Relation of atrial fibrillation and right-sided cardiac thrombus to outcomes in patients with acute pulmonary embolism

Causal effect of atrial fibrillation on pulmonary embolism: a mendelian randomization study

Atrial fibrillation (AF) can increase thrombosis, especially arterial thrombosis, and some studies show that AF patients have a higher risk of developing pulmonary embolism (PE). The objective of our study is to investigate whether there is a direct causal effect of AF on PE. A two-sample Mendelian randomization (MR) approach was utilized to determine whether there is a causal relationship between AF and PE. European population-based consortia provided statistical data on the associations between Single Nucleotide Polymorphisms (SNPs) and relevant traits. The AF dataset was obtained from genome-wide association studies (GWAS) comprising 60,620 cases and 970,216 controls, while a GWAS of 1846 cases and 461,164 controls identified genetic variations associated with PE. Estimation of the causal effect was mainly performed using the random effects inverse-variance weighted method (IVW). Additionally, other tests such as MR-Egger intercept, MR-PRESSO, Cochran's Q test, "Leave-one-out," and funnel plots were conducted to assess the extent of pleiotropy and heterogeneity. Using 70 SNPs, there was no evidence to suggest an association between genetically predicted AF and risk of PE with multiplicative random-effects IVW MR analysis (odds ratio = 1.0003, 95% confidence interval: 0.9998-1.0008, P = 0.20). A null association was also observed in other methods. MR-Egger regression and MR-PRESSO respectively showed no evidence of directional (intercept, - 2.25; P = 0.94) and horizontal(P-value in the global heterogeneity test = 0.99) pleiotropic effect across the genetic variants. No substantial evidence was found to support the causal role of AF in the development of PE.

New-Onset Paroxysmal Atrial Fibrillation in the Setting of Acute Pulmonary Embolism Is Associated with All-Cause Hospital Mortality in Women but Not in Men

BACKGROUND

Patients with acute pulmonary embolism (PE) may have various types of atrial fibrillation (AF). The role of AF in hemodynamic states and outcomes may differ between men and women.

METHODS

In total, 1600 patients (743 males and 857 females) with acute PE were enrolled in this study. The severity of PE was assessed using the European Society of Cardiology (ESC) mortality risk model. Patients were allocated into three groups according to their electrocardiography recordings taken during hospitalization: sinus rhythm, new-onset paroxysmal AF, and persistent/permanent AF. The association between the types of AF and all-cause hospital mortality was tested using regression models and net reclassification index (NRI) and integrated discrimination index (IDI) statistics with respect to sex.

RESULTS

There were no differences between the frequencies of the types of AF between men and women: 8.1% vs. 9.1% and 7.5% vs. 7.5% (p = 0.766) for paroxysmal and persistent/permanent AF, respectively. We found that the rates of paroxysmal AF significantly increased across the mortality risk strata in both sexes. Among the types of AF, the presence of paroxysmal AF had a predictive value for all-cause hospital mortality independent of mortality risk and age in women only (adjusted HR, 2.072; 95% CI, 1.274-3.371; p = 0.003). Adding paroxysmal AF to the ESC risk model did not improve the reclassification of patient risk for the prediction of all-cause mortality, but instead enhanced the discriminative power of the existing model in women only (NRI, not significant; IDI, 0.022 (95% CI, 0.004-0.063); p = 0.013).

CONCLUSION

The occurrence of paroxysmal AF in female patients with acute PE has predictive value for all-cause hospital mortality independent of age and mortality risk.

Right Atrial Appendage Thrombus in a Patient Undergoing Thoracoscopic Left Atrial Appendectomy for Atrial Fibrillation

Left atrial appendage (LAA) closure may prevent atrial fibrillation (AF)-induced thromboembolism. We describe a rare case of right atrial (RA) thrombus after thoracoscopic left atrial appendectomy and pulmonary vein isolation. Careful evaluation for the presence of RA thrombus in patients with persistent AF after LAA occlusion may be necessary. (Level of Difficulty: Intermediate.).

Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application

Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.

Less Known but Clinically Relevant Comorbidities of Atrial Fibrillation: A Narrative Review

BACKGROUND

The important risk factors for atrial fibrillation (AF) in the general population are not always equally important in specific and relatively prevalent diseases.

OBJECTIVE

The main goal of this narrative review is to focus attention on the presence and the relationship of AF with several important diseases, such as cancer or sepsis, in order to: 1) stimulate further research in the field, and 2) draw attention to this relationship and search for AF in clinical practice.

METHODS

We searched PubMed, SCOPUS, Elsevier, Wiley, Springer, Oxford Journals, Cambridge, SAGE, and Google Scholar for less-known comorbidities of AF. The search was limited to publications in English. No time limits were applied.

RESULTS

AF is widely represented in cardiovascular and other important diseases, even in those in which AF is rarely mentioned. In some specific clinical subsets of AF patients (e.g., patients with sepsis or cancer), the general risk factors for AF may not be so important. Patients with new-onset AF have a several-fold increase in relative risk of cancer, deep vein thrombosis, and pulmonary thromboembolism (PTE) during the follow-up.

