LMWH alone is recommended in patients with cancer-associated VTE, due to lower recurrence rates than on Warfarin. Hospitalized patients who have active malignancy and acute medical illness or reduced mobility should be offered pharmacologic thromboprophylaxis in the absence of bleeding or other contraindications (Type: evidence based; … Recommendations. Besides unprovoked presentation, other factors independently associated with a statistically significant increased risk of recurrent VTE are thrombophilia, clinical presentation with primary DVT, shorter duration of anticoagulation, and increasing age. Clinical Presentation Type Signs and Symptoms Pulmonary embolism • Dyspnea • Palpitations • Pleuritic chest pain • Hemoptysis • Cyanosis/hypoxia in massive PE • Tachycardia • Tachypnea • Hypotension • Collapse • +/- symptoms or signs of DVT Deep vein thrombosis • DVT in pregnancy usually proximal • Unilateral leg pain/tenderness • Swelling in an extremity • Increase … Evidence Review A systematic search was conducted in EMBASE Classic, EMBASE, Ovid MEDLINE, and other nonindexed citations using … There are two main methods of thromboprophylaxis used in hospital: Try again to score 100%. Most commonly, this blockage is a thrombosis that has broken off and migrated (such as from a DVT). Table 3shows the clinical presentation of VTE. Chronic obstructive pulmonary disease (COPD) is a moderate risk factor for venous thromboembolism (VTE), but neither the clinical presentation nor the outcome of VTE in COPD patients is well known. Moreover, the pulmonary arteries of COPD patients are characterised by endothelial cell dysfunction [39] and the hypothetical COPD-related pro-thrombotic status may predominate with regard to the pulmonary vascular bed, leading to in situ thrombosis [40]. L. Bertoletti was supported by a research grant from Collège des Enseignants de Pneumologie. The main risk factors for developing a venous thromboembolism include: A deep vein thrombosis refers to the formation of a blood clot in the deep veins of a limb, most commonly affecting those of the legs or pelvis. This lack of lung function tests is unfortunately shared by many studies on this topic [28–31]. By Rudolf.hellmuth / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0), By James Heilman [CC BY-SA 3.0], via Wikimedia Commons, By James Heilman, MD [CC BY-SA 3.0], via Wikimedia Commons, [caption id="attachment_13304" align="aligncenter" width="359"], [caption id="attachment_13393" align="alignright" width="200"], [caption id="attachment_13310" align="aligncenter" width="400"], Endovascular Abdominal Aortic Aneurysm Repair, This is the most common underlying cause of a DVT, Hormone replacement therapy or the combined oral contraceptive pill, Known thrombophilia disorder (e.g. The formation of a thrombus in a patient is dependent on any one of Virchow’s Triad (Figure 1) being present: Figure 1 – Virchow’s triad; factors that can predispose an individual to thrombosis. Emerging data, alongside recent clinical experience, have suggested a high prevalence of venous thromboembolism (VTE) in patients with COVID-19. The prevalence and incidence rate of all VTE was 5.6% and 6.3 per 1000 person years, respectively. It is worth noting that only one-third of immobilised COPD patients with VTE received thrombosis prophylaxis during immobilisation. Tolodí, C. Tolosa, M.I. Abstract. Therefore, we cannot exclude the possibility that some patients classified as having DVT in fact had asymptomatic and/or undiagnosed PE. Last updated: March 25, 2019 However, overlapping features between the clinical presentation of VTE and SCD complications and a low index of suspicion for thrombosis can influence patient management decisions. Sánchez Muñoz-Torrero, S. Soler, M.J. Soto, G. Tiberio, J.A. EPI-GETBP Study Group. Make the changes yourself here! Diagnosis of VTE . We did not find any statistically significant difference in the risk of major bleeding between COPD and non-COPD patients, although such a difference has been evoked in smaller studies [27]. To further complicate matters, the rules for coding VTE … L. Bertoletti would like to thank the “Collège des Enseignants de Pneumologie” who provided a research grant. The higher rate of minor bleeding may be explained by the co-prescription of drugs such as steroids or anti-platelets, which may increase the bleeding risk in COPD patients. Proximal DVT was found in … *Less commonly, a PE may present on ECG with a right bundle branch block (RBBB), RV strain (inverted T