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Ibrahim H, El-Maadawy SM. Role of multidetector CT in predicting patient outcome in cases of pulmonary embolism: correlation between imaging findings, ICU admissions and mortality rate. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00593-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pulmonary embolism (PE) is a critical medical condition that requires prompt diagnosis and treatment to avoid serious morbidity and mortality risk. Multidetector CT pulmonary angiography (CTPA) is considered the first-line imaging modality for suspected acute PE. The presence of right heart strain, which supports the diagnosis, requires special attention. The aim of our retrospective study is to assess the reliability of CTPA hemodynamic indices in predicting patients’ outcome in cases of PE.
Results
Sixty patients were included in our study. CTPA parameters including main pulmonary artery (MPA) diameter, left ventricle (LV) diameter, right ventricle (RV)/LV ratio, and septal deviation had a clinical prognostic value for short-term 30-day mortality and ICU admission. Statistically significant relationship between MPA diameter > 29 mm, LV diameter, RV/LV ratio > 1, left-sided septal deviation and contrast reflux into the IVC/distal hepatic veins with ICU admission was observed with p values 0.031, 0.000, 0.000, 0.005 and 0.028 respectively. There was a statistically significant correlation between MPA diameter > 29 mm, LV diameter, RV/LV > 1 ratio and septal deviation with 30-day mortality with p values of < 0.001, 0.001, < 0.001 and 0.015 respectively. No significant correlation was found between 30-day mortality and contrast reflux to IVC with p value of 0.070.
Conclusions
CTPA measurements including MPA diameter, RV/LV ratio and septal deviation were found to be significantly correlated to ICU admission and 30-day mortality as predictors for PE severity. CT contrast reflux was found to be correlated to ICU admission; however, it was not significantly correlated to 30-day mortality.
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Mazur ES, Mazur VV, Rabinovich RM, Bachurina MA. Clinical and angiopulmonographic association in pulmonary embolism. TERAPEVT ARKH 2021; 93:363-368. [DOI: 10.26442/00403660.2021.04.200674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/01/2021] [Indexed: 12/11/2022]
Abstract
Aim. To detect the effect of the feature of the pulmonary vascular obstruction on the clinical manifestations of pulmonary embolism (PE).
Materials and methods. The 127 patients with PE were included in this study. PE verified with multidetector computed tomography with pulmonary angiography. Among them were 57 patients with high-risk PE, and 39 patients with intermediate-risk PE and 31 patients with low-risk PE. The pulmonary artery obstruction index and the obstruction level were determined.
Results. The mean values of the pulmonary artery obstruction index in high and intermediate risk patients were 42.5%, and in low risk patients 12.5% (p0.001). The trunk or main branches obstruction was in 80.7% of high-risk PE patients, the main or lobar branches obstruction in 92.3% of intermediate-risk patients and lobar or segmental branches obstruction in 93.5% of low-risk patients. Pulmonary infarction was detected in 89.2% of patients with the segmental branches obstruction and with another level of obstruction in 28.0% of patients only (p0.001).
Conclusion. The hemodynamic disorder in pulmonary embolism associate with the pulmonary artery obstruction index of more than 30%. The development of obstructive shock is associated with the pulmonary artery trunk obstruction, and the development of pulmonary infarction associated with the segmental branches obstruction.
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Ozmen C, Deveci OS, Karaaslan MB, Baydar O, Akray A, Deniz A, Cagliyan CE, Hanta I, Usal A. Predictive value of plasma copeptin level for diagnosis and mortality of pulmonary embolism. Rev Assoc Med Bras (1992) 2020; 66:1645-1650. [DOI: 10.1590/1806-9282.66.12.1645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 08/08/2020] [Indexed: 11/22/2022] Open
Abstract
SUMMARY OBJECTIVE: Early diagnosis and risk stratification may provide a better prognosis in pulmonary embolism (PE). Copeptin has emerged as a valuable predictive biomarker in various cardiovascular diseases. The aim of this study was to determine the levels of copeptin in patients with acute PE and to evaluate its relationship with disease severity and PE-related death. METHODS: Fifty-four patients and 60 healthy individuals were included in this study. Copeptin concentrations and right ventricular dysfunction were analyzed. The correlation between copeptin levels and hemodynamic and echocardiographic parameters was examined. After these first measurements, patients were evaluated with PE-related mortality at the one-year follow-up. RESULTS: The copeptin levels were higher in PE patients than in the control group (8.3 ng/mL vs 3.8 ng/mL, p<0.001). Copeptin levels were found to be significantly higher in patients with PE-related death and right ventricular dysfunction (10.2 vs 7.5 ng/ml, p=0.001; 10.5 vs 7.5 ng/ml, p=0.002, respectively). When the cut-off value of copeptin was ≥5.85, its sensitivity and specificity for predicting PE were 71.9% and 85.0%, respectively (AUC=0.762, 95% CI=0.635-0.889, p<0.001). CONCLUSIONS: The copeptin measurement had moderate sensitivity and specificity in predicting the diagnosis of PE, and the copeptin level was significantly higher in patients with PE-related death at the one-year follow-up. Copeptin may be a useful new biomarker in predicting diagnosis, risk stratification, and prognosis of PE.
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Affiliation(s)
| | | | | | - Oya Baydar
- Cukurova University Faculty of Medicine, Turkey
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Right ventricular dysfunction is superior and sufficient for risk stratification by a pulmonary embolism response team. J Thromb Thrombolysis 2020; 49:34-41. [PMID: 31375993 DOI: 10.1007/s11239-019-01922-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Several risk stratification tools are available to predict short-term mortality in patients with acute pulmonary embolism (PE). The presence of right ventricular (RV) dysfunction is an independent predictor of mortality and may be a more efficient way to stratify risk for patients assessed by a Pulmonary Embolism Response Team (PERT). We evaluated 571 patients presenting with acute PE, then stratified them by the pulmonary embolism severity index (PESI), by the BOVA score, or categorically as low risk (no RV dysfunction by imaging), intermediate risk/submassive (RV dysfunction by imaging), or high risk/massive PE (RV dysfunction with sustained hypotension). Using imaging data to firstly define the presence of RV strain, and plasma cardiac biomarkers as additional evidence for myocardial dysfunction, we evaluated whether PESI, BOVA, or RV strain by imaging were more appropriate for determining patient risk by a PERT where rapid decision making is important. Cardiac biomarkers poorly distinguished between PESI classes and BOVA stages in patients with acute PE. Cardiac TnT and NT-proBNP easily distinguished low risk from submassive PE with an area under the curve (AUC) of 0.84 (95% CI 0.73-0.95, p < 0.0001), and 0.88 (95% CI 0.79-0.97, p < 0.0001), respectively. Cardiac TnT and NT-proBNP easily distinguished low risk from massive PE with an area under the curve (AUC) of 0.89 (95% CI 0.78-1.00, p < 0.0001), and 0.89 (95% CI 0.82-0.95, p < 0.0001), respectively. In patients with RV dysfunction, the predicted short-term mortality by PESI score or BOVA stage was lower than the observed mortality by a two-fold order of magnitude. The presence of RV dysfunction alone in the context of acute PE is sufficient for the purposes of risk stratification. More complicated risk stratification tools which require the consideration of multiple clinical variables may under-estimate short-term mortality risk.
