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Lasserson D, Gaddu P, Mehta S, Ignatowicz A, Greenfield S, Prince C, Cummins C, Robinson G, Rodrigues J, Noble S, Jowett S, Toshner M, Newnham M, Turner A. Stopping anticoagulation for isolated or incidental pulmonary embolism: the STOPAPE RCT protocol. Health Technol Assess 2024:1-17. [PMID: 38970429 DOI: 10.3310/hrcw7937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2024] Open
Abstract
Research question Is withholding anticoagulation for patients with isolated or incidental subsegmental pulmonary embolism clinically and cost-effective compared with full anticoagulation for 3 months? Background There has been an increase in the diagnosis of subsegmental pulmonary embolism since the advent of computed tomography pulmonary angiogram to investigate patients with suspected pulmonary embolism. Subsegmental pulmonary embolism is not often detectable with older nuclear medicine-based diagnostic imaging for ventilation/perfusion mismatch. The case fatality of pulmonary embolism has reduced as subsegmental pulmonary embolism diagnoses from computed tomography pulmonary angiogram have increased. There is growing equipoise about the optimal treatment for patients with subsegmental pulmonary embolism, given that full anticoagulation has significant risks of bleeding and subsegmental pulmonary embolism was not often diagnosed previously with ventilation/perfusion scanning and therefore most likely left predominantly untreated prior to the introduction of computed tomography pulmonary angiogram scanning. Objectives Determine whether withholding anticoagulation for isolated or incidental subsegmental pulmonary embolism (i.e. subsegmental pulmonary embolism with no coexisting deep-vein thrombosis) reduces the harms of recurrent thromboembolism and major bleeding compared with 3 months of full anticoagulation at 3, 6 and 12 months. Determine the rate of complications of anticoagulation therapy (predominantly bleeding) in patients with isolated subsegmental pulmonary embolism. Determine whether not treating isolated subsegmental pulmonary embolism is acceptable to clinicians and patients. Determine the reclassification rate of subsegmental pulmonary embolism diagnoses made by general reporting radiologists when reviewed by specialist respiratory radiologists and develop a set of rules to improve general radiologists' diagnoses of subsegmental pulmonary embolism. Assess cost-effectiveness of not treating patients with isolated subsegmental pulmonary embolism with anticoagulation, taking a health service perspective. Methods Prospective individually randomised open controlled trial with blinded end-point committee assessment for outcomes, powered for non-inferiority for recurrent venous thromboembolism and for superiority for bleeding events. An internal pilot phase is included for feasibility and acceptability of no anticoagulation. We planned to recruit 1466 patients from at least 50 acute hospital sites. Allowing for a dropout rate of 15%, this would have given us 90% power to detect a reduction in major and clinically relevant non-major bleeding from 7.3% in the anticoagulation arm to 3% in the intervention arm. We were powered to determine that a strategy of no anticoagulation was non-inferior to anticoagulation with an upper margin of a 2.3% increase in recurrent venous thromboembolism from an expected rate of 2% in those who receive full anticoagulation. We also planned to undertake a study comparing acute reporting radiologists' diagnoses of subsegmental pulmonary embolism from all computed tomography pulmonary angiograms with specialist respiratory radiologists. This would have allowed us to determine safety in the pilot study (i.e. patients with pulmonary embolism that was in fact larger than subsegmental would have been identified) and develop guidance for subsegmental pulmonary embolism diagnosis for general radiologists. Patients with lived experience of thrombosis contributed to all aspects of the trial design and were part of the Trial Management Group. Progress of study The STOPAPE trial was stopped prematurely due to a low recruitment rate in the wake of the COVID pandemic and prioritisation of recovery of the National Institute for Health and Care Research research portfolio. There are no outcome data available for this trial. Separate NIHR Library publications will detail the linked qualitative study examining the views of patients and clinicians around withholding anticoagulation for isolated subsegmental pulmonary embolism as well as presenting all collected data of recruited patients. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR128073. A plain language summary of this research article is available on the NIHR Journals Library Website https://doi.org/10.3310/HRCW7937.
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Affiliation(s)
| | - Pooja Gaddu
- Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Samir Mehta
- Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Sheila Greenfield
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Carole Cummins
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | | | - Sue Jowett
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Michael Newnham
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Alice Turner
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Xu J, Hu Z, Miao J, Cao L, Tian Z, Yao C, Huang K. MACHINE LEARNING FOR PREDICTING HEMODYNAMIC DETERIORATION OF PATIENTS WITH INTERMEDIATE-RISK PULMONARY EMBOLISM IN INTENSIVE CARE UNIT. Shock 2024; 61:68-75. [PMID: 38010031 DOI: 10.1097/shk.0000000000002261] [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: 11/29/2023]
Abstract
ABSTRACT Background: Intermediate-risk pulmonary embolism (PE) patients in the intensive care unit (ICU) are at a higher risk of hemodynamic deterioration than those in the general ward. This study aimed to construct a machine learning (ML) model to accurately identify the tendency for hemodynamic deterioration in the ICU patients with intermediate-risk PE. Method: A total of 704 intermediate-risk PE patients from the MIMIC-IV database were retrospectively collected. The primary outcome was defined as hemodynamic deterioration occurring within 30 days after admission to ICU. Four ML algorithms were used to construct models on the basis of all variables from MIMIC IV database with missing values less than 20%. The extreme gradient boosting (XGBoost) model was further simplified for clinical application. The performance of the ML models was evaluated by using the receiver operating characteristic curve, calibration plots, and decision curve analysis. Predictive performance of simplified XGBoost was compared with the simplified Pulmonary Embolism Severity Index score. SHapley Additive explanation (SHAP) was performed on a simplified XGBoost model to calculate the contribution and impact of each feature on the predicted outcome and presents it visually. Results: Among the 704 intermediate-risk PE patients included in this study, 120 patients experienced hemodynamic deterioration within 30 days after admission to the ICU. Simplified XGBoost model demonstrated the best predictive performance with an area under the curve of 0.866 (95% confidence interval, 0.800-0.925), and after recalibrated by isotonic regression, the area under the curve improved to 0.885 (95% confidence interval, 0.822-0.935). Based on the simplified XGBoost model, a web app was developed to identify the tendency for hemodynamic deterioration in ICU patients with intermediate-risk PE. Conclusion: A simplified XGBoost model can accurately predict the occurrence of hemodynamic deterioration for intermediate-risk PE patients in the ICU, assisting clinical workers in providing more personalized management for PE patients in the ICU.
