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Chopard R, Morillo R, Meneveau N, Jiménez D. Integration of Extracorporeal Membrane Oxygenation into the Management of High-Risk Pulmonary Embolism: An Overview of Current Evidence. Hamostaseologie 2024. [PMID: 38531394 DOI: 10.1055/a-2215-9003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
High-risk pulmonary embolism (PE) refers to a large embolic burden causing right ventricular failure and hemodynamic instability. It accounts for approximately 5% of all cases of PE but contributes significantly to overall PE mortality. Systemic thrombolysis is the first-line revascularization therapy in high-risk PE. Surgical embolectomy or catheter-directed therapy is recommended in patients with an absolute contraindication to systemic thrombolysis. Extracorporeal membrane oxygenation (ECMO) provides respiratory and hemodynamic support for the most critically ill PE patients with refractory cardiogenic shock or cardiac arrest. The complex management of these individuals requires urgent yet coordinated multidisciplinary care. In light of existing evidence regarding the utility of ECMO in the management of high-risk PE patients, a number of possible indications for ECMO utilization have been suggested in the literature. Specifically, in patients with refractory cardiac arrest, resuscitated cardiac arrest, or refractory shock, including in cases of failed thrombolysis, venoarterial ECMO (VA-ECMO) should be considered, either as a bridge to percutaneous or surgical embolectomy or as a bridge to recovery after surgical embolectomy. We review here the current evidence on the use of ECMO as part of the management strategy for the highest-risk presentations of PE and summarize the latest data in this indication.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, Besançon, France
- SINERGIES, University of Franche-Comté, Besançon, France
- F-CRIN, INNOVTE network, France
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, Besançon, France
- SINERGIES, University of Franche-Comté, Besançon, France
- F-CRIN, INNOVTE network, France
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
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Jiang R, Dai HL. Normotensive pulmonary embolism: nothing to sneeze at. J Thromb Haemost 2023; 21:3072-3074. [PMID: 37858522 DOI: 10.1016/j.jtha.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hai-Long Dai
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Clinical Medicine Center for Cardiovascular Disease of Yunnan Province, Department of Cardiology, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, China.
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de Wit K, D'Arsigny CL. Risk stratification of acute pulmonary embolism. J Thromb Haemost 2023; 21:3016-3023. [PMID: 37187357 DOI: 10.1016/j.jtha.2023.05.003] [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: 12/30/2022] [Revised: 04/18/2023] [Accepted: 05/01/2023] [Indexed: 05/17/2023]
Abstract
Approximately 5% of pulmonary embolism (PE) cases present with persistent hypotension, obstructive shock, or cardiac arrest. Given the high short-term mortality, management of high-risk PE cases focuses on immediate reperfusion therapies. Risk stratification of normotensive PE is important to identify patients with an elevated risk of hemodynamic collapse or an elevated risk of major bleeding. Risk stratification for short-term hemodynamic collapse includes assessment of physiological parameters, right heart dysfunction, and identification of comorbidities. Validated tools such as European Society of Cardiology guidelines and Bova score can identify normotensive patients with PE and an elevated risk of subsequent hemodynamic collapse. At present, we lack high-quality evidence to recommend one treatment over another (systemic thrombolysis, catheter-directed therapy, or anticoagulation with close monitoring) for patients at elevated risk of hemodynamic collapse. Newer, less well-validated scores such as BACS and PE-CH may help identify patients at a high risk of major bleeding following systemic thrombolysis. The PE-SARD score may identify those at risk of major anticoagulant-associated bleeding. Patients at low risk of short-term adverse outcomes can be considered for outpatient management. The simplified Pulmonary Embolism Severity Index score or Hestia criteria are safe decision aids when combined with physician global assessment of the need for hospitalization following the diagnosis of PE.
