Pulmonary embolism in the elderly

Patients Who Have a Prior History of Pulmonary Embolism Require Increased Postoperative Care Following Total Joint Arthroplasty

BACKGROUND

This study examined the effect of prior pulmonary embolism (PE) on total joint arthroplasty (TJA) outcomes.

METHODS

We reviewed patients who had a prior PE undergoing TJA at a single tertiary medical center between January 1, 2012 and January 1, 2021. There were 177 TJA patients who had a prior PE who underwent 1:3 propensity-matching to patients without a history of prior PE. Bivariable and multivariable analyses were performed. Changes over time were evaluated.

RESULTS

Patients undergoing total knee arthroplasty who had a prior PE had more complications (25.3% versus 2.0%, P < .001), and postoperative PE (17.3% versus 0.0%, P < .001).and longer hospitalizations (3.15 versus 2.32 days, P = .006). Patients undergoing total hip arthroplasty who had a prior PE demonstrated more complications (14.7% versus 1.77%, P < .001) more postoperative PE (17.3% versus 0.0%, P < .001), and longer hospitalizations (3.30 versus 2.11 days, P < .001). Over the study, complication rates and hospitalizations lengths remained elevated in patients who had a prior PE. On multivariate analyses, prior PE was associated with longer hospitalizations (β: 0.67, P = .015) and increased complications (odds ratio [OR]: 9.44, P < .001) among total hip arthroplasty patients. Total knee arthroplasty patients had increased readmission (OR: 4.89, P = .003) and complication rates (OR: 21.4, P < .001).

CONCLUSIONS

Patients undergoing TJA who had a prior PE are at higher risk of requiring postoperative care. Therefore, thorough preoperative evaluation must be implemented, especially in clinical environments lacking resources for acute care escalation.

In-Hospital versus Out-of-Hospital Pulmonary Embolism: Clinical Characteristics, Biochemical Markers and Echocardiographic Indices

BACKGROUND

A significant proportion of pulmonary embolisms (PEs) occurs in patients during hospitalisation for another reason. However, limited data regarding differences between out-of-hospital PE (OHPE) and in-hospital PE (IHPE) is available. We aimed to compare these groups regarding their clinical characteristics, biochemical markers, and echocardiographic indices.

METHODS

This was a prospective, single-arm, single-centre study. Adult consecutive patients with non-COVID-related PE from September 2019 to March 2022 were included and followed up for 12 months.

RESULTS

The study included 180 (84 women) patients, with 89 (49.4%) suffering from IHPE. IHPE patients were older, they more often had cancer, were diagnosed earlier after the onset of symptoms, they had less frequent pain and higher values of high sensitivity troponin I and brain natriuretic peptide levels compared to OHPE patients. Echocardiographic right ventricular (RV) dysfunction was detected in similar proportions in the 2 groups. IHPE had increased in-hospital mortality (14.6% vs. 3.3%, p = 0.008) and similar post-discharge to 12-month mortality with OHPE patients.

CONCLUSIONS

In this prospective cohort study, IHPE differed from OHPE patients regarding age, comorbidities, symptoms, and levels of biomarkers associated with RV dysfunction. IHPE patients had higher in-hospital mortality compared to OHPE patients and a similar risk of death after discharge.

Trends in prescribing and outcomes in obese versus non-obese patients receiving rivaroxaban therapy: an observational study using real-world data

PURPOSE

To investigate real-world prescribing trends and clinical outcomes based on body mass index (BMI) categorization in patients who received rivaroxaban therapy.

METHODS

This was a retrospective cohort study involving all patients who received rivaroxaban therapy across all Hamad Medical Corporation (HMC) hospitals from 2015 to 2020.

RESULTS

The number of patients initiated on rivaroxaban therapy significantly increased from 152 (3.3%) in 2015 to 1342 (28.9%) in 2020 (p <0.001). Within BMI categories, a similar increasing trend was observed in underweight, normal, and overweight patients, while from 2018 to 2020, there was a decreasing trend in rivaroxaban prescribing in all obese classes. The prevalence rate of all-cause mortality differed significantly between the BMI groups, with the highest mortality being among morbidly obese patients (BMI ≥ 40 kg/m2) (p< 0.001). On the other hand, no significant differences were found between the BMI groups in terms of bleeding, pulmonary embolism, deep vein thrombosis and stroke incidences. Multivariate logistic regression analyses showed that the likelihood of all-cause mortality was significantly higher in overweight and all categories of obese patients compared to underweight patients: overweight (OR: 5.3, 95% CI: 2.3-11.9, p< 0.001); obese class 1 (OR: 5.4, 95% CI: 2.3 - 12.2, p< 0.001); obese class 2 (OR: 6.5, 95% CI: 2.7 - 15.6, p< 0.001); and obese class 3 (OR: 3.7, 95% CI: 1.6 - 8.7, p = 0.003).