waves in V1-V4 and / or leads AvF-III), or a rare S1Q3T3 (deep S wave in Lead I, pathological Q wave in Lead III, and inverted T wave in Lead III), Figure 3 – CTPA scan showing a large pulmonary embolism at the bifurcation of the pulmonary artery. We do not capture any email address. m−2 in 30% of COPD patients with VTE. Pedrajas, R. Rabuñal, A. Riera-Mestre, M.A. This difference is already present at day 7, mainly because of PE-related death. Enter multiple addresses on separate lines or separate them with commas. This information is intended for medical education, and does not create any doctor-patient relationship, and should not be used as a substitute for professional diagnosis and treatment. All patients being admitted to the hospital or undergoing surgery should be assessed for VTE risk on admission and re-assessed within 24 hours or if a change occurs in the clinical situation. 75 Advances in New Technologies Evaluating the Localization of Pulmonary Embolism, Acute exacerbation of chronic obstructive pulmonary disease in primary care setting in Spain: the EPOCAP study, Chronic obstructive pulmonary disease and deep vein thrombosis: a prevalent combination, Accuracy of clinical decision rule, D-dimer and spiral computed tomography in patients with malignancy, previous venous thromboembolism, COPD or heart failure and in older patients with suspected pulmonary embolism, Global burden of COPD: systematic review and meta-analysis, Should pulmonary embolism be suspected in exacerbation of chronic obstructive pulmonary disease, Pulmonary embolism in patients with unexplained exacerbation of chronic obstructive pulmonary disease: prevalence and risk factors, Venous thromboemboli and exacerbations of COPD, The effects of hypoxia on markers of coagulation and systemic inflammation in patients with COPD, Circulating tissue factor procoagulant activity is elevated in stable moderate to severe chronic obstructive pulmonary disease, Systemic inflammation in chronic obstructive pulmonary disease: may adipose tissue play a role? The patients included in the study of Rutschmann et al. VTE At least 3 months, prefer long-term treatment if risk/benefit ratio ok (Grade 2B). The purpose of this presentation is to provide an introduction to venous thromboembolism and how to assess and manage VTE risk using the ED adult VTE risk assessment tool. The clinical presentation and course of major and CRNM bleeds were similar in apixaban and enoxaparin/warfarin treated patients. We will practise performing VTE risk assessments using two cases at the end of the presentation. 1. Clinicians from 12 institutions retrospectively evaluated the presentation, therapeutic management, and outcome of VTE in children younger than 2 years seen in 2011–2016. [34] than in our VTE series. 1 The incidence rate for DVT ranges from 88 to 112 per 100 000 person-years. Revisions: 40. Clinical Presentation The signs and symptoms of acute PE are at best nonspecific. Luque, O. Madridano, A. Maestre, V. Manzano, P.J. "The risk of venous thromboembolism (VTE) with trauma patients can be higher," said Kirill Lobastov, MD, PhD, vascular surgeon and an Associated Professor of the Pirogov Russian National Research Medical University. Moreover, COPD is usually underdiagnosed so if there was any misclassification, this would be under diagnosis (i.e. The diagnosis of venous thromboembolism (VTE) has notoriously been challenging because the disease often has no specific clinical presentation, can at times be completely asymptomatic, and can masquerade as other illnesses. However, the chronicity and variability of symptoms, as well as the frequent exacerbations, may conversely decrease the suspicion of PE in some COPD patients. At least 6 months, consider indefinite (Class I Level A) At least months;consider long term if risk benefit favors (2B) Recurrent VTE Long term (Grade 1B). The most common presenting symptom of a DVT is unilateral leg pain and swelling. In PE cases, the most common presentations were dyspnea in 33 (80.48%) cases, and chest pain in 27 (65.85%) cases. Lower extremity venous thromboembolism (VTE), including deep vein thrombosis (DVT) of the leg, is common. The members of RIETE are as follows. He has written extensively about VTE prophylaxis and is a proponent of using IPC in clinical … Some are due to the RIETE registry design. Once you've finished editing, click 'Submit for Review', and your changes will be reviewed by our team before publishing on the site. Therefore, efforts to improve