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Li Y, Xue P, Zhang T, Peng M, Sun X, Shi J. Clinical characteristics and anticoagulation patterns of patients with acute pulmonary thromboembolism and hemoptysis. Pulm Circ 2024; 14:e12422. [PMID: 39092169 PMCID: PMC11291552 DOI: 10.1002/pul2.12422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 04/26/2024] [Accepted: 07/15/2024] [Indexed: 08/04/2024] Open
Abstract
Hemoptysis is a frequently encountered manifestation in cases of acute pulmonary thromboembolism (PTE), significantly impacting clinical decision-making. Despite its clinical relevance, studies focusing on patients with acute PTE and hemoptysis are notably scarce. In this retrospective study, we examined data from hospitalized patients with acute PTE at Peking Union Medical College Hospital (PUMCH) between January 2012 and October 2020. Among the 896 patients analyzed, 105 (11.7%) presented with hemoptysis. Patients with hemoptysis were younger, had higher RRs, and frequently reported chest pain, predominantly showing a negative sPESI score. A significant association with autoimmune diseases was observed (39.0% vs. 16.1%; p < 0.001), along with higher occurrences of pulmonary infections (29.5%), lung cancer (21.0%), and chronic heart failure (16.2%). Hemoptysis in PTE is multifactorial; 51.4% of cases were PTE-related, with 85.2% experiencing mild hemoptysis. Among patients with disease-related hemoptysis (13.3%), 90.9% with massive hemoptysis had underlying diseases, predominantly lung cancer. In 35.2% of cases, the cause of hemoptysis remained undetermined, with vasculitis accounting for 29.7%. Anticoagulation strategies varied with the severity of hemoptysis; 82.9% with mild and only 27.3% with massive hemoptysis received therapeutic-dose anticoagulation. Multivariate analysis identified massive hemoptysis as the most significant determinant of anticoagulation decisions. Patients with massive hemoptysis had the poorest outcomes, with an in-hospital mortality rate of 36.4% and 72.7% receiving reduced or no anticoagulation.
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Affiliation(s)
- Yiyao Li
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare DiseasesPeking Union Medical College HospitalBeijingChina
- Chinese Academy of Medical Sciences, Peking Union Medical CollegeBeijingChina
| | - Peijun Xue
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare DiseasesPeking Union Medical College HospitalBeijingChina
| | - Ting Zhang
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare DiseasesPeking Union Medical College HospitalBeijingChina
| | - Min Peng
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare DiseasesPeking Union Medical College HospitalBeijingChina
| | - Xuefeng Sun
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare DiseasesPeking Union Medical College HospitalBeijingChina
| | - Juhong Shi
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare DiseasesPeking Union Medical College HospitalBeijingChina
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2
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Shetty SM, Vora A, George R, M V. Challenges, Recommendations, and Epidemiology of Pulmonary Embolism in India: A Narrative Review. Cureus 2024; 16:e64195. [PMID: 39130902 PMCID: PMC11310498 DOI: 10.7759/cureus.64195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2024] [Indexed: 08/13/2024] Open
Abstract
An embolized clot that travels to the lungs from the legs or, less commonly, other parts of the body (known as deep vein thrombosis or DVT) causes pulmonary embolism (PE), which is characterized by obstruction of blood flow to the pulmonary artery. As PE has the propensity to masquerade as various illnesses affecting both the cardiovascular (CV) and the respiratory system, it is crucial to identify PE at the earliest. Appropriate diagnosis of PE may lead to earlier treatment and improved patient outcomes. While pulmonary angiography remains the established gold standard for diagnosing PE, the contemporary standard of care for this condition is the computed tomography pulmonary angiogram (CTPA). Anticoagulation therapy is the fundamental strategy for managing PE, with the forefront of treatment being the use of novel and upcoming oral anticoagulants known as non-vitamin K antagonist oral anticoagulants (NOACs). The NOACs provide a practical single-drug treatment strategy, which does not hinder the patient's lifestyle and domestic responsibilities. Although PE may be fatal, early detection may lead to effective management. Despite that, mortality and morbidity associated with PE are very high in India. The awareness among Indian healthcare professionals about PE should be improved, and unified pan-country diagnostic and management guidelines should be formulated to tackle the country's PE burden.
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Affiliation(s)
- Sadanand M Shetty
- Cardiology, Karamshibhai Jethabhai Somaiya Super Specialty Institute, Mumbai, IND
| | - Agam Vora
- Pulmonology, Vora Clinic, Mumbai, IND
| | - Robbie George
- Department of Vascular and Endovascular Surgery, Narayana Institute of Vascular Sciences, Bangalore, IND
| | - Vidita M
- Internal Medicine, Pfizer Ltd, Mumbai, IND
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3
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Townsend Reeves M, Lahil H, Gold A, Danckers M, Dubensky L, Slesinger TL. Emergency Ultrasound Unveils Intermediate-High Risk Saddle Pulmonary Embolism with Extensive Bilateral Clot Burden, Masquerading as Micturition Syncope: A Case Report. J Emerg Med 2024; 66:e694-e700. [PMID: 38763838 DOI: 10.1016/j.jemermed.2024.01.018] [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: 11/29/2023] [Revised: 12/27/2023] [Accepted: 01/06/2024] [Indexed: 05/21/2024]
Abstract
BACKGROUND Isolated syncope as the manifestation of pulmonary embolism (PE) is a rare and diagnostically challenging presentation that often leads to delayed or missed diagnosis, increasing morbidity and mortality. In spite of emphasizing cardiovascular etiologies of syncope, current guidelines offer essentially no guidance in establishing a diagnostic workup for PE in these patients. By performing bedside echocardiography, emergency physicians can accurately identify concerning features suggestive of PE in patients with syncope. CASE REPORT A 78-year-old man, receiving ertapenem via a peripherally inserted central catheter for treatment of extended spectrum β-lactamase urinary tract infection, presented to the emergency department for isolated syncope with collapse while urinating. Arriving asymptomatic with normal vital signs and a benign physical examination, a presumptive diagnosis of micturition syncope was made. However, subtle vital sign changes on reassessment prompted performance of a point-of-care echocardiogram, which revealed signs of right heart strain. A computed tomography angiogram confirmed a saddle PE with extensive bilateral clot burden. Catheter-directed thrombectomy was performed via interventional radiology, with successful removal of pulmonary emboli. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pulmonary embolism presenting as isolated syncope represents a daunting diagnostic dilemma, as emergency physicians may not consider it, or anchor on more benign etiologies of syncope. Although lacking sufficient sensitivity to rule out PE, point-of-care echocardiography to evaluate for signs of right heart strain can quickly and effectively point toward the diagnosis, while also assessing for other emergent cardiovascular causes of syncope. Given the lack of evidence-based guidance concerning PE presenting as syncope, bedside echocardiography should be highly considered as a part of the emergency physician's diagnostic workup, especially in patients with abnormal vital signs.
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Affiliation(s)
- M Townsend Reeves
- Department of Emergency Medicine, HCA Florida Aventura Hospital, Aventura, Florida
| | - Harjeev Lahil
- Department of Emergency Medicine, HCA Florida Aventura Hospital, Aventura, Florida
| | - Aaron Gold
- Department of Radiology, HCA Florida Aventura Hospital, Aventura, Florida
| | - Mauricio Danckers
- Division of Critical Care, HCA Florida Aventura Hospital, Aventura, Florida
| | - Laurence Dubensky
- Department of Emergency Medicine, HCA Florida Aventura Hospital, Aventura, Florida
| | - Todd L Slesinger
- Department of Emergency Medicine, HCA Florida Aventura Hospital, Aventura, Florida
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4
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Mohyeldin M, Ezukuse V, Bhattarai R, Nasr R. Pulmonary Embolism in a Young African American Male: A Diagnostic Challenge. Cureus 2024; 16:e62348. [PMID: 39006732 PMCID: PMC11246543 DOI: 10.7759/cureus.62348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2024] [Indexed: 07/16/2024] Open
Abstract
This case report highlights the diagnostic challenges posed by pulmonary embolism (PE) in a young, otherwise healthy 33-year-old African American male with no apparent risk factors. The patient presented with penile pain, swelling, hematuria, flank pain, and rash, and was admitted for balanoposthitis and acute urinary retention. Despite prophylactic heparin, he suffered two cardiac arrests secondary to PE on the fifth day of hospitalization. Prompt thrombolytic therapy and heparin infusion were initiated, but his course was complicated by anuric acute kidney injury requiring hemodialysis, shock liver, and gastrointestinal bleeding. Imaging revealed a substantial thrombus burden in the pulmonary arteries. Notably, a hypercoagulable workup was negative. The absence of typical risk factors, negative hypercoagulable workup, and occurrence of PE despite prophylaxis underscore the importance of vigilance in recognizing atypical presentations. This case emphasizes the need for a high index of suspicion and comprehensive evaluation to diagnose PE in young patients without clear predisposing factors.
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Affiliation(s)
| | - Vanisa Ezukuse
- Internal Medicine, BronxCare Health System, Bronx, USA
- Department of Medicine, American University of the Caribbean School of Medicine, Cupecoy, SXM
| | | | - Rabih Nasr
- Nephrology, BronxCare Health System, Bronx, USA
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5
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Glazier MM, Glazier JJ. Diagnostic Strategies in Pulmonary Embolism. Int J Angiol 2024; 33:89-94. [PMID: 38846998 PMCID: PMC11152624 DOI: 10.1055/s-0044-1779661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
Key to the diagnosis of pulmonary embolism (PE) is a careful bedside evaluation. After this, there are three further diagnostic steps. In all patients, estimation of the clinical probability of PE is performed. The other two steps are measurement of D-dimer when indicated and chest imaging when indicated. The clinical probability of PE is estimated at low, moderate, or high. The prevalence of PE is less than 15% among patients with low clinical probability, 15 to 40% with moderate clinical probability, and >40% in patients with high clinical probability. Clinical gestalt has been found to be very useful in estimating probability of PE. However, clinical prediction rules, such as Wells criteria, the modified Geneva score, and the PE rule out criteria have been advocated as adjuncts. In patients with high clinical probability, the high prevalence of PE can lower the D-dimer negative predictive value, which could increase the risk of diagnostic failure. Consequently, patients with high probability for PE need to proceed directly to chest imaging, without prior measurement of D-dimer level. Key studies in determining which low to moderate probability patients require chest imaging are the Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism (ADJUST-PE), the Simplified diagnostic management of suspected pulmonary embolism (YEARS), and the Pulmonary Embolism Graduated D-Dimer trials. In patients with low clinical probability, PE can be excluded without imaging studies if D-dimer is less than 1,000 ng/mL. In patients in whom there is not a low likelihood for PE, this can be excluded without imaging studies if the D-dimer is below the age-adjusted threshold.
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Affiliation(s)
| | - James J. Glazier
- Department of Medicine, Wayne State University School of Medicine, Detroit, Michigan
- Department of Cardiology, Oakland University William Beaumont School of Medicine, Rochester, Michigan
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Mohammed AQI, Berman L, Staroselsky M, Wenn P, Hai O, Makaryus AN, Zeltser R. Clinical Presentation and Risk Stratification of Pulmonary Embolism. Int J Angiol 2024; 33:82-88. [PMID: 38846996 PMCID: PMC11152639 DOI: 10.1055/s-0044-1786878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
Pulmonary embolism (PE) presents with a spectrum of symptoms, ranging from asymptomatic cases to life-threatening events. Common symptoms include sudden dyspnea, chest pain, limb swelling, syncope, and hemoptysis. Clinical presentation varies based on thrombus burden, demographics, and time to presentation. Diagnostic evaluation involves assessing symptoms, physical examination findings, and utilizing laboratory tests, including D-dimer. Risk stratification using tools like Wells score, Pulmonary Embolism Severity Index, and Hestia criteria aids in determining the severity of PE. PE is categorized based on hemodynamic status, temporal patterns, and anatomic locations of emboli to guide in making treatment decisions. Risk stratification plays a crucial role in directing management strategies, with elderly and comorbid individuals at higher risk. Early identification and appropriate risk stratification are essential for effective management of PE. As we delve into this review article, we aim to enhance the knowledge base surrounding PE, contributing to improved patient outcomes through informed decision-making in clinical practice.
