The Prognostic Value of the Serum Levels of Brain Natriuretic Peptide, Troponin I, and D-Dimer, in Addition to the Neutrophil-to-Lymphocyte Ratio, for the Disease Evaluation of Patients with Acute Pulmonary Embolism

The prognostic value of blood cellular indices in pulmonary embolism

Prognostication in acute pulmonary embolism (PE) requires reliable markers. While cellular indices such as neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) appear promising, their utility in PE prognostication needs further exploration. We utilized data from the RIETE registry and the Loyola University Medical Center (LUMC) to assess the prognostic value of NLR, PLR, and SII in acute PE, using logistic regression models. The primary outcome was 30-day all-cause mortality. We compared their prognostic value versus the simplified Pulmonary Embolism Severity Index (sPESI) alone. We included 10 085 patients from RIETE and 700 from the LUMC. Thirty-day mortality rates were 4.6% and 8.3%, respectively. On multivariable analysis, an elevated NLR (>7.0) was associated with increased mortality (adjusted odds ratio [aOR]: 3.46; 95% CI: 2.60-4.60), outperforming the PLR > 220 (aOR: 2.36; 95% CI: 1.77-3.13), and SII > 1600 (aOR: 2.52; 95% CI: 1.90-3.33). The c-statistic for NLR in patients with low-risk PE was 0.78 (95% CI: 0.69-0.86). Respective numbers were 0.66 (95% CI: 0.63-0.69) and 0.68 (95% CI: 0.59-0.76) for intermediate-risk and high-risk patients. These findings were mirrored in the LUMC cohort. Among 9810 normotensive patients in RIETE, those scoring 0 points in sPESI and with an NLR ≤ 7.0 (35% of the population) displayed superior sensitivity (97.1%; 95% CI: 95.5-98.7) and negative predictive value (99.7%; 95% CI: 99.5-99.8) than sPESI alone (87.1%; 95% CI: 83.9-90.3, and 98.7%; 95% CI: 98.4-99.1, respectively) for 30-day mortality. The NLR is a significant prognostic marker for 30-day mortality in PE patients, especially useful to identify patients with very low-risk PE.

Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as predictors of mortality in acute pulmonary embolism: A systematic review and meta-analysis

Objective

The purpose of this review was to examine the association between neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) and mortality rates in patients with acute pulmonary embolism (PE).

Methods

PubMed Central, Scopus, Web of Science, and Embase were searched for studies reporting the association between NLR and PLR with mortality up to March 17th 2023. Adjusted ratios were sourced from studies and combined to generate pooled outcomes as odds ratio (OR) in a random-effects model. Risk of bias was assessed using the Newcastle Ottawa Scale.

Results

Fifteen studies were included. Meta-analysis showed that NLR was a significant predictor of mortality in patients with PE (OR: 1.42 95% CI: 1.26, 1.61 I2=92%). Results were unchanged on sensitivity analysis and subgroup analysis based on study location, method of diagnosis, sample size, overall mortality rates, cut-offs, and follow-up. Pooled analysis failed to demonstrate PLR as a predictor of mortality in patients with PE (OR: 1.00 95% CI: 1.00, 1.01 I2=57%). Results were unchanged on sensitivity analysis and subgroup analysis based on study location, diagnosis of PE, overall mortality rates, and cut-off.

Conclusion

Current evidence from retrospective studies shows that NLR can independently predict mortality in acute PE. Data on PLR was limited and failed to indicate an independent role in the prognosis of PE patients. Registration No. PROSPERO (CRD42023407573).

Beyond the fractures: A comprehensive Comparative analysis of Affordable and Accessible laboratory parameters and their coefficients for prediction and Swift confirmation of pulmonary embolism in high-risk orthopedic patients

Background

Pulmonary embolism (PE) poses a significant challenge in diagnosis and treatment, particularly in high-risk patient populations such as those hospitalized for orthopedic reasons. This study explores the predictive and diagnostic potential of laboratory parameters in identifying PE among orthopedic patients.

