Brain-type natriuretic peptide levels in the prediction of adverse outcome in patients with pulmonary embolism: a systematic review and meta-analysis

Age-adjusted cut-off values of natriuretic peptides for right ventricular dysfunction in acute pulmonary embolism: Post-hoc analysis from CURES

BACKGROUND

Cut-off values of natriuretic peptides [NPs, including B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP)] for right ventricular dysfunction (RVD) in acute pulmonary embolism (PE) are not standardized.

METHODS

Patients with acute PE enrolled between 2016 and 2021 were selected from a large prospective nationwide cohort in China. Patients with available values of NPs were included. RVD was confirmed by echocardiography or computed tomography pulmonary angiography. We used receiver operating characteristic curves to determine optimal cut-off values. Kaplan-Meier curves and log-rank test were performed to show the association between NPs and 30-day all-cause mortality, stratified by these thresholds.

RESULTS

A total of 4105 patients (median age, 65 years; 50.5 % male) were enrolled, with 743 (18.1 %) developing RVD. The optimal NT-proBNP threshold for RVD was identified as 641 pg/ml, yielding an area under the curve (AUC) of 0.713 (95 % CI 0.686-0.740). For individuals aged <55, 55-69, and ≥ 70 years, the cut-off values were 356 pg/ml, 526 pg/ml, and 647 pg/ml, with AUCs of 0.750, 0.712, and 0.689, respectively. The optimal cut-off value of BNP was 194 pg/ml, with an AUC of 0.679 (95 % CI 0.647-0.712). Age-adjusted thresholds were 83 pg/ml, 146 pg/ml, and 200 pg/ml, with AUCs of 0.705, 0.699, and 0.646, respectively. All thresholds demonstrated negative predictive value approximately 0.9 (range: 0.884-0.916). Elevated NPs based on thresholds for the rounded tens were associated with an increased risk of death within 30 days.

CONCLUSIONS

Age-adjusted NP thresholds offer improved RVD detection. Physicians should emphasize the importance of NPs in acute PE.

Clinical characteristics and prognosis of patients with central pulmonary embolism

BACKGROUND

The impact of central localization of pulmonary embolism (PE) on clinical outcomes is uncertain.

OBJECTIVES

To compare clinical presentation, risk factors, and outcomes between patients with central pulmonary embolism (cPE) and non-cPE.

METHODS

We retrospectively analyzed 597 patients with acute PE from the prospective SWITCO65+ cohort between September 2009 and December, 2013. cPE was defined as an embolus in the pulmonary trunk or the left or right pulmonary artery. We compared baseline clinical characteristics and outcomes at 3 months (recurrent venous thromboembolism [VTE], overall/PE-related mortality, PE-related quality of life) and over the entire follow-up (recurrent VTE, overall/PE-related mortality) between patients with cPE vs non-cPE. We examined the association between PE localization and recurrent VTE and overall mortality, adjusting for multiple confounders including thrombolysis, periods of anticoagulation, and competing risk of non-VTE-related death if appropriate.

RESULTS

Overall, 217 (36.3%) patients had cPE. Symptoms/signs of respiratory distress, right ventricular dysfunction, and myocardial injury were more prevalent in those with cPE. VTE recurrence, overall/PE-related mortality, and PE-related quality of life at 3 months did not vary by PE localization. After a median follow-up of 29.6 months, patients with cPE had a higher risk of fatal PE (5.5% vs 2.1%; P = .033). After adjustment, cPE was associated with recurrent VTE (subhazard ratio, 2.22; 95% CI, 1.25-3.91) but not with overall mortality (hazard ratio, 0.74; 95% CI, 0.45-1.21) during follow-up.

CONCLUSION

cPE was associated with a 2.2-fold increased risk of recurrent VTE compared to non-cPE. Whether an extended anticoagulation duration could reduce the recurrence risk following cPE should be further examined.

Hemostatic and Inflammatory Biomarkers are Associated with Functional Limitations after Venous Thromboembolism: A Prospective Cohort Study

Functional limitations often persist in patients with venous thromboembolism (VTE). The relevance of biomarkers for these outcomes remains unexplored. Therefore, we aimed to investigate the association of hemostatic, inflammatory, and cardiovascular biomarkers with functional limitations 3 months after VTE. We conducted a prospective cohort study, including patients with acute VTE within 21 days of diagnosis. Biomarker levels (D-dimer, fibrinogen, factor VIII [FVIII], von Willebrand factor antigen [VWF], C-reactive protein [CRP], troponin T, N-terminal pro-B-type natriuretic peptide [proBNP]) were measured at inclusion and 3 months. Functional limitations at 3 months were evaluated with the post-VTE functional status (PVFS) scale (0-4, higher indicating more limitations). The association of biomarkers with functional limitations was assessed with proportional odds models adjusted for confounders. Furthermore, we evaluated the area under the receiver operating characteristic curve (AUC-ROC) for the presence of slight-to-severe functional limitations. Overall, we included 290 patients (41.4% of women) with a median age of 54.9 years (interquartile range [IQR]: 43.1-64.2). D-dimer, fibrinogen, FVIII, VWF, and CRP measured at inclusion were independently associated with functional limitations at 3 months. VWF showed the most favorable AUC-ROC (0.62, 95% CI, 0.55-0.69). In patients with pulmonary embolism, troponin T and proBNP were not associated with functional limitations. At the 3-month follow-up, D-dimer was the only biomarker independently associated with functional limitations, yielding an area under the curve (AUC) of 0.62 (95% CI, 0.55-0.69). In conclusion, we identified biomarkers independently associated with functional limitations 3 months after VTE. Our results indicate a role of these biomarkers in the early identification of patients at risk of persistent functional limitations and suggest their involvement in the underlying mechanisms.

Effective management of pulmonary embolism after initial diagnosis of acute coronary syndrome: a case report highlighting differential diagnosis challenges

Pulmonary embolism (PE) often presents with symptoms similar to acute coronary syndrome (ACS), making diagnosis challenging. We report a case of a 55-year-old male with hypertension, chronic kidney disease, and hyperuricemia who developed chest pain and shortness of breath. Initial evaluation suggested ACS due to electrocardiogram changes and elevated cardiac biomarkers. However, coronary angiography (CAG) showed no significant stenosis, prompting further diagnostic workup. Computed tomography pulmonary angiography (CTPA) confirmed PE, likely secondary to deep vein thrombosis (DVT) in the right lower extremity. The patient was treated with an inferior vena cava (IVC) filter and thrombus aspiration, followed by anticoagulation therapy. This case highlights the critical need to differentiate PE from ACS and emphasizes the importance of a multidisciplinary approach in managing thromboembolic events to ensure optimal patient outcomes.

Perfusion index: could it be a new tool for early identification of pulmonary embolism severity?

Perfusion index (PI) is a promising indicator for monitoring peripheral perfusion. The present study aimed to compare the efficiency of PI and PESI score in estimating the 30-day mortality and treatment needs of patients diagnosed with pulmonary embolism in the emergency department. This study was prospective and observational. The demographic features of the patients, comorbidities, vital signs, PESI score, PI, treatment applied to the patient and airway management, right ventricular diameter/left ventricular diameter ratio, length of hospital stay, outcome, and 30-day mortality were recorded. A total of 94 patients were included. All patients' vital signs and PI values were recorded on admission. The mean pulse rate (p = 0.001) and shock index (p = 0.017) values of deceased patients were statistically significantly higher, while the mean PI (p = 0.034) was statistically significantly lower. PESI score and PI were statistically significant to predict the need for mechanical ventilation (PI, p = 0.004; PESI score, p < 0.001), inotropic treatment (PI, p = 0.047; PESI score p = 0.005), and thrombolytic therapy (PI, p = 0.035; PESI score p = 0.003). According to the ROC curve, the mortality prediction power of both PESI (AUC: 0.787, 95% CI 0.688-0.886, cutoff: 109.5, p < 0.001) and PI index (AUC: 0.668, 95% CI 0.543-0.793, cutoff: 1, p = 0.011) were determined as statistically significant. PI might be helpful in clinical practice as a tool that can be applied to predict mortality and treatment needs in PE.

