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Song ZK, Cao H, Wu H, Wei Q, Tang M, Yang S, Liu Y, Qin L. Current status of rivaroxaban in elderly patients with pulmonary embolism (Review). Exp Ther Med 2020; 19:2817-2825. [PMID: 32256765 PMCID: PMC7086161 DOI: 10.3892/etm.2020.8559] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 01/22/2020] [Indexed: 01/14/2023] Open
Abstract
Acute pulmonary embolism (PE) occurs with a high incidence rate in elderly patients, demonstrating complex clinical manifestations, as well as a difficult anticoagulant treatment strategy. Currently, there is limited understanding of the selection criteria for anticoagulant treatment in elderly patients with PE. In fact, the vitamin K antagonist warfarin, a commonly prescribed anticoagulant, has multiple disadvantages, including a narrow therapeutic range, unpredictable pharmacokinetics, multiple food and drug interactions and genetic polymorphisms resulting in poor response to this therapy; therefore, routine laboratory monitoring is required. Most elderly patients with PE fail to adhere to the treatment regimen or even discontinue it, and clinicians are equally hesitant to initiate oral anticoagulants in elderly patients with PE. This leads to a dilemma regarding the use of anticoagulation therapies and a worse prognosis for the patients. Rivaroxaban, a direct Xa factor inhibitor, has demonstrated considerable practical and clinical advantages, exhibits fast-start action pharmacokinetic and pharmacodynamic characteristics, and has an enhanced predictable anticoagulant effect with fewer drug-drug interactions. Based on randomized controlled trials and real-world clinical practice, rivaroxaban has also been recognized as a safe and effective anticoagulant, and these advantages have improved the therapeutic compliance of elderly patients with PE. Thus, this review focused on the current status of rivaroxaban treatment for elderly patients with PE, and described its significance in changing the current anticoagulation treatment regimens for patients. It is expected that rivaroxaban will become a good choice for the treatment of PE in elderly patients.
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Affiliation(s)
- Zi-Kai Song
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Hongyan Cao
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Haidi Wu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Qi Wei
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Minglong Tang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Shuo Yang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Yang Liu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Ling Qin
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
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152
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Mazur ES, Mazur VV, Rabinovich RM, Myasnikov KS, Bachurina MA. [On the Causes of Angina Pectoris in Patients With Pulmonary Embolism]. KARDIOLOGIYA 2020; 60:28-34. [PMID: 32245352 DOI: 10.18087/cardio.2020.1.n729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/19/2019] [Accepted: 10/29/2019] [Indexed: 11/18/2022]
Abstract
Objective Compare the distance between the pulmonary artery (PA) and the left coronary artery (LCA) using pulmonary angiography and the rate of detection of the signs of left ventricular myocardial ischemiain the first electrocardiogram (ECG) in pulmonary embolism (PE) patients with or without angina to detect possible causes of angina pectoris.Material and Methods Measurement of the minimum distance between the PA and LCA in multislice spiral computed tomography and analysis of the first ECG were performed in 55 PE patients. 15 (27.3%) patients had angina pectoris at the onset of the disease.Results Angina pectoris was observed in 14 (93.3%) of 15 patients with the distance between the PA andLCA less than 4.3 mm, and in one (2.5%) of 40 patients with the distance between these vessels equalto or exceeding the specified value (p<0.001). In the first ECG, the ST elevation in the aVR lead wasdetected in 10 (66.7%) patients with angina pectoris, and only in 3 (7.5%) patients without anginapectoris (p<0.001).Conclusions The findings suggest that angina pectoris in acute pulmonary embolism may be caused by compression of the LCA by the dilated PA.
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153
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Aday AW, Beckman JA. Pulmonary Embolism and Unfractionated Heparin: Time to End the Roller Coaster Ride. Acad Emerg Med 2020; 27:176-178. [PMID: 31625222 PMCID: PMC7018537 DOI: 10.1111/acem.13871] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Aaron W. Aday
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joshua A. Beckman
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Spampinato MD, Bucci S, Migliano MT, Ricciardelli MA, Strada A, Rossin F, Rotini C, Manfredini R, De Giorgio R, Ursini F. Assessing Pretest Clinical Risk of Pulmonary Thromboembolism in the Emergency Department: Proposal of a Simple Modification to the Wells' Score. J Emerg Med 2020; 58:385-390. [PMID: 31964543 DOI: 10.1016/j.jemermed.2019.11.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 11/18/2019] [Accepted: 11/23/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Clinical scores have been proposed to stratify the risk of pulmonary thromboembolism (PTE), although this approach suffers a low specificity and the unavoidable need for computed tomography pulmonary angiography (CTPA) scans. OBJECTIVE Our study aimed to investigate a simple modification to the already validated Wells' score to improve its diagnostic accuracy in the emergency department (ED). METHODS We retrospectively reviewed all CTPA scans performed in the ED setting to rule out PTE over a 1-year (2017) period. Clinical variables potentially associated with PTE were assessed to improve diagnostic accuracy of the Wells' score, thus introducing a modified Wells' score (mWells). RESULTS Four thousand four hundred thirteen CTPAs were identified, of which 504 were for suspected PTE. The prevalence of PTE was 23.9%. Among clinical data, only peripheral capillary oxygen saturation was consistently correlated with PTE at univariate (odds ratio 2.75 [95% confidence interval 1.61-4.73]) and multivariate (odds ratio 3.78 [95% confidence interval 2.13-6.72]) logistic regression analysis. The mWells' score had a higher area under the receiver operating characteristic curve compared with the original Wells' score: 0.71 (95% confidence interval 0.67-0.75) vs. 0.65 (95% confidence interval 0.61-0.69) (p < .01) and improved diagnostic accuracy. CONCLUSIONS Current clinical stratification tools for PTE are characterized by low specificity, leading to an overuse of CTPA. mWells', rather than Wells', score showed a better predictive performance of PTE detection. Our results suggest that current diagnostic pathway for PTE may be improved by simple adjustments (i.e., mWells') of clinical prediction scores.
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Affiliation(s)
| | - Simone Bucci
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | | | - Andrea Strada
- Emergency Medicine, St. Anna Hospital, Ferrara, Italy
| | - Federica Rossin
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Carlotta Rotini
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | | | - Francesco Ursini
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
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155
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Renal dysfunction and long-term clinical outcomes in patients with venous thromboembolism: From the COMMAND VTE Registry. Thromb Res 2020; 187:39-47. [PMID: 31951937 DOI: 10.1016/j.thromres.2020.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/29/2019] [Accepted: 01/08/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Patients with renal dysfunction are at high risk for developing venous thromboembolism (VTE). However, the impact of renal dysfunction on recurrent VTE remains to be clarified. We assessed the relationship between estimated glomerular filtration rate (eGFR) at diagnosis and long-term clinical outcomes in VTE patients. MATERIALS AND METHODS The COMMAND VTE Registry is a multicenter registry enrolling consecutive patients with acute symptomatic VTE among 29 centers in Japan between January 2010 and August 2014. Patients with available creatinine values (N = 2829) were divided into the reference eGFR (≥60 mL/min/1.73 m2) group (N = 1760) and the low eGFR (<60 mL/min/1.73 m2) group (N = 1069). The low eGFR group was further subdivided into the moderately low eGFR (30-59 mL/min/1.73 m2) group (N = 898) and very low eGFR (<30 mL/min/1.73 m2) group (N = 171). RESULTS The low eGFR group was independently associated with the increased risk for recurrent VTE (adjusted HR 1.55, 95%CI 1.15-2.08). When the low eGFR group was subdivided into the moderately low and very low eGFR groups, the risk for recurrent VTE increased with decreasing eGFR (adjusted HR 1.43, 95%CI 1.04-1.95, and adjusted HR 2.54, 95%CI 1.42-4.28). The risk for major bleeding was higher in the very low eGFR group, but not in the moderately low eGFR group (adjusted HR 1.70, 95%CI 1.06-2.61, and adjusted HR 0.85, 95%CI 0.73-1.28). CONCLUSIONS Renal dysfunction measured by eGFR was associated with an increased risk for recurrent VTE, which was more prominent in severe renal dysfunction. Severe renal dysfunction was also associated with a higher risk for major bleeding.
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156
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Yoshikawa Y, Yamashita Y, Morimoto T, Mabuchi H, Amano H, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Izumi T, Tada T, Chen PM, Murata K, Tsuyuki Y, Saga S, Nishimoto Y, Sasa T, Sakamoto J, Kinoshita M, Togi K, Takabayashi K, Shiomi H, Kato T, Makiyama T, Ono K, Murakami T, Kimura T. Effect of Statins on Recurrent Venous Thromboembolism (from the COMMAND VTE Registry). Am J Cardiol 2020; 125:189-197. [PMID: 31744599 DOI: 10.1016/j.amjcard.2019.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 11/16/2022]
Abstract
Statins, which are considered as essential for primary and secondary prevention of atherosclerotic diseases, were also reported to reduce first venous thromboembolism (VTE). However, the effect of statins on VTE recurrence remains conflicting. We aimed to examine the association between statin use and VTE recurrence in a large observational study in Japan. The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic VTE in 29 centers in Japan between January 2010 and August 2014. In the current study, the entire cohort was divided into statin group (N = 437) and no-statin group (N = 2590) according to the status of statin use at baseline. The statin group as compared with the no-statin group was older (statin group 71.2 vs no-statin group 66.5 years, p <0.001), included more women (67% vs 60%, p = 0.008), and less frequently had active cancer (12% vs 25%, p <0.001). There was no significant difference in the clinical presentation of VTE (pulmonary embolism, 58% vs 56%, p = 0.44). The cumulative 3-year incidence of recurrent VTE was significantly lower in the statin group than the no-statin group (3.8% vs 8.8%, p <0.001). After adjusting for confounders including active cancer, statin use was associated with significantly lower risk for recurrent VTE (Hazard ratio 0.49, 95% confidence interval 0.29 to 0.78, p = 0.002). The results were consistent in a sensitivity sub-group analysis with and without active cancer. In conclusion, statin use was associated with significantly lower risk for the recurrent VTE in patients with VTE.
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Affiliation(s)
- Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | - Hidewo Amano
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Seiichi Hiramori
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Toshiaki Izumi
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute Kitano Hospital, Osaka, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yoshiaki Tsuyuki
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Syunsuke Saga
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Jiro Sakamoto
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | | | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Ikoma, Japan
| | | | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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157
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Çinar T, Hayıroğlu Mİ, Oz A. Successful treatment of pulmonary embolism in a patient with polycythemia vera by rheolytic thrombectomy. J Cardiovasc Thorac Res 2019; 11:325-327. [PMID: 31824617 PMCID: PMC6891036 DOI: 10.15171/jcvtr.2019.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 03/11/2019] [Indexed: 11/09/2022] Open
Abstract
Acute pulmonary embolism (APE) may lead to life-threatening conditions such as cardiac death and congestive heart failure. Thus, a proper diagnosis and management play a crucial role to prevent such complications. Moreover, APE is a rare clinical onset of chronic myeloproliferative disease. We herein describe a 67-year-old patient with polycythemia vera presented to our cardiology clinic with pulmonary embolism despite the fact that an intense antiplatelet treatment started secondary to acute myocardial infarction prior. Because the patient had hypotension and head trauma, rheolytic thrombectomy was performed successfully to restore adequate pulmonary perfusion.
