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Bleetman A, Wolanski MA, Brodie J. Mechanical chest compressions as a last-ditch attempt to salvage a profoundly hypoxic but normotensive patient with a massive pulmonary embolism. BMJ Case Rep 2024; 17:e261132. [PMID: 39038877 DOI: 10.1136/bcr-2024-261132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024] Open
Abstract
Massive pulmonary embolism is a common cause of morbidity and mortality. For patients presenting with massive pulmonary embolism, severe hypoxia is usually associated with severe hypotension. These patients should be considered for thrombectomy should thrombolysis and respiratory support fail to improve their condition. Should thrombectomy not be available or suitable, consideration should be given to offering mechanical chest compressions to 'break up the clot'. We describe a case in which this seemingly led to survival and full recovery.
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Stampfl M, DeBlieux P. A Clinical Review of Vasopressors in Emergency Medicine. J Emerg Med 2024; 67:e31-e41. [PMID: 38789351 DOI: 10.1016/j.jemermed.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 01/22/2024] [Accepted: 03/06/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Vasopressor medications raise blood pressure through vasoconstriction and are essential in reversing the hypotension seen in many critically ill patients. Previously, vasopressor administration was largely limited to continuous infusions through central venous access. OBJECTIVES OF THE REVIEW This review addresses the clinical use of vasopressors in various shock states, including practical considerations and innovations in vasopressor administration. The focus is on the clinical administration of vasopressors across a range of shock states, including hypovolemic, distributive, cardiogenic, and obstructive shock. DISCUSSION Criteria for starting vasopressors are not clearly defined, though early use may be beneficial. A number of physiologic factors affect the body's response to vasopressors, such as acidosis and adrenal insufficiency. Peripheral and push-dose administration of vasopressors are becoming more common. Distributive shock is characterized by inappropriate vasodilation and vasopressors play a crucial role in maintaining adequate blood pressure. The use of vasopressors is more controversial in hypovolemic shock, as the preferred treatment is correction of the volume deficit. Evidence for vasopressors is limited in cardiogenic shock. For obstructive shock, vasopressors can temporize a patient's blood pressure until definitive therapy can reverse the underlying cause. CONCLUSION Across the categories of shock states, norepinephrine has wide applicability and is a reasonable first-line agent for shock of uncertain etiology. Keeping a broad differential when hypotension is refractory to vasopressors may help to identify adjunctive treatments in physiologic states that impair vasopressor effectiveness. Peripheral administration of vasopressors is safe and facilitates early administration, which may help to improve outcomes in some shock states.
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Affiliation(s)
- Matthew Stampfl
- UW Health Med Flight, Madison, Wisconsin; BerbeeWalsh Department of Emergency Medicine, Madison, Wisconsin.
| | - Peter DeBlieux
- Louisiana State University Medical Center, New Orleans, Louisiana; Tulane University School of Medicine Department of Surgery, New Orleans, Louisiana
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3
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Iqbal P, Habib MB, Hatim A, Alkhatib M, Bakar MA, Koya SH, Alshurafa A, Rehman HU. Dilemma of Thrombolysis in a patient with high-risk Pulmonary Embolism with severe Thrombocytopenia: A case report. Qatar Med J 2024; 2023:39. [PMID: 38223832 PMCID: PMC10787518 DOI: 10.5339/qmj.2023.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 11/30/2023] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND Managing a high-risk pulmonary embolism (PE) in a critically ill patient with severe thrombocytopenia can present a challenging dilemma. There is a high risk of fatal bleeding due to anticoagulation in high-risk PE with thrombocytopenia; therefore, risks and benefits are balanced while dealing with such a critical scenario. CASE REPORT We present a case of a female patient with thrombocytopenia who was admitted for management of lymphoma. Her hospital course was complicated by high-risk PE, leading to acute respiratory failure and hypotension, necessitating urgent transfer to the medical intensive care unit. She was intubated and placed on mechanical ventilation. Multiple cardiac arrests occurred due to compromised cardiac output from a severely dilated right ventricle on bedside transthoracic echocardiography. As a last resort to save her life in this critical state and severe thrombocytopenia, she was given a half bolus dose of the recommended drug, i.e., 50mg IV of Alteplase. Subsequently, she stabilized and was extubated without any further complications. DISCUSSION High-risk PE needs prompt management with anticoagulation to avoid fatal outcomes. However, on the other hand, anticoagulation carries a high risk of bleeding, especially in patients with thrombocytopenia. These challenges prompt a modern perspective in situations where clear guidelines are absent. CONCLUSION We aim to discuss our contemporary clinical practice in managing such a complex case and highlight the need for further studies.
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Affiliation(s)
- Phool Iqbal
- Department of Internal Medicine, New York Medical College/Metropolitan Hospital Center, New York, USA
| | - Mhd Baraa Habib
- Department of Internal Medicine, Hamad Medical Corporation, Qatar
| | - Ahmed Hatim
- Department of Internal Medicine, Hamad Medical Corporation, Qatar
| | | | | | | | - Awni Alshurafa
- Department of Hematology, Hamad Medical Corporation, Qatar
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Evlice M, Kurt İH. The relationship between echocardiographic parameters and albumin bilirubin score in patients with acute pulmonary thromboembolism. Perfusion 2023:2676591231221706. [PMID: 38085551 DOI: 10.1177/02676591231221706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
PURPOSE The Albumin-Bilirubin (ALBI) score is useful and easy-to-use for objectively assessing liver function. We investigated whether the ALBI score, a parameter indicating liver stiffness, congestion and fibrosis, has any relationship with echocardiographic parameters in patients with acute pulmonary thromboembolism (PTE). MATERIAL AND METHODS A total of 140 patients diagnosed with acute PTE were retrospectively analyzed. These patients were divided into three groups according to the hemodynamic severity of acute PTE: Group I [Low risk]; Group II [Submassive or intermediate-risk]; and Group III [Massive or high-risk]. Biochemical data obtained from venous blood samples taken at admission were analyzed. In addition, data were also analyzed from transthoracic echocardiography and pulmonary computed tomographic angiography performed at admission. ALBI, Bova, and PESI scores were calculated. RESULTS ALBI scores (-3.32 ± 0.21 vs -2.86 ± 0.15 vs -2.46 ± 0.2, p < .001) were statistically significantly higher in Group III than Groups I and II. There was a significant difference between the three groups in terms of echocardiographic parameters, and LVEF and TAPSE values tended to decrease from group I to group III. In multivariate linear regression analysis, sPAP, RV/RA diameter, and NT-pro-BNP were found to be significantly associated with the ALBI score. An ALBI score higher than -2.87 was associated with Bova stage II-III in patients with Group I and Group II PTE, with a sensitivity of 87% and a specificity of 62% (AUC = 0.804; 95% CI 0.713-0.895; p < .001). CONCLUSION The ALBI score, which is a common, easy-to-use, and inexpensive method, may be beneficial to select intermediate and high-risk patients in patients with acute PTE. Additionally, it may have prognostic value in distinguishing low and intermediate-risk acute PTE patients.
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Affiliation(s)
- Mert Evlice
- Department of Cardiology, Health Sciences University-Adana City Training and Research Hospital, Adana, Turkey
| | - İbrahim H Kurt
- Department of Cardiology, Health Sciences University-Adana City Training and Research Hospital, Adana, Turkey
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Fulton B, Bashir R, Weinberg MD, Lakhter V, Rali P, Pugliese S, Giri J, Kobayashi T. Advanced Treatment of Hemodynamically Unstable Acute Pulmonary Embolism and Clinical Follow-up. Semin Thromb Hemost 2023; 49:785-796. [PMID: 37696292 DOI: 10.1055/s-0043-1772840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
High-risk acute pulmonary embolism (PE), defined as acute PE associated with hemodynamic instability, remains a significant contributor to cardiovascular morbidity and mortality in the United States and worldwide. Historically, anticoagulant therapy in addition to systemic thrombolysis has been the mainstays of medical therapy for the majority of patients with high-risk PE. In efforts to reduce the morbidity and mortality, a wide array of interventional and surgical therapies has been developed and employed in the management of these patients. However, the most recent guidelines for the management of PE have reserved the use of these advanced therapies in scenarios where thrombolytic therapy plus anticoagulation are unsuccessful. This is due largely to the lack of prospective, randomized studies in this population. Stemming from this, the approach to treatment of these patients varies widely depending on institutional experience and resources. Furthermore, morbidity and mortality remain unacceptably high in this population, with estimated 30-day mortality of at least 30%. As such, development of a standardized approach to treatment of these patients is paramount to improving outcomes. Early and accurate risk stratification in conjunction with a multidisciplinary team approach in the form of a PE response team is crucial. With the advent of novel therapies for the treatment of acute PE, in addition to the growing availability of and familiarity with mechanical circulatory support systems, such a standardized approach may now be within reach.