Predictive value and optimal cut-off level of high-sensitivity troponin T in patients with acute pulmonary embolism

BACKGROUND/AIMS

Elevated troponin levels predict in-hospital mortality and influence decisions regarding thrombolytic therapy in patients with acute pulmonary embolism (PE). However, the usefulness of high-sensitivity troponin T (hsTnT) regarding PE remains uncertain. We aimed to establish the optimal cut-off level and compare its performance for precise risk stratification.

METHODS

374 patients diagnosed with acute PE were reviewed. PE-related adverse outcomes, a composite of PE-related deaths, cardiopulmonary resuscitation incidents, systolic blood pressure < 90 mmHg, and all-cause mortality within 30 days were evaluated. The optimal hsTnT cut-off for all-cause mortality, and the net reclassification index (NRI) was used to assess the incremental value in risk stratification.

RESULTS

Among 343 normotensive patients, 17 (5.0%) experienced all-cause mortality, while 40 (10.7%) had PE-related adverse outcomes. An optimal hsTnT cut-off value of 60 ng/L for all-cause mortality (AUC 0.74, 95% CI 0.61-0.85, p < 0.001) was identified, which was significantly associated with PE-related adverse outcomes (OR 4.07, 95% CI 2.06-8.06, p < 0.001). Patients with hsTnT ≥ 60 ng/L were older, hypotensive, had higher creatinine levels, and right ventricular dysfunction signs. Combining hsTnT ≥ 60 ng/L with simplified pulmonary embolism severity index ≥1 provided additional prognostic information. Reclassification analysis showed a significant shift in risk categories, with an NRI of 1.016 ± 0.201 (p < 0.001).

CONCLUSION

We refined troponin's predictive value in patients with acute PE, proposing a new cut-off value of hsTnT ≥ 60 ng/L. Validation through large-scale studies is essential to offer clinically useful guidance for managing patient population.

A Practical Clinical Approach to Navigate Pulmonary Embolism Management: A Primer and Narrative Review of the Evolving Landscape

Advances in imaging, pharmacological, and procedural technologies have rapidly expanded the care of pulmonary embolism. Earlier, more accurate identification and quantification has enhanced risk stratification across the spectrum of the disease process, with a number of clinical tools available to prognosticate outcomes and guide treatment. Direct oral anticoagulants have enabled a consistent and more convenient long-term therapeutic option, with a greater shift toward outpatient treatment for a select group of low-risk patients. The array of catheter-directed therapies now available has contributed to a more versatile and nuanced armamentarium of treatment options, including ultrasound-facilitated thrombolysis and mechanical thrombectomy. Research into supportive care for pulmonary embolism have explored the optimal use of vasopressors and volume resuscitation, as well as utilization of various devices, including right ventricular mechanical support and extracorporeal membrane oxygenation. Even in the realm of surgery, outcomes have steadily improved in experienced centers. This rapid expansion in diagnostic and therapeutic data has necessitated implementation of pulmonary embolism response teams to better interpret the available evidence, manage the utilization of advanced therapies, and coordinate multidisciplinary care. We provide a narrative review of the risk stratification and management of pulmonary embolism, with a focus on structuralizing the multidisciplinary approach and organizing the literature on new and emerging therapies.

Acute Pulmonary Embolism: Evidence, Innovation, and Horizons

PURPOSE OF REVIEW

Pulmonary embolism (PE) is the third most common cause of cardiovascular morbidity and mortality. The goal of this review is to discuss the most up-to-date literature on epidemiology, diagnosis, risk stratification, and management of acute PE.

RECENT FINDINGS

Despite an increase in annual incidence rate of PE in the United States and development of multiple advanced therapies for treatment of acute PE, PE-related mortality is not consistently decreasing across populations. Although multiple risk stratification schemes have been developed, it is still unclear which advanced therapy should be used for the individual patient and optimal timing. Fortunately, multiple randomized clinical trials are underway to answer these questions. Nevertheless, up to 50% of patients have persistent reduced quality of life 6 months after acute PE, termed post-PE syndrome. Despite advances in therapeutic options for management of acute PE, many questions remain unanswered, including optimal risk stratification and management of acute PE.

Impact of Natriuretic Peptide on the Evolution of Patients With Pulmonary Embolism and Neoplasm

This retrospective study investigated the prognostic value of N-terminal pro-brain natriuretic peptide (NT-proBNP) in 106 patients with pulmonary embolism (PE) and associated oncological pathology. The study aimed to evaluate the predictive accuracy of NT-proBNP for both the prognosis and complication risk, such as early mortality (≤ 30 days), late mortality (≥ 30 days), and PE recurrence, in relation to the neoplasm's location and stage. Additionally, it explored the relationship between NT-proBNP, hemodynamic status (stable/unstable), and the location of PE in the pulmonary arteries (main, lobar, segmental) for prognostic and complication risk assessment. The results showed that cancer patients with NT-proBNP levels above 600 ng/L had a significantly higher risk of acute PE recurrence compared to those with lower levels, especially in cases involving the main pulmonary arteries. Hemodynamic instability further elevated the risk of PE recurrence and death, underscoring the importance of NT-proBNP as a prognostic marker for this population. Patients with unstable hemodynamic status were more likely to have elevated NT-proBNP levels, and this was associated with a markedly increased risk of early as well as late demise. Furthermore, patients with multiple tumor locations demonstrated a heightened risk of mortality when NT-proBNP levels were elevated. These findings highlight the potential of NT-proBNP as a valuable tool for risk stratification and patient management in individuals with PE and associated oncological pathology.

Pulmonary Embolism in Critically Ill Patients-Prevention, Diagnosis, and Management

Critically ill patients in the intensive care unit (ICU) are often immobilized and on mechanical ventilation, placing them at increased risk for thromboembolic diseases, particularly deep vein thrombosis (DVT) and, to a lesser extent, pulmonary embolism (PE). While these conditions are frequently encountered in the emergency department, managing them in the ICU presents unique challenges. Although existing guidelines are comprehensive and effective, they are primarily designed for patients presenting with PE in the emergency department and do not fully address the complexities of managing critically ill patients in the ICU. This review aims to summarize the available data on these challenging cases, offering a practical approach to the prevention, diagnosis, and treatment of PE, particularly when it is acquired in the ICU.

The prognostic significance of pro-BNP and heart failure in acute pulmonary embolism: A systematic review

Pulmonary embolism (PE) is the third most common type of cardiovascular disease and carries a high mortality rate of 30% if left untreated. Although it is commonly known that individuals who suffer heart failure (HF) are more likely to experience a pulmonary embolism, little is known concerning the prognostic relationship between acute PE and HF. This study aims to evaluate the prognostic usefulness of heart failure and pro-BNP in pulmonary embolism cases. A scientific literature search, including PubMed, Medline, and Cochrane reviews, was used to assess and evaluate the most pertinent research that has been published. The findings showed that increased N-terminal brain natriuretic peptide (NT-proBNP) levels could potentially identify pulmonary embolism patients with worse immediate prognoses and were highly predictive of all-cause death. Important prognostic information can be obtained from NT-proBNP and Heart-type Fatty Acid Binding Proteins (H-FABP) when examining individuals with PE. The heart, distal tubular cells of the renal system, and skeletal muscle are where H-FABP is primarily found, with myocardial cells having the highest concentration. Recent studies have indicated that these biomarkers may also help assess the severity of PE and its long-term risk.

Life expectancy in cancer patients with pulmonary thromboembolism: From clinical prognostic biomarkers and paraclinical investigations to therapeutic approaches (Review)

Pulmonary embolisms (PEs) are obstructions of the pulmonary arteries by thrombi, which are emboli and they most frequently originate from the deep venous system of the inferior limbs. Emboli can also come from the inferior vena cava, abdominal and pelvic veins, or the upper body venous system from the right atrium or ventricle of the heart. Thrombi can form in situ inside pulmonary arteries as well. A cancer patient is at a higher risk for thromboembolic phenomena given both the oncological pathological context and also due to the associated medical or surgical treatment they receive. PE is a high-risk medical emergency that is associated with an increased risk of early mortality, with sudden death occurring in 25% of patients. The long-term presence of this condition can result in thromboembolic pulmonary hypertension. The risk of mortality, both in the acute and long-term, is dependent on the severity of the acute form, the recurrence of the embolism and the associated conditions. The majority of deaths associated with PE can be prevented by early diagnosis. The aim of the present review was to describe the various biological and cellular parameters, together with known paraclinical investigations, to assist in the rapid diagnosis of PE. Mortality in patients with PE and neoplastic conditions may be reduced by initiating anticoagulant treatment as soon as possible. PE may be the first manifestation of an underlying silent malignancy or may represent a complication of an already diagnosed malignancy. Exclusion or confirmation of the diagnosis is of utmost importance to avoid unnecessary anticoagulant treatment associated with a high risk of bleeding or to start immediate anticoagulant treatment if required.