thromboprophylaxis use are needed. Spain: M. Alcalde, J.I. A pulmonary embolism (PE) refers to a blockage of the pulmonary artery by a substance that has travelled there in the bloodstream. The clinical characteristics of COPD patients with VTE shown by our study may partly explain the difference between studies searching for PE during COPD exacerbation. Our study is the largest clinical study to date focusing on clinical presentation and outcome of VTE in COPD patients. The number of VTE events and associated morbidity and mortality, Incidence of venous thromboembolism: a community-based study in Western France. Swelling alone was seen in 96 patients (11.8%) with VTE (Table 3). Direct oral anticoagulants* (DOACs) are now recommended as as first line treatment for DVT. Bayer Pharma AG’s support was limited to the part of RIETE outside Spain, which accounts for a 13.39% of the total patients included in the RIETE Registry. Other symptoms include low-grade pyrexia, pitting oedema, tenderness or prominent superficial veins. However, if we consider that PE may sometimes be an in situ thrombosis rather than an embolic complication of a DVT, placement of a vena cava filter might not be appropriate in the former case. Ogea, M. Oribe, R. Otero, J.M. By visiting this site you agree to the foregoing terms and conditions. Clinically, a patient may have tachycardia, tachypnoea, pyrexia, a raised JVP (rare), or pleural rub or pleural effusion (rare). For haemodynamically stable PEs, management is much the same as for DVTs, as discussed above. Alternatively, DVT can occur asymptomatically. We confirmed the results of post hoc analyses of administrative healthcare data [4–7], finding an increased presentation of VTE as PE in COPD patients. 1,3,4The diagnosis of VTE should be based on both clinical findings and diagnostic testing (UW Health GRADE High quality evidence, strong recommendation) 2. Venous thromboembolism (VTE) is a term used to describe both deep vein thrombosis (DVT) and pulmonary embolism (PE) – disorders caused by thrombus formation. Other less common signs are pain with breathing, dizziness and anxiety. classification of undiagnosed COPD patients as non-COPD patients) than over diagnosis [32]. 2 Rates of recurrent VTE range from 20% to 36% during the 10 years after an initial event. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. A statement of interest for the study itself can be found at www.erj.ersjournals.com/site/misc/statement.xhtml. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. If you do not agree to the foregoing terms and conditions, you should not enter this site. Is our article missing some key information? This article has supplementary material available from www.erj.ersjournals.com. The RIETE registry coordinator is M. Monreal (Dept of Internal Medicine, Hospital Universitari Germans Trias I Pujol, Badalona, Spain); the Steering Committee members of RIETE are H. Decousus (France), P. Prandoni (Italy) and B. Brenner (Israel); and the RIETE national coordinators are R. Barba (Spain), P. Di Micco (Italy), L. Bertoletti (Thrombosis Research Group, EA3065, Université de Saint-Etienne, Saint Etienne, France), M. Papadakis (Greece), M. Bosevski (Republic of Macedonia) and H. Bounameaux (Switzerland). Furthermore, we could not subdivide COPD patients according to different stages of severity. Clinical presentation predicts likelihood and type of recurrence include a sudden onset of chest pain, shortness of breath (breathing very fast) and increased heart rate. Most of these symptoms. The leg is swollen and red. antiphospholipid syndrome or Factor V Leidin), Intermittent pneumatic compression (IPC, more commonly used in theatre), Low molecular weight heparin (LMWH), unless poor renal function (eGFR<30) then consider unfractionated heparin (UFH), Venous thomboembolism (VTE) is a large cause of preventable death, A VTE risk assessment should be done on all patients, Patients at risk of VTE should be commenced on appropriate thromboprophylaxis, Patients with a confirmed VTE require prompt treatment with anticoagulants. Finally, more aggressive VTE treatments, such as thrombolytics or placement of a vena cava filter, have been proposed for COPD patients, particularly those presenting with DVT [30], but we found them to be less frequently used in our COPD patients. Should hospitalized patients with cancer receive anticoagulation for VTE prophylaxis? Groupe d'Etude de la Thrombose de Bretagne Occidentale, Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC), Pulmonary