Trends in risk stratification, in-hospital management and mortality of patients with acute pulmonary embolism: an analysis from China pUlmonary thromboembolism REgistry Study (CURES)

Whole genome sequencing identifies pathogenic genetic variants in Han Chinese patients with familial venous thromboembolism

Genetic factors play a pivotal role in determining venous thromboembolism (VTE) risk, particularly in cases of unprovoked early-onset VTE and those with a family history. While genome-wide association studies (GWAS) has advanced our understanding, high-quality whole-genome sequencing (WGS) from family-based studies is essential to elucidate the role of rare variants. In this study, we performed WGS on 216 individuals from 35 Han Chinese VTE pedigrees and validated findings in 99 high-heritability VTE cases using whole-exome sequencing. Functional impact was assessed via qPCR and Western Blot in HEK293T cells. Classical genes explained partial familial inheritance (20/35), while non-classical genes showed comparable effects on VTE recurrence and CTEPH. From 36 rare variants, 34 pedigrees (97%) were interpreted, with 29 variants reported for the first time. Notably, three novel variants, GP6 (c.G1094A:p.R365H), TET2 (c.G3451T:p.E1151X), and JAK2 (c.G380A:p.G127D), shared in two unrelated pedigrees each and are classified as low frequency in East Asians. Functional analyses revealed significant changes in GP6 and TET2 expression compared to the wild type. These findings provide novel insights into the genetic architecture of VTE and highlight GP6, TET2, and JAK2 as potential risk factors in East Asian populations, underscoring the clinical relevance of rare variants in VTE pathogenesis.

Estimated Glomerular Filtration Rate Decline is Causally Associated with Acute Pulmonary Embolism: A Nested Case-Control and Mendelian Randomization Study

Renal dysfunction is highly prevalent among patients with pulmonary embolism (PE). This study combined population-based study and Mendelian randomization (MR) to observe the relationship between renal function and PE.A nested case-control study were performed using data of PE patients and controls were from two nationwide cohorts, the China pUlmonary thromboembolism REgistry Study (CURES) and China Health and Retirement Longitudinal Survey (CHARLS). Baseline characteristics were balanced using propensity score matching and inverse probability of treatment weighting. Restricted cubic spline models were applied for the relationship between estimated glomerular filtration rate (eGFR) decline and the risk of PE. Bidirectional two-sample MR analyses were performed using genome-wide association study summary statistics for eGFR involving 1,201,909 individuals and for PE from the FinnGen consortium.The nested case-control study including 17,547 participants (6,322 PE patients) found that eGFR distribution was significantly different between PE patients and controls (p < 0.001), PE patients had a higher proportion of eGFR < 60 mL/min/1.73 m2. eGFR below 88 mL/min/1.73 m2 was associated with a steep elevation in PE risk. MR analyses indicated a potential causal effect of eGFR decline on PE (odds ratio = 4·26, 95% confidence interval: 2·07-8·79), with no evidence of horizontal pleiotropy and reverse causality.Our findings support the hypothesis that renal function decline contributes to an elevated PE risk. Together with the high prevalence of chronic kidney diseases globally, there arises the necessity for monitoring and modulation of renal function in effective PE prevention.

Analysis of clinical characteristics in 1940 patients with acute pulmonary embolism

BACKGROUND

The clinical characteristics of acute pulmonary embolism (APE) according to mortality risk has been partly explored. Further research is required in light of the latest guide update on risk stratification for APE.

METHODS

We collected the data from hospitalized patients with APE. Patients were classified according to the 2019 European Society of Cardiology's (ESC) guidelines. The clinical traits between different risk stratification of APE was investigated.

RESULTS

A total of 1940 patients had APE. Patients who were stratified as high risk showed the highest frequency of both syncope (4.5 % vs 6.6 % vs 12.7 %; P = 0.002) and dyspnea (61.9 % vs 73.0 % vs 73.8 %, P = 0.007) when compared to the other two groups. The rates of deep venous thrombosis (DVT) were: 49.4 % in low-risk stratification, 63.2 % in intermediate-risk stratification, and 68.1 % in high-risk stratification, (Pfor trend = 0.001), while the proportion of low-risk stratification patients increased (2.5 %-13.3 %, Pfor trend<0.001).

CONCLUSION

In conclusion, clinical characteristics differ among pulmonary embolism patients with different risk stratification. Furthermore, the percentage of low-risk patients increased progressively while overall in-hospital death rates among APE patients gradually decreased.

Trends in Initial Anticoagulation Among US Patients Hospitalized With Acute Pulmonary Embolism 2011-2020

STUDY OBJECTIVE

Guidelines recommend low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOACs) rather than unfractionated heparin (UFH) for treatment of acute pulmonary embolism (PE) given their efficacy and reduced risk of bleeding. Using data from a large consortium of US hospitals, we examined trends in initial anticoagulation among hospitalized patients diagnosed with acute PE.

METHODS

We conducted a retrospective study of inpatient and observation cases between January 1, 2011, and December 31, 2020, among individuals aged more than or equal to 18 years treated at acute care hospitals contributing data to the Premier Healthcare Database. Included cases received a diagnosis of acute PE, underwent imaging for PE, and received anticoagulation at the time of admission. The primary outcome was the initial anticoagulant selected for treatment.