CONCLUSION

AF presence, prognosis, and optimal therapeutic approach are insufficiently recognised in several prevalent diseases, including life-threatening ones. There is a need for a better search for AF in PTE, pulmonary oedema, aortic dissection, sepsis, cancer and several gastrointestinal diseases. Improved AF detection would influence treatment and improve outcomes.

Clinical, imaging and hemodynamic correlates and prognostic impact of syncope in acute pulmonary embolism: A single-center study

BACKGROUND

We aimed to determine the clinical, echocardiographic and hemodynamic correlates of syncope as a presenting symptom in pulmonary embolism and its impact on in-hospital and long-term outcomes.

METHODS

Between July 2012 and October 2019, a total of 641 patients with PE (277 males, 364 females; median age: 65 years; range, 51 to 74 years) in whom the diagnostic work-up and risk-based management were performed according to the current pulmonary embolism guidelines were retrospectively analyzed. Clinical, laboratory and imaging data of the patients were obtained from hospital database system.

RESULTS

Syncope was noted in 193 (30.2%) of patients on admission, and was associated with a significantly higher-risk status manifested by elevated troponin and D-dimer levels, a higher Pulmonary Embolism Severity Index scores, deterioration of right-to-left ventricular diameter ratio, right ventricular longitudinal contraction measures, the higher Qanadli score, and higher rates of thrombolytic therapies (p<0.001) and rheolytic-thrombectomy (p=0.037) therapies. In-hospital mortality (p=0.007) and minor bleeding (p<0.001) were significantly higher in syncope subgroup. Multivariate logistic regression analysis showed that higher Pulmonary Embolism Severity Index scores and right-to-left ventricular diameter ratio were independently associated with syncope, while aging and increased heart rate predicted in-hospital mortality. Malignancy and right-to-left ventricular diameter ratio at discharge, but not syncope, were independent predictors of cumulative mortality during follow-up.

CONCLUSION

Syncope as the presenting symptom is associated with a higher risk due to more severe obstructive pressure load and right ventricular dysfunction requiring more proactive strategies in patients with pulmonary embolism. However, with appropriate risk-based therapies, neither in-hospital mortality nor long-term mortality can be predicted by syncope.

A Novel Electrocardiography Model for the Diagnosis of Acute Pulmonary Embolism

Acute pulmonary embolism (acPE) is a severe disease that is often misdiagnosed as it is difficult to detect quickly and accurately. In this study, a novel electrocardiogram (ECG) model was used to estimate the probability of acPE rapidly via analysis of ECG characteristics. A total of 327 patients with acPE who were diagnosed at the Sichuan Provincial People's Hospital (SPPH) between 2018 and 2021 were retrospectively studied. A total of 331 patients were randomly selected as the control group, which included patients hospitalized during the same time period. The control group included patients who presented with characteristic symptoms of acPE, but this diagnosis was ruled out following further diagnostic testing. This study compared the diagnostic value of the ECG model with those of another ECG scoring model (Daniel-ECG score) and the most common prediction models (Wells score and Geneva score). This study established an ECG-predictive model using analysis of the ECG abnormalities in patients with acPE. The final ECG model included certain novel ECG signs that had not been incorporated in the previous ECG score of the patients, and thus, compared to the previous ECG score, exhibited a more favorable area under the receiver operating characteristic curve (AUC) value (0.8741). The model developed in this study was named the SPPH-ECG model. Furthermore, this study compared the SPPH-ECG model with Daniel-ECG score, Wells score, and Geneva score, and the SPPH-ECG model was demonstrated to exhibit a superior AUC value (0.8741), sensitivity (79.08%), negative predictive value (79.52%), and test accuracy (79.42%), while the Geneva score presented superior specificity (100%) and positive predictive value (100%) compared with the SPPH-ECG model. In conclusion, the SPPH-ECG model may play a role in ruling out acPE in patients during diagnostic testing and diagnose acPE rapidly and accurately in combination with the Geneva scoring system.

Right heart thrombi (RHT) and clot in transit with concomitant PE management: Approach and considerations

Right heart thrombi (RHT) continues to pose a clinical dilemma for multiple specialties and is especially concerning when present with concomitant pulmonary embolism (PE). Patients with PE and RHT are at an increased risk of poor outcomes compared to PE without RHT. Although the exact incidence of RHT is unknown, the increasing use of point-of-care ultrasound may lead to an increased detection and frequency of RHT. There are multiple treatment strategies available for RHT, including anticoagulation, systemic thrombolysis, and endovascular and surgical therapies. Given that these treatment strategies involve multiple medical specialties, the management of RHT with concomitant PE can be complex. Currently, there is limited clinical data and guidelines on the treatment and management of RHT. We aim to provide a review on RHT with concomitant PE, including risk stratification, treatment considerations, and our approach to the management of RHT.

Retrospective cohort study of new-onset atrial fibrillation in acute pulmonary embolism on prognosis

OBJECTIVES

To investigate the characteristics of new-onset atrial fibrillation (AF) and its impact on prognosis in acute pulmonary embolism (aPE).

DESIGN

A retrospective cohort study SETTING: The study cohort included patients diagnosed with aPE who were admitted to the Renmin Hospital of Wuhan University from January 2017 to January 2019.

