Comparison of PESI, echocardiogram, CTPA, and NT-proBNP as risk stratification tools in patients with acute pulmonary embolism

The correlation between the CT angiographic pulmonary artery obstructive index and clinical data in patients with acute pulmonary thromboembolism

PURPOSE

The potentially fatal consequences of pulmonary embolism emphasize the need for more effective diagnostic methods. The Qanadli obstruction index has been described as a convenient tool for risk stratification to determine and quantify the degree of obstruction. This study aimed to assess the correlations between the Qanadli index with clinical and paraclinical findings (D-dimer, troponin, and echocardiographic findings) in patients with pulmonary embolism.

MATERIALS AND METHODS

A total of 102 patients with pulmonary embolism underwent echocardiography and CT pulmonary angiography at a single tertiary referral center between 2019 and 2020. The clinical and paraclinical findings, pulmonary arterial obstruction index, atrial measurements, right and left ventricle size and function, tricuspid annular plane systolic excursion, pulmonary artery pressure, and pulmonary hypertension (PH) were analyzed. Vital signs were recorded and assessed. The Qanadli index score was measured, and graded risk stratification was measured based on the quantified index score.

RESULTS

The total mean Qanadli index was 28.75 ± 23.75, and there was no significant relationship between the Qanadli index and gender. Patients' most common clinical findings were exertional dyspnea (84.3%; n = 86) and chest pain (71.7%; n = 73). There were significant correlations between the Qanadli index and pulse rate (PR), troponin, D-dimer levels, and PH. Four patients died during the study, including one from a cardiac condition and three with non-cardiac conditions.

CONCLUSIONS

It is possible to determine the severity, prognosis, and appropriate treatment by the Qanadli index based on strong correlations with PR, troponin, D-dimer levels, and PH.

Clot ratio, new clot burden score with deep learning, correlates with the risk stratification of patients with acute pulmonary embolism

Background

Risk stratification for patients with acute pulmonary embolism (APE) is significantly important for treatment and prognosis evaluation. We aimed to develop a novel clot burden score on computed tomography pulmonary angiography (CTPA) based on deep learning (DL) algorithm for risk stratification of APE.

Methods

The study retrospectively enrolled patients newly diagnosed with APE in China-Japan Friendship Hospital consecutively. We collected baseline data and CTPA parameters, and calculated four different clot burden scores, including Qanadli score, Mastora score, clot volume and clot ratio. The former two were calculated by two radiologists separately, while clot volume and clot ratio were based on the DL algorithm. The area under the curve (AUC) of four clot burden scores were analyzed.

Results

Seventy patients were enrolled, including 17 in high-/intermediate-high risk and 53 in low-/intermediate-low risk. Clot burden was related to the risk stratification of APE. Among four clot burden scores, clot ratio had the highest AUC (0.719, 95% CI: 0.569-0.868) to predict patients with higher risk. In the patients with hemodynamically stable APE, only clot ratio presented statistical difference (P=0.046).

Conclusions

Clot ratio is a new imaging marker of clot burden which correlates with the risk stratification of patients with APE. Higher clot ratio may indicate higher risk and acute right ventricular dysfunction in patients with hemodynamically stable status.

Application of CT pulmonary angiography and echocardiography in acute pulmonary embolism: A cross-sectional study

Background

Pulmonary Embolism (PE) is an acute and potentially fatal condition defined as the blockage of pulmonary arteries by an embolism that can be from various origins.

Objective

The present study aimed to investigate the findings of computed tomography pulmonary angiography (CTPA) and echocardiography in patients with acute PE.

Methods

The present cross-sectional study included some patients with clinical manifestations of PE who underwent CTPA and echocardiography. The radiologic findings, PE severity, and outcome of the patients were recorded. Moreover, echocardiography was performed by an expert cardiologist using a high-resolution device, while CTPA was performed by an expert radiologist using a 16-slice device and a two-step selective test bolus method.

Results

According to our findings, a total number of 147 patients were diagnosed with PE, including 44 (29.93%), 44 (29.93%), and 59 (40.14%) cases of mild, moderate, and severe PE, respectively. Moreover, 25 patients (17%) finally expired due to PE. Regarding the CTPA findings, 31 patients (21.1%) had septum flattening, while 35 (23.8%) had a septum deviation toward the left ventricle. Also, there were significant correlations between mortality and some CTPA findings, including severe PE (p < 0.001), the presence of septal deviation (p = 0.007), and higher diameters of the main pulmonary artery (p < 0.001) and right ventricle (p = 0.008).

