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Singh G, Bamba H, Inban P, Chandrasekaran SH, Priyatha V, John J, Prajjwal P. The prognostic significance of pro-BNP and heart failure in acute pulmonary embolism: A systematic review. Dis Mon 2024; 70:101783. [PMID: 38955637 DOI: 10.1016/j.disamonth.2024.101783] [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: 07/04/2024]
Abstract
Pulmonary embolism (PE) is the third most common type of cardiovascular disease and carries a high mortality rate of 30% if left untreated. Although it is commonly known that individuals who suffer heart failure (HF) are more likely to experience a pulmonary embolism, little is known concerning the prognostic relationship between acute PE and HF. This study aims to evaluate the prognostic usefulness of heart failure and pro-BNP in pulmonary embolism cases. A scientific literature search, including PubMed, Medline, and Cochrane reviews, was used to assess and evaluate the most pertinent research that has been published. The findings showed that increased N-terminal brain natriuretic peptide (NT-proBNP) levels could potentially identify pulmonary embolism patients with worse immediate prognoses and were highly predictive of all-cause death. Important prognostic information can be obtained from NT-proBNP and Heart-type Fatty Acid Binding Proteins (H-FABP) when examining individuals with PE. The heart, distal tubular cells of the renal system, and skeletal muscle are where H-FABP is primarily found, with myocardial cells having the highest concentration. Recent studies have indicated that these biomarkers may also help assess the severity of PE and its long-term risk.
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Affiliation(s)
- Gurmehar Singh
- Government Medical College and Hospital, Chandigarh, India
| | - Hyma Bamba
- Government Medical College and Hospital, Chandigarh, India
| | - Pugazhendi Inban
- Internal Medicine, St. Mary's General Hospital and Saint Clare's Health, NY, USA.
| | | | | | - Jobby John
- Dr. Somervell Memorial CSI Medical College and Hospital Karakonam, Trivandrum, India
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2
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Becattini C, Vedovati MC, Colombo S, Vanni S, Abrignani MG, Scardovi AB, Marrazzo A, Borselli M, Barchetti M, Fabbri A, Dentali F, Maggioni AP, Agnelli G, Gulizia MM. Identification of hemodynamically stable patients with acute pulmonary embolism at high risk for death: external validation of different models. J Thromb Haemost 2024; 22:2502-2513. [PMID: 38810699 DOI: 10.1016/j.jtha.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] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 04/14/2024] [Accepted: 04/30/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND The optimal strategy for identification of hemodynamically stable patients with acute pulmonary embolism (PE) at risk for death and clinical deterioration remains undefined. OBJECTIVES We aimed to assess the performances of currently available models/scores for identifying hemodynamically stable patients with acute, symptomatic PE at risk of death and clinical deterioration. METHODS This was a prospective multicenter cohort study including patients with acute PE (NCT03631810). Primary study outcome was in-hospital death within 30 days or clinical deterioration. Other outcomes were in-hospital death, death, and PE-related death, all at 30 days. We calculated positive and negative predictive values, c-statistics of European Society of Cardiology (ESC)-2014, ESC-2019, Pulmonary Embolism Thrombolysis (PEITHO), Bova, Thrombo-embolism lactate outcome study (TELOS), fatty acid binding protein, syncope and tachicardia (FAST), and National Early Warning Scale 2 (NEWS2) for the study outcomes. RESULTS In 5036 hemodynamically stable patients with acute PE, positive predictive values for the evaluated models/scores were all below 10%, except for TELOS and NEWS2; negative predictive values were above 98% for all the models/scores, except for FAST and NEWS2. ESC-2014 and TELOS had good performances for in-hospital death or clinical deterioration (c-statistic of 0.700 and 0.722, respectively), in-hospital death (c-statistic of 0.713 and 0.723, respectively), and PE-related death (c-statistic of 0.712 and 0.777, respectively); PEITHO, Bova, and NEWS2 also had good performances for PE-related death (c-statistic of 0.738, 0.741, and 0.742, respectively). CONCLUSION In hemodynamically stable patients with acute PE, the accuracy for identification of hemodynamically stable patients at risk for death and clinical deterioration varies across the available models/scores; TELOS seems to have the best performance. These data can inform management studies and clinical practice.
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Affiliation(s)
- Cecilia Becattini
- Internal, Vascular and Emergency Medicine - Stroke Unit, Department of Medicine and Surgery, University of Perugia, Perugia, Italy.
| | - Maria Cristina Vedovati
- Internal, Vascular and Emergency Medicine - Stroke Unit, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | | | - Simone Vanni
- Emergency Department, Saint Joseph Hospital, Empoli, Italy
| | | | | | - Alessandra Marrazzo
- General Medicine, Pavullo nel Frignano Hospital, Pavullo nel Frignano, Italy
| | - Matteo Borselli
- Emergency Department, Misericordia Hospital, Grosseto, Italy
| | | | - Andrea Fabbri
- Emergency Department, Romagna Hospital, Forlì, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Aldo Pietro Maggioni
- ANMCO (Associazione Nazionale Medici Cardiologi Ospedalieri) Research Center, Heart Cre Foundation, Florence, Italy
| | - Giancarlo Agnelli
- Internal, Vascular and Emergency Medicine - Stroke Unit, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Meyer HJ, Ehrengut C, Aghayev A, Hinnerichs M, Schramm D, Meinel FG, Borggrefe J, Surov A. Pleural and pericardial effusions as prognostic factors in patients with acute pulmonary embolism: a multicenter study. Emerg Radiol 2024:10.1007/s10140-024-02281-7. [PMID: 39210199 DOI: 10.1007/s10140-024-02281-7] [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: 07/25/2024] [Accepted: 08/16/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE The prognostic role of pleural and pericardial effusion in patients with acute pulmonary embolism (PE) is still unclear with a trend for worse clinical outcome. The aim of the present study was to demonstrate the prognostic role of pleural and pericardial effusion in patients with acute PE in a large multicentre setting. METHODS The investigated patient sampled was retrospectively comprised of 1082 patients (494 female, 45.7%) with a mean age of 63.8 years ± 15.8. In every case, contrast enhanced computed tomography (CT) pulmonalis angiography was analyzed to diagnose and quantify the pleural and pericardial effusion. The 30-day mortality was the primary endpoint of this study. RESULTS A total of 127 patients (11.7%) died within the 30-day observation period. Pleural effusion was identified in 438 patients (40.5%) and pericardial effusion was identified in 196 patients (18.1%). The presence of pleural effusion was associated with 30-day mortality, HR = 2.78 (95%CI1.89-4.0), p < 0.001 (univariable analysis), and HR = 2.52 (95%CI1.69-3.76), p < 0.001 (multivariable analysis). The pleural effusion width and density were not associated with 30-day mortality. The presence of pericardial effusion was not associated with 30-day mortality in multivariable analysis, HR = 1.28 (95%CI 0.80-2.03), p = 0.29. CONCLUSIONS Pleural effusion is a common finding in patients with acute pulmonary embolism, occurring in 40.5% of cases, and is a prognostic imaging finding associated with 30-day mortality. The presence of pleural effusion alone, regardless of volume or density, has been shown to be prognostic and should be included in CT reports. The prognostic role of pericardial effusion is limited.
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Affiliation(s)
- Hans-Jonas Meyer
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany.
| | - Constantin Ehrengut
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany
| | - Anar Aghayev
- Department of Radiology and Nuclear Medicine, Otto von Guericke University, Magdeburg, Germany
| | - Mattes Hinnerichs
- Department of Radiology and Nuclear Medicine, Otto von Guericke University, Magdeburg, Germany
| | - Dominik Schramm
- Department of Diagnostic and Interventional Radiology, University of Halle- Wittenberg, Halle (Saale), Germany
| | - Felix G Meinel
- Department of Diagnostic and Interventional Radiology, University of Rostock, Rostock, Germany
| | - Jan Borggrefe
- Department of Radiology, Neuroradiology and Nuclear Medicine, Johannes Wesling University Hospital, Ruhr University Bochum, Minden, Germany
| | - Alexey Surov
- Department of Radiology, Neuroradiology and Nuclear Medicine, Johannes Wesling University Hospital, Ruhr University Bochum, Minden, Germany
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4
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Li R, Shen S, Jiang J, Liu Y. Prognostic Value of Neutrophil/Lymphocyte Ratio for Pulmonary Embolism: A Meta-Analysis and External Validation. Ann Vasc Surg 2024; 105:48-59. [PMID: 38582200 DOI: 10.1016/j.avsg.2024.01.019] [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: 11/06/2023] [Revised: 12/26/2023] [Accepted: 01/21/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Prognostic value of neutrophil/lymphocyte ratio (NLR) for pulmonary embolism (PE) has been reported in several retrospective studies. The purpose of this investigation was to perform a pooled analysis and external validation of predictive value of NLR. METHODS PubMed, Embase, and Cochrane databases were searched from inception to November 5, 2022. A random effects model was used. Grade was used to evaluate the certainty of evidence. External validation was conducted in clinical cohorts before and after a propensity scoring matching (PSM). Covariates include basic clinical characteristics, such as age, gender, etc. The value of NLR in prediction model was also evaluated. RESULTS A total of 15 studies comprising 5,874 patients were included. Pooled risk ratio of NLR was 2.33 (95% confidence interval [CI]: 1.97-2.75), with an area under the curve of 0.78 (95% CI: 0.74-0.81), a sensitivity of 0.75 (95% CI: 0.71-0.79), a specificity of 0.67 (95% CI: 0.61-0.73), and a median cut-off value of 5.7. Grade of Recommendations Assessment Development and Evaluation (GRADE) certainty analysis showed the quality of the evidence was moderate. Before (n = 336) and after (n = 152) propensity scoring matching, risk ratio of NLR was 2.69 (95% CI: 1.04-6.97) and 6.58 (95% CI: 1.99-17.75). A prediction model consisting of NLR, age, D-dimer, and simplified PE severity index had an area under the curve of 0.809 (95% CI: 0.738-0.88), a sensitivity of 0.638 (95% CI: 0.511-0.745), and a specificity of 0.851 (95% CI: 0.709-0.917). Net reclassification index (12%, P = 0.035) and integrated discrimination improvement (17%, P = 0.022) indicated an improvement caused by NLR. CONCLUSIONS Prognostic value of NLR for PE was confirmed by meta-analysis and validated in an independent cohort, deserving further clinical application.
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Affiliation(s)
- Ruihua Li
- Department of General Surgery, Vascular Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Shuohao Shen
- Department of General Surgery, Vascular Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Jianjun Jiang
- Department of General Surgery, Vascular Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China.
| | - Yang Liu
- Department of General Surgery, Vascular Surgery, Qilu Hospital of Shandong University, Jinan, Shandong, China.
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Artac I, Ilis D, Karakayali M, Omar T, Arslan A, Topaloğlu I, Karabag Y, Karakayon S, Rencuzogullari I. The prognostic value of the MAGGIC risk score in patients with acute pulmonary embolism. Am J Med Sci 2024:S0002-9629(24)01386-7. [PMID: 39094978 DOI: 10.1016/j.amjms.2024.07.029] [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: 09/25/2023] [Revised: 07/17/2024] [Accepted: 07/17/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVES Acute pulmonary embolism (PE) is a potentially life-threatening condition characterized by the sudden blockage of the pulmonary arteries. Although the MAGGIC risk score has emerged as a valuable tool in predicting outcomes in patients with chronic heart failure, it has also been demonstrated and identified as a prognostic model in various cardiac diseases other than heart failure. In this study, we aimed to investigate the relationship between MAGGIC score and adverse outcomes in patients with PE. MATERIALS AND METHODS A total of 302 consecutive patients diagnosed with acute PE were retrospectively included in the present study. For each patient, the MAGGIC score was calculated. The study population was divided into two groups according to the median value of MAGGIC score. RESULTS Patients with high MAGGIC score had a significantly higher proportion of elderly and female individuals, lower BMI, higher presence of CAD, DM, AFib, HF, HT, CKD, COPD, and ACEI/ARB and NOAC usage. Logistic regression analyses was carried out using univariate and multivariate analysis to predict the in-hospital and 30-day mortality predictors in the included PE patients. For in-hospital mortality, diastolic blood pressure, heart rate, RV dilatation, and the MAGGIC score (HR: 1.166, 95 % CI 1.077-1.263, p < 0.001) and for short-term mortality, sPESI and the MAGGIC score (HR: 1.925, 95 % CI 1.243-2.983, p:0.003) were found to be independent predictors for adverse outcomes in patients with acute PE. CONCLUSION Our study demonstrates that the MAGGIC score can be applied as a valuable prognostic tool for acute pulmonary embolism.
