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Sagoschen I, Scibior B, Farmakis IT, Keller K, Graafen D, Griemert EV, Vosseler M, Treede H, Münzel T, Knorr M, Gori T, Konstantinides S, Hobohm L. A multidisciplinary pulmonary embolism response team (PERT): first experience from a single center in Germany. Clin Res Cardiol 2024; 113:581-590. [PMID: 38112742 PMCID: PMC10954947 DOI: 10.1007/s00392-023-02364-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 12/07/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Over the last few years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has emerged to encounter the increasing variety and complexity in managing acute pulmonary embolism (PE). PURPOSE To investigate PERT's composition and added clinical value in a university center in Germany. METHODS Over 4 years (01/2019-11/2022), patients with confirmed PE were enrolled in a prospective single-center cohort study (PERT Mainz). We investigated the composition of PERT and compared, after propensity score matching, patients with acute PE before and after the initiation of PERT at our Medical University Centre. The primary outcome was in-hospital PE-related mortality. RESULTS From 2019 to 2022, 88 patients with acute PE with a PERT decision were registered. Of those, 13 (14.8%) patients died during the in-hospital stay. Patients evaluated by a PERT had a median age of 68; 48.9% were females, and 21.7% suffered from malignancy. Right ventricular dysfunction was present in 76.1% of all patients. In total, 42.0% were classified as intermediate-high-risk PE and 11.4% as high-risk PE. First PERT contact mainly originated from emergency departments (33.3%) and intensive care units (30.0%), followed by chest pain units (21.3%) and regular wards (12.0%). The participation rate of medical specialties demonstrated that cardiologists (100%) or cardiac/vascular surgeons (98.6%) were included in almost all PERT consultations, followed by radiologists (95.9%) and anesthesiologists (87.8%). Compared to the PERT era, more patients in the pre-PERT era were classified as simplified pulmonary embolism severity index (sPESI) ≥ 1 (78.4% vs 71.6%) and as high-risk PE according to ESC 2019 guidelines (18.2% vs. 11.4%). In the pre-PERT era, low- and intermediate-low patients with PE received more frequently advanced reperfusion therapies such as systemic thrombolysis or surgical embolectomy compared to the PERT era (10.7% vs. 2.5%). Patients in the pre-PERT were found to have a considerably higher all-cause mortality and PE-related mortality rate (31.8% vs. 14.8%) compared to patients in the PERT era (22.7% vs. 13.6%). After propensity matching (1:1) by including parameters as age, sex, sPESI, and ESC risk classes, univariate regression analyses demonstrated that the PE management based on a PERT decision was associated with lower risk of all-cause mortality (OR, 0.37 [95%CI 0.18-0.77]; p = 0.009). For PE-related mortality, a tendency for reduction was observed (OR, 0.54 [95%CI 0.24-1.18]; p = 0.121). CONCLUSION PERT implementation was associated with a lower risk of all-cause mortality rate in patients with acute PE. Large prospective studies are needed further to explore the impact of PERTs on clinical outcomes.
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Affiliation(s)
- Ingo Sagoschen
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Barbara Scibior
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Karsten Keller
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Medical Clinic VII, University Hospital Heidelberg, Heidelberg, Germany
| | - Dirk Graafen
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Eva-Verena Griemert
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Markus Vosseler
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Hendrik Treede
- Department for Cardiac and Vascular Surgery, University Medical Center Mainz of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Maike Knorr
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Tommaso Gori
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Komotini, Greece
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.
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Boberg E, Hedman A, Hollenberg J. Pulmonary embolism with paradoxical embolization to right coronary artery in the presence of a large patent foramen ovale: a case report. Eur Heart J Case Rep 2024; 8:ytae133. [PMID: 38617591 PMCID: PMC11014684 DOI: 10.1093/ehjcr/ytae133] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/28/2024] [Accepted: 03/13/2024] [Indexed: 04/16/2024]
Abstract
Background Pulmonary embolism (PE) is the leading cause of in-hospital death and the third most frequent cause of cardiovascular death. The clinical presentation of PE is variable, and choosing the appropriate treatment for individual patients can be challenging. Case summary A 64-year-old man presented to hospital with acute chest pain, shortness of breath, and pulmonary oedema. Electrocardiogram revealed ST-elevation myocardial infarction. D-dimer was 18.8 mg/L fibrinogen equivalent units (FEU) (normal <0.64), and troponin was 25 (normal 5-14 ng/L). After systemic thrombolysis, respiratory failure persisted, and the arterial blood gas showed PaO2 of 6.0 kPa (normal 10.5-13.5 kPa), with 100% oxygen delivery via high-flow nasal cannula. A computed tomography diagnosed bilateral lobar PE, and coronary angiogram showed multiple thrombus in the right coronary artery. A bubble study with thoracic echocardiogram revealed a large right-left inter-atrial shunt. The patient denied treatment with extracorporeal membrane oxygenation and surgical thrombectomy. With no access to percutaneous catheter-directed thrombectomy, the patient received three separate thrombolysis treatments followed by a continued infusion for 22 h. After 6 weeks in hospital, the patient was discharged to rehab. Discussion For a long time, PE has been largely seen as a medical disease. Intra-cardiac shunts such as patent foramen ovale can complicate thrombo-venous disease and introduce paradoxical shunts leading to arterial emboli and persistent hypoxaemia. Over recent years, modern percutaneous catheter-directed thrombectomy has been developed for both high-risk and intermediate to high-risk PEs. Thrombectomy might improve right ventricular function and haemodynamics, but there is lacking evidence from randomized trials on efficacy, safety, and long-term outcome.
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Affiliation(s)
- Erik Boberg
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Entrevägen 2, 182 88 Stockholm, Sweden
| | - Anders Hedman
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Entrevägen 2, 182 88 Stockholm, Sweden
| | - Jacob Hollenberg
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Entrevägen 2, 182 88 Stockholm, Sweden
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Andò G, Pelliccia F, Saia F, Tarantini G, Fraccaro C, D'Ascenzo F, Zimarino M, Di Marino M, Niccoli G, Porto I, Calabrò P, Gragnano F, De Rosa S, Piccolo R, Moscarella E, Fabris E, Montone RA, Spaccarotella C, Indolfi C, Sinagra G, Perrone Filardi P. Management of high and intermediate-high risk pulmonary embolism: A position paper of the Interventional Cardiology Working Group of the Italian Society of Cardiology. Int J Cardiol 2024; 400:131694. [PMID: 38160911 DOI: 10.1016/j.ijcard.2023.131694] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024]
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition that remains a major global health concern. Noteworthy, patients with high- and intermediate-high-risk PE pose unique challenges because they often display clinical and hemodynamic instability, thus requiring rapid intervention to mitigate the risk of clinical deterioration and death. Importantly, recovery from PE is associated with long-term complications such as recurrences, bleeding with oral anticoagulant treatment, pulmonary hypertension, and psychological distress. Several novel strategies to improve risk factor characterization and management of patients with PE have recently been introduced. Accordingly, this position paper of the Working Group of Interventional Cardiology of the Italian Society of Cardiology deals with the landscape of high- and intermediate-high risk PE, with a focus on bridging the gap between the evolving standards of care and the current clinical practice. Specifically, the growing importance of catheter-directed therapies as part of the therapeutic armamentarium is highlighted. These interventions have been shown to be effective strategies in unstable patients since they offer, as compared with thrombolysis, faster and more effective restoration of hemodynamic stability with a consistent reduction in the risk of bleeding. Evolving standards of care underscore the need for continuous re-assessment of patient risk stratification. To this end, a multidisciplinary approach is paramount in refining selection criteria to deliver the most effective treatment to patients with unstable hemodynamics. In conclusion, the current management of unstable patients with PE should prioritize tailored treatment in a patient-oriented approach in which transcatheter therapies play a central role.
