601
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Direct oral anticoagulants in patients with severe inherited thrombophilia: a single-center cohort study. Int J Hematol 2020; 113:190-198. [PMID: 33040276 DOI: 10.1007/s12185-020-03012-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/22/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Abstract
We investigated the safety and efficacy of direct oral anticoagulants (DOACs) in patients with venous thromboembolism (VTE) associated with severe inherited thrombophilia. In this single-center cohort study, we enrolled 56 consecutive VTE patients with severe inherited thrombophilia, defined as the presence of antithrombin (n = 18), protein C (n = 12) and protein S (n = 12) deficiencies, homozygous Factor V Leiden (n = 3) and prothrombin G20210AA (n = 4) mutations, or combined defects (n = 7). During a median follow-up of 44.5 (IQR 30-52.5) months, rivaroxaban was used in 30 (53.6%), apixabanin 14 (25%), and dabigatran in 12 (21.4%) subjects. Recurrent nonfatal VTE was observed in 5 (8.9%) patients (2.4 per 100 patient-years), treated with rivaroxaban (n = 4) and apixaban (n = 1). Major bleeding and clinically relevant non-major bleeding (CRNMB) occurred in 2 (3.5%) and 4 (7%) subjects, respectively (0.96 per 100 patient-years and 1.92 per 100 patient-years, respectively), including 4 patients on rivaroxaban. The event-free survival analysis showed that the use of rivaroxaban was associated with increased risk of recurrent VTE or bleeding, compared with apixaban or dabigatran (HR 2.76, 95% CI 1.26-3.92, p = 0.039). In conclusion, the results of our cohort study indicate that full-dose dabigatran or apixaban are effective and safe in patients with severe inherited thrombophilia.
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602
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Yogeswaran A, Richter MJ, Sommer N, Ghofrani HA, Seeger W, Tello K, Gall H. Advanced risk stratification of intermediate risk group in pulmonary arterial hypertension. Pulm Circ 2020; 10:2045894020961739. [PMID: 33088480 PMCID: PMC7545769 DOI: 10.1177/2045894020961739] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/05/2020] [Indexed: 01/12/2023] Open
Abstract
In 301 treatment-naïve patients with pulmonary arterial hypertension stratified by the European Society of Cardiology/European Respiratory Society risk score, further stratification of intermediate-risk patients based on six-minute walk distance and the tricuspid annular plane systolic excursion/systolic pulmonary artery pressure ratio identified a subset with mortality rates comparable to low-risk patients.
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Affiliation(s)
- Athiththan Yogeswaran
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Manuel J Richter
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Natascha Sommer
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Hossein A Ghofrani
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Werner Seeger
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Khodr Tello
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Henning Gall
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
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603
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Abstract
Purpose of the Review Over 100,000 cardiovascular-related deaths annually are caused by acute pulmonary embolism (PE). While anticoagulation has historically been the foundation for treatment of PE, this review highlights the recent rapid expansion in the interventional strategies for this condition. Recent Findings At the time of diagnosis, appropriate risk stratification helps to accurately identify patients who may be candidates for advanced therapeutic interventions. While systemic thrombolytics (ST) is the mostly commonly utilized intervention for high-risk PE, the risk profile of ST for intermediate-risk PE limits its use. Assessment of an individualized patient risk profile, often via a multidisciplinary pulmonary response team (PERT) model, there are various interventional strategies to consider for PE management. Novel therapeutic options include catheter-directed thrombolysis, catheter-based embolectomy, or mechanical circulatory support for certain high-risk PE patients. Current data has established safety and efficacy for catheter-based treatment of PE based on surrogate outcome measures. However, there is limited long-term data or prospective comparisons between treatment modalities and ST. While PE diagnosis has improved with modern cross-sectional imaging, there is interest in improved diagnostic models for PE that incorporate artificial intelligence and machine learning techniques. Summary In patients with acute pulmonary embolism, after appropriate risk stratification, some intermediate and high-risk patients should be considered for interventional-based treatment for PE.
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604
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Tian Z, Jiang X, Jing ZC. How should a physician approach the pharmacological management of chronic thromboembolic pulmonary hypertension? Expert Opin Pharmacother 2020; 22:557-563. [PMID: 33016151 DOI: 10.1080/14656566.2020.1828349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by the presence of organized thromboembolic material and proliferative fibrous intima occluding varying degrees of the pulmonary arteries, and is also accompanied by small vessel vasculopathy in occluded and non-occluded pulmonary vasculature. The similarity in hemodynamics and pathophysiology between CTEPH and group 1 pulmonary arterial hypertension provides the rationale for clinical use of pulmonary arterial hypertension (PAH)-specific therapy. AREAS COVERED The authors present the current knowledge concerning the updated therapeutic strategies in CTEPH, and try to illustrate the established and uncertain role of PAH-specific therapy and anticoagulation therapy. The real-world observational registries and landmark randomized controlled trials of PAH-specific drugs in CTEPH are emphasized in the manuscript. EXPERT OPINION Despite surgical and interventional therapies, which could provide effective and potential curable treatments, medical therapies are still the substantial and irreplaceable option for patients with CTEPH. More and more PAH-specific drugs have demonstrated favorable efficacy and safety profiles in patients with CTEPH. Additionally, anticoagulation therapy is also a substantial medical treatment in all CTEPH patients without contradiction. However, the benefit-to-risk balance in life-long anticoagulation and whether more individualized anticoagulation strategies are needed warrants further investigation.
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Affiliation(s)
- Zhuang Tian
- Department of Cardiology, Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy Medical Sciences, Beijing, China
| | - Xin Jiang
- Department of Cardiology, Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy Medical Sciences, Beijing, China
| | - Zhi-Cheng Jing
- Head of Cardiology Department, Key Laboratory of Pulmonary Vascular Medicine, Peking Union Medical College Hospital, Chinese Academy Medical Sciences, Beijing, China
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605
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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] [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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606
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Le Roux PY, Le Gal G, Salaun PY. Lung scintigraphy for pulmonary embolism diagnosis during the COVID-19 pandemic: does the benefit-risk ratio really justify omitting the ventilation study? Eur J Nucl Med Mol Imaging 2020; 47:2499-2500. [PMID: 32700057 PMCID: PMC7375202 DOI: 10.1007/s00259-020-04964-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 01/06/2023]
Affiliation(s)
- Pierre-Yves Le Roux
- Service de médecine nucléaire, CHRU de Brest, EA3878 (GETBO), Université de Brest, CHRU Morvan, Médecine nucléaire, 2 avenue Foch, 29609, Brest Cedex, France.
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Pierre-Yves Salaun
- Service de médecine nucléaire, CHRU de Brest, EA3878 (GETBO), Université de Brest, CHRU Morvan, Médecine nucléaire, 2 avenue Foch, 29609, Brest Cedex, France
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607
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Kline J, Adler D, Alanis N, Bledsoe J, Courtney D, D'Etienne J, B Diercks D, Garrett J, Jones AE, MacKenzie D, Madsen T, Matuskowitz A, Mumma B, Nordenholz K, Pagenhardt J, Runyon M, Stubblefield W, Willoughby C. Study protocol for a multicentre implementation trial of monotherapy anticoagulation to expedite home treatment of patients diagnosed with venous thromboembolism in the emergency department. BMJ Open 2020; 10:e038078. [PMID: 33004396 PMCID: PMC7534683 DOI: 10.1136/bmjopen-2020-038078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/23/2020] [Accepted: 07/29/2020] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION In the USA, many emergency departments (EDs) have established protocols to treat patients with newly diagnosed deep vein thrombosis (DVT) as outpatients. Similar treatment of patients with pulmonary embolism (PE) has been proposed, but no large-scale study has been published to evaluate a comprehensive, integrated protocol that employs monotherapy anticoagulation to treat patients diagnosed with DVT and PE in the ED. METHODS AND ANALYSIS This protocol describes the implementation of the Monotherapy Anticoagulation To expedite Home treatment of Venous ThromboEmbolism (MATH-VTE) study at 33 hospitals in the USA. The study was designed and executed to meet the requirements for the Standards for Reporting Implementation Studies guideline. The study was funded by investigator-initiated awards from industry, with Indiana University as the sponsor. The study principal investigator and study associates travelled to each site to provide on-site training. The protocol identically screens patients with both DVT or PE to determine low risk of death using either the modified Hestia criteria or physician judgement plus a negative result from the simplified PE severity index. Patients must be discharged from the ED within 24 hours of triage and treated with either apixaban or rivaroxaban. Overall effectiveness is based upon the primary efficacy and safety outcomes of recurrent VTE and bleeding requiring hospitalisation respectively. Target enrolment of 1300 patients was estimated with efficacy success defined as the upper limit of the 95% CI for the 30-day frequency of VTE recurrence below 2.0%. Thirty-three hospitals in 17 states were initiated in 2016-2017. ETHICS AND DISSEMINATION All sites had Institutional Review Board approval. We anticipate completion of enrolment in June 2020; study data will be available after peer-reviewed publication. MATH-VTE will provide information from a large multicentre sample of US patients about the efficacy and safety of home treatment of VTE with monotherapy anticoagulation.
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Affiliation(s)
- Jeffrey Kline
- Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - David Adler
- Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Naomi Alanis
- Emergency Medicine, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Joseph Bledsoe
- Emergency Medicine, Intermountain Health Care Inc, Salt Lake City, Utah, USA
| | - Daniel Courtney
- Emergency Medicine, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - James D'Etienne
- Emergency Medicine, John Peter Smith Hospital, Fort Worth, Texas, USA
| | - Deborah B Diercks
- Emergency Medicine, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - John Garrett
- Emergency Medicine, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Alan E Jones
- Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - David MacKenzie
- Emergency Medicine, Maine Medical Center, Portland, Maine, USA
| | - Troy Madsen
- Emergency Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Andrew Matuskowitz
- Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bryn Mumma
- Emergency Medicine, University of California Davis, Davis, California, USA
| | - Kristen Nordenholz
- Emergency Medicine, University of Colorado Denver, Denver, Colorado, USA
| | - Justine Pagenhardt
- Emergency Medicine, West Virginia University - Health Sciences Campus, Morgantown, West Virginia, USA
| | - Michael Runyon
- Emergency Medicine, Atrium Health, Charlotte, North Carolina, USA
| | - William Stubblefield
- Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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608
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Abstract
Abstract
Cardiovascular disease remains the leading cause of death and morbidity worldwide. The appearance of the pandemic with COVID-19 at the beginning of this year all over the world makes the approach of the patients different. SARS-CoV-2 has major implications for the cardiovascular system. In addition to acute complications, COVID-19 infection can predispose to cardiovascular disease. Recent data show that myocarditis occurs in some patients with COVID-19, a few days after the onset of fever. This indicates the possibility of viral nature of myocardial lesions. In addition, patients infected with COVID-19 may be tachycardic (with or without palpitations) in relation to other symptoms related to the disease (fever, tachypnea, pain). They noticed several particular aspects, including rhythm disorders.
It is known that in patients with pneumonia, hypercoagulability and systemic inflammatory activity may persist for a long time. This explains the occurrence of arterial and venous thrombotic complications in acute coronary syndromes or venous thromboembolism. The latest guideline for the diagnosis and management of cardiovascular disease during the COVID-19 pandemic states that, although there is no solid evidence to date, the incidence of pulmonary thromboembolism in infected patients is high, thus recommending prophylactic doses of anticoagulant. The COVID-19 pandemic has affected millions of patients and poses an international health threat and considerable efforts are currently being made to evaluate new therapies to counteract this virus.