PARTICIPANTS

Patients were ≥18 years of age and hospitalised for aPE.

OUTCOME MEASURES

AF was diagnosed based on an ECG recording or a Holter monitor during hospitalisation. aPE was diagnosed by CT pulmonary angiography. The prescription was determined from the discharge medication list. All-cause mortality was observed after 6-month follow-up. The logistic regression model and Cox proportional hazards model were used to study the risk factor of the new-onset AF and the predictor of all-cause mortality, respectively.

RESULTS

A total of 590 patients with aPE were enrolled, 23 (3.9%) in the new-onset paroxysmal AF group, 31 (5.3%) in the new-onset persistent AF group and 536 (90.8%) in the sinus rhythm (SR) group. The incidence of the new-onset AF was 9.2% (54/590). A significant difference in age, heart rate, cardiac troponin I ultra, amino-terminal pro-brain natriuretic peptide, D-dimer, left atrial diameter, left ventricular ejection fraction, pulmonary infection, venous thromboembolism, congestive heart failure, chronic cor pulmonale and ischaemic heart disease was found among the three groups (p<0.05). Risk factors for the new-onset AF were massive PE, ischaemic heart disease and congestive heart failure. The survival rate of the paroxysmal and persistent AF group was significantly lower than that of the SR group within 6 months (60.9% and 51.6% vs 88.8%, p<0.001). New-onset persistent AF (OR 2.73; 95% CI 1.28 to 5.81; p=0.009) was an independent predictor affecting the 6-month survival in aPE patients.

CONCLUSIONS

Massive PE, ischaemic heart disease and congestive heart failure are high-risk factors which were related to new-onset AF in aPE. New-onset persistent AF was an independent predictor for 6-month all-cause mortality in PE patients.

'Pulmonary thrombosis in situ': risk factors, clinic characteristics and long-term evolution

: Pulmonary embolism typically occurs from deep venous thrombosis (DVT). However, not always a DVT can be identified, and 'in situ' generation of pulmonary embolism has been considered, referred to in the literature as 'De novo pulmonary embolism' (DNPE). The objective of the study is to assess risk factors, comorbidities, clinic characteristics and long-term evolution of patients with pulmonary embolism in the absence of an identified source. Retrospective study of 280 patients with pulmonary embolism, 190 pulmonary embolisms with DVT group and 90 (32%) pulmonary embolism without DVT (DNPE group), admitted to an Internal Medicine Department of a tertiary hospital from January 2012 to December 2015. In the DNPE group, segmental and subsegmental arteries were more frequently affected (P = 0.01). As compared with pulmonary embolisms with DVT group: older age, female sex, sedentary lifestyle, diabetes mellitus, arterial hypertension, heart failure, respiratory infections and chronic obstructive pulmonary disease (COPD) were significantly more frequent in DNPE. In multivariate analysis, respiratory infection [odds ratio (OR) 12.2, P < 0.0001], COPD (OR 8.7, P < 0.0001) and female sex (OR 3.0, P = 0.003) were independently associated risk factors. Long-term mortality (median follow-up 15 months) was also higher in DNPE group (34 vs. 16%, P = 0.01). De novo pulmonary embolism occurred in 32% of cases of pulmonary embolisms and was more frequent in female and COPD patients or those with respiratory infections as compared with pulmonary embolisms in which DVT was identified as a source of embolism.

Risk Stratification in Acute Pulmonary Embolism: The Latest Algorithms

Pulmonary embolism (PE) is a common clinical entity, which most clinicians will encounter. Appropriate risk stratification of patients is key to identify those who may benefit from reperfusion therapy. The first step in risk assessment should be the identification of hemodynamic instability and, if present, urgent patient consideration for systemic thrombolytics. In the absence of shock, there is a plethora of imaging studies, biochemical markers, and clinical scores that can be used to further assess the patients' short-term mortality risk. Integrated prediction models incorporate more information toward an individualized and precise mortality prediction. Additionally, bleeding risk scores should be utilized prior to initiation of anticoagulation and/or reperfusion therapy administration. Here, we review the latest algorithms for a comprehensive risk stratification of the patient with acute PE.

New-Onset Atrial Fibrillation and Adverse In-Hospital Outcome in Patients with Acute Pulmonary Embolism

