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Ghorbani A, Greathouse J, Bakhshaei S, Ghorbani A, Zamiri K, Ho L, Ho A. Persistent Peril: Recurrent Deep Vein Thrombosis and Pulmonary Embolism in a Patient With Protein S Deficiency Despite Optimal Anticoagulation Therapies. Cureus 2024; 16:e60517. [PMID: 38883011 PMCID: PMC11180491 DOI: 10.7759/cureus.60517] [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] [Accepted: 05/17/2024] [Indexed: 06/18/2024] Open
Abstract
The clotting system has evolved as an adaptive mechanism to prevent blood loss during vascular damage. However, the intricate nature of the clotting cascade and the complexities of human life can sometimes lead to the unnatural activation of this delicate cascade. This can result in blood clot formation within the cardiovascular system, contributing to a wide range of pathological conditions. Abnormal intravascular coagulation most commonly occurs in the deep veins of the lower extremities, and can emboli to other organs, hence, it is termed "venous thromboembolism" (VTE). In this report, we introduce a challenging case of VTE that poses a dilemma for current medical management. The patient with possible protein S deficiency underwent various guideline-directed medical treatments, yet experienced recurrent VTE episodes, including deep vein thrombosis (DVT) and pulmonary embolism (PE), leading to hospital readmissions. This case report sheds light on our challenges in effectively treating VTE.
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Affiliation(s)
- Ali Ghorbani
- Internal Medicine, Southwest Healthcare, Temecula, USA
| | | | - Sina Bakhshaei
- Internal Medicine, Southern California Medical Education Consortium, Temecula Valley Hospital, Temecula, USA
| | - Aida Ghorbani
- Neurology, UCLA School of Medicine, Los Angeles, USA
| | - Kurosh Zamiri
- Biology, University of California Los Angeles, Los Angeles, USA
| | - Lauren Ho
- Cardiology, Temecula Valley Hospital, Temecula, USA
| | - Andrew Ho
- Cardiology, Temecula Valley Hospital, Temecula, USA
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Gotta J, Koch V, Geyer T, Martin SS, Booz C, Mahmoudi S, Eichler K, Reschke P, D'Angelo T, Klimek K, Vogl TJ, Gruenewald LD. Imaging-based risk stratification of patients with pulmonary embolism based on dual-energy CT-derived radiomics. Eur J Clin Invest 2024; 54:e14139. [PMID: 38063028 DOI: 10.1111/eci.14139] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 03/13/2024]
Abstract
BACKGROUND Technological progress in the acquisition of medical images and the extraction of underlying quantitative imaging data has introduced exciting prospects for the diagnostic assessment of a wide range of conditions. This study aims to investigate the diagnostic utility of a machine learning classifier based on dual-energy computed tomography (DECT) radiomics for classifying pulmonary embolism (PE) severity and assessing the risk for early death. METHODS Patients who underwent CT pulmonary angiogram (CTPA) between January 2015 and March 2022 were considered for inclusion in this study. Based on DECT imaging, 107 radiomic features were extracted for each patient using standardized image processing. After dividing the dataset into training and test sets, stepwise feature reduction based on reproducibility, variable importance and correlation analyses were performed to select the most relevant features; these were used to train and validate the gradient-boosted tree models. RESULTS The trained machine learning classifier achieved a classification accuracy of .90 for identifying high-risk PE patients with an area under the receiver operating characteristic curve of .59. This CT-based radiomics signature showed good diagnostic accuracy for risk stratification in individuals presenting with central PE, particularly within higher risk groups. CONCLUSION Models utilizing DECT-derived radiomics features can accurately stratify patients with pulmonary embolism into established clinical risk scores. This approach holds the potential to enhance patient management and optimize patient flow by assisting in the clinical decision-making process. It also offers the advantage of saving time and resources by leveraging existing imaging to eliminate the necessity for manual clinical scoring.