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Correlation of thrombosed vessel location and clot burden score with severity of disease and risk stratification in patients with acute pulmonary embolism. Anatol J Cardiol 2020; 24:247-253. [PMID: 33001050 PMCID: PMC7585957 DOI: 10.14744/anatoljcardiol.2020.55013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: Computed tomography pulmonary angiography (CTPA) is used for the main diagnosis in acute pulmonary embolism (APE). Determining the thrombus location in the pulmonary vascular tree is also important for predicting disease severity. This study aimed to analyze the correlation of the thrombus location and the clot burden with the disease severity and the risk stratification in patients with APE. Methods: The study included patients with APE diagnosed by CTPA who were admitted to the hospital between January 28, 2016, and July 1, 2019. Data collected were markers of severity in APE, including patient demographics, comorbidities, length of hospital stay, pulmonary embolism severity index (PESI) score, modified PESI score, Wells score, risk stratification according to the American Heart Association, systolic blood pressure (SBP), right ventricle diameter to left ventricle diameter ratio, pulmonary arterial pressure, brain natriuretic peptide, troponin, D-dimer, and plasma lactate levels, and vessel location of the thrombus, clot burden score, ratio of the pulmonary artery trunk diameter/aortic diameter, superior vena cava diameter (SVC) by CTPA, and survival. All parameters were analyzed in correlation with clot load and vessel location. Results: Thrombus vascular location was found to be correlated with risk stratification and negatively correlated with SBP. Simplified Mastora score was correlated with risk stratification, SVC diameter, and D-dimer and negatively correlated with SBP. Occlusion of both the pulmonary artery trunk and any pulmonary artery with thrombus was associated with massive APE. Conclusion: The level of the occluded vessel on CTPA may provide the ability to risk-stratify, and the clot burden score may be used for assessing both risk stratification and cardiac strain.
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Abdelghany EA, Othman AM, Abdelfatah RA, Magdy ME, Abd Elghany HS, Higazi MM. Can alveolar—arterial oxygen gradient predict severity of pulmonary embolism? THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2019. [DOI: 10.4103/ejb.ejb_62_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Cabrini L, Brusasco C, Roasio A, Corradi F, Nardelli P, Filippini M, Cotticelli V, Belletti A, Ferrera L, Antonucci E, Baiardo Redaelli M, Lattuada M, Colombo S, Olper L, Ponzetta G, Ananiadou S, Monti G, Severi L, Maj G, Giardina G, Biondi-Zoccai G, Benedetto U, Gemma M, Cavallero SSM, Hajjar LA, Zangrillo A, Bellomo R, Landoni G. Non-invAsive VentIlation for early General wArd respiraTory failurE (NAVIGATE): A multicenter randomized controlled study. Protocol and statistical analysis plan. Contemp Clin Trials 2019; 78:126-132. [PMID: 30739002 DOI: 10.1016/j.cct.2019.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/31/2019] [Accepted: 02/06/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Few randomized trials have evaluated the use of non-invasive ventilation (NIV) for early acute respiratory failure (ARF) in non-intensive care unit (ICU) wards. The aim of this study is to test the hypothesis that early NIV for mild-moderate ARF in non-ICU wards can prevent development of severe ARF. DESIGN Pragmatic, parallel group, randomized, controlled, multicenter trial. SETTING Non-intensive care wards of tertiary centers. PATIENTS Non-ICU ward patients with mild to moderate ARF without an established indication for NIV. INTERVENTIONS Patients will be randomized to receive or not receive NIV in addition to best available care. MEASUREMENTS AND MAIN RESULTS We will enroll 520 patients, 260 in each group. The primary endpoint of the study will be the development of severe ARF. Secondary endpoints will be 28-day mortality, length of hospital stay, safety of NIV in non-ICU environments, and a composite endpoint of all in-hospital respiratory complications. CONCLUSIONS This trial will help determine whether the early use of NIV in non-ICU wards can prevent progression from mild-moderate ARF to severe ARF.
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Affiliation(s)
- Luca Cabrini
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Claudia Brusasco
- Department of Anesthesia and Intensive Care, EO Ospedali Galliera, Genova, Italy
| | - Agostino Roasio
- Department of Anesthesia and Intensive Care, Ospedale Civile di Asti, Asti, Italy
| | - Francesco Corradi
- Department of Anesthesia and Intensive Care, EO Ospedali Galliera, Genova, Italy; Università degli Studi di Pisa, Pisa, Italy
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Filippini
- Department of Anesthesia and Critical Care Medicine, Spedali Civili, Brescia, Italy
| | | | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Ferrera
- Department of Pneumology, Ospedale Villa Scassi ASL 3 Genovese, Genova, Italy
| | - Elio Antonucci
- Department of Emergency-Urgency Medicine, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Lattuada
- Department of Anesthesia and Intensive Care, EO Ospedali Galliera, Genova, Italy
| | - Sergio Colombo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Olper
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe Ponzetta
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sofia Ananiadou
- Department of Anesthesia and Intensive Care, ASST Cremona, Cremona, Italy
| | - Giacomo Monti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Severi
- Department of Anesthesia and Intensive Care, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | - Giulia Maj
- Department of Anesthesia and Intensive Care, Sant'Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Giuseppe Giardina
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; IRCCS NEUROMED, Pozzilli, IS, Italy
| | - Umberto Benedetto
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, United Kingdom
| | - Marco Gemma
- Department of Anesthesia and Intensive Care - Ospedale Fatebenefratelli (ASST Fatebenefratelli-Sacco), Milan, Italy
| | | | - Ludhmila Abrahao Hajjar
- Department of Cardiopneumology, Heart Institute, Faculty of Medicine, University of Sao Paulo, Hospital Siriolibanes, Sao Paulo, Brazil
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University Milan, Italy
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Hospital, Heidelberg, Melbourne, Australia; Australian and New Zealand Intensive Care Research Center, Monash University, Melbourne, VIC, Australia; School of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University Milan, Italy.
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Peacock WF, Coleman CI, Wells P, Fermann GJ, Wang L, Baser O, Schein J, Crivera C. Clinical and Economic Outcomes in Low-risk Pulmonary Embolism Patients Treated with Rivaroxaban versus Standard of Care. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2019; 6:160-173. [PMID: 32685588 PMCID: PMC7299482 DOI: 10.36469/9936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND Rivaroxaban, a fixed-dose oral direct factor Xa inhibitor, does not require continuous monitoring and thus reduces the hospital stay and economic burden in low-risk pulmonary embolism (LRPE) patients. Study Question: What is the effectiveness of rivaroxaban versus the standard of care (SOC; low-molecular-weight heparin, unfractionated heparin, warfarin) among LRPE patients in the Veterans Health Administration? STUDY DESIGN Adult patients with continuous health plan enrollment for ≥12 months pre- and 3 months post-inpatient PE diagnosis (index date=discharge date) between October 1, 2011-June 30, 2015 and an anticoagulant claim during the index hospitalization were included. MEASURES AND OUTCOMES Patients scoring 0 points on the simplified Pulmonary Embolism Stratification Index were considered low-risk and were stratified into SOC and rivaroxaban cohorts. Propensity score matching (PSM) was used to compare hospital-acquired complications (HACs), PE-related outcomes (recurrent venous thromboembolism, major bleeding, and death), and healthcare utilization and costs between the rivaroxaban and SOC cohorts. RESULTS Among 6746 PE patients, 1918 were low-risk; of these, 73 were prescribed rivaroxaban, 1546 were prescribed SOC, and 299 were prescribed other anticoagulants during the index hospitalization. After 1:3 PSM, 64 rivaroxaban and 192 SOC patients were included. During the index hospitalization, rivaroxaban users (versus SOC) had similar inpatient length of stay (LOS; 7.0 vs 6.7 days, standardized difference [STD]=1.8) but fewer HACs (4.7% vs 10.4%; STD: 21.7). In the 90-day post-discharge period, PE-related outcome rates were similar between the cohorts (all p>0.05). However, rivaroxaban users had fewer outpatient (15.9 vs 20.4; p=0.0002) visits per patient as well as lower inpatient ($765 vs $2,655; p<0.0001), pharmacy ($711 vs $1,086; p=0.0033), and total costs ($6,270 vs $9,671; p=0.0027). CONCLUSIONS LRPE patients prescribed rivaroxaban had similar index LOS and PE-related outcomes, but fewer HACs, and lower total costs than those prescribed SOC.
