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Becattini C, Vedovati MC, Colombo S, Vanni S, Abrignani MG, Scardovi AB, Marrazzo A, Borselli M, Barchetti M, Fabbri A, Dentali F, Maggioni AP, Agnelli G, Gulizia MM. Identification of hemodynamically stable patients with acute pulmonary embolism at high risk for death: external validation of different models. J Thromb Haemost 2024; 22:2502-2513. [PMID: 38810699 DOI: 10.1016/j.jtha.2024.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/14/2024] [Accepted: 04/30/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND The optimal strategy for identification of hemodynamically stable patients with acute pulmonary embolism (PE) at risk for death and clinical deterioration remains undefined. OBJECTIVES We aimed to assess the performances of currently available models/scores for identifying hemodynamically stable patients with acute, symptomatic PE at risk of death and clinical deterioration. METHODS This was a prospective multicenter cohort study including patients with acute PE (NCT03631810). Primary study outcome was in-hospital death within 30 days or clinical deterioration. Other outcomes were in-hospital death, death, and PE-related death, all at 30 days. We calculated positive and negative predictive values, c-statistics of European Society of Cardiology (ESC)-2014, ESC-2019, Pulmonary Embolism Thrombolysis (PEITHO), Bova, Thrombo-embolism lactate outcome study (TELOS), fatty acid binding protein, syncope and tachicardia (FAST), and National Early Warning Scale 2 (NEWS2) for the study outcomes. RESULTS In 5036 hemodynamically stable patients with acute PE, positive predictive values for the evaluated models/scores were all below 10%, except for TELOS and NEWS2; negative predictive values were above 98% for all the models/scores, except for FAST and NEWS2. ESC-2014 and TELOS had good performances for in-hospital death or clinical deterioration (c-statistic of 0.700 and 0.722, respectively), in-hospital death (c-statistic of 0.713 and 0.723, respectively), and PE-related death (c-statistic of 0.712 and 0.777, respectively); PEITHO, Bova, and NEWS2 also had good performances for PE-related death (c-statistic of 0.738, 0.741, and 0.742, respectively). CONCLUSION In hemodynamically stable patients with acute PE, the accuracy for identification of hemodynamically stable patients at risk for death and clinical deterioration varies across the available models/scores; TELOS seems to have the best performance. These data can inform management studies and clinical practice.
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Affiliation(s)
- Cecilia Becattini
- Internal, Vascular and Emergency Medicine - Stroke Unit, Department of Medicine and Surgery, University of Perugia, Perugia, Italy.
| | - Maria Cristina Vedovati
- Internal, Vascular and Emergency Medicine - Stroke Unit, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | | | - Simone Vanni
- Emergency Department, Saint Joseph Hospital, Empoli, Italy
| | | | | | - Alessandra Marrazzo
- General Medicine, Pavullo nel Frignano Hospital, Pavullo nel Frignano, Italy
| | - Matteo Borselli
- Emergency Department, Misericordia Hospital, Grosseto, Italy
| | | | - Andrea Fabbri
- Emergency Department, Romagna Hospital, Forlì, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Aldo Pietro Maggioni
- ANMCO (Associazione Nazionale Medici Cardiologi Ospedalieri) Research Center, Heart Cre Foundation, Florence, Italy
| | - Giancarlo Agnelli
- Internal, Vascular and Emergency Medicine - Stroke Unit, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Singh G, Bamba H, Inban P, Chandrasekaran SH, Priyatha V, John J, Prajjwal P. The prognostic significance of pro-BNP and heart failure in acute pulmonary embolism: A systematic review. Dis Mon 2024:101783. [PMID: 38955637 DOI: 10.1016/j.disamonth.2024.101783] [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: 07/04/2024]
Abstract
Pulmonary embolism (PE) is the third most common type of cardiovascular disease and carries a high mortality rate of 30% if left untreated. Although it is commonly known that individuals who suffer heart failure (HF) are more likely to experience a pulmonary embolism, little is known concerning the prognostic relationship between acute PE and HF. This study aims to evaluate the prognostic usefulness of heart failure and pro-BNP in pulmonary embolism cases. A scientific literature search, including PubMed, Medline, and Cochrane reviews, was used to assess and evaluate the most pertinent research that has been published. The findings showed that increased N-terminal brain natriuretic peptide (NT-proBNP) levels could potentially identify pulmonary embolism patients with worse immediate prognoses and were highly predictive of all-cause death. Important prognostic information can be obtained from NT-proBNP and Heart-type Fatty Acid Binding Proteins (H-FABP) when examining individuals with PE. The heart, distal tubular cells of the renal system, and skeletal muscle are where H-FABP is primarily found, with myocardial cells having the highest concentration. Recent studies have indicated that these biomarkers may also help assess the severity of PE and its long-term risk.
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Affiliation(s)
- Gurmehar Singh
- Government Medical College and Hospital, Chandigarh, India
| | - Hyma Bamba
- Government Medical College and Hospital, Chandigarh, India
| | - Pugazhendi Inban
- Internal Medicine, St. Mary's General Hospital and Saint Clare's Health, NY, USA.
| | | | | | - Jobby John
- Dr. Somervell Memorial CSI Medical College and Hospital Karakonam, Trivandrum, India
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Zhang Y, Chen Y, Chen H, Dong C, Hu X, Xu X, Zhu L, Cheng Z, Wang D, Zhang Z, Xie W, Wan J, Yang P, Wang S, Wang C, Zhai Z. Performance of the Simplified Pulmonary Embolism Severity Index in predicting 30-day mortality after acute pulmonary embolism: Validation from a large-scale cohort. Eur J Intern Med 2024; 124:46-53. [PMID: 38350784 DOI: 10.1016/j.ejim.2024.01.037] [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: 10/03/2023] [Revised: 01/18/2024] [Accepted: 01/30/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND The performance of existing prognostic scores including the simplified Pulmonary Embolism Severity Index (sPESI) for short-term mortality of non-high-risk PE in Chinese population has not been widely validated. METHODS Non-high-risk patients were included from the prospective cohort of the China pUlmonary Thromboembolism REgistry Study (CURES). The sPESI, RIETE, Geneva, modified FAST, and Bova score were validated. The discriminatory performance was measured by the area under the curve (AUC). We also compared the sensitivity, odds ratio, specificity, positive predictive value and negative predictive value of these scores. RESULTS A total of 6,873 non-high-risk patients with acute PE were included and 241 (3.5 %) patients died within 30 days. Compared to the Geneva, modified FAST, and Bova score, the AUCs for predicting 30-day death of sPESI and RIETE score were higher at 0.712 (95 % CI, 0.680, 0.743) and 0.723 (95 % CI, 0.691, 0.755) respectively. The sPESI demonstrated the highest sensitivity at 0.809, while the RIETE score, Geneva, Modified FAST and BOVA score showed sensitivities of 0.622, 0.568, 0.477 and 0.502 respectively. A sPESI ⩾1 point was associated with a 4.7-fold increased risk of 30-day all-cause mortality (95 % CI, 3.427, 6.563, p < 0.001), while a RIETE score of ⩾1 point was associated with a 4.5-fold increased risk (95 % CI, 3.127, 6.341, p < 0.001). The Geneva score, modified FAST and Bova score showed inferior performance. CONCLUSIONS The implementation of the fewer-parameter, easier-to-calculate sPESI in Chinese patients with PE can help to discriminate patients with extremely low risk of short-term mortality for home treatment or early discharge.
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Affiliation(s)
- Yu Zhang
- China-Japan Friendship Hospital, Capital Medical University, Beijing, China; National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Yinong Chen
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China; Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chunling Dong
- Department of Pulmonary and Critical Care Medicine, The Second Hospital of Jilin University, Changchun, China
| | - Xiaoyun Hu
- Department of Pulmonary and Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Xiaomao Xu
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, Beijing, China
| | - Ling Zhu
- Department of Pulmonary and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Zhe Cheng
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Dingyi Wang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China; Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Zhu Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Wanmu Xie
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Jun Wan
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Peiran Yang
- State Key Laboratory of Respiratory Health and Multimorbidity, Department of Physiology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Shengfeng Wang
- Department of Epidemiology & Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Chen Wang
- China-Japan Friendship Hospital, Capital Medical University, Beijing, China; National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China; Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.
| | - Zhenguo Zhai
- China-Japan Friendship Hospital, Capital Medical University, Beijing, China; National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China; Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.
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Jiao S, Liu Y, He H, Li Q, Wang Z, Chen Y, Zhu L, Zheng S, Yang F, Zhai Z, Sun Y. The Predictive Value of the MELD Scores for In-Hospital Adverse Events in Normotensive Patients with Acute Pulmonary Embolism. Clin Appl Thromb Hemost 2024; 30:10760296241266607. [PMID: 39129349 PMCID: PMC11322942 DOI: 10.1177/10760296241266607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 06/06/2024] [Accepted: 06/20/2024] [Indexed: 08/13/2024] Open
Abstract
The model for end-stage liver disease (MELD) and the model for end-stage liver disease excluding international normalized ratio (INR) (MELD-XI) scores, which reflect dysfunction of liver and kidneys, have been reported to be related to the prognosis of patients with right-sided "backward" failure. However, the relationship between the MELD/MELD-XI score and the in-hospital adverse events in pulmonary embolism (PE) patients was unknown. Normotensive PE patients were retrospectively enrolled at China-Japan friendship hospital from January 2017 to February 2020. The primary outcome was defined as death and clinical deterioration during hospitalization. Multivariate logistic analysis was used to explore the association between the MELD and MELD-XI scores for in-hospital adverse events. We also compared the accuracy of the MELD, MELD-XI, and the pulmonary embolism severity index (PESI) score using the time-dependent receiver operating characteristic curve and corresponding areas under the curve (AUC). A total of 222 PE patients were analyzed. Logistic regression analysis showed that the MELD score was independently associated with in-hospital adverse events (odds ratio = 1.115, 95% confidential interval = 1.022-1.217, P = .014). The MELD score has an AUC of 0.731 and was better than PESI (AUC of 0.629) in predicting in-hospital adverse events. Among PE patients with normal blood pressure on admission, the MELD score was associated with increased in-hospital adverse events.
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Affiliation(s)
- Siqi Jiao
- Peking University Health Science Center, China–Japan Friendship Hospital, Beijing, China
| | - Ying Liu
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Haoming He
- Department of Cardiology, China–Japan Friendship Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qing Li
- Peking University Health Science Center, China–Japan Friendship Hospital, Beijing, China
| | - Zhe Wang
- Department of Cardiology, China–Japan Friendship Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yinong Chen
- Peking University Health Science Center, China–Japan Friendship Hospital, Beijing, China
| | - Longyang Zhu
- Peking University Health Science Center, China–Japan Friendship Hospital, Beijing, China
| | - Shuwen Zheng
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Furong Yang
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China–Japan Friendship Hospital, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China–Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Yihong Sun
- Department of Cardiology, China–Japan Friendship Hospital, Beijing, China
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Xiong W, Cheng Y, Zhao Y. Risk Scores in Venous Thromboembolism Guidelines of ESC, ACCP, and ASH: An Updated Review. Clin Appl Thromb Hemost 2024; 30:10760296241263856. [PMID: 38887044 PMCID: PMC11185021 DOI: 10.1177/10760296241263856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/24/2024] [Accepted: 06/07/2024] [Indexed: 06/20/2024] Open
Abstract
Venous thromboembolism (VTE) is associated with high morbidity and mortality. Risk scores associated with VTE have been widely used in clinical practice. Among numerous scores published, those included in guidelines are usually typical risk scores which have been extensively validated and globally recognized. This review provides an updated overview of the risk scores associated with VTE endorsed by 3 guidelines which are highly recognized in the field of VTE including the European Society of Cardiology, American College of Chest Physicians, and American Society of Hematology, focusing on the development, modification, validation, and comparison of these scores, to provide a comprehensive and updated understanding of all the classic risk scores associated with VTE to medical readers including but not limited to cardiologists, pulmonologists, hematologists, intensivists, physicians, surgeons, and researchers. Although each score recommended by these guidelines was more or less validated, there may still be room for further improvement. It may still be necessary to seek simpler, more practical, and more universally applicable VTE-related risk scores in the future.