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Affiliation(s)
- Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, AOU Policlinico "Gaetano Martino", Messina, Italy
| | - Francesco Pelliccia
- Department of Cardiovascular Sciences, "La Sapienza" University, Rome, Italy.
| | - Francesco Saia
- Department of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S Orsola-Malpighi, Bologna, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Turin, Italy
| | - Marco Zimarino
- Department of Neuroscience, Imaging and Clinical Sciences, "Gabriele D'Annunzio" University of Chieti-Pescara, Chieti, Italy; Department of Cardiology, "SS. Annunziata Hospital", ASL 2 Abruzzo, Chieti, Italy
| | - Mario Di Marino
- Department of Neuroscience, Imaging and Clinical Sciences, "Gabriele D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Giampaolo Niccoli
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Italo Porto
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties, University of Genoa, Genoa, Italy; Cardiology Unit, Cardiothoracic and Vascular Department (DICATOV) IRCCS, Ospedale Policlinico San Martino, Genoa, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Italy; Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Italy; Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Italy; Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Enrico Fabris
- Cardio-thoraco-vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Rocco Antonio Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Carmen Spaccarotella
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Gianfranco Sinagra
- Cardio-thoraco-vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
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Martinho M, Calé R, Grade Santos J, Rita Pereira A, Alegria S, Ferreira F, José Loureiro M, Judas T, Ferreira M, Gomes A, Morgado G, Martins C, Gonzalez F, Lohmann C, Delerue F, Pereira H. Underuse of reperfusion therapy with systemic thrombolysis in high-risk acute pulmonary embolism in a Portuguese center. Rev Port Cardiol 2024; 43:55-64. [PMID: 37940074 DOI: 10.1016/j.repc.2023.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 05/16/2023] [Accepted: 07/03/2023] [Indexed: 11/10/2023] Open
Abstract
INTRODUCTION Reperfusion therapy is generally recommended in acute high-risk pulmonary embolism (HR-PE), but several population-based studies report that it is underused. Data on epidemiology, management and outcomes of HR-PE in Portugal are scarce. OBJECTIVE To determine the reperfusion rate in HR-PE patients, the reasons for non-reperfusion, and how it influences outcomes. METHODS In this retrospective cohort study of consecutive HR-PE patients admitted to a thromboembolic disease referral center between 2008 and 2018, independent predictors for non-reperfusion were assessed by multivariate logistic regression. PE-related mortality and long-term MACE (cardiovascular mortality, PE recurrence and chronic thromboembolic disease) were calculated according to the Kaplan-Meier method. Differences stratified by reperfusion were assessed using the log-rank test. RESULTS Of 1955 acute PE patients, 3.8% presented with hemodynamic instability. The overall reperfusion rate was 50%: 35 patients underwent systemic thrombolysis, one received first-line percutaneous embolectomy and one rescue endovascular treatment. Independent predictors of non-reperfusion were: age, with >75 years representing 12 times the risk of non-treatment (OR 11.9, 95% CI 2.7-52.3, p=0.001); absolute contraindication for thrombolysis (31.1%), with recent major surgery and central nervous system disease as the most common reasons (OR 16.7, 95% CI 3.2-87.0, p<0.001); and being hospitalized (OR 7.7, 95% CI 1.4-42.9, p=0.020). At a mean follow-up of 2.5±3.3 years, the survival rate was 33.8%. Although not reaching statistical significance for hospital mortality, mortality in the reperfusion group was significantly lower at 30 days, 12 months and during follow-up (relative risk reduction of death of 64% at 12 months, p=0.013). Similar results were found for MACE. CONCLUSIONS In this population, the recommended reperfusion therapy was performed in only 50% of patients, with advanced age and absolute contraindications to fibrinolysis being the main predictors of non-reperfusion. In this study, thrombolysis underuse was associated with a significant increase in short- and long-term mortality and events.
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Affiliation(s)
- Mariana Martinho
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal.
| | - Rita Calé
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | | | - Ana Rita Pereira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Sofia Alegria
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Filipa Ferreira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | | | - Tiago Judas
- Internal Medicine Department, Hospital Garcia de Orta, Almada, Portugal
| | - Melanie Ferreira
- Internal Medicine Department, Hospital Garcia de Orta, Almada, Portugal
| | - Ana Gomes
- Internal Medicine Department, Hospital Garcia de Orta, Almada, Portugal
| | - Gonçalo Morgado
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Cristina Martins
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Filipe Gonzalez
- Intensive Care Unit, Hospital Garcia de Orta, Almada, Portugal
| | - Corinna Lohmann
- Intensive Care Unit, Hospital Garcia de Orta, Almada, Portugal
| | - Francisca Delerue
- Internal Medicine Department, Hospital Garcia de Orta, Almada, Portugal
| | - Hélder Pereira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal; CCUL, CAML, Universidade de Lisboa, Lisboa, Portugal
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Calé R, Ascenção R, Bulhosa C, Pereira H, Borges M, Costa J, Caldeira D. In-hospital mortality of high-risk pulmonary embolism: a nationwide population-based cohort study in Portugal from 2010 to 2018. Pulmonology 2024:S2531-0437(23)00200-3. [PMID: 38307782 DOI: 10.1016/j.pulmoe.2023.11.002] [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: 11/05/2022] [Revised: 10/23/2023] [Accepted: 11/06/2023] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND The mortality associated with high-risk pulmonary embolism (PE) is remarkably high, and reperfusion to unload right ventricle should be a priority. However, several registries report reperfusion underuse. In Portugal, epidemiological data about the incidence, rate of reperfusion and mortality of high-risk PE are not known. METHODS Nationwide population-based temporal trend study in the incidence and outcome of high-risk PE, who were admitted to hospitals of the National Health Service in Portugal between 2010 and 2018. High-risk PE was defined as patients with PE who developed cardiogenic shock or cardiac arrest. International Classification of Diseases (ICD), 9th and 10th revision, Clinical Modification codes, were used for data from the period between 2010 and 2016 (ICD-9-CM) and 2017-2018 (ICD-10-CM), respectively. The assessment focused on trends in the use of reperfusion treatment, which was defined by application of thrombolysis or pulmonary embolectomy. A comparison was made between the use or non-use of reperfusion therapy in order to examine trends in in-hospital mortality among high-risk PE cases. RESULTS From 2010 and 2018, there were 40.311 hospitalization episodes for PE in adult patients at hospitals of the National Health Service in mainland Portugal. There was a significant increase in the annual incidence of PE (41/100.000 inhabitants in 2010 to 46/100.000 in 2018; R2=0.582, p = 0.010). The average annual incidence was 45/100.000 inhabitants/year, with 2,7% of the PE episodes (1104) categorized as high-risk. The mortality rate associated with high-risk PE was high, although it has decreased over the years (74.2% in 2010 to 63.6% in 2018; R2=0.484; p = 0.022). Thrombolytic therapy was underused in high-risk PE, and its usage has not increased in recent years (17.3% in 2010 to 21.1% in 2018, R2=-0.127; p = 0.763). Surgical pulmonary embolectomy was used in 0.27% of cases, and there was no registry of catheter-directed thrombolysis. Patients with high-risk PE undergoing reperfusion therapy had lower in-hospital mortality compared to non-reperfused patients (OR=0.52; IC95% 0.38-0.70). CONCLUSION In Portugal, between 2010 and 2018, very few patients with PE developed high-risk forms of the disease, but the mortality rate among those patients was high. The low reperfusion rate could be associated with high in-hospital mortality and highlights the need to implement advanced therapies, as an alternative to systemic thrombolysis.