Atrial fibrillation (AF) can be secondary to acute pulmonary embolism (PE). This study aimed to investigate the prognostic impact of new-onset AF on patients with acute PE. In this study, 4,288 consecutive patients who were diagnosed with acute PE were retrospectively screened. In total, 77 patients with acute PE and new-onset AF were analyzed. Another 154 acute PE patients without AF were selected as the age- and sex-matched control group. Adverse in-hospital outcome comprised one of the following conditions: all-cause death, endotracheal intubation, cardiopulmonary resuscitation, and intravenous catecholamine therapy. The patients with new-onset AF had higher prevalence of congestive heart failure, higher simplified PE severity index (sPESI), higher creatinine, and larger left atrium diameter. The incidences of adverse in-hospital outcomes were 10.4 and 2.6% in patients with new-onset AF and no AF, respectively (p = 0.02). Patients with sPESI ≥ 1 had higher incidence of adverse in-hospital outcomes than those with sPESI = 0 (9.4 vs. 0.9%, p < 0.01). The area under the receiver operating characteristic curve of sPESI and sPESI + AF (adding 1 point for new-onset AF) scores in assessing the adverse in-hospital outcome were 0.80 (95% confidence interval [CI]: 0.68-0.93) and 0.84 (95% CI: 0.72-0.96), respectively. In multivariable analysis, sPESI ≥ 1 (odds ratio, 8.88; 95% CI: 1.10-72.07; p = 0.04) was an independent predictor of adverse in-hospital outcome. However, new-onset AF was not an independent predictor. In the population studied, sPESI is an independent predictor of adverse in-hospital outcomes, whereas new-onset AF following acute PE is not, but it may add predictive value to sPESI.

Right Atrial Thrombosis and Pulmonary Embolism: A Narrative Review

Prompt diagnosis of pulmonary embolism (PE) remains challenging, which often results in a delayed or inappropriate treatment of this life-threatening condition. Mobile thrombus in the right cardiac chambers is a neglected cause of PE. It poses an immediate risk to life and is associated with an unfavorable outcome and high mortality. Thrombus residing in the right atrial appendage (RAA) is an underestimated cause of PE, especially in patients with atrial fibrillation. This article reviews achievements and challenges of detection and management of the right atrial thrombus with emphasis on RAA thrombus. The capabilities of transthoracic and transesophageal echocardiography and advantages of three-dimensional and two-dimensional echocardiography are reviewed. Strengths of cardiac magnetic resonance imaging (CMR), computed tomography, and cardiac ventriculography are summarized. We suggest that a targeted search for RAA thrombus is necessary in high-risk patients with PE and atrial fibrillation using transesophageal echocardiography and/or CMR when available independently on the duration of the disease. High-risk patients may also benefit from transthoracic echocardiography with right parasternal approach. The examination of high-risk patients should involve compression ultrasonography of lower extremity veins along with the above-mentioned technologies. Algorithms for RAA thrombus risk assessment and protocols aimed at identification of patients with RAA thrombosis, who will potentially benefit from treatment, are warranted. The development of treatment protocols specific for the diverse populations of patients with right cardiac thrombosis is important.

Atrial fibrillation, venous thromboembolism, ischemic stroke, and all-cause mortality: The Tromsø study

Background

Atrial fibrillation (AF) is associated with increased risk of ischemic stroke and all-cause mortality. Patients with AF are also at increased risk of venous thromboembolism (VTE), but information on how AF impacts VTE-related mortality is scarce.

Objectives

To investigate the impact of AF on all-cause mortality in subjects with and without a thromboembolic event (VTE or ischemic stroke).

Methods

We followed 29 833 participants from the Tromsø study (1994-2008) through 2013 and recorded all deaths during follow-up. Incident AF, VTE, and ischemic stroke were registered as time-dependent exposures. We calculated mortality rates (MRs) by exposure during follow-up and obtained hazard ratios (HRs) for death with 95% confidence intervals (CIs).

Results

A total of 2087 AF cases, 756 VTEs, and 1279 ischemic strokes were registered during a median follow-up of 18.7 years, and 4797 people (16.1%) died. The age-adjusted MR for participants without any event was 1.19 per 100 person-years (PY; 95% CI, 1.15-1.23). Compared to these participants, subjects with the joint AF + VTE exposure had a 3.7-fold increased risk of death (HR, 3.67; 95% CI, 2.77-4.66) in age- and sex-adjusted analyses, similar to the risk observed for VTE alone (HR, 3.76; 95% CI, 3.28-4.30). Participants with stroke had a 2.9-fold increased risk of death (HR, 2.85; 95% CI, 2.56-3.18), and the risk was further increased in participants with both AF and stroke (HR, 4.38; 95% CI, 3.85-4.98).

Conclusions

AF was significantly associated with increased risk of death in participants with incident stroke. In contrast, concomitant AF was not associated with excess mortality risk in VTE patients.

Atrial fibrillation in the elderly: a risk factor beyond stroke

Atrial fibrillation (AF) represents the most common arrhythmia worldwide and its prevalence exponentially increases with age. It is related to increased risk of ischemic stroke or systemic embolism, which determines a significant burden of morbidity and mortality, as widely documented in the literature. AF also constitutes a risk factor for other less investigated conditions, such as heart failure, pulmonary embolism, impairment in physical performance, reduced quality of life, development of disability, mood disorders and cognitive impairment up to dementia. In the elderly population, the management of AF and its complications is particularly complex due to the heterogeneity of the ageing process, the lack of specific evidence-based recommendations, as well as the high grade of comorbidity and disability characterizing the over 65 years aged people. In the present review, we aim to summarize the pieces of the most updated evidence on AF complications beyond stoke, mainly focusing on the elderly population.

Atrial fibrillation is frequent but does not affect risk stratification in pulmonary embolism

BACKGROUND

Although prior studies indicate a high prevalence of atrial fibrillation (AF) in patients with pulmonary embolism (PE), the exact prevalence and prognostic impact are unknown.

