Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolism

Predicting in-hospital mortality in patients admitted from the emergency department for pulmonary embolism: Incidence and prognostic value of deep vein thrombosis. A retrospective study

BACKGROUND

Pulmonary embolism (PE) is one of the most common causes of death from cardiovascular disease. Although deep vein thrombosis (DVT) is the leading cause of PE, its prognostic role is unclear. This study investigated the incidence and prognostic value of DVT in predicting in-hospital mortality (IHM) in patients admitted from the emergency department (ED) for PE.

METHODS

This retrospective cohort study was conducted in the ED of a third-level university hospital. Patients over 18 years admitted for PE between 1 January 2018 and 31 December 2022 were included.

RESULTS

Five hundred and thirty patients (mean age 73.13 years, 6% IHM) were included. 69.1% of cases had DVT (36.4% unilateral femoral vein, 3.6% bilateral, 39.1% unilateral popliteal vein, 2.8% bilateral, 45.7% distal vein thrombosis and 7.4% iliocaval involvement). Patients who died in hospital had a higher Pulmonary Embolism Severity Index (PESI) (138.6 vs. 99.65, p < 0.001), European Society of Cardiology risk class (15.6% vs. 1%, intermediate-high in 50% vs. 6.4%, p < 0.001) and more DVT involving the iliac-caval vein axis (18.8% vs. 6.6%, p = 0.011). PESI class >II, right ventricular dysfunction, increased blood markers of myocardial damage and involvement of the iliocaval venous axis were independent predictors of IHM on multivariate analysis.

CONCLUSIONS

Although further studies are needed to confirm the prognostic role of DVT at PE, involvement of the iliocaval venous axis should considered to be a sign of a higher risk of IHM and may be a key factor in prognostic stratification.

Mean arterial pressure predicts 48 h clinical deterioration in intermediate-high risk patients with acute pulmonary embolism

AIMS

We assess the prognostic role of mean arterial pressure (MAP) for 48 h clinical deterioration in intermediate-high risk pulmonary embolism (PE) patients after admission.

METHODS AND RESULTS

A post hoc analysis of intermediate-high-risk PE and intermediate-low-risk PE patients enrolled in the Italian Pulmonary Embolism Registry (IPER) (Trial registry: ClinicalTrials.gov; No.: NCT01604538) was performed. Clinical deterioration within 48 h was defined as patient worsening from a stable to an unstable haemodynamic condition, need of catecholamine infusion, endotracheal intubation, or cardiopulmonary resuscitation. Of 450 intermediate-high risk PE patients (mean age 71.4 ± 13.8 years, 298 males), 40 (8.8%) experienced clinical deterioration within 48 h from admission. Receiver operating characteristic analysis established the optimal cut-off value for MAP, as a predictor of 48 h clinical deterioration, ≤81.5 mmHg [area under curve (AUC) of 0.77 ± 0.3] with sensitivity, specificity, positive predictive value, and negative predictive value were 77.5, 95.0, 63.2, and 97.7%, respectively. Multivariate Cox regression analysis showed that independent risk factors for 48 h clinical deterioration were age [hazard ratio (HR): 1.26, 95% confidence interval (CI): 1.19-1.28, P < 0.0001], history of heart failure (HR: 1.76, 95% CI: 1.72-1.81, P < 0.0001), simplified Pulmonary Embolism Severity Index (HR: 1.52, 95% CI: 1.49-1.58, P = 0.001), systemic thrombolysis (HR: 0.54, 95% CI: 0.30-0.65, P < 0.0001), and a MAP of ≤81.5 mmHg at admission (HR: 3.25, 95% CI: 1.89-5.21, P < 0.0001). The deteriorating group had a significantly higher risk of 30-day mortality (HR: 2.61, 95% CI: 2.54-2.66, P < 0.0001) compared with the non-deteriorating group.

CONCLUSION

The mean arterial pressure appears to be a useful, bedside, and non-invasive prognostic tool potentially capable of promptly identifying intermediate-high risk PE patients at higher risk of 48 h clinical deterioration.

Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline 2022

No matter the practice setting, physical therapists work with patients who are at risk for or who have a history of venous thromboembolism (VTE). In 2016, the first clinical practice guideline (CPG) addressing the physical therapist management of VTE was published with support by the American Physical Therapy Association's Academy of Cardiovascular and Pulmonary Physical Therapy and Academy of Acute Care, with a primary focus on lower extremity deep vein thrombosis (DVT). This CPG is an update of the 2016 CPG and contains the most current evidence available for the management of patients with lower extremity DVT and new key action statements (KAS), including guidance on upper extremity DVT, pulmonary embolism, and special populations. This document will guide physical therapist practice in the prevention of and screening for VTE and in the management of patients who are at risk for or who have been diagnosed with VTE. Through a systematic review of published studies and a structured appraisal process, KAS were written to guide the physical therapist. The evidence supporting each action was rated, and the strength of statement was determined. Clinical practice algorithms based on the KAS were developed that can assist with clinical decision-making. Physical therapists, along with other members of the health care team, should implement these KAS to decrease the incidence of VTE, improve the diagnosis and acute management of VTE, and reduce the long-term complications of VTE.

Neurological Complications of Pulmonary Embolism: a Literature Review

PURPOSE OF REVIEW

The present review discusses in-depth about neurological complications following acute venous thromboembolism (VTE).

RECENT FINDINGS

Intracranial hemorrhage, acute ischemic cerebrovascular events, and VTE in brain tumors are described as central nervous system (CNS) complications of PE, while peripheral neuropathy and neuropathic pain are reported as peripheral nervous system (PNS) sequelae of PE. Syncope and seizure are illustrated as atypical neurological presentations of PE. Mounting evidence suggests higher risk of venous thromboembolism (VTE) in patients with neurological diseases, but data on reverse, i.e., neurological sequelae following VTE, is underexplored. The present review is an attempt to explore some of the latter issues categorized into CNS, PNS, and atypical complications following VTE.

