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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Venous thromboembolism &#40;VTE&#41; is the third most common cardiovascular disease&#44; after stroke and myocardial infarction&#44; affecting at least one individual per 1000 of the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> Its incidence rises exponentially with age&#58; two-thirds of patients with pulmonary embolism &#40;PE&#41; are aged 60 years or more&#46; VTE is a frequent cause of death&#44; responsible for over three million deaths a year&#44; while PE is the leading preventable cause of hospitalization-related mortality&#46; Untreated PE is fatal in 30&#37; of cases&#44; half of all deaths &#40;many of them sudden&#41; occurring in the first few hours&#46; The clinical presentation of PE is highly variable and diagnosis requires a high level of suspicion&#46; For these reasons&#44; VTE has been the subject of particular attention among healthcare policy-makers&#46; Prevention&#44; diagnosis and rapid and appropriate treatment are crucial to any strategy to reduce the mortality and disease burden due to VTE&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Other consequences of VTE include recurrence &#40;which is particularly common in the first months after the initial episode and in spontaneous or cancer-associated VTE&#41; and chronic complications such as post-thrombotic syndrome and thromboembolic pulmonary hypertension&#44; which cause suffering and morbidity and can shorten life expectancy&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The epidemiology of PE in Portugal was recently analyzed using data on hospitalizations in National Health Service hospitals between 2003 and 2013&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> In this period there were 35<span class="elsevierStyleHsp" style=""></span>200 episodes of hospitalizations of adults in which at least one of the diagnoses was PE &#40;the primary diagnosis in 67&#37; of cases&#41;&#46; The estimated incidence in 2013 was 35 per 100<span class="elsevierStyleHsp" style=""></span>000 of the adult population&#44; a lower figure than in other countries&#44; which suggests the possibility of underdiagnosis in Portugal&#46; Between 2003 and 2013 the annual number of episodes increased&#44; but in-hospital mortality decreased &#40;from 31&#46;8&#37; to 17&#37; in all episodes and from 25&#37; to 11&#46;2&#37; in episodes in which PE was the primary diagnosis&#41;&#46; The authors estimated that 79&#37; of the reduction in PE-associated in-hospital mortality in recent years could be attributed to more effective hospital care and the remainder to favorable changes in patient characteristics associated with risk of death&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">VTE&#44; and especially PE&#44; are more closely linked to cardiology than is generally realized&#46; Several of the risk factors predisposing to VTE are frequently found in patients with heart disease&#58; advanced age&#44; obesity&#44; diabetes&#44; heart failure&#44; smoking&#44; chronic obstructive pulmonary disease&#44; dyslipidemia and hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Coronary calcification is significantly more prevalent in patients with a history of spontaneous VTE than in the general population&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> and in the first year after an episode of VTE the likelihood of hospitalization for myocardial infarction or stroke increases two- to three-fold&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> while in the first six months after a myocardial infarction&#44; there is an eight-fold increase in risk of PE&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Reperfusion therapy&#44; usually thrombolysis&#44; is essential in PE presenting with shock or hypotension &#40;considered high-risk PE&#41;&#46; In lower-risk PE&#44; anticoagulation for at least three months is mandatory to avoid early death or symptomatic or fatal recurrence&#46; The European Society of Cardiology guidelines<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> recommend beginning with a parenteral anticoagulant &#40;unfractionated heparin&#44; low molecular weight heparin or fondaparinux&#41; over the first 5-10 days overlapping with the initiation of a vitamin K antagonist &#40;VKA&#41; or followed by one of the new oral anticoagulants &#40;NOACs&#41;&#58; dabigatran or edoxaban&#46; If rivaroxaban or apixaban is given instead&#44; oral treatment with one of these agents should be started directly&#44; although in this case with an increased dose over the first three weeks or the first seven days &#40;for rivaroxaban or apixaban&#44; respectively&#41;&#46; In patients at greater risk of recurrence&#44; anticoagulation should be extended beyond the initial three months or even indefinitely&#44; weighing the individual&#39;s bleeding risk and periodically reassessing the decision&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Clinical trials of the four NOACs for treating VTE show that these drugs are at least as effective as a VKA&#44; and may be safer in terms of major bleeding&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Bearing in mind the various limitations of VKAs and the inconvenience and risk of parenteral anticoagulants&#44; these results show that NOACs are an attractive option for prevention and treatment of VTE&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The article by Santos et al&#46; in this issue of the <span class="elsevierStyleItalic">Journal</span> is a contribution to the growing experience of NOACs in moderate- to high-risk VTE&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> The authors conclude that these drugs are as effective and safe as the conventional approach&#44; and reduce hospital length of stay&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In summary&#44; VTE is a common and often lethal condition that affects both in- and outpatients&#44; frequently recurs&#44; is underdiagnosed&#44; and leads to chronic complications&#46; Cardiovascular medicine can play an important part in reducing the disease burden attributable to VTE&#46; Anticoagulation is crucial to the treatment of VTE and for this purpose NOACs have a better risk-benefit ratio than VKAs&#44; simplifying treatment and reducing inconvenience&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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