1
|
Keller K, Schmitt VH, Hahad O, Hobohm L. Outcome of Pulmonary Embolism with and without Ischemic Stroke. J Clin Med 2024; 13:2730. [PMID: 38792272 PMCID: PMC11122224 DOI: 10.3390/jcm13102730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/10/2024] [Accepted: 05/03/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Ischemic stroke is the second, and pulmonary embolism (PE) is the third most common cardiovascular cause of death after myocardial infarction. Data regarding risk factors for ischemic stroke in patients with acute PE are limited. Methods: Patients were selected by screening the German nationwide in-patient sample for PE (ICD-code I26) and were stratified by ischemic stroke (ICD code I63) and compared. Results: The nationwide in-patient sample comprised 346,586 hospitalized PE patients (53.3% females) in Germany from 2011 to 2014; among these, 6704 (1.9%) patients had additionally an ischemic stroke. PE patients with ischemic stroke had a higher in-hospital mortality rate than those without (28.9% vs. 14.5%, p < 0.001). Ischemic stroke was independently associated with in-hospital death (OR 2.424, 95%CI 2.278-2.579, p < 0.001). Deep venous thrombosis and/or thrombophlebitis (DVT) combined with heart septal defect (OR 24.714 [95%CI 20.693-29.517], p < 0.001) as well as atrial fibrillation/flutter (OR 2.060 [95%CI 1.943-2.183], p < 0.001) were independent risk factors for stroke in PE patients. Systemic thrombolysis was associated with a better survival in PE patients with ischemic thrombolysis who underwent cardio-pulmonary resuscitation (CPR, OR 0.55 [95%CI 0.36-0.84], p = 0.006). Conclusions: Ischemic stroke did negatively affect the survival of PE. Combination of DVT and heart septal defect and atrial fibrillation/flutter were strong and independent risk factors for ischemic stroke in PE patients. In PE patients with ischemic stroke, who had to underwent CPR, systemic thrombolysis was associated with improved survival.
Collapse
Affiliation(s)
- Karsten Keller
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (V.H.S.); (O.H.); (L.H.)
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Volker H. Schmitt
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (V.H.S.); (O.H.); (L.H.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Omar Hahad
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (V.H.S.); (O.H.); (L.H.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (V.H.S.); (O.H.); (L.H.)
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| |
Collapse
|
2
|
Birrenkott DA, Kabrhel C, Dudzinski DM. Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies. Cardiol Clin 2024; 42:215-235. [PMID: 38631791 DOI: 10.1016/j.ccl.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.
Collapse
Affiliation(s)
- Drew A Birrenkott
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiac Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| |
Collapse
|
3
|
Ballas C, Lakkas L, Kardakari O, Papaioannou E, Siaravas KC, Naka KK, Michalis LK, Katsouras CS. In-Hospital versus Out-of-Hospital Pulmonary Embolism: Clinical Characteristics, Biochemical Markers and Echocardiographic Indices. J Cardiovasc Dev Dis 2024; 11:103. [PMID: 38667721 PMCID: PMC11050175 DOI: 10.3390/jcdd11040103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
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.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Christos S. Katsouras
- Second Department of Cardiology, University Hospital of Ioannina, 45500 Ioannina, Greece (L.L.); (O.K.); (E.P.); (K.C.S.); (K.K.N.); (L.K.M.)
| |
Collapse
|
4
|
Chaibi S, Roy PM, Guénégou AA, Tran Y, Hugli O, Penaloza A, Couturaud F, Tromeur C, Szwebel TA, Pernod G, Elias A, Ghuysen A, Benhamou Y, Falvo N, Juchet H, Nijkeuter M, Mairuhu R, Faber LM, Mahé I, Montaclair K, Planquette B, Jimenez D, Huisman MV, Klok FA, Sanchez O. Outpatient management of cancer-associated pulmonary embolism: A post-hoc analysis from the HOME-PE trial. Thromb Res 2024; 235:79-87. [PMID: 38308882 DOI: 10.1016/j.thromres.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Cancer-related pulmonary embolism (PE) is associated with poor prognosis. Some decision rules identifying patients eligible for home treatment categorize cancer patients at high risk of complications, precluding home treatment. We sought to assess the effectiveness and the safety of outpatient management of patients with low-risk cancer-associated PE. METHODS In the HOME-PE trial, hemodynamically stable patients with symptomatic PE were randomized to either triaging with Hestia criteria or sPESI score. We analyzed 3 groups of low-risk PE patients: 47 with active cancer treated at home (group 1), 691 without active cancer treated at home (group 2), and 33 with active cancer as the only sPESI criterion qualifying them for hospitalization (group 3). The main outcome was the composite of recurrent venous thromboembolism, major bleeding, and all-cause death within 30 days after randomization. RESULTS Patients treated at home had composite outcome rates of 4.3 % (2/47) for those with cancer vs. 1.0 % (7/691) for those without (odds ratio (OR) 4.98, 95%CI 1.15-21.49). Patients with cancer had rates of complications of 4.3 % when treated at home vs. 3.0 % (1/33) when hospitalized (OR 1.19, 95%CI 0.15-9.47). In multivariable analysis, active cancer was associated with an increased risk of complications for patients treated at home (OR 7.95; 95%CI 1.48-42.82). For patients with active cancer, home treatment was not associated with the primary outcome (OR 1.19, 95%CI 0.15-9.74). CONCLUSIONS Among patients treated at home, active cancer was a risk factor for complications, but among patients with active cancer, home treatment was not associated with adverse outcomes.
Collapse
Affiliation(s)
- Sérine Chaibi
- Université Paris Cité, Paris, France; Department of Pneumology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, Paris F-75908, France
| | - Pierre-Marie Roy
- Emergency Department, CHU Angers, Angers F-49000, France; Univ. Angers, INSERM, CNRS, MITOVASC, Equipe CARME, SFR ICAT, Angers, France; F-CRIN, INNOVTE, Saint-Etienne, France
| | - Armelle Arnoux Guénégou
- Université Paris Cité, AP-HP, Hôpital Européen Georges Pompidou, Clinical research unit, Clinical Investigation Center 1418 Clinical Epidemiology, INSERM, INRIA, HeKA, Paris, France
| | - Yohann Tran
- Université Paris Cité, AP-HP, Hôpital Européen Georges Pompidou, Clinical research unit, Clinical Investigation Center 1418 Clinical Epidemiology, INSERM, Paris, France
| | - Olivier Hugli
- Emergency Department, University Hospital of Lausanne and Lausanne University, Lausanne, Switzerland
| | - Andréa Penaloza
- Emergency Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium; UCLouvain, Brussels, Belgium
| | - Francis Couturaud
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Internal Medicine and Chest Disease, CHU Brest, Brest, France; INSERM U1304-GETBO, CIC-INSERM1412, Univ-Brest, F20609 Brest, France
| | - Cécile Tromeur
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Internal Medicine and Chest Disease, CHU Brest, Brest, France; INSERM U1304-GETBO, CIC-INSERM1412, Univ-Brest, F20609 Brest, France
| | - Tali-Anne Szwebel
- Department of Internal Medicine, Cochin Hospital, APHP, Paris, France
| | - Gilles Pernod
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Vascular Medicine, CHU Grenoble Alpes, Grenoble, France; University Grenoble Alpes, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble, France
| | - Antoine Elias
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Cardiology and Vascular Medicine, Sainte Musse Hospital, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Toulon, France
| | - Alexandre Ghuysen
- Emergency Department, Sart Tilman University Hospital, Liège, Belgium
| | - Ygal Benhamou
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Internal Medicine, CHU Charles Nicolle, Rouen, France; Normandie University, UNIROUEN, INSERM U1096 EnVI, Rouen, France
| | - Nicolas Falvo
- F-CRIN, INNOVTE, Saint-Etienne, France; Vascular Medicine Department, CHU Dijon, Dijon, France
| | - Henry Juchet
- Emergency Department, CHU Toulouse, Toulouse, France
| | - Mathilde Nijkeuter
- Department of emergency medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ronne Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Laura M Faber
- Department of Internal Medicine, Rode Kruis Hospital, Beverwijk, DTN, the Netherlands
| | - Isabelle Mahé
- Université Paris Cité, Paris, France; F-CRIN, INNOVTE, Saint-Etienne, France; Department of Internal Medicine, Louis Mourier Hospital, AP-HP, Colombes, France; Inserm UMR_S1140 Innovations Thérapeutiques en Hémostase, Paris, France
| | - Karine Montaclair
- F-CRIN, INNOVTE, Saint-Etienne, France; Department of Cardiology, CH Le Mans, Le Mans, France
| | - Benjamin Planquette
- Université Paris Cité, Paris, France; Department of Pneumology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, Paris F-75908, France; F-CRIN, INNOVTE, Saint-Etienne, France; Inserm UMR_S1140 Innovations Thérapeutiques en Hémostase, Paris, France
| | - David Jimenez
- Respiratory Department and Medicine Department, Ramon y Cajal Hospital (IRYCIS) and Alcala University, CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Federikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Olivier Sanchez
- Université Paris Cité, Paris, France; Department of Pneumology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, Paris F-75908, France; F-CRIN, INNOVTE, Saint-Etienne, France; Inserm UMR_S1140 Innovations Thérapeutiques en Hémostase, Paris, France.
| |
Collapse
|
5
|
Ballas C, Lakkas L, Kardakari O, Konstantinidis A, Exarchos K, Tsiara S, Kostikas K, Naka KΚ, Michalis LK, Katsouras CS. What is the real incidence of right ventricular affection in patients with acute pulmonary embolism? Acta Cardiol 2023; 78:1089-1098. [PMID: 37581357 DOI: 10.1080/00015385.2023.2246197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/19/2022] [Accepted: 08/03/2023] [Indexed: 08/16/2023]
Abstract
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.
