Delayed anticoagulation is associated with poor outcomes in high-risk acute pulmonary embolism

New Diagnostic Tools for Pulmonary Embolism Detection

The presentation of pulmonary embolism (PE) varies from asymptomatic to life-threatening, and management involves multiple specialists. Timely diagnosis of PE is based on clinical presentation, D-dimer testing, and computed tomography pulmonary angiogram (CTPA), and assessment by a Pulmonary Embolism Response Team (PERT) is critical to management. Artificial intelligence (AI) technology plays a key role in the PE workflow with automated detection and flagging of suspected PE in CTPA imaging. HIPAA-compliant communication features of mobile and web-based applications may facilitate PERT workflow with immediate access to imaging, team activation, and real-time information sharing and collaboration. In this review, we describe contemporary diagnostic tools, specifically AI, that are important in the triage and diagnosis of PE.

Predicting Hospital Survival in Patients Admitted to ICU with Pulmonary Embolism

OBJECTIVE

The Pulmonary Embolism Severity Index (PESI) and simplified PESI (sPESI) predict mortality for patients with PE. We compared PESI/sPESI to the Acute Physiology and Chronic Health Evaluation IV (APACHE-IV) in predicting mortality in patients with PE admitted to the intensive care unit (ICU). Additionally, we assessed the performance of a novel ICU-sPESI score created by adding three clinical variables associated with acuity of PE presentation (intubation, confusion [altered mental status], use of vasoactive infusions) to sPESI.

MATERIALS AND METHODS

Using the eICU Collaborative Research Database from 2014 to 2015, we conducted a large retrospective cohort study of adult patients admitted to the ICU with a primary diagnosis of PE. We calculated APACHE-IV, PESI, sPESI, and ICU-sPESI scores and compared their performance for predicting in-hospital mortality using area under the receiver operating characteristic (AUROC) curve. Score thresholds for >99% negative predictive values (NPV) were calculated for each score. Survival was estimated using the Kaplan-Meier method.

RESULTS

We included 1424 PE cases. In-hospital mortality was 6.3% [95% CI: 5.1%-7.6%]. AUROC for APACHE-IV, PESI, and sPESI were 0.870, 0.848, and 0.777, respectively. APACHE-IV and PESI outperformed sPESI (P < 0.01 for both comparisons), while APACHE-IV and PESI demonstrated similar performance (P = 0.322). The ICU-sPESI performance was similar to APACHE-IV and PESI (AUROC = 0.847; AUROC comparison: APACHE-IV vs ICU-sPESI: P = 0.396; PESI vs ICU-sPESI: P = 0.945). Hospital mortality for ICU-sPESI scores 0-2 was 1.1%, and for scores 3, 4, 5, 6, and ≥7 was 8.6%, 11.7%, 29.2%, 37.5%, and 76.9%, respectively. Score thresholds for >99% NPV were ≤48 for APACHE-IV, ≤115 for PESI, and 0 points for sPESI and ICU-sPESI.

CONCLUSIONS

By accounting for severity of PE presentation, our newly proposed ICU-sPESI score provided improved PE mortality prediction compared to the original sPESI score and offered excellent discrimination of mortality risk.

Management of high-risk pulmonary embolism in the emergency department: A narrative review

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.

Influencing factors on the time to CT in suspected pulmonary embolism: an explorative investigation

Pulmonary embolism is a potentially fatal condition with increased mortality if anticoagulation is delayed. This study aimed to find influencing factors on the duration from requesting a computed tomography (CT) pulmonary angiography (CTPA) to performing a CTPA in suspected acute pulmonary embolism. In 1849 cases, automatically generated time data were extracted from the radiological information system. The impact of the distance to the scanner, case-related features (sector of patient care, triage), and workload (demand for CTs, performed CTs, available staff, hospital occupancy) were investigated retrospectively using multiple regression. The time to CTPA was shorter in cases from the emergency room (ER) than in inpatients and outpatients at distances below 160 m and 240 m, respectively. While requests from the ER were also performed faster than cases from regular wards (< 180 m), no difference was found between the ER and intensive care units. Compared to "not urgent" cases, the workflow was shorter in "urgent" (- 17%) and "life-threatening" (- 67%) situations. The process was prolonged with increasing demand (+ 5%/10 CTs). The presented analysis identified relevant in-hospital influences on the CTPA workflow, including the distance to the CT together with the sector of patient care, the case triage, and the demand for imaging.

Addressing the rising trend of high-risk pulmonary embolism mortality: Clinical and research priorities

BACKGROUND

Deaths from high-risk pulmonary embolism (PE) appear to have increased in the US over the last decade. Modifiable risks contributing to this worrisome trend present opportunities for physicians, researchers, and healthcare policymakers to improve care.

METHODS

We sought to contextualize contemporary, high-risk PE epidemiology and examine clinical trials, quality improvement opportunities, and healthcare policy initiatives directed at reducing mortality.