CONCLUSIONS

Rivaroxaban prescribing has significantly increased over the years across general population, with a noticeable decline in obese population during the last few years (from 2018 onwards). Furthermore, an appreciable association was evident between all-cause mortality and BMI of these patients.

Risk factors of pulmonary embolism in the elderly patients: a retrospective study

AIM

We aimed to summarize the clinical feature and risk factors of patients suffering from pulmonary embolism (PE) in the elderly patients, and explore the change in D-dimer after anti-coagulant therapy.

METHODS

A total of 426 patients with PE admitted from August 2012 to January 2019 in the Cangzhou Central Hospital were analyzed in this retrospective study. A comparison of clinical features and risk factors was conducted between the elderly group and non-elderly groups. Blood levels of D-dimer, C-reactive protein (CRP), tumor necrosis factor-α and interferon-γ were measured before and 3 days after anti-coagulant therapy in two groups.

RESULTS

The most important risk factor for the elderly patients was stroke, while for non-elderly patients was deep vein thrombosis (DVT). After anti-coagulant therapy, the decreasing level of D-dimer and CRP showed statistically significant differences between the two groups. Between the elderly and non-elderly groups, the main clinical manifestations were similar. The risk factors of elderly patients were chronic obstructive pulmonary disease, malignant tumor, DVT and stroke. After anti-coagulant therapy, the content of D-dimer was lower than 3 days ago.

CONCLUSION

Blood levels of D-dimer and CRP may be potent screening markers for PE especially among elderly patients.

Coagulation and Aging: Implications for the Anesthesiologist

Purpose of Review

This narrative review focuses on aging-related modifications in coagulation resulting in increased thromboembolic and hemorrhagic risk of the elderly. We further discuss the current evidence and emerging data relating the perioperative treatment of elderly patients with antithrombotic therapy.

Recent Findings

Relevant changes in all elements of the Virchow’s triad can be found with aging. Increased blood stasis due to immobility, progressive endothelial dysfunction with altered microcirculation, elevated concentrations of several coagulation factors, and increased platelet reactivity all lead to a procoagulant state. Elderly people are, therefore, commonly treated with oral anticoagulation and antiplatelet drugs. This antithrombotic therapy might be essentially causative for their increased bleeding risk.

Summary

Elderly patients are at increased risk for thromboembolism due to changes in the hemostatic system in combination with frailty and multimorbidity. Both the thromboembolic due to aging and bleeding risk due to antithrombotic therapy need special attention in the elderly surgical patients.

Pulmonary Embolism Hospitalization, Readmission, and Mortality Rates in US Older Adults, 1999-2015

This study uses Medicare billing codes to characterize trends in readmission and mortality rates for Medicare fee-for-service beneficiaries with pulmonary embolism (PE) between 1999 and 2015 to assess changes accompanying recent diagnostic and therapeutic changes in management of the disease.

The problem of under-diagnosis and over-diagnosis of pulmonary embolism

Pulmonary embolism (PE) is an increasingly recognised condition which is associated with significant morbidity and mortality. Despite the better awareness of this serious condition, the diagnosis is still overlooked in many cases with sometimes fatal consequences. Under-diagnosis may be due to several reasons including reliance on non-specific 'classic' symptoms, belief that bedside measurements will likely be abnormal in the setting of acute PE, and confounding factors like co-existent cardiorespiratory diseases or being in an intensive care unit, where the diagnosis may not be considered. At the same time, incidental diagnosis of PE is occurring more often due to frequent use of imaging investigations alongside advancements in CT technology, and dilemma exists as to whether the chance finding of PE requires anticoagulation, especially when identified only at the subsegmental level. This article reviews these two issues of under-diagnosis and over-diagnosis of PE in the current era.

Low-Molecular-Weight Heparin for the Treatment of Venous Thromboembolism in the Elderly

Venous thromboembolism (deep vein thrombosis and/or pulmonary embolism) is a common problem in the elderly population. Indeed, increasing age is a significant risk factor for venous thromboembolism. The treatment of venous thromboembolism in the elderly population presents certain unique problems related to aging, such as decreasing body weight, increasing renal insufficiency and numerous comorbid conditions, which complicate therapy. Treatment of venous thromboembolism in the elderly has been complicated by an increased incidence of bleeding, particularly with the use of warfarin. The risk of bleeding may be substantially reduced by carefully adjusting the warfarin dose to maintain a therapeutic INR and for this purpose anticoagulant management clinics have been shown to be useful. The low-molecular-weight heparins have been shown to be efficacious and safe for the treatment of venous thromboembolism in several clinical trials, including many patients in the older age brackets. Furthermore, these agents can safely be used in the out-of-hospital setting. Long-term use of low-molecular-weight heparin is an alternative to the use of oral anticoagulant therapy, particularly in patients with cancer or recurrent venous thromboembolism.

