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Yaman M, Orak M, Durgun HM, Tekin V, Ülgüt ŞG, Belek S, Günel BT, Üstündağ M, Güloğlu C, Gündüz E. The prognostic value of HALP score and sPESI in predicting in-hospital mortality in patients with pulmonary thromboembolism. Postgrad Med J 2024:qgae124. [PMID: 39301789 DOI: 10.1093/postmj/qgae124] [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: 08/05/2024] [Revised: 08/24/2024] [Accepted: 09/03/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Pulmonary thromboembolism (PTE), often arising from deep vein thrombosis, remains a high-mortality condition despite diagnostic advancements. Prognostic models like Pulmonary Embolism Severity Index (PESI) and sPESI identify low-risk groups effectively. The Hemoglobin, Albumin, Lymphocyte, and Platelet (HALP) score, reflecting nutritional status and systemic inflammation, shows prognostic value in cancers and cardiovascular diseases. This study examines the relationship between in-hospital mortality HALP score and simplified PESI (sPESI) in PTE patients. METHODS This retrospective observational study included patients diagnosed with PTE in the emergency department of a tertiary medical faculty from 2018 to 2023. PTE diagnosis was confirmed via computed tomography pulmonary angiography. Data on transthoracic echocardiography, D-dimer levels, demographics, laboratory results, PESI, sPESI, and HALP scores, and in-hospital mortality were collected. RESULTS In this study, clinical characteristics of 171 patients with PTE were analysed. The average age was 61.88 ± 19.94 years, and 53.2% were female. Mortality was observed in 19.3% of patients. PESI and sPESI scores were significant predictors of mortality, with area under the curve values of 0.938 and 0.879, respectively. PESI score > 175.50 indicated a significantly higher mortality risk (HR = 18.208; P < .001), while sPESI >2.50 was also a strong predictor (HR = 11.840; P < .001). No significant cut-off value for HALP in predicting mortality was identified. CONCLUSIONS Our study supports the reliability of sPESI and PESI scores in predicting in-hospital mortality in PTE patients. However, the prognostic value of the HALP score requires further investigation. Our findings highlight the need for developing risk stratification models. Key message What is already known on this topic? The PESI and sPESI scores are established prognostic models that effectively identify low-risk groups in patients with PTE. The HALP score, reflecting nutritional status and systemic inflammation, has shown prognostic value in cancer and cardiovascular diseases. What this study adds? This study demonstrates that while PESI and sPESI scores are significant predictors of in-hospital mortality in PTE patients, the HALP score does not have a significant cut-off value for predicting mortality. How this study might affect research, practice, or policy? The findings support the continued use of PESI and sPESI scores for risk stratification in clinical practice, potentially influencing guidelines and policies on managing PTE. Further research into the HALP score's role in other contexts may refine its prognostic utility.
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Affiliation(s)
- Mahmut Yaman
- Dicle University Faculty of Medicine, Department of Emergency of Medicine, 21280 Diyarbakır, Turkey
| | - Murat Orak
- Dicle University Faculty of Medicine, Department of Emergency of Medicine, 21280 Diyarbakır, Turkey
| | - Hasan Mansur Durgun
- Dicle University Faculty of Medicine, Department of Emergency of Medicine, 21280 Diyarbakır, Turkey
| | - Veysi Tekin
- Dicle University Faculty of Medicine, Department of Pulmonary Diseases, 21280 Diyarbakır, Turkey
| | - Şilan Göger Ülgüt
- Dicle University Faculty of Medicine, Department of Emergency of Medicine, 21280 Diyarbakır, Turkey
| | - Sema Belek
- Dicle University Faculty of Medicine, Department of Emergency of Medicine, 21280 Diyarbakır, Turkey
| | - Berçem Tugay Günel
- Dicle University Faculty of Medicine, Department of Emergency of Medicine, 21280 Diyarbakır, Turkey
| | - Mehmet Üstündağ
- Dicle University Faculty of Medicine, Department of Emergency of Medicine, 21280 Diyarbakır, Turkey
| | - Cahfer Güloğlu
- Dicle University Faculty of Medicine, Department of Emergency of Medicine, 21280 Diyarbakır, Turkey
| | - Ercan Gündüz
- Dicle University Faculty of Medicine, Department of Emergency Medicine, Internal Medicine, 21280 Diyarbakir, Türkiye
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Keller K, Schmitt VH, Hahad O, Espinola-Klein C, Münzel T, Lurz P, Konstantinides S, Hobohm L. Categorization of Patients With Pulmonary Embolism by Charlson Comorbidity Index. Am J Med 2024; 137:727-735. [PMID: 38663792 DOI: 10.1016/j.amjmed.2024.04.025] [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: 04/02/2024] [Revised: 04/11/2024] [Accepted: 04/11/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Short-term outcomes of pulmonary embolism are closely related to right ventricular dysfunction and patient's hemodynamic status, but also to individual comorbidity profile. However, the impact of patients' comorbidities on survival during pulmonary embolism might be underrated. Although the Charlson Comorbidity Index (CCI) is the most extensively studied comorbidity index for detecting comorbidity burden, studies analyzing the impact of CCI on pulmonary embolism patients' survival are limited. METHODS We used the German nationwide inpatient sample to analyze all hospitalized patients with pulmonary embolism in Germany 2005-2020 and calculated CCI for each patient, compared the CCI classes (very low: CCI = 0 points, mild: CCI = 1-2 points, moderate: CCI = 3-4, high severity: CCI >4 points) and impact of CCI class on outcomes. RESULTS Overall, 1,373,145 hospitalizations of patients with acute pulmonary embolism (53.0% females, 55.9% aged ≥70 years) were recorded in Germany between 2005 and 2020; the CCI class stratified them. Among these, 100,156 (7.3%) were categorized as very low; 221,545 (16.1%) as mild; 394,965 (28.8%) as moderate; and 656,479 (47.8%) as patients with a high comorbidity burden according to CCI class. In-hospital case fatality increased depending on the CCI class: 3.6% in very low, 6.5% in mild, 12.1% in moderate, and 22.1% in high CCI class (P < .001). CCI class was associated with increased in-hospital case fatality (odds ratio 2.014; 95% confidence interval, 2.000-2.027; P < .001). CONCLUSION Our study results may help practitioners to better understand and measure the association between an aggravated comorbidity profile and increased in-hospital case fatality in patients with pulmonary embolism.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Germany; Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Germany.
| | - Volker H Schmitt
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Omar Hahad
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Christine Espinola-Klein
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Philipp Lurz
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Germany
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Keller K, Schmitt VH, Sagoschen I, Münzel T, Espinola-Klein C, Hobohm L. CRB-65 for Risk Stratification and Prediction of Prognosis in Pulmonary Embolism. J Clin Med 2023; 12:1264. [PMID: 36835800 PMCID: PMC9961795 DOI: 10.3390/jcm12041264] [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: 12/31/2022] [Revised: 01/29/2023] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is accompanied by high morbidity and mortality. The search for simple and easily assessable risk stratification scores with favourable effectiveness is still ongoing, and prognostic performance of the CRB-65 score in PE might promising. METHODS The German nationwide inpatient sample was used for this study. All patient cases of patients with PE in Germany 2005-2020 were included and stratified for CRB-65 risk class: low-risk group (CRB-65-score 0 points) vs. high-risk group (CRB-65-score ≥1 points). RESULTS Overall, 1,373,145 patient cases of patients with PE (76.6% aged ≥65 years, 47.0% females) were included. Among these, 1,051,244 patient cases (76.6%) were classified as high-risk according to CRB-65 score (≥1 points). The majority of high-risk patients according to CRB-65 score were females (55.8%). Additionally, high-risk patients according to CRB-65 score showed an aggravated comorbidity profile with increased Charlson comorbidity index (5.0 [IQR 4.0-7.0] vs. 2.0 [0.0-3.0], p < 0.001). In-hospital case fatality (19.0% vs. 3.4%, p < 0.001) and MACCE (22.4% vs. 5.1%, p < 0.001) occurred distinctly more often in PE patients of the high-risk group according to CRB-65 score (≥1 points) compared to the low-risk group (= 0 points). The CRB-65 high-risk class was independently associated with in-hospital death (OR 5.53 [95%CI 5.40-5.65], p < 0.001) as well as MACCE (OR 4.31 [95%CI 4.23-4.40], p < 0.001). CONCLUSIONS Risk stratification with CRB-65 score was helpful for identifying PE patients being at higher risk of adverse in-hospital events. The high-risk class according to CRB-65 score (≥1 points) was independently associated with a 5.5-fold increased occurrence of in-hospital death.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Volker H. Schmitt
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Ingo Sagoschen
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 55131 Mainz, Germany
| | - Christine Espinola-Klein
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
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Lee HJ, Wanderley M, da Silva Rubin VC, Alcala GC, Costa ELV, Parga JR, Amato MBP. Quantitative analysis of pulmonary perfusion with dual-energy CT angiography: comparison of two quantification methods in patients with pulmonary embolism. Int J Cardiovasc Imaging 2022; 39:853-862. [PMID: 36565388 DOI: 10.1007/s10554-022-02781-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 12/11/2022] [Indexed: 12/25/2022]
Abstract
The study aimed to evaluate a quantification method of pulmonary perfusion with Dual-Energy CT Angiography (DE-CTA) normalized by lung density in the prediction of outcome in acute pulmonary embolism (PE). In this prospective study with CTA scans acquired with different breathing protocols, two perfusion parameters were calculated: %PBV (relative value of PBV, expressed per unit volume) and PBVm (PBV normalized by lung density, expressed per unit mass). DE-CTA parameters were correlated with simplified pulmonary embolism severity index (sPESI) and with outcome groups, alone and in combinationwith tomographic right-to-left ventricular ratios (RV/LV). PBVm showed significant correlation with sPESI. PBVm presented higher accuracy than %PBV In the prediction of ICU admission or death in patients with PE, with the best performance when combined with RV/LV volumetric ratio.
