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Sikorski C, Mavromanoli AC, Manji K, Behzad D, Kreatsoulas C. Adverse Childhood Experiences and Primary Headache Disorders: A Systematic Review, Meta-analysis, and Application of a Biological Theory. Neurology 2023; 101:e2151-e2161. [PMID: 37879940 PMCID: PMC10663032 DOI: 10.1212/wnl.0000000000207910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/15/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Headache disorders are among the leading causes of disability worldwide. While an association between adverse childhood experiences and primary headaches has been reported, the pooled magnitude across studies and pathways of the association are unknown. Our objectives were (1) to estimate the pooled effect of ≥1 adverse childhood experience (ACE) on primary headache disorders in adulthood and (2) to test the hypothesis that ACEs categorized as "threat" traumas or "deprivation" traumas have distinct effects on primary headaches based on a selected theory from our narrative review of how ACEs affect human development along the life course. METHODS PubMed, EMBASE, MEDLINE, Web of Science, Google Scholar, Biological Psychiatry, and gray literature were searched up to March 16, 2023 (PROSPERO, CRD42020223403). Selected articles included (1) observational studies with a comparator group, (2) ACEs that occurred before 18 years of age, and (3) primary headaches occurring at or after 21 years of age. Pooled odds ratios (ORs) were calculated using multilevel linear random-effects modeling. The narrative review included theories that describe how ACEs affect human development and disease across the life course. We selected a theory from our narrative review and tested ACEs categorized according to this theory for any modification of point estimates. RESULTS Our search identified 32 studies, of which 28 were eligible for meta-analysis (n = 154,739 participants, 19 countries). The occurrence of ≥1 adverse childhood experience(s) was associated with primary headaches (pooled OR = 1.48 [95% CI 1.36-1.61]; high-quality evidence, 134,696 participants). As the number of ACEs increased, the odds of primary headaches increased (range: 1 ACE OR = 1.24 [95% CI 1.14-1.35] to ≥4 ACEs OR = 2.09 [95% CI 1.83-2.38], p for trend <0.0001). From the narrative review, a neurodevelopmental theory that categorizes ACEs into threat or deprivation was tested, and both were independently associated with primary headaches (threat OR = 1.46 [95% CI 1.32-1.60] and deprivation OR = 1.35 [95% CI 1.23-1.49], respectively), accounting for heterogeneity (p = 0.021). DISCUSSION This systematic review and meta-analysis confirm that ACEs are important risk factors of primary headache disorders in adulthood. Our findings provide epidemiologic support that ACEs categorized as threat and deprivation may manifest as distinct pathways of early adversity.
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Affiliation(s)
- Claudia Sikorski
- From the Department of Health Research Methods, Evidence, and Impact (C.S.), McMaster University Hamilton, Ontario, Canada; University Medical Center of the Johannes Gutenberg University (A.C.M.), Mainz, Germany; Department of Family and Community Medicine (K.M.), University of Toronto, Ontario, Canada; Department of Health Sciences (D.B.), Brock University St. Catherines, Ontario, Canada; and Health Policy and Management (C.K.), Harvard T.H. Chan School of Public Health, Boston, MA.
| | - Anna C Mavromanoli
- From the Department of Health Research Methods, Evidence, and Impact (C.S.), McMaster University Hamilton, Ontario, Canada; University Medical Center of the Johannes Gutenberg University (A.C.M.), Mainz, Germany; Department of Family and Community Medicine (K.M.), University of Toronto, Ontario, Canada; Department of Health Sciences (D.B.), Brock University St. Catherines, Ontario, Canada; and Health Policy and Management (C.K.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Karishma Manji
- From the Department of Health Research Methods, Evidence, and Impact (C.S.), McMaster University Hamilton, Ontario, Canada; University Medical Center of the Johannes Gutenberg University (A.C.M.), Mainz, Germany; Department of Family and Community Medicine (K.M.), University of Toronto, Ontario, Canada; Department of Health Sciences (D.B.), Brock University St. Catherines, Ontario, Canada; and Health Policy and Management (C.K.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Danial Behzad
- From the Department of Health Research Methods, Evidence, and Impact (C.S.), McMaster University Hamilton, Ontario, Canada; University Medical Center of the Johannes Gutenberg University (A.C.M.), Mainz, Germany; Department of Family and Community Medicine (K.M.), University of Toronto, Ontario, Canada; Department of Health Sciences (D.B.), Brock University St. Catherines, Ontario, Canada; and Health Policy and Management (C.K.), Harvard T.H. Chan School of Public Health, Boston, MA
| | - Catherine Kreatsoulas
- From the Department of Health Research Methods, Evidence, and Impact (C.S.), McMaster University Hamilton, Ontario, Canada; University Medical Center of the Johannes Gutenberg University (A.C.M.), Mainz, Germany; Department of Family and Community Medicine (K.M.), University of Toronto, Ontario, Canada; Department of Health Sciences (D.B.), Brock University St. Catherines, Ontario, Canada; and Health Policy and Management (C.K.), Harvard T.H. Chan School of Public Health, Boston, MA
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Mavromanoli AC, Jiménez D, Sanchez O, Sobkowicz B, Vanni S, Kurzyna M, Becattini C, Pruszczyk P, Wilkens H, Bova C, Tschöpe C, Sawicka-Śmiarowska E, Grifoni C, Kostrubiec M, Torbicki A, Meneveau N, Kresoja KP, Konstantinides SV. Major in-hospital bleeding in patients with pulmonary embolism treated with systemic thrombolysis. Thromb Res 2023; 231:29-31. [PMID: 37778058 DOI: 10.1016/j.thromres.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 09/06/2023] [Accepted: 09/18/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Anna C Mavromanoli
- Center for Thrombosis and Haemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - David Jiménez
- Department of Respiratory Diseases, Ramon y Cajal Hospital, Universidad de Alcalá (IRYCIS), CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Olivier Sanchez
- University Paris Cité; Department of Pneumology and Critical Care Medicine, Hôpital Européen Georges Pompidou, APHP. Center Université Paris Cité; INSERM UMRS 1140 Innovative Therapies in Haemostasis; F-CRIN INNOVTE, Paris, France
| | - Bożena Sobkowicz
- Department of Cardiology, Medical University of Bialystok, Białystok, Poland
| | - Simone Vanni
- Emergency Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, Otwock, Poland
| | - Cecilia Becattini
- Department of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Heinrike Wilkens
- Clinic for Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, Saarland University Hospital, Homburg /Saar, Germany
| | - Carlo Bova
- Department of Internal Medicine, University Hospital of Cosenza, Cosenza, Italy
| | - Carsten Tschöpe
- Dept Cardiology, Angiology, and Intensive Medicine (CVK) at the German Heart Center of the Charite (DHZC), Charité Universitätsmedizin, Berlin, Germany; Berlin Institute of Health (BIH) for Regenerative Therapies (BCRT) at Charite; Charité Universitätsmedizin, Berlin, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | | | - Caterina Grifoni
- Emergency Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Maciej Kostrubiec
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Adam Torbicki
- Department of Pulmonary Circulation and Thromboembolic Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France; EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Karl-Patrik Kresoja
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Haemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece.