Perioperative Management and Outcomes after Endovascular Mechanical Thrombectomy in Patients with Submassive (Intermediate-Risk) Pulmonary Embolism: A Retrospective Observational Cohort Study

Pulmonary embolism (PE) embodies a large healthcare burden globally and is the third leading cause of morbidity and mortality worldwide. Submassive (intermediate-risk) PE accounts for 40% of this burden. However, the optimal treatment pathway for this population remains complex and ill-defined. Catheter-directed interventions (CDIs) have shown promise in directly impacting morbidity and mortality while demonstrating a favorable success rate, safety profile, and decreased length of stay (LOS) in the intensive care unit and hospital. This retrospective review included 22 patients (50% female) with submassive PE who underwent mechanical thrombectomy (MT). A total of 45% had a contraindication to thrombolytics, the mean pulmonary embolism severity index was 127, 36% had saddle PE, the average decrease in mean pulmonary artery pressure (PAP) was 7.2 mmHg following MT, the average LOS was 6.9 days, the 30-day mortality rate was 9%, the major adverse event (MAE) rate was 9%, and the readmission rate was 13.6%. A total of 82% had successful removal of thrombus during MT with no major bleeding complications, intracranial hemorrhage events, or device-related deaths. Acknowledging the limitation of our small sample size, our data indicate that MT in the intermediate-high-risk submassive pulmonary embolism (PE) cohort resulted in a decreased hospital length of stay (LOS) and in-hospital mortality compared to standard anticoagulation therapy alone.

Safety of treating acute pulmonary embolism at home: an individual patient data meta-analysis

BACKGROUND AND AIMS

Home treatment is considered safe in acute pulmonary embolism (PE) patients selected by a validated triage tool (e.g. simplified PE severity index score or Hestia rule), but there is uncertainty regarding the applicability in underrepresented subgroups. The aim was to evaluate the safety of home treatment by performing an individual patient-level data meta-analysis.

METHODS

Ten prospective cohort studies or randomized controlled trials were identified in a systematic search, totalling 2694 PE patients treated at home (discharged within 24 h) and identified by a predefined triage tool. The 14- and 30-day incidences of all-cause mortality and adverse events (combined endpoint of recurrent venous thromboembolism, major bleeding, and/or all-cause mortality) were evaluated. The relative risk (RR) for 14- and 30-day mortalities and adverse events is calculated in subgroups using a random effects model.

RESULTS

The 14- and 30-day mortalities were 0.11% [95% confidence interval (CI) 0.0-0.24, I2 = 0) and 0.30% (95% CI 0.09-0.51, I2 = 0). The 14- and 30-day incidences of adverse events were 0.56% (95% CI 0.28-0.84, I2 = 0) and 1.2% (95% CI 0.79-1.6, I2 = 0). Cancer was associated with increased 30-day mortality [RR 4.9; 95% prediction interval (PI) 2.7-9.1; I2 = 0]. Pre-existing cardiopulmonary disease, abnormal troponin, and abnormal (N-terminal pro-)B-type natriuretic peptide [(NT-pro)BNP] at presentation were associated with an increased incidence of 14-day adverse events [RR 3.5 (95% PI 1.5-7.9, I2 = 0), 2.5 (95% PI 1.3-4.9, I2 = 0), and 3.9 (95% PI 1.6-9.8, I2 = 0), respectively], but not mortality. At 30 days, cancer, abnormal troponin, and abnormal (NT-pro)BNP were associated with an increased incidence of adverse events [RR 2.7 (95% PI 1.4-5.2, I2 = 0), 2.9 (95% PI 1.5-5.7, I2 = 0), and 3.3 (95% PI 1.6-7.1, I2 = 0), respectively].

CONCLUSIONS

The incidence of adverse events in home-treated PE patients, selected by a validated triage tool, was very low. Patients with cancer had a three- to five-fold higher incidence of adverse events and death. Patients with increased troponin or (NT-pro)BNP had a three-fold higher risk of adverse events, driven by recurrent venous thromboembolism and bleeding.

The significance of B-type natriuretic peptide in predicting early mortality among pulmonary embolism patients, alongside troponin: insights from a multicentric registry

BACKGROUND

Early mortality assessment in acute pulmonary embolism (PE) is crucial for treatment decisions. The role of natriuretic peptides in this context is debated. This study explores elevated B-type natriuretic peptide (BNP) levels, relative to the upper normal limit (UNL), predicting mortality in PE, comparing with troponin (Tn).

METHODOLOGY

A multicenter PE registry analyzed predictive values for early mortality risk using BNP and Tn, based on proportional elevation to the UNL. Patients followed current PE guidelines.

RESULTS

Among 1677 PE patients, BNP's AUC exceeded Tn for all-cause (0.727 vs. 0.614) and PE-related mortality (0.785 vs. 0.644), though nonsignificant. BNP's cutoff was 3.5 times UNL for both all-cause and PE-related mortalities; Tn cutoffs were 1.38 and 1.23 times UNL, respectively.

CONCLUSION

Elevated BNP relative to UNL significantly predicts all-cause and PE-related mortality. While akin to Tn, BNP merits consideration in assessing acute PE risk, especially in intermediate-high-risk cases.

In-Hospital versus Out-of-Hospital Pulmonary Embolism: Clinical Characteristics, Biochemical Markers and Echocardiographic Indices

BACKGROUND

A significant proportion of pulmonary embolisms (PEs) occurs in patients during hospitalisation for another reason. However, limited data regarding differences between out-of-hospital PE (OHPE) and in-hospital PE (IHPE) is available. We aimed to compare these groups regarding their clinical characteristics, biochemical markers, and echocardiographic indices.

METHODS

This was a prospective, single-arm, single-centre study. Adult consecutive patients with non-COVID-related PE from September 2019 to March 2022 were included and followed up for 12 months.

RESULTS

The study included 180 (84 women) patients, with 89 (49.4%) suffering from IHPE. IHPE patients were older, they more often had cancer, were diagnosed earlier after the onset of symptoms, they had less frequent pain and higher values of high sensitivity troponin I and brain natriuretic peptide levels compared to OHPE patients. Echocardiographic right ventricular (RV) dysfunction was detected in similar proportions in the 2 groups. IHPE had increased in-hospital mortality (14.6% vs. 3.3%, p = 0.008) and similar post-discharge to 12-month mortality with OHPE patients.

CONCLUSIONS

In this prospective cohort study, IHPE differed from OHPE patients regarding age, comorbidities, symptoms, and levels of biomarkers associated with RV dysfunction. IHPE patients had higher in-hospital mortality compared to OHPE patients and a similar risk of death after discharge.

Integrating Cardiac Biomarkers and Electrocardiogram in Pulmonary Embolism Prognosis

Pulmonary embolism (PE) represents a significant clinical challenge that substantially impacts healthcare systems. This case report focuses on the nuances of risk stratification in PE, highlighted through the presentation of a 64-year-old female patient. The uniqueness of this case lies in the patient's atypical presentation, where decreased exercise tolerance was the sole symptom leading to the diagnosis of PE. The patient was found to have new-onset atrial fibrillation, elevated levels of N-terminal pro-brain natriuretic peptide (NT-proBNP), and signs of right ventricular strain on imaging. This scenario underscores the necessity for a comprehensive assessment in PE cases, particularly when classic symptoms (e.g., tachycardia, shortness of breath, chest pain) are absent. We explore the incidence of PE in patients diagnosed with deep vein thrombosis, examining the critical role of cardiac biomarkers, including B-type natriuretic peptide, NT-proBNP, and troponins, in prognostication and their potential use in risk assessment tools for PE patients. Additionally, the significance of electrocardiogram evaluation in these patients and its role in risk stratification is thoroughly assessed.

