Clinical, historical and diagnostic findings associated with right ventricular dysfunction in patients with central and non-massive pulmonary embolism

The genetic causal relationship between type 2 diabetes, glycemic traits and venous thromboembolism, deep vein thrombosis, pulmonary embolism: a two-sample Mendelian randomization study

OBJECTIVE

To investigate the genetic underpinnings of the association between type 2 diabetes (T2D), glycemic indicators such as fasting glucose (FG), fasting insulin (FI), and glycated hemoglobin (GH), and venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), thereby contributing novel insights to the scholarly discourse within this domain.

METHODS

Genome-wide association study (GWAS) summary data pertaining to exposures (T2D, FG, FI, GH) and outcomes (VTE, DVT, PE) were acquired from the IEU Open GWAS database, encompassing participants of European descent, including both male and female individuals. Two-sample Mendelian randomization (MR) analyses were conducted utilizing the TwoSampleMR and MRPRESSO packages within the R programming environment. The primary analytical approach employed was the random-effects inverse variance weighted (IVW) method. Heterogeneity was assessed via Cochran's Q statistic for MR-IVW and Rucker's Q statistic for MR-Egger. Horizontal pleiotropy was evaluated using the intercept test of MR Egger and MR pleiotropy residual sum and outlier (MR-PRESSO) analysis, with the latter also employed for outlier detection. Additionally, a "Leave one out" analysis was conducted to ascertain the influence of individual single nucleotide polymorphisms (SNPs) on MR results.

RESULTS

The random-effects IVW analysis revealed a negative genetic causal association between T2D) and VTE (P = 0.008, Odds Ratio [OR] 95% confidence interval [CI] = 0.896 [0.827-0.972]), as well as between FG and VTE (P = 0.002, OR 95% CI = 0.655 [0.503-0.853]), GH and VTE (P = 0.010, OR 95% CI = 0.604 [0.412-0.884]), and GH and DVT (P = 0.002, OR 95% CI = 0.413 [0.235-0.725]). Conversely, the random-effects IVW analysis did not detect a genetic causal relationship between FI and VTE (P > 0.05), nor between T2D, FG, or FI and DVT (P > 0.05), or between T2D, FG, FI, or GH and PE (P > 0.05). Both the Cochran's Q statistic for MR-IVW and Rucker's Q statistic for MR-Egger indicated no significant heterogeneity (P > 0.05). Moreover, the intercept tests of MR Egger and MR-PRESSO suggested the absence of horizontal pleiotropy (P > 0.05). MR-PRESSO analysis identified no outliers, while the "Leave one out" analysis underscored that the MR analysis was not influenced by any single SNP.

CONCLUSION

Our investigation revealed that T2D, FG, and GH exhibit negative genetic causal relationships with VTE at the genetic level, while GH demonstrates a negative genetic causal relationship with DVT at the genetic level. These findings furnish genetic-level evidence warranting further examination of VTE, DVT, and PE, thereby making a contribution to the advancement of related research domains.

Pulmonary Embolism Complicated by Acute Limb Ischemia Managed by Surgical Pulmonary Embolectomy

Acute pulmonary embolism (PE) is a manifestation of venous thromboembolic disease with potential serious and life-threatening complications. Management options for acute PE have drastically improved over the last 15 years with the introduction of multidisciplinary pulmonary embolism response teams throughout the world. We present the case of an 18-year-old woman diagnosed with acute PE complicated by near-complete occlusion of her left common femoral artery from a paradoxical embolus in the setting of patent foramen ovale (PFO), managed with surgical pulmonary embolectomy and surgical PFO repair.