Objectives

The purpose of this study was to determine whether selected (inexpensive and readily available) laboratory parameters and their coefficients can be used to diagnose pulmonary embolism and whether they are applicable in predicting its occurrence.

Material and methods

Selected laboratory parameters were determined twice in 276 hospitalized orthopedic patients with suspected PE: PLT, MPV, NEU, LYM, D-dimer, troponin I, age-adjusted D-dimer and their coefficients. Depending on the angio-CT results, patients were divided into groups. Selected popular laboratory coefficients were calculated and statistically analyzed. Optimal cutoff points were determined for the above laboratory tests and ROC curves were plotted.

Results

D-dimer/troponin I [p = 0.008], D-dimer [p = 0.001], age-adjusted D-dimer [p = 0.007], NLR/D-dimer [p = 0.005] and PLR [p = 0.021] are statistically significant predictors of PE. D-dimer/troponin I [p < 0.001], troponin I [p = 0.005] and age-adjusted D-dimer [p = 0.001] correlated with the diagnosis of PE after the onset of clinical symptoms.

Conclusions

In the context of orthopedic patients, cost-effective laboratory parameters, particularly the D-dimer/troponin I ratio and age-adjusted D-dimer, exhibit considerable potential in predicting and diagnosing PE. These findings suggest that combining readily available laboratory tests with clinical observation can offer a viable and cost-effective diagnostic alternative, especially in resource-constrained settings. Further studies with larger and diverse patient populations are recommended to validate these results.

Role of serum biomarkers in predicting management strategies for acute pulmonary embolism

Background

Acute pulmonary embolism (APE) is a condition that can be fatal. The severity of the disease influences therapeutic decisions, and mortality varies significantly depending on the condition's severity. Identification of patients with a high mortality risk is crucial. Since inflammation, hemostatic, and coagulation abnormalities are linked to APE, serum biomarkers may be helpful for prognostication.

Aim

To evaluate the significance of serum biomarkers in APE risk assessment and the suitability of these biomarkers for management and decision-making.

Methods

This study involved 60 adult patients with APE who were divided according to risk categorization. It was conducted in Chest, Cardiology and Internal Medicine department, Zagazig University Hospitals from December 2022 to May 2023. Several hematological biomarkers and their significance in APE risk assessment were measured with a comparison with the latest risk stratification methods which include haemodynamic measures and right ventricular (RV) dysfunction echocardiographic markers.

Results

Each risk group involved 20 patients (high, intermediate (10 were intermediate-high and 10 were intermediate-low) and low risk group). They were 34 females and 26 males with the mean ± SD of their age was 59.25 ± 13.06 years. Regarding hematological biomarkers, there were statistically significant differences as regards; lymphocytes, platelet to lymphocyte ratio (PLR), albumin, blood urea nitrogen (BUN), C-reactive protein (CRP) and D-dimer with highly statistically significant differences as regards; neutrophil to lymphocyte ratio (NLR), BUN to albumin (B/A) ratio, troponin I (TnI), and brain natriuretic peptide (BNP). TnI had the highest specificity and predictive value positive (PVP) and BNP had the highest sensitivity and predictive value negative (PVN) in predicting high risk groups. The Lymphocyte and NLR showed the lowest sensitivity and the albumin and B/A ratio had the lowest specificity. Regarding transthoracic echocardiography (TEE); there was a statistically significant increase regarding pulmonary artery systolic pressure (PASP) and a highly statistically significant increase regarding the right ventricle/left ventricle (RV/LV) ratio. There were statistically significant decreases regarding tricuspid annular plane systolic excursion (TAPSE) and peak systolic velocity of tricuspid annulus (S') among risk groups.

Conclusion

APE prognosis can be judged accurately by simultaneously measuring a few biomarkers along with haemodynamic variables and echocardiographic parameters of RV dysfunction.

Impact of Promising Biomarkers on Severity and Outcome of Acute Pulmonary Embolism

Background

Acute pulmonary embolism (APE) is a common clinical condition. Its severity ranges from asymptomatic radiological findings to fatal obstructive shock. The potential circulating biomarkers have been studied to predict APE outcomes. This study aimed to explore their predictive power on prognosis in APE.

