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Robert P, Lattuca B. [An infarction, but not a myocardial infarction!]. Ann Cardiol Angeiol (Paris) 2024; 73:101795. [PMID: 39126749 DOI: 10.1016/j.ancard.2024.101795] [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: 07/02/2024] [Accepted: 07/10/2024] [Indexed: 08/12/2024]
Abstract
Pulmonary embolism (PE) is a common and serious cardiovascular disease. The management of PE patients with myocardial damage but without hemodynamic instability (intermediate/high risk) has long remained limited to anticoagulant therapy with no demonstrated positive effect of thrombolysis. In this specific population, percutaneous techniques have been developed and appear as interesting alternative in patients with clinical, biological and morphological severity criteria to reduce the evolutive risk to a more severe form and improve patients' prognosis. We report here the case of a 49-year-old patient treated for a massive bilateral and proximal PE revealed by syncope with right ventricular impact in whom percutaneous pulmonary thrombectomy was proposed in the absence of clinical improvement after the initiation of anticoagulant therapy. The precise indications for percutaneous techniques need to be clarified in patients with intermediate/high risk PE and ongoing randomized studies should provide additional results to better identify their place in the therapeutic arsenal.
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Affiliation(s)
- Pierre Robert
- Département de cardiologie, CHU Caremeau Nîmes, Université de Montpellier, Nîmes, France
| | - Benoit Lattuca
- Département de cardiologie, CHU Caremeau Nîmes, Université de Montpellier, Nîmes, France.
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2
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Yhim HY. Proper application of anticoagulation therapy on cancer-associated venous thrombosis. Blood Res 2024; 59:25. [PMID: 39093370 PMCID: PMC11296996 DOI: 10.1007/s44313-024-00029-3] [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: 05/29/2024] [Accepted: 07/25/2024] [Indexed: 08/04/2024] Open
Abstract
Cancer-associated venous thromboembolism (VTE) significantly impacts morbidity and mortality. The introduction of direct oral anticoagulants over the past decade has revolutionized VTE treatment in patients with active cancer, offering potential advantages over traditional therapies. However, uncertainties persist regarding the optimal selection and dosage of anticoagulants, particularly in patients with specific risk factors for bleeding, such as certain cancer types (e.g., upper gastrointestinal cancer, genitourinary cancer, primary or metastatic brain tumor, and hematologic malignancies) and specific patient characteristics (e.g., renal dysfunction and thrombocytopenia). Recent data on the thrombotic risk associated with low thrombotic burden VTE, such as subsegmental pulmonary embolism and isolated distal deep vein thrombosis, underscore the need for updated management strategies in daily clinical practice. This review aims to explore these issues and highlight the evolving landscape of cancer-associated VTE management.
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Affiliation(s)
- Ho-Young Yhim
- Department of Internal Medicine, Jeonbuk National University Medical School, 20 Geonji-Ro, Deokjin-Gu, Jeonju, 54907, Republic of Korea.
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3
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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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4
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Hobohm L, Paschke LM, Farmakis IT, Barco S, Partovi S, Münzel T, Konstantinides S, Keller K, Below M. Diagnosis of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: data from a practice-based longitudinal cohort. J Thromb Haemost 2024; 22:2203-2210. [PMID: 38677594 DOI: 10.1016/j.jtha.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/11/2024] [Accepted: 04/11/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND A large prospective multicenter cohort study with systematic follow-up recently reported a 2.3% 2-year cumulative incidence of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE). OBJECTIVES The present investigation aimed to determine the reported prevalence and incidence of CTEPH diagnosis after acute PE in real-world practice over a 12-year period. METHODS This study was based on nationwide ambulatory billing claims and drug prescription data of all residents with public health insurance in Germany from 2010 to 2021. RESULTS A total of 573 972 patients with acute PE (median age, 71 years; 57.4% women) were identified between 2010 and 2021. Prevalence of CTEPH among patients with history of PE increased during the period from 0.4% in 2010 to 0.9% in 2021. CTEPH was diagnosed in 2556 patients after acute PE, with most (17.6%) diagnoses reported within the first 3 months after the index PE event. The cumulative incidence rate after 3 months (first quarter) was calculated at 0.08% and after the first 2 years (eighth quarter) at 0.36%; it was 0.75% over the entire (90-month) follow-up period. Patients with CTEPH diagnosis during follow-up more often had right ventricular dysfunction at the index acute PE (14.9% vs 8.3%; P < .001). CONCLUSION The low CTEPH incidence rate after acute PE in the present analysis suggests low awareness of CTEPH. It further suggests a lack of systematic follow-up protocols for acute PE survivors in the real world. Improved implementation of existing recommendations on follow-up strategies after PE is warranted.
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Affiliation(s)
- Lukas Hobohm
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany; Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
| | - Lena Marie Paschke
- Department of Prescription Data, Central Research Institute of Ambulatory Health Care, Berlin, Germany
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany; Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany; Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Sasan Partovi
- Vascular and Interventional Radiology, Cleveland Clinic Main Campus, Cleveland, Ohio, USA
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany; German Center for Cardiovascular Research, Partner Site Rhine-Main, Mainz, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Karsten Keller
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany; Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany; Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Maike Below
- Department of Prescription Data, Central Research Institute of Ambulatory Health Care, Berlin, Germany
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Shahzadi I, Zwanenburg A, Frohwein LJ, Schramm D, Meyer HJ, Hinnerichs M, Moenninghoff C, Niehoff JH, Kroeger JR, Borggrefe J, Surov A. Short-term mortality prediction in acute pulmonary embolism: Radiomics values of skeletal muscle and intramuscular adipose tissue. J Cachexia Sarcopenia Muscle 2024; 15:1430-1440. [PMID: 38859660 PMCID: PMC11294025 DOI: 10.1002/jcsm.13488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 03/08/2024] [Accepted: 03/22/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Acute pulmonary embolism (APE) is a potentially life-threatening disorder, emphasizing the importance of accurate risk stratification and survival prognosis. The exploration of imaging biomarkers that can reflect patient survival holds the potential to further enhance the stratification of APE patients, enabling personalized treatment and early intervention. Therefore, in this study, we develop computed tomography pulmonary angiography (CTPA) radiomic signatures for the prognosis of 7- and 30-day all-cause mortality in patients with APE. METHODS Diagnostic CTPA images from 829 patients with APE were collected. Two hundred thirty-four features from each skeletal muscle (SM), intramuscular adipose tissue (IMAT) and both tissues combined (SM + IMAT) were calculated at the level of thoracic vertebra 12. Radiomic signatures were derived using 10 times repeated three-fold cross-validation on the training data for SM, IMAT and SM + IMAT for predicting 7- and 30-day mortality independently. The performance of the radiomic signatures was then evaluated on held-out test data and compared with the simplified pulmonary embolism severity index (sPESI) score, a well-established biomarker for risk stratification in APE. Predictive accuracy was assessed by the area under the receiver operating characteristic curve (AUC) with a 95% confidence interval (CI), sensitivity and specificity. RESULTS The radiomic signatures based on IMAT and a combination of SM and IMAT (SM + IMAT) achieved moderate performance for the prediction of 30-day mortality on test data (IMAT: AUC = 0.68, 95% CI [0.57-0.78], sensitivity = 0.57, specificity = 0.73; SM + IMAT: AUC = 0.70, 95% CI [0.60-0.79], sensitivity = 0.74, specificity = 0.54). Radiomic signatures developed for predicting 7-day all-cause mortality showed overall low performance. The clinical signature, that is, sPESI, achieved slightly better performance in terms of AUC on test data compared with the radiomic signatures for the prediction of both 7- and 30-day mortality on the test data (7 days: AUC = 0.73, 95% CI [0.67-0.79], sensitivity = 0.92, specificity = 0.16; 30 days: AUC = 0.74, 95% CI [0.66-0.82], sensitivity = 0.97, specificity = 0.16). CONCLUSIONS We developed and tested radiomic signatures for predicting 7- and 30-day all-cause mortality in APE using a multicentric retrospective dataset. The present multicentre work shows that radiomics parameters extracted from SM and IMAT can predict 30-day all-cause mortality in patients with APE.
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Affiliation(s)
- Iram Shahzadi
- Department of Radiology, Neuroradiology and Nuclear MedicineJohannes Wesling University Hospital, Ruhr University BochumBochumGermany
- Siemens Healthineers GmbHErlangenGermany
| | - Alex Zwanenburg
- OncoRay‐National Center for Radiation Research in Oncology, Faculty of Medicine, and University Hospital Carl Gustav CarusTechnische Universität Dresden, Helmholtz‐Zentrum Dresden‐RossendorfDresdenGermany
- National Center for Tumor Diseases (NCT), Partner Site DresdenDresdenGermany
| | | | | | | | | | - Christoph Moenninghoff
- Department of Radiology, Neuroradiology and Nuclear MedicineJohannes Wesling University Hospital, Ruhr University BochumBochumGermany
| | - Julius Henning Niehoff
- Department of Radiology, Neuroradiology and Nuclear MedicineJohannes Wesling University Hospital, Ruhr University BochumBochumGermany
| | - Jan Robert Kroeger
- Department of Radiology, Neuroradiology and Nuclear MedicineJohannes Wesling University Hospital, Ruhr University BochumBochumGermany
| | - Jan Borggrefe
- Department of Radiology, Neuroradiology and Nuclear MedicineJohannes Wesling University Hospital, Ruhr University BochumBochumGermany
| | - Alexey Surov
- Department of Radiology, Neuroradiology and Nuclear MedicineJohannes Wesling University Hospital, Ruhr University BochumBochumGermany
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Stortecky S, Barco S, Windecker S, Heg D, Kadner A, Englberger L, Kucher N. Ultrasound-assisted catheter-directed thrombolysis versus surgical pulmonary embolectomy for intermediate-high or high-risk pulmonary embolism: a randomized phase II non-inferiority trial. Eur J Cardiothorac Surg 2024; 66:ezae252. [PMID: 38991831 DOI: 10.1093/ejcts/ezae252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/03/2024] [Accepted: 07/10/2024] [Indexed: 07/13/2024] Open
Abstract
OBJECTIVES We hypothesized that ultrasound-assisted thrombolysis (USAT) is non-inferior to surgical pulmonary embolectomy (SPE) to improve right ventricular (RV) function in patients with acute pulmonary embolism (PE). METHODS In a single-centre, non-inferiority trial, we randomly assigned 27 patients with intermediate-high or high-risk acute PE to undergo either USAT or SPE stratified by PE risk. Primary and secondary outcomes were the baseline-to-72-h difference in right-to-left ventricular (RV/LV) ratio and the Qanadli pulmonary occlusion score, respectively, by contrast-enhanced chest-computed tomography assessed by a blinded CoreLab. RESULTS The trial was prematurely terminated due to slow enrolment. Mean age was 62.6 (SD 12.4) years, 26% were women, and 15% had high-risk PE. Mean change in RV/LV ratio was -0.34 (95% CI -0.50 to -0.18) in the USAT and -0.53 (95% CI -0.68 to -0.38) in the SPE group (mean difference: 0.152; 95% CI 0.032-0.271; Pnon-inferiority = 0.80; Psuperiority = 0.013). Mean change in Qanadli pulmonary occlusion score was -7.23 (95% CI -9.58 to -4.88) in the USAT and -11.36 (95% CI -15.27 to -7.44) in the SPE group (mean difference: 5.00; 95% CI 0.44-9.56, P = 0.032). Clinical and functional outcomes were similar between the 2 groups up to 12 months. CONCLUSIONS In patients with intermediate-high and high-risk acute PE, USAT was not non-inferior when compared with SPE in reducing RV/LV ratio within the first 72 h. In a post hoc superiority analysis, SPE resulted in greater improvement of RV overload and reduction of thrombus burden.
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Affiliation(s)
- Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | - Alexander Kadner
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lars Englberger
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Cardiac Surgery, Hirslanden Clinic Aarau, Aarau, Switzerland
| | - Nils Kucher
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
- Department of Angiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Mai V, Girardi L, de Wit K, Castellucci L, Aaron S, Couturaud F, Fergusson DA, Le Gal G. Chronic obstructive pulmonary disease exacerbation purulence status and its association with pulmonary embolism: protocol for a systematic review with meta-analysis. BMJ Open 2024; 14:e085328. [PMID: 38904133 PMCID: PMC11191811 DOI: 10.1136/bmjopen-2024-085328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 06/11/2024] [Indexed: 06/22/2024] Open
Abstract
INTRODUCTION Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) increases the risk of pulmonary embolism (PE). AECOPD and PE have similar symptoms which results in a high proportion of patients with AECOPD undergoing imaging to rule out PE. Finding predictors and explanatory factors of PE in AECOPD, such as purulence status, could help reduce the need for imaging. This systematic review with meta-analysis aims to evaluate if there is an association between purulence status in AECOPD and PE diagnosis. METHODS AND ANALYSIS MEDLINE, EMBASE and CENTRAL will be searched from database inception to April 2024. Randomised trials, cohort studies and cross-sectional studies on the prevalence of PE in patients with AECOPD will be included if the prevalence of PE based on the AECOPD purulence status is available. There will be no restriction on language. The primary outcome will be PE at the initial assessment and secondary outcomes will be all venous thromboembolism (deep venous thrombosis (DVT) and PE) and DVT, respectively, diagnosed at the initial assessment. Relative risks with their 95% CI will be calculated by using a Mantel-Haenszel random-effect model to compare the association between the risk of PE and the AECOPD purulence status (purulent vs non-purulent/unknown). Subgroup analyses will be performed based on the type of study, systematic search of PE versus no systematic search of PE and localisation of PE. Risk of bias will be evaluated by the ROBINS-E tool, publication bias will be evaluated with the funnel plot. The manuscript will be drafted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. ETHICS AND DISSEMINATION This study does not require ethics approval. This work will be submitted for presentation at an international conference and for publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42023459429.
