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Henkin S, Ujueta F, Sato A, Piazza G. Acute Pulmonary Embolism: Evidence, Innovation, and Horizons. Curr Cardiol Rep 2024:10.1007/s11886-024-02128-0. [PMID: 39215952 DOI: 10.1007/s11886-024-02128-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE OF REVIEW Pulmonary embolism (PE) is the third most common cause of cardiovascular morbidity and mortality. The goal of this review is to discuss the most up-to-date literature on epidemiology, diagnosis, risk stratification, and management of acute PE. RECENT FINDINGS Despite an increase in annual incidence rate of PE in the United States and development of multiple advanced therapies for treatment of acute PE, PE-related mortality is not consistently decreasing across populations. Although multiple risk stratification schemes have been developed, it is still unclear which advanced therapy should be used for the individual patient and optimal timing. Fortunately, multiple randomized clinical trials are underway to answer these questions. Nevertheless, up to 50% of patients have persistent reduced quality of life 6 months after acute PE, termed post-PE syndrome. Despite advances in therapeutic options for management of acute PE, many questions remain unanswered, including optimal risk stratification and management of acute PE.
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Affiliation(s)
- Stanislav Henkin
- Gonda Vascular Center, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Francisco Ujueta
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alyssa Sato
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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Zuin M, Aggarwal R, Bikdeli B, Kirksey L, Hussain MA, Bilato MJ, Bilato C, Piazza G. Abdominal Aortic Aneurysm-Attributed Mortality in the United States. J Am Coll Cardiol 2024; 84:595-601. [PMID: 39084833 DOI: 10.1016/j.jacc.2024.05.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 08/02/2024]
Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy; Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, Padova, Italy.
| | - Rahul Aggarwal
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA
| | - Lee Kirksey
- Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mohamad A Hussain
- Division of Vascular and Endovascular Surgery and the Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marco J Bilato
- Division of Vascular and Endovascular Surgery, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Claudio Bilato
- Division of Cardiology, West Vicenza General Hospitals, Arzignano, Vicenza, Italy
| | - Gregory Piazza
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Zuin M, Henkin S, Harder EM, Piazza G. Optimal hemodynamic parameters for risk stratification in acute pulmonary embolism patients. J Thromb Thrombolysis 2024; 57:918-928. [PMID: 38762710 DOI: 10.1007/s11239-024-02998-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/20/2024]
Abstract
Hemodynamic assessment of patients with pulmonary embolism (PE) remains a fundamental component of early risk stratification that in turn, influences subsequent monitoring and therapeutic strategies. The current body of literature and international evidence-based clinical practice guidelines focus mainly on the use of systolic blood pressure (SBP). The accuracy of this single hemodynamic parameter, however, and its optimal values for the identification of hemodynamic instability have been recently questioned by clinicians. For example, abnormal SBP or shock index may be a late indicator of adverse outcomes, signaling a patient in whom the cascade of hemodynamic compromise is already well underway. The aim of the present article is to review the current evidence supporting the use of SBP and analyze the potential integration of other parameters to assess the hemodynamic stability, impending clinical deterioration, and guide the reperfusion treatment in patients with PE, as well as to suggest potential strategies to further investigate this issue.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Via Aldo Moro 8, Ferrara, 44124, Italy.
| | | | - Eileen M Harder
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Piazza G. A hard look in the mirror: disparities in reperfusion therapy for acute pulmonary embolism in the United States and failure to reduce mortality. J Thromb Haemost 2024; 22:1838-1840. [PMID: 38945666 DOI: 10.1016/j.jtha.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/15/2024] [Indexed: 07/02/2024]
Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Zuin M, Overvad TF, Albertsen IE, Bilato C, Piazza G. Trends of Pulmonary Embolism-Related Sudden Cardiac Death in the United States, 1999-2019. J Thromb Thrombolysis 2024; 57:483-491. [PMID: 38281229 DOI: 10.1007/s11239-024-02946-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/01/2024] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Up-to-date population-based data on pulmonary embolism (PE)-related sudden cardiac death (SCD) mortality trends in the United States (US) are scant. We assess the current trends in PE-related SCD mortality in US over the past two decades and determine differences by sex, race, ethnicity, age, and census region. METHODS We extracted PE-related SCD mortality rates from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) database from 1999 to 2019, in patients aged ≥ 15 years old. Age-adjusted mortality rates (AAMRs) were assessed using the Joinpoint regression modeling and expressed as estimated average annual percentage change (AAPC) with relative 95% confidence intervals (CIs). RESULTS Between 1999 and 2019, the AAMR from acute PE-related SCD mortality in the US linearly increased [AAPC: +2.4% (95% CI: 2.2 to 2.6), p < 0.001)]. The AAMR increase was more pronounced in men [AAPC: +2.8% (95% CI: 2.6 to 2.9), p < 0.001], Whites [AAPC: +2.7% (95% CI: 2.3 to 3.1), p < 0.001], Latinx/Hispanic patients [AAPC:+2.0% (95% CI: 1.2 to 2.8), p < 0.001], subjects younger than 65 years [AAPC: +2.4% (95% CI: 2.1 to 2.6), p < 0.001] and in residents of rural areas [AAPC: +3.6% (95% CI: 3.3 to 3.9), p < 0.001]. Moreover, higher percentages of PE-related SCD and the relative absolute number of deaths were observed in the South compared with other geographical regions. CONCLUSIONS PE-related SCD mortality in the US has increased over the last two decades. Stratification by race, ethnicity, urbanization, and census region demonstrates ethnoracial and regional disparities that require further investigation and remedy.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Via Aldo Moro 8, Ferrara, 44124, Italy.
