1
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Xie L, Lan P, Liu M, Zhou K. ECMO management for severe pulmonary embolism with concurrent cerebral hemorrhage: a case report. Front Cardiovasc Med 2024; 11:1410134. [PMID: 38803663 PMCID: PMC11128567 DOI: 10.3389/fcvm.2024.1410134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 05/01/2024] [Indexed: 05/29/2024] Open
Abstract
Background Acute pulmonary embolism (APE) is a common and potentially fatal cardiovascular disease that can lead to sudden cardiac arrest in severe cases. When conventional cardiopulmonary resuscitation measures fail to achieve the return of spontaneous circulation (ROSC) in patients with APE, venoarterial extracorporeal membrane oxygenation (ECMO) becomes a viable therapeutic option. As an advanced life support treatment, ECMO ensures the perfusion of critical organs, providing sufficient time for interventions necessary for ROSC. Case introduction We report the case of a patient who experienced cardiac arrest due to pulmonary embolism. During the treatment, the patient received two sessions of external cardiopulmonary resuscitation (ECPR) as supportive care and experienced cerebral hemorrhage. Ultimately, the patient improved and was discharged following support from extracorporeal membrane oxygenation (ECMO), careful anticoagulation strategies, and intervention with balloon pulmonary angioplasty. Conclusion ECMO can serve as an important life support technology for patients with severe APE. Through a cautious anticoagulation therapy, not only was the ECMO support successfully maintained but also was further deterioration of cerebral hemorrhage effectively prevented. For patients with concurrent main pulmonary artery embolism and bleeding, balloon pulmonary angioplasty may be an option.
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Affiliation(s)
| | | | | | - Kechun Zhou
- Department of Emergency, Lishui Central Hospital, Zhejiang, China
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2
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Rouleau SG, Casey SD, Kabrhel C, Vinson DR, Long B. Management of high-risk pulmonary embolism in the emergency department: A narrative review. Am J Emerg Med 2024; 79:1-11. [PMID: 38330877 DOI: 10.1016/j.ajem.2024.01.039] [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: 11/11/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE. OBJECTIVE This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations. DISCUSSION High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions. CONCLUSIONS Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.
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Affiliation(s)
- Samuel G Rouleau
- Department of Emergency Medicine, UC Davis Health, University of California, Davis, Sacramento, CA, United States of America.
| | - Scott D Casey
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, CA, United States of America.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - David R Vinson
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
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3
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Zhang RS, Alviar CL, Yuriditsky E, Alam U, Zhang PS, Elbaum L, Grossman K, Singh A, Maqsood MH, Greco AA, Postelnicu R, Mukherjee V, Horowitz J, Keller N, Bangalore S. Percutaneous mechanical thrombectomy in acute pulmonary embolism: Outcomes from a safety-net hospital. Catheter Cardiovasc Interv 2024. [PMID: 38577945 DOI: 10.1002/ccd.31024] [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: 11/24/2023] [Revised: 02/23/2024] [Accepted: 03/19/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Our study aims to present clinical outcomes of mechanical thrombectomy (MT) in a safety-net hospital. METHODS This is a retrospective study of intermediate or high-risk pulmonary embolism (PE) patients who underwent MT between October 2020 and May 2023. The primary outcome was 30-day mortality. RESULTS Among 61 patients (mean age 57.6 years, 47% women, 57% Black) analyzed, 12 (19.7%) were classified as high-risk PE, and 49 (80.3%) were intermediate-risk PE. Of these patients, 62.3% had Medicaid or were uninsured, 50.8% lived in a high poverty zip code. The prevalence of normotensive shock in intermediate-risk PE patients was 62%. Immediate hemodynamic improvements included 7.4 mmHg mean drop in mean pulmonary artery pressure (-21.7%, p < 0.001) and 93% had normalization of their cardiac index postprocedure. Thirty-day mortality for the entire cohort was 5% (3 patients) and 0% when restricted to the intermediate-risk group. All 3 patients who died at 30 days presented with cardiac arrest. There were no differences in short-term mortality based on race, insurance type, citizenship status, or socioeconomic status. All-cause mortality at most recent follow up was 13.1% (mean follow up time of 13.4 ± 8.5 months). CONCLUSION We extend the findings from prior studies that MT demonstrates a favorable safety profile with immediate improvement in hemodynamics and a low 30-day mortality in patients with acute PE, holding true even with relatively higher risk and more vulnerable population within a safety-net hospital.