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609
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Ramjug S, Weatherald J, Sahay S, Khoury J, Foris V, Chandran N, Bokan A, Godinas L, Delcroix M. ERS International Congress, Madrid, 2019: highlights from the Pulmonary Vascular Diseases Assembly. ERJ Open Res 2020; 6:00304-2020. [PMID: 33083438 PMCID: PMC7553109 DOI: 10.1183/23120541.00304-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/28/2020] [Indexed: 12/17/2022] Open
Abstract
The 2019 European Respiratory Society (ERS) International Congress, held in Madrid, Spain, had exciting sessions regarding the field of pulmonary vascular disease. The symposia related to the new ERS/European Society of Cardiology (ESC) Guidelines for the diagnosis and management of acute pulmonary embolism were well received, as were sessions on pulmonary hypertension related to lung disease, demonstrating the concept of pulmonary hypertension not being the rarity that it was previously thought to be. The use of risk stratification in relation to pulmonary arterial hypertension (PAH) was heavily featured and the scientific sessions informing the respiratory community of potential biomarkers and targets for future therapies were thought-provoking. This article discusses highlights of the 2019 pulmonary vascular disease sessions as a summary of current knowledge and practice. We have summarised the key points from the sessions pertaining to the new ERS/ESC Guidelines for the management of acute pulmonary embolism. We have also focused on prognostic factors and potential therapies in pulmonary hypertension related to interstitial lung disease. Relating to PAH, we have reviewed the symposia on risk stratification, along with the use of noninvasive measures and the sessions relating to biomarkers in PAH.
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Affiliation(s)
- Sheila Ramjug
- Dept of Respiratory Medicine, Manchester University NHS Foundation Trust, Wythenshawe, UK
| | - Jason Weatherald
- Dept of Medicine, Division of Respirology, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Sandeep Sahay
- Houston Methodist Lung Center, Division of Pulmonary Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Johad Khoury
- Pulmonary Division, Lady Davis-Carmel Medical Center, Haifa, Israel
| | - Vasile Foris
- Medical University of Graz, Dept of Internal Medicine, Division of Pulmonology, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Nagaraj Chandran
- Medical University of Graz, Dept of Internal Medicine, Division of Pulmonology, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Aleksandar Bokan
- Dept for Emergency Pulmonology, Institute for Pulmonary Diseases of Vojvodina, Faculty of Medicine Novi Sad, Novi Sad, Serbia
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610
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Bertoletti L, Huisman MV. How can we better predict pulmonary blood clots in patients hospitalised for COVID-19? Eur Respir J 2020; 56:2003092. [PMID: 32907888 PMCID: PMC7487270 DOI: 10.1183/13993003.03092-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/12/2020] [Indexed: 12/21/2022]
Abstract
The emergence of coronavirus disease 2019 (COVID-19) has put pressure on health systems around the world [1, 2]. This coronavirus has also questioned much of our medical knowledge, with each day seeing the appearance of a new possible clinical expression of the virus [3]. Although its physiopathology is still poorly understood, the vascular tropism of the disease now seems to be a major pathway [4]. Recent studies highlight the development of a specific pulmonary vascular endothelialitis associated with thrombosis and angiogenesis [5]. D-dimer threshold at 2590 ng·mL−1 is able to predict pulmonary embolism in COVID-19 patients with clinical deterioration https://bit.ly/3kYObc3
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Affiliation(s)
- Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- INSERM, CIC-1408, CHU Saint-Etienne, Saint-Etienne, France
- F-CRIN INNOVTE network, Saint-Etienne, France
| | - Menno V. Huisman
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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611
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Evaluation of thrombolytic treatment effect on frontal plane QRS-T angle in patients with acute pulmonary embolism : A novel marker of successful thrombolysis. Herz 2020; 46:187-190. [PMID: 32975629 DOI: 10.1007/s00059-020-04978-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Acute pulmonary embolism (APE) patients with hypotension and/or shock should be evaluated for thrombolytic therapy, and hemodynamics often improves after thrombolytic therapy. Frontal plane QRS‑T (f[QRS-T]) angle, which is between the directions QRS axis and T axis, was described as a novel marker of ventricular repolarization heterogeneity. With right ventricular pressure overload, axis of heart may be affected and thrombolytic treatment may have an effect on this situation. This study aimed to investigate thrombolytic efficiency and effect on axis of heart by using f(QRS-T) angle. METHOD A total of 61 APE patients treated with thrombolytics and 71 APE patients treated without thrombolytics were included. Clinical findings and electrocardiogram (ECG) at diagnosis were collected. Second ECGs were included for patients with thrombolytics after 24 h, without thrombolytics after 72 h on average. RESULTS No significant differences were observed with regard to gender, age, hypertension, diabetes and cardiovascular disease. In patients with thrombolytics, respiratory rate, heart rate and pulmonary artery systolic pressure were significantly higher; oxygen saturation (Sat O2) as well as systolic and diastolic pressure were significantly lower. f(QRS-T) was markedly higher in APE with right ventricular pressure overload and changed significantly after thrombolytic therapy. CONCLUSION Right ventricular pressure overload in APE has an effect on f(QRS-T). In thrombolytic treatment, the change of f(QRS-T) angle may be a marker of successful thrombolysis.
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612
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Savioli G, Ceresa IF, Maggioni P, Lava M, Ricevuti G, Manzoni F, Oddone E, Bressan MA. Impact of ED Organization with a Holding Area and a Dedicated Team on the Adherence to International Guidelines for Patients with Acute Pulmonary Embolism: Experience of an Emergency Department Organized in Areas of Intensity of Care. MEDICINES 2020; 7:medicines7100060. [PMID: 32987644 PMCID: PMC7598623 DOI: 10.3390/medicines7100060] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/07/2020] [Accepted: 09/11/2020] [Indexed: 02/07/2023]
Abstract
Background: Adherence to guidelines by physicians of an emergency department (ED) depends on many factors: guideline and environmental factors; patient and practitioner characteristics; the social-political context. We focused on the impact of the environmental influence and of the patients’ characteristics on adherence to the guidelines. It is our intention to demonstrate how environmental factors such as ED organization more affect adherence to guidelines than the patient’s clinical presentation, even in a clinically insidious disease such as pulmonary embolism (PE). Methods: A single-center observational study was carried out on all patients who were seen at our Department of Emergency and Acceptance from 1 January to 31 December 2017 for PE. For the assessment of adherence to guidelines, we used the European guidelines 2014 and analyzed adherence to the correct use of clinical decision rule (CDR as Wells, Geneva, and YEARS); the correct initiation of heparin therapy; and the management of patients at high risk for short-term mortality. The primary endpoint of our study was to determine whether adherence to the guidelines as a whole depends on patients’ management in a holding area. The secondary objective was to determine whether adherence to the guidelines depended on patient characteristics such as the presence of typical symptoms or severe clinical features (massive pulmonary embolism; organ damage). Results: There were significant differences between patients who passed through OBI and those who did not, in terms of both administration of heparin therapy alone (p = 0.007) and the composite endpoints of heparin therapy initiation and observation/monitoring (p = 0.004), as indicated by the guidelines. For the subgroups of patients with massive PE, organ damage, and typical symptoms, there was no greater adherence to the decision making, administration of heparin therapy alone, and the endpoints of heparin therapy initiation and guideline-based observation/monitoring. Conclusions: Patients managed in an ED holding area were managed more in accordance with the guidelines than those who were managed only in the visiting ED rooms and directly hospitalized from there.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
- PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Correspondence: ; Tel.: +39-340-9070-001
| | - Iride Francesca Ceresa
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
| | - Paolo Maggioni
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
| | - Massimiliano Lava
- Neuro Radiodiagnostic, Irccs Policlinico San Matteo, 27100 Pavia, Italy;
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, Italy, Saint Camillus International University of Health Sciences, 00131 Rome, Italy;
| | - Federica Manzoni
- Clinical Epidemiology and Biometry Unit, Irccs Policlinico San Matteo, 27100 Pavia, Italy;
| | - Enrico Oddone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy;
| | - Maria Antonietta Bressan
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
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613
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How I assess and manage the risk of bleeding in patients treated for venous thromboembolism. Blood 2020; 135:724-734. [PMID: 31951652 DOI: 10.1182/blood.2019001605] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 12/23/2019] [Indexed: 12/13/2022] Open
Abstract
For patients with venous thromboembolism (VTE), prediction of bleeding is relevant throughout the course of treatment, although the means and goal of this prediction differ between the subsequent stages of treatment: treatment initiation, hospital discharge, 3-month follow-up, and long-term follow-up. Even in the absence of fully established risk prediction schemes and outcome studies using a prediction scheme for treatment decisions, the present evidence supports screening for and targeting of modifiable risk factors for major bleeding, as well as the application of decision rules to identify patients at low risk of bleeding complications, in whom long-term anticoagulant treatment is likely safe. Moving forward, prediction tools need to be incorporated in well-designed randomized controlled trials aiming to establish optimal treatment duration in patients at high risk of recurrent VTE. Moreover, the benefit of their longitudinal assessment rather than application as stand-alone baseline assessments should be studied, because changes in bleeding risk over time likely constitute the best predictor of major bleeding. We provide the state-of-the-art of assessing and managing bleeding risk in patients with acute VTE and highlight a practical approach for daily practice illustrated by 2 case scenarios.
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614
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Rolving N, Bloch-Nielsen JR, Brocki BC, Andreasen J. Perspectives of patients and health professionals on important factors influencing rehabilitation following acute pulmonary embolism: A multi-method study. Thromb Res 2020; 196:283-290. [PMID: 32947067 DOI: 10.1016/j.thromres.2020.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND International guidelines on pulmonary embolism (PE) management and rehabilitation have recently been published. However, the contained recommendation about an efficient follow-up strategy after PE is difficult for health care professionals to implement because limited research exists about what strategies are efficient. OBJECTIVES The study aimed to 1) describe and explore perspectives and experiences of health care professionals (HCPs) and patients participating in a post-PE rehabilitation intervention, and 2) provide suggestions for future post-PE management and rehabilitation interventions. PATIENTS/METHODS The study was a multi-method study, nested in a larger randomized controlled trial, combining data from two focus group interviews with 10 HCPs, 16 individual interviews with patients, data from exercise diaries and logbooks from HCPs participating in a rehabilitation intervention. RESULTS Key factors for successful post-PE management, considered important for reducing anxiety and confusion by both patients and HCPs, were the presence of a multidisciplinary specialized team, initiation of management shortly after discharge, and having regular follow-ups, e.g. telephone consultations. In terms of rehabilitation, repeatedly testing physical performance, resuming exercise under the guidance and support of specialized personnel, and access to peer support, were considered important for increasing motivation and self-efficacy for engaging in physical activity again. CONCLUSIONS This study offers suggestions for key elements to include in post-PE management and rehabilitation interventions, as well as the structuring of care. However, research still needs to be undertaken before solid recommendations for the content and structure of successful post-PE management and rehabilitation can be given.
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Affiliation(s)
- Nanna Rolving
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark; DEFACTUM, Corporate Quality, Central Denmark Region, Aarhus, Denmark.
| | | | | | - Jane Andreasen
- Department of Physical and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark; Public Health and Epidemiology Group, Department of Health, Science and Technology, Aalborg University, Denmark
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615
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Criado-García J. Prophylaxis of venous thromboembolism in medical patients. Rev Clin Esp 2020; 220:S0014-2565(20)30209-5. [PMID: 32958201 DOI: 10.1016/j.rce.2020.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 07/17/2020] [Accepted: 07/26/2020] [Indexed: 11/17/2022]
Abstract
Venous thromboembolism (VTE) is a prevalent and serious complication in hospitalized medical patients. Pulmonary embolism is the most common preventable cause of hospital death. VTE extends hospitalization, with a higher resource consumption and an increase in healthcare costs. Risk factors for VTE include intrinsic factors and those related to hospitalization. It is important to know and to identify these factors at the moment of hospital admission and during the course of disease. VTE prophylaxis has demonstrated to be an efficient and effective action. Its implementation reduces life-threatening pulmonary embolism, symptomatic deep vein thrombosis and death rate three months after discharge. An individual and detailed assessment of prophylaxis risk-benefit is a priority. In our country, low molecular weight heparins are still the first option for VTE pharmacological prophylaxis. In those patients at high risk of bleeding or in whom anticoagulation is contraindicated mechanical methods could be used.
