Long-term mortality after massive, submassive, and low-risk pulmonary embolism

Predicting Hospital Survival in Patients Admitted to ICU with Pulmonary Embolism

OBJECTIVE

The Pulmonary Embolism Severity Index (PESI) and simplified PESI (sPESI) predict mortality for patients with PE. We compared PESI/sPESI to the Acute Physiology and Chronic Health Evaluation IV (APACHE-IV) in predicting mortality in patients with PE admitted to the intensive care unit (ICU). Additionally, we assessed the performance of a novel ICU-sPESI score created by adding three clinical variables associated with acuity of PE presentation (intubation, confusion [altered mental status], use of vasoactive infusions) to sPESI.

MATERIALS AND METHODS

Using the eICU Collaborative Research Database from 2014 to 2015, we conducted a large retrospective cohort study of adult patients admitted to the ICU with a primary diagnosis of PE. We calculated APACHE-IV, PESI, sPESI, and ICU-sPESI scores and compared their performance for predicting in-hospital mortality using area under the receiver operating characteristic (AUROC) curve. Score thresholds for >99% negative predictive values (NPV) were calculated for each score. Survival was estimated using the Kaplan-Meier method.

RESULTS

We included 1424 PE cases. In-hospital mortality was 6.3% [95% CI: 5.1%-7.6%]. AUROC for APACHE-IV, PESI, and sPESI were 0.870, 0.848, and 0.777, respectively. APACHE-IV and PESI outperformed sPESI (P < 0.01 for both comparisons), while APACHE-IV and PESI demonstrated similar performance (P = 0.322). The ICU-sPESI performance was similar to APACHE-IV and PESI (AUROC = 0.847; AUROC comparison: APACHE-IV vs ICU-sPESI: P = 0.396; PESI vs ICU-sPESI: P = 0.945). Hospital mortality for ICU-sPESI scores 0-2 was 1.1%, and for scores 3, 4, 5, 6, and ≥7 was 8.6%, 11.7%, 29.2%, 37.5%, and 76.9%, respectively. Score thresholds for >99% NPV were ≤48 for APACHE-IV, ≤115 for PESI, and 0 points for sPESI and ICU-sPESI.

CONCLUSIONS

By accounting for severity of PE presentation, our newly proposed ICU-sPESI score provided improved PE mortality prediction compared to the original sPESI score and offered excellent discrimination of mortality risk.

De Ritis Ratio to Predict Clinical Outcomes of Intermediate- and High-Risk Pulmonary Embolisms

Background: Abnormal liver function tests can identify severe cardiopulmonary failure. The aspartate transaminase/alanine transaminase (AST/ALT) ratio, or the De Ritis ratio, is commonly used to evaluate acute liver damage. However, its prognostic value in pulmonary embolism (PE) is unknown. Methods: Two cohorts, including patients with intermediate- and high-risk PEs, were established: one with an abnormal baseline AST/ALT ratio (>1) and another with a normal baseline AST/ALT ratio (<1). The primary outcome was a 60-day mortality. Secondary outcomes included peak N-terminal pro-brain-natriuretic-peptide (NT-proBNP) levels, complications, and the need for critical care treatment. To assess the effect of abnormal AST/ALT ratios, inverse probability weighted (IPW) analyses were performed. Results: In total, 230 patients were included in the analysis, and 52 (23%) had an abnormal AST/ALT ratio. After the IPW correction, patients with an abnormal AST/ALT ratio had a significantly higher mortality rate and peak NT-proBNP levels. The relative risks of 60-day mortality, shock development, use of inotropes/vasopressors, mechanical ventilation, and extracorporeal life support were 9.2 (95% confidence interval: 3.3-25.3), 10.1 (4.3-24), 2.7 (1.4-5.2), 2.3 (1.4-3.7), and 5.7 (1.4-23.1), respectively. Conclusions: The baseline AST/ALT ratio can be a predictor of shock, multiorgan failure, and mortality in patients with a pulmonary embolism.

Improving Venous Thromboembolism Prophylaxis Through Service Integration, Policy Enhancement, and Health Informatics

Introduction

Venous thromboembolism (VTE) prevention and management are susceptible issues that require specific rules to sustain and oversee their functioning, as preventing VTE is a vital patient safety priority. This paper aims to investigate and provide recommendations for VTE assessment and reassessment through policy enhancement and development.

Methods

We reviewed different papers and policies to propose recommendations and theme analysis for policy modifications and enhancements to improve VTE prophylaxis and management.

Results

Recommendations were set to enhance the overall work of VTE prophylaxis, where the current VTE protocols and policies must ensure high levels of patient safety and satisfaction. The recommendations included working through a well-organized multidisciplinary team and staff engagement to support and enhance VTE's work. Nurses', pharmacists', and physical therapists' involvement in setting up the plan and prevention is the way to share the knowledge and paradigm of experience to standardize the management. Promoting policies regarding VTE prophylaxis assessment and reassessment using electronic modules as a part of the digital health process was proposed. A deep understanding of the underlying issues and the incorporation of generic policy recommendations were set.

Conclusion

This article presents recommendations for stakeholders, social media platforms, and healthcare practitioners to enhance VTE prophylaxis and management.

Underuse of reperfusion therapy with systemic thrombolysis in high-risk acute pulmonary embolism in a Portuguese center

INTRODUCTION

Reperfusion therapy is generally recommended in acute high-risk pulmonary embolism (HR-PE), but several population-based studies report that it is underused. Data on epidemiology, management and outcomes of HR-PE in Portugal are scarce.

OBJECTIVE

To determine the reperfusion rate in HR-PE patients, the reasons for non-reperfusion, and how it influences outcomes.

METHODS

In this retrospective cohort study of consecutive HR-PE patients admitted to a thromboembolic disease referral center between 2008 and 2018, independent predictors for non-reperfusion were assessed by multivariate logistic regression. PE-related mortality and long-term MACE (cardiovascular mortality, PE recurrence and chronic thromboembolic disease) were calculated according to the Kaplan-Meier method. Differences stratified by reperfusion were assessed using the log-rank test.