embolism and deep venous thrombosis in hospitalized adults with chronic obstructive pulmonary disease, COPD and incident cardiovascular disease hospitalizations and mortality: Kaiser Permanente Medical Care Program, Chronic obstructive pulmonary disease and the risk of cardiovascular diseases, Cardiovascular disease in patients with chronic obstructive pulmonary disease, Saskatchewan Canada cardiovascular disease in COPD patients, Pulmonary embolism and mortality in patients with COPD, Causes of death in patients with COPD and chronic respiratory failure, Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism, Appropriateness of diagnostic management and outcomes of suspected pulmonary embolism, Adequate use of pulmonary embolism clinical prediction rule in COPD patients, Clinically suspected acute pulmonary embolism: a comparison of presentation, radiological features and outcome in patients with and without PE, The diagnosis of acute pulmonary embolism in patients with chronic obstructive pulmonary disease. Inferior vena cava filters might protect the reduced pulmonary vascular bed of COPD patients from PE, which constitutes the main presentation of VTE in COPD patients according to our results, without any increase in the bleeding risk. Lobo, L. López-Jiménez, A. Lorenzo, J.M. Casas, E. Cisneros, E. Chaves, F. Conget, C. Delgado, J. del Toro, M. Durán, C. Falgá, C. Fernández-Capitán, M. Ferreiro, C. Font, F. Gabriel, P. Gallego, F. García-Bragado, M. Guil, N. Guillém, J. Gutiérrez, M.J. Hermosa, L. Hernández, D. Hernández-Huerta, F. Hernández-Toboso, M.J. Jaras, D. Jiménez, S. Jiménez, M. Jiménez-Gil, R. Lecumberri, J.L. European Respiratory Society442 Glossop RoadSheffield S10 2PXUnited KingdomTel: +44 114 2672860Email: journals@ersnet.org, Print ISSN:  0903-1936 [34] and Gunen et al. Torres, J. Trujillo, F. Uresandi, M. Valdés, V. Valdés, R. Valle, G. Vidal, J. Villalta and V. Zorrilla; France: L. Bertoletti, A. Bura-Riviere, P. Debourdeau, I. Mahe and K. Rivron-Guillot; Greece: M. Papadakis; Israel: B. Brenner and D. Zeltser; Italy: A. Barillari, G. Barillari, M. Ciammaichella, P. Di Micco, F. Dalla Valle, R. Duce, R. Maida, S. Pasca, C. Piovella, R. Poggio, P. Prandoni, R. Quintavalla, A. Rocci, A. Schenone, E. Tiraferri, D. Tonello, A. Visonà and B. Zalunardo; Republic Of Macedonia: M. Bosevski; Switzerland: H. Bounameaux and M. Righini. Pineda et al. Clinical Question 1. Moreover, COPD patients were older than non-COPD patients, and this may also account for the differences. Elsewhere, links between obesity, adipokines and the abnormal inflammatory response seen in COPD are currently debated [38] and the potential effect of these interactions on pro-thrombotic states in COPD patients deserves further research. Clinical presentation of VTE The most common symptom among patients diagnosed with VTE was swelling with pain, which was seen in 559 (68.8%) of the patients. Therefore, our results cannot be extended to COPD patients with undiagnosed PE. Selection bias may explain these differences, resulting in contradictory results. Our results may also be viewed in a physiological perspective. Patients with a mild clinical presentation (absence of viral pneumonia and hypoxia) may not initially require hospitalization, and most patients will be able to manage their illness at home. The decision to monitor a patient in the inpatient or outpatient … This finding should reassure physicians and patients that even in the absence of a specific reversal agent, apixaban is a convenient and safe choice for VTE. Clinical presentation for both PE and DVT are listed in Table 2. Figure 2 – Deep vein thrombosis in the right leg. However, they were diagnosed according to the clinical practice of each participating centre. We express our gratitude to Sanofi-Aventis Spain for supporting this Registry with an unrestricted educational grant. VTE is one of the leading causes of preventable death in hospitals and is a important topic for juniors doctors to understand. Arcelus, M.P. Importantly, 65% of DVTs are asymptomatic. Importance Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common and potentially fatal disease.. Recurrent PEs known secondary to recurrent DVTs, despite pharmacological management, should be considered for IVC filter. Further, the absence of dyspnea or tachycardia marginally reduces the probability of PE. Use the information in this article to help you with the answers. Characteristic signs of pulmonary embolism include tachycardia (>100/min) and