Prognostic role of a new risk index for the prediction of 30-day cardiovascular mortality in patients with acute pulmonary embolism: the Age-Mean Arterial Pressure Index (AMAPI)

Optimal hemodynamic parameters for risk stratification in acute pulmonary embolism patients

Hemodynamic assessment of patients with pulmonary embolism (PE) remains a fundamental component of early risk stratification that in turn, influences subsequent monitoring and therapeutic strategies. The current body of literature and international evidence-based clinical practice guidelines focus mainly on the use of systolic blood pressure (SBP). The accuracy of this single hemodynamic parameter, however, and its optimal values for the identification of hemodynamic instability have been recently questioned by clinicians. For example, abnormal SBP or shock index may be a late indicator of adverse outcomes, signaling a patient in whom the cascade of hemodynamic compromise is already well underway. The aim of the present article is to review the current evidence supporting the use of SBP and analyze the potential integration of other parameters to assess the hemodynamic stability, impending clinical deterioration, and guide the reperfusion treatment in patients with PE, as well as to suggest potential strategies to further investigate this issue.

Prognostic impact of the e-TAPSE ratio in intermediate-high risk pulmonary embolism patients

We assess the prognostic role of a new index (Age-T index), based on age and the tricuspid annular plane systolic excursion (TAPSE) for the estimation of 30-day mortality and risk of 48-h clinical deterioration since admission, in intermediate-high risk Pulmonary Embolism (PE) patients. A post-hoc analysis of intermediate-high risk PE patients enrolled in the Italian Pulmonary Embolism Registry (IPER) (Trial registry: ClinicalTrials.gov; No.: NCT01604538) was performed. The Age-T index was calculated as the ratio between age and TAPSE. The primary outcome was the 30-day mortality risk while the risk of clinical deterioration within 48 h in the same patients was chosen as the secondary outcome. Among 450 intermediate-high risk PE patients (mean age 71.4 ± 13.8 years, 298 males), 40 (8.8%) experienced clinical deterioration within 48 h since admission and 32 (7.1%) died within 30-day. Receiver operating characteristic analysis established ≥ 4.9 as the optimal cut-off value for the Age-T index in predicting 30-day mortality (AUC of 0.76 ± 0.1). Sensitivity, specificity, PPV and NPV were 81.2, 85.6, 30.2 and 98.3%, respectively. Multivariate Cox regression analysis showed that an Age-T index ≥ 4.9 predicts 30-day mortality (HR: 3.24, 95% CI: 1.58-4.96, p < 0.001) and was also associated with a significantly higher risk of 48-h clinical deterioration (HR: 2.02, 95% CI 1.96-2.08, p < 0.0001) in intermediate-high risk PE patients. Age-T Index appears as a useful, bed-side and non-invasive prognostic tool to identify intermediate-high risk PE patients at higher risk of death and/or 48-h clinical deterioration.

Influences of Antithrombotic Elastic Socks Combined with Air Pressure in Reducing Lower Extremity Deep Venous Thrombosis for Patients Undergoing Cardiothoracic Surgery

This study was designed to investigate the application and therapeutic effect of antithrombotic elastic socks combined with air pressure in the prevention of lower extremity deep venous thrombosis in patients undergoing cardiothoracic surgery. Sixty patients in cardiothoracic surgery of our hospital from January 2019 to December 2020 were randomly divided into a study group and control group. The control group was treated with routine treatment intervention. Based on routine treatment intervention, the study group was treated with antithrombotic elastic socks combined with pneumatic treatment intervention. The activated partial thromboplastin time (APTT), thrombin time (TT), femoral venous blood flow velocity of both lower limbs, and the incidence of lower extremity deep venous thrombosis (LEDVT), postoperative lower extremity swelling, inflammatory factors, and satisfaction were measured. After intervention, APTT (31.74 ± 1.15 s) and TT (14.58 ± 0.24 s) in the study group were higher than those in the control group APTT (25.13 ± 1.14 s) and TT (12.14 ± 0.23 s) (P < 0.05). The left lower limb femoral vein blood flow velocity and the right lower limb femoral vein blood flow velocity in the study group were better than those in the control group (P < 0.05). The incidence of postoperative lower limb swelling and deep vein in the study group was lower than that in the control group (P < 0.05). Serum tumor necrosis factor alpha and interleukin-6 concentrations in the study group were lower than those in the control group (P < 0.05). The satisfaction rate of patients in the study group (93.33%) was significantly higher than that in the control group (70.00%) (P < 0.05). In conclusion, after cardiothoracic surgery, antithrombotic elastic socks combined with air pressure can significantly reduce the incidence of LEDVT by improving patients' coagulation function, reducing inflammatory reaction. It is worthy of popularization and application in relevant surgery.

