Association between statin use and acute pulmonary embolism in intensive care unit patients with sepsis: a retrospective cohort study

Introduction

Acute pulmonary embolism (APE) is a life-threatening medical condition that is frequently encountered and associated with significant incidence and mortality rates, posing a substantial threat to patients' well-being and quality of life. Sepsis is prominent independent risk factor for the development of APE. Despite recent investigations indicating a reduced APE risk through statin therapy, its impact on patients with sepsis and APE remains unresolved.

Methods

The Medical Information Mart for Intensive Care (MIMIC)-IV database was utilized to identify patients diagnosed with sepsis and APE, irrespective of statin treatment status, as part of this study. The primary study aim was to assess the risk of APE, which was analyzed using multivariate logistic regression models.

Results

The study encompassed a total of 16,633 participants, with an average age of 64.8 ± 16.2 years. Multivariate logistic regression revealed that septic patients receiving statin therapy in the intensive care unit (ICU) exhibited a 33% reduction in the risk of developing APE (OR = 0.67, 95% CI: 0.52-0.86, p < 0.001). The findings of further analyses, including stratification based on statin usage, dosage, and propensity score matching, consistently reinforced the hypothesis that administering statins to patients with sepsis effectively mitigates their potential APE risk.

Discussion

The results of the study provide compelling evidence in favor of administering statins to septic patients as a prophylactic measure against APE, given that statins may reduce the risk of developing APE, and their anti-APE effect appears to be dose-dependent. Nonetheless, future randomized controlled trials are needed to validate these results.

A cross-sectional study of outcomes for patients undergoing mechanical thrombectomy for pulmonary embolism during 2018-2022: Insights from the PINC AI Healthcare Database

Background and Aims

Mechanical thrombectomy (MT) treatments for pulmonary embolism (PE) have yet to be compared directly. We aimed to determine if patient outcomes varied following treatment of PE with different MT devices.

Methods

All PE encounters with an index treatment of MT between January 2018 and March 2022 were analyzed for in-hospital mortality, discharge to home, and 30-day readmission outcomes in the PINC AI™ Healthcare Database. MT devices used in each encounter were extracted from hospital charge description free-text fields using keyword text and fuzzy matching. Unadjusted and adjusted logistic regression was used to model outcomes by device.

Results

A total of 5893 encounters were identified using MT as the sole index PE treatment and 1812 using MT with another treatment. Of these, 41% had insufficient information to identify the devices used (unspecified MT), 33% used the FlowTriever System (large-bore volume-controlled aspiration MT), 23% the Indigo System (continuous aspiration MT), and 3% some other MT. Large-bore volume-controlled aspiration MT was used with other treatments 13% of the time compared with 23% and 39% for unspecified MT and continuous aspiration MT, respectively. Adjusted logistic regression modeling revealed the odds of in-hospital mortality were significantly higher for patients treated with unspecified MT ([OR] = 1.42, 95% confidence interval [CI]: [1.10-1.83], p = 0.008) or continuous aspiration MT (OR = 1.63, 95% CI: [1.21-2.19], p = 0.001) compared with large-bore volume-controlled aspiration MT. Discharge to home was significantly lower in these same groups (OR = 0.84, 95% CI: [0.73-0.96], p = 0.01, and OR = 0.63, 95% CI: [0.53-0.74], p < 0.001, respectively), but readmission risks at 30 days were comparable (OR = 1.08, 95% CI: [0.84-1.38], p = 0.56, and OR = 1.20, 95% CI: [0.89-1.62], p = 0.24, respectively).

Conclusion

PE outcomes and treatment patterns differ significantly based on the type of MT utilized. Clinical studies directly comparing MT treatments are needed to further understand optimal treatment of PE.

Sildenafil improves hemodynamic changes caused by acute pulmonary embolism by inhibiting Rho kinase activity

OBJECTIVE

This study examined the effects of sildenafil on acute pulmonary embolism (APE) using a rat model.

METHODS

Sprague-Dawley rats were randomly divided into the sham, pulmonary thromboembolism (PTE), and sildenafil groups. The sham and PTE groups received normal saline once daily via gavage for 14 consecutive days, whereas the sildenafil group received sildenafil (0.5 mg/kg/day) once daily via gavage for 14 consecutive days. Autologous emboli were prepared from blood samples collected from the left femoral artery of rats in each group on day 13, and autologous emboli were injected into the jugular vein cannula of rats in the PTE and sildenafil groups on day 14. Sham-treated rats received the same volume of saline. Right systolic ventricular pressure (RVSP) and mean pulmonary arterial pressure (MPAP) were used to assess pulmonary embolism, and western blotting and enzyme-linked immunosorbent assay were used to detect relevant markers.

RESULTS

The Rho kinase signaling pathway was significantly activated in rats with APE, and sildenafil significantly inhibited this activation.

CONCLUSIONS

Sildenafil protected against APE through inhibiting Rho kinase activity, thereby reducing pulmonary vasoconstriction and decreasing elevated pulmonary arterial pressure. These findings might provide new ideas for the clinical treatment of acute pulmonary thromboembolism.

A machine learning model for diagnosing acute pulmonary embolism and comparison with Wells score, revised Geneva score, and Years algorithm

BACKGROUND

Acute pulmonary embolism (APE) is a fatal cardiovascular disease, yet missed diagnosis and misdiagnosis often occur due to non-specific symptoms and signs. A simple, objective technique will help clinicians make a quick and precise diagnosis. In population studies, machine learning (ML) plays a critical role in characterizing cardiovascular risks, predicting outcomes, and identifying biomarkers. This work sought to develop an ML model for helping APE diagnosis and compare it against current clinical probability assessment models.

METHODS

This is a single-center retrospective study. Patients with suspected APE were continuously enrolled and randomly divided into two groups including training and testing sets. A total of 8 ML models, including random forest (RF), Naïve Bayes, decision tree, K-nearest neighbors, logistic regression, multi-layer perceptron, support vector machine, and gradient boosting decision tree were developed based on the training set to diagnose APE. Thereafter, the model with the best diagnostic performance was selected and evaluated against the current clinical assessment strategies, including the Wells score, revised Geneva score, and Years algorithm. Eventually, the ML model was internally validated to assess the diagnostic performance using receiver operating characteristic (ROC) analysis.

RESULTS

The ML models were constructed using eight clinical features, including D-dimer, cardiac troponin T (cTNT), arterial oxygen saturation, heart rate, chest pain, lower limb pain, hemoptysis, and chronic heart failure. Among eight ML models, the RF model achieved the best performance with the highest area under the curve (AUC) (AUC = 0.774). Compared to the current clinical assessment strategies, the RF model outperformed the Wells score ( P = 0.030) and was not inferior to any other clinical probability assessment strategy. The AUC of the RF model for diagnosing APE onset in internal validation set was 0.726.

CONCLUSIONS

Based on RF algorithm, a novel prediction model was finally constructed for APE diagnosis. When compared to the current clinical assessment strategies, the RF model achieved better diagnostic efficacy and accuracy. Therefore, the ML algorithm can be a useful tool in assisting with the diagnosis of APE.

Clinical Features and Predictors of Mortality in Patients With Acute Pulmonary Embolism: A Retrospective Study From Southern Saudi Arabia

BACKGROUND AND METHODOLOGY

We aimed to investigate the clinical characteristics, outcomes, and mortality predictors in patients with acute pulmonary embolism (PE). Adult patients who were admitted to the Armed Forces Hospital Southern Region, Khamis Mushait, a large tertiary hospital in Southern Saudi Arabia, with the diagnosis of acute PE were retrospectively examined for the predictors of one-year mortality.

RESULTS

The overall in-hospital mortality was 15.6% among 212 patients. In univariate analysis, only age was significantly associated with increased early mortality, whereas age, obesity, presence of active malignancy, hypertension, use of thrombolytics, and Simplified Pulmonary Embolism Severity Index (sPESI) were significantly associated with increased late mortality. By use of binary logistic regression, the presence of obesity (HR 6.010, 95%CI 0.048-16.853, p=0.030), active malignancy (HR 3.040, 95%CI 1.147-8.059, p=0.025), and the use of thrombolytics (HR 8.074, 95%CI 2.719-23.977, p<0.001), were independently significant factors for late (overall) mortality, respectively.