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Affiliation(s)
- Wei Xiong
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yi Cheng
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yunfeng Zhao
- Department of Pulmonary and Critical Care Medicine, Punan Hospital, Pudong New District, Shanghai, China
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Barca-Hernando M, Jara-Palomares L. Pulmonary embolism: a practical approach to update risk stratification and treatment decisions based on the guidelines. Expert Rev Respir Med 2023; 17:1151-1158. [PMID: 38133539 DOI: 10.1080/17476348.2023.2298826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/20/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Pulmonary embolism (PE) is a prevalent condition with a substantial morbi-mortality worldwide. Proper risk stratification of PE is essential for identifying the most suitable therapeutic strategy and the optimal care setting for the patient. This process entails evaluating various factors, including symptoms, comorbidities, and right heart dysfunction. AREAS COVERED This review assesses the tools and methods utilized to identify and stratify individuals based on the probability of developing deterioration or death related to PE. Current guidelines divide PE into three groups: high-risk (previously termed massive) PE, intermediate-risk (sub-massive) PE, and low-risk PE. Various risk scores, such as the simplified pulmonary embolism severity index (sPESI), Bova score, and the FAST score (incorporating Heart-Fatty Acid binding protein [H-ABP], Syncope, Tachycardia), aid in identifying patients at higher risk. Additionally, the Hestia score is instrumental in pinpointing low-risk patients. EXPERT OPINION Presently, there is a dearth of high-quality frameworks for the optimal management and treatment of PE patients at risk of hemodynamic collapse. A consortium of experts is in the process of formulating a new conceptual model for risk stratification, taking into account a comprehensive array of variables and outcomes to facilitate more individualized management of acute PE.
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Affiliation(s)
| | - Luis Jara-Palomares
- Respiratory Department, Hospital Virgen del Rocio, Sevilla, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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Tsujisaka Y, Yamashita Y, Morimoto T, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Chen PM, Murata K, Tsuyuki Y, Nishimoto Y, Sakamoto J, Togi K, Mabuchi H, Takabayashi K, Kato T, Ono K, Kimura T. Application of the RIETE score to identify low-risk patients with pulmonary embolism: From the COMMAND VTE Registry. Thromb Res 2023; 232:35-42. [PMID: 37922657 DOI: 10.1016/j.thromres.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/18/2023] [Accepted: 10/23/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The RIETE score could be specifically useful for identification of low-risk pulmonary embolism (PE) patients for home treatment. However, the external validation of the RIETE score has been limited. METHODS The COMMAND VTE Registry is a multicenter registry enrolling consecutive patients with acute symptomatic venous thromboembolism (VTE). The current study population consisted of 1479 patients with acute PE, who were divided into 2 groups; RIETE scores of 0 (N = 260) and ≥ 1 (N = 1219). RESULTS The cumulative 10-day and 30-day incidences of a composite endpoint of all-cause death, recurrent PE, or major bleeding were lower in patients with the RIETE score of 0 than in those with the RIETE score of ≥1 (10-day: 0.4 % vs. 6.7 %, P < 0.001, and 30-day: 0.4 % vs. 10.0 %, P < 0.001). The area under the receiver-operating characteristic curve (AUC) in the RIETE score for the 10-day composite endpoint showed numerically better predictive ability than that in the sPESI score (0.77 vs. 0.73, P = 0.07), and the AUC in the RIETE score for the 30-day composite endpoint showed significantly better predictive ability than that in the sPESI score (0.77 vs. 0.71, P = 0.003). CONCLUSIONS The RIETE score was well validated in the current large real-world registry. The RIETE score of 0 could identify patients with reasonably low risks of the 10-day and 30-day composite endpoint of all-cause death, recurrent PE, or major bleeding.
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Affiliation(s)
- Yuta Tsujisaka
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - 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
| | - 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
| | - 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
| | - 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
| | | | - Takao Kato
- 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 Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan
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Götzinger F, Lauder L, Sharp ASP, Lang IM, Rosenkranz S, Konstantinides S, Edelman ER, Böhm M, Jaber W, Mahfoud F. Interventional therapies for pulmonary embolism. Nat Rev Cardiol 2023; 20:670-684. [PMID: 37173409 PMCID: PMC10180624 DOI: 10.1038/s41569-023-00876-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 05/15/2023]
Abstract
Pulmonary embolism (PE) is the leading cause of in-hospital death and the third most frequent cause of cardiovascular death. The clinical presentation of PE is variable, and choosing the appropriate treatment for individual patients can be challenging. Traditionally, treatment of PE has involved a choice of anticoagulation, thrombolysis or surgery; however, a range of percutaneous interventional technologies have been developed that are under investigation in patients with intermediate-high-risk or high-risk PE. These interventional technologies include catheter-directed thrombolysis (with or without ultrasound assistance), aspiration thrombectomy and combinations of the aforementioned principles. These interventional treatment options might lead to a more rapid improvement in right ventricular function and pulmonary and/or systemic haemodynamics in particular patients. However, evidence from randomized controlled trials on the safety and efficacy of these interventions compared with conservative therapies is lacking. In this Review, we discuss the underlying pathophysiology of PE, provide assistance with decision-making on patient selection and critically appraise the available clinical evidence on interventional, catheter-based approaches for PE treatment. Finally, we discuss future perspectives and unmet needs.
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Affiliation(s)
- Felix Götzinger
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Lucas Lauder
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Andrew S P Sharp
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
- Cardiff University, Cardiff, UK
| | - Irene M Lang
- Department of Cardiology, Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Stephan Rosenkranz
- Department of Cardiology - Internal Medicine III, Cologne University Heart Center, Cologne, Germany
- Cologne Cardiovascular Research Center (CCRC), Cologne University Heart Center, Cologne, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michael Böhm
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Wissam Jaber
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Felix Mahfoud
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany.
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
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Su H, Han Z, Fu Y, Zhao D, Yu F, Heidari AA, Zhang Y, Shou Y, Wu P, Chen H, Chen Y. Detection of pulmonary embolism severity using clinical characteristics, hematological indices, and machine learning techniques. Front Neuroinform 2022; 16:1029690. [PMID: 36590906 PMCID: PMC9800512 DOI: 10.3389/fninf.2022.1029690] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Pulmonary embolism (PE) is a cardiopulmonary condition that can be fatal. PE can lead to sudden cardiovascular collapse and is potentially life-threatening, necessitating risk classification to modify therapy following the diagnosis of PE. We collected clinical characteristics, routine blood data, and arterial blood gas analysis data from all 139 patients. Methods Combining these data, this paper proposes a PE risk stratified prediction framework based on machine learning technology. An improved algorithm is proposed by adding sobol sequence and black hole mechanism to the cuckoo search algorithm (CS), called SBCS. Based on the coupling of the enhanced algorithm and the kernel extreme learning machine (KELM), a prediction framework is also proposed. Results To confirm the overall performance of SBCS, we run benchmark function experiments in this work. The results demonstrate that SBCS has great convergence accuracy and speed. Then, tests based on seven open data sets are carried out in this study to verify the performance of SBCS on the feature selection problem. To further demonstrate the usefulness and applicability of the SBCS-KELM framework, this paper conducts aided diagnosis experiments on PE data collected from the hospital. Discussion The experiment findings show that the indicators chosen, such as syncope, systolic blood pressure (SBP), oxygen saturation (SaO2%), white blood cell (WBC), neutrophil percentage (NEUT%), and others, are crucial for the feature selection approach presented in this study to assess the severity of PE. The classification results reveal that the prediction model's accuracy is 99.26% and its sensitivity is 98.57%. It is expected to become a new and accurate method to distinguish the severity of PE.
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Affiliation(s)
- Hang Su
- College of Computer Science and Technology, Changchun Normal University, Changchun, Jilin, China
| | - Zhengyuan Han
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yujie Fu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Dong Zhao
- College of Computer Science and Technology, Changchun Normal University, Changchun, Jilin, China,*Correspondence: Dong Zhao,
| | - Fanhua Yu
- College of Computer Science and Technology, Changchun Normal University, Changchun, Jilin, China
| | - Ali Asghar Heidari
- School of Surveying and Geospatial Engineering, College of Engineering, University of Tehran, Tehran, Iran
| | - Yu Zhang
- College of Computer Science and Technology, Changchun Normal University, Changchun, Jilin, China
| | - Yeqi Shou
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peiliang Wu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Huiling Chen
- College of Computer Science and Artificial Intelligence, Wenzhou University, Wenzhou, Zhejiang, China,Huiling Chen,
| | - Yanfan Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China,Yanfan Chen,
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10
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Machanahalli Balakrishna A, Reddi V, Belford PM, Alvarez M, Jaber WA, Zhao DX, Vallabhajosyula S. Intermediate-Risk Pulmonary Embolism: A Review of Contemporary Diagnosis, Risk Stratification and Management. Medicina (B Aires) 2022; 58:medicina58091186. [PMID: 36143863 PMCID: PMC9504600 DOI: 10.3390/medicina58091186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/25/2022] Open
Abstract
Pulmonary embolism (PE) can have a wide range of hemodynamic effects, from asymptomatic to a life-threatening medical emergency. Pulmonary embolism (PE) is associated with high mortality and requires careful risk stratification for individualized management. PE is divided into three risk categories: low risk, intermediate-risk, and high risk. In terms of initial therapeutic choice and long-term management, intermediate-risk (or submassive) PE remains the most challenging subtype. The definitions, classifications, risk stratification, and management options of intermediate-risk PE are discussed in this review.
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Affiliation(s)
| | - Vuha Reddi
- Department of Medicine, Danbury Hospital/Yale University School of Medicine, Danbury, CT 06810, USA
| | - Peter Matthew Belford
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
| | - Manrique Alvarez
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
| | - Wissam A. Jaber
- Section of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30307, USA
| | - David X. Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
- Department of Implementation Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
- Correspondence: ; Tel.: +1-(336)-878-6000
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11
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Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand (TRAIL): A Novel Biomarker for Prognostic Assessment and Risk Stratification of Acute Pulmonary Embolism. J Clin Med 2022; 11:jcm11133908. [PMID: 35807194 PMCID: PMC9267658 DOI: 10.3390/jcm11133908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 06/02/2022] [Accepted: 06/27/2022] [Indexed: 12/10/2022] Open
Abstract
Background: Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) is associated with poor prognosis in cardiovascular diseases. However, the predictive value of TRAIL for the short-term outcome and risk stratification of acute pulmonary embolism (PE) remains unknown. Methods: This study prospectively included 151 normotensive patients with acute PE. The study outcome was a composite of 30-day adverse events, defined as PE-related death, shock, mechanical ventilation, cardiopulmonary resuscitation, and major bleeding. Results: Overall, nine of 151 (6.0%) patients experienced 30-day adverse composite events. Multivariable logistic regression showed that TRAIL was an independent predictor of study outcome (OR 0.19 per SD; 95% CI 0.04–0.90). An ROC curve revealed that TRAIL’s area under the curve (AUC) was 0.83 (95% CI 0.76–0.88). The optimal cut-off value for TRAIL was 18 pg/mL, with a sensitivity, specificity, negative predictive value, positive predictive value, positive likelihood ratio, and negative likelihood ratio of 89%, 69%, 99%, 15%, 2.87, and 0.16, respectively. Compared with the risk stratification algorithm outlined in the 2019 ESC guidelines, our biomarker-based risk stratification strategy (combining TRAIL and hs-cTnI) has a similar risk classification effect. Conclusion: Reduced plasma TRAIL levels predict short-term adverse events in normotensive patients with acute PE. The combination of the 2019 ESC algorithm and TRAIL aids risk stratification in normotensive patients with acute PE.