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Affiliation(s)
- Brian Fulton
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Riyaz Bashir
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Mitchell D Weinberg
- Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, Staten Island, New York
| | - Vladimir Lakhter
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Steve Pugliese
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jay Giri
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
| | - Taisei Kobayashi
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
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Osmani N, Marinaro J, Guliani S. Life-threatening pulmonary embolism: overview and management. Int Anesthesiol Clin 2023; 61:35-42. [PMID: 37622318 DOI: 10.1097/aia.0000000000000417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Affiliation(s)
- Nizar Osmani
- Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Jonathan Marinaro
- Center for Adult Critical Care, University of New Mexico, Albuquerque, New Mexico
| | - Sundeep Guliani
- Center for Adult Critical Care, University of New Mexico, Albuquerque, New Mexico
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Lasanudin JEF, Laksono S, Kusharsamita H. Current Diagnosis and Management of Acute Pulmonary Embolism: A Strategy for General Practitioners in Emergency Department. ACTA MEDICA (HRADEC KRALOVE) 2023; 66:138-145. [PMID: 38588391 DOI: 10.14712/18059694.2024.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Pulmonary embolism (PE) is a disease with a relatively good prognosis when diagnosed and treated properly. This review aims to analyse available data and combine them into algorithms that physicians can use in the emergency department for quick decision-making in diagnosing and treating PE. The available data show that PE can be excluded through highly sensitive clinical decision rules, i.e. Pulmonary Embolism Rule-Out Criteria (PERC), Wells criteria, and Revised Geneva criteria, combined with D-dimer assessment. In cases where PE could not be excluded through the mentioned strategies, imaging modalities, such as compression ultrasonography (CUS), computed tomographic pulmonary angiography (CTPA), and planar ventilation/perfusion (V/Q) scan, are indicated for a definite diagnosis. Once a diagnosis has been made, treatment of PE depends on its mortality risk as patients are divided into low-, intermediate-, and high-risk cases. High-risk cases are treated for their hemodynamic instability, given parenteral or oral anticoagulant therapy, and are indicated for reperfusion therapy. Intermediate-risk PE is only given parenteral or oral anticoagulants and reperfusion is indicated when anticoagulants fail. Low-risk cases are given oral anticoagulants and based on the Hestia criteria, patients may be discharged and treated as outpatients.
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Affiliation(s)
| | - Sidhi Laksono
- Department of Cardiology and Vascular Medicine, Central Pertamina Hospital, Jakarta, Indonesia.
- Faculty of Medicine, Universitas Muhammadiyah Prof Dr Hamka, Tangerang, Indonesia.
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Kerget B, Özkan HB, Afşin DE, Koçak AO, Laloglu E, Uçar EY, Sağlam L. Evaluation of serum YKL-40 level among clinical risk scores for early mortality in acute pulmonary thromboembolism. Clin Biochem 2022; 108:20-26. [PMID: 35853494 DOI: 10.1016/j.clinbiochem.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/08/2022] [Accepted: 07/13/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Pulmonary embolism (PE) often occurs secondary to deep vein thrombosis and is an important cause of mortality and morbidity. This study aimed to evaluate the relationship between YKL-40 level and clinical risk score in patients with PE. METHODS The study included a total of 100 patients, 80 patients diagnosed with PE in the emergency department and 20 healthy controls. Patients with PE were divided into four groups: high-risk patients (n = 20), high-intermediate-risk patients (n = 20), low-intermediate-risk patients (n = 20), and low-risk patients (n = 20). Serum YKL-40 levels were measured by enzyme-linked immunosorbent assay. Pulmonary artery obstruction index (PAOI) was calculated from computed tomography angiography images. RESULTS PAOI increased in correlation with PE risk and differed significantly between all patient groups (p < 0.001). Troponin-I levels were significantly higher in the high-risk and high-intermediate-risk groups compared to the other groups (p < 0.001), but did not differ significantly between high-risk and high-intermediate-risk patients (p = 0.09). YKL-40 level was significantly higher in the high-risk PE group than the high-intermediate-risk group (p < 0.001). In receiving operator characteristic curve analysis assessing the discriminatory value of YKL-40 for high-risk PE patients, a cut-off value of 227.2 ng/mL had sensitivity of 85 % and specificity of 70 %. DISCUSSION YKL-40 may be an important biomarker in decisions regarding early thrombolytic treatment in patients with high-intermediate-risk PE. In addition, medical treatments targeting YKL-40 may also reduce thrombotic tendency in high-risk patient groups.
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Affiliation(s)
- Buğra Kerget
- Department of Pulmonary Diseases, Ataturk University School of Medicine, 25240, Yakutiye, Erzurum, Turkey.
| | - Hatice Beyza Özkan
- Department of Pulmonary Diseases, Ataturk University School of Medicine, 25240, Yakutiye, Erzurum, Turkey
| | - Dursun Erol Afşin
- Depertmant of Pulmonary Diseases, Health Sciences University Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Abdullah Osman Koçak
- Department of Emergency Medicine, Ataturk University School of Medicine, 25240, Yakutiye, Erzurum, Turkey
| | - Esra Laloglu
- Department of Biochemistry, Ataturk University School of Medicine, 25240, Yakutiye, Erzurum, Turkey
| | - Elif Yılmazel Uçar
- Department of Pulmonary Diseases, Ataturk University School of Medicine, 25240, Yakutiye, Erzurum, Turkey
| | - Leyla Sağlam
- Department of Pulmonary Diseases, Ataturk University School of Medicine, 25240, Yakutiye, Erzurum, Turkey
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9
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Clinical and radiological characteristics of acute pulmonary embolus in relation to 28-day and 6-month mortality. PLoS One 2021; 16:e0258843. [PMID: 34962922 PMCID: PMC8714121 DOI: 10.1371/journal.pone.0258843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/07/2021] [Indexed: 12/03/2022] Open
Abstract
Background Patients with acute pulmonary embolism (PE) exhibit a wide spectrum of clinical and laboratory features when presenting to hospital and pathophysiologic mechanisms differentiating low-risk and high-risk PE are poorly understood. Objectives To investigate the prognostic value of clinical, laboratory and radiological information that is available within routine tests undertaken for patients with acute PE. Methods Electronic patient records (EPR) of patients who underwent Computed Tomography Pulmonary Angiogram (CTPA) scan for the investigation of acute PE during 6-month period (01.01.2016–30.06.2016) were examined. Data was gathered from EPR for patients that met inclusion criteria and all CTPA scans were re-evaluated. Biochemical thresholds of low-grade and high-grade inflammation, serum CRP >10mg/L and >150mg/L and serum albumin concentrations <35g/L and <25 g/L, were combined in the Glasgow Prognostic Score (GPS) and peri-operative Glasgow Prognostic Score (poGPS) respectively. Neutrophil Lymphocyte ratio (NLR) was also calculated. Pulmonary Embolus Severity Index score was calculated. Results Of the total CTPA reports (n = 2129) examined, 245 patients were eligible for inclusion. Of these, 20 (8%) patients had died at 28-days and 43 (18%) at 6-months. Of the 197 non-cancer related presentations, 28-day and 6-month mortality were 3% and 8% respectively. Of the 48 cancer related presentations, 28-day and 6-month mortality were 29% and 58% respectively. On univariate analysis, age ≥65 years (p<0.01), PESI score ≥100(p = <0.001), NLR ≥3(p<0.001) and Coronary Artery Calcification (CAC) score ≥ 6 (p<0.001) were associated with higher 28-day and 6-month mortality. PESI score ≥100 (OR 5.2, 95% CI: 1.1, 24.2, P <0.05), poGPS ≥1 (OR 2.5, 95% CI: 1.2–5.0, P = 0.01) and NLR ≥3 (OR 3.7, 95% CI: 1.0–3.4, P <0.05) remained independently associated with 28-day mortality. On multivariate binary logistic regression analysis of factors associated with 6-month mortality, PESI score ≥100 (OR 6.2, 95% CI: 2.3–17.0, p<0.001) and coronary artery calcification score ≥6 (OR 2.3, 95% CI: 1.1–4.8, p = 0.030) remained independently associated with death at 6-months. When patients who had an underlying cancer diagnosis were excluded from the analysis only GPS≥1 remained independently associated with 6-month mortality (OR 5.0, 95% CI 1.2–22.0, p<0.05). Conclusion PESI score >100, poGPS≥1, NLR ≥3 and CAC score ≥6 were associated with 28-day and 6-month mortality. PESI score ≥100, poGPS≥1 and NLR ≥3 remained independently associated with 28-day mortality. PESI score ≥100 and CAC score ≥6 remained independently associated with 6-month mortality. When patients with underlying cancer were excluded from the analysis, GPS≥1 remained independently associated with 6-month mortality. The role of the systemic inflammatory response (SIR) in determining treatment and prognosis requires further study. Routine reporting of CAC scores in CTPA scans for acute PE may have a role in aiding clinical decision-making regarding treatment and prognosis.