The safety and efficacy of systemic versus catheter-based therapies: application of a prognostic model by a pulmonary embolism response team

The decision by pulmonary embolism response teams (PERTs) to utilize anticoagulation (AC) with or without systemic thrombolysis (ST) or catheter-directed therapies (CDT) for pulmonary embolism (PE) is a balance between the desire for a positive outcome and safety. Our primary aim was to develop a predictive model of in-hospital mortality for patients with high- or intermediate-risk PE managed by PERT while externally validating this model. Our secondary aim was to compare the relative safety and efficacy of ST and CDT in this cohort. Consecutive patients hospitalized between June 2014 and January 2020 at the Cleveland Clinic Foundation and The University of Rochester with acute high- or intermediate-risk PE managed by PERT were retrospectively evaluated. Groups were stratified by treatment strategy. The primary outcome was in-hospital mortality, and secondary outcome was major bleeding. A logistic regression model to predict the primary outcome was built using the derivation cohort, with 100-fold bootstrapping for internal validation. External validation was performed and the area under the receiver operating curve (AUC) was calculated. Of 549 included patients, 421 received AC alone, 71 received ST, and 64 received CDT. Predictors of major bleeding include ESC risk category, PESI score, hypoxia, hemodynamic instability, and serum lactate. CDT trended towards lower mortality but with an increased risk of bleeding relative to ST (OR = 0.42; 95% CI [0.15, 1.17] and OR = 2.14; 95% CI [0.9, 5.06] respectively). In the multivariable logistic regression model in the derivation institution cohort, predictors of in-hospital mortality were age, cancer, hemodynamic instability requiring vasopressors, and elevated NT-proBNP (AUC = 0.86). This model was validated using the validation institution cohort (AUC = 0.88). We report an externally-validated model for predicting in-hospital mortality in patients with PE managed by PERT. The decision by PERT to initiate CDT or ST for these patients had no impact on mortality or major bleeding, yet the long-term efficacy of these interventions needs to be elucidated.

Randomised controlled trial of a prognostic assessment and management pathway to reduce the length of hospital stay in normotensive patients with acute pulmonary embolism

BACKGROUND

The length of hospital stay (LOS) for acute pulmonary embolism (PE) varies considerably. Whether the upfront use of a PE prognostic assessment and management pathway is effective in reducing the LOS remains unknown.

METHODS

We conducted a randomised, controlled trial of adults hospitalised for acute PE: patients were assigned to a prognostic assessment and management pathway involving risk stratification, followed by predefined criteria for mobilisation and discharge (intervention group), or usual care (control group). The primary end point was LOS. The secondary end points were the cost of prognostic tests and of hospitalisation, and 30-day clinical outcomes.

RESULTS

Of 500 patients who underwent randomisation, 498 were included in the modified intention-to-treat analysis. The median LOS was 4.0 days (interquartile range [IQR], 3.7 to 4.2 days) in the intervention group and 6.1 days (IQR, 5.7 to 6.5 days) in the control group (p<0.001). The mean total cost of prognostic tests was €174.76 in the intervention group, as compared with €233.12 in the control group (mean difference, €-58.37; 95% confidence interval [CI], €-84.34 to €-32.40). The mean total hospitalisation cost per patient was €2085.66 in the intervention group, compared with €3232.97 in the control group (mean difference, €-1147.31; 95% CI, €-1414.97 to €-879.65). No significant differences were observed in 30-day readmissions (4.0% versus 4.8%, respectively), or all-cause (2.4% versus 2.0%) and PE-related mortality rates (0.8% versus 1.2%).

CONCLUSIONS

The use of a prognostic assessment and management pathway was effective in reducing the LOS for acute PE.

Right ventricle assessment in patients with pulmonary embolism at low risk for death based on clinical models: an individual patient data meta-analysis

AIMS

Patients with acute pulmonary embolism (PE) at low risk for short-term death are candidates for home treatment or short-hospital stay. We aimed at determining whether the assessment of right ventricle dysfunction (RVD) or elevated troponin improves identification of low-risk patients over clinical models alone.

METHODS AND RESULTS

Individual patient data meta-analysis of studies assessing the relationship between RVD or elevated troponin and short-term mortality in patients with acute PE at low risk for death based on clinical models (Pulmonary Embolism Severity Index, simplified Pulmonary Embolism Severity Index or Hestia). The primary study outcome was short-term death defined as death occurring in hospital or within 30 days. Individual data of 5010 low-risk patients from 18 studies were pooled. Short-term mortality was 0.7% [95% confidence interval (CI) 0.4-1.3]. RVD at echocardiography, computed tomography or B-type natriuretic peptide (BNP)/N-terminal pro BNP (NT-proBNP) was associated with increased risk for short-term death (1.5 vs. 0.3%; OR 4.81, 95% CI 1.98-11.68), death within 3 months (1.6 vs. 0.4%; OR 4.03, 95% CI 2.01-8.08), and PE-related death (1.1 vs. 0.04%; OR 22.9, 95% CI 2.89-181). Elevated troponin was associated with short-term death (OR 2.78, 95% CI 1.06-7.26) and death within 3 months (OR 3.68, 95% CI 1.75-7.74).

CONCLUSION

RVD assessed by echocardiography, computed tomography, or elevated BNP/NT-proBNP levels and increased troponin are associated with short-term death in patients with acute PE at low risk based on clinical models. RVD assessment, mainly by BNP/NT-proBNP or echocardiography, should be considered to improve identification of low-risk patients that may be candidates for outpatient management or short hospital stay.

Rapid prediction of adverse outcomes for acute normotensive pulmonary embolism: derivation of the Calgary Acute Pulmonary Embolism score

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

Prognostic Significance of Incidental Deep Vein Thrombosis in Patients with Cancer Presenting with Incidental Pulmonary Embolism

In symptomatic acute pulmonary embolism (PE), the presence of deep vein thrombosis (DVT) is a risk factor for 30- and 90-day mortality. In patients with cancer and incidental PE, the prognostic effect of concomitant incidental DVT is unknown. In this retrospective study, we examined the effect of incidental DVT on all-cause mortality in such patients. Adjusted Cox multivariate regression analysis was used for relevant covariates. From January 2010 to March 2018, we included 200 patients (mean age, 65.3 ± 12.4 years) who were followed up for 12.5 months (interquartile range 7.4-19.4 months). Of these patients, 62% had metastases, 31% had concomitant incidental DVT, and 40.1% (n = 81) died during follow-up. All-cause mortality did not increase in patients with DVT (hazard ratio [HR] 1.01, 95% confidence interval [CI] 0.43-2.75, p = 0.855). On multivariate analysis, weight (adjusted HR 0.96, 95% CI 0.92-0.99, p = 0.032), and metastasis (adjusted HR 10.26, 95% CI 2.35-44.9, p = 0.002) were predictors of all-cause mortality. In conclusion, low weight and presence of metastases were associated with all-cause mortality, while presence of concomitant DVT was unrelated to poorer survival.