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Affiliation(s)
| | - Lorin Berman
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
| | - Mark Staroselsky
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
| | - Peter Wenn
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
| | - Ofek Hai
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
| | - Amgad N. Makaryus
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Roman Zeltser
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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7
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Li Y, Yang J, Xue P, Zhang T, Sun X, Peng M, Shi J. Clinical Characteristics and Prognosis of Acute Pulmonary Embolism with Hemoptysis in Autoimmune Disease Patients. Int J Med Sci 2024; 21:1399-1407. [PMID: 38903924 PMCID: PMC11186428 DOI: 10.7150/ijms.94052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/16/2024] [Indexed: 06/22/2024] Open
Abstract
Background: Hemoptysis is prevalent in acute pulmonary embolism (PE) and significantly influences clinical decision-making. Despite the increasing reports of PE in patients with autoimmune diseases, limited studies have investigated the association between acute PE with hemoptysis and autoimmune disease. Methods: The retrospective study aimed to investigate patients with autoimmune disease who presented with acute PE and hemoptysis at Peking Union Medical College Hospital (PUMCH) between January 2012 and October 2020. A comparative analysis was conducted between patients with and without hemoptysis, as well as between those with autoimmune diseases and those without. Clinical characteristics, PE severity stratification, the amount of hemoptysis, initial anticoagulation management, and prognosis were analyzed descriptively. Results: The study analyzed 896 patients diagnosed with acute PE, of whom 105 (11.7%) presented with hemoptysis. Hemoptysis in PE patients was frequently associated with autoimmune diseases (39%, 41/105), a younger patient population (42.0 vs. 52.7 years old, P =0.002), and a higher prevalence of low-risk PE (53.7 vs. 28.1, P=0.008) compared with non-autoimmune disease patients. Multivariate logistic analysis showed PE patients with primary or metastatic lung cancer, chest pain, age < 48 years old, chronic heart failure, autoimmune disease, pulmonary infection and male were more likely to develop hemoptysis. Patients were grouped based on maximum daily sputum blood volume and PE risk stratification. Most patients (73.2%) received therapeutic-dose anticoagulation. Poor prognosis is observed in patients with moderate to massive hemoptysis and intermediate-high-risk or high-risk PE. Conclusions: Hemoptysis is a relatively common manifestation in patients with PE, and its presence during the diagnostic workup of acute PE necessitates careful analysis of underlying comorbidities. In cases where hemoptysis occurs in individuals with autoimmune diseases in the context of PE, proactive management strategies targeting the primary disease are crucial. Therapeutic decisions should consider both PE severity stratification and the volume of hemoptysis.
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Affiliation(s)
- Yiyao Li
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Jianian Yang
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Peijun Xue
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
| | - Ting Zhang
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
| | - Xuefeng Sun
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
| | - Min Peng
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
| | - Juhong Shi
- Department of Pulmonary and Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
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Ghorbani A, Greathouse J, Bakhshaei S, Ghorbani A, Zamiri K, Ho L, Ho A. Persistent Peril: Recurrent Deep Vein Thrombosis and Pulmonary Embolism in a Patient With Protein S Deficiency Despite Optimal Anticoagulation Therapies. Cureus 2024; 16:e60517. [PMID: 38883011 PMCID: PMC11180491 DOI: 10.7759/cureus.60517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 06/18/2024] Open
Abstract
The clotting system has evolved as an adaptive mechanism to prevent blood loss during vascular damage. However, the intricate nature of the clotting cascade and the complexities of human life can sometimes lead to the unnatural activation of this delicate cascade. This can result in blood clot formation within the cardiovascular system, contributing to a wide range of pathological conditions. Abnormal intravascular coagulation most commonly occurs in the deep veins of the lower extremities, and can emboli to other organs, hence, it is termed "venous thromboembolism" (VTE). In this report, we introduce a challenging case of VTE that poses a dilemma for current medical management. The patient with possible protein S deficiency underwent various guideline-directed medical treatments, yet experienced recurrent VTE episodes, including deep vein thrombosis (DVT) and pulmonary embolism (PE), leading to hospital readmissions. This case report sheds light on our challenges in effectively treating VTE.
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Affiliation(s)
- Ali Ghorbani
- Internal Medicine, Southwest Healthcare, Temecula, USA
| | | | - Sina Bakhshaei
- Internal Medicine, Southern California Medical Education Consortium, Temecula Valley Hospital, Temecula, USA
| | - Aida Ghorbani
- Neurology, UCLA School of Medicine, Los Angeles, USA
| | - Kurosh Zamiri
- Biology, University of California Los Angeles, Los Angeles, USA
| | - Lauren Ho
- Cardiology, Temecula Valley Hospital, Temecula, USA
| | - Andrew Ho
- Cardiology, Temecula Valley Hospital, Temecula, USA
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9
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Birrenkott DA, Kabrhel C, Dudzinski DM. Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies. Cardiol Clin 2024; 42:215-235. [PMID: 38631791 DOI: 10.1016/j.ccl.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.
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Affiliation(s)
- Drew A Birrenkott
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiac Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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10
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Abdulfattah A, John S. Navigating Diagnostic Challenges: Severe Pulmonary Hypertension in Acute Exacerbation of Chronic Obstructive Pulmonary Disease vs. Pulmonary Embolism. Cureus 2024; 16:e56907. [PMID: 38659531 PMCID: PMC11042794 DOI: 10.7759/cureus.56907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
A 63-year-old male with an unremarkable medical history presented to the emergency room (ER) with shortness of breath and bilateral lower extremity edema. In the ER, he was found to be hypoxic and hypercapnic on an arterial blood gas. CT angiography of the chest revealed severe emphysematous changes and large right apical bullae. A bedside point-of-care ultrasound demonstrated many bilateral B-lines as well as normal ejection fraction (EF). An echocardiogram revealed a small left ventricular cavity with an EF of 65%, severely dilated right ventricle, severe right ventricular dysfunction, "D" shaped interventricular septum, severely dilated right atrium, and severe pulmonary arterial hypertension (PAH) with a calculated pulmonary artery systolic pressure of 72 mmHg. The patient was initiated on bilevel positive airway pressure, glucocorticoids, bronchodilator nebulization, and diuretics with symptomatic improvement. Herein, this case report discusses similarities and differences between presentations and echocardiographic manifestations of severe PAH in the setting of acute exacerbation of chronic obstructive pulmonary disease and pulmonary embolism in the acute setting.
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Affiliation(s)
- Ammar Abdulfattah
- Department of Internal Medicine, State University of New York Downstate Medical Center, Brooklyn, USA
| | - Sabu John
- Department of Cardiology, State University of New York Downstate Medical Center, Brooklyn, USA
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11
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Maughan BC, Jarman AF, Redmond A, Geersing GJ, Kline JA. Pulmonary embolism. BMJ 2024; 384:e071662. [PMID: 38331462 DOI: 10.1136/bmj-2022-071662] [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] [Indexed: 02/10/2024]
Affiliation(s)
- Brandon C Maughan
- Department of Emergency Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Angela F Jarman
- Department of Emergency Medicine, University of California Davis, Sacramento, CA
| | | | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Jeffrey A Kline
- Department of Emergency Medicine, Wayne State School of Medicine, Detroit, MI
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12
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Sera S, Okazaki Y, Kashiwa K, Ichiba T. A Case Report of Under-Recognized Conditions in Pulmonary Embolism: Patent Foramen Ovale and Right Ventricular Thrombus. Cureus 2024; 16:e52535. [PMID: 38371032 PMCID: PMC10870038 DOI: 10.7759/cureus.52535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition that presents with a spectrum of clinical symptoms ranging from asymptomatic to hemodynamic instability. The early diagnosis in the emergency department is often challenging. Although the association between patent foramen ovale (PFO) and thromboembolic events in patients with PE is well-documented, the significance of the presence of PFO in patients with PE may be underrecognized. In addition, the occurrence of right ventricular thrombus (RVT) in PE is a rare but significant complication with implications for disease management. We report a case of acute-on-chronic PE with concurrent bilateral renal infarction due to a paradoxical embolus, alongside RVT. A 35-year-old male presented at our emergency department with complaints of sudden onset abdominal pain. Bilateral renal infarction was identified on a contrast-enhanced computed tomography (CT). Point-of-care ultrasound showed suggestive findings of PE and RVT. Subsequently, a pulmonary CT angiography confirmed bilateral PE, a PFO, and RVT. The patient was effectively managed with thrombolytic therapy, with extracorporeal membrane oxygenation on standby. This case highlights the need to recognize the diverse clinical manifestations of PE and the importance of considering coexisting PFO and RVT in affected patients. The diagnosis of PE can be complex when symptoms overlap with arterial thrombosis, such as renal infarction secondary to a PFO. In addition, RVT, although uncommon, is a serious complication in patients with PE that may require careful evaluation for thrombolytic or anticoagulant therapy. It is critical to consider the possibility of a PFO in all cases of PE, even in the absence of arterial embolism, and to promptly evaluate for RVT prior to initiating treatment.
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Affiliation(s)
- Satoshi Sera
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
| | - Yuji Okazaki
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
| | - Kenichiro Kashiwa
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
| | - Toshihisa Ichiba
- Department of Emergency Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, JPN
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Gade IL, Riddersholm SJ, Stilling-Vinther T, Brøndum RF, Bennike TB, Honoré B. A clinical proteomics study of exhaled breath condensate and biomarkers for pulmonary embolism. J Breath Res 2023; 18:016007. [PMID: 37939397 DOI: 10.1088/1752-7163/ad0aaa] [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: 06/23/2023] [Accepted: 11/07/2023] [Indexed: 11/10/2023]
Abstract
Pulmonary embolism (PE) can be a diagnostic challenge. Current diagnostic markers for PE are unspecific and new diagnostic tools are needed. The air we exhale is a possible new source for biomarkers which can be tapped into by analysing the exhaled breath condensate (EBC). We analysed the EBC from patients with PE and controls to investigate if the EBC is a useful source for new diagnostic biomarkers of PE. We collected and analysed EBC samples from patients with suspected PE and controls matched on age and sex. Patients in whom PE was ruled out after diagnostic work-up were included in the control group to increase the sensitivity and generalizability of the identified markers. EBC samples were collected using an RTube™. The protein composition of the EBCs were analysed using data dependent label-free quantitative nano liquid chromatography-tandem mass spectrometry. EBC samples from 28 patients with confirmed PE, and 49 controls were analysed. A total of 928 EBC proteins were identified in the 77 EBC samples. As expected, a low protein concentration was determined which resulted in many proteins with unmeasurable levels in several samples. The levels of HSPA5, PEBP1 and SFTPA2 were higher and levels of POF1B, EPPK1, PSMA4, ALDOA, and CFL1 were lower in PE compared with controls. In conclusion, the human EBC contained a variety of endogenous proteins and may be a source for new diagnostic markers of PE and other diseases.
