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Melamed R, Tierney DM, Xia R, Brown CS, Mara KC, Lillyblad M, Sidebottom A, Wiley BM, Khapov I, Gajic O. Safety and Efficacy of Reduced-Dose Versus Full-Dose Alteplase for Acute Pulmonary Embolism: A Multicenter Observational Comparative Effectiveness Study. Crit Care Med 2024; 52:729-742. [PMID: 38165776 DOI: 10.1097/ccm.0000000000006162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
OBJECTIVES Systemic thrombolysis improves outcomes in patients with pulmonary embolism (PE) but is associated with the risk of hemorrhage. The data on efficacy and safety of reduced-dose alteplase are limited. The study objective was to compare the characteristics, outcomes, and complications of patients with PE treated with full- or reduced-dose alteplase regimens. DESIGN Multicenter retrospective observational study. SETTING Tertiary care hospital and 15 community and academic centers of a large healthcare system. PATIENTS Hospitalized patients with PE treated with systemic alteplase. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pre- and post-alteplase hemodynamic and respiratory variables, patient outcomes, and complications were compared. Propensity score (PS) weighting was used to adjust for imbalances of baseline characteristics between reduced- and full-dose patients. Separate analyses were performed using the unweighted and weighted cohorts. Ninety-eight patients were treated with full-dose (100 mg) and 186 with reduced-dose (50 mg) regimens. Following alteplase, significant improvements in shock index, blood pressure, heart rate, respiratory rate, and supplemental oxygen requirements were observed in both groups. Hemorrhagic complications were lower with the reduced-dose compared with the full-dose regimen (13% vs. 24.5%, p = 0.014), and most were minor. Major extracranial hemorrhage occurred in 1.1% versus 6.1%, respectively ( p = 0.022). Complications were associated with supratherapeutic levels of heparin anticoagulation in 37.5% of cases and invasive procedures in 31.3% of cases. The differences in complications persisted after PS weighting (15.4% vs. 24.7%, p = 0.12 and 1.3% vs. 7.1%, p = 0.067), but did not reach statistical significance. There were no significant differences in mortality, discharge destination, ICU or hospital length of stay, or readmission after PS weighting. CONCLUSIONS In a retrospective, PS-weighted observational study, when compared with the full-dose, reduced-dose alteplase results in similar outcomes but fewer hemorrhagic complications. Avoidance of excessive levels of anticoagulation or invasive procedures should be considered to further reduce complications.
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Affiliation(s)
- Roman Melamed
- Department of Critical Care, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - David M Tierney
- Department of Graduate Medical Education, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
- Department of Medicine, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - Ranran Xia
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Matthew Lillyblad
- Department of Pharmacy, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - Abbey Sidebottom
- Department of Care Delivery Research, Allina Health, Minneapolis, MN
| | - Brandon M Wiley
- Department of Medicine, Los Angeles General Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ivan Khapov
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Ognjen Gajic
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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Rouleau SG, Casey SD, Kabrhel C, Vinson DR, Long B. Management of high-risk pulmonary embolism in the emergency department: A narrative review. Am J Emerg Med 2024; 79:1-11. [PMID: 38330877 DOI: 10.1016/j.ajem.2024.01.039] [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: 11/11/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE. OBJECTIVE This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations. DISCUSSION High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions. CONCLUSIONS Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.
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Affiliation(s)
- Samuel G Rouleau
- Department of Emergency Medicine, UC Davis Health, University of California, Davis, Sacramento, CA, United States of America.
| | - Scott D Casey
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, CA, United States of America.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - David R Vinson
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
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Parmar CD, Felsenreich DM, Salminen P, Di Lorenzo N, Prager G. Guidelines for Management of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) Occurring After Metabolic Bariatric Surgery (MBS). Obes Surg 2024; 34:1964-1968. [PMID: 38530553 DOI: 10.1007/s11695-024-07187-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 03/28/2024]
Affiliation(s)
- Chetan D Parmar
- Whittington Hospital, London, N19 5NF, UK.
- University College London, London, UK.
- Apollo Hospitals, Chennai, India.
| | | | | | - Nicola Di Lorenzo
- Department of Surgical Sciences, University of Tor Vergata, Policlinico Tor Vergata, Rome, Italy
| | - Gerhard Prager
- Department of Surgery, Vienna Medical University, Vienna, Austria
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4
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Opitz CF, Meyer FJ. Pulmonary Embolism: An Update Based on the Revised AWMF-S2k Guideline. Hamostaseologie 2024; 44:111-118. [PMID: 38688269 DOI: 10.1055/s-0044-1779011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
Pulmonary embolism (PE) is the third most common acute cardiovascular disease. The risk of PE increases with age and mortality is high. Patients are stratified into hemodynamically stable versus unstable patients, as this has important implications for diagnosis and therapy. Since clinical signs and symptoms of acute PE are nonspecific, the clinical likelihood of PE is estimated to guide diagnostic pathways. D-dimer testing is performed in hemodynamically stable patients with low or intermediate probability of PE and the visualization of thromboembolism and its sequelae is commonly achieved with computed tomography pulmonary angiography (CTPA), supplemented by ultrasound techniques. With confirmed PE, another risk stratification estimates disease severity and defines intensity and setting of the ensuing treatment. The therapeutic spectrum ranges from outpatient treatment with initial oral anticoagulation to thrombolytic or interventional treatment in the intensive care unit or catheterization laboratory. In single cases, even acute surgical thrombectomy is attempted.
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Affiliation(s)
| | - F Joachim Meyer
- Lungenzentrum München (Bogenhausen-Harlaching), München Klinik gGmbH, Sanatoriumsplatz 2, München, Germany
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5
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Casey SD, Stubblefield WB, Luijten D, Klok FA, Westafer LM, Vinson DR, Kabrhel C. Addressing the rising trend of high-risk pulmonary embolism mortality: Clinical and research priorities. Acad Emerg Med 2024; 31:288-292. [PMID: 38129964 DOI: 10.1111/acem.14859] [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: 09/05/2023] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Deaths from high-risk pulmonary embolism (PE) appear to have increased in the US over the last decade. Modifiable risks contributing to this worrisome trend present opportunities for physicians, researchers, and healthcare policymakers to improve care. METHODS We sought to contextualize contemporary, high-risk PE epidemiology and examine clinical trials, quality improvement opportunities, and healthcare policy initiatives directed at reducing mortality. RESULTS We observed significant and modifiable excess mortality due to high-risk PE. We identified several opportunities to improve care including: (1) rapid translation of forthcoming data on reperfusion strategies into clinical practice; (2) improved risk stratification tools; (3) quality improvement initiatives to address presumptive anticoagulation practice gaps; and (3) adoption of health policy initiatives to establish pulmonary embolism response teams and address the social determinants of health. CONCLUSION Addressing knowledge and practice gaps in intermediate and high-risk PE management must be prioritized and informed by forthcoming high-quality data. Implementation efforts are needed to improve acute PE management and resolve treatment disparities.
