1
|
Mathiyalagan P, Rajangam T, Bhargavi K, Gnanaraj R, Sundaram S. Clinical Profile, Immediate- and Short-term Outcome of Patients with Intermediate-risk Acute Pulmonary Thromboembolism. Indian J Crit Care Med 2022; 26:1192-1197. [PMID: 36873599 PMCID: PMC9983647 DOI: 10.5005/jp-journals-10071-24351] [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] [Received: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022] Open
Abstract
Background Long-term outcomes of acute pulmonary thromboembolism (PTE) have been reported. However, the immediate- and short-term outcomes have not been reported adequately. Objectives Primary objective was to determine the patient characteristics, and immediate- and short-term outcomes of intermediate-risk PTE, and the secondary objective was to evaluate the benefit of thrombolysis in normotensive PTE patients. Material and methods This study included patients diagnosed with acute intermediate PTE. Patient's electrocardiography (ECG) parameters along with echocardiography (echo), etc., conducted at the time of admission, during their stay in hospital, at the time of discharge, and during follow-up were recorded. The patients were treated using thrombolysis or anticoagulants depending on hemodynamic decompensation. During follow-up, they were reassessed for echo parameters-right ventricular (RV) function and pulmonary arterial hypertension (PAH). Results Among 55 patients, 29 (52.73%) were diagnosed with intermediate high-risk PTE and 26 (47.27%) with intermediate low-risk PTE. They were normotensive and most of them had a simplified pulmonary embolism severity index (sPESI) score <2. Typical ECG pattern S1Q3T3 along with echo patterns and elevated cardiac troponin levels were observed in most of the patients. Patients treated with thrombolytic agents showed a reduction in hemodynamic decompensation as opposed to patients treated with anticoagulants who had clinical signs of right heart failure (RHF) on follow-up after 3 months. Conclusion This study contributes to the existing literature on outcomes of intermediate-risk PTE and the effect of thrombolysis on patients with hemodynamic stability. Thrombolysis reduced the incidence and progression of RHF in patients with hemodynamic instability. How to cite this article Mathiyalagan P, Rajangam T, Bhargavi K, Gnanaraj R, Sundaram S. Clinical Profile, Immediate- and Short-term Outcome of Patients with Intermediate-risk Acute Pulmonary Thromboembolism. Indian J Crit Care Med 2022;26(11):1192-1197.
Collapse
Affiliation(s)
- Praveen Mathiyalagan
- Department of Medicine, PSG Institute of Medical Sciences & Research, Coimbatore, Tamil Nadu, India
| | - Tolstoy Rajangam
- Department of Medicine, PSG Institute of Medical Sciences & Research, Coimbatore, Tamil Nadu, India
| | - Kumar Bhargavi
- Department of Medicine, PSG Institute of Medical Sciences & Research, Coimbatore, Tamil Nadu, India
| | - Ramya Gnanaraj
- Department of Ophthalmology, Sankara Nethralaya Foundation, Coimbatore, Tamil Nadu, India
| | - Shanmuga Sundaram
- Department of Cardiology, PSG Institute of Medical Sciences & Research, Coimbatore, Tamil Nadu, India
| |
Collapse
|
2
|
Chober D, Aksak-Wąs B, Niścigorska-Olsen J, Niekrasz M, Parczewski M. Tocilizumab Use among Patients Who Developed Pulmonary Embolism in the Course of Cytokine Release Storm and COVID-19 Pneumonia-A Retrospective Study. Biomedicines 2022; 10:biomedicines10071581. [PMID: 35884886 PMCID: PMC9313102 DOI: 10.3390/biomedicines10071581] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/24/2022] [Accepted: 06/28/2022] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Thromboembolic events, including mainly pulmonary embolisms and ischemic strokes, occur in up to one-third of COVID-19 patients. As efficacy of tocilizumab (TCZ) among patients with acute pulmonary embolism (PE) was not previously investigated, this study aimed to provide such data. OBJECTIVES The aim of the study was to investigate the effect of TCZ on mortality in patients with confirmed