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Affiliation(s)
- J Criado-García
- Unidad de Enfermedad Tromboembólica Venosa, Unidad de Gestión Clínica de Medicina Interna, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Universidad de Córdoba, Córdoba, España.
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616
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Nawazani A, Ghanaim M, Tariq S. Case of COVID-19 infection and polycythaemia presenting with massive acute pulmonary embolism. BMJ Case Rep 2020; 13:e237390. [PMID: 32948531 PMCID: PMC7511615 DOI: 10.1136/bcr-2020-237390] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2020] [Indexed: 01/08/2023] Open
Abstract
We are reporting a middle-aged male patient with polycythaemia vera comorbidity. The patient was exhibiting symptoms including fever, cough and shortness of breath and was found to have acute pulmonary embolism. He was diagnosed with SARS-CoV-2. This case suggests that a high index of suspicion should be taken into consideration for thromboembolic events, when treating patients with COVID-19 with breathing difficulty and low oxygen saturation levels, especially in those who have underlying predisposing conditions for coagulopathy.
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Affiliation(s)
| | - Mahmoud Ghanaim
- Emergency Department, Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates
| | - Sadia Tariq
- Internal Medicine, Dubai Hospital, Dubai, United Arab Emirates
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617
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Dong S, Zhang Y, Li Y, Li Y, Miao Y, Zhao R, Zhai S. Direct Oral Anticoagulant for the Treatment of VTE in Cancer Patients: A Systematic Review and Meta-analysis. Ann Pharmacother 2020; 55:430-439. [PMID: 32938202 DOI: 10.1177/1060028020960037] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Recent clinical guidelines suggest direct oral anticoagulants (DOACs) as treatment for cancer-associated thrombosis (CAT), but the strength of such recommendations was not clear. Newly released trials add uncertainties to the benefit and risk assessment between DOACs and conventional therapy (low-molecular-weight heparin [LMWH] or vitamin K antagonists [VKAs]). OBJECTIVE To evaluate the efficacy and safety of DOACs in patients with CAT, as compared with LMWH and VKAs. METHODS PubMed, EMBASE, Cochrane Library, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched. Randomized controlled trials (RCTs) that reported outcomes of DOACs for treating CAT were included. Relative risk (RR), risk difference, and 95% CIs were pooled using the Mantel-Haenszel method. RESULTS A total of 8 RCTs were included. DOACs significantly reduced VTE recurrence (RR = 0.59; 95% CI = 0.48-0.73) compared with conventional therapy. Results were similar in the LMWH and VKA subgroups. DOACs had a higher, though nonsignificant, risk of major bleeding compared with LMWH (RR = 1.33; 95% CI = 0.94-1.89) but lower risk of major bleeding compared with VKAs (RR = 0.60; 95% CI = 0.39-0.93). Findings were consistent across patients with active cancer and history of cancer. CONCLUSION AND RELEVANCE DOACs have better efficacy to prevent recurrent VTE compared with conventional therapy. Regarding the safety profile, DOACs may carry higher risk of bleeding compared with LMWH but lower risk of bleeding compared with VKAs. Further studies are needed to inform the optimal anticoagulation approach for different types of cancers.
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Affiliation(s)
- Shujie Dong
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Yatong Zhang
- Department of Pharmacy, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Li
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Yongjun Li
- Department of Vascular Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuqing Miao
- Department of Vascular Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Suodi Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
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618
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Gómez-Cuervo C, Rivas A, Visonà A, Ruiz-Giménez N, Blanco-Molina Á, Cañas I, Portillo J, López-Miguel P, Flores K, Monreal M. Predicting the risk for major bleeding in elderly patients with venous thromboembolism using the Charlson index. Findings from the RIETE. J Thromb Thrombolysis 2020; 51:1017-1025. [PMID: 32945982 DOI: 10.1007/s11239-020-02274-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2020] [Indexed: 11/29/2022]
Abstract
Old patients receiving anticoagulant therapy for venous thromboembolism (VTE) are at an increased risk for bleeding. We used data from the RIETE registry to assess the prognostic ability of the Comorbidity Charlson Index (CCI) to predict the risk for major bleeding in patients aged > 75 years receiving anticoagulation for VTE beyond the third month. We calculated the area under the receiver-operating characteristic curve (AUC), the category-based net reclassification index (NRI) and the net benefit (NB). We included 4303 patients with a median follow-up of 706 days (interquartile range [IQR] 462-1101). Of these, 147 (3%) developed major bleeding (27 died of bleeding). The AUC was 0.569 (95% CI 0.524-0.614). Patients with CCI ≤ 4 points were at a lower risk for adverse outcomes than those with CCI > 10 (major bleeding 0.81 (95% CI 0.53-1.19) vs. 2.21 (95% CI 1.18-3.79) per 100 patient-years; p < 0.05; all-cause death 1.9 (95% CI 1.45-2.44) vs. 15.67 (95% CI 12.63-19.22) per 100 patient-years; p < 0.05). A cut-off point of 4 points (CCI4) had a sensitivity of 82% (95% CI 75-89) and a specificity of 30% (95% CI 29-31) to predict major bleeding beyond the third month. CCI4 reclassification improved the NB of the RIETE bleeding score to predict bleeding beyond the third month (CCI4 NB 1.78% vs. RIETE NB 0.44%). Although the AUC of the CCI to predict major bleeding was modest, it could become an additional help to select patients aged > 75 years that obtain more benefit of extended anticoagulation, due to a lower risk for bleeding and better survival.
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Affiliation(s)
- Covadonga Gómez-Cuervo
- Department of Internal Medicine, Hospital Universitario, 12 de Octubre, Avenida de Córdoba s/n 28041, Madrid, Spain.
| | - Agustina Rivas
- Department of Pneumonology, Hospital Universitario Araba, Álava, Spain
| | - Adriana Visonà
- Department of Vascular Medicine, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
| | - Nuria Ruiz-Giménez
- Department of Internal Medicine, Hospital Universitario, de La Princesa, Madrid, Spain
| | | | - Inmaculada Cañas
- Department of Internal Medicine, Hospital General de Granollers, Barcelona, Spain
| | - José Portillo
- Department of Internal Medicine, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Patricia López-Miguel
- Department of Pneumonology, Hospital General, Universitario de Albacete, Albacete, Spain
| | - Katia Flores
- Department of Hematology, Hospital Universitario General de Cataluña, Barcelona, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Universidad Autónoma de Barcelona, Badalona, Barcelona, Spain
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619
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Martin PV, Chataigneau A, Arnaud FX, Rozwadowski F, Cournac JM, Martin AC. Transthoracic Doppler echocardiography during a military mission in a French role II in Mali: is it useful to learn this practice? Mil Med 2020; 185:e1562-e1568. [DOI: 10.1093/milmed/usaa126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Ultrasound is now recognized as a key tool in the practice of medicine in isolated situations. This study aims to evaluate the impact of transthoracic echocardiography (TTE) in a military mission when performed by a trained military practitioner (MP).
Materials and Methods
We conducted a 2-month retrospective observational study on the use of TTE in a French medical complex in Mali with a mission that included providing a medical aid to the population. All patients were included. Every ultrasound performed by the MP was listed, and the epidemiologic data, indication for the exam and results were collected for each TTE.
Results
A total of 349 patients were included, 16 were war-wounded patients and 333 came for a general medical consultation. In all, 153 ultrasounds were performed, including 48 TTEs. Sixteen TTEs were performed to evaluate injuries in war-wounded patients. During the 333 medical consultations, 32 TTEs were realized. The indications were dyspnoea (10), heart murmur (7), acute chest pain (5) and assessment of heart disease (10). TTE permitted a direct positive diagnosis for 18 patients: 7 with acute heart failure and 11 with morphologic problems. The normality of the exam was a supplementary argument to exclude a cardiac implication for eight patients.
Conclusions
TTE can provide important information with a direct impact on the management of patients. Faced with cardiac emergencies, an adapted training can be proposed for the MP. Thereby, the transfer of conventional cardiac views could facilitate the advice of a cardiologist.
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Affiliation(s)
- Paul-Vincent Martin
- Emergency department at the Percy Army training Hospital, 101 avenue Henri Barbusse, 92140 Clamart, France
| | - Anaïs Chataigneau
- Orthopedic and traumatology department at the Percy Army training Hospital, 101 avenue Henri Barbusse, 92140 Clamart, France
| | - François-Xavier Arnaud
- Radiology department at the Percy Army training Hospital, 101 avenue Henri Barbusse, 92140 Clamart, France
| | - Faye Rozwadowski
- FAAFP, Primary Care Physician for U.S. Military Veterans, Tallahassee, Florida, 3231, USA
| | - Jean-Marie Cournac
- Internal Medecine department at the Percy Army training Hospital, 101 avenue Henri Barbusse, 92140 Clamart, France
| | - Anne-Céline Martin
- Department of Cardiology, European Hospital Georges Pompidou, Paris, France
- Université de Paris, Innovative Therapy in Haemostasis, INSERM 1140, Paris, France
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620
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Polzin A, Dannenberg L, Thienel M, Orban M, Wolff G, Hohlfeld T, Zeus T, Kelm M, Petzold T. Noncanonical Effects of Oral Thrombin and Factor Xa Inhibitors in Platelet Activation and Arterial Thrombosis. Thromb Haemost 2020; 121:122-130. [PMID: 32942315 DOI: 10.1055/s-0040-1716750] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Nonvitamin K oral anticoagulants (NOACs) or direct oral anticoagulants comprise inhibitors of factor Xa (rivaroxaban, apixaban, edoxaban) or factor IIa (dabigatran). Both classes efficiently interfere with the final or penultimate step of the coagulation cascade and showed superior net clinical benefit compared with vitamin K antagonists for prevention of thromboembolic events in patients with AF and for prevention and therapy of deep vein thrombosis and pulmonary embolism. None the less, accumulating data suggested, that there may be differences regarding the frequency of atherothrombotic cardiovascular events between NOACs. Thus, the optimal individualized NOAC for each patient remains a matter of debate. Against this background, some basic and translational analyses emphasized NOAC effects that impact on platelet activity and arterial thrombus formation beyond inhibition of plasmatic coagulation. In this review, we will provide an overview of the available clinical and translational evidence for so-called noncanonical NOAC effects on platelet activation and arterial thrombosis.
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Affiliation(s)
- Amin Polzin
- Department of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Lisa Dannenberg
- Department of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Manuela Thienel
- Department of Cardiology, LMU München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Munich, Germany
| | - Martin Orban
- Department of Cardiology, LMU München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Munich, Germany
| | - Georg Wolff
- Department of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Thomas Hohlfeld
- Instituton of Pharmacology and Clinical Pharmacology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tobias Zeus
- Department of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tobias Petzold
- Department of Cardiology, LMU München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Munich, Germany
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621
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Vadukul P, Sharma DS, Vincent P. Massive pulmonary embolism following recovery from COVID-19 infection: inflammation, thrombosis and the role of extended thromboprophylaxis. BMJ Case Rep 2020; 13:13/9/e238168. [PMID: 32928824 PMCID: PMC7488789 DOI: 10.1136/bcr-2020-238168] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
COVID-19 is the infectious disease caused by a recently discovered SARS-CoV-2. Following an initial outbreak in December 2019 in Wuhan, China, the virus has spread globally culminating in the WHO declaring a pandemic on 11 March 2020. We present the case of a patient with an initial presentation of COVID-19 pneumonitis requiring mechanical ventilation for nearly 2 weeks and total admission time of 3 weeks. She was given prophylactic dose anticoagulation according to hospital protocol during this time. Following a week at home, she was readmitted with acute massive pulmonary embolism with severe respiratory and cardiac failure, representing the first such case in the literature.
