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Becattini C, Vedovati MC, Colombo S, Vanni S, Abrignani MG, Scardovi AB, Marrazzo A, Borselli M, Barchetti M, Fabbri A, Dentali F, Maggioni AP, Agnelli G, Gulizia MM. Identification of hemodynamically stable patients with acute pulmonary embolism at high risk for death: external validation of different models. J Thromb Haemost 2024; 22:2502-2513. [PMID: 38810699 DOI: 10.1016/j.jtha.2024.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/14/2024] [Accepted: 04/30/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND The optimal strategy for identification of hemodynamically stable patients with acute pulmonary embolism (PE) at risk for death and clinical deterioration remains undefined. OBJECTIVES We aimed to assess the performances of currently available models/scores for identifying hemodynamically stable patients with acute, symptomatic PE at risk of death and clinical deterioration. METHODS This was a prospective multicenter cohort study including patients with acute PE (NCT03631810). Primary study outcome was in-hospital death within 30 days or clinical deterioration. Other outcomes were in-hospital death, death, and PE-related death, all at 30 days. We calculated positive and negative predictive values, c-statistics of European Society of Cardiology (ESC)-2014, ESC-2019, Pulmonary Embolism Thrombolysis (PEITHO), Bova, Thrombo-embolism lactate outcome study (TELOS), fatty acid binding protein, syncope and tachicardia (FAST), and National Early Warning Scale 2 (NEWS2) for the study outcomes. RESULTS In 5036 hemodynamically stable patients with acute PE, positive predictive values for the evaluated models/scores were all below 10%, except for TELOS and NEWS2; negative predictive values were above 98% for all the models/scores, except for FAST and NEWS2. ESC-2014 and TELOS had good performances for in-hospital death or clinical deterioration (c-statistic of 0.700 and 0.722, respectively), in-hospital death (c-statistic of 0.713 and 0.723, respectively), and PE-related death (c-statistic of 0.712 and 0.777, respectively); PEITHO, Bova, and NEWS2 also had good performances for PE-related death (c-statistic of 0.738, 0.741, and 0.742, respectively). CONCLUSION In hemodynamically stable patients with acute PE, the accuracy for identification of hemodynamically stable patients at risk for death and clinical deterioration varies across the available models/scores; TELOS seems to have the best performance. These data can inform management studies and clinical practice.
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Affiliation(s)
- Cecilia Becattini
- Internal, Vascular and Emergency Medicine - Stroke Unit, Department of Medicine and Surgery, University of Perugia, Perugia, Italy.
| | - Maria Cristina Vedovati
- Internal, Vascular and Emergency Medicine - Stroke Unit, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | | | - Simone Vanni
- Emergency Department, Saint Joseph Hospital, Empoli, Italy
| | | | | | - Alessandra Marrazzo
- General Medicine, Pavullo nel Frignano Hospital, Pavullo nel Frignano, Italy
| | - Matteo Borselli
- Emergency Department, Misericordia Hospital, Grosseto, Italy
| | | | - Andrea Fabbri
- Emergency Department, Romagna Hospital, Forlì, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Aldo Pietro Maggioni
- ANMCO (Associazione Nazionale Medici Cardiologi Ospedalieri) Research Center, Heart Cre Foundation, Florence, Italy
| | - Giancarlo Agnelli
- Internal, Vascular and Emergency Medicine - Stroke Unit, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Mujovic N, Potpara TS. Pulmonary Thromboembolism after Catheter Ablation of Cardiac Arrhythmias. Thromb Haemost 2024; 124:870-873. [PMID: 39013457 DOI: 10.1055/a-2366-7245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Affiliation(s)
- Nebojsa Mujovic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Invasive Electrophysiology, Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Intensive Arrhythmia Care, Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
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Westafer LM, Presti T, Shieh MS, Pekow PS, Barnes GD, Kapoor A, Lindenauer PK. Trends in Initial Anticoagulation Among US Patients Hospitalized With Acute Pulmonary Embolism 2011-2020. Ann Emerg Med 2024:S0196-0644(24)00277-4. [PMID: 38888528 DOI: 10.1016/j.annemergmed.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 06/20/2024]
Abstract