acute pulmonary embolism, cytokine release storm and COVID-19 pneumonia. PATIENTS AND METHODS Longitudinal data of 4287 patients with confirmed SARS-CoV-2 infection were collected between 4 March 2020 and 16 January 2022. In this study, we retrospectively analyzed the samples and dataset of cases with confirmed acute pulmonary embolism associated with at least moderate lung involvement due to COVID-19 pneumonia. RESULTS In the analyzed dataset, 64 adult patients were diagnosed with PE, and of these, 28 (44%) cases were treated with two 8 mg/kg doses of TCZ, and 36 (56%) did not receive this agent. The groups were balanced regarding demographics, comorbidities and the biochemical markers. Overall mortality in our study was 29.6% (n = 17). Mortality in the group treated with TCZ was 43% (n = 12) compared to 19% (n = 7) in the group without TCZ. In multivariate proportional Cox hazards models, intravenous administration of TCZ was independently associated with higher mortality (HR: 3.342 (CI: 1.077-10.370), p = 0.036). CONCLUSIONS In patients with COVID-19 pneumonia with at least moderate lung involvement, CRS and acute pulmonary embolism, administration of TCZ is associated with increased mortality. Therefore, TCZ should be used with caution in SARS-CoV-2 cases with pulmonary embolism.
Collapse
Affiliation(s)
- Daniel Chober
- Department of Infectious, Tropical Diseases and Immune Deficiency, Pomeranian Medical University in Szczecin, 71-455 Szczecin, Poland; (B.A.-W.); (J.N.-O.)
- Correspondence: (D.C.); (M.P.)
| | - Bogusz Aksak-Wąs
- Department of Infectious, Tropical Diseases and Immune Deficiency, Pomeranian Medical University in Szczecin, 71-455 Szczecin, Poland; (B.A.-W.); (J.N.-O.)
| | - Jolanta Niścigorska-Olsen
- Department of Infectious, Tropical Diseases and Immune Deficiency, Pomeranian Medical University in Szczecin, 71-455 Szczecin, Poland; (B.A.-W.); (J.N.-O.)
| | - Małgorzata Niekrasz
- Department of Neurology, Regional Hospital in Szczecin, 71-455 Szczecin, Poland;
| | - Miłosz Parczewski
- Department of Infectious, Tropical Diseases and Immune Deficiency, Pomeranian Medical University in Szczecin, 71-455 Szczecin, Poland; (B.A.-W.); (J.N.-O.)
- Correspondence: (D.C.); (M.P.)
| |
Collapse
|
3
|
Gökçek K, Gökçek A, Demir A, Yıldırım B, Acar E, Alataş ÖD. In-hospital mortality of acute pulmonary embolism: Predictive value of shock index, modified shock index, and age shock index scores. Med Clin (Barc) 2021; 158:351-355. [PMID: 34404518 DOI: 10.1016/j.medcli.2021.04.035] [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: 11/30/2020] [Revised: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The shock index (SI), modified shock index (MSI), and age shock index (ASI) have been reported to predict adverse outcomes in patients with different acute cardiovascular conditions. This study aimed to investigate the association between these indexes and in-hospital mortality in patients with acute pulmonary embolism. METHODS The medical records of all adult patients who were hospitalized with acute pulmonary embolism between June 2014 and June 2019, were examined. Collected data included vital signs, demographic characteristics, comorbidities, and laboratory values on presentation. The predictive value of SI, MSI, ASI, and pulmonary embolism severity index (PESI) for predicting in-hospital mortality were compared by C-statistics. RESULTS A total of 602 consecutive patients (mean age 66.7±13.2 years, 55% female) were included, and 62 (10.3%) of the patients died during their in-hospital course. The admission SI, MSI, ASI, and PESI were significantly higher in the deceased patients. After adjusting for other factors, the SI, MSI, PESI, and ASI were independent predictors of in-hospital mortality. The prognostic performance of ASI (C-statistics 0.74) was better than MSI (C-statistics 0.71), SI (C-statistics 0.68), and PESI (C-statistics 0.65). CONCLUSION The ASI may be used to identify patients at risk for in-hospital mortality following acute pulmonary embolism.
