951
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Michaelov T, Blickstein D, Levy D, Berliner S, Ellis MH. Removal of retrievable vena cava filters in routine practice: a multicenter study. Eur J Intern Med 2011; 22:e87-9. [PMID: 22075319 DOI: 10.1016/j.ejim.2011.08.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 08/21/2011] [Accepted: 08/23/2011] [Indexed: 10/17/2022]
Abstract
UNLABELLED Vena cava filters (VCFs) are used to prevent pulmonary embolism when anticoagulation is contraindicated or in the event of progression of thrombosis despite adequate anticoagulation. Retrievable VCFs provide a potential advantage over permanent VCFs, but the appropriateness of their use and the frequency with which they are removed is not well established. OBJECTIVES Document the indications for insertion of retrievable VCFs, filter removal in hospital practice. METHODS Observational study conducted in three academic medical centers. Consecutive patients undergoing retrievable VCF insertion were identified. Clinical data was extracted from the patients' charts and follow up data were obtained from treating physicians after discharge. RESULTS 300 patients were studied. The indication for filter insertion was acute bleeding (46.1%) or surgery (24.2%) in patients with acute thrombosis, prevention of venous thromboembolism in trauma (13.3%), potential bleeding in patients with deep vein thrombosis (9.1%) thromboembolism while on adequate anticoagulation (5.7%) and other (1.3%). 21 (7%) filters were removed. An unsuccessful attempt at retrieval was undertaken in a further 9 (3%) patients. CONCLUSIONS The use of retrievable VCFs was appropriate, with the possible exception of their prophylactic use in major trauma. The majority of VCFs were not removed, for reasons that are not apparent.
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952
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Porpodis K, Konoglou M, Zarogoulidis P, Kaimakamis E, Kontakiotis T, Papakosta D, Zervas V, Katsikogiannis N, Courcoutsakis N, Mitrakas A, Touzopoulos P, Karanikas M, Zarogoulidis K, Markopoulou A. Pulmonary thromboendarterectomy after treatment with treprostenil in a chronic thromboembolic pulmonary hypertension patient: a case report. Int J Gen Med 2011; 4:767-72. [PMID: 22114523 PMCID: PMC3219765 DOI: 10.2147/ijgm.s26494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In recent years, there has been a major advance in the treatment of pulmonary hypertension. New medications are continually added to the therapeutic arsenal. The prostanoids are among the first agents used to treat pulmonary hypertension and are currently considered the most effective. This case study describes a 63-year-old man who was diagnosed with chronic thromboembolic pulmonary hypertension and successfully treated with subcutaneously administered treprostenil for 6 months before a successful pulmonary thromboendarterectomy. Treatment of chronic thromboembolic pulmonary hypertension often requires a multidisciplinary approach before surgery. Further evaluation of prostanoids is needed to define their role and time of initiation of medical therapy in these patients.
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Affiliation(s)
- Konstantinos Porpodis
- Pulmonary Department, "G Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Greece
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953
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954
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Dores H, Fonseca C, Leal S, Rosário I, Abecasis J, Monge J, Correia MJ, Bronze L, Leitão A, Arroja I, Aleixo A, Silva A. [NT-proBNP for risk stratification of pulmonary embolism]. Rev Port Cardiol 2011; 30:881-6. [PMID: 22100750 DOI: 10.1016/j.repc.2011.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Accepted: 06/24/2011] [Indexed: 10/15/2022] Open
Abstract
INTRODUCTION Pulmonary embolism (PE) is an entity with high mortality and morbidity, in which risk stratification for adverse events is essential. N-terminal brain natriuretic peptide (NT-proBNP), a right ventricular dysfunction marker, may be useful in assessing the short-term prognosis of patients with PE. AIMS To characterize a sample of patients hospitalized with PE according to NT-proBNP level at hospital admission and to assess the impact of this biomarker on short-term evolution. METHODS We performed a retrospective analysis of consecutive patients admitted with PE over a period of 3.5 years. Based on the median NT-proBNP at hospital admission, patients were divided into two groups (Group 1: NT-proBNP<median and Group 2: NT-proBNP ≥ median). The two groups were compared in terms of demographic characteristics, personal history, clinical presentation, laboratory, electrocardiographic and echocardiographic data, drug therapy, in-hospital course (catecholamine support, invasive ventilation and in-hospital death and the combined endpoint of these events) and 30-day all-cause mortality. A receiver operating characteristic (ROC) curve was constructed to determine the discriminatory power and cut-off value of NT-proBNP for 30-day all-cause mortality. RESULTS Ninety-one patients, mean age 69±16.4 years (51.6% aged ≥75 years), 53.8% male, were analyzed. Of the total sample, 41.8% had no etiological or predisposing factors for PE and most (84.6%) were stratified as intermediate-risk PE. Median NT-proBNP was 2440 pg/ml. Patients in Group 2 were significantly older (74.8±13.2 vs. 62.8±17.2 years, p=0.003) and more had a history of heart failure (35.5% vs. 3.3%, p=0.002) and chronic kidney disease (32.3% vs. 6.7%, p=0.012). They had more tachypnea on initial clinical evaluation (74.2% vs. 44.8, p=0.02), less chest pain (16.1% vs. 46.7%, p=0.01) and higher creatininemia (1.7±0.9 vs. 1.1±0.5mg/dl, p=0.004). Group 2 also more frequently had right chamber dilatation (85.7% vs. 56.7%, p=0.015) and lower left ventricular ejection fraction (56.4±17.6% vs. 66.2±13.5%, p=0.036) on echocardiography. There were no significant differences in drug therapy between the two groups. Regarding the studied endpoints, Group 2 patients needed more catecholamine support (25.8% vs. 6.7%, p=0.044), had higher in-hospital mortality (16.1% vs. 0.0%, p=0.022) and more frequently had the combined endpoint (32.3% vs. 10.0%, p=0.034). All-cause mortality at 30 days was seen only in Group 2 patients (24.1% vs. 0.0%, p=0.034). By ROC curve analysis, NT-proBNP had excellent discriminatory power for this event, with an area under the curve of 0.848. The best NT-proBNP cut-off value was 4740 pg/ml. CONCLUSION Elevated NT-proBNP levels identified PE patients with worse short-term prognosis, and showed excellent power to predict 30-day all-cause mortality. The results of this study may have important clinical implications. The inclusion of NT-proBNP measurement in the initial evaluation of patients with PE can add valuable prognostic information.
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Affiliation(s)
- Hélder Dores
- UNICARD, Serviço de Cardiologia, Hospital de São Francisco Xavier - Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal.
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955
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Sechtem U, Achenbach S, Friedrich M, Wackers F, Zamorano JL. Non-invasive imaging in acute chest pain syndromes. Eur Heart J Cardiovasc Imaging 2011; 13:69-78. [PMID: 22094238 DOI: 10.1093/ejechocard/jer250] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
This review has the purpose of informing the reader about the current use of imaging techniques in patients presenting with acute chest pain to the emergency department. We will focus on three aspects of managing the patient with acute chest pain: Imaging to increase the number of correct diagnoses in the acute situation; Imaging to rule out other than coronary causes of chest pain; Use of imaging for risk stratification once myocardial infarction has been ruled out in the CPU. Special emphasis is given to how these management aspects are discussed in current guidelines on the management of patients with acute chest pain or acute coronary syndrome.
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Affiliation(s)
- Udo Sechtem
- Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376 Stuttgart.
