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Chopard R, Morillo R, Meneveau N, Jiménez D. Integration of Extracorporeal Membrane Oxygenation into the Management of High-Risk Pulmonary Embolism: An Overview of Current Evidence. Hamostaseologie 2024; 44:182-192. [PMID: 38531394 DOI: 10.1055/a-2215-9003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
High-risk pulmonary embolism (PE) refers to a large embolic burden causing right ventricular failure and hemodynamic instability. It accounts for approximately 5% of all cases of PE but contributes significantly to overall PE mortality. Systemic thrombolysis is the first-line revascularization therapy in high-risk PE. Surgical embolectomy or catheter-directed therapy is recommended in patients with an absolute contraindication to systemic thrombolysis. Extracorporeal membrane oxygenation (ECMO) provides respiratory and hemodynamic support for the most critically ill PE patients with refractory cardiogenic shock or cardiac arrest. The complex management of these individuals requires urgent yet coordinated multidisciplinary care. In light of existing evidence regarding the utility of ECMO in the management of high-risk PE patients, a number of possible indications for ECMO utilization have been suggested in the literature. Specifically, in patients with refractory cardiac arrest, resuscitated cardiac arrest, or refractory shock, including in cases of failed thrombolysis, venoarterial ECMO (VA-ECMO) should be considered, either as a bridge to percutaneous or surgical embolectomy or as a bridge to recovery after surgical embolectomy. We review here the current evidence on the use of ECMO as part of the management strategy for the highest-risk presentations of PE and summarize the latest data in this indication.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, Besançon, France
- SINERGIES, University of Franche-Comté, Besançon, France
- F-CRIN, INNOVTE network, France
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, Besançon, France
- SINERGIES, University of Franche-Comté, Besançon, France
- F-CRIN, INNOVTE network, France
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
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Donadini MP, Mumoli N, Fenu P, Pomero F, Re R, Palmiero G, Spadafora L, Mazzi V, Grittini A, Bertù L, Aujesky D, Dentali F, Ageno W, Squizzato A. The Clinical Impact of the Pulmonary Embolism Severity Index on the Length of Hospital Stay of Patients with Pulmonary Embolism: A Randomized Controlled Trial. Diagnostics (Basel) 2024; 14:776. [PMID: 38611689 PMCID: PMC11011567 DOI: 10.3390/diagnostics14070776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/02/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND The Pulmonary Embolism Severity Index (PESI) is an extensively validated prognostic score, but impact analyses of the PESI on management strategies, outcomes and health care costs are lacking. Our aim was to assess whether the adoption of the PESI for patients admitted to an internal medicine ward has the potential to safely reduce the length of hospital stay (LOS). METHODS We carried out a multicenter randomized controlled trial, enrolling consecutive adult outpatients diagnosed with acute PE and admitted to an internal medicine ward. Within 48 h after diagnosis, the treating physicians were randomized, for every patient, to calculate and report the PESI in the clinical record form on top of the standard of care (experimental arm) or to continue routine clinical practice (standard of care). The ClinicalTrials.gov identifier is NCT03002467. RESULTS This study was prematurely stopped due to slow recruitment. A total of 118 patients were enrolled at six internal medicine units from 2016 to 2019. The treating physicians were randomized to the use of the PESI for 59 patients or to the standard of care for 59 patients. No difference in the median LOS was found between the experimental arm (8, IQR 6-12) and the standard-of-care arm (8, IQR 6-12) (p = 0.63). A pre-specified secondary analysis showed that the LOS was significantly shorter among the patients who were treated with DOACs (median of 8 days, IQR 5-11) compared to VKAs or heparin (median of 9 days, IQR 7-12) (p = 0.04). CONCLUSIONS The formal calculation of the PESI in the patients already admitted to internal medicine units did not impact the length of hospital stay.
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Affiliation(s)
- Marco Paolo Donadini
- Thrombosis and Haemostasis Center, Ospedale di Circolo, ASST Sette Laghi, 21100 Varese, Italy; (M.P.D.); (F.D.); (W.A.)
