Prognostic performance of the Bova, sPESI, and Qanadli scores in patients with acute pulmonary embolism

BACKGROUND

Acute pulmonary embolism (PE) is a disease with a serious prognosis and a high probability of death in the emergency department.

PURPOSE

To investigate the prediction of PE-related mortality and intensive care admission (ICU) of Qanadli (Qscore), Bova, and simplified Pulmonary Embolism Severity Index (sPESI) scores.

MATERIAL AND METHODS

This retrospective observational study consisted of all patients diagnosed with acute PE who were imaged under computed tomography pulmonary angiography (CTPA) for a total of 5 years between 1 June 2018 and 1 June 2023. The prediction of radiological and clinical scores for mortality and ICU admission was examined.

RESULTS

A total of 95 patients were analyzed. Patients who died and those who were admitted to the ICU had a significantly higher frequency of being found to have a high-risk (≥1) sPESI score (P = 0.04 and P = 0.016, respectively). For mortality, the sPESI score was found to be significant; the sensitivity and specificity were observed as 54% and 66% (area under the curve [AUC]=0.670, 95% confidence interval [CI]=0.527-0.814; P = 0.020). For ICU admission, the sensitivity and specificity of the Qscore, sPESI, and Bova scores were 35%, 77%, and 58%, and 78%, 65%, and 84% respectively (AUC=0.626, 95% CI=0.511-0.740, P = 0.031; AUC=0.769, 95% CI=0.674-0.865, P < 0.001; and AUC=0.767, 95% CI=0.671-0.862, P < 0.001, respectively).

CONCLUSION

It was found that the sPESI score was effective at predicting mortality in patients with acute PE. Qscore, sPESI, and Bova scores have been shown to be useful in predicting ICU admission.

Selection of Home Treatment and Identification of Low-Risk Patients With Pulmonary Embolism Based on Simplified Pulmonary Embolism Severity Index Score in the Era of Direct Oral Anticoagulants

BACKGROUND

The simplified Pulmonary Embolism Severity Index (sPESI) score could help identify low-risk patients with pulmonary embolism for home treatment. However, the application of the sPESI score and selection for home treatment have not been fully evaluated in the direct oral anticoagulants era.

METHODS AND RESULTS

The COMMAND VTE (Contemporary Management and Outcomes in Patients With Venous Thromboembolism) Registry-2 is a multicenter registry enrolling consecutive patients with acute symptomatic venous thromboembolism. The current study population consists of 2496 patients with hemodynamically stable pulmonary embolism (2100 patients [84%] treated with direct oral anticoagulants), who were divided into 2 groups: sPESI scores of 0 and ≥1. We investigated the 30-day mortality, home treatment prevalence, and factors predisposing to home treatment using the Kaplan-Meier method and logistic regression model. Patients with an sPESI score of 0 accounted for 612 (25%) patients, and only 17% among 532 patients with out-of-hospital pulmonary embolism were treated at home. The cumulative 30-day mortality was lower in patients with an sPESI score of 0 than the score of ≥1 (0% and 4.8%, log-rank P<0.001). There was no patient with 30-day mortality with an sPESI score of 0. Independent factors for home treatment among out-of-hospital pulmonary embolism patients with an sPESI score of 0 were no transient risk factors for venous thromboembolism, no cardiac biomarker elevation, and direct oral anticoagulants use in the acute phase.

CONCLUSIONS

The 30-day mortality rate was notably low in an sPESI score of 0. Nevertheless, only a minority of patients with an sPESI score of 0 were treated at home between 2015 and 2020 after the introduction of direct oral anticoagulants for venous thromboembolismin Japan.

Performance of the Simplified Pulmonary Embolism Severity Index in predicting 30-day mortality after acute pulmonary embolism: Validation from a large-scale cohort

BACKGROUND

The performance of existing prognostic scores including the simplified Pulmonary Embolism Severity Index (sPESI) for short-term mortality of non-high-risk PE in Chinese population has not been widely validated.

METHODS

Non-high-risk patients were included from the prospective cohort of the China pUlmonary Thromboembolism REgistry Study (CURES). The sPESI, RIETE, Geneva, modified FAST, and Bova score were validated. The discriminatory performance was measured by the area under the curve (AUC). We also compared the sensitivity, odds ratio, specificity, positive predictive value and negative predictive value of these scores.

RESULTS

A total of 6,873 non-high-risk patients with acute PE were included and 241 (3.5 %) patients died within 30 days. Compared to the Geneva, modified FAST, and Bova score, the AUCs for predicting 30-day death of sPESI and RIETE score were higher at 0.712 (95 % CI, 0.680, 0.743) and 0.723 (95 % CI, 0.691, 0.755) respectively. The sPESI demonstrated the highest sensitivity at 0.809, while the RIETE score, Geneva, Modified FAST and BOVA score showed sensitivities of 0.622, 0.568, 0.477 and 0.502 respectively. A sPESI ⩾1 point was associated with a 4.7-fold increased risk of 30-day all-cause mortality (95 % CI, 3.427, 6.563, p < 0.001), while a RIETE score of ⩾1 point was associated with a 4.5-fold increased risk (95 % CI, 3.127, 6.341, p < 0.001). The Geneva score, modified FAST and Bova score showed inferior performance.

CONCLUSIONS

The implementation of the fewer-parameter, easier-to-calculate sPESI in Chinese patients with PE can help to discriminate patients with extremely low risk of short-term mortality for home treatment or early discharge.

Predicting Hospital Survival in Patients Admitted to ICU with Pulmonary Embolism

OBJECTIVE

The Pulmonary Embolism Severity Index (PESI) and simplified PESI (sPESI) predict mortality for patients with PE. We compared PESI/sPESI to the Acute Physiology and Chronic Health Evaluation IV (APACHE-IV) in predicting mortality in patients with PE admitted to the intensive care unit (ICU). Additionally, we assessed the performance of a novel ICU-sPESI score created by adding three clinical variables associated with acuity of PE presentation (intubation, confusion [altered mental status], use of vasoactive infusions) to sPESI.