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Affiliation(s)
| | | | - Phil Wells
- Institution: University of Ottawa and the Ottawa Hospital Research Institute
| | | | - Li Wang
- Institution: STATinMED Research
| | | | - Jeff Schein
- Institution: Janssen Scientific Affairs, LLC
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Villablanca PA, Vlismas PP, Aleksandrovich T, Omondi A, Gupta T, Briceno DF, Garcia MJ, Wiley J. Case report and systematic review of pulmonary embolism mimicking ST-elevation myocardial infarction. Vascular 2018; 27:90-97. [DOI: 10.1177/1708538118791917] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background To study trends in the clinical presentation, electrocardiograms, and diagnostic imaging in patients with pulmonary embolism presenting as ST segment elevation. Methods We performed a systematic literature search for all reported cases of pulmonary embolism mimicking ST-elevation myocardial infarction. Pre-specified data such as clinical presentation, electrocardiogram changes, transthoracic echocardiographic findings, cardiac biomarkers, diagnostic imaging, therapy, and outcomes were collected. Results We identified a total of 34 case reports. There were 23 males. Mean age of the population was 56.5 ± 15.5 years. Patients presented with dyspnea (76.4%), chest pain (63.6%), and tachycardia (71.4%). All patients presented with ST-elevations, with the most common location being in the anterior-septal distribution, lead V3 (74%), V2 (71%), V1 (62%) and V4 (47%). ST-segment elevations in the inferior distribution were present in lead II (12%), III (18%), and aVF (21%). Presentation was least likely in the lateral distribution. Troponin was elevated in 78.9% of cases. Right ventricular strain was the most common echocardiographic finding. Over 80% of patients had findings consistent with elevated right ventricular pressure, with 50% reported RV dilatation and 20% RV hypokinesis. The most commonly used imaging modality was contrast-enhanced pulmonary angiography. There was a greater incidence of bilateral compared to unilateral pulmonary emboli (72.4% vs. 10%). About 65% patients received anticoagulation and 36.3% were treated with thrombolytics. Forty-six percent of patients required intensive care and 18.7% intubation. Overall mortality was 25.8%. Conclusions A review of the literature reveals that in patients presenting with pulmonary embolism, electrocardiogram findings of ST-segment elevations will occur predominantly in the anterior-septal distribution.
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Affiliation(s)
- Pedro A Villablanca
- Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Peter P Vlismas
- Division of Cardiology, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Tatsiana Aleksandrovich
- Department of Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Arthur Omondi
- Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Tanush Gupta
- Division of Cardiology, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - David F Briceno
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mario J Garcia
- Division of Cardiology, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Jose Wiley
- Division of Cardiology, Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
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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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11
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Osman AM, Abdeldayem EH. Value of CT pulmonary angiography to predict short-term outcome in patient with pulmonary embolism. Int J Cardiovasc Imaging 2018; 34:975-983. [PMID: 29349525 DOI: 10.1007/s10554-018-1304-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/15/2018] [Indexed: 01/18/2023]
Abstract
To evaluate the role of CT pulmonary angiography (CTPA) in the assessment of pulmonary embolism (PE) severity and the related CT cardiac changes, reflecting the clinical status of the patients and predicting the outcome. A prospective study of 184 patients presented with suspicious acute PE. All patients underwent CTPA followed by ECHO. Pulmonary artery obstructive index (PAOI) using Qanadli Score was calculated and cardiac changes recorded. The patients' outcome was followed up for 30 days. Only 150 patients completed the study; 26.7% needed ICU admission while 13.3% died during follow-up. There was a significant relationship between the PAOI and the risk classification, right ventricular dysfunction (RVD) diagnosed by ECHO and the patients' short outcome. We found PAOI cut off value 45% for mortality and 35% for ICU admission and 27.5% for RVD with 60, 75 and 90% sensitivity and 80, 73.3 and 68.6% specificity respectively. CT RV/LV ratio was the most sensitive parameter to predict RV dysfunction followed by pulmonary artery diameter. CTPA is not only used for diagnosis but also to assess the severity of PE, the effect on the right ventricular function and subsequently the need for ICU admission and prediction of the outcome.
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Affiliation(s)
- Ahmed M Osman
- Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Emad H Abdeldayem
- Radiology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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12
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Quezada CA, Zamarro C, Gómez V, Guerassimova I, Nieto R, Barbero E, Chiluiza D, Barrios D, Morillo R, Jiménez D. Clinical gestalt versus prognostic scores for prognostication of patients with acute symptomatic pulmonary embolism. Med Clin (Barc) 2017; 151:136-140. [PMID: 29276010 DOI: 10.1016/j.medcli.2017.11.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 10/08/2017] [Accepted: 11/02/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE To determine the accuracy of clinical gestalt to identify patients with acute symptomatic pulmonary embolism (PE) at low-risk for short-term complications. PATIENTS AND METHODS This study included a total of 154 consecutive patients diagnosed with acute symptomatic PE in a tertiary university hospital. We compared the prognostic accuracy of the Pulmonary Embolism Severity Index (PESI), the simplified PESI (sPESI), and clinical gestalt of 1) 2senior physicians (one with and one without experience in the management of patients with PE), 2) a fourth-year resident of Pneumology, 3) a third-year resident of Pneumology, and 4) a second-year resident of Pneumology. The primary outcome was all-cause mortality during the first month after the diagnosis of PE. RESULTS Thirty-day all-cause mortality was 8.4% (13/154; 8.4%; 95% confidence interval [CI], 4.1-12.8%). The PESI and clinical gestalt classified more patients as low-risk, compared to the sPESI (36.4%, 31.3% y 28.6%, respectively). There were no deaths in the sPESI low-risk category (negative predictive value 100%). Prognostic accuracy increased with increasing experience (84.6 vs. 92.3%; P=.049). CONCLUSIONS The sPESI showed the best accuracy at correctly identifying low-risk patients with acute symptomatic PE. Clinical gestalt is not inferior to standardized clinical prediction rules to prognosticate patients with acute PE.
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Affiliation(s)
| | - Celia Zamarro
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Vicente Gómez
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Ina Guerassimova
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Rosa Nieto
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Esther Barbero
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Diana Chiluiza
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Deisy Barrios
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Raquel Morillo
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - David Jiménez
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España; IRYCIS, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, España; Facultad de Medicina, Universidad de Alcalá, Madrid, España.
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13
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Cheta J, Long A, Marik P. Use of Tachycardia in Patients With Submassive Pulmonary Emboli to Risk Stratify for Early Initiation of Thrombolytic Therapy: A Case Series Comparing Early Versus Late Thrombolytic Initiation. J Investig Med High Impact Case Rep 2017; 5:2324709617744232. [PMID: 29276710 PMCID: PMC5734466 DOI: 10.1177/2324709617744232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 10/04/2017] [Accepted: 10/31/2017] [Indexed: 11/15/2022] Open
Abstract
Pulmonary embolism (PE) represents a prevalent cause of morbidity and mortality in the United States, with approximately 600 000 cases diagnosed annually. The mortality rate for untreated PE is as high as 30%. Right ventricular (RV) dysfunction is a sign of possible adverse outcomes with right-sided heart failure being the usual cause of death from PE. There is a spectrum of clinical presentations associated with PE diagnoses, from incidental and asymptomatic to rapid hemodynamic collapse. Despite successes in identifying patients with "high-risk" PEs for aggressive thrombolytic interventions and "low-risk" PEs for outpatient anticoagulation, a significant lack of consensus exists regarding intervention modalities for PEs identified as "intermediate risk" or "submassive," defined as normotensive (systolic blood pressure ≥90 mm Hg) with acute RV dysfunction and myocardial injury. In this case series, we review the management and outcomes of 2 patients with submassive PEs and sustained tachycardia in the setting of normal blood pressures, and we address the need to recognize tachycardia as an ominous RV compensatory sign, indicative of impending hemodynamic collapse, that should lead to aggressive therapy with vascular intervention.