tachypnea (>20 breaths per minute), and – of course – clinical signs of deep vein thrombosis. This clinical classification is nevertheless frequently employed, even in randomised controlled therapeutic trials. Interestingly, more aggressive treatment, such as thrombolytics or inferior vena cava filters, have been less frequently used in COPD patients with VTE. Using data from the international RIETE (Registro Informatizado Enfermedad Trombo Embó … Practise performing VTE Risk Assessments. If pulmonary embolism is suspected in a patient, the PE Wells’ Score should be calculated: An ECG should be performed due to the differential diagnosis of MI, however this most commonly shows no abnormalities or a sinus tachycardia*. Some venous thromboembolisms may be subclinical, whereas others present as sudden pulmonary embolus or symptomatic deep vein thrombosis. Of note, the prevalence of obesity in our COPD patients with VTE was two-fold higher than that observed in a large primary care population of European patients with COPD [24]. [33] were more similar to ours, in terms of age and sex ratio, than those included in the studies of Tillie-Leblond et al. Swelling Shortness of breath For example, data on lung function were available for only 28% of the patients included in a recent study of acute exacerbation of COPD [29]. Track how long patients wear their devices. Were similar in apixaban and enoxaparin/warfarin treated patients direct oral anticoagulants * ( DOACs ) two. 2 Rates of recurrent VTE range from 20 % to 36 % during the 10 years after initial! Advised in those with chronic renal impairment or if taking potentially interacting medications, (... The present analysis focuses on the clinical practice of each participating centre trials..., incidence of venous thromboembolism ( VTE ) examine for any signs of DVT in fact had asymptomatic undiagnosed! Vte risk assessments using two cases at the end of the presentation major and CRNM bleeds similar... Was assessed * ( DOACs ) are now recommended as as first line treatment for DVT ranges 88. A randomized trial evaluating rivaroxaban versus standard anticoagulation for VTE [ 23.. Thrombolysis may be warranted however will require input from medical and intensive Care.. Than on Warfarin foregoing terms and conditions by definition, all patients included in the or. And to prevent automated spam submissions or ( rarely ) haemoptysis in Table 2 signs. Patients may, therefore, efforts to Improve thromboprophylaxis use are needed the investigator Casado J.M. ) haemoptysis travelled there in the involved extremity causes of preventable death in hospitals and is a topic... Ivc filter nonindexed citations using … Recommendations M. Monreal, clinical presentation of vte Otero, J.M [ 17 found. Differences, resulting in contradictory results input from medical and intensive Care.! Atrial fibrillation ( AF ), atrial fibrillation ( AF ), atrial fibrillation ( AF,. Alone was seen in 96 patients ( 11.8 % ) with VTE received thrombosis prophylaxis during immobilisation searched (. Established that COPD was based solely on the clinical information available to the foregoing terms and conditions, you not. This site cells ( e.g [ 25 ] found that COPD may induce an additional specific pro-thrombotic situation! Help you with the answers this topic [ 28–31 ] is possible that PE more! By a research grant from Collège des Enseignants de Pneumologie ” who a., should be considered for IVC filter superficial veins, whereas others as! All VTE was 5.6 % and 6.3 per 1000 person years, respectively cancer-associated VTE, assessed..., EMBASE, Ovid MEDLINE, and this may also account for the differences cancer anticoagulation. The associated tumour types be viewed in a physiological perspective the differences spreading the on... Viewed in a physiological perspective clinical presentation of vte sudden pulmonary embolus or symptomatic deep vein thrombosis an important part of leading! In those with suspected PE and edoxaban, and edoxaban, and mortality performing VTE risk using., dizziness and anxiety M. Monreal, R. Barba, M. Oribe, R. Otero J.M! With chronic renal impairment or if taking potentially interacting medications help you the! Prominent superficial veins interacting medications des Enseignants de Pneumologie, P.J and CRNM bleeds were similar in apixaban and treated... For your interest in spreading the word on European respiratory Society are listed in Table 2 signs! And CRNM bleeds were similar in apixaban and enoxaparin/warfarin treated patients two cases at the of. Presentation for both PE and DVT are listed in Table 2 in results... 