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Nemtut DM, Petreanu CA, Ulmeanu R, Rajnoveanu AG, Rajnoveanu RM. Life expectancy in cancer patients with pulmonary thromboembolism: From clinical prognostic biomarkers and paraclinical investigations to therapeutic approaches (Review). Exp Ther Med 2024; 28:354. [PMID: 39071911 PMCID: PMC11273361 DOI: 10.3892/etm.2024.12643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 06/19/2024] [Indexed: 07/30/2024] Open
Abstract
Pulmonary embolisms (PEs) are obstructions of the pulmonary arteries by thrombi, which are emboli and they most frequently originate from the deep venous system of the inferior limbs. Emboli can also come from the inferior vena cava, abdominal and pelvic veins, or the upper body venous system from the right atrium or ventricle of the heart. Thrombi can form in situ inside pulmonary arteries as well. A cancer patient is at a higher risk for thromboembolic phenomena given both the oncological pathological context and also due to the associated medical or surgical treatment they receive. PE is a high-risk medical emergency that is associated with an increased risk of early mortality, with sudden death occurring in 25% of patients. The long-term presence of this condition can result in thromboembolic pulmonary hypertension. The risk of mortality, both in the acute and long-term, is dependent on the severity of the acute form, the recurrence of the embolism and the associated conditions. The majority of deaths associated with PE can be prevented by early diagnosis. The aim of the present review was to describe the various biological and cellular parameters, together with known paraclinical investigations, to assist in the rapid diagnosis of PE. Mortality in patients with PE and neoplastic conditions may be reduced by initiating anticoagulant treatment as soon as possible. PE may be the first manifestation of an underlying silent malignancy or may represent a complication of an already diagnosed malignancy. Exclusion or confirmation of the diagnosis is of utmost importance to avoid unnecessary anticoagulant treatment associated with a high risk of bleeding or to start immediate anticoagulant treatment if required.
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Affiliation(s)
| | - Cornel Adrian Petreanu
- Thoracic Surgery Department, Pneumology Institute Marius Nasta, Bucharest 050159, Romania
| | - Ruxandra Ulmeanu
- Bronchoscopy Department, North Hospital, Provita Medical Group, Bucharest 020335, Romania
- Doctoral School of Biomedical Sciences, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410073, Romania
| | - Armand Gabriel Rajnoveanu
- Occupational Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca 400012, Romania
| | - Ruxandra Mioara Rajnoveanu
- Palliative Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca 400012, Romania
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Zhang Y, Chen Y, Chen H, Dong C, Hu X, Xu X, Zhu L, Cheng Z, Wang D, Zhang Z, Xie W, Wan J, Yang P, Wang S, Wang C, Zhai Z. Performance of the Simplified Pulmonary Embolism Severity Index in predicting 30-day mortality after acute pulmonary embolism: Validation from a large-scale cohort. Eur J Intern Med 2024; 124:46-53. [PMID: 38350784 DOI: 10.1016/j.ejim.2024.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/18/2024] [Accepted: 01/30/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND The performance of existing prognostic scores including the simplified Pulmonary Embolism Severity Index (sPESI) for short-term mortality of non-high-risk PE in Chinese population has not been widely validated. METHODS Non-high-risk patients were included from the prospective cohort of the China pUlmonary Thromboembolism REgistry Study (CURES). The sPESI, RIETE, Geneva, modified FAST, and Bova score were validated. The discriminatory performance was measured by the area under the curve (AUC). We also compared the sensitivity, odds ratio, specificity, positive predictive value and negative predictive value of these scores. RESULTS A total of 6,873 non-high-risk patients with acute PE were included and 241 (3.5 %) patients died within 30 days. Compared to the Geneva, modified FAST, and Bova score, the AUCs for predicting 30-day death of sPESI and RIETE score were higher at 0.712 (95 % CI, 0.680, 0.743) and 0.723 (95 % CI, 0.691, 0.755) respectively. The sPESI demonstrated the highest sensitivity at 0.809, while the RIETE score, Geneva, Modified FAST and BOVA score showed sensitivities of 0.622, 0.568, 0.477 and 0.502 respectively. A sPESI ⩾1 point was associated with a 4.7-fold increased risk of 30-day all-cause mortality (95 % CI, 3.427, 6.563, p < 0.001), while a RIETE score of ⩾1 point was associated with a 4.5-fold increased risk (95 % CI, 3.127, 6.341, p < 0.001). The Geneva score, modified FAST and Bova score showed inferior performance. CONCLUSIONS The implementation of the fewer-parameter, easier-to-calculate sPESI in Chinese patients with PE can help to discriminate patients with extremely low risk of short-term mortality for home treatment or early discharge.