RESULTS

Among 299,016 cases at 1,045 hospitals, similar proportions received initial treatment with UFH (47.4%) and LMWH (47.9%). Between 2011 and 2020, the proportion of patients initially treated with UFH increased from 41.9% to 56.3%. Over this period, use of LMWH as the initial anticoagulant was reduced from 58.1% in 2011 to 37.3% in 2020. The proportion of cases admitted to the ICU, treated with mechanical ventilation or vasopressors, and inpatient mortality were stable. Factors most strongly associated with receipt of UFH were admission to the ICU (odds ratio [OR] 6.90; 95% confidence interval [CI] 6.31 to 7.54) or step-down unit (OR 2.30; 95% CI 2.16 to 2.45), receipt of thrombolysis (OR 4.25; 95% CI 3.09 to 5.84) or vasopressors (OR 1.83; 95% CI 1.32 to 2.54), and chronic renal disease (OR 1.67; 95% CI 1.54 to 1.81).

CONCLUSIONS

Despite recommendations that LMWH and DOACs be considered first-line for most patients with acute PE, use of UFH is common and increasing. Further research is needed to elucidate factors associated with persistent use of UFH and opportunities for deimplementation of low-value care.

Sex disparities of clinical manifestations in acute pulmonary embolism and predictive value for in-hospital mortality: Insights from CURES

BACKGROUND

Pulmonary embolism (PE) is a common and potentially fatal disease, with differences in mortality rates among PE patients of different sexes. This study aims to investigate the disparities in clinical manifestations and in-hospital mortality rates between sexes in PE patients, as well as the association of clinical symptoms with in-hospital mortality.

METHODS

We analyzed data from the China pUlmonary thromboembolism REgistry Study (CURES), a nationwide, multicenter, prospective registry focusing on patients with acute PE. Using propensity score matching (PSM) to pair male and female patients with PE, we explored the correlation between clinical symptoms and in-hospital mortality through multivariable regression analysis.

RESULTS

A total of 15,203 patients with acute PE were enrolled, and 380 died during hospitalization. The incidence of chest pain, hemoptysis, and palpitations was significantly higher in males compared to females. The incidence of dyspnea, fever, and syncope was higher in females. Hemoptysis and dyspnea were associated with increased in-hospital mortality in males, whereas dyspnea, fever, and palpitations were linked to higher mortality in females. Overall, males exhibited a higher in-hospital mortality than females (2.9 % vs. 2.1 %, p = 0.002). After matching 13,130 patients using the PSM method, the mortality rate of males remained higher than that of females (2.7 % vs. 2.1 %, p = 0.020).

CONCLUSIONS

Our study demonstrates that male patients with PE have a higher risk of in-hospital mortality than females. Significant differences in clinical symptoms between sexes are associated with increased mortality risk, emphasizing the need for clinical awareness.

Relationship between serum uric acid levels and pulmonary embolism: an age-based stratified analysis

BACKGROUND

The association between uric acid and pulmonary embolism(PE) remains controversial, and there has been limited investigation into how uric acid influences pulmonary embolism across different age groups. Our study aimed to elucidate the relationship between uric acid levels and pulmonary embolism, considering variations across age groups.

METHODS

A total of 368 patients who underwent computed tomography pulmonary angiography from July 2018 to May 2022 were included in the analysis. Subsequently, the cohort was stratified by age, with separate univariate and multivariate logistic regression analyses conducted for the elderly (aged ≥ 60 years) and non-elderly (aged < 60 years), respectively.

RESULTS

The study revealed that patients with PE exhibited higher uric acid levels compared to those without (325.11 ± 137.02 vs. 298.26 ± 110.54 (umol/l), p = 0.039). This disparity persisted even after adjusting for multiple confounders (OR = 1.002, 95% CI 1.000-1.005, p = 0.042). Additionally, a notable age difference was observed between PE and non-PE patients (65.7 ± 16.12 vs. 61.42 ± 15.03 (umol/l), p = 0.009). Subsequently, upon age stratification, significant differences (p < 0.05) in serum uric acid were noted between PE and non-PE patients in both elderly and non-elderly populations. However, elevated uric acid levels were independently associated with PE only in the elderly following adjustment for multiple confounders (OR = 1.003, 95% CI 1.001-1.005, p = 0.008).

CONCLUSION

High uric acid levels are an independent risk factor for pulmonary embolism in the elderly (≥ 60 years).

Blood cell traits and venous thromboembolism in East Asians: Observational and genetic evidence

Previous studies have indicated that various blood cell traits are associated with a higher risk of venous thromboembolism (VTE). However, the causal relationship remains uncertain. We collected data from the China pulmonary thromboembolism registry study and the China pulmonary health study, using propensity score matching and two-sample Mendelian randomization analyses with summary statistics from genome-wide association studies of blood cell traits and VTE in the East Asian population. Our findings revealed that platelet (PLT) count and hemoglobin (Hb) levels were significantly higher in VTE patients compared to the general population (p value <0.01). Genetically predicted Hb levels were positively associated with VTE, with an odds ratio (OR) of 2.38 (1.13-5.01), p value = 0.022. Similarly, genetically predicted PLT count was positively correlated with VTE, with an OR of 1.33 (1.02-1.74), p value = 0.038. These results suggest a causal relationship and potential targets for prevention.