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Affiliation(s)
- Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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Risk Stratification in Patients with Acute Pulmonary Embolism: Current Evidence and Perspectives. J Clin Med 2022; 11:jcm11092533. [PMID: 35566658 PMCID: PMC9104204 DOI: 10.3390/jcm11092533] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022] Open
Abstract
Risk stratification is one of the cornerstones of the management of acute pulmonary embolism (PE) and determines the choice of both diagnostic and therapeutic strategies. The first step is the identification of patent circulatory failure, as it is associated with a high risk of immediate mortality and requires a rapid diagnosis and prompt reperfusion. The second step is the estimation of 30-day mortality based on clinical parameters (e.g., original and simplified version of the pulmonary embolism severity index): low-risk patients without right ventricular dysfunction are safely managed with ambulatory anticoagulation. The remaining group of hemodynamically stable patients, labeled intermediate-risk PE, requires hospital admission, even if most of them will heal without complications. In recent decades, efforts have been made to identify a subgroup of patients at an increased risk of adverse outcomes (intermediate-high-risk PE), who might benefit from a more aggressive approach, including reperfusion therapies and admission to a monitored unit. The cur-rent approach, combining markers of right ventricular dysfunction and myocardial injury, has an insufficient positive predictive value to guide primary thrombolysis. Sensitive markers of circulatory failure, such as plasma lactate, have shown interesting prognostic accuracy and may play a central role in the future. Furthermore, the improved security of reduced-dose thrombolysis may enlarge the indication of this treatment to selected intermediate–high-risk PE.
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Slobodan O, Boris D, Bojana S, Jovan M, Zorica M, Aleksandar B, Jadranka T, Sandra P, Sonja S, Ljiljana J, Ljiljana K, Tamara K, Maja N, Vladimir M, Ana K, Nenad Z, Natasa M, Ilija S, Zoran G, Srdjan K, Sasa P, Aleksandar N, Stavros K. Predictive value of heart failure with reduced versus preserved ejection fraction for outcome in pulmonary embolism. ESC Heart Fail 2020; 7:4061-4070. [PMID: 32936530 PMCID: PMC7754916 DOI: 10.1002/ehf2.13015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 08/20/2020] [Accepted: 09/02/2020] [Indexed: 12/24/2022] Open
Abstract
AIMS This study aimed to investigate whether the risk of short-term mortality is different in pulmonary embolism (PE) patients who have heart failure with reduced ejection fraction (HFrEF) as compared with those with heart failure with preserved ejection fraction (HFpEF). METHODS AND RESULTS Predictive value of HFrEF or HFpEF for 7-day (intrahospital) and 30-day all-cause mortality was determined in the cohort of 1055 out of 1201 consecutive acute PE patients from the Serbian multicentre PE registry. Patients were classified into either HFrEF or HFpEF group, according to guideline-proposed criteria. A 7-day (intrahospital) and 30-day all-cause mortality was 18.5% vs. 7.3% vs. 4.5% (P < 0.001) and 22.2% vs. 16.3% vs. 7.9% (P < 0.001) for patients with the history of HFrEF, HFpEF, and without HF, respectively. Multivariable analysis adjusted to age, gender, history of chronic obstructive pulmonary disease, diabetes mellitus, arterial hypertension, presence of atrial fibrillation, and mortality risk assessment at admission has shown that only HFrEF, but not HFpEF, was an independent predictor for 7-day mortality (hazard ratio 2.22, 95% confidence interval 1.25-4,38.41, P = 0.021) and neither HFrEF or HFpEF was an independent predictor for 30-day mortality. Among various admission parameters associated to PE outcome, only systolic pressure in HFrEF patients (P < 0.001), heart rate (P = 0.01), and right ventricle systolic pressure (P = 0.039) in HFpEF patients were significantly different in patients who died compared with those who survived at 7 days. CONCLUSIONS Our study has shown that the presence of previous history of HFrEF, but not HFpEF, in acute PE is an independent risk factor for mortality at 7 days.