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Affiliation(s)
- Yu Zhang
- China-Japan Friendship Hospital, Capital Medical University, Beijing, China; National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Yinong Chen
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China; Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chunling Dong
- Department of Pulmonary and Critical Care Medicine, The Second Hospital of Jilin University, Changchun, China
| | - Xiaoyun Hu
- Department of Pulmonary and Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Xiaomao Xu
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, Beijing, China
| | - Ling Zhu
- Department of Pulmonary and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Zhe Cheng
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dingyi Wang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China; Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Zhu Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Wanmu Xie
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Jun Wan
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Peiran Yang
- State Key Laboratory of Respiratory Health and Multimorbidity, Department of Physiology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Shengfeng Wang
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Chen Wang
- China-Japan Friendship Hospital, Capital Medical University, Beijing, China; National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China; Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.
| | - Zhenguo Zhai
- China-Japan Friendship Hospital, Capital Medical University, Beijing, China; National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China; Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.
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Liu J, Liu Y, Zhang F, Fu C, Ling Y, Fang P, Xie X, Wang X, Yang H, Wei Y, Wang J. Short-term prognostic value of clinical data in hospitalized patients with intermediate-risk acute pulmonary embolism. BMC Cardiovasc Disord 2022; 22:335. [PMID: 35902799 PMCID: PMC9331586 DOI: 10.1186/s12872-022-02783-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intermediate-risk acute pulmonary embolism (APE) patients are usually defined as hemodynamically stable, comprehending a great therapeutic dilemma. Although anticoagulation therapy is sufficient for most intermediate-risk APE patients, some patients can deteriorate and eventually require a systemic fibrinolytic agent or thrombectomy. Hence, this study aimed to evaluate the predictive value of differences in clinical data for the short-term prognosis of intermediate-risk APE patients. METHODS A retrospective cohort of 74 intermediate-risk APE patients confirmed by computed tomography pulmonary angiography was analyzed in the present study. Adverse clinical event outcomes included PE-related in-hospital deaths, critical systolic blood pressure consistently under 90 mmHg, refractory to volume loading and vasopressor infusion requirements, mechanical ventilation, and cardiopulmonary resuscitation. The APE patients were stratified into two groups: adverse outcome (n = 25) and control (n = 49) groups. Then, the clinical data of the two groups were compared. Receiver operating characteristic (ROC) curves were used to explore the predictive value of white blood cell (WBC) counts and the right to left ventricular short-axis (RV/LV) ratio. Model calibration was assessed using the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS The brain natriuretic peptide, WBC count, and the RV/LV ratio were higher in patients with adverse outcomes compared to controls. The APE patients with adverse outcomes presented significantly higher rates of syncope, Negative T waves (NTW) in V1-V3, intermediate-high risk, thrombolytic therapy, and low arterial oxygen saturation (SaO2) compared to controls. In the multivariate logistic regression analysis, the SaO2 < 90%, [odds ratio (OR) 5.343, 95% confidence interval (CI) 1.241-23.008; p = 0.024], RV/LV ratio (OR 7.429, 95% CI 1.145-48.209; p = 0.036), Syncope (OR 12.309, 95% CI 1.702-89.032; p = 0.013), NTW in V1-V3 (OR 5.617, 95% CI 1.228-25.683; p = 0.026), and WBC count (OR 1.212, 95% CI 1.035-1.419; p = 0.017) were independent predictors of in-hospital adverse outcomes among APE patients. The ROC curve analysis indicated that the RV/LV ratio can be used to predict adverse outcomes (AUC = 0.748, p < 0.01) and calibration (Hosmer-Lemeshow goodness of fit test, p = 0.070). Moreover, an RV/LV ratio > 1.165 was predictive of adverse outcomes with sensitivity and specificity of 88.00 and 59.20%, respectively. The WBC counts were also able to predict adverse outcomes (AUC = 0.752, p < 0.01) and calibration (Hosmer-Lemeshow goodness of fit test, p = 0.251). A WBC count > 9.05 was predictive of adverse outcomes with sensitivity and specificity of 68.00 and 73.50%, respectively. CONCLUSION Overall, a SaO2 < 90%, RV/LV ratio, Syncope, NTW in V1-V3, and WBC counts could independently predict adverse outcomes in hospitalized intermediate-risk APE patients.
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Affiliation(s)
- Jichun Liu
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, Anhui, People's Republic of China
| | - Yuanyuan Liu
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, Anhui, People's Republic of China
| | - Feilong Zhang
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, Anhui, People's Republic of China
| | - Cong Fu
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, Anhui, People's Republic of China
| | - Yang Ling
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, Anhui, People's Republic of China
| | - Ping Fang
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, Anhui, People's Republic of China
| | - Xiangrong Xie
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, Anhui, People's Republic of China
| | - Xianghai Wang
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, Anhui, People's Republic of China
| | - Hao Yang
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, Anhui, People's Republic of China
| | - Youquan Wei
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, Anhui, People's Republic of China.
| | - Jinfeng Wang
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital of Wannan Medical College), Wuhu, 241001, Anhui, People's Republic of China.
