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Wei X, Zou Y, Dong S, Chen Y, Li G, Wang B. Recombinant hirudin attenuates pulmonary hypertension and thrombosis in acute pulmonary embolism rat model. PeerJ 2024; 12:e17039. [PMID: 38590700 PMCID: PMC11000639 DOI: 10.7717/peerj.17039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 02/12/2024] [Indexed: 04/10/2024] Open
Abstract
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.
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Affiliation(s)
- Xiang Wei
- Department of Respiratory Medicine, Huzhou Central Hospital, Huzhou, Zhejiang Province, China
- Huzhou Key Laboratory of Precision Diagnosis and Treatment in Respiratory Diseases, Huzhou, Zhejiang Province, China
| | - Yanfen Zou
- Departments of Obstetrics and Gynecology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shangdong Province, China
| | - Shunli Dong
- Department of Respiratory Medicine, Huzhou Central Hospital, Huzhou, Zhejiang Province, China
- Huzhou Key Laboratory of Precision Diagnosis and Treatment in Respiratory Diseases, Huzhou, Zhejiang Province, China
| | - Yi Chen
- Department of Respiratory Medicine, Huzhou Central Hospital, Huzhou, Zhejiang Province, China
- Huzhou Key Laboratory of Precision Diagnosis and Treatment in Respiratory Diseases, Huzhou, Zhejiang Province, China
| | - Guoping Li
- Department of Respiratory Medicine, Huzhou Central Hospital, Huzhou, Zhejiang Province, China
- Huzhou Key Laboratory of Precision Diagnosis and Treatment in Respiratory Diseases, Huzhou, Zhejiang Province, China
| | - Bin Wang
- Department of Respiratory Medicine, Huzhou Central Hospital, Huzhou, Zhejiang Province, China
- Huzhou Key Laboratory of Precision Diagnosis and Treatment in Respiratory Diseases, Huzhou, Zhejiang Province, China
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Luijten D, de Jong CMM, Ninaber MK, Spruit MA, Huisman MV, Klok FA. Post-Pulmonary Embolism Syndrome and Functional Outcomes after Acute Pulmonary Embolism. Semin Thromb Hemost 2023; 49:848-860. [PMID: 35820428 DOI: 10.1055/s-0042-1749659] [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: 10/17/2022]
Abstract
Survivors of acute pulmonary embolism (PE) are at risk of developing persistent, sometimes disabling symptoms of dyspnea and/or functional limitations despite adequate anticoagulant treatment, fulfilling the criteria of the post-PE syndrome (PPES). PPES includes chronic thromboembolic pulmonary hypertension (CTEPH), chronic thromboembolic pulmonary disease, post-PE cardiac impairment (characterized as persistent right ventricle impairment after PE), and post-PE functional impairment. To improve the overall health outcomes of patients with acute PE, adequate measures to diagnose PPES and strategies to prevent and treat PPES are essential. Patient-reported outcome measures are very helpful to identify patients with persistent symptoms and functional impairment. The primary concern is to identify and adequately treat patients with CTEPH as early as possible. After CTEPH is ruled out, additional diagnostic tests including cardiopulmonary exercise tests, echocardiography, and imaging of the pulmonary vasculature may be helpful to rule out non-PE-related comorbidities and confirm the ultimate diagnosis. Most PPES patients will show signs of physical deconditioning as main explanation for their clinical presentation. Therefore, cardiopulmonary rehabilitation provides a good potential treatment option for this patient category, which warrants testing in adequately designed and executed randomized trials. In this review, we describe the definition and characteristics of PPES and its diagnosis and management.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Cindy M M de Jong
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn A Spruit
- Department of Research & Development, Ciro, Horn, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands
| | - Menno V Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Luijten D, Klok FA, van Mens TE, Huisman MV. Clinical controversies in the management of acute pulmonary embolism: evaluation of four important but controversial aspects of acute pulmonary embolism management that are still subject of debate and research. Expert Rev Respir Med 2023; 17:181-189. [PMID: 36912598 DOI: 10.1080/17476348.2023.2190888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/10/2023] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Acute pulmonary embolism (PE) is a disease with a broad spectrum of clinical presentations. While some patients can be treated at home or may even be left untreated, other patients require an aggressive approach with reperfusion treatment. AREAS COVERED (1) Advanced reperfusion treatment in hemodynamically stable acute PE patients considered to be at high risk of decompensation and death, (2) the treatment of subsegmental pulmonary embolism, (3) outpatient treatment for hemodynamically stable PE patients with signs of right ventricle (RV) dysfunction, and (4) the optimal approach to identify and treatpost-PE syndrome. EXPERT OPINION Outside clinical trials, hemodynamically stable acute PE patients should not be treated with primary reperfusion therapy. Thrombolysis and/or catheter-directed therapy are only to be considered as rescue treatment. Subsegmental PE can be left untreated in selected low-risk patients, after proximal deep vein thrombosis has been ruled out. Patients with an sPESI or Hestia score of 0 criteria can be treated at home, independent of the presence of RV overload. Finally, health-care providers should be aware of post-PE syndrome and diagnose chronic thromboembolic pulmonary disease (CTEPD) as early as possible. Persistently symptomatic patients without CTEPD benefit from exercise training and cardiopulmonary rehabilitation.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Thijs E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