METHODS

We aimed to investigate the prevalence, risk factors and prognostic impact of AF on risk stratification, in-hospital adverse outcomes and mortality in 528 consecutive PE patients enrolled in a single-centre registry between 09/2008 and 09/2017.

RESULTS

Overall, 52 patients (9.8%) had known AF and 57 (10.8%) presented with AF on admission; of those, 34 (59.6%) were newly diagnosed with AF. Compared to patients with no AF, overt hyperthyroidism was associated with newly diagnosed AF (OR 7.89 [2.99-20.86]), whilst cardiovascular risk comorbidities were more frequently observed in patients with known AF. Patients with AF on admission had more comorbidities, presented more frequently with tachycardia and elevated cardiac biomarkers and were hence stratified to higher risk classes. However, AF on admission had no impact on in-hospital adverse outcome (8.3%) and in-hospital mortality (4.5%). In multivariate logistic regression analyses corrected for AF on admission, NT-proBNP and troponin elevation as well as higher risk classes in risk assessment models remained independent predictors of an in-hospital adverse outcome.

CONCLUSION

Atrial fibrillation is a frequent finding in PE, affecting more than 10% of patients. However, AF was not associated with a higher risk of in-hospital adverse outcomes and did not affect the prognostic performance of risk assessment strategies. Thus, our data support the use of risk stratification tools for patients with acute PE irrespective of the heart rhythm on admission.

Atrial Fibrillation in Patients with Acute Pulmonary Embolism: Clinical Significance and Impact on Prognosis

Pulmonary embolism (PE) is one of the most common causes of cardiovascular death. The most often PE etiology is a deep vein thrombosis (DVT) of the lower extremities, but embolic material can arise in pelvic or upper extremity veins as well as in right heart chambers. There is growing number of evidences of atrial fibrillation (AF) involvement in PE. The presence of AF in patients with PE may be both the cause and the consequence of PE. The PE association with AF should be considered in patients without confirmed DVT and with history of AF, which itself is associated with prothrombotic state. The valuable diagnostic method is echocardiography that may bring the insight into source of embolic material. Another possible AF and PE association is the AF as a consequence of an abrupt increase in pulmonary vascular resistance due to the occlusion of the pulmonary vessels. Large-scale population-based studies have provided a considerable body of evidence on the involvement of PE in the onset of subsequent AF. Another important issue is the influence of AF on prognosis in patients with PE. Most investigators demonstrated a negative impact of AF on mortality. The main problem to resolve is whether AF is an independent mortality risk factor or whether it occurs as a result of comorbidities or the severity of a PE episode. Although the pathophysiological basis of this bidirectional relationship exists, many questions are still unresolved and require further studies, including the significance of paroxysmal AF accompanying an acute PE episode, the usefulness of PE risk scales in patients with concomitant AF, and the effect of anticoagulant treatment on PE and AF occurrence. Regardless of the type of AF, clinicians should be alert to the possibility of PE in patients with previous history of AF or presenting with new-onset AF.

Permanent atrial fibrillation and pulmonary embolism in elderly patients without deep vein thrombosis: is there a relationship?

BACKGROUND AND AIM

Permanent Atrial Fibrillation (pAF) is associated with increased risk of embolic complications. The relationship between pAF and pulmonary embolism (PE) has not been extensively investigated in elderly patients. Here, we aim at verifying whether pAF is associated to an increased risk of PE in a cohort of elderly patients with and without Deep Vein Thrombosis (DVT).

METHODS

235 patients older than 65 years with PE with or without pAF were retrospectively enrolled and stratified by the absence or presence of DVT. The diagnosis of PE was performed by computed tomography angiography (CTA). Right echocardiographic parameters were monitored. The severity of PE was evaluated by CTA quantization (PE score = 1, involvement of main branches of pulmonary artery) and by dimer-D (> 3000 µg/L).

RESULTS

DVT was identified only in 51 cases of PE (21.7%). pAF prevalence was higher in PE without than in those with DVT (64.9% vs. 35.1%, p < 0.01). PE severity was more evident in pAF patients without than in those with DVT. Multivariate analysis of the role of pAF on PE severity confirms these results (RR = 3.41 for PE score = 1, and 8.55 for dimer-D > 3000 µg/L).

CONCLUSIONS

We conclude that in elderly patients with PE, the prevalence of pFA was doubled, in the absence of DVT, and it is associated with a more severe PE in the absence than in the presence of DVT. Thus, in the absence of DVT, pFA should be considered as cause of PE.