Collapse
Affiliation(s)
- Christos Ballas
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
| | - Lampros Lakkas
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
| | - Olga Kardakari
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
| | | | | | - Stavroula Tsiara
- Second Department of Internal Medicine, University Hospital of Ioannina, Ioannina, Greece
| | | | - Katerina Κ Naka
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
| | - Lampros K Michalis
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
| | - Christos S Katsouras
- Second Department of Cardiology, University Hospital of Ioannina, Ioannina, Greece
| |
Collapse
|
6
|
Osmani N, Marinaro J, Guliani S. Life-threatening pulmonary embolism: overview and management. Int Anesthesiol Clin 2023; 61:35-42. [PMID: 37622318 DOI: 10.1097/aia.0000000000000417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Affiliation(s)
- Nizar Osmani
- Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Jonathan Marinaro
- Center for Adult Critical Care, University of New Mexico, Albuquerque, New Mexico
| | - Sundeep Guliani
- Center for Adult Critical Care, University of New Mexico, Albuquerque, New Mexico
| |
Collapse
|
7
|
Martinez Manzano JM, Lo KB, Cantu-Martinez O, Nguyen L, Chiang B, Jarrett SA, Tito S, Prendergast A, Planchart Ferretto MA, Roque W, Wattoo A, Azmaiparashvili Z, Benzaquen S. Clinical predictors and outcomes of pulmonary infarction in patients with central pulmonary embolism. Expert Rev Respir Med 2023; 17:815-821. [PMID: 37750314 DOI: 10.1080/17476348.2023.2263359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 09/22/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Given the heterogeneity of predisposing factors associated with pulmonary infarction (PI) and the lack of clinically relevant outcomes among patients with acute pulmonary embolism (PE) complicated by PI, further investigation is required. METHODS Retrospective study of patients with central PE in an 11-year period. Data were stratified according to the diagnosis of PI. Multivariable logistic regression analysis was used to analyze factors associated with PI development and determine if PI was associated with severe hypoxemic respiratory failure and mechanical ventilation use. RESULTS Of 645 patients with central PE, 24% (n = 156) had PI. After adjusting for demographics, comorbidities, and clinical features on admission, only age (OR 0.98, CI 0.96-0.99; p = 0.008) was independently associated with PI. Regarding outcomes, 35% (n = 55) had severe hypoxemic respiratory failure, and 19% (n = 29) required mechanical ventilation. After adjusting for demographics, PE severity, and right ventricular dysfunction, PI was independently associated with severe hypoxemic respiratory failure (OR 1.78; CI 1.18-2.69, p = 0.005) and mechanical ventilation (OR 1.92; CI 1.14-3.22, p = 0.013). CONCLUSIONS Aging is a protective factor against PI. In acute central PE, subjects with PI had higher odds of developing severe hypoxemic respiratory failure and requiring mechanical ventilation.
Collapse
Affiliation(s)
- Jose Manuel Martinez Manzano
- Einstein Medical Center Philadelphia, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA, USA
| | - Kevin Bryan Lo
- Einstein Medical Center Philadelphia, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA, USA
| | - Omar Cantu-Martinez
- Einstein Medical Center Philadelphia, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA, USA
| | - Long Nguyen
- Einstein Medical Center Philadelphia, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Radiology, Einstein Medical Center Philadelphia, Philadelphia, PA, USA
| | - Brenda Chiang
- Einstein Medical Center Philadelphia, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA, USA
| | - Simone A Jarrett
- Einstein Medical Center Philadelphia, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA, USA
| | - Sahana Tito
- Einstein Medical Center Philadelphia, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA, USA
| | - Alexander Prendergast
- Einstein Medical Center Philadelphia, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA, USA
| | | | - Willy Roque
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ammaar Wattoo
- Einstein Medical Center Philadelphia, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA, USA
| | - Zurab Azmaiparashvili
- Einstein Medical Center Philadelphia, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA, USA
| | - Sadia Benzaquen
- Einstein Medical Center Philadelphia, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Pulmonary and Critical Care Medicine, Einstein Medical Center Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
8
|
Cantu-Martinez O, Martinez Manzano JM, Tito S, Prendergast A, Jarrett SA, Chiang B, Wattoo A, Azmaiparashvili Z, Lo KB, Benzaquen S, Eiger G. Clinical features and risk factors of adverse clinical outcomes in central pulmonary embolism using machine learning analysis. Respir Med 2023:107295. [PMID: 37236407 DOI: 10.1016/j.rmed.2023.107295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/26/2023] [Accepted: 05/23/2023] [Indexed: 05/28/2023]
Abstract
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.
Collapse
Affiliation(s)
- Omar Cantu-Martinez
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA.
| | | | - Sahana Tito
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Alexander Prendergast
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Simone A Jarrett
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Brenda Chiang
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Ammaar Wattoo
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA; Sidney Kimmel College of Medicine, Thomas Jefferson University, PA 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Zurab Azmaiparashvili
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA; Sidney Kimmel College of Medicine, Thomas Jefferson University, PA 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Kevin Bryan Lo
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA; Sidney Kimmel College of Medicine, Thomas Jefferson University, PA 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Sadia Benzaquen
- Department of Medicine, Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, PA, 19414, USA; Sidney Kimmel College of Medicine, Thomas Jefferson University, PA 5501 Old York Road, Philadelphia, PA, 19414, USA; Department of Pulmonary and Critical Care Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA, 19414, USA
| | - Glenn Eiger
- Sidney Kimmel College of Medicine, Thomas Jefferson University, PA 5501 Old York Road, Philadelphia, PA, 19414, USA; Department of Pulmonary and Critical Care Medicine, Einstein Medical Center, 5501 Old York Road, Philadelphia, PA, 19414, USA
| |
Collapse
|
9
|
Keller K, Schmitt VH, Sagoschen I, Münzel T, Espinola-Klein C, Hobohm L. CRB-65 for Risk Stratification and Prediction of Prognosis in Pulmonary Embolism. J Clin Med 2023; 12:jcm12041264. [PMID: 36835800 PMCID: PMC9961795 DOI: 10.3390/jcm12041264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/29/2023] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is accompanied by high morbidity and mortality. The search for simple and easily assessable risk stratification scores with favourable effectiveness is still ongoing, and prognostic performance of the CRB-65 score in PE might promising. METHODS The German nationwide inpatient sample was used for this study. All patient cases of patients with PE in Germany 2005-2020 were included and stratified for CRB-65 risk class: low-risk group (CRB-65-score 0 points) vs. high-risk group (CRB-65-score ≥1 points). RESULTS Overall, 1,373,145 patient cases of patients with PE (76.6% aged ≥65 years, 47.0% females) were included. Among these, 1,051,244 patient cases (76.6%) were classified as high-risk according to CRB-65 score (≥1 points). The majority of high-risk patients according to CRB-65 score were females (55.8%). Additionally, high-risk patients according to CRB-65 score showed an aggravated comorbidity profile with increased Charlson comorbidity index (5.0 [IQR 4.0-7.0] vs. 2.0 [0.0-3.0], p < 0.001). In-hospital case fatality (19.0% vs. 3.4%, p < 0.001) and MACCE (22.4% vs. 5.1%, p < 0.001) occurred distinctly more often in PE patients of the high-risk group according to CRB-65 score (≥1 points) compared to the low-risk group (= 0 points). The CRB-65 high-risk class was independently associated with in-hospital death (OR 5.53 [95%CI 5.40-5.65], p < 0.001) as well as MACCE (OR 4.31 [95%CI 4.23-4.40], p < 0.001). CONCLUSIONS Risk stratification with CRB-65 score was helpful for identifying PE patients being at higher risk of adverse in-hospital events. The high-risk class according to CRB-65 score (≥1 points) was independently associated with a 5.5-fold increased occurrence of in-hospital death.
Collapse
Affiliation(s)
- Karsten Keller
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
- Correspondence:
| | - Volker H. Schmitt
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Ingo Sagoschen
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Christine Espinola-Klein
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| |
Collapse
|
10
|
Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand (TRAIL): A Novel Biomarker for Prognostic Assessment and Risk Stratification of Acute Pulmonary Embolism. J Clin Med 2022; 11:jcm11133908. [PMID: 35807194 PMCID: PMC9267658 DOI: 10.3390/jcm11133908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/02/2022] [Accepted: 06/27/2022] [Indexed: 12/10/2022] Open
Abstract
Background: Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) is associated with poor prognosis in cardiovascular diseases. However, the predictive value of TRAIL for the short-term outcome and risk stratification of acute pulmonary embolism (PE) remains unknown. Methods: This study prospectively included 151 normotensive patients with acute PE. The study outcome was a composite of 30-day adverse events, defined as PE-related death, shock, mechanical ventilation, cardiopulmonary resuscitation, and major bleeding. Results: Overall, nine of 151 (6.0%) patients experienced 30-day adverse composite events. Multivariable logistic regression showed that TRAIL was an independent predictor of study outcome (OR 0.19 per SD; 95% CI 0.04–0.90). An ROC curve revealed that TRAIL’s area under the curve (AUC) was 0.83 (95% CI 0.76–0.88). The optimal cut-off value for TRAIL was 18 pg/mL, with a sensitivity, specificity, negative predictive value, positive predictive value, positive likelihood ratio, and negative likelihood ratio of 89%, 69%, 99%, 15%, 2.87, and 0.16, respectively. Compared with the risk stratification algorithm outlined in the 2019 ESC guidelines, our biomarker-based risk stratification strategy (combining TRAIL and hs-cTnI) has a similar risk classification effect. Conclusion: Reduced plasma TRAIL levels predict short-term adverse events in normotensive patients with acute PE. The combination of the 2019 ESC algorithm and TRAIL aids risk stratification in normotensive patients with acute PE.
Collapse
|
11
|
Albricker ACL, Freire CMV, Santos SND, Alcantara MLD, Saleh MH, Cantisano AL, Teodoro JAR, Porto CLL, Amaral SID, Veloso OCG, Petisco ACGP, Barros FS, Barros MVLD, Souza AJD, Sobreira ML, Miranda RBD, Moraes DD, Verrastro CGY, Mançano AD, Lima RDSL, Muglia VF, Matushita CS, Lopes RW, Coutinho AMN, Pianta DB, Santos AASMDD, Naves BDL, Vieira MLC, Rochitte CE. Diretriz Conjunta sobre Tromboembolismo Venoso – 2022. Arq Bras Cardiol 2022; 118:797-857. [PMID: 35508060 PMCID: PMC9007000 DOI: 10.36660/abc.20220213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
|
12
|
Abstract
The role of thrombolysis in submassive pulmonary embolism (PE) is controversial due to the high risk of hemorrhage. This study aimed to evaluate the role of half-dose tissue-type plasminogen activator (rt-PA) in preventing death/hemodynamic decompensation in submassive (intermediate-risk) PE without increasing the risk of bleeding. In a prospective, non-randomized, open-label, single-center trial, we compared 50 mg rt-PA plus low molecular weight heparin (LMWH) with LMWH in submassive (intermediate-risk) PE. Eligible cases had confirmed pulmonary hypertension on echocardiography, and/or right ventricular cavity expansion and/or interventricular septal deviation on echocardiography, and/or right to left ventricular ratio equal to or greater than 0.9 mm on CT angiography. The primary outcome was death or hemodynamic decompensation within 7 and 30 days after treatment was given. The primary safety outcome was major extracranial bleeding or hemorrhagic stroke within 7 days. Seventy-six patients were included in the study. Total death/hemodynamic decompensation in the first 7 and 30 days was significantly less in the half-dose rt-PA group than in the LMWH group (p=0.028 and p=0.009, respectively). No significant differences were found between the two groups in terms of recurrent embolism and pulmonary hypertension at 6-month follow-up (p=1.000 and p=0.778). There was no intracranial hemorrhage in any of the patients. There were no statistically significant differences between the two groups in terms of major or minor bleeding complications. This trial showed half-dose rt-PA treatment in submassive (intermediate-risk) PE prevented death/hemodynamic decompensation in the first 7-day and 30-day period compared with LMWH treatment without increasing the risk of bleeding.
