morbidity and mortality during pregnancy and the puerperium. However, the role of mutations in the prothrombin and factor V genes and other...

REVIEW ARTICLE: Unstable Angina Pectoris

Thu, 13Â JanÂ 2000 00:00:00 -05:00

Unstable angina accounts for more than 1 million hospital admissions annually1; 6 to 8 percent of patients with this condition have nonfatal myocardial infarction or die within the first year...

ORIGINAL ARTICLE: Long-Term Benefit of Primary Angioplasty as Compared with Thrombolytic Therapy for Acute Myocardial Infarction

Thu, 04Â NovÂ 1999 00:00:00 -05:00

Background: As compared with thrombolytic therapy, primary coronary angioplasty results in a higher rate of patency of the infarct-related coronary artery, lower rates of stroke and reinfarction, and higher in-hospital...

ORIGINAL ARTICLE: The Risk of Recurrent Deep Venous Thrombosis among Heterozygous Carriers of Both Factor V Leiden and the G20210A Prothrombin Mutation

Thu, 09Â SepÂ 1999 00:00:00 -05:00

Background: Point mutations in the factor V gene (factor V Leiden) and the prothrombin gene (the substitution of A for G at position 20210) are the most common causes of...

ORIGINAL ARTICLE: A Comparison of Enoxaparin with Placebo for the Prevention of Venous Thromboembolism in Acutely Ill Medical Patients

Thu, 09Â SepÂ 1999 00:00:00 -05:00

Background: The efficacy and safety of thromboprophylaxis in patients with acute medical illnesses who may be at risk for venous thromboembolism have not been determined in adequately designed trials.

Methods: In...

REVIEW ARTICLE: Disseminated Intravascular Coagulation

Marcel Levi, M.D., and Hugo ten Cate, M.D. — Thu, 19Â AugÂ 1999 00:00:00 -05:00

Disseminated intravascular coagulation is characterized by the widespread activation of coagulation, which results in the intravascular formation of fibrin and ultimately thrombotic occlusion of small and midsize vessels.123 Intravascular coagulation...

ORIGINAL ARTICLE: Complementary Clinical Benefits of Coronary-Artery Stenting and Blockade of Platelet Glycoprotein IIb/IIIa Receptors

Thu, 29Â JulÂ 1999 00:00:00 -05:00

Background: Inhibition of the platelet glycoprotein IIb/IIIa receptor with the monoclonal-antibody fragment abciximab reduces the acute ischemic complications associated with percutaneous coronary revascularization, whereas coronary-stent implantation reduces restenosis. We conducted...

ORIGINAL ARTICLE: Effects of Tissue Plasminogen Activator for Acute Ischemic Stroke at One Year

Thu, 10Â JunÂ 1999 00:00:00 -05:00

Background: In 1995, the two-part National Institute of Neurological Disorders and Stroke (NINDS) Recombinant Tissue Plasminogen Activator Stroke Study found that patients who were treated with tissue plasminogen activator (t-PA)...

ORIGINAL ARTICLE: Benefit of Abciximab in Patients with Refractory Unstable Angina in Relation to Serum Troponin T Levels

Thu, 27Â MayÂ 1999 00:00:00 -05:00

Background: In patients with refractory unstable angina, the platelet glycoprotein IIb/IIIaâreceptor antibody abciximab reduces the incidence of cardiac events before and during coronary angioplasty. We investigated whether serum troponin T...

REVIEW ARTICLE: Vascular-BedâSpecific Hemostasis and Hypercoagulable States

Robert D. Rosenberg, M.D., Ph.D., and William C. Aird, M.D. — Thu, 20Â MayÂ 1999 00:00:00 -05:00

Hemostasis is a physiologic mechanism that maintains blood in a fluid state within the circulation. The coagulation of blood is mediated by cellular components and soluble plasma proteins. In response...

EDITORIAL: âAnnexinopathiesâ â A New Class of Diseases

Thu, 01Â AprÂ 1999 00:00:00 -05:00

The annexins were first described as a family of proteins in 1990,1 and they have since been extensively reviewed.2 Individual members of the family had previously been isolated, characterized, and...

EDITORIAL: Venous Thrombosis as a Chronic Disease

Thu, 25Â MarÂ 1999 00:00:00 -05:00

The lethal complication of deep-vein thrombosis is pulmonary embolism. Since about 80 percent of the patients who die of pulmonary embolism succumb within two hours of the onset of symptoms,1...

ORIGINAL ARTICLE: A Comparison of Three Months of Anticoagulation with Extended Anticoagulation for a First Episode of Idiopathic Venous Thromboembolism

Thu, 25Â MarÂ 1999 00:00:00 -05:00

Background: Patients who have a first episode of venous thromboembolism in the absence of known risk factors for thrombosis (idiopathic thrombosis) are often treated with anticoagulant therapy for three months....

ORIGINAL ARTICLE: Increased Frequency of Genetic Thrombophilia in Women with Complications of Pregnancy

Thu, 07Â JanÂ 1999 00:00:00 -05:00

Background: Obstetrical complications such as severe preeclampsia, abruptio placentae, fetal growth retardation, and stillbirth are associated with intervillous or spiral-artery thrombosis and inadequate placental perfusion. Whether these complications are associated...

EDITORIAL: Thrombophilias and Adverse Outcomes of Pregnancy â What Should a Clinician Do?