Risk Stratification and Management of Intermediate-Risk Acute Pulmonary Embolism

Pulmonary embolism (PE) is the third most common cause of cardiovascular death and necessitates prompt, accurate risk assessment at initial diagnosis to guide treatment and reduce associated mortality. Intermediate-risk PE, defined as the presence of right ventricular (RV) dysfunction in the absence of hemodynamic compromise, carries a significant risk for adverse clinical outcomes and represents a unique diagnostic challenge. While small clinical trials have evaluated advanced treatment strategies beyond standard anticoagulation, such as thrombolytic or endovascular therapy, there remains continued debate on the optimal care for this patient population. Here, we review the most recent risk stratification models, highlighting differences between prediction scores and their limitations, and discuss the utility of serologic biomarkers and imaging modalities to detect right ventricular dysfunction. Additionally, we examine current treatment recommendations including anticoagulation strategies, use of thrombolytics at full and reduced doses, and utilization of invasive treatment options. Current knowledge gaps and ongoing studies are highlighted.

Charlson and Elixhauser Comorbidity Indices for Prediction of Mortality and Hospital Readmission in Patients With Acute Pulmonary Embolism

Several risk stratification systems aid clinicians in classifying pulmonary embolism (PE) severity and prognosis. We compared 2 clinical PE scoring systems, the PESI and sPESI scores, with 2 comorbidity indices, the Charlson Comorbidity Index (CCI) and the val Walraven Elixhauser Comorbidity Index (ECI), to determine the utility of each in predicting mortality and hospital readmission. Information was collected from 436 patients presenting with PE via retrospective chart review. The PESI, sPESI, CCI, and ECI scores were calculated for each patient. Multivariate analysis was used to determine each system's ability to predict in-hospital mortality, 90-day mortality, overall mortality, and all-cause hospital readmission. The impact of various demographic and clinical characteristics of each patient on these outcomes was also assessed. The PESI score was found to be an independent predictor of in-hospital mortality and 90-day mortality. The PESI score and the CCI were able to independently predict overall mortality. None of the 4 risk scores independently predicted hospital readmission. Other factors including hypoalbuminemia, serum BNP, coagulopathy, anemia, and diabetes were associated with increased mortality and readmission at various endpoints. The PESI score was the best tool for predicting mortality at any endpoint. The CCI may have utility in predicting long-term outcomes. Further work is needed to better determine the roles of the CCI and ECI in predicting patient outcomes in PE. The potential prognostic implications of low serum albumin and anemia at the time of PE also warrant further investigation.

What is the real incidence of right ventricular affection in patients with acute pulmonary embolism?

BACKGROUND

Echocardiographic markers of right ventricular dysfunction or pressure overload (RVd/PO) have been used in risk assessment of patients with acute pulmonary embolism (APE). Nevertheless, the role of echocardiography in these patients is incompletely determined. We evaluated the right ventricular function using 'non-conventional' markers of RVd/PO in patients with APE.

METHODS

This was a prospective, single-arm, single-centre study. Consecutive adult patients hospitalised for APE were included. The RV free wall longitudinal strain (RV-FWLS), the fractional area change (FAC), the ratio tricuspid annular plane systolic excursion (TAPSE)/pulmonary arterial systolic pressure (PASP), and the pulmonary vascular resistance (PVR) were evaluated.

RESULTS

One hundred patients (mean age 70.0 ± 13.9 years, female 48%) were screened and 73 had adequate RV-FWLS images. The most common abnormal echocardiographic marker was RV-FWLS (44/73; p < 0.001, for all other echocardiographic indices). Thirty-one patients had either PASP ≥ 36 mmHg or PVR > 2 WU (49.2% of the patients with both indices available). There were significant correlations between RV-FWLS, TAPSE/PASP and PVR with both D-Dimers and B-type natriuretic peptide (BNP), and between FAC and BNP. RF-FWLS differed significantly between patients with a simplified pulmonary embolism severity index (sPESI) score 0 and those with a score ≥1 (p < 0.001).

CONCLUSIONS

RVd/PO coexists with APE in a large proportion of patients. RV-FWLS is the most abnormal echocardiographic sign and is related to clinical and biochemical prognostic indices.

Medical Emergencies in Pulmonary Hypertension

The management of acute medical emergencies in patients with pulmonary hypertension (PH) can be challenging. Patients with preexisting PH can rapidly deteriorate due to right ventricular decompensation when faced with acute physiological challenges that would usually be considered low-risk scenarios. This review considers the assessment and management of acute medical emergencies in patients with PH, encompassing both pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH), acknowledging these comprise the more severe groups of PH. Management protocols are described in a systems-based approach. Respiratory emergencies include pulmonary embolism, airways disease, and pneumonia; cardiac emergencies including arrhythmia and chest pain with acute myocardial infarction are discussed, alongside PH-specific emergencies such as pulmonary artery dissection and extrinsic coronary artery compression by a dilated proximal pulmonary artery. Other emergencies including sepsis, severe gastroenteritis with dehydration, syncope, and liver failure are also considered. We propose management recommendations for medical emergencies based on available evidence, international guidelines, and expert consensus. We aim to provide advice to the specialist alongside the generalist, and emergency doctors, nurses, and acute physicians in nonspecialist centers. A multidisciplinary team approach is essential in the management of patients with PH, and communication with local and specialist PH centers is paramount. Close hemodynamic monitoring during medical emergencies in patients with preexisting PH is vital, with early referral to critical care recommended given the frequent deterioration and high mortality in this setting.

Recovery of right ventricular function after intermediate-risk pulmonary embolism: results from the multicentre Pulmonary Embolism International Trial (PEITHO)-2

BACKGROUND

Right ventricular (RV) function plays a critical role in the pathophysiology and acute prognosis of pulmonary embolism (PE). We analyzed the temporal changes of RV function in the cohort of a prospective multicentre study investigating if an early switch to oral anticoagulation in patients with intermediate-risk PE is effective and safe.

METHODS

Echocardiographic and laboratory examinations were performed at baseline (PE diagnosis), 6 days and 6 months. Echocardiographic parameters were classified into categories representing RV size, RV free wall/tricuspid annulus motion, RV pressure overload and right atrial (RA)/central venous pressure.

RESULTS

RV dysfunction based on any abnormal echocardiographic parameter was present in 84% of patients at baseline. RV dilatation was the most frequently abnormal finding (40.6%), followed by increased RA/central venous pressure (34.6%), RV pressure overload (32.1%), and reduced RV free wall/tricuspid annulus motion (20.9%). As early as day 6, RV size remained normal or improved in 260 patients (64.7%), RV free wall/tricuspid annulus motion in 301 (74.9%), RV pressure overload in 297 (73.9%), and RA/central venous pressure in 254 (63.2%). At day 180, the frequencies slightly increased. The median NT-proBNP level decreased from 1448 pg/ml at baseline to 256.5 on day 6 and 127 on day 180.

CONCLUSION

In the majority of patients with acute intermediate-risk PE switched early to a direct oral anticoagulant, echocardiographic parameters of RV function normalised within 6 days and remained normal throughout the first 6 months. Almost one in four patients, however, continued to have evidence of RV dysfunction over the long term.

Interventional therapies for pulmonary embolism

Pulmonary embolism (PE) is the leading cause of in-hospital death and the third most frequent cause of cardiovascular death. The clinical presentation of PE is variable, and choosing the appropriate treatment for individual patients can be challenging. Traditionally, treatment of PE has involved a choice of anticoagulation, thrombolysis or surgery; however, a range of percutaneous interventional technologies have been developed that are under investigation in patients with intermediate-high-risk or high-risk PE. These interventional technologies include catheter-directed thrombolysis (with or without ultrasound assistance), aspiration thrombectomy and combinations of the aforementioned principles. These interventional treatment options might lead to a more rapid improvement in right ventricular function and pulmonary and/or systemic haemodynamics in particular patients. However, evidence from randomized controlled trials on the safety and efficacy of these interventions compared with conservative therapies is lacking. In this Review, we discuss the underlying pathophysiology of PE, provide assistance with decision-making on patient selection and critically appraise the available clinical evidence on interventional, catheter-based approaches for PE treatment. Finally, we discuss future perspectives and unmet needs.