RESULTS

Of 1955 acute PE patients, 3.8% presented with hemodynamic instability. The overall reperfusion rate was 50%: 35 patients underwent systemic thrombolysis, one received first-line percutaneous embolectomy and one rescue endovascular treatment. Independent predictors of non-reperfusion were: age, with >75 years representing 12 times the risk of non-treatment (OR 11.9, 95% CI 2.7-52.3, p=0.001); absolute contraindication for thrombolysis (31.1%), with recent major surgery and central nervous system disease as the most common reasons (OR 16.7, 95% CI 3.2-87.0, p<0.001); and being hospitalized (OR 7.7, 95% CI 1.4-42.9, p=0.020). At a mean follow-up of 2.5±3.3 years, the survival rate was 33.8%. Although not reaching statistical significance for hospital mortality, mortality in the reperfusion group was significantly lower at 30 days, 12 months and during follow-up (relative risk reduction of death of 64% at 12 months, p=0.013). Similar results were found for MACE.

CONCLUSIONS

In this population, the recommended reperfusion therapy was performed in only 50% of patients, with advanced age and absolute contraindications to fibrinolysis being the main predictors of non-reperfusion. In this study, thrombolysis underuse was associated with a significant increase in short- and long-term mortality and events.

In-hospital mortality of high-risk pulmonary embolism: a nationwide population-based cohort study in Portugal from 2010 to 2018

BACKGROUND

The mortality associated with high-risk pulmonary embolism (PE) is remarkably high, and reperfusion to unload right ventricle should be a priority. However, several registries report reperfusion underuse. In Portugal, epidemiological data about the incidence, rate of reperfusion and mortality of high-risk PE are not known.

METHODS

Nationwide population-based temporal trend study in the incidence and outcome of high-risk PE, who were admitted to hospitals of the National Health Service in Portugal between 2010 and 2018. High-risk PE was defined as patients with PE who developed cardiogenic shock or cardiac arrest. International Classification of Diseases (ICD), 9th and 10th revision, Clinical Modification codes, were used for data from the period between 2010 and 2016 (ICD-9-CM) and 2017-2018 (ICD-10-CM), respectively. The assessment focused on trends in the use of reperfusion treatment, which was defined by application of thrombolysis or pulmonary embolectomy. A comparison was made between the use or non-use of reperfusion therapy in order to examine trends in in-hospital mortality among high-risk PE cases.

RESULTS

From 2010 and 2018, there were 40.311 hospitalization episodes for PE in adult patients at hospitals of the National Health Service in mainland Portugal. There was a significant increase in the annual incidence of PE (41/100.000 inhabitants in 2010 to 46/100.000 in 2018; R2=0.582, p = 0.010). The average annual incidence was 45/100.000 inhabitants/year, with 2,7% of the PE episodes (1104) categorized as high-risk. The mortality rate associated with high-risk PE was high, although it has decreased over the years (74.2% in 2010 to 63.6% in 2018; R2=0.484; p = 0.022). Thrombolytic therapy was underused in high-risk PE, and its usage has not increased in recent years (17.3% in 2010 to 21.1% in 2018, R2=-0.127; p = 0.763). Surgical pulmonary embolectomy was used in 0.27% of cases, and there was no registry of catheter-directed thrombolysis. Patients with high-risk PE undergoing reperfusion therapy had lower in-hospital mortality compared to non-reperfused patients (OR=0.52; IC95% 0.38-0.70).

CONCLUSION

In Portugal, between 2010 and 2018, very few patients with PE developed high-risk forms of the disease, but the mortality rate among those patients was high. The low reperfusion rate could be associated with high in-hospital mortality and highlights the need to implement advanced therapies, as an alternative to systemic thrombolysis.

Short- and Long-Term Mortality for Patients With and Without a Cancer Diagnosis Following Pulmonary Embolism in Denmark, 2000 to 2020: A Nationwide Study

BACKGROUND

New treatment regimens have been introduced in the past 20 years, which may influence the short- and long-term prognosis for patients with and without a cancer diagnosis following pulmonary embolism. However, newer studies investigating these trends are lacking. Therefore, we aimed to investigate the 30- and 31- to 365-day mortality following pulmonary embolism.

METHODS AND RESULTS

Using the Danish nationwide registries, patients with a diagnosis of pulmonary embolism between 2000 and 2020 were included. Age- and sex-standardized 30- and 31- to 365-day mortality was calculated and stratified by cancer status. In total, 60 614 patients (29.6% with recent cancer; mean age, 68.2 years) were included. The 30-day mortality for patients with no recent cancer decreased from 19.1% (95% CI, 17.9%-20.4%) in 2000 to 7.3% (95% CI, 6.7%-8.0%) in 2018 to 2020 (hazard ratio [HR], 0.36 [95% CI, 0.32-0.40]; P<0.001). The 30-day mortality for patients with recent cancer decreased from 32.2% (95% CI, 28.8%-36.6%) to 14.1% (95% CI, 12.7%-15.5%) (HR, 0.38 [95% CI, 0.33-0.44]; P<0.001). The 31- to 365-day mortality for patients with no recent cancer decreased from 12.5% (95% CI, 11.4%-13.6%) to 9.4% (95% CI, 8.6%-10.2%) (HR, 0.73 [95% CI, 0.64-0.83]; P<0.001).The 31- to 365-day mortality for patients with recent cancer remained stable: 39.4% (95% CI, 35.1%-43.7%) to 38.3% (95% CI, 35.9%-40.6%) (HR, 0.97 [95% CI, 0.84-1.12]; P=0.69).

CONCLUSIONS

From 2000 to 2020, improvements were observed in 30-day mortality following pulmonary embolism regardless of cancer status. For patients with recent cancer, 31- to 365-day mortality did not improve, whereas a minor improvement was observed for patients without recent cancer.