MATERIALS AND METHODS

Using the eICU Collaborative Research Database from 2014 to 2015, we conducted a large retrospective cohort study of adult patients admitted to the ICU with a primary diagnosis of PE. We calculated APACHE-IV, PESI, sPESI, and ICU-sPESI scores and compared their performance for predicting in-hospital mortality using area under the receiver operating characteristic (AUROC) curve. Score thresholds for >99% negative predictive values (NPV) were calculated for each score. Survival was estimated using the Kaplan-Meier method.

RESULTS

We included 1424 PE cases. In-hospital mortality was 6.3% [95% CI: 5.1%-7.6%]. AUROC for APACHE-IV, PESI, and sPESI were 0.870, 0.848, and 0.777, respectively. APACHE-IV and PESI outperformed sPESI (P < 0.01 for both comparisons), while APACHE-IV and PESI demonstrated similar performance (P = 0.322). The ICU-sPESI performance was similar to APACHE-IV and PESI (AUROC = 0.847; AUROC comparison: APACHE-IV vs ICU-sPESI: P = 0.396; PESI vs ICU-sPESI: P = 0.945). Hospital mortality for ICU-sPESI scores 0-2 was 1.1%, and for scores 3, 4, 5, 6, and ≥7 was 8.6%, 11.7%, 29.2%, 37.5%, and 76.9%, respectively. Score thresholds for >99% NPV were ≤48 for APACHE-IV, ≤115 for PESI, and 0 points for sPESI and ICU-sPESI.

CONCLUSIONS

By accounting for severity of PE presentation, our newly proposed ICU-sPESI score provided improved PE mortality prediction compared to the original sPESI score and offered excellent discrimination of mortality risk.

Risk Stratification and Management of Intermediate-Risk Acute Pulmonary Embolism

Pulmonary embolism (PE) is the third most common cause of cardiovascular death and necessitates prompt, accurate risk assessment at initial diagnosis to guide treatment and reduce associated mortality. Intermediate-risk PE, defined as the presence of right ventricular (RV) dysfunction in the absence of hemodynamic compromise, carries a significant risk for adverse clinical outcomes and represents a unique diagnostic challenge. While small clinical trials have evaluated advanced treatment strategies beyond standard anticoagulation, such as thrombolytic or endovascular therapy, there remains continued debate on the optimal care for this patient population. Here, we review the most recent risk stratification models, highlighting differences between prediction scores and their limitations, and discuss the utility of serologic biomarkers and imaging modalities to detect right ventricular dysfunction. Additionally, we examine current treatment recommendations including anticoagulation strategies, use of thrombolytics at full and reduced doses, and utilization of invasive treatment options. Current knowledge gaps and ongoing studies are highlighted.

Machine Learning-Based Prediction of Pulmonary Embolism Prognosis Using Nutritional and Inflammatory Indices

PURPOSE

This study aimed to create and assess machine learning (ML) models that utilize nutritional and inflammatory indices, focusing on the advanced lung cancer inflammation index (ALI) and neutrophil-to-albumin ratio (NAR), to improve the prediction accuracy of PE prognosis.

PATIENTS AND METHODS

We conducted a retrospective analysis of 312 patients, comprising 254 survivors and 58 non-survivors. The Boruta algorithm was used to identify significant variables, and four ML models (XGBoost, Random Forest, Logistic Regression, and SVM) were employed to analyze the clinical data and assess the performance of the models.

RESULTS

The XGBoost model, with optimal hyperparameters, achieved the best performance, with an accuracy of 0.882, an F1-score of 0.889, a precision of 0.917, a sensitivity of 0.863, a specificity of 0.905, and an AUC of 0.873. Analysis of feature importance indicated that the most critical predictors across models were respiratory failure, log-transformed ALI, albumin level, age, diastolic blood pressure, and NAR.

CONCLUSION

The ML-based prediction models effectively predicted the prognosis of PE, with the XGBoost model exhibiting good performance. Respiratory failure, ALI, albumin level, age, diastolic blood pressure, and NAR were correlated with PE prognosis.

Predicting acute and long-term mortality in a cohort of pulmonary embolism patients using machine learning

BACKGROUND

Pulmonary embolism (PE) is a severe condition that causes significant mortality and morbidity. Due to its acute nature, scores have been developed to stratify patients at high risk of 30-day mortality. Here we develop a machine-learning based score to predict 30-day, 90-day, and 365-day mortality in PE patients.

METHODS

The Birmingham and Black Country Venous Thromboembolism registry (BBC-VTE) of 2183 venous thromboembolism patients is used. Random forests were trained on a 70% training cohort and tested against 30% held-out set. The outcomes of interest were 30-day, 90-day, and 365-day mortality. These were compared to the pulmonary embolism severity index (PESI) and simplified pulmonary embolism severity index (sPESI). Shapley values were used to determine important predictors. Oral anticoagulation at discharge was also investigated as a predictor of mortality.

RESULTS

The machine learning risk score predicted 30-day mortality with AUC 0.71 [95% CI: 0.63 - 0.78] compared to the sPESI AUC of 0.65 [95% CI: 0.57 - 0.73] and PESI AUC of 0.64 [95% CI: 0.56 - 0.72]. 90-day mortality and 365-day mortality were predicted with an AUC of 0.74 and 0.73 respectively. High counts of neutrophils, white blood cell counts, and c-reactive protein and low counts of haemoglobin were important for 30-day mortality prediction but progressively lost importance with time. Older age was an important predictor of high risk throughout.

CONCLUSION

Machine learning algorithms have improved on standard clinical risk stratification for PE patients. External cohort validation is required before incorporation into clinical workflows.

Intensify Standardized Anticoagulation for Cancer-associated Pulmonary Embolism: From Single-center Real-world Data

PURPOSE

Pulmonary embolism (PE) is a significant contributor to mortality in patients with cancer. Although anticoagulation serves as the cornerstone of treatment for cancer-associated PE, it has not been emphasized in real-world settings. The aim of this study was to examine the impact of suboptimal anticoagulant treatment on the prognosis of cancer-associated PE.

