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Nemtut DM, Petreanu CA, Ulmeanu R, Rajnoveanu AG, Rajnoveanu RM. Life expectancy in cancer patients with pulmonary thromboembolism: From clinical prognostic biomarkers and paraclinical investigations to therapeutic approaches (Review). Exp Ther Med 2024; 28:354. [PMID: 39071911 PMCID: PMC11273361 DOI: 10.3892/etm.2024.12643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 06/19/2024] [Indexed: 07/30/2024] Open
Abstract
Pulmonary embolisms (PEs) are obstructions of the pulmonary arteries by thrombi, which are emboli and they most frequently originate from the deep venous system of the inferior limbs. Emboli can also come from the inferior vena cava, abdominal and pelvic veins, or the upper body venous system from the right atrium or ventricle of the heart. Thrombi can form in situ inside pulmonary arteries as well. A cancer patient is at a higher risk for thromboembolic phenomena given both the oncological pathological context and also due to the associated medical or surgical treatment they receive. PE is a high-risk medical emergency that is associated with an increased risk of early mortality, with sudden death occurring in 25% of patients. The long-term presence of this condition can result in thromboembolic pulmonary hypertension. The risk of mortality, both in the acute and long-term, is dependent on the severity of the acute form, the recurrence of the embolism and the associated conditions. The majority of deaths associated with PE can be prevented by early diagnosis. The aim of the present review was to describe the various biological and cellular parameters, together with known paraclinical investigations, to assist in the rapid diagnosis of PE. Mortality in patients with PE and neoplastic conditions may be reduced by initiating anticoagulant treatment as soon as possible. PE may be the first manifestation of an underlying silent malignancy or may represent a complication of an already diagnosed malignancy. Exclusion or confirmation of the diagnosis is of utmost importance to avoid unnecessary anticoagulant treatment associated with a high risk of bleeding or to start immediate anticoagulant treatment if required.
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Affiliation(s)
| | - Cornel Adrian Petreanu
- Thoracic Surgery Department, Pneumology Institute Marius Nasta, Bucharest 050159, Romania
| | - Ruxandra Ulmeanu
- Bronchoscopy Department, North Hospital, Provita Medical Group, Bucharest 020335, Romania
- Doctoral School of Biomedical Sciences, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410073, Romania
| | - Armand Gabriel Rajnoveanu
- Occupational Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca 400012, Romania
| | - Ruxandra Mioara Rajnoveanu
- Palliative Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca 400012, Romania
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Keller K, Schmitt VH, Hahad O, Espinola-Klein C, Münzel T, Lurz P, Konstantinides S, Hobohm L. Categorization of Patients With Pulmonary Embolism by Charlson Comorbidity Index. Am J Med 2024; 137:727-735. [PMID: 38663792 DOI: 10.1016/j.amjmed.2024.04.025] [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] [Received: 04/02/2024] [Revised: 04/11/2024] [Accepted: 04/11/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Short-term outcomes of pulmonary embolism are closely related to right ventricular dysfunction and patient's hemodynamic status, but also to individual comorbidity profile. However, the impact of patients' comorbidities on survival during pulmonary embolism might be underrated. Although the Charlson Comorbidity Index (CCI) is the most extensively studied comorbidity index for detecting comorbidity burden, studies analyzing the impact of CCI on pulmonary embolism patients' survival are limited. METHODS We used the German nationwide inpatient sample to analyze all hospitalized patients with pulmonary embolism in Germany 2005-2020 and calculated CCI for each patient, compared the CCI classes (very low: CCI = 0 points, mild: CCI = 1-2 points, moderate: CCI = 3-4, high severity: CCI >4 points) and impact of CCI class on outcomes. RESULTS Overall, 1,373,145 hospitalizations of patients with acute pulmonary embolism (53.0% females, 55.9% aged ≥70 years) were recorded in Germany between 2005 and 2020; the CCI class stratified them. Among these, 100,156 (7.3%) were categorized as very low; 221,545 (16.1%) as mild; 394,965 (28.8%) as moderate; and 656,479 (47.8%) as patients with a high comorbidity burden according to CCI class. In-hospital case fatality increased depending on the CCI class: 3.6% in very low, 6.5% in mild, 12.1% in moderate, and 22.1% in high CCI class (P < .001). CCI class was associated with increased in-hospital case fatality (odds ratio 2.014; 95% confidence interval, 2.000-2.027; P < .001). CONCLUSION Our study results may help practitioners to better understand and measure the association between an aggravated comorbidity profile and increased in-hospital case fatality in patients with pulmonary embolism.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Germany; Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Germany.
| | - Volker H Schmitt
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Omar Hahad
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Christine Espinola-Klein
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Philipp Lurz
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Germany
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Keller K, Schmitt VH, Hahad O, Hobohm L. Outcome of Pulmonary Embolism with and without Ischemic Stroke. J Clin Med 2024; 13:2730. [PMID: 38792272 PMCID: PMC11122224 DOI: 10.3390/jcm13102730] [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: 03/26/2024] [Revised: 04/10/2024] [Accepted: 05/03/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Ischemic stroke is the second, and pulmonary embolism (PE) is the third most common cardiovascular cause of death after myocardial infarction. Data regarding risk factors for ischemic stroke in patients with acute PE are limited. Methods: Patients were selected by screening the German nationwide in-patient sample for PE (ICD-code I26) and were stratified by ischemic stroke (ICD code I63) and compared. Results: The nationwide in-patient sample comprised 346,586 hospitalized PE patients (53.3% females) in Germany from 2011 to 2014; among these, 6704 (1.9%) patients had additionally an ischemic stroke. PE patients with ischemic stroke had a higher in-hospital mortality rate than those without (28.9% vs. 14.5%, p < 0.001). Ischemic stroke was independently associated with in-hospital death (OR 2.424, 95%CI 2.278-2.579, p < 0.001). Deep venous thrombosis and/or thrombophlebitis (DVT) combined with heart septal defect (OR 24.714 [95%CI 20.693-29.517], p < 0.001) as well as atrial fibrillation/flutter (OR 2.060 [95%CI 1.943-2.183], p < 0.001) were independent risk factors for stroke in PE patients. Systemic thrombolysis was associated with a better survival in PE patients with ischemic thrombolysis who underwent cardio-pulmonary resuscitation (CPR, OR 0.55 [95%CI 0.36-0.84], p = 0.006). Conclusions: Ischemic stroke did negatively affect the survival of PE. Combination of DVT and heart septal defect and atrial fibrillation/flutter were strong and independent risk factors for ischemic stroke in PE patients. In PE patients with ischemic stroke, who had to underwent CPR, systemic thrombolysis was associated with improved survival.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (V.H.S.); (O.H.); (L.H.)
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Volker H. Schmitt
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (V.H.S.); (O.H.); (L.H.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Omar Hahad
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (V.H.S.); (O.H.); (L.H.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany; (V.H.S.); (O.H.); (L.H.)
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
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Cardona S, Downing JV, Witting MD, Haase DJ, Powell EK, Dahi S, Pasrija C, Tran QK. Venoarterial Extracorporeal Membrane Oxygenation With or Without Advanced Intervention for Massive Pulmonary Embolism. Perfusion 2024; 39:665-674. [PMID: 37246150 DOI: 10.1177/02676591231177909] [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] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Massive pulmonary embolism (MPE) is a rare but highly fatal condition. Our study's objective was to evaluate the association between advanced interventions and survival among patients with MPE treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO). METHODS This is a retrospective review of the Extracorporeal Life Support Organization (ELSO) registry data. We included adult patients with MPE who were treated with VA-ECMO during 2010-2020. Our Primary outcome was survival to hospital discharge; secondary outcomes were ECMO duration among survivors and rates of ECMO-related complications. Clinical variables were compared using the Pearson chi-square and Kruskal-Wallis H tests. RESULTS We included 802 patients; 80 (10%) received SPE and 18 (2%) received CDT. Overall, 426 (53%) survived to discharge; survival was not significantly different among those treated with SPE or CDT on VA-ECMO (70%) versus VA-ECMO alone (52%) or SPE or CDT before VA-ECMO (52%). Multivariable regression found a trend towards increased survival among those treated with SPE or CDT while on ECMO (AOR 1.8, 95% CI 0.9-3.6), but no significant correlation. There was no association between advanced interventions and ECMO duration among survivors, or rates of ECMO-related complications. CONCLUSION Our study found no difference in survival in patients with MPE who received advanced interventions prior to ECMO, and a slight non-significant benefit in those who received advanced interventions while on ECMO.
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Affiliation(s)
- Stephanie Cardona
- Department of Critical Care Medicine, The Mount Sinai Hospital, New York, NY, USA
| | - Jessica V Downing
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael D Witting
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel J Haase
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elizabeth K Powell
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Siamak Dahi
- Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Chetan Pasrija
- Department of Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Quincy K Tran
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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Cahan N, Klang E, Marom EM, Soffer S, Barash Y, Burshtein E, Konen E, Greenspan H. Multimodal fusion models for pulmonary embolism mortality prediction. Sci Rep 2023; 13:7544. [PMID: 37160926 PMCID: PMC10170065 DOI: 10.1038/s41598-023-34303-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/27/2023] [Indexed: 05/11/2023] Open
Abstract
Pulmonary embolism (PE) is a common, life threatening cardiovascular emergency. Risk stratification is one of the core principles of acute PE management and determines the choice of diagnostic and therapeutic strategies. In routine clinical practice, clinicians rely on the patient's electronic health record (EHR) to provide a context for their medical imaging interpretation. Most deep learning models for radiology applications only consider pixel-value information without the clinical context. Only a few integrate both clinical and imaging data. In this work, we develop and compare multimodal fusion models that can utilize multimodal data by combining both volumetric pixel data and clinical patient data for automatic risk stratification of PE. Our best performing model is an intermediate fusion model that incorporates both bilinear attention and TabNet, and can be trained in an end-to-end manner. The results show that multimodality boosts performance by up to 14% with an area under the curve (AUC) of 0.96 for assessing PE severity, with a sensitivity of 90% and specificity of 94%, thus pointing to the value of using multimodal data to automatically assess PE severity.
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Affiliation(s)
- Noa Cahan
- Department of Biomedical Engineering, Tel-Aviv University, Tel Aviv, Israel.
| | - Eyal Klang
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel affiliated with the Tel Aviv University, Tel Aviv, Israel
| | - Edith M Marom
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel affiliated with the Tel Aviv University, Tel Aviv, Israel
| | - Shelly Soffer
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel affiliated with the Tel Aviv University, Tel Aviv, Israel
| | - Yiftach Barash
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel affiliated with the Tel Aviv University, Tel Aviv, Israel
| | - Evyatar Burshtein
- Department of Biomedical Engineering, Tel-Aviv University, Tel Aviv, Israel
| | - Eli Konen
- Department of Diagnostic Imaging, Sheba Medical Center, Ramat Gan, Israel affiliated with the Tel Aviv University, Tel Aviv, Israel
| | - Hayit Greenspan
- Department of Biomedical Engineering, Tel-Aviv University, Tel Aviv, Israel.
- Biomedical Engineering and Imaging Institute, Radiology Dept., Icahn School of Medicine at Mount Sinai, New York, United States.