Collapse
Affiliation(s)
- Emine Serap Yilmaz
- Pulmonary Medicine, Ordu University Faculty of Medicine, Training and Research Hospital, Ordu, Turkey
| | - Oğuz Uzun
- Pulmonary Medicine, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| |
Collapse
|
13
|
Weekes AJ, Raper JD, Lupez K, Thomas AM, Cox CA, Esener D, Boyd JS, Nomura JT, Davison J, Ockerse PM, Leech S, Johnson J, Abrams E, Murphy K, Kelly C, Norton HJ. Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE). PLoS One 2021; 16:e0260036. [PMID: 34793539 PMCID: PMC8601564 DOI: 10.1371/journal.pone.0260036] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Anthony J. Weekes
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Jaron D. Raper
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Kathryn Lupez
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Alyssa M. Thomas
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Carly A. Cox
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Dasia Esener
- Department of Emergency Medicine, Kaiser Permanente, San Diego, CA, United States of America
| | - Jeremy S. Boyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Jason T. Nomura
- Department of Emergency Medicine, Christiana Care, Newark, DE, United States of America
| | - Jillian Davison
- Department of Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Patrick M. Ockerse
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT, United States of America
| | - Stephen Leech
- Department of Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Jakea Johnson
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Eric Abrams
- Department of Emergency Medicine, Kaiser Permanente, San Diego, CA, United States of America
| | - Kathleen Murphy
- Department of Emergency Medicine, Christiana Care, Newark, DE, United States of America
| | - Christopher Kelly
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT, United States of America
| | - H. James Norton
- Professor Emeritus of Biostatistics, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| |
Collapse
|
14
|
Abstract
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.
Collapse
|
15
|
Lim P, Delmas C, Sanchez O, Meneveau N, Rosario R, Bouvaist H, Bernard A, Mansourati J, Couturaud F, Sebbane M, Coste P, Rohel G, Tardy B, Biendel C, Lairez O, Ivanes F, Gallet R, Dubois-Rande JL, Fard D, Chatelier G, Simon T, Paul M, Natella PA, Layese R, Bastuji-Garin S. Diuretic vs. placebo in intermediate-risk acute pulmonary embolism: a randomized clinical trial. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 11:2-9. [PMID: 34632490 DOI: 10.1093/ehjacc/zuab082] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/01/2021] [Indexed: 11/12/2022]
Abstract
AIMS The role of diuretics in patients with intermediate-risk pulmonary embolism (PE) is controversial. In this multicentre, double-blind trial, we randomly assigned normotensive patients with intermediate-risk PE to receive either a single 80 mg bolus of furosemide or a placebo. METHODS AND RESULTS Eligible patients had at least a simplified PE Severity Index (sPESI) ≥1 with right ventricular dysfunction. The primary efficacy endpoint assessed 24 h after randomization included (i) absence of oligo-anuria and (ii) normalization of all sPESI items. Safety outcomes were worsening renal function and major adverse outcomes at 48 hours defined by death, cardiac arrest, mechanical ventilation, or need of catecholamine. A total of 276 patients underwent randomization; 135 were assigned to receive the diuretic, and 141 to receive the placebo. The primary outcome occurred in 68/132 patients (51.5%) in the diuretic and in 49/132 (37.1%) in the placebo group (relative risk = 1.30, 95% confidence interval 1.04-1.61; P = 0.021). Major adverse outcome at 48 h occurred in 1 (0.8%) patients in the diuretic group and 4 patients (2.9%) in the placebo group (P = 0.19). Increase in serum creatinine level was greater in diuretic than placebo group [+4 µM/L (-2; 14) vs. -1 µM/L (-11; 6), P < 0.001]. CONCLUSION In normotensive patients with intermediate-risk PE, a single bolus of furosemide improved the primary efficacy outcome at 24 h and maintained stable renal function. In the furosemide group, urine output increased, without a demonstrable improvement in heart rate, systolic blood pressure, or arterial oxygenation.ClinicalTrials.gov identifier NCT02268903.
Collapse
Affiliation(s)
- Pascal Lim
- Université Paris Est Creteil, INSERM, IMRB, Creteil F-94010, France.,Department of Cardiology, AP-HP Hôpitaux Universitaires Henri-Mondor, Créteil, France
| | | | - Olivier Sanchez
- Université de Paris, Paris, France.,Division of Respiratory and Intensive Care, AP-HP, Hôpital Europèen Georges Pompidou, Paris, France.,INSERM UMR-S 1140, Innovative Therapies in Haemostasis, Paris, France
| | - Nicolas Meneveau
- Cardiology Department, Besancon University Hospital, EA3920, University of Burgundy Franche-Comté, Besancon, France
| | - Roger Rosario
- Cardiology Department, Hôpital Saint-Joseph, Marseille, France
| | | | - Anne Bernard
- Cardiology Department, CHU, Tours, France and EA4245, Université de Tours, France
| | - Jacques Mansourati
- Respiratory Department, CHRU de la Cavale Blanche, Brest, France and University Hospital of Brest and UBO (Université de Bretagne Occidentale)
| | - Francis Couturaud
- Respiratory Department, CHRU de la Cavale Blanche, Brest, France and University Hospital of Brest and UBO (Université de Bretagne Occidentale)
| | | | - Pierre Coste
- Cardiology Department, Bordeaux University Hospital, France
| | - Gwenole Rohel
- Cardiology Department, Military Hospital of Clermont Tonnerre, Brest, France
| | - Bernard Tardy
- Emergency Department, CHU Saint Etienne, Saint Pirest en Jarez, France
| | | | | | - Fabrice Ivanes
- Cardiology Department, CHU, Tours, France and EA4245, Université de Tours, France
| | - Romain Gallet
- Department of Cardiology, AP-HP Hôpitaux Universitaires Henri-Mondor, Créteil, France.,Emergency Department, CHRU Lapeyronie, Montpellier, France
| | - Jean-Luc Dubois-Rande
- Université Paris Est Creteil, INSERM, IMRB, Creteil F-94010, France.,Department of Cardiology, AP-HP Hôpitaux Universitaires Henri-Mondor, Créteil, France
| | - Damien Fard
- Université Paris Est Creteil, INSERM, IMRB, Creteil F-94010, France.,Department of Cardiology, AP-HP Hôpitaux Universitaires Henri-Mondor, Créteil, France
| | - Gilles Chatelier
- Clinical Research Department, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Tabassome Simon
- Cinical Pharmacology, AP-HP, Hôpital Saint-Antoine, Paris, France
| | - Muriel Paul
- Université Paris Est Creteil, INSERM, IMRB, Creteil F-94010, France.,AP-HP Hôpitaux Universitaires Henri-Mondor, Clinical Pharmacology, Créteil F-94010, France
| | - Pierre-André Natella
- Université Paris Est Creteil, INSERM, IMRB, Creteil F-94010, France.,Department of Public Health, AP-HP Hôpitaux Universitaires Henri-Mondor, Creteil F-94010, France
| | - Richard Layese
- Université Paris Est Creteil, INSERM, IMRB, Creteil F-94010, France
| | - Sylvie Bastuji-Garin
- Université Paris Est Creteil, INSERM, IMRB, Creteil F-94010, France.,Department of Public Health, AP-HP Hôpitaux Universitaires Henri-Mondor, Creteil F-94010, France
| |
Collapse
|
16
|
Sanchez O, Charles-Nelson A, Ageno W, Barco S, Binder H, Chatellier G, Duerschmied D, Empen K, Ferreira M, Girard P, Huisman MV, Jiménez D, Katsahian S, Kozak M, Lankeit M, Meneveau N, Pruszczyk P, Petris A, Righini M, Rosenkranz S, Schellong S, Stefanovic B, Verhamme P, de Wit K, Vicaut E, Zirlik A, Konstantinides SV, Meyer G. Reduced-Dose Intravenous Thrombolysis for Acute Intermediate-High-risk Pulmonary Embolism: Rationale and Design of the Pulmonary Embolism International THrOmbolysis (PEITHO)-3 trial. Thromb Haemost 2021; 122:857-866. [PMID: 34560806 PMCID: PMC9197594 DOI: 10.1055/a-1653-4699] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Intermediate–high-risk pulmonary embolism (PE) is characterized by right ventricular (RV) dysfunction and elevated circulating cardiac troponin levels despite apparent hemodynamic stability at presentation. In these patients, full-dose systemic thrombolysis reduced the risk of hemodynamic decompensation or death but increased the risk of life-threatening bleeding. Reduced-dose thrombolysis may be capable of improving safety while maintaining reperfusion efficacy. The Pulmonary Embolism International THrOmbolysis (PEITHO)-3 study (ClinicalTrials.gov Identifier: NCT04430569) is a randomized, placebo-controlled, double-blind, multicenter, multinational trial with long-term follow-up. We will compare the efficacy and safety of a reduced-dose alteplase regimen with standard heparin anticoagulation. Patients with intermediate–high-risk PE will also fulfill at least one clinical criterion of severity: systolic blood pressure ≤110 mm Hg, respiratory rate >20 breaths/min, or history of heart failure. The primary efficacy outcome is the composite of all-cause death, hemodynamic decompensation, or PE recurrence within 30 days of randomization. Key secondary outcomes, to be included in hierarchical analysis, are fatal or GUSTO severe or life-threatening bleeding; net clinical benefit (primary efficacy outcome plus severe or life-threatening bleeding); and all-cause death, all within 30 days. All outcomes will be adjudicated by an independent committee. Further outcomes include PE-related death, hemodynamic decompensation, or stroke within 30 days; dyspnea, functional limitation, or RV dysfunction at 6 months and 2 years; and utilization of health care resources within 30 days and 2 years. The study is planned to enroll 650 patients. The results are expected to have a major impact on risk-adjusted treatment of acute PE and inform guideline recommendations.