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Mavromanoli AC, Barco S, Ageno W, Bouvaist H, Brodmann M, Cuccia C, Couturaud F, Dellas C, Dimopoulos K, Duerschmied D, Empen K, Faggiano P, Ferrari E, Galiè N, Galvani M, Ghuysen A, Giannakoulas G, Huisman MV, Jiménez D, Kozak M, Lang IM, Meneveau N, Münzel T, Palazzini M, Petris AO, Piovaccari G, Salvi A, Schellong S, Schmidt KH, Verschuren F, Schmidtmann I, Toenges G, Klok FA, Konstantinides SV. Recovery of right ventricular function after intermediate-risk pulmonary embolism: results from the multicentre Pulmonary Embolism International Trial (PEITHO)-2. Clin Res Cardiol 2023; 112:1372-1381. [PMID: 36539534 PMCID: PMC10562278 DOI: 10.1007/s00392-022-02138-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Right ventricular (RV) function plays a critical role in the pathophysiology and acute prognosis of pulmonary embolism (PE). We analyzed the temporal changes of RV function in the cohort of a prospective multicentre study investigating if an early switch to oral anticoagulation in patients with intermediate-risk PE is effective and safe. METHODS Echocardiographic and laboratory examinations were performed at baseline (PE diagnosis), 6 days and 6 months. Echocardiographic parameters were classified into categories representing RV size, RV free wall/tricuspid annulus motion, RV pressure overload and right atrial (RA)/central venous pressure. RESULTS RV dysfunction based on any abnormal echocardiographic parameter was present in 84% of patients at baseline. RV dilatation was the most frequently abnormal finding (40.6%), followed by increased RA/central venous pressure (34.6%), RV pressure overload (32.1%), and reduced RV free wall/tricuspid annulus motion (20.9%). As early as day 6, RV size remained normal or improved in 260 patients (64.7%), RV free wall/tricuspid annulus motion in 301 (74.9%), RV pressure overload in 297 (73.9%), and RA/central venous pressure in 254 (63.2%). At day 180, the frequencies slightly increased. The median NT-proBNP level decreased from 1448 pg/ml at baseline to 256.5 on day 6 and 127 on day 180. CONCLUSION In the majority of patients with acute intermediate-risk PE switched early to a direct oral anticoagulant, echocardiographic parameters of RV function normalised within 6 days and remained normal throughout the first 6 months. Almost one in four patients, however, continued to have evidence of RV dysfunction over the long term.
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Affiliation(s)
- Anna C Mavromanoli
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Hélène Bouvaist
- Department of Cardiology, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, La Tronche, France
| | | | - Claudio Cuccia
- Cardiovascular Department, Fondazione Poliambulanza, Istituto Ospedaliero, Brescia, Italy
| | - Francis Couturaud
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Brest, France
- INSERM U1304-GETBO, FCRIN INNOVTE, Brest University, Brest, France
| | - Claudia Dellas
- Clinic of Paediatric Cardiology and Intensive Care, ACHD Center, University Medical Center Goettingen, Goettingen, Germany
| | - Konstantinos Dimopoulos
- Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Klaus Empen
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany
| | | | - Emile Ferrari
- Service de Cardiologie, Hôpital Pasteur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Nazzareno Galiè
- Cardiology Unit, IRCCS Azienda Ospedaliero and Dipartimento DIMES-Università di Bologna, Bologna, Italy
| | - Marcello Galvani
- Division of Cardiology, Department of Cardiovascular Diseases - AUSL Romagna, Ospedale Morgagni-Pierantoni, Forli, Italy
- Cardiovascular Research Unit, Fondazione Cardiologica Myriam Zito Sacco, Forli, Italy
| | | | - George Giannakoulas
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - David Jiménez
- Department of Respiratory Diseases, Ramon y Cajal Hospital, Universidad de Alcalá (IRYCIS), CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Matija Kozak
- Department of Vascular Diseases, University Medical Center, Ljubljana, Slovenia
| | - Irene M Lang
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France
- EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Massimiliano Palazzini
- Cardiology Unit, IRCCS Azienda Ospedaliero and Dipartimento DIMES-Università di Bologna, Bologna, Italy
| | - Antoniu Octavian Petris
- Cardiology Clinic, "St. Spiridon" County Clinical Emergency Hospital, Grigore T. Popa University of Medicine and Pharmacy Iasi, Iasi, Romania
| | - Giancarlo Piovaccari
- Department of Cardiovascular Diseases, Infermi Hospital, AUSL Romagna, Rimini, Italy
| | - Aldo Salvi
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" di Ancona, Ancona, Italy
| | - Sebastian Schellong
- Department of Internal Medicine 2, Municipal Hospital Dresden, Dresden, Germany
| | - Kai-Helge Schmidt
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Franck Verschuren
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Gerrit Toenges
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Frederikus A Klok
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany.
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece.
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Hobohm L, Farmakis IT, Keller K, Scibior B, Mavromanoli AC, Sagoschen I, Münzel T, Ahrens I, Konstantinides S. Pulmonary embolism response team (PERT) implementation and its clinical value across countries: a scoping review and meta-analysis. Clin Res Cardiol 2023; 112:1351-1361. [PMID: 35976429 PMCID: PMC9383680 DOI: 10.1007/s00392-022-02077-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/29/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Over the last years, multidisciplinary pulmonary embolism response teams (PERTs) have emerged to encounter the increasing variety and complexity in the management of acute pulmonary embolism (PE). We aimed to systematically investigate the composition and added clinical value of PERTs. METHODS We searched PubMed, CENTRAL and Web of Science until January 2022 for articles designed to describe the structure and function of PERTs. We performed a random-effects meta-analysis of controlled studies (PERT vs. pre-PERT era) to investigate the impact of PERTs on clinical outcomes and advanced therapies use. RESULTS We included 22 original studies and four surveys. Overall, 31.5% of patients with PE were evaluated by PERT referred mostly by emergency departments (59.4%). In 11 single-arm studies (1532 intermediate-risk and high-risk patients evaluated by PERT) mortality rate was 10%, bleeding rate 9% and length of stay 7.3 days [95% confidence interval (CI) 5.7-8.9]. In nine controlled studies there was no difference in mortality [risk ratio (RR) 0.89, 95% CI 0.67-1.19] by comparing pre-PERT with PERT era. When analysing patients with intermediate or high-risk class only, the effect estimate for mortality tended to be lower for patients treated in the PERT era compared to those treated in the pre-PERT era (RR 0.71, 95% CI 0.45-1.12). The use of advanced therapies was higher (RR 2.67, 95% CI 1.29-5.50) and the in-hospital stay shorter (mean difference - 1.6 days) in PERT era compared to pre-PERT era. CONCLUSIONS PERT implementation led to greater use of advanced therapies and shorter in-hospital stay. Our meta-analysis did not show a survival benefit in patients with PE since PERT implementation. Large prospective studies are needed to further explore the impact of PERTs on clinical outcomes. REGISTRATION Open Science Framework 10.17605/OSF.IO/SBFK9.
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Affiliation(s)
- Lukas Hobohm
- Department of Cardiology, Center of Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Karsten Keller
- Department of Cardiology, Center of Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Medical Clinic VII, University Hospital Heidelberg, Heidelberg, Germany
| | - Barbara Scibior
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Anna C Mavromanoli
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Ingo Sagoschen
- Department of Cardiology, Center of Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, Center of Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital, Academic Teaching Hospital University of Cologne, Cologne, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Thrace, Greece
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Farmakis IT, Valerio L, Barco S, Alsheimer E, Ewert R, Giannakoulas G, Hobohm L, Keller K, Mavromanoli AC, Rosenkranz S, Morris TA, Konstantinides SV, Held M, Dumitrescu D. Cardiopulmonary exercise testing during follow-up after acute pulmonary embolism. Eur Respir J 2023; 61:2300059. [PMID: 36958742 PMCID: PMC10249018 DOI: 10.1183/13993003.00059-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/03/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) may provide prognostically valuable information during follow-up after pulmonary embolism (PE). Our objective was to investigate the association of patterns and degree of exercise limitation, as assessed by CPET, with clinical, echocardiographic and laboratory abnormalities and quality of life (QoL) after PE. METHODS In a prospective cohort study of unselected consecutive all-comers with PE, survivors of the index acute event underwent 3- and 12-month follow-ups, including CPET. We defined cardiopulmonary limitation as ventilatory inefficiency or insufficient cardiocirculatory reserve. Deconditioning was defined as peak O2 uptake (V'O2 ) <80% with no other abnormality. RESULTS Overall, 396 patients were included. At 3 months, prevalence of cardiopulmonary limitation and deconditioning was 50.1% (34.7% mild/moderate; 15.4% severe) and 12.1%, respectively; at 12 months, it was 44.8% (29.1% mild/moderate; 15.7% severe) and 14.9%, respectively. Cardiopulmonary limitation and its severity were associated with age (OR per decade 2.05, 95% CI 1.65-2.55), history of chronic lung disease (OR 2.72, 95% CI 1.06-6.97), smoking (OR 5.87, 95% CI 2.44-14.15) and intermediate- or high-risk acute PE (OR 4.36, 95% CI 1.92-9.94). Severe cardiopulmonary limitation at 3 months was associated with the prospectively defined, combined clinical-haemodynamic end-point of "post-PE impairment" (OR 6.40, 95% CI 2.35-18.45) and with poor disease-specific and generic health-related QoL. CONCLUSIONS Abnormal exercise capacity of cardiopulmonary origin is frequent after PE, being associated with clinical and haemodynamic impairment as well as long-term QoL reduction. CPET can be considered for selected patients with persisting symptoms after acute PE to identify candidates for closer follow-up and possible therapeutic interventions.