Thu, 07Â JanÂ 1999 00:00:00 -05:00

Approximately 1 to 5 percent of pregnant women have serious complications of pregnancy, such as severe preeclampsia, abruptio placentae, intrauterine fetal death, or severe fetal growth retardation. The rates are...

ORIGINAL ARTICLE: A Clinical Trial Comparing Three Antithrombotic-Drug Regimens after Coronary-Artery Stenting

Thu, 03Â DecÂ 1998 00:00:00 -05:00

Background: Antithrombotic drugs are used after coronary-artery stenting to prevent stent thrombosis. We compared the efficacy and safety of three antithrombotic-drug regimens â aspirin alone, aspirin and warfarin, and aspirin...

EDITORIAL: Moschcowitz, Multimers, and Metalloprotease

Thu, 26Â NovÂ 1998 00:00:00 -05:00

In 1924, Dr. Eli Moschcowitz described the abrupt onset of petechiae and pallor, followed rapidly by paralysis, coma, and death, in a 16-year-old girl.1 Terminal arterioles and capillaries in the...

ORIGINAL ARTICLE: Antibodies to von Willebrand FactorâCleaving Protease in Acute Thrombotic Thrombocytopenic Purpura

Han-Mou Tsai, M.D., and Eric Chun-Yet Lian, M.D. — Thu, 26Â NovÂ 1998 00:00:00 -05:00

Background: Thrombotic thrombocytopenic purpura is a potentially fatal disease characterized by widespread platelet thrombi in the microcirculation. In the normal circulation, von Willebrand factor is cleaved by a plasma protease....

ORIGINAL ARTICLE: von Willebrand FactorâCleaving Protease in Thrombotic Thrombocytopenic Purpura and the HemolyticâUremic Syndrome

Thu, 26Â NovÂ 1998 00:00:00 -05:00

Background: Thrombotic thrombocytopenic purpura and the hemolyticâuremic syndrome are severe microvascular disorders of platelet clumping with similar signs and symptoms. Unusually large multimers of von Willebrand factor, capable of agglutinating...

IMAGES IN CLINICAL MEDICINE:

Kumar Rajamani, M.D. and Mark Fisher, M.D. — Thu, 17Â SepÂ 1998 00:00:00 -05:00

Figure 1. A 19-year-old man presented to the emergency room after sustaining a gunshot wound to the right side of his chest. He had a hemopneumothorax, but his condition was...

ORIGINAL ARTICLE: Inhibition of Platelet Glycoprotein IIb/IIIa with Eptifibatide in Patients with Acute Coronary Syndromes

The PURSUIT Trial Investigators — Thu, 13Â AugÂ 1998 00:00:00 -05:00

Background: Aggregation of platelets is the pathophysiologic basis of the acute coronary syndromes. Eptifibatide, a synthetic cyclic heptapeptide, is a selective high-affinity inhibitor of the platelet glycoprotein IIb/IIIa receptor, which...

REVIEW ARTICLE: Pulmonary Embolism

Samuel Z. Goldhaber, M.D. — Thu, 09Â JulÂ 1998 00:00:00 -05:00

The diagnosis and treatment of pulmonary embolism demand an interdisciplinary approach, combining medical, surgical, and radiologic specialties. Despite substantial advances, mortality and recurrence rates remain high. The present article addresses...

IMAGES IN CLINICAL MEDICINE: Floating Right Atrial Thrombus and Massive Pulmonary Embolism

Andreas Baumbach, M.D. and Christiane M. Erley, M.D. — Thu, 09Â JulÂ 1998 00:00:00 -05:00

Figure 1. Four weeks after undergoing surgery to remove an intraventricular meningioma, a 64-year-old woman had recurrent episodes of dyspnea and hypotension. Ultrasonography revealed a deep venous thrombosis involving the...

ORIGINAL ARTICLE: Enoxaparin plus Compression Stockings Compared with Compression Stockings Alone in the Prevention of Venous Thromboembolism after Elective Neurosurgery

Thu, 09Â JulÂ 1998 00:00:00 -05:00

Background: Compression stockings are recommended for prophylaxis against venous thromboembolism in patients undergoing neurosurgery, but anticoagulant agents have not gained wide acceptance because of concern about intracranial bleeding.

Methods: In a...

EDITORIAL: Venous Thrombosis â The Interaction of Genes and Environment

Thu, 18Â JunÂ 1998 00:00:00 -05:00

Venous thrombosis is the obstruction of the circulation by clots that have been formed locally in the veins or have been released from a thrombus elsewhere. The usual sites of...

EDITORIAL: Use and Overuse of Angiography and Revascularization for Acute Coronary Syndromes

Thu, 18Â JunÂ 1998 00:00:00 -05:00

Over the past two decades, clinical and pathological studies have examined the pathophysiology of the acute coronary syndromes, unstable angina, and nonâQ-wave and Q-wave myocardial infarction. In these conditions, rupture...

ORIGINAL ARTICLE: Outcomes in Patients with Acute NonâQ-Wave Myocardial Infarction Randomly Assigned to an Invasive as Compared with a Conservative Management Strategy

Thu, 18Â JunÂ 1998 00:00:00 -05:00

Background: NonâQ-wave myocardial infarction is usually managed according to an âinvasiveâ strategy (i.e., one of routine coronary angiography followed by myocardial revascularization).

Methods: We randomly assigned 920 patients to either âinvasiveâ...

EDITORIAL: Platelet Glycoprotein IIb/IIIa Receptor Blockade in Unstable Coronary Disease

Thu, 21Â MayÂ 1998 00:00:00 -05:00

Coronary atherosclerosis develops over decades and then may suddenly lead to an acute coronary event. Often this occurs in an artery with a minor stenosis. The culprit lesion usually has...