Collapse
Affiliation(s)
- Kemal Gökçek
- Muğla Sitki Koçman University, Faculty of Medicine, Department of Emergency Medicine, Muğla, Turkey.
| | - Aysel Gökçek
- Muğla Sitki Koçman University, Faculty of Medicine, Department of Cardiology, Muğla, Turkey
| | - Ahmet Demir
- Muğla Sitki Koçman University, Faculty of Medicine, Department of Emergency Medicine, Muğla, Turkey
| | - Birdal Yıldırım
- Muğla Sitki Koçman University, Faculty of Medicine, Department of Emergency Medicine, Muğla, Turkey
| | - Ethem Acar
- Muğla Sitki Koçman University, Faculty of Medicine, Department of Emergency Medicine, Muğla, Turkey
| | - Ömer Doğan Alataş
- Muğla Sitki Koçman University, Faculty of Medicine, Department of Emergency Medicine, Muğla, Turkey
| |
Collapse
|
4
|
Nishanth KR, Math RS, Shankar M, Ravindranath KS, Manjunath CN. Thrombolysis with reteplase in acute pulmonary embolism. Indian Heart J 2019; 71:464-467. [PMID: 32248919 PMCID: PMC7136336 DOI: 10.1016/j.ihj.2019.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 05/19/2019] [Accepted: 09/01/2019] [Indexed: 11/06/2022] Open
Abstract
Objective Reteplase (recombinant plasminogen activator) is a mutant of alteplase. It has a longer half-life than its parent molecule and has shown better vessel patency rates in acute myocardial infarction. In this study, we analyzed the efficacy and safety of reteplase in acute pulmonary embolism (PE). Methods This observational study included patients with high- and intermediate-risk acute PE, presenting within 14 days of symptom onset. The patients were treated with reteplase, which was given in two bolus doses of 10 U each, 30 min apart, along with intravenous heparin. Patients with hemodynamic compromise (high-risk or massive PE) and normotensive patients with evidence of right ventricular (RV) dysfunction (intermediate-risk or submassive PE) on echocardiography or computed tomography were included in the study. The efficacy outcomes assessed were in-hospital death and improvement of RV function by echocardiography. The safety outcomes were major bleeding, minor bleeding, and ischemic or hemorrhagic stroke during hospitalization. Results Of the 40 patients included, 25% were classified as high risk with hemodynamic compromise and 75% were classified as intermediate risk. RV dysfunction was present in all the patients (100%). Concomitant lower extremity deep vein thrombosis was present in 55% of the patients. The mortality rate was 5%. There was significant improvement in RV function and reduction in pulmonary artery systolic pressure and tricuspid regurgitation severity. There was no major bleeding event or stroke, and 7.5% patients had minor extracranial bleeding. Conclusions Double-bolus reteplase given with heparin is effective in the treatment of high- and intermediate-risk PE, with minimal risk of bleeding.
Collapse
Affiliation(s)
- K R Nishanth
- Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bengaluru, India.
