N-terminal Pro-B type natriuretic peptide as long-term predictor of death after an acute pulmonary embolism

Recombinant hirudin attenuates pulmonary hypertension and thrombosis in acute pulmonary embolism rat model

Background

Acute pulmonary embolism (APE) is classified as a subset of diseases that are characterized by lung obstruction due to various types of emboli. Current clinical APE treatment using anticoagulants is frequently accompanied by high risk of bleeding complications. Recombinant hirudin (R-hirudin) has been found to have antithrombotic properties. However, the specific impact of R-hirudin on APE remains unknown.

Methods

Sprague-Dawley (SD) rats were randomly assigned to five groups, with thrombi injections to establish APE models. Control and APE group rats were subcutaneously injected with equal amounts of dimethyl sulfoxide (DMSO). The APE+R-hirudin low-dose, middle-dose, and high-dose groups received subcutaneous injections of hirudin at doses of 0.25 mg/kg, 0.5 mg/kg, and 1.0 mg/kg, respectively. Each group was subdivided into time points of 2 h, 6 h, 1 d, and 4 d, with five animals per point. Subsequently, all rats were euthanized, and serum and lung tissues were collected. Following the assessment of right ventricular pressure (RVP) and mean pulmonary artery pressure (mPAP), blood gas analysis, enzyme-linked immunosorbnent assay (ELISA), pulmonary artery vascular testing, hematoxylin-eosin (HE) staining, Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labeling (TUNEL) staining, immunohistochemistry, and Western blot experiments were conducted.

Results

R-hirudin treatment caused a significant reduction of mPAP, RVP, and Malondialdehyde (MDA) content, as well as H2O2 and myeloperoxidase (MPO) activity, while increasing pressure of oxygen (PaO2) and Superoxide Dismutase (SOD) activity. R-hirudin also decreased wall area ratio and wall thickness to diameter ratio in APE rat pulmonary arteries. Serum levels of endothelin-1 (ET-1) and thromboxaneB2 (TXB2) decreased, while prostaglandin (6-K-PGF1α) and NO levels increased. Moreover, R-hirudin ameliorated histopathological injuries and reduced apoptotic cells and Matrix metalloproteinase-9 (MMP9), vascular cell adhesion molecule-1 (VCAM-1), p-Extracellular signal-regulated kinase (ERK)1/2/ERK1/2, and p-P65/P65 expression in lung tissues.

Conclusion

R-hirudin attenuated pulmonary hypertension and thrombosis in APE rats, suggesting its potential as a novel treatment strategy for APE.

The Neutrophil-to-Lymphocyte Ratio’s Predictive Utility in Acute Pulmonary Embolism: Systematic Review

Acute pulmonary embolism is a cardiovascular emergency with a significant morbidity and mortality. In the last decade, attempts have been made to find prognostic markers for pulmonary embolism. We conducted a systematic review of the literature for studies that assess the relationship between the neutrophil-to-lymphocyte ratio (NLR) and disease progression in patients with pulmonary embolism. We included a total of seven studies published between 2016 and 2021, reporting on a total of 4,272 patients. The mean NLR observed in these studies was 5.93, with values ranging from 5.12 to 7.3. Elevated NLR was significantly associated with an increased rate of mortality in all studies. Furthermore, the collected data revealed a 2-to-15 times higher mortality rate in the group with NLR values higher than the mean. Due to its accessibility and the simplicity with which it can be calculated, as well as the outcomes revealed in this review, we strongly emphasize that NLR should be used more in medical practice.

Cardiovascular Mortality after Venous Thromboembolism: A Meta-Analysis of Prospective Cohort Studies

Many studies from current literature show that cardiovascular diseases in patients with venous thromboembolism (VTE) are more frequent than in the general population without VTE. However, data summarizing the impact of cardiovascular diseases on mortality of patients with VTE are lacking. In this systematic review and meta-analysis, we aimed to determine the frequency and incidence rate of cardiovascular death in patients with VTE. MEDLINE and EMBASE were searched from January 1, 2000 to February 28, 2021. Eligible studies were observational prospective cohort studies including patients with VTE and reporting all causes of death. Cardiovascular death was defined as deaths that result from new or recurrent pulmonary embolism, death due to acute myocardial infarction, sudden cardiac death or heart failure, death due to stroke, death due to cardiovascular procedures or hemorrhage, death due to ruptured aortic aneurysm or aortic dissection and death due to other cardiovascular causes. Random-effect models meta-analysis served to determine all pooled effect size of interest with their 95% confidence interval (CI). Thirteen observational studies enrolling 22,251 patients were identified and included. The mean/median age varied between 49 and 75 years. The proportion of men ranged from 38.3 to 53.2%. The overall pooled frequency of cardiovascular death in patients with VTE was 3.9% (95% CI: 2.5-5.6%), while the overall pooled frequency of all-cause mortality was 12.0% (95% CI: 9.1-15.4%). The pooled proportion of cardiovascular death among all causes of deaths in patients with VTE was 35.2% (95% CI: 22.2-49.3%). The pooled incidence rate of cardiovascular death was 1.92 per 100 patient-years (95% CI: 0-4.1). The frequency of cardiovascular death in patients with VTE was significantly higher than in patients without VTE (risk ratio: 3.85, 95% CI: 2.75-5.39). Based on this updated meta-analysis from 13 prospective cohort studies, cardiovascular death in patients with VTE is more frequent than in the general population without VTE.