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Affiliation(s)
- Obradovic Slobodan
- Clinic of Cardiology and Emergency Internal MedicineMilitary Medical AcademyBelgradeSerbia
- School of MedicineUniversity of DefenseBelgradeSerbia
| | - Dzudovic Boris
- Clinic of Cardiology and Emergency Internal MedicineMilitary Medical AcademyBelgradeSerbia
| | - Subotic Bojana
- Clinic of Cardiology and Emergency Internal MedicineMilitary Medical AcademyBelgradeSerbia
| | - Matijasevic Jovan
- Institute for Pulmonary Diseases of VojvodinaSremska KamenicaSerbia
- School of MedicineUniversity of Novi SadNovi SadSerbia
| | - Mladenovic Zorica
- Clinic of Cardiology and Emergency Internal MedicineMilitary Medical AcademyBelgradeSerbia
- School of MedicineUniversity of DefenseBelgradeSerbia
| | - Bokan Aleksandar
- Institute for Pulmonary Diseases of VojvodinaSremska KamenicaSerbia
| | - Trobok Jadranka
- Institute for Pulmonary Diseases of VojvodinaSremska KamenicaSerbia
| | - Pekovic Sandra
- Institute for Pulmonary Diseases of VojvodinaSremska KamenicaSerbia
| | | | | | - Kos Ljiljana
- Clinic of Cardiology, Clinical Center Banja Luka, School of MedicineUniversity of Banja LukaBanja LukaRepublic of Srpska, Bosnia and Herzegovina
| | - Kovacevic‐Preradovic Tamara
- Clinic of Cardiology, Clinical Center Banja Luka, School of MedicineUniversity of Banja LukaBanja LukaRepublic of Srpska, Bosnia and Herzegovina
| | - Nikolic Maja
- Clinic of Cardiology, Clinical Center Kragujevac, School of MedicineUniversity of KragujevacKragujevacSerbia
| | - Miloradovic Vladimir
- Clinic of Cardiology, Clinical Center Kragujevac, School of MedicineUniversity of KragujevacKragujevacSerbia
| | | | - Zec Nenad
- Department for Internal MedicineGeneral Hospital PancevoPancevoSerbia
| | - Markovic‐Nikolic Natasa
- Clinic of CardiologyUniversity Hospital ZvezdaraBelgradeSerbia
- Faculty of MedicineUniversity of BelgradeBelgradeSerbia
| | - Srdanovic Ilija
- Institute for Cardiovascular Medicine Vojvodina, School of MedicineUniversity of Novi SadNovi SadSerbia
| | - Gluvic Zoran
- Intensive Care Unit, Clinic of Internal MedicineClinical Hospital Center ZemunBelgradeSerbia
| | - Kafedzic Srdjan
- Intensive Care Unit, Clinic of Internal MedicineClinical Hospital Center ZemunBelgradeSerbia
| | - Pancevacki Sasa
- Intensive Care Unit, Clinic of Internal MedicineClinical Hospital Center ZemunBelgradeSerbia
| | - Neskovic Aleksandar
- Faculty of MedicineUniversity of BelgradeBelgradeSerbia
- Department of CardiologyClinical Hospital Center ZemunBelgradeSerbia
| | - Konstantinides Stavros
- Center for Thrombosis and HemostasisJohannes Gutenberg University of MainzMainzGermany
- Department of CardiologyDemocritus University of ThraceKomotiniGreece
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Cormican D, Morkos MS, Winter D, Rodrigue MF, Wendel J, Ramakrishna H. Acute Perioperative Pulmonary Embolism-Management Strategies and Outcomes. J Cardiothorac Vasc Anesth 2019; 34:1972-1984. [PMID: 31883768 DOI: 10.1053/j.jvca.2019.11.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/12/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Daniel Cormican
- Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA; Division of Critical Care Medicine, Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
| | - Michael S Morkos
- Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
| | - Daniel Winter
- Department of Anesthesiology, Northwestern Medicine, Chicago, IL
| | - Marc F Rodrigue
- Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
| | - Justin Wendel
- Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Darwish OS, Mahayni A, Patel M, Amin A. Cardiac Troponins in Low-Risk Pulmonary Embolism Patients: A Systematic Review and Meta-Analysis. J Hosp Med 2018; 13:706-712. [PMID: 29694453 DOI: 10.12788/jhm.2961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients with low-risk pulmonary embolism (PE) should be considered as per current scoring systems for ambulatory treatment. However, there is uncertainty whether patients with low scores and positive troponins should require hospitalization. METHODS We searched MEDLINE, SCOPUS, and Cochrane Library databases from inception to December 2016 and collected longitudinal studies that evaluated the prognostic value of troponins in patients with low-risk PE. The primary outcome measure was 30-day all-cause mortality. We calculated odds ratio (OR), likelihood ratios (LRs), and 95% confidence intervals (CI) by using randomeffects models. RESULTS The literature search identified 117 candidate articles, of which 16 met the criteria for review. Based on pulmonary embolism severity index (PESI) or simplified PESI score, 1.2% was the all-cause mortality rate across 2,662 participants identified as low-risk. A positive troponin status in patients with low-risk PE was associated with an increased risk of 30-day all-cause mortality (odds ratio [OR]: 4.79; 95% confidence interval [CI]: 1.11 to 20.68). The pooled likelihood ratios (LRs) for all-cause mortality were positive LR 2.04 (95% CI, 1.53 to 2.72) and negative LR 0.072 (95% CI, 0.37 to 1.40). CONCLUSIONS The use of positive troponin status as a predictor of increased mortality in low-risk PE patients exhibited relatively poor performance given the crossed negative LR CI (1.0) and modest positive LR. Larger prospective trials must be conducted to elucidate if patients with low-risk PE and positive troponin status can avoid hospitalization.