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Affiliation(s)
- Hye Ju Lee
- Department of Radiology, Hospital das Clinicas da Faculdade Medicina da Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
| | - Mark Wanderley
- Department of Radiology, Hospital das Clinicas da Faculdade Medicina da Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Vivian Cardinal da Silva Rubin
- Department of Radiology, Hospital das Clinicas da Faculdade Medicina da Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Glasiele Cristina Alcala
- Pneumology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Instituto do Coracao, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Eduardo Leite Vieira Costa
- Pneumology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Instituto do Coracao, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Jose Rodrigues Parga
- Department of Radiology, Hospital das Clinicas da Faculdade Medicina da Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Marcelo Britto Passos Amato
- Pneumology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Instituto do Coracao, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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Xia W, Yu H, Chen W, Chen B, Huang Y. A Radiological Nomogram to Predict 30-day Mortality in Patients with Acute Pulmonary Embolism. Acad Radiol 2021; 29:1169-1177. [PMID: 34953727 DOI: 10.1016/j.acra.2021.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022]
Abstract
RATIONALE AND OBJECTIVES Acute pulmonary embolism (APE) is a common disease with a high mortality, especially in the short term. Computed tomographic pulmonary angiography (CTPA) is a recommended method in the diagnostic workup for APE; thus, this study aimed to establish a CTPA-based radiological nomogram to predict the 30-day mortality in patients with APE, and to further compare this model with the pulmonary embolism severity index (PESI) and simplified pulmonary embolism severity index (SPESI). MATERIALS AND METHODS We retrospectively recruited 158 adults with confirmed APE who underwent CTPA from August 1, 2017, to August 1, 2020. These adults were stratified into two groups according to their 30-day mortality. CTPA-based variables were analyzed using univariate and multivariate analyses, independent risk factors for 30-day mortality were established, and a radiological nomogram was constructed. Subsequently, PESI and SPESI were calculated. The performance of the radiological nomogram model was compared to that of the PESI and SPESI using decision curve analysis and receiver-operating characteristic curve analysis. RESULTS Thirty-three patients died within 30 days (30-day mortality rate, 20.9%). On logistic regression analysis, the right and left ventricular diameter ratio (odds ratio [OR] = 8.709, 95% confidence interval [CI]: 1.085-69.903, p = 0.042), ventricular septal bowing (OR = 8.085, 95% CI: 1.947-33.567, p = 0.004), chronic bronchitis (OR = 4.383, 95% CI: 1.025-18.740, p = 0.046), malignant lung lesions (OR = 17.530, 95% CI: 2.408-127.636, p = 0.005), and pneumonia (OR = 3.477, 95% CI: 1.123-10.766, p = 0.031) were identified as the independent predictors of 30-day mortality. The area under the curve of the radiological nomogram, PESI, and SPESI were 0.900 (95% CI: 0.828-0.971), 0.729 (95% CI: 0.642-0.815), and 0.718 (95% CI: 0.621-0.815), respectively. CONCLUSION The CTPA-based radiological nomogram appeared valuable for the prediction of 30-day mortality in patients with APE, and was superior to both PESI and SPESI.
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Slajus B, Brailovsky Y, Darwish I, Fareed J, Darki A. Utility of Blood Cellular Indices in the Risk Stratification of Patients Presenting with Acute Pulmonary Embolism. Clin Appl Thromb Hemost 2021; 27:10760296211052292. [PMID: 34846193 PMCID: PMC8649084 DOI: 10.1177/10760296211052292] [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] [Indexed: 11/16/2022] Open
Abstract
Pulmonary embolism (PE) clinical manifestations vary widely, and that scope is not fully captured by current all-cause mortality risk models. PE is associated with inflammatory, coagulation, and hemostatic imbalances so blood cellular indices may be prognostically useful. Complete blood count (CBC) data may improve current risk models like the simplified pulmonary embolism severity index (sPESI) for all-cause mortality, offering greater accuracy and analytic ability. Acute PE patients (n = 228) with confirmatory diagnostic imaging were followed for all-cause mortality. Blood cellular indices were assessed for association to all-cause mortality and were supplemented into sPESI using multivariate logistic regression. Multiple blood cellular indices were found to be significantly associated with all-cause mortality in acute PE. sPESI including red cell distribution width, hematocrit and neutrophil-lymphocyte ratio had better predictive ability as compared to sPESI alone (AUC: 0.852 vs 0.754). Blood cellular indices contribute an inflammatory and hemodynamic perspective not currently included in sPESI. CBC with differential is a widely used, low-cost test that can augment current risk stratification tools for all-cause mortality in acute PE patients.
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Affiliation(s)
- Brett Slajus
- Loyola University Medical Center, Stritch School of Medicine, Maywood, IL, USA
| | - Yevgeniy Brailovsky
- Advanced Heart Failure, Mechanical Circulatory Support, Heart Transplant, Jefferson Heart Institute, Sidney Kimmel School of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Iman Darwish
- Loyola University Medical Center, Stritch School of Medicine, Maywood, IL, USA
| | - Jawed Fareed
- Cardiovascular Research Institute, Hemostasis and Thrombosis Research Division, 2456Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - Amir Darki
- Loyola University Medical Center, Stritch School of Medicine, Maywood, IL, USA
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Weekes AJ, Raper JD, Lupez K, Thomas AM, Cox CA, Esener D, Boyd JS, Nomura JT, Davison J, Ockerse PM, Leech S, Johnson J, Abrams E, Murphy K, Kelly C, Norton HJ. Development and validation of a prognostic tool: Pulmonary embolism short-term clinical outcomes risk estimation (PE-SCORE). PLoS One 2021; 16:e0260036. [PMID: 34793539 PMCID: PMC8601564 DOI: 10.1371/journal.pone.0260036] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Develop and validate a prognostic model for clinical deterioration or death within days of pulmonary embolism (PE) diagnosis using point-of-care criteria. METHODS We used prospective registry data from six emergency departments. The primary composite outcome was death or deterioration (respiratory failure, cardiac arrest, new dysrhythmia, sustained hypotension, and rescue reperfusion intervention) within 5 days. Candidate predictors included laboratory and imaging right ventricle (RV) assessments. The prognostic model was developed from 935 PE patients. Univariable analysis of 138 candidate variables was followed by penalized and standard logistic regression on 26 retained variables, and then tested with a validation database (N = 801). RESULTS Logistic regression yielded a nine-variable model, then simplified to a nine-point tool (PE-SCORE): one point each for abnormal RV by echocardiography, abnormal RV by computed tomography, systolic blood pressure < 100 mmHg, dysrhythmia, suspected/confirmed systemic infection, syncope, medico-social admission reason, abnormal heart rate, and two points for creatinine greater than 2.0 mg/dL. In the development database, 22.4% had the primary outcome. Prognostic accuracy of logistic regression model versus PE-SCORE model: 0.83 (0.80, 0.86) vs. 0.78 (0.75, 0.82) using area under the curve (AUC) and 0.61 (0.57, 0.64) vs. 0.50 (0.39, 0.60) using precision-recall curve (AUCpr). In the validation database, 26.6% had the primary outcome. PE-SCORE had AUC 0.77 (0.73, 0.81) and AUCpr 0.63 (0.43, 0.81). As points increased, outcome proportions increased: a score of zero had 2% outcome, whereas scores of six and above had ≥ 69.6% outcomes. In the validation dataset, PE-SCORE zero had 8% outcome [no deaths], whereas all patients with PE-SCORE of six and above had the primary outcome. CONCLUSIONS PE-SCORE model identifies PE patients at low- and high-risk for deterioration and may help guide decisions about early outpatient management versus need for hospital-based monitoring.
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Affiliation(s)
- Anthony J. Weekes
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Jaron D. Raper
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Kathryn Lupez
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Alyssa M. Thomas
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Carly A. Cox
- Department of Emergency Medicine, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
| | - Dasia Esener
- Department of Emergency Medicine, Kaiser Permanente, San Diego, CA, United States of America
| | - Jeremy S. Boyd
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Jason T. Nomura
- Department of Emergency Medicine, Christiana Care, Newark, DE, United States of America
| | - Jillian Davison
- Department of Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Patrick M. Ockerse
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT, United States of America
| | - Stephen Leech
- Department of Emergency Medicine, Orlando Health, Orlando, FL, United States of America
| | - Jakea Johnson
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Eric Abrams
- Department of Emergency Medicine, Kaiser Permanente, San Diego, CA, United States of America
| | - Kathleen Murphy
- Department of Emergency Medicine, Christiana Care, Newark, DE, United States of America
| | - Christopher Kelly
- Division of Emergency Medicine, University of Utah Health, Salt Lake City, UT, United States of America
| | - H. James Norton
- Professor Emeritus of Biostatistics, Atrium Health’s Carolinas Medical Center, Charlotte, NC, United States of America
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Stevens SM, Woller SC, Baumann Kreuziger L, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest 2021; 160:e545-e608. [PMID: 34352278 DOI: 10.1016/j.chest.2021.07.055] [Citation(s) in RCA: 388] [Impact Index Per Article: 129.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/11/2021] [Accepted: 07/08/2021] [Indexed: 01/06/2023] Open
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Todoran TM, Petkovich B. Aggressive Therapy for Acute Pulmonary Embolism: Systemic Thrombolysis and Catheter-Directed Approaches. Semin Respir Crit Care Med 2021; 42:250-262. [PMID: 33548933 DOI: 10.1055/s-0040-1722291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Venous thromboembolism (VTE) is the third most common cause of cardiovascular disease after myocardial infarction and stroke. Population-based studies estimate that up to 94,000 new cases of pulmonary embolism (PE) occur in the United States annually with an increasing incidence with age. Mortality from PE is the greatest in the first 24 hours, with a decreased survival extending out 3 months. Thus, acute PE is a potentially fatal illness if not recognized and treated in a timely manner. Contemporary management includes systemic anticoagulation, thrombolysis, catheter-based procedures, and surgical embolectomy. This article reviews current clinical evidence and societal guidelines for the use of systemic and catheter-directed thrombolysis for treatment of acute PE.