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Affiliation(s)
| | - Zhensheng Hu
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Jianhang Miao
- Department of Vascular Surgery, Zhongshan City People's Hospital, Zhongshan, China
| | - Lin Cao
- The First Clinical College of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Zhenluan Tian
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Breast Tumor Center, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chen Yao
- Department of Vascular Surgery, the First Affiliated Hospital of Sun Yat-sen University, Sun Yat-Sen University, Guangzhou, China
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Gade IL, Riddersholm SJ, Stilling-Vinther T, Brøndum RF, Bennike TB, Honoré B. A clinical proteomics study of exhaled breath condensate and biomarkers for pulmonary embolism. J Breath Res 2023; 18:016007. [PMID: 37939397 DOI: 10.1088/1752-7163/ad0aaa] [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: 06/23/2023] [Accepted: 11/07/2023] [Indexed: 11/10/2023]
Abstract
Pulmonary embolism (PE) can be a diagnostic challenge. Current diagnostic markers for PE are unspecific and new diagnostic tools are needed. The air we exhale is a possible new source for biomarkers which can be tapped into by analysing the exhaled breath condensate (EBC). We analysed the EBC from patients with PE and controls to investigate if the EBC is a useful source for new diagnostic biomarkers of PE. We collected and analysed EBC samples from patients with suspected PE and controls matched on age and sex. Patients in whom PE was ruled out after diagnostic work-up were included in the control group to increase the sensitivity and generalizability of the identified markers. EBC samples were collected using an RTube™. The protein composition of the EBCs were analysed using data dependent label-free quantitative nano liquid chromatography-tandem mass spectrometry. EBC samples from 28 patients with confirmed PE, and 49 controls were analysed. A total of 928 EBC proteins were identified in the 77 EBC samples. As expected, a low protein concentration was determined which resulted in many proteins with unmeasurable levels in several samples. The levels of HSPA5, PEBP1 and SFTPA2 were higher and levels of POF1B, EPPK1, PSMA4, ALDOA, and CFL1 were lower in PE compared with controls. In conclusion, the human EBC contained a variety of endogenous proteins and may be a source for new diagnostic markers of PE and other diseases.
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Affiliation(s)
- Inger Lise Gade
- Department of Hematology and Clinical Cancer Research Center, Aalborg University Hospital, 9000 Aalborg, Denmark
| | | | | | - Rasmus Froberg Brøndum
- Center for Clinical Data Science, Aalborg University and Aalborg University Hospital, 9260 Gistrup, Denmark
| | - Tue Bjerg Bennike
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Bent Honoré
- Department of Clinical Medicine, Aalborg University, 9000 Aalborg, Denmark
- Department of Biomedicine, Aarhus University, 8000 Aarhus, Denmark
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Elshahaat HA, Zayed NE, Ateya MAM, Safwat M, El Hawary AT, Abozaid M. Role of serum biomarkers in predicting management strategies for acute pulmonary embolism. Heliyon 2023; 9:e21068. [PMID: 38027791 PMCID: PMC10651461 DOI: 10.1016/j.heliyon.2023.e21068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/06/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Background Acute pulmonary embolism (APE) is a condition that can be fatal. The severity of the disease influences therapeutic decisions, and mortality varies significantly depending on the condition's severity. Identification of patients with a high mortality risk is crucial. Since inflammation, hemostatic, and coagulation abnormalities are linked to APE, serum biomarkers may be helpful for prognostication. Aim To evaluate the significance of serum biomarkers in APE risk assessment and the suitability of these biomarkers for management and decision-making. Methods This study involved 60 adult patients with APE who were divided according to risk categorization. It was conducted in Chest, Cardiology and Internal Medicine department, Zagazig University Hospitals from December 2022 to May 2023. Several hematological biomarkers and their significance in APE risk assessment were measured with a comparison with the latest risk stratification methods which include haemodynamic measures and right ventricular (RV) dysfunction echocardiographic markers. Results Each risk group involved 20 patients (high, intermediate (10 were intermediate-high and 10 were intermediate-low) and low risk group). They were 34 females and 26 males with the mean ± SD of their age was 59.25 ± 13.06 years. Regarding hematological biomarkers, there were statistically significant differences as regards; lymphocytes, platelet to lymphocyte ratio (PLR), albumin, blood urea nitrogen (BUN), C-reactive protein (CRP) and D-dimer with highly statistically significant differences as regards; neutrophil to lymphocyte ratio (NLR), BUN to albumin (B/A) ratio, troponin I (TnI), and brain natriuretic peptide (BNP). TnI had the highest specificity and predictive value positive (PVP) and BNP had the highest sensitivity and predictive value negative (PVN) in predicting high risk groups. The Lymphocyte and NLR showed the lowest sensitivity and the albumin and B/A ratio had the lowest specificity. Regarding transthoracic echocardiography (TEE); there was a statistically significant increase regarding pulmonary artery systolic pressure (PASP) and a highly statistically significant increase regarding the right ventricle/left ventricle (RV/LV) ratio. There were statistically significant decreases regarding tricuspid annular plane systolic excursion (TAPSE) and peak systolic velocity of tricuspid annulus (S') among risk groups. Conclusion APE prognosis can be judged accurately by simultaneously measuring a few biomarkers along with haemodynamic variables and echocardiographic parameters of RV dysfunction.
