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Westafer LM, Presti T, Shieh MS, Pekow PS, Barnes GD, Kapoor A, Lindenauer PK. Trends in Initial Anticoagulation Among US Patients Hospitalized With Acute Pulmonary Embolism 2011-2020. Ann Emerg Med 2024; 84:518-529. [PMID: 38888528 PMCID: PMC11493503 DOI: 10.1016/j.annemergmed.2024.05.009] [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] [Received: 02/14/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 06/20/2024]
Abstract
STUDY OBJECTIVE Guidelines recommend low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOACs) rather than unfractionated heparin (UFH) for treatment of acute pulmonary embolism (PE) given their efficacy and reduced risk of bleeding. Using data from a large consortium of US hospitals, we examined trends in initial anticoagulation among hospitalized patients diagnosed with acute PE. METHODS We conducted a retrospective study of inpatient and observation cases between January 1, 2011, and December 31, 2020, among individuals aged more than or equal to 18 years treated at acute care hospitals contributing data to the Premier Healthcare Database. Included cases received a diagnosis of acute PE, underwent imaging for PE, and received anticoagulation at the time of admission. The primary outcome was the initial anticoagulant selected for treatment. RESULTS Among 299,016 cases at 1,045 hospitals, similar proportions received initial treatment with UFH (47.4%) and LMWH (47.9%). Between 2011 and 2020, the proportion of patients initially treated with UFH increased from 41.9% to 56.3%. Over this period, use of LMWH as the initial anticoagulant was reduced from 58.1% in 2011 to 37.3% in 2020. The proportion of cases admitted to the ICU, treated with mechanical ventilation or vasopressors, and inpatient mortality were stable. Factors most strongly associated with receipt of UFH were admission to the ICU (odds ratio [OR] 6.90; 95% confidence interval [CI] 6.31 to 7.54) or step-down unit (OR 2.30; 95% CI 2.16 to 2.45), receipt of thrombolysis (OR 4.25; 95% CI 3.09 to 5.84) or vasopressors (OR 1.83; 95% CI 1.32 to 2.54), and chronic renal disease (OR 1.67; 95% CI 1.54 to 1.81). CONCLUSIONS Despite recommendations that LMWH and DOACs be considered first-line for most patients with acute PE, use of UFH is common and increasing. Further research is needed to elucidate factors associated with persistent use of UFH and opportunities for deimplementation of low-value care.
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Affiliation(s)
- Lauren M Westafer
- Department of Emergency Medicine, University of Massachusetts Chan Medical School - Baystate, Springfield, MA; Department of Healthcare Delivery and Population Science University of Massachusetts Chan Medical School - Baystate, Springfield, MA.
| | - Thomas Presti
- Division of Pulmonary and Critical Care, Baystate Medical Center, Springfield, MA
| | - Meng-Shiou Shieh
- Department of Healthcare Delivery and Population Science University of Massachusetts Chan Medical School - Baystate, Springfield, MA
| | - Penelope S Pekow
- Department of Healthcare Delivery and Population Science University of Massachusetts Chan Medical School - Baystate, Springfield, MA; School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Alok Kapoor
- Department of Population and Quantitative Health Science, University of Massachusetts Medical School, Worcester, MA; Department of Medicine, Division of Hospital Medicine, University of Massachusetts Chan Medical School, Worcester, MA
| | - Peter K Lindenauer
- Department of Healthcare Delivery and Population Science University of Massachusetts Chan Medical School - Baystate, Springfield, MA; Department of Population and Quantitative Health Science, University of Massachusetts Medical School, Worcester, MA; Division of Hospital Medicine, Baystate Medical Center, Springfield, MA
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Zuin M, Bikdeli B, Ballard-Hernandez J, Barco S, Battinelli EM, Giannakoulas G, Jimenez D, Klok FA, Krishnathasan D, Lang IM, Moores L, Sylvester KW, Weitz JI, Piazza G. International Clinical Practice Guideline Recommendations for Acute Pulmonary Embolism: Harmony, Dissonance, and Silence. J Am Coll Cardiol 2024; 84:1561-1577. [PMID: 39384264 DOI: 10.1016/j.jacc.2024.07.044] [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: 03/08/2024] [Revised: 07/01/2024] [Accepted: 07/02/2024] [Indexed: 10/11/2024]
Abstract
Despite abundant clinical innovation and burgeoning scientific investigation, pulmonary embolism (PE) has continued to pose a diagnostic and management challenge worldwide. Aging populations, patients living with a mounting number of chronic medical conditions, particularly cancer, and increasingly prevalent health care disparities herald a growing burden of PE. In the meantime, navigating expanding strategies for immediate and long-term anticoagulation, as well as advanced therapies, including catheter-based interventions for patients with more severe PE, has become progressively daunting. Accordingly, clinicians frequently turn to evidence-based clinical practice guidelines for diagnostic and management recommendations. However, numerous international guidelines, heterogeneity in recommendations, as well as areas of uncertainty or omission may leave the readers and clinicians without a clear management pathway. In this review of international PE guidelines, we highlight key areas of consistency, difference, and lack of recommendations (silence) with an emphasis on critical clinical and research needs.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy; Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padova, Padova, Italy.