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Affiliation(s)
- Inger Lise Gade
- Department of Hematology and Clinical Cancer Research Center, Aalborg University Hospital, 9000 Aalborg, Denmark
| | | | | | - Rasmus Froberg Brøndum
- Center for Clinical Data Science, Aalborg University and Aalborg University Hospital, 9260 Gistrup, Denmark
| | - Tue Bjerg Bennike
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Bent Honoré
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
- Department of Biomedicine, Aarhus University, 8000 Aarhus, Denmark
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14
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Falster C, Hellfritzsch M, Gaist TA, Brabrand M, Bhatnagar R, Nybo M, Andersen NH, Egholm G. Comparison of international guideline recommendations for the diagnosis of pulmonary embolism. Lancet Haematol 2023; 10:e922-e935. [PMID: 37804848 DOI: 10.1016/s2352-3026(23)00181-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 06/09/2023] [Accepted: 06/16/2023] [Indexed: 10/09/2023]
Abstract
Pulmonary embolism is one of the leading causes of death due to cardiovascular disease. Timely diagnosis is crucial, but challenging, as the clinical presentation of pulmonary embolism is unspecific and easily mistaken for other common medical emergencies. Clinical prediction rules and D-dimer measurement allow stratification of patients into groups of expected prevalence and are key elements in adequate selection of patients for diagnostic imaging; however, the strengths and weaknesses of the multiple proposed prediction rules, when to measure D-dimer, and which cutoff to apply might be elusive to a significant proportion of physicians. 13 international guidelines authored by medical societies or expert author groups provide recommendations on facets of the diagnostic investigations in suspected pulmonary embolism, some of which are hallmarked by pronounced heterogeneity. This Review summarises key recommendations of each guideline, considers the most recent evidence on the topic, compares guideline recommendations on each facet of the diagnosis of pulmonary embolism, and provides a synthesis on the most common recommendations.
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Affiliation(s)
- Casper Falster
- Odense Respiratory Research Unit, University of Southern Denmark, Odense, Denmark; Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark.
| | - Maja Hellfritzsch
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Danish Society of Thrombosis and Hemostasis, Roskilde, Denmark
| | | | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Rahul Bhatnagar
- Respiratory Medicine Department, North Bristol National Health Service Trust, Southmead Hospital, Bristol, UK; Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Mads Nybo
- Department of Clinical Biochemistry, Odense University Hospital, Odense, Denmark
| | | | - Gro Egholm
- Department of Cardiology, Odense University Hospital, Odense, Denmark
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15
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Amin MS, Ershad R, Kadam N, Khan Z. ECG Features of Pulmonary Embolism in a Patient With Normal D-Dimer and Hypoxia. Cureus 2023; 15:e49433. [PMID: 38149149 PMCID: PMC10750804 DOI: 10.7759/cureus.49433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2023] [Indexed: 12/28/2023] Open
Abstract
Pulmonary embolism is a life-threatening condition that requires urgent treatment. We present the case of a 76-year-old male referred to our medical team with dyspnoea, shortness of breath on exertion, and chest pain. Upon further questioning, the patient reported a two-week history of right-sided parasternal pleuritic chest pain without radiation. He denied any history of haemoptysis, calf swelling or pain, recent surgery, and reduced mobility. The patient had a medical history of bilateral cataracts, glaucoma, and hypertension. Clinical examination was unremarkable except for requiring 2L/minute supplemental oxygen to maintain an oxygen saturation of 94%, and blood tests were unremarkable, including a normal D-dimer. Chest radiography revealed no obvious pathological findings. However, the electrocardiogram showed a right bundle branch, sinus tachycardia, and an S1Q3T3 pattern. A computed tomography pulmonary angiogram confirmed pulmonary emboli within the right lower lobe segmental artery, extending into the bilateral basal segmental branch and posterior basal segmental branch. The patient was commenced on low molecular weight heparin initially followed by rivaroxaban 20 mg once daily. This case highlights the importance of having a high degree of suspicion for pulmonary embolism, and D-dimer is an important screening test that can be normal.
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Affiliation(s)
- Mehul S Amin
- Internal Medicine, Southend University Hospital, London, GBR
| | - Rifat Ershad
- General Medicine, Basildon Hospital, London, GBR
| | - Nikhil Kadam
- Internal Medicine, Mid and South Essex NHS Foundation Trust, Southend on Sea, GBR
| | - Zahid Khan
- Acute Medicine, Mid and South Essex NHS Foundation Trust, Southend on Sea, GBR
- Cardiology, Bart's Heart Centre, London, GBR
- Cardiology and General Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, GBR
- Cardiology, Royal Free Hospital, London, GBR
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16
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Gharepapagh E, Rahimi F, Koohi A, Bakhshandeh H, Mousavi-Aghdas SA, Sadeghipoor P, Fakhari A, Amirnia M, Javadrashid R, Rashidi F. Clot Burden As a Predictor of Chronic Thromboembolic Pulmonary Hypertension After Acute Pulmonary Embolism: A Cohort Study. THORACIC RESEARCH AND PRACTICE 2023; 24:276-281. [PMID: 37712867 PMCID: PMC10544596 DOI: 10.5152/thoracrespract.2023.22160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 07/04/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE A small percentage of acute pulmonary thromboembolisms (PTE) persist as chronic fibrin clots, potentially leading to chronic thromboembolic pulmonary hypertension (CTEPH). A scoring system for evaluating the burden of acute PTE based on computed tomography pulmonary angiogram (CTPA) findings was tested for its association with CTEPH within one year. MATERIAL AND METHODS In this retrospective cohort of 475 patients with a definitive diagnosis of acute PTE, the Qanadli score (QS) was calculated on the initial CTPA. Through regular follow-up over 1 year, symptomatic patients underwent extensive evaluation. RESULTS Of the 475 patients enrolled in the study [age 58.3 ± 16.6, 195 (41.1%) female, QS: 13.01 ± 7.37/40], 321 patients completed the study. A total of 22 (6.8%) patients were definitively diagnosed with CTEPH. In univariate analysis, the initial QS was significantly higher in patients with subsequent CTEPH than in patients without (17 ± 5.6 vs. 13 ± 7.6, P = .009). QS was directly associated with CTEPH (odds ratio: 1.08, 95% confidence interval: 1.0-1.16, P = .042). The evolution of CTEPH in men could be predicted with a sensitivity of 100% and a specificity of 54% when a cut-off point of 14.5 (43.5%) was set for QS. The area under the receiver operating characteristic curve in this setting was 0.74 with a P-value of .032. Qanadli score failed to predict CTEPH in women. CONCLUSION Scoring the clot burden in the pulmonary arteries through the Qanadli method can predict the evolution of CTEPH only in men 1 year after acute PTE. Women comprise most of the CTEPH patients. Thus, strict follow-up adherence seems to be even more important in women.
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Affiliation(s)
- Esmaeil Gharepapagh
- Medical Radiation Sciences Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Rahimi
- Department of Radiology, Imam Reza Medical Training & Research Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Koohi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hooman Bakhshandeh
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Ali Mousavi-Aghdas
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Parham Sadeghipoor
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ashraf Fakhari
- Medical Radiation Sciences Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehrad Amirnia
- Department of Radiology, Imam Reza Medical Training & Research Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Javadrashid
- Department of Radiology, Imam Reza Medical Training & Research Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farid Rashidi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Falster C, Egholm G, Jacobsen N, Poulsen MK, Posth S, Møller JE, Brabrand M, Laursen CB. Multiorgan ultrasonographic findings in patients with pulmonary embolism at diagnosis and clinical follow-up: a proof of concept study. J Ultrasound 2023; 26:663-672. [PMID: 36114986 PMCID: PMC10468447 DOI: 10.1007/s40477-022-00716-w] [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: 06/24/2022] [Accepted: 08/04/2022] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The purpose of this descriptive feasibility study was to assess the clinical impact and feasibility of conducting a multiorgan ultrasound examination of patients with pulmonary embolism at both time of diagnosis and at clinical follow-up. METHODS Hemodynamically stable patients with pulmonary embolism verified by CT pulmonary angiography or ventilation perfusion scintigraphy were eligible for inclusion. Enrolled patients underwent multiorgan ultrasound investigation encompassing echocardiography supplemented with focused lung and deep venous ultrasound emphasizing right ventricular strain, subpleural consolidations and presence of deep venous thrombi. Identical investigations were conducted at 3 months follow-up. The presence of ultrasonographic findings at diagnosis and follow-up was compared and the clinical impact of any remaining pathology or strain was described. RESULTS Twenty-one patients were enrolled in the study of whom 20 survived to attend follow-up. Mean age was 62 ± 15 years and 48% were female. At diagnosis, the most prevalent ultrasonographic findings were subpleural consolidations in 11 patients and right ventricular dilation in eight. At follow-up, signs of right ventricular strain had resolved in all patients. However, in one patient, no resolution was seen in a subpleural consolidation observed at the time of pulmonary embolism diagnosis, resulting in referral to a chest CT. Additionally, one patient exhibited residual deep venous thrombotic material, leading to prolongation of anticoagulative treatment. CONCLUSION In patients with pulmonary embolism, multiorgan ultrasound is feasible in follow-up and adequately powered studies should determine the clinical utility of such an approach.
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Affiliation(s)
- Casper Falster
- Department of Respiratory Medicine, Odense University Hospital, Entrance 122, 5000, Odense C, Denmark.
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- OPEN, Open Patient Data Explorative Network, Odense University Hospital, Odense, Region of Southern Denmark, Denmark.
| | - Gro Egholm
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Niels Jacobsen
- Department of Respiratory Medicine, Odense University Hospital, Entrance 122, 5000, Odense C, Denmark
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mikael K Poulsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Stefan Posth
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Jacob E Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Christian B Laursen
- Department of Respiratory Medicine, Odense University Hospital, Entrance 122, 5000, Odense C, Denmark
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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18
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Westafer LM, Long B, Gottlieb M. Managing Pulmonary Embolism. Ann Emerg Med 2023; 82:394-402. [PMID: 36805291 PMCID: PMC10432572 DOI: 10.1016/j.annemergmed.2023.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 02/19/2023]
Affiliation(s)
- Lauren M Westafer
- Department for Healthcare Delivery and Population Science and Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
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19
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Santus P, Radovanovic D, Saad M, Zilianti C, Coppola S, Chiumello DA, Pecchiari M. Acute dyspnea in the emergency department: a clinical review. Intern Emerg Med 2023; 18:1491-1507. [PMID: 37266791 PMCID: PMC10235852 DOI: 10.1007/s11739-023-03322-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
Acute dyspnea represents one of the most frequent symptoms leading to emergency room evaluation. Its significant prognostic value warrants a careful evaluation. The differential diagnosis of dyspnea is complex due to the lack of specificity and the loose association between its intensity and the severity of the underlying pathological condition. The initial assessment of dyspnea calls for prompt diagnostic evaluation and identification of optimal monitoring strategy and provides information useful to allocate the patient to the most appropriate setting of care. In recent years, accumulating evidence indicated that lung ultrasound, along with echocardiography, represents the first rapid and non-invasive line of assessment that accurately differentiates heart, lung or extra-pulmonary involvement in patients with dyspnea. Moreover, non-invasive respiratory support modalities such as high-flow nasal oxygen and continuous positive airway pressure have aroused major clinical interest, in light of their efficacy and practicality to treat patients with dyspnea requiring ventilatory support, without using invasive mechanical ventilation. This clinical review is focused on the pathophysiology of acute dyspnea, on its clinical presentation and evaluation, including ultrasound-based diagnostic workup, and on available non-invasive modalities of respiratory support that may be required in patients with acute dyspnea secondary or associated with respiratory failure.
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Affiliation(s)
- Pierachille Santus
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy.