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Affiliation(s)
- Inanc Artac
- Kafkas University Faculty of Medicine Department of Cardiology Kars Turkey.
| | - Dogan Ilis
- Kafkas University Faculty of Medicine Department of Cardiology Kars Turkey
| | - Muammer Karakayali
- Kafkas University Faculty of Medicine Department of Cardiology Kars Turkey
| | - Timor Omar
- Kafkas University Faculty of Medicine Department of Cardiology Kars Turkey
| | - Ayca Arslan
- Kafkas University Faculty of Medicine Department of Cardiology Kars Turkey
| | - Ihsan Topaloğlu
- Kafkas University Faculty of Medicine Department of Pulmonary Medicine Kars Turkey
| | - Yavuz Karabag
- Kafkas University Faculty of Medicine Department of Cardiology Kars Turkey
| | - Suleyman Karakayon
- Kocaeli Health and Technology University Department of Health Science Kocaeli Turkey
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6
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Ding CW, Liu C, Zhang ZP, Cheng CY, Pei GS, Jing ZC, Qiu JY. Development and external validation of a nomogram for predicting short-term prognosis in patients with acute pulmonary embolism. Int J Cardiol 2024; 407:132065. [PMID: 38642720 DOI: 10.1016/j.ijcard.2024.132065] [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: 03/18/2024] [Accepted: 04/17/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Accurate assessment and timely intervention play a crucial role in ameliorating poor short-term prognosis of acute pulmonary embolism (APE) patients. The currently employed scoring models exhibit a degree of complexity, and some models may not comprehensively incorporate relevant indicators, thereby imposing limitations on the evaluative efficacy. Our study aimed to construct and externally validate a nomogram that predicts 30-day all-cause mortality risk in APE patients. METHODS Clinical data from APE patients in Intensive Care-IV database was included as a training cohort. Additionally, we utilized our hospital's APE database as an external validation cohort. The nomogram was developed, and its predictive ability was evaluated using receiver operating characteristic (ROC) curves, calibration plots and decision curve analysis. RESULTS A collective of 1332 patients and 336 patients were respectively enrolled as the training cohort and the validation cohort in this study. Five variables including age, malignancy, oxygen saturation, blood glucose, and the use of vasopressor, were identified based on the results of the multivariate Cox regression model. The ROC value for the nomogram in the training cohort yielded 0.765, whereas in the validation group, it reached 0.907. Notably, these values surpassed the corresponding ROC values for the Pulmonary Embolism Severity Index, which were 0.713 in the training cohort and 0.754 in the validation cohort. CONCLUSIONS The nomogram including five indicators had a good performance in predicting short-term prognosis in patients with APE, which was easier to apply and provided better recommendations for clinical decision-making.
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Affiliation(s)
- Chao-Wei Ding
- Department of Respiratory and Critical Care Medicine, Xiamen Humanity Hospital Fujian Medical University, Xiamen, Fujian, 361000, China; Department of Respiratory and Critical Care Medicine, the Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050000, China
| | - Chao Liu
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Zi-Ping Zhang
- Department of Respiratory and Critical Care Medicine, the Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050000, China
| | - Chun-Yan Cheng
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, Guangdong, 510080, China
| | - Guang-Sheng Pei
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan, 471003, China
| | - Zhi-Cheng Jing
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, Guangdong, 510080, China.
| | - Jia-Yong Qiu
- Department of Respiratory and Critical Care Medicine, the Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 050000, China; Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China; Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, Guangdong, 510080, China; Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, Henan, 471003, China.
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7
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Nilsson LT, Andersson T, Carlberg B, Johansson LÅ, Söderberg S. Electrocardiographic abnormalities and NT-proBNP levels at long-term follow-up of patients with dyspnea after pulmonary embolism. SCAND CARDIOVASC J 2024; 58:2373090. [PMID: 38957080 DOI: 10.1080/14017431.2024.2373090] [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: 09/30/2023] [Accepted: 06/22/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVES Electrocardiogram (ECG) and measurement of plasma brain natriuretic peptides (BNP) are established markers of right ventricular dysfunction (RVD) in the setting of acute pulmonary embolism (PE) but their value at long-term follow-up is largely unknown. The purpose of this prospective study was to determine the prevalence of ECG abnormalities, describe levels of N-terminal proBNP (NT-proBNP), and establish their association with dyspnea at long-term follow-up after PE. DESIGN All Swedish patients diagnosed with acute PE in 2005 (n = 5793) were identified through the Swedish National Patient Registry. Surviving patients in 2007 (n = 3510) were invited to participate. Of these, 2105 subjects responded to a questionnaire about dyspnea and comorbidities. Subjects with dyspnea or risk factors for development of chronic thromboembolic pulmonary hypertension were included in the study in a secondary step, which involved collection of blood samples and ECG registration. RESULTS Altogether 49.3% had a completely normal ECG. The remaining participants had a variety of abnormalities, 7.2% had atrial fibrillation/flutter (AF). ECG with any sign of RVD was found in 7.2% of subjects. Right bundle branch block was the most common RVD sign with a prevalence of 6.4%. An abnormal ECG was associated with dyspnea. AF was associated with dyspnea, whereas ECG signs of RVD were not. 61.2% of subjects had NT-proBNP levels above clinical cut-off (>125 ng/L). The degree of dyspnea did not associate independently with NT-proBNP levels. CONCLUSIONS We conclude that the value of ECG and NT-proBNP in long term follow-up after PE lies mostly in differential diagnostics.
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Affiliation(s)
- Lars T Nilsson
- Department of Public Health and Clinical Medicine, Unit of Medicine, Umeå University, Umeå, Sweden
| | - Therese Andersson
- Department of Public Health and Clinical Medicine, Unit of Medicine, Umeå University, Umeå, Sweden
| | - Bo Carlberg
- Department of Public Health and Clinical Medicine, Unit of Medicine, Umeå University, Umeå, Sweden
| | - Lars Å Johansson
- Department of Public Health and Clinical Medicine, Unit of Medicine, Umeå University, Umeå, Sweden
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, Unit of Medicine, Umeå University, Umeå, Sweden
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8
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Hu J, Zhou Y. The association between lactate dehydrogenase to serum albumin ratio and in-hospital mortality in patients with pulmonary embolism: a retrospective analysis of the MIMIC-IV database. Front Cardiovasc Med 2024; 11:1398614. [PMID: 38962086 PMCID: PMC11220285 DOI: 10.3389/fcvm.2024.1398614] [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: 03/10/2024] [Accepted: 05/27/2024] [Indexed: 07/05/2024] Open
Abstract
Background Lactate dehydrogenase (LDH) and albumin (ALB) were found to be significantly correlated with mortality in pulmonary embolism (PE) patients. However, data regarding the LDH/ALB ratio (LAR) in patients with acute PE are scanty. Therefore, the aim of this study was to investigate the association between LAR and the risk of mortality in patients with acute PE. Methods A retrospective cohort study was conducted on patients with acute PE represented in the Medical Information Mart for Intensive Care IV (MIMIC-IV). A receiver operating characteristic (ROC) curve analysis and calibration curve were used to assess the accuracy of the LAR for predicting mortality in patients with acute PE. We utilized Cox regression analysis to determine adjusted hazard ratios (HR) and 95% confidence interval (CI). Survival curves were used to evaluate a connection between the LAR and prognosis in patients with acute PE. Results The study comprised 581 patients, and the 30-day all-cause mortality rate was 7.7%. We observed a higher LAR in the non-survival group compared to the surviving group (21.24 ± 21.22 vs. 8.99 ± 7.86, p < 0.0001). The Kaplan-Meier analysis showed that patients with an elevated LAR had a significantly lower likelihood of surviving the 30-day mortality compared to those with a low LAR. Cox regression analysis showed that LAR (HR = 1.04, 95% CI: 1.03-1.05) might have associations with 30-day mortality in patients with acute PE. This result was supported by sensitivity analyses. According to the results of the ROC curve analysis, the LAR's prediction of 30-day mortality in patients with acute PE yielded an area under the ROC curve of 0.73. A calibration curve showed LAR is well calibrated. Conclusion Our research suggests LAR monitoring may be promising as a prognostic marker among patients with acute PE.
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Affiliation(s)
| | - Yidan Zhou
- Department of Emergency Medicine, Hangzhou Third People’s Hospital, Hangzhou, China
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9
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Spampinato MD, Portoraro A, Sofia SM, Luppi F, Benedetto M, D'Angelo L, Galizia G, Fabbri IS, Pagano T, Perna B, Guarino M, Passarini G, Pavasini R, Passaro A, De Giorgio R. The role of echocardiography in pulmonary embolism for the prediction of in-hospital mortality: a retrospective study. J Ultrasound 2024; 27:355-362. [PMID: 38519765 PMCID: PMC11178708 DOI: 10.1007/s40477-024-00874-z] [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: 11/27/2023] [Accepted: 01/11/2024] [Indexed: 03/25/2024] Open
Abstract
PURPOSE Pulmonary Embolism (PE) is the third leading cause of cardiovascular death, following myocardial infarction and stroke. The latest European Society of Cardiology (ESC) guidelines on PE recommend short-term prognostic stratification based on right ventricular (RV) overload detected by transthoracic echocardiography (TTE) or contrast-enhanced chest CT. The aim of the study is to find out which of the signs of right ventricular dysfunction best predicts in-hospital mortality (IHM). METHODS This is a monocentric, retrospective study including adult patients admitted from the emergency department with a c-e cCT confirmed diagnosis of PE between January 2018 and December 2022 who underwent a TTE within 48 h. RESULTS 509 patients (median age 76 years [IQR 67-84]) were included, with 7.1% IHM. At univariate analysis, RV/LV ratio > 1 (OR 2.23, 95% CI 1.1-4.5), TAPSE < 17 mm (OR 4.73, 95% CI 2.3-9.8), the D-shape (OR 3.73, 95% CI 1.71-8.14), and LVEF < 35% (OR 5.78, 95% CI 1.72-19.47) resulted significantly correlated with IHM. However, at multivariate analysis including also haemodynamic instability, PESI class > II, and abnormal hs-cTnI levels, only LVEF < 35% (OR 5.46, 95% CI 1.32-22.61) resulted an independent predictor of IHM. CONCLUSION Despite the recognised role of TTE in the early management of patients with circulatory shock and suspected PE, signs of RV dysfunction have been shown to be poor predictors of IHM, whereas severely reduced LVEF is an independent risk factor for in-hospital death.
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Affiliation(s)
- Michele Domenico Spampinato
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
- Emergency Medicine Unit, St.Anna University Hospital, Ferrara, Italy
| | - Andrea Portoraro
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Soccorsa M Sofia
- Emergency Medicine Unit, Emergency department, Maggiore Hospital Bologna, Azienda Unità Sanitaria Locale Bologna, Bologna, Italy.
| | - Francesco Luppi
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Marcello Benedetto
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Luca D'Angelo
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Giorgio Galizia
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Irma Sofia Fabbri
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Teresa Pagano
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Benedetta Perna
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Matteo Guarino
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
- Emergency Medicine Unit, St.Anna University Hospital, Ferrara, Italy
| | - Giulia Passarini
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Ferrara, Italy
| | - Rita Pavasini
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Ferrara, Italy
| | - Angelina Passaro
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
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Goraya SR, O'Hare C, Grace KA, Schaeffer WJ, Hyder SN, Barnes GD, Greineder CF. Optimizing Use of High-Sensitivity Troponin for Risk-Stratification of Acute Pulmonary Embolism. Thromb Haemost 2024. [PMID: 38788767 DOI: 10.1055/s-0044-1786820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
BACKGROUND High-sensitivity troponin T (HS-TnT) may improve risk-stratification in hemodynamically stable acute pulmonary embolism (PE), but an optimal strategy for combining this biomarker with clinical risk-stratification tools has not been determined. STUDY HYPOTHESIS We hypothesized that different HS-TnT cutoff values may be optimal for identifying (1) low-risk patients who may be eligible for outpatient management and (2) patients at increased risk of clinical deterioration who might benefit from advanced PE therapies. METHODS Retrospective analysis of hemodynamically stable patients in the University of Michigan acute ED-PE registry with available HS-TnT values. Primary and secondary outcomes were 30-day mortality and need for intensive care unit-level care. Receiver operating characteristic curves were used to determine optimal HS-TnT cutoffs in the entire cohort, and for those at higher risk based on the simplified Pulmonary Embolism Severity Index (PESI) or imaging findings. RESULTS The optimal HS-TnT cutoff in the full cohort, 12 pg/mL, was significantly associated with 30-day mortality (odds ratio [OR]: 3.94, 95% confidence interval [CI]: 1.48-10.50) and remained a significant predictor after adjusting for the simplified PESI (sPESI) score and serum creatinine (adjusted OR: 3.05, 95% CI: 1.11-8.38). A HS-TnT cutoff of 87 pg/mL was associated with 30-day mortality (OR: 5.01, 95% CI: 2.08-12.06) in patients with sPESI ≥1 or right ventricular dysfunction. CONCLUSION In this retrospective, single-center study of acute PE patients, we identified distinct optimal HS-TnT values for different clinical uses-a lower cutoff, which identified low-risk patients even in the absence of other risk-stratification methods, and a higher cutoff, which was strongly associated with adverse outcomes in patients at increased risk.
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Affiliation(s)
- Sayhaan R Goraya
- University of Michigan Medical School, Ann Arbor, Michigan, United States
| | - Connor O'Hare
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Kelsey A Grace
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - William J Schaeffer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - S Nabeel Hyder
- Division of Cardiovascular Medicine, Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, United States
| | - Geoffrey D Barnes
- University of Michigan Medical School, Ann Arbor, Michigan, United States
- Division of Cardiovascular Medicine, Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, United States
| | - Colin F Greineder
- University of Michigan Medical School, Ann Arbor, Michigan, United States
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, United States
- Department of Pharmacology, University of Michigan, Ann Arbor, Michigan, United States
- BioInterfaces Institute, University of Michigan, Ann Arbor, Michigan, United States
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11
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Birrenkott DA, Kabrhel C, Dudzinski DM. Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies. Cardiol Clin 2024; 42:215-235. [PMID: 38631791 DOI: 10.1016/j.ccl.2024.02.008] [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] [Indexed: 04/19/2024]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.