STUDY OBJECTIVE Guidelines recommend low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOACs) rather than unfractionated heparin (UFH) for treatment of acute pulmonary embolism (PE) given their efficacy and reduced risk of bleeding. Using data from a large consortium of US hospitals, we examined trends in initial anticoagulation among hospitalized patients diagnosed with acute PE. METHODS We conducted a retrospective study of inpatient and observation cases between January 1, 2011, and December 31, 2020, among individuals aged more than or equal to 18 years treated at acute care hospitals contributing data to the Premier Healthcare Database. Included cases received a diagnosis of acute PE, underwent imaging for PE, and received anticoagulation at the time of admission. The primary outcome was the initial anticoagulant selected for treatment. RESULTS Among 299,016 cases at 1,045 hospitals, similar proportions received initial treatment with UFH (47.4%) and LMWH (47.9%). Between 2011 and 2020, the proportion of patients initially treated with UFH increased from 41.9% to 56.3%. Over this period, use of LMWH as the initial anticoagulant was reduced from 58.1% in 2011 to 37.3% in 2020. The proportion of cases admitted to the ICU, treated with mechanical ventilation or vasopressors, and inpatient mortality were stable. Factors most strongly associated with receipt of UFH were admission to the ICU (odds ratio [OR] 6.90; 95% confidence interval [CI] 6.31 to 7.54) or step-down unit (OR 2.30; 95% CI 2.16 to 2.45), receipt of thrombolysis (OR 4.25; 95% CI 3.09 to 5.84) or vasopressors (OR 1.83; 95% CI 1.32 to 2.54), and chronic renal disease (OR 1.67; 95% CI 1.54 to 1.81). CONCLUSIONS Despite recommendations that LMWH and DOACs be considered first-line for most patients with acute PE, use of UFH is common and increasing. Further research is needed to elucidate factors associated with persistent use of UFH and opportunities for deimplementation of low-value care.
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Affiliation(s)
- Lauren M Westafer
- Department of Emergency Medicine, University of Massachusetts Chan Medical School - Baystate, Springfield, MA; Department of Healthcare Delivery and Population Science University of Massachusetts Chan Medical School - Baystate, Springfield, MA.
| | - Thomas Presti
- Division of Pulmonary and Critical Care, Baystate Medical Center, Springfield, MA
| | - Meng-Shiou Shieh
- Department of Healthcare Delivery and Population Science University of Massachusetts Chan Medical School - Baystate, Springfield, MA
| | - Penelope S Pekow
- Department of Healthcare Delivery and Population Science University of Massachusetts Chan Medical School - Baystate, Springfield, MA; School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Alok Kapoor
- Department of Population and Quantitative Health Science, University of Massachusetts Medical School, Worcester, MA; Department of Medicine, Division of Hospital Medicine, University of Massachusetts Chan Medical School, Worcester, MA
| | - Peter K Lindenauer
- Department of Healthcare Delivery and Population Science University of Massachusetts Chan Medical School - Baystate, Springfield, MA; Department of Population and Quantitative Health Science, University of Massachusetts Medical School, Worcester, MA; Division of Hospital Medicine, Baystate Medical Center, Springfield, MA
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Pizzi R, Cimini LA, Ageno W, Becattini C. Direct Oral Anticoagulants for Pulmonary Embolism. Hamostaseologie 2024; 44:206-217. [PMID: 38467144 DOI: 10.1055/a-2105-8736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Abstract
Venous thromboembolism (VTE) is the third most common cardiovascular disease. For most patients, the standard of treatment has long consisted on low-molecular-weight heparin followed by vitamin K antagonists, but a number of clinical trials and, subsequently, post-marketing studies have shown that direct oral anticoagulants (DOACs) with or without lead-in heparin therapy are effective alternatives with fewer adverse effects. This evidence has led to important changes in the guidelines on the treatment of VTE, including pulmonary embolism (PE), with the DOACs being now recommended as the first therapeutic choice. Additional research has contributed to identifying low-risk PE patients who can benefit from outpatient management or from early discharge from the emergency department with DOAC treatment. There is evidence to support the use of DOACs in intermediate-risk PE patients as well as in high-risk patients receiving thrombolytic treatment. The use of DOACs has also been proven to be safe and effective in special populations of PE patients, such as patients with renal impairment, liver impairment, and cancer.
