Pulmonary embolism as a cause of death in patients with heart disease: an autopsy study

Reporting of Incidental Thrombotic Arteriopathy in Lung Resection Specimens: Examination of Clinical Impact

Pulmonary thrombotic arteriopathy (PTA) can be an incidental finding in lung resections performed for various indications. Historic studies largely examined PTA in autopsies. Thus, the prevalence in surgical samples, particularly in the modern era of lung cancer screening, is poorly defined. Detection of PTA in surgical samples may provide an opportunity for therapeutic intervention, but the impact of this finding on clinical management is unknown. We retrospectively examined consecutive lung surgical resections containing a report of incidental PTA between 2019 and 2022 in our institution. A retrospective chart review was performed to determine the history of systemic thromboembolism and clinical and radiographic follow-up. All slides were reviewed to morphologically characterize the vascular changes. Among 2930 pulmonary resections, 66 (2.3%) reportedly contained PTA. Twenty-four (36.4%) patients had a clinically recognized thromboembolic event either before or after surgical resection. Patients with clinically recognized thromboembolic disease were significantly more likely to have both acute and organized thrombi affecting large arteries. The presence of infarct, chronic hypertensive vasculopathy, or number of vessels with thrombi were not significantly associated with a clinically detected event. Reporting of incidental PTA led to clinical intervention in six patients and confirmed systemic thromboembolic disease in 2. Moreover, 2 patients with no further workup based on the incidental pathology findings subsequently developed pulmonary embolism. PTA is incidentally detected in 2.3% of surgical lung resections, and in two-thirds of cases, there is no clinical suspicion of thromboembolic disease. Pathologic reporting of PTA rarely led to clinical intervention, suggesting a need for improved communication of incidental pathology findings.

In-hospital mortality of high-risk pulmonary embolism: a nationwide population-based cohort study in Portugal from 2010 to 2018

BACKGROUND

The mortality associated with high-risk pulmonary embolism (PE) is remarkably high, and reperfusion to unload right ventricle should be a priority. However, several registries report reperfusion underuse. In Portugal, epidemiological data about the incidence, rate of reperfusion and mortality of high-risk PE are not known.

METHODS

Nationwide population-based temporal trend study in the incidence and outcome of high-risk PE, who were admitted to hospitals of the National Health Service in Portugal between 2010 and 2018. High-risk PE was defined as patients with PE who developed cardiogenic shock or cardiac arrest. International Classification of Diseases (ICD), 9th and 10th revision, Clinical Modification codes, were used for data from the period between 2010 and 2016 (ICD-9-CM) and 2017-2018 (ICD-10-CM), respectively. The assessment focused on trends in the use of reperfusion treatment, which was defined by application of thrombolysis or pulmonary embolectomy. A comparison was made between the use or non-use of reperfusion therapy in order to examine trends in in-hospital mortality among high-risk PE cases.

RESULTS

From 2010 and 2018, there were 40.311 hospitalization episodes for PE in adult patients at hospitals of the National Health Service in mainland Portugal. There was a significant increase in the annual incidence of PE (41/100.000 inhabitants in 2010 to 46/100.000 in 2018; R2=0.582, p = 0.010). The average annual incidence was 45/100.000 inhabitants/year, with 2,7% of the PE episodes (1104) categorized as high-risk. The mortality rate associated with high-risk PE was high, although it has decreased over the years (74.2% in 2010 to 63.6% in 2018; R2=0.484; p = 0.022). Thrombolytic therapy was underused in high-risk PE, and its usage has not increased in recent years (17.3% in 2010 to 21.1% in 2018, R2=-0.127; p = 0.763). Surgical pulmonary embolectomy was used in 0.27% of cases, and there was no registry of catheter-directed thrombolysis. Patients with high-risk PE undergoing reperfusion therapy had lower in-hospital mortality compared to non-reperfused patients (OR=0.52; IC95% 0.38-0.70).

CONCLUSION

In Portugal, between 2010 and 2018, very few patients with PE developed high-risk forms of the disease, but the mortality rate among those patients was high. The low reperfusion rate could be associated with high in-hospital mortality and highlights the need to implement advanced therapies, as an alternative to systemic thrombolysis.

Pulmonary Embolism and Respiratory Deterioration in Chronic Cardiopulmonary Disease: A Narrative Review

Patients with chronic cardiopulmonary pathologies have an increased risk of developing venous thromboembolic events. The worsening of dyspnoea is a frequent occurrence and often leads patients to consult the emergency department. Pulmonary embolism can then be an exacerbation factor, a differential diagnosis or even a secondary diagnosis. The prevalence of pulmonary embolism in these patients is unknown, especially in cases of chronic heart failure. The challenge lies in needing to carry out a systematic or targeted diagnostic strategy for pulmonary embolism. The occurrence of a pulmonary embolism in patients with chronic cardiopulmonary disease clearly worsens their prognosis. In this narrative review, we study pulmonary embolism and chronic obstructive pulmonary disease, after which we turn to pulmonary embolism and chronic heart failure.