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Affiliation(s)
- Jennifer Gotta
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Vitali Koch
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tobias Geyer
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon S Martin
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Booz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Katrin Eichler
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Philipp Reschke
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Konrad Klimek
- Goethe University Frankfurt, University Hospital, Clinic for Nuclear Medicine, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
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Casey SD, Stubblefield WB, Luijten D, Klok FA, Westafer LM, Vinson DR, Kabrhel C. Addressing the rising trend of high-risk pulmonary embolism mortality: Clinical and research priorities. Acad Emerg Med 2024; 31:288-292. [PMID: 38129964 DOI: 10.1111/acem.14859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Deaths from high-risk pulmonary embolism (PE) appear to have increased in the US over the last decade. Modifiable risks contributing to this worrisome trend present opportunities for physicians, researchers, and healthcare policymakers to improve care. METHODS We sought to contextualize contemporary, high-risk PE epidemiology and examine clinical trials, quality improvement opportunities, and healthcare policy initiatives directed at reducing mortality. RESULTS We observed significant and modifiable excess mortality due to high-risk PE. We identified several opportunities to improve care including: (1) rapid translation of forthcoming data on reperfusion strategies into clinical practice; (2) improved risk stratification tools; (3) quality improvement initiatives to address presumptive anticoagulation practice gaps; and (3) adoption of health policy initiatives to establish pulmonary embolism response teams and address the social determinants of health. CONCLUSION Addressing knowledge and practice gaps in intermediate and high-risk PE management must be prioritized and informed by forthcoming high-quality data. Implementation efforts are needed to improve acute PE management and resolve treatment disparities.
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Affiliation(s)
- Scott D Casey
- Kaiser Permanente Division of Research, Oakland, California, USA
- The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, California, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dieuwke Luijten
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medicine Center, Leiden, Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medicine Center, Leiden, Netherlands
| | - Lauren M Westafer
- Department of Emergency Medicine, UMASS Chan Medical School-Baystate, Springfield, Massachusetts, USA
- Department of Healthcare Delivery and Population Science, UMASS Chan Medical School-Baystate, Springfield, Massachusetts, USA
| | - David R Vinson
- Kaiser Permanente Division of Research, Oakland, California, USA
- The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Alhuarrat MAD, Barssoum K, Chowdhury M, Mathai SV, Helft M, Grushko M, Singh P, Jneid H, Motiwala A, Faillace RT, Sokol SI. Comparison of In-Hospital Outcomes between Early and Late Catheter-Directed Thrombolysis in Acute Pulmonary Embolism: A Retrospective Observational Study. J Clin Med 2024; 13:1093. [PMID: 38398406 PMCID: PMC10889518 DOI: 10.3390/jcm13041093] [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: 01/16/2024] [Revised: 02/09/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
The purpose of this study is to evaluate whether early initiation of catheter-directed thrombolysis (CDT) in patients presenting with acute pulmonary embolism is associated with improved in-hospital outcomes. A retrospective cohort was extracted from the 2016-2019 National Inpatient Sample database, consisting of 21,730 weighted admissions undergoing CDT acute PE. From the time of admission, the sample was divided into early (<48 h) and late interventions (>48 h). Outcomes were measured using regression analysis and propensity score matching. No significant differences in mortality, cardiac arrest, cardiogenic shock, or intracranial hemorrhage (p > 0.05) were found between the early and late CDT groups. Late CDT patients had a higher likelihood of receiving systemic thrombolysis (3.21 [2.18-4.74], p < 0.01), blood transfusion (1.84 [1.41-2.40], p < 0.01), intubation (1.33 [1.05-1.70], p = 0.02), discharge disposition to care facilities (1.32 [1.14-1.53], p < 0.01). and having acute kidney injury (1.42 [1.25-1.61], p < 0.01). Predictors of late intervention were older age, female sex, non-white ethnicity, non-teaching hospital admission, hospitals with higher bed sizes, and weekend admission (p < 0.01). This study represents a comprehensive evaluation of outcomes associated with the time interval for initiating CDT, revealing reduced morbidity with early intervention. Additionally, it identifies predictors associated with delayed CDT initiation. The broader ramifications of these findings, particularly in relation to hospital resource utilization and health disparities, warrant further exploration.