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Keller K, Schmitt VH, Sagoschen I, Münzel T, Espinola-Klein C, Hobohm L. CRB-65 for Risk Stratification and Prediction of Prognosis in Pulmonary Embolism. J Clin Med 2023; 12:jcm12041264. [PMID: 36835800 PMCID: PMC9961795 DOI: 10.3390/jcm12041264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/29/2023] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is accompanied by high morbidity and mortality. The search for simple and easily assessable risk stratification scores with favourable effectiveness is still ongoing, and prognostic performance of the CRB-65 score in PE might promising. METHODS The German nationwide inpatient sample was used for this study. All patient cases of patients with PE in Germany 2005-2020 were included and stratified for CRB-65 risk class: low-risk group (CRB-65-score 0 points) vs. high-risk group (CRB-65-score ≥1 points). RESULTS Overall, 1,373,145 patient cases of patients with PE (76.6% aged ≥65 years, 47.0% females) were included. Among these, 1,051,244 patient cases (76.6%) were classified as high-risk according to CRB-65 score (≥1 points). The majority of high-risk patients according to CRB-65 score were females (55.8%). Additionally, high-risk patients according to CRB-65 score showed an aggravated comorbidity profile with increased Charlson comorbidity index (5.0 [IQR 4.0-7.0] vs. 2.0 [0.0-3.0], p < 0.001). In-hospital case fatality (19.0% vs. 3.4%, p < 0.001) and MACCE (22.4% vs. 5.1%, p < 0.001) occurred distinctly more often in PE patients of the high-risk group according to CRB-65 score (≥1 points) compared to the low-risk group (= 0 points). The CRB-65 high-risk class was independently associated with in-hospital death (OR 5.53 [95%CI 5.40-5.65], p < 0.001) as well as MACCE (OR 4.31 [95%CI 4.23-4.40], p < 0.001). CONCLUSIONS Risk stratification with CRB-65 score was helpful for identifying PE patients being at higher risk of adverse in-hospital events. The high-risk class according to CRB-65 score (≥1 points) was independently associated with a 5.5-fold increased occurrence of in-hospital death.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
- Correspondence:
| | - Volker H. Schmitt
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Ingo Sagoschen
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Christine Espinola-Klein
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
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Keller K, Schmitt VH, Ostad MA, Münzel T, Hobohm L, Espinola‐Klein C. Mansoor's Self-Report Tool for Cardiovascular Risk Assessment predicts adverse in-hospital events in patients with pulmonary embolism. THE CLINICAL RESPIRATORY JOURNAL 2022; 17:80-89. [PMID: 36544042 PMCID: PMC9892697 DOI: 10.1111/crj.13571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/28/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is a life-threatening acute disease accompanied by high morbidity and mortality. Regarding hospitalizations of patients with PE, risk stratification of these patients is crucial. Thus, risk stratification tools like risk scores are of key interest. METHODS The nationwide German inpatient sample of the years 2005-2018 was used for this present analysis. Hospitalized PE patients were stratified according to Mansoor's Self-Report Tool for Cardiovascular Risk Assessment class, and the performance of this score was evaluated to predict adverse in-hospital events. RESULTS Overall, 1 174 196 hospitalizations of PE patients (53.5% females; 56.4% ≥70 years) were registered in Germany between 2005 and 2018. According to the Mansoor's self-report tool for cardiovascular risk assessment, 346 126 (29.5%) PE patients were classified as high risk. Higher Mansoor's Self-Report Tool for Cardiovascular Risk Assessment class was predictive for in-hospital death (OR 1.129 [95%CI 1.117-1.141], P < 0.001), shock (OR 1.117 [95%CI 1.095-1.140], P < 0.001), cardiopulmonary resuscitation (OR 1.109 [95%CI 1.092-1.126], P < 0.001), right ventricular dysfunction (OR 1.039 [95%CI 1.030-1.048], P < 0.001), intracerebral bleeding (OR 1.316 [95%CI 1.275-1.358], P < 0.001), and gastro-intestinal bleeding (OR 1.316 [95%CI 1.275-1.358], P < 0.001). Systemic thrombolysis was not associated with lower in-hospital mortality in high-risk class (OR 5.139 [95%CI 4.961-5.323], P < 0.001). CONCLUSIONS Prognostic performance of the Mansoor's Self-Report Tool for Cardiovascular Risk Assessment for risk stratification of PE patients was poor and not able to identify those PE patients, who might benefit from systemic thrombolysis. However, the Mansoor's Self-Report Tool for Cardiovascular Risk Assessment was moderately helpful to identify PE patients at higher risk for bleeding events.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, Cardiology IUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany,Center for Thrombosis and Hemostasis (CTH)University Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany,Medical Clinic VII, Department of Sports MedicineUniversity Hospital HeidelbergHeidelbergGermany
| | - Volker H. Schmitt
- Department of Cardiology, Cardiology IUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany,German Center for Cardiovascular Research (DZHK), Partner Site Rhine MainMainzGermany
| | - Mir A. Ostad
- Department of Cardiology, Cardiology IUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
| | - Thomas Münzel
- Department of Cardiology, Cardiology IUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany,German Center for Cardiovascular Research (DZHK), Partner Site Rhine MainMainzGermany
| | - Lukas Hobohm
- Department of Cardiology, Cardiology IUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany,Center for Thrombosis and Hemostasis (CTH)University Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
| | - Christine Espinola‐Klein
- Department of Cardiology, Cardiology IUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany,Center for Thrombosis and Hemostasis (CTH)University Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
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Su H, Han Z, Fu Y, Zhao D, Yu F, Heidari AA, Zhang Y, Shou Y, Wu P, Chen H, Chen Y. Detection of pulmonary embolism severity using clinical characteristics, hematological indices, and machine learning techniques. Front Neuroinform 2022; 16:1029690. [PMID: 36590906 PMCID: PMC9800512 DOI: 10.3389/fninf.2022.1029690] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Pulmonary embolism (PE) is a cardiopulmonary condition that can be fatal. PE can lead to sudden cardiovascular collapse and is potentially life-threatening, necessitating risk classification to modify therapy following the diagnosis of PE. We collected clinical characteristics, routine blood data, and arterial blood gas analysis data from all 139 patients. Methods Combining these data, this paper proposes a PE risk stratified prediction framework based on machine learning technology. An improved algorithm is proposed by adding sobol sequence and black hole mechanism to the cuckoo search algorithm (CS), called SBCS. Based on the coupling of the enhanced algorithm and the kernel extreme learning machine (KELM), a prediction framework is also proposed. Results To confirm the overall performance of SBCS, we run benchmark function experiments in this work. The results demonstrate that SBCS has great convergence accuracy and speed. Then, tests based on seven open data sets are carried out in this study to verify the performance of SBCS on the feature selection problem. To further demonstrate the usefulness and applicability of the SBCS-KELM framework, this paper conducts aided diagnosis experiments on PE data collected from the hospital. Discussion The experiment findings show that the indicators chosen, such as syncope, systolic blood pressure (SBP), oxygen saturation (SaO2%), white blood cell (WBC), neutrophil percentage (NEUT%), and others, are crucial for the feature selection approach presented in this study to assess the severity of PE. The classification results reveal that the prediction model's accuracy is 99.26% and its sensitivity is 98.57%. It is expected to become a new and accurate method to distinguish the severity of PE.
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Affiliation(s)
- Hang Su
- College of Computer Science and Technology, Changchun Normal University, Changchun, Jilin, China
| | - Zhengyuan Han
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yujie Fu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Dong Zhao
- College of Computer Science and Technology, Changchun Normal University, Changchun, Jilin, China,*Correspondence: Dong Zhao,
| | - Fanhua Yu
- College of Computer Science and Technology, Changchun Normal University, Changchun, Jilin, China
| | - Ali Asghar Heidari
- School of Surveying and Geospatial Engineering, College of Engineering, University of Tehran, Tehran, Iran
| | - Yu Zhang
- College of Computer Science and Technology, Changchun Normal University, Changchun, Jilin, China
| | - Yeqi Shou
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peiliang Wu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Huiling Chen
- College of Computer Science and Artificial Intelligence, Wenzhou University, Wenzhou, Zhejiang, China,Huiling Chen,
| | - Yanfan Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China,Yanfan Chen,
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Zimmermann L, Laufs U, Petros S, Lenk K. Outcome After Thrombolysis in Patients With Intermediate High-Risk Pulmonary Embolism: A Propensity Score Analysis. J Emerg Med 2022; 62:378-389. [PMID: 35042625 DOI: 10.1016/j.jemermed.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 10/13/2021] [Accepted: 10/17/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND The role of thrombolytic treatment in patients with intermediate high-risk pulmonary embolism (IHR-PE) remains controversial. OBJECTIVES In this study, we assessed whether systemic thrombolysis decreases hemodynamic decompensation and mortality in a cohort of unselected patients with IHR compared with patients with conventional anticoagulation. METHODS Between January 2014 and December 2018, 137 patients with IHR-PE were identified among 539 consecutive patients treated for symptomatic PE. In 35 patients (25.5%), systemic thrombolysis was used. Propensity score matching was performed based on 17 pretreatment variables. The primary outcome was hemodynamic decompensation, defined by systolic hypotension, need for catecholamines or signs of end-organ hypoperfusion, and all-cause mortality during hospitalization. Secondary outcomes, such as 1-year survival, and safety outcomes, such as bleeding events, were analyzed. RESULTS The effects of systemic thrombolysis and anticoagulation were compared in 55 matched patients with IHR-PE (systemic thrombolysis n = 21; anticoagulation n = 34). Thrombolysis was associated with a reduction (0% vs. 31%; p = 0.004) of the primary outcome during hospitalization and a 1-year survival benefit (100% vs. 83.2%; p = 0.036). Severe bleeding events occurred in 4.8% vs. 0% (p = 0.382) and moderate bleeding was observed in 14.3% vs. 7.1% (p = 0.359) in patients with thrombolysis compared with anticoagulation, respectively. CONCLUSIONS Thrombolysis was associated with a significant reduction of the combined endpoint of hemodynamic decompensation and death during hospitalization and lower all-cause mortality after 1 year in an unselected group of patients with IHR-PE. Further studies are required to improve the therapy of IHR-PE and to identify the subgroup of patients that might benefit from thrombolytic therapy.
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Affiliation(s)
- Luisa Zimmermann
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Ulrich Laufs
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Sirak Petros
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Karsten Lenk
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
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Zhu H, Qi J, Schoepf J, Savage RH, Tang C, Lu M, Zhou C, Lu G, Wang D, Zhang L. Prevalence and Associated Risk Factors of Pulmonary Embolism in Children and Young Adults With Nephrotic Syndrome: A Chinese Large Cohort Study. J Thorac Imaging 2021; 36:326-332. [PMID: 34269751 DOI: 10.1097/rti.0000000000000603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE Nephrotic syndrome (NS) is highly associated with an increased risk of pulmonary embolism (PE) in children and young adults. However, few studies have specified the risk factors of PE in children and young adults with NS. We sought to determine the prevalence and associated factors of PE confirmed with computed tomography pulmonary angiography in Chinese children and young adults with NS. METHODS Data from 444 children and young adults with NS who had computed tomography pulmonary angiography from December 2010 to October 2018 were retrospectively analyzed. The prevalence of PE was estimated for different age, sex, and histopathologic types of NS. Multivariable logistic regression was used to identify independent risk factors of PE in children and young adults with NS. Models incorporating the independent risk factors were evaluated using receiver operation characteristic curves. Area under the curve was used to determine the best-performing prognosticators for predicting PE. RESULTS There were 444 patients in the study cohort (310 male patients, 134 female patients; mean age 19±3 y; range: 6 to 25 y). PE was present in 24.8% of the participants (110 of 444, 18.2% female). Children and young adult NS patients with PE tend to be older, male, to have a previous thromboembolism history and smoking, and have a higher level of proteinuria, D-dimer, and serum albumin (P<0.05 for all). Children and young adults with membranous nephropathy are likely to have a higher incidence of PE than those with other types of nephropathy. Membranous nephropathy and proteinuria were significant predictors of PE in children and young adults with NS (P<0.05 for all). The area under the curves of each model for the presence of PE in children and young adults with NS based on biochemical parameters and clinical information (model 1), adjusted for proteinuria (model 2), and adjusted for membranous nephropathy (model 3) were 0.578, 0.657, and 0.709, respectively. Compared with model 1, model 2, and model 3 showed statistically significant differences (model 1 vs. model 2, P=0.0336; model 1 vs. model 3, P=0.0268). There was no statistically significant difference between model 2 and model 3 (P=0.2947). CONCLUSION This study identified membranous nephropathy and proteinuria as independent associated factors of PE in children and young adults with NS, which can be noted as a risk factor to guide clinician management in this population.