Effective Prevention of Arterial Thrombosis with Albumin-Thrombin Inhibitor Conjugates

Thromboprophylaxis is indicated in patients at an elevated risk of developing thrombotic disorders, typically using direct oral anticoagulants or low-molecular-weight heparins. We postulated that transient thromboprophylaxis (days-weeks) could be provided by a single dose of an anticoagulant engineered for prolonged pharmacokinetics. In the present work, d-phenylalanyl-l-prolyl-l-arginine chloromethyl ketone (PPACK) was used as a model anticoagulant to test the hypothesis that conjugation of thrombin inhibitors to the surface of albumin would provide durable protection against thrombotic insults. Covalent conjugates were formed between albumin and PPACK using click chemistry, and they were tested in vitro using a thrombin activity assay and a clot formation assay. Thromboprophylactic efficacy was tested in mouse models of arterial thrombosis, both chemically induced (FeCl3) and following ischemia-reperfusion (transient middle cerebral artery occlusion; tMCAO). Albumin-PPACK conjugates were shown to have nanomolar potency in both in vitro assays, and following intravenous injection had prolonged circulation. Conjugates did not impact hemostasis (tail clipping) or systemic coagulation parameters in normal mice. Intravenous injection of conjugates prior to FeCl3-induced thrombosis provided significant protection against occlusion of the middle cerebral and common carotid arteries, and injection immediately following ischemia-reperfusion reduced stroke volume measured 3 days after injury by ∼40% in the tMCAO model. The data presented here provide support for the use of albumin-linked anticoagulants as an injectable, long-circulating, safe thromboprophylactic agent. In particular, albumin-PPACK provides significant protection against thrombosis induced by multiple mechanisms, without adversely affecting hemostasis.

Association between diabetes and venous thromboembolism: A systematic review and meta-analysis

BACKGROUND

Diabetes mellitus (DM) plays a vital role in the development of cardiovascular disease. However, its association with venous thromboembolism (VTE) remains unclear, for the published study results are conflicting. We performed a meta-analysis of published cohort studies and case-control studies to assess the role of DM in the formation and prognosis of VTE.

METHODS

PubMed and EMBASE databases were searched for articles from the database's establishment until September 15, 2022. Of the 15,754 publications retrieved, 50 studies were identified that met the selection criteria. The New castle-Ottawa Scale was used to evaluate the quality of the literature. Pooled odds ratios (ORs) and 95% confidence intervals were calculated using fixed- or random-effect models.

RESULTS

We combined OR using a random-effects or fixed-effects model: patients with DM had an increased risk of VTE (OR 1.27, 95% confidence interval [CI]: 1.15-1.41), which still showed a partial association in studies adjusted by confounding factors (OR 1.20, 95% CI: 1.07-1.35). DM was not significantly associated with VTE when analyzed in studies adjusted by body mass index (OR 1.04, 95% CI: 0.94-1.15). VTE patients with DM had a higher risk of short-term and long-term mortality than those without DM (OR 1.58 [95% CI: 1.26-1.99] for long-term mortality and OR 1.20 [95% CI: 1.19-1.21] for short-term mortality).

CONCLUSION

There was no significant association between DM and VTE risk, and body mass index may be a significant confounding factor between DM and VTE risk. However, DM can still lead to an increased risk of long-term and short-term mortality in patients with VTE.

Comparative Outcomes of Catheter-Directed Thrombolysis Plus Systemic Anticoagulation Versus Systemic Anticoagulation Alone in the Management of Intermediate-Risk Pulmonary Embolism in a Systematic Review and Meta-Analysis

There are limited and conflicting data on the initial management of intermediate-risk (or submassive) pulmonary embolism (PE). This study sought to compare the outcomes of catheter-directed thrombolysis (CDT) in combination with systemic anticoagulation (SA) to SA alone. A systematic search was conducted in MEDLINE, EMBASE, PubMed, and the Cochrane databases from inception to March 1, 2023 for studies comparing the outcomes of CDT + SA versus SA alone in intermediate-risk PE. The outcomes were in-hospital, 30-day, 90-day, and 1-year mortality; bleeding; blood transfusion; right ventricular recovery; and length of stay. Random-effects models was used to calculate the pooled incidence and risk ratios (RRs) with 95% confidence intervals (CIs). A total of 15 (2 randomized and 13 observational) studies with 10,549 (2,310 CDT + SA and 8,239 SA alone) patients were included. Compared with SA, CDT + SA was associated with significantly lower in-hospital mortality (RR 0.41, 95% CI 0.30 to 0.56, p <0.001), 30-day mortality (RR 0.34, 95% CI 0.18 to 0.67, p = 0.002), 90-day mortality (RR 0.34, 95% CI 0.17 to 0.67, p = 0.002), and 1-year mortality (RR 0.58, 95% CI 0.34 to 0.97, p = 0.04). There were no significant differences between the 2 cohorts in the rates of major bleeding (RR 1.39, 95% CI 0.72 to 2.68, p = 0.56), minor bleeding (RR 1.83, 95% CI 0.97 to 3.46, p = 0.06), and blood transfusion (RR 0.34, 95% CI 0.10 to 1.15, p = 0.08). In conclusion, CDT + SA is associated with significantly lower short-term and long-term all-cause mortality, without any differences in major/minor bleeding, in patients with intermediate-risk PE.

Neurological outcomes and reperfusion strategies in out-of-hospital cardiac arrest patients due to pulmonary embolism who underwent venoarterial extracorporeal membrane oxygenation: A post-hoc analysis of a multicenter retrospective cohort study

INTRODUCTION

This study aimed to evaluate the effect of different reperfusion strategies on neurological outcomes in patients with pulmonary embolism who received venoarterial extracorporeal membrane oxygenation (VA-ECMO) for out-of-hospital cardiac arrest (OHCA).

METHODS

This was a post-hoc analysis of a multicenter retrospective cohort study conducted in 36 institutions in Japan over six years. We included patients who underwent VA-ECMO and were diagnosed with pulmonary embolism caused by OHCA. Neurological outcomes were evaluated on the basis of the cerebral performance category at hospital discharge. We also assessed the association between reperfusion strategies and successful separation from ECMO.

RESULTS

Among the 78 included patients, approximately half were successfully weaned from ECMO. Hospital mortality and favorable neurological outcomes at hospital discharge were 60.3% and 17.9%, respectively. Thirty-one patients (39.7%) underwent reperfusion strategies after ECMO, including 13 who received systemic thrombolytic therapy and 18 who underwent mechanical reperfusion strategy. After adjusting for prespecified covariates using the competing risk model, reperfusion strategies increased ECMO separation rate (systemic thrombolytic therapy: subdistribution hazard ratio [sHR] 2.24, 95% confidence interval [CI] 1.21-4.17, P = 0.011; mechanical reperfusion strategy: sHR 1.70, 95% CI 0.86-3.41, P = 0.129) compared with anticoagulation therapy alone, whereas higher cardiac Sequential Organ Failure Assessment score decreased ECMO separation rate (sHR 0.81, 95% CI 0.67-0.97, P = 0.020).