METHODS

A cohort of 356 individuals newly diagnosed with acute PE were enrolled. The primary outcome of the study was recurrent venous thromboembolism (VTE), and the secondary outcomes were all-cause mortality and major bleeding (consisting of a reduction in the hemoglobin level by at least 20 g/L, transfusion of at least 2 units of blood, or symptomatic bleeding in a critical area or organ or fatal bleeding).

FINDINGS

Of the total participants, 156 (43.8%) were diagnosed with cancer. A comparison between the cancer and noncancer groups revealed that patients with cancer were more frequently asymptomatic (41.0% vs 4.5%; P < 0.001), less likely to have right ventricular dysfunction (4.5% vs 14.0%; P = 0.001), received less anticoagulant treatment during hospitalization (85.3% vs 98.5%; P < 0.001), and had a shorter duration of anticoagulation (5.02 [7.40] months vs 14.19 [10.65] months; P < 0.001). In addition, patients with cancer were found to be at a higher risk of recurrent VTE (17.3% vs 4.0%; P < 0.001) and all-cause mortality (23.7% vs 10.5%; P = 0.001). Multiple Cox regression analysis indicated that discontinuation of anticoagulation at 3 months was a significant risk factor for recurrent VTE in the cancer group (HR, 15.815; 95% CI, 3.047-82.079; P = 0.001).

IMPLICATIONS

The brief duration of anticoagulation therapy and elevated likelihood of recurrent VTE serve as cautionary indicators for the need to enhance awareness of standardized anticoagulant treatment for cancer-associated PE. The ultimate goal is to enhance patient prognosis and quality of life.

Validation of the Pulmonary Embolism Severity Index Risk Classification and the 2019 European Society of Cardiology Risk Stratification in the Southeast Asian Population with Acute Pulmonary Embolism

AIM

To date, no studies representing the Southeast Asian population have validated the Pulmonary Embolism Severity Index (PESI) and 2019 European Society of Cardiology (ESC) risk stratification. Therefore, this study aimed to validate the PESI score, simplified PESI (sPESI), PESI risk classification, and 2019 ESC risk stratification in Southeast Asian patients with acute pulmonary embolism (APE).

METHODS

The present study is a 10-year cross-sectional study. Here, risk regressions were conducted to identify the PESI risk classification, sPESI, and 2019 ESC risk stratification as predictors for 30-day all-cause and PE-related mortalities. Receiver operating characteristic (ROC) curves were constructed to determine the diagnostic ability of the PESI score, sPESI score, PESI risk classification, and 2019 ESC risk stratification to predict 30-day mortality.

RESULTS

A total of 696 patients (male, 286; female, 410; mean age, 57.7±15.7 years) were included in this study from 2011 to 2020. The risk of 30-day all-cause mortality progressively increased with the 2019 ESC risk stratification, being approximately 6-fold higher in the high-risk than in the low-risk class [risk ratio: 6.24 (95% confidence interval (CI), 3.12, 12.47), P＜0.001]. The risk of 30-day all-cause mortality with the PESI risk classification also increased with the risk classes, being approximately 6-fold higher in class V than in class I [adjusted risk ratio: 5.91 (95% CI, 2.25, 15.51), P＜0.001]. The highest area under the receiver operating characteristic curve (AuROC) of the predictive model was the PESI score [AuROC=0.733 (95% CI, 0.685, 0.782)].

CONCLUSION

Our study represents a good validation of the PESI and 2019 ESC risk stratification to predict 30-day mortality after APE diagnosis in the Southeast Asian population.

Acute pulmonary embolism: Diagnosis and management

Acute pulmonary embolism (PE) can present with non-specific signs and symptoms and thus the diagnosis and management might not be as straightforward. This review outlines the new PE management guidelines in the Indian context. The exact prevalence in the Indian population is not well defined; despite recent studies suggesting an increasing trend in the Asian population. A delay in treatment can be fatal, especially in massive PE. The nuances associated with stratification and management have led to heterogeneity in acute PE management. The purpose of the review is. 1: To highlight the principles of stratification, diagnosis and management of acute PE with a special attention towards the Indian population. 2: To aid patient selection for newer catheter based therapies. To conclude, formulation of pulmonary embolism guidelines in the Indian setting is required underlying the role of further research in this area.

Gender Disparities in Presentation, Management, and Outcomes of Acute Pulmonary Embolism

Pulmonary embolism (PE) is the third most common cause of cardiovascular death; however, gender disparities in PE remain understudied. All PE cases at a single institution between January 2013 and June 2019 were retrospectively reviewed. The clinical presentation, treatment modalities, and outcomes were compared between men and women using univariate and multivariate analyses adjusting for differences in baseline characteristics. A total of 1,345 patients were diagnosed with acute PE, of whom 56.3% were women (n = 757). Women had a significantly higher mean body mass index (29.4 vs 28.4) and a higher frequency of hypertension (53% vs 46%) and hormone use (6.6% vs 0%; all p <0.02). Men had a higher frequency of smoking (45% vs 33%, p <0.0001). Women had significantly lower PE severity index classifications (p = 0.0009). The rates of intensive care unit admission, vasopressor requirements, extracorporeal membrane oxygenation cannulation, and mechanical ventilation were similar between the genders. There was no significant difference in the treatment modality used between the genders. Although the risk factors and PE severity index class differed between the genders, there was no significant difference in resource utilization or treatment modality. Gender was also not a significant predictor of in-hospital mortality, moderate or severe bleeding, increased length of stay, or readmission in the study population.

Predictive Ability of the National Early Warning Score in Mortality Prediction of Acute Pulmonary Embolism in the Southeast Asian Population

BACKGROUND

The National Early Warning Scores (NEWS) easily and objectively measures acute clinical deterioration. However, the performance of NEWS to predict mortality in patients with acute pulmonary embolism (APE) is still required. Therefore, the objective of this study was to evaluate the performance of the NEWS in predicting the mortality of patients with APE.

METHODS

NEWS and Pulmonary Embolism Severity Index (PESI) at diagnosis time were calculated. Risk regression analysis was performed to identify the NEWS and PESI risk classification as a predictor for 30 days all-cause mortality and PE-related mortality.