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milan, Italy.
| | - Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milan, Italy
| | - Marina Saad
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Camilla Zilianti
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, Ospedale Universitario San Paolo, Milan, Italy
| | - Davide Alberto Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, Ospedale Universitario San Paolo, Milan, Italy
- Department of Health Sciences, Università Degli Studi Di Milano, Milan, Italy
- Coordinated Research Center On Respiratory Failure, Università Degli Studi Di Milano, Milan, Italy
| | - Matteo Pecchiari
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
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20
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Khasin M, Gur I, Evgrafov EV, Toledano K, Zalts R. Clinical presentations of acute pulmonary embolism: A retrospective cohort study. Medicine (Baltimore) 2023; 102:e34224. [PMID: 37443506 PMCID: PMC10344497 DOI: 10.1097/md.0000000000034224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/15/2023] [Indexed: 07/15/2023] Open
Abstract
We aimed to investigate whether the unusual clinical presentation of pulmonary embolism (PE) varies by the type of provocation. In this retrospective cohort study, we examined the electronic health records (EHR) records of all patients diagnosed with PE (upon presentation or during hospitalization) presented to our tertiary hospital during 2014 to 2019. Inclusion criteria were the diagnosis of acute PE and age above 18 years. Excluded were all patients to whom complete EHR were not available. The primary outcome was the main presenting symptom, categorized by a multidisciplinary consensus expert committee as either typical or atypical of PE. Comorbidities, vital signs, medications and laboratory results on presentations were recorded. 591 patients were included in the final analysis. Dyspnea was significantly less common and hemoptysis and chest pain more common in the unprovoked PE group (35%, 5%, and 25%, respectively) compared with nonmalignant (42.6%, 0%, and 16.3%) and malignancy-associated (47.7%, 0.9%, and 8.2%) PE (Pv = 0.02, 0.002 and 0.001, respectively). No recorded symptoms were the third most common presentation overall, accounting for a significantly (Pv < 0.001) higher proportion of PE patients with malignancy (19%) whereas atypical presentation was the hallmark of patients with nonmalignant provokation (19.7%) (Pv = 0.005). Accounting for multiple potential confounders, the risk of atypical or asymptomatic presentation was higher with lower heart rates (RR = 0.974 95%C.I. [0.957-0.990]) and higher pulse oximetry saturation (RR = 1.114 95%CI [1.034-1.201]). The clinical presentation of PE varies with different types of provoking factors, with atypical presentation most common in nonmalignant provocation and asymptomatic presentation most prevalent in patients with underlying malignancy. Further studies are needed to determine the effect of said variance on long term clinical outcomes.
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Affiliation(s)
- Moshe Khasin
- Rambam Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Ivan Gur
- Rambam Medical Center, Haifa, Israel
| | - Elite Vainer Evgrafov
- Rambam Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Kohava Toledano
- Rambam Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Ronen Zalts
- Rambam Medical Center, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
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21
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Ali L, Sharif M, Naqvi SGA, Mohammed I, Baig MA, Sidratul Muntaha K, Chalil AR, Ali H, Aweida HA, Iqrar A. To Study the Correlation of Clinical Severity and Cytokine Storm in COVID-19 Pulmonary Embolism Patients by Using Computed Tomography Pulmonary Angiography (CTPA) Qanadli Clot Burden Scoring System. Cureus 2023; 15:e39263. [PMID: 37342749 PMCID: PMC10278873 DOI: 10.7759/cureus.39263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is a fatal form of venous thromboembolism (VTE), with an overall untreated mortality of up to 30%. Greater than 50% of patients with lower extremity proximal DVT have concurrent PE at presentation. VTE has been seen in up to one-third of patients with COVID-19 infections requiring intensive care unit (ICU) admission. The objective of this study is to determine the correlation between CT pulmonary angiography, pulmonary embolism clot burden, and the Qanadli scoring system with clinically severe COVID-19 pneumonia and cytokine storm. MATERIAL AND METHOD 153 COVID-19 hospitalized patients who underwent CT pulmonary angiography (CTPA) for likely PE on pretest probability modified Wells criteria were enrolled. COVID-19 pneumonia was classified as URTI (upper respiratory tract infection), mild, severe, and critical COVID pneumonia. For data analysis, we categorized into two groups: (1) the non-severe group included URTI and mild pneumonia, and (2) the severe group included severe and critical pneumonia. We used the Qanadli scoring system to assess the PE percentages of pulmonary vascular obstruction using CTPA. Results: 41.8% (64) of COVID-19 patients were diagnosed with pulmonary embolism (PE) on CTPA. The majority of 51.6% of pulmonary vascular occlusions using the Qanadli scoring system for pulmonary embolism were at segmental arterial levels. Out of 104 COVID-19 cytokine storm patients, 45 (43%) were associated with pulmonary embolism. Overall, a 25% (16) mortality rate was observed in COVID-19 patients with pulmonary embolism. DISCUSSION The pathogenesis of hypercoagulability in COVID-19 may include direct endothelial cell invasion by the virus, microvascular inflammation, endothelial exocytosis, and endotheliitis. A meta-analysis of 71 studies to investigate the occurrence of PE on CTPA in COVID-19 patients found 48.6% in ICU settings and 65.3% of patients have clots in the peripheral pulmonary vasculature. CONCLUSIONS There is a significant correlation between pulmonary embolism and high clot burden Qanadli CTPA scores, as well as between the severity of COVID-19 pneumonia and mortality. The association between critically ill COVID-19 pneumonia and pulmonary embolism may result in higher mortality and a poor prognostic marker.
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Affiliation(s)
- Liaquat Ali
- Neurology, Hamad General Hospital, Doha, QAT
- Neurology, Weill Cornell Medicine-Qatar, Doha, QAT
| | | | | | | | | | | | | | - Hanna Ali
- Medicine, Hamad General Hospital, Doha, QAT
| | | | - Ambreen Iqrar
- Neurology, Aga Khan University Hospital, Karachi, PAK
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22
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Menakuru SR, Atta M, Dhillon VS, Salih A. Testosterone Usage Leading to Pulmonary Embolisms and Deep Vein Thrombosis: A Case Report and Review of the Literature. Hematol Rep 2023; 15:290-297. [PMID: 37218821 DOI: 10.3390/hematolrep15020029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/30/2023] [Accepted: 04/19/2023] [Indexed: 05/24/2023] Open
Abstract
Androgen usage has widely increased in recent times via prescribed and unprescribed means. Testosterone is a popular androgen taken by both athletes and the general population. While there is some evidence of androgens being thrombogenic, we report on a 19-year-old male who presented to the hospital after the usage of testosterone for one month, leading to the development of multiple pulmonary emboli and deep vein thrombosis. The authors hope to elucidate the relationship between testosterone usage and thrombosis formation.
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Affiliation(s)
- Sasmith R Menakuru
- Department of Internal Medicine, Indiana University School of Medicine, Muncie, IN 47306, USA
| | - Mona Atta
- Department of Internal Medicine, Indiana University School of Medicine, Muncie, IN 47306, USA
| | - Vijaypal S Dhillon
- Department of Internal Medicine, Indiana University School of Medicine, Muncie, IN 47306, USA
| | - Ahmed Salih
- Department of Internal Medicine, Indiana University School of Medicine, Muncie, IN 47306, USA
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23
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Ružičić DP, Dzudovic B, Matijasevic J, Benic M, Salinger S, Kos L, Kovacevic-Preradovic T, Mitevska I, Neskovic A, Bozovic B, Bulatovic N, Miloradovic V, Djuric I, Obradovic S. Signs and symptoms of acute pulmonary embolism and their predictive value for all-cause hospital death in respect of severity of the disease, age, sex and body mass index: retrospective analysis of the Regional PE Registry (REPER). BMJ Open Respir Res 2023; 10:10/1/e001559. [PMID: 37076250 PMCID: PMC10124252 DOI: 10.1136/bmjresp-2022-001559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/31/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND The incidence of the signs and symptoms of acute pulmonary embolism (PE) according to mortality risk, age and sex has been partly explored. PATIENTS AND METHODS A total of 1242 patients diagnosed with acute PE and included in the Regional Pulmonary Embolism Registry were enrolled in the study. Patients were classified as low risk, intermediate risk or high risk according to the European Society of Cardiology mortality risk model. The incidence of the signs and symptoms of acute PE at presentation with respect to sex, age, and PE severity was investigated. RESULTS The incidence of haemoptysis was higher in younger men with intermediate-risk (11.7% vs 7.5% vs 5.9% vs 2.3%; p=0.01) and high-risk PE (13.8% vs 2.5% vs 0.0% vs 3.1%; p=0.031) than in older men and women. The frequency of symptomatic deep vein thrombosis was not significantly different between subgroups. Older women with low-risk PE presented with chest pain less commonly (35.8% vs 55.8% vs 48.8% vs 51.9%, respectively; p=0.023) than men and younger women. However, younger women had a higher incidence of chest pain in the lower-risk PE group than in the intermediate-risk and high-risk PE subgroups (51.9%, 31.4% and 27.8%, respectively; p=0.001). The incidence of dyspnoea (except in older men), syncope and tachycardia increased with the risk of PE in all subgroups (p<0.01). In the low-risk PE group, syncope was present more often in older men and women than in younger patients (15.5% vs 11.3% vs 4.5% vs 4.5%; p=0.009). The incidence of pneumonia was higher in younger men with low-risk PE (31.8% vs<16% in the other subgroups, p<0.001). CONCLUSION Haemoptysis and pneumonia are prominent features of acute PE in younger men, whereas older patients more frequently have syncope with low-risk PE. Dyspnoea, syncope and tachycardia are symptoms of high-risk PE irrespective of sex and age.
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Affiliation(s)
- Dušan Predrag Ružičić
- Department of Internal Medicine and Invasive Cardiology, General Hospital Valjevo, Valjevo, Serbia
| | - Boris Dzudovic
- Clinic Of Emergency Internal Medicine, Military Medical Academy, Belgrade, Serbia
- School of Medicine, University of Defense, Belgrade, Serbia
| | - Jovan Matijasevic
- Institute of Pulmonary Diseases of Vojvodina, Novi Sad, Serbia
- School of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Marija Benic
- Institute of Pulmonary Diseases of Vojvodina, Novi Sad, Serbia
| | - Sonja Salinger
- Clinic of Cardiology, Clinical Center Nis, Nis, Serbia
- School of Medicine, University of Nis, Nis, Serbia
| | - Ljiljana Kos
- Clinic of Cardiology, Clinical Center Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Tamara Kovacevic-Preradovic
- Clinic of Cardiology, Clinical Center Banja Luka, Banja Luka, Bosnia and Herzegovina
- School of Medicine, University of Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Irena Mitevska
- Clinic of Cardiology, Intensive Care Unit, School of Medicine Skopje, University of Skopje, Skopje, North Republic of Macedonia
| | - Aleksandar Neskovic
- Clinic of Cardiology, Clinical Center Zemun, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Bjanka Bozovic
- Clinic of Cardiology, Clinical Center Podgorica, Podgorica, Montenegro
| | - Nebojsa Bulatovic
- Clinic of Cardiology, Clinical Center Podgorica, Podgorica, Montenegro
- School of Medicine, University of Podgorica, Podgorica, Montenegro
| | - Vladimir Miloradovic
- Clinic of Cardiology, Clinical Center Kragujevac, Kragujevac, Serbia
- School of Medicine, University of Kragujevac, Kragujevac, Serbia
| | - Ivica Djuric
- Clinic of Cardiology, Military Medical Academy, Belgrade, Serbia
| | - Slobodan Obradovic
- School of Medicine, University of Defense, Belgrade, Serbia
- Clinic of Cardiology, Military Medical Academy, Belgrade, Serbia
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24
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Abstract
BACKGROUND Intermediate-risk pulmonary embolism is a common disease that is associated with significant morbidity and mortality; however, a standardized treatment protocol is not well-established. AREAS OF UNCERTAINTY Treatments available for intermediate-risk pulmonary embolisms include anticoagulation, systemic thrombolytics, catheter-directed therapies, surgical embolectomy, and extracorporeal membrane oxygenation. Despite these options, there is no clear consensus on the optimal indication and timing of these interventions. THERAPEUTIC ADVANCES Anticoagulation remains the cornerstone of treatment for pulmonary embolism; however, over the past 2 decades, there have been advances in the safety and efficacy of catheter-directed therapies. For massive pulmonary embolism, systemic thrombolytics and, sometimes, surgical thrombectomy are considered first-line treatments. Patients with intermediate-risk pulmonary embolism are at high risk of clinical deterioration; however, it is unclear whether anticoagulation alone is sufficient. The optimal treatment of intermediate-risk pulmonary embolism in the setting of hemodynamic stability with right heart strain present is not well-defined. Therapies such as catheter-directed thrombolysis and suction thrombectomy are being investigated given their potential to offload right ventricular strain. Several studies have recently evaluated catheter-directed thrombolysis and embolectomies and demonstrated the efficacy and safety of these interventions. Here, we review the literature on the management of intermediate-risk pulmonary embolisms and the evidence behind those interventions. CONCLUSIONS There are many treatments available in the management of intermediate-risk pulmonary embolism. Although the current literature does not favor 1 treatment as superior, multiple studies have shown growing data to support catheter-directed therapies as potential options for these patients. Multidisciplinary pulmonary embolism response teams remain a key feature in improving the selection of advanced therapies and optimization of care.