Joint analysis of D-dimer, N-terminal pro b-type natriuretic peptide, and cardiac troponin I on predicting acute pulmonary embolism relapse and mortality

Previous studies on the adverse events of acute pulmonary embolism (APE) were mostly limited to single marker, and short follow-up duration, from hospitalization to up to 30 days. We aimed to predict the long-term prognosis of patients with APE by joint assessment of D-dimer, N-Terminal Pro-Brain Natriuretic Peptide (NT-ProBNP), and troponin I (cTnI). Newly diagnosed patients of APE from January 2011 to December 2015 were recruited from three hospitals. Medical information of the patients was collected retrospectively by reviewing medical records. Adverse events (APE recurrence and all-cause mortality) of all enrolled patients were followed up via telephone. D-dimer > 0.50 mg/L, NT-ProBNP > 500 pg/mL, and cTnI > 0.40 ng/mL were defined as the abnormal. Kaplan–Meier curve was used to compare the cumulative survival rate between patients with different numbers of abnormal markers. Cox proportional hazard regression model was used to further test the association between numbers of abnormal markers and long-term prognosis of patients with APE after adjusting for potential confounding. During follow-up, APE recurrence and all-cause mortality happened in 78 (30.1%) patients. The proportion of APE recurrence and death in one abnormal marker, two abnormal markers, and three abnormal markers groups were 7.69%, 28.21%, and 64.10% respectively. Patients with three abnormal markers had the lowest survival rate than those with one or two abnormal markers (Log-rank test, P < 0.001). After adjustment, patients with two or three abnormal markers had a significantly higher risk of the total adverse event compared to those with one abnormal marker. The hazard ratios (95% confidence interval) were 6.27 (3.24, 12.12) and 10.7 (4.1, 28.0), respectively. Separate analyses for APE recurrence and all-cause death found similar results. A joint test of abnormal D-dimer, NT-ProBNP, and cTnI in APE patients could better predict the long-term risk of APE recurrence and all-cause mortality.

Evaluation of cardiac biomarkers and right ventricular dysfunction in patients with acute pulmonary embolism

OBJECTIVE

Right ventricular dysfunction (RVD) with myocardial damage may lead to fatal complications in patients with acute pulmonary embolism (PE). Cytoplasmic heart-type fatty acid-binding protein (HFABP) and the N-terminal fragment of its prohormone (NT-proBNP) are sensitive and specific biomarkers of myocardial damage. We evaluated RVD and cardiac biomarkers for myocardial damage and short-term mortality in patients with acute PE.

METHODS

We analyzed 41 patients (24 females, 17 males) with confirmed acute PE prospective. Three groups (massive, submassive, and non-massive) of patients were defined, based on systemic systolic blood pressure measured on admission and RVD by transthoracic echocardiography (TTE). Also, systolic (s) and mean (m) pulmonary artery pressures (PAPs) were recorded by TTE, and plasma concentrations of cardiac troponin T (cTn-T), NT-proBNP, and HFABP were evaluated 6 month follow-up.

RESULTS

Seventeen (41.5%) patients experienced a complicated clinical course in the 6-month follow-up for the combined end-point, including at least one of the following: death (n=12, 29.3%; 3 PE-related), chronic PE (n=4, 9.8%), pulmonary hypertension (n=2, 4.9%), and recurrent PE (n=1, 2.4%). Multivariate hazard ratio analysis revealed HFABP, NT-proBNP, and PAPs as the 6-month mortality predictors (HR 1.02, 95% CI 1.01-1.05; HR 1.01, 95% CI 1.01-1.04; and HR 1.02, 95% CI 1.02-1.05, respectively).

CONCLUSION

HFABP, NT-proBNP, and PAPs measured on admission may be useful for short-term risk stratification and in the prediction of 6-month PE-related mortality in patients with acute PE.