The post-PE syndrome: a new concept for chronic complications of pulmonary embolism

Research progress on the association between lung cancer and pulmonary embolism

Pulmonary embolism (PE), a form of venous thromboembolism, is a frequently observed complication in malignancies, with a notably high incidence in individuals with lung cancer. The presence of PE markedly reduces the quality of life and has a significant impact on the prognosis of those diagnosed with both lung cancer and PE. As a result, timely diagnosis and intervention are of paramount importance. The presence of PE markedly reduces the quality of life and has a significant impact on the prognosis of those diagnosed with both lung cancer and PE. As a result, timely diagnosis and intervention are of paramount importance.

Cardiopulmonary Exercise Testing, Rehabilitation, and Exercise Training in Postpulmonary Embolism

Long-term exercise intolerance and functional limitations are common after an episode of acute pulmonary embolism (PE), despite 3 to 6 months of anticoagulation. These persistent symptoms are reported in more than half of the patients with acute PE and are referred as "post-PE syndrome." Although these functional limitations can occur from persistent pulmonary vascular occlusion or pulmonary vascular remodeling, significant deconditioning can be a major contributing factor. Herein, the authors review the role of exercise testing to elucidate the mechanisms of exercise limitations to guide next steps in management and exercise training for musculoskeletal deconditioning.

The Plasma Proteome and Risk of Future Venous Thromboembolism-Results from the HUNT Study

BACKGROUND

 This study aimed to identify novel plasma proteins associated with first-lifetime venous thromboembolism (VTE) and molecular pathways involved in VTE pathogenesis.

METHODS

 A case-cohort comprising incident VTE cases (n = 294) and a randomly sampled age- and sex-weighted subcohort (n = 1,066) was derived from the Trøndelag Health Study (HUNT3, n = 50,800). Blood samples were collected and stored at cohort inclusion (2006-2008), and participants were followed up to 5 years. Proteome-wide analyses was performed using the 7k SomaScan® proteomics platform, and weighted Cox-regression models adjusted for age, sex, and sample batch were conducted, with the Bonferroni method applied to account for multiple testing. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses were applied on the top-ranked 200 proteins associated with VTE.

RESULTS

 Out of 7,288 human proteins, 7 proteins were significantly associated with higher VTE risk with p-value <6.9 × 10-6 (hazard ratios per 1 standard deviation increase in protein levels ranging from 1.39 to 1.86). Except for coagulation factor VIII and tumor necrosis factor soluble receptor II, these proteins were novel associations and included collagen alpha-3(VI):BPTI/Kunitz inhibitor, histo-blood group ABO system transferase, peroxidasin, human epididymis protein 4, and regulator of G protein signaling 3. KEGG analyses of the top-ranked 200 proteins revealed significant pathway enrichment of nine proteins in the complement (mainly lectin pathway) and coagulation (mainly intrinsic pathway) cascades.

CONCLUSION

 Our proteome-wide analysis led to discovery of five novel protein candidates associated with 5-year risk of future VTE. KEGG analyses supported an interplay between the complement and coagulation pathways in the pathogenesis of VTE.

Effectiveness of rehabilitation programmes targeting quality of life, psychological wellbeing, and functional capacity in pulmonary embolism survivors; a systematic review and best evidence synthesis

BACKGROUND

Half of people post pulmonary embolism (PE) experience ongoing symptoms such as dyspnoea, anxiety and depression, exercise limitation and fatigue. These symptoms can reduce their quality of life (QoL), psychological wellbeing, and functional capacity. The efficacy of rehabilitation interventions to prevent and manage these symptoms has not been established. The objectives of this review were to synthesise the evidence on interventions targeting QoL, psychological wellbeing, and functional capacity post PE, and to identify intervention characteristics and behaviour change techniques (BCTs) that contribute to successful rehabilitation programmes.

METHODS

The PRISMA reporting guidelines were followed. Five electronic databases were searched; PubMED, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. Searching began in November 2023, with the final search run in December 2023. Studies using experimental designs, in adult populations, employing rehabilitation programmes to target patient outcomes post PE were included. The Template of Intervention Description and Replication (TIDieR) 12 item checklist was used to score the description and replicability of the intervention and control conditions and the BCT taxonomy V1 was used to identify BCTs across the included interventions. Data was extracted and a best evidence synthesis was conducted.

RESULTS

Of 7321 studies identified, 12 studies (n = 648 participants) met the inclusion criteria; four randomised controlled trials (RCTs), one pilot RCT study and seven prospective cohort studies, all conducted at different timepoints in the disease course, using different selection criteria and with different interventions. Eight of the 12 included studies were evaluated as being of low quality based on the Effective Public Health Practice Project (EPHPP) tool. The mean TIDieR score was six out of 24 for intervention completeness and reporting. Twenty five BCTs were identified across the included studies, three of which were identified in all studies ("Instruction on how to perform the behaviour", "demonstration of the behaviour" and "behaviour practice/ rehearsal"). Overall the best evidence synthesis provided a mixed level of evidence for the effectiveness of rehabilitation interventions post PE. There is a limited level of evidence that rehabilitation has a positive effect on patient perceived QoL and inconsistent evidence that rehabilitation has any effect on psychological wellbeing. There is however, a moderate level of evidence to support the effectiveness of rehabilitation when it comes to improving functional capacity.

CONCLUSION

This review highlights heterogeneity across available studies and provides some evidence supporting rehabilitation programmes to improve functional capacity in people living post PE. However, further research is required to establish their effectiveness for improving QoL and psychological wellbeing. Although a number of BCTs were identified, few of those identified were linked to behaviour change theory. This, combined with limited reporting of components of the rehabilitation interventions, restricted evaluation of their effectiveness.

PROSPERO REGISTRATION

PROSPERO 2020 CRD42023459411 Available from: https://www.crd.york.ac.uk/prospero/#recordDetails.

Anticoagulation at the end of life: whether, when, and how to treat

Nearly 2 out of 3 patients with venous thromboembolism (VTE) and 1 out of 4 patients with atrial fibrillation (AF) will die within the year. Whether, when, and how to manage anticoagulation at the end of life requires many trade-offs. Patients and clinicians must balance symptom burden, greatly elevated bleeding and thrombosis risks, competing comorbidities and medications, and changing goals over time. This review uses cases of VTE and AF to present a framework for care that draws upon existing disease-specific data and cutting-edge palliative care science. It reviews strategies for the difficult task of estimating a patient's prognosis, characterizes the enormous public health burden of anticoagulation in serious illness, and analyzes the data on anticoagulation outcomes among those with limited life expectancy. Finally, an approach to individualized decision-making that is predicated on patients' priorities and evidence-based strategies for starting, continuing, or stopping anticoagulation at the end of life are presented.

Rationale and design of the PE-TRACT trial: A multicenter randomized trial to evaluate catheter-directed therapy for the treatment of intermediate-risk pulmonary embolism

BACKGROUND

The optimal management of patients with intermediate-risk pulmonary embolism (PE), who have right heart dysfunction (determined by a combination of imaging and cardiac biomarkers) but a normal blood pressure, is uncertain. These patients suffer from reduced functional capacity and a lower quality of life over the long-term, despite use of anticoagulant therapy. Catheter-directed therapy (CDT) is a promising treatment for acute PE that rapidly removes thrombus and potentially improves cardiac dysfunction. However, CDT has risk and is costly, and it is not known whether it improves long-term cardiorespiratory fitness and/or quality of life compared with anticoagulation alone.

METHODS

We are therefore conducting an open-label, assessor-blinded, multicenter randomized trial, the Pulmonary Embolism: Thrombus Removal with Catheter-Directed Therapy (PE-TRACT) Study, to compare CDT plus anticoagulation (CDT group) with anticoagulation alone (No-CDT group) in 500 patients with intermediate-risk PE. The primary study hypothesis is that CDT will increase the peak oxygen uptake (peak VO2) with cardiopulmonary exercise testing at 3 months and reduce New York Heart Association (NYHA) Class at 12 months compared with No-CDT. These 2 primary efficacy outcomes will be analyzed sequentially using a "gatekeeping" procedure; for NYHA class to be compared, peak oxygen consumption must first be shown to be significantly increased by CDT. Safety and cost-effectiveness will also be assessed.

CONCLUSION

When completed, PE-TRACT will provide important evidence regarding the benefits and risks of CDT to treat intermediate-risk PE compared with anticoagulation alone.

TRIAL REGISTRATION

clinicaltrials.gov: NCT05591118.