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Affiliation(s)
- Omar S Darwish
- University of California, Irvine, UCI Medical Center, Orange, California, USA.
| | - Abdullah Mahayni
- Mr. Mahayni is now with King Saud bin Abdulaziz University for Health Sciences, University in Riyadh, Saudi Arabia
| | - Mukti Patel
- University of California, Irvine, UCI Medical Center, Orange, California, USA
| | - Alpesh Amin
- University of California, Irvine, UCI Medical Center, Orange, California, USA
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Sex differences in the characteristics and short-term prognosis of patients presenting with acute symptomatic pulmonary embolism. PLoS One 2017; 12:e0187648. [PMID: 29107971 PMCID: PMC5673176 DOI: 10.1371/journal.pone.0187648] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/22/2017] [Indexed: 11/23/2022] Open
Abstract
Background We sought to examine sex-related differences in the characteristics and outcome in patients presenting with acute symptomatic pulmonary embolism (PE). Methods We conducted a retrospective cohort study of 2,096 patients diagnosed with acute PE. The characteristics were recorded at presentation. Treatment was at the discretion of patients’ physicians. The primary study outcome, all-cause mortality, and the secondary outcomes of PE-specific mortality, recurrent venous thromboembolism, and major bleeding were assessed during the first month of follow-up after PE diagnosis. Results Overall, the women were older than the men and had significantly higher rates of immobilization. They had significantly lower rates of chronic obstructive pulmonary disease and cancer. Women had a higher prevalence of syncope and elevated brain natriuretic peptide levels. Thirty-day all-cause mortality was similar between women and men (7.1% versus 6.2%; P = 0.38). Male gender was not independently significantly associated with PE-related death (adjusted odds ratio [OR] 1.02; 95% CI, 0.50 to 2.07; P = 0.96). Restricting the analyses to haemodynamically stable patients (n = 2,021), female gender was an independent predictor of all-cause (adjusted OR 1.56; 95% CI, 1.07 to 2.28; P = 0.02) and PE-specific mortality (adjusted OR 1.85; 95% CI, 1.02 to 3.33; P = 0.04). Compared with men, women were 2.05 times more likely to experience a major bleed. Conclusions Women and men with PE had different clinical characteristics, presentation, and outcomes. Women receiving anticoagulation have a significantly higher risk of major bleeding, suggesting the need for careful monitoring of anticoagulant intensity in women.
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Assessment of right ventricular function in acute pulmonary embolism. Am Heart J 2017; 185:123-129. [PMID: 28267465 DOI: 10.1016/j.ahj.2016.12.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 12/22/2016] [Indexed: 01/29/2023]
Abstract
The optimal approach to assess right ventricular (RV) function in patients with acute symptomatic pulmonary embolism (PE) lacks clarity. METHODS This study aimed to evaluate the optimal approach to assess RV function in normotensive patients with acute symptomatic PE. Outcomes assessed through 30-days after the diagnosis of PE included all-cause mortality and complicated course. RESULTS Eight hundred forty-eight patients were enrolled. Multidetector computed tomography (MDCT) and transthoracic echocardiography agreed on the presence or absence of RV overload in 449 (53%) patients. The combination of the simplified Pulmonary Embolism Severity Index (sPESI) and MDCT showed a negative predictive value for 30-day all-cause mortality of 100%. Of the 43% that had an sPESI of >0 points and MDCT RV enlargement, 41 (11.3%) experienced a complicated course that included 24 (6.6%) deaths. One hundred twenty-nine patients (15%) had an sPESI of >0 points, MDCT, and echocardiographic RV overload. Of these, 21 (16.3%) experienced a complicated course within the first 30days, and 10 (7.7%) of them died. CONCLUSIONS Incorporation of echocardiographic RV overload to the sPESI and MDCT did not improve identification of low-risk PE patients, whereas it improved identification of those at intermediate-high risk for short-term complications.