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Affiliation(s)
- Drew A Birrenkott
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiac Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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12
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Finocchiaro S, Mauro MS, Rochira C, Spagnolo M, Laudani C, Landolina D, Mazzone PM, Agnello F, Ammirabile N, Faro DC, Imbesi A, Occhipinti G, Greco A, Capodanno D. Percutaneous interventions for pulmonary embolism. EUROINTERVENTION 2024; 20:e408-e424. [PMID: 38562073 PMCID: PMC10979388 DOI: 10.4244/eij-d-23-00895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/19/2024] [Indexed: 04/04/2024]
Abstract
Pulmonary embolism (PE) ranks as a leading cause of in-hospital mortality and the third most common cause of cardiovascular death. The spectrum of PE manifestations varies widely, making it difficult to determine the best treatment approach for specific patients. Conventional treatment options include anticoagulation, thrombolysis, or surgery, but emerging percutaneous interventional procedures are being investigated for their potential benefits in heterogeneous PE populations. These novel interventional techniques encompass catheter-directed thrombolysis, mechanical thrombectomy, and hybrid approaches combining different mechanisms. Furthermore, inferior vena cava filters are also available as an option for PE prevention. Such interventions may offer faster improvements in right ventricular function, as well as in pulmonary and systemic haemodynamics, in individual patients. Moreover, percutaneous treatment may be a valid alternative to traditional therapies in high bleeding risk patients and could potentially reduce the burden of mortality related to major bleeds, such as that of haemorrhagic strokes. Nevertheless, the safety and efficacy of these techniques compared to conservative therapies have not been conclusively established. This review offers a comprehensive evaluation of the current evidence for percutaneous interventions in PE and provides guidance for selecting appropriate patients and treatments. It serves as a valuable resource for future researchers and clinicians seeking to advance this field. Additionally, we explore future perspectives, proposing "percutaneous primary pulmonary intervention" as a potential paradigm shift in the field.
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Affiliation(s)
- Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Antonino Imbesi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
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13
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Abuelhassan UE, Alsalem AA, Alshafa FA, Alshahrani FS, AlShahrani MA, ALAmri AK, Alaqil MA, Al Asim AA, Alsultan EM, Al Mani SY, Badawi AG, Alshehri EF, Alshehri EA, ALAmri NK, Abdalla AM, Khalaf M, Ghalyoob TM, Elnamaky M, Mahmoud IM. Clinical Features and Predictors of Mortality in Patients With Acute Pulmonary Embolism: A Retrospective Study From Southern Saudi Arabia. Cureus 2024; 16:e55623. [PMID: 38586707 PMCID: PMC10995892 DOI: 10.7759/cureus.55623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND AND METHODOLOGY We aimed to investigate the clinical characteristics, outcomes, and mortality predictors in patients with acute pulmonary embolism (PE). Adult patients who were admitted to the Armed Forces Hospital Southern Region, Khamis Mushait, a large tertiary hospital in Southern Saudi Arabia, with the diagnosis of acute PE were retrospectively examined for the predictors of one-year mortality. RESULTS The overall in-hospital mortality was 15.6% among 212 patients. In univariate analysis, only age was significantly associated with increased early mortality, whereas age, obesity, presence of active malignancy, hypertension, use of thrombolytics, and Simplified Pulmonary Embolism Severity Index (sPESI) were significantly associated with increased late mortality. By use of binary logistic regression, the presence of obesity (HR 6.010, 95%CI 0.048-16.853, p=0.030), active malignancy (HR 3.040, 95%CI 1.147-8.059, p=0.025), and the use of thrombolytics (HR 8.074, 95%CI 2.719-23.977, p<0.001), were independently significant factors for late (overall) mortality, respectively. CONCLUSIONS Among Saudi Arabian patients in the Southern Region, our data show that age is an independent factor for increased early and late mortality. The presence of obesity, active malignancy, and the use of thrombolytics, were independently significant factors for increased late (one-year) mortality. These factors should be taken into account for risk stratification and decisions on tailored management of patients with PE. Further prospective multicenter studies are needed.
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Affiliation(s)
- Usama E Abuelhassan
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, SAU
- Department of Respiratory Medicine, Faculty of Medicine, Cairo University, Cairo, EGY
| | - Ali A Alsalem
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, SAU
| | - Fawwaz A Alshafa
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, SAU
| | - Fahad S Alshahrani
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, SAU
| | - Maram A AlShahrani
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, SAU
| | - Amal K ALAmri
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, SAU
| | - Meaad A Alaqil
- Department of Internal Medicine, King Khalid University Hospital, Abha, SAU
| | - Ahmad Ali Al Asim
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, SAU
| | - Eman M Alsultan
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, SAU
| | - Salihah Y Al Mani
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, SAU
| | - Azizah G Badawi
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, SAU
| | - Elham F Alshehri
- Department of Medicine, Ministry of Health, Aseer District, Abha, SAU
| | - Eissa A Alshehri
- Department of Radiology, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, SAU
| | - Nour K ALAmri
- Department of Internal Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, SAU
| | | | - Mervat Khalaf
- Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, EGY
| | - Tayseer M Ghalyoob
- Department of Radiology, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, SAU
| | - Medhat Elnamaky
- Department of Pulmonary Medicine, Al-Azhar University - Assiut Branch, Assiut, EGY
| | - Ibrahim M Mahmoud
- Department of Critical Care Medicine, Armed Forces Hospital Southern Region (AFHSR), Khamis Mushayt, SAU
- Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, EGY
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14
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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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15
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Zhang SJ, Wang LT, Li X. Postpulmonary embolism syndrome: what should we focus on? J Thromb Haemost 2024; 22:362-364. [PMID: 38309812 DOI: 10.1016/j.jtha.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 11/15/2023] [Accepted: 11/17/2023] [Indexed: 02/05/2024]
Affiliation(s)
- Si-Jin Zhang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Li-Ting Wang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Xin Li
- Department of Emergency Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China.
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16
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Tehrani BN, Batchelor WB, Spinosa D. High-Risk Acute Pulmonary Embolism: Where Do We Go From Here? J Am Coll Cardiol 2024; 83:44-46. [PMID: 38171709 DOI: 10.1016/j.jacc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 01/05/2024]
Affiliation(s)
| | | | - David Spinosa
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA; Fairfax Radiologic Consultants, Fairfax, Virginia, USA
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17
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Xiong W, Cheng Y, Zhao Y. Risk Scores in Venous Thromboembolism Guidelines of ESC, ACCP, and ASH: An Updated Review. Clin Appl Thromb Hemost 2024; 30:10760296241263856. [PMID: 38887044 PMCID: PMC11185021 DOI: 10.1177/10760296241263856] [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: 03/22/2024] [Revised: 05/24/2024] [Accepted: 06/07/2024] [Indexed: 06/20/2024] Open
Abstract
Venous thromboembolism (VTE) is associated with high morbidity and mortality. Risk scores associated with VTE have been widely used in clinical practice. Among numerous scores published, those included in guidelines are usually typical risk scores which have been extensively validated and globally recognized. This review provides an updated overview of the risk scores associated with VTE endorsed by 3 guidelines which are highly recognized in the field of VTE including the European Society of Cardiology, American College of Chest Physicians, and American Society of Hematology, focusing on the development, modification, validation, and comparison of these scores, to provide a comprehensive and updated understanding of all the classic risk scores associated with VTE to medical readers including but not limited to cardiologists, pulmonologists, hematologists, intensivists, physicians, surgeons, and researchers. Although each score recommended by these guidelines was more or less validated, there may still be room for further improvement. It may still be necessary to seek simpler, more practical, and more universally applicable VTE-related risk scores in the future.
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Affiliation(s)
- Wei Xiong
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yi Cheng
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yunfeng Zhao
- Department of Pulmonary and Critical Care Medicine, Punan Hospital, Pudong New District, Shanghai, China
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18
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Schiza S, Schwarz EI, Bonsignore MR, McNicholas WT, Pataka A, Bouloukaki I. Co-existence of OSA and respiratory diseases and the influence of gender. Expert Rev Respir Med 2023; 17:1221-1235. [PMID: 38198636 DOI: 10.1080/17476348.2024.2304065] [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: 10/22/2023] [Accepted: 01/08/2024] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Sleep-disordered breathing (SDB), especially obstructive sleep apnea (OSA), is commonly associated with respiratory diseases, such as COPD, asthma and interstitial lung disease. AREAS COVERED This narrative review aims to comprehensively synthesize the existing information on SDB in respiratory diseases, investigate the role of gender in this association, and highlight the importance of OSA management in improving sleep, quality of life, and disease prognosis in these specific patient populations. EXPERT OPINION Research indicates a synergistic link between OSA and chronic respiratory diseases, which leads to greater morbidity and mortality compared to each disorder alone. Given the lack of an optimal OSA screening tool for these patients, a comprehensive patient approach and overnight diagnostic sleep study are imperative. Despite the limited evidence available, it seems that gender has an impact on the prevalence, severity, and susceptibility of this coexistence. Recognizing the role of gender in the coexistence of OSA and other respiratory diseases can enhance everyday medical practice and enable clinicians to adopt a more personalized approach toward optimal screening and diagnosis of these patients.
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Affiliation(s)
- Sophia Schiza
- Sleep Disorders Center, Department of Respiratory Medicine, University of Crete School of Medicine, Crete, Greece
| | - Esther I Schwarz
- Department of Pulmonology, University Hospital Zurich and University of Zurich, University of Zurich Faculty of Medicine, Zurich, Switzerland
| | - Maria R Bonsignore
- Division of Respiratory Medicine, PROMISE Department, University of Palermo Faculty of Medicine and Surgery, Palermo, Italy
| | - Walter T McNicholas
- Department of Respiratory and Sleep Medicine, St Vincent's Hospital Group, University College Dublin, Dublin, Ireland
| | - Athanasia Pataka
- Respiratory Failure Unit, G Papanikolaou Hospital, Medical School, Aristoteleio Panepistemio Thessalonikes Schole Epistemon Ygeias, Thessaloniki, Greece
| | - Izolde Bouloukaki
- Sleep Disorders Center, Department of Respiratory Medicine, University of Crete School of Medicine, Crete, Greece
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19
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Barca-Hernando M, Jara-Palomares L. Pulmonary embolism: a practical approach to update risk stratification and treatment decisions based on the guidelines. Expert Rev Respir Med 2023; 17:1151-1158. [PMID: 38133539 DOI: 10.1080/17476348.2023.2298826] [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: 11/09/2023] [Accepted: 12/20/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Pulmonary embolism (PE) is a prevalent condition with a substantial morbi-mortality worldwide. Proper risk stratification of PE is essential for identifying the most suitable therapeutic strategy and the optimal care setting for the patient. This process entails evaluating various factors, including symptoms, comorbidities, and right heart dysfunction. AREAS COVERED This review assesses the tools and methods utilized to identify and stratify individuals based on the probability of developing deterioration or death related to PE. Current guidelines divide PE into three groups: high-risk (previously termed massive) PE, intermediate-risk (sub-massive) PE, and low-risk PE. Various risk scores, such as the simplified pulmonary embolism severity index (sPESI), Bova score, and the FAST score (incorporating Heart-Fatty Acid binding protein [H-ABP], Syncope, Tachycardia), aid in identifying patients at higher risk. Additionally, the Hestia score is instrumental in pinpointing low-risk patients. EXPERT OPINION Presently, there is a dearth of high-quality frameworks for the optimal management and treatment of PE patients at risk of hemodynamic collapse. A consortium of experts is in the process of formulating a new conceptual model for risk stratification, taking into account a comprehensive array of variables and outcomes to facilitate more individualized management of acute PE.
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Affiliation(s)
| | - Luis Jara-Palomares
- Respiratory Department, Hospital Virgen del Rocio, Sevilla, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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20
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Ding C, Zhang Z, Qiu J, Du D, Liu Z. Association of red blood cell distribution width to albumin ratio with the prognosis of acute severe pulmonary embolism: A cohort study. Medicine (Baltimore) 2023; 102:e36141. [PMID: 38013321 PMCID: PMC10681614 DOI: 10.1097/md.0000000000036141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/25/2023] [Indexed: 11/29/2023] Open
Abstract
Red blood cell distribution width (RDW) to human serum albumin (ALB) ratio (RDW/ALB Ratio, RAR) is a prognostic factor for adverse outcomes in different disease populations. However, the relationship between RAR and pulmonary embolism outcomes remains unclear. Therefore, this study set out to investigate the association between RAR and the risk of all-cause death in acute pulmonary embolism (APE) patients admitted to the intensive care unit (ICU). This is a retrospective study based on the MIMIC-IV database. The primary outcome was all-cause mortality among patients with APE (in-hospital and 1-year mortality). The relationship between RAR and all-cause mortality was assessed using Cox regression analysis. The survival curve was drawn to evaluate the predictive value of RAR for patient mortality. Correlations and threshold effects between RAR and all-cause mortality were analyzed using the generalized additive model (GAM). The study included 773 patients, and fully adjusted Cox regression models showed that RAR was associated with higher all-cause mortality in the hospital and one year later (all P < .05). In the GAM, the relationship between RAR and all-cause mortality was shown to be nonlinear, with a positive association between RAR and all-cause mortality in APE patients when RAR values were at low to moderate levels. This study revealed a significant association between RAR and the risk of all-cause day death in patients with pulmonary embolism. Higher RAR value was associated with increased in-hospital mortality and 1-year mortality.
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Affiliation(s)
- Chaowei Ding
- Department of Respiratory and Critical Care Medicine, Xiamen Humanity Hospital Fujian Medical University, Xiamen, Fujian, China
- Department of Respiratory and Critical Care Medicine, the Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Ziping Zhang
- Department of Respiratory and Critical Care Medicine, the Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Jiayong Qiu
- Department of Respiratory and Critical Care Medicine, the Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
- Department of Respiratory and Critical Care Medicine, the Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou Province, China
| | - Dan Du
- Department of Respiratory and Critical Care Medicine, the Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
| | - Zexin Liu
- Department of Respiratory and Critical Care Medicine, the Second Hospital of Hebei Medical University, Shijiazhuang, Hebei Province, China
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Jiang R, Dai HL. Normotensive pulmonary embolism: nothing to sneeze at. J Thromb Haemost 2023; 21:3072-3074. [PMID: 37858522 DOI: 10.1016/j.jtha.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/01/2023] [Accepted: 06/05/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hai-Long Dai
- Key Laboratory of Cardiovascular Disease of Yunnan Province, Clinical Medicine Center for Cardiovascular Disease of Yunnan Province, Department of Cardiology, Yan'an Affiliated Hospital of Kunming Medical University, Kunming, China.