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Affiliation(s)
- Prakash Vadukul
- Anaesthesia and Intensive Care Medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, West Midlands, UK
| | - Deepak S Sharma
- Anaesthesia and Intensive Care Medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, West Midlands, UK
| | - Paul Vincent
- Acute Medicine and Intensive Care Medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, West Midlands, UK
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622
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Massive pulmonary embolism in patients with extreme bleeding risk: a case series on the successful use of ultrasound-assisted, catheter directed thrombolysis in a district general hospital. J Thromb Thrombolysis 2020; 51:1120-1126. [PMID: 32886243 PMCID: PMC8084778 DOI: 10.1007/s11239-020-02258-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Massive pulmonary embolism (PE), characterised by profound arterial hypotension, is a life-threatening emergency with a 90-day mortality of over 50%. Systemic thrombolysis can significantly reduce the risk of death or cardiovascular collapse in these patients, by around 50%, but these benefits are offset by a fivefold increased risk of intracranial haemorrhage and major bleeding, which may limit its use in patients at high risk of catastrophic haemorrhage. We describe a case series of 3 patients presenting with massive PE, each with extreme risk of bleeding and contra-indication to systemic thrombolysis, treated successfully with ultrasound-assisted, catheter directed thrombolysis (U-ACDT). Our experience of this novel technique using the EkoSonic Endovascular System (Ekos, BTG, London, UK) on carefully selected patients has demonstrated the potential to improve clinical status in shocked patients, with minimal bleed risk. There have been several clinical studies evaluating the Ekos system. Both the ULTIMA and SEATTLE II studies have shown significant reductions in RV/LV ratio by CT scanning when compared to standard anticoagulation in patients with intermediate-risk PE, with minimal bleeding complications. However, there is a pressing need for a randomised trial demonstrating improvement in robust clinical outcomes when comparing U-ACDT to simple anticoagulation. We believe that this case series adds new insight and highlights the potential of catheter directed thrombolysis in this high-risk patient cohort and consideration should be made to its use in cases where systemic thrombolysis is felt to be too high risk.
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623
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Fryk K, Rylander C, Svennerholm K. Repeated and adaptive multidisciplinary assessment of a patient with acute pulmonary embolism and recurrent cardiac arrests. BMJ Case Rep 2020; 13:13/9/e234647. [PMID: 32878851 DOI: 10.1136/bcr-2020-234647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
High-risk pulmonary embolism (PE) is a life-threatening condition that must be recognised and treated rapidly. The importance of correct risk stratification to guide therapeutic decisions has prompted the introduction of multidisciplinary PE response teams (PERTs). The recommended first-line treatment for high-risk PE is intravenous thrombolysis. Alternatives to consider if thrombolysis has insufficient effect or may cause significant haemorrhagic complications include catheter-directed intervention (CDI) and surgical thrombectomy. For patients in deep shock or cardiac arrest, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be instituted for cardiopulmonary rescue and support during CDI, thrombectomy or pharmacological treatment. We present a complex case of high-risk PE that illustrates the importance of an early PERT conference and repeated decision-making when the initial therapy fails. After a trial of thrombolysis with insufficient effect, VA-ECMO was used to reverse circulatory and respiratory collapse in a patient with PE and recurrent episodes of cardiac arrest.
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Affiliation(s)
- Karin Fryk
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Christian Rylander
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Kristina Svennerholm
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Goteborg, Sweden
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624
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Robert-Ebadi H, Righini M. D-dimer: Well beyond diagnosis! JOURNAL DE MEDECINE VASCULAIRE 2020; 45:239-240. [PMID: 32862979 PMCID: PMC7343641 DOI: 10.1016/j.jdmv.2020.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/03/2020] [Indexed: 06/11/2023]
Affiliation(s)
- H Robert-Ebadi
- Division of angiology and hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | - M Righini
- Division of angiology and hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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625
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Wang CC, Lu CR, Hsieh LC, Lin YK, Chang KC, Hsu CH. Clinical Outcomes of Patients with Intermediate-to-High-Risk Pulmonary Embolism Undergoing Ultrasound-Assisted Catheter-Based Fibrinolysis Therapy in a Mid-Term Follow-Up Period - A Retrospective Observational Study. ACTA CARDIOLOGICA SINICA 2020; 36:493-502. [PMID: 32952359 PMCID: PMC7490606 DOI: 10.6515/acs.202009_36(5).20200330a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 03/30/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Endovascular therapy with ultrasound-assisted catheter-directed thrombolysis (UACDT) theoretically provides higher efficacy while reducing the bleeding risk compared with conventional systemic thrombolysis. The clinical outcomes of UACDT in treating intermediate-to-high-risk pulmonary embolism (PE) are lacking in an Asian population. METHODS Forty-two patients who presented with intermediate-to-high-risk PE received UACDT. The patients were divided into two groups based on the incidence of procedure-related bleeding events, and baseline demographics were compared between the two groups. A paired-Student's t test was conducted to evaluate the efficacy of UACDT. Univariate and multivariate logistic regression analyses were conducted to identify independent risk factors for significant bleeding events. RESULTS The average age was 58.93 ± 20.48 years, and 33.33% of the study participants were male. A total of 85.7% of the participants had intermediate-risk PE. Compared with pre-intervention pulmonary artery pressure, the mean pulmonary artery pressure decreased significantly (37.61 ± 9.57 mmHg vs. 25.7 ± 9.84 mmHg, p < 0.01) after UACDT. The cumulative total tissue plasminogen activator dosage and total infusion duration were 44.54 ± 20.55 mg and 39.14 ± 19.06 hours respectively. Overall, 21.43% of the participants had severe bleeding events during the endovascular fibrinolysis treatment period. Forward conditional multivariate logistic regression analysis revealed that the lowest fibrinogen level during thrombolysis was an independent factor associated with moderate-to-severe bleeding (odds ratio: 0.40, 95% confidence interval: 0.19-0.88, p = 0.02). CONCLUSIONS UACDT exhibited high efficacy, but resulted in a higher-than-expected bleeding rate in this real-world study of an Asian population. The lowest fibrinogen level during thrombolysis was an independent risk factor associated with procedure-related bleeding events.
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Affiliation(s)
- Chun-Cheng Wang
- Graduate Institute of Biomedical Science, China Medical University
- Division of Cardiovascular Medicine, Department of Internal Medicine
- Cardiovascular Research Laboratory, China Medical University Hospital, Taichung, Taiwan
| | - Chiung-Ray Lu
- Division of Cardiovascular Medicine, Department of Internal Medicine
| | - Li-Chuan Hsieh
- Division of Cardiovascular Medicine, Department of Internal Medicine
| | - Yu-Kai Lin
- Graduate Institute of Biomedical Science, China Medical University
- Division of Cardiovascular Medicine, Department of Internal Medicine
- Cardiovascular Research Laboratory, China Medical University Hospital, Taichung, Taiwan
| | - Kuan-Cheng Chang
- Graduate Institute of Biomedical Science, China Medical University
- Division of Cardiovascular Medicine, Department of Internal Medicine
- Cardiovascular Research Laboratory, China Medical University Hospital, Taichung, Taiwan
| | - Chung-Ho Hsu
- Division of Cardiovascular Medicine, Department of Internal Medicine
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626
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Falaschi Z, Danna PSC, Arioli R, Pasché A, Zagaria D, Percivale I, Tricca S, Barini M, Aquilini F, Andreoni S, Carriero A. Chest CT accuracy in diagnosing COVID-19 during the peak of the Italian epidemic: A retrospective correlation with RT-PCR testing and analysis of discordant cases. Eur J Radiol 2020; 130:109192. [PMID: 32738464 PMCID: PMC7382359 DOI: 10.1016/j.ejrad.2020.109192] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/04/2020] [Accepted: 07/14/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The goal of this study was to assess chest computed tomography (CT) diagnostic accuracy in clinical practice using RT-PCR as standard of reference. METHODS From March 4th to April 9th 2020, during the peak of the Italian COVID-19 epidemic, we enrolled a series of 773 patients that performed both non-contrast chest CT and RT-PCR with a time interval no longer than a week due to suspected SARS-CoV-2 infection. The diagnostic performance of CT was evaluated according to sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy, considering RT-PCR as the reference standard. An analysis on the patients with discrepant CT scan and RT-PCR result and on the patient with both negative tests was performed. RESULTS RT-PCR testing showed an overall positive rate of 59.8 %. CT sensitivity, specificity, PPV, NPV, and accuracy for SARS-CoV-2 infection were 90.7 % [95 % IC, 87.7%-93.2%], 78.8 % [95 % IC, 73.8-83.2%], 86.4 % [95 % IC, 76.1 %-88.9 %], 85.1 % [95 % IC, 81.0 %-88.4] and 85.9 % [95 % IC 83.2-88.3%], respectively. Twenty-five/66 (37.6 %) patients with positive CT and negative RT-PCR results and 12/245 (4.9 %) patients with both negative tests were nevertheless judged as positive cases by the clinicians based on clinical and epidemiological criteria and consequently treated. CONCLUSIONS In our experience, in a context of high pre-test probability, CT scan shows good sensitivity and a consistently higher specificity for the diagnosis of COVID-19 pneumonia than what reported by previous studies, especially when clinical and epidemiological features are taken into account.
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Affiliation(s)
- Zeno Falaschi
- Department of Diagnosis and Treatment Services, Radiodiagnostics, Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italy.
| | - Pietro S C Danna
- Department of Diagnosis and Treatment Services, Radiodiagnostics, Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italy
| | - Roberto Arioli
- Department of Diagnosis and Treatment Services, Radiodiagnostics, Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italy
| | - Alessio Pasché
- Department of Diagnosis and Treatment Services, Radiodiagnostics, Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italy
| | - Domenico Zagaria
- Department of Diagnosis and Treatment Services, Radiodiagnostics, Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italy
| | - Ilaria Percivale
- Department of Diagnosis and Treatment Services, Radiodiagnostics, Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italy
| | - Stefano Tricca
- Department of Diagnosis and Treatment Services, Radiodiagnostics, Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italy
| | - Michela Barini
- Department of Diagnosis and Treatment Services, Radiodiagnostics, Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italy
| | - Ferruccio Aquilini
- Direzione Sanitaria, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Stefano Andreoni
- Department of Diagnosis and Treatment Services, Radiodiagnostics, Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italy
| | - Alessandro Carriero
- Department of Diagnosis and Treatment Services, Radiodiagnostics, Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italy
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627
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Moores LK, Tritschler T, Brosnahan S, Carrier M, Collen JF, Doerschug K, Holley AB, Jimenez D, Le Gal G, Rali P, Wells P. Prevention, Diagnosis, and Treatment of VTE in Patients With Coronavirus Disease 2019: CHEST Guideline and Expert Panel Report. Chest 2020; 158:1143-1163. [PMID: 32502594 PMCID: PMC7265858 DOI: 10.1016/j.chest.2020.05.559] [Citation(s) in RCA: 443] [Impact Index Per Article: 110.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Emerging evidence shows that severe coronavirus disease 2019 (COVID-19) can be complicated by a significant coagulopathy, that likely manifests in the form of both microthrombosis and VTE. This recognition has led to the urgent need for practical guidance regarding prevention, diagnosis, and treatment of VTE. METHODS A group of approved panelists developed key clinical questions by using the PICO (Population, Intervention, Comparator, Outcome) format that addressed urgent clinical questions regarding the prevention, diagnosis, and treatment of VTE in patients with COVID-19. MEDLINE (via PubMed or Ovid), Embase, and Cochrane Controlled Register of Trials were systematically searched for relevant literature, and references were screened for inclusion. Validated evaluation tools were used to grade the level of evidence to support each recommendation. When evidence did not exist, guidance was developed based on consensus using the modified Delphi process. RESULTS The systematic review and critical analysis of the literature based on 13 Population, Intervention, Comparator, Outcome questions resulted in 22 statements. Very little evidence exists in the COVID-19 population. The panel thus used expert consensus and existing evidence-based guidelines to craft the guidance statements. CONCLUSIONS The evidence on the optimal strategies to prevent, diagnose, and treat VTE in patients with COVID-19 is sparse but rapidly evolving.