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Affiliation(s)
| | - Niveen E. Zayed
- Chest Department, faculty of Medicine of Zagazig University, Zagazig, Egypt
| | | | - Mohamed Safwat
- Cardiology Department, Faculty of medicine of Zagazig University, Zagazig, Egypt
| | - Amr Talaat El Hawary
- Internal Medicine Department, Faculty of medicine of Zagazig University, Zagazig, Egypt
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Agarwal MA, AlMahmeed W, Butler J. Cardiac Biomarkers in Dyspnea Hospitalizations - Still Breathing Not Predictively. Cardiology 2023; 149:51-54. [PMID: 37883930 PMCID: PMC10836920 DOI: 10.1159/000534369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023]
Affiliation(s)
- Manyoo A. Agarwal
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Wael AlMahmeed
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- University of Mississippi, Jackson, MS, USA
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Gotta J, Gruenewald LD, Eichler K, Martin SS, Mahmoudi S, Booz C, Biciusca T, Reschke P, Bernatz S, Pinto Dos Santos D, Scholtz JE, Alizadeh LS, Nour-Eldin NEA, Hammerstingl RM, Gruber-Rouh T, Mader C, Hardt SE, Sommer CM, Bucolo G, D'Angelo T, Onay M, Finkelmeier F, Leistner DM, Vogl TJ, Giannitsis E, Koch V. Unveiling the diagnostic enigma of D-dimer testing in cancer patients: Current evidence and areas of application. Eur J Clin Invest 2023; 53:e14060. [PMID: 37409393 DOI: 10.1111/eci.14060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 05/30/2023] [Accepted: 06/15/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Cancer is a well-known risk factor for venous thromboembolism (VTE). A combined strategy of D-dimer testing and clinical pre-test probability is usually used to exclude VTE. However, its effectiveness is diminished in cancer patients due to reduced specificity, ultimately leading to a decreased clinical utility. This review article seeks to provide a comprehensive summary of how to interpret D-dimer testing in cancer patients. METHODS In accordance with PRISMA standards, literature pertaining to the diagnostic and prognostic significance of D-dimer testing in cancer patients was carefully chosen from reputable sources such as PubMed and the Cochrane databases. RESULTS D-dimers have not only a diagnostic value in ruling out VTE but can also serve as an aid for rule-in if their values exceed 10-times the upper limit of normal. This threshold allows a diagnosis of VTE in cancer patients with a positive predictive value of more than 80%. Moreover, elevated D-dimers carry important prognostic information and are associated with VTE reoccurrence. A gradual increase in risk for all-cause death suggests that VTE is also an indicator of biologically more aggressive cancer types and advanced cancer stages. Considering the lack of standardization for D-dimer assays, it is essential for clinicians to carefully consider the variations in assay performance and the specific test characteristics of their institution. CONCLUSIONS Standardizing D-dimer assays and developing modified pretest probability models specifically for cancer patients, along with adjusted cut-off values for D-dimer testing, could significantly enhance the accuracy and effectiveness of VTE diagnosis in this population.
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Affiliation(s)
- Jennifer Gotta
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Katrin Eichler
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon S Martin
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Christian Booz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Teodora Biciusca
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Philipp Reschke
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon Bernatz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Jan-Erik Scholtz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Leona S Alizadeh
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | | | | | - Christoph Mader
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stefan E Hardt
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christof M Sommer
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Giuseppe Bucolo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Melis Onay
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - David M Leistner
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Vitali Koch
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
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7
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Koch V, Martin SS, Gruber-Rouh T, Eichler K, Mahmoudi S, Leistner DM, Scholtz JE, Bernatz S, Puntmann VO, Nagel E, Booz C, D'Angelo T, Alizadeh LS, Yel I, Ziegengeist NS, Torgashov K, Geyer T, Hardt SE, Vogl TJ, Gruenewald LD, Giannitsis E. Cancer patients with venous thromboembolism: Diagnostic and prognostic value of elevated D-dimers. Eur J Clin Invest 2023; 53:e13914. [PMID: 36444723 DOI: 10.1111/eci.13914] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND D-dimer testing is known to have a high sensitivity at simultaneously low specificity, resulting in nonspecific elevations in a variety of conditions. METHODS This retrospective study sought to assess diagnostic and prognostic features of D-dimers in cancer patients referred to the emergency department for suspected pulmonary embolism (PE) and deep vein thrombosis (DVT). In total, 526 patients with a final adjudicated diagnosis of PE (n = 83) and DVT (n = 69) were enrolled, whereas 374 patients served as the comparative group, in which venous thromboembolism (VTE) has been excluded. RESULTS For the identification of VTE, D-dimers yielded the highest positive predictive value of 96% (95% confidence interval (CI), 85-99) at concentrations of 9.9 mg/L and a negative predictive value of 100% at .6 mg/L (95% CI, 97-100). At the established rule-out cut-off level of .5 mg/L, D-dimers were found to be very sensitive (100%) at a moderate specificity of nearly 65%. Using an optimised cut-off value of 4.9 mg/L increased the specificity to 95% for the detection of life-threatening VTE at the cost of moderate sensitivities (64%). During a median follow-up of 30 months, D-dimers positively correlated with the reoccurrence of VTE (p = .0299) and mortality in both cancer patients with VTE (p < .0001) and without VTE (p = .0008). CONCLUSIONS Although D-dimer testing in cancer patients is discouraged by current guidelines, very high concentrations above the 10-fold upper reference limit contain diagnostic and prognostic information and might be helpful in risk assessment, while low concentrations remain useful for ruling out VTE.
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Affiliation(s)
- Vitali Koch
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany.,Department of Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Heidelberg, Germany
| | - Simon S Martin
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Katrin Eichler
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - David M Leistner
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Jan-Erik Scholtz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon Bernatz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Eike Nagel
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Booz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital Messina, Messina, Italy
| | - Leona S Alizadeh
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Ibrahim Yel
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | | | - Tobias Geyer
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stefan E Hardt
- Department of Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas J Vogl
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Evangelos Giannitsis
- Department of Cardiology, Angiology, and Pulmonology, University Hospital Heidelberg, Heidelberg, Germany
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Feroze R, Arora S, Tashtish N, Dong T, Jaswaney R, Castro-Dominguez Y, Hammad T, Osman MN, Carman T, Schilz R, Shishehbor MH, Li J. Comparison of Large-Bore Thrombectomy With Catheter-Directed Thrombolysis for the Treatment of Pulmonary Embolism. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100453. [PMID: 39132536 PMCID: PMC11308115 DOI: 10.1016/j.jscai.2022.100453] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/16/2022] [Accepted: 08/28/2022] [Indexed: 08/13/2024]
Abstract
Background There is significant debate on whether large-bore thrombectomy (LBT) or catheter-directed thrombolysis (CDT) is superior for the treatment of intermediate- and high-risk pulmonary embolism (PE) while employing an early invasive strategy through endovascular therapies. Methods Between 2018 and 2021, 147 patients who presented to our institution with acute intermediate- or high-risk PE and had undergone PE Response Team-guided endovascular intervention with either LBT (Inari FlowTriever) or CDT (EKOSonic) were retrospectively reviewed. Data on the patients' clinical characteristics, comorbidities, serum biomarkers, hemodynamics, and imaging characteristics were obtained. The primary outcome was all-cause mortality; the secondary outcomes were all-cause readmission, readmission for PE, and length of stay in the intensive care unit and hospital. The safety outcome of procedure-related bleeding was evaluated. Kaplan-Meier curves were used to estimate the cumulative event rate. Multivariate Cox-proportional hazard regression and inverse propensity weighting were used to adjust for confounders. Results The median age of the patients was 63 (IQR, 53-73) years, and 48.3% of the patients were women. Patients in the LBT group had a higher PE Severity Index score (LBT vs CDT: median, 132 vs 108; P = .015) and greater prevalence of malignancy (LBT vs CDT: median, 22.7% vs 6%; P = .011). After propensity matching for baseline characteristics, there was no significant difference in all-cause mortality (LBT vs CDT: median, 15.8% vs 9.1%; hazard ratio, 0.64; 95% CI, 0.21-1.98; P = .442) for up to 1 year. The secondary outcomes or safety end points were also similar between the 2 interventions. An exploratory analysis showed elevated PE Severity Index scores, lower systolic blood pressures, and higher lactic acid levels to be associated with an increased risk of early death at 30 days. Conclusions In this retrospective cohort study, there was no significant difference in the cumulative event rate of all-cause mortality between LBT and CDT. Further studies are needed to evaluate the use of LBT versus CDT versus noninvasive therapy to understand outcomes and appropriate patient selection among those with intermediate- and high-risk PE.