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Affiliation(s)
- R Calé
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal.
| | - R Ascenção
- Centro Cardiovascular da Universidade de Lisboa-CCUL (CCUL@RISE), CAML, Faculdade de Medicina, Universidade de Lisboa, Portugal; Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - C Bulhosa
- Evigrade, an IQVIA company, Lisboa, Portugal
| | - H Pereira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal; Centro Cardiovascular da Universidade de Lisboa-CCUL (CCUL@RISE), CAML, Faculdade de Medicina, Universidade de Lisboa, Portugal
| | - M Borges
- Laboratory of Clinical Pharmacology and Therapeutics, Faculdade de Medicina, Universidade de Lisboa, Portugal; Evigrade, an IQVIA company, Lisboa, Portugal
| | - J Costa
- Evigrade, an IQVIA company, Lisboa, Portugal
| | - D Caldeira
- Centro Cardiovascular da Universidade de Lisboa-CCUL (CCUL@RISE), CAML, Faculdade de Medicina, Universidade de Lisboa, Portugal; Evigrade, an IQVIA company, Lisboa, Portugal; Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal; Serviço de Cardiologia, Departamento do Coração e Vasos, Hospital Universitário de Santa Maria-CHULN, Lisboa, Portugal; Centro de Estudos de Medicina Baseada na Evidência (CEMBE), Faculdade de Medicina, Universidade de Lisboa, Portugal
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Hobohm L, Farmakis IT, Keller K, Scibior B, Mavromanoli AC, Sagoschen I, Münzel T, Ahrens I, Konstantinides S. Pulmonary embolism response team (PERT) implementation and its clinical value across countries: a scoping review and meta-analysis. Clin Res Cardiol 2023; 112:1351-1361. [PMID: 35976429 PMCID: PMC9383680 DOI: 10.1007/s00392-022-02077-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/29/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Over the last years, multidisciplinary pulmonary embolism response teams (PERTs) have emerged to encounter the increasing variety and complexity in the management of acute pulmonary embolism (PE). We aimed to systematically investigate the composition and added clinical value of PERTs. METHODS We searched PubMed, CENTRAL and Web of Science until January 2022 for articles designed to describe the structure and function of PERTs. We performed a random-effects meta-analysis of controlled studies (PERT vs. pre-PERT era) to investigate the impact of PERTs on clinical outcomes and advanced therapies use. RESULTS We included 22 original studies and four surveys. Overall, 31.5% of patients with PE were evaluated by PERT referred mostly by emergency departments (59.4%). In 11 single-arm studies (1532 intermediate-risk and high-risk patients evaluated by PERT) mortality rate was 10%, bleeding rate 9% and length of stay 7.3 days [95% confidence interval (CI) 5.7-8.9]. In nine controlled studies there was no difference in mortality [risk ratio (RR) 0.89, 95% CI 0.67-1.19] by comparing pre-PERT with PERT era. When analysing patients with intermediate or high-risk class only, the effect estimate for mortality tended to be lower for patients treated in the PERT era compared to those treated in the pre-PERT era (RR 0.71, 95% CI 0.45-1.12). The use of advanced therapies was higher (RR 2.67, 95% CI 1.29-5.50) and the in-hospital stay shorter (mean difference - 1.6 days) in PERT era compared to pre-PERT era. CONCLUSIONS PERT implementation led to greater use of advanced therapies and shorter in-hospital stay. Our meta-analysis did not show a survival benefit in patients with PE since PERT implementation. Large prospective studies are needed to further explore the impact of PERTs on clinical outcomes. REGISTRATION Open Science Framework 10.17605/OSF.IO/SBFK9.
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Affiliation(s)
- Lukas Hobohm
- Department of Cardiology, Center of Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany.
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Karsten Keller
- Department of Cardiology, Center of Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Medical Clinic VII, University Hospital Heidelberg, Heidelberg, Germany
| | - Barbara Scibior
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Anna C Mavromanoli
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Ingo Sagoschen
- Department of Cardiology, Center of Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, Center of Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital, Academic Teaching Hospital University of Cologne, Cologne, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Thrace, Greece
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Mathew D, Seelam S, Bumrah K, Sherif A, Shrestha U. Systemic thrombolysis with newer thrombolytics vs anticoagulation in acute intermediate risk pulmonary embolism: a systematic review and meta-analysis. BMC Cardiovasc Disord 2023; 23:482. [PMID: 37770910 PMCID: PMC10540330 DOI: 10.1186/s12872-023-03528-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 05/29/2023] [Accepted: 09/22/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) comparing systemic thrombolysis to anticoagulation in intermediate risk pulmonary embolism (PE) have yielded mixed results. A prior meta-analysis on this topic had included studies that used lower than standard dose of thrombolytics and included thrombolytic agents that are no longer available. Hence, interpreting the findings of that paper is not valid in contemporary practice. OBJECTIVES We undertook a systematic review and meta-analysis of randomized controlled trials of systemic thrombolysis with newer thrombolytic agents vs anticoagulation in intermediate risk PE. METHODS This systematic review and meta-analysis is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. RESULTS Nine randomized controlled trials were included in the study. We did not find any difference in in-hospital mortality (RR: 0.79; 95% CI: 0.42-1.50; I2: 0) or risk of major bleeding (RR:2.08;95% CI: 0.98-4.42; I2: 23.9%) between systemic thrombolysis and anticoagulation. Systemic thrombolysis was associated with lower risks for vasopressor use (RR: 0.27; 95% CI: 0.11-0.64, I2: 0) and secondary/rescue thrombolysis (RR: 0.25; 95% CI: 0.14-0.45; I2: 0). But systemic thrombolysis was found to have an increased risk of intracranial hemorrhage (RR: 4.55; 95% CI: 1.30-15.91; I2:0). There was no difference in mechanical ventilation between the two groups (RR: 0.61; 95% CI: 0.31-1.19, I2:0). CONCLUSION In our meta-analysis of randomized controlled trials of systemic thrombolysis vs anticoagulation in intermediate risk PE, we did not find any difference in in-hospital mortality or overall risk of major bleeding. With systemic thrombolysis, we found lower risks for vasopressor use and need for secondary/ rescue thrombolysis and an increased risk of intracranial hemorrhage.
