Does Thrombolysis Have a Place in the Cardiopulmonary Resuscitation of Patients With Acute Pulmonary Embolism? A Case of Successful Thrombolysis During Pulmonary Embolism Induced Cardiopulmonary Arrest

OBJECTIVE

Pulmonary embolism often causes cardiac arrest. When this occurs, thrombolytic therapy is not routinely administered. There are multiple reasons for this, including difficulty with rapidly adequately diagnosing the embolus, the lack of good data supporting the use of thrombolytics during resuscitation, the belief that thrombolytic therapy is ineffective once a patient has already arrested, the difficulty of obtaining thrombolytics at the bedside rapidly enough to administer during a code, and the increased risks of bleeding, particularly with ongoing chest compressions. In this case report, we present a patient who was successfully treated with thrombolytic therapy during pulmonary embolism-induced cardiopulmonary arrest and discuss the role of thrombolytics in cardiopulmonary resuscitation.

DESIGN

Case report.

SETTING

Surgical ICU in a comprehensive cancer center.

PATIENT

A 56-year-old man who developed hypotension, dyspnea, hypoxia, and pulseless electrical activity 10 days after resection of a benign colon lesion with a right hemicolectomy and primary end-to-end anastomosis.

INTERVENTIONS

After a rapid bedside echocardiogram suggesting pulmonary embolus, thrombolytic therapy was administered during cardiopulmonary resuscitative efforts.

MEASUREMENTS AND MAIN RESULTS

The patient had a return of spontaneous circulation and showed improvement in repeat echocardiographic imaging. He had a prolonged course in the ICU and hospital, but eventually made an essentially complete clinical recovery.

CONCLUSION

As bedside echocardiographic technology becomes more rapidly and readily available, the rapid diagnosis of pulmonary embolism and use of thrombolytics during cardiopulmonary resuscitation may need to be more routinely considered a potential therapeutic adjunctive measure.

Rheolytic thrombectomy in patient with acute pulmonary embolism, heparin-induced thrombocytopenia and recent stoke. When percutaneous treatment is the only therapeutic alternative

To report the combined use of rheolytic thrombectomy (RT) and inferior vena cava (IVC) filter placement in the setting of acute pulmonary embolism (PE), heparin-induced thrombocytopenia (HIT) type II (HIT-II) and recent ischemic stroke. A 66-year-old man with an HIT-II and recent ischemic stroke was referred to our institution from a secondary regional center for acute PE and left deep vein thrombosis (DVT), confirmed at chest computed tomography (CT) and lower limb ultrasound, respectively. RT was attempted because intravenous heparin anticoagulation was contraindicated by the patient’s medical history while recent ischemic stroke contraindicated thrombolysis. An Angiojet® catheter was used to perform RT. An IVC filter was placed after the procedure. The patient was discharged after 13 days and did very well, both at the 6- and 12-month follow-ups, with no recurrence of the venous thromboembolism. This case demonstrates the usefulness of RT in treating acute PE in clinically difficult scenarios, especially when thrombolytic therapy is contraindicated.

Improved early right ventricular function recovery but increased complications with catheter-directed interventions compared with anticoagulation alone for submassive pulmonary embolism

OBJECTIVE

The purpose of this study was to determine the short-term and midterm outcomes of catheter-directed intervention (CDI) compared with anticoagulation (AC) alone in patients with submassive pulmonary embolism (sPE).

METHODS

This was a retrospective review of all patients treated for sPE between January 2009 and October 2014. Two groups were identified on the basis of the therapy: AC and CDI. End points included complications, mortality, and change in echocardiographic parameters. Standard statistical techniques were used.

RESULTS

There were 64 patients who received AC and 64 patients who received CDI (five were initially treated with AC but did not improve or worsened; six received ≤8 mg of tissue plasminogen activator). Most baseline characteristics, including the Pulmonary Embolism Severity Index, were similar among the AC and CDI groups. There was no difference in PE-related death (one in each group) or major bleeding events (three in the AC group, four in the CDI group), but CDIs had two additional procedural complications that required open heart surgery. CDIs showed significantly more minor bleeding events (6 vs 0; P = .028) and significantly shorter intensive care unit stay (2.7 ± 2.1 vs 5.6 ± 7.5 days; P = .04). The mean difference in right ventricular/left ventricular ratio from baseline to the first subsequent echocardiogram (within 30 days) showed a trend for higher reduction in favor of CDI (AC, 0.17 ± 0.12; CDI, 0.27 ± 0.15; P = .076). Between 3 and 8 months, significant improvement was evident within groups in all assessed right-sided heart echocardiographic parameters, but there was no difference between groups. Pulmonary hypertension (pulmonary artery pressure >40 mm Hg) was present in 7 of 15 of the AC group vs 6 of 19 of the CDI group (P = .484). During the follow-up, dyspnea or oxygen dependence, not existing before the index PE event, was recorded in 5 of 49 (10.2%) of the AC patients and 8 of 52 (15.4%) of the CDI patients (P = .556).

CONCLUSIONS

CDI for sPE can result in faster restoration of right ventricular function and shorter intensive care unit stay, but at the cost of a higher complication rate, with similar midterm outcomes compared with AC alone. A potential effect of CDI on mortality and pulmonary hypertension needs further investigation through larger studies.

