1
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Lyhne MD, Schultz JG, Mortensen CS, Kramer A, Nielsen-Kudsk JE, Andersen A. Immediate cardiopulmonary responses to consecutive pulmonary embolism: a randomized, controlled, experimental study. BMC Pulm Med 2024; 24:233. [PMID: 38745282 PMCID: PMC11093735 DOI: 10.1186/s12890-024-03006-9] [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: 01/02/2024] [Accepted: 04/10/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Acute pulmonary embolism (PE) induces ventilation-perfusion mismatch and hypoxia and increases pulmonary pressure and right ventricular (RV) afterload, entailing potentially fatal RV failure within a short timeframe. Cardiopulmonary factors may respond differently to increased clot burden. We aimed to elucidate immediate cardiopulmonary responses during successive PE episodes in a porcine model. METHODS This was a randomized, controlled, blinded study of repeated measurements. Twelve pigs were randomly assigned to receive sham procedures or consecutive PEs every 15 min until doubling of mean pulmonary pressure. Cardiopulmonary assessments were conducted at 1, 2, 5, and 13 min after each PE using pressure-volume loops, invasive pressures, and arterial and mixed venous blood gas analyses. ANOVA and mixed-model statistical analyses were applied. RESULTS Pulmonary pressures increased after the initial PE administration (p < 0.0001), with a higher pulmonary pressure change compared to pressure change observed after the following PEs. Conversely, RV arterial elastance and pulmonary vascular resistance was not increased after the first PE, but after three PEs an increase was observed (p = 0.0103 and p = 0.0015, respectively). RV dilatation occurred following initial PEs, while RV ejection fraction declined after the third PE (p = 0.004). RV coupling exhibited a decreasing trend from the first PE (p = 0.095), despite increased mechanical work (p = 0.003). Ventilatory variables displayed more incremental changes with successive PEs. CONCLUSION In an experimental model of consecutive PE, RV afterload elevation and dysfunction manifested after the third PE, in contrast to pulmonary pressure that increased after the first PE. Ventilatory variables exhibited a more direct association with clot burden.
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Affiliation(s)
- Mads Dam Lyhne
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens Boulevard 82, Aarhus N, 8200, Denmark.
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Aarhus N, DK-8200, Denmark.
| | - Jacob Gammelgaard Schultz
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens Boulevard 82, Aarhus N, 8200, Denmark
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Aarhus N, 8200, Denmark
| | - Christian Schmidt Mortensen
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens Boulevard 82, Aarhus N, 8200, Denmark
| | - Anders Kramer
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens Boulevard 82, Aarhus N, 8200, Denmark
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Aarhus N, 8200, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens Boulevard 82, Aarhus N, 8200, Denmark
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Aarhus N, 8200, Denmark
| | - Asger Andersen
- Department of Clinical Medicine, Aarhus University, Palle Juul Jensens Boulevard 82, Aarhus N, 8200, Denmark
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, Aarhus N, 8200, Denmark
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2
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Nishikawa T, Fujita T, Morishima T, Okawa S, Hino T, Yasui T, Shioyama W, Oka T, Miyashiro I, Fujita M. Prognostic Effect of Incidental Pulmonary Embolism on Long-Term Mortality in Cancer Patients. Circ J 2024; 88:198-204. [PMID: 33597323 DOI: 10.1253/circj.cj-20-1160] [Citation(s) in RCA: 4] [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] [Indexed: 11/09/2022]
Abstract
BACKGROUND The effect of incidental pulmonary embolism (PE) on long-term prognosis in cancer patients is unclear. This study assessed the characteristics of cancer and venous thromboembolism (VTE) and the effect of incidental PE identified by oncologists on long-term survival of patients with cancer.Methods and Results:This single-center, retrospective, cohort study used hospital-based cancer registry data from the Osaka International Cancer Institute linked with electronic medical records and administrative data from Japan's Diagnosis Procedure Combination Per-diem Payment System. Overall, 15,689 cancer patients underwent contrast-enhanced thoracic computed tomography during 2010-2018. After excluding patients with missing data, symptomatic patients, or patients with suspected PE, 174 with incidental PE (PE+ group) and 13,197 with no PE (PE- group) were identified. The total incidence of incidental PE was 1.3%. No deaths from thrombotic events were identified in the PE+ group. Both groups were adjusted for cancer- and VTE-related characteristics using inverse probability weighting. After adjusting for immortal time bias in the PE+ group, Kaplan-Meier analysis revealed that all-cause mortality was higher in the PE+ group (hazard ratio, 2.26; 95% confidence interval, 1.53-3.33). A Cox proportional hazard model revealed that metastatic cancer and a history of curative treatment were significant prognostic factors, whereas central PE and residual proximal deep vein thrombosis were not. CONCLUSIONS Incidental PE in cancer patients indicates poorer prognosis. Cancer-related but not thrombosis-related factors determine prognosis.
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Affiliation(s)
| | - Takeshi Fujita
- Department of Onco-Cardiology, Osaka International Cancer Institute
| | | | - Sumiyo Okawa
- Cancer Control Center, Osaka International Cancer Institute
| | - Terutaka Hino
- Department of Medical Informatics, Osaka International Cancer Institute
| | - Taku Yasui
- Department of Onco-Cardiology, Osaka International Cancer Institute
| | - Wataru Shioyama
- Department of Onco-Cardiology, Osaka International Cancer Institute
| | - Toru Oka
- Department of Onco-Cardiology, Osaka International Cancer Institute
| | - Isao Miyashiro
- Cancer Control Center, Osaka International Cancer Institute
| | - Masashi Fujita
- Department of Onco-Cardiology, Osaka International Cancer Institute
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3
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Othman MK, Yusof Z, Ismail ZKA, Sayuti KA, W Isa WYH. The Zurkurnai ECG Pattern: A Novel ECG Pattern of the High-Risk Features of Acute Pulmonary Embolism. Cureus 2024; 16:e52889. [PMID: 38274596 PMCID: PMC10808894 DOI: 10.7759/cureus.52889] [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] [Accepted: 01/24/2024] [Indexed: 01/27/2024] Open
Abstract
Acute pulmonary embolism is an important differential diagnosis in patients presenting with acute shortness of breath. However, the overlapping clinical presentation between acute coronary syndrome, aortic dissection, pneumonia, and heart failure made the diagnosis of pulmonary embolism very challenging in a limited resources center. We present a case of acute pulmonary embolism with an uncommon ECG pattern that was initially misdiagnosed as acute coronary syndrome. The authors made the appropriate diagnosis using the Zurkurnai ECG pattern in acute pulmonary embolism, which is defined as the presence of right axis deviation, deep symmetrical T wave inversion in V1 to V5, II, III, and AVF with the maximum at V3-V4 and poor R wave progression, which indicates the high-risk features of acute pulmonary embolism.
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Affiliation(s)
- Mohd Khairi Othman
- Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, MYS
| | - Zurkurnai Yusof
- Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, MYS
| | | | - Khairil Amir Sayuti
- Department of Radiology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, MYS
| | - W Yus Haniff W Isa
- Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, MYS
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4
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Fang A, Mayorga-Carlin M, Han P, Cassady S, John T, LaRocco A, Etezadi V, Jones K, Nagarsheth K, Toursavadkohi S, Jeudy J, Anderson D, Griffith B, Sorkin JD, Sarkar R, Lal BK, Cires-Drouet RS. Risk factors and treatment interventions associated with incomplete thrombus resolution and pulmonary hypertension after pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2024; 12:101665. [PMID: 37595746 PMCID: PMC10939011 DOI: 10.1016/j.jvsv.2023.08.006] [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: 04/25/2023] [Revised: 07/23/2023] [Accepted: 08/08/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Residual pulmonary vascular occlusion (RPVO) affects one half of patients after a pulmonary embolism (PE). The relationship between the risk factors and therapeutic interventions for the development of RPVO and chronic thromboembolic pulmonary hypertension is unknown. METHODS This retrospective review included PE patients within a 26-month period who had baseline and follow-up imaging studies (ie, computed tomography [CT], ventilation/perfusion scans, transthoracic echocardiography) available. We collected the incidence of RPVO, percentage of pulmonary artery occlusion (%PAO), baseline CT %PAO, most recent CT %PAO, and difference between the baseline and most recent %PAO on CT (Δ%PAO). RESULTS A total of 354 patients had imaging reports available; 197 with CT and 315 with transthoracic echocardiography. The median follow-up time was 144 days (interquartile range [IQR], 102-186 days). RPVO was present in 38.9% of the 354 patients. The median Δ%PAO was -10.0% (IQR, -32% to -1.2%). Fewer patients with a provoked PE developed RPVO (P ≤ .01), and the initial troponin level was lower in patients who developed RPVO (P = .03). The initial thrombus was larger in the patients who received advanced intervention vs anticoagulation (baseline CT %PAO: median, 61.2%; [IQR, 27.5%-75.0%] vs median, 12.5% [IQR, 2.5%-40.0%]; P ≤ .0001). Catheter-directed thrombolysis (CDT; median Δ%PAO, -47.5%; IQR, -63.7% to -8.7%) and surgical pulmonary embolectomy (SPE; median Δ%PAO, -42.5; IQR, -68.1% to -18.7%) had the largest thrombus reduction compared with anticoagulation (P = .01). Of the 354 patients, 76 developed pulmonary hypertension; however, only 14 received pulmonary hypertension medications and 12 underwent pulmonary thromboendarterectomy. Cancer (odds ratio [OR], 1.7) and planned prolonged anticoagulation (>1 year; OR, 2.20) increased the risk of RPVO. In contrast, the risk was lower for men (OR, 0.61), patients with recent surgery (OR, 0.33), and patients treated with SPE (OR, 0.42). A larger Δ%PAO was found in men (coefficient, -8.94), patients with a lower body mass index (coefficient, -0.66), patients treated with CDT (coefficient, -18.12), and patients treated with SPE (coefficient, -21.69). A lower Δ%PAO was found in African-American patients (coefficient, 7.31). CONCLUSIONS The use of CDT and SPE showed long-term benefit in thrombus reduction.
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Affiliation(s)
- Adam Fang
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, MD
| | | | - Paul Han
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Steven Cassady
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Thomas John
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Allison LaRocco
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Vahid Etezadi
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, MD
| | - Kevin Jones
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD; The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD
| | | | | | - Jean Jeudy
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland, Baltimore, MD
| | | | | | - John D Sorkin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD; Baltimore Veterans Affairs Geriatrics Research, Education, and Clinical Center, Baltimore Veterans Affairs Medical Center, Baltimore, MD
| | | | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, MD; Vascular Service, Baltimore Veterans Affairs Medical Center, Baltimore, MD
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5
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Wada N, Li Y, Gagne S, Hino T, Valtchinov VI, Gay E, Nishino M, Hammer MM, Madore B, Guttmann CRG, Ishigami K, Hunninghake GM, Levy BD, Kaye KM, Christiani DC, Hatabu H. Incidence and severity of pulmonary embolism in COVID-19 infection: Ancestral, Alpha, Delta, and Omicron variants. Medicine (Baltimore) 2023; 102:e36417. [PMID: 38050198 PMCID: PMC10695578 DOI: 10.1097/md.0000000000036417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/10/2023] [Indexed: 12/06/2023] Open
Abstract
Little information is available regarding incidence and severity of pulmonary embolism (PE) across the periods of ancestral strain, Alpha, Delta, and Omicron variants. The aim of this study is to investigate the incidence and severity of PE over the dominant periods of ancestral strain and Alpha, Delta, and Omicron variants. We hypothesized that the incidence and the severity by proximity of PE in patients with the newer variants and vaccination would be decreased compared with those in ancestral and earlier variants. Patients with COVID-19 diagnosis between March 2020 and February 2022 and computed tomography pulmonary angiogram performed within a 6-week window around the diagnosis (-2 to +4 weeks) were studied retrospectively. The primary endpoints were the associations of the incidence and location of PE with the ancestral strain and each variant. Of the 720 coronavirus disease 2019 patients with computed tomography pulmonary angiogram (58.6 ± 17.2 years; 374 females), PE was diagnosed among 42/358 (12%) during the ancestral strain period, 5/60 (8%) during the Alpha variant period, 16/152 (11%) during the Delta variant period, and 13/150 (9%) during the Omicron variant period. The most proximal PE (ancestral strain vs variants) was located in the main/lobar arteries (31% vs 6%-40%), in the segmental arteries (52% vs 60%-75%), and in the subsegmental arteries (17% vs 0%-19%). There was no significant difference in both the incidence and location of PE across the periods, confirmed by multivariable logistic regression models. In summary, the incidence and severity of PE did not significantly differ across the periods of ancestral strain and Alpha, Delta, and Omicron variants.