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, 21100 Varese and 22100 Como, Italy; (L.B.); (A.S.)
| | - Nicola Mumoli
- Department of Internal Medicine, Magenta Hospital, 20013 Magenta, Italy;
- Presidio Ospedaliero di Livorno, Azienda USL Toscana Nord Ovest, 57124 Livorno, Italy;
| | - Patrizia Fenu
- Presidio Ospedaliero di Cecina, Azienda USL Toscana Nord Ovest, 57023 Cecina, Italy;
| | - Fulvio Pomero
- Internal Medicine Unit, Michele e Pietro Ferrero Hospital, 12060 Verduno, Italy; (F.P.); (L.S.)
| | - Roberta Re
- Medicina Interna, Ospedale S. Andrea, ASL Vercelli, 13100 Vercelli, Italy;
| | - Gerardo Palmiero
- Ospedale Versilia, Azienda USL Toscana Nord Ovest, 55049 Viareggio, Italy;
| | - Laura Spadafora
- Internal Medicine Unit, Michele e Pietro Ferrero Hospital, 12060 Verduno, Italy; (F.P.); (L.S.)
| | - Valeria Mazzi
- Presidio Ospedaliero di Livorno, Azienda USL Toscana Nord Ovest, 57124 Livorno, Italy;
| | | | - Lorenza Bertù
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, 21100 Varese and 22100 Como, Italy; (L.B.); (A.S.)
| | - Drahomir Aujesky
- Department of General Internal Medicine, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Francesco Dentali
- Thrombosis and Haemostasis Center, Ospedale di Circolo, ASST Sette Laghi, 21100 Varese, Italy; (M.P.D.); (F.D.); (W.A.)
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, 21100 Varese and 22100 Como, Italy; (L.B.); (A.S.)
| | - Walter Ageno
- Thrombosis and Haemostasis Center, Ospedale di Circolo, ASST Sette Laghi, 21100 Varese, Italy; (M.P.D.); (F.D.); (W.A.)
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, 21100 Varese and 22100 Como, Italy; (L.B.); (A.S.)
| | - Alessandro Squizzato
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, 21100 Varese and 22100 Como, Italy; (L.B.); (A.S.)
- Internal Medicine Unit, ‘Sant’Anna’ Hospital, ASST Lariana, 22042 San Fermo della Battagli, Italy
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Chopard R, Bertoletti L, Piazza G, Jimenez D, Barillari G, Llamas P, Rubio CM, Aujayeb A, Monreal M, Meneveau N. External validation of the PE-SARD risk score for predicting early bleeding in acute pulmonary embolism in the RIETE Registry. Thromb Res 2024; 235:22-31. [PMID: 38295598 DOI: 10.1016/j.thromres.2024.01.013] [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: 09/11/2023] [Revised: 01/04/2024] [Accepted: 01/17/2024] [Indexed: 02/02/2024]
Abstract
INTRODUCTION The PE-SARD score (syncope, anemia, renal dysfunction) was developed to predict the risk of major bleeding in the acute phase of pulmonary embolism (PE). METHODS We analyzed data from 50,686 patients with acute PE included in the RIETE registry to externally validate the PE-SARD score. We calculated the overall reliability of the PE-SARD score, as well as discrimination and calibration for predicting the risk of major bleeding at 30 days. The performance of PE-SARD was compared to the BACS and PE-CH models. RESULTS During the first 30 days, 640 patients (1.3 %) had a major bleeding event. The incidence of major bleeding within 30 days was 0.6 % in the PE-SARD-defined low-risk group, 1.5 % in the intermediate-risk group, and 2.5 % in the high-risk group, for an OR of 2.22 (95 % CI, 2.02-2.43) for the intermediate-risk group (vs low-risk group), and 3.94 for the high-risk group (vs low-risk group). The corresponding sensitivity was 81.1 % (intermediate/high vs low risk), and specificity was 85.9 % (95 % CI, 85.8-86.1) (low/intermediate vs high risk). The applicability of PE-SARD was consistent across clinically relevant patient subgroups and over shorter time periods of follow-up (i.e., 3 and 7 days). The C-index was 0.654 and calibration was excellent. The PE-SARD bleeding score improved the major bleeding risk prediction compared with the BACS and PE-CH scores. CONCLUSIONS The PE-SARD score identifies PE patients with a higher risk of bleeding, which could assist providers for potentially adjusting PE management, in a framework of shared decision-making with individual patients.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, 25000 Besançon, France; EA3920, University of Franche-Comté, 25000 Besançon, France; F-CRIN, INNOVTE network, France.