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Affiliation(s)
- Haitao Zhu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
- Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang, China
| | - Jianchen Qi
- Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang, China
| | - Joseph Schoepf
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging, Medical University of South Carolina, Charleston, SC
| | - Rock H Savage
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
- Department of Radiology and Radiological Science, Division of Cardiovascular Imaging, Medical University of South Carolina, Charleston, SC
| | - Chunxiang Tang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
| | - Mengjie Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
| | - Changsheng Zhou
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
| | - Guangming Lu
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
| | - Dongqing Wang
- Affiliated Hospital of Jiangsu University, Jiangsu University, Zhenjiang, China
| | - Longjiang Zhang
- Department of Medical Imaging, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu
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11
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Im DJ, Hur J, Han K, Suh YJ, Hong YJ, Lee HJ, Kim YJ, Choi BW. Prognostic Value of Dual-Energy CT-Based Iodine Quantification versus Conventional CT in Acute Pulmonary Embolism: A Propensity-Match Analysis. Korean J Radiol 2020; 21:1095-1103. [PMID: 32691545 PMCID: PMC7371622 DOI: 10.3348/kjr.2019.0645] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 02/26/2020] [Accepted: 03/09/2020] [Indexed: 12/25/2022] Open
Abstract
Objective The present study aimed to investigate whether quantitative dual-energy computed tomography (DECT) parameters offer an incremental risk stratification benefit over the CT ventricular diameter ratio in patients with acute pulmonary embolism (PE) by using propensity score analysis. Materials and Methods This study was conducted on 480 patients with acute PE who underwent CT pulmonary angiography (CTPA) or DECT pulmonary angiography (DE CT-PA). This propensity-matched study population included 240 patients with acute PE each in the CTPA and DECT groups. Altogether, 260 (54.1%) patients were men, and the mean age was 64.9 years (64.9 ± 13.5 years). The primary endpoint was all-cause death within 30 days. The Cox proportional hazards regression model was used to identify associations between CT parameters and outcomes and to identify potential predictors. Concordance (C) statistics were used to compare the prognoses between the two groups. Results In both CTPA and DECT groups, right to left ventricle diameter ratio ≥ 1 was associated with an increased risk of all-cause death within 30 days (hazard ratio: 3.707, p < 0.001 and 5.573, p < 0.001, respectively). However, C-statistics showed no statistically significant difference between the CTPA and DECT groups for predicting death within 30 days (C-statistics: 0.759 vs. 0.819, p = 0.117). Conclusion Quantitative measurement of lung perfusion defect volume by DECT had no added benefit over CT ventricular diameter ratio for predicting all-cause death within 30 days.
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Affiliation(s)
- Dong Jin Im
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Hur
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Kyunghwa Han
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Joo Suh
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoo Jin Hong
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Jeong Lee
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Jin Kim
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byoung Wook Choi
- Department of Radiology and Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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12
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Savioli G, Ceresa IF, Maggioni P, Lava M, Ricevuti G, Manzoni F, Oddone E, Bressan MA. Impact of ED Organization with a Holding Area and a Dedicated Team on the Adherence to International Guidelines for Patients with Acute Pulmonary Embolism: Experience of an Emergency Department Organized in Areas of Intensity of Care. MEDICINES 2020; 7:medicines7100060. [PMID: 32987644 PMCID: PMC7598623 DOI: 10.3390/medicines7100060] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/07/2020] [Accepted: 09/11/2020] [Indexed: 02/07/2023]
Abstract
Background: Adherence to guidelines by physicians of an emergency department (ED) depends on many factors: guideline and environmental factors; patient and practitioner characteristics; the social-political context. We focused on the impact of the environmental influence and of the patients’ characteristics on adherence to the guidelines. It is our intention to demonstrate how environmental factors such as ED organization more affect adherence to guidelines than the patient’s clinical presentation, even in a clinically insidious disease such as pulmonary embolism (PE). Methods: A single-center observational study was carried out on all patients who were seen at our Department of Emergency and Acceptance from 1 January to 31 December 2017 for PE. For the assessment of adherence to guidelines, we used the European guidelines 2014 and analyzed adherence to the correct use of clinical decision rule (CDR as Wells, Geneva, and YEARS); the correct initiation of heparin therapy; and the management of patients at high risk for short-term mortality. The primary endpoint of our study was to determine whether adherence to the guidelines as a whole depends on patients’ management in a holding area. The secondary objective was to determine whether adherence to the guidelines depended on patient characteristics such as the presence of typical symptoms or severe clinical features (massive pulmonary embolism; organ damage). Results: There were significant differences between patients who passed through OBI and those who did not, in terms of both administration of heparin therapy alone (p = 0.007) and the composite endpoints of heparin therapy initiation and observation/monitoring (p = 0.004), as indicated by the guidelines. For the subgroups of patients with massive PE, organ damage, and typical symptoms, there was no greater adherence to the decision making, administration of heparin therapy alone, and the endpoints of heparin therapy initiation and guideline-based observation/monitoring. Conclusions: Patients managed in an ED holding area were managed more in accordance with the guidelines than those who were managed only in the visiting ED rooms and directly hospitalized from there.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
- PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Correspondence: ; Tel.: +39-340-9070-001
| | - Iride Francesca Ceresa
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
| | - Paolo Maggioni
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
| | - Massimiliano Lava
- Neuro Radiodiagnostic, Irccs Policlinico San Matteo, 27100 Pavia, Italy;
| | - Giovanni Ricevuti
- Department of Drug Science, University of Pavia, Italy, Saint Camillus International University of Health Sciences, 00131 Rome, Italy;
| | - Federica Manzoni
- Clinical Epidemiology and Biometry Unit, Irccs Policlinico San Matteo, 27100 Pavia, Italy;
| | - Enrico Oddone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy;
| | - Maria Antonietta Bressan
- Emergency Department, Irccs Policlinico San Matteo, 27100 Pavia, Italy; (I.F.C.); (P.M.); (M.A.B.)
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13
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Öner Ö, Deveci F, Telo S, Kuluöztürk M, Balin M. MR-proADM and MR-proANP levels in patients with acute pulmonary embolism. J Med Biochem 2020; 39:328-335. [PMID: 33269021 PMCID: PMC7682857 DOI: 10.2478/jomb-2019-0049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/07/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The aim of this study was to determine levels of Mid-regional Pro-adrenomedullin (MR-proADM) and Mid-regional Pro-atrial Natriuretic Peptide (MR-proANP) in patients with acute pulmonary embolism (PE), the relationship between these parameters and the risk classification in addition to determining the relationship between 1and 3month mortality. METHODS 82 PE patients and 50 healthy control subjects were included in the study. Blood samples for Mr-proANP and Mr-proADM were obtained from the subjects prior to the treatment. Risk stratification was determined according to sPESI (Simplified Pulmonary Embolism Severity Index). Following these initial measurements, cases with PE were assessed in terms of all causative and PE related mortalities. RESULTS The mean serum Mr-proANP and Mr-proADM levels in acute PE patients were found to be statistically higher compared to the control group (p < 0.001, p < 0.01; respectively) and statistically significantly higher in high-risk patients than low-risk patients (p < 0.01, p < 0.05; respectively). No statistical difference was determined in high-risk patients in case of sPESI compared to low-risk patients while hospital mortality rates were higher. It was determined that the hospital mortality rate in cases with Mr-proANP ≥ 123.30 pmol/L and the total 3-month mortality rate in cases with Mr-proADM ≥ 152.2 pg/mL showed a statistically significant increase. CONCLUSIONS This study showed that Mr-proANP and MRproADM may be an important biochemical marker for determining high-risk cases and predicting the mortality in PE patients and we believe that these results should be supported by further and extensive studies.
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Affiliation(s)
- Önsel Öner
- Firat University, School of Medicine, Department of Pulmonary Medicine, Elazig, Turkey
| | - Figen Deveci
- Firat University, School of Medicine, Department of Pulmonary Medicine, Elazig, Turkey
| | - Selda Telo
- Firat University, School of Medicine, Department of Biochemistry, Elazig, Turkey
| | - Mutlu Kuluöztürk
- Firat University, School of Medicine, Department of Pulmonary Medicine, Elazig, Turkey
| | - Mehmet Balin
- Firat University, School of Medicine, Department of Cardiology, Elazig, Turkey
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14
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Zia MA. Streptokinase: An Efficient Enzyme in Cardiac Medicine. Protein Pept Lett 2020; 27:111-119. [PMID: 31612811 DOI: 10.2174/0929866526666191014150408] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/22/2019] [Accepted: 08/06/2019] [Indexed: 01/27/2023]
Abstract
An imbalance in oxygen supply to cardiac tissues or formation of thrombus leads to deleterious results like pulmonary embolism, coronary heart disease and acute cardiac failure. The formation of thrombus requires clinical encounter with fibrinolytic agents including streptokinase, urokinase or tissue plasminogen activator. Irrespective to urokinase and tissue plasminogen activator, streptokinase is still a significant agent in treatment of cardiovascular diseases. Streptokinase, being so economical, has an important value in treating cardiac diseases in developing countries. This review paper will provide the maximum information to enlighten all the pros and cons of streptokinase up till now. It has been concluded that recent advances in structural/synthetic biology improved SK with enhanced half-life and least antigenicity. Such enzyme preparations would be the best thrombolytic agents.
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Affiliation(s)
- Muhammad A Zia
- Enzyme Biotechnology Laboratory, Department of Biochemistry, University of Agriculture, Faisalabad-38040,Pakistan
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15
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Treatment of a Child With Submassive Pulmonary Embolism Associated With Hereditary Spherocytosis Using Ultrasound-Assisted Catheter-Directed Thrombolysis. Ochsner J 2019; 19:264-270. [PMID: 31528140 DOI: 10.31486/toj.18.0147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: The clinical presentation of hereditary spherocytosis varies from no symptoms to severe hemolytic anemia requiring splenectomy. Splenectomy imposes the risk of hypercoagulability and acute pulmonary embolism. Catheter-directed thrombolysis is an established treatment for submassive pulmonary embolism in adults. However, the literature regarding its use in children is limited. Case Report: We present the case of a 12-year-old male with hereditary spherocytosis who was diagnosed with pulmonary embolism and successfully treated with catheter-directed thrombolysis. The patient was initially treated with 10.5 mg of recombinant tissue plasminogen activator (r-tPA) delivered over 8 hours. However, because of minimal clinical and hemodynamic improvement, a second course of thrombolytic was administered for an additional 24 hours (25 mg of r-tPA), and the treatment resulted in marked clinical and hemodynamic improvement. Clot resolution was confirmed via angiography. The patient was discharged on enoxaparin and with regular follow-up. One year later, the patient was asymptomatic on enoxaparin. Conclusion: This case demonstrates that catheter-based treatment of submassive pulmonary embolism restores hemodynamic stability and thus is an alternative to surgery or systemic thrombolysis, even in the pediatric setting. While catheter-directed thrombolysis is a safe and effective alternative to systemic thrombolysis, further research is needed to establish appropriate dosing and indications in the adolescent population.