CONCLUSIONS

Favorable neurological outcomes were observed in less than 20% of patients with OHCA due to pulmonary embolism undergoing ECMO. Reperfusion strategies may be associated with shorter ECMO durations in these patients.

CLINICAL TRIAL REGISTRATION

https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041577 (unique identifier: UMIN000036490).

Impact of Promising Biomarkers on Severity and Outcome of Acute Pulmonary Embolism

Background

Acute pulmonary embolism (APE) is a common clinical condition. Its severity ranges from asymptomatic radiological findings to fatal obstructive shock. The potential circulating biomarkers have been studied to predict APE outcomes. This study aimed to explore their predictive power on prognosis in APE.

Material and Method

It was a prospective observational study between March 2008 and April 2010. All consecutive patients diagnosed with APE were categorized as massive/high-risk, submassive/moderate-risk, and non-massive/low-risk. Cardiac troponin T (cTnT), myoglobin, N-terminal pro-brain natriuretic peptide (NT-proBNP), heart-type fatty acid-binding protein (H-FABP), growth differentiation factor-15 (GDF-15), and D-dimer levels were measured.

Results

Of these patients, 14 (29.8%), 16 (34.0%), and 17 (36.2%) patients were categorized as low-risk, moderate-risk, and high risk-patients, respectively. There was no significant difference between the patient groups categorized based on the risk stratification in terms of demographic and clinical characteristics. The cTnT, myoglobin, HFABP, and D-dimer levels have also not differed significantly between the groups. There was a significant difference between the groups in respect of NT-proBNP and GDF-15 levels (p=0.009 and p=0.037, respectively). Nine (19.1%) patients had died by the 3rd-month follow-up. Adverse events were seen in 26 (55.3%) patients. GDF-15 had the highest area under the curve (AUC) value for predicting any adverse event (cut-off value=9.3 ng/mL, AUC=0.796, CI (confidence interval) 95%: 0.653-0.899). NT-ProBNP was determined as the best predictor for mortality (cut-off value=229.2 pg/mL, AUC=0.889, CI 95%: 0.756-0.964).

Conclusion

Higher levels of NT-proBNP and GDF-15 were found to be associated with more severe APE, worse outcomes, and mortality.

Impact of Baseline Heart Failure on Acute Pulmonary Embolism Risk Stratification and Clinical Outcomes

Among patients with acute pulmonary embolism (PE), abnormal cardiac biomarkers and elevated right ventricular to left ventricular (RV/LV) diameter ratio are associated with increased morbidity and mortality. However, subjects with baseline heart failure (HF) have abnormalities in cardiac chamber dimensions and biomarkers. We sought to describe risk stratification variables in a cohort with acute PE and categorized HF status as no HF, HF with reduced ejection fraction (HFrEF), or HF with preserved ejection fraction (HFpEF). In total, 182 subjects were identified for this study, of whom 142 were categorized as having no HF, 16 as having HFrEF, and 24 as having HFpEF. The median age was 65 years [interquartile range 51 to 75 years], and 43% were male. Subjects with HFrEF had significantly greater LV diameters and significantly lower RV/LV diameter ratio (no HF 0.94, HFrEF 0.65, HFpEF 0.89, p = 0.002). Subjects with HFrEF also had significantly higher B-type natriuretic peptide levels (no HF 112 pg/mL, HFrEF 835 pg/mL, HFpEF 241 pg/mL, p <0.001) and higher 90-day mortality rates. Among subjects with acute PE, those with baseline HFrEF had significantly greater LV diameter and lower RV/LV diameter ratio than those of patients with HFpEF or no HF. In addition, subjects with HFrEF had significantly higher B-type natriuretic peptide levels and worse survival at 90 days. In conclusion, these results indicate that PE risk stratification using current guidelines, especially reliance on RV/LV ratio, is inaccurate among subjects with baseline HFrEF.

Incidence of Venous Thromboembolism in Adults Receiving Extracorporeal Membrane Oxygenation: A Systematic Review

Extracorporeal membrane oxygenation (ECMO) has become an increasingly used tool for cardiorespiratory support. Thrombosis is a well-recognized complication of ECMO, yet the burden of disease remains unclear. We undertook a systematic review to investigate the incidence of venous thromboembolism (VTE) during ECMO or soon after decannulation, in patients screened for VTE. We retrieved all studies that evaluated VTE incidence in ECMO patients in EMBASE, MEDLINE, Web of Science, and Cochrane Library from inception to April 2, 2021. Studies reporting incidence of VTE diagnosed on systematic screening tests during ECMO or within 7 days of decannulation in adult patients were included. A total of 18 studies were included in the systematic review. These studies screened a total of 1095 ECMO patients. Most studies screened for cannula-associated deep vein thrombosis (CaDVT) after decannulation. The overall incidence of DVT was 52.8% (95% CI, 49.8-55.8%). Incidence of DVT was 53.5% (95% CI, 50.0-57.0%) for venovenous ECMO vs. 34.0% (95% CI, 26.5-42.2%) for venoarterial ECMO. No studies screened for pulmonary embolism. Our systematic review found a very high incidence of DVT among patients treated with ECMO. Routine screening for DVT after decannulation for all ECMO patients may be warranted.

Catheter-Directed Thrombolysis vs Anticoagulation in Patients With Acute Intermediate-High-risk Pulmonary Embolism: The CANARY Randomized Clinical Trial

Importance

The optimal treatment of intermediate-high-risk pulmonary embolism (PE) remains unknown.

Objective

To assess the effect of conventional catheter-directed thrombolysis (cCDT) plus anticoagulation vs anticoagulation monotherapy in improving echocardiographic measures of right ventricle (RV) to left ventricle (LV) ratio in acute intermediate-high-risk PE.