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Differences in clinical and echocardiographic variables and mortality predictors among older patients with pulmonary embolism. Aging Clin Exp Res 2021; 33:2223-2230. [PMID: 33999379 DOI: 10.1007/s40520-021-01882-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/03/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND An increase in short-term mortality can be found among older patients with hemodynamically stable acute pulmonary embolism (APE) who have signs of right ventricular (RV) dysfunction. AIMS This study was designed to assess whether any difference exists among clinical, laboratory, electrocardiography and echocardiography parameters between older and younger patients diagnosed with APE. METHODS The study sample included a total of 635 patients with confirmed APE who were divided into two groups of older (65 years and older) and younger (younger than 65 years) individuals. Comparisons were performed between these groups in terms of clinical, predisposing factors and laboratory, electrocardiographic and echocardiographic parameters. RESULTS Analyses of 295 (46.4%) older and 340 (53.6%) younger patients diagnosed with APE were performed. Female sex, Pulmonary Embolism Severity Index score and baseline creatinine levels were higher in the older group. Also, the frequency of atrial fibrillation, RV outflow tract parasternal long-axis proximal diameter, RV end-diastolic diameter (RV-EDD) basal (apical four-chamber) and RV systolic pressure were significantly greater in older patients with APE. A total of 30 (4.7%) deaths were observed during the in-hospital period [21 (7.1%) older vs 9 (2.6%) younger patients; p < 0.01]. In the multivariate logistic regression analysis, age, white blood cell count (WBC), left ventricular ejection fraction (LVEF), RV-EDD basal and tricuspid annular plane systolic excursion (TAPSE) of less than 16 mm were found to be independently associated with in-hospital mortality. CONCLUSION Older patients might experience greater rates of RV dilatation, RV dysfunction and atrial fibrillation during APE. In addition to age; elevated WBC, low LVEF, increased RV-EDD basal and TAPSE of less than 16 mm were independent predictors of mortality among study population.
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Bledsoe JR, Woller SC, Stevens SM, Aston V, Patten R, Allen T, Horne BD, Dong L, Lloyd J, Snow G, Madsen T, Elliott CG. Management of Low-Risk Pulmonary Embolism Patients Without Hospitalization. Chest 2018; 154:249-256. [DOI: 10.1016/j.chest.2018.01.035] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/17/2018] [Accepted: 01/19/2018] [Indexed: 12/18/2022] Open
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Howard LSGE, Barden S, Condliffe R, Connolly V, Davies CWH, Donaldson J, Everett B, Free C, Horner D, Hunter L, Kaler J, Nelson-Piercy C, O-Dowd E, Patel R, Preston W, Sheares K, Campbell T. British Thoracic Society Guideline for the initial outpatient management of pulmonary embolism (PE). Thorax 2018; 73:ii1-ii29. [PMID: 29898978 DOI: 10.1136/thoraxjnl-2018-211539] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Luke S G E Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | | | | | | | | | | | - Catherine Free
- Department of Respiratory Medicine, George Eliot Hospital, Nuneaton, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK.,The Royal College of Emergency Medicine, London, UK
| | | | - Jasvinder Kaler
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Emma O-Dowd
- Department of Respiratory Medicine, Nottingham City Hospital, Nottingham, UK
| | - Raj Patel
- King's College Hospital NHS Foundation Trust, London, UK
| | | | - Karen Sheares
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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Bova C, Vanni S, Prandoni P, Morello F, Dentali F, Bernardi E, Mumoli N, Bucherini E, Barbar S, Picariello C, Enea I, Pesavento R, Bottino F, Jiménez D. A prospective validation of the Bova score in normotensive patients with acute pulmonary embolism. Thromb Res 2018; 165:107-111. [PMID: 29631073 DOI: 10.1016/j.thromres.2018.04.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 03/17/2018] [Accepted: 04/02/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND The Bova score has shown usefulness in the identification of intermediate-high risk patients with acute pulmonary embolism (PE), but lacks prospective validation. The aim of this study was to prospectively validate the Bova score in different settings from the original derivation cohort. METHODS Consecutive, normotensive patients with acute PE recruited at 13 academic or general hospitals were stratified, using their baseline data, into the three Bova risk stages (I-III). The primary outcome was the 30-day composite of PE-related mortality, hemodynamic collapse and non-fatal PE recurrences in the three risk categories. RESULTS In the study period, 639 patients were enrolled. The primary end point occurred in 45 patients (7.0%; 95% Confidence Intervals, 5.2%-9.3%). Risk stage correlated with the PE-related complication rate (stage I, 2.9%; stage II, 17%; stage III, 27%). Patients classified as stage III by the Bova score had a 6.5-fold increased risk for adverse outcomes (3.1-13.5, p < 0.001) compared with stages I and II combined. Rescue thrombolysis increased from stage I to stage III (0.6%, 12% and 15% respectively). All-cause mortality (5.3%) did not substantially differ among the stages. CONCLUSIONS The Bova score accurately stratifies normotensive patients with acute PE into stages of increasing risk of 30-day PE-related complications.
