The Vulnerable Elders Survey-13 scale is superior to the simplified Pulmonary Embolism Score Index in predicting 3-month postdischarge mortality in elderly survivors of acute pulmonary embolism

INTRODUCTION

Acute pulmonary embolism (APE) is the most serious manifestation of venous thromboembolism. The simplified Pulmonary Embolism Severity Index (sPESI) is employed for prediction of 30-day mortality in APE. The Vulnerable Elders Survey (VES-13) is used to identify participants at a risk of health impairment.

OBJECTIVES

We aimed to compare the VES-13 and sPESI scales for prediction of 3-month mortality inelderly patients hospitalized for APE.

PATIENTS AND METHODS

All patients with APE were managed according to the European Society of Cardiology (ESC) guidelines and followed up for at least 3 months after discharge. Clinical evaluation of all patients involved the Charlson Comorbidity Index (CCI) and biochemical tests. The patients with VES-13 score equal to or above 3 (VES-13≥3) were evaluated with comprehensive geriatric assessment (CGA).

RESULTS

A total of 164 patients met the inclusion criteria. There were significantly fewer men in the VES-13≥3 than the VES-13<3 group (34% vs 54.5%; P <0.01). The patients in the VES-13≥3 group had lower median (interquartile range [IQR]) body mass index and higher sPESI score than those in the VES-13<3 group (25.6 [21.8-28.4] kg/m2 vs 28 [25.3-31] kg/m2; P = 0.001 and 2 [1-2] points vs 1 [0-1] point; P <0.001, respectively). There were no differences in APE severity according to the ESC stratification and CCI. Logistic regression analysis identified the VES-13 score as a significant independent risk factor for 3-month mortality.

CONCLUSIONS

The VES-13 score is a better tool than sPESI for predicting 3-month mortality. Geriatric survivors of APE characterized with VES-13≥3 points should be closely monitored after discharge. The Norton Scale Score in a combination with the VES-13 may be useful in predicting 3-month mortality among numerous tests used in the CGA.

Refined balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension - reference center experience

Introduction

Chronic thromboembolic pulmonary hypertension (CTEPH), characterized by thromboembolic changes affecting the pulmonary bed, leads to ventricular function deterioration and premature death. The introduction of balloon pulmonary angioplasty (BPA) has significantly improved the prognosis of CTEPH patients.

Aim

The authors of this article decided to summarize the experience of the BPA program, conducted between 2014 and 2022, at the reference center.

Material and methods

Among 111 CTEPH patients, 55 were included in the analysis. A total of 226 sessions were performed, with a significant percentage of intravascular imaging and pressure catheter use.

Results

Mean pulmonary pressure decreased significantly from 42 (22-66) to 26.5 mm Hg (11-54) (p < 0.05). Pulmonary vascular resistance and natriuretic peptide concentration decreased from 6.67 (1.66-14) to 3.295 Wood units (1.09-11.11), respectively, and from 1934 (60-16963) to 296 (21-9901) ng/ml (p < 0.05). There was also an improvement in the functional class (WHO) from 2.85 ±0.61 to 2.15 ±0.62 and an increase in the 6-minute walking distance from 300 ±131 to 367 ±154 m (p < 0.05). There were no in-hospital deaths or within 30 days of the procedure. Arterial damage occurred during nine sessions (n = 9/226, 4%), while 0.9% (n = 2/226) were complicated by acute right ventricular failure. Post-reperfusion pulmonary edema (RPE 0 - none) was observed in almost 90% of the sessions, grade 1 to 3 RPE occurred in 10.2%, and grade 4 RPE was not noted.

Conclusions

BPA programs conducted in experienced centers are a safe and effective treatment option for inoperable CTEPH patients.

Electrocardiogram, Echocardiogram and NT-proBNP in Screening for Thromboembolism Pulmonary Hypertension in Patients after Pulmonary Embolism

Background: The annual mortality of patients with untreated chronic thromboembolism pulmonary hypertension (CTEPH) is approximately 50% unless a timely diagnosis is followed by adequate treatment. In pulmonary embolism (PE) survivors with functional limitation, the diagnostic work-up starts with echocardiography. It is followed by lung scintigraphy and right heart catheterization. However, noninvasive tests providing diagnostic clues to CTEPH, or ascertaining this diagnosis as very unlikely, would be extremely useful since the majority of post PE functional limitations are caused by deconditioning. Methods: Patients after acute PE underwent a structured clinical evaluation with electrocardiogram, routine laboratory tests including NT-proBNP and echocardiography. The aim of this study was to verify whether the parameters from echocardiographic or perhaps electrocardiographic examination and NT-proBNP concentration best determine the risk of CTEPH. Results: Out of the total number of patients (n = 261, male n = 123) after PE who were included in the study, in the group of 155 patients (59.4%) with reported functional impairment, 13 patients (8.4%) had CTEPH and 7 PE survivors had chronic thromboembolic pulmonary disease (CTEPD) (4.5%). Echo parameters differed significantly between CTEPH/CTEPD cases and other symptomatic PE survivors. Patients with CTEPH/CTEPD also had higher levels of NT-proBNP (p = 0.022) but concentration of NT-proBNP above 125 pg/mL did not differentiate patients with CTEPH/CTEPD (p > 0.05). Additionally, the proportion of patients with right bundle brunch block registered in ECG was higher in the CTEPH/CTED group (23.5% vs. 5.8%, p = 0.034) but there were no differences between the other ECG characteristics of right ventricle overload. Conclusions: Screening for CTEPH/CTEPD should be performed in patients with reduced exercise tolerance compared to the pre PE period. It is not effective in asymptomatic PE survivors. Patients with CTEPH/CTED predominantly had abnormalities indicating chronic thromboembolism in the echocardiographic assessment. NT-proBNP and electrocardiographic characteristics of right ventricle overload proved to be insufficient in predicting CTEPH/CTEPD development.