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Affiliation(s)
- Robert S Zhang
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Carlos L Alviar
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Eugene Yuriditsky
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Usman Alam
- Department of Medicine, New York University, New York City, New York, USA
| | - Peter S Zhang
- Department of Medicine, New York University, New York City, New York, USA
| | - Lindsay Elbaum
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Kelsey Grossman
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Arushi Singh
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Muhammad H Maqsood
- Department of Cardiology, DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Allison A Greco
- Division of Pulmonary Critical Care, and Sleep Medicine, New York University, New York City, New York, USA
| | - Radu Postelnicu
- Division of Pulmonary Critical Care, and Sleep Medicine, New York University, New York City, New York, USA
| | - Vikramjit Mukherjee
- Division of Pulmonary Critical Care, and Sleep Medicine, New York University, New York City, New York, USA
| | - James Horowitz
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Norma Keller
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Sripal Bangalore
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
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4
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Zhu E, Yuriditsky E, Raco V, Katz A, Papadopoulos J, Horowitz J, Maldonado T, Ahuja T. Anti-factor Xa as the preferred assay to monitor heparin for the treatment of pulmonary embolism. Int J Lab Hematol 2024; 46:354-361. [PMID: 37989523 DOI: 10.1111/ijlh.14207] [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: 08/31/2023] [Accepted: 11/06/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION The mainstay of acute pulmonary embolism (PE) treatment is anticoagulation. Timely anticoagulation correlates with decreased PE-associated mortality, but the ability to achieve a therapeutic activated partial thromboplastin time (aPTT) with unfractionated heparin (UFH) remains limited. Although some institutions have switched to a more accurate and reproducible test to assess for heparin's effectiveness, the anti-factor Xa (antiXa) assay, data correlating a timely therapeutic antiXa to PE-associated clinical outcomes remains scarce. We evaluated time to a therapeutic antiXa using intravenous heparin after PE response team (PERT) activation and assessed clinical outcomes including bleeding and recurrent thromboembolic events. METHODS This was a retrospective cohort study at NYU Langone Health. All adult patients ≥18 years with a confirmed PE started on IV UFH with >2 antiXa levels were included. Patients were excluded if they received thrombolysis or alternative anticoagulation. The primary endpoint was the time to a therapeutic antiXa level of 0.3-0.7 units/mL. Secondary outcomes included recurrent thromboembolism, bleeding and PE-associated mortality within 3 months. RESULTS A total of 330 patients with a PERT consult were identified with 192 patients included. The majority of PEs were classified as sub massive (64.6%) with 87% of patients receiving a bolus of 80 units/kg of UFH prior to starting an infusion at 18 units/kg/hour. The median time to the first therapeutic antiXa was 9.13 hours with 93% of the cohort sustaining therapeutic anticoagulation at 48 hours. Recurrent thromboembolism, bleeding and mortality occurred in 1%, 5% and 6.2%, respectively. Upon univariate analysis, a first antiXa <0.3 units/ml was associated with an increased risk of mortality [27.78% (5/18) vs 8.05% (14/174), p = 0.021]. CONCLUSION We observed a low incidence of recurrent thromboembolism or PE-associated mortality utilizing an antiXa titrated UFH protocol. The use of an antiXa based heparin assay to guide heparin dosing and monitoring allows for timely and sustained therapeutic anticoagulation for treatment of PE.