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956
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Martin SL, Tellez MG. Utilization of alteplase in trauma victim with an open abdomen. J Emerg Trauma Shock 2011; 4:427-9. [PMID: 21887042 PMCID: PMC3162721 DOI: 10.4103/0974-2700.83880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 05/23/2011] [Indexed: 12/02/2022] Open
Abstract
Trauma victims with multisystem injuries are at risk for the development of deep vein thrombosis and pulmonary embolus (PE). The use of thrombolytic therapy remains very controversial and not well-documented in both the postsurgical and trauma subset of patients. Major trauma, surgery or head injury have been noted as absolute contraindications to thrombolysis in acute myocardial infarction. The decision to utilize thrombolytic therapy cannot be algorithmic; it must be based on the assessment findings for each individual patient. The risk to benefit ratio should be the major consideration to ensure the best possible outcome is granted. Treating injured patients experiencing high-risk PE causing an immediate threat to life may necessitate forming a comparative view of the adverse events associated with thrombolytic medications.
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Affiliation(s)
- Sharolyn L Martin
- Department of Emergency Medicine, John Peter Smith Hospital, Ft. Worth, Texas, USA
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957
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Abstract
Untreated acute pulmonary thromboembolism (APTE) is associated with high mortality, which is reduced by prompt treatment. Anticoagulation is fundamental in the treatment of APTE and should be initiated from suspicion. The efficacy and safety of novel anticoagulant drugs, such as oral anti-Xa and anti-IIa inhibitors, are topics in the treatment of APTE and are now under investigation. Thrombolytic therapy is a widely accepted treatment strategy for massive APTE, but its use for submassive APTE is controversial. Catheter intervention, percutaneous cardiopulmonary support and surgical embolectomy are also necessary and effective for some patients with APTE. A retrievable inferior vena cava filter is preferred for transient protection against APTE. Some studies have demonstrated the feasibility of outpatient treatment in patients with APTE after risk stratification.
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Affiliation(s)
- Norikazu Yamada
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Japan.
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958
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Allenet B, Schmidlin S, Genty C, Bosson JL. Antipsychotic drugs and risk of pulmonary embolism. Pharmacoepidemiol Drug Saf 2011; 21:42-8. [DOI: 10.1002/pds.2210] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Revised: 05/20/2011] [Accepted: 06/22/2011] [Indexed: 12/23/2022]
Affiliation(s)
| | - Sophie Schmidlin
- Clinical Research Center; Grenoble University Hospital; Grenoble; France
| | - Céline Genty
- ThEMAS TIMC; Joseph Fourier University; Grenoble; France
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959
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Dessap AM, Deux JF, Abidi N, Lavenu-Bombled C, Melica G, Renaud B, Godeau B, Adnot S, Brochard L, Brun-Buisson C, Galacteros F, Rahmouni A, Habibi A, Maitre B. Pulmonary Artery Thrombosis during Acute Chest Syndrome in Sickle Cell Disease. Am J Respir Crit Care Med 2011; 184:1022-9. [DOI: 10.1164/rccm.201105-0783oc] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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960
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Fasullo S, Maringhini G, Terrazzino G, Ganci F, Paterna S, Di Pasquale P. Thrombolysis for massive pulmonary embolism in pregnancy: a case report. Int J Emerg Med 2011; 4:69. [PMID: 22041192 PMCID: PMC3222602 DOI: 10.1186/1865-1380-4-69] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Accepted: 10/31/2011] [Indexed: 11/10/2022] Open
Abstract
Mortality from pulmonary embolism (PE) in pregnancy might be related to challenges in targeting the right population for prevention. Such targeting could help ensure that the correct diagnosis is suspected and adequately investigated, and allow the initiation of the timely and best possible treatment of this disease. In the literature to date only 18 case reports of thrombolysis in pregnant women with PE have been reported, and showed beneficial effects for both mother and fetus in terms of mortality and complications with acceptable bleeding risks. We present here the case of a pregnant patient with massive PE who underwent successful thrombolysis. A 26-year-old pregnant (at 24 weeks) woman was admitted 4 h after onset of sudden acute dyspnea and chest pain. An immediate electrocardiogram showed a typical S1-Q3-T3 pattern. The echocardiogram showed a distended right ventricle with free-wall hypokinesia and displacement of the interventricular septum toward the left ventricle. Thrombolysis with recombinant tissue plasminogen activator (alteplase 10 mg bolus, then 90 mg over 2 h) was administered. Pelvic examination and ultrasound showed regular fetal heart beat, and regular placental and liquid presence. No problems developed for the mother or fetus in the subsequent days or at discharge. In conclusion, in pregnant patients with life-threatening massive PE, thrombolytic therapy can be administered, and the use of echocardiographic, laboratory, and clinical data can be useful tools to achieve a rapid diagnosis and make a therapeutic decision, but additional studies need to be performed to further define its use.
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Affiliation(s)
- Sergio Fasullo
- Division of Cardiology, "Paolo Borsellino" G,F, Ingrassia Hospital, Palermo, Italy.
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961
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Berghaus TM, Behr W, von Scheidt W, Schwaiblmair M. The N-terminal pro-brain-type natriuretic peptide based short-term prognosis in patients with acute pulmonary embolism according to renal function. J Thromb Thrombolysis 2011; 33:58-63. [DOI: 10.1007/s11239-011-0649-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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962
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Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry). J Am Coll Cardiol 2011; 57:700-6. [PMID: 21292129 DOI: 10.1016/j.jacc.2010.05.071] [Citation(s) in RCA: 345] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Revised: 05/03/2010] [Accepted: 05/17/2010] [Indexed: 11/23/2022]
Abstract
OBJECTIVES In a large U.S. sample, this study measured the presentation features, testing, treatment strategies, and outcomes of patients diagnosed with pulmonary embolism (PE) in the emergency department (ED). BACKGROUND No data have quantified the demographics, clinical features, management, and outcomes of outpatients diagnosed with PE in the ED in a large, multicenter U.S. study. METHODS Patients of any hemodynamic status were enrolled from the ED after confirmed acute PE or with a high clinical suspicion prompting anticoagulation before imaging for PE. Exclusions were inability to provide informed consent (where required) or unavailability for follow-up. RESULTS A total of 1,880 patients with confirmed acute PE were enrolled from 22 U.S. EDs. Diagnosis of PE was based upon positive results of computerized tomographic pulmonary angiogram in most cases (n = 1,654 [88%]). Patients represented both sexes equally, and racial and ethnic composition paralleled the overall U.S. ED population. Most (79%) patients with PE were employed, and one-third were older than age 65 years. The mortality rate directly attributed to PE was 20 in 1,880 (1%; 95% confidence interval [CI]: 0% to 1.6%). Mortality from hemorrhage was 0.2%, and the all-cause 30-day mortality rate was 5.4% (95% CI: 4.4% to 6.6%). Only 3 of 20 patients with major PE that ultimately proved fatal had systemic anticoagulation initiated before diagnostic confirmation, and another 3 of these 20 received a fibrinolytic agent. CONCLUSIONS Patients diagnosed with acute PE in U.S. EDs have high functional status, and their mortality rate is low. These registry data suggest that appropriate initial medical management of ED patients with severe PE with anticoagulation is poorly standardized and indicate a need for research to determine the appropriate threshold for empiric treatment when PE is suspected before diagnostic confirmation.
