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Pizzi R, Cimini LA, Ageno W, Becattini C. Direct Oral Anticoagulants for Pulmonary Embolism. Hamostaseologie 2024; 44:206-217. [PMID: 38467144 DOI: 10.1055/a-2105-8736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Abstract
Venous thromboembolism (VTE) is the third most common cardiovascular disease. For most patients, the standard of treatment has long consisted on low-molecular-weight heparin followed by vitamin K antagonists, but a number of clinical trials and, subsequently, post-marketing studies have shown that direct oral anticoagulants (DOACs) with or without lead-in heparin therapy are effective alternatives with fewer adverse effects. This evidence has led to important changes in the guidelines on the treatment of VTE, including pulmonary embolism (PE), with the DOACs being now recommended as the first therapeutic choice. Additional research has contributed to identifying low-risk PE patients who can benefit from outpatient management or from early discharge from the emergency department with DOAC treatment. There is evidence to support the use of DOACs in intermediate-risk PE patients as well as in high-risk patients receiving thrombolytic treatment. The use of DOACs has also been proven to be safe and effective in special populations of PE patients, such as patients with renal impairment, liver impairment, and cancer.
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Affiliation(s)
- Roberto Pizzi
- Department of Emergency Medicine and Thrombosis Center, Ospedale di Circolo di Varese and Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Ludovica Anna Cimini
- Vascular and Internal Medicine- Stroke Unit, University of Perugia, Perugia, Italy
| | - Walter Ageno
- Department of Emergency Medicine and Thrombosis Center, Ospedale di Circolo di Varese and Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Cecilia Becattini
- Vascular and Internal Medicine- Stroke Unit, University of Perugia, Perugia, Italy
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Rouleau SG, Casey SD, Kabrhel C, Vinson DR, Long B. Management of high-risk pulmonary embolism in the emergency department: A narrative review. Am J Emerg Med 2024; 79:1-11. [PMID: 38330877 DOI: 10.1016/j.ajem.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE. OBJECTIVE This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations. DISCUSSION High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions. CONCLUSIONS Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.
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Affiliation(s)
- Samuel G Rouleau
- Department of Emergency Medicine, UC Davis Health, University of California, Davis, Sacramento, CA, United States of America.
| | - Scott D Casey
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, CA, United States of America.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - David R Vinson
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
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Barba-Martín R. Optimizing treatment strategies for intermediate-to-high risk pulmonary embolism. Int J Cardiol 2023; 390:131212. [PMID: 37506975 DOI: 10.1016/j.ijcard.2023.131212] [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: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 07/30/2023]
Affiliation(s)
- Raquel Barba-Martín
- Internal Medicine Department, Hospital Universitario Rey Juan Carlos, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Madrid, Spain.
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Silver MJ, Giri J, Duffy Á, Jaber WA, Khandhar S, Ouriel K, Toma C, Tu T, Horowitz JM. Incidence of Mortality and Complications in High-Risk Pulmonary Embolism: A Systematic Review and Meta-Analysis. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100548. [PMID: 39132523 PMCID: PMC11308857 DOI: 10.1016/j.jscai.2022.100548] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/13/2022] [Accepted: 11/08/2022] [Indexed: 08/13/2024]
Abstract
Background The relationship between the early hemodynamic consequences of acute pulmonary embolism (PE) and short-term morbidity and mortality has long been recognized. The mortality incidence and other complications after high-risk (massive) PE, the most severe category of the disease, are summarized in this meta-analysis. Methods A systematic review and meta-analysis of studies reporting on patients with massive PE indexed by PubMed and the Cochrane Library over a 10-year period (2010-2020) was conducted. Studies with adequate information to specify a cohort of patients with high-risk PE defined by the American Heart Association and European Society of Cardiology criteria and their clinical outcomes were included. Incidences were calculated as weighted averages with 95% CIs. Results A total of 27 publications spanning 1517 patients were identified that met the search criteria for high-risk PE. In-hospital all-cause mortality averaged 28.3% (95% CI, 20.9%-37.0%) in patients at high risk, comparable to the 30-day all-cause mortality of 30.2% (95% CI, 22.3%-39.6%). In-hospital major bleeding was 13.8% (95% CI, 9.3%-20.0%), and intracranial hemorrhage was reported in 3.6% (95% CI, 2.2%-5.9%). The risk of bias in publications was graded as low-to-moderate, with substantial heterogeneity among the studies. Conclusions This systematic review and meta-analysis provided low-quality to moderate-quality evidence documenting mortality, major bleeding, and other complications in patients meeting the American Heart Association and European Society of Cardiology criteria for high-risk PE. This information was used to inform the design of the FLowTriever for Acute Massive Pulmonary Embolism (FLAME) study (NCT04795167), a study evaluating an advanced therapy for patients with high-risk PE.