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Affiliation(s)
- Rafey Feroze
- Division of Cardiology, Department of Medicine, University Hospitals, Cleveland, Ohio
| | - Shilpkumar Arora
- Division of Cardiology, Department of Medicine, University Hospitals, Cleveland, Ohio
| | - Nour Tashtish
- Division of Cardiology, Department of Medicine, University Hospitals, Cleveland, Ohio
| | - Tony Dong
- Department of Medicine, University Hospitals, Cleveland, Ohio
| | - Rahul Jaswaney
- Department of Medicine, University Hospitals, Cleveland, Ohio
| | | | - Tarek Hammad
- Division of Cardiology, Department of Medicine, University Hospitals, Cleveland, Ohio
| | - Mohammad Najeeb Osman
- Division of Cardiology, Department of Medicine, University Hospitals, Cleveland, Ohio
| | - Teresa Carman
- Division of Cardiology, Department of Medicine, University Hospitals, Cleveland, Ohio
| | - Robert Schilz
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University Hospitals, Cleveland, Ohio
| | - Mehdi H. Shishehbor
- Division of Cardiology, Department of Medicine, University Hospitals, Cleveland, Ohio
| | - Jun Li
- Division of Cardiology, Department of Medicine, University Hospitals, Cleveland, Ohio
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Haba MȘC, Tudorancea I, Miftode RȘ, Popa IP, Mitu O, Mihai CT, Haba RM, Onofrei VA, Petris AO, Costache II, Haba D, Șorodoc L. Pulmonary Embolism Risk Assessment Using Blood Copeptin Concentration and Pulmonary Arteries Thrombotic Burden Evaluated by Computer Tomography. J Pers Med 2022; 12:jpm12122084. [PMID: 36556304 PMCID: PMC9786201 DOI: 10.3390/jpm12122084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/06/2022] [Accepted: 12/16/2022] [Indexed: 12/23/2022] Open
Abstract
(1) Background: Pulmonary embolism (PE) represents the third most important cardiovascular cause of death after myocardial infarction and stroke. The proper management of this condition is dependent on adequate risk stratification, due to the life-threatening complications of more aggressive therapies such as thrombolysis. Copeptin is a surrogate marker of vasopressin which is found increased in several cardiovascular conditions. The Mastora score is an imagistic evaluation of the degree of pulmonary arteries thrombotic burden based on computed tomography angiography. In this study, we aimed to evaluate the diagnostic and prognostic role of copeptin in patients with acute PE. Furthermore, we analyzed the relationship between copeptin and Mastora score and their role in PE risk profiling. (2) Methods: We conducted a single center prospective study that included 112 patients with PE and 53 healthy volunteers. Clinical and paraclinical parameters, together with plasma levels of copeptin and the Mastora score, were evaluated in all patients after admission. (3) Results: Copeptin levels were significantly increased in PE patients compared with the general population (26.05 vs. 9.5 pmol/L, p < 0.001), while receiver operating characteristic (ROC) analysis revealed an AUC of 0.800 (95% CI 0.728−0.873, p < 0.001). Copeptin directly correlated with the Mastora score (r = 0.535, p = 0.011) and both parameters were strong predictors for adverse clinical events and death. Receiver operating characteristic (ROC) analysis for death within 30 days revealed a copeptin cut-off of 38.36 pmol/L, which presented a specificity of 79.6% and a sensitivity of 88.9%, and a Mastora score cut-off of 82 points, which presented a specificity of 74.8% and a sensitivity of 77.8%. (4) Conclusions: Our results showed that copeptin and the Mastora score are both correlated with adverse cardiovascular events and mortality in PE patients, and this may pave the way for their use in clinical practice, helping physicians to select the best therapeutical management.
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Affiliation(s)
- Mihai Ștefan Cristian Haba
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
| | - Ionut Tudorancea
- Department of Morpho-Functional Sciences II-Physiology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
- Correspondence: ; Tel.: +40-232-301-603
| | - Radu Ștefan Miftode
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
| | - Irene Paula Popa
- Department of Morpho-Functional Sciences II-Physiology, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
| | - Ovidiu Mitu
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
| | - Cosmin Teodor Mihai
- Advanced Research and Development Center for Experimental Medicine (CEMEX), “Grigore T. Popa” University of Medicine and Pharmacy of Iasi, 700115 Iasi, Romania
| | - Raluca Maria Haba
- Faculty of General Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Viviana Aursulesei Onofrei
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
| | - Antoniu Octavian Petris
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
| | - Irina Iuliana Costache
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
| | - Danisia Haba
- Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, “Gr. T. Popa” University of Medicine and Pharmacy, 16 Universitatii Str., 700115 Iasi, Romania
| | - Laurentiu Șorodoc
- Department of Internal Medicine III, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania
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10
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Omran F, Kyrou I, Osman F, Lim VG, Randeva HS, Chatha K. Cardiovascular Biomarkers: Lessons of the Past and Prospects for the Future. Int J Mol Sci 2022; 23:5680. [PMID: 35628490 PMCID: PMC9143441 DOI: 10.3390/ijms23105680] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular diseases (CVDs) are a major healthcare burden on the population worldwide. Early detection of this disease is important in prevention and treatment to minimise morbidity and mortality. Biomarkers are a critical tool to either diagnose, screen, or provide prognostic information for pathological conditions. This review discusses the historical cardiac biomarkers used to detect these conditions, discussing their application and their limitations. Identification of new biomarkers have since replaced these and are now in use in routine clinical practice, but still do not detect all disease. Future cardiac biomarkers are showing promise in early studies, but further studies are required to show their value in improving detection of CVD above the current biomarkers. Additionally, the analytical platforms that would allow them to be adopted in healthcare are yet to be established. There is also the need to identify whether these biomarkers can be used for diagnostic, prognostic, or screening purposes, which will impact their implementation in routine clinical practice.