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16
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Deveci F, Öner Ö, Telo S, Kırkıl G, Balin M, Kuluöztürk M. Prognostic value of copeptin in patients with acute pulmonary thromboembolism. CLINICAL RESPIRATORY JOURNAL 2019; 13:630-636. [DOI: 10.1111/crj.13071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/18/2019] [Accepted: 07/19/2019] [Indexed: 01/22/2023]
Affiliation(s)
- Figen Deveci
- Department of Pulmonary Medicine, School of Medicine Firat University Elazig Turkey
| | - Önsel Öner
- Department of Pulmonary Medicine, School of Medicine Firat University Elazig Turkey
| | - Selda Telo
- Department of Biochemistry, Faculty of Medicine, School of Medicine Firat University Elazig Turkey
| | - Gamze Kırkıl
- Department of Pulmonary Medicine, School of Medicine Firat University Elazig Turkey
| | - Mehmet Balin
- Department of Cardiology, School of Medicine Firat University Elazig Turkey
| | - Mutlu Kuluöztürk
- Department of Pulmonary Medicine, School of Medicine Firat University Elazig Turkey
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Abstract
Intermediate-risk pulmonary embolism is common and carries a risk of progression to hemodynamic collapse and death. Catheter-directed thrombolysis is an increasingly used treatment option, based largely on the assumptions that it is more efficacious than anticoagulation alone and safer than systemic thrombolysis. In this review, we critically analyze the published data regarding catheter-directed thrombolysis for the treatment of intermediate-risk pulmonary embolism. Catheter-directed thrombolysis reduces right heart strain and lowers pulmonary artery pressures more quickly than anticoagulation alone. The mortality for patients with intermediate-risk pulmonary embolism treated with catheter-directed thrombolysis is low, between 0% and 4%. However, similarly low mortality is seen with anticoagulation alone. Catheter-directed thrombolysis appears to be safer than systemic thrombolysis, and procedural complications are uncommon. Bleeding risk appears to be slightly higher than with anticoagulation alone. Randomized, controlled trials are needed to compare the efficacy and safety of catheter-directed thrombolysis versus anticoagulation for intermediate-risk pulmonary embolism. There is no evidence that catheter-directed thrombolysis decreases the incidence of chronic thromboembolic pulmonary hypertension. There is no evidence from clinical studies that ultrasound-assisted thrombolysis is more effective or safer than standard catheter-directed thrombolysis.
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18
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Derivation and external validation of the SHIeLD score for predicting outcome in normotensive pulmonary embolism. Int J Cardiol 2019; 281:119-124. [DOI: 10.1016/j.ijcard.2018.12.062] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 11/22/2018] [Accepted: 12/21/2018] [Indexed: 12/17/2022]
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Trimaille A, Marchandot B, Girardey M, Muller C, Lim HS, Trinh A, Ohlmann P, Moulin B, Jesel L, Morel O. Assessment of Renal Dysfunction Improves the Simplified Pulmonary Embolism Severity Index (sPESI) for Risk Stratification in Patients with Acute Pulmonary Embolism. J Clin Med 2019; 8:jcm8020160. [PMID: 30717116 PMCID: PMC6406501 DOI: 10.3390/jcm8020160] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 01/22/2019] [Accepted: 01/24/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Whereas the major strength of the simplified pulmonary embolism severity index (sPESI) lies in ruling out an adverse outcome in patients with sPESI of 0, the accuracy of sPESI ≥ 1 in risk assessment remains questionable. In acute pulmonary embolism (APE), the estimated glomerular filtration rate (eGFR) can be viewed as an integrate marker reflecting not only previous chronic kidney disease (CKD) damage but also comorbid conditions and hemodynamic disturbances associated with APE. We sought to determine whether renal dysfunction assessment by eGFR improves the sPESI score risk stratification in patients with APE. Methods: 678 consecutive patients with APE were prospectively enrolled. Renal dysfunction (RD) at diagnosis of APE was defined by eGFR < 60 mL/min/1.73 m2 and acute kidney injury (AKI) by elevation of creatinine level >25% during in-hospital stay. Results: RD was observed in 26.9% of the cohort. AKI occurred in 18.8%. A stepwise increase in 30-day mortality, cardiovascular mortality and overall mortality was evident with declining renal function. Multivariate analysis identified RD and CRP (C-reactive protein) level but not sPESI score as independent predictors of 30-day mortality. AKI, 30-day mortality, overall mortality, and cardiovascular mortality were at their highest level in patients with eGFR < 60 mL/min/1.73 m2 and sPESI ≥1. Conclusion: in patients with APE, the addition of RD to the sPESI score identifies a specific subset of patients at very high mortality.
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Affiliation(s)
- Antonin Trimaille
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Benjamin Marchandot
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Mélanie Girardey
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Clotilde Muller
- Pôle NUDE, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Han S Lim
- Department of Cardiology, Austin and Northern Health, Melbourne 3084, Australia.
| | - Annie Trinh
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Patrick Ohlmann
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Bruno Moulin
- Pôle NUDE, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Laurence Jesel
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
- Laboratory of Regenerative Nanomedicine, UMR 1260, INSERM (French National Institute of Health and Medical Research), FMTS (Fédération de Médecine Translationnelle de l'Université de Strasbourg), Faculté de Médecine, Université de Strasbourg, 11 rue Humann, 67085 Strasbourg, France.
| | - Olivier Morel
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
- Laboratory of Regenerative Nanomedicine, UMR 1260, INSERM (French National Institute of Health and Medical Research), FMTS (Fédération de Médecine Translationnelle de l'Université de Strasbourg), Faculté de Médecine, Université de Strasbourg, 11 rue Humann, 67085 Strasbourg, France.
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Guo ZJ, Liu HT, Bai ZM, Lin Q, Zhao BH, Xu Q, Zeng YH, Feng WQ, Zhou HT, Liang F, Cui JY. A new method of CT for the cardiac measurement: correlation of computed tomography measured cardiac parameters and pulmonary obstruction index to assess cardiac morphological changes in acute pulmonary embolism patients. J Thromb Thrombolysis 2018; 45:410-416. [PMID: 29417409 DOI: 10.1007/s11239-018-1628-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Acute pulmonary embolism (APE) is a serious disease which is life-threatening. Since it is crucial for APE patients to assess the changes of cardiac function safely and timely, the imaging research of cardiac morphology and function is becoming more and more important. The correlation of computed tomography (CT) measured cardiac parameters and pulmonary obstruction index (POI) was analyzed to discuss the morphological changes of the heart of APE patients in order to provide a new method to evaluate cardiac functions accurately and effectively. 118 APE patients confirmed with CT pulmonary angiography (CTPA) were divided into high-risk group (47 cases, POI ≥ 20) and low-risk group (71 cases, POI < 20) according to the Qanadli Score. The left to right diameter (RL) and the anteroposterior diameter (AP) of the cardiac chambers were compared among the high-risk group, the low-risk group, and the normal group (60 cases). The correlation between CT measured cardiac parameters and the POI was analyzed. Except for left ventricular AP and right atrial AP, there were statistically significant differences (P < 0.05) in the RL and AP of the each cardiac cavity, these parameters meant that right hearts were enlarged and the left hearts were decreased in size. The ratio of right/left heart diameter was statistically significant among the three groups, a < b < c (P < 0.05). Moreover, the POI of 118 APE patients was 14.29 ± 9.53, and there was significant linear correlation between CT measured cardiac parameters and the POI (P < 0.05), excluding the left ventricular AP and right atrial AP. The correlation coefficient reached 0.5 or more in terms of the right atrial LR, the right ventricular LR, the ratio of right/left atrial diameter and the ratio of right/left ventricular diameter. With the increasing value of POI, the right atrium and right ventricular of APE patients were enlarged, and the left atrium and left ventricular were decreased in size. These heart changes can be observed by using CTPA, even non-enhanced chest CT.
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Affiliation(s)
- Zhi-Jun Guo
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China.
| | - Hai-Tao Liu
- Department of Respiratory Medicine, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Ze-Mei Bai
- Department of Medical Administration, Huabei Petroleum Health Bureau, Renqiu, 062552, Hebei, China
| | - Qiang Lin
- Department of Oncology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Bao-Hong Zhao
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Qian Xu
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Yan-Hong Zeng
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Wen-Qiu Feng
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Hai-Tao Zhou
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Fei Liang
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
| | - Ji-Yan Cui
- Department of Radiology, Huabei Petroleum General Hospital, Renqiu, 062552, Hebei, China
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21
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Riva N, Puljak L, Moja L, Ageno W, Schünemann H, Magrini N, Squizzato A. Multiple overlapping systematic reviews facilitate the origin of disputes: the case of thrombolytic therapy for pulmonary embolism. J Clin Epidemiol 2018; 97:1-13. [DOI: 10.1016/j.jclinepi.2017.11.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 09/25/2017] [Accepted: 11/13/2017] [Indexed: 01/08/2023]
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22
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Elder M, Blank N, Kaki A, Alraies MC, Grines CL, Kajy M, Hasan R, Mohamad T, Schreiber T. Mechanical circulatory support for acute right ventricular failure in the setting of pulmonary embolism. J Interv Cardiol 2018. [PMID: 29514403 DOI: 10.1111/joic.12503] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Right ventricular (RV) failure due to pulmonary embolism (PE) increases morbidity and mortality and contributes to prolonged hospital length of stay and higher costs of care. RV mechanical circulatory support (MCS) including Impella RP devices have been increasingly used in hemodynamically compromised PE patients who are refractory to intravascular volume expansion and inotropic therapy. However, effectiveness and safety of Impella RP, in hemodynamically unstable PE patients is unknown. METHODS We included consecutive patients who presented to Detroit Medical Center between November 3, 2015 and October 2, 2017 with acute PE and had evidence of hemodynamic compromise indicating Impella RP. RESULTS Total of five cases were identified. All patients met the shock definition due to massive or submassive PE and therefore received Impella RP on admission. Cardiac index was improved from mean of 1.69/min/m2, (0.88-2.15 L/min/m2 ), to 2.5 L/min/m2 (range 1.88-3.4), after 24 h of treatment. Similarly, mean heart rate reduced to 92 beats per minute (79-105), and mean systolic blood pressure increased to 140 mmHg (115-179). No significant changes were found in renal function, hemoglobin and platelets level during device use. One patient experienced hemoglobin drop from 13.7 to 7.3 g/dL but did not require blood transfusion. All patients survived to discharge. CONCLUSION In patients with PE and RV shock, Impella RP device resulted in immediate hemodynamic benefit with reversal of shock and favorable survival to discharge.