Pulmonary embolism and deep venous thrombosis in China

The Annual Report on Cardiovascular Health and Diseases in China (2022) intricate landscape of cardiovascular health in China. In connection with the previous section, this eighth section of the report offers a comprehensive analysis of pulmonary embolism and deep venous thrombosis. In recent years, research in the field of pulmonary vessel in China has made great progress. A number of nationwide multi-center registry research results have filled the gaps in the epidemiology, diagnosis and treatment of pulmonary hypertension and venous thromboembolism. Different types of pulmonary hypertension still need attention to the identification of risk factors and/or risk stratification, and venous thromboembolism needs attention in the prevention and the overall management inside and outside hospital. In the future, we look forward to the publication of more high-quality research in China, which could be able to improve relevant guidelines for pulmonary vascular diseases both domestically and internationally.

Overcoming challenges in the treatment of massive pulmonary embolism in the elderly: Role of extracorporeal membrane oxygenation

Population aging represents a paramount medical and socio-demographic challenge globally. As living standards improve and medical technology advances, the elderly population experiences an increasing number of detected and treated pulmonary embolisms (PE). However, rescuing massive pulmonary embolism (MPE) in the elderly remains a difficult task. Conventional thrombolysis or surgical thrombolysis might be contraindicated, leading extracorporeal membrane oxygenation (ECMO) to emerge as a treatment modality for MPE in the elderly. Nevertheless, data are scarce regarding the use of ECMO as a standalone treatment for MPE. In this paper, we present the case of an 85-year-old patient with a prior cerebral infarction, who received a diagnosis of MPE in the main trunks of bilateral pulmonary arteries. Considering the patient's systemic condition, the Pulmonary Embolism Response Team (PERT) opted to administer VA-ECMO as the sole treatment approach. Remarkably, the patient achieved a favorable recovery outcome. Our case report contributes new evidence to the treatment of elderly individuals with MPE and highlights the potential of ECMO-only regimens for addressing such cases.

Adjusting Atrial Size Parameters for Body Surface Area: Does it Affect the Association With Pulmonary Embolism-related Adverse Events?

PURPOSE

Small left atrial (LA) volume was recently reported to be one of the best predictors of acute pulmonary embolism (PE)-related adverse events (AE). There is currently no data available regarding the impact that body surface area (BSA)-indexing of atrial measurements has on the association with PE-related adverse events. Our aim is to assess the impact of indexing atrial measurements to BSA on the association between computed tomography (CT) atrial measurements and AE.

MATERIALS AND METHODS

Retrospective study (IRB: 2015P000425). A database of hospitalized patients with acute PE diagnosed on CT pulmonary angiography (CTPA) between May 2007 and December 2014 was reviewed. Right and left atrial volume, largest axial area, and axial diameters were measured. Patients undergo both echocardiographies (from which the BSA was extracted) and CTPAs within 48 hours of the procedure. The patient's body weight was measured during each admission. LA measurements were correlated to AE (defined as the need for advanced therapy or PE-related mortality at 30 days) before and after indexing for BSA. The area under the ROC curve was calculated to determine the predictive value of the atrial measurements in predicting AE.

RESULTS

The study included 490 acute PE patients; 62 (12.7%) had AE. There was a significant association of reduced BSA-indexed and non-indexed LA volume (both <0.001), area (<0.001 and 0.001, respectively), and short-axis diameters (both <0.001), and their respective RA/LA ratios (all <0.001) with AE. The AUC values were similar for BSA-indexed and non-indexed LA volume, diameters, and area with LA volume measurements being the best predictor of adverse outcomes (BSA-indexed AUC=0.68 and non-indexed AUC=0.66), followed by non-indexed LA short-axis diameter (indexed AUC=0.65, non-indexed AUC=0.64), and LA area (indexed AUC=0.64, non-indexed AUC=0.63).

CONCLUSION

Adjusting for BSA does not substantially affect the predictive ability of atrial measurements on 30-day PE-related adverse events, and therefore, this adjustment is not necessary in clinical practice. While LA volume is the better predictor of AE, LA short-axis diameter has a similar predictive value and is more practical to perform clinically.

Performance of the Simplified Pulmonary Embolism Severity Index in predicting 30-day mortality after acute pulmonary embolism: Validation from a large-scale cohort

BACKGROUND

The performance of existing prognostic scores including the simplified Pulmonary Embolism Severity Index (sPESI) for short-term mortality of non-high-risk PE in Chinese population has not been widely validated.

METHODS

Non-high-risk patients were included from the prospective cohort of the China pUlmonary Thromboembolism REgistry Study (CURES). The sPESI, RIETE, Geneva, modified FAST, and Bova score were validated. The discriminatory performance was measured by the area under the curve (AUC). We also compared the sensitivity, odds ratio, specificity, positive predictive value and negative predictive value of these scores.

RESULTS

A total of 6,873 non-high-risk patients with acute PE were included and 241 (3.5 %) patients died within 30 days. Compared to the Geneva, modified FAST, and Bova score, the AUCs for predicting 30-day death of sPESI and RIETE score were higher at 0.712 (95 % CI, 0.680, 0.743) and 0.723 (95 % CI, 0.691, 0.755) respectively. The sPESI demonstrated the highest sensitivity at 0.809, while the RIETE score, Geneva, Modified FAST and BOVA score showed sensitivities of 0.622, 0.568, 0.477 and 0.502 respectively. A sPESI ⩾1 point was associated with a 4.7-fold increased risk of 30-day all-cause mortality (95 % CI, 3.427, 6.563, p < 0.001), while a RIETE score of ⩾1 point was associated with a 4.5-fold increased risk (95 % CI, 3.127, 6.341, p < 0.001). The Geneva score, modified FAST and Bova score showed inferior performance.