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Taşkın Ö, Kekeç Z, Belli F, Tuğcan MO. The Effectiveness of a Patient’s Bedside Ultrasonography in Diagnosing a Pulmonary Embolism, in the Emergency Department. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2023. [DOI: 10.1177/87564793231153842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Objective: The research aim was to analyze the function of focused cardiac ultrasonography (FoCUS) in diagnosing a pulmonary embolism (PE) and contributing to the practice of emergency medicine and expediting the treatment of PE. Materials and Methods: In this prospective and observational study, Wells scores were calculated on those patients who presented to the emergency department over the last 2 years and were evaluated with a preliminary diagnosis of PE, as well as the biochemical values and imaging techniques. In all cases, FoCUS was used as the diagnostic tool. Results: A PE was detected in 38 (63.3%) of 60 patients. According to Wells score, it was determined that 5 (8.3%) patients had low-risk, 41 (68.3%) had medium-risk, and 14 (23.3%) had high-risk Wells score. There was a statistically significant correlation between the existence of PE and the findings of FoCUS in patients with right ventricular dilatation ( P < .001). According to Wells score, moderate-risk individuals with PE were more likely to exhibit right ventricular dilatation ( P = .003). Conclusion: The FoCUS results either alone or in conjunction with the Wells score, reviewed in the diagnosis of PE, effectively indicated and directed the diagnosis and treatment of patients admitted to this particular emergency department.
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Affiliation(s)
- Ömer Taşkın
- Emergency Service, Yüreğir State Hospital, Adana, Turkey
| | - Zeynep Kekeç
- Department of Emergency Medicine, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Fuat Belli
- Emergency Service, 25 Aralik State Hospital, Gaziantep, Turkey
| | - Mustafa Oğuz Tuğcan
- Department of Emergency Medicine, Health Sciences University, Adana City Research and Training Hospital, Adana, Turkey
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Gupta A, Thulasidasan N, Mak SM, Rawal B, Padley SPG, Karunanithy N. Contemporary interventional management of pulmonary embolism. Clin Radiol 2023; 78:315-322. [PMID: 36804271 DOI: 10.1016/j.crad.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 01/02/2023] [Accepted: 01/18/2023] [Indexed: 02/01/2023]
Abstract
Minimally invasive interventional techniques are being utilised more frequently in the management of acute and chronic pulmonary emboli; however, robust clinical evidence is only emerging for the utilisation of these techniques. Hence, there is a need for a robust mechanism of patient selection and careful consideration of the benefits and risks of the interventions. In this review, we discuss the risk stratification mechanisms; the role of the multidisciplinary pulmonary embolism response team to support decision-making; and describe the various commonly used interventional techniques and how these can be integrated into treatment strategies for the benefit of our patients.
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Affiliation(s)
- A Gupta
- Department of Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - N Thulasidasan
- Department of Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - S M Mak
- Department of Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - B Rawal
- Department of Radiology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - S P G Padley
- Department of Radiology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - N Karunanithy
- Department of Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK; School of Biomedical Engineering & Imaging Science, King's College London, UK.
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Falster C, Egholm G, Wiig R, Poulsen MK, Møller JE, Posth S, Brabrand M, Laursen CB. Diagnostic Accuracy of a Bespoke Multiorgan Ultrasound Approach in Suspected Pulmonary Embolism. Ultrasound Int Open 2023; 8:E59-E67. [PMID: 36726389 PMCID: PMC9886498 DOI: 10.1055/a-1971-7454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 10/23/2022] [Indexed: 01/18/2023] Open
Abstract
Purpose The aims of this study were to prospectively assess the diagnostic accuracy of a bespoke multiorgan point-of-care ultrasound approach for suspected pulmonary embolism and evaluate if this model allows reduced referral to further radiation diagnostics while maintaining safety standards. Materials and Methods Patients with suspected pulmonary embolism referred for CT pulmonary angiography or ventilation/perfusion scintigraphy were included as a convenience sample. All patients were subject to blinded ultrasound investigation with cardiac, lung, and deep venous ultrasound. The sensitivity and specificity of applied ultrasound signs and the hypothetical reduction in the need for further diagnostic workup were calculated. Results 75 patients were prospectively enrolled. The Wells score was below 2 in 48 patients, between 2 and 6 in 24 patients, and above 6 in 3 patients. The prevalence of pulmonary embolism was 28%. The most notable ultrasound signs were presence of a deep venous thrombus, at least two hypoechoic pleural-based lesions, the D-sign, the 60/60-sign, and a visible right ventricular thrombus which all had a specificity of 100%. Additionally, a multiorgan ultrasound investigation with no findings compatible with pulmonary embolism yielded a sensitivity of 95.2% (95%CI: 76.2-99.9). CT or scintigraphy could be safely avoided in 70% of cases (95%CI: 63.0-83.1%). Conclusion The findings of our study suggest that implementation of a multiorgan ultrasound assessment in patients with suspected pulmonary embolism may safely reduce the need for CT or scintigraphy by confirming or dismissing the suspicion.
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Affiliation(s)
- Casper Falster
- Department of Respiratory Medicine, Odense University Hospital, Odense,
Denmark,Odense Respiratory Research Unit (ODIN), Department of Clinical
Research, University of Southern Denmark, Odense, Denmark,OPEN, Open Patient data Explorative Network, Odense University
Hospital, Odense, Denmark,Correspondence Dr. Casper Falster Odense
University HospitalDepartment of respiratory
medicineKløvervænget
25000
OdenseDenmark+4560139562
| | - Gro Egholm
- Department of Cardiology, Odense University Hospital, Odense,
Denmark
| | - Rune Wiig
- Odense Respiratory Research Unit (ODIN), Department of Clinical
Research, University of Southern Denmark, Odense, Denmark
| | | | | | - Stefan Posth
- Department of Emergency Medicine, Odense University Hospital, Odense,
Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense,
Denmark
| | - Christian Borbjerg Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense,
Denmark,Odense Respiratory Research Unit (ODIN), Department of Clinical
Research, University of Southern Denmark, Odense, Denmark
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Ahaneku CA, Akpu BB, Njoku CH, Elem DE, Ekeng BE. Pulmonary embolism presenting as delirium: an acute confusional state in an elderly patient-a case report. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2023; 35:8. [PMID: 36777903 PMCID: PMC9899661 DOI: 10.1186/s43162-023-00193-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/24/2023] [Indexed: 02/07/2023] Open
Abstract
Background Large numbers of elderly patients are admitted to hospitals in acute confusional states. In many, the underlying causes are easily found; in some, correct diagnosis is difficult. Pulmonary embolism (PE), the most serious clinical presentation of venous thromboembolism, is often misdiagnosed because of its non-specific features including delirium. Case presentation A 73-year-old woman was admitted to our hospital in a confused state with no obvious risk factors of PE. D-dimer levels were elevated and contrast-enhanced high-resolution computed tomography (HRCT) of the chest confirmed the diagnosis of PE. She was treated with enoxaparin and discharged on dabigatran. Her symptoms had resolved at the time of discharge, and she has been stable for over three month's follow-up visit. Conclusion PE should be regarded as a differential in elderly patients with an acute confusional state despite the absence of obvious risk factors. Investigating for and treating when confirmed may save a life.
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Affiliation(s)
- Chidimma A. Ahaneku
- grid.413097.80000 0001 0291 6387Department of Internal Medicine, Respiratory Unit, University of Calabar, Teaching Hospital, Calabar, Nigeria
| | - Benard B. Akpu
- grid.413097.80000 0001 0291 6387Department of Internal Medicine, Cardiology, Unit, University of Calabar, Teaching Hospital, Calabar, Nigeria
| | - Chibueze H. Njoku
- grid.413097.80000 0001 0291 6387Department of Internal Medicine, Respiratory Unit, University of Calabar, Teaching Hospital, Calabar, Nigeria
| | - David E. Elem
- grid.413097.80000 0001 0291 6387Department of Internal Medicine, Infectious Disease Unit, University of Calabar, Teaching Hospital, Calabar, Nigeria
| | - Bassey E. Ekeng
- grid.413097.80000 0001 0291 6387Department of Internal Medicine, Infectious Disease Unit, University of Calabar, Teaching Hospital, Calabar, Nigeria
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Asadi Anar M, Ansari A, Erabi G, Rahmanian M, Movahedi M, Chichagi F, Deravi N, Taghavi F, Kazemi B, Javanshir E, Amouei E, Ghaffari S. Prognostic value of fragmented QRS in acute pulmonary embolism: a cross-sectional-analytic study of the Iranian population. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2023; 13:21-28. [PMID: 36938519 PMCID: PMC10017924 DOI: pmid/36938519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 02/09/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Acute Pulmonary embolism (APE) is considered one of the deadliest cardiovascular diseases. Electrocardiographic (ECG) abnormalities in pulmonary embolism (PE) are increasingly reported. A growing number of studies have recommended that ECG plays a crucial role in the prognostic assessment of PE patients. However, there is scarce data on the prognostic importance of fragmented QRS (fQRS) on outcomes in patients with APE. This study aims to investigate the prognostic value of fQRS in APE patients. MATERIALS AND METHODS This is a cross-sectional-analytic study. This study included 280 patients diagnosed with APE admitted to Shahid Madani hospital, Tabriz, Iran. Computed tomography pulmonary angiography (CTPA) was used to diagnose APE. A checklist was prepared for all patients, demographic, clinical characteristics, and Major Adverse Cardiopulmonary events (MACPE), including in-hospital mortality, need for thrombolysis, mechanical ventilation, and surgical embolectomy, were recorded. Patients were divided into two groups: patients who manifested fQRS on their ECG and patients who did not; Then, demographic, clinical characteristics, and MACPE were compared in the two groups, as mentioned earlier. Furthermore, all statistical analyses were carried out using SPSS software. RESULTS 48 patients (17.14%) had fQRS(+) on their ECG, and 232 patients (82.86%) did not have it on their ECG. In data analysis, 22 patients (8.7%) had in-hospital mortality, 35 patients (13.9%) needed thrombolysis, nine patients (3.9%) required mechanical ventilation, and 13 patients (5.1%) needed surgical embolectomy. fQRS was not significantly associated with in-hospital mortality (P = 0.225), need for thrombolysis (P = 0.684), mechanical ventilation (P = 1.000), and surgical embolectomy (P = 1.000). Demographic and clinical characteristics were also similar in both groups. CONCLUSIONS This study does not support the idea that fQRS on ECG is a valuable predictor of in-hospital mortality, the need for thrombolysis, mechanical ventilation, and surgical embolectomy.