Gene expression profiling in Venous thromboembolism: Insights from publicly available datasets

BACKGROUND

Venous thromboembolism (VTE) is the third most common cardiovascular disease and is a major cause of mobility and mortality worldwide. VTE is a complex multifactorial disease and genetic mechanisms underlying its pathogenesis is yet to be completely elucidated. The aim of the present study was to identify hub genes and pathways involved in development and progression of blood clot during VTE using gene expression data from public repositories.

METHODOLOGY

Differential gene expression (DEG) data from two datasets, GSE48000 and GSE19151 were analysed using GEO2R tool. Gene expression data of VTE patients were compared to that of healthy controls using various bioinformatics tools.

RESULTS

When the differentially expressed genes of the two datasets were compared, it was found that 19 genes were up-regulated while 134 genes were down-regulated. Gene ontology (GO) and pathway analysis revealed that pathways such as complement and coagulation cascade and B-cell receptor signalling along with DNA methylation, DNA alkylation and inflammatory genes were significantly up-regulated in VTE patients. On the other hand, differentially down-regulated genes included mitochondrial translation elongation, termination and biosysthesis along with heme biosynthesis, erythrocyte differentiation and homeostasis. The top 5 up-regulated hub genes obtained by protein-protein interaction (PPI) network analysis included MYC, FOS, SGK1, CR2 and CXCR4, whereas the top 5 down-regulated hub genes included MRPL13, MRPL3, MRPL11, RPS29 and RPL9. The up-regulated hub genes are functionally involved in maintain vascular integrity and complementation cascade while the down-regulated hub genes were mostly mitochondrial ribosomal proteins.

CONCLUSION

Present study highlights significantly enriched pathways and genes associated with VTE development and prognosis. The data hereby obtained could be used for designing newer diagnostic and therapeutic tools for VTE management.

Post-Pulmonary Embolism Syndrome-A Diagnostic Dilemma and Challenging Management

Historically, research on pulmonary embolism (PE) management has focused on short-term outcomes, such as acute cardiovascular collapse, change in right ventricular function, and in-hospital mortality. However, long-standing functional impairments from acute PE occur in up to half of all patients. This chronic syndrome has been termed the post-PE syndrome, which describes patients who have persistent or worsening symptoms, functional limitations, and cardiorespiratory impairment not explained by a comorbid condition. Diagnosis and management are challenging, and post-PE syndrome remains an underrecognized and undertreated condition. This review seeks to increase awareness of the syndrome that affects a significant portion of PE survivors. The epidemiology, pathophysiology, and clinical features are discussed, followed by a description of imaging findings and management options across the entire spectrum of post-PE syndrome.

Long-term monitoring and treatment of venous thromboembolic disease: recommendations of the Thromboembolic Disease Group of the Spanish Society of Internal Medicine 2024

Venous thromboembolim (VTE) is a highly prevalent condition that requires long-term monitoring and treatment. This monitoring includes: 1) completing the etiological study and determining the risk of VTE recurrence; 2) establishing the optimal duration of anticoagulant treatment, as well as the type of therapy and its dosage; 3) estimating the risk of bleeding, and 4) identifying the occurrence of chronic complications. This consensus document, prepared by the VTE Group of the Spanish Society of Internal Medicine (SEMI), aims to update and establish consensus recommendations on these aspects. The document focuses on four aspects of management: the first includes risk factors for VTE recurrence after an unprovoked VTE episode and describes the predictive scores of VTE recurrence; the second focuses on risk factors for bleeding; the third provides recommendations for long-term follow-up in VTE, addressing specific considerations for screening chronic thromboembolic pulmonary hypertension and post-thrombotic syndrome of the lower limbs; and the fourth provides guidance on the optimal duration of extended anticoagulant treatment, as well as the type of therapy and its dosage. For each area, an exhaustive literature review was conducted, analyzing the updated VTE clinical guidelines and recent studies. This document is intended to be a guide in the long-term management of VTE based on the most current knowledge.

Development of a predictive nomogram for early identification of pulmonary embolism in hospitalized patients: a retrospective cohort study

BACKGROUND

Hospitalized patients often present with complex clinical conditions, but there is a lack of effective tools to assess their risk of pulmonary embolism (PE). Therefore, our study aimed to develop a nomogram model for better predicting PE in hospitalized populations.

METHODS

Data from hospitalized patients (aged ≥ 15 years) who underwent computed tomography pulmonary angiography (CTPA) to confirm PE and non-PE were collected from December 2013 to April 2023. Univariate and multivariate stepwise logistic regression analyses were conducted to identify independent predictors of PE, followed by the construction of a predictive nomogram and internal validation. The efficiency and clinical utility of the nomogram model were assessed using receiver operating characteristic (ROC) curve, decision curve analysis (DCA), and clinical impact curve (CIC).

RESULTS

The study included 313 PE and 339 non-PE hospitalized patients. Male gender, dyspnea or shortness of breath, interstitial lung disease, lower limb deep vein thrombosis, elevated fibrin degradation product (FDP), pulmonary arterial hypertension, and tricuspid regurgitation were identified as independent risk factors. The AUC of the predictive nomogram model was 0.956 (95% CI: 0.939-0.974), demonstrating superior performance compared with the simplified Wells score of 0.698 (95% CI: 0.654-0.741) and the modified Geneva score of 0.758 (95% CI: 0.717-0.799).

CONCLUSION

Our study demonstrated that challenges remain in the accuracy of the Wells score and revised Geneva score in assessing PE in hospitalized patients. Fortunately, the nomogram we developed has shown a favorable ability to discriminate PE cases, providing high reference value for clinical practice. However, given that this was a single-center study, we plan to expand efforts to collect data from additional centers to further validate our model.

Practice Variations in the Diagnosis and Treatment of Pulmonary Embolism

Venous thromboembolism is responsible for a significant burden of disease worldwide. Despite the publication of multiple international guidelines, anecdotal evidence suggests significant clinical variation exists in the diagnostic and management pathways of pulmonary embolism (PE). We conducted a retrospective cohort study using electronic medical records to examine clinical variation in patients admitted to a tertiary referral center in Australia with a diagnosis of PE between November 2018 and January 2020. Three hundred cases met the inclusion criteria; we found variation in rates of compression ultrasonography, acute investigation of the right ventricle, and planning of repeat imaging at specialist follow-up. Guidelines do not address the use of compression ultrasonography in already diagnosed PE, are conflicting in their recommendation for acute investigation of the right ventricle, and recommend repeat imaging only if there are persistent symptoms at the time of specialist follow-up. The variations we found in this study may in part be due to physician preference or due to the paucity of evidence for some of these diagnostic practices. Robust future studies are required to guide the use of these investigations in PE.

Development of A structured integrated post-Pulmonary Embolism care model: The Attend-PE model

BACKGROUND

More than 50% of patients with pulmonary embolism (PE) experience persistent functional limitations. Despite guideline recommendations for a structured integrated care model for patients with PE, consensus on an optimal follow-up strategy is lacking, and evidence is insufficient.

OBJECTIVES

To describe the development of a structured model for PE follow-up using coproduction methods.

METHODS

Coproduction of A structured integrated postPulmonary Embolism care (Attend-PE) model was conducted from October 2021 to June 2022, featuring participatory design techniques. This was combined with a stepwise approach based on Intervention Mapping to ensure that the developed model was evidence-based and theoretically grounded.

RESULTS

Development of the Attend-PE model included 1) a needs assessment mapping follow-up at 18 sites treating PE in Denmark; 2) definition of the overall goal and performance objectives of the Attend-PE model, based on the needs assessment in combination with a literature review; 3) coproduction of the Attend-PE model in workshops with patient representatives, healthcare professionals, and experts in the field; and 4) refinement of the structure and organization of the Attend-PE model and production of the patient education material. The Attend-PE model outlines a structured approach for in-hospital follow-up, involving group-based patient education, individual consultations, and patient-reported outcomes to assess physical and psychological well-being. The model supports a personalized posthospitalization care plan.

CONCLUSION

The coproduction process was successful in developing a structured follow-up model aligned with patients' needs, health provider perspectives, and existing guidelines. The Attend-PE model is currently undergoing clinical evaluation to determine its effectiveness and usability.

Acute Pulmonary Embolism: Evidence, Innovation, and Horizons

PURPOSE OF REVIEW

Pulmonary embolism (PE) is the third most common cause of cardiovascular morbidity and mortality. The goal of this review is to discuss the most up-to-date literature on epidemiology, diagnosis, risk stratification, and management of acute PE.