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Affiliation(s)
- Scott D Casey
- Kaiser Permanente Division of Research, Oakland, California, USA
- The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, California, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dieuwke Luijten
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medicine Center, Leiden, Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medicine Center, Leiden, Netherlands
| | - Lauren M Westafer
- Department of Emergency Medicine, UMASS Chan Medical School-Baystate, Springfield, Massachusetts, USA
- Department of Healthcare Delivery and Population Science, UMASS Chan Medical School-Baystate, Springfield, Massachusetts, USA
| | - David R Vinson
- Kaiser Permanente Division of Research, Oakland, California, USA
- The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Abumoawad A, ElBallat A, Mkhaimer Y, Ghanem F, Obaed N, Bunte MC. Trends and outcomes of lytic-based therapies for high-risk pulmonary embolism: A nationwide analysis. Vasc Med 2024; 29:26-35. [PMID: 38084862 DOI: 10.1177/1358863x231211331] [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] [Indexed: 02/10/2024]
Abstract
BACKGROUND Systemic thrombolysis (ST) is the guideline-recommended treatment for high-risk pulmonary embolism (PE), although catheter-directed thrombolysis (CDT) may provide a treatment alternative associated with lower rates of bleeding. Furthermore, the treatment trends and outcomes among those with high-risk PE according to treatment assignments of no lytic therapy (NLT), ST, and CDT are underreported. METHODS Patients hospitalized for high-risk PE between 2016 and 2019 were identified by administrative claims codes from the National Readmission Database. Therapy assignment was similarly defined by administrative codes, then stratified into NLT, ST, and CDT cohorts to report patient characteristics, care settings, and clinical outcomes. The primary outcome was in-hospital mortality with rates adjusted for patient and hospital characteristics using multivariable logistic regression. Secondary outcomes included intracranial hemorrhage (ICH), gastrointestinal bleeding (GIB), and 90-day readmission. Over the years of interest, trends in lytic treatment along with concomitant use of mechanical or surgical thrombectomy were reported. RESULTS Among 74,516 patients with high-risk PE, 61,569 (82.6%) received NLT, 8445 (11.3%) received ST, and 4502 (6.04%) received CDT. The NLT subgroup, relative to ST and CDT, tended to be older (66.1 ± 15.4, 62.8 ± 15.3, and 63.4 ± 14.4; p < 0.001) and more frequently women (56.0%, 54.4%, and 51.3%; p < 0.001), respectively. The unadjusted in-hospital mortality rate was highest for ST (18.8%, 34.1%, and 18.3% for NLT, ST, and CDT, respectively; p < 0.001) and persisted after multivariable adjustment (adjusted odds ratio (aOR) 0.43; 95% CI 0.38-0.49; p < 0.0001) of in-hospital mortality for CDT relative to ST. The unadjusted rate of ICH or GIB was lowest for NLT (1.0%, 2.0%, and 0.6% for NLT, ST, and CDT, respectively; p < 0.001). CDT, relative to ST, was associated with reduced odds of ICH (aOR 0.32; 95% CI 0.18-0.55; p < 0.0001) and GIB (aOR 0.78; 95% CI 0.62-0.98; p < 0.0001). Readmissions were highest for NLT (21.7%, 9.6%, and 12.1% for NLT, ST, and CDT, respectively; p < 0.001). CDT was associated with a higher incidence of 90-day readmission relative to ST (aOR 1.32; 95% CI 1.10-1.57; p < 0.001). From 2016 to 2019, individual treatment trends were not significantly different, although NLT tended to be offered among smaller and rural hospitals. Rates of concomitant thrombectomy were low in all three treatment groups. CONCLUSIONS Among a large, contemporary, US cohort with high-risk PE, over 80% of patients did not receive any form of thrombolysis. High-risk PE that did receive systemic thrombolysis was associated with the highest rates of in-hospital mortality, suggesting opportunities to study the implementation of lytic and nonlytic-based treatments to improve outcomes for those presenting with high-risk PE.
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Affiliation(s)
- Abdelrhman Abumoawad
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- Department of Cardiovascular Medicine, Boston University Medical Center, Boston, MA, USA
| | - Ahmed ElBallat
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Yaman Mkhaimer
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Fares Ghanem
- Department of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Nadia Obaed
- Nova Southeastern University College of Allopathic Medicine, Davie, FL, USA
| | - Matthew C Bunte
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
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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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Bejjani A, Khairani CD, Piazza G. Right Ventricular Recovery: Early and Late Changes after Acute PE Diagnosis. Semin Thromb Hemost 2023; 49:797-808. [PMID: 35777420 DOI: 10.1055/s-0042-1750025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Right ventricular (RV) failure is a critical cause of morbidity and mortality in patients presenting with pulmonary embolism (PE). The presentation of RV failure is based on the combination of clinical findings, laboratory abnormalities, and imaging evidence. An improved understanding of the pathophysiology of RV dysfunction following PE has given rise to more accurate risk stratification and broader therapeutic approaches. A subset of patients with PE develop chronic RV dysfunction with or without pulmonary hypertension. In this review, we focus on the impact of PE on the RV and its implications for risk stratification, prognosis, acute management, and long-term therapy.
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Affiliation(s)
- Antoine Bejjani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Candrika D Khairani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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de Wit K, D'Arsigny CL. Risk stratification of acute pulmonary embolism. J Thromb Haemost 2023; 21:3016-3023. [PMID: 37187357 DOI: 10.1016/j.jtha.2023.05.003] [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: 12/30/2022] [Revised: 04/18/2023] [Accepted: 05/01/2023] [Indexed: 05/17/2023]
Abstract
Approximately 5% of pulmonary embolism (PE) cases present with persistent hypotension, obstructive shock, or cardiac arrest. Given the high short-term mortality, management of high-risk PE cases focuses on immediate reperfusion therapies. Risk stratification of normotensive PE is important to identify patients with an elevated risk of hemodynamic collapse or an elevated risk of major bleeding. Risk stratification for short-term hemodynamic collapse includes assessment of physiological parameters, right heart dysfunction, and identification of comorbidities. Validated tools such as European Society of Cardiology guidelines and Bova score can identify normotensive patients with PE and an elevated risk of subsequent hemodynamic collapse. At present, we lack high-quality evidence to recommend one treatment over another (systemic thrombolysis, catheter-directed therapy, or anticoagulation with close monitoring) for patients at elevated risk of hemodynamic collapse. Newer, less well-validated scores such as BACS and PE-CH may help identify patients at a high risk of major bleeding following systemic thrombolysis. The PE-SARD score may identify those at risk of major anticoagulant-associated bleeding. Patients at low risk of short-term adverse outcomes can be considered for outpatient management. The simplified Pulmonary Embolism Severity Index score or Hestia criteria are safe decision aids when combined with physician global assessment of the need for hospitalization following the diagnosis of PE.
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Affiliation(s)
- Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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10
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Petretta M, Nappi C, Cuocolo A. Pitfalls in Risk Stratification: The Case of Acute Pulmonary Embolism. Am J Cardiol 2023; 200:232-233. [PMID: 37302926 PMCID: PMC10251195 DOI: 10.1016/j.amjcard.2023.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 05/21/2023] [Indexed: 06/13/2023]
Affiliation(s)
- Mario Petretta
- Scientific Institute for Research, Hospitalization and Healthcare SYNLAB SDN, Naples, Italy.
| | - Carmela Nappi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Alberto Cuocolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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Porres-Aguilar M, Rosovsky RP, Jiménez D, Mukherjee D, Rivera-Lebron BN, Kaatz S, Anaya-Ayala JE, Jerjes-Sánchez C. "Pulmonary embolism response teams: changing the paradigm in the care for acute pulmonary embolism": reply. J Thromb Haemost 2023; 21:1390-1392. [PMID: 37121622 DOI: 10.1016/j.jtha.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/02/2023] [Indexed: 05/02/2023]
Affiliation(s)
- Mateo Porres-Aguilar
- Department of Internal Medicine, Divisions of Hospital and Adult Thrombosis Medicine, Texas Tech University Health Sciences Center and Paul L. Foster School of Medicine, El Paso, Texas, USA.