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Affiliation(s)
- Lisa K Moores
- Department of Medicine, F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences, Bethesda, MD.
| | - Tobias Tritschler
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Shari Brosnahan
- Division of Pulmonary, Critical Care, and Sleep Medicine, New York University Langone Health System, New York, NY
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Jacob F Collen
- Department of Medicine, F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences, Bethesda, MD; Pulmonary, Critical Care and Sleep Medicine Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - Kevin Doerschug
- Pulmonary, Critical Care, and Occupational Medicine, University of Iowa, Iowa City, IA
| | - Aaron B Holley
- Department of Medicine, F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences, Bethesda, MD; Pulmonary, Critical Care and Sleep Medicine Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - David Jimenez
- Respiratory Medicine, Ramón y Cajal Hospital (IRYCIS), Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Gregoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Philip Wells
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
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628
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Toma C, Khandhar S, Zalewski AM, D'Auria SJ, Tu TM, Jaber WA. Percutaneous thrombectomy in patients with massive and very high-risk submassive acute pulmonary embolism. Catheter Cardiovasc Interv 2020; 96:1465-1470. [PMID: 32866345 DOI: 10.1002/ccd.29246] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/24/2020] [Accepted: 08/02/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Examine FlowTriever thrombectomy feasibility in high-risk PE patients. BACKGROUND The FlowTriever thrombectomy system (Inari Medical, Irvine, CA) can reduce right ventricle (RV) strain in acute submassive pulmonary embolism (PE) patients. This technology has not been studied in higher risk PE patients. METHODS This multicenter retrospective analysis included patients treated with FlowTriever between 2017 and 2019 if they met at least one of the following: vasopressor dependence, PE induced respiratory failure, or decreased cardiac index (CI) measured by right heart catheterization. RESULTS Analysis included 34 patients: 18 massive, four intubated, 12 normotensive but with CI < 1.8. Average age was 56 and their median simplified PE severity index was 2. Patients had high bleeding risk, with 13 having recent surgery, six posttrauma, and four recent strokes. Six patients received cardiopulmonary resuscitation, and two received additional mechanical circulatory support. All patients had RV dilatation and elevated biomarkers. Clot removal was successful in 32/34 patients. CI improved from 2.0 ± 0.1 L/min/m2 before thrombectomy to 2.4 ± 0.1 L/min/m2 after (p = .01). The mean pulmonary artery pressure decreased from 33.2 ± 1.6 mmHg to 25.0 ± 1.5 mmHg (p = .01). The two patients-both with no or minimal thrombus removed-deteriorated during the procedure: one died and the other was successfully stabilized on ECMO. There were no other major complications. All other patients were alive at the time of data collection (mean follow-up of 205 days). CONCLUSION Aspiration thrombectomy appears feasible in higher risk acute PE patients with immediate hemodynamic improvement and low in-hospital mortality.
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Affiliation(s)
- Catalin Toma
- Division of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sameer Khandhar
- Division of Cardiology, Penn-Presbyterian Medical Center, Philadelphia, Pennsylvania, USA
| | - Adrian M Zalewski
- Division of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Stephen J D'Auria
- Division of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Wissam A Jaber
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
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629
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Barco S, Schmidtmann I, Ageno W, Anušić T, Bauersachs RM, Becattini C, Bernardi E, Beyer-Westendorf J, Bonacchini L, Brachmann J, Christ M, Czihal M, Duerschmied D, Empen K, Espinola-Klein C, Ficker JH, Fonseca C, Genth-Zotz S, Jiménez D, Harjola VP, Held M, Iogna Prat L, Lange TJ, Lankeit M, Manolis A, Meyer A, Münzel T, Mustonen P, Rauch-Kroehnert U, Ruiz-Artacho P, Schellong S, Schwaiblmair M, Stahrenberg R, Valerio L, Westerweel PE, Wild PS, Konstantinides SV. Survival and quality of life after early discharge in low-risk pulmonary embolism. Eur Respir J 2020; 57:13993003.02368-2020. [DOI: 10.1183/13993003.02368-2020] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/21/2020] [Indexed: 11/05/2022]
Abstract
IntroductionEarly discharge of patients with acute low-risk pulmonary embolism requires validation by prospective trials with clinical and quality-of-life outcomes.MethodsThe multinational Home Treatment of Patients with Low-Risk Pulmonary Embolism with the Oral Factor Xa Inhibitor Rivaroxaban (HoT-PE) single-arm management trial investigated early discharge followed by ambulatory treatment with rivaroxaban. The study was stopped for efficacy after the positive results of the predefined interim analysis at 50% of the planned population. The present analysis includes the entire trial population (576 patients). In addition to 3-month recurrence (primary outcome) and 1-year overall mortality, we analysed self-reported disease-specific (Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire) and generic (five-level five-dimension EuroQoL (EQ-5D-5L) scale) quality of life as well as treatment satisfaction (Anti-Clot Treatment Scale (ACTS)) after pulmonary embolism.ResultsThe primary efficacy outcome occurred in three (0.5%, one-sided upper 95% CI 1.3%) patients. The 1-year mortality was 2.4%. The mean±sd PEmb-QoL decreased from 28.9±20.6% at 3 weeks to 19.9±15.4% at 3 months, a mean change (improvement) of −9.1% (p<0.0001). Improvement was consistent across all PEmb-QoL dimensions. The EQ-5D-5L was 0.89±0.12 at 3 weeks after enrolment and improved to 0.91±0.12 at 3 months (p<0.0001). Female sex and cardiopulmonary disease were associated with poorer disease-specific and generic quality of life; older age was associated with faster worsening of generic quality of life. The ACTS burden score improved from 40.5±6.6 points at 3 weeks to 42.5±5.9 points at 3 months (p<0.0001).ConclusionsOur results further support early discharge and ambulatory oral anticoagulation for selected patients with low-risk pulmonary embolism. Targeted strategies may be necessary to further improve quality of life in specific patient subgroups.
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630
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Xiong W, Du H, Xu M, Ding W, Sun J, Han F, Guo X. An authoritative algorithm most appropriate for the prediction of pulmonary embolism in patients with AECOPD. Respir Res 2020; 21:218. [PMID: 32811494 PMCID: PMC7437016 DOI: 10.1186/s12931-020-01483-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 08/10/2020] [Indexed: 12/23/2022] Open
Abstract
Background Contemporarily authoritative algorithms for the prediction of acute pulmonary embolism (PE) comprise the Standard algorithm, the Age-adjusted algorithm, the YEARS algorithm, the PERC algorithm, and the PEGeD algorithm. To date, little is known with respect to which algorithm is most appropriate for the PE prediction in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Methods The patients with AECOPD who underwent the confirmed chest imaging investigations of PE due to the likelihood of PE predicted by the Standard algorithm were retrospectively reviewed. The patients were reassessed by the other four algorithms to reveal which algorithm had the best diagnostic accuracy for the likelihood prediction of PE for patients with AECOPD. Results The results showed that the PEGeD algorithm(88.6, 80.7, 50.4, 97.0%, 4.591, 0.141, 0.693, 82.1%) performed better overall in the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, Youden index, and diagnostic accuracy, in comparison with the Age-adjusted algorithm (78.6, 74.1, 40.1, 94.0%, 3.034, 0.289, 0.527, 74.9%), the YEARS algorithm (71.4, 76.6, 40.3, 92.4%, 3.051, 0.373, 0.480,75.6%), the PERC algorithm (98.6, 1.6, 18.2, 83.3%, 1.002, 0.875, 0.002, 19.2%). The difference of number of patients who were necessary to undergo chest imaging examinations and missed diagnoses resulted from each algorithm between the PEGeD algorithm and the Standard algorithm, the Age-adjusted algorithm, the YEARS algorithm, as well as the PERC algorithm were [− 789 (− 68.1%), N/A], [− 42 (− 3.6%),-21 (− 1.8%)], [− 3 (− 0.3%),-36 (− 3.1%)],[− 771 (− 66.6%), 21 (1.8%)], respectively. Conclusions To date, the PEGeD algorithm is the most appropriate strategy among the authoritative algorithms for the likelihood prediction of pulmonary embolism in patients with AECOPD.
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Affiliation(s)
- Wei Xiong
- Department of Respiratory Medicine, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, No. 1665, Kongjiang Road, Yangpu District, Shanghai, 200092, China.
| | - He Du
- Department of Oncology, Shanghai Pulmonary Hospital Affiliated to Tongji University School of Medicine, Shanghai, China
| | - Mei Xu
- Department of General Practice, North Bund Community Health Center, Hongkou District, Shanghai, China
| | - Wei Ding
- Department of Pulmonary and Critical Care Medicine, Punan Hospital, Pudong New District, Shanghai, China
| | - Jinyuan Sun
- Department of Respiratory Medicine, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, No. 1665, Kongjiang Road, Yangpu District, Shanghai, 200092, China
| | - Fengfeng Han
- Department of Respiratory Medicine, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, No. 1665, Kongjiang Road, Yangpu District, Shanghai, 200092, China.
| | - Xuejun Guo
- Department of Respiratory Medicine, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, No. 1665, Kongjiang Road, Yangpu District, Shanghai, 200092, China.
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631
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Brueilly KE, Hergott CG, Fox AM, Dowling JS. Early Rehabilitation Following Saddle Pulmonary Embolism: Perspective From Physical Therapist as Patient. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2020. [DOI: 10.1097/jat.0000000000000149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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632
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Higazi MM, Fattah RARA, Abdelghany EA, Ghany HSA. Efficacy of Computed Tomography Pulmonary Angiography as Non-invasive Imaging Biomarker for Risk Stratification of Acute Pulmonary Embolism. J Clin Imaging Sci 2020; 10:49. [PMID: 32874754 PMCID: PMC7451145 DOI: 10.25259/jcis_75_2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/17/2020] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES Massive and sub-massive pulmonary embolisms (PEs) are associated with high mortality and morbidity. The mainstay of treatment for PE is anticoagulation. However, high- and intermediate-risk patients may benefit from interventional thrombolytic therapy. Computed tomography pulmonary angiography (CTPA) is widely available, fast, and non-invasive technique, and it can identify pulmonary thrombus down to at least a segmental level. In this study, we attempt to evaluate the efficacy of CTPA as a non-invasive imaging biomarker for risk stratification of acute PE (APE) patients. MATERIAL AND METHODS This is a prospective study conducted on 150 patients who proved to have APE by CTPA. The simplified PE severity index score was obtained. The pulmonary artery obstruction index (PAOI) using and right to left ventricular (RV/LV) diameter ratios were calculated. RESULTS The patients were divided into (1) high risk (shocked) and (2) non-high risk groups. There was a significant difference between the 1st and 2nd groups regarding PAOI. Hemodynamically stable patients were further subclassified according to the right ventricular dysfunction (RVD) into Group Ia (intermediate risk) and Group Ib (low risk). There was a significant difference between subgroups regarding PAOI (P < 0.0001, r = 0.385). Receiver operating characteristic curve analysis revealed PAOI >47% associated with RV/LV ratio >1. CONCLUSION Our results support the use of CTPA as a surrogate imaging biomarker for both diagnosis and risk stratification of APE patients. CTPA allows assessment of clot burden through PAOI calculation and identification of intermediate-risk PE through the assessment of RVD.