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Affiliation(s)
- Don Mathew
- Department of Internal Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA.
| | - Susmitha Seelam
- Department of Internal Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Karandeep Bumrah
- Department of Internal Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Akil Sherif
- Department of Cardiology, St Vincent Hospital, Worcester, MA, USA
| | - Utsav Shrestha
- Department of Pulmonary and Critical Care Medicine, West Virginia University, Morgantown, WV, USA
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8
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Karami M, Mandigers L, Miranda DDR, Rietdijk WJR, Binnekade JM, Knijn DCM, Lagrand WK, den Uil CA, Henriques JPS, Vlaar APJ. Response letter: In patients with massive pulmonary embolism, we think a combination of VA-ECMO and other therapies should be studied. J Crit Care 2021; 67:225-226. [PMID: 34794835 DOI: 10.1016/j.jcrc.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/07/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Mina Karami
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Loes Mandigers
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Dinis Dos Reis Miranda
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wim J R Rietdijk
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jan M Binnekade
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Daniëlle C M Knijn
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Wim K Lagrand
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Corstiaan A den Uil
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Intensive Care Medicine, Maasstad Hospital, Rotterdam, the Netherlands
| | - José P S Henriques
- Heart Center, Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
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9
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Hobohm L, Sagoschen I, Habertheuer A, Barco S, Valerio L, Wild J, Schmidt FP, Gori T, Münzel T, Konstantinides S, Keller K. Clinical use and outcome of extracorporeal membrane oxygenation in patients with pulmonary embolism. Resuscitation 2021; 170:285-292. [PMID: 34653550 DOI: 10.1016/j.resuscitation.2021.10.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [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: 06/09/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 02/02/2023]
Abstract
AIM OF THE STUDY Extracorporeal membrane oxygenation (ECMO) is considered a life-saving treatment option for patients in cardiogenic shock or cardiac arrest undergoing cardiopulmonary resuscitation (CPR) due to acute pulmonary embolism (PE). We sought to analyze use and outcome of ECMO with or without adjunctive treatment strategies in patients with acute PE. METHODS We retrospectively analyzed data on patient characteristics, treatments, and in-hospital outcomes for all PE patients (ICD-code I26) undergoing ECMO in Germany between 2005 and 2018. RESULTS At total of 1,172,354 patients were hospitalized with PE; of those, 2,197 (0.2%) were treated with ECMO support. Cardiac arrest requiring cardiopulmonary resuscitation was present in 77,196 (6.5%) patients. While more than one fourth of those patients were treated with systemic thrombolysis alone (n = 20,839 patients; 27.0%), a minority of patients received thrombolysis and VA-ECMO (n = 165; 0.2%), embolectomy and VA-ECMO (n = 385; 0.5%) or VA-ECMOalone (n = 588; 0.8%). A multivariable logistic regression analysis indicated the lowest risk for in-hospital death in patients who received embolectomy in combination with VA-ECMO (OR, 0.50 [95% CI, 0.41-0.61], p < 0.001), thrombolysis and VA-ECMO (0.60 [0.43-0.85], p = 0.003) or VA-ECMO alone (0.68 [0.57-0.82], p < 0.001) compared to thrombolysis alone (1.04 [0.99-1.01], p = 0.116). CONCLUSION Our findings suggest that the use of VA-ECMO alone or as part of a multi-pronged reperfusion approach including embolectomy or thrombolysis might offer survival advantages compared to thrombolysis alone in patients with PE deteriorating to cardiac arrest.
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Affiliation(s)
- Lukas Hobohm
- Department of Cardiology, University Medical Center Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.
| | - Ingo Sagoschen
- Department of Cardiology, University Medical Center Mainz, Germany
| | - Andreas Habertheuer
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany; Department of Angiology, University Hospital Zurich, Switzerland
| | - Luca Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany
| | - Johannes Wild
- Department of Cardiology, University Medical Center Mainz, Germany
| | | | - Tommaso Gori
- Department of Cardiology, University Medical Center Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, Germany
| | | | - Karsten Keller
- Department of Cardiology, University Medical Center Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany; Medical Clinic VII, University Hospital Heidelberg, Germany
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10
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Hassan AKM, Ahmed H, Ahmed Y, Elfadl AEA, Omar A. Efficacy and safety of hydro-mechanical defragmentation in intermediate- and high-risk pulmonary embolism. Egypt Heart J 2021; 73:84. [PMID: 34564780 PMCID: PMC8464550 DOI: 10.1186/s43044-021-00204-2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/01/2021] [Indexed: 11/22/2022] Open
Abstract
Background Pulmonary embolism (PE) is the third most common acute cardiovascular syndrome. Percutaneous catheter directed hydro-mechanical defragmentation (HMD) is one of the recommended treatment options for PE in patients with contraindications to thrombolytic therapy or failed systemic thrombolysis (ST). We aimed to identify the safety and outcomes of catheter directed HMD in patients with high-risk PE. This nonrandomized controlled trial enrolled all patients with confirmed diagnoses of high- and intermediate-high-risk PE from October 2019 till January 2021. Fifty patients were included and divided into two groups by the PE response team according to the presence or absence of a contraindication for ST. Group B (ST) consists of 25 patients and group A (HMD) of 25 patients who cannot receive ST. Results The two groups were comparable regarding baseline clinical characteristics with mean age 51 ± 13 years. In group A, systolic blood pressure (BP) and oxygen saturation increased after 24 h (p = 0.002) and 48 h (p < 0.001) compared to pre-HMD procedure. Mean pulmonary artery systolic pressure (PASP) and respiratory rate (RR) decreased after 48 h and at 30 days (p < 0.001) compared to pre-HMD procedure. The increase in systolic BP and oxygen saturation were significantly higher in HMD group compared with ST group after 48 h and at 30 days (p < 0.007). The decrease in PASP and RR was significantly higher in HMD group compared to ST group after 48 h and at 30 days (p < 0.001). Mortality rate at 30 days was 20% in HMD group compared to 32% in ST group. Conclusions Catheter directed HMD for high-risk and intermediate-high-risk PE is safe and effective with acceptable mortality Trial registration Clinical trial ID: NCT04099186.
