A novel H-FABP assay and a fast prognostic score for risk assessment of normotensive pulmonary embolism

Risk Scores in Venous Thromboembolism Guidelines of ESC, ACCP, and ASH: An Updated Review

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.

Interventional therapies for pulmonary embolism

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.

Usefulness of the National Early Warning Score for Risk Stratification of Stable Patients With Acute Symptomatic Pulmonary Embolism

OBJECTIVES

The aim of this study was to assess the performance of the National Early Warning Score 2 (NEWS2) in predicting a short-term complicated outcome in stable patients with acute symptomatic pulmonary embolism (PE). We also studied the ability of the NEWS2 score compared with the simplified Pulmonary Embolism Severity Index (sPESI) for identifying low-risk patients with acute PE.

METHODS

We performed a retrospective analysis of a prospective cohort composed of 848 patients with acute PE. The NEWS2 and the sPESI were calculated for each patient according to different clinical variables. We assessed the predictive accuracy of these scores for a 30-day complicated outcome using the C statistic, which was obtained by logistic regression models and ROC curves. We also assessed the test and performance characteristics of the low-risk versus high-risk categories of each prediction rule.

RESULTS

Overall, 63 out of 848 patients died (7.4%; 95% confidence interval, 5.7%-9.2%) during the first month of follow-up. Both scores showed a similarly poor predictive value for 30-day complicated outcome (C statistic, 0.68 and 0.62). The sPESI classified fewer patients as low-risk (36.9% versus 44.5%; P<0.01). Compared with the NEWS2 score, the sPESI showed significantly higher sensitivity (92.1% versus 66.7%) and a better negative predictive value (98.4% versus 94.4%).

CONCLUSION

Both scores provide similar information for stratifying the risk of a complicated outcome in stable patients with PE. The sPESI identified low-risk patients with PE better than the NEWS2 score.

Utility of Combining High-Sensitive Cardiac Troponin I and PESI Score for Risk Management in Patients with Pulmonary Embolism in the Emergency Department

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.

Predictive Value of Heart-Type Fatty Acid-Binding Protein for Mortality Risk in Critically Ill Patients

Objective

Our study assessed the predictive value of heart-type fatty acid-binding protein (H-FABP) for critically ill patients.

Methods

150 critically ill patients admitted to the emergency department of Beijing Chaoyang Hospital, Capital Medical University, were included in our study from August 2021 to April 2022. Serum H-FABP, procalcitonin (PCT), lactate (LAC), and other markers were determined within 1 h after admission. The Sequential Organ Failure Assessment (SOFA) score and the Acute Physiology and Chronic Health Evaluation II (APACHE II) were calculated. The independent predictors of 28-day mortality in critically ill patients were analyzed by logistic regression, and the receiver operating characteristic curve (ROC) was used to analyze the predictive value for 28-day mortality in critically ill patients.

Results

Age, APACHE II, SOFA, GCS, LAC, H-FABP, IL-6, Scr, and D-dimer were significantly different in the nonsurvivor vs. survivor groups (P < 0.05), with H-FABP correlating with cTNI, Scr, PCT, and SOFA scores (P < 0.05). Logistic regression analysis showed that H-FABP, APACHE II, LAC, and age were independent predictors for 28-day mortality in critically ill patients (P < 0.05). The AUC of ROC curve in H-FABP was 0.709 (sensitivity 72.9%, specificity 66.1%, and cut-off 4.35), which was slightly lower than AUC of ROC curve in LAC (AUC 0.750, sensitivity 58.3%, specificity 76.1%, and cut-off 1.95) and APACHE II (AUC 0.731, sensitivity 77.1%, specificity 58.7%, and cut-off 12.5). However, statistically, there was no difference in the diagnostic value of H-FABP compared with the other two indicators (Z ₁ = 0.669, P = 0.504; Z ₂ = 0.383, P = 0.702). But H-FABP (72.9%) has higher sensitivity than LAC (58.3%). The combined evaluation of H-FABP+APACHE II score (AUC 0.801, sensitivity 71.7%, and specificity 78.2%; Z = 2.612, P = 0.009) had better diagnostic value than H-FABP alone and had high sensitivity (71.7%) and specificity (78.2%).

Conclusion

H-FABP, LAC, APACHE II, and age can be used as independent risk factors affecting the prognosis of critically ill patients. Compared with using the above indicators alone, the H-FABP+APACHE II has a high diagnostic value, and the early and rapid evaluation is particularly important for the adjustment of treatment plans and prognosis.

Risk stratification and treatment of pulmonary embolism with intermediate-risk of mortality

PURPOSE OF REVIEW

Intermediate-risk pulmonary embolisms (PE) represent a heterogeneous group at the high end of hemodynamically stable patients, characterized by a higher mortality rate. This challenging population gathers many unsolved question regarding its therapeutic management. The purpose of this review is to provide an updated overview of the literature regarding further risk stratification and treatment options in this population.