Incremental Value of ePLAR—The Echocardiographic Pulmonary to Left Atrial Ratio in the Assessment of Sub-Massive Pulmonary Emboli

Background: Acute pulmonary embolism (PE) is characterized hemodynamically by abrupt obstruction in trans-pulmonary blood flow. The echocardiographic Pulmonary to Left Atrial ratio (ePLAR, tricuspid regurgitation Vmax/mitral E/e’) has been validated as a non-invasive surrogate for trans-pulmonary gradient (TPG) that accurately differentiates pre-capillary from post-capillary chronic pulmonary hypertension. This study assessed ePLAR as an incremental echocardiographic assessment tool compared with traditional measures of right ventricular pressure and function. Methods: In total, 110 (57.4 ± 17.6 years) patients with confirmed sub-massive pulmonary emboli with contemporaneous echocardiograms (0.3 ± 0.9 days) were compared with 110 age-matched controls (AMC). Results: Tricuspid velocities were higher than AMC (2.6 ± 0.6 m/s vs. 2.4 ± 0.3 m/s, p < 0.05), although still consistent with “normal” right ventricular systolic pressures (34.2 ± 13.5 mmHg vs. 25 ± 5.3 mmHg, p < 0.05) with lower mitral E/e’ values (8.2 ± 3.8 vs. 10.8 ± 5.1, p < 0.05). ePLAR values were higher than AMC (0.36 ± 0.14 m/s vs. 0.26 ± 0.10, p < 0.05) suggesting significantly elevated TPG. Detection of abnormal echocardiographic findings increased from 29% (TRVmax ≥ 2.9 m/s) and 32% (reduced tricuspid annular plane systolic excursion) to 70% with ePLAR ≥ 0.3 m/s. Conclusions: Raised ePLAR values in acute sub-massive pulmonary embolism suggest elevated trans-pulmonary gradients even in the absence of acutely increased pulmonary artery pressures. ePLAR dramatically increases the sensitivity of echocardiography for detection of hemodynamic perturbations in sub-massive pulmonary embolism patients, which may offer clinical utility in diagnosis and management.

Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practice from the PERT Consortium

Pulmonary embolism (PE) is a life-threatening condition and a leading cause of morbidity and mortality. There have been many advances in the field of PE in the last few years, requiring a careful assessment of their impact on patient care. However, variations in recommendations by different clinical guidelines, as well as lack of robust clinical trials, make clinical decisions challenging. The Pulmonary Embolism Response Team Consortium is an international association created to advance the diagnosis, treatment, and outcomes of patients with PE. In this consensus practice document, we provide a comprehensive review of the diagnosis, treatment, and follow-up of acute PE, including both clinical data and consensus opinion to provide guidance for clinicians caring for these patients.

Intermediate-High Risk Pulmonary Embolism

Limited information exists about the prevalence, management, and outcomes of intermediate-high risk patients with acute pulmonary embolism (PE). In a prospective cohort study, we evaluated consecutive patients with intermediate-high risk PE at a large, tertiary, academic medical center between January 1, 2015 and March 31, 2019. Adjudicated outcomes included PE-related mortality and a complicated course through 30 days after initiation of PE treatment. Repeat systolic blood pressure (SBP), heart rate (HR), brain natriuretic peptide (BNP), and cardiac troponin I (cTnI) measurements, and echocardiography were performed within 48 hours after diagnosis. Among 1,015 normotensive patients with acute PE, 97 (9.6%) had intermediate-high risk PE. A 30-day complicated course and 30-day PE-related mortality occurred in 23 (24%) and 7 patients (7.2%) with intermediate-high risk PE. Seventeen (18%) intermediate-high risk patients received reperfusion therapy. Within 48 hours after initiation of anticoagulation, normalization of SBP, HR, cTnI, BNP, and echocardiography occurred in 82, 86, 78, 72, and 33% of survivors with intermediate-high risk PE who did not receive immediate thrombolysis. A complicated course between day 2 and day 30 after PE diagnosis for the patients who normalized SBP, HR, cTnI, BNP, and echocardiography measured at 48 hours occurred in 2.9, 1.4, 4.5, 3.3, and 14.3%, respectively. Intermediate-high risk PE occurs in approximately one-tenth of patients with acute symptomatic PE, and is associated with high morbidity and mortality. Normalization of HR 48 hours after diagnosis might identify a group of patients with a very low risk of deterioration during the first month of follow-up.

Differential impact of syncope on the prognosis of patients with acute pulmonary embolism: a systematic review and meta-analysis

Aims

Controversial reports exist in the literature regarding the prognostic role and therapeutic implications of syncope in patients with acute pulmonary embolism (PE). We conducted a systematic review and meta-analysis to investigate the association between syncope and short-term adverse outcomes, taking into account the presence or absence of haemodynamic compromise at acute PE presentation.

Methods and results

The literature search identified 1664 studies, 29 of which were included for a total of 21 956 patients with PE (n = 3706 with syncope). Syncope was associated with higher prevalence of haemodynamic instability [odds ratio (OR) 3.50; 95% confidence interval (CI) 2.67-4.58], as well as with echocardiographic signs of right ventricular (RV) dysfunction (OR 2.10; CI 1.60-2.77) at presentation. Patients with syncope had a higher risks of all-cause early (either in-hospital or within 30 days) death (OR 1.73; CI 1.22-2.47) and PE-related 30-day adverse outcomes (OR 2.00; CI 1.11-3.60). The absolute risk difference (95% CI) for all-cause death was +6% (+1% to +10%) in studies including unselected patients, but it was -1% (-2% to +1%) in studies restricted to normotensive patients. We observed no prognostic impact of syncope in studies with a lower score at formal quality assessment and in those conducted retrospectively.

Conclusion

Syncope as a manifestation of acute PE was associated with a higher prevalence of haemodynamic instability and RV dysfunction at presentation, and an elevated risk for early PE-related adverse outcomes. The association with an increased risk of early death appeared more prominent in studies including unselected patients, when compared with those focusing on normotensive patients only.

Elevated serum cardiac troponin and mortality in acute pulmonary embolism: Systematic review and meta-analysis

OBJECTIVES

To evaluate whether elevated levels of cardiac troponin increases the risk of mortality in patients with acute PE.

METHODS

We conducted a systematic review and meta-analysis with rigorous statistical evaluation using publications (2000-2018) from Cochrane Library, MEDLINE, PubMed, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), WHO International Clinical Trials Registry Platform, and Google Scholar databases. We searched for retrospective, prospective, and randomized controlled trials (RCT) or quasi-RCT studies that assessed the effect of elevated troponin versus normal levels on the outcomes of PE. The main outcome of interest was all-cause mortality. Extracted data included authors, the origin of studies, source population, study settings and duration, inclusion/exclusion criteria, data sources and measurement, sample size, and mortality. Data heterogeneity was assessed using the Cochrane Q homogeneity test with a significance set at p < 0.10. If the studies were statistically homogeneous, a fixed effect model was selected.