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22
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de Wit K, D'Arsigny CL. Risk stratification of acute pulmonary embolism. J Thromb Haemost 2023; 21:3016-3023. [PMID: 37187357 DOI: 10.1016/j.jtha.2023.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 04/18/2023] [Accepted: 05/01/2023] [Indexed: 05/17/2023]
Abstract
Approximately 5% of pulmonary embolism (PE) cases present with persistent hypotension, obstructive shock, or cardiac arrest. Given the high short-term mortality, management of high-risk PE cases focuses on immediate reperfusion therapies. Risk stratification of normotensive PE is important to identify patients with an elevated risk of hemodynamic collapse or an elevated risk of major bleeding. Risk stratification for short-term hemodynamic collapse includes assessment of physiological parameters, right heart dysfunction, and identification of comorbidities. Validated tools such as European Society of Cardiology guidelines and Bova score can identify normotensive patients with PE and an elevated risk of subsequent hemodynamic collapse. At present, we lack high-quality evidence to recommend one treatment over another (systemic thrombolysis, catheter-directed therapy, or anticoagulation with close monitoring) for patients at elevated risk of hemodynamic collapse. Newer, less well-validated scores such as BACS and PE-CH may help identify patients at a high risk of major bleeding following systemic thrombolysis. The PE-SARD score may identify those at risk of major anticoagulant-associated bleeding. Patients at low risk of short-term adverse outcomes can be considered for outpatient management. The simplified Pulmonary Embolism Severity Index score or Hestia criteria are safe decision aids when combined with physician global assessment of the need for hospitalization following the diagnosis of PE.
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Affiliation(s)
- Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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23
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Götzinger F, Lauder L, Sharp ASP, Lang IM, Rosenkranz S, Konstantinides S, Edelman ER, Böhm M, Jaber W, Mahfoud F. Interventional therapies for pulmonary embolism. Nat Rev Cardiol 2023; 20:670-684. [PMID: 37173409 PMCID: PMC10180624 DOI: 10.1038/s41569-023-00876-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 05/15/2023]
Abstract
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. Traditionally, treatment of PE has involved a choice of anticoagulation, thrombolysis or surgery; however, a range of percutaneous interventional technologies have been developed that are under investigation in patients with intermediate-high-risk or high-risk PE. These interventional technologies include catheter-directed thrombolysis (with or without ultrasound assistance), aspiration thrombectomy and combinations of the aforementioned principles. These interventional treatment options might lead to a more rapid improvement in right ventricular function and pulmonary and/or systemic haemodynamics in particular patients. However, evidence from randomized controlled trials on the safety and efficacy of these interventions compared with conservative therapies is lacking. In this Review, we discuss the underlying pathophysiology of PE, provide assistance with decision-making on patient selection and critically appraise the available clinical evidence on interventional, catheter-based approaches for PE treatment. Finally, we discuss future perspectives and unmet needs.
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Affiliation(s)
- Felix Götzinger
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Lucas Lauder
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Andrew S P Sharp
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
- Cardiff University, Cardiff, UK
| | - Irene M Lang
- Department of Cardiology, Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Stephan Rosenkranz
- Department of Cardiology - Internal Medicine III, Cologne University Heart Center, Cologne, Germany
- Cologne Cardiovascular Research Center (CCRC), Cologne University Heart Center, Cologne, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michael Böhm
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Wissam Jaber
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Felix Mahfoud
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany.
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
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24
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Alsubhi YM, Alhadi AH, Hammudah AM, Alahmadi RA, Aljohani AM, Dubai SA, Susi AI, Almuwallad K, Alwasaidi TA. Comparison of laboratory biomarkers for the prediction of in-hospital mortality and severity of acute pulmonary embolism: A multi-center study. Saudi Med J 2023; 44:898-903. [PMID: 37717976 PMCID: PMC10505296 DOI: 10.15537/smj.2023.44.9.20230441] [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: 06/12/2023] [Accepted: 08/14/2023] [Indexed: 09/19/2023] Open
Abstract
OBJECTIVES To assess the specificity and sensitivity of prognostic biomarkers in individuals diagnosed with acute pulmonary embolism (PE). METHODS This study retrospectively enrolled 162 patients from the 741 patients who were hospitalized with acute PE and diagnosed using pulmonary computed tomography (CT) angiogram at 5 hospitals in Saudi Arabia between January 2015 and December 2019. Pulmonary embolism patients classified into survivor and non-survivor groups. Neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and red cell distribution width (RDW) were all recorded and were compared between the groups. The evaluation of mortality prediction, sensitivity, and specificity was carried out by employing receiver operating characteristic curves. RESULTS The variables NLR and RDW exhibited a statistically significant correlation with increased mortality and disease severity. A total of 8 patients among the 162 patients died. At the cut-off value of 5.5, NLR was showed an association with all-cause mortality, demonstrating a sensitivity of 75% and a specificity of 82%. At the cut-off value of 18.15, RDW was found to be significantly associated with all-cause mortality, displaying a sensitivity of 63% and a specificity of 88%. CONCLUSION Multiple parameters have been implicated in the mortality and severity of PE. Our study revealed a statistically significant association between NLR, RDW, and PE mortality. These tests are easily accessible and may provide insights into the mortality associated with PE.
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Affiliation(s)
- Yasir M. Alsubhi
- From the Department of Medicine (Alsubhi, Hammudah, Alahmadi); from the Department of Critical Care (Almuwallad), King Fahad General Hospital, from the Department of Medicine (Alhadi); from the Division of Hematology (Alwasaidi), Prince Mohammed Bin Abdulaziz Hospital, Ministry of National Guard Health Affairs, from the Department of Preventive Medicine (Aljohani), Division of Infection Prevention and Control; from the Preventive Medicine Joint Program (Al Dubai), Post Graduate Studies, Ministry of Health, from the Department of Medicine (Alwasaidi), College of Medicine, Taibah University, Al-Madinah Al-Munawarah, and from the Department of Emergency Medicine (Susi), King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia.
| | - Ahmed H. Alhadi
- From the Department of Medicine (Alsubhi, Hammudah, Alahmadi); from the Department of Critical Care (Almuwallad), King Fahad General Hospital, from the Department of Medicine (Alhadi); from the Division of Hematology (Alwasaidi), Prince Mohammed Bin Abdulaziz Hospital, Ministry of National Guard Health Affairs, from the Department of Preventive Medicine (Aljohani), Division of Infection Prevention and Control; from the Preventive Medicine Joint Program (Al Dubai), Post Graduate Studies, Ministry of Health, from the Department of Medicine (Alwasaidi), College of Medicine, Taibah University, Al-Madinah Al-Munawarah, and from the Department of Emergency Medicine (Susi), King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia.
| | - Abdulaziz M. Hammudah
- From the Department of Medicine (Alsubhi, Hammudah, Alahmadi); from the Department of Critical Care (Almuwallad), King Fahad General Hospital, from the Department of Medicine (Alhadi); from the Division of Hematology (Alwasaidi), Prince Mohammed Bin Abdulaziz Hospital, Ministry of National Guard Health Affairs, from the Department of Preventive Medicine (Aljohani), Division of Infection Prevention and Control; from the Preventive Medicine Joint Program (Al Dubai), Post Graduate Studies, Ministry of Health, from the Department of Medicine (Alwasaidi), College of Medicine, Taibah University, Al-Madinah Al-Munawarah, and from the Department of Emergency Medicine (Susi), King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia.
| | - Riyadh A. Alahmadi
- From the Department of Medicine (Alsubhi, Hammudah, Alahmadi); from the Department of Critical Care (Almuwallad), King Fahad General Hospital, from the Department of Medicine (Alhadi); from the Division of Hematology (Alwasaidi), Prince Mohammed Bin Abdulaziz Hospital, Ministry of National Guard Health Affairs, from the Department of Preventive Medicine (Aljohani), Division of Infection Prevention and Control; from the Preventive Medicine Joint Program (Al Dubai), Post Graduate Studies, Ministry of Health, from the Department of Medicine (Alwasaidi), College of Medicine, Taibah University, Al-Madinah Al-Munawarah, and from the Department of Emergency Medicine (Susi), King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia.
| | - Azhar M. Aljohani
- From the Department of Medicine (Alsubhi, Hammudah, Alahmadi); from the Department of Critical Care (Almuwallad), King Fahad General Hospital, from the Department of Medicine (Alhadi); from the Division of Hematology (Alwasaidi), Prince Mohammed Bin Abdulaziz Hospital, Ministry of National Guard Health Affairs, from the Department of Preventive Medicine (Aljohani), Division of Infection Prevention and Control; from the Preventive Medicine Joint Program (Al Dubai), Post Graduate Studies, Ministry of Health, from the Department of Medicine (Alwasaidi), College of Medicine, Taibah University, Al-Madinah Al-Munawarah, and from the Department of Emergency Medicine (Susi), King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia.
| | - Sami Al Dubai
- From the Department of Medicine (Alsubhi, Hammudah, Alahmadi); from the Department of Critical Care (Almuwallad), King Fahad General Hospital, from the Department of Medicine (Alhadi); from the Division of Hematology (Alwasaidi), Prince Mohammed Bin Abdulaziz Hospital, Ministry of National Guard Health Affairs, from the Department of Preventive Medicine (Aljohani), Division of Infection Prevention and Control; from the Preventive Medicine Joint Program (Al Dubai), Post Graduate Studies, Ministry of Health, from the Department of Medicine (Alwasaidi), College of Medicine, Taibah University, Al-Madinah Al-Munawarah, and from the Department of Emergency Medicine (Susi), King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia.
| | - Abdulqader I. Susi
- From the Department of Medicine (Alsubhi, Hammudah, Alahmadi); from the Department of Critical Care (Almuwallad), King Fahad General Hospital, from the Department of Medicine (Alhadi); from the Division of Hematology (Alwasaidi), Prince Mohammed Bin Abdulaziz Hospital, Ministry of National Guard Health Affairs, from the Department of Preventive Medicine (Aljohani), Division of Infection Prevention and Control; from the Preventive Medicine Joint Program (Al Dubai), Post Graduate Studies, Ministry of Health, from the Department of Medicine (Alwasaidi), College of Medicine, Taibah University, Al-Madinah Al-Munawarah, and from the Department of Emergency Medicine (Susi), King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia.
| | - Kholoud Almuwallad
- From the Department of Medicine (Alsubhi, Hammudah, Alahmadi); from the Department of Critical Care (Almuwallad), King Fahad General Hospital, from the Department of Medicine (Alhadi); from the Division of Hematology (Alwasaidi), Prince Mohammed Bin Abdulaziz Hospital, Ministry of National Guard Health Affairs, from the Department of Preventive Medicine (Aljohani), Division of Infection Prevention and Control; from the Preventive Medicine Joint Program (Al Dubai), Post Graduate Studies, Ministry of Health, from the Department of Medicine (Alwasaidi), College of Medicine, Taibah University, Al-Madinah Al-Munawarah, and from the Department of Emergency Medicine (Susi), King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia.
| | - Turki A. Alwasaidi
- From the Department of Medicine (Alsubhi, Hammudah, Alahmadi); from the Department of Critical Care (Almuwallad), King Fahad General Hospital, from the Department of Medicine (Alhadi); from the Division of Hematology (Alwasaidi), Prince Mohammed Bin Abdulaziz Hospital, Ministry of National Guard Health Affairs, from the Department of Preventive Medicine (Aljohani), Division of Infection Prevention and Control; from the Preventive Medicine Joint Program (Al Dubai), Post Graduate Studies, Ministry of Health, from the Department of Medicine (Alwasaidi), College of Medicine, Taibah University, Al-Madinah Al-Munawarah, and from the Department of Emergency Medicine (Susi), King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia.
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25
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Jiménez D, Bikdeli B, Rodríguez C, Muriel A, Ballaz A, Soler S, Schellong S, Gil-Díaz A, Skride A, Riera-Mestre A, Monreal M. Identification of Low-risk Patients With Acute Symptomatic Pulmonary Embolism. Arch Bronconeumol 2023; 59:575-580. [PMID: 37455150 DOI: 10.1016/j.arbres.2023.06.010] [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: 04/18/2023] [Revised: 06/03/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Identification of patients with acute symptomatic pulmonary embolism (PE) who are at low-risk for short-term complications to warrant outpatient care lacks clarity. METHOD In order to identify patients at low-risk for 30-day all-cause and PE-related mortality, we used a cohort of haemodynamically stable patients from the RIETE registry to compare the false-negative rate of four strategies: the simplified Pulmonary Embolism Severity Index (sPESI); a modified (i.e., heart rate cutoff of 100beats/min) sPESI; and a combination of the original and the modified sPESI with computed tomography (CT)-assessed right ventricle (RV)/left ventricle (LV) ratio. RESULTS Overall, 137 of 3117 patients with acute PE (4.4%) died during the first month. Of these, 41 (1.3%) died from PE, and 96 (3.1%) died from other causes. The proportion of patients categorized as having low-risk was highest with the sPESI and lowest with the combination of a modified sPESI and CT-assessed RV/LV ratio (32.5% versus 16.5%; P<0.001). However, among patients identified as low-risk, the 30-day mortality rate was lowest with the combination of a modified sPESI and CT-assessed RV/LV ratio and highest with the sPESI (0.4% versus 1.0%; P=0.03). The 30-day PE-related mortality rates for patients designated as low-risk by the sPESI, the modified sPESI, and the combination of the original and modified sPESI with CT-assessed RV/LV ratio were 0.7%, 0.4%, 0.7%, and 0.2%, respectively. CONCLUSIONS The combination of a negative modified sPESI with CT-assessed RV/LV ratio ≤1 identifies patients with acute PE who are at very low-risk for short-term mortality.