RESULTS

NEWS was significantly higher in non-survivors compared to survivors (median (IQR) was 10 (7, 11) vs. 7 (2, 9), respectively, p < 0.001). The best cut-off point of NEWS in discriminating APE patients who non-survived from those who survived at 30 days was ≥9, with a sensitivity and specificity of 66.9% and 66.3%, respectively. The adjusted risk ratio of 30-day all-cause mortality in patients with initial NEWS ≥ 9 was 2.96 (95% CI; 2.13, 4.12, p < 0.001).

CONCLUSIONS

The NEWS can be used for mortality prediction in patients with APE. APE patients with NEWS ≥ 9 are associated with a high risk of mortality and should be closely monitored.

Deep vein thrombosis symptoms and 30-day mortality in acute pulmonary embolism

BACKGROUND

In patients with acute symptomatic pulmonary embolism (PE), the presence of concomitant lower-limb deep vein thrombosis (DVT) has been associated with a higher mortality rate. The prognostic significance of DVT symptoms among these patients remains uncertain.

METHODS

We used the RIETE (Registro Informatizado de Enfermedad TromboEmbólica) registry to compare the 30-day mortality rate in patients with PE and concomitant lower-limb DVT, according to the presence or absence of DVT symptoms. Primary outcomes were all-cause death and PE-related death within the first 30 days.

RESULTS

Since March 2001 to June 2021, there were 17,742 patients with acute symptomatic PE and objectively proven concomitant lower-limb DVT. Of these, 11,984 (68%) had DVT symptoms. Most patients with or without DVT symptoms (82% vs. 81%) received low-molecular-weight heparin initially. Then, most (61% vs. 58%) switched to vitamin K antagonists. During the first 30 days of therapy, 497 patients with DVT symptoms (4.1%) and 164 (2.8%) with no DVT symptoms died (rate ratio [RR]: 1.48; 95%CI: 1.23-1.77). The rates of PE-related death were: 1.0% vs. 0.7%, respectively (RR: 1.50; 95%CI: 1.04-2.16). On multivariable analysis, patients with DVT symptoms were at increased risk for all-cause death (adjusted hazard ratio [aHR]: 1.49; 95%CI: 1.24-1.78), and PE-related death (aHR: 1.52; 95%CI: 1.05-2.20).

CONCLUSION

Among patients with acute symptomatic PE and concomitant lower-limb DVT, those with DVT symptoms had an increased all-cause and PE-related mortality within 30 days. Assessment of DVT symptoms would assist with risk stratification of these patients.

Acute phase characteristics and long-term complications of pulmonary embolism in COVID-19 compared to non-COVID-19 cohort: a large single-centre study

BACKGROUND

To compare the severity of pulmonary embolism (PE) and the long-term complications between patients with and without COVID-19, and to investigate whether the tools for risk stratification of death are valid in this population.

METHODS

We retrospectively included hospitalized patients with PE from 1 January 2016 to 31 December 2022. Comparisons for acute episode characteristics, risk stratification of the PE, outcomes, and long-term complications were made between COVID and non-COVID patients.

RESULTS

We analyzed 116 (27.5%) COVID patients and 305 (72.4%) non-COVID patients. In patients with COVID-19, the traditional risk factors for PE were absent, and the incidence of deep vein thrombosis was lower. COVID patients showed significantly higher lymphocyte count, lactate dehydrogenase, lactic acid, and D-dimer levels. COVID patients had PE of smaller size (12.3% vs. 25.5% main pulmonary artery, 29.8% vs. 37.1% lobar, 44.7% vs. 29.5% segmental and 13.2% vs. 7.9% subsegmental, respectively; p < 0.001), less right ventricular dysfunction (7.7% vs. 17.7%; p = 0.007) and higher sPESI score (1.66 vs. 1.11; p < 0.001). The need for mechanical ventilation was significantly higher in COVID patients (8.6% vs. 1.3%; p < 0.001); However, the in-hospital death was less (5.2% vs. 10.8%; p = 0.074). The incidence of long-term complications was lower in COVID cohort (p < 0.001). PE severity assessed by high sPESI and intermediate and high-risk categories were independently associated with in-hospital mortality in COVID patients.

CONCLUSION

The risk of in-hospital mortality and the incidence of long-term complications were lower in COVID-19. The usual tools for risk stratification of PE are valid in COVID patients.

Impact of Heart Rate at Diagnosis on Clinical Outcomes in Patients With Acute Pulmonary Embolism

Data on the impact of heart rate (HR) at diagnosis on clinical outcomes in patients with acute pulmonary embolism (PE) remain scarce. The present study population consisted of 1,532 patients with PE; the patients were divided into 4 groups, including (1) HR <80 beats/min (n = 451, 29%), (2) 80 ≤HR <100 beats/min (n = 620, 40%), (3) 100 ≤HR <110 beats/min (n = 215, 14%), and (4) HR ≥110 beats/min (n = 246, 16%). The cumulative 30-day incidences of all-cause death were significantly higher in the 100 ≤HR <110 and HR ≥110 beats/min groups than in the HR <80 beats/min group. Incidences were 2.7%, 3.6%, 6.6%, and 5.7% (p = 0.04) in the HR <80 beats/min, 80 ≤HR <100 beats/min, 100 ≤HR <110 beats/min, and HR ≥110 beats/min groups, respectively. With the HR <80 beats/min group as reference, the 100 ≤HR <110 and HR ≥110 groups, but not the 80 ≤HR <100 group, were significantly associated with an increased risk of 30-day all-cause death. Hazard ratio was 2.53 (95% confidence interval [CI] 1.17 to 5.56, p = 0.02) for the 80 ≤HR <100 beats/min group, 2.20 (95% CI 1.02 to 4.84, p = 0.046) for the 100 ≤HR <110 beats/min group, and 1.34 (95% CI 0.67 to 2.79, p = 0.41) for the HR ≥110 beats/min group. The cumulative 30-day incidences of all-cause death in patients with simplified Pulmonary Embolism Severity Index score = 0 were 0.6%, 0.3%, and 0.7% when based on cut-off values of HR ≥110 beats/min, HR ≥100 beats/min, and ≥80 beats/min, respectively. Patients with moderate tachycardia (100 ≤HR <110) seemed to be at comparable risk of 30-day all-cause death to those with HR ≥110 beats/min and at higher risk of 30-day all-cause death than those with HR <80 beats/min; this may suggest a potential benefit of the alternative cut-off value of HR ≥100 beats/min in the simplified Pulmonary Embolism Severity Index score for identification of low-risk patients.