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12
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Wang Y, Feng Y, Yang X, Mao H. Prognostic role of elevated lactate in acute pulmonary embolism: A systematic review and meta-analysis. Phlebology 2022; 37:338-347. [PMID: 35282737 DOI: 10.1177/02683555221081818] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Previous studies have shown elevated lactate was a good predictor for the prognosis of pulmonary embolism (PE). However, due to low number of patients and different expression of blood lactate in separate study, these results are inconsistent. Therefore, the aim of this meta-analysis is to evaluate the relationship between increased lactate levels and adverse outcome in acute PE. METHOD The literatures search was conducted in PubMed, Web of Science, and EMBASE until May 29, 2021. RESULTS Finally, 6 studies with 1706 patients were included in our meta-analysis. High lactate levels were markedly associated with overall mortality both in unselected PE patients (OR 5.13, 95% CI: 3.36-7.86, p < .00,001) and normotensive PE patients (OR 4.54, 95% CI: 2.64-7.80, p < .00,001), and PE-related short-term mortality in patients with elevated lactate was significantly higher than that in patients with normal levels (OR 9.05, 95% CI :4.08-20.10, p < .00,001). The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of lactate for predicting overall mortality in patients with acute PE were 0.67 (95% CI: 0.43-0.85), 0.73 (95% CI: 0.60-0.83), 2.5 (95% CI: 2.0-3.1), and 0.45 (95% CI: 0.26-0.78), respectively. The area under SROC curve (AUC) was 0.76 (95% CI: 0.73-0.80). CONCLUSION The result of our meta-analysis indicate that elevated blood lactate is a good predictor for overall mortality and short-term mortality in patients with acute PE, and can be routinely measured in risk stratification, but its prognostic role in patients with different risk classes still need to be verified.
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Affiliation(s)
- Yubin Wang
- Department of Respiratory and Critical Care Medicine, 34753West China Hospital, Sichuan University, Chengdu, China
| | - Yinhe Feng
- Department of Respiratory and Critical Care Medicine, People's Hospital of Deyang City, Deyang, China
| | - Xiaoya Yang
- Department of Respiratory and Critical Care Medicine, 34753West China Hospital, Sichuan University, Chengdu, China
| | - Hui Mao
- Department of Respiratory and Critical Care Medicine, 34753West China Hospital, Sichuan University, Chengdu, China
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13
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Maraziti G, Cimini LA, Becattini C. Risk stratification to optimize the management of acute pulmonary embolism. Expert Rev Cardiovasc Ther 2022; 20:377-387. [PMID: 35544707 DOI: 10.1080/14779072.2022.2077194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pulmonary embolism (PE) is a life-threatening disease. Risk stratification in patients with acute PE can guide clinical decisions. Clinical assessment, including hemodynamics, respiratory parameters, patient history, and right ventricle evaluation, has a pivotal role in this scope. AREAS COVERED This review aims to describe: i) the role of individual tools for prognostic stratification, from simple clinical parameters to the models suggested by international guidelines; ii) the implications of risk stratification in terms of patient disposition and treatment. The bleeding risk assessment in acute PE was also reviewed. The literature search was performed in PubMed and Embase to address these issues. EXPERT OPINION Prognostic assessment is essential to proceed with life-saving treatments in hemodynamically unstable patients and consider home treatment or short hospital stay in patients at low risk for death. In hemodynamically stable patients, risk stratification allows the implementation of personalized treatment pathways to reduce the risk of death, early PE recurrence, and bleeding. With the aim of optimizing healthcare resources, risk stratification may suggest appropriate patient disposition.
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Affiliation(s)
- Giorgio Maraziti
- Internal and Cardiovascular Medicine - Stroke Unit, Ospedale Santa Maria della Misericordia -University of Perugia, Perugia, Italy
| | - Ludovica Anna Cimini
- Internal and Cardiovascular Medicine - Stroke Unit, Ospedale Santa Maria della Misericordia -University of Perugia, Perugia, Italy
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, Ospedale Santa Maria della Misericordia -University of Perugia, Perugia, Italy
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14
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Risk Stratification in Patients with Acute Pulmonary Embolism: Current Evidence and Perspectives. J Clin Med 2022; 11:jcm11092533. [PMID: 35566658 PMCID: PMC9104204 DOI: 10.3390/jcm11092533] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022] Open
Abstract
Risk stratification is one of the cornerstones of the management of acute pulmonary embolism (PE) and determines the choice of both diagnostic and therapeutic strategies. The first step is the identification of patent circulatory failure, as it is associated with a high risk of immediate mortality and requires a rapid diagnosis and prompt reperfusion. The second step is the estimation of 30-day mortality based on clinical parameters (e.g., original and simplified version of the pulmonary embolism severity index): low-risk patients without right ventricular dysfunction are safely managed with ambulatory anticoagulation. The remaining group of hemodynamically stable patients, labeled intermediate-risk PE, requires hospital admission, even if most of them will heal without complications. In recent decades, efforts have been made to identify a subgroup of patients at an increased risk of adverse outcomes (intermediate-high-risk PE), who might benefit from a more aggressive approach, including reperfusion therapies and admission to a monitored unit. The cur-rent approach, combining markers of right ventricular dysfunction and myocardial injury, has an insufficient positive predictive value to guide primary thrombolysis. Sensitive markers of circulatory failure, such as plasma lactate, have shown interesting prognostic accuracy and may play a central role in the future. Furthermore, the improved security of reduced-dose thrombolysis may enlarge the indication of this treatment to selected intermediate–high-risk PE.
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15
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Zhang S, Xu X, Ji Y, Yang Y, Yi Q, Chen H, Hu X, Liu Z, Mao Y, Zhang J, Shi J, Lei J, Wang D, Zhang Z, Wu S, Gao Q, Tao X, Xie W, Wan J, Zhang Y, Zhang M, Shao X, Zhang Z, Fang B, Yang P, Zhai Z, Wang C. Clinical Phenotypes With Prognostic Implications in Pulmonary Embolism Patients With Syncope. Front Cardiovasc Med 2022; 9:836850. [PMID: 35242828 PMCID: PMC8886035 DOI: 10.3389/fcvm.2022.836850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesThere are conflicting data concerning the prognostic significance of syncope in acute pulmonary embolism (PE). This study aimed to investigate the impact of syncope on clinical outcomes of acute PE, and determine the clinical phenotypes of PE patients with syncope and their correlation with prognosis.MethodsIn the ongoing, national, multicenter, registry study, the China pUlmonary thromboembolism REgistry Study (CURES) enrolling consecutive patients with acute PE, patients with and without syncope were investigated. Principal component analysis (PCA) was performed using nine variables relevant to syncope and PE, including age, sex, body mass index, history of cardiovascular disease, recent surgery or trauma, malignancy, pulse, systolic blood pressure, and respiratory rate. Patient classification was performed using cluster analysis based on the PCA-transformed data. The clinical presentation, disease severity and outcomes were compared among the phenotypes.ResultsIn 7,438 patients with acute PE, 777 (10.4%) had syncope, with younger age, more females and higher body mass index. Patients with syncope had higher frequency of precordial pain, palpitation, and elevated cardiac biomarkers, as well as higher D-Dimer level. In the syncope group, more patients had right ventricular/left ventricular ratio > 0.9 in ultrasonic cardiogram and these patients had higher estimated pulmonary arterial systolic pressure compared with patients without syncope. As the initial antithrombotic treatment, more patients with syncope received systemic thrombolysis. Despite a higher prevalence of hemodynamic instability (OR 7.626, 95% CI 2.960–19.644, P < 0.001), syncope did not increase in-hospital death. Principal component analysis revealed that four independent components accounted for 60.3% of variance. PE patients with syncope were classified into four phenotypes, in which patients with high pulse and respiratory rate had markedly higher all-cause mortality during admission.ConclusionSyncope was associated with hemodynamic instability and more application of thrombolysis, without increasing in-hospital deaths. Different clinical phenotypes existed in PE patients with syncope, which might be caused by various mechanisms and thus correlated with clinical outcomes.
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Affiliation(s)
- Shuai Zhang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
| | - Xiaomao Xu
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, Beijing, China
| | - Yingqun Ji
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yuanhua Yang
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qun Yi
- Department of Pulmonary and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoyun Hu
- Department of Pulmonary and Critical Care Medicine, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Zhihong Liu
- National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Yimin Mao
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Jie Zhang
- Department of Pulmonary and Critical Care Medicine, The Second Hospital of Jilin University, Changchun, China
| | - Juhong Shi
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Jieping Lei
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Dingyi Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Zhu Zhang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
| | - Sinan Wu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Qian Gao
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
| | - Xincao Tao
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
| | - Wanmu Xie
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
| | - Jun Wan
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
| | - Yunxia Zhang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
| | - Meng Zhang
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiang Shao
- Department of Traditional Chinese Medicine for Pulmonary Diseases, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Zhonghe Zhang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Baomin Fang
- Department of Pulmonary and Critical Care Medicine, Beijing Hospital, Beijing, China
| | - Peiran Yang
- Department of Pathophysiology, Peking Union Medical College, Beijing, China
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- *Correspondence: Zhenguo Zhai
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Department of Respiratory Medicine, Capital Medical University, Beijing, China
- Chen Wang
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16
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Weekes AJ, Raper JD, Lupez K, Thomas AM, Cox CA, Esener D, Boyd JS, Nomura JT, Davison J, Ockerse PM, Leech S, Johnson J, Abrams E, Murphy K, Kelly C, Norton HJ. Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE). PLoS One 2021; 16:e0260036. [PMID: 34793539 PMCID: PMC8601564 DOI: 10.1371/journal.pone.0260036] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Develop and validate a prognostic model for clinical deterioration or death within days of pulmonary embolism (PE) diagnosis using point-of-care criteria. METHODS We used prospective registry data from six emergency departments. The primary composite outcome was death or deterioration (respiratory failure, cardiac arrest, new dysrhythmia, sustained hypotension, and rescue reperfusion intervention) within 5 days. Candidate predictors included laboratory and imaging right ventricle (RV) assessments. The prognostic model was developed from 935 PE patients. Univariable analysis of 138 candidate variables was followed by penalized and standard logistic regression on 26 retained variables, and then tested with a validation database (N = 801). RESULTS Logistic regression yielded a nine-variable model, then simplified to a nine-point tool (PE-SCORE): one point each for abnormal RV by echocardiography, abnormal RV by computed tomography, systolic blood pressure < 100 mmHg, dysrhythmia, suspected/confirmed systemic infection, syncope, medico-social admission reason, abnormal heart rate, and two points for creatinine greater than 2.0 mg/dL. In the development database, 22.4% had the primary outcome. Prognostic accuracy of logistic regression model versus PE-SCORE model: 0.83 (0.80, 0.86) vs. 0.78 (0.75, 0.82) using area under the curve (AUC) and 0.61 (0.57, 0.64) vs. 0.50 (0.39, 0.60) using precision-recall curve (AUCpr). In the validation database, 26.6% had the primary outcome. PE-SCORE had AUC 0.77 (0.73, 0.81) and AUCpr 0.63 (0.43, 0.81). As points increased, outcome proportions increased: a score of zero had 2% outcome, whereas scores of six and above had ≥ 69.6% outcomes. In the validation dataset, PE-SCORE zero had 8% outcome [no deaths], whereas all patients with PE-SCORE of six and above had the primary outcome. CONCLUSIONS PE-SCORE model identifies PE patients at low- and high-risk for deterioration and may help guide decisions about early outpatient management versus need for hospital-based monitoring.