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10
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Kerget B, Erol Afşin D, Aksakal A, Kerget F, Aşkın S, Yılmazel Uçar E, Sağlam L. Could VEGF-D level have a role in clinical risk scoring, estimation of thrombus burden, and treatment in acute pulmonary thromboembolism? Int J Clin Pract 2021; 75:e14601. [PMID: 34228874 DOI: 10.1111/ijcp.14601] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 07/02/2021] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Pulmonary embolism (PE) is usually a complication of deep vein thrombosis and is an important cause of mortality and morbidity. Vascular endothelial growth factor D (VEGF-D) is a secretory protein that plays a role in the remodelling of blood vessels and the lymphatic system. This study aimed to determine the relationship between VEGF-D level and clinical risk scoring in patients with PE. METHODS The study included 117 patients admitted for PE that were divided into four groups: high-risk patients (n = 35), high-intermediate-risk patients (n = 30), low-intermediate-risk patients (n = 24), and low-risk patients (n = 28). Plasma VEGF-D was measured from peripheral venous blood samples (5 mL) using a commercial enzyme-linked immunosorbent assay (ELISA) kit. Pulmonary Artery Obstruction Index (PAOI) was calculated from CT angiography imaging. RESULTS There was no significant difference in troponin-I and NT-proBNP levels between the high-intermediate-risk and high-risk PE patients (P = .134, .146). VEGF-D and PAOI levels were found to be statistically significantly higher in high-risk patients compared with high-intermediate-risk patients (P = .016, .001). VEGF-D level was moderately correlated with mean pulmonary artery pressure and PAOI (r = .481, P = .01; r = .404, P = .01). In ROC curve analysis, a cut-off of 370.1 pg/mL for VEGF-D had 91.4% sensitivity and 67% specificity in the differentiation of high-intermediate-risk and high-risk PE patients. CONCLUSION This study showed that plasma VEGF-D level was more reliable than troponin-I and NT-proBNP in clinical risk scoring and demonstrating thrombus burden. VEGF-D can be used as a biomarker in clinical risk scoring and estimation of thrombus burden in patients with acute PE.
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Affiliation(s)
- Buğra Kerget
- Department of Pulmonary Diseases, Ataturk University School of Medicine, Erzurum, Turkey
| | - Dursun Erol Afşin
- Department of Pulmonary Diseases, Health Sciences University Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Alperen Aksakal
- Department of Pulmonary Diseases, Health Sciences University Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Ferhan Kerget
- Department of Infection Diseases and Clinical Microbiology, Health Sciences University Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Seda Aşkın
- Department of Biochemistry, Ataturk University School of Medicine, Erzurum, Turkey
| | - Elif Yılmazel Uçar
- Department of Pulmonary Diseases, Ataturk University School of Medicine, Erzurum, Turkey
| | - Leyla Sağlam
- Department of Pulmonary Diseases, Ataturk University School of Medicine, Erzurum, Turkey
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Tsangaris A, Alexy T, Kalra R, Kosmopoulos M, Elliott A, Bartos JA, Yannopoulos D. Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock. Front Cardiovasc Med 2021; 8:686558. [PMID: 34307500 PMCID: PMC8292640 DOI: 10.3389/fcvm.2021.686558] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/11/2021] [Indexed: 12/25/2022] Open
Abstract
Cardiogenic shock accounts for ~100,000 annual hospital admissions in the United States. Despite improvements in medical management strategies, in-hospital mortality remains unacceptably high. Multiple mechanical circulatory support devices have been developed with the aim to provide hemodynamic support and to improve outcomes in this population. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the most advanced temporary life support system that is unique in that it provides immediate and complete hemodynamic support as well as concomitant gas exchange. In this review, we discuss the fundamental concepts and hemodynamic aspects of VA-ECMO support in patients with cardiogenic shock of various etiologies. In addition, we review the common indications, contraindications and complications associated with VA-ECMO use.
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Affiliation(s)
- Adamantios Tsangaris
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Rajat Kalra
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Andrea Elliott
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Jason A Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States.,Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States.,Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
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12
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Jové NA, Samaan S, Pizzimenti NM, Lincoln D, Markel DC. Characterization of Pulmonary Emboli in Total Joint Arthroplasty Patients Compared to General Medical Patients. J Knee Surg 2020; 33:1232-1237. [PMID: 31288268 DOI: 10.1055/s-0039-1693417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pulmonary emboli (PEs) occur in medical and postoperative total joint arthroplasty (TJA) patients. These are different patient populations, yet both undergo identical diagnosis and treatment regardless of PEs size and quantity. To date, there has been no analysis of the location, size, and quantity of emboli that occur postoperatively in TJA compared with general medical patients. We hypothesized TJA patients would have different size and distribution of PEs per event compared with medical patients. A retrospective chart review was conducted of patients who underwent total hip or knee arthroplasty in comparison to general medical patients at our institution from 2006 to 2011 with a PE diagnosis. Medical co-morbidities, sex, age, procedure, postoperative day, size, and location of PE using spiral computed tomography were recorded using a novel mapping scheme. Embolus size was defined based on blockage level in the pulmonary arterial tree. Of the 4,178 TJA patients reviewed, 51 were diagnosed with a PE. A total of 67% of TJA patients were women, yet women represented 90% (n = 46) of TJA PE patients (p < 0.0001). Medical patients had an equal distribution of men and women with PEs. Orthopaedic patients averaged more (4.0 vs. 2.2, p < 0.0001) and smaller PEs compared with medical patients (p < 0.0001). In conclusion, women undergoing TJA had significantly higher risk of developing PE compared with male arthroplasty or medical patients. Differences were observed in size and distribution of PEs between medical and TJA patients, which suggest a different nature of embolic phenomenon.
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Affiliation(s)
- Nathaniel A Jové
- Department of Orthopaedic Surgery, Detroit Medical Center/Providence Hospital Orthopaedic Surgery Residency Program, Detroit, Michigan.,Department of Orthopaedic Surgery, Providence Hospital and Medical Center, Southfield, Michigan
| | - Sam Samaan
- Department of Radiology, Providence Hospital and Medical Center, Southfield, Michigan
| | | | - Denis Lincoln
- Department of Radiology, Providence Hospital and Medical Center, Southfield, Michigan
| | - David C Markel
- Department of Orthopaedic Surgery, Detroit Medical Center/Providence Hospital Orthopaedic Surgery Residency Program, Detroit, Michigan.,Department of Orthopaedic Surgery, Providence Hospital and Medical Center, Southfield, Michigan
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13
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Tse B, Lim G, Sholzberg M, Pavenski K. Describing the point prevalence and characteristics of venous thromboembolism in patients with thrombotic thrombocytopenic purpura. J Thromb Haemost 2020; 18:2870-2877. [PMID: 33448602 DOI: 10.1111/jth.15027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/18/2020] [Accepted: 07/15/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Arterial thromboembolic events are relatively common and well-described in patients with thrombotic thrombocytopenic purpura (TTP). However, the literature describing venous thromboembolism (VTE) in TTP is scarce. METHODS Single-institution retrospective chart review was conducted in TTP patients over a 10-year period to describe the point prevalence of VTE. Data were analyzed using descriptive statistics. RESULTS We identified 77 consecutive patients with 123 episodes of TTP. Of these patients, 14 (18%) experienced 16 VTEs (6 pulmonary embolisms, 6 deep vein thromboses, 4 superficial vein thromboses [SVT]). Excluding SVT, the point prevalence of VTE was 14%. All were acute and associated with admission for acute TTP. All patients were treated with plasma exchange (PLEX); 6/8 patients on concurrent PLEX at VTE diagnosis were exchanged with solvent-detergent plasma (SDP). Platelet and lactate dehydrogenase levels at time of VTE diagnosis had largely normalized from presentation values (median 175 × 109 U/L [interquartile range 130.75, 250] and 232 U/L [interquartile range 178.75, 263.5], respectively). Most VTEs (9/16) occurred while patients were not on pharmacologic thromboprophylaxis. All but one VTE was treated with anticoagulation. No VTEs were fatal or massive. CONCLUSIONS Our data provide additional evidence that TTP patients may be at risk for VTE. It is possible that SDP exerted a prothrombotic effect. TTP-associated VTEs may be pathophysiologically distinct from arterial thromboses because they occur following hematological recovery. VTE thromboprophylaxis was not commonly used. Our findings suggest the need to implement VTE thromboprophylaxis earlier in hospitalized patients with TTP.
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Affiliation(s)
- Brandon Tse
- Division of Hematology, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Gloria Lim
- Division of Hematology, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Division of Hematology, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Laboratory Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Katerina Pavenski
- Division of Hematology, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Laboratory Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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14
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Selvakumar D, Chien J. “PERT-inent” Management: The Role of the Pulmonary Embolus Response Team in Managing Paradoxical Embolus in Transit. CJC Open 2020; 2:687-690. [PMID: 33305228 PMCID: PMC7710955 DOI: 10.1016/j.cjco.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 06/14/2020] [Indexed: 11/28/2022] Open
Abstract
A 52-year-old man presented with palpitations and dyspnea. Extensive bilateral pulmonary emboli (PEs) were identified on computed tomography pulmonary angiogram. Transthoracic echocardiography demonstrated a mobile bi-atrial thrombus straddling the interatrial septum. Consensus decision of a multidisciplinary pulmonary embolus response team was made for emergency thrombectomy of the pulmonary and intra-cardiac clot. Intraoperatively, a patent foramen ovale was identified and repaired. He had an excellent outcome and was discharged home on oral anticoagulation. In this unique case of a bi-atrial thrombus and sub-massive PEs, we demonstrate the utility of dedicated pulmonary embolus response teams in providing rapid and individualized management decisions for complex PE patients.