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633
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Francis S, Kabrhel C. Current Controversies in Caring for the Critically Ill Pulmonary Embolism Patient. Emerg Med Clin North Am 2020; 38:931-944. [PMID: 32981627 DOI: 10.1016/j.emc.2020.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Emergency physicians must be prepared to rapidly diagnose and resuscitate patients with pulmonary embolism (PE). Certain aspects of PE resuscitation run counter to typical approaches. A specific understanding of the pathophysiology of PE is required to avoid cardiovascular collapse potentially associated with excessive intravenous fluids and positive pressure ventilation. Once PE is diagnosed, rapid risk stratification should be performed and treatment guided by patient risk class. Although anticoagulation remains the mainstay of PE treatment, emergency physicians also must understand the indications and contraindications for thrombolysis and should be aware of new therapies and models of care that may improve outcomes.
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Affiliation(s)
- Samuel Francis
- Division of Emergency Medicine, Department of Surgery, Duke University Hospital, DUH Box 3096, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA. https://twitter.com/chriskabrhel
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634
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Colombo L, Macheda A, Gentile D, Panizzardi F, Pierini S, Codazzi C, Meloni L, Bianchi F, Santangelo G. How to manage thromboembolic risk in patient with SARS-CoV-2-related disease in the Emergency Department: A case report of cardiogenic shock due to massive pulmonary embolism. Respir Med Case Rep 2020; 31:101185. [PMID: 32834988 PMCID: PMC7419271 DOI: 10.1016/j.rmcr.2020.101185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 08/02/2020] [Accepted: 08/05/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Although the most known feature of SARS-CoV-2 associated infection is a mild to severe pneumonia, increasing evidence suggests the existence of an infection-associated risk of both arterial and venous thromboembolism (VTE), but the exact magnitude of this phenomenon is still unknown.Given that, it is important for the Emergency Physician to remember that a SARS-CoV-2 associated respiratory failure can be caused not only by the pulmonary parenchymal inflammation that characterizes the pneumonia, but also by an associated pulmonary thromboembolism. CASE REPORT A healthy 73-years old woman admitted to the ED for dyspnea, fever and thoracic pain. Cardiac ultrasound, electrocardiogram and clinical findings suggested a diagnosis of cardiogenic obstructive shock due to acute pulmonary embolism, successfully treated with thrombolysis. A CT angiography confirmed the pulmonary embolism (EP) diagnosis and showed bilateral pneumonia, caused by SARS-CoV-2 infection. CONCLUSION Considering the high prevalence of thromboembolic events in COVID-19 patients it is mandatory for the emergency physician to systematically evaluate signs of pulmonary thromboembolism, in order to perform the most patient-tailored therapy as soon as possible.
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Affiliation(s)
- L. Colombo
- Emergency Department, Ospedale San Paolo, Milano, Italy
| | - A. Macheda
- Emergency Department, Ospedale San Paolo, Milano, Italy
| | - D. Gentile
- Cardiology Department, Ospedale San Paolo, Milano, Italy
| | - F. Panizzardi
- Emergency Department, Ospedale San Paolo, Milano, Italy
| | - S. Pierini
- Emergency Department, Ospedale San Paolo, Milano, Italy
| | - C. Codazzi
- Emergency Department, Ospedale San Paolo, Milano, Italy
| | - L. Meloni
- Emergency Department, Ospedale San Paolo, Milano, Italy
| | - F. Bianchi
- Emergency Department, Ospedale San Paolo, Milano, Italy
| | - G. Santangelo
- Cardiology Department, Ospedale San Paolo, Milano, Italy
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635
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Abstract
Pulmonary embolism is a common and potentially fatal cardiovascular disorder that must be promptly diagnosed and treated. The diagnosis, risk assessment, and management of pulmonary embolism have evolved with a better understanding of efficient use of diagnostic and therapeutic options. The use of either clinical probability adjusted or age adjusted D-dimer interpretation has led to a reduction in diagnostic imaging to exclude pulmonary embolism. Direct oral anticoagulation therapies are safe, effective, and convenient treatments for most patients with acute venous thromboembolism, with a lower risk of bleeding than vitamin K antagonists. These oral therapeutic options have opened up opportunities for safe outpatient management of pulmonary embolism in selected patients. Recent clinical trials exploring the use of systemic thrombolysis in intermediate to high risk pulmonary embolism suggest that this therapy should be reserved for patients with evidence of hemodynamic compromise. The role of low dose systemic or catheter directed thrombolysis in other patient subgroups is uncertain. After a diagnosis of pulmonary embolism, all patients should be assessed for risk of recurrent venous thromboembolism to guide duration of anticoagulation. Patients with a venous thromboembolism associated with a strong, transient, provoking risk factor can safely discontinue anticoagulation after three months of treatment. Patients with an ongoing strong risk factor, such as cancer, or unprovoked events are at increased risk of recurrent events and should be considered for extended treatment. The use of a risk prediction score can help to identify patients with unprovoked venous thromboembolism who can benefit from extended duration therapy. Despite major advances in the management of pulmonary embolism, up to half of patients report chronic functional limitations. Such patients should be screened for chronic thromboembolic pulmonary hypertension, but only a small proportion will have this as the explanation of their symptoms. In the remaining patients, future studies are needed to understand the pathophysiology and explore interventions to improve quality of life.
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Affiliation(s)
- Lisa Duffett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lana A Castellucci
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Melissa A Forgie
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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636
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Ala-Seppälä HM, Ukkonen MT, Lehtomäki AI, Pohja ES, Nieminen JJ, Laurikka JO, Khan JA. High Occurrence of Thrombo-Embolic Complications During Long-Term Follow-up After Pleural Infections-A Single-Center Experience with 536 Consecutive Patients Over 17 Years. Lung 2020; 198:671-678. [PMID: 32607673 PMCID: PMC7374478 DOI: 10.1007/s00408-020-00374-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 06/22/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Pleural infections are associated with significant inflammation, long hospitalizations, frequent comorbidities, and are often treated operatively-all of which are consequential risk factors for thrombo-embolic complications. However, their occurrence following the treatment of pleural infection is still unknown. The aim of the study was to ascertain the early and long-term occurrence of thrombo-embolic events in patients treated for pleural infections. METHODS The study included all patients that were treated for pleural infections in Tampere University Hospital between January 2000 and December 2016. Data regarding later treatment episodes due to pulmonary embolisms and/or deep vein thromboses as well as survival data were requested from national registries. The rates were also compared to a demographically matched reference population adjusted for age, sex, and the location of residence. RESULTS The final study population comprised 536 patients and 5318 controls (median age 60, 78% men). The most common etiology for pleural infection was pneumonia (73%) and 85% underwent surgical treatment for pleural infection. The occurrence of thrombo-embolic complications in patients and controls was 3.8% vs 0.1% at three months, 5.0% vs 0.4% at one year, 8.8% vs 1.0% at three years, and 12.4% vs 1.8% at five years, respectively, p < 0.001 each. Female sex, advanced age, chronic lung disease, immunosuppression, video-assisted surgery, and non-pneumonic etiology were associated with a higher incidence of thrombo-embolism. CONCLUSIONS The occurrence of thrombo-embolic events-particularly pulmonary embolism but also deep vein thrombosis-was significant in patients treated for pleural infections, both initially and during long-term follow-up.
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Affiliation(s)
- Henna Maria Ala-Seppälä
- Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Ensitie 4, 33520, Tampere, Finland
| | - Mika Tapani Ukkonen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, P.O. Box 2000, 33521, Tampere, Finland
- Faculty of Medicine and Life Sciences, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland
| | - Antti Ilmari Lehtomäki
- Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Ensitie 4, 33520, Tampere, Finland
| | - Emilia Susanna Pohja
- Faculty of Medicine and Life Sciences, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland
| | - Jaakko Juhani Nieminen
- Faculty of Medicine and Life Sciences, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland
| | - Jari Olavi Laurikka
- Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Ensitie 4, 33520, Tampere, Finland
- Faculty of Medicine and Life Sciences, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland
| | - Jahangir Ari Khan
- Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Ensitie 4, 33520, Tampere, Finland.
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Boon GJAM, Bogaard HJ, Klok FA. Essential aspects of the follow-up after acute pulmonary embolism: An illustrated review. Res Pract Thromb Haemost 2020; 4:958-968. [PMID: 32864549 PMCID: PMC7443426 DOI: 10.1002/rth2.12404] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 12/31/2022] Open
Abstract
Care for patients with acute pulmonary embolism (PE) involves more than determination of the duration of anticoagulant therapy. After choosing the optimal initial management strategy based on modern risk stratification schemes, patients require focused attention aimed at prevention of major bleeding, identification of underlying (malignant) disease, prevention of cardiovascular disease, and monitoring for long-term complications. The most frequent complication of PE is the so-called "post-PE syndrome," a phenomenon of permanent functional limitations after PE occurring in up to 50% of patients. The post-PE syndrome is caused by persistent deconditioning, anxiety, and/or ventilatory or circulatory impairment as a result of acute PE. The most severe and most feared presentation of the post-PE syndrome is chronic thromboembolic pulmonary hypertension (CTEPH), a deadly disease if it remains untreated. While CTEPH may be successfully treated with pulmonary endarterectomy, balloon pulmonary angioplasty, and/or pulmonary hypertension drugs, the major challenge is to diagnose CTEPH at an early stage. Poor awareness for the post-PE syndrome and in particular for CTEPH, high prevalence of persistent symptoms after PE and inefficient application of diagnostic tests in clinical practice all contribute to an unacceptable diagnostic delay and underdiagnosis. Its consequences are dire: increased mortality in patients with CTEPH, and excess health care costs, higher prevalence of depression, more unemployment and poorer quality of life in patients with post-PE syndrome in general. In this review, we provide an overview of the incidence and impact of the post-PE syndrome, and illustrate the clinical presentation, optimal diagnostic strategy as well as therapeutic options.
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Affiliation(s)
- Gudula J. A. M. Boon
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary DiseasesInstitute for Cardiovascular Research (ICaR‐VU)Amsterdam University Medical Centerlocation VUmcAmsterdamThe Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
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638
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Zornitzki L, Bornstein G. Potential role for furosemide in the treatment of acute respiratory distress syndrome (ARDS) and an unusual presentation of pulmonary embolism in a complex patient. BMJ Case Rep 2020; 13:13/8/e235010. [DOI: 10.1136/bcr-2020-235010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
An 81-year-old woman was admitted to our hospital after experiencing syncope. She was diagnosed with a large pulmonary embolism and was hemodynamically unstable therefore requiring endotracheal intubation and norepinephrine support. She presented with an upper gastrointestinal bleed which prevented her from receiving tissue plasminogen activator. She was treated with enoxaparin and ceftriaxone. Her blood, sputum and urine cultures were negative. When transferred to our ward, her antibiotic treatment was changed to piperacillin–tazobactam. A lumbar puncture was not suggestive of a central nervous system infection. Chest X-rays demonstrated rapid advancement of diffuse bilateral infiltrates which were not present at first and were interpreted by radiology consultation as suggestive of acute respiratory distress syndrome. An echocardiography showed right ventricle dilatation without left-sided heart failure. Diuretics were added and with this treatment, a quick respiratory improvement was noted as she regained consciousness and extubated shortly after.