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Affiliation(s)
- Vicky Mai
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Laura Girardi
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Kerstin de Wit
- Department of Emergency Medicine and Medicine, Queens University, Kingston, Ontario, Canada
| | - Lana Castellucci
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Shawn Aaron
- Department of Medicine, Faculty of Medicine, Division of Respirology, University of Ottawa, Ottawa, Ontario, Canada
| | - Francis Couturaud
- INSERM U1304-GETBO, CIC INSERM 1412, Univ_Brest, Département de Médecine Interne et Pneumologie, Centre Hospitalier Universitaire de Brest, Brest, FCRIN INNOVTE, France
| | - Dean A Fergusson
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Morello F, Bima P, Castelli M, Capretti E, de Matos Soeiro A, Cipriano A, Costantino G, Vanni S, Leidel BA, Kaufmann BA, Osman A, Candelli M, Capsoni N, Behringer W, Capuano M, Ascione G, Leal TDCAT, Ghiadoni L, Pivetta E, Grifoni S, Lupia E, Nazerian P. Diagnosis of acute aortic syndromes with ultrasound and d-dimer: the PROFUNDUS study. Eur J Intern Med 2024:S0953-6205(24)00234-6. [PMID: 38871565 DOI: 10.1016/j.ejim.2024.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/10/2024] [Accepted: 05/22/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND In patients complaining common symptoms such as chest/abdominal/back pain or syncope, acute aortic syndromes (AAS) are rare underlying causes. AAS diagnosis requires urgent advanced aortic imaging (AAI), mostly computed tomography angiography. However, patient selection for AAI poses conflicting risks of misdiagnosis and overtesting. OBJECTIVES We assessed the safety and efficiency of a diagnostic protocol integrating clinical data with point-of-care ultrasound (POCUS) and d-dimer (single/age-adjusted cutoff), to select patients for AAI. METHODS This prospective study involved 12 Emergency Departments from 5 countries. POCUS findings were integrated with a guideline-compliant clinical score, to define the integrated pre-test probability (iPTP) of AAS. If iPTP was high, urgent AAI was requested. If iPTP was low and d-dimer was negative, AAS was ruled out. Patients were followed for 30 days, to adjudicate outcomes. RESULTS Within 1979 enrolled patients, 176 (9 %) had an AAS. POCUS led to net reclassification improvement of 20 % (24 %/-4 % for events/non-events, P < 0.001) over clinical score alone. Median time to AAS diagnosis was 60 min if POCUS was positive vs 118 if negative (P = 0.042). Within 941 patients satisfying rule-out criteria, the 30-day incidence of AAS was 0 % (95 % CI, 0-0.41 %); without POCUS, 2 AAS were potentially missed. Protocol rule-out efficiency was 48 % (95 % CI, 46-50 %) and AAI was averted in 41 % of patients. Using age-adjusted d-dimer, rule-out efficiency was 54 % (difference 6 %, 95 % CI, 4-9 %, vs standard cutoff). CONCLUSIONS The integrated algorithm allowed rapid triage of high-probability patients, while providing safe and efficient rule-out of AAS. Age-adjusted d-dimer maximized efficiency. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov, NCT04430400.
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Affiliation(s)
- Fulvio Morello
- Department of Medical Sciences, Università degli Studi di Torino, Torino, Italy; Department of Emergency Medicine, Ospedale Molinette, A.O.U. Città della Salute e della Scienza, Torino, Italy.
| | - Paolo Bima
- Department of Medical Sciences, Università degli Studi di Torino, Torino, Italy
| | - Matteo Castelli
- Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy
| | - Elisa Capretti
- Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy
| | | | - Alessandro Cipriano
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | | | - Simone Vanni
- Medicina d'Urgenza, Ospedale San Giuseppe, Empoli, Italy
| | - Bernd A Leidel
- Department of Emergency Medicine, Campus Benjamin Franklin, Charité-Universitätsmedizin Berlin, Germany
| | - Beat A Kaufmann
- Department of Cardiology, University Hospital and University of Basel, Basel, Switzerland
| | - Adi Osman
- Resuscitation & Emergency Critical Care Unit, Trauma and Emergency Department, Raja Permaisuri Bainun Hospital, Ipoh, Perak Darul Ridzuan, Malaysia
| | - Marcello Candelli
- Emergency, Anesthesiological and Reanimation Sciences Department, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Roma, Italy
| | - Nicolò Capsoni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Wilhelm Behringer
- Department of Emergency Medicine, Medical University of Vienna, Austria; Department of Emergency Medicine, Universitätsklinikum Jena, Germany
| | - Marialessia Capuano
- Department of Emergency Medicine, Ospedale Molinette, A.O.U. Città della Salute e della Scienza, Torino, Italy
| | - Giovanni Ascione
- Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy
| | | | - Lorenzo Ghiadoni
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Emanuele Pivetta
- Department of Medical Sciences, Università degli Studi di Torino, Torino, Italy; Department of Emergency Medicine, Ospedale Molinette, A.O.U. Città della Salute e della Scienza, Torino, Italy
| | - Stefano Grifoni
- Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy
| | - Enrico Lupia
- Department of Medical Sciences, Università degli Studi di Torino, Torino, Italy; Department of Emergency Medicine, Ospedale Molinette, A.O.U. Città della Salute e della Scienza, Torino, Italy
| | - Peiman Nazerian
- Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy
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9
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Baumgartner C, Tritschler T, Aujesky D. Subsegmental Pulmonary Embolism. Hamostaseologie 2024; 44:197-205. [PMID: 37871632 DOI: 10.1055/a-2163-3111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023] Open
Abstract
Subsegmental pulmonary embolism (SSPE) is increasingly diagnosed with the growing use and technological advancements of multidetector computed tomography pulmonary angiography. Its diagnosis is challenging, and some presumed SSPE may actually represent imaging artifacts. Indirect evidence and results from small observational studies suggest that SSPE may be more benign than more proximal pulmonary embolism, and may thus not always require treatment. Therefore, guidelines suggest to consider a management strategy without anticoagulation in selected patients with SSPE at low risk of recurrent venous thromboembolism (VTE), in whom proximal deep vein thrombosis is excluded. Recently, a large prospective study among low-risk patients with SSPE who were left untreated showed a higher VTE recurrence risk than initially deemed acceptable by the investigators, and thus was prematurely interrupted after recruitment of 97% of the target population. However, the risk-benefit ratio of anticoagulation for low-risk patients with SSPE remains unclear, and results from randomized trials are needed to answer the question about their optimal management.
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Affiliation(s)
- Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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10
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Valiente Fernández M, Lesmes González de Aledo A, Delgado Moya FDP, Martín Badía I, Álvaro Valiente E, Blanco Otaegui N, Risco Torres P, Saéz de la Fuente I, Chacón Alves S, Orejón García L, Sánchez-Bayton Griffith M, Sánchez-Izquierdo Riera JÁ. Shock Index and Physiological Stress Index for reestratifying patients with intermediate-high risk pulmonary embolism. Med Intensiva 2024; 48:309-316. [PMID: 38000946 DOI: 10.1016/j.medine.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/23/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVE Study and Evaluation of Two Scores: Shock Index (SI) and Physiological Stress Index (PSI) as discriminators for proactive treatment (reperfusion before decompensated shock) in a population of intermediate-high risk pulmonary embolism (PE). DESIGN Using a database from a retrospective cohort with clinical variables and the outcome variable of "proactive treatment", a comparison of the populations was conducted. Optimal cut-off for "proactive treatment" points were obtained according to the SI and PSI. Comparisons were carried out based on the cut-off points of both indices. SETTING Patients admitted to a mixed ICU for PE. PARTICIPANTS Patients >18 years old admitted to the ICU with intermediate-high risk PE recruited from January 2015 to October 2022. INTERVENTIONS None. MAIN VARIABLES OF INTEREST Population comparison and metrics regarding predictive capacity when determining proactive treatment. RESULTS SI and PSI independently have a substandard predictive capacity for discriminating patients who may benefit from an early reperfusion therapy. However, their combined use improves detection of sicker intermediate-high risk PE patients (Sensitivity = 0.66) in whom an early reperfusion therapy may improve outcomes (Specificity = 0.9). CONCLUSIONS The use of the SI and PSI in patients with intermediate-high risk PE could be useful for selecting patients who would benefit from proactive treatment.
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Affiliation(s)
| | | | | | - Isaías Martín Badía
- Hospital Universitario 12 de Octubre, Avda. de Córdoba s/n, 28041 Madrid, Spain
| | | | | | - Pablo Risco Torres
- Hospital Universitario 12 de Octubre, Avda. de Córdoba s/n, 28041 Madrid, Spain
| | | | - Silvia Chacón Alves
- Hospital Universitario 12 de Octubre, Avda. de Córdoba s/n, 28041 Madrid, Spain
| | - Lidia Orejón García
- Hospital Universitario 12 de Octubre, Avda. de Córdoba s/n, 28041 Madrid, Spain
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Hobohm L, Farmakis IT, Duerschmied D, Keller K. The Current Evidence of Pulmonary Embolism Response Teams and Their Role in Future. Hamostaseologie 2024; 44:172-181. [PMID: 38471662 DOI: 10.1055/a-2232-5395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Abstract
Acute pulmonary embolism (PE) remains a critical medical condition requiring prompt and accurate management. The introduction and growing significance of pulmonary embolism response teams (PERT), also termed EXPERT-PE teams, signify a paradigm shift toward a collaborative, multidisciplinary approach in managing this complex entity. As the understanding of acute PE continues to evolve, PERTs stand as a linkage of optimized care, offering personalized and evidence-based management strategies for patients afflicted by this life-threatening condition. The evolving role of PERTs globally is evident in their increasing integration into the standard care pathways for acute PE. These teams have demonstrated benefits such as reducing time to diagnosis and treatment initiation, optimizing resource utilization, and improving patient outcomes.
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Affiliation(s)
- Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
- Center for Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), and DZHK Standort Rhein-Main, Mainz, Germany
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
- Center for Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), and DZHK Standort Rhein-Main, Mainz, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Hemostasis, and Medical Intensive Care, University Medical Centre Mannheim, Medical Faulty Mannheim, University of Heidelberg, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/ Mannheim, and Centre for Cardiovascular Acute Medicine Mannheim (ZKAM), Medical Centre Mannheim, Heidelberg University, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
- Center for Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), and DZHK Standort Rhein-Main, Mainz, Germany
- Department of Sports Medicine, Internal Medicine VII, Medical Clinic, University Hospital, Heidelberg, Germany
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12
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Sharp A, Mahfoud F. Contemporary outcomes in patients hospitalized with pulmonary embolism: what can we learn from observational data? Eur Heart J 2024:ehae263. [PMID: 38805685 DOI: 10.1093/eurheartj/ehae263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024] Open
Affiliation(s)
- Andrew Sharp
- Department of Cardiology, University Hospital of Wales, and Cardiff University, Heath Park Way, Cardiff CF14 4XW, United Kingdom
| | - Felix Mahfoud
- Clinic of Cardiology, Angiology and Internal Medicine, University Hospital Homburg, Saarland University, Saarbrücken, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, United States of America
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13
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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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14
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Rajpurkar M, Rosovsky RP, Williams S, Chan AKC, van Ommen CH, Faustino EVS, White M, Parikh M, Sirachainan N, Biss T, Goldenberg NA. Considerations for instituting pediatric pulmonary embolism response teams: A tool kit. Thromb Res 2024; 236:97-107. [PMID: 38417301 DOI: 10.1016/j.thromres.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 03/01/2024]
Abstract
The incidence of pediatric pulmonary embolism (PE) has increased by 200 % in the last decade, but at a single center, it is still infrequent. Given the unique epidemiologic features of pediatric PE, diagnosis is often delayed, and the management is empiric, based on individual physician experience or preference. Thus, there is a strong need for center-specific uniform management of pediatric PE patients. In adults, the development of pulmonary embolism response teams (PERTs) or PE critical care pathways has shortened the time to diagnosis and the initiation of definitive management. Evidence to support an improvement in PE outcomes after the development of PERTs does not exist in children. Nonetheless, we have summarized the practical practice guidelines that physicians and institutions can adopt to establish their institutional PERTs or critical pathways. We also provide strategies for resource-challenged institutions for partnering with centers with expertise in the management of pediatric PE.
