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Birrenkott DA, Kabrhel C, Dudzinski DM. Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies. Cardiol Clin 2024; 42:215-235. [PMID: 38631791 DOI: 10.1016/j.ccl.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.
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Affiliation(s)
- Drew A Birrenkott
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiac Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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2
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Rouleau SG, Casey SD, Kabrhel C, Vinson DR, Long B. Management of high-risk pulmonary embolism in the emergency department: A narrative review. Am J Emerg Med 2024; 79:1-11. [PMID: 38330877 DOI: 10.1016/j.ajem.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE. OBJECTIVE This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations. DISCUSSION High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions. CONCLUSIONS Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.
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Affiliation(s)
- Samuel G Rouleau
- Department of Emergency Medicine, UC Davis Health, University of California, Davis, Sacramento, CA, United States of America.
| | - Scott D Casey
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, CA, United States of America.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - David R Vinson
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
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Al Jalbout N, Ma I, Shokoohi H, McFadden K, Kabrhel C, Giordano N, Liteplo A. A Novel Tool for Predicting an Abnormal Echocardiogram in Patients with Pulmonary Embolism: The PEACE Score. J Emerg Med 2024; 66:e403-e412. [PMID: 38311529 DOI: 10.1016/j.jemermed.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 11/09/2023] [Accepted: 11/16/2023] [Indexed: 02/06/2024]
Abstract
BACKGROUND Transthoracic echocardiography (TTE) is an essential tool for risk-stratifying patients with pulmonary embolism (PE), but its availability is limited, often requiring hospitalization. Minimal research exists evaluating clinical and laboratory criteria to predict lack of abnormal TTE findings. OBJECTIVE We aimed to identify predictors associated with abnormal TTE results in patients with PE to potentially identify those safe for early discharge. METHODS In this retrospective study, we analyzed an existing database of patients with venous thromboembolism (VTE) at two academic emergency departments, including adult patients with confirmed PE who underwent TTE. The primary goal was to develop and validate a score predicting abnormal TTE, defined as presence of one of the following: right ventricle (RV) dilatation or hypokinesis, septal flattening, right heart thrombus in transit, or ejection fraction < 50%. Variables were demographic characteristics, symptoms, computed tomography (CT) RV strain, troponin T, and N-terminal prohormone of brain natriuretic peptide (NTproBNP). Stepwise logistic regression was used to identify variables independently associated with abnormal TTE. Model discrimination was evaluated using area under the curve (AUC) of the receiver operating characteristic curve. A clinical prediction rule was developed. RESULTS 530 of 2235 patients were included; 56% (297 of 530) had an abnormal TTE. The following six variables were independently associated with abnormal TTE: dyspnea, dizziness, troponin T ≥ 0.1 ng/mL, NTproBNP > 900 pg/mL, CT RV strain, and nonsubsegmental PE. A clinical prediction rule using these six criteria yielded scores between 0 and 7, performing well with AUC of 0.80 (95% CI 0.79-0.80). A score of 1 was 99.7% sensitive in identifying no abnormality. A score ≥ 5 was 98% specific for an abnormality. CONCLUSIONS The PEACE (Pulmonary Embolism and Abnormal Cardiac Echocardiogram) criteria, composed of six variables, is highly effective in predicting abnormal TTE in patients with PE, potentially identifying who is safe for early discharge from the hospital.
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Affiliation(s)
- Nour Al Jalbout
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Irene Ma
- Department of Internal Medicine, University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Hamid Shokoohi
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kathleen McFadden
- Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicholas Giordano
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew Liteplo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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4
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Casey SD, Stubblefield WB, Luijten D, Klok FA, Westafer LM, Vinson DR, Kabrhel C. Addressing the rising trend of high-risk pulmonary embolism mortality: Clinical and research priorities. Acad Emerg Med 2024; 31:288-292. [PMID: 38129964 DOI: 10.1111/acem.14859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Deaths from high-risk pulmonary embolism (PE) appear to have increased in the US over the last decade. Modifiable risks contributing to this worrisome trend present opportunities for physicians, researchers, and healthcare policymakers to improve care. METHODS We sought to contextualize contemporary, high-risk PE epidemiology and examine clinical trials, quality improvement opportunities, and healthcare policy initiatives directed at reducing mortality. RESULTS We observed significant and modifiable excess mortality due to high-risk PE. We identified several opportunities to improve care including: (1) rapid translation of forthcoming data on reperfusion strategies into clinical practice; (2) improved risk stratification tools; (3) quality improvement initiatives to address presumptive anticoagulation practice gaps; and (3) adoption of health policy initiatives to establish pulmonary embolism response teams and address the social determinants of health. CONCLUSION Addressing knowledge and practice gaps in intermediate and high-risk PE management must be prioritized and informed by forthcoming high-quality data. Implementation efforts are needed to improve acute PE management and resolve treatment disparities.
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Affiliation(s)
- Scott D Casey
- Kaiser Permanente Division of Research, Oakland, California, USA
- The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, California, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dieuwke Luijten
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medicine Center, Leiden, Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medicine Center, Leiden, Netherlands
| | - Lauren M Westafer
- Department of Emergency Medicine, UMASS Chan Medical School-Baystate, Springfield, Massachusetts, USA
- Department of Healthcare Delivery and Population Science, UMASS Chan Medical School-Baystate, Springfield, Massachusetts, USA
| | - David R Vinson
- Kaiser Permanente Division of Research, Oakland, California, USA
- The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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5
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Jee YH, Thibord F, Dominguez A, Sept C, Boulier K, Venkateswaran V, Ding Y, Cherlin T, Verma SS, Faro VL, Bartz TM, Boland A, Brody JA, Deleuze JF, Emmerich J, Germain M, Johnson AD, Kooperberg C, Morange PE, Pankratz N, Psaty BM, Reiner AP, Smadja DM, Sitlani CM, Suchon P, Tang W, Trégouët DA, Zöllner S, Pasaniuc B, Damrauer SM, Sanna S, Snieder H, Kabrhel C, Smith NL, Kraft P. Multi-ancestry polygenic risk scores for venous thromboembolism. medRxiv 2024:2024.01.09.24300914. [PMID: 38260294 PMCID: PMC10802635 DOI: 10.1101/2024.01.09.24300914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Venous thromboembolism (VTE) is a significant contributor to morbidity and mortality, with large disparities in incidence rates between Black and White Americans. Polygenic risk scores (PRSs) limited to variants discovered in genome-wide association studies in European-ancestry samples can identify European-ancestry individuals at high risk of VTE. However, there is limited evidence on whether high-dimensional PRS constructed using more sophisticated methods and more diverse training data can enhance the predictive ability and their utility across diverse populations. We developed PRSs for VTE using summary statistics from the International Network against Venous Thrombosis (INVENT) consortium GWAS meta-analyses of European- (71,771 cases and 1,059,740 controls) and African-ancestry samples (7,482 cases and 129,975 controls). We used LDpred2 and PRSCSx to construct ancestry-specific and multi-ancestry PRSs and evaluated their performance in an independent European- (6,261 cases and 88,238 controls) and African-ancestry sample (1,385 cases and 12,569 controls). Multi-ancestry PRSs with weights tuned in European- and African-ancestry samples, respectively, outperformed ancestry-specific PRSs in European- (PRSCSXEUR: AUC=0.61 (0.60, 0.61), PRSCSX_combinedEUR: AUC=0.61 (0.60, 0.62)) and African-ancestry test samples (PRSCSXAFR: AUC=0.58 (0.57, 0.6), PRSCSX_combined AFR: AUC=0.59 (0.57, 0.60)). The highest fifth percentile of the best-performing PRS was associated with 1.9-fold and 1.68-fold increased risk for VTE among European- and African-ancestry subjects, respectively, relative to those in the middle stratum. These findings suggest that the multi-ancestry PRS may be used to identify individuals at highest risk for VTE and provide guidance for the most effective treatment strategy across diverse populations.
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Affiliation(s)
- Yon Ho Jee
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, MA, USA
| | - Florian Thibord
- Population Sciences Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, MD, USA
- The Framingham Heart Study, 73 Mt. Wayte Ave, Suite #2, Framingham, MA, 01702 USA
| | - Alicia Dominguez
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Corriene Sept
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Kristin Boulier
- Bioinformatics Interdepartmental Program, University of California Los Angeles, Los Angeles, CA, USA
| | - Vidhya Venkateswaran
- Department of Oral Biology, University of California Los Angeles School of Dentistry, Los Angeles, CA, USA
| | - Yi Ding
- Bioinformatics Interdepartmental Program, University of California Los Angeles, Los Angeles, CA, USA
| | - Tess Cherlin
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Shefali Setia Verma
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Valeria Lo Faro
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Immunology, Genetics and Pathology, Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Traci M. Bartz
- Cardiovascular Health Research Unit, Departments of Biostatistics and Medicine, University of Washington, 4333 Brooklyn Ave, Seattle, WA 98195
| | - Anne Boland
- Université Paris-Saclay, CEA, Centre National de Recherche en Génomique Humaine, Evry, France
- Laboratory of Excellence in Medical Genomics, GENMED, Evry, France
| | - Jennifer A. Brody
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, 4333 Brooklyn Ave, Seattle, WA 98195
| | - Jean-Francois Deleuze
- Université Paris-Saclay, CEA, Centre National de Recherche en Génomique Humaine, Evry, France
- Laboratory of Excellence in Medical Genomics, GENMED, Evry, France
- Centre d’Etude du Polymorphisme Humain, Fondation Jean Dausset, Paris, France
| | - Joseph Emmerich
- Department of Vascular Medicine, Paris Saint-Joseph Hospital Group, University of Paris, Paris, France
- UMR1153, INSERM CRESS, Paris, France
| | - Marine Germain
- University of Bordeaux, INSERM, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
| | - Andrew D. Johnson
- Population Sciences Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, MD, USA
- The Framingham Heart Study, 73 Mt. Wayte Ave, Suite #2, Framingham, MA, 01702 USA
| | - Charles Kooperberg
- Division of Public Health Sciences, Fred Hutchinbson Cancer Center, Seattle WA 98109
| | - Pierre-Emmanuel Morange
- Aix-Marseille University, INSERM, INRAE, Centre de Recherche en CardioVasculaire et Nutrition, Laboratory of Haematology, CRB Assistance Publique – Hôpitaux de Marseille, HemoVasc, Marseille, France
| | - Nathan Pankratz
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, 55455, USA
| | - Bruce M. Psaty
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, 4333 Brooklyn Ave, Seattle, WA 98195
- Department of Epidemiology, University of Washington, 4333 Brooklyn Ave, Seattle, WA 98195
- Department of Health Systems and Population Health, University of Washington, 4333 Brooklyn Ave, Seattle, WA 98195
| | - Alexander P. Reiner
- Division of Public Health Sciences, Fred Hutchinbson Cancer Center, Seattle WA 98109
- Department of Epidemiology, University of Washington, 4333 Brooklyn Ave, Seattle, WA 98195
| | - David M. Smadja
- Innovative Therapies in Hemostasis, Université de Paris, INSERM, F-75006 Paris, France
- Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance Publique Hôpitaux de Paris, Centre-Université de Paris (APHP-CUP), F-75015 Paris, France
| | - Colleen M. Sitlani
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, 4333 Brooklyn Ave, Seattle, WA 98195
| | - Pierre Suchon
- Aix-Marseille University, INSERM, INRAE, Centre de Recherche en CardioVasculaire et Nutrition, Laboratory of Haematology, CRB Assistance Publique – Hôpitaux de Marseille, HemoVasc, Marseille, France
| | - Weihong Tang
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, 55454, USA
| | - David-Alexandre Trégouët
- University of Bordeaux, INSERM, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
| | - Sebastian Zöllner
- Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA
| | - Bogdan Pasaniuc
- Department of Oral Biology, University of California Los Angeles School of Dentistry, Los Angeles, CA, USA
| | - Scott M. Damrauer
- Department of Genetics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Surgery, Department of Genetics, and Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
- Department of Surgery, Corporal Michael Crescenz VA Medical Center, Philadelphia PA
| | - Serena Sanna
- University of Groningen, UMCG, Department of Genetics, Groningen, the Netherlands
- Institute for Genetics and Biomedical Research, National Research Council, Monserrato, Italy
| | - Harold Snieder
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Christopher Kabrhel
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicholas L. Smith
- Department of Health Systems and Population Health, University of Washington, 4333 Brooklyn Ave, Seattle, WA 98195
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle WA 98101, USA
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle WA 98108, USA
| | - Peter Kraft
- Transdivisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, MD, USA
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Lyhne MD, Bikdeli B, Dudzinski DM, Muriel-García A, Kabrhel C, Sancho-Bueso T, Pérez-David E, Lobo JL, Alonso-Gómez Á, Jiménez D, Monreal M. Validation of Echocardiographic Measurements in Patients with Pulmonary Embolism in the RIETE Registry. TH Open 2024; 8:e1-e8. [PMID: 38197015 PMCID: PMC10774011 DOI: 10.1055/s-0043-1777765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/01/2023] [Indexed: 01/11/2024] Open
Abstract
Background In acute pulmonary embolism (PE), echocardiographic identification of right ventricular (RV) dysfunction will inform prognostication and clinical decision-making. Registro Informatizado Enfermedad TromboEmbolica (RIETE) is the world's largest registry of patients with objectively confirmed PE. The reliability of site-reported RV echocardiographic measurements is unknown. We aimed to validate site-reported key RV echocardiographic measurements in the RIETE registry. Methods Fifty-one randomly chosen patients in RIETE who had transthoracic echocardiogram (TTE) performed for acute PE were included. TTEs were de-identified and analyzed by a core laboratory of two independent observers blinded to site-reported data. To investigate reliability, intraclass correlation coefficients (ICCs) and Bland-Altman plots between the two observers, and between an average of the two observers and the RIETE site-reported data were obtained. Results Core laboratory interobserver variations were very limited with correlation coefficients >0.8 for all TTE parameters. Agreement was substantial between core laboratory observers and site-reported data for key parameters including tricuspid annular plane systolic excursion (ICC 0.728; 95% confidence interval [CI], 0.594-0.862) and pulmonary arterial systolic pressure (ICC 0.726; 95% CI, 0.601-0.852). Agreement on right-to-left ventricular diameter ratio (ICC 0.739; 95% CI, 0.443-1.000) was validated, although missing data limited the precision of the estimates. Bland-Altman plots showed differences close to zero. Conclusion We showed substantial reliability of key RV site-reported measurements in the RIETE registry. Ascertaining the validity of such data adds confidence and reliability for subsequent investigations.
