1151
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Muntz JE, Michota FA. Prevention and management of venous thromboembolism in the surgical patient: options by surgery type and individual patient risk factors. Am J Surg 2010; 199:S11-20. [DOI: 10.1016/j.amjsurg.2009.10.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 10/27/2009] [Accepted: 10/27/2009] [Indexed: 10/20/2022]
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1152
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Segovia J, Bermejo J, Alfonso F, Heras M. Corazón derecho y circulación pulmonar: ¿una circulación menor? Rev Esp Cardiol 2010. [DOI: 10.1016/s0300-8932(10)70011-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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1153
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Tokyo CCU Network Scientific Committee. Latest Management and Outcomes of Major Pulmonary Embolism in the Cardiovascular Disease Early Transport System: Tokyo CCU Network. Circ J 2010; 74:289-93. [DOI: 10.1253/circj.cj-09-0623] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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1154
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Sosa Lozano LA, Goodman LR, Shahir K. Pulmonary embolism: optimizing the diagnostic imaging approach. Hosp Pract (1995) 2010; 38:153-162. [PMID: 20890065 DOI: 10.3810/hp.2010.06.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Venous thromboembolism is a common medical problem that can affect a wide range of patients. The clinical presentation ranges from minor, nonspecific signs and symptoms to severe clinical scenarios. The combination of objective pretest clinical probability, D-dimer testing, and imaging studies plays a critical role in its diagnosis. There are multiple imaging modalities to confirm or exclude the presence of pulmonary embolism and deep vein thrombosis, but, at present, computed tomography angiography is the most frequently used. Other imaging, however, is required for several subpopulations.
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1155
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Wang C, Zhai Z, Yang Y, Yuan Y, Cheng Z, Liang L, Dai H, Huang K, Lu W, Zhang Z, Cheng X, Shen YH. Efficacy and safety of 2-hour urokinase regime in acute pulmonary embolism: a randomized controlled trial. Respir Res 2009; 10:128. [PMID: 20040086 PMCID: PMC2806365 DOI: 10.1186/1465-9921-10-128] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2009] [Accepted: 12/29/2009] [Indexed: 11/10/2022] Open
Abstract
Backgrounds Urokinase (UK) 2 200 U/kg·h for 12 hours infusion(UK-12 h)is an ACCP recommended regimen in treating acute pulmonary embolism (PE). It is unclear whether this dose and time can be reduced further. We compared the efficacy and safety of 20, 000 U/kg for 2 hours (UK-2 h) with the UK-12 h regime in selected PE patients. Methods A randomized trial involving 129 patients was conducted. Patients with acute PE were randomly assigned to receive either UK-12 h (n = 70), or UK-2 h (n = 59). The efficacy was determined by the improvement of right heart dysfunction and perfusion defect at 24 h and 14 d post UK treatment. The bleeding incidence, death rate and PE recurrence were also evaluated. Results Similarly significant improvements in right heart dysfunction and lung perfusion defects were observed in both groups. Overall bleeding incidents were low in both groups. Major bleeding directly associated with UK infusion occurred in one patient in the UK-2 h group and one in the UK-12 h group. Mortality rates were low, with one reported fatal recurrent in the UK-12 h group and none in the UK-2 h group. When the rate of bleeding, death and PE recurrence were compared separately in the hemodynamic instability and the massive anatomic obstruction subgroups, no significant difference was found. Conclusions The UK-2 h regimen exhibits similar efficacy and safety as the UK-12 h regimen for acute PE. Trial Registration Clinical trial registered with http://clinicaltrials.gov/ct2/show/NCT00799968 (Identifier: NCT 00799968)
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Affiliation(s)
- Chen Wang
- Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China.
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1156
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Er F, Nia AM, Gassanov N, Caglayan E, Erdmann E, Hoppe UC. Impact of rescue-thrombolysis during cardiopulmonary resuscitation in patients with pulmonary embolism. PLoS One 2009; 4:e8323. [PMID: 20016808 PMCID: PMC2788709 DOI: 10.1371/journal.pone.0008323] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Accepted: 11/19/2009] [Indexed: 12/26/2022] Open
Abstract
Background Cardiac arrest in patients with pulmonary embolism (PE) is associated with high morbidity and mortality. Thrombolysis is expected to improve the outcome in these patients. However studies evaluating rescue-thrombolysis in patients with PE are missing, mainly due to the difficulties of clinical diagnosis of PE. We aimed to determine the success influencing factors of thrombolysis during resuscitation in patients with PE. Methodology/Principal Findings We analyzed retrospectively the outcome of 104 consecutive patients with confirmed (n = 63) or highly suspected (n = 41) PE and monitored cardiac arrest. In all patients rtPA was administrated for thrombolysis during cardiopulmonary resuscitation. In 40 of the 104 patients (38.5%) a return of spontaneous circulation (ROSC) could be achieved successfully. Patients with ROSC received thrombolysis significantly earlier after CPR onset compared to patients without ROSC (13.6±1.2 min versus 24.6±0.8 min; p<0.001). 19 patients (47.5%) out of the 40 patients with initially successful resuscitation survived to hospital discharge. In patients with hospital discharge thrombolysis therapy was begun with a significantly shorter delay after cardiac arrest compared to all other patients (11.0±1.3 vs. 22.5±0.9 min; p<0.001). Conclusion Rescue-thrombolysis should be considered and started in patients with PE and cardiac arrest, as soon as possible after cardiac arrest onset.
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Affiliation(s)
- Fikret Er
- Department of Internal Medicine III, University of Cologne, Cologne, Germany.