ORIGINAL ARTICLE: A Comparison of Aspirin plus Tirofiban with Aspirin plus Heparin for Unstable Angina

Thu, 21Â MayÂ 1998 00:00:00 -05:00

Background: Activation of platelets is central to the pathophysiology of unstable angina. We studied whether inhibition of the final common pathway for platelet aggregation with tirofiban, a nonpeptide glycoprotein IIb/IIIa...

ORIGINAL ARTICLE: Inhibition of the Platelet Glycoprotein IIb/IIIa Receptor with Tirofiban in Unstable Angina and NonâQ-Wave Myocardial Infarction

Thu, 21Â MayÂ 1998 00:00:00 -05:00

Background: Antithrombotic therapy improves the prognosis of patients with acute coronary syndromes, yet the syndromes remain a therapeutic challenge. We evaluated tirofiban, a specific inhibitor of the platelet glycoprotein IIb/IIIa...

EDITORIAL: Primary Venous Thromboembolism and Cancer Screening

Thu, 23Â AprÂ 1998 00:00:00 -05:00

For more than a century we have known that deep venous thrombosis or pulmonary embolism may be the presenting feature of an occult cancer. The association between venous thromboembolism and...

ORIGINAL ARTICLE: The Risk of a Diagnosis of Cancer after Primary Deep Venous Thrombosis or Pulmonary Embolism

Thu, 23Â AprÂ 1998 00:00:00 -05:00

Background: Several small studies have indicated an association between deep venous thrombosis or pulmonary embolism and a subsequent diagnosis of cancer, but the subject is controversial.

Methods: We conducted a nationwide...

EDITORIAL: Thrombolysis for Acute Arterial Occlusion of the Legs

Thu, 16Â AprÂ 1998 00:00:00 -05:00

Since the initial clinical description by Tillett and associates1 more than 40 years ago, thrombolytic therapy has been hovering on the outskirts of medical practice. Despite intense interest by the...

ORIGINAL ARTICLE: A Comparison of Recombinant Urokinase with Vascular Surgery as Initial Treatment for Acute Arterial Occlusion of the Legs

Thu, 16Â AprÂ 1998 00:00:00 -05:00

Background: Recent controlled trials suggest that thrombolytic therapy may be an effective initial treatment for acute arterial occlusion of the legs. A major potential benefit of initial thrombolytic therapy is...

IMAGES IN CLINICAL MEDICINE: Thromboatheromatous Aortic Coarctation

Abdolhamid Sheikhzadeh, M.D. and Hans B. Gehl, M.D. — Thu, 09Â AprÂ 1998 00:00:00 -05:00

Figure 1. A 53-year-old man with a family history of premature atherosclerosis, borderline hypercholesterolemia, and a 15-pack-year history of cigarette smoking was seen for intermittent claudication, which had been present...

EDITORIAL: Vena Caval Filters for the Prevention of Pulmonary Embolism

Thu, 12Â FebÂ 1998 00:00:00 -05:00

Interruption of the inferior vena cava to prevent pulmonary thromboembolism has been practiced since the late 1930s. Initially, this treatment strategy involved a major retroperitoneal surgical procedure to ligate or...

ORIGINAL ARTICLE: A Clinical Trial of Vena Caval Filters in the Prevention of Pulmonary Embolism in Patients with Proximal Deep-Vein Thrombosis

Thu, 12Â FebÂ 1998 00:00:00 -05:00

Background: The efficacy and safety of vena caval filters in the prevention of pulmonary embolism in patients with proximal deep-vein thrombosis are still a matter of debate.

Methods: Using a two-by-two...

ORIGINAL ARTICLE: Effect of Ticlopidine on the Long-Term Patency of Saphenous-Vein Bypass Grafts in the Legs

Thu, 11Â DecÂ 1997 00:00:00 -05:00

Background: Optimal therapy to prevent late occlusion of arterial bypass grafts in the legs has not been determined. We assessed the effect of ticlopidine, an inhibitor of platelet aggregation, on...

EDITORIAL: Antithrombotic Agents and Thromboembolic Disease

Thu, 06Â NovÂ 1997 00:00:00 -05:00

Among patients undergoing elective hip replacement, the incidence of deep-vein thrombosis in the absence of prophylactic anticoagulation approaches 50 percent.12 Thrombus formation is multifocal, occurring principally in the surgically manipulated...

ORIGINAL ARTICLE: A Comparison of Recombinant Hirudin with a Low-Molecular-Weight Heparin to Prevent Thromboembolic Complications after Total Hip Replacement

Thu, 06Â NovÂ 1997 00:00:00 -05:00

Background: Patients who undergo total hip replacement have a high risk of thromboembolic complications. Recombinant hirudin (desirudin), a specific inhibitor of thrombin, represents a new development in antithrombotic therapy. We...

ORIGINAL ARTICLE: A Comparison of Continuous Infusion of Alteplase with Double-Bolus Administration for Acute Myocardial Infarction

Thu, 16Â OctÂ 1997 00:00:00 -05:00

Background: Accelerated infusion of alteplase (tissue plasminogen activator) over a period of 90 minutes induces more rapid lysis of coronary-artery thrombi than a 3-hour infusion. With two bolus doses of...