Design, Setting, and Participants

The Catheter-Directed Thrombolysis vs Anticoagulation in Patients with Acute Intermediate-High-Risk Pulmonary Embolism (CANARY) trial was an open-label, randomized clinical trial of patients with intermediate-high-risk PE, conducted in 2 large cardiovascular centers in Tehran, Iran, between December 22, 2018, through February 2, 2020.

Interventions

Patients were randomly assigned to cCDT (alteplase, 0.5 mg/catheter/h for 24 hours) plus heparin vs anticoagulation monotherapy.

Main Outcomes and Measures

The proportion of patients with a 3-month echocardiographic RV/LV ratio greater than 0.9, assessed by a core laboratory, was the primary outcome. The proportion of patients with an RV/LV ratio greater than 0.9 at 72 hours after randomization and the 3-month all-cause mortality were among secondary outcomes. Major bleeding (Bleeding Academic Research Consortium type 3 or 5) was the main safety outcome. A clinical events committee, masked to the treatment assignment, adjudicated clinical outcomes.

Results

The study was prematurely stopped due to the COVID-19 pandemic after recruiting 94 patients (mean [SD] age, 58.4 [2.5] years; 27 women [29%]), of whom 85 patients completed the 3-month echocardiographic follow-up. Overall, 2 of 46 patients (4.3%) in the cCDT group and 5 of 39 patients (12.8%) in the anticoagulation monotherapy group met the primary outcome (odds ratio [OR], 0.31; 95% CI, 0.06-1.69; P = .24). The median (IQR) 3-month RV/LV ratio was significantly lower with cCDT (0.7 [0.6-0.7]) than with anticoagulation (0.8 [0.7-0.9); P = .01). An RV/LV ratio greater than 0.9 at 72 hours after randomization was observed in fewer patients treated with cCDT (13 of 48 [27.0%]) than anticoagulation (24 of 46 [52.1%]; OR, 0.34; 95% CI, 0.14-0.80; P = .01). Fewer patients assigned to cCDT experienced a 3-month composite of death or RV/LV greater than 0.9 (2 of 48 [4.3%] vs 8 of 46 [17.3%]; OR, 0.20; 95% CI, 0.04-1.03; P = .048). One case of nonfatal major gastrointestinal bleeding occurred in the cCDT group.

Conclusions and Relevance

This prematurely terminated randomized clinical trial of patients with intermediate-high-risk PE was hypothesis-generating for improvement in some efficacy outcomes and acceptable rate of major bleeding for cCDT compared with anticoagulation monotherapy and provided support for a definitive clinical outcomes trial.

Trial Registration

ClinicalTrials.gov Identifier: NCT05172115.

Successful thrombolysis with low dose thrombolytic agent in a patient with acute life-threatening massive pulmonary thromboembolism: A case report

Introduction

and importance: Acute massive pulmonary thromboembolism is a potentially life-threatening condition requiring urgent management to decrease mortality. Although the standard dose of systemic thrombolysis with alteplase is 100 mg, half the dose of alteplase can be used to break up clots successfully, especially if bleeding is a concern.

Case presentation

We report a case of massive pulmonary thromboembolism presenting with cardiopulmonary arrest, successfully managed with advanced cardiac life support, anticoagulants, and low-dose thrombolytics.

Clinical discussion

Management of massive pulmonary thromboembolism includes medical thrombolysis along with maintenance of hemodynamic stability. Our patient was successfully managed with low-dose thrombolytics and was continued with standard oral anticoagulants for 6 months.

Conclusion

In patients of acute massive pulmonary thromboembolism, a low dose of the thrombolytic agent can achieve complete resolution of the thrombus with less bleeding risk.

•

Acute massive pulmonary thromboembolism is a life-threatening condition requiring urgent diagnosis and management.

•

Management of massive pulmonary thromboembolism includes hemodynamic stability and medical thrombolysis.

•

Successful thrombolysis can be achieved with low-dose thrombolytics in patients with higher risk of bleeding complications.

Prehospital Ultrasound Diagnosis of Massive Pulmonary Embolism by Non-Physicians: A Case Series

Massive pulmonary embolism (hemodynamically unstable, defined as systolic BP <90 mmHg) has significant morbidity and mortality. Point of care ultrasound (POCUS) has allowed clinicians to detect evidence of massive pulmonary embolism much earlier in the patient's clinical course, especially when patient instability precludes computerized tomography confirmation. POCUS detection of massive pulmonary embolism has traditionally been performed by physicians. This case series demonstrates four cases of massive pulmonary embolism diagnosed with POCUS performed by non-physician prehospital personnel.

Current trends in image-guided chest interventions

Interventional radiology (IR) is a rapidly expanding medical subspecialty and refers to a range of image‐guided procedural techniques. The image guidance allows real‐time visualization and precision placement of a needle, catheter, wire and device to deep body structures through small incisions. Advantages include reduced risks, faster recovery and shorter hospital stays, lower costs and less patient discomfort. The range of chest interventional procedures keeps on expanding due to improved imaging facilities, better percutaneous assess devices and advancing ablation and embolization techniques. These advances permit procedures to be undertaken safely, simultaneously and effectively, hence escalating the role of IR in the treatment of chest disorders. This review article aims to cover the latest developments in some image‐guided techniques of the chest, including thermal ablation therapy of lung malignancy, targeted therapy of pulmonary embolism, angioplasty and stenting of mediastinal venous/superior vena cava occlusion, pulmonary arteriovenous malformation treatment and bronchial artery embolization for haemoptysis.

Venous Thromboembolism During Pregnancy and the Postpartum Period: Risk Factors, Diagnostic Testing, and Treatment

Importance

The risk of venous thromboembolism (VTE) increases during pregnancy and the postpartum period. Deep vein thrombosis is the most common VTE during pregnancy, but pulmonary embolism is typically of greater concern as it contributes to far higher morbidity and mortality. Diagnosis and treatment of VTE during pregnancy differ substantially from the general nonpregnant population.

Objective

This review describes the epidemiology, risk factors, clinical presentation, diagnosis, and treatment of VTE during pregnancy and the postpartum period.

Evidence Acquisition

First, we reviewed the VTE guidelines from professional societies in obstetrics, cardiology, hematology, emergency medicine, pulmonology, and critical care. Second, we examined references from these documents and used PubMed to identify recent articles that cited the guidelines. Finally, we searched PubMed and Google Scholar for articles published since 2018 that included terms for pregnancy and the epidemiology, risk factors, diagnostic imaging, or treatment of VTE.