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Affiliation(s)
- Mahir Elder
- Wayne State University School of Medicine, Detroit Medical Center Heart Hospital, Detroit, Michigan
| | - Nimrod Blank
- Wayne State University School of Medicine, Detroit Medical Center Heart Hospital, Detroit, Michigan
| | - Amir Kaki
- Wayne State University School of Medicine, Detroit Medical Center Heart Hospital, Detroit, Michigan
| | - M Chadi Alraies
- Wayne State University School of Medicine, Detroit Medical Center Heart Hospital, Detroit, Michigan
| | - Cindy L Grines
- Zucker School of Medicine at Hofstra Northwell Health, Northshore University Hospital, Manhasset, New York
| | - Marvin Kajy
- Wayne State University School of Medicine, Detroit Medical Center Heart Hospital, Detroit, Michigan
| | | | - Tamam Mohamad
- Wayne State University School of Medicine, Detroit Medical Center Heart Hospital, Detroit, Michigan
| | - Theodore Schreiber
- Wayne State University School of Medicine, Detroit Medical Center Heart Hospital, Detroit, Michigan
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23
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Abraham P, Arroyo DA, Giraud R, Bounameaux H, Bendjelid K. Understanding haemorrhagic risk following thrombolytic therapy in patients with intermediate-risk and high-risk pulmonary embolism: a hypothesis paper. Open Heart 2018. [PMID: 29531763 PMCID: PMC5845427 DOI: 10.1136/openhrt-2017-000735] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
While systemic intravenous thrombolysis decreases mortality in patients with high-risk pulmonary embolism (PE), it clearly increases haemorrhagic risk. There are many contraindications to thrombolysis, and efforts should aim at selecting those patients who will benefit most, without suffering complications. The current review summarises the evidence for the use of thrombolytic therapy in PE. It clarifies the pathophysiological mechanisms in PE and acute cor pulmonale that increase the risk of bleeding following thrombolysis. It discusses future management challenges, namely tailored drug administration, new treatment monitoring techniques and catheter-directed thrombolysis.
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Affiliation(s)
- Paul Abraham
- Intensive Care Unit, Geneva University Hospitals, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland
| | - Diego A Arroyo
- Intensive Care Unit, Geneva University Hospitals, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland.,Department of Cardiology, University and Hospital Fribourg, Fribourg, Switzerland
| | - Raphael Giraud
- Intensive Care Unit, Geneva University Hospitals, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland
| | - Henri Bounameaux
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Karim Bendjelid
- Intensive Care Unit, Geneva University Hospitals, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland
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24
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Keller K, Beule J, Balzer JO, Dippold W. D-Dimer and thrombus burden in acute pulmonary embolism. Am J Emerg Med 2018; 36:1613-1618. [PMID: 29371044 DOI: 10.1016/j.ajem.2018.01.048] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 01/12/2018] [Accepted: 01/13/2018] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Thrombus burden in pulmonary embolism (PE) is associated with higher D-Dimer-levels and poorer prognosis. We aimed to investigate i) the influence of right ventricular dysfunction (RVD), deep venous thrombosis (DVT), and high-risk PE-status on D-Dimer-levels and ii) effectiveness of D-Dimer to predict RVD in normotensive PE patients. METHODS Overall, 161 PE patients were analyzed retrospectively, classified in 5 subgroups of thrombus burden according to clinical indications and compared regarding D-Dimer-levels. Linear regression models were computed to investigate the association between D-Dimer and the groups. In hemodynamically stable PE patients, a ROC curve was calculated to assess the effectiveness of D-Dimer for predicting RVD. RESULTS Overall, 161 patients (60.9% females, 54.0% aged >70 years) were included in this analysis. The D-Dimer-level was associated with group-category in a univariate linear regression model (β 0.050 (95%CI 0.002-0.099), P = .043). After adjustment for age, sex, cancer, and pneumonia in a multivariate model we observed an association between D-Dimer and group-category with borderline significance (β 0.047 (95%CI 0.002-0.096), P = .058). The Kruskal-Wallis test demonstrated that D-Dimer increased significantly with higher group-category. In 129 normotensive patients, patients with RVD had significantly higher D-Dimer values compared to those without (1.73 (1.11/3.48) vs 1.17 (0.65/2.90) mg/l, P = .049). A ROC curve showed an AUC of 0.61, gender non-specific, with calculated optimal cut-off of 1.18 mg/l. Multi-variate logistic regression model confirmed an association between D-Dimer >1.18 mg/l and RVD (OR2.721 (95%CI 1.196-6.190), P = .017). CONCLUSIONS Thrombus burden in PE is related to elevated D-Dimer levels, and D-Dimer values >1.18 mg/l were predictive for RVD in normotensive patients. D-Dimer levels were influenced by DVT, but not by cancer, pneumonia, age, or renal impairment.
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Affiliation(s)
- Karsten Keller
- Center for thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Johannes Gutenberg-University Mainz, Germany; Cardiology I, Center of Cardiology, University Medical Center Mainz, Mainz, Johannes Gutenberg-University Mainz, Germany.
| | - Johannes Beule
- Department of Internal Medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM), Mainz, Germany
| | - Jörn Oliver Balzer
- Department of Radiology and Nuclear Medicine, Catholic Clinic Mainz (KKM), Mainz, Germany; Department of Diagnostic and Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt (Main), Frankfurt, Germany
| | - Wolfgang Dippold
- Department of Internal Medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM), Mainz, Germany
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25
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Keller K, Beule J, Balzer JO, Dippold W. Renal function as a cofactor for risk stratification and short-term outcome in acute pulmonary embolism. Exp Gerontol 2017; 100:11-16. [DOI: 10.1016/j.exger.2017.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 10/03/2017] [Accepted: 10/07/2017] [Indexed: 12/15/2022]
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26
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Ende-Verhaar YM, Kroft LJM, Mos ICM, Huisman MV, Klok FA. Accuracy and reproducibility of CT right-to-left ventricular diameter measurement in patients with acute pulmonary embolism. PLoS One 2017; 12:e0188862. [PMID: 29182657 PMCID: PMC5705138 DOI: 10.1371/journal.pone.0188862] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 11/14/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Right ventricular (RV) dysfunction caused by acute pulmonary embolism (PE) is associated with poor short- and long-term prognosis. RV dilatation as a proxy for RV dysfunction can be assessed by calculating the right-to-left ventricle diameter (RV/LV) ratio on standard computed tomography pulmonary angiography (CTPA) images. It is unknown whether dedicated training is required to accurately and reproducibly measure RV/LV ratio therefore we aimed to assess these parameters in residents in internal medicine without experience in CTPA reading. METHODS CTPA images of 100 patients with PE were assessed by three residents after single instruction, and one experienced thoracic radiologist. Maximum diameters were evaluated in the axial view by measuring the distance between the ventricular endocardium and the interventricular septum, perpendicular to the long axis of the heart. RV dilatation was defined as a ratio of ≥1.0. Interobserver accuracy and reproducibility was determined using Kappa statistics, Bland-Altman analysis and Spearman's rank correlation. RESULTS The kappa statistic for the presence of RV dilatation of the residents compared to the experienced radiologist ranged from 0.83-0.94. The average interobserver difference in calculated RV/LV ratio's (±SD) between the three residents was: -0.01 (SD0.11), 0.07 (SD0.14) and 0.06 (SD0.18) with an overall mean RV/LV diameter ratio of 1.04. In line with this, Spearman's rank correlation coefficients were 0.92, 0.88 and 0.85 respectively indicating very good correlation (p<0.01 for all). CONCLUSION After simple instruction, RV/LV diameter ratio assessment on CTPA images by clinical residents is accurate and reproducible, which is of help in identifying PE patients at risk.
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Affiliation(s)
- Yvonne M. Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
| | - Lucia J. M. Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Inge C. M. Mos
- 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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Nelson SM, Craig SH. Ekosonic Endovascular System (EKOS) in a trauma patient with intracranial bleed, recent major surgery, and massive pulmonary embolus: A case report. Radiol Case Rep 2017; 13:156-160. [PMID: 29487650 PMCID: PMC5826738 DOI: 10.1016/j.radcr.2017.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 10/01/2017] [Accepted: 10/02/2017] [Indexed: 01/17/2023] Open
Abstract
Pulmonary embolism is a life-threatening condition treated with anticoagulation and systemic thrombolysis when appropriate. In patients with contraindications to thrombolysis, catheter-directed thrombolysis may be considered. Here, we present a patient with massive pulmonary embolus and 3 contraindications to systemic thrombolysis who was successfully treated with pharmacomechanical thrombolysis using the Ekosonic Endovascular System.
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Affiliation(s)
- Steve M Nelson
- San Antonio Uniformed Services Health Education Consortium (SAUSCHEC), 3551 Roger Brooke Dr., San Antonio, Texas 78234 USA
| | - Steven H Craig
- San Antonio Uniformed Services Health Education Consortium (SAUSCHEC), 3551 Roger Brooke Dr., San Antonio, Texas 78234 USA
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28
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Diuretics versus volume expansion in acute submassive pulmonary embolism. Arch Cardiovasc Dis 2017; 110:616-625. [DOI: 10.1016/j.acvd.2017.01.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 12/07/2016] [Accepted: 01/25/2017] [Indexed: 11/19/2022]
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29
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Acute Pulmonary Embolism: Retrospective Cohort Study of the Predictive Value of Perfusion Defect Volume Measured With Dual-Energy CT. AJR Am J Roentgenol 2017; 209:1015-1022. [DOI: 10.2214/ajr.17.17815] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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30
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Abstract
We describe the successful use and complications of bolus-dose alteplase to treat strongly suspected pulmonary embolism (PE) with cardiac arrest in a patient initially presenting as ST-elevation myocardial infarcation (MI). Case description is followed by a review of the indications, safety, and dosing of systemic thrombolytic therapy for high-risk PE in the emergency department (ED). Diagnostic and therapeutic approach to PE in critically ill patients is also considered, including the potential utility of point-of-care ultrasound (PoCUS) in the ED.
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31
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Bai Z, Huang Y, Song C, Liu H, Chen Y, Zhang H, Lu X, Song Y, Zhang X. Clinical application of the Innovance D-dimer assay in the diagnosis of acute pulmonary thromboembolism. Exp Ther Med 2017; 13:3543-3548. [PMID: 28587438 DOI: 10.3892/etm.2017.4400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 01/26/2017] [Indexed: 11/06/2022] Open
Abstract
Patients with acute pulmonary thromboembolism (APTE) have a high short-term mortality rate. The current study aimed to investigate the use of D-dimer in the diagnosis of APTE in suspected APTE patients. All suspected APTE patients were classified into diagnosis or control groups according to the results of a computed tomography pulmonary angiogram. Mann-Whitney U and Kruskal-Wallis H tests were used to evaluate the association between D-dimer values and APTE. Area under the curve (AUC) values and the Youden Index were used to determine D-dimer cut-off levels for the prediction of APTE. The data of 112 suspected APTE patients (54.8% women; mean age, 70.5 years) were analyzed prospectively. There were no significant differences in age (74.5 vs. 73.5 years, P=0.538) or gender distribution (female ratio 56.5 vs. 53.0%, P=0.847) between the diagnosis and control groups. The incidence of symptoms including dyspnea (67.4 vs. 33.3%; P<0.01), chest distress (47.8 vs. 25.8%; P<0.05) and elevated D-dimer (8.49 vs. 0.97 mg/l; P<0.001) were significantly higher in patients with APTE compared with the control group. D-dimer values >3.32 mg/l fibrinogen equivalent units (FEU) were indicative of APTE and the Youden Index was 0.69. The maximum AUC was 0.87 (95% CI: 0.79-0.92), the sensitivity and specificity were 89.13 and 80.30%, respectively, the positive and negative likelihood ratios were 4.53 and 0.14, respectively, and the positive and negative predictive values were 75.90 and 91.40%, respectively. A D-dimer value <0.60 mg/l FEU was the optimal threshold for excluding APTE diagnosis, with a sensitivity of 100.0% and a specificity of 28.79%. The positive and negative likelihood ratios were 1.40 and 0.00, respectively, and the positive and negative predictive values were 49.50 and 100.00%, respectively. Thus, D-dimer levels, combined with clinical assessment, yield high sensitivity and specificity in diagnosing APTE.