RESULTS

Out of 1825 references, 46 analytical studies were included with a total of 10842 patients with PE. The effect of elevated troponin on mortality had a pooled odd ratio (OR) of 4.33 for all studies, 3.7for HsTnT, 14.81 for HsTnI, 7.85 for cTnT, 2.81 for cTnI, 9.02 for low-risk PE and 4.80 for 90-day mortality. The pooled negative likelihood ratios for all-cause mortality using HsTnI, cTnI and cTnT assay were 0.21, 0.33 and 0.65, respectively.

CONCLUSION

Regardless of the troponin assay, pooled analysis indicates that elevated troponin is significantly associated with higher mortality in patients with PE.

Role of echocardiography in managing acute pulmonary embolism

The role of echocardiography in acute pulmonary embolism (PE) remains incompletely defined. Echocardiography cannot reliably diagnose acute PE, and it does not improve prognostication of patients with low-risk acute PE who lack other clinical features of right ventricular (RV) dysfunction. Echocardiography, however, may yield additional prognostic information in higher risk patients and can aid in distinguishing acute from chronic RV dysfunction. Specific echocardiographic markers of RV dysfunction have the potential to enhance prognostication beyond existing risk models. Until these markers are subjected to rigorous prospective studies, the therapeutic utility and economic value of echocardiography in acute PE are uncertain.

Risk stratification in normotensive acute pulmonary embolism patients: focus on the intermediate-high risk subgroup

BACKGROUND

Patients with acute pulmonary embolism are at intermediate-high risk in the presence of imaging signs of right ventricular dysfunction plus one or more elevated cardiac biomarker. We hypothesised that intermediate-high risk patients with two elevated cardiac biomarkers and imaging signs of right ventricular dysfunction have a worse prognosis than those with one cardiac biomarker and imaging signs of right ventricular dysfunction.

METHODS

We analysed the cumulative presence of cardiac biomarkers and imaging signs of right ventricular dysfunction in 525 patients with intermediate risk pulmonary embolism (intermediate-high risk = 237) presenting at the emergency department in two centres. Studied endpoints were composites of all-cause mortality and/or rescue thrombolysis at 30 days (primary endpoint; n=58) and pulmonary embolism-related mortality and/or rescue thrombolysis at 30 days (secondary endpoint; n=40).

RESULTS

Patients who experienced the primary endpoint showed a higher proportion of elevated troponin (47% vs. 76%, P<0.001), elevated N-terminal pro-brain natriuretic peptide (67% vs. 93%, P<0.001) and imaging signs of right ventricular dysfunction (47% vs. 80%, P<0.001). Multivariate analysis revealed N-terminal pro-brain natriuretic peptide (hazard ratio (HR) 3.6, 95% confidence interval (CI) 1.3-10.3; P=0.015) and imaging signs of right ventricular dysfunction (HR 2.8, 95% CI 1.5-5.2; P=0.001) as independent predictors of events. In the intermediate-high risk group, patients with two cardiac biomarkers performed worse than those with one cardiac biomarker (HR 3.3, 95% CI 1.8-6.2; P=0.003).

CONCLUSIONS

Risk stratification in normotensive pulmonary embolism should consider the cumulative presence of cardiac biomarkers and imaging signs of right ventricular dysfunction, especially in the intermediate-high risk subgroup.

Catheter-directed Thrombolysis for Intermediate-Risk Pulmonary Embolism

Intermediate-risk pulmonary embolism is common and carries a risk of progression to hemodynamic collapse and death. Catheter-directed thrombolysis is an increasingly used treatment option, based largely on the assumptions that it is more efficacious than anticoagulation alone and safer than systemic thrombolysis. In this review, we critically analyze the published data regarding catheter-directed thrombolysis for the treatment of intermediate-risk pulmonary embolism. Catheter-directed thrombolysis reduces right heart strain and lowers pulmonary artery pressures more quickly than anticoagulation alone. The mortality for patients with intermediate-risk pulmonary embolism treated with catheter-directed thrombolysis is low, between 0% and 4%. However, similarly low mortality is seen with anticoagulation alone. Catheter-directed thrombolysis appears to be safer than systemic thrombolysis, and procedural complications are uncommon. Bleeding risk appears to be slightly higher than with anticoagulation alone. Randomized, controlled trials are needed to compare the efficacy and safety of catheter-directed thrombolysis versus anticoagulation for intermediate-risk pulmonary embolism. There is no evidence that catheter-directed thrombolysis decreases the incidence of chronic thromboembolic pulmonary hypertension. There is no evidence from clinical studies that ultrasound-assisted thrombolysis is more effective or safer than standard catheter-directed thrombolysis.

Deep venous thrombosis in the clinical course of pulmonary embolism

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.

Impact of symptomatic atherosclerosis in patients with pulmonary embolism

BACKGROUND

Atherosclerosis is associated with increased cardiovascular mortality. Associations between venous thromboembolism and atherosclerosis were recently reported. We aimed to investigate the impact of symptomatic atherosclerosis on adverse outcomes in patients with pulmonary embolism (PE) and to identify significant differences among patients with PE stratified by symptomatic atherosclerosis.

METHODS

Patients were selected by screening the nationwide inpatients sample for PE (ICD-code I26) stratified by symptomatic atherosclerosis (composite of coronary artery disease [ICD-code I25], myocardial infarction [ICD-code I21], ischemic stroke [ICD-code I63], and/or atherosclerotic arterial diseases [ICD-code I70]). We compared PE patients with (PE + Athero) and without (PE - Athero) symptomatic atherosclerosis and analysed the impact of symptomatic atherosclerosis on adverse outcomes.

RESULTS

Overall, 213,995 patients with PE (54.2% females) were included in this analysis. Of these, 30,157 (14.1%) had symptomatic atherosclerosis with age-dependent incline. Deep vein thrombosis or thrombophlebitis (45.1% vs. 36.9%, P < 0.001) was more commonly observed in the PE - Athero group (Odds Ratio (OR) 0.713 [95% CI 0.695-0.731], P < 0.001). In-hospital mortality (12.1% vs. 9.6%, P < 0.001) and adverse in-hospital events (16.8% vs. 12.6%, P < 0.001) were affected by symptomatic atherosclerosis; both in-hospital mortality (OR 1.107 [95% CI 1.061-1.155], P < 0.001) and adverse in-hospital outcomes (OR 1.143 [95%CI 1.102-1.186], P < 0.001) were affected independently of age, gender, comorbidities, and reperfusion treatments.