Collapse
Affiliation(s)
- Olivier Sanchez
- AP-HP, hôpital européen Georges-Pompidou, Service de Pneumologie et de Soins Intensifs, APHP.Centre - Université de Paris, Paris, France.,INSERM UMR S 1140 Innovative Therapies in Hemostasis, Paris, France.,Université de Paris, Paris, France.,FCRIN INNOVTE, St-Etienne, France
| | - Anaïs Charles-Nelson
- AP-HP, hôpital européen Georges-Pompidou, Unité de Recherche Clinique, APHP.Centre, Paris, France.,INSERM, Centre d'Investigation Clinique 1418 (CIC1418) Épidémiologie Clinique, Paris, France
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Harald Binder
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Gilles Chatellier
- Université de Paris, Paris, France.,AP-HP, hôpital européen Georges-Pompidou, Unité de Recherche Clinique, APHP.Centre, Paris, France.,INSERM, Centre d'Investigation Clinique 1418 (CIC1418) Épidémiologie Clinique, Paris, France
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Empen
- Department of Internal Medicine, Städtisches Klinikum Dessau, Germany
| | - Melanie Ferreira
- Internal Medicine Department, Hospital Garcia de Orta, Almada, Portugal
| | - Philippe Girard
- FCRIN INNOVTE, St-Etienne, France.,Département Thoracique, Institut Mutualiste Montsouris, Paris, France
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Dutch Thrombosis Network, Leiden, The Netherlands
| | - David Jiménez
- Department of Respiratory Diseases, Ramon y Cajal Hospital, Universidad de Alcalá (IRYCIS), CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Sandrine Katsahian
- Université de Paris, Paris, France.,AP-HP, hôpital européen Georges-Pompidou, Unité de Recherche Clinique, APHP.Centre, Paris, France.,INSERM, Centre d'Investigation Clinique 1418 (CIC1418) Épidémiologie Clinique, Paris, France.,INSERM UMR_S 1138 équipe 22, Centre de Recherche des Cordeliers, Paris, France
| | - Matija Kozak
- Department of Vascular Diseases, University Medical Center, Ljubljana, Slovenia
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Department of Internal Medicine, Vascular Medicine and Haemostaseology, Vivantes Klinikum im Friedrichshain, Berlin, Germany.,Clinic of Cardiology and Pneumology, University Medical Center Goettingen, Goettingen, Germany
| | - Nicolas Meneveau
- FCRIN INNOVTE, St-Etienne, France.,Department of Cardiology, University Hospital Jean Minjoz, Besançon, France.,EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Antoniu Petris
- Grigore T. Popa University of Medicine and Pharmacy Iasi, Cardiology Clinic, "St. Spiridon" County Clinical Emergency Hospital, Iasi, Romania
| | - Marc Righini
- Division of Angiology and Haemostasis, Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - Stephan Rosenkranz
- Department III of Internal Medicine and Cologne Cardiovascular Research Center (CCRC), Cologne University Heart Center, Cologne, Germany
| | - Sebastian Schellong
- Department of Internal Medicine 2, Municipal Hospital Dresden, Dresden, Germany
| | - Branislav Stefanovic
- Cardiology Clinic, Emergency Center, University Clinical Center of Serbia, School of Medicine University Belgrade, Belgrade, Serbia
| | - Peter Verhamme
- Vascular Medicine and Haemostasis, Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Kerstin de Wit
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Eric Vicaut
- AP-HP, Unité de Recherche Clinique St-Louis-Lariboisière, Université Denis Diderot, Paris, France
| | - Andreas Zirlik
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Guy Meyer
- AP-HP, hôpital européen Georges-Pompidou, Service de Pneumologie et de Soins Intensifs, APHP.Centre - Université de Paris, Paris, France.,Université de Paris, Paris, France.,FCRIN INNOVTE, St-Etienne, France
| | | |
Collapse
|
17
|
Chopard R, Piazza G, Falvo N, Ecarnot F, Besutti M, Capellier G, Schiele F, Badoz M, Meneveau N. An Original Risk Score to Predict Early Major Bleeding in Acute Pulmonary Embolism: The Syncope, Anemia, Renal Dysfunction (PE-SARD) Bleeding Score. Chest 2021; 160:1832-1843. [PMID: 34217683 DOI: 10.1016/j.chest.2021.06.048] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/03/2021] [Accepted: 06/14/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Improved prediction of the risk of early major bleeding in pulmonary embolism (PE) is needed to optimize acute management. RESEARCH QUESTION Does a simple scoring system predict early major bleeding in acute PE patients, identifying patients with either high or low probability of early major bleeding? STUDY DESIGN AND METHODS From a multicenter prospective registry including 2,754 patients, we performed post hoc multivariable logistic regression analysis to build a risk score to predict early (up to hospital discharge) major bleeding events. We validated the endpoint model internally, using bootstrapping in the derivation dataset by sampling with replacement for 500 iterations. Performances of this novel score were compared with that of the VTE-BLEED, RIETE, and BACS models. RESULTS Multivariable regression identified three predictors for the occurrence of 82 major bleeds (3.0%; 95% CI, 2.39%-3.72%): Syncope (+1.5); Anemia, defined as hemoglobin <12 g/dL (+2.5); and Renal Dysfunction, defined as glomerular filtration rate <60 mL/min (+1 point) (SARD). The PE-SARD bleeding score was calculated by summing all the components. Overall, 52.2% (95% CI; 50.29%-54.11%) of patients were classified as low bleeding-risk (score, 0 point), 35.2% (95% CI, 33.39%-37.04%) intermediate-risk (score, 1-2.5 points), and 12.6% (95% CI, 9.30%-16.56%) high-risk (score >2.5 points). Observed bleeding rates increased with increasing risk group, from 0.97% (95% CI, 0.53%-1.62%) in the low-risk to 8.93% (95% CI, 6.15%-12.44%) in the high-risk group. C-index was 0.74 (95% CI, 0.73-0.76) and Brier score 0.028 in the derivation cohort. Similar values were calculated from internal bootstrapping. Performance of the PE-SARD score was better than that observed with the VTE-BLEED, RIETE, and BACS scores, leading to a high proportion of bleeding-risk reclassification in patients who bled and those who did not. INTERPRETATION The PE-SARD bleeding risk score is an original, user-friendly score to estimate risk of early major bleeding in patients with acute PE.
Collapse
Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France; EA3920, University of Burgundy Franche-Comté, Besançon, France; F-CRIN, INNOVTE network, France.
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Nicolas Falvo
- Department of Internal Medicine, University Hospital Dijon-Bourgogne, Dijon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France; EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Mathieu Besutti
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France
| | - Gilles Capellier
- EA3920, University of Burgundy Franche-Comté, Besançon, France; Medical Intensive Care Unit, University Hospital Jean Minjoz, Besançon, France
| | - François Schiele
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France; EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Marc Badoz
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France; EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France; EA3920, University of Burgundy Franche-Comté, Besançon, France; F-CRIN, INNOVTE network, France
| |
Collapse
|
18
|
Caliskan T, Turkoglu O, Canoglu K, Ayten O, Saylan B, Okutan O, Kartaloglu Z. The Comparison Between Non-High Risk Patients with and Without Cancer Diagnosed with Pulmonary Embolism. Medeni Med J 2021; 36:30-35. [PMID: 33828887 PMCID: PMC8020190 DOI: 10.5222/mmj.2021.43066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/27/2021] [Indexed: 12/11/2022] Open
Abstract
Objective This study aimed to compare the pulmonary embolism (PE) location and clot burden on computed tomography pulmonary angiography (CTPA), the degree of right ventricular dysfunction (RVD), D-dimer, and cardiac troponin I (cTnI) levels, and the presence of a lower extremity deep venous thrombosis (DVT) in patients with and without cancer diagnosed with a non high risk pulmonary embolism (PE). Method We calculated Miller score for each patient for clot burden. The location of PE was also evaluated at CTPA. D-dimer and cardiac cTnI levels were measured. Patients had echocardiography for RVD and lower extremity color flow Doppler ultrasonography for DVT. Results The study included 71 patients with PE. The patients were divided into two groups according to the presence of cancer. There was no statistically significant difference for D-dimer levels (P=0.15), PE location (p=0.67), clot burden (P=0.34), RVD (P=0.28) and DVT (P=0.33) between groups (P=0.15). Cancer patients diagnosed as PE had statistically significantly higher levels of cTnI than those who were diagnosed as PE without cancer (P=0.03). Conclusion There was no significant difference between patients diagnosed as PE with and without cancer in terms of D-dimer levels, clot burden and emboli location, RVD and DVT. cTnI levels were higher in non-high risk PE patients with cancer than these patients without cancer.
Collapse
Affiliation(s)
- Tayfun Caliskan
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| | - Ozlem Turkoglu
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Radiology, Istanbul, Turkey
| | - Kadir Canoglu
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| | - Omer Ayten
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| | - Bengu Saylan
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| | - Oguzhan Okutan
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| | - Zafer Kartaloglu
- Health Sciences University, Sultan 2. Abdulhamit Han Training and Research Hospital, Department of Pulmonology, Istanbul, Turkey
| |
Collapse
|
19
|
Gao Y, Ji C, Zhao H, Han J, Shen H, Jia D. Developing a scoring tool to estimate the risk of deterioration for normotensive patients with acute pulmonary embolism on admission. Respir Res 2021; 22:9. [PMID: 33407492 PMCID: PMC7788965 DOI: 10.1186/s12931-020-01602-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 12/14/2020] [Indexed: 12/23/2022] Open
Abstract
Background It is important to identify deterioration in normotensive patients with acute pulmonary embolism (PE). This study aimed to develop a tool for predicting deterioration among normotensive patients with acute PE on admission. Methods Clinical, laboratory, and computed tomography parameters were retrospectively collected for normotensive patients with acute PE who were treated at a Chinese center from January 2011 to May 2020 on admission into the hospital. The endpoint of the deterioration was any adverse outcome within 30 days. Eligible patients were randomized 2:1 to derivation and validation cohorts, and a nomogram was developed and validated by the aforementioned cohorts, respectively. The areas under the curves (AUCs) with 95% confidence intervals (CIs) were calculated. A risk-scoring tool for predicting deterioration was applied as a web-based calculator. Results The 845 eligible patients (420 men, 425 women) had an average age of 60.05 ± 15.43 years. Adverse outcomes were identified for 81 patients (9.6%). The nomogram for adverse outcomes included heart rate, systolic pressure, N-terminal-pro brain natriuretic peptide, and ventricle/atrial diameter ratios at 4-chamber view, which provided AUC values of 0.925 in the derivation cohort (95% CI 0.900–0.946, p < 0.001) and 0.900 in the validation cohort (95% CI 0.883–0.948, p < 0.001). A risk-scoring tool was published as a web-based calculator (https://gaoyzcmu.shinyapps.io/APE9AD/). Conclusions We developed a web-based scoring tool that may help predict deterioration in normotensive patients with acute PE.
Collapse
Affiliation(s)
- Yizhuo Gao
- Department of Pulmonary and Critical Care Medicine, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, China
| | - Chao Ji
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, China
| | - Hongyu Zhao
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, China
| | - Jun Han
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, China
| | - Haitao Shen
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, China
| | - Dong Jia
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Shenyang, China.
| |
Collapse
|
20
|
Jugular vein diameter: A new player in normotensive pulmonary embolism. Clin Imaging 2021; 74:4-9. [PMID: 33421699 DOI: 10.1016/j.clinimag.2020.12.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 12/12/2020] [Accepted: 12/30/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE The majority of the patients with pulmonary embolism (PE) are those with normotensive PE. Right ventricular dysfunction (RVD) and myocardial injury markers are associated with mortality although they have a low predictive impact. Here, we aim to study the performance characteristics of jugular vein diameter to predict 30-day mortality. MATERIALS AND METHODS In this prospective, observational cohort study, we included normotensive patients who were diagnosed with PE using computed tomography angiography or scintigraphy in the emergency service. The demographic characteristics, blood pressures, pulses, shock indexes, troponin and lactate levels, echocardiography findings, and internal jugular vein diameters (IJV) of the patients were recorded. Testing characteristics of IJV in predicting 30-day mortality were studied. RESULTS The mean age of the 81 patients was 66.8±16.9 years and 37% of them were male. Age, shock index, lactate, RVD, PESI, and IJV diameters during inspiration and expiration were indicators for 30-day mortality. The cut-off value obtained using the ROC curve for mortality was an IJV-exp-AP of ≤8.9 mm (sensitivity,73.3%; specificity,92.4%; +LR,9.68; -LR,0.29; NPD,93.8%; PPD,68.7%; area under the curve, 0.76; 95% confidence interval, 0.65-0.84; p=0.004). CONCLUSION IJV diameter is an indicator of 30-day mortality. It can be used to detect low-risk patients.