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Affiliation(s)
- Zhuxiao Bai
- Clinical Laboratory, the First Affiliated Hospital of the Medical College, Shihezi University, Shihezi, Xinjiang 832000, P.R. China.,Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Yurong Huang
- Department of Respiratory Medicine, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Chenghua Song
- Department of Respiratory Medicine, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Huimin Liu
- Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Yihui Chen
- Department of Respiratory Medicine, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Haitao Zhang
- Department of Respiratory Medicine, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Xinhong Lu
- Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Yingbo Song
- Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
| | - Xin Zhang
- Clinical Laboratory, Hospital of Xinjiang Production and Construction Corps, Urumqi, Xinjiang 830002, P.R. China
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32
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Bougouin W, Marijon E, Planquette B, Karam N, Dumas F, Celermajer DS, Jost D, Lamhaut L, Beganton F, Cariou A, Meyer G, Jouven X. Pulmonary embolism related sudden cardiac arrest admitted alive at hospital: Management and outcomes. Resuscitation 2017; 115:135-140. [DOI: 10.1016/j.resuscitation.2017.04.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 04/13/2017] [Indexed: 02/02/2023]
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33
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Zuin M, Conte L, Picariello C, Pastore G, Vassiliev D, Lanza D, Zonzin P, Zuliani G, Rigatelli G, Roncon L. TIMI Risk Index as a Predictor of 30-Day Outcomes in Patients With Acute Pulmonary Embolism. Heart Lung Circ 2017; 27:190-198. [PMID: 28487060 DOI: 10.1016/j.hlc.2017.02.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 02/10/2017] [Accepted: 02/27/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Available studies have already identified age, heart rate (HR) and systolic blood pressure (SBP) as strong predictors of early mortality in acute pulmonary embolism (PE). MATERIAL AND METHODS One-hundred-seventy patients, with acute PE confirmed on computed tomography angiography (CTA) were enrolled. Thrombolysis In Myocardial Infarction (TIMI) risk index (TRI) was calculated using the formula [heart rate (HR) x (AGE/102)/ systolic blood pressure (SBP)]. Study outcomes were 30-day mortality and/or clinical deterioration. RESULTS Receiver operating characteristics (ROC) curve revealed that a TRI ≥45 was highly specific for both outcomes (AUC 0.91, 95% CI 0.83-0.98, p<0.0001) with a positive predictive value (PPV) and negative predictive value (NPV) of 8.3 and 96% for 30-day mortality while PPV and NPV for 30-day mortality and/or clinical deterioration were 21.1 and 98.2%, respectively. Multivariate regression analysis showed that TRI ≥45 was an independent predictor of 30-day mortality (O.R. 22.24, 95% CI 2.54-194.10, p=0.005) independently from positive cTnI and RVD (O.R. 9.57, 95% CI 1.88-48.78, p=0.007; OR 24.99, 95% CI 2.84-219.48, p=0.004). Similarly, 30-day mortality and/or clinical deterioration was predicted by TRI ≥45 (O.R. 11.57, 95% CI 2.36-56.63, p=0.003) and thrombolysis (3.83, 95% CI 1.04-14.09, p=0.043), independently from age, RVD and positive cTnI. Cox regression analysis confirmed the role of TRI as independent predictor for both outcomes. Mantel-Cox analysis showed that after 30-day follow-up there was a statistically significant difference in the distribution of survival between patients with and without TRI ≥45 [log rank (Mantel-Cox) chi-square 17.04, p<0.0001]. CONCLUSIONS Thrombolysis In Myocardial Infarction (TIMI) risk index (TRI) predicted both 30-days mortality (all-causes) and/or clinical deterioration in patients with acute PE.
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Affiliation(s)
- Marco Zuin
- Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy; Section of Internal and Cardiopulmonary Medicine, Department of Medical Science, University of Ferrara, Ferrara, Italy
| | - Luca Conte
- Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Claudio Picariello
- Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Gianni Pastore
- Arrhythmia and Electrophysiology Unit, Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Dobrin Vassiliev
- Cardiology Clinic, Alexandroska University Hospital, Sofia, Bulgaria
| | - Daniela Lanza
- Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Pietro Zonzin
- Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy
| | - Giovanni Zuliani
- Section of Internal and Cardiopulmonary Medicine, Department of Medical Science, University of Ferrara, Ferrara, Italy
| | - Gianluca Rigatelli
- Section of Adult Congenital and Adult Heart Disease, Cardiovascular Diagnosis and Endoluminal Interventions, Rovigo General Hospital, Italy
| | - Loris Roncon
- Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy.
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Kosova EC, Desai KR, Schimmel DR. Endovascular Management of Massive and Submassive Acute Pulmonary Embolism: Current Trends in Risk Stratification and Catheter-Directed Therapies. Curr Cardiol Rep 2017; 19:54. [DOI: 10.1007/s11886-017-0864-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Yuan X, Hou X, Guo W, Jiang H, Zheng J, Paudyal S, Lyu Y. A case report of PVOD patient combined with pulmonary embolism: Anticoagulation or not? Medicine (Baltimore) 2017; 96:e6507. [PMID: 28353604 PMCID: PMC5380288 DOI: 10.1097/md.0000000000006507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE Pulmonary veno-occlusive disease (PVOD) is a rare form of pulmonary arterial hypertension (PAH). Oral anticoagulation is confined to patients with idiopathic PAH (IPAH), but no oral anticoagulation has been recommended for PVOD, because occult pulmonary hemorrhage was a common finding in PVOD. PATIENT CONCERNS We report a case of PVOD, who was misdiagnosed as IPAH for 5 years with worsening dyspnea and two episodes of pulmonary embolism (PE). DIAGNOSES He was confirmed as PVOD combined with PE by biopsy of the explanted lung specimen. INTERVENTIONS He took oral anticoagulation, warfarin, to treat his first-time PE in July 2010, and his disease was kept stable for about 4 years, until he discontinued the anticoagulation therapy by himself sometime in 2014. Later on, a life-threatening PE recurred in January 2015, so he resumed the anticoagulation therapy. OUTCOMES Fortunately, the bilateral sequential lung transplantation that was performed in July 2015 in time saved his life. He has been living well without dyspnea and the echocardiography showed the normalizations of the once increased pulmonary arterial pressure and the once enlarged right ventricle of his heart. In addition, to the best of my knowledge, he was the first PVOD patient receiving lung transplantation in China. LESSONS We recommend that PVOD patients combined with PE should be treated with anticoagulation therapy indefinitely to prevent the recurrence of life-threatening PE until they get a chance for lung transplantation.
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Affiliation(s)
| | | | | | - Haiming Jiang
- Cardiothoracic Surgery, People's Hospital of Zhongshan City, Zhongshan City
| | - Junmeng Zheng
- Cardiothoracic Surgery, People's Hospital of Zhongshan City, Zhongshan City
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den Exter PL, Zondag W, Klok FA, Brouwer RE, Dolsma J, Eijsvogel M, Faber LM, van Gerwen M, Grootenboers MJ, Heller-Baan R, Hovens MM, Jonkers GJPM, van Kralingen KW, Melissant CF, Peltenburg H, Post JP, van de Ree MA, Vlasveld LT(T, de Vreede MJ, Huisman MV. Efficacy and Safety of Outpatient Treatment Based on the Hestia Clinical Decision Rule with or without N-Terminal Pro–Brain Natriuretic Peptide Testing in Patients with Acute Pulmonary Embolism. A Randomized Clinical Trial. Am J Respir Crit Care Med 2016; 194:998-1006. [DOI: 10.1164/rccm.201512-2494oc] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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37
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Ates H, Ates I, Kundi H, Yilmaz FM. Diagnostic validity of hematologic parameters in evaluation of massive pulmonary embolism. J Clin Lab Anal 2016; 31. [PMID: 27709684 DOI: 10.1002/jcla.22072] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 08/31/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The aim of this study was to determine the hematologic parameter with the highest diagnostic differentiation in the identification of massive acute pulmonary embolism (APE). METHODS A retrospective study was performed on patients diagnosing with APE between June 2014 and June 2016. All radiological and laboratory parameters of patients were scanned through the electronic information management system of the hospital. PLR was obtained from the ratio of platelet count to lymphocyte count, NLR was obtained from the ratio of neutrophil count to lymphocyte count, WMR was obtained from white blood cell in mean platelet volume ratio, MPR was obtained from the ratio of mean platelet volume to platelet count, and RPR was obtained from the ratio of red distribution width to platelet count. RESULTS Six hundred and thirty-nine patients consisting of 292 males (45.7%) and 347 females (54.3%) were included in the research. Independent predictors of massive risk as compared to sub-massive group were; pulmonary arterial systolic pressure (PASP) (OR=1.40; P=.001), PLR (OR=1.59; P<.001), NLR (OR=2.22; P<.001), WMR (OR=1.22; P<.001), MPR (OR=0.33; P<.001), and RPR (OR=0.68; P<.001). Upon evaluation of the diagnostic differentiation of these risk factors for massive APE by employing receiver operating characteristic curve analysis, it was determined that PLR (AUC±SE=0.877±0.015; P<.001), and NLR (AUC±SE=0.893±0.013; P<.001) have similar diagnostic differentiation in diagnosing massive APE and these two parameters are superior over PASP, MPR, WMR, and RPR. CONCLUSION We determined that the levels of NLR and PLR are superior to other parameters in the determination of clinical severity in APE cases.
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Affiliation(s)
- Hale Ates
- Department of Chest Disease, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Ihsan Ates
- Department of Internal Medicine, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Harun Kundi
- Department of Cardiology, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Fatma Meric Yilmaz
- Department of Biochemistry, Ankara Numune Training and Research Hospital, Ankara, Turkey
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Keller K, Geyer M, Coldewey M, Beule J, Balzer JO, Dippold W. Elevated systolic pulmonary artery pressure for prediction of myocardial necrosis and right ventricular dysfunction in acute pulmonary embolism. COR ET VASA 2016. [DOI: 10.1016/j.crvasa.2015.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Kurnicka K, Lichodziejewska B, Goliszek S, Dzikowska-Diduch O, Zdończyk O, Kozłowska M, Kostrubiec M, Ciurzyński M, Palczewski P, Grudzka K, Krupa M, Koć M, Pruszczyk P. Echocardiographic Pattern of Acute Pulmonary Embolism: Analysis of 511 Consecutive Patients. J Am Soc Echocardiogr 2016; 29:907-13. [PMID: 27427291 DOI: 10.1016/j.echo.2016.05.016] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND There is no comprehensive analysis of transthoracic echocardiographic findings of pulmonary embolism (PE). The aim of this study was to assess the frequency of right ventricular (RV) dysfunction (RVD), typical echocardiographic signs of acute PE (TES), and incidental abnormalities. METHODS A single-center, retrospective analysis was conducted of 511 consecutive patients (281 women; mean age, 64.0 ± 18.6 years) with PE confirmed by contrast-enhanced multidetector computed tomography who underwent transthoracic echocardiography for the assessment of left ventricular and RV alterations. The McConnell sign, the "60/60" sign, and right heart thrombus were regarded as TES. RVD included RV free wall hypokinesis and RV to LV end-diastolic ratio > 0.9. Incidental echocardiographic alterations were also reported. RESULTS RV enlargement, RV free wall hypokinesis, and interventricular septal flattening were found in 27.4%, 26.6%, and 18.4% of patients, respectively. Tricuspid regurgitation peak systolic gradient > 30 mmHg and pulmonary ejection acceleration time < 80 msec were measured in 46.6% and 37.2% of patients, respectively. RVD was found in 20.0% of patients, while normal RV function was present in 33.4% of patients. The McConnell sign, 60/60 sign, and right heart thrombus were found in 19.8%, 12.9%, 1.8% of subjects, respectively. All 16 hemodynamically unstable patients with PE presented enlarged hypokinetic right ventricle and at least one TES. However, in three of them, RV to LV end-diastolic ratio was <0.9. Incidental abnormalities were found in 9.6% of 364 stable patients with PE without RVD and TES. CONCLUSIONS Transthoracic echocardiography showed no significant abnormalities suggestive of PE in 71% of patients with PE, while in approximately 10%, transthoracic echocardiography revealed incidental findings. The coexistence of an enlarged hypokinetic right ventricle with the McConnell sign together with the 60/60 sign seems to be the most useful echocardiographic criterion for RVD.