| | - Laurent Bertoletti
- F-CRIN, INNOVTE network, France; Université Jean Monnet Saint-Étienne, CHU Saint-Étienne, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, CIC 1408, Département of Médecine Vasculaire et Thérapeutique, 42055 Saint-Etienne, France
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
| | | | - Pilar Llamas
- Department of Hematology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Carmen Mª Rubio
- Department of Internal Medicine, Hospital Alto Guadalquivir Andújar, Jaén, Spain
| | - Avinash Aujayeb
- Northumbria Healthcare Foundation trust, Newcastle, United Kingdom
| | - Manuel Monreal
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Cátedra de Enfermedad Tromboembólica, Universidad Católica de Murcia, Murcia, Spain
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, 25000 Besançon, France; EA3920, University of Franche-Comté, 25000 Besançon, France; F-CRIN, INNOVTE network, France
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Jiménez D, Tapson V, Yusen RD, Becattini C, Moores L, Barnes GD, Monreal M, Konstantinides S, Bikdeli B. Revised Paradigm for Acute Pulmonary Embolism Prognostication and Treatment. Am J Respir Crit Care Med 2023; 208:524-527. [PMID: 37450886 PMCID: PMC10492237 DOI: 10.1164/rccm.202212-2234vp] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 07/14/2023] [Indexed: 07/18/2023] Open
Affiliation(s)
- David Jiménez
- Servicio de Neumología, Hospital Ramón y Cajal e Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- Departamento de Medicina, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Victor Tapson
- Cedars-Sinai Medical Center, Los Angeles, California
| | - Roger D. Yusen
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine–Stroke Unit, University of Perugia, Perugia, Italy
| | - Lisa Moores
- F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, Maryland
| | - Geoffrey D. Barnes
- Frankel Cardiovascular Center and Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, Michigan
| | - Manuel Monreal
- Centro de Investigación en Red de Enfermedades Respiratorias, Madrid, Spain
- Facultad de Ciencias de la Salud, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, Connecticut; and
- Cardiovascular Research Foundation, New York, New York
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Jiménez D, Bikdeli B, Rodríguez C, Muriel A, Ballaz A, Soler S, Schellong S, Gil-Díaz A, Skride A, Riera-Mestre A, Monreal M. Identification of Low-risk Patients With Acute Symptomatic Pulmonary Embolism. Arch Bronconeumol 2023; 59:575-580. [PMID: 37455150 DOI: 10.1016/j.arbres.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/03/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Identification of patients with acute symptomatic pulmonary embolism (PE) who are at low-risk for short-term complications to warrant outpatient care lacks clarity. METHOD In order to identify patients at low-risk for 30-day all-cause and PE-related mortality, we used a cohort of haemodynamically stable patients from the RIETE registry to compare the false-negative rate of four strategies: the simplified Pulmonary Embolism Severity Index (sPESI); a modified (i.e., heart rate cutoff of 100beats/min) sPESI; and a combination of the original and the modified sPESI with computed tomography (CT)-assessed right ventricle (RV)/left ventricle (LV) ratio. RESULTS Overall, 137 of 3117 patients with acute PE (4.4%) died during the first month. Of these, 41 (1.3%) died from PE, and 96 (3.1%) died from other causes. The proportion of patients categorized as having low-risk was highest with the sPESI and lowest with the combination of a modified sPESI and CT-assessed RV/LV ratio (32.5% versus 16.5%; P<0.001). However, among patients identified as low-risk, the 30-day mortality rate was lowest with the combination of a modified sPESI and CT-assessed RV/LV ratio and highest with the sPESI (0.4% versus 1.0%; P=0.03). The 30-day PE-related mortality rates for patients designated as low-risk by the sPESI, the modified sPESI, and the combination of the original and modified sPESI with CT-assessed RV/LV ratio were 0.7%, 0.4%, 0.7%, and 0.2%, respectively. CONCLUSIONS The combination of a negative modified sPESI with CT-assessed RV/LV ratio ≤1 identifies patients with acute PE who are at very low-risk for short-term mortality.
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Affiliation(s)
- David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain; Medicine Department, Universidad de Alcalá, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain.