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Affiliation(s)
- Tufan Çinar
- Health Sciences University, Sultan Abdülhamid Han Training and Research Hospital, Department of Cardiology, Istanbul, Turkey
| | - Mert İlker Hayıroğlu
- Health Sciences University, Sultan Abdülhamid Han Training and Research Hospital, Department of Cardiology, Istanbul, Turkey
| | - Ahmet Oz
- Health Sciences University, Sultan Abdülhamid Han Training and Research Hospital, Department of Cardiology, Istanbul, Turkey
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158
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Reichelt A, Meinel FG, Wirth S, Weber MA, Bath K. [Sudden chest pain and lower abdominal pain : The usual suspects]. Radiologe 2019; 60:216-225. [PMID: 31820015 DOI: 10.1007/s00117-019-00618-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CLINICAL PROBLEM Sudden chest pain and sudden abdominal pain are among the most common reasons that lead patients to the emergency room. The heterogeneous field of possible, sometimes serious diagnoses requires a structured and rapid interdisciplinary clarification in order to be able to promptly provide patients with an adequate therapy. STANDARD RADIOLOGICAL PROCEDURES Knowing the "usual suspects" of sudden chest and abdominal pain enables the radiologist to quickly select the appropriate imaging method that allows a diagnosis to be made without delay. In addition to pain localization and character, age, gender, any previous illnesses and laboratory results are taken into account in the differential diagnosis. METHODICAL INNOVATION AND EVALUATION The technical state of computer tomography (CT) now ensures that most diagnoses can be clarified due to its excellent spatial and temporal resolution. In the abdomen, however, ultrasound should continue to be used at least for primary evaluation. Only if there is a further need for abdominal imaging afterwards is CT indicated for clarification. Magnetic resonance imaging is rarely used in the emergency setting of abdominal pain except to avoid radiation exposure in children or pregnant women. RECOMMENDATION FOR THE PRACTICE Knowledge of the usual diagnoses that cause sudden chest or abdominal pain, as well as knowledge of the appropriate examination procedures and classic radiological signs are essential to avoid errors and delays in the emergency diagnosis of sudden chest and abdominal pain.
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Affiliation(s)
- Angela Reichelt
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland.
| | - Felix G Meinel
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland
| | - Stefan Wirth
- Institut für Radiologie, Schnittbilddiagnostik, DONAUISAR Klinikum Deggendorf, Akademisches Lehrkrankenhaus der Medizinischen Hochschule Hannover, Perlasberger Str. 41, 94469, Deggendorf, Deutschland
| | - Marc-André Weber
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland
| | - Kristina Bath
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland
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159
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Pandor A, Horner D, Davis S, Goodacre S, Stevens JW, Clowes M, Hunt BJ, Nokes T, Keenan J, de Wit K. Different strategies for pharmacological thromboprophylaxis for lower-limb immobilisation after injury: systematic review and economic evaluation. Health Technol Assess 2019; 23:1-190. [PMID: 31851608 PMCID: PMC6936165 DOI: 10.3310/hta23630] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Thromboprophylaxis can reduce the risk of venous thromboembolism (VTE) during lower-limb immobilisation, but it is unclear whether or not this translates into meaningful health benefit, justifies the risk of bleeding or is cost-effective. Risk assessment models (RAMs) could select higher-risk individuals for thromboprophylaxis. OBJECTIVES To determine the clinical effectiveness and cost-effectiveness of different strategies for providing thromboprophylaxis to people with lower-limb immobilisation caused by injury and to identify priorities for future research. DATA SOURCES Ten electronic databases and research registers (MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Review of Effects, the Cochrane Central Register of Controlled Trials, Health Technology Assessment database, NHS Economic Evaluation Database, Science Citation Index Expanded, ClinicalTrials.gov and the International Clinical Trials Registry Platform) were searched from inception to May 2017, and this was supplemented by hand-searching reference lists and contacting experts in the field. REVIEW METHODS Systematic reviews were undertaken to determine the effectiveness of pharmacological thromboprophylaxis in lower-limb immobilisation and to identify any study of risk factors or RAMs for VTE in lower-limb immobilisation. Study quality was assessed using appropriate tools. A network meta-analysis was undertaken for each outcome in the effectiveness review and the results of risk-prediction studies were presented descriptively. A modified Delphi survey was undertaken to identify risk predictors supported by expert consensus. Decision-analytic modelling was used to estimate the incremental cost per quality-adjusted life-year (QALY) gained of different thromboprophylaxis strategies from the perspectives of the NHS and Personal Social Services. RESULTS Data from 6857 participants across 13 trials were included in the meta-analysis. Thromboprophylaxis with low-molecular-weight heparin reduced the risk of any VTE [odds ratio (OR) 0.52, 95% credible interval (CrI) 0.37 to 0.71], clinically detected deep-vein thrombosis (DVT) (OR 0.40, 95% CrI 0.12 to 0.99) and pulmonary embolism (PE) (OR 0.17, 95% CrI 0.01 to 0.88). Thromboprophylaxis with fondaparinux (Arixtra®, Aspen Pharma Trading Ltd, Dublin, Ireland) reduced the risk of any VTE (OR 0.13, 95% CrI 0.05 to 0.30) and clinically detected DVT (OR 0.10, 95% CrI 0.01 to 0.94), but the effect on PE was inconclusive (OR 0.47, 95% CrI 0.01 to 9.54). Estimates of the risk of major bleeding with thromboprophylaxis were inconclusive owing to the small numbers of events. Fifteen studies of risk factors were identified, but only age (ORs 1.05 to 3.48), and injury type were consistently associated with VTE. Six studies of RAMs were identified, but only two reported prognostic accuracy data for VTE, based on small numbers of patients. Expert consensus was achieved for 13 risk predictors in lower-limb immobilisation due to injury. Modelling showed that thromboprophylaxis for all is effective (0.015 QALY gain, 95% CrI 0.004 to 0.029 QALYs) with a cost-effectiveness of £13,524 per QALY, compared with thromboprophylaxis for none. If risk-based strategies are included, it is potentially more cost-effective to limit thromboprophylaxis to patients with a Leiden thrombosis risk in plaster (cast) [L-TRiP(cast)] score of ≥ 9 (£20,000 per QALY threshold) or ≥ 8 (£30,000 per QALY threshold). An optimal threshold on the L-TRiP(cast) receiver operating characteristic curve would have sensitivity of 84-89% and specificity of 46-55%. LIMITATIONS Estimates of RAM prognostic accuracy are based on weak evidence. People at risk of bleeding were excluded from trials and, by implication, from modelling. CONCLUSIONS Thromboprophylaxis for lower-limb immobilisation due to injury is clinically effective and cost-effective compared with no thromboprophylaxis. Risk-based thromboprophylaxis is potentially optimal but the prognostic accuracy of existing RAMs is uncertain. FUTURE WORK Research is required to determine whether or not an appropriate RAM can accurately select higher-risk patients for thromboprophylaxis. STUDY REGISTRATION This study is registered as PROSPERO CRD42017058688. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John W Stevens
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mark Clowes
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Beverley J Hunt
- Haemostasis Research Unit, King's College London, London, UK
| | - Tim Nokes
- Department of Haematology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jonathan Keenan
- Department of Haematology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Kerstin de Wit
- Department of Medicine, Hamilton General Hospital, Hamilton, ON, Canada
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160
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Fang MC, Fan D, Sung SH, Witt DM, Schmelzer JR, Williams MS, Yale SH, Baumgartner C, Go AS. Treatment and Outcomes of Acute Pulmonary Embolism and Deep Venous Thrombosis: The CVRN VTE Study. Am J Med 2019; 132:1450-1457.e1. [PMID: 31247183 PMCID: PMC6917856 DOI: 10.1016/j.amjmed.2019.05.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Few studies describe both inpatient and outpatient treatment and outcomes of patients with acute venous thromboembolism in the United States. METHODS A multi-institutional cohort of patients diagnosed with confirmed pulmonary embolism or deep venous thrombosis during the years 2004 through 2010 was established from 4 large, US-based integrated health care delivery systems. Computerized databases were accessed and medical records reviewed to collect information on patient demographics, clinical risk factors, initial antithrombotic treatment, and vital status. Multivariable Cox regression models were used to estimate the risk of death at 90 days. RESULTS The cohort comprised 5497 adults with acute venous thromboembolism. Pulmonary embolism was predominantly managed in the hospital setting (95.0%), while 54.5% of patients with lower extremity thrombosis were treated as outpatients. Anticoagulant treatment differed according to thromboembolism type: 2688 patients (92.8%) with pulmonary embolism and 1625 patients (86.9%) with lower extremity thrombosis were discharged on anticoagulants, compared with 286 patients (80.1%) with upper extremity thrombosis and 69 (54.8%) patients with other thrombosis. While 4.5% of patients died during the index episode, 15.4% died within 90 days. Pulmonary embolism was associated with a higher 90-day death risk than lower extremity thrombosis (adjusted hazard ratio 1.23; 95% confidence interval, 1.04-1.47), as was not being discharged on anticoagulants (adjusted hazard ratio 5.56; 95% confidence interval, 4.76-6.67). CONCLUSIONS In this multicenter, community-based study of patients with acute venous thromboembolism, anticoagulant treatment and outcomes varied by thromboembolism type. Although case fatality during the acute episode was relatively low, 15.4% of people with thromboembolism died within 90 days of the index diagnosis.
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Affiliation(s)
- Margaret C Fang
- Division of Hospital Medicine, University of California, San Francisco.
| | - Dongjie Fan
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City
| | | | | | - Steven H Yale
- Department of Medicine, University of Central Florida College of Medicine, Orlando
| | - Christine Baumgartner
- Division of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland; Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco; Departments of Medicine, Health Research and Policy, Stanford University School of Medicine, Palo Alto, Calif
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161
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Alerhand S, Hickey SM. Tricuspid Annular Plane Systolic Excursion (TAPSE) for Risk Stratification and Prognostication of Patients with Pulmonary Embolism. J Emerg Med 2019; 58:449-456. [PMID: 31735658 DOI: 10.1016/j.jemermed.2019.09.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND The categorization of pulmonary embolism (PE) as non-massive, sub-massive, and massive helps guide acute management. The presence of right ventricular (RV) strain differentiates sub-massive from non-massive PEs. Unlike laboratory markers and electrocardiogram changes, the classic parameters used in the echocardiographic diagnosis of RV strain have a technical component that is operator-dependent. OBJECTIVE This narrative review will describe the physiologic effects of a PE on the RV and how this affects prognosis. It will summarize the literature evaluating the accuracy and prognostic ability of tricuspid annular plane systolic excursion (TAPSE) in the echocardiographic assessment of RVfunction. The review will describe the appeal of TAPSE for this purpose, provide cutoff measurements, and then illustrate how to perform the technique itself, while offering associated pearls and pitfalls in this bedside evaluation. DISCUSSION RV function and dynamics undergo acute changes in the setting of a PE. RV dysfunction predicts poor outcomes in both the short and long term. However, RV strain is difficult to capture on echocardiography due to the chamber's complex geometric shape and contraction. From the apical four-chamber window, TAPSE offers a quantitative measure that is more easily performed with high interobserver reliability for evaluating systolic RV contraction. This measurement carries prognostic value in patients diagnosed with PE. CONCLUSIONS Along with other more qualitative echocardiographic parameters, TAPSE can be used as a simple quantitative measure of RV dysfunction for differentiating sub-massive from non-massive PEs. This categorization helps guide acute management and disposition.
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Affiliation(s)
- Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Sean M Hickey
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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162
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Roy PM, Revel MP, Salaün PY, Sanchez O. [How to make the diagnosis of pulmonary embolism?]. Rev Mal Respir 2019; 38 Suppl 1:e7-e23. [PMID: 31734045 DOI: 10.1016/j.rmr.2019.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- P-M Roy
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Département de médecine d'urgence et service de médecine vasculaire, CHU Angers, 49000 Angers, France; UMR 1083, UFR santé, Institut Mitovasc, université d'Angers, 49000 Angers, France
| | - M-P Revel
- Service de radiologie A, hôpital Cochin, Université de Paris, Assistance publique des Hôpitaux de Paris, 75014 Paris, France
| | - P-Y Salaün
- Inserm EA3878 (GETBO), service de médecine nucléaire, université de Bretagne occidentale, CHRU de Brest, 29200 Brest, France
| | - O Sanchez
- F-CRIN INNOVTE, 42055 St-Étienne cedex 2, France; Université de Paris, service de pneumologie et soins intensifs, AH-HP, hôpital Européen Georges-Pompidou, 75015 Paris, France; Innovations Thérapeutiques en Hémostase, INSERM UMRS 1140, 75006 Paris, France.