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, USA
| | - Jennifer Ballard-Hernandez
- Cardiology Division, Department of Medicine, Department of Veterans Affairs, VA Long Beach Healthcare System, Long Beach, California, USA; Sue and Bill Gross School of Nursing University of California-Irvine, Irvine, California, USA
| | - 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, Mainz, Germany
| | - Elisabeth M Battinelli
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, LUMC, Leiden, the Netherlands
| | - Darsiya Krishnathasan
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Lisa Moores
- The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Katelyn W Sylvester
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Zuin M, Lang I, Chopard R, Sharp ASP, Byrne RA, Rigatelli G, Piazza G. Innovation in Catheter-Directed Therapy for Intermediate-High-Risk and High-Risk Pulmonary Embolism. JACC Cardiovasc Interv 2024; 17:2259-2273. [PMID: 39415385 DOI: 10.1016/j.jcin.2024.07.033] [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: 02/01/2024] [Revised: 07/03/2024] [Accepted: 07/23/2024] [Indexed: 10/18/2024]
Abstract
Although anticoagulation remains the cornerstone treatment for patients with acute pulmonary embolism (PE), catheter-directed therapy (CDT) has generated great interest as an adjunctive option for those presenting with hemodynamic decompensation or high risk for deterioration and in whom systemic thrombolysis has failed or is contraindicated. However, randomized controlled data supporting the efficacy and safety of CDT in addition to antithrombotic therapy in patients with high-risk and intermediate- to high-risk PE compared with anticoagulation and systemic thrombolysis alone are lacking. This paucity of high-quality data hampers guideline recommendations regarding the optimal therapeutic approach in such patients with PE. The aim of the present paper is to critically appraise the current evidence for CDT in patients with high-risk and intermediate- to high-risk PE and to highlight major areas of innovation in the recent literature. In addition, the authors describe unmet clinical and research needs, potential strategies to resolve these knowledge gaps, and pathways for device selection.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy; Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Ferrara, Ferrara, Italy.
| | - Irene Lang
- Clinical Division of Cardiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Romain Chopard
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France
| | - Andrew S P Sharp
- Department of Cardiology, University Hospital of Wales and Cardiff University, Cardiff, United Kingdom
| | - Robert A Byrne
- Cardiovascular Research Institute Dublin and Department of Cardiology, Mater Private Network, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Gianluca Rigatelli
- Department of Cardiology, Ospedali Riuniti Padova Sud, Schiavonia, Padova, Italy
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Dubois-Silva Á, Bikdeli B. Anticoagulant Therapy in Patients Undergoing Acute Pulmonary Embolism Interventions. Interv Cardiol Clin 2024; 13:561-575. [PMID: 39245555 DOI: 10.1016/j.iccl.2024.07.004] [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: 09/10/2024]
Abstract
Catheter-based interventions and surgical embolectomy represent alternatives to systemic fibrinolysis for patients with high-risk pulmonary embolism (PE) or those with intermediate-high-risk PE who deteriorate hemodynamically. They are indicated when systemic fibrinolysis is contraindicated or ineffective, or if obstructive shock is imminent. Extracorporeal membrane oxygenation can be added to reperfusion therapies or used alone for severe right ventricular dysfunction and cardiogenic shock. These advanced therapies complement but do not replace anticoagulation, which remains the cornerstone in PE management. This review summarizes the evidence and shares practical recommendations for the use of anticoagulant therapy before, during, and after acute PE interventions.
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Affiliation(s)
- Álvaro Dubois-Silva
- Venous Thromboembolism Unit, Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain; Universidade da Coruña (UDC), A Coruña, Spain; Hospital at Home and Palliative Care Department, Complexo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine and the Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA.
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5
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Wrenn JO, Kabrhel C. Emergency department diagnosis and management of acute pulmonary embolism. Br J Haematol 2024. [PMID: 39183380 DOI: 10.1111/bjh.19725] [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: 04/01/2024] [Accepted: 08/13/2024] [Indexed: 08/27/2024]
Abstract
Despite advances in clinical decision support, the diagnosis, prognostic risk stratification, treatment and disposition of emergency department patients with pulmonary embolism remain challenging. The use of diagnostic risk stratification tools and D-dimer can decrease unnecessary exposure to radiation and intravenous contrast; however, D-dimer is elevated in many conditions including normal pregnancy, so imaging is often indicated. Once diagnosed, prognostic risk stratification tools can inform treatment decisions across the risk spectrum, including identifying low-risk patients with pulmonary embolism who can safely be treated at home. For patients requiring hospitalization, alternatives to unfractionated heparin can improve time to therapeutic anticoagulation and reduce treatment-related bleeding risk.