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Affiliation(s)
- Mahsa Asadi Anar
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical SciencesTehran, Iran
| | - Akram Ansari
- Medical Student, Shantou University Medical CollegeShantou, Guangdong, China
| | - Gisou Erabi
- Student Research Committee, Urmia University of Medical SciencesUrmia, Iran
| | - Mohammad Rahmanian
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical SciencesTehran, Iran
| | | | - Fatemeh Chichagi
- Students’ Scientific Research Center (SSRC), Tehran University of Medical SciencesTehran, Iran
| | - Niloofar Deravi
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical SciencesTehran, Iran
| | - Farid Taghavi
- Cardiovascular Research Center, Tabriz University of Medical SciencesTabriz, Iran
| | - Babak Kazemi
- Cardiovascular Research Center, Tabriz University of Medical SciencesTabriz, Iran
| | - Elnaz Javanshir
- Cardiovascular Research Center, Tabriz University of Medical SciencesTabriz, Iran
| | - Erfan Amouei
- Research Center for Prevention of Cardiovascular Disease, Institute of Endocrinology & Metabolism, Iran University of Medical ScienceTehran, Iran
| | - Samad Ghaffari
- Cardiovascular Research Center, Tabriz University of Medical SciencesTabriz, Iran
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Impact of clinical profile at admission on the outcomes in patients hospitalized for acute pulmonary embolism: data from the IPER Registry. J Thromb Thrombolysis 2023; 55:166-174. [PMID: 36350468 DOI: 10.1007/s11239-022-02726-1] [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: 10/21/2022] [Indexed: 11/11/2022]
Abstract
Acute pulmonary embolism (PE) is characterized by a large heterogeneity of clinical presentation and disease course. We investigate whether different symptom PE phenotypes in hemodynamically stable PE could be associated with 30-day mortality risk. Hemodynamically stable patients from the multicentre, prospective Italian Pulmonary Embolism Registry (IPER) (September 2006-August 2010) presenting the most common four clinical phenotypes (< 24 h onset dyspnoea, chest pain, pleuritic pain and phlebitis) at admission were included and compared to those who were asymptomatic at admission. Overall, 1365 (mean age 68.7 ± 15.3 years, 609 males) were evaluated. Recent onset dyspnoea (< 24 h), chest pain, pleuritic pain and phlebitis were observed in 28.4%, 19.7%, 12.9% and 25.2%, respectively while asymptomatic patients represented the remaining 13.6% of cases. PE presenting with recent dyspnoea onset and chest pain had a lower 30-day overall survival (log-rank p = 0.01 and p < 0.001, respectively). By contrast, there were no significant differences when comparing patients with pleuritic pain or phlebitis (log-rank p = 0.2). Similar findings were confirmed at the Cox multivariate regression analysis which indicated a higher mortality risk in patients with chest pain [HR 3.21, 95% CI 2.16-4.78, p < 0.001] or recent dyspnoea [HR 2.12, 95% CI 1.22-3.87, p = 0.002] independent of age, heart rate, presence of right ventricular dysfunction, positive cardiac troponin and administration of systemic thrombolysis. Hemodynamically stable PE patients presenting with chest pain or recent onset dyspnoea had a lower 30-day survival compared to those asymptomatic or presenting pleuritic or phlebitis pain.Trial registry ClinicalTrials.gov; No: NCT01604538).
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Prandoni P, Lensing AWA, Prins MH, Ciammaichella M, Pirillo S, Pace F, Zalunardo B, Bottino F, Ageno W, Muiesan ML, Forlin M, Depietri L, Bova C, Costantini N, Caviglioli C, Migliaccio L, Noventa F, Levi M, Davidson BL, Palareti G. Prevalence of pulmonary embolism among patients with recent onset of dyspnea on exertion. A cross-sectional study. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:68-75. [PMID: 36695397 DOI: 10.1016/j.jtha.2022.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Exertional dyspnea is a frequently encountered complaint in clinical practice. However, the prevalence of pulmonary embolism (PE) among patients with dyspnea on exertion has not been reported. OBJECTIVE The objective of this study was to assess the prevalence of objectively confirmed PE among consecutive patients visiting an emergency department because of recent onset of exertional dyspnea. METHODS Patients aged ≤75 years with recent (<1 month) marked exertional dyspnea had a systematic workup for PE, irrespective of concomitant signs or symptoms of venous thromboembolism and alternative explanations for dyspnea. PE was excluded on the basis of a low pretest clinical probability and normal age-adjusted D-dimer. All other patients had computed tomography pulmonary angiography. An interim analysis after inclusion of 400 patients would stop recruitment if the 95% confidence interval (CI) of the PE prevalence had a lower limit exceeding 20%. RESULTS The study was prematurely terminated after the inclusion of 417 patients. In 134 patients (32.1%), PE was excluded based on low clinical probability and normal D-dimer. PE was found in 134 (47.3%) of the remaining 283 patients, for an overall prevalence of 32.1% (95% CI, 27.8-36.8). PE was present in 40 of 204 (19.6%) patients without other findings suspicious for PE and in 94 of 213 patients (44.1%) with such findings. PE involved a main pulmonary artery in 37% and multiple lobes in 87% of the patients. CONCLUSION The angiographic demonstration of PE is common in patients presenting with recent onset of marked exertional dyspnea, including 20% without other findings suggesting pulmonary embolism.
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Affiliation(s)
| | | | - Martin H Prins
- Department of Clinical Epidemiology, University of Maastricht, The Netherlands
| | | | - Silvana Pirillo
- Department of Radiology, S. Giovanni-Addolorata Hospital, Rome, Italy
| | | | - Beniamino Zalunardo
- Angiology Unit and Emergency Medicine Unit, San Giacomo Hospital, Castelfranco Veneto, Italy
| | | | - Walter Ageno
- Department of Internal Medicine, University of Insubria, Varese, Italy
| | - Maria L Muiesan
- Department of Internal Medicine, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Marco Forlin
- Emergency Department, Civic Hospital, Pieve di Soligo, Italy
| | - Luca Depietri
- Cardiovascular Medicine, Civic Hospital, Reggio Emilia, Italy
| | - Carlo Bova
- Department of Internal Medicine, Civic Hospital, Cosenza, Italy
| | | | - Cosimo Caviglioli
- Emergency Department, University of Firenze Careggi, Florence, Italy
| | | | - Franco Noventa
- Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bruce L Davidson
- Washington State University Floyd College of Medicine, Seattle, Washington State, USA
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Pulmonary Embolism and Respiratory Deterioration in Chronic Cardiopulmonary Disease: A Narrative Review. Diagnostics (Basel) 2023; 13:diagnostics13010141. [PMID: 36611433 PMCID: PMC9818351 DOI: 10.3390/diagnostics13010141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 12/29/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023] Open
Abstract
Patients with chronic cardiopulmonary pathologies have an increased risk of developing venous thromboembolic events. The worsening of dyspnoea is a frequent occurrence and often leads patients to consult the emergency department. Pulmonary embolism can then be an exacerbation factor, a differential diagnosis or even a secondary diagnosis. The prevalence of pulmonary embolism in these patients is unknown, especially in cases of chronic heart failure. The challenge lies in needing to carry out a systematic or targeted diagnostic strategy for pulmonary embolism. The occurrence of a pulmonary embolism in patients with chronic cardiopulmonary disease clearly worsens their prognosis. In this narrative review, we study pulmonary embolism and chronic obstructive pulmonary disease, after which we turn to pulmonary embolism and chronic heart failure.
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Yılmaz F, Tekin Y, Toprak N, Eyı̇nç MB, Arslan ED. A case of massive pulmonary embolism causing cardiac arrest managed with successful systemic thrombolytic in the emergency department. EMERGENCY CARE JOURNAL 2022. [DOI: 10.4081/ecj.2022.10827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Pulmonary Embolism (PE), when complicated by cardiac arrest, is almost always fatal despite all resuscitative efforts. However, a more favorable is possible when PE is rapidly identified as the cause of cardiac arrest and pulmonary circulation is quickly re-established by specific therapy. A 54-year-old woman was brought to the Emergency Department (ED) by 112 emergency ambulance service with the complaint of shortness of breath that had started 2 hours ago. She developed cardiac arrest while being physical examined 2 minutes after admission, and Cardiopulmonary Resuscitation (CPR) was immediately begun. Massive PE was considered the most likely diagnosis in the light of her history, physical examined, and bedside ultrasonography findings; thus, recombinant tissue Plasminogen Activator (r-tPA) was administered during CPR. The second CPR attempt achieved return of spontaneous circulation within 5 minutes. She was treated at intensive care unit for 32 days and discharged from the hospital with complete recovery.
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Leong W, Zhang Y, Huang X, Luo Z, Wang Y, Rainer TH, Wai AKC, Huang Y. Seizure as the clinical presentation of massive pulmonary embolism: Case report and literature review. Front Med (Lausanne) 2022; 9:980847. [PMID: 36479099 PMCID: PMC9721361 DOI: 10.3389/fmed.2022.980847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/25/2022] [Indexed: 09/19/2023] Open
Abstract
Massive pulmonary embolism (MPE) is a high-risk medical emergency. Seizure as the clinical presentation of MPE is extremely rare, and to our knowledge, there have been no reports on successful percutaneous, catheter-based treatment of MPE presenting with new-onset seizures and cardiac arrest. In this report, we discuss the case of a 64-year-old woman who presented with an episode of seizure that lasted 5 h. Seizure occurred four times within 12 h after arrival at the hospital, and in the end, she sustained a cardiac arrest. The patient had no past history of seizure or cardiopulmonary disease. Bilateral MPE was detected by a computed tomography pulmonary angiogram, and she was successfully treated with percutaneous, catheter-directed anticoagulant therapy. Pulmonary embolism-related seizures are more difficult to diagnose and have higher mortality rates than seizures. MPE should be suspected in patients presenting with new-onset seizures and hemodynamic instability.
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Affiliation(s)
- Waiian Leong
- Department of Accident and Emergency, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yueqi Zhang
- Department of Neurology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Xinxiang Huang
- Department of Accident and Emergency, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Zhendong Luo
- Department of Radiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Yanli Wang
- Department of Accident and Emergency, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Timothy Hudson Rainer
- Department of Emergency Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Abraham K. C. Wai
- Department of Accident and Emergency, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
- Department of Emergency Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Yi Huang
- Department of Accident and Emergency, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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El-Azrak M, Boutaybi M, Mouedder F, EL Ouafi N, Ismaili N. Massive pulmonary embolism with ST-segment elevation mimicking an isolated right ventricular myocardial infarction in a patient with COVID-19 pneumonia: Case report. Ann Med Surg (Lond) 2022; 84:104943. [PMCID: PMC9671607 DOI: 10.1016/j.amsu.2022.104943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/25/2022] [Accepted: 11/13/2022] [Indexed: 11/18/2022] Open
Abstract
Pulmonary embolism (PE) is a great simulator; It mimics step by step its main differential diagnosis which is myocardial infarction. Its clinical and electrical manifestations are unspecific. Rarely, an ST-segment elevation can occur making the diagnosis more difficult. Recognizing such an uncommon electrocardiographic (ECG) pattern is of an important relevance to lead to a prompt and suitable therapeutic management. In our paper, we discuss a 68 years-old man case who presents with dyspnea and chest pain with ST-segment elevation in V1, aVR, DIII, and right-sided leads suggestive of isolated right ventricular infarction, admitted in a stable hemodynamical status which rapidly deteriorated. Echocardiographic assessment has shown signs of acute pulmonary heart disease with the presence of the specific McConnell's sign. A computed tomography pulmonary angiogram was performed revealing massive bilateral PE that benefited from thrombolytic therapy with alteplase with a remarkable following and regression of the ST-segment elevation. To our knowledge, this is the first case report of massive PE presenting with these ECG findings in the context of COVID 19 pneumonia, of which practitioners should be aware to better orient diagnosis and therapeutic management.
