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Kenneweg F, Hobohm L, Bang C, Gupta SK, Xiao K, Thum S, Ten Cate V, Rapp S, Hasenfuß G, Wild P, Konstantinides S, Wachter R, Lankeit M, Thum T. Circulating miR-let7a levels predict future diagnosis of chronic thromboembolic pulmonary hypertension. Sci Rep 2024; 14:4514. [PMID: 38402278 PMCID: PMC10894210 DOI: 10.1038/s41598-024-55223-1] [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] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/21/2024] [Indexed: 02/26/2024] Open
Abstract
Distinct patterns of circulating microRNAs (miRNAs) were found to be involved in misguided thrombus resolution. Thus, we aimed to investigate dysregulated miRNA signatures during the acute phase of pulmonary embolism (PE) and test their diagnostic and predictive value for future diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH). Microarray screening and subsequent validation in a large patient cohort (n = 177) identified three dysregulated miRNAs as potential biomarkers: circulating miR-29a and miR-720 were significantly upregulated and miR-let7a was significantly downregulated in plasma of patients with PE. In a second validation study equal expression patterns for miR-29a and miR-let7a regarding an acute event of recurrent venous thromboembolism (VTE) or deaths were found. MiR-let7a concentrations significantly correlated with echocardiographic and laboratory parameters indicating right ventricular (RV) dysfunction. Additionally, circulating miR-let7a levels were associated with diagnosis of CTEPH during follow-up. Regarding CTEPH diagnosis, ROC analysis illustrated an AUC of 0.767 (95% CI 0.54-0.99) for miR-let7a. Using logistic regression analysis, a calculated patient-cohort optimized miR-let7a cut-off value derived from ROC analysis of ≥ 11.92 was associated with a 12.8-fold increased risk for CTEPH. Therefore, miR-let7a might serve as a novel biomarker to identify patients with haemodynamic impairment and as a novel predictor for patients at risk for CTEPH.
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Affiliation(s)
- Franziska Kenneweg
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
- REBIRTH Excellence Cluster, Hannover Medical School, Hannover, Germany
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center Mainz, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Claudia Bang
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
| | - Shashi K Gupta
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
| | - Ke Xiao
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
| | - Sabrina Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
| | - Vincent Ten Cate
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center Mainz, Mainz, Germany
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - Steffen Rapp
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center Mainz, Mainz, Germany
- German Cardiovascular Research Centre (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Gerd Hasenfuß
- Institute of Molecular Biology (IMB), Mainz, Germany
| | - Philipp Wild
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center Mainz, Mainz, Germany
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
- German Cardiovascular Research Centre (DZHK), Partner Site Rhine Main, Mainz, Germany
- Institute of Molecular Biology (IMB), Mainz, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Rolf Wachter
- Clinic of Cardiology and Pneumology, Heart Center, University Medical Center, Goettingen, Germany
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité-University Medicine Berlin, Berlin, Germany
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany.
- REBIRTH Excellence Cluster, Hannover Medical School, Hannover, Germany.
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Ten Cate V, Rapp S, Schulz A, Pallares Robles A, Jurk K, Koeck T, Espinola-Klein C, Halank M, Seyfarth HJ, Beutel ME, Schuster AK, Marini F, Hobohm L, Lankeit M, Lackner KJ, Ruf W, Münzel T, Andrade-Navarro MA, Prochaska JH, Konstantinides SV, Wild PS. Circulating microRNAs predict recurrence and death following venous thromboembolism. J Thromb Haemost 2023; 21:2797-2810. [PMID: 37481073 DOI: 10.1016/j.jtha.2023.07.010] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/10/2023] [Accepted: 07/07/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Recurrent events frequently occur after venous thromboembolism (VTE) and remain difficult to predict based on established genetic, clinical, and proteomic contributors. The role of circulating microRNAs (miRNAs) has yet to be explored in detail. OBJECTIVES To identify circulating miRNAs predictive of recurrent VTE or death, and to interpret their mechanistic involvement. METHODS Data from 181 participants of a cohort study of acute VTE and 302 individuals with a history of VTE from a population-based cohort were investigated. Next-generation sequencing was performed on EDTA plasma samples to detect circulating miRNAs. The endpoint of interest was recurrent VTE or death. Penalized regression was applied to identify an outcome-relevant miRNA signature, and results were validated in the population-based cohort. The involvement of miRNAs in coregulatory networks was assessed using principal component analysis, and the associated clinical and molecular phenotypes were investigated. Mechanistic insights were obtained from target gene and pathway enrichment analyses. RESULTS A total of 1950 miRNAs were detected across cohorts after postprocessing. In the discovery cohort, 50 miRNAs were associated with recurrent VTE or death (cross-validated C-index, 0.65). A weighted miRNA score predicted outcome over an 8-year follow-up period (HRSD, 2.39; 95% CI, 1.98-2.88; P < .0001). The independent validation cohort validated 20 miRNAs (ORSD for score, 3.47; 95% CI, 2.37-5.07; P < .0001; cross-validated-area under the curve, 0.61). Principal component analysis revealed 5 miRNA networks with distinct relationships to clinical phenotype and outcome. Mapping of target genes indicated regulation via transcription factors and kinases involved in signaling pathways associated with fibrinolysis. CONCLUSION Circulating miRNAs predicted the risk of recurrence or death after VTE over several years, both in the acute and chronic phases.
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Affiliation(s)
- Vincent Ten Cate
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Partner Site Rhine-Main, German Centre for Cardiovascular Research (DZHK), Mainz, Germany. https://twitter.com/cesm_mainz
| | - Steffen Rapp
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Andreas Schulz
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Alejandro Pallares Robles
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Kerstin Jurk
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Partner Site Rhine-Main, German Centre for Cardiovascular Research (DZHK), Mainz, Germany
| | - Thomas Koeck
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christine Espinola-Klein
- Department of Angiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Michael Halank
- Department of Internal Medicine I and Pulmonology, Carl Gustav Carus Hospital, University of Dresden, Dresden, Germany
| | | | - Manfred E Beutel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Alexander K Schuster
- Department of Ophthalmology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Federico Marini
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Germany
| | - Karl J Lackner
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Wolfram Ruf
- Partner Site Rhine-Main, German Centre for Cardiovascular Research (DZHK), Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Department of Immunology and Microbiology, Scripps Research, La Jolla, California, USA
| | - Thomas Münzel
- Partner Site Rhine-Main, German Centre for Cardiovascular Research (DZHK), Mainz, Germany; Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Miguel A Andrade-Navarro
- Institute of Organismic and Molecular Evolution, Faculty of Biology, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jürgen H Prochaska
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Partner Site Rhine-Main, German Centre for Cardiovascular Research (DZHK), Mainz, Germany
| | - Stavros V Konstantinides
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Germany
| | - Philipp S Wild
- Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Partner Site Rhine-Main, German Centre for Cardiovascular Research (DZHK), Mainz, Germany; Institute of Molecular Biology (IMB), Mainz, Germany.
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Eckelt J, Hobohm L, Merten MC, Pagel CF, Eggers AS, Lerchbaumer MH, Stangl K, Hasenfuß G, Konstantinides S, Schmidtmann I, Lankeit M, Ebner M. Long-term mortality in patients with pulmonary embolism: results in a single-center registry. Res Pract Thromb Haemost 2023; 7:100280. [PMID: 37601025 PMCID: PMC10439384 DOI: 10.1016/j.rpth.2023.100280] [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: 11/15/2022] [Revised: 04/03/2023] [Accepted: 05/31/2023] [Indexed: 08/22/2023] Open
Abstract
Background While numerous studies have investigated short-term outcomes after pulmonary embolism (PE), long-term mortality remains insufficiently studied. Objectives To investigate long-term outcomes in an unselected cohort of patients with PE. Methods A total of 896 consecutive patients with PE enrolled in a single-center registry between May 2005 and December 2017 were followed up for up to 14 years. The observed mortality rate was compared with the expected rate in the general population. Results The total follow-up time was 3908 patient-years (median, 3.1 years). The 1- and 5-year mortality rates were 19.7% (95% CI, 17.2%-22.4%) and 37.1% (95% CI, 33.6%-40.5%), respectively. The most frequent causes of death were cancer (28.5%), PE (19.4%), infections (13.9%), and cardiovascular events (11.6%). Late mortality (after >30 days) was more frequent than expected in the general population, a finding that was consistent in patients without cancer (the 5-year standardized mortality ratios were 2.77 [95% CI, 2.41-3.16] and 1.80 [95% CI, 1.50-2.14], respectively). Active cancer was the strongest risk factor for death between 30 days and 3 years (hazard ratio [HR], 6.51; 95% CI, 4.67-9.08) but was not associated with later mortality. Death after >3 years was predicted by age (HR, 1.86; 95% CI, 1.51-2.29 per decade), chronic heart failure (HR, 1.66; 95% CI, 1.02-2.70), and anemia (HR, 1.62; 95% CI, 1.09-2.41). Conclusion The risk of mortality in patients with PE remained elevated compared with that in the general population throughout the follow-up period. The main driver of long-term mortality during the first 3 years was cancer. After that, mortality was predicted by age, chronic heart failure, and anemia.
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Affiliation(s)
- Johannes Eckelt
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Marie C. Merten
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Charlotta F. Pagel
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Ann-Sophie Eggers
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Markus H. Lerchbaumer
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Department of Radiology, Campus Charité Mitte (CCM), Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Karl Stangl
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Gerd Hasenfuß
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Göttingen, Göttingen, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Mainz, Mainz, Germany
| | - Mareike Lankeit
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Berlin, Berlin, Germany
| | - Matthias Ebner
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
- Charité – Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner site Berlin, Berlin, Germany
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Eggers AS, Hafian A, Lerchbaumer MH, Hasenfuß G, Stangl K, Pieske B, Lankeit M, Ebner M. Acute Infections and Inflammatory Biomarkers in Patients with Acute Pulmonary Embolism. J Clin Med 2023; 12:jcm12103546. [PMID: 37240652 DOI: 10.3390/jcm12103546] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
Although infections are frequent in patients with pulmonary embolism (PE), its effect on adverse outcome risk remains unclear. We investigated the incidence and prognostic impact of infections requiring antibiotic treatment and of inflammatory biomarkers (C-reactive protein [CRP] and procalcitonin [PCT]) on in-hospital adverse outcomes (all-cause mortality or hemodynamic insufficiency) in 749 consecutive PE patients enrolled in a single-centre registry. Adverse outcomes occurred in 65 patients. Clinically relevant infections were observed in 46.3% of patients and there was an increased adverse outcome risk with an odds ratio (OR) of 3.12 (95% confidence interval [CI] 1.70-5.74), comparable to an increase in one risk class of the European Society of Cardiology (ESC) risk stratification algorithm (OR 3.45 [95% CI 2.24-5.30]). CRP > 124 mg/dL and PCT > 0.25 µg/L predicted patient outcome independent of other risk factors and were associated with respective ORs for an adverse outcome of 4.87 (95% CI 2.55-9.33) and 5.91 (95% CI 2.74-12.76). In conclusion, clinically relevant infections requiring antibiotic treatment were observed in almost half of patients with acute PE and carried a similar prognostic effect to an increase in one risk class of the ESC risk stratification algorithm. Furthermore, elevated levels of CRP and PCT seemed to be independent predictors of adverse outcome.
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Affiliation(s)
- Ann-Sophie Eggers
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité Campus Virchow-Klinikum Mittelallee, German Heart Center of the Charité-University Medicine Berlin, 13353 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
| | - Alaa Hafian
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, 37075 Goettingen, Germany
| | - Markus H Lerchbaumer
- Department of Radiology, Campus Charité Mitte (CCM), Charité-University Medicine Berlin, 10117 Berlin, Germany
| | - Gerd Hasenfuß
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, 37075 Goettingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Goettingen, 37075 Goettingen, Germany
| | - Karl Stangl
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité Campus Mitte, German Heart Center of the Charité-University Medicine Berlin, 10117 Berlin, Germany
| | | | - Mareike Lankeit
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, 37075 Goettingen, Germany
| | - Matthias Ebner
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité Campus Mitte, German Heart Center of the Charité-University Medicine Berlin, 10117 Berlin, Germany
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5
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Lerchbaumer MH, Aviram G, Ebner M, Ritter CO, Steimke L, Rozenbaum Z, Adam SZ, Granot Y, Hasenfuß G, Lotz J, Hamm B, Konstantinides SV, Lankeit M. Optimized definition of right ventricular dysfunction on computed tomography for risk stratification of pulmonary embolism. Eur J Radiol 2022; 157:110554. [PMID: 36308850 DOI: 10.1016/j.ejrad.2022.110554] [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: 05/21/2022] [Revised: 10/01/2022] [Accepted: 10/07/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES There is an ongoing discussion on the optimal right to left (RV/LV) diameter ratio threshold and the best definition of RV dysfunction on computed tomography pulmonary angiography (CTPA) for risk assessment of pulmonary embolism (PE). METHODS On routine diagnostic CTPA, volumetric and diameter measurements (axial and reconstructed views) of the ventricles and reflux of contrast medium into the inferior vena cava (IVC) and hepatic veins were assessed in consecutive PE patients enrolled in a prospective single-center registry. In-hospital adverse outcome was defined as PE-related death, cardiopulmonary resuscitation, mechanical ventilation or catecholamine administration. RESULTS Of 609 patients (median age, 69 [IQR, 56-77] years; 47 % male) included in the analysis, 68 patients (11.2 %) had an adverse outcome and 35 (5.7 %) died. While neither a RV/LV volume ratio ≥1.0 nor RV/LV diameter ratios ≥1.0 were able to predict an adverse outcome, higher thresholds increased specificity. Further, neither volumetric measurements nor reconstruction of images provided superior prognostic information compared to RV/LV ratios measured in axial planes. The combination of an axial RV/LV diameter ratio ≥1.5 with substantial reflux of contrast medium was present in 134 patients (22 %) and associated with the best prognostic performance to predict an adverse outcome in unselected (OR 3.7 [95 % CI, 2.0-6.6]) and normotensive (OR 2.8 [95 % CI, 1.1-6.7]) patients. CONCLUSION A new definition of RV dysfunction (axial RV/LV diameter ratio ≥1.5 and substantial reflux of contrast medium to the IVC and hepatic veins) allows an optimized CTPA-based prediction of PE-related adverse outcome.
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Affiliation(s)
| | - Galit Aviram
- Department of Radiology, Tel Aviv Medical Centre, Tel Aviv, Israel(2)
| | - Matthias Ebner
- Department of Cardiology and Angiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Germany
| | - Christian O Ritter
- Institute for Diagnostic and Interventional Radiology, University Medical Center, Goettingen, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Goettingen, Germany
| | - Laura Steimke
- Clinic of Cardiology and Pneumology, University Medical Center, Goettingen, Germany
| | - Zach Rozenbaum
- Department of Cardiology, Tel Aviv Medical Centre, Tel Aviv, Israel(3)
| | - Sharon Z Adam
- Department of Radiology, Tel Aviv Medical Centre, Tel Aviv, Israel(2)
| | - Yoav Granot
- Department of Cardiology, Tel Aviv Medical Centre, Tel Aviv, Israel(3)
| | - Gerd Hasenfuß
- German Center for Cardiovascular Research (DZHK), Partner Site Goettingen, Germany; Clinic of Cardiology and Pneumology, University Medical Center, Goettingen, Germany
| | - Joachim Lotz
- Institute for Diagnostic and Interventional Radiology, University Medical Center, Goettingen, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Goettingen, Germany
| | - Bernd Hamm
- Department of Radiology, Charité - University Medicine Berlin, Germany
| | - Stavros V Konstantinides
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany
| | - Mareike Lankeit
- Clinic of Cardiology and Pneumology, University Medical Center, Goettingen, Germany; Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
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6
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Wiedenroth CB, Bandorski D, Ariobi K, Ghofrani HA, Lankeit M, Liebetrau C, Pruefer D, Mayer E, Kriechbaum SD, Guth S. Does Age Matter? Pulmonary Endarterectomy in the Elderly Patient with CTEPH. Thorac Cardiovasc Surg 2022; 70:663-670. [PMID: 35038757 DOI: 10.1055/s-0041-1740559] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND The gold standard treatment of patients with chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy (PEA). Little is known about the influence of advanced age on surgical outcome. Therefore, the aim of this study was to investigate the impact of patient's age on postoperative morbidity, mortality, and quality of life in a German referral center. METHODS Prospectively collected data from 386 consecutive patients undergoing PEA between 01/2014 and 12/2016 were analyzed. Patients were divided into three groups according to their age: group 1: ≤ 50 years, group 2: > 50 ≤ 70 years, group 3: > 70 years. RESULTS After PEA, distinct improvements in pulmonary hemodynamics, physical capacity (World Health Organization [WHO] functional class and 6-minute walking distance) and quality of life were found in all groups. There were more complications in elderly patients with longer time of invasive ventilation, intensive care, and in-hospital stay. However, the in-hospital mortality was comparable (0% in group 1, 2.6% in group 2, and 2.1% in group 3 [p = 0.326]). Furthermore, the all-cause mortality at 1 year was 1.1% in group 1, 3.2% in group 2, and 6.3% in group 3 (p = 0.122). CONCLUSIONS PEA is an effective treatment for CTEPH patients of all ages accompanied by low perioperative and 1-year mortality. CTEPH patients in advanced age carefully selected by thorough preoperative evaluation should be offered PEA in expert centers to improve quality of life, symptoms, and pulmonary hemodynamics.
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Affiliation(s)
| | - Dirk Bandorski
- Faculty of Medicine, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Kanischka Ariobi
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - H-Ardeschir Ghofrani
- Department of Pulmonology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany.,Department of Medicine, Imperial College, London, United Kingdom
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Germany Clinic for Cardiology and Pneumology, University Medical Center Göttingen, Germany
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt am Main, Germany.,Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | - Diethard Pruefer
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Steffen D Kriechbaum
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt am Main, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
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7
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Ebner M, Eckelt J, Hobohm L, Merten MC, Pagel CF, Fischer AS, Lerchbaumer MH, Stangl K, Hasenfuss G, Konstantinides SV, Schmidtmann I, Lankeit M. Causes of death and predictors of long-term mortality after pulmonary embolism. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1896] [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
While a large number of studies has investigated short-term outcome after pulmonary embolism (PE), the effects of PE on long-term mortality are insufficiently studied.
Purpose
To investigate long-term outcomes in an unselected real-world cohort of patients with acute PE.