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Affiliation(s)
- Jesse O Wrenn
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Division of Emergency Medicine, Tennessee Valley Healthcare System VA, Nashville, Tennessee, USA
| | - Christopher Kabrhel
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Motiwala A, Tanwir H, Duarte A, Gilani S, DeAnda A, Zaidan MF, Jneid H. Multidisciplinary Approach to Pulmonary Embolism and the Role of the Pulmonary Embolism Response Team. Curr Cardiol Rep 2024; 26:843-849. [PMID: 38963612 DOI: 10.1007/s11886-024-02084-9] [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] [Accepted: 06/17/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE OF REVIEW Acute pulmonary embolism (PE) is a leading cause of cardiovascular death and morbidity, and presents a major burden to healthcare systems. The field has seen rapid growth with development of innovative clot reduction technologies, as well as ongoing multicenter trials that may completely revolutionize care of PE patients. However, current paucity of robust clinical trials and guidelines often leave individual physicians managing patients with acute PE in a dilemma. RECENT FINDINGS The pulmonary embolism response team (PERT) was developed as a platform to rapidly engage multiple specialists to deliver evidence-based, organized and efficient care and help address some of the gaps in knowledge. Several centers investigating outcomes following implementation of PERT have demonstrated shorter hospital and intensive-care unit stays, lower use of inferior vena cava filters, and in some instances improved mortality. Since the advent of PERT, early findings demonstrate promise with improved outcomes after implementation of PERT. Incorporation of artificial intelligence (AI) into PERT has also shown promise with more streamlined care and reducing response times. Further clinical trials are needed to examine the impact of PERT model on care delivery and clinical outcomes.
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Affiliation(s)
- Afaq Motiwala
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA.
| | - Hira Tanwir
- University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
| | - Alexander Duarte
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Syed Gilani
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | - Abe DeAnda
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
| | | | - Hani Jneid
- University of Texas Medical Branch, 301 University Blvd, Galveston, TX, 77555, USA
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Xie L, Lan P, Liu M, Zhou K. ECMO management for severe pulmonary embolism with concurrent cerebral hemorrhage: a case report. Front Cardiovasc Med 2024; 11:1410134. [PMID: 38803663 PMCID: PMC11128567 DOI: 10.3389/fcvm.2024.1410134] [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: 03/31/2024] [Accepted: 05/01/2024] [Indexed: 05/29/2024] Open
Abstract
Background Acute pulmonary embolism (APE) is a common and potentially fatal cardiovascular disease that can lead to sudden cardiac arrest in severe cases. When conventional cardiopulmonary resuscitation measures fail to achieve the return of spontaneous circulation (ROSC) in patients with APE, venoarterial extracorporeal membrane oxygenation (ECMO) becomes a viable therapeutic option. As an advanced life support treatment, ECMO ensures the perfusion of critical organs, providing sufficient time for interventions necessary for ROSC. Case introduction We report the case of a patient who experienced cardiac arrest due to pulmonary embolism. During the treatment, the patient received two sessions of external cardiopulmonary resuscitation (ECPR) as supportive care and experienced cerebral hemorrhage. Ultimately, the patient improved and was discharged following support from extracorporeal membrane oxygenation (ECMO), careful anticoagulation strategies, and intervention with balloon pulmonary angioplasty. Conclusion ECMO can serve as an important life support technology for patients with severe APE. Through a cautious anticoagulation therapy, not only was the ECMO support successfully maintained but also was further deterioration of cerebral hemorrhage effectively prevented. For patients with concurrent main pulmonary artery embolism and bleeding, balloon pulmonary angioplasty may be an option.
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Affiliation(s)
| | | | | | - Kechun Zhou
- Department of Emergency, Lishui Central Hospital, Zhejiang, China
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8
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Rouleau SG, Casey SD, Kabrhel C, Vinson DR, Long B. Management of high-risk pulmonary embolism in the emergency department: A narrative review. Am J Emerg Med 2024; 79:1-11. [PMID: 38330877 DOI: 10.1016/j.ajem.2024.01.039] [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: 11/11/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE. OBJECTIVE This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations. DISCUSSION High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions. CONCLUSIONS Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.