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Affiliation(s)
- Dinesh Selvakumar
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
- School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
- Corresponding author: Dinesh Selvakumar, 176 Hawkesbury Road, Westmead, NSW 2145, Australia. Tel: +1-612 8627 3000.
| | - Jimmy Chien
- School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
- Department of Respiratory & Sleep Medicine, Westmead Hospital, Westmead, New South Wales, Australia
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15
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Higazi MM, Fattah RARA, Abdelghany EA, Ghany HSA. Efficacy of Computed Tomography Pulmonary Angiography as Non-invasive Imaging Biomarker for Risk Stratification of Acute Pulmonary Embolism. J Clin Imaging Sci 2020; 10:49. [PMID: 32874754 PMCID: PMC7451145 DOI: 10.25259/jcis_75_2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/17/2020] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES Massive and sub-massive pulmonary embolisms (PEs) are associated with high mortality and morbidity. The mainstay of treatment for PE is anticoagulation. However, high- and intermediate-risk patients may benefit from interventional thrombolytic therapy. Computed tomography pulmonary angiography (CTPA) is widely available, fast, and non-invasive technique, and it can identify pulmonary thrombus down to at least a segmental level. In this study, we attempt to evaluate the efficacy of CTPA as a non-invasive imaging biomarker for risk stratification of acute PE (APE) patients. MATERIAL AND METHODS This is a prospective study conducted on 150 patients who proved to have APE by CTPA. The simplified PE severity index score was obtained. The pulmonary artery obstruction index (PAOI) using and right to left ventricular (RV/LV) diameter ratios were calculated. RESULTS The patients were divided into (1) high risk (shocked) and (2) non-high risk groups. There was a significant difference between the 1st and 2nd groups regarding PAOI. Hemodynamically stable patients were further subclassified according to the right ventricular dysfunction (RVD) into Group Ia (intermediate risk) and Group Ib (low risk). There was a significant difference between subgroups regarding PAOI (P < 0.0001, r = 0.385). Receiver operating characteristic curve analysis revealed PAOI >47% associated with RV/LV ratio >1. CONCLUSION Our results support the use of CTPA as a surrogate imaging biomarker for both diagnosis and risk stratification of APE patients. CTPA allows assessment of clot burden through PAOI calculation and identification of intermediate-risk PE through the assessment of RVD.
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16
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Kerget B, Afşin DE, Aksakal A, Aşkin S, Araz Ö. Could HIF-1α be a novel biomarker for the clinical course and treatment of pulmonary embolism? Turk J Med Sci 2020; 50:963-968. [PMID: 32421278 PMCID: PMC7379473 DOI: 10.3906/sag-1908-93] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 05/16/2020] [Indexed: 11/03/2022] Open
Abstract
Background/aim Pulmonary embolism (PE) is associated with high morbidity and mortality rates if not diagnosed and treated rapidly. The aim of our study was to investigate the relationship between levels of hypoxia-induced factor-1 alpha (HIF-1α) and clinical course and prognosis in patients with intermediate low-risk, intermediate high-risk, and high-risk PE. Materials and methods The study included 240 subjects in 4 groups: a healthy control group (n = 60, mean age = 60 ± 15.2, female/male = 30/30 ), intermediate low-risk PE group (n = 60, mean age = 60 ± 12,5, female/male = 27/33), intermediate high-risk PE group (n = 60, mean age = 61,4 ± 14,8, female/male = 36/24), and high-risk PE group (n = 60, mean age = 62,3 ± 15, female/male = 33/27). Plasma HIF-1α levels were measured using commercial enzyme-linked immunosorbent assay (ELISA) kit. Results Comparison of HIF-1α levels revealed a statistically significant difference between the groups in proportion to clinical scoring (P = 0.001 for all). Comparison of initial HIF-1α and troponin levels in intermediate high-risk PE patients given thrombolytic therapy and those treated with enoxaparin sodium showed that HIF-1α levels were significantly higher in the group that received thrombolytic therapy (P = 0.001), while there was no difference in troponin levels (P = 0.146). Conclusion HIF-1α can be used in the PE clinical risk stratification and monitoring of PE and may also serve as a valuable early indicator in intermediate high-risk PE, for which early reperfusion therapy is important.
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Affiliation(s)
- Buğra Kerget
- Department of Pulmonary Diseases, Health Sciences University Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | | | - Alperen Aksakal
- Department of Pulmonary Diseases, School of Medicine, Atatürk University, Erzurum, Turkey
| | - Seda Aşkin
- Department of Biochemistry, School of Medicine, Atatürk University, Erzurum, Turkey
| | - Ömer Araz
- Department of Pulmonary Diseases, School of Medicine, Atatürk University, Erzurum, Turkey
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17
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Physical activity and respiratory symptoms after pulmonary embolism. A longitudinal observational study. Thromb Res 2020; 189:55-60. [DOI: 10.1016/j.thromres.2020.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/13/2020] [Accepted: 02/14/2020] [Indexed: 01/23/2023]
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18
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Lio KU, Jiménez D, Moores L, Rali P. Clinical conundrum: concomitant high-risk pulmonary embolism and acute ischemic stroke. Emerg Radiol 2020; 27:433-439. [PMID: 32211984 DOI: 10.1007/s10140-020-01772-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/13/2020] [Indexed: 01/01/2023]
Abstract
High-risk PE can be complicated by the presence of a patent foramen ovale (PFO), which can lead to paradoxical systemic embolization, including cerebral embolism ultimately leading to acute ischemic stroke (AIS). Acute management is challenging given the competing benefits and risks of systemic thrombolysis. Herein, we aim to provide a review of clinical presentations, diagnostic findings, and treatment and outcome from the available literature, with the hopes of providing insight into treatment options. We followed the guidelines outlined by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic literature search using PubMed/MEDLINE database, Cochrane Library, and Google Scholar for all reported cases/case series of concomitant high-risk PE and paradoxical ischemic stroke was conducted from inception to July 2019. Twenty-nine cases from 27 articles (26 single case reports, 1 case series of 3 patients) were included. There were 10 men and 19 women, ranging in age from 29 to 81 years (mean 56.1 ± 13.5 years). PFO was diagnosed in 89.7% of patients, mostly by transesophageal echocardiography. Treatment modalities included systemic thrombolysis (40%), anticoagulation alone (36%), surgical thrombectomy (16%), and percutaneous thrombectomy (8%). Overall mortality rate was 31%. Patients receiving thrombolysis and surgical thrombectomy had the most favorable outcome. Survival to discharge was 90% (9 out of 10), 100% (5 out of 5), and 50% (4 out of 8) in the systemic thrombolysis, surgical thrombectomy, and anticoagulation alone groups respectively. In the setting of combined high-risk PE and ischemic stroke, PFO can be detected in 90% of published cases. Thrombolysis and surgical thrombectomy seem to be effective management, but further studies are needed for validation.
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Affiliation(s)
- Ka U Lio
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcala, Madrid, Spain
| | - Lisa Moores
- Department of Medicine, F. Edward Hebert School of Medicine, The Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School Of Medicine, Temple University Hospital, Philadelphia, PA, USA.
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19
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The Results of Thrombolytic Treatment in Patients With High-risk Pulmonary Embolism. JOURNAL OF CARDIOVASCULAR EMERGENCIES 2019. [DOI: 10.2478/jce-2019-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Background: Mortality rates due to massive pulmonary embolism (PE) are much higher than estimated. Although thrombolytic therapy is controversial, it can be a life-saving procedure and can be safely used in patients with massive PE.
Study aim: We aimed to share the results of thrombolytic treatment in patients with massive PE.
Material and methods: We retrospectively evaluated 72 patients with PE admitted between January 2010 and April 2018 to the Department of Pulmonary Medicine, VM Medicalpark Samsun Hospital, Samsun, Turkey. The data of patients who received thrombolytic treatment were retrospectively analyzed.
Results: The female to male ratio was 24/48, with a mean age of 62.7 ± 12.6 (minimum 27, maximum 88) years. The diagnosis of massive PE was established with echocardiography in all patients and was confirmed via pulmonary CT angiography in 45 patients (62.5%) who presented an appropriate clinical status for this imaging technique. The most common symptoms were dyspnea (90.3%), chest pain (83.3%), and syncope (40.2%). The S1Q3T3 electrocardiography pattern was noted in 82% of patients, who rapidly recovered after thrombolytic therapy. Cardiopulmonary arrest was seen in 25 patients (37.2%), and thrombolytic treatment was administered during cardiopulmonary resuscitation in 18% (n = 13) of patients. The survival rate was 30.7% (n = 4) in patients with cardiopulmonary arrest who received thrombolytic treatment in the emergency room. The complications of rt-PA treatment included minor hemorrhages in 6.4% (n = 5), major hemorrhages in 2.7% (n = 2), and allergic reactions in 1.3% (n = 1) of patients. None of the patients had deceased as a complication of thrombolytic treatment. The overall mortality rate was 26.2% (n = 19), and 12.5% (n = 9) of the patients have died in first 24 hours after thrombolysis.
Conclusions: We concluded that the risk factors, ECG, and echocardiography are key indicators for the suspicion of massive PE in patients with hemodynamic shock. Based on our experience, early thrombolytic therapy is a life-saving intervention in patients with diagnosed and/or suspected massive PE.
