Clinical presentation and in-hospital death in acute pulmonary embolism: does cancer matter?

Acute pulmonary embolism and cancer: findings from the COPE study

BACKGROUND

Patients with acute venous thromboembolism associated with cancer have an increased risk of recurrences and bleeding in the long term.

RESEARCH QUESTION

To describe the clinical features and short-term course of patients with acute pulmonary embolism (PE) and active cancer, previous cancer or no cancer.

STUDY DESIGN AND METHODS

Patients with acute PE included in COPE-prospective, multicentre study of adult patients with acute, symptomatic, objectively diagnosed PE-were classified as having active cancer, previous cancer, or no cancer.

RESULTS

Overall, 832 patients had active cancer, 464 with previous cancer and 3660 patients had no cancer at the time of acute PE. The most prevalent primary sites of active cancer were urogenital (23.0%), gastrointestinal (21.0%), and lung (19.8%), with a high prevalence of metastatic disease (57.6%) and ongoing anticancer treatment (16.2%). At discharge, a direct oral anticoagulant was used in 43.1%, 78.8%, and 82.0% of patients with active cancer, previous cancer, and no cancer, respectively. Rates of death in-hospital and at 30 days were higher in patients with active cancer compared to patients with previous cancer and no cancer (7.9% vs. 4.3% vs. 2.2% and 13.8% vs. 5.2% vs. 2.6%, respectively). Rates of major bleeding were 4.8%, 2.6%, and 2.4%, respectively. Among patients with active cancer, lung or metastatic cancer were independent predictors of death; brain, hematological or gastrointestinal cancer had the highest risk of major bleeding.

INTERPRETATION

Among patients with acute PE, those with active cancer have high risks for death or major bleeding within 30 days. These risks vary based on primary site of cancer.

CLINICAL TRIAL REGISTRATION

clinicaltrial.gov identifier: NCT03631810.

Clinical manifestations of cancer in patients with acute pulmonary embolism

BACKGROUND

Neoplasmatic disease increases the risk of acute pulmonary embolism (APE) by different pathophysiological mechanisms that favor thrombosis in patients with cancer. Recently, the role of cancer (active and occult) in the prevalence of venous thromboembolism has been discussed more thoroughly in the subject literature.

MATERIAL

Medical records of 366 consecutive patients with a diagnosis of APE (aged: mean = 65.0 ± 16.6, median = 68, range = 19-94; men = 41%/women = 59%) were collected with a wide range of demographic data, medical history of coexisting diseases, computer examination, and laboratory tests.

METHODS

The APE patients were analyzed in two groups: negative cancer cases (83%), i.e. without concomitant active malignancy or a history of cancer, and positive ones (17%), i.e. those hospitalized with concomitant active cancer disease or a history of cancer within the past 5 years.

RESULTS

Based on the application of the Student's t-test for independent samples and the χ2 test of independence, a statistically significant difference (P < 0.05) between cancer (-) and cancer(+) groups of patients was calculated for the following selected risk factors: BMI, smoking status, hemoglobin, hematocrit, red blood cell, urea, glomerular filtration rate, high-sensitivity troponin T, C-reactive protein (CRP), D-dimer, and NT-proBNP. Using univariate Cox regression and a discrete-time hazard model, the estimated hazard ratios and odds ratios, respectively, for the risk of an earlier death from cancer as well as for a secondary APE episode in APE patients with malignancy are more than three times higher than in cancer-free patients and they are statistically significant (P < 0.05). Moreover, the modeled discrete-time hazard curves show a constant excess risk of death and a secondary APE episode in patients diagnosed with malignancy over the period of observation.

CONCLUSION

Cancer and APE seem to go 'hand in hand'. Attention should be paid to many factors, primarily clinical, differentiating patients with cancer from those with an APE incident. The patients with cancer after a primary APE should receive anticoagulants to prevent a secondary APE episode and to reduce the risk of mortality.

Cardiogenic shock among cancer patients

Sophisticated cancer treatments, cardiovascular risk factors, and aging trigger acute cardiovascular diseases in an increasing number of cancer patients. Among acute cardiovascular diseases, cancer treatment, as well as the cancer disease itself, may induce a cardiogenic shock. Although increasing, these cardiogenic shocks are still relatively limited, and their management is a matter of debate in cancer patients. Etiologies that cause cardiogenic shock are slightly different from those of non-cancer patients, and management has some specific features always requiring a multidisciplinary approach. Recent guidelines and extensive data from the scientific literature can provide useful guidance for the management of these critical patients. Even if no etiologic therapy is available, maximal intensive supportive measures can often be justified, as most of these cardiogenic shocks are potentially reversible. In this review, we address the major etiologies that can lead to cardiogenic shock in cancer patients and discuss issues related to its management.