Rivaroxaban for the treatment of venous thromboembolism. The SWIss Venous ThromboEmbolism Registry (SWIVTER)

We investigated three-month clinical outcomes in patients with venous thromboembolism (VTE) treated with rivaroxaban or conventional anticoagulation in routine clinical practice. Between November 2012 and February 2015, 2,062 consecutive patients with VTE from 11 acute care hospitals in Switzerland were enrolled in the SWIss Venous ThromboEmbolism Registry (SWIVTER). Overall, 417 (20 %) patients were treated with rivaroxaban. In comparison to 1,645 patients on conventional anticoagulation, patients on rivaroxaban were younger (56 ± 18 vs. 65 ± 17 years; p<0.001), less often had pulmonary embolism (38 % vs 66 %; p<0.001), hypertension (26 % vs 41 %; p<0.001), cancer (10 % vs 28 %; p<0.001), congestive heart failure (10 % vs 17 %; p=0.001), diabetes (8 % vs 15 %; p<0.001), chronic lung disease (7 % vs 13 %; p=0.001), renal insufficiency (7 % vs 13 %; p=0.001), recent surgery (7 % vs 14 %; p<0.001), and acute coronary syndrome (1 % vs 4 %; p=0.009). VTE reperfusion therapy was more frequently used (28 % vs 9 %; p<0.001) and indefinite-duration anticoagulation treatment less often planned (26 % vs 39 %; p<0.001), respectively. In the propensity score-adjusted population, the risk of recurrent VTE was similar in patients on rivaroxaban vs conventional anticoagulation (1.2 % vs 2.1 %, hazard ratio [HR] 0.55, 95 % confidence interval [CI] 0.18-1.65; p=0.29); the risk of major bleeding was also similar, respectively (0.5 % vs 0.5 %, HR 1.00, 95 %CI 0.14-7.07; p=1.00). Conventional anticoagulation is still frequently used for the treatment of VTE, particularly in the elderly and those with comorbidities. Early clinical outcomes were comparable between propensity score-adjusted patient populations on rivaroxaban and conventional anticoagulation.

Serum microRNA-1233 is a specific biomarker for diagnosing acute pulmonary embolism

Background

Circulating microRNAs (miRNAs) emerge as novel biomarkers in cardiovascular diseases. Diagnosing acute pulmonary embolism (PE) remains challenging due to a diverse clinical presentation and the lack of specific biomarkers. Here we evaluate serum miRNAs as potential biomarkers in acute PE.

Methods

We enrolled 30 patients with acute, CT (computed tomography)-angiographically confirmed central PE and collected serum samples on the day of emergency room admission (1st day) and from 22 of these patients 9 months thereafter. For comparison, we examined serum samples from patients with acute non ST-segment elevation myocardial infarction (NSTEMI, n = 30) and healthy individuals (n = 12).

Results

We randomly selected 16 out of 30 PE patients and screened sera from the acute (1st day) and chronic stages (9 months) for 754 miRNAs using microarrays and found 37 miRNAs to be differentially regulated. Across all miRNAs, miRNA-1233 displayed the highest fold change (FC) from acute to chronic stage (log₂FC 11.5, p < 0.004). We validated miRNA-1233 by real-time quantitative polymerase chain reaction (RT-qPCR). In acute PE (1st day) we found elevated levels of miRNA-1233 in comparison to NSTEMI (log₂FC 5.7, p < 0.0001) and healthy controls (log₂FC 7.7, p < 0.0001). miRNA-1233 differentiated acute PE from NSTEMI patients and healthy individuals with 90 and 90 % sensitivity, and 100 and 92 % specificity [area under the curve (AUC) 0.95, p < 0.001 and 0.91, p < 0.001], respectively.

Conclusions

This is the first report that identifies a miRNA that allows distinguishing acute PE from acute NSTEMI and healthy individuals with high specificity and sensitivity.

Molecular Imaging of Activated Platelets Allows the Detection of Pulmonary Embolism with Magnetic Resonance Imaging

Early and reliable detection of pulmonary embolism (PE) is critical for improving patient morbidity and mortality. The desire for low-threshold screening for pulmonary embolism is contradicted by unfavorable radiation of currently used computed tomography or nuclear techniques, while standard magnetic resonance imaging still struggles to provide sufficient diagnostic sensitivity in the lung. In this study we evaluate a molecular-targeted contrast agent against activated platelets for non-invasive detection of murine pulmonary thromboembolism using magnetic resonance imaging. By intravenous injection of human thrombin, pulmonary thromboembolism were consistently induced as confirmed by immunohistochemistry of the lung. Magnetic resonance imaging after thrombin injection showed local tissue edema in weighted images which co-localized with the histological presence of pulmonary thromboembolism. Furthermore, injection of a functionalized contrast agent targeting activated platelets provided sensitive evidence of focal accumulation of activated platelets within the edematous area, which, ex vivo, correlated well with the size of the pulmonary embolism. In summary, we here show delivery and specific binding of a functionalized molecular contrast agent against activated platelets for targeting pulmonary thromboembolism. Going forward, molecular imaging may provide new opportunities to increase sensitivity of magnetic resonance imaging for detection of pulmonary embolism.

[Dyspnea. From the concept up to diagnostics]

Dyspnea represents one of the most frequent and heterogeneous symptoms. The term dyspnea describes the subjective perception of an inadequate effort to breathe. In general, acute and chronic forms have to be differentiated. Due to its prognostic implications a structured work-up to find the correct diagnosis is of great importance. Depending on the condition of the patient, simple algorithms including biomarkers, an electrocardiogram, echocardiography and other imaging procedures are used when needed. Especially in its acute appearance life-threatening situations, such as myocardial ischemia, heart failure, pulmonary embolism and pneumothorax have to be rapidly and effectively excluded in the differential diagnostics. In contrast, the underlying diseases in chronic dyspnea are bronchial asthma, chronic obstructive airway diseases, heart failure and a combination of obesity and deconditioning in up to 85 % of all cases. The differential diagnosis needs a structured approach including anamnestic and medical technical methods, aiming an efficient differentiation of cardiac and pulmonary causes. As a high number of patients suffer from more than one significant disease, the differential diagnostic assessment needs to be focused on the assessment of the predominant cause of the dyspnea. For this purpose, exercise tests provide helpful algorithms to answer this question.