| | - Rachel P Rosovsky
- Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David Jiménez
- Department of Respiratory Medicine, Ramón y Cajal Hospital (IRYCIS), CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases; Texas Tech University Health Sciences Center and Paul L. Foster School of Medicine, El Paso, Texas, USA
| | - Belinda N Rivera-Lebron
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Scott Kaatz
- Department of Internal Medicine, Division of Hospital Medicine; Henry Ford Hospital; Detroit, Michigan, USA
| | - Javier E Anaya-Ayala
- Department of Surgery, Vascular Surgery and Endovascular Therapy Section; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos Jerjes-Sánchez
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey; and Instituto de Cardiologia y Medicina Vascular, Hospital Zambrano Hellion y TEC Salud, Monterrey, Mexico
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12
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Utility of Combining High-Sensitive Cardiac Troponin I and PESI Score for Risk Management in Patients with Pulmonary Embolism in the Emergency Department. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020185. [PMID: 36837387 PMCID: PMC9968180 DOI: 10.3390/medicina59020185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/29/2022] [Accepted: 01/09/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Pulmonary embolism (PE) has a major burden of morbidity and mortality, consequently the need for a prompt risk stratification for these subjects is crucial. In order to evaluate the risk management and final disposition of patients with PE in the Emergency Department (ED), we conducted a study that was divided in two phases: Phase I retrospective study (RS), Phase II prospective study (PS). MATERIALS AND METHODS In Phase I, 291 patients were enrolled while in Phase II, 83 subjects were evaluated. In both study phases, the enrolled subjects were analyzed for final disposition in ED using PESI score, right ventricle (RV) imaging, and high-sensitive cardiac troponin I (hs-cTnI) data. The RS patients were divided into low risk and high risk according to the sPESI score, while PS patients were grouped in low, intermediate, and high risk classes according to PESI score. In both study phases, all the studied patients were further divided into negative (hs-cTnI-) or positive (hs-cTnI+) groups according to hs-cTnI levels within normal or above cutoff values, respectively. For all enrolled subjects, CT pulmonary angiography was analyzed to assess the RV/LV diameter and volume ratio as an indicator of RV involvement. RESULTS In both RS and PS phases, hs-cTnI+ group showed a higher PESI score. Nevertheless, a significant percentage of hs-cTnI+ patients resulted to be in the low-risk PESI class. Patients with a positive RV/LV ratio were more likely to have a hs-cTnI+ (p < 0.01), while among those with a negative ratio, 24 to 32% showed as hs-cTnI+. In the hs-cTnI+ group from both study phases, patients were more likely to be admitted in an ICU (RR 3.7, IC: 2.1-6.5). CONCLUSIONS In conclusion, in patients with PE in the ED compared PESI score alone, the combination of hs-cTnI and PESI seems to be of greater utility in improving risk stratification and final disposition decision-making.
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Oh JK, Park JH. Role of echocardiography in acute pulmonary embolism. Korean J Intern Med 2023:kjim.2022.273. [PMID: 36587934 DOI: 10.3904/kjim.2022.273] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/28/2022] [Indexed: 01/03/2023] Open
Abstract
Although pulmonary embolism (PE)-related mortality rate has decreased because of prompt diagnosis and effective therapy use, acute PE remains a potentially lethal disease. Due to its increasing prevalence, clinicians should pay attention to diagnosing and managing patients with acute PE. Echocardiography is the most commonly used method for diagnosing and managing acute PE; it also provides clues about hemodynamic instability in an emergency situation. It has been validated in the early risk stratification and impacts management strategies for treating acute PE. In hemodynamically unstable patients with acute PE, echocardiographic detection of right ventricular dysfunction is an indication for administering thrombolytics. In this review article, we discuss the role of echocardiography in the diagnosis and management of patients with acute PE.
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Affiliation(s)
- Jin Kyung Oh
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong, Korea
| | - Jae-Hyeong Park
- Department of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
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14
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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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15
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Kanjee Z, Freed JA, Carroll BJ, Reynolds EE. How Would You Treat This Patient With Pulmonary Embolism? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2022; 175:1161-1169. [PMID: 35939811 DOI: 10.7326/m22-0989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pulmonary embolism can be acutely life-threatening and is associated with long-term consequences such as recurrent venous thromboembolism and chronic thromboembolic pulmonary hypertension. In 2020, the American Society of Hematology published updated guidelines on the management of patients with venous thromboembolism. Here, a hematologist and a cardiology and vascular medicine specialist discuss these guidelines in the context of the care of a patient with pulmonary embolism. They discuss advanced therapies such as catheter-directed thrombolysis in the short-term management of patients with intermediate-risk disease, recurrence risk stratification at presentation, and ideal antithrombotic regimens for patients whose pulmonary embolism was associated with a transient minor risk factor.
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Affiliation(s)
- Zahir Kanjee
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Z.K., J.A.F., B.J.C., E.E.R.)
| | - Jason A Freed
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Z.K., J.A.F., B.J.C., E.E.R.)
| | - Brett J Carroll
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Z.K., J.A.F., B.J.C., E.E.R.)
| | - Eileen E Reynolds
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (Z.K., J.A.F., B.J.C., E.E.R.)
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Maughan BC, Marin M, Han J, Gibbins KJ, Brixey AG, Caughey AB, Kline JA, Jarman AF. Venous Thromboembolism During Pregnancy and the Postpartum Period: Risk Factors, Diagnostic Testing, and Treatment. Obstet Gynecol Surv 2022; 77:433-444. [PMID: 35792687 PMCID: PMC10042329 DOI: 10.1097/ogx.0000000000001043] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance The risk of venous thromboembolism (VTE) increases during pregnancy and the postpartum period. Deep vein thrombosis is the most common VTE during pregnancy, but pulmonary embolism is typically of greater concern as it contributes to far higher morbidity and mortality. Diagnosis and treatment of VTE during pregnancy differ substantially from the general nonpregnant population. Objective This review describes the epidemiology, risk factors, clinical presentation, diagnosis, and treatment of VTE during pregnancy and the postpartum period. Evidence Acquisition First, we reviewed the VTE guidelines from professional societies in obstetrics, cardiology, hematology, emergency medicine, pulmonology, and critical care. Second, we examined references from these documents and used PubMed to identify recent articles that cited the guidelines. Finally, we searched PubMed and Google Scholar for articles published since 2018 that included terms for pregnancy and the epidemiology, risk factors, diagnostic imaging, or treatment of VTE. Results Venous thromboembolism risk increases throughout pregnancy and peaks shortly after delivery. More than half of pregnancy-related VTE are associated with thrombophilia; other major risks include cesarean delivery, postpartum infection, and the combination of obesity with immobilization. Most VTE can be treated with low molecular weight heparin, but cases of limb- or life-threatening VTE require consideration of thrombolysis and other reperfusion therapies. Conclusions and Relevance Venous thromboembolism is far more frequent in antepartum and postpartum women than age-matched controls, and clinical suspicion for VTE in this population should incorporate pregnancy-specific risks. Treatment of limb- or life-threatening antepartum or postpartum VTE requires multispecialty coordination to optimize maternal and fetal outcomes.