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Affiliation(s)
- Eric Zhu
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Eugene Yuriditsky
- Department of Medicine, Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Veronica Raco
- Department of Pharmacy, NYU Langone Brooklyn, Brooklyn, New York, USA
| | - Alyson Katz
- Department of Pharmacy, NYU Langone Health, New York, New York, USA
| | | | - James Horowitz
- Department of Medicine, Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Thomas Maldonado
- Department of Surgery, Vascular, NYU Grossman School of Medicine, New York, New York, USA
| | - Tania Ahuja
- Department of Medicine, Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA
- Department of Pharmacy, NYU Langone Health, New York, New York, USA
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5
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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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6
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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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7
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Fulton B, Bashir R, Weinberg MD, Lakhter V, Rali P, Pugliese S, Giri J, Kobayashi T. Advanced Treatment of Hemodynamically Unstable Acute Pulmonary Embolism and Clinical Follow-up. Semin Thromb Hemost 2023; 49:785-796. [PMID: 37696292 DOI: 10.1055/s-0043-1772840] [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: 09/13/2023]
Abstract
High-risk acute pulmonary embolism (PE), defined as acute PE associated with hemodynamic instability, remains a significant contributor to cardiovascular morbidity and mortality in the United States and worldwide. Historically, anticoagulant therapy in addition to systemic thrombolysis has been the mainstays of medical therapy for the majority of patients with high-risk PE. In efforts to reduce the morbidity and mortality, a wide array of interventional and surgical therapies has been developed and employed in the management of these patients. However, the most recent guidelines for the management of PE have reserved the use of these advanced therapies in scenarios where thrombolytic therapy plus anticoagulation are unsuccessful. This is due largely to the lack of prospective, randomized studies in this population. Stemming from this, the approach to treatment of these patients varies widely depending on institutional experience and resources. Furthermore, morbidity and mortality remain unacceptably high in this population, with estimated 30-day mortality of at least 30%. As such, development of a standardized approach to treatment of these patients is paramount to improving outcomes. Early and accurate risk stratification in conjunction with a multidisciplinary team approach in the form of a PE response team is crucial. With the advent of novel therapies for the treatment of acute PE, in addition to the growing availability of and familiarity with mechanical circulatory support systems, such a standardized approach may now be within reach.
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Affiliation(s)
- Brian Fulton
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Riyaz Bashir
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Mitchell D Weinberg
- Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, Staten Island, New York
| | - Vladimir Lakhter
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Steve Pugliese
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jay Giri
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
| | - Taisei Kobayashi
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
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8
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Westafer LM, Long B, Gottlieb M. Managing Pulmonary Embolism. Ann Emerg Med 2023; 82:394-402. [PMID: 36805291 PMCID: PMC10432572 DOI: 10.1016/j.annemergmed.2023.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 02/19/2023]
Affiliation(s)
- Lauren M Westafer
- Department for Healthcare Delivery and Population Science and Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
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9
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Nguyen L, Qi X, Karimi-asl A, Thole A, Wendte J, Meissner T, Xu B, Dvoracek K. Evaluation of anti-Xa levels in patients with venous thromboembolism within the first 48 h of anticoagulation with unfractionated heparin. SAGE Open Med 2023; 11:20503121231190963. [PMID: 37602272 PMCID: PMC10438427 DOI: 10.1177/20503121231190963] [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: 02/23/2023] [Accepted: 07/13/2023] [Indexed: 08/22/2023] Open
Abstract
Background: A 2019 study by Prucnal and colleagues found that the majority of patients treated with unfractionated heparin for pulmonary embolism did not maintain therapeutic activated partial thromboplastin time levels during the first 48 h of therapy. Objective: The purpose of this study was to evaluate the ability of an institution's unfractionated heparin dosing protocol to achieve and maintain therapeutic anti-Xa levels within the first 48 h of therapy in patients with venous thromboembolism. Methods: This retrospective study included 205 patients from May 2016 through September 2020. Patients were divided into two cohorts: bolus plus infusion (N = 89) and infusion only (N = 116). The primary objective was to determine the number of patients who achieved at least one therapeutic level. Results: Overall, 200 patients (97.6%) had at least one therapeutic level with no statistically significant difference between cohorts (p = 0.65). No more than 60% of patients achieved a therapeutic level at any of the 6-h intervals throughout the timeframe. The median time to the first therapeutic level in the overall group was 12.8 h with no statistically significant difference between the bolus plus infusion and infusion-only cohorts (13.3 h versus 12.7 h, respectively, p = 0.48). Conclusions: Most patients were able to achieve at least one therapeutic level within the first 48 h, but fewer were able to maintain therapeutic levels. Further studies are warranted to determine whether alternative dosing strategies would yield consistent achievement of therapeutic levels and affect patient-oriented outcomes.