CONCLUSIONS

The implementation of the fewer-parameter, easier-to-calculate sPESI in Chinese patients with PE can help to discriminate patients with extremely low risk of short-term mortality for home treatment or early discharge.

NF-κB affected the serum levels of TNF-α and IL-1β via activation of the MAPK/NF-κB signaling pathway in rat model of acute pulmonary microthromboembolism

Pulmonary thromboembolism caused by thrombi blocking major pulmonary artery and its branches, is a frequently encountered phenomenon and an important cause of high morbidity and mortality in lung diseases and may develop into persistent pulmonary hypertension (PH). Nuclear factor-κB (NF-κB) signaling pathway had been reported participated in the formation and development of PH by promoting inflammatory response. The aim of this study was to investigate the effects of NF-κB activation on the serum levels of tumor necrosis factor α (TNF-α) and interleukin-1β (IL-1β) in acute pulmonary microthromboembolism (APMTE) rats. Rats were randomized into five groups. APMTE group received jugular vein injection of autologous thrombus, while control group rats received normal saline injection. Pulmonary hemodynamic parameters were measured through ECHO-guided transthoracic puncture. Pulmonary vascular morphological changes were analyzed by HE. The expression changes of NF-κB and serum TNF-α、IL-1β levels were detected by enzyme-linked immunosorbent assay. Protein expression of the MAPK/NF-κB signaling pathway including p-IκBα, p-p38 MAPK, p-NF-κB p65, IκBα, p38 MAPK, and NF-κB p65 was determined using western blot analysis. Compared with control group, the expression of NF-κB in lung tissue and the levels of serum TNF-α and IL-1β rats were higher, a significant reduction in IκBα and elevation in the phosphorylation of IκBα, p38 MAPK, and NF-κB p65 were found in APMTE group rats. And UK administration reversed the APMTE-induced increase in TNF-α, IL-1β, p-IκBα, p-MAPK, and p-NF-κB protein. Furthermore, the levels of NF-κB, TNF-α, and IL-1β were positively correlated with mean pulmonary artery. And the levels of TNF-α and IL-1β were positively correlated with NF-κB. These findings suggest that the activation of MAPK/NF-κB pathway as a critical driver of increasing TNF-α and IL-1β level in APMTE rats and UK exerted protective effects against APMTE-induced PH may be related to the downregulation of the MAPK/NF-κB signaling pathway.

Dust particulate matter increases pulmonary embolism onset: A nationwide time-stratified case-crossover study in China

BACKGROUND

Particulate matter (PM) has been found to elevate the risk of pulmonary embolism (PE) onset. Among the contributors to PM, dust PM stands as the second natural source, and its emissions are escalating due to climate change. Despite this, information on the effect of dust PM on PE onset is scarce. Hence, this study aims to investigate the impacts of dust PM10, dust PM2.5-10, and dust PM2.5 on PE onset.

METHODS

A nationwide time-stratified case-crossover study was conducted between 2015 and 2020, using data from 18,616 PE onset cases across 1,921 hospitals in China. The analysis employed a conditional logistic regression model to quantify the associations between dust PM10, dust PM2.5-10, and dust PM2.5 and PE onset. Furthermore, the study explored the time-distributed lag pattern of the effect of dust PM on PE development. Stratified analyses were performed based on sex, age, region, and season.

RESULTS

Dust PM10, dust PM2.5-10, and dust PM2.5 exhibited significant health effects on PE onset, particularly concerning exposure on the same day. The peak estimates were observed at lag 01 day, with the odds ratio being 1.011 [95 % confidence interval (CI): 1.003, 1.019], 1.014 (95 % CI: 1.003, 1.026), and 1.039 (95 % CI: 1.011, 1.068), for a 10 μg/m3 increase in the concentration of dust PM10, dust PM2.5-10, and dust PM2.5, respectively. In addition, the study identified a higher risk of PE onset associated with dust PM exposure during the warm season than that in cool season, particularly for dust PM2.5.

CONCLUSIONS

The findings from this study suggest that short-term exposure to dust PM, particularly dust PM2.5, may trigger PE onset, posing a significant health threat. Implementing measures to mitigate dust PM emissions and protect patients with PE from dust PM exposure is imperative.

Identifying prognostic factors for pulmonary embolism patients with hemodynamic decompensation admitted to the intensive care unit

We aimed to determine prognostic indicators of PE patients with hemodynamic decompensation admitted to the ICU. PE patients with hemodynamic decompensation at ICU admission from Medical Information Mart for Intensive Care IV database were included. Least absolute shrinkage and selection operator with 2 specific lambdas were performed to reduce the dimension of variables after univariate analysis. Then we conducted multivariate logistic regression analysis and 2 models were built. A total of 548 patients were included, among whom 187 died. Lactate, creatine-kinase MB, troponin-T were significantly higher in death group. Eight common factors were screened out from first model statistically mostly in consistent with second model: older age, decreased hemoglobin, elevated anion gap, elevated International Standard Ratio (INR), elevated respiratory rate, decreased temperature, decreased blood oxygen saturation (SpO2) and the onset of cardiac arrest were significantly risk factors for in-Hospital mortality. The nonlinear relationships between these indicators and mortality were showed by the restricted cubic spline and cutoff values were determined. Our study demonstrated that age, hemoglobin levels, anion gap levels, INR, respiratory rate, temperature, SpO2 levels, the onset of cardiac arrest could be applied to predict mortality of PE patients with hemodynamic decompensation at ICU admission.