Methods
Consecutive patients with acute PE enrolled in a prospective single-centre registry between 05/2005 and 12/2017 were followed for up to 14 years. The primary study outcome was all-cause mortality during follow-up. Kaplan-Meier analyses were used to evaluate the probability of long-term survival. The prognostic relevance of baseline characteristics was assessed using Cox proportional hazards models. Standardised mortality rates (SMR) were calculated to estimate relative rates of mortality in the study cohort compared to the expected mortality in the general population adjusted for sex, age and year of birth.
Results
We analysed data from 882 patients (age 69 [interquartile range (IQR) 56–77] years), followed for a total of 3,904 patient years (median follow-up 3.2 [IQR 1.3–7.2] years). Overall, 40.9% of patients died during follow-up. One- and five-year mortality rates were 19.8% and 33.7%, respectively. While most early deaths could be attributed to PE or associated complications, cancer was the predominant cause of death between 30 days and 3 years after PE, whereas cardiovascular events and infections were the most frequent causes of death after more than 3 years (Figure 1).
In patients who survived the first 30 days after PE, the observed number of deaths was higher than the expected mortality in the general population throughout the follow-up period (Figure 2; 5-year SMR 2.77 [95% CI 2.42–3.15]). The strongest predictor of late mortality was active cancer at the time of PE, that was associated with a Hazard Ratio [HR] of 4.03 [95% CI 3.07–5.28]) for death after >30 days. Of note, active cancer was only associated with an increased mortality risk during the first three years of follow-up, but did not predict death after more than three years. In non-cancer patients, mortality was also elevated compared to the general population (5-year SMR 1.80 [95% CI 1.51–2.14]) and late mortality was predicted by chronic pulmonary disease (HR 2.22 [95% CI 1.51–3.27]), chronic heart failure (HR 1.90 [95% CI 1.36–2.66]), age per decade (HR 1.79 [95% CI 1.54–2.09]) and anaemia (HR 1.59 [95% CI 1.16–2.17]).
Conclusion
Even after survival of the acute phase, the mortality risk of PE patients remained elevated compared to the general population throughout the 14 year follow-up period. The main driver of late mortality is cancer. However, elevated mortality was also observed in in PE patients without cancer, in whom late mortality was predicted by chronic cardiopulmonary comorbidities, age and anaemia.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).
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Affiliation(s)
- M Ebner
- Charite - Campus Mitte (CCM), Department of Cardiology and Angiology , Berlin , Germany
| | - J Eckelt
- Georg-August University, Clinic of Cardiology and Pneumology, Heart Center , Gottingen , Germany
| | - L Hobohm
- University Medical Center Mainz, Center for Thrombosis and Hemostasis (CTH) , Mainz , Germany
| | - M C Merten
- Georg-August University, Clinic of Cardiology and Pneumology, Heart Center , Gottingen , Germany
| | - C F Pagel
- Georg-August University, Clinic of Cardiology and Pneumology, Heart Center , Gottingen , Germany
| | - A S Fischer
- Charite - Campus Virchow-Klinikum (CVK), Department of Cardiology , Berlin , Germany
| | - M H Lerchbaumer
- Charite - Campus Mitte (CCM), Department of Radiology , Berlin , Germany
| | - K Stangl
- Charite - Campus Mitte (CCM), Department of Cardiology and Angiology , Berlin , Germany
| | - G Hasenfuss
- Georg-August University, Clinic of Cardiology and Pneumology, Heart Center , Gottingen , Germany
| | - S V Konstantinides
- University Medical Center Mainz, Center for Thrombosis and Hemostasis (CTH) , Mainz , Germany
| | - I Schmidtmann
- University Medical Center Mainz, Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI) , Mainz , Germany
| | - M Lankeit
- Georg-August University, Clinic of Cardiology and Pneumology, Heart Center , Gottingen , Germany
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8
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Pohl KR, Hobohm L, Krieg VJ, Sentler C, Rogge NI, Steimke L, Ebner M, Lerchbaumer M, Hasenfuß G, Konstantinides S, Lankeit M, Keller K. Impact of thyroid dysfunction on short-term outcomes and long-term mortality in patients with pulmonary embolism. Thromb Res 2022; 211:70-78. [DOI: 10.1016/j.thromres.2022.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 12/16/2021] [Accepted: 01/12/2022] [Indexed: 10/19/2022]
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9
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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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10
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Hobohm L, Lankeit M. [Pulmonary Embolism]. Pneumologie 2021; 75:800-818. [PMID: 34662916 DOI: 10.1055/a-1029-9937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pulmonary embolism (PE) is a life-threatening disease and the third most frequent cardiovascular cause of death after stroke and myocardial infarction. The annual incidence is increasing (in Germany from 85 cases per 100000 population in the year 2005 to 109 cases per 100000 population in the year 2015). The individual risk for PE-related complications and death increases with the number of comorbidities and severity of right ventricular dysfunction. Using clinical, laboratory and imaging parameters, patients with PE can be stratified to four risk classes (high, intermediate-high, intermediate-low and low risk). This risk stratification has concrete therapeutic consequences ranging from out-of-hospital treatment of low-risk patients to reperfusion treatment of (intermediate)-high-risk patients. For haemodynamically unstable patients, treatment decision should preferably be made in interdisciplinary "Pulmonary Embolism Response Teams" (PERT). Due to their comparable efficacy and preferable safety profile compared to vitamin-K antagonists (VKAs), non-vitamin K-dependent oral anticoagulants (NOACs) are increasingly considered the treatment of choice for initial and prolonged anticoagulation of patients with pulmonary embolism. Use of low molecular weight heparins (LMWHs) is recommended for PE patients with cancer; however, recent studies indicate that treatment with factor Xa-inhibitors may be effective and safe (in patients without gastrointestinal cancer). Only prolonged anticoagulation (in reduced dosage) will ensure reduction of VTE recurrence and should thus be considered for all patients with unprovoked events.
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11
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Sanchez O, Charles-Nelson A, Ageno W, Barco S, Binder H, Chatellier G, Duerschmied D, Empen K, Ferreira M, Girard P, Huisman MV, Jiménez D, Katsahian S, Kozak M, Lankeit M, Meneveau N, Pruszczyk P, Petris A, Righini M, Rosenkranz S, Schellong S, Stefanovic B, Verhamme P, de Wit K, Vicaut E, Zirlik A, Konstantinides SV, Meyer G. Reduced-Dose Intravenous Thrombolysis for Acute Intermediate-High-risk Pulmonary Embolism: Rationale and Design of the Pulmonary Embolism International THrOmbolysis (PEITHO)-3 trial. Thromb Haemost 2021; 122:857-866. [PMID: 34560806 PMCID: PMC9197594 DOI: 10.1055/a-1653-4699] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Intermediate–high-risk pulmonary embolism (PE) is characterized by right ventricular (RV) dysfunction and elevated circulating cardiac troponin levels despite apparent hemodynamic stability at presentation. In these patients, full-dose systemic thrombolysis reduced the risk of hemodynamic decompensation or death but increased the risk of life-threatening bleeding. Reduced-dose thrombolysis may be capable of improving safety while maintaining reperfusion efficacy. The Pulmonary Embolism International THrOmbolysis (PEITHO)-3 study (ClinicalTrials.gov Identifier: NCT04430569) is a randomized, placebo-controlled, double-blind, multicenter, multinational trial with long-term follow-up. We will compare the efficacy and safety of a reduced-dose alteplase regimen with standard heparin anticoagulation. Patients with intermediate–high-risk PE will also fulfill at least one clinical criterion of severity: systolic blood pressure ≤110 mm Hg, respiratory rate >20 breaths/min, or history of heart failure. The primary efficacy outcome is the composite of all-cause death, hemodynamic decompensation, or PE recurrence within 30 days of randomization. Key secondary outcomes, to be included in hierarchical analysis, are fatal or GUSTO severe or life-threatening bleeding; net clinical benefit (primary efficacy outcome plus severe or life-threatening bleeding); and all-cause death, all within 30 days. All outcomes will be adjudicated by an independent committee. Further outcomes include PE-related death, hemodynamic decompensation, or stroke within 30 days; dyspnea, functional limitation, or RV dysfunction at 6 months and 2 years; and utilization of health care resources within 30 days and 2 years. The study is planned to enroll 650 patients. The results are expected to have a major impact on risk-adjusted treatment of acute PE and inform guideline recommendations.
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Affiliation(s)
- Olivier Sanchez
- AP-HP, hôpital européen Georges-Pompidou, Service de Pneumologie et de Soins Intensifs, APHP.Centre - Université de Paris, Paris, France.,INSERM UMR S 1140 Innovative Therapies in Hemostasis, Paris, France.,Université de Paris, Paris, France.,FCRIN INNOVTE, St-Etienne, France
| | - Anaïs Charles-Nelson
- AP-HP, hôpital européen Georges-Pompidou, Unité de Recherche Clinique, APHP.Centre, Paris, France.,INSERM, Centre d'Investigation Clinique 1418 (CIC1418) Épidémiologie Clinique, Paris, France
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Harald Binder
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Gilles Chatellier
- Université de Paris, Paris, France.,AP-HP, hôpital européen Georges-Pompidou, Unité de Recherche Clinique, APHP.Centre, Paris, France.,INSERM, Centre d'Investigation Clinique 1418 (CIC1418) Épidémiologie Clinique, Paris, France
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Empen
- Department of Internal Medicine, Städtisches Klinikum Dessau, Germany
| | - Melanie Ferreira
- Internal Medicine Department, Hospital Garcia de Orta, Almada, Portugal
| | - Philippe Girard
- FCRIN INNOVTE, St-Etienne, France.,Département Thoracique, Institut Mutualiste Montsouris, Paris, France
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Dutch Thrombosis Network, Leiden, The Netherlands
| | - David Jiménez
- Department of Respiratory Diseases, Ramon y Cajal Hospital, Universidad de Alcalá (IRYCIS), CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Sandrine Katsahian
- Université de Paris, Paris, France.,AP-HP, hôpital européen Georges-Pompidou, Unité de Recherche Clinique, APHP.Centre, Paris, France.,INSERM, Centre d'Investigation Clinique 1418 (CIC1418) Épidémiologie Clinique, Paris, France.,INSERM UMR_S 1138 équipe 22, Centre de Recherche des Cordeliers, Paris, France
| | - Matija Kozak
- Department of Vascular Diseases, University Medical Center, Ljubljana, Slovenia
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Department of Internal Medicine, Vascular Medicine and Haemostaseology, Vivantes Klinikum im Friedrichshain, Berlin, Germany.,Clinic of Cardiology and Pneumology, University Medical Center Goettingen, Goettingen, Germany
| | - Nicolas Meneveau
- FCRIN INNOVTE, St-Etienne, France.,Department of Cardiology, University Hospital Jean Minjoz, Besançon, France.,EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Antoniu Petris
- Grigore T. Popa University of Medicine and Pharmacy Iasi, Cardiology Clinic, "St. Spiridon" County Clinical Emergency Hospital, Iasi, Romania
| | - Marc Righini
- Division of Angiology and Haemostasis, Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - Stephan Rosenkranz
- Department III of Internal Medicine and Cologne Cardiovascular Research Center (CCRC), Cologne University Heart Center, Cologne, Germany
| | - Sebastian Schellong
- Department of Internal Medicine 2, Municipal Hospital Dresden, Dresden, Germany
| | - Branislav Stefanovic
- Cardiology Clinic, Emergency Center, University Clinical Center of Serbia, School of Medicine University Belgrade, Belgrade, Serbia
| | - Peter Verhamme
- Vascular Medicine and Haemostasis, Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Kerstin de Wit
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Eric Vicaut
- AP-HP, Unité de Recherche Clinique St-Louis-Lariboisière, Université Denis Diderot, Paris, France
| | - Andreas Zirlik
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Guy Meyer
- AP-HP, hôpital européen Georges-Pompidou, Service de Pneumologie et de Soins Intensifs, APHP.Centre - Université de Paris, Paris, France.,Université de Paris, Paris, France.,FCRIN INNOVTE, St-Etienne, France
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12
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Keller K, Hobohm L, Münzel T, Lankeit M, Konstantinides S, Ostad MA. Impact of Systemic Atherosclerosis on Clinical Characteristics and Short-term Outcomes in Patients with Deep Venous Thrombosis or Thrombophlebitis. Am J Med Sci 2021; 363:232-241. [PMID: 34551354 DOI: 10.1016/j.amjms.2021.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 07/07/2020] [Revised: 05/27/2021] [Accepted: 09/14/2021] [Indexed: 01/25/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) and atherosclerosis are accompanied by substantial cardiovascular mortality; links between both disease entities were reported. We aimed to investigate the impact of systemic atherosclerosis on adverse outcomes in patients with deep venous thrombosis or thrombophlebitis (DVT) and to identify differences in DVT patients with and without systemic atherosclerosis. METHODS The German nationwide inpatient sample was used for this analysis. Patients admitted for DVT were included in this study and stratified by systemic atherosclerosis (composite of coronary artery disease, myocardial infarction, ischemic stroke, and/or atherosclerotic arterial diseases). We compared DVT patients with (DVT+Athero) and without (DVT-Athero) systemic atherosclerosis and analysed the impact of systemic atherosclerosis on adverse outcomes. RESULTS Overall, 489,679 patients with DVT (55.7% females) were included in this analysis. Among these, 53,309 (10.9%) were coded with concomitant systemic atherosclerosis with age-dependent incline. Concomitant PE (4.1% vs.3.8%, P=0.001) was more frequently in DVT-Athero and risk for PE in DVT patients was independently associated with absence of systemic atherosclerosis (OR 0.87 [95%CI 0.83-0.91], P<0.001). In-hospital mortality (3.4% vs.1.4%, P<0.001) and adverse in-hospital events (2.2% vs.0.8%,P<0.001) were more prevalent in DVT+Athero compared to DVT-Athero; both, in-hospital mortality (OR 1.52 [95%CI 1.41-1.63], P<0.001) and adverse in-hospital events (OR 1.49 [95%CI 1.40-1.58], P<0.001) were affected independently of sex, age and comorbidities by systemic atherosclerosis. CONCLUSIONS Systemic atherosclerosis in DVT patients was accompanied by poorer outcomes. Systemic atherosclerosis was associated with higher bleeding rate and with isolated DVT (without concomitant PE).
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany.
| | - Lukas Hobohm
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Department of Cardiology, Democritus University Thrace, Alexandroupolis, Greece
| | - Mir Abolfazl Ostad
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
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13
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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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14
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Ebner M, Sentler C, Harjola VP, Bueno H, Lerchbaumer MH, Hasenfuß G, Eckardt KU, Konstantinides SV, Lankeit M. Outcome of patients with different clinical presentations of high-risk pulmonary embolism. Eur Heart J Acute Cardiovasc Care 2021; 10:787-796. [PMID: 34125186 PMCID: PMC8483764 DOI: 10.1093/ehjacc/zuab038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 02/28/2021] [Indexed: 01/01/2023]
Abstract
Aims The 2019 European Society of Cardiology (ESC) guidelines provide a revised definition of high-risk pulmonary embolism (PE) encompassing three clinical presentations: Cardiac arrest, obstructive shock, and persistent hypotension. This study investigated the prognostic implications of this new definition. Methods and results Data from 784 consecutive PE patients prospectively enrolled in a single-centre registry were analysed. Study outcomes include an in-hospital adverse outcome (PE-related death or cardiopulmonary resuscitation) and in-hospital all-cause mortality. Overall, 86 patients (11.0%) presented with high-risk PE and more often had an adverse outcome (43.0%) compared to intermediate-high-risk patients (6.1%; P < 0.001). Patients with cardiac arrest had the highest rate of an in-hospital adverse outcome (78.4%) and mortality (59.5%; both P < 0.001 compared to intermediate-high-risk patients). Obstructive shock and persistent hypotension had similar rates of adverse outcomes (15.8% and 18.2%, respectively; P = 0.46), but the only obstructive shock was associated with an increased all-cause mortality risk. Use of an optimised venous lactate cut-off value (3.8 mmol/L) to diagnose obstructive shock allowed differentiation of adverse outcome risk between patients with shock (21.4%) and persistent hypotension (9.5%), resulting in a net reclassification improvement (0.24 ± 0.08; P = 0.002). Conclusion The revised ESC 2019 guidelines definition of high-risk PE stratifies subgroups at different risk of in-hospital adverse outcomes and all-cause mortality. Risk prediction can be improved by using an optimised venous lactate cut-off value to diagnose obstructive shock, which might help to better assess the risk-to-benefit ratio of systemic thrombolysis in different subgroups of high-risk patients.
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Affiliation(s)
- Matthias Ebner
- Department of Cardiology and Angiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
| | - Carmen Sentler
- Clinic of Cardiology and Pneumology, University Medical Center, Göttingen, Germany
| | - Veli-Pekka Harjola
- Department of Emergency Medicine and Services, University of Helsinki, Emergency Medicine, Helsinki University Hospital, Helsinki, Finland
| | - Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital, 12 de Octubre (imas12), Madrid, Spain.,Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Markus H Lerchbaumer
- Department of Radiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Germany
| | - Gerd Hasenfuß
- Clinic of Cardiology and Pneumology, University Medical Center, Göttingen, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Göttingen, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité - University Medicine Berlin, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Mareike Lankeit
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Germany.,Clinic of Cardiology and Pneumology, University Medical Center, Göttingen, Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
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15
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Lerchbaumer MH, Ebner M, Ritter CO, Steimke L, Rogge NIJ, Sentler C, Thielmann A, Hobohm L, Keller K, Lotz J, Hasenfuß G, Wachter R, Hamm B, Konstantinides SV, Aviram G, Lankeit M. Prognostic value of right atrial dilation in patients with pulmonary embolism. ERJ Open Res 2021; 7:00414-2020. [PMID: 34046488 PMCID: PMC8141828 DOI: 10.1183/23120541.00414-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/15/2020] [Indexed: 11/05/2022] Open
Abstract
Aims Right atrial (RA) dilation and stretch provide prognostic information in patients with cardiovascular diseases. We investigated the prevalence, confounding factors and prognostic relevance of RA dilation in patients with pulmonary embolism (PE). Methods Overall, 609 PE patients were consecutively included in a prospective single-centre registry between September 2008 and August 2017. Volumetric measurements of heart chambers were performed on routine non-electrocardiographic-gated computed tomography and plasma concentrations of mid-regional pro-atrial natriuretic peptide (MR-proANP) measured on admission. An in-hospital adverse outcome was defined as PE-related death, cardiopulmonary resuscitation, mechanical ventilation or catecholamine administration. Results Patients with an adverse outcome (11.2%) had larger RA volumes (median 120 (interquartile range 84-152) versus 102 (78-134) mL; p=0.013), RA/left atrial (LA) volume ratios (1.7 (1.2-2.4) versus 1.3 (1.1-1.7); p<0.001) and MR-proANP levels (282 (157-481) versus 129 (64-238) pmol·L-1; p<0.001) compared to patients with a favourable outcome. Overall, 499 patients (81.9%) had a RA/LA volume ratio ≥1.0 and a calculated cut-off value of 1.8 (area under the curve 0.64, 95% CI 0.56-0.71) predicted an adverse outcome, both in unselected (OR 3.1, 95% CI 1.9-5.2) and normotensive patients (OR 2.7, 95% CI 1.3-5.6). MR-proANP ≥120 pmol·L-1 was identified as an independent predictor of an adverse outcome, both in unselected (OR 4.6, 95% CI 2.3-9.3) and normotensive patients (OR 5.1, 95% CI 1.5-17.6). Conclusions RA dilation is a frequent finding in patients with PE. However, the prognostic performance of RA dilation appears inferior compared to established risk stratification markers. MR-proANP predicted an in-hospital adverse outcome, both in unselected and normotensive PE patients, integrating different prognostic relevant information from comorbidities.