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Affiliation(s)
- Anthony J. Weekes
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Jaron D. Raper
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Kathryn Lupez
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Alyssa M. Thomas
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Carly A. Cox
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Dasia Esener
- Department of Emergency Medicine, Kaiser Permanente, San Diego, CA, United States of America
| | - Jeremy S. Boyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Jason T. Nomura
- Department of Emergency Medicine, Christiana Care, Newark, DE, United States of America
| | - Jillian Davison
- Department of Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Patrick M. Ockerse
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT, United States of America
| | - Stephen Leech
- Department of Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Jakea Johnson
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Eric Abrams
- Department of Emergency Medicine, Kaiser Permanente, San Diego, CA, United States of America
| | - Kathleen Murphy
- Department of Emergency Medicine, Christiana Care, Newark, DE, United States of America
| | - Christopher Kelly
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT, United States of America
| | - H. James Norton
- Professor Emeritus of Biostatistics, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
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17
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Surov A, Akritidou M, Bach AG, Bailis N, Lerche M, Meyer HJ, Pech M, Wienke A. A New Index for the Prediction of 30-Day Mortality in Patients With Pulmonary Embolism: The Pulmonary Embolism Mortality Score (PEMS). Angiology 2021; 72:787-793. [PMID: 33557585 PMCID: PMC8326960 DOI: 10.1177/0003319721993346] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Our aim was to analyze possibility of combination of basic clinical and radiological signs to predict 30-day mortality after acute pulmonary embolism (PE). We included 486 patients. Age, gender, simplified pulmonary embolism index (sPESI), pH, troponin, N-terminal natriuretic peptide, minimal systolic and diastolic blood pressure, O2 saturation, syncope, need for vasopressors, thrombotic obstruction, vessel diameter, short axis ratio right ventricle/left ventricle, and contrast medium reflux into the inferior vena cava (IVC) were analyzed. A backward algorithm in a logistic regression model was used to identify relevant risk factors. Multiple logistic regression analysis identified that sPESI, pH, minimal diastolic blood pressure, IVC reflux, and need for vasopressors influenced 30-day mortality. A score for mortality prediction was constructed (the Pulmonary Embolism Mortality Score): sPESI >2 points (1 point), pH <7.35 (1 point), minimal diastolic blood pressure <45 mm Hg (1 point), IVC reflux (1 point), and need for vasopressors (2 points). Patients with >3 points showed higher 30-day mortality (sensitivity: 84.9%, specificity: 83.0%, positive predictive value: 51.8%, negative predictive value: 96.2%). The net reclassification improvement compared with the sPESI was 0.94 (95% CI = 0.73-1.15). In conclusion, a new score can predict 30-day mortality in patients with PE and is more sensitive than sPESI.
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Affiliation(s)
- Alexey Surov
- Department of Radiology, University of Leipzig, Germany
- Department of Radiology and Nuclear Medicine, Otto-von-Guericke University Magdeburg, Germany
| | - Mideia Akritidou
- Department of Internal Medicine, Otto-von-Guericke University Magdeburg, Germany
| | - Andreas Gunther Bach
- Department of Radiology, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | | | - Marianne Lerche
- Department of Respiratory Medicine, University of Leipzig, Germany
| | | | - Maciej Pech
- Department of Radiology and Nuclear Medicine, Otto-von-Guericke University Magdeburg, Germany
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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18
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Jaureguízar A, Jiménez D, Bikdeli B, Ruiz-Artacho P, Muriel A, Tapson V, López-Reyes R, Valero B, Kenet G, Monreal M. Heart Rate and Mortality in Patients With Acute Symptomatic Pulmonary Embolism. Chest 2021; 161:524-534. [PMID: 34478718 DOI: 10.1016/j.chest.2021.08.059] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 08/19/2021] [Accepted: 08/24/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The association between heart rate (HR) and pulmonary embolism (PE) outcomes has not been well studied. Furthermore, optimal cutoffs to identify low-risk and intermediate- to high-risk patients are not well known. RESEARCH QUESTION Does an association exist between baseline HR and PE outcome across the continuum of HR values? STUDY DESIGN AND METHODS The current study included 44,331 consecutive nonhypotensive patients with symptomatic PE from the Registro Informatizado de la Enfermedad TromboEmbólica registry between 2001 and 2021. Outcomes included 30-day all-cause and PE-specific mortality. We used hierarchical logistic regression to assess the association between admission HR and outcomes. RESULTS A positive relationship was found between admission HR and 30-day all-cause and PE-related mortality. Considering an HR of 80 to 99 beats/min as a reference, patients in the higher HR strata showed higher rates of all-cause death (adjusted OR, 1.5 for HR of 100-109 beats/min; OR, 1.7 for HR of 110-119 beats/min; OR, 1.9 for HR of 120-139 beats/min; and OR, 2.4 for HR of ≥ 140 beats/min). Patients in the lower strata of HR showed significantly lower rates of 30-day all-cause mortality compared with the same reference group (adjusted OR, 0.6 for HR of 60-79 beats/min; and OR, 0.5 for HR of < 60 beats/min). The findings for 30-day PE-related mortality were similar. For identification of low-risk patients, a cutoff value of 80 beats/min (vs 110 beats/min) increased the sensitivity of the simplified Pulmonary Embolism Severity Index (sPESI) from 93.4% to 98.8%. For identification of intermediate- to high-risk patients, a cutoff value of 140 beats/min (vs 110 beats/min) increased the specificity of the Bova score from 93.2% to 98.0%. INTERPRETATION In nonhypotensive patients with acute symptomatic PE, a high HR portends an increased risk of all-cause and PE-related mortality. Modifying the HR cutoff in the sPESI and the Bova score improves prognostication of patients with PE.
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Affiliation(s)
- Ana Jaureguízar
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, CT; Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - Pedro Ruiz-Artacho
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Department of Internal Medicine, Clínica Universidad de Navarra, Madrid, Spain; Interdisciplinar Teragnosis and Radiosomics Research Group, Universidad de Navarra, Madrid, Spain
| | - Alfonso Muriel
- Department of Biostatistics, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBERESP, Madrid, Spain
| | | | - Raquel López-Reyes
- Department of Pneumology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Beatriz Valero
- Department of Internal Medicine, Hospital General Universitario de Alicante, Alicante, Spain
| | - Gili Kenet
- Department of Pediatric Hemato-Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Manuel Monreal
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona; Universidad Católica de Murcia, Murcia, Spain
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Joint analysis of D-dimer, N-terminal pro b-type natriuretic peptide, and cardiac troponin I on predicting acute pulmonary embolism relapse and mortality. Sci Rep 2021; 11:14909. [PMID: 34290322 PMCID: PMC8295248 DOI: 10.1038/s41598-021-94346-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 06/30/2021] [Indexed: 11/09/2022] Open
Abstract
Previous studies on the adverse events of acute pulmonary embolism (APE) were mostly limited to single marker, and short follow-up duration, from hospitalization to up to 30 days. We aimed to predict the long-term prognosis of patients with APE by joint assessment of D-dimer, N-Terminal Pro-Brain Natriuretic Peptide (NT-ProBNP), and troponin I (cTnI). Newly diagnosed patients of APE from January 2011 to December 2015 were recruited from three hospitals. Medical information of the patients was collected retrospectively by reviewing medical records. Adverse events (APE recurrence and all-cause mortality) of all enrolled patients were followed up via telephone. D-dimer > 0.50 mg/L, NT-ProBNP > 500 pg/mL, and cTnI > 0.40 ng/mL were defined as the abnormal. Kaplan–Meier curve was used to compare the cumulative survival rate between patients with different numbers of abnormal markers. Cox proportional hazard regression model was used to further test the association between numbers of abnormal markers and long-term prognosis of patients with APE after adjusting for potential confounding. During follow-up, APE recurrence and all-cause mortality happened in 78 (30.1%) patients. The proportion of APE recurrence and death in one abnormal marker, two abnormal markers, and three abnormal markers groups were 7.69%, 28.21%, and 64.10% respectively. Patients with three abnormal markers had the lowest survival rate than those with one or two abnormal markers (Log-rank test, P < 0.001). After adjustment, patients with two or three abnormal markers had a significantly higher risk of the total adverse event compared to those with one abnormal marker. The hazard ratios (95% confidence interval) were 6.27 (3.24, 12.12) and 10.7 (4.1, 28.0), respectively. Separate analyses for APE recurrence and all-cause death found similar results. A joint test of abnormal D-dimer, NT-ProBNP, and cTnI in APE patients could better predict the long-term risk of APE recurrence and all-cause mortality.
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20
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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, Ní Áinle F, 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 Heart J 2021; 41:543-603. [PMID: 31504429 DOI: 10.1093/eurheartj/ehz405] [Citation(s) in RCA: 2083] [Impact Index Per Article: 694.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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21
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Triantafyllou GA, O'Corragain O, Rivera-Lebron B, Rali P. Risk Stratification in Acute Pulmonary Embolism: The Latest Algorithms. Semin Respir Crit Care Med 2021; 42:183-198. [PMID: 33548934 DOI: 10.1055/s-0041-1722898] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pulmonary embolism (PE) is a common clinical entity, which most clinicians will encounter. Appropriate risk stratification of patients is key to identify those who may benefit from reperfusion therapy. The first step in risk assessment should be the identification of hemodynamic instability and, if present, urgent patient consideration for systemic thrombolytics. In the absence of shock, there is a plethora of imaging studies, biochemical markers, and clinical scores that can be used to further assess the patients' short-term mortality risk. Integrated prediction models incorporate more information toward an individualized and precise mortality prediction. Additionally, bleeding risk scores should be utilized prior to initiation of anticoagulation and/or reperfusion therapy administration. Here, we review the latest algorithms for a comprehensive risk stratification of the patient with acute PE.
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Affiliation(s)
- Georgios A Triantafyllou
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Oisin O'Corragain
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania
| | - Belinda Rivera-Lebron
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania
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22
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Gök G, Karadağ M, Çinar T, Nurkalem Z, Duman D. In-hospital and short-term predictors of mortality in patients with intermediate-high risk pulmonary embolism. J Cardiovasc Thorac Res 2021; 12:321-327. [PMID: 33510882 PMCID: PMC7828758 DOI: 10.34172/jcvtr.2020.51] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/13/2020] [Indexed: 12/28/2022] Open
Abstract
Introduction: The aim of this study was to evaluate the in-hospital and short-term predictive factors of mortality in intermediate-high risk acute pulmonary embolism (PE) patients with right ventricle (RV)dysfunction and myocardial injury.
Methods: In this retrospective study, the medical records of 187 patients with a diagnosis of intermediate high risk acute PE were evaluated. A contrast-enhanced multi-detector pulmonary angiography was used to confirm diagnosis in all cases. All-cause mortality was determined by obtaining both in hospital and 30 days follow-up data of patients from medical records.
Results: During the in-hospital stay (9.5±4.72 days), 7 patients died, resulting in an acute PE related in-hospital mortality of 3.2%. Admission heart rate (HR), (Odds ratio (OR), 1.028 95% Confidence interval (CI), 0.002-1.121; P = 0.048) and blood urea nitrogen (BUN) (OR, 1.028 95% CI, 0.002-1.016; P = 0.044) were found to be independent predictors for in-hospital mortality in a multi variate logistic regression analysis. In total, 32 patients (20.9%) died during 30 days follow-up.The presence of congestive heart failure (OR, 0.015, 95%CI, 0.001-0.211; P = 0.002) and dementia (OR, 0.029, 95%CI,0.002-0.516; P = 0.016) as well as low albumin level (OR, 0.049 95%CI, 0.006-0.383; P = 0.049) were associated with 30 days mortality.
Conclusion: HR and BUN were independent predictors of in-hospital mortality and the presence of congestive heart failure, dementia, and low albumin levels were associated with higher 30 days mortality.