Home Treatment of Patients with Pulmonary Embolism: A Single Center 10-Year Experience from Ljubljana Registry

Current guidelines suggest careful risk stratification using a structured clinical approach when selecting patients with pulmonary embolism (PE) for home treatment. The aim of our study was to assess whether PE patients referred to home treatment are appropriately risk-stratified according to guidelines prior to referral and what the real-life course of the disease in these patients is. We included patients with confirmed PE referred to outpatient management and treated with anticoagulants between 2010 and 2019, whose data were collected in a prospective management registry. Using simplified PE severity index and/or signs of right ventricular strain, we classified patients to either appropriate or inappropriate low-risk classes for outpatient management. We compared 30-day mortality, overall mortality, and rates of recurrent thromboembolism or major bleeding between both classes. Among 278 patients, 188 (67.6%) and 90 (32.4%) were classified as appropriate or inappropriate class, respectively. In total, 30-day mortality was low in both groups: 0% in appropriate class and 1.1% in inappropriate class. The overall mortality rate was higher in the inappropriate than in the appropriate class (12.1 vs 0.9/100 patient-years, respectively, P < .001). Rates of recurrent thromboembolism and major bleeding were similar for both classes. We conclude that in real-life, a significant proportion of inappropriate low-risk class PE patients are referred to outpatient management. However, with careful follow-up, early mortality is low, even in home-treated patients inappropriately classified as low-risk.

Lipoprotein(a) and Pulmonary Embolism Severity-A Retrospective Data Analysis

Aim

We aimed to investigate a correlation between PE severity and Lp(a) levels.

Methods

We performed a retrospective data analysis from our medical records of PE patients admitted to the University Hospital Graz, Austria. Patients with an Lp(a) reading within a 1-year interval before and after PE diagnosis were included. In accordance with the 2019 ESC guidelines for the diagnosis and management of acute PE, severity assessment was carried out classifying patients into four groups: low risk (LR), intermediate low risk (IML), intermediate high risk (IMH) and high risk (HR). The study period of interest was between January 1, 2002 and August 1, 2020.

Results

We analyzed 811 patients with PE, of whom 323 (40%) had low-risk PE, 343 (42%) had intermediate-low-risk PE, 64 (8%) had intermediate-high-risk PE, and 81 (10%) had high-risk PE, respectively. We did not observe an association between PE severity and Lp(a) concentrations. In detail, median Lp(a) concentrations were 17 mg/dL [25–75th percentile: 10-37] in low-risk PE patients, 16 mg/dL [10–37] in intermediate-low-risk PE patients, 15mg/dL [10–48] in intermediate-high-risk PE patients, and 13mg/dL [10–27] in high-risk PE patients, respectively (Kruskal-Wallis p = 0.658, p for linear trend = 0.358).

Conclusion

The current findings suggest no correlation between PE severity and Lp(a) levels.

Venous thromboembolism: Recent advancement and future perspective

Clinicians have been more and more often encountering patients with venous thromboembolism (VTE), including pulmonary embolism and deep vein thrombosis, leading to the increased importance of VTE in daily clinical practice. VTE is becoming a common issue in Asian countries including Japan. The management strategies of VTE have changed dramatically in the past decade including the introduction of direct oral anticoagulants (DOACs). In addition, there have been several landmark clinical trials assessing acute treatment strategies including thrombolysis and inferior vena cava (IVC) filter. The current VTE guidelines do not recommend the routine use of thrombolysis or IVC filters based on recent evidence; Nevertheless, the prevalence of thrombolysis and IVC filter use in Japan was strikingly high. The novel profiles of DOACs with rapid onset of action and potential benefit of a lower risk for bleeding compared with vitamin K antagonist could make home treatment feasible and is safer even with extended anticoagulation therapy. One of the most clinically relevant issues for VTE treatment is optimal duration of anticoagulation for the secondary prevention of VTE. Considering recent evidence, optimal duration of anticoagulation should be determined based on the risk for recurrence as well as the risk for bleeding in an individual patient. Despite the recent advances for VTE management, there are still a number of uncertain issues that challenge clinicians in daily clinical practice, such as cancer-associated VTE and minor VTE including subsegmental pulmonary embolism and distal deep vein thrombosis, warranting future research. Several clinical trials are now ongoing for these issues, globally as well as in Japan. The current review is aimed to overview the recent advances in VTE management, describe the current status including some domestic issues in Japan, and discuss the future perspective of VTE.

Heart Rate and Mortality in Patients With Acute Symptomatic Pulmonary Embolism

BACKGROUND

The association between heart rate (HR) and pulmonary embolism (PE) outcomes has not been well studied. Furthermore, optimal cutoffs to identify low-risk and intermediate- to high-risk patients are not well known.

RESEARCH QUESTION

Does an association exist between baseline HR and PE outcome across the continuum of HR values?

STUDY DESIGN AND METHODS

The current study included 44,331 consecutive nonhypotensive patients with symptomatic PE from the Registro Informatizado de la Enfermedad TromboEmbólica registry between 2001 and 2021. Outcomes included 30-day all-cause and PE-specific mortality. We used hierarchical logistic regression to assess the association between admission HR and outcomes.