RECENT FINDINGS

If anticoagulation represents the undisputed first line of treatment, some patients especially in the intermediate-high risk subgroup may necessitate or could benefit from therapeutic escalation with reperfusion therapies. This includes systemic thrombolysis (ST) or catheter-directed therapies (CDT). ST, despite its high efficacy, is not recommended in this population because of prohibitive bleeding complications. Therefore, reduced-dose ST appears to be a promising option and is actually under evaluation. CDT are percutaneous reperfusion techniques developed to acutely decrease pulmonary vascular obstruction with lower-dose or no thrombolytic agents and, thus, potentially improved safety compared to ST.

SUMMARY

Great progress has been made in the recent years providing a wide range of therapeutic options. Optimal selection of patients who could benefit from these treatments is the key and is based on clinical, biological and radiological parameters evaluating right ventricle function and allowing accurate risk stratification. Pulmonary Embolism Response Team represents an efficient modality for therapeutic management especially in the intermediate-high risk subgroup.

Prognostic role of elevated lactate in acute pulmonary embolism: A systematic review and meta-analysis

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.

Risk stratification for clinical severity of pulmonary embolism in patients with cancer: a narrative review and MASCC clinical guidance for daily care

Pulmonary embolism (PE) is a leading cause of morbidity and mortality in patients with cancer. The clinical presentation and outcomes of PE range from an acute life-threatening condition requiring intensive care to a mild symptomatic condition associated with favorable outcomes and potentially candidate for early hospital discharge. The wide clinical spectrum of PE has led to the development of risk stratification models aimed at the triage of patients in emergency care departments and optimizing the utilization of health care resources. Incidental or unsuspected PE (UPE), detected during routine staging computed tomography scans, make up a significant proportion of this cohort among the oncology population. The present narrative review is aimed at examining the currently available PE risk assessment models developed for the general population and for patients with cancer including UPE. We include general recommendations for the daily care of patients with cancer-related PE and hypothesize on the factors that would potentially favor hospitalization with early discharge or ambulatory management in this setting.

Risk stratification to optimize the management of acute pulmonary embolism

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.

Cardiac Biomarkers in Patients with Acute Pulmonary Embolism

Pulmonary embolism is a frequent and potentially fatal disease. The major challenge of initial management lies in prognostic stratification. Since 2014, the European recommendations on the diagnosis and management of acute pulmonary embolism are based on assessing the risk stratification regarding hemodynamic status first, then on a combined risk assessment model using a clinical score, an imaging evaluation of right heart size and the concentration of a serum cardiac biomarker. Usual biomarkers cover cardiac ischemia (troponin and derivates) and dilatation (BNP and derivates). The aim of this review is to offer a practical update on the role of the Troponins and BNPs families of biomarkers and the prognosis of pulmonary embolism, and furthermore, to provide a brief overview of their place in current management.

Comparison of 5 acute pulmonary embolism mortality risk scores in patients with COVID-19

Objective

Methods

Results

Conclusion

Prognostic Performance of Hestia Criteria in Acute Pulmonary Embolism: A Systematic Review and Meta-Analysis

Previous studies have suggested that Hestia criteria could effectively identifying patients with acute pulmonary embolism (PE) who were at low risk of mortality for outpatient treatment or early discharge. But the performance of Hestia criteria in stratifying patients at different risk class is still unknown. We sought to comprehensively evaluate the prognostic impact of Hestia criteria for PE. The literatures search was conducted in PubMed, Web of Science and EMBASE from 1 August 2011 to 31 October 2021. Finally, Eight studies with 4110 patients were included in our meta-analysis. Overall, the pool percentage of patients classified as low-risk group and high-risk group were 41.4%% and 58.6% respectively, and the all-course mortality rates of each group were 2.3% and 10.6%, respectively. The pooled rate of PE-related composite adverse outcomes in high-risk group was increasingly higher than in low-risk group (15.7% vs 4.4%). High risk group was also markedly associated with overall mortality (OR: 7.21, 95%CI: 4.96-10.46, p < 0.00001), and PE-related adverse outcomes (OR:5.38, 95% CI:3.95-7.32, p < 0.00001). The pooled sensitivity, specificity, PLR, NLR of Hestia criteria for overall mortality were 0.90 (95% CI:0.83-0.94), 0.43 (95% CI:0.31-0.55), 1.6 (95% CI:1.3-1.9), 0.23 (95% CI: 0.15-0.35), respectively. The area under SROC curve (AUC) was 0.81 (95% CI: 0.77-0.84). The result of our meta-analysis indicate that Hestia criteria can effectively identify PE patients at low risk of poor prognosis with high sensitivity and NPV, but its prognostic role in patients with higher risk class still need to be verified.

Rapid prediction of adverse outcomes for acute normotensive pulmonary embolism: derivation of the Calgary Acute Pulmonary Embolism score

Background

Acute pulmonary embolism (PE) has a wide spectrum of outcomes, but the best method to risk-stratify normotensive patients for adverse outcomes remains unclear.