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Affiliation(s)
| | | | - Paul Marik
- Eastern Virginia Medical School, Norfolk, VA, USA
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14
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Wang L, Baser O, Wells P, Peacock WF, Coleman CI, Fermann GJ, Schein J, Crivera C. Benefit of early discharge among patients with low-risk pulmonary embolism. PLoS One 2017; 12:e0185022. [PMID: 29016692 PMCID: PMC5634547 DOI: 10.1371/journal.pone.0185022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/04/2017] [Indexed: 12/20/2022] Open
Abstract
Clinical guidelines recommend early discharge of patients with low-risk pulmonary embolism (LRPE). This study measured the overall impact of early discharge of LRPE patients on clinical outcomes and costs in the Veterans Health Administration population. Adult patients with ≥1 inpatient diagnosis for pulmonary embolism (PE) (index date) between 10/2011-06/2015, continuous enrollment for ≥12 months pre- and 3 months post-index date were included. PE risk stratification was performed using the simplified Pulmonary Embolism Stratification Index. Propensity score matching (PSM) was used to compare 90-day adverse PE events (APEs) [recurrent venous thromboembolism, major bleed and death], hospital-acquired complications (HACs), healthcare utilization, and costs among short (≤2 days) versus long length of stay (LOS). Net clinical benefit was defined as 1 minus the combined rate of APE and HAC. Among 6,746 PE patients, 95.4% were men, 22.0% were African American, and 1,918 had LRPE. Among LRPE patients, only 688 had a short LOS. After 1:1 PSM, there were no differences in APE, but short LOS had fewer HAC (1.5% vs 13.3%, 95% CI: 3.77–19.94) and bacterial pneumonias (5.9% vs 11.7%, 95% CI: 1.24–3.23), resulting in better net clinical benefit (86.9% vs 78.3%, 95% CI: 0.84–0.96). Among long LOS patients, HACs (52) exceeded APEs (14 recurrent DVT, 5 bleeds). Short LOS incurred lower inpatient ($2,164 vs $5,100, 95% CI: $646.8-$5225.0) and total costs ($9,056 vs $12,544, 95% CI: $636.6-$6337.7). LRPE patients with short LOS had better net clinical outcomes at lower costs than matched LRPE patients with long LOS.
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Affiliation(s)
- Li Wang
- STATinMED Research, Plano, Texas, United States of America
- * E-mail:
| | - Onur Baser
- STATinMED Research, Plano, Texas, United States of America
- Center for Innovation & Outcomes Research, Department of Surgery, Columbia University and STATinMED Research, New York, New York, United States of America
- MEF University, Department of Economics, Istanbul, Turkey
| | - Phil Wells
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - W. Frank Peacock
- Emergency Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Craig I. Coleman
- School of Pharmacy, University of Connecticut, Hartford, Connecticut, United States of America
| | - Gregory J. Fermann
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Jeff Schein
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, United States of America
| | - Concetta Crivera
- Janssen Scientific Affairs, LLC, Titusville, New Jersey, United States of America
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15
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Adibi A, Nouri S, Moradi M, Shahabi J. Clinical and echocardiographic findings of patients with suspected acute pulmonary thromboembolism who underwent computed tomography pulmonary angiography. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2017; 21:118. [PMID: 28255326 PMCID: PMC5331763 DOI: 10.4103/1735-1995.193509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/01/2016] [Accepted: 08/20/2016] [Indexed: 11/04/2022]
Abstract
Background: The aim of the study was to determine the correlation between clinical and echocardiographic findings and risk factors of patients with suspected acute pulmonary thromboembolism (PTE) who underwent computed tomography pulmonary angiography (CTPA). Materials and Methods: In this cross-sectional study, 310 hospitalized patients aged >18 years with high clinical suspicion of PTE referred to imaging center of our hospital from different wards for CTPA were enrolled. The frequency of different clinical presentations, risk factors, items of Wells’ criteria, and echocardiographic findings was compared in patients with and without PTE, which have been diagnosed according to the CTPA results. Results: PTE was diagnosed in 53 (17.1%) of patients with suspected PTE. From clinical manifestations, tachypnea, pleuritic chest pain, and edema of lower extremities were significantly more frequent among patients with PTE (P < 0.05). Major surgery was the risk factor which was significantly more prevalent among patients with PTE (P < 0.05). Frequency of all criteria of Wells’ criteria, except hemoptysis, was significantly higher in patients with PTE (P < 0.05). The frequency of all studied echocardiographic variables was significantly higher in patients with PTE (P < 0.05). Conclusion: It is suggested that we could use the results of this study for utilizing the diagnostic process of PTE in patients with highly clinical suspicion of PTE and providing more validated decision. Using the results of this study, we could identify high-risk patients and made appropriate risk assessment for better management of patients with suspected PTE as well as reduce the rate of unnecessary CTPA and its related adverse consequences.
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Affiliation(s)
- Atoosa Adibi
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shadi Nouri
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Moradi
- Department of Radiology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Javad Shahabi
- Department of Cardiology, Isfahan University of Medical Sciences, Isfahan, Iran
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16
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Doğan H, de Roos A, Geleijins J, Huisman MV, Kroft LJM. The role of computed tomography in the diagnosis of acute and chronic pulmonary embolism. Diagn Interv Radiol 2016; 21:307-16. [PMID: 26133321 DOI: 10.5152/dir.2015.14403] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pulmonary embolism (PE) is a potentially life threatening condition requiring adequate diagnosis and treatment. Computed tomography pulmonary angiography (CTPA) is excellent for including and excluding PE, therefore CT is the first-choice diagnostic imaging technique in patients suspected of having acute PE. Due to its wide availability and low invasiveness, CTPA tends to be overused. Correct implementation of clinical decision rules in diagnostic workup for PE improves adequate use of CT. Also, CT adds prognostic value by evaluating right ventricular (RV) function. CT-assessed RV dysfunction and to lesser extent central emboli location predicts PE-related mortality in normotensive and hypotensive patients, while PE embolic obstruction index has limited prognostic value. Simple RV/left ventricular (LV) diameter ratio measures >1.0 already predict risk for adverse outcome, whereas ratios <1.0 can safely exclude adverse outcome. Consequently, assessing the RV/LV diameter ratio may help identify patients who are potential candidates for treatment at home instead of treatment in the hospital. A minority of patients develop chronic thromboembolic pulmonary hypertension (CTEPH) following acute PE, which is a life-threatening condition that can be diagnosed by CT. In proximal CTEPH, involving the more central pulmonary arteries, thrombectomy usually results in good outcome in terms of both functional status and long-term survival rate. CT is becoming the imaging method of choice for diagnosing CTEPH as it can identify patients who may benefit from thrombectomy. New CT developments such as distensibility measurements and dual-energy or subtraction techniques may further refine diagnosis and prognosis for improved patient care.
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Affiliation(s)
- Halil Doğan
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.
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17
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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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18
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Lilje C, Chauhan A, Turner JP, Carson TH, Velez MC, Arcement C, Caspi J. Pediatric Pulmonary Embolism: Diagnostic and Management Challenges. World J Pediatr Congenit Heart Surg 2016; 9:110-113. [PMID: 27619327 DOI: 10.1177/2150135116663698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A rare case of massive pulmonary embolism is presented in an oligosymptomatic teenager with predisposing factors. Computed tomography pulmonary angiography supported by three-dimensional reconstruction was diagnostic. The embolus qualified as massive by conventional anatomical guidelines, but as low risk by more recent functional criteria. Functional assessment has complemented morphologic assessment for risk stratification in adult patients. Such evidence is scarce in pediatrics. The patient underwent surgical embolectomy, followed by prophylactic anticoagulation, without further events. Diagnostic and management challenges are discussed.