Clinical features and risk factors of adverse clinical outcomes in central pulmonary embolism using machine learning analysis

BACKGROUND

In prior studies, central pulmonary embolism (PE) was associated with high clot burden and was considered an independent predictor for thrombolysis. Further information about predictors of adverse outcomes in these patients is needed for better risk stratification. The objective is to describe independent predictors of adverse clinical outcomes in patients with central PE.

METHODS

Large retrospective, observational, and single-center study of hospitalized patients with central PE. Data were gathered on demographics, comorbidities, clinical features on admission, imaging, treatments, and outcomes. Multivariable standard and Least Absolute Shrinkage and Selection Operator (LASSO) machine learning logistic regressions and sensitivity analyses were used to analyze factors associated with a composite of adverse clinical outcomes, including vasopressor use, mechanical ventilation, and inpatient mortality.

RESULTS

A total of 654 patients had central PE. The mean age was 63.1 years, 59% were women, and 82% were African American. The composite adverse outcome was observed in 18% (n = 115) of patients. Serum creatinine elevation (odds ratio [OR] = 1.37, 95% CI = 1.20-1.57; p = 0.0001), white blood cell (WBC) count elevation (OR = 1.10, 95% CI = 1.05-1.15; p < 0.001), higher simplified pulmonary embolism severity index (sPESI) score (OR = 1.47, 95% CI = 1.18-1.84; p = 0.001), serum troponin elevation (OR = 1.26, 95% CI 1.02-1.56; p = 0.03), and respiratory rate increase (OR = 1.03, 95% CI = 1.0-1.05; p = 0.02) were independent predictors of adverse clinical outcomes.

CONCLUSION

Among patients with central PE, higher sPESI score, WBC count elevation, serum creatinine elevation, serum troponin elevation, and respiratory rate increase were independent predictors of adverse clinical outcomes. Right ventricular dysfunction on imaging and saddle PE location did not predict adverse outcomes.

Prevalence and Predictors of Cardiogenic Shock in Intermediate-Risk Pulmonary Embolism: Insights From the FLASH Registry

BACKGROUND

Patients with acute pulmonary embolism (PE) and hypotension (high-risk PE) have high mortality. Cardiogenic shock can also occur in nonhypotensive or normotensive patients (intermediate-risk PE) but is less well characterized.

OBJECTIVES

The authors sought to evaluate the prevalence and predictors of normotensive shock in intermediate-risk PE.

METHODS

Intermediate-risk PE patients in the FLASH (FlowTriever All-Comer Registry for Patient Safety and Hemodynamics) registry undergoing mechanical thrombectomy with the FlowTriever System (Inari Medical) were included. The prevalence of normotensive shock (systolic blood pressure ≥90 mm Hg but cardiac index ≤2.2 L/min/m²) was assessed. A composite shock score consisting of markers of right ventricular function and ischemia (elevated troponin, elevated B-type natriuretic peptide, moderately/severely reduced right ventricular function), central thrombus burden (saddle PE), potential additional embolization (concomitant deep vein thrombosis), and cardiovascular compensation (tachycardia) was prespecified and assessed for its ability to identify normotensive shock patients.

RESULTS

Over one-third of intermediate-risk PE patients in FLASH (131/384, 34.1%) were in normotensive shock. The normotensive shock prevalence was 0% in patients with a composite shock score of 0 and 58.3% in those with a score of 6 (highest score). A score of 6 was a significant predictor of normotensive shock (odds ratio: 5.84; 95% CI: 2.00-17.04). Patients showed significant on-table improvements in hemodynamics post-thrombectomy, including normalization of the cardiac index in 30.5% of normotensive shock patients. Right ventricular size, function, dyspnea, and quality of life significantly improved at the 30-day follow-up.

CONCLUSIONS

Although hemodynamically stable, over one-third of intermediate-risk FLASH patients were in normotensive shock with a depressed cardiac index. A composite shock score effectively further risk stratified these patients. Mechanical thrombectomy improved hemodynamics and functional outcomes at the 30-day follow-up.

Prognostic value of echocardiographic indices in risk stratification of intermediate-risk pulmonary embolism

Background

Regarding risk stratification of intermediate-risk pulmonary embolism, data are still not sufficient. Transthoracic echocardiography parameters may be useful in risk evaluation in those patients. Some novel echocardiographic indices mainly tricuspid regurgitation peak gradient (TRPG), pulmonary artery acceleration time, and tricuspid annulus plane systolic excursion (TAPSE) were evaluated showing that they may be used for risk stratification of normotensive cases with acute pulmonary embolism (APE).

Results

The studied cases were subdivided into two classes:

Class I with intermediate-low-risk pulmonary embolism included 32 patients (53.3%) and class II with intermediate high-risk pulmonary embolism involved 28 cases (46.7%). Dyspnea, tachypnea, troponin level, RVD, RVD/LVD, TR velocity, and TRPG/TAPSE were statistically higher in cases of class II than that of class I (p < 0.001). On the other hand, TAPSE and PA acceleration time were markedly lower in the case of class II than that of class I (p < 0.001). Ten cases (35.7%) of group II required thrombolytic agents with a significant difference (p<0.001).

Conclusions

RVD/LVD ratio, TAPSE, TRPG/TAPSE ratio, and PA acceleration time are echocardiographic parameters that might be helpful for risk stratification of cases with moderate-risk pulmonary embolism. The addition of elevated levels of cardiac troponins to imaging and clinical findings can improve PE-related risk identification.

Trial registration

NCT04020250. Registered on 16 July 2019.

Association Between the Severity of Obstructive Sleep Apnea and the Risk Stratification of Acute Pulmonary Embolism

Obstructive sleep apnea (OSA) has been associated with the initiation and progression of cardiovascular disease. This study aimed to explore the relationship between the severity of OSA and the risk stratification of acute pulmonary embolism (PE). In this single-center cohort study, patients diagnosed with PE were evaluated for OSA via polygraphy monitoring. The simplified PE severity index (sPESI) and the number of patients requiring systemic thrombolysis were used to determine the severity of the disease. Echocardiography was performed on all participants. All patients were divided into 2 groups (OSA group and non-OSA group), and the patients in OSA group were then divided into 3 groups based on the severity of OSA. Patients with severe OSA had a significantly higher number of patients with sPESI ≥ 1 (P = .005). A higher proportion of patients with severe OSA require systemic thrombolysis (P = .010). Patients with apnea-hypopnea index (AHI) > 30/h had a much higher fibrinogen (P = .004) and D-dimer (P = .040) level than those in the non-OSA group. The levels of creatinine were significantly higher in patients with OSA (P = .040). Echocardiography showed a significant difference in left ventricular ejection fraction (LVEF) between patients in non-OSA and severe OSA groups (P = .035). And brain natriuretic peptide (BNP) also exhibited a progressive worsening related to the deepest desaturation and oxygen desaturation index. OSA, especially with AHI > 30/h, is correlated with the severity and prognosis of acute PE. This might be attributed to the prothrombotic effect, renal impairment, and cardiac dysfunction in patients with severe OSA.

Risk factors for hospital outcomes in pulmonary embolism: A retrospective cohort study

Background

Pulmonary embolism (PE) is not only a life-threatening disease but also a public health issue with significant economic burden. The aim of the study was to identify factors-including the role of primary care-that predict length of hospital stay (LOHS), mortality and re-hospitalization within 6 months of patients admitted for PE.

Method

A retrospective cohort study was conducted with patients presenting to a Swiss public hospital with PE diagnosed at the hospital between November 2018 and October 2020. Multivariable logistic and zero-truncated negative binomial regression analyses were performed to assess risk factors for mortality, re-hospitalization and LOHS. Primary care variables encompassed whether patients were sent by their general practitioner (GP) to the emergency department and whether a GP follow-up assessment after discharge was recommended. Further analyzed variables were pulmonary embolism severity index (PESI) score, laboratory values, comorbidities, and medical history.