Impact of the COVID-19 Pandemic on Pulmonary Hypertension Patients: Insights from the BNP-PL National Database

We aimed to evaluate the clinical course and impact of the SARS-CoV-2 pandemic on the rate of diagnosis and therapy in the complete Polish population of patients (pts) with pulmonary arterial hypertension (PAH-1134) and CTEPH (570 pts) treated within the National Health Fund program and reported in the national BNP-PL database. Updated records of 1704 BNP-PL pts collected between March and December 2020 were analyzed with regard to incidence, clinical course and mortality associated with COVID-19. Clinical characteristics of the infected pts and COVID-19 decedents were analyzed. The rates of new diagnoses and treatment intensification in this period were studied and collated to the proper intervals of the previous year. The incidence of COVID-19 was 3.8% (n = 65) (PAH, 4.1%; CTEPH, 3.2%). COVID-19-related mortality was 28% (18/65 pts). Those who died were substantially older and had a more advanced functional WHO class and more cardiovascular comorbidities (comorbidity score, 4.0 ± 2.1 vs. 2.7 ± 1.8; p = 0.01). During the pandemic, annualized new diagnoses of PH diminished by 25–30% as compared to 2019. A relevant increase in total mortality was also observed among the PH pts (9.7% vs. 5.9% pre-pandemic, p = 0.006), whereas escalation of specific PAH/CTEPH therapies occurred less frequently (14.7% vs. 21.6% pre-pandemic). The COVID-19 pandemic has affected the diagnosis and treatment of PH by decreasing the number of new diagnoses, escalating therapy and enhancing overall mortality. Pulmonary hypertension is a risk factor for worsened course of COVID-19 and elevated mortality.

Characteristics and outcomes of patients with chronic thromboembolic pulmonary hypertension in the era of modern therapeutic approaches: data from the Polish multicenter registry (BNP-PL)

Background:

Significant achievements in the treatment of chronic thromboembolic pulmonary hypertension (CTEPH) have provided effective therapeutic options for most patients. However, the true impact of the changed landscape of CTEPH therapies on patients’ management and outcomes is poorly known. We aimed to characterize the incidence, clinical characteristics, and outcomes of CTEPH patients in the modern era of CTEPH therapies.

Methods:

We analyzed the data of CTEPH adults enrolled in the prospective multicenter registry.

Results:

We enrolled 516 patients aged 63.8 ± 15.4 years. The incidence rate of CTEPH was 3.96 per million adults per year. The group was burdened with several comorbidities. New oral anticoagulants (n = 301; 58.3%) were preferred over vitamin K antagonists (n = 159; 30.8%). Pulmonary endarterectomy (PEA) was performed in 120 (23.3%) patients and balloon pulmonary angioplasty (BPA) in 258 (50%) patients. PEA was pretreated with targeted pharmacotherapy in 19 (15.8%) patients, and BPA in 124 (48.1%) patients. Persistent CTEPH was present in 46% of PEA patients and in 65% of patients after completion of BPA. Persistent CTEPH after PEA was treated with targeted pharmacotherapy in 72% and with BPA in 27.7% of patients. At a mean time period of 14.3 ± 5.8 months, 26 patients had died. The use of PEA or BPA was associated with better survival than the use of solely medical treatment.

Conclusions:

The modern population of CTEPH patients comprises mostly elderly people significantly burdened with comorbid conditions. This calls for treatment decisions that are tailored individually for every patient. The combination of two or three methods is currently a frequent approach in the treatment of CTEPH.

Clinical Trial Registration:

clinicaltrials.gov/ct2/show/NCT03959748

Non-invasive early exclusion of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the InShape II study

BACKGROUND

The current diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE) is unacceptably long, causing loss of quality-adjusted life years and excess mortality. Validated screening strategies for early CTEPH diagnosis are lacking. Echocardiographic screening among all PE survivors is associated with overdiagnosis and cost-ineffectiveness. We aimed to validate a simple screening strategy for excluding CTEPH early after acute PE, limiting the number of performed echocardiograms.

METHODS

In this prospective, international, multicentre management study, consecutive patients were managed according to a screening algorithm starting 3 months after acute PE to determine whether echocardiographic evaluation of pulmonary hypertension (PH) was indicated. If the 'CTEPH prediction score' indicated high pretest probability or matching symptoms were present, the 'CTEPH rule-out criteria' were applied, consisting of ECG reading and N-terminalpro-brain natriuretic peptide. Only if these results could not rule out possible PH, the patients were referred for echocardiography.

RESULTS

424 patients were included. Based on the algorithm, CTEPH was considered absent in 343 (81%) patients, leaving 81 patients (19%) referred for echocardiography. During 2-year follow-up, one patient in whom echocardiography was deemed unnecessary by the algorithm was diagnosed with CTEPH, reflecting an algorithm failure rate of 0.29% (95% CI 0% to 1.6%). Overall CTEPH incidence was 3.1% (13/424), of whom 10 patients were diagnosed within 4 months after the PE presentation.

CONCLUSIONS

The InShape II algorithm accurately excluded CTEPH, without the need for echocardiography in the overall majority of patients. CTEPH was identified early after acute PE, resulting in a substantially shorter diagnostic delay than in current practice.