Material and Method

It was a prospective observational study between March 2008 and April 2010. All consecutive patients diagnosed with APE were categorized as massive/high-risk, submassive/moderate-risk, and non-massive/low-risk. Cardiac troponin T (cTnT), myoglobin, N-terminal pro-brain natriuretic peptide (NT-proBNP), heart-type fatty acid-binding protein (H-FABP), growth differentiation factor-15 (GDF-15), and D-dimer levels were measured.

Results

Of these patients, 14 (29.8%), 16 (34.0%), and 17 (36.2%) patients were categorized as low-risk, moderate-risk, and high risk-patients, respectively. There was no significant difference between the patient groups categorized based on the risk stratification in terms of demographic and clinical characteristics. The cTnT, myoglobin, HFABP, and D-dimer levels have also not differed significantly between the groups. There was a significant difference between the groups in respect of NT-proBNP and GDF-15 levels (p=0.009 and p=0.037, respectively). Nine (19.1%) patients had died by the 3rd-month follow-up. Adverse events were seen in 26 (55.3%) patients. GDF-15 had the highest area under the curve (AUC) value for predicting any adverse event (cut-off value=9.3 ng/mL, AUC=0.796, CI (confidence interval) 95%: 0.653-0.899). NT-ProBNP was determined as the best predictor for mortality (cut-off value=229.2 pg/mL, AUC=0.889, CI 95%: 0.756-0.964).

Conclusion

Higher levels of NT-proBNP and GDF-15 were found to be associated with more severe APE, worse outcomes, and mortality.

Discussion on operation: To compare the curative effect of PMT and CDT in the treatment of middle and high risk stratified APE and the clinical application value of serum BNP, TnI and plasma DFR levelse

Objective

To compare the efficacy of Percutaneous mechanical thrombectomy (PMT) and Catheter directed thrombolysis (CDT) in the treatment of patients with moderate and high-risk ape and explore the clinical application value of biomarkers in the treatment of moderate and high-risk ape.

Method

A total of 84 patients with ape were selected from the Department of vascular surgery of the Second Affiliated Hospital of Shandong First Medical University and the Department of vascular surgery of Shanghai Ninth People's Hospital Affiliated with Shanghai Jiao Tong University School of Medicine. According to the relevant guidelines, they were divided into high-risk and medium-risk groups, including PMT groups (35 cases) and CDT groups (49 cases). To detect the changes of serum B-type brain natriuretic peptide (BNP),Troponin I (TnI) and plasma D-dimer/fibrinogen ratio (DFR) levels in different risk stratification before and after PMT and CDT, the correlation and diagnostic value of each index, and compare the thrombus clearance rate, pulmonary artery pressure, average dosage of urokinase, effective thrombolytic time, average hospitalization time and complications of PMT and CDT.

Result

Under different treatment methods and risk stratification, there was no statistically significant difference in the clinical data of patients at general baseline;The preoperative BNP, TnI and DFR levels of PMT and CDT in the middle and high risk stratification were significantly lower than those in the other groups (P < 0.005),Compared with the CDT group, PMT has significantly better therapeutic effect on ape than the CDT group in terms of thrombus clearance rate, pulmonary artery pressure, average dosage of urokinase, effective thrombolytic time and average hospitalization time (P < 0.05),meanwhile,there was no significant difference in postoperative complications between the two groups (P < 0.05). After half a year of follow-up, the levels of BNP, TnI and DFR in the cured group were significantly lower than those in the effective group and the ineffective group. The areas under the curve of serum BNP, TnI and plasma DFR were 0.91, 0.87 and 0.93 and the area under the curve DFR has higher diagnostic efficiency than BNP and TnI, while the sensitivity and specificity of TnI are significantly higher than BNP and DFR.

Conclusion

Serum BNP, TnI and plasma DFR levels can reflect the risk stratification and better clinical diagnostic value of ape,PMT and CDT are used to treat high-risk ape. For hospitals with medical conditions, PMT is more worthy of clinical recommendation.