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Affiliation(s)
- Roberto Pizzi
- Department of Emergency Medicine and Thrombosis Center, Ospedale di Circolo di Varese and Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Ludovica Anna Cimini
- Vascular and Internal Medicine- Stroke Unit, University of Perugia, Perugia, Italy
| | - Walter Ageno
- Department of Emergency Medicine and Thrombosis Center, Ospedale di Circolo di Varese and Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Cecilia Becattini
- Vascular and Internal Medicine- Stroke Unit, University of Perugia, Perugia, Italy
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Donadini MP, Mumoli N, Fenu P, Pomero F, Re R, Palmiero G, Spadafora L, Mazzi V, Grittini A, Bertù L, Aujesky D, Dentali F, Ageno W, Squizzato A. The Clinical Impact of the Pulmonary Embolism Severity Index on the Length of Hospital Stay of Patients with Pulmonary Embolism: A Randomized Controlled Trial. Diagnostics (Basel) 2024; 14:776. [PMID: 38611689 PMCID: PMC11011567 DOI: 10.3390/diagnostics14070776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/02/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND The Pulmonary Embolism Severity Index (PESI) is an extensively validated prognostic score, but impact analyses of the PESI on management strategies, outcomes and health care costs are lacking. Our aim was to assess whether the adoption of the PESI for patients admitted to an internal medicine ward has the potential to safely reduce the length of hospital stay (LOS). METHODS We carried out a multicenter randomized controlled trial, enrolling consecutive adult outpatients diagnosed with acute PE and admitted to an internal medicine ward. Within 48 h after diagnosis, the treating physicians were randomized, for every patient, to calculate and report the PESI in the clinical record form on top of the standard of care (experimental arm) or to continue routine clinical practice (standard of care). The ClinicalTrials.gov identifier is NCT03002467. RESULTS This study was prematurely stopped due to slow recruitment. A total of 118 patients were enrolled at six internal medicine units from 2016 to 2019. The treating physicians were randomized to the use of the PESI for 59 patients or to the standard of care for 59 patients. No difference in the median LOS was found between the experimental arm (8, IQR 6-12) and the standard-of-care arm (8, IQR 6-12) (p = 0.63). A pre-specified secondary analysis showed that the LOS was significantly shorter among the patients who were treated with DOACs (median of 8 days, IQR 5-11) compared to VKAs or heparin (median of 9 days, IQR 7-12) (p = 0.04). CONCLUSIONS The formal calculation of the PESI in the patients already admitted to internal medicine units did not impact the length of hospital stay.
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Affiliation(s)
- Marco Paolo Donadini
- Thrombosis and Haemostasis Center, Ospedale di Circolo, ASST Sette Laghi, 21100 Varese, Italy; (M.P.D.); (F.D.); (W.A.)
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, 21100 Varese and 22100 Como, Italy; (L.B.); (A.S.)
| | - Nicola Mumoli
- Department of Internal Medicine, Magenta Hospital, 20013 Magenta, Italy;
- Presidio Ospedaliero di Livorno, Azienda USL Toscana Nord Ovest, 57124 Livorno, Italy;
| | - Patrizia Fenu
- Presidio Ospedaliero di Cecina, Azienda USL Toscana Nord Ovest, 57023 Cecina, Italy;
| | - Fulvio Pomero
- Internal Medicine Unit, Michele e Pietro Ferrero Hospital, 12060 Verduno, Italy; (F.P.); (L.S.)
| | - Roberta Re
- Medicina Interna, Ospedale S. Andrea, ASL Vercelli, 13100 Vercelli, Italy;
| | - Gerardo Palmiero
- Ospedale Versilia, Azienda USL Toscana Nord Ovest, 55049 Viareggio, Italy;
| | - Laura Spadafora
- Internal Medicine Unit, Michele e Pietro Ferrero Hospital, 12060 Verduno, Italy; (F.P.); (L.S.)