Conclusion

CTPA is a valid and accessible modality for diagnosing and evaluating PE in suspected patients. Moreover, several findings in CTPA could predict adverse outcomes, such as death, in patients with PE.

Filler-induced non-thrombotic pulmonary embolism after genital aesthetic injection

Genital aesthetic procedures have increased in popularity among women and men. Many clinicians tried to expand the application of fill injection by using it for genital aesthetic injection. However, this procedure is not so safe as imagined and may lead to a fatal complication of pulmonary embolism. This article summarizes the clinical manifestations and proposed mechanism of the filler-induced non-thrombotic pulmonary embolism (FINTPE) cases. A literature review was performed with the search keywords including "genital aesthetic injection, vaginal injection, vaginoplasty, vaginal tightening, penile augmentation, penis injection, hyaluronic acid, fat grafting, pulmonary embolism, alveolar hemorrhage, hypoxemia, and dyspnea." Among the 14 cases from 11 articles enrolled, 12 patients were female, and two were male. Eight patients received silicone injection, followed by two received fat grafting and hyaluronic acid injection, respectively. All the female patients had one single injection site, including 11 cases for the vaginal wall and one for G-spot, while all the male patients received injections into the penis and scrotum. The main symptoms were dyspnea and chest pain. Almost 60% of FINTPE patients presented respiratory disorders within 12 hours post-operation. Treatment includes oxygen therapy, corticosteroids, and anticoagulation. Five patients improved with an average of 14.6-day treatment, and seven died due to organ failures. Genital aesthetic filler injections are experimental procedures without being strictly reviewed or approved. As a severe complication following these procedures, FINTPE requires cautious performance, careful prevention, timely identification, and treatment to decrease its incidence and mortality.

Predictive Value of MPV and Plasma NT-ProBNP Combined with the Simplified Geneva Scale for the Prognosis of Acute Pulmonary Embolism

OBJECTIVE

To explore the predictive value of mean platelet volume (MPV) and plasma N-terminal probrain natriuretic peptide (NT-ProBNP) combined with a simplified Geneva scale for the prognosis of acute pulmonary embolism (APE).

METHODS

The clinical data of 68 patients with APE admitted to our hospital from October 2017 to October 2019 were collected. According to the prognosis, the patients were divided into a good prognosis group (n = 45) and a poor prognosis group (n = 23). The clinical data, laboratory clinical indexes, and simplified Geneva scale scores were recorded for the two groups. The risk factors of poor prognosis were analyzed by binary multivariate logistic regression analysis; the predictive ability of each index on the prognosis of patients with APE was analyzed by the ROC curve.

RESULTS

The incidences of deep vein thrombosis, diabetes, and hyperlipidemia in the poor prognosis group were higher than those in the good prognosis group (P < 0.05). PLT, platelet distribution width (PDW), MPV, and plasma NT-ProBNP in the poor prognosis group were higher than those in the good prognosis group (P < 0.05). The simplified Geneva scale score of the poor prognosis group was higher than that of the good prognosis group (P < 0.05). PDW, MPV, plasma NT-ProBNP, and simplified Geneva scale were all independent risk factors for the poor prognosis of APE patients (P < 0.05). The AUC of MPV in predicting the prognosis of APE patients was 0.818 (95% CI: 0.712-0.925). When the optimal cutoff value was 0.571, the sensitivity was 77.1%, and the specificity was 80.0%. The AUC of plasma NT-ProBNP in predicting the prognosis of APE patients was 0.762 (95% CI: 0.634-0.891). When the optimal cutoff value was 0.475, the sensitivity was 71.5%, and the specificity was 76.0%. The AUC of the simplified Geneva scale in predicting the prognosis of APE patients was 0.749 (95% CI: 0.618-0.879). When the optimal cutoff value was 0.469, the sensitivity was 82.9%, and the specificity was 64.0%. The AUC of MPV and plasma NT-ProBNP combined with the simplified Geneva scale in predicting the prognosis of APE patients was 0.907 (95% CI: 0.826-0.988). When the optimal cutoff value was 0.726, the sensitivity was 88.6%, and the specificity was 84.0%.