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Luijten D, Meijer FMM, Boon GJAM, Ende-Verhaar YM, Bavalia R, El Bouazzaoui LH, Delcroix M, Huisman MV, Mairuhu ATA, Middeldorp S, Pruszcyk P, Ruigrok D, Verhamme P, Vonk Noordegraaf A, Vriend JWJ, Vliegen HW, Klok FA. Diagnostic efficacy of ECG-derived ventricular gradient for the detection of chronic thromboembolic pulmonary hypertension in patients with acute pulmonary embolism. J Electrocardiol 2022; 74:94-100. [PMID: 36057190 DOI: 10.1016/j.jelectrocard.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/03/2022] [Accepted: 08/19/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Application of the chronic thromboembolic pulmonary hypertension (CTEPH) rule out criteria (manual electrocardiogram [ECG] reading and N-terminal pro-brain natriuretic peptide [NTproBNP] test) can rule out CTEPH in pulmonary embolism (PE) patients with persistent dyspnea (InShape II algorithm). Increased pulmonary pressure may also be identified using automated ECG-derived ventricular gradient optimized for right ventricular pressure overload (VG-RVPO). METHOD A predefined analysis of the InShape II study was performed. The diagnostic performance of the VG-RVPO for the detection of CTEPH and the incremental diagnostic value of the VG-RVPO as new rule-out criteria in the InShape II algorithm were evaluated. RESULTS 60 patients were included; 5 (8.3%) were ultimately diagnosed with CTEPH. The mean baseline VG-RVPO (at time of PE diagnosis) was -18.12 mV·ms for CTEPH patients and - 21.57 mV·ms for non-CTEPH patients (mean difference 3.46 mV·ms [95%CI -29.03 to 35.94]). The VG-RVPO (after 3-6 months follow-up) normalized in patients with and without CTEPH, without a clear between-group difference (mean Δ VG-RVPO of -8.68 and - 8.42 mV·ms respectively; mean difference of -0.25 mV·ms, [95%CI -12.94 to 12.44]). The overall predictive accuracy of baseline VG-RVPO, follow-up RVPO and Δ VG-RVPO for CTEPH was moderate to poor (ROC AUC 0.611, 0.514 and 0.539, respectively). Up to 76% of the required echocardiograms could have been avoided with VG-RVPO criteria replacing the InShape II rule-out criteria, however at cost of missing up to 80% of the CTEPH diagnoses. CONCLUSION We could not demonstrate (additional) diagnostic value of VG-RVPO as standalone test or as on top of the InShape II algorithm.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Fleur M M Meijer
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gudula J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Yvonne M Ende-Verhaar
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Roisin Bavalia
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Marion Delcroix
- Department of Pneumology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Piotr Pruszcyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Dieuwertje Ruigrok
- Department of Pulmonology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Peter Verhamme
- Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, University Hospitals Leuven, Leuven, Belgium
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Joris W J Vriend
- Department of Cardiology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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Boon GJAM, van den Hout WB, Barco S, Bogaard HJ, Delcroix M, Huisman MV, Konstantinides SV, Meijboom LJ, Nossent EJ, Symersky P, Vonk Noordegraaf A, Klok FA. A model for estimating the health economic impact of earlier diagnosis of chronic thromboembolic pulmonary hypertension. ERJ Open Res 2021; 7:00719-2020. [PMID: 34853780 PMCID: PMC8628742 DOI: 10.1183/23120541.00719-2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 06/14/2021] [Indexed: 11/06/2022] Open
Abstract
Background Diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH)
exceeds 1 year, contributing to higher mortality. Health economic
consequences of late CTEPH diagnosis are unknown. We aimed to develop a
model for quantifying the impact of diagnosing CTEPH earlier on survival,
quality-adjusted life-years (QALYs) and healthcare costs. Material and methods A Markov model was developed to estimate lifelong outcomes, depending on the
degree of delay. Data on survival and quality of life were obtained from
published literature. Hospital costs were assessed from patient records
(n=498) at the Amsterdam UMC – VUmc, which is a Dutch CTEPH
referral center. Medication costs were based on a mix of standard medication
regimens. Results For 63-year-old CTEPH patients with a 14-month diagnostic delay of CTEPH
(median age and delay of patients in the European CTEPH Registry), lifelong
healthcare costs were estimated at EUR 117 100 for a mix of treatment
options. In a hypothetical scenario of maximal reduction of current delay,
improved survival was estimated at a gain of 3.01 life-years and 2.04 QALYs.