CONCLUSIONS

Among Saudi Arabian patients in the Southern Region, our data show that age is an independent factor for increased early and late mortality. The presence of obesity, active malignancy, and the use of thrombolytics, were independently significant factors for increased late (one-year) mortality. These factors should be taken into account for risk stratification and decisions on tailored management of patients with PE. Further prospective multicenter studies are needed.

Clinical characteristics, risk factors and outcomes of acute pulmonary embolism in Thailand: 6-year retrospective study

Background & Objectives

Acute pulmonary embolism (APE) is a fatal disease with varying clinical characteristics and imaging. The aim of this study was to define the clinical characteristics, risk factors, and outcomes in patients with APE at a university hospital in Thailand.

Methods

Patients diagnosed with APE and admitted to our institute between January 1, 2017 and December 31, 2022 were retrospectively enrolled. The clinical characteristics, investigations, and outcomes were recorded.

Results

Over the 6-year study period, 369 patients were diagnosed with APE. The mean age was 65 years; 64.2% were female. The most common risk factor for APE was malignancy (46.1%). In-hospital mortality rate was 23.6%. The computed tomography pulmonary artery (PA) revealed the most proximal clots largely in segmental PA (39.0%), followed by main PA (36.3%). This distribution was consistent between survivors and non-survivors. Multivariate logistic regression analysis revealed that APE mortality was associated with active malignancy, higher serum creatinine, lower body mass index (BMI), and tachycardia with adjusted OR (95% CI) of 3.70 (1.59, 8.58), 3.54 (1.35, 9.25), 2.91 (1.26, 6.75), and 2.54 (1.14, 5.64), respectively. The prediction model was constructed with area under the curve (95% CI) of 0.77 (0.70, 0.84).

Conclusion

The overall mortality rate among APE patients was 23.6%, with APE-related death accounting for 5.1%. APE mortality was associated with active malignancy, higher serum creatinine, lower BMI, and tachycardia.

Enhancing Pulmonary Embolism Mortality Risk Stratification Using Machine Learning: The Role of the Neutrophil-to-Lymphocyte Ratio

(1) Background: Acute pulmonary embolism (PE) is a significant public health concern that requires efficient risk estimation to optimize patient care and resource allocation. The purpose of this retrospective study was to show the correlation of NLR (neutrophil-to-lymphocyte ratio) and PESI (pulmonary embolism severity index)/sPESI (simplified PESI) in determining the risk of in-hospital mortality in patients with pulmonary thromboembolism. (2) Methods: A total of 160 patients admitted at the County Clinical Emergency Hospital of Sibiu from 2019 to 2022 were included and their hospital records were analyzed. (3) Results: Elevated NLR values were significantly correlated with increased in-hospital mortality. Furthermore, elevated NLR was associated with PESI and sPESI scores and their categories, as well as the individual components of these parameters, namely increasing age, hypotension, hypoxemia, and altered mental status. We leveraged the advantages of machine learning algorithms to integrate elevated NLR into PE risk stratification. Utilizing two-step cluster analysis and CART (classification and regression trees), several distinct patient subgroups emerged with varying in-hospital mortality rates based on combinations of previously validated score categories or their defining elements and elevated NLR, WBC (white blood cell) count, or the presence COVID-19 infection. (4) Conclusion: The findings suggest that integrating these parameters in risk stratification can aid in improving predictive accuracy of estimating the in-hospital mortality of PE patients.

Comparison of In-Hospital Outcomes between Early and Late Catheter-Directed Thrombolysis in Acute Pulmonary Embolism: A Retrospective Observational Study

The purpose of this study is to evaluate whether early initiation of catheter-directed thrombolysis (CDT) in patients presenting with acute pulmonary embolism is associated with improved in-hospital outcomes. A retrospective cohort was extracted from the 2016-2019 National Inpatient Sample database, consisting of 21,730 weighted admissions undergoing CDT acute PE. From the time of admission, the sample was divided into early (<48 h) and late interventions (>48 h). Outcomes were measured using regression analysis and propensity score matching. No significant differences in mortality, cardiac arrest, cardiogenic shock, or intracranial hemorrhage (p > 0.05) were found between the early and late CDT groups. Late CDT patients had a higher likelihood of receiving systemic thrombolysis (3.21 [2.18-4.74], p < 0.01), blood transfusion (1.84 [1.41-2.40], p < 0.01), intubation (1.33 [1.05-1.70], p = 0.02), discharge disposition to care facilities (1.32 [1.14-1.53], p < 0.01). and having acute kidney injury (1.42 [1.25-1.61], p < 0.01). Predictors of late intervention were older age, female sex, non-white ethnicity, non-teaching hospital admission, hospitals with higher bed sizes, and weekend admission (p < 0.01). This study represents a comprehensive evaluation of outcomes associated with the time interval for initiating CDT, revealing reduced morbidity with early intervention. Additionally, it identifies predictors associated with delayed CDT initiation. The broader ramifications of these findings, particularly in relation to hospital resource utilization and health disparities, warrant further exploration.

Distinct age-adjusted D-dimer threshold to rule out acute pulmonary embolism in outpatients and inpatients

INTRODUCTION

The diagnosis of acute pulmonary embolism (PE) is combinations of clinical probability assessments, plasma D-dimer (DD) test results, and/or computed tomographic pulmonary angiography (CTPA).

OBJECTIVE

The aim of this study is to explore the appropriate DD cutoff using the immunoturbidimetric method in outpatients and inpatients.

METHODS

We retrospectively enrolled 2689 patients with suspected PE between January 2014 and December 2019. All patients underwent clinical probability assessments, DD tests, and CTPA. We investigated the appropriate cutoff level for plasma DD tests in the correlation analysis and receiver operating characteristic (ROC) curves.

RESULTS

Among all patients, 1263 were confirmed acute PE. The age-adjusted DD level was determined to be age × 10 μg/L (for patients aged >50 years) in outpatients. This cutoff value resulted in a sensitivity of 96.75% and a specificity of 87.02%, with the area under the curve (AUC) of 0.908 and the number needed to treat (NNT) of 1.18. For inpatients, the age-adjusted cutoff values for the biomarker DD demonstrated poor specificity (13.34%) and NNT (9.88). However, when the DD cutoff was adjusted to 2 × the upper limit of normal (ULN), the sensitivity increased to 93.19%, while the specificity remained at 29.55%, with the AUC of 0.610 and the NNT of 4.76. The optimal DD cut-off value was 3010 μg/L (about 5 × ULN), resulting in a sensitivity of 75.22% and specificity of 61.72%, with the AUC of 0.727 and the NNT of 2.7.

CONCLUSION

Using the immunoturbidimetric method to measure DD, an age-adjusted DD cutoff (age × 10 μg/L, if aged >50 years) should be considered for outpatients with suspected PE. For inpatients, increasing the DD cutoff value to at least 2 × ULN yields the best test performance.

Can GRACE Risk Score Predict Mortality and the Need for Thrombolytic Treatment in Acute Pulmonary Embolism?

Acute coronary syndrome and pulmonary embolism (PE) are clinical entities sharing similar presentation and risk factors. Risk scores and indexes help to identify disease severity in both diseases. In this study, we aimed to evaluate if the Global Registry of Acute Coronary Events (GRACE) risk score could predict 30-day mortality and the need for thrombolytic treatment in patients with acute PE. Patients hospitalized with a diagnosis of PE in our tertiary center between January 2018 and May 2022 were included in this retrospective study. Pulmonary Embolism Severity Index (PESI) and GRACE risk scores on admission were calculated using clinical, electrocardiographic, and laboratory parameters for each patient. A total of 197 patients were included. The 30-day mortality rate was 28.4% whereas 32.5% of the patients required thrombolytic treatment. GRACE and PESI scores were found independent risk factors associated with 30-day mortality and the need for thrombolytic treatment. A cut-off value of 160.5 for GRACE score was associated with 88.5% sensitivity and 89.4% specificity in prediction of 30-day mortality. In contrast, GRACE score had 61.0% sensitivity and 60.0% specificity in the prediction of the need for thrombolytic treatment when the cut-off value was 147. In conclusion, GRACE risk score has an effective discriminating power in determining the early mortality of patients with acute PE. The incidence of short-term PE-related mortality was significantly increased in patients with high GRACE risk scores. Concomitant use of GRACE and PESI risk scores may aid in defining patients with high-risk PE and help predict poor prognosis with high specificity and probability.