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Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Eva Alsheimer
- Clinic for General and Interventional Cardiology and Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Ralf Ewert
- Clinic for Internal Medicine, Greifswald University Hospital, Greifswald, Germany
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Anna C Mavromanoli
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stephan Rosenkranz
- Department of Cardiology, Heart Center at the University Hospital Cologne and Cologne Cardiovascular Research Center, Cologne, Germany
| | - Timothy A Morris
- Division of Pulmonary and Critical Care Medicine, University of California at San Diego, La Jolla, CA, USA
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Matthias Held
- Department of Pulmonary Medicine, KWM Missio Clinic, Würzburg, Germany
- These authors contributed equally and share last authorship
| | - Daniel Dumitrescu
- Clinic for General and Interventional Cardiology and Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
- These authors contributed equally and share last authorship
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Barco S, Mavromanoli AC, Kreitner KF, Bunck AC, Gertz RJ, Ley S, Valerio L, Klok FA, Gerhardt F, Rosenkranz S, Konstantinides SV. Preexisting Chronic Thromboembolic Pulmonary Hypertension in Acute Pulmonary Embolism. Chest 2023; 163:923-932. [PMID: 36621756 DOI: 10.1016/j.chest.2022.11.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/17/2022] [Accepted: 11/16/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is considered a complication of pulmonary embolism (PE). However, signs of CTEPH may exist in patients with a first symptomatic PE. RESEARCH QUESTION Which radiologic findings on CT pulmonary angiography (CTPA) at the time of acute PE could indicate the presence of preexisting CTEPH? STUDY DESIGN AND METHODS This study included unselected patients with acute PE who were prospectively followed up for 2 years with a structured visit schedule. Two expert radiologists independently assessed patients' baseline CTPAs for preexisting CTEPH; in case of disagreement, a decision was reached by a 2:1 majority with a third expert radiologist. In addition, the radiologists checked for predefined individual parameters suggesting chronic PE and pulmonary hypertension. RESULTS Signs of chronic PE or CTEPH at baseline were identified in 46 of 303 included patients (15%). Intravascular webs, arterial narrowing or retraction, dilated bronchial arteries, and right ventricular hypertrophy were the main drivers of the assessment. Five (1.7%) patients were diagnosed with CTEPH during follow-up. All four patients diagnosed with CTEPH early (83-108 days following acute PE) were found in enriched subgroups based on the experts' overall assessment or fulfilling a minimum number of the predefined radiologic criteria at baseline. The specificity of preexisting CTEPH diagnosis and the level of radiologists' agreement improved as the number of required criteria increased. INTERPRETATION Searching for predefined radiologic parameters suggesting preexisting CTEPH at the time of acute PE diagnosis may allow for targeted follow-up strategies and risk-adapted CTEPH screening, thus facilitating earlier CTEPH diagnosis.
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Affiliation(s)
- Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Angiology, University Hospital Zurich, Zurich, Switzerland.
| | - Anna C Mavromanoli
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Karl-Friedrich Kreitner
- Department of Radiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Alexander C Bunck
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Roman J Gertz
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Sebastian Ley
- Diagnostic and Interventional Radiology, Artemed Klinikum München Süd, Munich, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Cardiology I, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Frederikus A Klok
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Felix Gerhardt
- Department of Cardiology, Heart Center at the University Hospital Cologne, and Cologne Cardiovascular Research Center, Cologne, Germany
| | - Stephan Rosenkranz
- Department of Cardiology, Heart Center at the University Hospital Cologne, and Cologne Cardiovascular Research Center, Cologne, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
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7
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Farmakis IT, Barco S, Hobohm L, Braekkan SK, Connors JM, Giannakoulas G, Hunt BJ, Keller K, Mavromanoli AC, Trinchero A, Konstantinides SV, Valerio L. Maternal mortality related to pulmonary embolism in the United States, 2003-2020. Am J Obstet Gynecol MFM 2023; 5:100754. [PMID: 36155111 DOI: 10.1016/j.ajogmf.2022.100754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Pulmonary embolism is a leading cause of maternal morbidity and mortality in Western countries. In the United States, pulmonary embolism-related mortality rates have plateaued in the general population after an initial decrease in the past 20 years. OBJECTIVE This study aimed to describe the changes in pulmonary embolism-related maternal mortality rates in the United States over the past 2 decades. STUDY DESIGN In this epidemiologic study of public vital registration data (death certificates encompassing underlying and contributing causes of death) from the Centers for Disease Control and Prevention Multiple Cause of Death database (2003-2020), we identified all maternal deaths with a pulmonary embolism code listed in any position of the death certificates. We investigated the changes in annual crude pulmonary embolism-related maternal mortality rates for the years 2003 to 2020, considering the effect of the introduction of the pregnancy checkbox in death certificates on the pulmonary embolism-related maternal mortality rates. RESULTS Overall, 735 pulmonary embolism-related maternal deaths out of 12,871 total maternal deaths (5.7%) were recorded between 2003 and 2020; the overall pulmonary embolism-related maternal mortality rate was 1.02 (95% confidence interval, 0.95-1.10) per 100,000 live births. The pulmonary embolism-related maternal mortality rate increased from 0.93 in 2003 to 1.96 in 2020; however, when accounting for the implementation of the pregnancy checkbox in the death certificates, the trends in pulmonary embolism-related maternal mortality were largely unchanged from 2003 to 2020. The crude pulmonary embolism-related maternal mortality rates differed across maternal age groups (overall 0.61, 1.09, and 3.83 maternal deaths per 100,000 live births for those aged ≤24, 25-39, and ≥40 years, respectively) and racial/ethnicity groups (2.89, 0.47, 0.77, and 0.63 maternal deaths per 100,000 live births for Black non-Hispanics, other non-Hispanics, White non-Hispanics, and Hispanics, respectively). CONCLUSION Maternal mortality rates related to pulmonary embolism did not decrease during the period from 2003 to 2020, as opposed to mortality rates related to pulmonary embolism in the general population. More research is required to assess whether improvement in venous thromboembolism prevention and pulmonary embolism diagnosis and management strategies might reduce death owing to pulmonary embolism in this vulnerable population.