[Dyspnea in airway and pulmonary diseases]

The subjective perception of pulmonary dyspnea varies based on behavioral and physiological responses. Acute pulmonary dyspnea is the most common symptom of diseases of the airways and the lungs and the differential diagnosis includes harmless causes, such as lack of training as well as acute life-threatening diseases, such as thromboembolism, obstruction of the upper or lower airway, pneumonia, pulmonary hemorrhage and pneumothorax. Most cases of chronic pulmonary dyspnea result from asthma, chronic obstructive pulmonary disease (COPD), pulmonary arterial hypertension, pulmonary fibrosis and pleural disorders. Listening to the patient's "language of dyspnea" may already provide indications for the diagnosis. Initial testing includes chest radiography, spirometry, complete blood count and the basic metabolic panel. Measurement of brain natriuretic peptide levels may help to exclude heart failure in COPD and D-dimer testing may help rule out pulmonary embolisms. Computed tomography of the chest is the most appropriate imaging procedure for diagnosing pulmonary embolism and interstitial lung disease. To diagnose pulmonary arterial hypertension echocardiography and right heart catheterization may be necessary.

Giant right ventricular outflow tract thrombus in hereditary spherocytosis: a case report

Background

In hereditary spherocytosis with severe anemia, splenectomy is a recommended treatment. However, the spleen carries an important role both in immune function and coagulation. The increased risk of bacterial infections associated with splenectomy is well known. Recently, hypercoagulation disorders have also been linked to splenectomy through loss of regulation of platelet activity, loss of filtering function and post-splenectomy thrombocytosis.

Case presentation

A 28 year-old smoking women who had previously undergone splenectomy due to hereditary spherocytosis with a moderate thrombocytosis (platelet count 553–635*10⁹/L), presented with recurrent episodes of pulmonary embolisms. Further examination by multimodality cardiac imaging demonstrated a giant chronic thrombus in the right ventricular outflow tract, which eventually had to be surgically removed.

Conclusions

The present case highlights the increased risk of severe thromboembolic complications following therapeutic splenectomy in hereditary spherocytosis, and emphasis the important role of multimodality cardiac imaging in recurrent pulmonary embolism, diagnosing a giant chronic thrombus in the right ventricular outflow tract.

Electronic supplementary material

The online version of this article (doi:10.1186/s12959-016-0083-3) contains supplementary material, which is available to authorized users.

Role of clinical and pulmonary computed tomography angiographic parameters in the prediction of short- and long-term mortality in patients with pulmonary embolism

The utility of pulmonary computed tomography angiography (CTA) in the prediction of short- and long-term outcomes after pulmonary embolism (PE) is controversial. Between November 2011 and September 2014, 190 normotensive patients (age, 61 ± 16.90 years, 53.7 % female) were diagnosed with acute PE using a 128-slice dual-source pulmonary CTA scanner. All the related clinical and cardiovascular measurements were recorded. Primary endpoints were 30-day PE-related death, 30-day composite complications (death, hemodynamic instability, thrombolysis and thrombectomy, inotrope, and mechanical ventilation use), and long-term all-cause mortality during a median follow-up of 14.78 months. Overall 1-month mortality is 5.8 %, and death is PE-related in 4.7 % of total patients. Although non-significant, O2 saturation <90 % and the right ventricular short-axis to left ventricular short-axis diameters (RV/LV) ratio increase the risk of PE-related death by 3.5 and 2 times, respectively. The independent predictors of 30-day complications (15.8 %) are O2 saturation <90 % (OR: 3.924, 95 % CI 1.505-10.229), RV/LV ratio (OR: 3.018, 95 % CI 1.455-6.263), and heart rate ≥ 110 beats/min (OR: 2.607, 95 % CI 1.063-6.391). For long-term mortality (13.7 %), O2 saturation <90 % is an independent predictor (HR: 4.454, 95 % CI 2.016-8.862). The independent impact of the RV/LV ratio on the long-term mortality has a trend towards statistical significance (HR: 1.762, 95 % CI 0.968-4.218; p value = 0.064). The PE-related death is 4.7 % within 30 days after admisson and 13.7 % after a median follow-up of 14 months. Among the pulmonary CTA parameters, only the RV/LV ratio and among the clinical and paraclinical measures, O2 saturation <90 % remain independent predictors of short- and long-term mortality and complications after the diagnosis of PE.