A Radiological Nomogram to Predict 30-day Mortality in Patients with Acute Pulmonary Embolism

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.

Interhospital Transfer of Patients With Acute Pulmonary Embolism (PE): Challenges and Opportunities

Acute pulmonary embolism (PE) is associated with significant morbidity and mortality. The management paradigm for acute PE has evolved in recent years with wider availability of advanced treatment modalities ranging from catheter-directed reperfusion therapies to mechanical circulatory support. This evolution has coincided with the development and implementation of institutional pulmonary embolism response teams (PERT) nationwide and internationally. Because most institutions are not equipped or staffed for advanced PE care, patients often require transfer to centers with more comprehensive resources, including PERT expertise. One of the unmet needs in current PE care is an organized approach to the process of interhospital transfer (IHT) of critically ill PE patients. In this review, we discuss medical optimization and support of patients before and during transfer, transfer checklists, defined roles of emergency medical services, and the roles and responsibilities of referring and receiving centers involved in the IHT of acute PE patients.

Hospitalizations for High-Risk Pulmonary Embolism

BACKGROUND

The incidence of pulmonary embolism has been increasing. It has been suggested that this may reflect overdiagnosis due to widespread use of computed tomographic pulmonary angiography. The purpose of the present investigation is to further evaluate whether the increasing incidence of pulmonary embolism represents overdiagnosis.

METHODS

This was a retrospective cohort study based on administrative data from the National (Nationwide) Inpatient Sample 1999-2014. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used. The population of the United States according to year was determined from the Centers for Disease Control and Prevention.

RESULTS

The incidence of pulmonary embolism increased from 65/100,000 population in 1999 to 137/100,000 population in 2014 (P < .0001). High-risk pulmonary embolism increased from 2.2/100,000 population to 9.9/100,000 population (P < .0001). The incidence of primary pulmonary embolism increased from 40/100,000 population in 1999 to 73/100,000 population in 2014 (P < .0001). High-risk pulmonary embolism in patients with a primary diagnosis of pulmonary embolism increased from 0.8/100,000 population in 1999 to 2.3/100,000 population in 2014 (P < .0001). Among patients with pulmonary embolism, the incidence of high-risk pulmonary embolism increased from 1999-2014 (P = .0025). In-hospital all-cause mortality in high-risk patients was 102,402 of 195,909 (52.2%).

CONCLUSIONS

The incidence of high-risk pulmonary embolism has increased concordantly with the increasing incidence of all pulmonary embolism. Increasing proportions of patients with potentially lethal pulmonary embolism are being diagnosed.

Semi-automated Analysis of Ventilation-Perfusion Single-Photon Emission Tomography in the Diagnosis of Pulmonary Embolism – Does it add extra value?

Aim Diagnosis of pulmonary embolism using V/P-SPECT may include the application of advanced image-processing techniques to identify V/P-mismatches. Aim of this study was to evaluate the benefit in clinical decision making in the diagnosis of pulmonary embolism.by whether adding to conventional reading a software that automatically calculates and visualizes the ventilation/perfusion-quotient pixel by pixel.

Methods 63 consecutive patients with a clinical suspicion of PE who underwent V/P-SPECT were included in this retrospective study. Images were randomly ordered both for standard as well as for software-assisted reading using V/P-quotients. Studies were read independently by 2 experienced and 2 inexperienced raters. Diagnostic performance and observer agreement of all readers and both reading methods were determined.

Results Expert observers consistently achieved a high diagnostic accuracy both in conventional as well as in software-assisted reporting (sensitivity: 0.94 vs. 0.94, specificity: 0.96 vs. 0.97, LR+: 17.32 vs. 28.86, LR– stayed constant at 0.06). For inexperienced readers, diagnostic performance improved: sensitivity raised from 0.74 to 0.85 and specificity from 0.86 to 0.95, LR+ raised from 5.20 to 15.69, LR– decreased from 0.31 to 0.16. Inter-rater reliability (Fleiss’ κ) improved from 0.63 to 0.86 by using V/P quotient.

Conclusion Benefit from a software-tool that calculates V/P-ratio automatically is only small when used by experienced physicians If inexperienced readers use the software, the diagnostic accuracy increases. Images generated by automated calculation of V/P-mismatches are easy to read and their use might help to standardize and objectify interpretation of V/P-SPECT in the diagnosis of PE.

Randomized Trial of Deep Vein Thrombosis Chemoprophylaxis with Bemiparin and Enoxaparin in Patients with Moderate to High Thrombogenic Risk Undergoing Plastic and Reconstructive Surgery Procedures

BACKGROUND

Deep vein thrombosis (DVT) is a common complication during postoperative convalescence characterized by hypercoagulability, vascular endothelium damage and blood stasis. It increases noticeably in peri/postoperative phases of surgery procedures. Pulmonary embolism secondary to iliofemoral DVT is a frequent cause of death.

