Management of pulmonary embolism: recent evidence and the new European guidelines

Clinical Evaluation for the Role of High-Sensitivity C-Reactive Protein in Combination with D-Dimer and Wells Score Probability Test to Predict the Incidence of Deep Vein Thrombosis Among Cancer Patients

Background

Deep vein thrombosis (DVT) is a frequent complication in cancer patients and is the second leading cause of death. The high level of C-reactive protein (CRP) is an acute phase reactant that induces tissue factor (TF) expression in monocytes, smooth muscle cells, and endothelial cells. The CRP level positively correlates with the incidence, extension, and volume of thrombus. TF expression triggers the coagulation system including the formation of thrombin and circulating fibrin such as prothrombin fragment 1+2 (F_{1 + 2}) and D-dimer.

Objective

To determine the diagnostic value of high-sensitivity (hs)-CRP, D-dimer, and Wells score combination to predict the incidence of DVT on clinically suspected DVT (Wells score ≥2) cancer patients.

Subjects and Methods

This study was a cross-sectional study on a diagnostic test to determine the diagnostic value of hs-CRP and D-dimer for early detection of DVT on clinically suspected DVT (Wells score ≥2) cancer patients. It was conducted in Dr. Kariadi Hospital, Semarang Indonesia on 35 subjects. The diagnosis of DVT was confirmed by color duplex sonography. The diagnostic accuracy of combination of hs-CRP, D-dimer, and Wells score was analyzed by logistic regression.

Results

DVT was confirmed in 10 subjects (28,6%). The cut-off point of hs-CRP levels for probable DVT was ≥51.05 mg/L and for D-dimer was ≥5030 µg/L. The median levels of both variables were higher in the subjects with DVT compared with the subjects without DVT, but it was not statistically significant. The combination of hs-CRP (≥51.05 mg/L), D-dimer (≥5030 µg/L), and Wells score ≥3 had the high accuracy (94.1%) to predict the incidence of DVT compared with hs-CRP (65.0%), D-dimer (54.7%), and combination of hs-CRP and D-dimer (71.0%).

Conclusion

The combination of hs-CRP (≥51.05 mg/L), D-dimer (≥5030 µg/L), and Wells score ≥3 can predict the incidence of DVT in cancer.

Evaluating time to treatment and in-hospital outcomes of pulmonary embolism response teams

BACKGROUND

Pulmonary embolism response teams (PERTs) have become increasingly popular at institutions around the country, although the evidence to support their efficacy is limited. PERTs are mechanisms for rapid involvement of a multidisciplinary team in the management of a time-sensitive condition with many treatment options.

METHODS

We retrospectively reviewed 201 patients with PERT activations since inception, collecting data on demographics, time to treatment, treatment modality, and in-hospital outcomes.

RESULTS

Massive pulmonary embolism accounted for 16 (8.7%) PERT activations. The majority of patients were treated without invasive intervention; 91.4% (95% confidence interval [CI], 87.1%-95.7%) of patients received anticoagulation alone, 4.5% (95% CI, 0%-18.6%) had catheter-directed therapy (CDT), and 3.0% (95% CI, 0%-16.9%) had systemic administration of tissue plasminogen activator (tPA). The average time to intervention was 665 minutes (95% CI, 249-1080 minutes) for CDT and 22 minutes (95% CI, 0-456 minutes) for systemic TPA. The average time to anticoagulation was 2.3 minutes (95% CI, 0-43 minutes). There was a trend toward higher rates of cardiac events (odds ratio [OR], 12.68; 95% CI, 0.62-65.74) and death (OR, 3.19; 95% CI, 0.28-5.18) among patients with massive PE. There was a higher rate of cardiac events (OR, 5.66; 95% CI, 1.34-23.83) among patients who received tPA or an invasive intervention. There was no difference in mortality rates of patients who underwent aggressive management compared with anticoagulation alone.

CONCLUSIONS

A dedicated PERT results in efficient delivery of care and excellent outcomes, in part owing to the rapid (on average, 8 minutes) time to initiation of a multidisciplinary discussion. Patients who ultimately underwent CDT had an interval of >10 hours on average between diagnosis and CDT. This provisional or delayed approach to CDT in selected patients who were not improving with anticoagulation alone (and therefore had potential for higher net benefit from a procedure with its own inherent risks) may have resulted in a lower rate of CDT.

[Diagnosis and Treatment Strategy of Pulmonary Embolism after Video-assisted Thoracic Lobectomy]

背景与目的

总结胸腔镜肺叶切除术后肺栓塞患者的临床特征，探讨肺叶切除术后肺栓塞的诊治方法及预防手段。

方法

回顾性分析哈尔滨医科大学附属第二医院胸外科2007年7月-2017年7月间肺叶切除术术后6例肺栓塞患者的临床资料。

结果

6例患者中3例在发病24 h内死亡，3例患者治愈出院。

结论

肺叶切除术后肺栓塞是胸外科少见的术后并发症，诊断困难，病死率高。术前血栓风险评估及术后预防十分重要。

Comorbidities, Complications and Non-Pharmacologic Treatment in Idiopathic Pulmonary Fibrosis

Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive and fatal disease. The treatment is challenging and nowadays a comprehensive approach based not only in pharmacological strategies is necessary. Identification and control of comorbidities, non-pharmacological treatment, prevention and management of exacerbations as well as other areas of care (social, psychological) are fundamental for a holistic management of IPF. Gastroesophageal reflux, pulmonary hypertension, obstructive sleep apnea, combined with emphysema, lung cancer and cardiovascular involvement are the main comorbidities associated with IPF. Non-pharmacological treatment includes the use of oxygen in patients with rest or nocturnal hypoxemia and other support therapies such as non-invasive ventilation or even a high-flow nasal cannula to improve dyspnea. In some patients, lung transplant should be considered as this enhances survival. Pulmonary rehabilitation can add benefits in outcomes such control of dyspnea, exercise capacity distance and, overall, improve the quality of life; therefore it should be considered in patients with IPF. Also, multidisciplinary palliative care programs could help with symptom control and psychological support, with the aim of maintaining quality of life during the whole process of the disease. This review intends to provide clear information to help those involved in IPF follow up to improve patients’ daily care.