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Affiliation(s)
- Christian Lilje
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Aman Chauhan
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Jason P Turner
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Thomas H Carson
- 2 Department of Pathology, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
| | - Maria C Velez
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Christopher Arcement
- 3 Department of Radiology, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Joseph Caspi
- 4 Department of Surgery, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
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19
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Keller K, Geyer M, Coldewey M, Beule J, Balzer JO, Dippold W. Elevated systolic pulmonary artery pressure for prediction of myocardial necrosis and right ventricular dysfunction in acute pulmonary embolism. COR ET VASA 2016. [DOI: 10.1016/j.crvasa.2015.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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20
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Utilization and Safety of a Pulmonary Embolism Treatment Protocol in an Emergency Department Observation Unit. Crit Pathw Cardiol 2016. [PMID: 26214810 DOI: 10.1097/hpc.0000000000000046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Pulmonary embolism (PE) is a common disease in emergency medicine and treatment approaches vary greatly. Emergency department observation units (EDOUs) have provided the opportunity to complete a PE workup, initiate treatment, and arrange appropriate follow-up for low-risk patients. OBJECTIVE We sought to evaluate the utilization and safety of a treatment protocol for low-risk PE in an EDOU. METHODS A prospective evaluation was performed in our EDOU for the treatment of low-risk PE between December 1, 2010 and May 31, 2012. The PE treatment protocol included telemetry monitoring, initiation of anticoagulation, performance of an echocardiogram, bilateral lower extremity duplex ultrasound, and consultation by the hospital's thrombosis service to arrange outpatient follow-up. The primary outcome measure was inpatient admission and any complications during the EDOU stay or during a 30-day follow-up period. RESULTS Twelve patients were assigned to the EDOU for the PE treatment protocol during the 18-month study period. Six patients (50%) were admitted to an inpatient unit following the EDOU stay. Reasons for inpatient admission included hypoxia/worsening dyspnea (2), right ventricular strain on echocardiogram (1), large clot burden on duplex ultrasound (1), and lack of availability of testing/thrombosis service consultation during the EDOU stay (2). There were no adverse events in the EDOU. All patients reported compliance with outpatient follow-up, and none of the patients reported hospitalization or adverse events during the 30-day follow-up period. Utilization of the PE treatment protocol in our EDOU was surprisingly low (<1 patient/month), possibly because of provider awareness of the protocol. CONCLUSIONS Although the overall inpatient admission rate from the EDOU was high, some of these cases related to logistical issues rather than medical concerns or complications. Further evaluation of an EDOU PE protocol may continue to demonstrate the safety and efficiency of this approach when compared with inpatient admission.
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21
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Fan Y, Huang H, Xiong J, Yang M, Kong B, Liao JF, He WW, Wang ZQ. Comparison of efficacy of different treatments for pulmonary embolism. JOURNAL OF HUAZHONG UNIVERSITY OF SCIENCE AND TECHNOLOGY. MEDICAL SCIENCES = HUA ZHONG KE JI DA XUE XUE BAO. YI XUE YING DE WEN BAN = HUAZHONG KEJI DAXUE XUEBAO. YIXUE YINGDEWEN BAN 2016; 36:254-258. [PMID: 27072972 DOI: 10.1007/s11596-016-1576-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 03/17/2016] [Indexed: 01/21/2023]
Abstract
An optimal therapy for pulmonary embolism (PE) was explored by comparing three different methods in order to alleviate the sufferings of PE patients and reduce the mortality. Eighty patients with PE diagnosed by computed tomography angiography (CTA) were treated with thrombolysis, anticoagulation only, or surgery/intervention. The clinical efficacy of different treatments were compared and analyzed. Twenty-four out of the 26 patients (92%) in anticoagulation only group showed improvement in CTA and clinical presentations, which was significantly higher than that in the thrombolysis group (87%, n=39, P<0.05). However, there was no significant difference in the rate of mortality between thrombolysis group and anticoagulation only group. In the surgery/interventional group (n=15), the success rate was 47%, and the mortality rate was 14%. Both of them were significantly different from those in thrombolysis and anticoagulation only groups (both P<0.05). Log-rank analysis of the data of 5-year follow-up revealed that the survival time in surgery/intervention group was significantly shorter than in the other two groups (P<0.05). It was suggested that it is of importance to choose the appropriate therapeutic regimen for PE patients. Mortality may be reduced and prognosis may be improved with anticoagulation only and thrombolysis therapy.
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Affiliation(s)
- Yang Fan
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Hubei Key Laboratory of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - He Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China.
- Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, 430060, China.
- Hubei Key Laboratory of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China.
| | - Jun Xiong
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Hubei Key Laboratory of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Mei Yang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Hubei Key Laboratory of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Bin Kong
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Hubei Key Laboratory of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Jia-Fen Liao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Hubei Key Laboratory of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Wang-Wei He
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Hubei Key Laboratory of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Zhi-Qiang Wang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Hubei Key Laboratory of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
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Keller K, Beule J, Balzer JO, Dippold W. Syncope and collapse in acute pulmonary embolism. Am J Emerg Med 2016; 34:1251-7. [PMID: 27107684 DOI: 10.1016/j.ajem.2016.03.061] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 03/26/2016] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Syncope and collapse (=presyncope) are 2 symptoms of pulmonary embolism (PE), which are suspected of being connected with poorer outcome, regardless of haemodynamic instability. However, pathomechanisms are not completely understood. We aimed to investigate these pathomechanisms in regard to blood pressure and heart rate of syncope/collapse in PE. METHODS We performed a retrospective study of consecutive PE patients, who were treated in the Internal Medicine Department. Patients with and without syncope/collapse were compared. Regression models for associations between syncope/collapse and blood pressure, heart rate and shock index (SI) were computed. Moreover we calculated ROC analyses and Youden indices for effectiveness and cut-off-values of these parameters for the probability of syncope/collapse. RESULTS 182 patients (mean-age 68.5±15.3years; 61.5% female) with confirmed PE were included in this study. 20 PE patients (11.0%) showed a syncope/collapse. PE patients with syncope/collapse were in median 7.5years older (78.5 (72.0/82.3) vs. 71.0 (61.0/80.0) years, P=.0575), had lower systolic (132.0 (108.8/154.0) vs. 145.5 (127.0/166.0) mmHg, P=.0845) and diastolic (70.0±27.0 vs. 78.4±18.4mmHg, P=.0740) blood pressure, whereas heart rate (103.5 (87.8/116.0) vs. 90.0 (76.0/102.0)beats/min, P=.0518), SI (0.78 (0.65/1.01) vs. 0.60(0.50/0.79), P=.0127) and frequency of right ventricular dysfunction (RVD) (88.2% vs. 55.8%, P=.0294) were higher in PE patients with syncope/collapse than in those without. Hypotension (systolic blood pressure<90mmHg), tachycardia and SI>1.0were connected with 6.4-fold, 2.5-fold and 5.8-fold higher probability of syncope/collapse, respectively. ROC analyses revealed cut-off values of ≤110mmHg, ≥107beats/min and >0.62 for systolic blood pressure, heart rate and SI with low AUC values, respectively. CONCLUSIONS The pathomechanism of syncope/collapse in patients with acute PE seems to be connected with blood pressure fall, heart rate increase and RVD, in terms of cardiovascular syncope with reduced cardiac output and vasovagal reflex.