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Affiliation(s)
- Ayman K M Hassan
- Cardiology Department, Assiut University, P.Box: 71526, Asyut, Egypt.
| | - Heba Ahmed
- Chest Department, Assiut University, Asyut, Egypt
| | - Yousef Ahmed
- Chest Department, Assiut University, Asyut, Egypt
| | | | - Amany Omar
- Chest Department, Assiut University, Asyut, Egypt
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11
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Katsarava Z, Akhvlediani T, Janelidze T, Gudadze T, Todua M, Akhvlediani K, Khinikadze M, Egutidze G, Margania T, Tsiskaridze A. Establishing Stroke Services in the Republic of Georgia. Eur Neurol 2021; 85:56-64. [PMID: 34569481 DOI: 10.1159/000518845] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 07/27/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This article summarizes the medical experience in establishing stroke units and systemic thrombolysis in Georgia, which, like many other post-Soviet countries, still faces problems in organizing stroke care even after 30 years of independence. PATIENTS AND METHODS We created an example of treating acute stroke with systemic thrombolysis and introduced stroke units in several hospitals in the country, including standardization of the diagnostic and treatment process, consistent evaluation, and monthly feedback to the stroke unit staff. RESULTS Systemic thrombolysis has become a clinical routine in some large hospitals and is meanwhile reimbursed by the state insurance. The data of consecutive 1,707 stroke patients in 4 major cities demonstrated significant time lost at the prehospital level, due to failure in identifying stroke symptoms, delay in notification, or transportation. The consequent quality reports resulted in a dramatic increase in adherence to the European and national guidelines. A mandatory dysphagia screening and subsequent treatment led to a decrease in pneumonia rates. DISCUSSION We discuss our experience and suggestions on how to overcome clinical, financial, and ethical problems in establishing a stroke services in a developing country. CONCLUSION The Georgian example might be useful for doctors in other post-Soviet countries or other parts of the world.
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Affiliation(s)
- Zaza Katsarava
- Evex Medical Corporation, Tbilisi, Georgia.,Evangelical Hospital Unna, Unna, Germany.,Department of Neurology, University of Duisburg-Essen, Essen, Germany.,I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Tamar Akhvlediani
- American MD Program, Faculty of Medicine, Tbilisi State Medical University, Tbilisi, Georgia
| | | | | | | | | | - Mirza Khinikadze
- Evex Medical Corporation, Tbilisi, Georgia.,Pineo Medical Ecosystem, Tbilisi, Georgia.,Tbilisi Institute of Medicine, Tbilisi, Georgia.,New Vision University, Tbilisi, Georgia
| | | | | | - Alexander Tsiskaridze
- Pineo Medical Ecosystem, Tbilisi, Georgia.,Tbilisi Institute of Medicine, Tbilisi, Georgia.,Ivane Javakhishvili Tbilisi State University, Tbilisi, Georgia.,Georgian Stroke Association, Tbilisi, Georgia
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12
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Bralic M, Sosic M, Kovacic S, Vuletic V. Reperfusion therapy in a patient with early recurrence of ischemic stroke. Neurol Sci 2021; 43:673-676. [PMID: 34480242 DOI: 10.1007/s10072-021-05587-3] [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: 06/17/2021] [Accepted: 08/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute ischemic stroke (AIS) has a high risk of recurrence, particularly in the early stage. Recurrent ischemic stroke (RIS) is associated with adverse neurological outcomes but the phenomenon of early RIS in the endovascular thrombectomy era has not been frequently discussed. We report a case addressing this issue. CASE PRESENTATION We present a patient who was successfully treated by mechanical thrombectomy (MT) for middle cerebral artery occlusion. Due to an early stroke recurrence, within 72 h after the first MT, he received systemic thrombolysis and repeated MT was performed with excellent clinical outcome. DISCUSSION We discuss the aspects of reperfusion therapy for patients experiencing early stroke recurrence. Consideration was given to stroke etiology and off-label use of thrombolytic therapy. Also, effectiveness of repeated MT for early re-occlusion of initially reanalyzed vessel was evaluated in order to allow more patients with RIS to benefit from reperfusion therapy.
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Affiliation(s)
- Marina Bralic
- Department of Neurology, Clinical Hospital Centre Rijeka, Kresimirova 42, 51 000, Rijeka, Croatia.
| | - Matija Sosic
- Department of Neurology, Clinical Hospital Centre Rijeka, Kresimirova 42, 51 000, Rijeka, Croatia
| | - Slavica Kovacic
- Department of Radiology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - Vladimira Vuletic
- Department of Neurology, Clinical Hospital Centre Rijeka, Kresimirova 42, 51 000, Rijeka, Croatia
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13
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Pasha AK, Siddiqui MU, Siddiqui MD, Ahmed A, Abdullah A, Riaz I, Murad MH, Bjarnason H, Wysokinski WE, McBane RD. Catheter directed compared to systemically delivered thrombolysis for pulmonary embolism: a systematic review and meta-analysis. J Thromb Thrombolysis 2021; 53:454-466. [PMID: 34463919 DOI: 10.1007/s11239-021-02556-7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
To compare the efficacy and safety of systemic and catheter directed thrombolysis for patients with pulmonary embolism. Pubmed and Cochrane Central Register of Controlled Trials were systematically searched from inception to May 31st 2020 to identify relevant studies. Outcomes of interest were in-hospital mortality and major bleeding including intracranial hemorrhage. We included 8 observational studies comprising 11,932 patients with PE. Catheter directed thrombolysis was associated with lower in-hospital mortality [RR 0.52; 95% confidence interval (CI) 0.40-0.68]. Although there was no difference in major bleeding by treatment strategy (RR 0.80; 95% CI 0.37-1.76), intracranial hemorrhage was lower in patients receiving catheter directed therapy (RR 0.66; 95% CI, 0.47-0.94).The certainty in these estimates was low. Non-randomized studies suggest that catheter directed delivery of thrombolytic therapy may be associated with lower in-hospital mortality and intracranial hemorrhage rates. These results may help inform management strategies for health care and pulmonary embolism response teams (PERT) involved in the management of high risk patients with massive or submassive pulmonary emboli.