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Affiliation(s)
- Gulay Gök
- Medipol University Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Mehmet Karadağ
- Hatay Mustafa Kemal University Faculty of Medicine, Department of Biostatistics, Hatay, Turkey
| | - Tufan Çinar
- Health Sciences University, Sultan 2. Abdülhamid Han Training and Research Hospital, Department of Cardiology, İstanbul, Turkey
| | - Zekeriya Nurkalem
- Medipol University Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
| | - Dursun Duman
- Medipol University Faculty of Medicine, Department of Cardiology, Istanbul, Turkey
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23
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Ebner M, Guddat N, Keller K, Merten MC, Lerchbaumer MH, Hasenfuß G, Konstantinides SV, Lankeit M. High-sensitivity troponin I for risk stratification in normotensive pulmonary embolism. ERJ Open Res 2021; 6:00625-2020. [PMID: 33447616 PMCID: PMC7792860 DOI: 10.1183/23120541.00625-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/06/2020] [Indexed: 11/14/2022] Open
Abstract
While numerous studies have confirmed the prognostic role of high-sensitivity troponin T (hsTnT) in pulmonary embolism (PE), high-sensitivity troponin I (hsTnI) is inappropriately studied. This study aimed to investigate the prognostic relevance of hsTnI in normotensive PE, establish the optimal cut-off value for risk stratification and to compare the prognostic performances of hsTnI and hsTnT. Based on data from 459 consecutive PE patients enrolled in a single-centre registry, receiver operating characteristic analysis was used to identify an optimal hsTnI cut-off value for prediction of in-hospital adverse outcomes (PE-related death, cardiopulmonary resuscitation or vasopressor treatment) and all-cause mortality. Patients who suffered an in-hospital adverse outcome (4.8%) had higher hsTnI concentrations compared with those with a favourable clinical course (57 (interquartile range (IQR) 22–197) versus 15 (IQR 10–86) pg·mL−1, p=0.03). A hsTnI cut-off value of 16 ng·mL−1 provided optimal prognostic performance and predicted in-hospital adverse outcomes (OR 6.5, 95% CI 1.9–22.4) and all-cause mortality (OR 3.7, 95% CI 1.0–13.3). Between female and male patients, no relevant differences in hsTnI concentrations (17 (IQR 10–97) versus 17 (IQR 10–92) pg·mL−1, p=0.79) or optimised cut-off values were observed. Risk stratification according to the 2019 European Society of Cardiology algorithm revealed no differences if calculated based on either hsTnI or hsTnT (p=0.68). Our findings confirm the prognostic role of hsTnI in normotensive PE. HsTnI concentrations >16 pg·mL−1 predicted in-hospital adverse outcome and all-cause mortality; sex-specific cut-off values do not seem necessary. Importantly, our results suggest that hsTnI and hsTnT can be used interchangeably for risk stratification. The study confirms the prognostic relevance of high-sensitivity troponin I in normotensive pulmonary embolism. A cut-off value of 16 pg·mL−1 can be used for risk stratification in male and female patients; sex-specific adjustments do not appear necessary.https://bit.ly/3lCECip
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Affiliation(s)
- Matthias Ebner
- Dept of Cardiology and Angiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Berlin, Germany.,German Center for Cardiovascular Research (DZHK), partner site Berlin, Germany
| | - Niklas Guddat
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany.,Center for Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Marie Christine Merten
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Gerd Hasenfuß
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), partner site Goettingen, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany.,Dept of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Mareike Lankeit
- German Center for Cardiovascular Research (DZHK), partner site Berlin, Germany.,Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany.,Dept of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Berlin, Germany
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24
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Tandon R, Singh A, Mohan B. Risk Stratification in Acute Normotensive Pulmonary Embolism– Role of Echocardiography Imaging and Biomarkers. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2021. [DOI: 10.4103/jiae.jiae_41_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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25
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Hobohm L, Becattini C, Ebner M, Lerchbaumer MH, Casazza F, Hasenfuß G, Konstantinides SV, Lankeit M. Definition of tachycardia for risk stratification of pulmonary embolism. Eur J Intern Med 2020; 82:76-82. [PMID: 32843290 DOI: 10.1016/j.ejim.2020.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/19/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Tachycardia is a reliable predictor of adverse outcomes in normotensive patients with acute pulmonary embolism (PE). However, different prognostic relevant heart rate thresholds have been proposed. The aim of the study was to investigate the prognostic performance of different thresholds used for defining tachycardia in normotensive PE patients. METHODS We performed a post-hoc analysis of normotensive patients with confirmed PE consecutively included in a single-centre and a multi-centre registry. An adverse outcome was defined as PE-related death, need for mechanical ventilation, cardiopulmonary resuscitation or administration of catecholamines. RESULTS Of 1567 patients (median age: 72 [IQR, 59-79] years; females: 46.1%) included in the analysis, 78 patients (5.0%) had an in-hospital adverse outcome. The rate of an adverse outcome was higher in patients with a heart rate ≥100 bpm (7.6%) and ≥110 bpm (8.3%) compared to patients with a heart rate <100 bpm (3.0%). A heart rate ≥100 bpm and ≥110 bpm was associated with a 2.7 (95% CI 1.7-4.3) and 2.4-fold (95% CI 1.5-3.7) increased risk for an adverse outcome, respectively. Receiver operating characteristics analysis revealed a similar area under the curve with regard to an adverse outcome for all scores and algorithm (ESC 2019 algorithm, modified FAST and Bova score) if calculated with a heart rate threshold of ≥100 bpm or of ≥110 bpm. CONCLUSIONS Defining tachycardia by a heart rate ≥100 bpm is sufficient for risk stratification of normotensive patients with acute PE. The use of different heart rate thresholds for calculation of scores and algorithm does not appear necessary.
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Affiliation(s)
- Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Centre of the Johannes Gutenberg University Mainz, Germany; Center for Cardiology, Cardiology I, University Medical Centre of the Johannes Gutenberg-University Mainz, Germany
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Italy
| | - Matthias Ebner
- Department of Cardiology and Angiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Germany
| | - Markus H Lerchbaumer
- Department of Radiology, Campus Charité Mitte (CCM), Charité - University Medicine Berlin, Germany
| | - Franco Casazza
- Cardiology Department, San Carlo Borromeo Hospital, Milan, Italy
| | - Gerd Hasenfuß
- Clinic of Cardiology and Pneumology, University Medical Centre Göttingen, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Centre of the Johannes Gutenberg University Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Centre of the Johannes Gutenberg University Mainz, Germany; Clinic of Cardiology and Pneumology, University Medical Centre Göttingen, Germany; Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Germany.
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26
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de Winter MA, van Bergen EDP, Welsing PMJ, Kraaijeveld AO, Kaasjager KHAH, Nijkeuter M. The Prognostic Value of Syncope on Mortality in Patients With Pulmonary Embolism: A Systematic Review and Meta-analysis. Ann Emerg Med 2020; 76:527-541. [PMID: 32461009 DOI: 10.1016/j.annemergmed.2020.03.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/18/2020] [Accepted: 03/25/2020] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVE Syncope is a presenting symptom in 10% to 20% of patients with pulmonary embolism. We perform a meta-analysis to clarify the prognostic value of syncope on short-term mortality in pulmonary embolism patients and its association with hemodynamic instability. METHODS PubMed, EMBASE, and the Cochrane Library were searched up until January 7, 2020. Studies reporting inhospital or 30-day mortality of adults with pulmonary embolism with and without syncope were included. Quality of included studies was evaluated with the Quality in Prognosis Studies tool. Meta-analysis was conducted to derive pooled odds ratios (ORs) and risk differences for the relation of syncope with mortality and hemodynamic instability. To study the influence of hemodynamic instability on the association between syncope and mortality, meta-regression was performed. RESULTS Search and selection resulted in 26 studies, of which 20 were pooled, involving 9,419 of 335,120 patients (3%) with syncope. Syncope was associated with higher mortality (OR 1.82; 95% confidence interval [CI] 1.14 to 2.90; I2 88%; risk difference 4% [95% CI 1% to 8%]) and higher prevalence of hemodynamic instability (OR 4.36; 95% CI 2.27 to 8.37; I2 93%; risk difference 12% [95% CI 7% to 18%]). OR for mortality in patients with pulmonary embolism with syncope versus without it was higher in the presence of a larger difference in hemodynamic instability between groups (coefficient 0.05; 95% CI 0.01 to 0.09). CONCLUSION The association between syncope and short-term mortality in patients with pulmonary embolism is explained by a difference in hemodynamic instability. This emphasizes the importance of risk stratification by hemodynamic status in pulmonary embolism patients with and without syncope.
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Affiliation(s)
- Maria A de Winter
- Department of Internal Medicine, UMC Utrecht, Utrecht, the Netherland.
| | | | - Paco M J Welsing
- Department of Internal Medicine, UMC Utrecht, Utrecht, the Netherland
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27
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Sin D, McLennan G, Rengier F, Haddadin I, Heresi GA, Bartholomew JR, Fink MA, Thompson D, Partovi S. Acute pulmonary embolism multimodality imaging prior to endovascular therapy. Int J Cardiovasc Imaging 2020; 37:343-358. [PMID: 32862293 PMCID: PMC7456521 DOI: 10.1007/s10554-020-01980-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 08/19/2020] [Indexed: 12/15/2022]
Abstract
The manuscript discusses the application of CT pulmonary angiography, ventilation–perfusion scan, and magnetic resonance angiography to detect acute pulmonary embolism and to plan endovascular therapy. CT pulmonary angiography offers high accuracy, speed of acquisition, and widespread availability when applied to acute pulmonary embolism detection. This imaging modality also aids the planning of endovascular therapy by visualizing the number and distribution of emboli, determining ideal intra-procedural catheter position for treatment, and signs of right heart strain. Ventilation–perfusion scan and magnetic resonance angiography with and without contrast enhancement can also aid in the detection and pre-procedural planning of endovascular therapy in patients who are not candidates for CT pulmonary angiography.
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Affiliation(s)
- David Sin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Gordon McLennan
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Fabian Rengier
- Section of Emergency Radiology, Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ihab Haddadin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - John R Bartholomew
- Section of Vascular Medicine, Heart and Vascular Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Matthias A Fink
- Section of Emergency Radiology, Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Dustin Thompson
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA
| | - Sasan Partovi
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, OH, USA.
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28
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Chen X, Shao X, Zhang Y, Zhang Z, Tao X, Zhai Z, Wang C. Assessment of the Bova score for risk stratification of acute normotensive pulmonary embolism: A systematic review and meta-analysis. Thromb Res 2020; 193:99-106. [PMID: 32534329 DOI: 10.1016/j.thromres.2020.05.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/09/2020] [Accepted: 05/27/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Identification of normotensive pulmonary embolism (PE) at high risk of early adverse outcome is crucial for guiding treatment. Studies showed the Bova score had promising performance in stratifying normotensive PE. METHODS We conducted a systematic review and meta-analysis to evaluate the prognostic performance of the Bova score for normotensive PE. RESULTS Nine studies involving 8342 acute normotensive PE patients were enrolled. Overall, 71.4%, 20.2% and 8.4% patients were stratified as risk class I, II and III. Pooled incidence of short-term PE related composite adverse outcome of each group were 3.8%, 10.8% and 19.9%, respectively, exhibiting a significant rising trend. Increasing trends of 30-day and in-hospital composite adverse outcome rates, as well as PE related mortality, were also observed with upper risk classes. Compared with risk class I and II, high risk group (class III) was significantly associated with short-term PE related composite adverse outcome (OR: 5.45, 95% CI, 3.70-8.02) and PE related death (OR: 5.09, 95% CI, 3.54-7.30). Pooled sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of the score for predicting short-term composite adverse outcome were 0.25 (95% CI, 0.22-0.29), 0.93 (95% CI, 0.92-0.93), 4.05 (95% CI, 2.90-5.67) and 0.81 (95% CI, 0.74-0.88), respectively. The weighted area under the summarized receiver characteristics operation curve for predicting composite adverse outcome was 0.73 ± 0.09. CONCLUSION The Bova score could effectively discriminate normotensive PE with different short-term prognosis and has good performance in identifying patients at higher risk of short-term adverse events.