Home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban. Rationale and design of the HoT-PE Trial

Pulmonary embolism (PE) is a potentially life-threatening acute cardiovascular syndrome. However, more than 95 % of patients are haemodynamically stable at presentation, and among them are patients at truly low risk who may qualify for immediate or early discharge. The Home Treatment of Pulmonary Embolism (HoT-PE) study is a prospective international multicentre single-arm phase 4 management (cohort) trial aiming to determine whether home treatment of acute low-risk PE with the oral factor Xa inhibitor rivaroxaban is feasible, effective, and safe. Patients with confirmed PE, who have no right ventricular dysfunction or free floating thrombi in the right atrium or ventricle, are eligible if they meet none of the exclusion criteria indicating haemodynamic instability, serious comorbidity or any condition mandating hospitalisation, or a familial/social environment unable to support home treatment. The first dose of rivaroxaban is given in hospital, and patients are discharged within 48 hours of presentation. Rivaroxaban is taken for at least three months. The primary outcome is symptomatic recurrent venous thromboembolism or PE-related death within three months of enrolment. Secondary outcomes include quality of life and patient satisfaction, and health care resource utilisation compared to existing data on standard-duration hospital treatment. HoT-PE is planned to analyse 1,050 enrolled patients, providing 80 % power to reject the null hypothesis that the recurrence rate of venous thromboembolism is >3 % with α≤0.05. If the hypothesis of HoT-PE is confirmed, early discharge and out-of-hospital treatment may become an attractive, potentially cost-saving option for a significant proportion of patients with acute PE.

External validation of prognostic rules for early post-pulmonary embolism mortality: assessment of a claims-based and three clinical-based approaches

Background

Studies show the In-hospital Mortality for Pulmonary embolism using Claims daTa (IMPACT) rule can accurately identify pulmonary embolism (PE) patients at low-risk of early mortality in a retrospective setting using only claims for the index admission. We sought to externally validate IMPACT, Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI) and Hestia for predicting early mortality.

Methods

We identified consecutive adults admitted for objectively-confirmed PE between 10/21/2010 and 5/12/2015. Patients undergoing thrombolysis/embolectomy within 48 h were excluded. All-cause in-hospital and 30 day mortality (using available Social Security Death Index data through January 2014) were assessed and prognostic accuracies of IMPACT, PESI, sPESI and Hestia were determined.

Results

Twenty-one (2.6 %) of the 807 PE patients died before discharge. All rules classified 26.1–38.3 % of patients as low-risk for early mortality. Fatality among low-risk patients was 0 % (sPESI and Hestia), 0.4 % (IMPACT) and 0.6 % (PESI). IMPACT’s sensitivity was 95.2 % (95 % confidence interval [CI] = 74.1–99.8 %), and the sensitivities of clinical rules ranged from 91 (PESI)-100 % (sPESI and Hestia). Specificities of all rules ranged between 26.8 and 39.1 %. Of 573 consecutive patients in the 30 day mortality analysis, 33 (5.8 %) died. All rules classified 27.9–38.0 % of patients as low-risk, and fatality occurred in 0 (Hestia)-1.4 % (PESI) of low-risk patients. IMPACT’s sensitivity was 97.0 % (95%CI = 82.5–99.8 %), while sensitivities for clinical rules ranged from 91 (PESI)-100 % (Hestia). Specificities of rules ranged between 29.6 and 39.8 %.

Conclusion

In this analysis, IMPACT identified low-risk PE patients with similar accuracy as clinical rules. While not intended for prospective clinical decision-making, IMPACT appears useful for identification of low-risk PE patient in retrospective claims-based studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12959-016-0081-5) contains supplementary material, which is available to authorized users.

Recent advances in the management of pulmonary embolism: focus on the critically ill patients

The aim of this narrative review is to summarize for intensivists or any physicians managing “severe” pulmonary embolism (PE) the main recent advances or recommendations in the care of patients including risk stratification, diagnostic algorithm, hemodynamic management in the intensive care unit (ICU), recent data regarding the use of thrombolytic treatment and retrievable vena cava filters and finally results of direct oral anticoagulants. Thanks to the improvements achieved in the risk stratification of patients with PE, a better therapeutic approach is now recommended from diagnosis algorithm and indication to admission in ICU to indication of thrombolysis and general hemodynamic support in patients with shock. Given at current dosage, thrombolytic therapy is associated with a reduction in the combined end-point of mortality and hemodynamic decompensation in patients with intermediate-risk PE, but this is obtained without a decrease in overall mortality and with a significant increase in major extracranial and intracranial bleeding. In patients with high-intermediate-risk PE, thrombolytic therapy should be given in case of hemodynamic worsening. Vena cava filters are of little help when anticoagulant treatment is not contraindicated, even in patients with PE and features of clinical severity. Finally, direct oral anticoagulants have been shown to be as effective as and safer than the combination of low molecular weight heparin and vitamin K antagonist(s) in patients with venous thromboembolism and low- to intermediate-risk PE.

Is Routine Thromboprophylaxis Needed in Korean Patients Undergoing Unicompartmental Knee Arthroplasty?

This study was undertaken to determine the prevalence and the natural course of venous thromboembolism (VTE) without thromboprophylaxis to ascertain whether routine thromboprophylaxis is necessary following unicompartmental knee arthroplasty (UKA) in Korean patients. The medical records and multidetector row computed tomography (MDCT) imaging of the consecutive 77 UKAs in 70 patients were reviewed. In all patients, MDCTs were undertaken preoperatively and at 1-week after surgery, and VTE symptoms were evaluated. At postoperative 6-months, follow-up MDCTs were undertaken in all patients in whom VTEs were newly detected after surgery. VTE lesions were newly detected in 18 (26%) of the 70 patients. However, none of the patients complained of VTE-related symptoms and MDCT demonstrated that all VTEs were small and involved limited portion without lower leg edema or pleuroparenchymal complication. At the 6-month follow up MDCT, all types of VTEs were shown to be completely resolved, regardless of their location. All of the VTE lesions maintained an asymptomatic status for 6-month after surgery. VTE following UKA in Korean patients who do not receive thromboprophylaxis seems to occur frequently, but all of the VTEs are clinically insignificant and all VTEs are spontaneously regressed. Routine thromboprophylaxis or thrombolytic treatment in Korean patients undergoing UKA may not be necessary.