Collapse
|
21
|
Сherepanova NA, Mullova IS, Kiselev AR, Pavlova TV, Khokhlunov SM, Duplyakov DV. Thrombolytic Therapy in Normotensive Patients with Pulmonary Embolism (Data from the Retrospective Study). RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-10-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background. The thrombolytic therapy is absolutely recommended for patients in shock or hypotension because the benefits are clearly outweighing the risks. However, in hemodynamically stable patients, including those with acute right ventricular dysfunction and/or myocardial damage, thrombolysis has a significantly lower evidence level.Aim. To study the criteria based on which doctors decide to conduct thrombolytic therapy in normotensive patients in real clinical practice according to the retrospective data.Material and methods. A single-center retrospective cohort study analyzed medical records of patients hospitalized in 2006-2017 with a verified diagnosis of pulmonary embolism (PE) and who had a systolic blood pressure >90 mm Hg at the time of admission.Results. The present study population included 299 patients with a verified diagnosis of PE from 2006 to 2017 years. Patients were divided into two groups: with thrombolysis (group 1) and without thrombolysis (group 2). Logistic regression analysis showed that age younger than 60 years, the presence of varicose veins of the lower extremities, skin cyanosis, syncope in the debut of PE were independent clinical factors that significantly influence the doctor's decision to perform thrombolysis. Increased troponin I, right ventricular dysfunction, and the severity of PE according to the PESI score showed no significant impact on this decision. In-hospital mortality in the group 2 was 1.9% (5 patients), while there were no deaths in the group 1. But the analysis of the association of thrombolysis with survival was difficult to perform due to the low incidence of deaths and the small number of patients in the group with thrombolysis (odds ratio 0.34; 95% confidence interval 0.03-8.18; р=0.856). No major bleeding was registered in any group.Conclusion. We were not able to clearly identify independent clinical or instrumental factors that influence the decision to perform thrombolysis in patients with PE outside the framework of evidence-based medicine. Further research is needed.
Collapse
Affiliation(s)
- N. A. Сherepanova
- Samara Regional Cardiology Dispensary named after V.P. Polyakov;
Samara State Medical University
| | - I. S. Mullova
- Samara Regional Cardiology Dispensary named after V.P. Polyakov;
Samara State Medical University
| | - A. R. Kiselev
- Saratov State Medical University named after V.I. Razumovsky
| | | | | | - D. V. Duplyakov
- Samara Regional Cardiology Dispensary named after V.P. Polyakov;
Samara State Medical University
| |
Collapse
|
22
|
Anderson JF, Raptis C, Bhalla S. Performance of Computed Tomographic Pulmonary Angiography Compared With Standard Chest Computed Tomography for Identification of Solid Organ, Serosal, and Nodal Findings. J Thorac Imaging 2020; 35:294-301. [PMID: 32073540 DOI: 10.1097/rti.0000000000000476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Computed tomographic pulmonary angiography (CTPA) is the test of choice for patients with acute chest pain and suspected pulmonary embolism (PE). This examination is excellent for the diagnosis of PE and can also often identify alternative diagnoses. The early phase of contrast, however, may not allow for optimal evaluation of lymph nodes, serosal surfaces, and solid organs, leading to the nonvisualization of important findings and the potential for missed diagnoses. The purpose of this study was to determine the frequency of relevant findings only identified on standard portal venous phase CT compared with CTPA. MATERIALS AND METHODS The reports for all patients in the previous 10 years who underwent both standard CT and CTPA within 7 days, for a total of 675 pairs of scans, were tabulated according to the presence of PE, serosal abnormalities, solid organ abnormalities, and lymphadenopathy. All findings were categorized as present on both scans, standard CT only, or CTPA only. The scans were manually evaluated to exclude findings that were new or resolved on the second study or outside the field of view on one of the studies. RESULTS Significantly more PEs were identified only on CTPA examinations. However, significantly more pleural, peritoneal, and solid organ abnormalities, and abnormal mediastinal and abdominal lymph nodes were identified on standard CT only. There was no significant difference in the identification of pericardial abnormalities or abnormal hilar lymph nodes between the two scans. CONCLUSIONS Many serosal abnormalities, solid organ abnormalities, and lymphadenopathy were only reported on standard portal venous phase CT compared with CTPA.
Collapse
|
23
|
Comparison of seven prognostic tools to identify low-risk pulmonary embolism in patients aged <50 years. Sci Rep 2019; 9:20064. [PMID: 31882805 PMCID: PMC6934558 DOI: 10.1038/s41598-019-55213-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 11/23/2019] [Indexed: 11/21/2022] Open
Abstract
In young patients with acute pulmonary embolism (PE), the predictive value of currently available prognostic tools has not been evaluated. Our objective was to compare prognostic value of 7 available tools (GPS, PESI, sPESI, Prognostic Algorithm, PREP, shock index and RIETE) in patients aged <50 years. We used the RIETE database, including PE patients from 2001 to 2017. The major outcome was 30-day all-cause mortality. Of 34,651 patients with acute PE, 5,822 (17%) were aged <50 years. Of these, 83 (1.4%) died during the first 30 days. Number of patients deemed low risk with tools was: PREP (95.9%), GPS (89.6%), PESI (87.2%), Shock index (70.9%), sPESI (59.4%), Prognostic algorithm (58%) and RIETE score (48.6%). The tools with a highest sensitivity were: Prognostic Algorithm (91.6%; 95% CI: 85.6–97.5), RIETE score (90.4%; 95%CI: 84.0–96.7) and sPESI (88%; 95% CI: 81–95). The RIETE, Prognostic Algorithm and sPESI scores obtained the highest overall sensitivity estimates for also predicting 7- and 90-day all-cause mortality, 30-day PE-related mortality, 30-day major bleeding and 30-day VTE recurrences. The proportion of low-risk patients who died within the first 30 days was lowest using the Prognostic Algorithm (0.2%), RIETE (0.3%) or sPESI (0.3%) scores. In PE patients less 50 years, 30-day mortality was low. Although sPESI, RIETE and Prognostic Algorithm scores were the most sensitive tools to identify patients at low risk to die, other tools should be evaluated in this population to obtain more efficient results.
Collapse
|
24
|
Barco S, Ende-Verhaar YM, Becattini C, Jimenez D, Lankeit M, Huisman MV, Konstantinides SV, Klok FA. Differential impact of syncope on the prognosis of patients with acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2019; 39:4186-4195. [PMID: 30339253 DOI: 10.1093/eurheartj/ehy631] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 09/18/2018] [Indexed: 01/08/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Stefano Barco
- Center for Thrombosis and Haemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany
| | - Yvonne M Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Albinusdreef 2, RC, Leiden, the Netherlands
| | - Cecilia Becattini
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, via Dottori 1, Perugia, Italy
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Ctra. Colmenar Km. 9,100, Madrid, Spain
| | - Mareike Lankeit
- Center for Thrombosis and Haemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Augustenburger Platz 1, Berlin, Germany.,Clinic for Cardiology and Pneumology, Georg-August University of Göttingen, Göttingen, Germany
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Albinusdreef 2, RC, Leiden, the Netherlands
| | - Stavros V Konstantinides
- Center for Thrombosis and Haemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany.,Department of Cardiology Democritus University of Thrace, University General Hospital, Alexandroupolis, Greece
| | - Frederikus A Klok
- Center for Thrombosis and Haemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany.,Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Albinusdreef 2, RC, Leiden, the Netherlands
| |
Collapse
|
25
|
Gul MH, Htun ZM, Rigdon J, Rivera-Lebron B, Perez VDJ. Clinical outcomes of inferior vena cava filter in complicated pulmonary embolism. Pulm Circ 2019; 9:2045894019882636. [PMID: 31798833 DOI: 10.1177/2045894019882636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 09/24/2019] [Indexed: 12/25/2022] Open
Abstract
Background: Previous observational studies suggest that inferior vena cava filter placement in pulmonary embolism patients complicated with congestive heart failure, mechanical ventilation, and shock may have a mortality benefit. We sought to analyze the survival benefits of inferior vena cava filter in pulmonary embolism patients complicated with acute myocardial infarction, acute respiratory failure, shock, or requiring treatment with thrombolytics. Methods: This retrospective observational study used hospital discharge data from the National Inpatient Sample Data (NIS). ICD-9-CM coding was used to identify complicated pulmonary embolism patients (N = 254,465) in NIS from 2002 to 2014, including the subgroups of acute myocardial infarction, acute respiratory failure, shock, and thrombolytics. Inferior vena cava filter recipients were 1:1 propensity score-matched on age, sex, race, deep vein thrombosis, Elixhauser comorbidities, and other pulmonary embolism comorbidities (45 covariates) to non-inferior vena cava filter recipients in complicated pulmonary embolism patients and separately in each subgroup. Clinical outcomes were compared between the inferior vena cava filter group and the non-inferior vena cava filter group. Results: Mortality rate in complicated pulmonary embolism patients with inferior vena cava filter placement was lower (20.9% vs. 33%; NNT = 8.28, 95% confidence interval (CI) 7.91-8.69, E-value = 2.53) and in the subgroups; acute myocardial infarction (17.9% vs. 30.1%; NNT = 8.19, 95% CI 7.52-8.92, E-value = 2.76), acute respiratory failure (19.5% vs. 29.7%; NNT = 9.76, 95% CI 8.67-11.16, E-value = 2.38), shock (30.7% vs. 47.1%; NNT = 6.08, 95% CI 5.73-6.47, E-value = 2.43), and with the use of thrombolytics (7% vs. 12.9 %; NNT 17.1, 95% CI 14.88-20.12, E-value = 3.01) (p < 0.001 for all). Conclusion: Inferior vena cava filter placement in pulmonary embolism complicated with acute myocardial infarction, acute respiratory failure, shock, or requiring thrombolytic therapy was associated with reduced mortality.
Collapse
Affiliation(s)
- Muhammad H Gul
- Internal Medicine, Amita-Presence Saint Joseph Hospital Chicago, Chicago, IL, USA
| | - Zin M Htun
- Internal Medicine, Weiss Memorial Hospital Chicago, Chicago, IL, USA
| | - Joseph Rigdon
- Quantitative Sciences Unit, Stanford University California, Stanford, CA, USA
| | - Belinda Rivera-Lebron
- Pulmonary and Critical Care Medicine, University of Pittsburgh Pennsylvania, Pittsburgh, PA, USA
| | | |
Collapse
|
26
|
Computed tomography pulmonary angiography for acute pulmonary embolism: prediction of adverse outcomes and 90-day mortality in a single test. Pol J Radiol 2019; 84:e436-e446. [PMID: 31969963 PMCID: PMC6964354 DOI: 10.5114/pjr.2019.89896] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 10/01/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose Pulmonary embolism (PE) is a potentially fatal cardiopulmonary disease; therefore, rapid risk stratification is necessary to make decisions of appropriate management strategies. The aim of this study was to assess various computed tomography (CT) findings in order to find new prognostic factors of adverse outcome and mortality. Material and methods The study enrolled 104 patients with acute PE. Based on their outcome, patients were categorised into four groups. Comorbidities such as ischaemic heart disease were obtained from their medical records. Patients CT angiography were reviewed for recording variables such as main pulmonary artery diameter and right ventricle (RV)/left ventricle (LV) ratio. Patient deaths up to three months since diagnosis of PE had been registered. Logistic regression analysis was performed to find predictors. Results Based on multiple logistic regression, RV/LV ratio, LV diameter, and right-sided pulmonary infarction are predictors of mortality in 30 days. An RV/LV ratio of 1.19 could successfully discriminate patients who died within 30 days and those who did not. Conclusions RV/LV ratio, LV diameter, right-sided pulmonary infarction, assessed with helical CT, can help predict 30-day mortality.