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Affiliation(s)
- Noriaki Wada
- Center for Pulmonary Functional Imaging, Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Yi Li
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Staci Gagne
- Center for Pulmonary Functional Imaging, Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Takuya Hino
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka City, Fukuoka, Japan
| | - Vladimir I. Valtchinov
- Center for Pulmonary Functional Imaging, Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Elizabeth Gay
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Mizuki Nishino
- Center for Pulmonary Functional Imaging, Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Mark M. Hammer
- Center for Pulmonary Functional Imaging, Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Bruno Madore
- Center for Pulmonary Functional Imaging, Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Charles R. G. Guttmann
- Center for Neurological Imaging, Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Kousei Ishigami
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka City, Fukuoka, Japan
| | - Gary M. Hunninghake
- Center for Pulmonary Functional Imaging, Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Bruce D. Levy
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Kenneth M. Kaye
- Division of Infectious Diseases, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - David C. Christiani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA
| | - Hiroto Hatabu
- Center for Pulmonary Functional Imaging, Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
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6
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Casey SD, Zekar L, Somers MJ, Westafer LM, Reed ME, Vinson DR. Bilateral Emboli and Highest Heart Rate Predict Hospitalization of Emergency Department Patients With Acute, Low-Risk Pulmonary Embolism. Ann Emerg Med 2023; 82:369-380. [PMID: 37028997 PMCID: PMC11126867 DOI: 10.1016/j.annemergmed.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/14/2023] [Accepted: 02/16/2023] [Indexed: 04/09/2023]
Abstract
STUDY OBJECTIVE Some patients with acute pulmonary embolism (PE) will suffer adverse clinical outcomes despite being low risk by clinical decision rules. Emergency physician decisionmaking processes regarding which low-risk patients require hospitalization are unclear. Higher heart rate (HR) or embolic burden may increase short-term mortality risk, and we hypothesized that these variables would be associated with an increased likelihood of hospitalization for patients designated as low risk by the PE Severity Index. METHODS This was a retrospective cohort study of 461 adult emergency department (ED) patients with a PE Severity Index score of fewer than 86 points. Primary exposures were the highest observed ED HR, most proximal embolus location (proximal vs distal), and embolism laterality (bilateral vs unilateral PE). The primary outcome was hospitalization. RESULTS Of 461 patients meeting inclusion criteria, most (57.5%) were hospitalized, 2 patients (0.4%) died within 30 days, and 142 (30.8%) patients were at elevated risk by other criteria (Hestia criteria or biochemical/radiographic right ventricular dysfunction). Variablesassociated with an increased likelihood of admission were highest observed ED HR of ≥110 beats/minute (vs HR <90 beats/min) (adjusted odds ratio [aOR] 3.11; 95% confidence interval [CI] 1.07 to 9.57), highest ED HR 90 to 109 (aOR 2.03; 95% CI 1.18-3.50) and bilateral PE (aOR 1.92; 95% CI 1.13 to 3.27). Proximal embolus location was not associated with the likelihood of hospitalization (aOR 1.19; 95% CI 0.71 to 2.00). CONCLUSIONS Most patients were hospitalized, often with recognizable high-risk characteristics not accounted for by the PE Severity Index. Highest ED HR of ≥90 beats/min and bilateral PE were associated with a physician's decision for hospitalization.
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Affiliation(s)
- Scott D Casey
- Permanente Medical Group, Oakland, CA; Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network.
| | - Lara Zekar
- Department of Emergency Medicine, University of California, Davis, CA
| | - Madeline J Somers
- Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network
| | - Lauren M Westafer
- Department of Emergency Medicine, UMASS Chan Medical School-Baystate, Springfield, MA
| | - Mary E Reed
- Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network
| | - David R Vinson
- Permanente Medical Group, Oakland, CA; Kaiser Permanente Division of Research, Oakland, CA; Kaiser Permanente CREST Network; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA
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7
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Tang L, Hu Y, Pan D, Yang C, Tang C, Huang Y, Gu J, Min M, Lin X, Tong C. PECSS: Pulmonary Embolism Comprehensive Screening Score to safely rule out pulmonary embolism among suspected patients presenting to emergency department. BMC Pulm Med 2023; 23:287. [PMID: 37550677 PMCID: PMC10408070 DOI: 10.1186/s12890-023-02580-8] [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: 05/18/2023] [Accepted: 07/22/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Pulmonary embolism is a severe cardiovascular disease and can be life-threatening if left untreated. However, the detection rate of pulmonary embolism using existing pretest probability scores remained relatively low and clinical rule out often relied on excessive use of computed tomographic pulmonary angiography. METHODS We retrospectively collected data from pulmonary embolism suspected patients in Zhongshan Hospital from July 2018 to October 2022. Pulmonary embolism diagnosis and severity grades were confirmed by computed tomographic pulmonary angiography. Patients were randomly divided into derivation and validation set. To construct the Pulmonary Embolism Comprehensive Screening Score (PECSS), we first screened for candidate clinical predictors using univariate logistic regression models. These predictors were then included in a searching algorithm with indicators of Wells score, where a series of points were assigned to each predictor. Optimal D-Dimer cutoff values were investigated and incorporated with PECSS to rule out pulmonary embolism. RESULTS In addition to Wells score, PECSS identified seven clinical predictors (anhelation, abnormal blood pressure, in critical condition when admitted, age > 65 years and high levels of pro-BNP, CRP and UA,) strongly associated with pulmonary embolism. Patients can be safely ruled out of pulmonary embolism if PECSS ≤ 4, or if 4 < PECSS ≤ 6 and D-Dimer ≤ 2.5 mg/L. Comparing with Wells approach, PECSS achieved lower failure rates across all pulmonary embolism severity grades. These findings were validated in the held-out validation set. CONCLUSIONS Compared to Wells score, PECSS approaches achieved lower failure rates and better compromise between sensitivity and specificity. Calculation of PECSS is easy and all predictors are readily available upon emergency department admission, making it widely applicable in clinical settings. TRAIL REGISTRATION The study was retrospectively registered (No. CJ0647) and approved by Human Genetic Resources in China in April 2022. Ethical approval was received from the Medical Ethics Committee of Zhongshan Hospital (NO.B2021-839R).
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Affiliation(s)
- Luojia Tang
- Emergency Department of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yundi Hu
- School of Data Science, Fudan University, Shanghai, China
| | - Dong Pan
- Department of Information and Intelligence Development of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chun Yang
- Department of Information and Intelligence Development of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Cheng Tang
- Emergency Department of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yunchuan Huang
- Emergency Department of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianyong Gu
- Emergency Department of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Min Min
- Emergency Department of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaolei Lin
- School of Data Science, Fudan University, Shanghai, China.
| | - Chaoyang Tong
- Emergency Department of Zhongshan Hospital, Fudan University, Shanghai, China.
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8
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Gleditsch J, Jervan Ø, Klok F, Holst R, Hopp E, Tavoly M, Ghanima W. Does the clot burden as assessed by the Mean Bilateral Proximal Extension of the Clot score reflect mortality and adverse outcome after pulmonary embolism? Acta Radiol Open 2023; 12:20584601231187094. [PMID: 37426515 PMCID: PMC10328056 DOI: 10.1177/20584601231187094] [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: 12/19/2022] [Accepted: 06/24/2023] [Indexed: 07/11/2023] Open
Abstract
Background Rapid diagnosis and risk stratification are important to reduce the risk of adverse clinical events and mortality in acute pulmonary embolism (PE). Although clot burden has not been consistently shown to correlate with disease outcomes, proximally located PE is generally perceived as more severe. Purpose To explore the ability of the Mean Bilateral Proximal Extension of the Clot (MBPEC) score to predict mortality and adverse outcome. Methods This was a single center retrospective cohort study. 1743 patients with computed tomography pulmonary arteriography (CTPA) verified PE diagnosed between 2005 and 2020 were included. Patients with active malignancy were excluded. The PE clot burden was assessed with MBPEC score: The most proximal extension of PE was scored in each lung from 1 = sub-segmental to 4 = central. The MBPEC score is the score from each lung divided by two and rounded up to nearest integer. Results We found inconsistent associations between higher and lower MBPEC scores versus mortality. The all-cause 30-day mortality of 3.9% (95% CI: 3.0-4.9). The PE-related mortality was 2.4% (95% CI: 1.7-3.3). Patients with MBPEC score 1 had higher all-cause mortality compared to patients with MBPEC score 4: Crude Hazard Ratio (cHR) was 2.02 (95% CI: 1.09-3.72). PE-related mortality was lower in patients with MBPEC score 3 compared to score 4: cHR 0.22 (95% CI: 0.05-0.93). Patients with MBPEC score 4 did more often receive systemic thrombolysis compared to patients with MBPEC score 1-3: 3.2% vs. 0.6% (p < .001). Patients with MBPEC score 4 where more often admitted to the intensive care unit: 13% vs. 4.7% (p < .001). Conclusion We found no consistent association between the MBPEC score and mortality. Our results therefore indicate that peripheral PE does not necessarily entail a lower morality risk than proximal PE.
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Affiliation(s)
- Jostein Gleditsch
- Department of Radiology, Østfold Hospital, Kalnes, Norway
- Institute of Clinical Medicine, University of Oslo Faculty of
Medicine, Oslo, Norway
| | - Øyvind Jervan
- Institute of Clinical Medicine, University of Oslo Faculty of
Medicine, Oslo, Norway
- Department of Cardiology, Østfold Hospital, Kalnes, Norway
| | - Frederikus Klok
- Department of Medicine – Thrombosis
and Hemostasis, Leiden University Medical
Center, Leiden, The Netherlands
| | - René Holst
- Oslo Centre for Biostatistics and
Epidemiology, University of Oslo and Oslo
University Hospital, Oslo, Norway
| | - Einar Hopp
- Division of Radiology and Nuclear
Medicine, Oslo University
Hospital, Oslo, Norway
| | - Mazdak Tavoly
- Department of Medicine, Sahlgrenska University
Hospital, Gothenburg, Sweden
| | - Waleed Ghanima
- Internal Medicine Clinic, Østfold Hospital, Kalnes, Norway
- Department of Hematology, Oslo
University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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9
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Jenab Y, Hosseini K, Esmaeili Z, Tofighi S, Ariannejad H, Sotoudeh H. Prediction of in-hospital adverse clinical outcomes in patients with pulmonary thromboembolism, machine learning based models. Front Cardiovasc Med 2023; 10:1087702. [PMID: 36998977 PMCID: PMC10043172 DOI: 10.3389/fcvm.2023.1087702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
BackgroundPulmonary thromboembolism (PE) is the third leading cause of cardiovascular events. The conventional modeling methods and severity risk scores lack multiple laboratories, paraclinical and imaging data. Data science and machine learning (ML) based prediction models may help better predict outcomes.Materials and methodsIn this retrospective registry-based design, all consecutive hospitalized patients diagnosed with pulmonary thromboembolism (based on pulmonary CT angiography) from 2011 to 2019 were recruited. ML based algorithms [Gradient Boosting (GB) and Deep Learning (DL)] were applied and compared with logistic regression (LR) to predict hemodynamic instability and/or all-cause mortality.ResultsA total number of 1,017 patients were finally enrolled in the study, including 465 women and 552 men. Overall incidence of study main endpoint was 9.6%, (7.2% in men and 12.4% in women; p-value = 0.05). The overall performance of the GB model is better than the other two models (AUC: 0.94 for GB vs. 0.88 and 0.90 for DL and LR models respectively). Based on GB model, lower O2 saturation and right ventricle dilation and dysfunction were among the strongest adverse event predictors.ConclusionML-based models have notable prediction ability in PE patients. These algorithms may help physicians to detect high-risk patients earlier and take appropriate preventive measures.