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163
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Mansueto G, Costa D, Capasso E, Varavallo F, Brunitto G, Caserta R, Esposito S, Niola M, Sardu C, Marfella R, Napoli C, Paternoster M. The dating of thrombus organization in cases of pulmonary embolism: an autopsy study. BMC Cardiovasc Disord 2019; 19:250. [PMID: 31703628 PMCID: PMC6839118 DOI: 10.1186/s12872-019-1219-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 10/04/2019] [Indexed: 12/27/2022] Open
Abstract
Background Pulmonary embolism (PE) is associated to high mortality rate worldwide. However, the diagnosis of PE often results inaccurate. Many cases of PE are incorrectly diagnosed or missed and they are often associated to sudden unexpected death (SUD). In forensic practice, it is important to establish the time of thrombus formation in order to determine the precise moment of death. The autopsy remains the gold standard method for the identification of death cause allowing the determination of discrepancies between clinical and autopsy diagnoses. The aim of our study was to verify the morphological and histological criteria of fatal cases of PE and evaluate the dating of thrombus formation considering 5 ranges of time. Methods Pulmonary vessels sections were collected from January 2010 to December 2017. Sections of thrombus sampling were stained with hematoxylin and eosin. The content of infiltrated cells, fibroblasts and collagen fibers were scored using a semi-quantitative three-point scale of range values. Results The 30 autopsies included 19 males (63.3%) and 11 females (36.7%) with an average age of 64.5 ± 12.3 years. The time intervals were as follows: early (≤1 h), recent (> 1 h to 24 h), recent-medium (> 24 h to 48 h), medium (> 48 h to 72 h) and old (> 72 h). In the first hour, we histologically observed the presence of platelet aggregation by immunofluorescence method for factor VIII and fibrinogen. The presence of lymphocytes has been identified from recent thrombus (> 1 h to 24 h) and the fibroblast cells were peripherally located in vascular tissue between 48 and 72 h, whereas they resulted central and copious after 72 h. Conclusions After a macroscopic observation and a good sampling traditional histology, it is important to identify the time of thrombus formation. We identified histologically a range of time in the physiopathology of the thrombus (early, recent, recent-medium, medium, old), allowing to determine the dating of thrombus formation and the exact time of death. Clinical trial number NCT03887819. Trial registration The trial registry is Cliniclatrials.gov, with the unique identifying number NCT03887819. The date of registration was 03/23/2019 and it was “Retrospectively registered”.
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Affiliation(s)
- Gelsomina Mansueto
- Department of Advanced Biomedical Sciences, Legal Medicine Unit, University of Naples Federico II, Naples, Italy.,Department of Advanced Biomedical Sciences, Pathology Unit, University of Naples Federico II, Naples, Italy
| | - Dario Costa
- Clinical Department of Internal Medicine and Specialistics, U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Emanuele Capasso
- Department of Advanced Biomedical Sciences, Legal Medicine Unit, University of Naples Federico II, Naples, Italy
| | | | | | - Rosanna Caserta
- Unit of Pathological Anatomy, Aversa Hospital, Caserta, Italy
| | | | - Massimo Niola
- Department of Advanced Biomedical Sciences, Legal Medicine Unit, University of Naples Federico II, Naples, Italy
| | - Celestino Sardu
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Piazza Miraglia, 2 -, 80138, Naples, Italy.
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Piazza Miraglia, 2 -, 80138, Naples, Italy
| | - Claudio Napoli
- Clinical Department of Internal Medicine and Specialistics, U.O.C. Division of Clinical Immunology, Immunohematology, Transfusion Medicine and Transplant Immunology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Mariano Paternoster
- Department of Advanced Biomedical Sciences, Legal Medicine Unit, University of Naples Federico II, Naples, Italy
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164
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Bajc M, Schümichen C, Grüning T, Lindqvist A, Le Roux PY, Alatri A, Bauer RW, Dilic M, Neilly B, Verberne HJ, Delgado Bolton RC, Jonson B. EANM guideline for ventilation/perfusion single-photon emission computed tomography (SPECT) for diagnosis of pulmonary embolism and beyond. Eur J Nucl Med Mol Imaging 2019; 46:2429-2451. [PMID: 31410539 PMCID: PMC6813289 DOI: 10.1007/s00259-019-04450-0] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 07/17/2019] [Indexed: 12/18/2022]
Abstract
These guidelines update the previous EANM 2009 guidelines on the diagnosis of pulmonary embolism (PE). Relevant new aspects are related to (a) quantification of PE and other ventilation/perfusion defects; (b) follow-up of patients with PE; (c) chronic PE; and (d) description of additional pulmonary physiological changes leading to diagnoses of left ventricular heart failure (HF), chronic obstructive pulmonary disease (COPD) and pneumonia. The diagnosis of PE should be reported when a mismatch of one segment or two subsegments is found. For ventilation, Technegas or krypton gas is preferred over diethylene triamine pentaacetic acid (DTPA) in patients with COPD. Tomographic imaging with V/PSPECT has higher sensitivity and specificity for PE compared with planar imaging. Absence of contraindications makes V/PSPECT an essential method for the diagnosis of PE. When V/PSPECT is combined with a low-dose CT, the specificity of the test can be further improved, especially in patients with other lung diseases. Pitfalls in V/PSPECT interpretation are discussed. In conclusion, V/PSPECT is strongly recommended as it accurately establishes the diagnosis of PE even in the presence of diseases like COPD, HF and pneumonia and has no contraindications.
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Affiliation(s)
- Marika Bajc
- Department of Clinical Sciences, Clinical Physiology and Nuclear Medicine, University of Lund, Lund, Sweden.
| | - Carl Schümichen
- University of Rostock, Formerly Clinic for Nuclear Medicine, Rostock, Germany
| | - Thomas Grüning
- Department of Nuclear Medicine, University Hospitals Plymouth, Plymouth, UK
| | - Ari Lindqvist
- Research Unit of Pulmonary Diseases, Clinical Research Institute, HUS Helsinki University Hospital, Helsinki, Finland
| | | | - Adriano Alatri
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Ralf W Bauer
- RNS Gemeinschaftspraxis, Wiesbaden, Germany
- Department of Diagnostic and Interventional Radiology, Goethe University Frankfurt (Main), Frankfurt, Germany
| | - Mirza Dilic
- Clinic of Heart and Blood Vessel Disease, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Brian Neilly
- Department of Nuclear Medicine, Royal Infirmary, Glasgow, UK
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roberto C Delgado Bolton
- Department of Diagnostic Imaging (Radiology) and Nuclear Medicine, University Hospital San Pedro and Centre for Biomedical Research of La Rioja (CIBIR), Logroño, La Rioja, Spain
| | - Bjorn Jonson
- Department of Clinical Sciences, Clinical Physiology and Nuclear Medicine, University of Lund, Lund, Sweden
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165
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Abstract
RATIONALE Pulmonary embolism (PE) is one of the serious cardiopulmonary diseases that can endanger life. Early diagnosis and timely treatment are key factors to reduce its high mortality rate. Abdominal pain is not currently included in the symptoms of PE in textbooks and guidelines. PATIENT CONCERNS A 49-year-old man was hospitalized for an exacerbation of right upper quadrant abdominal pain and sudden left upper quadrant pain that lasted for 2 hours. DIAGNOSES The patient was initially misdiagnosed as cholecystitis and pneumonia, and later was diagnosed as PE by computed tomography pulmonary angiography (CTPA). INTERVENTIONS The patient received low molecular weight heparin for anticoagulant therapy. OUTCOMES His abdominal pain disappeared after one week. The patient was later discharged. LESSONS Sometimes abdominal pain may be the only manifestation of PE. However, most clinicians do not think of the possibility of PE in patients with abdominal pain. This might have contributed greatly to the rate of misdiagnosis of PE in the past. We hope to improve the alertness of the diagnosis of PE in clinical practice. In patients with abdominal pain, the possibility of PE should be considered to avoid mis- or under-diagnosis.
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Affiliation(s)
- Yu Han
- The Second Clinical Institute, Southern Medical University
| | - Yuxin Gong
- Department of Respiratory, Zhujiang Hospital of Southern Medical University, Guangzhou, China
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166
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Yamashita Y, Morimoto T, Amano H, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Izumi T, Tada T, Chen PM, Murata K, Tsuyuki Y, Nishimoto Y, Saga S, Sasa T, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Yoshikawa Y, Shiomi H, Kato T, Makiyama T, Ono K, Kimura T. Usefulness of Simplified Pulmonary Embolism Severity Index Score for Identification of Patients With Low-Risk Pulmonary Embolism and Active Cancer: From the COMMAND VTE Registry. Chest 2019; 157:636-644. [PMID: 31605702 DOI: 10.1016/j.chest.2019.08.2206] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/07/2019] [Accepted: 08/31/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The simplified Pulmonary Embolism Severity Index (sPESI) score is a practical score for identification of patients with low-risk pulmonary embolism (PE), although it has not been applied in patients with active cancer. The current study aimed to evaluate the usefulness of the sPESI score in patients with PE and active cancer. METHODS The COMMAND VTE Registry is a multicenter registry enrolling consecutive patients with acute symptomatic VTE. The current study population consisted of 368 patients with PE and active cancer. The 30-day clinical outcomes were compared between patients with sPESI score = 1 and patients with sPESI scores ≥ 2. RESULTS Overall, 37 patients (10%) died during the 30 days after diagnosis. The cumulative 30-day incidences of mortality, and PE-related death, were lower in patients with sPESI score = 1 than in patients with sPESI scores ≥ 2 (6.3% vs 13.1%; log-rank P = .03; and 0.7% vs 3.9%; log-rank P = .046). Among patients with sPESI score = 1, the predominant cause of death was cancer. There were no significant differences in the cumulative 30-day incidence of recurrent VTE and major bleeding between the two groups (3.9% vs 5.6%; log-rank P = .46; and 6.4% vs 4.5%; log-rank P = .45). CONCLUSIONS Among patients with PE and active cancer, patients with sPESI score = 1 had a lower 30-day mortality rate compared with patients with sPESI scores ≥ 2, and they showed very low PE-related mortality risk, although the overall mortality rate remained high because of cancer-related mortality. They also showed relatively high risks for recurrence and major bleeding, suggesting the need for careful follow-up. TRIAL REGISTRY UMIN Clinical Trials Registry; No.: UMIN000021132; URL: http://www.umin.ac.jp/ctr/index.htm.
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Affiliation(s)
- Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hidewo Amano
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Seiichi Hiramori
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yohei Kobayashi
- Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Toshiaki Izumi
- Cardiovascular Center, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yoshiaki Tsuyuki
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Syunsuke Saga
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Jiro Sakamoto
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | | | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Ikoma, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | | | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
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167
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Giri J, Sista AK, Weinberg I, Kearon C, Kumbhani DJ, Desai ND, Piazza G, Gladwin MT, Chatterjee S, Kobayashi T, Kabrhel C, Barnes GD. Interventional Therapies for Acute Pulmonary Embolism: Current Status and Principles for the Development of Novel Evidence: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e774-e801. [PMID: 31585051 DOI: 10.1161/cir.0000000000000707] [Citation(s) in RCA: 243] [Impact Index Per Article: 48.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pulmonary embolism (PE) represents the third leading cause of cardiovascular mortality. The technological landscape for management of acute intermediate- and high-risk PE is rapidly evolving. Two interventional devices using pharmacomechanical means to recanalize the pulmonary arteries have recently been cleared by the US Food and Drug Administration for marketing, and several others are in various stages of development. The purpose of this document is to clarify the current state of endovascular interventional therapy for acute PE and to provide considerations for evidence development for new devices that will define which patients with PE would derive the greatest net benefit from their use in various clinical settings. First, definitions and limitations of commonly used risk stratification tools for PE are reviewed. An adjudication of risks and benefits of available interventional therapies for PE follows. Next, considerations for optimal future evidence development in this field are presented in the context of the current US regulatory framework. Finally, the document concludes with a discussion of the pros and cons of the rapidly expanding PE response team model of care delivery.
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168
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Kotsiou OS, Karadontas V, Daniil Z, Zakynthinos E, Gourgoulianis KI. Transcutaneous carbon dioxide monitoring as a predictive tool for all-cause 6-month mortality after acute pulmonary embolism. Eur J Intern Med 2019; 68:44-50. [PMID: 31416659 DOI: 10.1016/j.ejim.2019.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 07/27/2019] [Accepted: 07/30/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) frequently remains undiagnosed. The partial pressure of carbon dioxide (PaCO2), a surrogate of dead-space ventilation, is useful in the evaluation of the degree of pulmonary artery occlusion. At present, there is no knowledge about the prognostic role of PaCΟ2 variations during the first hours of an acute PE. Transcutaneous measurement of CO2 (PtcCO2) is a simple, non-invasive method that correlates well with PaCO2 levels, evaluated in this study for the first time in patients with PE. PURPOSE To assess the correlation between PtcCO2 and PaCO2 levels in the acute phase of PE and the role of PtcCO2 in predicting 6-months mortality. METHODS This was a pilot study including 53 patients with acute PE who hospitalized in Respiratory Medicine Department at University Hospital of Larissa in central Greece during 15 months. PtcCO2 was constantly monitored for four hours after PE diagnosis with the TCM40 monitoring system (SmartCal). Simultaneous arterial blood gas measurements were performed. Each patient was prospectively recorded for six months via standard telephone calls. RESULTS PaCO2 and PtcCO2 values were well-correlated in the acute phase of PE. Decreased PtcCO2 levels in the first monitoring hour were associated with a higher risk of mortality. In the PE subgroup who died, the lower PtcCO2 level in the first hour of PE was a predictor of shorter survival time independently of gender, age, comorbidities, and smoking status. CONCLUSION PtcCO2 measurement, especially in the first hour after PE, seemed to be a valid tool in predicting all-cause 6-month mortality.