Methods

A multicentre retrospective cohort study of acute PE patients admitted from emergency departments in Calgary, Canada, between 2012 and 2017 was used to develop a refined acute PE risk score. The composite primary outcome of in-hospital PE-related death or haemodynamic decompensation. The model was internally validated using bootstrapping and the prognostic value of the derived risk score was compared to the Bova score.

Results

Of 2067 patients with normotensive acute PE, the primary outcome (haemodynamic decompensation or PE-related death) occurred in 32 (1.5%) patients. In simplified Pulmonary Embolism Severity Index high-risk patients (n=1498, 78%), a multivariable model used to predict the primary outcome retained computed tomography (CT) right–left ventricular diameter ratio ≥1.5, systolic blood pressure 90–100 mmHg, central pulmonary artery clot and heart rate ≥100 beats·min⁻¹ with a C-statistic of 0.89 (95% CI 0.82–0.93). Three risk groups were derived using a weighted score (score, prevalence, primary outcome event rate): group 1 (0–3, 73.8%, 0.34%), group 2 (4–6, 17.6%, 5.8%), group 3 (7–9, 8.7%, 12.8%) with a C-statistic 0.85 (95% CI 0.78–0.91). In comparison the prevalence (primary outcome) by Bova risk stages (n=1179) were stage I 49.8% (0.2%); stage II 31.9% (2.7%); and stage III 18.4% (7.8%) with a C-statistic 0.80 (95% CI 0.74–0.86).

Conclusions

A simple four-variable risk score using clinical data immediately available after CT diagnosis of acute PE predicts in-hospital adverse outcomes. External validation of the Calgary Acute Pulmonary Embolism score is required.

Derivation of a simple four-variable risk score that uses parameters available at the time of PE diagnosis to risk stratify acute normotensive PE patients, which may help clinicians better decide how to monitor and treat patientshttps://bit.ly/37PdyrM

Promising Novel Biomarkers in Cardiovascular Diseases

Cardiovascular diseases remain the most common causes of death globally, according to the World Health Organization. In recent years, a great number of biomarkers have been investigated, whereas only some have gained value in the diagnosis, prognosis, and risk stratification of different cardiovascular illnesses. As numerous studies have investigated the diagnostic yield of novel biomarkers in various disease entities every year, this review aims to provide an overview of the current status of four promising representatives. In particular, this manuscript refers to soluble suppression of tumorigenicity 2 (sST2), heart-type fatty acid binding protein (H-FABP), growth differentiation factor (GDF-15) and soluble urokinase-type plasminogen activator receptor (suPAR). These markers are of special interest as they are thought to provide an accurate estimate of cardiovascular risk in certain patient populations, especially those with pre-existing diseases, such as obesity or diabetes mellitus. We sought to give an overview of their function, individual diagnostic and predictive value and determination in the laboratory. A review of the literature regarding the aforementioned cardiovascular biomarkers yielded manifold results with respect to their individual diagnostic and prognostic value. Yet, the clinical relevance of these findings remains unclear, warranting further studies to identify their optimal use in clinical routine.

Risk Stratification in Acute Pulmonary Embolism: The Latest Algorithms

Pulmonary embolism (PE) is a common clinical entity, which most clinicians will encounter. Appropriate risk stratification of patients is key to identify those who may benefit from reperfusion therapy. The first step in risk assessment should be the identification of hemodynamic instability and, if present, urgent patient consideration for systemic thrombolytics. In the absence of shock, there is a plethora of imaging studies, biochemical markers, and clinical scores that can be used to further assess the patients' short-term mortality risk. Integrated prediction models incorporate more information toward an individualized and precise mortality prediction. Additionally, bleeding risk scores should be utilized prior to initiation of anticoagulation and/or reperfusion therapy administration. Here, we review the latest algorithms for a comprehensive risk stratification of the patient with acute PE.

Jugular vein diameter: A new player in normotensive pulmonary embolism

PURPOSE

The majority of the patients with pulmonary embolism (PE) are those with normotensive PE. Right ventricular dysfunction (RVD) and myocardial injury markers are associated with mortality although they have a low predictive impact. Here, we aim to study the performance characteristics of jugular vein diameter to predict 30-day mortality.

MATERIALS AND METHODS

In this prospective, observational cohort study, we included normotensive patients who were diagnosed with PE using computed tomography angiography or scintigraphy in the emergency service. The demographic characteristics, blood pressures, pulses, shock indexes, troponin and lactate levels, echocardiography findings, and internal jugular vein diameters (IJV) of the patients were recorded. Testing characteristics of IJV in predicting 30-day mortality were studied.

RESULTS

The mean age of the 81 patients was 66.8±16.9 years and 37% of them were male. Age, shock index, lactate, RVD, PESI, and IJV diameters during inspiration and expiration were indicators for 30-day mortality. The cut-off value obtained using the ROC curve for mortality was an IJV-exp-AP of ≤8.9 mm (sensitivity,73.3%; specificity,92.4%; +LR,9.68; -LR,0.29; NPD,93.8%; PPD,68.7%; area under the curve, 0.76; 95% confidence interval, 0.65-0.84; p=0.004).