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Affiliation(s)
- Mads Dam Lyhne
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
- Yale-New Haven Hospital (YNHH)/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, United States
| | - David M. Dudzinski
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Alfonso Muriel-García
- Unidad de Bioestadística Clínica, Hospital Universitario Ramón y Cajal, Madrid and CIBERESP, Universidad de Alcalá, Madrid, Spain
| | - Christopher Kabrhel
- Department of Emergency Medicine, Centre of Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Teresa Sancho-Bueso
- Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
| | | | - José Luis Lobo
- Department of Pneumonology, Hospital Universitario Araba, Álava, Spain
| | | | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá, Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Manuel Monreal
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM - Universidad Católica San Antonio de Murcia, Murcia, Spain
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7
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Kaptoge S, Seshasai SRK, Sun L, Walker M, Bolton T, Spackman S, Ataklte F, Willeit P, Bell S, Burgess S, Pennells L, Altay S, Assmann G, Ben-Shlomo Y, Best LG, Björkelund C, Blazer DG, Brenner H, Brunner EJ, Dagenais GR, Cooper JA, Cooper C, Crespo CJ, Cushman M, D'Agostino RB, Daimon M, Daniels LB, Danker R, Davidson KW, de Jongh RT, Donfrancesco C, Ducimetiere P, Elders PJM, Engström G, Ford I, Gallacher I, Bakker SJL, Goldbourt U, de La Cámara G, Grimsgaard S, Gudnason V, Hansson PO, Imano H, Jukema JW, Kabrhel C, Kauhanen J, Kavousi M, Kiechl S, Knuiman MW, Kromhout D, Krumholz HM, Kuller LH, Laatikainen T, Lowler DA, Meyer HE, Mukamal K, Nietert PJ, Ninomiya T, Nitsch D, Nordestgaard BG, Palmieri L, Price JF, Ridker PM, Sun Q, Rosengren A, Roussel R, Sakurai M, Salomaa V, Schöttker B, Shaw JE, Strandberg TE, Sundström J, Tolonen H, Tverdal A, Verschuren WMM, Völzke H, Wagenknecht L, Wallace RB, Wannamethee SG, Wareham NJ, Wassertheil-Smoller S, Yamagishi K, Yeap BB, Harrison S, Inouye M, Griffin S, Butterworth AS, Wood AM, Thompson SG, Sattar N, Danesh J, Di Angelantonio E, Tipping RW, Russell S, Johansen M, Bancks MP, Mongraw-Chaffin M, Magliano D, Barr ELM, Zimmet PZ, Knuiman MW, Whincup PH, Willeit J, Willeit P, Leitner C, Lawlor DA, Ben-Shlomo Y, Elwood P, Sutherland SE, Hunt KJ, Cushman M, Selmer RM, Haheim LL, Ariansen I, Tybjaer-Hansen A, Frikkle-Schmidt R, Langsted A, Donfrancesco C, Lo Noce C, Balkau B, Bonnet F, Fumeron F, Pablos DL, Ferro CR, Morales TG, Mclachlan S, Guralnik J, Khaw KT, Brenner H, Holleczek B, Stocker H, Nissinen A, Palmieri L, Vartiainen E, Jousilahti P, Harald K, Massaro JM, Pencina M, Lyass A, Susa S, Oizumi T, Kayama T, Chetrit A, Roth J, Orenstein L, Welin L, Svärdsudd K, Lissner L, Hange D, Mehlig K, Salomaa V, Tilvis RS, Dennison E, Cooper C, Westbury L, Norman PE, Almeida OP, Hankey GJ, Hata J, Shibata M, Furuta Y, Bom MT, Rutters F, Muilwijk M, Kraft P, Lindstrom S, Turman C, Kiyama M, Kitamura A, Yamagishi K, Gerber Y, Laatikainen T, Salonen JT, van Schoor LN, van Zutphen EM, Verschuren WMM, Engström G, Melander O, Psaty BM, Blaha M, de Boer IH, Kronmal RA, Sattar N, Rosengren A, Nitsch D, Grandits G, Tverdal A, Shin HC, Albertorio JR, Gillum RF, Hu FB, Cooper JA, Humphries S, Hill- Briggs F, Vrany E, Butler M, Schwartz JE, Kiyama M, Kitamura A, Iso H, Amouyel P, Arveiler D, Ferrieres J, Gansevoort RT, de Boer R, Kieneker L, Crespo CJ, Assmann G, Trompet S, Kearney P, Cantin B, Després JP, Lamarche B, Laughlin G, McEvoy L, Aspelund T, Thorsson B, Sigurdsson G, Tilly M, Ikram MA, Dorr M, Schipf S, Völzke H, Fretts AM, Umans JG, Ali T, Shara N, Davey-Smith G, Can G, Yüksel H, Özkan U, Nakagawa H, Morikawa Y, Ishizaki M, Njølstad I, Wilsgaard T, Mathiesen E, Sundström J, Buring J, Cook N, Arndt V, Rothenbacher D, Manson J, Tinker L, Shipley M, Tabak AG, Kivimaki M, Packard C, Robertson M, Feskens E, Geleijnse M, Kromhout D. Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation. Lancet Diabetes Endocrinol 2023; 11:731-742. [PMID: 37708900 PMCID: PMC7615299 DOI: 10.1016/s2213-8587(23)00223-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 07/14/2023] [Accepted: 07/14/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy. METHODS For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU. FINDINGS For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier. INTERPRETATION Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes. FUNDING British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.
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Lyhne MD, Dudzinski DM, Andersen A, Nielsen-Kudsk JE, Muzikansky A, Kabrhel C. Right-to-left ventricular ratio is higher in systole than diastole in patients with acute pulmonary embolism. Echocardiography 2023; 40:925-931. [PMID: 37477341 DOI: 10.1111/echo.15655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/11/2023] [Accepted: 07/12/2023] [Indexed: 07/22/2023] Open
Abstract
OBJECTIVES In acute pulmonary embolism (PE), the right ventricle (RV) may dilate compromising left ventricular (LV) size, thereby increasing RV/LV ratio. End-diastolic RV/LV ratio is often used in PE risk stratification, though the cause of death is RV systolic failure. We aimed to confirm our pre-clinical observations of higher RV/LV ratio in systole compared to diastole in human patients with PE. METHODS We blinded and independently analyzed echocardiograms from 606 patients with PE, evaluated by a Pulmonary Embolism Response Team. We measured RV/LV ratios in end-systole and end-diastole and fractional area change (FAC). Our primary outcome was a composite of 7-day clinical deterioration, treatment escalation or death. Secondary outcomes were 7-day and 30-day all-cause mortality. RESULTS RV/LV ratio was higher in systole compared to diastole (median 1.010 [.812-1.256] vs. .975 [.843-1.149], p < .0001). RV/LV in systole and diastole were correlated (slope = 1.30 [95% CI 1.25-1.35], p < .0001 vs. slope = 1). RV/LV ratios in both systole and diastole were associated with the primary composite outcome but not with all-cause mortality. CONCLUSION The RV/LV ratio is higher when measured in systole versus in diastole in patients with acute PE. The two approaches had similar associations with clinical outcomes, that is, it appears reasonable to measure RV/LV ratio in diastole.
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Affiliation(s)
- Mads Dam Lyhne
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - David M Dudzinski
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Asger Andersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Alona Muzikansky
- Biostatistics Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts, USA
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Smyth R, Kabrhel C, Morris T. Treatment of Intermediate-Risk Pulmonary Embolism. N Engl J Med 2023; 389:184-187. [PMID: 37437150 DOI: 10.1056/nejmclde2301330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
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Lyhne MD, Giordano N, Dudzinski D, Torrey J, Wang G, Zheng H, Parry BA, Kalra MK, Kabrhel C. Authors' reply. Emerg Radiol 2023:10.1007/s10140-023-02145-6. [PMID: 37301788 DOI: 10.1007/s10140-023-02145-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Mads Dam Lyhne
- Department of Emergency Medicine, Massachusetts General Hospital, 0 Emerson Place, Suite 3B, Boston, MA, 02114, USA
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Nicholas Giordano
- Department of Emergency Medicine, Massachusetts General Hospital, 0 Emerson Place, Suite 3B, Boston, MA, 02114, USA
| | - David Dudzinski
- Department of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Jasmine Torrey
- Department of Emergency Medicine, Massachusetts General Hospital, 0 Emerson Place, Suite 3B, Boston, MA, 02114, USA
| | - Grace Wang
- Department of Emergency Medicine, Massachusetts General Hospital, 0 Emerson Place, Suite 3B, Boston, MA, 02114, USA
| | - Hui Zheng
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA, USA
| | - Blair Alden Parry
- Department of Emergency Medicine, Massachusetts General Hospital, 0 Emerson Place, Suite 3B, Boston, MA, 02114, USA
| | - Mannudeep K Kalra
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, 0 Emerson Place, Suite 3B, Boston, MA, 02114, USA.
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Lyhne MD, Giordano N, Dudzinski D, Torrey J, Wang G, Zheng H, Parry BA, Kalra MK, Kabrhel C. Low concordance between CTPA and echocardiography in identification of right ventricular strain in PERT patients with acute pulmonary embolism. Emerg Radiol 2023; 30:325-331. [PMID: 37084161 DOI: 10.1007/s10140-023-02130-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/29/2023] [Indexed: 04/22/2023]
Abstract
PURPOSE Right ventricular strain (RVS) is used to risk stratify patients with acute pulmonary embolism (PE) and influence treatment decisions. Guidelines suggest that either computed tomography pulmonary angiography (CTPA) or transthoracic echocardiography (TTE) can be used to assess RVS. We sought to determine how often CTPA and TTE yield discordant results and to assess the test characteristics of CTPA compared to TTE. METHODS We analyzed data from a single-center registry of PE cases severe enough to warrant activation of the hospital's Pulmonary Embolism Response Team (PERT). We defined RVS as a right ventricular to left ventricular ratio (RV/LV) ≥ 1 or radiologist's interpretation of RVS on CTPA or as the presence of either RV dilation, hypokinesis, or septal bowing on TTE. RESULTS We included 554 patients in our analysis, of whom 333 (60%) had concordant RVS findings on CTPA and TTE. Using TTE as the reference standard, CTPA had a sensitivity of 95% (95% CI 92-97%) and a specificity of 4% (95% CI 2-8%) for identifying RVS. CONCLUSIONS In a selected population of patients with acute PE for which PERT was activated, CTPA is highly sensitive but not specific for the detection of RVS when compared to TTE.