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Affiliation(s)
- Samuel G Rouleau
- Department of Emergency Medicine, UC Davis Health, University of California, Davis, Sacramento, CA, United States of America.
| | - Scott D Casey
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, CA, United States of America.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - David R Vinson
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
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Zhang RS, Alviar CL, Yuriditsky E, Alam U, Zhang PS, Elbaum L, Grossman K, Singh A, Maqsood MH, Greco AA, Postelnicu R, Mukherjee V, Horowitz J, Keller N, Bangalore S. Percutaneous mechanical thrombectomy in acute pulmonary embolism: Outcomes from a safety-net hospital. Catheter Cardiovasc Interv 2024. [PMID: 38577945 DOI: 10.1002/ccd.31024] [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: 11/24/2023] [Revised: 02/23/2024] [Accepted: 03/19/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Our study aims to present clinical outcomes of mechanical thrombectomy (MT) in a safety-net hospital. METHODS This is a retrospective study of intermediate or high-risk pulmonary embolism (PE) patients who underwent MT between October 2020 and May 2023. The primary outcome was 30-day mortality. RESULTS Among 61 patients (mean age 57.6 years, 47% women, 57% Black) analyzed, 12 (19.7%) were classified as high-risk PE, and 49 (80.3%) were intermediate-risk PE. Of these patients, 62.3% had Medicaid or were uninsured, 50.8% lived in a high poverty zip code. The prevalence of normotensive shock in intermediate-risk PE patients was 62%. Immediate hemodynamic improvements included 7.4 mmHg mean drop in mean pulmonary artery pressure (-21.7%, p < 0.001) and 93% had normalization of their cardiac index postprocedure. Thirty-day mortality for the entire cohort was 5% (3 patients) and 0% when restricted to the intermediate-risk group. All 3 patients who died at 30 days presented with cardiac arrest. There were no differences in short-term mortality based on race, insurance type, citizenship status, or socioeconomic status. All-cause mortality at most recent follow up was 13.1% (mean follow up time of 13.4 ± 8.5 months). CONCLUSION We extend the findings from prior studies that MT demonstrates a favorable safety profile with immediate improvement in hemodynamics and a low 30-day mortality in patients with acute PE, holding true even with relatively higher risk and more vulnerable population within a safety-net hospital.
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Affiliation(s)
- Robert S Zhang
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Carlos L Alviar
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Eugene Yuriditsky
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Usman Alam
- Department of Medicine, New York University, New York City, New York, USA
| | - Peter S Zhang
- Department of Medicine, New York University, New York City, New York, USA
| | - Lindsay Elbaum
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Kelsey Grossman
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Arushi Singh
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Muhammad H Maqsood
- Department of Cardiology, DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA
| | - Allison A Greco
- Division of Pulmonary Critical Care, and Sleep Medicine, New York University, New York City, New York, USA
| | - Radu Postelnicu
- Division of Pulmonary Critical Care, and Sleep Medicine, New York University, New York City, New York, USA
| | - Vikramjit Mukherjee
- Division of Pulmonary Critical Care, and Sleep Medicine, New York University, New York City, New York, USA
| | - James Horowitz
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Norma Keller
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
| | - Sripal Bangalore
- Division of Cardiovascular Medicine, New York University, New York City, New York, USA
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Zhu E, Yuriditsky E, Raco V, Katz A, Papadopoulos J, Horowitz J, Maldonado T, Ahuja T. Anti-factor Xa as the preferred assay to monitor heparin for the treatment of pulmonary embolism. Int J Lab Hematol 2024; 46:354-361. [PMID: 37989523 DOI: 10.1111/ijlh.14207] [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: 08/31/2023] [Accepted: 11/06/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION The mainstay of acute pulmonary embolism (PE) treatment is anticoagulation. Timely anticoagulation correlates with decreased PE-associated mortality, but the ability to achieve a therapeutic activated partial thromboplastin time (aPTT) with unfractionated heparin (UFH) remains limited. Although some institutions have switched to a more accurate and reproducible test to assess for heparin's effectiveness, the anti-factor Xa (antiXa) assay, data correlating a timely therapeutic antiXa to PE-associated clinical outcomes remains scarce. We evaluated time to a therapeutic antiXa using intravenous heparin after PE response team (PERT) activation and assessed clinical outcomes including bleeding and recurrent thromboembolic events. METHODS This was a retrospective cohort study at NYU Langone Health. All adult patients ≥18 years with a confirmed PE started on IV UFH with >2 antiXa levels were included. Patients were excluded if they received thrombolysis or alternative anticoagulation. The primary endpoint was the time to a therapeutic antiXa level of 0.3-0.7 units/mL. Secondary outcomes included recurrent thromboembolism, bleeding and PE-associated mortality within 3 months. RESULTS A total of 330 patients with a PERT consult were identified with 192 patients included. The majority of PEs were classified as sub massive (64.6%) with 87% of patients receiving a bolus of 80 units/kg of UFH prior to starting an infusion at 18 units/kg/hour. The median time to the first therapeutic antiXa was 9.13 hours with 93% of the cohort sustaining therapeutic anticoagulation at 48 hours. Recurrent thromboembolism, bleeding and mortality occurred in 1%, 5% and 6.2%, respectively. Upon univariate analysis, a first antiXa <0.3 units/ml was associated with an increased risk of mortality [27.78% (5/18) vs 8.05% (14/174), p = 0.021]. CONCLUSION We observed a low incidence of recurrent thromboembolism or PE-associated mortality utilizing an antiXa titrated UFH protocol. The use of an antiXa based heparin assay to guide heparin dosing and monitoring allows for timely and sustained therapeutic anticoagulation for treatment of PE.