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Affiliation(s)
- Mitchell J. Silver
- Department of Cardiovascular Medicine, Ohio Health Heart and Vascular, Columbus, Ohio
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Áine Duffy
- North American Science Associates, LLC, New York, New York
| | - Wissam A. Jaber
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Sameer Khandhar
- Division of Cardiovascular Medicine, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania
| | - Kenneth Ouriel
- North American Science Associates, LLC, New York, New York
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Machanahalli Balakrishna A, Reddi V, Belford PM, Alvarez M, Jaber WA, Zhao DX, Vallabhajosyula S. Intermediate-Risk Pulmonary Embolism: A Review of Contemporary Diagnosis, Risk Stratification and Management. Medicina (B Aires) 2022; 58:medicina58091186. [PMID: 36143863 PMCID: PMC9504600 DOI: 10.3390/medicina58091186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/25/2022] Open
Abstract
Pulmonary embolism (PE) can have a wide range of hemodynamic effects, from asymptomatic to a life-threatening medical emergency. Pulmonary embolism (PE) is associated with high mortality and requires careful risk stratification for individualized management. PE is divided into three risk categories: low risk, intermediate-risk, and high risk. In terms of initial therapeutic choice and long-term management, intermediate-risk (or submassive) PE remains the most challenging subtype. The definitions, classifications, risk stratification, and management options of intermediate-risk PE are discussed in this review.
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Affiliation(s)
| | - Vuha Reddi
- Department of Medicine, Danbury Hospital/Yale University School of Medicine, Danbury, CT 06810, USA
| | - Peter Matthew Belford
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
| | - Manrique Alvarez
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
| | - Wissam A. Jaber
- Section of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30307, USA
| | - David X. Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
- Department of Implementation Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
- Correspondence: ; Tel.: +1-(336)-878-6000
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Oxygen Therapy Lowers Right Ventricular Afterload in Experimental Acute Pulmonary Embolism. Crit Care Med 2021; 49:e891-e901. [PMID: 33870917 DOI: 10.1097/ccm.0000000000005057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To investigate if oxygen could unload the right ventricle and improve right ventricle function in a porcine model mimicking intermediate-high risk acute pulmonary embolism. DESIGN Controlled, blinded, animal study. SETTING Tertiary university hospital, animal research laboratory. SUBJECTS Female, Danish pigs (n = 16, approximately 60 kg). INTERVENTIONS Acute autologous pulmonary embolism was induced until doubling of baseline mean pulmonary arterial pressure. Group 1 animals (n = 8) received increasing Fio2 (40%, 60%, and 100%) for time intervals of 15 minutes returning to atmospheric air between each level of Fio2. In group 2 (n = 8), the effects of Fio2 40% maintained over 75 minutes were studied. In both groups, pulmonary vasodilatation from inhaled nitric oxide (40 parts per million) was used as a positive control. MEASUREMENTS AND MAIN RESULTS Effects were evaluated by biventricular pressure-volume loop recordings, right heart catheterization, and arterial and mixed venous blood gasses. Pulmonary embolism increased mean pulmonary arterial pressure from 15 ± 4 to 33 ± 6 mm Hg (p = 0.0002) and caused right ventricle dysfunction (p < 0.05) with troponin release (p < 0.0001). In group 1, increasing Fio2 lowered mean pulmonary arterial pressure (p < 0.0001) and pulmonary vascular resistance (p = 0.0056) and decreased right ventricle volumes (p = 0.0018) and right ventricle mechanical work (p = 0.034). Oxygenation was improved and pulmonary shunt was lowered (p < 0.0001). Maximal hemodynamic effects were seen at Fio2 40% with no additional benefit from higher fractions of oxygen. In group 2, the effects of Fio2 40% were persistent over 75 minutes. Supplemental oxygen showed the same pulmonary vasodilator efficacy as inhaled nitric oxide (40 parts per million). No adverse effects were observed. CONCLUSIONS In a porcine model mimicking intermediate-high risk pulmonary embolism, oxygen therapy reduced right ventricle afterload and lowered right ventricle mechanical work. The effects were immediately present and persistent and were similar to inhaled nitric oxide. The intervention is easy and safe. The study motivates extended clinical evaluation of supplemental oxygen in acute pulmonary embolism.