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Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany (Drs Farmakis, Barco, Hobohm, Keller, Mavromanoli, Konstantinides, and Valerio)
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany (Drs Farmakis, Barco, Hobohm, Keller, Mavromanoli, Konstantinides, and Valerio); Department of Angiology, University Hospital of Zurich, Zurich, Switzerland (Dr Barco)
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany (Drs Farmakis, Barco, Hobohm, Keller, Mavromanoli, Konstantinides, and Valerio); Department of Cardiology, University Medical Center Mainz, Mainz, Germany (Drs Hobohm, Keller, and Valerio)
| | - Sigrid K Braekkan
- Thrombosis Research Center (TREC), Department of Clinical Medicine, University of Tromsø - The Arctic University of Norway, Tromsø, Norway (Dr Braekkan); Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway (Dr Braekkan)
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (Dr Connors)
| | - George Giannakoulas
- Department of Cardiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece (Dr Giannakoulas)
| | - Beverley J Hunt
- St Thomas' Hospital Thrombosis and Haemophilia Centre and Thrombosis and Vascular Biology Group, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom (Dr Hunt)
| | - Karsten Keller
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany (Drs Farmakis, Barco, Hobohm, Keller, Mavromanoli, Konstantinides, and Valerio); Department of Cardiology, University Medical Center Mainz, Mainz, Germany (Drs Hobohm, Keller, and Valerio); Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany (Dr Keller)
| | - Anna C Mavromanoli
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany (Drs Farmakis, Barco, Hobohm, Keller, Mavromanoli, Konstantinides, and Valerio)
| | - Alice Trinchero
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland (Dr Trinchero)
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany (Drs Farmakis, Barco, Hobohm, Keller, Mavromanoli, Konstantinides, and Valerio); Department of Cardiology, Democritus University of Thrace, Komotini, Greece (Dr Konstantinides)
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany (Drs Farmakis, Barco, Hobohm, Keller, Mavromanoli, Konstantinides, and Valerio); Department of Cardiology, University Medical Center Mainz, Mainz, Germany (Drs Hobohm, Keller, and Valerio).
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8
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Bougioukas KI, Diakonidis T, Mavromanoli AC, Haidich A. ccaR: a package for assessing primary study overlap across systematic reviews in overviews. Res Synth Methods 2022; 14:443-454. [PMID: 36369993 DOI: 10.1002/jrsm.1610] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/28/2022] [Accepted: 11/07/2022] [Indexed: 11/15/2022]
Abstract
An overview of reviews aims to collect, assess, and synthesize evidence from multiple systematic reviews (SRs) on a specific topic using rigorous and reproducible methods. An important methodological challenge in conducting an overview of reviews is the management of overlapping data due to the inclusion of the same primary studies in SRs. We present a free, open-source R package called ccaR (https://github.com/thdiakon/ccaR) that provides easy-to-use functions for assessing the degree of overlap of primary studies in an overview of reviews with the use of the corrected cover area (CCA) index. A worked example with and without consideration of chronological structural missingness is outlined, illustrating the steps involved in, calculating the CCA index and creating a publication-ready heatmap. We expect ccaR to be useful for overview authors, methodologists, and reviewers who are familiar with the basics of R and contribute to the discussion on different methodological approaches for implementing the CCA index. Future research and applications could further investigate the functionality or potential limitations of our package and other potential uses.
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Affiliation(s)
- Konstantinos I. Bougioukas
- Department of Hygiene, Social‐Preventive Medicine & Medical Statistics, School of Medicine, Faculty of Health Sciences Aristotle University of Thessaloniki, University Campus Thessaloniki Greece
| | - Theodoros Diakonidis
- Department of Hygiene, Social‐Preventive Medicine & Medical Statistics, School of Medicine, Faculty of Health Sciences Aristotle University of Thessaloniki, University Campus Thessaloniki Greece
| | - Anna C. Mavromanoli
- Department of Hygiene, Social‐Preventive Medicine & Medical Statistics, School of Medicine, Faculty of Health Sciences Aristotle University of Thessaloniki, University Campus Thessaloniki Greece
| | - Anna‐Bettina Haidich
- Department of Hygiene, Social‐Preventive Medicine & Medical Statistics, School of Medicine, Faculty of Health Sciences Aristotle University of Thessaloniki, University Campus Thessaloniki Greece
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9
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Farmakis IT, Barco S, Mavromanoli AC, Konstantinides SV, Valerio L. Performance Status and Long-Term Outcomes in Cancer-Associated Pulmonary Embolism. JACC: CardioOncology 2022; 4:507-518. [DOI: 10.1016/j.jaccao.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/17/2022]
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10
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Farmakis IT, Barco S, Mavromanoli AC, Agnelli G, Cohen AT, Giannakoulas G, Mahan CE, Konstantinides SV, Valerio L. Cost-of-Illness Analysis of Long-Term Health Care Resource Use and Disease Burden in Patients With Pulmonary Embolism: Insights From the PREFER in VTE Registry. J Am Heart Assoc 2022; 11:e027514. [PMID: 36250664 DOI: 10.1161/jaha.122.027514] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background As mortality from pulmonary embolism (PE) decreases, the personal and societal costs among survivors are receiving increasing attention. Detailing this burden would support an efficient public health resource allocation. We aimed to provide estimates for the economic and disease burden of PE also accounting for long-term health care use and both direct and indirect costs beyond the acute phase. Methods and Results This is a cost-of-illness analysis with a bottom-up approach based on data from the PREFER in VTE registry (Prevention of Thromboembolic Events-European Registry in Venous Thromboembolism). We calculated direct (clinical events and anticoagulation) and indirect costs (loss of productivity) of an acute PE event and its 12-month follow-up in 2020 Euros. We estimated a disability weight for the 12-month post-PE status and corresponding disability adjusted life years presumably owing to PE. Disease-specific costs in the first year of follow-up after an incident PE case ranged between 9135 Euros and 10 620 Euros. The proportion of indirect costs was 42% to 49% of total costs. Costs were lowest in patients with ongoing cancer, mainly because productivity loss was less evident in this already burdened population. The calculated disability weight for survivors who were cancer free 12 months post-PE was 0.017, and the estimated disability adjusted life years per incident case were 1.17. Conclusions The economic burden imposed by PE to society and affected patients is considerable, and productivity loss is its main driver. The disease burden from PE is remarkable and translates to the loss of roughly 1.2 years of healthy life per incident PE case.
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Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis University Medical Center of the Johannes Gutenberg University Mainz Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis University Medical Center of the Johannes Gutenberg University Mainz Germany.,Department of Angiology University Hospital Zurich Zurich Switzerland
| | - Anna C Mavromanoli
- Center for Thrombosis and Hemostasis University Medical Center of the Johannes Gutenberg University Mainz Germany
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine-Stroke Unit University of Perugia Perugia Italy
| | - Alexander T Cohen
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust King's College London London UK
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital Aristotle University of Thessaloniki Thessaloniki Greece
| | | | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis University Medical Center of the Johannes Gutenberg University Mainz Germany.,Department of Cardiology Democritus University of Thrace Alexandroupolis Greece
| | - Luca Valerio
- Center for Thrombosis and Hemostasis University Medical Center of the Johannes Gutenberg University Mainz Germany.,Department of Cardiology University Medical Center of the Johannes Gutenberg University Mainz Germany
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11
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Mavromanoli AC, Barco S, Farmakis IT, Rosenkranz S, Konstantinides SV, Valerio L. Two-year quality of life after acute pulmonary embolism: results from the FOCUS study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background/Introduction
No firm prospective evidence exists on the long-term course of disease-specific and generic quality of life (QoL) or their determinants in patients with acute pulmonary embolism (PE). Reliable data on this topic is essential for early identification of patients at risk of deviating from the expected course and prevention of clinical events affecting QoL recovery after PE.
Purpose
We examined the two-year course of QoL and the impact of events occurring after the acute phase of PE in patients from the prospective multicentre FOllow-up after aCUte pulmonary emboliSm (FOCUS) study.
