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Cimini LA, Luijten D, Barco S, Ghanima W, Jervan Ø, Kahn SR, Konstantinides S, Lachant D, Nakano Y, Ninaber M, van Es J, van Mens T, Vonk Noordegraaf A, Becattini C, Klok FA. Pulmonary perfusion defects or residual vascular obstruction and persistent symptoms after pulmonary embolism: a systematic review and meta-analysis. ERJ Open Res 2024; 10:01010-2023. [PMID: 39076522 PMCID: PMC11284598 DOI: 10.1183/23120541.01010-2023] [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: 12/14/2023] [Accepted: 03/20/2024] [Indexed: 07/31/2024] Open
Abstract
Introduction Up to 50% of pulmonary embolism (PE) patients have perfusion defects or residual vascular obstruction during follow-up despite adequate anticoagulant treatment, and a similar percentage experience chronic functional limitations and/or dyspnoea post-PE. We aimed to evaluate the association between pulmonary perfusion defects or residual vascular obstruction and functional recovery after PE. Methods We performed a systematic review and meta-analysis including studies assessing both the presence of perfusion defects or residual vascular obstruction and functional recovery (i.e. persistent symptoms, quality of life, exercise endurance). An odds ratio was pooled for perfusion defects or residual vascular obstruction and persistent symptoms using a random-effect model. Results 12 studies were included totalling 1888 PE patients; at a median of 6 months after PE (range 2-72 months), 34% had perfusion defects or residual vascular obstruction and 37% reported persistent symptoms. Among patients with perfusion defects or residual vascular obstruction, 48% (95% CI 37-60%, I2=82%) remained symptomatic during follow-up, compared to 34% (95% CI 20-51%, I2=96%) of patients without such defects. Presence of perfusion defects or residual vascular obstruction was associated with persistent symptoms (OR 2.15, 95% CI 1.66-2.78; I2=0%, τ=0). Notably, there was no association between these defects and quality of life or cardiopulmonary exercise test parameters. Conclusion While the odds of having persistent symptoms was higher in patients with perfusion defects or residual vascular obstruction after acute PE, a significant proportion of these patients reported no limitations. A possible causality between perfusion defects or residual vascular obstruction and residual functional limitation therefore remains to be proven.
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Affiliation(s)
- Ludovica Anna Cimini
- Vascular and Emergency Medicine, University of Perugia, Perugia, Italy
- L.A. Cimini and D. Luijten contributed equally and share first authorship
| | - Dieuwke Luijten
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
- L.A. Cimini and D. Luijten contributed equally and share first authorship
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Waleed Ghanima
- Department of Internal Medicine, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
| | - Øyvind Jervan
- Department of Internal Medicine, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Susan R. Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada
- Division of Internal Medicine and Division of Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Daniel Lachant
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Yoshihisa Nakano
- Department of Cardiology, Nagoya University Hospital, Nagoya, Japan
- Department of Public Health and Health Systems, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Maarten Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Josien van Es
- Department of Pulmonology, Amsterdam UMC, Cardiovascular sciences, VU University Amsterdam, Amsterdam, The Netherlands
- Department of Pulmonology, OLVG, Amsterdam, The Netherlands
| | - Thijs van Mens
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam UMC, Cardiovascular sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Cecilia Becattini
- Vascular and Emergency Medicine, University of Perugia, Perugia, Italy
| | - Frederikus A. Klok
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Centre, Leiden, The Netherlands
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2
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Mohr K, Hobohm L, Kaier K, Farmakis IT, Valerio L, Barco S, Abele C, Münzel T, Neusius T, Konstantinides S, Binder H, Keller K. Drivers and recent trends of hospitalisation costs related to acute pulmonary embolism. Clin Res Cardiol 2024:10.1007/s00392-024-02437-y. [PMID: 38565711 DOI: 10.1007/s00392-024-02437-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND AND AIMS The socio-economic burden imposed by acute pulmonary embolism (PE) on European healthcare systems is largely unknown. We sought to determine temporal trends and identify cost drivers of hospitalisation for PE in Germany. METHODS AND RESULTS We analysed the totality of reimbursed hospitalisation costs in Germany (G-DRG system) in the years 2016-2020. Overall, 484 884 PE hospitalisations were coded in this period. Direct hospital costs amounted to a median of 3572 (IQR, 2804 to 5869) euros, resulting in average total reimbursements of 710 million euros annually. Age, PE severity, comorbidities and in-hospital (particularly bleeding) complications were identified by multivariable logistic regression as significant cost drivers. Use of catheter-directed therapy (CDT) constantly increased (annual change in the absolute proportion of hospitalisations with CDT + 0.40% [95% CI + 0.32% to + 0.47%]; P < 0.001), and it more than doubled in the group of patients with severe PE (28% of the entire population) over time. Although CDT use was overall associated with increased hospitalisation costs, this association was no longer present (adjusted OR 1.02 [0.80-1.31]) in patients with severe PE and shock; this was related, at least in part, to a reduction in the median length of hospital stay (for 14.0 to 8.0 days). CONCLUSIONS We identified current and emerging cost drivers of hospitalisation for PE, focusing on severe disease and intermediate/high risk of an adverse early outcome. The present study may inform reimbursement decisions by policymakers and help to guide future health economic analysis of advanced treatment options for patients with PE.