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Affiliation(s)
- Farah Omran
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK; (F.O.); (I.K.); (F.O.); (V.G.L.); (H.S.R.)
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, UK
- Clinical Sciences Research Laboratories, University Hospitals Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Ioannis Kyrou
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK; (F.O.); (I.K.); (F.O.); (V.G.L.); (H.S.R.)
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, UK
- Centre of Applied Biological & Exercise Sciences, Faculty of Health & Life Sciences, Coventry University, Coventry CV1 5FB, UK
- Aston Medical School, College of Health and Life Sciences, Aston University, Birmingham B4 7ET, UK
- Laboratory of Dietetics and Quality of Life, Department of Food Science and Human Nutrition, School of Food and Nutritional Sciences, Agricultural University of Athens, 11855 Athens, Greece
| | - Faizel Osman
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK; (F.O.); (I.K.); (F.O.); (V.G.L.); (H.S.R.)
- Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, UK
| | - Ven Gee Lim
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK; (F.O.); (I.K.); (F.O.); (V.G.L.); (H.S.R.)
- Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, UK
| | - Harpal Singh Randeva
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK; (F.O.); (I.K.); (F.O.); (V.G.L.); (H.S.R.)
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, UK
- Clinical Sciences Research Laboratories, University Hospitals Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Kamaljit Chatha
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK; (F.O.); (I.K.); (F.O.); (V.G.L.); (H.S.R.)
- Biochemistry and Immunology Department, University Hospitals Coventry and Warwickshire NHS Trust, Coventry CV2 2DX, UK
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11
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Koch V, Booz C, Gruenewald LD, Albrecht MH, Gruber-RouhMD T, Eichler K, Yel I, Mahmoudi S, Scholtz JE, Martin SS, Graf C, Vogl TJ, Weber C, Hardt SE, Frey N, Giannitsis E. Diagnostic performance and predictive value of D-dimer testing in patients referred to the emergency department for suspected myocardial infarction. Clin Biochem 2022; 104:22-29. [PMID: 35181290 DOI: 10.1016/j.clinbiochem.2022.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/08/2022] [Accepted: 02/08/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE The study sought to assess the performance of D-dimer testing for the diagnosis of acute coronary syndrome (ACS) and prediction of outcomes in patients admitted for suspected myocardial infarction (MI). RESULTS A total of 3,557 patients with suspected ACS presenting to a single center with a broad range of symptoms including atypical chest pain were retrospectively recruited between 02/2012-01/2019. Of the study cohort, 435 patients had unstable angina (UA), 420 non-ST-segment elevation myocardial infarction (NSTEMI), 22 ST-segment elevation myocardial infarction (STEMI), and 2,680 non-coronary chest pain. Plasma D-dimer concentrations in patients with hs-cTnT >14 ng/L differed significantly from those with hs-cTnT <14 ng/L (1.5 ± 3.6 mg/L vs. 0.5 ± 0.8 mg/L; p<0.0001). Positive predictive value for a final diagnosis of ACS increased proportionally to rising D-dimer concentrations. The area under the curve (AUC) to discriminate STEMI from non-coronary chest pain (AUC 0.729, 95% confidence interval [CI] 0.71-0.75) was moderate and differed not significantly to UA (AUC 0.595, 95% CI 0.58-0.61; p=0.0653). During a median follow-up of 29 months, higher D-dimer was associated with a significantly increased risk of recurrent MI (quartile 4 vs. 1: hazard ratio [HR], 6.9 [95% CI 1.2-39.9]; p<0.0001) and higher all-cause mortality (HR, 17.4 [95% CI 4.3-69.9]; p<0.0001). D-dimer was an independent predictor of all-cause mortality (p<0.0001) and subsequent MI events (p=0.0333). CONCLUSIONS D-dimer testing revealed great potential to provide independent prognostic information on recurrent MI and all-cause mortality. However, D-dimers do not improve the diagnostic performance except if values exceed the 95th percentile.
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Affiliation(s)
- Vitali Koch
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany.
| | | | | | | | | | | | - Ibrahim Yel
- Goethe University, Frankfurt Frankfurt am Main, Germany
| | | | | | | | | | - Thomas J Vogl
- Goethe University, Frankfurt Frankfurt am Main, Germany
| | - Christophe Weber
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan E Hardt
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Norbert Frey
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
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12
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Koch V, Biener M, Müller-Hennessen M, Vafaie M, Staudacher I, Katus HA, Giannitsis E. Diagnostic performance of D-dimer in predicting venous thromboembolism and acute aortic dissection. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:559–566. [PMID: 32186398 PMCID: PMC8248847 DOI: 10.1177/2048872620907322] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 01/29/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND D-dimer is elevated in a variety of conditions. The purpose of this study was to assess the positive predictive value of D-dimer to rule in patients with confirmed pulmonary embolism, deep vein thrombosis, acute aortic dissection or thrombosis of the upper extremity in comparison to patients with elevated D-dimer for other reasons. METHODS AND RESULTS We studied 1334 patients presenting to the emergency department with pulmonary embolism (n=193), deep vein thrombosis (n=73), acute aortic dissection (n=22), thrombosis of the upper extremity (n=8) and 1038 controls. The positive predictive value was increased with higher D-dimer concentrations improving the ability to identify diseases with high thrombus burden. Patients with venous thromboembolism, acute aortic dissection and thrombosis of the upper extremity showed a maximum positive predictive value of 85.2% at a D-dimer level of 7.8 mg/L (95% confidence interval (CI) 78.1 to 90.4). The maximum positive predictive value was lower in cancer patients with venous thromboembolism, acute aortic dissection and thrombosis of the upper extremity, reaching 68.9% at a D-dimer level of 7.5 mg/L (95% CI 57.4 to 78.4). The positive likelihood ratio was very consistent with the positive predictive value. Using a cut-off level of 0.5 mg/L, D-dimer showed a high sensitivity of at least 93%, but a very low specificity of nearly 0%. Conversely, an optimised cut-off value of 4.6 mg/L increased specificity to 95% for the detection of life-threatening venous thromboembolism, acute aortic dissection or thrombosis of the upper extremity at the costs of moderate sensitivities (58% for pulmonary embolism, 41% for deep vein thrombosis, 65% for pulmonary embolism with co-existent deep vein thrombosis, 50% for acute aortic dissection and 13% for thrombosis of the upper extremity). Using the same cut-off in cancer patients, higher values were observed for sensitivity at a specificity level of more than 95%. The area under the curve for the discrimination of venous thromboembolism/acute aortic dissection/thrombosis of the upper extremity from controls was significantly higher in cancer versus non-cancer patients (area under the curve 0.905 in cancer patients, 95% CI 0.89 to 0.92, vs. area under the curve 0.857 in non-cancer patients, 95% CI 0.84 to 0.88; P=0.0349). CONCLUSION D-dimers are useful not only to rule out but also to rule in venous thromboembolism and acute aortic dissection with an at least moderate discriminatory ability, both in patients with and without cancer.