Performance of the right ventricular outflow tract/aortic diameter as a novel predictor of risk in patients with acute pulmonary embolism

Right ventricular (RV) enlargement, determined via the ratio of the right to left ventricular diameters (RV/LV) by CT imaging is used to classify the severity of acute pulmonary embolism (PE) and impacts treatment decisions. The RV/LV ratio may be an unreliable marker of RV dysfunction, due in part to the complex RV geometry. This study compared the RV/LV ratio to a novel metric, the ratio of the right ventricular to aortic outflow tract diameters (RVOT/Ao) in patients with acute PE treated with catheter-directed therapies (CDT). RVOT/Ao and RV/LV ratios were measured on CT images from 103 patients who received CDT for acute submassive or massive PE and were compared to RV dysfunction severity determined by transthoracic echocardiography. Ratios and biomarkers on admission were assessed for correlation with invasively-measured hemodynamics [right atrial (RA) pressure, mean pulmonary artery (PA) pressure, cardiac output (CO)]. RVOT/Ao but not RV/LV ratios were increased in patients with moderate or severe RV dysfunction compared to those without RV dysfunction (p < 0.05). Neither ratio showed significant correlation with RA (r = 0.09 vs 0.055, p > 0.05), mean PA pressure (r = 0.167 vs 0.146, p > 0.05), or CO (r = 0.021 vs - 0.183, p > 0.05). proBNP correlated with mean PA pressure (r = 0.377, p < 0.05). The RVOT/Ao ratio may be better at assessing RV dysfunction than the RV/LV ratio in patients presenting with acute PE. Although currently accepted protocols rely on the RV/LV ratio in determining when CDT are of benefit, the RVOT/Ao ratio may be a more useful tool in identifying high risk patients.

Difficulties of Managing Submassive and Massive Pulmonary Embolism in the Era of COVID-19

Acute pulmonary embolism (PE) is a potentially life-threatening manifestation of venous thromboembolic disease. Severe acute respiratory syndrome-coronavirus-2, a novel coronavirus that causes coronavirus disease-2019 (COVID-19), has been associated with an increased risk of thrombosis. We describe the therapeutic challenges of 3 patients presenting with PE and suspected or confirmed COVID-19. (Level of Difficulty: Beginner.).

Relationship Between CHA2DS2-VASc Score and Right Ventricular Dysfunction in Patients With Acute Pulmonary Thromboembolism

In this study, the association between the right ventricular dysfunction (RVD) and CHA2DS2-VASc (C: congestive heart failure or left ventricular systolic dysfunction, H: hypertension, A: age of ≥ 75 years, D: diabetes mellitus, S: previous stroke, V: vascular disease, A: age between 65 and 74 years, Sc: female gender) scores was investigated in patients with acute pulmonary thromboembolism (PTE). The patients have been assigned to 3 subgroups as massive, submassive, and nonmassive PTE. The CHA2DS2-VASc scores were calculated for all of the patients, and the scores have been classified into 3 groups as the scores between 0 and 1, the scores of 2, and the scores of 3 and over. The independent predictors of the RVD were investigated by the univariate and multivariate regression analyses. The independent predictors of the RVD were determined to be the CHA2DS2-VASc scores (P = .034), the systolic pulmonary artery pressure (P < .001), the presence of acute deep vein thrombosis (P = .007), high simplified Pulmonary Embolism Severity Index (P < .001), D-dimer (P < .006), and the mean platelet volume (P < .001). The CHA2DS2-VASc scores predicted the RVD with 70% sensitivity and 50% specificity as determined by the receiver operating characteristic analysis. The CHA2DS2-VASc score is an independent predictor of the RVD in patients with acute PTE.

The use of echocardiographic indices in defining and assessing right ventricular systolic function in critical care research

PURPOSE

Many echocardiographic indices (or methods) for assessing right ventricular (RV) function are available, but each has its strengths and limitations. In some cases, there might be discordance between the indices. We conducted a systematic review to audit the echocardiographic RV assessments in critical care research to see if a consistent pattern existed. We specifically looked into the kind and number of RV indices used, and how RV dysfunction was defined in each study.