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Affiliation(s)
- Mads Dam Lyhne
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark & Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Nicholas Giordano
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David Dudzinski
- Department of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Jasmine Torrey
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Grace Wang
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Blair Alden Parry
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Mannudeep K Kalra
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher Kabrhel
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.
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Thomas SA, Wang G, Giordano N, Matthews T, Torrey J, Kabrhel C. Calendar month variation in the diagnosis and severity of pulmonary embolism. Intern Emerg Med 2023; 18:879-887. [PMID: 36656430 DOI: 10.1007/s11739-022-03180-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 12/13/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is the third-leading cause of cardiovascular death in the United States, and several studies suggest PE shows seasonal variation. Variation in monthly PE diagnosis may be due to pathophysiologic factors or confounding/bias. However, severe PE may be less prone to diagnostic bias. To address this gap, we analyzed two registries from 1/2013-12/2018 with the aim of describing temporal trends in PE diagnosis and severity. METHODS We performed a retrospective analysis of two existing databases containing: (1) consecutive patients diagnosed with PE in the emergency departments (EDs) of two large, urban teaching hospitals, and (2) severe PEs requiring PE Response Team (PERT) activation at one of the above hospitals. The primary outcome was to assess variation in PE diagnosis and severity by calendar month. Separate analysis of these two databases sought to control for workup bias by trainee experience across the academic year. One-way ANOVA and Poisson regression were performed to assess for cyclical variation across calendar months, using Stata v16.1. RESULTS The PE diagnosis database contained 1324 patients over 36 months. One-way ANOVA did not reveal a statistically significant (p = 0.713) association between calendar month and PE number. The PERT activation database contained 1082 patients over 72 months. One-way ANOVA revealed a statistically significant (p = 0.024) association between calendar month and activations, repeated year-on-year. CONCLUSION Our results indicate correlation between calendar month and PERT activation; however, this pattern was not observed for PE diagnoses. This finding warrants further investigation into the causes of calendar month variation of PERT activations.
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Affiliation(s)
- Sarah Alice Thomas
- Faculty of Medicine, BSc Medical Biosciences Candidate, Imperial College London, London, UK
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Grace Wang
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicholas Giordano
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tim Matthews
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jasmine Torrey
- Institute of Health Professionals, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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DeBerry J, Rali P, McDaniel M, Kabrhel C, Rosovsky R, Melamed R, Friedman O, Elwing JM, Balasubramanian V, Sahay S, Bossone E, Farmer MJS, Klein AJP, Hamm ME, Ross CB, Rivera-Lebron BN. Barriers and facilitators to interhospital transfer of acute pulmonary embolism: An inductive qualitative analysis. Front Med (Lausanne) 2023; 10:1080342. [PMID: 36936238 PMCID: PMC10014587 DOI: 10.3389/fmed.2023.1080342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 02/10/2023] [Indexed: 03/05/2023] Open
Abstract
Background Interhospital transfer (IHT) of patients with acute life-threatening pulmonary embolism (PE) is necessary to facilitate specialized care and access to advanced therapies. Our goal was to understand what barriers and facilitators may exist during this transfer process from the perspective of both receiving and referring physicians. Methods This qualitative descriptive study explored physician experience taking care of patients with life threatening PE. Subject matter expert physicians across several different specialties from academic and community United States hospitals participated in qualitative semi-structured interviews. Interview transcripts were subsequently analyzed using inductive qualitative description approach. Results Four major themes were identified as barriers that impede IHT among patients with life threatening PE. Inefficient communication which mainly pertained to difficulty when multiple points of contact were required to complete a transfer. Subjectivity in the indication for transfer which highlighted the importance of physicians understanding how to use standardized risk stratification tools and to properly triage these patients. Delays in data acquisition were identified in regards to both obtaining clinical information and imaging in a timely fashion. Operation barriers which included difficulty finding available beds for transfer and poor weather conditions inhibiting transportation. In contrast, two main facilitators to transfer were identified: good communication and reliance on colleagues and dedicated team for transferring and treating PE patients. Conclusion The most prominent themes identified as barriers to IHT for patients with acute life-threatening PE were: (1) inefficient communication, (2) subjectivity in the indication for transfer, (3) delays in data acquisition (imaging or clinical), and (4) operational barriers. Themes identified as facilitators that enable the transfer of patients were: (1) good communication and (2) a dedicated transfer team. The themes presented in our study are useful in identifying opportunities to optimize the IHT of patients with acute PE and improve patient care. These opportunities include instituting educational programs, streamlining the transfer process, and formulating a consensus statement to serve as a guideline regarding IHT of patients with acute PE.
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Affiliation(s)
- Jacob DeBerry
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Parth Rali
- Department of Medicine, Temple University, Philadelphia, PA, United States
| | - Michael McDaniel
- Department of Medicine, Emory University, Atlanta, GA, United States
| | - Christopher Kabrhel
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Rachel Rosovsky
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Roman Melamed
- Abbott Northwestern Hospital, Minneapolis, MN, United States
| | - Oren Friedman
- Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Jean M. Elwing
- College of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Vijay Balasubramanian
- School of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Sandeep Sahay
- Houston Methodist Hospital, Houston, TX, United States
| | | | - Mary Jo S. Farmer
- Baystate Medical Center, University of Massachusetts Baystate, Springfield, MA, United States
| | | | - Megan E. Hamm
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | | | - Belinda N. Rivera-Lebron
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
- *Correspondence: Belinda N. Rivera-Lebron,
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Thibord F, Klarin D, Brody JA, Chen MH, Levin MG, Chasman DI, Goode EL, Hveem K, Teder-Laving M, Martinez-Perez A, Aïssi D, Daian-Bacq D, Ito K, Natarajan P, Lutsey PL, Nadkarni GN, de Vries PS, Cuellar-Partida G, Wolford BN, Pattee JW, Kooperberg C, Braekkan SK, Li-Gao R, Saut N, Sept C, Germain M, Judy RL, Wiggins KL, Ko D, O’Donnell CJ, Taylor KD, Giulianini F, De Andrade M, Nøst TH, Boland A, Empana JP, Koyama S, Gilliland T, Do R, Huffman JE, Wang X, Zhou W, Soria JM, Souto JC, Pankratz N, Haessler J, Hindberg K, Rosendaal FR, Turman C, Olaso R, Kember RL, Bartz TM, Lynch JA, Heckbert SR, Armasu SM, Brumpton B, Smadja DM, Jouven X, Komuro I, Clapham KR, Loos RJ, Willer CJ, Sabater-Lleal M, Pankow JS, Reiner AP, Morelli VM, Ridker PM, van Hylckama Vlieg A, Deleuze JF, Kraft P, Rader DJ, Lee KM, Psaty BM, Skogholt AH, Emmerich J, Suchon P, Rich SS, Vy HMT, Tang W, Jackson RD, Hansen JB, Morange PE, Kabrhel C, Trégouët DA, Damrauer SM, Johnson AD, Smith NL. Cross-Ancestry Investigation of Venous Thromboembolism Genomic Predictors. Circulation 2022; 146:1225-1242. [PMID: 36154123 PMCID: PMC10152894 DOI: 10.1161/circulationaha.122.059675] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 08/09/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a life-threatening vascular event with environmental and genetic determinants. Recent VTE genome-wide association studies (GWAS) meta-analyses involved nearly 30 000 VTE cases and identified up to 40 genetic loci associated with VTE risk, including loci not previously suspected to play a role in hemostasis. The aim of our research was to expand discovery of new genetic loci associated with VTE by using cross-ancestry genomic resources. METHODS We present new cross-ancestry meta-analyzed GWAS results involving up to 81 669 VTE cases from 30 studies, with replication of novel loci in independent populations and loci characterization through in silico genomic interrogations. RESULTS In our genetic discovery effort that included 55 330 participants with VTE (47 822 European, 6320 African, and 1188 Hispanic ancestry), we identified 48 novel associations, of which 34 were replicated after correction for multiple testing. In our combined discovery-replication analysis (81 669 VTE participants) and ancestry-stratified meta-analyses (European, African, and Hispanic), we identified another 44 novel associations, which are new candidate VTE-associated loci requiring replication. In total, across all GWAS meta-analyses, we identified 135 independent genomic loci significantly associated with VTE risk. A genetic risk score of the significantly associated loci in Europeans identified a 6-fold increase in risk for those in the top 1% of scores compared with those with average scores. We also identified 31 novel transcript associations in transcriptome-wide association studies and 8 novel candidate genes with protein quantitative-trait locus Mendelian randomization analyses. In silico interrogations of hemostasis and hematology traits and a large phenome-wide association analysis of the 135 GWAS loci provided insights to biological pathways contributing to VTE, with some loci contributing to VTE through well-characterized coagulation pathways and others providing new data on the role of hematology traits, particularly platelet function. Many of the replicated loci are outside of known or currently hypothesized pathways to thrombosis. CONCLUSIONS Our cross-ancestry GWAS meta-analyses identified new loci associated with VTE. These findings highlight new pathways to thrombosis and provide novel molecules that may be useful in the development of improved antithrombosis treatments.