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20
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Going with the Flow: Saddle Pulmonary Embolism Complicated by Severe Hypoxemia without Shock. Ann Am Thorac Soc 2019; 14:1479-1484. [PMID: 28862494 DOI: 10.1513/annalsats.201702-145cc] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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21
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Iaccarino A, Frati G, Schirone L, Saade W, Iovine E, D'Abramo M, De Bellis A, Sciarretta S, Greco E. Surgical embolectomy for acute massive pulmonary embolism: state of the art. J Thorac Dis 2018; 10:5154-5161. [PMID: 30233892 DOI: 10.21037/jtd.2018.07.87] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Massive pulmonary embolism (PE) is a severe condition that can potentially lead to death caused by right ventricular (RV) failure and the consequent cardiogenic shock. Despite the fact thrombolysis is often administrated to critical patients to increase pulmonary perfusion and to reduce RV afterload, surgical treatment represents another valid option in case of failure or contraindications to thrombolytic therapy. Correct risk stratification and multidisciplinary proactive teams are critical factors to dramatically decrease the mortality of this global health burden. In fact, the worldwide incidence of PE is 60-70 per 100,000, with a mortality ranging from 1% for small PE to 65% for massive PE. This review provides an overview of the diagnosis and management of this highly lethal pathology, with a focus on the surgical approaches at the state of the art.
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Affiliation(s)
- Alessandra Iaccarino
- Department of Medico Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Department of General and Specialistic Surgery "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Giacomo Frati
- Department of Medico Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy
| | - Leonardo Schirone
- Department of Medico Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Wael Saade
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Elio Iovine
- Department of Medico Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Mizar D'Abramo
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Antonio De Bellis
- Department of Cardiology and Cardiac Surgery, Casa di Cura San Michele, Maddaloni, Caserta, Italy
| | - Sebastiano Sciarretta
- Department of Medico Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy
| | - Ernesto Greco
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
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22
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Mohan B, Tandon R, Bansal R, Singh M, Singh B, Goyal A, Chhabra ST, Aslam N, Wander GS. Determinants of in-hospital clinical outcome in patients with sub-massive pulmonary embolism. Indian Heart J 2018; 70 Suppl 3:S90-S95. [PMID: 30595328 PMCID: PMC6310705 DOI: 10.1016/j.ihj.2018.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 11/09/2022] Open
Abstract
Introduction There is limited data regarding in hospital determinants of clinical deterioration and outcome in sub massive pulmonary embolism (PE). We aimed to evaluate these determinants by comparing biomarkers, CT pulmonary angiogram echocardiography, electrocardiography variables. Methods 57 patients of sub massive PE diagnosed on CT pulmonary angiogram were included. All patients received UFH on admission and were divided into two groups based on their clinical course. Group 1 comprised of patients who remained stable, group 2 of patients who showed signs of clinical deterioration. Results There were 34(59.6%) patients in group 1 and 23(40.4%) patients in group 2. No significant difference in age, gender, BMI. 59.37% had sub massive PE, 5.26% had mortality and 40.4% had clinical deterioration. Intravenous UFH infusion given to 59.6%, systemic thrombolysis 22.8%, catheter directed mechanical breakdown 14%, surgical embolectomy in 3.5% patients. S1Q3T3, new onset RBBB, T wave inversion > 1.63 mm, Basal RV size > 40 mm, RV: LV ratio > 1.2, Global RV longitudinal strain <−10.75% and RVSP > 39 mmHg profiled high risk group. Serum BNP and CT pulmonary angiogram derived scores didn’t differ significantly although CT findings helped to exclude low risk patients (specificity 88%, sensitivity 95%). Conclusions Physicians should be aware that patients who have ECG and Echocardiography changes suggestive of right ventricular strain and dysfunction above the cut off values and have documented thrombus in Proximal branches (RPA/LPA) or in distal portion of main pulmonary artery may require aggressive management with systemic/catheter based thrombolysis besides routine anticoagulation with heparin to prevent clinical deterioration.
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Affiliation(s)
- Bishav Mohan
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
| | - Rohit Tandon
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India.
| | - Raahat Bansal
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
| | - Maninder Singh
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
| | - Bhupinder Singh
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
| | - Abhishek Goyal
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
| | - Shibba Takkar Chhabra
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
| | - Naved Aslam
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
| | - Gurpreet S Wander
- Department of Cardiology Dayanand Medical College & Hospital Unit Hero, DMC Heart Institute, Ludhiana 141001, Punjab, India
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23
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Kırış T, Yazıcı S, Durmuş G, Çanga Y, Karaca M, Nazlı C, Dogan A. The relation between international normalized ratio and mortality in acute pulmonary embolism: A retrospective study. J Clin Lab Anal 2018; 32:e22164. [PMID: 28213956 PMCID: PMC6817039 DOI: 10.1002/jcla.22164] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 01/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute pulmonary embolism (PE) is a serious clinical disease characterized by a high mortality rate. The aim of this study was to assess the prognostic value of international normalized ratio (INR) in acute PE patients not on anticoagulant therapy. METHODS The study included 244 hospitalized acute PE patients who were not receiving previous anticoagulant therapy. Based on their 30-day mortality, patients were categorized as survivors or non-survivors. INR was measured during the patients' admission, on the same day as the diagnosis of PE but before anticoagulation started. RESULTS Thirty-day mortality occurred in 39 patients (16%). INR was higher in non-survivors than in survivors (1.3±0.4 vs 1.1±0.3, P=.003). In multivariate analysis, INR (HR: 3.303, 95% CI: 1.210-9.016, P=.020) was independently associated with 30-day mortality from PE. Inclusion of INR in a model with simplified pulmonary embolism severity index (sPESI) score improved the area under the receiver operating characteristics (ROC) curve from 0.736 (95% CI: 0.659-0.814) to 0.775 (95% CI: 0.701-0.849) (P=.028). Also, the addition of INR to sPESI score enhanced the net reclassification improvement (NRI=8.8%, P<.001) and integrated discrimination improvement (IDI=0.043, P=.027). CONCLUSION Elevated INR may have prognostic value for 30-day mortality in acute PE patients not on anticoagulation. Combining INR with sPESI score improved the predictive value for all-cause mortality. However, further large-scale studies are needed to confirm it's prognostic role.
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Affiliation(s)
- Tuncay Kırış
- Department of CardiologyAtaturk Training and Research HospitalIzmir Katip Celebi UniversityIzmirTurkey
| | - Selcuk Yazıcı
- Department of CardiologyDr. Siyami Ersek Thoracic and Cardiovascular Surgery Center Training Research HospitalIstanbulTurkey
| | - Gündüz Durmuş
- Department of CardiologyHaseki Training and Research HospitalIstanbulTurkey
| | - Yiğit Çanga
- Department of CardiologyDr. Siyami Ersek Thoracic and Cardiovascular Surgery Center Training Research HospitalIstanbulTurkey
| | - Mustafa Karaca
- Department of CardiologyMedical SchoolAtaturk Training and Research HospitalIzmir Katip Celebi UniversityIzmirTurkey
| | - Cem Nazlı
- Department of CardiologyMedical SchoolAtaturk Training and Research HospitalIzmir Katip Celebi UniversityIzmirTurkey
| | - Abdullah Dogan
- Department of CardiologyMedical SchoolAtaturk Training and Research HospitalIzmir Katip Celebi UniversityIzmirTurkey
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24
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Salsano A, Sportelli E, Olivieri GM, Di Lorenzo N, Borile S, Santini F. RVAD Support in the Setting of Submassive Pulmonary Embolism. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2017; 49:304-306. [PMID: 29302122 PMCID: PMC5737418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 09/13/2017] [Indexed: 06/07/2023]
Abstract
Patients with submassive pulmonary embolism (PE), although normotensive, are characterized by right ventricular (RV) dysfunction and elevated levels of biomarkers of cardiac damage. The best treatment option in these cases is still a subject of debate and the use of thrombolysis in submassive PE remains controversial. A 57-year-old Caucasian male with unprovoked PE, normal blood pressure, and elevated troponin I values was referred to the cardiovascular department. In view of the presence of a right atrium thrombus, the patient underwent surgical embolectomy under extracorporeal circulation, with the extraction of a huge thrombus together with fragmented thrombi from both pulmonary arteries. The patient developed an acute right heart failure solved with a temporary RV assist device (RVAD) support. The RV recovery was observed after 72 hours following the implantation. RVAD placement should be considered in the management of PE in case of acute right heart failure after reperfusion therapy since it can bring the patient out of a death spiral.
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Affiliation(s)
| | | | | | | | - Silvia Borile
- Cardiology, University of Genova Medical School, Genova, Italy
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25
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Jia D, Liu F, Zhang Q, Zeng GQ, Li XL, Hou G. Rapid on-site evaluation of routine biochemical parameters to predict right ventricular dysfunction in and the prognosis of patients with acute pulmonary embolism upon admission to the emergency room. J Clin Lab Anal 2017; 32:e22362. [PMID: 29160572 DOI: 10.1002/jcla.22362] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 10/30/2017] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Patients with acute pulmonary embolism(APE)who present with right ventricular dysfunction (RVD) have a worse prognosis. This study aimed to evaluate the value of routine biochemical parameters in predicting RVD and 30-day mortality in patients with APE. METHODS We retrospectively collected the clinical data for 154 enrolled patients, including the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), D-dimer, cardiac troponin I (cTnI), and N-terminal pro-brain natriuretic peptide (NT-proBNP). We analyzed the correlation between RVD and the parameters and conducted a receiver operating characteristic (ROC) curve to confirm the cut-off values for predicting RVD and 30-day mortality. Formulas were built with relevant parameters to predict RVD and 30-day mortality. RESULTS Age, NLR, PLR, D-dimer, the ratio of cTnI (+), and NT-proBNP (+) were significantly higher in RVD (+) patients. The ratio of cTnI (+) and NT-proBNP (+) in 30-day mortality (+) patients was significantly higher than that in 30-day mortality (-) patients. According to the logistic regression analysis, NLR, cTnI (+), and NT-proBNP (+) correlated with RVD. The formula for the RVD risk score is 0.072 × NLR+1.460 × NT-proBNP (+)+2.113 × cTnI (+), and the area under the curve (AUC) = 0.890 (95% CI: 0.839-0.941, P = .001). The formula for the 30-day mortality risk score is 0.115 × NLR + 2.046 × NT-proBNP (+) + 1.946 × cTnI (+) -0.016 × PLR, and the AUC = 0.903 (95% CI: 0.829-0.976, P = .001). CONCLUSIONS The rapid on-site evaluation of routine biochemical parameters, including NLR, cTnI, and NT-proBNP levels, and the formula developed using these parameters are valuable for predicting RVD and 30-day mortality in patients with APE.