Atrial fibrillation, an obscured cause of pulmonary embolism can be revealed by adding to Wells criteria

Among the various clinical scoring methods used for the prediagnosis of pulmonary embolism (PE), Wells criteria is the most common. It relies on the findings and story of deep venous thrombosis (DVT), PE and malignancy. It is known that atrial fibrillation (AF) is a risk factor for PE like as DVT or malignancy. We aimed to evaluate the possibility of diagnosing more patients with PE by including AF in the Wells criteria. This prospective study included 250 patients admitted to the emergency department with PE findings. Wells scoring and Wells scoring with AF were performed for each patient. Out of 250 patients, 165 patients were diagnosed as PE. Wells score was >4 in 61.8% of patients with PE and 28.2% of patients without PE. Out of false negative 63 patients with PE, 21 of them had AF. According to Wells scoring with AF the score of 148 (89.7%) patients with PE diagnosis was ≥3, whereas the score of 45 (52.9%) patients without PE was ≥3. AF was detected in 15.8% of patients with PE. The sensitivity of Wells score with AF was significantly higher than that of the Wells score (p<0.001). As a result, when AF, which is one of an important PE cause such as DVT and malignancy, was added to the Wells criteria, an additional correct PE estimate was obtained in 46 patients. We recommend using Wells score with AF since prediagnosing more PE is more valuable than having some false negative PE predictions.

The Value of Bedside Echocardiogram in the Setting of Acute and Chronic Pulmonary Embolism

Echocardiography is valuable in the evaluation and risk stratification of patients with acute and chronic pulmonary embolism (PE). Patients with acute PE who have echocardiographic evidence of right ventricular dilatation and/or right ventricular dysfunction have a worse prognosis. A minority of patients with acute PE can develop chronic thromboembolic pulmonary hypertension. Patients with chronic thromboembolic pulmonary hypertension often have echocardiographic evidence of elevated pulmonary arterial pressures, right ventricular hypertrophy, right ventricular dysfunction, and/or left ventricular impaired relaxation.

Atrial fibrillation is related to lower incidence of deep venous thrombosis in patients with pulmonary embolism

Background

Atrial fibrillation (AF) is an established risk factor of left atrial thrombosis and systemic embolism. Traditionally pulmonary embolism (PE) is a recognized complication of deep vein thrombosis (DVT). However, whether AF is responsible for right atrial thrombosis and leads to PE has not been examined.

Methods

We retrospectively analyzed medical records of patients with confirmed diagnosis of PE with AF (study group) from 2002-2015. Patients with PE without AF, matched by age and sex, served as controls (control group). The CHA₂DS₂-VASc and CHADS₂ scores were classified into two categories, low-intermediate (<2 points) and high-risk (≥2 points).

Results

A total of 330 patients (110 in study group and 220 in control group). The study group had significantly lower incidence of newly diagnosed DVT (21% vs. 44%, P<0.001), previous history of DVT (6% vs. 17%, P=0.006) and recent surgery or trauma (10% vs. 23%, P=0.004) compared to the control group. When stratified by the CHADS₂ score, 49 patients (44.5%) were considered low-intermediate risk. This proportion significantly differed when stratified using CHA₂DS₂-VASc, in which 13 patients (13.6%) were considered low-intermediate risk, P<0.001.

Conclusions

The incidence of DVT was much lower in the study group, suggesting the possibility of clots originated from the right heart that may increase the risk of PE. The CHA₂DS₂-VASc scoring system might be more sensitive for prediction and stratification of the PE in AF patients than the CHADS₂ score.

The value of electrocardiography in prognosticating clinical deterioration and mortality in acute pulmonary embolism: A systematic review and meta-analysis

The role of electrocardiography (ECG) in prognosticating pulmonary embolism (PE) is increasingly recognized. ECG is quickly interpretable, noninvasive, inexpensive, and available in remote areas. We hypothesized that ECG can provide useful information about PE prognostication. We searched MEDLINE, EMBASE, Google Scholar, Web of Science, abstracts, conference proceedings, and reference lists through February 2017. Eligible studies used ECG to prognosticate for the main outcomes of death and clinical deterioration or escalation of therapy. Two authors independently selected studies; disagreement was resolved by consensus. Ad hoc piloted forms were used to extract data and assess risk of bias. We used a random-effects model to pool relevant data in meta-analysis with odds ratios (ORs) and 95% confidence intervals (CIs); all other data were synthesized qualitatively. Statistical heterogeneity was assessed using the I ² value. We included 39 studies (9198 patients) in the systematic review. There was agreement in study selection (κ: 0.91, 95% CI: 0.86-0.96). Most studies were retrospective; some did not appropriately control for confounders. ECG signs that were good predictors of a negative outcome included S1Q3T3 (OR: 3.38, 95% CI: 2.46-4.66, P < 0.001), complete right bundle branch block (OR: 3.90, 95% CI: 2.46-6.20, P < 0.001), T-wave inversion (OR: 1.62, 95% CI: 1.19-2.21, P = 0.002), right axis deviation (OR: 3.24, 95% CI: 1.86-5.64, P < 0.001), and atrial fibrillation (OR: 1.96, 95% CI: 1.45-2.67, P < 0.001) for in-hospital mortality. Several ischemic patterns also were significantly predictive. Our conclusion is that ECG is potentially valuable in prognostication of acute PE.