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Affiliation(s)
- Eric Zhu
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Eugene Yuriditsky
- Department of Medicine, Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Veronica Raco
- Department of Pharmacy, NYU Langone Brooklyn, Brooklyn, New York, USA
| | - Alyson Katz
- Department of Pharmacy, NYU Langone Health, New York, New York, USA
| | | | - James Horowitz
- Department of Medicine, Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA
| | - Thomas Maldonado
- Department of Surgery, Vascular, NYU Grossman School of Medicine, New York, New York, USA
| | - Tania Ahuja
- Department of Medicine, Division of Cardiology, NYU Grossman School of Medicine, New York, New York, USA
- Department of Pharmacy, NYU Langone Health, New York, New York, USA
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11
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Zuin M, Becattini C, Piazza G. Early predictors of clinical deterioration in intermediate-high risk pulmonary embolism: clinical needs, research imperatives, and pathways forward. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:297-303. [PMID: 37967341 DOI: 10.1093/ehjacc/zuad140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/17/2023]
Abstract
A subset of intermediate-high risk pulmonary embolism (PE) patients will suffer clinical deterioration in the early hours following the acute event. Current evidence-based guidelines for the management of acute PE have provided limited direction for identification of which intermediate-high risk PE patients will go on to develop haemodynamic decompensation. Furthermore, a paucity of data further hampers guideline recommendations regarding the optimal approach and duration of intensive monitoring, best methods to assess the early response to anticoagulation, and the ideal window for reperfusion therapy, if decompensation threatens. The aim of the present article is to identify the current unmet needs related to the early identification of intermediate-high risk PE patients at higher risk of clinical deterioration and mortality during the early hours after the acute cardiovascular event and suggest some potential strategies to further explore gaps in the literature.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Via Luigi Borsari, 46 - 44121 Ferrara, Italy
| | - Cecilia Becattini
- Department of Internal Medicine, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Casey SD, Stubblefield WB, Luijten D, Klok FA, Westafer LM, Vinson DR, Kabrhel C. Addressing the rising trend of high-risk pulmonary embolism mortality: Clinical and research priorities. Acad Emerg Med 2024; 31:288-292. [PMID: 38129964 DOI: 10.1111/acem.14859] [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: 09/05/2023] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Deaths from high-risk pulmonary embolism (PE) appear to have increased in the US over the last decade. Modifiable risks contributing to this worrisome trend present opportunities for physicians, researchers, and healthcare policymakers to improve care. METHODS We sought to contextualize contemporary, high-risk PE epidemiology and examine clinical trials, quality improvement opportunities, and healthcare policy initiatives directed at reducing mortality. RESULTS We observed significant and modifiable excess mortality due to high-risk PE. We identified several opportunities to improve care including: (1) rapid translation of forthcoming data on reperfusion strategies into clinical practice; (2) improved risk stratification tools; (3) quality improvement initiatives to address presumptive anticoagulation practice gaps; and (3) adoption of health policy initiatives to establish pulmonary embolism response teams and address the social determinants of health. CONCLUSION Addressing knowledge and practice gaps in intermediate and high-risk PE management must be prioritized and informed by forthcoming high-quality data. Implementation efforts are needed to improve acute PE management and resolve treatment disparities.
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Affiliation(s)
- Scott D Casey
- Kaiser Permanente Division of Research, Oakland, California, USA
- The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, California, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dieuwke Luijten
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medicine Center, Leiden, Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medicine Center, Leiden, Netherlands
| | - Lauren M Westafer
- Department of Emergency Medicine, UMASS Chan Medical School-Baystate, Springfield, Massachusetts, USA
- Department of Healthcare Delivery and Population Science, UMASS Chan Medical School-Baystate, Springfield, Massachusetts, USA
| | - David R Vinson
- Kaiser Permanente Division of Research, Oakland, California, USA
- The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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13
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Fulton B, Bashir R, Weinberg MD, Lakhter V, Rali P, Pugliese S, Giri J, Kobayashi T. Advanced Treatment of Hemodynamically Unstable Acute Pulmonary Embolism and Clinical Follow-up. Semin Thromb Hemost 2023; 49:785-796. [PMID: 37696292 DOI: 10.1055/s-0043-1772840] [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: 09/13/2023]
Abstract
High-risk acute pulmonary embolism (PE), defined as acute PE associated with hemodynamic instability, remains a significant contributor to cardiovascular morbidity and mortality in the United States and worldwide. Historically, anticoagulant therapy in addition to systemic thrombolysis has been the mainstays of medical therapy for the majority of patients with high-risk PE. In efforts to reduce the morbidity and mortality, a wide array of interventional and surgical therapies has been developed and employed in the management of these patients. However, the most recent guidelines for the management of PE have reserved the use of these advanced therapies in scenarios where thrombolytic therapy plus anticoagulation are unsuccessful. This is due largely to the lack of prospective, randomized studies in this population. Stemming from this, the approach to treatment of these patients varies widely depending on institutional experience and resources. Furthermore, morbidity and mortality remain unacceptably high in this population, with estimated 30-day mortality of at least 30%. As such, development of a standardized approach to treatment of these patients is paramount to improving outcomes. Early and accurate risk stratification in conjunction with a multidisciplinary team approach in the form of a PE response team is crucial. With the advent of novel therapies for the treatment of acute PE, in addition to the growing availability of and familiarity with mechanical circulatory support systems, such a standardized approach may now be within reach.