METHODS

Adult patients scheduled for plastic and reconstructive surgery (PRSx) with moderate to high thrombogenic risk were selected. We evaluated the efficacy and safety of bemiparin compared to enoxaparin as chemoprophylaxis for DVT. Following balanced general anesthesia techniques, patients were randomly assigned for subcutaneous enoxaparin 40 IU (Group-E) or bemiparin 3500 IU (Group-B) q24h starting 6 h after procedure conclusion for at least 10 days. All patients were evaluated for DVT through Doppler ultrasound mapping of the lower limbs.

RESULTS

Seventy-eight patients were evaluated, mostly women (83%), physical status ASA II (59%), ASA III (10%); Caprini's thrombogenic risk score 3-4 (moderate) 58%, 5-6 (high) 29%, > 6 (too high) 13%; demographics, clinical variables and scores were similar between groups. Median drainage time in breast surgery was 4 days in both groups (p = 0.238). In the case of abdominal surgery, median was 14 days in Group-E versus 13 days in Group-B (p = 0.059). No DVT was detected in either group.

CONCLUSIONS

DVT was prevented with bemiparin, without significant bleeding increase nor adverse events; moreover, the cost of bemiparin is lower than enoxaparin. Bemiparin can be considered as alternative drug for DVT chemoprophylaxis in PRSx procedures.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Outcomes of catheter-directed versus systemic thrombolysis for the treatment of pulmonary embolism: A real-world analysis of national administrative claims

Catheter-directed thrombolysis (CDT) and systemic thrombolysis (ST) are used to treat intermediate/high-risk pulmonary embolism (PE) in the absence of comparative safety and effectiveness data. We utilized a large administrative database to perform a comparative safety and effectiveness analysis of catheter-directed versus systemic thrombolysis. From the Optum^® Clinformatics^® Data Mart private-payer insurance claims database, we identified 100,744 patients hospitalized with PE between 2004 and 2014. We extracted demographic characteristics, high-risk PE features, components of the Elixhauser Comorbidity Index, and outcomes including intracranial hemorrhage (ICH), all-cause bleeding, and mortality among all patients receiving CDT and ST. We used propensity score methods to compare outcomes between matched cohorts adjusted for observed confounders. A total of 1915 patients (1.9%) received either CDT (n = 632) or ST (n = 1283). Patients in the CDT group had fewer high-risk features including less shock (5.4 vs 11.1%; p < 0.001) and cardiac arrest (6.8 vs 11.0%; p = 0.004). In 1:1 propensity-matched groups, ICH rates were 1.9% in both the CDT and ST groups (p = 1.0). All-cause bleeding was higher in the CDT group (15.9 vs 8.7%; p < 0.001), while in-hospital mortality was lower (6.5 vs 10.0%; p = 0.02). Among a nationally representative cohort of patients with PE at higher risk for mortality, CDT was associated with similar ICH rates, increased all-cause bleeding, and lower short and intermediate-term mortality when compared with ST. The competing risks and benefits of CDT in real-world practice suggest the need for large-scale randomized clinical trials with appropriate comparator arms.

Severe Myocardial Steatosis: Incidental Finding or a Significant Anatomic Substrate for Sudden Cardiac Arrest?

Myocardial steatosis, also known as lipomatosis cordis, is characterized by adipose tissue within the myocardium without significant fibrosis. Evidence suggests that accumulation of fat can disturb the normal electromechanical physiology of the myocardium. Herein, we discuss the case of a 60-year-old woman with a history of chronic obstructive pulmonary disease who died because of anoxic encephalopathy after a sudden cardiac arrest (SCA). An electrocardiogram showed QRS fragmentation noted as notched R in inferior leads. The autopsy revealed a very small thromboembolus in a distal subsegmental branch of the pulmonary artery, which could not explain the SCA. There was an extensive intramyocardial accumulation of adipose tissue involving the right ventricle and interventricular septum, which split the myocardium into discrete bundles. Arrhythmogenic right ventricular cardiomyopathy was ruled out based on the absence of typical fibrofatty changes. The mechanism of fat replacement was likely secondary to redistribution of visceral fat in the setting of Cushing syndrome. We propose that severe myocardial steatosis can create an anatomic substrate to facilitate the development of SCA. Myocardial steatosis should be reported to identify patients who are at risk for developing cardiovascular events secondary to extreme cardiac adiposity.

Advances in the diagnosis of acute pulmonary embolism

Venous thromboembolism is a common disease which remains underdiagnosed because of nonspecific presentations which can range from asymptomatic incidental imaging findings to sudden death. Symptoms can overlap with comorbid cardiopulmonary disease, and risk factors that offer clues to the clinician are not always present. The diagnostic approach can vary depending on the specific clinical presentation, but ruling in the diagnosis nearly always depends on lung imaging. Overuse of diagnostic testing is another recognized problem; a cautious, evidence-based approach is required, although physician gestalt must be acknowledged. The following review offers an approach to the diagnosis of acute pulmonary embolism based on the assessment of symptoms, signs, risk factors, laboratory findings, and imaging studies.