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Affiliation(s)
- David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain; Medicine Department, Universidad de Alcalá, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain.
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Alfonso Muriel
- Biostatistics Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBERESP, Madrid, Spain
| | - Aitor Ballaz
- Department of Pneumonology, Hospital de Galdakao, Vizcaya, Spain
| | - Silvia Soler
- Department of Internal Medicine, Hospital Olot i Comarcal de la Garrotxa, Gerona, Spain
| | - Sebastian Schellong
- Department of Medical Clinic, Municipal Hospital of Dresden Friedrichstadt, Dresden, Germany
| | - Aída Gil-Díaz
- Department of Internal Medicine, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Andris Skride
- Department of Cardiology, Ospedale Pauls Stradins Clinical University Hospital, Riga Stradiņš University, Riga, Latvia
| | - Antoni Riera-Mestre
- Internal Medicine Department, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM-Universidad Católica San Antonio de Murcia, Murcia, Spain
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26
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Wang G, Xu J, Lin X, Lai W, Lv L, Peng S, Li K, Luo M, Chen J, Zhu D, Chen X, Yao C, Wu S, Huang K. Machine learning-based models for predicting mortality and acute kidney injury in critical pulmonary embolism. BMC Cardiovasc Disord 2023; 23:385. [PMID: 37533004 PMCID: PMC10399014 DOI: 10.1186/s12872-023-03363-z] [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: 04/15/2023] [Accepted: 06/22/2023] [Indexed: 08/04/2023] Open
Abstract
OBJECTIVES We aimed to use machine learning (ML) algorithms to risk stratify the prognosis of critical pulmonary embolism (PE). MATERIAL AND METHODS In total, 1229 patients were obtained from MIMIC-IV database. Main outcomes were set as all-cause mortality within 30 days. Logistic regression (LR) and simplified eXtreme gradient boosting (XGBoost) were applied for model constructions. We chose the final models based on their matching degree with data. To simplify the model and increase its usefulness, finally simplified models were built based on the most important 8 variables. Discrimination and calibration were exploited to evaluate the prediction ability. We stratified the risk groups based on risk estimate deciles. RESULTS The simplified XGB model performed better in model discrimination, which AUC were 0.82 (95% CI: 0.78-0.87) in the validation cohort, compared with the AUC of simplified LR model (0.75 [95% CI: 0.69-0.80]). And XGB performed better than sPESI in the validation cohort. A new risk-classification based on XGB could accurately predict low-risk of mortality, and had high consistency with acknowledged risk scores. CONCLUSIONS ML models can accurately predict the 30-day mortality of critical PE patients, which could further be used to reduce the burden of ICU stay, decrease the mortality and improve the quality of life for critical PE patients.
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Affiliation(s)
- Geng Wang
- Department of Vascular Interventional Radiology, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan, China
| | - Jiatang Xu
- Department of Cardiovascular Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No.33, Yingfeng Road, Haizhu District, Guangdong Province, 510000, Guangzhou, China
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Xixia Lin
- Department of Medicine, Sun Yat-Sen Memorial Hospital South Campus Clinic, Guangzhou, China
| | - Weijie Lai
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Lin Lv
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Senyi Peng
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Kechen Li
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China
| | - Mingli Luo
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
- Department of Urology, SunYat-Sen Memorial Hospital, SunYat-Sen University, Guangzhou, China
| | - Jiale Chen
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Dongxi Zhu
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Xiong Chen
- Department of Urology, SunYat-Sen Memorial Hospital, SunYat-Sen University, Guangzhou, China
| | - Chen Yao
- Department of Vascular Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Shaoxu Wu
- Department of Urology, SunYat-Sen Memorial Hospital, SunYat-Sen University, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, China.
| | - Kai Huang
- Department of Cardiovascular Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No.33, Yingfeng Road, Haizhu District, Guangdong Province, 510000, Guangzhou, China.
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Weekes AJ, Davison J, Lupez K, Raper JD, Thomas AM, Cox CA, Esener D, Boyd JS, Nomura JT, Murphy K, Ockerse PM, Leech S, Johnson J, Abrams E, Kelly C, O'Connell NS. Quality of life 1 month after acute pulmonary embolism in emergency department patients. Acad Emerg Med 2023; 30:819-831. [PMID: 36786661 DOI: 10.1111/acem.14692] [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: 11/28/2022] [Revised: 01/30/2023] [Accepted: 02/07/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVE The Pulmonary Embolism Quality-of-Life (PEmb-QoL) questionnaire assesses quality of life (QoL) after pulmonary embolism (PE). We aimed to determine whether any clinical or pathophysiologic features of PE were associated with worse PEmb-QoL scores 1 month after PE. METHODS In this prospective multicenter registry, we conducted PEmb-QoL questionnaires. We determined differences in QoL domain scores for four primary variables: clinical deterioration (death, cardiac arrest, respiratory failure, hypotension requiring fluid bolus, catecholamine support, or new dysrhythmia), right ventricular dysfunction (RVD), PE risk stratification, and subsequent rehospitalization. For overall QoL score, we fit a multivariable regression model that included these four primary variables as independent variables. RESULTS Of 788 PE patients participating in QoL assessments, 156 (19.8%) had a clinical deterioration event, 236 (30.7%) had RVD of which 38 (16.1%) had escalated interventions. For those without and with clinical deterioration, social limitations had mean (±SD) scores of 2.07 (±1.27) and 2.36 (±1.47), respectively (p = 0.027). For intensity of complaints, mean (±SD) scores for patients without RVD (4.32 ± 2.69) were significantly higher than for those with RVD with or without reperfusion interventions (3.82 ± 1.81 and 3.83 ± 2.11, respectively; p = 0.043). There were no domain score differences between PE risk stratification groups. All domain scores were worse for patients with rehospitalization versus without. By multivariable analysis, worse total PEmb-QoL scores with effect sizes were subsequent rehospitalization 11.29 (6.68-15.89), chronic obstructive pulmonary disease (COPD) 8.17 (3.91-12.43), and longer index hospital length of stay 0.06 (0.03-0.08). CONCLUSIONS Acute clinical deterioration, RVD, and PE severity were not predictors of QoL at 1 month post-PE. Independent predictors of worsened QoL were rehospitalization, COPD, and index hospital length of stay.
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Affiliation(s)
- Anthony J Weekes
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Jillian Davison
- Department of Emergency Medicine, Orlando Health, Orlando, Florida, USA
| | - Kathryn Lupez
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Department of Emergency Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jaron D Raper
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Alyssa M Thomas
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Emergency Department, Houston Methodist Baytown Hospital, Houston, Texas, USA
| | - Carly A Cox
- Department of Emergency Medicine, Atrium Health's Carolinas Medical Center, Charlotte, North Carolina, USA
- Emergency Medicine of Idaho, Meridian, Idaho, USA
| | - Dasia Esener
- Department of Emergency Medicine, Kaiser Permanente, San Diego, California, USA
| | - Jeremy S Boyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jason T Nomura
- Department of Emergency Medicine, Christiana Care, Newark, Delaware, USA
| | - Kathleen Murphy
- Department of Emergency Medicine, Christiana Care, Newark, Delaware, USA
| | - Patrick M Ockerse
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Stephen Leech
- Department of Emergency Medicine, Orlando Health, Orlando, Florida, USA
| | - Jakea Johnson
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric Abrams
- Department of Emergency Medicine, Kaiser Permanente, San Diego, California, USA
| | - Christopher Kelly
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Nathaniel S O'Connell
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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28
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Pallares Robles A, Ten Cate V, Lenz M, Schulz A, Prochaska JH, Rapp S, Koeck T, Leineweber K, Heitmeier S, Opitz CF, Held M, Espinola-Klein C, Lackner KJ, Münzel T, Konstantinides SV, Ten Cate-Hoek A, Ten Cate H, Wild PS. Unsupervised clustering of venous thromboembolism patients by clinical features at presentation identifies novel endotypes that improve prognostic stratification. Thromb Res 2023:S0049-3848(23)00124-X. [PMID: 37202285 DOI: 10.1016/j.thromres.2023.04.023] [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: 02/23/2023] [Revised: 04/20/2023] [Accepted: 04/28/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Individuals with acute venous thromboembolism (VTE) constitute a heterogeneous group of patients with diverse clinical characteristics and outcome. OBJECTIVES To identify endotypes of individuals with acute VTE based on clinical characteristics at presentation through unsupervised cluster analysis and to evaluate their molecular proteomic profile and clinical outcome. METHODS Data from 591 individuals from the Genotyping and Molecular phenotyping of Venous thromboembolism (GMP-VTE) project were explored. Hierarchical clustering was applied to 58 variables to define VTE endotypes. Clinical characteristics, three-year incidence of thromboembolic events or death, and acute-phase plasma proteomics were assessed. RESULTS Four endotypes were identified, exhibiting different patterns of clinical characteristics and clinical course. Endotype 1 (n = 300), comprising older individuals with comorbidities, had the highest incidence of thromboembolic events or death (HR [95 % CI]: 3.76 [1.96-7.19]), followed by endotype 4 (n = 127) (HR [95 % CI]: 2.55 [1.26-5.16]), characterised by men with history of VTE and provoking risk factors, and endotype 3 (n = 57) (HR [95 % CI]: 1.57 [0.63-3.87]), composed of young women with provoking risk factors, vs. reference endotype 2 (n = 107). The reference endotype was constituted by individuals diagnosed with PE without comorbidities, who had the lowest incidence of the investigated endpoint. Differentially expressed proteins associated with the endotypes were related to distinct biological processes, supporting differences in molecular pathophysiology. The endotypes had superior prognostic ability compared to existing risk stratifications such as provoked vs unprovoked VTE and D-dimer levels. CONCLUSION Four endotypes of VTE were identified by unsupervised phenotype-based clustering that diverge in clinical outcome and plasmatic protein signature. This approach might support the future development of individualized treatment in VTE.
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Affiliation(s)
- Alejandro Pallares Robles
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Germany; Departments of Internal Medicine and Biochemistry, Thrombosis Expertise Center, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Vincent Ten Cate
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Germany; Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Michael Lenz
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Andreas Schulz
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Jürgen H Prochaska
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Germany; Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Steffen Rapp
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Thomas Koeck
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | | | | | | | - Matthias Held
- Department of Internal Medicine, Medical Mission Hospital, Academic Teaching Hospital, Würzburg, Germany
| | - Christine Espinola-Klein
- Center for Cardiology-Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Karl J Lackner
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Thomas Münzel
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Germany; Center for Cardiology-Cardiology I, 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
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Arina Ten Cate-Hoek
- Departments of Internal Medicine and Biochemistry, Thrombosis Expertise Center, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Hugo Ten Cate
- Departments of Internal Medicine and Biochemistry, Thrombosis Expertise Center, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Philipp S Wild
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Germany; Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Germany; Institute of molecular biology (IMB), Mainz, Germany.
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Komatsu S, Takahashi S, Yutani C, Ohara T, Takewa M, Kodama K. Angioscopy-Guided Selective Pulmonary Thrombectomy and Angioscopy-Monitored Systemic Thrombosis for a Pulmonary Embolism. Cureus 2023; 15:e38365. [PMID: 37139049 PMCID: PMC10150236 DOI: 10.7759/cureus.38365] [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] [Accepted: 04/30/2023] [Indexed: 05/05/2023] Open
Abstract
Few modalities have the capacity to demonstrate massive or fragmented thrombi to evaluate the effect of catheter-based or systemic thrombosis for pulmonary embolism (PE). We herein present a patient who underwent a thrombectomy for PE using a non-obstructive general angioscopy (NOGA) system. Small floating mobile thrombi were aspirated using the original method, and massive thrombi were aspirated using the NOGA system. Systemic thrombosis was also monitored via NOGA for 30 minutes. Detachment of thrombi from the wall of the pulmonary artery began two minutes after infusion of a recombinant tissue plasminogen activator (rt-PA). Six minutes after thrombolysis, the thrombi lost their erythematous color, and the white thrombi gradually floated and dissolved. NOGA-guided selective pulmonary thrombectomy and NOGA-monitored systemic thrombosis contributed to improved patient survival. Rapid systemic thrombosis for PE using rt-PA was also demonstrated by NOGA.
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Affiliation(s)
- Sei Komatsu
- Cardiovascular Center, Osaka Gyoumeikan Hospital, Osaka, JPN
| | | | - Chikao Yutani
- Cardiovascular Center, Osaka Gyoumeikan Hospital, Osaka, JPN
| | - Tomoki Ohara
- Cardiovascular Center, Osaka Gyoumeikan Hospital, Osaka, JPN
| | | | - Kazuhisa Kodama
- Cardiovascular Center, Osaka Gyoumeikan Hospital, Osaka, JPN
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Gkena N, Kirgou P, Gourgoulianis KI, Malli F. Mental Health and Quality of Life in Pulmonary Embolism: A Literature Review. Adv Respir Med 2023; 91:174-184. [PMID: 37102782 PMCID: PMC10135604 DOI: 10.3390/arm91020015] [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: 01/15/2023] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 04/28/2023]
Abstract
Pulmonary embolismis an acute disease with chronic complications and, although it is not considered a chronic disease, it requires close follow-up. The scope of the present literature review is to decode the existing data concerning quality of life and the mental health impact of PE during the acute and long-term phases of the disease. The majority of studies reported impaired quality of life in patients with PE when compared to population norms, both in the acute phase and >3 months after PE. Quality of life improves over time, irrespectively of the measurement used. Fear of recurrences, elderly, stroke, obesity, cancer and cardiovascular comorbidities are independently associated with worse QoL at follow-up. Although disease specific instruments exist (e.g., the Pulmonary Embolism Quality of Life questionnaire), further research is required in order to develop questionnaires that may fulfil international guideline requirements. The fear of recurrences and the development of chronic symptoms, such as dyspnea or functional limitations, may further impair the mental health burden of PE patients. Mental health may be implicated by post-traumatic stress disorder, anxiety and depressive symptoms present following the acute event. Anxiety may persist for 2 years following diagnosis and may be exaggerated by persistent dyspnea and functional limitations. Younger patients are at higher risk of anxiety and trauma symptoms while elderly patients and patients with previous cardiopulmonary disease, cancer, obesity or persistent symptoms exhibit more frequently impaired QoL. The optimal strategy for the assessment of mental health in this patient pool is not well defined in the literature. Despite mental burden being common following a PE event, current guidelines have not incorporated the assessment or management of mental health issues. Further studies are warranted to longitudinally assess the psychological burden and elucidate the optimal follow-up approach.