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Affiliation(s)
- Thomas M Todoran
- Division of Cardiovascular Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Bradley Petkovich
- Divisions of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, South Carolina
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Andrade I, García A, Mercedes E, León F, Velasco D, Rodríguez C, Pintado B, Pérez A, Jiménez D. Necesidad de una ecocardiografía transtorácica en pacientes con tromboembolia de pulmón de riesgo bajo: revisión sistemática y metanálisis. Arch Bronconeumol 2020; 56:306-313. [DOI: 10.1016/j.arbres.2019.08.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 10/25/2022]
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Boucly A, Savale L, Vuillard C, Turpin M, Jaïs X, Montani D, Humbert M, Sitbon O. [Management of right ventricular failure in pulmonary vascular diseases]. Rev Mal Respir 2020; 37:171-179. [PMID: 32061440 DOI: 10.1016/j.rmr.2019.07.012] [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: 11/19/2018] [Accepted: 07/19/2019] [Indexed: 10/25/2022]
Abstract
Right ventricular failure (RVF) is a common cause of admission to the intensive care unit and its presence is a major prognostic factor in acute pulmonary embolism (PE) and chronic pulmonary hypertension (PH). RVF results from an incapacity of the RV to adapt to an increase in afterload so it can become critical in acute PE and chronic PH. The presence of RVF in cases of acute PE with haemodynamic instability is an indication for thrombolytic therapy. RVF represents the most common cause of death in chronic PH. Factors triggering RV failure in PH, such as infection, PE, arrhythmias, or unplanned withdrawal of pulmonary arterial hypertension (PAH)-targeted therapy, have to be considered and treated if identified. However, RVF may also represent progression to end-stage disease. The management of RVF in patients with PH requires expertise and consists of optimization of fluid balance (with diuretics), cardiac output (with inotropic support such as dobutamine), perfusion pressure (with norepinephrine), and reduction of RV afterload with PAH-targeted therapies. Extracorporeal life support, lung transplantation or heart-lung transplantation should be considered in cases of refractory RVF in eligible patients.
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Affiliation(s)
- A Boucly
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France
| | - L Savale
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France
| | - C Vuillard
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France
| | - M Turpin
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France
| | - X Jaïs
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France
| | - D Montani
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France
| | - M Humbert
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France
| | - O Sitbon
- Faculté de médecine, université Paris-Saclay, université Paris-Sud, 94270 Le Kremlin-Bicêtre, France; Service de Pneumologie et soins intensifs respiratoires, Centre de référence de l'hypertension pulmonaire sévère, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France; Inserm UMR_S 999, hôpital Marie-Lannelongue, 92350 Le Plessis-Robinson, France.
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Yousif M, Hussein SA. Original, simplified, and modified pulmonary embolism severity indices in risk stratification of pulmonary embolism. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2019. [DOI: 10.4103/ejb.ejb_68_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Akyol PY, Karakaya Z, Topal FE, Payza U, Kuday Kaykısız E. Simplified Pulmonary Embolism Severity Index in Predicting Mortality in ED. KONURALP TIP DERGISI 2019. [DOI: 10.18521/ktd.511525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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14
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Prentice D, Wipke-Tevis DD. Diagnosis of pulmonary embolism: Following the evidence from suspicion to certainty. JOURNAL OF VASCULAR NURSING 2019; 37:28-42. [PMID: 30954195 DOI: 10.1016/j.jvn.2018.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/23/2018] [Accepted: 10/02/2018] [Indexed: 12/16/2022]
Abstract
Accurate, timely and cost-effective identification of pulmonary embolism remains a diagnostic challenge. This article reviews the pulmonary embolism diagnostic process with a focus on the best practice advice from the American College of Physicians. Benefits and risks of each diagnostic step are discussed. Emerging diagnostic tools, not included in the algorithm, are briefly reviewed.
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Affiliation(s)
- Donna Prentice
- Clinical Nurse Specialist, Barnes-Jewish Hospital, St. Louis, MO; PhD Candidate, Sinclair School of Nursing, University of Missouri, Columbia, MO.
| | - Deidre D Wipke-Tevis
- Associate Professor and PhD Program Director, Sinclair School of Nursing, University of Missouri, Columbia, MO
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15
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Trimaille A, Marchandot B, Girardey M, Muller C, Lim HS, Trinh A, Ohlmann P, Moulin B, Jesel L, Morel O. Assessment of Renal Dysfunction Improves the Simplified Pulmonary Embolism Severity Index (sPESI) for Risk Stratification in Patients with Acute Pulmonary Embolism. J Clin Med 2019; 8:jcm8020160. [PMID: 30717116 PMCID: PMC6406501 DOI: 10.3390/jcm8020160] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 01/22/2019] [Accepted: 01/24/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Whereas the major strength of the simplified pulmonary embolism severity index (sPESI) lies in ruling out an adverse outcome in patients with sPESI of 0, the accuracy of sPESI ≥ 1 in risk assessment remains questionable. In acute pulmonary embolism (APE), the estimated glomerular filtration rate (eGFR) can be viewed as an integrate marker reflecting not only previous chronic kidney disease (CKD) damage but also comorbid conditions and hemodynamic disturbances associated with APE. We sought to determine whether renal dysfunction assessment by eGFR improves the sPESI score risk stratification in patients with APE. Methods: 678 consecutive patients with APE were prospectively enrolled. Renal dysfunction (RD) at diagnosis of APE was defined by eGFR < 60 mL/min/1.73 m2 and acute kidney injury (AKI) by elevation of creatinine level >25% during in-hospital stay. Results: RD was observed in 26.9% of the cohort. AKI occurred in 18.8%. A stepwise increase in 30-day mortality, cardiovascular mortality and overall mortality was evident with declining renal function. Multivariate analysis identified RD and CRP (C-reactive protein) level but not sPESI score as independent predictors of 30-day mortality. AKI, 30-day mortality, overall mortality, and cardiovascular mortality were at their highest level in patients with eGFR < 60 mL/min/1.73 m2 and sPESI ≥1. Conclusion: in patients with APE, the addition of RD to the sPESI score identifies a specific subset of patients at very high mortality.
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Affiliation(s)
- Antonin Trimaille
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Benjamin Marchandot
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Mélanie Girardey
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Clotilde Muller
- Pôle NUDE, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Han S Lim
- Department of Cardiology, Austin and Northern Health, Melbourne 3084, Australia.
| | - Annie Trinh
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Patrick Ohlmann
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Bruno Moulin
- Pôle NUDE, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
| | - Laurence Jesel
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
- Laboratory of Regenerative Nanomedicine, UMR 1260, INSERM (French National Institute of Health and Medical Research), FMTS (Fédération de Médecine Translationnelle de l'Université de Strasbourg), Faculté de Médecine, Université de Strasbourg, 11 rue Humann, 67085 Strasbourg, France.
| | - Olivier Morel
- Pôle d'Activité Médico-Chirurgicale Cardio-Vasculaire, Nouvel Hôpital Civil, Centre Hospitalier Universitaire, Université de Strasbourg, 67091 Strasbourg, France.
- Laboratory of Regenerative Nanomedicine, UMR 1260, INSERM (French National Institute of Health and Medical Research), FMTS (Fédération de Médecine Translationnelle de l'Université de Strasbourg), Faculté de Médecine, Université de Strasbourg, 11 rue Humann, 67085 Strasbourg, France.
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Pouzet G, Dubie E, Belle L, Lesage P, Usseglio P. [Evaluation of the management of low-risk pulmonary embolism diagnosed in an emergency department. HoPE study (Home treatment of Pulmonary Embolism)]. Ann Cardiol Angeiol (Paris) 2019; 68:1-5. [PMID: 30292444 DOI: 10.1016/j.ancard.2018.08.005] [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: 06/24/2018] [Accepted: 08/07/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Risk stratification allows outpatient management of low-risk pulmonary embolism (PE). Here, we carry out an evaluation of the professional practices on the emergency management of low-risk PE, after selection with the sPESI score. MATERIAL AND METHOD All patients admitted to the emergency department of Chambéry hospital, with a final diagnosis of PE are analyzed. The PE of score sPESI at 0 are included, in the absence of contraindications. Ninety-day follow-up is done. The objective is to evaluate the proportion of ambulatory care for low-risk patients. RESULTS Eighty PE were diagnosed in 2016, 28 with sPESI score at 0 and 3 patients excluded. Of the 25 inclusions, 6 patients had signs of right ventricular dysfunction and were therefore hospitalized. The remaining 19 were eligible for outpatient care but only 8 of them stayed less than 24hours in the hospital. DISCUSSION The sPESI score is a decision support tool for outpatient management but should not be used alone. The search for right ventricular dysfunction seems important here.