| | - Valeria Mazzi
- Presidio Ospedaliero di Livorno, Azienda USL Toscana Nord Ovest, 57124 Livorno, Italy;
| | | | - Lorenza Bertù
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, 21100 Varese and 22100 Como, Italy; (L.B.); (A.S.)
| | - Drahomir Aujesky
- Department of General Internal Medicine, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Francesco Dentali
- Thrombosis and Haemostasis Center, Ospedale di Circolo, ASST Sette Laghi, 21100 Varese, Italy; (M.P.D.); (F.D.); (W.A.)
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, 21100 Varese and 22100 Como, Italy; (L.B.); (A.S.)
| | - Walter Ageno
- Thrombosis and Haemostasis Center, Ospedale di Circolo, ASST Sette Laghi, 21100 Varese, Italy; (M.P.D.); (F.D.); (W.A.)
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, 21100 Varese and 22100 Como, Italy; (L.B.); (A.S.)
| | - Alessandro Squizzato
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, 21100 Varese and 22100 Como, Italy; (L.B.); (A.S.)
- Internal Medicine Unit, ‘Sant’Anna’ Hospital, ASST Lariana, 22042 San Fermo della Battagli, Italy
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Spoladore R, Milani M, Spreafico LP, Agnelli G, Savonitto S. Prevention of thromboembolism after a fracture: is aspirin enough? Eur Heart J Suppl 2024; 26:i102-i107. [PMID: 38867879 PMCID: PMC11167982 DOI: 10.1093/eurheartjsupp/suae025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
Venous thromboembolism (VTE) is a serious complication that can arise during and after hospitalization, particularly following surgery under general anaesthesia. Particularly at risk are major orthopaedic surgical procedures such as elective knee or hip replacement and the treatment of hip fractures. In these patients, current guidelines recommend (low or low-moderate level of evidence) aspirin as a possible alternative to anticoagulant therapy for the prophylaxis of long-term venous thromboembolism after an initial period with anticoagulant drugs. Several randomized trials and meta-analyses demonstrate no significant differences in the risk of VTE when comparing aspirin with anticoagulants. However, it must be considered that most recommendations are based on elective orthopaedic surgery and that trials after fractures have excluded patients at high thrombotic risk. Consequently, the overall incidence of major clinical events (death and pulmonary embolism) was ∼1% with wide confidence margins in even large non-inferiority studies. The incidence of asymptomatic VTE, especially distal, appears to be higher with aspirin. Patient preference and lower costs could play an important role in the choice in favour of aspirin.
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Affiliation(s)
| | | | | | - Giancarlo Agnelli
- Department of Medicine, University of Perugia, Perugia, Italy
- Department of Medicine, ICS Maugeri IRCCS, Pavia, Italy
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Zuin M, Becattini C, Piazza G. Early predictors of clinical deterioration in intermediate-high risk pulmonary embolism: clinical needs, research imperatives, and pathways forward. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:297-303. [PMID: 37967341 DOI: 10.1093/ehjacc/zuad140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/17/2023]
Abstract
A subset of intermediate-high risk pulmonary embolism (PE) patients will suffer clinical deterioration in the early hours following the acute event. Current evidence-based guidelines for the management of acute PE have provided limited direction for identification of which intermediate-high risk PE patients will go on to develop haemodynamic decompensation. Furthermore, a paucity of data further hampers guideline recommendations regarding the optimal approach and duration of intensive monitoring, best methods to assess the early response to anticoagulation, and the ideal window for reperfusion therapy, if decompensation threatens. The aim of the present article is to identify the current unmet needs related to the early identification of intermediate-high risk PE patients at higher risk of clinical deterioration and mortality during the early hours after the acute cardiovascular event and suggest some potential strategies to further explore gaps in the literature.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Via Luigi Borsari, 46 - 44121 Ferrara, Italy
| | - Cecilia Becattini