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Alfonso Muriel
- Biostatistics Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBERESP, Madrid, Spain
| | - Aitor Ballaz
- Department of Pneumonology, Hospital de Galdakao, Vizcaya, Spain
| | - Silvia Soler
- Department of Internal Medicine, Hospital Olot i Comarcal de la Garrotxa, Gerona, Spain
| | - Sebastian Schellong
- Department of Medical Clinic, Municipal Hospital of Dresden Friedrichstadt, Dresden, Germany
| | - Aída Gil-Díaz
- Department of Internal Medicine, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Andris Skride
- Department of Cardiology, Ospedale Pauls Stradins Clinical University Hospital, Riga Stradiņš University, Riga, Latvia
| | - Antoni Riera-Mestre
- Internal Medicine Department, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM-Universidad Católica San Antonio de Murcia, Murcia, Spain
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Porres-Aguilar M, Rosovsky RP, Jiménez D, Mukherjee D, Rivera-Lebron BN, Kaatz S, Anaya-Ayala JE, Jerjes-Sánchez C. "Pulmonary embolism response teams: changing the paradigm in the care for acute pulmonary embolism": reply. J Thromb Haemost 2023; 21:1390-1392. [PMID: 37121622 DOI: 10.1016/j.jtha.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/02/2023] [Indexed: 05/02/2023]
Affiliation(s)
- Mateo Porres-Aguilar
- Department of Internal Medicine, Divisions of Hospital and Adult Thrombosis Medicine, Texas Tech University Health Sciences Center and Paul L. Foster School of Medicine, El Paso, Texas, USA.
| | - Rachel P Rosovsky
- Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David Jiménez
- Department of Respiratory Medicine, Ramón y Cajal Hospital (IRYCIS), CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases; Texas Tech University Health Sciences Center and Paul L. Foster School of Medicine, El Paso, Texas, USA
| | - Belinda N Rivera-Lebron
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Scott Kaatz
- Department of Internal Medicine, Division of Hospital Medicine; Henry Ford Hospital; Detroit, Michigan, USA
| | - Javier E Anaya-Ayala
- Department of Surgery, Vascular Surgery and Endovascular Therapy Section; Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos Jerjes-Sánchez
- Escuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey; and Instituto de Cardiologia y Medicina Vascular, Hospital Zambrano Hellion y TEC Salud, Monterrey, Mexico
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Mirambeaux R, Rodríguez C, Muriel A, González S, Briceño W, Durán D, Retegui A, Otero R, Bikdeli B, Jiménez D. Comparison of various prognostic scores for identification of patients with intermediate-high risk pulmonary embolism. Thromb Res 2023; 223:61-68. [PMID: 36708691 DOI: 10.1016/j.thromres.2023.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/11/2022] [Accepted: 01/18/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Various risk assessment tools have been proposed to identify stable patients with acute pulmonary embolism (PE) who are at high risk of early adverse outcome (i.e., intermediate-high risk). METHODS We evaluated the ability of the 2019 ESC, Bova, modified FAST and PEITHO-3 models for predicting a 30-day complicated course (death, haemodynamic collapse, and/or recurrent PE) in a cohort of 848 stable patients with acute PE. We also tested whether replacement of echocardiographic right ventricle (RV) dysfunction by computed tomographic (CT) RV enlargement provides comparable prognostic information for identifying these patients. RESULTS A complicated course occurred in 63 (7.4 %) of the 848 patients with PE during the first month of follow-up. The proportion of patients designated as having intermediate-high risk PE was 6.7 % with the ESC model, 4.4 % with the Bova score, 15.7 % with the FAST score, and 5.2 % with the PEITHO-3 model. However, among patients identified as intermediate-high risk, the 30-day complicated course rate was higher with the Bova score (21.6 %) than with the ESC model (17.5 %), the PEITHO-3 model (15.9 %), or the modified FAST score (14.3 %). When echocardiographic RV dysfunction was replaced by CT RV enlargement in the models, the proportion of patients classified as having intermediate-high risk PE and the rate of an adverse outcome among them slightly increased. CONCLUSIONS The Bova score might identify patients with intermediate-high risk PE slightly better than the ESC, PEITHO-3, and modified FAST score. When echocardiography is not readily available, CT-assessed RV enlargement might be used for identifying intermediate-high risk PE. CLINICALTRIALS gov number: NCT02238639.
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Affiliation(s)
- Rosa Mirambeaux
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Alfonso Muriel
- Biostatistics Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Sara González
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Winnifer Briceño
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Diego Durán
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Ana Retegui
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Remedios Otero
- Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, CT, USA; Cardiovascular Research Foundation, New York, USA
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain; Medicine Department, Universidad de Alcalá, Madrid, Spain.