The associated cost increase was EUR 44 654, of which 87% was
due to prolonged medication use. This accounts for an incremental
cost–utility ratio of EUR 21 900/QALY. Conclusion Our constructed model based on the Dutch healthcare setting demonstrates a
substantial health gain when CTEPH is diagnosed earlier. According to Dutch
health economic standards, additional costs remain below the deemed
acceptable limit of EUR 50 000/QALY for the particular disease
burden. This model can be used for evaluating cost-effectiveness of
diagnostic strategies aimed at reducing the diagnostic delay. This constructed model based on the Dutch healthcare setting can be used
for evaluating cost-effectiveness of diagnostic strategies aimed at reducing
the diagnostic delay of chronic thromboembolic pulmonary hypertensionhttps://bit.ly/35yXPM3
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Affiliation(s)
- Gudula J A M Boon
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert B van den Hout
- Dept of Biomedical Data Science - Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany.,Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Harm Jan Bogaard
- Dept of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Marion Delcroix
- Dept of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Menno V Huisman
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany.,Dept of Cardiology, Democritus University of Thrace, Xanthi, Greece
| | - Lilian J Meijboom
- Dept of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Esther J Nossent
- Dept of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Petr Symersky
- Dept of Cardiac Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Frederikus A Klok
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Center for Thrombosis and Hemostasis, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
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Prediction of chronic thromboembolic pulmonary hypertension with standardised evaluation of initial computed tomography pulmonary angiography performed for suspected acute pulmonary embolism. Eur Radiol 2021; 32:2178-2187. [PMID: 34854928 PMCID: PMC8921171 DOI: 10.1007/s00330-021-08364-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/05/2021] [Accepted: 09/27/2021] [Indexed: 11/21/2022]
Abstract
Objectives Closer reading of computed tomography pulmonary angiography (CTPA) scans of patients presenting with acute pulmonary embolism (PE) may identify those at high risk of developing chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to validate the predictive value of six radiological predictors that were previously proposed. Methods Three hundred forty-one patients with acute PE were prospectively followed for development of CTEPH in six European hospitals. Index CTPAs were analysed post hoc by expert chest radiologists blinded to the final diagnosis. The accuracy of the predictors using a predefined threshold for ‘high risk’ (≥ 3 predictors) and the expert overall judgment on the presence of CTEPH were assessed. Results CTEPH was confirmed in nine patients (2.6%) during 2-year follow-up. Any sign of chronic thrombi was already present in 74/341 patients (22%) on the index CTPA, which was associated with CTEPH (OR 7.8, 95%CI 1.9–32); 37 patients (11%) had ≥ 3 of 6 radiological predictors, of whom 4 (11%) were diagnosed with CTEPH (sensitivity 44%, 95%CI 14–79; specificity 90%, 95%CI 86–93). Expert judgment raised suspicion of CTEPH in 27 patients, which was confirmed in 8 (30%; sensitivity 89%, 95%CI 52–100; specificity 94%, 95%CI 91–97). Conclusions The presence of ≥ 3 of 6 predefined radiological predictors was highly specific for a future CTEPH diagnosis, comparable to overall expert judgment, while the latter was associated with higher sensitivity. Dedicated CTPA reading for signs of CTEPH may therefore help in early detection of CTEPH after PE, although in our cohort this strategy would not have detected all cases. Key Points • Three expert chest radiologists re-assessed CTPA scans performed at the moment of acute pulmonary embolism diagnosis and observed a high prevalence of chronic thrombi and signs of pulmonary hypertension. • On these index scans, the presence of ≥ 3 of 6 predefined radiological predictors was highly specific for a future diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH), comparable to overall expert judgment. • Dedicated CTPA reading for signs of CTEPH may help in early detection of CTEPH after acute pulmonary embolism. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-08364-0.