Admission Glucose Level Predicts In-hospital Mortality in Patients with Acute Pulmonary Embolism Who Were Treated with Thrombolytic Therapy

BACKGROUND

Elevated admission serum glucose level is associated with unfavourable clinical outcomes in various clinical conditions. The aim of this study was to investigate the relationship between admission glucose levels and in-hospital and long-term adverse clinical outcomes in patients with pulmonary embolism (PE) treated with thrombolytic therapy.

METHODS

A total of 183 consecutive confirmed acute PE patients (98 female and 85 male; mean age 61.9 ± 15.7 years) who were treated with thrombolytic therapy enrolled in this study. The study population was categorised into four quartiles according to admission serum glucose levels (group I: glucose ≤115 mg/dl; group II: glucose >115-141 mg/dl; group III: glucose >141-195 mg/dl; and group IV: glucose ≥196 mg/dl).

RESULTS

In-hospital mortality was significantly higher in group IV (28.8 %) compared to group III (15.2 %), group II (6.6 %), and group I (2.1 %) (p < 0.001). In multivariate analysis, admission glucose level (OR 1.013, 95 % CI 1.004-1.021, p = 0.004) and admission anaemia (OR 0.602, 95 % CI 0.380-0.955, p = 0.03) were independent predictors of in-hospital mortality. The mean follow-up period was 34 months. During long-term follow-up, all-cause mortality, recurrent PE, major and minor bleeding were similar among the four groups.

CONCLUSION

Admission glucose level is a simple, inexpensive, easily available, and effective laboratory parameter for predicting in-hospital mortality in patients with PE.

Chest pain: coronary CT in the ER

Cardiac CT has developed into a robust clinical tool during the past 15 years. Of the fields in which the potential of cardiac CT has raised more interest is chest pain in acute settings. In fact, the possibility to exclude with high reliability obstructive coronary artery disease (CAD) in patients at low-to-intermediate risk is of great interest both from the clinical standpoint and from the management standpoint. Several other modalities, with or without imaging, have been used during the past decades in the settings of new onset chest pain or in acute chest pain for both diagnostic and prognostic assessment of CAD. Each one has advantages and disadvantages. Most imaging modalities also focus on inducible ischaemia to guide referral to invasive coronary angiography. The advent of cardiac CT has introduced a new practice diagnostic paradigm, being the most accurate non-invasive method for identification and exclusion of CAD. Furthermore, the detection of subclinical CAD and plaque imaging offer the opportunity to improve risk stratification. Moreover, recent advances of the latest generation CT scanners allow combining both anatomical and functional imaging by stress myocardial perfusion. The role of cardiac CT in acute settings is already important and will become progressively more important in the coming years.

Role of cardiovascular magnetic resonance in the guidelines of the European Society of Cardiology

BACKGROUND

Despite common enthusiasm for cardiovascular magnetic resonance (CMR), its application in Europe is quite diverse. Restrictions are attributed to a number of factors, like limited access, deficits in training, and incomplete reimbursement. Aim of this study is to perform a systematic summary of the representation of CMR in the guidelines of the European Society of Cardiology (ESC).

METHODS

Twenty-nine ESC guidelines were screened for the terms "magnetic", "MRI", "CMR", "MR" and "imaging". As 3 topics were published twice (endocarditis, pulmonary hypertension, NSTEMI), 26 guidelines were finally included. MRI in the context of non-cardiovascular examinations was not recognized. The main CMR-related conclusions and, if available, the level of evidence and the class of recommendation were extracted.

RESULTS

Fourteen of the 26 guidelines (53.8%) contain specific recommendations regarding the use of CMR. Nine guidelines (34.6%) mention CMR in the text, and 3 (11.5%) do not mention CMR. The 14 guidelines with recommendations regarding the use of CMR contain 39 class-I recommendations, 12 class-IIa recommendations, 10 class-IIb recommendations and 2 class-III recommendations. Most of the recommendations have evidence level C (41/63; 65.1%), followed by level B (16/63; 25.4%) and level A (6/63; 9.5%). The four guidelines, which absolutely contained most recommendations for CMR, were stable coronary artery disease (n = 14), aortic diseases (n = 9), HCM (n = 7) and myocardial revascularization (n = 7).

CONCLUSIONS

CMR is represented in the majority of the ESC guidelines. They contain many recommendations in favour of the use of CMR in specific scenarios. Issues regarding access, training and reimbursement have to be solved to offer CMR to patients in accordance with the ESC guidelines.

A Case of Klippel-Trenaunay Syndrome with Acute Submassive Pulmonary Thromboembolism Treated with Thrombolytic Therapy

Klippel-Trenaunay syndrome is a rare congenital mesodermal abnormality characterized by varicose veins, cutaneous hemangiomas, soft tissue and bony hypertrophy of limb. Potential complications such as deep venous thrombosis and pulmonary thromboembolism have not been reported in Korea to date. We demonstrate the case of a 48-year-old woman with Klippel-Trenaunay syndrome with extensive varicose veins on right lower limb, hypertrophy of left big toe and basilar artery tip aneurysm, complicated with acute submassive pulmonary thromboembolism treated successfully with intravenous thrombolytic therapy.