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963
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Yoo JW, Hong SB, Lim CM, Koh Y. Clinical implications of right ventricular dysfunction in patients with acute symptomatic pulmonary embolism: short- and long-term clinical outcomes. J Crit Care 2011; 27:325.e1-6. [PMID: 22033062 DOI: 10.1016/j.jcrc.2011.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 06/20/2011] [Accepted: 08/09/2011] [Indexed: 10/15/2022]
Abstract
PURPOSE Right ventricular dysfunction (RVD) has been found to have a negative impact on the short-term prognosis of patients with pulmonary embolism (PE). However, the long-term prognosis of such patients has not been well defined. We evaluated the effect of RVD on short- and long-term mortality in Korean patients with PE. MATERIALS AND METHODS We retrospectively assessed 180 patients with PE who underwent transthoracic echocardiography to evaluate RVD between January 2004 and December 2008. Patients were categorized as hemodynamically stable without RVD (stable without RVD, n = 70), hemodynamically stable with RVD (stable with RVD, n = 74), or hemodynamically unstable with RVD (unstable with RVD, n = 36). The clinical courses of all patients were followed up in-hospital and after discharge. RESULTS Nineteen patients (10.5%) died during hospitalization, with the unstable with RVD group showing the highest rate of in-hospital mortality (27.8%, P < .05) and PE-related deaths (16.7%, P < .05), but no difference in these parameters was noted between the other 2 groups. Multivariate analysis showed that older age and hemodynamic instability were independent risk factors for poor in-hospital outcomes. Eleven patients died after discharge. Multivariate analysis showed that older age, immobilization, and malignancy were independent predictors of long-term mortality. CONCLUSION Right ventricular dysfunction without hemodynamic instability was not associated with short- or long-term mortality of patients with PE.
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Affiliation(s)
- Jung-Wan Yoo
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, College of Medicine, University of Ulsan,Songpa-gu, Seoul, South Korea
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964
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Moores LK, King CS, Holley AB. Current approach to the diagnosis of acute nonmassive pulmonary embolism. Chest 2011; 140:509-518. [PMID: 21813530 DOI: 10.1378/chest.10-2468] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Pulmonary embolism is a common and potentially lethal disease. Given the variable presentation and associated morbidity of this condition, an accurate and efficient diagnostic algorithm is required. Clinical pretest probability serves as the root of any diagnostic approach. We, thus, review several clinical decision rules that may help standardize this determination. Using a review of the literature, the accuracy, predictive values, and likelihood ratios for several diagnostic tests are described. The combination of these tests, based on the pretest probability of disease, can be used in a Bayesian fashion to make accurate treatment decisions. A completely noninvasive diagnostic algorithm for patients presenting with suspected acute pulmonary embolism is proposed.
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Affiliation(s)
- Lisa K Moores
- Department of Medicine, the Uniformed Services University of the Health Sciences, Bethesda, MD.
| | - Christopher S King
- Pulmonary and Critical Care Medicine Service, William Beaumont Army Medical Center, El Paso, TX
| | - Aaron B Holley
- Pulmonary, Critical Care, and Sleep Medicine Service, Walter Reed Army Medical Center, Washington, DC
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965
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Yi I, Park JC, Cho KS, Kim BS, Kim SC, Kim DH, Kim JH, Youn HC. Pulmonary thromboembolectomy for acute pulmonary thromboembolism. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2011; 44:343-7. [PMID: 22263185 PMCID: PMC3249337 DOI: 10.5090/kjtcs.2011.44.5.343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Revised: 09/28/2010] [Accepted: 06/21/2011] [Indexed: 11/28/2022]
Abstract
Background Acute pulmonary thromboembolism is fatal because of abruptly occurring hypoxemia and right ventricular failure. There are several treatment modalities, including anticoagulation, thrombolytics, ECMO (extracorporeal membrane oxygenator), and thromboembolectomy, for managing acute pulmonary thromboembolism. Materials and Methods Medical records from January 1999 to December 2004 at our institution were retrospectively reviewed for pulmonary thromboembolectomy. There were 7 patients (4 men and 3 women), who underwent a total of 8 operations because one patient had post-operative recurrent emboli and underwent reoperation. Surgery was indicatedfor mild hypoxemia and performed with CPB (cardiopulmonary bypass) in a beating heart state. Results The patients had several symptoms, such as dyspnea, chest discomfort, and palpitation. Four patients had deep vein thromboembolisms and 3 had psychotic problems, specifically schizophrenia. Post-operative complications included hemothorax, pleural effusion, and pericardial effusion. There were two hospital deaths, one each by brain death and right heart failure. Conclusion Emergency operation should be performed when medical treatments are no longer effective.
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Affiliation(s)
- Inho Yi
- Department of Thoracic and Cardiovascular Surgery, Mokpo Hankook Hospital, Korea
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966
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Vanni S, Nazerian P, Pepe G, Baioni M, Risso M, Grifoni G, Viviani G, Grifoni S. Comparison of two prognostic models for acute pulmonary embolism: clinical vs. right ventricular dysfunction-guided approach. J Thromb Haemost 2011; 9:1916-23. [PMID: 21819540 DOI: 10.1111/j.1538-7836.2011.04459.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recently, some prognostic models for acute pulmonary embolism (PE) have been proposed. We investigated whether the Pulmonary Embolism Severity Index (PESI) and the European Society of Cardiology (ESC) prognostic approaches result in different prognoses. METHODS Consecutive adult patients with acute PE were included. According to the ESC guidelines, high-risk patients were identified by the presence of shock/hypotension, intermediate-risk patients by elevated troponin I or right ventricular dysfunction as assessed by echocardiography, and low-risk patients by the absence of any of the above. In the PESI model, 11 clinical variables, easily accessible at the bedside, were used to generate three risk classes. The main outcomes were all-cause and PE-related in-hospital mortality. RESULTS Forty-one patients (8%, 95% confidence interval [CI] 5.8-10.8) of 510 died. According to the ESC model, 40% were at low risk of short-term mortality, 54% at intermediate risk, and 6% at high risk. The distribution according to the PESI model was 31% (P < 0.05 vs. ESC), 49% and 20% (P < 0.05 vs. ESC), respectively. Mortality increased through the risk classes (P < 0.01), without significant differences between the models. The ESC model identified with higher accuracy than the PESI model both high-risk and low-risk patients (P < 0.05 for both). When patients with shock/hypotension were excluded, the PESI model stratified patients into classes with increasing PE-related mortality (0.7%, 4.3%, and 11.6%, P < 0.05). Troponin I and right ventricular dysfunction added incremental prognostic value to the PESI model, particularly in normotensive patients at intermediate risk. CONCLUSIONS The ESC model showed higher accuracy than the PESI model in identifying high-risk and low-risk patients. In normotensive patients, the PESI model could guide clinical management as well as troponin I and echocardiography testing.
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Affiliation(s)
- S Vanni
- Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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967
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Abstract
Lung failure is the most common organ failure seen in the intensive care unit. The pathogenesis of acute respiratory failure (ARF) can be classified as (1) neuromuscular in origin, (2) secondary to acute and chronic obstructive airway diseases, (3) alveolar processes such as cardiogenic and noncardiogenic pulmonary edema and pneumonia, and (4) vascular diseases such as acute or chronic pulmonary embolism. This article reviews the more common causes of ARF from each group, including the pathological mechanisms and the principles of critical care management, focusing on the supportive, specific, and adjunctive therapies for each condition.
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Affiliation(s)
- Rob Mac Sweeney
- Centre for Infection and Immunity, Queens University Belfast, Belfast, Northern Ireland
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968
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Treatment of pulmonary embolism: anticoagulation, thrombolytic therapy, and complications of therapy. Crit Care Clin 2011; 27:825-39, vi. [PMID: 22082516 DOI: 10.1016/j.ccc.2011.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
During the last two decades, considerable progress in technology and clinical research methods have led to advances in the approach to the diagnosis, prevention, and treatment of acute venous thromboembolism (VTE). Despite this, however, the diagnosis is often delayed and preventive methods are often ignored. Thus, the morbidity and mortality associated with VTE remain high. The therapeutic approach to acute VTE is discussed in this article, with a particular focus on the intensive care unit setting.