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Affiliation(s)
- Ahmed K Pasha
- Vascular Division, Department of Cardiology, Mayo Clinic, Rochester, MN, 55905, USA.,Gonda Vascular Center, Mayo Clinic, Rochester, MN, 55905, USA
| | | | | | - Adnan Ahmed
- Amita St. Joseph Hospital, Chicago, IL, 60657, USA
| | - Ammar Abdullah
- Department of Medicine, University of South Dakota, Vermillion, SD, 57069, USA
| | - Irbaz Riaz
- Division of Hematology and Oncology, Mayo Clinic, Rochester, MN, 55905, USA
| | - M Hassan Murad
- Mayo Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, USA.,Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Haraldur Bjarnason
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, 55905, USA.,Interventional Radiology Division, Department of Radiology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Waldemar E Wysokinski
- Vascular Division, Department of Cardiology, Mayo Clinic, Rochester, MN, 55905, USA.,Gonda Vascular Center, Mayo Clinic, Rochester, MN, 55905, USA
| | - Robert D McBane
- Vascular Division, Department of Cardiology, Mayo Clinic, Rochester, MN, 55905, USA. .,Gonda Vascular Center, Mayo Clinic, Rochester, MN, 55905, USA.
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14
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Keller K, Hobohm L, Münzel T, Lankeit M, Ostad MA. Impact of pulmonary embolism on in-hospital mortality of patients with ischemic stroke. J Neurol Sci 2020; 419:117174. [PMID: 33059297 DOI: 10.1016/j.jns.2020.117174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 09/09/2020] [Accepted: 10/05/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is a frequent complication in immobile stroke patients and an important cause of death in stroke patients. We aimed to investigate predictors of PE and the impact of PE on survival of ischemic stroke patients. METHODS Patients were selected by screening the German nationwide inpatient sample (2005-2017) for ischemic stroke (ICD-code I63) and stratified for occurrence of PE (ICD-code I26). Impact of PE on mortality and predictors for PE in ischemic stroke patients were analysed. RESULTS Overall, 2,914,546 patients were hospitalized due to ischemic stroke (50.5% females; 69.3% aged ≥70 years) in Germany 2005-2017. Among these, 0.4% had PE and 7.2% died during hospitalization. In-hospital mortality rate of ischemic stroke patients with PE was substantially higher compared to those patients without PE (28.4% vs. 7.1%, P < 0.001). PE was strongly associated with in-hospital death (OR 5.786, 95%CI 5.515-6.070, P < 0.001). Important predictors of PE were cancer (OR 3.165, 95%CI 2.969-3.374, P < 0.001), coagulation abnormalities (OR 2.672, 95CI 2.481-2.878, P < 0.001), heart failure (OR 1.553, 95%CI 1.472-1.639, P < 0.001) and obesity (OR 1.559, 95%CI 1.453-1.672, P < 0.001). Systemic thrombolysis was not beneficial regarding survival in unselected ischemic stroke patients. In contrast, systemic thrombolysis was beneficial in ischemic stroke patients without PE, who had to undergo cardio-pulmonary resuscitation (OR 0.866, 95%CI 0.782-0.960, P = 0.006). CONCLUSIONS Patients with ischemic stroke revealed still a high in-hospital mortality of 7.2% in Germany. While only a minority of 0.4% of the ischemic stroke patients suffered from occurrence of PE, PE was accompanied by a substantial increase regarding in-hospital mortality. Systemic thrombolysis was beneficial regarding short-term survival in ischemic stroke patients without PE, who had to undergo cardio-pulmonary resuscitation.
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15
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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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16
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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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17
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Zuin M, Rigatelli G, Zuliani G, Zonzin P, Ramesh D, Roncon L. Thrombolysis in hemodynamically unstable patients: still underused: a review based on multicenter prospective registries on acute pulmonary embolism. J Thromb Thrombolysis 2019; 48:323-330. [PMID: 31025166 DOI: 10.1007/s11239-019-01867-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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] [Indexed: 10/27/2022]
Abstract
Hemodynamically unstable pulmonary embolism (PE) represents a complex and life-threatening event with a highly variable course and poor prognosis in the short-term period. Despite an immediate reperfusion treatment is recommended in these patients, previous investigations have reported a lower use of systemic thrombolysis (ST). The aim of the present review is to assess and describe the real use of ST in hemodynamically unstable patients with acute PE enrolled in prospective-multicenter registries between the 1990 and 2018. Over that period, 1216 articles were identified in Pubmed. After excluding the duplicates obtained using the different searching MeSH (n = 703), 513 articles were screened and then excluded for not meeting inclusion criteria due the article type, design of the study or no English language. As result, 13 articles were assessed for eligibility and carefully reviewed. Finally, five studies met the inclusion criteria and were included in the analysis. The identified study registries enrolled prospectively 41364 consecutive patients with acute PE between the 1993 and the 2016. Among these, 2168 (5.2%) were hemodynamically unstable at presentation. ST was administered in 29.7% (n = 645) of patients while catheter-direct treatment (CDT) was used only in 1.4% (n = 32) of cases. Conversely, surgical pulmonary embolectomy (SPE) was adopted as reperfusion treatment in 39 patients (1.7%). Intriguingly, the 68% of patients not received a reperfusion treatment despite they were hemodynamically unstable at admission. Despite the internationals guidelines recommendations, a prompt reperfusion is performed only in one on three hemodynamically unstable patients with acute PE.
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Affiliation(s)
- Marco Zuin
- Section of Internal and Cardiopulmonary Medicine, University of Ferrara, Ferrara, Italy
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | - Gianluca Rigatelli
- Cardiovascular Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Rovigo, Italy
| | - Giovanni Zuliani
- Section of Internal and Cardiopulmonary Medicine, University of Ferrara, Ferrara, Italy
| | - Pietro Zonzin
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | - Daggubati Ramesh
- Division of Cardiology, Department of Cardiovascular Sciences, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Loris Roncon
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy.
- Department of Cardiology, Santa Maria della Misericordia Hospital, Viale Tre Martiri 140, 45100, Rovigo, Italy.
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18
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Virk HUH, Chatterjee S, Sardar P, Bavishi C, Giri J, Chatterjee S. Systemic Thrombolysis for Pulmonary Embolism: Evidence, Patient Selection, and Protocols for Management. Interv Cardiol Clin 2018; 7:71-80. [PMID: 29157526 DOI: 10.1016/j.iccl.2017.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Acute pulmonary embolism presents a clinical challenge for optimal risk stratification. Although associated with significant morbidity and mortality at the population level, the spectrum of presentation in an individual patient varies from mild symptoms to cardiac arrest. Treatment options include anticoagulation, systemic thrombolysis, catheter-based interventions, and surgical embolectomy. In this article, an attempt is made to optimally identify patients who, based on available evidence, may benefit from systemic thrombolytic therapy. The clinical efficacy of systemic thrombolysis must be balanced against increased risks of major bleeding and intracranial hemorrhage.
