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Lyhne MD, Bikdeli B, Dudzinski DM, Muriel-García A, Kabrhel C, Sancho-Bueso T, Pérez-David E, Lobo JL, Alonso-Gómez Á, Jiménez D, Monreal M. Validation of Echocardiographic Measurements in Patients with Pulmonary Embolism in the RIETE Registry. TH OPEN 2024; 8:e1-e8. [PMID: 38197015 PMCID: PMC10774011 DOI: 10.1055/s-0043-1777765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/01/2023] [Indexed: 01/11/2024] Open
Abstract
Background In acute pulmonary embolism (PE), echocardiographic identification of right ventricular (RV) dysfunction will inform prognostication and clinical decision-making. Registro Informatizado Enfermedad TromboEmbolica (RIETE) is the world's largest registry of patients with objectively confirmed PE. The reliability of site-reported RV echocardiographic measurements is unknown. We aimed to validate site-reported key RV echocardiographic measurements in the RIETE registry. Methods Fifty-one randomly chosen patients in RIETE who had transthoracic echocardiogram (TTE) performed for acute PE were included. TTEs were de-identified and analyzed by a core laboratory of two independent observers blinded to site-reported data. To investigate reliability, intraclass correlation coefficients (ICCs) and Bland-Altman plots between the two observers, and between an average of the two observers and the RIETE site-reported data were obtained. Results Core laboratory interobserver variations were very limited with correlation coefficients >0.8 for all TTE parameters. Agreement was substantial between core laboratory observers and site-reported data for key parameters including tricuspid annular plane systolic excursion (ICC 0.728; 95% confidence interval [CI], 0.594-0.862) and pulmonary arterial systolic pressure (ICC 0.726; 95% CI, 0.601-0.852). Agreement on right-to-left ventricular diameter ratio (ICC 0.739; 95% CI, 0.443-1.000) was validated, although missing data limited the precision of the estimates. Bland-Altman plots showed differences close to zero. Conclusion We showed substantial reliability of key RV site-reported measurements in the RIETE registry. Ascertaining the validity of such data adds confidence and reliability for subsequent investigations.
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Affiliation(s)
- Mads Dam Lyhne
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
- Yale-New Haven Hospital (YNHH)/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, United States
| | - David M. Dudzinski
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Alfonso Muriel-García
- Unidad de Bioestadística Clínica, Hospital Universitario Ramón y Cajal, Madrid and CIBERESP, Universidad de Alcalá, Madrid, Spain
| | - Christopher Kabrhel
- Department of Emergency Medicine, Centre of Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Teresa Sancho-Bueso
- Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
| | | | - José Luis Lobo
- Department of Pneumonology, Hospital Universitario Araba, Álava, Spain
| | | | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá, Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Manuel Monreal
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM - Universidad Católica San Antonio de Murcia, Murcia, Spain
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El-Bouri WK, Sanders A, Lip GYH. Predicting acute and long-term mortality in a cohort of pulmonary embolism patients using machine learning. Eur J Intern Med 2023; 118:42-48. [PMID: 37487827 DOI: 10.1016/j.ejim.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/22/2023] [Accepted: 07/10/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is a severe condition that causes significant mortality and morbidity. Due to its acute nature, scores have been developed to stratify patients at high risk of 30-day mortality. Here we develop a machine-learning based score to predict 30-day, 90-day, and 365-day mortality in PE patients. METHODS The Birmingham and Black Country Venous Thromboembolism registry (BBC-VTE) of 2183 venous thromboembolism patients is used. Random forests were trained on a 70% training cohort and tested against 30% held-out set. The outcomes of interest were 30-day, 90-day, and 365-day mortality. These were compared to the pulmonary embolism severity index (PESI) and simplified pulmonary embolism severity index (sPESI). Shapley values were used to determine important predictors. Oral anticoagulation at discharge was also investigated as a predictor of mortality. RESULTS The machine learning risk score predicted 30-day mortality with AUC 0.71 [95% CI: 0.63 - 0.78] compared to the sPESI AUC of 0.65 [95% CI: 0.57 - 0.73] and PESI AUC of 0.64 [95% CI: 0.56 - 0.72]. 90-day mortality and 365-day mortality were predicted with an AUC of 0.74 and 0.73 respectively. High counts of neutrophils, white blood cell counts, and c-reactive protein and low counts of haemoglobin were important for 30-day mortality prediction but progressively lost importance with time. Older age was an important predictor of high risk throughout. CONCLUSION Machine learning algorithms have improved on standard clinical risk stratification for PE patients. External cohort validation is required before incorporation into clinical workflows.