Results

A total of 248 patients were analyzed (median 73 years and 51.6% females). On average patients were hospitalized for 5 days (IQR 3-8). Altogether, 5.6% of these patients died in hospital, and 1.6% died within 30 days (all-cause mortality), 21.8% were re-hospitalized within 6 months. In addition to high PESI scores, we detected that, patients with an elevated serum troponin, as well as with diabetes had a significantly longer hospital stay. Significant risk factors for mortality were elevated NT-proBNP and PESI scores. Further, high PESI score and LOHS were associated with re-hospitalization within 6 months. PE patients who were sent to the emergency department by their GPs did not show improved outcomes. Follow-up with GPs did not have a significant effect on re-hospitalization.

Conclusion

Defining the factors that are associated with LOHS in patients with PE has clinical implications and may help clinicians to allocate adequate resources in the management of these patients. Serum troponin and diabetes in addition to PESI score might be of prognostic use for LOHS. In this single-center cohort study, PESI score was not only a valid predictive tool for mortality but also for long-term outcomes such as re-hospitalization within 6 months.

Mechanical thrombectomy versus catheter directed thrombolysis in patients with pulmonary embolism: A multicenter experience

OBJECTIVES

Compare in-hospital outcomes of patients treated with either mechanical thrombectomy (MT) or catheter directed lysis (CDL) in treatment of acute pulmonary embolism (PE).

METHODS

This is a multicenter, retrospective cohort study of patients undergoing MT or CDL for acute PE between 2014 and 2021. The primary outcome was the composite of in-hospital death, significant bleed, vascular complication, or need for mechanical support post-procedure. Secondary outcomes included the individual components of the composite outcome in addition to blood transfusions, invasive hemodynamics, echocardiographic data, and intensive care unit (ICU) utilization.

RESULTS

458 patients were treated for PE with 266 patients in the CDL arm and 192 patients in the MT arm. The primary composite endpoint was not significantly different between the two groups with CDL 12% versus MT 11% (p = 0.5). There was a significant difference in total length of ICU time required with more in the CDL group versus MT (3.8 ± 2.0 vs. 2.8 ± 3.0 days, p = 0.009). All other secondary end points showed no significant difference between the groups.

CONCLUSIONS

In patients undergoing catheter directed treatment of PE, there was no difference between MT and CDL in terms of in-hospital mortality, bleeds, catheter-related complications, and hemodynamics.

Pulmonary Embolism Risk Assessment Using Blood Copeptin Concentration and Pulmonary Arteries Thrombotic Burden Evaluated by Computer Tomography

(1) Background: Pulmonary embolism (PE) represents the third most important cardiovascular cause of death after myocardial infarction and stroke. The proper management of this condition is dependent on adequate risk stratification, due to the life-threatening complications of more aggressive therapies such as thrombolysis. Copeptin is a surrogate marker of vasopressin which is found increased in several cardiovascular conditions. The Mastora score is an imagistic evaluation of the degree of pulmonary arteries thrombotic burden based on computed tomography angiography. In this study, we aimed to evaluate the diagnostic and prognostic role of copeptin in patients with acute PE. Furthermore, we analyzed the relationship between copeptin and Mastora score and their role in PE risk profiling. (2) Methods: We conducted a single center prospective study that included 112 patients with PE and 53 healthy volunteers. Clinical and paraclinical parameters, together with plasma levels of copeptin and the Mastora score, were evaluated in all patients after admission. (3) Results: Copeptin levels were significantly increased in PE patients compared with the general population (26.05 vs. 9.5 pmol/L, p < 0.001), while receiver operating characteristic (ROC) analysis revealed an AUC of 0.800 (95% CI 0.728−0.873, p < 0.001). Copeptin directly correlated with the Mastora score (r = 0.535, p = 0.011) and both parameters were strong predictors for adverse clinical events and death. Receiver operating characteristic (ROC) analysis for death within 30 days revealed a copeptin cut-off of 38.36 pmol/L, which presented a specificity of 79.6% and a sensitivity of 88.9%, and a Mastora score cut-off of 82 points, which presented a specificity of 74.8% and a sensitivity of 77.8%. (4) Conclusions: Our results showed that copeptin and the Mastora score are both correlated with adverse cardiovascular events and mortality in PE patients, and this may pave the way for their use in clinical practice, helping physicians to select the best therapeutical management.

Cardiac Biomarkers and Risk Scores in Relation with History of Atherosclerotic Cardiovascular Disease in Patients Admitted with COVID-19: The Experience of an Eastern European Center

BACKGROUND

Data regarding the combined prognostic role of biomarkers and risk scores in relation with the history of atherosclerotic cardiovascular disease (ASCVD) in COVID-19 patients are lacking.

METHODS

The aim of this observational cohort study was to evaluate the combined prognostic value of N-terminal pro B-type natriuretic peptide (NT-pro BNP), troponin and risk scores in relation with ASCVD history in hospitalized COVID-19 patients. The primary composite endpoint was Intensive Care Unit (ICU) admission and death.

RESULTS

From April 2020 to June 2022, 1066 consecutive COVID-19 patients with available biomarkers upon admission were included. During a median follow-up period of 12 days, 176 patients (16.5%) died. Independent predictors of ICU admission and death in patients with ASCVD were NT-pro BNP (HR 2.63; 95% CI, 1.65-4.18) and troponin (HR 1.51; 95% CI, 1.13-2.03). In patients without ASCVD, only NT-pro BNP was predictive for the primary endpoint (HR 1.66; 95% CI, 1.10-2.53). This remained significant after adjustment for other relevant covariates (HR 3.54; 95% CI, 1.98-6.33) in patients with ASCVD and in patients without ASCVD (HR 1.82; 95% CI, 1.02-3.26).

CONCLUSIONS

These data showed the combined prognostic accuracy of NT-pro BNP and troponin in relation with ASCVD history for ICU admission and death in COVID-19 patients.

Intermediate-Risk Pulmonary Embolism: A Review of Contemporary Diagnosis, Risk Stratification and Management

Pulmonary embolism (PE) can have a wide range of hemodynamic effects, from asymptomatic to a life-threatening medical emergency. Pulmonary embolism (PE) is associated with high mortality and requires careful risk stratification for individualized management. PE is divided into three risk categories: low risk, intermediate-risk, and high risk. In terms of initial therapeutic choice and long-term management, intermediate-risk (or submassive) PE remains the most challenging subtype. The definitions, classifications, risk stratification, and management options of intermediate-risk PE are discussed in this review.

Brain-Derived Neurotrophic Factor Expression in Patients with Acute Pulmonary Embolism Compared to the General Population: Diagnostic and Prognostic Implications

(1) Background: Pulmonary embolism (PE) is a severe condition, representing the third most important cardiovascular cause of death after myocardial infarction and stroke. Despite the use of clinical pre-test probability scores, D-dimer measuring, and computer tomography pulmonary angiography (CTPA), PE diagnosis remains a challenge. Brain-derived neurotrophic factor (BDNF) is the most important member of the neurotrophin family, which has also been shown to be involved in the physiopathology of cardiovascular conditions such as heart failure and myocardial infarction. In this study, we aimed to assess the BDNF expression in patients with acute PE compared to the general population, and to also investigate its diagnostic and prognostic role. (2) Methods: We conducted a single center prospective study, which included 90 patients with PE and 55 healthy volunteers. Clinical and paraclinical parameters, together with plasma levels of BDNF, were evaluated in all patients after admission. (3) Results: The plasma levels of BDNF were significantly lower in the PE patients compared with the control group (403 vs. 644 pg/mL, p < 0.001). ROC analysis revealed an AUC of 0.806 (95% CI 0.738−0.876, p < 0.001) and a cut-off value of 564 pg/mL, which associated a sensitivity of 74.4% and a specificity of 78.2% for PE. Low BDNF levels also correlated with prognostic markers of PE, such as PESI score (p = 0.023), NT-proBNP (p < 0.01), right ventricular diameter (p = 0.029), and tricuspid annular plane systolic elevation (p = 0.016). Moreover, we identified a decreased BDNF expression in patients with high-risk PE (p < 0.01), thrombolytic treatment (p = 0.01), and patients who died within 30 days (p = 0.05). (4) Conclusions: Our study revealed that plasma BNDF is significantly lower in patients with PE when compared with the general population, and may be considered as a promising biomarker in complementing the current diagnostic tools for PE. Furthermore, low levels of BDNF might also be used to predict a poor outcome of this condition.