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Affiliation(s)
- Brandon C Maughan
- Assistant Professor, Department of Emergency Medicine, Oregon Health & Science University School of Medicine, Portland, OR
| | - Maria Marin
- Medical Student, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA
| | - Justin Han
- Medical Student, College of Medicine, Northeast Ohio Medical University, Rootstown, OH
| | - Karen J Gibbins
- Assistant Professor, Division of Perinatology, Department of Obstetrics and Gynecology
| | - Anupama G Brixey
- Assistant Professor, Section of Cardiothoracic Imaging, Department of Diagnostic Radiology
| | - Aaron B Caughey
- Professor and Chair, Department of Obstetrics and Gynecology, Oregon Health & Science University School of Medicine, Portland, OR
| | - Jeffrey A Kline
- Professor and Associate Chair of Research, Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - Angela F Jarman
- Assistant Professor, Department of Emergency Medicine, University of California Davis, Davis, CA
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17
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Muñoz-Guglielmetti D, Cooksley T, Ahn S, Beato C, Aramberri M, Escalante C, Font C. Risk stratification for clinical severity of pulmonary embolism in patients with cancer: a narrative review and MASCC clinical guidance for daily care. Support Care Cancer 2022; 30:8527-8538. [PMID: 35579753 DOI: 10.1007/s00520-022-07131-1] [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: 10/21/2021] [Accepted: 05/09/2022] [Indexed: 11/26/2022]
Abstract
Pulmonary embolism (PE) is a leading cause of morbidity and mortality in patients with cancer. The clinical presentation and outcomes of PE range from an acute life-threatening condition requiring intensive care to a mild symptomatic condition associated with favorable outcomes and potentially candidate for early hospital discharge. The wide clinical spectrum of PE has led to the development of risk stratification models aimed at the triage of patients in emergency care departments and optimizing the utilization of health care resources. Incidental or unsuspected PE (UPE), detected during routine staging computed tomography scans, make up a significant proportion of this cohort among the oncology population. The present narrative review is aimed at examining the currently available PE risk assessment models developed for the general population and for patients with cancer including UPE. We include general recommendations for the daily care of patients with cancer-related PE and hypothesize on the factors that would potentially favor hospitalization with early discharge or ambulatory management in this setting.
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Affiliation(s)
| | - Tim Cooksley
- The Christie Hospital, University of Manchester, Wythenshawe Hospital, Manchester, UK
| | - Shin Ahn
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Carmen Beato
- Medical Oncology Department, Hospital Universitario Macarena, Seville, Spain
| | - Mario Aramberri
- Internal Medicine Department, Hospital Galdakao-Usansolo, Vizcaya, Spain
| | - Carmen Escalante
- Internal Medicine Department, MD Anderson Cancer Center, University of Texas, Houston, USA
| | - Carme Font
- Medical Oncology Department, Hospital Clinic Barcelona, Barcelona, Spain.
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Barbero E, Mañas E, Bikdeli B, García-Ortega A, Oscullo G, García-Sánchez A, Durán D, Retegui A, Rodríguez C, Cano-Pumarega I, Martinez-Garcia MÁ, Jimenez D. Untreated obstructive sleep apnea and cardiovascular outcomes in patients with acute symptomatic pulmonary embolism. Thromb Res 2022; 214:87-92. [DOI: 10.1016/j.thromres.2022.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/04/2022] [Accepted: 04/27/2022] [Indexed: 11/30/2022]
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19
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Pulmonary embolism bleeding score index (PEBSI): A new tool for the detection of patients with low risk for major bleeding on thrombolytic therapy. Thromb Res 2022; 214:138-143. [DOI: 10.1016/j.thromres.2022.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/25/2022] [Accepted: 05/02/2022] [Indexed: 11/20/2022]
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20
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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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Yoo HHB. Trombólise na Embolia Pulmonar: Octogenários Merecem mais Atenção! Arq Bras Cardiol 2022; 118:75-76. [PMID: 35195212 PMCID: PMC8959059 DOI: 10.36660/abc.20210912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Zengin A, Karataş MB, Çanga Y, Güzelburç Ö, Yelgeç NS, Emre A. Terapia Trombolítica em Octogenários com Embolia Pulmonar Aguda. Arq Bras Cardiol 2021; 118:68-74. [PMID: 35195211 PMCID: PMC8959058 DOI: 10.36660/abc.20201060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 02/24/2021] [Indexed: 11/25/2022] Open
Abstract
Fundamento Apesar da grande proporção de octogenários com embolia pulmonar aguda, há pouca informação indicando a estratégia de manejo ideal, especialmente medidas terapêuticas, como a terapia lítica. Objetivos O número de pacientes idosos diagnosticados com embolia pulmonar aguda aumenta constantemente. Porém, o papel do tratamento trombolítico não está claramente definido entre os octogenários. Nosso objetivo é avaliar a efetividade da terapia lítica em pacientes octogenários diagnosticados com embolia pulmonar. Métodos Cento e quarenta e oito indivíduos (70,3% de mulheres, n=104) com mais de 80 anos foram incluídos no estudo. Os pacientes foram divididos em dois grupos: tratamento trombolítico versus não-trombolítico. As taxas de mortalidade hospitalar e episódios de sangramento foram definidos como desfechos do estudo. Valor de p <0,05 foi considerado como estatisticamente significativo. Resultados A mortalidade hospitalar reduziu significativamente no grupo trombolítico em comparação ao não-trombolítico (10,5% vs. 24,2%; p=0,03). Episódios de sangramento menores foram mais comuns no braço que recebeu o tratamento trombolítico, mas grandes hemorragias não diferiram entre os grupos (35,1% vs. 13,2%, p<0,01; 7% vs. 5,5% p=0,71, respectivamente). O escore de PESI alto (OR: 1,03 IC95%; 1,01-1,04 p<0,01), a terapia trombolítica (OR: 0,15 IC95%; 0,01-0,25, p< 0,01) e níveis altos de troponina (OR: 1,20 IC95%; 1,01-1,43, p=0,03) estiveram independentemente associados a taxas de mortalidade hospitalar na análise de regressão multivariada. Conclusão A terapia trombolítica esteve associada à mortalidade hospitalar reduzida em detrimento do aumento geral das complicações de sangramento em octogenários.
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Abstract
A new cancer diagnosis is expected to affect approximately 1.9 million people in the United States in 2021. A small percentage of these patients will experience an emergent cancer-related complication. Oncologic emergencies may be encountered in emergency departments or require intensive care management. Patients newly diagnosed with cancer are more likely to present with emergencies related to the underlying malignancies. Oncologic emergencies can have various manifestations, ranging from mechanical obstruction due to tumor growth to metabolic derangements due to abnormal secretions from the tumor. Therefore, early identification and treatment of life-threatening oncologic events is critical. Although there are several different types of oncologic emergencies, this article focuses on metabolic emergencies (tumor lysis syndrome and cytoreductive hyperthermic intraperitoneal chemotherapy) and structural emergencies (increased intracranial pressure and vena cava thrombus). The purpose of this article is to provide acute care clinicians with an overview of selected oncologic emergencies and their evidence-based management.
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Affiliation(s)
- Ninotchka Brydges
- Ninotchka Brydges is Manager and Advanced Practice Provider, Department of Critical Care Medicine, Division of Anesthesia, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston TX 77030
| | - Garry J Brydges
- Garry J. Brydges is Director, Anesthesia Safety and Quality, Department of Anesthesiology, Division of Anesthesia, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Nguyen PC, Stevens H, Peter K, McFadyen JD. Submassive Pulmonary Embolism: Current Perspectives and Future Directions. J Clin Med 2021; 10:jcm10153383. [PMID: 34362166 PMCID: PMC8347177 DOI: 10.3390/jcm10153383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/26/2021] [Accepted: 07/27/2021] [Indexed: 11/22/2022] Open
Abstract
Submassive pulmonary embolism (PE) lies on a spectrum of disease severity between standard and high-risk disease. By definition, patients with submassive PE have a worse outcome than the majority of those with standard-risk PE, who are hemodynamically stable and lack imaging or laboratory features of cardiac dysfunction. Systemic thrombolytic therapy has been proven to reduce mortality in patients with high-risk disease; however, its use in submassive PE has not demonstrated a clear benefit, with haemodynamic improvements being offset by excess bleeding. Furthermore, meta-analyses have been confusing, with conflicting results on overall survival and net gain. As such, significant interest remains in optimising thrombolysis, with recent efforts in catheter-based delivery as well as upcoming studies on reduced systemic dosing. Recently, long-term cardiorespiratory limitations following submassive PE have been described, termed post-PE syndrome. Studies on the ability of thrombolytic therapy to prevent this condition also present conflicting evidence. In this review, we aim to clarify the current evidence with respect to submassive PE management, and also to highlight shortcomings in current definitions and prognostic factors. Additionally, we discuss novel therapies currently in preclinical and early clinical trials that may improve outcomes in patients with submassive PE.