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Affiliation(s)
- Brian Fulton
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Riyaz Bashir
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Mitchell D Weinberg
- Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, Staten Island, New York
| | - Vladimir Lakhter
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Steve Pugliese
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jay Giri
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
| | - Taisei Kobayashi
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
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14
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Westafer LM, Long B, Gottlieb M. Managing Pulmonary Embolism. Ann Emerg Med 2023; 82:394-402. [PMID: 36805291 PMCID: PMC10432572 DOI: 10.1016/j.annemergmed.2023.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 02/19/2023]
Affiliation(s)
- Lauren M Westafer
- Department for Healthcare Delivery and Population Science and Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
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15
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Nguyen L, Qi X, Karimi-asl A, Thole A, Wendte J, Meissner T, Xu B, Dvoracek K. Evaluation of anti-Xa levels in patients with venous thromboembolism within the first 48 h of anticoagulation with unfractionated heparin. SAGE Open Med 2023; 11:20503121231190963. [PMID: 37602272 PMCID: PMC10438427 DOI: 10.1177/20503121231190963] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 07/13/2023] [Indexed: 08/22/2023] Open
Abstract
Background: A 2019 study by Prucnal and colleagues found that the majority of patients treated with unfractionated heparin for pulmonary embolism did not maintain therapeutic activated partial thromboplastin time levels during the first 48 h of therapy. Objective: The purpose of this study was to evaluate the ability of an institution's unfractionated heparin dosing protocol to achieve and maintain therapeutic anti-Xa levels within the first 48 h of therapy in patients with venous thromboembolism. Methods: This retrospective study included 205 patients from May 2016 through September 2020. Patients were divided into two cohorts: bolus plus infusion (N = 89) and infusion only (N = 116). The primary objective was to determine the number of patients who achieved at least one therapeutic level. Results: Overall, 200 patients (97.6%) had at least one therapeutic level with no statistically significant difference between cohorts (p = 0.65). No more than 60% of patients achieved a therapeutic level at any of the 6-h intervals throughout the timeframe. The median time to the first therapeutic level in the overall group was 12.8 h with no statistically significant difference between the bolus plus infusion and infusion-only cohorts (13.3 h versus 12.7 h, respectively, p = 0.48). Conclusions: Most patients were able to achieve at least one therapeutic level within the first 48 h, but fewer were able to maintain therapeutic levels. Further studies are warranted to determine whether alternative dosing strategies would yield consistent achievement of therapeutic levels and affect patient-oriented outcomes.
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Affiliation(s)
- Lily Nguyen
- Department of Pharmacy, Avera McKennan Hospital and University Health Center, Sioux Falls, SD, USA
| | - Xiaoxiao Qi
- Department of Pharmacy, Nebraska Medicine, Omaha, NE, USA
| | | | - Alicia Thole
- Department of Pharmacy, Avera McKennan Hospital and University Health Center, Sioux Falls, SD, USA
| | - Jodi Wendte
- Department of Pharmacy, Avera McKennan Hospital and University Health Center, Sioux Falls, SD, USA
| | - Tobias Meissner
- Department of Cancer Genomics, Avera Cancer Institute Center for Precision Oncology, Sioux Falls, SD, USA
| | - Bing Xu
- Department of Cancer Genomics, Avera Cancer Institute Center for Precision Oncology, Sioux Falls, SD, USA
| | - Kyle Dvoracek
- Department of Pharmacy, Avera McKennan Hospital and University Health Center, Sioux Falls, SD, USA
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16
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Porres-Aguilar M, Rosovsky RP, Jiménez D, Mukherjee D, Rivera-Lebron BN, Kaatz S, Anaya-Ayala JE, Jerjes-Sánchez C. "Pulmonary embolism response teams: changing the paradigm in the care for acute pulmonary embolism": reply. J Thromb Haemost 2023; 21:1390-1392. [PMID: 37121622 DOI: 10.1016/j.jtha.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/02/2023] [Indexed: 05/02/2023]
Affiliation(s)
- Mateo Porres-Aguilar
- Department of Internal Medicine, Divisions of Hospital and Adult Thrombosis Medicine, Texas Tech University Health Sciences Center and Paul L. Foster School of Medicine, El Paso, Texas, USA.