Methods
All patients with complete QoL assessment at 3, 12 and 24 months (N=462) were included in the analysis of the two-year course of QoL; all patients with QoL assessment at 12 months, 24 months, or both (N=740) contributed to a multivariable linear mixed-effects regression for the investigation of determinants of long-term QoL. Disease-specific QoL was assessed with the Pulmonary Embolism Quality of Life (PEmb-QoL) instrument (global score: 0 = best, 100 = worst QoL), generic health-related QoL with the Euro Quality of life group (EuroQol) five-dimensions utility index (EQ-5D-5L; 0 = worst, 1 = best QoL) and the EuroQol visual analogue scale (0 = worst, 100 = best QoL). Incident events (recurrent PE, bleeding, stroke, new cancer diagnosis, and re-hospitalization) were modelled as time-varying covariates from discharge to month 12 and from month 12 to month 24.
Results
Among 462 patients with complete QoL assessment [200 (43.3%) women, median age 61.5 (IQR: 49–72) years, high-risk PE 15/462 (3.2%)], the median (IQR) PEmb-QoL score at 3, 12, and 24 months was 20 (9–36), 14 (5–30) and 13 (5–28), with a similar trend across all sub-dimensions (Figure 1); the mean (95% CI) EQ-5D-5L utility index 0.86 (0.84–0.88), 0.88 (0.87–0.90) and 0.87 (0.85–0.89); the mean (95% CI) EuroQoL visual analogue scale 74.2 (72.5–75.9), 76.8 (75.2–78.4) and 76.3 (74.6–78.0). Upon multivariable analysis in 740 patients with QoL data at 12 or 24 months, QoL according to all three scales was worse in women, patients of older age, with cardiopulmonary disease, with higher BMI, and in smokers, but did not change significantly at 24 vs 12 months. Incident PE recurrence or stroke did not considerably affect any of the QoL dimensions, whereas re-hospitalization for any cause worsened disease-specific QoL, a new cancer diagnosis worsened both scales of generic QoL, and bleeding worsened generic QoL as assessed by the Visual Analogue Scale (Table 1).
Conclusion
Generic and disease-specific QoL after PE improved in the first year and then plateaued in the second year. Disease-specific QoL was adversely affected by re-hospitalization for any cause but was robust to new cancer diagnosis and bleedings, which instead worsened generic QoL. These findings may support long-term management of patients with PE and contribute to design and interpretation of interventional studies.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Bayer Health Care
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Affiliation(s)
- A C Mavromanoli
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University , Mainz , Germany
| | - S Barco
- Department of Angiology, University Hospital Zurich , Zurich , Switzerland
| | - I T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University , Mainz , Germany
| | - S Rosenkranz
- Department of Cardiology, Heart Center at the University Hospital Cologne, and Cologne Cardiovascular Research Center , Cologne , Germany
| | - S V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University , Mainz , Germany
| | - L Valerio
- Center for Thrombosis and Hemostasis & Department of Cardiology, University Medical Center of the Johannes Gutenberg University , Mainz , Germany
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12
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Farmakis I, Keller K, Scibior B, Mavromanoli AC, Sagoschen I, Munzel T, Ahrens I, Konstantinides S, Hobohm L. Pulmonary embolism response team implementation and its clinical value across countries: a scoping review and meta-analysis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Over the last years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has been developed to encounter the increasing variety and complexity in the management of acute pulmonary embolism (PE), but data on the use and the benefit of PERT are sparse.
Purpose
We aimed to systematically investigate the composition of PERT and its clinical value in clinical routine across different countries.
Methods
We searched PubMed, CENTRAL and Web of Science until January 2022 for full-text, prospective and retrospective observational studies, which included patients with acute PE who were evaluated by a PERT. Eligible articles were designed to either describe the structure and function of PERTs and/or to investigate outcomes related to the implementation of PERT. We performed a random-effects meta-analysis of controlled studies (PERT vs. pre-PERT era) to investigate the impact of PERTs on clinical outcomes and use of advanced therapies.
Results
We included 22 original studies and four surveys. Overall, 31.5% of patients with PE were evaluated by PERT referred mostly by emergency departments (59.4%). In total, PERT involved a median of 6 (range 2–10) specialties for guiding further diagnostic and treatment modalities. Patients evaluated by a PERT had a mean age of 60 years; of them, 48.7% were females, and 23.5% suffered from malignancy. Right ventricular dysfunction was present in 55% of the patients. In total, 74.5% were classified as intermediate-risk PE and 16% as high-risk PE. In eleven single-arm studies, 1,532 patients with intermediate- and high-risk PE were evaluated by PERT with a mortality rate of 10% and a bleeding rate of 9%. The mean length of stay was 7.3 days and the use of advanced therapy was reported in 30% of all cases. From these, catheter-directed treatment (CDT) was performed in 22% and inferior vena cava filter was inserted in 15%, while systemic thrombolysis was administered in only 6%, surgical thrombectomy in 2% and ECMO in 3% of all cases. When comparing PERT and pre-PERT era no difference in mortality (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.67–1.19, I2=63%) was observed based on nine controlled studies, while mortality tended to be lower when including only intermediate and high-risk patients in the analysis (RR 0.71, 95% CI 045–1.12) (Figure 1). The use of advanced therapies was more common (RR 2.67, 95% CI 1.29–5.50) and the in-hospital stay as well as the duration of treatment in intensive care unit was shorter (mean difference −1.6 days and −1.8 days, respectively) in the PERT era.
Conclusion
PERT implementation tended to reduce the mortality rate in patients with intermediate- and high-risk PE and resulted in a shorter in-hospital stay. Large prospective studies are needed to further explore the impact of PERTs on clinical outcomes.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- I Farmakis
- Center for Thrombosis and Hemostasis , Mainz , Germany
| | - K Keller
- University Medical Center Mainz, Department of Cardiology , Mainz , Germany
| | - B Scibior
- Center for Thrombosis and Hemostasis , Mainz , Germany
| | | | - I Sagoschen
- University Medical Center Mainz, Department of Cardiology , Mainz , Germany
| | - T Munzel
- University Medical Center Mainz, Department of Cardiology , Mainz , Germany
| | - I Ahrens
- Hospital der Augustinerinnen, Department of Cardiology and Medical Intensive Care , Cologne , Germany
| | | | - L Hobohm
- Center for Thrombosis and Hemostasis , Mainz , Germany
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13
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Farmakis I, Valerio L, Mavromanoli AC, Bikdeli B, Connors JM, Giannakoulas G, Goldhaber SZ, Hobohm L, Hunt BJ, Keller K, Klok FA, Spyropoulos AC, Kucher N, Konstantinides S, Barco S. Mortality related to pulmonary embolism in the United States before and during the COVID-19 pandemic: an analysis of the CDC Multiple Cause of Death database. Eur Heart J 2022. [PMCID: PMC9619500 DOI: 10.1093/eurheartj/ehac544.1869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background The COVID-19 pandemic caused a large number of excess deaths. COVID-19 emerged as a prothrombotic disease often complicated by pulmonary embolism (PE). In light of this, we hypothesized that PE-related mortality rates (stable before the pandemic) would be characterized by an increasing trend following the COVID-19 outbreak. Purpose To investigate the mortality rates associated with PE among deaths with or without COVID-19 during the 2020 pandemic in the United States (US). Methods For this retrospective epidemiological study, we analyzed public medically certified vital registration data (death certificates encompassing underlying and multiple causes of death) from the Mortality Multiple Cause-of-Death database provided by the Division of Vital Statistics of the US Centers for Disease Control and Prevention (CDC; US, 2018–20). We investigated the time trends in monthly PE-related crude mortality rates for 2018–2019 and for 2020 (the latter associated vs. not associated with COVID-19), utilizing annual national population totals from the US Census Bureau. Second, we calculated the PE-related proportionate mortality among COVID-19 deaths (overall and limited to autopsy-based diagnosis). We performed subgroup analyses based on age groups, sex and race. Results During 2020, 49,423 deaths in association with PE were reported, vs. 39,450 in 2019 and 38,215 in 2018. The crude PE-related mortality rate without COVID-19 was 13.3 per 100,000 population in 2020 compared to 11.7 in 2018 and 12.0 in 2019 (Figure 1A). The PE-related mortality rate with COVID-19 was 1.6 per 100,000 population in 2020. Among non-COVID-19-related deaths, the crude PE-related mortality rate was higher in women; among COVID-19-related deaths, it was higher in men. PE-related mortality rates were approximately two-fold higher among black (vs. white) general population irrespective of COVID-19 status (Figures 1B and 1C). Among COVID-19 deaths, PE-related deaths corresponded to 1.4% of total; the value rose to 6.0% when an autopsy was performed. This figure was higher in men and its time evolution is depicted in Figure 2A. The proportionate mortality of PE in COVID-19 deaths was higher for younger age groups (15–44 years) compared to non-COVID-19-related deaths (Figure 2B). Conclusion In 2020, an overall 20%-increase in PE-related mortality was reported, not being limited to patients with COVID-19. Our findings could be interpreted in the context of undiagnosed COVID-19 cases, uncounted late sequelae, and possibly sedentary lifestyle and avoidance of healthcare facilities during the pandemic that may have prevented timely diagnosis and treatment of other diseases. Whether vaccination programs had an impact on PE-associated mortality in the year 2021, remains to be determined. Funding Acknowledgement Type of funding sources: None.