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Affiliation(s)
- Ourania S Kotsiou
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, BIOPOLIS, 41500 Larissa, Greece.
| | - Vasileios Karadontas
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, BIOPOLIS, 41500 Larissa, Greece
| | - Zoe Daniil
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, BIOPOLIS, 41500 Larissa, Greece
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169
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Pillus D, Bruno E, Farcy D, Vilke GM, Childers R. Systematic Review: The Role of Thrombolysis in Intermediate-Risk Pulmonary Embolism. J Emerg Med 2019; 57:517-522. [PMID: 31477311 DOI: 10.1016/j.jemermed.2019.06.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 06/15/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND This systemic review provides practicing emergency physicians updated information about the role of thrombolysis in the treatment of intermediate-risk pulmonary embolism. METHODS A PubMed literature search from January 1, 2005 to December 31, 2018 was conducted and limited to human clinical trials written in English with relevant keywords. High-quality studies were identified and then underwent a structured review. Recommendations are made based on the literature review. RESULTS Sixty-three articles met criteria for rigorous review, of which 13 were appropriate for citation in this review. Of these 13, there were 6 prospective studies and 7 retrospective studies. CONCLUSIONS Thrombolysis, either catheter-directed or systemic, is a treatment option in the management of patients with intermediate-risk pulmonary embolism and a high likelihood of clinical deterioration. Each method of thrombolysis carries risks and benefits. Based on the available evidence, transfer to a facility for the purpose of catheter-directed thrombolysis is not recommended.
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Affiliation(s)
- David Pillus
- Department of Emergency Medicine, University of Tennessee, Nashville, Tennessee
| | - Eric Bruno
- Department of Emergency Medicine, University of Tennessee, Nashville, Tennessee
| | - David Farcy
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, Florida
| | - Gary M Vilke
- Department of Emergency Medicine, University of California, San Diego Health, San Diego, California
| | - Richard Childers
- Department of Emergency Medicine, University of California, San Diego Health, San Diego, California
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170
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Holder T, Sullivan AE, Truong T, Patel MR, Sofela O, Green CL, Dahhan T, Jones WS. Identification, diagnosis, treatment, and in-hospital outcomes of acute pulmonary embolism: Results from a single integrated health system. Am Heart J 2019; 216:136-142. [PMID: 31434031 DOI: 10.1016/j.ahj.2019.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 06/25/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Although the high-risk acute pulmonary embolism (PE) population has been described, little is known about the contemporary inpatient experience and practice patterns of the PE population as a whole. METHODS All patients with a diagnosis of acute PE from January 1, 2016, to June 30, 2017 within our academic, multihospital health system were retrospectively identified using International Classification of Diseases, 10th Revision, codes, and data were manually abstracted by 2 clinical investigators. Descriptive analyses were performed according to clinical risk stratification categories from the European Society of Cardiology. RESULTS Of 829 total patients, 372 (44.8%) patients had intermediate or high-risk PE. Mean age was 62.1 years old, and 42.1% of patients had a history of malignancy. One hundred fifty-three (18.5%) patients had an acute PE during a hospitalization for another indication. A total of 6.0% underwent invasive PE therapies, 26.1% required intensive care unit admission, and 9.0% experienced in-hospital death or hospice discharge. In a subgroup description, patients who developed acute PE during a hospitalization for another indication had a higher incidence of incomplete risk stratification and a higher mortality (9.8%) than the primary cohort. Mortality was attributed to PE in 48.4% of cases. CONCLUSIONS This contemporary description of acute PE managed at a single large, multihospital academic health system highlights substantial health care utilization and high mortality despite the available of advanced therapeutics. Additional work is needed to standardize care for the heterogeneous PE population to ensure appropriate allocation of resources and improved outcomes for all PE patients.
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171
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Hepburn-Brown M, Darvall J, Hammerschlag G. Acute pulmonary embolism: a concise review of diagnosis and management. Intern Med J 2019; 49:15-27. [PMID: 30324770 DOI: 10.1111/imj.14145] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 09/27/2018] [Accepted: 10/01/2018] [Indexed: 12/14/2022]
Abstract
An acute pulmonary embolism (aPE) is characterised by occlusion of one or more pulmonary arteries. Physiological disturbance may be minimal, but often cardiac output decreases as the right ventricle attempts to overcome increased afterload. Additionally, ventilation-perfusion mismatches can develop in affected vascular beds, reducing systemic oxygenation. Incidence is reported at 50-75 per 100 000 in Australia and New Zealand, with 30-day mortality rates ranging from 0.5% to over 20%. Incidence is likely to increase with the ageing population, increased survival of patients with comorbidities that are considered risk factors and improving sensitivity of imaging techniques. Use of clinical prediction scores, such as the Wells score, has assisted in clinical decision-making and decreased unnecessary radiological investigations. However, imaging (i.e. computed tomography pulmonary angiography or ventilation-perfusion scans) is still necessary for objective diagnosis. Anti-coagulation remains the foundation of PE management. Haemodynamically unstable patients require thrombolysis unless absolutely contraindicated, while stable patients with right ventricular dysfunction or ischaemia should be aggressively anti-coagulated. Stable patients with no right ventricular dysfunction can be discharged home early with anti-coagulation and review. However, treatment should be case dependent with full consideration of the patient's clinical state. Direct oral anti-coagulants have become an alternative to vitamin K antagonists and are facilitating shorter hospital admissions. Additionally, duration of anti-coagulation must be decided by considering any provoking factors, bleeding risk and comorbid state. Patients with truly unprovoked or idiopathic PE often require indefinite treatment, while in provoked cases it is typically 3 months with some patients requiring longer periods of 6-12 months.
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Affiliation(s)
- Morgan Hepburn-Brown
- Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Jai Darvall
- Department of Intensive Care and Anaesthesia/Pain Management, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Gary Hammerschlag
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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172
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The authors reply. Crit Care Med 2019; 46:e623-e624. [PMID: 29762423 DOI: 10.1097/ccm.0000000000003065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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173
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Abstract
Pulmonary embolism (PE) presents a spectrum of hemodynamic consequences, ranging from being asymptomatic to a life-threatening medical emergency. Management of submassive and massive PE often involves clinicians from multiple specialties, which can potentially delay the development of a unified treatment plan. In addition, patients with submassive PE can deteriorate after their presentation and require escalation of care. Underlying comorbidities such as chronic obstructive pulmonary disease, cancer, congestive heart failure, and interstitial lung disease can impact the patient's hemodynamic ability to tolerate submassive PE. In this review, we address the definitions, risk stratification (clinical, laboratory, and imaging), management approaches, and long-term outcomes of submassive PE. We also discuss the role of the PE response team in management of patients with PE.
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Affiliation(s)
- Parth M Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
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Bulajic B, Welzel T, Vallabh K. Clinical presentation and diagnostic work up of suspected pulmonary embolism in a district hospital emergency centre serving a high HIV/TB burden population. Afr J Emerg Med 2019; 9:134-139. [PMID: 31528531 PMCID: PMC6742596 DOI: 10.1016/j.afjem.2019.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 03/26/2019] [Accepted: 05/17/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction The diagnosis of pulmonary embolism (PE) is challenging to make and is often missed in the emergency centre. The diagnostic work-up of PE has been improved by the use of clinical decision rules (CDRs) and CT pulmonary angiography (CTPA) in high-income countries. CDRs have not been validated in the South African environment where HIV and tuberculosis (TB) are highly prevalent. Both conditions are known to induce a hyper-coagulable state. The objective of this study was to describe the clinical presentation and diagnostic workup of suspected PE in our setting and to determine the prevalence of HIV and TB in our sample of patients with confirmed PE. Methods This study was a retrospective chart review of patients with suspected PE who had CTPAs performed between October 2013 and October 2015 at a district hospital in Cape Town, South Africa. Data were collected on demographics, presenting signs and symptoms, vitals, bedside investigations, HIV and TB status. A Revised Geneva score (RGS) was calculated retrospectively and compared to the CTPA result. Results The median age of patients with confirmed PE was 45 years and 68% were female. The CTPA yield for PE in our study population was 32%. The most common presenting complaint was dyspnoea (83%). Deep venous thrombosis (DVT) was present in 29%. No sign or symptom was observed to be markedly different in patients with confirmed PE vs no PE. Among patients with confirmed PE, 37% were HIV positive and 52% had current TB. RGS compared poorly with CTPA results. Conclusions PE remains a diagnostic challenge. In our study, the retrospectively calculated CDR was not predictive of PE in a population with a high prevalence of HIV and TB. Emergency physicians should be cautious when making a clinical probability assessment of PE in this setting. However, further studies are needed to develop a predictive CDR for the local environment.
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Affiliation(s)
- Bojana Bulajic
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
- Corresponding author at: Division of Emergency Medicine, University of Cape Town, F51 Old Main Building, Groote Schuur Hospital, Main Road, Observatory, Cape Town, 7925, South Africa
| | - Tyson Welzel
- Division of Emergency Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Kamil Vallabh
- Department of Emergency Medicine, Mitchell's Plain Hospital, Cape Town, South Africa
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175
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Guerreiro I, Magalhães H, Coelho S, Ribeiro A, Ferreira S, Araújo E, Bettencourt P, Lourenço P. Long term prognosis of acute pulmonary embolism. Eur J Intern Med 2019; 67:84-88. [PMID: 31326193 DOI: 10.1016/j.ejim.2019.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/04/2019] [Accepted: 07/09/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Acute pulmonary embolism (PE) can be fatal if left untreated. Long-term prognosis of acute PE in the 21st century has not been fully reported. We aimed to determine the long-term prognosis of patients hospitalized with acute PE and compare survivalof patients with idiopathic and secondary PE. MATERIALS AND METHODS We retrospectively analysed a cohort of hospitalized patients with acute PE between 2006 and 2013. EXCLUSION CRITERIA <18 years, venous embolism of non-pulmonary veins, chronic thromboembolic pulmonary hypertension, and presumptive diagnosis without image confirmation. Only patients with a first PE episode were included. End-point: all-cause mortality. Patients were compared according to PE aetiology: idiopathic, secondary to neoplastic conditions and secondary to non-neoplastic conditions. A Cox-regression analysis was used to study the prognostic impact of PE aetiology. RESULTS We studied 872 hospitalized acute PE patients. Median age 70 years, 56.9% were women. PE was idiopathic in 376 (43.1%), secondary to a neoplastic condition in 284 (32.6%) and secondary to a condition other than neoplasia in 212 (24.3%). Patients were followed for a median 25 months period and 508 (58.3%) died. Patients with PE attributed to a neoplastic condition had the worst survival. Patients with idiopathic PE had a multivariate-adjusted HR of mortality of 1.46 (1.08-1.99) during the over 2-year follow-up period when compared to those with acute PE attributed to a non-neoplastic condition. CONCLUSIONS Patients with idiopathic acute PE have an almost 50% higher death risk in a median 2-year follow-up period than those with acute PE secondary to a condition other than neoplasia.