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Affiliation(s)
- Wahbi K El-Bouri
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
| | - Alexander Sanders
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
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Lyhne MD, Dudzinski DM, Andersen A, Nielsen-Kudsk JE, Muzikansky A, Kabrhel C. Right-to-left ventricular ratio is higher in systole than diastole in patients with acute pulmonary embolism. Echocardiography 2023; 40:925-931. [PMID: 37477341 DOI: 10.1111/echo.15655] [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: 02/28/2023] [Revised: 06/11/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023] Open
Abstract
OBJECTIVES In acute pulmonary embolism (PE), the right ventricle (RV) may dilate compromising left ventricular (LV) size, thereby increasing RV/LV ratio. End-diastolic RV/LV ratio is often used in PE risk stratification, though the cause of death is RV systolic failure. We aimed to confirm our pre-clinical observations of higher RV/LV ratio in systole compared to diastole in human patients with PE. METHODS We blinded and independently analyzed echocardiograms from 606 patients with PE, evaluated by a Pulmonary Embolism Response Team. We measured RV/LV ratios in end-systole and end-diastole and fractional area change (FAC). Our primary outcome was a composite of 7-day clinical deterioration, treatment escalation or death. Secondary outcomes were 7-day and 30-day all-cause mortality. RESULTS RV/LV ratio was higher in systole compared to diastole (median 1.010 [.812-1.256] vs. .975 [.843-1.149], p < .0001). RV/LV in systole and diastole were correlated (slope = 1.30 [95% CI 1.25-1.35], p < .0001 vs. slope = 1). RV/LV ratios in both systole and diastole were associated with the primary composite outcome but not with all-cause mortality. CONCLUSION The RV/LV ratio is higher when measured in systole versus in diastole in patients with acute PE. The two approaches had similar associations with clinical outcomes, that is, it appears reasonable to measure RV/LV ratio in diastole.
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Affiliation(s)
- Mads Dam Lyhne
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - David M Dudzinski
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Asger Andersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Alona Muzikansky
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts, USA
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Sistla P, Kheder K, Iourinets J, Arora P, Desai PV, Brailovsky Y, Darki A. Catheter-Directed Thrombolysis or Catheter-Based Thrombectomy in Acute Pulmonary Embolism: Horses for Courses. Interv Cardiol Clin 2023; 12:309-321. [PMID: 37290836 DOI: 10.1016/j.iccl.2023.03.003] [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: 06/10/2023]
Abstract
Venous thromboembolism is a common disorder encompassing both pulmonary embolism (PE) and deep vein thrombosis (DVT). In the United States, up to 2 million people are diagnosed with DVT and 600,000 with PE annually. The purpose of this review is to discuss the indications and evidence for catheter-directed thrombolysis versus catheter-based thrombectomy.
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Affiliation(s)
- Phanicharan Sistla
- Department of Interventional Cardiology, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Kevin Kheder
- Department of Interventional Cardiology, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Julia Iourinets
- Stritch School of Medicine, Loyola University Chicago, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Punit Arora
- Department of Internal Medicine, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Parth V Desai
- Department of Interventional Cardiology, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Yevgeniy Brailovsky
- Department of Advanced Heart Failure and Transplantation, Thomas Jefferson University Hospital, 925 Chestnut Street, Philadelphia, PA 19107, USA
| | - Amir Darki
- Department of Interventional Cardiology, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA; Cardiology, Loyola University Medical Center, Pulmonary Embolism Response Team.