Serum Albumin for Short-Term Poor Prognosis in Patients With Acute Pulmonary Embolism: A Clinical Study Based on a Database

The relationship between serum albumin (ALB) and short-term prognosis in patients with acute pulmonary embolism (APE) remains unclear. We investigated the predictive value of ALB for short-term prognosis in APE patients using our hospital pulmonary embolism (PE) database (384 patients consecutively collected). Logistic regression analysis and nomograms were applied to construct the predictive model, and validation was assessed. A total of 340 APE patients were included, with a 30-day all-cause mortality rate of 8.5%. The incidence of hypoalbuminemia was 15.9%. The odds ratio (OR) for short-term mortality in patients with high ALB was 0.89 (0.886, 95% CI: 0.812-0.967). Additionally, we created a nomogram for individualized mortality risk prediction. Receiver operating characteristic (ROC) curve analysis showed that the diagnostic area under the curve (AUC) of ALB was 0.758 (95% CI 0.683-0.833), and the best cut-off value was 33.85 g/L. Optimal simplified Pulmonary Embolism Severity Index (sPESI) (ALB combined sPESI) AUC was 0.835 (95% CI 0.775-0.896). Baseline hypoalbuminemia may be an independent prognostic indicator of short-term mortality in patients with APE.

A Case Report of Under-Recognized Conditions in Pulmonary Embolism: Patent Foramen Ovale and Right Ventricular Thrombus

Pulmonary embolism (PE) is a potentially life-threatening condition that presents with a spectrum of clinical symptoms ranging from asymptomatic to hemodynamic instability. The early diagnosis in the emergency department is often challenging. Although the association between patent foramen ovale (PFO) and thromboembolic events in patients with PE is well-documented, the significance of the presence of PFO in patients with PE may be underrecognized. In addition, the occurrence of right ventricular thrombus (RVT) in PE is a rare but significant complication with implications for disease management. We report a case of acute-on-chronic PE with concurrent bilateral renal infarction due to a paradoxical embolus, alongside RVT. A 35-year-old male presented at our emergency department with complaints of sudden onset abdominal pain. Bilateral renal infarction was identified on a contrast-enhanced computed tomography (CT). Point-of-care ultrasound showed suggestive findings of PE and RVT. Subsequently, a pulmonary CT angiography confirmed bilateral PE, a PFO, and RVT. The patient was effectively managed with thrombolytic therapy, with extracorporeal membrane oxygenation on standby. This case highlights the need to recognize the diverse clinical manifestations of PE and the importance of considering coexisting PFO and RVT in affected patients. The diagnosis of PE can be complex when symptoms overlap with arterial thrombosis, such as renal infarction secondary to a PFO. In addition, RVT, although uncommon, is a serious complication in patients with PE that may require careful evaluation for thrombolytic or anticoagulant therapy. It is critical to consider the possibility of a PFO in all cases of PE, even in the absence of arterial embolism, and to promptly evaluate for RVT prior to initiating treatment.

Predictive Value of Pulmonary Artery Distensibility for Short-Term Adverse Clinical Outcomes in Patients with Acute Pulmonary Embolism

We aimed to explore the relationship between pulmonary artery distensibility obtained from computed tomography pulmonary angiography (CTPA) and short-term adverse clinical outcomes in patients with acute pulmonary embolism (APE). We included patients who underwent retrospective electrocardiogram-gated CTPA and were subsequently diagnosed with APE. Patients were categorized into good and poor outcome groups based on short-term clinical outcomes. Pulmonary artery distensibility (AD), right ventricle/left ventricle (RV/LV) ratio, and pulmonary artery obstruction index (PAOI) were measured, and the receiver operating characteristic curves were constructed. Sixty-four patients with APE (good outcome, 46; poor outcome, 18) were enrolled. AD, RV/LV ratio, and PAOI differed significantly between groups (P < 0.05). Pulmonary artery AD in the good outcome group was greater than that in the poor outcome group (P < 0.001). The poor outcome group exhibited a higher RV/LV ratio and PAOI than the good outcome group (P < 0.05). AD and PAOI were independent predictors of adverse clinical outcomes. Areas under the curve for AD and PAOI were 0.860 (95% confidence interval [CI]: 0.750-0.934) and 0.675 (95%CI: 0.546-0.786), and the combined curve of the AD and RV/LV ratio was 0.906 (95%CI: 0.806-0.965). The calibration curve showed a combined curve superior to the other curves. The decision curve showed high clinical application value of the combined curve. Retrospective electrocardiogram-gated CTPA-derived AD could serve as an indicator for predicting short-term adverse clinical outcomes in APE. Combining AD and PAOI has a high predictive value for short-term adverse clinical outcomes.

The Zurkurnai ECG Pattern: A Novel ECG Pattern of the High-Risk Features of Acute Pulmonary Embolism

Acute pulmonary embolism is an important differential diagnosis in patients presenting with acute shortness of breath. However, the overlapping clinical presentation between acute coronary syndrome, aortic dissection, pneumonia, and heart failure made the diagnosis of pulmonary embolism very challenging in a limited resources center. We present a case of acute pulmonary embolism with an uncommon ECG pattern that was initially misdiagnosed as acute coronary syndrome. The authors made the appropriate diagnosis using the Zurkurnai ECG pattern in acute pulmonary embolism, which is defined as the presence of right axis deviation, deep symmetrical T wave inversion in V1 to V5, II, III, and AVF with the maximum at V3-V4 and poor R wave progression, which indicates the high-risk features of acute pulmonary embolism.

A Rare Case of Successful Management of Postpartum COVID-19-Related Coagulopathy

Pulmonary embolism, while a rare and life-threatening condition, is increasingly recognized in the context of pregnancy, particularly when compounded by infections such as coronavirus disease 2019 (COVID-19). This case report describes a 34-year-old pregnant woman, at 32 weeks of gestation, who developed COVID-19-related coagulopathy despite prophylactic treatment with low molecular weight heparin (LMWH). Admitted with symptoms of breathlessness, fever, and cough, she was diagnosed with COVID-19 and subsequently developed pulmonary embolism. This development was particularly unusual given her ongoing LMWH therapy. Diagnosis in such cases relies heavily on clinical assessment, evaluation of risk factors, and diagnostic tools, with computed tomography pulmonary angiography being pivotal for confirmation. This case highlights the complexities involved in managing COVID-19 among pregnant patients, especially the increased risk and diagnostic challenges associated with thromboembolic disorders. The successful resolution of the case, attributed to a multidisciplinary team's timely intervention and coordinated approach, emphasizes the critical need for prompt and individualized treatment strategies in similar clinical scenarios.

Diagnosis of Acute Pulmonary Embolism on a Non-contrast CT Scan

Teaching Point: There are two important signs that could be seen on a non-contrast chest CT scan that can lead to the diagnosis of a pulmonary embolism: the hyperdense pulmonary artery sign and pulmonary infarction.

Pulmonary Embolization After Gastric Varices Obliteration

N-butyl-2-cyanoacrylate (NB2CYA) is frequently used in the treatment of variceal hemorrhage with a success rate in hemostatic control of 87%-100%. Although rare, complications include esophageal perforation, infection, or arterial and venous embolization. We present the case of a 67-year-old male with chronic ethanolic liver disease hospitalized due to melena and hematemesis. He had anemia requiring transfusion support, octreotide, and pantoprazole infusion. Upper digestive endoscopy was performed showing gastric varices with a hemorrhagic rupture point treated with cyanoacrylate. The patient developed respiratory failure over the next 48 hours with chest computed tomography (CT) angiography showing several dense, scattered linear images, with arterial vascular trajectories suggestive of cyanoacrylate embolization. It was decided to provide ventilatory support with invasive mechanical ventilation, initiate systemic corticosteroid therapy, and transfer the patient to the intensive care unit (ICU). The patient was ventilated for 11 days with initial favorable evolution, but after two episodes of decompensation of his chronic liver disease (CLD) (hepatic encephalopathy and hepatorenal syndrome) and a new nosocomial pneumonia, he ended up dying. The present case illustrates a rare but potentially fatal complication associated with cyanoacrylate, highlighting the importance of a high suspicion index in cases of respiratory failure and dyspnea after this therapy.

Takayasu arteritis with acute pulmonary embolism as the primary clinical symptom: A case study

We report a case of Takayasu arteritis with acute pulmonary embolism as the first clinical manifestation for the first time.