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Affiliation(s)
- I Guerreiro
- Department of Medical Oncology, Portuguese Oncology Institute of Porto (IPO-Porto), Porto, Portugal
| | - H Magalhães
- Department of Medical Oncology, Portuguese Oncology Institute of Porto (IPO-Porto), Porto, Portugal
| | - S Coelho
- Department of Medical Oncology, Portuguese Oncology Institute of Porto (IPO-Porto), Porto, Portugal
| | - A Ribeiro
- Department of Internal Medicine, São João Hospital Centre, Porto, Portugal
| | - S Ferreira
- Department of Internal Medicine, São João Hospital Centre, Porto, Portugal
| | - E Araújo
- Department of Internal Medicine, São João Hospital Centre, Porto, Portugal
| | - P Bettencourt
- Department of Internal Medicine, CUF Hospital Centre Porto, Porto, Portugal; University of Porto, Faculty of Medicine, Portugal
| | - P Lourenço
- Department of Internal Medicine, São João Hospital Centre, Porto, Portugal.
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176
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Áinle FN, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Respir J 2019; 54:13993003.01647-2019. [DOI: 10.1183/13993003.01647-2019] [Citation(s) in RCA: 509] [Impact Index Per Article: 101.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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177
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Saban M, Shachar T, Salama R, Darawsha A. Improving STEMI management in the emergency department: Examining the role of minority groups and sociodemographic characteristics. Am J Emerg Med 2019; 38:1102-1109. [PMID: 31400825 DOI: 10.1016/j.ajem.2019.158380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 07/23/2019] [Accepted: 07/30/2019] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate whether a fast-track intervention program will reduce time-lags of patients with STEMI considering minority groups, various socioeconomic status (SES) and clinical risk factors. METHODS A retrospective-archive study was conducted according to clinical guidelines, comparing all STEMI patients (n = 140) admitted to the emergency department (ED) before (n = 60) and during (n = 80) implementation of the fast track intervention program. The program comprised four steps: (1) immediate bed rest, (2) marking patient chart, (3) assessing time-lags according to defined clinical guidelines, and (4) physician signing a dedicated sticker on the ECG. RESULTS The major ethnic group compared to other minority patients with STEMI were less delayed for physician examination (r = -0.398, p < 0.01), spent less time at ED (r = -0.541, p < 0.01) and reached percutaneous coronary intervention earlier (r = -0.672, p < 0.01). Patients with higher SES spent less time for physician (r = -338, p < 0.05) and in the ED (r = -0.415, p < 0.01). Before intervention patients with diabetes mellitus (DM) spent more time at ED compared to non DM patients, however during intervention this difference was blurred (β = -0.803, p < 0.001). Gaps regarding sociodemographic bias remained present throughout the intervention despite monthly staff evaluations considering patient cases. CONCLUSIONS The fast track intervention was associated with less time at ED and to cardiac reperfusion. Yet, sociodemographic bias was present. Our findings highlight the need for the healthcare profession to address the role of biases in disparities in healthcare.
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Affiliation(s)
- Mor Saban
- Department of Nursing, The Faculty of Health and Welfare Sciences, University of Haifa, Haifa, Israel; Rambam Health Care Campus, Haifa, Israel.
| | - Tal Shachar
- The Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
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178
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Nishimoto Y, Yamashita Y, Morimoto T, Saga S, Amano H, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Izumi T, Tada T, Chen PM, Murata K, Tsuyuki Y, Sasa T, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Yoshikawa Y, Shiomi H, Kato T, Makiyama T, Ono K, Sato Y, Kimura T. Thrombolysis with tissue plasminogen activator in patients with acute pulmonary embolisms in the real world: from the COMMAND VTE registry. J Thromb Thrombolysis 2019; 48:587-595. [PMID: 31278648 DOI: 10.1007/s11239-019-01913-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
There is still uncertainty about the optimal usage of thrombolysis for acute pulmonary embolisms (PEs), leading to a widely varying usage in the real world. The COMMAND VTE Registry is a multicenter retrospective registry enrolling consecutive patients with acute symptomatic venous thromboembolisms (VTEs) in Japan. The present study population consisted of 1549 patients with PEs treated with tissue plasminogen activator (t-PA) thrombolysis (N = 180, 12%) or without thrombolysis (N = 1369). Thrombolysis with t-PA was implemented in 33% of patients with severe PEs, and 9.2% of patients with mild PEs with a wide variation across the participating centers. Patients with t-PA thrombolysis were younger, and less frequently had active cancer, history of major bleeding, and anemia. At 30 days, t-PA thrombolysis as compared to no thrombolysis was associated with similar mortality rates (5.0% vs. 6.9%, P = 0.33), but a lower adjusted mortality risk (OR 0.41; 95% CI 0.18-0.90, P = 0.03), while it was associated with a trend for higher rates of major bleeding (5.6% vs. 2.9%, P = 0.06) and a significantly higher adjusted risk for major bleeding (OR 2.39; 95% CI 1.06-5.36, P = 0.03). In patients with severe PEs, the mortality rates at 30 days were significantly lower in the t-PA thrombolysis group than no thrombolysis group (15% vs. 37%, P = 0.006). In the present real-world VTE registry in Japan, t-PA thrombolysis was not infrequently implemented, not only in patients with severe PEs, but also in patients with mild PEs. A substantial mortality risk reduction might be suggested with t-PA thrombolysis in patients with severe PEs.
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Affiliation(s)
- Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Syunsuke Saga
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Hidewo Amano
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Seiichi Hiramori
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Toshiaki Izumi
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yoshiaki Tsuyuki
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Jiro Sakamoto
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | | | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Ikoma, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | | | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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179
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Rosovsky R, Zhao K, Sista A, Rivera‐Lebron B, Kabrhel C. Pulmonary embolism response teams: Purpose, evidence for efficacy, and future research directions. Res Pract Thromb Haemost 2019; 3:315-330. [PMID: 31294318 PMCID: PMC6611377 DOI: 10.1002/rth2.12216] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 04/09/2019] [Indexed: 12/20/2022] Open
Abstract
Pulmonary embolism (PE) is a major cause of morbidity and mortality in the United States. Although new therapeutic tools and strategies have recently been developed for the diagnosis and treatment of patients with PE, the outcomes for patients who present with massive or high-risk PE remain dismal. To address this crisis, pulmonary embolism response teams (PERTs) are being created around the world in an effort to immediately and simultaneously engage multiple specialists to determine the best course of action and coordinate the clinical care for patients with acute PE. The scope of this review is to describe the PERT model and purpose, present the structure and organization, examine the available evidence for efficacy and usefulness, and propose future directions for research that is needed to demonstrate the value of PERT and determine if this multidisciplinary approach represents a new standard of care.
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Affiliation(s)
- Rachel Rosovsky
- Division of Hematology & OncologyDepartment of MedicineMassachusetts HospitalBostonMassachusetts
| | - Ken Zhao
- Division of Interventional RadiologyDepartment of RadiologyNew York University Langone Medical CenterNew YorkNew York
| | - Akhilesh Sista
- Division of Interventional RadiologyDepartment of RadiologyNew York University Langone Medical CenterNew YorkNew York
| | - Belinda Rivera‐Lebron
- Division of Pulmonary, Allergy and Critical Care MedicineDepartment of MedicineUniversity of PittsburghPittsburghPennsylvania
| | - Christopher Kabrhel
- Center for Vascular EmergenciesDepartment of Emergency MedicineMassachusetts General HospitalBostonMassachusetts
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180
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Yoshikawa Y, Yamashita Y, Morimoto T, Amano H, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Izumi T, Tada T, Chen PM, Murata K, Tsuyuki Y, Saga S, Sasa T, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Shiomi H, Kato T, Makiyama T, Ono K, Kimura T. Sex Differences in Clinical Characteristics and Outcomes of Patients With Venous Thromboembolism ― From the COMMAND VTE Registry ―. Circ J 2019; 83:1581-1589. [DOI: 10.1253/circj.cj-19-0229] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Hidewo Amano
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital
| | | | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Toshiaki Izumi
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital
| | | | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital
| | | | | | - Syunsuke Saga
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital
| | | | | | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine
| | | | | | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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181
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Yamashita Y, Yoshikawa Y, Morimoto T, Amano H, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Tada T, Chen PM, Murata K, Tsuyuki Y, Saga S, Sasa T, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Shiomi H, Kato T, Makiyama T, Ono K, Kimura T. The association of recurrence and bleeding events with mortality after venous thromboembolism: From the COMMAND VTE Registry. Int J Cardiol 2019; 292:198-204. [PMID: 31239211 DOI: 10.1016/j.ijcard.2019.06.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 05/10/2019] [Accepted: 06/12/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND The duration of anticoagulation therapy after venous thromboembolism (VTE) should be based on the balance between risks of recurrent VTE and bleeding. However, there is uncertainty about the impact of these events on subsequent mortality. METHODS We evaluated the association of recurrent VTE and major bleeding events with mortality among 3026 patients in the COMMAND VTE Registry. We estimated the risks of the recurrent VTE events and the major bleeding events for subsequent mortality by the time-updated multivariable Cox proportional hazard model. RESULTS During the median follow-up period of 1218 days, 225 patients developed recurrent VTE events, 274 patients developed major bleeding events, and 763 patients died. The multivariable Cox proportional hazard model revealed that both the recurrent VTE and major bleeding events were strongly associated with subsequent mortality risk (recurrent VTE: HR 3.24, 95%CI 2.57-4.08, P < 0.001; major bleeding: HR 3.53, 95%CI 2.88-4.31, P < 0.001). Both the recurrent pulmonary embolism (PE) and recurrent deep vein thrombosis (DVT) events were associated with subsequent mortality risk (recurrent PE events: HR 4.42, 95%CI 3.28-5.95, P < 0.001; recurrent DVT events: HR 2.42, 95%CI 1.75-3.36, P < 0.001). CONCLUSIONS In the real-world patients with VTE, both the recurrent VTE events and the major bleeding events were strongly associated with subsequent mortality risk with the comparable effect size. The recurrent PE and recurrent DVT events were also associated with increased risks for mortality, although the magnitude of the effect on mortality was numerically greater with the recurrent PE events than with the recurrent DVT events.
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Affiliation(s)
- Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hidewo Amano
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Seiichi Hiramori
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yoshiaki Tsuyuki
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Syunsuke Saga
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Jiro Sakamoto
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | | | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Ikoma, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | | | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
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182
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Stüssi-Helbling M, Arrigo M, Huber LC. Pearls and Myths in the Evaluation of Patients with Suspected Acute Pulmonary Embolism. Am J Med 2019; 132:685-691. [PMID: 30710540 DOI: 10.1016/j.amjmed.2019.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 01/15/2019] [Accepted: 01/17/2019] [Indexed: 11/25/2022]
Abstract
Significant improvement has been achieved in diagnostic accuracy, validation of probability scores, and standardized treatment algorithms for patients with suspected acute pulmonary embolism. These developments have provided the tools for a safe and cost-effective management for most of these patients. In our experience, however, the presence of medical myths and ongoing controversies seem to hinder the implementation of these tools in everyday clinical practice. This review provides a selection of such dilemmas and controversies and discusses the published evidence beyond them. By doing so, we try to overcome these dilemmas and suggest pragmatic approaches guided by the available evidence and current guidelines.
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Affiliation(s)
- Melina Stüssi-Helbling
- Department of Internal Medicine, Clinic for Internal Medicine, City Hospital Triemli Zurich, Switzerland.
| | - Mattia Arrigo
- Division of Cardiology, University Hospital Zurich, Switzerland
| | - Lars C Huber
- Department of Internal Medicine, Clinic for Internal Medicine, City Hospital Triemli Zurich, Switzerland
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183
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Nishimoto Y, Yamashita Y, Morimoto T, Saga S, Amano H, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Izumi T, Tada T, Chen PM, Murata K, Tsuyuki Y, Sasa T, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Shiomi H, Kato T, Makiyama T, Ono K, Sato Y, Kimura T. Clinical Characteristics and Outcomes of Venous Thromboembolisms According to an Out-of-Hospital vs. In-Hospital Onset - From the COMMAND VTE Registry. Circ J 2019; 83:1377-1384. [PMID: 30930347 DOI: 10.1253/circj.cj-18-1314] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Differences in the clinical characteristics and outcomes of venous thromboembolisms (VTEs) based on different clinical situations surrounding the onset might be important for directing appropriate treatment strategies, but have not yet been appropriately evaluated. Methods and Results: The COMMAND VTE Registry is a multicenter registry enrolling 3,027 consecutive patients with acute symptomatic VTEs in Japan between January 2010 and August 2014. We divided the study population into 3 groups: Out-of-hospital onset (n=2,308), In-hospital onset with recent surgery (n=310), and In-hospital onset without recent surgery (n=374). Active cancer was most prevalent in the In-hospital onset without recent surgery group, and least in the Out-of-hospital onset group (Out-of-hospital onset group: 20%, In-hospital onset with recent surgery group: 26%, and In-hospital onset without recent surgery group: 38%, P<0.001). The cumulative 5-year incidence of recurrent VTEs did not significantly differ across the 3 groups (11.4%, 5.8%, and 8.7%, respectively; P=0.11). The cumulative 5-year incidences of major bleeding and all-cause death were highest in the In-hospital onset without recent surgery group (11.1%, 8.5%, and 23.3%, P<0.001; 26.8%, 24.9%, and 48.4%, P<0.001, respectively). CONCLUSIONS In the real-world VTE registry, the clinical characteristics and long-term outcomes substantially differed according to the clinical situation of VTE onset, suggesting the need for different treatment strategies for VTEs in different clinical settings.