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Affiliation(s)
- Yaser Jenab
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Esmaeili
- Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeed Tofighi
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Correspondence: Saeed Tofighi
| | - Hamid Ariannejad
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Houman Sotoudeh
- Department of Radiology, University of Alabama at Birmingham (UAB), Birmingham, AL, United States
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Casey SD, Rouleau SG, Vinson DR, Roubinian NH. Letter to the editor: "Clinical controversies in the management of acute pulmonary embolism". Expert Rev Respir Med 2023; 17:425-426. [PMID: 37177988 DOI: 10.1080/17476348.2023.2214733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Affiliation(s)
- Scott D Casey
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Samuel G Rouleau
- Department of Emergency Medicine, University of California, Davis Health Sacramento, CA, USA
| | - David R Vinson
- Kaiser Permanente Division of Research, Oakland, CA, USA
- Department of Emergency Medicine, Kaiser Permanente Roseville Medicine Center, Roseville, CA, USA
| | - Nareg H Roubinian
- Kaiser Permanente Division of Research, Oakland, CA, USA
- Department of Pulmonary and Critical Care Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
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11
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Luijten D, Klok FA, van Mens TE, Huisman MV. Response to letter to the editor: "Clinical controversies in the management of acute pulmonary embolism: evaluation of four important but controversial aspects of acute pulmonary embolism management that are still subject of debate and research". Expert Rev Respir Med 2023; 17:427-428. [PMID: 37191014 DOI: 10.1080/17476348.2023.2215015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Affiliation(s)
- Dieuwke Luijten
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Thijs E van Mens
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - Menno V Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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12
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Chang HY, Chen PW, Chang WT, Yeh JK, Liu PY, Hsu CH, Lin CC. Evolutionary changes in thrombus features on computed tomography: An effective approach for identifying subacute pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2023; 11:100-108.e1. [PMID: 35961630 DOI: 10.1016/j.jvsv.2022.07.003] [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: 02/25/2022] [Revised: 06/22/2022] [Accepted: 07/06/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Thrombus features on computed tomography (CT) play a key role in distinguishing between acute and chronic pulmonary embolisms (PEs). However, the thrombus features of subacute PE are largely unknown. METHODS This retrospective study included 358 patients (age, 65 ± 16 years; percentage of men, 38%) diagnosed with PE from 2008 to 2019. The patients were divided into a study group and a verification group. Thrombus features that changed over time were determined in the study group according to the time of PE occurrence. Next, we determined the thrombus features of subacute PE and verified them in the verification group. Finally, we compared clinical deterioration and the 1-month mortality rate between the patients with acute and subacute PEs. RESULTS The main feature of eccentric thrombi that changed over time was the angle with the arterial wall, whereas those of centric thrombi were recanalization and heterogeneity. Taken together, the features of subacute PE were determined to be an obtuse angle with the arterial wall, recanalization, and heterogeneity. The accuracy of these features in identifying subacute PE was 94% during verification. Between the patients with acute and subacute PEs, there was no significant difference in clinical deterioration (19% vs 14%; P = .32) or the 1-month mortality rate (15% vs 8%; P = .11). With multivariate analysis, subacute events were also not associated with clinical deterioration (P = .8) or the 1-month mortality rate (P = .11). CONCLUSIONS We determined the time trend of thrombus features on CT in patients with PE and found that these features can improve the identification of subacute events. Patients with acute and subacute PEs do not have different risks of clinical deterioration and 1-month mortality.
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Affiliation(s)
- Hsien-Yuan Chang
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Wei Chen
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ting Chang
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan; Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Jian-Kuan Yeh
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ping-Yen Liu
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Hsin Hsu
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Chan Lin
- Division of Cardiology, Department of Internal Medicine, An Nan Hospital, China Medical University, Tainan, Taiwan.
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13
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Leong DW, Ayadi B, Dexter DJ, Rosenberg M, Horowitz JM, Chuang ML, Dohad S. Continuous mechanical aspiration thrombectomy performs equally well in main versus branch pulmonary emboli: A subgroup analysis of the EXTRACT-PE trial. Catheter Cardiovasc Interv 2022; 101:468-475. [PMID: 36525386 DOI: 10.1002/ccd.30524] [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: 08/21/2022] [Revised: 11/30/2022] [Accepted: 12/04/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The EXTRACT-PE trial evaluated the safety and performance of the Indigo Aspiration System (Penumbra Inc.) with an 8F continuous mechanical aspiration thrombectomy system for the treatment of pulmonary embolism (PE). This subgroup analysis evaluates performance outcomes of patients with main pulmonary artery (PA) emboli versus discrete unilateral or bilateral PA emboli without main PA involvement. METHODS The EXTRACT-PE trial was a prospective, single-arm, multicenter trial that enrolled 119 patients with acute submassive PE. Emboli location was collected at the time of enrollment, CT obstruction was measured and assessed by a Core Lab, and patients were grouped on whether emboli involved the main PA (with or without branch vessels) or not (branch vessels alone). Procedural device time, changes in the right ventricle to left ventricle (RV/LV) ratio, and systolic PA pressure from pre-and posttreatment were compared between the two groups. RESULTS Out of the 119 patients enrolled, 118 had core lab-assessed clot locations. Forty-five (38.1%) had emboli that involved the main PA and 73 (61.9%) had only branch emboli. No significant difference was observed between these groups for 30-day mortality, procedural device time, changes in RV/LV ratio, reduction in CT Obstruction Index, or for systolic PA pressure from pre-and posttreatment. The mean absolute reduction in clot burden was significant in both groups. CONCLUSION Continuous mechanical aspiration thrombectomy with the 8F Indigo Aspiration System was effective at improving clinical outcomes for submassive PE patients regardless of emboli location, and clot burden was significantly reduced in both groups.
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Affiliation(s)
- Derek W Leong
- Cedars Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA
| | - Bahram Ayadi
- Department of Biological Science, Florida State University, Florida, Tallahassee, USA
| | - David J Dexter
- Department of Vascular Surgery, Sentara Norfolk General Hospital, Norfolk, Virginia, USA
| | - Michael Rosenberg
- Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - James M Horowitz
- Department of Radiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Michael L Chuang
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Suhail Dohad
- Cedars Sinai Medical Center, Smidt Heart Institute, Los Angeles, California, USA
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14
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Ak M, Gumus S, Aghayev A, Chang CH, Fu B, Roberts MS, Woodard PK, Bae KT. The Resolution Rate of Pulmonary Embolism on CT Pulmonary Angiography: a Prospective Study. Eur J Radiol 2022; 155:110466. [PMID: 35986988 DOI: 10.1016/j.ejrad.2022.110466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 07/25/2022] [Accepted: 08/06/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE To prospectively assess the rate of clot resolution from CT pulmonary angiography (CTPA) in patients with acute pulmonary embolism (PE). MATERIALS AND METHODS This prospective cohort study included 290 patients (136 men, 154 women; mean age, 51.9 years) with acute PE. All patients had a CTPA at the presentation and had at least one follow-up within 6 months (mean 72.7 days). Sixty-four percent of patients had follow-up scans for research purposes within a pre-determined period (between 28 and 184 days; mean, 78.27 days) and 36 % had (between 2 and 184 days; mean, 62.78 days) for a clinical indication. The volume of each clot was measured using a semi-automated quantification program. The resolution rate was evaluated by interval-censored analysis. RESULTS The overall estimated probability of complete resolution was 42 % at 7 days, 56 % at 10 days, and 71 % at 45 days. Achieving complete resolution was significantly faster in patients with peripheral clots (HR: 1.78; CI: 1.05-3.03, p = 0.032) but slower in patients with consolidation and history of venous thromboembolism (VTE), (HR: 0.37; CI: 0.18-0.79, p = 0.01 and HR: 0.57; CI: 0.35-0.91, p = 0.019, respectively). Although the patients with cancer showed a faster resolution rate (HR: 1.67; CI: 1.05-2.68, p = 0.032), the mortality rate was significantly higher than non-cancer patients. CONCLUSION The resolution rate of clot burden in acute PE was associated with patients' clinical presentation variables and CTPA imaging biomarkers. This information may be incorporated into designing a prediction rule and determining the appropriate duration of anticoagulation therapy in patients with acute PE.
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Affiliation(s)
- M Ak
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - S Gumus
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.
| | - A Aghayev
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - C H Chang
- Department of Medicine, School of Medicine, Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - B Fu
- Data and Statistical Sciences, Abbvie, Inc., Lake Bluff, IL, United States
| | - M S Roberts
- Department of Medicine, School of Medicine, Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - P K Woodard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, United States
| | - K T Bae
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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15
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Liguori C, Tamburrini S, Ferrandino G, Leboffe S, Rosano N, Marano I. Role of CT and MRI in Cardiac Emergencies. Tomography 2022; 8:1386-1400. [PMID: 35645398 PMCID: PMC9149871 DOI: 10.3390/tomography8030112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 11/25/2022] Open
Abstract
Current strategies for the evaluation of patients with chest pain have significantly changed thanks to the implemented potentiality of CT and MRI. The possible fatal consequences and high malpractice costs of missed acute coronary syndromes lead to unnecessary hospital admissions every year. CT provides consistent diagnostic support, mainly in suspected coronary disease in patients with a low or intermediate pre-test risk. Moreover, it can gain information in the case of cardiac involvement in pulmonary vascular obstructive disease. MRI, on the other hand, has a leading role in the condition of myocardial damage irrespective of the underlying inflammatory or stress related etiology. This article discusses how radiology techniques (CT and MRI) can impact the diagnostic workflow of the most common cardiac and vascular pathologies that are responsible for non-traumatic chest pain admissions to the Emergency Department.
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16
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17
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Qiu M, Meng Y, Wang H, Sun L, Liu Z, Kan S, Wang T, Zhang S. Concurrence of Gastric Cancer and Incidental Pulmonary Embolism May Be a Prognostic Factor for Advanced Gastric Cancer Patients with Incidental Pulmonary Embolism. Cancer Manag Res 2021; 13:7637-7644. [PMID: 34675659 PMCID: PMC8500498 DOI: 10.2147/cmar.s329329] [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: 07/21/2021] [Accepted: 09/09/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Cancer is well known as the most important risk factor for the emergence of pulmonary embolism (PE). The incidence of incidental PE (IPE) has increased with widely use of multi-detector-row computed tomography (CT) technology. Simultaneously, more new cancer patients diagnosed concomitantly with IPE are found. No study has examined the presentation and prognosis of incidental pulmonary embolism (IPE) in gastric cancer patients. The aim of this study was to analyse prognostic factors in patients with advanced gastric cancer complicated with IPE. Patients and Methods Ninety patients with histologically confirmed advanced gastric adenocarcinoma diagnosed with IPE were enrolled. Continuous variables were compared using Student’s t-test or the Mann–Whitney U-test if non-normally distributed. The Chi-squared test (or Fisher’s exact test where appropriate) was used to compare categorical variables. The Kaplan–Meier method and the Log rank test were used for survival analysis. Independent prognostic factors for survival were determined using a Cox proportional hazards model. A two-sided P-value < 0.05 was considered statistically significant. Results Nineteen patients were diagnosed with IPE concomitantly with gastric cancer. Concurrence of gastric cancer and IPE, lack of anticoagulation therapy, and location of IPE were associated with survival. After adjusting for age and sex, the concurrence of gastric cancer and IPE, lack of anticoagulation, and central IPE independently influenced the survival of advanced gastric cancer patients with IPE. Subgroup analysis of patients with peripheral pulmonary embolisms confirmed that anticoagulant therapy provided a survival benefit. Conclusion Concurrence of gastric cancer and IPE may be a prognostic factor for advanced gastric cancer patients with IPE.