RECENT FINDINGS

Despite an increase in annual incidence rate of PE in the United States and development of multiple advanced therapies for treatment of acute PE, PE-related mortality is not consistently decreasing across populations. Although multiple risk stratification schemes have been developed, it is still unclear which advanced therapy should be used for the individual patient and optimal timing. Fortunately, multiple randomized clinical trials are underway to answer these questions. Nevertheless, up to 50% of patients have persistent reduced quality of life 6 months after acute PE, termed post-PE syndrome. Despite advances in therapeutic options for management of acute PE, many questions remain unanswered, including optimal risk stratification and management of acute PE.

Thromboprophylaxis during neoadjuvant chemotherapy for bladder cancer reduces thromboembolism and bleeding

OBJECTIVES

To assess the risk of venous thromboembolic events (VTEs) and bleeding with or without thromboprophylaxis during neoadjuvant chemotherapy in bladder cancer patients scheduled for radical cystectomy.

MATERIALS AND METHODS

We conducted a retrospective cohort study in 4886 patients with non-metastatic bladder cancer undergoing cystectomy across 28 centres in 13 countries between 1990 and 2021. Inverse probability weighting analyses were performed to estimate the effect of thromboprophylaxis on VTE and bleeding.

RESULTS

In 147 patients (3%) VTEs were recorded within the first year. These occurred a median (interquartile range [IQR]) of 127 (82-198) days after bladder cancer diagnosis. Bleeding events occurred in 131 patients (3%) within the first year. These occurred a median (IQR) of 101 (83-171) days after cancer diagnosis. In inverse probability weighting analyses, compared to patients without thromboprophylaxis during chemotherapy, patients with thromboprophylaxis had not only a lower risk of VTE (hazard ratio [HR] 0.32, 95% confidence interval [CI] 0.12-0.81; P = 0.016) but also a lower bleeding risk (HR 0.03, 95% CI 0.09-0.12; P <0.0001). The retrospective nature of the study was its main limitation.

CONCLUSIONS

In this retrospective analysis, the benefit of thromboprophylaxis during neoadjuvant chemotherapy before cystectomy is in line with data from randomised trials in other malignancies. Our data suggest thromboprophylaxis is protective against VTEs and should be the standard of care during neoadjuvant chemotherapy.

Sequelae of Acute Pulmonary Embolism: From Post-Pulmonary Embolism Functional Impairment to Chronic Thromboembolic Disease

Among survivors of acute pulmonary embolism (PE), roughly half report persistent dyspnea, impaired functional status, and decreased quality of life. Post-pulmonary embolism syndrome (PPES) is a broad condition which has been increasingly recognized in recent years and may be due to post-pulmonary embolism functional impairment, chronic thromboembolic disease, or the most severe long-term complication of PE, chronic thromboembolic pulmonary hypertension. Despite guideline recommendations for appropriate follow-up for post-pulmonary embolism patients, PPES remains underrecognized and diagnostic testing underutilized. Patients with symptoms suggestive of PPES at follow-up should undergo a transthoracic echocardiogram to screen for the presence of pulmonary hypertension; additional testing, such as a ventilation/perfusion scan, right heart catheterization, and cardiopulmonary exercise testing may be indicated. The pathophysiology of post-pulmonary embolism syndrome is complex and heterogeneous. In chronic thromboembolic pulmonary hypertension, the pathophysiology reflects persistent pulmonary arterial thrombi and a progressive small vessel vasculopathy. In patients with chronic thromboembolic disease or chronic thromboembolic pulmonary hypertension, medical therapy, balloon pulmonary angioplasty, or pulmonary thromboendarterectomy should be considered, and in cases of chronic thromboembolic pulmonary hypertension, pulmonary thromboendarterectomy significantly improves mortality. In all causes of post-pulmonary embolism syndrome, rehabilitation is a safe treatment option that may improve quality of life.

3-year quality of life, functional performance, and long-term survival after acute pulmonary embolism; A prospective study

Our prospective study investigates the 3-year trajectory of disease-specific quality of life (QoL) using the PEmb-QoL questionnaire, functional performance via 6-min walk tests, and the 5-year survival following acute pulmonary embolism (PE) and explores their association with patient demographics and clinical characteristics. We highlight that PE-specific QoL improves over time despite no significant changes in cardiopulmonary performance.

Exercise pulmonary hypertension in chronic thromboembolic pulmonary disease: A right heart catheterization study

Many patients with chronic thromboembolic pulmonary disease (CTEPD) suffer from exertional dyspnea. It is unclear if CTEPD is associated with exercise pulmonary hypertension (ePH). This cross-sectional study aimed to determine the occurrence of ePH in patients with CTEPD and to identify the haemodynamic changes during exercise. We recruited 36 patients with persistent dyspnoea and residual perfusion defects by ventilation/perfusion scintigraphy from a large cohort of patients with previous pulmonary embolism. All patients underwent exercise right heart catheterization before being classified into the following groups: (1) CTEPD without ePH; comprising patients with normal mean pulmonary artery pressure (mPAP) of ≤20 mmHg, but with mPAP/cardiac output (CO) slope of ≤3 mmHg/L/min, (2) CTEPD with ePH (CTEPD-ePH); those with CTEPD with an mPAP/CO slope of >3 mmHg/L/min, (3) chronic thromboembolic pulmonary hypertension (CTEPH); those with mPAP >20 mmHg, pulmonary arterial wedge pressure (PAWP) ≤ 15 mmHg and pulmonary vascular resistance >2 WU. The postcapillary contribution during exercise was considered present if the PAWP/CO slope of >2 mmHg/L/min. CTEPD without resting pulmonary hypertension (PH) was present in 29 (81%) of the 36 patients, of whom six (21%) had ePH, while five (14%) had CTEPH. Two patients had unclassified PH. Two (33%) of the six patients with CTEPD-ePH had a PAWP/CO slope of >2 mmHg/L/min, compared with two (40%) of the five of those with CTEPH. In conclusion, about 20% of patients with CTEPD and exertional dyspnoea had ePH. Exercise right heart catheterization revealed a notable proportion of patients with postcapillary contribution.

Cardiopulmonary exercise testing following acute pulmonary embolism: Systematic review and pooled analysis of global studies

Recent reports have revealed a substantial morbidity burden associated with "post-PE syndrome" (PPES). Cardiopulmonary exercise testing (CPET) has shown promise in better characterizing these patients. In this systematic review and pooled analysis, we aim to use CPET data from PE survivors to understand PPES better. A literature search was conducted in PubMed, EMBASE, and Cochrane for studies reporting CPET results in post-PE patients without known pulmonary hypertension published before August 1, 2023. Studies were independently reviewed by two authors. CPET findings were subcategorized into (1) exercise capacity (percent predicted pVO2 and pVO2) and (2) ventilatory efficiency (VE/VCO2 slope and VD/VT). We identified 14 studies (n = 804), 9 prospective observational studies, 4 prospective case-control studies, and 1 randomized trial. Pooled analysis demonstrated a weighted mean percent predicted pVO2 of 76.09 ± 20.21% (n = 184), with no difference between patients tested <6 months (n = 76, 81.69±26.06%) compared to ≥6 months post-acute PE (n = 88, 82.55 ± 21.47%; p = 0.817). No difference was seen in pVO2 in those tested <6 months (n = 76, 1.67 ± 0.51 L/min) compared to ≥6 months post-acute PE occurrence (n = 144, 1.75 ± 0.57 L/min; p = 0.306). The weighted mean VE/VCO2 slope was 32.72 ± 6.02 (n = 244), with a significant difference noted between those tested <6 months (n = 91, 36.52 ± 6.64) compared to ≥6 months post-acute PE (n = 191, 31.99 ± 5.7; p < 0.001). In conclusion, this study, which was limited by small sample sizes and few multicenter studies, found no significant difference in exercise capacity between individuals tested <6 months versus ≥6 months after acute PE. However, ventilatory efficiency was significantly improved in patients undergoing CPET ≥ 6 months compared to those <6 months from the index PE.

The Attend-PE model: A feasibility study of a structured follow-up care model for patients with pulmonary embolism

BACKGROUND

Pulmonary embolism may have both physical and psychological consequences for the affected person. Guidelines recommend structured follow-up care, yet this is still not widely practised. Therefore, a national research project was initiated in Denmark in 2021, with the aim of developing, testing, implementing, and evaluating a structured post-pulmonary embolism follow-up care model, 'Attend-PE'. The objective of this feasibility study was to examine the fidelity, acceptability, and appropriateness of the Attend-PE model in a Danish hospital setting.