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Affiliation(s)
- Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Syunsuke Saga
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Hidewo Amano
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital
| | | | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Toshiaki Izumi
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital
| | | | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital
| | | | | | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital
| | | | | | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine
| | | | | | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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184
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Abstract
BACKGROUND Syncope represents a common condition among the general population. It is also a frequent complaint of patients in the emergency department (ED). Pulmonary embolism (PE) considers a differential diagnosis, particularly in a case of syncope without chest pain. STUDY QUESTION What is the prevalence of PE among patients who presented an episode of syncope to the ED and among those hospitalized for syncope in a tertiary care hospital? STUDY DESIGN From January 2012 to December 2017, we conducted a prospective observational study among adult patients presenting themselves to the ED consecutively or admitted for syncope. MEASURES AND OUTCOMES Syncope and PE were defined by professional guidelines. PE was ruled out in patients who had a low pretest clinical probability, as per Wells score and a negative D-dimer assay. In other patients, computed tomography pulmonary angiography was performed. RESULTS Seventeen thousand eight-two patients (mean age 71.3 ± 13.24 years) visited the ED for syncope. PE was detected in 45 patients (mean age 65.75 ± 9.45 years): 4 with low risk, 26 with intermediate risk, and 15 with high risk. The prevalence of PE in those hospitalized with syncope was 11.47%, which is 45 of 392 (confidence interval 95% 8.48-15.04), and was 2.52%, 45 of 1782 (confidence interval 95% 1.8-3.3), in patients presenting with syncope to the ED. The location of the embolus was bilateral in 24 patients (53.33%), in a main pulmonary artery in 10 (22.22%), in a lobar artery in 10 (22.22%), and in a segmental artery in 1 (2.22%). CONCLUSIONS The occurrence of syncope, if not explained otherwise, should alert one to consider PE as a differential diagnosis. PE rate, presenting as syncope, is the highest in patients with large thrombi, which is responsible for bilateral or proximal obstruction in a main or lobar pulmonary artery.
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185
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Ebner M, Kresoja KP, Keller K, Hobohm L, Rogge NIJ, Hasenfuß G, Pieske B, Konstantinides SV, Lankeit M. Temporal trends in management and outcome of pulmonary embolism: a single-centre experience. Clin Res Cardiol 2019; 109:67-77. [PMID: 31065790 PMCID: PMC6952327 DOI: 10.1007/s00392-019-01489-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 04/29/2019] [Indexed: 01/14/2023]
Abstract
Background Real-world data on the impact of advances in risk-adjusted management on the outcome of patients with pulmonary embolism (PE) are limited. Methods To investigate temporal trends in treatment, in-hospital adverse outcomes and 1-year mortality, we analysed data from 605 patients [median age, 70 years (IQR 56–77) years, 53% female] consecutively enrolled in a single-centre registry between 09/2008 and 08/2016. Results Over the 8-year period, more patients were classified to lower risk classes according to the European Society of Cardiology (ESC) 2014 guideline algorithm while the number of high-risk patients with out-of-hospital cardiac arrest (OHCA) increased. Although patients with OHCA had an exceptionally high in-hospital mortality rate of 59.3%, the rate of PE-related in-hospital adverse outcomes (12.2%) in the overall patient cohort remained stable over time. The rate of reperfusion treatment was 9.6% and tended to increase in high-risk patients. We observed a decrease in the median duration of in-hospital stay from 10 (IQR 6–14) to 7 (IQR 4–15) days, an increase of patients discharged early from 2.1 to 12.2% and an increase in the use of non-vitamin K-dependent oral anticoagulants (NOACs) from 12.6 to 57.2% in the last 2 years (09/2014–08/2016) compared to first 6 years (09/2008–08/2014). The 1-year mortality rate (16.9%) remained stable throughout the study period. Conclusion In-hospital adverse outcomes and 1-year mortality remained stable despite more patients with OHCA, shorter in-hospital stays, more patients discharged early and a more frequent NOAC use. Electronic supplementary material The online version of this article (10.1007/s00392-019-01489-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthias Ebner
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Karl-Patrik Kresoja
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
- Cardiology I, Center for Cardiology, University Medical Center Mainz, Mainz, Germany
| | - Nina I J Rogge
- Clinic of Cardiology and Pneumology, Heart Center, University Medical Center Goettingen, Goettingen, Germany
| | - Gerd Hasenfuß
- Clinic of Cardiology and Pneumology, Heart Center, University Medical Center Goettingen, Goettingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Goettingen, Goettingen, Germany
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Mareike Lankeit
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany.
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany.
- Clinic of Cardiology and Pneumology, Heart Center, University Medical Center Goettingen, Goettingen, Germany.
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Abstract
Venous thromboembolism (VTE) includes pulmonary embolism (PE) and deep vein thrombosis. PE is the third most common cause of cardiovascular death worldwide after stroke and heart attack. Management of PE has evolved recently with the availability of local thrombolysis; mechanical extraction devices; hemodynamic support devices, like extracorporeal membrane oxygenation; and surgical embolectomy. There has been development of multidisciplinary PE response teams nationwide to optimize the care of patients with VTE. This review describes the epidemiology of PE, discusses diagnostic strategies and current and emerging treatments for VTE, and considers post-PE follow-up care.
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Affiliation(s)
- Eno-Obong Essien
- Division of Internal Medicine Residency Program, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - Parth Rali
- Division of Thoracic Surgery and Medicine, Pulmonary Embolism Response Team (PERT), Temple University Hospital, 3401 North Broad Street, Philadelphia, PA 19140, USA.
| | - Stephen C Mathai
- John Hopkins Hospital, 830 East Monument Street, 1830 Building 5th Floor Pulmonary, Baltimore, MD 21287, USA
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187
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Health-related quality of life and mortality in patients with pulmonary embolism: a prospective cohort study in seven European countries. Qual Life Res 2019; 28:2111-2124. [PMID: 30949836 PMCID: PMC6620245 DOI: 10.1007/s11136-019-02175-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2019] [Indexed: 12/14/2022]
Abstract
Purpose Little is known about the quality of life following pulmonary embolism (PE). The aim of the study was to assess the 12-month illness burden in terms of health-related quality of life (HrQoL) and mortality, in relation to differences in patient characteristics. Methods The PREFER in VTE registry, a prospective, observational study conducted in seven European countries, was used. Within 2 weeks following an acute symptomatic PE, patients were recruited and followed up for 12 months. Associations between patient characteristics and HrQoL (EQ-5D-5L) and mortality were examined using a regression approach. Results Among 1399 PE patients, the EQ-5D-5L index score at baseline was 0.712 (SD 0.265), which among survivors gradually improved to 0.835 (0.212) at 12 months. For those patients with and without active cancer, the average index score at baseline was 0.658 (0.275) and 0.717 (0.264), respectively. Age and previous stroke were significant factors for predicting index scores in those with/without active cancer. Bleeding events but not recurrences had a noticeable impact on the HrQoL of patients without active cancer. The 12-month mortality rate post-acute period was 8.1%, ranging from 1.4% in Germany, Switzerland, and Austria to 16.8% in Italy. Mortality differed between patients with active cancer and those without (42.7% vs. 4.7%). Conclusion PE is associated with a substantial decrease in HrQoL at baseline which normalizes following treatment. PE is associated with a high mortality rate especially in patients with cancer, with significant country variation. Bleeding events, in particular, impact the burden of PE.
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188
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Yoo HHB, Nunes‐Nogueira VS, Fortes Villas Boas PJ, Broderick C. Outpatient versus inpatient treatment for acute pulmonary embolism. Cochrane Database Syst Rev 2019; 3:CD010019. [PMID: 30839095 PMCID: PMC6402388 DOI: 10.1002/14651858.cd010019.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is a common life-threatening cardiovascular condition, with an incidence of 23 to 69 new cases per 100,000 people each year. For selected low-risk patients with acute PE, outpatient treatment might provide several advantages over traditional inpatient treatment, such as reduction of hospitalisations, substantial cost savings, and improvements in health-related quality of life. This is an update of the review first published in 2014. OBJECTIVES To compare the efficacy and safety of outpatient versus inpatient treatment in low-risk patients with acute PE for the outcomes of all-cause and PE-related mortality; bleeding; adverse events such as haemodynamic instability; recurrence of PE; and patients' satisfaction. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers, to 26 March 2018. We also undertook reference checking to identify additional studies. SELECTION CRITERIA We included randomised controlled trials of outpatient versus inpatient treatment of adults (aged 18 years and over) diagnosed with low-risk acute PE. DATA COLLECTION AND ANALYSIS Two review authors selected relevant trials, assessed methodological quality, and extracted and analysed data. We calculated effect estimates using risk ratio (RR) with 95% confidence intervals (CIs), or mean differences (MDs) with 95% CIs. We used standardised mean differences (SMDs) to combine trials that measured the same outcome but used different methods. We assessed the quality of the evidence using GRADE criteria. MAIN RESULTS One new study was identified for this 2018 update, bringing the total number of included studies to two and the total number of participants to 451. Both trials discharged patients randomised to the outpatient group within 36 hours of initial triage and both followed participants for 90 days. One study compared the same treatment regimens in both outpatient and inpatient groups, and the other study used different treatment regimes. There was no clear difference in treatment effect for the outcomes of short-term mortality (30 days) (RR 0.33, 95% CI 0.01 to 7.98, P = 0.49; low-quality evidence), long-term mortality (90 days) (RR 0.98, 95% CI 0.06 to 15.58, P = 0.99, low-quality evidence), major bleeding at 14 days (RR 4.91, 95% CI 0.24 to 101.57, P = 0.30; low-quality evidence) and at 90 days (RR 6.88, 95% CI 0.36 to 132.14, P = 0.20; low-quality evidence), minor bleeding (RR 1.08, 95% CI 0.07 to 16.79; P = 0.96, low-quality evidence), recurrent PE within 90 days (RR 2.95, 95% CI 0.12 to 71.85, P = 0.51, low-quality evidence), and participant satisfaction (RR 0.97, 95% CI 0.90 to 1.04, P = 0.39; moderate-quality evidence). We downgraded the quality of the evidence because the CIs were wide and included treatment effects in both directions, the sample sizes and numbers of events were small, and because the effect of missing data and the absence of publication bias could not be verified. PE-related mortality, and adverse effects such as haemodynamic instability and compliance, were not assessed by the included studies. AUTHORS' CONCLUSIONS Currently, only low-quality evidence is available from two published randomised controlled trials on outpatient versus inpatient treatment in low-risk patients with acute PE. The studies did not provide evidence of any clear difference between the interventions in overall mortality, bleeding and recurrence of PE.