RESULTS

We observed significant and modifiable excess mortality due to high-risk PE. We identified several opportunities to improve care including: (1) rapid translation of forthcoming data on reperfusion strategies into clinical practice; (2) improved risk stratification tools; (3) quality improvement initiatives to address presumptive anticoagulation practice gaps; and (3) adoption of health policy initiatives to establish pulmonary embolism response teams and address the social determinants of health.

CONCLUSION

Addressing knowledge and practice gaps in intermediate and high-risk PE management must be prioritized and informed by forthcoming high-quality data. Implementation efforts are needed to improve acute PE management and resolve treatment disparities.

Decreased Hospital Length of Stay for ICH and PE after Adoption of an Artificial Intelligence-Augmented Radiological Worklist Triage System

The purpose of the study was to determine whether there was a difference in the length of stay (LOS) for inpatients diagnosed with intracranial hemorrhage (ICH) or pulmonary embolism (PE) prior to and following implementation of an (AI) triage software. A retrospective review was performed for patients that underwent CT imaging procedures related to ICH and PE from April 2016 to October 2019. All patient encounters that included noncontrast head computed tomography (CT) or CT chest angiogram (CTCA) procedures, identified by the DICOM study descriptions, from April 2016 to April 2019 were included for ICH and PE, respectively. All patients that were diagnosed with ICH or PE were identified using ICD9 and ICD10 codes. Three separate control groups were defined as follows: (i) all remaining patients that underwent the designated imaging studies, (ii) patients diagnosed with hip fractures, and (iii) all hospital wide encounters, during the study period. Pre-AI and post-AI time periods were defined around the deployment dates of the ICH and PE modules, respectively. The reduction in LOS was 1.30 days (95% C.I. 0.1–2.5), resulting in an observed percentage decrease of 11.9% (p value = 0.032), for ICH and 2.07 days (95% C.I. 0.1–4.0), resulting in an observed percentage decrease of 26.3% (p value = 0.034), for PE when comparing the pre-AI and post-AI time periods. Reductions in LOS were observed in the ICH pre-AI and post-AI time period group for patients that were not diagnosed with ICH, but that underwent related imaging, 0.46 days (95% C.I. 0.1–0.8) resulting in an observed percentage decrease of 5% (p value = 0.018), and inpatients that were diagnosed with hip fractures, 0.60 days (95% C.I. 0.1–1.2) resulting in an observed percentage decrease of 8.3% (p value = 0.004). No other significant decrease in length of stay was observed in any of the other patient groups. The introduction of computer-aided triage and prioritization software into the radiological workflow was associated with a significant decrease in length of stay for patients diagnosed with ICH and PE.

Pharmacists as members of an interdisciplinary pulmonary embolism response team

Introduction

Pulmonary embolism response teams (PERTs) were developed to assist with diagnosis, risk stratification, and management of intermediate and high-risk pulmonary embolism (PE) and have been shown to reduce 90-day mortality. The pharmacist's role on the PERT is not well defined.

Objectives

Describe the pharmacist's role as a PERT member and determine if pharmacists can improve time to anticoagulation and promote use of low molecular weight heparin (LMWH) instead of unfractionated heparin (UFH).

Methods

A retrospective, observational study of adult patients with massive or submassive PE between January 2014 and May 2020. Patient demographics, clinical variables, anticoagulation treatment/timing, and pharmacist activities during PERT response were evaluated. Patients were divided into three groups for comparisons (pre-PERT vs post-PERT with a pharmacist vs post-PERT without a pharmacist). Wilcoxon rank-sum or Kruskal-Wallis test and chi-squared analysis were used for continuous and categorical data, respectively.

Results

A total of 573 patients were included (mean age 63.2 ± 15.6 years, 54% male, 78% submassive PE); 137 in the pre-PERT and 436 in the post-PERT groups. Within the post-PERT group, 305 patients (70%) had a pharmacist as a member of the PERT, of which 222 (73%) had a documented pharmacotherapy-related intervention/activity. Most (n = 178, 58%) involved a pharmacist facilitating ordering/administration of an anticoagulant/thrombolytic. Median time from diagnosis to anticoagulation was significantly reduced in the post-PERT groups (pre-PERT: 104 minutes [IQR 124.5], post-PERT with a pharmacist: 63 minutes [IQR 84], post-PERT without a pharmacist: 75.5 minutes [IQR 113], P = .0001). More patients in the post-PERT groups received LMWH compared to UFH when a pharmacist was involved vs without a pharmacist (69.5% vs 53.3%, P = .0019) and major bleeding events were reduced (pre-PERT: 14.6%, post-PERT with a pharmacist: 4.6%, and post-PERT without a pharmacist: 9.9%, P = .0013).