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Affiliation(s)
- Vitali Koch
- Department of Internal Medicine III, Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany
| | - Moritz Biener
- Department of Internal Medicine III, Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany
| | - Matthias Müller-Hennessen
- Department of Internal Medicine III, Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany
| | - Mershad Vafaie
- Department of Internal Medicine III, Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany
| | - Ingo Staudacher
- Department of Internal Medicine III, Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany
| | - Hugo A Katus
- Department of Internal Medicine III, Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany
| | - Evangelos Giannitsis
- Department of Internal Medicine III, Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Germany
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13
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Loomba RS, Villarreal EG, Farias JS, Aggarwal G, Aggarwal S, Flores S. Serum biomarkers for prediction of mortality in patients with COVID-19. Ann Clin Biochem 2021; 59:15-22. [PMID: 33874737 DOI: 10.1177/00045632211014244] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND There is limited information regarding the role of biomarker levels at predicting mortality in patients with the coronavirus disease (COVID-19) pandemic. The purpose of this study is to determine the differences in serum biomarker levels in adults with COVID-19 who survived hospitalization from those who did not. METHODS A comprehensive search was completed on PubMed, EMBASE and Cochrane libraries to identify studies of interest. Endpoints of interest were blood counts, hepatic function test, acute phase reactants, cytokines and cardiac biomarkers. RESULTS A total of 10 studies with 1584 patients were included in the pooled analyses. Biomarkers that were noted to be significantly higher in those who died from coronavirus disease included: white blood cell count, neutrophil count, C-reactive protein, high sensitivity C-reactive protein, procalcitonin, ferritin, D-dimer, interleukin-6, lactate dehydrogenase, creatine kinase, prothrombin time, aspartate aminotransferase, alanine aminotransferase, total bilirubin and creatinine. Lymphocyte count, platelet count and albumin were significantly lower in patients who died. CONCLUSION This pooled analysis of 10 studies including 1584 patients identified significant differences in biomarkers on admission in patients who survived from those who did not. Further research is needed to develop risk stratification models to help with judicious use of limited health-care resources.
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Affiliation(s)
- Rohit S Loomba
- Department of Pediatric Critical Care, Advocate Children's Hospital, Oak Lawn, IL, USA.,Department of Pediatrics, Chicago Medical School/Rosalind Franklin University of Medicine and Science, Chicago, IL, USA
| | - Enrique G Villarreal
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico
| | - Juan S Farias
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico
| | - Gaurav Aggarwal
- Department of Medicine, Jersey City Medical Center, Jersey City, NJ, USA
| | | | - Saul Flores
- Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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14
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Al-Nouri O, Locham S, Mannava K, Malas MB. Short Duration Catheter-directed Thrombolysis for Acute Pulmonary Embolism Rapidly Improves Acute Cardiac Function. Ann Vasc Surg 2020; 72:373-382. [PMID: 33227469 DOI: 10.1016/j.avsg.2020.09.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/12/2020] [Accepted: 09/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Treatment of massive and submassive pulmonary embolism (PE) has been shown to be a valuable therapeutic modality. However, a paucity of data exists, regarding length and guidelines for treatment and typically these patients are treated by other than vascular surgery specialists. The aim of this study is to evaluate the effectiveness and safety of short duration treatment of massive and submassive PE, exclusively by vascular surgeons, without routine follow-up pulmonary angiography. METHODS Retrospective analysis of prospectively collected data at a single-institution treating massive and submassive PE with catheter-directed thrombolysis (CDT). Internal review board approval was obtained. Descriptive statistical analysis was performed from the data set. Continuous covariates were presented in mean (SD) or median (IQR) and categorical covariates as number (percentage). For continuous variables, a paired t test was used to measure results against the baseline. P value less than 0.05 was defined as statistically significant. STATA® statistical software was used for analysis. RESULTS From January of 2013 to December of 2016, 28 consecutive patients were treated for massive and submassive PE with CDT. All patients had evidence of right heart strain on echocardiogram, as evidence by a right ventricular to left ventricular (RV/LV) diameter ratio of >0.9. Of the 28 patients, 19 (68%) had hemodynamic derangement with either systolic blood pressure (SBP) less then 90 or tachycardia (HR > 100). The mean RV/LV ratio before CDT was 1.18. After therapy, RV/LV ratio was reduced to 0.86 at 48 hr (P < 0.0001). In addition, mean right ventricular systolic pressure (RVSP) before CDT treatment was 53 mm Hg, and after treatment, RVSP was reduced to 40 mm Hg at 48-hr (P value = 0.0001). There was complete resolution of hypotension in hemodynamically unstable patients (i.e., SBP <90) after CDT. Mean HR before therapy was 102. After 24 hr of CDT, mean HR reduced to 84 (P < 0.0001). From 2013 to 2016, there was a significant decrease in mean hospital length of stay from 8 days to 4 days (P = 0.05). Mean t-PA dose used decreased, as well, from 2014 (21.7 mg) to 2016 (14.9 mg), but this was not statistically significant (P = 0.13). There was no major bleeding complications or CDT-related death in any of the patients treated during the study period. CONCLUSIONS CDT treatment of massive and submassive PE is safe and highly efficacious at reducing right heart strain acutely. Significant hemodynamic improvement was shown in our cohort throughout the study period. Improvement in tachycardia and resolution of hypotension were seen within 24 hr of CDT. Tissue plasminogen activator dosage decreased throughout the study period as a more restrictive approach to follow-up angiography was used without adverse safety or patient outcomes.