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Affiliation(s)
- Hugo HB Yoo
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Vania Santos Nunes‐Nogueira
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Paulo J Fortes Villas Boas
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Cathryn Broderick
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsTeviot PlaceEdinburghUKEH8 9AG
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Soriano LDA, Castro TT, Vilalva K, Borges MDC, Pazin-Filho A, Miranda CH. Validation of the Pulmonary Embolism Severity Index for risk stratification after acute pulmonary embolism in a cohort of patients in Brazil. J Bras Pneumol 2019; 45:e20170251. [PMID: 30810642 PMCID: PMC6534413 DOI: 10.1590/1806-3713/e20170251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/12/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To validate the Pulmonary Embolism Severity Index (PESI), which was developed for risk stratification after acute pulmonary embolism (PE), for use in Brazil. METHODS This was a single-center retrospective study involving patients admitted to the emergency department with acute PE. The original and simplified versions of the PESI were calculated using hospital admission data from medical records. The outcome measure was the overall 30-day mortality rate. RESULTS We included 123 patients. The mean age was 57 ± 17 years, and there was a predominance of females, who accounted for 60% of the cohort. There were 28 deaths, translating to an overall 30-day mortality rate of 23%. In the cluster analysis by risk class, overall 30-day mortality was 2.40% for classes I-II, compared with 20.00% for classes III-IV-V (relative risk [RR] = 5.9; 95% CI: 1.88-18.51; p = 0.0002). When we calculated overall 30-day mortality using the simplified version (0 points vs. ≥ 1 point), we found it to be 3.25% for 0 points and 19.51% for ≥ 1 point (RR = 2.38; 95% CI: 0.89-6.38; p = 0.06). Using the original version, a survival analysis showed that risk classes I and II presented similar Kaplan-Meier curves (p = 0.59), as did risk classes III, IV, and V (p = 0.25). However, the curve of the clusters based on the original version, showed significantly higher mortality in the III-IV-V classes than in the I-II classes (RR = 7.63; 95% CI: 2.29-25.21; p = 0.0001). The cluster analysis based on the original version showed a greater area under the ROC curve than did the analysis based on the simplified version (0.70; 95% CI: 0.62-0.77 vs. 0.60; 95% CI: 0.51-0.67; p = 0.05). CONCLUSIONS The PESI adequately predicted the prognosis after acute PE in this sample of the population of Brazil. The cluster analysis based on the original version is the most appropriate analysis in this setting.
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Affiliation(s)
- Leonardo de Araujo Soriano
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Talita Tavares Castro
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Kelvin Vilalva
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Marcos de Carvalho Borges
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Antonio Pazin-Filho
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
| | - Carlos Henrique Miranda
- . Divisão de Emergências Clínicas, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
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Changes in treatment and outcomes after creation of a pulmonary embolism response team (PERT), a 10-year analysis. J Thromb Thrombolysis 2019; 47:31-40. [PMID: 30242551 DOI: 10.1007/s11239-018-1737-8] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Multidisciplinary pulmonary embolism response teams (PERTs) are being implemented to improve care of patients with life-threatening PE. We sought to determine how the creation of PERT affects treatment and outcomes of patients with serious PE. A pre- and post-intervention study was performed using an interrupted time series design, to compare patients with PE before (2006-2012) and after (2012-2016) implementation of PERT at a university hospital. T-tests, Chi square tests and logistic regression were used to compare outcomes, and multivariable regression were used to adjust for differences in PE severity. Two-sided p-value < 0.05 was considered significant. For the interrupted time-series analysis, data was divided into mutually exclusive 6-month time periods (11 pre- and 7 post-PERT). To examine changes in treatment and outcomes associated with PERT, slopes and change points were compared pre- and post-PERT. Two-hundred and twelve pre-PERT and 228 post-PERT patients were analyzed. Patient demographics were generally similar, though pre-PERT, PE were more likely to be low-risk (37% vs. 19%) while post-PERT, PE were more likely to be submassive (32% vs. 49%). More patients underwent catheter directed therapy (1% vs. 14%, p = < 0.0001) or any advanced therapy (19 [9%] vs. 44 [19%], p = 0.002) post PERT. Interrupted time series analysis demonstrated that this increase was sudden and coincident with implementation of PERT, and most noticeable among patients with submassive PE. There were no differences in major bleeding or mortality pre- and post-PERT. While the use of advanced therapies, particularly catheter-directed therapies, increased after creation of PERT, especially among patients with submassive PE, there was no apparent increase in bleeding.
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191
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Trimaille A, Marchandot B, Girardey M, Muller C, Lim HS, Trinh A, Ohlmann P, Moulin B, Jesel L, Morel O. Assessment of Renal Dysfunction Improves the Simplified Pulmonary Embolism Severity Index (sPESI) for Risk Stratification in Patients with Acute Pulmonary Embolism. J Clin Med 2019; 8:jcm8020160. [PMID: 30717116 PMCID: PMC6406501 DOI: 10.3390/jcm8020160] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 01/22/2019] [Accepted: 01/24/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Whereas the major strength of the simplified pulmonary embolism severity index (sPESI) lies in ruling out an adverse outcome in patients with sPESI of 0, the accuracy of sPESI ≥ 1 in risk assessment remains questionable. In acute pulmonary embolism (APE), the estimated glomerular filtration rate (eGFR) can be viewed as an integrate marker reflecting not only previous chronic kidney disease (CKD) damage but also comorbid conditions and hemodynamic disturbances associated with APE. We sought to determine whether renal dysfunction assessment by eGFR improves the sPESI score risk stratification in patients with APE. Methods: 678 consecutive patients with APE were prospectively enrolled. Renal dysfunction (RD) at diagnosis of APE was defined by eGFR < 60 mL/min/1.73 m2 and acute kidney injury (AKI) by elevation of creatinine level >25% during in-hospital stay. Results: RD was observed in 26.9% of the cohort. AKI occurred in 18.8%. A stepwise increase in 30-day mortality, cardiovascular mortality and overall mortality was evident with declining renal function. Multivariate analysis identified RD and CRP (C-reactive protein) level but not sPESI score as independent predictors of 30-day mortality. AKI, 30-day mortality, overall mortality, and cardiovascular mortality were at their highest level in patients with eGFR < 60 mL/min/1.73 m2 and sPESI ≥1. Conclusion: in patients with APE, the addition of RD to the sPESI score identifies a specific subset of patients at very high mortality.
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Affiliation(s)
- Antonin Trimaille
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Benjamin Marchandot
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Mélanie Girardey
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Clotilde Muller
- Pôle NUDE, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Han S Lim
- Department of Cardiology, Austin and Northern Health, Melbourne 3084, Australia.
| | - Annie Trinh
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Patrick Ohlmann
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Bruno Moulin
- Pôle NUDE, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Laurence Jesel
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
- Laboratory of Regenerative Nanomedicine, UMR 1260, INSERM (French National Institute of Health and Medical Research), FMTS (Fédération de Médecine Translationnelle de l'Université de Strasbourg), Faculté de Médecine, Université de Strasbourg, 11 rue Humann, 67085 Strasbourg, France.
| | - Olivier Morel
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
- Laboratory of Regenerative Nanomedicine, UMR 1260, INSERM (French National Institute of Health and Medical Research), FMTS (Fédération de Médecine Translationnelle de l'Université de Strasbourg), Faculté de Médecine, Université de Strasbourg, 11 rue Humann, 67085 Strasbourg, France.
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Grothusen C, Lankeit M, Olsson K, Panholzer B, Haneya A, Cremer J. Akute Lungenembolie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-018-0286-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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193
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Na YS, Jang S, Hong S, Oh YM, Lee SD, Lee JS. Clinical Phenotype of a First Unprovoked Acute Pulmonary Embolism Associated with Antiphospholipid Antibody Syndrome. Tuberc Respir Dis (Seoul) 2019; 82:53-61. [PMID: 30574689 PMCID: PMC6304333 DOI: 10.4046/trd.2018.0045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 07/22/2018] [Accepted: 10/16/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Antiphospholipid antibody syndrome (APS), an important cause of acquired thrombophilia, is diagnosed when vascular thrombosis or pregnancy morbidity occurs with persistently positive antiphospholipid antibodies (aPL). APS is a risk factor for unprovoked recurrence of pulmonary embolism (PE). Performing laboratory testing for aPL after a first unprovoked acute PE is controversial. We investigated if a specific phenotype existed in patients with unprovoked with acute PE, suggesting the need to evaluate them for APS. METHODS We retrospectively reviewed patients with PE and APS (n=24) and those with unprovoked PE with aPL negative (n=44), evaluated 2006-2016 at the Asan Medical Center. We compared patient demographics, clinical manifestations, laboratory findings, and radiological findings between the groups. RESULTS On multivariate logistic regression analysis, two models of independent risk factors for APS-PE were suggested. Model I included hemoptysis (odds ratio [OR], 12.897; 95% confidence interval [CI], 1.025-162.343), low PE severity index (OR, 0.948; 95% CI, 0.917-0.979), and activated partial thromboplastin time (aPTT; OR, 1.166; 95% CI, 1.040-1.307). Model II included age (OR, 0.930; 95% CI, 0.893-0.969) and aPTT (OR, 1.104; 95% CI, 1.000-1.217). CONCLUSION We conclude that patients with first unprovoked PE with hemoptysis and are age <40; have a low pulmonary embolism severity index, especially in risk class I-II; and/or prolonged aPTT (above 75th percentile of the reference interval), should be suspected of having APS, and undergo laboratory testing for aPL.
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Affiliation(s)
- Yong Sub Na
- Department of Pulmonary and Critical Care Medicine, Chosun University Hospital, Gwangju, Korea
| | - Seongsoo Jang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seokchan Hong
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon Mok Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Do Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, Center for Pulmonary Hypertension and Venous Thrombosis, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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194
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Stoeva N, Staneva M, Kirova G, Bakalova R. Deep venous thrombosis in the clinical course of pulmonary embolism. Phlebology 2018; 34:453-458. [PMID: 30582739 DOI: 10.1177/0268355518819510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objectives The aim of the study is to find how concomitant deep venous thrombosis (DVT) changes the clinical course of pulmonary embolism. Methods Three hundred and five patients with pulmonary embolism were examined and grouped into DVT and non-DVT groups. Both groups were compared with regard to demography, predisposing factors, clinical signs, thrombotic burden, and one-month mortality rate. Results The patients with DVT had a more severe clinical presentation: higher heart rate (94.80 ± 18.66 beats per minute versus 87.9 ± 13.90 in the non-DVT group, p = 0.00033), more hemodynamic instability (11.35% versus 3.05% in the non-DVT group, p = 0.005), and less pCO2 in arterial blood gases (30.81 ± 7.94 mmHg versus 32.59 ± 7.35 mmHg in the non-DVT group, p = 0.049). The DVT group had heavier thrombotic burden in pulmonary artery, measured by Mastora score. The one-month mortality rate did not differ statistically between groups. Conclusions Patients with symptomatic pulmonary embolism and concomitant DVT have heavier thrombotic burden in the pulmonary artery and more severe clinical presentation compared to those without DVT, but a similar one-month mortality rate.
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Affiliation(s)
- Natalia Stoeva
- 1 Pulmonary Department, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Milena Staneva
- 2 Angiology Department, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Galina Kirova
- 3 Imaging Department, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Rumiana Bakalova
- 4 Department of Molecular Imaging and Theranostics, National Institute of Radiological Sciences, QST, Chiba, Japan.,5 Group of Quantum-state Controlled MRI, National Institute of Radiological Sciences, QST, Chiba, Japan.,6 Medical Faculty, Sofia University "St. Kliment Ohridski", Sofia, Bulgaria
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195
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Vinson DR, Mark DG, Chettipally UK, Huang J, Rauchwerger AS, Reed ME, Lin JS, Kene MV, Wang DH, Sax DR, Pleshakov TS, McLachlan ID, Yamin CK, Elms AR, Iskin HR, Vemula R, Yealy DM, Ballard DW. Increasing Safe Outpatient Management of Emergency Department Patients With Pulmonary Embolism: A Controlled Pragmatic Trial. Ann Intern Med 2018; 169:855-865. [PMID: 30422263 DOI: 10.7326/m18-1206] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Many low-risk patients with acute pulmonary embolism (PE) in the emergency department (ED) are eligible for outpatient care but are hospitalized nonetheless. One impediment to home discharge is the difficulty of identifying which patients can safely forgo hospitalization. OBJECTIVE To evaluate the effect of an integrated electronic clinical decision support system (CDSS) to facilitate risk stratification and decision making at the site of care for patients with acute PE. DESIGN Controlled pragmatic trial. (ClinicalTrials.gov: NCT03601676). SETTING All 21 community EDs of an integrated health care delivery system (Kaiser Permanente Northern California). PATIENTS Adult ED patients with acute PE. INTERVENTION Ten intervention sites selected by convenience received a multidimensional technology and education intervention at month 9 of a 16-month study period (January 2014 to April 2015); the remaining 11 sites served as concurrent controls. MEASUREMENTS The primary outcome was discharge to home from either the ED or a short-term (<24-hour) outpatient observation unit based in the ED. Adverse outcomes included return visits for PE-related symptoms within 5 days and recurrent venous thromboembolism, major hemorrhage, and all-cause mortality within 30 days. A difference-in-differences approach was used to compare pre-post changes at intervention versus control sites, with adjustment for demographic and clinical characteristics. RESULTS Among 881 eligible patients diagnosed with PE at intervention sites and 822 at control sites, adjusted home discharge increased at intervention sites (17.4% pre- to 28.0% postintervention) without a concurrent increase at control sites (15.1% pre- and 14.5% postintervention). The difference-in-differences comparison was 11.3 percentage points (95% CI, 3.0 to 19.5 percentage points; P = 0.007). No increases were seen in 5-day return visits related to PE or in 30-day major adverse outcomes associated with CDSS implementation. LIMITATION Lack of random allocation. CONCLUSION Implementation and structured promotion of a CDSS to aid physicians in site-of-care decision making for ED patients with acute PE safely increased outpatient management. PRIMARY FUNDING SOURCE Garfield Memorial National Research Fund and The Permanente Medical Group Delivery Science and Physician Researcher Programs.