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Affiliation(s)
- Madhvi Rajpurkar
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Central Michigan University, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA.
| | - Rachel P Rosovsky
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Suzan Williams
- Division of Hematology/Oncology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Canada
| | | | - C Heleen van Ommen
- Department of Pediatric Hematology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - E Vincent S Faustino
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Melissa White
- Division of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mihir Parikh
- Department of Pediatric Anesthesiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nongnuch Sirachainan
- Division of Hematology/Oncology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Bangkok, Thailand
| | - Tina Biss
- Department of Haematology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Neil A Goldenberg
- Department of Pediatrics and Medicine, Division of Hematology, Johns Hopkins, University School of Medicine, Baltimore, MD, USA; Johns Hopkins All Children's Institute for Clinical and Translational Research, Cancer and Blood Disorder Institute, and Heart Institute, Johns Hopkins All Children's, Hospital, St. Petersburg, FL, USA
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15
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Sagoschen I, Scibior B, Farmakis IT, Keller K, Graafen D, Griemert EV, Vosseler M, Treede H, Münzel T, Knorr M, Gori T, Konstantinides S, Hobohm L. A multidisciplinary pulmonary embolism response team (PERT): first experience from a single center in Germany. Clin Res Cardiol 2024; 113:581-590. [PMID: 38112742 PMCID: PMC10954947 DOI: 10.1007/s00392-023-02364-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 12/07/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Over the last few years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has emerged to encounter the increasing variety and complexity in managing acute pulmonary embolism (PE). PURPOSE To investigate PERT's composition and added clinical value in a university center in Germany. METHODS Over 4 years (01/2019-11/2022), patients with confirmed PE were enrolled in a prospective single-center cohort study (PERT Mainz). We investigated the composition of PERT and compared, after propensity score matching, patients with acute PE before and after the initiation of PERT at our Medical University Centre. The primary outcome was in-hospital PE-related mortality. RESULTS From 2019 to 2022, 88 patients with acute PE with a PERT decision were registered. Of those, 13 (14.8%) patients died during the in-hospital stay. Patients evaluated by a PERT had a median age of 68; 48.9% were females, and 21.7% suffered from malignancy. Right ventricular dysfunction was present in 76.1% of all patients. In total, 42.0% were classified as intermediate-high-risk PE and 11.4% as high-risk PE. First PERT contact mainly originated from emergency departments (33.3%) and intensive care units (30.0%), followed by chest pain units (21.3%) and regular wards (12.0%). The participation rate of medical specialties demonstrated that cardiologists (100%) or cardiac/vascular surgeons (98.6%) were included in almost all PERT consultations, followed by radiologists (95.9%) and anesthesiologists (87.8%). Compared to the PERT era, more patients in the pre-PERT era were classified as simplified pulmonary embolism severity index (sPESI) ≥ 1 (78.4% vs 71.6%) and as high-risk PE according to ESC 2019 guidelines (18.2% vs. 11.4%). In the pre-PERT era, low- and intermediate-low patients with PE received more frequently advanced reperfusion therapies such as systemic thrombolysis or surgical embolectomy compared to the PERT era (10.7% vs. 2.5%). Patients in the pre-PERT were found to have a considerably higher all-cause mortality and PE-related mortality rate (31.8% vs. 14.8%) compared to patients in the PERT era (22.7% vs. 13.6%). After propensity matching (1:1) by including parameters as age, sex, sPESI, and ESC risk classes, univariate regression analyses demonstrated that the PE management based on a PERT decision was associated with lower risk of all-cause mortality (OR, 0.37 [95%CI 0.18-0.77]; p = 0.009). For PE-related mortality, a tendency for reduction was observed (OR, 0.54 [95%CI 0.24-1.18]; p = 0.121). CONCLUSION PERT implementation was associated with a lower risk of all-cause mortality rate in patients with acute PE. Large prospective studies are needed further to explore the impact of PERTs on clinical outcomes.
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Affiliation(s)
- Ingo Sagoschen
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Barbara Scibior
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Karsten Keller
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Medical Clinic VII, University Hospital Heidelberg, Heidelberg, Germany
| | - Dirk Graafen
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Eva-Verena Griemert
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Markus Vosseler
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Hendrik Treede
- Department for Cardiac and Vascular Surgery, University Medical Center Mainz of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Maike Knorr
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Tommaso Gori
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Komotini, Greece
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.
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16
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Janssens U. Intensive Care Treatment of Pulmonary Embolism: An Update Based on the Revised AWMF S2k Guideline. Hamostaseologie 2024; 44:119-127. [PMID: 38499185 DOI: 10.1055/a-2237-7428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
Acute pulmonary embolism (PE) remains a significant cause of morbidity and requires prompt diagnosis and management. The prognosis of affected patients depends on the clinical severity. Therefore, risk stratification is imperative for therapeutic decision-making. Patients with high-risk PE need intensive care. These include patients who have successfully survived resuscitation, with obstructive shock or persistent haemodynamic instability. Bedside diagnostics by means of sonographic procedures are of outstanding importance in this high-risk population. In addition to the treatment of hypoxaemia with noninvasive and invasive techniques, the focus is on drug-based haemodynamic stabilisation and usually requires the elimination or reduction of pulmonary vascular thrombotic obstruction by thrombolysis. In the event of a contraindication to thrombolysis or failure of thrombolysis, various catheter-based procedures for thrombus extraction and local thrombolysis are available today and represent an increasing alternative to surgical embolectomy. Mechanical circulatory support systems can bridge the gap between circulatory arrest or refractory shock and definitive stabilisation but are reserved for centres with the appropriate expertise. Therapeutic strategies for patients with intermediate- to high-risk PE in terms of reduced-dose thrombolytic therapy or catheter-based procedures need to be further evaluated in prospective clinical trials.
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Affiliation(s)
- Uwe Janssens
- Medical Clinic and Intensive Care Medicine, St. Antonius Hospital Eschweiler, Eschweiler, Germany
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17
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Boberg E, Hedman A, Hollenberg J. Pulmonary embolism with paradoxical embolization to right coronary artery in the presence of a large patent foramen ovale: a case report. Eur Heart J Case Rep 2024; 8:ytae133. [PMID: 38617591 PMCID: PMC11014684 DOI: 10.1093/ehjcr/ytae133] [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: 02/06/2023] [Revised: 02/28/2024] [Accepted: 03/13/2024] [Indexed: 04/16/2024]
Abstract
Background Pulmonary embolism (PE) is the leading cause of in-hospital death and the third most frequent cause of cardiovascular death. The clinical presentation of PE is variable, and choosing the appropriate treatment for individual patients can be challenging. Case summary A 64-year-old man presented to hospital with acute chest pain, shortness of breath, and pulmonary oedema. Electrocardiogram revealed ST-elevation myocardial infarction. D-dimer was 18.8 mg/L fibrinogen equivalent units (FEU) (normal <0.64), and troponin was 25 (normal 5-14 ng/L). After systemic thrombolysis, respiratory failure persisted, and the arterial blood gas showed PaO2 of 6.0 kPa (normal 10.5-13.5 kPa), with 100% oxygen delivery via high-flow nasal cannula. A computed tomography diagnosed bilateral lobar PE, and coronary angiogram showed multiple thrombus in the right coronary artery. A bubble study with thoracic echocardiogram revealed a large right-left inter-atrial shunt. The patient denied treatment with extracorporeal membrane oxygenation and surgical thrombectomy. With no access to percutaneous catheter-directed thrombectomy, the patient received three separate thrombolysis treatments followed by a continued infusion for 22 h. After 6 weeks in hospital, the patient was discharged to rehab. Discussion For a long time, PE has been largely seen as a medical disease. Intra-cardiac shunts such as patent foramen ovale can complicate thrombo-venous disease and introduce paradoxical shunts leading to arterial emboli and persistent hypoxaemia. Over recent years, modern percutaneous catheter-directed thrombectomy has been developed for both high-risk and intermediate to high-risk PEs. Thrombectomy might improve right ventricular function and haemodynamics, but there is lacking evidence from randomized trials on efficacy, safety, and long-term outcome.
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Affiliation(s)
- Erik Boberg
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Entrevägen 2, 182 88 Stockholm, Sweden
| | - Anders Hedman
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Entrevägen 2, 182 88 Stockholm, Sweden
| | - Jacob Hollenberg
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Entrevägen 2, 182 88 Stockholm, Sweden
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Meyer FJ, Opitz C. Post-Pulmonary Embolism Syndrome: An Update Based on the Revised AWMF-S2k Guideline. Hamostaseologie 2024; 44:128-134. [PMID: 38531395 DOI: 10.1055/a-2229-4190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
In survivors of acute pulmonary embolism (PE), the post-PE syndrome (PPES) may occur. In PPES, patients typically present with persisting or progressive dyspnea on exertion despite 3 months of therapeutic anticoagulation. Therefore, a structured follow-up is warranted to identify patients with chronic thromboembolic pulmonary disease (CTEPD) with normal pulmonary pressure or chronic thromboembolic pulmonary hypertension (CTEPH). Both are currently understood as a dual vasculopathy, that is, secondary arterio- and arteriolopathy, affecting the large and medium-sized pulmonary arteries as well as the peripheral vessels (diameter < 50 µm). The follow-up algorithm after acute PE commences with identification of clinical symptoms and risk factors for CTEPH. If indicated, a stepwise performance of echocardiography, ventilation-perfusion scan (or alternative imaging), N-terminal prohormone of brain natriuretic peptide (NT-proBNP) level, cardiopulmonary exercise testing, and pulmonary artery catheterization with angiography should follow. CTEPH patients should be treated in a multidisciplinary center with adequate experience in the complex therapeutic options, comprising pulmonary endarterectomy, balloon pulmonary angioplasty, and pharmacological interventions.
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Affiliation(s)
- F Joachim Meyer
- Lungenzentrum München (Bogenhausen-Harlaching) - München Klinik gGmbH, Sanatoriumsplatz 2 München, München, Bavaria, Germany
| | - Christian Opitz
- Klinik für Innere Medizin, Schwerpunkt Kardiologie, DRK Kliniken Berlin Westend, Berlin, Germany
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19
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Murguia AR, Mukherjee D, Ojha C, Rajachandran M, Siddiqui TS, Nickel NP. Reduced-Dose Thrombolysis in Acute Pulmonary Embolism A Systematic Review. Angiology 2024; 75:208-218. [PMID: 37060258 DOI: 10.1177/00033197231167062] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Pulmonary embolism (PE) is the third-leading cause of cardiovascular mortality and the second-leading cause of death in cancer patients. The clinical efficacy of thrombolysis for acute PE has been proven, yet the therapeutic window seems narrow, and the optimal dosing for pharmaceutical reperfusion therapy has not been established. Higher doses of systemic thrombolysis inevitably associated with an incremental increase in major bleeding risk. To date, there is no high-quality evidence regarding dosing and infusion rates of thrombolytic agents to treat acute PE. Most clinical trials have focused on thrombolysis compared with anticoagulation alone, but dose-finding studies are lacking. Evidence is now emerging that lower-dose thrombolytic administered through a peripheral vein is efficacious in accelerating thrombolysis in the central pulmonary artery and preventing acute right heart failure, with reduced risk for major bleeding. The present review will systematically summarize the current evidence of low-dose thrombolysis in acute PE.
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Affiliation(s)
- Adrian Rojas Murguia
- Department of Internal Medicine, Texas Tech University Health Sciences Center of El Paso, Texas, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Department of Internal Medicine, Health Sciences Center of El Paso, Texas, TX, USA
| | - Chandra Ojha
- Division of Cardiovascular Medicine, Department of Internal Medicine, Health Sciences Center of El Paso, Texas, TX, USA
| | - Manu Rajachandran
- Division of Cardiovascular Medicine, Department of Internal Medicine, Health Sciences Center of El Paso, Texas, TX, USA
| | - Tariq S Siddiqui
- Division of Cardiovascular Medicine, Department of Internal Medicine, Health Sciences Center of El Paso, Texas, TX, USA
| | - Nils P Nickel
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center of El Paso, Texas, TX, USA
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20
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Sharp ASP, Piazza G. Editorial: More than one way to skin a clot? Differing techniques for solving the problem of clinically significant pulmonary embolism. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 60:53-54. [PMID: 38105133 DOI: 10.1016/j.carrev.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 11/30/2023] [Indexed: 12/19/2023]
Affiliation(s)
- Andrew S P Sharp
- Dept of Cardiology, University Hospital of Wales and Cardiff University, Cardiff, UK.
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
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21
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Shu L, Zhou J, He X. Intraoperative Cardiac Arrest During Liposuction: A Case Report. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5619. [PMID: 38463704 PMCID: PMC10923351 DOI: 10.1097/gox.0000000000005619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 01/09/2024] [Indexed: 03/12/2024]
Abstract
Background With the popularity of liposuction surgery, more awareness should be obtained regarding complications. Liposuction has been thought of as a safe procedure with a very low incidence of major complications. However, life-threatening risks of liposuction have rarely been reported. Methods We present a case of a 36-year-old woman who developed cardiac arrest during a liposuction procedure, and we present a literature review. Results She was previously healthy and had no risk factors for pulmonary embolism. The diagnosis was made based on clinical presentation and the presence of an electrolyte disorder and a positive sign on computed tomography pulmonary angiogram (CTPA). Mild hypothermia treatment, symptomatic treatment, and supportive therapy were applied. As the respiratory and circulation were smooth, she was discharged to a rehabilitation hospital. Seven months after discharge, the patient was still in a coma with eye opening. Conclusions Spinal anesthesia, pulmonary embolism, and hyperkalemia are the most probable contributors to the cardiac arrest observed during the liposuction procedure in this specific case. There is a heightened imperative to vigilantly monitor for critical incidents during these operations and to meticulously identify associated risk factors during liposuction.