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Elias A, Mallett S, Daoud-Elias M, Poggi JN, Clarke M. Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis. BMJ Open 2016; 6:e010324. [PMID: 27130162 PMCID: PMC4854007 DOI: 10.1136/bmjopen-2015-010324] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To review the evidence for existing prognostic models in acute pulmonary embolism (PE) and determine how valid and useful they are for predicting patient outcomes. DESIGN Systematic review and meta-analysis. DATA SOURCES OVID MEDLINE and EMBASE, and The Cochrane Library from inception to July 2014, and sources of grey literature. ELIGIBILITY CRITERIA Studies aiming at constructing, validating, updating or studying the impact of prognostic models to predict all-cause death, PE-related death or venous thromboembolic events up to a 3-month follow-up in patients with an acute symptomatic PE. DATA EXTRACTION Study characteristics and study quality using prognostic criteria. Studies were selected and data extracted by 2 reviewers. DATA ANALYSIS Summary estimates (95% CI) for proportion of risk groups and event rates within risk groups, and accuracy. RESULTS We included 71 studies (44,298 patients). Among them, 17 were model construction studies specific to PE prognosis. The most validated models were the PE Severity Index (PESI) and its simplified version (sPESI). The overall 30-day mortality rate was 2.3% (1.7% to 2.9%) in the low-risk group and 11.4% (9.9% to 13.1%) in the high-risk group for PESI (9 studies), and 1.5% (0.9% to 2.5%) in the low-risk group and 10.7% (8.8% to12.9%) in the high-risk group for sPESI (11 studies). PESI has proved clinically useful in an impact study. Shifting the cut-off or using novel and updated models specifically developed for normotensive PE improves the ability for identifying patients at lower risk for early death or adverse outcome (0.5-1%) and those at higher risk (up to 20-29% of event rate). CONCLUSIONS We provide evidence-based information about the validity and utility of the existing prognostic models in acute PE that may be helpful for identifying patients at low risk. Novel models seem attractive for the high-risk normotensive PE but need to be externally validated then be assessed in impact studies.
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Affiliation(s)
- Antoine Elias
- Department of Vascular Medicine, Sainte Musse Hospital, Toulon La Seyne Hospital Centre, Toulon, France
- DPhil Programme in Evidence-Based Healthcare, University of Oxford, Oxford, UK
| | - Susan Mallett
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marie Daoud-Elias
- Department of Vascular Medicine, Sainte Musse Hospital, Toulon La Seyne Hospital Centre, Toulon, France
| | - Jean-Noël Poggi
- Department of Vascular Medicine, Sainte Musse Hospital, Toulon La Seyne Hospital Centre, Toulon, France
| | - Mike Clarke
- Northern Ireland Network for Trials Methodology Research, Queen's University Belfast, Belfast, UK
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Jiménez D, Lobo JL, Barrios D, Prandoni P, Yusen RD. Risk stratification of patients with acute symptomatic pulmonary embolism. Intern Emerg Med 2016; 11:11-8. [PMID: 26768476 DOI: 10.1007/s11739-015-1388-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 12/30/2015] [Indexed: 01/18/2023]
Abstract
Patients with acute symptomatic pulmonary embolism (PE) who present with arterial hypotension or shock have a high risk of death (high-risk PE), and treatment guidelines recommend strong consideration of thrombolysis in this setting. For normotensive patients diagnosed with PE, risk stratification should aim to differentiate the group of patients deemed as having a low risk for early complications (all-cause mortality, recurrent venous thromboembolism, and major bleeding) (low-risk PE) from the group of patients at higher risk for PE-related complications (intermediate-high risk PE), so low-risk patients could undergo consideration of early outpatient treatment of PE and intermediate-high risk patients would undergo close observation and consideration of thrombolysis. Clinicians should also use risk stratification and eligibility criteria to identify a third group of patients that should not undergo escalated or home therapy (intermediate-low risk PE). Such patients should initiate standard therapy of PE while in the hospital. Clinical models [e.g., Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI)] may accurately identify those at low risk of dying shortly after the diagnosis of PE. For identification of intermediate-high risk patients with acute PE, studies have validated predictive models that use a combination of clinical, laboratory and imaging variables.