Recent developments in the diagnosis and treatment of pulmonary embolism

Due to the nonspecific symptoms of the condition, a diagnosis of acute pulmonary embolism (PE) is frequently considered. However, PE will only be confirmed in 10-20% of patients. Because the imaging test of choice, computed tomography pulmonary angiography (CTPA), is costly and associated with radiation exposure and other complications, a validated diagnostic algorithm consisting of a clinical decision rule and D-dimer test should be used to safely exclude PE in 20-30% of patients without the need for CTPA. Recently, the age-adjusted D-dimer threshold has been validated, and this has increased the proportion of patients at older age in whom PE can be excluded without CTPA. Initial therapeutic management of PE depends on the risk of short-term PE-related mortality. Haemodynamically unstable patients should be closely monitored and receive thrombolytic therapy unless contraindicated because of an unacceptably high bleeding risk, whereas patients with low-risk PE may be safely discharged early from hospital or receive only outpatient treatment. The PESI score and Hestia decision rule are available to select patients in whom early discharge or outpatient treatment will be safe, although the safety of these strategies should be confirmed in additional studies. Standard PE therapy consists of low molecular weight heparin (LMWH) followed by vitamin K antagonists (VKAs). Recently, several nonvitamin K-dependent oral anticoagulants have been shown to be as effective as LMWH/VKAs, and maybe safer. Determining the optimal duration of treatment for a first unprovoked PE remains a challenge, although clinical prediction rules for estimating the risk of recurrence of venous thromboembolism and anticoagulation-associated haemorrhage are under investigation. Using these prediction rules may lead to both more standardized and more individualized long-term treatment of PE.

Guidance for the treatment and prevention of obstetric-associated venous thromboembolism

Venous thromboembolism (VTE), which may manifest as pulmonary embolism (PE) or deep vein thrombosis (DVT), is a serious and potentially fatal condition. Treatment and prevention of obstetric-related VTE is complicated by the need to consider fetal, as well as maternal, wellbeing when making management decisions. Although absolute VTE rates in this population are low, obstetric-associated VTE is an important cause of maternal morbidity and mortality. This manuscript, initiated by the Anticoagulation Forum, provides practical clinical guidance on the prevention and treatment of obstetric-associated VTE based on existing guidelines and consensus expert opinion based on available literature where guidelines are lacking.

Is diabetes a hypercoagulable state? A critical appraisal

Diabetes mellitus (DM), a chronic disease with an increasing incidence and prevalence worldwide, is an established risk factor for arterial cardiovascular, cerebrovascular and peripheral vascular diseases including acute myocardial infarction, stroke and peripheral artery disease. On the other hand, its role as independent risk factor for venous thromboembolism (VTE) and for cardioembolic stroke or systemic embolism (SE) in patients with atrial fibrillation (AF) is more conflicting. Venous and arterial thromboses have traditionally been regarded as separate diseases, but recent studies have documented an association between these vascular complications. Cardiovascular risk factors may contribute to unprovoked VTE, and VTE may be an early symptomatic event in patients at high cardiovascular risk, including diabetic patients. Compelling evidences suggest that DM is associated with a higher risk of development and progression of AF. Furthermore, in AF patients with a coexisting DM the risk of cardioembolic stroke/SE appeared increased. Thus, DM has been included as one of the items of the CHADS2 score and of the subsequent CHA2DS2-VASc score that have been developed to assess the arterial tromboembolic risk of AF patients. Such a high incidence of thromboembolic events observed in these clinical subsets may be attributable to the DM-related prothrombotic state due to a number of changes in primary and secondary hemostasis. Although of potential clinical interest, unfortunately, to date, no study has properly evaluated the effects of drugs used to control blood glucose levels on the risk of venous thromboembolism and arterial cardioembolic events in patients with DM.

[Pulmonary embolism]

Pulmonary embolism is a potentially fatal disorder and frequently seen in critical care and emergency medicine. Due to a high mortality rate within the first few hours, the accurate initiation of rational diagnostic pathways in patients with suspected pulmonary embolism and timely consecutive treatment is essential. In this review, the current European guidelines on the diagnosis and therapy of acute pulmonary embolism are presented. Special focus is put on a structured patient management based on the individual risk of early mortality. In particular risk assessment and new risk-adjusted treatment recommendations are presented and discussed in this article.

The Interdisciplinary Management of Acute Chest Pain

BACKGROUND

Acute chest pain of non-traumatic origin is a common reason for presentation to physician's offices and emergency rooms. Coronary heart disease is the cause in up to 25% of cases. Because acute chest pain, depending on its etiology, may be associated with a high risk of death, rapid, goal-oriented management is mandatory.

METHODS

This review is based on pertinent articles and guidelines retrieved by a selective search in PubMed.

RESULTS

History-taking, physical examination, and a 12-lead electrocardiogram (ECG) are the first steps in the differential diagnostic process and generally allow the identification of features signifying a high risk of lifethreatening illness. If the ECG reveals ST-segment elevation, cardiac catheterization is indicated. The timedependent measurement of highly sensitive troponin values is a reliable test for the diagnosis or exclusion of acute myocardial infarction. A wide variety of other potential causes (e.g., vascular, musculoskeletal, gastroenterologic, or psychosomatic) must be identified from the history if they are to be treated appropriately. Elderly patients need special attention.

CONCLUSION

Acute chest pain is a major diagnostic challenge for the physician. Common errors are traceable to non-recognition of important causes and to an inadequate diagnostic work-up. Future studies should be designed to help optimize the interdisciplinary management of patients with chest pain.