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19
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Knadler JJ, Zobeck M, Masand P, Sartain S, Kyle WB. In Utero Aortic Arch Thrombosis Masquerading as Interrupted Aortic Arch: A Case Report and Review of the Literature. Pediatr Cardiol 2019; 40:658-663. [PMID: 30734851 DOI: 10.1007/s00246-019-02068-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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] [Received: 11/03/2018] [Accepted: 01/31/2019] [Indexed: 10/27/2022]
Abstract
Aortic arch thrombosis is an extremely rare but life-threatening diagnosis that is often misdiagnosed in the neonatal period. Strategies including surgical intervention, systemic anticoagulation, and thrombolysis have been previously described in the treatment of these neonates. We describe the case of a neonate who presented with concern for interrupted aortic arch and was diagnosed with an in utero aortic arch thrombosis. To our knowledge, this is the first reported case with evidence of aortic arch thrombosis in fetal life. The patient underwent successful treatment with systemic thrombolysis with tissue plasminogen activator. A brief review of the literature regarding the diagnosis, treatment, and management of neonatal aortic arch thrombosis is also presented.
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Affiliation(s)
- Joseph J Knadler
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin St, Legacy Tower, E1920, Houston, TX, 77030, USA.
| | - Mark Zobeck
- Section of Hematology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin St, Houston, TX, 77030, USA
| | - Prakash Masand
- Section of Radiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin St, Houston, TX, 77030, USA
| | - Sarah Sartain
- Section of Hematology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin St, Houston, TX, 77030, USA
| | - William B Kyle
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, 6621 Fannin St, Legacy Tower, E1920, Houston, TX, 77030, USA
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20
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Heinrichs A, Nikoubashman O, Schürmann K, Tauber SC, Wiesmann M, Schulz JB, Reich A. Relevance of standard intravenous thrombolysis in endovascular stroke therapy of a tertiary stroke center. Acta Neurol Belg 2018; 118:105-111. [PMID: 29435828 DOI: 10.1007/s13760-018-0892-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 11/06/2017] [Accepted: 02/01/2018] [Indexed: 11/26/2022]
Abstract
The majority of patients undergoing endovascular stroke treatment (EST) in randomized controlled trials received additional systemic thrombolysis ("combination or bridging therapy (C/BT)"). Nevertheless, its usefulness in this subtype of acute ischemic stroke (AIS) is discussed controversially. Of all consecutive AIS patients, who received any kind of reperfusion therapy in a tertiary university stroke center between January 2015 and March 2016, those with large vessel occlusions (LVO) and EST with or without additional C/BT, were compared primarily regarding procedural aspects. Data were extracted from an investigator-initiated, single-center, prospective and blinded end-point study. 70 AIS patients with EST alone and 118 with C/BT were identified. Significant baseline differences existed in pre-existing cardiovascular disease (52.9% (EST alone) vs. 35.6% (C/BT), p = 0.023), use of anticoagulation (30.6% vs. 5.9%, p < 0.001), and frequency of unknown time of symptom onset (65.7% vs. 32.2%, p < 0.001), in-hospital stroke (18.6% vs. 1.7%, p < 0.001), pre-treatment ASPECT scores (7.9 vs. 8.9, p = 0.004), and frequency of occlusion in the posterior circulation (18.6% vs. 5.1%, p = 0.003). Pre-interventional procedural time intervals tended to be shorter in the C/BT group, reaching statistical significance in door-to-image time (30.3 (EST alone) vs. 22.2 min (C/BT), p < 0.001). Good clinical outcome (mRS d90) was reached more often in the C/BT group (24.5% vs. 11.8%, p = 0.064). Rates of symptomatic intracranial hemorrhages (sICH) were comparable (4.3% (EST alone) vs. 6.8% (C/BT), p = 0.481). Additional systemic thrombolysis did not delay EST. On the contrary, application of IVRTPA seemed to be a positive indicator for faster EST without increased side effects.
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Affiliation(s)
- Annette Heinrichs
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany
| | - Kolja Schürmann
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Simone C Tauber
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany
| | - Jörg B Schulz
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen, Germany
| | - Arno Reich
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.
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21
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Poor AD, Poor HD. Successful Treatment of Refractory Massive Pulmonary Embolism with Repeated Administration of Systemic Thrombolysis. Tanaffos 2018; 17:127-131. [PMID: 30627185 PMCID: PMC6320563] [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] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND We report a case series of two patients in the intensive care unit with massive pulmonary embolism and obstructive shock who had resolution of shock after repeated administration of alteplase. CASE SUMMARIES Both patients were initially dosed 10 mg of alteplase followed by infusion of 90 mg over 2 hours, but remained in obstructive shock requiring significant inotropic and vasopressor support. Both patients were deemed poor candidates for embolectomy. The first patient received repeated doses reaching an accumulative dose of 200 mg alteplase over 15 hours. The second patient received an accumulative dose of 250 mg alteplase over 36 hours. Both patients had resolution of shock within 24 hours of repeated administration of alteplase, but also experienced significant drops in hemoglobin, which were supported with transfusions. They were transferred out of the intensive care unit after resolution of obstructive shock and hemorrhage. The first patient died one week after transfer from the intensive care unit due to invasive candidiasis and septic shock. The second patient was weaned from the ventilator and discharged home. CONCLUSION Patients with obstructive shock secondary to massive pulmonary embolism despite a one-time dose of alteplase and poor candidacy for embolectomy may benefit from repeated doses of alteplase. Due to the short half-life, repeated administration of thrombolytic may be appropriate for younger patients without absolute contraindications to thrombolysis, but future studies are needed to identify the optimal patient population.
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Affiliation(s)
- Armeen D. Poor
- Correspondence to: Armeen D. Poor Address: Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029 USA, Email address:
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22
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Nardetto L, Giometto B, Moretto G, Mantoan D, Saia M. Hub-and-spoke stroke network in the Veneto region: a retrospective study investigating the effectiveness of the stroke pathway and trends over time. Neurol Sci 2017; 38:2117-2121. [PMID: 28905212 DOI: 10.1007/s10072-017-3118-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 05/07/2017] [Accepted: 09/07/2017] [Indexed: 01/03/2023]
Abstract
After recognizing the pivotal role played by stroke unit (SU) admission in reducing mortality and dependency in stroke patients, the need to organize and monitor stroke networks has become an increasingly essential aspect of stroke care. We conducted a retrospective study of stroke patients admitted to hospitals in the Veneto region from 2007 to 2015 in order to evaluate the effectiveness of the stroke pathway and trends over time. Between 2007 and 2015, 61,062 stroke patients were discharged from Veneto hospitals: they were more frequently female, females were older than males, and had higher intrahospital mortality and a lower probability of undergoing systemic thrombolysis. Patients admitted to facilities with a level 2 SU were twice as likely to undergo thrombolytic treatment compared to those admitted to facilities with a level 1 and had a lower intrahospital mortality rate. During the collection period, thrombolytic treatments increased in both level 1 and 2 SUs, as did the number of patients admitted to neurology wards and to facilities with an SU. Our study confirmed that thrombolytic treatment and admission to a facility with an SU are important determinants in improving stroke patient outcome. The increase in the proportion of both SU admissions and thrombolytic treatments demonstrates the effectiveness of the regional hub-and-spoke organization model, suggesting that implementation of highly specialized facilities is an efficient strategy in improving stroke care. The role of the observed sex bias in stroke treatment and outcome needs to be explored.