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Lyhne MD, Giordano N, Dudzinski D, Torrey J, Wang G, Zheng H, Parry BA, Kalra MK, Kabrhel C. Low concordance between CTPA and echocardiography in identification of right ventricular strain in PERT patients with acute pulmonary embolism. Emerg Radiol 2023; 30:325-331. [PMID: 37084161 DOI: 10.1007/s10140-023-02130-z] [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: 01/10/2023] [Accepted: 03/29/2023] [Indexed: 04/22/2023]
Abstract
PURPOSE Right ventricular strain (RVS) is used to risk stratify patients with acute pulmonary embolism (PE) and influence treatment decisions. Guidelines suggest that either computed tomography pulmonary angiography (CTPA) or transthoracic echocardiography (TTE) can be used to assess RVS. We sought to determine how often CTPA and TTE yield discordant results and to assess the test characteristics of CTPA compared to TTE. METHODS We analyzed data from a single-center registry of PE cases severe enough to warrant activation of the hospital's Pulmonary Embolism Response Team (PERT). We defined RVS as a right ventricular to left ventricular ratio (RV/LV) ≥ 1 or radiologist's interpretation of RVS on CTPA or as the presence of either RV dilation, hypokinesis, or septal bowing on TTE. RESULTS We included 554 patients in our analysis, of whom 333 (60%) had concordant RVS findings on CTPA and TTE. Using TTE as the reference standard, CTPA had a sensitivity of 95% (95% CI 92-97%) and a specificity of 4% (95% CI 2-8%) for identifying RVS. CONCLUSIONS In a selected population of patients with acute PE for which PERT was activated, CTPA is highly sensitive but not specific for the detection of RVS when compared to TTE.
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Affiliation(s)
- Mads Dam Lyhne
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark & Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Nicholas Giordano
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David Dudzinski
- Department of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Jasmine Torrey
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Grace Wang
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Blair Alden Parry
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Mannudeep K Kalra
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher Kabrhel
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.
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Lyhne MD, Witkin AS, Dasegowda G, Tanayan C, Kalra MK, Dudzinski DM. Evaluating cardiopulmonary function following acute pulmonary embolism. Expert Rev Cardiovasc Ther 2022; 20:747-760. [PMID: 35920239 DOI: 10.1080/14779072.2022.2108789] [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: 10/16/2022]
Abstract
INTRODUCTION Pulmonary embolism is a common cause of cardiopulmonary mortality and morbidity worldwide. Survivors of acute pulmonary embolism may experience dyspnea, report reduced exercise capacity, or develop overt pulmonary hypertension. Clinicians must be alert for these phenomena and appreciate the modalities and investigations available for evaluation. AREAS COVERED In this review, the current understanding of available contemporary imaging and physiologic modalities is discussed, based on available literature and professional society guidelines. The purpose of the review is to provide clinicians with an overview of these modalities, their strengths and disadvantages, and how and when these investigations can support the clinical work-up of patients post-pulmonary embolism. EXPERT OPINION Echocardiography is a first test in symptomatic patients post-pulmonary embolism, with ventilation/perfusion scanning vital to determination of whether there is chronic residual emboli. The role of computed tomography and magnetic resonance in assessing the pulmonary arterial tree in post-pulmonary embolism patients is evolving. Functional testing, in particular cardiopulmonary exercise testing, is emerging as an important modality to quantify and determine cause of functional limitation. It is possible that future investigations of the post-pulmonary embolism recovery period will better inform treatment decisions for acute pulmonary embolism patients.