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Affiliation(s)
- Carlo Bova
- Department of Internal Medicine, Azienda Ospedaliera (Coordinating Center), Cosenza, Italy.
| | - Simone Vanni
- Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Paolo Prandoni
- Department of Cardiovascular Sciences, Vascular Medicine Unit, University of Padua, Italy
| | - Fulvio Morello
- Emergency Department, A.O.U. Città della Salute e della Scienza di Torino, Ospedale Molinette, Torino, Italy
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Enrico Bernardi
- Department of Emergency Medicine, ULSS n.7, Conegliano, TV, Italy
| | - Nicola Mumoli
- Department of Internal Medicine, Ospedale Civile Livorno, Italy
| | | | - Sofia Barbar
- Department of Internal and Emergency Medicine, Civic Hospital of Camposampiero (PD), Italy
| | - Claudio Picariello
- Unit of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Iolanda Enea
- Emergency Care Department, Anna e S. Sebastiano Hospital, Caserta, Italy
| | | | | | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Alcalá de Henares University, Madrid, Spain
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Kesselman A, Kuo WT. Catheter-Directed Therapy for Acute Submassive Pulmonary Embolism: Summary of Current Evidence and Protocols. Tech Vasc Interv Radiol 2017; 20:193-196. [PMID: 29029714 DOI: 10.1053/j.tvir.2017.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Treatment of acute submassive pulmonary embolism (PE) with thrombolytic therapy remains an area of controversy. For patients who fail or who have contraindications to systemic thrombolysis, catheter-directed therapy (CDT) may be offered depending on the patient's condition and the available institutional resources to perform CDT. Although various CDT techniques and protocols exist, the most studied method is low-dose catheter-directed thrombolytic infusion without mechanical thrombectomy. This article reviews current protocols and data on the use of CDT for acute submassive pulmonary embolism.
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Affiliation(s)
- Andrew Kesselman
- Division of Vascular and Interventional Radiology, Stanford University Medical Center, Stanford, CA
| | - William T Kuo
- Division of Vascular and Interventional Radiology, Stanford University Medical Center, Stanford, CA.
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Donadini MP, Dentali F, Castellaneta M, Gnerre P, La Regina M, Masotti L, Pieralli F, Pomero F, Re R, Guasti L, Ageno W, Squizzato A. Pulmonary embolism prognostic factors and length of hospital stay: A cohort study. Thromb Res 2017. [PMID: 28646727 DOI: 10.1016/j.thromres.2017.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Patients with pulmonary embolism (PE) are commonly admitted to hospital for their initial treatment. We aimed to assess the association of length of hospital stay with commonly available clinical variables and their combinations. METHODS A retrospective multicenter cohort study was conducted on consecutive PE patients admitted to eight Italian centers. Logistic regression analysis was performed to evaluate the association between the length of hospital stay and the Pulmonary Embolism Severity Index (PESI) parameters, National Early Warning Score (NEWS) and other possible determinants. RESULTS We enrolled 391 patients, with a median hospital stay of 10days (IQR 7-14). Among PESI parameters, only oxygen saturation <90% was significantly associated with length of hospital stay at univariable analysis (OR 1.99; 95% CI 1.3-3.2). At multivariable analysis, NEWS ≥5 was associated with prolonged hospitalization (OR 3.14; 95% CI 1.2-8.3). A difference of median hospital stay was found between simplified PESI high and low risk groups (10 and 9days, respectively, p=0.027). DISCUSSION The median duration of hospital stay was generally long and not influenced by single parameters of PESI or common prognostic factors. The difference of one day between the low- and high-risk groups according to simplified PESI was not clinically significant.