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1157
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Rumpf TH, Krizmaric M, Grmec S. Capnometry in suspected pulmonary embolism with positive D-dimer in the field. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R196. [PMID: 19995420 PMCID: PMC2811920 DOI: 10.1186/cc8197] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 10/14/2009] [Accepted: 12/08/2009] [Indexed: 12/02/2022]
Abstract
Introduction Pulmonary embolism (PE) is one of the greatest diagnostic challenges in prehospital emergency setting. Most patients with suspected PE have a positive D-dimer and undergo diagnostic testing. Excluding PE with additional non-invasive tests would reduce the need for further imaging tests. We aimed to determine the effectiveness of combination of clinical probability and end-tidal carbon dioxide (PetCO2) for evaluation of suspected PE with abnormal concentrations of D-dimer in prehospital emergency setting. Methods We assessed clinical probability of PE and PetCO2 measurement in 100 consecutive patients with suspected PE and positive D-dimer in the field. PetCO2 > 28 mmHg was considered as the best cut-off point. PE was excluded or confirmed by hospital physicians in the University Clinical Center Maribor by computer tomography (CT), ventilation/perfusion scan echocardiography and pulmonary angiography. Results PE was confirmed in 41 patients. PetCO2 had a sensitivity of 92.6% (95% CI, 79 to 98%), a negative predictive value of 94.2% (95% CI, 83 to 99%), a specificity of 83% (95% CI, 71 to 91%) and a positive predictive value of 79.2% (95% CI, 65 to 89%). Thirty-five patients (35%) had both a low (PE unlikely) clinical probability and a normal PetCO2 (sensitivity: 100%, 95% CI: 89 to 100%) and twenty-eight patients (28%) had both a high clinical probability (PE likely) and abnormal PetCO2 (specificity: 93.2%, 95% CI: 83 to 98%). Conclusions The combination of clinical probability and PetCO2 may safely rule out PE in patients with suspected PE and positive D-dimer in the prehospital setting.
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1158
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Bircan A, Karadeniz N, Ozden A, Cakir M, Varol E, Oyar O, Ozaydin M. A simple clinical model composed of ECG, shock index, and arterial blood gas analysis for predicting severe pulmonary embolism. Clin Appl Thromb Hemost 2009; 17:188-96. [PMID: 19959488 DOI: 10.1177/1076029609351877] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Objective diagnosis of severe pulmonary embolism (PE) is obligatory because of its considerable mortality. AIM To assess the abilities of electrocardiography (ECG) score (sECG) and the newly generated scoring system composed of the scores obtained from arterial blood gas (ABG) analysis and shock index (SI) in addition to sECG in predicting severe PE. MATERIAL AND METHODS The degree of pulmonary vascular obstruction (sPVO) and the right ventricular dysfunction (RVD) were determined with spiral computed tomography (CT) in 53 consequent patients with PE. Twelve-lead ECG taken within a day of PE event and ABG values were evaluated according to ECG scoring system and original Geneva system, respectively. RESULTS The mean age of patients was 62.6 ± 13.4 years. Right ventricular dysfunction, sPVO ≥ 50%, hypoxemia, and SI were present in 34 (64.2%), 27 (50.9%), 50 (94.3%), and 22 (41.5%) patients, respectively. The mean sECG, 5.9 ± 5.1, was correlated with sPVO, maximum diameter of right ventricle (RV), and right ventricle to left ventricle (RV/LV) ratio (r = .385, r = .415, and r = .329, respectively). The mean newly generated score was 10.9 ± 5.5 and correlated with sPVO, maximum diameter of RV, and RV/LV ratio (r = .394, r = .483, and r = .393, respectively). Receiver operator characteristic (ROC) curve analyses revealed that sECG ≥ 3.5, s (ECG + SI) ≥ 4.5, and s (ECG + SI + ABG) ≥ 9.5 predict the severe PE patients with 70.6%, 61.8%, 58.8% sensitivities and 52.6%, 63.2%, 73.7% specificities, respectively. CONCLUSION Adding the scores obtained from SI and ABG to the sECG enhances the specificity of sECG in predicting RVD (+) or severe PE patients, although a lesser degree decreasing in sensitivity may occur.
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Affiliation(s)
- Ahmet Bircan
- Department of Pulmonary Diseases, Suleyman Demirel University Faculty of Medicine, Isparta, Turkey.
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1159
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Lankeit M, Konstantinides S. Thrombolysis for hemodynamically stable patients with pulmonary embolism: Still searching for the intermediate-risk group. Thromb Res 2009; 124:647-8. [DOI: 10.1016/j.thromres.2009.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Revised: 07/06/2009] [Accepted: 07/06/2009] [Indexed: 11/26/2022]
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1160
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Liu CC, Hung TC, Hou CJY, Tsai CH. Acute Pulmonary Embolism Mimics Acute Coronary Syndrome in Older Patient. INT J GERONTOL 2009. [DOI: 10.1016/s1873-9598(10)70010-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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1161
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Paneni F, Pagannone E, Gurgo A, Sciarretta S, Autore C, Volpe M. A case of thrombolysis in acute pulmonary embolism with right atrial thrombus: comparing current and past guidelines. Intern Emerg Med 2009; 4:497-500. [PMID: 19714441 DOI: 10.1007/s11739-009-0304-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2009] [Accepted: 07/22/2009] [Indexed: 10/20/2022]
Affiliation(s)
- Francesco Paneni
- Cardiology Department, II Faculty of Medicine, S. Andrea Hospital, University of Rome La Sapienza, Rome, Italy
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1162
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Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barberá JA, Beghetti M, Corris P, Gaine S, Simon Gibbs J, Gómez-Sánchez MÁ, Jondeau G, Klepetko W, Opitz C, Peacock A, Rubin L, Zellweger M, Simonneau G. Guía de práctica clínica para el diagnóstico y tratamiento de la hipertensión pulmonar. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)73130-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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1163
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Remy-Jardin M, Hachulla AL, Pontana F, Faivre JB, Remy J. Sémiologie des atteintes du cœur droit en pathologie pulmonaire. ACTA ACUST UNITED AC 2009; 90:1819-29. [DOI: 10.1016/s0221-0363(09)73285-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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current treatment of patients with acute and subacute pulmonary embolism with respect to the newly published guidelines on the diagnosis and treatment of this disease. COR ET VASA 2009. [DOI: 10.33678/cor.2009.190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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1165
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Lobo JL, Zorrilla V, Aizpuru F, Grau E, Jiménez D, Palareti G, Monreal M. D-dimer levels and 15-day outcome in acute pulmonary embolism. Findings from the RIETE Registry. J Thromb Haemost 2009; 7:1795-801. [PMID: 19691481 DOI: 10.1111/j.1538-7836.2009.03576.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND A number of variables have been evaluated for risk stratification in patients with acute pulmonary embolism (PE). Whereas increased D-dimer levels have been associated with mortality at 3 months, its role in predicting short-term outcome (the period of time during which any therapeutic decision has to be taken) remains unclear. METHODS RIETE is an ongoing, prospective registry of consecutive patients with acute venous thromboembolism. We assessed the prognostic value of D-dimer levels at baseline, measured with an automated latex agglutination test (IL Test D-dimer), on the 15-day outcome in patients with acute PE. Overall mortality, fatal PE and major bleeding rates were compared by quartile. RESULTS As of February 2008, 1707 patients with acute PE underwent D-dimer testing. Of these, 72 patients (4.2%) died during the first 15 days, 11 (0.6%) had recurrent PE, and 29 (1.7%) had major bleeding. Overall mortality increased with increasing D-dimer levels, from 2.7% in the first quartile (< 1050 ng mL(-1)) to 7.0% in the fourth quartile (>or= 4200 ng mL(-1)). The rates of fatal PE and major bleeding also increased. On multivariate analysis, patients with D-dimer levels in the fourth quartile had an increased risk for overall death (odds ratio, 1.8; 95% CI, 1.1-3.2), fatal PE (odds ratio, 2.0; 95% CI, 1.0-3.8) or major bleeding (odds ratio, 3.2; 95% CI, 1.5-7.0). CONCLUSIONS PE patients with D-dimer levels in the fourth quartile had an increased incidence of overall death, fatal PE and major bleeding within 15 days both before and after multivariate adjustment.
