Enfermedad tromboembólica pulmonar. Manejo clínico de la enfermedad aguda y crónica

Optimal Mean Arterial Pressure Within 24 Hours of Admission for Patients With Intermediate-Risk and High-Risk Pulmonary Embolism

We aimed to determine whether the average mean arterial pressure (aMAP) in the first 24 hours of hospital admission is useful in predicting short-term outcomes of patients with intermediate- and high-risk pulmonary embolism (PE). We conducted a single-center retrospective study. From May 2012 to April 2019, 122 patients with intermediate- and high-risk PE were included. The primary outcome was in-hospital mortality. The secondary outcome was adverse events. Receiver operating characteristic (ROC) curves and cutoff values for aMAP predicting in-hospital death were computed. According to cutoff values, we categorized 5 groups defined as follows: group 1: aMAP < 70 mm Hg; group 2: 70 mm Hg ≤ aMAP < 80 mm Hg; group 3: 80 mm Hg ≤ aMAP < 90 mm Hg; group 4: 90 mm Hg ≤ aMAP <100 mm Hg; and group 5: aMAP ≥ 100 mm Hg. Cox regression models were calculated to investigate associations between aMAP and in-hospital death. In the study group of 122 patients, 15 (12.30%) patients died in the hospital due to PE. The ROC analysis for MAP predicting in-hospital death revealed an area under the curve of 0.729 with a cutoff value of 79.4 mm Hg. Cox regression models showed a significant association between in-hospital death and aMAP group 1 (ref), aMAP group 2 (odds ratio [OR] = 1.680, 95% CI: 0.020-140.335), aMAP group 3 (OR = 0.003, 95% CI: 0.0001-0.343), aMAP group 4 (OR = 0.006, 95% CI: 0.0001-1.671), and aMAP group 5 (OR = 0.003, 95% CI: 0.0001-9.744). In particular, those with an aMAP of 80 to 90 mm Hg had minimum adverse events. The optimal range of MAP for patients with intermediate- and high-risk PE may be 80 to 90 mm Hg.

Prospective Randomized Comparison of High-pitch CT at 80 kVp Under Free Breathing with Standard-pitch CT at 100 kVp Under Breath-Hold for Detection of Pulmonary Embolism

RATIONALE AND OBJECTIVES

To prospectively compare high-pitch computed tomography (HPCT) under free breathing (FB) with standard-pitch CT (SPCT) under breath-hold (BH) for detection of pulmonary embolism (PE).

MATERIALS AND METHODS

One hundred consecutive patients (47 females; mean age 58.7 ± 16.6) randomly underwent HPCT-FB (n = 50) or SPCT-BH (n = 50). Radiation doses were documented. One reader measured pulmonary artery attenuation and noise; mean signal-to-noise ratio (SNR) was calculated. Two readers assessed image quality, diagnostic confidence for detection of PE, motion artifacts, assessability of anatomical structures, and presence of transient interruption of contrast as sign of Valsalva maneuver. Inter-reader agreement was calculated.

RESULTS

Radiation dose was significantly lower in HPCT compared to SPCT (2.68 ± 0.60 mGy vs 6.01 ± 2.26 mGy; P < .001). Mean pulmonary artery attenuation and image noise were significantly higher in HPCT (attenuation: 479 Hounsfield unit (HU) vs 343HU; P < .001; noise: 16 HU vs 10 HU; P < .001) whereas SNR was similar between groups (34 HU vs 38 HU; P = .258). HPCT had significantly higher diagnostic confidence for PE detection (P = .048), less cardiac and breathing artifacts (P < .001), better assessability of anatomical structures, and fewer cases of transient interruption of contrast (P < .001) compared to the SPCT.

CONCLUSIONS

HPCT-FB allows for a significant reduction of breathing and motion artifacts compared to SPCT-BH. Diagnostic confidence, assessability of vascular and bronchial structures, as well as SNR are maintained.

Cardiac arrest during a twin birth caesarean delivery

The case of a 35 year-old pregnant woman with a right ovarian vein thrombosis complicated with a floating thrombus in the inferior vena cava reaching the right atrium, is presented. The patient had a cardiac arrest due to a pulmonary embolism during a twin-birth caesarean delivery. Discussion includes the pathophysiology of this condition and management options in a cardiac arrest secondary to this aetiology, recovered with stable blood pressure, highlighting the role of thrombolytic therapy in the Postoperative Care Unit in this situation.

[Acute massive pulmonary embolism with thrombus entrapped in patent foramen ovale]

Thromboembolic disease is a potentially severe pathology, which can represent a life threat if it is not diagnosed early, especially when the cardiopulmonary backup is limited. When its clinical feature implies a massive occlusion of the arterial pulmonary tree and a cardiac failure is ensued, it can be seriously life threatening, even for young patients. Less frequent features as right or left atrium thrombosis could increase de morbidity and mortality of this disease. We present the case of a young woman with severe respiratory insufficiency. The CT pulmonary angiography revealed an acute massive pulmonary embolism, with a right atrium thrombus extending towards the left atrium, through a patent foramen ovale. We discuss the imaging characteristics and the importance of the precise information obtained with the CT pulmonary angiography, essential in the rapid establishment of a given treatment protocol and an outcome prognosis for the patient.

[Pulmonary circulation: what has 2010 brought?]

In both thromboembolic disease and pulmonary hypertension, 2010 has been a prodigious year for interesting publications. Some data have helped to elucidate the factors associated with a greater risk of thromboembolic disease, such as long journeys and certain polymorphisms. New recommendations on diagnosis have been made, giving a greater role to computed tomography angiography. Magnetic resonance imaging is also gaining ground. More accurate risk evaluation is one of the objectives of the new guidelines of the European Society of Cardiology, which substitute some terms such as massive or submassive for high- and low-risk. Maintaining anticoagulation indefinitely in idiopathic pulmonary thromboembolism is recommended. Evidence on the efficacy of new drugs such as rivaroxaban, dabigatran and indraparinux is beginning to appear. In pulmonary hypertension, smoking seems to play a role as a risk factor. Some registries indicate that new treatments have not improved survival. Greater knowledge has been gained of the role of inflammation in the pathogenesis of the disease and a Spanish study supports the role of the 6-minute walk test in patient evaluation. Some drugs are highlighted in the literature. Imatinib is promising but probably only in some patients. Riociguat provides good results and inhaled treprostinil has emerged as a new option.