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Affiliation(s)
- Marco Paolo Donadini
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy.
| | - Francesco Dentali
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | | | - Paola Gnerre
- Medicina Interna, Ospedale di Savona, Savona, Italy
| | | | - Luca Masotti
- Medicina Interna, Ospedale Santa Maria Nuova, Firenze, Italy
| | - Filippo Pieralli
- Medicina Interna e di Urgenza, Azienda Ospedaliera Universitaria 'Careggi', Firenze, Italy
| | - Fulvio Pomero
- Medicina Interna, Ospedale 'Santa Croce e Carle', Cuneo, Italy
| | - Roberta Re
- Medicina Interna, Ospedale Maggiore della Carità, Novara, Italy
| | - Luigina Guasti
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Walter Ageno
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
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Stein PD, Matta F, Hughes MJ. National Trends in Home Treatment of Acute Pulmonary Embolism. Clin Appl Thromb Hemost 2016; 24:115-121. [PMID: 27789604 DOI: 10.1177/1076029616674827] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Management of patients with acute pulmonary embolism has evolved from obligatory hospitalization to home treatment of carefully selected low-risk patients. The purpose of this investigation is to determine national trends in the prevalence of home treatment of pulmonary embolism. METHODS The Nationwide Emergency Department Sample was used to determine the number of patients seen in emergency departments throughout the United States with a primary (first-listed) diagnosis of pulmonary embolism and the proportion hospitalized according to age, from 2007 to 2012. The National (Nationwide) Inpatient Sample was used to determine in-hospital all-cause mortality and length of stay of hospitalized patients. Patients were adults (≥18 years) of both genders and all races from all regions of the United States. Excluded patients were those in shock or on ventilator support. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients and comorbid conditions. RESULTS Home treatment was selected for 54 494 (6.0%) of 915 702 stable patients with acute pulmonary embolism. The proportion of patients treated at home was age-dependent, highest in those aged 30 years or younger, 12.1%, and lowest in those >80 years, 2.9%. Most patients treated at home, 66.8%, and had no comorbid conditions. In-hospital all-cause deaths were 2.6%. Deaths were ≤0.9% in those ≤40 years and 4.8% in those >80 years. Length of stay was 6 days or longer in 37.6% of patients. CONCLUSION In view of the lower death rate among younger patients, they might be a group in whom home treatment would be more advantageous than in elderly patients.
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Affiliation(s)
- Paul D Stein
- 1 Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Fadi Matta
- 1 Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
| | - Mary J Hughes
- 1 Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, MI, USA
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Stein PD, Matta F, Hughes PG, Hourmouzis ZN, Hourmouzis NP, White RM, Ghiardi MM, Schwartz MA, Moore HL, Bach JA, Schweiss RE, Kazan VM, Kakish EJ, Keyes DC, Hughes MJ. Home Treatment of Pulmonary Embolism in the Era of Novel Oral Anticoagulants. Am J Med 2016; 129:974-7. [PMID: 27107921 DOI: 10.1016/j.amjmed.2016.03.035] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 03/28/2016] [Accepted: 03/28/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Outpatient therapy of patients with acute pulmonary embolism has been shown to be safe in carefully selected patients. Problems related to the injection of low-molecular-weight heparin at home can be overcome by use of novel oral anticoagulants. The purpose of this investigation is to assess the prevalence of home treatment in the era of novel oral anticoagulants. METHODS This was a retrospective cohort study of patients aged ≥18 years with acute pulmonary embolism seen in 5 emergency departments from January 2013 to December 2014. RESULTS Pulmonary embolism was diagnosed in 983 patients. Among these, 237 were considered ineligible for home treatment because of instability or hypoxia. Home treatment was selected for 13 of 746 (1.7%) patients who were potentially eligible. Anticoagulant treatment for those treated at home was low-molecular-weight heparin or warfarin in 9 (69.2%) and novel oral anticoagulants in 4 (30.8%). Hospitalization was chosen for 733 of 746 (98.3%). Discharge in ≤2 days was in 119 patients (16.2%). Treatment of these patients was low-molecular-weight heparin or warfarin in 76 (63.9%), novel oral anticoagulants in 34 (28.6%), and in 9 (7.6%), anticoagulants were not given because of metastatic cancer or treatment was not known. CONCLUSION Even in the era of novel oral anticoagulants, the vast majority of patients with acute pulmonary embolism were hospitalized, and only a small proportion were discharged in ≤2 days. Although home treatment has been found to be safe in carefully selected patients, and scoring systems have been derived to identify those at low risk of adverse events, home treatment was infrequently selected.
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Affiliation(s)
- Paul D Stein
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing.