Management of Low-Risk Pulmonary Embolism

Pulmonary embolism remains a leading cause of morbidity and mortality in the United States. However, with improved recognition and diagnosis, the risk of death diminishes. The diagnosis depends on the clinician's suspicion. Pulmonary emboli are categorized into low, intermediate, or high risk based on the scoring scales and patients' hemodynamic stability versus instability. Imaging plus biomarkers help stratify patients according to risk. With the advent of the computed tomography multidetector scanners, the improved imaging has increased the detection of subsegmental and incidental pulmonary emboli. Treatment of low-risk as well as subsegmental and incidental pulmonary embolism is evolving.

Endovascular therapy for acute severe pulmonary embolism

Acute pulmonary embolism (PE) is a major public health problem and accounts for 100,000-180,000 deaths per year in the United States. Current prognostic stratification separates acute PE into massive, submassive, and low-risk by the presence or absence of sustained hypotension, RV dysfunction, and myocardial necrosis. Massive, submassive and low-risk PE have mortality rates of 25-65%, 3%, and < 1%, respectively. In this review we will focus on therapies currently available to manage acute massive and submassive PE.

Portable Ventilation/Perfusion Scanning is Useful for Evaluating Clinically Significant Pulmonary Embolism in the ICU Despite Abnormal Chest Radiography

OBJECTIVE

Computed tomography angiography is limited in the intensive care unit (ICU) due to renal insufficiency, hemodynamic instability, and difficulty transporting unstable patients. A portable ventilation/perfusion (V/Q) scan can be used. However, it is commonly believed that an abnormal chest radiograph can result in a nondiagnostic scan. In this retrospective study, we demonstrate that portable V/Q scans can be helpful in ruling in or out clinically significant pulmonary embolism (PE) despite an abnormal chest x-ray in the ICU.

DESIGN

Two physicians conducted chart reviews and original V/Q reports. A staff radiologist, with 40 years of experience, rated chest x-ray abnormalities using predetermined criteria.

SETTING

The study was conducted in the ICU.

PATIENTS

The first 100 consecutive patients with suspected PE who underwent a portable V/Q scan.

INTERVENTIONS

Those with a portable V/Q scan.

RESULTS

A normal baseline chest radiograph was found in only 6% of patients. Fifty-three percent had moderate, 24% had severe, and 10% had very-severe radiographic abnormalities. Despite the abnormal x-rays, 88% of the V/Q scans were low probability for a PE despite an average abnormal radiograph rating of moderate. A high-probability V/Q for PE was diagnosed in 3% of the population despite chest x-ray ratings of moderate to severe. Six patients had their empiric anticoagulation discontinued after obtaining the results of the V/Q scan, and no anticoagulation was started for PE after a low-probability V/Q scan.

CONCLUSION

Despite the large percentage of moderate-to-severe x-ray abnormalities, PE can still be diagnosed (high-probability scan) in the ICU with a portable V/Q scan. Although low-probability scans do not rule out acute PE, it appeared less likely that any patient with a low-probability V/Q scan had severe hypoxemia or hemodynamic instability due to a significant PE, which was useful to clinicians and allowed them to either stop or not start anticoagulation.

Endovascular treatment of pulmonary embolism: Selective review of available techniques

Acute pulmonary embolism (PE) is the third most common cause of death in hospitalized patients. The development of sophisticated diagnostic and therapeutic modalities for PE, including endovascular therapy, affords a certain level of complexity to the treatment of patients with this important clinical entity. Furthermore, the lack of level I evidence for the safety and effectiveness of catheter directed therapy brings controversy to a promising treatment approach. In this review paper, we discuss the pathophysiology and clinical presentation of PE, review the medical and surgical treatment of the condition, and describe in detail the tools that are available for the endovascular therapy of PE, including mechanical thrombectomy, suction thrombectomy, and fibrinolytic therapy. We also review the literature available to date on these methods, and describe the function of the Pulmonary Embolism Response Team.

Concomitant coronary and pulmonary embolism associated with patent foramen ovale: A case report

RATIONALE

The differential diagnosis of acute chest pain is very important, and can sometimes be challenging. Related diseases share a number of risk factors, and occasionally, 1 condition causes another disease to develop.

PATIENT CONCERNS

We described a 59-year-old man who presented to emergency department complaining of chest pain.

DIAGNOSES

He was suffered acute myocardial infarction (MI) and pulmonary embolism (PE) simultaneously.

INTERVENTIONS

Dual antiplatelet therapy, statin, and low molecular weight heparin were administrated during his stay. The searches for cancers, autoimmune diseases, and hematologic diseases were unremarkable, ruling out a hypercoagulable state. Subsequent ultrasound scan revealed a thrombus in a vein of the lower left extremity. Thus, paradoxical embolism was highly suspected.

OUTCOMES

Paradoxical embolism is a rare cause of acute MI, which may have occurred in our patient. This was evidenced by a previously unrecognized patent foramen ovale (PFO) with a right-to-left atrial shunt detected using contrast transesophageal echocardiography.