ORIGINAL ARTICLE: A Comparison of Reteplase with Alteplase for Acute Myocardial Infarction

Thu, 16Â OctÂ 1997 00:00:00 -05:00

Background: Reteplase (recombinant plasminogen activator), a mutant of alteplase tissue plasminogen activator, has a longer half-life than its parent molecule and produced superior angiographic results in pilot studies of acute...

REVIEW ARTICLE: Low-Molecular-Weight Heparins

Jeffrey I. Weitz, M.D. — Thu, 04Â SepÂ 1997 00:00:00 -05:00

After almost two decades of intensive research, low-molecular-weight heparins have established their niche as an important class of antithrombotic compounds. The demonstration that these compounds are safe and effective for...

IMAGES IN CLINICAL MEDICINE: Paradoxical Embolism â Thrombus in Transit through a Patent Foramen Ovale

T. Narain Srivastava, M.D. and Michael F. Payment, M.D. — Thu, 04Â SepÂ 1997 00:00:00 -05:00

Figure 1. An obese 46-year-old man came to the emergency room with the acute onset of numbness and a cold feeling in both hands; he had had shortness of breath...

ORIGINAL ARTICLE: A Comparison of Low-Molecular-Weight Heparin with Unfractionated Heparin for Acute Pulmonary Embolism

Thu, 04Â SepÂ 1997 00:00:00 -05:00

Background: Low-molecular-weight heparin appears to be at least as effective and safe as standard, unfractionated heparin for the treatment of deep-vein thrombosis, but only limited data are available on the...

ORIGINAL ARTICLE: Low-Molecular-Weight Heparin in the Treatment of Patients with Venous Thromboembolism

The Columbus Investigators — Thu, 04Â SepÂ 1997 00:00:00 -05:00

Background: Low-molecular-weight heparin is known to be safe and effective for the initial treatment of patients with proximal deep-vein thrombosis. However, its application to patients with pulmonary embolism or previous...

EDITORIAL: Heparin in Acute Coronary Disease â Requiem for a Heavyweight?

Thu, 14Â AugÂ 1997 00:00:00 -05:00

Unstable angina and nonâQ-wave myocardial infarction together constitute a formidable medical problem. Remarkable recent advances in our understanding of the pathophysiology of acute coronary syndromes have, thus far, outpaced progress...

ORIGINAL ARTICLE: A Comparison of Low-Molecular-Weight Heparin with Unfractionated Heparin for Unstable Coronary Artery Disease

Thu, 14Â AugÂ 1997 00:00:00 -05:00

Background: Antithrombotic therapy with heparin plus aspirin reduces the rate of ischemic events in patients with unstable coronary artery disease. Low-molecular-weight heparin has a more predictable anticoagulant effect than standard...

IMAGES IN CLINICAL MEDICINE: Cerebral Venous Thrombosis

Amir Jaffer, M.D. and Dana Leifer, M.D. — Thu, 07Â AugÂ 1997 00:00:00 -05:00

Figure 1. An 18-year-old woman presented three weeks post partum with a one-week history of headaches and two days of nausea, vomiting, and photophobia. On examination she was drowsy and...

ORIGINAL ARTICLE: Pregnancy Loss in the Antiphospholipid-Antibody Syndrome â A Possible Thrombogenic Mechanism

Thu, 17Â JulÂ 1997 00:00:00 -05:00

Background: The mechanisms of vascular thrombosis and pregnancy loss in the antiphospholipid-antibody syndrome are unknown. Levels of annexin V, a phospholipid-binding protein with potent anticoagulant activity, are markedly reduced on...

EDITORIAL: Preventing Coronary Restenosis and Complications

Thu, 12Â JunÂ 1997 00:00:00 -05:00

Interventions aimed at opening occluded coronary arteries continue to evolve. Two fundamental problems that limit the clinical efficacy of coronary interventions are restenosis after coronary angioplasty or atherectomy,123 reported since...

ORIGINAL ARTICLE: Platelet Glycoprotein IIb/IIIa Receptor Blockade and Low-Dose Heparin during Percutaneous Coronary Revascularization

The EPILOG Investigators — Thu, 12Â JunÂ 1997 00:00:00 -05:00

Background: Blockade of the platelet glycoprotein IIb/IIIa receptor with abciximab (a monoclonal-antibody Fab fragment directed against the receptor) has been shown to diminish ischemic complications among patients undergoing high-risk coronary...

ORIGINAL ARTICLE: A Clinical Trial Comparing Primary Coronary Angioplasty with Tissue Plasminogen Activator for Acute Myocardial Infarction

Thu, 05Â JunÂ 1997 00:00:00 -05:00

Background: Among physicians who treat patients with acute myocardial infarction, there is controversy about the magnitude of the clinical benefit of primary (i.e., immediate) coronary angioplasty as compared with thrombolytic...

REVIEW ARTICLE: Management of Anticoagulation before and after Elective Surgery

Clive Kearon, M.D., Ph.D., and Jack Hirsh, M.D. — Thu, 22Â MayÂ 1997 00:00:00 -05:00

The most common indications for warfarin therapy are atrial fibrillation, the presence of a mechanical heart valve, and venous thromboembolism.12 Treatment with warfarin presents a problem if patients with these...

EDITORIAL: Pulmonary Embolism â New Diagnostic Approaches

Thu, 15Â MayÂ 1997 00:00:00 -05:00

Pulmonary angiography and contrast venography are nearly 100 percent sensitive and specific in making the diagnoses of pulmonary embolism and deep-vein thrombosis. Nevertheless, these conditions frequently go undetected, often with...