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639
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Ribes A, Vardon-Bounes F, Mémier V, Poette M, Au-Duong J, Garcia C, Minville V, Sié P, Bura-Rivière A, Voisin S, Payrastre B. Thromboembolic events and Covid-19. Adv Biol Regul 2020; 77:100735. [PMID: 32773098 PMCID: PMC7833411 DOI: 10.1016/j.jbior.2020.100735] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 01/08/2023]
Abstract
The novel Corona virus infection (Covid-19) first identified in China in December 2019 has rapidly progressed in pandemic leading to significant mortality and unprecedented challenge for healthcare systems. Although the clinical spectrum of Covid-19 is variable, acute respiratory failure and systemic coagulopathy are common in severe Covid-19 patients. Lung is an important target of the SARS-CoV-2 virus causing eventually acute respiratory distress syndrome associated to a thromboinflammatory state. The cytokinic storm, thromboinflammation and pulmonary tropism are the bedrock of tissue lesions responsible for acute respiratory failure and for prolonged infection that may lead to multiple organ failure and death. The thrombogenicity of this infectious disease is illustrated by the high frequency of thromboembolic events observed even in Covid-19 patients treated with anticoagulation. Increased D-Dimers, a biomarker reflecting activation of hemostasis and fibrinolysis, and low platelet count (thrombocytopenia) are associated with higher mortality in Covid-19 patients. In this review, we will summarize our current knowledge on the thromboembolic manifestations, the disturbed hemostatic parameters, and the thromboinflammatory conditions associated to Covid-19 and we will discuss the modalities of anticoagulant treatment or other potential antithrombotic options.
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Affiliation(s)
- Agnès Ribes
- Inserm U1048 and Université Toulouse III Paul Sabatier, I2MC, 31024, Toulouse Cedex 03, France; Laboratoire d'Hématologie, CHU de Toulouse, 31059, Toulouse, France
| | - Fanny Vardon-Bounes
- Inserm U1048 and Université Toulouse III Paul Sabatier, I2MC, 31024, Toulouse Cedex 03, France; Pôle Anesthésie-Réanimation, CHU de Toulouse, 31059, Toulouse, France
| | - Vincent Mémier
- Laboratoire d'Hématologie, CHU de Toulouse, 31059, Toulouse, France
| | - Michael Poette
- Inserm U1048 and Université Toulouse III Paul Sabatier, I2MC, 31024, Toulouse Cedex 03, France; Pôle Anesthésie-Réanimation, CHU de Toulouse, 31059, Toulouse, France
| | - Jonathan Au-Duong
- Inserm U1048 and Université Toulouse III Paul Sabatier, I2MC, 31024, Toulouse Cedex 03, France; Pôle Anesthésie-Réanimation, CHU de Toulouse, 31059, Toulouse, France
| | - Cédric Garcia
- Inserm U1048 and Université Toulouse III Paul Sabatier, I2MC, 31024, Toulouse Cedex 03, France; Laboratoire d'Hématologie, CHU de Toulouse, 31059, Toulouse, France
| | - Vincent Minville
- Pôle Anesthésie-Réanimation, CHU de Toulouse, 31059, Toulouse, France
| | - Pierre Sié
- Inserm U1048 and Université Toulouse III Paul Sabatier, I2MC, 31024, Toulouse Cedex 03, France; Laboratoire d'Hématologie, CHU de Toulouse, 31059, Toulouse, France
| | | | - Sophie Voisin
- Inserm U1048 and Université Toulouse III Paul Sabatier, I2MC, 31024, Toulouse Cedex 03, France; Laboratoire d'Hématologie, CHU de Toulouse, 31059, Toulouse, France
| | - Bernard Payrastre
- Inserm U1048 and Université Toulouse III Paul Sabatier, I2MC, 31024, Toulouse Cedex 03, France; Laboratoire d'Hématologie, CHU de Toulouse, 31059, Toulouse, France.
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640
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National Outcomes of Surgical Embolectomy for Acute Pulmonary Embolism. Ann Thorac Surg 2020; 110:441-447. [DOI: 10.1016/j.athoracsur.2020.02.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/22/2019] [Accepted: 02/06/2020] [Indexed: 12/18/2022]
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Alzghoul BN, Reddy R, Chizinga M, Innabi A, Zou B, Papierniak ES, Faruqi I. Pulmonary Embolism in Acute Asthma Exacerbation: Clinical Characteristics, Prediction Model and Hospital Outcomes. Lung 2020; 198:661-669. [PMID: 32424799 PMCID: PMC7711330 DOI: 10.1007/s00408-020-00363-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 05/11/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE Little is known about the characteristics and impact of acute pulmonary embolism (PE) during episodes of asthma exacerbation. We aimed to characterize patients diagnosed with acute PE in the setting of asthma exacerbation, develop a prediction model to help identify future patients and assess the impact of acute PE on hospital outcomes. METHODS We included 758 patients who were treated for asthma exacerbation and underwent a computed tomographic pulmonary angiography (CTA) during the same encounter at a university-based hospital between June 2011 and October 2018. We compared clinical characteristics of patients with and without acute PE and developed a machine learning prediction model to classify the PE status based on the clinical variables. We used multivariable regression analysis to evaluate the impact of acute PE on hospital outcomes. RESULTS Twenty percent of the asthma exacerbation patients who underwent CTA had an acute PE. Factors associated with acute PE included previous history of PE, high CHA2DS2-VASc score, hyperlipidemia, history of deep vein thrombosis, malignancy, chronic systemic corticosteroids use, high body mass index and atrial fibrillation. Using these factors, we developed a random forest machine learning prediction model which had an 88% accuracy in classifying the acute PE status of the patients (area under the receiver operating characteristic curve = 0.899; 95% confidence interval: 0.885-0.913). Acute PE in asthma exacerbation was associated with longer hospital stay and intensive care unit stay. CONCLUSION It is important to consider acute PE, a potentially life-threatening event, in the setting of asthma exacerbation especially when other risk factors are present.
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Affiliation(s)
- Bashar N Alzghoul
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Road, Box 100277, Gainesville, FL, 32608, USA.
- Department of Medicine, University of Florida, Gainesville, FL, USA.
| | - Raju Reddy
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Road, Box 100277, Gainesville, FL, 32608, USA
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Mwelwa Chizinga
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Road, Box 100277, Gainesville, FL, 32608, USA
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Ayoub Innabi
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Road, Box 100277, Gainesville, FL, 32608, USA
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Baiming Zou
- Department of Biostatistics and School of Nursing, University of North Carolina, Chapel Hill, NC, USA
| | - Eric S Papierniak
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Road, Box 100277, Gainesville, FL, 32608, USA
- Department of Medicine, University of Florida, Gainesville, FL, USA
| | - Ibrahim Faruqi
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Road, Box 100277, Gainesville, FL, 32608, USA
- Department of Medicine, University of Florida, Gainesville, FL, USA
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642
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Abstract
Nox2 is responsible for artery dysfunction via production of reactive oxidant species. RNA viruses may activate Nox2, but it is unknown if this occurs in coronavirus 2019(Covid-19). Nox2 activation by soluble Nox2-derived peptide(sNox2-dp) was measured in patients hospitalized for Covid-19 (n = 182) and controls (n = 91). sNox2-dp values were higher in Covid-19 patients versus controls and in severe versus non severe Covid-19. Patients with thrombotic events(n = 35,19%) had higher sNox2-dp than thrombotic event-free ones. A logistic regression analysis showed that sNox2 and coronary heart disease predicted thrombotic events. Oxidative stress by Nox2 activation is associated severe disease and thrombotic events in Covid-19 patients. Nox2 is responsible for artery dysfunction via production of reactive oxidant species. sNox2-dp values, markers of Nox2 activation, were high in Covid-19 patients and higher in those with severe disease. A logistic regression analysis showed that sNox2 predicted thrombotic events. Oxidative stress by Nox2 activation is associated severe disease and thrombotic events in Covid-19 patients.
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643
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Abstract
Patients resuscitated from cardiac arrest require complex management. An organized approach to early postarrest care can improve patient outcomes. Priorities include completing a focused diagnostic work-up to identify and reverse the inciting cause of arrest, stabilizing cardiorespiratory instability to prevent rearrest, minimizing secondary brain injury, evaluating the risk and benefits of transfer to a specialty care center, and avoiding early neurologic prognostication.
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644
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Fu Z, Zhuang X, He Y, Huang H, Guo W. The diagnostic value of D-dimer with simplified Geneva score (SGS) pre-test in the diagnosis of pulmonary embolism (PE). J Cardiothorac Surg 2020; 15:176. [PMID: 32690039 PMCID: PMC7372827 DOI: 10.1186/s13019-020-01222-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 07/13/2020] [Indexed: 11/16/2022] Open
Abstract
Background Pulmonary embolism (PE) is the third most common cardiovascular syndrome with an average annual incidence rate of 77 per 100,000 population in the worldwide. The diagnose algorithms for suspected PE are generally include clinical scoring assessment and plasma D-dimer evaluation, patients with high risk of PE require computed tomographic pulmonary angiogram (CTPA) detection for confirmation. Methods In this retrospective analysis, 1035 patients with suspected PE were recruited. All the patients were clinically received simplified Geneva score (SGS) pre-test, determination of plasma D-dimer level, and CTPA detection. All enrolled patients were grouped according to the CTPA results: PE patients and non-PE patients. Then, receiver operating characteristic (ROC) curve were constructed to determine the optimal D-dimer cutoff point value which is based on Yonden’s index (YI). Results 294 (28.4%) patients were confirmed with PE and 741(71.6%) individuals were regarded as non-PE cases by CTPA detection. Using the SGS pre-test, 829 (80.1%) patients were classified PE-unlikely (SGS ≤ 2) and 206 (19.9%) patients were PE-likely (SGS ≥ 3). Patients with D-dimer levels above 1.96 mg/L had a significant risk to suffer from PE (area under curve (AUC), 0.707; 95% CI, 0.678–0.735; p < 0.05). Meanwhile, in patients with SGS ≥ 3, the D-dimer cutoff point value moved to 2.2 mg/L (AUC, 0.644; 95% CI, 0.574–0.709; p < 0.05). Conclusion D-dimer test in combination with SGS pre-test could improve the accuracy of PE diagnosis. Patients with D-dimer levels over 1.96 mg/L (4 times of the normal level) have a significant risk for PE. In patients with SGS ≥ 3, the D-dimer cutoff point concentration for PE risk moves to the levels of 2.2 mg/L.
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Affiliation(s)
- Zhihui Fu
- Department of Respiratory, Quanzhou First Hospital Affiliated to Fujian Medical University, No. 248-252 Dongjie Street, Quanzhou, 362000, Fujian Province, China.
| | - Xibin Zhuang
- Department of Respiratory, Quanzhou First Hospital Affiliated to Fujian Medical University, No. 248-252 Dongjie Street, Quanzhou, 362000, Fujian Province, China
| | - Yueming He
- Department of Respiratory, Quanzhou First Hospital Affiliated to Fujian Medical University, No. 248-252 Dongjie Street, Quanzhou, 362000, Fujian Province, China
| | - Hong Huang
- Department of Respiratory, Quanzhou First Hospital Affiliated to Fujian Medical University, No. 248-252 Dongjie Street, Quanzhou, 362000, Fujian Province, China
| | - Weifeng Guo
- Department of Respiratory, Quanzhou First Hospital Affiliated to Fujian Medical University, No. 248-252 Dongjie Street, Quanzhou, 362000, Fujian Province, China
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645
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Pohlan J, Kamel SN, Torsello GF, Zickler D, Kruse JM, Eckardt KU, Gebauer B. Successful aspiration thrombectomy in a patient with submassive, intermediate-risk pulmonary embolism following COVID-19 pneumonia. Radiol Case Rep 2020; 15:1764-1768. [PMID: 32774577 PMCID: PMC7365091 DOI: 10.1016/j.radcr.2020.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/11/2020] [Accepted: 07/11/2020] [Indexed: 01/23/2023] Open
Abstract
A 64-year-old female patient presented with severe dyspnea shortly after apparent recovery from COVID-19 disease. Chest computed tomography revealed central pulmonary embolism and ultrasonography showed a deep vein thrombosis of her right leg. The patient was tachycardiac with evidence of right ventricular strain on echocardiography. An interdisciplinary decision for interventional therapy was made. Angiographic aspiration thrombectomy resulted in a significant reduction of thrombus material and improved flow in the pulmonary arteries and immediate marked clinical improvement and subsequent normalization of functional echocardiographic parameters. This case adds to the emerging evidence for severe thromboembolic complications following COVID-19 and suggests aspiration thrombectomy can be considered in pulmonary embolism of intermediate risk.