LESSONS

Acute MI complicated with PE is not common in the clinical setting. The fatal condition is difficult to diagnose because of the similar symptoms and confusing causes. Paradoxical embolism can cause this phenomenon, and physicians should be highly vigilant in the search for a PFO in cases of paradoxical embolism.

Catheter-Directed Therapy for Pulmonary Embolism: Patient Selection and Technical Considerations

Acute pulmonary embolism (PE) is the third most common cause of death among hospitalized patients. Treatment escalation beyond anticoagulation therapy is necessary in patients with cardiogenic shock and may be of benefit in select normotensive patients with right heart strain. Percutaneous catheter-based techniques (catheter-directed mechanical thrombectomy, clot maceration, and/or pharmacologic thrombolysis) as an alternative or adjunct to systemic thrombolysis can rapidly debulk central clot in patients with shock. Catheter-directed thrombolysis, which uses a low-dose intraclot prolonged thrombolytic infusion, is a promising but insufficiently studied therapy for patients presenting with acute intermediate-risk PE.

Comparison of In-Hospital Outcomes and Readmission Rates in Acute Pulmonary Embolism Between Systemic and Catheter-Directed Thrombolysis (from the National Readmission Database)

There are sparse comparative data on in-hospital outcomes and readmission rates in patients with acute pulmonary embolism (PE) who receive systemic thrombolytics versus catheter-directed thrombolysis (CDT). The study cohort was derived from the National Readmission Database 2013 to 2014, subset of the Healthcare Cost and Utilization Project sponsored by the Agency for Healthcare Research and Quality. Systemic and CDT were identified using appropriate International Classification of Diseases, 9th Revision, Clinical Modification codes. The co-primary outcomes were in-hospital mortality and 30-day readmissions and secondary outcome was combined in-hospital mortality + gastrointestinal bleed + intracranial hemorrhage. We used propensity score match analysis without replacement using Greedy's algorithm to adjust for possible confounders. We identified a total of 4,426 patients (3,107: systemic thrombolysis and 1,319: CDT) with acute PE who were treated with thrombolysis. In our 2:1 propensity score algorithm, in-hospital mortality was lower in the CDT group (6.12%) versus systemic thrombolytics (14.94%) (odds ratio 0.37, 95% confidence interval 0.28 to 0.49, p <0.001). There was also a lower composite secondary outcome (in-hospital mortality + gastrointestinal bleed + intracranial hemorrhage) in patients who received CDT (8.42%) versus those who received systemic thrombolytics (18.13%) (odds ratio 0.41, 95% confidence interval 0.33 to 0.53, p <0.001). Thirty-day readmission was lower in patients with CDT group (7.65%) compared with systemic thrombolytics (10.58%, p = 0.009). In conclusion, in-hospital mortality, as well as bleeding during primary admission was significantly lower with CDT compared with systemic thrombolytics for patients with acute PE. There was also significant decrease in rate of readmissions among patients receiving CDT compared with systemic thrombolytics.

Epidemiology, Pathophysiology, Stratification, and Natural History of Pulmonary Embolism

Pulmonary embolism (PE) is a common and potentially fatal form of venous thromboembolism that can be challenging to diagnose and manage. PE occurs when there is obstruction of the pulmonary vasculature and is a common cause of morbidity and mortality in the United States. A combination of acquired and inherited factors may contribute to the development of this disease and should be considered, since they have implications for both susceptibility to PE and treatment. Patients with suspected PE should be evaluated efficiently to diagnose and administer therapy as soon as possible, but the presentation of PE is variable and nonspecific so diagnosis is challenging. PE can range from small, asymptomatic blood clots to large emboli that can occlude the pulmonary arteries causing sudden cardiovascular collapse and death. Thus, risk stratification is critical to both the prognosis and management of acute PE. In this review, we discuss the epidemiology, risk factors, pathophysiology, and natural history of PE and deep vein thrombosis.

Vascular Causes of Syncope: An Emergency Medicine Review

BACKGROUND

Syncope is a common emergency department (ED) complaint, accounting for 2% of visits annually. A wide variety of etiologies can result in syncope, and vascular causes may be deadly.

OBJECTIVE

This review evaluates vascular causes of syncope and their evaluation and management in the ED.

DISCUSSION

Syncope is defined by a brief loss of consciousness with loss of postural tone and complete, spontaneous recovery without medical intervention. Causes include cardiac, vasovagal, orthostatic, neurologic, medication-related, and idiopathic, and most cases of syncope will not receive a specific diagnosis pertaining to the cause. Emergency physicians are most concerned with life-threatening causes such as dysrhythmia and obstruction, and electrocardiogram is a primary means of evaluation. However, vascular etiologies can result in patient morbidity and mortality. These conditions include pulmonary embolism, subclavian steal, aortic dissection, cerebrovascular disease, intracerebral hemorrhage, carotid/vertebral dissection, and abdominal aortic aneurysm. A focused history and physical examination can assist emergency physicians in determining the need for further testing and management.

CONCLUSIONS

Syncope is common and may be the result of a deadly condition. The emergency physician, through history and physical examination, can determine the need for further evaluation and resuscitation of these patients, with consideration of vascular etiologies of syncope.