CONCLUSION

IJV diameter is an indicator of 30-day mortality. It can be used to detect low-risk patients.

Implications of Abnormal Troponin Levels With Normal Right Ventricular Function in Normotensive Patients With Acute Pulmonary Embolism

Among patients with pulmonary embolism (PE), various permutations of normal or abnormal cardiac troponin results and normal or abnormal echocardiographic right ventricular function are encountered in clinical practice. We aimed to explore whether there is a true gradient of risk based on troponin and echocardiographic results. This study included normotensive patients with PE from the PROgnosTic valuE of CT scan in hemodynamically stable patients with acute symptomatic pulmonary embolism (PROTECT) study. Patients were categorized as having -Troponin/-Echo, -Troponin/+Echo, +Troponin/-Echo, and +Troponin/+Echo. The primary outcome was 30-day “complicated course,” including death from any cause, hemodynamic collapse, or recurrent PE. Secondary outcomes included individual adverse event rates. Of the 834 patients who had echocardiographic and troponin results, 569 patients (68%) had -Troponin/-Echo, 126 patients (15%) had -Troponin/+Echo, 74 patients (8.9%) had +Troponin/-Echo, and 65 patients (7.8%) had +Troponin/+Echo. The incidence of 30-day complicated course was 4.6% in patients with -Troponin/-Echo, 11.9% in patients with -Troponin/+Echo, 13.5% in patients with +Troponin/-Echo, and 16.9% in patients with +Troponin/+Echo (P for trend <0.001). In the subgroup of patients with a high-risk sPESI (i.e., intermediate-risk according to the ESC guidelines) (n = 527), the incidence of 30-day complicated course was 14.9% in patients with -Troponin/+Echo, 18.5% in patients with +Troponin/-Echo, and 17.5% in patients with +Troponin/+Echo (P for trend <0.01). In patiens with PE, there seems to be a risk gradient based on troponin and echocardiographic results. This study did not detect a significant risk difference in those with +Troponin/-Echo compared with -Troponin/+Echo.

Definition of tachycardia for risk stratification of pulmonary embolism

BACKGROUND

Tachycardia is a reliable predictor of adverse outcomes in normotensive patients with acute pulmonary embolism (PE). However, different prognostic relevant heart rate thresholds have been proposed. The aim of the study was to investigate the prognostic performance of different thresholds used for defining tachycardia in normotensive PE patients.

METHODS

We performed a post-hoc analysis of normotensive patients with confirmed PE consecutively included in a single-centre and a multi-centre registry. An adverse outcome was defined as PE-related death, need for mechanical ventilation, cardiopulmonary resuscitation or administration of catecholamines.

RESULTS

Of 1567 patients (median age: 72 [IQR, 59-79] years; females: 46.1%) included in the analysis, 78 patients (5.0%) had an in-hospital adverse outcome. The rate of an adverse outcome was higher in patients with a heart rate ≥100 bpm (7.6%) and ≥110 bpm (8.3%) compared to patients with a heart rate <100 bpm (3.0%). A heart rate ≥100 bpm and ≥110 bpm was associated with a 2.7 (95% CI 1.7-4.3) and 2.4-fold (95% CI 1.5-3.7) increased risk for an adverse outcome, respectively. Receiver operating characteristics analysis revealed a similar area under the curve with regard to an adverse outcome for all scores and algorithm (ESC 2019 algorithm, modified FAST and Bova score) if calculated with a heart rate threshold of ≥100 bpm or of ≥110 bpm.

CONCLUSIONS

Defining tachycardia by a heart rate ≥100 bpm is sufficient for risk stratification of normotensive patients with acute PE. The use of different heart rate thresholds for calculation of scores and algorithm does not appear necessary.

Acute pulmonary embolism multimodality imaging prior to endovascular therapy

The manuscript discusses the application of CT pulmonary angiography, ventilation–perfusion scan, and magnetic resonance angiography to detect acute pulmonary embolism and to plan endovascular therapy. CT pulmonary angiography offers high accuracy, speed of acquisition, and widespread availability when applied to acute pulmonary embolism detection. This imaging modality also aids the planning of endovascular therapy by visualizing the number and distribution of emboli, determining ideal intra-procedural catheter position for treatment, and signs of right heart strain. Ventilation–perfusion scan and magnetic resonance angiography with and without contrast enhancement can also aid in the detection and pre-procedural planning of endovascular therapy in patients who are not candidates for CT pulmonary angiography.