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Affiliation(s)
- Omar Al-Nouri
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA.
| | - Satinderjit Locham
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Krishna Mannava
- Fairfield Medical Center, Department of Surgery, Lancaster OH
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
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15
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Jenab Y, Haji-Zeinali AM, Alemzadeh-Ansari MJ, Shirani S, Salarifar M, Alidoosti M, Vahidi H, Pourjafari M, Jalali A. Does Baseline BUN Have an Additive Effect on the Prediction of Mortality in Patients with Acute Pulmonary Embolism? J Tehran Heart Cent 2020; 15:57-63. [PMID: 33552195 PMCID: PMC7825466 DOI: 10.18502/jthc.v15i2.4184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/18/2020] [Indexed: 11/24/2022] Open
Abstract
Background: In patients with heart failure, elevated levels of blood urea nitrogen (BUN) is a prognostic factor. In this study, we investigated the prognostic value of elevated baseline BUN in short-term mortality among patients with acute pulmonary embolism (PE). Methods: Between 2007 and 2014, cardiac biomarkers and BUN levels were measured in patients with acute PE. The primary endpoint was 30-day mortality, evaluated based on the baseline BUN (≥14 ng/L) level in 4 groups of patients according to the European Society of Cardiology's risk stratification (low-risk, intermediate low-risk, intermediate high-risk, and high-risk). Results: Our study recruited 492 patients with a diagnosis of acute PE (mean age=60.58±16.81 y). The overall 1-month mortality rate was 6.9% (34 patients). Elevated BUN levels were reported in 316 (64.2%) patients. A high simplified pulmonary embolism severity index (sPESI) score (OR: 5.23, 95% CI: 1.43-19.11; P=0.012), thrombolytic or thrombectomy therapy (OR: 2.42, 95% CI: 1.01-5.13; P=0.021), and elevated baseline BUN levels (OR: 1.04, 95% CI: 1.01-1.03; P=0.029) were the independent predictors of 30-day mortality. According to our receiver-operating characteristics analysis for 30-day mortality, a baseline BUN level of greater than 14.8 mg/dL was considered elevated. In the intermediate-low-risk patients, mortality occurred only in those with elevated baseline BUN levels (7.2% vs. 0; P=0.008). Conclusion: An elevated baseline BUN level in our patients with PE was an independent predictor of short-term mortality, especially among those in the intermediate-risk group.
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Affiliation(s)
- Yaser Jenab
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
| | | | - Mohammad Javad Alemzadeh-Ansari
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Shapour Shirani
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mojtaba Salarifar
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Alidoosti
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Hamed Vahidi
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Marzieh Pourjafari
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Arash Jalali
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
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16
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Deveci F, Öner Ö, Telo S, Kırkıl G, Balin M, Kuluöztürk M. Prognostic value of copeptin in patients with acute pulmonary thromboembolism. CLINICAL RESPIRATORY JOURNAL 2019; 13:630-636. [DOI: 10.1111/crj.13071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 07/18/2019] [Accepted: 07/19/2019] [Indexed: 01/22/2023]
Affiliation(s)
- Figen Deveci
- Department of Pulmonary Medicine, School of Medicine Firat University Elazig Turkey
| | - Önsel Öner
- Department of Pulmonary Medicine, School of Medicine Firat University Elazig Turkey
| | - Selda Telo
- Department of Biochemistry, Faculty of Medicine, School of Medicine Firat University Elazig Turkey
| | - Gamze Kırkıl
- Department of Pulmonary Medicine, School of Medicine Firat University Elazig Turkey
| | - Mehmet Balin
- Department of Cardiology, School of Medicine Firat University Elazig Turkey
| | - Mutlu Kuluöztürk
- Department of Pulmonary Medicine, School of Medicine Firat University Elazig Turkey
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17
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Abstract
Current medical management of pulmonary embolism (PE) is driven by risk stratification, with thrombolytic treatment reserved for patients with hemodynamic instability. We describe a case of a man with acute submassive bilateral pulmonary emboli and a right popliteal deep vein thrombosis (DVT), who had persistent shortness of breath, tachycardia, and hypoxemia but remained normotensive and was therefore not treated with thrombolytics until he suffered a fatal cardiac arrest on hospital day six. We examine the indications, risks, and potential benefits of thrombolytic treatment in patients with submassive PE who exhibit signs of instability but do not meet current indications for thrombolytic treatment with persistent hypotension or shock.
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Affiliation(s)
- Megan Obi
- Internal Medicine, Case Western Reserve University School of Medicine, Cleveland, USA
| | - Clifford D Packer
- Internal Medicine, Case Western Reserve University School of Medicine, Cleveland, USA
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18
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Pentraxin-3 Levels Relate to the Wells Score and Prognosis in Patients with Acute Pulmonary Embolism. DISEASE MARKERS 2019; 2019:2324515. [PMID: 30992732 PMCID: PMC6434296 DOI: 10.1155/2019/2324515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/14/2018] [Accepted: 02/05/2019] [Indexed: 12/02/2022]
Abstract
Objective To investigate the value of the PTX-3 test in evaluating the prognosis of acute pulmonary embolism (APE). Method 117 APE patients were selected and divided into two groups according to plasma PTX-3 levels, including the group in which PTX − 3 ≥ 3.0 ng/mL (n = 42) and the group in which PTX − 3 < 3.0 ng/mL (n = 75). Patients were stratified into high-risk, medium-risk, and low-risk groups according to the Wells scores, and the PTX-3 levels were compared among the groups. Patients had been followed-up as well. Results According to the Wells scores, 11 patients were classified as high-risk (9.4%) and 68 were medium-risk (58.1%), while 38 were low-risk (32.5%). The PTX-3 levels in different risk groups were statistically different (all P < 0.05). During the follow-up period, 6 deaths occurred in the group with elevated PTX-3 (≥3.0 ng/mL), while 2 deaths occurred in the group with nonelevated PTX-3 (<3.0 ng/mL). The difference between the two groups was statistically significant (P < 0.01). 13 patients were hospitalized due to recurrent pulmonary embolism, of which 12 were in the group with elevated PTX-3 (≥3.0 ng/mL), while 1 patient was in the group with nonelevated PTX-3 (<3.0 ng/mL). The difference was statistically significant (P < 0.01). Conclusion The plasma PTX-3 level in APE patients is correlated with PE risk stratification. There is a significant correlation between PTX-3 levels and PE-related cardiac deaths, as well as the prognosis of recurrent PE. PTX-3 can be used as a clinical indicator of PE prognosis.