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Affiliation(s)
- Majd Al Deen Alhuarrat
- Division of Internal Medicine, NYC Health + Hospitals, Jacobi Medical Center, Albert Einstein College Medicine, Bronx, NY 10461, USA; (M.A.D.A.); (R.T.F.)
| | - Kirolos Barssoum
- Division of Cardiology, University of Texas Medical Branch, Houston, TX 77002, USA; (K.B.); (H.J.); (A.M.)
| | - Medhat Chowdhury
- Ascension Providence Southfield Campus, Southfield, MI 48075, USA
| | - Sheetal Vasundara Mathai
- Division of Internal Medicine, NYC Health + Hospitals, Jacobi Medical Center, Albert Einstein College Medicine, Bronx, NY 10461, USA; (M.A.D.A.); (R.T.F.)
| | - Miriam Helft
- College of Art and Sciences, New York University, New York, NY 10003, USA
| | - Michael Grushko
- Division of Cardiology, NYC Health + Hospitals, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (M.G.); (P.S.)
| | - Prabhjot Singh
- Division of Cardiology, NYC Health + Hospitals, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (M.G.); (P.S.)
| | - Hani Jneid
- Division of Cardiology, University of Texas Medical Branch, Houston, TX 77002, USA; (K.B.); (H.J.); (A.M.)
| | - Afaq Motiwala
- Division of Cardiology, University of Texas Medical Branch, Houston, TX 77002, USA; (K.B.); (H.J.); (A.M.)
| | - Robert T. Faillace
- Division of Internal Medicine, NYC Health + Hospitals, Jacobi Medical Center, Albert Einstein College Medicine, Bronx, NY 10461, USA; (M.A.D.A.); (R.T.F.)
| | - Seth I. Sokol
- Division of Cardiology, NYC Health + Hospitals, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY 10461, USA; (M.G.); (P.S.)
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Arora S, Vallabhajosyula S, Aggarwal V, Basir MB, Kelly B, Atreya AR. Novel Risk Stratification and Hemodynamic Profiling in Acute Pulmonary Embolism: A Proposed Classification Inspired by Society for Cardiovascular Angiography and Intervention Shock Staging. Interv Cardiol Clin 2023; 12:e1-e20. [PMID: 38964819 DOI: 10.1016/j.iccl.2024.04.002] [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] [Indexed: 07/06/2024]
Abstract
Treatment options for patients with acute pulmonary embolism (PE) and right ventricular shock (RVS) have grown exponentially. Therapy options include anticoagulation, systemic thrombolysis, catheter-based thrombolysis/ thrombectomy, and may include short-term mechanical circulatory support. However, the incidence of short-term morbidity and mortality has not changed despite the emergence of several advanced therapies in acute PE. This is possibly due to the inclusion of heterogenous populations in research studies without differentiation based on the acuity/severity of presentation. We propose a novel classification for PE-RVS to allow for standardizing appropriate therapy escalation and better communication of the severity among cardiovascular critical care, and emergency health care professionals.
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Affiliation(s)
- Sonali Arora
- Institute of Heart and Lung Transplant, Krishna Institute of Medical Sciences Hospitals, Secunderabad, Telangana, India
| | - Saraschandra Vallabhajosyula
- Section of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI, USA
| | - Vikas Aggarwal
- Division of Cardiology, Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Mir B Basir
- Division of Cardiology, Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Bryan Kelly
- Division of Pulmonary Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA; Department of Osteopathic Medical Specialties, Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA
| | - Auras R Atreya
- AIG Institute of Cardiac Sciences and Research, Gachibowli, Hyderabad, Telangana, India; Sciences and Research, Gachibowli, Hyderabad, Telangana, India.
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