Use of Tachycardia in Patients With Submassive Pulmonary Emboli to Risk Stratify for Early Initiation of Thrombolytic Therapy: A Case Series Comparing Early Versus Late Thrombolytic Initiation

Pulmonary embolism (PE) represents a prevalent cause of morbidity and mortality in the United States, with approximately 600 000 cases diagnosed annually. The mortality rate for untreated PE is as high as 30%. Right ventricular (RV) dysfunction is a sign of possible adverse outcomes with right-sided heart failure being the usual cause of death from PE. There is a spectrum of clinical presentations associated with PE diagnoses, from incidental and asymptomatic to rapid hemodynamic collapse. Despite successes in identifying patients with "high-risk" PEs for aggressive thrombolytic interventions and "low-risk" PEs for outpatient anticoagulation, a significant lack of consensus exists regarding intervention modalities for PEs identified as "intermediate risk" or "submassive," defined as normotensive (systolic blood pressure ≥90 mm Hg) with acute RV dysfunction and myocardial injury. In this case series, we review the management and outcomes of 2 patients with submassive PEs and sustained tachycardia in the setting of normal blood pressures, and we address the need to recognize tachycardia as an ominous RV compensatory sign, indicative of impending hemodynamic collapse, that should lead to aggressive therapy with vascular intervention.

Thromboembolic burden, prognostic assessment and outcomes of females compared to males in acute pulmonary embolism

BACKGROUND

Literature lacks on sex differences in acute pulmonary embolism (PE). Therefore, the aim of our study was to provide information about sex difference in thromboembolic burden, prognostic assessment and outcomes of PE.

MATERIALS AND METHODS

We analyzed and compared differences between females and males retrieving data of a multicenter, observational, retrospective, cohort study aimed to analyze characteristics of PE patients admitted in Internal Medicine wards of Tuscany, Italy.

RESULTS

272 (60.1%) of 452 patients enrolled in the study were females. Females were older than males (76.6 ± 12.0 vs. 73.5 ± 13.4 years, p = 0.0005). Mean length of hospital stay was longer in females (11.3 vs. 9.5 days, p = 0053). Reduced mobility was more frequent in females (46.3% vs. 35.5%, p = 0.0322), whereas COPD and active cancer were in males (20% vs. 9.9%, p = 0.0034, and 39.4% vs. 23.8%, p = 0.0004, respectively). Incidental diagnosis of PE was performed more often in males compared to females (19.3% vs. 11.4%, p = 0.0289). No sex difference was found in diagnostic approach, despite females underwent more often to legs ultrasonography compared to males (90.7% vs. 79.4%, p = 0.0008). Both all cause and PE-related mortality were higher in males (12.2 and 8.3% vs. 7.7 and 5.1%, respectively), despite difference was not significant. Females were found to have more likely central PE and distal deep vein thrombosis compared to males (57.7% vs. 43.8%, p = 0.0039, and 22.9% vs. 13.9%, p = 0.0206, respectively). None difference was found in shock index and median simplified PESI score between females and males, whereas according to 2008 ESC prognostic model females were more likely to be categorized at high or intermediate risk than in males (81.5% vs. 71.5%, p = 0.0159). Echocardiographic right heart dysfunction was found more often in females than in males (56.5% vs. 44%, p = 0.0124). No sex difference was found neither on acute treatment nor in prescription of vitamin K antagonists at hospital discharge. Bleeding events were significantly higher in females compared to males (4.7% vs. 0.5%, p = 0.0189).

CONCLUSION

Understanding the difference between females and males is of utmost importance for physicians who manage acute PE in clinical practice. Females present major pulmonary thromboembolic burden, more frequently right heart dysfunction and treatment-related bleedings but lower in-hospital mortality than males. Our study could implicate that management of acute PE should be tailored according to sex. Prospective studies are warranted to better clarify this topic.

The TL,NO /TL,CO ratio cannot be used to exclude pulmonary embolism

BACKGROUND

The existing screening modalities for pulmonary embolism (PE), such as D-dimer and clinical prediction rules, have low positive predictive values. With its capability to indicate pulmonary vascular abnormalities, the ratio of the transfer factor of the lungs for nitric oxide and the transfer factor of the lungs for carbon monoxide (T_L,NO /T_L,CO ) might be an additional discriminating parameter.

METHODS

Carbon monoxide/Nitric oxide diffusion measurements were performed on unselected patients seen on the emergency department for which due to suspected PE a computed tomography pulmonary angiogram (CTPA) was ordered.

RESULTS

A total of 28 patients were included, PE was found in 12 on CTPA. Median T_L,NO /T_L,CO ratio was 4·09 (interquartile range (IQR) 3·83-4·40) in the no PE group versus 4·00 (IQR 3·78-4·32) in the PE group (P = 0·959). Median alveolar volume was 77·1% of predicted in the no PE group versus 71·0% of predicted in the PE group (P = 0·353). Median T_L,CO was 75·8% of predicted in the no PE group versus 68·8% of predicted in the PE group (P = 0·120). Median T_L,NO was 69·3% of predicted in the no PE group versus 60·5% of predicted in the PE group (P = 0·078).

CONCLUSION

The presented data indicate that the T_L,NO /T_L,CO ratio cannot be used to exclude PE.