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Affiliation(s)
- Florian Thibord
- Population Sciences Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, 73 Mt. Wayte Ave, Suite #2, Framingham, MA, 01702, USA
- The Framingham Heart Study, Boston University and NHLBI, 73 Mt. Wayte Ave, Suite #2, Framingham, MA, 01702, USA
| | - Derek Klarin
- Division of Vascular Surgery, Stanford University School of Medicine, Stanford, CA, 94305, USA
- VA Palo Alto Healthcare System, Palo Alto, CA, 94550, USA
| | - Jennifer A. Brody
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, 1730 Minor Ave, Suite 1360, Seattle, WA, 98101, USA
| | - Ming-Huei Chen
- Population Sciences Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, 73 Mt. Wayte Ave, Suite #2, Framingham, MA, 01702, USA
- The Framingham Heart Study, Boston University and NHLBI, 73 Mt. Wayte Ave, Suite #2, Framingham, MA, 01702, USA
| | - Michael G. Levin
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Daniel I. Chasman
- Division of Preventive Medicine, Brigham and Women’s Hospital, 900 Commonwealth Ave, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Ellen L. Goode
- Department of Quantitative Health Sciences, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kristian Hveem
- HUNT Research Center, Department of Public Health and Nursing, Norwegian University of Science and Technology, Forskningsvegen 2, Levanger, 7600, Norway
- K.G. Jebsen Centre for Genetic Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology, Håkon Jarls gate 11, Trondheim, 7030, Norway
| | - Maris Teder-Laving
- Institute of Genomics, University of Tartu, Riia 23b, Tartu, Tartu, 51010, Estonia
| | - Angel Martinez-Perez
- Genomics of Complex Disease Unit, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), St Quinti 77-79, Barcelona, 8041, Spain
| | - Dylan Aïssi
- Bordeaux Population Health Research Center, University of Bordeaux, 146 rue Léo Saignat, Bordeaux, 33076, France
- UMR1219, INSERM, 146 rue Léo Saignat, Bordeaux, 33076, France
| | - Delphine Daian-Bacq
- Centre National de Recherche en Génomique Humaine, CEA, Université Paris-Saclay, 2 Rue Gaston Crémieux, Evry, 91057, France
- Laboratory of Excellence on Medical Genomics, GenMed, France
| | - Kaoru Ito
- Laboratory for Cardiovascular Genomics and Informatics, RIKEN Center for Integrative Medical Sciences, 1-7-22 Suehirocho, Tsurumi-ku, Yokohama, Kanagawa, 230-0045, Japan
| | - Pradeep Natarajan
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA, 02446, USA
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard & MIT, 75 Ames St, Cambridge, MA, 02142, USA
- Department of Medicine, Harvard Medical School, Shattuck St, Boston, MA, 02115, USA
| | - Pamela L. Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 South Second Street, Minneapolis, MN, 55454, USA
| | - Girish N. Nadkarni
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, 1 Gu stave L. Levy Pl, New York, NY, 10029, USA
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA
| | - Paul S. de Vries
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, 1200 Pressler St, Houston, TX, 77030, USA
| | | | - Brooke N. Wolford
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Jack W. Pattee
- Division of Biostatistics, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
- Center for Innovative Design & Analysis and Department of Biostatistics & Informatics, Colorado School of Public Health, 13001 East 17th Place, Aurora, CO, 80045, USA
| | - Charles Kooperberg
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Sigrid K. Braekkan
- Thrombosis Research Center (TREC), UiT - The Arctic University of Norway, Universitetsvegen 57, Tromsø, 9037, Norway
- Division of internal medicine, University Hospital of North Norway, Tromsø, 9038, Norway
| | - Ruifang Li-Gao
- Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands
| | - Noemie Saut
- Hematology Laboratory, La Timone University Hospital of Marseille, 264 Rue Saint-Pierre, Marseille, 13385, France
| | - Corriene Sept
- Department of Epidemiology, Harvard TH Chan Harvard School of Public Health, 655 Huntington Ave., Building II, Boston, MA, 02115, USA
| | - Marine Germain
- Bordeaux Population Health Research Center, University of Bordeaux, 146 rue Léo Saignat, Bordeaux, 33076, France
- UMR1219, INSERM, 146 rue Léo Saignat, Bordeaux, 33076, France
- Laboratory of Excellence on Medical Genomics, GenMed, France
| | - Renae L. Judy
- Surgery, University of Pennsylvania, 3401 Walnut Street, Philadelphia, PA, 19104, USA
| | - Kerri L. Wiggins
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, 1730 Minor Ave, Suite 1360, Seattle, WA, 98101, USA
| | - Darae Ko
- The Framingham Heart Study, Boston University and NHLBI, 73 Mt. Wayte Ave, Suite #2, Framingham, MA, 01702, USA
- Section of Cardiovascular Medicine, Boston University School of Medicine, 85 East Newton Street, Boston, MA, 02118, USA
| | - Christopher J. O’Donnell
- Cardiology Section, Department of Medicine, VA Boston Healthcare System, Boston, MA, 02132, USA
- Department of Medicine, Harvard Medical School, Boston, MA, 02115, USA
| | - Kent D. Taylor
- Institute for Translational Genomics and Population Sciences, The Lundquist Institute for Biomedical Innovation, 1124 W Carson St., Torrance, CA, 90502, USA
| | - Franco Giulianini
- Division of Preventive Medicine, Brigham and Women’s Hospital, 900 Commonwealth Ave, Boston, MA, 02215, USA
| | - Mariza De Andrade
- Department of Quantitative Health Sciences, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Therese H. Nøst
- K.G. Jebsen Centre for Genetic Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology, Håkon Jarls gate 11, Trondheim, 7030, Norway
| | - Anne Boland
- Centre National de Recherche en Génomique Humaine, CEA, Université Paris-Saclay, 2 Rue Gaston Crémieux, Evry, 91057, France
- Laboratory of Excellence on Medical Genomics, GenMed, France
| | - Jean-Philippe Empana
- Integrative Epidemiology of cardiovascular diseases, Université Paris Cité, Paris Cardiovascular Research Center (PARCC), 56 rue Leblanc, Paris, 75015, France
- Department of Cardiology, APHP, Hopital Européen Georges Pompidou, 20 rue Leblanc, Paris, 75015, France
| | - Satoshi Koyama
- Laboratory for Cardiovascular Genomics and Informatics, RIKEN Center for Integrative Medical Sciences, 1-7-22 Suehirocho, Tsurumi-ku, Yokohama, Kanagawa, 230-0045, Japan
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA, 02446, USA
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard & MIT, 75 Ames St, Cambridge, MA, 02142, USA
| | - Thomas Gilliland
- Cardiovascular Research Center, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA, 02446, USA
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard & MIT, 75 Ames St, Cambridge, MA, 02142, USA
- Department of Medicine, Harvard Medical School, Shattuck St, Boston, MA, 02115, USA
| | - Ron Do
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, 1 Gu stave L. Levy Pl, New York, NY, 10029, USA
- BioMe Phenomics Center, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA
| | - Jennifer E. Huffman
- MAVERIC, VA Boston Heathcare System, 2 Avenue de Lafayette, Boston, MA, 02111, USA
| | - Xin Wang
- 23andMe, Inc., 223 N Mathilda Ave, Sunnyvale, CA, 94086, USA
| | - Wei Zhou
- Analytic and Translational Genetics Unit, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Jose Manuel Soria
- Genomics of Complex Disease Unit, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), St Quinti 77-79, Barcelona, 8041, Spain
| | - Juan Carlos Souto
- Genomics of Complex Disease Unit, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), St Quinti 77-79, Barcelona, 8041, Spain
- Unit of Thrombosis and Hemostasis, Hospital de la Santa Creu i Sant Pau, St Quinti 89, Barcelona, 8041, Spain
| | - Nathan Pankratz
- Department of Laboratory Medicine and Pathology, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN, 55455, USA
| | - Jeffery Haessler
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
| | - Kristian Hindberg
- Thrombosis Research Center (TREC), UiT - The Arctic University of Norway, Universitetsvegen 57, Tromsø, 9037, Norway
| | - Frits R. Rosendaal
- Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands
| | - Constance Turman
- Department of Epidemiology, Harvard TH Chan Harvard School of Public Health, 655 Huntington Ave., Building II, Boston, MA, 02115, USA
| | - Robert Olaso
- Centre National de Recherche en Génomique Humaine, CEA, Université Paris-Saclay, 2 Rue Gaston Crémieux, Evry, 91057, France
- Laboratory of Excellence on Medical Genomics, GenMed, France
| | - Rachel L. Kember
- Psychiatry, University of Pennsylvania, 3401 Walnut Street, Philadelphia, PA, 19104, USA
| | - Traci M. Bartz
- Cardiovascular Health Research Unit, Departments of Biostatistics and Medicine, University of Washington, 1730 Minor Ave, Suite 1360, Seattle, WA, 98101, USA
| | - Julie A. Lynch
- VA Informatics & Computing Infrastructure, VA Salt Lake City Healthcare System, 500 Foothills Drive, Salt Lake City, UT, 84148, USA
- Epidemiology, University of Utah, 500 Foothills Drive, Salt Lake City, UT, 84148, USA
| | - Susan R. Heckbert
- Department of Epidemiology, University of Washington, 1730 Minor Ave, Suite 1360, Seattle, WA, 98101, USA
| | - Sebastian M. Armasu
- Department of Quantitative Health Sciences, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Ben Brumpton
- K.G. Jebsen Centre for Genetic Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology, Håkon Jarls gate 11, Trondheim, 7030, Norway
| | - David M. Smadja
- Hematology Department and Biosurgical Research Lab (Carpentier Foundation), European Georges Pompidou Hospital, Assistance Publique Hôpitaux de Paris, 20 rue Leblanc, Paris, 75015, France
- Innovative Therapies in Haemostasis, INSERM, Université de Paris, 4 avenue de l’Observatoire, Paris, 75270, France
| | - Xavier Jouven
- Integrative Epidemiology of cardiovascular diseases, Université Paris Descartes, Sorbonne Paris Cité, 56 rue Leblanc, Paris, 75015, France
- Paris Cardiovascular Research Center, Inserm U970, Université Paris Descartes, Sorbonne Paris Cité, 20 rue Leblanc, Paris, 75015, France
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, Tokyo, 113-8655, Japan
| | - Katharine R. Clapham
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard & MIT, 75 Ames St, Cambridge, MA, 02142, USA
- Department of Medicine, Harvard Medical School, Shattuck St, Boston, MA, 02115, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, 900 Commonwealth Ave, Boston, MA, 02215, USA
| | - Ruth J.F. Loos
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA
| | - Cristen J. Willer
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Maria Sabater-Lleal
- Genomics of Complex Disease Unit, Institut d’Investigació Biomèdica Sant Pau (IIB SANT PAU), St Quinti 77-79, Barcelona, 8041, Spain
- Cardiovascular Medicine Unit, Department of Medicine, Karolinska Institutet, Center for Molecular Medicine, Stockholm, 17176, Sweden
| | - James S. Pankow
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 South Second Street, Minneapolis, MN, 55454, USA
| | - Alexander P. Reiner
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave N, Seattle, WA, 98109, USA
- Department of Epidemiology, University of Washington, 1730 Minor Ave, Suite 1360, Seattle, WA, 98101, USA
| | - Vania M. Morelli
- Thrombosis Research Center (TREC), UiT - The Arctic University of Norway, Universitetsvegen 57, Tromsø, 9037, Norway
- Division of internal medicine, University Hospital of North Norway, Tromsø, 9038, Norway
| | - Paul M. Ridker
- Division of Preventive Medicine, Brigham and Women’s Hospital, 900 Commonwealth Ave, Boston, MA, 02215, USA
- Harvard Medical School, Boston, MA, 02115, USA
| | - Astrid van Hylckama Vlieg
- Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, Leiden, 2300 RC, The Netherlands
| | - Jean-François Deleuze
- Centre National de Recherche en Génomique Humaine, CEA, Université Paris-Saclay, 2 Rue Gaston Crémieux, Evry, 91057, France
- Laboratory of Excellence on Medical Genomics, GenMed, France
- Centre D’Etude du Polymorphisme Humain, Fondation Jean Dausset, 27 rue Juliette Dodu, Paris, 75010, France
| | - Peter Kraft
- Department of Epidemiology, Harvard TH Chan Harvard School of Public Health, 655 Huntington Ave., Building II, Boston, MA, 02115, USA
| | - Daniel J. Rader
- Departments of Medicine and Genetics and Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | | | | | | | | | | | - Kyung Min Lee
- VA Informatics & Computing Infrastructure, VA Salt Lake City Healthcare System, 500 Foothills Drive, Salt Lake City, UT, 84148, USA
| | - Bruce M. Psaty
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, 1730 Minor Ave, Suite 1360, Seattle, WA, 98101, USA
- Department of Epidemiology, University of Washington, 1730 Minor Ave, Suite 1360, Seattle, WA, 98101, USA
- Department of Health Systems and Population Heath, University of Washington, 1730 Minor Ave, Suite 1360, Seattle, WA, 98101, USA
| | - Anne Heidi Skogholt
- K.G. Jebsen Centre for Genetic Epidemiology, Department of Public Health and Nursing, Norwegian University of Science and Technology, Håkon Jarls gate 11, Trondheim, 7030, Norway
| | - Joseph Emmerich
- Department of vascular medicine, Paris Saint-Joseph Hospital Group, University of Paris, 185 rue Raymond Losserand, Paris, 75674, France
- UMR1153, INSERM CRESS, 185 rue Raymond Losserand, Paris, 75674, France
| | - Pierre Suchon
- Hematology Laboratory, La Timone University Hospital of Marseille, 264 Rue Saint-Pierre, Marseille, 13385, France
- C2VN, INSERM, INRAE, Aix-Marseille University, 27, bd Jean Moulin, Marseille, 13385, France
| | - Stephen S. Rich
- Center for Public Health Genomics, University of Virginia, 3242 West Complex, Charlottesville, VA, 22908-0717, USA
| | - Ha My T. Vy
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, 1 Gu stave L. Levy Pl, New York, NY, 10029, USA
| | - Weihong Tang
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 South Second Street, Minneapolis, MN, 55454, USA
| | - Rebecca D. Jackson
- College of Medicine, Ohio State University, 376 W. 10th Ave, Columbus, OH, 43210, USA
| | - John-Bjarne Hansen
- Thrombosis Research Center (TREC), UiT - The Arctic University of Norway, Universitetsvegen 57, Tromsø, 9037, Norway
- Division of internal medicine, University Hospital of North Norway, Tromsø, 9038, Norway
| | - Pierre-Emmanuel Morange
- Hematology Laboratory, La Timone University Hospital of Marseille, 264 Rue Saint-Pierre, Marseille, 13385, France
- C2VN, INSERM, INRAE, Aix-Marseille University, 27, bd Jean Moulin, Marseille, 13385, France
| | - Christopher Kabrhel
- Emergency Medicine, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA, 02114, USA
- Emergency Medicine, Harvard Medical School, Zero Emerson Place, Suite 3B, Boston, MA, 02114, USA
| | - David-Alexandre Trégouët
- Bordeaux Population Health Research Center, University of Bordeaux, 146 rue Léo Saignat, Bordeaux, 33076, France
- UMR1219, INSERM, 146 rue Léo Saignat, Bordeaux, 33076, France
- Laboratory of Excellence on Medical Genomics, GenMed, France
| | - Scott M. Damrauer
- Corporal Michael J. Crescenz Philadelphia VA Medical Center, 3900 Woodland Ave, Philadelphia, PA, 19104, USA
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Andrew D. Johnson
- Population Sciences Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, 73 Mt. Wayte Ave, Suite #2, Framingham, MA, 01702, USA
- The Framingham Heart Study, Boston University and NHLBI, 73 Mt. Wayte Ave, Suite #2, Framingham, MA, 01702, USA
| | - Nicholas L. Smith
- Department of Epidemiology, University of Washington, 1730 Minor Ave, Suite 1360, Seattle, WA, 98101, USA
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, 98101, USA
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, 98108, USA
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15
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Thoppil JJ, Courtney DM, McDonald S, Kabrhel C, Nordenholz KE, Camargo CA, Kline JA. SARS-CoV-2 Positivity in Ambulatory Symptomatic Patients Is Not Associated With Increased Venous or Arterial Thrombotic Events in the Subsequent 30 Days. J Emerg Med 2022; 62:716-724. [PMID: 35177286 PMCID: PMC8761548 DOI: 10.1016/j.jemermed.2021.12.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/29/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND COVID-19 has been associated with increased risk of thromboembolism in critically ill patients. OBJECTIVE We sought to examine the association of SARS-CoV-2 test positivity and subsequent acute vascular thrombosis, including venous thromboembolism (VTE) or arterial thrombosis (AT), in a large nationwide registry of emergency department (ED) patients tested with a nucleic acid test for suspected SARS-CoV-2. METHODS The RECOVER (Registry of Potential COVID-19 in Emergency Care) registry includes 155 EDs across the United States. We performed a retrospective cohort study to produce odds ratios (ORs) for COVID-19-positive vs. COVID-19-negative status as a predictor of 30-day VTE or AT, adjusting for age, sex, active cancer, intubation, hospital length of stay, and intensive care unit (ICU) care. RESULTS Comparing 14,056 COVID-19-positive patients with 12,995 COVID-19-negative patients, the overall 30-day prevalence of VTE events was 1.4% vs. 1.3%, respectively (p = 0.44, χ2). Multivariable analysis identified that testing positive for SARS-CoV-2 status was negatively associated with both VTE (OR 0.76; 95% confidence interval [CI] 0.61-0.94) and AT (OR 0.51; 95% CI 0.32-0.80), whereas intubation, ICU care, and age 50 years or older were positively associated with both VTE and AT. CONCLUSIONS In contrast to other reports, results from this large, hetereogenous national sample of ED patients tested for SARS-CoV-2, showed no association between vascular thrombosis and COVID-19 test positivity.