ORIGINAL ARTICLE: Diagnosis of Pulmonary Embolism with Magnetic Resonance Angiography

Thu, 15Â MayÂ 1997 00:00:00 -05:00

Background: Diagnosing pulmonary embolism may be difficult, because there is no reliable noninvasive imaging method. We compared a new noninvasive method, gadolinium-enhanced pulmonary magnetic resonance angiography, with standard pulmonary angiography...

REVIEW ARTICLE: Aspirin, Heparin, and Fibrinolytic Therapy in Suspected Acute Myocardial Infarction

Thu, 20Â MarÂ 1997 00:00:00 -05:00

In this article, we review the randomized clinical trials of aspirin, of heparin, and of fibrinolytic therapy in patients with suspected acute myocardial infarction to determine which of these treatments...

ORIGINAL ARTICLE: Effects of Hormone-Replacement Therapy on Fibrinolysis in Postmenopausal Women

Thu, 06Â MarÂ 1997 00:00:00 -05:00

Background: Plasma levels of plasminogen-activator inhibitor type 1 (PAI-1), an essential inhibitor of fibrinolysis in humans, increase in women after menopause, and this may contribute to the risk of cardiovascular...

EDITORIAL: Oral Anticoagulant Therapy for Venous Thromboembolism

Thu, 06Â FebÂ 1997 00:00:00 -05:00

Patients with venous thromboembolic disease require treatment to stop the thrombotic process. The importance of immediate therapy with parenteral anticoagulants or thrombolytic agents (or both) is unquestioned.12 Furthermore, several well-designed...

IMAGES IN CLINICAL MEDICINE: Massive Pulmonary Embolism

Poll A. van der Wouw, M.D. and Matthijs Bax, M.D. — Thu, 06Â FebÂ 1997 00:00:00 -05:00

Figure 1. An 82-year-old woman with a history of myocardial infarction and heart failure collapsed during rehabilitation following a cerebral infarction with hemiparesis. Several days earlier, the presence of deep...

ORIGINAL ARTICLE: The Risk of Recurrent Venous Thromboembolism in Patients with an ArgâGln Mutation in the Gene for Factor V (Factor V Leiden)

Thu, 06Â FebÂ 1997 00:00:00 -05:00

Background: A recently discovered mutation in coagulation factor V (Arg506âGln, referred to as factor V Leiden), which results in resistance to activated protein C, is found in approximately one fifth...

ORIGINAL ARTICLE: The Duration of Oral Anticoagulant Therapy after a Second Episode of Venous Thromboembolism

Thu, 06Â FebÂ 1997 00:00:00 -05:00

Background: A consensus has not been reached about the optimal duration of oral anticoagulant therapy after a second episode of venous thromboembolism.

Methods: In a multicenter trial, we compared six months...

ORIGINAL ARTICLE: The Effect of Aggressive Lowering of Low-Density Lipoprotein Cholesterol Levels and Low-Dose Anticoagulation on Obstructive Changes in Saphenous-Vein Coronary-Artery Bypass Grafts

The Post Coronary Artery Bypass Graft Trial Investigators — Thu, 16Â JanÂ 1997 00:00:00 -05:00

Background: Obstructive changes often occur in aortocoronary saphenous-vein bypass grafts because of atherosclerosis and thrombosis. We studied whether aggressive lowering of low-density lipoprotein (LDL) cholesterol levels or low-dose anticoagulation would...

REVIEW ARTICLE: Management of Venous Thromboembolism

Jeffrey Stephen Ginsberg, M.D. — Thu, 12Â DecÂ 1996 00:00:00 -05:00

Venous thromboembolism, which includes deep-vein thrombosis (usually involving leg veins) and pulmonary embolism, is a common cause of death. Treatment of affected patients reduces the incidence of fatal pulmonary embolism,...

ORIGINAL ARTICLE: A Comparison of Thrombolytic Therapy with Primary Coronary Angioplasty for Acute Myocardial Infarction

Thu, 24Â OctÂ 1996 00:00:00 -05:00

Background: Several relatively small randomized trials have shown that primary angioplasty results in a better short-term outcome than thrombolytic therapy in patients with acute myocardial infarction. These results, however, have...

SPECIAL ARTICLE: Determinants of the Use of Coronary Angiography and Revascularization after Thrombolysis for Acute Myocardial Infarction

Thu, 17Â OctÂ 1996 00:00:00 -05:00

Background: Clinical trials and practice guidelines have identified clinical criteria for the use of coronary angiography and revascularization procedures after thrombolysis for acute myocardial infarction. The effect of these criteria...

ORIGINAL ARTICLE: A Comparison of Recombinant Hirudin with Heparin for the Treatment of Acute Coronary Syndromes

Thu, 12Â SepÂ 1996 00:00:00 -05:00

Background: Thrombin has a pivotal role in the pathogenesis of acute coronary thrombosis. We compared the clinical efficacy of a potent, direct thrombin inhibitor, recombinant hirudin, with that of heparin...

ORIGINAL ARTICLE: A Comparison of Low-Dose Heparin with Low-Molecular-Weight Heparin as Prophylaxis against Venous Thromboembolism after Major Trauma

Thu, 05Â SepÂ 1996 00:00:00 -05:00

Background: Patients who have had major trauma are at very high risk for venous thromboembolism if they do not receive thromboprophylaxis. We compared low-dose heparin and a low-molecular-weight heparin with...