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Affiliation(s)
- Lu Shu
- From the Department of Thoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Jian Zhou
- Department of Intensive Care Medicine, Xintian General Hospital, Xintian, Hunan, P.R. China
| | - Xue He
- From the Department of Thoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
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22
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Palareti G, Antonucci E, Bucherini E, Caronna A, Chistolini A, Di Giorgio A, Di Giulio R, Falanga A, Fregoni V, Garzia M, Mastroiacovo D, Marzolo M, Pancani R, Pastori D, Podda GM, Rigoni AM, Ria L, Sivera P, Testa S, Visonà A, Parisi R, Poli D, Investigators OBOTSTARTPOSTVTE. Long-Term Outcomes in Two-Year Follow-Up after Primary Treatment in Patients with a Prior Venous Thromboembolic Event: A Prospective, Observational, Real-Life Study. J Clin Med 2024; 13:1343. [PMID: 38592175 PMCID: PMC10931842 DOI: 10.3390/jcm13051343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/09/2024] [Accepted: 02/14/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Patients with acute venous thromboembolism (VTE) need anticoagulation (AC) therapy for at least 3/6 months (primary treatment); after that period, they should receive a decision on the duration of therapy. METHODS This study examined the complications occurring during two years of follow-up (FU) in patients with a first VTE who were recruited in 20 clinical centers and had discontinued or prolonged AC. They were included in the START2-POST-VTE prospective observational study. RESULTS A total of 720 patients (53.5% males) who, after the completion of primary treatment, had received the decision to continue (n = 281, 39%; 76.1% with a DOAC) or discontinue (n = 439, 61%) AC were followed up for 2 years (total FU = 1318 years). The decision to prolong or suspend AC was made in similar proportions in patients with unprovoked or provoked index events. Courses of sulodexide treatment or Aspirin (100 mg daily) were prescribed to 20.3% and 4.5%, respectively, of the patients who discontinued AC. The bleeding rate was significantly higher in patients who extended AC (1.6% pt/y) than in those who stopped AC (0.1% pt/y; p = 0.001) and was higher in patients using standard-dose DOACs (3.1% pt/y) than in those using reduced-dose DOACs (0.4% pt/y). The recurrent VTE rates were similar between the two groups (2.2% pt/y during AC vs. 3% pt/y off AC). CONCLUSION Physicians' decisions about AC duration were independent of the unprovoked/provoked nature of the index event. The bleeding rate was higher in patients who continued AC using standard-dose DOACs. Surprisingly, the rate of thrombotic recurrence was not different between those who continued or discontinued AC. Randomized studies comparing different procedures to decide on the duration of AC after a first VTE are needed.
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Affiliation(s)
| | | | - Eugenio Bucherini
- SS Medicina Vascolare e Angiologia, AUSL Romagna, 48121 Ravenna, Italy;
| | - Antonella Caronna
- Centro per la Diagnosi e la Sorveglianza della Malattia Tromboembolica, UO Medicina Interna D’urgenza, Azienda Ospedaliero Universitaria Policlinico di Modena, Ospedale Civile Baggiovara, 41124 Modena, Italy;
| | - Antonio Chistolini
- Dipartimento di Medicina Traslazionale e di Precisione Sapienza Università di Roma, 00197 Roma, Italy;
| | - Angela Di Giorgio
- Angiologia Diagnostica Vascolare Non Invasiva, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | - Rosella Di Giulio
- U.O. Programma Dipartimentale di Ecografia-AUSL, 40133 Bologna, Italy;
| | - Anna Falanga
- School of Medicine, Università di Milano Bicocca, 20126 Milano, Italy;
- Immunoematologia e Medicina Trasfusionale ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Vittorio Fregoni
- U.O.C. Medicina Generale, Ospedale di Sondalo, ASST della Valtellina e dell’Alto Lario, 23035 Sondalo, Italy;
| | - Mariagrazia Garzia
- UOC Ematologia-Trapianto Cellule Staminali, Azienda Ospedaliera S.Camillo-Forlanini, 00152 Roma, Italy;
| | - Daniela Mastroiacovo
- UOSD Angiologia e Diagnostica Vascolare, Ospedale SS Filippo e Nicola, Avezzano (L’Aquila), 67051 L’Aquila, Italy;
| | - Marco Marzolo
- UOS Angiologia Medica, Ospedale di Rovigo, 45100 Rovigo, Italy;
| | - Roberta Pancani
- U.O. Pneumologia, Dipartimento Cardiotoraco-Vascolare, Azienda Ospedaliero-Universitaria Pisana, Ospedale di Cisanello, 56126 Pisa, Italy;
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00197 Roma, Italy;
| | - Gian Marco Podda
- Medicina Generale 2, ASST Santi Paolo e Carlo, Università degli Studi di Milano, 20142 Milano, Italy;
| | - Anna Maria Rigoni
- UOC di Angiologia, Azienda Ospedaliero Universitaria Integrata, 37126 Verona, Italy;
| | - Luigi Ria
- UO Medicina Interna, Presidio Ospedaliero di Gallipoli (Lecce), 73014, Gallipoli, Italy;
| | - Piera Sivera
- S.C.D.U. EMATOLOGIA Azienda Ospedaliera Ordine Mauriziano, 10128 Torino, Italy;
| | - Sophie Testa
- Centro Emostasi e Trombosi, ASST Cremona, 26100 Cremona, Italy;
| | - Adriana Visonà
- UOC Angiologia, Dipartimento di Medicina Clinica, Azienda ULSS 2 Marca Trevigiana, Ospedale San Giacomo Apostolo, 31033 Castelfranco Veneto, Italy;
| | - Roberto Parisi
- UOSD Ipertensione e Patologie Endocrine Metaboliche Angiologiche, Ospedale SS. Giovanni e Paolo, 30122 Venezia, Italy;
| | - Daniela Poli
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, 50134 Firenze, Italy;
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23
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Kenneweg F, Hobohm L, Bang C, Gupta SK, Xiao K, Thum S, Ten Cate V, Rapp S, Hasenfuß G, Wild P, Konstantinides S, Wachter R, Lankeit M, Thum T. Circulating miR-let7a levels predict future diagnosis of chronic thromboembolic pulmonary hypertension. Sci Rep 2024; 14:4514. [PMID: 38402278 PMCID: PMC10894210 DOI: 10.1038/s41598-024-55223-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/21/2024] [Indexed: 02/26/2024] Open
Abstract
Distinct patterns of circulating microRNAs (miRNAs) were found to be involved in misguided thrombus resolution. Thus, we aimed to investigate dysregulated miRNA signatures during the acute phase of pulmonary embolism (PE) and test their diagnostic and predictive value for future diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH). Microarray screening and subsequent validation in a large patient cohort (n = 177) identified three dysregulated miRNAs as potential biomarkers: circulating miR-29a and miR-720 were significantly upregulated and miR-let7a was significantly downregulated in plasma of patients with PE. In a second validation study equal expression patterns for miR-29a and miR-let7a regarding an acute event of recurrent venous thromboembolism (VTE) or deaths were found. MiR-let7a concentrations significantly correlated with echocardiographic and laboratory parameters indicating right ventricular (RV) dysfunction. Additionally, circulating miR-let7a levels were associated with diagnosis of CTEPH during follow-up. Regarding CTEPH diagnosis, ROC analysis illustrated an AUC of 0.767 (95% CI 0.54-0.99) for miR-let7a. Using logistic regression analysis, a calculated patient-cohort optimized miR-let7a cut-off value derived from ROC analysis of ≥ 11.92 was associated with a 12.8-fold increased risk for CTEPH. Therefore, miR-let7a might serve as a novel biomarker to identify patients with haemodynamic impairment and as a novel predictor for patients at risk for CTEPH.
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Affiliation(s)
- Franziska Kenneweg
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
- REBIRTH Excellence Cluster, Hannover Medical School, Hannover, Germany
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center Mainz, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Claudia Bang
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
| | - Shashi K Gupta
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
| | - Ke Xiao
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
| | - Sabrina Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
| | - Vincent Ten Cate
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center Mainz, Mainz, Germany
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - Steffen Rapp
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center Mainz, Mainz, Germany
- German Cardiovascular Research Centre (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Gerd Hasenfuß
- Institute of Molecular Biology (IMB), Mainz, Germany
| | - Philipp Wild
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center Mainz, Mainz, Germany
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
- German Cardiovascular Research Centre (DZHK), Partner Site Rhine Main, Mainz, Germany
- Institute of Molecular Biology (IMB), Mainz, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
| | - Rolf Wachter
- Clinic of Cardiology and Pneumology, Heart Center, University Medical Center, Goettingen, Germany
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité-University Medicine Berlin, Berlin, Germany
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany.
- REBIRTH Excellence Cluster, Hannover Medical School, Hannover, Germany.
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24
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Magyar U, Stalder O, Baumgartner C, Méan M, Righini M, Schuetz P, Bassetti S, Rodondi N, Tritschler T, Aujesky D. Association between severity of pulmonary embolism and health-related quality of life. J Thromb Haemost 2024; 22:516-525. [PMID: 38966659 PMCID: PMC7616132 DOI: 10.1016/j.jtha.2023.10.016] [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: 07/06/2024]
Abstract
Background Health-related quality of life (QoL) impairment is common after pulmonary embolism (PE). Whether the severity of the initial PE has an impact on QoL is unknown. Objectives To evaluate the association between severity of PE and QoL over time. Methods We prospectively assessed PE-specific QoL using the Pulmonary Embolism Quality of Life (lower scores indicate better QoL) questionnaire and generic QoL using the Short Form 36 (higher scores indicate better QoL) questionnaire at baseline and 3 and 12 months in older patients with acute PE. We examined whether QoL differed by PE severity based on hemodynamic status, simplified Pulmonary Embolism Severity Index (sPESI), right ventricular function, and high-sensitivity troponin T in mixed-effects models, adjusting for known QoL predictors after PE. Results Among 546 patients with PE (median age, 74 years), severe vs nonsevere PE based on the sPESI was associated with a worse PE-specific (adjusted mean Pulmonary Embolism Quality of Life score difference of 6.1 [95% CI, 2.4-9.8] at baseline, 7.6 [95% CI, 4.0-11.3] at 3 months, and 6.7 [95% CI, 2.9-10.4] at 12 months) and physical generic QoL (adjusted mean Short Form 36 Physical Component Summary score difference of -3.8 [95% CI, -5.5 to -2.1] at baseline, -4.8 [95% CI, -6.4 to -3.1] at 3 months, and -4.1 [95% CI, -5.8 to -2.3] at 12 months). Elevated troponin levels were also associated with lower PE-specific QoL at 3 months and lower physical generic QoL at 3 and 12 months. QoL did not differ by hemodynamic status or right ventricular function. Conclusion Severe PE based on the sPESI was consistently associated with worse PE-specific and physical generic QoL over time as compared to nonsevere PE.
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Affiliation(s)
- Ursula Magyar
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Odile Stalder
- Clinical Trials Unit (CTU) Bern, University of Bern, Bern, Switzerland
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marie Méan
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - Philipp Schuetz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Stefano Bassetti
- Division of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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25
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Affiliation(s)
- Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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26
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Dönmez E, Özcan S, Sahin İ, Ziyrek M, Okuyan E. Can GRACE Risk Score Predict Mortality and the Need for Thrombolytic Treatment in Acute Pulmonary Embolism? Am J Cardiol 2024; 211:115-121. [PMID: 37923156 DOI: 10.1016/j.amjcard.2023.10.077] [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: 07/13/2023] [Revised: 09/29/2023] [Accepted: 10/28/2023] [Indexed: 11/07/2023]
Abstract
Acute coronary syndrome and pulmonary embolism (PE) are clinical entities sharing similar presentation and risk factors. Risk scores and indexes help to identify disease severity in both diseases. In this study, we aimed to evaluate if the Global Registry of Acute Coronary Events (GRACE) risk score could predict 30-day mortality and the need for thrombolytic treatment in patients with acute PE. Patients hospitalized with a diagnosis of PE in our tertiary center between January 2018 and May 2022 were included in this retrospective study. Pulmonary Embolism Severity Index (PESI) and GRACE risk scores on admission were calculated using clinical, electrocardiographic, and laboratory parameters for each patient. A total of 197 patients were included. The 30-day mortality rate was 28.4% whereas 32.5% of the patients required thrombolytic treatment. GRACE and PESI scores were found independent risk factors associated with 30-day mortality and the need for thrombolytic treatment. A cut-off value of 160.5 for GRACE score was associated with 88.5% sensitivity and 89.4% specificity in prediction of 30-day mortality. In contrast, GRACE score had 61.0% sensitivity and 60.0% specificity in the prediction of the need for thrombolytic treatment when the cut-off value was 147. In conclusion, GRACE risk score has an effective discriminating power in determining the early mortality of patients with acute PE. The incidence of short-term PE-related mortality was significantly increased in patients with high GRACE risk scores. Concomitant use of GRACE and PESI risk scores may aid in defining patients with high-risk PE and help predict poor prognosis with high specificity and probability.
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Affiliation(s)
- Esra Dönmez
- Department of Cardiology, Bağcılar Training and Research Hospital, Bağcılar, İstanbul, Turkey
| | - Sevgi Özcan
- Department of Cardiology, Bağcılar Training and Research Hospital, Bağcılar, İstanbul, Turkey.
| | - İrfan Sahin
- Department of Cardiology, Bağcılar Training and Research Hospital, Bağcılar, İstanbul, Turkey
| | - Murat Ziyrek
- Department of Cardiology, Bağcılar Training and Research Hospital, Bağcılar, İstanbul, Turkey
| | - Ertugrul Okuyan
- Department of Cardiology, Bağcılar Training and Research Hospital, Bağcılar, İstanbul, Turkey
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27
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Calé R. Looking for the "magic formula" to restratify non-high risk pulmonary embolism: Are we missing the essential? Rev Port Cardiol 2024; 43:9-11. [PMID: 37421999 DOI: 10.1016/j.repc.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/06/2023] [Indexed: 07/10/2023] Open
Affiliation(s)
- Rita Calé
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal.