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Affiliation(s)
- Dong Jia
- Emergency Department, Shengjing Hospital of China Medical University, Shenyang, China.,Institute of Respiratory Disease, the First Hospital of China Medical University, Shenyang, China
| | - Fan Liu
- Institute of Respiratory Disease, the First Hospital of China Medical University, Shenyang, China
| | - Qin Zhang
- Institute of Respiratory Disease, the First Hospital of China Medical University, Shenyang, China
| | - Guang-Qiao Zeng
- State Key Laboratory of Respiratory Disease, National Clinical Research Center of Respiratory Disease, Guangzhou Institute of Respiratory Diseases, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xue-Lian Li
- Department of Epidemiology, School of Public Health, China Medical University, Shenyang, China
| | - Gang Hou
- Institute of Respiratory Disease, the First Hospital of China Medical University, Shenyang, China
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Huynh N, Fares WH, Brownson K, Brahmandam A, Lee AI, Dardik A, Sarac T, Ochoa Chaar CI. Risk factors for presence and severity of pulmonary embolism in patients with deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2017; 6:7-12. [PMID: 29074107 DOI: 10.1016/j.jvsv.2017.08.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 08/07/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The Caprini model estimates patients' risk for venous thromboembolism by 30 different factors. Hemodynamically significant pulmonary embolism (PE), defined as high-risk (massive) or intermediate-risk (submassive) PE, has high morbidity and mortality rates. This study tests whether the Caprini model and deep venous thrombosis (DVT) characteristics correlate with the prevalence of PE and hemodynamically significant PE in patients with DVT. METHODS A retrospective review of patients diagnosed with DVT between January 2013 and August 2014 in a tertiary care center was performed. Multivariable analysis was used to determine predictors of PE and hemodynamically significant PE. RESULTS Of 838 consecutive patients with DVT, 217 (25.9%) had concomitant PE at presentation, of whom 135 had hemodynamically significant PE (101 submassive PE, 34 massive PE). The mean age was 65 years, and 51.0% were women. There was no significant relation between age or gender and the occurrence of PE or hemodynamically significant PE. Patients with PE were less likely to have undergone recent surgery (18.4% vs 30.3%; P = .001), to have sepsis (4.6% vs 11.8%; P = .002), and to have higher Caprini scores (6.1 vs 6.5; P = .047). Patients with DVT were less likely to have hemodynamically significant PE after recent surgery (13.3% vs 27.2%; P = .011) but more likely to have hemodynamically significant PE with proximal DVT (80.7% vs 64.2%). There was no association between Caprini score and hemodynamically significant PE (6.3 vs 5.7; P = .171). CONCLUSIONS The Caprini model has a poor association with PE or hemodynamically significant PE in patients with DVT. Among all patients with DVT, a concomitant diagnosis of PE or hemodynamically significant PE is less common in those with sepsis or undergoing recent surgery but more common in those with proximal DVT.
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Affiliation(s)
- Nancy Huynh
- Yale University School of Medicine, New Haven, Conn
| | - Wassim H Fares
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn
| | - Kirstyn Brownson
- Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Anand Brahmandam
- Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Alfred I Lee
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn
| | - Alan Dardik
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Timur Sarac
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Cassius Iyad Ochoa Chaar
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn.
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Heavner MS, Zhang M, Bast CE, Parker L, Eyler RF. Thrombolysis for Massive Pulmonary Embolism in Pregnancy. Pharmacotherapy 2017; 37:1449-1457. [DOI: 10.1002/phar.2025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Mojdeh S. Heavner
- Department of Pharmacy Practice and Science; University of Maryland School of Pharmacy; Baltimore Maryland
| | - Min Zhang
- Department of Pharmacy Services; Yale-New Haven Hospital; New Haven Connecticut
| | - Chelsea E. Bast
- Department of Pharmacy; Baylor University Medical Center; Dallas Texas
| | - Lindsey Parker
- Department of Pharmacy; The Johns Hopkins University Hospital; Baltimore Maryland
| | - Rachel F. Eyler
- Department of Pharmacy Practice; University of Connecticut School of Pharmacy; Storrs Connecticut
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Danielsbacka JS, Olsén MF, Hansson PO, Mannerkorpi K. Lung function, functional capacity, and respiratory symptoms at discharge from hospital in patients with acute pulmonary embolism: A cross-sectional study. Physiother Theory Pract 2017; 34:194-201. [DOI: 10.1080/09593985.2017.1377331] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Jenny S. Danielsbacka
- Department of Physiotherapy, Sahlgrenska University Hospital/Sahlgrenska, Gothenburg, Sweden
| | - Monika Fagevik Olsén
- Department of Physiotherapy, Sahlgrenska University Hospital/Sahlgrenska, Gothenburg, Sweden
| | - Per-Olof Hansson
- Department of Medicine, Sahlgrenska University Hospital/Sahlgrenska, Gothenburg, Sweden
| | - Kaisa Mannerkorpi
- Department of Health and Rehabilitation, Unit of Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Paczyńska M, Sobieraj P, Burzyński Ł, Kostrubiec M, Wiśniewska M, Bienias P, Kurnicka K, Lichodziejewska B, Pruszczyk P, Ciurzyński M. Tricuspid annulus plane systolic excursion (TAPSE) has superior predictive value compared to right ventricular to left ventricular ratio in normotensive patients with acute pulmonary embolism. Arch Med Sci 2016; 12:1008-1014. [PMID: 27695491 PMCID: PMC5016574 DOI: 10.5114/aoms.2016.57678] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 03/11/2015] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Right ventricular dysfunction (RVD) is an indicator of poor prognosis in normotensive patients with acute pulmonary embolism (APE). The aim of this study was to compare right ventricular (RV)/left ventricular (LV) ratio measured by echocardiography and multidetector computed tomography (MDCT) with tricuspid annulus plane systolic excursion (TAPSE) as a prognostic factor of APE-related 30-day mortality. MATERIAL AND METHODS We examined 76 patients with confirmed APE, hemodynamically stable at admission. We evaluated the prognostic value of RV/LV ratio in the apical 4-chamber view and TAPSE measured at echocardiography and the MDCT RV/LV ratio. RESULTS Thirty-day APE-related mortality was 10.5% (8 patients). The area under the curve (AUC) for TAPSE in the prediction of APE-related mortality was higher (p < 0.00001) (0.905, 95% CI: 0.828-0.983) than the AUC of the echo RV/LV ratio (0.427, 95% CI: 0.183-0.672) and MDCT RV/LV ratio (0.371, 95% CI: 0.145-0.598). In univariable Cox analysis, TAPSE was the only significant mortality predictor, with hazard ratio (HR) 0.73 (95% CI: 0.62-0.87, p = 0.0004). In multivariable Cox analysis TAPSE was the only significant mortality predictor, with HR 0.62 (95% CI: 0.46-0.85; p = 0.003), while age, heart rate, and RV/LV ratio in echo or MDCT were non-significant. TAPSE ≤ 15 mm was a significant predictor of APE-related mortality, with HR 26.2 (95% CI: 3.2-214.1; p = 0.002), PPV 44% and NPV 98%. CONCLUSIONS The TAPSE is preferable to echo and MDCT RV/LV ratio for risk stratification in initially normotensive patients with APE. The TAPSE ≤ 15 mm identifies patients with an increased risk of 30-day APE-related mortality.