Results

Venous thromboembolism risk increases throughout pregnancy and peaks shortly after delivery. More than half of pregnancy-related VTE are associated with thrombophilia; other major risks include cesarean delivery, postpartum infection, and the combination of obesity with immobilization. Most VTE can be treated with low molecular weight heparin, but cases of limb- or life-threatening VTE require consideration of thrombolysis and other reperfusion therapies.

Conclusions and Relevance

Venous thromboembolism is far more frequent in antepartum and postpartum women than age-matched controls, and clinical suspicion for VTE in this population should incorporate pregnancy-specific risks. Treatment of limb- or life-threatening antepartum or postpartum VTE requires multispecialty coordination to optimize maternal and fetal outcomes.

BEE FIRST: A standardized point-of-care ultrasound approach to a patient with dyspnea

Dyspnea is a common complaint in patients who present to the emergency department and can be due to numerous etiologies. This case report details a 90-year-old female with a history significant for hypertension, hyperlipidemia, and new diagnosis of ovarian malignancy whose symptoms increased over the past three days. Point-of-care Ultrasonography showed multiple B-lines, a plethoric IVC without respiratory variation, a markedly low EF and a lack of RV dilation. There was also no evidence of effusion which led the emergency medicine team to the diagnosis of acute decompensated heart failure. This quick diagnosis was possible due to using the standardized POCUS approach guided by the BEE FIRST algorithm. BEE FIRST can help physicians remember: B-lines are indicative of interstitial thickening, Effusion such as pericardial or pleural should be checked for, Ejection Fraction is useful in assessing for heart failure, IVC/Infection/Infarct correlates with central venous pressure, and can be used to assess volume status, check for enlargement, evidence of pneumonia, subpleural consolidation “shred sign”, hepatization of lung, and/or pulmonary infarction related to pulmonary embolism, Right Heart Strain can indicate pulmonary embolism or pulmonary hypertension, Sliding Lung can assess for pneumothorax and pleural characteristics, and lastly, Thrombosis/Tumor can assess for myxoma and interrogation of lower extremities for deep vein thrombosis can aid in dyspnea differentiation. In this report, we demonstrate how the framework BEE FIRST offers a standardized stepwise approach to the utilization of POCUS in a patient with acute dyspnea in the ED setting.

Endovascular Management of Venous Thromboembolic Disease in the Oncologic Patient Population

PURPOSE OF REVIEW

Venous thromboembolic disease causes significant mortality and morbidity in the oncologic patient population. Recently, minimally invasive endovascular technologies have been developed as an adjunct to antithrombotic therapy for the management of DVT and PE. The current and potential roles for endovascular treatment of cancer-associated venous thromboembolism (VTE) will be reviewed in this article.

RECENT FINDINGS

The recent NCCN guidelines recommend endovascular therapy in patients eligible for therapeutic anticoagulation who present with life-, organ-, or limb-threatening thrombosis. However, symptomatic non-life-threatening VTE can negatively affect QOL and physical function, both of which have prognostic implications in the cancer population. Endovascular therapies have been shown to improve physical function and QOL in prospective trials performed in a non-oncologic patient population as well as small retrospective studies in the cancer population. In addition to treating life- and limb-threatening thrombosis, endovascular therapy for VTE can improve QOL and physical function in comparison to anticoagulation alone. Prospective trials are warranted to assess the benefit of endovascular therapy for quality of life-years, performance status, and overall survival in the oncologic patient population.

The Association Between Mean Corpuscular Hemoglobin Concentration and Prognosis in Patients with Acute Pulmonary Embolism: A Retrospective Cohort Study

Introduction

Acute pulmonary embolism (APE) is a typical cardiovascular emergency worldwide. Mean hemoglobin concentration (MCHC) is a standard indicator of anemia. Studies on the association between MCHC and APE are scarce. We aimed to investigate the relationship between MCHC and APE.

Methods

Clinical data were extracted from the Medical Information Bank for Intensive Care (MIMIC)-III. Adult (≥18 years) patients with APE admitted for the first time were included in this study. An analysis was conducted to evaluate the association between MCHC and the prognosis of patients by the Cox regression analysis, generalized additives models and Kaplan–Meier survival curves. The primary outcome was 30-day mortality, and the secondary outcomes were 1-year and 3-year mortality.

Results

A total of 813 patients who met the selection criteria were enrolled, of whom 130 (16.0%) died within 30 days of admission. Univariate Cox regression indicated that MCHC was significantly associated with mortality (30-day: HR = 0.74, 95% CI = 0.66–0.82, P < 0.001; 1-year: HR = 0.80, 95% CI = 0.74–0.86, P < 0.001; 3-year: HR = 0.82, 95% CI = 0.77–0.88, P < 0.001). MCHC remains stable after adjusting multiple models. Kaplan-Meier survival curves showed that patients with lower MCHC had a poorer 30-day prognosis.

Conclusions

Lower MCHC is an independent risk factor for increased mortality in patients with APE. As an inexpensive biomarker, MCHC should receive more attention.

Do Patients with a Family or Personal History of Venous Thromboembolism have an Increased Risk of Recurrence?

BACKGROUND

 A family (FH) and personal history (PH) of venous thromboembolism (VTE) are commonly evaluated risk factors for recurrence. We examined the association between FH/PH of VTE and the risk of recurrence and whether a stronger history status (i.e., both FH/PH vs. no FH/PH) carries an increased recurrence risk.

METHODS

 We prospectively followed 813 patients aged ≥ 65 years with acute VTE from 9 Swiss hospitals. We classified patients into four groups: no FH/PH, FH only, PH only, and both FH/PH. The primary outcome was recurrent VTE during the full observation period. We examined the association between FH/PH status and the time to VTE recurrence using competing risk regression, adjusting for confounders and periods of anticoagulation.