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Affiliation(s)
- Katharina Mohr
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Christina Abele
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Thomas Neusius
- Wiesbaden Business School, RheinMain University of Applied Sciences, Wiesbaden, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece.
| | - Harald Binder
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
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3
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Ogihara Y, Yamashita Y, Morimoto T, Chatani R, Kaneda K, Nishimoto Y, Ikeda N, Kobayashi Y, Ikeda S, Kim K, Inoko M, Takase T, Tsuji S, Oi M, Takada T, Otsui K, Sakamoto J, Inoue T, Usami S, Chen PM, Togi K, Koitabashi N, Hiramori S, Doi K, Mabuchi H, Tsuyuki Y, Murata K, Takabayashi K, Nakai H, Sueta D, Shioyama W, Dohke T, Sato T, Nishikawa R, Kimura T, Dohi K. Fragility and long-term clinical outcomes in patients with venous thromboembolism receiving direct oral anticoagulants: From the COMMAND VTE REGISTRY-2. Thromb Res 2024; 236:191-200. [PMID: 38461613 DOI: 10.1016/j.thromres.2024.02.023] [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: 11/22/2023] [Revised: 02/12/2024] [Accepted: 02/22/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION There is limited data on the safety of direct oral anticoagulants (DOACs) in fragile patients with venous thromboembolism (VTE). MATERIALS AND METHODS We used the COMMAND VTE Registry-2 enrolling patients with acute symptomatic VTE. The study population consisted of 3928 patients receiving DOACs, who were divided into fragile (2136 patients) and non-fragile groups (1792 patients). Fragility was defined as patients of age ≥ 75 years, creatinine clearance level ≤ 50 ml/min, and/or body weight ≤ 50 kg. RESULTS The fragile group significantly more often received reduced doses of DOACs compared to the non-fragile group (51 % and 19 %, P < 0.001). The cumulative 5-year incidence of major bleeding was numerically higher in the fragile group than the non-fragile group (15.0 % and 11.1 %, P = 0.052), even with no significant excess risk after adjusting for confounders (HR 1.03, 95%CI 0.81-1.31, P = 0.78). The cumulative 5-year incidence of clinically relevant bleeding was significantly higher in the fragile group than the non-fragile group (28.6 % and 19.6 %, P < 0.001), even after adjusting for confounders (HR 1.28, 95%CI 1.08-1.53, P = 0.005). There was no significant difference in cumulative 5-year incidence of recurrent VTE between the groups (9.6 % and 8.9 %, P = 0.68), which was consistent after adjusting for confounders (HR 1.13, 95%CI 0.84-1.51, P = 0.41). CONCLUSIONS Among VTE patients receiving DOACs, fragile patients were associated with a numerically higher rate of major bleeding and a significantly increased risk of clinically relevant bleeding, but not an increased risk of recurrent VTE.
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Affiliation(s)
- Yoshito Ogihara
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan.