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Affiliation(s)
- Marzanna Paczyńska
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Sobieraj
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Łukasz Burzyński
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Kostrubiec
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | - Piotr Bienias
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Kurnicka
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Barbara Lichodziejewska
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Michał Ciurzyński
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
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Soylu K, Gedikli Ö, Ekşi A, Avcıoğlu Y, Soylu Aİ, Yüksel S, Aksan G, Gülel O, Yılmaz Ö. Neutrophil-to-lymphocyte ratio for the assessment of hospital mortality in patients with acute pulmonary embolism. Arch Med Sci 2016; 12:95-100. [PMID: 26925123 PMCID: PMC4754370 DOI: 10.5114/aoms.2016.57585] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 05/25/2014] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Neutrophil-to-lymphocyte ratio (NLR), which is an essential marker of inflammation, has been shown to be associated with adverse outcomes in various cardiovascular diseases in the literature. In this study we sought to evaluate the association between NLR and prognosis of acute pulmonary embolism (APE). MATERIAL AND METHODS We retrospectively evaluated blood counts and clinical data of 142 patients with the diagnosis of pulmonary embolism (PE) from Ondokuz Mayis University Hospital between January 2006 and December 2012. The patients were divided into two groups according to NLR: NLR < 4.4 (low NLR group, n = 71) and NLR ≥ 4.4 (high NLR group, n = 71). RESULTS Massive embolism (66.2% vs. 36.6%, p < 0.001) and in-hospital mortality (21.1%, 1.4%, p < 0.001) were higher in the high NLR group. In multivariate regression analysis NLR ≥ 5.7, systolic blood pressure (BP) < 90 mm Hg, serum glucose > 126 mg/dl, heart rate > 110 beats/min, and PCO2 < 35 or > 50 mm Hg were predictors of in-hospital mortality. The optimal NLR cutoff value was 5.7 for mortality in receiver operating characteristic (ROC) analysis. Having an NLR value above 5.7 was found to be associated with a 10.8 times higher mortality rate than an NLR value below 5.7. CONCLUSIONS In patients presenting with APE, NLR value is an independent predictor of in-hospital mortality and may be used for clinical risk classification.
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Affiliation(s)
- Korhan Soylu
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Ömer Gedikli
- Department of Cardiology, Artvin State Hospital, Artvin, Turkey
| | - Alay Ekşi
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Yonca Avcıoğlu
- Department of Cardiology, Düzen Laboratories Group, Ankara, Turkey
| | - Ayşegül İdil Soylu
- Department of Radiology, Samsun Training and Research Hospital, Samsun, Turkey
| | - Serkan Yüksel
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Gökhan Aksan
- Department of Cardiology, Gazi State Hospital, Samsun, Turkey
| | - Okan Gülel
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
| | - Özcan Yılmaz
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey
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Azari A, Beheshti AT, Moravvej Z, Bigdelu L, Salehi M. Surgical embolectomy versus thrombolytic therapy in the management of acute massive pulmonary embolism: Short and long-term prognosis. Heart Lung 2015; 44:335-9. [PMID: 26077690 DOI: 10.1016/j.hrtlng.2015.04.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Revised: 04/12/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Comparison between surgical embolectomy and thrombolytic therapy in patients suffering from acute massive pulmonary embolism (AMPE). BACKGROUND Prompt treatment of AMPE is necessary, although optimal management is a matter of debate. METHODS Patients with AMPE were assigned to either thrombolytic therapy or pulmonary surgical embolectomy. Early and late mortality, systolic pulmonary artery pressure (SPAP), right ventricular diameter (RVD) and bleeding complications were evaluated. RESULTS Seventy eight patients were treated with thrombolytic therapy and 30 patients underwent surgery. The difference between pre-intervention and third-day post-intervention in terms of RVD and SPAP was significantly greater in patients under surgical embolectomy (P < 0.001). There was a significant decline in RVD and SPAP in both groups during follow-up (P < 0.001). Mortality rate in the surgical embolectomy group was lower than the thrombolytic group although not significantly. CONCLUSION Early surgical treatment was associated with fewer complications in comparison to thrombolytic therapy.
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Affiliation(s)
- Ali Azari
- Department of Cardiac Surgery, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Member of Cardiovascular Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ahmad Tashakori Beheshti
- Member of Cardiovascular Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Moravvej
- Member of Cardiovascular Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Students Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Leila Bigdelu
- Member of Cardiovascular Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Cardiology, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Maryam Salehi
- Department of Community Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Xu Q, Huang K, Zhai Z, Yang Y, Wang J, Wang C. Initial thrombolysis treatment compared with anticoagulation for acute intermediate-risk pulmonary embolism: a meta-analysis. J Thorac Dis 2015; 7:810-21. [PMID: 26101636 DOI: 10.3978/j.issn.2072-1439.2015.04.51] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 04/16/2015] [Indexed: 01/25/2023]
Abstract
BACKGROUND The use of thrombolysis in patients with acute, intermediate-risk pulmonary embolism (PE) remains controversial. This meta-analysis compared the efficacy and safety of thrombolysis and anticoagulation treatments for intermediate-risk PE patients. METHODS Two investigators independently reviewed the literature and collected data from randomized controlled trials (RCTs) of thrombolysis for intermediate-risk PE in the PubMed, MEDLINE, EMBASE, the Cochrane Library, and Chinese Biomedical Literature Databases (CBM). RESULTS A total of 1,631 intermediate-risk PE patients from seven studies were included. Significant differences were not found regarding the 30-day, all-cause mortality rates between the thrombolytic and anticoagulant groups [odds ratio (OR), 0.60; 95% confident interval (CI), 0.34-1.06; P=0.08]. The rate of clinical deterioration in the thrombolytic group was lower than that in the anticoagulant group (OR, 0.27; 95% CI, 0.18-0.41; P<0.01). Recurrent PE in the thrombolytic group was also significantly lower than that in the anticoagulant group (OR, 0.34; 95% CI, 0.15-0.77; P=0.01). Comparing the thrombolytic and anticoagulation groups, the incidence of minor bleeding was significantly higher in the thrombolytic group (OR, 5.33; 95% CI, 2.85-9.97; P<0.00001), but there were no difference in the incidences of major bleeding events (OR, 2.07; 95% CI, 0.60-7.16; P=0.25). CONCLUSIONS Thrombolytic treatment for intermediate-risk PE patients, if not contraindicated, could reduce clinical deterioration and recurrence of PE, and trends towards a decrease in all-cause, 30-day mortality. Despite thrombolytic treatment having an increased total bleeding risk, there was no difference in the incidence of major bleeding events, compared with patients receiving anticoagulation treatment.
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Affiliation(s)
- Qixia Xu
- 1 Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100069, China ; 3 Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, China ; 4 Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Peking University Health Science Center, Beijing 100029, China ; 5 Department of Physiology, School of Basic Medical Science, Capital Medical University, Beijing 100069, China ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
| | - Ke Huang
- 1 Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100069, China ; 3 Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, China ; 4 Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Peking University Health Science Center, Beijing 100029, China ; 5 Department of Physiology, School of Basic Medical Science, Capital Medical University, Beijing 100069, China ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
| | - Zhenguo Zhai
- 1 Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100069, China ; 3 Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, China ; 4 Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Peking University Health Science Center, Beijing 100029, China ; 5 Department of Physiology, School of Basic Medical Science, Capital Medical University, Beijing 100069, China ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
| | - Yuanhua Yang
- 1 Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100069, China ; 3 Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, China ; 4 Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Peking University Health Science Center, Beijing 100029, China ; 5 Department of Physiology, School of Basic Medical Science, Capital Medical University, Beijing 100069, China ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
| | - Jun Wang
- 1 Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100069, China ; 3 Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, China ; 4 Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Peking University Health Science Center, Beijing 100029, China ; 5 Department of Physiology, School of Basic Medical Science, Capital Medical University, Beijing 100069, China ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
| | - Chen Wang
- 1 Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China ; 2 Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing 100069, China ; 3 Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Bengbu Medical College, Bengbu 233004, China ; 4 Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Peking University Health Science Center, Beijing 100029, China ; 5 Department of Physiology, School of Basic Medical Science, Capital Medical University, Beijing 100069, China ; 6 Department of Respiratory Medicine, Capital Medical University, Beijing 100069, China ; 7 China-Japan Friendship Hospital, Beijing 100029, China
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Efficacy and safety of flow-directed pulmonary artery catheter thrombolysis for treatment of submassive pulmonary embolism. AJR Am J Roentgenol 2014; 202:1355-60. [PMID: 24848835 DOI: 10.2214/ajr.13.11366] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the efficacy and safety of flow-directed catheter thrombolysis for treatment of submassive pulmonary embolism (PE). MATERIALS AND METHODS In this single-institution retrospective study, 19 patients (nine men and 10 women; mean age [± SD], 54 ± 13 years) with submassive PE underwent catheter-directed thrombolysis between 2009 and 2013. Presenting symptoms included dyspnea in 18 of 19 (95%) cases. Submassive PE was diagnosed by pulmonary CT arteriography and right ventricular strain. PE was bilateral in 17 of 19 (89%) and unilateral in two of 19 (11%) cases. Thrombolysis was performed via a pulmonary artery (PA) catheter infusing 0.5- 1.0 mg alteplase per hour and was continued to complete or near complete clot dissolution with reduction in PA pressure. IV systemic heparin was administered. Measured outcomes included procedural success, PA pressure reduction, clinical success, survival, and adverse events. RESULTS Procedural success, defined as successful PA catheter placement, fibrinolytic agent delivery, PA pressure reduction, and achievement of complete or near complete clot dissolution, was achieved in 18 of 19 (95%) cases. Thrombolysis required 57 ± 31 mg of alteplase administered over 89 ± 32 hours. Initial and final PA pressures were 30 ± 10 mm Hg and 20 ± 8 mm Hg (p < 0.001). All 18 (100%) technically successful cases achieved clinical success because all patients experienced symptomatic improvement. Eighteen of 19 (95%) patients survived to hospital discharge; 18 of 19 (95%) and 15 of 16 (94%) patients had documented 1-month and 3-month survival. One fatal case of intracranial hemorrhage was attributed to supratherapeutic anticoagulation because normal fibrinogen levels did not suggest remote fibrinolysis; procedural success was not achieved in this case because of early thrombolysis termination. No other complications were encountered. CONCLUSION Among a small patient cohort, flow-directed catheter thrombolysis with alteplase effectively dissolved submassive PE and reduced PA pressure. Postprocedure short-term survival was high, and patients undergoing thrombolysis required close observation for bleeding events.