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969
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Massive pulmonary thromboembolism and stroke. Case Rep Med 2011; 2011:398571. [PMID: 21966293 PMCID: PMC3182343 DOI: 10.1155/2011/398571] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 06/22/2011] [Indexed: 11/17/2022] Open
Abstract
A 38-year-old HIV-positive female, recently started on antiretroviral therapy, presented in extremis. She had features suggestive of an HIV-associated cardiomyopathy complicated by the following problems: a four-day-old stroke, extensive deep venous thrombosis, and massive pulmonary embolism. She received intravenous streptokinase with rapid improvement, both haemodynamically and, unexpectedly, neurologically. Our case illustrates that a positive outcome is potentially possible where the two conditions coincide.
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970
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Wang Y, Liu ZH, Zhang HL, Luo Q, Zhao ZH, Zhao Q. Association of elevated NTproBNP with recurrent thromboembolic events after acute pulmonary embolism. Thromb Res 2011; 129:688-92. [PMID: 21955395 DOI: 10.1016/j.thromres.2011.08.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Revised: 08/09/2011] [Accepted: 08/15/2011] [Indexed: 11/25/2022]
Abstract
INTRODUCTION N-Terminal Pro-Brain Natriuretic Peptide (NTproBNP) is a predictor of adverse short-term clinical outcomes in patients with acute pulmonary embolism (APE), but its long-term prognostic value remains largely undefined. The aim of this study was to assess the value of plasma NTproBNP with regard to recurrent venous thromboembolism (VTE). MATERIALS AND METHODS NTproBNP levels were measured in 224 consecutive patients with the first episode of acute pulmonary embolism occurring from January 2005 through October 2010. Patients were categorized into two groups by NTproBNP reference range. Follow-ups were performed at 3, 6, and 12months and yearly thereafter. The primary end point was symptomatic, recurrent fatal or nonfatal VTE. RESULTS NTproBNP was elevated in 158 (70.5%) patients and not elevated in 66 (29.5%) patients. After a mean follow-up period of 31.0±19.4months, patients with elevated NTproBNP showed an increased risk of recurrent VTE (20 patients, 12.7%) compared to those without elevated NTproBNP (only 1 patient, 1.5%) (P=0.009). Of the 7 deaths related to pulmonary embolism, 6 occurred in patients with elevated NTproBNP compared to patients with normal NTproBNP (1 of 7 deaths). In a multivariate analysis stratified by oral anticoagulant treatment duration, elevated NTproBNP was an independent predictor of recurrent VTE (hazard ratio, 9.32; P=0.02). CONCLUSIONS Elevated NTproBNP is associated with recurrent VTE in acute pulmonary embolism patients.
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Affiliation(s)
- Yong Wang
- Center for Pulmonary Vascular Disease Diagnosis and Treatment, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College
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971
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Xiao J, Jing ZC, Ellinor PT, Liang D, Zhang H, Liu Y, Chen X, Pan L, Lyon R, Liu Y, Peng LY, Liang X, Sun Y, Popescu LM, Condorelli G, Chen YH. MicroRNA-134 as a potential plasma biomarker for the diagnosis of acute pulmonary embolism. J Transl Med 2011; 9:159. [PMID: 21943159 PMCID: PMC3189884 DOI: 10.1186/1479-5876-9-159] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Accepted: 09/24/2011] [Indexed: 12/21/2022] Open
Abstract
Background Acute pulmonary embolism (APE) remains a diagnostic challenge due to a variable clinical presentation and the lack of a reliable screening tool. MicroRNAs (miRNAs) regulate gene expression in a wide range of pathophysiologic processes. Circulating miRNAs are emerging biomarkers in heart failure, type 2 diabetes and other disease states; however, using plasma miRNAs as biomarkers for the diagnosis of APE is still unknown. Methods Thirty-two APE patients, 32 healthy controls, and 22 non-APE patients (reported dyspnea, chest pain, or cough) were enrolled in this study. The TaqMan miRNA microarray was used to identify dysregulated miRNAs in the plasma of APE patients. The TaqMan-based miRNA quantitative real-time reverse transcription polymerase chain reactions were used to validate the dysregulated miRNAs. The receiver-operator characteristic (ROC) curve analysis was conducted to evaluate the diagnostic accuracy of the miRNA identified as the candidate biomarker. Results Plasma miRNA-134 (miR-134) level was significantly higher in the APE patients than in the healthy controls or non-APE patients. The ROC curve showed that plasma miR-134 was a specific diagnostic predictor of APE with an area under the curve of 0.833 (95% confidence interval, 0.737 to 0.929; P < 0.001). Conclusions Our findings indicated that plasma miR-134 could be an important biomarker for the diagnosis of APE. Because of this finding, large-scale investigations are urgently needed to pave the way from basic research to clinical utilization.
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Affiliation(s)
- Junjie Xiao
- Key Laboratory of Arrhythmias, Ministry of Education, China (East Hospital, Tongji University School of Medicine), Shanghai, China
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972
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Konstantinides S. A New Method to Diagnose Pulmonary Embolism: David against Goliath(s). Am J Respir Crit Care Med 2011; 184:626-7. [DOI: 10.1164/rccm.201106-1114ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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973
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Debney MT. Acute pulmonary embolus with visible right heart thrombus in transit. BMJ Case Rep 2011; 2011:bcr.07.2011.4553. [PMID: 22679233 DOI: 10.1136/bcr.07.2011.4553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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974
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Increased d-dimer levels predict cardiovascular mortality in patients with systolic heart failure. J Thromb Thrombolysis 2011; 33:322-8. [DOI: 10.1007/s11239-011-0635-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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975
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Elia F, Ferrari G, Aprà F. Do we need echocardiography before commencing thrombolytic therapy also for pulmonary embolism? Am J Emerg Med 2011; 29:817-8. [DOI: 10.1016/j.ajem.2011.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 03/15/2011] [Indexed: 11/16/2022] Open
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976
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Cronin P, Kelly AM. Influence of population prevalences on numbers of false positives: an overlooked entity. Acad Radiol 2011; 18:1087-93. [PMID: 21703881 DOI: 10.1016/j.acra.2011.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Revised: 04/26/2011] [Accepted: 04/29/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Disease prevalence alters the number of true positives (TP), true negatives (TN), false negatives (FN), and false positives (FP), even if the sensitivity and specificity of a test stays the same. METHODS AND MATERIALS We illustrate this using data for the detection of suspected acute pulmonary embolism (PE) from the Prospective Investigation of Pulmonary Embolism Diagnosis II (PIOPED II). We chose PE because of the clinical significance of the disease, the low prevalence of PE in the patient population being tested with CTPA with the widespread adoption of CTPA, and the serious clinical consequences of anticoagulation therapy in FP patients. RESULTS Based on PIOPED II data (sensitivity 83%, specificity 96%), at a disease prevalence of approximately 5%, the number of FP patients is greater than the number of TP patients. Scaled to the US population, at a disease prevalence of 5%, there would be 139,800 FPs and 3,356,200 TNs. Assuming a mortality rate of 0.5% and a 3.0% rate of major bleeding secondary to anticoagulation therapy for well-controlled patients, if all FP patients received anticoagulation, there would be 699 deaths and 4194 major bleeding complications. CONCLUSIONS At a prevalence of approximately 5% for PE, the number of FPs approaches or is greater than the number of TPs for CTPA for the detection of suspected acute PE. Patients with FP results may receive unnecessary, potentially harmful treatment with anticoagulation therapy. Population prevalence of disease needs to be taken into account along with the diagnostic accuracy of a test, because this may significantly affect downstream patient outcomes.