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Ryuki Chatani
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kazuhisa Kaneda
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Nobutaka Ikeda
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Shuhei Tsuji
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Takuma Takada
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunori Otsui
- Department of General Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Jiro Sakamoto
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | - Takeshi Inoue
- Department of Cardiology, Shiga General Hospital, Moriyama, Japan
| | - Shunsuke Usami
- Department of Cardiology, Kansai Electric Power Hospital, Osaka, Japan
| | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Ikoma, Japan
| | - Norimichi Koitabashi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Seiichi Hiramori
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Kosuke Doi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | - Yoshiaki Tsuyuki
- Division of Cardiology, Shimada General Medical Center, Shimada, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | | | - Hisato Nakai
- Department of Cardiovascular Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Obama, Japan
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Wataru Shioyama
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Tomohiro Dohke
- Division of Cardiology, Kohka Public Hospital, Koka, Japan
| | - Toru Sato
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
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4
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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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5
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Bastas D, Brandão LR, Vincelli J, Wilson D, Perrem L, Guerra V, Wong G, Bentley RF, Tole S, Schneiderman JE, Amiri N, Williams S, Avila ML. Long-term outcomes of pulmonary embolism in children and adolescents. Blood 2024; 143:631-640. [PMID: 38134357 DOI: 10.1182/blood.2023021953] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 12/24/2023] Open
Abstract
ABSTRACT Knowledge regarding the long-term consequences of pulmonary embolism (PE) in children is limited. This cohort study describes the long-term outcomes of PE in children who were followed-up at a single-center institution using a local protocol that included clinical evaluation, chest imaging, echocardiography, pulmonary function tests, and cardiopulmonary exercise tests at follow-up, starting 3 to 6 months after acute PE. Children objectively diagnosed with PE at age 0 to 18 years, who had ≥6 months of follow-up were included. Study outcomes consisted of PE resolution, PE recurrence, death, and functional outcomes (dyspnea, impaired pulmonary or cardiac function, impaired aerobic capacity, and post-PE syndrome). The frequency of outcomes was compared between patients with/without underlying conditions. In total, 150 patients were included; median age at PE was 16 years (25th-75th percentile, 14-17 years); 61% had underlying conditions. PE did not resolve in 29%, recurrence happened in 9%, and death in 5%. One-third of patients had at least 1 documented abnormal functional finding at follow-up (ventilatory impairments, 31%; impaired aerobic capacity, 31%; dyspnea, 26%; and abnormal diffusing capacity of the lungs to carbon monoxide, 22%). Most abnormalities were transient. When alternative explanations for the impairments were considered, the frequency of post-PE syndrome was lower, ranging between 0.7% and 8.5%. Patients with underlying conditions had significantly higher recurrence, more pulmonary function and ventilatory impairments, and poorer exercise capacity. Exercise intolerance was, in turn, most frequently because of deconditioning than to respiratory or cardiac limitation, highlighting the importance of physical activity promotion in children with PE.