Accurate and efficient non-invasive strategy for early identification of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism (InShape II study)

Background

The current diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE) is unacceptably long exceeding 1 year, causing loss of quality-adjusted life years and excess mortality. Validated screening strategies to diagnose CTEPH earlier are lacking. Importantly, performing echocardiography in all PE patients for this purpose has a low diagnostic yield, is associated with overdiagnosis and is not cost-effective. Moreover, expertise in performing high-quality PH-dedicated echocardiograms may not be available outside expert centers.

Aim

To validate a simple screening strategy aimed at identifying CTEPH early in the course after acute PE, avoiding echocardiography if possible (Figure 1).

Methods

In this prospective, international, multicenter management study, consecutive PE survivors were managed according to the predefined algorithm starting three months after acute PE. All were followed for a total period of two years. The study protocol was approved by all local IRBs and all patients provided informed consent.

Results

424 patients were included across three European countries (Table 1). Following the algorithm, CTEPH was considered excluded in 343 (81%) patients based on clinical pre-test probability assessment by the “CTEPH prediction score”, evaluation of symptoms and application of the “CTEPH rule-out criteria” (Figure 1); only 19% was subjected to echocardiography. Only 1 of 343 patients managed without echocardiography was diagnosed with CTEPH, 10 months after initial PE, for a failure rate of 0.29% (95% CI 0–1.6%). Overall, 13 patients were diagnosed with CTEPH (incidence 3.1%), of whom 10 within 4 months after PE diagnosis.

Conclusions

The algorithm accurately ruled out CTEPH and avoided echocardiography in 81% of patients. The vast majority of CTEPH cases were identified early in the course of acute PE which is a considerable improvement compared to current clinical practice with an economic use of healthcare resources.

Figure 1. Study flowchart

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): This study was supported by unrestricted grants from Bayer/Merck Sharp & Dohme (MSD) and Actelion Pharmaceuticals Ltd. F.A. Klok and G.J.A.M. Boon were supported by the Dutch Heart Foundation (2017T064).

P304 The importance of echocardiographic pulmonary flow notch ratio in the assessment of patients with acute pulmonary embolism

Background

There are several echocardiographic features such as right ventricle dilatation, interventricular septum flattening, McConnel sign and 60/60 sign reflecting the extent and severity of acute pulmonary embolism (APE). In quite a large number of APE patients we can observe a pulmonary flow (PF) profile abnormality in the form of a mid-systolic notch (MSN).

Purpose

To assess the profile of pulmonary Doppler flow in consecutive patients with acute pulmonary embolism and to establish its clinical utility.

Methods

We reviewed pulmonary Doppler flow profiles from 127 consecutive patients (m. age 64 years,72 F) with symptomatic APE managed in our department. APE was confirmed by contrast-enhanced multi detector computed tomography when thromboemboli were visualized at least in segmental pulmonary arteries. Individuals with preexisting pulmonary arterial hypertension were excluded. The pulmonary flow notch ratio (PNR) defined as the time from onset of PF until mid-systolic notch divided by the time from notch to the end of pulmonary ejection was evaluated. The comparison of patients with PNR &lt; 1 (Group 1) and PNR &gt; 1 (Group 2) was performed.

Results

We found the MSN in 50 patients (39.4%). Seventy seven patients had a normal shape of Doppler PF envelope. The presence of MSN was associated with more pronounced echocardiographic signs of right ventricle overload (RVOT diameter 32.4± 5.2 vs 29.1 ±3.3 mm, p &lt; 0.001; TRPG 42.3 ± 14.4 vs 24.8 ±9.5 mmHg, p &lt; 0.0001; RVSP 49.4 ±14.9 vs 31.2 ±10.6 mmHg, p &lt; 0.0001; TAPSE 20.3± 4.1 vs 23.4 ±4.0 mm, p &lt; 0.001; PF Acceleration Time 64.5 ±13.7 vs 109.8 ±24.6 ms, p &lt; 0.001, and a presence of septal flattening). Obviously, patients with MSN presented more proximal location of thrombi in comparison to those with symmetrical shape of PF envelope (in MPA 18% vs 5.2%, p = 0.038 and in both LPA + RPA 22% vs 9%, p = 0.08, respectively). The PNR &lt; 1 was found in 35 (70%) of 50 patients with MSN (Group 1). In these patients thrombi were located more proximally than in patients with PNR &gt; 1 (Group 2), and angio-CT confirm anatomically massive PE. A percentage of patients with thrombi in both, left and right pulmonary arteries, in both lobar pulmonary arteries and lobar+ segmental arteries was higher in Group 1 (PNR &lt; 1) than in Group 2 (PNR &gt; 1): LPA + RPA: 28.6 vs 6.7%, lobar L and R: 57 vs 26.6%, lobar + segmental: 31 vs 20%. A number of patients with thrombi in the MPA was similar in both groups.

Conclusion

A noninvasive pulmonary flow notch ratio (PNR) may be useful for indicating APE patients with more extensive disease and proximal location of thrombi, at least in lobar pulmonary arteries.