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Affiliation(s)
- Lily Nguyen
- Department of Pharmacy, Avera McKennan Hospital and University Health Center, Sioux Falls, SD, USA
| | - Xiaoxiao Qi
- Department of Pharmacy, Nebraska Medicine, Omaha, NE, USA
| | | | - Alicia Thole
- Department of Pharmacy, Avera McKennan Hospital and University Health Center, Sioux Falls, SD, USA
| | - Jodi Wendte
- Department of Pharmacy, Avera McKennan Hospital and University Health Center, Sioux Falls, SD, USA
| | - Tobias Meissner
- Department of Cancer Genomics, Avera Cancer Institute Center for Precision Oncology, Sioux Falls, SD, USA
| | - Bing Xu
- Department of Cancer Genomics, Avera Cancer Institute Center for Precision Oncology, Sioux Falls, SD, USA
| | - Kyle Dvoracek
- Department of Pharmacy, Avera McKennan Hospital and University Health Center, Sioux Falls, SD, USA
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10
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Porres-Aguilar M, Rosovsky RP, Jiménez D, Mukherjee D, Rivera-Lebron BN, Kaatz S, Anaya-Ayala JE, Jerjes-Sánchez C. "Pulmonary embolism response teams: changing the paradigm in the care for acute pulmonary embolism": reply. J Thromb Haemost 2023; 21:1390-1392. [PMID: 37121622 DOI: 10.1016/j.jtha.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/02/2023] [Indexed: 05/02/2023]
Affiliation(s)
- Mateo Porres-Aguilar
- Department of Internal Medicine, Divisions of Hospital and Adult Thrombosis Medicine, Texas Tech University Health Sciences Center and Paul L. Foster School of Medicine, El Paso, Texas, USA.
| | - Rachel P Rosovsky
- Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David Jiménez
- Department of Respiratory Medicine, Ramón y Cajal Hospital (IRYCIS), CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases; Texas Tech University Health Sciences Center and Paul L. Foster School of Medicine, El Paso, Texas, USA
| | - Belinda N Rivera-Lebron
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Scott Kaatz
- Department of Internal Medicine, Division of Hospital Medicine; Henry Ford Hospital; Detroit, Michigan, USA
| | - Javier E Anaya-Ayala
- Department of Surgery, Vascular Surgery and Endovascular Therapy Section; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos Jerjes-Sánchez
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey; and Instituto de Cardiologia y Medicina Vascular, Hospital Zambrano Hellion y TEC Salud, Monterrey, Mexico
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11
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Davidson BL. "Pulmonary embolism response teams: Changing the paradigm in the care for acute pulmonary embolism": comment. J Thromb Haemost 2023; 21:1388-1389. [PMID: 37121621 DOI: 10.1016/j.jtha.2022.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 05/02/2023]
Affiliation(s)
- Bruce L Davidson
- Department of Medicine, Washington State University Floyd College of Medicine, Everett, Washington, USA.