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Affiliation(s)
- Julian Pohlan
- Department of Diagnostic and Interventional radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Sarah Nadine Kamel
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Giovanni Federico Torsello
- Department of Diagnostic and Interventional radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Daniel Zickler
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Matthias Kruse
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Bernard Gebauer
- Department of Diagnostic and Interventional radiology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
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646
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Kuhrau S, Masic D, Mancl E, Brailovsky Y, Porcaro K, Morris S, Haines J, Charo K, Fareed J, Darki A. Impact of Pulmonary Embolism Response Team on Anticoagulation Prescribing Patterns in Patients With Acute Pulmonary Embolism. J Pharm Pract 2020; 35:38-43. [PMID: 32666864 DOI: 10.1177/0897190020940125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Anticoagulation remains the mainstay pharmacotherapy for acute pulmonary embolism (PE), but multiple treatment options exist. The Pulmonary Embolism Response Team (PERT) is a multidisciplinary group that evaluates patients, formulates evidence-based treatment plans, and mobilizes resources. The objective of this study was to characterize the anticoagulation prescribing patterns made by PERT and to determine the clinical impact of anticoagulant selection. MATERIALS AND METHODS This was a retrospective analysis of patients evaluated by PERT from 2016 to 2018. Multivariable linear regression was conducted to determine predictors of length of stay (LOS). RESULTS A total of 209 patients were evaluated by PERT and received anticoagulation on discharge. Of those, 47% received a non-vitamin K oral anticoagulant (NOAC), 29% received warfarin, and 23% received low-molecular-weight heparin. Patient preferences and comorbidities were the most common reasons for NOAC omission. Patients who received NOACs had a shorter median LOS than warfarin (6.1 [4.6-7.6] days vs 10.9 [8.4-13.4] days; P < .05). Selection of NOAC upon discharge was the only factor independently associated with reduced LOS (β coefficient: -0.6; 95% CI: -1.01 to -0.18; P < .01). CONCLUSION The most common recommendation made by PERT was to initiate a NOAC upon discharge, resulting in shorter hospital LOS compared to patients who received warfarin.
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Affiliation(s)
- Shannon Kuhrau
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL, USA
| | - Dalila Masic
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL, USA
| | - Erin Mancl
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL, USA
| | | | - Katerina Porcaro
- Division of Cardiology, Loyola University Medical Center, Maywood, IL, USA
| | - Stephen Morris
- Department of Internal Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Jeremiah Haines
- Department of Internal Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Kim Charo
- Department of Internal Medicine, Gottlieb Memorial Hospital, Melrose Park, IL, USA
| | - Jawed Fareed
- Department of Pathology, Loyola University Medical Center Hospital, Maywood, IL, USA
| | - Amir Darki
- Division of Cardiology, Loyola University Medical Center, Maywood, IL, USA
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647
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Sethi SS, Zilinyi R, Green P, Eisenberger A, Brodie D, Agerstrand C, Takeda K, Kirtane AJ, Parikh SA, Rosenzweig EB. Right Ventricular Clot in Transit in COVID-19: Implications for the Pulmonary Embolism Response Team. JACC Case Rep 2020; 2:1391-1396. [PMID: 32835284 PMCID: PMC7259913 DOI: 10.1016/j.jaccas.2020.05.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/14/2020] [Accepted: 05/20/2020] [Indexed: 01/30/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 is associated with a prothrombotic state in infected patients. After presenting a case of right ventricular thrombus in a patient with coronavirus disease-2019 (COVID-19), we discuss the unique challenges in the evaluation and treatment of COVID-19 patients, highlighting our COVID-19-modified pulmonary embolism response team algorithm. (Level of Difficulty: Beginner.).
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Key Words
- ARDS, acute respiratory distress syndrome
- COVID-19, coronavirus disease-2019
- CTA, computed tomography angiography
- ECMO, extracorporeal membrane oxygenation
- ICU, intensive care unit
- PE, pulmonary embolism
- PERT, pulmonary embolism response team
- PPE, personal protective equipment
- Pao2, partial arterial pressure of oxygen
- SARS-CoV-2, severe acute respiratory syndrome-coronavirus-2
- TTE, transthoracic echocardiography
- VTE, venous thromboembolism
- clot in transit
- pulmonary embolism
- right ventricle
- tPA, tissue plasminogen activator
- thrombus
- vascular disease
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Affiliation(s)
- Sanjum S. Sethi
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Robert Zilinyi
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Philip Green
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Andrew Eisenberger
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Daniel Brodie
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Cara Agerstrand
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Koji Takeda
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Ajay J. Kirtane
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Sahil A. Parikh
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Erika B. Rosenzweig
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
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648
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Sun N, Fan Y, Chang J, Chen Y, Gao X, Sun H, Wang Z, Gu X, Tian J, Zhao Y, Yu B, Tian J, Wu B. Plasma irisin level associated with hemodynamic parameters and predict clinical outcome in patients with acute pulmonary embolism. Respir Med 2020; 171:106072. [PMID: 32658835 DOI: 10.1016/j.rmed.2020.106072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The purpose of the present study is to investigate the correlation of plasma irisin level and hemodynamic parameters in patients with acute pulmonary embolism (APE) and to estimate clinical outcome prediction value of plasma irisin level. METHODS We prospectively recruited 86 adult patients with APE in the present study. All recruited patients conduct measurement of plasma irisin levels using ELISA kits. Baseline clinical characteristics, hemodynamic parameters and prognostic conditions were evaluated according to different plasma irisin levels. RESULTS According to median values of irisin levels, APE patients were divided into high irisin group (irisin≥6.9 μg/ml) and low irisin group (irisin<6.9 μg/ml). Plasma NT-proBNP (P = 0.044), mean pulmonary artery pressure (mPAP, P = 0.013), systolic pulmonary artery pressure (sPAP, P = 0.001), mean right ventricular pressure (mRVP, P = 0.021) and systolic right ventricular pressure (sPVP, P = 0.003) were higher in low irisin group compared with high irisin group. Hemodynamic parameters of mPAP, sPAP, mRVP and sRVP were negatively correlated with plasma irisin levels. Kaplan- Meier survival analysis showed that APE patients with lower plasma irisin levels had significantly higher clinical worsening event rate (P = 0.026) and could be the independent predictor of prognosis in multivariate analysis (P = 0.035). CONCLUSION Plasma irisin level was negatively correlated with hemodynamic parameters in patients with APE. Low irisin group patients had significantly higher clinical worsening event rate and could be the independent predictor of clinical outcome in multivariate analysis.
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Affiliation(s)
- Na Sun
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China; Key Laboratory of Myocardial Ischemia, Ministry of Education, Harbin Medical University, Harbin, China
| | - Youli Fan
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jiaxue Chang
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yiqiang Chen
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xuan Gao
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hongru Sun
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China; Department of Epidemiology, Public Health College, Harbin Medical University, Harbin, China
| | - Zhuozhong Wang
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China; Key Laboratory of Myocardial Ischemia, Ministry of Education, Harbin Medical University, Harbin, China
| | - Xia Gu
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China; Key Laboratory of Myocardial Ischemia, Ministry of Education, Harbin Medical University, Harbin, China; Department of Cardiology, Heilongjiang Provincial Hospital, Harbin, China
| | - Jiangtian Tian
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China; Key Laboratory of Myocardial Ischemia, Ministry of Education, Harbin Medical University, Harbin, China
| | - Yingzi Zhao
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bo Yu
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China; Key Laboratory of Myocardial Ischemia, Ministry of Education, Harbin Medical University, Harbin, China
| | - Jinwei Tian
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China; Key Laboratory of Myocardial Ischemia, Ministry of Education, Harbin Medical University, Harbin, China.
| | - Bingxiang Wu
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China; Key Laboratory of Myocardial Ischemia, Ministry of Education, Harbin Medical University, Harbin, China.
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Doundoulakis I, Antza C, Karvounis H, Giannakoulas G. Non-Vitamin K Antagonist Oral Anticoagulants in Pulmonary Embolism: An Overview of Systematic Reviews. Curr Pharm Des 2020; 26:2686-2691. [DOI: 10.2174/1381612826666200506114450] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/13/2020] [Indexed: 12/12/2022]
Abstract
Background:
Anticoagulation in patients with pulmonary embolism.
Objective:
To identify how non-vitamin K antagonist oral anticoagulants are associated with multiple outcomes in
patients with pulmonary embolism.
Methods:
We performed a systematic search of systematic reviews via multiple electronic databases from inception to August 19th, 2019, without language restriction. Two authors independently extracted data and assessed
the methodological quality of the included systematic reviews using the ROBIS tool.
Results:
We found twelve systematic reviews. Eleven SRs collected their data from randomized clinical trials and
one from observational studies. All the included studies were published between 2014 and 2019 in English. The
methodological quality of the 12 systematic reviews was low to high. None of the systematic reviews, which are
included in our overview of systematic reviews, has evaluated the overall quality of evidence outcome using the
Grading of Recommendations Assessments, Development and Evaluation (GRADE) approach.
Conclusion:
This is the first effort to summarize evidence about non-vitamin K antagonist oral anticoagulants in
an overview of systematic reviews focusing exclusively on patients with pulmonary embolism. The evidence
suggests that the non-vitamin K antagonist oral anticoagulants seem to be more effective and safer than a dualdrug approach with LMWH- VKA.
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Affiliation(s)
- Ioannis Doundoulakis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christina Antza
- Third Department of Internal Medicine, Hypertension-24h ABPM ESH Center of Excellence, Papageorgiou Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Haralambos Karvounis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Prothrombotic fibrin clot properties associated with NETs formation characterize acute pulmonary embolism patients with higher mortality risk. Sci Rep 2020; 10:11433. [PMID: 32651425 PMCID: PMC7351737 DOI: 10.1038/s41598-020-68375-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 02/12/2020] [Indexed: 11/09/2022] Open
Abstract
Venous thromboembolism is associated with formation of denser fibrin clots resistant to lysis. We investigated whether prothrombotic plasma clot properties are associated with the severity of acute pulmonary embolism (PE). We enrolled 126 normotensive acute PE patients (aged 58 ± 14 years) and 25 age- and sex-matched healthy controls. Plasma fibrin clot permeability (Ks), clot lysis time (CLT), endogenous thrombin potential (ETP), plasminogen activator inhibitor-1 (PAI-1), and citrullinated histone H3 (citH3) were evaluated on admission. PE patients compared to controls had 370% higher citH3 levels, 41% higher ETP, 16.5% reduced Ks, and 25.6% prolonged CLT. Patients with intermediate-high (n = 29) and intermediate-low (n = 77) PE mortality risk had reduced Ks and prolonged CLT, increased PAI-1 and ETP as compared to low-risk PE (n = 20) patients. Prolonged CLT was predicted by PAI-1 and citH3, while low Ks by C-reactive protein. During a 12-month follow-up 9 (7.1%) patients who had 24% higher ETP, 45% higher citH3 levels, and 18% prolonged CLT at baseline died. High ETP combined with elevated citH3 levels and prolonged CLT was associated with eightfold increased risk of PE-related death. Prothrombotic fibrin clot properties and enhanced neutrophil extracellular traps formation are associated with higher early mortality risk in acute PE patients, which suggests a prognostic role of these biomarkers.
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