P2771A novel doppler index for the diagnosis of post pulmonary embolism impairment syndrome

Introduction

Follow-up studies demonstrated that after an episode of acute pulmonary embolism (PE), half of patients report functional limitation. Chronic thromboembolic pulmonary hypertension (CTEPH) is diagnosed in approximately 4%, while others are supposed to have heart failure with preserved ejection fraction (HFpEF) or chronic thromboembolic disease (CTED). Echo can not only assess tricuspidal regurgitation pressure gradient (TRPG) indicating pulmonary hypertension but also with tissue Doppler, E/e' ratio can diagnose left ventricular diastolic dysfunction. We tried to asses if a novel echo index: TRPG to E/e' could be useful in differentiation between CTEPH, CTED and HFpEF.

Material and methods

We analyzed data of consecutive 535 PE survivors (313 F, aged 61±17 yrs). 342/535 (64%) reported significant functional impairment after at least 6 months anticoagulation. All symptomatic subjects underwent detailed diagnostic workup which included standardized echocardiography, lung scintigraphy, pulmonary functional tests, and chest CT, RHC and coronary angiography when appropriate.

Results

Eventually, out of 342 symptomatic PE survivors (220 F, aged 65±15 yrs) CTEPH was diagnosed In 17 cases, CTED in 8 pts and HFpEF in 174 pts and in the remaining other causes were found (i.e. coronary artery disease, anemia, pulmonary disease). Doppler echocardiography showed that TRPG/E/e' was significantly increased in CTEPH and CTED patients when compared to subjects with HFpEF (Table 1).

Echocardiographic doppler assessment HFpEF p CTEPH p CTED p n=174 HFpEF vs CTEPH n=17 CTEPH vs CTED n=8 HFpEF vs CTED TRPG (mmHg) 26.7±8.9 <0.01 59.5±32.0 0.013 34.4±15.1 ns E/e' 11.1±2.9 ns 10.1±32.0 ns 8.9±2.0 ns TRPG / E/e' 2.5±1.0 <0.001 6.0±2.4 <0.01 3.8±1.1 0.013 TRPG, Tricuspidal regurgitation pressure gradient; CTEPH, Chronic thromboembolic pulmonary hypertension; CTED, Chronic thromboembolic disease; HFpEF, Heart failure with preserved ejection fraction.

Conclusion

Our data indicate that echocardiographic index TRPG/(E/e') may be helpful in the differentiation of functional limitation in patients after pulmonary embolism.

P2768Post-PE impairment is mostly related to newly diagnosed heart failure with preserved ejection fraction

Introduction

Recently, the concept of post-PE impairment (PPEI) was proposed which includes various combinations of functional, haemodynamic or imaging abnormalities in patients after acute pulmonary embolism (PE). Chronic residual obstruction of pulmonary vascular bed, despite adequate anticoagulation, is suggested to be a major cause of PPEI.

Material and methods

We report data of consecutive 700 PE survivors (390 F, aged 62±18 yrs). In all patients PE was diagnosed and treated according to ESC recommendations. Patients were anticoagulated and followed for at least 6 months in outpatient clinic (median 6, 6–18 months). All symptomatic subjects underwent detailed diagnostic workup which included standardized echocardiography, lung scintigraphy, pulmonary functional tests, and chest CT, RHC and coronary angiography when appropriate.

Results

207/700 (29,6%) of PE survivors completely recovered functionally. However, when compared to prePEperiod 493/700 (70,4%) patients reported functional limitation compatible with PPEI. Exertional dyspnoea was present in 36,5% of symptomatic patients, then 25,5% others presented effort angina with or without dyspnoea, 11% of symptomatic patients reported palpitations and 27% complained of reduced exercise tolerance.

After diagnostic workup, CTEPH was diagnosed in 38 of 493 (7,7%) symptomatic subjects (5,4% of all survivors) and chronic thromboembolic pulmonary disease (CTED) in 12/493 (2,4%) of them. 52,9% pts have chronic heart failure with reduced ejection fraction (EF) 4,2% and 37,2% with preserved EF; valve heart disease was detected in 8,9% and significant arrhythmia, mostly atrial fibrillation, in 2,6%. Breathlessness and reduce exercise tolerance in the others were caused by coronary artery diseases or non-cardiovascular pathologies (e.g. anaemia, pulmonary disease).

Conclusions

Follow-up demonstrated that after an episode of PE, approximately 70% of patients report functional impairment. Although persistent pulmonary artery thromboemobli resulting in CTEPH or CTED were detected in 7,1% of PE survivors and 10% of symptomatic patients. Left ventricular diastolic dysfunction is the most common cause of PPEI.

Echocardiography in adults

Transthoracic echocardiography is the primary non-invasive modality for anatomical and functional cardiac assessment. All one-, two-dimensional and Doppler modes use the same phenomenon, i.e. the piezoelectric effect, to visualize mobile cardiac structures and blood flow in cardiac cavities. Novel techniques for myocardial imaging, such as tissue Doppler and acoustic marker tracing, allow for the assessment of regional myocardial contractility of the left and the right ventricle. Cardiac assessment is performed in standard views characterized by an optimal acoustic window. The goal of each cardiac echo is to assess cardiac function and morphology using all available imaging modes. The evaluation of acquired valvular heart diseases should include morphological and functional changes indicative of the type (stenosis, regurgitation, complex defect) and the mechanism (Carpentier’s classification of mitral regurgitation) of the defect, as well as its stage (mild, moderate, severe). The assessment of left and right ventricular function should involve the measurement of global and regional parameters. An echocardiographic report should also include information on septal continuity and the presence of additional structures or intracardiac masses.