Risk stratification of normotensive pulmonary embolism: prognostic impact of copeptin

The prognostic value of copeptin, the C-terminal fragment of the precursor protein of vasopressin which is released upon stress, and hypotension in pulmonary embolism is unknown, especially if combined with biomarkers reflecting different pathophysiological axes such as myocardial injury (high-sensitivity troponin T (hsTnT)) and stretch (N-terminal pro-brain natriuretic peptide (NT-proBNP)).

We prospectively studied 268 normotensive pulmonary embolism patients included in a single-centre cohort study.

Patients with an adverse 30-day outcome (5.6%) had higher copeptin levels than patients with a favourable course (median (interquartile range) 51.8 (21.6–90.8) versus 13.2 (5.9–39.3) pmol·L−1; p=0.020). Patients with copeptin levels above the calculated optimal cut-off value of 24 pmol·L−1 had a 5.4-fold increased risk for an adverse outcome (95% CI 1.68–17.58; p=0.005). We developed a strategy for risk stratification based on biomarkers. None of 141 patients (52.6%) with hsTnT <14 pg·mL−1 or NT-proBNP <600 pg·mL−1 had an adverse outcome (low risk). Copeptin ≥24 pmol·L−1 stratified patients with elevated hsTnT and NT-proBNP as intermediate–low and intermediate–high risk (5.6% and 20.0% adverse outcome, respectively). Compared to the algorithm proposed by the 2014 European Society of Cardiology guideline, more patients were classified as low risk (52.8% versus 17.5%, p<0.001) and more patients in the intermediate–high risk group had an adverse outcome (20.0% versus 11.6%).

Copeptin might be helpful for risk stratification of normotensive patients with pulmonary embolism, especially if integrated into a biomarker-based algorithm.

Dosing of rivaroxaban by indication: getting the right dose for the patient

INTRODUCTION

Vitamin K antagonists were the only oral anticoagulants available for several decades, but they require frequent coagulation monitoring and dose adjustment. The direct oral anticoagulants rivaroxaban , dabigatran, apixaban, and, most recently, edoxaban have been approved for the management of specific thromboembolic indications.

AREAS COVERED

This review will provide a brief overview of the cell-based coagulation model, the main determinants of arterial and venous thrombosis, and the pharmacological rationale and clinical evidence for the different dosing regimens of rivaroxaban. Published articles indexed on PubMed and Medline covering arterial and venous thrombi pathophysiology, pharmacokinetics, and pharmacodynamics of rivaroxaban, and Phase II and Phase III clinical studies with rivaroxaban as well as real-world evidence were analyzed.

EXPERT OPINION

Education on pharmacokinetic/pharmacodynamic characteristics, as well as how to manage adverse events, is needed to increase physician knowledge and confidence in using direct oral anticoagulants, as specifically discussed for rivaroxaban in this article. The continued uptake of direct oral anticoagulants in clinical practice depends on understanding of the clinical evidence and reassurance provided by emerging real-world data.

Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin. A position paper of the Acute Cardiovascular Care Association (ACCA) of the ESC

Chest pain and acute dyspnoea are frequent causes of emergency medical services activation. The pre-hospital management of these conditions is heterogeneous across different regions of the world and Europe, as a consequence of the variety of emergency medical services and absence of specific practical guidelines. This position paper focuses on the practical aspects of the pre-hospital treatment on board and transfer of patients taken in charge by emergency medical services for chest pain and dyspnoea of suspected cardiac aetiology after the initial assessment and diagnostic work-up. The objective of the paper is to provide guidance, based on evidence, where available, or on experts’ opinions, for all emergency medical services’ health providers involved in the pre-hospital management of acute cardiovascular care.

Venous thromboembolism in the ICU: main characteristics, diagnosis and thromboprophylaxis

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep venous thrombosis (DVT), is a common and severe complication of critical illness. Although well documented in the general population, the prevalence of PE is less known in the ICU, where it is more difficult to diagnose and to treat. Critically ill patients are at high risk of VTE because they combine both general risk factors together with specific ICU risk factors of VTE, like sedation, immobilization, vasopressors or central venous catheter. Compression ultrasonography and computed tomography (CT) scan are the primary tools to diagnose DVT and PE, respectively, in the ICU. CT scan, as well as transesophageal echography, are good for evaluating the severity of PE. Thromboprophylaxis is needed in all ICU patients, mainly with low molecular weight heparin, such as fragmine, which can be used even in cases of non-severe renal failure. Mechanical thromboprophylaxis has to be used if anticoagulation is not possible. Nevertheless, VTE can occur despite well-conducted thromboprophylaxis.

Rationale and design of three observational, prospective cohort studies including biobanking to evaluate and improve diagnostics, management strategies and risk stratification in venous thromboembolism: the VTEval Project

INTRODUCTION

Venous thromboembolism (VTE) with its two manifestations deep vein thrombosis (DVT) and pulmonary embolism (PE) is a major public health problem. The VTEval Project aims to investigate numerous research questions on diagnosis, clinical management, treatment and prognosis of VTE, which have remained uncertain to date.

METHODS AND ANALYSIS

The VTEval Project consists of three observational, prospective cohort studies on VTE comprising cohorts of individuals with a clinical suspicion of acute PE (with or without DVT), with a clinical suspicion of acute DVT (without symptomatic PE) and with an incidental diagnosis of VTE (PE or DVT). The VTEval Project expects to enrol a total of approximately 2000 individuals with subsequent active and passive follow-up investigations over a time period of 5 years per participant. Time points for active follow-up investigations are at months 3, 6, 12, 24 and 36 after diagnosis (depending on the disease cohort); passive follow-up investigations via registry offices and the cancer registry are performed 48 and 60 months after diagnosis for all participants. Primary short-term outcome is defined by overall mortality (PE-related death and all other causes of death), primary long-term outcome by symptomatic VTE (PE-related death, recurrence of non-fatal PE or DVT). The VTEval Project includes three 'all-comer' studies and involves the standardised acquisition of high-quality data, covering the systematic assessment of VTE including symptoms, risk profile, psychosocial, environmental and lifestyle factors as well as clinical and subclinical disease, and it builds up a large state-of-the-art biorepository containing various materials from serial blood samplings.