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Affiliation(s)
- G Pouzet
- Urgence/SAMU/SMUR, centre hospitalier Métropole Savoie, 505, faubourg Maché, 73000 Chambéry, France.
| | - E Dubie
- Urgence/SAMU/SMUR, centre hospitalier Métropole Savoie, 505, faubourg Maché, 73000 Chambéry, France
| | - L Belle
- Cardiologie, centre hospitalier Annecy-Genevois, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - P Lesage
- Urgence/SAMU/SMUR, centre hospitalier Métropole Savoie, 505, faubourg Maché, 73000 Chambéry, France
| | - P Usseglio
- Urgence/SAMU/SMUR, centre hospitalier Métropole Savoie, 505, faubourg Maché, 73000 Chambéry, France
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Risk stratification of acute pulmonary embolism based on clinical parameters, H-FABP and multidetector CT. Int J Cardiol 2018; 265:223-228. [DOI: 10.1016/j.ijcard.2018.04.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 02/05/2018] [Accepted: 04/16/2018] [Indexed: 12/17/2022]
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18
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Kozlowska M, Plywaczewska M, Koc M, Pacho S, Wyzgal A, Zdonczyk O, Furdyna A, Ciurzynski M, Kurnicka K, Jankowski K, Lipinska A, Palczewski P, Bienias P, Pruszczyk P. d-Dimer Assessment Improves the Simplified Pulmonary Embolism Severity Index for In-Hospital Risk Stratification in Acute Pulmonary Embolism. Clin Appl Thromb Hemost 2018; 24:1340-1346. [PMID: 29806471 PMCID: PMC6714762 DOI: 10.1177/1076029618776799] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
d-dimer (DD) levels are used in the diagnostic workup of suspected acute pulmonary embolism (APE), but data on DD for early risk stratification in APE are limited. In this post hoc analysis of a prospective observational study of 270 consecutive patients, we aimed to optimize the discriminant capacity of the simplified pulmonary embolism severity index (sPESI), an APE risk assessment score currently used, by combining it with DD for in-hospital adverse event prediction. We found that DD levels were higher in patients with complicated versus benign clinical course 7.2 mg/L (25th-75th percentile: 4.5-27.7 mg/L) versus 5.1 mg/L (25th-75th percentile: 2.1-11.2 mg/L), P = .004. The area under the curve of DD for serious adverse event (SAE) was 0.672, P = .003. d-dimer =1.35 mg/L showed 100% negative predictive value for SAE and identified 11 sPESI ≥1 patients with a benign clinical course, detecting the 1 patient with SAE from sPESI = 0. d-dimer >15 mg/L showed heart rate for SAE 3.04 (95% confidence interval [CI]: 1-9). A stratification model which with sPESI + DD >1.35 mg/L demonstrated improved prognostic value when compared to sPESI alone (net reclassification improvement: 0.085, P = .04). d-dimer have prognostic value, values <1.35 mg/L identify patients with a favorable outcome, improving the prognostic potential of sPESI, while DD >15 mg/L is an independent predictor of SAE.
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Affiliation(s)
- Marta Kozlowska
- 1 Department of Internal Medicine & Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Magdalena Plywaczewska
- 1 Department of Internal Medicine & Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Koc
- 1 Department of Internal Medicine & Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Szymon Pacho
- 1 Department of Internal Medicine & Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Anna Wyzgal
- 1 Department of Internal Medicine & Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Olga Zdonczyk
- 1 Department of Internal Medicine & Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Aleksandra Furdyna
- 1 Department of Internal Medicine & Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Michal Ciurzynski
- 1 Department of Internal Medicine & Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Kurnicka
- 1 Department of Internal Medicine & Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Jankowski
- 1 Department of Internal Medicine & Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Anna Lipinska
- 1 Department of Internal Medicine & Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Palczewski
- 2 I Department of Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Bienias
- 1 Department of Internal Medicine & Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Pruszczyk
- 1 Department of Internal Medicine & Cardiology, Medical University of Warsaw, Warsaw, Poland
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Ciurzyński M, Kurnicka K, Lichodziejewska B, Kozłowska M, Pływaczewska M, Sobieraj P, Dzikowska-Diduch O, Goliszek S, Bienias P, Kostrubiec M, Pruszczyk P. Tricuspid Regurgitation Peak Gradient (TRPG)/Tricuspid Annulus Plane Systolic Excursion (TAPSE) ― A Novel Parameter for Stepwise Echocardiographic Risk Stratification in Normotensive Patients With Acute Pulmonary Embolism ―. Circ J 2018; 82:1179-1185. [DOI: 10.1253/circj.cj-17-0940] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Michał Ciurzyński
- Department of Internal Medicine and Cardiology, The Medical University of Warsaw
| | - Katarzyna Kurnicka
- Department of Internal Medicine and Cardiology, The Medical University of Warsaw
| | | | - Marta Kozłowska
- Department of Internal Medicine and Cardiology, The Medical University of Warsaw
| | | | - Piotr Sobieraj
- Department of Internal Medicine, Hypertension and Vascular Diseases, The Medical University of Warsaw
| | | | - Sylwia Goliszek
- Department of Internal Medicine and Cardiology, The Medical University of Warsaw
| | - Piotr Bienias
- Department of Internal Medicine and Cardiology, The Medical University of Warsaw
| | - Maciej Kostrubiec
- Department of Internal Medicine and Cardiology, The Medical University of Warsaw
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, The Medical University of Warsaw
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20
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Maestre Peiró A, Gonzálvez Gasch A, Monreal Bosch M. Update on the risk stratification of acute symptomatic pulmonary thromboembolism. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2017.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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21
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Update on the risk stratification of acute symptomatic pulmonary thromboembolism. Rev Clin Esp 2017; 217:342-350. [PMID: 28476246 DOI: 10.1016/j.rce.2017.02.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 02/22/2017] [Accepted: 02/23/2017] [Indexed: 01/22/2023]
Abstract
Early mortality in patients with pulmonary thromboembolism (PTE) varies from 2% in normotensive patients to 30% in patients with cardiogenic shock. The current risk stratification for symptomatic PTE includes 4 patient groups, and the recommended therapeutic strategies are based on this stratification. Patients who have haemodynamic instability are considered at high risk. Fibrinolytic treatment is recommended for these patients. In normotensive patients, risk stratification helps differentiate between those of low risk, intermediate-low risk and intermediate-high risk. There is currently insufficient evidence on the benefit of intensive monitoring and fibrinolytic treatment in patients with intermediate-high risk. For low-risk patients, standard anticoagulation is indicated. Early discharge with outpatient management may be considered, although its benefit has still not been firmly established.
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22
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Cardiovascular Conditions in the Observation Unit: Beyond Chest Pain. Emerg Med Clin North Am 2017; 35:549-569. [PMID: 28711124 DOI: 10.1016/j.emc.2017.03.004] [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: 11/23/2022]
Abstract
The first emergency department observation units (EDOUs) focused on chest pain and potential acute coronary syndromes. However, most EDOUs now cover multiple other conditions that lend themselves to protocolized, aggressive diagnostic and therapeutic regimens. In this article, the authors discuss the management of 4 cardiovascular conditions that have been successfully deployed in EDOUs around the country.
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Paroxysmal Atrial Fibrillation in the Course of Acute Pulmonary Embolism: Clinical Significance and Impact on Prognosis. BIOMED RESEARCH INTERNATIONAL 2017; 2017:5049802. [PMID: 28280732 PMCID: PMC5322430 DOI: 10.1155/2017/5049802] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 01/16/2017] [Indexed: 11/17/2022]
Abstract
The relationship and clinical implications of atrial fibrillation (AF) in acute pulmonary embolism (PE) are poorly investigated. We aimed to analyze clinical characteristics and prognosis in PE patients with paroxysmal AF episode. Methods. From the 391 patients with PE 31 subjects with paroxysmal AF were selected. This group was compared with patients with PE and sinus rhythm (SR) and 32 patients with PE and permanent AF. Results. Paroxysmal AF patients were the oldest. Concomitant DVT varies between groups: paroxysmal AF 32.3%, SR 49.5%, and permanent AF 28.1% (p = 0.02). The stroke history frequency was 4.6% SR, 12.9% paroxysmal AF, and 21.9% permanent AF (p < 0.001). Paroxysmal AF comparing to permanent AF and SR individuals had higher estimated SPAP (56 versus 48 versus 47 mmHg, p = 0.01) and shorter ACT (58 versus 65 versus 70 ms, p = 0.04). Patients with AF were more often classified into high-risk group according to revised Geneva score and sPESI than SR patients. In-hospital mortality was lower in SR (5%) and paroxysmal AF (6.5%) compared to permanent AF group (25%) (p < 0.001). Conclusions. Patients with PE-associated paroxysmal AF constitute a separate population. More severe impairment of the parameters reflecting RV afterload may indicate relation between PE severity and paroxysmal AF episode. Paroxysmal AF has no impact on short-term mortality.
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Giannitsis E, Katus HA. Biomarkers for Clinical Decision-Making in the Management of Pulmonary Embolism. Clin Chem 2017; 63:91-100. [DOI: 10.1373/clinchem.2016.255240] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 07/12/2016] [Indexed: 12/13/2022]
Abstract
Abstract
BACKGROUND
Pulmonary embolism (PE) is associated with high all-cause and PE-related mortality and requires individualized management. After confirmation of PE, a refined risk stratification is particularly warranted among normotensive patients. Previous prognostic models favored combinations of echocardiography or computed tomography suggestive of right ventricular (RV) dysfunction together with biomarkers of RV dysfunction (natriuretic peptides) or myocardial injury (cardiac troponins) to identify candidates for thrombolysis or embolectomy. In contrast, current predictive models using clinical scores such as the Pulmonary Embolism Severity Index (PESI) or its simplified version (sPESI) rather seek to identify patients, not only those at higher risk requiring observation for early detection of hemodynamic decompensation, and the need for initiation of rescue reperfusion therapy, but also those at low risk qualifying for early discharge and outpatient treatment. Almost all prediction models advocate the additional measurement of biomarkers along with imaging of RV dysfunction as part of a comprehensive algorithm.
CONTENT
The following mini-review will provide an updated overview on the individual components of different algorithms with a particular focus on guideline-recommended and new, less-established biomarkers for risk stratification, and how biomarkers should be implemented and interpreted.