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Affiliation(s)
- Denise Bastas
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leonardo R Brandão
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jennifer Vincelli
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - David Wilson
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Vitor Guerra
- Division of Cardiology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Gina Wong
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Robert F Bentley
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada
| | - Soumitra Tole
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital, London Health Sciences Centre, London, ON, Canada
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Jane E Schneiderman
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Nour Amiri
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Suzan Williams
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - M Laura Avila
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
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6
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Khattar G, Siddiqui FS, Grovu R, Baker SA, Sanayeh EB, Wei C, El Gharib K, Sattar SBA, Elsayegh D, El-Hage H, Sayegh SE, Chalhoub M, Mustafa A. The calcium-clot connection: investigating the association between primary hyperparathyroidism and acute venous thromboembolism. J Thromb Thrombolysis 2024; 57:220-225. [PMID: 37848627 DOI: 10.1007/s11239-023-02906-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2023] [Indexed: 10/19/2023]
Abstract
Primary hyperthyroidism (PHPT) is a relatively uncommon disease and leads to increased calcium levels. Ionized calcium, known as clotting Factor IV, may lead to overt coagulation cascade activation, increasing the risk of venous thromboembolism (VTE). National Inpatient Sample Database was used to sample individuals with primary hyperparathyroidism, and baseline demographics and comorbidities were collected using ICD-10 codes. Patients with missing data and age less than 18 were excluded. Moreover, patients with other types of hyperparathyroidism and risk factors for VTE, such as malignancy, thrombophilia, chronic kidney and liver disease, fractures, trauma, oral contraceptive/steroid use, and organ transplant, were excluded. Greedy propensity matching using R was performed to match patients with and without primary hyperparathyroidism on age, race, gender, and 10 other comorbidities, including chronic deep venous thromboembolism. Univariate analysis pre- and post-match were performed. Binary logistic regression was performed after matching to assess whether primary hyperparathyroidism was an independent risk factor for acute VTE. A p-value of < 0.05 was considered statistically significant. Out of 460,529 patients included in the study, 1114 (6.5%) had PHPT. Baseline comorbidities were more common in the PHPT group. On univariate analysis, patients with PHPT were more likely to have acute VTE (2.5% vs. 1.4%; p < 0.001). After 1:1 matching, PHPT patients were twice as likely to have Acute VTE. (OR: 2.1 [1.08-4.1]; p < 0.025). These findings suggest an association between PHPT and VTE, which should be further investigated to prevent the increasing incidence of VTE and its recurrence.
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Affiliation(s)
- Georges Khattar
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, 475 Seaview Ave, Staten Island, NY, 10305, USA.
| | - Fasih Sami Siddiqui
- Department of Pulmonary and Critical Care, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Radu Grovu
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, 475 Seaview Ave, Staten Island, NY, 10305, USA
| | - Saif Abu Baker
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, 475 Seaview Ave, Staten Island, NY, 10305, USA
| | - Elie Bou Sanayeh
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, 475 Seaview Ave, Staten Island, NY, 10305, USA
| | - Chapman Wei
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, 475 Seaview Ave, Staten Island, NY, 10305, USA
| | - Khalil El Gharib
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, 475 Seaview Ave, Staten Island, NY, 10305, USA
| | - Saud Bin Abdul Sattar
- Department of Pulmonary and Critical Care, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Dany Elsayegh
- Department of Pulmonary and Critical Care, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Halim El-Hage
- Department of Pulmonary and Critical Care, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Suzanne El Sayegh
- Department of Internal Medicine, Staten Island University Hospital/Northwell Health, 475 Seaview Ave, Staten Island, NY, 10305, USA
- Department of Nephrology, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Michel Chalhoub
- Department of Pulmonary and Critical Care, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
| | - Ahmad Mustafa
- Department of Cardiology, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA
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7
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Farmakis IT, Kaier K, Hobohm L, Mohr K, Valerio L, Barco S, Konstantinides SV, Binder H. Healthcare resource utilisation and associated costs after low-risk pulmonary embolism: pre-specified analysis of the Home Treatment of Pulmonary Embolism (HoT-PE) study. Clin Res Cardiol 2024:10.1007/s00392-023-02355-5. [PMID: 38170252 DOI: 10.1007/s00392-023-02355-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/01/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Pulmonary embolism (PE) and its sequelae impact healthcare systems globally. Low-risk PE patients can be managed with early discharge strategies leading to cost savings, but post-discharge costs are undetermined. PURPOSE To define healthcare resource utilisation and overall costs during follow-up of low-risk PE. METHODS We used an incidence-based, bottom-up approach and calculated direct and indirect costs over 3-month follow-up after low-risk PE, with data from the Home Treatment of Patients with Low-Risk Pulmonary Embolism (HoT-PE) cohort study. RESULTS Average 3-month costs per patient having suffered low-risk PE were 7029.62 €; of this amount, 4872.93 € were associated with PE, accounting to 69.3% of total costs. Specifically, direct costs totalled 3019.33 €, and of those, 862.64 € (28.6%) were associated with PE. Anticoagulation (279.00 €), rehospitalisations (296.83 €), and ambulatory visits (194.95 €) comprised the majority of the 3-month direct costs. The remaining costs amounting to 4010.29 € were indirect costs due to loss of productivity. CONCLUSION In a patient cohort with acute low-risk PE followed over 3 months, the majority of costs were indirect costs related to productivity loss, whereas direct, PE-specific post-discharge costs were low. Effective interventions are needed to reduce the burden of PE and associated costs, especially those related to productivity loss.