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Affiliation(s)
- Katarzyna Kurnicka
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland.
| | - Barbara Lichodziejewska
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Sylwia Goliszek
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Olga Dzikowska-Diduch
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Olga Zdończyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marta Kozłowska
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Kostrubiec
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Michał Ciurzyński
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Palczewski
- Department of Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Grudzka
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Krupa
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Koć
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
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Vuilleumier N, Simona A, Méan M, Limacher A, Lescuyer P, Gerstel E, Bounameaux H, Aujesky D, Righini M. Comparison of Cardiac and Non-Cardiac Biomarkers for Risk Stratification in Elderly Patients with Non-Massive Pulmonary Embolism. PLoS One 2016; 11:e0155973. [PMID: 27219621 PMCID: PMC4878757 DOI: 10.1371/journal.pone.0155973] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 05/06/2016] [Indexed: 11/21/2022] Open
Abstract
Biomarkers unrelated to myocardial necrosis, such as cystatin C, copeptin, and mid-regional pro-adrenomedullin (MR-proADM), showed promise for cardiovascular risk prediction. Knowing whether they are comparable to cardiac biomarkers such as high-sensitive cardiac-troponin T (hs-cTnT) or N-terminal pro-Brain natriuretic peptide (NT-proBNP) in elderly patients with acute non-massive pulmonary embolism (NMPE) remains elusive. This study aims at comparing the prognostic accuracy of cardiac and non-cardiac biomarkers in patients with NMPE aged ≥65 years over time. In the context of the SWITCO65+ cohort, we evaluated 227 elderly patients with an available blood sample taken within one day from diagnosis. The primary study endpoint was defined as PE-related mortality and the secondary endpoint as PE-related complications. The biomarkers’ predictive ability at 1, 3, 12 and 24 months was determined using C-statistics and Cox regression. For both study endpoints, C-statistics (95% confidence interval) were stable over time for all biomarkers, with the highest value for hs-cTnT, ranging between 0.84 (0.68–1.00) and 0.80 (0.70–0.90) for the primary endpoint, and between 0.74 (0.63–0.86) and 0.65 (0.57–0.73) for the secondary endpoint. For both study endpoints, cardiac biomarkers were found to be independently associated with risk, NT-proBNP displaying a negative predictive value of 100%. Among non-cardiac biomarkers, only copeptin and MR-proADM were independent predictors of PE-related mortality but they were not independent predictors of PE-related complications, and displayed lower negative predictive values. In elderly NMPE patients, cardiac biomarkers appear to be valuable prognostic to identify very low-risk individuals. Trial Registration: ClinicalTrials.gov NCT00973596
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Affiliation(s)
- Nicolas Vuilleumier
- Division of Laboratory Medicine, Department of Genetics and Laboratory Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Aurélien Simona
- Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- * E-mail:
| | - Marie Méan
- Division of General Internal Medicine, Bern University Hospital and University of Bern, Bern, Switzerland
- Service of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Andreas Limacher
- CTU Bern, Department of Clinical Research and Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Pierre Lescuyer
- Division of Laboratory Medicine, Department of Genetics and Laboratory Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Eric Gerstel
- Department of Internal Medicine, Rehabilitation and Geriatrics, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- Clinique de la Colline, Geneva, Switzerland
| | - Henri Bounameaux
- Division of Angiology and Haemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Drahomir Aujesky
- Division of General Internal Medicine, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Marc Righini
- Division of Angiology and Haemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Kessler T, Erdmann J, Vilne B, Bruse P, Kurowski V, Diemert P, Schunkert H, Sager HB. Serum microRNA-1233 is a specific biomarker for diagnosing acute pulmonary embolism. J Transl Med 2016; 14:120. [PMID: 27150028 PMCID: PMC4858885 DOI: 10.1186/s12967-016-0886-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 04/28/2016] [Indexed: 12/26/2022] Open
Abstract
Background Circulating microRNAs (miRNAs) emerge as novel biomarkers in cardiovascular diseases. Diagnosing acute pulmonary embolism (PE) remains challenging due to a diverse clinical presentation and the lack of specific biomarkers. Here we evaluate serum miRNAs as potential biomarkers in acute PE. Methods We enrolled 30 patients with acute, CT (computed tomography)-angiographically confirmed central PE and collected serum samples on the day of emergency room admission (1st day) and from 22 of these patients 9 months thereafter. For comparison, we examined serum samples from patients with acute non ST-segment elevation myocardial infarction (NSTEMI, n = 30) and healthy individuals (n = 12). Results We randomly selected 16 out of 30 PE patients and screened sera from the acute (1st day) and chronic stages (9 months) for 754 miRNAs using microarrays and found 37 miRNAs to be differentially regulated. Across all miRNAs, miRNA-1233 displayed the highest fold change (FC) from acute to chronic stage (log2FC 11.5, p < 0.004). We validated miRNA-1233 by real-time quantitative polymerase chain reaction (RT-qPCR). In acute PE (1st day) we found elevated levels of miRNA-1233 in comparison to NSTEMI (log2FC 5.7, p < 0.0001) and healthy controls (log2FC 7.7, p < 0.0001). miRNA-1233 differentiated acute PE from NSTEMI patients and healthy individuals with 90 and 90 % sensitivity, and 100 and 92 % specificity [area under the curve (AUC) 0.95, p < 0.001 and 0.91, p < 0.001], respectively. Conclusions This is the first report that identifies a miRNA that allows distinguishing acute PE from acute NSTEMI and healthy individuals with high specificity and sensitivity.
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Affiliation(s)
- Thorsten Kessler
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - Jeanette Erdmann
- Institut für Integrative und Experimentelle Genomik, Universität zu Lübeck, Lübeck, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK) e.V., partner site Hamburg/Lübeck/Kiel, Lübeck, Germany
| | - Baiba Vilne
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - Petra Bruse
- Institut für Integrative und Experimentelle Genomik, Universität zu Lübeck, Lübeck, Germany
| | | | | | - Heribert Schunkert
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany.,Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK) e.V., partner site Munich Heart Alliance (MHA), Munich, Germany
| | - Hendrik B Sager
- Deutsches Herzzentrum München, Klinik für Herz- und Kreislauferkrankungen, Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany.
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Dilektasli AG, Demirdogen Cetinoglu E, Acet NA, Erdogan C, Ursavas A, Ozkaya G, Coskun F, Karadag M, Ege E. Catheter-Directed Therapy in Acute Pulmonary Embolism with Right Ventricular Dysfunction: A Promising Modality to Provide Early Hemodynamic Recovery. Med Sci Monit 2016; 22:1265-73. [PMID: 27081754 PMCID: PMC4835153 DOI: 10.12659/msm.897617] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Catheter-directed therapy (CDT) for pulmonary embolism (PE) is considered as an alternative to systemic thrombolysis (ST) in patients with hemodynamically unstable acute PE who are considered at high bleeding risk for ST. We aimed to evaluate the efficacy and safety of CDT in the management of acute PE with right ventricular dysfunction (RVD). The primary outcomes were mortality, clinical success, and complications. Secondary outcomes were change in hemodynamic parameters in the first 24 hours following the procedure. MATERIAL AND METHODS Medical records of consecutive patients diagnosed as having acute massive or submassive PE with accompanying RVD treated by immediate CDT at our institution from January 2007 to January 2014 were reviewed. Patient characteristics, mortality, achievement of clinical success, and minor and major bleeding complications were analyzed in the overall study group, as well as massive vs. submassive PE subgroups. Change in hemodynamic parameters in the second, eighth, and 24th hours after the CDT procedure were also analyzed. RESULTS The study included 15 consecutive patients (M/F=10/5) with a mean age of 54.2 ± 16.6 years who underwent immediate CDT. Nine of the patients had submassive PE, and 6 had massive PE. In-hospital mortality rate was 13.3% (95% CI, 0.04-0.38). One major, but not life-threatening, bleeding episode was evident in the whole group. Hemodynamic parameters were stabilized and clinical success was achieved in 14/15 (93.3%; 95% CI, 70.2-98.8) of the patients in the first 24 hours. Notably, the hemodynamic recovery was significantly evident in the first 8 hours after the procedure. CONCLUSIONS CDT is a promising treatment option for patients with acute PE with RVD with no fatal bleeding complication. In experienced centers, CDT should be considered as a first-line treatment for patients with acute PE and RVD and contraindications for ST, with the advantage of providing early hemodynamic recovery.
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Affiliation(s)
- Asli Gorek Dilektasli
- Department of Pulmonary Medicine, Uludag University Faculty of Medicine, Bursa, Turkey
| | | | - Nilufer Aylin Acet
- Department of Pulmonary Medicine, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Cuneyt Erdogan
- Department of Radiology, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Ahmet Ursavas
- Department of Pulmonary Medicine, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Guven Ozkaya
- Department of Biostatistics, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Funda Coskun
- Department of Pulmonary Medicine, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Mehmet Karadag
- Department of Pulmonary Medicine, Uludag University Faculty of Medicine, Bursa, Turkey
| | - Ercument Ege
- Department of Pulmonary Medicine, Uludag University Faculty of Medicine, Bursa, Turkey
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Keller K, Beule J, Balzer JO, Dippold W. Syncope and collapse in acute pulmonary embolism. Am J Emerg Med 2016; 34:1251-7. [PMID: 27107684 DOI: 10.1016/j.ajem.2016.03.061] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 03/26/2016] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Syncope and collapse (=presyncope) are 2 symptoms of pulmonary embolism (PE), which are suspected of being connected with poorer outcome, regardless of haemodynamic instability. However, pathomechanisms are not completely understood. We aimed to investigate these pathomechanisms in regard to blood pressure and heart rate of syncope/collapse in PE. METHODS We performed a retrospective study of consecutive PE patients, who were treated in the Internal Medicine Department. Patients with and without syncope/collapse were compared. Regression models for associations between syncope/collapse and blood pressure, heart rate and shock index (SI) were computed. Moreover we calculated ROC analyses and Youden indices for effectiveness and cut-off-values of these parameters for the probability of syncope/collapse. RESULTS 182 patients (mean-age 68.5±15.3years; 61.5% female) with confirmed PE were included in this study. 20 PE patients (11.0%) showed a syncope/collapse. PE patients with syncope/collapse were in median 7.5years older (78.5 (72.0/82.3) vs. 71.0 (61.0/80.0) years, P=.0575), had lower systolic (132.0 (108.8/154.0) vs. 145.5 (127.0/166.0) mmHg, P=.0845) and diastolic (70.0±27.0 vs. 78.4±18.4mmHg, P=.0740) blood pressure, whereas heart rate (103.5 (87.8/116.0) vs. 90.0 (76.0/102.0)beats/min, P=.0518), SI (0.78 (0.65/1.01) vs. 0.60(0.50/0.79), P=.0127) and frequency of right ventricular dysfunction (RVD) (88.2% vs. 55.8%, P=.0294) were higher in PE patients with syncope/collapse than in those without. Hypotension (systolic blood pressure<90mmHg), tachycardia and SI>1.0were connected with 6.4-fold, 2.5-fold and 5.8-fold higher probability of syncope/collapse, respectively. ROC analyses revealed cut-off values of ≤110mmHg, ≥107beats/min and >0.62 for systolic blood pressure, heart rate and SI with low AUC values, respectively. CONCLUSIONS The pathomechanism of syncope/collapse in patients with acute PE seems to be connected with blood pressure fall, heart rate increase and RVD, in terms of cardiovascular syncope with reduced cardiac output and vasovagal reflex.