The effect of aging on pulmonary function: implications for monitoring and support of the surgical and trauma patient

Age-related anatomic, physiologic, and immunologic changes to the pulmonary system, as well as a high prevalence of chronic pulmonary diseases, puts the geriatric patient at an especially high risk for postoperative pulmonary complications. Successful perioperative respiratory care of the geriatric patient relies on careful risk assessment and optimization of pulmonary function and support. The success of such efforts aimed at preventing and/or mitigating pulmonary complications in the geriatric patient depends on a thorough, individualized, yet standardized and evidence-based approach to the care of every patient.

Prophylaxis against pulmonary embolism in patients undergoing total hip arthroplasty

BACKGROUND

The optimal method of prophylaxis for the prevention of pulmonary embolism in patients undergoing total hip arthroplasty remains controversial. Guidelines appear to be contradictory. The purpose of the present study was to examine whether a best prophylactic agent exists for the prevention of postoperative pulmonary embolism and whether the type of anesthesia affects the rates of pulmonary embolism.

METHODS

From 2001 to 2008, a total joint registry from a nationwide health maintenance organization was evaluated to determine the rates of pulmonary embolism, fatal pulmonary embolism, and death among 17,595 patients without a history of venous thromboembolism who were managed with unilateral total hip arthroplasty. All patients were followed for ninety days postoperatively. Data were abstracted electronically and were validated through chart reviews. Multivariate logistic regression models were used to assess associations between the types of prophylaxis and anesthesia that were used and pulmonary embolism while adjusting for other risk factors.

RESULTS

Patients received either mechanical prophylaxis alone (N = 1533) or chemical prophylaxis (aspirin [N = 934], Coumadin [warfarin] [N = 6063], or low-molecular-weight heparin [N = 7202]) with or without mechanical prophylaxis. The rate of pulmonary embolism was 0.41% (95% confidence interval [CI], 0.32% to 0.51%) overall, 0.37% (95% CI, 0.05% to 0.70%) for mechanical prophylaxis, 0.43% (95% CI, 0.01% to 0.85%) for aspirin, 0.43% (95% CI, 0.26% to 0.59%) for Coumadin, 0.40% (95% CI, 0.26% to 0.55%) for low-molecular-weight heparin, 0.43% (95% CI, 0.28% to 0.58%) for general anesthesia, and 0.40% (95% CI, 0.28% to 0.52%) for non-general anesthesia. The mortality rate was 0.51% (95% CI, 0.40% to 1.01%) overall, 0.67% (95% CI, 0.23% to 1.34%) for mechanical prophylaxis, 0.64% (95% CI, 0.13% to 1.28%) for aspirin, 0.51% (95% CI, 0.33% to 1.02%) for Coumadin, 0.42% (95% CI, 0.27% to 0.83%) for low-molecular-weight heparin, 0.51% (95% CI, 0.35% to 0.67%) for general anesthesia, and 0.50% (95% CI, 0.36% to 0.64%) for non-general anesthesia. Regression models did not show any association between the type of prophylaxis used or the choice of anesthesia and increased odds of pulmonary embolism when adjusting for age, sex, and American Society of Anesthesiologists score.

CONCLUSIONS

No clinical differences were detected among the types of prophylaxis against venous thromboembolism or the types of anesthesia with respect to pulmonary embolism, fatal pulmonary embolism, or death on the basis of prospective collection of data by a contemporary total joint registry.

Pulmonary Emergencies in the Elderly

The aging process results in changes in pulmonary physiology that make the elderly population more susceptible to pulmonary disease. These physiologic changes also alter the clinical presentation of such diseases, making the diagnosis and treatment of pulmonary disorders particularly challenging for the clinician. It is important for the clinician to have a high index of suspicion for pulmonary disorders to make the proper diagnosis. It is essential to keep in mind the subtle differences between pulmonary diseases in the elderly compared with younger patients.