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Affiliation(s)
- J L Lobo
- Servicio de Neumología, Hospital Txagorritxu, Vitoria, Spain
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1166
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Kline JA, Steuerwald MT, Marchick MR, Hernandez-Nino J, Rose GA. Prospective evaluation of right ventricular function and functional status 6 months after acute submassive pulmonary embolism: frequency of persistent or subsequent elevation in estimated pulmonary artery pressure. Chest 2009; 136:1202-1210. [PMID: 19542256 PMCID: PMC2818852 DOI: 10.1378/chest.08-2988] [Citation(s) in RCA: 172] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2008] [Accepted: 05/11/2009] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND No published data have systematically documented pulmonary artery pressure over an intermediate time period after submassive pulmonary embolism (PE). The aim of this work was to document the rate of pulmonary hypertension, as assessed noninvasively by estimated right ventricular systolic pressure (RVSP) of >or= 40 mm Hg 6 months after the diagnosis of submassive PE. METHODS We enrolled 200 normotensive patients with CT angiography-proven PE and a baseline echocardiogram to estimate RVSP. All patients received therapy with unfractionated heparin initially, but 21 patients later received alteplase in response to circulatory shock or respiratory failure. Patients returned at 6 months for repeat RVSP measurement, and assessments of the New York Heart Association (NYHA) score and 6-min walk distance (6MWD). RESULTS Six months after receiving a diagnosis, 162 of 180 survivors (90%) returned for follow-up, including 144 patients who had been treated with heparin (heparin-only group) and 18 patients who had been treated with heparin plus alteplase (heparin-plus-alteplase group). Among the heparin-only patients, the RVSP at diagnosis was >or= 40 mm Hg in 50 of 144 patients (35%; 95% CI, 27% to 43%), compared with 10 of 144 patients at follow-up (7%; 95% CI, 3% to 12%). However, the RVSP at follow-up was higher than the baseline RVSP in 39 of 144 patients (27%; 95% CI, 9% to 35%), and 18 of these 39 patients had a NYHA score of >or= 3 or exercise intolerance (6MWD, < 330 m). Among heparin-plus-alteplase patients, the RVSP was >or= 40 mm Hg in 11 of 18 patients at diagnosis (61%; 95% CI, 36% to 83%), compared with 2 of 18 patients at follow-up (11%; 95% CI, 1% to 35%). The RVSP at follow-up was not higher than at the time of diagnosis in any of the heparin-plus-alteplase patients (95% CI, 0% to 18%). CONCLUSIONS Six months after experiencing submassive PE, a significant proportion of patients had echocardiographic and functional evidence of pulmonary hypertension.
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Affiliation(s)
- Jeffrey A Kline
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC.
| | | | - Michael R Marchick
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
| | | | - Geoffrey A Rose
- Carolinas Heart and Vascular Institute, Carolinas Medical Center, Charlotte, NC
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Abstract
The stress-responsive transforming growth factor-beta-related cytokine, growth-differentiation factor-15 (GDF-15), is emerging as a new biomarker in patients with cardiovascular disease. The circulating levels of GDF-15 are elevated and independently related to an adverse prognosis in acute coronary syndrome and left- or right-sided heart failure. GDF-15 adds significant prognostic information to established clinical and biochemical risk markers in these conditions. Elevated levels of GDF-15 may identify patients who have non-ST-elevation acute coronary syndrome who derive the greatest benefit from an invasive treatment strategy. As with other heart failure biomarkers, including BNP, it is currently not known what specific therapies could be used to reduce the risk associated with elevated levels of GDF-15 in heart failure. Further elucidation of the pathobiology and upstream inducers of this new biomarker may lead to new therapeutic concepts that address the risk associated with elevated GDF-15 levels. A commercial assay for GDF-15 should be available in the near future.
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1168
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Wittenberg R, Peters JF, Sonnemans JJ, Prokop M, Schaefer-Prokop CM. Computer-assisted detection of pulmonary embolism: evaluation of pulmonary CT angiograms performed in an on-call setting. Eur Radiol 2009; 20:801-6. [PMID: 19862534 PMCID: PMC2835722 DOI: 10.1007/s00330-009-1628-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Revised: 08/12/2009] [Accepted: 09/14/2009] [Indexed: 11/07/2022]
Abstract
Purpose The purpose of the study was to assess the stand-alone performance of computer-assisted detection (CAD) for evaluation of pulmonary CT angiograms (CTPA) performed in an on-call setting. Methods In this institutional review board-approved study, we retrospectively included 292 consecutive CTPA performed during night shifts and weekends over a period of 16 months. Original reports were compared with a dedicated CAD system for pulmonary emboli (PE). A reference standard for the presence of PE was established using independent evaluation by two readers and consultation of a third experienced radiologist in discordant cases. Results Original reports had described 225 negative studies and 67 positive studies for PE. CAD found PE in seven patients originally reported as negative but identified by independent evaluation: emboli were located in segmental (n = 2) and subsegmental arteries (n = 5). The negative predictive value (NPV) of the CAD algorithm was 92% (44/48). On average there were 4.7 false positives (FP) per examination (median 2, range 0–42). In 72% of studies ≤5 FP were found, 13% of studies had ≥10 FP. Conclusion CAD identified small emboli originally missed under clinical conditions and found 93% of the isolated subsegmental emboli. On average there were 4.7 FP per examination.