SUMMARY
Ideally, biomarkers should be part of a comprehensive risk stratification algorithm used together with clinical risk scores as a basis, and/or imaging. For this purpose, cardiac troponins, including high-sensitivity troponin generations, natriuretic peptides, and h-FABP (heart-type fatty acid–binding protein) are currently recommended in guidelines. There is emerging evidence for several novel biomarkers that require further validation before being applied in clinical practice.
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Affiliation(s)
- Evangelos Giannitsis
- Department of Internal Medicine III, Cardiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Department of Internal Medicine III, Cardiology, University Hospital Heidelberg, Heidelberg, Germany
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Zhou XY, Chen HL, Ni SS. Hyponatremia and short-term prognosis of patients with acute pulmonary embolism: A meta-analysis. Int J Cardiol 2017; 227:251-256. [DOI: 10.1016/j.ijcard.2016.11.120] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 11/06/2016] [Indexed: 10/20/2022]
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Mortality Related Risk Factors in High-Risk Pulmonary Embolism in the ICU. Can Respir J 2016; 2016:2432808. [PMID: 28025592 PMCID: PMC5153485 DOI: 10.1155/2016/2432808] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/12/2016] [Accepted: 10/26/2016] [Indexed: 12/24/2022] Open
Abstract
Introduction. We sought to identify possible risk factors associated with mortality in patients with high-risk pulmonary embolism (PE) after intensive care unit (ICU) admission. Patients and Methods. PE patients, diagnosed with computer tomography pulmonary angiography, were included from two ICUs and were categorized into groups: group 1 high-risk patients and group 2 intermediate/low-risk patients. Results. Fifty-six patients were included. Of them, 41 (73.2%) were group 1 and 15 (26.7%) were group 2. When compared to group 2, need for vasopressor therapy (0 vs 68.3%; p < 0.001) and need for invasive mechanical ventilation (6.7 vs 36.6%; p = 0.043) were more frequent in group 1. The treatment of choice for group 1 was thrombolytic therapy in 29 (70.7%) and anticoagulation in 12 (29.3%) patients. ICU mortality for group 1 was 31.7% (n = 13). In multivariate logistic regression analysis, APACHE II score >18 (OR 42.47 95% CI 1.50–1201.1), invasive mechanical ventilation (OR 30.10 95% CI 1.96–463.31), and thrombolytic therapy (OR 0.03 95% CI 0.01–0.98) were found as independent predictors of mortality. Conclusion. In high-risk PE, admission APACHE II score and need for invasive mechanical ventilation may predict death in ICU. Thrombolytic therapy seems to be beneficial in these patients.
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Dubie E, Pouzet G, Bohyn E, Meunier C, Wuyts A, Chateigner Coelsch S, Lesage P, Morvan C, Belle L, Vanzetto G. [Outpatient management of pulmonary embolism diagnosed in emergency services]. Ann Cardiol Angeiol (Paris) 2016; 65:322-325. [PMID: 27693164 DOI: 10.1016/j.ancard.2016.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 09/02/2016] [Indexed: 10/20/2022]
Abstract
In the emergency department, the management of patients with pulmonary embolism depends on the early mortality risk. Outpatient care is possible in low-risk patients. We present the existing scores and the strategy proposed by the North Alps Emergency Network, which uses the simplified PESI score (Pulmonary Embolism Severity Index) to select those low-risk patients, candidates for early discharge.
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Affiliation(s)
- E Dubie
- Centre hospitalier métropole Savoie, Medical Emergency Service, BP 31125, 7, square Massalaz, 73011 Chambéry cedex, France.
| | - G Pouzet
- Centre hospitalier métropole Savoie, Medical Emergency Service, BP 31125, 7, square Massalaz, 73011 Chambéry cedex, France
| | - E Bohyn
- Centre hospitalier Annecy-Genevois, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - C Meunier
- Centre hospitalier de Saint-Jean-de-Maurienne, rue du Dr-Grange, 73300 Saint-Jean-de-Maurienne, France
| | - A Wuyts
- Centre hospitalier d'Albertville-Moutiers, 253, rue Pierre-de-Coubertin, 73200 Albertville, France
| | - S Chateigner Coelsch
- Centre hospitalier de Bourg-Saint-Maurice, 139, rue du Nantet, 73700 Bourg-Saint-Maurice, France
| | - P Lesage
- Centre hospitalier métropole Savoie, Medical Emergency Service, BP 31125, 7, square Massalaz, 73011 Chambéry cedex, France
| | - C Morvan
- Réseau Nord-Alpin des urgences, centre hospitalier Annecy-Genevois, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - L Belle
- Réseau Nord-Alpin des urgences, centre hospitalier Annecy-Genevois, 1, avenue de l'Hôpital, 74370 Metz-Tessy, France
| | - G Vanzetto
- Centre hospitalier universitaire Grenoble-Alpes, boulevard de la Chantourne, 38700 la Tronche, France
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Youssef AEI, ElShahat HM, Radwan AS, Al-Sadek MES. Comparison of two prognostic models for acute pulmonary embolism. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2016. [DOI: 10.1016/j.ejcdt.2016.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Elias A, Mallett S, Daoud-Elias M, Poggi JN, Clarke M. Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis. BMJ Open 2016; 6:e010324. [PMID: 27130162 PMCID: PMC4854007 DOI: 10.1136/bmjopen-2015-010324] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To review the evidence for existing prognostic models in acute pulmonary embolism (PE) and determine how valid and useful they are for predicting patient outcomes. DESIGN Systematic review and meta-analysis. DATA SOURCES OVID MEDLINE and EMBASE, and The Cochrane Library from inception to July 2014, and sources of grey literature. ELIGIBILITY CRITERIA Studies aiming at constructing, validating, updating or studying the impact of prognostic models to predict all-cause death, PE-related death or venous thromboembolic events up to a 3-month follow-up in patients with an acute symptomatic PE. DATA EXTRACTION Study characteristics and study quality using prognostic criteria. Studies were selected and data extracted by 2 reviewers. DATA ANALYSIS Summary estimates (95% CI) for proportion of risk groups and event rates within risk groups, and accuracy. RESULTS We included 71 studies (44,298 patients). Among them, 17 were model construction studies specific to PE prognosis. The most validated models were the PE Severity Index (PESI) and its simplified version (sPESI). The overall 30-day mortality rate was 2.3% (1.7% to 2.9%) in the low-risk group and 11.4% (9.9% to 13.1%) in the high-risk group for PESI (9 studies), and 1.5% (0.9% to 2.5%) in the low-risk group and 10.7% (8.8% to12.9%) in the high-risk group for sPESI (11 studies). PESI has proved clinically useful in an impact study. Shifting the cut-off or using novel and updated models specifically developed for normotensive PE improves the ability for identifying patients at lower risk for early death or adverse outcome (0.5-1%) and those at higher risk (up to 20-29% of event rate). CONCLUSIONS We provide evidence-based information about the validity and utility of the existing prognostic models in acute PE that may be helpful for identifying patients at low risk. Novel models seem attractive for the high-risk normotensive PE but need to be externally validated then be assessed in impact studies.
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Affiliation(s)
- Antoine Elias
- Department of Vascular Medicine, Sainte Musse Hospital, Toulon La Seyne Hospital Centre, Toulon, France
- DPhil Programme in Evidence-Based Healthcare, University of Oxford, Oxford, UK
| | - Susan Mallett
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Marie Daoud-Elias
- Department of Vascular Medicine, Sainte Musse Hospital, Toulon La Seyne Hospital Centre, Toulon, France
| | - Jean-Noël Poggi
- Department of Vascular Medicine, Sainte Musse Hospital, Toulon La Seyne Hospital Centre, Toulon, France
| | - Mike Clarke
- Northern Ireland Network for Trials Methodology Research, Queen's University Belfast, Belfast, UK
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Jiménez D, Lobo JL, Barrios D, Prandoni P, Yusen RD. Risk stratification of patients with acute symptomatic pulmonary embolism. Intern Emerg Med 2016; 11:11-8. [PMID: 26768476 DOI: 10.1007/s11739-015-1388-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 12/30/2015] [Indexed: 01/18/2023]
Abstract
Patients with acute symptomatic pulmonary embolism (PE) who present with arterial hypotension or shock have a high risk of death (high-risk PE), and treatment guidelines recommend strong consideration of thrombolysis in this setting. For normotensive patients diagnosed with PE, risk stratification should aim to differentiate the group of patients deemed as having a low risk for early complications (all-cause mortality, recurrent venous thromboembolism, and major bleeding) (low-risk PE) from the group of patients at higher risk for PE-related complications (intermediate-high risk PE), so low-risk patients could undergo consideration of early outpatient treatment of PE and intermediate-high risk patients would undergo close observation and consideration of thrombolysis. Clinicians should also use risk stratification and eligibility criteria to identify a third group of patients that should not undergo escalated or home therapy (intermediate-low risk PE). Such patients should initiate standard therapy of PE while in the hospital. Clinical models [e.g., Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI)] may accurately identify those at low risk of dying shortly after the diagnosis of PE. For identification of intermediate-high risk patients with acute PE, studies have validated predictive models that use a combination of clinical, laboratory and imaging variables.