| | - Rachel P Rosovsky
- Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David Jiménez
- Department of Respiratory Medicine, Ramón y Cajal Hospital (IRYCIS), CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases; Texas Tech University Health Sciences Center and Paul L. Foster School of Medicine, El Paso, Texas, USA
| | - Belinda N Rivera-Lebron
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Scott Kaatz
- Department of Internal Medicine, Division of Hospital Medicine; Henry Ford Hospital; Detroit, Michigan, USA
| | - Javier E Anaya-Ayala
- Department of Surgery, Vascular Surgery and Endovascular Therapy Section; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos Jerjes-Sánchez
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey; and Instituto de Cardiologia y Medicina Vascular, Hospital Zambrano Hellion y TEC Salud, Monterrey, Mexico
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17
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Davidson BL. "Pulmonary embolism response teams: Changing the paradigm in the care for acute pulmonary embolism": comment. J Thromb Haemost 2023; 21:1388-1389. [PMID: 37121621 DOI: 10.1016/j.jtha.2022.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 05/02/2023]
Affiliation(s)
- Bruce L Davidson
- Department of Medicine, Washington State University Floyd College of Medicine, Everett, Washington, USA.
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18
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Porres-Aguilar M, Rosovsky RP, Rivera-Lebron BN, Kaatz S, Mukherjee D, Anaya-Ayala JE, Jimenez D, Jerjes-Sánchez C. Pulmonary embolism response teams: Changing the paradigm in the care for acute pulmonary embolism. J Thromb Haemost 2022; 20:2457-2464. [PMID: 35895858 DOI: 10.1111/jth.15832] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/16/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022]
Abstract
Pulmonary embolism response teams (PERTs) have emerged as a multidisciplinary, multispecialty team of experts in the care of highly complex symptomatic acute pulmonary embolism (PE), with a centralized unique activation process, providing rapid multimodality assessment and risk stratification, formulating the best individualized diagnostic and therapeutic approach, streamlining the care in challenging clinical case scenarios (e.g., intermediate-high risk and high-risk PE), and facilitating the implementation of the recommended therapeutic strategies on time. PERTs are currently changing how complex acute PE cases are approached. The structure, organization, and function of a given PERT may vary from hospital to hospital, depending on local expertise, specific resources, and infrastructure for a given academic hospital center. Current emerging data demonstrate the value of PERTs in improving time to PE diagnosis; shorter time to initiation of anticoagulation reducing hospital length of stay; increasing use of advanced therapies without an increase in bleeding; and in some reports, decreasing mortality. Importantly, PERTs are positively impacting outcomes by changing the paradigm of care for acute PE through global adoption by the health-care community.
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Affiliation(s)
- Mateo Porres-Aguilar
- Department of Medicine, Division of Hospital and Adult Thrombosis Medicine, Texas Tech University Health Sciences Center and Paul L. Foster School of Medicine, El Paso, Texas, USA
| | - Rachel P Rosovsky
- Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Belinda N Rivera-Lebron
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Scott Kaatz
- Department of Internal Medicine, Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Texas Tech University Health Sciences Center and Paul L. Foster School of Medicine, El Paso, Texas, USA
| | - Javier E Anaya-Ayala
- Department of Surgery, Vascular Surgery and Endovascular Therapy Section, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - David Jimenez
- Department of Respiratory Medicine, Ramón y Cajal Hospital (IRYCIS), CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Carlos Jerjes-Sánchez
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Instituto de Cardiologia y Medicina Vascular, Hospital Zambrano Hellion, Monterrey, Mexico
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19
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Huang CB, Hong CX, Xu TH, Zhao DY, Wu ZY, Chen L, Xie J, Jin C, Wang BZ, Yang L. Risk Factors for Pulmonary Embolism in ICU Patients: A Retrospective Cohort Study from the MIMIC-III Database. Clin Appl Thromb Hemost 2022; 28:10760296211073925. [PMID: 35043708 DOI: 10.1177/10760296211073925] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Pulmonary embolism (PE) is a common and potentially lethal form of venous thromboembolic disease in ICU patients. A limited number of risk factors have been associated with PE in ICU patients. In this study, we aimed to screen the independent risk factors of PE in ICU patients that can be used to evaluate the patient's condition and provide targeted treatment. We performed a retrospective cohort study using a freely accessible critical care database Medical Information Mart for Intensive Care (MIMIC)-III. The ICU patients were divided into two groups based on the incidence of PE. Finally, 9871 ICU patients were included, among which 204 patients (2.1%) had pulmonary embolism. During the multivariate logistic regression analysis, sepsis, hospital_LOS (the length of stay in hospital), type of admission, tumor, APTT (activated partial thromboplastin time) and platelet were independent risk factors for patients for PE in ICU, with OR values of 1.471 (95%CI 1.001-2.162), 1.001 (95%CI 1.001-1.001), 3.745 (95%CI 2.187-6.414), 1.709 (95%CI 1.247-2.341), 1.014 (95%CI 1.010-1.017) and 1.002 (95%CI 1.001-1.003) (Ps < 0.05). ROC curve analysis showed that the composite indicator had a higher predictive value for ICU patients with PE, with a ROC area under the curve (AUC) of 0.743 (95%CI 0.710 -0.776, p < 0.001). Finally, sepsis, tumor, platelet count, length of stay in the hospital, emergency admission and APTT were independent predictors of PE in ICU patients.