Collapse
|
27
|
Meneveau N, Sanchez O. [How to estimate the prognosis of a pulmonary embolism?]. Rev Mal Respir 2019; 38 Suppl 1:e32-e40. [PMID: 31585779 DOI: 10.1016/j.rmr.2019.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- N Meneveau
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Service de cardiologie, CHU Jean-Minjoz, EA3920, université de Bourgogne-Franche Comté, boulevard Fleming, 25030 Besançon cedex, France
| | - O Sanchez
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Université de Paris, Service de pneumologie et soins intensifs, AH-HP, hôpital Européen Georges-Pompidou, 75015 Paris, France; Innovations Thérapeutiques en Hémostase, INSERM UMRS 1140, 75006 Paris, France.
| |
Collapse
|
28
|
Guo J, Deng QF, Xiong W, Pudasaini B, Yuan P, Liu JM, Zhou CC. Comparison among different presentations of venous thromboembolism because of lung cancer. CLINICAL RESPIRATORY JOURNAL 2019; 13:574-582. [PMID: 31306554 DOI: 10.1111/crj.13060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/12/2018] [Accepted: 07/08/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) because of lung cancer has been sufficiently studied, nevertheless, little is known regarding the discrepancy of clinical characteristics and predictive factors among different presentations of VTE because of lung cancer. OBJECTIVES This study was designed to investigate the distinction of clinical characteristics and predictive factors among different presentations of VTE because of lung cancer. METHODS All patients concomitant lung cancer and VTE were stratified into three groups: pulmonary embolism (PE) group in which patients had sole PE, deep vein thrombosis (DVT) group with sole DVT and concomitance group with both PE and DVT. RESULTS Concomitance of PE and DVT (28.2 days) mostly occurred at the early stage after the diagnosis of lung cancer, by contrast with DVT (63.6 days) which did at the latest stage, whereas PE (36.7 days) generally developed intermediately in between (P = .02). In a Kaplan-Meier analysis, the cumulative survival rate of DVT group was higher than that of concomitance group, whereas the rate of PE group lied in between. (P = .002) The strongest correlated factors with the development of DVT, PE and concomitance were adenocarcinoma (HR 3.27, P = .003), chemotherapy (HR 2.62, P = .005) and D-Dimer (HR 3.88, P < .001), respectively. The strongest correlated factors with the mortality of DVT, PE and concomitance were comorbidity (HR 2.32, P = .003), metastasis (HR 3.12, P < .001), and metastasis (HR 4.29, P < .001), respectively. CONCLUSION Concomitance of DVT and PE represents the severest state of lung cancer, the earliest occurrence of VTE, and the worst survival rate, whereas DVT stands for the mildest condition of lung cancer and stablest pattern of VTE.
Collapse
Affiliation(s)
- Jian Guo
- Soochow University, Suzhou, China.,Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qin-Fang Deng
- Soochow University, Suzhou, China.,Department of Oncology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wei Xiong
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Respiratory Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Bigyan Pudasaini
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ping Yuan
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jin-Ming Liu
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Cai-Cun Zhou
- Soochow University, Suzhou, China.,Department of Oncology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| |
Collapse
|
29
|
Becattini C, Cimini LA, Vedovati MC. Patients with acute pulmonary embolism at intermediate risk for death: Can we further stratify? Eur J Intern Med 2019; 65:29-31. [PMID: 31248737 DOI: 10.1016/j.ejim.2019.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 06/13/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy.
| | - Ludovica Anna Cimini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | | |
Collapse
|
30
|
Kruger PC, Eikelboom JW, Douketis JD, Hankey GJ. Pulmonary embolism: update on diagnosis and management. Med J Aust 2019; 211:82-87. [PMID: 31216072 DOI: 10.5694/mja2.50233] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition, mandating urgent diagnosis and treatment. The symptoms of PE may be non-specific; diagnosis therefore relies on a clinical assessment and objective diagnostic testing. A clinical decision rule can determine the pre-test probability of PE. If PE is "unlikely", refer for a D-dimer test. If the D-dimer result is normal, PE can be excluded. If D-dimer levels are increased, refer for chest imaging. If PE is "likely", refer for chest imaging. Imaging with computed tomography pulmonary angiogram is accurate and preferred for diagnosing PE, but may detect asymptomatic PE of uncertain clinical significance. Imaging with ventilation-perfusion (VQ) scan is associated with lower radiation exposure than computed tomography pulmonary angiogram, and may be preferred in younger patients and pregnancy. A low probability or high probability VQ scan is helpful for ruling out or confirming PE, respectively; however, an intermediate probability VQ scan requires further investigation. The direct oral anticoagulants have expanded the anticoagulation options for PE. These are the preferred anticoagulant for most patients with PE because they are associated with a lower risk of bleeding, and have the practical advantages of fixed dosage, no need for routine monitoring, and fewer drug interactions compared with vitamin K antagonists. Initial parenteral treatment is required before dabigatran and edoxaban.
Collapse
Affiliation(s)
- Paul C Kruger
- Fiona Stanley Hospital, Perth, WA.,PathWest Laboratory Medicine, Perth, WA.,Population Health Research Institute, Hamilton, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, Canada.,Hamilton Health Sciences, Hamilton, Canada
| | - James D Douketis
- Hamilton Health Sciences, Hamilton, Canada.,St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, Canada
| | | |
Collapse
|
31
|
Santos AR, Freitas P, Ferreira J, Oliveira A, Gonçalves M, Faria D, Bicho Augusto J, Simões J, Santos A, Gago M, Oliveira J, Antunes RM, Correia D, Lynce A, Brito J, Morais C, Campos L, Mendes M. Risk stratification in normotensive acute pulmonary embolism patients: focus on the intermediate-high risk subgroup. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 9:279-285. [PMID: 31017472 DOI: 10.1177/2048872619846506] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- Ana Rita Santos
- Internal Medicine Department, Hospital de São Francisco Xavier, Portugal
| | - Pedro Freitas
- Cardiology Department, Hospital de Santa Cruz, Portugal
| | | | | | | | - Daniel Faria
- Cardiology Department, Hospital Prof Doutor Fernando Fonseca, Portugal
| | | | - Joana Simões
- Cardiology Department, Hospital Prof Doutor Fernando Fonseca, Portugal
| | - Ana Santos
- Radiology Department, Centro Hospitalar Lisboa Ocidental, Portugal
| | - Miguel Gago
- Radiology Department, Centro Hospitalar Lisboa Ocidental, Portugal
| | - João Oliveira
- Radiology Department, Centro Hospitalar Lisboa Ocidental, Portugal
| | | | - David Correia
- Radiology Department, Centro Hospitalar Lisboa Ocidental, Portugal
| | - Ana Lynce
- Internal Medicine Department, Hospital de São Francisco Xavier, Portugal
| | - João Brito
- Cardiology Department, Hospital de Santa Cruz, Portugal
| | - Carlos Morais
- Cardiology Department, Hospital Prof Doutor Fernando Fonseca, Portugal
| | - Luís Campos
- Internal Medicine Department, Hospital de São Francisco Xavier, Portugal
| | - Miguel Mendes
- Cardiology Department, Hospital de Santa Cruz, Portugal
| |
Collapse
|
32
|
Grothusen C, Lankeit M, Olsson K, Panholzer B, Haneya A, Cremer J. Akute Lungenembolie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-018-0286-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
33
|
Keller K, Beule J, Balzer JO, Dippold W. Evaluation of Risk Stratification Markers and Models in Acute Pulmonary Embolism: Rationale and Design of the MARS-PE (Mainz Retrospective Study of Pulmonary Embolism) Study Programme. ACTA MEDICA (HRADEC KRÁLOVÉ) 2018; 61:93-97. [DOI: 10.14712/18059694.2018.124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
An acute pulmonary embolism (PE) is a crucial event in patients’ life and connected with serious morbidity and mortality. Regarding a high case-fatality rate, early and accurate risk-stratification is crucial. Risk for mortality and complications are closely related to hemodynamic stability and cardiac adaptations. The currently recommended risk-stratification approach is not overall simple to use and might delay the identification of those patients, who should be monitored more closely and may treated with more aggressive treatment strategies. Additionally, some risk-stratification criteria for the imaging procedures are still imprecise. Summarized, the search for the most effective risk-stratification tools is still ongoing and some diagnostic criteria might have to be refined. In the MAinz Retrospective Study of Pulmonary Embolism (MARS-PE), overall 182 consecutive patients with confirmed PE were retrospectively included over a 5-year period. Clinical, echocardiographic, functional and laboratory parameters were assessed. The study was designed to provide answers to some of the mentioned relevant questions.
Collapse
|
34
|
Philippot Q, Roche A, Goyard C, Pastré J, Planquette B, Meyer G, Sanchez O. Prise en charge de l'embolie pulmonaire grave en réanimation. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L'embolie pulmonaire (EP) grave, définie par la présence d’un état de choc, est à l'origine d'une mortalité importante. L'objectif de cette mise au point est de synthétiser les dernières avancées et recommandations concernant la prise en charge des formes graves d'EP. La stratification du risque individuel de mortalité précoce permet d'apporter une stratégie diagnostique et thérapeutique optimisée pour chaque patient. Le traitement symptomatique consiste essentiellement en la prise en charge de l'état de choc. L'anticoagulation curative par héparine non fractionnée est réservée aux patients hémodynamiquement instables. Chez ces patients à haut risque, la thrombolyse systémique diminue la mortalité et le risque de récidive d'EP. Chez les patients à risque intermédiaire élevé, la thrombolyse systémique à dose standard diminue le risque de choc secondaire mais sans impact sur la mortalité globale. La thrombolyse est donc réservée aux patients à risque intermédiaire élevé présentant secondairement un état de choc. L'embolectomie chirurgicale reste indiquée en cas de contre-indication absolue à la thrombolyse ou en cas d'échec de celle-ci. Le positionnement dans l'algorithme thérapeutique de l'assistance extracorporelle et des techniques percutanées de revascularisation reste à définir. Leurs indications doivent donc être discutées dans des centres experts après une concertation multidisciplinaire incluant pneumologues, cardiologues, réanimateurs, radiologues interventionnels et chirurgiens cardiaques.