Terapia fibrinolítica sistêmica no tromboembolismo pulmonar

O tromboembolismo pulmonar permanece como um grande desafio terapêutico para os médicos especialistas, pois, apesar de todo investimento e desenvolvimento em seu diagnóstico, profilaxia e tratamento, essa condição continua sendo a principal causa de morte evitável em ambiente hospitalar. Ainda restam muitas dúvidas em relação a qual perfil de paciente vai se beneficiar de fato da terapia fibrinolítica sistêmica, sem ficar exposto a um grande risco de sangramento. A estratificação de risco e a avaliação do prognóstico do evento, através de escores clínicos de insuficiência ventricular direita, marcadores de dilatação e disfunção do ventrículo direito e avaliação da massa trombótica, associados ou de forma isolada, são ferramentas que podem auxiliar na identificação do paciente que irá se beneficiar dessa terapia. Os únicos consensos em relação à terapia fibrinolítica no tratamento do tromboembolismo pulmonar são: não deve ser indicada de forma rotineira; nenhum dos escores ou marcadores, isoladamente, devem justificar seu uso; e os pacientes com instabilidade hemodinâmica são os mais beneficiados. Além disto, deve-se avaliar cada caso em relação ao risco de sangramento, especialmente no sistema nervoso central.

Diagnostic implications of computed tomography pulmonary angiography in patients with pulmonary embolism

INTRODUCTION:

Pulmonary embolism (PE) is a serious cardiovascular and pulmonary complication worldwide. We aimed to assess the implications of different computed tomography pulmonary angiography (CTPA) parameters in patients with acute PE.

METHODS:

A retrospective observational study to include patients presented with clinical suspicious of PE who underwent CTPA was conducted. Patients' demographics, clinical presentation, risk factors, laboratory investigations, management, and outcome were analyzed. Computed tomography findings included clot burden (Qanadli score [QS]) and right ventricular dysfunction (RVD) parameters.

RESULTS:

A total of 45 patients with radiologically confirmed diagnosis of PE were included in the study; of these patients, 8 (17.8%) died during the hospital course. Patients who died were 13 years older than those who survived, and the mortality rate was significantly higher in patients with cancer. The two groups were comparable for cardiovascular parameters. The mean clot burden (QS) was 19.5 ± 11.3 points and 53% of patients had QS >18 points. Obesity (52.4% vs. 12.5%; P = 0.01), hypertension (54.4% vs. 23.8%; P = 0.03), and median D-dimer levels (7.8 vs. 3.4; P = 0.03) were significantly higher in patients with QS >18. Among right ventricular (RV) dysfunction parameters, only higher RV/left ventricular (LV) ratio (P = 0.001) and bowing of interventricular septum (P = 0.001) were associated with higher QS. A significant positive correlation was found between RV short axis (r = 0.499, P = 0.001), RV/LV ratio (r = 0.592, P = 0.001), and pulmonary artery (PA) diameter (r = 0.301, P = 0.04) with the PA clot burden. Receiver operating characteristic curve for clot burden showed a cutoff value of 17.5 points to accurately predict RV dysfunction.

CONCLUSIONS:

Clot burden >18 is associated with RV dysfunction in patients with acute PE. Echocardiography and RVD parameters showed no correlation with in-hospital deaths. CTPA has clinicoradiological implications for risk stratification in PE patients. As the sample size is small, our findings warrant further larger prospective studies.

Venous thromboembolism: identifying patients at risk and establishing prophylaxis

Venous thromboembolism (VTE) is a major cause of morbidity and mortality and is associated with substantial healthcare costs. Identification of patients at risk of developing VTE enables appropriate thromboprophylaxis to be implemented. Although no predisposing risk factors can be identified in many patients in whom VTE develops, most have at least one underlying risk factor which can be categorized according to whether it confers low, moderate, or high risk. Clinical trials have demonstrated the effectiveness of thromboprophylaxis, both non-pharmacological and pharmacological, in a host of medical settings and there is sufficient evidence to support routine prophylaxis in many groups of patients. The implementation of decision making tools based on risk factor assessment improves the prescription of appropriate VTE prophylaxis. Nonetheless, thromboprophylaxis is often inadequate, with haphazard risk assessment and application of guidelines, leading to easily preventable instances of VTE. The most commonly used agents for pharmacological thromboprophylaxis of VTE are low dose unfractionated heparin; a low molecular weight heparin such as dalteparin, enoxaparin or tinzaparin; fondaparinux; warfarin; or aspirin. However, these have a number of drawbacks, principally the need for parenteral administration (with heparins) and frequent coagulation monitoring (with warfarin). The optimal anticoagulant would be orally administered, with a wide therapeutic window, rapid onset of action, predictable pharmacodynamics and pharmacokinetics, minimal interactions with food and other drugs, an ability to inhibit free and clot-bound coagulation factors, low, non-specific binding, and no requirement for routine coagulation monitoring or dose adjustment. A number of novel, single-target oral anticoagulants have been developed that appear to fulfill many of these requirements. This narrative review discusses the use of guidelines and risk assessment tools to identify patients at risk of VTE; it provides an overview of appropriate prophylaxis strategies in these patients with a summary of clinical trial results with novel oral anticoagulants.