| | - Ravi S Math
- Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bengaluru, India
| | | | - K S Ravindranath
- Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bengaluru, India
| | - C N Manjunath
- Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bengaluru, India
| |
Collapse
|
5
|
Fernández C, Bova C, Sanchez O, Prandoni P, Lankeit M, Konstantinides S, Vanni S, Fernández-Golfín C, Yusen RD, Jiménez D. Validation of a Model for Identification of Patients at Intermediate to High Risk for Complications Associated With Acute Symptomatic Pulmonary Embolism. Chest 2015; 148:211-218. [DOI: 10.1378/chest.14-2551] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
|
6
|
Marti C, John G, Konstantinides S, Combescure C, Sanchez O, Lankeit M, Meyer G, Perrier A. Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2014; 36:605-14. [PMID: 24917641 PMCID: PMC4352209 DOI: 10.1093/eurheartj/ehu218] [Citation(s) in RCA: 319] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
AIM Thrombolytic therapy induces faster clot dissolution than anticoagulation in patients with acute pulmonary embolism (PE) but is associated with an increased risk of haemorrhage. We reviewed the risks and benefits of thrombolytic therapy in the management of patients with acute PE. METHODS AND RESULTS We systematically reviewed randomized controlled studies comparing systemic thrombolytic therapy plus anticoagulation with anticoagulation alone in patients with acute PE. Fifteen trials involving 2057 patients were included in our meta-analysis. Compared with heparin, thrombolytic therapy was associated with a significant reduction of overall mortality (OR; 0.59, 95% CI: 0.36-0.96). This reduction was not statistically significant after exclusion of studies including high-risk PE (OR; 0.64, 95% CI: 0.35-1.17). Thrombolytic therapy was associated with a significant reduction in the combined endpoint of death or treatment escalation (OR: 0.34, 95% CI: 0.22-0.53), PE-related mortality (OR: 0.29; 95% CI: 0.14-0.60) and PE recurrence (OR: 0.50; 95% CI: 0.27-0.94). Major haemorrhage (OR; 2.91, 95% CI: 1.95-4.36) and fatal or intracranial bleeding (OR: 3.18, 95% CI: 1.25-8.11) were significantly more frequent among patients receiving thrombolysis. CONCLUSIONS Thrombolytic therapy reduces total mortality, PE recurrence, and PE-related mortality in patients with acute PE. The decrease in overall mortality is, however, not significant in haemodynamically stable patients with acute PE. Thrombolytic therapy is associated with an increase of major and fatal or intracranial haemorrhage.
Collapse
Affiliation(s)
- Christophe Marti
- Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and Geneva Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Gregor John
- Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and Geneva Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Christophe Combescure
- Department of Health and Community Medicine, University Hospitals of Geneva and Geneva Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Switzerland
| | - Olivier Sanchez
- Hôpital Européen Georges Pompidou, AP-HP; Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S 970, Paris; GIRC Thrombose, France
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Guy Meyer
- Hôpital Européen Georges Pompidou, AP-HP; Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR S 970, Paris; GIRC Thrombose, France
| | - Arnaud Perrier
- Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and Geneva Faculty of Medicine, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Switzerland
| |
Collapse
|
7
|
Castelli R, Bucciarelli P, Porro F, Depetri F, Cugno M. Pulmonary embolism in elderly patients: prognostic impact of the Cumulative Illness Rating Scale (CIRS) on short-term mortality. Thromb Res 2014; 134:326-30. [PMID: 24951337 DOI: 10.1016/j.thromres.2014.05.042] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 05/26/2014] [Accepted: 05/30/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is associated with high short-term mortality in elderly patients, even when hemodynamically stable. METHODS One hundred and seventy hemodynamically stable patients with confirmed PE (41<65years and 129≥65years) were prospectively followed for one month in order to assess whether comorbidities can predict short-term mortality in elderly patients. Upon admission, patients' clinical characteristics (including instrumental and laboratory parameters) were evaluated, and two clinical scores were calculated: the Cumulative Illness Rating Scale (CIRS), commonly used to evaluate comorbidities in elderly patients, and the Pulmonary Embolism Severity Index (PESI). RESULTS Fifteen patients (all elderly) died within one month from their PE diagnosis (mortality rate=8.8%; 95%CI:4.6-13.1%). In these non survivors, arterial partial oxygen pressure (p<0.0001) and saturation (p<0.0001), pH (p=0.001) and systolic blood pressure (p=0.017) at admission were significantly lower than in survivors, whereas their respiratory rate (p<0.0001), white blood cells (p<0.0001), lactate dehydrogenase (p<0.0001), troponin T (p=0.001) and D-dimer (p=0.023) were significantly higher. CIRS correlated with PESI (rho=0.54, p<0.0001), and was higher in non-survivors (p=0.002). The age- and sex-adjusted odds ratio of 1-month mortality was 1.91 (95%CI:1.24-2.95) for every 1-point increase in CIRS. The AUC was 0.78 (95%CI:0.67-0.89) for the logistic model containing CIRS, and 0.88 (95%CI:0.79-0.96) for that containing PESI (p=0.059). CONCLUSIONS In elderly patients with PE, CIRS demonstrated a fairly good performance in predicting short-term mortality. Its easiness and suitability for use in common clinical practice make CIRS a potentially useful prognostic score for short-term mortality in these patients.