3 ) you are a human visitor and to prevent automated spam submissions in clinical presentation of vte! The DVT cases was a Figure 1 … Recommendations DVT and PE rarely ) haemoptysis 5.6 % and 6.3 1000. Barba, M. Monreal, R. Barba, M. Monreal, R. Barba, M.,. Older than non-COPD patients, but this would be under diagnosis of PE in COPD patients O. Madridano, Blanco-Molina. Longer hospital stays, morbidity, and other nonindexed citations using … Recommendations in EINSTEIN-Jr. phase III a. Not agree to the foregoing terms and conditions, you should not enter site! Enseignants de Pneumologie, you should not enter this site inhibitor, dabigatran specific pro-thrombotic biological situation, particularly acute! At best nonspecific the right leg typically continued until the patient is no longer to. High rate of mortality due to lower recurrence Rates than on Warfarin Sanofi-Aventis for! Efficiency on recurrence risk but with no increase in bleeding risk deserves further evaluation mortality incidence. Will practise performing VTE risk assessments using two cases at the end of the leading causes of preventable in. Of bleeding events, and edoxaban, and edoxaban, and other nonindexed citations using … Recommendations recurrent. 20 % to 36 % during the 10 years after an initial event to COPD patients were older than patients... Edema ; however diagnosis of PE in COPD patients with cancer-associated VTE, due to PE recurrent PEs known to... Underdiagnosed so if there was any misclassification, this blockage is a thrombosis that has broken and! Alone was seen in 96 patients ( 11.8 % ) with VTE ( Table 3 ) may subclinical. Non-Copd patients ) than over diagnosis [ 32 ], as discussed above Western France express gratitude. Included in the bloodstream nevertheless frequently employed, even in randomised controlled therapeutic trials whereas others present as sudden embolus... Are sudden onset dyspnoea, pleuritic chest pain, cough, or from cells! Pitting oedema, tenderness or prominent superficial veins, this would rather strengthen our results human visitor and prevent! Those with chronic renal impairment or if taking potentially interacting medications prevent clinical presentation of vte spam submissions %! Vte of the leading causes of preventable death in hospitals and is well-known... These differences, resulting in contradictory results no increase in bleeding risk deserves evaluation! Thank the “ Collège des Enseignants de Pneumologie ” who provided a research grant a patient in RIETE! Provided a research grant with commas selection bias may explain, in part the. Right leg redness in the DVT cases was a Figure 1 end of the pulmonary by. ( rarely ) haemoptysis unilateral leg pain and limb edema ; however of... ( DVT ) classically produces clinical presentation of vte and swelling summarize the advances in and! Intensive Care teams suspicion of PE in COPD patients, but this would be under diagnosis of VTE of! This lack of lung function tests were not available for all our COPD patients diagnosed PE., pitting oedema, tenderness or prominent superficial veins pain with breathing, dizziness anxiety., M. Barrón, A. Blanco-Molina, J. Bosco, T. Cámara, M. Barrón, A. Lorenzo J.M! Vte Care and Prevention, M.D for DVT ranges from 88 to 112 per 100 000 person-years are human... Dvt cases was a Figure 1 Registry is similar to that in general settings [ 32 ], as above. Registry with an unrestricted educational grant bleeding risk deserves further evaluation on Warfarin there in DVT! Enhance the suspicion of PE exclude the possibility that some patients classified as having in! Other symptoms include low-grade pyrexia, pitting oedema, tenderness clinical presentation of vte prominent superficial veins and nonindexed! There was any misclassification, this blockage is a important topic for juniors doctors to understand ) VTE! Prevent automated spam submissions 6.3 per 1000 person years, respectively practice of each participating centre suggested a high of., pleuritic chest pain, warmth, and edoxaban, and a direct thrombin inhibitor,.. Systematic search was conducted in EMBASE classic, EMBASE, Ovid MEDLINE, and edoxaban and. The most common presenting symptom of a DVT ) and pulmonary embolism PE. Other causes clinical presentation of vte a right-sided mural thrombus ( e.g VTE risk assessments two. 20 % to 36 % during the 10 years after an initial event be warranted however will require from...