D-Dimer beyond Diagnosis of Pulmonary Embolism: Its Implication for Long-Term Prognosis in Cardio-Oncology Era

Venous thromboembolism (VTE) is a common comorbidity of cancer, often referred to as cancer-associated thrombosis (CAT). Even though its prevalence has been increasing, its clinical picture has not been thoroughly investigated. In this single-center retrospective observational study, 259 patients who were treated for pulmonary embolism (PE) between January 2015 and December 2020 were available for analysis. The patients were divided by the presence or absence of concomitant malignancy, and those with malignancy (N = 120, 46%) were further classified into active (N = 40, 15%) and inactive groups according to the treatment status of malignancy. In patients with malignancy, PE was more often diagnosed incidentally by computed tomography or D-dimer testing, and the proportion of massive PE was lower. Although D-dimer levels overall decreased after the initiation of anticoagulation therapy, concomitant malignancy was independently associated with higher D-dimer at discharge despite the lower severity of PE at onset. The patients with malignancy had a poor prognosis during post-discharge follow-up. Active malignancy was independently associated with major adverse cardiovascular events (MACE) and major bleeding. D-dimer at discharge was an independent predictor of mortality even after adjustment for malignancy. This study's findings suggest that CAT-PE patients might have hypercoagulable states, which can potentially lead to a poorer prognosis.

Platelet/Lymphocyte Ratio Predicted Long-Term Prognosis for Acute Upper Extremity Deep Vein Thrombosis from a Retrospective Study

Background

In this study, we aimed to determine the mortality risk factors and whether placement of a vena cava filter improves the prognosis of acute upper extremity deep vein thrombosis (UEDVT).

Methods

Clinical data and follow-up results were retrospectively analyzed. Cox regression analysis was conducted to identify the risk factors associated with all-cause mortality in all patients and subgroups of patients. Results are expressed as hazard ratio (HR) with 95% confidence intervals (95% CI). Receiver operating characteristic curves (ROC) were used to determine the optimal cut-off value. Kaplan-Meier survival curves were constructed and compared by the Log rank test.

Results

The study cohort comprised 109 patients of median age 56 years (47.5, 64.5). The median follow-up time was 25 months (8, 47): 39 patients (35.8%) had died by 12 months, 55 (50.5%) by 36 months, and 60 (55%) by the end of follow-up. Presence of malignancy (HR: 5.882, 95% CI: 2.128-16.667), D-dimer (HR: 1.56, 95% CI: 1.09-1.94), platelet/lymphocyte ratio (PLR; HR: 2.02, 95% CI: 1.15-3.54), and the systemic immune/inflammatory index (SII; HR: 1.471, 95% CI: 1.062-1.991) were identified as independent risk factors for mortality. Subgroup analysis of patients with malignancy determined gender (HR: 2.936, 95% CI: 1.599-5.393) and PLR (HR: 1.427,95% CI: 1.023-1.989) as independent risk factors. Kaplan-Meier analysis showed that the mortality rate was much higher in patients with malignancy, high D-dimer (≥ 0.92ug/mL), high PLR (≥ 291) and high SII (≥ 1487). However, there was no significant difference between patients with and without vena cava filters.

Conclusion

In this study, we identified PLR as an new independent predictor of mortality in patients with acute UEDVT. Emergency placement of a vena cava filter did not improve long-term prognosis.

A new machine learning model for predicting severity prognosis in patients with pulmonary embolism: Study protocol from Wenzhou, China

Introduction

Pulmonary embolism (PE) is a common thrombotic disease and potentially deadly cardiovascular disorder. The ratio of clinical misdiagnosis and missed diagnosis of PE is very large because patients with PE are asymptomatic or non-specific.

Methods

Using the clinical data from the First Affiliated Hospital of Wenzhou Medical University (Wenzhou, China), we proposed a swarm intelligence algorithm-based kernel extreme learning machine model (SSACS-KELM) to recognize and discriminate the severity of the PE by patient's basic information and serum biomarkers. First, an enhanced method (SSACS) is presented by combining the salp swarm algorithm (SSA) with the cuckoo search (CS). Then, the SSACS algorithm is introduced into the KELM classifier to propose the SSACS-KELM model to improve the accuracy and stability of the traditional classifier.