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Affiliation(s)
- Cheng-Bin Huang
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Chen-Xuan Hong
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Tian-Hao Xu
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Ding-Yun Zhao
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zong-Yi Wu
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China
| | - Liang Chen
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Jun Xie
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Chen Jin
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Bing-Zhang Wang
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
| | - Lei Yang
- 26452The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, Wenzhou, China.,Key Laboratory of Orthopaedics of Zhejiang Province, Wenzhou, China
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Affiliation(s)
- Kathryn A Hibbert
- From the Departments of Medicine (K.A.H., A.E.F.) and Radiology (R.J.G.), Massachusetts General Hospital, and the Departments of Medicine (K.A.H., A.E.F.) and Radiology (R.J.G.), Harvard Medical School - both in Boston
| | - Reece J Goiffon
- From the Departments of Medicine (K.A.H., A.E.F.) and Radiology (R.J.G.), Massachusetts General Hospital, and the Departments of Medicine (K.A.H., A.E.F.) and Radiology (R.J.G.), Harvard Medical School - both in Boston
| | - Annemarie E Fogerty
- From the Departments of Medicine (K.A.H., A.E.F.) and Radiology (R.J.G.), Massachusetts General Hospital, and the Departments of Medicine (K.A.H., A.E.F.) and Radiology (R.J.G.), Harvard Medical School - both in Boston
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21
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Fitzpatrick T, Wong C, Shen C, Pham P, Teo V, Selby R, Geerts W, Khosravani H. Quality of anticoagulation using intravenous unfractionated heparin for cerebrovascular indications. Thromb Res 2021; 199:79-81. [PMID: 33476900 DOI: 10.1016/j.thromres.2020.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/26/2020] [Accepted: 12/29/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Tess Fitzpatrick
- Neurology Quality and Innovation Lab, Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre (SHSC), University of Toronto, Toronto, Canada
| | | | - Cindy Shen
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada; The CanVECTOR Network, Canada
| | - Peter Pham
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Vincent Teo
- Department of Pharmacy, SHSC, Toronto, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Rita Selby
- Departments of Laboratory Medicine & Molecular Diagnostics and Medicine, SHSC, University of Toronto, Toronto, Canada; The CanVECTOR Network, Canada
| | - William Geerts
- Thromboembolism Program, Department of Medicine, SHSC, University of Toronto, Toronto, Canada; The CanVECTOR Network, Canada
| | - Houman Khosravani
- Neurology Quality and Innovation Lab, Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre (SHSC), University of Toronto, Toronto, Canada; The CanVECTOR Network, Canada.
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22
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Rivera-Lebron BN, Rali PM, Tapson VF. The PERT Concept: A Step-by-Step Approach to Managing Pulmonary Embolism. Chest 2020; 159:347-355. [PMID: 32758561 DOI: 10.1016/j.chest.2020.07.065] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/30/2020] [Accepted: 07/16/2020] [Indexed: 11/28/2022] Open
Abstract
Pulmonary embolism (PE) is a major source of morbidity and mortality. The presentation of acute PE varies, ranging from few or no symptoms to sudden death. Patient outcome depends on how well the right ventricle can sustain the increased afterload caused by the embolic burden. Careful risk stratification is critical, and the PE response team (PERT) concept offers a rapid and multidisciplinary approach. Anticoagulation is essential unless contraindicated; thrombolysis, surgical embolectomy, and catheter-directed approaches are also available. Clinical consensus statements have been published that offer a guide to PE management, but areas remain for which the evidence is inadequate. Although the management of low-risk and high-risk patients is more straightforward, optimal management of intermediate-risk patients remains controversial. In this document, we offer a case-based approach to PE management, beginning with diagnosis and risk stratification, followed by therapeutic alternatives, and finishing with follow-up care.
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Affiliation(s)
- Belinda N Rivera-Lebron
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Parth M Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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