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Affiliation(s)
- Karsten Keller
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany; Center of Cardiology, Department of Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany.
| | - Johannes Beule
- Department of internal medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM), Mainz, Germany
| | - Jörn Oliver Balzer
- Department of Radiology and Nuclear medicine, Catholic Clinic Mainz (KKM), Mainz, Germany; Department of Diagnostic and Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt, Main, Frankfurt, Germany
| | - Wolfgang Dippold
- Department of internal medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM), Mainz, Germany
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Konstantinides SV, Barco S, Lankeit M, Meyer G. Management of Pulmonary Embolism. J Am Coll Cardiol 2016; 67:976-990. [DOI: 10.1016/j.jacc.2015.11.061] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 11/11/2015] [Accepted: 11/17/2015] [Indexed: 10/22/2022]
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Management of massive and submassive pulmonary embolism: focus on recent randomized trials. Curr Opin Pulm Med 2015; 20:393-9. [PMID: 25029299 DOI: 10.1097/mcp.0000000000000089] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Although early pulmonary revascularization is the treatment of choice for patients with high-risk (massive) pulmonary embolism, it remains controversial in patients with intermediate-risk (submassive) pulmonary embolism until recently. Recent published data on the management of high-risk and intermediate-risk pulmonary embolism patients will be the main focus of this review. RECENT FINDINGS The PEITHO trial supports the rationale of risk stratification in normotensive patients with pulmonary embolism. Patients with right ventricular dilation on echocardiography and positive cardiac troponin test have a high intermediate risk of complication and death. Thrombolysis prevents hemodynamic collapse in these patients but with an increased risk of major bleeding particularly in older patients (>75 years). Reduced dose of thrombolysis and catheter-based reperfusion with or without fibrinolysis have shown promising results. SUMMARY Thrombolysis is the treatment of choice for patients with high-risk pulmonary embolism. Surgical embolectomy is recommended in case of absolute contra-indication to thrombolysis. In patients with acute right ventricular dysfunction on cardiac imaging and myocardial injury, thrombolysis should be considered if they are 75 years or less of age and are at low risk of bleeding. Full-dose thrombolysis may be excessively risky in patients over 75 years. In patients with either RV dilation or elevated cardiac biomarker, thrombolysis is not recommended.
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Darze ES, Casqueiro JB, Ciuffo LA, Santos JM, Magalhães IR, Latado AL. Pulmonary Embolism Mortality in Brazil from 1989 to 2010: Gender and Regional Disparities. Arq Bras Cardiol 2015; 106:4-12. [PMID: 26559854 PMCID: PMC4728589 DOI: 10.5935/abc.20160001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 08/27/2015] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A significant variation in pulmonary embolism (PE) mortality trends have been documented around the world. We investigated the trends in mortality rate from PE in Brazil over a period of 21 years and its regional and gender differences. METHODS Using a nationwide database of death certificate information we searched for all cases with PE as the underlying cause of death between 1989 and 2010. Population data were obtained from the Brazilian Institute of Geography and Statistics (IBGE). We calculated age-, gender- and region-specific mortality rates for each year, using the 2000 Brazilian population for direct standardization. RESULTS Over 21 years the age-standardized mortality rate (ASMR) fell 31% from 3.04/100,000 to 2.09/100,000. In every year between 1989 and 2010, the ASMR was higher in women than in men, but both showed a significant declining trend, from 3.10/100,000 to 2.36/100,000 and from 2.94/100,000 to 1.80/100,000, respectively. Although all country regions showed a decline in their ASMR, the largest fall in death rates was concentrated in the highest income regions of the South and Southeast Brazil. The North and Northeast regions, the lowest income areas, showed a less marked fall in death rates and no distinct change in the PE mortality rate in women. CONCLUSIONS Our study showed a reduction in the PE mortality rate over two decades in Brazil. However, significant variation in this trend was observed amongst the five country regions and between genders, pointing to possible disparities in health care access and quality in these groups.
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Moodley O, Goubran H. Should lifelong anticoagulation for unprovoked venous thromboembolism be revisited? Thromb J 2015; 13:33. [PMID: 26500456 PMCID: PMC4618533 DOI: 10.1186/s12959-015-0063-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 06/17/2015] [Indexed: 01/17/2023] Open
Abstract
Venous thromboembolism [VTE] is a common medical condition that has significant morbidity and mortality. Although stringent guidelines recommend lifelong anticoagulation for patients with unprovoked VTE, the optimal management strategy for their long term treatment remains controversial. Whereas in cancer-associated VTE and second unprovoked VTE lifelong anticoagulation is universally accepted, a careful analysis of the benefit vs. risk of long-term anticoagulation following a first unprovoked VTE should be considered as case fatality rates [CFR] from VTE appear more pronounced in the first few months. The CFR from major bleeding remains constant throughout therapy. Therefore, the risk of bleeding may be underestimated over longer treatment periods relative to the morbidity of recurrent VTE which appears to peak in the first year. The current review highlights the balance between the recurrence risk and bleeding risks in the era of direct oral anticoagulants. Vitamin K antagonists have been the standard of care for over 50 years bearing significant bleeding risks. The new oral anticoagulants [NOACs] have shown similar efficacy and perhaps a questionable improved safety profile when compared to warfarin. Aspirin has historically not been a useful agent in the management of VTE. However, two recent trials [WARFASA and ASPIRE] showed a likely 20-30 % risk reduction when compared to placebo for recurrent VTE after initial anticoagulation. The risk of major hemorrhage was low in both trials. With the emergence of NOACs and the increased utility of aspirin, there are multiple therapeutic options for long term management for VTE. Given comparable efficacy and improved safety of NOACs and aspirin, the risk benefit of anticoagulation is improving. A risk stratification model may help identifying patients at high risk for recurrence necessitating a lifelong anticoagulation. This cohort should be separated from a low risk group that may benefit from clinical observation, aspirin or NOACs. Prospective clinical trials are needed to support these clinical observations.
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Affiliation(s)
- Otto Moodley
- Saskatoon Cancer Centre and College of Medicine, University of Saskatchewan, 20, Campus Drive, Saskatoon, SK S7N4H4 Canada
| | - Hadi Goubran
- Saskatoon Cancer Centre and College of Medicine, University of Saskatchewan, 20, Campus Drive, Saskatoon, SK S7N4H4 Canada
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Ingrisch M, Maxien D, Meinel FG, Reiser MF, Nikolaou K, Dietrich O. Detection of pulmonary embolism with free-breathing dynamic contrast-enhanced MRI. J Magn Reson Imaging 2015; 43:887-93. [DOI: 10.1002/jmri.25050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 09/04/2015] [Accepted: 09/04/2015] [Indexed: 11/05/2022] Open
Affiliation(s)
- Michael Ingrisch
- Josef-Lissner-Laboratory for Biomedical Imaging; Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich; Munich Germany
| | - Daniel Maxien
- Institute for Clinical Radiology; Ludwig-Maximilians-University Hospital Munich; Munich Germany
| | - Felix G. Meinel
- Institute for Clinical Radiology; Ludwig-Maximilians-University Hospital Munich; Munich Germany
| | - Maximilian F. Reiser
- Institute for Clinical Radiology; Ludwig-Maximilians-University Hospital Munich; Munich Germany
| | - Konstantin Nikolaou
- Institute for Clinical Radiology; Ludwig-Maximilians-University Hospital Munich; Munich Germany
- Department of Diagnostic and Interventional Radiology; Eberhard-Karls-University; Tübingen Germany
| | - Olaf Dietrich
- Josef-Lissner-Laboratory for Biomedical Imaging; Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich; Munich Germany
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Keller K, Beule J, Schulz A, Coldewey M, Dippold W, Balzer JO. D-dimer for risk stratification in haemodynamically stable patients with acute pulmonary embolism. Adv Med Sci 2015; 60:204-10. [PMID: 25847178 DOI: 10.1016/j.advms.2015.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 01/30/2015] [Accepted: 02/20/2015] [Indexed: 12/19/2022]
Abstract
PURPOSE Patients with submassive pulmonary embolism (PE) have a higher short-term mortality than those with low-risk PE. Rapid identification of submassive PE is important for adequate treatment of non-massive PE. We aimed to investigate the utility of D-dimer for the prediction of submassive PE stadium in normotensive PE patients. PATIENTS AND METHODS Normotensive PE patients were classified into submassive or low-risk PE groups. In addition to the comparison of the groups, area under the curve (AUC) and D-dimer cut-off for the prediction of submassive PE stadium, multi-variate logistic regression for association between D-dimer values above this cut-off and submassive PE stadium were also calculated. RESULTS The data of 129 normotensive PE patients (59.7% women, mean age 70.0 years (60.7/81.0)) were analysed retrospectively. Patients with submassive PE were older (75.0 years (61.7/81.0) vs. 66.5 years (55.7/74.2), P=0.026) and more frequently female (63.6% vs. 53.8%, P=0.35). Heart rate (100.0beats/min (85.0/108.0) vs. 80.0beats/min (70.0/96.2), P<0.0001), systolic pulmonary-artery pressure (41.55±16.79mmHg vs. 22.62±14.81mmHg, P<0.0001), and D-dimer (2.00mg/l (1.09/3.98) vs. 1.21mg/l (0.75/1.99), P=0.011) were higher in patients with submassive PE. D-dimer values >1.32mg/l were indicative of submassive PE and shock-index ≥0.7. The effectiveness (AUC) of the test was 0.63 for submassive PE and 0.64 for shock-index ≥0.7. D-dimer values >1.32mg/l were associated with submassive PE stadium (OR 3.81 (95% CI: 1.74-8.35), P=0.00083) as well as with systolic blood pressure (OR 0.98 (95% CI: 0.97-0.99), P=0.033), heart rate (OR 1.02 (95% CI: 1.00-1.04), P=0.023) and shock-index value (OR 15.89 (95% CI: 1.94-130.08), P=0.0099). CONCLUSIONS D-dimer values >1.32mg/l are indicative of submassive PE stadium and shock-index ≥0.7. Efficacy of D-dimer for predicting submassive PE stadium was only weak to moderate.
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