ORIGINAL ARTICLE: Low-Molecular-Weight Heparin (Enoxaparin) as Prophylaxis against Venous Thromboembolism after Total Hip Replacement

Thu, 05Â SepÂ 1996 00:00:00 -05:00

Background: The risk of venous thromboembolism in patients undergoing total hip replacement is known to be high. However, the optimal duration of prophylaxis with anticoagulant agents after this procedure is...

EDITORIAL: The Scylla and Charybdis of Oral Anticoagulant Treatment

Thu, 22Â AugÂ 1996 00:00:00 -05:00

Treatment with oral anticoagulant drugs (i.e., coumarin derivatives such as warfarin) is effective in the prevention of venous and arterial thromboembolism. In patients with atrial fibrillation, anticoagulation reduces the risk...

ORIGINAL ARTICLE: An Analysis of the Lowest Effective Intensity of Prophylactic Anticoagulation for Patients with Nonrheumatic Atrial Fibrillation

Thu, 22Â AugÂ 1996 00:00:00 -05:00

Background: To avert major hemorrhage, physicians need to know the lowest intensity of anticoagulation that is effective in preventing stroke in patients with atrial fibrillation. Since the low rate of...

ORIGINAL ARTICLE: Thrombolytic Therapy with Streptokinase in Acute Ischemic Stroke

The Multicenter Acute Stroke Trial â Europe Study Group — Thu, 18Â JulÂ 1996 00:00:00 -05:00

Background: In patients with acute ischemic stroke, early treatment with thrombolytic agents is thought to permit reperfusion of ischemic neurons and to promote recovery of function. The Multicenter Acute Stroke...

REVIEW ARTICLE: Venous Thromboembolism during Pregnancy

Marc R. Toglia, M.D., and John G. Weg, M.D. — Thu, 11Â JulÂ 1996 00:00:00 -05:00

Venous thromboembolism is an uncommon but leading cause of illness and death during pregnancy and the puerperium.12 It has been reported to occur in 1 in 1000 to 1 in...

ORIGINAL ARTICLE: Stroke in Users of Low-Dose Oral Contraceptives

Thu, 04Â JulÂ 1996 00:00:00 -05:00

Background: Previous studies have linked the use of oral contraceptive agents to an increased risk of stroke, but those studies have been limited to oral contraceptives containing more estrogen than...

EDITORIAL: Low-Dose Oral Contraceptives and Stroke

Thu, 04Â JulÂ 1996 00:00:00 -05:00

For decades it has been known that oral contraceptive drugs are one of the most effective forms of birth control. Despite their clear and substantial benefits, concern has remained about...

ORIGINAL ARTICLE: A Randomized Comparison of Antiplatelet and Anticoagulant Therapy after the Placement of Coronary-Artery Stents

Thu, 25Â AprÂ 1996 00:00:00 -05:00

Background: The clinical benefit of coronary-artery stenting performed in conjunction with coronary angioplasty is limited by the risk of thrombotic occlusion of the stent as well as hemorrhagic and vascular...

ORIGINAL ARTICLE: Coexistence of Hereditary Homocystinuria and Factor V Leiden â Effect on Thrombosis

Thu, 21Â MarÂ 1996 00:00:00 -05:00

Background: Venous and arterial thromboembolism occurs in only about one third of patients homozygous for homocystinuria, which suggests that other, contributory factors are necessary for the development of thrombosis in...

ORIGINAL ARTICLE: Hyperhomocysteinemia as a Risk Factor for Deep-Vein Thrombosis

Thu, 21Â MarÂ 1996 00:00:00 -05:00

Background: Previous studies have suggested that hyperhomocysteinemia may be a risk factor for venous thrombosis. To assess the risk of venous thrombosis associated with hyperhomocysteinemia, we studied plasma homocysteine levels...

EDITORIAL: Low-Molecular-Weight Heparin â An Opportunity for Home Treatment of Venous Thrombosis

Thu, 14Â MarÂ 1996 00:00:00 -05:00

Venous thromboembolism, a disease now recognized in most cases to have a genetic basis,1 is the discharge diagnosis of more than a quarter-million patients in U.S. hospitals annually.2 Heparin has...

ORIGINAL ARTICLE: Treatment of Venous Thrombosis with Intravenous Unfractionated Heparin Administered in the Hospital as Compared with Subcutaneous Low-Molecular-Weight Heparin Administered at Home

Thu, 14Â MarÂ 1996 00:00:00 -05:00

Background: An intravenous course of standard (unfractionated) heparin with the dose adjusted to prolong the activated partial-thromboplastin time to a desired length is the standard initial in-hospital treatment for patients...

ORIGINAL ARTICLE: A Comparison of Low-Molecular-Weight Heparin Administered Primarily at Home with Unfractionated Heparin Administered in the Hospital for Proximal Deep-Vein Thrombosis

Thu, 14Â MarÂ 1996 00:00:00 -05:00

Background: Patients with acute proximal deep-vein thrombosis are usually treated first in the hospital with intravenous standard (unfractionated) heparin. However, the longer plasma half-life, better bioavailability after subcutaneous administration, and...

ORIGINAL ARTICLE: Preinfarction Angina as a Predictor of More Rapid Coronary Thrombolysis in Patients with Acute Myocardial Infarction

Thu, 04Â JanÂ 1996 00:00:00 -05:00

Background: When a myocardial infarction is preceded by angina, the infarct tends to be smaller than when there is no preinfarction angina. Prompt recanalization of the occluded infarct-related artery is...