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977
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Is a V/Q scan based algorithm correctly used to diagnose acute pulmonary embolism? A daily practice survey. Thromb Res 2011; 128:221-6. [DOI: 10.1016/j.thromres.2011.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 03/11/2011] [Accepted: 03/21/2011] [Indexed: 11/19/2022]
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978
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Nassiri N, Jain A, McPhee D, Mina B, Rosen RJ, Giangola G, Carroccio A, Green RM. Massive and submassive pulmonary embolism: experience with an algorithm for catheter-directed mechanical thrombectomy. Ann Vasc Surg 2011; 26:18-24. [PMID: 21885244 DOI: 10.1016/j.avsg.2011.05.026] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2011] [Revised: 05/19/2011] [Accepted: 05/29/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND The role of catheter-directed mechanical thrombectomy (CDMT) for the treatment of massive pulmonary embolism (MPE) and submassive pulmonary embolism (SMPE) is not clearly defined. We report our experience with an algorithm for CDMT as a primary treatment in patients with MPE and SMPE. METHODS We retrospectively reviewed our experience in treating MPE and SMPE in consecutive patients over a 2-year period (2008-2010). Patients with computed tomography angiography evidence of saddle, main branch, or ≥2 lobar pulmonary emboli in the setting of hypoxia, tachycardia, echocardiographic right heart strain, and/or cardiogenic shock underwent AngioJet CDMT, with or without adjunctive thrombolytic power-pulse spray. Outcomes, including angiographic success, clinical improvement, complications, and survival to discharge, were evaluated. RESULTS Fifteen patients (8 men, 7 women; 14 SMPE, 1 SMPE) with a mean age of 59 years (range: 35-90 years) were treated for heart strain (100%), tachycardia (67%), hypoxia (67%), and cardiogenic shock (7%). Ten patients (67%) also received Alteplase power-pulse spray. Resolution of symptoms and improvement in heart strain were achieved in all patients. There were no in-hospital mortalities. Complications occurred in 3 patients (20%), including 2 patients with acute tubular necrosis and 1 patient with an intraoperative cardiac arrest. Average hospitalization was 9 days (range: 4-26 days). All patients were discharged on full anticoagulation. None required supplemental oxygen at discharge. CONCLUSION CDMT as primary treatment of MPE and SMPE has a high rate of technical and clinical success in a high-risk patient population. Experience and strict patient selection criteria may improve therapeutic outcomes.
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Affiliation(s)
- Naiem Nassiri
- Department of Surgery, Division of Vascular & Endovascular Surgery, The Heart & Vascular Institute of New York, Lenox Hill Hospital, New York, NY 10075, USA.
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979
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Fineschi V, Bafunno V, Bello S, De Stefano F, Margaglione M, Neri M, Riezzo I, Turillazzi E, Bonsignore A, Vecchione G, Ventura F, Grandone E. Fatal pulmonary thromboembolism. A retrospective autopsy study: searching for genetic thrombophilias (Factor V Leiden (G1691A) and FII (G20210A) gene variants) and dating the thrombus. Forensic Sci Int 2011; 214:152-8. [PMID: 21871746 DOI: 10.1016/j.forsciint.2011.07.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 06/26/2011] [Accepted: 07/25/2011] [Indexed: 10/17/2022]
Abstract
The accuracy of antemortem diagnosis of pulmonary embolism is within the range of just 10-30%, so representing one of the most frequent missed diagnosis in sudden, unexpected death. We describe 43 fatal cases of pulmonary embolism as confirmed by post-mortem examination. The aim of our study was to verify the systematic search for the most common genetic thrombophilias (Factor V Leiden (G1691A) and FII (G20210A) gene variants) and dating the thrombus. As a whole, 41 patients (95.3%) had at least one risk factor. Pre-existing symptoms are described just before fatal embolism in 18 (41.9%) out 43 patients. In 18 out of 43 (41.9%) it was not possible to find the thrombotic site. In 24 out of the remaining 25 cases the involvement of the deep veins of one leg was shown; in 1 case the thrombus was localised in the inferior caval vein. 10 (41.7%) were iliac vein thromboses, 7 (29.1%) femoral, 2 (8.3%) popliteal, 3 (12.6%) posterior-tibial, 1 (4.1%) anterior-tibial and 1 (4.1%) peroneal vein thromboses. In our cohort of patients, 4 (10%) out of 40 cases carried the 20210A prothrombin gene variant in heterozygosis. One (2.5%) out of 40 carried the Factor V Leiden (G1691A) gene variant in heterozygosis. Patients carrying these gene variants in homozygosis or carrying both were not present in our case-series. We strongly underline the relevance of a complete methodological approach, integrating clinical data by means of autopsy findings and histological study. On the contrary, investigating common inherited thrombophilia is not warranted.
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Affiliation(s)
- Vittorio Fineschi
- Department of Forensic Pathology, University of Foggia, Ospedale Colonnello D'Avanzo, Foggia, Italy.
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980
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Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, Cifkova R, Ferreira R, Foidart JM, Gibbs JSR, Gohlke-Baerwolf C, Gorenek B, Iung B, Kirby M, Maas AHEM, Morais J, Nihoyannopoulos P, Pieper PG, Presbitero P, Roos-Hesselink JW, Schaufelberger M, Seeland U, Torracca L. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:3147-97. [PMID: 21873418 DOI: 10.1093/eurheartj/ehr218] [Citation(s) in RCA: 953] [Impact Index Per Article: 73.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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981
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[Competence development in sonography for our discipline. E pluribus unum]. Anaesthesist 2011; 60:201-2. [PMID: 21424307 DOI: 10.1007/s00101-011-1876-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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982
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Wenk M, Pöpping DM, Hillyard S, Albers H, Möllmann M. Intraoperative thrombolysis in a patient with cardiopulmonary arrest undergoing caesarean delivery. Anaesth Intensive Care 2011; 39:671-4. [PMID: 21823388 DOI: 10.1177/0310057x1103900422] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Thromboembolic events during pregnancy remain a major cause of morbidity and mortality with possible catastrophic sequelae for the patient. The decision whether to use high-risk therapeutic thrombolytics during pregnancy or perinatally is complicated and many considerations pertain. We report on the thrombolytic management of a 34-year-old woman who had an asystolic cardiac arrest secondary to massive pulmonary embolism while undergoing emergency caesarean delivery. The patient was thrombolysed during successful cardiopulmonary resuscitation. Return of spontaneous circulation was accompanied by massive uterine bleeding. Instead of performing a postpartum hysterectomy, the uterus was preserved through continuous manual pressure and packing for four hours by the obstetric team until haemostasis was achieved. The patient survived and was later discharged without any major neurological deficit.
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Affiliation(s)
- M Wenk
- Department of Anesthesiology and Intensive Care, St. Franziskus Hospital Muenster, Muenster, Germany
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983
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Wang Y, Liu ZH, Zhang HL, Luo Q, Zhao ZH, Zhao Q. Predictive value of D-dimer test for recurrent venous thromboembolism at hospital discharge in patients with acute pulmonary embolism. J Thromb Thrombolysis 2011; 32:410-6. [DOI: 10.1007/s11239-011-0625-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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984
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Lima JS, Sandler B, McWilliams E. Chest pain, dyspnoea and elevated D-dimer in a recent air traveller. BMJ Case Rep 2011; 2011:bcr.04.2011.4104. [PMID: 22688933 DOI: 10.1136/bcr.04.2011.4104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A previously asymptomatic 69-year-old lady, who recently travelled on a 4 h flight, presented with acute left-sided pleuritic pain, dyspnoea and calf pain. Blood gases revealed hypoxaemia and D-dimer was significantly elevated. She also had low-grade fever, leukocytosis and a small left-sided pleural effusion on chest x-ray. The working diagnosis was pulmonary embolism and chest infection and she received low molecular weight heparin and antibiotics. A subsequent CT pulmonary angiogram ruled out pulmonary embolism but revealed an abnormal finding in the ascending aorta, suggestive of a penetrating aortic ulcer. Urgent transoesophageal echocardiography was consistent with an intramural haematoma and the patient underwent emergency aortic root replacement with imminent aortic rupture confirmed at surgery. This case highlights the fact that acute aortic syndromes may have atypical presentations and also emphasises the fact that D-dimer levels are elevated in aortic syndromes.