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Affiliation(s)
- Xinwang Chen
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Xiang Shao
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China; Beijing University of Chinese Medicine, Beijing, China
| | - Yunxia Zhang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Zhu Zhang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China; Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xincao Tao
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China; Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China.
| | - Chen Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China; Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Hobohm L, Becattini C, Konstantinides SV, Casazza F, Lankeit M. Validation of a fast prognostic score for risk stratification of normotensive patients with acute pulmonary embolism. Clin Res Cardiol 2020; 109:1008-1017. [PMID: 32025793 PMCID: PMC7376081 DOI: 10.1007/s00392-019-01593-w] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/22/2019] [Indexed: 12/19/2022]
Abstract
Background Recent studies demonstrate an improved prognostic performance of the 2014 European Society of Cardiology (ESC) algorithm for risk stratification of patients with pulmonary embolism (PE) compared to the 2008 ESC algorithm. The modified FAST and Bova scores appear especially helpful to identify PE patients at intermediate-high risk. Methods We validated the prognostic performance of the modified FAST score compared to other scores for risk stratification in a post-hoc analysis of 868 normotensive PE patients included in the prospective Italian Pulmonary Embolism Registry. In-hospital adverse outcome was defined as PE-related death, mechanical ventilation, cardiopulmonary resuscitation or administration of catecholamines. Results Overall, 27 patients (3.1%) had an adverse outcome and 32 patients (3.7%) died. The rate of an adverse outcome was highest in the intermediate-high risk classes of the 2019 ESC algorithm (7.5%) and the modified FAST score (5.3%) while the Bova score failed to discriminate between intermediate-low and intermediate-high-risk patients. Patients classified as intermediate-high risk by the 2019 ESC algorithm (Odds Ratio [OR], 4.2 [95% CI, 1.9–9.0]) and modified FAST score (OR, 2.8 [1.3–6.2]) had a higher risk of an adverse outcome compared to patients classified by the Bova score (OR, 1.6 [0.7–3.7]). The c-index was higher for the 2019 ESC algorithm and the modified FAST score (AUC, 0.69 [0.58–0.79] and 0.67 [0.59–0.76]) compared to the Bova score (AUC, 0.64 [0.55–0.73]). Conclusions The 2019 ESC algorithm provided the best prognostic performance, but also the modified FAST score accurately stratified normotensive PE patients in different risk classes while the Bova score failed to identify patients at highest risk. Graphic abstract ![]()
Electronic supplementary material The online version of this article (10.1007/s00392-019-01593-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany.,Center for Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Franco Casazza
- Cardiology Department, San Carlo Borromeo Hospital, Milan, Italy
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany. .,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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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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Risk stratification of acute pulmonary embolism based on clinical parameters, H-FABP and multidetector CT. Int J Cardiol 2018; 265:223-228. [DOI: 10.1016/j.ijcard.2018.04.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 02/05/2018] [Accepted: 04/16/2018] [Indexed: 12/17/2022]
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Bledsoe JR, Woller SC, Stevens SM, Aston V, Patten R, Allen T, Horne BD, Dong L, Lloyd J, Snow G, Madsen T, Elliott CG. Management of Low-Risk Pulmonary Embolism Patients Without Hospitalization. Chest 2018; 154:249-256. [DOI: 10.1016/j.chest.2018.01.035] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/17/2018] [Accepted: 01/19/2018] [Indexed: 12/18/2022] Open
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Hellenkamp K, Pruszczyk P, Jiménez D, Wyzgał A, Barrios D, Ciurzyński M, Morillo R, Hobohm L, Keller K, Kurnicka K, Kostrubiec M, Wachter R, Hasenfuß G, Konstantinides S, Lankeit M. Prognostic impact of copeptin in pulmonary embolism: a multicentre validation study. Eur Respir J 2018; 51:13993003.02037-2017. [DOI: 10.1183/13993003.02037-2017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 02/28/2018] [Indexed: 12/23/2022]
Abstract
To externally validate the prognostic impact of copeptin, either alone or integrated in risk stratification models, in pulmonary embolism (PE), we performed a post hoc analysis of 843 normotensive PE patients prospectively included in three European cohorts.Within the first 30 days, 21 patients (2.5%, 95% CI 1.5–3.8) had an adverse outcome and 12 (1.4%, 95% CI 0.7–2.5) died due to PE. Patients with copeptin ≥24 pmol·L−1 had a 6.3-fold increased risk for an adverse outcome (95% CI 2.6–15.5, p<0.001) and a 7.6-fold increased risk for PE-related death (95% CI 2.3–25.6, p=0.001). Risk classification according to the 2014 European Society of Cardiology (ESC) guideline algorithm identified 248 intermediate-high-risk patients (29.4%) with 5.6% (95% CI 3.1–9.3) at risk of adverse outcomes. A stepwise biomarker-based risk assessment strategy (based on high-sensitivity troponin T, N-terminal pro-brain natriuretic peptide and copeptin) identified 123 intermediate-high-risk patients (14.6%) with 8.9% (95% CI 4.5–15.4) at risk of adverse outcomes. The identification of patients at higher risk was even better when copeptin was measured on top of the 2014 ESC algorithm in intermediate-high-risk patients (adverse outcome OR 11.1, 95% CI 4.6–27.1, p<0.001; and PE-related death OR 13.5, 95% CI 4.2–43.6, p<0.001; highest risk group versus all other risk groups). This identified 85 patients (10.1%) with 12.9% (95% CI 6.6–22.0) at risk of adverse outcomes and 8.2% (95% CI 3.4–16.2) at risk of PE-related deaths.Copeptin improves risk stratification of normotensive PE patients, especially when identifying patients with an increased risk of an adverse outcome.
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Abellás M, Menéndez A, Morillo R, Jara-Palomares L, Barrios D, Nieto R, Barbero E, Corres J, Ruiz-Artacho P, Jiménez D. Clinical Characteristics and Prognosis of Pulmonary Embolism Caused by Economy Class Syndrome. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.arbr.2017.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Vanni S, Nazerian P, Bova C, Bondi E, Morello F, Pepe G, Paladini B, Liedl G, Cangioli E, Grifoni S, Jiménez D. Comparison of clinical scores for identification of patients with pulmonary embolism at intermediate-high risk of adverse clinical outcome: the prognostic role of plasma lactate. Intern Emerg Med 2017; 12:657-665. [PMID: 27350628 DOI: 10.1007/s11739-016-1487-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 06/09/2016] [Indexed: 10/21/2022]
Abstract
To compare the prognostic accuracy of the 2014 risk model of the European Society of Cardiology (ESC) and of Bova and TELOS scores for identification of normotensive patients with pulmonary embolism (PE) at high risk for short-term adverse events (i.e., intermediate-high risk patients), we retrospectively applied these tests to a prospective cohort of 994 normotensive patients with objectively confirmed PE. Sixty-three (6.3 %) patients reached the primary outcome, a composite of hemodynamic collapse and death within 7 days from diagnosis. The Bova and TELOS scores classified the same proportion of patients in intermediate-high risk category (5.9 and 5.7 %, respectively), with a similar primary outcome rate (18.6 and 21.1 %, respectively). The 2014 ESC model classified in the intermediate-high risk category the largest proportion of patients (12.5 %, p < 0.001 vs Bova and TELOS), with the lowest primary outcome rate (13 %, p = ns vs Bova and TELOS). When lactate determination was added to the Bova score, 112 patients (11.2 %) were classified in the intermediate-high risk category (p < 0.05 vs Bova and TELOS), with a slight increase in the primary outcome rate (25.9 %, p = 0.014 vs 2014 ESC model), allowing the recognition of a twofold higher number of patients reaching the primary outcome (29 vs 15, 11 and 12 patients in the 2014 ESC model, Bova and TELOS scores, respectively, p < 0.01 for all). The 2014 ESC model, Bova and TELOS scores identify a small number of intermediate-high risk patients with PE, without differences among tests. Adding plasma lactate to the Bova score significantly improves the identification of intermediate-high risk patients.
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Affiliation(s)
- Simone Vanni
- Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy.
| | - Peiman Nazerian
- Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Carlo Bova
- Department of Medicine, University Hospital of Cosenza, Cosenza, Italy
| | - Ernesta Bondi
- Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Fulvio Morello
- Emergency Department, A.O.U. Città della Salute e della Scienza di Torino, Ospedale Molinette, Turin, Italy
| | - Giuseppe Pepe
- Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Barbara Paladini
- Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Giovanni Liedl
- Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Elisabetta Cangioli
- Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - Stefano Grifoni
- Emergency Department, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 3, 50139, Florence, Italy
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Alcalá de Henares University, Madrid, Spain
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Zuin M, Conte L, Picariello C, Pastore G, Vassiliev D, Lanza D, Zonzin P, Zuliani G, Rigatelli G, Roncon L. TIMI Risk Index as a Predictor of 30-Day Outcomes in Patients With Acute Pulmonary Embolism. Heart Lung Circ 2017; 27:190-198. [PMID: 28487060 DOI: 10.1016/j.hlc.2017.02.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 02/10/2017] [Accepted: 02/27/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Available studies have already identified age, heart rate (HR) and systolic blood pressure (SBP) as strong predictors of early mortality in acute pulmonary embolism (PE). MATERIAL AND METHODS One-hundred-seventy patients, with acute PE confirmed on computed tomography angiography (CTA) were enrolled. Thrombolysis In Myocardial Infarction (TIMI) risk index (TRI) was calculated using the formula [heart rate (HR) x (AGE/102)/ systolic blood pressure (SBP)]. Study outcomes were 30-day mortality and/or clinical deterioration. RESULTS Receiver operating characteristics (ROC) curve revealed that a TRI ≥45 was highly specific for both outcomes (AUC 0.91, 95% CI 0.83-0.98, p<0.0001) with a positive predictive value (PPV) and negative predictive value (NPV) of 8.3 and 96% for 30-day mortality while PPV and NPV for 30-day mortality and/or clinical deterioration were 21.1 and 98.2%, respectively. Multivariate regression analysis showed that TRI ≥45 was an independent predictor of 30-day mortality (O.R. 22.24, 95% CI 2.54-194.10, p=0.005) independently from positive cTnI and RVD (O.R. 9.57, 95% CI 1.88-48.78, p=0.007; OR 24.99, 95% CI 2.84-219.48, p=0.004). Similarly, 30-day mortality and/or clinical deterioration was predicted by TRI ≥45 (O.R. 11.57, 95% CI 2.36-56.63, p=0.003) and thrombolysis (3.83, 95% CI 1.04-14.09, p=0.043), independently from age, RVD and positive cTnI. Cox regression analysis confirmed the role of TRI as independent predictor for both outcomes. Mantel-Cox analysis showed that after 30-day follow-up there was a statistically significant difference in the distribution of survival between patients with and without TRI ≥45 [log rank (Mantel-Cox) chi-square 17.04, p<0.0001]. CONCLUSIONS Thrombolysis In Myocardial Infarction (TIMI) risk index (TRI) predicted both 30-days mortality (all-causes) and/or clinical deterioration in patients with acute PE.