CONCLUSION

MPV, plasma NT-ProBNP, and simplified Geneva scale have a certain predictive value for the prognosis of APE. Compared with a single index, the combination of the three indexes has a significant improvement in predicting the prognosis of APE and has better clinical value.

Detection of right ventricular dysfunction in acute pulmonary embolism by computed tomography or echocardiography: A systematic review and meta-analysis

BACKGROUND

Right ventricular (RV) dysfunction predicts worse outcomes in acute pulmonary embolism (PE). Because computed tomography (CT) pulmonary angiography visualizes cardiac structures, it is a potential method for assessing RV function without the delays associated with inpatient echocardiography.

OBJECTIVES

We conducted a systematic review and meta-analysis to assess the diagnostic accuracy of CT scan findings for detecting RV dysfunction compared with echocardiography.

METHODS

We searched MEDLINE and EMBASE from inception to April 2020 for studies comparing RV dysfunction on CT scan with echocardiography standard. Study quality was assessed with the QUADAS-2 risk of bias tool. Meta-analysis was performed using a bivariate mixed effects regression framework.

RESULTS

After screening, 26 studies (3508 patients) were included. In a pooled analysis, septal deviation (5 studies; 459 patients) had a sensitivity of 0.31 (95% CI 0.25-0.38; I2  = 0%), specificity of 0.98 (95% CI 0.90-1.00; I2  = 59.4%), and positive likelihood ratio of 13.6 (95% CI 3.1-60.4) for RV dysfunction compared with echocardiography. The pooled sensitivity of increased RV/left ventricular ratio (21 studies; 3111 patients) was 0.83 (95% CI 0.78-0.87; I2  = 81.8%), whereas the pooled specificity was 0.75 (95% CI 0.66-0.82; I2  = 94.2%) and negative likelihood ratio was 0.23 (0.18-0.29).

CONCLUSIONS

Overall, RV dysfunction can be detected by CT imaging but the diagnostic accuracy when compared with echocardiography varies depending on specific findings. The presence of septal bowing appears to be highly specific for RV dysfunction. Our findings suggest that multiple CT findings of RV dysfunction may improve diagnostic accuracy and further studies are warranted.

Prognostic significance of computed tomography-assessed right ventricular enlargement in low-risk patients with pulmonary embolism: Systematic review and meta-analysis

BACKGROUND

For patients with acute low-risk pulmonary embolism (PE), determined by a validated clinical prognostic score, the additive prognostic significance of computed tomography (CT)-assessed right ventricular (RV) enlargement is uncertain.

METHODS

We performed a systematic review and meta-analysis of studies that enrolled patients with acute low-risk PE to assess the prognostic value of concomitant CT-assessed RV enlargement for 30-day all-cause mortality and PE-related death. We conducted unrestricted searches of PubMed and Embase through December 2019. We used a random-effects model to pool study results; Begg rank correlation method to evaluate for publication bias; and I² testing to assess for heterogeneity.

RESULTS

Of the 7 cohorts with 2197 participants who had low-risk PE and provided results on the primary outcome, 743 (34%; 95% confidence interval [CI], 32-36%) patients had concomitant RV enlargement. Six of 743 (0.8%; 95% CI, 0.3-1.8%) patients with concomitant RV enlargement died 30-days after the diagnosis of PE compared with 3 of 1454 (0.2%, 95% CI, 0-0.6%) without RV enlargement. CT-assessed RV enlargement did not have a significant association with 30-day all-cause mortality (odds ratio [OR], 2.6; 95% CI, 0.7-9.4; I² = 0%; P = 0.15) or PE-related mortality (OR, 2.8; 95% CI, 0.7-12.1; I² = 0%; P = 0.16).

CONCLUSIONS

CT-assessed RV enlargement occurs in a third of PE patients identified as low-risk by clinical scores. Mortality rate in these patients is low, and CT-assessed RV enlargement was not associated with a significantly increased risk of death within 30 days of PE diagnosis.

Risk stratification of acute pulmonary embolism based on the clot volume and right ventricular dysfunction on CT pulmonary angiography

OBJECTIVE

To test the feasibility of the clot volume and right ventricular dysfunction for risk stratification of acute pulmonary embolism (APE) patients.