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Affiliation(s)
- David Jiménez
- Respiratory Department and Medicine Department, Ramón y Cajal Hospital and Alcalá de Henares University, IRYCIS, 28034, Madrid, Spain.
| | | | - Deisy Barrios
- Respiratory Department and Medicine Department, Ramón y Cajal Hospital and Alcalá de Henares University, IRYCIS, 28034, Madrid, Spain
| | - Paolo Prandoni
- Department of Cardiovascular Sciences, Vascular Medicine Unit, University Hospital of Padua, Padua, Italy
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
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Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016; 149:315-352. [PMID: 26867832 DOI: 10.1016/j.chest.2015.11.026] [Citation(s) in RCA: 3312] [Impact Index Per Article: 414.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 11/24/2015] [Accepted: 11/25/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND We update recommendations on 12 topics that were in the 9th edition of these guidelines, and address 3 new topics. METHODS We generate strong (Grade 1) and weak (Grade 2) recommendations based on high- (Grade A), moderate- (Grade B), and low- (Grade C) quality evidence. RESULTS For VTE and no cancer, as long-term anticoagulant therapy, we suggest dabigatran (Grade 2B), rivaroxaban (Grade 2B), apixaban (Grade 2B), or edoxaban (Grade 2B) over vitamin K antagonist (VKA) therapy, and suggest VKA therapy over low-molecular-weight heparin (LMWH; Grade 2C). For VTE and cancer, we suggest LMWH over VKA (Grade 2B), dabigatran (Grade 2C), rivaroxaban (Grade 2C), apixaban (Grade 2C), or edoxaban (Grade 2C). We have not changed recommendations for who should stop anticoagulation at 3 months or receive extended therapy. For VTE treated with anticoagulants, we recommend against an inferior vena cava filter (Grade 1B). For DVT, we suggest not using compression stockings routinely to prevent PTS (Grade 2B). For subsegmental pulmonary embolism and no proximal DVT, we suggest clinical surveillance over anticoagulation with a low risk of recurrent VTE (Grade 2C), and anticoagulation over clinical surveillance with a high risk (Grade 2C). We suggest thrombolytic therapy for pulmonary embolism with hypotension (Grade 2B), and systemic therapy over catheter-directed thrombolysis (Grade 2C). For recurrent VTE on a non-LMWH anticoagulant, we suggest LMWH (Grade 2C); for recurrent VTE on LMWH, we suggest increasing the LMWH dose (Grade 2C). CONCLUSIONS Of 54 recommendations included in the 30 statements, 20 were strong and none was based on high-quality evidence, highlighting the need for further research.
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Zhang S, Zhai Z, Yang Y, Zhu J, Kuang T, Xie W, Yang S, Liu F, Gong J, Shen YH, Wang C. Pulmonary embolism risk stratification by European Society of Cardiology is associated with recurrent venous thromboembolism: Findings from a long-term follow-up study. Int J Cardiol 2016; 202:275-81. [DOI: 10.1016/j.ijcard.2014.09.142] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 08/29/2014] [Accepted: 09/27/2014] [Indexed: 01/08/2023]
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Management of massive and submassive pulmonary embolism: focus on recent randomized trials. Curr Opin Pulm Med 2015; 20:393-9. [PMID: 25029299 DOI: 10.1097/mcp.0000000000000089] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Although early pulmonary revascularization is the treatment of choice for patients with high-risk (massive) pulmonary embolism, it remains controversial in patients with intermediate-risk (submassive) pulmonary embolism until recently. Recent published data on the management of high-risk and intermediate-risk pulmonary embolism patients will be the main focus of this review. RECENT FINDINGS The PEITHO trial supports the rationale of risk stratification in normotensive patients with pulmonary embolism. Patients with right ventricular dilation on echocardiography and positive cardiac troponin test have a high intermediate risk of complication and death. Thrombolysis prevents hemodynamic collapse in these patients but with an increased risk of major bleeding particularly in older patients (>75 years). Reduced dose of thrombolysis and catheter-based reperfusion with or without fibrinolysis have shown promising results. SUMMARY Thrombolysis is the treatment of choice for patients with high-risk pulmonary embolism. Surgical embolectomy is recommended in case of absolute contra-indication to thrombolysis. In patients with acute right ventricular dysfunction on cardiac imaging and myocardial injury, thrombolysis should be considered if they are 75 years or less of age and are at low risk of bleeding. Full-dose thrombolysis may be excessively risky in patients over 75 years. In patients with either RV dilation or elevated cardiac biomarker, thrombolysis is not recommended.
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Pollack C, Hiestand B, Singer A, Macchiavelli A, Amin A, Merli G. The Impact of Risk Stratification of Venous Thromboembolism on Complexity and Site of Management. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2015. [DOI: 10.1007/s40138-015-0073-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Ozsu S, Bektas H, Abul Y, Ozlu T, Örem A. Value of Cardiac Troponin and sPESI in Treatment of Pulmonary Thromboembolism at Outpatient Setting. Lung 2015; 193:559-65. [PMID: 25840529 DOI: 10.1007/s00408-015-9727-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/26/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Currently, guidelines do not recommend any standard approach for treatment of pulmonary thromboembolism (PTE) at outpatient setting. We investigated the efficacy and safety of a 90-day anticoagulant treatment of outpatients diagnosed with PTE who had negative troponin levels and low-risk simplified pulmonary embolism severity index (sPESI) at presentation. METHODS This prospective cohort study included a total of 206 patients with objectively confirmed acute symptomatic PTE. Any troponin negative (cTn-) and low sPESI patients (as classified Group-1) were treated in outpatient setting. The primary endpoint was all-cause mortality during the first 90 days, and the secondary endpoint included non-fatal symptomatic recurrent PTE or non-fatal major bleeding. Presence of cancer was excluded from sPESI score. RESULTS Fifty-two of 206 patients were eligible for had Group-1, and 31 were treated at outpatients settings. The 90-day all-cause mortality rate was 3.2 % among patients who received outpatient treatment. Otherwise cTn+ and high-risk sPESI 90-day mortality rate was 43.7 %. No difference was found in terms of secondary endpoints between the patients who received outpatient treatment and those who received inpatient treatment in Group-1 (p = NS). In our study, cancer was present in 16 (51.6 %) of the 31 outpatients. CONCLUSION We observed that patients with acute PTE, low-risk sPESI, and negative troponin levels can be safely treated in the outpatient settings. Also the presence of cancer alone does not necessitate hospitalization.
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Affiliation(s)
- Savas Ozsu
- Department of Pulmonary Medicine, School of Medicine, Karadeniz Technical University, Trabzon, Turkey,
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Simplified CRB-65 for risk stratification and predicting prognosis in acute pulmonary embolism. PHLEBOLOGIE 2015. [DOI: 10.12687/phleb2251-4-2015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
SummaryBackground: Pulmonary embolism (PE) and community acquired pneumonia (CAP) are potentially life-threatening diseases. In CAP CRB-65 is used for risk stratification and prognosis prediction. The aim of this study was to examine a simplified CRB-65 (sCRB-65) for predicting prognosis in PE.Methods: We retrospectively analyzed the data of 182 PE patients. Patients were, according to the score of sCRB-65 (respectively 1 point for dyspnoea, systolic blood pressure < 90 mmHg or diastolic blood pressure60 mmHg, age65years), subdivided in risk-classes 1–4.Risk classes were compared with Kruskal-Wallis test. Logistic multivariable regression and Pearson correlation matrix were calculated for coherence of sCRB-65 and in-hospital death, right ventricular load and PE severity stadium as well as sCRB-65 > 2points and in-hospital death an PE stadium. ROC analysis was performed to evaluate efficiency of sCRB-65 score to predict in-hospital death and PE severity stadium.Results: PE severity stadium, systolic pulmonary artery pressure (sPAP) and frequency of in-hospital death increased with growing risk class.Risk class 1 showed lower PE sever-ity stadium than 2 (P=0.0253), 3 (P=0.0132) and 4 (P=0.00162), lower percentage of patients with sPAP > 30mmHg than 2 (0 % vs. 48.9 %, P=0.0419), 3 (0 % vs. 70.8 %, P=0.00112) and 4 (0 % vs. 75.0 %, P=0.0113). Frequency of in-hospital deaths was higher in risk class 4 than in 1 (P=0.0024), 2 (P=0.00014) and 3 (P=0.000058). Multi-variable logistic regression showed an association between sCRB-65 scored>0 and PE severity stadium (OR 11.42, 95 %CI: 1.35–96.66, P=0.0254), RVD (OR 10.09, 1.16–87.78, P=0.0363) and sPAP (OR 1.08, 1.02–1.15, P=0.0092) as well as a trend towards significance (OR 12.39, 0.90–171.34, P=0.060) between in-hospital death and sCRB-65. sCRB-65 correlated with PE severity stadium (r=0.258, P<0.001) and sPAP (r=0.280, P=0.001). sCRB-65 >2 points was strongly associated with both inhospital death (OR 36.22, 95%CI: 1.59–827.71, P=0.0245) and high-risk PE stadium (OR 57.94, 95%CI: 7.17–468.33, P=0.000141). ROC analysis for CRB-65 predicting in-hospital death and high-risk PE stadium showed AUC values of respectively 0.764 and 0.892 with sCRB-65 cut-off value of 2.5 points, respectively.Conclusions: sCRB-65 is closely correlated with PE severity stadium and load of the right heart as well as prognosis. PE patients with sCRB-65 score >2 points revealed a 36.2-fold risk to die during in-hospital course after acute PE event. Efficiency of sCRB-65 to predict in-hospital death was good.