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28
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Tavares IR, Caffaro RA, Portugal MF, Ribeiro CM, da Silva VS, Krupa E, Nikolovski S, de Britto KF, Gomes Pereira Petisco AC, Miranda MC, Gomes de Souza Santos S, da Silva Dourado M, Siqueira PV, Siddiqui F, Fareed J, Ramacciotti E. Biomarkers Profile in Provoked Versus Unprovoked Deep Venous Thrombosis. Clin Appl Thromb Hemost 2024; 30:10760296241238211. [PMID: 38566607 PMCID: PMC10989034 DOI: 10.1177/10760296241238211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 02/12/2024] [Accepted: 02/23/2024] [Indexed: 04/04/2024] Open
Abstract
Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), represents a substantial healthcare challenge. Provoked and unprovoked DVT cases carry distinct risks and treatment considerations. Recognizing the limitations of this classification, molecular markers may enhance diagnostic precision and guide anticoagulation therapy duration relying on patient history and risk factors. This preliminary, open-label, prospective cohort study was conducted including 15 patients (10 provoked DVT and 5 unprovoked DVT) and a control group of healthy plasmatic subjects. Plasma levels of 9 biomarkers were measured at diagnosis (baseline, day 0, and D0) and after 30 days (day 30-D30). Patient demographics, clinical data, and biomarker concentrations were analyzed. Serum concentrations of D-dimer, von Willebrand factor, C-reactive protein, and Anti-Xa were elevated in DVT groups at D0 compared to controls. No significant differences were observed between the provoked and unprovoked groups on the day of diagnosis and 30 days later. Over 30 days, the provoked group exhibited significant biomarker changes related to temporal assessment. No significant differences were noted in the biomarker profile between provoked and unprovoked DVT groups. This study is indicative of the concept of individualized thrombosis assessment and subsequent treatment for VTE. Larger cohorts are warranted to validate these findings and further define the most appropriate use of the molecular markers.
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Affiliation(s)
- Isabela Rodrigues Tavares
- Department of Vascular Surgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil
- Dante Pazzanese Cardiology Institute, São Paulo, SP, Brazil
| | - Roberto Augusto Caffaro
- Department of Vascular Surgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil
| | | | | | | | - Emily Krupa
- Pathology Department, Hemostasis & Thrombosis Research Laboratories at Loyola University Medical Center, Maywood, IL, USA
| | - Srdjan Nikolovski
- Pathology Department, Hemostasis & Thrombosis Research Laboratories at Loyola University Medical Center, Maywood, IL, USA
| | - Karen Falcão de Britto
- Department of Vascular Surgery, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil
| | | | | | | | | | | | - Fakiha Siddiqui
- Pathology Department, Hemostasis & Thrombosis Research Laboratories at Loyola University Medical Center, Maywood, IL, USA
- Program in Health Sciences. UCAM - Universidad Católica San Antonio de Murcia, Guadalupe, Murcia, Spain
| | - Jawed Fareed
- Pathology Department, Hemostasis & Thrombosis Research Laboratories at Loyola University Medical Center, Maywood, IL, USA
| | - Eduardo Ramacciotti
- Science Valley Research Institute, Santo André, São Paulo, Brazil
- Pathology Department, Hemostasis & Thrombosis Research Laboratories at Loyola University Medical Center, Maywood, IL, USA
- Department of Cardiovascular Medicine, Hospital e Maternidade Christóvão da Gama, Grupo DASA, Santo André, São Paulo, Brazil
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29
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Kevane B, Áinle FN. Prevention, diagnosis, and management of PE and DVT in pregnant women. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:237-247. [PMID: 38066865 PMCID: PMC10727078 DOI: 10.1182/hematology.2023000476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Venous thromboembolism (VTE) is a leading cause of maternal morbidity and mortality worldwide. Despite the impact of VTE on pregnant and postpartum people and on society, guidelines addressing prevention, diagnosis, and management of VTE in pregnant and postpartum people frequently are based on recommendations from expert opinion and are extrapolated from data in nonpregnant populations. Pregnant individuals are frequently excluded from clinical trials, which is a barrier to providing safe, effective care. Anchoring to a case discussion, this review provides an update on recently published and ongoing randomized clinical trials (RCTs), prospective clinical management studies, and other research in this area. It highlights, in particular, the results of the Highlow RCT, which addresses optimal prevention of recurrence during pregnancy in people with prior VTE. Finally, we raise awareness of the impact of national and international clinical trial networks on the conduct of RCTs in pregnancy. We conclude, based on these data, that academic VTE clinical trials in pregnant women can and must be done.
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Affiliation(s)
- Barry Kevane
- Department of Hematology, Mater University Hospital, Dublin, Ireland
- Department of Hematology, Rotunda Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Irish Network for VTE Research, University College Dublin, Dublin, Ireland
| | - Fionnuala Ní Áinle
- Department of Hematology, Mater University Hospital, Dublin, Ireland
- Department of Hematology, Rotunda Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Irish Network for VTE Research, University College Dublin, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
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30
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Heyman SN, Herzog E. Clinical Decisions in the Management of Pulmonary Thromboembolism: Are There Bullets Left in the Cartridge? Crit Pathw Cardiol 2023; 22:124-127. [PMID: 37526954 DOI: 10.1097/hpc.0000000000000329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Affiliation(s)
| | - Eyal Herzog
- Cardiology, Hadassah Hebrew University Hospitals, Jerusalem, Israel
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31
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Jozwiak M, Doyen D, Denormandie P, Goury A, Marey J, Pène F, Cariou A, Mira JP, Dellamonica J, Nguyen LS. Impact of sex differences on cardiac injury in critically ill patients with COVID-19. Respir Res 2023; 24:292. [PMID: 37986157 PMCID: PMC10662091 DOI: 10.1186/s12931-023-02581-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 10/26/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND COVID-19 infections are associated with accrued inflammatory responses which may result in cardiac injury. Immune response to infection appears different between men and women, suggesting that COVID-19 patients' outcomes may differ according to biological sex. However, the impact of biological sex on the occurrence of cardiac injury during intensive care unit (ICU) stay in COVID-19 patients remain unclear. METHODS In this multicenter and prospective study, we included consecutive patients admitted to ICU for severe COVID-19 pneumonia, during the first two pandemic waves. Biological, electrocardiogram (ECG) and echocardiographic variables were collected on ICU admission. Cardiac injury was defined by increased troponin above 99th percentile of upper norm value and newly diagnosed ECG and/or echocardiographic abnormalities. The primary endpoint was the proportion of patients with cardiac injury during ICU stay according to biological sex. The impact of biological sex on other subsequent clinical outcomes was also evaluated. RESULTS We included 198 patients with a median age of 66 (56-73) years, 147 (74%) patients were men and 51 (26%) were women. Overall, 119 (60%) patients had cardiac injury during ICU stay and the proportion of patients with cardiac injury during ICU stay was not different between men and women (60% vs. 61%, p = 1.00). Patients with cardiac injury during ICU stay showed more cardiovascular risk factors and chronic cardiac disease and had a higher ICU mortality rate. On ICU admission, they had a more marked lymphopenia (0.70 (0.40-0.80) vs. 0.80 (0.50-1.10) × 109/L, p < 0.01) and inflammation (C-Reactive Protein (155 (88-246) vs. 111 (62-192) mg/L, p = 0.03); D-Dimers (1293 (709-2523) vs. 900 (560-1813) µg/L, p = 0.03)). Plasmatic levels of inflammatory biomarkers on ICU admission correlated with SAPS-2 and SOFA scores but not with the different echocardiographic variables. Multivariate analysis confirmed cardiovascular risk factors (OR = 2.31; 95%CI (1.06-5.02), p = 0.03) and chronic cardiac disease (OR = 8.58; 95%CI (1.01-73.17), p = 0.04) were independently associated with the occurrence of cardiac injury during ICU stay, whereas biological sex (OR = 0.88; 95%CI (0.42-1.84), p = 0.73) was not. Biological sex had no impact on the occurrence during ICU stay of other clinical outcomes. CONCLUSIONS Most critically ill patients with COVID-19 were men and experienced cardiac injury during ICU stay. Nevertheless, biological sex had no impact on the occurrence of cardiac injury during ICU stay or on other clinical outcomes. Clinical trial registration NCT04335162.
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Affiliation(s)
- Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Assistance Publique, Hôpitaux de Paris, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France.
- Université Paris Cité, Paris, France.
- UR2CA, Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, Nice, France.
| | - Denis Doyen
- UR2CA, Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, Nice, France
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nice, Hôpital L'Archet 1, 151 Rue Saint Antoine de Ginestière, 06200, Nice, France
| | - Pierre Denormandie
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Assistance Publique, Hôpitaux de Paris, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Antoine Goury
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Reims, Rue du Général Koenig, 51092, Reims, France
| | - Jonathan Marey
- Unité de Soins Intensifs Pneumologiques, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Assistance Publique, Hôpitaux de Paris, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
| | - Frédéric Pène
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Assistance Publique, Hôpitaux de Paris, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
- Université Paris Cité, Paris, France
| | - Alain Cariou
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Assistance Publique, Hôpitaux de Paris, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
- Université Paris Cité, Paris, France
| | - Jean-Paul Mira
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Assistance Publique, Hôpitaux de Paris, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
- Université Paris Cité, Paris, France
| | - Jean Dellamonica
- UR2CA, Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, Nice, France
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nice, Hôpital L'Archet 1, 151 Rue Saint Antoine de Ginestière, 06200, Nice, France
| | - Lee S Nguyen
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Paris Centre, Hôpital Cochin, Assistance Publique, Hôpitaux de Paris, 27 Rue du Faubourg Saint Jacques, 75014, Paris, France
- Recherche et Innovation, Groupe hospitalier privé Ambroise Paré, Hartmann, 48Ter Bd Victor Hugo, 92200, Neuilly-Sur-Seine, France
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Monteleone P, Thangam M. Who Is Dying of Pulmonary Embolism? Am J Cardiol 2023; 207:490-492. [PMID: 37833167 DOI: 10.1016/j.amjcard.2023.08.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 10/15/2023]
Affiliation(s)
- Peter Monteleone
- Department of Cardiovascular Medicine, University of Texas at Austin Dell School of Medicine, Ascension Texas Cardiovascular, Austin, Texas.
| | - Manoj Thangam
- Department of Cardiovascular Medicine, University of Texas at Austin Dell School of Medicine, Ascension Texas Cardiovascular, Austin, Texas
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Ording AG, Nielsen PB, Skjøth F, Overvad TF, Noble S, Lash TL, Goldhaber SZ, Christensen TD, Larsen TB, Søgaard M. Risk of recurrent cancer-associated venous thromboembolism: A Danish nationwide cohort study. Int J Cardiol 2023; 390:131271. [PMID: 37591413 DOI: 10.1016/j.ijcard.2023.131271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/24/2023] [Accepted: 08/14/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Predictive factors for recurrent cancer-associated venous thromboembolism have been inconsistent across previous studies. To provide data for improved risk stratification, we described the risk of recurrent venous thromboembolism overall and across age, sex, calendar period, cancer type, Ottawa risk score, cancer stage, and cancer treatment in a nationwide cohort of patients with active cancer. METHODS Using Danish administrative registries, we identified a cohort of all adult patients with active cancer and a first-time diagnosis of venous thromboembolism during 2003-2018. We accounted for the competing risk of death and calculated absolute risks of recurrent venous thromboembolism at six months. RESULTS The population included 34,072 patients with active cancer and venous thromboembolism. Recurrence risks at six months were higher for patients with genitourinary cancer (6.5%), lung cancer (6.1%), gastrointestinal cancer (5.6%), brain cancer (5.2%), and hematological cancer (5.1%) than for patients with gynecological cancer (4.7%), breast cancer (4.1%), and other cancer types (4.8%). Recurrence risks were similar for men (5.2%) and women (4.9%), with and without chemotherapy (5.1%), across Ottawa risk score group (low: 5.0%; high: 5.1%) and across calendar periods but increased with increasing cancer stage. The overall six-month all-cause mortality risk was 26%, and highest for patients with lung cancer (49%) and lowest among breast cancer patients (4.1%). CONCLUSIONS Six-month recurrence risk after first-time cancer-associated venous thromboembolism was high and varied by cancer type and patient characteristics. Refining risk stratification for recurrence may improve decision-making regarding treatment duration after cancer-associated thromboembolism.
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Affiliation(s)
- Anne Gulbech Ording
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.
| | - Peter Brønnum Nielsen
- Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark
| | - Flemming Skjøth
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark; Unit for Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Thure Filskov Overvad
- Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Department of Clinical Pharmacology, Aalborg University Hospital, Aalborg, Denmark
| | - Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - Timothy L Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, USA; Cancer Prevention and Control Research Program, Winship Cancer Institute of Emory University, USA
| | - Samuel Zachery Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery & Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Torben Bjerregaard Larsen
- Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark
| | - Mette Søgaard
- Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark
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Kojodjojo P, Ng CH, Ong KC, Zuzarte-Ng R, Chan WX. Large-bore suction thrombectomy for sub-massive pulmonary embolism during second trimester of pregnancy: a case report. Eur Heart J Case Rep 2023; 7:ytad523. [PMID: 37942349 PMCID: PMC10629693 DOI: 10.1093/ehjcr/ytad523] [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: 06/09/2023] [Revised: 09/29/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023]
Abstract
Background Pregnancy-associated pulmonary embolism (PAPE) remains a significant cause of maternal mortality. Anticoagulation remains the mainstay of therapy for most pulmonary embolism (PE)-related pregnancies. However, in patients with haemodynamic compromise or those refractory to anticoagulation, management is challenging. Systemic thrombolysis is associated with a substantial risk of maternal bleeding and fetal loss. In non-pregnant PE patients, large bore catheter-directed suction thrombectomy is a proven and important technique to manage intermediate or high-risk PE, allowing for normalization of pulmonary pressures, avoidance of haemodynamic deterioration, without the need for thrombolytics, major surgery, significant blood loss, or prolonged hospitalization. Case summary A primigravid patient in her second trimester of pregnancy, initially diagnosed with a deep vein thrombosis refractory to heparin, presents with near-syncope due to sub-massive pulmonary embolism. The various management options including thrombolysis and surgical embolectomy etc. were discussed in detail by a multi-disciplinary PE team. She underwent large bore suction thrombectomy with complete thrombi removal, normalization of right heart strain, without the need for thrombolytics or surgery, minimal blood loss and was discharged after a short length of stay. She gave birth at term to a healthy infant. Conclusion Suction thrombectomy is an important consideration for physicians managing high-risk PAPE and is likely to be associated with much a lower risk of maternal and fetal mortality compared to thrombolysis or surgery.