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Boon GJAM, Jairam PM, Groot GMC, van Rooden CJ, Ende-Verhaar YM, Beenen LFM, Kroft LJM, Bogaard HJ, Huisman MV, Symersky P, Vonk Noordegraaf A, Meijboom LJ, Klok FA. Identification of chronic thromboembolic pulmonary hypertension on CTPAs performed for diagnosing acute pulmonary embolism depending on level of expertise. Eur J Intern Med 2021; 93:64-70. [PMID: 34294517 DOI: 10.1016/j.ejim.2021.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/30/2021] [Accepted: 07/08/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Expert reading often reveals radiological signs of chronic thromboembolic pulmonary hypertension (CTEPH) or chronic PE on computed tomography pulmonary angiography (CTPA) performed at the time of acute pulmonary embolism (PE) presentation preceding CTEPH. Little is known about the accuracy and reproducibility of CTPA reading by radiologists in training in this setting. OBJECTIVES To evaluate 1) whether signs of CTEPH or chronic PE are routinely reported on CTPA for suspected PE; and 2) whether CTEPH-non-expert readers achieve comparable predictive accuracy to CTEPH-expert radiologists after dedicated instruction. METHODS Original reports of CTPAs demonstrating acute PE in 50 patients whom ultimately developed CTEPH, and those of 50 PE who did not, were screened for documented signs of CTEPH. All scans were re-assessed by three CTEPH-expert readers and two CTEPH-non-expert readers (blinded and independently) for predefined signs and overall presence of CTEPH. RESULTS Signs of chronic PE were mentioned in the original reports of 14/50 cases (28%), while CTEPH-expert radiologists had recognized 44/50 (88%). Using a standardized definition (≥3 predefined radiological signs), moderate-to-good agreement was reached between CTEPH-non-expert readers and the experts' consensus (k-statistics 0.46; 0.61) at slightly lower sensitivities. The CTEPH-non-expert readers had moderate agreement on the presence of CTEPH (κ-statistic 0.38), but both correctly identified most cases (80% and 88%, respectively). CONCLUSIONS Concomitant signs of CTEPH were poorly documented in daily practice, while most CTEPH patients were identified by CTEPH-non-expert readers after dedicated instruction. These findings underline the feasibility of achieving earlier CTEPH diagnosis by assessing CTPAs more attentively.
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Affiliation(s)
- Gudula J A M Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | - Pushpa M Jairam
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Gerie M C Groot
- Department of Radiology, Medical Center Gelderse Vallei, Ede, the Netherlands
| | | | - Yvonne M Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Ludo F M Beenen
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Petr Symersky
- Department of Cardiothoracic Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Abstract
PURPOSE OF REVIEW In the past decades, the diagnostic and therapeutic management of chronic thromboembolic pulmonary hypertension (CTEPH) has been revolutionized. RECENT FINDINGS Advances in epidemiological knowledge and follow-up studies of pulmonary embolism patients have provided more insight in the incidence and prevalence. Improved diagnostic imaging techniques allow accurate assessment of the location and extend of the thromboembolic burden in the pulmonary artery tree, which is important for the determination of the optimal treatment strategy. Next to the pulmonary endarterectomy, the newly introduced technique percutaneous pulmonary balloon angioplasty and/or P(A)H-targeted medical therapy has been shown to be beneficial in selected patients with CTEPH and might also be of importance in patients with chronic thromboembolic pulmonary vascular disease. SUMMARY In this era of a comprehensive approach to CTEPH with different treatment modalities, a multidisciplinary approach guides management decisions leading to optimal treatment and follow-up of patients with CTEPH.
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Cullivan S, McCormack C, O’Callaghan M, Kevane B, NiAinle F, McCullagh B, Gaine SP. Characteristics of chronic thromboembolic pulmonary hypertension in Ireland. Pulm Circ 2021; 11:20458940211048703. [PMID: 34646498 PMCID: PMC8504238 DOI: 10.1177/20458940211048703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/03/2021] [Indexed: 11/19/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and under-recognised complication of acute pulmonary embolism. Information regarding the characteristics of CTEPH in Ireland is limited, and the aim of this retrospective cohort study was to address this knowledge gap. Seventy-two cases of CTEPH were diagnosed in the National Pulmonary Hypertension Unit (NPHU) in Ireland between 2010 and 2020. This accounted for 6% of all referrals to the unit and translates to an estimated annual incidence of 1.39 per million population (95% confidence interval, 0.33-2.46). The prevalence of diagnosed CTEPH in Ireland in 2020 was estimated at 12.05 per million population (95% CI 9.00-15.10). The average duration of symptoms prior to CTEPH diagnosis was 23 (±22) months. Patients with CTEPH were more likely to be male (n = 40, 56%), older (60 ± 17 years) and have identifiable risk factors for CTEPH (n = 61, 85%) at diagnosis. Regarding treatment, pulmonary hypertension (PH) vasodilator therapy was prescribed in 75% (n = 54) within 12 months of diagnosis, inferior vena cava filters were placed in 24% (n = 17) and 97% (n = 70) of cases were anticoagulated. Pulmonary endarterectomy was performed in 35% (n = 25), balloon pulmonary angioplasty in 6% (n = 4). One-, three- and five-year survival was 93%, 80% and 65% from the time of diagnosis, and this was significantly better in patients who underwent pulmonary endarterectomy (p = 0.01). This is the first study describing the characteristics of CTEPH in Ireland and highlights suboptimal disease recognition and referral for the assessment for pulmonary endarterectomy.