- Department of Internal Medicine, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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González S, Najarro M, Briceño W, Rodríguez C, Barrios D, Morillo R, Olavarría A, Lietor A, Gómez Del Olmo V, Osorio Á, Sánchez-Recalde Á, Muriel A, Jiménez D. Impact of a pulmonary embolism response team (PERT) in the prognosis of patients with acute symptomatic pulmonary embolism. Rev Clin Esp 2024; 224:141-149. [PMID: 38336141 DOI: 10.1016/j.rceng.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
BACKGROUND The effect of a pulmonary embolism response team (PERT) in the short-term prognosis of patients with acute symptomatic pulmonary embolism (PE) lacks clarity. We therefore aimed at evaluating the effect of a PERT team on short-term mortality among patients with acute PE. METHODS We retrospectively reviewed consecutive patients with acute symptomatic PE enrolled in a single-center registry between 2007 and 2022. We used propensity score matching to compare treatment effects for patients with similar predicted probabilities of receiving management by the PERT team. The primary outcome was all-cause mortality within 30 days following the diagnosis of PE. The secondary outcome was 30-day PE-related mortality. RESULTS Of the 2,902 eligible patients who had acute symptomatic PE, 223 (7.7%; 95% confidence interval [CI], 6.7%-8.7%) were managed by the PERT team. Two hundred and seven patients who were treated by the PERT were matched with 207 patients who were not. Matched pairs did not show a statistically significant lower all-cause (odds ratio [OR], 1.09; 95% CI, 0.63-1.89) or PE-related death (OR, 1.30; 95% CI, 0.47-3.62) for PERT management compared with no PERT management through 30 days after diagnosis of PE. CONCLUSIONS Our results suggest that multidisciplinary care of patients with acute symptomatic PE by a PERT team is not associated with a significant reduction in short-term all-cause or PE-related mortality.
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Affiliation(s)
- S González
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - M Najarro
- Servicio de Urgencias, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - W Briceño
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - C Rodríguez
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - D Barrios
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - R Morillo
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - A Olavarría
- Servicio de Radiología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - A Lietor
- Servicio de Medicina Intensiva, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - V Gómez Del Olmo
- Servicio de Medicina Interna, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Á Osorio
- Servicio de Cirugía Vascular, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Á Sánchez-Recalde
- Servicio de Cardiología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Alfonso Muriel
- Servicio de Bioestadística, Hospital Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain
| | - D Jiménez
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain; Departamento de Medicina, Universidad de Alcalá, Madrid, Spain.
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Casey SD, Stubblefield WB, Luijten D, Klok FA, Westafer LM, Vinson DR, Kabrhel C. Addressing the rising trend of high-risk pulmonary embolism mortality: Clinical and research priorities. Acad Emerg Med 2024; 31:288-292. [PMID: 38129964 DOI: 10.1111/acem.14859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Deaths from high-risk pulmonary embolism (PE) appear to have increased in the US over the last decade. Modifiable risks contributing to this worrisome trend present opportunities for physicians, researchers, and healthcare policymakers to improve care. METHODS We sought to contextualize contemporary, high-risk PE epidemiology and examine clinical trials, quality improvement opportunities, and healthcare policy initiatives directed at reducing mortality. RESULTS We observed significant and modifiable excess mortality due to high-risk PE. We identified several opportunities to improve care including: (1) rapid translation of forthcoming data on reperfusion strategies into clinical practice; (2) improved risk stratification tools; (3) quality improvement initiatives to address presumptive anticoagulation practice gaps; and (3) adoption of health policy initiatives to establish pulmonary embolism response teams and address the social determinants of health. CONCLUSION Addressing knowledge and practice gaps in intermediate and high-risk PE management must be prioritized and informed by forthcoming high-quality data. Implementation efforts are needed to improve acute PE management and resolve treatment disparities.