Peak systolic velocity of tricuspid annulus is inferior to tricuspid annular plane systolic excursion for 30 days prediction of adverse outcome in acute pulmonary embolism

BACKGROUND

Tricuspid annular plane systolic excursion (TAPSE) is an established index of right ventricular (RV) systolic function and a significant predictor in normotensive patients with pulmonary embolism (PE). Recently, Doppler tissue imaging-derived tricuspid annular systolic velocity (TV S'), a modern parameter of RV function was reported to be useful in the diagnosis and prognosis of a broad spectrum of heart diseases. Therefore, herein, is an analysis of the prognostic value of both parameters in normotensive PE patients.

METHODS

One hundred and thirty nine consecutive PE patients (76 female, age 56.4 ± 19.5 years) were included in this study. All patients were initially anticoagulated. Transthoracic echocardiography was performed on admission. The study endpoint (SE) was defined as PE-related 30-day mortality and/or need for rescue thrombolysis.

RESULTS

Seven (5%) patients who met the criteria for SE presented more severe RV dysfunction at echocardiography. Univariable Cox regression analysis showed that RV/LV ratio predicted SE with hazard risk (HR) 10.6 (1.4-80.0; p = 0.02); TAPSE and TV S' showed HR 0.77 (0.67-0.89), p < 0.001, and 0.71 (0.52-0.97), p = 0.03, respectively. Area under the curve for TAPSE in the prediction of SE was 0.881; 95% CI 0.812-0.932, p = 0.0001, for TV S' was 0.751; 95% CI 0.670-0.820, p = 0.001. Multivariable analysis showed that the optimal prediction model included TAPSE and systolic blood pressure (SBP showed HR 0.89 95% CI 0.83-0.95, p < 0.001 and TAPSE HR 0.67, 95% CI 0.52-0.87, p<0.03). Kaplan-Meier analysis showed that initially PE patients with TAPSE ≥ 18 mm had a much more favorable prognosis that patients with TAPSE < 18 mm (p < 0.01), while analysis of S' was only of borderline statistical significance.

CONCLUSIONS

It seems that TV S' is inferior to TAPSE for 30 day prediction of adverse outcome in acute pulmonary embolism.

Increased systemic arterial stiffness in patients with chronic thromboembolic pulmonary hypertension

BACKGROUND

Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of venous thromboembolism (VTE) resulting from non-dissolving thromboemboli in the pulmonary arteries. Previous observations indicate a higher prevalence of atherosclerosis and cardiovascular risk factors in patients with VTE and CTEPH. The purpose of the present study was to evaluate the arterial stiffening assessed by pulse wave velocity (PWV), a marker of arterial stiffness, in CTEPH patients in comparison with a matched control group (CG).

METHODS

The study group consisted of 26 CTEPH patients (9 male and 17 female, age 69 ± 10 years) and 22 CG (10 male, 12 female, age 67 ± 8 years). In all subjects a physical examination, carotid-femoral PWV and transthoracic echocardiography were performed. Right heart catheterization was done in all CTEPH.

RESULTS

Chronic tromboembolic pulmonary hypertension patients had significantly higher PWV than CG (10.3 ± 2.5 m/s vs. 9 ± 1.3 m/s, p < 0.05), even though systolic blood pressure was higher in CG (120 ± 11 vs. 132 ± 14 mmHg, p = 0.002). PWV correlated only with age and pulmonary vascular resistance (PVR) in CTEPH (r = 0.45, p = 0.03 and r = 0.43, p = 0.03, respectively). Arterial stiffening defined as PWV > 10 m/s was found in 11 (42%) CTEPH patients and in 5 (23%) cases from CG (p = 0.13). CTEPH patients with PWV > 10 m/s were older (74 ± 8 vs. 66 ± 10 years, p < 0.05), had decreased oxygen saturation (SaO2 89 [73-96]% vs. 96 [85-98]%, p < 0.01) and tended to have higher PVR (8.1 [3.1-14.0] vs. 5.2 [3.1-12.7] HRU, p = 0.10).

CONCLUSIONS

Arterial stiffness, assessed with PWV, is increased in CTEPH. The elevated PWV is associated with older age, lower SaO2 and higher PVR in CTEPH.

E-selectin and sICAM-1, biomarkers of endothelial function, predict recurrence of venous thromboembolism

BACKGROUND

Risk factors for atherosclerosis and venous thromboembolism (VTE) overlap and are mostly associated with endothelial dysfunction (ED). We hypothesized that ED is present in patients after the first episode of acute pulmonary embolism (APE) and predicts the risk of VTE recurrence.

DESIGN AND METHODS

Patients, at least 6months after the first episode of symptomatic, confirmed APE were included in this case-control study. The exclusion criteria were risk factors for cardiovascular diseases and other conditions associated with endothelial dysfunction. Eighty two patients (aged 38±11years; 44 M; 38 F) were enrolled in the study, 39 after provoked APE, 43 after unprovoked APE, and 30 controls (C) (aged 38±12years; 15 M, 15 F). In order to evaluate the endothelial function in patients with a history of APE flow-mediated dilation (FMD) of the brachial artery and biomarkers of endothelial dysfunction (sVCAM-1, sICAM-1, ADMA, E-selectin) were measured. Subsequently all patients were followed up in an outpatient clinic for VTE recurrence.

RESULTS

FMD was more often impaired in APE patients than in controls (5.3% (0.8-20.3) vs. 13.8% (4.1-24.3); p<0.0001). Biomarker levels differed between APE and C groups: sVCAM-1 (631ng/ml (105-2382) vs. 495ng/ml (348-934); p=0.04) and sICAM-1 (679ng/ml (279-1006) vs. 600ng/ml (394-766); p=0.002). There were 19 recurrences of VTE during the at least 12-month follow-up (15 with history of unprovoked-APE and 4 after provoked-APE). E-selectin ≥39ng/ml and sICAM-1≤655ng/ml indicated the group without recurrence of VTE. In a group of 43 unprovoked APE patients both E-selectin<39ng/ml and sICAM-1>655ng/ml were found in 17 subjects. Eleven of them (65%) were diagnosed with recurrent VTE.

