Pulmonary embolism: whom to discharge and whom to thrombolyze?

Additive prognostic value of serum calcium to the ESC risk stratification in patients with acute pulmonary embolism

BACKGROUND

Hypocalcemia has been shown to be involved in the adverse outcomes of acute pulmonary embolism (APE). We aimed to determine the incremental value of adding hypocalcemia, defined as serum calcium level ≤ 2.12 mmol/L, on top of the European Society of Cardiology (ESC) prognostic algorithm, for the prediction of in-hospital mortality in APE patients, which in turn could lead to the optimization of APE management.

METHODS

This study was conducted at West China Hospital of Sichuan University from January 2016 to December 2019. Patients with APE were retrospectively analyzed and divided into 2 groups based on serum calcium levels. Associations between hypocalcemia and adverse outcomes were assessed by Cox analysis. The accuracy of risk stratification for in-hospital mortality was assessed with the addition of serum calcium to the current ESC prognostic algorithm.

RESULTS

Among 803 patients diagnosed with APE, 338 (42.1%) patients had serum calcium levels ≤ 2.12 mmol/L. Hypocalcemia was significantly associated with higher in-hospital and 2-year all-cause mortality compared to the control group. The addition of serum calcium to ESC risk stratification enhanced net reclassification improvement. Low-risk group with serum calcium level > 2.12 mmol/L had a 0% mortality rate, improving the negative predictive value up to 100%, while high-risk group with serum calcium level ≤ 2.12 mmol/L indicated a higher mortality of 25%.

CONCLUSION

Our study identified serum calcium as a novel predictor of mortality in patients with APE. In the future, serum calcium may be added to the commonly used ESC prognostic algorithm for better risk stratification of patients suffering from APE.

Ultra-Low-Dose Systemic Tissue Plasminogen Activator in High-Risk Submassive Pulmonary Embolism

Risk stratification of pulmonary embolism (PE) is vital for clinical management. While low-risk and high-risk PE management are clearly defined in many societal guidelines, the management of moderate-risk, also called submassive, PE remains unsettled. There is a subgroup of patients with submassive PE that progress to the severe category despite receiving systemic anticoagulation. The role of thrombolysis in the management of submassive PE remains to be established. We share our experience with ultra-low-dose (25-mg) systemic tissue plasminogen activator in a series of 4 patients with high-risk submassive PE.

Temporal trends in management and outcome of pulmonary embolism: a single-centre experience

Background

Real-world data on the impact of advances in risk-adjusted management on the outcome of patients with pulmonary embolism (PE) are limited.

Methods

To investigate temporal trends in treatment, in-hospital adverse outcomes and 1-year mortality, we analysed data from 605 patients [median age, 70 years (IQR 56–77) years, 53% female] consecutively enrolled in a single-centre registry between 09/2008 and 08/2016.

Results

Over the 8-year period, more patients were classified to lower risk classes according to the European Society of Cardiology (ESC) 2014 guideline algorithm while the number of high-risk patients with out-of-hospital cardiac arrest (OHCA) increased. Although patients with OHCA had an exceptionally high in-hospital mortality rate of 59.3%, the rate of PE-related in-hospital adverse outcomes (12.2%) in the overall patient cohort remained stable over time. The rate of reperfusion treatment was 9.6% and tended to increase in high-risk patients. We observed a decrease in the median duration of in-hospital stay from 10 (IQR 6–14) to 7 (IQR 4–15) days, an increase of patients discharged early from 2.1 to 12.2% and an increase in the use of non-vitamin K-dependent oral anticoagulants (NOACs) from 12.6 to 57.2% in the last 2 years (09/2014–08/2016) compared to first 6 years (09/2008–08/2014). The 1-year mortality rate (16.9%) remained stable throughout the study period.

Conclusion

In-hospital adverse outcomes and 1-year mortality remained stable despite more patients with OHCA, shorter in-hospital stays, more patients discharged early and a more frequent NOAC use.

Electronic supplementary material

The online version of this article (10.1007/s00392-019-01489-9) contains supplementary material, which is available to authorized users.