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Affiliation(s)
- Meiqing Qiu
- Cheeloo College of Medicine, Shandong University, Jinan, People's Republic of China.,Department of Oncology, Zaozhuang Municipal Hospital, Zaozhuang, 277100, People's Republic of China.,Department of Gastroenterology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Ying Meng
- Department of Gastroenterology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Huijun Wang
- Department of Gastroenterology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Li Sun
- Department of Gastroenterology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Zhen Liu
- Department of Gastroenterology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
| | - Shifeng Kan
- Department of Oncology, Zaozhuang Municipal Hospital, Zaozhuang, 277100, People's Republic of China
| | - Tao Wang
- Department of Oncology, Zaozhuang Municipal Hospital, Zaozhuang, 277100, People's Republic of China
| | - Shu Zhang
- Department of Gastroenterology, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, People's Republic of China
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18
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Abstract
Pulmonary CTA is a ubiquitous study interpreted by radiologists with different levels of experience in a variety of practice settings. Pulmonary embolism (PE) can range from an incidental and clinically insignificant finding to a clinically significant thrombus that can be managed on an outpatient basis to a potentially fatal condition requiring immediate medical or invasive management. Accordingly, a clear and concise pulmonary CTA report should effectively communicate the most pertinent findings to help the treating medical team diagnose or exclude the diagnosis of PE and provide information to guide appropriate management. In this expert panel narrative review, we discuss the purpose of the radiology report for pulmonary CTA, the optimal report format, the relevant findings that need to be addressed and their clinical significance.
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19
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Mortensen CS, Kramer A, Schultz JG, Giordano N, Zheng H, Andersen A, Nielsen-Kudsk JE, Kabrhel C. Predicting factors for pulmonary embolism response team activation in a general pulmonary embolism population. J Thromb Thrombolysis 2021; 53:506-513. [PMID: 34370168 DOI: 10.1007/s11239-021-02533-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2021] [Indexed: 11/30/2022]
Abstract
Pulmonary embolism response teams (PERT) aim to improve treatment of acute pulmonary embolism (PE). PERT focus on intermediate- and high-risk PE patients, but recent multicenter studies show that low-risk PE patients compose one in five of all PERT cases. Conversely, not all intermediate- and high-risk PE patients elicit a PERT activation. The factors leading to PERT activations remain unknown. This study aims to describe the patient characteristics associated with PERT activation for low-risk PE patients and characteristics precluding PERT activation for intermediate/high-risk PE patients. We analysed data from all patients with confirmed PE diagnosed in the Massachusetts General Hospital Emergency Department from August 2013 to February 2017 and cross-referred these data with patients who received a PERT activation and patients who did not. Patients were stratified into low-risk or intermediate/high-risk PE. Univariate analyses were performed within each risk group comparing patients with a PERT activation and patients without. Fifteen percent (56/374) of low-risk PE patients triggered a PERT activation. Patient characteristics associated with PERT activation were: (1) vascular disease, (2) pulmonary diseases, (3) thrombophilia, (4) current use of anticoagulants, (5) central PE and (6) concurrent DVT. Thirty-five percent (110/283) of intermediate/high-risk PE patients did not elicit a PERT activation. Patient characteristics precluding a PERT activation were: (1) vascular disease, (2) malignancies and (3) asymptomatic presentation. Low-risk PE patients with PERT activations had more extensive clot burden, complex comorbidities, or had failed anticoagulation treatment. Intermediate/high-risk PE patients without PERT activations tended to have malignancies or vascular disease.
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Affiliation(s)
- Christian Schmidt Mortensen
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. .,Department of Cardiology, Aarhus University Hospital, Århus, Denmark.
| | - Anders Kramer
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Cardiology, Aarhus University Hospital, Århus, Denmark
| | - Jacob Gammelgaard Schultz
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Cardiology, Aarhus University Hospital, Århus, Denmark
| | - Nicholas Giordano
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hui Zheng
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Århus, Denmark
| | | | - Christopher Kabrhel
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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20
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Roy PM, Douillet D, Penaloza A. Contemporary management of acute pulmonary embolism. Trends Cardiovasc Med 2021; 32:259-268. [PMID: 34214598 DOI: 10.1016/j.tcm.2021.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/17/2021] [Accepted: 06/26/2021] [Indexed: 12/14/2022]
Abstract
This review examines the recent progress in the initial management of pulmonary embolism (PE). Diagnostic strategies allowing the safe decrease of imaging testing have been proposed. New modalities of catheter-based interventions have emerged for hemodynamically unstable PE patients. For normotensive PE patients, direct oral anticoagulant treatment has become the new norm and a large proportion of patients are eligible for home treatment.
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Affiliation(s)
- Pierre-Marie Roy
- Angers University Hospital, Emergency Department; UNIV Angers, Health Faculty, UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CarMe; F-CRIN INNOVTE; Angers, France.
| | - Delphine Douillet
- Angers University Hospital, Emergency Department; UNIV Angers, Health Faculty, UMR MitoVasc CNRS 6015 - INSERM 1083, Equipe CarMe; F-CRIN INNOVTE; Angers, France
| | - Andrea Penaloza
- Cliniques Universitaires Saint Luc, Emrgency Department; UCLouvain; F-CRIN INNOVTE; Brussels, Belgium.
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21
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Cozzi D, Moroni C, Cavigli E, Bindi A, Caviglioli C, Nazerian P, Vanni S, Miele V, Bartolucci M. Prognostic value of CT pulmonary angiography parameters in acute pulmonary embolism. Radiol Med 2021; 126:1030-1036. [PMID: 33961187 DOI: 10.1007/s11547-021-01364-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Computed tomographic pulmonary angiography (CTPA) is the first-line test in acute pulmonary embolism (APE) diagnostic algorithm, but its correlation with short-term outcome remains not clear at all. The aim is to determine whether CTPA findings can predict 30-day mortality of patients with APE in Emergency Department. METHODS This retrospective monocentric study involved 780 patients with APE diagnosed at the Emergency Department of our institution (period 2010-2019). These CTPA findings were evaluated: embolic obstruction burden score (Qanadli score), common pulmonary artery trunk diameter, right-to-left ventricular ratio, azygos vein and coronary sinus diameters. Comorbidities and fatal/nonfatal adverse outcomes within 30 days were recorded. Troponin I values were correlated with angiographic parameters with multiple logistic regression analysis. RESULTS The all-cause and APE-related 30-day mortality rates were 5.9% and 3.6%, respectively. Patients who died within 30 days were older with higher prevalence rates of malignancy. Qanadli score and all CTPA parameters correlate with Troponin I level and the presence of RVD at echocardiography (p values < 0.0001). Instead, RV/LV ratio and coronary sinus diameter correlate with 30-day mortality (p values < 0.05). At the multivariate logistic regression analysis, only coronary sinus and RVD remained significant with an HR = 2.5 (95% CI 1.1-5.6) and HR = 1.9 (95% CI 0.95-3.7), respectively. CONCLUSION CTPA quantification of right ventricular strain is an accurate predictor of 30-day mortality. In particular, it seems that a dilated coronary sinus (>9 mm) has an additional prognostic value in association with echocardiographic signs of right-heart disfunction and high Troponin I levels.
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Affiliation(s)
- Diletta Cozzi
- Department of Emergency Radiology, Careggi University Hospital, L.go Brambilla 3, 50134, Florence, Italy.
| | - Chiara Moroni
- Department of Emergency Radiology, Careggi University Hospital, L.go Brambilla 3, 50134, Florence, Italy
| | - Edoardo Cavigli
- Department of Emergency Radiology, Careggi University Hospital, L.go Brambilla 3, 50134, Florence, Italy
| | - Alessandra Bindi
- Department of Emergency Radiology, Careggi University Hospital, L.go Brambilla 3, 50134, Florence, Italy
| | - Cosimo Caviglioli
- Department of Emergency Medicine, Careggi University Hospital, Florence, Italy
| | - Peiman Nazerian
- Department of Emergency Medicine, Careggi University Hospital, Florence, Italy
| | - Simone Vanni
- Department of Emergency Medicine, San Giuseppe Hospital, Empoli, Italy
| | - Vittorio Miele
- Department of Emergency Radiology, Careggi University Hospital, L.go Brambilla 3, 50134, Florence, Italy
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22
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Solverson K, Humphreys C, Liang Z, Prosperi-Porta G, Andruchow JE, Boiteau P, Ferland A, Herget E, Helmersen D, Weatherald J. Rapid prediction of adverse outcomes for acute normotensive pulmonary embolism: derivation of the Calgary Acute Pulmonary Embolism score. ERJ Open Res 2021; 7:00879-2020. [PMID: 33898622 PMCID: PMC8053914 DOI: 10.1183/23120541.00879-2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/18/2021] [Indexed: 11/18/2022] Open
Abstract
Background Acute pulmonary embolism (PE) has a wide spectrum of outcomes, but the best method to risk-stratify normotensive patients for adverse outcomes remains unclear. Methods A multicentre retrospective cohort study of acute PE patients admitted from emergency departments in Calgary, Canada, between 2012 and 2017 was used to develop a refined acute PE risk score. The composite primary outcome of in-hospital PE-related death or haemodynamic decompensation. The model was internally validated using bootstrapping and the prognostic value of the derived risk score was compared to the Bova score. Results Of 2067 patients with normotensive acute PE, the primary outcome (haemodynamic decompensation or PE-related death) occurred in 32 (1.5%) patients. In simplified Pulmonary Embolism Severity Index high-risk patients (n=1498, 78%), a multivariable model used to predict the primary outcome retained computed tomography (CT) right–left ventricular diameter ratio ≥1.5, systolic blood pressure 90–100 mmHg, central pulmonary artery clot and heart rate ≥100 beats·min−1 with a C-statistic of 0.89 (95% CI 0.82–0.93). Three risk groups were derived using a weighted score (score, prevalence, primary outcome event rate): group 1 (0–3, 73.8%, 0.34%), group 2 (4–6, 17.6%, 5.8%), group 3 (7–9, 8.7%, 12.8%) with a C-statistic 0.85 (95% CI 0.78–0.91). In comparison the prevalence (primary outcome) by Bova risk stages (n=1179) were stage I 49.8% (0.2%); stage II 31.9% (2.7%); and stage III 18.4% (7.8%) with a C-statistic 0.80 (95% CI 0.74–0.86). Conclusions A simple four-variable risk score using clinical data immediately available after CT diagnosis of acute PE predicts in-hospital adverse outcomes. External validation of the Calgary Acute Pulmonary Embolism score is required. Derivation of a simple four-variable risk score that uses parameters available at the time of PE diagnosis to risk stratify acute normotensive PE patients, which may help clinicians better decide how to monitor and treat patientshttps://bit.ly/37PdyrM
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Affiliation(s)
- Kevin Solverson
- Dept of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Zhiying Liang
- Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada
| | | | - James E Andruchow
- Dept of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Paul Boiteau
- Dept of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Andre Ferland
- Dept of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Eric Herget
- Dept of Radiology, University of Calgary, Calgary, AB, Canada
| | - Doug Helmersen
- Section of Respirology, Dept of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jason Weatherald
- Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada.,Section of Respirology, Dept of Medicine, University of Calgary, Calgary, AB, Canada
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Caliskan T, Turkoglu O, Canoglu K, Ayten O, Saylan B, Okutan O, Kartaloglu Z. The Comparison Between Non-High Risk Patients with and Without Cancer Diagnosed with Pulmonary Embolism. Medeni Med J 2021; 36:30-35. [PMID: 33828887 PMCID: PMC8020190 DOI: 10.5222/mmj.2021.43066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/27/2021] [Indexed: 12/11/2022] Open
Abstract
Objective This study aimed to compare the pulmonary embolism (PE) location and clot burden on computed tomography pulmonary angiography (CTPA), the degree of right ventricular dysfunction (RVD), D-dimer, and cardiac troponin I (cTnI) levels, and the presence of a lower extremity deep venous thrombosis (DVT) in patients with and without cancer diagnosed with a non high risk pulmonary embolism (PE). Method We calculated Miller score for each patient for clot burden. The location of PE was also evaluated at CTPA. D-dimer and cardiac cTnI levels were measured. Patients had echocardiography for RVD and lower extremity color flow Doppler ultrasonography for DVT. Results The study included 71 patients with PE. The patients were divided into two groups according to the presence of cancer. There was no statistically significant difference for D-dimer levels (P=0.15), PE location (p=0.67), clot burden (P=0.34), RVD (P=0.28) and DVT (P=0.33) between groups (P=0.15). Cancer patients diagnosed as PE had statistically significantly higher levels of cTnI than those who were diagnosed as PE without cancer (P=0.03). Conclusion There was no significant difference between patients diagnosed as PE with and without cancer in terms of D-dimer levels, clot burden and emboli location, RVD and DVT. cTnI levels were higher in non-high risk PE patients with cancer than these patients without cancer.