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Affiliation(s)
- I Farmakis
- Center for Thrombosis and Hemostasis , Mainz , Germany
| | - L Valerio
- Center for Thrombosis and Hemostasis , Mainz , Germany
| | | | - B Bikdeli
- Brigham and Women's Hospital, Cardiovascular Medicine Division , Boston , United States of America
| | - J M Connors
- Brigham and Women's Hospital, Hematology Division , Boston , United States of America
| | - G Giannakoulas
- AHEPA University General Hospital, Department of Cardiology , Thessaloniki , Greece
| | - S Z Goldhaber
- Brigham and Women's Hospital, Cardiovascular Medicine Division , Boston , United States of America
| | - L Hobohm
- Center for Thrombosis and Hemostasis , Mainz , Germany
| | - B J Hunt
- Guy's & St Thomas' NHS Foundation Trust, St Thomas' Hospital Thrombosis and Haemophilia Centre and Thrombosis and Vascular Biology Group , London , United Kingdom
| | - K Keller
- University Medical Center Mainz, Department of Cardiology , Mainz , Germany
| | - F A Klok
- Leiden University Medical Center, Department of Medicine - Thrombosis and Hemostasis , Leiden , The Netherlands
| | - A C Spyropoulos
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell , Hempstead , United States of America
| | - N Kucher
- University Hospital Zurich, Department of Angiology , Zurich , Switzerland
| | | | - S Barco
- University Hospital Zurich, Department of Angiology , Zurich , Switzerland
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14
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Mavromanoli AC, Valerio L, Bunck AC, Kreitner KF, Ley S, Gertz RJ, Rosenkranz S, Konstantinides SV, Barco S. Signs of chronic thromboembolic pulmonary hypertension in acute pulmonary embolism: results from the FOCUS study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background/Introduction
Chronic thromboembolic pulmonary hypertension (CTEPH) is considered to be a late complication of acute pulmonary embolism (PE). However, up to one third of CTEPH patients do not report prior symptomatic venous thromboembolism (VTE). Furthermore, a substantial proportion of patients presenting with an acute PE event may exhibit radiological signs of chronicity at baseline computed tomography pulmonary angiography (CTPA).
Purpose
To determine the prevalence of baseline radiological parameters indicating chronic thrombosis or pulmonary hypertension, and ultimately pre-existing CTEPH, among patients with acute PE enrolled in the prospective multicentre Follow-Up after Acute Pulmonary Embolism (FOCUS) cohort study.
Methods
Patients with acute symptomatic PE and absence of a known history of CTEPH, enrolled at two large FOCUS centres, were included. The assessment of index CTPA scans was conducted by two independent expert radiologists who were unaware of the clinical characteristics and the follow-up data of the patients. CTPA parameters indicating chronicity were prespecified on the basis of recently proposed criteria in the literature. A third independent expert radiologist provided an assessment in case of disagreement between the first two. Baseline radiological data were prospectively validated with the aid of two-year prospective clinical follow-up data focusing on CTEPH and the post-PE syndrome (co-primary outcomes of the FOCUS study).
Results
A total of 303 patients (median age: 63 years, 44.6% women) were included. In >95% of the patients, the expert radiologists could confirm signs of acute PE at baseline CTPA. Radiological signs of chronic thrombi or pulmonary hypertension at baseline were detected in 46 (15.2%) patients. In 8 patients, the expert radiologists agreed on the presence of pre-existing CTEPH based on their interpretation of the overall radiological pattern. During follow-up, five (1.7%; 95% CI 0.7–3.8%) of 303 patients were diagnosed with CTEPH, over a median time of 95 days after baseline. Four of them were among the 8 patients in whom the radiological experts suspected pre-existing CTEPH at baseline, and among the 46 patients in whom CTPA findings suggesting chronic thrombi or chronic pulmonary hypertension were present at baseline. The use of the predefined individual parameters of chronicity from the literature also helped identifying patients with chronic disease, and could be used as a tool for screening acute PE patients for pre-existing CTEPH.
Conclusion
A substantial proportion of patients who are diagnosed with CTEPH during follow-up after acute PE may already have pre-existing CTEPH at the time of the index event. An intensified follow-up programme and focussed screening for CTEPH should be considered in patients with signs of chronicity at baseline CTPA.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Bayer Health Care
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Affiliation(s)
- A C Mavromanoli
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University , Mainz , Germany
| | - L Valerio
- Center for Thrombosis and Hemostasis & Department of Cardiology, University Medical Center of the Johannes Gutenberg University , Mainz , Germany
| | - A C Bunck
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne , Cologne , Germany
| | - K F Kreitner
- Department of Radiology, University Medical Center of the Johannes Gutenberg University , Mainz , Germany
| | - S Ley
- Diagnostic and Interventional Radiology, Artemed Klinikum München Süd , Munich , Germany
| | - R J Gertz
- Department of Diagnostic and Interventional Radiology, University of Cologne, Faculty of Medicine and University Hospital Cologne , Cologne , Germany
| | - S Rosenkranz
- Department of Cardiology, Heart Center at the University Hospital Cologne, and Cologne Cardiovascular Research Center , Cologne , Germany
| | - S V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University , Mainz , Germany
| | - S Barco
- Department of Angiology, University Hospital Zurich , Zurich , Switzerland
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15
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Farmakis I, Barco S, Mavromanoli AC, Mahan CE, Giannakoulas G, Cohen AT, Konstantinides S, Valerio L. Cost-of-illness analysis of long-term healthcare resource utilization and disease burden in patients with pulmonary embolism: insights from the PREFER in VTE registry. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Pulmonary embolism (PE) is responsible for considerable personal and societal costs. Detailing this burden would support an efficient public health resource allocation. However, cost estimates so far have failed to account for both resource utilization and excess costs in its long-term management beyond the acute phase.
Purpose
To provide estimates for the economic and disease burden of PE in the European Union (EU) also accounting for long-term healthcare utilization and costs beyond the acute phase.