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Affiliation(s)
- Joaquim Santos Lima
- Cardiology Department, Conquest Hospital, St Leonards-on-sea, East Sussex, UK
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985
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Golpe R, Testa-Fernandez A, Perez-de-Llano LA, Castro-Anon O, Gonzalez-Juanatey C, Perez-Fernandez R, Farinas MC. Long-term clinical outcome of patients with persistent right ventricle dysfunction or pulmonary hypertension after acute pulmonary embolism. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2011; 12:756-61. [DOI: 10.1093/ejechocard/jer125] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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986
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Cardiac biomarkers in the critically ill. Crit Care Clin 2011; 27:327-43. [PMID: 21440204 DOI: 10.1016/j.ccc.2010.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Cardiac biomarkers have well-established roles in acute coronary syndrome and congestive heart failure. In many instances, the detection of cardiac biomarkers may aid in the diagnosis and risk assessment of critically ill patients. Despite increasing interest in the use of cardiac biomarkers in noncardiac critical illness, no clear consensus exists on how and in which settings markers should be measured. This article briefly describes what constitutes an ideal biomarker and focuses on those that have been most well studied in critical illness, specifically troponin, the natriuretic peptides, and heart-type fatty acid-binding protein.
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987
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Keltai M, Keltai K. [New anticoagulants in the prevention and treatment of venous thromboembolism]. Orv Hetil 2011; 152:983-92. [PMID: 21642050 DOI: 10.1556/oh.2011.29140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Clinical data on the risk factors, incidence, consequences and current treatment options of venous thromboembolism are reviewed. Current guidelines advise anticoagulant treatment for a few weeks or months in immobilized patients treated in hospital, and after major surgery. The initial treatment is based on heparin, followed by vitamin K antagonist treatment. Recently a number of new, partially orally administered medications have undergone clinical investigations and based on the results three of them were also registered for the prevention and treatment of venous thromboembolism. Direct thrombin inhibitors, direct and indirect Factor Xa inhibitors exhibited proven non-inferiority or superiority compared with traditional treatment options. The superior efficacy or non-inferiority was not accompanied with an increase in the bleeding risk. Results of the most important clinical trials are reviewed. Based on these results, prevention and treatment of venous thromboembolism will change substantially in the near future.
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Affiliation(s)
- Mátyás Keltai
- Gottsegen György Országos Kardiológiai Intézet, Budapest.
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988
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Vanni S, Socci F, Pepe G, Nazerian P, Viviani G, Baioni M, Conti A, Grifoni S. High plasma lactate levels are associated with increased risk of in-hospital mortality in patients with pulmonary embolism. Acad Emerg Med 2011; 18:830-5. [PMID: 21843218 DOI: 10.1111/j.1553-2712.2011.01128.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES The objective was to investigate the prognostic value of plasma lactate in patients with acute pulmonary embolism (PE). METHODS This was a retrospective study at the emergency department (ED) of a third-level teaching hospital. The authors considered consecutive patients with a diagnosis of PE established by lung scan or spiral computed tomography (CT) and confirmed by pulmonary angiography if necessary. Only patients for whom plasma lactate levels had been tested within 6 hours from presentation to the ED were included. Primary outcome was in-hospital death due to any cause; secondary outcome was mortality related to PE. RESULTS From September 1997 to June 2006, a total of 384 patients were diagnosed with PE in the ED. Of these patients, 287 had registered plasma lactate levels and were included in this analysis. Included patients had a mean age of 70 (SD ± 15 years, range = 18 to 100 years), 163 (57%) were female, 26 (9%) showed systolic blood pressure lower than 100 mm Hg at presentation, and 160 (56%) had echocardiographic evidence of right ventricular dysfunction (RVD). Twenty patients died during their hospital stay (7%). Plasma lactate levels ≥ 2 mmol/L were associated with in-hospital mortality from all causes (odds ratio [OR] = 4.60, 95% confidence interval [CI] = 1.57 to 13.53) and with PE-related mortality (OR = 4.94, 95% CI = 1.38 to 17.63), independent of hypotension or RVD at presentation. CONCLUSIONS High plasma lactate was associated with increased in-hospital mortality in this sample of patients with acute PE.
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Affiliation(s)
- Simone Vanni
- Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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989
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Zondag W, Mos ICM, Creemers-Schild D, Hoogerbrugge ADM, Dekkers OM, Dolsma J, Eijsvogel M, Faber LM, Hofstee HMA, Hovens MMC, Jonkers GJPM, van Kralingen KW, Kruip MJHA, Vlasveld T, de Vreede MJM, Huisman MV. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost 2011; 9:1500-7. [PMID: 21645235 DOI: 10.1111/j.1538-7836.2011.04388.x] [Citation(s) in RCA: 235] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Traditionally, patients with pulmonary embolism (PE) are initially treated in the hospital with low molecular weight heparin (LMWH). The results of a few small non-randomized studies suggest that, in selected patients with proven PE, outpatient treatment is potentially feasible and safe. OBJECTIVE To evaluate the efficacy and safety of outpatient treatment according to predefined criteria in patients with acute PE. PATIENTS AND METHODS A prospective cohort study of patients with objectively proven acute PE was conducted in 12 hospitals in The Netherlands between 2008 and 2010. Patients with acute PE were triaged with the predefined criteria for eligibility for outpatient treatment, with LMWH (nadroparin) followed by vitamin K antagonists. All patients eligible for outpatient treatment were sent home either immediately or within 24 h after PE was objectively diagnosed. Outpatient treatment was evaluated with respect to recurrent venous thromboembolism (VTE), including PE or deep vein thrombosis (DVT), major hemorrhage and total mortality during 3 months of follow-up. RESULTS Of 297 included patients, who all completed the follow-up, six (2.0%; 95% confidence interval [CI] 0.8-4.3) had recurrent VTE (five PE [1.7%] and one DVT [0.3%]). Three patients (1.0%, 95% CI 0.2-2.9) died during the 3 months of follow-up, none of fatal PE. Two patients had a major bleeding event, one of which was fatal intracranial bleeding (0.7%, 95% CI 0.08-2.4). CONCLUSION Patients with PE selected for outpatient treatment with predefined criteria can be treated with anticoagulants on an outpatient basis. (Dutch Trial Register No 1319; http://www.trialregister.nl/trialreg/index.asp).
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Affiliation(s)
- W Zondag
- Section of Vascular Medicine, Department of General Internal Medicine-Endocrinology, LUMC, Leiden, The Netherlands.