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Affiliation(s)
- Marco Zuin
- Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy; Section of Internal and Cardiopulmonary Medicine, Department of Medical Science, University of Ferrara, Ferrara, Italy
| | - Luca Conte
- Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Claudio Picariello
- Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Gianni Pastore
- Arrhythmia and Electrophysiology Unit, Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Dobrin Vassiliev
- Cardiology Clinic, Alexandroska University Hospital, Sofia, Bulgaria
| | - Daniela Lanza
- Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Pietro Zonzin
- Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Giovanni Zuliani
- Section of Internal and Cardiopulmonary Medicine, Department of Medical Science, University of Ferrara, Ferrara, Italy
| | - Gianluca Rigatelli
- Section of Adult Congenital and Adult Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Italy
| | - Loris Roncon
- Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy.
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Clinical Characteristics and Prognosis of Pulmonary Embolism Caused by Economy Class Syndrome. Arch Bronconeumol 2017; 53:495-500. [PMID: 28366298 DOI: 10.1016/j.arbres.2017.02.011] [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: 12/05/2016] [Revised: 02/15/2017] [Accepted: 02/18/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Clinical presentation and short-term prognosis of patients with travel-associated acute pulmonary embolism (PE) (i.e., economy class syndrome [ECS]) is not well understood. METHODS In this retrospective cohort study of patients with acute PE identified from a single center registry, we assessed the clinical presentation and the association between ECS and the outcomes of all-cause mortality, PE-related mortality, nonfatal venous thromboembolism and nonfatal major bleeding rates through 30days after initiation of PE treatment. RESULTS Of the 2,333 patients with acute symptomatic PE, 124 (5.3%; 95% confidence interval, 4.4-6.3%) had ECS. Patients with ECS were younger and had fewer comorbid diseases (recent bleeding, chronic obstructive pulmonary disease, congestive heart failure), but they presented with more signs of clinical severity (syncope [48% vs. 14%; P<.001], tachycardia [37% vs. 21%; P<.001], right ventricular dysfunction [31% vs. 19%; P<.01] and myocardial injury [57% vs. 28%; P<.001]) compared to those without ECS. Regression analyses showed a significantly lower risk of all-cause mortality for patients with ECS compared to patients without ECS (1.6% vs. 9.6%; P<.01). We did not detect a difference in PE-related mortality at 30days between those with and those without ECS (0.8% vs. 3.1%; P=.18). CONCLUSIONS PE patients with ECS are younger and have fewer comorbid diseases compared to those without ECS. Though they present with more signs of clinical severity, their short-term prognosis is excellent.
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Giannitsis E, Katus HA. Biomarkers for Clinical Decision-Making in the Management of Pulmonary Embolism. Clin Chem 2017; 63:91-100. [DOI: 10.1373/clinchem.2016.255240] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 07/12/2016] [Indexed: 12/13/2022]
Abstract
Abstract
BACKGROUND
Pulmonary embolism (PE) is associated with high all-cause and PE-related mortality and requires individualized management. After confirmation of PE, a refined risk stratification is particularly warranted among normotensive patients. Previous prognostic models favored combinations of echocardiography or computed tomography suggestive of right ventricular (RV) dysfunction together with biomarkers of RV dysfunction (natriuretic peptides) or myocardial injury (cardiac troponins) to identify candidates for thrombolysis or embolectomy. In contrast, current predictive models using clinical scores such as the Pulmonary Embolism Severity Index (PESI) or its simplified version (sPESI) rather seek to identify patients, not only those at higher risk requiring observation for early detection of hemodynamic decompensation, and the need for initiation of rescue reperfusion therapy, but also those at low risk qualifying for early discharge and outpatient treatment. Almost all prediction models advocate the additional measurement of biomarkers along with imaging of RV dysfunction as part of a comprehensive algorithm.
CONTENT
The following mini-review will provide an updated overview on the individual components of different algorithms with a particular focus on guideline-recommended and new, less-established biomarkers for risk stratification, and how biomarkers should be implemented and interpreted.
SUMMARY
Ideally, biomarkers should be part of a comprehensive risk stratification algorithm used together with clinical risk scores as a basis, and/or imaging. For this purpose, cardiac troponins, including high-sensitivity troponin generations, natriuretic peptides, and h-FABP (heart-type fatty acid–binding protein) are currently recommended in guidelines. There is emerging evidence for several novel biomarkers that require further validation before being applied in clinical practice.
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Affiliation(s)
- Evangelos Giannitsis
- Department of Internal Medicine III, Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Department of Internal Medicine III, Cardiology, University Hospital Heidelberg, Heidelberg, Germany
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Becattini C, Agnelli G. Risk stratification and management of acute pulmonary embolism. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:404-412. [PMID: 27913508 PMCID: PMC6142437 DOI: 10.1182/asheducation-2016.1.404] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The clinical management of patients with acute pulmonary embolism is rapidly changing over the years. The widening spectrum of clinical management strategies for these patients requires effective tools for risk stratification. Patients at low risk for death could be candidates for home treatment or early discharge. Clinical models with high negative predictive value have been validated that could be used to select patients at low risk for death. In a major study and in several meta-analyses, thrombolysis in hemodynamically stable patients was associated with unacceptably high risk for major bleeding complications or intracranial hemorrhage. Thus, the presence of shock or sustained hypotension continues to be the criterion for the selection of candidates for thrombolytic treatment. Interventional procedures for early revascularization should be reserved to selected patients until further evidence is available. No clinical advantage is expected with the insertion of a vena cava filter in the acute-phase management of patients with acute pulmonary embolism. Direct oral anticoagulants used in fixed doses without laboratory monitoring showed similar efficacy (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.70-1.12) and safety (OR, 0.89; 95% CI, 0.77-1.03) in comparison with conventional anticoagulation in patients with acute pulmonary embolism. Based on these results and on their practicality, direct oral anticoagulants are the agents of choice for the treatment of the majority of patients with acute pulmonary embolism.
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Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
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Elias A, Mallett S, Daoud-Elias M, Poggi JN, Clarke M. Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis. BMJ Open 2016; 6:e010324. [PMID: 27130162 PMCID: PMC4854007 DOI: 10.1136/bmjopen-2015-010324] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To review the evidence for existing prognostic models in acute pulmonary embolism (PE) and determine how valid and useful they are for predicting patient outcomes. DESIGN Systematic review and meta-analysis. DATA SOURCES OVID MEDLINE and EMBASE, and The Cochrane Library from inception to July 2014, and sources of grey literature. ELIGIBILITY CRITERIA Studies aiming at constructing, validating, updating or studying the impact of prognostic models to predict all-cause death, PE-related death or venous thromboembolic events up to a 3-month follow-up in patients with an acute symptomatic PE. DATA EXTRACTION Study characteristics and study quality using prognostic criteria. Studies were selected and data extracted by 2 reviewers. DATA ANALYSIS Summary estimates (95% CI) for proportion of risk groups and event rates within risk groups, and accuracy. RESULTS We included 71 studies (44,298 patients). Among them, 17 were model construction studies specific to PE prognosis. The most validated models were the PE Severity Index (PESI) and its simplified version (sPESI). The overall 30-day mortality rate was 2.3% (1.7% to 2.9%) in the low-risk group and 11.4% (9.9% to 13.1%) in the high-risk group for PESI (9 studies), and 1.5% (0.9% to 2.5%) in the low-risk group and 10.7% (8.8% to12.9%) in the high-risk group for sPESI (11 studies). PESI has proved clinically useful in an impact study. Shifting the cut-off or using novel and updated models specifically developed for normotensive PE improves the ability for identifying patients at lower risk for early death or adverse outcome (0.5-1%) and those at higher risk (up to 20-29% of event rate). CONCLUSIONS We provide evidence-based information about the validity and utility of the existing prognostic models in acute PE that may be helpful for identifying patients at low risk. Novel models seem attractive for the high-risk normotensive PE but need to be externally validated then be assessed in impact studies.
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Affiliation(s)
- Antoine Elias
- Department of Vascular Medicine, Sainte Musse Hospital, Toulon La Seyne Hospital Centre, Toulon, France
- DPhil Programme in Evidence-Based Healthcare, University of Oxford, Oxford, UK
| | - Susan Mallett
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marie Daoud-Elias
- Department of Vascular Medicine, Sainte Musse Hospital, Toulon La Seyne Hospital Centre, Toulon, France
| | - Jean-Noël Poggi
- Department of Vascular Medicine, Sainte Musse Hospital, Toulon La Seyne Hospital Centre, Toulon, France
| | - Mike Clarke
- Northern Ireland Network for Trials Methodology Research, Queen's University Belfast, Belfast, UK
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Keller K, Beule J, Balzer JO, Dippold W. Syncope and collapse in acute pulmonary embolism. Am J Emerg Med 2016; 34:1251-7. [PMID: 27107684 DOI: 10.1016/j.ajem.2016.03.061] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 03/26/2016] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Syncope and collapse (=presyncope) are 2 symptoms of pulmonary embolism (PE), which are suspected of being connected with poorer outcome, regardless of haemodynamic instability. However, pathomechanisms are not completely understood. We aimed to investigate these pathomechanisms in regard to blood pressure and heart rate of syncope/collapse in PE. METHODS We performed a retrospective study of consecutive PE patients, who were treated in the Internal Medicine Department. Patients with and without syncope/collapse were compared. Regression models for associations between syncope/collapse and blood pressure, heart rate and shock index (SI) were computed. Moreover we calculated ROC analyses and Youden indices for effectiveness and cut-off-values of these parameters for the probability of syncope/collapse. RESULTS 182 patients (mean-age 68.5±15.3years; 61.5% female) with confirmed PE were included in this study. 20 PE patients (11.0%) showed a syncope/collapse. PE patients with syncope/collapse were in median 7.5years older (78.5 (72.0/82.3) vs. 71.0 (61.0/80.0) years, P=.0575), had lower systolic (132.0 (108.8/154.0) vs. 145.5 (127.0/166.0) mmHg, P=.0845) and diastolic (70.0±27.0 vs. 78.4±18.4mmHg, P=.0740) blood pressure, whereas heart rate (103.5 (87.8/116.0) vs. 90.0 (76.0/102.0)beats/min, P=.0518), SI (0.78 (0.65/1.01) vs. 0.60(0.50/0.79), P=.0127) and frequency of right ventricular dysfunction (RVD) (88.2% vs. 55.8%, P=.0294) were higher in PE patients with syncope/collapse than in those without. Hypotension (systolic blood pressure<90mmHg), tachycardia and SI>1.0were connected with 6.4-fold, 2.5-fold and 5.8-fold higher probability of syncope/collapse, respectively. ROC analyses revealed cut-off values of ≤110mmHg, ≥107beats/min and >0.62 for systolic blood pressure, heart rate and SI with low AUC values, respectively. CONCLUSIONS The pathomechanism of syncope/collapse in patients with acute PE seems to be connected with blood pressure fall, heart rate increase and RVD, in terms of cardiovascular syncope with reduced cardiac output and vasovagal reflex.