An Update on the Management of Acute High-Risk Pulmonary Embolism

Hemodynamic instability and right ventricular (RV) dysfunction are the key determinants of short-term prognosis in patients with acute pulmonary embolism (PE). High-risk PE encompasses a wide spectrum of clinical situations from sustained hypotension to cardiac arrest. Early recognition and treatment tailored to each individual are crucial. Systemic fibrinolysis is the first-line pulmonary reperfusion therapy to rapidly reverse RV overload and hemodynamic collapse, at the cost of a significant rate of bleeding. Catheter-directed pharmacological and mechanical techniques ensure swift recovery of echocardiographic parameters and may possess a better safety profile than systemic thrombolysis. Further clinical studies are mandatory to clarify which pulmonary reperfusion strategy may improve early clinical outcomes and fill existing gaps in the evidence.

Risk stratification to optimize the management of acute pulmonary embolism

INTRODUCTION

Pulmonary embolism (PE) is a life-threatening disease. Risk stratification in patients with acute PE can guide clinical decisions. Clinical assessment, including hemodynamics, respiratory parameters, patient history, and right ventricle evaluation, has a pivotal role in this scope.

AREAS COVERED

This review aims to describe: i) the role of individual tools for prognostic stratification, from simple clinical parameters to the models suggested by international guidelines; ii) the implications of risk stratification in terms of patient disposition and treatment. The bleeding risk assessment in acute PE was also reviewed. The literature search was performed in PubMed and Embase to address these issues.

EXPERT OPINION

Prognostic assessment is essential to proceed with life-saving treatments in hemodynamically unstable patients and consider home treatment or short hospital stay in patients at low risk for death. In hemodynamically stable patients, risk stratification allows the implementation of personalized treatment pathways to reduce the risk of death, early PE recurrence, and bleeding. With the aim of optimizing healthcare resources, risk stratification may suggest appropriate patient disposition.

Cardiac Biomarkers in Patients with Acute Pulmonary Embolism

Pulmonary embolism is a frequent and potentially fatal disease. The major challenge of initial management lies in prognostic stratification. Since 2014, the European recommendations on the diagnosis and management of acute pulmonary embolism are based on assessing the risk stratification regarding hemodynamic status first, then on a combined risk assessment model using a clinical score, an imaging evaluation of right heart size and the concentration of a serum cardiac biomarker. Usual biomarkers cover cardiac ischemia (troponin and derivates) and dilatation (BNP and derivates). The aim of this review is to offer a practical update on the role of the Troponins and BNPs families of biomarkers and the prognosis of pulmonary embolism, and furthermore, to provide a brief overview of their place in current management.

Usefulness of a refined computed tomography imaging method to assess the prevalence of residual pulmonary thrombi in patients 1 year after acute pulmonary embolism: The Nagoya PE study

BACKGROUND

Post-pulmonary embolism (PE) syndrome is an important clinical condition that can affect the long-term prognosis after acute PE.

OBJECTIVE

We aimed to evaluate the prevalence of residual pulmonary thrombi and the thrombotic burden 1 year after acute PE, by using our refined computed tomography (CT) imaging method.

PATIENTS/METHODS

In this prospective study, patients diagnosed with acute PE were recruited and examinations were conducted at 1 month, 6 months, and 1 year. Especially at 1 year, patients were evaluated multifacetedly, including by laboratory tests, quality-of-life, 6-min walking test, and enhanced CT.

RESULTS

Fifty-two patients were enrolled. Two patients (3.8%) developed chronic thromboembolic pulmonary hypertension. A total of 43 patients completed evaluation at 1 year, among whom (74%) had residual thrombi, with a median modified CT obstruction index (mCTOI) of 10.7%. In multivariate analysis, residual thrombi at 1 month was the only factor significantly related to residual thrombi at 1 year (odds ratio, 103.4; 95% confidence interval, 4.2-2542.1). The tricuspid regurgitation pressure gradient ≥60 mmHg and left ventricular end-diastolic dimension at diagnosis were significantly related to mCTOI at 1 year (β = 0.367, P = .003; and β = -0.435, P = .001, respectively).

CONCLUSIONS

Using our improved CT imaging protocol, we found a high prevalence of residual thrombi 1 year after acute PE. Furthermore, right ventricular overload was related to the thrombotic burden. The long-term treatment strategy of acute PE could be modified to include precise CT imaging.

Outcome After Thrombolysis in Patients With Intermediate High-Risk Pulmonary Embolism: A Propensity Score Analysis

BACKGROUND

The role of thrombolytic treatment in patients with intermediate high-risk pulmonary embolism (IHR-PE) remains controversial.

OBJECTIVES

In this study, we assessed whether systemic thrombolysis decreases hemodynamic decompensation and mortality in a cohort of unselected patients with IHR compared with patients with conventional anticoagulation.

METHODS

Between January 2014 and December 2018, 137 patients with IHR-PE were identified among 539 consecutive patients treated for symptomatic PE. In 35 patients (25.5%), systemic thrombolysis was used. Propensity score matching was performed based on 17 pretreatment variables. The primary outcome was hemodynamic decompensation, defined by systolic hypotension, need for catecholamines or signs of end-organ hypoperfusion, and all-cause mortality during hospitalization. Secondary outcomes, such as 1-year survival, and safety outcomes, such as bleeding events, were analyzed.

RESULTS

The effects of systemic thrombolysis and anticoagulation were compared in 55 matched patients with IHR-PE (systemic thrombolysis n = 21; anticoagulation n = 34). Thrombolysis was associated with a reduction (0% vs. 31%; p = 0.004) of the primary outcome during hospitalization and a 1-year survival benefit (100% vs. 83.2%; p = 0.036). Severe bleeding events occurred in 4.8% vs. 0% (p = 0.382) and moderate bleeding was observed in 14.3% vs. 7.1% (p = 0.359) in patients with thrombolysis compared with anticoagulation, respectively.

CONCLUSIONS

Thrombolysis was associated with a significant reduction of the combined endpoint of hemodynamic decompensation and death during hospitalization and lower all-cause mortality after 1 year in an unselected group of patients with IHR-PE. Further studies are required to improve the therapy of IHR-PE and to identify the subgroup of patients that might benefit from thrombolytic therapy.

NT Pro-BNP can be used as a risk predictor of clinical atrial fibrillation with or without left atrial enlargement

Background

NT Pro‐BNP is a blood marker secreted by cardiomyocytes. Myocardial stretch is the main factor to stimulate NT Pro‐BNP secretion in cardiomyocytes. NT Pro‐BNP is an important risk factor for cardiac dysfunction, stroke, and pulmonary embolism. So does atrial myocyte stretching occur when patients have atrial fibrillation (AF)? Whether atrial muscle stretch induced by AF leads to increased NT Pro‐BNP remains unclear. The purpose of this study is to investigate the relationship between NT Pro‐BNP and AF.

Hypothesis

AF can cause changes in myocardial tension. Changes in myocardial tension may lead to increased secretion of NT Pro‐BNP. We hypothesize that NT Pro‐BNP may increase in AF with or without LAD enlargement.

Methods

This clinical study is an observational study and has been approved by the Ethics Committee of the First Affiliated Hospital of Xi'an Jiaotong University. Ethical approval documents is attached. The study retrospectively reviewed 1345 patients with and without AF. After excluding 102 patients who were not eligible, the final total sample size was 1243 cases: AF group 679 patients (378, 55.7% males) and non‐AF group 564 patients (287, 50.8% males). NT Pro‐BNP was observed in AF group and non‐AF group with or without LAD. After adjusting for age, gender, BMI, left atrial diameter, hypertension, diabetes, coronary heart disease, and cerebral infarction, NT Pro‐BNP remains statistically significant with AF.

Conclusion

NT Pro‐BNP can be used as a risk predictor of AF with or without left atrial enlargement.