New guidelines for the diagnosis and management of pulmonary embolism: Key changes

Pulmonary embolism (PE) is an important public health problem. In August 2019, the European Society of Cardiology in collaboration with the European Respiratory Society released new guidelines for the diagnosis and management of PE. We discuss the basic changes between these recent guidelines and the previous guidelines that were published in 2014. Regarding diagnosis, the new guidelines propose the use of an age-adjusted cut-off level of D-dimers instead of a fixed cut-off value. A D-dimer test adapted to clinical possibility should also be considered instead of fixed cut-off level of D-dimer. Detailed recommendations for the diagnosis of PE during pregnancy are also provided. Regarding risk stratification, assessment of PE-related early mortality risk is recommended. Moreover, the importance of right ventricular dysfunction is emphasized in low-risk patients. For further risk stratification of the severity of PE in patients without hemodynamic instability, use of validated scores that combine clinical, imaging and laboratory PE-related prognostic factors might also be considered. Regarding treatment, the possibility of early discharge is mentioned in patients without severe comorbidities, who are not of high risk for sudden death and in whom proper medical management at home and proper medical follow up can be ensured. The new guidelines also suggest that pro-brain natriuretic peptide levels, right ventricular function and the presence of thrombus in the right heart could be useful for guiding the decision of early discharge. Overall, these new guidelines introduce several key changes and knowledge and adherence to them will improve the outcome of patients with PE.

Validation of a fast prognostic score for risk stratification of normotensive patients with acute pulmonary embolism

Background

Recent studies demonstrate an improved prognostic performance of the 2014 European Society of Cardiology (ESC) algorithm for risk stratification of patients with pulmonary embolism (PE) compared to the 2008 ESC algorithm. The modified FAST and Bova scores appear especially helpful to identify PE patients at intermediate-high risk.

Methods

We validated the prognostic performance of the modified FAST score compared to other scores for risk stratification in a post-hoc analysis of 868 normotensive PE patients included in the prospective Italian Pulmonary Embolism Registry. In-hospital adverse outcome was defined as PE-related death, mechanical ventilation, cardiopulmonary resuscitation or administration of catecholamines.

Results

Overall, 27 patients (3.1%) had an adverse outcome and 32 patients (3.7%) died. The rate of an adverse outcome was highest in the intermediate-high risk classes of the 2019 ESC algorithm (7.5%) and the modified FAST score (5.3%) while the Bova score failed to discriminate between intermediate-low and intermediate-high-risk patients. Patients classified as intermediate-high risk by the 2019 ESC algorithm (Odds Ratio [OR], 4.2 [95% CI, 1.9–9.0]) and modified FAST score (OR, 2.8 [1.3–6.2]) had a higher risk of an adverse outcome compared to patients classified by the Bova score (OR, 1.6 [0.7–3.7]). The c-index was higher for the 2019 ESC algorithm and the modified FAST score (AUC, 0.69 [0.58–0.79] and 0.67 [0.59–0.76]) compared to the Bova score (AUC, 0.64 [0.55–0.73]).

Conclusions

The 2019 ESC algorithm provided the best prognostic performance, but also the modified FAST score accurately stratified normotensive PE patients in different risk classes while the Bova score failed to identify patients at highest risk.

Graphic abstract

Electronic supplementary material

The online version of this article (10.1007/s00392-019-01593-w) contains supplementary material, which is available to authorized users.

Intermediate-High Risk Pulmonary Embolism

Limited information exists about the prevalence, management, and outcomes of intermediate-high risk patients with acute pulmonary embolism (PE). In a prospective cohort study, we evaluated consecutive patients with intermediate-high risk PE at a large, tertiary, academic medical center between January 1, 2015 and March 31, 2019. Adjudicated outcomes included PE-related mortality and a complicated course through 30 days after initiation of PE treatment. Repeat systolic blood pressure (SBP), heart rate (HR), brain natriuretic peptide (BNP), and cardiac troponin I (cTnI) measurements, and echocardiography were performed within 48 hours after diagnosis. Among 1,015 normotensive patients with acute PE, 97 (9.6%) had intermediate-high risk PE. A 30-day complicated course and 30-day PE-related mortality occurred in 23 (24%) and 7 patients (7.2%) with intermediate-high risk PE. Seventeen (18%) intermediate-high risk patients received reperfusion therapy. Within 48 hours after initiation of anticoagulation, normalization of SBP, HR, cTnI, BNP, and echocardiography occurred in 82, 86, 78, 72, and 33% of survivors with intermediate-high risk PE who did not receive immediate thrombolysis. A complicated course between day 2 and day 30 after PE diagnosis for the patients who normalized SBP, HR, cTnI, BNP, and echocardiography measured at 48 hours occurred in 2.9, 1.4, 4.5, 3.3, and 14.3%, respectively. Intermediate-high risk PE occurs in approximately one-tenth of patients with acute symptomatic PE, and is associated with high morbidity and mortality. Normalization of HR 48 hours after diagnosis might identify a group of patients with a very low risk of deterioration during the first month of follow-up.