Annexin V-Conjugated Mixed Micelles as a Potential Drug Delivery System for Targeted Thrombolysis

To alleviate the hemorrhagic side effect of thrombolysis therapy, a thrombus targeted drug delivery system based on the specific affinity of Annexin V to phosphatidylserine exposed on the membrane surface of activated platelet was developed. The amphiphilic and biodegradable biomaterial, polycaprolactone-block-poly(2-(dimethylamino)ethyl methacrylate)-block-poly(2-hydroxyethyl methacrylate) (PCL-b-PDMAEMA-b-PHEMA (PCDH)) triblock polymer, was synthesized via ring opening polymerization (ROP) and atom transfer radical polymerization (ATRP) to use as the nanocarriers of thrombolytic drug. In order to conjugate Annexin V to the polymer, PCDH was modified by succinic anhydride via ring-opening reaction to introduce the carboxyl group (PCDH-COOH). After preparation of PCDH/PCDH-COOH (9/1, m/m) mixed micelles, Annexin V was coupled with the micelles using carbodiimide chemistry. The blood clot lysis assay in vitro confirmed that lumbrokinase-loaded targeted micelles (LKTM) had stronger thrombolysis potency than free lumbrokinase (LK) and LK-loaded nontargeted micelles (LKM, P < 0.05). In vivo thrombolytic assay, multispectral, optoacoustic tomography (MSOT) was used to assess the target ability of LKTM. The results of MSOT images indicated the fluorescence intensity of the LKTM group located in the blood clot position were significantly stronger than the LKM group. A 5 mm of carotid artery containing blood clot was cut out 24 h later after administration to assess the degree of thrombolysis. The results of thrombolytic assay in vivo were consistent with the assay in vitro, which the differences between LK, LKM, and LKTM groups were both statistically significant. All the results of thrombolysis assays above proved that the capacity of thrombolysis in the LKTM group was optimal. It suggested that Annexin V-conjugated micelles will be a potential drug delivery system for targeted thrombolysis.

Correlations between electrocardiogram and biomarkers in acute pulmonary embolism: Analysis of ZATPOL-2 Registry

BACKGROUND

Electrocardiography (ECG) is still one of the first tests performed at admission, mostly in patients (pts) with chest pain or dyspnea. The aim of this study was to assess the correlation between electrocardiographic abnormalities and cardiac biomarkers as well as echocardiographic parameter in patients with acute pulmonary embolism.

METHODS

We performed a retrospective analysis of 614 pts. (F/M 334/280; mean age of 67.9 ± 16.6 years) with confirmed acute pulmonary embolism (APE) who were enrolled to the ZATPOL-2 Registry between 2012 and 2014.

RESULTS

Elevated cardiac biomarkers were observed in 358 pts (74.4%). In this group the presence of atrial fibrillation (p = .008), right axis deviation (p = .004), S₁ Q₃ T₃ sign (p < .001), RBBB (p = .006), ST segment depression in leads V₄ -V₆ (p < .001), ST segment depression in lead I (p = .01), negative T waves in leads V₁ -V₃ (p < .001), negative T waves in leads V₄ -V₆ (p = .005), negative T waves in leads II, III and aVF (p = .005), ST segment elevation in lead aVR (p = .002), ST segment elevation in lead III (p = .0038) was significantly more frequent in comparison to subjects with normal serum level of cardiac biomarkers. In multivariate regression analysis, clinical predictors of "abnormal electrocardiogram" were as follows: increased heart rate (OR 1.09, 95% CI 1.02-1.17, p = .012), elevated troponin concentration (OR 3.33, 95% CI 1.94-5.72, p = .000), and right ventricular overload (OR 2.30, 95% CI 1.17-4.53, p = .016).

CONCLUSIONS

Electrocardiographic signs of right ventricular strain are strongly related to elevated cardiac biomarkers and echocardiographic signs of right ventricular overload. ECG may be used in preliminary risk stratification of patient with intermediate- or high-risk forms of APE.

Paroxysmal Atrial Fibrillation in the Course of Acute Pulmonary Embolism: Clinical Significance and Impact on Prognosis

The relationship and clinical implications of atrial fibrillation (AF) in acute pulmonary embolism (PE) are poorly investigated. We aimed to analyze clinical characteristics and prognosis in PE patients with paroxysmal AF episode. Methods. From the 391 patients with PE 31 subjects with paroxysmal AF were selected. This group was compared with patients with PE and sinus rhythm (SR) and 32 patients with PE and permanent AF. Results. Paroxysmal AF patients were the oldest. Concomitant DVT varies between groups: paroxysmal AF 32.3%, SR 49.5%, and permanent AF 28.1% (p = 0.02). The stroke history frequency was 4.6% SR, 12.9% paroxysmal AF, and 21.9% permanent AF (p < 0.001). Paroxysmal AF comparing to permanent AF and SR individuals had higher estimated SPAP (56 versus 48 versus 47 mmHg, p = 0.01) and shorter ACT (58 versus 65 versus 70 ms, p = 0.04). Patients with AF were more often classified into high-risk group according to revised Geneva score and sPESI than SR patients. In-hospital mortality was lower in SR (5%) and paroxysmal AF (6.5%) compared to permanent AF group (25%) (p < 0.001). Conclusions. Patients with PE-associated paroxysmal AF constitute a separate population. More severe impairment of the parameters reflecting RV afterload may indicate relation between PE severity and paroxysmal AF episode. Paroxysmal AF has no impact on short-term mortality.