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Trends in management and outcomes of pulmonary embolism with a multidisciplinary response team. J Thromb Thrombolysis 2022; 54:449-460. [PMID: 36057054 DOI: 10.1007/s11239-022-02697-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 10/14/2022]
Abstract
Multidisciplinary pulmonary embolism (PE) response teams have garnered widespread adoption given the complexities of managing acute PE and provide a platform for assessment of trends in therapy and outcomes. We describe temporal trends in PE management and outcomes following the deployment of such a team. All consecutive patients managed by our multidisciplinary PE response team activated by the Emergency Department were included over a 5-year calendar period. We examined temporal trends in management and rates of a composite primary endpoint (all-cause-death, major bleeding, recurrent venous thromboembolism, and readmission) at 30 days and 6 months. We assessed 425 patients between 2015 and 2019. We observed an increase in PE acuity and use of systemic thrombolysis. The primary endpoint at 30 days decreased from 16.3% in 2015 to 7.1% in 2019 (adjusted rate ratio per period, 0.63; 95%CI, 0.47-0.84), driven by a decrease in the adjusted rate of major bleeding. Among 406 patients with complete follow-up, the adjusted rate ratio per year for the primary outcome at 6 months was 0.37 (95%CI, 0.19-0.71), driven by a decrease in all-cause mortality. We observed evidence of temporal changes in clinical presentation, therapeutic strategies, and outcomes for acute PE, in parallel to, but not necessarily because of, the implementation of a multidisciplinary response team. Over time, major bleeding, mortality and readmission rates decreased, despite an increase in PE risk category.
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Chopard R, Behr J, Vidoni C, Ecarnot F, Meneveau N. An Update on the Management of Acute High-Risk Pulmonary Embolism. J Clin Med 2022; 11:jcm11164807. [PMID: 36013046 PMCID: PMC9409943 DOI: 10.3390/jcm11164807] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 11/16/2022] Open
Abstract
Hemodynamic instability and right ventricular (RV) dysfunction are the key determinants of short-term prognosis in patients with acute pulmonary embolism (PE). High-risk PE encompasses a wide spectrum of clinical situations from sustained hypotension to cardiac arrest. Early recognition and treatment tailored to each individual are crucial. Systemic fibrinolysis is the first-line pulmonary reperfusion therapy to rapidly reverse RV overload and hemodynamic collapse, at the cost of a significant rate of bleeding. Catheter-directed pharmacological and mechanical techniques ensure swift recovery of echocardiographic parameters and may possess a better safety profile than systemic thrombolysis. Further clinical studies are mandatory to clarify which pulmonary reperfusion strategy may improve early clinical outcomes and fill existing gaps in the evidence.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
- F-CRIN, INNOVTE Network, 42055 Saint-Etienne, France
- Correspondence:
| | - Julien Behr
- Department of Radiology, University Hospital Besançon, 25000 Besancon, France
| | - Charles Vidoni
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
- F-CRIN, INNOVTE Network, 42055 Saint-Etienne, France
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Hillegass E, Lukaszewicz K, Puthoff M. Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline 2022. Phys Ther 2022; 102:6585463. [PMID: 35567347 DOI: 10.1093/ptj/pzac057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/24/2022] [Accepted: 02/22/2022] [Indexed: 11/14/2022]
Abstract
No matter the practice setting, physical therapists work with patients who are at risk for or who have a history of venous thromboembolism (VTE). In 2016, the first clinical practice guideline (CPG) addressing the physical therapist management of VTE was published with support by the American Physical Therapy Association's Academy of Cardiovascular and Pulmonary Physical Therapy and Academy of Acute Care, with a primary focus on lower extremity deep vein thrombosis (DVT). This CPG is an update of the 2016 CPG and contains the most current evidence available for the management of patients with lower extremity DVT and new key action statements (KAS), including guidance on upper extremity DVT, pulmonary embolism, and special populations. This document will guide physical therapist practice in the prevention of and screening for VTE and in the management of patients who are at risk for or who have been diagnosed with VTE. Through a systematic review of published studies and a structured appraisal process, KAS were written to guide the physical therapist. The evidence supporting each action was rated, and the strength of statement was determined. Clinical practice algorithms based on the KAS were developed that can assist with clinical decision-making. Physical therapists, along with other members of the health care team, should implement these KAS to decrease the incidence of VTE, improve the diagnosis and acute management of VTE, and reduce the long-term complications of VTE.