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36
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Roman S, Rushdy A, Ashkar H, Millet C, Mekheal E, Abuarqob S, Virk H. How we dealt with the double whammy! Acute pulmonary embolism with abdominal aortic clot and renal infarcts. Radiol Case Rep 2022; 17:3816-3819. [PMID: 35965922 PMCID: PMC9372741 DOI: 10.1016/j.radcr.2022.07.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 07/09/2022] [Accepted: 07/13/2022] [Indexed: 11/23/2022] Open
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular mortality in the United States, and the submassive PE accounts for 20%-25% of all acute PE. In the last decade, endovascular therapy with catheter-directed thrombolysis (CDT) intervention has shown great success in the treatment of submassive PE. There is limited data regarding using these devices to treat patients with concomitant abdominal aortic and renal vessel clots. Herein, we present a case of a 23-year-old male who presented with submassive PE associated with abdominal aortic thrombosis and renal infarcts. The patient was successfully treated with CDT with complete resolution of pulmonary and bilateral renal artery clots.
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Merchant SA, Nadkarni P, Shaikh MJS. Augmentation of literature review of COVID-19 radiology. World J Radiol 2022; 14:342-351. [PMID: 36186515 PMCID: PMC9521431 DOI: 10.4329/wjr.v14.i9.342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/26/2022] [Accepted: 08/21/2022] [Indexed: 02/08/2023] Open
Abstract
We suggest an augmentation of the excellent comprehensive review article titled "Comprehensive literature review on the radiographic findings, imaging modalities, and the role of radiology in the coronavirus disease 2019 (COVID-19) pandemic" under the following categories: (1) "Inclusion of additional radiological features, related to pulmonary infarcts and to COVID-19 pneumonia"; (2) "Amplified discussion of cardiovascular COVID-19 manifestations and the role of cardiac magnetic resonance imaging in monitoring and prognosis"; (3) "Imaging findings related to fluorodeoxyglucose positron emission tomography, optical, thermal and other imaging modalities/devices, including 'intelligent edge' and other remote monitoring devices"; (4) "Artificial intelligence in COVID-19 imaging"; (5) "Additional annotations to the radiological images in the manuscript to illustrate the additional signs discussed"; and (6) "A minor correction to a passage on pulmonary destruction".
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Affiliation(s)
| | - Prakash Nadkarni
- College of Nursing, University of Iowa, Iowa City, IA 52242, United States
| | - Mohd Javed Saifullah Shaikh
- Department of Radiology, North Bengal Neuro Centre - Jupiter MRI & Diagnostic Centre, Siliguri 734003, West Bengal, India
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Lasica R, Asanin M, Djukanovic L, Radovanovic N, Savic L, Polovina M, Stankovic S, Ristic A, Zdravkovic M, Lasica A, Kravic J, Perunicic J. Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application. Pharmaceuticals (Basel) 2022; 15:ph15091146. [PMID: 36145366 PMCID: PMC9501350 DOI: 10.3390/ph15091146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/03/2022] [Accepted: 09/06/2022] [Indexed: 11/24/2022] Open
Abstract
Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.
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Affiliation(s)
- Ratko Lasica
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Correspondence:
| | - Milika Asanin
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lazar Djukanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nebojsa Radovanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lidija Savic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marija Polovina
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Sanja Stankovic
- Center for Medical Biochemistry, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Arsen Ristic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | | | | | - Jelena Kravic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Jovan Perunicic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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de Boer HC, Rajaram S, Chopra A, Hurdman JA, Maclean RM. 10,589 CT pulmonary angiograms: evaluating the yield of acute pulmonary embolism. Br J Radiol 2022; 95:20220254. [PMID: 35816548 PMCID: PMC10996955 DOI: 10.1259/bjr.20220254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/28/2022] [Accepted: 07/04/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To evaluate the change in the number of CT pulmonary angiograms (CTPAs) performed and the change in the yield of acute pulmonary embolism (PE) on CTPA at a busy tertiary teaching hospital from 2016 to 2019. METHODS All CTPA examinations for both in-patients and emergency department patients performed at our busy tertiary teaching hospital between 1 January 2016 and 31 December 2019 were identified from the radiology information system. A natural language processing technique called phrase matching was employed to assign each of the examination reports a result of either positive, negative or equivocal for acute PE. This algorithm was validated on a sample of 200 reports. RESULTS The number of CTPAs performed increased 59% from 2016 to 2019. The overall yield of acute PE has remained steady averaging 15.9%, ranging from 15.0% to 17.2%. CONCLUSIONS Over 3 years, there has been a significant increase in the demand for CTPA examinations. The yield of acute PE has remained steady indicating a justified increase in demand. The yield of acute PE on CTPA within our centre is higher than the Royal College of Radiologists' suggested minimum of 15.4% which suggests the current guidelines used for the investigation of suspected acute PE within our centre are appropriate. ADVANCES IN KNOWLEDGE The guidelines and subsequent yield of acute PE on CTPA at our tertiary teaching hospital can be used as a reference standard for other similar institutes.
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Affiliation(s)
| | - Smitha Rajaram
- Sheffield Teaching Hospitals NHS Foundation
Trust, Sheffield,
England
| | - Annu Chopra
- Sheffield Teaching Hospitals NHS Foundation
Trust, Sheffield,
England
| | - Judith A Hurdman
- Sheffield Teaching Hospitals NHS Foundation
Trust, Sheffield,
England
| | - Ronna M Maclean
- Sheffield Teaching Hospitals NHS Foundation
Trust, Sheffield,
England
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Ata F, Ibrahim WH, Choudry H, Shams A, Arshad A, Younas HW, Bilal ABI, Ikram MQ, Tahir S, Mogassabi WW, Errayes NM. Optimal management, prevalence, and clinical behavior of saddle pulmonary embolism: A systematic review and meta-analysis. Thromb Res 2022; 217:86-95. [PMID: 35926347 DOI: 10.1016/j.thromres.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 07/05/2022] [Accepted: 07/25/2022] [Indexed: 11/16/2022]
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Thapi S, Tsega S, Zhao C, Olson APJ, Sherman SV. Dyspneic and dizzy. J Hosp Med 2022; 17:657-660. [PMID: 35535933 DOI: 10.1002/jhm.12815] [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: 10/24/2021] [Revised: 02/15/2022] [Accepted: 02/23/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Sahityasri Thapi
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Surafel Tsega
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Division of Hospital Medicine, Department of Medicine, The Mount Sinai Hospital, New York, New York, USA
| | - Connie Zhao
- Department of Medicine, The Mount Sinai Hospital, New York, New York, USA
| | - Andrew P J Olson
- Departments of Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Thachil R, Nagraj S, Kharawala A, Sokol SI. Pulmonary Embolism in Women: A Systematic Review of the Current Literature. J Cardiovasc Dev Dis 2022; 9:jcdd9080234. [PMID: 35893223 PMCID: PMC9330775 DOI: 10.3390/jcdd9080234] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/19/2022] [Accepted: 07/22/2022] [Indexed: 01/27/2023] Open
Abstract
Cardiovascular disease is the leading cause of death in women. Pulmonary embolism (PE) is the third most-common cause of cardiovascular death, after myocardial infarction (MI) and stroke. We aimed to evaluate the attributes and outcomes of PE specifically in women and explore sex-based differences. We conducted a systematic review of the literature using electronic databases PubMed and Embase up to 1 April 2022 to identify studies investigating PE in women. Of the studies found, 93 studies met the eligibility criteria and were included. The risk of PE in older women (especially >40 years of age) superseded that of age-matched men, although the overall age- and sex-adjusted incidence of PE was found to be lower in women. Risk factors for PE in women included age, rheumatologic disorders, hormone replacement therapy or oral contraceptive pills, pregnancy and postpartum period, recent surgery, immobilization, trauma, increased body mass index, obesity, and heart failure. Regarding pregnancy, a relatively higher incidence of PE has been observed in the immediate postpartum period compared to the antenatal period. Women with PE tended to be older, presented more often with dyspnea, and were found to have higher NT-proBNP levels compared to men. No sex-based differences in in-hospital mortality and 30-day all-cause mortality were found. However, PE-related mortality was higher in women, particularly in hemodynamically stable patients. These differences form the basis of future research and outlets for reducing the incidence, morbidity, and mortality of PE in women.
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Affiliation(s)
- Rosy Thachil
- Correspondence: ; Tel.: +718-918-5937; Fax: +(571)-376-6710
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Mu G, Li F, Chen X, Zhao B, Li G, Fu H. A visualized pulmonary arterial thrombus by using a modified echocardiographic view in an intermediate-risk acute pulmonary embolism patient: A case report. Clin Case Rep 2022; 10:e6105. [PMID: 35865766 PMCID: PMC9295681 DOI: 10.1002/ccr3.6105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/23/2022] [Accepted: 07/02/2022] [Indexed: 11/09/2022] Open
Abstract
Acute pulmonary embolism (APE) is a life-threatening disease with nonspecific clinical signs and symptoms. Rapid and accurate diagnosis is crucial for the clinical management of patients with acute pulmonary embolism. A recommended echocardiography view may be of further help in the diagnosis and evaluation of the change in thrombosis and treatment. We reported a case of a 74-year-old man with a 12-day history of decreased exercise capacity and dyspnea. The patient was diagnosed with intermediate-risk APE as several pulmonary emboli in pulmonary artery were seen in multidetector computed tomographic pulmonary angiography with normal blood pressure and echocardiographic right ventricular overload. And we found a pulmonary artery clot in the right pulmonary artery through transthoracic echocardiography. After 11-days anticoagulation, the patient underwent a reassessment, showed a decrease in RV diameter and pulmonary artery thrombus. This case highlights the significant role that echocardiography played in a patient who presented pulmonary embolism with a stable hemodynamic situation and normal blood pressure. The modified echocardiographic view could provide correct diagnosis by identifying the clot size and location visually. Knowledge of the echocardiography results of APE would aid the diagnosis.
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Affiliation(s)
- Guanyu Mu
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
| | - Feixue Li
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
| | - Xiaolin Chen
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
| | - Bo Zhao
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
| | - Guangping Li
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
| | - Huaying Fu
- Tianjin Key Laboratory of Ionic‐Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of CardiologySecond Hospital of Tianjin Medical UniversityTianjinChina
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Characteristics and Outcomes of Patients Consulted by a Multidisciplinary Pulmonary Embolism Response Team: 5-Year Experience. J Clin Med 2022; 11:jcm11133812. [PMID: 35807097 PMCID: PMC9267516 DOI: 10.3390/jcm11133812] [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: 04/30/2022] [Revised: 06/09/2022] [Accepted: 06/28/2022] [Indexed: 01/27/2023] Open
Abstract
(1) Background: Pulmonary embolism (PE) is the third most frequent acute cardiovascular condition worldwide. PE response teams (PERTs) have been created to facilitate treatment implementation in PE patients. Here, we report on the 5-year experience of PERT operating in Warsaw, Poland, with regard to the characteristics and outcomes of the consulted patients. (2) Methods: Patients diagnosed with PE between September 2017 and December 2021 were included in the study. Clinical and treatment data were obtained from medical records. Patient outcomes were assessed in-hospital, at a 1- and 12-month follow-up. (3) Results: There were 235 PERT activations. The risk of early mortality was low in 51 patients (21.8%), intermediate–low in 83 (35.3%), intermediate–high in 80 (34.0%) and high in 21 (8.9%) patients. Anticoagulation alone was the most frequently administered treatment in all patient subgroups (altogether 84.7%). Systemic thrombolysis (47.6%) and interventional therapy (52%) were the prevailing treatment options in high-risk patients. The in-hospital mortality was 6.4%. The adverse events during 1-year follow-up included five deaths, two recurrent VTE and two minor bleeding events. (4) Conclusions: Our initial 5-year experience showed that the activity of the local PERT facilitated patient-tailored decision making and the access to advanced therapies, with subsequent low overall mortality and treatment complication rates, confirming the benefits of PERT implementation.