Collapse
|
35
|
Bledsoe JR, Woller SC, Stevens SM, Aston V, Patten R, Allen T, Horne BD, Dong L, Lloyd J, Snow G, Madsen T, Elliott CG. Management of Low-Risk Pulmonary Embolism Patients Without Hospitalization. Chest 2018; 154:249-256. [DOI: 10.1016/j.chest.2018.01.035] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/17/2018] [Accepted: 01/19/2018] [Indexed: 12/18/2022] Open
|
36
|
Abstract
Pulmonary embolism (PE) in children is a rare condition with potential for high mortality. PE incidence is increasing owing to increased survival of children with predisposing conditions, increased use of central venous catheters, and improved awareness and recognition. Although pediatric PE is distinct from adult PE, management guidelines in children are extrapolated from the adult data. Treatment includes thrombolysis or thrombectomy, and pharmacologic anticoagulation. Ongoing clinical trials are evaluating the use of direct oral anticoagulants in children. Further research is required to develop pediatric-specific evidence-based guidelines for diagnosis and management of PE.
Collapse
Affiliation(s)
- Sarah Ramiz
- Division of Pediatric Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Street, Detroit, MI 48201, USA
| | - Madhvi Rajpurkar
- Division of Pediatric Hematology Oncology, Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children's Hospital of Michigan, 3901 Beaubien Street, Detroit, MI 48201, USA.
| |
Collapse
|
37
|
Bova C, Vanni S, Prandoni P, Morello F, Dentali F, Bernardi E, Mumoli N, Bucherini E, Barbar S, Picariello C, Enea I, Pesavento R, Bottino F, Jiménez D. A prospective validation of the Bova score in normotensive patients with acute pulmonary embolism. Thromb Res 2018; 165:107-111. [PMID: 29631073 DOI: 10.1016/j.thromres.2018.04.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 03/17/2018] [Accepted: 04/02/2018] [Indexed: 11/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- Carlo Bova
- Department of Internal Medicine, Azienda Ospedaliera (Coordinating Center), Cosenza, Italy.
| | - Simone Vanni
- Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Paolo Prandoni
- Department of Cardiovascular Sciences, Vascular Medicine Unit, University of Padua, Italy
| | - Fulvio Morello
- Emergency Department, A.O.U. Città della Salute e della Scienza di Torino, Ospedale Molinette, Torino, Italy
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Enrico Bernardi
- Department of Emergency Medicine, ULSS n.7, Conegliano, TV, Italy
| | - Nicola Mumoli
- Department of Internal Medicine, Ospedale Civile Livorno, Italy
| | | | - Sofia Barbar
- Department of Internal and Emergency Medicine, Civic Hospital of Camposampiero (PD), Italy
| | - Claudio Picariello
- Unit of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Iolanda Enea
- Emergency Care Department, Anna e S. Sebastiano Hospital, Caserta, Italy
| | | | | | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Alcalá de Henares University, Madrid, Spain
| |
Collapse
|
38
|
Hellenkamp K, Pruszczyk P, Jiménez D, Wyzgał A, Barrios D, Ciurzyński M, Morillo R, Hobohm L, Keller K, Kurnicka K, Kostrubiec M, Wachter R, Hasenfuß G, Konstantinides S, Lankeit M. Prognostic impact of copeptin in pulmonary embolism: a multicentre validation study. Eur Respir J 2018; 51:13993003.02037-2017. [DOI: 10.1183/13993003.02037-2017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 02/28/2018] [Indexed: 12/23/2022]
Abstract
To externally validate the prognostic impact of copeptin, either alone or integrated in risk stratification models, in pulmonary embolism (PE), we performed a post hoc analysis of 843 normotensive PE patients prospectively included in three European cohorts.Within the first 30 days, 21 patients (2.5%, 95% CI 1.5–3.8) had an adverse outcome and 12 (1.4%, 95% CI 0.7–2.5) died due to PE. Patients with copeptin ≥24 pmol·L−1 had a 6.3-fold increased risk for an adverse outcome (95% CI 2.6–15.5, p<0.001) and a 7.6-fold increased risk for PE-related death (95% CI 2.3–25.6, p=0.001). Risk classification according to the 2014 European Society of Cardiology (ESC) guideline algorithm identified 248 intermediate-high-risk patients (29.4%) with 5.6% (95% CI 3.1–9.3) at risk of adverse outcomes. A stepwise biomarker-based risk assessment strategy (based on high-sensitivity troponin T, N-terminal pro-brain natriuretic peptide and copeptin) identified 123 intermediate-high-risk patients (14.6%) with 8.9% (95% CI 4.5–15.4) at risk of adverse outcomes. The identification of patients at higher risk was even better when copeptin was measured on top of the 2014 ESC algorithm in intermediate-high-risk patients (adverse outcome OR 11.1, 95% CI 4.6–27.1, p<0.001; and PE-related death OR 13.5, 95% CI 4.2–43.6, p<0.001; highest risk group versus all other risk groups). This identified 85 patients (10.1%) with 12.9% (95% CI 6.6–22.0) at risk of adverse outcomes and 8.2% (95% CI 3.4–16.2) at risk of PE-related deaths.Copeptin improves risk stratification of normotensive PE patients, especially when identifying patients with an increased risk of an adverse outcome.
Collapse
|
39
|
Howard LS. Non-vitamin K antagonist oral anticoagulants for pulmonary embolism: who, where and for how long? Expert Rev Respir Med 2018. [PMID: 29542359 DOI: 10.1080/17476348.2018.1452614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Acute pulmonary embolism (PE) is a relatively common cardiopulmonary emergency that is a major cause of hospitalization and morbidity and is the primary cause of mortality associated with venous thromboembolism (VTE). During the last decade, one of the biggest changes in the management of PE has been the approval of four non-vitamin K antagonist oral anticoagulants (NOACs; apixaban, dabigatran, edoxaban and rivaroxaban) for the treatment of PE and deep vein thrombosis and secondary prevention of VTE. Areas covered: This article reviews the evolving management of PE in the NOAC era and addresses three fundamental questions: who should receive NOACs over conventional heparin/vitamin K antagonist regimens for the treatment of acute PE; should patients be treated as inpatients or outpatients; and how long should patients be treated to reduce the risk of recurrence? Expert commentary: The management of PE is changing. NOACs provide new anticoagulant treatment options for patients with PE, based on Phase III clinical study results. The consistent efficacy and safety profile of NOACs across many PE patient subgroups, including the elderly, fragile patients, those with active cancer and high-risk (right ventricular dysfunction) patients, suggests NOAC use will increase among these patients.
Collapse
Affiliation(s)
- Luke S Howard
- a Imperial College Healthcare NHS Trust , Hammersmith Hospital , London , UK
| |
Collapse
|
40
|
Nguyen E, Caranfa JT, Lyman GH, Kuderer NM, Stirbis C, Wysocki M, Coleman CI, Weeda ER, Kohn CG. Clinical prediction rules for mortality in patients with pulmonary embolism and cancer to guide outpatient management: a meta-analysis. J Thromb Haemost 2018; 16:279-292. [PMID: 29215781 DOI: 10.1111/jth.13921] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Indexed: 01/27/2023]
Abstract
Essentials Clinical prediction rules (CPRs) can stratify patients with pulmonary embolism (PE) and cancer. A meta-analysis was done to assess prognostic accuracy in CPRs for mortality in these patients. Eight studies evaluating ten CPRs were included in this study. CPRs should continue to be used with other patient factors for mortality risk stratification. SUMMARY Background Cancer treatment is commonly complicated by pulmonary embolism (PE), which remains a leading cause of morbidity and mortality in these patients. Some guidelines recommend the use of clinical prediction rules (CPRs) to help clinicians identify patients at low risk of mortality and therefore guide care. Objective To determine and compare the accuracy of available CPRs for identifying cancer patients with PE at low risk of mortality. Methods A literature search of Medline and Scopus (January 2000 to August 2017) was performed. Studies deriving/validating ≥ 1 CPR for early post-PE all-cause mortality were included. A bivariate, random-effects model was used to pool sensitivity and specificity estimates for each CPR. Traditional random-effects meta-analysis was performed to estimate the weighted proportion of patients deemed at low risk of early mortality, mortality in low risk patients and odds ratios for death compared with higher-risk patients. Results Eight studies evaluating 10 CPRs were included. The highest sensitivities were observed with Hestia (98.1%, 95% confidence interval [CI] = 75.6-99.9%) and the EPIPHANY index (97.4%, 95% CI = 93.2-99.0%); sensitivities of remaining rules ranged from 59.9 to 96.6%. Of the six CPRs with sensitivities ≥ 95%, none had specificities > 33%. Random-effects meta-analysis suggested that 6.6-51.6% of cancer patients with PE were at low risk of mortality, 0-14.3% of low-risk patients died and low-risk patients had a 43-94% lower odds of death compared with those at higher risk. Conclusions Because of the limited total body of evidence regarding CPRs, their results, in conjunction with other pertinent patient-specific clinical factors, should continue to be used in identifying appropriate management for PE in patients with cancer.
Collapse
Affiliation(s)
- E Nguyen
- Idaho State University College of Pharmacy, Meridian, ID, USA
| | - J T Caranfa
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - G H Lyman
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- University of Washington School of Medicine, Seattle, WA, USA
| | - N M Kuderer
- University of Washington School of Medicine, Seattle, WA, USA
| | - C Stirbis
- University of Saint Joseph School of Pharmacy, Hartford, CT, USA
| | - M Wysocki
- University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - C I Coleman
- University of Connecticut School of Pharmacy, Storrs, CT, USA
- UConn/Hartford Hospital Evidence-based Practice Center, Hartford, CT, USA
| | - E R Weeda
- Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
| | - C G Kohn
- University of Connecticut School of Medicine, Farmington, CT, USA
- UConn/Hartford Hospital Evidence-based Practice Center, Hartford, CT, USA
| |
Collapse
|
41
|
Keller K, Beule J, Balzer JO, Dippold W. D-Dimer and thrombus burden in acute pulmonary embolism. Am J Emerg Med 2018; 36:1613-1618. [PMID: 29371044 DOI: 10.1016/j.ajem.2018.01.048] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 01/12/2018] [Accepted: 01/13/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Thrombus burden in pulmonary embolism (PE) is associated with higher D-Dimer-levels and poorer prognosis. We aimed to investigate i) the influence of right ventricular dysfunction (RVD), deep venous thrombosis (DVT), and high-risk PE-status on D-Dimer-levels and ii) effectiveness of D-Dimer to predict RVD in normotensive PE patients. METHODS Overall, 161 PE patients were analyzed retrospectively, classified in 5 subgroups of thrombus burden according to clinical indications and compared regarding D-Dimer-levels. Linear regression models were computed to investigate the association between D-Dimer and the groups. In hemodynamically stable PE patients, a ROC curve was calculated to assess the effectiveness of D-Dimer for predicting RVD. RESULTS Overall, 161 patients (60.9% females, 54.0% aged >70 years) were included in this analysis. The D-Dimer-level was associated with group-category in a univariate linear regression model (β 0.050 (95%CI 0.002-0.099), P = .043). After adjustment for age, sex, cancer, and pneumonia in a multivariate model we observed an association between D-Dimer and group-category with borderline significance (β 0.047 (95%CI 0.002-0.096), P = .058). The Kruskal-Wallis test demonstrated that D-Dimer increased significantly with higher group-category. In 129 normotensive patients, patients with RVD had significantly higher D-Dimer values compared to those without (1.73 (1.11/3.48) vs 1.17 (0.65/2.90) mg/l, P = .049). A ROC curve showed an AUC of 0.61, gender non-specific, with calculated optimal cut-off of 1.18 mg/l. Multi-variate logistic regression model confirmed an association between D-Dimer >1.18 mg/l and RVD (OR2.721 (95%CI 1.196-6.190), P = .017). CONCLUSIONS Thrombus burden in PE is related to elevated D-Dimer levels, and D-Dimer values >1.18 mg/l were predictive for RVD in normotensive patients. D-Dimer levels were influenced by DVT, but not by cancer, pneumonia, age, or renal impairment.