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Affiliation(s)
- Sarah Cullivan
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ciara McCormack
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Marissa O’Callaghan
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Barry Kevane
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Fionnuala NiAinle
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Brian McCullagh
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean P. Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
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Kanwar MK, Cole M, Gauthier-Loiselle M, Manceur AM, Tsang Y, Lefebvre P, Panjabi S, Benza RL. Development and validation of a claims-based model to identify patients at risk of chronic thromboembolic pulmonary hypertension following acute pulmonary embolism. Curr Med Res Opin 2021; 37:1483-1491. [PMID: 34166172 DOI: 10.1080/03007995.2021.1947215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease that often follows pulmonary embolism (PE). Screening for CTEPH is challenging, often delaying diagnosis and worsening prognosis. Predictive risk models for CTEPH could help identify at-risk patients, but existing models require multiple clinical inputs. We developed and validated a predictive risk model for CTEPH using health insurance claims that can be used by payers/quality-of-care organizations to screen patients post-PE. METHODS Adult patients newly diagnosed with acute PE (index date) were identified from the Optum De-identified Clinformatics Extended DataMart (January 2007-March 2018; development set) and IBM MarketScan (January 2008-June 2019; validation set) databases. Predictors were identified 12 months before or on the index PE. Risk of "likely CTEPH" was assessed post-PE based on CTEPH-related diagnoses and procedures since the CTEPH diagnosis code (ICD-10-CM: I27.24) was not available until 1 October 2017. Stepwise variable selection was used to build the model using the development set; model validation was subsequently conducted using the validation set. RESULTS The development set included 93,428 patients, of whom 11,878 (12.7%) developed likely CTEPH. Older age (odds ratios [OR] = 1.16-1.49), female (OR = 1.09), unprovoked PE (i.e. without thrombotic factors; OR = 1.14), hypertension (OR = 1.07), osteoarthritis (OR = 1.08), diabetes (OR = 1.07), chronic obstructive pulmonary disease (OR = 1.11), obesity (OR = 1.21) were associated with higher odds of likely CTEPH, and oral anticoagulants with lower odds (OR= 0.50, all p < .01). C-statistic was 0.77 in the development and validation sets. CONCLUSION A claims-based risk model reliably predicted the risk of CTEPH post-PE and could be used to identify high-risk patients who may benefit from focused monitoring.
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Affiliation(s)
- Manreet K Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA, USA
| | - Michele Cole
- Actelion Pharmaceuticals US, Inc, a Janssen Pharmaceutical Company of Johnson & Johnson, South San Francisco, CA, USA
| | | | | | - Yuen Tsang
- Actelion Pharmaceuticals US, Inc, a Janssen Pharmaceutical Company of Johnson & Johnson, South San Francisco, CA, USA
| | | | - Sumeet Panjabi
- Actelion Pharmaceuticals US, Inc, a Janssen Pharmaceutical Company of Johnson & Johnson, South San Francisco, CA, USA
| | - Raymond L Benza
- Division of Cardiovascular Diseases, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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11
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de Perrot M, Gopalan D, Jenkins D, Lang IM, Fadel E, Delcroix M, Benza R, Heresi GA, Kanwar M, Granton JT, McInnis M, Klok FA, Kerr KM, Pepke-Zaba J, Toshner M, Bykova A, Armini AMD, Robbins IM, Madani M, McGiffin D, Wiedenroth CB, Mafeld S, Opitz I, Mercier O, Uber PA, Frantz RP, Auger WR. Evaluation and management of patients with chronic thromboembolic pulmonary hypertension - consensus statement from the ISHLT. J Heart Lung Transplant 2021; 40:1301-1326. [PMID: 34420851 DOI: 10.1016/j.healun.2021.07.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 07/22/2021] [Indexed: 02/08/2023] Open
Abstract
ISHLT members have recognized the importance of a consensus statement on the evaluation and management of patients with chronic thromboembolic pulmonary hypertension. The creation of this document required multiple steps, including the engagement of the ISHLT councils, approval by the Standards and Guidelines Committee, identification and selection of experts in the field, and the development of 6 working groups. Each working group provided a separate section based on an extensive literature search. These sections were then coalesced into a single document that was circulated to all members of the working groups. Key points were summarized at the end of each section. Due to the limited number of comparative trials in this field, the document was written as a literature review with expert opinion rather than based on level of evidence.