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12
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Porres-Aguilar M, Rosovsky RP, Rivera-Lebron BN, Kaatz S, Mukherjee D, Anaya-Ayala JE, Jimenez D, Jerjes-Sánchez C. Pulmonary embolism response teams: Changing the paradigm in the care for acute pulmonary embolism. J Thromb Haemost 2022; 20:2457-2464. [PMID: 35895858 DOI: 10.1111/jth.15832] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/16/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022]
Abstract
Pulmonary embolism response teams (PERTs) have emerged as a multidisciplinary, multispecialty team of experts in the care of highly complex symptomatic acute pulmonary embolism (PE), with a centralized unique activation process, providing rapid multimodality assessment and risk stratification, formulating the best individualized diagnostic and therapeutic approach, streamlining the care in challenging clinical case scenarios (e.g., intermediate-high risk and high-risk PE), and facilitating the implementation of the recommended therapeutic strategies on time. PERTs are currently changing how complex acute PE cases are approached. The structure, organization, and function of a given PERT may vary from hospital to hospital, depending on local expertise, specific resources, and infrastructure for a given academic hospital center. Current emerging data demonstrate the value of PERTs in improving time to PE diagnosis; shorter time to initiation of anticoagulation reducing hospital length of stay; increasing use of advanced therapies without an increase in bleeding; and in some reports, decreasing mortality. Importantly, PERTs are positively impacting outcomes by changing the paradigm of care for acute PE through global adoption by the health-care community.
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Affiliation(s)
- Mateo Porres-Aguilar
- Department of Medicine, Division of Hospital and Adult Thrombosis Medicine, Texas Tech University Health Sciences Center and Paul L. Foster School of Medicine, El Paso, Texas, USA
| | - Rachel P Rosovsky
- Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Belinda N Rivera-Lebron
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Scott Kaatz
- Department of Internal Medicine, Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Texas Tech University Health Sciences Center and Paul L. Foster School of Medicine, El Paso, Texas, USA
| | - Javier E Anaya-Ayala
- Department of Surgery, Vascular Surgery and Endovascular Therapy Section, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - David Jimenez
- Department of Respiratory Medicine, Ramón y Cajal Hospital (IRYCIS), CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Carlos Jerjes-Sánchez
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Instituto de Cardiologia y Medicina Vascular, Hospital Zambrano Hellion, Monterrey, Mexico
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13
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Huang CB, Hong CX, Xu TH, Zhao DY, Wu ZY, Chen L, Xie J, Jin C, Wang BZ, Yang L. Risk Factors for Pulmonary Embolism in ICU Patients: A Retrospective Cohort Study from the MIMIC-III Database. Clin Appl Thromb Hemost 2022; 28:10760296211073925. [PMID: 35043708 DOI: 10.1177/10760296211073925] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Pulmonary embolism (PE) is a common and potentially lethal form of venous thromboembolic disease in ICU patients. A limited number of risk factors have been associated with PE in ICU patients. In this study, we aimed to screen the independent risk factors of PE in ICU patients that can be used to evaluate the patient's condition and provide targeted treatment. We performed a retrospective cohort study using a freely accessible critical care database Medical Information Mart for Intensive Care (MIMIC)-III. The ICU patients were divided into two groups based on the incidence of PE. Finally, 9871 ICU patients were included, among which 204 patients (2.1%) had pulmonary embolism. During the multivariate logistic regression analysis, sepsis, hospital_LOS (the length of stay in hospital), type of admission, tumor, APTT (activated partial thromboplastin time) and platelet were independent risk factors for patients for PE in ICU, with OR values of 1.471 (95%CI 1.001-2.162), 1.001 (95%CI 1.001-1.001), 3.745 (95%CI 2.187-6.414), 1.709 (95%CI 1.247-2.341), 1.014 (95%CI 1.010-1.017) and 1.002 (95%CI 1.001-1.003) (Ps < 0.05). ROC curve analysis showed that the composite indicator had a higher predictive value for ICU patients with PE, with a ROC area under the curve (AUC) of 0.743 (95%CI 0.710 -0.776, p < 0.001). Finally, sepsis, tumor, platelet count, length of stay in the hospital, emergency admission and APTT were independent predictors of PE in ICU patients.