Prognostic Significance of Right Heart Thrombi in Patients With Acute Symptomatic Pulmonary Embolism: Systematic Review and Meta-analysis

BACKGROUND

For patients diagnosed with acute pulmonary embolism (PE), the prognostic significance of concomitant right heart thrombi (RHT) lacks clarity.

METHODS

We performed a meta-analysis of studies that enrolled patients with acute PE to assess the prognostic value of echocardiography-detectable RHT for the primary outcome of short-term all-cause mortality and the secondary outcome of short-term PE-related mortality. Unrestricted searches were conducted of PubMed and Embase from 1980 through January 31, 2016, and used the terms "right heart thrombi," "pulmonary embolism," and "prognos.*" A random effects model was used to pool study results; Begg rank correlation method was used to evaluate for publication bias; and I² testing was used to assess for heterogeneity.

RESULTS

Six of 79 potentially relevant studies met the inclusion criteria (15,220 patients). Overall, 99 of 593 patients with echocardiography-detectable RHT died (16.7% [95% CI, 13.8-19.9]) compared with 639 of 14,627 without RHT (4.4% [95% CI, 4.0-4.7]). RHT had a significant association with short-term all-cause mortality in all patients (OR, 3.0 [95% CI, 2.2 to 4.1]; I² = 20%) and with PE-related death (three cohorts, 12,955 patients; OR: 4.8 [95% CI, 2.0-11.3; I² = 76%). Results were consistent for the prospective (two cohorts, 514 patients; OR, 4.8 [95% CI, 1.7-13.6]; I² = 56%) and the retrospective (four cohorts, 14,706 patients; OR, 2.8 [95% CI, 2.1 to 3.8]; I² = 0%) studies.

CONCLUSIONS

In patients diagnosed with acute PE, concomitant RHT were significantly associated with an increased risk of death within 30 days of PE diagnosis.

TRIAL REGISTRY

PROSPERO registry; No.: CRD42016033960; URL: https://www.crd.york.ac.uk/prospero/.

The Prevalence and Incidence of Atrial Fibrillation in Patients with Acute Pulmonary Embolism

Background

Symptomatic pulmonary embolism (PE) is a major cause of cardiovascular death and morbidity. Estimated prevalence and incidence of atrial fibrillation (AF) in developed countries are between 388–661 per 100,000, and 90–123 per 100,000 person-years respectively. However, the prevalence and incidence of AF in patients presenting with an acute PE and its predictors are not clear.

Methods

Individual patient clinical details were retrieved from a database containing all confirmed acute PE presentations to a tertiary institution from 2001–2012. Prevalence and incidence of AF was tracked from a population registry by systematically searching for AF during any hospital admission (2000–2013) based on International Classification of Disease (ICD-10) code.

Results

Of the 1,142 patients included in this study, 935 (81.9%) had no AF during index PE admission whilst 207 patients had documented baseline AF (prevalence rate 18,126 per 100,000; age-adjusted 4,672 per 100,000). Of the 935 patients without AF, 126 developed AF post-PE (incidence rate 2,778 per 100,000 person-years; age-adjusted 984 per 100,000 person-years). Mean time from PE to subsequent AF was 3.4 ± 2.9 years. Total mortality (mean follow-up 5.0 ± 3.7 years) was 42% (n = 478): 35% (n = 283), 59% (n = 119) and 60% (n = 76) in the no AF, baseline AF and subsequent AF cohorts respectively. Independent predictors for subsequent AF after acute PE include age (hazard ratio [HR] 1.06, 95% confidence interval [CI] 1.04–1.08, p<0.001), history of congestive cardiac failure (HR 1.88, 95% CI 1.12–3.16, p = 0.02), diabetes (HR 1.72, 95% CI 1.07–2.77, p = 0.02), obstructive sleep apnea (HR 4.83, 1.48–15.8, p = 0.009) and day-1 serum sodium level during index PE admission (HR 0.94, 95% CI 0.90–0.98, p = 0.002).

Conclusions

Patients presenting with acute PE have a markedly increased age-adjusted prevalence and subsequent incidence of AF. Screening for AF may be of importance post-PE.

The value of electrocardiographic abnormalities in the prognosis of pulmonary embolism: a consensus paper

Electrocardiographic (ECG) abnormalities in the setting of acute pulmonary embolism (PE) are being increasingly characterized and mounting evidence suggests that ECG plays a valuable role in prognostication for PE. We review the historical 21-point ECG prognostic score for the severity of PE and examine the updated evidence surrounding the utility of ECG abnormalities in prognostication for severity of acute PE. We performed a literature search of MEDLINE, EMBASE, and PubMed up to February 2015. Article titles and abstracts were screened, and articles were included if they were observational studies that used a surface 12-lead ECG as the instrument for measurement, a diagnosis of PE was confirmed by imaging, arteriography or autopsy, and analysis of prognostic outcomes was performed. Thirty-six articles met our inclusion criteria. We review the prognostic value of ECG abnormalities included in the 21-point ECG score, including new evidence that has arisen since the time of its publication. We also discuss the potential prognostic value of several ECG abnormalities with newly identified prognostic value in the setting of acute PE.