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Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Deepa Gopalan
- Department of Radiology, Imperial College Healthcare NHS Trust, London & Cambridge University Hospital, Cambridge, UK
| | - David Jenkins
- National Pulmonary Endarterectomy Service, Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Department of Cardiology, Pulmonary Hypertension Unit, Medical University of Vienna, Vienna, Austria
| | - Elie Fadel
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Pulmonary Hypertension Centre, UZ Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU, Leuven, Belgium
| | - Raymond Benza
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - John T Granton
- Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | - Micheal McInnis
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK
| | - Mark Toshner
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK; Heart Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Anastasia Bykova
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrea M D' Armini
- Unit of Cardiac Surgery, Intrathoracic-Trasplantation and Pulmonary Hypertension, University of Pavia, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Ivan M Robbins
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Madani
- Department of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, California
| | - David McGiffin
- Department of Cardiothoracic Surgery, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Campus Kerckhoff of the University of Giessen, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Sebastian Mafeld
- Division of Vascular and Interventional Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Olaf Mercier
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Patricia A Uber
- Pauley Heart Center, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Robert P Frantz
- Department of Cardiovascular Disease, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - William R Auger
- Pulmonary Hypertension and CTEPH Research Program, Temple Heart and Vascular Institute, Temple University, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
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12
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Boon GJAM, Ende-Verhaar YM, Bavalia R, El Bouazzaoui LH, Delcroix M, Dzikowska-Diduch O, Huisman MV, Kurnicka K, Mairuhu ATA, Middeldorp S, Pruszczyk P, Ruigrok D, Verhamme P, Vliegen HW, Vonk Noordegraaf A, Vriend JWJ, Klok FA. Non-invasive early exclusion of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the InShape II study. Thorax 2021; 76:1002-1009. [PMID: 33758073 DOI: 10.1136/thoraxjnl-2020-216324] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 02/09/2021] [Accepted: 02/23/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND The current diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE) is unacceptably long, causing loss of quality-adjusted life years and excess mortality. Validated screening strategies for early CTEPH diagnosis are lacking. Echocardiographic screening among all PE survivors is associated with overdiagnosis and cost-ineffectiveness. We aimed to validate a simple screening strategy for excluding CTEPH early after acute PE, limiting the number of performed echocardiograms. METHODS In this prospective, international, multicentre management study, consecutive patients were managed according to a screening algorithm starting 3 months after acute PE to determine whether echocardiographic evaluation of pulmonary hypertension (PH) was indicated. If the 'CTEPH prediction score' indicated high pretest probability or matching symptoms were present, the 'CTEPH rule-out criteria' were applied, consisting of ECG reading and N-terminalpro-brain natriuretic peptide. Only if these results could not rule out possible PH, the patients were referred for echocardiography. RESULTS 424 patients were included. Based on the algorithm, CTEPH was considered absent in 343 (81%) patients, leaving 81 patients (19%) referred for echocardiography. During 2-year follow-up, one patient in whom echocardiography was deemed unnecessary by the algorithm was diagnosed with CTEPH, reflecting an algorithm failure rate of 0.29% (95% CI 0% to 1.6%). Overall CTEPH incidence was 3.1% (13/424), of whom 10 patients were diagnosed within 4 months after the PE presentation. CONCLUSIONS The InShape II algorithm accurately excluded CTEPH, without the need for echocardiography in the overall majority of patients. CTEPH was identified early after acute PE, resulting in a substantially shorter diagnostic delay than in current practice.
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Affiliation(s)
- Gudula J A M Boon
- Department of Thrombosis and Hemostasis, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Yvonne M Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Roisin Bavalia
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marion Delcroix
- Department of Pneumology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Olga Dzikowska-Diduch
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Katarzyna Kurnicka
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Dieuwertje Ruigrok
- Department of Pulmonology, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands
| | - Peter Verhamme
- Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, University Hospitals Leuven, Leuven, Belgium
| | - Hubert W Vliegen
- Department of Cardiology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam UMC, VU University Medical Centre, Amsterdam, The Netherlands
| | - Joris W J Vriend
- Department of Cardiology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
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13
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Miotti C, D'Armini AM, Scardovi B, Ghio S, Sinagra G, Serra W, Romaniello A, Galgano G, Roncon L, D'Alto M, Giannazzo D, Vitulo P, Bongarzoni A, Ruzzolini M, Albera C, Casu G, Perazzolo Marra M, Pierdomenico SD, Luongo F, Manzi G, Papa S, Scoccia G, Cedrone N, Badagliacca R, Vizza CD. Chronic thromboembolic pulmonary hypertension risk score evaluation and validation (CTEPH Solution): proposal of a study protocol aimed to realize a validated risk score for early diagnosis. Minerva Cardiol Angiol 2021; 70:545-554. [PMID: 33703863 DOI: 10.23736/s2724-5683.21.05575-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is the most serious long-term complication of acute pulmonary embolism (PE) though it is the only potentially reversible form of Pulmonary Hypertension (PH). Its incidence is mainly limited to the first 2 years following the embolic event, however it is often underdiagnosed or misdiagnosed. METHODS This is a multicenter observational cross-sectional and prospective study. Patients with a prior diagnosis of PE will be enrolled and undergo baseline evaluation for prevalent PH detection through a clinical examination and an echocardiogram as first screening exam. All cases of intermediate-high echocardiographic probability of PH will be confirmed by right heart catheterization and then identified as CTEPH through appropriate imaging and functional examinations in order to exclude other causes of PH. A CTEPH Risk Score will be created using retrospective data from this prevalent cohort of patients and will be then validated on an incident cohort of patients with acute PE. RESULTS 1000 retrospective and 218 prospective patients are expected to be enrolled and the study is expected to be completed by the end of 2021. Up to now 841 patients (620 retrospective and 221 prospective) have been enrolled. CONCLUSIONS This study is the first large prospective study for the prediction of CTEPH development in patients with PE. It aims to create a comprehensive scoring tool that includes echocardiographic data which may allow early detection of CTEPH and the application of targeted follow up screening programs in patients with PE.