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Affiliation(s)
| | - Matthias Ebner
- Dept of Nephrology and Medical Intensive Care, Charité - University Medicine Berlin, Berlin, Germany.,Dept of Internal Medicine and Cardiology, Charité - University Medicine Berlin, Berlin, Germany
| | - Christian O Ritter
- Institute for Diagnostic and Interventional Radiology, University Medical Center Göttingen, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Laura Steimke
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Nina I J Rogge
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Carmen Sentler
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Aaron Thielmann
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Cardiology I, Center for Cardiology, University Medical Center Mainz, Mainz, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Cardiology I, Center for Cardiology, University Medical Center Mainz, Mainz, Germany
| | - Joachim Lotz
- Institute for Diagnostic and Interventional Radiology, University Medical Center Göttingen, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Gerd Hasenfuß
- German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany.,Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Rolf Wachter
- German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany.,Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany.,Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Bernd Hamm
- Dept of Radiology, Charité - University Medicine Berlin, Berlin, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Dept of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Galit Aviram
- Dept of Radiology, Tel Aviv Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mareike Lankeit
- Dept of Internal Medicine and Cardiology, Charité - University Medicine Berlin, Berlin, Germany.,Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
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16
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Hobohm L, Kölmel S, Niemann C, Kümpers P, Krieg VJ, Bochenek ML, Lukasz AH, Reiss Y, Plate KH, Liebetrau C, Wiedenroth CB, Guth S, Münzel T, Hasenfuß G, Wenzel P, Mayer E, Konstantinides SV, Schäfer K, Lankeit M. Role of angiopoietin-2 in venous thrombus resolution and chronic thromboembolic disease. Eur Respir J 2021; 58:13993003.04196-2020. [PMID: 33986029 DOI: 10.1183/13993003.04196-2020] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 04/10/2021] [Indexed: 11/05/2022]
Abstract
Defective angiogenesis, incomplete thrombus revascularisation and fibrosis are considered critical pathomechanisms of chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE). Angiopoietin-2 (ANGPT2) has been shown to regulate angiogenesis, but its importance for thrombus resolution and remodelling is unknown.ANGPT2 plasma concentrations were measured in patients with CTEPH (n=68) and acute PE (n=84). Tissue removed during pulmonary endarterectomy (PEA) for CTEPH was analysed (immuno)histologically. A mouse model of inferior vena cava ligation was used to study the kinetics of venous thrombus resolution in wild-type mice receiving recombinant ANGPT2 via osmotic pumps, and in transgenic mice overexpressing ANGPT2 in endothelial cells.Circulating ANGPT2 levels were higher in CTEPH patients compared to patients with idiopathic pulmonary arterial hypertension and healthy controls, and decreased after PEA. Plasma ANGPT2 levels were also elevated in patients with PE and diagnosis of CTEPH during follow-up. Histological analysis of PEA specimens confirmed increased ANGPT2 expression, and low levels of phosphorylated TIE2 were observed in regions with early-organised pulmonary thrombi, myofibroblasts and fibrosis. Microarray and high-resolution microscopy analysis could localise ANGPT2 overexpression to endothelial cells, and hypoxia and TGF-β1 were identified as potential stimuli. Gain-of-function experiments in mice demonstrated that exogenous ANGPT2 administration and transgenic endothelial ANGPT2 overexpression resulted in delayed venous thrombus resolution, and thrombi were characterised by lower TIE2 phosphorylation and fewer microvessels.Our findings suggest that ANGPT2 delays venous thrombus resolution and that overexpression of ANGPT2 contributes to thrombofibrosis and may thus support the transition from PE to CTEPH.
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Affiliation(s)
- Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center, Mainz, Germany.,Department of Cardiology, Cardiology I, University Medical Center, Mainz, Germany
| | - Sebastian Kölmel
- Internal Medicine & Endocrinology/Diabetes, Kantonsspital St.Gallen, Sankt Gallen, Switzerland
| | - Caroline Niemann
- Clinic of Gynaecology, St. Franziskus Hospital Münster, Münster, Germany
| | - Philipp Kümpers
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital Münster, Münster, Germany
| | - Valentin J Krieg
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Magdalena L Bochenek
- Center for Thrombosis and Hemostasis (CTH), University Medical Center, Mainz, Germany.,Department of Cardiology, Cardiology I, University Medical Center, Mainz, Germany.,German Cardiovascular Research Centre, partner site Rhine-Main, Germany
| | - Alexander H Lukasz
- Department of Medicine D, Division of General Internal Medicine, Nephrology and Rheumatology, University Hospital Münster, Münster, Germany
| | - Yvonne Reiss
- German Cardiovascular Research Centre, partner site Rhine-Main, Germany.,Institute of Neurology (Edinger Institute), University Hospital, Goethe University, Frankfurt, Germany
| | - Karl-Heinz Plate
- German Cardiovascular Research Centre, partner site Rhine-Main, Germany.,Institute of Neurology (Edinger Institute), University Hospital, Goethe University, Frankfurt, Germany
| | - Christoph Liebetrau
- German Cardiovascular Research Centre, partner site Rhine-Main, Germany.,Department of Cardiology, Kerckhoff Clinic, Bad Nauheim, Germany.,Department of Cardiology, Justus-Liebig University of Giessen, Giessen, Germany
| | | | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center, Mainz, Germany.,German Cardiovascular Research Centre, partner site Rhine-Main, Germany
| | - Gerd Hasenfuß
- Clinic of Cardiology and Pneumology, Heart Center, University Medical Center Göttingen, Goettingen, Germany.,German Cardiovascular Research Centre, partner site Goettingen, Germany
| | - Philip Wenzel
- Center for Thrombosis and Hemostasis (CTH), University Medical Center, Mainz, Germany.,Department of Cardiology, Cardiology I, University Medical Center, Mainz, Germany.,German Cardiovascular Research Centre, partner site Rhine-Main, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center, Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Katrin Schäfer
- Department of Cardiology, Cardiology I, University Medical Center, Mainz, Germany.,German Cardiovascular Research Centre, partner site Rhine-Main, Germany
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center, Mainz, Germany .,Clinic of Cardiology and Pneumology, Heart Center, University Medical Center Göttingen, Goettingen, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité - University Medicine, Berlin, Germany.,German Cardiovascular Research Centre, partner site Berlin, Germany
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17
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Hobohm L, Keller K, Münzel T, Konstantinides SV, Lankeit M. Time trends of pulmonary endarterectomy in patients with chronic thromboembolic pulmonary hypertension. Pulm Circ 2021; 11:20458940211008069. [PMID: 33996027 PMCID: PMC8108078 DOI: 10.1177/20458940211008069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/16/2021] [Indexed: 11/17/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension is considered as a rare but severe complication after acute pulmonary embolism and is potentially curable by pulmonary endarterectomy. We aimed to evaluate, over an 11-year period, time trends of in-hospital outcomes of pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension patients and to investigate predictors of the in-hospital course. We analyzed data on the characteristics, comorbidities, treatments, and in-hospital outcomes for all chronic thromboembolic pulmonary hypertension patients treated with pulmonary endarterectomy in the German nationwide inpatient sample between 2006 and 2016. Overall, 1398 inpatients were included. Annual number of pulmonary endarterectomy increased from 67 in 2006 to 194 in 2016 (P < 0.001), in parallel with a significant decrease of in-hospital mortality (10.9% in 2008 to 1.5% in 2016; P < 0.001). Patients' characteristics shifted slightly toward older age and higher prevalence of chronic renal insufficiency and obesity over time, whereas duration of hospital stay decreased over time. Independent predictors of in-hospital mortality were age (OR 1.03 (95%CI: 1.01-1.05); P = 0.001), right heart failure (2.55 (1.37-4.76); P = 0.003), in-hospital complications such as ischemic stroke (6.87 (1.06-44.70); P = 0.044) and bleeding events like hemopneumothorax (24.93 (6.18-100.57); P < 0.001). Annual pulmonary endarterectomy volumes per center below 10 annual procedures were associated with higher rates of adverse in-hospital outcomes. Annual numbers of chronic thromboembolic pulmonary hypertension patients treated with pulmonary endarterectomy increased markedly in Germany between 2006 and 2016, in parallel with a decrease of in-hospital mortality. Our findings suggest that perioperative management of pulmonary endarterectomy, institutional experience, and patient selection is crucial and has improved over time.
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Affiliation(s)
- Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Department of Cardiology, University Medical Center Mainz, Mainz, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Department of Cardiology, University Medical Center Mainz, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Frankfurt, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
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18
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Ebner M, Pagel CF, Sentler C, Harjola VP, Bueno H, Lerchbaumer MH, Stangl K, Pieske B, Hasenfuß G, Konstantinides SV, Lankeit M. Venous lactate improves the prediction of in-hospital adverse outcomes in normotensive pulmonary embolism. Eur J Intern Med 2021; 86:25-31. [PMID: 33558162 DOI: 10.1016/j.ejim.2021.01.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/07/2021] [Accepted: 01/20/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Arterial lactate is an established risk marker in patients with pulmonary embolism (PE). However, its clinical applicability is limited by the need of an arterial puncture. In contrast, venous lactate can easily be measured from blood samples obtained via routine peripheral venepuncture. METHODS We investigated the prognostic value of venous lactate with regard to in-hospital adverse outcomes and mortality in 419 consecutive PE patients enrolled in a single-center registry between 09/2008 and 09/2017. RESULTS An optimised venous lactate cut-off value of 3.3 mmol/l predicted both, in-hospital adverse outcome (OR 11.0 [95% CI 4.6-26.3]) and all-cause mortality (OR 3.8 [95%CI 1.3-11.3]). The established cut-off value for arterial lactate (2.0 mmol/l) and the upper limit of normal for venous lactate (2.3 mmol/l) had lower prognostic value for adverse outcomes (OR 3.6 [95% CI 1.5-8.7] and 5.7 [95% CI 2.4-13.6], respectively) and did not predict mortality. If added to the 2019 European Society of Cardiology (ESC) algorithm, venous lactate <2.3 mmol/l was associated with a high negative predictive value (0.99 [95% CI 0.97-1.00]) for adverse outcomes in intermediate-low-risk patients, whereas levels ≥3.3 mmol/l predicted adverse outcomes in the intermediate-high-risk group (OR 5.2 [95% CI 1.8-15.0]). CONCLUSION Venous lactate above the upper limit of normal was associated with increased risk for adverse outcomes and an optimised cut-off value of 3.3 mmol/l predicted adverse outcome and mortality. Adding venous lactate to the 2019 ESC algorithm may improve risk stratification. Importantly, the established cut-off value for arterial lactate has limited specificity in venous samples and should not be used.
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Affiliation(s)
- Matthias Ebner
- Department of Cardiology and Angiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner site Berlin, Germany
| | - Charlotta F Pagel
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Germany
| | - Carmen Sentler
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Germany
| | - Veli-Pekka Harjola
- University of Helsinki, Emergency Medicine, Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Markus H Lerchbaumer
- Department of Radiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Germany
| | - Karl Stangl
- Department of Cardiology and Angiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Germany
| | - Burkert Pieske
- German Center for Cardiovascular Research (DZHK), Partner site Berlin, Germany; Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Germany; Berlin Institute of Health, Berlin, Germany
| | - Gerd Hasenfuß
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Germany; German Center for Cardiovascular Research (DZHK), Partner site Göttingen, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Mareike Lankeit
- German Center for Cardiovascular Research (DZHK), Partner site Berlin, Germany; Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Germany; Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.
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19
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Barco S, Schmidtmann I, Ageno W, Bauersachs RM, Becattini C, Bernardi E, Beyer-Westendorf J, Bonacchini L, Brachmann J, Christ M, Czihal M, Duerschmied D, Empen K, Espinola-Klein C, Ficker JH, Fonseca C, Genth-Zotz S, Jiménez D, Harjola VP, Held M, Iogna Prat L, Lange TJ, Manolis A, Meyer A, Mustonen P, Rauch-Kroehnert U, Ruiz-Artacho P, Schellong S, Schwaiblmair M, Stahrenberg R, Westerweel PE, Wild PS, Konstantinides SV, Lankeit M. Early discharge and home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban: an international multicentre single-arm clinical trial. Eur Heart J 2021; 41:509-518. [PMID: 31120118 DOI: 10.1093/eurheartj/ehz367] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 04/27/2019] [Accepted: 05/13/2019] [Indexed: 12/30/2022] Open
Abstract
AIMS To investigate the efficacy and safety of early transition from hospital to ambulatory treatment in low-risk acute PE, using the oral factor Xa inhibitor rivaroxaban. METHODS AND RESULTS We conducted a prospective multicentre single-arm investigator initiated and academically sponsored management trial in patients with acute low-risk PE (EudraCT Identifier 2013-001657-28). Eligibility criteria included absence of (i) haemodynamic instability, (ii) right ventricular dysfunction or intracardiac thrombi, and (iii) serious comorbidities. Up to two nights of hospital stay were permitted. Rivaroxaban was given at the approved dose for PE for ≥3 months. The primary outcome was symptomatic recurrent venous thromboembolism (VTE) or PE-related death within 3 months of enrolment. An interim analysis was planned after the first 525 patients, with prespecified early termination of the study if the null hypothesis could be rejected at the level of α = 0.004 (<6 primary outcome events). From May 2014 through June 2018, consecutive patients were enrolled in seven countries. Of the 525 patients included in the interim analysis, three (0.6%; one-sided upper 99.6% confidence interval 2.1%) suffered symptomatic non-fatal VTE recurrence, a number sufficiently low to fulfil the condition for early termination of the trial. Major bleeding occurred in 6 (1.2%) of the 519 patients comprising the safety population. There were two cancer-related deaths (0.4%). CONCLUSION Early discharge and home treatment with rivaroxaban is effective and safe in carefully selected patients with acute low-risk PE. The results of the present trial support the selection of appropriate patients for ambulatory treatment of PE.