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990
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Fesmire FM, Brown MD, Espinosa JA, Shih RD, Silvers SM, Wolf SJ, Decker WW. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Ann Emerg Med 2011; 57:628-652.e75. [PMID: 21621092 DOI: 10.1016/j.annemergmed.2011.01.020] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This clinical policy from the American College of Emergency Physicians is the revision of a 2003 clinical policy on the evaluation and management of adult patients presenting with suspected pulmonary embolism (PE).(1) A writing subcommittee reviewed the literature to derive evidence-based recommendations to help clinicians answer the following critical questions: (1) Do objective criteria provide improved risk stratification over gestalt clinical assessment in the evaluation of patients with possible PE? (2) What is the utility of the Pulmonary Embolism Rule-out Criteria (PERC) in the evaluation of patients with suspected PE? (3)What is the role of quantitative D-dimer testing in the exclusion of PE? (4) What is the role of computed tomography pulmonary angiogram of the chest as the sole diagnostic test in the exclusion of PE? (5) What is the role of venous imaging in the evaluation of patients with suspected PE? (6) What are the indications for thrombolytic therapy in patients with PE? Evidence was graded and recommendations were given based on the strength of the available data in the medical literature.
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991
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Popp FC, Fillenberg B, Eggenhofer E, Renner P, Dillmann J, Benseler V, Schnitzbauer AA, Hutchinson J, Deans R, Ladenheim D, Graveen CA, Zeman F, Koller M, Hoogduijn MJ, Geissler EK, Schlitt HJ, Dahlke MH. Safety and feasibility of third-party multipotent adult progenitor cells for immunomodulation therapy after liver transplantation--a phase I study (MISOT-I). J Transl Med 2011; 9:124. [PMID: 21798013 PMCID: PMC3166276 DOI: 10.1186/1479-5876-9-124] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Accepted: 07/28/2011] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Liver transplantation is the definitive treatment for many end-stage liver diseases. However, the life-long immunosuppression needed to prevent graft rejection causes clinically significant side effects. Cellular immunomodulatory therapies may allow the dose of immunosuppressive drugs to be reduced. In the current protocol, we propose to complement immunosuppressive pharmacotherapy with third-party multipotent adult progenitor cells (MAPCs), a culture-selected population of adult adherent stem cells derived from bone marrow that has been shown to display potent immunomodulatory and regenerative properties. In animal models, MAPCs reduce the need for pharmacological immunosuppression after experimental solid organ transplantation and regenerate damaged organs. METHODS Patients enrolled in this phase I, single-arm, single-center safety and feasibility study (n = 3-24) will receive 2 doses of third-party MAPCs after liver transplantation, on days 1 and 3, in addition to a calcineurin-inhibitor-free "bottom-up" immunosuppressive regimen with basiliximab, mycophenolic acid, and steroids. The study objective is to evaluate the safety and clinical feasibility of MAPC administration in this patient cohort. The primary endpoint of the study is safety, assessed by standardized dose-limiting toxicity events. One secondary endpoint is the time until first biopsy-proven acute rejection, in order to collect first evidence of efficacy. Dose escalation (150, 300, 450, and 600 million MAPCs) will be done according to a 3 + 3 classical escalation design (4 groups of 3-6 patients each). DISCUSSION If MAPCs are safe for patients undergoing liver transplantation in this study, a phase II/III trial will be conducted to assess their clinical efficacy.
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Affiliation(s)
- Felix C Popp
- Department of Surgery, University Medical Center Regensburg, Regensburg, Germany
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992
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Barbash IM, Schenke WH, Halabi M, Ratnayaka K, Faranesh AZ, Kocaturk O, Lederman RJ. Experimental model of large pulmonary embolism employing controlled release of subacute caval thrombus in swine. J Vasc Interv Radiol 2011; 22:1471-7. [PMID: 21802315 DOI: 10.1016/j.jvir.2011.06.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Revised: 06/09/2011] [Accepted: 06/20/2011] [Indexed: 10/17/2022] Open
Abstract
PURPOSE To develop a catheter-based model of large pulmonary embolism (PE) in swine based on in situ venous thrombus formation. MATERIALS AND METHODS Ten Yorkshire swine underwent transjugular implantation of a retrievable inferior vena cava (IVC) filter. A thrombin and collagen mixture was injected into a confined space created by two balloons inflated proximal and distal to the IVC filter. Animals were left to survive for 7 days ± 3 to allow thrombus to organize in situ. The caval thrombus was released on transcatheter retrieval of the IVC filter and embolized into the main and branch pulmonary arteries. The severity of PE was scored based on digital subtraction angiography with the Miller index. At necropsy, thrombi were recovered and analyzed histopathologically. RESULTS Large PE was induced in all animals (Miller index score of 15 ± 5). Two animals developed saddle embolus with bilateral pulmonary artery occlusion, and five developed proximal occlusion of the left or right pulmonary artery. Nevertheless, no animal exhibited significant hemodynamic compromise. Large tubular thrombi were explanted in the size range of 5-10 cm long and 0.5-1 cm wide. Histologic analysis indicated an organized thrombus with infiltration of white blood cells and fibrin deposition. CONCLUSIONS Large caval thrombi can be formed in vivo and released at a predetermined time to induce large PE in a large animal model. This may help in the development and testing of new therapeutic approaches for PE.
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Affiliation(s)
- Israel M Barbash
- Cardiovascular and Pulmonary Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1538, USA
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993
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Ozsu S, Abul Y, Yilmaz I, Ozsu A, Oztuna F, Bulbul Y, Ozlu T. Prognostic significance of PaO2/PaCO2 ratio in normotensive patients with pulmonary embolism. CLINICAL RESPIRATORY JOURNAL 2011; 6:104-11. [DOI: 10.1111/j.1752-699x.2011.00253.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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994
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Gopie P, Sakhamuri S, Sharma A, Solomon S, Teelucksingh S. Acute pneumonitis secondary to subcutaneous silicone injection. Int J Gen Med 2011; 4:477-9. [PMID: 21760748 PMCID: PMC3133515 DOI: 10.2147/ijgm.s20071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Indexed: 11/23/2022] Open
Abstract
Following silicone injection, end organ toxicity can occur. To our knowledge this report documents the first case of silicone embolization in the Caribbean and serves to highlight an emergent danger associated with its illicit use for cosmetic purposes in this region.
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Affiliation(s)
- Priya Gopie
- Clinical Medical Sciences, University of the West Indies, St Augustine, Trinidad
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995
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Frazier A, Hunt EA, Holmes K. Pediatric cardiac emergencies: Children are not small adults. J Emerg Trauma Shock 2011; 4:89-96. [PMID: 21633575 PMCID: PMC3097588 DOI: 10.4103/0974-2700.76842] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Accepted: 09/29/2010] [Indexed: 11/04/2022] Open
Abstract
Compared with adults, cardiac emergencies are infrequent in children and clinical presentation is often quite variable. In adults, cardiac emergencies are most commonly related to complications of coronary artery disease; however, in pediatric cases, the coronaries are only rarely the underlying problem. Pediatric cardiac emergencies comprise a range of pathology including but not limited to undiagnosed congenital heart disease in the infant; complications of palliated congenital heart disease in children; arrhythmias related to underlying cardiac pathology in the teenager and acquired heart disease. The emergency room physician and pediatric intensivist will usually be the first and second lines of care for pediatric cardiac emergencies and thus it is imperative that they have knowledge of the diverse presentations of cardiac disease in order to increase the likelihood of delivering early appropriate therapy and referral. The objective of this review is to outline cardiac emergencies in the pediatric population and contrast the presentation with adults.