CONCLUSIONS

Endothelial function is significantly impaired in patients after an episode of APE as indicated by FMD assessment and biomarker levels. Low concentrations of E-selectin and high levels of sICAM-1 are associated with a high risk of recurrent thromboembolism.

Refined balloon pulmonary angioplasty-A therapeutic option in very elderly patients with chronic thromboembolic pulmonary hypertension

INTRODUCTION/OBJECTIVES

Balloon pulmonary angioplasty (BPA) is a developing treatment for inoperable chronic thromboembolic pulmonary hypertension (CTEPH). However, to our knowledge there are no published data on BPA in CTEPH subjects aged 75 or over. The aim of the study was to analyze clinical and hemodynamic outcomes of sequential BPA in very elderly patients disqualified from pulmonary endarterectomy (PEA).

PATIENTS AND METHODS

We enrolled 10 patients (4 male, 6 female, median age 81 [75-88]) with confirmed CTEPH, mPAP > 30 mmHg, and WHO class > II, disqualified from PEA. Overall, 10 patients underwent 39 BPA sessions (mean 3.9 sessions per patient, range 1-9), and 70 pulmonary arteries were dilated, (mean 6.5 vessels per patient, range 1-14).

RESULTS

Pulmonary angioplasty resulted in significant clinical and hemodynamic improvement in every patient: 6 MWT distance increased from a median of 221 m (80-320) to 345 (230-455) and plasma NT-proBNP levels decreased (P < 0.01). Sequential BPA resulted in normalization of mPAP (<25 mmHg) in 6 of 10 patients and mPAP decreased to 25-30 mmHg in three others. In the whole group mPAP decreased from 41 (31-53) mmHg to 23 (17-33) mmHg (P < 0.01). Overall, mean PAP and PVR decreased significantly in all cases, while CO and CI increased (P < 0.01). No severe complications occurred during BPA and over a median follow-up of 553 days (range 81-784), and all patients are still alive and in good general health.

CONCLUSION

This study demonstrated the safety and efficacy of refined BPA in CTEPH patients aged 75 or over, disqualified from PEA. Refined BPA may emerge as an alternative therapeutic strategy in very elderly CTEPH patients who are suitable for surgery, but this requires further validation in a large prospective study.

Echocardiographic Pattern of Acute Pulmonary Embolism: Analysis of 511 Consecutive Patients

BACKGROUND

There is no comprehensive analysis of transthoracic echocardiographic findings of pulmonary embolism (PE). The aim of this study was to assess the frequency of right ventricular (RV) dysfunction (RVD), typical echocardiographic signs of acute PE (TES), and incidental abnormalities.

METHODS

A single-center, retrospective analysis was conducted of 511 consecutive patients (281 women; mean age, 64.0 ± 18.6 years) with PE confirmed by contrast-enhanced multidetector computed tomography who underwent transthoracic echocardiography for the assessment of left ventricular and RV alterations. The McConnell sign, the "60/60" sign, and right heart thrombus were regarded as TES. RVD included RV free wall hypokinesis and RV to LV end-diastolic ratio > 0.9. Incidental echocardiographic alterations were also reported.

RESULTS

RV enlargement, RV free wall hypokinesis, and interventricular septal flattening were found in 27.4%, 26.6%, and 18.4% of patients, respectively. Tricuspid regurgitation peak systolic gradient > 30 mmHg and pulmonary ejection acceleration time < 80 msec were measured in 46.6% and 37.2% of patients, respectively. RVD was found in 20.0% of patients, while normal RV function was present in 33.4% of patients. The McConnell sign, 60/60 sign, and right heart thrombus were found in 19.8%, 12.9%, 1.8% of subjects, respectively. All 16 hemodynamically unstable patients with PE presented enlarged hypokinetic right ventricle and at least one TES. However, in three of them, RV to LV end-diastolic ratio was <0.9. Incidental abnormalities were found in 9.6% of 364 stable patients with PE without RVD and TES.

CONCLUSIONS

Transthoracic echocardiography showed no significant abnormalities suggestive of PE in 71% of patients with PE, while in approximately 10%, transthoracic echocardiography revealed incidental findings. The coexistence of an enlarged hypokinetic right ventricle with the McConnell sign together with the 60/60 sign seems to be the most useful echocardiographic criterion for RVD.

Acute pulmonary embolism treatment with rivaroxaban results in a shorter duration of hospitalisation compared to standard therapy: an academic centre experience

BACKGROUND

Depending on the severity of clinical condition, acute pulmonary embolism (APE) is treated with unfraction-ated heparin (UFH), low-molecular weight heparin (LMWH), oral anticoagulants or, in the most severe form, with fibrinolytic agents. Following APE, patients require prolonged anticoagulant therapy for 3-6 months or in some cases indefinitely. Treatment options in this period include vitamin K antagonists (VKA) and non-VKA oral anticoagulants (NOAC) including rivaroxaban. The most recent European Society of Cardiology guidelines on the diagnosis and management of APE recommend use of NOAC in patients at a low-to-moderate risk of early mortality (a class I B recommendation). Rivaroxaban may be used in haemodynamically stable patients since the first day of therapy and was approved for this indication in Poland in December 2012.