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Kohn CG, Mearns ES, Parker MW, Hernandez AV, Coleman CI. Prognostic Accuracy of Clinical Prediction Rules for Early Post-Pulmonary Embolism All-Cause Mortality. Chest 2015; 147:1043-1062. [DOI: 10.1378/chest.14-1888] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Konstantinides SV, Wärntges S. Acute phase treatment of venous thromboembolism: advanced therapy. Systemic fibrinolysis and pharmacomechanical therapy. Thromb Haemost 2015; 113:1202-9. [PMID: 25789580 DOI: 10.1160/th14-11-0998] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 02/01/2015] [Indexed: 11/05/2022]
Abstract
Venous thromboembolism, which encompasses deep-vein thrombosis and acute pulmonary embolism (PE), represents a major contributor to global disease burden worldwide. For patients who present with cardiogenic shock or persistent hypotension (acute high-risk PE), there is consensus that immediate reperfusion treatment applying systemic fibrinolysis or, in the case of a high bleeding risk, surgical or catheter-directed techniques, is indicated. On the other hand, for the large, heterogeneous group of patients presenting without overt haemodynamic instability, the indications for advanced therapy are less clear. The recently updated guidelines of the European Society of Cardiology emphasise the importance of clinical prediction rules in combination with imaging procedures (assessment of right ventricular function) and laboratory biomarkers (indicative of myocardial stress or injury) for distinguishing between an intermediate and a low risk for an adverse early outcome. In intermediate-high-risk PE defined by the presence of both right ventricular dysfunction on echocardiography (or computed tomography) and a positive troponin (or natriuretic peptide) test, the bleeding risks of full-dose fibrinolytic treatment have been shown to outweigh its potential clinical benefits unless clinical signs of haemodynamic decompensation appear (rescue fibrinolysis). Recently published trials suggest that catheter-directed, ultrasound-assisted, low-dose local fibrinolysis may provide an effective and particularly safe treatment option for some of these patients.
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Affiliation(s)
- Stavros V Konstantinides
- Stavros V. Konstantinides, MD, FESC, Center for Thrombosis and Haemostasis, University Medical Centre Mainz, Langenbeckstrasse 1, Bldg. 403, 55131 Mainz, Germany, Tel.: +49 6131 178382, Fax: +49 6131 173456, E-mail:
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Kilic T, Gunen H, Gulbas G, Hacievliyagil SS, Ozer A. Prognostic role of simplified Pulmonary Embolism Severity Index and the European Society of Cardiology Prognostic Model in short- and long-term risk stratification in pulmonary embolism. Pak J Med Sci 2015; 30:1259-64. [PMID: 25674119 PMCID: PMC4320711 DOI: 10.12669/pjms.306.5737] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 08/02/2014] [Accepted: 08/05/2014] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Hemodynamic status, cardiac enzymes, and imaging-based risk stratification are frequently used to evaluate a pulmonary embolism (PE). This study investigated the prognostic role of a simplified Pulmonary Embolism Severity Index (sPESI) score and the European Society of Cardiology (ESC) model. Methods : The study included 50 patients from the emergency and pulmonology department of one medical center between October 2005 and June 2006. The ability of the sPESI and ESC model to predict short-term (in-hospital) and long-term (6-month and 6-year) overall mortality was assessed, in addition to the accurancy of the sPESI and ESC model in predicting short-term adverse events, such as cardiopulmonary resuscitation, or major bleeding. Results : Of the 50 patients, the in-hospital and 6-year mortality rates were 14% and 46%, respectively. Fifteen (30%) of these experienced adverse events during hospitalization. Importantly, patients classified as low-risk according to the sPESI had no short-term adverse events as opposed to 4.8 % in the ESC low-risk group. They also had no in-hospital, 6-month, or 6-year mortality compared to 4.8%, %14.3, and %23.8, respectively, in the ESC low-risk group. CONCLUSIONS The sPESI predicted short-term and long-term survival. The exclusion of short-term adverse events does not appear to require imaging and laboratory testing.
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Affiliation(s)
- Talat Kilic
- Talat Kilic, Department of Pulmonary Medicine, Inonu University Faculty of Medicine, Turgut Ozal Medical Center, Malatya, Turkey
| | - Hakan Gunen
- Hakan Gunen, Department of Pulmonary Medicine, Training and Research Hospital of Ministry of Health, Istanbul, Turkey
| | - Gazi Gulbas
- Gazi Gulbas, Department of Pulmonary Medicine, Inonu University Faculty of Medicine, Turgut Ozal Medical Center, Malatya, Turkey
| | - Suleyman Savas Hacievliyagil
- Suleyman Savas Hacievliyagil, Department of Pulmonary Medicine, Inonu University Faculty of Medicine, Turgut Ozal Medical Center, Malatya, Turkey
| | - Ali Ozer
- Ali Ozer, Department of Public Health, Inonu University Faculty of Medicine, Turgut Ozal Medical Center, Malatya, Turkey
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Senturk A, Ucar EY, Berk S, Ozlu T, Altınsoy B, Dabak G, Cakır E, Kadıoglu EE, Sen HS, Ozsu S. Should Low-Molecular-Weight Heparin be Preferred Over Unfractionated Heparin After Thrombolysis for Severity Pulmonary Embolism? Clin Appl Thromb Hemost 2015; 22:395-9. [PMID: 25630985 DOI: 10.1177/1076029614564863] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The role of low-molecular-weight heparin (LMWH) in managing nonmassive pulmonary embolism (PE) is well known. In unstable cases, especially after thrombolytic therapy for massive PE, unfractionated heparin (UFH) is preferred for PE management. This study aimed to investigate the effectiveness and safety of LMWH after thrombolytic therapy. METHODS A prospective, observational multicenter trial was performed in 249 patients with acute PE who required thrombolysis. Massive and submassive PEs were categorized into 2 groups depending on whether they were treated with LMWH or UFH after thrombolytic treatment. The primary end point was all-cause mortality during the first 30 days; the secondary end point included all-cause mortality, nonfatal symptomatic recurrent PEs, or nonfatal major bleeding. RESULTS The mean age at diagnosis was 60.7 ± 15.5 years. The PE severity was massive in 186 (74.7%) patients and submassive in 63 (25.3%). The incidence of all-cause 30-day death was 8.2% and 17.3% in patients with LMWH and UFH, respectively (P = .031). Major hemorrhage occurred in 4% (n = 5) and 7.9% (n = 10) of patients and minor hemorrhage occurred in 9% (n = 11) and 13.4% (n = 17) of the cases treated with LMWH and UFH, respectively. CONCLUSION These results suggest that LMWH treatment can be used safely in patients with PE after thrombolytic therapy.
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Affiliation(s)
- Aysegul Senturk
- Department of Pulmonary Medicine, Ankara Atatürk Training and Research Hospital, Ankara, Turkey
| | - Elif Yilmazel Ucar
- Department of Pulmonary Medicine, Atatürk University School of Medicine, Erzurum, Turkey
| | - Serdar Berk
- Department of Pulmonary Medicine, Cumhuriyet University, School of Medicine, Sivas, Turkey
| | - Tevfik Ozlu
- Department of Pulmonary Medicine, Karadeniz Technical University, School of Medicine, Trabzon, Turkey
| | - Bulent Altınsoy
- Department of Pulmonary Medicine, Bülent Ecevit University School of Medicine, Zonguldak, Turkey
| | - Gul Dabak
- Department of Pulmonary Medicine, Istanbul Kartal Kosuyolu Yuksek Ihtisas Training and Research Hospital, İstanbul, Turkey
| | - Ebru Cakır
- Department of Pulmonary Medicine, Trakya University, School of Medicine, Edirne, Turkey
| | - Esra Ekbic Kadıoglu
- Department of Pulmonary Medicine, Erzurum Regional Training and Research Hospital, Erzurum, Turkey
| | - Hadice Selimoglu Sen
- Department of Pulmonary Medicine, Dicle University School of Medicine, Diyarbakır, Turkey
| | - Savas Ozsu
- Department of Pulmonary Medicine, Karadeniz Technical University, School of Medicine, Trabzon, Turkey
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Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N, Gibbs JSR, Huisman MV, Humbert M, Kucher N, Lang I, Lankeit M, Lekakis J, Maack C, Mayer E, Meneveau N, Perrier A, Pruszczyk P, Rasmussen LH, Schindler TH, Svitil P, Vonk Noordegraaf A, Zamorano JL, Zompatori M. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35:3033-69, 3069a-3069k. [PMID: 25173341 DOI: 10.1093/eurheartj/ehu283] [Citation(s) in RCA: 1856] [Impact Index Per Article: 185.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Abstract
Venous thromboembolism covers a range of conditions from deep vein thrombosis to pulmonary embolism. Treatment aims to alleviate symptoms, minimize acute morbidity and mortality by preventing the extension or potentially fatal embolization of the initial thrombus, and avoid postthrombotic syndrome. Anticoagulant therapy is the mainstay of treatment, but treatment decisions and the choice of an appropriate anticoagulation agent are modified according to the predisposition for venous thromboembolism, the site and extent of thrombus, the presence or absence of symptomatic embolism, and patient's bleeding risk. Newer oral anticoagulants have been developed to overcome the drawbacks of other agents, improve patient care, and simplify and improve management.
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Affiliation(s)
- Ahmed Al-Badri
- Department of Medicine, Lenox Hill Hospital, NSLIJHS, 130 East 77th Street, 6th Floor, Black Hall Building, New York, NY 10075, USA.
| | - Alex C Spyropoulos
- Department of Medicine, Lenox Hill Hospital, NSLIJHS, 130 East 77th Street, 5th Floor, Achilles Building, New York, NY 10075, USA
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Nobre C, Mesquita D, Thomas B, Ponte T, Santos L, Tavares J. A clinical audit of thrombolytic therapy in patients with normotensive pulmonary embolism and intermediate risk. ACUTE CARDIAC CARE 2014; 16:63-66. [PMID: 24617753 DOI: 10.3109/17482941.2014.881503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION There is considerable debate regarding the use of thrombolytic therapy in patients with pulmonary embolism, normal blood pressure and intermediate clinical risk, as defined by right ventricular dysfunction on transthoracic echocardiography or elevated serum markers of cardiac necrosis. AIMS AND OBJECTIVES A clinical audit of normotensive patients diagnosed with acute pulmonary embolism using multi- detector computerized tomography pulmonary angiography (MDCTPA) and intermediate risk, was conducted to determine clinical outcomes at 30 days. The specific role played by imaging findings and clinical severity, on the decision to thrombolyse, was assessed. METHODS The two cohorts who did (n = 15) and did not receive thrombolysis (n = 20) were compared for age, heart rate, blood pressure and oxyhemoglobin saturation at presentation, and the simplified PESI score was calculated in each patient. MDCTPA findings suggestive of adverse clinical outcome including central PE and an increased RV/LV diameter were determined for each patient. RV dysfunction on echocardiography was compared to clinical scoring, and findings on MDCTPA. RESULTS The patients who received thrombolytic therapy were younger (48.6 ± 19.11 years versus 64.2 ± 13.83 years) (P < 0.01) and had a higher heart rate (107.6 ± 17.1/min versus 91.7 ± 17.8/min) (P < 0.05). More patients with a higher clinical severity, as determined by the simplified PESI score (12/20) and a higher shock index (0.94 ± 0.23), were thrombolysed as compared to the proportion with a lower score (3/15) (P < 0.05) or index (0.70 ± 0.20) (P < 0.005). In-hospital mortality and hemorrhagic complications at 30 days were zero in both groups. RV dysfunction by echocardiography was not a strong determinant for choosing thrombolytic therapy while central PE on MDCTPA tilted the decision towards thrombolysis. CONCLUSION Our clinical audit revealed a predilection to use thrombolysis in younger patients with clinical severity and imaging findings on MDCTPA being the key drivers. A perception of a fragile hemodynamic status, as implied by a higher heart rate and shock index, despite a normal BP probably inclined us to thrombolyse.