Clinical characteristics and mortality predictors among very old patients with pulmonary thromboembolism: a multicenter study report

BACKGROUND

Clinical characteristics of patients with pulmonary thromboembolism have been described in previous studies. Although very old patients with pulmonary thromboembolism are a special group based on comorbidities and age, they do not receive special attention.

OBJECTIVE

This study aims to explore the clinical characteristics and mortality predictors among very old patients with pulmonary thromboembolism in a relatively large population.

DESIGN AND PARTICIPANTS

The study included a total of 7438 patients from a national, multicenter, registry study, the China pUlmonary thromboembolism REgistry Study (CURES). Consecutive patients with acute pulmonary thromboembolism were enrolled and were divided into three groups. Comparisons were performed between these three groups in terms of clinical characteristics, comorbidities and in-hospital prognosis. Mortality predictors were analyzed in very old patients with pulmonary embolism.

KEY RESULTS

In 7,438 patients with acute pulmonary thromboembolism, 609 patients aged equal to or greater than 80 years (male 354 (58.1%)). There were 2743 patients aged between 65 and 79 years (male 1313 (48%)) and 4095 patients aged younger than 65 years (male 2272 (55.5%)). Patients with advanced age had significantly more comorbidities and worse condition, however, some predisposing factors were more obvious in younger patients with pulmonary thromboembolism. PaO2 < 60 mmHg, eGFR < 60 mL/min/1.73m2, malignancy, anticoagulation as first therapy were mortality predictors for all-cause death in very old patients with pulmonary thromboembolism. The analysis found that younger patients were more likely to have chest pain, hemoptysis (the difference was statistically significant) and dyspnea triad.

CONCLUSION

In very old population diagnosed with pulmonary thromboembolism, worse laboratory results, atypical symptoms and physical signs were common. Mortality was very high and comorbid conditions were their features compared to younger patients. PaO2 < 60 mmHg, eGFR < 60 mL/min/1.73m2 and malignancy were positive mortality predictors for all-cause death in very old patients with pulmonary thromboembolism while anticoagulation as first therapy was negative mortality predictors.

The Predictive Value of the MELD Scores for In-Hospital Adverse Events in Normotensive Patients with Acute Pulmonary Embolism

The model for end-stage liver disease (MELD) and the model for end-stage liver disease excluding international normalized ratio (INR) (MELD-XI) scores, which reflect dysfunction of liver and kidneys, have been reported to be related to the prognosis of patients with right-sided "backward" failure. However, the relationship between the MELD/MELD-XI score and the in-hospital adverse events in pulmonary embolism (PE) patients was unknown. Normotensive PE patients were retrospectively enrolled at China-Japan friendship hospital from January 2017 to February 2020. The primary outcome was defined as death and clinical deterioration during hospitalization. Multivariate logistic analysis was used to explore the association between the MELD and MELD-XI scores for in-hospital adverse events. We also compared the accuracy of the MELD, MELD-XI, and the pulmonary embolism severity index (PESI) score using the time-dependent receiver operating characteristic curve and corresponding areas under the curve (AUC). A total of 222 PE patients were analyzed. Logistic regression analysis showed that the MELD score was independently associated with in-hospital adverse events (odds ratio = 1.115, 95% confidential interval = 1.022-1.217, P = .014). The MELD score has an AUC of 0.731 and was better than PESI (AUC of 0.629) in predicting in-hospital adverse events. Among PE patients with normal blood pressure on admission, the MELD score was associated with increased in-hospital adverse events.

Development and external validation of a prediction model for venous thromboembolism in systemic lupus erythematosus

OBJECTIVE

Patients with systemic lupus erythematosus (SLE) have an increased risk of venous thromboembolism (VTE). We conducted this study to develop a risk score algorithm for VTE in patients with SLE that provides individualised risk estimates.

METHODS

We developed a clinical prediction model of VTE in 4502 patients with SLE based on the Chinese SLE Treatment and Research group cohort (CSTAR) from January 2009 to January 2020 and externally validated in 3780 patients with SLE in CSTAR from January 2020 to January 2022. Baseline data were obtained and VTE events were recorded during the follow-up. The prediction model was developed to predict VTE risk within 6 months in patients with SLE, using multivariate logistic regression and least absolute shrinkage and selection operator. SLE-VTE score and nomogram were established according to the model.

RESULTS

A total of 4502 patients included in the development cohort, 135 had VTE events. The final prediction model (SLE-VTE score) included 11 variables: gender, age, body mass index, hyperlipidaemia, hypoalbuminaemia, C reactive protein, anti-β2GPI antibodies, lupus anticoagulant, renal involvement, nervous system involvement and hydroxychloroquine, with area under the curve of 0.947 and 0.808 in the development (n=4502) and external validation cohort (n=3780), respectively. According to the net benefit and predicted probability thresholds, we recommend annual screening of VTE in high risk (≥1.03%) patients with SLE.