Comparison of Dual-Energy Computed Tomography Pulmonary Angiography-Derived Contrast Enhancement with Standard Dual-Energy Pulmonary Angiography in Diagnosing Subsegmental Pulmonary Embolism: A Prospective Study

Objective  In this study, we compare the diagnostic accuracy of dual-energy (DE) computed tomography pulmonary angiography (CTPA) derived contrast enhancement (DECTPA, CTPA images with iodine maps) with standard dual-energy pulmonary angiography (SCTPA) for diagnosis of subsegmental pulmonary embolism in the cases with clinical suspicion of acute pulmonary embolism (APE). Materials and Methods  We included 50 cases with clinical suspicion of APE that were referred for CTPA. All the patients underwent CTPA in the dual-energy protocol. Two radiologists evaluated the images. The first radiologist interpreted the SCTPA images (vascular images) and the second radiologist interpreted the DECTPA (CTPA images with iodine maps) for findings of APE. We calculated the sensitivity, specificity, and negative predictive value of DECTPA vis-à-vis SCTPA images. Results  The DECTPA with the advantage of iodine map utilization yielded higher detection of thrombi in peripheral subsegmental arteries (72 vs. 99; p  = - 0.001) as compared to the SCTPA images by identification of 18 new perfusion defects (interquartile range [IQR]: 0-1) that were consistent with APE. Filling defects were identified in 27 (IQR: 0-4) more subsegmental arteries supplying these 18 areas, which were not detected on SCTPA alone. These 18 perfusion defects were identified in 13 cases. In these 13 cases, 4 new cases were diagnosed that were negative on CTPA ( p  = -0.125). In the evaluation of the APE, sensitivity and specificity were calculated and it was found that DECTPA showed 100% sensitivity and 86% specificity with 100% negative predictive value in the detection of thrombi as compared to the routine CTPA. Conclusion  DECTPA has higher sensitivity and negative predictive value in the detection of the subsegmental perfusion defect identification as compared to SCTPA.

An Interesting Case of Takayasu Arteritis With Acute Bilateral Pulmonary Thromboembolism

Takayasu arteritis (TA) is an autoimmune vasculitis with unknown etiology. It can have varied presentations ranging from nonspecific symptoms to florid vasculitic symptoms. Awareness of the complications of this disease is also vital in managing patients who are already diagnosed with TA. We present the interesting case of a middle-aged woman, diagnosed case of TA who presented with an acute pulmonary embolism masquerading as an acute lower respiratory infection. Delayed diagnosis or misdiagnosis of acute major thromboembolism can be fatal. There needs to be a high index of suspicion from the clinician's end to reach a diagnosis and prompt intervention.

Diagnostic values of serum BNP, PTX3, and VEGF in acute pulmonary embolism complicated by pulmonary artery hypertension and their correlations with severity of pulmonary artery hypertension

OBJECTIVE

This paper aimed to unveil the diagnostic values of serum brain natriuretic peptide (BNP), pentraxin 3 (PTX3), and vascular endothelial growth factor (VEGF) in acute pulmonary embolism complicated by pulmonary artery hypertension (APE-PAH) and their correlations with severity of PAH.

METHODS

A total of 153 patients with APE were selected for our study and divided into the PAH and Non-PAH groups according to the measurement of pulmonary artery pressure by echocardiography. Serum BNP levels were measured by chemiluminescence immunoassay, and serum PTX3 and VEGF levels were appraised by ELISA. The predictive values of BNP, PTX3, and VEGF for APE-PAH were evaluated by applying the receiver operating characteristic (ROC) curve. Spearman test was implemented to correlate BNP, PTX3, and VEGF with the severity of PAH.

RESULTS

Higher serum levels of BNP, PTX3, and VEGF were observed in the PAH group versus the Non-PAH group (p < .05). ROC curve analysis indicated that BNP, PTX3, and VEGF had acceptable diagnostic value for predicting APE-PAH. Higher serum levels of BNP, PTX3, and VEGF were witnessed in the moderate and severe PAH groups in contrast to the mild PAH group (p < .05), and the levels of these parameters were elevated in the severe PAH group versus the moderate PAH group (p < .05). Spearman correlation analysis signified that serum BNP (r = 0.377), PTX3 (r = 0.488), and VEGF (r = 0.575) levels were positively correlated with the severity of PAH in APE-PAH patients.

CONCLUSION

Serum BNP, PTX3, and VEGF levels are significantly elevated in APE-PAH patients. Serum BNP, PTX3, and VEGF levels are of clinical value in the diagnosis of APE-PAH patients, and serum BNP, PTX3, and VEGF levels are positively correlated with the severity of PAH and can be used as predictors of the severity of PAH.

ST-Segment Elevation: An Unexpected Culprit

The clinical presentation of pulmonary embolism (PE) and acute coronary syndrome can be similar. We report a case of a patient presenting with antero-septal ST-segment elevation after cardiac arrest, found to have acute-PE-mimicking ST-segment elevation myocardial infarction (STEMI), treated with aspiration thrombectomy and catheter-directed thrombolysis (CDT). A 78-year-old man was admitted with dyspnea, chest pain and tachycardia. During evaluation, cardiac arrest in pulseless electrical activity was documented. Advanced life support was started immediately. ECG post-ROSC revealed ST-segment elevation in V1-V4 and aVR. Echocardiography showed normal left ventricular function but right ventricular (RV) dilation and severe dysfunction. The patient was in shock and was promptly referred to cardiac catheterization that excluded significant CAD. Due to the discordant ECG and echocardiogram findings, acute PE was suspected, and immediate invasive pulmonary angiography revealed bilateral massive pulmonary embolism. Successful aspiration thrombectomy was performed followed by local alteplase infusion. At the end of the procedure, mPAP was reduced and blood pressure normalized allowing withdrawal of vasopressor support. Twenty-four-hour echocardiographic reassessment showed normal-sized cardiac chambers with preserved biventricular systolic function. Bedside echocardiography in patients with ST-segment elevation post-ROSC is instrumental in raising the suspicion of acute PE. In the absence of a culprit coronary lesion, prompt pulmonary angiography should be considered if immediately feasible. In these cases, CDT and aspiration in high-risk acute PE seem safe and effective in relieving obstructive shock and restoring hemodynamics.

The Combined Heterozygosity of Factor V Leiden and G20210A Prothrombin Gene Mutation in a Patient With Venous Thromboembolism

Venous thromboembolism (VTE) is a chronic illness that includes pulmonary embolism (PE) and deep vein thrombosis (DVT), and many risk factors are associated. Anticoagulation therapy remains the cornerstone of venous thromboembolism management, and the duration of anticoagulation depends on the risk of venous thromboembolism. We report a case of a female with a combined heterozygosity of factor V Leiden and G20210A prothrombin gene mutation.

Predicting acute pulmonary embolism in COVID-19

Acute pulmonary embolism (PE) is a life-threatening condition in patients with Coronavirus disease-2019 (COVID-19). Computed tomography pulmonary angiography is the preferred test to confirm the diagnosis. However, computed tomography pulmonary angiography is expensive and is not available in every clinic. This study aimed to determine whether clinical findings, symptoms, and parameters that are cost-effective and available in many clinics such as C-reactive protein (CRP) lymphocyte ratio (CLR), and ferritin CRP ratio (FCR) can be used in the diagnosis of PE in patients with COVID-19. Out of the reviewed files, 127 patients were diagnosed with PE, whereas 105 patients had no PE. At the first admission, laboratory parameters, complaints, respiratory rate, and percent oxygen saturation in the blood (SpO2) with a pulse oximeter were recorded for each patient. Eosinophil levels remained lower, whereas ferritin lymphocyte ratio and CLR were higher in the PE group. Patients with more elevated ferritin, CRP, and CLR had an increased mortality risk. Shortness of breath and tiredness was more common in the PE group. A decrease in eosinophil levels, whereas an increase in CLR, D-dimer, and CRP may predict PE. Elevated CLR is highly predictive of PE and is associated with increased mortality risk. COVID-19 patients with a CLR level above 81 should be investigated for PE.