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Affiliation(s)
- Mads Dam Lyhne
- Department of Cardiology, Massachusetts General Hospital, Boston, MA, USA.,Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Denmark
| | - Alison S Witkin
- Department of Pulmonary Medicine and Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Giridhar Dasegowda
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher Tanayan
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, MA, USA
| | - Mannudeep K Kalra
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - David M Dudzinski
- Department of Cardiology, Massachusetts General Hospital, Boston, MA, USA.,Echocardiography Laboratory, Massachusetts General Hospital, Boston, MA, USA
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Kantarcioglu B, Darki A, Siddiqui F, Hoppensteadt D, Lewis J, Krämer R, Adiguzel C, Fareed J. The Relevance of Anti-PF4 Antibody Isotypes and Endogenous Glycosaminoglycans and their Relationship with Inflammatory Biomarkers in Pulmonary Embolism Patients. Clin Appl Thromb Hemost 2022; 28:10760296221091770. [PMID: 35360982 PMCID: PMC8980416 DOI: 10.1177/10760296221091770] [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] [Indexed: 01/01/2023] Open
Abstract
Introduction Previous studies have shown that inflammation may contribute to the interplay of endogenous glycosaminoglycans (GAGs) and anti-PF4 antibodies. In this study, we quantified the levels of anti-PF4 antibody isotypes and endogenous GAGs together with inflammatory biomarkers in pulmonary embolism (PE) patients to determine whether there is a relationship in between. Identification of this relationship may provide insight to the complex pathophysiology of PE and HIT and may also be useful for development of potential prognostic, diagnostic and therapeutic interventions. Materials and Methods Plasma samples from PE patients (n: 210) were analyzed for anti-PF4 antibody isotypes and various thrombo-inflammatory cytokines utilizing commercially available biochip array and ELISA methods. The endogenous GAG levels in PE patients’ plasma were quantified using a fluorescence quenching method. The collected data analyzed to demonstrate the relationship between various parameters. Results The endogenous GAG levels were increased in the PE group (P < .05). The levels of anti-PF4 antibody isotypes were higher in varying levels in comparison to the normal group (P < .05). Inflammatory cytokines have shown varying levels of increase with IL-6, IL-8 and IL-10 showing the most pronounced values. Mortality outcome was related to increased GAGs and some of the cytokines. Conclusion In this study, we demonstrated increased levels of anti-PF4 antibody isotypes, endogenous GAGs, and inflammatory biomarkers in a large patient cohort in PE. The levels of the endogenous GAGs and inflammatory biomarkers were associated with PE severity and mortality. More studies are needed to understand this complex pathophysiology.
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Affiliation(s)
- Bulent Kantarcioglu
- Department of Pathology and Laboratory Medicine, Health Sciences Division, Cardiovascular Research Institute, Loyola University Chicago, Maywood, IL, USA
| | - Amir Darki
- Division of Cardiovascular Disease, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, IL, USA
- Department of Internal Medicine, Loyola University Medical Center, Loyola Stritch School of Medicine, Maywood, IL, USA
| | - Fakiha Siddiqui
- Department of Pathology and Laboratory Medicine, Health Sciences Division, Cardiovascular Research Institute, Loyola University Chicago, Maywood, IL, USA
| | - Debra Hoppensteadt
- Department of Pathology and Laboratory Medicine, Health Sciences Division, Cardiovascular Research Institute, Loyola University Chicago, Maywood, IL, USA
| | - Joseph Lewis
- Department of Pathology and Laboratory Medicine, Health Sciences Division, Cardiovascular Research Institute, Loyola University Chicago, Maywood, IL, USA
| | - Roland Krämer
- Institute of Inorganic Chemistry, Heidelberg University, Heidelberg, Germany
| | - Cafer Adiguzel
- Department of Internal Medicine, Division of Hematology, Bahcesehir University, Istanbul, Turkey
| | - Jawed Fareed
- Department of Pathology and Laboratory Medicine, Health Sciences Division, Cardiovascular Research Institute, Loyola University Chicago, Maywood, IL, USA