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996
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Bahloul M, Chaari A, Kallel H, Abid L, Hamida CB, Dammak H, Rekik N, Mnif J, Chelly H, Bouaziz M. Pulmonary embolism in intensive care unit: Predictive factors, clinical manifestations and outcome. Ann Thorac Med 2011; 5:97-103. [PMID: 20582175 PMCID: PMC2883205 DOI: 10.4103/1817-1737.62473] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Accepted: 01/20/2010] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE: To determine predictive factors, clinical and demographics characteristics of patients with pulmonary embolism (PE) in ICU, and to identify factors associated with poor outcome in the hospital and in the ICU. METHODS: During a four-year prospective study, a medical committee of six ICU physicians prospectively examined all available data for each patient in order to classify patients according to the level of clinical suspicion of pulmonary thromboembolism. During the study periods, all patients admitted to our ICU were classified into four groups. The first group includes all patients with confirmed PE; the second group includes some patients without clinical manifestations of PE; the third group includes patients with suspected and not confirmed PE and the fourth group includes all patients with only deep vein thromboses (DVTs) without suspicion of PE. The diagnosis of PE was confirmed either by a high-probability ventilation/perfusion (V/Q) scan or by a spiral computed tomography (CT) scan showing one or more filling defects in the pulmonary artery or in its branches. The diagnosis was also confirmed by echocardiography when a thrombus in the pulmonary artery was observed. RESULTS: During the study periods, 4408 patients were admitted in our ICU. The diagnosis of PE was confirmed in 87 patients (1.9%). The mean delay of development of PE was 7.8 ± 9.5 days. On the day of PE diagnosis, clinical examination showed that 50 patients (57.5%) were hypotensive, 63 (72.4%) have SIRS, 15 (17.2%) have clinical manifestations of DVT and 71 (81.6%) have respiratory distress requiring mechanical ventilation. In our study, intravenous unfractionated heparin was used in 81 cases (93.1%) and low molecular weight heparins were used in 4 cases (4.6%). The mean ICU stay was 20.2 ± 25.3 days and the mean hospital stay was 25.5 ± 25 days. The mortality rate in ICU was 47.1% and the in-hospital mortality rate was 52.9%. Multivariate analysis showed that factors associated with a poor prognosis in ICU are the use of norepinephrine and epinephrine. Furthermore, factors associated with in-hospital poor outcome in multivariate analysis were a number of organ failure associated with PE ≥ 3. Moreover, comparison between patients with and without pe showed that predictive factors of pe are: acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO2/FiO2 ratio <300 and the absence of pharmacological prevention of venous thromboembolism. CONCLUSION: Despite the high frequency of DVT in critically ill patients, symptomatic PE remains not frequently observed, because systematic screening is not performed. Pulmonary embolism is associated with a high ICU and in-hospital mortality rate. Predictive factors of PE are acute medical illness, the presence of meningeal hemorrhage, the presence of spine fracture, hypoxemia with PaO2/FiO2 < 300 and the absence of pharmacological prevention of venous thromboembolism.
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Affiliation(s)
- Mabrouk Bahloul
- Department of Intensive Care, Habib Bourguiba University Hospital Sfax, Tunisia.
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997
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Aujesky D, Roy PM, Verschuren F, Righini M, Osterwalder J, Egloff M, Renaud B, Verhamme P, Stone RA, Legall C, Sanchez O, Pugh NA, N'gako A, Cornuz J, Hugli O, Beer HJ, Perrier A, Fine MJ, Yealy DM. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomised, non-inferiority trial. Lancet 2011; 378:41-8. [PMID: 21703676 DOI: 10.1016/s0140-6736(11)60824-6] [Citation(s) in RCA: 390] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although practice guidelines recommend outpatient care for selected, haemodynamically stable patients with pulmonary embolism, most treatment is presently inpatient based. We aimed to assess non-inferiority of outpatient care compared with inpatient care. METHODS We undertook an open-label, randomised non-inferiority trial at 19 emergency departments in Switzerland, France, Belgium, and the USA. We randomly assigned patients with acute, symptomatic pulmonary embolism and a low risk of death (pulmonary embolism severity index risk classes I or II) with a computer-generated randomisation sequence (blocks of 2-4) in a 1:1 ratio to initial outpatient (ie, discharged from hospital ≤24 h after randomisation) or inpatient treatment with subcutaneous enoxaparin (≥5 days) followed by oral anticoagulation (≥90 days). The primary outcome was symptomatic, recurrent venous thromboembolism within 90 days; safety outcomes included major bleeding within 14 or 90 days and mortality within 90 days. We used a non-inferiority margin of 4% for a difference between inpatient and outpatient groups. We included all enrolled patients in the primary analysis, excluding those lost to follow-up. This trial is registered with ClinicalTrials.gov, number NCT00425542. FINDINGS Between February, 2007, and June, 2010, we enrolled 344 eligible patients. In the primary analysis, one (0·6%) of 171 outpatients developed recurrent venous thromboembolism within 90 days compared with none of 168 inpatients (95% upper confidence limit [UCL] 2·7%; p=0·011). Only one (0·6%) patient in each treatment group died within 90 days (95% UCL 2·1%; p=0·005), and two (1·2%) of 171 outpatients and no inpatients had major bleeding within 14 days (95% UCL 3·6%; p=0·031). By 90 days, three (1·8%) outpatients but no inpatients had developed major bleeding (95% UCL 4·5%; p=0·086). Mean length of stay was 0·5 days (SD 1·0) for outpatients and 3·9 days (SD 3·1) for inpatients. INTERPRETATION In selected low-risk patients with pulmonary embolism, outpatient care can safely and effectively be used in place of inpatient care. FUNDING Swiss National Science Foundation, Programme Hospitalier de Recherche Clinique, and the US National Heart, Lung, and Blood Institute. Sanofi-Aventis provided free drug supply in the participating European centres.
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998
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Kang DK, Sun JS, Park KJ, Lim HS. Usefulness of combined assessment with computed tomographic signs of right ventricular dysfunction and cardiac troponin T for risk stratification of acute pulmonary embolism. Am J Cardiol 2011; 108:133-40. [PMID: 21529730 DOI: 10.1016/j.amjcard.2011.03.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Revised: 03/03/2011] [Accepted: 03/03/2011] [Indexed: 11/29/2022]
Abstract
The aim of this study was to evaluate the incremental value of combined assessment with computed tomographic (CT) signs of right ventricular (RV) dysfunction and cardiac troponin T level for predicting early death or adverse outcomes due to acute pulmonary embolism (PE). One hundred seventy-three non-high-risk patients with acute PE, confirmed by CT pulmonary angiography, were retrospectively evaluated. The area under the curve and hazard ratio of CT signs and troponin T levels were compared for predicting early death or adverse outcomes. Patients were classified into intermediate- and low-risk groups on the basis of CT signs and troponin T levels, and mortality was compared. Seventeen patients (9.8%) died within 3 months. Early mortality of intermediate-risk patients (14% to 19%) was higher than that of low-risk patents (2% to 6%). A ratio of RV volume to left ventricular volume > 1.5 had the highest area under the curve (0.709) and hazard ratio (5.402) for predicting early death. The combination of CT signs and elevated troponin T level had an increased area under the curve and hazard ratio for predicting early death and adverse outcomes compared to those of CT signs or elevated troponin T level alone. In conclusion, the combined assessment of the ratio of RV volume to left ventricular volume and an elevated troponin T level provided incrementally more prognostic information in non-high-risk patients with acute PE compared to the single predictor of CT signs or troponin T level.
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Affiliation(s)
- Doo Kyoung Kang
- Department of Radiology, Ajou University School of Medicine, Suwon, South Korea.
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999
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Effectiveness of thrombolysis for massive pulmonary embolism with an atrial septal defect. Resuscitation 2011; 82:960-1. [DOI: 10.1016/j.resuscitation.2011.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 03/31/2011] [Indexed: 11/21/2022]
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1000
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Evaluation of right ventricular dysfunction and prediction of clinical outcomes in acute pulmonary embolism by chest computed tomography: comparisons with echocardiography. Int J Cardiovasc Imaging 2011; 28:979-87. [DOI: 10.1007/s10554-011-9912-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 06/12/2011] [Indexed: 11/30/2022]
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