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Affiliation(s)
- Pipin Kojodjojo
- Asian Heart & Vascular Centre, 3 Mount Elizabeth, #10-14, Singapore 228510, Singapore
| | | | - Kymin Cayla Ong
- Asian Heart & Vascular Centre, 3 Mount Elizabeth, #10-14, Singapore 228510, Singapore
| | | | - Wan Xian Chan
- Asian Heart & Vascular Centre, 3 Mount Elizabeth, #10-14, Singapore 228510, Singapore
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Andersson T, Nilsson L, Larsen F, Carlberg B, Söderberg S. Long-term sequelae following acute pulmonary embolism: A nationwide follow-up study regarding the incidence of CTEPH, dyspnea, echocardiographic and V/Q scan abnormalities. Pulm Circ 2023; 13:e12306. [PMID: 37927611 PMCID: PMC10621320 DOI: 10.1002/pul2.12306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/01/2023] [Accepted: 10/22/2023] [Indexed: 11/07/2023] Open
Abstract
We aimed to follow a nationwide cohort of patients with pulmonary embolism (PE) without any exclusions to generate information regarding long-term symptoms, investigational findings and to determine the prevalence of chronic thromboembolic pulmonary hypertension (CTEPH). We hypothesized that this approach would yield generalizable estimates of CTEPH prevalence and incidence. All individuals diagnosed with acute PE in Sweden in 2005 were identified using the National Patient Register. In 2007, survivors were asked to complete a questionnaire regarding current symptoms. Those with dyspnea were referred for further examinations with laboratory tests, electrocardiogram (ECG), and a ventilation/perfusion scan (V/Q scan). If CTEPH was suspected, a referral to the nearest pulmonary arterial hypertension-center was recommended. Of 5793 unique individuals with PE diagnosis in 2005, 3510 were alive at the beginning of 2007. Altogether 53% reported dyspnea at some degree whereof a large proportion had V/Q scans indicating mismatched defects. Further investigation revealed 6 cases of CTEPH and in parallel 18 cases were diagnosed outside this study. The overall prevalence of CTEPH was 0.4% (95% confidence interval [CI]: 0.2%-0.6%) and 0.7% (95% CI: 0.4%-1.0%) among the survivors. The cumulative incidence of CTEPH in the group of patients who underwent a V/Q scan was 1.1% (95% CI: 0.2%-2.0%). There was a high mortality following an acute PE, a high proportion of persistent dyspnea among survivors, whereof several had pathological findings on V/Q scans and echocardiography. Only a minority developed CTEPH, indicating that CTEPH is the tip of the iceberg of post-PE disturbances.
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Affiliation(s)
- Therese Andersson
- Department of Public Health and Clinical Medicine, Unit of MedicineUmeå UniversityUmeåSweden
| | - Lars Nilsson
- Department of Public Health and Clinical Medicine, Unit of MedicineUmeå UniversityUmeåSweden
| | - Flemming Larsen
- Department of Molecular Medicine and Surgery, Section of Clinical PhysiologyKarolinska InstituteStockholmSweden
- Department of Clinical PhysiologyKarolinska University HospitalStockholmSweden
| | - Bo Carlberg
- Department of Public Health and Clinical Medicine, Unit of MedicineUmeå UniversityUmeåSweden
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, Unit of MedicineUmeå UniversityUmeåSweden
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Felix G, Ferreira E, Ribeiro A, Guerreiro I, Araújo E, Ferreira S, Coelho S, Magalhães H, Almeida J, Lourenço P. Predictors of cancer in patients with acute pulmonary embolism. Thromb Res 2023; 230:11-17. [PMID: 37598636 DOI: 10.1016/j.thromres.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/05/2023] [Accepted: 08/08/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Acute pulmonary embolism (PE) can occur as a manifestation of an underlying cancer and be of paraneoplastic aetiology. A previously unknown cancer is sometimes diagnosed after the acute PE diagnosis. The identification of a group of patients with elevated probability of having an occult cancer underlying PE was never performed. We aimed to determine predictors of occult cancer in acute PE. Our hypothesis was that the D-dimer levels would be a predictor of cancer. PATIENTS AND METHODS We retrospectively analysed a cohort of patients hospitalized with acute PE. EXCLUSION CRITERIA <18 years, venous embolism only of veins other than pulmonary territory or when the embolism was considered chronic, and no image confirmation of acute PE. Patients were grouped according to the timing of cancer diagnosis: 1) known concomitant active cancer, 2) cancer diagnosed during acute PE admission or in the following 2 years and, 3) no known cancer during the 2-year follow-up since PE diagnosis. Predictors of concomitant cancer were determined using a logistic regression analysis. Multivariate models were built. RESULTS We studied 562 patients; median age was 72 years and 219 (39.0 %) were men. In 223 (39.7 %) of the patients the PE was of central arteries and 61.4 % presented with bilateral PE. PE was considered unprovoked at time of discharge in 47.7 %. Median (interquartile range) D-dimer level was 7.98 (3.30-14.99) μg/mL. A total of 126 (22.4 %) patients were in group 1, 47 in group 2 (cancer diagnosed after the diagnosis of acute PE and up to 2 years) and 389 patients were in group 3. Elevated D-dimer levels were independently associated with already known cancer. D-dimer were independent predictors of future cancer diagnosis: OR = 1.07 ((95 % CI: 1.01-1.14) per each 5 ng/mL increase; for patients with D-dimer >15.0 μg/mL the OR of future cancer was 2.10 (1.05-4.18). If only patients with unprovoked PE upon admission (n = 307) were to be considered results were similar considering D-dimer; anaemia also predicted unknown cancer [OR = 2.13 (1.08-4.16)]. CONCLUSIONS Patients with D-dimer >15 μg/mL presented a >2-fold higher risk of being diagnosed with a cancer condition in the upcoming 2 years. D-dimer may help clinicians in identifying which patients are at higher risk of occult cancer.
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Affiliation(s)
- Gonçalo Felix
- Faculdade de Medicina da Universidade do Porto, Portugal
| | - Ester Ferreira
- Serviço de Medicina Interna, Centro Hospitalar São João, Porto, Portugal; Departamento de Medicina da Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Ana Ribeiro
- Serviço de Medicina Interna, Centro Hospitalar São João, Porto, Portugal; Departamento de Medicina da Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Inês Guerreiro
- Serviço de Oncologia, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| | - Emanuel Araújo
- Unidade de Cuidados Agudos Polivalente do Centro Hospitalar de Leiria, Leiria, Portugal
| | - Sara Ferreira
- Serviço de Cuidados Paliativos do Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal
| | - Sara Coelho
- Serviço de Oncologia do Instituto Português de Oncologia do Porto Francisco Gentil, Porto, Portugal
| | - Helena Magalhães
- Serviço de Oncologia, Unidade Local Saúde Matosinhos, Matosinhos, Portugal
| | - Jorge Almeida
- Serviço de Medicina Interna, Centro Hospitalar São João, Porto, Portugal; Departamento de Medicina da Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Patrícia Lourenço
- Serviço de Medicina Interna, Centro Hospitalar São João, Porto, Portugal; Departamento de Medicina da Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
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Banaszkiewicz M, Kurzyna P, Kubikowska N, Mucha M, Rudnik A, Gąsecka A, Pietrasik A, Grabowski M, Jaguszewski MJ, Kasprzyk P, Kędzierski P, Ciećwierz D, Żuk G, Szwed P, Piłka M, Florczyk M, Kurzyna M, Darocha S. Emerging Role of Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Disease-Insights from the 2022 ESC Guidelines. J Clin Med 2023; 12:5336. [PMID: 37629379 PMCID: PMC10455782 DOI: 10.3390/jcm12165336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
In this article, we discuss the topic of chronic thromboembolic pulmonary disease (CTEPD) and the growing role of balloon pulmonary angioplasty (BPA) in its treatment. We present the pathophysiology of CTEPD which arises from an incomplete resolution of thrombi in the pulmonary arteries and leads to stenosis and occlusion of the vessels. The article focuses mainly on the chronic thromboembolic pulmonary hypertension (CTEPH) subpopulation for which prognosis is very poor when left untreated. We describe a multimodal approach to treating CTEPH, including pulmonary endarterectomy (PEA), BPA, and pharmacological therapies. Additionally, the benefits of pharmacological pre-treatment before BPA and the technical aspects of the procedure itself are outlined. It is emphasized that BPA does not replace PEA but serves as a complementary treatment option for eligible patients. We summarized efficacy and treatment goals including an improvement in functional and biochemical parameters before and after BPA. Patients who received pre-treatment with riociguat prior to BPA exhibited a notable reduction in the occurrence of less severe complications. However, elderly patients are still perceived as an especially vulnerable group. It is shown that the prognosis of patients undergoing BPA is similar to PEA in the first years after the procedure but the long-term prognosis of BPA still remains unclear. The 2022 ESC/ERS guidelines highlight the significant role of BPA in the multimodal treatment of CTEPH, emphasizing its effectiveness and recommending its consideration as a therapeutic option for patients with CTEPD, both with and without pulmonary hypertension. This review summarizes the available evidence for BPA, patient selection, procedural details, and prognosis and discusses the potential future role of BPA in the management of CTEPH.
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Affiliation(s)
- Marta Banaszkiewicz
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Paweł Kurzyna
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Nina Kubikowska
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Magda Mucha
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Aleksander Rudnik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Arkadiusz Pietrasik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Marcin Grabowski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | | | - Piotr Kasprzyk
- 1st Department of Cardiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Piotr Kędzierski
- 1st Department of Cardiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Dariusz Ciećwierz
- 1st Department of Cardiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Grzegorz Żuk
- 1st Department of Cardiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Piotr Szwed
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Michał Piłka
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Michał Florczyk
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Marcin Kurzyna
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Szymon Darocha
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
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Robert-Ebadi H, Roy PM, Sanchez O, Verschuren F, Le Gal G, Righini M. External validation of the PEGeD diagnostic algorithm for suspected pulmonary embolism in an independent cohort. Blood Adv 2023; 7:3946-3951. [PMID: 36521170 PMCID: PMC10410134 DOI: 10.1182/bloodadvances.2022007729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 10/18/2022] [Accepted: 10/18/2022] [Indexed: 12/23/2022] Open
Abstract
Sequential diagnostic algorithms are used in the case of suspected pulmonary embolism (PE). The PEGeD study proposed a new diagnostic strategy to reduce the use of computed tomography pulmonary angiography (CTPA). We aimed to externally validate this diagnostic strategy in an independent cohort. We analyzed data from 3 prospective studies of outpatients with suspected PE. As per the PEGeD algorithm, patients were classified as having a low, moderate, or high clinical pretest probability (C-PTP). PE was excluded with a D-dimer <1000 ng/mL in case of low C-PTP and <500 ng/mL in case of moderate C-PTP. We assessed the yield and safety of this approach and compared them with those of previously validated algorithms. Among the 3308 evaluated patients, 1615 (49%) patients could have had PE excluded according to the PEGeD algorithm, without the need for imaging. Of these patients, 38 (2.3%; 95% confidence interval [CI], 1.7-3.2) were diagnosed with a symptomatic PE at initial testing or during the 3-month follow-up. On further analysis, 36 patients out of these 38 patients had a positive age-adjusted D-dimer. The risk of venous thromboembolic events among the 414 patients with a D-dimer <1000 ng/mL but above the age-adjusted D-dimer cut-off was 36 of 414 (8.7%; 95% CI, 6.4-11.8). We provide external validation of the PEGeD algorithm in an independent cohort. Compared with standard algorithms, the PEGeD decreased the number of CTPA examinations. However, caution is required in patients with a low C-PTP and a D-dimer <1000 ng/mL but above their age-adjusted D-dimer cut-off.