NEJM â Collection Updates for Anticoagulants/Thromboembolism

CLINICAL PROBLEM-SOLVING: Painful Purple Toes

INTERACTIVE MEDICAL CASE: Painful Purple Toes

ORIGINAL ARTICLE: Dabigatran versus Warfarin in the Treatment of Acute Venous Thromboembolism

ORIGINAL ARTICLE: X-Linked Thrombophilia with a Mutant Factor IX (Factor IX Padua)

EDITORIAL: Can We Rely on RE-LY?

ORIGINAL ARTICLE: Dabigatran versus Warfarin in Patients with Atrial Fibrillation

EDITORIAL: Ticagrelor â Is There Need for a New Player in the Antiplatelet-Therapy Field?

ORIGINAL ARTICLE: Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndromes

PERSPECTIVE: Weighing Benefits and Risks â The FDA's Review of Prasugrel

PERSPECTIVE: Prasugrel in Clinical Practice

ORIGINAL ARTICLE: Apixaban or Enoxaparin for Thromboprophylaxis after Knee Replacement

CLINICAL IMPLICATIONS OF BASIC RESEARCH: Platelets, Pyrexia, and Plasmodia

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 23-2009 â A 13-Year-Old Boy with Headache, Nausea, Seizures, and Hypertension

ORIGINAL ARTICLE: Thrombomodulin Mutations in Atypical HemolyticâUremic Syndrome

EDITORIAL: Routine Angioplasty after Fibrinolysis â How Early Should âEarlyâ Be?

ORIGINAL ARTICLE: Routine Early Angioplasty after Fibrinolysis for Acute Myocardial Infarction

PERSPECTIVE: Left Atrial Appendage Occlusion â Closure or Just the Beginning?

CLINICAL PRACTICE: Chronic Venous Insufficiency and Varicose Veins

EDITORIAL: Antiplatelet Therapy and Vascular-Access Patency

ORIGINAL ARTICLE: Effect of Dipyridamole plus Aspirin on Hemodialysis Graft Patency

EDITORIAL: The ACTIVE Pursuit of Stroke Prevention in Patients with Atrial Fibrillation

ORIGINAL ARTICLE: Effect of Clopidogrel Added to Aspirin in Patients with Atrial Fibrillation

ORIGINAL ARTICLE: A Randomized Trial of Rosuvastatin in the Prevention of Venous Thromboembolism

IMAGES IN CLINICAL MEDICINE: Prosthetic Mitral Valve with Partial Thrombosis

IMAGES IN CLINICAL MEDICINE: Venous Obstruction of the Thigh

EDITORIAL: Pharmacogenetics â Tailoring Treatment for the Outliers

ORIGINAL ARTICLE: Estimation of the Warfarin Dose with Clinical and Pharmacogenetic Data

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 5-2009 â A 47-Year-Old Woman with a Rash and Numbness and Pain in the Legs

IMAGES IN CLINICAL MEDICINE: Metallic Mercury Embolism to the Hand

EDITORIAL: Clopidogrel, Genetics, and Drug Responsiveness

ORIGINAL ARTICLE: Genetic Determinants of Response to Clopidogrel and Cardiovascular Events

ORIGINAL ARTICLE: Cytochrome P-450 Polymorphisms and Response to Clopidogrel

CLINICAL PRACTICE: Acute Pulmonary Embolism

CORRESPONDENCE: Prothrombin Time for Detection of Contaminated Heparins

IMAGES IN CLINICAL MEDICINE: Postpartum Venous Thromboembolism

ORIGINAL ARTICLE: Outbreak of Adverse Reactions Associated with Contaminated Heparin

ORIGINAL ARTICLE: Thrombolysis during Resuscitation for Out-of-Hospital Cardiac Arrest

CLINICAL PROBLEM-SOLVING: Taken Out of Context

IMAGES IN CLINICAL MEDICINE: Cavernous Sinus Thrombosis

REVIEW ARTICLE: Venous Thromboembolic Disease and Pregnancy

SPECIAL ARTICLE: Cardiovascular Outcomes after a Change in Prescription Policy for Clopidogrel

EDITORIAL: Thrombolytic Therapy for Acute Stroke â Not a Moment to Lose

ORIGINAL ARTICLE: Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke

EDITORIAL: Stroke Prevention â Insights from Incoherence

ORIGINAL ARTICLE: Aspirin and Extended-Release Dipyridamole versus Clopidogrel for Recurrent Stroke

CLINICAL PROBLEM-SOLVING: Collateral Damage

REVIEW ARTICLE: Mechanisms of Thrombus Formation

IMAGES IN CLINICAL MEDICINE: Infrarenal Aortic Occlusion

ORIGINAL ARTICLE: Bivalirudin versus Unfractionated Heparin during Percutaneous Coronary Intervention

IMAGES IN CLINICAL MEDICINE: Spontaneous Thrombolysis of an Obstructed Mechanical Aortic Valve

EDITORIAL: New Anticoagulants â The Path from Discovery to Clinical Practice

ORIGINAL ARTICLE: Rivaroxaban versus Enoxaparin for Thromboprophylaxis after Total Knee Arthroplasty

ORIGINAL ARTICLE: Rivaroxaban versus Enoxaparin for Thromboprophylaxis after Hip Arthroplasty

IMAGES IN CLINICAL MEDICINE: Central Hemiretinal Arterial Occlusion

EDITORIAL: Heparin Comes Clean

ORIGINAL ARTICLE: Contaminated Heparin Associated with Adverse Clinical Events and Activation of the Contact System

EDITORIAL: Antithrombotic Therapy to Support Primary PCI

EDITORIAL: Does Thrombolytic Therapy Facilitate or Foil Primary PCI?