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Affiliation(s)
- Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Mainz, Obere Zahlbacher Strasse 69, 55131 Mainz, Germany
| | - Walter Ageno
- Department of Medicine and Surgery, Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
| | - Rupert M Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt, Grafenstrasse 9, 64283 Darmstadt, Germany
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Via G. Dottori 1, 06129 Perugia, Italy
| | - Enrico Bernardi
- Department of Emergency Medicine, ULSS n.7, Via Brigata Bisagno 4, 31015 Conegliano (Treviso), Italy
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division of Hematology, Department of Medicine I, University Hospital "Carl Gustav Carus", Fetscherstrasse 74, 01307 Dresden, Germany.,Kings Thrombosis Service, Department of Hematology, Kings College London, Denmark Hill, Brixton, SE5 9RS, London, UK
| | - Luca Bonacchini
- S.C. Medicina d'Urgenza e Pronto Soccorso, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore 3, 20162 Milano, Italy
| | - Johannes Brachmann
- II Medical Department, Coburg Hospital, Ketschendorfer Strasse 33, 96450 Coburg, Germany
| | - Michael Christ
- Emergency Care (Notfallzentrum), Luzerner Kantonsspital, 6000 Luzern, Switzerland
| | - Michael Czihal
- Division of Vascular Medicine, Hospital of the Ludwig-Maximilians-University, Georgenstrasse 5, 80799 Munich, Germany
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany
| | - Klaus Empen
- Department of Internal Medicine, University Medical Center, Fleischmannstrasse 6, 17489 Greifswald, Germany
| | - Christine Espinola-Klein
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany.,Center for Cardiology, Cardiology 1, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Joachim H Ficker
- Department of Respiratory Medicine, Nuremberg General Hospital/Paracelsus Medical University, Prof.-Ernst-Nathan-Strasse 1, 90419 Nuremberg, Germany
| | - Cândida Fonseca
- Department of Internal Medicine, Hospital S. Francisco Xavier/CHLO, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria 130, 1169-056 Lisbon, Portugal
| | - Sabine Genth-Zotz
- Department of Internal Medicine I, Katholisches Klinikum Mainz, An der Goldrube 11, 55131 Mainz, Germany
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, Universidad de Alcala, IRYCIS, Ctra. Colmenar Viejo, km. 9, 100, 28034 Madrid, Spain
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Department of Emergency Medicine and Services, Helsinki University Hospital, Tukholmankatu 8A, 00290 Helsinki, Finland
| | - Matthias Held
- Department of Internal Medicine, Medical Mission Hospital, Academic Teaching Hospital of the Julius-Maximilian University of Wuerzburg, Josef-Schneider-Strasse 2, 97080 Wuerzburg, Germany
| | - Lorenzo Iogna Prat
- Department of Emergency Medicine, Santa Maria della Misericordia Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
| | - Tobias J Lange
- Department of Internal Medicine II, Division of Pneumology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Athanasios Manolis
- Department of Cardiology, General Hospital 'Asklepeion Voulas', Leof. Vasileos Pavlou 1, 166 73 Athens, Greece
| | - Andreas Meyer
- Kliniken Maria Hilf, Klinik für Pneumologie, Krankenhaus St. Franziskus, Viersener Str. 450, 41063 Mönchengladbach, Germany
| | - Pirjo Mustonen
- Department of Medicine, Keski-Suomi Central Hospital and University of Jyväskylä, Keskussairaalantie 19, 40620 Jyväskylä, Finland
| | - Ursula Rauch-Kroehnert
- Department of Cardiology, University Heart Center Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Pedro Ruiz-Artacho
- Emergency Department, Clinico San Carlos Hospital, IdISSC, alle del Prof Martín Lagos, s/n, 28040 Madrid, Spain.,Internal Medicine Department, University Clinic of Navarra, Calle Marquesado de Sta. Marta 1, 28027 Madrid, Spain
| | - Sebastian Schellong
- Vascular Center, Municipal Hospital of Dresden-Friedrichstadt, Friedrichstraße 41, 01067 Dresden, Germany
| | - Martin Schwaiblmair
- Department of Cardiology, Respiratory Medicine and Intensive Care, Klinikum Augsburg, Ludwig-Maximilians-University Munich, Stenglinstrasse 2, 86156 Munich, Germany
| | - Raoul Stahrenberg
- Helios Albert-Schweitzer-Klinik, Albert-Schweitzer-Weg 1, 37154 Northeim, Germany
| | - Peter E Westerweel
- Department of Internal Medicine, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands
| | - Philipp S Wild
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany.,Center for Cardiology, Preventive Cardiology and Preventive Medicine, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité - University Medicine Berlin, Augustenburgerplatz 1, 13353 Berlin, Germany.,Clinic of Cardiology and Pneumology, Heart Center, University Medical Center Goettingen, Robert-Koch-Strasse 40, 37075 Goettingen, Germany
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20
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2021; 41:543-603. [PMID: 31504429 DOI: 10.1093/eurheartj/ehz405] [Citation(s) in RCA: 1914] [Impact Index Per Article: 638.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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21
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Ebner M, Guddat N, Keller K, Merten MC, Lerchbaumer MH, Hasenfuß G, Konstantinides SV, Lankeit M. High-sensitivity troponin I for risk stratification in normotensive pulmonary embolism. ERJ Open Res 2021; 6:00625-2020. [PMID: 33447616 PMCID: PMC7792860 DOI: 10.1183/23120541.00625-2020] [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] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/06/2020] [Indexed: 11/14/2022] Open
Abstract
While numerous studies have confirmed the prognostic role of high-sensitivity troponin T (hsTnT) in pulmonary embolism (PE), high-sensitivity troponin I (hsTnI) is inappropriately studied. This study aimed to investigate the prognostic relevance of hsTnI in normotensive PE, establish the optimal cut-off value for risk stratification and to compare the prognostic performances of hsTnI and hsTnT. Based on data from 459 consecutive PE patients enrolled in a single-centre registry, receiver operating characteristic analysis was used to identify an optimal hsTnI cut-off value for prediction of in-hospital adverse outcomes (PE-related death, cardiopulmonary resuscitation or vasopressor treatment) and all-cause mortality. Patients who suffered an in-hospital adverse outcome (4.8%) had higher hsTnI concentrations compared with those with a favourable clinical course (57 (interquartile range (IQR) 22–197) versus 15 (IQR 10–86) pg·mL−1, p=0.03). A hsTnI cut-off value of 16 ng·mL−1 provided optimal prognostic performance and predicted in-hospital adverse outcomes (OR 6.5, 95% CI 1.9–22.4) and all-cause mortality (OR 3.7, 95% CI 1.0–13.3). Between female and male patients, no relevant differences in hsTnI concentrations (17 (IQR 10–97) versus 17 (IQR 10–92) pg·mL−1, p=0.79) or optimised cut-off values were observed. Risk stratification according to the 2019 European Society of Cardiology algorithm revealed no differences if calculated based on either hsTnI or hsTnT (p=0.68). Our findings confirm the prognostic role of hsTnI in normotensive PE. HsTnI concentrations >16 pg·mL−1 predicted in-hospital adverse outcome and all-cause mortality; sex-specific cut-off values do not seem necessary. Importantly, our results suggest that hsTnI and hsTnT can be used interchangeably for risk stratification. The study confirms the prognostic relevance of high-sensitivity troponin I in normotensive pulmonary embolism. A cut-off value of 16 pg·mL−1 can be used for risk stratification in male and female patients; sex-specific adjustments do not appear necessary.https://bit.ly/3lCECip
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Affiliation(s)
- Matthias Ebner
- Dept of Cardiology and Angiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin, Germany
| | - Niklas Guddat
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany.,Center for Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Marie Christine Merten
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Gerd Hasenfuß
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), partner site Goettingen, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany.,Dept of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Mareike Lankeit
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Germany.,Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany.,Dept of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Berlin, Germany
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22
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Hobohm L, Becattini C, Ebner M, Lerchbaumer MH, Casazza F, Hasenfuß G, Konstantinides SV, Lankeit M. Definition of tachycardia for risk stratification of pulmonary embolism. Eur J Intern Med 2020; 82:76-82. [PMID: 32843290 DOI: 10.1016/j.ejim.2020.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/19/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Tachycardia is a reliable predictor of adverse outcomes in normotensive patients with acute pulmonary embolism (PE). However, different prognostic relevant heart rate thresholds have been proposed. The aim of the study was to investigate the prognostic performance of different thresholds used for defining tachycardia in normotensive PE patients. METHODS We performed a post-hoc analysis of normotensive patients with confirmed PE consecutively included in a single-centre and a multi-centre registry. An adverse outcome was defined as PE-related death, need for mechanical ventilation, cardiopulmonary resuscitation or administration of catecholamines. RESULTS Of 1567 patients (median age: 72 [IQR, 59-79] years; females: 46.1%) included in the analysis, 78 patients (5.0%) had an in-hospital adverse outcome. The rate of an adverse outcome was higher in patients with a heart rate ≥100 bpm (7.6%) and ≥110 bpm (8.3%) compared to patients with a heart rate <100 bpm (3.0%). A heart rate ≥100 bpm and ≥110 bpm was associated with a 2.7 (95% CI 1.7-4.3) and 2.4-fold (95% CI 1.5-3.7) increased risk for an adverse outcome, respectively. Receiver operating characteristics analysis revealed a similar area under the curve with regard to an adverse outcome for all scores and algorithm (ESC 2019 algorithm, modified FAST and Bova score) if calculated with a heart rate threshold of ≥100 bpm or of ≥110 bpm. CONCLUSIONS Defining tachycardia by a heart rate ≥100 bpm is sufficient for risk stratification of normotensive patients with acute PE. The use of different heart rate thresholds for calculation of scores and algorithm does not appear necessary.
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Affiliation(s)
- Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Centre of the Johannes Gutenberg University Mainz, Germany; Center for Cardiology, Cardiology I, University Medical Centre of the Johannes Gutenberg-University Mainz, Germany
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Italy
| | - Matthias Ebner
- Department of Cardiology and Angiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Germany
| | - Markus H Lerchbaumer
- Department of Radiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Germany
| | - Franco Casazza
- Cardiology Department, San Carlo Borromeo Hospital, Milan, Italy
| | - Gerd Hasenfuß
- Clinic of Cardiology and Pneumology, University Medical Centre Göttingen, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Centre of the Johannes Gutenberg University Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Centre of the Johannes Gutenberg University Mainz, Germany; Clinic of Cardiology and Pneumology, University Medical Centre Göttingen, Germany; Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Germany.
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23
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Hobohm L, Schmidt FP, Gori T, Schmidtmann I, Barco S, Münzel T, Lankeit M, Konstantinides SV, Keller K. In-hospital outcomes of catheter-directed thrombolysis in patients with pulmonary embolism. Eur Heart J Acute Cardiovasc Care 2020; 10:258-264. [PMID: 33620441 DOI: 10.1093/ehjacc/zuaa026] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022]
Abstract
AIMS Catheter-directed treatment of acute pulmonary embolism (PE) is technically advancing. Recent guidelines acknowledge this treatment option for patients with overt or imminent haemodynamic decompensation, particularly when systemic thrombolysis is contraindicated. We investigated patients with PE who underwent catheter-directed thrombolysis (CDT) in the German nationwide inpatient cohort. METHODS AND RESULTS Data from hospitalizations with PE (International Classification of Disease code I26) between 2005 and 2016 were collected by the Federal Office of Statistics in Germany. Patients with PE who underwent CDT (OPS 8-838.60 or OPS code 8-83b.j) were compared with patients receiving systemic thrombolysis (OPS code 8-020.8), and those without thrombolytic or other reperfusion treatment. The analysis was not prespecified; therefore, our findings can only be considered to be hypothesis generating. We analysed data from 978 094 hospitalized patients with PE. Of these, 41 903 (4.3%) patients received thrombolytic treatment [systemic thrombolysis in 4.2%, CDT in 0.1% (1175 patients)]. Among patients with shock, CDT was associated with lower in-hospital mortality compared to systemic thrombolysis [odds ratios (OR) 0.30 (95% 0.14-0.67); P = 0.003]. Intracranial bleeding occurred in 14 (1.2%) patients who received CDT. Among haemodynamically stable patients with right ventricular dysfunction (intermediate-risk PE), CDT also was associated with a lower risk of in-hospital mortality compared to systemic thrombolysis {OR 0.55 [95% confidence interval (CI) 0.40-0.75]; P < 0.001} or no thrombolytic treatment [0.45 (95% CI 0.33-0.62); P < 0.001]. CONCLUSION In the German nationwide inpatient cohort, based on administrative data, CDT was associated with lower in-hospital mortality rates compared to systemic thrombolysis, but the overall rate of intracranial bleeding in patients who received CDT was not negligible. Prospective controlled data are urgently needed to determine the true value of this treatment option in acute PE.
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Affiliation(s)
- Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstrasse 1, 55131 Mainz, Germany.,Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), DZHK Standort Rhein-Main, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Frank P Schmidt
- Department of Cardiology, Mutterhaus Trier, Feldstraße 16, 54290 Trier, Germany
| | - Tommaso Gori
- Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), DZHK Standort Rhein-Main, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Irene Schmidtmann
- Institute for Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Johannes Gutenberg University Mainz, Obere Zahlbacherstraße 69, 55131 Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstrasse 1, 55131 Mainz, Germany.,Clinic of Angiology, University Hospital Zurich, Rämistraße 100, 8091 Zurich, Switzerland
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), DZHK Standort Rhein-Main, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstrasse 1, 55131 Mainz, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine, Augustenburgerplatz 1, 13353 Berlin, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstrasse 1, 55131 Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstrasse 1, 55131 Mainz, Germany.,Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), DZHK Standort Rhein-Main, Langenbeckstrasse 1, 55131 Mainz, Germany.,Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Dragana, 68100 8: Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
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24
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Ebner M, Pagel C, Sentler C, Harjola VP, Bueno H, Lerchbaumer M, Stangl K, Pieske B, Hasenfuss G, Konstantinides S, Lankeit M. Venous lactate predicts adverse outcomes in normotensive pulmonary embolism. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2241] [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: 11/13/2022] Open
Abstract
Abstract
Background/Introduction
Arterial lactate is an established risk marker in patients with acute pulmonary embolism (PE). However, its clinical application is limited by the need for an arterial puncture, a procedure not routinely performed in haemodynamically stable PE patients. In contrast, information on venous lactate can be easily obtained via peripheral venepuncture and might thus be more suitable for risk assessment in normotensive PE.
Purpose
To investigate the prognostic value of peripheral venous lactate for outcome prediction in normotensive patients with acute PE.
Methods
Consecutive normotensive PE patients enrolled in a prospective single-centre registry between 09/2008 and 03/2018 were studied. Study outcomes included in-hospital adverse outcome (PE-related death, cardiopulmonary resuscitation or vasopressor treatment) and all-cause mortality. An optimised venous lactate cut-off concentration was identified using receiver operating curve analysis and its prognostic value compared to the established cut-off value for arterial lactate (2.0 mmol/l) and the upper limit of normal for venous lactate (2.3 mmol/l). Furthermore, we tested if addition of venous lactate to the 2019 European Society of Cardiology (ESC) risk stratification algorithm improves risk prediction.
Results
We analysed data from 419 (age 70 [interquartile range (IQR) 57–79] years; 53% female) patients. Patients with an in-hospital adverse outcome had higher venous lactate concentrations than those with a favourable clinical course (3.1 [IQR 1.3–4.9] vs. 1.6 [IQR 1.2–2.3] mmol/l, p=0.001). An optimized cut-off value of 3.3 mmol/l predicted both, adverse outcome (OR 11.0 [95% CI 4.6–26.3]) and all-cause mortality (OR 3.8 [95% CI 1.3–11.3]). Venous lactate ≥2.0 mmol/l and ≥2.3 mmol/l had lower predictive value for an adverse outcome (OR 3.6 [95% CI 1.5–8.7] and OR 5.7 [95% CI 2.4–13.6], respectively) and did not predict all-cause mortality. If venous lactate was added to the 2019 ESC algorithm (Figure), a cut-off concentration of 2.3 mmol/l had high negative predictive value (0.99 [95% CI 0.97–1.00]) for an adverse outcome in intermediate-low-risk patients, whereas levels ≥3.3 mmol/l predicted adverse outcomes in the intermediate-high-risk group (OR 5.2 (95% CI 1.8–15.0).
Conclusions
Even modest venous lactate elevations above the upper limit of normal (2.3 mmol/l) were associated with increased risk for an in-hospital adverse outcome and a cut-off value of 3.3 mmol/l provided optimal prognostic performance predicting both, an adverse outcome and all-cause mortality. Adding venous lactate to the 2019 ESC algorithm seems to further improve risk stratification. Importantly, the established cut-off value for arterial lactate (2.0 mmol/l) has limited specificity in venous samples and should not be used.
Venous lactate for risk stratification
Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503). The authors are responsible for the contents of this publication. BRAHMS GmbH, part of Thermo Fisher Scientific, Hennigsdorf/Berlin, Germany provided financial support for biomarker measurements. The sponsor was neither involved in biomarker measurements, statistical analyses, writing of the abstract nor had any influence on the scientific contents.
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Affiliation(s)
- M Ebner
- Charite - Campus Mitte (CCM), Department of Cardiology and Angiology, Berlin, Germany
| | - C.F Pagel
- Georg-August University, Clinic of Cardiology and Pneumology, Heart Center, Gottingen, Germany
| | - C Sentler
- Georg-August University, Clinic of Cardiology and Pneumology, Heart Center, Gottingen, Germany
| | - V.-P Harjola
- Helsinki University Hospital, Department of Emergency Medicine and Services, Helsinki, Finland
| | - H Bueno
- University Hospital 12 de Octubre, Department of Cardiology, Madrid, Spain
| | - M.H Lerchbaumer
- Charite - Campus Mitte (CCM), Department of Radiology, Berlin, Germany
| | - K Stangl
- Charite - Campus Mitte (CCM), Department of Cardiology and Angiology, Berlin, Germany
| | - B Pieske
- Charite - Campus Virchow-Klinikum (CVK), Department of Cardiology, Berlin, Germany
| | - G Hasenfuss
- Georg-August University, Clinic of Cardiology and Pneumology, Heart Center, Gottingen, Germany
| | - S.V Konstantinides
- University Medical Center of Mainz, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - M Lankeit
- Charite - Campus Virchow-Klinikum (CVK), Department of Cardiology, Berlin, Germany
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Hobohm L, Schmidt F, Gori T, Schmidtmann I, Barco S, Munzel T, Lankeit M, Konstantinides S, Keller K. In-hospital outcomes of catheter-directed thrombolysis in patients with pulmonary embolism. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2258] [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 and purpose
Catheter-directed treatment of acute pulmonary embolism (PE) is technically advancing. Recent guidelines acknowledge this treatment option for patients with overt or imminent haemodynamic decompensation, particularly when systemic thrombolysis is contraindicated or has failed. We investigated baseline characteristics and in-hospital outcomes of patients with PE who underwent catheter-directed thrombolysis (CDT) in the German nationwide inpatient cohort.
Methods
Data from hospitalizations with PE between 2005 and 2016 were collected by the Federal Office of Statistics (Statistisches Bundesamt) in Germany and included in this analysis. Patients with PE who underwent CDT were compared with patients receiving systemic thrombolysis, and those without thromboytic or other reperfusion treatment.
Results
We analyzed data from 978,094 hospitalized patients with PE. Of these, 41,903 (4.3%) patients received thrombolytic treatment (systemic thrombolysis in 4.2%, CDT in 0.1%). Among PE patients with shock, CDT was associated with lower in-hospital mortality compared to systemic thrombolysis (OR, 0.29, 95% CI 0.13–0.66, P=0.003). No intracranial bleeding occurred among PE patients with shock who received CDT. Among haemodynamically stable PE patients with right ventricular (RV) dysfunction (intermediate-risk PE), CDT also was associated with a lower risk of in-hospital mortality compared to systemic thrombolysis (OR, 0.52 [95% CI 0.38–0.70]; P<0.001) or no thrombolytic treatment (0.45 [95% CI 0.33–0.62]; P<0.001).
Conclusion
In the German nationwide inpatient cohort, CDT was associated with lower in-hospital mortality rates compared to systemic thrombolysis. Prospective controlled data are urgently needed to determine the true value of this treatment option in acute PE.
Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).
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Affiliation(s)
- L Hobohm
- University Medical Center of Mainz, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - F Schmidt
- University Medical Center of Mainz, Center for Cardiology, Cardiology I, Mainz, Germany
| | - T Gori
- University Medical Center of Mainz, Center for Cardiology, Cardiology I, Mainz, Germany
| | - I Schmidtmann
- University Medical Center of Mainz, Institute for Medical Biostatistics, Epidemiology and Informatics (IMBEI), Mainz, Germany
| | - S Barco
- University Medical Center of Mainz, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - T Munzel
- University Medical Center of Mainz, Center for Cardiology, Cardiology I, Mainz, Germany
| | - M Lankeit
- Charite - Campus Virchow-Klinikum (CVK), Department of Internal Medicine and Cardiology, Berlin, Germany
| | - S.V Konstantinides
- University Medical Center of Mainz, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - K Keller
- University Medical Center of Mainz, Center for Cardiology, Cardiology I, Mainz, Germany
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Kriechbaum S, Rudolph F, Scherwitz L, Scheche L, Lippert C, Wiedenroth C, Haas M, Wolter J, Keller T, Hamm C, Konstantinidis S, Mayer E, Lankeit M, Liebetrau C. Copeptin as a non-invasive biomarker in chronic thromboembolic pulmonary hypertension. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2271] [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: 11/13/2022] Open
Abstract
Abstract
Introduction
Copeptin is the C-terminal fragment of the precursor protein of vasopressin. In acute pulmonary embolism, copeptin has been suggested to be a strong predictor of outcome and to provide additional predictive value to the established cardiac biomarkers high-sensitivity cardiac troponin and N-terminal pro-brain natriuretic peptide (NT-proBNP). Chronic thromboembolic pulmonary hypertension (CTEPH) is diagnosed in about 5% of patients who survive acute pulmonary embolism. Individualized risk stratification remains a challenge in the work-up of CTEPH patients.