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Affiliation(s)
- Phillip C. Nguyen
- Department of Haematology, Alfred Hospital, Melbourne, VIC 3181, Australia; (P.C.N.); (H.S.)
| | - Hannah Stevens
- Department of Haematology, Alfred Hospital, Melbourne, VIC 3181, Australia; (P.C.N.); (H.S.)
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC 3004, Australia;
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC 3004, Australia;
- Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC 3800, Australia
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, VIC 3010, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC 3181, Australia
| | - James D. McFadyen
- Department of Haematology, Alfred Hospital, Melbourne, VIC 3181, Australia; (P.C.N.); (H.S.)
- Atherothrombosis and Vascular Biology, Baker Heart and Diabetes Institute, Melbourne, VIC 3004, Australia;
- Department of Medicine, Central Clinical School, Monash University, Melbourne, VIC 3800, Australia
- Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, VIC 3010, Australia
- Correspondence: ; Tel.: +61-3-9076-2179
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Singh M, Shafi I, Rali P, Panaro J, Lakhter V, Bashir R. Contemporary Catheter-Based Treatment Options for Management of Acute Pulmonary Embolism. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021; 23:44. [PMID: 33994774 PMCID: PMC8113788 DOI: 10.1007/s11936-021-00920-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 01/21/2023]
Abstract
Introduction Acute pulmonary embolism (PE) remains an important cause of cardiovascular mortality and morbidity in the USA and worldwide. Catheter-based therapies are emerging as a new armamentarium for improving outcomes in these patients. Purpose of review The purpose of this review is to familiarize the clinicians with (1) various types of catheter-based modalities available for patients with acute PE, (2) advantages, disadvantages, and appropriate patient selection for the use of these devices, and (3) evidence base and the relevance of such therapies in the COVID-19 pandemic. Recent findings There are four main types of catheter-based therapies in acute PE: (1) standard catheter-directed thrombolysis (CDT), (2) ultrasound-assisted CDT, (3) pharmacomechanical CDT, and (4) mechanical thrombectomy without thrombolysis. Ultrasound-assisted thrombolysis is the most widely studied modality in this group; however, evidence base for other catheter-based technologies is rapidly emerging. Summary Current use of catheter-based therapies is most suitable for patients with intermediate and high-risk acute PE. The adoption of a multidisciplinary approach like the pulmonary embolism response team (PERT) is desirable for appropriate patient selection and possibly/potentially improving patient outcomes. We discuss the current status of these therapies.
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Affiliation(s)
- Maninder Singh
- Department of Cardiovascular Disease, Temple University Hospital, Philadelphia, PA USA
| | - Irfan Shafi
- Department of Internal Medicine, Wayne State University/DMC, Detroit, MI USA
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA USA
| | - Joseph Panaro
- Department of Radiology, Temple University Hospital, Philadelphia, PA USA
| | - Vladimir Lakhter
- Department of Cardiovascular Disease, Temple University Hospital, Philadelphia, PA USA
| | - Riyaz Bashir
- Department of Cardiovascular Disease, Temple University Hospital, Philadelphia, PA USA.,Division of Cardiovascular Diseases, Temple University Hospital, 3401 N. Broad Street (9PP), Philadelphia, PA 19140 USA
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Morillo R, Jiménez D, Bikdeli B, Rodríguez C, Tenes A, Yamashita Y, Morimoto T, Kimura T, Vidal G, Ruiz-Giménez N, Espitia O, Monreal M. Refinement of a modified simplified Pulmonary Embolism Severity Index for elderly patients with acute pulmonary embolism. Int J Cardiol 2021; 335:111-117. [PMID: 33621625 DOI: 10.1016/j.ijcard.2021.02.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/25/2021] [Accepted: 02/12/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the utility of a modified (i.e., without the variable "Age >80 years") simplified Pulmonary Embolism Severity Index (sPESI) in elderly patients with acute symptomatic pulmonary embolism (PE), and to derive and validate a refined version of the sPESI for identification of elderly patients at low risk of adverse events. METHODS The study included normotensive patients aged >80 years with acute PE enrolled in the RIETE registry. We used multivariable logistic regression analysis to create a new risk score to predict 30-day all-cause mortality. We externally validated the new risk score in elderly patients from the COMMAND VTE registry. RESULTS Multivariable logistic regression identified four predictors for mortality: high-risk sPESI, immobilization, coexisting deep vein thrombosis (DVT), and plasma creatinine >2 mg/dL. In the RIETE derivation cohort, the new model classified fewer patients as low risk (4.0% [401/10,106]) compared to the modified sPESI (35% [3522/10,106]). Low-risk patients based on the new model had a lower 30-day mortality than those based on the modified sPESI (1.2% [95% CI, 0.4-2.9%] versus 4.7% [95% CI, 4.0-5.4%]). In the COMMAND VTE validation cohort, 1.5% (3/206) of patients were classified as having low risk of death according to the new model, and the overall 30-day mortality of this group was 0% (95% CI, 0-71%), compared to 5.9% (95% CI, 3.1-10.1%) in the high-risk group. CONCLUSIONS For predicting short-term mortality among elderly patients with acute PE, this study suggests that the new model has a substantially higher sensitivity than the modified sPESI. A minority of these patients might benefit from safe outpatient therapy of their disease.
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Affiliation(s)
- Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; Medicine Department, Universidad de Alcala (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Andrés Tenes
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - 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
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Gemma Vidal
- Department of Internal Medicine, Corporación Sanitaria Parc Taulí, Barcelona, Spain
| | - Nuria Ruiz-Giménez
- Department of Internal Medicine, Hospital Universitario de La Princesa, Madrid, Spain
| | | | - Manuel Monreal
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Universidad Autónoma de Barcelona, Barcelona, Spain
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Real world data on clinical profile, management and outcomes of venous thromboembolism from a tertiary care centre in India. Indian Heart J 2021; 73:336-341. [PMID: 34154752 PMCID: PMC8322750 DOI: 10.1016/j.ihj.2021.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 01/21/2021] [Accepted: 02/14/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Venous thromboembolism (VTE) is a major cause of mortality and morbidity worldwide. This study describes a real-world scenario of VTE presenting to a tertiary care hospital in India. METHODS All patients presenting with acute VTE or associated complications from January 2017 to January 2020 were included in the study. RESULTS A total of 330 patient admissions related to VTE were included over 3 years, of which 303 had an acute episode of VTE. The median age was 50 years (IQR 38-64); 30% of patients were younger than 40 years of age. Only 24% of patients had provoked VTE with recent surgery (56%) and malignancy (16%) being the commonest risk factors. VTE manifested as isolated DVT (56%), isolated pulmonary embolism (PE; 19.1%), combined DVT/PE (22.4%), and upper limb DVT (2.3%). Patients with PE (n = 126) were classified as low-risk (15%), intermediate-risk (55%) and high-risk (29%). Reperfusion therapy was performed for 15.7% of patients with intermediate-risk and 75.6% with high-risk PE. In-hospital mortality for the entire cohort was 8.9%; 35% for high-risk PE and 11% for intermediate-risk PE. On multivariate analysis, the presence of active malignancy (OR = 5.8; 95% CI: 1.1-30.8, p = 0.038) and high-risk PE (OR = 4.8; 95% CI: 1.6-14.9, p = 0.006) were found to be independent predictors of mortality. CONCLUSION Our data provides real-world perspectives on the demographic sand management of patients presenting with acute VTE in a referral hospital setting. We observed relatively high mortality for intermediate-risk PE, necessitating better subclassification of this group to identify candidates for more aggressive approaches.