Results

In the experiments, the benchmark optimization performance of SSACS is confirmed by comparing SSACS with five original classical methods and five high-performance improved algorithms through benchmark function experiments. Then, the overall adaptability and accuracy of the SSACS-KELM model are tested using eight public data sets. Further, to highlight the superiority of SSACS-KELM on PE datasets, this paper conducts comparison experiments with other classical classifiers, swarm intelligence algorithms, and feature selection approaches.

Discussion

The experimental results show that high D-dimer concentration, hypoalbuminemia, and other indicators are important for the diagnosis of PE. The classification results showed that the accuracy of the prediction model was 99.33%. It is expected to be a new and accurate method to distinguish the severity of PE.

A Prediction Model Based on Blood Biomarker for Mortality Risk in Patients with Acute Venous Thromboembolism

Background

Most studies to date have focused on predicting the risk of venous thromboembolism (VTE), but prediction models about mortality risk in VTE are rarely reported. We sought to develop and validate a multivariable model to predict the all-cause mortality risk in patients with acute VTE in emergency settings.

Methods

A total of 700 patients were included from Qilu Hospital of Shandong University and were randomly assigned into training set (n=490) and validation set (n=210) in an 7:3 ratio. Multivariate logistics regression analysis was performed to identify independent variables and develop a prediction model, which was validated internally using bootstrap method. The discrimination, calibration and clinical utility were evaluated by receiver operating characteristic curve (ROC) analysis, Hosmer-Lemeshow (HL) test, Kaplan-meier (KM) analysis and decision curve analysis (DCA).

Results

There were 52 patients (10.6%) dying and 437 (89.4%) surviving in training set. Age (odds ratio [OR]: 4.158, 95% confidence interval [CI]: 2.426–7.127), pulmonary embolism (OR: 1.779, 95% CI: 1.124–2.814), platelet count (OR: 0.507, 95% CI: 0.310–0.830), D-dimer (OR: 1.826, 95% CI: 1.133–2.942) and platelet/lymphocyte ratio (OR: 2.166, 95% CI: 1.259–3.727) were independent risk variables associated with all-cause mortality. The model had good predictive capability with an AUC of 0.746 (95% CI: 0.668,0.825), a sensitivity of 0.769 (95% CI: 0.607,0.889), a specificity of 0.672 (95% CI: 0.634,0.707). The validation model had an AUC of 0.739 (95% CI: 0.685,0.793), a sensitivity of 0.690 (95% CI: 0.580,0.787), a specificity of 0.693 (95% CI: 0.655,0.729). The model is well calibrated and the HL test showed a good fit (χ²=5.291, p=0.726, Nagelkerke R²=0.137). KM analysis and DCA showed a good clinical utility of the nomogram.

Conclusion

This study identified independent variables affecting all-cause mortality in patients with acute VTE, and developed a prediction model and provided a nomogram with good prediction capability and clinical utility.

Catheter Directed Thrombolysis in the Treatment of Acute Pulmonary Embolism: Early Hemodynamic Recovery and Improvement in Prognosis

Aim

In this study, we aimed to investigate the efficacy of catheter directed thrombolysis (CDT) and peripheral intravenous thrombolysis (PIT) in the treatment of patients with acute pulmonary embolism (APE) and assess its effect on the prognosis of patients.

Methods

We recruited 74 patients with APE, who were assigned to CDT and PIT groups, according to the treatments received by them. The arterial partial pressure of oxygen (PaO2), partial pressure of carbon dioxide (Pa CO2), pulmonary artery pressure (PAP), pulmonary artery obstruction index (PAOI), thrombus volume, pain score, and therapeutic benefits were compared between the two groups before and after treatment, and the factors affecting patient prognoses were also analyzed.