RESULTS

A positive relationship was found between admission HR and 30-day all-cause and PE-related mortality. Considering an HR of 80 to 99 beats/min as a reference, patients in the higher HR strata showed higher rates of all-cause death (adjusted OR, 1.5 for HR of 100-109 beats/min; OR, 1.7 for HR of 110-119 beats/min; OR, 1.9 for HR of 120-139 beats/min; and OR, 2.4 for HR of ≥ 140 beats/min). Patients in the lower strata of HR showed significantly lower rates of 30-day all-cause mortality compared with the same reference group (adjusted OR, 0.6 for HR of 60-79 beats/min; and OR, 0.5 for HR of < 60 beats/min). The findings for 30-day PE-related mortality were similar. For identification of low-risk patients, a cutoff value of 80 beats/min (vs 110 beats/min) increased the sensitivity of the simplified Pulmonary Embolism Severity Index (sPESI) from 93.4% to 98.8%. For identification of intermediate- to high-risk patients, a cutoff value of 140 beats/min (vs 110 beats/min) increased the specificity of the Bova score from 93.2% to 98.0%.

INTERPRETATION

In nonhypotensive patients with acute symptomatic PE, a high HR portends an increased risk of all-cause and PE-related mortality. Modifying the HR cutoff in the sPESI and the Bova score improves prognostication of patients with PE.

Right ventricle assessment in patients with pulmonary embolism at low risk for death based on clinical models: an individual patient data meta-analysis

AIMS

Patients with acute pulmonary embolism (PE) at low risk for short-term death are candidates for home treatment or short-hospital stay. We aimed at determining whether the assessment of right ventricle dysfunction (RVD) or elevated troponin improves identification of low-risk patients over clinical models alone.

METHODS AND RESULTS

Individual patient data meta-analysis of studies assessing the relationship between RVD or elevated troponin and short-term mortality in patients with acute PE at low risk for death based on clinical models (Pulmonary Embolism Severity Index, simplified Pulmonary Embolism Severity Index or Hestia). The primary study outcome was short-term death defined as death occurring in hospital or within 30 days. Individual data of 5010 low-risk patients from 18 studies were pooled. Short-term mortality was 0.7% [95% confidence interval (CI) 0.4-1.3]. RVD at echocardiography, computed tomography or B-type natriuretic peptide (BNP)/N-terminal pro BNP (NT-proBNP) was associated with increased risk for short-term death (1.5 vs. 0.3%; OR 4.81, 95% CI 1.98-11.68), death within 3 months (1.6 vs. 0.4%; OR 4.03, 95% CI 2.01-8.08), and PE-related death (1.1 vs. 0.04%; OR 22.9, 95% CI 2.89-181). Elevated troponin was associated with short-term death (OR 2.78, 95% CI 1.06-7.26) and death within 3 months (OR 3.68, 95% CI 1.75-7.74).

CONCLUSION

RVD assessed by echocardiography, computed tomography, or elevated BNP/NT-proBNP levels and increased troponin are associated with short-term death in patients with acute PE at low risk based on clinical models. RVD assessment, mainly by BNP/NT-proBNP or echocardiography, should be considered to improve identification of low-risk patients that may be candidates for outpatient management or short hospital stay.

Healthcare and Economic Impact of Lung Perfusion Scintigraphy in Patients Affected by Acute Pulmonary Embolism

Acute pulmonary embolism (APE) is a cardiovascular emergency, representing the main cause of mortality, morbidity, and hospitalisation in Europe. We aim to evaluate the economic and healthcare impact of lung perfusion scintigraphy (LPS) used in patients with suspected APE, in the event of non-conclusive or contraindicated computed tomography pulmonary angiography (CTPA). We considered two alternative healthcare processes for APE diagnosis, with and without LPS. We performed a cost analysis with the aim of evaluating the average direct healthcare costs for diagnosis, risk assessment, and treatment of APE. We used data from a monocentric trial. Our economic model showed that the strategy with LPS was preferable in terms of costs. The average per-patient costs for the diagnosis and treatment of the acute phase of PE in low-risk patients with a non-conclusive or not-executable CTPA, with and without LPS, are EUR 2145.25 and EUR 4912.45, respectively. LPS is a simple, quick, and economic examination, useful in this setting of patients not only for an early diagnosis but also to exclude APE, demonstrating an advantage in terms of healthcare resources. To the best of our knowledge, this study is the first to analyse the economic and healthcare impact of the use of LPS in the diagnostic pathway of suspected APE.

Outpatient treatment of emergency department patients diagnosed with venous thromboembolism

Venous thromboembolism (VTE) includes the diagnosis of either deep venous thrombosis (DVT) and/or pulmonary embolism (PE). This review discusses an evidence-based approach to the outpatient treatment of VTE in the emergency care setting. Main findings: The majority of patients diagnosed with VTE in the acute care setting are at low risk for an adverse event. Outpatient treatment for patients deemed low-risk by validated clinical decision tools leads to safe, efficacious, patient-centered, and cost-effective care. From a patient perspective, outpatient treatment of VTE can been simplified by the use of direct oral anticoagulant (DOACs) medications, and is supported by clinical trial evidence, and clinical practice guidelines from international societies. Outpatient treatment of patients with DVT has been more widely accepted as a best practice, while adoption of outpatient treatment of low-risk patients with acute PE has lagged. Many acute care clinicians remain wary of discharging patients with PE, concerned about drug access, adherence, and follow-up. Patients with VTE should be risk stratified identically as emerging evidence has demonstrated efficacy and safety in the interdependence of acute care protocols for the outpatient treatment of low-risk DVT and PE. Clinicians who practice in the acute care setting should be comfortable with risk stratification, anticoagulation, and discharge of low-risk VTE.

Refinement of a modified simplified Pulmonary Embolism Severity Index for elderly patients with acute pulmonary embolism

OBJECTIVE

To evaluate the utility of a modified (i.e., without the variable "Age >80 years") simplified Pulmonary Embolism Severity Index (sPESI) in elderly patients with acute symptomatic pulmonary embolism (PE), and to derive and validate a refined version of the sPESI for identification of elderly patients at low risk of adverse events.

METHODS

The study included normotensive patients aged >80 years with acute PE enrolled in the RIETE registry. We used multivariable logistic regression analysis to create a new risk score to predict 30-day all-cause mortality. We externally validated the new risk score in elderly patients from the COMMAND VTE registry.