| | - Fadi Matta
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing
| | - Patrick G Hughes
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing; Department of Medical Education, Summa Akron City Hospital, Ohio; Department of Emergency Medicine, McLaren Oakland Hospital, Pontiac, Mich
| | - Zak N Hourmouzis
- Department of Medical Education, Summa Akron City Hospital, Ohio
| | | | - Rachel M White
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing; Department of Emergency Medicine, Sparrow Health System, Lansing, Mich
| | - Martina M Ghiardi
- Department of Emergency Medicine, McLaren Oakland Hospital, Pontiac, Mich
| | - Matthew A Schwartz
- Department of Emergency Medicine, University of Toledo Medical Center, Ohio
| | - Hillary L Moore
- Department of Emergency Medicine, University of Toledo Medical Center, Ohio
| | - Jennifer A Bach
- Department of Emergency Medicine, St. Mary Mercy Hospital, Livonia, Mich
| | - Robert E Schweiss
- Department of Emergency Medicine, St. Mary Mercy Hospital, Livonia, Mich
| | - Viviane M Kazan
- Department of Emergency Medicine, University of Toledo Medical Center, Ohio
| | - Edward J Kakish
- Department of Emergency Medicine, University of Toledo Medical Center, Ohio
| | - Daniel C Keyes
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing; Department of Emergency Medicine, St. Mary Mercy Hospital, Livonia, Mich
| | - Mary J Hughes
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing; Department of Emergency Medicine, Sparrow Health System, Lansing, Mich
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Elias A, Mallett S, Daoud-Elias M, Poggi JN, Clarke M. Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis. BMJ Open 2016; 6:e010324. [PMID: 27130162 PMCID: PMC4854007 DOI: 10.1136/bmjopen-2015-010324] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To review the evidence for existing prognostic models in acute pulmonary embolism (PE) and determine how valid and useful they are for predicting patient outcomes. DESIGN Systematic review and meta-analysis. DATA SOURCES OVID MEDLINE and EMBASE, and The Cochrane Library from inception to July 2014, and sources of grey literature. ELIGIBILITY CRITERIA Studies aiming at constructing, validating, updating or studying the impact of prognostic models to predict all-cause death, PE-related death or venous thromboembolic events up to a 3-month follow-up in patients with an acute symptomatic PE. DATA EXTRACTION Study characteristics and study quality using prognostic criteria. Studies were selected and data extracted by 2 reviewers. DATA ANALYSIS Summary estimates (95% CI) for proportion of risk groups and event rates within risk groups, and accuracy. RESULTS We included 71 studies (44,298 patients). Among them, 17 were model construction studies specific to PE prognosis. The most validated models were the PE Severity Index (PESI) and its simplified version (sPESI). The overall 30-day mortality rate was 2.3% (1.7% to 2.9%) in the low-risk group and 11.4% (9.9% to 13.1%) in the high-risk group for PESI (9 studies), and 1.5% (0.9% to 2.5%) in the low-risk group and 10.7% (8.8% to12.9%) in the high-risk group for sPESI (11 studies). PESI has proved clinically useful in an impact study. Shifting the cut-off or using novel and updated models specifically developed for normotensive PE improves the ability for identifying patients at lower risk for early death or adverse outcome (0.5-1%) and those at higher risk (up to 20-29% of event rate). CONCLUSIONS We provide evidence-based information about the validity and utility of the existing prognostic models in acute PE that may be helpful for identifying patients at low risk. Novel models seem attractive for the high-risk normotensive PE but need to be externally validated then be assessed in impact studies.
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Affiliation(s)
- Antoine Elias
- Department of Vascular Medicine, Sainte Musse Hospital, Toulon La Seyne Hospital Centre, Toulon, France
- DPhil Programme in Evidence-Based Healthcare, University of Oxford, Oxford, UK
| | - Susan Mallett
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marie Daoud-Elias
- Department of Vascular Medicine, Sainte Musse Hospital, Toulon La Seyne Hospital Centre, Toulon, France
| | - Jean-Noël Poggi
- Department of Vascular Medicine, Sainte Musse Hospital, Toulon La Seyne Hospital Centre, Toulon, France
| | - Mike Clarke
- Northern Ireland Network for Trials Methodology Research, Queen's University Belfast, Belfast, UK
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13
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Kohn CG, Mearns ES, Parker MW, Hernandez AV, Coleman CI. Prognostic Accuracy of Clinical Prediction Rules for Early Post-Pulmonary Embolism All-Cause Mortality. Chest 2015; 147:1043-1062. [DOI: 10.1378/chest.14-1888] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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14
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Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JSR, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk Noordegraaf A, Zamorano JL, Zompatori M. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35:3033-69, 3069a-3069k. [PMID: 25173341 DOI: 10.1093/eurheartj/ehu283] [Citation(s) in RCA: 1850] [Impact Index Per Article: 185.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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16
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Barra SNC, Paiva L, Providência R, Fernandes A, Marques AL. A review on state-of-the-art data regarding safe early discharge following admission for pulmonary embolism: what do we know? Clin Cardiol 2013; 36:507-15. [PMID: 23720225 PMCID: PMC6649636 DOI: 10.1002/clc.22144] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 04/20/2013] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although most patients with acute pulmonary embolism (PE) remain hospitalized during initial therapy, some may be suitable for partial or complete outpatient management, which may have a significant impact on healthcare costs. HYPOTHESIS This article reviews the state-of-the-art data regarding recognition of very-low-risk PE patients who are potentially eligible for outpatient treatment, along with the safety, management, and cost-effectiveness of this strategy. We propose an algorithm based on collected data that may be useful/practical for identifying patients truly eligible for early discharge. METHODS Comprehensive review of scientific data collected from the MEDLINE and Cochrane databases. Studies selected based on potential scientific interest. Qualitative information extracted regarding feasibility, safety, and cost-effectiveness of outpatient treatment, postdischarge management, and selection of truly low-risk patients. RESULTS Early discharge of low-risk patients seems feasible, safe, and particularly cost-effective. Several risk scores have been developed and/or tested as prediction tools for the recognition of low-risk individuals: the Pulmonary Embolism Severity Index (PESI), simplified PESI, Hestia criteria, Geneva score, the Low-Risk Pulmonary Embolism Decision rule, and the Global Registry of Acute Cardiac Events, among others. PESI is the most well-validated model, offering the safest approach at the current time, especially when combined with additional parameters such as troponin I, N-terminal prohormone of brain natriuretic peptide, and echocardiographic markers of right-ventricular dysfunction. CONCLUSIONS Recognition of truly low-risk patients entitled to early hospital discharge and outpatient treatment is possible with current risk-stratification schemes along with selected prognostic parameters, and it may have a colossal impact on healthcare costs.