Supervised Versus Unsupervised Pulmonary Rehabilitation in Patients with Pulmonary Embolism: A Valuable Alternative in COVID Era

The aim of our study was to assess the effect of 8 weeks of pulmonary rehabilitation (PR) in patients with pulmonary embolism (PE) during unsupervised PR (unSPRgroup) versus supervised PR (SPRgroup) on cardiopulmonary exercise testing (CPET) parameters, sleep quality, quality of life and cardiac biomarkers (NT-pro-BNP). Fourteen patients with PE (unSPRgroup, n = 7, vs. SPRgroup, n = 7) were included in our study (age, 50.7 ± 15.1 years; BMI, 30.0 ± 3.3 kg/m2). We recorded anthropometric characteristics and questionnaires (Quality of life (SF-36) and Pittsburg sleep quality index (PSQI)), we performed blood sampling for NT-pro-BNP measurement and underwent CPET until exhausting before and after the PR program. All patients were subjected to transthoracic echocardiography prior to PR. The SPRgroup differed in mean arterial pressure at rest before and after the PR program (87.6 ± 3.3 vs. 95.0 ± 5.5, respectively, p = 0.010). Patients showed increased levels of leg fatigue (rated after CPET) before and after PR (p = 0.043 for SPRgroup, p = 0.047 for unSPRgroup) while the two groups differed between each other (p = 0.006 for post PR score). Both groups showed increased levels in SF-36 scores (general health; p = 0.032 for SPRgroup, p = 0.010 for unSPRgroup; physical health; p = 0.009 for SPRgroup, p = 0.022 for unSPRgroup) and reduced levels in PSQI (cannot get to sleep within 30-min; p = 0.046 for SPRgroup, p = 0.007 for unSPRgroup; keep up enough enthusiasm to get things done; p = 0.005 for SPRgroup, p = 0.010 for unSPRgroup) following the PR program. The ΝT-pro-BNP was not significantly different before and after PR or between groups. PR may present a safe intervention in patients with PE. The PR results are similar in SPRgroup and unSPRgroup.

Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE)

OBJECTIVE

Develop and validate a prognostic model for clinical deterioration or death within days of pulmonary embolism (PE) diagnosis using point-of-care criteria.

METHODS

We used prospective registry data from six emergency departments. The primary composite outcome was death or deterioration (respiratory failure, cardiac arrest, new dysrhythmia, sustained hypotension, and rescue reperfusion intervention) within 5 days. Candidate predictors included laboratory and imaging right ventricle (RV) assessments. The prognostic model was developed from 935 PE patients. Univariable analysis of 138 candidate variables was followed by penalized and standard logistic regression on 26 retained variables, and then tested with a validation database (N = 801).

RESULTS

Logistic regression yielded a nine-variable model, then simplified to a nine-point tool (PE-SCORE): one point each for abnormal RV by echocardiography, abnormal RV by computed tomography, systolic blood pressure < 100 mmHg, dysrhythmia, suspected/confirmed systemic infection, syncope, medico-social admission reason, abnormal heart rate, and two points for creatinine greater than 2.0 mg/dL. In the development database, 22.4% had the primary outcome. Prognostic accuracy of logistic regression model versus PE-SCORE model: 0.83 (0.80, 0.86) vs. 0.78 (0.75, 0.82) using area under the curve (AUC) and 0.61 (0.57, 0.64) vs. 0.50 (0.39, 0.60) using precision-recall curve (AUCpr). In the validation database, 26.6% had the primary outcome. PE-SCORE had AUC 0.77 (0.73, 0.81) and AUCpr 0.63 (0.43, 0.81). As points increased, outcome proportions increased: a score of zero had 2% outcome, whereas scores of six and above had ≥ 69.6% outcomes. In the validation dataset, PE-SCORE zero had 8% outcome [no deaths], whereas all patients with PE-SCORE of six and above had the primary outcome.

CONCLUSIONS

PE-SCORE model identifies PE patients at low- and high-risk for deterioration and may help guide decisions about early outpatient management versus need for hospital-based monitoring.

Prognosis of patients with acute pulmonary embolism and discordant right ventricle strain serum biomarkers

BACKGROUND

Right ventricle strain serum biomarkers, such as high-sensitivity cardiac troponin T (hs-cTnT) and NT-pro-brain natriuretic peptide (NT-proBNP), are prognostic in patients with pulmonary embolism (PE). Prognosis accuracy in patients with discordancy between serum biomarkers remains, however, unknown.

METHODS

We performed a retrospective analysis in patients with intermediate or high risk PE and discordant serum biomarkers of RV strain as follows: high hs-cTnT and low NT-proBNP ('high troponin discordance'), compared to patients with low hs-cTnT and high NT-proBNP ('high NT-proBNP discordance'). Cut-off values for high hs-cTnT were ≥14 pg/mL in patients <75 years and ≥45 pg/mL in patients >75-year. Cut-off values for high NT-proBNP were ≥600 pg/mL. The primary end-point was a composite of death, resuscitated cardiac arrest, mechanical ventilation, and inotrope use at one month. 'High troponin discordance', age, sex and body mass index (BMI) were included in a logistic regression model. Time to event analysis was performed using Kaplan Meier curves and Log-rank test.

RESULTS

73 patients were included. 'High troponin discordance' patients (n=41) were younger, presented with a higher heart rate, more frequent bilateral PE, and received more thrombolytics as treatment compared with 'high NT-proBNP discordance' patients (n = 32). Primary end-point was significantly higher in the 'high troponin discordance' patients (29.3% vs 9.4%, p=0.045). 'High troponin discordance' was independently associated with the primary end-point after adjusting for age, sex and BMI. Log rank test confirmed worse outcome in the high troponin discordance group (p=0.037).

CONCLUSIONS

High troponin discordance' patients with intermediate/high risk PE, had worse outcomes than patients with high BNP discordance.

Venous thromboembolism: Recent advancement and future perspective

Clinicians have been more and more often encountering patients with venous thromboembolism (VTE), including pulmonary embolism and deep vein thrombosis, leading to the increased importance of VTE in daily clinical practice. VTE is becoming a common issue in Asian countries including Japan. The management strategies of VTE have changed dramatically in the past decade including the introduction of direct oral anticoagulants (DOACs). In addition, there have been several landmark clinical trials assessing acute treatment strategies including thrombolysis and inferior vena cava (IVC) filter. The current VTE guidelines do not recommend the routine use of thrombolysis or IVC filters based on recent evidence; Nevertheless, the prevalence of thrombolysis and IVC filter use in Japan was strikingly high. The novel profiles of DOACs with rapid onset of action and potential benefit of a lower risk for bleeding compared with vitamin K antagonist could make home treatment feasible and is safer even with extended anticoagulation therapy. One of the most clinically relevant issues for VTE treatment is optimal duration of anticoagulation for the secondary prevention of VTE. Considering recent evidence, optimal duration of anticoagulation should be determined based on the risk for recurrence as well as the risk for bleeding in an individual patient. Despite the recent advances for VTE management, there are still a number of uncertain issues that challenge clinicians in daily clinical practice, such as cancer-associated VTE and minor VTE including subsegmental pulmonary embolism and distal deep vein thrombosis, warranting future research. Several clinical trials are now ongoing for these issues, globally as well as in Japan. The current review is aimed to overview the recent advances in VTE management, describe the current status including some domestic issues in Japan, and discuss the future perspective of VTE.

A New Index for the Prediction of 30-Day Mortality in Patients With Pulmonary Embolism: The Pulmonary Embolism Mortality Score (PEMS)

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.

Submassive Pulmonary Embolism: Current Perspectives and Future Directions

Submassive pulmonary embolism (PE) lies on a spectrum of disease severity between standard and high-risk disease. By definition, patients with submassive PE have a worse outcome than the majority of those with standard-risk PE, who are hemodynamically stable and lack imaging or laboratory features of cardiac dysfunction. Systemic thrombolytic therapy has been proven to reduce mortality in patients with high-risk disease; however, its use in submassive PE has not demonstrated a clear benefit, with haemodynamic improvements being offset by excess bleeding. Furthermore, meta-analyses have been confusing, with conflicting results on overall survival and net gain. As such, significant interest remains in optimising thrombolysis, with recent efforts in catheter-based delivery as well as upcoming studies on reduced systemic dosing. Recently, long-term cardiorespiratory limitations following submassive PE have been described, termed post-PE syndrome. Studies on the ability of thrombolytic therapy to prevent this condition also present conflicting evidence. In this review, we aim to clarify the current evidence with respect to submassive PE management, and also to highlight shortcomings in current definitions and prognostic factors. Additionally, we discuss novel therapies currently in preclinical and early clinical trials that may improve outcomes in patients with submassive PE.