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Affiliation(s)
- Helia Robert-Ebadi
- Division of Angiology and Hemostasis and Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre-Marie Roy
- Department of Emergency Medicine, University Hospital of Angers, Angers, France
| | - Olivier Sanchez
- Department of Respiratory Disease, Hôpital Européen Georges Pompidou, APHP, and Université Paris Descartes, Paris, France
| | - Frank Verschuren
- Emergency Department, Saint-Luc University Hospital, Brussels, Belgium
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Marc Righini
- Division of Angiology and Hemostasis and Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
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Tang L, Hu Y, Pan D, Yang C, Tang C, Huang Y, Gu J, Min M, Lin X, Tong C. PECSS: Pulmonary Embolism Comprehensive Screening Score to safely rule out pulmonary embolism among suspected patients presenting to emergency department. BMC Pulm Med 2023; 23:287. [PMID: 37550677 PMCID: PMC10408070 DOI: 10.1186/s12890-023-02580-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/22/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Pulmonary embolism is a severe cardiovascular disease and can be life-threatening if left untreated. However, the detection rate of pulmonary embolism using existing pretest probability scores remained relatively low and clinical rule out often relied on excessive use of computed tomographic pulmonary angiography. METHODS We retrospectively collected data from pulmonary embolism suspected patients in Zhongshan Hospital from July 2018 to October 2022. Pulmonary embolism diagnosis and severity grades were confirmed by computed tomographic pulmonary angiography. Patients were randomly divided into derivation and validation set. To construct the Pulmonary Embolism Comprehensive Screening Score (PECSS), we first screened for candidate clinical predictors using univariate logistic regression models. These predictors were then included in a searching algorithm with indicators of Wells score, where a series of points were assigned to each predictor. Optimal D-Dimer cutoff values were investigated and incorporated with PECSS to rule out pulmonary embolism. RESULTS In addition to Wells score, PECSS identified seven clinical predictors (anhelation, abnormal blood pressure, in critical condition when admitted, age > 65 years and high levels of pro-BNP, CRP and UA,) strongly associated with pulmonary embolism. Patients can be safely ruled out of pulmonary embolism if PECSS ≤ 4, or if 4 < PECSS ≤ 6 and D-Dimer ≤ 2.5 mg/L. Comparing with Wells approach, PECSS achieved lower failure rates across all pulmonary embolism severity grades. These findings were validated in the held-out validation set. CONCLUSIONS Compared to Wells score, PECSS approaches achieved lower failure rates and better compromise between sensitivity and specificity. Calculation of PECSS is easy and all predictors are readily available upon emergency department admission, making it widely applicable in clinical settings. TRAIL REGISTRATION The study was retrospectively registered (No. CJ0647) and approved by Human Genetic Resources in China in April 2022. Ethical approval was received from the Medical Ethics Committee of Zhongshan Hospital (NO.B2021-839R).
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Affiliation(s)
- Luojia Tang
- Emergency Department of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yundi Hu
- School of Data Science, Fudan University, Shanghai, China
| | - Dong Pan
- Department of Information and Intelligence Development of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chun Yang
- Department of Information and Intelligence Development of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Cheng Tang
- Emergency Department of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yunchuan Huang
- Emergency Department of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianyong Gu
- Emergency Department of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Min Min
- Emergency Department of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaolei Lin
- School of Data Science, Fudan University, Shanghai, China.
| | - Chaoyang Tong
- Emergency Department of Zhongshan Hospital, Fudan University, Shanghai, China.
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Zuin M, Bikdeli B, Davies J, Krishnathasan D, Rigatelli G, Roncon L, Bilato C, Piazza G. Contemporary trends in mortality related to high-risk pulmonary embolism in US from 1999 to 2019. Thromb Res 2023; 228:72-80. [PMID: 37295022 DOI: 10.1016/j.thromres.2023.05.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 05/27/2023] [Accepted: 05/30/2023] [Indexed: 06/11/2023]
Abstract
BACKGROUND Population-based data on high-risk pulmonary embolism (PE) mortality trends in the United States (US) are scant. OBJECTIVES To assess current trends in US mortality related to high-risk PE over the past 21 years and determine differences by sex, race, ethnicity, age and census region. METHODS Data were extracted from the Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER) to determine trends in age-adjusted mortality rates (AAMR) per 100,000 people, due to high-risk PE. To calculate nationwide annual trends, we assessed the average (AAPC) and annual percent change (APC) with relative 95 % confidence intervals (CIs) using Joinpoint regression. RESULTS Between 1999 and 2019, high-risk PE was listed as the underlying cause of death in 209,642 patients, corresponding to an AAMR of 3.01 per 100,000 people (95 % CI: 2.99 to 3.02). AAMR from high-risk PE remained stable from 1999 to 2007 [APC: -0.2 %, (95 % CI: -2.0 to 0.5, p = 0.22)] and then significantly increased [APC: 3.1 % (95 % CI: 2.6 to 3.6), p < 0.0001], especially in males [AAPC: 1.9 % (95 % CI: 1.4 to 2.4), p < 0.001 vs AAPC: 1.5 % (95 % CI: 1.1 to 2.2), p < 0.001]. AAMR increase was more pronounced in those <65 years, Black Americans, and residents of rural areas. CONCLUSIONS In an US population analysis, high-risk PE mortality rate increased, with racial, sex-based, and regional variations. Further studies are needed to understand root causes for these trends and to implement appropriate corrective strategies.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.
| | - Behnood Bikdeli
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, CT, United States
| | - Julia Davies
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darsiya Krishnathasan
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Loris Roncon
- Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Claudio Bilato
- Department of Cardiology, West Vicenza Hospital, Arzignano, Italy
| | - Gregory Piazza
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Visovatti SH. Pulmonary Embolism Center of Excellence: Putting It All Together. Interv Cardiol Clin 2023; 12:393-398. [PMID: 37290842 DOI: 10.1016/j.iccl.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Center of excellence (COE) designations are generally used to identify programs with expertise in a specific area of medicine. Meeting criteria for a COE may result in advantages including improved clinical outcomes, marketing advantages, and improved financial performance. However, criteria for COE designations are highly variable, and they are granted by a wide variety of entities. The diagnosis and treatment of both acute pulmonary emboli and chronic thromboembolic pulmonary hypertension are disciplines that require multidisciplinary expertise, highly coordinated care, specialized technology and advanced skillsets gained through high patient volumes.
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Affiliation(s)
- Scott H Visovatti
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University, Davis Heart and Lung Research Institute, 473 West 12th Avenue, Columbus, OH 43210, USA.
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Thangavel S, Korsholm K, Veien KT, Larsen KM, Andersen A. Catheter-directed mechanical thrombectomy in a patient with high-risk pulmonary embolism complicated by out-of-hospital cardiac arrest: a case report. Eur Heart J Case Rep 2023; 7:ytad307. [PMID: 37485290 PMCID: PMC10358429 DOI: 10.1093/ehjcr/ytad307] [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: 12/23/2022] [Revised: 03/06/2023] [Accepted: 07/06/2023] [Indexed: 07/25/2023]
Abstract
Background Pulmonary embolism (PE) is common, and it is the third leading cause of cardiovascular death. The management of patients with high-risk PE generally consists of systemic thrombolysis; however, surgical or catheter-directed treatment (CDT) can be considered in selected cases. Case summary A 78-year-old female patient presenting with acute severe dyspnoea develops out-of-hospital cardiac arrest (OHCA). She was admitted with return of spontaneous circulation and a critical haemodynamic state upon arrival to the catheterization laboratory with an estimated no-flow time of 1 min and low-flow time of 52 min. An acute pulmonary angiogram reveals massive PE. After a PE response team conference, the patient was not found eligible for extracorporeal membrane oxygenation, surgery, or thrombolysis. The patient was treated with catheter-directed mechanical thrombectomy 129 min after first medical contact. The patient recovered and was discharged without any neurological deficits. Discussion Catheter-directed mechanical thrombectomy was a successful treatment in a patient with OHCA secondary to high-risk PE, where thrombolysis and surgical interventions were considered contraindicated. This case underlines the future perspectives of CDT and also that a multidisciplinary team approach may benefit patients with high-risk PE.
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Affiliation(s)
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Karsten Tange Veien
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Kim M Larsen
- Prehospital Emergency Medical Services, Central Denmark Region, Aarhus N, Denmark
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Kharawala A, Seo J, Barzallo D, Romero GH, Demirhan YE, Duarte GJ, Vegivinti CTR, Hache-Marliere M, Balasubramanian P, Santos HT, Nagraj S, Alhuarrat MAD, Karamanis D, Varrias D, Palaiodimos L. Assessment of the Utilization of Validated Diagnostic Predictive Tools and D-Dimer in the Evaluation of Pulmonary Embolism: A Single-Center Retrospective Cohort Study from a Public Hospital in New York City. J Clin Med 2023; 12:jcm12113629. [PMID: 37297824 DOI: 10.3390/jcm12113629] [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: 04/03/2023] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 06/12/2023] Open
Abstract
INTRODUCTION A significant increase in the use of computed tomography with pulmonary angiography (CTPA) for the diagnosis of pulmonary embolism (PE) has been observed in the past twenty years. We aimed to investigate whether the validated diagnostic predictive tools and D-dimers were adequately utilized in a large public hospital in New York City. METHODS We conducted a retrospective review of patients who underwent CTPA for the specific indication of ruling out PE over a period of one year. Two independent reviewers, blinded to each other and to the CTPA and D-dimer results, estimated the clinical probability (CP) of PE using Well's score, the YEARS algorithm, and the revised Geneva score. Patients were classified based on the presence or absence of PE in the CTPA. RESULTS A total of 917 patients were included in the analysis (median age: 57 years, female: 59%). The clinical probability of PE was considered low by both independent reviewers in 563 (61.4%), 487 (55%), and 184 (20.1%) patients based on Well's score, the YEARS algorithm, and the revised Geneva score, respectively. D-dimer testing was conducted in less than half of the patients who were deemed to have low CP for PE by both independent reviewers. Using a D-dimer cut-off of <500 ng/mL or the age-adjusted cut-off in patients with a low CP of PE would have missed only a small number of mainly subsegmental PE. All three tools, when combined with D-dimer < 500 ng/mL or <age-adjusted cut-off, yielded a NPV of > 95%. CONCLUSION All three validated diagnostic predictive tools were found to have significant diagnostic value in ruling out PE when combined with a D-dimer cut-off of <500 ng/mL or the age-adjusted cut-off. Excessive use of CTPA was likely secondary to suboptimal use of diagnostic predictive tools.
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Affiliation(s)
- Amrin Kharawala
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Jiyoung Seo
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Diego Barzallo
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Gabriel Hernandez Romero
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Yunus Emre Demirhan
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Gustavo J Duarte
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Charan Thej Reddy Vegivinti
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Manuel Hache-Marliere
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Prasanth Balasubramanian
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Heitor Tavares Santos
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Sanjana Nagraj
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Majd Al Deen Alhuarrat
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Dimitrios Karamanis
- Department of Economics, University of Piraeus, 18534 Attica, Greece
- Department of Health Informatics, Rutgers School of Health Professions, Newark, NJ 07107, USA
| | - Dimitrios Varrias
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Leonidas Palaiodimos
- Department of Medicine, New York City Health + Hospitals/Jacobi, Bronx, NY 10461, USA
- Albert Einstein College of Medicine, Bronx, NY 10461, USA
- School of Medicine, City University of New York, New York, NY 10031, USA
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Eggers AS, Hafian A, Lerchbaumer MH, Hasenfuß G, Stangl K, Pieske B, Lankeit M, Ebner M. Acute Infections and Inflammatory Biomarkers in Patients with Acute Pulmonary Embolism. J Clin Med 2023; 12:jcm12103546. [PMID: 37240652 DOI: 10.3390/jcm12103546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
Although infections are frequent in patients with pulmonary embolism (PE), its effect on adverse outcome risk remains unclear. We investigated the incidence and prognostic impact of infections requiring antibiotic treatment and of inflammatory biomarkers (C-reactive protein [CRP] and procalcitonin [PCT]) on in-hospital adverse outcomes (all-cause mortality or hemodynamic insufficiency) in 749 consecutive PE patients enrolled in a single-centre registry. Adverse outcomes occurred in 65 patients. Clinically relevant infections were observed in 46.3% of patients and there was an increased adverse outcome risk with an odds ratio (OR) of 3.12 (95% confidence interval [CI] 1.70-5.74), comparable to an increase in one risk class of the European Society of Cardiology (ESC) risk stratification algorithm (OR 3.45 [95% CI 2.24-5.30]). CRP > 124 mg/dL and PCT > 0.25 µg/L predicted patient outcome independent of other risk factors and were associated with respective ORs for an adverse outcome of 4.87 (95% CI 2.55-9.33) and 5.91 (95% CI 2.74-12.76). In conclusion, clinically relevant infections requiring antibiotic treatment were observed in almost half of patients with acute PE and carried a similar prognostic effect to an increase in one risk class of the ESC risk stratification algorithm. Furthermore, elevated levels of CRP and PCT seemed to be independent predictors of adverse outcome.