CONCLUSION

Various factors are related to the occurrence of VTE in patients with SLE. The proposed SLE-VTE risk score can accurately predict the risk of VTE and help identify patients with SLE with a high risk of VTE who may benefit from thromboprophylaxis.

Association between uric acid and risk of venous thromboembolism in East Asian populations: a cohort and Mendelian randomization study

Background

Serum uric acid (SUA) levels have been associated with an increased risk and recurrence of venous thromboembolism (VTE) in European populations, but the potential causal relationship remains unclear. Large-scale studies on the association between SUA and VTE in East Asian populations are lacking, despite the high prevalence of hyperuricemia in this region. To address this, we conducted a cohort analysis and a two-sample Mendelian randomization (MR) study in East Asian populations.

Methods

We collected data on VTE patients from the China Pulmonary Thromboembolism Registry Study (CURES) and compared them to controls obtained from the China Health and Retirement Longitudinal Survey (CHARLS). Propensity score matching (PSM) and cubic-spline models were applied to assess the effect of SUA on VTE risk while adjusting for multiple covariates. We also performed two-sample MR analyses to infer potential causality based on summary statistics from Genome-wide Association Studies (GWAS) of SUA and VTE in the East Asian population.

Findings

We found that the SUA levels were higher in VTE patients (317.95 mmol/L) compared to the general population (295.75 mmol/L), and SUA ≥ 325 mmol/L was associated with an increased risk of VTE recurrence (P-value = 0.0001). The univariable MR suggested a causal relationship between elevated SUA and higher VTE risk (Pinverse variance weighted < 0.05), and multivariable MR showed that elevated SUA levels continued to promote the development of VTE after adjusting for multiple covariates (Pmultivariable residual < 0.05). Sensitivity analyses produced similar results for these estimations.

Interpretation

Our study provides evidence supporting a robust positive association between SUA and VTE in the East Asian population, and MR analyses suggest that this association is likely to be causal. Our findings underscore the importance of monitoring SUA levels in VTE prevention and call for urgent action to address the growing burden of hyperuricemia in the Asia-Pacific region.

Funding

This research was funded by Beijing Nova Program (No. Z211100002121057), National Natural Science Foundation of China (No. 82100065 and No. 62350004), CAMS Innovation Fund for Medical Sciences (No. 2021-I2M-1-061 and No. 2021-1-I2M-001), Elite Medical Professionals project of China-Japan Friendship Hospital (No. ZRJY2021-QM12), National Key Research and Development Project (No. 2021YFF1201200 and No. 2022YFC3341004).

Genome-wide association analyses identified novel susceptibility loci for pulmonary embolism among Han Chinese population

BACKGROUND

A large proportion of pulmonary embolism (PE) heritability remains unexplained, particularly among the East Asian (EAS) population. Our study aims to expand the genetic architecture of PE and reveal more genetic determinants in Han Chinese.

METHODS

We conducted the first genome-wide association study (GWAS) of PE in Han Chinese, then performed the GWAS meta-analysis based on the discovery and replication stages. To validate the effect of the risk allele, qPCR and Western blotting experiments were used to investigate possible changes in gene expression. Mendelian randomization (MR) analysis was employed to implicate pathogenic mechanisms, and a polygenic risk score (PRS) for PE risk prediction was generated.

RESULTS

After meta-analysis of the discovery dataset (622 cases, 8853 controls) and replication dataset (646 cases, 8810 controls), GWAS identified 3 independent loci associated with PE, including the reported loci FGG rs2066865 (p-value = 3.81 × 10^-14), ABO rs582094 (p-value = 1.16 × 10^-10) and newly reported locus FABP2 rs1799883 (p-value = 7.59 × 10^-17). Previously reported 10 variants were successfully replicated in our cohort. Functional experiments confirmed that FABP2-A163G(rs1799883) promoted the transcription and protein expression of FABP2. Meanwhile, MR analysis revealed that high LDL-C and TC levels were associated with an increased risk of PE. Individuals with the top 10% of PRS had over a fivefold increased risk for PE compared to the general population.

CONCLUSIONS

We identified FABP2, related to the transport of long-chain fatty acids, contributing to the risk of PE and provided more evidence for the essential role of metabolic pathways in PE development.

Right ventricular area predicts short-term mortality in acute pulmonary embolism based on CT pulmonary angiography: A retrospective study

We performed this cohort study to assess the prognostic value of right ventricular size, including diameter, area, and volume, in short-term mortality of acute pulmonary embolism (APE) based on 256-slice computed tomography compared with D-dimer, creatine kinase muscle and brain isoenzyme, and Wells scores. A total of 225 patients with APE, who were followed up for 30 days were enrolled in this cohort study. Clinical data, laboratory indices (creatine kinase, creatine kinase muscle and brain isoenzyme, and D-dimer), and Wells scores were collected. The 256-slice computed tomography was used to quantify cardiac parameters (RVV/LVV, RVD/LVD-ax, RVA/LVA-ax, RVD/LVD-4ch, RVA/LVA-4ch) and the diameter of the coronary sinus. Participants were divided into non-death and death groups. The values mentioned above were compared between the 2 groups. The RVD/LVD-ax, RVA/LVA-ax, RVA/LVA-4ch, RVV/LVV, D-dimer, and creatine kinase levels were significantly higher in the death group than in the non-death group (P < .05). The active period of the malignant tumor, heart rate ≥ 100 beats/minutes, and RVA/LVA-ax were positively correlated with early death from APE (P < .05). Active stage of malignant tumor (OR:9.247, 95%CI:2.682-31.888, P < .001) and RVA/LVA-ax (OR:3.073, 95%CI:1.447-6.528, P = .003) were independent predictors of early death due to APE. According to the receiver operating characteristic curve, the cutoff point of RVA/LVA-ax was 1.68 with a sensitivity of 46.7% and specificity of 84.8%. The measurement of ventricular size in the short-axis plane is more convenient and reliable than that in the 4-chamber cardiac plane. RVA/LVA-ax is an independent predictor of early death from APE, and when RVA/LVA-ax > 1.68, the risk of early death from APE increases.