Research priorities for the influence of gender on diagnostic imaging choices in the emergency department setting

Diagnostic imaging is a cornerstone of patient evaluation in the acute care setting, but little effort has been devoted to understanding the appropriate influence of sex and gender on imaging choices. This article provides background on this issue and a description of the working group and consensus findings reached during the diagnostic imaging breakout session at the 2014 Academic Emergency Medicine consensus conference "Gender-specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes." Our goal was to determine research priorities for how sex and gender may (or should) affect imaging choices in the acute care setting. Prior to the conference, the working group identified five areas for discussion regarding the research agenda in sex- and gender-based imaging using literature review and expert consensus. The nominal group technique was used to identify areas for discussion for common presenting complaints to the emergency department where ionizing radiation is often used for diagnosis: suspected pulmonary embolism, suspected kidney stone, lower abdominal pain with a concern for appendicitis, and chest pain concerning for coronary artery disease. The role of sex- and gender-based shared decision-making in diagnostic imaging decisions is also raised.

Treatment of acute pulmonary embolism: update on newer pharmacologic and interventional strategies

Acute pulmonary embolism (PE) is a common complication in hospitalized patients, spanning multiple patient populations and crossing various therapeutic disciplines. Current treatment paradigm in patients with massive PE mandates prompt risk stratification with aggressive therapeutic strategies. With the advent of endovascular technologies, various catheter-based thrombectomy and thrombolytic devices are available to treat patients with massive or submassive PE. In this paper, a variety of newer treatment strategies for PE are analyzed, with special emphasis on various interventional treatment strategies. Clinical evidence for utilizing endovascular treatment modalities, based on our institutional experience as well as a literature review, is provided.

Medical and interventional options to treat pulmonary embolism

Venous thromboembolism remains one of the most common conditions. Pulmonary embolism carries a mortality rate of over 15 % in the first 3 months after diagnosis. Venous thromboembolism is the fourth leading cause of death in the Western world, and the third leading cause of cardiovascular death trailing myocardial infarction and stroke. This section highlights the medical and interventional options presently available to treat this potentially lethal disease.

Primary Nephrotic Syndrome in Adults as a Risk Factor for Pulmonary Embolism: An Up-to-Date Review of the Literature

Patients with nephrotic syndrome are at an increased risk for thrombotic events; deep venous thrombosis, renal vein thrombosis, and pulmonary embolism are quite common in patients with nephrotic syndrome. It is important to note that nephrotic syndrome secondary to membranous nephropathy may impose a greater thrombotic risk for unclear reasons. Increased platelet activation, enhanced red blood cell aggregation, and an imbalance between procoagulant and anticoagulant factors are thought to underlie the excessive thrombotic risk in patients with nephrotic syndrome. The current scientific literature suggests that patients with low serum albumin levels and membranous nephropathy may benefit from primary prophylactic anticoagulation. A thorough approach which includes accounting for all additional thrombotic risk factors is, therefore, essential. Patient counseling regarding the pros and cons of anticoagulation is of paramount importance. Future prospective randomized studies should address the question regarding the utility of primary thromboprophylaxis in patients with nephrotic syndrome.

Clinical manifestations and pulmonary histopathological analysis related to different diseases in patients with fatal pulmonary thromboembolism: an autopsy study

Background

To correlate underlying diseases, in autopsies of patients with pulmonary thromboembolism (PTE) to histological findings and manifestations reviewed in the medical records.

Methods

The autopsy records between 2001 and 2008 of 291 patients whose cause of death was PTE were reviewed. The following data were obtained: age, sex, clinical “in vivo” manifestations, postmortem pathological patterns, and main associated underlying diseases, cancers, and surgeries performed in the last hospitalization. The pulmonary histopathological changes were categorized as diffuse alveolar damage, pulmonary edema, alveolar hemorrhage, and lymphoid interstitial pneumonia. Odds ratios of positive relations were obtained by logistic regression and were considered significant when P<0.05.

Results

The median age was 64 years old. About 64% of patients presented cardiovascular illness associated with PTE. The most prevalent pulmonary finding was pulmonary edema. Only 13% of cases had clinical suspicion of PTE. Acute respiratory failure was positively related to pulmonary edema, alveolar hemorrhage, and diffuse alveolar damage as well as hemodynamic instability to alveolar hemorrhage and diffuse alveolar damage.

Conclusion

We found important relations between clinical data and histological findings of patients with fatal PTE. A greater understanding of the pulmonary physiopathological mechanisms involved with each disease associated to PTE could improve its diagnosis and treatment.