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Affiliation(s)
- Joby J. Thoppil
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - D. Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samuel McDonald
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston Massachusetts
| | | | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston Massachusetts
| | - Jeffrey A. Kline
- Department of Emergency Medicine, Wayne State University, Detroit, Michigan,Reprint Address: Jeffrey A. Kline, MD, Department of Emergency Medicine, Wayne State University, 4201 St. Antoine, University Health Center – 6G, Detroit, MI 48201
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16
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Martin S, Tyrrell J, Thomas EL, Bown MJ, Wood AR, Beaumont RN, Tsoi LC, Stuart PE, Elder JT, Law P, Houlston R, Kabrhel C, Papadimitriou N, Gunter M, Bull C, Bell JA, Vincent EE, Sattar N, Dunlop MG, Tomlinson IPM, Lindström S, Bell JD, Frayling T, Yaghootkar H. Correction: Disease consequences of higher adiposity uncoupled from its adverse metabolic effects using Mendelian randomisation. eLife 2022; 11:e80233. [PMID: 35583923 PMCID: PMC9116939 DOI: 10.7554/elife.80233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
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17
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Martin S, Tyrrell J, Thomas EL, Bown MJ, Wood AR, Beaumont RN, Tsoi LC, Stuart PE, Elder JT, Law P, Houlston R, Kabrhel C, Papadimitriou N, Gunter MJ, Bull CJ, Bell JA, Vincent EE, Sattar N, Dunlop MG, Tomlinson IPM, Lindström S, Bell JD, Frayling TM, Yaghootkar H. Disease consequences of higher adiposity uncoupled from its adverse metabolic effects using Mendelian randomisation. eLife 2022; 11:e72452. [PMID: 35074047 PMCID: PMC8789289 DOI: 10.7554/elife.72452] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/21/2021] [Indexed: 12/13/2022] Open
Abstract
Background Some individuals living with obesity may be relatively metabolically healthy, whilst others suffer from multiple conditions that may be linked to adverse metabolic effects or other factors. The extent to which the adverse metabolic component of obesity contributes to disease compared to the non-metabolic components is often uncertain. We aimed to use Mendelian randomisation (MR) and specific genetic variants to separately test the causal roles of higher adiposity with and without its adverse metabolic effects on diseases. Methods We selected 37 chronic diseases associated with obesity and genetic variants associated with different aspects of excess weight. These genetic variants included those associated with metabolically 'favourable adiposity' (FA) and 'unfavourable adiposity' (UFA) that are both associated with higher adiposity but with opposite effects on metabolic risk. We used these variants and two sample MR to test the effects on the chronic diseases. Results MR identified two sets of diseases. First, 11 conditions where the metabolic effect of higher adiposity is the likely primary cause of the disease. Here, MR with the FA and UFA genetics showed opposing effects on risk of disease: coronary artery disease, peripheral artery disease, hypertension, stroke, type 2 diabetes, polycystic ovary syndrome, heart failure, atrial fibrillation, chronic kidney disease, renal cancer, and gout. Second, 9 conditions where the non-metabolic effects of excess weight (e.g. mechanical effect) are likely a cause. Here, MR with the FA genetics, despite leading to lower metabolic risk, and MR with the UFA genetics, both indicated higher disease risk: osteoarthritis, rheumatoid arthritis, osteoporosis, gastro-oesophageal reflux disease, gallstones, adult-onset asthma, psoriasis, deep vein thrombosis, and venous thromboembolism. Conclusions Our results assist in understanding the consequences of higher adiposity uncoupled from its adverse metabolic effects, including the risks to individuals with high body mass index who may be relatively metabolically healthy. Funding Diabetes UK, UK Medical Research Council, World Cancer Research Fund, National Cancer Institute.
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Affiliation(s)
- Susan Martin
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Research, Innovation, Learning and Development building, Royal Devon & Exeter HospitalExeterUnited Kingdom
| | - Jessica Tyrrell
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Research, Innovation, Learning and Development building, Royal Devon & Exeter HospitalExeterUnited Kingdom
| | - E Louise Thomas
- Research Centre for Optimal Health, School of Life Sciences, University of WestminsterLondonUnited Kingdom
| | - Matthew J Bown
- Department of Cardiovascular Sciences, University of LeicesterLeicesterUnited Kingdom
- NIHR Leicester Biomedical Research CentreLeicesterUnited Kingdom
| | - Andrew R Wood
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Research, Innovation, Learning and Development building, Royal Devon & Exeter HospitalExeterUnited Kingdom
| | - Robin N Beaumont
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Research, Innovation, Learning and Development building, Royal Devon & Exeter HospitalExeterUnited Kingdom
| | - Lam C Tsoi
- Department of Dermatology, University of MichiganAnn ArborUnited States
| | - Philip E Stuart
- Department of Dermatology, University of MichiganAnn ArborUnited States
| | - James T Elder
- Department of Dermatology, University of MichiganAnn ArborUnited States
- Ann Arbor Veterans Affairs HospitalAnn ArborUnited States
| | - Philip Law
- The Institute of Cancer ResearchLondonUnited Kingdom
| | | | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General HospitalBostonUnited States
- Department of Emergency Medicine, Harvard Medical SchoolBostonUnited States
| | - Nikos Papadimitriou
- Nutrition and Metabolism Branch, International Agency for Research on CancerLyonFrance
| | - Marc J Gunter
- Nutrition and Metabolism Branch, International Agency for Research on CancerLyonFrance
| | - Caroline J Bull
- MRC Integrative Epidemiology Unit at the University of BristolBristolUnited Kingdom
- Population Health Sciences, Bristol Medical School, University of BristolBristolUnited Kingdom
- School of Cellular and Molecular Medicine, University of BristolBristolUnited Kingdom
| | - Joshua A Bell
- MRC Integrative Epidemiology Unit at the University of BristolBristolUnited Kingdom
- Population Health Sciences, Bristol Medical School, University of BristolBristolUnited Kingdom
| | - Emma E Vincent
- MRC Integrative Epidemiology Unit at the University of BristolBristolUnited Kingdom
- Population Health Sciences, Bristol Medical School, University of BristolBristolUnited Kingdom
- School of Cellular and Molecular Medicine, University of BristolBristolUnited Kingdom
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of GlasgowGlasgowUnited Kingdom
| | - Malcolm G Dunlop
- University of EdinburghEdinburghUnited Kingdom
- Western General HospitalEdinburghUnited Kingdom
| | - Ian PM Tomlinson
- Edinburgh Cancer Research Centre, IGMM, University of EdinburghEdinburghUnited Kingdom
| | - Sara Lindström
- Department of Epidemiology, University of WashingtonSeattleUnited States
- Division of Public Health Sciences, Fred Hutchinson Cancer Research CenterSeattleUnited States
| | | | - Jimmy D Bell
- Research Centre for Optimal Health, School of Life Sciences, University of WestminsterLondonUnited Kingdom
| | - Timothy M Frayling
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Research, Innovation, Learning and Development building, Royal Devon & Exeter HospitalExeterUnited Kingdom
| | - Hanieh Yaghootkar
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Research, Innovation, Learning and Development building, Royal Devon & Exeter HospitalExeterUnited Kingdom
- Research Centre for Optimal Health, School of Life Sciences, University of WestminsterLondonUnited Kingdom
- Centre for Inflammation Research and Translational Medicine (CIRTM), Department of Life Sciences, Brunel University LondonUxbridgeUnited Kingdom
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18
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Glober N, Stewart L, Seo J, Kabrhel C, Nordenholz K, Camargo C, Kline J. Incidence and characteristics of arterial thromboemboli in patients with COVID-19. Thromb J 2021; 19:104. [PMID: 34930306 PMCID: PMC8685823 DOI: 10.1186/s12959-021-00357-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 12/07/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Studies have reported COVID-19 as an independent risk factor for arterial thromboemboli. METHODS From a cross-sectional sample, we determined the incidence and location of arterial thromboemboli (myocardial infarction, ischemic stroke, peripheral artery), stratified by COVID-19 status, in the RECOVER database, which included data on patients at 45 United States medical centers in 22 states. Epidemiological factors, clinical characteristics and outcomes were collected through a combination of individual chart review and automatic electronic query and recorded in REDCap®. We investigated the association of baseline comorbidities on the development of arterial thromboemboli and analyzed results based on the presence or absence of concomitant COVID-19 infection, testing this association with Chi-squared. We also described use of anticoagulants and statins. RESULTS Data were collected on 26,974 patients, of which 13,803 (51.17%) tested positive for COVID-19. Incidence of arterial thromboemboli during hospitalization was 0.13% in patients who tested positive for COVID-19 and 0.19% in patients who tested negative. Arterial thromboemboli tended to be more common in extremities than in core organs (heart, kidney, lung, liver) in patients with COVID-19, odds ratio 2.04 (95% CI 0.707 - 5.85). Patients with COVID-19 were less likely to develop an arterial thrombus when on baseline statin medication (p=0.014). Presence of metabolic syndrome predicted presence of core arterial thrombus (p=0.001) and extremity arterial thrombus (p=0.010) in those with COVID-19. Arterial thromboemboli were less common in patients with COVID-19 than in those who tested negative for COVID-19. CONCLUSIONS Presence of a composite metabolic syndrome profile may be associated with arterial clot formation in patients with COVID-19 infection.
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Affiliation(s)
- Nancy Glober
- Indiana University, Indianapolis, Indiana, United States
| | - Lauren Stewart
- Indiana University, Indianapolis, Indiana, United States
| | - JangDong Seo
- Indiana University, Indianapolis, Indiana, United States
| | | | - Kristen Nordenholz
- University of Colorado Anschutz Medical Campus, Colorado, Aurora, United States
| | - Carlos Camargo
- Harvard Medical School, Boston, Massachusetts, United States
| | - Jeffrey Kline
- Department of Emergency Medicine, Wayne State University School of Medicine, 4201 St. Antoine, 48201, Detroit, Michigan, United States.