Oxygenation index and NT-proBNP as predictors of pulmonary hypertension and ventilation/perfusion mismatch in acute pulmonary embolism

Introduction

The magnitude of pulmonary artery pressure (PAP) and the extent of ventilation/perfusion (V/Q) mismatch are essential for assessing the prognosis of acute pulmonary embolism (APE). We aimed to develop a model for predicting the status of the pulmonary circulation and arterial gas exchange functions using serum levels of cardiac biomarkers and arterial oxygenation index (OI) values.

Materials and methods

This single-center, retrospective observational cohort study included 224 patients with APE. Multivariate linear regression and Poisson regression were used to test the statistical association between cardiac biomarkers, OI, PAP, and V/Q mismatch. Diagnostic efficiency was calculated from a receiver operating characteristic (ROC) curve.

Results

Serum levels of troponin I (TNI), N-terminal pro-brain natriuretic peptide (NT-proBNP), and arterial OI magnitude significantly correlated with PAP and V/Q mismatches (P < 0.05). Multivariate linear regression showed that NT-proBNP serum levels (β = 0.002, P < 0.001) and OI values (β = -0.022, P = 0.001) significantly influenced PAP. Arterial OI (β = -0.039, P < 0.001) had a significant influence on the percentage of pulmonary vascular obstruction (PVO) as determined by perfusion scanning. Poisson regression showed that OI (odds ratio: 0.995, p < 0.001) was a predictor of the number of lung segments with V/Q mismatches. ROC area under the curve (AUC) values of NT-proBNP and OI predicting pulmonary hypertension were 0.716 and 0.730, respectively, and for V/Q mismatch scanning, the results were 0.601 and 0.634, respectively.

Conclusion

Arterial OI and serum levels of cardiac biomarkers may be used as indicators of pulmonary hypertension and V/Q mismatch.

Derivation and Validation of a Prognostic Model for Mortality in Chinese Patients with Acute Pulmonary Embolism

INTRODUCTION

We aim to explore the risk factors for in-hospital mortality and to derive a prognostic model for patients with APE in China.

MATERIALS AND METHODS

Inpatients with APE were enrolled from West China Hospital between January 2016 and December 2019. Logistic regression analyses were used to explore risk factors for in-hospital mortality and develop a prognostic model.

RESULTS

A total of 813 subjects with APE were included in this study, of whom 542 were in the training set and 271 were in the test set. Multivariable regression analyses indicated that age, male, heart rate, systolic blood pressure, elevated NT-proBNP or troponin T, malignancy, chronic renal insufficiency, and respiratory failure were independent risk factors for in-hospital mortality. For the training set, the area under the curve (AUC) of the ROC curve was 0.899, with a sensitivity and specificity of 89.7% and 77.7%, respectively. The model had higher prediction accuracy than the PESI and sPESI.

CONCLUSIONS

The prediction model has proven excellent discrimination and calibration, which may be a useful tool to help physicians make decisions regarding the best treatment strategy.

Risk Stratification in Patients with Acute Pulmonary Embolism: Current Evidence and Perspectives

Risk stratification is one of the cornerstones of the management of acute pulmonary embolism (PE) and determines the choice of both diagnostic and therapeutic strategies. The first step is the identification of patent circulatory failure, as it is associated with a high risk of immediate mortality and requires a rapid diagnosis and prompt reperfusion. The second step is the estimation of 30-day mortality based on clinical parameters (e.g., original and simplified version of the pulmonary embolism severity index): low-risk patients without right ventricular dysfunction are safely managed with ambulatory anticoagulation. The remaining group of hemodynamically stable patients, labeled intermediate-risk PE, requires hospital admission, even if most of them will heal without complications. In recent decades, efforts have been made to identify a subgroup of patients at an increased risk of adverse outcomes (intermediate-high-risk PE), who might benefit from a more aggressive approach, including reperfusion therapies and admission to a monitored unit. The cur-rent approach, combining markers of right ventricular dysfunction and myocardial injury, has an insufficient positive predictive value to guide primary thrombolysis. Sensitive markers of circulatory failure, such as plasma lactate, have shown interesting prognostic accuracy and may play a central role in the future. Furthermore, the improved security of reduced-dose thrombolysis may enlarge the indication of this treatment to selected intermediate–high-risk PE.

Tenecteplase in Pulmonary Embolism Patients: A Meta-Analysis and Systematic Review

Objective

To assess the efficacy and safety of tenecteplase in patients with pulmonary embolism (PE).