Prevalence and clinical significance of deep vein thrombosis in Hispanic patients with acute pulmonary embolism

The prevalence of concomitant deep vein thrombosis (DVT) and its impact on 30-day outcomes in Hispanic patients with acute pulmonary embolism (PE) is unknown. We retrospectively studied a cohort of Hispanic patients admitted for acute PE to determine the relationship of concomitant DVT to clot burden on chest computer tomography (CT), right heart strain, and 30-day mortality. We identified 391 patients admitted with acute PE; 168 (42.9%) had concomitant DVTs on admission; 39 patients (9.9%) died during the 30-day follow-up: 12 patients without concomitant DVT and 27 with concomitant DVT, respectively (p < .001). The presence of a proximal DVT independently predicted 30-day mortality even after adjusting for age, gender and admission PE severity index scores (PESI) (hazard ratio [HR] 2.0; 95% confidence interval [CI]: 1.4-3.0, p = .001). Proximal DVTs remained a significant predictor of 30-day mortality in patients with low and intermediate PESI scores (HR 2.5; 95% CI: 1.1-6.0, p = .035). The prevalence of concomitant DVT in Hispanic patients presenting with acute DVT is relatively lower than other ethnic groups. However, a proximal location of a DVT is of significant prognostic relevance. Hispanic patients with acute PE should routinely undergo compression doppler ultrasonography (CDUS) of the lower extremities.

A Simple Vitamin Deficiency With Life-Threatening Complications: A Case of B12 Deficiency and Hyperhomocysteinemia-Induced Thrombosis

While macrocytic anemia is common in vitamin B12 deficiency, rarely, pancytopenia and hemolytic anemia can occur. Homocysteine levels are elevated in severe B12 deficiency, and this is linked to thrombus formation with potentially life-threatening complications. We present a patient with severe vitamin B12 deficiency complicated by hyperhomocysteinemia and obstructive shock from pulmonary embolism. A 56-year-old male with no medical history presented to the hospital with altered mentation. The patient's family stated he was experiencing bilateral paresthesias of his lower extremities, progressive depression, anxiety, and insomnia. Initial vitals were blood pressure of 76/36, heart rate of 70 beats per minute, respiratory rate of 14, and temperature of 36.3 degrees Celsius. He was intubated due to severe encephalopathy. Relevant labs indicated severe macrocytic anemia, thrombocytopenia, decreased B12 levels, elevated methylmalonic acid, and elevated homocysteine. Imaging demonstrated a right common femoral vein thrombosis and subsegmental pulmonary emboli. Peripheral blood smear revealed schistocytes, anisopoikilocytosis, and decreased platelet count. The patient required fluid resuscitation, antibiotics, and multiple blood products. Vitamin B12 was administered intramuscularly, which improved the anemia. Esophagogastroduodenoscopy (EGD) demonstrated gastritis. Gastric and duodenal biopsies were negative for Helicobacter pylori and celiac disease. He was negative for intrinsic factor (IF) antibodies but had elevated gastrin levels. An intravenous unfractionated heparin infusion was started when the platelet count was above 50000. The patient was extubated after seven days. Heparin was transitioned to apixaban and an inferior vena cava (IVC) filter was placed. Hyperhomocysteinemia is a known pro-thrombotic factor that can lead to the development of venous thromboembolism. B12 malabsorption can stem from inflammatory bowel disease, celiac disease, gastritis, pancreatic insufficiency, gastrectomy, gastric bypass surgery, or antibodies to IF. While this case showed gastritis and negative IF antibodies, gastrin levels were elevated, indicating a mixed picture. This highlights the challenge of definitively diagnosing pernicious anemia as the cause of vitamin B12 deficiency. Vitamin B12 deficiency may lead to critical illness in which thromboembolism develops secondary to hyperhomocysteinemia.

Impact of Baseline Heart Failure on Acute Pulmonary Embolism Risk Stratification and Clinical Outcomes

Among patients with acute pulmonary embolism (PE), abnormal cardiac biomarkers and elevated right ventricular to left ventricular (RV/LV) diameter ratio are associated with increased morbidity and mortality. However, subjects with baseline heart failure (HF) have abnormalities in cardiac chamber dimensions and biomarkers. We sought to describe risk stratification variables in a cohort with acute PE and categorized HF status as no HF, HF with reduced ejection fraction (HFrEF), or HF with preserved ejection fraction (HFpEF). In total, 182 subjects were identified for this study, of whom 142 were categorized as having no HF, 16 as having HFrEF, and 24 as having HFpEF. The median age was 65 years [interquartile range 51 to 75 years], and 43% were male. Subjects with HFrEF had significantly greater LV diameters and significantly lower RV/LV diameter ratio (no HF 0.94, HFrEF 0.65, HFpEF 0.89, p = 0.002). Subjects with HFrEF also had significantly higher B-type natriuretic peptide levels (no HF 112 pg/mL, HFrEF 835 pg/mL, HFpEF 241 pg/mL, p <0.001) and higher 90-day mortality rates. Among subjects with acute PE, those with baseline HFrEF had significantly greater LV diameter and lower RV/LV diameter ratio than those of patients with HFpEF or no HF. In addition, subjects with HFrEF had significantly higher B-type natriuretic peptide levels and worse survival at 90 days. In conclusion, these results indicate that PE risk stratification using current guidelines, especially reliance on RV/LV ratio, is inaccurate among subjects with baseline HFrEF.

A Novel Composed Index to Evaluate the Right Ventricle Free-Wall Adaptation Against Ventricular Wall Stress in Acute Pulmonary Embolism

BACKGROUND

Pulmonary embolism severity index and simplified pulmonary embolism severity index have been utilized in initial risk evaluation in patients with acute pulmonary embolism. However, these models do not include any imaging measure of right ventricle function. In this study, we proposed a novel index and aimed to evaluate the clinical impact.

METHODS

Our study population comprised retrospectively evaluated 502 patients with acute pulmonary embolism managed with different treatment modalities. Echocardiographic and computed tomographic pulmonary angiography evaluations were performed at admission to the emergency room within maximally 30 minutes. The formula of our index was as follows: (right ventricle diameter × systolic pulmonary arterial pressure-echo)/(right ventricle free-wall diameter × tricuspid annular plane systolic excursion).

RESULTS

This index value showed significant correlations to clinical and hemodynamic severity measures. Only pulmonary embolism severity index, but not our index value, independently predicted in-hospital mortality. However, an index value higher than 17.8 predicted the long-term mortality with a sensitivity of 70% and specificity of 40% (areas under the curve = 0.652, 95% CI, 0.557-0.747, P =.001). According to the adjusted variable plot, the risk of long-term mortality increased until an index level of 30 but remained unchanged thereafter. The cumulative hazard curve also showed a higher mortality with high-index value versus low-index value.

CONCLUSIONS

Our index composed from measures of computed tomographic pulmonary angiography and transthoracic echocardiography may provide important insights regarding the adaptation status of right ventricle against pressure/wall stress in acute pulmonary embolism, and a higher value seems to be associated with severity of the clinical and hemodynamic status and long-term mortality but not with in-hospital mortality. However, the pulmonary embolism severity index remained as the only independent predictor for in-hospital mortality.

Right heart thrombus in acute pulmonary embolism: A single center experience in China

Right heart thrombus (RHT) is a rare but life-threatening condition in acute pulmonary embolism (APE) without clear management guidelines. This study aimed to address the clinical characteristics and outcomes of RHT-APE in Chinese patients. In this study, 17 RHT-APE and 329 non-RHT-APE patients, who were diagnosed between September 2015 and August 2019, were retrospectively recruited with the median follow-up was 360 days. The overall prevalence of RHT was 4.91% in APE. Its prevalence increased along the increase of APE risk stratifications. Comparisons showed that with higher proportion of male gender and younger age, RHT-APE patients also had worse hemodynamic instability and heart function, and higher risk stratification levels than non-RHT-APE patients. After adjusting by age and gender, multivariate logistic regression analysis found high/intermediate-high risk stratification, decreased right ventricular (RV) motion, NT-proBNP >600 pg/mL, and RV dysfunction were risk factors for RHT. Kaplan-Meier analysis showed non-RHT had better prognosis than RHT patients (30-day survival: log-rank: p < 0.001; 90-day survival: log-rank: p = 0.002). The multivariate logistic regression analysis showed RHT was an independent risk factor for 30-day mortality in APE. The subgroup analysis showed RHT would result in worse outcomes in patients who already had higher APE early mortality risk. RHT would increase the risk of 30- and 90-day mortality in APE. More attention should be paid to young male APE patients with decreased RV motion, NT-proBNP >600 pg/mL, RV dysfunction, or high level of risk stratification, to exclude the coexistence of RHT.