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Affiliation(s)
- David R Vinson
- The Permanente Medical Group and Kaiser Permanente Northern California, Oakland, and Kaiser Permanente Sacramento Medical Center, Sacramento, California (D.R.V.)
| | - Dustin G Mark
- The Permanente Medical Group, Kaiser Permanente Northern California, and Kaiser Permanente Oakland Medical Center, Oakland, California (D.G.M.)
| | - Uli K Chettipally
- The Permanente Medical Group, Oakland, and Kaiser Permanente South San Francisco Medical Center, South San Francisco, California (U.K.C.)
| | - Jie Huang
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - Adina S Rauchwerger
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - Mary E Reed
- Kaiser Permanente Northern California, Oakland, California (J.H., A.S.R., M.E.R.)
| | - James S Lin
- The Permanente Medical Group, Oakland, and Kaiser Permanente Santa Clara Medical Center, Sacramento, California (J.S.L.)
| | - Mamata V Kene
- The Permanente Medical Group, Oakland, and Kaiser Permanente San Leandro Medical Center, Sacramento, California (M.V.K.)
| | | | - Dana R Sax
- The Permanente Medical Group and Kaiser Permanente Oakland Medical Center, Oakland, California (D.R.S., C.K.Y.)
| | - Tamara S Pleshakov
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California (T.S.P.)
| | - Ian D McLachlan
- The Permanente Medical Group, Oakland, and Kaiser Permanente San Francisco Medical Center, San Francisco, California (I.D.M.)
| | - Cyrus K Yamin
- The Permanente Medical Group and Kaiser Permanente Oakland Medical Center, Oakland, California (D.R.S., C.K.Y.)
| | - Andrew R Elms
- The Permanente Medical Group, Oakland, and Kaiser Permanente South Sacramento Medical Center, Sacramento, California (A.R.E.)
| | - Hilary R Iskin
- University of Michigan Medical School, Ann Arbor, Michigan (H.R.I.)
| | - Ridhima Vemula
- University of Cincinnati College of Medicine, Cincinnati, Ohio (R.V.)
| | - Donald M Yealy
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (D.M.Y.)
| | - Dustin W Ballard
- The Permanente Medical Group and Kaiser Permanente Northern California, Oakland, and Kaiser Permanente San Rafael Medical Center, San Rafael, California (D.W.B.)
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196
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Yamashita Y, Morimoto T, Amano H, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Izumi T, Tada T, Chen PM, Murata K, Tsuyuki Y, Saga S, Sasa T, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Watanabe H, Shiomi H, Kato T, Makiyama T, Ono K, Kimura T. Influence of Baseline Platelet Count on Outcomes in Patients With Venous Thromboembolism (from the COMMAND VTE Registry). Am J Cardiol 2018; 122:2131-2141. [PMID: 30293653 DOI: 10.1016/j.amjcard.2018.08.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/20/2018] [Accepted: 08/24/2018] [Indexed: 01/21/2023]
Abstract
The influence of thrombocytopenia on the long-term clinical outcomes has not been thoroughly evaluated in patients with venous thromboembolism (VTE). This study sought to elucidate association of baseline thrombocytopenia with bleeding, recurrent VTE, and mortality risk. We evaluated the influence of baseline thrombocytopenia among 3,012 patients whose baseline platelet counts were available in the COMMAND VTE Registry in Japan with a median follow-up period of 1,219 days. Baseline thrombocytopenia was classified as follows: mild: 100,000 to 150,000/μl; moderate: 50,000 to 99,999/μl; and severe: <50,000/μl. The primary outcome measurement was International Society of Thrombosis and Hemostasis major bleeding, and the secondary outcome measurements were recurrent VTE and all-cause death. There were 167 patients (5.5%) with moderate or severe thrombocytopenia (moderate: 144 patients and severe: 23 patients), 523 patients (17.4%) with mild thrombocytopenia, and 2,322 patients (77.1%) without thrombocytopenia. The cumulative 5-year incidence of major bleeding was markedly higher in patients with moderate or severe thrombocytopenia (moderate or severe 29.4% vs mild: 14.1% vs no thrombocytopenia: 10.6%, p <0.001). After adjusting the confounders, the risk of or thrombocytopenia relative to no thrombocytopenia for major bleeding remained significant (adjusted hazard ratio [HR] 2.15, 95% confidence interval [CI] 1.43 to 3.13, p <0.001). The excess risk of moderate or severe thrombocytopenia relative to no thrombocytopenia was also significant for mortality (adjusted HR 1.54, 95% CI 1.18 to 1.97, p = 0.002), but the risk was neutral for recurrent VTE (adjusted HR 1.05, 95% CI 0.55 to 1.81, p = 0.87). In conclusion, VTE patients with baseline moderate or severe thrombocytopenia had higher risk for major bleeding events and mortality without significant excess risk for recurrent VTE events.
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Affiliation(s)
- Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hidewo Amano
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Seiichi Hiramori
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Toshiaki Izumi
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yoshiaki Tsuyuki
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Syunsuke Saga
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Jiro Sakamoto
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | | | - Kiyonori Togi
- Division of Cardiology, Faculty of Medicine, Nara Hospital, Kinki University, Ikoma, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | | | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
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197
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Barrett TW, Freeman CL. Outpatient Pulmonary Embolism Management: If You Walk Into the Emergency Department With a Pulmonary Embolism, Maybe You Should Also Walk Out. Ann Emerg Med 2018; 72:725-730. [DOI: 10.1016/j.annemergmed.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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198
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Freeland ZK, Clayton JT, Rosenblatt RL. Management of pulmonary embolism at a large academic hospital. Proc (Bayl Univ Med Cent) 2018; 32:9-13. [PMID: 30956571 DOI: 10.1080/08998280.2018.1503476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 07/16/2018] [Accepted: 07/19/2018] [Indexed: 10/27/2022] Open
Abstract
The initial management of patients presenting with acute pulmonary embolism (PE) is individualized based on hemodynamic status and other prognostic factors. Patients at low risk of adverse outcomes are treated conservatively with anticoagulation, whereas high-risk and selected intermediate-risk patients should be considered for advanced interventions. Seeking to better understand local practice patterns, we retrospectively reviewed 196 cases of acute PE diagnosed in the emergency department of Baylor University Medical Center over a 12-month period. Given the available data, we classified 86 cases as low risk, 101 as intermediate risk, and 9 as high risk for early mortality. Four patients with high-risk PE and 11 patients with intermediate-risk PE were treated with thrombolytic therapy. Central embolus location, right ventricular dilation on computed tomography, and right ventricular strain on electrocardiogram were associated with the use of thrombolytic therapy in the intermediate-risk group. In total, 9 patients died and 11 suffered major bleeding. Patients with acute PE are a remarkably heterogeneous group with wide variations in workup, treatment, and outcomes.
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Affiliation(s)
- Zachary K Freeland
- Department of Internal Medicine, Baylor University Medical CenterDallasTexas
| | - Joshua T Clayton
- Department of Radiology, Baylor University Medical CenterDallasTexas
| | - Randall L Rosenblatt
- Division of Pulmonary and Critical Care Medicine, Baylor University Medical CenterDallasTexas
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199
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Weeda ER, Butt S. Systematic Review of Real-World Studies Evaluating Characteristics Associated With or Programs Designed to Facilitate Outpatient Management of Deep Vein Thrombosis. Clin Appl Thromb Hemost 2018; 24:301S-313S. [PMID: 30428693 PMCID: PMC6714833 DOI: 10.1177/1076029618811082] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Select patients with acute deep vein thrombosis (DVT) can be managed as outpatients. We sought to conduct a systematic review of real-world studies describing either (1) the clinical characteristics associated with outpatient DVT treatment in all-comers or (2) emergency department (ED) programs designed to facilitate outpatient DVT treatment. MEDLINE and SCOPUS were searched (January 1, 2012, to May 1, 2018) to identify citations meeting the aforementioned criteria. Twenty-one real-world studies were included. The proportion of all-comer patients with DVT managed as outpatients was ≤50% in 11 of 15 studies. With the exception of younger age, no characteristics were consistently associated with outpatient treatment across the 13 studies reporting these characteristics. We identified 8 studies describing ED programs aimed at facilitating DVT outpatient treatment, all of which provided education and included measures to encourage early outpatient follow-up after ED discharge. In conclusion, the proportion of patients with DVT managed as outpatients across real-world studies was low. Several ED programs aimed at facilitating this treatment have been described. It is possible that programs similar to these will increase the proportion of patients with DVT that can be safely managed as outpatients.
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Affiliation(s)
- Erin R Weeda
- Department of Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
| | - Sofia Butt
- Department of Clinical Pharmacy and Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
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200
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Ermin S, Çinkooğlu A, Susam S, Batum Ö, Yılmaz U. A new perspective for pulmonary thromboembolism radiology: 'Pulmonary vein sign'. CLINICAL RESPIRATORY JOURNAL 2018; 12:2653-2658. [PMID: 30341929 DOI: 10.1111/crj.12971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 08/12/2018] [Accepted: 10/15/2018] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Pulmonary thromboembolism (PTE) is a clinical condition that can result in sudden death. Computed tomography pulmonary angiography (CTPA) is the most sensitive imaging technique for the diagnosis of PTE. Filling defects in the pulmonary veins, which can be identified in areas adjacent to PTE, have been named the 'pulmonary vein sign' (PVS). OBJECTIVES The aim of our study is to determine the frequency, sensitivity and specificity of PVS due to the decreased venous drainage in the affected area in PTE patients. METHODS Patients who were admitted to the emergency department due to the suspicion of PTE and who underwent CTPA were evaluated retrospectively. The study group consisted of the patients who had an arterial filling defect on CTPA and were diagnosed with PTE. The control group consisted of the patients who had no arterial filling defect on CTPA. RESULTS This study included 286 patients with a mean age of 62(20-94) years. The PVS was detected in 51(32.7%) of the patients in the study group and in 15(11.5%) of the patients in the control group. The PVS had a sensitivity of 32.69%, a specificity of 88.46%, a positive predictive value of 77.27% and a negative predictive value of 52.27% for PTE. The PVS was significantly more common in the patients having PTE in the bilateral pulmonary arteries or the main pulmonary arteries. CONCLUSION Despite low sensitivity, the presence of PVS on CTPA is a radiographic marker with high specificity for PTE. To use in practice, there is need for studies with large numbers of patients.
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Affiliation(s)
- Sinem Ermin
- Department of Chest Diseases, Dr Suat Seren Chest Diseases and Surgery Training and Research Hospital, University of Health Sciences, Izmir, Turkey
| | - Akın Çinkooğlu
- Deparment of Radiology, Dr Suat Seren Chest Diseases and Surgery Training and Research Hospital, University of Health Sciences, Izmir, Turkey
| | - Seher Susam
- Deparment of Radiology, Dr Suat Seren Chest Diseases and Surgery Training and Research Hospital, University of Health Sciences, Izmir, Turkey
| | - Özgür Batum
- Department of Chest Diseases, Dr Suat Seren Chest Diseases and Surgery Training and Research Hospital, University of Health Sciences, Izmir, Turkey
| | - Ufuk Yılmaz
- Department of Chest Diseases, Dr Suat Seren Chest Diseases and Surgery Training and Research Hospital, University of Health Sciences, Izmir, Turkey
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