Methods

We completed the literature search on May 31, 2021 using PubMed, EMBASE and the Web of Science. Analyses were conducted according to PE risk stratification, study design and duration of follow-up. The pooled risk ratios (RRs) and its 95% confident intervals (CIs) for death and major bleeding were calculated using a random-effect model.

Results

A total of six studies, with four randomized controlled trials (RCTs) and two cohort studies, were included in this study out of the 160 studies retrieved. For patients with high-risk PE, tenecteplase increased 30-day survival rate (16% vs 6%; P = 0.005) and did not increase the incidence of bleeding (6% vs 5%; P = 0.73). For patients with intermediate-risk PE, four RCTs suggested that tenecteplase reduced right ventricular insufficiency at 24h early in the onset and the incidence of hemodynamic failure without affecting mortality in a short/long-term [<30 days RR = 0.83, 95% CI (0.47, 1.46);≥30 days RR = 1.04, 95% CI (0.88, 1.22)]. However, tenecteplase was associated with high bleeding risk [<30 days RR = 1.79, 95% CI (1.61, 2.00); ≥30 days RR = 1.28, 95% CI (0.62, 2.64)].

Conclusions

Tenecteplase may represent a promising candidate for patients with high risk PE. However, tenecteplase is not recommended for patients with intermediate-risk PE because of high bleeding risk. More large-scale studies focused on tenecteplase are still needed for PE patients.

cRGD Urokinase Liposomes for Thrombolysis in Rat Model of Acute Pulmonary Microthromboembolism

Purpose

To study the thrombolytic effect and safety of cRGD urokinase liposomes (cRGD-UK-LIP) in rats with acute pulmonary microthromboembolism (APMTE), and explore the application value of echocardiography (ECHO) in animal models.

Patients and Methods

Ninety-six SD rats were randomized into 6 groups (16/group): normal control, sham operation, APMTE, normal saline (NS), free urokinase (UK), cRGD-UK-LIP. Four groups (APMTE, NS, UK, cRGD-UK-LIP) of rats were injected with autologous thrombus to induce APMTE. Samples were injected into 3 groups (NS, UK, cRGD-UK-LIP) of rats after modeling. Echocardiography was used to assess right ventricle (RV) function and morphology in rats. Six rats in each group were randomly selected and pulmonary artery pressure (PAP) of them was measured through ECHO-guided transthoracic puncture. Finally, the rats were killed and their tissues were taken for pathological examination.

Results

Compared with normal control or sham operation group, rats in APMTE group had enlarged RV, decreased RV function, increased PAP, and lung tissue of them showed postthromboembolic appearance. There was no significant difference between NS group and APMTE group. RV morphology and function of rats in the UK group and cRGD-UK-LIP group were better and vessels with residual thrombus in these 2 groups were less than APMTE group, especially in the cRGD-UK-LIP group. In terms of PAP, only cRGD-UK-LIP group was significantly lower than APMTE group. No hyperemia, bleeding and swelling were observed in heart, liver and kidney of rats in each group.

Conclusion

A rat model of APMTE was successfully established. cRGD-UK-LIP has better thrombolytic effect than free urokinase and it is safe. Echocardiography is not merely an important way to evaluate the morphology and function of RV, transthoracic puncture measurement under the guidance of it can be an effective way to monitor PAP in animal models.

Arterial partial pressure of oxygen and diffusion function as prognostic biomarkers for acute pulmonary embolism

BACKGROUND

Risk stratification for acute pulmonary embolism (PE) ignores the roles of respiratory function and gas exchange. We aimed to identify the role of arterial partial pressure of oxygen (PO2) and diffusion function as prognostic biomarkers.

METHODS

We collected the data from hospitalised patients with acute PE. We used Spearman's correlation coefficient and Cox regression analysis to explore the clinical and prognostic values of PO2 and predicted percentage diffusing lung capacity for carbon monoxide (DLCO%pred) to predict the 30-day mortality.

RESULTS

We included 309 patients (mean age: 67.93 ± 13.31 years); 46.6% were men, and 12.62% were haemodynamically unstable. The 30-day all-cause mortality rates in the high-, intermediate high-, intermediate low-, and low-risk groups were 7.7%, 4.7%, 2.9%, and 0.0%, respectively (P < 0.05). PO2 (P = 0.012) and DLCO%pred (P = 0.036) were significantly different between the four risk groups. There were strong correlations between PO2, DLCO%pred, PO2*DLCO%pred, and other markers (P < 0.05), especially troponin I, N-terminal pro-brain natriuretic peptide, and systolic pulmonary artery pressure. PO2 and PO2*DLCO%pred were prognostic factors for death in haemodynamically stable patients (hazard ratio [HR] 0.618, 95% confidence interval [CI] 0.389-0.980, P = 0.041, and HR 0.501, 95% CI 0.26-0.96, P = 0.036, respectively). A lower PO2 (<8 kPa) was associated with a higher risk of mortality in all patients and in haemodynamically stable ones (HR 9.462, 95% CI 2.365-37.860, P = 0.001, and HR 6.597, 95% CI 1.102-39.495, P = 0.039, respectively).

CONCLUSIONS

PO2, PO2*DLCO%pred, and PO2 < 8 kPa were predictors of 30-day all-cause mortality in all patients and haemodynamically stable ones.

TRIAL REGISTRATION

ChiCTR2000030448.