Mechanical Thrombectomy of a Submassive Pulmonary Embolism in the Second Trimester of Pregnancy

Venous thromboembolism (VTE) represents a potentially severe and infrequent complication that can occur in the pregnant population. The nuance in recognizing and diagnosing this condition can be quite difficult due to the changes that occur during pregnancy. This case highlights the importance of diagnosing pulmonary embolism in pregnancy, classifying the degree of disease, and determining the best treatment for both mother and fetus. Although rare, early diagnosis and treatment are crucial in order to reduce morbidity and mortality.

Successful use of rivaroxaban achieving therapeutic anti-factor xa levels in a morbidly obese patient with acute intermediate-high risk pulmonary embolism

Direct oral anticoagulants (DOACs) have become the standard of care for acute and long-term therapy for venous thromboembolism (VTE) due to their efficacy and safety profiles. The 2021 International Society on Thrombosis and Haemostasis guidelines recommend using standard DOAC dosages in patients with BMI >40 kg/m2 or weight >120 kg. Use of DOACs remains uncertain in morbidly obese patients with VTE, including acute PE. A morbidly obese woman in her 30s who presented with acute worsening of dyspnea was diagnosed with acute intermediate-high risk acute pulmonary embolism and concomitant proximal deep vein thrombosis, constituting a clinically challenging scenario for treating her with rivaroxaban. Standard doses of rivaroxaban for acute and extended phase treatment of venous thromboembolism in individuals with morbid obesity at BMI>70 kg/m2 may be effective, and safe.

Extracorporeal membrane oxygenation for acute pulmonary embolism after postoperative craniocerebral trauma: a case report

Introduction

Massive pulmonary embolism (PE) is a life-threatening complication of major surgery with a mortality rate of up to 50%. Extracorporeal membrane oxygenation (ECMO) is primarily used for respiratory and circulatory support. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is used to stabilize patients with acute massive PE. Acute brain injury, vascular disease, and immunosuppression are contraindications to ECMO, as stated in the 2021 Extracorporeal Life Support Organization guidelines.

Case summary

We report a case of a patient with craniocerebral trauma whose postoperative course was complicated by massive PE and subsequent cardiac arrest that required urgent VA-ECMO, followed by anticoagulation with heparin. The patient showed hemodynamic improvement and was discharged 68 days after hospitalization.

Discussion

ECMO has gradually been accepted for patients with craniocerebral injuries. The safety and effectiveness of ECMO in patients with craniocerebral injury, along with the optimal duration of ECMO and anticoagulation strategies, require further study.

Serum metabolic signatures for acute pulmonary embolism identified by untargeted metabolomics

Background and aims

The important metabolic features of acute pulmonary embolism (APE) risk stratification and their underlying biological basis remain elusive. Our study aims to develop early diagnostic models and classification models by analyzing the plasma metabolic profile of patients with APE.

Materials and methods

Serum samples were collected from 68 subjects, including 19 patients with confirmed APE, 35 patients with confirmed NSTEMI, and 14 healthy individuals. A comprehensive metabolic assessment was performed using ultra-performance liquid chromatography-mass spectrometry based on an untargeted metabolomics approach. In addition, an integrated machine learning strategy based on LASSO and logistic regression was used for feature selection and model building.

Results

The metabolic profiles of patients with acute pulmonary embolism and NSTEMI is significantly altered relative to that of healthy individuals. KEGG pathway enrichment analysis revealed differential metabolites between acute pulmonary embolism and healthy individuals mainly involving glycerophosphate shuttle, riboflavin metabolism, and glycerolipid metabolism. A panel of biomarkers was defined to distinguish acute pulmonary embolism, NSTEMI, and healthy individuals with an area under the receiver operating characteristic curve exceeding 0.9 and higher than that of D-dimers.

Conclusion

This study contributes to a better understanding of the pathogenesis of APE and facilitates the discovery of new therapeutic targets. The metabolite panel can be used as a potential non-invasive diagnostic and risk stratification tool for APE.

Surgical pulmonary embolectomy: state of the art

Acute pulmonary embolism is a significant cause of morbidity and mortality. Patients in life-threatening conditions require timely and effective interventions to improve pulmonary perfusion. The indications for surgical embolectomy in the thrombolysis era have been limited. This article discusses surgical techniques and outlines the position of surgical embolectomy concerning other treatment modalities.

Extensive Postpartum Upper and Lower Extremity Deep Vein Thrombosis in a Patient With a History of Preeclampsia

We describe the case of a 19-year-old woman with no significant medical history who developed progressive right-sided neck pain and palpitations one month following a pregnancy complicated by preeclampsia. Family history was significant for unprovoked deep vein thrombosis (DVT) and pulmonary embolism (PE) in her father at age 44. Systemic examination revealed mild swelling of the right upper extremity with pain on palpation. Computed tomography (CT) of the thorax with contrast demonstrated extensive occlusion of right upper extremity veins and collateralization of chest wall veins. Pulmonary emboli were present bilaterally in the segmental and subsegmental branches of the lower lobe pulmonary arteries. CT of the abdomen with contrast revealed thrombi in the left common and external iliac veins. Thrombophilia screening was normal. The patient was treated with enoxaparin and ampicillin/sulbactam. Her clinical condition improved, and she was discharged with an outpatient clinic follow-up appointment.

Comparison of therapeutic effect of catheter direct thrombolysis and peripheral venous thrombolysis on acute pulmonary embolism

We compared the therapeutic effect of catheter direct thrombolysis (CDT) and peripheral venous thrombolysis (PVT) for patients with acute pulmonary embolism (APE). Totally, 74 patients with APE were enrolled, including 37 in the CDT group and 37 in the PVT group. The changes in clinical indicators pre and posttreatment were observed. Clinical efficacy was evaluated. Kaplan-Meier method was used to analyze the survival of patients during follow-up. In both the PVT group and CDT group, partial pressure of oxygen after treatment increased significantly than that before treatment (P < .05). However, in both groups, the levels of partial pressure of carbon dioxide, D-dimer, B-type brain natriuretic peptide, pulmonary arterial pressure, and thrombus volume after treatment were significantly decreased than those before treatment (P < .05). After treatment, patients from the CDT group had significantly lower D-dimers, partial pressure of carbon dioxide, brain natriuretic peptide, and pulmonary arterial pressure, and significantly higher partial pressure of oxygen compared to patients from the PVT group (P < .05). The total effective rate was 97.2% in the CDT group and 81.0% in the PVT group. The bleeding incidence in the CDT group was significantly lower than that in the PVT group (P < .05). The median survival time in the CDT group was significantly longer than that in the PVT group (P < .05). CDT can more effectively improve symptoms, cardiac function, and survival rate of APE patients while reducing bleeding incidence than PVT, and thus is safe and effective in treating APE.

Pulmonary Cement Embolism After Vertebroplasty

Pulmonary cement embolism (PCE) is a known complication that can occur in the setting of vertebroplasty. The majority of these cases are asymptomatic and found incidentally on imaging. There are no current management recommendations regarding PCE. We present a case of a patient who underwent vertebroplasty complicated by a symptomatic sub-massive PCE.

Two cases of acute pulmonary artery embolism triggered by fresh and chronic mixed-vein thrombosis with a "Blowfish sign"

Ultrasonography and computed tomography of the lower extremities revealed fresh and chronic mixed-vein thrombosis (FCMVTs) presenting the "Blowfish sign," accompanied by pulmonary embolism. FCMVTs presenting the "Blowfish sign" may increase the risk of fatal pulmonary embolism, and its detection by ultrasonography is important for preventing pulmonary embolism.

Clinical application value of echocardiography in evaluating left ventricular diastolic function in patients with acute pulmonary embolism

OBJECTIVE

To explore the clinical value of echocardiography in the assessment of left ventricular diastolic function in patients with acute pulmonary embolism (APE).

METHODS

APE patients in our hospital from June 2019 to June 2021 were selected as the observation group. They were divided into low-risk group (19 cases), medium-risk group (16 cases) and high-risk group (15 cases). The non-APE people in our hospital during the same period were selected as the control group. All subjects underwent echocardiography to observe the performance of APE patients under echocardiography. The peak velocity ratio S-wave/D-wave (S/D), early diastolic annular velocity/advanced diastolic annular velocity (Ea/Aa), early filling/early diastolic annular velocity (E/Ea), and early filling/early diastolic annular velocity (E/Ea) were compared with Ar and Vp, respectively; receiver operator characteristic (ROC) curve was used to evaluate the value of echocardiography in evaluating left ventricular diastolic function in patients with APE.