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19
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Abstract
Cardiac biomarkers are an integral part of the diagnostic work-up and risk stratification of patients with chest pain. Cardiac troponins are highly sensitive diagnostic biomarkers in patients with acute coronary syndrome and have prognostic value in a multitude of acute and chronic diseases. In patients with suspected pulmonary embolism (PE) D‑dimer can be used together with the Wells score for exclusion of PE. In patients with confirmed PE, B‑type natriuretic peptide (BNP), N‑terminal pro-BNP (NT-proBNP) and heart-type fatty acid binding protein (h-FABP) can be used for risk stratification. Although normal D‑dimer levels largely decrease the possibility of acute aortic dissection, clinicians should not rely on D‑dimer alone to exclude the diagnosis of acute aortic syndrome. This continuing medical education article provides an overview of the most important biomarkers recommended in current guidelines for differential diagnoses of patients with chest pain with a focus on cardiac troponins in acute coronary syndrome.
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Giannitsis E, Katus HA. Troponins: established and novel indications in the management of cardiovascular disease. Heart 2018; 104:1714-1722. [PMID: 29724751 DOI: 10.1136/heartjnl-2017-311387] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | - Hugo A Katus
- Medizinische Klinik III, University of Heidelberg, Heidelberg, Germany
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21
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Biener M, Giannitsis E, Kuhner M, Zelniker T, Mueller-Hennessen M, Vafaie M, Stoyanov KM, Neumann FJ, Katus HA, Hochholzer W, Valina CM. Risk prediction in stable cardiovascular disease using a high-sensitivity cardiac troponin T single biomarker strategy compared to the ESC-SCORE. Open Heart 2018; 5:e000710. [PMID: 29713483 PMCID: PMC5922562 DOI: 10.1136/openhrt-2017-000710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 11/25/2017] [Accepted: 03/27/2018] [Indexed: 12/17/2022] Open
Abstract
Objective To evaluate the prognostic performance of high-sensitivity cardiac troponin T (hs-cTnT) compared with the ESC-SCORE. Methods We included low-risk outpatients with stable cardiovascular (CV) disease categorised into need for non-secondary and secondary prevention. The prognostication of hs-cTnT at index visit was compared with the European Society of Cardiology-Systematic COronary Risk Evaluation (ESC-SCORE) with respect to all-cause mortality (ACM) and two composite endpoints (ACM, acute myocardial infarction (AMI) and stroke and ACM, AMI, stroke and rehospitalisation for acute coronary syndrome (ACS) and decompensated heart failure (DHF)). Results Within a median follow-up of 796 days, a total of 16 deaths, 32 composite endpoints of ACM, AMI and stroke and 83 composite endpoints of ACM, AMI, stroke, rehospitalisation for ACS and DHF were observed among 693 stable low-risk outpatients. Using C-statistics, measurement of hs-cTnT alone outperformed the ESC-SCORE for the prediction of ACM in the entire study population (Δarea under the curve (AUC) 0.221, p=0.0039) and both prevention groups (non-secondary: ΔAUC 0.164, p=0.0208; secondary: ΔAUC 0.264, p=0.0134). For the prediction of all other secondary endpoints, hs-cTnT was at least as effective as the ESC-SCORE, both in secondary and non-secondary prevention. Using continuous and categorical net reclassification improvement and integrated discrimination improvement, hs-cTnT significantly improved reclassification regarding all endpoints in the entire population and in the secondary prevention cohort. In non-secondary prevention, hs-cTnT improved reclassification only for ACM. The results were confirmed in an independent external cohort on 2046 patients. Conclusions Hs-cTnT is superior to the multivariable ESC-SCORE for the prediction of ACM and a composite endpoint in stable outpatients with and without relevant CV disease. Trial registration number NCT01954303; Pre-results.
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Affiliation(s)
- Moritz Biener
- Zentrum für Innere Medizin, Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Evangelos Giannitsis
- Zentrum für Innere Medizin, Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Manuel Kuhner
- Zentrum für Innere Medizin, Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Thomas Zelniker
- Zentrum für Innere Medizin, Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Matthias Mueller-Hennessen
- Zentrum für Innere Medizin, Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Mehrshad Vafaie
- Zentrum für Innere Medizin, Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Kiril M Stoyanov
- Klinik für Kardiologie und Angiologie II, Universitäts-Herzzentrum Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Franz-Josef Neumann
- Klinik für Kardiologie und Angiologie II, Universitäts-Herzzentrum Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Hugo A Katus
- Zentrum für Innere Medizin, Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Willibald Hochholzer
- Klinik für Kardiologie und Angiologie II, Universitäts-Herzzentrum Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Christian Marc Valina
- Klinik für Kardiologie und Angiologie II, Universitäts-Herzzentrum Freiburg Bad Krozingen, Bad Krozingen, Germany
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22
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Eggers KM, Lindahl B. Application of Cardiac Troponin in Cardiovascular Diseases Other Than Acute Coronary Syndrome. Clin Chem 2017; 63:223-235. [DOI: 10.1373/clinchem.2016.261495] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 07/18/2016] [Indexed: 12/13/2022]
Abstract
Abstract
BACKGROUND
Increased cardiac troponin concentrations in acute coronary syndrome (ACS) identify patients with ongoing cardiomyocyte necrosis who are at increased risk. However, with the use of more precise assays, cardiac troponin increases are commonly noted in other cardiovascular conditions as well. This has generated interest in the use of cardiac troponin for prognostic assessment and clinical management of these patients. In this review, we have summarized the data from studies investigating the implications of cardiac troponin concentrations in various acute and chronic conditions beyond ACS, i.e., heart failure, myocarditis, Takotsubo cardiomyopathy, aortic dissection, supraventricular arrhythmias, valve disease, pulmonary arterial hypertension, stroke, and in the perioperative setting.
CONTENT
Cardiac troponin concentrations are often detectable and frankly increased in non-ACS conditions, in particular when measured with high-sensitivity (hs) assays. With the exception of myocarditis and Takotsubo cardiomyopathy, cardiac troponin concentrations carry strong prognostic information, mainly with respect to mortality, or incipient and/or worsening heart failure. Studies investigating the prognostic benefit associated with cardiac troponin–guided treatments however, are almost lacking and the potential role of cardiac troponin in the management of non-ACS conditions is not defined.
SUMMARY
Increased cardiac troponin indicates increased risk for adverse outcome in patients with various cardiovascular conditions beyond ACS. Routine measurement of cardiac troponin concentrations can however, not be generally recommended unless there is a suspicion of ACS. Nonetheless, any finding of an increased cardiac troponin concentration in a patient without ACS should at least prompt the search for possible underlying conditions and these should be managed meticulously according to current guidelines to improve outcome.
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Affiliation(s)
| | - Bertil Lindahl
- Department of Medical Sciences and
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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