METHODS

This feasibility study was conducted in two Danish hospitals, using a prospective study design with six months' follow-up. The fidelity, acceptability, and appropriateness of the Attend-PE model's components were evaluated using surveys, registrations sheets, and interviews with two physicians, three nurses, and 29 patients. Qualitative data were analysed using a deductive content analysis, while quantitative data were analysed using descriptive statistics.

RESULTS

Fidelity with the Attend-PE model was good, with a high participation rate of patients in all components of the model. Acceptability was likewise good, as both patients and health care professionals expressed a high level of satisfaction with the model. The health care professionals considered the model to be relevant and suitable in a Danish hospital setting, confirming appropriateness of the model.

CONCLUSION

This study showed that the Attend-PE model for patients with pulmonary embolism is feasible and acceptable in a Danish hospital setting.

Dyspnea After an Acute Intermediate-Risk Pulmonary Embolism: A Case-Based Approach to Evaluation and Treatment

Exercise intolerance after acute pulmonary embolism may be caused by residual pulmonary vascular obstruction, which presents as chronic thromboembolic pulmonary disease with or without pulmonary hypertension. We present a case highlighting a systematic approach to evaluating functional limitations due to residual pulmonary vascular obstruction, emphasizing the utility of cardiopulmonary exercise testing.

Chronic thromboembolic pulmonary hypertension: the diagnostic assessment

Chronic Thromboembolic Pulmonary Hypertension (CTEPH) presents a significant diagnostic challenge due to its complex and often nonspecific clinical manifestations. This review outlines a comprehensive approach to the diagnostic assessment of CTEPH, emphasizing the importance of a high index of suspicion in patients with unexplained dyspnea or persistent symptoms post-acute pulmonary embolism. We discuss the pivotal role of multimodal imaging, including echocardiography, ventilation/perfusion scans, CT pulmonary angiography, and magnetic resonance imaging, in the identification and confirmation of CTEPH. Furthermore, the review highlights the essential function of right heart catheterization in validating the hemodynamic parameters indicative of CTEPH, establishing its definitive diagnosis. Advances in diagnostic technologies and the integration of a multidisciplinary approach are critical for the timely and accurate diagnosis of CTEPH, facilitating early therapeutic intervention and improving patient outcomes. This manuscript aims to equip clinicians with the knowledge and tools necessary for the efficient diagnostic workflow of CTEPH, promoting awareness and understanding of this potentially treatable cause of pulmonary hypertension.

Epidemiology of deep vein thrombosis

Deep vein thrombosis (DVT) is a cause of considerable morbidity worldwide. It is a common clinical disease in the daily practice of several medical disciplines including general medicine, angiology, and internal medicine, as well as of interest to public health because of its preventability and its sensitivity to secular changes in the distribution of population risk factors. In this review we present a comprehensive overview of the epidemiological features of DVT, including incidence and risk factors. Additionally, we give an overview of the burden that DVT poses on modern health care systems.

Categorization of Patients With Pulmonary Embolism by Charlson Comorbidity Index

BACKGROUND

Short-term outcomes of pulmonary embolism are closely related to right ventricular dysfunction and patient's hemodynamic status, but also to individual comorbidity profile. However, the impact of patients' comorbidities on survival during pulmonary embolism might be underrated. Although the Charlson Comorbidity Index (CCI) is the most extensively studied comorbidity index for detecting comorbidity burden, studies analyzing the impact of CCI on pulmonary embolism patients' survival are limited.

METHODS

We used the German nationwide inpatient sample to analyze all hospitalized patients with pulmonary embolism in Germany 2005-2020 and calculated CCI for each patient, compared the CCI classes (very low: CCI = 0 points, mild: CCI = 1-2 points, moderate: CCI = 3-4, high severity: CCI >4 points) and impact of CCI class on outcomes.

RESULTS

Overall, 1,373,145 hospitalizations of patients with acute pulmonary embolism (53.0% females, 55.9% aged ≥70 years) were recorded in Germany between 2005 and 2020; the CCI class stratified them. Among these, 100,156 (7.3%) were categorized as very low; 221,545 (16.1%) as mild; 394,965 (28.8%) as moderate; and 656,479 (47.8%) as patients with a high comorbidity burden according to CCI class. In-hospital case fatality increased depending on the CCI class: 3.6% in very low, 6.5% in mild, 12.1% in moderate, and 22.1% in high CCI class (P < .001). CCI class was associated with increased in-hospital case fatality (odds ratio 2.014; 95% confidence interval, 2.000-2.027; P < .001).

CONCLUSION

Our study results may help practitioners to better understand and measure the association between an aggravated comorbidity profile and increased in-hospital case fatality in patients with pulmonary embolism.

Prevalence and incidence of venous thromboembolism in geriatric patients admitted to long-term care hospitals

The risk of venous thromboembolism (VTE) increases with age. However, the risk of VTE in the setting of long-term care hospitals is understudied. Our objective was to provide data on the prevalence and incidence of VTE in older adults admitted to long-term care hospitals. In this retrospective cohort study, we collected data about chronically ill and multimorbid patients aged 65 years and older from two long-term care hospitals. The primary endpoint of this study was the lifetime prevalence of VTE, and the secondary endpoint was VTE incidence during residency in long-term care hospitals. We analysed data from 1148 patients with a mean age of 84.1 ± 7.9 years, of whom 74.2% were women. The lifetime prevalence of VTE at baseline was 9.6% (95% CI 7.9-11.4). Cumulative incidence of VTE at 1, 2, and 3 years from baseline was estimated at 3.5% (95% CI 2.5-4.7), 4.2% (95% CI 3.1-5.5), and 5.4% (95% CI 4.1-7.0), respectively. Overall, the incidence rate of VTE in our study was 2.82 (95% CI 2.18-3.66) per 100 person-years. The study indicated a considerably high lifetime prevalence and incidence of VTE during residence in long-term care hospital settings, requiring further evaluation in larger prospective studies.

Association between Mid-Term Functionality and Clinical Severity in Patients Hospitalized for Pulmonary Embolism

The aim of this study is to evaluate the relationship between clinical severity and functionality, occupational performance, and health-related quality of life in patients hospitalized with pulmonary embolism. Pulmonary embolism patients were grouped by clinical severity using the Pulmonary Embolism Severity Index. Those scoring ≥160 were in the high-severity group (HSG); those scoring < 160 in the low-moderate group (LMSG). The main variables were functionality assessed by the World Health Organization Disability Assessment Schedule (WHODAS), self-perception of occupational performance assessed by the Canadian Occupational Performance Measure (COPM), pain and fatigue assessed by a Visual Analogue Scale (VAS), and health-related quality of life assessed by the EuroQol-5Dimensions (EQ-5D). Patients were evaluated at hospital admission and at 1-month and 3-month follow-up. At admission, there were significant differences between groups in the WHODAS and health-related quality of life in favor of the LMSG. At 1-month and at 3-month follow-up, there were significant differences between the LMSG and HSG in WHODAS, COMP, NRS pain, fatigue and EQ-5D scores in favor of the LMSG. An association exists between clinical severity and mid-term functionality, self-perception of occupational performance, pain, fatigue, and health-related quality of life in PE patients.

Pulmonary perfusion defects or residual vascular obstruction and persistent symptoms after pulmonary embolism: a systematic review and meta-analysis

Introduction

Up to 50% of pulmonary embolism (PE) patients have perfusion defects or residual vascular obstruction during follow-up despite adequate anticoagulant treatment, and a similar percentage experience chronic functional limitations and/or dyspnoea post-PE. We aimed to evaluate the association between pulmonary perfusion defects or residual vascular obstruction and functional recovery after PE.

Methods

We performed a systematic review and meta-analysis including studies assessing both the presence of perfusion defects or residual vascular obstruction and functional recovery (i.e. persistent symptoms, quality of life, exercise endurance). An odds ratio was pooled for perfusion defects or residual vascular obstruction and persistent symptoms using a random-effect model.

Results

12 studies were included totalling 1888 PE patients; at a median of 6 months after PE (range 2-72 months), 34% had perfusion defects or residual vascular obstruction and 37% reported persistent symptoms. Among patients with perfusion defects or residual vascular obstruction, 48% (95% CI 37-60%, I2=82%) remained symptomatic during follow-up, compared to 34% (95% CI 20-51%, I2=96%) of patients without such defects. Presence of perfusion defects or residual vascular obstruction was associated with persistent symptoms (OR 2.15, 95% CI 1.66-2.78; I2=0%, τ=0). Notably, there was no association between these defects and quality of life or cardiopulmonary exercise test parameters.