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Affiliation(s)
- L Nardetto
- Neurology, Ospedale San Antonio, Via Facciolati n° 71, 35127, Padua, Italy.
| | - B Giometto
- Neurology, Ospedale San Antonio, Via Facciolati n° 71, 35127, Padua, Italy
| | - G Moretto
- Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - D Mantoan
- Veneto Region Health Directorate, Venice, Italy
| | - M Saia
- Medical Directorate, Ospedale San Antonio, Padua, Italy
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23
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Falsetti L, Viticchi G, Buratti L, Balucani C, Marra AM, Silvestrini M. From head to toe: Sex and gender differences in the treatment of ischemic cerebral disease. Pharmacol Res 2017; 121:240-250. [PMID: 28506796 DOI: 10.1016/j.phrs.2017.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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] [Received: 08/08/2016] [Revised: 03/27/2017] [Accepted: 05/09/2017] [Indexed: 11/27/2022]
Abstract
Stroke is a major cause of mortality and morbidity, particularly in the older ages. Women have a longer life expectancy and are more likely to experience stroke than men. Interestingly, the increased risk of ischemic stroke in women seems to be independent from age or classical cardiovascular risk factors. Notwithstanding the fact that stroke outcomes and survival are usually poorer in women, current evidence suggests that thrombolysis, antiplatelet and anticoagulant therapies are more beneficial in women than in men. A possible explanation of this paradox might be that females are often undertreated and they have fewer chances to be submitted to an effective and timely treatment for stroke than the male counterpart. The first step in the attempt to solve this obvious discrimination is surely to emphasize any reasons for differences in the therapeutic approach in relation to gender and then to denounce the lack of a sustainable motivation for them. In this article, we aimed to review the existing literature about gender-related differences on efficacy, administration and side effects of the most common drugs used for the treatment of ischemic stroke. The most striking result was the evidence that the therapeutic approach for stroke is often different according to patients' gender with a clear detrimental prognostic effect for women. A major effort is necessary to overcome this problem in order to ensure equal right to treatment without any sexual discrimination.
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Affiliation(s)
- Lorenzo Falsetti
- Internal and Sub-intensive Medicine Department, A.O.U. "Ospedali Riuniti", Ancona, Italy; University of Bologna, Cardio-Nephro-Thoracic Sciences PhD School, Italy.
| | - Giovanna Viticchi
- Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Laura Buratti
- Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Clotilde Balucani
- Department of Neurology, SUNY Downstate Medical Center, Brooklyn, New York, United States
| | | | - Mauro Silvestrini
- Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
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24
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Comerota AJ, Sandset PM, Konstantinides S, de Graaf R, Wakefield TW, Arnoldussen CWKP, Lam YL, van Gent WB, de Wolf MAF, Catarinella FS, Kurstjens RLM, Alshabatat A, Wittens CHA. Theme 4: Invasive management of (recurrent) VTE and PTS. Thromb Res 2015; 136 Suppl 1:S19-25. [PMID: 26387732 DOI: 10.1016/j.thromres.2015.07.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | | | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Rick de Graaf
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Thomas W Wakefield
- Department of Surgery, Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, Ann Arbor, MI, USA
| | - Carsten W K P Arnoldussen
- Department of Radiology and Interventional Radiology, VieCuri Medical Centre, Venlo, The Netherlands
| | - Yee Lai Lam
- Department of Venous Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wijnand B van Gent
- Department of Venous Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Mark A F de Wolf
- Department of Venous Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Fabio S Catarinella
- Department of Venous Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ralph L M Kurstjens
- Department of Venous Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ashraf Alshabatat
- Department of Venous Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Vascular Surgery, University Hospital Aachen, Aachen, Germany
| | - Cees H A Wittens
- Department of Venous Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Vascular Surgery, University Hospital Aachen, Aachen, Germany.
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25
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Almendrote M, Millán M, Prats LA, Pérez de la Ossa N, López-Cancio E, Gomis M, Dorado L, Hernández-Pérez M, Hidalgo C, García-Bermejo P, Castaño C, Domenech S, Dávalos A. Impact of a comprehensive stroke centre on the care of patients with acute ischaemic stroke due to cervical artery dissection. Neurologia 2014; 30:331-8. [PMID: 24560473 DOI: 10.1016/j.nrl.2014.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 12/25/2013] [Accepted: 01/16/2014] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Cervical artery dissection (CAD) is the cause of 2% to 3% of ischaemic strokes and 10% to 25% of the ischaemic strokes in young people. Our objective is to evaluate whether implementation of a comprehensive stroke centre (CSC) improves the diagnosis and modifies the prognosis of patients with acute stroke due to CAD. PATIENTS AND METHODS Retrospective study of a registry of consecutive patients with acute stroke due to CAD. They were classified according to the period of care at our centre: pre-CSC (October 2004-March 2008, 42 months) or post-CSC (April 2008-June 2012, 51 months). We compared baseline characteristics, methods of diagnosis, treatment and outcome of these patients in both periods. RESULTS Nine patients were diagnosed with CAD in pre-CSC and 26 in post-CSC, representing 0.8% and 2.1% of all ischaemic strokes treated in each period, respectively. The diagnosis of CAD was made within the first 24 hours in 42.3% of the patients in post-CSC versus 0% in pre-CSC, by using urgent cerebral angiography as a diagnostic test in 46.2% of cases in the second period compared to 0% in the first. Both severity of stroke (median NIHSS score 11 vs. 3, P=.014) and time to neurological care (265 min vs 148, P=.056) were higher in the post-CSC period. Endovascular treatment was performed in 34.3%, and all treatments were post-CSC. The functional outcome was comparable for both periods. CONCLUSIONS Implementation of a CSC increases the frequency of the diagnosis of CAD, as well as the treatment options for these patients in the acute phase of stroke.
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Affiliation(s)
- M Almendrote
- Unidad de Ictus, Hospital Germans Trias i Pujol, Badalona, Barcelona, España.
| | - M Millán
- Unidad de Ictus, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - L A Prats
- Unidad de Ictus, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - N Pérez de la Ossa
- Unidad de Ictus, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - E López-Cancio
- Unidad de Ictus, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - M Gomis
- Unidad de Ictus, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - L Dorado
- Unidad de Ictus, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - M Hernández-Pérez
- Unidad de Ictus, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - C Hidalgo
- Unidad de Neurorradiología Intervencionista, Departamento de Neurociencias, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - P García-Bermejo
- Unidad de Neurorradiología Intervencionista, Departamento de Neurociencias, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - C Castaño
- Unidad de Neurorradiología Intervencionista, Departamento de Neurociencias, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - S Domenech
- Institut de Diagnòstic per la Imatge, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
| | - A Dávalos
- Unidad de Ictus, Hospital Germans Trias i Pujol, Badalona, Barcelona, España
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