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Affiliation(s)
- Rianne Wittenberg
- Department of Radiology, Academic Medical Centre, Amsterdam, The Netherlands.
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1169
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Yang Wang, Chen Wang, Yuanhua Yang, Baosen Pang. Effect of recombinant single-chain urokinase-type plasminogen activator on experimental pulmonary embolism. Clin Appl Thromb Hemost 2009; 16:537-42. [PMID: 19833628 DOI: 10.1177/1076029609343003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
UNLABELLED To compare experimental canine pulmonary thromboembolism (PTE) treatment effects among domestic recombinant single-chain urokinase-type plasminogen activator (scu-PA), recombinant tissue plasminogen activator (rt-PA), and heparin, we injected autologous blood clots into 19 dogs. Those dogs were divided into 3 groups randomly: (1) scu-PA group (n = 6), (2) rt-PA group (n = 6), and (3) heparin group (n = 7). The measurement of hemodynamics and pulmonary angiography was, respectively, carried out at the time spots of preemboli and postemboli, 2 hours and 3 hours after treatment. RESULTS (1) An obvious increase in mean pulmonary arterial pressure (mPAP) from preemboli (P < .01) and a decrease in cardiac output (CO; P < .01) after blood clot injection. (2) Intergroup comparisons 2 and 3 hours after treatment: mPAP in scu-PA and rt-PA groups were remarkably lower than those of heparin group (P < .05). (3) Intragroup comparisons after thrombolysis, mPAP declined obviously (P < .01), heparin group saw a further decrease in CO. (4) Pulmonary angiography scoring: decrease in the 2 thrombolytic groups was higher than that of the heparin group. CONCLUSIONS The effects of domestic recombinant scu-PA in experimental PTE resemble that of rt-PA in terms of the improvements of hemodynamics and angiography, better than heparin.
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Affiliation(s)
- Yang Wang
- Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
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1170
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Walther A, Schellhaass A, Böttiger BW, Konstantinides S. [Diagnosis, therapy and secondary prophylaxis of acute pulmonary embolism. Presentation of and commentary on the new ESC 2008 guidelines]. Anaesthesist 2009; 58:1048-54. [PMID: 19823784 DOI: 10.1007/s00101-009-1616-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Acute venous thromboembolism is a common cardiovascular emergency. Acute pulmonary embolism (PE) is present in one third of these patients. With an average lethality rate of 11% within the first two weeks following diagnosis, approximately 40,000 patients in Germany die annually as a result of PE; therefore, their diagnosis and therapy is of particular importance. For this reason, the European Society of Cardiology published guidelines on diagnosis and therapy in 2000. The current article presents and discusses the points as updated and extended in the 2008 version of the guidelines, including: (1) initial risk stratification--when PE is already suspected; (2) diagnostic procedures and algorithms; (3) further risk stratification; (4) therapeutic strategies in the acute phase; (5) further management and (6) long-term anticoagulation and secondary prophylaxis.
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Affiliation(s)
- A Walther
- Klinik für Anaesthesiologie, Universitätsklinikum Heidelberg, Heidelberg
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1171
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Deitelzweig SB, Sasahara A, Michota F, McKean SC, Jacobson A. Guidelines-based use of thromboprophylaxis. J Hosp Med 2009; 4:S8-S15. [PMID: 19830847 DOI: 10.1002/jhm.596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Steven B Deitelzweig
- Department of Hospital Medicine, Ochsner Health System, New Orleans, LA 70121, USA.
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1172
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Sasahara A, Michota F, McKean SC, Deitelzweig SB, Jacobson A. Optimizing management of venous thromboembolism: diagnosis, treatment, and secondary prevention. J Hosp Med 2009; 4:S16-23. [PMID: 19830848 DOI: 10.1002/jhm.586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Arthur Sasahara
- Cardiovascular Division, Brigham & Women's Hospital, Boston, MA 02461-1154, USA.
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1173
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Imberti D, Di Nisio M, Donati MB, Falanga A, Ghirarduzzi A, Guarneri D, Piovella F, Santoro RC, Baldini E, Zampogna S. Treatment of venous thromboembolism in patients with cancer: Guidelines of the Italian Society for Haemostasis and Thrombosis (SISET). Thromb Res 2009; 124:e32-40. [PMID: 19744700 DOI: 10.1016/j.thromres.2009.08.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Revised: 07/31/2009] [Accepted: 08/04/2009] [Indexed: 02/05/2023]
Abstract
BACKGROUND The treatment of venous thromboembolism (VTE) in cancer patients remains controversial. PURPOSE The Italian Society for Thrombosis and Haemostasis (SISET) commissioned a project to develop clinical practice guidelines for the therapy of VTE in patients with malignancies. METHODS Key questions about the treatment of VTE in patients with malignancies were formulated by a multidisciplinary working group consisting of experts in clinical medicine and research. After a systematic review and discussion of the literature, recommendations were formulated and graded according to the supporting evidence. For those questions for which the literature search did not yield any definitive answer (absence of evidence evidence of low quality, and contradictory evidence), a formal consensus method was used to issue clinical recommendations. RESULTS The results of the available literature on VTE treatment in cancer patients were reviewed and clinical recommendations were drafted. CONCLUSION We describe the results of a systematic literature review and an explicit approach to consensus techniques which resulted in recommendations for the key therapeutic issues in cancer patients with VTE.