Conclusion

While the odds of having persistent symptoms was higher in patients with perfusion defects or residual vascular obstruction after acute PE, a significant proportion of these patients reported no limitations. A possible causality between perfusion defects or residual vascular obstruction and residual functional limitation therefore remains to be proven.

Electrocardiographic abnormalities and NT-proBNP levels at long-term follow-up of patients with dyspnea after pulmonary embolism

OBJECTIVES

Electrocardiogram (ECG) and measurement of plasma brain natriuretic peptides (BNP) are established markers of right ventricular dysfunction (RVD) in the setting of acute pulmonary embolism (PE) but their value at long-term follow-up is largely unknown. The purpose of this prospective study was to determine the prevalence of ECG abnormalities, describe levels of N-terminal proBNP (NT-proBNP), and establish their association with dyspnea at long-term follow-up after PE.

DESIGN

All Swedish patients diagnosed with acute PE in 2005 (n = 5793) were identified through the Swedish National Patient Registry. Surviving patients in 2007 (n = 3510) were invited to participate. Of these, 2105 subjects responded to a questionnaire about dyspnea and comorbidities. Subjects with dyspnea or risk factors for development of chronic thromboembolic pulmonary hypertension were included in the study in a secondary step, which involved collection of blood samples and ECG registration.

RESULTS

Altogether 49.3% had a completely normal ECG. The remaining participants had a variety of abnormalities, 7.2% had atrial fibrillation/flutter (AF). ECG with any sign of RVD was found in 7.2% of subjects. Right bundle branch block was the most common RVD sign with a prevalence of 6.4%. An abnormal ECG was associated with dyspnea. AF was associated with dyspnea, whereas ECG signs of RVD were not. 61.2% of subjects had NT-proBNP levels above clinical cut-off (>125 ng/L). The degree of dyspnea did not associate independently with NT-proBNP levels.

CONCLUSIONS

We conclude that the value of ECG and NT-proBNP in long term follow-up after PE lies mostly in differential diagnostics.

Post-pulmonary embolism syndrome: A reminder for clinicians

Acute pulmonary embolism (APE) is one of the leading causes of cardiovascular emergencies and the third leading cause of death. Although efforts focus on treating the acute event, patients who survive APE may develop long-term sequelae. Research reveals that approximately half of patients who have suffered an APE do not regain their previous level of function and experience a reduction in their quality of life for several years after the episode. Acute pulmonary embolism can be classified according to the risk of short-term mortality, with most mortality and morbidity concentrated in high-risk and intermediate-risk cases. The first-line treatment for APE is systemic anticoagulation. However, identifying and more aggressively treating people with intermediate to high risk, who have a more favorable risk profile for reperfusion treatments, could reduce short-term mortality and mitigate post-pulmonary embolism syndrome (PPES). Post-pulmonary embolism syndrome refers to a variety of persistent symptoms and functional limitations that occur after an APE. The presence of persistent dyspnea, functional limitations, and/or decreased quality of life after an APE has been recently termed "PPES," although this entity encompasses different manifestations. The most severe cause of persistent dyspnea is chronic thromboembolic pulmonary hypertension, where increased pulmonary artery pressure is due to the fibrotic organization of unresolved APE. Post-PE Syndrome is not always systematically addressed in management guidelines, and its prevalence may be underestimated. More research is needed to fully understand its causes and risk factors. Interventions such as cardiopulmonary rehabilitation have been suggested to improve the quality of life of patients with PPES. A comprehensive, evidence-based approach is essential to effectively prevent and manage PPES and improve the long-term outcomes and well-being of affected patients.

High risk of rehospitalization within 1 year following a pulmonary embolism-insights from the Danish nationwide registries from 2000-2020

AIM

To identify the absolute risk, causes, and factors associated with rehospitalization within 1 year of discharge with a pulmonary embolism (PE).

METHODS AND RESULTS

Using the Danish nationwide registries, all patients admitted with a first-time PE between 2000 and 2020 and discharged alive were included. Subsequent hospitalizations were categorized and crude cumulative incidences were used to estimate the absolute risk (AR) of any rehospitalization and specific causes of rehospitalizations. Risk factors for rehospitalization were investigated using cause specific Cox regression models.A total of 55 201 patients were identified. The median age of the study population was 70 years (inter quartile range: 59;79), and the most prevalent comorbidities were cancer (29.3%) and ischemic heart disease (12.7%). The 1-year AR of any rehospitalization after discharge with a PE was 48.6% (95% confidence interval (CI); 48.2%-48.8%). The most common cause for being rehospitalized was due to respiratory disease [1-year AR: 9.5% (95% CI: 9.3%-9.8%)], followed by cardiovascular disease [1-year AR: 6.3% (95% CI: 5.9%-6.5%)], cancer [1-year AR: 6.0% (95% CI: 5.8%-6.4%)], venous thromboembolism [1-year AR: 5.2% (95% CI: 5.0%-5.2%)], and symptom diagnoses [1-year AR: 5.2% (95% CI: 5.0%-5.4%)]. Factors that were associated with an increased risk of rehospitalization were cancer, liver disease, chronic obstructive pulmonary disease, chronic kidney disease, and immobilization.

CONCLUSION

Patients with PE have a high risk of rehospitalization, with almost half of patients being rehospitalized within 1 year. Identification of high-risk patients may help target interventions aiming at reducing the risk of rehospitalization.

Outcome of Pulmonary Embolism with and without Ischemic Stroke

Background: Ischemic stroke is the second, and pulmonary embolism (PE) is the third most common cardiovascular cause of death after myocardial infarction. Data regarding risk factors for ischemic stroke in patients with acute PE are limited. Methods: Patients were selected by screening the German nationwide in-patient sample for PE (ICD-code I26) and were stratified by ischemic stroke (ICD code I63) and compared. Results: The nationwide in-patient sample comprised 346,586 hospitalized PE patients (53.3% females) in Germany from 2011 to 2014; among these, 6704 (1.9%) patients had additionally an ischemic stroke. PE patients with ischemic stroke had a higher in-hospital mortality rate than those without (28.9% vs. 14.5%, p < 0.001). Ischemic stroke was independently associated with in-hospital death (OR 2.424, 95%CI 2.278-2.579, p < 0.001). Deep venous thrombosis and/or thrombophlebitis (DVT) combined with heart septal defect (OR 24.714 [95%CI 20.693-29.517], p < 0.001) as well as atrial fibrillation/flutter (OR 2.060 [95%CI 1.943-2.183], p < 0.001) were independent risk factors for stroke in PE patients. Systemic thrombolysis was associated with a better survival in PE patients with ischemic thrombolysis who underwent cardio-pulmonary resuscitation (CPR, OR 0.55 [95%CI 0.36-0.84], p = 0.006). Conclusions: Ischemic stroke did negatively affect the survival of PE. Combination of DVT and heart septal defect and atrial fibrillation/flutter were strong and independent risk factors for ischemic stroke in PE patients. In PE patients with ischemic stroke, who had to underwent CPR, systemic thrombolysis was associated with improved survival.

Functional limitations 3 and 12 months after venous thromboembolism: a cohort study

Background

Venous thromboembolism (VTE) is associated with various long-term complications.

Objectives

We aimed to investigate the association of clinical characteristics at VTE diagnosis with functional limitations 3 and 12 months afterward.

Methods

We conducted a prospective cohort study of VTE patients, excluding patients with cancer, pregnancy, and postpartum period. Functional limitations were assessed with the post-VTE functional status (PVFS) scale (range, 0-4) within 21 days of diagnosis, after 3 and 12 months (prospectively), and 1 month before diagnosis (retrospectively). Twelve-month follow-up was only performed in patients on anticoagulation. We fitted 2 proportional odds logistic regression models for the 3- and 12-month follow-ups and computed odds ratios (ORs) with 95% bootstrap percentile confidence intervals (CIs).

Results

We included 307 patients (42% female, median age 55.6 years) with a median (IQR) PVFS scale grade of 2 (2-3) at study inclusion and 0 (0-0) before diagnosis. After 3 months, PVFS scale grade in 269 patients was 1 (0-2). Female sex (OR, 2.15; 95% CI, 1.26-4.14), body mass index (OR per 1 kg/m2 increase, 1.05; 95% CI, 1.00-1.10), functional limitations at baseline, and older age were associated with functional limitations. After 12 months, PVFS scale grade in 124 patients was 1 (0-2). Female sex (OR, 4.47; 95% CI, 2.11-16.00), history of cardiovascular/pulmonary disease (OR, 2.36; 95% CI, 1.01-6.89), and functional limitations at baseline were associated with functional limitations.