RESULTS

 Of 813 patients with VTE, 59% had no FH/PH, 11% a FH only, 24% a PH only, and 7% had both a FH and PH of VTE. Overall, 105 patients had recurrent VTE during the full observation period. After adjustment, patients with a FH only (subhazard ratio [SHR] 0.8, 95% confidence interval [CI] 0.4-1.7), PH only (SHR 1.5, 95% CI 0.9-2.5), and both FH/PH (SHR 1.4, 95% CI 0.6-3.1) did not have an increased risk of recurrent VTE compared with those without FH/PH. When we considered the period after the completion of initial anticoagulation only, the results were similar.

CONCLUSION

 Our findings indicate that in patients with acute VTE, a FH and/or PH of VTE does not convey an increased risk of recurrent VTE. In particular, we did not find a "dose-effect" relationship between FH/PH status and VTE recurrence.

Elderly Population with COVID-19 and the Accuracy of Clinical Scales and D-Dimer for Pulmonary Embolism: The OCTA-COVID Study

BACKGROUND

Elderly COVID-19 patients have a high risk of pulmonary embolism (PE), but factors that predict PE are unknown in this population. This study assessed the Wells and revised Geneva scoring systems as predictors of PE and their relationships with D-dimer (DD) in this population.

METHODS

This was a longitudinal, observational study that included patients ≥75 years old with COVID-19 and suspected PE. The performances of the Wells score, revised Geneva score and DD levels were assessed. The combinations of the DD level and the clinical scales were evaluated using positive rules for higher specificity.

RESULTS

Among 305 patients included in the OCTA-COVID study cohort, 50 had suspected PE based on computed tomography pulmonary arteriography (CTPA), and the prevalence was 5.6%. The frequencies of PE in the low-, intermediate- and high-probability categories were 5.9%, 88.2% and 5.9% for the Geneva model and 35.3%, 58.8% and 5.9% for the Wells model, respectively. The DD median was higher in the PE group (4.33 mg/L; interquartile range (IQR) 2.40-7.17) than in the no PE group (1.39 mg/L; IQR 1.01-2.75) (p < 0.001). The area under the curve (AUC) for DD was 0.789 (0.652-0.927). After changing the cutoff point for DD to 4.33 mg/L, the specificity increased from 42.5% to 93.9%.

CONCLUSIONS

The cutoff point DD > 4.33 mg/L has an increased specificity, which can discriminate false positives. The addition of the DD and the clinical probability scales increases the specificity and negative predictive value, which helps to avoid unnecessary invasive tests in this population.

Severity of pulmonary embolism at initial diagnosis and long-term clinical outcomes: From the COMMAND VTE Registry

BACKGROUND

There is a paucity of data on the long-term clinical outcomes according to the severity of pulmonary embolism (PE) at initial diagnosis.

METHODS

The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic venous thromboembolism (VTE). After excluding 1312 patients without PE, the current study population consisted of 1715 patients with PE, who were divided into 3 groups according to the clinical severity; massive PE, sub-massive PE and low-risk PE.

RESULTS

There were 179 patients (10%) with massive PE, 742 patients (43%) with sub-massive PE, and 794 patients (46%) with low-risk PE. By the landmark analysis at 3 months, the cumulative incidences of recurrent VTE were similar among the 3 groups both within and beyond 3 months (Massive PE: 2.9%, Sub-massive PE: 4.2%, and Low-risk PE: 3.3%, P = 0.61, and 4.3%, 8.8%, and 7.8% at 5 years, P = 0.47, respectively). After adjusting confounders, the risk of massive PE relative to low-risk PE for recurrent VTE beyond 3 months remained insignificant (adjusted HR 0.54, 95% CI: 0.13-1.51, P = 0.27). Patients with massive PE at initial diagnosis more often presented as severe recurrent PE events than those with sub-massive and low-risk PE.

CONCLUSIONS

In the current real-world large registry, the long-term risk of overall recurrent VTE in patients with massive PE at initial diagnosis did not significantly differ from those with sub-massive and low-risk PE beyond 3 months, although patients with massive PE at initial diagnosis more frequently developed recurrent VTE as PE with severe clinical presentation.

Performance of pulmonary embolism severity index in predicting long-term mortality after acute pulmonary embolism

OBJECTIVE

In this study, we aimed to evaluate the accuracy of the original and simplified pulmonary embolism (PE) severity index (PESI) to predict all-cause mortality after 30 days of acute PE diagnosis up to five years within consecutive sub-periods.

METHODS

Adult patients diagnosed with acute PE between January 1, 2003, and June 30, 2013, were retrospectively included. Data on baseline characteristics and mortality during a five-year follow-up were collected.

RESULTS

The study included 414 patients (Male/Female=192/222). The median age at diagnosis was 61.5 (minimum-maximum, 18-93) years. Mortality rates were 13.3% at 30 days, 21.8% at 90 days, 32.6% at one year, and 51.0% at five years. Both stratification into risk classes according to the original PESI and low vs. high-risk classification of original and simplified PESI were significantly correlated with the 30-day, 31-90-day, 91-day-one-year, and one-five-year mortality. Significant PESI predictors for mortality were history of cancer [hazard ratio (HR): 3.31, 95% confidence interval (CI): 1.64-6.68; p=0.001] and heart failure (HR: 2.35, 95% CI: 1.04-5.32, p=0.041) at 31-90-day, history of cancer (HR: 5.45, 95% CI: 2.86-10.40, p<0.001) at 91-day-one-year, advancing age (HR: 1.04, 95% CI: 1.02-1.06, p<0.001) and history of cancer (HR: 5.53, 95% CI: 3.41-8.98, p<0.001) at one-five-year after acute PE diagnosis.

CONCLUSION

All-cause long-term mortality in high-risk patients with acute PE according to original or simplified PESI significantly increased up to five years of follow-up. This survival disadvantage was mainly related to cancer and comorbidities rather than acute clinical manifestations. Future prospective studies are needed to demonstrate the effect of various comorbidities on long-term mortality in these patients.

Differences in clinical and echocardiographic variables and mortality predictors among older patients with pulmonary embolism

BACKGROUND

An increase in short-term mortality can be found among older patients with hemodynamically stable acute pulmonary embolism (APE) who have signs of right ventricular (RV) dysfunction.

AIMS

This study was designed to assess whether any difference exists among clinical, laboratory, electrocardiography and echocardiography parameters between older and younger patients diagnosed with APE.