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Affiliation(s)
- Niki Gkena
- Respiratory Disorders Lab, Faculty of Nursing, University of Thessaly, Gaiopolis, 41500 Larissa, Greece
| | - Paraskevi Kirgou
- Respiratory Disorders Lab, Faculty of Nursing, University of Thessaly, Gaiopolis, 41500 Larissa, Greece
- Respiratory Medicine Department, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | - Konstantinos I Gourgoulianis
- Respiratory Medicine Department, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | - Foteini Malli
- Respiratory Disorders Lab, Faculty of Nursing, University of Thessaly, Gaiopolis, 41500 Larissa, Greece
- Respiratory Medicine Department, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, 41110 Larissa, Greece
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Assessment of sST2 Behaviors to Evaluate Severity/Clinical Impact of Acute Pulmonary Embolism. Int J Mol Sci 2023; 24:ijms24054591. [PMID: 36902022 PMCID: PMC10002919 DOI: 10.3390/ijms24054591] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/04/2023] [Accepted: 02/07/2023] [Indexed: 03/03/2023] Open
Abstract
Pulmonary embolism (PE) is a potentially life-threatening disorder. Beyond its usefulness in the prognostic stratification of heart failure, sST2 can represent a biomarker with high utility in several acute conditions. Our study was aimed to investigate whether sST2 can be used as a clinical marker of severity and prognostic outcome in acute PE. We enrolled 72 patients with documented PE and 38 healthy subjects; we measured the plasma concentrations of sST2 to evaluate the prognostic and severity performance of different levels of sST2 according to its association with the pulmonary embolism severity index (PESI) score and several parameters of respiratory function. PE patients had significantly higher levels of sST2 compared with healthy subjects (87.74 ± 17.1 vs. 17.1 ± 0.4 ng/mL, p < 0.001); we found higher PESI scores and serum lactate values in the group of patients with sST2 > 35 ng/mL compared with patients with sST2 < 35 ng/mL (138.7 ± 14.9 vs. 103.7 ± 15.1 and 2.43 ± 0.69 vs. 1.025 ± 0.05 mmol/L, respectively; p < 0.05). Patients with sST2 > 35 ng/mL showed higher radiological severity of PE compared with patients with sST2 < 35 ng/mL. Moreover, sST2 was the strongest parameter with a discriminative capacity for the development of acute respiratory failure and a PESI score >106 with respect to C reactive protein (CRP), creatinine, d-dimer, and serum lactate. We clearly demonstrated that sST2 significantly increased in PE and that its elevation was associated with disease severity. Therefore, sST2 may be used as a clinical marker in the evaluation of PE severity. However, further studies with larger patient populations are required to confirm these findings.
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Plasma Troponins Identify Patients with Very Low-Risk Acute Pulmonary Embolism. J Clin Med 2023; 12:jcm12041276. [PMID: 36835814 PMCID: PMC9963057 DOI: 10.3390/jcm12041276] [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: 12/27/2022] [Revised: 01/29/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023] Open
Abstract
INTRODUCTION Although in the non-vitamin K oral anticoagulants (NOAC) era majority of low-risk acute pulmonary embolism (APE) patients can be treated at home, identifying those at very low risk of clinical deterioration may be challenging. We aimed to propose the risk stratification algorithm in sPESI 0 point APE patients, allowing them to select candidates for safe outpatient treatment. MATERIALS AND METHODS Post hoc analysis of a prospective study of 1151 normotensive patients with at least segmental APE. In the final analysis, we included 409 sPESI 0 point patients. Cardiac troponin assessment and echocardiographic examination were performed immediately after admission. Right ventricular dysfunction was defined as the right ventricle/left ventricle ratio (RV/LV) > 1.0. The clinical endpoint (CE) included APE-related mortality and/or rescue thrombolysis and/or immediate surgical embolectomy in patients with clinical deterioration. RESULTS CE occurred in four patients who had higher serum troponin levels than subjects with a favorable clinical course (troponin/ULN: 7.8 (6.4-9.4) vs. 0.2 (0-1.36) p = 0.000). Receiver operating characteristic (ROC) analysis showed that the area under the curve for troponin in the prediction of CE was 0.908 (95% CI 0.831-0.984; p < 0.001). We defined the cut-off value of troponin at >1.7 ULN with 100% PPV for CE. In univariate and multivariate analysis, elevated serum troponin level was associated with an increased risk of CE, whereas RV/LV > 1.0 was not. CONCLUSIONS Solely clinical risk assessment in APE is insufficient, and patients with sPESI 0 points require further assessment based on myocardial damage biomarkers. Patients with troponin levels not exceeding 1.7 ULN constitute the group of "very low risk" with a good prognosis.
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Predictive Ability of the National Early Warning Score in Mortality Prediction of Acute Pulmonary Embolism in the Southeast Asian Population. J Cardiovasc Dev Dis 2023; 10:jcdd10020060. [PMID: 36826556 PMCID: PMC9960332 DOI: 10.3390/jcdd10020060] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/26/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The National Early Warning Scores (NEWS) easily and objectively measures acute clinical deterioration. However, the performance of NEWS to predict mortality in patients with acute pulmonary embolism (APE) is still required. Therefore, the objective of this study was to evaluate the performance of the NEWS in predicting the mortality of patients with APE. METHODS NEWS and Pulmonary Embolism Severity Index (PESI) at diagnosis time were calculated. Risk regression analysis was performed to identify the NEWS and PESI risk classification as a predictor for 30 days all-cause mortality and PE-related mortality. RESULTS NEWS was significantly higher in non-survivors compared to survivors (median (IQR) was 10 (7, 11) vs. 7 (2, 9), respectively, p < 0.001). The best cut-off point of NEWS in discriminating APE patients who non-survived from those who survived at 30 days was ≥9, with a sensitivity and specificity of 66.9% and 66.3%, respectively. The adjusted risk ratio of 30-day all-cause mortality in patients with initial NEWS ≥ 9 was 2.96 (95% CI; 2.13, 4.12, p < 0.001). CONCLUSIONS The NEWS can be used for mortality prediction in patients with APE. APE patients with NEWS ≥ 9 are associated with a high risk of mortality and should be closely monitored.
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Zhang W, Ding Y. Impact of obstructive sleep apnea on outcomes of pulmonary embolism: A systematic review and meta‑analysis. Exp Ther Med 2023; 25:120. [PMID: 36815968 PMCID: PMC9932632 DOI: 10.3892/etm.2023.11819] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 01/10/2023] [Indexed: 02/04/2023] Open
Abstract
The current review aimed to assess the effect of obstructive sleep apnea (OSA) on the severity and outcomes of pulmonary embolism (PE). PubMed, Embase, ScienceDirect, CENTRAL and Google Scholar were searched for studies assessing the impact of OSA on severity and outcomes of PE. A total of 12 studies were included. Meta-analysis revealed that simplified PE severity index of >1 and pulmonary artery obstruction index score was significantly higher in patients with OSA as compared with controls, but there was no difference in right ventricle to left ventricle short-axis diameter. The need for non-invasive ventilation was significantly higher in patients with OSA but there was no difference in the need for mechanical ventilation. Patients with OSA had a significantly higher incidence of recurrence of PE. Meta-analysis also showed a statistically significantly lower risk of in-hospital mortality in patients with OSA as compared with controls, but without any difference in the risk of late mortality. Adjusted data on mortality indicated a significantly lower risk of mortality in PE patients with comorbid OSA. Limited data shows that comorbid OSA increases the severity of PE but has no effect on right ventricular function. OSA may increase the risk of recurrent PE. Paradoxically, the presence of OSA may also reduce the risk of in-hospital mortality. Results must be interpreted with caution owing to high inter-study heterogeneity and lack of matching of baseline characteristics. Current evidence needs to be confirmed by high-quality prospective studies.
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Affiliation(s)
- Wen Zhang
- Department of Pulmonary and Critical Care Medicine, Shengzhou People's Hospital (The First Affiliated Hospital of Zhejiang University Shengzhou Branch) Shengzhou, Zhejiang 312400, P.R. China
| | - Yongmin Ding
- Department of Pulmonary and Critical Care Medicine, Shengzhou People's Hospital (The First Affiliated Hospital of Zhejiang University Shengzhou Branch) Shengzhou, Zhejiang 312400, P.R. China,Correspondence to: Dr Yongmin Ding, Department of Pulmonary and Critical Care Medicine, Shengzhou People's Hospital (The First Affiliated Hospital of Zhejiang University Shengzhou Branch), 666 Dangui Road, Shengzhou, Zhejiang 312400, P.R. China
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Utility of Combining High-Sensitive Cardiac Troponin I and PESI Score for Risk Management in Patients with Pulmonary Embolism in the Emergency Department. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020185. [PMID: 36837387 PMCID: PMC9968180 DOI: 10.3390/medicina59020185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/29/2022] [Accepted: 01/09/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Pulmonary embolism (PE) has a major burden of morbidity and mortality, consequently the need for a prompt risk stratification for these subjects is crucial. In order to evaluate the risk management and final disposition of patients with PE in the Emergency Department (ED), we conducted a study that was divided in two phases: Phase I retrospective study (RS), Phase II prospective study (PS). MATERIALS AND METHODS In Phase I, 291 patients were enrolled while in Phase II, 83 subjects were evaluated. In both study phases, the enrolled subjects were analyzed for final disposition in ED using PESI score, right ventricle (RV) imaging, and high-sensitive cardiac troponin I (hs-cTnI) data. The RS patients were divided into low risk and high risk according to the sPESI score, while PS patients were grouped in low, intermediate, and high risk classes according to PESI score. In both study phases, all the studied patients were further divided into negative (hs-cTnI-) or positive (hs-cTnI+) groups according to hs-cTnI levels within normal or above cutoff values, respectively. For all enrolled subjects, CT pulmonary angiography was analyzed to assess the RV/LV diameter and volume ratio as an indicator of RV involvement. RESULTS In both RS and PS phases, hs-cTnI+ group showed a higher PESI score. Nevertheless, a significant percentage of hs-cTnI+ patients resulted to be in the low-risk PESI class. Patients with a positive RV/LV ratio were more likely to have a hs-cTnI+ (p < 0.01), while among those with a negative ratio, 24 to 32% showed as hs-cTnI+. In the hs-cTnI+ group from both study phases, patients were more likely to be admitted in an ICU (RR 3.7, IC: 2.1-6.5). CONCLUSIONS In conclusion, in patients with PE in the ED compared PESI score alone, the combination of hs-cTnI and PESI seems to be of greater utility in improving risk stratification and final disposition decision-making.
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36
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Oh JK, Park JH. Role of echocardiography in acute pulmonary embolism. Korean J Intern Med 2023:kjim.2022.273. [PMID: 36587934 DOI: 10.3904/kjim.2022.273] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/28/2022] [Indexed: 01/03/2023] Open
Abstract
Although pulmonary embolism (PE)-related mortality rate has decreased because of prompt diagnosis and effective therapy use, acute PE remains a potentially lethal disease. Due to its increasing prevalence, clinicians should pay attention to diagnosing and managing patients with acute PE. Echocardiography is the most commonly used method for diagnosing and managing acute PE; it also provides clues about hemodynamic instability in an emergency situation. It has been validated in the early risk stratification and impacts management strategies for treating acute PE. In hemodynamically unstable patients with acute PE, echocardiographic detection of right ventricular dysfunction is an indication for administering thrombolytics. In this review article, we discuss the role of echocardiography in the diagnosis and management of patients with acute PE.
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Affiliation(s)
- Jin Kyung Oh
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong, Korea
| | - Jae-Hyeong Park
- Department of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
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Serebriakoff P, Cafferkey J, de Wit K, Horner DE, Reed MJ. Pulmonary embolism management in the emergency department: part 2. J Accid Emerg Med 2023; 40:69-75. [PMID: 35383107 DOI: 10.1136/emermed-2021-212001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 03/20/2022] [Indexed: 01/10/2023]
Abstract
Pulmonary embolism (PE) can present with a range of severity. Prognostic risk stratification is important for efficacious and safe management. This second of two review articles discusses the management of high-, intermediate- and low-risk PE. We discuss strategies to identify patients suitable for urgent outpatient care in addition to identification of patients who would benefit from thrombolysis. We discuss specific subgroups of patients where optimal treatment differs from the usual approach and identify emerging management paradigms exploring new therapies and subgroups.