Prognostic role of neutrophils to lymphocytes ratio in patients with acute pulmonary embolism: a systematic review and meta-analysis of the literature

The prognostic assessment of patients with acute pulmonary embolism (PE) is essential to drive its management. The search for new prognostic factors is a central issue for a more accurate estimate of short-term adverse events. Circulating neutrophils/lymphocytes ratio (NLR) has been suggested as prognostic biomarker for different cardiovascular diseases. Given the central role of inflammation, and in particular of neutrophils in the pathogenesis of VTE and its clinical history, NLR might represent a prognostic tool also in this setting. We performed a systematic review and meta-analysis of the literature to assess the prognostic role of NLR in patients with acute PE. MEDLINE and EMBASE were searched up to 2017, week 21. A bivariate random-effects regression approach was used to obtain summary estimate of accuracy of the high NLR adjusting for inter-study variability. Six studies for a total of 1424 patient are included. High NLR has a weighted mean sensitivity of 77% (95% CI 68-83) and a weighted mean specificity of 74% (95% CI 68-79). High NLR positive and negative predictive values are 24.4% (95% CI 20.4-28.3) and 96.7% (95% CI 95.6-97.8), respectively. The relevant impact of NLR on short-term mortality after an acute PE makes it a promising biomarker to better stratify patient prognosis.

How much do we really know about von Willebrand disease?

PURPOSE OF REVIEW

In the last nine decades, large advances have been made toward the characterization of the pathogenic basis and clinical management of von Willebrand disease (VWD), the most prevalent inherited bleeding disorder. Pathological variations at the von Willebrand factor (VWF) locus present as a range of both quantitative and qualitative abnormalities that make up the complex clinical spectrum of VWD. This review describes the current understanding of the pathobiological basis of VWD.

RECENT FINDINGS

The molecular basis of type 2 (qualitative abnormalities) and type 3 VWD (total quantitative deficiency) have been well characterized in recent decades. However, knowledge of type 1 VWD (partial quantitative deficiency) remains incomplete because of the allelic and locus heterogeneity of this trait, and is complicated by genetic variability at the VWF gene, interactions between the VWF gene and the environment, and the involvement of external modifying loci. Recent genome wide association studies and linkage analyses have sought to identify additional genes that modify the type 1 VWD phenotype.

SUMMARY

Understanding the pathogenic basis of VWD will facilitate the development of novel treatment regimens for this disorder, and improve the ability to provide complementary molecular diagnostics for type 1 VWD.

Risk stratifying emergency department patients with acute pulmonary embolism: Does the simplified Pulmonary Embolism Severity Index perform as well as the original?

INTRODUCTION

The Pulmonary Embolism Severity Index (PESI) is a validated prognostic score to estimate the 30-day mortality of emergency department (ED) patients with acute pulmonary embolism (PE). A simplified version (sPESI) was derived but has not been as well studied in the U.S. We sought to validate both indices in a community hospital setting in the U.S. and compare their performance in predicting 30-day all-cause mortality and classification of cases into low-risk and higher-risk categories.

MATERIALS AND METHODS

This retrospective cohort study included adults with acute objectively confirmed PE from 1/2013 to 4/2015 across 21 community EDs. We evaluated the misclassification rate of the sPESI compared with the PESI. We assessed accuracy of both indices with regard to 30-day mortality.

RESULTS

Among 3006 cases of acute PE, the 30-day all-cause mortality rate was 4.4%. The sPESI performed as well as the PESI in identifying low-risk patients: both had similar sensitivities, negative predictive values, and negative likelihood ratios. The sPESI, however, classified a smaller proportion of patients as low risk than the PESI (27.5% vs. 41.0%), but with similar low-risk mortality rates (<1%). Compared with the PESI, the sPESI overclassified 443 low-risk patients (14.7%) as higher risk, yet their 30-day mortality was 0.7%. The sPESI underclassified 100 higher-risk patients (3.3%) as low risk who also had a low mortality rate (1.0%).

CONCLUSIONS

Both indices identified patients with PE who were at low risk for 30-day mortality. The sPESI, however, misclassified a significant number of low-mortality patients as higher risk, which could lead to unnecessary hospitalizations.