Methods
This is a cost-of-illness analysis, from a societal perspective, with a bottom-top approach and a time horizon of 12 months based on data from the PREFER in VTE registry. We calculated direct and indirect costs of an acute PE event and its 12-month follow-up. We used cost inputs derived from the literature and as directly reported in the PREFER in VTE registry and we adjusted them for inflation and purchasing power parity to 2020 Euros (€). Total average costs per PE patient comprised six general categories: costs for the index PE hospitalization; costs for clinical events during follow-up; costs for anticoagulation after the index event; costs for ambulatory visits during follow-up; the patient's own contribution; and costs related to productivity loss (using the friction cost method). A stratified analysis was performed according to the presence of active cancer, non-cancer provoked PE, and unprovoked PE. In addition, we used the EQ-5D health questionnaire to derive a disability weight for the post-PE state 12 months after the index event and the corresponding disability adjusted life years (DALYs) presumably due to PE.
Results
Annual disease-specific costs for each incident PE case ranged between 9,135 € and 10,620 €. Costs for patients with cancer (8,274 to 9,752 €) and patients with unprovoked PE (8,695 to 9,612 €) were lower than costs for non-cancer patients with provoked PE (10,423 to 11,307 €), mainly due to differences in productivity loss. The indirect costs were mainly driven by productivity losses and their proportion to total costs was 42–49% for the overall population (28–33% for cancer, 52–56% for non-cancer provoked PE and 43–47% for unprovoked PE) (Figure 1). Anticoagulation accounted for 18–21% of total costs for cancer patients (while only 5–6% for non-cancer patients) and was primarily driven by the use of low-molecular-weight heparins and fondaparinux (Figure 2). The calculated disability weight for cancer-free survivors of PE 12 months after the index event was 0.017 (bootstrapped 95% CI 0.0002–0.0344) and the estimated annual DALYs per incident case were 1.17 (bootstrapped 95% CI 0.75–1.59).
Conclusion
PE imposes a significant annual economic burden, for which productivity loss is the main driver. Total costs in the EU could range between 0.5 and 3.8 billion €. The disease burden from PE is notable and translates to the loss of roughly 1.2 years of healthy life per incident PE case per year.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This study was supported by an unrestricted grant from Daiichi Sankyo (Title: “Filling the gaps of knowledge on healthcare outcomes during long-term anticoagulant treatment of pulmonary embolism”, grant number DSE-DE-CV-20001).
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Affiliation(s)
- I Farmakis
- Center for Thrombosis and Hemostasis , Mainz , Germany
| | - S Barco
- University Hospital Zurich, Department of Angiology , Zurich , Switzerland
| | | | - C E Mahan
- University of New Mexico College of Pharmacy , Albuquerque , United States of America
| | - G Giannakoulas
- AHEPA University General Hospital, Department of Cardiology , Thessaloniki , Greece
| | - A T Cohen
- Guy's and St Thomas' NHS Trust Hospitals, Department of Haematological Medicine , London , United Kingdom
| | | | - L Valerio
- Center for Thrombosis and Hemostasis , Mainz , Germany
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16
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Valerio L, Mavromanoli AC, Barco S, Abele C, Becker D, Bruch L, Ewert R, Faehling M, Fistera D, Gerhardt F, Ghofrani HA, Grgic A, Grünig E, Halank M, Held M, Hobohm L, Hoeper MM, Klok FA, Lankeit M, Leuchte HH, Martin N, Mayer E, Meyer FJ, Neurohr C, Opitz C, Schmidt KH, Seyfarth HJ, Wachter R, Wilkens H, Wild PS, Konstantinides SV, Rosenkranz S. OUP accepted manuscript. Eur Heart J 2022; 43:3387-3398. [PMID: 35484821 PMCID: PMC9492241 DOI: 10.1093/eurheartj/ehac206] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/21/2022] [Accepted: 04/07/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Anna C Mavromanoli
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
- Department of Angiology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Christina Abele
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
- Department of Psychology, University of Siegen, Adolf-Reichwein-Straße 2, 57076 Siegen, Germany
| | - Dorothea Becker
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Leonhard Bruch
- Klinik für Innere Medizin und Kardiologie, Unfallkrankenhaus Berlin, Warener Str. 7, 12683 Berlin, Germany
| | - Ralf Ewert
- Clinic for Internal Medicine, Greifswald University Hospital, Fleischmannstraße 6, 17489 Greifswald, Germany
| | - Martin Faehling
- Klinik für Kardiologie, Angiologie und Pneumologie, Klinikum Esslingen, Hirschlandstraße 97, 73730 Esslingen am Neckar, Germany
| | - David Fistera
- Department of Pulmonary Medicine, University Medicine Essen – Ruhrlandklinik, Tueschener Weg 40, 45239 Essen, Germany
| | - Felix Gerhardt
- Department of Cardiology, Heart Center at the University Hospital Cologne, and Cologne Cardiovascular Research Center, Kerpener Str. 62, 50937 Cologne, Germany
- Cardiological Center Hohenlind, Werthmannstraße 1B, 50935 Cologne, Germany
| | - Hossein Ardeschir Ghofrani
- Lung Center at the University of Giessen and Marburg, Member of the German Center for Lung Research (DZL), Aulweg 130, 35392 Giessen, Germany
- Department of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Aleksandar Grgic
- Radiologische Praxis Homburg, Am Zweibrücker Tor 12, 66424 Homburg/Saar, Germany
| | - Ekkehard Grünig
- Thoraxklinik at Heidelberg University Hospital, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - Michael Halank
- Medizinische Klinik und Poliklinik I, Universitätsklinikum an der TU Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Matthias Held
- Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Missioklinik Klinikum Würzburg Mitte, Salvatorstraße 7, 97074 Würzburg, Germany
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Marius M Hoeper
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Member of the DZL, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Frederikus A Klok
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
- Clinic of Cardiology and Pneumology, University Medical Center Goettingen, Robert-Koch-Straße 40, 37075 Goettingen, Germany
- Department of Internal Medicine and Cardiology, Charité-University Medicine Berlin, Charitépl. 1, 10117 Berlin, Germany
| | - Hanno H Leuchte
- Department of Internal Medicine II, Neuwittelsbach Academic Hospital (of the Ludwig Maximilians University), Member of the DZL, Renatastraße 71A, 80639 Munich, Germany
| | - Nadine Martin
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Heart and Lung Center, Benekestraße 2-8, 61231 Bad Nauheim, Germany
| | - F Joachim Meyer
- Lungenzentrum München, Klinik für Pneumologie und Pneumologische Onkologie, Klinikum Bogenhausen, Englschalkinger Str. 77, 81925 Munich, Germany
| | - Claus Neurohr
- Department of Pneumology and Respiratory Medicine, Robert-Bosch-Krankenhaus Klinik Schillerhöhe, Solitudestraße 18, 70839 Gerlingen, Germany
| | - Christian Opitz
- Klinik für Innere Medizin, DRK Kliniken Berlin Westend, Spandauer Damm 130, 14050 Berlin, Germany
| | - Kai Helge Schmidt
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Hans Jürgen Seyfarth
- Department of Pneumology, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103 Leipzig, Germany
| | - Rolf Wachter
- Clinic of Cardiology and Pneumology, University Medical Center Goettingen, Robert-Koch-Straße 40, 37075 Goettingen, Germany
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103 Leipzig, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Heinrike Wilkens
- Department of Pneumology, Allergology and Intensive Care Medicine, Saarland University Hospital, Kirrberger Str. 100, 66421 Homburg, Germany
| | - Philipp S Wild
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Mainz, Germany