Purpose
The current study investigated whether copeptin has the potential to aid the stratification of patients who have experienced pulmonary embolism and CTEPH patients. We examined the baseline (BL) levels and dynamics of copeptin during therapy in CTEPH patients who underwent balloon pulmonary angioplasty (BPA) or pulmonary endarterectomy (PEA). Moreover, the study compared copeptin levels between patients with or without therapy response.
Methods
The study included a total of 125 CTEPH patients scheduled for treatment. A total of 78 underwent staged BPA and 64 underwent PEA. In accordance with recent studies from our group, therapy success was defined as a decrease in meanPAP ≥25% and PVR ≥35% or a normalization below the thresholds defining pulmonary hypertension. Blood samples were collected at BL, prior to each BPA session in the BPA cohort, and at follow-up (FU) 6 months after BPA or 12 months after PEA. Copeptin was measured in thawed serum aliquots by an immunochemical method.
Results
The 78 patients in the BPA cohort underwent a mean of 6 BPA procedures each; there were a total of 413 interventions. The hemodynamic clinical and functional status the CTEPH patients improved after BPA and PEA therapy: meanPAP (BL: 43±9 mmHg vs. FU: 27±9 mmHg; p<0.001); PVR (BL: 7.6±3.4 WU vs. FU: 3.8±2.0 WU; p<0.001); RAP (BL: 7.9±5.8 mmHg vs. FU: 5.4±2.7 mmHg; p<0.001); WHO functional class [BL: I:0 / II:25 / III:80 / IV:20 vs. FU: I:56 / II:57 / III:10 / IV:2]; 6-minute-walk distance (BL: 405±99 m vs. FU: 456±112 m; p<0.001).
The median serum levels of copeptin [BL 7.7 (4.6–14.2) pmol/L vs. FU 6.3 (3.9–12.5); p=0.009] and NT-proBNP [BL: 811 (157–1857) ng/L vs. FU: 142 (72–335) ng/L p<0.001] decreased significantly after therapy. The copeptin levels did not correlate with hemodynamics at BL: PVR (rrs=0.02; p=0.79) and meanPAP (rrs=0.03; p=0.75). The copeptin levels at BL (AUC=0.61) and the relative change (AUC=0.53) did not predict the endpoint of therapy response.
Conclusions
Copeptin levels are elevated in CTEPH patients compared with normal values in the literature. Although copeptin is known to provide additional value in the context of risk stratification in acute pulmonary embolism, it failed to provide additional diagnostic benefit in CTEPH in the current study.
Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): SFB 1213 area CP01
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Affiliation(s)
- S.D Kriechbaum
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - F Rudolph
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - L Scherwitz
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - L Scheche
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - C.F Lippert
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - C.B Wiedenroth
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - M Haas
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - J.S Wolter
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - T Keller
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - C.W Hamm
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - S Konstantinidis
- University Medical Center Mainz, Center for Thrombosis and Haemostasis, Mainz, Germany
| | - E Mayer
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - M Lankeit
- Charite - Campus Virchow-Klinikum (CVK), Internal Medicine and Cardiology, Berlin, Germany
| | - C Liebetrau
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
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Hobohm L, Keller K, Munzel T, Konstantinides S, Lankeit M. Time trends of pulmonary endarterectomy in patients with chronic thromboembolic pulmonary hypertension. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2265] [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: 11/13/2022] Open
Abstract
Abstract
Background and purpose
Chronic thromboembolic pulmonary hypertension (CTEPH) is considered as a rare but severe complication after acute pulmonary embolism (PE) and is potentially curable by pulmonary endarterectomy (PEA). We aimed to evaluate, over an 11-year period, time trends of in-hospital outcomes of PEA in CTEPH patients in the German nationwide inpatient sample.
Methods and results
We analyzed data on the characteristics, comorbidities, treatments and in-hospital outcomes for all CTEPH patients treated with PEA in Germany between 2006 and 2016. Overall, 1,398 inpatients were included. The annual number of PEA increased from 67 in 2006 to 194 in 2016 (β 0.69 [95% CI 0.51 to 0.86]; p<0.001) in parallel with a significant decrease of in-hospital mortality (10.9% in 2008 to 1.5% in 2016; β −1.85 [95% CI: −2.46 to −1.24]; p<0.001). Patients' characteristics shifted slightly towards older age and higher prevalence of chronic renal insufficiency and obesity over time, whereas duration of hospital stay decreased over time. Independent predictors of in-hospital mortality were age and right heart failure, and in-hospital complications such as ischemic stroke and bleeding events.
Conclusions
The number of CTEPH patients treated with PEA increased markedly in Germany between 2006 and 2016, in parallel with a decrease of in-hospital mortality. Our findings may suggest that the perioperative management of PEA and the general patients' selection have improved over time and might draw more attention to predictors for in-hospital mortality for CTEPH patients hospitalized for PEA.
Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).
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Affiliation(s)
- L Hobohm
- University Medical Center of Mainz, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - K Keller
- University Medical Center of Mainz, Center for Cardiology, Cardiology I, Mainz, Germany
| | - T Munzel
- University Medical Center of Mainz, Center for Cardiology, Cardiology I, Mainz, Germany
| | - S.V Konstantinides
- University Medical Center of Mainz, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - M Lankeit
- Charite - Campus Virchow-Klinikum (CVK), Department of Internal Medicine and Cardiology, Berlin, Germany
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Ebner M, Guddat N, Keller K, Merten M, Lerchbaumer M, Hasenfuss G, Konstantinides S, Lankeit M. Identification of the optimal hsTnI cut-off value for risk stratification of normotensive patients with pulmonary embolism. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2240] [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
While numerous studies confirmed the prognostic role of high-sensitivity troponin T (hsTnT) in pulmonary embolism (PE), the prognostic relevance of high-sensitivity troponin I (hsTnI) is inappropriately studied and disease specific cut-off values remain undefined.
Purpose
To investigate the prognostic relevance of hsTnI in normotensive PE patients, establish the optimal cut-off value for risk stratification and compare the prognostic performances of hsTnI and hsTnT.
Methods
Consecutive PE patients enrolled in a prospective single-centre registry between 09/2008 and 04/2018 were studied. Using receiver operating curve analysis, an optimised hsTnI cut-off concentration was identified and the prognostic value for the prediction of in-hospital adverse outcomes (PE-related death, cardiopulmonary resuscitation or vasopressor treatment) and all-cause mortality analysed.
Results
We analysed data from 459 PE patients (age 69 [interquartile range (IQR) 57–77] years, 52% female). Patients who suffered an in-hospital adverse outcome (4.8%) had higher median hsTnI concentrations compared to those with a favorable clinical course (57 [IQR 22–197] vs. 15 [IQR 10–86] pg/ml, p=0.03). A hsTnI cut-off value of 16 ng/ml provided the best prognostic performance and predicted an in-hospital adverse outcome (Odds ratio [OR] 6.5, 95% confidence interval [CI] 1.9–22.4) and all-cause mortality (OR 3.7, 95% CI 1.0–13.3). Between female and male patients, no relevant differences in hsTnI concentrations (17 [IQR 10–97] vs. 17 [IQR 10–92] pg/ml, p=0.79) or optimized cut-off values (17 pg/ml and 19 pg/ml, respectively) were observed. Stratification of patients to risk classes according to the 2019 European Society of Cardiology (ESC) algorithm revealed no differences if calculated based on either hsTnI or hsTnT (Table).
Conclusions
Our findings confirm the prognostic relevance of hsTnI in normotensive PE. An optimal hsTnI cut-off value of 16 pg/ml predicted in-hospital adverse outcome and all-cause mortality. The use of sex specific cut-off values does not appear necessary. Importantly, our results suggest that hsTnI and hsTnT can be used interchangeably for risk stratification.
Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503). BRAHMS GmbH, part of Thermo Fisher Scientific, Hennigsdorf/Berlin, Germany provided financial support for biomarker measurements. The sponsor was neither involved in biomarker measurements, statistical analyses, writing of the abstract nor had any influence on the scientific contents.
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Affiliation(s)
- M Ebner
- Charite - Campus Mitte (CCM), Department of Cardiology and Angiology, Berlin, Germany
| | - N Guddat
- Georg-August University, Clinic of Cardiology and Pneumology, Heart Center, Gottingen, Germany
| | - K Keller
- University Medical Center Mainz, Center for Cardiology, Mainz, Germany
| | - M.C Merten
- Georg-August University, Clinic of Cardiology and Pneumology, Heart Center, Gottingen, Germany
| | - M.H Lerchbaumer
- Charite - Campus Mitte (CCM), Department of Radiology, Berlin, Germany
| | - G Hasenfuss
- Georg-August University, Clinic of Cardiology and Pneumology, Heart Center, Gottingen, Germany
| | - S.V Konstantinides
- University Medical Center of Mainz, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - M Lankeit
- Charite - Campus Virchow-Klinikum (CVK), Department of Cardiology, Berlin, Germany
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Valerio L, Barco S, Jankowski M, Rosenkranz S, Lankeit M, Held M, Gerhardt F, Bruch L, Ewert R, Faehling M, Freise J, Ardeschir Ghofrani H, Gruenig E, Halank M, Konstantinides S. Quality of life 3 and 12 months after acute pulmonary embolism: analysis of 617 patients from the prospective multicentre FOCUS study. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2276] [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
Few data are available on the long-term course and predictors of quality of life (QoL) after acute pulmonary embolism (PE).
Aims
To evaluate the kinetics and determinants of QoL at 3 and 12 months after acute PE.
Methods
The Follow-Up after acute pulmonary embolism (FOCUS) study prospectively followed consecutive adult patients with objectively diagnosed PE. For this analysis, we considered patients who completed the Pulmonary Embolism QoL (PEmb-QoL) Questionnaire at two predefined visits 3 and 12 months after PE. PEmb-QoL, studied as total score and in its six dimensions, ranges from 0% (best QoL) to 100% (worst QoL). We studied the course of PEmb-QoL and the impact of baseline characteristics using multivariable linear regression.
Results
In 617 included patients (44% women, median age 62 years), overall QoL improved from 3 to 12 months, with a decrease of the mean PEmb-QoL score from 25.3% to 21.5% (p-value <0.001). Intra-individual correlation between PEmb-QoL score at 3 and 12 months was high; Figure A. The improvement was consistent across all PEmb-QoL dimensions; Figure B. Female sex, cardiopulmonary diseases, and higher body mass index were the main factors associated with a worse QoL; Table. Age and smoking affected QoL only at 12 months. The improvement in QoL was faster in patients without cardiopulmonary diseases (−4.2%; 95% CI: −5.2% to −3.1%), without previous VTE (−4.3%; −5.5% to −3.2%), and in non-smokers (−4.2%; −5.3% to −3.1%).
Conclusions
In a large cohort of patients with pulmonary embolism, we quantified the improvement of QoL between 3 and 12 months after diagnosis. We identified factors independently associated with lower QoL and slower recovery of QoL that may reflect special patient needs. These estimates may facilitate the planning and interpretation of clinical trials with QoL as a study outcome.
Figure 1
Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): University Medical Center of the Johannes Gutenberg University, Mainz, Germany; German Federal Ministry of Education and Research
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Affiliation(s)
- L Valerio
- University Medical Center of Mainz, Center for Thrombosis and Hemostasis, Mainz, Germany
| | - S Barco
- University Medical Center of Mainz, Center for Thrombosis and Hemostasis, Mainz, Germany
| | - M Jankowski
- University Medical Center of Mainz, Center for Thrombosis and Hemostasis, Mainz, Germany
| | - S Rosenkranz
- Heart Center at the University of Cologne, Cologne, Germany
| | - M Lankeit
- University Medical Center of Mainz, Center for Thrombosis and Hemostasis, Mainz, Germany
| | - M Held
- Klinikum Würzburg Mitte - Missioklinik Würzburg, Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Würzburg, Germany
| | - F Gerhardt
- Heart Center at the University of Cologne, Cologne, Germany
| | - L Bruch
- Unfallkrankenhaus Berlin, Klinik für Innere Medizin und Kardiologie, Berlin, Germany
| | - R Ewert
- University Hospital of Greifswald, Clinic for Internal Medicine, Greifswald, Germany
| | - M Faehling
- Klinikum Esslingen, Klinik für Kardiologie, Angiologie und Pneumologie, Esslingen, Germany
| | - J Freise
- Medizinische Hochschule Hannover, Klinik für Pneumologie, Hannover, Germany
| | | | - E Gruenig
- University Hospital of Heidelberg, Thoraxklinik, Heidelberg, Germany
| | - M Halank
- Universitätsklinimum an der TU, Medizinische Klinik und Poliklinik I, Dresden, Germany
| | - S.V Konstantinides
- University Medical Center of Mainz, Center for Thrombosis and Hemostasis, Mainz, Germany
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Hobohm L, Keller K, Valerio L, Ni Ainle F, Klok FA, Münzel T, Kucher N, Lankeit M, Konstantinides SV, Barco S. Fatality rates and use of systemic thrombolysis in pregnant women with pulmonary embolism. ESC Heart Fail 2020; 7:2365-2372. [PMID: 32567197 PMCID: PMC7524052 DOI: 10.1002/ehf2.12775] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/28/2020] [Accepted: 04/28/2020] [Indexed: 11/11/2022] Open
Abstract
AIMS Data on the early course and use of systemic thrombolysis in pregnant women with pulmonary embolism associated or not with haemodynamic failure are scarce. We investigated these aspects using the information from the German Nationwide Inpatient Registry (years 2005-2016). METHODS AND RESULTS In Germany, all diagnoses referring to hospitalized patients are coded according to the International Classification of Diseases and Related Health Problems, 10th Revision with German Modification. We analysed data of pregnant women aged 18-50 years for whom the following diagnoses were recorded during hospitalization: (i) pulmonary embolism (I26) during pregnancy or peripartum (O09) or (ii) obstetric thromboembolism (O88.2). Haemodynamic failure at any time during the in-hospital stay was defined as need for cardiopulmonary resuscitation (OPS code 8-77) or the presence of shock (International Classification of Diseases and Related Health Problems, 10th Revision with German Modification code R57). The primary study outcome was in-hospital death. A total of 8 271 327 births were registered in Germany from 2005 to 2016. During this 12 year time period, there were 1846 hospitalizations for pregnancy-associated pulmonary embolism in patients aged 18-50, corresponding to 2.2 [95% confidence interval (CI): 2.1-2.3] cases every 10 000 births and 0.2% of all hospitalizations for pulmonary embolism in Germany. The median age was 31 years, and the median length of hospitalization was 8 days. A total of 63 deaths were reported, corresponding to an overall in-hospital fatality rate of 3.4% (95% CI: 2.7-4.4) and a pulmonary embolism-related mortality rate of 0.8 (95% CI: 0.6-1.0) per 100 000 (live) births per year. Pulmonary embolism-related deaths in hospitalized pregnant women represented 14% of all maternal deaths recorded in Germany between 2005 and 2016. A total of 135 (7.3%) women had haemodynamic failure, of whom 51 (37.8%) received systemic thrombolysis and 50 (37.0%) died. CONCLUSIONS Pulmonary embolism-related fatality remains substantial in pregnant women with pulmonary embolism and represents a frequent cause of maternal mortality. The use of systemic thrombolysis was reported in one third of pregnant women with pulmonary embolism and haemodynamic failure. Better preventive and management strategies should be urgently implemented in this vulnerable patient group.
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Affiliation(s)
- Lukas Hobohm
- Center for Cardiology, Cardiology IUniversity Medical Center MainzMainzGermany
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
| | - Karsten Keller
- Center for Cardiology, Cardiology IUniversity Medical Center MainzMainzGermany
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
| | - Fionnuala Ni Ainle
- Department of HaematologyMater Misericordiae University HospitalDublinIreland
- SPHERE Research Group, Conway InstituteUniversity College DublinDublinIreland
- The Rotunda HospitalDublinIreland
- Irish Centre for Vascular BiologyRoyal College of Surgeons in IrelandDublinIreland
- School of MedicineUniversity College DublinDublinIreland
| | - Frederikus A. Klok
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
- Department of Medicine – Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Thomas Münzel
- Center for Cardiology, Cardiology IUniversity Medical Center MainzMainzGermany
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
| | - Nils Kucher
- Clinic of AngiologyUniversity Hospital ZürichZürichSwitzerland
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK)Charité – University MedicineBerlinGermany
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
- Department of CardiologyDemocritus University of ThraceAlexandroupolisGreece
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzLangenbeckstrasse 1Mainz55131Germany
- Clinic of AngiologyUniversity Hospital ZürichZürichSwitzerland
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Kriechbaum SD, Scherwitz L, Wiedenroth CB, Rudolph F, Wolter JS, Haas M, Fischer-Rasokat U, Rolf A, Hamm CW, Mayer E, Guth S, Keller T, Konstantinides SV, Lankeit M, Liebetrau C. Mid-regional pro-atrial natriuretic peptide and copeptin as indicators of disease severity and therapy response in CTEPH. ERJ Open Res 2020; 6:00356-2020. [PMID: 33263045 PMCID: PMC7682678 DOI: 10.1183/23120541.00356-2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/18/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) leads to right heart failure. Pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) restore pulmonary haemodynamics and allow cardiac recovery. This study examined the relationship of copeptin and mid-regional pro-atrial natriuretic peptide (MR-proANP) levels to disease severity and therapy response. METHODS This observational cohort study included 125 patients (55 PEA/70 BPA) who underwent treatment and completed a 6-/12-month follow-up. Biomarkers, measured at baseline, prior to every BPA and at follow-up, were compared to 1) severe disease at baseline (right atrial pressure (RAP) ≥8 mmHg and cardiac index ≤2.4 L·min-1·m-2) and 2) optimal therapy response (no persistent pulmonary hypertension combined with a normalised RAP (mean PAP ≤25 mmHg, pulmonary vascular resistance (PVR) ≤3 WU and RAP ≤6 mmHg) or a reduction in mean PAP ≥25%, PVR ≥35% and RAP ≥25%). RESULTS Severely diseased patients had higher levels of MR-proANP (320 (246-527) pmol·L-1 versus 133 (82-215) pmol·L-1; p=0.001) and copeptin (12.7 (7.3-20.6) pmol·L-1 versus 6.8 (4.4-12.8) pmol·L-1; p=0.015) at baseline than the rest of the cohort. At baseline, MR-proANP (area under the curve (AUC) 0.91; cut-off value 227 pmol·L-1; OR 56, 95% CI 6.9-454.3) and copeptin (AUC 0.70; cut-off value 10.9 pmol·L-1; OR 1.5, 95% CI 1.2-1.9) identified severely diseased patients. After PEA/BPA, levels of MR-proANP (99 (58-145) pmol·L-1; p<0.001) and copeptin (6.3 (3.7-12.6) pmol·L-1; p=0.009) decreased and indicated optimal therapy response (MR-proANP <123 pmol·L-1 (AUC 0.70) and copeptin <10.1 pmol·L-1 (AUC 0.58)). CONCLUSION MR-proANP and copeptin levels are affected in CTEPH and decrease after therapy. MR-proANP identifies a severe disease status and optimal therapy response.