Conclusion

Pharmacists have an active role on the PERT and their involvement was associated with a shorter diagnosis to anticoagulation time, increased LMWH use, and fewer major bleeding events.

Time series analysis of the in-hospital diagnostic process in suspected pulmonary embolism evaluated by computed tomography: An explorative study

PURPOSE

This retrospective study aims to analyze the distribution of demand and the duration of the diagnostic workup of suspected pulmonary embolism (PE) using computed tomography pulmonary angiography (CTPA).

METHODS

Time data from physical examination to report creation were identified for each CTPA in 2013 and 2018 at a tertiary hospital. Multivariable multinomial logistic and linear regression models were used to evaluate differences between 3 time intervals (I1: 6am-2pm, I2: 2pm-10pm, I3: 10pm-6am). A cosinor model was applied to analyze the amount of CTPA per hour.

RESULTS

The relative demand for CTPA from the emergency room was lower in l1 compared to l2 and l3 (I1/I2: odds ratio (OR) 0.84, 95 % confidence interval (CI) 0.78-0.91; I1/I3: OR 0.80, 95 % CI 0.72-0.89; peak 4:23 pm). Requests for in-patients displayed a tendency towards I1 (I1/2: OR 1.15, 95 % CI 1.06-1.24; l1/l3: OR 1.19, 95 % CI 1.07-1.33; peak 1:54 pm). The time from CTPA request to study was shorter in I3 compared to I1 and I2 in 2013 (I1/I3: ratio 5.23, 95 % CI 3.38-8.10; I2/I3: ratio 3.50, 95 % CI 2.24-5.45) and 2018 (I1/I3: ratio 2.27, 95 % CI 1.60-3.22; I2/I3: ratio 2.11, 95 % CI 1.50-2.97). This applied similarly to fatal cases (I1/I3: ratio 2.91, 95 % CI 1.78-4.75; I2/I3: ratio 2.45, 95 % CI1.52-3.95).

CONCLUSIONS

The temporal distribution of demand for CTPA depends on the sector of patient care and the processing time differs substantially during the day. Time series analysis can reveal such coherences and may help to optimize workflows in radiology departments.

Challenging anticoagulation cases: A case of acute pulmonary embolism in a patient with chronic thrombocytopenia

We present a case of acute pulmonary embolism in a patient with myelofibrosis and thrombocytopenia. The patient had a history of portal vein thrombosis and had taken warfarin for the past six years. At the time of his pulmonary embolism diagnosis, his INR was 1.5 and platelet count 58 × 10⁹/L. This article discusses how to balance the risk of thrombosis against the risk of bleeding, and reviews the options for pulmonary embolism treatment including transition to low-molecular-weight heparin, direct oral anticoagulants and/or inferior vena cava filters.

Pulmonary embolism during the COVID-19 pandemic: Decline in diagnostic procedures and incidence at a university hospital

BACKGROUND

The COVID-19 pandemic has focused medical attention on treating affected patients and protecting others from infection. However, concerns have been raised regarding the pandemic´s impact and associated containment measures (eg curfew, lockdown) on non-coronavirus disease 2019 (COVID-19)-related acute medical diseases.

OBJECTIVES

To investigate changes in the incidence of pulmonary embolism (PE) during the COVID-19 pandemic compared to the period before the pandemic and reference periods in previous years.

METHODS

In this single-center study, we explored all diagnostic imaging tests performed for suspected PE between weeks 1 and 17 of the years 2018, 2019, and 2020. Incidence of PE (ie, primary outcome) was analyzed. Secondary outcomes included number of imaging tests for suspected PE.

RESULTS

Compared to weeks 1 to 11, 2020, an abrupt decline in PE diagnosis (mean weekly rate, 5.2; 95% confidence interval [CI], 3.8-6.6 vs 1.8; 95% CI, 0.0-3.6) and imaging tests (mean weekly rate, 32.5; 95% CI, 27.5-37.6 vs. 17.3; 95% CI, 11.6-23.1) was observed from week 12, with beginning of the containment measures and public lockdown in Austria. Compared to weeks 12 to 17 of 2018 and 2019, PE incidence and imaging tests were similarly decreased from 5.3 (95% CI, 3.6-7.1) to 1.8 (95% CI, 0.0-3.6) and 31.5 (95% CI, 27.1-35.9) to 17.3 (95% CI, 11.6-23.1), respectively. The median simplified pulmonary embolism severity index (sPESI) score of PE patients during the pandemic was higher than in all other PE patients (3; interquartile range, 1-3 vs 1; interquartile range, 0-2; P = .002).

CONCLUSION

Our study demonstrates that the COVID-19 pandemic has an impact on non-COVID-19-related acute diseases as shown by the decline in incidence of PE and imaging procedures for diagnostic workup. Further studies from other hospitals are needed to confirm our findings.