| | | | - Ida Ehlers Albertsen
- Department of Otolaryngology, Head and Neck Surgery and Audiology, Aalborg University Hospital, Aalborg, Denmark
| | - Claudio Bilato
- Department of Cardiology, West Vicenza Hospital, Arzignano, Italy
| | - Gregory Piazza
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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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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Millington SJ, Aissaoui N, Bowcock E, Brodie D, Burns KEA, Douflé G, Haddad F, Lahm T, Piazza G, Sanchez O, Savale L, Vieillard-Baron A. High and intermediate risk pulmonary embolism in the ICU. Intensive Care Med 2024; 50:195-208. [PMID: 38112771 DOI: 10.1007/s00134-023-07275-6] [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: 09/14/2023] [Accepted: 11/11/2023] [Indexed: 12/21/2023]
Abstract
Pulmonary embolism (PE) is a common and important medical emergency, encountered by clinicians across all acute care specialties. PE is a relatively uncommon cause of direct admission to the intensive care unit (ICU), but these patients are at high risk of death. More commonly, patients admitted to ICU develop PE as a complication of an unrelated acute illness. This paper reviews the epidemiology, diagnosis, risk stratification, and particularly the management of PE from a critical care perspective. Issues around prevention, anticoagulation, fibrinolysis, catheter-based techniques, surgical embolectomy, and extracorporeal support are discussed.
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Affiliation(s)
- Scott J Millington
- Critical Care, The University of Ottawa/The Ottawa Hospital, Ottawa, ON, Canada
| | - Nadia Aissaoui
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP). Centre & Université Paris Cité, Paris, France
| | - Emma Bowcock
- Department of Intensive Care, Nepean Hospital, University of Sydney, Sydney, Australia
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karine E A Burns
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, Toronto, Canada
| | - Ghislaine Douflé
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada
| | - François Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease at Stanford University, Stanford, CA, USA
| | - Tim Lahm
- Pulmonary Sciences and Critical Care Medicine, National Jewish Health, University of Colorado, Rocky Mountain Regional VA Medical Center, Denver, CO, USA
| | - Gregory Piazza
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivier Sanchez
- Service de pneumologie et soins intensifs, Hopital Européen Georges Pompidou, APHP, Paris, France
- INSERM UMR S 1140, Innovative Therapies in Hemostasis, Université Paris Cité, Paris, France
| | - Laurent Savale
- Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Antoine Vieillard-Baron
- Medical and Surgical ICU, University Hospital Ambroise Pare, GHU Paris-Saclay, APHP, Boulogne-Billancourt, France.
- Inserm U1018, CESP, Universite Versailles Saint-Quentin en Yvelines, Guyancourt, France.
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Cayuela L, Jara-Palomares L, Rondón P, Gaeta AM, Cayuela A. Age and sex differences in pulmonary embolism mortality rates in Spain from 1999 to 2021. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:183-185. [PMID: 37730115 DOI: 10.1016/j.rec.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/24/2023] [Indexed: 09/22/2023]
Affiliation(s)
- Lucía Cayuela
- Departmento de Medicina Interna, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - Luis Jara-Palomares
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Seville, Spain; Instituto de Biomedicina de Sevilla (IBiS), Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain.
| | - Pilar Rondón
- Departmento de Medicina Interna, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain; Facultad de Medicina, Universidad Alfonso X El Sabio, Madrid, Spain
| | - Anna M Gaeta
- Servicio de Neumología, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - Aurelio Cayuela
- Unidad de Salud Pública, Prevención y Promoción de la Salud, Área de Salud Sur de Sevilla, Seville, Spain
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Becattini C. Provoked vs minimally provoked vs unprovoked VTE: does it matter? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:600-605. [PMID: 38066936 PMCID: PMC10727063 DOI: 10.1182/hematology.2023000492] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Venous thromboembolism (VTE) is a multifactorial disease, and its risk depends on exposure to risk factors and predisposing conditions. Based on their strength of association with a VTE episode, risk factors are classified as major or minor and determined using a temporal pattern to be transient or persistent. All patients with VTE should receive anticoagulant treatment for at least 3 months in the absence of an absolute contraindication. Beyond this period, selected patients may be candidates for an extended phase of anticoagulation aimed at secondary VTE prevention. The risk of recurrent VTE if anticoagulation is discontinued is probably the main driver of decision-making regarding extended treatment. The risk of recurrence after VTE associated with major risk factors is low if the risk factor is no longer present. In this case, treatment can be discontinued. If the major risk factor is persistent, anticoagulation should be continued. After VTE occurring in the absence of risk factors, anticoagulation should probably be continued indefinitely if the risk for bleeding is low and preferably with minimal effective doses of anticoagulants. VTE occurring after exposure to minor risk factors is probably the most challenging situation, especially if the clinical manifestation was acute pulmonary embolism. Understanding the actual role of minor risk factors in the occurrence of VTE helps in estimating the risk of recurrence and avoiding the dangers associated with unnecessary anticoagulation. The availability of safer strategies for anticoagulation could allow personalized strategies for secondary prevention of VTE.
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Affiliation(s)
- Cecilia Becattini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
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Monteleone P, Thangam M. Who Is Dying of Pulmonary Embolism? Am J Cardiol 2023; 207:490-492. [PMID: 37833167 DOI: 10.1016/j.amjcard.2023.08.099] [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: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 10/15/2023]
Affiliation(s)
- Peter Monteleone
- Department of Cardiovascular Medicine, University of Texas at Austin Dell School of Medicine, Ascension Texas Cardiovascular, Austin, Texas.
| | - Manoj Thangam
- Department of Cardiovascular Medicine, University of Texas at Austin Dell School of Medicine, Ascension Texas Cardiovascular, Austin, Texas
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