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Affiliation(s)
- Cheng-Bin Huang
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Chen-Xuan Hong
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Tian-Hao Xu
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Ding-Yun Zhao
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zong-Yi Wu
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China
| | - Liang Chen
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Jun Xie
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Chen Jin
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Bing-Zhang Wang
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Lei Yang
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
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Affiliation(s)
- Kathryn A Hibbert
- From the Departments of Medicine (K.A.H., A.E.F.) and Radiology (R.J.G.), Massachusetts General Hospital, and the Departments of Medicine (K.A.H., A.E.F.) and Radiology (R.J.G.), Harvard Medical School - both in Boston
| | - Reece J Goiffon
- From the Departments of Medicine (K.A.H., A.E.F.) and Radiology (R.J.G.), Massachusetts General Hospital, and the Departments of Medicine (K.A.H., A.E.F.) and Radiology (R.J.G.), Harvard Medical School - both in Boston
| | - Annemarie E Fogerty
- From the Departments of Medicine (K.A.H., A.E.F.) and Radiology (R.J.G.), Massachusetts General Hospital, and the Departments of Medicine (K.A.H., A.E.F.) and Radiology (R.J.G.), Harvard Medical School - both in Boston
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15
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Fitzpatrick T, Wong C, Shen C, Pham P, Teo V, Selby R, Geerts W, Khosravani H. Quality of anticoagulation using intravenous unfractionated heparin for cerebrovascular indications. Thromb Res 2021; 199:79-81. [PMID: 33476900 DOI: 10.1016/j.thromres.2020.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/26/2020] [Accepted: 12/29/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Tess Fitzpatrick
- Neurology Quality and Innovation Lab, Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre (SHSC), University of Toronto, Toronto, Canada
| | | | - Cindy Shen
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada; The CanVECTOR Network, Canada
| | - Peter Pham
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Vincent Teo
- Department of Pharmacy, SHSC, Toronto, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Rita Selby
- Departments of Laboratory Medicine & Molecular Diagnostics and Medicine, SHSC, University of Toronto, Toronto, Canada; The CanVECTOR Network, Canada
| | - William Geerts
- Thromboembolism Program, Department of Medicine, SHSC, University of Toronto, Toronto, Canada; The CanVECTOR Network, Canada
| | - Houman Khosravani
- Neurology Quality and Innovation Lab, Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre (SHSC), University of Toronto, Toronto, Canada; The CanVECTOR Network, Canada.
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16
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Rivera-Lebron BN, Rali PM, Tapson VF. The PERT Concept: A Step-by-Step Approach to Managing Pulmonary Embolism. Chest 2020; 159:347-355. [PMID: 32758561 DOI: 10.1016/j.chest.2020.07.065] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/30/2020] [Accepted: 07/16/2020] [Indexed: 11/28/2022] Open
Abstract
Pulmonary embolism (PE) is a major source of morbidity and mortality. The presentation of acute PE varies, ranging from few or no symptoms to sudden death. Patient outcome depends on how well the right ventricle can sustain the increased afterload caused by the embolic burden. Careful risk stratification is critical, and the PE response team (PERT) concept offers a rapid and multidisciplinary approach. Anticoagulation is essential unless contraindicated; thrombolysis, surgical embolectomy, and catheter-directed approaches are also available. Clinical consensus statements have been published that offer a guide to PE management, but areas remain for which the evidence is inadequate. Although the management of low-risk and high-risk patients is more straightforward, optimal management of intermediate-risk patients remains controversial. In this document, we offer a case-based approach to PE management, beginning with diagnosis and risk stratification, followed by therapeutic alternatives, and finishing with follow-up care.
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Affiliation(s)
- Belinda N Rivera-Lebron
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Parth M Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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