Collapse
Affiliation(s)
- Roberto Castelli
- Department of Pathophysiology and Transplantation, Internal Medicine Section, University of Milan, and Department of Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Bucciarelli
- A. Bianchi Bonomi Hemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fernando Porro
- Department of Internal Medicine and Medical Specialties, Emergency Medicine Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Depetri
- Department of Pathophysiology and Transplantation, Internal Medicine Section, University of Milan, and Department of Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Cugno
- Department of Pathophysiology and Transplantation, Internal Medicine Section, University of Milan, and Department of Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| |
Collapse
|
8
|
Piran S, Le Gal G, Wells PS, Gandara E, Righini M, Rodger MA, Carrier M. Outpatient treatment of symptomatic pulmonary embolism: A systematic review and meta-analysis. Thromb Res 2013; 132:515-9. [DOI: 10.1016/j.thromres.2013.08.012] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 07/22/2013] [Accepted: 08/13/2013] [Indexed: 10/26/2022]
|
9
|
Prognostic value of computed tomographic pulmonary angiography and the pulmonary embolism severity index in patients with acute pulmonary embolism. Blood Coagul Fibrinolysis 2013; 24:64-70. [PMID: 23103727 DOI: 10.1097/mbc.0b013e32835a72c2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pulmonary embolism is a serious and potentially fatal disorder. Pulmonary embolism risk stratification may allow early hospital discharge and outpatient treatment for low-risk patients. Also, it may prevent death by early medical intervention in high-risk groups. We evaluated objectively confirmed pulmonary embolism in 126 patients by multidetector computed tomographic pulmonary angiography at a single center from January 2008 to January 2010. The Pulmonary Severity Embolism Index (PESI), the right ventricle (RV) to left ventricle (LV) diameter (RV/LV) ratio and the vascular obstruction index (VOI) were derived from data extracted from electronic hospital records and image database. A total of six out of 96 patients (6.3%) died during follow-up. There was an association between PESI and mortality (P-value < 0.001 χ² test). PESI class I-II had a 100% negative predictive value for death in 90 days. No association was found between the RV/LV ratio, the VOI and mortality (P-value > 0.05 χ² test). Also, no association was found between the RV/LV ratio and the VOI and PESI (P-value > 0.05 χ² test). PESI is an accurate tool for pulmonary embolism prognostic stratification. It safely discriminates low-risk from high-risk patients regarding death outcome. We were unable to demonstrate an association between image scores and mortality.
Collapse
|
10
|
|
11
|
Abrahams-van Doorn PJ, Hartmann IJC. Cardiothoracic CT: one-stop-shop procedure? Impact on the management of acute pulmonary embolism. Insights Imaging 2011; 2:705-15. [PMID: 23100045 PMCID: PMC3289035 DOI: 10.1007/s13244-011-0123-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 05/02/2011] [Accepted: 07/18/2011] [Indexed: 10/26/2022] Open
Abstract
In the treatment of pulmonary embolism (PE) two groups of patients are traditionally identified, namely the hemodynamically stable and instable groups. However, in the large group of normotensive patients with PE, there seems to be a subgroup of patients with an increased risk of an adverse outcome, which might benefit from more aggressive therapy than the current standard therapy with anticoagulants. Risk stratification is a commonly used method to define subgroups of patients with either a high or low risk of an adverse outcome. In this review the clinical parameters and biomarkers of myocardial injury and right ventricular dysfunction (RVD) that have been suggested to play an important role in the risk stratification of PE are described first. Secondly, the use of more direct imaging techniques like echocardiography and CT in the assessment of RVD are discussed, followed by a brief outline of new imaging techniques. Finally, two risk stratification models are proposed, combining the markers of RVD with cardiac biomarkers of ischemia to define whether patients should be admitted to the intensive care unit (ICU) and/or be given thrombolysis, admitted to the medical ward, or be safely treated at home with anticoagulant therapy.