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Affiliation(s)
- Karsten Keller
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany; Center of Cardiology, Department of Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany.
| | - Johannes Beule
- Department of internal medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM), Mainz, Germany
| | - Jörn Oliver Balzer
- Department of Radiology and Nuclear medicine, Catholic Clinic Mainz (KKM), Mainz, Germany; Department of Diagnostic and Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt, Main, Frankfurt, Germany
| | - Wolfgang Dippold
- Department of internal medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM), Mainz, Germany
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Impact of relative contraindications to home management in emergency department patients with low-risk pulmonary embolism. Ann Am Thorac Soc 2016; 12:666-73. [PMID: 25695933 DOI: 10.1513/annalsats.201411-548oc] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Studies of adults presenting to the emergency department (ED) with acute pulmonary embolism (PE) suggest that those who are low risk on the PE Severity Index (classes I and II) can be managed safely without hospitalization. However, the impact of relative contraindications to home management on outcomes has not been described. OBJECTIVES To compare 5-day and 30-day adverse event rates among low-risk ED patients with acute PE without and with outpatient ineligibility criteria. METHODS We conducted a retrospective multicenter cohort study of adults presenting to the ED with acute low-risk PE between 2010 and 2012. We evaluated the association between outpatient treatment eligibility criteria based on a comprehensive list of relative contraindications and 5-day adverse events and 30-day outcomes, including major hemorrhage, recurrent venous thromboembolism, and all-cause mortality. MEASUREMENTS AND MAIN RESULTS Of 423 adults with acute low-risk PE, 271 (64.1%) had no relative contraindications to outpatient treatment (outpatient eligible), whereas 152 (35.9%) had at least one contraindication (outpatient ineligible). Relative contraindications were categorized as PE-related factors (n = 112; 26.5%), comorbid illness (n = 42; 9.9%), and psychosocial barriers (n = 19; 4.5%). There were no 5-day events in the outpatient-eligible group (95% upper confidence limit, 1.7%) and two events (1.3%; 95% confidence interval [CI], 0.1-5.0%) in the outpatient-ineligible group (P = 0.13). At 30 days, there were five events (two recurrent venous thromboemboli and three major bleeding events) in the outpatient-eligible group (1.8%; 95% CI, 0.7-4.4%) compared with nine in the ineligible group (5.9%; 95% CI, 2.7-10.9%; P < 0.05). This difference remained significant when controlling for PE severity class. CONCLUSIONS Nearly two-thirds of adults presenting to the ED with low-risk PE were potentially eligible for outpatient therapy. Relative contraindications to outpatient management were associated with an increased frequency of adverse events at 30 days among adults with low-risk PE.
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Hobohm L, Hellenkamp K, Hasenfuß G, Münzel T, Konstantinides S, Lankeit M. Comparison of risk assessment strategies for not-high-risk pulmonary embolism. Eur Respir J 2016; 47:1170-8. [PMID: 26743479 DOI: 10.1183/13993003.01605-2015] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 11/12/2015] [Indexed: 01/28/2023]
Abstract
We compared the prognostic performance of the 2014 European Society of Cardiology (ESC) risk stratification algorithm with the previous 2008 ESC algorithm, the Bova score and the modified FAST score (based on a positive heart-type fatty acid-binding protein (H-FABP) test, syncope and tachycardia, modified using high-sensitivity troponin T instead of H-FABP) in 388 normotensive pulmonary embolism patients included in a single-centre cohort study.Overall, 25 patients (6.4%) had an adverse 30-day outcome. Regardless of the score or algorithm used, the rate of an adverse outcome was highest in the intermediate-high-risk classes, while all patients classified as low-risk had a favourable outcome (no pulmonary embolism-related deaths, 0-1.4% adverse outcome). The area under the curve for predicting an adverse outcome was higher for the 2014 ESC algorithm (0.76, 95% CI 0.68-0.84) compared with the 2008 ESC algorithm (0.65, 95% CI 0.56-0.73) and highest for the modified FAST score (0.82, 95% CI 0.75-0.89). Patients classified as intermediate-high-risk by the 2014 ESC algorithm had a 8.9-fold increased risk for an adverse outcome (3.2-24.2, p<0.001 compared with intermediate-low- and low-risk patients), while the highest OR was observed for a modified FAST score ≥3 points (OR 15.9, 95% CI 5.3-47.6, p<0.001).The 2014 ESC algorithm improves risk stratification of not-high-risk pulmonary embolism compared with the 2008 ESC algorithm. All scores and algorithms accurately identified low-risk patients, while the modified FAST score appears more suitable to identify intermediate-high-risk patients.
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Affiliation(s)
- Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany Center for Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Kristian Hellenkamp
- Clinic of Cardiology and Pneumology, Heart Center, University of Göttingen, Göttingen, Germany
| | - Gerd Hasenfuß
- Clinic of Cardiology and Pneumology, Heart Center, University of Göttingen, Göttingen, Germany German Center for Cardiovascular Research, Partner Site Göttingen, Göttingen, Germany
| | - Thomas Münzel
- Center for Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg University, Mainz, Germany German Center for Cardiovascular Research, Partner Site Rhein-Main, Mainz, Germany Center for Translational Vascular Biology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany Clinic of Cardiology and Pneumology, Heart Center, University of Göttingen, Göttingen, Germany
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Management of massive and submassive pulmonary embolism: focus on recent randomized trials. Curr Opin Pulm Med 2015; 20:393-9. [PMID: 25029299 DOI: 10.1097/mcp.0000000000000089] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Although early pulmonary revascularization is the treatment of choice for patients with high-risk (massive) pulmonary embolism, it remains controversial in patients with intermediate-risk (submassive) pulmonary embolism until recently. Recent published data on the management of high-risk and intermediate-risk pulmonary embolism patients will be the main focus of this review. RECENT FINDINGS The PEITHO trial supports the rationale of risk stratification in normotensive patients with pulmonary embolism. Patients with right ventricular dilation on echocardiography and positive cardiac troponin test have a high intermediate risk of complication and death. Thrombolysis prevents hemodynamic collapse in these patients but with an increased risk of major bleeding particularly in older patients (>75 years). Reduced dose of thrombolysis and catheter-based reperfusion with or without fibrinolysis have shown promising results. SUMMARY Thrombolysis is the treatment of choice for patients with high-risk pulmonary embolism. Surgical embolectomy is recommended in case of absolute contra-indication to thrombolysis. In patients with acute right ventricular dysfunction on cardiac imaging and myocardial injury, thrombolysis should be considered if they are 75 years or less of age and are at low risk of bleeding. Full-dose thrombolysis may be excessively risky in patients over 75 years. In patients with either RV dilation or elevated cardiac biomarker, thrombolysis is not recommended.
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Klok F, Tesche C, Rappold L, Dellas C, Hasenfuß G, Huisman M, Konstantinides S, Lankeit M. External validation of a simple non-invasive algorithm to rule out chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. Thromb Res 2015; 135:796-801. [DOI: 10.1016/j.thromres.2014.12.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 12/03/2014] [Accepted: 12/06/2014] [Indexed: 01/21/2023]
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Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JSR, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk Noordegraaf A, Zamorano JL, Zompatori M. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35:3033-69, 3069a-3069k. [PMID: 25173341 DOI: 10.1093/eurheartj/ehu283] [Citation(s) in RCA: 1843] [Impact Index Per Article: 184.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Seyyedi SR, Jenab Y, Tokaldany ML, Shirani S, Sadeghian S, Jalali A. Syncope paradox in the outcome of patients with pulmonary thromboembolism: short-term and midterm outcome. CLINICAL RESPIRATORY JOURNAL 2014; 10:90-7. [DOI: 10.1111/crj.12183] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 06/16/2014] [Accepted: 07/03/2014] [Indexed: 11/29/2022]
Affiliation(s)
| | - Yaser Jenab
- Tehran Heart Center; Tehran University of Medical Sciences; Tehran Iran
| | | | - Shapoor Shirani
- Tehran Heart Center; Tehran University of Medical Sciences; Tehran Iran
| | - Saeed Sadeghian
- Tehran Heart Center; Tehran University of Medical Sciences; Tehran Iran
| | - Arash Jalali
- Tehran Heart Center; Tehran University of Medical Sciences; Tehran Iran
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Dellas C, Tschepe M, Seeber V, Zwiener I, Kuhnert K, Schäfer K, Hasenfuß G, Konstantinides S, Lankeit M. A novel H-FABP assay and a fast prognostic score for risk assessment of normotensive pulmonary embolism. Thromb Haemost 2014; 111:996-1003. [PMID: 24477222 DOI: 10.1160/th13-08-0663] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 12/19/2013] [Indexed: 01/15/2023]
Abstract
We tested whether heart-type fatty acid binding protein (H-FABP) measured by a fully-automated immunoturbidimetric assay in comparison to ELISA provides additive prognostic value in patients with pulmonary embolism (PE), and validated a fast prognostic score in comparison to the ESC risk prediction model and the simplified Pulmonary Embolism Severity Index (sPESI). We prospectively examined 271 normotensive patients with PE; of those, 20 (7%) had an adverse 30-day outcome. H-FABP levels determined by immunoturbidimetry were higher (median, 5.2 [IQR; 2.7-9.8] ng/ml) than those by ELISA (2.9 [1.1-5.4] ng/ml), but Bland-Altman plot demonstrated a good agreement of both assays. The area under the curve for H-FABP was greater for immunoturbidimetry than for ELISA (0.82 [0.74-0.91] vs 0.78 [0.68-0.89]; P=0.039). H-FABP measured by immunoturbidimetry (but not by ELISA) provided additive prognostic information to other predictors of 30-day outcome (OR, 12.4 [95% CI, 1.6-97.6]; P=0.017). When H-FABP determined by immunoturbidimetry was integrated into a novel prognostic score (H-FABP, Syncope, and Tachycardia; FAST score), the score provided additive prognostic information by multivariable analysis (OR, 14.2 [3.9-51.4]; p<0.001; c-index, 0.86) which were superior to information obtained by the ESC model (c-index, 0.62; net reclassification improvement (NRI), 0.39 [0.21-0.56]; P<0.001) or the sPESI (c-index, 0.68; NRI, 0.24 [0.05-0.43]; P=0.012). In conclusion, determination of H-FABP by immunoturbidimetry provides prognostic information superior to that of ELISA and, if integrated in the FAST score, appears more suitable to identify patients with an adverse 30-day outcome compared to the ESC model and sPESI.
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Affiliation(s)
- Claudia Dellas
- Claudia Dellas, Department of Cardiology and Pneumology, Heart Center, Georg August University of Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany, Tel.: +49 551 3912575, Fax: +49 551 3914142, E-mail:
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Lankeit M, Dellas C, Benz V, Hasenfuß G, Konstantinides S. The predictive value of heart-type fatty acid-binding protein is independent from symptom duration in normotensive patients with pulmonary embolism. Thromb Res 2013; 132:543-7. [PMID: 24094603 DOI: 10.1016/j.thromres.2013.09.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 09/09/2013] [Accepted: 09/17/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Heart-type fatty acid-binding protein (H-FABP) is a useful biomarker for risk stratification of patients with pulmonary embolism (PE). In patients with acute myocardial infarction, H-FABP plasma concentrations rise after 30 minutes and return to normal within 20-24 hours. We tested whether the predictive value of H-FABP is affected by the duration of symptoms prior to diagnosis in patients with PE. MATERIAL AND METHODS We prospectively studied 257 consecutive normotensive patients with confirmed symptomatic PE. RESULTS Patients with acute (<24 hours; n=150) symptom onset presented more often with syncope (28.7% vs. 6.5%; p<0.001) compared to patients with symptoms ≥ 24 hours (n=107); other baseline characteristics, comorbidities, and risk factors were distributed equally. Patients with an adverse 30-day outcome (6.6%) had higher H-FABP levels (11.84 [3.57-19.62] ng/ml) compared to patients with a favorable course (3.42 [1.92-5.42] ng/ml; p<0.001). However, the proportion of patients with H-FABP levels ≥ 6 ng/ml did not differ among patients with acute symptom onset and late presentation (p=0.104). Only tachycardia and elevation of H-FABP were associated with an increased risk of an adverse 30-day outcome both in patients with acute symptom onset (H-FABP: OR, 5.8; 95% CI, 1.4-24.5; p=0.016; tachycardia: 7.0 [1.4-36.0]; p=0.018) and late presentation (H-FABP: 9.3 [2.0-43.2]; p=0.004 and tachycardia: 12.3 [1.5-103.6]; p=0.021). The prognostic value could further be improved by the use of a simple H-FABP-based clinical prediction score. CONCLUSIONS Our findings indicate that H-FABP is a useful biomarker for risk stratification of normotensive patients with PE regardless of symptom duration prior to diagnosis.
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Affiliation(s)
- Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg University of Mainz, Germany; Department of Cardiology and Pulmonology, Heart Center of the Georg August University of Göttingen, Germany.
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