RESULTS

Multivariable logistic regression identified four predictors for mortality: high-risk sPESI, immobilization, coexisting deep vein thrombosis (DVT), and plasma creatinine >2 mg/dL. In the RIETE derivation cohort, the new model classified fewer patients as low risk (4.0% [401/10,106]) compared to the modified sPESI (35% [3522/10,106]). Low-risk patients based on the new model had a lower 30-day mortality than those based on the modified sPESI (1.2% [95% CI, 0.4-2.9%] versus 4.7% [95% CI, 4.0-5.4%]). In the COMMAND VTE validation cohort, 1.5% (3/206) of patients were classified as having low risk of death according to the new model, and the overall 30-day mortality of this group was 0% (95% CI, 0-71%), compared to 5.9% (95% CI, 3.1-10.1%) in the high-risk group.

CONCLUSIONS

For predicting short-term mortality among elderly patients with acute PE, this study suggests that the new model has a substantially higher sensitivity than the modified sPESI. A minority of these patients might benefit from safe outpatient therapy of their disease.

Indigo Aspiration System for Treatment of Pulmonary Embolism: Results of the EXTRACT-PE Trial

OBJECTIVES

This study sought to prospectively evaluate the safety and efficacy of the Indigo aspiration system in submassive acute pulmonary embolism (PE).

BACKGROUND

PE treatment with thrombolytics has bleeding risks. Aspiration thrombectomy can remove thrombus without thrombolytics, but data are lacking.

METHODS

This study was a prospective, single-arm, multicenter study that enrolled patients with symptomatic acute PE ≤14 days, systolic blood pressure ≥90 mm Hg, and right ventricular-to-left ventricular (RV/LV) ratio >0.9. The primary efficacy endpoint was change in RV/LV ratio from baseline to 48 h post-procedure on core lab-adjudicated computed tomography angiography. The primary safety endpoint was a composite of 48-h major adverse events: device-related death, major bleeding, and device-related serious adverse events (clinical deterioration, pulmonary vascular, or cardiac injury). All sites received Institutional Review Board approval.

RESULTS

A total of 119 patients (mean age 59.8 ± 15.0 years) were enrolled at 22 U.S. sites between November 2017 and March 2019. Median device insertion to removal time was 37.0 (interquartile range: 23.5 to 60.0) min. Two (1.7%) patients received intraprocedural thrombolytics. Mean RV/LV ratio reduction from baseline to 48 h post-procedure was 0.43 (95% confidence interval: 0.38 to 0.47; p < 0.0001). Two (1.7%) patients experienced 3 major adverse events. Rates of cardiac injury, pulmonary vascular injury, clinical deterioration, major bleeding, and device-related death at 48 h were 0%, 1.7%, 1.7%, 1.7%, and 0.8%, respectively.

CONCLUSIONS

In this prospective, multicenter study the Indigo aspiration system was associated with a significant reduction in the RV/LV ratio and a low major adverse event rate in submassive PE patients. Intraprocedural thrombolytic drugs were avoided in 98.3% of patients. (Evaluating the Safety and Efficacy of the Indigo aspiration system in Acute Pulmonary Embolism [EXTRACT-PE]; NCT03218566).

Efficacy of Computed Tomography Pulmonary Angiography as Non-invasive Imaging Biomarker for Risk Stratification of Acute Pulmonary Embolism

OBJECTIVES

Massive and sub-massive pulmonary embolisms (PEs) are associated with high mortality and morbidity. The mainstay of treatment for PE is anticoagulation. However, high- and intermediate-risk patients may benefit from interventional thrombolytic therapy. Computed tomography pulmonary angiography (CTPA) is widely available, fast, and non-invasive technique, and it can identify pulmonary thrombus down to at least a segmental level. In this study, we attempt to evaluate the efficacy of CTPA as a non-invasive imaging biomarker for risk stratification of acute PE (APE) patients.

MATERIAL AND METHODS

This is a prospective study conducted on 150 patients who proved to have APE by CTPA. The simplified PE severity index score was obtained. The pulmonary artery obstruction index (PAOI) using and right to left ventricular (RV/LV) diameter ratios were calculated.

RESULTS

The patients were divided into (1) high risk (shocked) and (2) non-high risk groups. There was a significant difference between the 1st and 2nd groups regarding PAOI. Hemodynamically stable patients were further subclassified according to the right ventricular dysfunction (RVD) into Group Ia (intermediate risk) and Group Ib (low risk). There was a significant difference between subgroups regarding PAOI (P < 0.0001, r = 0.385). Receiver operating characteristic curve analysis revealed PAOI >47% associated with RV/LV ratio >1.

CONCLUSION

Our results support the use of CTPA as a surrogate imaging biomarker for both diagnosis and risk stratification of APE patients. CTPA allows assessment of clot burden through PAOI calculation and identification of intermediate-risk PE through the assessment of RVD.

Prognostic value of respiratory index in haemodynamically stable patients with acute pulmonary embolism: The Respiratory Index model study

Background:

Current strategies for prognostic stratification in haemodynamically stable patients with acute pulmonary embolism require improvement. The aims of this study in haemodynamically stable patients with acute pulmonary embolism were (a) to evaluate the prognostic value of a novel respiratory index (oxygen saturation in air to respiratory rate ratio) and (b) to derive a risk model which includes the respiratory index and evaluate its value in predicting 30-day mortality.

Methods:

Prospective cohorts of haemodynamically stable patients with acute pulmonary embolism were merged to a collaborative database that served to create two subsequent derivation and validation cohorts based on a temporal criterion. The study outcome was 30-day all-cause death.

Results:

Thirty-day all-cause death occurred in 7.5% and in 6.9% of patients in the derivation and validation cohorts (each composed of 319 patients). In the derivation cohort, the respiratory index (odds ratio 0.66, 95% confidence interval 0.48–0.90) and simplified Pulmonary Embolism Severity Index (odds ratio 9.16, 95% confidence interval 1.22–68.89) were predictors of 30-day mortality. The cut-off value of the respiratory index ⩽3.8 was identified to best predict 30-day all-cause death (15.4% vs 5.0%, odds ratio 2.94, 95% confidence interval 1.22–7.11). The respiratory index ⩽3.8 was combined with the simplified Pulmonary Embolism Severity Index to create the Respiratory Index model that showed a good discriminatory power in the derivation (c-statistic 0.703, 95% confidence interval 0.60–0.80) and in the validation cohort (c-statistic 0.838, 95% confidence interval 0.768–0.907).