Conclusion

Functional limitations in VTE patients improved 3 and 12 months after diagnosis but did not return to pre-VTE values. We identified clinical characteristics that could help identify patients at risk of persisting functional limitations after VTE.

A pharmacoepidemiological nested case-control study of risk factors for venous thromboembolism with the focus on diabetes, cancer, socioeconomic group, medications, and comorbidities

OBJECTIVES

A pharmacoepidemiological study to assess VTE risk factors in a diabetes-rich population.

METHODS

The study comprised 299,590 individuals. We observed 3450 VTEs and matched them with 15,875 controls using a nested case-control approach and collected data on comorbidities and prescriptions. By multivariable conditional logistic regression, we calculated ORs with 95%CIs for comorbidities and medications to evaluate their associations with VTE.

RESULTS

Diabetes (aOR 2.16; 95%CI 1.99-2.34), inflammatory bowel disease (1.84; 1.27-2.66), and severe psychiatric disorders (1.72; 1.43-2.05) had the strongest associations among the non-cancer comorbidities. Pancreatic (12.32; 7.11-21.36), stomach (8.57; 4.07-18.03), lung and bronchus (6.26; 4.16-9.43), and ovarian (6.72; 2.95-15.10) cancers were ranked as high-risk for VTE. Corticosteroids, gabapentinoids, psychotropic drugs, risedronic acid, and pramipexole were most strongly associated (aOR exceeding 1.5) with VTE. Insulin (3.86; 3.33-4.47) and sulphonylureas (2.62; 2.18-3.16) had stronger associations than metformin (1.65; 1.49-1.83). Statins and lercanidipine (0.78; 0.62-0.98) were associated with a lowered risk of VTE.

CONCLUSIONS

In this cohort, with 50% diabetes prevalence, pancreatic, stomach, lung and bronchus, and ovarian cancers were strongly associated with VTE. Corticosteroids, gabapentinoids, and psychotropic medications had the strongest associations with VTE among medications. This may be valuable for generating hypotheses for the further research. Lercanidipine may be a novel protective medication against VTE.

Chronic thromboembolic pulmonary disease: Association with exercise-induced pulmonary hypertension and right ventricle adaptation over time

BACKGROUND AND AIM

Chronic thromboembolic pulmonary disease (CTEPD) is a progressive condition caused by fibrotic thrombi and vascular remodeling in the pulmonary circulation despite prolonged anticoagulation. We evaluated clinical factors associated with CTEPD, as well as its impact on functional capacity, pulmonary haemodynamics at rest and after exercise, and right ventricle (RV) morphology and function.

METHODS

We compared 33 consecutive patients with a history of acute pulmonary embolism and either normal pulmonary vascular imaging (negative Q-scan, group 1, n = 16) or persistent defects on lung perfusion scan (positive Q-scan) despite oral anticoagulation at 4 months (group 2, n = 17). Investigations included thrombotic load, the Pulmonary Embolism Severity Index (PESI) score, functional class, N-terminal prohormone of brain natriuretic peptide (NT-proBNP), cardiopulmonary exercise test (CPET) and echocardiographic parameters at rest and after exercise (ESE), at 4 and at 24 months.

RESULTS

Compared with group 1, group 2 featured a higher PESI score (p = 0.02) and a higher thrombotic load (p = 0.004) at hospital admission. At 4 months, group 2 developed exercise-induced pulmonary hypertension (Ex-PH) at CPET (p < 0.001) and ESE (p < 0.001). At 24 months group 2 showed higher NT-proBNP (p < 0.001), WHO-FC (p < 0.001), systolic (p<0.001) and diastolic (p = 0.037) RV dysfunction and worse RV-arterial coupling (p < 0.001) despite maintaining a low or intermediate echocardiographic probability of PH.

CONCLUSIONS

This is the first "proof of concept" study showing that patients with a positive Q-scan frequently develop Ex-PH and RV functional deterioration as well as reduced functional capacity, generating the hypothesis that Ex-PH could help detect the progression to CTEPD.

Impact of reperfusion therapies on clot resolution and long-term outcomes in patients with pulmonary embolism

OBJECTIVE

Major progress in reperfusion strategies has substantially improved the short-term outcomes of patients with pulmonary embolism (PE), however, up to 50% of patients report persistent dyspnea after acute PE.

METHODS

A retrospective study of the PE response team registry and included patients with repeat imaging at 3 to 12 months. The primary outcome was to determine the incidence of residual pulmonary vascular obstruction following acute PE. Secondary outcomes included the development of PE recurrence, right ventricular (RV) dysfunction, chronic thromboembolic pulmonary hypertension, readmission, and mortality at 12 months.

RESULTS

A total of 382 patients were included, and 107 patients received reperfusion therapies followed by anticoagulation. Patients who received reperfusion therapies including systemic thrombolysis, catheter-directed thrombolysis, and mechanical thrombectomy presented with a higher vascular obstructive index (47% vs 28%; P < .001) and signs of right heart strain on echocardiogram (81% vs 43%; P < .001) at the time of diagnosis. A higher absolute reduction in vascular obstructive index (45% vs 26%; 95% confidence interval, 14.0-25.6; P < .001), greater improvement in RV function (82% vs 65%; P = .021), and lower 12-month mortality rate (2% vs 7%; P = .038) and readmission rate (33% vs 46%; P = .031) were observed in the reperfusion group. No statistically significant differences were found between groups in the development of chronic thromboembolic pulmonary hypertension (8% vs 5%; P = .488) and PE recurrence (8% vs 6%; P = .646).

CONCLUSIONS

We observed a favorable survival and greater improvement in clot resolution and RV function in patients treated with reperfusion therapies.

High microRNA-145 plasma levels are associated with decreased risk of future incident venous thromboembolism: the HUNT study

ABSTRACT

MicroRNA-145 (miR-145) has been reported to downregulate the expression of tissue factor and factor XI in vitro and decrease venous thrombus formation in animal models. However, the association between miR-145 and risk of future venous thromboembolism (VTE) in the general population remains unknown. We investigated the association between plasma levels of miR-145 and risk of future VTE in a case-cohort study. Incident VTE cases (n = 510) and a subcohort (n = 1890) were derived from the third survey of the Trøndelag Health Study (HUNT3), a population-based cohort. The expression levels of miR-145 were measured in plasma samples obtained at baseline. The study population was divided into quartiles based on miR-145 levels in participants in the subcohort, and weighted Cox regression was used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). Plasma levels of miR-145 were inversely associated with VTE risk. Participants with miR-145 levels in the highest quartile had a 49% lower risk of VTE (HR, 0.51; 95% CI, 0.38-0.68) than those with miR-145 in the lowest quartile in age- and sex-adjusted analysis, and the inverse association was most pronounced for unprovoked VTE (HR, 0.39; 95% CI, 0.25-0.61). Risk estimates remained virtually the same after further adjustment for body mass index, and cancer and arterial cardiovascular disease at baseline. In conclusion, elevated expression levels of miR-145 in plasma were associated with decreased risk of future incident VTE. The protective role of miR-145 against VTE is consistent with previous experimental data and suggests that miR-145 has the potential to be a target for VTE prevention.

Catheter-based therapy for high-risk or intermediate-risk pulmonary embolism: death and re-hospitalization

BACKGROUND AND AIMS

Catheter-based therapies (CBTs) have been developed as a treatment option in patients with pulmonary embolism (PE). There remains a paucity of data to inform decision-making in patients with intermediate-risk or high-risk PE. The aim of this study was to characterize in-hospital and readmission outcomes in patients with intermediate-risk or high-risk PE treated with vs. without CBT in a large retrospective registry.

METHODS

Patients hospitalized with intermediate-risk or high-risk PE were identified using the 2017-20 National Readmission Database. In-hospital outcomes included death and bleeding and 30- and 90-day readmission outcomes including all-cause, venous thromboembolism (VTE)-related and bleeding-related readmissions. Inverse probability of treatment weighting (IPTW) was utilized to compare outcomes between CBT and no CBT.