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Affiliation(s)
- Cristiano Miotti
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Andrea M D'Armini
- Dipartimento di Scienze Clinico-Chirurgiche, Diagnostiche e Pediatriche, Sezione di Cardiochirurgia, Policlinico San Matteo Pavia, Pavia, Italy
| | | | - Stefano Ghio
- Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Gianfranco Sinagra
- Dipartimento Cardiovascolare Azienda Ospedaliero-Universitaria Ospedali Riuniti, Trieste, Italy
| | - Walter Serra
- UO Cardiologia, AOU di Parma, Ospedale Maggiore di Parma, Parma, Italy
| | | | - Giuseppe Galgano
- UOC Cardiologia, UTIC, Ospedale Generale Regionale Francesco Miulli, Acquaviva delle Fonti, Bari, Italy
| | - Loris Roncon
- Divisione di Cardiologia, ULSS 18 Rovigo, Ospedale Santa Maria della Misericordia, Rovigo, Italy
| | - Michele D'Alto
- Department of Cardiology, Monaldi Hospital, University L. Vanvitelli, Naples, Italy
| | - Daniela Giannazzo
- AOU Policlinico Vittorio Emanuele, Divisione di Cardiologia, Ospedale Ferrarotto, Catania, Italy
| | - Patrizio Vitulo
- Dipartimento di Pneumologia, Istituto Mediterraneo Trapianti e Terapie Alta Specializzazione ISMETT, Palermo, Italy
| | - Amedeo Bongarzoni
- Dipartimento di Cardiologia, Ospedale San Carlo Borromeo, Milano, Italy
| | - Matteo Ruzzolini
- Unità Operativa Complessa di Cardiologia e UTIC, Ospedale San Giovanni Calibita Fatebenefratelli, Roma, Italy
| | - Carlo Albera
- SC Pneumologia U, Ospedale Molinette, Torino, Italy
| | - Gavino Casu
- UOC Cardiologia, Ospedale San Francesco, Nuoro, Italy
| | - Martina Perazzolo Marra
- Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, Azienda Ospedaliera, Padova, Italy
| | - Sante D Pierdomenico
- Unità di Malattie dell'apparato Cardiovascolare, Dipartimento di Scienze Mediche, Orali e Biotecnologiche, Università degli Studi G. d'Annunzio, Chieti-Pescara, Italy
| | - Federico Luongo
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Giovanna Manzi
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Silvia Papa
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Gianmarco Scoccia
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Nadia Cedrone
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Roberto Badagliacca
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| | - Carmine D Vizza
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy -
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14
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Kruip MJHA, Cannegieter SC, ten Cate H, van Gorp ECM, Juffermans NP, Klok FA, Maas C, Vonk‐Noordegraaf A. Caging the dragon: Research approach to COVID-19-related thrombosis. Res Pract Thromb Haemost 2021; 5:278-290. [PMID: 33733026 PMCID: PMC7938618 DOI: 10.1002/rth2.12470] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 12/18/2022] Open
Abstract
The incidence of venous thrombosis, mostly pulmonary embolism (PE), ranging from local immunothrombosis to central emboli, but also deep vein thrombosis (DVT) in people with coronavirus disease 2019 (COVID-19) is reported to be remarkably high. The relevance of better understanding, predicting, treating, and preventing COVID-19-associated venous thrombosis meets broad support, as can be concluded from the high number of research, review, and guideline papers that have been published on this topic. The Dutch COVID & Thrombosis Coalition (DCTC) is a multidisciplinary team involving a large number of Dutch experts in the broad area of venous thrombosis and hemostasis research, combined with experts on virology, critically ill patients, pulmonary diseases, and community medicine, across all university hospitals and many community hospitals in the Netherlands. Within the consortium, clinical data of at least 5000 admitted COVID-19-infected individuals are available, including substantial collections of biobanked materials in an estimated 3000 people. In addition to considerable experience in preclinical and clinical thrombosis research, the consortium embeds virology-hemostasis research models within unique biosafety facilities to address fundamental questions on the interaction of virus with epithelial and vascular cells, in relation to the coagulation and inflammatory system. The DCTC has initiated a comprehensive research program to answer many of the current questions on the pathophysiology and best anticoagulant treatment of COVID-19-associated thrombotic complications. The research program was funded by grants of the Netherlands Thrombosis Foundation and the Netherlands Organization for Health Research and Development. Here, we summarize the design and main aims of the research program.