Conclusion:

In hemodynamically stable patients with acute pulmonary embolism, the respiratory index was an independent predictor of 30-day all-cause death. The Respiratory Index model which includes the simplified Pulmonary Embolism Severity Index and the respiratory index, provides a good risk stratification of haemodynamically stable patients with acute pulmonary embolism.

Temporal Trends in the Practice Pattern for Venous Thromboembolism in Japan: Insight From JROAD-DPC

Background

Recently, direct oral anticoagulants have been introduced for venous thromboembolism (VTE), which might change the management strategies of VTE. However, there have been limited data on the current real‐world practice pattern for VTE in Asian countries.

Methods and Results

The JROAD‐DPC (Japanese Registry of All Cardiac and Vascular Diseases\xF6Diagnosis Procedure Combination) is a nationwide claim database from 1022 hospitals in Japan between April 2012 and March 2017. We identified 54 369 patients who were hospitalized with a diagnosis of VTE at admission based on the International Classification of Diseases, Tenth Revision (ICD‐10) code. The mean age was 69.1±15.6 years, 59% were women, and mean body mass index was 23.5±5.0 kg/m². The proportion of patients with deep vein thrombosis decreased over time from 72% in 2012 to 38% in 2017. After the release of direct oral anticoagulants, the proportion of patients receiving direct oral anticoagulants increased dramatically among patients with anticoagulation therapy at discharge with the use of edoxaban, rivaroxaban, and apixaban in 35%, 22%, and 27% of patients, respectively, in 2017. On the other hand, the proportion of patients receiving warfarin decreased from 94% in 2012 to 15% in 2017. The median length of a hospital stay decreased over time from 20 days in 2012 to 13 days in 2017 in patients with pulmonary embolism, and from 14 days in 2012 to 12 days in 2017 in patients with deep vein thrombosis. The median cost of hospitalization for pulmonary embolism moderately decreased over time, whereas that for deep vein thrombosis slightly decreased over time.

Conclusions

A nationwide claim‐based database provided the current practice pattern for VTE in Japan, which revealed dynamic changes after the release of direct oral anticoagulants.

Clinical Trial Registration

URL: http://www.umin.ac.jp. Unique identifier: UMIN000037868.

Usefulness of Simplified Pulmonary Embolism Severity Index Score for Identification of Patients With Low-Risk Pulmonary Embolism and Active Cancer: From the COMMAND VTE Registry

BACKGROUND

The simplified Pulmonary Embolism Severity Index (sPESI) score is a practical score for identification of patients with low-risk pulmonary embolism (PE), although it has not been applied in patients with active cancer. The current study aimed to evaluate the usefulness of the sPESI score in patients with PE and active cancer.

METHODS

The COMMAND VTE Registry is a multicenter registry enrolling consecutive patients with acute symptomatic VTE. The current study population consisted of 368 patients with PE and active cancer. The 30-day clinical outcomes were compared between patients with sPESI score = 1 and patients with sPESI scores ≥ 2.

RESULTS

Overall, 37 patients (10%) died during the 30 days after diagnosis. The cumulative 30-day incidences of mortality, and PE-related death, were lower in patients with sPESI score = 1 than in patients with sPESI scores ≥ 2 (6.3% vs 13.1%; log-rank P = .03; and 0.7% vs 3.9%; log-rank P = .046). Among patients with sPESI score = 1, the predominant cause of death was cancer. There were no significant differences in the cumulative 30-day incidence of recurrent VTE and major bleeding between the two groups (3.9% vs 5.6%; log-rank P = .46; and 6.4% vs 4.5%; log-rank P = .45).

CONCLUSIONS

Among patients with PE and active cancer, patients with sPESI score = 1 had a lower 30-day mortality rate compared with patients with sPESI scores ≥ 2, and they showed very low PE-related mortality risk, although the overall mortality rate remained high because of cancer-related mortality. They also showed relatively high risks for recurrence and major bleeding, suggesting the need for careful follow-up.

TRIAL REGISTRY

UMIN Clinical Trials Registry; No.: UMIN000021132; URL: http://www.umin.ac.jp/ctr/index.htm.

Clinical Characteristics and Outcomes of Venous Thromboembolisms According to an Out-of-Hospital vs. In-Hospital Onset - From the COMMAND VTE Registry

BACKGROUND

Differences in the clinical characteristics and outcomes of venous thromboembolisms (VTEs) based on different clinical situations surrounding the onset might be important for directing appropriate treatment strategies, but have not yet been appropriately evaluated.

METHODS AND RESULTS

The COMMAND VTE Registry is a multicenter registry enrolling 3,027 consecutive patients with acute symptomatic VTEs in Japan between January 2010 and August 2014. We divided the study population into 3 groups: Out-of-hospital onset (n=2,308), In-hospital onset with recent surgery (n=310), and In-hospital onset without recent surgery (n=374). Active cancer was most prevalent in the In-hospital onset without recent surgery group, and least in the Out-of-hospital onset group (Out-of-hospital onset group: 20%, In-hospital onset with recent surgery group: 26%, and In-hospital onset without recent surgery group: 38%, P<0.001). The cumulative 5-year incidence of recurrent VTEs did not significantly differ across the 3 groups (11.4%, 5.8%, and 8.7%, respectively; P=0.11). The cumulative 5-year incidences of major bleeding and all-cause death were highest in the In-hospital onset without recent surgery group (11.1%, 8.5%, and 23.3%, P<0.001; 26.8%, 24.9%, and 48.4%, P<0.001, respectively).

CONCLUSIONS

In the real-world VTE registry, the clinical characteristics and long-term outcomes substantially differed according to the clinical situation of VTE onset, suggesting the need for different treatment strategies for VTEs in different clinical settings.