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Affiliation(s)
- Tayfun Caliskan
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| | - Ozlem Turkoglu
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Radiology, Istanbul, Turkey
| | - Kadir Canoglu
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| | - Omer Ayten
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| | - Bengu Saylan
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| | - Oguzhan Okutan
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| | - Zafer Kartaloglu
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
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Surov A, Akritidou M, Bach AG, Bailis N, Lerche M, Meyer HJ, Pech M, Wienke A. A New Index for the Prediction of 30-Day Mortality in Patients With Pulmonary Embolism: The Pulmonary Embolism Mortality Score (PEMS). Angiology 2021; 72:787-793. [PMID: 33557585 PMCID: PMC8326960 DOI: 10.1177/0003319721993346] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Our aim was to analyze possibility of combination of basic clinical and radiological signs to predict 30-day mortality after acute pulmonary embolism (PE). We included 486 patients. Age, gender, simplified pulmonary embolism index (sPESI), pH, troponin, N-terminal natriuretic peptide, minimal systolic and diastolic blood pressure, O2 saturation, syncope, need for vasopressors, thrombotic obstruction, vessel diameter, short axis ratio right ventricle/left ventricle, and contrast medium reflux into the inferior vena cava (IVC) were analyzed. A backward algorithm in a logistic regression model was used to identify relevant risk factors. Multiple logistic regression analysis identified that sPESI, pH, minimal diastolic blood pressure, IVC reflux, and need for vasopressors influenced 30-day mortality. A score for mortality prediction was constructed (the Pulmonary Embolism Mortality Score): sPESI >2 points (1 point), pH <7.35 (1 point), minimal diastolic blood pressure <45 mm Hg (1 point), IVC reflux (1 point), and need for vasopressors (2 points). Patients with >3 points showed higher 30-day mortality (sensitivity: 84.9%, specificity: 83.0%, positive predictive value: 51.8%, negative predictive value: 96.2%). The net reclassification improvement compared with the sPESI was 0.94 (95% CI = 0.73-1.15). In conclusion, a new score can predict 30-day mortality in patients with PE and is more sensitive than sPESI.
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Affiliation(s)
- Alexey Surov
- Department of Radiology, University of Leipzig, Germany.,Department of Radiology and Nuclear Medicine, Otto-von-Guericke University Magdeburg, Germany
| | - Mideia Akritidou
- Department of Internal Medicine, Otto-von-Guericke University Magdeburg, Germany
| | - Andreas Gunther Bach
- Department of Radiology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | | | - Marianne Lerche
- Department of Respiratory Medicine, University of Leipzig, Germany
| | | | - Maciej Pech
- Department of Radiology and Nuclear Medicine, Otto-von-Guericke University Magdeburg, Germany
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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Tandon R, Singh A, Mohan B. Risk Stratification in Acute Normotensive Pulmonary Embolism– Role of Echocardiography Imaging and Biomarkers. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2021. [DOI: 10.4103/jiae.jiae_41_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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26
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The use of thrombolytic therapy in a multidisciplinary pulmonary embolism response team. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Correlation of thrombosed vessel location and clot burden score with severity of disease and risk stratification in patients with acute pulmonary embolism. Anatol J Cardiol 2020; 24:247-253. [PMID: 33001050 PMCID: PMC7585957 DOI: 10.14744/anatoljcardiol.2020.55013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: Computed tomography pulmonary angiography (CTPA) is used for the main diagnosis in acute pulmonary embolism (APE). Determining the thrombus location in the pulmonary vascular tree is also important for predicting disease severity. This study aimed to analyze the correlation of the thrombus location and the clot burden with the disease severity and the risk stratification in patients with APE. Methods: The study included patients with APE diagnosed by CTPA who were admitted to the hospital between January 28, 2016, and July 1, 2019. Data collected were markers of severity in APE, including patient demographics, comorbidities, length of hospital stay, pulmonary embolism severity index (PESI) score, modified PESI score, Wells score, risk stratification according to the American Heart Association, systolic blood pressure (SBP), right ventricle diameter to left ventricle diameter ratio, pulmonary arterial pressure, brain natriuretic peptide, troponin, D-dimer, and plasma lactate levels, and vessel location of the thrombus, clot burden score, ratio of the pulmonary artery trunk diameter/aortic diameter, superior vena cava diameter (SVC) by CTPA, and survival. All parameters were analyzed in correlation with clot load and vessel location. Results: Thrombus vascular location was found to be correlated with risk stratification and negatively correlated with SBP. Simplified Mastora score was correlated with risk stratification, SVC diameter, and D-dimer and negatively correlated with SBP. Occlusion of both the pulmonary artery trunk and any pulmonary artery with thrombus was associated with massive APE. Conclusion: The level of the occluded vessel on CTPA may provide the ability to risk-stratify, and the clot burden score may be used for assessing both risk stratification and cardiac strain.
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Higazi MM, Fattah RARA, Abdelghany EA, Ghany HSA. Efficacy of Computed Tomography Pulmonary Angiography as Non-invasive Imaging Biomarker for Risk Stratification of Acute Pulmonary Embolism. J Clin Imaging Sci 2020; 10:49. [PMID: 32874754 PMCID: PMC7451145 DOI: 10.25259/jcis_75_2020] [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: 05/19/2020] [Accepted: 07/17/2020] [Indexed: 01/26/2023] Open
Abstract
Objectives: Massive and sub-massive pulmonary embolisms (PEs) are associated with high mortality and morbidity. The mainstay of treatment for PE is anticoagulation. However, high- and intermediate-risk patients may benefit from interventional thrombolytic therapy. Computed tomography pulmonary angiography (CTPA) is widely available, fast, and non-invasive technique, and it can identify pulmonary thrombus down to at least a segmental level. In this study, we attempt to evaluate the efficacy of CTPA as a non-invasive imaging biomarker for risk stratification of acute PE (APE) patients. Material and Methods: This is a prospective study conducted on 150 patients who proved to have APE by CTPA. The simplified PE severity index score was obtained. The pulmonary artery obstruction index (PAOI) using and right to left ventricular (RV/LV) diameter ratios were calculated. Results: The patients were divided into (1) high risk (shocked) and (2) non-high risk groups. There was a significant difference between the 1st and 2nd groups regarding PAOI. Hemodynamically stable patients were further subclassified according to the right ventricular dysfunction (RVD) into Group Ia (intermediate risk) and Group Ib (low risk). There was a significant difference between subgroups regarding PAOI (P < 0.0001, r = 0.385). Receiver operating characteristic curve analysis revealed PAOI >47% associated with RV/LV ratio >1. Conclusion: Our results support the use of CTPA as a surrogate imaging biomarker for both diagnosis and risk stratification of APE patients. CTPA allows assessment of clot burden through PAOI calculation and identification of intermediate-risk PE through the assessment of RVD.
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Rotzinger DC, Knebel JF, Jouannic AM, Adler G, Qanadli SD. CT Pulmonary Angiography for Risk Stratification of Patients with Nonmassive Acute Pulmonary Embolism. Radiol Cardiothorac Imaging 2020; 2:e190188. [PMID: 33778598 DOI: 10.1148/ryct.2020190188] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 02/24/2020] [Accepted: 04/21/2020] [Indexed: 01/21/2023]
Abstract
Purpose To investigate the prognostic value of an integrative approach combining clinical variables and the Qanadli CT obstruction index (CTOI) in patients with nonmassive acute pulmonary embolism (PE). Materials and Methods This retrospective study included 705 consecutive patients (mean age, 63 years; range, 18-95 years) with proven PE. Clot burden was quantified using the CTOI, which reflects the ratio of fully or partially obstructed pulmonary arteries to normal arteries. Patients were subdivided into two groups according to the presence (group A) or absence (group B) of preexisting cardiopulmonary disease. Thirty-day and 3-month mortality was evaluated. CTOI thresholds of 20% and 40% were used to stratify patients regarding outcome (low, intermediate, and high risk). The predictive value of CTOI was assessed through logistic regression analysis. Results Analysis included 690 patients (mean age, 63.3 years ± 18 [standard deviation]) with complete follow-up data: 247 (36%) in group A and 443 (64%) in group B. The mean CTOI was 23% ± 19, 30-day mortality was 9.7%, and 3-month mortality was 11.6%. Three-month mortality was higher in group A than in group B (17.8% and 8.1%, respectively; P = .001). Within group B, CTOI predicted outcome and allowed stratification: significantly higher mortality with CTOI greater than 40% (P < .001) and lower mortality with CTOI less than 20% (P = .05). CTOI did not predict outcome in group A. Age was an independent mortality risk factor (P ≤ .04). Conclusion CTOI predicted outcome in this cohort of patients with PE and no cardiopulmonary disease, and it may provide a simple single-examination-based approach for risk stratification in this subset of patients.© RSNA, 2020See also the commentary by Kay and Abbara in this issue.
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Affiliation(s)
- David C Rotzinger
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology (D.C.R., A.M.J., S.D.Q.) and EEG Brain Mapping Core, Centre for Biomedical Imaging (CIBM) and Laboratory for Investigative Neurophysiology (The LINE), Department of Radiology (J.F.K.), Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland; Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland (D.C.R., J.F.K., S.D.Q.); and Imagerive Diagnostic Radiology Institute, Geneva, Switzerland (G.A.)
| | - Jean-François Knebel
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology (D.C.R., A.M.J., S.D.Q.) and EEG Brain Mapping Core, Centre for Biomedical Imaging (CIBM) and Laboratory for Investigative Neurophysiology (The LINE), Department of Radiology (J.F.K.), Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland; Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland (D.C.R., J.F.K., S.D.Q.); and Imagerive Diagnostic Radiology Institute, Geneva, Switzerland (G.A.)
| | - Anne-Marie Jouannic
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology (D.C.R., A.M.J., S.D.Q.) and EEG Brain Mapping Core, Centre for Biomedical Imaging (CIBM) and Laboratory for Investigative Neurophysiology (The LINE), Department of Radiology (J.F.K.), Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland; Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland (D.C.R., J.F.K., S.D.Q.); and Imagerive Diagnostic Radiology Institute, Geneva, Switzerland (G.A.)
| | - Ghazal Adler
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology (D.C.R., A.M.J., S.D.Q.) and EEG Brain Mapping Core, Centre for Biomedical Imaging (CIBM) and Laboratory for Investigative Neurophysiology (The LINE), Department of Radiology (J.F.K.), Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland; Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland (D.C.R., J.F.K., S.D.Q.); and Imagerive Diagnostic Radiology Institute, Geneva, Switzerland (G.A.)
| | - Salah D Qanadli
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology (D.C.R., A.M.J., S.D.Q.) and EEG Brain Mapping Core, Centre for Biomedical Imaging (CIBM) and Laboratory for Investigative Neurophysiology (The LINE), Department of Radiology (J.F.K.), Lausanne University Hospital (CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland; Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland (D.C.R., J.F.K., S.D.Q.); and Imagerive Diagnostic Radiology Institute, Geneva, Switzerland (G.A.)
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30
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Kramer A, Mortensen CS, Schultz JG, Lyhne MD, Andersen A, Nielsen-Kudsk JE. Inhaled nitric oxide has pulmonary vasodilator efficacy both in the immediate and prolonged phase of acute pulmonary embolism. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2020; 10:2048872620918713. [PMID: 32662283 DOI: 10.1177/2048872620918713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 03/24/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inhaled nitric oxide (iNO) effectively reduces right ventricular afterload when administered in the immediate phase of acute pulmonary embolism (PE) in preclinical animal models. In a porcine model of intermediate-risk PE, we aimed to investigate whether iNO has pulmonary vasodilator efficacy both in the immediate and prolonged phase of acute PE. METHODS Anesthetized pigs (n = 18) were randomized into three subgroups. An acute PE iNO-group (n = 6) received iNO at 40 ppm at one, three, six, nine and 12 hours after onset of PE. Vehicle animals (n = 6) received PE, but no active treatment. A third group of sham animals (n = 6) received neither PE nor treatment. Animals were evaluated using intravascular pressures, respiratory parameters, biochemistry and intracardiac pressure-volume measurements. RESULTS The administration of PE increased mean pulmonary artery pressure (mPAP) (vehicle vs sham; 33.3 vs 17.7 mmHg, p < 0.0001), pulmonary vascular resistance (vehicle vs sham; 847.5 vs 82.0 dynes, p < 0.0001) and right ventricular arterial elastance (vehicle vs sham; 1.2 vs 0.2 mmHg/ml, p < 0.0001). Significant mPAP reduction by iNO was preserved at 12 hours after the onset of acute PE (vehicle vs iNO; 0.5 vs -3.5 mmHg, p < 0.0001). However, this response was attenuated over time (p = 0.0313). iNO did not affect the systemic circulation. CONCLUSIONS iNO is a safe and effective pulmonary vasodilator both in the immediate and prolonged phase of acute PE in an in-vivo porcine model of intermediate-risk PE.