Collapse
Affiliation(s)
- Pauline J Abrahams-van Doorn
- Department of Radiology, Erasmus MC University Medical Center Rotterdam, 's-Gravendijkwal 230, NL-3015 CE, Rotterdam, The Netherlands,
| | | |
Collapse
|
12
|
Abstract
Pulmonary thromboembolism is a frequent disease in emergency departments and often poses a diagnostic challenge that requires appropriate strategies. Clinical information, laboratory tests such as a D-dimer and imaging techniques such as computed tomography (CT) angiography, ventilation-perfusion scintigraphy or echocardiography help to establish clinical probability and the severity of the disease. With all this information, risk scores can be constructed, such as the Pulmonary Embolism Severity Index (PESI) score, which has high sensitivity in predicting mortality. Treatment should be started immediately with heparin, usually low molecular weight heparin. If the patient is at high risk, thrombolytic therapy is indicated, although possible contraindications should be thoroughly assessed. Supportive treatment may be considered in a few patients.
Collapse
|
13
|
Affiliation(s)
- T Baglin
- Department of Haematology, Cambridge University Hospitals NHS Trust, Addenbrooke's Hospital, Cambridge, UK.
| |
Collapse
|
14
|
Alehagen U, Dahlström U, Rehfeld JF, Goetze JP. Prognostic Assessment of Elderly Patients with Symptoms of Heart Failure by Combining High-Sensitivity Troponin T and N-Terminal Pro–B-Type Natriuretic Peptide Measurements. Clin Chem 2010; 56:1718-24. [DOI: 10.1373/clinchem.2009.141341] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND
N-terminal pro–B-type natriuretic peptide (NT-proBNP) is a useful biomarker in heart failure assessment, whereas measurement of cardiac troponin is central in the diagnosis of patients with acute coronary syndromes. This report examined the prognostic use of combining high-sensitivity cardiac troponin T (hs-cTnT) and NT-proBNP measurements in elderly patients presenting to a primary care center with symptoms associated with heart failure.
METHODS
A total of 470 elderly patients (age range 65–86 years) presenting with symptoms of heart failure were recruited from primary healthcare. In addition to clinical examination and echocardiography, hs-cTnT and NT-proBNP plasma concentrations were measured. All patients were followed for 10 years, and cardiovascular mortality was registered.
RESULTS
By use of the hs-cTnT assay, 80.4% of the population had plasma concentrations above the lower detection limit of the assay. Of those displaying a plasma concentration of hs-cTnT >99th percentile of a healthy population, 43% also had an NT-proBNP concentration in the fourth quartile (>507 ng/L). In the multivariate analysis, we observed a 2.5-fold increased risk for cardiovascular mortality in individuals with a plasma NT-proBNP concentration >507 ng/L (P < 0.0001). Conversely, patients with hs-cTnT >99th percentile displayed an approximately 2-fold increased risk for cardiovascular mortality (P = 0.0002). Combining the 2 biomarkers, NT-proBNP concentrations >507 ng/L with hs-cTnT >99th percentile increased the risk 3-fold, even after adjustment for clinical variables such as age, sex, impaired estimated glomerular filtration rate, and anemia (P < 0.0001).
CONCLUSIONS
hs-cTnT and NT-proBNP measurements combined provide better prognostic information than using either biomarker separately in elderly patients with symptoms associated with heart failure.