Pulmonary embolism: an unsuspected killer

The presentation of PE is often subtle and may mimic other diseases. Many pulmonary emboli invariably preclude diagnosis by their occult nature or by leading to rapid death from cardiopulmonary arrest. In patients who do manifest symptoms from PE, accurate diagnosis is essential. Often it is difficult to distinguish the vague symptoms of PE from other diagnoses, such as acute coronary syndrome, pneumonia, COPD, CHF,aortic dissection, myocarditis or pericarditis, pneumothorax, and musculo-skeletal or gastrointestinal causes. Regardless of the presentation, the most fundamental step in making the diagnosis of PE is first to consider it. Historical clues and risk factors should raise the clinician's suspicion.PE is an unsuspected killer with a nebulous presentation and high mortality. In all likelihood, PE will remain an elusive diagnosis despite advances in technology and a wealth of research. A high index of suspicion is required, but no amount of suspicion would eliminate all missed cases. Patients with significant underlying cardiopulmonary disease seem to be the most challenging. Patients with significant comorbidity have poor reserve and are likely to have poor outcomes, especially if the diagnosis is not made and anticoagulation is not initiated early. Controversy exists over the best diagnostic approach to PE. A battery of diagnostic studies is available, with few providing definitive answers. Studies such as CT may be helpful at some institutions but offer poor predictive value at others. Other diagnostic tests are not universally available. It is hoped that further research and improvements in current diagnostic modalities will clear some of the current confusion and controversy of this ubiquitous and deadly disease.

The Management of Venous Thromboembolic Disease in Older Adults

The incidence and prevalence of venous thromboembolic disease (VTED) increase progressively with age. Although the clinical features, diagnosis, and treatment of VTED are generally similar in older and younger adults, prevalent comorbidities often complicate the management of VTED in the elderly. The Sixth American College of Chest Physicians Consensus Conference on Antithrombotic Therapy provides comprehensive recommendations for the management of VTED. This article summarizes these recommendations as they apply to older adults and highlights factors that may modulate the diagnosis and treatment of VTED in the elderly patient.

Pulmonary embolism

PE is one of the great challenges in medicine. It is a disease that carries with it a high mortality rate, yet no historical piece of information, physical examination finding, or diagnostic modality is perfect at excluding its possibility. Emergency physicians must be vigilant about considering PE in the differential diagnosis of a variety of presenting complaints and must use a variety of diagnostic and therapeutic options as they manage patients with suspected or confirmed PE. The diagnostic options range from bedside diagnostic tests to highly specialized imaging available at only specialized institutions. Knowing the advantages and disadvantages of each of the diagnostic modalities assists the physician in employing the best test. Therapeutic options also vary widely and include anticoagulation, vena caval interruption, systemic thrombolysis, embolectomy, and other therapeutic adjuncts, such as ECMO and inhaled nitric oxide. Similarly, awareness of the indications and contraindications to the varied therapeutic agents ensures appropriate therapy when the diagnosis is made.

Pulmonary embolism in very old patients

BACKGROUND AND AIMS

Diagnosis of pulmonary embolism (PE) in the elderly remains difficult and is often late, although its incidence increases steadily with age. Since few studies have reported the clinical picture of this disease in very old patients, the aim of our study was to focus on clinical, instrumental and laboratory aspects in patients 75 years of age and over with suspected PE.

METHODS

Symptoms, signs, risk factors for venous thromboembolic diseases, 12-lead electrocardiograms, B-mode echocardiograms, chest X-rays, leg compression venous ultrasonography, latex-assay quantitative D-dimer, and arterial blood gas analyses were collected for 96 elderly patients of 75 years and over (mean age 81.22 +/- 4.81) with suspected PE, admitted to our acute geriatric ward from 1997 to 2000. Patients were divided into two groups: 59 patients with PE (PE+) confirmed by pulmonary angiography, scintigraphic lung scan or necropsy, and 37 patients with normal lung scan or without PE at necropsy (PE-).

RESULTS

Dyspnea and chest pain were the most common symptoms in both groups, but significantly more frequent in the PE+ group. Tachycardia, fever, cyanosis, and tachypnea were the most common objective signs in both groups; tachycardia and tachypnea were not significantly different between the two groups. Bed rest, venous insufficiency and leg deep vein thrombosis were the most common venous risk factors in PE+ and significantly different with respect to PE-. Sinus tachycardia, ST-T abnormalities and right bundle branch block were the most common electrocardiographic aspects in PE+; echocardiograms showed significantly more frequent acute involvement of right heart in PE+, whereas chest X-rays were rarely compatible with PE and did not reveal differences between the two groups. D-Dimer was significantly higher in PE+ but was below 500 ng/mL only in 25% of cases in PE-. More severe hypoxemla, oxy-hemoglobin hyposaturation and increased alveolar-arterial oxygen gradients were found at arterial blood gas analysis in PE+.

CONCLUSIONS

Although many analyzed clinical, instrumental and laboratory aspects were significantly more frequent in the PE+ group, they were all non-specific and not conclusive for diagnosis of PE. Our retrospective study focus may add information about the picture and diagnostic difficulties of PE in very old patients.