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Blondon M, Jimenez D, Robert‐Ebadi H, Del Toro J, Lopez‐Jimenez L, Falga C, Skride A, Font L, Vazquez FJ, Bounameaux H, Monreal M, Prandoni P, Brenner, B, Farge‐Bancel D, Barba R, Di Micco P, Bertoletti L, Schellong S, Tzoran I, Reis A, Bosevski M, Malý R, Verhamme P, Caprini JA, My Bui H, Adarraga MD, Agud M, Aibar J, Aibar MA, Alfonso J, Amado C, Arcelus JI, Baeza C, Ballaz A, Barba R, Barbagelata C, Barrón M, Barrón‐Andrés B, Blanco‐Molina A, Botella E, Camon AM, Castro J, Caudevilla MA, Cerdà P, Chasco L, Criado J, de Ancos C, de Miguel J, Demelo‐Rodríguez P, Díaz‐Peromingo JA, Díez‐Sierra J, Díaz‐Simón R, Domínguez IM, Encabo M, Escribano JC, Falgá C, Farfán AI, Fernández‐Capitán C, Fernández‐Reyes JL, Fidalgo MA, Flores K, Font C, Francisco I, Gabara C, Galeano‐Valle F, García MA, García‐Bragado F, García‐Mullor MM, Gavín‐Blanco O, Gavín‐Sebastián O, Gil‐Díaz A, Gómez‐Cuervo C, González‐Martínez J, Grau E, Guirado L, Gutiérrez J, Hernández‐Blasco L, Jara‐Palomares L, Jaras MJ, Jiménez D, Joya MD, Jou I, Lacruz B, Lecumberri R, Lima J, Lobo JL, López‐Brull H, López‐Jiménez L, López‐Miguel P, López‐Núñez JJ, López‐Reyes R, López‐Sáez JB, Lorente MA, Lorenzo A, Loring M, Madridano O, Maestre A, Marchena PJ, Martín del Pozo M, Martín‐Martos F, Martínez‐Baquerizo C, Mella C, Mellado M, Mercado MI, Moisés J, Morales MV, Muñoz‐Blanco A, Muñoz‐Guglielmetti D, Muñoz‐Rivas N, Nart E, Nieto JA, Núñez MJ, Olivares MC, Ortega‐Michel C, Ortega‐Recio MD, Osorio J, Otalora S, Otero R, Parra P, Parra V, Pedrajas JM, Pellejero G, Pérez‐Jacoiste A, Peris ML, Pesántez D, Porras JA, Portillo J, Reig L, Riera‐Mestre A, Rivas A, Rodríguez‐Cobo A, Rodríguez‐Matute C, Rogado J, Rosa V, Rubio CM, Ruiz‐Artacho P, Ruiz‐Giménez N, Ruiz‐Ruiz J, Ruiz‐Sada P, Sahuquillo JC, Salgueiro G, Sampériz A, Sánchez‐Muñoz‐Torrero JF, Sancho T, Sigüenza P, Sirisi M, Soler S, Suárez S, Suriñach JM, Tiberio G, Torres MI, Tolosa C, Trujillo‐Santos J, Uresandi F, Usandizaga E, Valle R, Vela JR, Vidal G, Vilar C, Villares P, Zamora C, Gutiérrez P, Vázquez FJ, Vanassche T, Vandenbriele C, Verhamme P, Hirmerova J, Malý R, Salgado E, Benzidia I, Bertoletti L, Bura‐Riviere A, Crichi B, Debourdeau P, Espitia O, Farge‐Bancel D, Helfer H, Mahé I, Moustafa F, Poenou G, Schellong S, Braester A, Brenner B, Tzoran I, Amitrano M, Bilora F, Bortoluzzi C, Brandolin B, Ciammaichella M, Colaizzo D, Dentali F, Di Micco P, Giammarino E, Grandone E, Mangiacapra S, Mastroiacovo D, Maida R, Mumoli N, Pace F, Pesavento R, Pomero F, Prandoni P, Quintavalla R, Rocci A, Siniscalchi C, Tufano A, Visonà A, Vo Hong N, Zalunardo B, Kalejs RV, Maķe K, Ferreira M, Fonseca S, Martins F, Meireles J, Bosevski M, Zdraveska M, Mazzolai L, Caprini JA, Tafur AJ, Weinberg I, Wilkins H, Bui HM. Comparative clinical prognosis of massive and non-massive pulmonary embolism: A registry-based cohort study. J Thromb Haemost 2021; 19:408-416. [PMID: 33119949 DOI: 10.1111/jth.15146] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/29/2020] [Accepted: 10/21/2020] [Indexed: 01/16/2023]
Abstract
AIMS Little is known about the prognosis of patients with massive pulmonary embolism (PE) and its risk of recurrent venous thromboembolism (VTE) compared with non-massive PE, which may inform clinical decisions. Our aim was to compare the risk of recurrent VTE, bleeding, and mortality after massive and non-massive PE during anticoagulation and after its discontinuation. METHODS AND RESULTS We included all participants in the RIETE registry who suffered a symptomatic, objectively confirmed segmental or more central PE. Massive PE was defined by a systolic hypotension at clinical presentation (<90 mm Hg). We compared the risks of recurrent VTE, major bleeding, and mortality using time-to-event multivariable competing risk modeling. There were 3.5% of massive PE among 38 996 patients with PE. During the anticoagulation period, massive PE was associated with a greater risk of major bleeding (subhazard ratio [sHR] 1.72, 95% confidence interval [CI] 1.28-2.32), but not of recurrent VTE (sHR 1.15, 95% CI 0.75-1.74) than non-massive PE. An increased risk of mortality was only observed in the first month after PE. After discontinuation of anticoagulation, among 11 579 patients, massive PE and non-massive PE had similar risks of mortality, bleeding, and recurrent VTE (sHR 0.85, 95% CI 0.51-1.40), but with different case fatality of recurrent PE (11.1% versus 2.4%, P = .03) and possibly different risk of recurrent fatal PE (sHR 3.65, 95% CI 0.82-16.24). CONCLUSION In this large prospective registry, the baseline hemodynamic status of the incident PE did not influence the risk of recurrent VTE, during and after the anticoagulation periods, but was possibly associated with recurrent PE of greater severity.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - David Jimenez
- Respiratory Department Hospital Ramón y Cajal and Medicine Department Universidad de Alcalá (IRYCIS) Madrid Spain
| | - Helia Robert‐Ebadi
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Jorge Del Toro
- Department of Internal Medicine Hospital General Universitario Gregorio Marañón Madrid Spain
| | | | - Conxita Falga
- Department of Internal Medicine Hospital de Mataro Barcelona Spain
| | - Andris Skride
- Department of Cardiology Ospedale Pauls Stradins Clinical University Hospital Riga Latvia
| | - Llorenç Font
- Department of Haematology Hospital de Tortosa Verge de la Cinta Tarragona Spain
| | | | - Henri Bounameaux
- Division of Angiology and Hemostasis Geneva University Hospitals and Faculty of Medicine Geneva Switzerland
| | - Manuel Monreal
- Department of Internal Medicine Hospital Germans Trias i Pujol Badalona Spain
- Universidad Catolica de Murcia Murcia Spain
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Premkumar M, Kajal K, Kulkarni AV, Gupta A, Divyaveer S. Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era. J Intensive Care Med 2021; 36:511-523. [PMID: 33438491 DOI: 10.1177/0885066620988281] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to "collateral damage" in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.