Submassive Pulmonary Embolism

Pulmonary embolism (PE) presents a spectrum of hemodynamic consequences, ranging from being asymptomatic to a life-threatening medical emergency. Management of submassive and massive PE often involves clinicians from multiple specialties, which can potentially delay the development of a unified treatment plan. In addition, patients with submassive PE can deteriorate after their presentation and require escalation of care. Underlying comorbidities such as chronic obstructive pulmonary disease, cancer, congestive heart failure, and interstitial lung disease can impact the patient's hemodynamic ability to tolerate submassive PE. In this review, we address the definitions, risk stratification (clinical, laboratory, and imaging), management approaches, and long-term outcomes of submassive PE. We also discuss the role of the PE response team in management of patients with PE.

Temporal trends in management and outcome of pulmonary embolism: a single-centre experience

Background

Real-world data on the impact of advances in risk-adjusted management on the outcome of patients with pulmonary embolism (PE) are limited.

Methods

To investigate temporal trends in treatment, in-hospital adverse outcomes and 1-year mortality, we analysed data from 605 patients [median age, 70 years (IQR 56–77) years, 53% female] consecutively enrolled in a single-centre registry between 09/2008 and 08/2016.

Results

Over the 8-year period, more patients were classified to lower risk classes according to the European Society of Cardiology (ESC) 2014 guideline algorithm while the number of high-risk patients with out-of-hospital cardiac arrest (OHCA) increased. Although patients with OHCA had an exceptionally high in-hospital mortality rate of 59.3%, the rate of PE-related in-hospital adverse outcomes (12.2%) in the overall patient cohort remained stable over time. The rate of reperfusion treatment was 9.6% and tended to increase in high-risk patients. We observed a decrease in the median duration of in-hospital stay from 10 (IQR 6–14) to 7 (IQR 4–15) days, an increase of patients discharged early from 2.1 to 12.2% and an increase in the use of non-vitamin K-dependent oral anticoagulants (NOACs) from 12.6 to 57.2% in the last 2 years (09/2014–08/2016) compared to first 6 years (09/2008–08/2014). The 1-year mortality rate (16.9%) remained stable throughout the study period.

Conclusion

In-hospital adverse outcomes and 1-year mortality remained stable despite more patients with OHCA, shorter in-hospital stays, more patients discharged early and a more frequent NOAC use.

Electronic supplementary material

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Aggressive Treatment of Intermediate-Risk Patients with Acute Symptomatic Pulmonary Embolism

Contemporary studies of acute pulmonary embolism (PE) have evaluated the role of thrombolytics in intermediate-risk PE. Significant findings are that thrombolytic therapy may prevent hemodynamic deterioration and all-cause mortality but increases major bleeding. Benefits and harms are finely balanced with no convincing net benefit from thrombolytic therapy among unselected patients. Among patients with intermediate risk PE, additional prognostic factors or subtle hemodynamic changes might alter the risk-benefit assessment in favor of thrombolytic therapy before obvious hemodynamic instability.

Prognostic impact of copeptin in pulmonary embolism: a multicentre validation study

To externally validate the prognostic impact of copeptin, either alone or integrated in risk stratification models, in pulmonary embolism (PE), we performed a post hoc analysis of 843 normotensive PE patients prospectively included in three European cohorts.

Within the first 30 days, 21 patients (2.5%, 95% CI 1.5–3.8) had an adverse outcome and 12 (1.4%, 95% CI 0.7–2.5) died due to PE. Patients with copeptin ≥24 pmol·L−1 had a 6.3-fold increased risk for an adverse outcome (95% CI 2.6–15.5, p<0.001) and a 7.6-fold increased risk for PE-related death (95% CI 2.3–25.6, p=0.001). Risk classification according to the 2014 European Society of Cardiology (ESC) guideline algorithm identified 248 intermediate-high-risk patients (29.4%) with 5.6% (95% CI 3.1–9.3) at risk of adverse outcomes. A stepwise biomarker-based risk assessment strategy (based on high-sensitivity troponin T, N-terminal pro-brain natriuretic peptide and copeptin) identified 123 intermediate-high-risk patients (14.6%) with 8.9% (95% CI 4.5–15.4) at risk of adverse outcomes. The identification of patients at higher risk was even better when copeptin was measured on top of the 2014 ESC algorithm in intermediate-high-risk patients (adverse outcome OR 11.1, 95% CI 4.6–27.1, p<0.001; and PE-related death OR 13.5, 95% CI 4.2–43.6, p<0.001; highest risk group versus all other risk groups). This identified 85 patients (10.1%) with 12.9% (95% CI 6.6–22.0) at risk of adverse outcomes and 8.2% (95% CI 3.4–16.2) at risk of PE-related deaths.

Copeptin improves risk stratification of normotensive PE patients, especially when identifying patients with an increased risk of an adverse outcome.