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Affiliation(s)
| | - John Cafferkey
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, Ontario, Canada
| | - Daniel E Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, UK
| | - Matthew J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), NHS Lothian, Edinburgh, UK .,Acute Care Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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Su H, Han Z, Fu Y, Zhao D, Yu F, Heidari AA, Zhang Y, Shou Y, Wu P, Chen H, Chen Y. Detection of pulmonary embolism severity using clinical characteristics, hematological indices, and machine learning techniques. Front Neuroinform 2022; 16:1029690. [PMID: 36590906 PMCID: PMC9800512 DOI: 10.3389/fninf.2022.1029690] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
Introduction Pulmonary embolism (PE) is a cardiopulmonary condition that can be fatal. PE can lead to sudden cardiovascular collapse and is potentially life-threatening, necessitating risk classification to modify therapy following the diagnosis of PE. We collected clinical characteristics, routine blood data, and arterial blood gas analysis data from all 139 patients. Methods Combining these data, this paper proposes a PE risk stratified prediction framework based on machine learning technology. An improved algorithm is proposed by adding sobol sequence and black hole mechanism to the cuckoo search algorithm (CS), called SBCS. Based on the coupling of the enhanced algorithm and the kernel extreme learning machine (KELM), a prediction framework is also proposed. Results To confirm the overall performance of SBCS, we run benchmark function experiments in this work. The results demonstrate that SBCS has great convergence accuracy and speed. Then, tests based on seven open data sets are carried out in this study to verify the performance of SBCS on the feature selection problem. To further demonstrate the usefulness and applicability of the SBCS-KELM framework, this paper conducts aided diagnosis experiments on PE data collected from the hospital. Discussion The experiment findings show that the indicators chosen, such as syncope, systolic blood pressure (SBP), oxygen saturation (SaO2%), white blood cell (WBC), neutrophil percentage (NEUT%), and others, are crucial for the feature selection approach presented in this study to assess the severity of PE. The classification results reveal that the prediction model's accuracy is 99.26% and its sensitivity is 98.57%. It is expected to become a new and accurate method to distinguish the severity of PE.
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Affiliation(s)
- Hang Su
- College of Computer Science and Technology, Changchun Normal University, Changchun, Jilin, China
| | - Zhengyuan Han
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yujie Fu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Dong Zhao
- College of Computer Science and Technology, Changchun Normal University, Changchun, Jilin, China,*Correspondence: Dong Zhao,
| | - Fanhua Yu
- College of Computer Science and Technology, Changchun Normal University, Changchun, Jilin, China
| | - Ali Asghar Heidari
- School of Surveying and Geospatial Engineering, College of Engineering, University of Tehran, Tehran, Iran
| | - Yu Zhang
- College of Computer Science and Technology, Changchun Normal University, Changchun, Jilin, China
| | - Yeqi Shou
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peiliang Wu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Huiling Chen
- College of Computer Science and Artificial Intelligence, Wenzhou University, Wenzhou, Zhejiang, China,Huiling Chen,
| | - Yanfan Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China,Yanfan Chen,
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Pulmonary Embolism Severity Index Predicts Adverse Events in Hospitalized COVID-19 Patients: A Retrospective Observational Study. J Cardiothorac Vasc Anesth 2022; 36:4403-4409. [PMID: 36155716 PMCID: PMC9391081 DOI: 10.1053/j.jvca.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/04/2022] [Accepted: 08/12/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES Pulmonary embolism is one of the leading causes of death in patients with COVID-19. Autopsy findings showed that the incidence of thromboembolic events was higher than clinically suspected. In this study, the authors investigated the relationship between pulmonary embolism severity index (PESI) and simplified PESI (sPESI) on admission to the hospital, as well as adverse events in hospitalized COVID-19 patients without clinically documented venous and/or pulmonary embolism. The adverse events investigated were the development of acute respiratory distress syndrome, the need for intensive care unit admission, invasive or noninvasive mechanical ventilation, and in-hospital mortality. DESIGN A retrospective and observational study. SETTING Two large-volume tertiary hospitals in the same city. PARTICIPANTS A total of 720 hospitalized COVID-19 patients with a positive polymerase chain reaction were evaluated. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the study population, 48.6% (350) were women, and the median age was 66 years (19-96). The overall in-hospital mortality rate was 20.5%. In the multivariate logistic regression analysis, a significant relationship was found between the whole adverse events considered and PESI, as well as sPESI (p < 0.001). According to the results, sPESI ≥2 predicts in-hospital mortality with a sensitivity of 61.4% and specificity of 83.3% (area under the curve = 0.817, 95% confidence interval 0.787-0.845, p < 0.001). Similarly, PESI classes IV and V also were found as independent risk factors for in-hospital mortality (for PESI class IV, odds ratio = 2.81, p < 0.017; for PESI class V, odds ratio = 3.94, p < 0.001). CONCLUSIONS PESI and sPESI scoring systems were both found to be associated with adverse events, and they can be used to predict in-hospital mortality in hospitalized COVID-19 patients without documented venous and/or pulmonary embolism.
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Lasica R, Asanin M, Djukanovic L, Radovanovic N, Savic L, Polovina M, Stankovic S, Ristic A, Zdravkovic M, Lasica A, Kravic J, Perunicic J. Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application. Pharmaceuticals (Basel) 2022; 15:ph15091146. [PMID: 36145366 PMCID: PMC9501350 DOI: 10.3390/ph15091146] [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: 08/04/2022] [Revised: 09/03/2022] [Accepted: 09/06/2022] [Indexed: 11/24/2022] Open
Abstract
Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.
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Affiliation(s)
- Ratko Lasica
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Correspondence:
| | - Milika Asanin
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lazar Djukanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nebojsa Radovanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lidija Savic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marija Polovina
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Sanja Stankovic
- Center for Medical Biochemistry, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Arsen Ristic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | | | | | - Jelena Kravic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Jovan Perunicic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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Machanahalli Balakrishna A, Reddi V, Belford PM, Alvarez M, Jaber WA, Zhao DX, Vallabhajosyula S. Intermediate-Risk Pulmonary Embolism: A Review of Contemporary Diagnosis, Risk Stratification and Management. Medicina (B Aires) 2022; 58:medicina58091186. [PMID: 36143863 PMCID: PMC9504600 DOI: 10.3390/medicina58091186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/25/2022] Open
Abstract
Pulmonary embolism (PE) can have a wide range of hemodynamic effects, from asymptomatic to a life-threatening medical emergency. Pulmonary embolism (PE) is associated with high mortality and requires careful risk stratification for individualized management. PE is divided into three risk categories: low risk, intermediate-risk, and high risk. In terms of initial therapeutic choice and long-term management, intermediate-risk (or submassive) PE remains the most challenging subtype. The definitions, classifications, risk stratification, and management options of intermediate-risk PE are discussed in this review.
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Affiliation(s)
| | - Vuha Reddi
- Department of Medicine, Danbury Hospital/Yale University School of Medicine, Danbury, CT 06810, USA
| | - Peter Matthew Belford
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
| | - Manrique Alvarez
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
| | - Wissam A. Jaber
- Section of Cardiovascular Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30307, USA
| | - David X. Zhao
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
- Department of Implementation Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC 27262, USA
- Correspondence: ; Tel.: +1-(336)-878-6000
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Keskin B, Tokgöz HC, Akbal ÖY, Hakgör A, Karagöz A, Kültürsay B, Tanyeri S, Külahçıoğlu S, Halil Tanboğa İ, Özdemir N, Kaymaz C. Clinical, imaging and hemodynamic correlates and prognostic impact of syncope in acute pulmonary embolism: A single-center study. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2022; 30:317-326. [PMID: 36303697 PMCID: PMC9580286 DOI: 10.5606/tgkdc.dergisi.2022.22798] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/28/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND We aimed to determine the clinical, echocardiographic and hemodynamic correlates of syncope as a presenting symptom in pulmonary embolism and its impact on in-hospital and long-term outcomes. METHODS Between July 2012 and October 2019, a total of 641 patients with PE (277 males, 364 females; median age: 65 years; range, 51 to 74 years) in whom the diagnostic work-up and risk-based management were performed according to the current pulmonary embolism guidelines were retrospectively analyzed. Clinical, laboratory and imaging data of the patients were obtained from hospital database system. RESULTS Syncope was noted in 193 (30.2%) of patients on admission, and was associated with a significantly higher-risk status manifested by elevated troponin and D-dimer levels, a higher Pulmonary Embolism Severity Index scores, deterioration of right-to-left ventricular diameter ratio, right ventricular longitudinal contraction measures, the higher Qanadli score, and higher rates of thrombolytic therapies (p<0.001) and rheolytic-thrombectomy (p=0.037) therapies. In-hospital mortality (p=0.007) and minor bleeding (p<0.001) were significantly higher in syncope subgroup. Multivariate logistic regression analysis showed that higher Pulmonary Embolism Severity Index scores and right-to-left ventricular diameter ratio were independently associated with syncope, while aging and increased heart rate predicted in-hospital mortality. Malignancy and right-to-left ventricular diameter ratio at discharge, but not syncope, were independent predictors of cumulative mortality during follow-up. CONCLUSION Syncope as the presenting symptom is associated with a higher risk due to more severe obstructive pressure load and right ventricular dysfunction requiring more proactive strategies in patients with pulmonary embolism. However, with appropriate risk-based therapies, neither in-hospital mortality nor long-term mortality can be predicted by syncope.
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Affiliation(s)
- Berhan Keskin
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu High Specialization Training and Research Hospital, Istanbul, Türkiye
| | - Hacer Ceren Tokgöz
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu High Specialization Training and Research Hospital, Istanbul, Türkiye
| | - Özgür Yaşar Akbal
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu High Specialization Training and Research Hospital, Istanbul, Türkiye
| | - Aykun Hakgör
- Department of Cardiology, Medipol Mega University Hospital, Istanbul, Türkiye
| | - Ali Karagöz
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu High Specialization Training and Research Hospital, Istanbul, Türkiye
| | - Barkın Kültürsay
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu High Specialization Training and Research Hospital, Istanbul, Türkiye
| | - Seda Tanyeri
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu High Specialization Training and Research Hospital, Istanbul, Türkiye
| | - Seyhmuş Külahçıoğlu
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu High Specialization Training and Research Hospital, Istanbul, Türkiye
| | | | - Nihal Özdemir
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu High Specialization Training and Research Hospital, Istanbul, Türkiye
| | - Cihangir Kaymaz
- Department of Cardiology, University of Health Sciences, Kartal Koşuyolu High Specialization Training and Research Hospital, Istanbul, Türkiye
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van Royen FS, Moons KGM, Geersing GJ, van Smeden M. Developing, validating, updating and judging the impact of prognostic models for respiratory diseases. Eur Respir J 2022; 60:13993003.00250-2022. [PMID: 35728976 DOI: 10.1183/13993003.00250-2022] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 05/27/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Florien S van Royen
- Dept. General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Karel G M Moons
- Dept. Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Geert-Jan Geersing
- Dept. General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Maarten van Smeden
- Dept. Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Weekes AJ, Fraga DN, Belyshev V, Bost W, Gardner CA, O’Connell NS. Intermediate-risk pulmonary embolism: echocardiography predictors of clinical deterioration. Crit Care 2022; 26:160. [PMID: 35659340 PMCID: PMC9166499 DOI: 10.1186/s13054-022-04030-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 05/23/2022] [Indexed: 12/26/2022] Open
Abstract
Background We determine the predictive value of transthoracic echocardiographic (TTE) metrics for clinical deterioration within 5 days in adults with intermediate-risk pulmonary embolism (PE). Methods This was a prospective observational study of intermediate-risk PE patients. To determine associations of TTE and clinical predictors with clinical deterioration, we used univariable analysis, Youden’s index for optimal thresholds, and multivariable analyses to report odds ratios (ORs) or area under the curve (AUC). Results Of 306 intermediate-risk PE patients, 115 (37.6%) experienced clinical deterioration. PE patients who had clinical deterioration within 5 days had greater baseline right ventricle (RV) dilatation and worse systolic function than the group without clinical deterioration as indicated by the following: RV basal diameter 4.46 ± 0.77 versus 4.20 ± 0.77 cm; RV/LV basal width ratio 1.14 ± 0.29 versus 1.02 ± 0.24; tricuspid annular plane systolic excursion (TAPSE) 1.56 ± 0.55 versus 1.80 ± 0.52 cm; and RV systolic excursion velocity 10.40 ± 3.58 versus 12.1 ± 12.5 cm/s, respectively. Optimal thresholds for predicting clinical deterioration were: RV basal width 3.9 cm (OR 2.85 [1.64, 4.97]), RV-to-left ventricle (RV/LV) ratio 1.08 (OR 3.32 [2.07, 5.33]), TAPSE 1.98 cm (OR 3.3 [2.06, 5.3]), systolic excursion velocity 10.10 cm/s (OR 2.85 [1.75, 4.63]), and natriuretic peptide 190 pg/mL (OR 2.89 [1.81, 4.62]). Significant independent predictors were: transient hypotension 6.1 (2.2, 18.9), highest heart rate 1.02 (1.00, 1.03), highest respiratory rate 1.02 (1.00, 1.04), and RV/LV ratio 1.29 (1.14, 1.47). By logistic regression and random forest analyses, AUCs were 0.80 (0.73, 0.87) and 0.78 (0.70, 0.85), respectively. Conclusions Basal RV, RV/LV ratio, and RV systolic function measurements were significantly different between intermediate-risk PE patients grouped by subsequent clinical deterioration. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04030-z.