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Affiliation(s)
- Madhumita Premkumar
- Department of Hepatology, 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kamal Kajal
- Department of Anesthesia and Intensive Care, 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anand V Kulkarni
- Department of Hepatology, 78470Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Ankur Gupta
- Department of Cardiology, 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Smita Divyaveer
- Department of Nephrology, 29751Postgraduate Institute of Medical Education and Research, Chandigarh, India
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30
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Mirambeaux R, Le Mao R, Muriel A, Pintado B, Pérez A, Velasco D, Lobo JL, Barrios D, Morillo R, Bikdeli B, Jiménez D. Implications of Abnormal Troponin Levels With Normal Right Ventricular Function in Normotensive Patients With Acute Pulmonary Embolism. Clin Appl Thromb Hemost 2020; 26:1076029620967760. [PMID: 33315469 PMCID: PMC7739071 DOI: 10.1177/1076029620967760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Among patients with pulmonary embolism (PE), various permutations of normal or abnormal cardiac troponin results and normal or abnormal echocardiographic right ventricular function are encountered in clinical practice. We aimed to explore whether there is a true gradient of risk based on troponin and echocardiographic results. This study included normotensive patients with PE from the PROgnosTic valuE of CT scan in hemodynamically stable patients with acute symptomatic pulmonary embolism (PROTECT) study. Patients were categorized as having -Troponin/-Echo, -Troponin/+Echo, +Troponin/-Echo, and +Troponin/+Echo. The primary outcome was 30-day “complicated course,” including death from any cause, hemodynamic collapse, or recurrent PE. Secondary outcomes included individual adverse event rates. Of the 834 patients who had echocardiographic and troponin results, 569 patients (68%) had -Troponin/-Echo, 126 patients (15%) had -Troponin/+Echo, 74 patients (8.9%) had +Troponin/-Echo, and 65 patients (7.8%) had +Troponin/+Echo. The incidence of 30-day complicated course was 4.6% in patients with -Troponin/-Echo, 11.9% in patients with -Troponin/+Echo, 13.5% in patients with +Troponin/-Echo, and 16.9% in patients with +Troponin/+Echo (P for trend <0.001). In the subgroup of patients with a high-risk sPESI (i.e., intermediate-risk according to the ESC guidelines) (n = 527), the incidence of 30-day complicated course was 14.9% in patients with -Troponin/+Echo, 18.5% in patients with +Troponin/-Echo, and 17.5% in patients with +Troponin/+Echo (P for trend <0.01). In patiens with PE, there seems to be a risk gradient based on troponin and echocardiographic results. This study did not detect a significant risk difference in those with +Troponin/-Echo compared with -Troponin/+Echo.
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Affiliation(s)
- Rosa Mirambeaux
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain
| | - Raphael Le Mao
- Groupe d'Etude de la Thrombose de Bretagne Occidentale (GETBO), 137662Université Européenne de Bretagne, Brest, France
| | - Alfonso Muriel
- Biostatistics Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBERESP, Madrid, Spain
| | - Beatriz Pintado
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain
| | - Andrea Pérez
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain
| | - Diurbis Velasco
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain
| | - José Luis Lobo
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Respiratory Department, 37487Hospital Araba, Vitoria, Spain
| | - Deisy Barrios
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York-Presbyterian Hospital, NY, USA.,Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, USA.,Cardiovascular Research Foundation, NY, USA
| | - David Jiménez
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Medicine Department, Alcala de Henares University, IRYCIS, Madrid, Spain
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31
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Chiasakul T, Bauer KA. Thrombolytic therapy in acute venous thromboembolism. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:612-618. [PMID: 33275702 PMCID: PMC7727565 DOI: 10.1182/hematology.2020000148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Although anticoagulation remains the mainstay of treatment of acute venous thromboembolism (VTE), the use of thrombolytic agents or thrombectomy is required to immediately restore blood flow to thrombosed vessels. Nevertheless, systemic thrombolysis has not clearly been shown to improve outcomes in patients with large clot burdens in the lung or legs as compared with anticoagulation alone; this is in part due to the occurrence of intracranial hemorrhage in a small percentage of patients to whom therapeutic doses of a thrombolytic drug are administered. Algorithms have been developed to identify patients at high risk for poor outcomes resulting from large clot burdens and at low risk for major bleeding in an effort to improve outcomes in those receiving thrombolytic therapy. In acute pulmonary embolism (PE), hemodynamic instability is the key determinant of short-term survival and should prompt consideration of immediate thrombolysis. In hemodynamically stable PE, systemic thrombolysis is not recommended and should be used as rescue therapy if clinical deterioration occurs. Evidence is accumulating regarding the efficacy of administering reduced doses of thrombolytic agents systemically or via catheters directly into thrombi in an effort to lower bleed rates. In acute deep venous thrombosis, catheter-directed thrombolysis with thrombectomy can be used in severe or limb-threatening thrombosis but has not been shown to prevent postthrombotic syndrome. Because the management of acute VTE can be complex, having a rapid-response team (ie, PE response team) composed of physicians from different specialties may aid in the management of severely affected patients.
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Affiliation(s)
- Thita Chiasakul
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand; and
- Hematology-Oncology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kenneth A. Bauer
- Hematology-Oncology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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32
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Ortel TL, Neumann I, Ageno W, Beyth R, Clark NP, Cuker A, Hutten BA, Jaff MR, Manja V, Schulman S, Thurston C, Vedantham S, Verhamme P, Witt DM, D Florez I, Izcovich A, Nieuwlaat R, Ross S, J Schünemann H, Wiercioch W, Zhang Y, Zhang Y. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv 2020; 4:4693-4738. [PMID: 33007077 PMCID: PMC7556153 DOI: 10.1182/bloodadvances.2020001830] [Citation(s) in RCA: 559] [Impact Index Per Article: 139.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), occurs in ∼1 to 2 individuals per 1000 each year, corresponding to ∼300 000 to 600 000 events in the United States annually. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about treatment of VTE. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and adult patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 28 recommendations for the initial management of VTE, primary treatment, secondary prevention, and treatment of recurrent VTE events. CONCLUSIONS Strong recommendations include the use of thrombolytic therapy for patients with PE and hemodynamic compromise, use of an international normalized ratio (INR) range of 2.0 to 3.0 over a lower INR range for patients with VTE who use a vitamin K antagonist (VKA) for secondary prevention, and use of indefinite anticoagulation for patients with recurrent unprovoked VTE. Conditional recommendations include the preference for home treatment over hospital-based treatment for uncomplicated DVT and PE at low risk for complications and a preference for direct oral anticoagulants over VKA for primary treatment of VTE.