RESULTS

Echocardiography show different manifestations of APE patients. Compared with the control group, S/D, Ea/Aa, and Vp in the observation group were significantly decreased and E/Ea and Ar in the observation group were significantly increased (p < 0.05). With the increase of risk stratification, S/D, Ea/Aa, and Vp gradually decreased, E/Ea and Ar gradually increased, and the difference was statistically significant (p < 0.05). The sensitivity, specificity, accuracy, positive predictive value, negative predictive value, area under curve (AUC), and 95% CI were 89.52%, 65.57%, 72.86%, 80.82%, 75.38%, 0.730, and 0.629-0.831, respectively.

CONCLUSION

Echocardiography can effectively evaluate left ventricular diastolic function in patients with APE, and there are significant differences in left ventricular diastolic function in different risk stratification, which has important reference value for clinical diagnosis and treatment of APE.

A Quest to Find the Aetiology of Pulmonary Embolism Beyond the Common: A Case of Dyshypofibrinogenemia Presenting as Pulmonary Embolism

Hypodysfibrinogenemia-related thromboembolic disorder is a rarely encountered clinical entity. We present such a case of a 34-year-old lady with no known co-morbidities presenting to the accident and emergency unit with left-sided pleuritic chest pain associated with non-productive cough and breathlessness. Laboratory tests revealed fibrinogen level of 0.42 g/l (1.5-4g/l) with prolonged prothrombin time (PT), activated partial thromboplastin time (aPTT) along with elevated d-dimer, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and troponin. CT pulmonary angiogram (CTPA) found bilateral pulmonary embolism with right heart strain. Functional/antigenic fibrinogen ratio was 0.38. Genetic testing eventually revealed a heterozygous missense mutation in exon 8-p.1055G>C; p.Cys352Ser in the sequencing of the fibrinogen gene FGG (gamma chain) confirming the diagnosis of dyshypofibrinogenemia. She was treated with anticoagulants with fibrinogen replacement therapy and later discharged on apixaban.

Outcomes among heart failure patients hospitalized for acute pulmonary embolism and COVID-19 infection: Insight from the National Inpatient Sample

There is paucity of data regarding the outcomes of hospitalized acute pulmonary embolism (PE) patients with heart failure (HF) and Coronavirus Disease 2019 (COVID-19) infection. We utilized the 2020 National Inpatient Sample (NIS) Database in conducting a retrospective cohort study to investigate the outcomes of hospitalized acute PE patients with HF and COVID-19, looking at its impact on in-hospital mortality, thrombolysis, and thrombectomy utilization as well as hospital length of stay (LOS). A total of 23,413 hospitalized acute PE patients with HF were identified in our study, of which 1.26% (n = 295/23,413) had COVID-19 infection. Utilizing a stepwise survey multivariable logistic regression model that adjusted for confounders, COVID-19 infection among acute PE patients with HF was found to be an independent predictor of overall in-hospital mortality (adjusted odds ratio [aOR]: 2.77; 95% confidence interval [CI], 1.15-6.67; p = 0.023) and thrombolysis utilization (aOR: 5.52; 95% CI, 2.57-11.84; p ≤ 0.001) compared to those without COVID-19. However, there were comparable rates of thrombectomy utilization and LOS among acute PE patients with HF regardless of the COVID-19 infection status. On subgroup analysis, patients with HF with reduced ejection fraction was found to be associated with increased risk for in-hospital mortality (aOR: 3.89; 95% CI, 1.33-11.39; p = 0.013) and thrombectomy utilization (aOR: 4.58; 95% CI, 1.08-19.41; p = 0.042), whereas both HF subtypes were associated with increased thrombolysis utilization. COVID-19 infection among acute PE patients with HF was associated with higher over-all in-hospital mortality and increased thrombolysis utilization but had comparable hospital LOS as well as thrombectomy utilization.

Head-to-head comparison of ventilation/perfusion single photon emission computed tomography/computed tomography and multidetector computed tomography angiography for the detection of acute pulmonary embolism in clinical practice

INTRODUCTION

Computed tomography angiography (CTA) and ventilation/perfusion (V/Q) single photon emission computed tomography/CT (SPECT/CT) images have been widely used to detect PE, but few studies have performed a direct comparison between them. We aimed to evaluate the performance of these tests in the same group of patients, selected from the routine practice of a general hospital.

METHODS

Patients with suspected acute PE were prospectively submitted to CTA and V/Q SPECT/CT. General radiologists and nuclear physicians, respectively, interpreted the images. Data regarding age, sex, time between examinations, symptoms, and Wells score were also recorded. The final diagnosis was decided through a consensus among the clinicians, taking into account clinical, laboratory, follow-up, and all imaging procedures data.

RESULTS

Twenty-eight patients (15 male, 13 female, and median age of 51.5 years) were studied. Median duration of the onset of symptoms was 4 (1-14) days, and the median Wells score was 3.5 (1.5-6). Sensitivity, specificity, positive and negative predictive values, and accuracy were 84.6%, 80.0%, 78.6%, 85.7%, and 82.1% for V/Q SPECT/CT, and 46.1%, 100%, 100%, 68.2%, and 75.0% for CTA. The overall agreement between the methods was 57.1%. Of the 22 patients with negative CTA, 10 (45.4%) had positives V/Q SPECT/CT and seven of them classified as true positives.

CONCLUSIONS

Our results suggest that V/Q SPECT/CT is more sensitive and accurate than CTA when interpreted by general radiologists and nuclear medicine physicians.

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

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

HDAC6 inhibition alleviates acute pulmonary embolism: a possible future therapeutic option

INTRODUCTION

Acute pulmonary embolism (APE) is a clinical syndrome of pulmonary circulation disorder caused by obstruction of the pulmonary artery or its branches. Histone deacetylase 6 (HDAC6) has been reported to play an important role in lung-related diseases. However, the functional role of HDAC6 in APE remains unclear.

MATERIAL AND METHODS

Male Sprague Dawley rats were used. The APE model was constructed by inserting an intravenous cannula into the right femoral vein and injecting Sephadex G-50 microspheres (12 mg/kg; 300 µm in diameter). After 1 h, the control and APE rats were intraperitoneally injected with tubastatin A (TubA) (40 mg/kg, an inhibitor of HDAC6) and sampled at 24 h after modeling. H&E staining, arterial blood gas analysis, and wet/dry weight ratio were used to evaluate the histopathological changes and pulmonary function in APE rats. ELISA, Western blot, and immunohistochemistry were used to explore the potential mechanism of HDAC6-mediated inflammation in APE.

RESULTS

The results indicated that HDAC6 expression was significantly increased in lungs of APE rats. TubA treatment in vivo decreased HDAC6 expression in lung tissues. HDAC6 inhibition alleviated histopathological damage and pulmonary dysfunction, as evidenced by decreased PaO₂/FiO₂ ratio and W/D weight ratio in APE rats. Furthermore, HDAC6 inhibition alleviated APE-induced inflammatory response. Specifically, APE rats exhibited increased production of pro-inflammatory cytokines, including tumor necrosis factor-alpha (TNF-α), interleukin (IL)-1β, IL-6, and IL-18, however, this increase was reversed by HDAC6 inhibition. Meanwhile, the activation of the NLRP3 inflammasome was also observed in lungs of APE rats, while HDAC6 inhibition blocked this activation. Mechanically, we demonstrated that HDAC6 inhibition blocked the activation of the protein kinase B (AKT)/extracellular signal-regulated protein kinase (ERK) signaling pathway, a classic pathway promoting inflammation.

CONCLUSIONS

These findings demonstrate that the inhibition of HDAC6 may alleviate lung dysfunction and pathological injury resulting from APE by blocking the AKT/ERK signaling pathway, providing new theoretical fundamentals for APE therapy.

Predictive Ability of the National Early Warning Score in Mortality Prediction of Acute Pulmonary Embolism in the Southeast Asian Population

BACKGROUND

The National Early Warning Scores (NEWS) easily and objectively measures acute clinical deterioration. However, the performance of NEWS to predict mortality in patients with acute pulmonary embolism (APE) is still required. Therefore, the objective of this study was to evaluate the performance of the NEWS in predicting the mortality of patients with APE.

METHODS

NEWS and Pulmonary Embolism Severity Index (PESI) at diagnosis time were calculated. Risk regression analysis was performed to identify the NEWS and PESI risk classification as a predictor for 30 days all-cause mortality and PE-related mortality.