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Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Katharina Mohr
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131, Mainz, Germany.
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece.
| | - Harald Binder
- Institute of Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
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Nze Ossima A, Ngaleu Siaha BF, Mimouni M, Mezaour N, Darlington M, Berard L, Cachanado M, Simon T, Freund Y, Durand-Zaleski I. Cost-effectiveness of modified diagnostic strategy to safely rule-out pulmonary embolism in the emergency department: a non-inferiority cluster crossover randomized trial (MODIGLIA-NI). BMC Emerg Med 2023; 23:140. [PMID: 38030975 PMCID: PMC10687836 DOI: 10.1186/s12873-023-00910-x] [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: 03/21/2023] [Accepted: 11/11/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND The aim of this trial-based economic evaluation was to assess the incremental costs and cost-effectiveness of the modified diagnostic strategy combining the YEARS rule and age-adjusted D-dimer threshold compared with the control (which used the age-adjusted D-dimer threshold only) for the diagnosis of pulmonary embolism (PE) in the Emergency Department (ED). METHODS Economic evaluation from a healthcare system perspective alongside a non-inferiority, crossover, and cluster-randomized trial conducted in 16 EDs in France and two in Spain with three months of follow-up. The primary endpoint was the additional cost of a patient without failure of the diagnostic strategy, defined as venous thromboembolism (VTE) diagnosis at 3months after exclusion of PE during the initial ED visit. Mean differences in 3-month failure and costs were estimated using separate generalized linear-regression mixed models, adjusted for strategy type, period, and the interaction between strategy and period as fixed effects and the hospital as a random effect. The incremental cost-effectiveness ratio (ICER) was obtained by dividing the incremental costs by the incremental frequency of VTE. RESULTS Of the 1,414 included patients, 1,217 (86%) were analyzed in the per-protocol analysis (648 in the intervention group and 623 in the control group). At three months, there were no statistically significant differences in total costs (€-46; 95% CI: €-93 to €0.2), and the failure rate was non inferior in the intervention group (-0.64%, one-sided 97.5% CI: -∞ to 0.21%, non-inferiority margin 1.5%) between groups. The point estimate of the incremental cost-effectiveness ratio (ICER) indicating that each undetected VTE averted in the intervention group is associated with cost savings of €7,142 in comparison with the control group. There was a 93% probability that the intervention was dominant. Similar results were found in the as randomized population. CONCLUSIONS Given the observed cost decrease of borderline significance, and according to the 95% confidence ellipses, the intervention strategy has a potential to lead to cost savings as a result of a reduction in the use of chest imaging and of the number of undetected VTE averted. Policy-makers should investigate how these monetary benefits can be distributed across stakeholders. CLINICALTRIALS Trial registration number ClinicalTrials.gov Identifier: NCT04032769; July 25, 2019.
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Affiliation(s)
- Arnaud Nze Ossima
- Paris Health Economics and Health Services Research Unit, URC Eco IdF, AP-HP, Hotel Dieu, 1 Place du Parvis Notre Dame, Paris, 75004, France
| | - Bibi Fabiola Ngaleu Siaha
- Paris Health Economics and Health Services Research Unit, URC Eco IdF, AP-HP, Hotel Dieu, 1 Place du Parvis Notre Dame, Paris, 75004, France
| | - Maroua Mimouni
- Paris Health Economics and Health Services Research Unit, URC Eco IdF, AP-HP, Hotel Dieu, 1 Place du Parvis Notre Dame, Paris, 75004, France
| | - Nadia Mezaour
- Paris Health Economics and Health Services Research Unit, URC Eco IdF, AP-HP, Hotel Dieu, 1 Place du Parvis Notre Dame, Paris, 75004, France
| | - Meryl Darlington
- Paris Health Economics and Health Services Research Unit, URC Eco IdF, AP-HP, Hotel Dieu, 1 Place du Parvis Notre Dame, Paris, 75004, France
| | - Laurence Berard
- Département de Pharmacologie Clinique and Plateforme de Recherche Clinique de l'Est Parisien, URCEST-CRC-CRB), Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital St Antoine, Paris, France
| | - Marine Cachanado
- Département de Pharmacologie Clinique and Plateforme de Recherche Clinique de l'Est Parisien, URCEST-CRC-CRB), Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital St Antoine, Paris, France
| | - Tabassome Simon
- Département de Pharmacologie Clinique and Plateforme de Recherche Clinique de l'Est Parisien, URCEST-CRC-CRB), Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Hôpital St Antoine, Paris, France
| | - Yonathan Freund
- Service des Urgences, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
| | - Isabelle Durand-Zaleski
- Paris Health Economics and Health Services Research Unit, URC Eco IdF, AP-HP, Hotel Dieu, 1 Place du Parvis Notre Dame, Paris, 75004, France.