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Affiliation(s)
- Steffen D. Kriechbaum
- Kerckhoff Heart and Thorax Center, Dept of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Lillith Scherwitz
- Kerckhoff Heart and Thorax Center, Dept of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | | | - Felix Rudolph
- Kerckhoff Heart and Thorax Center, Dept of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Jan-Sebastian Wolter
- Kerckhoff Heart and Thorax Center, Dept of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Moritz Haas
- Kerckhoff Heart and Thorax Center, Dept of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Ulrich Fischer-Rasokat
- Kerckhoff Heart and Thorax Center, Dept of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
| | - Andreas Rolf
- Kerckhoff Heart and Thorax Center, Dept of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Christian W. Hamm
- Kerckhoff Heart and Thorax Center, Dept of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Eckhard Mayer
- Kerckhoff Heart and Thorax Center, Dept of Thoracic Surgery, Bad Nauheim, Germany
| | - Stefan Guth
- Kerckhoff Heart and Thorax Center, Dept of Thoracic Surgery, Bad Nauheim, Germany
| | - Till Keller
- Kerckhoff Heart and Thorax Center, Dept of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Dept of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Dept of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Berlin, Germany
- These authors contributed equally
| | - Christoph Liebetrau
- Kerckhoff Heart and Thorax Center, Dept of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Frankfurt am Main, Germany
- Justus Liebig University Giessen, Medical Clinic I, Division of Cardiology, Giessen, Germany
- These authors contributed equally
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Barco S, Schmidtmann I, Ageno W, Anušić T, Bauersachs RM, Becattini C, Bernardi E, Beyer-Westendorf J, Bonacchini L, Brachmann J, Christ M, Czihal M, Duerschmied D, Empen K, Espinola-Klein C, Ficker JH, Fonseca C, Genth-Zotz S, Jiménez D, Harjola VP, Held M, Iogna Prat L, Lange TJ, Lankeit M, Manolis A, Meyer A, Münzel T, Mustonen P, Rauch-Kroehnert U, Ruiz-Artacho P, Schellong S, Schwaiblmair M, Stahrenberg R, Valerio L, Westerweel PE, Wild PS, Konstantinides SV. Survival and quality of life after early discharge in low-risk pulmonary embolism. Eur Respir J 2020; 57:13993003.02368-2020. [DOI: 10.1183/13993003.02368-2020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/21/2020] [Indexed: 11/05/2022]
Abstract
IntroductionEarly discharge of patients with acute low-risk pulmonary embolism requires validation by prospective trials with clinical and quality-of-life outcomes.MethodsThe multinational Home Treatment of Patients with Low-Risk Pulmonary Embolism with the Oral Factor Xa Inhibitor Rivaroxaban (HoT-PE) single-arm management trial investigated early discharge followed by ambulatory treatment with rivaroxaban. The study was stopped for efficacy after the positive results of the predefined interim analysis at 50% of the planned population. The present analysis includes the entire trial population (576 patients). In addition to 3-month recurrence (primary outcome) and 1-year overall mortality, we analysed self-reported disease-specific (Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire) and generic (five-level five-dimension EuroQoL (EQ-5D-5L) scale) quality of life as well as treatment satisfaction (Anti-Clot Treatment Scale (ACTS)) after pulmonary embolism.ResultsThe primary efficacy outcome occurred in three (0.5%, one-sided upper 95% CI 1.3%) patients. The 1-year mortality was 2.4%. The mean±sd PEmb-QoL decreased from 28.9±20.6% at 3 weeks to 19.9±15.4% at 3 months, a mean change (improvement) of −9.1% (p<0.0001). Improvement was consistent across all PEmb-QoL dimensions. The EQ-5D-5L was 0.89±0.12 at 3 weeks after enrolment and improved to 0.91±0.12 at 3 months (p<0.0001). Female sex and cardiopulmonary disease were associated with poorer disease-specific and generic quality of life; older age was associated with faster worsening of generic quality of life. The ACTS burden score improved from 40.5±6.6 points at 3 weeks to 42.5±5.9 points at 3 months (p<0.0001).ConclusionsOur results further support early discharge and ambulatory oral anticoagulation for selected patients with low-risk pulmonary embolism. Targeted strategies may be necessary to further improve quality of life in specific patient subgroups.
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Keller K, Hobohm L, Geyer M, Kreidel F, Ostad MA, Lavie CJ, Lankeit M, Konstantinides S, Münzel T, von Bardeleben RS. Impact of obesity on adverse in-hospital outcomes in patients undergoing percutaneous mitral valve edge-to-edge repair using MitraClip® procedure - Results from the German nationwide inpatient sample. Nutr Metab Cardiovasc Dis 2020; 30:1365-1374. [PMID: 32513574 DOI: 10.1016/j.numecd.2020.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/29/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND AIM The number of percutaneous edge-to-edge mitral regurgitation (MR) valve repairs with MitraClip® implantations increased exponentially in recent years. Studies have suggested an obesity survival paradox in patients with cardiovascular diseases. We investigated the influence of obesity on adverse in-hospital outcomes in patients with MitraClip® implantation. METHODS AND RESULTS We analyzed data on characteristics of patients and in-hospital outcomes for all percutaneous mitral valve repairs using the edge-to-edge MitraClip®-technique in Germany 2011-2015 stratified for obesity vs. normal-weight/over-weight. The nationwide inpatient sample comprised 13,563 inpatients undergoing MitraClip® implantations. Among them, 1017 (7.5%) patients were coded with obesity. Obese patients were younger (75 vs.77 years,P < 0.001), more often female (45.4% vs.39.5%,P < 0.001), had more often heart failure (87.1% vs.79.2%,P < 0.001) and renal insufficiency (67.0% vs.56.4%,P < 0.001). Obese and non-obese patients were comparable regarding major adverse cardiac and cerebrovascular events (MACCE) and in-hospital death. The combined endpoint of cardio-pulmonary resuscitation (CPR), mechanical ventilation and death was more often reached in non-obese than in obese patients with a trend towards significance (20.6%vs.18.2%,P = 0.066). Obesity was an independent predictor of reduced events regarding the combined endpoint of CPR, mechanical ventilation and death (OR 0.75, 95%CI 0.64-0.89,P < 0.001), but not for reduced in-hospital mortality (P = 0.355) or reduced MACCE rate (P = 0.108). Obesity class III was associated with an elevated risk for pulmonary embolism (OR 5.66, 95%CI 1.35-23.77,P = 0.018). CONCLUSIONS We observed an obesity paradox regarding the combined endpoint of CPR, mechanical ventilation and in-hospital death in patients undergoing MitraClip® implantation, but our results failed to confirm an impact of obesity on in-hospital survival or MACCE.
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Affiliation(s)
- Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Heart Center Mainz, Center of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany.
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Heart Center Mainz, Center of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Martin Geyer
- Heart Center Mainz, Center of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Felix Kreidel
- Heart Center Mainz, Center of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Mir A Ostad
- Heart Center Mainz, Center of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Carl J Lavie
- Department of Cardiovascular Disease, John Ochsner Heart & Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, United States
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité-University Medicine, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Department of Cardiology, Democritus University Thrace, Alexandroupolis, Greece
| | - Thomas Münzel
- Heart Center Mainz, Center of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Ralph Stephan von Bardeleben
- Heart Center Mainz, Center of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
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Wiedenroth, MD CB, Rieth, MD AJ, Kriechbaum, MD S, Ghofrani, MD HA, Breithecker, MD A, Haas, MD M, Roller, MD F, Richter, MD MJ, Lankeit M, Mielzarek L, Rolf, MD A, Hamm, MD CW, Mayer, MD E, Guth, MD S, Liebetrau, MD C. Exercise right heart catheterization before and after balloon pulmonary angioplasty in inoperable patients with chronic thromboembolic pulmonary hypertension. Pulm Circ 2020; 10:2045894020917884. [PMID: 32874548 PMCID: PMC7436823 DOI: 10.1177/2045894020917884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 03/14/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND *These authors contributed equally as last authors.Balloon pulmonary angioplasty is an evolving, interventional treatment option for inoperable patients with chronic thromboembolic pulmonary hypertension (CTEPH). Pulmonary hypertension at rest as well as exercise capacity is considered to be relevant outcome parameters. The aim of the present study was to determine whether measurement of pulmonary hemodynamics during exercise before and six months after balloon pulmonary angioplasty have an added value. METHODS From March 2014 to July 2018, 172 consecutive patients underwent balloon pulmonary angioplasty. Of these, 64 consecutive patients with inoperable CTEPH underwent a comprehensive diagnostic workup that included right heart catheterization at rest and during exercise before balloon pulmonary angioplasty treatments and six months after the last intervention. RESULTS Improvements in pulmonary hemodynamics at rest and during exercise, in quality of life, and in exercise capacity were observed six months after balloon pulmonary angioplasty: WHO functional class improved in 78% of patients. The mean pulmonary arterial pressure (mPAP) at rest was reduced from 41 ± 9 to 31 ± 9 mmHg (p < 0.0001). The mPAP/cardiac output slope decreased after balloon pulmonary angioplasty (11.2 ± 25.6 WU to 7.7 ± 4.1 WU; p < 0.0001), and correlated with N-terminal fragment of pro-brain natriuretic peptide (p = 0.035) and 6-minute walking distance (p = 0.01). CONCLUSIONS Exercise right heart catheterization provides valuable information on the changes of pulmonary hemodynamics after balloon pulmonary angioplasty in inoperable CTEPH patients that are not obtainable by measuring resting hemodynamics.
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Affiliation(s)
| | - Andreas J. Rieth, MD
- Kerckhoff Clinic, Department of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt am Main, Germany
| | - Steffen Kriechbaum, MD
- Kerckhoff Clinic, Department of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt am Main, Germany
| | - H.-Ardeschir Ghofrani, MD
- Kerckhoff Clinic, Department of Pulmonology, Bad Nauheim, Germany
- Universities of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL)
- Department of Medicine, Imperial College London, UK
| | | | - Moritz Haas, MD
- Kerckhoff Clinic, Department of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt am Main, Germany
| | - Fritz Roller, MD
- University of Giessen, Department of Radiology, Giessen, Germany
| | - Manuel J. Richter, MD
- University of Giessen, Department of Internal Medicine, Division of Pulmonology, Giessen, Germany
| | - Mareike Lankeit
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité – University Medicine Berlin, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
| | - Lisa Mielzarek
- Kerckhoff Clinic, Department of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt am Main, Germany
| | - Andreas Rolf, MD
- Kerckhoff Clinic, Department of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt am Main, Germany
- University of Giessen, Department of Internal Medicine I, Division of Cardiology, Giessen, Germany
| | - Christian W. Hamm, MD
- Kerckhoff Clinic, Department of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt am Main, Germany
- University of Giessen, Department of Internal Medicine I, Division of Cardiology, Giessen, Germany
| | - Eckhard Mayer, MD
- Kerckhoff Clinic, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Stefan Guth, MD
- Kerckhoff Clinic, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Christoph Liebetrau, MD
- Kerckhoff Clinic, Department of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), partner site RheinMain, Frankfurt am Main, Germany
- University of Giessen, Department of Internal Medicine I, Division of Cardiology, Giessen, Germany
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Ebner M, Lankeit M. Antithrombotische Therapie bei Lungenembolie. Dtsch Med Wochenschr 2020; 145:970-977. [DOI: 10.1055/a-0955-3379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractThe present article addresses clinical challenges associated with the choice of the anticoagulant agent, the definition of the duration of anticoagulant treatment and the assessment of the risk-to-benefit ratio of prolonged anticoagulation for patients with pulmonary embolism (PE).Anticoagulation is performed with unfractionated heparin (UFH) in hemodynamically unstable patients and with low molecular weight heparins (LWMH) or fondaparinux in normotensive patients. In patients with high or intermediate clinical probability of pulmonary embolism, anticoagulation should be initiated without delay while awaiting the results of diagnostic tests. LMWH and fondaparinux are preferred over UFH in the initial anticoagulation of PE since they are associated with a lower risk of bleeding.All patients with PE require therapeutic anticoagulation for at least three months. The current 2019 guidelines of the European Society of Cardiology (ESC) recommend that all eligible patients should be treated with a non-vitamin K antagonist oral anticoagulant (NOAC) in preference to a vitamin K antagonist (VKA). In patients with active cancer, Apixaban, Edoxaban and Rivaroxaban are effective alternatives to treatment with LMWH.The decision on the duration of anticoagulation should consider both, the individual risk of PE recurrence and the individual risk of bleeding. The risk for recurrent PE after discontinuation of treatment is related to the features of the index PE event. While patients with a strong transient risk factor have a low risk of recurrence and anticoagulation can be discontinued after three months, patients with strong persistent risk factor (such as active cancer) have a high risk of recurrence and thus should receive anticoagulant treatment of indefinite duration. Given the favourable safety profile of NOACs (especially if a reduced dosage of Apixaban or Rivaroxaban is initiated after at least six months of therapeutic anticoagulation), extended oral anticoagulation of indefinite duration should be considered for all patients with intermediate risk of recurrence.
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Keller K, Hobohm L, Ostad MA, Göbel S, Lankeit M, Konstantinides S, Münzel T, Wenzel P. Temporal trends and predictors of inhospital death in patients hospitalised for heart failure in Germany. Eur J Prev Cardiol 2020; 28:990-997. [PMID: 32605456 DOI: 10.1177/2047487320936020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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] [Received: 03/13/2020] [Accepted: 06/01/2020] [Indexed: 12/30/2022]
Abstract
AIMS We investigated trends in incidence, case fatality rate, patient characteristics and adverse inhospital events of patients hospitalised for heart failure in Germany. METHODS AND RESULTS The German nationwide inpatient sample (2005-2016) was used for this analysis. Patients hospitalised due to heart failure were selected for analysis. Temporal trends in the incidence of hospitalisations, case fatality rate and treatments were analysed and predictors of inhospital death were identified. The analysis comprised a total number of 4,539,140 hospitalisations (52.0% women, 81.0% aged ≥70 years) due to heart failure. Although hospitalisations increased from 381 (2005) to 539 per 100,000 population (2016) (β estimate 0.06, 95% confidence interval (CI) 0.06 to 0.07, P < 0.001) in parallel with median age and prevalence of comorbidities, the inhospital case fatality rate decreased from 11.1% to 8.1% (β estimate -0.36, 95% CI -0.37 to -0.35, P < 0.001) and the rate of major adverse cardiovascular and cerebrovascular events (β estimate -0.24, 95% CI -0.25 to -0.23, P < 0.001) decreased from 12.7% to 10.3%. Age 70 years and older (odds ratio (OR) 2.60, 95% CI 2.57 to 2.63, P < 0.001) and cancer (OR 1.93, 95% CI 1.91 to 1.96, P < 0.001) were independent predictors of inhospital death. CONCLUSION Hospitalisations for heart failure increased in Germany from 2005 to 2016, whereas the major adverse cardiovascular and cerebrovascular event rate and inhospital case fatality rate decreased during this period despite higher patient age and increasing prevalence of comorbidities.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Germany.,Medical Clinic VII, University Hospital Heidelberg, Germany
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Germany
| | - Mir A Ostad
- Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Germany
| | - Sebastian Göbel
- Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Germany
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Germany.,Department of Internal Medicine and Cardiology, Charité - University Medicine, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Germany.,Department of Cardiology, Democritus University Thrace, Greece
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Germany
| | - Philip Wenzel
- Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Germany
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Pruszczyk P, Kurnicka K, Ciurzyński M, Hobohm L, Thielmann A, Sobkowicz B, Sawicka E, Kostrubiec M, Ptaszyńska-Kopczyńska K, Dzikowska-Diduch O, Lichodziejewska B, Lankeit M. Defining right ventricular dysfunction by the use of echocardiography in normotensive patients with pulmonary embolism. Pol Arch Intern Med 2020; 130:741-747. [DOI: 10.20452/pamw.15459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Keller K, Hobohm L, Münzel T, Konstantinides SV, Lankeit M. Sex-specific and age-related seasonal variations regarding incidence and in-hospital mortality of pulmonary embolism in Germany. ERJ Open Res 2020; 6:00181-2020. [PMID: 32607372 PMCID: PMC7306502 DOI: 10.1183/23120541.00181-2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/15/2020] [Indexed: 01/12/2023] Open
Abstract
Background Studies have reported seasonal variations regarding the incidence and the short-term mortality of pulmonary embolism (PE). The aim of this study was to identify sex-specific and age-related differences in seasonal patterns regarding hospitalisations and mortality of PE patients. Methods We analysed the impact of seasons on incidence and in-hospital mortality of male and female hospitalised PE patients in Germany (2005-2015) based on the German nationwide inpatient sample. Results The German nationwide inpatient sample comprised 885 806 hospitalisations due to PE (2005-2015). Seasonal variations of both incidence (p=0.021) and in-hospital mortality (p<0.001) were of significant magnitude. Quarterly annual incidence (25.5 versus 23.7 of 100 000 citizens per year, p=0.021) and in-hospital mortality (17.0% versus 16.7%, p=0.008) were higher in winter than in summer. Risk of in-hospital mortality in winter was slightly higher (OR 1.03 (95% CI 1.01-1.06), p=0.015) compared to summer, independently of sex, age and comorbidities. Additionally, we observed sex-specific differences during seasons: the highest number of hospitalisations of PE patients of both sexes was during winter, whereas the nadir of male patients was in spring and that of female patients was in summer. Both sexes showed a maximum of in-hospital mortality in spring. Seasonal variation regarding incidence and mortality was pronounced in older patients. Conclusion Incidence and the in-hospital mortality of PE patients showed a significant seasonal variation with sex-specific differences. Although it has to be hypothesised that the seasonal variation of PE is multifactorially dependent, variation in each season was not explained by seasonal differences regarding age, sex and the prevalence of important comorbidities.