ETHICS AND DISSEMINATION

The VTEval Project has been approved by the local data safety commissioner and the responsible ethics committee (reference no. 837.320.12 (8421-F)). Trial results will be published in peer-reviewed journals and presented at national and international scientific meetings.

TRIAL REGISTRATION NUMBER

NCT02156401.

Point-of-care ultrasound in the diagnosis of pulmonary embolism

The best diagnostic strategy to confirm or exclude pulmonary embolism (PE) suspicion needs an appropriate combination of clinical assessment, plasma D-dimer measurement, and computed tomographic pulmonary angiography (CTPA). CTPA should be used with caution in some patient groups, such as patients with known allergy to contrast media, those with severe renal insufficiency, and pregnant women, and could be not immediately available in case of unstable patients. In the emergency setting, alternative diagnostic strategies should be implemented to overcome CTPA limitations. Ultrasonography is certainly a valuable alternative diagnostic tool. In addition to echocardiography and lower limb compressive venous ultrasonography, lung ultrasound (US) may play an important role in selected patients’ subgroups. Recent data on the diagnostic performance of a triple point-of-care US (lung, heart, and leg vein US) are discussed in the present paper, and pros and cons of triple point-of-care US are compared with those of standard diagnostic approaches.

Acute phase treatment of venous thromboembolism: advanced therapy. Systemic fibrinolysis and pharmacomechanical therapy

Venous thromboembolism, which encompasses deep-vein thrombosis and acute pulmonary embolism (PE), represents a major contributor to global disease burden worldwide. For patients who present with cardiogenic shock or persistent hypotension (acute high-risk PE), there is consensus that immediate reperfusion treatment applying systemic fibrinolysis or, in the case of a high bleeding risk, surgical or catheter-directed techniques, is indicated. On the other hand, for the large, heterogeneous group of patients presenting without overt haemodynamic instability, the indications for advanced therapy are less clear. The recently updated guidelines of the European Society of Cardiology emphasise the importance of clinical prediction rules in combination with imaging procedures (assessment of right ventricular function) and laboratory biomarkers (indicative of myocardial stress or injury) for distinguishing between an intermediate and a low risk for an adverse early outcome. In intermediate-high-risk PE defined by the presence of both right ventricular dysfunction on echocardiography (or computed tomography) and a positive troponin (or natriuretic peptide) test, the bleeding risks of full-dose fibrinolytic treatment have been shown to outweigh its potential clinical benefits unless clinical signs of haemodynamic decompensation appear (rescue fibrinolysis). Recently published trials suggest that catheter-directed, ultrasound-assisted, low-dose local fibrinolysis may provide an effective and particularly safe treatment option for some of these patients.

The role of ischemia modified albumin in acute pulmonary embolism

Background:

Acute pulmonary embolism (PE) is a life-threatening and a relatively common cardiovascular pathology. Although the pathogenesis of PE is well defined, there is no ideal diagnostic biochemical marker. Previous studies showed an increased ischemia modified albumin (IMA) levels in acute PE; however, the relationship between IMA and right ventricular (RV) dysfunction has not been examined. The aim of this study was to evaluate the diagnostic value of IMA and the relationship with RV dysfunction in acute PE.

MATERIALS AND METHODS:

A total of 145 patients (70 females) with suspected acute PE was enrolled to the study. Eighty-nine patients were diagnosed with acute PE via computed tomographic pulmonary angiography. Sixty-five patients with similar demographic and clinical characteristics were assigned to the control group. All patients were evaluated for RV dysfunction using transthoracic echocardiography.

Results:

Serum IMA levels were significantly increased in acute PE compared with control group (0.41 ± 0.06 vs. 0.34 ± 0.11, P = 0.001). There was no relationship between serum IMA levels and RV dysfunction. IMA levels were positively correlated with shock index and heart rate. Receiver operating curve analysis demonstrated that serum IMA levels higher than 0.4 put the diagnosis at sensitivity of 53.85% and at specificity of 85.96%.

Conclusions:

Although IMA levels are increased in patients with acute PE, it failed to predict RV dysfunction.

Remarkable regression of massive deep vein thrombosis in response to intensive oral rivaroxaban treatment

Deep vein thrombosis (DVT) is a common disease and is associated with pulmonary embolism (PE). Proximal iliofemoral DVT may lead to severe PE and chronic venous insufficiency. The standard therapy for DVT is anticoagulant therapy using heparin and a vitamin K antagonist, but a recent clinical study showed that rivaroxaban, an oral Xa inhibitor, was comparable to standard therapy and had less bleeding complications. Intensive high-dose anticoagulation is recommended during the initial 3 weeks of DVT treatment. The present report describes a case of a 77-year-old male showing a remarkable regression of DVT in response to rivaroxaban treatment within the initial 3 weeks of therapy and who did not experience any adverse events. His DVT was massive and was accompanied by proximal iliofemoral vein thrombus and iliac vein compression syndrome. Rivaroxaban, especially in intensive high-dose treatment, might be a safe and effective therapeutic choice for massive DVT.