- URCEco Hôpital de l'Hôtel Dieu, Paris, F-75004, France.
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Farmakis IT, Valerio L, Barco S, Alsheimer E, Ewert R, Giannakoulas G, Hobohm L, Keller K, Mavromanoli AC, Rosenkranz S, Morris TA, Konstantinides SV, Held M, Dumitrescu D. Cardiopulmonary exercise testing during follow-up after acute pulmonary embolism. Eur Respir J 2023; 61:2300059. [PMID: 36958742 PMCID: PMC10249018 DOI: 10.1183/13993003.00059-2023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/03/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) may provide prognostically valuable information during follow-up after pulmonary embolism (PE). Our objective was to investigate the association of patterns and degree of exercise limitation, as assessed by CPET, with clinical, echocardiographic and laboratory abnormalities and quality of life (QoL) after PE. METHODS In a prospective cohort study of unselected consecutive all-comers with PE, survivors of the index acute event underwent 3- and 12-month follow-ups, including CPET. We defined cardiopulmonary limitation as ventilatory inefficiency or insufficient cardiocirculatory reserve. Deconditioning was defined as peak O2 uptake (V'O2 ) <80% with no other abnormality. RESULTS Overall, 396 patients were included. At 3 months, prevalence of cardiopulmonary limitation and deconditioning was 50.1% (34.7% mild/moderate; 15.4% severe) and 12.1%, respectively; at 12 months, it was 44.8% (29.1% mild/moderate; 15.7% severe) and 14.9%, respectively. Cardiopulmonary limitation and its severity were associated with age (OR per decade 2.05, 95% CI 1.65-2.55), history of chronic lung disease (OR 2.72, 95% CI 1.06-6.97), smoking (OR 5.87, 95% CI 2.44-14.15) and intermediate- or high-risk acute PE (OR 4.36, 95% CI 1.92-9.94). Severe cardiopulmonary limitation at 3 months was associated with the prospectively defined, combined clinical-haemodynamic end-point of "post-PE impairment" (OR 6.40, 95% CI 2.35-18.45) and with poor disease-specific and generic health-related QoL. CONCLUSIONS Abnormal exercise capacity of cardiopulmonary origin is frequent after PE, being associated with clinical and haemodynamic impairment as well as long-term QoL reduction. CPET can be considered for selected patients with persisting symptoms after acute PE to identify candidates for closer follow-up and possible therapeutic interventions.
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Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Eva Alsheimer
- Clinic for General and Interventional Cardiology and Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Ralf Ewert
- Clinic for Internal Medicine, Greifswald University Hospital, Greifswald, Germany
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Anna C Mavromanoli
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Stephan Rosenkranz
- Department of Cardiology, Heart Center at the University Hospital Cologne and Cologne Cardiovascular Research Center, Cologne, Germany
| | - Timothy A Morris
- Division of Pulmonary and Critical Care Medicine, University of California at San Diego, La Jolla, CA, USA
| | - Stavros V 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
| | - Matthias Held
- Department of Pulmonary Medicine, KWM Missio Clinic, Würzburg, Germany
- These authors contributed equally and share last authorship
| | - Daniel Dumitrescu
- Clinic for General and Interventional Cardiology and Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
- These authors contributed equally and share last authorship
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