RESULTS

A total of 14 903 [2076 (13.9%) with CBT] and 42 829 [8824 (20.6%) with CBT] patients with high-risk and intermediate-risk PE were included, respectively. Prior to IPTW, patients with CBT were younger and less likely to have cancer and cardiac arrest, receive systemic thrombolysis, or be on mechanical ventilation. In the IPTW logistic regression model, CBT was associated with lower odds of in-hospital death in high-risk [odds ratio (OR) 0.83, 95% confidence interval (CI) 0.80-0.87] and intermediate-risk PE (OR 0.76, 95% CI 0.70-0.83). Patients with high-risk PE treated with CBT were associated with lower risk of 90-day all-cause [hazard ratio (HR) 0.77, 95% CI 0.71-0.83] and VTE (HR 0.46, 95% CI 0.34-0.63) readmission. Patients with intermediate-risk PE treated with CBT were associated with lower risk of 90-day all-cause (HR 0.75, 95% CI 0.72-0.79) and VTE (HR 0.66, 95% CI 0.57-0.76) readmission.

CONCLUSIONS

Among patients with high-risk or intermediate-risk PE, CBT was associated with lower in-hospital death and 90-day readmission. Prospective, randomized trials are needed to confirm these findings.

Percutaneous interventions for pulmonary embolism

Pulmonary embolism (PE) ranks as a leading cause of in-hospital mortality and the third most common cause of cardiovascular death. The spectrum of PE manifestations varies widely, making it difficult to determine the best treatment approach for specific patients. Conventional treatment options include anticoagulation, thrombolysis, or surgery, but emerging percutaneous interventional procedures are being investigated for their potential benefits in heterogeneous PE populations. These novel interventional techniques encompass catheter-directed thrombolysis, mechanical thrombectomy, and hybrid approaches combining different mechanisms. Furthermore, inferior vena cava filters are also available as an option for PE prevention. Such interventions may offer faster improvements in right ventricular function, as well as in pulmonary and systemic haemodynamics, in individual patients. Moreover, percutaneous treatment may be a valid alternative to traditional therapies in high bleeding risk patients and could potentially reduce the burden of mortality related to major bleeds, such as that of haemorrhagic strokes. Nevertheless, the safety and efficacy of these techniques compared to conservative therapies have not been conclusively established. This review offers a comprehensive evaluation of the current evidence for percutaneous interventions in PE and provides guidance for selecting appropriate patients and treatments. It serves as a valuable resource for future researchers and clinicians seeking to advance this field. Additionally, we explore future perspectives, proposing "percutaneous primary pulmonary intervention" as a potential paradigm shift in the field.

Post-Pulmonary Embolism Syndrome: An Update Based on the Revised AWMF-S2k Guideline

In survivors of acute pulmonary embolism (PE), the post-PE syndrome (PPES) may occur. In PPES, patients typically present with persisting or progressive dyspnea on exertion despite 3 months of therapeutic anticoagulation. Therefore, a structured follow-up is warranted to identify patients with chronic thromboembolic pulmonary disease (CTEPD) with normal pulmonary pressure or chronic thromboembolic pulmonary hypertension (CTEPH). Both are currently understood as a dual vasculopathy, that is, secondary arterio- and arteriolopathy, affecting the large and medium-sized pulmonary arteries as well as the peripheral vessels (diameter < 50 µm). The follow-up algorithm after acute PE commences with identification of clinical symptoms and risk factors for CTEPH. If indicated, a stepwise performance of echocardiography, ventilation-perfusion scan (or alternative imaging), N-terminal prohormone of brain natriuretic peptide (NT-proBNP) level, cardiopulmonary exercise testing, and pulmonary artery catheterization with angiography should follow. CTEPH patients should be treated in a multidisciplinary center with adequate experience in the complex therapeutic options, comprising pulmonary endarterectomy, balloon pulmonary angioplasty, and pharmacological interventions.

Management of high and intermediate-high risk pulmonary embolism: A position paper of the Interventional Cardiology Working Group of the Italian Society of Cardiology

Pulmonary embolism (PE) is a potentially life-threatening condition that remains a major global health concern. Noteworthy, patients with high- and intermediate-high-risk PE pose unique challenges because they often display clinical and hemodynamic instability, thus requiring rapid intervention to mitigate the risk of clinical deterioration and death. Importantly, recovery from PE is associated with long-term complications such as recurrences, bleeding with oral anticoagulant treatment, pulmonary hypertension, and psychological distress. Several novel strategies to improve risk factor characterization and management of patients with PE have recently been introduced. Accordingly, this position paper of the Working Group of Interventional Cardiology of the Italian Society of Cardiology deals with the landscape of high- and intermediate-high risk PE, with a focus on bridging the gap between the evolving standards of care and the current clinical practice. Specifically, the growing importance of catheter-directed therapies as part of the therapeutic armamentarium is highlighted. These interventions have been shown to be effective strategies in unstable patients since they offer, as compared with thrombolysis, faster and more effective restoration of hemodynamic stability with a consistent reduction in the risk of bleeding. Evolving standards of care underscore the need for continuous re-assessment of patient risk stratification. To this end, a multidisciplinary approach is paramount in refining selection criteria to deliver the most effective treatment to patients with unstable hemodynamics. In conclusion, the current management of unstable patients with PE should prioritize tailored treatment in a patient-oriented approach in which transcatheter therapies play a central role.

Performance-based outcome measures for assessing physical capacity in patients with pulmonary embolism: A scoping review

INTRODUCTION

Up to 50 % of patients surviving a pulmonary embolism (PE) report persisting shortness of breath, reduced physical capacity and psychological distress. As the PE population is heterogeneous compared to other cardiovascular patient groups, outcome measures for assessing physical capacity traditionally used in cardiac populations may not be reliable for the PE population as a whole. This scoping review aims to 1) map performance-based outcome measures (PBOMs) used for assessing physical capacity in PE research, and 2) to report the psychometric properties of the identified PBOMs in a PE population.

METHODS

The review was conducted according to the Joanna Briggs Institute framework for scoping reviews and reported according to the PRISMA-Extension for Scoping Reviews guideline.

RESULTS

The systematic search of five databases identified 4585 studies, of which 243 studies met the inclusion criteria. Of these, 185 studies focused on a subgroup of patients with chronic thromboembolic pulmonary hypertension. Ten different PBOMs were identified in the included studies. The 6-minute walk test (6MWT) and cardiopulmonary exercise test (CPET) were the most commonly used, followed by the (Modified) Bruce protocol and Incremental Shuttle Walk test. No studies reported psychometric properties of any of the identified PBOMs in a PE population.

CONCLUSIONS

Publication of studies measuring physical capacity within PE populations has increased significantly over the past 5-10 years. Still, not one study was identified, reporting the validity, reliability, or responsiveness for any of the identified PBOMs in a PE population. This should be a priority for future research in the field.

The Risk of Incident Venous Thromboembolism Attributed to Overweight and Obesity: The Tromsø Study

BACKGROUND

 Obesity is a well-established risk factor for venous thromboembolism (VTE). However, data on the proportion of incident VTEs attributed to overweight and obesity in the general population are limited.

OBJECTIVE

 To investigate the population attributable fraction (PAF) of VTE due to overweight and obesity in a population-based cohort with repeated measurements of body mass index (BMI).

METHODS

 Participants from the fourth to seventh surveys of the Tromsø Study (enrolment: 1994-2016) were followed through 2020, and all incident VTEs were recorded. In total, 36,341 unique participants were included, and BMI measurements were updated for those attending more than one survey. BMI was categorized as <25 kg/m2, 25-30 kg/m2 (overweight), and ≥30 kg/m2 (obesity). Time-varying Cox regression models were used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). The PAF was estimated based on age- and sex-adjusted HRs and the prevalence of BMI categories in VTE cases.

RESULTS

 At baseline, the prevalence of overweight and obesity was 37.9 and 13.8%, respectively. During a median follow-up of 13.9 years, 1,051 VTEs occurred. The age- and sex-adjusted HRs of VTE were 1.40 (95% CI: 1.21-1.61) for overweight and 1.86 (95% CI: 1.58-2.20) for obesity compared with subjects with BMI <25 kg/m2. The PAF of VTE due to overweight and obesity was 24.6% (95% CI: 16.6-32.9), with 12.9% (95% CI: 6.6-19.0) being attributed to overweight and 11.7% (95% CI: 8.5-14.9) to obesity. Similar PAFs were obtained in analyses stratified by sex and VTE subtypes (provoked/unprovoked events, deep vein thrombosis, pulmonary embolism).

CONCLUSION

 Our findings indicate that almost 25% of all VTE events can be attributed to overweight and obesity in a general population from Norway.