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Affiliation(s)
- Karsten Keller
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany; Center of Cardiology, Department of Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany.
| | - Johannes Beule
- Department of internal medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM), Mainz, Germany
| | - Jörn Oliver Balzer
- Department of Radiology and Nuclear medicine, Catholic Clinic Mainz (KKM), Mainz, Germany; Department of Diagnostic and Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt, Main, Frankfurt, Germany
| | - Wolfgang Dippold
- Department of internal medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM), Mainz, Germany
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Bach AG, Taute BM, Baasai N, Wienke A, Meyer HJ, Schramm D, Surov A. 30-Day Mortality in Acute Pulmonary Embolism: Prognostic Value of Clinical Scores and Anamnestic Features. PLoS One 2016; 11:e0148728. [PMID: 26866472 PMCID: PMC4750907 DOI: 10.1371/journal.pone.0148728] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 01/01/2016] [Indexed: 12/03/2022] Open
Abstract
Purpose Identification of high-risk patients with pulmonary embolism is vital. The aim of the present study was to examine clinical scores, their single items, and anamnestic features in their ability to predict 30-day mortality. Materials and Methods A retrospective, single-center study from 06/2005 to 01/2010 was performed. Inclusion criteria were presence of pulmonary embolism, availability of patient records and 30-day follow-up. The following clinical scores were calculated: Acute Physiology and Chronic Health Evaluation II, original and simplified pulmonary embolism severity index, Glasgow Coma Scale, and euroSCORE II. Results In the study group of 365 patients 39 patients (10.7%) died within 30 days due to pulmonary embolism. From all examined scores and parameters the best predictor of 30-day mortality were the Glasgow Coma scale (≤ 10) and parameters of the circulatory system including presence of mechanical ventilation, arterial pH (< 7.335), and systolic blood pressure (< 99 mm Hg). Conclusions Easy to ascertain circulatory parameters have the same or higher prognostic value than the clinical scores that were applied in this study. From all clinical scores studied the Glasgow Coma Scale was the most time- and cost-efficient one.
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Affiliation(s)
- Andreas Gunter Bach
- Department of Radiology, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120 Halle, Germany
| | - Bettina-Maria Taute
- Department of Internal Medicine, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120 Halle, Germany
| | - Nansalmaa Baasai
- Department of Radiology, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120 Halle, Germany
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biostatistics and Informatics; Martin-Luther-University Halle-Wittenberg, Magdeburger-Str. 8, 06112 Halle, Germany
| | - Hans Jonas Meyer
- Department of Radiology, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120 Halle, Germany
| | - Dominik Schramm
- Department of Radiology, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120 Halle, Germany
| | - Alexey Surov
- Department of Radiology, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120 Halle, Germany
- * E-mail:
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Cimsit NC, Cimsit C, Onaygil C, Kuzan TY. Correlation of clot distribution with morphometric measurements and pleuroparenchymal findings in acute pulmonary embolism: experience with 692 cases. Clin Imaging 2015; 39:1012-7. [DOI: 10.1016/j.clinimag.2015.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/19/2015] [Accepted: 07/06/2015] [Indexed: 11/27/2022]
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Keller K, Geyer M, Beule J, Coldewey M, Balzer JO, Dippold W. Impact of cancer on the effectiveness of cardiac Troponin I to predict right ventricular dysfunction in acute pulmonary embolism. Thorac Cancer 2015; 6:584-8. [PMID: 26443088 PMCID: PMC4567003 DOI: 10.1111/1759-7714.12226] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 12/11/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Deep vein thrombosis (DVT) and pulmonary embolism (PE) are connected with a poor outcome in cancer patients. We aimed to investigate the impact of cancer on the effectiveness of cardiac Troponin I (cTnI) to predict right ventricular dysfunction (RVD) in acute PE. METHODS We retrospectively analyzed the data of 182 patients with confirmed PE. PE patients were subdivided into two groups: (i) with concomitant active cancer disease or history of cancer, and (ii) without known cancer. Receiver operating characteristic (ROC) curves with area under the curve (AUC) was calculated for cTnI predicting RVD and related cut-off levels for both groups. RESULTS Thirty-seven PE patients (20.3%) had an active cancer disease or a history of cancer. In contrast, 145 (79.7%) of the included PE patients did not have a known cancer disease or a history of cancer. In the PE group with cancer, analysis of the ROC curve showed an AUC of 0.76 for cTnI predicting RVD with an optimal cut-off value of 0.04 ng/mL; the risk of misclassification was 25.0%. In the PE group without cancer, AUC was 0.81 for cTnI predicting RVD with an optimal cut-off value of 0.015 ng/mL; the risk of misclassification was 24.9%. CONCLUSIONS cTnI is effective for predicting RVD in PE patients with and without cancer. However, the effectiveness of cTnI to predict RVD was higher in PE patients without cancer than in those with cancer or a history of cancer.
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Affiliation(s)
- Karsten Keller
- Department of Medicine II, University Medical Center Mainz, Johannes Gutenberg-University MainzMainz, Germany
- Center for thrombosis and hemostasis, University Medical Center Mainz, Johannes Gutenberg-University MainzMainz, Germany
| | - Martin Geyer
- Department of Medicine II, University Medical Center Mainz, Johannes Gutenberg-University MainzMainz, Germany
| | - Johannes Beule
- Department of internal medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM)Mainz, Germany
| | - Meike Coldewey
- Department of Medicine II, University Medical Center Mainz, Johannes Gutenberg-University MainzMainz, Germany
- Center for thrombosis and hemostasis, University Medical Center Mainz, Johannes Gutenberg-University MainzMainz, Germany
| | - Jörn Oliver Balzer
- Department of Radiology and Nuclear medicine, Catholic Clinic Mainz (KKM)Mainz, Germany
- Department of Diagnostic and Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/MainMainz, Germany
| | - Wolfgang Dippold
- Department of internal medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM)Mainz, Germany
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Keller K, Beule J, Coldewey M, Dippold W, Balzer JO. Heart rate in pulmonary embolism. Intern Emerg Med 2015; 10:663-9. [PMID: 25633234 DOI: 10.1007/s11739-015-1198-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 01/16/2015] [Indexed: 01/07/2023]
Abstract
Heart rate is a rapidly available risk stratification parameter in acute pulmonary embolism (PE). We aimed to investigate the effectiveness of heart rate in predicting the outcome in acute PE. Data of 182 patients with acute PE were analysed retrospectively. Logistic regression models were calculated to investigate the associations between heart rate and in-hospital death, myocardial necrosis, PE status and presence of right ventricular dysfunction (RVD), respectively. ROC curve and cut-off values for heart rate predicting RVD as well as intermediate risk PE status in normotensive PE patients and for heart rate predicting in-hospital death and myocardial necrosis in all PE patients were calculated. ROC analysis for heart rate predicting RVD and intermediate risk PE were 0.706 and 0.718, respectively, with cut-off value of 86 beats/min. Regression models showed associations between heart rate >85 beats/min and both RVD (OR 4.871, 95 % CI 2.256-10.515, P = 0.000055) and intermediate risk PE (OR 5.244, 95 % CI 2.418-11.377, P = 0.000027). In hemodynamically stable and unstable PE patients, logistic regression models showed a borderline significant association between tachycardia and in-hospital death (OR 7.066, 95 % CI 0.764-65.292, P = 0.0849) and a significant association between heart rate and myocardial necrosis (OR 0.975, 95 % CI 0.959-0.991, P = 0.00203). ROC analysis for heart rate predicting in-hospital death and myocardial necrosis revealed AUC of 0.655 and 0.703 with heart rate cut-off values of 99.5 beats/min and 92.5 beats/min, respectively. An elevated heart rate in acute PE is connected with a worse outcome. Effectiveness in the prediction of RVD, intermediate PE status, cardiac injury and in-hospital death is acceptable. The cut-off value for the prediction of RVD and intermediate risk PE status in normotensive PE is 86 beats/min, while tachycardia predicts in-hospital death.