CONCLUSIONS

Symptomatic atherosclerosis in patients with PE increased with age and was associated with a poorer outcome. Cardiovascular-atherosclerotic diseases might play a major role in thrombus formation in isolated PE.

Cardiac Troponins in Low-Risk Pulmonary Embolism Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with low-risk pulmonary embolism (PE) should be considered as per current scoring systems for ambulatory treatment. However, there is uncertainty whether patients with low scores and positive troponins should require hospitalization.

METHODS

We searched MEDLINE, SCOPUS, and Cochrane Library databases from inception to December 2016 and collected longitudinal studies that evaluated the prognostic value of troponins in patients with low-risk PE. The primary outcome measure was 30-day all-cause mortality. We calculated odds ratio (OR), likelihood ratios (LRs), and 95% confidence intervals (CI) by using randomeffects models.

RESULTS

The literature search identified 117 candidate articles, of which 16 met the criteria for review. Based on pulmonary embolism severity index (PESI) or simplified PESI score, 1.2% was the all-cause mortality rate across 2,662 participants identified as low-risk. A positive troponin status in patients with low-risk PE was associated with an increased risk of 30-day all-cause mortality (odds ratio [OR]: 4.79; 95% confidence interval [CI]: 1.11 to 20.68). The pooled likelihood ratios (LRs) for all-cause mortality were positive LR 2.04 (95% CI, 1.53 to 2.72) and negative LR 0.072 (95% CI, 0.37 to 1.40).

CONCLUSIONS

The use of positive troponin status as a predictor of increased mortality in low-risk PE patients exhibited relatively poor performance given the crossed negative LR CI (1.0) and modest positive LR. Larger prospective trials must be conducted to elucidate if patients with low-risk PE and positive troponin status can avoid hospitalization.

Aggressive Treatment of Intermediate-Risk Patients with Acute Symptomatic Pulmonary Embolism

Contemporary studies of acute pulmonary embolism (PE) have evaluated the role of thrombolytics in intermediate-risk PE. Significant findings are that thrombolytic therapy may prevent hemodynamic deterioration and all-cause mortality but increases major bleeding. Benefits and harms are finely balanced with no convincing net benefit from thrombolytic therapy among unselected patients. Among patients with intermediate risk PE, additional prognostic factors or subtle hemodynamic changes might alter the risk-benefit assessment in favor of thrombolytic therapy before obvious hemodynamic instability.

A prospective validation of the Bova score in normotensive patients with acute pulmonary embolism

BACKGROUND

The Bova score has shown usefulness in the identification of intermediate-high risk patients with acute pulmonary embolism (PE), but lacks prospective validation. The aim of this study was to prospectively validate the Bova score in different settings from the original derivation cohort.

METHODS

Consecutive, normotensive patients with acute PE recruited at 13 academic or general hospitals were stratified, using their baseline data, into the three Bova risk stages (I-III). The primary outcome was the 30-day composite of PE-related mortality, hemodynamic collapse and non-fatal PE recurrences in the three risk categories.

RESULTS

In the study period, 639 patients were enrolled. The primary end point occurred in 45 patients (7.0%; 95% Confidence Intervals, 5.2%-9.3%). Risk stage correlated with the PE-related complication rate (stage I, 2.9%; stage II, 17%; stage III, 27%). Patients classified as stage III by the Bova score had a 6.5-fold increased risk for adverse outcomes (3.1-13.5, p < 0.001) compared with stages I and II combined. Rescue thrombolysis increased from stage I to stage III (0.6%, 12% and 15% respectively). All-cause mortality (5.3%) did not substantially differ among the stages.

CONCLUSIONS

The Bova score accurately stratifies normotensive patients with acute PE into stages of increasing risk of 30-day PE-related complications.

Use of Tachycardia in Patients With Submassive Pulmonary Emboli to Risk Stratify for Early Initiation of Thrombolytic Therapy: A Case Series Comparing Early Versus Late Thrombolytic Initiation

Pulmonary embolism (PE) represents a prevalent cause of morbidity and mortality in the United States, with approximately 600 000 cases diagnosed annually. The mortality rate for untreated PE is as high as 30%. Right ventricular (RV) dysfunction is a sign of possible adverse outcomes with right-sided heart failure being the usual cause of death from PE. There is a spectrum of clinical presentations associated with PE diagnoses, from incidental and asymptomatic to rapid hemodynamic collapse. Despite successes in identifying patients with "high-risk" PEs for aggressive thrombolytic interventions and "low-risk" PEs for outpatient anticoagulation, a significant lack of consensus exists regarding intervention modalities for PEs identified as "intermediate risk" or "submassive," defined as normotensive (systolic blood pressure ≥90 mm Hg) with acute RV dysfunction and myocardial injury. In this case series, we review the management and outcomes of 2 patients with submassive PEs and sustained tachycardia in the setting of normal blood pressures, and we address the need to recognize tachycardia as an ominous RV compensatory sign, indicative of impending hemodynamic collapse, that should lead to aggressive therapy with vascular intervention.

Effectiveness of prognosticating pulmonary embolism using the ESC algorithm and the Bova score

The prognostic value of the European Society of Cardiology (ESC) 2014 algorithm and the Bova score has lacked adequate validation. According to the ESC 2014 guidelines and the Bova score, we retrospectively risk stratified normotensive patients with PE who were enrolled in the PROTECT study. This study used a complicated course (which consisted of death from any cause, haemodynamic collapse, or recurrent PE) as the primary endpoint, and follow-up occurred through 30 days after the PE diagnosis. Of 848 patients, 37 % had a sPESI of 0 and 5 (1.6 %; 95 % confidence interval [CI], 0.5-3.7 %) experienced a complicated course. Of 143 patients with a sPESI of 0 points and negative computed tomographic pulmonary angiography (CTPA) for right ventricle (RV) dysfunction, three (2.1 %; 95 % CI, 0.4-6.0 %) experienced a complicated course. Four hundred seventy-eight (56 %) patients with a sPESI ≥ 1 had echocardiographic evidence of RV dysfunction or elevated troponin level or none, and 48 (10 %, 95 % CI, 7.5-13.1 %) experienced a complicated course. Fifty-seven (6.7 %) patients with a sPESI ≥ 1 had echocardiographic RV dysfunction and elevated troponin level, and 10 (17.5 %; 95 % CI, 8.8-29.9 %) experienced a complicated course, compared to 21.6 % (8 of 37 patients, 21.6 %; 95 % CI, 9.8-38.2 %) in Bova risk class III. In conclusion, the ESC 2014 prognostic algorithm is effective in the risk stratification of normotensive patients with PE. Use of CTPA did not improve the ability for identification of low-risk PE. Bova risk scoring did not significantly improve identification of intermediate-high risk PE.