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Affiliation(s)
- Thomas L Ortel
- Division of Hematology, Department of Medicine, Duke University, Durham NC
| | | | - Walter Ageno
- Department of Medicine and Surgery, University of Insurbria, Varese, Italy
| | - Rebecca Beyth
- Division of General Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Nathan P Clark
- Clinical Pharmacy Anticoagulation Service, Kaiser Permanente, Aurora, CO
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Barbara A Hutten
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Veena Manja
- University of California Davis, Sacramento, CA
- Veterans Affairs Northern California Health Care System, Mather, CA
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Suresh Vedantham
- Division of Diagnostic Radiology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Peter Verhamme
- KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Ivan D Florez
- Department of Pediatrics, University of Antioquia, Medellin, Colombia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ariel Izcovich
- Internal Medicine Department, German Hospital, Buenos Aires, Argentina; and
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Stephanie Ross
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuqing Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Abstract
Given the broad treatment options, risk stratification of pulmonary embolism is a highly desirable component of management. The ideal tool identifies patients at risk of death from the original or recurrent pulmonary embolism. Using all-cause death in the first 30-days after pulmonary embolism diagnosis as a surrogate, clinical parameters, biomarkers, and radiologic evidence of right ventricular dysfunction and strain are predictive. However, no study has demonstrated improved mortality rates after implementation of a risk stratification strategy to guide treatment. Further research should use better methodology to study prognosis and test new management strategies in patients at high risk for death.
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Affiliation(s)
- Thomas Moumneh
- Department of Emergency Medicine, University Hospital of Angers, 4 rue Larrey, 49100 Angers, France; MITOVASC Institute, UMR CNRS 6015 UMR INSERM 1083, Angers University, 28, rue Roger-Amsler, 49045 Angers, France; University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, 501 Smyth Road, Suite M1857, PO Box 206, Ottawa, Ontario K1H 8L6, Canada.
| | - Sebastien Miranda
- University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada; Department of Internal Medicine, Vascular and Thrombosis Unit, Rouen University Hospital, 37 Boulevard Gambetta, 76000 Rouen, France; Normandie University, UNIROUEN, INSERM U1096, 22 Boulevard Gambetta, 76000 Rouen, France
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Jose A, Eckman MH, Elwing JM. Anticoagulation in pulmonary arterial hypertension: a decision analysis. Pulm Circ 2019; 9:2045894019895451. [PMID: 31903185 PMCID: PMC6928543 DOI: 10.1177/2045894019895451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/26/2019] [Indexed: 01/16/2023] Open
Abstract
Systemic anticoagulation may be beneficial in pulmonary arterial hypertension, but there is no randomized clinical trial data to guide therapeutic decision making, and current guidelines do not account for patient preferences or quality of life. Decision analytic models to evaluate the potential risks and benefits of systemic anticoagulation in pulmonary arterial hypertension patients, focusing on the benefit in quality-adjusted life years, may be helpful in clarifying this uncertainty. We constructed a 31-state Markov decision analytic model to explore anticoagulation and no anticoagulation strategies. Modeled patient characteristics included gender, use of central catheter-based pulmonary arterial hypertension therapy, type of pulmonary arterial hypertension (idiopathic, idiopathic pulmonary arterial hypertension, or connective-tissue associated, connective tissue disease-pulmonary arterial hypertension), and use of oral contraceptive medication by females. Modeled events included mortality, thromboembolic complications, atrial fibrillation, stroke, and anticoagulation bleeding. Deterministic and probabilistic sensitivity analyses were performed. Anticoagulation was favored in all idiopathic pulmonary arterial hypertension cases, with a gain of 0.43-0.51 quality-adjusted life years, and detrimental in all connective tissue disease-pulmonary arterial hypertension cases, with a loss of 0.66-1.89 quality-adjusted life years. Anticoagulation would need to demonstrate a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better to be favored. In our model, idiopathic pulmonary arterial hypertension patients benefit from anticoagulation in terms of quality-adjusted life years, and connective tissue disease-pulmonary arterial hypertension patients were harmed, with a hazard ratio for pulmonary arterial hypertension mortality of 0.95 or better being required to favorably impact quality-adjusted life years. These results suggest that anticoagulation significantly improves quality adjusted life years and should be offered to all idiopathic pulmonary arterial hypertension patients. Shared decision models based on these results may help clarify therapeutic decision-making uncertainty in pulmonary arterial hypertension patients.
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Affiliation(s)
- Arun Jose
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mark H Eckman
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jean M Elwing
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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35
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Dabbouseh NM, Patel JJ, Bergl PA. Role of echocardiography in managing acute pulmonary embolism. Heart 2019; 105:1785-1792. [DOI: 10.1136/heartjnl-2019-314776] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/06/2019] [Accepted: 07/22/2019] [Indexed: 12/29/2022] Open
Abstract
The role of echocardiography in acute pulmonary embolism (PE) remains incompletely defined. Echocardiography cannot reliably diagnose acute PE, and it does not improve prognostication of patients with low-risk acute PE who lack other clinical features of right ventricular (RV) dysfunction. Echocardiography, however, may yield additional prognostic information in higher risk patients and can aid in distinguishing acute from chronic RV dysfunction. Specific echocardiographic markers of RV dysfunction have the potential to enhance prognostication beyond existing risk models. Until these markers are subjected to rigorous prospective studies, the therapeutic utility and economic value of echocardiography in acute PE are uncertain.
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Zuin M, Rigatelli G, Zuliani G, Zonzin P, Ramesh D, Roncon L. Thrombolysis in hemodynamically unstable patients: still underused: a review based on multicenter prospective registries on acute pulmonary embolism. J Thromb Thrombolysis 2019; 48:323-330. [PMID: 31025166 DOI: 10.1007/s11239-019-01867-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Hemodynamically unstable pulmonary embolism (PE) represents a complex and life-threatening event with a highly variable course and poor prognosis in the short-term period. Despite an immediate reperfusion treatment is recommended in these patients, previous investigations have reported a lower use of systemic thrombolysis (ST). The aim of the present review is to assess and describe the real use of ST in hemodynamically unstable patients with acute PE enrolled in prospective-multicenter registries between the 1990 and 2018. Over that period, 1216 articles were identified in Pubmed. After excluding the duplicates obtained using the different searching MeSH (n = 703), 513 articles were screened and then excluded for not meeting inclusion criteria due the article type, design of the study or no English language. As result, 13 articles were assessed for eligibility and carefully reviewed. Finally, five studies met the inclusion criteria and were included in the analysis. The identified study registries enrolled prospectively 41364 consecutive patients with acute PE between the 1993 and the 2016. Among these, 2168 (5.2%) were hemodynamically unstable at presentation. ST was administered in 29.7% (n = 645) of patients while catheter-direct treatment (CDT) was used only in 1.4% (n = 32) of cases. Conversely, surgical pulmonary embolectomy (SPE) was adopted as reperfusion treatment in 39 patients (1.7%). Intriguingly, the 68% of patients not received a reperfusion treatment despite they were hemodynamically unstable at admission. Despite the internationals guidelines recommendations, a prompt reperfusion is performed only in one on three hemodynamically unstable patients with acute PE.
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Affiliation(s)
- Marco Zuin
- Section of Internal and Cardiopulmonary Medicine, University of Ferrara, Ferrara, Italy
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | - Gianluca Rigatelli
- Cardiovascular Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Rovigo, Italy
| | - Giovanni Zuliani
- Section of Internal and Cardiopulmonary Medicine, University of Ferrara, Ferrara, Italy
| | - Pietro Zonzin
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | - Daggubati Ramesh
- Division of Cardiology, Department of Cardiovascular Sciences, Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Loris Roncon
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy.
- Department of Cardiology, Santa Maria della Misericordia Hospital, Viale Tre Martiri 140, 45100, Rovigo, Italy.
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