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Affiliation(s)
- Karsten Keller
- Department of Medicine II, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany,
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Keller K, Beule J, Coldewey M, Geyer M, Balzer JO, Dippold W. The risk factor age in normotensive patients with pulmonary embolism: Effectiveness of age in predicting submassive pulmonary embolism, cardiac injury, right ventricular dysfunction and elevated systolic pulmonary artery pressure in normotensive pulmonary embolism patients. Exp Gerontol 2015; 69:116-21. [PMID: 25981740 DOI: 10.1016/j.exger.2015.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 03/20/2015] [Accepted: 05/13/2015] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Right ventricular dysfunction (RVD), submassive pulmonary embolism (PE), elevated systolic pulmonary artery pressure (sPAP), elevated cardiac troponin I (cTnI) and old age are well-known risk factors for poor outcome in acute normotensive PE. The aim of this analysis was to calculate age cut-off values to predict submassive PE, cardiac injury, RVD and elevated sPAP in normotensive PE patients. METHODS Retrospective analysis of clinical, laboratory, radiological and echocardiographic data of normotensive PE patients (2006-2011) was performed. Receiver operating characteristic (ROC) curves and Youden indexes were used to test the effectiveness of using patients' ages at the PE event to predict a submassive PE, cardiac injury (elevated cTnI >0.1ng/ml), RVD and elevated sPAP (>30mmHg) in normotensive PE patients and to calculate optimal cut-off values. Patients >76years were compared to those aged ≤76years. RESULTS 129 normotensive PE patients (59.7% women) met the inclusion criteria and were included in this analysis. The optimal cut-off value for patient ages to predict submassive PE, cardiac injury (elevated cTnI >0.1ng/ml), RVD and elevated sPAP (>30mmHg) was 76.5, 81.5, 66.5 and 66.5years, respectively, with moderate effectiveness (AUC 0.69, 0.58, 0.71 and 0.69, respectively). Patients >76years old had higher percentages of submassive PE (91.1% vs. 63.1%, P=0.000680), RVD (91.1% vs. 58.3%, P=0.000119), sPAP (42.64±16.70 vs. 29.24±17.56mmHg, P=0.000044) and cTnI (0.22±0.40 vs. 0.10±0.25ng/ml, P=0.00488). CONCLUSIONS Age is an important prognostic factor in acute normotensive PE. In addition to cTn and RVD, age should be taken into account in determining the risk stratification for acute PE.
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Affiliation(s)
- Karsten Keller
- Department of Medicine II, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany; Centrum for Thrombosis and Haemostasis, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany.
| | - Johannes Beule
- Department of Internal Medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM), Germany
| | - Meike Coldewey
- Department of Medicine II, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany; Centrum for Thrombosis and Haemostasis, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany
| | - Martin Geyer
- Department of Medicine II, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany
| | - Jörn Oliver Balzer
- Department of Radiology and Nuclear Medicine, Catholic Clinic Mainz (KKM), Germany; Department of Diagnostic and Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
| | - Wolfgang Dippold
- Department of Internal Medicine, St. Vincenz and Elisabeth Hospital Mainz (KKM), Germany
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Khemasuwan D, Yingchoncharoen T, Tunsupon P, Kusunose K, Moghekar A, Klein A, Tonelli AR. Right Ventricular Echocardiographic Parameters Are Associated with Mortality after Acute Pulmonary Embolism. J Am Soc Echocardiogr 2015; 28:355-62. [DOI: 10.1016/j.echo.2014.11.012] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Indexed: 11/26/2022]
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CT pulmonary angiography findings that predict 30-day mortality in patients with acute pulmonary embolism. Eur J Radiol 2015; 84:332-7. [DOI: 10.1016/j.ejrad.2014.11.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 11/07/2014] [Accepted: 11/11/2014] [Indexed: 10/24/2022]
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Keller K, Beule J, Schulz A, Coldewey M, Dippold W, Balzer JO. Cardiac troponin I for predicting right ventricular dysfunction and intermediate risk in patients with normotensive pulmonary embolism. Neth Heart J 2014; 23:55-61. [PMID: 25501268 PMCID: PMC4268209 DOI: 10.1007/s12471-014-0628-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Right ventricular dysfunction (RVD) and cardiac troponin I (cTnI) are important tools for risk stratification in pulmonary embolism (PE). We investigate the association of RVD and cTnI in normotensive PE patients and calculate a cTnI cut-off level for predicting RVD and submassive PE. Methods Clinical, laboratory, radiological and echocardiagraphic data were analysed. Patients were categorised into groups with or without RVD and compared focussing on cTnI. Effectiveness of cTnI for predicting RVD and submassive PE was tested. Results One hundred twenty-nine normotensive PE patients, 71 with and 58 without RVD, were included. Patients with RVD were older (75.0 years (61.3/81.0) vs. 66.0 years (57.7/75.1), P = 0.019). cTnI (0.06 ng/ml (0.02/0.23) vs. 0.01 ng/ml (0.00/0.03), P < 0.0001) and D-dimer values (2.00 mg/l (1.08/4.05) vs. 1.23 mg/l (0.76/2.26), P = 0.016) were higher in PE with RVD. cTnI was associated with RVD (OR 3.95; 95 % CI 1.95–8.02, p = 0.00014). AUC for cTnI diagnosing RVD was 0.79, and for submassive PE0.87. Cut-off values for cTnI predicting RVD and submassive PE were 0.01 ng/ml, with a negative predictive value of 73 %. cTnI was positively correlated with age, D-dimer and creatinine. Conclusions In normotensive PE patients, cTnI is helpful for risk stratification and excluding RVD. cTnI elevation is correlated with increasing age and reduced kidney function.
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Affiliation(s)
- K Keller
- Department of Medicine II, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Langenbeckstr. 1, 55131, Mainz, Germany,
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A single imaging modality in the diagnosis, severity, and prognosis of pulmonary embolism. BIOMED RESEARCH INTERNATIONAL 2014; 2014:470295. [PMID: 25580432 PMCID: PMC4279180 DOI: 10.1155/2014/470295] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 09/09/2014] [Indexed: 01/19/2023]
Abstract
Introduction. This study aimed to investigate the currency of computerized tomography pulmonary angiography-based parameters as pulmonary artery obstruction index (PAOI), as well as right ventricular diameters for pulmonary embolism (PE) risk evaluation and prediction of mortality and intensive care unit (ICU) requirement. Materials and Methods. The study retrospectively enrolled 203 patients hospitalized with acute PE. PAOI was calculated according to Qanadli score. Results. Forty-three patients (23.9%) were hospitalized in the ICU. Nineteen patients (10.6%) died during the 30-day follow-up period. The optimal cutoff value of PAOI for PE 30th day mortality and ICU requirement were found as 36.5% in ROC curve analysis. The pulmonary artery systolic pressure had a significant positive correlation with right/left ventricular diameter ratio (r = 0.531, P < 0.001), PAOI (r = 0.296, P < 0.001), and pulmonary artery diameter (r = 0.659, P < 0.001). The patients with PAOI values higher than 36.5% have a 5.7-times increased risk of death. Conclusion. PAOI is a fast and promising parameter for risk assessment in patients with acute PE. With greater education of clinicians in this radiological scoring, a rapid assessment for diagnosis, clinical risk evaluation, and prognosis may be possible in emergency services without the need for echocardiography.