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Bova C, Calcaterra R, De Vuono A, Pignataro FS, Fiaschi E. Pulmonary embolism and renal artery thrombosis in a patient with patent foramen ovale. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022209. [PMID: 35765933 PMCID: PMC10510980 DOI: 10.23750/abm.v93is1.12948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/24/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND AIM Paradoxical embolism is a rare condition in which a thrombus migrates from the venous system to the arterial circulation, usually through a patent foramen ovale (PFO). Pulmonary embolism (PE) and isolated occlusion of one renal artery has been seldom reported. METHODS We describe a case of a 47-year old white man with a one-month history of exertional dyspnea who was admitted to our hospital for severe pain in the right lumbar region. RESULTS A computed tomography showed PE and a thrombotic occlusion of the right renal artery. A trans-thoracic echocardiogram documented a PFO with right to left shunt. Magnetic resonance imaging of the brain and venous compression ultrasonography of the lower extremities were normal. Therapeutic anticoagulation was started. CONCLUSIONS Pulmonary embolism and thrombotic occlusion of one renal artery is a rare manifestation of paradoxical embolism. Exertional dyspnea is an atypical manifestation of PE and can delay the diagnosis.
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Affiliation(s)
- Carlo Bova
- a:1:{s:5:"en_US";s:27:"Azienda Ospedaliera Cosenza";}.
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Andersson T, Isaksson A, Khalil H, Lapidus L, Carlberg B, Söderberg S. Validation of the Swedish National Inpatient Register for the diagnosis of pulmonary embolism in 2005. Pulm Circ 2022; 12:e12037. [PMID: 35506065 PMCID: PMC9052966 DOI: 10.1002/pul2.12037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/02/2021] [Accepted: 12/26/2021] [Indexed: 11/06/2022] Open
Abstract
The Swedish National Inpatient Register (NPR) has near‐complete coverage of in‐hospital admissions and ICD codes in Sweden. Acute pulmonary embolism (PE) is a serious condition presenting challenges regarding diagnosis, treatment, and follow‐up. Here we aimed to validate the accuracy of acute PE diagnosis in the NPR, investigational findings, antithrombotic treatment, and follow‐up of PE patients in Sweden. From a nation‐wide cohort of all patients with in‐hospital diagnoses of acute PE (ICD‐10‐SE codes I26.0–I26.9) in 2005 (n = 5793), we selected those from two Swedish regions for thorough manual review of hospital records. We identified 599 patients with PE diagnoses according to the ICD‐10 coding system. We excluded 58 patients with admissions related to previous PE (47; 8%) or incorrect ICD codes (11; 2%), leaving 501 patients with probable PE diagnoses. We confirmed the diagnosis in 441 (79%) cases, which was based on imaging (435 patients; 73%) or autopsy (6; 1%). In the remaining 60 (11%) cases, the PE diagnosis was based on clinical findings and can therefore not be confirmed. Of the surviving patients with PE, 231 (47%) were offered follow‐up within 6 months after the acute event. At follow‐up, 67 patients (29%) had symptoms requiring clinical attention (dyspnoea or reduced general condition). The Swedish NPR showed acceptable accuracy for PE diagnosis, and could be reliably used for register‐based research regarding acute PE.
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Affiliation(s)
- Therese Andersson
- Department of Public Health and Clinical Medicine Unit of Medicine, Umeå University, Umeå, Sweden
| | - Anja Isaksson
- Department of Public Health and Clinical Medicine Unit of Medicine, Umeå University, Umeå, Sweden
| | - Hesham Khalil
- Department of Cardiology King Fahad General Hospital Jeddah Saudi Arabia
| | - Leif Lapidus
- Department of Medicine Sahlgrenska University Hospital Gothenburg Sweden
| | - Bo Carlberg
- Department of Public Health and Clinical Medicine Unit of Medicine, Umeå University, Umeå, Sweden
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine Unit of Medicine, Umeå University, Umeå, Sweden
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Circulating MicroRNAs for Diagnosis of Acute Pulmonary Embolism: Still a Long Way to Go. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4180215. [PMID: 35047634 PMCID: PMC8763471 DOI: 10.1155/2022/4180215] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 12/14/2021] [Accepted: 12/30/2021] [Indexed: 12/15/2022]
Abstract
Venous thromboembolism (VTE) represents the third most frequent cause of acute cardiovascular syndrome. Among VTE, acute pulmonary embolism (APE) is the most life-threatening complication. Due to the low specificity of symptoms clinical diagnosis of APE may be sometimes very difficult. Accordingly, the latest European guidelines only suggest clinical prediction tests for diagnosis of APE, eventually associated with D-dimer, a biomarker burdened by a very low specificity. A growing body of evidence is highlighting the role of miRNAs in hemostasis and thrombosis. Due to their partial inheritance and susceptibility to the environmental factors, miRNAs are increasingly described as active modifiers of the classical Virchow's triad. Clinical evidence on deep venous thrombosis reported specific miRNA signatures associated to thrombosis development, organization, recanalization, and resolution. Conversely, data of miRNA profiling as a predictor/diagnostic marker of APE are still preliminary. Here, we have summarized clinical evidence on the potential role of miRNA in diagnosis of APE. Despite some intriguing insight, miRNA assay is still far from any potential clinical application. Especially, the small sample size of cohorts likely represents the major limitation of published studies, so that extensive analysis of miRNA profiles with a machine learning approach are warranted in the next future. In addition, the cost-benefit ratio of miRNA assay still has a negative impact on their clinical application and routinely test.
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Innocenti F, Lazzari C, Ricci F, Paolucci E, Agishev I, Pini R. D-Dimer Tests in the Emergency Department: Current Insights. Open Access Emerg Med 2021; 13:465-479. [PMID: 34795538 PMCID: PMC8593515 DOI: 10.2147/oaem.s238696] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/18/2021] [Indexed: 12/24/2022] Open
Abstract
In the Emergency Medicine setting, D-dimer is currently employed in the diagnostic assessment of suspected venous thromboembolism and aortic syndrome. The nonspecific symptoms reported by patients, like chest pain, dyspnea or syncope, uncover a wide range of differential diagnosis, spanning from mild to life-threatening conditions. Therefore, we assumed the perspective of the Emergency Physician and, in this narrative review, we reported a brief presentation of the epidemiology of these symptoms and the characteristics of patients, in whom we could suspect the aforementioned pathologies. We also reported in which patients D-dimer gives useful information. In fact, when the probability of the disease is high, the D-dimer level is futile. On the contrary, given the low specificity of the test, when the probability of the disease is very low, a false-positive value of the D-dimer only increases the risk of overtesting. Patients with low to moderate probability really benefit from the D-dimer testing, in order to prevent the execution of expensive and potentially dangerous imaging tests. In the second part of the review, we focused on the prognostic value of the test in septic patients. The early prognostic stratification of septic patients remains a challenge for the Emergency Physician, in the absence of a definite biomarker or score to rely on. Therefore, we need several parameters for the early identification of patients at risk of an adverse prognosis and the D-dimer may play a role in this demanding task. SARS COVID-19 patients represent an emerging reality, where the role of the D-dimer for prognostic stratification could be relevant. In fact, in patients with severe forms of this disease, the D-dimer reaches very high values, which appear to parallel the course of respiratory failure. Whether the test may add useful information for the management of these patients remains to be determined.
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Affiliation(s)
- Francesca Innocenti
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Cristian Lazzari
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Francesca Ricci
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Elisa Paolucci
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Ilya Agishev
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Riccardo Pini
- Emergency Department High-Dependency Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
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Chaudhary N, Khan UH, Shah TH, Shaheen F, Mantoo S, Qadri SM, Mehfooz N, Shabir A, Siraj F, Shah S, Koul PA, Jan RA. Prevalence and predictors of pulmonary embolism in patients with acute exacerbation of chronic obstructive pulmonary disease. Lung India 2021; 38:533-539. [PMID: 34747735 PMCID: PMC8614611 DOI: 10.4103/lungindia.lungindia_79_21] [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] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: The prevalence of pulmonary embolism (PE) in patients of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) varies over a wide range. Early detection and treatment of PE in AECOPD is a key to improve patient outcome. The purpose of the study was to investigate the prevalence and predictors of PE in patients of AECOPD in a high burden region of North India. Materials and Methods: This prospective study included patients of AECOPD with no obvious cause of exacerbation on initial evaluation. Apart from routine workup, the participants underwent assessment of D-dimer, compression ultrasound and venous Doppler ultrasound of the lower limbs and pelvic veins, and a multidetector computed tomography pulmonary angiography. Results: A total of 100 patients of AECOPD with unknown etiology were included. PE as a possible cause of AE-COPD was observed in 14% of patients. Among the participants with PE, 63% (n = 9) had a concomitant presence of lower extremity deep venous thrombosis. Hemoptysis and chest pain were significantly higher in patients of AECOPD with PE ([35.7% vs. 7%, P = 0.002] and [92.9% vs. 38.4%, P = 0.001]). Likelihood of PE was significantly higher in patients who presented with tachycardia, tachypnea, respiratory alkalosis (PaCO2 <45 mmHg and pH >7.45), and hypotension. No difference was observed between the two groups in terms of in-hospital mortality, age, sex distribution, and risk factors for embolism except for the previous history of venous thromboembolism (35.7% vs. 12.8% P = 0.03). Conclusion: PE was probably responsible for AECOPD in 14% of patients with no obvious cause on initial assessment. Patients who present with chest pain, hemoptysis, tachypnea, tachycardia, and respiratory alkalosis should be particularly screened for PE.
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Affiliation(s)
- Nasir Chaudhary
- Department of Cardiology, GMC, Jammu, Jammu and Kashmir, India
| | - Umar Hafiz Khan
- Department of Geriatric Medicine, Sher E Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Tajamul Hussain Shah
- Department of Pulmonary Medicine, Sher E Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Feroze Shaheen
- Department of Radiology, Sher E Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Suhail Mantoo
- Department of Internal Medicine, Sher E Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Syed Mudasir Qadri
- Department of Internal Medicine, Sher E Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Nazia Mehfooz
- Department of Pulmonary Medicine, Sher E Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Afshan Shabir
- Department of Geriatric Medicine, Sher E Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Farhana Siraj
- Department of Internal Medicine, Sher E Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Sonaullah Shah
- Department of Internal and Pulmonary Medicine, Sher E Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Parvaiz A Koul
- Department of Internal and Pulmonary Medicine, Sher E Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Rafi Ahmed Jan
- Department of Internal and Pulmonary Medicine, Sher E Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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Affiliation(s)
- Neeraja Murali
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Sahar Morkos El Hayek
- Washington University in Saint Louis, 660 S Euclid Avenue CB 8072, St Louis, MO 63110, USA
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