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Klok FA, Toenges G, Mavromanoli AC, Barco S, Ageno W, Bouvaist H, Brodmann M, Cuccia C, Couturaud F, Dellas C, Dimopoulos K, Duerschmied D, Empen K, Faggiano P, Ferrari E, Galiè N, Galvani M, Ghuysen A, Giannakoulas G, Huisman MV, Jiménez D, Kozak M, Lang IM, Lankeit M, Meneveau N, Münzel T, Palazzini M, Petris AO, Piovaccari G, Salvi A, Schellong S, Schmidt KH, Verschuren F, Schmidtmann I, Meyer G, Konstantinides SV. Early switch to oral anticoagulation in patients with acute intermediate-risk pulmonary embolism (PEITHO-2): a multinational, multicentre, single-arm, phase 4 trial. Lancet Haematol 2021; 8:e627-e636. [PMID: 34363769 DOI: 10.1016/s2352-3026(21)00203-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/09/2021] [Accepted: 06/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Current guidelines recommend a risk-adjusted treatment strategy for the management of acute pulmonary embolism. This is a particular patient category for whom optimal treatment (anticoagulant treatment, reperfusion strategies, and duration of hospitalisation) is currently unknown. We investigated whether treatment of acute intermediate-risk pulmonary embolism with parenteral anticoagulation for a short period of 72 h, followed by a switch to a direct oral anticoagulant (dabigatran), is effective and safe. METHODS We did a multinational, multicentre, single-arm, phase 4 trial at 42 hospitals in Austria, Belgium, France, Germany, Italy, Netherlands, Romania, Slovenia, and Spain. Adult patients (aged ≥18 years) with symptomatic intermediate-risk pulmonary embolism, with or without deep-vein thrombosis, were enrolled. Patients received parenteral low-molecular-weight or unfractionated heparin for 72 h after diagnosis of pulmonary embolism before switching to oral dabigatran 150 mg twice per day following a standard clinical assessment. The primary outcome was recurrent symptomatic venous thromboembolism or pulmonary embolism-related death within 6 months. The primary and safety outcomes were assessed in the intention-to-treat population. The study was terminated early, as advised by the data safety and monitoring board, following sample size adaptation after the predefined interim analysis on Dec 18, 2018. This trial is registered with the EU Clinical Trials Register (EudraCT 2015-001830-12) and ClinicalTrials.gov (NCT02596555). FINDINGS Between Jan 1, 2016, and July 31, 2019, 1418 patients with pulmonary embolism were screened, of whom 402 were enrolled and were included in the intention-to-treat analysis (median age was 69·5 years [IQR 60·0-78·0); 192 [48%] were women and 210 [52%] were men). Median follow-up was 217 days (IQR 210-224) and 370 (92%) patients adhered to the protocol. The primary outcome occurred in seven (2% [upper bound of right-sided 95% CI 3]; p<0·0001 for rejecting the null hypothesis) patients, with all events occurring in those with intermediate-high-risk pulmonary embolism (seven [3%; upper bound of right-sided 95% CI 5] of 283). At 6 months, 11 (3% [95% CI 1-5]) of 402 patients had at least one major bleeding event and 16 (4% [2-6]) had at least one clinically relevant non-major bleeding event; the only fatal haemorrhage occurred in one (<1%) patient before the switch to dabigatran. INTERPRETATION A strategy of early switch from heparin to dabigatran following standard clinical assessment was effective and safe in patients with intermediate-risk pulmonary embolism. Our results can help to refine guideline recommendations for the initial treatment of acute intermediate-risk pulmonary embolism, optimising the use of resources and avoiding extended hospitalisation. FUNDING German Federal Ministry of Education and Research, University Medical Center Mainz, and Boehringer Ingelheim.
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Affiliation(s)
- Frederikus A Klok
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Gerrit Toenges
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Anna C Mavromanoli
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Hélène Bouvaist
- Department of Cardiology, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, La Tronche, France
| | | | - Claudio Cuccia
- Cardiovascular Department, Fondazione Poliambulanza, Istituto Ospedaliero, Brescia, Italy
| | - Francis Couturaud
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, and EA3878, FCRIN INNOVTE, Brest University, Brest, France
| | - Claudia Dellas
- Clinic of Paediatric Cardiology and Intensive Care, GUCH Center, University Medical Center Goettingen, Goettingen, Germany
| | - Konstantinos Dimopoulos
- Royal Brompton Hospital, and National Heart and Lung Institute, Imperial College London, London, UK
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Klaus Empen
- Department of Internal Medicine, Städtisches Klinikum Dessau, Dessau-Roßlau, Germany
| | - Pompilio Faggiano
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, Institute of Cardiology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Emile Ferrari
- Service de Cardiologie, Hôpital Pasteur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Nazzareno Galiè
- DIMES, University of Bologna and IRCCS, S Orsola University Hospital, Bologna, Italy
| | - Marcello Galvani
- Division of Cardiology, Department of Cardiovascular Diseases, AUSL Romagna, Ospedale Morgagni-Pierantoni, Forli, Italy; Cardiovascular Research Unit, Fondazione Cardiologica Myriam Zito Sacco, Forli, Italy
| | | | - George Giannakoulas
- Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - David Jiménez
- Department of Respiratory Diseases, Ramon y Cajal Hospital, Universidad de Alcalá, CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Matija Kozak
- Department of Vascular Diseases, University Medical Center, Ljubljana, Slovenia
| | - Irene Marthe Lang
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Clinic of Cardiology and Pneumology, University Medical Center Goettingen, Goettingen, Germany; Department of Internal Medicine and Cardiology, Charité-University Medicine Berlin, Germany
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France; EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | | | - Antoniu Octavian Petris
- Grigore T Popa University of Medicine and Pharmacy Iasi, Cardiology Clinic, St Spiridon County Clinical Emergency Hospital, Iasi, Romania
| | - Giancarlo Piovaccari
- Department of Cardiovascular Diseases, Infermi Hospital, AUSL Romagna, Rimini, Italy
| | - Aldo Salvi
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Ancona, Ancona, Italy
| | - Sebastian Schellong
- Department of Internal Medicine 2, Municipal Hospital Dresden, Dresden, Germany
| | - Kai-Helge Schmidt
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Franck Verschuren
- Emergency Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Guy Meyer
- Pulmonology and Intensive Care Service, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, INSERM UMR S 970, and INNOVTE, Paris, France
| | - Stavros V Konstantinides
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece; Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany.
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18
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Mavromanoli AC, Barco S, Konstantinides SV. Antithrombotics and new interventions for venous thromboembolism: Exploring possibilities beyond factor IIa and factor Xa inhibition. Res Pract Thromb Haemost 2021; 5:S2475-0379(22)01378-4. [PMID: 34027284 PMCID: PMC8130658 DOI: 10.1002/rth2.12509] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/19/2021] [Accepted: 03/04/2021] [Indexed: 12/17/2022] Open
Abstract
Direct oral anti-activated factor X and antithrombin agents have largely replaced vitamin K antagonists as the standard of care in treatment of venous thromboembolism. However, gaps in efficacy and safety persist, notably in end-stage renal disease, implantable heart valves or assist devices, extracorporeal support of the circulation, and antiphospholipid syndrome. Inhibition of coagulation factor XI (FXI) emerges as a promising new therapeutic target. Antisense oligonucleotides offer potential advantages as a prophylactic or therapeutic modality, with one dose-finding trial in orthopedic surgery already published. In addition, monoclonal antibodies blocking activation and/or activity of activated factor XI are investigated, as are small-molecule inhibitors with rapid offset of action. Further potential targets include upstream components of the contact pathway such as factor XII, polyphosphates, or kallikrein. Finally, catheter-directed, pharmacomechanical antithrombotic strategies have been developed for high- and intermediate-risk pulmonary embolism, and large randomized trials aiming to validate their efficacy, safety, and prognostic impact are about to start.
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Affiliation(s)
- Anna C. Mavromanoli
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg UniversityMainzGermany
- Clinic of AngiologyUniversity Hospital ZurichZurichSwitzerland
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg UniversityMainzGermany
- Department of CardiologyDemocritus University of ThraceAlexandroupolisGreece
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