Left atrial size measured on CT pulmonary angiography: another parameter of pulmonary embolism severity? A systematic review

We systematically review the potential role of left atrial (LA) size, evaluated at computed tomography angiography (CTA) in patients with acute pulmonary embolism (PE), as a new parameter of PE severity. A literature search based on PubMed (MEDLINE), Scopus, Cochrane library and Google Scholar databases was performed to locate previous published investigations reporting data on the severity of acute PE based on the evaluation of LA size (either volume, diameter or area). Six studies, corresponding to a total of 990 patients, published between 2012 and 2019 were included into the analysis. The severity of acute PE, in terms of hemodynamic impairment, increases with the reduction of the LA volume and a significant negative correlation was observed between the pulmonary artery obstruction index (PAOI) and the LA area. Similarly, the longest left-to-right as well as the anteroposterior diameters of the LA had a significant positive correlation with the PAOI index for both the measurement. The LA volume significantly decreased with the increasing of the PAOI index. Moreover, a lower LA volume was observed in those subjects with a saddle PE appearing as the best single parameter able to discriminate between patients having or not a saddle acute PE. Intriguingly, PE patients died within 30 days from the acute event had a significant small LA volume compared to survivors. Data obtained from the current medical literature seem to suggest that the evaluation of LA size evaluation could be a new parameter of PE severity. Further and larger prospective studies are needed to confirm preliminary findings.

Impella RP in hemodynamically unstable patients with acute pulmonary embolism

Over the last years, different case reports/studies have demonstrated that in patients with acute pulmonary embolism (PE) and refractory shock mechanical circulatory support (MCS) with Impella RP® (Abiomed, Inc, Danvers, Mass) increases the chances of survival, significantly unloading the right ventricle and improving both the cardiac output and the mean pulmonary artery pressure. We reviewed the medical literature about the use of Impella RP in patients with acute PE and refractory shock using PubMed (MEDLINE), Scopus, Cochrane library, and Google Scholar databases. The final research was conducted in July 2019. The results evidenced that available data are currently scant to definitively assess the real role Impella RP® in patient with acute PE and refractory shock. However, preliminary data seems to be very promising. Further larger studies are needed to confirm the safety and efficacy of MCS in these patients. A multidisciplinary assessment, using the PERT team, must be performed case by case to determine the need of MCS.

Cerebrovascular events after herpes zoster infection: a risk that should be not underestimated

The occurrence of a cerebrovascular event after a herpes zoster (HZ) infection represents a nightmare in clinical practice, especially in those patients with concomitant cardiovascular comorbidities/risk factors and disease related per se to a higher risk of zoster infection. Moreover, the absence of a consensus opinion regarding a specific and adequate prevention of cerebrovascular events in these patients further complicates the treatment. Accumulating evidences demonstrated that HZ and HZ ophtalmicus (HZO) increase the risk of cerebrovascular events in the short-and long-term periods. Moreover, patient's ages < 40 years old, despite having fewer traditional cardiovascular comorbidities, demonstrated a higher risk of cerebrovascular events after both HZ and HZO infection. Further prospective studies are needed to analyse the role of antiviral treatments and vaccination in these subjects to clarify if they could be able to reduce the risk of stroke after a zoster infection. In the meanwhile, physicians must be aware of a higher risk of cerebrovascular events, especially in younger patients, with few cardiovascular risk factors, after an HZ infection.

Age-Stratified National Trends in Pulmonary Embolism Admissions

BACKGROUND

Pulmonary embolism (PE) is one of the leading causes of death in hospitalized patients. Treatment patterns and patient demographics for PE are changing; therefore, we sought to evaluate national trends in admission rate, discharge disposition, and length of stay (LOS) in patients hospitalized with PE.

METHODS

The National Inpatient Sample database was used to collect data for hospitalizations of patients ≥ 20 years old with primary diagnosis of PE between January 2000 and September 2015. Patient demographics and hospital characteristics, stratified by patient age, were reported. Trends in rates of hospitalizations for PE, LOS, discharge disposition, and hospital charges were assessed across age groups.