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19
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Thomas SA, Puskarich M, Pulia MS, Meltzer AC, Camargo CA, Courtney DM, Nordenholz KE, Kline JA, Kabrhel C. Association between baseline use of angiotensin converting enzyme inhibitors and angiotensin receptor blockers and death among patients tested for COVID-19. J Clin Pharmacol 2021; 62:777-782. [PMID: 34921684 DOI: 10.1002/jcph.2015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/14/2021] [Indexed: 11/07/2022]
Abstract
Angiotensin converting enzyme inhibitor (ACEI) and angiotensin receptor blocker (ARB) drugs may modify risk associated with SARS-CoV-2. Therefore, we assessed whether baseline therapy with ACEI or ARB (ACEI/ARB) was associated with lower mortality, respiratory failure (non-invasive ventilation or intubation) and renal failure (new renal replacement therapy) in SARS-CoV-2-positive patients. This retrospective registry-based observational cohort study used data from a national database of Emergency Department (ED) patients tested for SARS-CoV-2. Symptomatic ED patients were accrued from January-October 2020, across 197 hospitals in the USA. Multivariable analysis using logistic regression evaluated endpoints among SARS-CoV-2-positive cases, focusing on ACEI/ARB and adjusting for covariates. Model performance was evaluated using the c statistic for discrimination, and Cox plotting for calibration. 13,859 (99.9%) patients had known mortality status, of whom 2,045 (14.8%) died. Respiratory failure occurred in 2,485/13,880 (17.9%) and renal failure in 548/13,813 (4.0%) patients with available data. ACEI/ARB status was associated with a 25% decrease in mortality odds (OR 0.75, 95% CI 0.59-0.94, p = .011, c = .82). ACEI/ARB was not significantly associated with respiratory failure (OR 0.89, 95% CI 0.78-1.06, p = .206) or renal failure (OR 0.75, 95% CI 0.55-1.04, p = .083). Adjusting for covariates, baseline ACEI/ARB was associated with 25% lower mortality in SARS-CoV-2-positive patients. The potential mechanism for ACEI/ARB mortality modification requires further exploration. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Sarah A Thomas
- BSc Medical Biosciences Candidate, Faculty of Medicine, Imperial College London, London, UK
| | | | - Michael S Pulia
- Depts of Emergency Medicine and Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Andrew C Meltzer
- Dept of Emergency Medicine, GWU School of Medicine & Health Sciences, Washington, District of Columbia, USA
| | - Carlos A Camargo
- Dept of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - D Mark Courtney
- Dept of Emergency Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Jeffrey A Kline
- Dept of Emergency Medicine, Wayne State University, Detroit, MI, USA
| | - Christopher Kabrhel
- Center for Vascular Emergencies, Dept of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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20
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Beiser DG, Jarou ZJ, Kassir AA, Puskarich MA, Vrablik MC, Rosenman ED, McDonald SA, Meltzer AC, Courtney DM, Kabrhel C, Kline JA. Predicting 30-day return hospital admissions in patients with COVID-19 discharged from the emergency department: A national retrospective cohort study. J Am Coll Emerg Physicians Open 2021; 2:e12595. [PMID: 35005705 PMCID: PMC8716570 DOI: 10.1002/emp2.12595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/09/2021] [Accepted: 10/15/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Identification of patients with coronavirus disease 2019 (COVID-19) at risk for deterioration after discharge from the emergency department (ED) remains a clinical challenge. Our objective was to develop a prediction model that identifies patients with COVID-19 at risk for return and hospital admission within 30 days of ED discharge. METHODS We performed a retrospective cohort study of discharged adult ED patients (n = 7529) with SARS-CoV-2 infection from 116 unique hospitals contributing to the National Registry of Suspected COVID-19 in Emergency Care. The primary outcome was return hospital admission within 30 days. Models were developed using classification and regression tree (CART), gradient boosted machine (GBM), random forest (RF), and least absolute shrinkage and selection (LASSO) approaches. RESULTS Among patients with COVID-19 discharged from the ED on their index encounter, 571 (7.6%) returned for hospital admission within 30 days. The machine-learning (ML) models (GBM, RF, and LASSO) performed similarly. The RF model yielded a test area under the receiver operating characteristic curve of 0.74 (95% confidence interval [CI], 0.71-0.78), with a sensitivity of 0.46 (95% CI, 0.39-0.54) and a specificity of 0.84 (95% CI, 0.82-0.85). Predictive variables, including lowest oxygen saturation, temperature, or history of hypertension, diabetes, hyperlipidemia, or obesity, were common to all ML models. CONCLUSIONS A predictive model identifying adult ED patients with COVID-19 at risk for return for return hospital admission within 30 days is feasible. Ensemble/boot-strapped classification methods (eg, GBM, RF, and LASSO) outperform the single-tree CART method. Future efforts may focus on the application of ML models in the hospital setting to optimize the allocation of follow-up resources.
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Affiliation(s)
- David G. Beiser
- Section of Emergency MedicineUniversity of ChicagoChicagoIllinoisUSA
| | - Zachary J. Jarou
- Department of Emergency MedicineSt. Joseph Mercy Ann Arbor HospitalUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Alaa A. Kassir
- Section of Emergency MedicineUniversity of ChicagoChicagoIllinoisUSA
| | - Michael A. Puskarich
- Department of Emergency MedicineHennepin County Medical CenterMinneapolisMinnesotaUSA
| | - Marie C. Vrablik
- Department of Emergency MedicineUniversity of WashingtonSeattleWashingtonUSA
| | | | - Samuel A. McDonald
- Department of Emergency MedicineUT Southwestern Medical CenterDallasTexasUSA
| | - Andrew C. Meltzer
- Department of Emergency MedicineGeorge Washington UniversityWashingtonDistrict of ColumbiaUSA
| | - D. Mark Courtney
- Department of Emergency MedicineUT Southwestern Medical CenterDallasTexasUSA
| | - Christopher Kabrhel
- Department of Emergency MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Jeffrey A. Kline
- Department of Emergency MedicineIndiana UniversityIndianapolisIndianaUSA
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21
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Kabrhel C, Vinson DR, Mitchell AM, Rosovsky RP, Chang AM, Hernandez‐Nino J, Wolf SJ. A clinical decision framework to guide the outpatient treatment of emergency department patients diagnosed with acute pulmonary embolism or deep vein thrombosis: Results from a multidisciplinary consensus panel. J Am Coll Emerg Physicians Open 2021; 2:e12588. [PMID: 34950930 PMCID: PMC8673564 DOI: 10.1002/emp2.12588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
The outpatient treatment of select emergency department patients with acute pulmonary embolism (PE) or deep vein thrombosis (DVT) has been shown to be safe, cost effective and associated with high patient satisfaction. Despite this, outpatient PE and DVT treatment remains uncommon. To address this, the American College of Emergency Physicians assembled a multidisciplinary team of content experts to provide evidence-based recommendations and practical advice to help clinicians safely treat patients with low-risk PE and DVT without hospitalization. The emergency clinician must stratify the patient's risk of clinical decompensation due to their PE or DVT as well as their risk of bleeding due to anticoagulation. The clinician must also select and start an anticoagulant and ensure that the patient has access to the medication in a timely manner. Reliable follow-up is critical, and the patient must also be educated about signs or symptoms that should prompt a return to the emergency department. To facilitate access to these recommendations, the consensus panel also created 2 web-based "point-of-care tools."
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Affiliation(s)
- Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular EmergenciesMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - David R. Vinson
- Department of Emergency Medicine, Kaiser Permanente Division of Research and the CREST Network, Oakland, CAKaiser Permanente Roseville Medical CenterRosevilleCaliforniaUSA
| | - Alice Marina Mitchell
- Department of Emergency Medicine, Richard L. Roudebush VAMCIndiana University School of MedicineIndianapolisIndianaUSA
| | - Rachel P. Rosovsky
- Division of HematologyDepartment of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Anna Marie Chang
- Department of Emergency MedicineThomas Jefferson University HospitalsPhiladelphiaPennsylvaniaUSA
| | | | - Stephen J. Wolf
- Department of Emergency MedicineDenver Health and University of Colorado School of MedicineDenverColoradoUSA
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22
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Mortensen CS, Kramer A, Schultz JG, Giordano N, Zheng H, Andersen A, Nielsen-Kudsk JE, Kabrhel C. Predicting factors for pulmonary embolism response team activation in a general pulmonary embolism population. J Thromb Thrombolysis 2021; 53:506-513. [PMID: 34370168 DOI: 10.1007/s11239-021-02533-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2021] [Indexed: 11/30/2022]
Abstract
Pulmonary embolism response teams (PERT) aim to improve treatment of acute pulmonary embolism (PE). PERT focus on intermediate- and high-risk PE patients, but recent multicenter studies show that low-risk PE patients compose one in five of all PERT cases. Conversely, not all intermediate- and high-risk PE patients elicit a PERT activation. The factors leading to PERT activations remain unknown. This study aims to describe the patient characteristics associated with PERT activation for low-risk PE patients and characteristics precluding PERT activation for intermediate/high-risk PE patients. We analysed data from all patients with confirmed PE diagnosed in the Massachusetts General Hospital Emergency Department from August 2013 to February 2017 and cross-referred these data with patients who received a PERT activation and patients who did not. Patients were stratified into low-risk or intermediate/high-risk PE. Univariate analyses were performed within each risk group comparing patients with a PERT activation and patients without. Fifteen percent (56/374) of low-risk PE patients triggered a PERT activation. Patient characteristics associated with PERT activation were: (1) vascular disease, (2) pulmonary diseases, (3) thrombophilia, (4) current use of anticoagulants, (5) central PE and (6) concurrent DVT. Thirty-five percent (110/283) of intermediate/high-risk PE patients did not elicit a PERT activation. Patient characteristics precluding a PERT activation were: (1) vascular disease, (2) malignancies and (3) asymptomatic presentation. Low-risk PE patients with PERT activations had more extensive clot burden, complex comorbidities, or had failed anticoagulation treatment. Intermediate/high-risk PE patients without PERT activations tended to have malignancies or vascular disease.
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Affiliation(s)
- Christian Schmidt Mortensen
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. .,Department of Cardiology, Aarhus University Hospital, Århus, Denmark.
| | - Anders Kramer
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Cardiology, Aarhus University Hospital, Århus, Denmark
| | - Jacob Gammelgaard Schultz
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Cardiology, Aarhus University Hospital, Århus, Denmark
| | - Nicholas Giordano
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hui Zheng
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Århus, Denmark
| | | | - Christopher Kabrhel
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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23
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Lyhne MD, Kabrhel C, Giordano N, Andersen A, Nielsen-Kudsk JE, Zheng H, Dudzinski DM. The echocardiographic ratio tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure predicts short-term adverse outcomes in acute pulmonary embolism. Eur Heart J Cardiovasc Imaging 2021; 22:285-294. [PMID: 33026070 DOI: 10.1093/ehjci/jeaa243] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 08/07/2020] [Indexed: 12/22/2022] Open
Abstract
AIMS Right ventricular (RV) failure causes death from acute pulmonary embolism (PE), due to a mismatch between RV systolic function and increased RV afterload. We hypothesized that an echocardiographic ratio of this mismatch [RV systolic function by tricuspid annular plane systolic excursion (TAPSE) divided by pulmonary arterial systolic pressure (PASP)] would predict adverse outcomes better than each measurement individually, and would be useful for risk stratification in intermediate-risk PE. METHODS AND RESULTS This was a retrospective analysis of a single academic centre Pulmonary Embolism Response Team registry from 2012 to 2019. All patients with confirmed PE and a formal transthoracic echocardiogram performed within 2 days were included. All echocardiograms were analysed by an observer blinded to the outcome. The primary endpoint was a 7-day composite outcome of death or haemodynamic deterioration. Secondary outcomes were 7- and 30-day all-cause mortality. A total of 627 patients were included; 135 met the primary composite outcome. In univariate analysis, the TAPSE/PASP was associated with our primary outcome [odds ratio = 0.028, 95% confidence interval (CI) 0.010-0.087; P < 0.0001], which was significantly better than either TAPSE or PASP alone (P = 0.017 and P < 0.0001, respectively). A TAPSE/PASP cut-off value of 0.4 was identified as the optimal value for predicting adverse outcome in PE. TAPSE/PASP predicted both 7- and 30-day all-cause mortality, while TAPSE and PASP did not. CONCLUSION A combined echocardiographic ratio of RV function to afterload is superior in prediction of adverse outcome in acute intermediate-risk PE. This ratio may improve risk stratification and identification of the patients that will suffer short-term deterioration after intermediate-risk PE.