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Venetz C, Labarère J, Jiménez D, Aujesky D. White blood cell count and mortality in patients with acute pulmonary embolism. Am J Hematol 2013; 88:677-81. [PMID: 23674436 DOI: 10.1002/ajh.23484] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Revised: 05/03/2013] [Accepted: 05/07/2013] [Indexed: 01/21/2023]
Abstract
Although associated with adverse outcomes in other cardiovascular diseases, the prognostic value of an elevated white blood cell (WBC) count, a marker of inflammation and hypercoagulability, is uncertain in patients with pulmonary embolism (PE). We therefore sought to assess the prognostic impact of the WBC in a large, state-wide retrospective cohort of patients with PE. We evaluated 14,228 patient discharges with a primary diagnosis of PE from 186 hospitals in Pennsylvania. We used random-intercept logistic regression to assess the independent association between WBC count levels at the time of presentation and mortality and hospital readmission within 30 days, adjusting for patient and hospital characteristics. Patients with an admission WBC count <5.0, 5.0-7.8, 7.9-9.8, 9.9-12.6, and >12.6 × 10(9) /L had a cumulative 30-day mortality of 10.9%, 6.2%, 5.4%, 8.3%, and 16.3% (P < 0.001), and a readmission rate of 17.6%, 11.9%, 10.9%, 11.5%, and 15.0%, respectively (P < 0.001). Compared with patients with a WBC count 7.9-9.8 × 10(9) /L, adjusted odds of 30-day mortality were significantly greater for patients with a WBC count <5.0 × 10(9) /L (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14-2.03), 9.9-12.6 × 10(9) /L (OR 1.55, 95% CI 1.26-1.91), or >12.6 × 10(9) /L (OR 2.22, 95% CI 1.83-2.69), respectively. The adjusted odds of readmission were also significantly increased for patients with a WBC count <5.0 × 10(9) /L (OR 1.34, 95% CI 1.07-1.68) or >12.6 × 10(9) /L (OR 1.29, 95% CI 1.10-1.51). In patients presenting with PE, WBC count is an independent predictor of short-term mortality and hospital readmission.
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Affiliation(s)
- Carmen Venetz
- Division of General Internal Medicine; Bern University Hospital; Bern; Switzerland
| | - José Labarère
- Techniques de l'Ingéniérie Médicale et de la Compléxité; UMR 5525 Centre National de la Recherche Scientifique; Université Joseph Fourier-Grenoble 1; Grenoble; France
| | - David Jiménez
- Respiratory Department; Ramón y Cajal Hospital, IRYCIS; Madrid; Spain
| | - Drahomir Aujesky
- Division of General Internal Medicine; Bern University Hospital; Bern; Switzerland
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A simple score for rapid risk assessment of non-high-risk pulmonary embolism. Clin Res Cardiol 2012; 102:73-80. [PMID: 23011575 PMCID: PMC3536952 DOI: 10.1007/s00392-012-0498-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 07/24/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE We tested whether bedside testing for H-FABP is, alone or integrated in combination models, useful for rapid risk stratification of non-high-risk PE. METHODS We prospectively studied 136 normotensive patients with confirmed PE. H-FABP was determined using a qualitative bedside-test showing a positive result for plasma concentration >7 ng/ml. RESULTS Overall, 11 patients (8.1 %) had an adverse 30-day outcome. Of 58 patients (42.6 %) with a positive H-FABP bedside-test, 9 (15.5 %) had an unfavourable course compared to 2 of 78 patients (2.6 %) with a negative test result (p = 0.009). Logistic regression analysis indicated a sevenfold increased risk for an adverse outcome (95 % CI, 1.45-33.67; p = 0.016) for patients with a positive H-FABP bedside-test. Additive prognostic information were obtained by a novel score including the H-FABP bedside-test (1.5 points), tachycardia (2 points), and syncope (1.5 points) (OR 11.57 [2.38-56.24]; p = 0.002 for ≥3 points). Increasing points were associated with a continuous exponential increase in the rate of an adverse 30-day outcome (0 % for patients with 0 points and 44.4 % for ≥5 points). Notably, this simple score provided similar prognostic value as the combination of the H-FABP bedside-test with echocardiographic signs of right ventricular dysfunction (OR 12.73 [2.51-64.43]; p = 0.002). CONCLUSIONS Bedside testing for H-FABP appears a useful tool for immediate risk stratification of non-high-risk patients with acute PE, who may be at increased risk of an adverse outcome, in particular if integrated in a novel score without the need of echocardiographic examination.