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Affiliation(s)
- Scott D Casey
- Kaiser Permanente Division of Research, Oakland, California, USA
- The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, California, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dieuwke Luijten
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medicine Center, Leiden, Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medicine Center, Leiden, Netherlands
| | - Lauren M Westafer
- Department of Emergency Medicine, UMASS Chan Medical School-Baystate, Springfield, Massachusetts, USA
- Department of Healthcare Delivery and Population Science, UMASS Chan Medical School-Baystate, Springfield, Massachusetts, USA
| | - David R Vinson
- Kaiser Permanente Division of Research, Oakland, California, USA
- The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Farmakis IT, Kaier K, Hobohm L, Mohr K, Valerio L, Barco S, Konstantinides SV, Binder H. Healthcare resource utilisation and associated costs after low-risk pulmonary embolism: pre-specified analysis of the Home Treatment of Pulmonary Embolism (HoT-PE) study. Clin Res Cardiol 2024:10.1007/s00392-023-02355-5. [PMID: 38170252 DOI: 10.1007/s00392-023-02355-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Pulmonary embolism (PE) and its sequelae impact healthcare systems globally. Low-risk PE patients can be managed with early discharge strategies leading to cost savings, but post-discharge costs are undetermined. PURPOSE To define healthcare resource utilisation and overall costs during follow-up of low-risk PE. METHODS We used an incidence-based, bottom-up approach and calculated direct and indirect costs over 3-month follow-up after low-risk PE, with data from the Home Treatment of Patients with Low-Risk Pulmonary Embolism (HoT-PE) cohort study. RESULTS Average 3-month costs per patient having suffered low-risk PE were 7029.62 €; of this amount, 4872.93 € were associated with PE, accounting to 69.3% of total costs. Specifically, direct costs totalled 3019.33 €, and of those, 862.64 € (28.6%) were associated with PE. Anticoagulation (279.00 €), rehospitalisations (296.83 €), and ambulatory visits (194.95 €) comprised the majority of the 3-month direct costs. The remaining costs amounting to 4010.29 € were indirect costs due to loss of productivity. CONCLUSION In a patient cohort with acute low-risk PE followed over 3 months, the majority of costs were indirect costs related to productivity loss, whereas direct, PE-specific post-discharge costs were low. Effective interventions are needed to reduce the burden of PE and associated costs, especially those related to productivity loss.
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Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Katharina Mohr
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany.
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece.
| | - Harald Binder
- Institute of Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
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Weber C, Rigby A, Lip GYH. Thrombosis and Haemostasis 2023 Editors' Choice Papers. Thromb Haemost 2024; 124:80-87. [PMID: 38211580 DOI: 10.1055/s-0043-1778032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Affiliation(s)
- Christian Weber
- Institute for Cardiovascular Prevention (IPEK), LMU Munich, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Munich, Germany
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Anne Rigby
- Institute for Cardiovascular Prevention (IPEK), LMU Munich, Munich, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Becattini C. Provoked vs minimally provoked vs unprovoked VTE: does it matter? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:600-605. [PMID: 38066936 PMCID: PMC10727063 DOI: 10.1182/hematology.2023000492] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Venous thromboembolism (VTE) is a multifactorial disease, and its risk depends on exposure to risk factors and predisposing conditions. Based on their strength of association with a VTE episode, risk factors are classified as major or minor and determined using a temporal pattern to be transient or persistent. All patients with VTE should receive anticoagulant treatment for at least 3 months in the absence of an absolute contraindication. Beyond this period, selected patients may be candidates for an extended phase of anticoagulation aimed at secondary VTE prevention. The risk of recurrent VTE if anticoagulation is discontinued is probably the main driver of decision-making regarding extended treatment. The risk of recurrence after VTE associated with major risk factors is low if the risk factor is no longer present. In this case, treatment can be discontinued. If the major risk factor is persistent, anticoagulation should be continued. After VTE occurring in the absence of risk factors, anticoagulation should probably be continued indefinitely if the risk for bleeding is low and preferably with minimal effective doses of anticoagulants. VTE occurring after exposure to minor risk factors is probably the most challenging situation, especially if the clinical manifestation was acute pulmonary embolism. Understanding the actual role of minor risk factors in the occurrence of VTE helps in estimating the risk of recurrence and avoiding the dangers associated with unnecessary anticoagulation. The availability of safer strategies for anticoagulation could allow personalized strategies for secondary prevention of VTE.
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Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
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