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Affiliation(s)
- Anders Kramer
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Christian Schmidt Mortensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Jacob Gammelgaard Schultz
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Mads Dam Lyhne
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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Abstract
Given the broad treatment options, risk stratification of pulmonary embolism is a highly desirable component of management. The ideal tool identifies patients at risk of death from the original or recurrent pulmonary embolism. Using all-cause death in the first 30-days after pulmonary embolism diagnosis as a surrogate, clinical parameters, biomarkers, and radiologic evidence of right ventricular dysfunction and strain are predictive. However, no study has demonstrated improved mortality rates after implementation of a risk stratification strategy to guide treatment. Further research should use better methodology to study prognosis and test new management strategies in patients at high risk for death.
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Affiliation(s)
- Thomas Moumneh
- Department of Emergency Medicine, University Hospital of Angers, 4 rue Larrey, 49100 Angers, France; MITOVASC Institute, UMR CNRS 6015 UMR INSERM 1083, Angers University, 28, rue Roger-Amsler, 49045 Angers, France; University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, 501 Smyth Road, Suite M1857, PO Box 206, Ottawa, Ontario K1H 8L6, Canada.
| | - Sebastien Miranda
- University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada; Department of Internal Medicine, Vascular and Thrombosis Unit, Rouen University Hospital, 37 Boulevard Gambetta, 76000 Rouen, France; Normandie University, UNIROUEN, INSERM U1096, 22 Boulevard Gambetta, 76000 Rouen, France
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32
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Shayganfar A, Hajiahmadi S, Astaraki M, Ebrahimian S. The assessment of acute pulmonary embolism severity using CT angiography features. Int J Emerg Med 2020; 13:15. [PMID: 32245363 PMCID: PMC7118936 DOI: 10.1186/s12245-020-00272-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 03/18/2020] [Indexed: 11/10/2022] Open
Abstract
Background This study was conducted to detect the association between radiologic features of CT pulmonary angiography (CTPA) and pulmonary embolism severity index (PESI). Methods A total of 150 patients with a definite diagnosis of PE entered the study. The CTPA feature including obstruction index, pulmonary trunk size, presence of backwash contrast, septal morphology, right ventricular (RV) and left ventricular (LV) dimensions, and RV/LV ratio were examined. The severity of the PE was estimated using PESI. The association between CTPA indices and PESI was measured. Statistical analysis was conducted using the SPSS software. P value < 0.05 was considered as statistically significant. Results A positive correlation was detected between the obstruction index and PESI (r = 0.45, P < 0.05). Moreover, PESI was significantly higher in patients with a more dilated pulmonary trunk (r = 0.20, P < 0.05). The backwash contrast and abnormal septal morphology were significantly more common among patients with higher PESI (P < 0.05). However, no significant correlation was detected between RV, LV, RV/LV, and PESI. The most predictor of high-risk PE was dilated pulmonary trunk with an odds ratio of 4.4. Conclusion Higher Obstruction index, dilated pulmonary trunk, presence of backwash contrast, and an abnormal septal morphology can be associated with a higher PESI.
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Affiliation(s)
- Azin Shayganfar
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Somayeh Hajiahmadi
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Astaraki
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shadi Ebrahimian
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran. .,Al-Zahra Hospital, Hezar Jerib Avenue, Isfahan, Iran.
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Van Galen J, Pava L, Wright C, Elbadawi A, Hamer A, Chaturvedi A, Cameron SJ. Effect of platelet inhibitors on thrombus burden in patients with acute pulmonary embolism. Platelets 2020; 32:138-140. [PMID: 32141372 DOI: 10.1080/09537104.2020.1732329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Venous thromboembolism (VTE) whether provoked or not can be life-threatening due to an acute increase in load on the right ventricle (RV) from obstruction of the pulmonary artery (PA). Treatment for and prevention of VTE involves anti-thrombotic agents; more specifically, medications targeting the anticoagulation cascade. In spite of the widespread acceptance of anticoagulants in the treatment of VTE, there appears to be an ongoing belief that platelet reactivity contributes to thrombus burden in patients with acute pulmonary embolism (PE). This investigation of 398 patients presenting with acute PE evaluated whether anti-platelet medication use, which consisted mostly of aspirin therapy, at the time of presentation, affects PA thrombus burden, RV load, or short-term patient outcomes. We conclude that platelets may have been erroneously incriminated as direct thrombotic mediators in patients with acute PE since aspirin neither decreased PA thrombus burden, nor did aspirin improve short-term mortality following acute PE.
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Affiliation(s)
- Joseph Van Galen
- Department of Medicine, University of Virginia , Charlottesville, VA, USA
| | - Libia Pava
- Department of Medicine, University of Rochester School of Medicine , Rochester, NY, USA
| | - Colin Wright
- Department of Medicine, University of Rochester School of Medicine , Rochester, NY, USA
| | - Ayman Elbadawi
- Department of Cardiovascular Medicine, University of Texas Medical Branch , Galveston, TX, USA
| | - Annelise Hamer
- Department of Medicine, University of Rochester School of Medicine , Rochester, NY, USA
| | - Abhishek Chaturvedi
- Department of Imaging Sciences, University of Rochester School of Medicine , Rochester, NY, USA
| | - Scott J Cameron
- Department of Medicine, University of Rochester School of Medicine , Rochester, NY, USA.,Heart Vascular and Thoracic Institute, Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation , Cleveland, OH, USA.,Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute , Cleveland, OH, USA
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[Risk factors for hospital mortality during pulmonary embolism]. Ann Cardiol Angeiol (Paris) 2020; 69:7-11. [PMID: 32127194 DOI: 10.1016/j.ancard.2020.01.001] [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: 09/12/2019] [Accepted: 01/05/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The objective of our work is to identify the risk factors for hospital mortality during pulmonary embolism in a pneumology department. MATERIAL AND METHOD All patients admitted to the pneumology department of Habib-Bourguiba hospital between 2014 and 2019, with a final diagnosis of PE are analyzed. RESULTS One hundred patients were included, 62% of whom were female, with an average age of 63±16 years. Pulmonary fibrosis was noted in eight patients. On admission, the mean Simplified Pulmonary Embolism Severity Index score was 1.46±1.05. The mean duration of hospitalization was 10.6±7 days. The hospital mortality rate was 12%. The independent risk factors for intra-hospital mortality were arterial hypotension (OR: 6.13; 95%CI: 2.88-14.35; p=0.001), cancer (OR: 2.66; 95%CI: 1.22-9.54; p=0.026), a VD/LV ratio at echocardiography>0.9 (OR: 1.84; 95%CI: 1.06-7.69; p=0.039) and severe hypoxemia (OR: 4.86; 95%CI: 2.19-11,34; p=0.006). CONCLUSION Pulmonary embolism mortality remains high despite improvements in diagnostic and therapeutic management. It is important for our country to take these results into consideration for a better management of patients admitted for pulmonary embolism, and to improve survival.
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Lyhne MD, Kline JA, Nielsen-Kudsk JE, Andersen A. Pulmonary vasodilation in acute pulmonary embolism - a systematic review. Pulm Circ 2020; 10:2045894019899775. [PMID: 32180938 PMCID: PMC7057411 DOI: 10.1177/2045894019899775] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/18/2019] [Indexed: 01/17/2023] Open
Abstract
Acute pulmonary embolism is the third most common cause of cardiovascular death. Pulmonary embolism increases right ventricular afterload, which causes right ventricular failure, circulatory collapse and death. Most treatments focus on removal of the mechanical obstruction caused by the embolism, but pulmonary vasoconstriction is a significant contributor to the increased right ventricular afterload and is often left untreated. Pulmonary thromboembolism causes mechanical obstruction of the pulmonary vasculature coupled with a complex interaction between humoral factors from the activated platelets, endothelial effects, reflexes and hypoxia to cause pulmonary vasoconstriction that worsens right ventricular afterload. Vasoconstrictors include serotonin, thromboxane, prostaglandins and endothelins, counterbalanced by vasodilators such as nitric oxide and prostacyclins. Exogenous administration of pulmonary vasodilators in acute pulmonary embolism seems attractive but all come with a risk of systemic vasodilation or worsening of pulmonary ventilation-perfusion mismatch. In animal models of acute pulmonary embolism, modulators of the nitric oxide-cyclic guanosine monophosphate-protein kinase G pathway, endothelin pathway and prostaglandin pathway have been investigated. But only a small number of clinical case reports and prospective clinical trials exist. The aim of this review is to give an overview of the causes of pulmonary embolism-induced pulmonary vasoconstriction and of experimental and human investigations of pulmonary vasodilation in acute pulmonary embolism.
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Affiliation(s)
- Mads Dam Lyhne
- Department of Cardiology, Aarhus University Hospital and Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jeffrey Allen Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital and Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital and Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
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de Winter MA, Vlachojannis GJ, Ruigrok D, Nijkeuter M, Kraaijeveld AO. Rationale for catheter-based therapies in acute pulmonary embolism. Eur Heart J Suppl 2019; 21:I16-I22. [PMID: 31777453 PMCID: PMC6868359 DOI: 10.1093/eurheartj/suz223] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Pulmonary embolism (PE) is a common disease resulting in significant morbidity and mortality. High-risk features of PE are hypotension or shock, and early reperfusion is warranted to unload the strained right ventricle and improve clinical outcomes. Currently, systemic thrombolysis (ST) is the standard of care but is associated with bleeding complications. Catheter-based therapies (CDT) have emerged as a promising alternative having demonstrated to be equally effective while having a lower risk of bleeding. Several CDT are currently available, some combining mechanical properties with low-dose thrombolytics. Recent guidelines suggest that CDT may be considered in patients with high-risk PE who have high bleeding risk, after failed ST, or in patients with rapid haemodynamic deterioration as bail-out before ST can be effective, depending on local availability and expertise. In haemodynamically stable patients with right ventricular (RV) dysfunction (intermediate-risk PE), CDT may be considered if clinical deterioration occurs after starting anticoagulation and relative contraindications for ST due to bleeding risk exist. Decision on treatment modality should follow a risk-benefit analysis on a case by case base, weighing the risk of PE-related complications; i.e. haemodynamic deterioration vs. bleeding. As timely initiation of treatment is warranted to prevent early mortality, bleeding risk factors should be assessed at an early stage in all patients with acute PE and signs of RV dysfunction. To ensure optimal management of complex cases of PE and assess a potential CDT strategy, a multidisciplinary approach is recommended. A dedicated Pulmonary Embolism Response Team may optimize this process.
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Affiliation(s)
- M A de Winter
- Department of Internal Medicine, UMC Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - G J Vlachojannis
- Department of Cardiology, UMC Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - D Ruigrok
- Department of Pulmonology, UMC Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - M Nijkeuter
- Department of Internal Medicine, UMC Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - A O Kraaijeveld
- Department of Cardiology, UMC Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
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Computed tomography pulmonary angiography for acute pulmonary embolism: prediction of adverse outcomes and 90-day mortality in a single test. Pol J Radiol 2019; 84:e436-e446. [PMID: 31969963 PMCID: PMC6964354 DOI: 10.5114/pjr.2019.89896] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 10/01/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose Pulmonary embolism (PE) is a potentially fatal cardiopulmonary disease; therefore, rapid risk stratification is necessary to make decisions of appropriate management strategies. The aim of this study was to assess various computed tomography (CT) findings in order to find new prognostic factors of adverse outcome and mortality. Material and methods The study enrolled 104 patients with acute PE. Based on their outcome, patients were categorised into four groups. Comorbidities such as ischaemic heart disease were obtained from their medical records. Patients CT angiography were reviewed for recording variables such as main pulmonary artery diameter and right ventricle (RV)/left ventricle (LV) ratio. Patient deaths up to three months since diagnosis of PE had been registered. Logistic regression analysis was performed to find predictors. Results Based on multiple logistic regression, RV/LV ratio, LV diameter, and right-sided pulmonary infarction are predictors of mortality in 30 days. An RV/LV ratio of 1.19 could successfully discriminate patients who died within 30 days and those who did not. Conclusions RV/LV ratio, LV diameter, right-sided pulmonary infarction, assessed with helical CT, can help predict 30-day mortality.