Jiménez et al. Validation of the ESC 2014 prognostication algorithm

Cardiac troponin testing and the simplified Pulmonary Embolism Severity Index

A low simplified Pulmonary Embolism Severity Index (sPESI), defined as age ≤80 years and absence of systemic hypotension, tachycardia, hypoxia, cancer, heart failure, and lung disease, identifies low-risk patients with acute pulmonary embolism (PE). It is unknown whether cardiac troponin testing improves the prediction of clinical outcomes if the sPESI is not low. In the prospective Swiss Venous Thromboembolism Registry, 369 patients with acute PE and a troponin test (conventional troponin T or I, highly sensitive troponin T) were enrolled from 18 hospitals. A positive test result was defined as a troponin level above the manufacturers assay threshold. Among the 106 (29%) patients with low sPESI, the rate of mortality or PE recurrence at 30 days was 1.0%. Among the 263 (71%) patients with high sPESI, 177 (67%) were troponin-negative and 86 (33%) troponin-positive; the rate of mortality or PE recurrence at 30 days was 4.6% vs. 12.8% (p=0.015), respectively. Overall, risk assessment with a troponin test (hazard ratio [HR] 3.39, 95% confidence interval [CI] 1.38–8.37; p=0.008) maintained its prognostic value for mortality or PE recurrence when adjusted for sPESI (HR 5.80, 95%CI 0.76–44.10; p=0.09). The combination of sPESI with a troponin test resulted in a greater area under the receiver-operating characteristic curve (HR 0.72, 95% CI 0.63–0.81) than sPESI alone (HR 0.63, 95% CI 0.57–0.68) (p=0.023). In conclusion, although cardiac troponin testing may not be required in patients with a low sPESI, it adds prognostic value for early death and recurrence for patients with a high sPESI.

Pulmonary embolism severity assessment and prognostication

For patients who have acute symptomatic pulmonary embolism (PE), risk of short-term death and adverse outcomes should drive the initial treatment decisions. Practice guidelines recommend that patients who have a high-risk of PE-related death and adverse outcomes, determined by the presence of haemodynamic instability (i.e., shock or hypotension), should receive systemically administered thrombolytic therapy. Intermediate-high risk patients might benefit from close observation, and some should undergo escalation of therapy beyond standard anticoagulation, particularly if haemodynamic deterioration occurs. Low-risk for adverse outcomes should lead to early hospital discharge or full treatment at home. Validated prognostic tools (i.e., clinical prognostic scoring systems, imaging studies, and cardiac laboratory biomarkers) assist with risk classification of patients who have acute symptomatic PE.

Comparison of clinical scores for identification of patients with pulmonary embolism at intermediate-high risk of adverse clinical outcome: the prognostic role of plasma lactate

To compare the prognostic accuracy of the 2014 risk model of the European Society of Cardiology (ESC) and of Bova and TELOS scores for identification of normotensive patients with pulmonary embolism (PE) at high risk for short-term adverse events (i.e., intermediate-high risk patients), we retrospectively applied these tests to a prospective cohort of 994 normotensive patients with objectively confirmed PE. Sixty-three (6.3 %) patients reached the primary outcome, a composite of hemodynamic collapse and death within 7 days from diagnosis. The Bova and TELOS scores classified the same proportion of patients in intermediate-high risk category (5.9 and 5.7 %, respectively), with a similar primary outcome rate (18.6 and 21.1 %, respectively). The 2014 ESC model classified in the intermediate-high risk category the largest proportion of patients (12.5 %, p < 0.001 vs Bova and TELOS), with the lowest primary outcome rate (13 %, p = ns vs Bova and TELOS). When lactate determination was added to the Bova score, 112 patients (11.2 %) were classified in the intermediate-high risk category (p < 0.05 vs Bova and TELOS), with a slight increase in the primary outcome rate (25.9 %, p = 0.014 vs 2014 ESC model), allowing the recognition of a twofold higher number of patients reaching the primary outcome (29 vs 15, 11 and 12 patients in the 2014 ESC model, Bova and TELOS scores, respectively, p < 0.01 for all). The 2014 ESC model, Bova and TELOS scores identify a small number of intermediate-high risk patients with PE, without differences among tests. Adding plasma lactate to the Bova score significantly improves the identification of intermediate-high risk patients.

Update on the risk stratification of acute symptomatic pulmonary thromboembolism

Early mortality in patients with pulmonary thromboembolism (PTE) varies from 2% in normotensive patients to 30% in patients with cardiogenic shock. The current risk stratification for symptomatic PTE includes 4 patient groups, and the recommended therapeutic strategies are based on this stratification. Patients who have haemodynamic instability are considered at high risk. Fibrinolytic treatment is recommended for these patients. In normotensive patients, risk stratification helps differentiate between those of low risk, intermediate-low risk and intermediate-high risk. There is currently insufficient evidence on the benefit of intensive monitoring and fibrinolytic treatment in patients with intermediate-high risk. For low-risk patients, standard anticoagulation is indicated. Early discharge with outpatient management may be considered, although its benefit has still not been firmly established.

Terapia fibrinolítica sistêmica no tromboembolismo pulmonar

O tromboembolismo pulmonar permanece como um grande desafio terapêutico para os médicos especialistas, pois, apesar de todo investimento e desenvolvimento em seu diagnóstico, profilaxia e tratamento, essa condição continua sendo a principal causa de morte evitável em ambiente hospitalar. Ainda restam muitas dúvidas em relação a qual perfil de paciente vai se beneficiar de fato da terapia fibrinolítica sistêmica, sem ficar exposto a um grande risco de sangramento. A estratificação de risco e a avaliação do prognóstico do evento, através de escores clínicos de insuficiência ventricular direita, marcadores de dilatação e disfunção do ventrículo direito e avaliação da massa trombótica, associados ou de forma isolada, são ferramentas que podem auxiliar na identificação do paciente que irá se beneficiar dessa terapia. Os únicos consensos em relação à terapia fibrinolítica no tratamento do tromboembolismo pulmonar são: não deve ser indicada de forma rotineira; nenhum dos escores ou marcadores, isoladamente, devem justificar seu uso; e os pacientes com instabilidade hemodinâmica são os mais beneficiados. Além disto, deve-se avaliar cada caso em relação ao risco de sangramento, especialmente no sistema nervoso central.