AIM

To evaluate the rate of rivaroxaban use, characterise patients with APE treated with rivaroxaban, and evaluate potential reduction of the duration of hospitalisation in patients treated with rivaroxaban compared to those receiving VKA.

METHODS

We evaluated hospital and postdischarge treatment in 215 consecutive APE patients (105 men, 110 women) at the mean age of 65.0 (range: 19.5-91.9) years. The study included patients hospitalised from January 2013 to November 2014, i.e. in the period immediately following approval of rivaroxaban for the treatment of APE in Poland. In the acute phase, patients were treated with LMWH, UFH, or rivaroxaban, and the treatment was continued with VKA, LMWH, or rivaroxaban. The timing of initiation of oral therapy depended on the haemodynamic stability of the patient.

RESULTS

Our study group of 215 APE patients included 157 (73%) moderate-risk patients, 51 (24%) low-risk, and 7 (3.3%) high-risk patients. Treatment was initiated with UFH or LMWH in 208 (96.7%) patients, and with rivaroxaban in 7 (3.3%) patients. In 33 (16.5%) patients, rivaroxaban was started after up to 3 days of heparin therapy. Chronic therapy prescribed at discharge in-cluded VKA in 64 (30.5%) patients, rivaroxaban in 82 (39%) patients, and LMWH in 64 (30.5%) patients. Five patients died during hospital, for the total mortality of 2.3%. Acute high-risk PE was diagnosed on admission in 2 of these patients, and moderate-risk PE in 3 patients. Treatment in this group included enoxaparin in 4 patients and UFH in 1 patient. Patients who were discharged on rivaroxaban stayed in hospital for a significantly shorter time compared to patients discharged on VKA (6 [2-22] vs. 8 [2-17] days, p = 0.0005). Duration of hospital stay was significantly shorter in APE patients with sPESI of 0 who were treated with rivaroxaban compared to those with sPESI of 0 treated with VKA (5 [2-11] vs. 6 [2-12] days, p = 0.002). A significant difference in the duration of hospital stay was also noted in patients with sPESI of ≥ 1 treated with rivaroxaban compared to those treated with VKA (7 [3-22] vs. 9 [3-17] days, p = 0.015). Patients with sPESI of ≥ 1 treated with rivaroxaban were hospitalised for a sig-nificantly longer time compared to those with sPESI of 0 treated with rivaroxaban (7 [3-22] vs. 5 [2-11] days, p = 0.00005).

CONCLUSIONS

Rivaroxaban therapy is a useful therapeutic option in patients with APE. Compared to standard therapy, use of rivaroxaban has been associated with a significant reduction of the duration of hospital stay.

Derivation of a clinical prediction score for chronic thromboembolic pulmonary hypertension after acute pulmonary embolism

Essentials Predicting chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism is hard. We studied 772 patients with pulmonary embolism who were followed for CTEPH (incidence 2.8%). Logistic regression analysis revealed 7 easily collectable clinical variables that combined predict CTEPH. Our score identifies patients at low (0.38%) or higher (10%) risk of CTEPH.

SUMMARY

Introduction Validated risk factors for the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE) are currently lacking. Methods This is a post hoc patient-level analysis of three large prospective cohorts with a total of 772 consecutive patients with acute PE, without major cardiopulmonary or malignant comorbidities. All underwent echocardiography after a median of 1.5 years. In cases with signs of pulmonary hypertension, additional diagnostic tests to confirm CTEPH were performed. Baseline demographics and clinical characteristics of the acute PE event were included in a multivariable regression analysis. Independent predictors were combined in a clinical prediction score. Results CTEPH was confirmed in 22 patients (2.8%) by right heart catheterization. Unprovoked PE, known hypothyroidism, symptom onset > 2 weeks before PE diagnosis, right ventricular dysfunction on computed tomography or echocardiography, known diabetes mellitus and thrombolytic therapy or embolectomy were independently associated with a CTEPH diagnosis during follow-up. The area under the receiver operating charateristic curve (AUC) of the prediction score including those six variables was 0.89 (95% confidence interval [CI] 0.84-0.94). Sensitivity analysis and bootstrap internal validation confirmed this AUC. Seventy-three per cent of patients were in the low-risk category (CTEPH incidence of 0.38%, 95% CI 0-1.5%) and 27% were in the high-risk category (CTEPH incidence of 10%, 95% CI 6.5-15%). Conclusion The 'CTEPH prediction score' allows for the identification of PE patients with a high risk of CTEPH diagnosis after PE. If externally validated, the score may guide targeting of CTEPH screening to at-risk patients.

Refined balloon pulmonary angioplasty driven by combined assessment of intra-arterial anatomy and physiology--Multimodal approach to treated lesions in patients with non-operable distal chronic thromboembolic pulmonary hypertension--Technique, safety and efficacy of 50 consecutive angioplasties

BACKGROUND/OBJECTIVES

Balloon pulmonary angioplasty (BPA) is an emerging therapeutic method in CTEPH. We aimed to prove the safety and efficacy of refined BPA driven by combined assessment of intra-arterial anatomy (IVUS/OCT) and physiology (pulmonary pressure ratio, PPR) in non-operable distal CTEPH.