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Affiliation(s)
- David Jiménez
- Respiratory Department and Medicine Department, Ramón y Cajal Hospital and Alcalá de Henares University, IRYCIS, 28034, Madrid, Spain.
| | | | - Deisy Barrios
- Respiratory Department and Medicine Department, Ramón y Cajal Hospital and Alcalá de Henares University, IRYCIS, 28034, Madrid, Spain
| | - Paolo Prandoni
- Department of Cardiovascular Sciences, Vascular Medicine Unit, University Hospital of Padua, Padua, Italy
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
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Kohn CG, Mearns ES, Parker MW, Hernandez AV, Coleman CI. Prognostic Accuracy of Clinical Prediction Rules for Early Post-Pulmonary Embolism All-Cause Mortality. Chest 2015; 147:1043-1062. [DOI: 10.1378/chest.14-1888] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Kabrhel C, Okechukwu I, Hariharan P, Takayesu JK, MacMahon P, Haddad F, Chang Y. Factors associated with clinical deterioration shortly after PE. Thorax 2014; 69:835-42. [DOI: 10.1136/thoraxjnl-2013-204762] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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14
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Tong C, Zhang Z. Evaluation factors of pulmonary embolism severity and prognosis. Clin Appl Thromb Hemost 2013; 21:273-84. [PMID: 24023267 DOI: 10.1177/1076029613501540] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Management of pulmonary embolism (PE) is still unclear. We summarized 16 kinds of evaluation factors of PE severity and prognosis, and we analyzed the single and joint value for short-term and long-term prognosis. Among them, biomarkers such as brain natriuretic peptide or N-terminal probrain natriuretic peptide, troponin, and heart-type fatty acid-binding protein are the best indicators of PE severity and short-term prognosis. They might replace imaging detections in evaluating PE severity. But the positive predictive value of all the biomarkers is low, and we need to improve each value through joint detection. The PE severity index and simplified PE severity index are more suitable for evaluating the overall risk and long-term prognosis. They could be used as complements of indicators of the PE severity, especially in identifying low-risk group. Integrated risk stratification and strategies of management should be established based on the 2 aspects mentioned previously.
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Affiliation(s)
- ChunRan Tong
- Department of Respiratory Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
| | - ZhongHe Zhang
- Department of Respiratory Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning Province, China
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Ferrer M, Morillo R, Elías T, Jara L, García L, Nieto R, Sandoval E, Uresandi F, Otero R, Jiménez D. Validation of two clinical prognostic models in patients with acute symptomatic pulmonary embolism. Arch Bronconeumol 2013; 49:427-31. [PMID: 23664248 DOI: 10.1016/j.arbres.2013.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 02/23/2013] [Accepted: 03/03/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of this study was to compare the predictive value of two clinical prognostic models, the Spanish score and the simplified Pulmonary Embolism Severity Index (sPESI), in an independent cohort of patients diagnosed of acute symptomatic pulmonary embolism (PE). METHODS We performed a retrospective analysis of a cohort composed of 1447patients with acute symptomatic PE. The Spanish score and the sPESI were calculated for each patient according to different clinical variables. We assessed the predictive accuracy of these scores for 30-day mortality, and a composite of non fatal recurrent venous thromboembolism and non fatal major bleeding, using Cstatistic, which was obtained by means of logistic regression and ROC curves. RESULTS Overall, 138 patients died (9.5%) during the first month of follow-up. Both scores showed an excellent predictive value for 30-day all-cause mortality (Cstatistic, 0.72 and 0.74), but the performance was poor for the secondary endpoint (Cstatistic, 0.60 and 0.59). The sPESI classified fewer patients as low risk (32% versus 62%; P<.001). Low-risk patients based on the sPESI had a lower 30-day mortality than those based on the Spanish score (1.1% versus 4.2%), while the 30-day rate of non fatal recurrent VTE or major bleeding was similar (2.2% versus 2.3%). CONCLUSIONS Both scores provide excellent information to stratify the risk of mortality in patients treated of PE. The usefulness of these models for nonfatal adverse events is questionable. The sPESI identified low-risk patients with PE better than the Spanish score.