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Affiliation(s)
- Marieke J. H. A. Kruip
- Department of HematologyErasmus MCErasmus University Medical CenterRotterdamThe Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Medicine – Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Hugo ten Cate
- Maastricht University Medical Center and CARIMMaastrichtThe Netherlands
| | - Eric C. M. van Gorp
- Department of ViroscienceErasmus MCErasmus University Medical CenterRotterdamThe Netherlands
- Department of Infectious DiseasesErasmus MCErasmus University Medical CenterRotterdamThe Netherlands
| | - Nicole P. Juffermans
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMC ‐ Location AMCAmsterdamThe Netherlands
- Department of Intensive CareOLVG HospitalAmsterdamThe Netherlands
| | - Frederikus A. Klok
- Department of Medicine – Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Coen Maas
- Department of Clinical Chemistry and HematologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Anton Vonk‐Noordegraaf
- Dept of Pulmonary MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
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15
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Boon GJ, Huisman MV, Klok FA. Why, Whom, and How to Screen for Chronic Thromboembolic Pulmonary Hypertension after Acute Pulmonary Embolism. Semin Thromb Hemost 2020; 47:692-701. [DOI: 10.1055/s-0040-1718925] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AbstractChronic thromboembolic pulmonary hypertension (CTEPH) is considered a long-term complication of acute pulmonary embolism (PE). Diagnosing CTEPH is challenging, as demonstrated by a considerable diagnostic delay exceeding 1 year, which has a negative impact on the patient's prognosis. Dedicated screening CTEPH strategies in PE survivors could potentially help diagnosing CTEPH earlier, although the optimal strategy is unknown. Recently published updated principles for screening in medicine outline the conditions that must be considered before implementation of a population-based screening program. Following these extensive principles, we discuss the pros and cons of CTEPH screening, touching on the epidemiology of CTEPH, the prognosis of CTEPH in the perspective of emerging treatment possibilities, and potentially useful tests and test combinations for screening. This review provides a modern perspective on CTEPH screening including a novel approach using a simple noninvasive algorithm of sequential diagnostic tests applied to all PE survivors.
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Affiliation(s)
- Gudula J.A.M. Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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16
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Klok FA, Couturaud F, Delcroix M, Humbert M. Diagnosis of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. Eur Respir J 2020; 55:13993003.00189-2020. [PMID: 32184319 DOI: 10.1183/13993003.00189-2020] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/03/2020] [Indexed: 02/05/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is the most severe long-term complication of acute pulmonary embolism (PE). Untreated CTEPH is fatal, but, if diagnosed in time, successful surgical (pulmonary endarterectomy), medical (pulmonary hypertension drugs) and/or interventional (balloon pulmonary angioplasty) therapies have been shown to improve clinical outcomes, especially in case of successful pulmonary endarterectomy. Early diagnosis has however been demonstrated to be challenging. Poor awareness of the disease by patients and physicians, high prevalence of the post-PE syndrome (i.e. persistent dyspnoea, functional limitations and/or decreased quality of life following an acute PE diagnosis), lack of clear guideline recommendations as well as inefficient application of diagnostic tests in clinical practice lead to a reported staggering diagnostic delay >1 year. Hence, there is a great need to improve current clinical practice and diagnose CTEPH earlier. In this review, we will focus on the clinical presentation of and risk factors for CTEPH, and provide best practices for PE follow-up programmes from expert centres, based on a clinical case.
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Affiliation(s)
- Fredrikus A Klok
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Francis Couturaud
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Univ Brest, Brest, France
| | - Marion Delcroix
- Dept of Respiratory Diseases, University Hospitals and Respiratory Division, Dept of Chronic Diseases, Metabolism and Aging, KU Leuven - University of Leuven, Leuven, Belgium
| | - Marc Humbert
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France.,Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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