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1174
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Wang C, Zhai Z, Yang Y, Wu Q, Cheng Z, Liang L, Dai H, Huang K, Lu W, Zhang Z, Cheng X, Shen YH. Efficacy and safety of low dose recombinant tissue-type plasminogen activator for the treatment of acute pulmonary thromboembolism: a randomized, multicenter, controlled trial. Chest 2009; 137:254-62. [PMID: 19741062 PMCID: PMC7126994 DOI: 10.1378/chest.09-0765] [Citation(s) in RCA: 181] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Optimal dosing of the recombinant tissue-type plasminogen activator (rt-PA) is important in treating pulmonary thromboembolism (PTE). The aim of this study was to compare the efficacy and safety of a 50 mg/2 h rt-PA regimen with a 100 mg/2 h rt-PA regimen in patients with acute PTE. Methods A prospective, randomized, multicenter trial was conducted in which 118 patients with acute PTE and either hemodynamic instability or massive pulmonary artery obstruction were randomly assigned to receive a treatment regiment of either rt-PA at 50 mg/2 h (n = 65) or 100 mg/2 h (n = 53). The efficacy was determined by observing the improvements of right ventricular dysfunctions (RVDs) on echocardiograms, lung perfusion defects on ventilation perfusion lung scans, and pulmonary artery obstructions on CT angiograms. The adverse events, including death, bleeding, and PTE recurrence, were also evaluated. Results Progressive improvements in RVDs, lung perfusion defects, and pulmonary artery obstructions were found to be similarly significant in both treatment groups. This is true for patients with either hemodynamic instability or massive pulmonary artery obstruction. Three (6%) patients in the rt-PA 100 mg/2 h group and one (2%) in the rt-PA 50 mg/2 h group died as the result of either PTE or bleeding. Importantly, the 50 mg/2 h rt-PA regimen resulted in less bleeding tendency than the 100 mg/2 h regimen (3% vs 10%), especially in patients with a body weight < 65 kg (14.8% vs 41.2%, P = .049). No fatal recurrent PTE was found in either group. Conclusions Compared with the 100 mg/2 h regimen, the 50 mg/2 h rt-PA regimen exhibits similar efficacy and perhaps better safety in patients with acute PTE. These findings support the notion that optimizing rt-PA dosing is worthwhile when treating patients with PTE. Trial registration clinicaltrials.gov; Identifier: NCT00781378
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Affiliation(s)
- Chen Wang
- Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, Republic of China
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1175
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Burnside PR, Green E, Kline JA. Indirect computed tomography venography: a report of vascular opacification. Emerg Radiol 2009; 17:195-201. [DOI: 10.1007/s10140-009-0831-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Accepted: 08/12/2009] [Indexed: 10/20/2022]
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1176
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1177
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Current World Literature. Curr Opin Pulm Med 2009; 15:521-7. [DOI: 10.1097/mcp.0b013e3283304c7b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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1178
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Mos ICM, Klok FA, Kroft LJM, DE Roos A, Dekkers OM, Huisman MV. Safety of ruling out acute pulmonary embolism by normal computed tomography pulmonary angiography in patients with an indication for computed tomography: systematic review and meta-analysis. J Thromb Haemost 2009; 7:1491-8. [PMID: 19552684 DOI: 10.1111/j.1538-7836.2009.03518.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Several outcome studies have ruled out acute pulmonary embolism (PE) by normal computed tomography pulmonary angiography (CTPA). We performed a meta-analysis in order to determine the safety of this strategy in a specific group of patients with a strict indication for CTPA, that is, 'likely' or 'high' clinical probability for PE, an elevated D-dimer concentration, or both. METHODS Studies that ruled out PE by normal CTPA, with or without subsequent normal bilateral compression ultrasonography (CUS), in patients with a strict indication for CTPA, were searched for in Medline, EMBASE, Web of Science and the Cochrane dataset. The primary endpoint was the occurrence of (fatal) venous thromboembolism (VTE) in a 3-month follow-up period. RESULTS Three studies were identified that excluded PE by CTPA alone (2020 patients), and three studies that performed additional CUS of the legs after normal CTPA (1069 patients). The pooled incidence of VTE at 3 months was 1.2% [95% confidence interval (CI) 0.8-1.8] based on a normal CTPA result as a sole test, and 1.1% (95% CI 0.6-2.0) based on normal CTPA and negative CUS findings, resulting in negative predictive values of 98.8% (95% CI 98.2-99.2) and 98.9% (95% CI 98.0-99.4), respectively. This compares favorably with the VTE failure rate after normal pulmonary angiography (1.7%, 95% CI 1.0-2.7). The risk of fatal PE did not differ between the diagnostic strategies (0.6% vs. 0.5%). CONCLUSION A normal CTPA result alone can safely exclude PE in all patients in whom CTPA is required to rule out this disease. There is no need for additional ultrasonography to rule out VTE in these patients.
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Affiliation(s)
- I C M Mos
- Section of Vascular Medicine, Department of General Internal Medicine--Endocrinology, Leiden, The Netherlands
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1179
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Galiè N, Hoeper MM, Humbert M, Torbicki A, Vachiery JL, Barbera JA, Beghetti M, Corris P, Gaine S, Gibbs JS, Gomez-Sanchez MA, Jondeau G, Klepetko W, Opitz C, Peacock A, Rubin L, Zellweger M, Simonneau G. Guidelines for the diagnosis and treatment of pulmonary hypertension: the Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS), endorsed by the International Society of Heart and Lung Transplantation (ISHLT). Eur Heart J 2009; 30:2493-537. [PMID: 19713419 DOI: 10.1093/eurheartj/ehp297] [Citation(s) in RCA: 2211] [Impact Index Per Article: 147.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nazzareno Galiè
- Institute of Cardiology, Bologna University Hospital, Via Massarenti, 9, 40138 Bologna, Italy.
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1180
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Abstract
PURPOSE OF REVIEW To emphasize the importance and clinical implications of right ventricular function assessment in many situations encountered by intensivists and to explain in practical terms how to perform such an assessment at the bedside. RECENT FINDINGS Assessment of right ventricular function requires a full understanding of the physiology of the right ventricle. The right ventricle, unlike the left ventricle, is sensitive to acute increases in its afterload. The right ventricle is usually dilated when its failure is the cause of shock. Three possible causes of right ventricular failure must be evaluated: decrease in contractility, pressure overload and volume overload. Many devices are available to assess right ventricular performance, but they are not equal in terms of accuracy and invasiveness. Although noncontinuous, echocardiography is probably the best device and this technique can also be employed by nonexpert intensivists. Two main signs must be sought: right ventricular dilatation and paradoxical septal motion. SUMMARY Assessment of right ventricular function in the ICU is crucial in many situations because right ventricular failure may be responsible for, or participate in, shock in pulmonary embolism, acute respiratory distress syndrome and septic shock. The best method is echocardiography, which is noninvasive and accurate.
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1181
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Ahmad A, Subkovas E, Ryan J. Pulmonary embolism presenting as non-ST elevation myocardial infarction: a case report. CASES JOURNAL 2009; 2:6328. [PMID: 19918576 PMCID: PMC2769286 DOI: 10.4076/1757-1626-2-6328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2009] [Accepted: 07/24/2009] [Indexed: 11/12/2022]
Abstract
We describe a case which highlights the difficulties in diagnosing pulmonary embolism as it can mimic other conditions. In a patient with chest pain with raised troponin, a diagnosis of pulmonary embolism should also be considered as well if the clinical picture does not fit with myocardial infarction. Otherwise, the diagnosis of pulmonary embolism can be easily missed and patients may not receive appropriate treatment resulting in increased mortality.