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Affiliation(s)
- Mads D Lyhne
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, 0 Emerson Place, MA 02114, USA.,Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark.,Department of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, 0 Emerson Place, MA 02114, USA
| | - Nicholas Giordano
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, 0 Emerson Place, MA 02114, USA
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, 50 Staniford Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, 0 Emerson Place, MA 02114, USA.,Department of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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24
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Reagh JJ, Zheng H, Stolz U, Parry BA, Chang AM, House SL, Giordano NJ, Cohen J, Singer AJ, Francis S, Prochaska JH, Zeserson E, Wild PS, Limkakeng AT, Walters EL, LoVecchio F, Theodoro D, Hollander JE, Kabrhel C, Fermann GJ. Sex-related differences in D-dimer levels for venous thromboembolism screening. Acad Emerg Med 2021; 28:873-881. [PMID: 33497508 DOI: 10.1111/acem.14220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 01/11/2021] [Accepted: 01/13/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND D-dimer is generally considered positive above 0.5 mg/L irrespective of sex. However, women have been shown to be more likely to have a positive D-dimer after controlling for other factors. Thus, differences may exist between males and females for using D-dimer as a marker of venous thromboembolic (VTE) disease. We hypothesized that the accuracy of D-dimer tests may be enhanced by using appropriate cutoff values that reflect sex-related differences in D-dimer levels. METHODS This research is a secondary analysis of a multicenter, international, prospective, observational study of adult (18+ years) patients suspected of VTE, with low-to-intermediate pretest probability based on Wells criteria ≤ 6 for pulmonary embolism (PE) and ≤ 2 for deep vein thrombosis (DVT). VTE diagnoses were based on computed tomography, ventilation perfusion scanning, or venous ultrasound. D-dimer levels were tested for statistical difference across groups stratified by sex and diagnosis. Multivariable regression was used to investigate sex as a predictor of diagnosis. Sex-specific optimal D-dimer thresholds for PE and DVT were calculated from receiver operating characteristic analyses. A Youden threshold (D-dimer level coinciding with the maximum of sensitivity plus specificity) and a cutoff corresponding to 95% sensitivity were calculated. Statistical difference for cutoffs was tested via 95% confidence intervals from 2,000 bootstrapped samples. RESULTS We included 3,586 subjects for analysis, of whom 61% were female. Race demographics were 63% White, 27% Black/African American, and 6% Hispanic. In the suspected PE cohort, 6% were diagnosed with PE, while in the suspected DVT cohort, 11% were diagnosed with DVT. D-dimer levels were significantly higher in males than females for the PE-positive group and the DVT-negative group, but males had significantly lower D-dimer levels than females in the PE-negative group. Regression models showed male sex as a significant positive predictor of DVT diagnosis, controlling for D-dimer levels. The Youden thresholds for PE patients were 0.97 (95% CI = 0.64 to 1.79) mg/L and 1.45 (95% CI = 1.36 to 1.95) mg/L for females and males, respectively; 95% sensitivity cutoffs for this group were 0.64 (95% CI = 0.20 to 0.89) and 0.55 (95% CI = 0.29 to 1.61). For DVT, the Youden thresholds were 0.98 (95% CI = 0.84 to 1.56) mg/L for females and 1.25 (95% CI = 0.65 to 3.33) mg/L for males with 95% sensitivity cutoffs of 0.33 (95% CI = 0.2 to 0.61) and 0.32 (95% CI = 0.18 to 0.7), respectively. CONCLUSION Differences in D-dimer levels between males and females are diagnosis specific; however, there was no significant difference in optimal cutoff values for excluding PE and DVT between the sexes.
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Affiliation(s)
- Justin J. Reagh
- Department of Emergency Medicine University of Cincinnati Cincinnati Ohio USA
| | - Hui Zheng
- Biostatistics Center Massachusetts General Hospital Boston Massachusetts USA
| | - Uwe Stolz
- Department of Emergency Medicine University of Cincinnati Cincinnati Ohio USA
| | - Blair A. Parry
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
- Department of Emergency Medicine Center for Vascular Emergencies Massachusetts General Hospital Boston Massachusetts USA
| | - Anna M. Chang
- Department of Emergency Medicine Sidney Kimmel Medical College of Thomas Jefferson University Philadelphia Pennsylvania USA
| | - Stacey L. House
- Division of Emergency Medicine/Emergency Care Research Section Washington University School of Medicine St. Louis Missouri USA
| | - Nicholas J. Giordano
- Department of Emergency Medicine Massachusetts General Hospital Boston Massachusetts USA
- Department of Emergency Medicine Center for Vascular Emergencies Massachusetts General Hospital Boston Massachusetts USA
| | - Jason Cohen
- Department of Emergency Medicine and Surgery Albany Medical Center Albany New York USA
| | - Adam J. Singer
- Department of Emergency Medicine Stony Brook University Stony Brook New York USA
| | - Samuel Francis
- Division of Emergency Medicine Duke University Durham North Carolina USA
| | - Jürgen H. Prochaska
- Center for Thrombosis and Hemostasis University Medical Center of the Johannes Gutenberg‐University Mainz Germany
- German Center for Cardiovascular Research (DZHK) University Medical Center of the Johannes Gutenberg‐University Partner site Rhine Main Mainz Germany
- Preventive Medicine and Preventive Cardiology – Center for Cardiology University Medical Center of the Johannes Gutenberg‐University Mainz Mainz Germany
| | - Eli Zeserson
- Department of Emergency Medicine Christiana Care Wilmington Delaware USA
| | - Philipp S. Wild
- Center for Thrombosis and Hemostasis University Medical Center of the Johannes Gutenberg‐University Mainz Germany
- German Center for Cardiovascular Research (DZHK) University Medical Center of the Johannes Gutenberg‐University Partner site Rhine Main Mainz Germany
- Preventive Medicine and Preventive Cardiology – Center for Cardiology University Medical Center of the Johannes Gutenberg‐University Mainz Mainz Germany
| | | | - Elizabeth L. Walters
- Department of Emergency Medicine Loma Linda University Loma Linda California USA
| | - Frank LoVecchio
- Department of Emergency Medicine University of Arizona Phoenix Arizona USA
| | - Daniel Theodoro
- Division of Emergency Medicine/Emergency Care Research Section Washington University School of Medicine St. Louis Missouri USA
| | - Judd E. Hollander
- Department of Emergency Medicine Sidney Kimmel Medical College of Thomas Jefferson University Philadelphia Pennsylvania USA
| | - Christopher Kabrhel
- Department of Emergency Medicine Center for Vascular Emergencies Massachusetts General Hospital Boston Massachusetts USA
- Department of Emergency Medicine Massachusetts General Hospital/Harvard Medical School Boston Massachusetts USA
| | - Gregory J. Fermann
- Department of Emergency Medicine University of Cincinnati Cincinnati Ohio USA
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25
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Rali P, Sacher D, Rivera-Lebron B, Rosovsky R, Elwing JM, Berkowitz J, Mina B, Dalal B, Davis GA, Dudzinski DM, Duval A, Ichinose E, Kabrhel C, Kapoor A, Lio KU, Lookstein R, McDaniel M, Melamed R, Naydenov S, Sokolow S, Rosenfield K, Tapson V, Bossone E, Keeling B, Channick R, Ross CB. Interhospital Transfer of Patients With Acute Pulmonary Embolism (PE): Challenges and Opportunities. Chest 2021; 160:1844-1852. [PMID: 34273391 DOI: 10.1016/j.chest.2021.07.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/23/2021] [Accepted: 07/02/2021] [Indexed: 01/07/2023] Open
Abstract
Acute pulmonary embolism (PE) is associated with significant morbidity and mortality. The management paradigm for acute PE has evolved in recent years with wider availability of advanced treatment modalities ranging from catheter-directed reperfusion therapies to mechanical circulatory support. This evolution has coincided with the development and implementation of institutional pulmonary embolism response teams (PERT) nationwide and internationally. Because most institutions are not equipped or staffed for advanced PE care, patients often require transfer to centers with more comprehensive resources, including PERT expertise. One of the unmet needs in current PE care is an organized approach to the process of interhospital transfer (IHT) of critically ill PE patients. In this review, we discuss medical optimization and support of patients before and during transfer, transfer checklists, defined roles of emergency medical services, and the roles and responsibilities of referring and receiving centers involved in the IHT of acute PE patients.
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Affiliation(s)
- Parth Rali
- Temple University Hospital, Philadelphia, PA.
| | | | | | - Rachel Rosovsky
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jean M Elwing
- University of Cincinnati College of Medicine, Cincinnati, OH
| | | | | | - Bhavinkumar Dalal
- Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | | | | | | | | | | | | | - Ka U Lio
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | | | | | | | | | | | | | | | | | | | - Charles B Ross
- Piedmont Heart Institute, Piedmont Atlanta Hospital, Atlanta, GA
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26
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Kline JA, Camargo CA, Courtney DM, Kabrhel C, Nordenholz KE, Aufderheide T, Baugh JJ, Beiser DG, Bennett CL, Bledsoe J, Castillo E, Chisolm-Straker M, Goldberg EM, House H, House S, Jang T, Lim SC, Madsen TE, McCarthy DM, Meltzer A, Moore S, Newgard C, Pagenhardt J, Pettit KL, Pulia MS, Puskarich MA, Southerland LT, Sparks S, Turner-Lawrence D, Vrablik M, Wang A, Weekes AJ, Westafer L, Wilburn J. Clinical prediction rule for SARS-CoV-2 infection from 116 U.S. emergency departments 2-22-2021. PLoS One 2021; 16:e0248438. [PMID: 33690722 PMCID: PMC7946184 DOI: 10.1371/journal.pone.0248438] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/25/2021] [Indexed: 12/11/2022] Open
Abstract
Objectives Accurate and reliable criteria to rapidly estimate the probability of infection with the novel coronavirus-2 that causes the severe acute respiratory syndrome (SARS-CoV-2) and associated disease (COVID-19) remain an urgent unmet need, especially in emergency care. The objective was to derive and validate a clinical prediction score for SARS-CoV-2 infection that uses simple criteria widely available at the point of care. Methods Data came from the registry data from the national REgistry of suspected COVID-19 in EmeRgency care (RECOVER network) comprising 116 hospitals from 25 states in the US. Clinical variables and 30-day outcomes were abstracted from medical records of 19,850 emergency department (ED) patients tested for SARS-CoV-2. The criterion standard for diagnosis of SARS-CoV-2 required a positive molecular test from a swabbed sample or positive antibody testing within 30 days. The prediction score was derived from a 50% random sample (n = 9,925) using unadjusted analysis of 107 candidate variables as a screening step, followed by stepwise forward logistic regression on 72 variables. Results Multivariable regression yielded a 13-variable score, which was simplified to a 13-point score: +1 point each for age>50 years, measured temperature>37.5°C, oxygen saturation<95%, Black race, Hispanic or Latino ethnicity, household contact with known or suspected COVID-19, patient reported history of dry cough, anosmia/dysgeusia, myalgias or fever; and -1 point each for White race, no direct contact with infected person, or smoking. In the validation sample (n = 9,975), the probability from logistic regression score produced an area under the receiver operating characteristic curve of 0.80 (95% CI: 0.79–0.81), and this level of accuracy was retained across patients enrolled from the early spring to summer of 2020. In the simplified score, a score of zero produced a sensitivity of 95.6% (94.8–96.3%), specificity of 20.0% (19.0–21.0%), negative likelihood ratio of 0.22 (0.19–0.26). Increasing points on the simplified score predicted higher probability of infection (e.g., >75% probability with +5 or more points). Conclusion Criteria that are available at the point of care can accurately predict the probability of SARS-CoV-2 infection. These criteria could assist with decisions about isolation and testing at high throughput checkpoints.