RESULTS

There were an estimated 2,159,568 hospitalizations with primary diagnosis of PE. The rate of PE per 100,000 persons increased by > 100%, and was highest among elderly patients. Increased age and comorbidity burden were independently associated with poor outcomes. Inpatient mortality and LOS decreased across all age groups, but was highest in the elderly. Home health utilization increased in patients ≥ 55 years old. Average hospital charges increased across all age groups, despite shorter length of stay, with patients ≥ 85 experiencing $13,000 average increase.

CONCLUSIONS

Between 2000 and 2015, the rate of hospitalization for PE increased across all age groups. Despite improvements in average LOS and inpatient mortality, hospitalizations became more expensive, and patients required more resources (ie, home health) on discharge. This increased resource utilization was most apparent in elderly patients. This suggests that targeted clinical trials designed to improve outcomes in all age brackets are needed.

Systemic thrombolysis in haemodynamically unstable pulmonary embolism: The earlier the better?

INTRODUCTION

The temporal window for the administration of systemic thrombolysis (ST) in acute pulmonary embolism (PE) has not yet been clarified. We assessed the relationship between short-term cardiovascular (CV) mortality and time of ST administration.

MATERIAL AND METHODS

Among 394 consecutive patients admitted between January 2010 and June 2017 with a confirmed PE, we retrospectively review the clinical and instrumental data of those labelled as high-risk PE (n = 76, 41 males, mean aged 64.7 ± 9.1 years old).

RESULTS

A receiving operating curve (ROC) analysis established the optimal temporal threshold for the administration of the ST, in respect to the 30-day CV mortality at 8.5 h from the symptom onset (Area under Curve 0.79 ± 0.6, 95% CI 0.73-0.86, p < 0.0001). Mantel-Cox analysis showed that there was a significant difference in the distribution of survival between patients treated within 8.5 h from the beginning of symptoms onset to those treated after 8.6 h [log rank (Mantel-Cox) chi-square 9.68 p = 0.002]. Cox-regression analysis demonstrated that the administration of ST after 8.6 h from the symptom's onset was an independent predictor of 30-day CV mortality in high-risk PE patients (HR 7.81, 95% CI 1.84-33.05, p = 0.005), independently from the occurrence of major bleeding events (HR 5.89, 95% CI 1.38-25.13, p = 0.01), previous CAD (HR 3.31, 95& CI 1.07-10.231. p = 0.03), RV/LV ratio after 2 h from the administration ST > 1 (HR (12.91, 95% CI 3.04-54.77, p = 0.001) and PAH at discharge (HR 3.86, 95% CI 2.22-4.68, p = 0.002).

CONCLUSIONS

ST administered within 8.5 h from symptoms onset may be associated with a reduced 30-day CV mortality in high-risk PE patients.

Validation of the Predictive Model of the European Society of Cardiology for Early Mortality in Acute Pulmonary Embolism

Background  Acute pulmonary embolism (PE) is burdened by high mortality, especially within 30 days from the diagnosis. The development and the validation of predictive models for the risk of early mortality allow to differentiate patients who can undergo home treatment from those who need admission into intensive care units. Methods  To validate the prognostic model for early mortality after PE diagnosis proposed by the European Society of Cardiology (ESC) in 2014, we analyzed data of a cohort of 272 consecutive patients with acute PE, observed in our hospital during a 10-year period. Moreover, we evaluated the additional contribution of D-dimer, measured at PE diagnosis, in improving the prognostic ability of the model. All cases of PE were objectively diagnosed by angiography chest CT scan or perfusion lung scan. Results  The overall mortality rate within 30 days from PE diagnosis was 10% (95% confidence interval [CI]: 6.4-13.5%). According to the ESC prognostic model, the risk of death increased 3.23 times in the intermediate-low-risk category, 5.55 times in the intermediate-high-risk category, and 23.78 times in the high-risk category, as compared with the low-risk category. The receiver operating characteristic analysis showed a good discriminatory power of the model (area under the curve [AUC] = 0.77 [95% CI: 0.67-0.87]), which further increased when D-dimer was added (AUC = 0.85 [95% CI: 0.73-0.96]). Conclusion  This study represents a good validation of the ESC predictive model whose performance can be further improved by adding D-dimer plasma levels measured at PE diagnosis.