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Affiliation(s)
- Karsten Keller
- Center for Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Lukas Hobohm
- Center for Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Thomas Münzel
- Center for Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany.,Dept of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany.,Dept of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine, Berlin, Germany.,DZHK, Partner Site Berlin, Berlin, Germany
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Barco S, Konstantinides SV, Lankeit M. Response to 'Detecting right ventricular dysfunction in patients diagnosed with low-risk pulmonary embolism: is routine computed tomographic pulmonary angiography sufficient?'. Eur Heart J 2020; 40:3357-3358. [PMID: 31539033 DOI: 10.1093/eurheartj/ehz656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, Mainz, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, Mainz, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité - University Medicine Berlin, Augustenburgerplatz 1, Berlin, Germany.,Clinic of Cardiology and Pneumology, Heart Center, University Medical Center Goettingen, Robert-Koch-Strasse 40, Goettingen, Germany
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40
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Abstract
Pulmonary embolism (PE) is a life-threatening disease and the third most frequent cardiovascular cause of death after stroke and myocardial infarction. The annual incidence is increasing. The recently published 2019 guidelines of the European Society of Cardiology integrate numerous new study findings and provide updated diagnostic and therapeutic algorithms. A standardized diagnostic approach based on clinical probability, D-dimer levels, compression sonography of the leg veins and (if necessary) CTPA should also be applied in pregnant patients with suspected PE. Assessment of right ventricular function on imaging should be part of risk stratification in every patient; the RV/LV diameter ratio can be assessed on CTPA performed for diagnosis of PE. Low risk patients are eligible for home treatment if no other reasons for hospitalization are present. Treatment decision for hemodynamically unstable patients should be made by interdisciplinary Pulmonary Embolism Response Teams. NOACs are recommended as the therapy of choice for anticoagulation of patients with PE. The duration of anticoagulation should be at least 3 months and prolonged anticoagulation should be considered for all patients without a strong triggering reversible risk factor.
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Affiliation(s)
- Matthias Ebner
- Medizinische Klinik mit Schwerpunkt Kardiologie und Angiologie, Campus Charité-Mitte (CCM), Charité-Universitätsmedizin Berlin
| | - Mareike Lankeit
- Medizinische Klinik mit Schwerpunkt Kardiologie, Campus Virchow-Klinikum (CVK), Charité-Universitätsmedizin Berlin
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41
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Hendriks SV, Lankeit M, den Exter PL, Zondag W, Brouwer R, Eijsvogel M, Grootenboers MJ, Faber LM, Heller-Baan R, Hofstee HMA, Iglesias Del Sol A, Mairuhu ATA, Melissant CF, Peltenburg HG, van de Ree MA, Serné EH, Konstantinides S, Klok FA, Huisman MV. Uncertain Value of High-sensitive Troponin T for Selecting Patients With Acute Pulmonary Embolism for Outpatient Treatment by Hestia Criteria. Acad Emerg Med 2020; 27:1043-1046. [PMID: 32163216 PMCID: PMC7687260 DOI: 10.1111/acem.13943] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Stephan V Hendriks
- From the, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,the, Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | - Mareike Lankeit
- the, Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.,the, Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Berlin, Germany
| | - Paul L den Exter
- From the, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wendy Zondag
- From the, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Rolf Brouwer
- the, Department of Internal Medicine, Reinier de Graaff Gasthuis, Delft, The Netherlands
| | - Michiel Eijsvogel
- the, Department of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Laura M Faber
- the, Department of Pulmonary medicine, Rode Kruis Hospital, Beverwijk, The Netherlands
| | | | - Herman M A Hofstee
- the, Department of Internal Medicine, Haaglanden MC, The Hague, The Netherlands
| | | | - Albert T A Mairuhu
- the, Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
| | | | - Henny G Peltenburg
- the, Department of Internal Medicine, Groene hart Hospital, Gouda, The Netherlands
| | - Marcel A van de Ree
- the, Department of Internal Medicine, Diakonessenhuis, Utrecht, The Netherlands
| | - Erik H Serné
- and the, Department of Internal Medicine, VU Medical Center, Amsterdam, The Netherlands
| | - Stavros Konstantinides
- the, Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Frederikus A Klok
- From the, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,the, Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Menno V Huisman
- From the, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Hobohm L, Becattini C, Konstantinides SV, Casazza F, Lankeit M. Validation of a fast prognostic score for risk stratification of normotensive patients with acute pulmonary embolism. Clin Res Cardiol 2020; 109:1008-1017. [PMID: 32025793 PMCID: PMC7376081 DOI: 10.1007/s00392-019-01593-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/22/2019] [Indexed: 12/19/2022]
Abstract
Background Recent studies demonstrate an improved prognostic performance of the 2014 European Society of Cardiology (ESC) algorithm for risk stratification of patients with pulmonary embolism (PE) compared to the 2008 ESC algorithm. The modified FAST and Bova scores appear especially helpful to identify PE patients at intermediate-high risk. Methods We validated the prognostic performance of the modified FAST score compared to other scores for risk stratification in a post-hoc analysis of 868 normotensive PE patients included in the prospective Italian Pulmonary Embolism Registry. In-hospital adverse outcome was defined as PE-related death, mechanical ventilation, cardiopulmonary resuscitation or administration of catecholamines. Results Overall, 27 patients (3.1%) had an adverse outcome and 32 patients (3.7%) died. The rate of an adverse outcome was highest in the intermediate-high risk classes of the 2019 ESC algorithm (7.5%) and the modified FAST score (5.3%) while the Bova score failed to discriminate between intermediate-low and intermediate-high-risk patients. Patients classified as intermediate-high risk by the 2019 ESC algorithm (Odds Ratio [OR], 4.2 [95% CI, 1.9–9.0]) and modified FAST score (OR, 2.8 [1.3–6.2]) had a higher risk of an adverse outcome compared to patients classified by the Bova score (OR, 1.6 [0.7–3.7]). The c-index was higher for the 2019 ESC algorithm and the modified FAST score (AUC, 0.69 [0.58–0.79] and 0.67 [0.59–0.76]) compared to the Bova score (AUC, 0.64 [0.55–0.73]). Conclusions The 2019 ESC algorithm provided the best prognostic performance, but also the modified FAST score accurately stratified normotensive PE patients in different risk classes while the Bova score failed to identify patients at highest risk. Graphic abstract ![]()
Electronic supplementary material The online version of this article (10.1007/s00392-019-01593-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany.,Center for Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Franco Casazza
- Cardiology Department, San Carlo Borromeo Hospital, Milan, Italy
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany. .,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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43
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Ebner M, Rogge NIJ, Parwani AS, Sentler C, Lerchbaumer MH, Pieske B, Konstantinides SV, Hasenfuß G, Wachter R, Lankeit M. Atrial fibrillation is frequent but does not affect risk stratification in pulmonary embolism. J Intern Med 2020; 287:100-113. [PMID: 31602725 DOI: 10.1111/joim.12985] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 01/21/2023]
Abstract
BACKGROUND Although prior studies indicate a high prevalence of atrial fibrillation (AF) in patients with pulmonary embolism (PE), the exact prevalence and prognostic impact are unknown. METHODS We aimed to investigate the prevalence, risk factors and prognostic impact of AF on risk stratification, in-hospital adverse outcomes and mortality in 528 consecutive PE patients enrolled in a single-centre registry between 09/2008 and 09/2017. RESULTS Overall, 52 patients (9.8%) had known AF and 57 (10.8%) presented with AF on admission; of those, 34 (59.6%) were newly diagnosed with AF. Compared to patients with no AF, overt hyperthyroidism was associated with newly diagnosed AF (OR 7.89 [2.99-20.86]), whilst cardiovascular risk comorbidities were more frequently observed in patients with known AF. Patients with AF on admission had more comorbidities, presented more frequently with tachycardia and elevated cardiac biomarkers and were hence stratified to higher risk classes. However, AF on admission had no impact on in-hospital adverse outcome (8.3%) and in-hospital mortality (4.5%). In multivariate logistic regression analyses corrected for AF on admission, NT-proBNP and troponin elevation as well as higher risk classes in risk assessment models remained independent predictors of an in-hospital adverse outcome. CONCLUSION Atrial fibrillation is a frequent finding in PE, affecting more than 10% of patients. However, AF was not associated with a higher risk of in-hospital adverse outcomes and did not affect the prognostic performance of risk assessment strategies. Thus, our data support the use of risk stratification tools for patients with acute PE irrespective of the heart rhythm on admission.
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Affiliation(s)
- M Ebner
- Department of Nephrology and Medical Intensive Care, Charité - University Medicine Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, Charité - University Medicine Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
| | - N I J Rogge
- Clinic of Cardiology and Pneumology, Heart Center, University Medical Center, Goettingen, Germany
| | - A S Parwani
- Department of Internal Medicine and Cardiology, Charité - University Medicine Berlin, Berlin, Germany
| | - C Sentler
- Clinic of Cardiology and Pneumology, Heart Center, University Medical Center, Goettingen, Germany
| | - M H Lerchbaumer
- Department of Radiology, Charité - University Medicine Berlin, Berlin, Germany
| | - B Pieske
- Department of Internal Medicine and Cardiology, Charité - University Medicine Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - S V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center, Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - G Hasenfuß
- Clinic of Cardiology and Pneumology, Heart Center, University Medical Center, Goettingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site, Goettingen, Germany
| | - R Wachter
- Clinic of Cardiology and Pneumology, Heart Center, University Medical Center, Goettingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site, Goettingen, Germany.,Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - M Lankeit
- Department of Internal Medicine and Cardiology, Charité - University Medicine Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany.,Clinic of Cardiology and Pneumology, Heart Center, University Medical Center, Goettingen, Germany.,Center for Thrombosis and Hemostasis, University Medical Center, Mainz, Germany
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44
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Hoeper MM, Lam CSP, Vachiery JL, Bauersachs J, Gerges C, Lang IM, Bonderman D, Olsson KM, Gibbs JSR, Dorfmuller P, Guazzi M, Galiè N, Manes A, Handoko ML, Vonk-Noordegraaf A, Lankeit M, Konstantinides S, Wachter R, Opitz C, Rosenkranz S. Pulmonary hypertension in heart failure with preserved ejection fraction: a plea for proper phenotyping and further research. Eur Heart J 2019; 38:2869-2873. [PMID: 28011705 DOI: 10.1093/eurheartj/ehw597] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 11/22/2016] [Indexed: 12/24/2022] Open
Affiliation(s)
- Marius M Hoeper
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Carolyn S P Lam
- National Centre Singapore and Duke-National University of Singapore, 5 Hospital Dr, Singapore 16960
| | - Jean-Luc Vachiery
- Pulmonary Vascular Disease and Heart Failure Clinic, CUB Hopital Erasme, Route de Lennik 808, 1070 Brussels, Belgium
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Christian Gerges
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Diana Bonderman
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Karen M Olsson
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - J Simon R Gibbs
- National Heart and Lung Institute, Imperial College, Sydney St, Chelsea, London SW3 6NP and National Pulmonary Hypertension Service, Hammersmith Hospital, Du Cane Rd, White City, London W12 0HS, United Kingdom
| | - Peter Dorfmuller
- Department of Pathology and INSERM UMR-S 999, Paris-South University, Marie Lannelongue Hospital, Le Plessis Robinson, 15 Rue Georges Clemenceau, 91400 Orsay, France
| | - Marco Guazzi
- Department of Cardiology, University of Milano, IRCCS Policlinico San Donato, Piazza Edmondo Malan, 1, 20097 San Donato Milanese, Milano, Italy
| | - Nazzareno Galiè
- Department of Experimental, Diagnostic and Speciality Medicine, Bologna University Hospital, Via Zamboni, 33, 40126 Bologna, Italy
| | - Alessandra Manes
- Department of Experimental, Diagnostic and Speciality Medicine, Bologna University Hospital, Via Zamboni, 33, 40126 Bologna, Italy
| | - M Louis Handoko
- Department of Cardiology, VU University Medical Center, De Boelelaan 1117, 1081 Amsterdam, The Netherlands
| | - Anton Vonk-Noordegraaf
- Department of Pneumology, VU University Medical Center, De Boelelaan 1117, 1081 Amsterdam, The Netherlands
| | - Mareike Lankeit
- Department of Cardiology, Charité University Medicine Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Stavros Konstantinides
- Centre for Thrombosis and Haemostasis, University Medical Centre Mainz, Langenbeckstraße 1, 55131 Mainz, Germany; and Department of Cardiology, Democritus University of Thrace, University Campus, 69100 Komotini, Alexandroupolis, Greece
| | - Rolf Wachter
- Department of Cardiology, University of Göttingen, and German Cardiovascular Research Center (DZHK), Robert-Koch-Str. 40, 37099 Göttingen, Germany
| | - Christian Opitz
- Department of Cardiology, DRK-Kliniken Berlin, Spandauer Damm 130, 14050 Berlin Germany
| | - Stephan Rosenkranz
- Department of Cardiology and Cologne Cardiovascular Research Centre (CCRC), University of Cologne, Kerpener Strasse 62, 50937 Köln, Germany
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45
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Barco S, Ende-Verhaar YM, Becattini C, Jimenez D, Lankeit M, Huisman MV, Konstantinides SV, Klok FA. Differential impact of syncope on the prognosis of patients with acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J 2019; 39:4186-4195. [PMID: 30339253 DOI: 10.1093/eurheartj/ehy631] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 09/18/2018] [Indexed: 01/08/2023] Open
Abstract
Aims Controversial reports exist in the literature regarding the prognostic role and therapeutic implications of syncope in patients with acute pulmonary embolism (PE). We conducted a systematic review and meta-analysis to investigate the association between syncope and short-term adverse outcomes, taking into account the presence or absence of haemodynamic compromise at acute PE presentation. Methods and results The literature search identified 1664 studies, 29 of which were included for a total of 21 956 patients with PE (n = 3706 with syncope). Syncope was associated with higher prevalence of haemodynamic instability [odds ratio (OR) 3.50; 95% confidence interval (CI) 2.67-4.58], as well as with echocardiographic signs of right ventricular (RV) dysfunction (OR 2.10; CI 1.60-2.77) at presentation. Patients with syncope had a higher risks of all-cause early (either in-hospital or within 30 days) death (OR 1.73; CI 1.22-2.47) and PE-related 30-day adverse outcomes (OR 2.00; CI 1.11-3.60). The absolute risk difference (95% CI) for all-cause death was +6% (+1% to +10%) in studies including unselected patients, but it was -1% (-2% to +1%) in studies restricted to normotensive patients. We observed no prognostic impact of syncope in studies with a lower score at formal quality assessment and in those conducted retrospectively. Conclusion Syncope as a manifestation of acute PE was associated with a higher prevalence of haemodynamic instability and RV dysfunction at presentation, and an elevated risk for early PE-related adverse outcomes. The association with an increased risk of early death appeared more prominent in studies including unselected patients, when compared with those focusing on normotensive patients only.
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Affiliation(s)
- Stefano Barco
- Center for Thrombosis and Haemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany
| | - Yvonne M Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Albinusdreef 2, RC, Leiden, the Netherlands
| | - Cecilia Becattini
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, via Dottori 1, Perugia, Italy
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Ctra. Colmenar Km. 9,100, Madrid, Spain
| | - Mareike Lankeit
- Center for Thrombosis and Haemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Augustenburger Platz 1, Berlin, Germany.,Clinic for Cardiology and Pneumology, Georg-August University of Göttingen, Göttingen, Germany
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Albinusdreef 2, RC, Leiden, the Netherlands
| | - Stavros V Konstantinides
- Center for Thrombosis and Haemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany.,Department of Cardiology Democritus University of Thrace, University General Hospital, Alexandroupolis, Greece
| | - Frederikus A Klok
- Center for Thrombosis and Haemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstraße 1, Mainz, Germany.,Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Albinusdreef 2, RC, Leiden, the Netherlands
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46
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Bochenek ML, Leidinger C, Rosinus NS, Gogiraju R, Guth S, Hobohm L, Jurk K, Mayer E, Münzel T, Lankeit M, Bosmann M, Konstantinides S, Schäfer K. Activated Endothelial TGFβ1 Signaling Promotes Venous Thrombus Nonresolution in Mice Via Endothelin-1: Potential Role for Chronic Thromboembolic Pulmonary Hypertension. Circ Res 2019; 126:162-181. [PMID: 31747868 DOI: 10.1161/circresaha.119.315259] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [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: 12/14/2022]
Abstract
RATIONALE Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by defective thrombus resolution, pulmonary artery obstruction, and vasculopathy. TGFβ (transforming growth factor-β) signaling mutations have been implicated in pulmonary arterial hypertension, whereas the role of TGFβ in the pathophysiology of CTEPH is unknown. OBJECTIVE To determine whether defective TGFβ signaling in endothelial cells contributes to thrombus nonresolution and fibrosis. METHODS AND RESULTS Venous thrombosis was induced by inferior vena cava ligation in mice with genetic deletion of TGFβ1 in platelets (Plt.TGFβ-KO) or TGFβ type II receptors in endothelial cells (End.TGFβRII-KO). Pulmonary endarterectomy specimens from CTEPH patients were analyzed using immunohistochemistry. Primary human and mouse endothelial cells were studied using confocal microscopy, quantitative polymerase chain reaction, and Western blot. Absence of TGFβ1 in platelets did not alter platelet number or function but was associated with faster venous thrombus resolution, whereas endothelial TGFβRII deletion resulted in larger, more fibrotic and higher vascularized venous thrombi. Increased circulating active TGFβ1 levels, endothelial TGFβRI/ALK1 (activin receptor-like kinase), and TGFβRI/ALK5 expression were detected in End.TGFβRII-KO mice, and activated TGFβ signaling was present in vessel-rich areas of CTEPH specimens. CTEPH-endothelial cells and murine endothelial cells lacking TGFβRII simultaneously expressed endothelial and mesenchymal markers and transcription factors regulating endothelial-to-mesenchymal transition, similar to TGFβ1-stimulated endothelial cells. Mechanistically, increased endothelin-1 levels were detected in TGFβRII-KO endothelial cells, murine venous thrombi, or endarterectomy specimens and plasma of CTEPH patients, and endothelin-1 overexpression was prevented by inhibition of ALK5, and to a lesser extent of ALK1. ALK5 inhibition and endothelin receptor antagonization inhibited mesenchymal lineage conversion in TGFβ1-exposed human and murine endothelial cells and improved venous thrombus resolution and pulmonary vaso-occlusions in End.TGFβRII-KO mice. CONCLUSIONS Endothelial TGFβ1 signaling via type I receptors and endothelin-1 contribute to mesenchymal lineage transition and thrombofibrosis, which were prevented by blocking endothelin receptors. Our findings may have relevant implications for the prevention and management of CTEPH.