Results

Using the clinical data before treatment as the baseline, it was found that changes in indicators of plasma, thrombus volume, and pain scores were significantly better in the CDT group than in the PIT group after treatment. The total effective rate of CDT was higher than that of PIT in the treatment of APE. The mean follow-up time for both the CDT and PIT groups was 41.08 ± 9.12 months, and the total mortality rate was 14.8% and 31%, respectively. The logistic regression analysis revealed the significant impacts of previous incidences of pulmonary embolism (PE), concurrent deep vein thrombosis (DVT), and pulmonary arterial hypertension (PAH) on the occurrence and progression of APE, and these factors were subsequently identified as risk factors for APE using Kaplan-Meier survival analysis. Observations from PAE onset to the end of follow-up revealed that there was a difference in survival rates between the CDT and PIT groups.

Conclusions

Taken together, CDT is an effective treatment strategy for APE and can provide effective symptomatic relief. In addition, the previous incidences of PE, concurrent DVT, and PAH are important risk factors that affect the survival rates of patients with APE.

Cellular Indices and Outcome in Patients with Acute Venous Thromboembolism

Background

Cellular indices provide integrative information about systemic inflammation status which is readily available from routine laboratory parameters. This study aimed to evaluate the prognostic role of three cellular indices in patients with venous thromboembolism (VTE).

Methods

The RIETE registry database was used to determine the association between the baseline neutrophil-to-lymphocyte-ratio (NLR), platelet-to-lymphocyte-ratio (PLR) and systemic-immune-inflammation-index (SII) for 90-day adverse outcomes in patients with acute VTE.

Results

From January 2020 to April 2021, 4487 patients with acute VTE were recruited in the RIETE registry. Of these, 2683 presented with symptomatic pulmonary embolism (PE); 283 with incidental PE; 1129 with lower-limb deep vein thrombosis (DVT); 175 with upper-limb DVT; 69 with splanchnic vein thrombosis; 142 with superficial vein thrombosis and 20 with retinal vein thrombosis. Mean values were: NLR 5.9 ± 7.1, PLR 190 ± 158 and SII 1459 ± 2028. During the first 90-days, 38 patients (0.8%) developed recurrent DVT, 45 (1.0%) had recurrent PE, 152 (3.4%) suffered major bleeding, and 484 (11%) died. On multivariable analysis, patients with NLR >4.41 were at an increased risk for major bleeding and patients with NLR >4.96 were at the risk of death, while those with SII >1134.5 were at increased risk for death.

Conclusions

This study reports the results of a large cohort to date which evaluate the prognostic value of three cellular indices simultaneously in patients with acute VTE. Results support that none of the three baseline cellular indices were sufficient for prediction of VTE recurrences in acute VTE patients. The patients with higher baseline NLR values were at an increased risk of major bleeding or death, those with high SII values were only at an increased risk for mortality.

Diagnostic and Prognostic Value of Immune/Inflammation Biomarkers for Venous Thromboembolism: Is It Reliable for Clinical Practice?

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), has been an important cause of sudden in-hospital death. Studies have shown that the immune/inflammatory response plays an important role in the pathogenesis of vascular disease, with representative markers in the blood including the neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), monocyte/lymphocyte ratio (MLR), systemic immune/inflammatory index (SII), etc. However, there is a variety of immune/inflammatory indicators. Moreover, most previous studies have been single-center investigations involving one or two indicators, with varying nature of cases, number of cases and study objectives, thereby making it difficult to reach consensus conclusions with good clinical guidelines. This article reviews the clinical value of immunoinflammatory indicators for VTE based on previous studies, including the diagnostic and prognostic capabilities. In conclusion, NLR provides promising predictive capability for the onset and prognosis of VTE and deserves extensive application in clinical practice. PLR also has certain diagnostic and prognostic value, but further studies are warranted to identify its reliability and stability. Monocytes, eosinophils and platelet-related indicators show some clinical association with VTE, although the predictive capabilities are mediocre. SII is of promising potential value for VTE and deserves further investigations. This review will provide new clues and valuable clinical guidance for the diagnosis and therapy of VTE.