METHODS

Studies conducted in critical care settings and reported echocardiographic RV function indices from 1997 to 2017 were searched systematically from three databases. Non-adult studies, case reports, reviews and secondary studies were excluded. These studies' characteristics and RV indices reported were summarized.

RESULTS

Out of 495 non-duplicated publications found, 81 studies were included in our systematic review. There has been an increasing trend of studying RV function by echocardiography since 2001, and most were conducted in ICU. Thirty-one studies use a single index, mostly TAPSE, to define RV dysfunction; 33 used composite indices and the combinations varied between studies. Seventeen studies did not define RV dysfunction. For those using composite indices, many did not explain their choices.

CONCLUSIONS

TAPSE seemed to be the most popular index in the last 2-3 years. Many studies used combinations of indices but, apart from cor pulmonale, we could not find a consistent pattern of RV assessment and definition of RV dysfunction amongst these studies.

The relation between international normalized ratio and mortality in acute pulmonary embolism: A retrospective study

BACKGROUND

Acute pulmonary embolism (PE) is a serious clinical disease characterized by a high mortality rate. The aim of this study was to assess the prognostic value of international normalized ratio (INR) in acute PE patients not on anticoagulant therapy.

METHODS

The study included 244 hospitalized acute PE patients who were not receiving previous anticoagulant therapy. Based on their 30-day mortality, patients were categorized as survivors or non-survivors. INR was measured during the patients' admission, on the same day as the diagnosis of PE but before anticoagulation started.

RESULTS

Thirty-day mortality occurred in 39 patients (16%). INR was higher in non-survivors than in survivors (1.3±0.4 vs 1.1±0.3, P=.003). In multivariate analysis, INR (HR: 3.303, 95% CI: 1.210-9.016, P=.020) was independently associated with 30-day mortality from PE. Inclusion of INR in a model with simplified pulmonary embolism severity index (sPESI) score improved the area under the receiver operating characteristics (ROC) curve from 0.736 (95% CI: 0.659-0.814) to 0.775 (95% CI: 0.701-0.849) (P=.028). Also, the addition of INR to sPESI score enhanced the net reclassification improvement (NRI=8.8%, P<.001) and integrated discrimination improvement (IDI=0.043, P=.027).

CONCLUSION

Elevated INR may have prognostic value for 30-day mortality in acute PE patients not on anticoagulation. Combining INR with sPESI score improved the predictive value for all-cause mortality. However, further large-scale studies are needed to confirm it's prognostic role.

Right ventricular function predicts cardiovascular events in outpatients with stable cardiovascular diseases: preliminary results

Right ventricular (RV) function impacts the outcome in cardiac and pulmonary diseases such as heart failure, pulmonary hypertension, myocardial infarction, valvular, and congenital heart diseases. To our knowledge, simultaneous evaluation of left ventricular (LV) and RV systolic and diastolic echocardiographic indices in outpatients with clinically stable cardiovascular diseases has never been performed. Thus, we designed a prospective cohort study to define the prognostic power of these parameters. One hundred and sixty-three patients were submitted to transthoracic echocardiography with multiparametric and tissue Doppler evaluation of the following indices: ejection fraction, MAPSE, TAPSE, RV presystolic peak, LV and RV diastolic function, pulmonary artery systolic pressure, and functional mitral regurgitation. All these parameters and clinical variables (age, sex, and prior cardiovascular events) were entered in a multivariable Cox regression model. The primary end point was the occurrence of major cardiovascular events (MACEs) during the follow-up period. Twenty-one MACEs were observed; in the final multivariable Cox regression model only prior cardiovascular events (B 1.305, p 0.004, 95% CI 1.523-8.933), age (B 0.067, p 0.005, 95% CI 1.020-1.121), and TAPSE (B -1.065, p 0.026, 95% CI 0.135-0.883) were associated with MACEs. TAPSE, a simple and reproducible echocardiographic index, may be viewed as an early echocardiographic marker of heart involvement in atherosclerosis. We believe that TAPSE may be useful in clinical practice for risk stratification.