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Chopard R, Jimenez D, Serzian G, Ecarnot F, Falvo N, Kalbacher E, Bonnet B, Capellier G, Schiele F, Bertoletti L, Monreal M, Meneveau N. Renal dysfunction improves risk stratification and may call for a change in the management of intermediate- and high-risk acute pulmonary embolism: results from a multicenter cohort study with external validation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:57. [PMID: 33563311 PMCID: PMC7874488 DOI: 10.1186/s13054-021-03458-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/01/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Renal dysfunction influences outcomes after pulmonary embolism (PE). We aimed to determine the incremental value of adding renal dysfunction, defined by estimated glomerular filtration rate (eGFR), on top of the European Society of Cardiology (ESC) prognostic model, for the prediction of 30-day mortality in acute PE patients, which in turn could lead to the optimization of acute PE management. METHODS We performed a multicenter, non-interventional retrospective post hoc analysis based on a prospectively collected cohort including consecutive confirmed acute PE stratified per ESC guidelines. We first identified which of three eGFR formulae most accurately predicted death. Changes in global model fit, discrimination, calibration and reclassification parameters were evaluated with the addition of eGFR to the prognostic model. RESULTS Among 1943 patients (mean age 67.3 (17.1), 50.4% women), 107 (5.5%) had died at 30 days. The 4-variable Modification of Diet in Renal Disease (eGFRMDRD4) formula predicted death most accurately. In total, 477 patients (24.5%) had eGFRMDRD4 < 60 ml/min. Observed mortality was higher for intermediate-low-risk and high-risk PE in patients with versus without renal dysfunction. The addition of eGFRMDRD4 information improved model fit, discriminatory capacity, and calibration of the ESC model. Reclassification parameters were significantly increased, yielding 18% reclassification of predicted mortality (p < 0.001). Predicted mortality reclassifications across risk categories were as follows: 63.1% from intermediate-low risk to eGFR-defined intermediate-high risk, 15.8% from intermediate-high risk to eGFR-defined intermediate-low risk, and 21.0% from intermediate-high risk to eGFR-defined high risk. External validation in a cohort of 14,234 eligible patients from the RIETE registry confirmed our findings with a significant improvement of Harrell's C index and reclassification parameters. CONCLUSION The addition of eGFRMDRD4-derived renal dysfunction on top of the prognostic algorithm led to risk reclassification within the intermediate- and high-risk PE categories. The impact of risk stratification integrating renal dysfunction on therapeutic management for acute PE requires further studies.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Jean Minjoz, 3 Boulevard Fleming, 25000, Besançon, France. .,EA3920, University of Burgundy Franche-Comté, Besançon, France. .,F-CRIN, INNOVTE, Saint-Etienne, France.
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.,Department of Medicine, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Guillaume Serzian
- Department of Cardiology, University Hospital Jean Minjoz, 3 Boulevard Fleming, 25000, Besançon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Jean Minjoz, 3 Boulevard Fleming, 25000, Besançon, France.,EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Nicolas Falvo
- Department of Internal Medicine, University Hospital Dijon-Bourgogne, Dijon, France
| | - Elsa Kalbacher
- Medical Oncology Unit, University Hospital Besançon, Besançon, France
| | | | - Gilles Capellier
- EA3920, University of Burgundy Franche-Comté, Besançon, France.,Medical Intensive Care Unit, University Hospital Jean Minjoz, Besançon, France
| | - François Schiele
- Department of Cardiology, University Hospital Jean Minjoz, 3 Boulevard Fleming, 25000, Besançon, France.,EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Laurent Bertoletti
- Department of Vascular and Therapeutic Medicine, Saint-Etienne University Hospital, Saint-Etienne, France.,INSERM CIC1408 and INSERM UMR 1059, Saint-Etienne, France.,F-CRIN, INNOVTE, Saint-Etienne, France
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias I Pujol, Badalona, Barcelona, Spain
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Jean Minjoz, 3 Boulevard Fleming, 25000, Besançon, France.,EA3920, University of Burgundy Franche-Comté, Besançon, France.,F-CRIN, INNOVTE, Saint-Etienne, France
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