Guidelines for the Use of Echocardiography in the Evaluation of a Cardiac Source of Embolism

Embolism from the heart or the thoracic aorta often leads to clinically significant morbidity and mortality due to transient ischemic attack, stroke or occlusion of peripheral arteries. Transthoracic and transesophageal echocardiography are the key diagnostic modalities for evaluation, diagnosis, and management of stroke, systemic and pulmonary embolism. This document provides comprehensive American Society of Echocardiography guidelines on the use of echocardiography for evaluation of cardiac sources of embolism. It describes general mechanisms of stroke and systemic embolism; the specific role of cardiac and aortic sources in stroke, and systemic and pulmonary embolism; the role of echocardiography in evaluation, diagnosis, and management of cardiac and aortic sources of emboli including the incremental value of contrast and 3D echocardiography; and a brief description of alternative imaging techniques and their role in the evaluation of cardiac sources of emboli. Specific guidelines are provided for each category of embolic sources including the left atrium and left atrial appendage, left ventricle, heart valves, cardiac tumors, and thoracic aorta. In addition, there are recommendation regarding pulmonary embolism, and embolism related to cardiovascular surgery and percutaneous procedures. The guidelines also include a dedicated section on cardiac sources of embolism in pediatric populations.

Prognostic Significance of Right Heart Thrombi in Patients With Acute Symptomatic Pulmonary Embolism: Systematic Review and Meta-analysis

BACKGROUND

For patients diagnosed with acute pulmonary embolism (PE), the prognostic significance of concomitant right heart thrombi (RHT) lacks clarity.

METHODS

We performed a meta-analysis of studies that enrolled patients with acute PE to assess the prognostic value of echocardiography-detectable RHT for the primary outcome of short-term all-cause mortality and the secondary outcome of short-term PE-related mortality. Unrestricted searches were conducted of PubMed and Embase from 1980 through January 31, 2016, and used the terms "right heart thrombi," "pulmonary embolism," and "prognos.*" A random effects model was used to pool study results; Begg rank correlation method was used to evaluate for publication bias; and I² testing was used to assess for heterogeneity.

RESULTS

Six of 79 potentially relevant studies met the inclusion criteria (15,220 patients). Overall, 99 of 593 patients with echocardiography-detectable RHT died (16.7% [95% CI, 13.8-19.9]) compared with 639 of 14,627 without RHT (4.4% [95% CI, 4.0-4.7]). RHT had a significant association with short-term all-cause mortality in all patients (OR, 3.0 [95% CI, 2.2 to 4.1]; I² = 20%) and with PE-related death (three cohorts, 12,955 patients; OR: 4.8 [95% CI, 2.0-11.3; I² = 76%). Results were consistent for the prospective (two cohorts, 514 patients; OR, 4.8 [95% CI, 1.7-13.6]; I² = 56%) and the retrospective (four cohorts, 14,706 patients; OR, 2.8 [95% CI, 2.1 to 3.8]; I² = 0%) studies.

CONCLUSIONS

In patients diagnosed with acute PE, concomitant RHT were significantly associated with an increased risk of death within 30 days of PE diagnosis.

TRIAL REGISTRY

PROSPERO registry; No.: CRD42016033960; URL: https://www.crd.york.ac.uk/prospero/.

The accuracy of combined use of troponin and red cell distribution width in predicting mortality of patients with acute pulmonary embolism

BACKGROUND

Cardiac troponins and red cell distribution width (RDW) are associated with increased mortality in acute pulmonary embolism (PE). In this study, we aimed to investigate the accuracy of the combined use of troponin and RDW in predicting short-term mortality in acute PE patients.

METHODS

The data of 201 patients with the diagnosis of acute PE were retrospectively analyzed. We obtained troponin-RDW scores (TR scores) using a combination of troponin and RDW values, and then evaluated this score's accuracy in predicting mortality in patients with acute PE.

RESULTS

The mean participant age was 68 ± 16 years, and 52 % of patients were female. Fifteen (7.4 %) patients died during the first month. Patients classified as high-risk according to TR scores were older (72 ± 15 vs. 66 ± 15 years, p = 0.005), and they had higher heart rates (101 ± 20 vs. 90 ± 15 beat/min, p < 0.001) and respiratory rates (23 ± 4 vs. 21 ± 3 breath/min, p = 0.001). In multivariate analysis, TR (odds ratio [OR] 4.93, 95 % confidence interval [CI] 1.13-21.38, p = 0.033) and simplified pulmonary embolism severity index (sPESI) scores (OR 3.78, 95 % CI 1.71-8.37, p = 0.002) were independent predictors of 30-day mortality. For 30-day mortality, the TR score had a slightly lower sensitivity (87 % vs. 93 %), but a higher specificity (69 % vs. 52 %) compared to the sPESI score.

CONCLUSION

The TR score is easy to calculate, and it may be used to predict early mortality in patients with acute PE.

Echocardiography does not predict mortality in hemodynamically stable elderly patients with acute pulmonary embolism

BACKGROUND

The evidence on the prognostic value of transthoracic echocardiography (TTE) in elderly, hemodynamically stable patients with Pulmonary Embolism (PE) is limited.

OBJECTIVES

To evaluate the prevalence of common echocardiographic signs of right ventricular (RV) dysfunction and their prognostic impact in hemodynamically stable patients aged ≥65years with acute PE in a prospective multicenter cohort.

METHODS

TTE was performed by cardiologists. We defined RV dysfunction as a RV/left ventricular ratio >0.9 or RV hypokinesis (primary definition) or the presence of ≥1 or ≥2 of 6 predefined echocardiographic signs (secondary definitions). Outcomes were overall mortality and mortality/non-fatal recurrent venous thromboembolism (VTE) at 30days, adjusting for the Pulmonary Embolism Severity Index risk score and highly sensitive troponin T values.

RESULTS

Of 400 patients, 36% had RV dysfunction based on our primary definition, and 81% (≥1 sign) and 53% (≥2 signs) based on our secondary definitions, respectively. Using our primary definition, there was no association between RV dysfunction and mortality (adjusted HR 0.90, 95% CI 0.31-2.58) and mortality/non-fatal VTE (adjusted HR 1.09, 95% CI 0.40-2.98). Similarly, there was no statistically significant association between the presence of ≥1 or ≥2 echocardiographic signs (secondary definitions) and clinical outcomes.

CONCLUSION

The prevalence of echocardiographic RV dysfunction varied widely depending upon the definition used. There was no association between RV dysfunction and clinical outcomes. Thus, TTE may not be suitable as a stand-alone risk assessment tool in elderly patients with acute PE.

CLINICAL TRIAL REGISTRATION

http://clinicaltrials.gov. Identifier: NCT00973596.

Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis

OBJECTIVE

To review the evidence for existing prognostic models in acute pulmonary embolism (PE) and determine how valid and useful they are for predicting patient outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

OVID MEDLINE and EMBASE, and The Cochrane Library from inception to July 2014, and sources of grey literature.

ELIGIBILITY CRITERIA

Studies aiming at constructing, validating, updating or studying the impact of prognostic models to predict all-cause death, PE-related death or venous thromboembolic events up to a 3-month follow-up in patients with an acute symptomatic PE.

DATA EXTRACTION

Study characteristics and study quality using prognostic criteria. Studies were selected and data extracted by 2 reviewers.

DATA ANALYSIS

Summary estimates (95% CI) for proportion of risk groups and event rates within risk groups, and accuracy.

RESULTS

We included 71 studies (44,298 patients). Among them, 17 were model construction studies specific to PE prognosis. The most validated models were the PE Severity Index (PESI) and its simplified version (sPESI). The overall 30-day mortality rate was 2.3% (1.7% to 2.9%) in the low-risk group and 11.4% (9.9% to 13.1%) in the high-risk group for PESI (9 studies), and 1.5% (0.9% to 2.5%) in the low-risk group and 10.7% (8.8% to12.9%) in the high-risk group for sPESI (11 studies). PESI has proved clinically useful in an impact study. Shifting the cut-off or using novel and updated models specifically developed for normotensive PE improves the ability for identifying patients at lower risk for early death or adverse outcome (0.5-1%) and those at higher risk (up to 20-29% of event rate).

CONCLUSIONS

We provide evidence-based information about the validity and utility of the existing prognostic models in acute PE that may be helpful for identifying patients at low risk. Novel models seem attractive for the high-risk normotensive PE but need to be externally validated then be assessed in impact studies.

Impact of relative contraindications to home management in emergency department patients with low-risk pulmonary embolism

RATIONALE

Studies of adults presenting to the emergency department (ED) with acute pulmonary embolism (PE) suggest that those who are low risk on the PE Severity Index (classes I and II) can be managed safely without hospitalization. However, the impact of relative contraindications to home management on outcomes has not been described.

OBJECTIVES

To compare 5-day and 30-day adverse event rates among low-risk ED patients with acute PE without and with outpatient ineligibility criteria.

METHODS

We conducted a retrospective multicenter cohort study of adults presenting to the ED with acute low-risk PE between 2010 and 2012. We evaluated the association between outpatient treatment eligibility criteria based on a comprehensive list of relative contraindications and 5-day adverse events and 30-day outcomes, including major hemorrhage, recurrent venous thromboembolism, and all-cause mortality.

MEASUREMENTS AND MAIN RESULTS

Of 423 adults with acute low-risk PE, 271 (64.1%) had no relative contraindications to outpatient treatment (outpatient eligible), whereas 152 (35.9%) had at least one contraindication (outpatient ineligible). Relative contraindications were categorized as PE-related factors (n = 112; 26.5%), comorbid illness (n = 42; 9.9%), and psychosocial barriers (n = 19; 4.5%). There were no 5-day events in the outpatient-eligible group (95% upper confidence limit, 1.7%) and two events (1.3%; 95% confidence interval [CI], 0.1-5.0%) in the outpatient-ineligible group (P = 0.13). At 30 days, there were five events (two recurrent venous thromboemboli and three major bleeding events) in the outpatient-eligible group (1.8%; 95% CI, 0.7-4.4%) compared with nine in the ineligible group (5.9%; 95% CI, 2.7-10.9%; P < 0.05). This difference remained significant when controlling for PE severity class.

CONCLUSIONS

Nearly two-thirds of adults presenting to the ED with low-risk PE were potentially eligible for outpatient therapy. Relative contraindications to outpatient management were associated with an increased frequency of adverse events at 30 days among adults with low-risk PE.

Risk stratification of patients with acute symptomatic pulmonary embolism

Patients with acute symptomatic pulmonary embolism (PE) who present with arterial hypotension or shock have a high risk of death (high-risk PE), and treatment guidelines recommend strong consideration of thrombolysis in this setting. For normotensive patients diagnosed with PE, risk stratification should aim to differentiate the group of patients deemed as having a low risk for early complications (all-cause mortality, recurrent venous thromboembolism, and major bleeding) (low-risk PE) from the group of patients at higher risk for PE-related complications (intermediate-high risk PE), so low-risk patients could undergo consideration of early outpatient treatment of PE and intermediate-high risk patients would undergo close observation and consideration of thrombolysis. Clinicians should also use risk stratification and eligibility criteria to identify a third group of patients that should not undergo escalated or home therapy (intermediate-low risk PE). Such patients should initiate standard therapy of PE while in the hospital. Clinical models [e.g., Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI)] may accurately identify those at low risk of dying shortly after the diagnosis of PE. For identification of intermediate-high risk patients with acute PE, studies have validated predictive models that use a combination of clinical, laboratory and imaging variables.

Comparison of risk assessment strategies for not-high-risk pulmonary embolism

We compared the prognostic performance of the 2014 European Society of Cardiology (ESC) risk stratification algorithm with the previous 2008 ESC algorithm, the Bova score and the modified FAST score (based on a positive heart-type fatty acid-binding protein (H-FABP) test, syncope and tachycardia, modified using high-sensitivity troponin T instead of H-FABP) in 388 normotensive pulmonary embolism patients included in a single-centre cohort study.Overall, 25 patients (6.4%) had an adverse 30-day outcome. Regardless of the score or algorithm used, the rate of an adverse outcome was highest in the intermediate-high-risk classes, while all patients classified as low-risk had a favourable outcome (no pulmonary embolism-related deaths, 0-1.4% adverse outcome). The area under the curve for predicting an adverse outcome was higher for the 2014 ESC algorithm (0.76, 95% CI 0.68-0.84) compared with the 2008 ESC algorithm (0.65, 95% CI 0.56-0.73) and highest for the modified FAST score (0.82, 95% CI 0.75-0.89). Patients classified as intermediate-high-risk by the 2014 ESC algorithm had a 8.9-fold increased risk for an adverse outcome (3.2-24.2, p<0.001 compared with intermediate-low- and low-risk patients), while the highest OR was observed for a modified FAST score ≥3 points (OR 15.9, 95% CI 5.3-47.6, p<0.001).The 2014 ESC algorithm improves risk stratification of not-high-risk pulmonary embolism compared with the 2008 ESC algorithm. All scores and algorithms accurately identified low-risk patients, while the modified FAST score appears more suitable to identify intermediate-high-risk patients.