Collapse
Affiliation(s)
- Karsten Keller
- Center for thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Johannes Gutenberg-University Mainz, Germany; Cardiology I, Center of Cardiology, University Medical Center Mainz, Mainz, Johannes Gutenberg-University Mainz, Germany.
| | - Johannes Beule
- Department of Internal Medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM), Mainz, Germany
| | - Jörn Oliver Balzer
- Department of Radiology and Nuclear Medicine, Catholic Clinic Mainz (KKM), Mainz, Germany; Department of Diagnostic and Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt (Main), Frankfurt, Germany
| | - Wolfgang Dippold
- Department of Internal Medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM), Mainz, Germany
| |
Collapse
|
42
|
Brekelmans MPA, Büller HR, Mercuri MF, Ageno W, Chen CZ, Cohen AT, van Es N, Grosso MA, Medina AP, Raskob G, Segers A, Vanassche T, Verhamme P, Wells PS, Zhang G, Weitz JI. Direct Oral Anticoagulants for Pulmonary Embolism: Importance of Anatomical Extent. TH OPEN 2018; 2:e1-e7. [PMID: 31249922 PMCID: PMC6524852 DOI: 10.1055/s-0037-1615251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 11/13/2017] [Indexed: 01/07/2023] Open
Abstract
Pulmonary embolism (PE) studies used direct oral anticoagulants (DOACs) with or without initial heparin. We aimed to (1) evaluate if PE patients benefit from initial heparin; (2) describe patient characteristics in the DOAC studies; and (3) investigate whether the anatomical extent of PE correlates with N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, cause of PE, and recurrence rate. Our methods were (1) an indirect meta-analysis comparing the recurrence risk in DOAC-treated patients with or without initial heparin to those patients given heparin/vitamin K antagonist (VKA). (2) To compare the PE studies, information was extracted on baseline characteristics including anatomical extent. (3) The Hokusai-VTE study was used to correlate anatomical extent of PE with NT-proBNP levels, causes of PE, and recurrent venous thromboembolism (VTE). The meta-analysis included 11,539 PE patients. The relative risk of recurrent VTE with DOACs versus heparin/VKAs was 0.8 (95% confidence interval [CI]: 0.6–1.1) with heparin lead-in and 1.1 (95% CI: 0.8–1.5) without heparin. In the DOAC studies, the proportion of patients with extensive PE varied from 24 to 47%. In Hokusai-VTE, NT-proBNP was elevated in 4% of patients with limited and in over 60% of patients with extensive disease. Cause of PE and anatomical extent were not related. Recurrence rates increased from 1.6% with limited to 3.2% with extensive disease in heparin/edoxaban-treated patients, and from 2.4 to 3.9% in heparin/warfarin recipients. In conclusion, indirect evidence suggests a heparin lead-in before DOACs may be advantageous in PE. Anatomical extent was related to elevated NT-proBNP and outcome, but not to PE cause.
Collapse
Affiliation(s)
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Michele F Mercuri
- Clinical Development, Daiichi Sankyo Pharma Development, Edison, New Jersey, United States
| | - Walter Ageno
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Cathy Z Chen
- Global Medical Affairs, Daiichi Sankyo Inc., Parsippany, New Jersey, United States
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and St Thomas' Hospitals, King's College London, London, United Kingdom
| | - Nick van Es
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Michael A Grosso
- Clinical Development, Daiichi Sankyo Pharma Development, Edison, New Jersey, United States
| | - Andria P Medina
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Gary Raskob
- College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | | | - Thomas Vanassche
- Vascular Medicine and Haemostasis, University of Leuven, Leuven, Belgium
| | - Peter Verhamme
- Vascular Medicine and Haemostasis, University of Leuven, Leuven, Belgium
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - George Zhang
- Clinical Development, Daiichi Sankyo Pharma Development, Edison, New Jersey, United States
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
43
|
Abstract
SummaryBackground: Age is an important and independent risk factor for venous thromboembolism (VTE) and pulmonary embolism (PE). The objectives of this study were to investigate the effects of aging process on PE with regard to the severity of PE, symptoms, inhospital death, history of PE, ECG, echocardiographic, and laboratory findings.Methods: 182 patients with confirmed PE were reviewed retrospectively and subdivided into 4 age groups (<60, 60–69, 70–79 and ≥ 80 years). Analysis of patients’ symptoms, history, echocardiographic, electrocardiographic and laboratory parameters was performed.Results: Proportion of women increased with age (<60 years: 41.5 % vs. 80+ years: 73.1 %, P<0.05). Also percentage of right ventricular dysfunction (RVD) was highest in eldest age group (60–69 years: 42.4 % vs. 80+ years: 75 %, P<0.05). Systolic pulmonary artery pressure (sPAP) was significantly higher in the 80+ years age group. The sPAP was constant from the <60 years group (29.0 ± 17.4 mmHg) to the 60–69 years group (27.4 ± 19.3 mmHg), and increased from the 60–69 years and 70–79 years group (33.8 ± 17.5 mmHg) to the 80+ years groups (44.3 ± 14.3 mmHg) (<60 vs. 80+ and 60–69 vs. 80+ years: respectively P<0.001 and 70–79 vs. 80+ years: P<0.05).Regression model for PE patients 80years showed an association between age 80+ and female gender (OR, 2.53; 95%CI: 1.07–5.99, p<0.05), right bundle branch block (OR, 3.07; 95%CI: 1.05–9.02, p<0.05), RVD (OR, 2.53; 95%CI: 1.07–6.00, p<0.05) and sPAP (OR, 1.05; 95%CI: 1.02–1.08, p<0.001). Pearson correlation matrix revealed a significant correlation between age and sPAP (r=0.30, P<0.001).Conclusions: Right ventricular load at acute PE event, evident from RVD and elevated sPAP, increases with age. RVD is connected with higher mortality in PE patients. High sPAP at acute PE event is one of the well-known risk factors for the development of chronic thromboembolic pulmonary hypertension in long-term. Proportion of female PE patients increases with age.
Collapse
|
44
|
Papanikolaou J, Spathoulas K, Makris D, Zakynthinos E. Thrombolysis for Massive Pulmonary Embolism in a Patient with Hemorrhagic Shock. Am J Respir Crit Care Med 2017; 194:e15-e16. [PMID: 27529567 DOI: 10.1164/rccm.201605-1035im] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- John Papanikolaou
- Department of Critical Care, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Konstantinos Spathoulas
- Department of Critical Care, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Demosthenes Makris
- Department of Critical Care, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Epaminondas Zakynthinos
- Department of Critical Care, University Hospital of Larissa, Faculty of Medicine, University of Thessaly, Larissa, Greece
| |
Collapse
|
45
|
Côté B, Jiménez D, Planquette B, Roche A, Marey J, Pastré J, Meyer G, Sanchez O. Prognostic value of right ventricular dilatation in patients with low-risk pulmonary embolism. Eur Respir J 2017; 50:50/6/1701611. [DOI: 10.1183/13993003.01611-2017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The prognosis of multidetector computed tomography (MDCT) assessed right ventricular dilatation (RVD) is unclear in patients with pulmonary embolism (PE) and a simplified Pulmonary Embolism Severity Index (sPESI) of 0. We investigated in these patients whether MDCT-assessed RVD, defined by a right to left ventricular ratio (RV/LV) ≥0.9 or ≥1.0, is associated with worse outcomes.We combined data from three prospective cohorts of patients with PE. The main study outcome was the composite of 30-day all-cause mortality, haemodynamic collapse or recurrent PE in patients with sPESI of 0.Among 779 patients with a sPESI 0, 420 (54%) and 299 (38%) had a RV/LV ≥0.9 and ≥1.0 respectively. No difference in primary outcome was observed, 0.95% (95% CI 0.31–2.59) versus 0.56% (95% CI 0.10–2.22; p=0.692) and 1.34% (95% CI 0.43–3.62) versus 0.42% (95% CI 0.07–1.67; p=0.211) with RV/LV ≥0.9 and ≥1.0 respectively. Increasing the RV/LV threshold to ≥1.1, the outcome occurred more often in patients with RVD (2.12%, 95% CI 0.68–5.68 versus 0.34%, 95% CI 0.06–1.36; p=0.033).MDCT RV/LV ratio of ≥0.9 and ≥1.0 in sPESI 0 patients is frequent but not associated with a worse prognosis but higher cut-off values might be associated with worse outcome in these patients.
Collapse
|
46
|
Keller K, Beule J, Balzer JO, Dippold W. Renal function as a cofactor for risk stratification and short-term outcome in acute pulmonary embolism. Exp Gerontol 2017; 100:11-16. [DOI: 10.1016/j.exger.2017.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 10/03/2017] [Accepted: 10/07/2017] [Indexed: 12/15/2022]
|
47
|
Lobo JL, Fernandez-Golfin C, Portillo AK, Nieto R, Lankeit M, Konstantinides S, Prandoni P, Muriel A, Yusen RD, Jimenez D. Effectiveness of prognosticating pulmonary embolism using the ESC algorithm and the Bova score. Thromb Haemost 2017; 115:827-34. [DOI: 10.1160/th15-09-0761] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 11/27/2015] [Indexed: 11/05/2022]
Abstract
SummaryThe 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
Collapse
|
48
|
Barrios D, Morillo R, Yusen RD, Jiménez D. Pulmonary embolism severity assessment and prognostication. Thromb Res 2017; 163:246-251. [PMID: 28911787 DOI: 10.1016/j.thromres.2017.09.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 07/04/2017] [Accepted: 09/04/2017] [Indexed: 01/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- Deisy Barrios
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Alcala de Henares University, Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Alcala de Henares University, Madrid, Spain
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Alcala de Henares University, Madrid, Spain.
| |
Collapse
|
49
|
Maestre Peiró A, Gonzálvez Gasch A, Monreal Bosch M. Update on the risk stratification of acute symptomatic pulmonary thromboembolism. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2017.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
50
|
Update on the risk stratification of acute symptomatic pulmonary thromboembolism. Rev Clin Esp 2017; 217:342-350. [PMID: 28476246 DOI: 10.1016/j.rce.2017.02.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 02/22/2017] [Accepted: 02/23/2017] [Indexed: 01/22/2023]
Abstract
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.
Collapse
|