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Affiliation(s)
- Marta Ferrer
- Servicio de Neumología, Hospital Virgen del Rocío-IBIS, CIBERES, Sevilla, España
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Zhou XY, Ben SQ, Chen HL, Ni SS. The prognostic value of pulmonary embolism severity index in acute pulmonary embolism: a meta-analysis. Respir Res 2012; 13:111. [PMID: 23210843 PMCID: PMC3571977 DOI: 10.1186/1465-9921-13-111] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 10/15/2012] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Prognostic assessment is important for the management of patients with acute pulmonary embolism (APE). Pulmonary Embolism Severity Index (PESI) and simple PESI (sPESI) are new emerged prognostic assessment tools for APE. The aim of this meta-analysis is to assess the accuracy of the PESI and the sPESI to predict prognostic outcomes (all-cause and PE-related mortality, serious adverse events) in APE patients, and compare between these two PESIs. METHODS MEDLINE and EMBASE database were searched up to June 2012 using the terms "Pulmonary Embolism Severity Index" and "pulmonary embolism". Summary odds ratio (OR) with 95% confidence intervals (CIs) for prognostic outcomes in low risk PESI versus high risk PESI were calculated. Summary receiver operating characteristic curve (SROC) used to estimate overall predicting accuracies of prognostic outcomes. RESULTS Twenty-one studies were included in this meta-analysis. The results showed low-risk PESI was significantly associated with lower all-cause mortality (OR 0.13; 95% CI 0.12 to 0.15), PE-related mortality (OR 0.09; 95% CI 0.05 to 0.17) and serious adverse events (OR 0.34; 95% CI 0.29 to 0.41), with no homogeneity across studies. In sPESI subgroup, the OR of all-cause mortality, PE-related mortality, and serious adverse events was 0.10 (95% CI 0.08 to 0.14), 0.09 (95% CI 0.03 to 0.26) and 0.40 (95% CI 0.31 to 0.51), respectively; while in PESI subgroup, the OR was 0.14 (95% CI 0.13 to 0.16), 0.09 (95% CI 0.04 to 0.21), and 0.30 (95% CI 0.23 to 0.38), respectively. For accuracy analysis, the pooled sensitivity, the pooled specificity, and the overall weighted AUC for PESI predicting all-cause mortality was 0.909 (95% CI: 0.900 to 0.916), 0.411 (95% CI: 0.407 to 0.415), and 0.7853±0.0058, respectively; for PE-related mortality, it was 0.953 (95% CI: 0.913 to 0.978), 0.374 (95% CI: 0.360 to 0.388), and 0.8218±0.0349, respectively; for serious adverse events, it was 0.821 (95% CI: 0.795 to 0.845), 0.389 (95% CI: 0.384 to 0.394), and 0.6809±0.0208, respectively. In sPESI subgroup, the AUC for predicting all-cause mortality, PE-related mortality, and serious adverse events was 0.7920±0.0117, 0.8317±0.0547, and 0.6454±0.0197, respectively. In PESI subgroup, the AUC was 0.7856±0.0075, 0.8158±0.0451, and 0.6609±0.0252, respectively. CONCLUSIONS PESI has discriminative power to predict the short-term death and adverse outcome events in patients with acute pulmonary embolism, the PESI and the sPESI have similar accuracy, while sPESI is easier to use. However, the calibration for predicting prognosis can't be calculated from this meta-analysis, some prospective studies for accessing PESI predicting calibration can be recommended.
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Affiliation(s)
- Xiao-Yu Zhou
- Department of Respiratory Diseases, Affiliated Hospital of Nantong University, Nantong City, Jiangsu Province, 226001, People's Republic of China
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Abstract
Pulmonary embolism is the third most common cardiovascular disease after myocardial infarction and stroke. The death rate from pulmonary embolism exceeds the death rate from myocardial infarction, because myocardial infarction is much easier to detect and to treat. Among survivors of pulmonary embolism, chronic thromboembolic pulmonary hypertension occurs in 2-4 of every 100 patients. Post-thrombotic syndrome of the legs, characterized by chronic venous insufficiency, occurs in up to half of patients who suffer deep vein thrombosis or pulmonary embolism. We have effective pharmacological regimens using fixed low dose unfractionated or low molecular weight heparin to prevent venous thromboembolism among hospitalized patients. There remains the problem of low rates of utilization of pharmacological prophylaxis. The biggest change in our understanding of the epidemiology of venous thromboembolism is that we now believe that deep vein thrombosis and pulmonary embolism share similar risk factors and pathophysiology with atherothrombosis and coronary artery disease.
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