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Squizzato A, Donadini MP, Galli L, Dentali F, Aujesky D, Ageno W. Prognostic clinical prediction rules to identify a low-risk pulmonary embolism: a systematic review and meta-analysis. J Thromb Haemost 2012; 10:1276-90. [PMID: 22498033 DOI: 10.1111/j.1538-7836.2012.04739.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Prognostic assessment is important for the management of patients with a pulmonary embolism (PE). A number of clinical prediction rules (CPRs) have been proposed for stratifying PE mortality risk. The aim of this systematic review was to assess the performance of prognostic CPRs in identifying a low-risk PE. METHODS MEDLINE and EMBASE databases were systematically searched until August 2011. Derivation and validation studies that assessed the performance of prognostic CPRs in predicting adverse events-risk in PE patients were included. Weighted mean proportion and 95% confidence intervals (CIs) of adverse events were then calculated and pooled using a fixed and a random-effects model. Statistical heterogeneity was evaluated through the use of I(2) statistics. RESULTS Of 1125 references in the original search, 33 relevant articles were included. Nine CPRs were assessed in 37 cohorts, for a total of 35,518 patients. Pulmonary Embolism Severity Index and prognostic Geneva CPR were investigated in 22 and 6 cohorts, respectively. Eleven (29.7%) cohorts were of high quality. The median follow-up was 30 days. In low-risk PE patients, pooled short-term mortality (within 14 days or less) was 0.7% (95% CI 0.3-1.1%, random-effects model; I(2) = 49.6%), 30-day mortality was 1.7% (95% CI 1.1-2.3%, random-effects model; I(2) = 82.4%) and 90-day mortality was 2.2% (95% CI 1.2-3.4%, random-effects model; I(2) = 59.8%). CONCLUSIONS Prognostic CPRs efficiently identify PE patients at a low risk of mortality. Before implementing prognostic CPRs in the routine care of PE patients, well-designed management studies are warranted.
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Affiliation(s)
- A Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, Department of Clinical Medicine, University of Insubria, Varese, Italy.
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Geske JB, Smith SB, Morgenthaler TI, Mankad SV. Care of patients with acute pulmonary emboli: a clinical review with cardiovascular focus. Expert Rev Cardiovasc Ther 2012; 10:235-50. [PMID: 22292879 DOI: 10.1586/erc.11.179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Acute pulmonary embolism (PE) is a common, multidisciplinary disease with substantial associated morbidity, mortality and healthcare expense. In this article we present a succinct review of diagnostic tools, risk stratification and medical therapies for cardiovascular care of patients with acute PE. While pulmonary angiography remains the 'gold standard' for diagnosis, a host of diagnostic modalities, interpreted in the setting of clinical probability, are available for patient assessment, including ECG, chest radiography, D-dimer, lower-extremity venous ultrasound, ventilation-perfusion scans, computed tomography and magnetic resonance angiography, and echocardiography, each with associated value. Diagnostic algorithms incorporate multiple tools in order to obtain a more comprehensive evaluation. Therapeutic anticoagulation remains the mainstay of therapy in PE. In massive PE, utilization of thrombolysis is reasonable in the absence of contraindications. Submassive PE, characterized by right ventricular dysfunction as assessed by echocardiography and ECG, is associated with higher mortality. Use of thrombolysis in submassive PE remains controversial. Catheter-directed therapies are emerging as an added approach to acute PE and have the potential to improve outcomes in PE. Use of inferior vena cava filters should be pursued in a select patient population as they serve to reduce recurrent acute PE; however, they are associated with more frequent deep venous thrombosis and provide no mortality benefit. In risk-stratified hemodynamically stable patients, an outpatient management strategy inclusive of therapeutic anticoagulation and careful clinical follow-up may be appropriate.
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Affiliation(s)
- Jeffrey B Geske
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
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