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Affiliation(s)
- Amir Ahmad
- Department of Cardiology, Glan Clwyd HospitalBodelwyddan Street, Rhyl, North Wales, LL18 5UJUK
| | - Eduardas Subkovas
- Department of Cardiology, Glan Clwyd HospitalBodelwyddan Street, Rhyl, North Wales, LL18 5UJUK
| | - Jean Ryan
- Library, Glan Clwyd HospitalBodelwyddan Street, Rhyl, North Wales, LL18 5UJUK
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1182
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Van Beek EJ, Elliot CA, Kiely DG. Diagnosis and initial treatment of patients with suspected pulmonary thromboembolism. ACTA ACUST UNITED AC 2009. [DOI: 10.1093/bjaceaccp/mkp016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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1183
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Squizzato A, Moja L, Gensini GF, Gusinu R, Conti AA. Is thrombolysis for intermediate-risk pulmonary embolism beneficial? The case of Emeritus Professor Crow. Intern Emerg Med 2009; 4:339-41. [PMID: 19506998 DOI: 10.1007/s11739-009-0267-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Alessandro Squizzato
- Department of Clinical Medicine, U.O. Medicina I, Ospedale di Circolo, University of Insubria, Viale Borri 57, 21100 Varese, Italy.
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1184
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Focused Echocardiography in Life Support: The Subcostal Window : What the Surgeon Should Know for Critical Care Applications. Eur J Trauma Emerg Surg 2009; 35:347. [PMID: 26815049 DOI: 10.1007/s00068-009-9093-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2009] [Accepted: 06/16/2009] [Indexed: 10/20/2022]
Abstract
CONTEXT Focused echocardiography evaluation in life support (FEEL) for emergency and critical caremedicine is an innovative approach to introducing limited-in-scope echocardiography in a timely fashion into periresuscitation care. FEEL is an advanced life support-conformed concept and a simple procedure that can be readily used in shock roomor pre-hospital scenarios as an extension of focused abdominal sonography for trauma (FAST). The subcostal window plays a pivotal role in this context, because it can easilybe applied inthesupine position, and is usually better than other windows in patients with mechanical ventilation or during resuscitation maneuvers. Most information can be obtained at a glance. AIM As the FAST exam was not developed for implementation in resuscitation or cardiac arrest procedures, herewedescribe an accurate and easymethod that allows non-cardiologists to add FEEL to the FAST exam. As a result, it conforms to actual resuscitation guidelines. To perform the FEEL procedure and the subcostal window, a specific training seems to bemandatory. The aim of this paper is to set special emphasis on the use of the subcostal window.
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1185
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Masotti L, Righini M, Vuilleumier N, Antonelli F, Landini G, Cappelli R, Ray P. Prognostic stratification of acute pulmonary embolism: focus on clinical aspects, imaging, and biomarkers. Vasc Health Risk Manag 2009; 5:567-75. [PMID: 19649307 PMCID: PMC2710971 DOI: 10.2147/vhrm.s4861] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Pulmonary embolism (PE) represents a common disease in emergency medicine and guidelines for diagnosis and treatment have had wide diffusion. However, PE morbidity and mortality remain high, especially when associated to hemodynamic instability or right ventricular dysfunction. Prognostic stratification to identify high risk patients needing to receive more aggressive pharmacological and closer monitoring is of utmost importance. Modern guidelines for management of acute PE are based on risk stratification using either clinical, radiological, or laboratory findings. This article reviews the modern treatment of acute PE, which is customized upon patient prognosis. Accordingly the current risk stratification tools described in the literature such as clinical scores, echocardiography, helical computer tomography, and biomarkers will be reviewed.
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Affiliation(s)
- Luca Masotti
- UO Medicina Interna, Ospedale di Cecina, Via Montanara, Località Ladronaia, 57023 Cecina (Li), Italy.
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1186
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Bernhard M, Busch CJ, Hainer C, Wente MN, Scheuren K, Rauch H, Martin E, Weigand MA. Is a 4 days transoesophageal training course sufficient to diagnose shock related pathologies? Resuscitation 2009; 80:1019-24. [PMID: 19581038 DOI: 10.1016/j.resuscitation.2009.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2008] [Revised: 04/30/2009] [Accepted: 05/06/2009] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Echocardiography is a useful tool in patients suffering from shock of unknown origin to evaluate cardiac function and volume status in order to decide on further treatment. The aim of the study was to evaluate how well participants could identify function, preload and regional wall motion abnormalities after attending a 4-day transoesophageal echocardiography (TOE) seminar. METHODS In this prospective educational trial, participants of six TOE seminars from 2005 to 2006 were evaluated. On the basis of seven echocardiographic studies, evaluations by participants concerning cardiac function, preload and regional wall motion were analyzed. Moreover, specific causes of undifferentiated hypotension were to be judged in three cases by the participants. RESULTS A total of 115 participants of the TOE seminars from 2005 to 2006 were evaluated. Correct sectional plane was recognized by more than 76% of the participants. Left ventricular function, preload, and regional wall abnormalities were assessed correctly by the participants in 98%, 96%, and 84%, respectively. Moreover, more than 70% of the participants recognized the correct cause of hemodynamic instability. CONCLUSION The results of the investigation show that participants of a 4-day TOE seminar can interpret left ventricular function, preload and regional wall motion abnormalities correctly at a very high rate. TOE seminars seem to be effective in teaching basic theoretical knowledge of TOE.
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Affiliation(s)
- Michael Bernhard
- Department of Anaesthesiology, University Hospital of Heidelberg, D-69120 Heidelberg, Germany
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1187
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Abstract
Risk stratification tools that accurately quantify the prognosis of patients with pulmonary embolism (PE) may be useful in guiding medical decision making. Prospective studies demonstrated that clinical factors, echocardiographic right ventricular dysfunction, and cardiac biomarkers (troponins, brain natriuretic peptides) are independent predictors of short-term mortality in patients with PE. The presence of systemic hypotension or shock carries the highest risk of death, and thrombolysis is usually indicated. Among hemodynamically stable patients, clinical prognostic models, echocardiography, and biomarkers accurately identify low-risk patients with PE who are potential candidates for less costly outpatient care. However, the practical use of these prognostic measures is currently limited by the lack of studies demonstrating a positive impact on patient care. The benefit of risk stratification strategies based on clinical prognostic models, echocardiography, and cardiac biomarkers should be demonstrated in prospective studies before their implementation as decision aid to guide initial treatment can be recommended.