Endovascular management of massive pulmonary embolism with clot fragmentation and suction

Massive pulmonary embolism with right ventricular dysfunction may be treated with thrombolysis, embolectomy, or percutaneous mechanical thrombectomy. This study describes our experience with two patients that had massive pulmonary embolism and were treated with percutaneous mechanical thrombectomy and reports on the mid-term results of this procedure. A 28-year-old man and a 70-year-old woman were diagnosed with deep venous thrombosis and massive pulmonary embolism. They first had lower limb edema followed by sudden onset of dyspnea. Their physical examination revealed edema, tachypnea, chest discomfort and jugular turgescence. Both needed to receive oxygen using a nasal cannula. Doppler ultrasound, echocardiography, and computed tomography angiography were used to establish the diagnoses. Patients underwent percutaneous mechanical thrombectomy using the Aspirex® system (Straub Medical), and their clinical condition and imaging study findings improved substantially. At mid-term follow-up, patient conditions were improving satisfactorily.

Pulmonary thromboembolism presenting with abdominal symptoms

Background:

Abdominal pain is rarely reported as the presenting complaint of pulmonary thromboembolism.

Case Report:

We report a case of a 42 year old white male with no known past medical problems except a left humeral fracture two weeks prior who presented to the emergency department with acute onset of right flank and lower abdominal pain. Initial evaluation including abdominal CT suggested cholecystitis. Lack of improvement with empiric antibiotics and symptomatic therapy prompted further evaluation revealing the patient to have a pulmonary thromboembolism (PTE).

Conclusions:

Pulmonary thromboembolism (PTE) can be effectively treated once diagnosed. Abdominal pain as a presenting complaint in PTE is rarely reported as a cause of PTE. We believe that clinicians should consider PTE in their differential of abdominal pain in patients with risk factors for VTE.

Endovascular therapy for acute pulmonary embolism

Acute pulmonary embolism (PE) is the third most common cause of death among hospitalized patients. Treatment escalation beyond anticoagulation therapy is necessary in patients with massive PE (defined by hemodynamic shock) as well as in many patients with submassive PE (defined by right ventricular strain). The best current evidence suggests that modern catheter-directed therapy to achieve rapid central clot debulking should be considered as an early or first-line treatment option for patients with acute massive PE; and emerging evidence suggests a catheter-directed thrombolytic infusion should be considered as adjunctive therapy for many patients with acute submassive PE. This article reviews the current approach to endovascular therapy for acute PE in the context of appropriate diagnosis, risk stratification, and management of acute massive and acute submassive PE.

High plasma lactate levels are associated with increased risk of in-hospital mortality in patients with pulmonary embolism

OBJECTIVES

The objective was to investigate the prognostic value of plasma lactate in patients with acute pulmonary embolism (PE).

METHODS

This was a retrospective study at the emergency department (ED) of a third-level teaching hospital. The authors considered consecutive patients with a diagnosis of PE established by lung scan or spiral computed tomography (CT) and confirmed by pulmonary angiography if necessary. Only patients for whom plasma lactate levels had been tested within 6 hours from presentation to the ED were included. Primary outcome was in-hospital death due to any cause; secondary outcome was mortality related to PE.

RESULTS

From September 1997 to June 2006, a total of 384 patients were diagnosed with PE in the ED. Of these patients, 287 had registered plasma lactate levels and were included in this analysis. Included patients had a mean age of 70 (SD ± 15 years, range = 18 to 100 years), 163 (57%) were female, 26 (9%) showed systolic blood pressure lower than 100 mm Hg at presentation, and 160 (56%) had echocardiographic evidence of right ventricular dysfunction (RVD). Twenty patients died during their hospital stay (7%). Plasma lactate levels ≥ 2 mmol/L were associated with in-hospital mortality from all causes (odds ratio [OR] = 4.60, 95% confidence interval [CI] = 1.57 to 13.53) and with PE-related mortality (OR = 4.94, 95% CI = 1.38 to 17.63), independent of hypotension or RVD at presentation.

CONCLUSIONS

High plasma lactate was associated with increased in-hospital mortality in this sample of patients with acute PE.

Massive pulmonary embolism in children

We present 3 children with massive pulmonary embolism and review 17 recent pediatric reports. Malignancies were a frequent cause (40%), and sudden death was common (60%). Compared with adults, diagnosis was more likely to be made at autopsy (P < .0001), more children were treated with embolectomy/thrombectomy (P = .0006), and mortality was greater (P = .03).

Pragmatic classification of the causes of high D-dimer

Venous thromboembolism (VTE) remains the most common preventable cause of in-hospital death and D-dimer (DD) is one of the essential diagnostic tools for it. Each risk factor for VTE can raise DD and they are numerous: 24 listed in 2008 European Guidelines. Acute coronary syndrome and stroke increase DD concentration, too. Thus, all three most important causes of cardiovascular death are capable of raising DD. Recent evidence suggests DD as a sensitive marker also for acute aortic dissection. Many other processes may raise DD concentration: atrial fibrillation, congestive heart failure, disseminated intravascular coagulation, etc. The adequate DD interpretation is additionally important due to the frequent usage of the test (probably millions of times a year in the world). Simple and concise classification is much easier to remember and such one is suggested.