Collapse
Affiliation(s)
- Urban Alehagen
- Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden
| | - Ulf Dahlström
- Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden
| | - Jens F Rehfeld
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
15
|
Hursting MJ, Pai PJ, McCracken JE, Hwang F, Suvarna S, Lokhnygina Y, Bandarenko N, Arepally GM. Platelet factor 4/heparin antibodies in blood bank donors. Am J Clin Pathol 2010; 134:774-80. [PMID: 20959660 PMCID: PMC3766530 DOI: 10.1309/ajcpg0mnr5ngknfx] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Platelet factor 4 (PF4)/heparin antibody, typically associated with heparin therapy, is reported in some heparin-naive people. Seroprevalence in the general population, however, remains unclear. We prospectively evaluated PF4/heparin antibody in approximately 4,000 blood bank donors using a commercial enzyme-linked immunosorbent assay for initial and then repeated (confirmatory) testing. Antibody was detected initially in 249 (6.6%; 95% confidence interval [CI], 5.8%-7.4%) of 3,795 donors and repeatedly in 163 (4.3%; 95% CI, 3.7%-5.0%) of 3,789 evaluable donors. "Unconfirmed" positives were mostly (93%) low positives (optical density [OD] = 0.40-0.59). Of 163 repeatedly positive samples, 116 (71.2%) were low positives, and 124 (76.1%) exhibited heparin-dependent binding. Predominant isotypes of intermediate to high seropositive samples (OD >0.6) were IgG (20/39 [51%]), IgM (9/39 [23%]), and indeterminate (10/39 [26%]). The marked background seroprevalence of PF4/heparin antibody (4.3%-6.6%) with the preponderance of low (and frequently nonreproducible) positives in blood donors suggests the need for further assay calibration, categorization of antibody level, and studies evaluating clinical relevance of "naturally occurring" PF4/heparin antibodies.
Collapse
Affiliation(s)
- Marcie J Hursting
- Duke University Health System, Box 3486, Room 304 Sands Bldg, Durham, NC 27710, USA
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Gadelha T, Roldán V, Lecumberri R, Trujillo-Santos J, del Campo R, Poggio R, Monreal M. Clinical characteristics of patients with factor V Leiden or prothrombin G20210A and a first episode of venous thromboembolism. Findings from the RIETE Registry. Thromb Res 2010; 126:283-6. [DOI: 10.1016/j.thromres.2010.06.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2010] [Revised: 05/12/2010] [Accepted: 06/17/2010] [Indexed: 11/26/2022]
|
17
|
Morphological identification of right ventricular failure in cases of fatal pulmonary thromboembolism. Int J Legal Med 2010; 125:45-50. [PMID: 20623132 DOI: 10.1007/s00414-010-0486-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Accepted: 06/28/2010] [Indexed: 12/26/2022]
Abstract
Pulmonary thromboembolism is a life-threatening event potentially determining right ventricular failure. Even if the pathophysiology of this phenomenon has been widely investigated, no morphological demonstration of right ventricular ischemic damage determining right ventricular failure in cases of fatal pulmonary embolism has been reported till now. We performed an immunohistochemical investigation with the markers fibronectin and C5b-9 in 26 cases of fatal pulmonary thromboembolism (16 ♀, 10 ♂, mean age 56.4 years), as well as in 25 cases of myocardial infarction (16♀, 9♂, mean age 60.8 years) and 20 cases of hanging (3♀, 17♂, mean age 40.8 years). In each case, at least one tissue slide from both cardiac ventricles (free wall of the right ventricle, anterior and/or posterior wall of the left ventricle) was prepared. The reactions were semiquantitatively classified and the groups compared. In the study group, the occurrence of ischemic changes at the right ventricle was significantly higher than in cases of myocardial infarction and global hypoxia due to hanging. The determining aspect of the immunohistochemical examination is the identification of the prevalent ischemic lesion at the right ventricle compared to the left one. This may indicate the primary involvement of the right ventricle thus demonstrating a right ventricular failure.
Collapse
|