Pulmonary embolism severity assessment and prognostication

For patients who have acute symptomatic pulmonary embolism (PE), risk of short-term death and adverse outcomes should drive the initial treatment decisions. Practice guidelines recommend that patients who have a high-risk of PE-related death and adverse outcomes, determined by the presence of haemodynamic instability (i.e., shock or hypotension), should receive systemically administered thrombolytic therapy. Intermediate-high risk patients might benefit from close observation, and some should undergo escalation of therapy beyond standard anticoagulation, particularly if haemodynamic deterioration occurs. Low-risk for adverse outcomes should lead to early hospital discharge or full treatment at home. Validated prognostic tools (i.e., clinical prognostic scoring systems, imaging studies, and cardiac laboratory biomarkers) assist with risk classification of patients who have acute symptomatic PE.

Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis

OBJECTIVE

To review the evidence for existing prognostic models in acute pulmonary embolism (PE) and determine how valid and useful they are for predicting patient outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

OVID MEDLINE and EMBASE, and The Cochrane Library from inception to July 2014, and sources of grey literature.

ELIGIBILITY CRITERIA

Studies aiming at constructing, validating, updating or studying the impact of prognostic models to predict all-cause death, PE-related death or venous thromboembolic events up to a 3-month follow-up in patients with an acute symptomatic PE.

DATA EXTRACTION

Study characteristics and study quality using prognostic criteria. Studies were selected and data extracted by 2 reviewers.

DATA ANALYSIS

Summary estimates (95% CI) for proportion of risk groups and event rates within risk groups, and accuracy.

RESULTS

We included 71 studies (44,298 patients). Among them, 17 were model construction studies specific to PE prognosis. The most validated models were the PE Severity Index (PESI) and its simplified version (sPESI). The overall 30-day mortality rate was 2.3% (1.7% to 2.9%) in the low-risk group and 11.4% (9.9% to 13.1%) in the high-risk group for PESI (9 studies), and 1.5% (0.9% to 2.5%) in the low-risk group and 10.7% (8.8% to12.9%) in the high-risk group for sPESI (11 studies). PESI has proved clinically useful in an impact study. Shifting the cut-off or using novel and updated models specifically developed for normotensive PE improves the ability for identifying patients at lower risk for early death or adverse outcome (0.5-1%) and those at higher risk (up to 20-29% of event rate).

CONCLUSIONS

We provide evidence-based information about the validity and utility of the existing prognostic models in acute PE that may be helpful for identifying patients at low risk. Novel models seem attractive for the high-risk normotensive PE but need to be externally validated then be assessed in impact studies.

Comparison of risk assessment strategies for not-high-risk pulmonary embolism

We compared the prognostic performance of the 2014 European Society of Cardiology (ESC) risk stratification algorithm with the previous 2008 ESC algorithm, the Bova score and the modified FAST score (based on a positive heart-type fatty acid-binding protein (H-FABP) test, syncope and tachycardia, modified using high-sensitivity troponin T instead of H-FABP) in 388 normotensive pulmonary embolism patients included in a single-centre cohort study.Overall, 25 patients (6.4%) had an adverse 30-day outcome. Regardless of the score or algorithm used, the rate of an adverse outcome was highest in the intermediate-high-risk classes, while all patients classified as low-risk had a favourable outcome (no pulmonary embolism-related deaths, 0-1.4% adverse outcome). The area under the curve for predicting an adverse outcome was higher for the 2014 ESC algorithm (0.76, 95% CI 0.68-0.84) compared with the 2008 ESC algorithm (0.65, 95% CI 0.56-0.73) and highest for the modified FAST score (0.82, 95% CI 0.75-0.89). Patients classified as intermediate-high-risk by the 2014 ESC algorithm had a 8.9-fold increased risk for an adverse outcome (3.2-24.2, p<0.001 compared with intermediate-low- and low-risk patients), while the highest OR was observed for a modified FAST score ≥3 points (OR 15.9, 95% CI 5.3-47.6, p<0.001).The 2014 ESC algorithm improves risk stratification of not-high-risk pulmonary embolism compared with the 2008 ESC algorithm. All scores and algorithms accurately identified low-risk patients, while the modified FAST score appears more suitable to identify intermediate-high-risk patients.

Prognostic Value of Biomarkers in Acute Non-massive Pulmonary Embolism: A Systematic Review and Meta-analysis

BACKGROUND

Various biomarkers have been evaluated to risk stratify patients with acute pulmonary embolism (PE). We aimed to summarize the available evidence to compare the prognostic value of three most widely studied biomarkers in normotensive patients with acute PE.

METHOD

A systematic literature review of database, including Pubmed, EMBASE and Cochrane, was done. Studies were included if those were done on patients with acute PE and serum troponin or brain natriuretic peptide and N-terminal proBNP (BNP/NT-proBNP) or Heart-type fatty acid-binding protein (H-FABP) assay was done. The primary end point was short-term all-cause mortality. The secondary end points were PE-related mortality and serious adverse events.