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Leitman EM, McDermott S. Pulmonary arteries: imaging of pulmonary embolism and beyond. Cardiovasc Diagn Ther 2019; 9:S37-S58. [PMID: 31559153 DOI: 10.21037/cdt.2018.08.05] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The pulmonary arteries are not just affected by thrombus. Various acquired and congenital conditions can also affect the pulmonary arteries. In this review we discuss cross sectional imaging modalities utilized for the imaging of the pulmonary arteries. Acquired pulmonary artery entities, including pulmonary artery sarcoma (PAS), vasculitis, aneurysm, and arteriovenous malformations, and congenital anomalies in adults, including proximal interruption of the pulmonary artery, pulmonary sling, pulmonary artery stenosis, and idiopathic dilatation of the pulmonary trunk, are also discussed. An awareness of these entities and their imaging findings is important for radiologists interpreting chest imaging.
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Affiliation(s)
| | - Shaunagh McDermott
- Division of Thoracic Imaging and Intervention, Massachusetts General Hospital, Boston, Massachusetts, USA
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Kim HY, Kim KH, Kim J, Park JC. Multimodality cardiovascular imaging in pulmonary embolism. Cardiol J 2019; 28:150-160. [PMID: 31478557 DOI: 10.5603/cj.a2019.0084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 08/20/2019] [Accepted: 08/20/2019] [Indexed: 11/25/2022] Open
Abstract
Acute pulmonary embolism (APE) is one of the leading causes of cardiovascular (CV) morbidity and mortality. To select appropriate therapeutic strategy and/or to minimize the mortality and morbidity, rapid and correct identification of life-threatening APE is very important. Also, right ventricular (RV) failure usually precedes acute hemodynamic compromise or death, and thus the identification of RV failure is another important step in risk stratification or treatment of APE. With advances in diagnosis and treatment, the prognosis of APE has been dramatically improving in most cases, but inadequate therapy or recurrent episodes of pulmonary embolism (PE) may result in negative outcomes or, so called, chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH is a condition characterized by remaining chronic thromboembolic material in the pulmonary vasculature and subsequent chronic pulmonary hypertension. Various imaging modalities include chest computed tomography pulmonary angiography (CTPA), echocardiography, magnetic resonance imaging, and nuclear imaging and each are used for the assessment of varying status of PE. Assessment of thromboembolic burden by chest CTPA is the first step in the diagnosis of PE. Hemodynamic assessment can be achieved by echocardiography and also by chest CTPA. Nuclear imaging is useful in discriminating CTEPH from APE. Better perspectives on diagnosis, risk stratification and decision making in PE can be provided by combining multimodality CV imaging. Here, the advantages or pitfalls of each imaging modality in diagnosis, risk stratification, or management of PE will be discussed.
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Affiliation(s)
- Hyung Yoon Kim
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Kye Hun Kim
- Chonnam National University Hospital, Gwangju, Republic of Korea.
| | - Jahae Kim
- Department of Nuclear Medicine, Chonnam National University Hospital, Gwangju, Korea, Republic Of
| | - Jong Chun Park
- Chonnam National University Hospital, Gwangju, Republic of Korea
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40
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Septal bowing and pulmonary artery diameter on computed tomography pulmonary angiography are associated with short-term outcomes in patients with acute pulmonary embolism. Emerg Radiol 2019; 26:623-630. [DOI: 10.1007/s10140-019-01709-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 07/12/2019] [Indexed: 10/26/2022]
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41
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Kruger PC, Eikelboom JW, Douketis JD, Hankey GJ. Pulmonary embolism: update on diagnosis and management. Med J Aust 2019; 211:82-87. [PMID: 31216072 DOI: 10.5694/mja2.50233] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition, mandating urgent diagnosis and treatment. The symptoms of PE may be non-specific; diagnosis therefore relies on a clinical assessment and objective diagnostic testing. A clinical decision rule can determine the pre-test probability of PE. If PE is "unlikely", refer for a D-dimer test. If the D-dimer result is normal, PE can be excluded. If D-dimer levels are increased, refer for chest imaging. If PE is "likely", refer for chest imaging. Imaging with computed tomography pulmonary angiogram is accurate and preferred for diagnosing PE, but may detect asymptomatic PE of uncertain clinical significance. Imaging with ventilation-perfusion (VQ) scan is associated with lower radiation exposure than computed tomography pulmonary angiogram, and may be preferred in younger patients and pregnancy. A low probability or high probability VQ scan is helpful for ruling out or confirming PE, respectively; however, an intermediate probability VQ scan requires further investigation. The direct oral anticoagulants have expanded the anticoagulation options for PE. These are the preferred anticoagulant for most patients with PE because they are associated with a lower risk of bleeding, and have the practical advantages of fixed dosage, no need for routine monitoring, and fewer drug interactions compared with vitamin K antagonists. Initial parenteral treatment is required before dabigatran and edoxaban.
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Affiliation(s)
- Paul C Kruger
- Fiona Stanley Hospital, Perth, WA.,PathWest Laboratory Medicine, Perth, WA.,Population Health Research Institute, Hamilton, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, Canada.,Hamilton Health Sciences, Hamilton, Canada
| | - James D Douketis
- Hamilton Health Sciences, Hamilton, Canada.,St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, Canada
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Rotzinger DC, Breault S, Knebel JF, Beigelman-Aubry C, Jouannic AM, Qanadli SD. Can a Trained Radiology Technician Do Arterial Obstruction Quantification in Patients With Acute Pulmonary Embolism? Front Cardiovasc Med 2019; 6:38. [PMID: 31024932 PMCID: PMC6469400 DOI: 10.3389/fcvm.2019.00038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/21/2019] [Indexed: 11/26/2022] Open
Abstract
Objectives: To assess interobserver variability between a trained radiology technician (RT) and an experienced radiologist in arterial obstruction quantification using the Qanadli obstruction index (QOI), in patients diagnosed with acute pulmonary embolism (APE) at CT pulmonary angiography (CTPA). Materials and Methods: A RT and a radiologist independently reviewed CTPAs of 97 consecutive, prospectively enrolled patients with APE, and calculated the QOI. They classified patients into three risk categories: high for QOI ≥40%, intermediate for QOI 20–37.5%, low for QOI <20%. Interobserver variability was investigated for QOI as a continuous variable and as a categorical variable (high, intermediate, and low-risk groups). Results: Mean QOI (±SD) was 39.5 ± 24.3% and 38.6 ± 18.9% for the RT and the radiologist, respectively. The mean QOI was not statistically different between the RT and the radiologist (p = 0.502), and the interobserver agreement was excellent (ICC = 0.905). The RT classified 54 patients (55.7%) as high, 17 (17.53%) as intermediate, and 26 (26.8%) as low risk. The radiologist classified 55 patients (56.7%) as high, 22 (22.7%) as intermediate, and 20 (20.6%) as low risk. The interrater agreement for risk stratification was excellent (weighted kappa = 0.844). Conclusion: Once the diagnosis of APE was established, an adequately trained RT achieved an accuracy comparable to that of an experienced radiologist regarding QOI calculation and risk assessment.
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Affiliation(s)
- David C Rotzinger
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Stéphane Breault
- Département D'imagerie Médicale, CIUSSS du Nord-de-l'île-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Montréal, QC, Canada
| | - Jean-François Knebel
- EEG Brain Mapping Core, Centre for Biomedical Imaging (CIBM) and Laboratory for Investigative Neurophysiology (The LINE), Department of Radiology, University Hospital Centre and University of Lausanne, Lausanne, Switzerland
| | - Catherine Beigelman-Aubry
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Anne-Marie Jouannic
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Salah D Qanadli
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
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43
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Aissa A, Mallat N, Aissa S, Alouini R. [Contribution of pulmonary CT angiography in assessing the severity of acute pulmonary embolism]. Ann Cardiol Angeiol (Paris) 2019; 68:71-79. [PMID: 30172353 DOI: 10.1016/j.ancard.2018.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 08/07/2018] [Indexed: 06/08/2023]
Abstract
Chest CT angiography has taken a major role in the management of patients with suspected pulmonary embolism. Meanwhile, it became necessary to determine the severity criteria at the time of diagnosis in order to properly assess the risk/benefit of treatment to consider. In recent years, pulmonary CT angiography has emerged as a useful tool for assessing the severity of acute lung embolism, based on morphological criteria. The two main approaches that were studied were the quantification of obstruction of pulmonary arterial bed and recognition of signs of right heart failure. The aim of our work is to define the morphological parameters in cardiovascular pulmonary CT angiography and to determine their value in the current clinical prognostic stratification of acute pulmonary embolism of, especially their correlation with the risk of developing signs of clinical severity at diagnosis and at 3 months of the occurrence of pulmonary embolism.
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Affiliation(s)
- A Aissa
- Service d'imagerie médicale, CHU Ibn EL Jazzar de Kairouan, 3100 Kairouan, Tunisie.
| | - N Mallat
- Service d'imagerie médicale, CHU Ibn EL Jazzar de Kairouan, 3100 Kairouan, Tunisie
| | - S Aissa
- Service de pneumologie clinique, CHU Farhat Hached de Sousse, Sousse Tunisie
| | - R Alouini
- Service d'imagerie médicale, CHU Ibn EL Jazzar de Kairouan, 3100 Kairouan, Tunisie
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Stoeva N, Staneva M, Kirova G, Bakalova R. Deep venous thrombosis in the clinical course of pulmonary embolism. Phlebology 2018; 34:453-458. [PMID: 30582739 DOI: 10.1177/0268355518819510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objectives The aim of the study is to find how concomitant deep venous thrombosis (DVT) changes the clinical course of pulmonary embolism. Methods Three hundred and five patients with pulmonary embolism were examined and grouped into DVT and non-DVT groups. Both groups were compared with regard to demography, predisposing factors, clinical signs, thrombotic burden, and one-month mortality rate. Results The patients with DVT had a more severe clinical presentation: higher heart rate (94.80 ± 18.66 beats per minute versus 87.9 ± 13.90 in the non-DVT group, p = 0.00033), more hemodynamic instability (11.35% versus 3.05% in the non-DVT group, p = 0.005), and less pCO2 in arterial blood gases (30.81 ± 7.94 mmHg versus 32.59 ± 7.35 mmHg in the non-DVT group, p = 0.049). The DVT group had heavier thrombotic burden in pulmonary artery, measured by Mastora score. The one-month mortality rate did not differ statistically between groups. Conclusions Patients with symptomatic pulmonary embolism and concomitant DVT have heavier thrombotic burden in the pulmonary artery and more severe clinical presentation compared to those without DVT, but a similar one-month mortality rate.