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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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Bavare AC, Naik SX, Lin PH, Poi MJ, Yee DL, Bronicki RA, Philip JX, Desai MS. Catheter-directed thrombolysis for severe pulmonary embolism in pediatric patients. Ann Vasc Surg 2014; 28:1794.e1-7. [PMID: 24698774 DOI: 10.1016/j.avsg.2014.03.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 03/21/2014] [Accepted: 03/25/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Catheter-directed thrombolytic (CDT) therapies for severe pulmonary embolism (PE) have been shown to be effective and safe when compared with systemic thrombolysis in adults. Pediatric studies assessing efficacy and safety of CDT for PE are lacking. Hence, our aim was to review CDT as a therapy for pediatric PE. METHODS We retrospectively reviewed charts of patients aged <18 years, who underwent CDT for main or major branch pulmonary artery occlusion associated with hypotension or right ventricular dysfunction secondary to PE during a 3-year period, in our tertiary care academic Pediatric Intensive Care Unit. RESULTS Six CDT interventions were performed on 5 patients with PE (median age: 16.5 years). All patients presented with chest pain and dyspnea. The predisposing factors for thrombogenesis differed in all patients, and all had multiple risk factors. Five of six procedures (83%) were accompanied by ultrasound agitation with EKOS endowave infusion system (ultrasound-accelerated CDT [UCDT]), whereas 1 had CDT without ultrasound agitation. Complete resolution of PE occurred in 4 instances (67%) at 24 hr, whereas in 2 cases (33%), there was partial resolution. One patient with complete resolution underwent another successful UCDT after 4 months for recurrence. Clinical parameters (heart rate, respiratory rate, blood pressure, and oxygen saturations) and echocardiographic findings improved after treatment in all the patients. Median duration of hospital stay was 9 days with no mortality and treatment-related complications. All patients were discharged with long-term anticoagulation. CONCLUSIONS Our case series is the first that describes CDT/UCDT as an effective and safe therapy for pediatric patients with severe PE. CDT is known to accelerate fibrinolysis via focused delivery of thrombolytic agent to the thrombus site. For carefully selected patients, CDT/UCDT provides a useful treatment option for severe PE irrespective of the etiology, predisposing conditions, and associated comorbidities.
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Affiliation(s)
- Aarti C Bavare
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX.
| | - Swati X Naik
- Section of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Peter H Lin
- Division of Vascular Surgery and Endovascular Therapy, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Mun Jye Poi
- Division of Vascular Surgery and Endovascular Therapy, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Donald L Yee
- Section of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Ronald A Bronicki
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Joseph X Philip
- Congenital Heart Center, Shands Hospital, University of Florida, Gainsville, Florida
| | - Moreshwar S Desai
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
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Al Otair HAK, Al-Boukai AA, Ibrahim GF, Al Shaikh MK, Mayet AY, Al-Hajjaj MS. Outcome of pulmonary embolism and clinico-radiological predictors of mortality: Experience from a university hospital in Saudi Arabia. Ann Thorac Med 2014; 9:18-22. [PMID: 24551013 PMCID: PMC3912681 DOI: 10.4103/1817-1737.124420] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 08/26/2013] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The objective of this study is to determine the outcome of pulmonary embolism (PE) and the clinico-radiological predictors of mortality in a university hospital setting. METHODS A Prospective observational study conducted at King Khalid University Hospital, Riyadh Saudi Arabia between January 2009 and 2012. A total of 105 consecutive patients (49.9 ± 18.7 years) with PE diagnosed by computed tomography pulmonary angiography were followed until death or hospital discharge. RESULTS Overall in hospital mortality rate was 8.6%, which is lower than other international reports. Two-thirds of patients developed PE during the hospitalization. The most common risk factors were surgery (35.2%), obesity (34.3%) and immobility (30.5%). The localization of the embolus was central in 32.4%, lobar in 19% and distal in 48.6%. A total of 26 patients (25%) had evidence of right ventricular strain and 14 (13.3%) were hypotensive. Multivariate analysis revealed that heart failure (Beta = -0.53, P < 0.001), palpitation (Beta = -0.24, P = 0.014) and high respiratory rate (Beta = -0.211, P < 0.036) were significant predictors of mortality. There was no significant difference in the localization of the embolus or obstruction score between survivors and non-survivors. CONCLUSION The outcome of PE is improving; however, it remains an important risk factor for mortality in hospitalized patients. Congestive heart failure, tachypnea and tachycardia at presentation were associated with higher mortality. These factors need to be considered for risk stratification and management decisions of PE patients. Radiological quantification of clot burden was not a predictor of death.
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Affiliation(s)
- Hadil A. K. Al Otair
- Department of Critical Care Medicine, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Ahmad A. Al-Boukai
- Department of Radiology, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Gehan F. Ibrahim
- Department of Radiology, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Mashael K. Al Shaikh
- Department of Pharmacy, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Ahmed Y. Mayet
- Department of Pharmacy, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Mohamed S. Al-Hajjaj
- Department of Medicine, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
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Zhang Z, Zhai ZG, Liang LR, Liu FF, Yang YH, Wang C. Lower dosage of recombinant tissue-type plasminogen activator (rt-PA) in the treatment of acute pulmonary embolism: a systematic review and meta-analysis. Thromb Res 2013; 133:357-63. [PMID: 24412030 DOI: 10.1016/j.thromres.2013.12.026] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 12/17/2013] [Accepted: 12/19/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVE According to US Food and Drugs Administration (FDA), 2 hour recombinant tissue plasminogen activator (rt-PA) 100mg infusion is recommended for eligible patients with acute pulmonary embolism (PE). However,there exists evidence implying that a lower dosage of rt-PA can be equally effective but potentially safer compared with rt-PA 100mg regimen. The aim of this systematic review and meta-analysis is to assess the efficacy and safety of low dose rt-PA in the treatment of acute PE. MATERIAL AND METHOD We searched Pubmed, EMBASE, the Cochrane library and CBM Literature Database for randomized controlled trials (RCT) focusing on low dose rt-PA for acute PE. Outcomes were described in terms of changes of image tests and echocardiography, major bleeding events, all-cause death, and recurrence of PE. RESULTS Five studies (440 patients) were included, three of which compared low dose rt-PA (0.6 mg/kg, maximum 50mg or 50mg infusion 2h) with standard dose (100mg infusion 2h). There were more major bleeding events in standard dose rt-PA group than in low dose group (OR 0.33, 95%CI 0.12-0.91;P=0.94,I(2)=0%), while there were no statistical differences in recurrent PE or all cause mortality between these two groups. Two studies compared low dose (0.6 mg/kg, maximum 50mg/2 min bolus or 10mg bolus, ≤40 mg/2 h) with heparin. There was no significant difference in major bleeding events (OR 0.73, 95% CI 0.14-3.98;P=0.72), recurrent PE or all cause mortality. No dose-related heterogeneity was found for all the included studies. CONCLUSIONS The results of this meta-analysis were hypothesis-generating. Based on the limited data, our systematic review suggested that low dose rt-PA had similar efficacy but was safer than standard dose of rt-PA. In addition, compared with heparin, low dose rt-PA didn't increase the risk of major bleeding for eligible PE patients.
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Affiliation(s)
- Zhu Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Zhen-guo Zhai
- Department of Respiratory and Critical Care Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China.
| | - Li-rong Liang
- Department of Respiratory and Critical Care Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Fang-fang Liu
- Department of Respiratory and Critical Care Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Yuan-hua Yang
- Department of Respiratory and Critical Care Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Chen Wang
- Department of Respiratory and Critical Care Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China; Beijing Hospital, Ministry of Health, Beijing, China
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Chandy D, Aronow WS, Banach M. Current perspectives on treatment of hypertensive patients with chronic obstructive pulmonary disease. Integr Blood Press Control 2013; 6:101-9. [PMID: 23901294 PMCID: PMC3724277 DOI: 10.2147/ibpc.s33982] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Systemic hypertension and chronic obstructive pulmonary disease (COPD) frequently coexist in the same patient, especially in the elderly. Today, a wide variety of antihypertensive drugs with different mechanisms of action are available to the prescribing physician. In addition, combination drugs for hypertension are becoming increasingly popular. Certain antihypertensive drugs can affect pulmonary function. Therefore the management of such patients can present therapeutic challenges. We have examined the literature pertaining to the use of antihypertensive drugs in patients with systemic hypertension and coexisting COPD. Although data are often limited or of poor quality, we have attempted to review and then provide recommendations regarding the use of all the specific classes of antihypertensive drug therapies including combination drugs in patients with COPD. The antihypertensive agents reviewed include diuretics, aldosterone receptor blockers, beta blockers, combined alpha and beta blockers, angiotensin-converting enzyme inhibitors, angiotensin II antagonists, calcium channel blockers, alpha-1 blockers, centrally acting drugs, direct vasodilators, and combinations of these drugs. Of these classes, calcium channel blockers and angiotensin II antagonists appear to be the best initial choices if hypertension is the only indication for treatment. However, the limited data available on many of these drugs suggest that additional studies are needed to more precisely determine the best treatment choices in this widely prevalent patient group.
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