METHODS

11 pts (mean age 76, 59–84, 7 males) were enrolled in the BPA program according to the following inclusion criteria: 1. Non-operable CTEPH; 2. RHC with mPAP > 30 mm Hg; 3. At least one segmental perfusion defect at lung scintigraphy; 4. WHO class > II. Overall, 9 pts underwent 27 BPA sessions (mean 3 sessions per patient, range 1–5), 50 pulmonary arteries were dilated (mean 6 vessels per patient, range 3–9; 2.03 dilated arteries per session). All the angioplasties were performed according to an algorithm, which incorporated anatomical and functional assessment of targeted lesions.

RESULTS

We performed BPA of 32 web lesions, 5 ring-like stenosis and 13 complete obstructions. BPA resulted in clinical and hemodynamic improvement. WHO class improved from pre-BPA to post-BPA (p = 0.018), and 6 MWD increased from 304 m to 384 m (p = 0.03), NT-proBNP dropped from 1248 pg/ml to 730 pg/ml (p < 0.001). Mean PAP and PVR decreased (p = 0.01), while CO and CI increased (p = 0.01). All dilated arteries were patent at angiographic reassessment. No significant complications occurred and all treated patients are still alive. Insignificant transient reperfusion pulmonary oedema occurred in only 2 patients, who responded well to supplemental oxygen.

CONCLUSIONS

Refined BPA with assessment of intrapulmonary physiology using a pressure wire and precise evaluation of anatomy with IVUS and OCT provides hemodynamic and functional improvement, with minimal complications in distal non-operable CTEPH. This observation requires further validation in a large prospective study.

Short-term cardiometabolic risk reduction after bariatric surgery

INTRODUCTION

Clinically severe obesity, defined as a body mass index (BMI) 40 kg/m2, increases cardiovascular risk and results in elevated mortality. The objective of this study was to examine the short-term health benefits after bariatric surgery. Using commonly recognized scoring systems, we assessed the shortterm reduction of calculated cardiometabolic risk following bariatric surgery.

METHODS

Short-term cardiovascular risk reduction was assessed prospectively in 50 consecutive, morbidly obese patients (45 women, 5 men, age 39.3 ± 8.97 years, BMI 50.67 ± 12.25 kg/m²) using the following scales: the Finnish Diabetes Risk Score, Reynolds Risk Score, Italian "Progetto Cuore" score, SCORE. The follow-up data at baseline and six months were recorded in all studied patients. Patients who did not meet the inclusion criteria of particular score systems were not included in the analysis. There were no revisions, surgical failures or deaths in the study group.

RESULTS

The average weight loss six months after bariatric surgery was 35.8 ± 10.59 kg (mean BMI 36.54 ± 5.92 kg/m²). The most interesting result was that the median value of a 10-year risk of developing type 2 diabetes according to the FINDRISC score was 15 (IQR 15-15) at baseline vs. 13 (IQR 13-13) following surgery, p<0.001. We observed a reduction of 2 points in the majority of patients. In addition, in 29 patients it was possible to calculate the 10-year probability of developing the first major cardiovascular event using the Italian "Progetto Cuore" score; the median score decreased from 2.0 to 0.8 (p<0.001).

CONCLUSIONS

Weight loss at 6 months, as a result of bariatric surgery in this group of clinically severely obese patients at a very high risk, was especially effective as concerns the reduction of the calculated risk of diabetes, cardiovascular diseases, and related mortality.

The short-term effect of bariatric surgery on non-invasive markers of artery function in patients with metabolic syndrome

BACKGROUND

An improved understanding of the vascular function, measured in non-invasive way, in constantly growing group of patients at increased risk of cardiovascular events is necessary. To evaluate the effects of metabolic syndrome in morbidly obese patients and body mass reduction secondary to gastric bypass surgery on convenient and new non-invasive markers of artery function: pulse wave velocity (PWV), flow- and nitroglycerin-mediated dilatation (FMD, NTG).

METHODS

There were 40 patients included into prospective study, who were qualified for bariatric surgery (OB1) and evaluated again 6 m after surgery (OB2). A control group (CG) consisted of 15 healthy women. A second control group (CG2) consisted of 15 women with grade 1 obesity. PWV, FMD, NTG were assessed.

RESULTS

The reduction of BMI (kg/m(2)) from 47.73 ± 6.18 (OB1) to 35.22 ± 5.20 (OB2) was observed. The PWV turned out to be higher before bariatric surgery (OB1 vs. OB2 8.53 ± 1.76 vs. 7.82 ± 1.49 m/s; p < 0.001), however it was no different than PWV in CG. In OB1 group PWV showed correlation with age (r = 0.492, p = 0.001), HR (r = 0.324, p = 0.04), %FM (r = 0.328; p = 0.039), NTG% (r = -0.332, p = 0.036) as well as hsCRP (r = 0.394, p = 0.014). A multivariate analysis showed that the most significant factors influencing PWV were age (p = 0.0005) and hsCRP (p = 0.0014), pseudo R(2) index 0.44365. The values of FMD differed between OB1 and OB2 groups (12.83 ± 5.15 vs. 17.52 ± 5.50 %; p < 0.0001), however, they were similar to results obtained in CG (14.45 ± 6.14 %; NS). The values of nitroglycerin-mediated dilatation differed between OB1 and OB2 groups (21.47 ± 8.31 vs. 28.54 ± 8.16 %; p < 0.0001) and were lower as compared with CG (31.42 ± 5.95 %; p = 0.0005).

CONCLUSION

Body mass reduction secondary to bariatric surgery in patients with severe obesity and metabolic syndrome results in improvement of functional markers of artery function and advantageous metabolic changes. The improvement in functional markers of artery function (NTG%) was correlated with change in triglyceride blood concentration.