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Affiliation(s)
- Ellen Hillegass
- Department of Physical Therapy, Mercer University, Atlanta, Georgia, USA
| | | | - Michael Puthoff
- Physical Therapy Department, St Ambrose University, Davenport, Iowa, USA
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Jiménez D, Rodríguez C, Pintado B, Pérez A, Jara-Palomares L, López-Reyes R, Ruiz-Artacho P, García-Ortega A, Bikdeli B, Lobo JL. Effect of Prognostic Guided Management of Patients With Acute Pulmonary Embolism According to the European Society of Cardiology Risk Stratification Model. Front Cardiovasc Med 2022; 9:872115. [PMID: 35497990 PMCID: PMC9039515 DOI: 10.3389/fcvm.2022.872115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/08/2022] [Indexed: 11/25/2022] Open
Abstract
Background A recent trial showed that management driven by prognostic assessment was effective in reducing the length of stay (LOS) for acute stable pulmonary embolism (PE). The efficacy and safety of this strategy in each subgroup of risk stratification remains unknown. Methods We conducted a post-hoc analysis of the randomized IPEP study to evaluate the effect of a management strategy guided by early use of a prognostic pathway in the low- and intermediate-high risk subgroups defined by the European Society of Cardiology (ESC) model. These subgroups were retrospectively identified in the control arm. The primary outcome was LOS. The secondary outcomes were 30-day clinical outcomes. Results Of 249 patients assigned to the intervention group, 60 (24%) were classified as low-, and 30 (12%) as intermediate-high risk. Among 249 patients assigned to the control group, 66 (27%) were low-, and 13 (5%) intermediate-high risk. In the low-risk group, the mean LOS was 2.1 (±0.9) days in the intervention group and 5.3 (±2.9) days in the control group (P < 0.001). In this group, no significant differences were observed in 30-day readmissions (0% vs. 3.0%, respectively), all-cause (0% vs. 0%) and PE-related mortality rates (0% vs. 0%), or severe adverse events (0% vs. 1.5%). In the intermediate-high risk group, the mean LOS was 5.3 (±1.8) days in the intervention group and 6.5 (±2.5) days in the control group (P = 0.08). In this group, no significant differences were observed in 30-day readmissions (3.3% vs. 3.0%, respectively), all-cause (6.7% vs. 7.7%) and PE-related mortality rates (6.7% vs. 7.7%), or severe adverse events (16.7% vs. 15.4%). Conclusion The use of a prognostic assessment and management pathway was effective in reducing the LOS for acute PE without comprising safety across subgroups of risk stratification. Clinical Trial Registration [ClinicalTrials.gov], Identifier [NCT02733198].
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Affiliation(s)
- David Jiménez
- Respiratory Department, Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
- Department of Medicine, Universidad de Alcalá, Madrid, Spain
- CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- *Correspondence: David Jiménez,
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Beatriz Pintado
- Respiratory Department, Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Andrea Pérez
- Respiratory Department, Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Luis Jara-Palomares
- Respiratory Department, Virgen del Rocío Hospital, Instituto de Biomedicina, Seville, Spain
| | | | - Pedro Ruiz-Artacho
- CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Department of Internal Medicine, Clínica Universidad de Navarra, Madrid, Spain
- Interdisciplinar Teragnosis and Radiosomics Research Group (INTRA-Madrid), Universidad de Navarra, Madrid, Spain
| | | | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT, United States
- Cardiovascular Research Foundation, New York, NY, United States
| | - José Luis Lobo
- CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Respiratory Department, Hospital Araba, Vitoria-Gasteiz, Spain
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Jaureguízar A, Jiménez D, Bikdeli B, Ruiz-Artacho P, Muriel A, Tapson V, López-Reyes R, Valero B, Kenet G, Monreal M. Heart Rate and Mortality in Patients With Acute Symptomatic Pulmonary Embolism. Chest 2021; 161:524-534. [PMID: 34478718 DOI: 10.1016/j.chest.2021.08.059] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 08/19/2021] [Accepted: 08/24/2021] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Ana Jaureguízar
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, CT; Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - Pedro Ruiz-Artacho
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Department of Internal Medicine, Clínica Universidad de Navarra, Madrid, Spain; Interdisciplinar Teragnosis and Radiosomics Research Group, Universidad de Navarra, Madrid, Spain
| | - Alfonso Muriel
- Department of Biostatistics, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBERESP, Madrid, Spain
| | | | - Raquel López-Reyes
- Department of Pneumology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Beatriz Valero
- Department of Internal Medicine, Hospital General Universitario de Alicante, Alicante, Spain
| | - Gili Kenet
- Department of Pediatric Hemato-Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Manuel Monreal
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona; Universidad Católica de Murcia, Murcia, Spain
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