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Affiliation(s)
- Carla Nobre
- Internal Medicine Service, Centro Hospitalar Barreiro-Montijo, EPE , Lisbon , Portugal
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Ozsu S, Ozlu T, Sentürk A, Uçar EY, Kırkıl G, Kadıoğlu EE, Altınsoy B, Saylan B, Selimoğlu HŞ, Dabak G, Tutar N, Uysal A. Combination and comparison of two models in prognosis of pulmonary embolism: results from TUrkey Pulmonary Embolism Group (TUPEG) study. Thromb Res 2014; 133:1006-10. [PMID: 24690480 DOI: 10.1016/j.thromres.2014.02.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 02/06/2014] [Accepted: 02/13/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clinical parameters, biomarkers and imaging-based risk stratification are widely accepted in pulmonary embolism(PE). The present study has investigated the prognostic role of simplified Pulmonary Embolism Severity Index (sPESI) score and the European Society of Cardiology (ESC) model. METHODS This prospective cohort study included a total of 1078 patients from a multi-center registry, with objectively confirmed acute symptomatic PE. The primary endpoint was all-cause mortality during the first 30days, and the secondary endpoint included all-cause mortality, nonfatal symptomatic recurrent PE, or nonfatal major bleeding. RESULTS Of the 1078 study patients, 95 (8.8%) died within 30days of diagnosis. There was no significant difference between non-low-risk patients ESC [12.2% (103 of 754;)] and high-risk patients as per the sPESI [11.6% (103 of 796)] for 30-day mortality. The nonfatal secondary endpoint occurred in 2.8% of patients in the the sPESI low-risk and 1.9% in the ESC low-risk group. Thirty-day mortality occurred in 2.2% of patients the sPESI low-risk and in 2.2% the ESC low-risk group (P=NS). In the present study, in the combination of the sPESI low-risk and ESC model low-risk mortality rate was 0%. CONCLUSIONS The sPESI and the ESC model showed a similar performance regarding 30-day mortality and secondary outcomes in the present study. However, the combination of these two models appears to be particularly valuable in PE.
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Affiliation(s)
- Savas Ozsu
- Karadeniz Technical University, School of Medicine, Department of Pulmonary Medicine, Trabzon, Turkey.
| | - Tevfik Ozlu
- Karadeniz Technical University, School of Medicine, Department of Pulmonary Medicine, Trabzon, Turkey.
| | - Ayşegül Sentürk
- Ankara Atatürk Training and Research Hospital, Department of Pulmonary Medicine, Ankara,Turkey.
| | - Elif Yılmazel Uçar
- Atatürk University School of Medicine, Department of Pulmonary Medicine, Erzurum, Turkey.
| | - Gamze Kırkıl
- Fırat University School of Medicine, Department of Chest, Pulmonary Medicine, Turkey.
| | - Esra Ekbiç Kadıoğlu
- Erzurum Regional Training and Research Hospital, Department of Pulmonary Medicine, Erzurum, Turkey.
| | - Bülent Altınsoy
- Bülent Ecevit University School of Medicine, Department of Pulmonary Medicine, Zonguldak, Turkey.
| | - Bengü Saylan
- Ümraniye Training and Research Hospital, Department of Pulmonary Medicine, İstanbul, Turkey.
| | - Hatice Şen Selimoğlu
- Dicle University School of Medicine, Department of Pulmonary Medicine, Diyarbakır, Turkey.
| | - Gül Dabak
- Koşuyolu Training and Research Hospital, Department of Pulmonary Medicine, İstanbul, Turkey.
| | - Nuri Tutar
- Erciyes University School of Medicine, Department of Pulmonary Medicine, Kayseri, Turkey.
| | - Ahmet Uysal
- Ege University School of Medicine, Department of Pulmonary Medicine, İzmir, Turkey.
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Bulj N, Potočnjak I, Sharma M, Pintaric H, Degoricija V. Timing of troponin T measurements in triage of pulmonary embolism patients. Croat Med J 2014; 54:561-8. [PMID: 24382851 PMCID: PMC3893989 DOI: 10.3325/cmj.2013.54.561] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Aim To determine the appropriate timing of cardiac troponin T (cTnT) measurement for the early triage of pulmonary embolism (PE) patients. Methods In this single-center prospective study, PE was confirmed in all patients using computed tomography. 104 consecutive patients were divided into three groups (high-risk, intermediate, and low-risk) based on their hemodynamic status and echocardiographic signs of right ventricular dysfunction. cTnT levels were measured on admission and then after 6, 24, 48, and 72 hours with threshold values greater than 0.1 ng/mL. Results Intermediate-risk PE patients had higher cTnT levels than low-risk patients already in the first measurement (P = 0.037). Elevated cTnT levels significantly correlated with disease severity after 6 hours (intermediate vs low risk patients, P = 0.016, all three groups, P = 0.009). Conclusion In hemodynamically stable patients, increased cTnT level on admission differentiated intermediate from low-risk patients and could be used as an important element for the appropriate triage of patients.
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Affiliation(s)
- Nikola Bulj
- Nikola Bulj, Department of Medicine, Vinogradska cesta 29, 10 000 Zagreb, Croatia,
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Kramm T, Guth S, Mayer E. Pulmonale Embolektomie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2014. [DOI: 10.1007/s00398-013-1067-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Sherwood MW, Kristin Newby L. High-sensitivity troponin assays: evidence, indications, and reasonable use. J Am Heart Assoc 2014; 3:e000403. [PMID: 24470520 PMCID: PMC3959691 DOI: 10.1161/jaha.113.000403] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 11/15/2013] [Indexed: 01/13/2023]
Affiliation(s)
- Matthew W. Sherwood
- Division of Cardiovascular Medicine, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (M.W.S., K.N.)
| | - L. Kristin Newby
- Division of Cardiovascular Medicine, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC (M.W.S., K.N.)
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Keller K, Beule J, Schulz A, Coldewey M, Dippold W, Balzer JO. Right ventricular dysfunction in hemodynamically stable patients with acute pulmonary embolism. Thromb Res 2014; 133:555-9. [PMID: 24461144 DOI: 10.1016/j.thromres.2014.01.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 01/02/2014] [Accepted: 01/06/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Echocardiography for risk stratification in hemodynamically stable patients with pulmonary embolism (PE) is well-established. Right ventricular dysfunction (RVD) is associated with an elevated mortality and adverse outcome. The aim of our study was to compare RVD criteria and investigate the role of elevated systolic pulmonary artery pressure (sPAP) in the diagnosis of RVD. METHODS We retrospectively analyzed the echocardiographic and laboratory data of all hemodynamically stable patients with confirmed PE (2006-2011). The data were compared with three different definitions of RVD: Definition 1: RV dilatation, abnormal motion of interventricular septum, RV hypokinesis or tricuspid regurgitation. Definition 2: as with definition 1 but including elevated sPAP (>30mmHg). Definition 3: elevated sPAP (>30mmHg) as single RVD criterion. RESULTS A total number of 129 patients (59.7% women, age 70.0years (60.7/81.0)) were included in this study. Median Troponin I level was measured as 0.02ng/ml (0/0.14); mean sPAP 33.9±18.5mmHg. The troponin cut-off levels for predicting a RVD of the 3 RVD definitions were in definition 1-3: >0.01ng/ml, >0.01ng/ml and >0.00ng/ml. Analysis of the ROC curve showed an AUC for RVD definitions 1-3: 0.790, 0.796 and 0.635. CONCLUSIONS The combination of commonly used RVD criteria with added elevated sPAP improves the diagnosis of RVD in acute PE. Troponin I values of >0.01ng/ml in acute PE point to an RVD.
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Affiliation(s)
- Karsten Keller
- Department of Medicine II, University Medical Center Mainz, Johannes Gutenberg-University Mainz; Center for Thrombosis and Haemostasis, University Medical Center Mainz, Johannes Gutenberg-University Mainz.
| | - Johannes Beule
- Department of Internal Medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM)
| | - Andreas Schulz
- Department of Medicine II, University Medical Center Mainz, Johannes Gutenberg-University Mainz
| | - Meike Coldewey
- Department of Medicine II, University Medical Center Mainz, Johannes Gutenberg-University Mainz; Center for Thrombosis and Haemostasis, University Medical Center Mainz, Johannes Gutenberg-University Mainz
| | - Wolfgang Dippold
- Department of Internal Medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM)
| | - Jörn Oliver Balzer
- Department of Radiology and Nuclear Medicine, Catholic Clinic Mainz (KKM); Department of Diagnostic and Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main
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