METHODS

CT pulmonary angiography (CTPA) images of 158 APE patients were collected. After excluding 38 (24.1%) patients due to unsatisfactory quality, 120 APE patients (61 males and 59 females) were divided into high-risk (n = 37) and non-high-risk (n = 83) groups. Clot burden was measured by an automated programme (clot volume) and by two semi-quantitative systems (Qanadli and Mastora scores). The ratios of the right ventricular diameter to left ventricular diameter (RVd/LVd) and area (RVa/LVa) were obtained. The correlations amongst the above parameters were analysed. Receiver operating characteristic (ROC) curves were calculated to determine the efficacy of high-risk APE. Multivariate analyses were used to identify the independent predictors.

RESULTS

Strong positive correlations were found between the clot volume and both Qanadli score (r²  = 0.696, P < 0.001) and Mastora score (r²  = 0.728, P < 0.001), and moderate correlations were found between the clot volume and both RVd/LVd (r²  = 0.392, P < 0.001) and RVa/LVa (r²  = 0.389, P < 0.001). The clot volume contributed the highest efficacy (AUC = 0.992) for the identification of high-risk cases, followed by Mastora score (0.968), Qanadli score (0.952), RVa/LVa (0.900) and RVd/LVd (0.892). The clot volume and RVd/LVd were two independent factors of high-risk APE.

CONCLUSIONS

The clot volume is correlated with semi-quantitative clot burden scores and CT measured cardiac parameters. The clot volume and RVd/LVd were two independent factors of high-risk APE patients.

A new method of CT for the cardiac measurement: correlation of computed tomography measured cardiac parameters and pulmonary obstruction index to assess cardiac morphological changes in acute pulmonary embolism patients

Acute pulmonary embolism (APE) is a serious disease which is life-threatening. Since it is crucial for APE patients to assess the changes of cardiac function safely and timely, the imaging research of cardiac morphology and function is becoming more and more important. The correlation of computed tomography (CT) measured cardiac parameters and pulmonary obstruction index (POI) was analyzed to discuss the morphological changes of the heart of APE patients in order to provide a new method to evaluate cardiac functions accurately and effectively. 118 APE patients confirmed with CT pulmonary angiography (CTPA) were divided into high-risk group (47 cases, POI ≥ 20) and low-risk group (71 cases, POI < 20) according to the Qanadli Score. The left to right diameter (RL) and the anteroposterior diameter (AP) of the cardiac chambers were compared among the high-risk group, the low-risk group, and the normal group (60 cases). The correlation between CT measured cardiac parameters and the POI was analyzed. Except for left ventricular AP and right atrial AP, there were statistically significant differences (P < 0.05) in the RL and AP of the each cardiac cavity, these parameters meant that right hearts were enlarged and the left hearts were decreased in size. The ratio of right/left heart diameter was statistically significant among the three groups, a < b < c (P < 0.05). Moreover, the POI of 118 APE patients was 14.29 ± 9.53, and there was significant linear correlation between CT measured cardiac parameters and the POI (P < 0.05), excluding the left ventricular AP and right atrial AP. The correlation coefficient reached 0.5 or more in terms of the right atrial LR, the right ventricular LR, the ratio of right/left atrial diameter and the ratio of right/left ventricular diameter. With the increasing value of POI, the right atrium and right ventricular of APE patients were enlarged, and the left atrium and left ventricular were decreased in size. These heart changes can be observed by using CTPA, even non-enhanced chest CT.

Predictors for Prognosis in Patients With Nonfatal Pulmonary Embolism: A Registry-Based Cohort Study

The article's aim was to determine predictors for short- and long-term prognosis of patients with pulmonary embolism (PE). Cohort prospective study based on the National registry on venous thromboembolism. Eighty-four patients with PE, on age 60.3 + 12.5 years, were selected and followed up in a prospective study. Pulmonary embolism was confirmed by computed tomography angiography in all the patients, while deep venous thrombosis was confirmed by ultrasound in 21 patients. Study population was followed up for 6.7 months. Multivariate regression analysis was done where right ventricular (RV) diameter (mean 37.5 mm), systolic pulmonary artery pressure (68 ± 23 mm Hg) measured by echocardiography, d-dimer level at baseline 2654.5 ± 420.3 ng/mL, number of comorbidities (2.4 ± 0.7), and present symptoms (3.1 ± 0.9) entered the model. The model was age-adjusted. d-dimer level was revealed as a predictor for the length of hospitalization (β = .25, P = .05) and RV diameter as a factor for duration of anticoagulation (β = .29, P = .05). Our results imply that the baseline measurement of these parameters independently influence both the short-term and long-term prognosis of patients with nonfatal PE.