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Affiliation(s)
- D Aujesky
- Division of General Internal Medicine, University of Lausanne, Lausanne, Switzerland.
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1188
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van Beek EJR. Should lung scan be abandoned for pulmonary embolism diagnosis in the age of multislice spiral CT? Yes. Intern Emerg Med 2009; 4:189-91. [PMID: 19377852 DOI: 10.1007/s11739-009-0252-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2009] [Accepted: 03/24/2009] [Indexed: 11/26/2022]
Affiliation(s)
- Edwin J R van Beek
- Department of Radiology, Carver College of Medicine, C-751 GH, 200 Hawkins Drive, Iowa City, IA 52242-1077, USA.
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1189
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Chronic Obstructive Pulmonary Disease in Patients With Acute Symptomatic Pulmonary Embolism. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/s1579-2129(09)72419-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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1190
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Bova C, Pesavento R, Marchiori A, Palla A, Enea I, Pengo V, Visonà A, Noto A, Prandoni P. Risk stratification and outcomes in hemodynamically stable patients with acute pulmonary embolism: a prospective, multicentre, cohort study with three months of follow-up. J Thromb Haemost 2009; 7:938-44. [PMID: 19302447 DOI: 10.1111/j.1538-7836.2009.03345.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND The role of risk stratification in normotensive patients with acute pulmonary embolism (PE) is still unclear. OBJECTIVES We evaluated, in these patients, the usefulness of six prognostic markers for predicting in-hospital adverse events related to PE and 3-month mortality. PATIENTS/METHODS Two hundred and one consecutive patients with confirmed acute PE and normal blood pressure, who were administered conventional anticoagulation, were recruited in a multicentre prospective cohort study with 3 months of follow-up. At baseline, they received a comprehensive risk-evaluation including echocardiographic assessment of right ventricular dysfunction, determination of troponin I, brain natriuretic peptide and D-dimer, arterial blood gas analysis and a clinical score. Primary outcome of the study was PE-related in-hospital death or clinical deterioration. Secondary outcomes were in-hospital and 3-month all-cause mortality. RESULTS The primary outcome occurred in one patient (0.5%), who died from PE during hospitalization. The in-hospital and 3-month all-cause mortality were 2% and 9%, respectively. None of the prognostic markers was predictive of the primary outcome. Clinical score, troponin I and hypoxemia predicted in-hospital all-cause mortality (P = 0.02, 0.01 and < 0.01, respectively). Clinical score (HR, 4.7; 95% CI, 1.9-12.0), D-dimer (4.8; 1.4-16.3), hypoxemia (5.7; 2.1-15.1) and troponin I (7.5; 2.5-22.7) were predictors of 3-month all-cause mortality on univariate analysis. On multivariate analysis clinical score and troponin I remained independently predictive. CONCLUSIONS We did not find prognostic markers useful as predictors of in-hospital PE-related adverse events. Clinical score, troponin I and hypoxemia predicted in-hospital all-cause mortality. Clinical score and troponin I independently predicted 3-month all-cause mortality.
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Affiliation(s)
- C Bova
- Department of Internal Medicine, Azienda ospedaliera, Cosenza, Italy.
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1191
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Endothelin is not elevated in acute pulmonary embolism. Thromb Res 2009; 124:157-60. [DOI: 10.1016/j.thromres.2008.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Revised: 10/30/2008] [Accepted: 11/10/2008] [Indexed: 11/21/2022]
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1192
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Chechi T, Vecchio S, Spaziani G, Giuliani G, Giannotti F, Arcangeli C, Rubboli A, Margheri M. Rheolytic thrombectomy in patients with massive and submassive acute pulmonary embolism. Catheter Cardiovasc Interv 2009; 73:506-13. [PMID: 19235240 DOI: 10.1002/ccd.21858] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To appraise the impact of AngioJet rheolytic thrombectomy (RT) on angiographic and clinical endpoints in patients with acute pulmonary embolism (PE). BACKGROUND The management of patients with acute PE and hemodynamic compromise, based mainly on anticoagulant and thrombolytic therapies, is challenging and still suboptimal in many patients. In such a setting, mechanical removal of thrombus from pulmonary circulation holds the promise of significant clinical benefits, albeit remains under debate. METHODS We retrospectively report on 51 patients referred to our catheterization laboratory and treated with AngioJet RT. Patients were classified according to the degree of hemodynamic compromise (shock, hypotension, and right ventricular dysfunction) to explore thoroughly the degree of angiographic pulmonary involvement (angiographic massive PE was defined as the presence of a Miller index >or= 17) and the impact on angiographic (obstruction, perfusion, and Miller indexes) and clinical (all-cause death, recurrence of PE, bleeding, renal failure, and severe thrombocytopenia) endpoints of AngioJet RT. RESULTS Angiographic massive PE was present in all patients with shock, whereas patients with right ventricular dysfunction and hypotension showed a similar substantial pulmonary vascular bed involvement. Technical success was obtained in 92.2% of patients, with a significant improvement in obstruction, perfusion and Miller indexes in each subgroup (all P < 0.0001). Four patients reported major bleedings and eight (15.7%) died in-hospital. Laboratory experience was significantly associated to a lower rate of major bleedings. All survivors were alive at long-term follow-up (35.5 +/- 21.7 months) except three who expired due to cancer and acute myocardial infarction. CONCLUSIONS In experienced hands AngioJet RT can be operated safely and effectively in most patients with acute PE, either massive or submassive, and substantial involvement of pulmonary vascular bed.