RESULTS

NEWS was significantly higher in non-survivors compared to survivors (median (IQR) was 10 (7, 11) vs. 7 (2, 9), respectively, p < 0.001). The best cut-off point of NEWS in discriminating APE patients who non-survived from those who survived at 30 days was ≥9, with a sensitivity and specificity of 66.9% and 66.3%, respectively. The adjusted risk ratio of 30-day all-cause mortality in patients with initial NEWS ≥ 9 was 2.96 (95% CI; 2.13, 4.12, p < 0.001).

CONCLUSIONS

The NEWS can be used for mortality prediction in patients with APE. APE patients with NEWS ≥ 9 are associated with a high risk of mortality and should be closely monitored.

Acute pulmonary embolism with coexisting right heart thrombi in transit-surgical treatment of 20 consecutive patients

OBJECTIVES

The presence of right heart thrombi in transit in the setting of acute pulmonary embolism is associated with high mortality. The optimal management in such cases is inconclusive. We present the results of surgical treatment of 20 consecutive patients diagnosed with high or intermediate-high risk pulmonary embolism with coexisting right heart thrombi in transit.

METHODS

A retrospective analysis was performed of all consecutive patients undergoing surgical treatment in the Medicover Hospital between 2013 and 2021 for acute pulmonary embolism with coexisting thrombi in-transit in right heart cavities. The diagnosis was based on echocardiography, computed tomography pulmonary angiography, and laboratory tests. Eligibility criteria for surgical treatment were acute pulmonary embolism with right heart thrombi in transit, right ventricular overload on imaging studies, and significantly elevated levels of cardiac troponin and NTproBNP. All patients were operated on with extracorporeal circulation using deep hypothermia and total circulatory arrest. The primary end-point was hospital all-cause mortality; secondary end-points were perioperative complications and long-term mortality.

RESULTS

The analysis included 20 patients. There was no in-hospital death. Nearly one-third of patients required temporal hemofiltration for postoperative renal failure, but this did not involve the need for dialysis at discharge. No neurological complications occurred in any patient. The mean follow-up was 46 months (range 13-98). There was one death in the long-term follow-up, not related to pulmonary embolism.

CONCLUSIONS

Surgical treatment of patients with acute pulmonary embolism and coexisting right heart thrombi in transit can provide favourable results.

Heart Rate Variability Impairment Is Associated with Right Ventricular Overload and Early Mortality Risk in Patients with Acute Pulmonary Embolism

The association between heart rate variability (HRV) and mortality risk of acute pulmonary embolism (APE), as well as its association with right ventricular (RV) overload is not well established. We performed an observational study on consecutive patients with confirmed APE. In the first 48 h after admission, 24 h Holter monitoring with assessment of time-domain HRV, echocardiography and NT-proBNP (N-terminal pro-B-type natriuretic peptide) measurement were performed in all participants. We pre-examined 166 patients: 32 (20%) with low risk of early mortality, 65 (40%) with intermediate-low, 65 (40%) with intermediate-high, and 4 (0.02%) in the high risk category. The last group was excluded from further analysis due to sample size, and finally, 162 patients aged 56.3 ± 18.5 years were examined. We observed significant correlations between HRV parameters and echocardiographic signs of RV overload. SDNN (standard deviation of intervals of all normal beats) correlated with echocardiography-derived RVSP (right ventricular systolic pressure; r = -0.31, p = 0.001), TAPSE (tricuspid annulus plane systolic excursion; r = 0.21, p = 0.033), IVC (inferior vena cava diameter; r = -0.27, p = 0.002) and also with NT-proBNP concentration (r = -0.30, p = 0.004). HRV indices were also associated with APE risk stratification, especially in the low-risk category (r = 0.30, p = 0.004 for SDNN). Univariate and multivariate analyses confirmed that SDNN values were associated with signs of RV overload. In conclusion, we observed a significant association between time-domain HRV parameters and echocardiographic and biochemical signs of RV overload. Impaired HRV parameters were also associated with worse a clinical risk status of APE.

Association Between the Severity of Obstructive Sleep Apnea and the Risk Stratification of Acute Pulmonary Embolism

Obstructive sleep apnea (OSA) has been associated with the initiation and progression of cardiovascular disease. This study aimed to explore the relationship between the severity of OSA and the risk stratification of acute pulmonary embolism (PE). In this single-center cohort study, patients diagnosed with PE were evaluated for OSA via polygraphy monitoring. The simplified PE severity index (sPESI) and the number of patients requiring systemic thrombolysis were used to determine the severity of the disease. Echocardiography was performed on all participants. All patients were divided into 2 groups (OSA group and non-OSA group), and the patients in OSA group were then divided into 3 groups based on the severity of OSA. Patients with severe OSA had a significantly higher number of patients with sPESI ≥ 1 (P = .005). A higher proportion of patients with severe OSA require systemic thrombolysis (P = .010). Patients with apnea-hypopnea index (AHI) > 30/h had a much higher fibrinogen (P = .004) and D-dimer (P = .040) level than those in the non-OSA group. The levels of creatinine were significantly higher in patients with OSA (P = .040). Echocardiography showed a significant difference in left ventricular ejection fraction (LVEF) between patients in non-OSA and severe OSA groups (P = .035). And brain natriuretic peptide (BNP) also exhibited a progressive worsening related to the deepest desaturation and oxygen desaturation index. OSA, especially with AHI > 30/h, is correlated with the severity and prognosis of acute PE. This might be attributed to the prothrombotic effect, renal impairment, and cardiac dysfunction in patients with severe OSA.

The Importance of Frontal QRS-T Angle in Predicting the Effectiveness and Success of Thrombolytic Therapy in Patients With Acute Pulmonary Embolism

OBJECTIVE

The frontal QRS-T angle (fQRS-T) is associated with myocardial ischemia and ventricular arrhythmias. On the other hand, acute pulmonary embolism (APE) is a major risk factor for cardiac adverse events. This research aimed to determine whether the fQRS-T, a marker of ventricular heterogeneity, can be used to predict successful thrombolytic therapy in patients with APE.

METHODS

This was a retrospective observational study. Patients diagnosed with APE and hospitalized in the intensive care unit between 2020 and 2022 were included in the research. A total of 136 individuals with APEs were enrolled in this research. The patients were divided into two groups: thrombolytic-treated (n=64) and non-treated (moderate to severe risk, n=72). An ECG was conducted for each patient, and echocardiography was performed.

RESULTS

The mean age of the thrombolytic group was 58.2±17.6 years, with 35 females (55.1% of the group) and 29 males (44.9%). The non-thrombolytic group had a mean age of 63.1±16.2, with 41 females (56.5%) and 31 males (43.5%). Respiratory rate, heart rate, and fQRS-T were higher in the thrombolytic group, and oxygen saturation ratio and systolic and diastolic blood pressure were higher in the non-thrombolytic group (p=0.006, p<0.001, p=0.021; p<0.001, p=0.015, p<0.001, respectively). In the thrombolytic therapy group, comparing pre- and post-treatment ECG data revealed a statistically significant change in the fQRS-T value (p=0.019).

CONCLUSION

The fQRS-T may provide important clues for the successful treatment of APEs.

Expert opinion of the Polish PERT Initiative, Working Group on Pulmonary Circulation, Association of Cardiovascular Interventions, and Association of Intensive Cardiac Care of the Polish Cardiac Society

Thanks to advances in interventional cardiology technologies, catheter-directed treatment has become recently a viable therapeutic option in the treatment of patients with acute pulmonary embolism at high risk of early mortality. Current transcatheter techniques allow for local fibrinolysis or embolectomy with minimal risk of complications. Therefore, these procedures can be considered in high-risk patients as an alternative to surgical pulmonary embolectomy when systemic thrombolysis is contraindicated or ineffective. They are also considered in patients with intermediate-high-risk pulmonary embolism who do not improve or deteriorate clinically despite anticoagulation. The purpose of this article is to present the role of transcatheter techniques in the treatment of patients with acute pulmonary embolism. We describe current knowledge and expert opinions in this field. Interventional treatment is described in the broader context of patient care organization and therapeutic modalities. We present the organization and responsibilities of pulmonary embolism response team, role of pre-procedural imaging, periprocedural anticoagulation, patient selection, timing of intervention, and intensive care support. Currently available catheter-directed therapies are discussed in detail including standardized protocols and definitions of procedural success and failure. This expert opinion has been developed in collaboration with experts from various Polish scientific societies, which highlights the role of teamwork in caring for patients with acute pulmonary embolism.