Long-term outcomes of pulmonary embolism in children and adolescents

ABSTRACT

Knowledge regarding the long-term consequences of pulmonary embolism (PE) in children is limited. This cohort study describes the long-term outcomes of PE in children who were followed-up at a single-center institution using a local protocol that included clinical evaluation, chest imaging, echocardiography, pulmonary function tests, and cardiopulmonary exercise tests at follow-up, starting 3 to 6 months after acute PE. Children objectively diagnosed with PE at age 0 to 18 years, who had ≥6 months of follow-up were included. Study outcomes consisted of PE resolution, PE recurrence, death, and functional outcomes (dyspnea, impaired pulmonary or cardiac function, impaired aerobic capacity, and post-PE syndrome). The frequency of outcomes was compared between patients with/without underlying conditions. In total, 150 patients were included; median age at PE was 16 years (25th-75th percentile, 14-17 years); 61% had underlying conditions. PE did not resolve in 29%, recurrence happened in 9%, and death in 5%. One-third of patients had at least 1 documented abnormal functional finding at follow-up (ventilatory impairments, 31%; impaired aerobic capacity, 31%; dyspnea, 26%; and abnormal diffusing capacity of the lungs to carbon monoxide, 22%). Most abnormalities were transient. When alternative explanations for the impairments were considered, the frequency of post-PE syndrome was lower, ranging between 0.7% and 8.5%. Patients with underlying conditions had significantly higher recurrence, more pulmonary function and ventilatory impairments, and poorer exercise capacity. Exercise intolerance was, in turn, most frequently because of deconditioning than to respiratory or cardiac limitation, highlighting the importance of physical activity promotion in children with PE.

Simple and secure thrombectomy without circulatory arrest for acute pulmonary embolism

BACKGROUND

Surgical pulmonary artery thrombectomy is a well-established emergency treatment for massive pulmonary embolism (PE) in which fibrinolysis or thrombolysis are not effective. However, surgery for massive PE that requires peripheral pulmonary artery thrombus removal remains challenging. We established a simple and secure pulmonary artery thrombectomy method using cardiopulmonary bypass and cardiac arrest. In this procedure, the surgical assistant arm, typically used for coronary artery bypass grafting, is used to obtain a feasible working space during thrombectomy.

CASE PRESENTATION

We present seven consecutive massive PE cases that were treated with the present surgical method and successfully weaned from cardiopulmonary bypass or extracorporeal membrane oxygenation postoperatively.

CONCLUSIONS

This procedure can be used to prevent right ventricular failure after surgery as surgeons can remove the peripheral thrombus with clear vision up to the second branch of the pulmonary artery.

Residual Pulmonary Vascular Obstruction Following Mechanical Thrombectomy for Submassive Pulmonary Embolism: A Single-Center Analysis

Background

Residual pulmonary vascular obstruction (RPVO) following pulmonary embolism (PE) is associated with residual dyspnea, recurrent venous thromboembolism, and chronic thromboembolic pulmonary hypertension. Historically, acute PE treated with anticoagulation alone results in high rates of significant RPVO. Contemporary treatment of submassive PE often involves catheter-based interventions, including mechanical thrombectomy (MT), although their relation to RPVO is not characterized. In this study, we aimed to evaluate the rate of ≥10% RPVO in patients treated with MT.

Methods

Twenty consecutive patients with submassive PE in a single center underwent MT and subsequent planar ventilation/perfusion scintigraphy scan at a median of 4 months after thrombectomy. A quantitative perfusion score was calculated for each planar ventilation/perfusion scintigraphy study to provide a % perfusion defect. Complete hemodynamic data were collected during the procedure and Miller score was calculated using prepulmonary and postpulmonary angiography. Echocardiographic data were collected prior to, 24 to 48 hours after, and 30 days after the procedure.

Results

Four of 20 patients (20%) had ≥10% RPVO at a median of 4 months follow-up. Following MT, the mean Miller score decreased from 24.5 ± 2.9 to 15.8 ± 3.3 (P < .001) and mean pulmonary artery pressure decreased from 36.1 ± 4.8 mm Hg to 26.8 ± 5.4 mm Hg (P < .001). Right ventricle-to-left ventricle ratio decreased from 1.44 ± 0.2 to 1.05 ± 0.24 by 24 to 48 hours (P < .001) and 0.85 ± 0.1 at 30 days (P < .001) and right ventricular systolic pressure decreased from 63.2 ± 10 mm Hg to 42.1 ± 9.8 mm Hg at 24 to 48 hours (P < .001) and 31.9 ± 10.4 at 30 days (P < .001).

Conclusions

In this prospective study of patients with submassive PE treated with MT, favorable rates of RPVO were noted in comparison to prior studies of anticoagulation alone along with expected acute hemodynamic and echocardiographic improvements. While this study was small in scope, the results suggest the potential for long-term benefits of MT in acute PE in addition to the acute benefits previously described.

Value of exercise right heart catheterization in the differential diagnosis of chronic thromboembolic pulmonary disease

INTRODUCTION AND OBJECTIVES

Chronic thromboembolic disease refers to the presence of chronic thrombotic pulmonary vascular thrombosis without pulmonary hypertension (PH) at rest but with exercise limitation after pulmonary embolism (PE). Our aim was to evaluate the hemodynamic response to exercise in these patients and its correlation with the values reached in cardiopulmonary exercise testing.

METHODS

We included symptomatic patients with persistent pulmonary thrombosis after PE. We excluded patients with left heart disease or significant PH (mean pulmonary arterial pressure [mPAP] >25mmHg, pulmonary vascular resistance >3 WU, and pulmonary capillary wedge pressure [PCWP] >15mmHg). Cardiopulmonary exercise testing and exercise right heart catheterization were performed. Exercise-induced precapillary PH was defined as mPAP/CO slope >3 and PCWP/CO slope <2mmHg/l/min. The hemodynamic response and the values obtained in cardiopulmonary exercise testing were compared between patients with and without exercise-induced precapillary PH.

RESULTS

We studied 36 patients; 4 were excluded due to incomplete hemodynamic data. Out of the 32 patients analyzed; 3 developed a pathological increase in PCWP. Among the remaining 29 patients (mean age, 49.4±13.7 years, 34.5% women), 13 showed exercise-induced PH. Resting mPAP was higher in those who developed exercise-induced PH (23.3±5.4 vs 19.0±3.8mmHg; P=.012), although CO was similar in the 2 groups. Patients with exercise-induced PH exhibited data of ventilatory inefficiency with reduced values of end-tidal CO2 pressure at the anaerobic threshold (32.8±3.0 vs 36.2±3.3mmHg; P=.021) and a higher Ve/VCO2 slope (34.2±4.8 vs 30.7±5.0; P=.049).

CONCLUSIONS

Exercise limitation and ventilatory inefficiency could be attributable to exercise-induced precapillary PH in a subgroup of patients with persistent pulmonary thrombosis and dyspnea.

Association between lactate metabolism‑related molecules and venous thromboembolism: A study based on bioinformatics and an in vitro model

Venous thromboembolism (VTE) is characterized by a high recurrence rate and adverse consequences, including high mortality. Damage to vascular endothelial cells (VECs) serves a key role in VTE and lactate (LA) metabolism is associated with VEC damage. However, the pathogenesis of VTE and the role of lactate metabolism-related molecules (LMRMs) remain unclear. Based on the GSE48000 dataset, the present study identified differentially expressed (DE-)LMRMs between healthy individuals and those with VTE. Thereafter, LMRMs were used to establish four machine learning models, namely, the random forest, support vector machine and generalized linear model (GLM) and eXtreme gradient boosting. To verify disease prediction efficiency of the models, nomograms, calibration curves, decision curve analyses and external datasets were used. The optimal machine learning model was used to predict genes involved in disease and an in vitro oxygen-glucose deprivation (OGD) model was used to detect the survival rate, LA levels and LMRM expression levels of VECs. A total of four DE-LMRMs, solute carrier family 16 member 1 (SLC16A1), SLC16A7, SLC16A8 and SLC5A12 were obtained and GLM was identified as the best performing model based on its ability to predict differential expression of the embigin, lactate dehydrogenase B, SLC16A1, SLC5A12 and SLC16A8 genes. Additionally, SLC16A1, SLC16A7 and SLC16A8 served key roles in VTE and the OGD model demonstrated a significant decrease in VEC survival rate as well as a significant increase and decrease in intracellular LA and SLC16A1 expression levels in VECs, respectively. Thus, LMRMs may be involved in VTE pathogenesis and be used to build accurate VTE prediction models. Further, it was hypothesized that the observed increase in intracellular LA levels in VECS was associated with the decrease in SLC16A1 expression. Therefore, SLC16A1 expression may be an essential target for VTE treatment.