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Kantarcioglu B, Darki A, Siddiqui F, Krupa E, Vural M, Kacmaz M, Hoppensteadt D, Iqbal O, Jeske W, Walenga J, Adiguzel C, Fareed J. Predictive Role of Blood Cellular Indices and Their Relationship with Endogenous Glycosaminoglycans as Determinants of Inflammatory Biomarkers in Pulmonary Embolism. Clin Appl Thromb Hemost 2022; 28:10760296221104801. [PMID: 35733366 PMCID: PMC9234831 DOI: 10.1177/10760296221104801] [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] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION In this study, we profiled the levels of blood cellular indices, endogenous glycosaminoglycans (GAGs) and inflammatory biomarkers in a cohort comprised of pulmonary embolism (PE) patients, to determine their inter-relationships. Identification of this relationship may provide insight to the complex pathophysiology of PE and the predictive role of blood cellular indices in acute PE patients. MATERIALS AND METHODS Plasma samples from PE patients and healthy controls were analyzed for thrombo-inflammatory biomarkers (IL-2, IL-4, IL-6, IL-8, IL-10, VEGF, IFN-ɣ, TNF-α, IL-1α, IL-1β, MCP-1, EGF, D-dimer, CRP and MMP-9) using biochip array and ELISA methods. The endogenous GAG levels were quantified using a fluorescence quenching method. The data regarding the blood cellular indices were collected through the review of patient medical records and analyzed to demonstrate their relationship. RESULTS The levels of inflammatory biomarkers and endogenous GAGs were elevated in acute PE patients compared to controls (P < .05). Most of the blood cellular indices have shown significant differences in acute PE patients compared to controls (P < .05). The levels of inflammatory biomarkers, endogenous GAGs and the blood cellular indices have shown significant associations in correlation and multivariable analysis. While NLR, PLR and SII were significantly predicting the 30-day mortality, PNR, ELR and EMR were not sufficient to predict 30-day mortality in acute PE. CONCLUSION Our results show that the increased thrombo-inflammatory response is associated with the release of GAGs and the changes in blood cellular indices. The predictive role of the blood cellular indices for mortality is dependent on their relationship with the inflammatory response.
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Affiliation(s)
- Bulent Kantarcioglu
- Department of Pathology and Laboratory Medicine, Health Sciences Division, Cardiovascular Research Institute, 2456Loyola University Chicago, Maywood, IL, USA
| | - Amir Darki
- Division of Cardiovascular Disease, Loyola Stritch School of Medicine, 25815Loyola University Medical Center, Maywood, Illinois, USA
| | - Fakiha Siddiqui
- Department of Pathology and Laboratory Medicine, Health Sciences Division, Cardiovascular Research Institute, 2456Loyola University Chicago, Maywood, IL, USA.,Program in Health Sciences. UCAM - Universidad Católica San Antonio de Murcia, Spain
| | - Emily Krupa
- Department of Pathology and Laboratory Medicine, Health Sciences Division, Cardiovascular Research Institute, 2456Loyola University Chicago, Maywood, IL, USA
| | - Mehmet Vural
- Department of Internal Medicine, Loyola Stritch School of Medicine, 25815Loyola University Medical Center, Maywood, Illinois, USA.,Department of Internal Medicine, 24558Weiss Memorial Hospital, Chicago, USA
| | - Murat Kacmaz
- Department of Internal Medicine, Division of Hematology, 52987Hatay Mustafa Kemal University, Hatay, Turkey
| | - Debra Hoppensteadt
- Department of Pathology and Laboratory Medicine, Health Sciences Division, Cardiovascular Research Institute, 2456Loyola University Chicago, Maywood, IL, USA
| | - Omer Iqbal
- Department of Pathology and Laboratory Medicine, Health Sciences Division, Cardiovascular Research Institute, 2456Loyola University Chicago, Maywood, IL, USA
| | - Walter Jeske
- Department of Pathology and Laboratory Medicine, Health Sciences Division, Cardiovascular Research Institute, 2456Loyola University Chicago, Maywood, IL, USA
| | - Jeanine Walenga
- Department of Pathology and Laboratory Medicine, Health Sciences Division, Cardiovascular Research Institute, 2456Loyola University Chicago, Maywood, IL, USA
| | - Cafer Adiguzel
- Department of Internal Medicine, Division of Hematology, Bahcesehir University, Istanbul, Turkey
| | - Jawed Fareed
- Department of Pathology and Laboratory Medicine, Health Sciences Division, Cardiovascular Research Institute, 2456Loyola University Chicago, Maywood, IL, USA
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