RESULTS

All three biomarkers were significantly associated with increased risk for short-term all-cause mortality, PE-related mortality and serious adverse events. All-cause mortality: troponin [odds ratio (OR) 4.80; 95% CI 3.25-7.08, I(2) = 54%], BNP or NT-proBNP (OR 7.98; 95% CI 4.34-14.67, I(2) = 0%); PE-related mortality: troponin (OR 3.80; 95% CI 2.74-5.27, I(2) = 0%), BNP or NT-proBNP (OR 7.57; 95% CI 2.89-19.81, I (2) = 0%) and H-FABP (OR 25.97; 95% CI 6.63-101.66, I(2) = 40%). H-FABP has the lowest negative likelihood ratio (NLR) of 0.17 for mortality followed by high-sensitive cardiac troponin T (hs-cTnT) with NLR of 0.21.

CONCLUSION

None of the biomarker identifies a subgroup of patients who can be managed as an outpatient versus patients who may get benefit from thrombolytics with certainty; however, H-FABP and hs-cTnT showed some promising results and should be investigated further.

Pulmonary embolism: whom to discharge and whom to thrombolyze?

Patients with pulmonary embolism can be divided in two groups according to their risk of death or major complication: a small group of high-risk patients defined by the presence of systemic hypotension or cardiogenic shock and a large group of normotensive patients. Among normotensive patients, further risk stratification, based on clinical grounds alone or on the combination of clinical data, biomarkers, and imaging tests, allows selection of low-risk patients and intermediate-risk patients. The safety of outpatient treatment for low-risk patients has been established mainly on the basis of retrospective and prospective cohorts using different selection tools. In most studies, about 50% of the patients have been safely treated at home. Although thrombolytic therapy has a favorable benefit to risk profile in patients with high-risk pulmonary embolism, the risk of major and especially intracranial bleeding outweighs the benefits in terms of hemodynamic decompensation in patients with intermediate-risk pulmonary embolism.

Acute phase treatment of venous thromboembolism: advanced therapy. Systemic fibrinolysis and pharmacomechanical therapy

Venous thromboembolism, which encompasses deep-vein thrombosis and acute pulmonary embolism (PE), represents a major contributor to global disease burden worldwide. For patients who present with cardiogenic shock or persistent hypotension (acute high-risk PE), there is consensus that immediate reperfusion treatment applying systemic fibrinolysis or, in the case of a high bleeding risk, surgical or catheter-directed techniques, is indicated. On the other hand, for the large, heterogeneous group of patients presenting without overt haemodynamic instability, the indications for advanced therapy are less clear. The recently updated guidelines of the European Society of Cardiology emphasise the importance of clinical prediction rules in combination with imaging procedures (assessment of right ventricular function) and laboratory biomarkers (indicative of myocardial stress or injury) for distinguishing between an intermediate and a low risk for an adverse early outcome. In intermediate-high-risk PE defined by the presence of both right ventricular dysfunction on echocardiography (or computed tomography) and a positive troponin (or natriuretic peptide) test, the bleeding risks of full-dose fibrinolytic treatment have been shown to outweigh its potential clinical benefits unless clinical signs of haemodynamic decompensation appear (rescue fibrinolysis). Recently published trials suggest that catheter-directed, ultrasound-assisted, low-dose local fibrinolysis may provide an effective and particularly safe treatment option for some of these patients.

Predictors of early death in patients with acute pulmonary embolism

AIM

We aimed to determine the predictors of early death in the course of acute pulmonary embolism (APE).

MATERIALS AND METHODS

We included 206 patients who had been admitted to our hospital between January 2011 and April 2013 with the diagnosis of APE. We derived a new model including corrected QT interval dispersion (QTcd) and P wave dispersion (Pd), echocardiographic findings, laboratory markers, and blood cell count indices to predict early death in patients with APE.

RESULTS

Thirty patients (14.5%) died; 176 patients (85.5%) lived after diagnosis of APE. Logistic regression (LR) analysis found that troponin I (odds ratio [OR], 1.084 [95% confidence interval {CI}, 1.009-1.165]), creatinine (OR, 4.153 [95% CI, 1.375-12.541]), mean platelet volume (OR, 1.991 [95% CI, 1.230-3.223]), neutrophil to lymphocyte ratio (NLR) (OR, 1.079 [95% CI, 1.005-1.160]), QTcd (OR, 1.084 [95% CI, 1.043-1.127]), Pd (OR, 1.049 [95% CI, 1.004-1.096]) were associated with early death in APE. New LR model (area under the curve [AUC], 0.970) performed better than the simplified pulmonary embolism severity index (sPESI) score (AUC, 0.859) in predicting early death in APE (P=.021). The predictivity of the sPESI score significantly improved after its single combination with creatinine, QTcd, or troponin I. When the combined model was constructed together with these 6 independent variables and sPESI score, stepwise LR model automatically excluded Pd and NLR, and the AUC from the rest of the combined model was 0.976, which is significantly different from the AUC of sPESI (0.859) (P=.0031).

CONCLUSIONS

Creatinine, troponin I, and QTcd significantly improves sPESI score. A new model with troponin I, creatinine, mean platelet volume, NLR, QTcd, and Pd seems to have greater prognostic power than the sPESI scoring system.