ORIGINAL ARTICLE: Bivalirudin during Primary PCI in Acute Myocardial Infarction

ORIGINAL ARTICLE: Facilitated PCI in Patients with ST-Elevation Myocardial Infarction

EDITORIAL: Intracerebral Hemorrhage â Improving Outcome by Reducing Volume?

ORIGINAL ARTICLE: Efficacy and Safety of Recombinant Activated Factor VII for Acute Intracerebral Hemorrhage

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 12-2008 â A Newborn Infant with Intermittent Apnea and Seizures

IMAGES IN CLINICAL MEDICINE: Cerebral Embolism of Probable Aortic Origin

IMAGES IN CLINICAL MEDICINE: Pseudoaneurysm of the Right Internal Thoracic Artery

ORIGINAL ARTICLE: VEGF Inhibition and Renal Thrombotic Microangiopathy

ORIGINAL ARTICLE: Genetic Determinants of Response to Warfarin during Initial Anticoagulation

EDITORIAL: Pharmacogenomics â Ready for Prime Time?

REVIEW ARTICLE: Acute Pulmonary Embolism

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 7-2008 â A 17-Year-Old Girl with Chest Pain and Hemoptysis

IMAGES IN CLINICAL MEDICINE: Retinal Arteriolar Cholesterol Emboli

EDITORIAL: Improving Reperfusion in Patients with Myocardial Infarction

ORIGINAL ARTICLE: Thrombus Aspiration during Primary Percutaneous Coronary Intervention

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 2-2008 â A 38-Year-Old Woman with Postpartum Visual Loss, Shortness of Breath, and Renal Failure

IMAGES IN CLINICAL MEDICINE: Retiform Purpura

IMAGES IN CLINICAL MEDICINE: Dissecting Aneurysm of the Posterior Cerebral Artery

IMAGES IN CLINICAL MEDICINE: Occlusion and Reperfusion of the Middle Cerebral Artery

REVIEW ARTICLE: Platelet Activation and Atherothrombosis

EDITORIAL: Intensifying Platelet Inhibition â Navigating between Scylla and Charybdis

NEJM â Collection Updates for Anticoagulants/Thromboembolism

EDITORIAL: Ticagrelor â Is There Need for a New Player in the Antiplatelet-Therapy Field?

PERSPECTIVE: Weighing Benefits and Risks â The FDA's Review of Prasugrel

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 23-2009 â A 13-Year-Old Boy with Headache, Nausea, Seizures, and Hypertension

ORIGINAL ARTICLE: Thrombomodulin Mutations in Atypical HemolyticâUremic Syndrome

EDITORIAL: Routine Angioplasty after Fibrinolysis â How Early Should âEarlyâ Be?

PERSPECTIVE: Left Atrial Appendage Occlusion â Closure or Just the Beginning?

EDITORIAL: Pharmacogenetics â Tailoring Treatment for the Outliers

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 5-2009 â A 47-Year-Old Woman with a Rash and Numbness and Pain in the Legs

EDITORIAL: Thrombolytic Therapy for Acute Stroke â Not a Moment to Lose

EDITORIAL: Stroke Prevention â Insights from Incoherence

EDITORIAL: New Anticoagulants â The Path from Discovery to Clinical Practice

EDITORIAL: Intracerebral Hemorrhage â Improving Outcome by Reducing Volume?

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 12-2008 â A Newborn Infant with Intermittent Apnea and Seizures

EDITORIAL: Pharmacogenomics â Ready for Prime Time?

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 7-2008 â A 17-Year-Old Girl with Chest Pain and Hemoptysis

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 2-2008 â A 38-Year-Old Woman with Postpartum Visual Loss, Shortness of Breath, and Renal Failure

EDITORIAL: Intensifying Platelet Inhibition â Navigating between Scylla and Charybdis

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 28-2007 â A 68-Year-Old Man with Syncope

EDITORIAL: Atherothrombosis â Wave Goodbye to Combined Anticoagulation and Antiplatelet Therapy?

CLINICAL PROBLEM-SOLVING: A Sinister Development â A 35-year-old woman presented to the emergency department with a 2-day history of progressive swelling and pain in her left leg, without antecedent trauma

PERSPECTIVE: Drug-Induced Immune-Mediated Thrombocytopenia â From Purpura to Thrombosis

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 1-2007 â A 40-Year-Old Woman with Epistaxis, Hematemesis, and Altered Mental Status

EDITORIAL: Treatment of In-Stent Restenosis â Back to the Future?

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 29-2006 â A 43-Year-Old Woman with Painful Nodules on the Fingertips, Shortness of Breath, and Fatigue

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 16-2006 â A 72-Year-Old Woman Admitted to the Emergency Department because of a Sudden Change in Mental Status

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 15-2006 â A 46-Year-Old Woman with Sudden Onset of Abdominal Distention

CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL: Case 14-2006 â A 25-Year-Old Woman with Anemia and Iron Overload

EDITORIAL: Therapy for Patients with Acute Coronary Syndromes â New Opportunities

EDITORIAL: Multislice Computed Tomography for Pulmonary Embolism â A Technological Marvel

EDITORIAL: Electronic Medical Alerts â So Simple, So Complex

PERSPECTIVE: Problems with Drug-Eluting Coronary Stents â The FDA Perspective