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Affiliation(s)
- Natalia Stoeva
- 1 Pulmonary Department, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Milena Staneva
- 2 Angiology Department, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Galina Kirova
- 3 Imaging Department, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Rumiana Bakalova
- 4 Department of Molecular Imaging and Theranostics, National Institute of Radiological Sciences, QST, Chiba, Japan.,5 Group of Quantum-state Controlled MRI, National Institute of Radiological Sciences, QST, Chiba, Japan.,6 Medical Faculty, Sofia University "St. Kliment Ohridski", Sofia, Bulgaria
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45
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Itri JN, Raghavan K, Patel SB, Broder JC, Tierney S, Gray D, Burleson J, MacDonald S, Seidenwurm DJ. Developing Quality Measures for Diagnostic Radiologists: Part 2. J Am Coll Radiol 2018; 15:1366-1384. [DOI: 10.1016/j.jacr.2018.05.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 04/23/2018] [Accepted: 05/05/2018] [Indexed: 12/21/2022]
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46
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Guo ZJ, Liu HT, Bai ZM, Lin Q, Zhao BH, Xu Q, Zeng YH, Feng WQ, Zhou HT, Liang F, Cui JY. A new method of CT for the cardiac measurement: correlation of computed tomography measured cardiac parameters and pulmonary obstruction index to assess cardiac morphological changes in acute pulmonary embolism patients. J Thromb Thrombolysis 2018; 45:410-416. [PMID: 29417409 DOI: 10.1007/s11239-018-1628-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Acute pulmonary embolism (APE) is a serious disease which is life-threatening. Since it is crucial for APE patients to assess the changes of cardiac function safely and timely, the imaging research of cardiac morphology and function is becoming more and more important. The correlation of computed tomography (CT) measured cardiac parameters and pulmonary obstruction index (POI) was analyzed to discuss the morphological changes of the heart of APE patients in order to provide a new method to evaluate cardiac functions accurately and effectively. 118 APE patients confirmed with CT pulmonary angiography (CTPA) were divided into high-risk group (47 cases, POI ≥ 20) and low-risk group (71 cases, POI < 20) according to the Qanadli Score. The left to right diameter (RL) and the anteroposterior diameter (AP) of the cardiac chambers were compared among the high-risk group, the low-risk group, and the normal group (60 cases). The correlation between CT measured cardiac parameters and the POI was analyzed. Except for left ventricular AP and right atrial AP, there were statistically significant differences (P < 0.05) in the RL and AP of the each cardiac cavity, these parameters meant that right hearts were enlarged and the left hearts were decreased in size. The ratio of right/left heart diameter was statistically significant among the three groups, a < b < c (P < 0.05). Moreover, the POI of 118 APE patients was 14.29 ± 9.53, and there was significant linear correlation between CT measured cardiac parameters and the POI (P < 0.05), excluding the left ventricular AP and right atrial AP. The correlation coefficient reached 0.5 or more in terms of the right atrial LR, the right ventricular LR, the ratio of right/left atrial diameter and the ratio of right/left ventricular diameter. With the increasing value of POI, the right atrium and right ventricular of APE patients were enlarged, and the left atrium and left ventricular were decreased in size. These heart changes can be observed by using CTPA, even non-enhanced chest CT.
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Affiliation(s)
- Zhi-Jun Guo
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China.
| | - Hai-Tao Liu
- Department of Respiratory Medicine, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Ze-Mei Bai
- Department of Medical Administration, Huabei Petroleum Health Bureau, Renqiu, 062552, Hebei, China
| | - Qiang Lin
- Department of Oncology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Bao-Hong Zhao
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Qian Xu
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Yan-Hong Zeng
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Wen-Qiu Feng
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Hai-Tao Zhou
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Fei Liang
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Ji-Yan Cui
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
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Goyard C, Côté B, Looten V, Roche A, Pastré J, Marey J, Planquette B, Meyer G, Sanchez O. Determinants and prognostic implication of diagnostic delay in patients with a first episode of pulmonary embolism. Thromb Res 2018; 171:190-198. [PMID: 30190113 DOI: 10.1016/j.thromres.2018.08.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 07/26/2018] [Accepted: 08/22/2018] [Indexed: 01/24/2023]
Abstract
Signs and symptoms of pulmonary embolism (PE) are not specific and this can lead to a diagnostic delay. Little is known about the determinants of this delay and its prognostic implication. We conducted a retrospective analysis of a prospective cohort involving 514 patients with a first episode of PE. The diagnostic delay was defined as a time from first symptom onset to diagnosis of >3 days, corresponding of the median time in the population. Multivariable logistic regression analysis was performed to identify determinants of diagnostic delay. Prognostic implication was measured as the occurrence of 30-day all-cause mortality, haemodynamic collapse or recurrent PE. A total of 240 (47%) among 514 patients had a time from first symptom to diagnosis > 3 days. Previous deep vein thrombosis (OR 0.55, 95% Confidence Interval (CI), 0.32-0.93), immobilization (OR 0.52, 95% CI, 0.28-0.96), surgery (OR 0.31, 95% CI, 0.16-0.62), chest pain (OR 0.58, 95% CI, 0.39-0.86), syncope (OR 0.48, 95% CI, 0.23-1.01), dyspnea (OR 2.48, 95% CI, 1.57-3.91) and hemoptysis (OR 3.57, 95% CI, 1.40-9.07) were associated with diagnostic delay. Twenty-two patients (4.3%, 95%CI, 2.8-6.5) experienced an outcome event within 30 days. Among them, 15 patients (6.2% 95%CI, 3.7-10.3) had a diagnostic delay and 7 (2.6%, 95% CI 1.1-5.4) did not (p = 0.039). In this cohort, diagnostic delay is associated with the absence of major risk factors for PE or clinical features such as chest pain or syncope and the presence of dyspnea or hemoptysis. Diagnostic delay is associated with a worse 30-day prognosis.
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Affiliation(s)
- Céline Goyard
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Respiratory and Intensive Care Medicine, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, France
| | - Benoit Côté
- Département de médecine interne, Hôpital de l'Enfant-Jésus du CHU de Québec, Université Laval, Québec, Canada.
| | - Vincent Looten
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Medical Informatics, Biostatistics and Public Health, Hôpital Européen Georges Pompidou, France; INSERM UMRS 1138, Paris, France
| | - Anne Roche
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Respiratory and Intensive Care Medicine, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, France
| | - Jean Pastré
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Respiratory and Intensive Care Medicine, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, France
| | - Jonathan Marey
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Respiratory and Intensive Care Medicine, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, France
| | - Benjamin Planquette
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Respiratory and Intensive Care Medicine, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, France; INSERM UMRS 1140, Paris, France; F-CRIN, INNOVTE, Saint-Etienne, France
| | - Guy Meyer
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Respiratory and Intensive Care Medicine, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, France; F-CRIN, INNOVTE, Saint-Etienne, France; INSERM UMRS_970 and CIC 1418, Paris, France
| | - Olivier Sanchez
- Université Paris Descartes, Sorbonne Paris Cité, France; Division of Respiratory and Intensive Care Medicine, Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, France; INSERM UMRS 1140, Paris, France; F-CRIN, INNOVTE, Saint-Etienne, France.
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48
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Mohan B, Tandon R, Bansal R, Singh M, Singh B, Goyal A, Chhabra ST, Aslam N, Wander GS. Determinants of in-hospital clinical outcome in patients with sub-massive pulmonary embolism. Indian Heart J 2018; 70 Suppl 3:S90-S95. [PMID: 30595328 PMCID: PMC6310705 DOI: 10.1016/j.ihj.2018.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 11/09/2022] Open
Abstract
Introduction There is limited data regarding in hospital determinants of clinical deterioration and outcome in sub massive pulmonary embolism (PE). We aimed to evaluate these determinants by comparing biomarkers, CT pulmonary angiogram echocardiography, electrocardiography variables. Methods 57 patients of sub massive PE diagnosed on CT pulmonary angiogram were included. All patients received UFH on admission and were divided into two groups based on their clinical course. Group 1 comprised of patients who remained stable, group 2 of patients who showed signs of clinical deterioration. Results There were 34(59.6%) patients in group 1 and 23(40.4%) patients in group 2. No significant difference in age, gender, BMI. 59.37% had sub massive PE, 5.26% had mortality and 40.4% had clinical deterioration. Intravenous UFH infusion given to 59.6%, systemic thrombolysis 22.8%, catheter directed mechanical breakdown 14%, surgical embolectomy in 3.5% patients. S1Q3T3, new onset RBBB, T wave inversion > 1.63 mm, Basal RV size > 40 mm, RV: LV ratio > 1.2, Global RV longitudinal strain <−10.75% and RVSP > 39 mmHg profiled high risk group. Serum BNP and CT pulmonary angiogram derived scores didn’t differ significantly although CT findings helped to exclude low risk patients (specificity 88%, sensitivity 95%). Conclusions Physicians should be aware that patients who have ECG and Echocardiography changes suggestive of right ventricular strain and dysfunction above the cut off values and have documented thrombus in Proximal branches (RPA/LPA) or in distal portion of main pulmonary artery may require aggressive management with systemic/catheter based thrombolysis besides routine anticoagulation with heparin to prevent clinical deterioration.
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Affiliation(s)
- Bishav Mohan
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
| | - Rohit Tandon
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India.
| | - Raahat Bansal
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
| | - Maninder Singh
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
| | - Bhupinder Singh
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
| | - Abhishek Goyal
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
| | - Shibba Takkar Chhabra
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
| | - Naved Aslam
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
| | - Gurpreet S Wander
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
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Alcántara Carmona S, Pérez Redondo M, Nombela Franco L, González Costero R, Balandín Moreno B, Valdivia de la Fuente M, Méndez Alonso S, García Suárez A, Royuela A. Local low-dose urokinase thrombolysis for the management of haemodynamically stable pulmonary embolism with right ventricular dysfunction. EUROINTERVENTION 2018; 14:238-246. [PMID: 29155385 DOI: 10.4244/eij-d-17-00544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to evaluate the effectiveness of local low-dose urokinase thrombolysis (LLDUT) in haemodynamically stable pulmonary embolism with right ventricular dysfunction (RVD). METHODS AND RESULTS This was a prospective study. LLDUT with a 200,000 IU bolus followed by a 100,000 IU/hr infusion was given. Treatment duration was determined through radiological control performed 48-72 hrs into treatment. A follow-up echocardiogram was performed within seven days after LLDUT completion. Evolution of thrombus burden, pulmonary artery pressures (PAP) and RVD were studied, and haemorrhagic complications and mortality were recorded. Eighty-seven patients were included (62.5±16.5 years). In 67 patients (77%), the baseline echocardiogram showed mild-to-severe RVD, a dilated right ventricle (diameter: 44.4±6.2 mm) and a decreased tricuspid annular plane systolic excursion (14 mm [12-17]). Seventy-six patients (87.4%) experienced radiological improvement. Initially high PAP (mmHg) decreased after LLDUT: systolic 52.4 vs. 35.2 (17.2 [95% CI: 14.5-19.9]; p<0.0001), mean 34.2 vs. 23.5 (10.7 [95% CI: 9.0-12.5]; p<0.0001) and diastolic 23.9 vs. 16.0 (7.9 [95% CI: 6.1-9.7]; p<0.0001). Follow-up echocardiography showed overall improvement of RVD. No life-threatening haemorrhagic complications were reported. Six-month survival was 96.5%. CONCLUSIONS LLDUT rapidly decreased thrombus burden and PAP, improving right ventricular function, and was not associated with any life-threatening complications or pulmonary embolism (PE)- or treatment-related mortality.
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Affiliation(s)
- Sara Alcántara Carmona
- Department of Intensive Care, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
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Peripheral Distribution of Thrombus Does Not Affect Outcomes After Surgical Pulmonary Embolectomy. Ann Thorac Surg 2018; 106:778-783. [PMID: 29626452 DOI: 10.1016/j.athoracsur.2018.02.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 02/16/2018] [Accepted: 02/26/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Thrombus located distal to the main or primary pulmonary arteries has been previously viewed as a relative contraindication to surgical pulmonary embolectomy. We compared outcomes for surgical pulmonary embolectomy for submassive and massive pulmonary embolism (PE) in patients with central vs peripheral thrombus burden. METHODS All consecutive patients (2011 to 2016) undergoing surgical pulmonary embolectomy at a single center were retrospectively reviewed. Computed tomography angiography of each patient was used to define central PE as any thrombus originating within the lateral pericardial borders (main or right/left pulmonary arteries). Peripheral PE was defined as thrombus exclusively beyond the lateral pericardial borders, involving the lobar pulmonary arteries or distal. The primary outcome was in-hospital and 90-day survival. RESULTS We identified 70 patients: 52 (74%) with central PE and 18 (26%) with peripheral PE. Preoperative vital signs and right ventricular dysfunction were similar between the two groups. Compared with the central PE cohort, operative time was significantly longer in the peripheral PE group (191 vs 210 minutes, p < 0.005). Median right ventricular dysfunction decreased from moderate dysfunction preoperatively to no dysfunction at discharge in both groups. Overall 90-day survival was 94%, with 100% survival in patients with submassive PE in both cohorts. CONCLUSIONS This single-center experience demonstrates excellent overall outcomes for surgical pulmonary embolectomy, with resolution of right ventricular dysfunction and comparable morbidity and mortality for central and peripheral PE. In an experienced center and when physiologically warranted, surgical pulmonary embolectomy for peripheral distribution of thrombus is technically feasible and effective.
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