Analysis of Partial Thromboplastin Times in Patients With Pulmonary Embolism During the First 48 Hours of Anticoagulation With Unfractionated Heparin

OBJECTIVE

The objective was to determine the proportion of patients with pulmonary embolism (PE) treated with unfractionated heparin (UFH) who achieved therapeutic activated partial thromboplastin time (aPTT) values within 48 hours of treatment.

METHODS

Retrospective analysis of a PE response team (PERT) database was performed at a large, urban, academic teaching hospital. Inclusion criteria were adult patients with acute PE for whom the PERT was consulted and who received anticoagulation (AC) with UFH according to guideline standard dosing. aPTT values during 6-hour time periods during the first 48 hours of AC were collected and analyzed.

RESULTS

A total of 505 patients met inclusion criteria. For patients receiving a bolus and infusion of UFH, the proportions (95% confidence interval [CI]) of patients in the therapeutic range were 19.0% (14.2% to 25.0%) at 12 hours, 26.3% (26.3% to 33.1%) at 24 hours, 28.3% (22.0% to 35.4%) at 36 hours, and 28.4% (20.8% to 37.5%) at 48 hours. For titrated infusion only, the proportions (95% CIs) of patients were 23.3% (16.2% to 32.3%) at 12 hours, 41.4% (31.6% to 51.9%) at 24 hours, 37.0% (26.8% to 48.5%) at 36 hours, and 42.1% (30.2% to 55.0%) at 48 hours. No patient had all therapeutic aPTT values.

CONCLUSIONS

The majority of patients with acute PE spend most of their first 48 hours outside of the therapeutic range of AC when treated with guideline standard dosing of UFH. Over half of the patients fail to achieve any therapeutic PTT level within 24 hours of UFH initiation, and no patient had all therapeutic aPTTs. Future research should focus on identifying factors associated with achieving therapeutic AC with UFH.

Evaluation of Time to Therapeutic Anticoagulation and Associated Outcomes in Critically Ill, Obese Patients With Pulmonary Embolism Receiving Unfractionated Heparin

BACKGROUND

Delays in time to therapeutic activated partial thromboplastin time (aPTT) have been associated with poor outcomes in patients with acute pulmonary embolism (PE).

OBJECTIVE

To investigate the relationship between time to therapeutic anticoagulation and in-hospital mortality in critically ill, obese patients with acute PE.

METHODS

This study examined 204 critically ill patients with a body mass index (BMI) ≥30 kg/m² receiving unfractionated heparin (UFH) for PE treatment. Patients achieving therapeutic anticoagulation within 24 hours of UFH initiation (early) were compared to those in >24 hours (delayed). Additional end points included 30-day mortality, median time to therapeutic aPTT, proportion of therapeutic and supratherapeutic aPTT values, hemodynamic deterioration, thrombolytic therapy after UFH initiation, length of stay, and bleeding.

RESULTS

No difference in in-hospital or 30-day all-cause mortality was seen (odds ratio [OR]: 1.33, confidence interval [CI]: 0.647-2.72; OR: 1.003, CI: 0.514-1.96). Patients in the early group had a greater proportion of therapeutic aPTT values (66.7% vs 50%, P < .001) and higher percentage of supratherapeutic aPTT values (20.9% vs 11.3%, P < .001); however, no increase in clinically significant bleeding was evident (15.2% vs 10.9%, P = .366).

CONCLUSION

In this population, a shorter time to therapeutic aPTT was not associated with improved survival.

Mortality Related Risk Factors in High-Risk Pulmonary Embolism in the ICU

Introduction. We sought to identify possible risk factors associated with mortality in patients with high-risk pulmonary embolism (PE) after intensive care unit (ICU) admission. Patients and Methods. PE patients, diagnosed with computer tomography pulmonary angiography, were included from two ICUs and were categorized into groups: group 1 high-risk patients and group 2 intermediate/low-risk patients. Results. Fifty-six patients were included. Of them, 41 (73.2%) were group 1 and 15 (26.7%) were group 2. When compared to group 2, need for vasopressor therapy (0 vs 68.3%; p < 0.001) and need for invasive mechanical ventilation (6.7 vs 36.6%; p = 0.043) were more frequent in group 1. The treatment of choice for group 1 was thrombolytic therapy in 29 (70.7%) and anticoagulation in 12 (29.3%) patients. ICU mortality for group 1 was 31.7% (n = 13). In multivariate logistic regression analysis, APACHE II score >18 (OR 42.47 95% CI 1.50–1201.1), invasive mechanical ventilation (OR 30.10 95% CI 1.96–463.31), and thrombolytic therapy (OR 0.03 95% CI 0.01–0.98) were found as independent predictors of mortality. Conclusion. In high-risk PE, admission APACHE II score and need for invasive mechanical ventilation may predict death in ICU. Thrombolytic therapy seems to be beneficial in these patients.