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Affiliation(s)
- Tania Chechi
- Division of Cardiology, Cardiologia e Cardiologia Invasiva 2, A.O.U. Careggi, Florence, Italy
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1193
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Fernández C, Jiménez D, De Miguel J, Martí D, Díaz G, Sueiro A. [Chronic obstructive pulmonary disease in patients with acute symptomatic pulmonary embolism]. Arch Bronconeumol 2009; 45:286-90. [PMID: 19394747 DOI: 10.1016/j.arbres.2008.10.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 10/15/2008] [Accepted: 10/22/2008] [Indexed: 11/17/2022]
Abstract
BACKGROUND The diagnosis of pulmonary embolism (PE) is often complicated by the presence of chronic obstructive pulmonary disease (COPD). Some studies have suggested that patients with PE and concomitant COPD have a worse prognosis than patients without COPD. PATIENTS AND METHODS Outpatients diagnosed with acute symptomatic PE at a university tertiary care hospital were prospectively included in the study. Clinical characteristics, time between onset of symptoms and diagnosis, and outcome were analyzed according to presence or absence of COPD. The primary endpoint was all-cause deaths at 3 months. RESULTS Of 882 patients with a confirmed diagnosis of acute symptomatic PE, 8% (95% confidence interval [CI], 6%-9%) had COPD. Patients with COPD were significantly more likely to have a delay in diagnosis of more than 3 days and to have a low pretest probability of pulmonary embolism according to a standardized clinical score. The total number of deaths during 3 months of follow-up was 128 (14%; 95% CI, 12%-17%). Factors significantly associated with mortality from all causes were a history of cancer or immobilization, systolic blood pressure less than 100mm Hg, and arterial oxyhemoglobin saturation less than 90%. COPD was significantly associated with PE-related death in the logistic regression analysis (relative risk, 2.2; 95% CI, 1.0-5.1). CONCLUSIONS Patients with COPD and PE more often have a lower pretest probability and a longer delay in diagnosis of PE. COPD is significantly associated with PE-related death in the 3 months following diagnosis.
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1194
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Masotti L, Mannucci A, Antonelli F, Maurini V, Testa R, Marchetti S, Landini G, Cappelli R. The Risk-based Treatment of Acute Pulmonary Embolism. J Clin Med Res 2009; 1:1-7. [PMID: 22505957 PMCID: PMC3318861 DOI: 10.4021/jocmr2009.03.1229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2009] [Indexed: 01/07/2023] Open
Abstract
UNLABELLED Risk evaluation and prognostic stratification based upon clinical and radiological findings and new cardiac biomarkers, such as natriuretic peptides (NP) and troponins, represent key points in modern management of acute pulmonary embolism (PE). Literature evidence shows that normotensive PE with right heart dysfunction (RHD), defined as submassive PE, has poorer prognosis when compared to normotensive PE without RHD, defined as non-massive PE; thus whether submassive PE should be managed more aggressively and with closer monitoring represents the crucial question about acute PE treatment. Although the answer is yet unclear, the most recent guidelines address to thrombolysis as treatment choice in selected high risk patients with submassive PE. Guidelines also clarify the indications for unfractioned and low molecular weight heparins and fondaparinux. Therefore, in the present article, the authors focus on modern risk-based therapeutic guidelines of acute PE. KEYWORDS Pulmonary embolism; Treatment; Prognosis; Biomarkers; Chocardiography; Hemodynamic; Guidelines.
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1195
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Jondeau G, Detaint D, Arnoult F, Phan G, Morgan C, Mercadier JJ, Aumont MC. Acute heart failure: How to evaluate left ventricular filling pressure in practice? Arch Cardiovasc Dis 2009; 102:319-26. [PMID: 19427609 DOI: 10.1016/j.acvd.2009.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Revised: 01/13/2009] [Accepted: 01/13/2009] [Indexed: 10/21/2022]
Abstract
Heart failure is one of the most frequent reasons for hospitalization due to a cardiac event. In most instances, the main difficulty is how to accurately evaluate left ventricular filling pressure. It can be evaluated clinically, biologically and invasively. Although historically, invasive management has been the reference, it is being used less and less frequently and expertise in the technique is being lost. This paper discusses the strength and weaknesses of the different techniques for evaluating filling pressure in these patients, and the importance of this parameter for their optimal treatment.
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1196
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Stein PD, Sostman HD, Hull RD, Goodman LR, Leeper KV, Gottschalk A, Tapson VF, Woodard PK. Diagnosis of pulmonary embolism in the coronary care unit. Am J Cardiol 2009; 103:881-6. [PMID: 19268750 PMCID: PMC2717714 DOI: 10.1016/j.amjcard.2008.11.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2008] [Revised: 11/09/2008] [Accepted: 11/09/2008] [Indexed: 12/11/2022]
Abstract
The clinical diagnosis of pulmonary embolism (PE) is difficult in coronary care units (CCUs) because many findings of PE are similar to those of acute coronary syndromes and heart failure. Immobilization of only 1 or 2 days may predispose to PE. Heart failure and acute myocardial infarction add to the risk. Dyspnea may be absent or occur only with exertion. The onset of dyspnea may occur over seconds to days. Orthopnea occurs with PE as well as heart failure. When the clinical probability and results of objective testing are discordant, the posttest probability of PE may be neither sufficiently high nor sufficiently low to permit therapeutic decisions. Objective scoring systems for clinical assessment have not been developed for patients in a CCU. d-dimer is likely to be of little value for the exclusion of PE in CCUs, because elevations occur with heart failure, unstable angina, and myocardial infarction. Computed tomographic pulmonary angiography with venous phase imaging of the low pelvic and proximal leg veins (computed tomographic venography) is recommended for imaging. Scintigraphy in women aged <50 years with normal or nearly normal results on chest x-ray may be the preferred imaging test to reduce the risk for radiation. Echocardiography with leg ultrasonography is a rapidly obtainable combination of bedside tests that may be useful for young patients and patients in extremis. In conclusion, the choice of diagnostic test depends on the clinical probability of PE, the condition of the patient, the availability of diagnostic tests, the risks of iodinated contrast material, radiation exposure, and cost.
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Affiliation(s)
- Paul D Stein
- Department of Research, St Joseph Mercy Oakland Hospital, Pontiac, MI, USA.
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1197
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1198
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Affiliation(s)
- Stavros Konstantinides
- Department of Cardiology and Pulmonology, Georg August University of Göttingen, Göttingen, Germany.
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Andreotti F, Rio T, Lavorgna A. Body fat and cardiovascular risk: understanding the obesity paradox. Eur Heart J 2008; 30:752-4. [DOI: 10.1093/eurheartj/ehp081] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Goran KP. Thrombolysis during cardiopulmonary resuscitation should be addressed in guidelines for pulmonary embolism. Eur Heart J 2008; 29:3066-7; author reply 3067-8. [PMID: 18952615 DOI: 10.1093/eurheartj/ehn474] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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