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Affiliation(s)
- Magdalena L Bochenek
- From the Center for Cardiology, Cardiology I (M.L.B., C.L., N.S.R., R.G., L.H., T.M., K.S.), University Medical Center Mainz, Germany.,Center for Thrombosis and Hemostasis (M.L.B., L.H., K.J., M.L., M.B., S.K.), University Medical Center Mainz, Germany.,German Center for Cardiovascular Research (DZHK e.V.; RheinMain) (M.L.B., N.S.R., R.G., E.M., T.M., K.S.)
| | - Christiane Leidinger
- From the Center for Cardiology, Cardiology I (M.L.B., C.L., N.S.R., R.G., L.H., T.M., K.S.), University Medical Center Mainz, Germany
| | - Nico S Rosinus
- From the Center for Cardiology, Cardiology I (M.L.B., C.L., N.S.R., R.G., L.H., T.M., K.S.), University Medical Center Mainz, Germany.,German Center for Cardiovascular Research (DZHK e.V.; RheinMain) (M.L.B., N.S.R., R.G., E.M., T.M., K.S.)
| | - Rajinikanth Gogiraju
- From the Center for Cardiology, Cardiology I (M.L.B., C.L., N.S.R., R.G., L.H., T.M., K.S.), University Medical Center Mainz, Germany.,German Center for Cardiovascular Research (DZHK e.V.; RheinMain) (M.L.B., N.S.R., R.G., E.M., T.M., K.S.)
| | - Stefan Guth
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany (S.G., E.M.)
| | - Lukas Hobohm
- From the Center for Cardiology, Cardiology I (M.L.B., C.L., N.S.R., R.G., L.H., T.M., K.S.), University Medical Center Mainz, Germany.,Center for Thrombosis and Hemostasis (M.L.B., L.H., K.J., M.L., M.B., S.K.), University Medical Center Mainz, Germany
| | - Kerstin Jurk
- Center for Thrombosis and Hemostasis (M.L.B., L.H., K.J., M.L., M.B., S.K.), University Medical Center Mainz, Germany
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany (S.G., E.M.).,German Center for Cardiovascular Research (DZHK e.V.; RheinMain) (M.L.B., N.S.R., R.G., E.M., T.M., K.S.)
| | - Thomas Münzel
- From the Center for Cardiology, Cardiology I (M.L.B., C.L., N.S.R., R.G., L.H., T.M., K.S.), University Medical Center Mainz, Germany.,German Center for Cardiovascular Research (DZHK e.V.; RheinMain) (M.L.B., N.S.R., R.G., E.M., T.M., K.S.)
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (M.L.B., L.H., K.J., M.L., M.B., S.K.), University Medical Center Mainz, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité -University Medicine, Berlin, Germany (M.L.)
| | - Markus Bosmann
- Center for Thrombosis and Hemostasis (M.L.B., L.H., K.J., M.L., M.B., S.K.), University Medical Center Mainz, Germany.,Department of Medicine, Boston University School of Medicine, MA (M.B.)
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (M.L.B., L.H., K.J., M.L., M.B., S.K.), University Medical Center Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece (S.K.)
| | - Katrin Schäfer
- From the Center for Cardiology, Cardiology I (M.L.B., C.L., N.S.R., R.G., L.H., T.M., K.S.), University Medical Center Mainz, Germany.,German Center for Cardiovascular Research (DZHK e.V.; RheinMain) (M.L.B., N.S.R., R.G., E.M., T.M., K.S.)
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47
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Keller K, Tesche C, Gerhold‐Ay A, Nickels S, Klok FA, Rappold L, Hasenfuß G, Dellas C, Konstantinides SV, Lankeit M. Quality of life and functional limitations after pulmonary embolism and its prognostic relevance. J Thromb Haemost 2019; 17:1923-1934. [PMID: 31344319 PMCID: PMC6900046 DOI: 10.1111/jth.14589] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 07/24/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND While the importance of patients' quality of life (QoL) in chronic cardiac or pulmonary disease is uncontroversial, the burden of an acute pulmonary embolism (PE) on QoL has received little attention thus far. OBJECTIVES We aimed to validate the German PEmb-QoL questionnaire, identify associations between QoL and clinical/functional parameters, and investigate the prognostic relevance of QoL for long-term survival in survivors of an acute PE episode. PATIENTS/METHODS Patients were invited for a clinical follow-up visit including assessment of QoL using the German PEmb-QoL questionnaire 6 months after an objectively confirmed PE at a single center. Internal consistency reliability, construct-related validity, and regressions between PEmb-QoL and clinical patient-characteristics were assessed using standard scale construction techniques. RESULTS Overall, 101 patients [median age, 69 ([interquartile range] IQR 57-75) years; women, 48.5%] were examined 208 (IQR 185-242) days after PE. Internal consistency reliability and construct-related validity of the PEmb-QoL questionnaire were acceptable. As many as 47.0% of patients reported dyspnea, 27.5% had right ventricular (RV) dysfunction on transthoracic echocardiography (TTE), and 25.3% were diagnosed with post-PE impairment (PPEI) at 6-month follow-up. Furthermore, 15.9% of patients were diagnosed with depression 6 months after an acute PE. The QoL was affected by dyspnea, preexisting pulmonary disease, and PPEI, and a reduced QoL was associated with an increased risk for long-term mortality after an observation period of 3.6 years. CONCLUSIONS The German PEmb-QoL questionnaire is a reliable instrument for assessing QoL 6 months after PE. The QoL was affected by dyspnea, preexisting pulmonary disease, and PPEI and was associated with long-term mortality.
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Affiliation(s)
- Karsten Keller
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzMainzGermany
| | - Clara Tesche
- Clinic for Cardiology and PulmonologyHeart CenterUniversity Medical CenterGoettingenGermany
- Department of AnesthesiologyUniversity Hospital DuesseldorfDuesseldorfGermany
| | - Aslihan Gerhold‐Ay
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzMainzGermany
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI)University Medical Center MainzMainzGermany
| | - Stefan Nickels
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzMainzGermany
- Department of OphthalmologyUniversity Medical Center MainzMainzGermany
| | - Frederikus A. Klok
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzMainzGermany
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Lisa Rappold
- Clinic for Cardiology and PulmonologyHeart CenterUniversity Medical CenterGoettingenGermany
- Clinic for Internal MedicineSiloah St. Trudpert ClinicPforzheimGermany
| | - Gerd Hasenfuß
- Clinic for Cardiology and PulmonologyHeart CenterUniversity Medical CenterGoettingenGermany
- German Center for Cardiovascular Research (DZHK)Partner Site GoettingenGoettingenGermany
| | - Claudia Dellas
- Department of Paediatric Cardiology and Intensive CareGUCH CenterUniversity Medical CenterGoettingenGermany
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzMainzGermany
- Department of CardiologyDemocritus University ThraceAlexandroupolisGreece
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH)University Medical Center MainzMainzGermany
- Clinic for Cardiology and PulmonologyHeart CenterUniversity Medical CenterGoettingenGermany
- Department of Internal Medicine and CardiologyCampus Virchow Klinikum (CVK)Charité – University Medicine BerlinBerlinGermany
- German Center for Cardiovascular Research (DZHK)Partner Site BerlinBerlinGermany
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Keller K, Hobohm L, Münzel T, Ostad MA, Espinola-Klein C, Lavie CJ, Konstantinides S, Lankeit M. Survival Benefit of Obese Patients With Pulmonary Embolism. Mayo Clin Proc 2019; 94:1960-1973. [PMID: 31585580 DOI: 10.1016/j.mayocp.2019.04.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 03/15/2019] [Accepted: 04/03/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To investigate the impact of obesity and underweight on adverse in-hospital outcomes in pulmonary embolism (PE). PATIENTS AND METHODS Patients diagnosed as having PE based on International Statistical Classification of Diseases and Related Health Problems, 10th Revision, German Modification code I26 in the German nationwide inpatient database were stratified for obesity, underweight, and normal weight/overweight (reference group) and compared regarding adverse in-hospital outcomes. RESULTS From January 1, 2011, through December 31, 2014, 345,831 inpatients (53.3% females) 18 years and older were included in this analysis; 8.6% were obese and 0.5% were underweight. Obese patients were younger (67.0 vs 73.0 years), were more frequently female (60.2% vs 52.7%), had a lower cancer rate (13.6% vs 20.5%), and were more often treated with systemic thrombolysis (6.4% vs 4.3%) and surgical embolectomy (0.3% vs 0.1%) vs the reference group (P<.001 for all). Overall, 51,226 patients (14.8%) died during in-hospital stay. Obese patients had lower mortality (10.9% vs 15.2%; P<.001) vs the reference group and a reduced odds ratio (OR) for in-hospital mortality (OR, 0.74; 95% CI, 0.71-0.77; P<.001) independent of age, sex, comorbidities, and reperfusion therapies. This survival benefit of obese patients was more pronounced in obesity classes I (OR, 0.56; 95% CI, 0.52-0.60; P<.001) and II (OR, 0.63; 95% CI 0.58-0.69; P<.001). Underweight patients had higher prevalence of cancer and higher mortality rates (OR, 1.15; 95% CI, 1.00-1.31; P=.04). CONCLUSION Obesity is associated with decreased in-hospital mortality rates in patients with PE. Although obese patients were more often treated with reperfusion therapies, the survival benefit of obese patients occurred independently of age, sex, comorbidities, and reperfusion treatment.
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Affiliation(s)
- Karsten Keller
- Center for Thrombosis and Hemostasis, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany.
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; German Center for Cardiovascular Research, Partner Site Rhine Main, Rhine Main, Germany
| | - Mir A Ostad
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Christine Espinola-Klein
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Carl J Lavie
- Department of Cardiovascular Disease, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Department of Cardiology, Democritus University Thrace, Alexandroupolis, Greece
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité-University Medicine, Berlin, Germany; Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
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49
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Ebner M, Sentler C, Harjola VP, Bueno H, Keller K, Lerchbaumer M, Hobohm L, Hasenfuss G, Eckardt KU, Konstantinides S, Lankeit M. P5021Hypoperfusion markers identify patients with acute pulmonary embolism at highest risk for an adverse outcome. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0199] [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: 11/13/2022] Open
Abstract
Abstract
Background/Introduction
According to the European Society of Cardiology (ESC) 2014 guideline, systemic hypotension (HT) is the critical variable defining high-risk in patients with pulmonary embolism (PE). However, signs of organ hypoperfusion might more adequately identify PE patients with cardiogenic shock due to right ventricular (RV) failure.
Purpose
We investigated whether hypoperfusion markers provide superior prognostic information for identifying PE patients at highest risk of early adverse outcomes.
Methods
Consecutive PE patients enrolled in a prospective single-centre registry between 09/2008 and 03/2018 were included. We analysed the predictive value of symptoms and findings suggesting hypoperfusion for in-hospital adverse outcome (catecholamine treatment, resuscitation or PE-related death) and in-hospital all-cause mortality.
Results
We analysed 814 patients, including 83 (10.2%) ESC 2014 high-risk patients. Patients presenting with cardiac arrest (CA, 4.5%) were a priori defined as high risk. Markers suggesting hypoperfusion of the brain (altered metal status, odds ratio [OR] 8.2 [95% CI, 4.2–16.0]), lung (respiratory insufficiency, 25.0 [9.4–66.7]) and tissue (venous lactate ≥2.2 mmol/l, 6.4 [3.2–12.9]) as well as HT (13.5 [6.7–27.2]) predicted an adverse outcome. The risk for an adverse outcome increased with the number of positive markers (AUC 0.86 [0.80–0.93]). Patients with ≥3 positive hypoperfusion markers had an OR of 42.9 (11.0–167.3) and patients defined as high-risk by the ESC 2014 an OR of 17.2 (8.8–33.3) with regard to an adverse outcome (Figure 1; Table 1).
A new definition of high-risk (CA or ≥3 hypoperfusion markers) was associated with an OR of 73.2 (31.3–171.1) for an in-hospital adverse outcome and 26.2 (12.1–56.7) for in-hospital mortality.
Table 1. Prognostic performance of hypoperfusion markers Adverse outcome (if negative) Adverse outcome (if positive) Sensitivity Specificity LR+ OR (95% CI) ≥1 hypoperfusion marker 1.1% 21.0% 91.9% 68.2% 2.9 24.4 (7.3–80.8) ≥2 hypoperfusion markers 4.7% 50.0% 48.6% 95.5% 10.9 20.3 (9.1–45.1) ≥3 hypoperfusion markers 6.5% 75.0% 24.3% 99.3% 32.7 42.9 (11.0–167.3) ESC 2014 high-risk 5.7% 51.1% 35.0% 96.9% 11.4 17.2 (8.8–33.3) Cardiac arrest 8.4% 86.5% 33.0% 99.3% 47.3 70.1 (26.4–186.1) Abbreviations: LR+, positive likelihood ratio; OR, odds ratio; CI, confidence interval.
Figure 1. Frequency of adverse outcome
Conclusions
Markers of organ hypoperfusion have high predictive value for early adverse outcomes in acute PE. Risk increases with the number of positive markers and is critically elevated in patients presenting with CA or ≥3 markers.
Acknowledgement/Funding
This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).
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Affiliation(s)
- M Ebner
- Charite University Hospital, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - C Sentler
- Georg-August University, Clinic of Cardiology and Pneumology, Heart Center, Gottingen, Germany
| | - V P Harjola
- Helsinki University Central Hospital, Department of Emergency Medicine, Helsinki, Finland
| | - H Bueno
- University Hospital 12 de Octubre, Department of Cardiology, Madrid, Spain
| | - K Keller
- University Medical Center of Mainz, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - M Lerchbaumer
- Charite - Campus Virchow-Klinikum (CVK), Department of Radiology, Berlin, Germany
| | - L Hobohm
- University Medical Center of Mainz, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - G Hasenfuss
- Georg-August University, Clinic of Cardiology and Pneumology, Heart Center, Gottingen, Germany
| | - K U Eckardt
- Charite University Hospital, Department of Nephrology and Medical Intensive Care, Berlin, Germany
| | - S Konstantinides
- University Medical Center of Mainz, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - M Lankeit
- Charite - Campus Virchow-Klinikum (CVK), Department of Cardiology, Berlin, Germany
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50
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Becattini C, Cimini LA, Lankeit M, Pruszczyk P, Vanni S, Nazerian P, Kozlowska M, Casula C, Vinci A, Ottaviani M, Coppa A, Vedovati MC, Agnelli G. P5588Early versus delayed oral anticoagulation in patients with acute pulmonary embolism: determinants and outcome. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0532] [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
Whether early oral anticoagulant treatment is appropriate for patients with acute pulmonary embolism (PE) regardless of PE severity is undefined. The aim of this study in patients with acute PE at intermediate risk of death were: I) to assess the determinants for the use of early vs delayed vs no oral anticoagulants in patients with acute PE and II) to assess the association between timing of oral anticoagulation and in-hospital mortality.
Methods
Prospective cohorts of patients with acute PE at intermediate risk of death according to the European Society of Cardiology Guidelines 2014 were merged in a collaborative database. The initiation of oral anticoagulation was classified as early (≤3 days) or delayed (between day 3 and 10 from diagnosis). Patients treated with parenteral anticoagulants for longer than 10 days were also included. In-hospital death was the primary study outcome.
Results
Overall, 557 patients were included in the study, 23 received thrombolytic treatment during the hospital stay. The mean duration of parenteral anticoagulation was 7±8 days (5 median), 348 patients were initiated on a direct oral anticoagulant and 79 on a vitamin K antagonist during the hospital stay. Initiation of oral anticoagulants occurred early or delayed in 209 (37%) and 218 (39%) patients, respectively and never occurred during the first 30 days in 130 (23%).
Intermediate-low risk patients more commonly received early and intermediate high delayed oral anticoagulation. Simplified PESI score of zero (OR 1.9, 95% CI 1.3–2.7) was independently associated with early oral anticoagulation; among sPESI components absence of cancer (OR 5.9, 95% CI 3.3–10) and heart rate <110 (OR 1.8, 95% CI 1.01–3.16) were independent predictors of early initiation of oral anticoagulants. The presence of both right ventricle dysfunction and injury was associated with delayed initiation of oral anticoagulants.
The incidence of death was 5.5%. Death occurred in 32 patients and was not related to the duration of parenteral anticoagulation (OR 1.01 per day, 95% CI 0.98–1.06) nor to right ventricle dysfunction but to sPESI 1 (OR 3.32, 95% CI 1.14–9.66). These results were partially confirmed in the 435 intermediate risk patients without cancer (OR 1.03, 95% CI 0.99–1.08 for days of parenteral treatment; OR 4.17, 95% CI 0.95–18 for sPESI 1).
Conclusion
The clinical severity of PE and not the timing of initiation of oral anticoagulants are associated with in-hospital death in patients with intermediate risk PE. Randomized studies are needed to definitively assess the role of heparin lead-in in patients with PE at intermediate risk for death.
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Affiliation(s)
- C Becattini
- University of Perugia, Internal Vascular and Emergency Medicine and Stroke Unit, Perugia, Italy
| | - L A Cimini
- University of Perugia, Internal Vascular and Emergency Medicine and Stroke Unit, Perugia, Italy
| | - M Lankeit
- Charite - Campus Virchow-Klinikum (CVK), Dept of Internal Medicine and Cardiology, Berlin, Germany
| | - P Pruszczyk
- Medical University of Warsaw, Department of Internal Medicine & Cardiology, Warsaw, Poland
| | - S Vanni
- Ospedale San Giuseppe, Emergency Medicine, Empoli, Italy
| | - P Nazerian
- Careggi University Hospital (AOUC), Emergency Department, Florence, Italy
| | - M Kozlowska
- Medical University of Warsaw, Department of Internal Medicine & Cardiology, Warsaw, Poland
| | - C Casula
- Ospedale San Giuseppe, Emergency Medicine, Empoli, Italy
| | - A Vinci
- University of Perugia, Internal Vascular and Emergency Medicine and Stroke Unit, Perugia, Italy
| | - M Ottaviani
- Careggi University Hospital (AOUC), Emergency Department, Florence, Italy
| | - A Coppa
- Ospedale San Giuseppe, Emergency Medicine, Empoli, Italy
| | - M C Vedovati
- University of Perugia, Internal Vascular and Emergency Medicine and Stroke Unit, Perugia, Italy
| | - G Agnelli
- University of Perugia, Internal Vascular and Emergency Medicine and Stroke Unit, Perugia, Italy
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