METHODS

The study sample included a total of 635 patients with confirmed APE who were divided into two groups of older (65 years and older) and younger (younger than 65 years) individuals. Comparisons were performed between these groups in terms of clinical, predisposing factors and laboratory, electrocardiographic and echocardiographic parameters.

RESULTS

Analyses of 295 (46.4%) older and 340 (53.6%) younger patients diagnosed with APE were performed. Female sex, Pulmonary Embolism Severity Index score and baseline creatinine levels were higher in the older group. Also, the frequency of atrial fibrillation, RV outflow tract parasternal long-axis proximal diameter, RV end-diastolic diameter (RV-EDD) basal (apical four-chamber) and RV systolic pressure were significantly greater in older patients with APE. A total of 30 (4.7%) deaths were observed during the in-hospital period [21 (7.1%) older vs 9 (2.6%) younger patients; p < 0.01]. In the multivariate logistic regression analysis, age, white blood cell count (WBC), left ventricular ejection fraction (LVEF), RV-EDD basal and tricuspid annular plane systolic excursion (TAPSE) of less than 16 mm were found to be independently associated with in-hospital mortality.

CONCLUSION

Older patients might experience greater rates of RV dilatation, RV dysfunction and atrial fibrillation during APE. In addition to age; elevated WBC, low LVEF, increased RV-EDD basal and TAPSE of less than 16 mm were independent predictors of mortality among study population.

The effect of COPD on the incidence and mortality of hospitalized patients with pulmonary embolism: A nationwide population-based study (2016-2018)

BACKGROUND

To examine the incidence, clinical characteristics, and in-hospital outcomes of pulmonary embolism (PE) among hospitalized patients with or without chronic obstructive pulmonary disease (COPD) in Spain, and to identify predictors of in-hospital-mortality (IHM) after PE among patients with and without COPD.

METHODS

We included all patients aged ≥ 40 years who were hospitalised for PE between 2016 and 2018. Data were collected from the Spanish National Hospital Discharge Database.

RESULTS

We identified 47,190 hospitalizations for PE during the study period, 7.49% with COPD. Adjusted incidence of PE was higher in COPD patients than in those without COPD (IRR 1.16; 95%CI 1.13-1.19). Crude IHM was significantly higher in PE hospitalized patients with COPD than in those without COPD (9.86% vs 3.59%; p<0.001). Predictor factors of IHM in COPD patients with PE included older age, higher Charlson comorbidity index, atrial fibrillation, massive PE and dependence on oxygen prior to hospital admission. However, obesity was associated with lower IHM. For PE hospitalized patients, suffering COPD increased the probability of dying in the hospital (adjusted OR 2.84; 95%CI 2.27-3.55).

CONCLUSIONS

Our results revealed that incidence of PE was higher in COPD patients than in those without COPD. Furthermore, COPD was a risk factor for IHM after PE.

Predictive value of heart failure with reduced versus preserved ejection fraction for outcome in pulmonary embolism

AIMS

This study aimed to investigate whether the risk of short-term mortality is different in pulmonary embolism (PE) patients who have heart failure with reduced ejection fraction (HFrEF) as compared with those with heart failure with preserved ejection fraction (HFpEF).

METHODS AND RESULTS

Predictive value of HFrEF or HFpEF for 7-day (intrahospital) and 30-day all-cause mortality was determined in the cohort of 1055 out of 1201 consecutive acute PE patients from the Serbian multicentre PE registry. Patients were classified into either HFrEF or HFpEF group, according to guideline-proposed criteria. A 7-day (intrahospital) and 30-day all-cause mortality was 18.5% vs. 7.3% vs. 4.5% (P < 0.001) and 22.2% vs. 16.3% vs. 7.9% (P < 0.001) for patients with the history of HFrEF, HFpEF, and without HF, respectively. Multivariable analysis adjusted to age, gender, history of chronic obstructive pulmonary disease, diabetes mellitus, arterial hypertension, presence of atrial fibrillation, and mortality risk assessment at admission has shown that only HFrEF, but not HFpEF, was an independent predictor for 7-day mortality (hazard ratio 2.22, 95% confidence interval 1.25-4,38.41, P = 0.021) and neither HFrEF or HFpEF was an independent predictor for 30-day mortality. Among various admission parameters associated to PE outcome, only systolic pressure in HFrEF patients (P < 0.001), heart rate (P = 0.01), and right ventricle systolic pressure (P = 0.039) in HFpEF patients were significantly different in patients who died compared with those who survived at 7 days.

CONCLUSIONS

Our study has shown that the presence of previous history of HFrEF, but not HFpEF, in acute PE is an independent risk factor for mortality at 7 days.

Type 2 Diabetes Is a Risk Factor for Suffering and for in-Hospital Mortality with Pulmonary Embolism. A Population-Based Study in Spain (2016-2018)

(1) Background: The relationship between type 2 diabetes (T2DM) and pulmonary embolism (PE) has not been well stablished so far. We aim to analyze incidence, clinical conditions and in-hospital mortality (IHM) according to the presence of T2DM among patients hospitalized for suffering from PE. The factors associated with IHM were identified. (2) Methods: Patients aged ≥40 years hospitalized for PE from 2016 to 2018 included in the Spanish National Health System Hospital Discharge Database were analyzed. Dependent variables included incidence, IHM and length of hospital stay. Independent variables were age, sex, diagnosed comorbidities, thrombolytic therapy and inferior vena cava filter placement. Poisson and logistic regression models were constructed for multivariable analysis. (3) Results: Of the 47,190 hospitalizations for PE recorded, 16.52% had T2DM. Adjusted incidence of PE was higher among T2DM women (IRR 1.83; 95% CI: 1.58-1.96) and men (IRR 1.22; 95% CI: 1.18-1.27) than among non-diabetic subjects. Crude IHM in T2DM patients with PE was similar in both sexes but higher than in non-diabetic patients. Among T2DM patients with PE, risk factors for IHM included older age, comorbidity, atrial fibrillation and massive PE. Obesity was associated with lower IHM. Suffering T2DM was a risk of IHM (OR 1.15; 95% CI 1.05-1.26) after PE. (4) Conclusions: The incidence of PE is higher in T2DM men and women than in non-diabetic patients. T2DM was a risk factor for IHM after PE.