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Keller K, Beule J, Coldewey M, Dippold W, Balzer JO. Impact of advanced age on the severity of normotensive pulmonary embolism. Heart Vessels 2014; 30:647-56. [DOI: 10.1007/s00380-014-0533-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 05/30/2014] [Indexed: 11/30/2022]
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Verschuren F, Bonnet M, Benoit MO, Gruson D, Zech F, Couturaud F, Meneveau N, Roy PM, Righini M, Meyer G, Sanchez O. The prognostic value of pro-B-Type natriuretic peptide in acute pulmonary embolism. Thromb Res 2013; 131:e235-9. [PMID: 23562569 DOI: 10.1016/j.thromres.2013.03.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 03/01/2013] [Accepted: 03/12/2013] [Indexed: 11/29/2022]
Abstract
AIMS To assess the clinical performance of pro-B-type natriuretic peptide 1-108 (proBNP) for the prognosis of acute pulmonary embolism. METHODS This study was ancillary to a recently published multicentre study including 570 patients with acute pulmonary embolism. ProBNP values were analysed using a new sandwich immunoassay proBNP1-108, Bioplex2200 (Bio-Rade Laboratories). Data was compared with BNP and N-terminal (NT) proBNP values. Adverse outcomes at 30 days were defined as death, secondary cardiogenic shock, or recurrent venous thromboembolism. RESULTS ProBNP values were analysed in 549 patients, with 39 (7.1%) presenting adverse outcomes. All three natriuretic peptides were significantly elevated in these 39 patients compared with the group without adverse outcomes (BNP: p < 0.001; NT-proBNP: p < 0.001; proBNP: 0.044), with median proBNP values being 605 pg/ml (113-1437) and 109 pg/ml (30-444), respectively. Multivariate analyses revealed that proBNP significantly depended on patient age (p < 0.001) and renal failure (p=0.001), with proBNP values increasing with both factors. The areas under the receiver operating curve were 0.74 (95% CI 0.69-0.79) for BNP, 0.76 (95% CI 0.72-0.80) for NT-proBNP, and 0.70 (95% CI 0.65-0.75) for proBNP, meaning that the performance of proBNP was significantly lower than that of the two other peptides (p = 0.017). CONCLUSION ProBNP, BNP, and NT-proBNP values were significantly increased in patients with adverse outcomes after acute pulmonary embolism. However, the prognostic performance of proBNP for predicting adverse versus favourable outcomes was lower than that of the other natriuretic peptides, thus limiting the clinical relevance of proBNP as a prognostic marker in pulmonary embolism.
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Affiliation(s)
- Franck Verschuren
- Université catholique de Louvain, Cliniques Universitaires Saint-Luc, Acute Medicine Departement, Accidents and Emergency Unit, Brussel, Belgium.
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Furlan A, Aghayev A, Chang CCH, Patil A, Jeon KN, Park B, Fetzer DT, Saul M, Roberts MS, Bae KT. Short-term mortality in acute pulmonary embolism: clot burden and signs of right heart dysfunction at CT pulmonary angiography. Radiology 2012; 265:283-93. [PMID: 22993221 DOI: 10.1148/radiol.12110802] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess the correlation between volumetric measurements of clot, semiquantitative clot burden indexes, and signs of right heart dysfunction at computed tomographic (CT) pulmonary angiography in patients with acute pulmonary embolism (PE) and to determine whether clot burden and signs of right heart dysfunction are associated with short-term mortality. MATERIALS AND METHODS This retrospective study was institutional review board approved and HIPAA compliant. CT pulmonary angiographic studies (January 2007 through December 2007) with findings positive for PE were retrieved. Two readers evaluated signs of right heart dysfunction at CT pulmonary angiography, measured clot volume using a dedicated software program, and assessed clot burden using semiquantitative scores (Qanadli and Mastora). Spearman rank coefficient was used to investigate correlation between clot burden measures and signs of right heart dysfunction. Uni- and multivariate analyses were used to test association between CT pulmonary angiographic findings and short-term mortality. RESULTS A total of 635 CT pulmonary angiographic studies from 635 patients (304 men, 331 women; mean age, 59 years) were included; 39 (6%) patients died within 30 days. Clot volume was strongly correlated with Qanadli score (ρ=0.841, P<.01) and Mastora score (ρ=0.863, P<.01) and moderately correlated (ρ=0.378, P<.01) with the ratio of right ventricle diameter to left ventricle diameter (RV/LV ratio). Among the pulmonary angiographic signs, only increase in RV/LV ratio (cut-off value, 1.0) was independently associated with short-term mortality in multivariate analysis. CONCLUSION Clot volume strongly correlated with semiquantitative CT scores of clot burden, and greater clot volume was associated with higher incidence of right heart dilatation. Increase in RV/LV ratio was associated with short-term mortality; however, measures of clot burden were not.
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Affiliation(s)
- Alessandro Furlan
- Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213, USA
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Comparison of Pulmonary Embolism and Subsequent Cardiovascular Events Between Elderly and Young Patients in the Emergency Department. INT J GERONTOL 2012. [DOI: 10.1016/j.ijge.2012.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Paranskaya L, Bozdag-Turan I, Kische S, Akin I, Turan G, Nienaber C, Ince H. [Dynamic left ventricular outflow tract obstruction in pulmonary embolism]. Internist (Berl) 2012; 53:751-5. [PMID: 22450772 DOI: 10.1007/s00108-012-3046-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Left ventricular hypertrophy, dehydration, sepsis, vasodilatation, excessive sympathetic stimulation, pericardial tamponade and surgical treatment of the atrioventricular valve are known causes of left ventricular outflow tract (LVOT) obstruction. We report the rare case of a patient who developed dynamic LVOT obstruction as a complication of acute pulmonary embolism.
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Affiliation(s)
- L Paranskaya
- Universitätsklinikum Rostock, Ernst-Heydemann-Strasse 6, Rostock, Germany.
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Platz E, Hassanein AH, Shah A, Goldhaber SZ, Solomon SD. Regional Right Ventricular Strain Pattern in Patients with Acute Pulmonary Embolism. Echocardiography 2012; 29:464-70. [DOI: 10.1111/j.1540-8175.2011.01617.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abrahams-van Doorn PJ, Hartmann IJC. Cardiothoracic CT: one-stop-shop procedure? Impact on the management of acute pulmonary embolism. Insights Imaging 2011; 2:705-15. [PMID: 23100045 PMCID: PMC3289035 DOI: 10.1007/s13244-011-0123-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 05/02/2011] [Accepted: 07/18/2011] [Indexed: 10/26/2022] Open
Abstract
In the treatment of pulmonary embolism (PE) two groups of patients are traditionally identified, namely the hemodynamically stable and instable groups. However, in the large group of normotensive patients with PE, there seems to be a subgroup of patients with an increased risk of an adverse outcome, which might benefit from more aggressive therapy than the current standard therapy with anticoagulants. Risk stratification is a commonly used method to define subgroups of patients with either a high or low risk of an adverse outcome. In this review the clinical parameters and biomarkers of myocardial injury and right ventricular dysfunction (RVD) that have been suggested to play an important role in the risk stratification of PE are described first. Secondly, the use of more direct imaging techniques like echocardiography and CT in the assessment of RVD are discussed, followed by a brief outline of new imaging techniques. Finally, two risk stratification models are proposed, combining the markers of RVD with cardiac biomarkers of ischemia to define whether patients should be admitted to the intensive care unit (ICU) and/or be given thrombolysis, admitted to the medical ward, or be safely treated at home with anticoagulant therapy.
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Affiliation(s)
- Pauline J Abrahams-van Doorn
- Department of Radiology, Erasmus MC University Medical Center Rotterdam, 's-Gravendijkwal 230, NL-3015 CE, Rotterdam, The Netherlands,
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Thieme SF, Ashoori N, Bamberg F, Sommer WH, Johnson TRC, Leuchte H, Becker A, Maxien D, Helck AD, Behr J, Reiser MF, Nikolaou K. Severity assessment of pulmonary embolism using dual energy CT – correlation of a pulmonary perfusion defect score with clinical and morphological parameters of blood oxygenation and right ventricular failure. Eur Radiol 2011; 22:269-78. [DOI: 10.1007/s00330-011-2267-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2011] [Revised: 07/14/2011] [Accepted: 07/30/2011] [Indexed: 10/17/2022]
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