Clinical presentations and outcomes in pulmonary embolism patients with cancer

To study whether a diagnosis of cancer affects the clinical presentation and outcomes of patients with pulmonary embolism (PE). A retrospective analysis was performed of all consecutive patients diagnosed with PE on a computed tomography scan from 2014 to 2016 at an urban tertiary-referral medical center. Baseline characteristics, treatment decisions, and mortality data were compared between study subjects with and without a known diagnosis of active cancer. There were 581 subjects, of which 187 (33.0%) had a diagnosis of cancer. On average, cancer subjects tended to be older (64.8 vs. 58.5 years, p < 0.01), had lower body mass index (BMI) (29.0 vs. 31.5 kg/m², p = 0.01), and were less likely to be active smokers (9.2% vs. 21.1%, p < 0.01), as compared to non-cancer subjects. Cancer subjects were also less likely to present with chest pain (18.2% vs. 37.4%, p < 0.01), syncope (2.7% vs. 6.6%, p = 0.05), bilateral PEs (50% vs. 60%, p = 0.025), and evidence of right heart strain (48% vs. 58%, p = 0.024). There was no difference in-hospital length of stay (8.9 vs. 9.4 days, p = 0.61) or rate of intensive care unit (ICU) admission (31.9% vs. 33.3%, p = 0.75) between the two groups. Presence of cancer increased the risk of all-cause one-year mortality (adjusted HR 9.7, 95% CI 4.8-19.7, p < 0.01); however, it did not independently affect in-hospital mortality (adjusted HR 2.9, 95% CI 0.86-9.87, p = 0.086). Patients with malignancy generally presented with less severe PE. In addition, malignancy did not independently increase the risk of in-hospital mortality among PE patients.

Pulmonary Embolism in the Intensive Care Unit: Therapy in Subpopulations

The optimal management of a submassive or massive pulmonary embolism (PE) during pregnancy is unclear because of a lack of large clinical trials. Evaluation of the patient who may be a candidate for more aggressive therapy includes the use of biomarkers and echocardiogram for risk stratification. PE Response teams (PERTs) have gained increasing acceptance by the medical community and are being implemented in hospitals in the United States and worldwide. PERTs bring together a team of specialists from different disciplines to enhance decision-making in the patient with acute submassive and massive PE.

Epidemiology and diagnosis of pulmonary embolism in lung cancer patients: is there a role for age adjusted D-dimers cutoff?

Our knowledge about the incidence of pulmonary embolism (PE) and the performance of age adjusted D-dimers (Dd) cutoff amongst patients with lung cancer (LC) and suspected PE, remains limited. We retrospectively analyzed all clinically suspected patients who underwent computed tomography pulmonary angiography (CTPA) in a tertiary hospital during a 19 month period. Cancer diagnosis was established using ICD10 code. Eligible for Dd analysis were those tested up to 24 h prior to the scan. We analyzed 2549 patients (54.6% males, median age 68.8 years, IQR 57-78), 15.8% had active LC and 5.4% other cancers (oC), while 70% were scanned in the Emergency Department (ED) and the rest during hospitalization. Overall incidence of PE was 16%. LC, but not oC, increased significantly the risk for PE (OR 1.58, 95% CI 1.21-2.06). LC patients were less likely to have bilateral (aOR 0.16, 95% CI 0.07-0.4) or central PE (aOR 0.2, 95% CI 0.09-0.48). Amongst those diagnosed with PE in the ED, LC increased all-cause inhospital mortality (aOR 6.7, 95% CI 2.64-16.95). When age adjusted instead of conventional Dd cutoff was used for ruling out PE in the ED, specificity for LC patients increased (10.16% vs 3.91%) without false negative tests (negative likelihood ratio-NLR = 0). A higher cutoff of 1.13 mg/l raised specificity to 28.9%, with only one case missed (sensitivity: 97.4%, NLR: 0.09, 95% CI 0.01-0.64). LC increases the risk for PE and adversely affects prognosis. Age adjusted and probably an even higher, "LC adjusted" Dd cutoff, could increase the specificity of the test without compromising its sensitivity.

Outcomes of fibrinolytic therapy for patients with metastatic cancer and acute pulmonary embolism

INTRODUCTION

Malignancy is a common cause of morbidity and mortality in the United States and around the world and the second leading cause of death in the United States. There is little data on the impact of metastatic cancer on the risk of hemorrhagic stroke or mortality among patients undergoing fibrinolytic therapy (FT) for acute PE.

METHODS

Using the National Inpatient Sample (NIS) database, we extracted admissions with a primary diagnosis of acute pulmonary embolism that underwent FT from 2010 to 2014. We performed a case control matched analysis between patients with and without metastatic cancer. Our primary outcome of interest was Mortality and our secondary outcome of interest was hemorrhagic stroke (HS).

RESULTS

Of the 883,183 patients with a primary diagnosis of acute PE between 2010 and 12014, 23,690 patients (2.7%) underwent FT. After exclusion, 22,592 patients were included in the analysis. Of these, 941 patients (4.2%) were reported to have metastatic cancer. There was a higher incidence of cerebrovascular accidents and intubation/mechanical ventilation in the metastatic cancer arm. Mortality was significantly higher in the metastatic cancer arm with no difference in the incidence of HS. In multivariate regression analysis, among all patients that underwent FT for acute PE, metastatic cancer was associated with a significant odds for mortality (OR 1.91, 95% CI 1.11-5.82, p < .001).

CONCLUSION

The presence of metastatic cancer in patients undergoing fibrinolytic therapy for acute pulmonary embolism is associated with increase mortality.