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Affiliation(s)
- Ann-Sophie Eggers
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité Campus Virchow-Klinikum Mittelallee, German Heart Center of the Charité-University Medicine Berlin, 13353 Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
| | - Alaa Hafian
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, 37075 Goettingen, Germany
| | - Markus H Lerchbaumer
- Department of Radiology, Campus Charité Mitte (CCM), Charité-University Medicine Berlin, 10117 Berlin, Germany
| | - Gerd Hasenfuß
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, 37075 Goettingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Goettingen, 37075 Goettingen, Germany
| | - Karl Stangl
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité Campus Mitte, German Heart Center of the Charité-University Medicine Berlin, 10117 Berlin, Germany
| | | | - Mareike Lankeit
- Clinic of Cardiology and Pneumology, University Medical Center Göttingen, 37075 Goettingen, Germany
| | - Matthias Ebner
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, 10785 Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Charité Campus Mitte, German Heart Center of the Charité-University Medicine Berlin, 10117 Berlin, Germany
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45
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Lanfang F, Xu M, Jun C, Jia Z, Wenchen L, Xinghua J. Developing a nomogram-based scoring model to estimate the risk of pulmonary embolism in respiratory department patients suspected of pulmonary embolisms. Front Med (Lausanne) 2023; 10:1164911. [PMID: 37265484 PMCID: PMC10229862 DOI: 10.3389/fmed.2023.1164911] [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: 02/13/2023] [Accepted: 04/24/2023] [Indexed: 06/03/2023] Open
Abstract
Objective Pulmonary embolisms (PE) are clinically challenging because of their high morbidity and mortality. This study aimed to create a nomogram to accurately predict the risk of PE in respiratory department patients in order to enhance their medical treatment and management. Methods This study utilized a retrospective method to collect information on medical history, complications, specific clinical characteristics, and laboratory biomarker results of suspected PE patients who were admitted to the respiratory department at Affiliated Dongyang Hospital of Wenzhou Medical University between January 2012 and December 2021. This study involved a total of 3,511 patients who were randomly divided into a training group (six parts) and a validation group (four parts) based on a 6:4 ratio. The LASSO regression and multivariate logistic regression were used to develop a scoring model using a nomogram. The performance of the model was evaluated using receiver operating characteristic curve (AUC), calibration curve, and clinical decision curve. Results Our research included more than 50 features from 3,511 patients. The nomogram-based scoring model was established using six predictive features including age, smoke, temperature, systolic pressure, D-dimer, and fibrinogen, which achieved AUC values of 0.746 in the training cohort (95% CI 0.720-0.765) and 0.724 in the validation cohort (95% CI 0.695-0.753). The results of the calibration curve revealed a strong consistency between probability predicted by the nomogram and actual probability. The decision curve analysis (DCA) also demonstrated that the nomogram-based scoring model produced a favorable net clinical benefit. Conclusion In this study, we successfully developed a novel numerical model that can predict the risk of PE in respiratory department patients suspected of PE, which can not only appropriately select PE prevention strategies but also decrease unnecessary computed tomographic pulmonary angiography (CTPA) scans and their adverse effects.
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Affiliation(s)
- Feng Lanfang
- Department of Respiratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Ma Xu
- Department of Vascular Surgery, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Chen Jun
- Department of Nuclear Medicine, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Zhao Jia
- Operation Center, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Li Wenchen
- Department of Neurology, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China
| | - Jia Xinghua
- Operation Center, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, China
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Noman A, Gosch K, Elkaryoni A, Buckley J, Letham O, Fleecs J, Wible BC, Bunte MC. Circumstances of Hospitalization Impact Outcomes of Pulmonary Embolism. Curr Probl Cardiol 2023:101773. [PMID: 37169155 DOI: 10.1016/j.cpcardiol.2023.101773] [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: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Clinical tools that stratify risk of acute pulmonary embolism (PE) are useful in guiding therapeutic decision making, although may neglect pragmatic and potentially impactful characteristics of hospitalization during care of venous thromboembolism (VTE). METHODS Using a retrospective cohort design, consecutive patients discharged after inpatient care for acute PE were retrospectively evaluated for features of hospitalization, including patient characteristics, treatment efficiency, and circumstances of hospitalization. A proportional hazards model incorporated non-traditional risk factors to assess their association with a primary composite endpoint of in-hospital bleeding or death after adjusting for conventional PE risk estimators, including the Pulmonary Artery Severity Index (PESI) and right ventricular/left ventricular (RV/LV) ratio. RESULTS From January 2016 to December 2018, 822 patients were discharged after treatment for acute PE, including high-risk (5.0%), intermediate-risk (64.2%), and low-risk (30.8%) PE. In-hospital death was 10-fold higher among those with high-risk PE compared to intermediate risk PE (36.6% vs 3.0%, p<0.001). Overall, 60.4% of hospitalizations were primarily attributed to presentation with VTE. High risk PE was observed more frequently as a secondary event during hospitalizations ostensibly unrelated to VTE (26.8%). After adjustment for PESI score and RV/LV ratio, hypoalbuminia, IVC filter, and non-VTE hospitalization had strong associations with the primary composite outcome. CONCLUSIONS Along with known markers of risk associated with PE, hypoalbuminia, IVC filter placement, and PE complicating hospitalization for circumstances not primarily related to VTE had strong associations with bleeding and death. These findings highlight the complex circumstances of acute PE care and need to refine practical risks.
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Affiliation(s)
- Anas Noman
- University of Missouri-Kansas City Department of Medicine, Kansas City, MO, USA
| | - Kensey Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | | | | | - Oliver Letham
- University of Missouri-Kansas City Department of Medicine, Kansas City, MO, USA
| | - Jacob Fleecs
- University of Missouri-Kansas City Department of Medicine, Kansas City, MO, USA
| | - Brandt C Wible
- Saint Luke's Hospital of Kansas City, Kansas City, MO, USA
| | - Matthew C Bunte
- University of Missouri-Kansas City Department of Medicine, Kansas City, MO, USA; Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; Saint Luke's Hospital of Kansas City, Kansas City, MO, USA.
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Hobohm L, Keller K, Konstantinides S. [Pulmonary embolism]. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2023; 37:133-142. [PMID: 37284023 PMCID: PMC10160724 DOI: 10.1007/s00398-023-00582-6] [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] [Indexed: 06/08/2023]
Abstract
Pulmonary embolism is a frequent cardiovascular disease which in recent years has shown a reduction in the mortality but an increase in the incidence. Due to the optimization of clinical probability scores and the interpretation of the D‑dimer test, unnecessary examinations using computed tomography with respect to the exclusion of an acute pulmonary embolism can be avoided, also in pregnant women. The evaluation of the right ventricle contributes to a risk-adapted treatment. Treatment consists of anticoagulation, alone or in combination with reperfusion treatment, such as systemic thrombolysis and also catheter-assisted or surgical treatment. In addition to acute treatment of pulmonary embolisms, an adequate aftercare is important, particularly for the early detection of long-term sequelae. This review article summarizes the current recommendations of international guidelines for patients with pulmonary embolism, accompanied by clinical case examples and a critical discussion.
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Affiliation(s)
- Lukas Hobohm
- Centrum für Thrombose und Hämostase, Universitätsmedizin Mainz, Mainz, Deutschland
- Kardiologie I, Zentrum für Kardiologie, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131 Mainz, Deutschland
| | - Karsten Keller
- Centrum für Thrombose und Hämostase, Universitätsmedizin Mainz, Mainz, Deutschland
- Kardiologie I, Zentrum für Kardiologie, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131 Mainz, Deutschland
- Innere Medizin VII, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Xiang J, He L, Peng T, Liang W, Wei S. Value of retrograde pulmonary vein perfusion combined with pulmonary artery thrombectomy in acute pulmonary embolism: a protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e069685. [PMID: 37147099 PMCID: PMC10163473 DOI: 10.1136/bmjopen-2022-069685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
INTRODUCTION Acute pulmonary embolism is a serious cardiovascular disease with high mortality. Surgery is an important therapeutic means. The traditional surgical method is pulmonary artery embolectomy with cardiopulmonary bypass, but there is a certain recurrence rate after surgery. Some scholars use retrograde pulmonary vein perfusion as an adjunct to conventional pulmonary artery embolectomy. However, whether this method can be used safely for acute pulmonary embolism and its long-term effects remains unclear. Therefore, we plan to conduct a systematic review and meta-analysis to investigate whether retrograde pulmonary vein perfusion combined with pulmonary artery thrombectomy can be safely used in acute pulmonary embolism. METHODS AND ANALYSIS We will search key databases (Ovid MEDLINE, PubMed, Web of Science, Cochrane Library, China Science and Technology Journals and Wanfang) for studies on acute pulmonary embolism treated with retrograde pulmonary vein perfusion from January 2002 to December 2022. The useful information will be consolidated into a piloting spreadsheet. The Cochrane Risk of Bias Tool will be used to assess the bias. Data will be synthesised and heterogeneity will be evaluated. The dichotomous variables will be determined by using risk ratio with 95% CI, and weighted mean differences (with 95% CI) or standardised mean differences (95% CI) will be used for continuous variables. Χ2 test and I2 test will be used to assess the statistical heterogeneity. Meta-analysis will be conducted when strong homogeneous data are accessible. ETHICS AND DISSEMINATION Approval of the ethics committee is not needed for this review. While results will be disseminated electronically, effective dissemination will be done through presentations and peer-reviewed publication. PROSPERO REGISTRATION NUMBER CRD42022345812; pre-results.
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Affiliation(s)
- Jun Xiang
- Department of Cardiovascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Ling He
- Department of Paediatrics, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Tailuan Peng
- Department of Cardiovascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Weiwei Liang
- Department of Cardiovascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Shuliang Wei
- Department of Cardiovascular Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
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Keller K, Kohring C, Farmakis IT, Valerio L, Barco S, Bätzing J, Akmatov MK, Konstantinides S, Münzel T, Hobohm L, Holstiege J. Impact of venous thromboembolism on incidence of arterial thromboembolism - An analysis of German outpatient claims data. Thromb Res 2023; 226:9-17. [PMID: 37079980 DOI: 10.1016/j.thromres.2023.04.008] [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: 01/07/2023] [Revised: 03/10/2023] [Accepted: 04/07/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) and arterial thromboembolism (ATE) are considered as two separate disease-entities. In recent years, studies have reported clear associations between VTE and atherosclerosis. We aimed to evaluate the long-term risk of ATE in VTE patients in comparison to controls without VTE. METHODS Nationwide outpatient claims data of all inhabitants with statutory health insurance in Germany were used for secondary data analysis between the years 2011 and 2020. Patients treated in 2013 were stratified by VTE event, and groups were 1:2-matched by age and sex. The hazard for an ATE event in a 5-year follow-up period between patients with and without VTE was calculated with multivariable Cox regression adjusted for age, sex, cardiovascular risk factors, and comorbidities. RESULTS Of 69,699,277 individuals treated in the year 2013 by German physicians in outpatient care, in total 686,382 individuals (age 59.8 ± 17.5 years, 65.4 % females) were included comprising 228,794 patients with VTE and 457,588 controls without VTE. VTE patients more often had cardiovascular risk factors (81.6 % vs. 62.2 %) and traditional VTE risk factors. The occurrence of ATE events during follow-up was 1.8 %-points higher in VTE patients in comparison to the controls (9.7 % vs. 7.9 %). VTE events were independently associated with increased occurrence of ATE events within follow-up (HRadjusted 1.19 [99%CI 1.16-1.23], p < 0.0001). CONCLUSIONS Patients with a VTE event have an increased long-term risk for subsequent arterial cardiovascular events. Large prospective cohorts are needed to identify patient subgroups with a very high ATE risk after VTE.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany.
| | - Claudia Kohring
- Department of Epidemiology and Health Care Atlas, Central Research Institute of Ambulatory Health Care, Berlin, Germany
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Luca Valerio
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Jörg Bätzing
- Department of Epidemiology and Health Care Atlas, Central Research Institute of Ambulatory Health Care, Berlin, Germany
| | - Manas K Akmatov
- Department of Epidemiology and Health Care Atlas, Central Research Institute of Ambulatory Health Care, Berlin, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Lukas Hobohm
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Jakob Holstiege
- Department of Epidemiology and Health Care Atlas, Central Research Institute of Ambulatory Health Care, Berlin, Germany
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Kojodjojo P, Ong HA, Loh PH, Tay E, Chang P, Kuntjoro I, Low TT, Lim Y. First use of large-bore suction thrombectomy for acute pulmonary embolism in Asia-Pacific: feasibility and short-term clinical outcomes. J Thromb Thrombolysis 2023; 55:660-666. [PMID: 37017871 PMCID: PMC10073780 DOI: 10.1007/s11239-023-02802-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/25/2023] [Indexed: 04/06/2023]
Abstract
Clinical outcomes for intermediate or high-risk pulmonary emboli (PE) remain sub-optimal, with limited improvements in survival for the past 15 years. Anticoagulation alone results in slow thrombus resolution, persistent right ventricular (RV) dysfunction, patients remaining at risk of haemodynamic decompensation and increased likelihood of incomplete recovery. Thrombolysis elevates risk of major bleeding and is thus reserved for high-risk PE. Thus, a huge clinical need exists for an effective technique to restore pulmonary perfusion with minimal risk and avoidance of lytic therapy. In 2021, large bore suction thrombectomy (ST) was introduced in Asia for the first time and this study assessed the feasibility and short-term outcomes of Asian patients undergoing ST for acute PE. 40 consecutive patients (58% male, mean age of 58.3 ± 16.6 years) with intermediate (87.5%) or high-risk PE (12.5%) were enrolled in this prospective registry. 20% had prior VTE, 42.5% had contraindications to thrombolysis, and 10% failed to respond to thrombolysis. PE was idiopathic in 40%, associated with active cancer in 15% and post-operative status in 12.5%. Procedural time was 124 ± 30 min. Emboli were aspirated in all patients without the need for thrombolytics, resulting in a 21.4% reduction in mean pulmonary arterial pressures and 123% increase TASPE-PASP ratio, a prognostic measure of RV-arterial coupling. (both p < 0.001) Procedural complications were 5% and 87.5% patients survived to discharge without symptomatic VTE recurrence during 184 days of mean follow-up. ST affords an effective reperfusion option for PE without thrombolytics, normalises RV overload and provides excellent short-term clinical outcomes.
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Affiliation(s)
- Pipin Kojodjojo
- Asian Heart and Vascular Centre, 3 Mount Elizabeth #10-14, Singapore, Singapore.
- Division of Cardiology, Ng Teng Fong General Hospital, Singapore, Singapore.
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore.
| | - Hean Ann Ong
- Division of Cardiology, Ng Teng Fong General Hospital, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Poay Huan Loh
- Division of Cardiology, Ng Teng Fong General Hospital, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Edgar Tay
- Asian Heart and Vascular Centre, 3 Mount Elizabeth #10-14, Singapore, Singapore
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Peter Chang
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Ivandito Kuntjoro
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Ting Ting Low
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Yinghao Lim
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
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