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Wang Y, Feng Y, Yang X, Mao H. Prognostic role of elevated lactate in acute pulmonary embolism: A systematic review and meta-analysis. Phlebology 2022; 37:338-347. [PMID: 35282737 DOI: 10.1177/02683555221081818] [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: 11/16/2022]
Abstract
BACKGROUND Previous studies have shown elevated lactate was a good predictor for the prognosis of pulmonary embolism (PE). However, due to low number of patients and different expression of blood lactate in separate study, these results are inconsistent. Therefore, the aim of this meta-analysis is to evaluate the relationship between increased lactate levels and adverse outcome in acute PE. METHOD The literatures search was conducted in PubMed, Web of Science, and EMBASE until May 29, 2021. RESULTS Finally, 6 studies with 1706 patients were included in our meta-analysis. High lactate levels were markedly associated with overall mortality both in unselected PE patients (OR 5.13, 95% CI: 3.36-7.86, p < .00,001) and normotensive PE patients (OR 4.54, 95% CI: 2.64-7.80, p < .00,001), and PE-related short-term mortality in patients with elevated lactate was significantly higher than that in patients with normal levels (OR 9.05, 95% CI :4.08-20.10, p < .00,001). The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of lactate for predicting overall mortality in patients with acute PE were 0.67 (95% CI: 0.43-0.85), 0.73 (95% CI: 0.60-0.83), 2.5 (95% CI: 2.0-3.1), and 0.45 (95% CI: 0.26-0.78), respectively. The area under SROC curve (AUC) was 0.76 (95% CI: 0.73-0.80). CONCLUSION The result of our meta-analysis indicate that elevated blood lactate is a good predictor for overall mortality and short-term mortality in patients with acute PE, and can be routinely measured in risk stratification, but its prognostic role in patients with different risk classes still need to be verified.
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Affiliation(s)
- Yubin Wang
- Department of Respiratory and Critical Care Medicine, 34753West China Hospital, Sichuan University, Chengdu, China
| | - Yinhe Feng
- Department of Respiratory and Critical Care Medicine, People's Hospital of Deyang City, Deyang, China
| | - Xiaoya Yang
- Department of Respiratory and Critical Care Medicine, 34753West China Hospital, Sichuan University, Chengdu, China
| | - Hui Mao
- Department of Respiratory and Critical Care Medicine, 34753West China Hospital, Sichuan University, Chengdu, China
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Jang J, Koo SM, Kim KU, Kim YK, Uh ST, Jang GE, Chang W, Lee BY. Clinical experiences of high-risk pulmonary thromboembolism receiving extracorporeal membrane oxygenation in single institution. Tuberc Respir Dis (Seoul) 2022; 85:249-255. [PMID: 35645168 PMCID: PMC9263344 DOI: 10.4046/trd.2022.0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/10/2022] [Indexed: 11/24/2022] Open
Abstract
Background The main cause of death in pulmonary embolism (PE) is right-heart failure due to acute pressure overload. In this sense, extracorporeal membrane oxygenation (ECMO) might be useful in maintaining hemodynamic stability and improving organ perfusion. Some previous studies have reported ECMO as a bridge to reperfusion therapy of PE. However, little is known about the patients that benefit from ECMO. Methods Patients who underwent ECMO due to pulmonary thromboembolism at a single university-affiliated hospital between January 2010 and December 2018 were retrospectively reviewed. Results During the study period, nine patients received ECMO in high-risk PE. The median age of the patients was 60 years (range, 22–76 years), and six (66.7%) were male. All nine patients had cardiac arrests, of which three occurred outside the hospital. All the patients received mechanical support with veno-arterial ECMO, and the median ECMO duration was 1.1 days (range, 0.2–14.0 days). ECMO with anticoagulation alone was performed in six (66.7%), and ECMO with reperfusion therapy was done in three (33.3%). The 30-day mortality rate was 77.8%. The median time taken from the first cardiac arrest to initiation of ECMO was 31 minutes (range, 30–32 minutes) in survivors (n=2) and 65 minutes (range, 33–482 minutes) in non-survivors (n=7). Conclusion High-risk PE with cardiac arrest has a high mortality rate despite aggressive management with ECMO and reperfusion therapy. Early decision to start ECMO and its rapid initiation might help save those with cardiac arrest in high-risk PE.
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Affiliation(s)
- Joonyong Jang
- Department of Internal Medicine, Soonchunhyang University Seoul hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - So-My Koo
- Division of Respiratory-Allergy Medicine, Department of Internal Medicine, Soonchunhyang University Seoul hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Ki-Up Kim
- Division of Respiratory-Allergy Medicine, Department of Internal Medicine, Soonchunhyang University Seoul hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Yang-Ki Kim
- Division of Respiratory-Allergy Medicine, Department of Internal Medicine, Soonchunhyang University Seoul hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Soo-taek Uh
- Division of Respiratory-Allergy Medicine, Department of Internal Medicine, Soonchunhyang University Seoul hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Gae-Eil Jang
- Department of Internal Medicine, Soonchunhyang University Seoul hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Wonho Chang
- Department of Chest Surgery, Soonchunhyang University Seoul hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Bo Young Lee
- Division of Respiratory-Allergy Medicine, Department of Internal Medicine, Soonchunhyang University Seoul hospital, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
- Address for correspondence Bo Young Lee, M.D., Ph.D. Division of Respiratory-Allergy Medicine, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, 59 Daesagwan-ro, Yongsan-gu, Seoul 04401, Republic of Korea Phone 82-2-709-4235 Fax 82-2-793-9965 E-mail
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Muñoz OM, Ruiz-Talero P, Hernández-Florez C, Lombo-Moreno CE, Casallas-Rivera MA, Mayorga-Hernández CA. Validation of the PESI Scale to Predict in-Hospital Mortality in Patients with Pulmonary Thromboembolism Secondary to SARS CoV - 2 Infection. Clin Appl Thromb Hemost 2022; 28:10760296221102940. [PMID: 35593084 PMCID: PMC9125100 DOI: 10.1177/10760296221102940] [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] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To evaluate the discriminative ability and the calibration of the Pulmonary Embolism Severity Index (PESI) to predict in-hospital mortality in patients with Pulmonary Embolism (PE) secondary to COVID 19 in two hospitals in Bogotá. METHODS External validation study of a prediction model based on a retrospective cohort of patients with PE secondary to COVID-19 treated at Hospital Universitario San Ignacio and Hospital universitario La Samaritana, between March 2020 and August 2021. Calibration of the scale was evaluated using the Hosmer-Lemeshow test and a calibration belt diagram. Discrimination ability was evaluated using a ROC curve. RESULTS 272 patients were included (median age 61.5 years, male 58.8%). PE was diagnosed in 45.6% of the patients at the time of admission. Of the remaining 54.4%, 95.9% received thromboprophylaxis until the time of diagnosis.17.6% of the patients died. Regarding calibration, the scale systematically underestimates risk in all classes of PESI. For class I, the ratio of observed/expected events was 4.4 vs 0.8%, class II 4.8 vs 1.8%, class III 15.2 vs 4.2%, class IV 14.3 vs 5.9% and class V 46.7 vs 5.8%. The calibration test rejected the adequate calibration hypothesis (p < 0.001). The discriminatory ability was adequate (AUC = 0.7128, 95% CI 0.63-0.79). CONCLUSIONS The PESI scale in patients with PE secondary to COVID 19 underestimates the risk of in-hospital mortality, while maintaining adequate discrimination. It is suggested not to use the PESI scale until it is recalibrated in this context.
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Affiliation(s)
- Oscar M Muñoz
- Internal Medicine Department, Pontificia Universidad Javeriana, Bogota, Colombia,Hospital Universitario San Ignacio, Bogota, Colombia
| | - Paula Ruiz-Talero
- Internal Medicine Department, Pontificia Universidad Javeriana, Bogota, Colombia,Hospital Universitario San Ignacio, Bogota, Colombia
| | - Catalina Hernández-Florez
- Internal Medicine Department, Pontificia Universidad Javeriana, Bogota, Colombia,Hospital Universitario San Ignacio, Bogota, Colombia
| | - Carlos Ernesto Lombo-Moreno
- Internal Medicine Department, Pontificia Universidad Javeriana, Bogota, Colombia,Carlos Ernesto Lombo-Moreno, Internal Medicine, Pontificia Universidad Javeriana, Cra 7 # 40-62. Piso 7, Bogotá, Colombia.
| | - Martha Alejandra Casallas-Rivera
- RICAVTA investigation group, Bogota, Colombia,Internal Medicine Department, Hospital Universitario La Samaritana, Bogota, Colombia,Universidad de La Sabana, Chia, Colombia
| | - Carol Anne Mayorga-Hernández
- Internal Medicine Department, Hospital Universitario La Samaritana, Bogota, Colombia,Universidad de La Sabana, Chia, Colombia
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Mahmoud SS, Esser M, Jain A. Thromboembolic events in pelvic and acetabulum fractures: a systematic review of the current literature on incidence, screening, and thromboprophylaxis. INTERNATIONAL ORTHOPAEDICS 2022; 46:1707-1720. [PMID: 35543748 DOI: 10.1007/s00264-022-05431-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/03/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Rates of venous thromboembolic events (VTEs) as high as 41% deep vein thrombosis (DVT) were reported in association with pelvic and acetabular fractures (PAFs). There is no clear consensus on VTE prophylaxis for PAFs. Extracting evidence-based guidelines is key to overcome this challenging complication. The aims of this review are (A) to highlight the incidence of VTEs in PAFs, (B) to examine the screening and prophylaxis methods available in the current literature, and (C) direct future creation of a best practice protocol to reduce the risk of VTE in PAFs. METHODS We performed a systematic search of Medline, EMBASE databases, and the Cochrane library. MESH terms were used to identify studies pertinent to VTE in PAFs, including incidence, prophylaxis, and screening. RESULTS In total, 28 studies were identified and grouped into four categories including incidence, screening, prophylaxis, and the use of inferior vena cava filters (IVCFs). Incidence of VTE ranged from 0.21 to 41% for DVT and 0 to 21.7% for PE. Nine studies screened 1360 patients using different imaging modalities. Ten articles, 2836 patients, examined different thromboprophylaxis protocols. Two out of three studies investigating the use of IVCF showed significant reduction of the rates of PE. CONCLUSION Incidence of VTE in PAF varies significantly with different protocols. The current literature shows that screening is still controversial. The combination of chemical and mechanical prophylaxis starting at 24 hours from the injury would provide the best protection. Guidelines were extracted; however, higher level multicenter studies are still required to guide future protocols.
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Affiliation(s)
- Samer Ss Mahmoud
- The Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3000, Australia.
| | - Max Esser
- Department of Orthopaedic Surgery, The Alfred Hospital, Melbourne, Australia.,Associate Professor, Department of Surgery, Monash University, Melbourne, Australia
| | - Arvind Jain
- Department of Orthopaedic Surgery, The Alfred Hospital, Melbourne, Australia.,Associate Professor, Department of Surgery, Monash University, Melbourne, Australia.,Melbourne Bone and Joint Clinic, 27 Erin Street Richmond, Melbourne, VIC, 3121, Australia
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Maraziti G, Cimini LA, Becattini C. Risk stratification to optimize the management of acute pulmonary embolism. Expert Rev Cardiovasc Ther 2022; 20:377-387. [PMID: 35544707 DOI: 10.1080/14779072.2022.2077194] [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: 10/18/2022]
Abstract
INTRODUCTION Pulmonary embolism (PE) is a life-threatening disease. Risk stratification in patients with acute PE can guide clinical decisions. Clinical assessment, including hemodynamics, respiratory parameters, patient history, and right ventricle evaluation, has a pivotal role in this scope. AREAS COVERED This review aims to describe: i) the role of individual tools for prognostic stratification, from simple clinical parameters to the models suggested by international guidelines; ii) the implications of risk stratification in terms of patient disposition and treatment. The bleeding risk assessment in acute PE was also reviewed. The literature search was performed in PubMed and Embase to address these issues. EXPERT OPINION Prognostic assessment is essential to proceed with life-saving treatments in hemodynamically unstable patients and consider home treatment or short hospital stay in patients at low risk for death. In hemodynamically stable patients, risk stratification allows the implementation of personalized treatment pathways to reduce the risk of death, early PE recurrence, and bleeding. With the aim of optimizing healthcare resources, risk stratification may suggest appropriate patient disposition.
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Affiliation(s)
- Giorgio Maraziti
- Internal and Cardiovascular Medicine - Stroke Unit, Ospedale Santa Maria della Misericordia -University of Perugia, Perugia, Italy
| | - Ludovica Anna Cimini
- Internal and Cardiovascular Medicine - Stroke Unit, Ospedale Santa Maria della Misericordia -University of Perugia, Perugia, Italy
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, Ospedale Santa Maria della Misericordia -University of Perugia, Perugia, Italy
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Risk Stratification in Patients with Acute Pulmonary Embolism: Current Evidence and Perspectives. J Clin Med 2022; 11:jcm11092533. [PMID: 35566658 PMCID: PMC9104204 DOI: 10.3390/jcm11092533] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 11/16/2022] Open
Abstract
Risk stratification is one of the cornerstones of the management of acute pulmonary embolism (PE) and determines the choice of both diagnostic and therapeutic strategies. The first step is the identification of patent circulatory failure, as it is associated with a high risk of immediate mortality and requires a rapid diagnosis and prompt reperfusion. The second step is the estimation of 30-day mortality based on clinical parameters (e.g., original and simplified version of the pulmonary embolism severity index): low-risk patients without right ventricular dysfunction are safely managed with ambulatory anticoagulation. The remaining group of hemodynamically stable patients, labeled intermediate-risk PE, requires hospital admission, even if most of them will heal without complications. In recent decades, efforts have been made to identify a subgroup of patients at an increased risk of adverse outcomes (intermediate-high-risk PE), who might benefit from a more aggressive approach, including reperfusion therapies and admission to a monitored unit. The cur-rent approach, combining markers of right ventricular dysfunction and myocardial injury, has an insufficient positive predictive value to guide primary thrombolysis. Sensitive markers of circulatory failure, such as plasma lactate, have shown interesting prognostic accuracy and may play a central role in the future. Furthermore, the improved security of reduced-dose thrombolysis may enlarge the indication of this treatment to selected intermediate–high-risk PE.
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