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Affiliation(s)
- Jeffrey A. Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
- * E-mail:
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - D. Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern, Dallas, Texas, United States of America
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kristen E. Nordenholz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Thomas Aufderheide
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Joshua J. Baugh
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
| | - David G. Beiser
- Section of Emergency Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Christopher L. Bennett
- Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Joseph Bledsoe
- Department of Emergency Medicine, Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, Utah, United States of America
| | - Edward Castillo
- Department of Emergency Medicine, University of California, San Diego, California, United States of America
| | - Makini Chisolm-Straker
- Department of Emergency Medicine, Mt. Sinai School of Medicine, New York, New York, United States of America
| | - Elizabeth M. Goldberg
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States of America
| | - Hans House
- Department of Emergency Medicine, University of Iowa School of Medicine, Iowa City, Iowa, United States of America
| | - Stacey House
- Department of Emergency Medicine, Washington University School of Medicine, St. Louise, Missouri, United States of America
| | - Timothy Jang
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, United States of America
| | - Stephen C. Lim
- University Medical Center New Orleans, Louisiana State University School of Medicine, New Orleans, Louisiana, United States of America
| | - Troy E. Madsen
- Division of Emergency Medicine, Department Surgery, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Danielle M. McCarthy
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Andrew Meltzer
- Department of Emergency Medicine, George Washington University School of Medicine, Washington D.C., DC, United States of America
| | - Stephen Moore
- Department of Emergency Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, United States of America
| | - Craig Newgard
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon, United States of America
| | - Justine Pagenhardt
- Department of Emergency Medicine, West Virginia University School of Medicine, Morgantown, West Virginia, United States of America
| | - Katherine L. Pettit
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Michael S. Pulia
- Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States of America
| | - Michael A. Puskarich
- Department of Emergency Medicine, Hennepin County Medical Center and the University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Lauren T. Southerland
- Department of Emergency Medicine, Ohio State University Medical Center, Columbus, Ohio, United States of America
| | - Scott Sparks
- Department of Emergency Medicine, Riverside Regional Medical Center, Newport News, Virginia, United States of America
| | - Danielle Turner-Lawrence
- Department of Emergency Medicine, Beaumont Health, Royal Oak, Michigan, United States of America
| | - Marie Vrablik
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Alfred Wang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Anthony J. Weekes
- Department of Emergency Medicine, Carolinas Medical Center at Atrium Health, Charlotte, North Carolina, United States of America
| | - Lauren Westafer
- Department of Emergency Medicine, Baystate Health, Springfield, Massachusetts, United States of America
| | - John Wilburn
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, United States of America
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Arru CD, Digumarthy SR, Hansen JV, Lyhne MD, Singh R, Rosovsky R, Nielsen-Kudsk JE, Kabrhel C, Saba L, Kalra MK. Qualitative and quantitative DECT pulmonary angiography in COVID-19 pneumonia and pulmonary embolism. Clin Radiol 2021; 76:392.e1-392.e9. [PMID: 33714541 PMCID: PMC7906503 DOI: 10.1016/j.crad.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 02/17/2021] [Indexed: 12/23/2022]
Abstract
AIM To assess differences in qualitative and quantitative parameters of pulmonary perfusion from dual-energy computed tomography (CT) pulmonary angiography (DECT-PA) in patients with COVID-19 pneumonia with and without pulmonary embolism (PE). MATERIALS AND METHODS This retrospective institutional review board-approved study included 74 patients (mean age 61±18 years, male:female 34:40) with COVID-19 pneumonia in two countries (one with 68 patients, and the other with six patients) who underwent DECT-PA on either dual-source (DS) or single-source (SS) multidetector CT machines. Images from DS-DECT-PA were processed to obtain virtual mono-energetic 40 keV (Mono40), material decomposition iodine (MDI) images and quantitative perfusion statistics (QPS). Two thoracic radiologists determined CT severity scores based on type and extent of pulmonary opacities, assessed presence of PE, and pulmonary parenchymal perfusion on MDI images. The QPS were calculated from the CT Lung Isolation prototype (Siemens). The correlated clinical outcomes included duration of hospital stay, intubation, SpO2 and death. The significance of association was determined by receiver operating characteristics and analysis of variance. RESULTS One-fifth (20.2%, 15/74 patients) had pulmonary arterial filling defects; most filling defects were occlusive (28/44) located in the segmental and sub-segmental arteries. The parenchymal opacities were more extensive and denser (CT severity score 24±4) in patients with arterial filling defects than without filling defects (20±8; p=0.028). Ground-glass opacities demonstrated increased iodine distribution; mixed and consolidative opacities had reduced iodine on DS-DECT-PA but increased or heterogeneous iodine content on SS-DECT-PA. QPS were significantly lower in patients with low SpO2 (p=0.003), intubation (p=0.006), and pulmonary arterial filling defects (p=0.007). CONCLUSION DECT-PA QPS correlated with clinical outcomes in COVID-19 patients.
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Affiliation(s)
- C D Arru
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA; Azienda Ospedaliera Universitaria, SS 554 km 4,500, Monserrato, 09042, Cagliari, Italy
| | - S R Digumarthy
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA.
| | - J V Hansen
- Department of Cardiology, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - M D Lyhne
- Department of Cardiology, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - R Singh
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - R Rosovsky
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - J E Nielsen-Kudsk
- Department of Cardiology, Department of Clinical Medicine, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - C Kabrhel
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - L Saba
- Azienda Ospedaliera Universitaria, SS 554 km 4,500, Monserrato, 09042, Cagliari, Italy
| | - M K Kalra
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
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Lun EWY, Giordano NJ, Kramer A, Mortensen CS, Torrey J, Zheng H, Kabrhel C. Patient and operational factors that influence the decision to place an inferior vena cava filter in a pulmonary embolism response team. J Vasc Surg Venous Lymphat Disord 2020; 9:895-903. [PMID: 33278645 DOI: 10.1016/j.jvsv.2020.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The use of inferior vena cava (IVC) filters is controversial. However, the procedure is widely performed for secondary prophylaxis in patients with severe pulmonary embolism (PE), including those treated by a PE response team (PERT). In this study, we analyzed patient factors associated with the clinical decision to place an IVC filter in PERT patients. METHODS Data were collected on all Massachusetts General Hospital patients who had a PERT activation from October 1, 2012, to January 29, 2019. Data describing demographics, medical history, PE characteristics and treatment were collected at the time of PERT activation and prospectively for one year after PERT activation. Univariate and multivariable regression analyses were performed to determine factors associated with IVC filter placement. RESULTS We identified 834 patients, of whom 91 (10.9%) had an IVC filter placed in the first 7 days after PERT activation. The majority of patients receiving an IVC filter were male (55/91 [60.4%]; P =.096) with a mean age of 65 ± 15.0 years. Patients who received an IVC filter were less likely to have had a PERT referral from the Emergency Department (ED) (41/544 [7.5%]; P < .001) and more likely to have been referred from the intensive care unit (24/107 [22.43%]; P ≤ .001) compared with a floor referral. Patients who presented with syncope (15/86 [17.4%]; P = .040), a history of recent trauma (12/41 [29.3%]; P < .001), intracranial hemorrhage (11/39 [28.2%]; P = .002), a recent surgery or invasive procedure (30/188 [16.0%]; P = .012), a recent surgery (29/160 [18.1%]; P = .001) and a recent hospitalization (38/250 [15.2%]; P = .009) were more likely to have an IVC filter placed. Patients receiving an IVC filter were also more likely to have evidence of right heart dysfunction on a computed tomography pulmonary angiogram (61/359 [17.0%]; P < .001) and an echocardiogram (26/144 [18.1%]; P = .003). Compared with patients without an IVC filter, the 30-day venous thromboembolism recurrence rate was higher (4.7% vs 11.0%) in patients with IVC filters (10/45 [22.2%]; P = .023). CONCLUSIONS Factors associated with venous thromboembolism severity (eg, PERT referral from intensive care unit and right ventricular dysfunction) and an increased bleeding risk (eg, recent surgery or trauma) were associated with IVC filter placement among PERT patients.
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Affiliation(s)
- Elizabeth Weng Yan Lun
- Emergency Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Faculty of Medicine, University of New South Wales, Sydney, Australia.
| | | | - Anders Kramer
- Emergency Medicine, Massachusetts General Hospital, Boston, Mass; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Schmidt Mortensen
- Emergency Medicine, Massachusetts General Hospital, Boston, Mass; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jasmine Torrey
- Emergency Medicine, Massachusetts General Hospital, Boston, Mass
| | - Hui Zheng
- Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Christopher Kabrhel
- Emergency Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
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Rosovsky RP, Grodzin C, Channick R, Davis GA, Giri JS, Horowitz J, Kabrhel C, Lookstein R, Merli G, Morris TA, Rivera-Lebron B, Tapson V, Todoran TM, Weinberg AS, Rosenfield K. Diagnosis and Treatment of Pulmonary Embolism During the Coronavirus Disease 2019 Pandemic: A Position Paper From the National PERT Consortium. Chest 2020; 158:2590-2601. [PMID: 32861692 PMCID: PMC7450258 DOI: 10.1016/j.chest.2020.08.2064] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/06/2020] [Accepted: 08/16/2020] [Indexed: 12/22/2022] Open
Abstract
The coexistence of coronavirus disease 2019 (COVID-19) and pulmonary embolism (PE), two life-threatening illnesses, in the same patient presents a unique challenge. Guidelines have delineated how best to diagnose and manage patients with PE. However, the unique aspects of COVID-19 confound both the diagnosis and treatment of PE, and therefore require modification of established algorithms. Important considerations include adjustment of diagnostic modalities, incorporation of the prothrombotic contribution of COVID-19, management of two critical cardiorespiratory illnesses in the same patient, and protecting patients and health-care workers while providing optimal care. The benefits of a team-based approach for decision-making and coordination of care, such as that offered by pulmonary embolism response teams (PERTs), have become more evident in this crisis. The importance of careful follow-up care also is underscored for patients with these two diseases with long-term effects. This position paper from the PERT Consortium specifically addresses issues related to the diagnosis and management of PE in patients with COVID-19.
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Affiliation(s)
| | - Charles Grodzin
- Emory University Hospital Midtown, Emory University, Atlanta, GA
| | - Richard Channick
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA
| | | | - Jay S Giri
- Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Geno Merli
- Thomas Jefferson University Hospitals, Philadelphia, PA
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Kline JA, Pettit KL, Kabrhel C, Courtney DM, Nordenholz KE, Camargo CA. Multicenter registry of United States emergency department patients tested for SARS-CoV-2. J Am Coll Emerg Physicians Open 2020; 1:1341-1348. [PMID: 33392542 PMCID: PMC7771823 DOI: 10.1002/emp2.12313] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 10/13/2020] [Accepted: 10/15/2020] [Indexed: 01/08/2023] Open
Abstract
This paper summarizes the methodology for the registry of suspected COVID-19 in emergency care (RECOVER), a large clinical registry of patients from 155 United States (US) emergency departments (EDs) in 27 states tested for SARS-CoV-2 from March-September 2020. The initial goals are to derive and test: (1) a pretest probability instrument for prediction of SARS-CoV-2 test results, and from this instrument, a set of simple criteria to exclude COVID-19 (the COVID-19 Rule-Out Criteria-the CORC rule), and (2) a prognostic instrument for those with COVID-19. Patient eligibility included any ED patient tested for SARS-CoV-2 with a nasal or oropharyngeal swab. Abstracted clinical data included 204 variables representing the earliest manifestation of infection, including week of testing, demographics, symptoms, exposure risk, past medical history, test results, admission status, and outcomes 30 days later. In addition to the primary goals, the registry will provide a vital platform for characterizing the course, epidemiology, clinical features, and prognosis of patients tested for COVID-19 in the ED setting.
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Affiliation(s)
- Jeffrey A. Kline
- Department of Emergency MedicineIndiana UniversityIndianapolisIndianaUSA
| | | | - Christopher Kabrhel
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - D. Mark Courtney
- Department of Emergency MedicineUniversity of Texas SouthwesternDallasTexasUSA
| | | | - Carlos A. Camargo
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
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Liteplo AS, Huang CK, Zheng H, Patel R, Ratanski D, Giordano NJ, Kabrhel C, Shokoohi H. Left Ventricular Dysfunction Correlates With Mortality in Pulmonary Embolism. J Emerg Med 2020; 60:135-143. [PMID: 33127261 DOI: 10.1016/j.jemermed.2020.09.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/20/2020] [Accepted: 09/12/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Risk stratification of patients with pulmonary embolism (PE) is essential to guide advanced interventional management and proper disposition. OBJECTIVES In this study, we sought to assess individual echocardiographic markers of right ventricular (RV) strain and left ventricular (LV) function in patients with high-risk PE and identify their association with the need for advanced intervention (such as thrombolysis) and 30-day mortality. METHODS This was a retrospective study of ED patients with PE who were subject to a pulmonary embolism response team activation over a 5-year period. Cardiac point-of-care ultrasound studies were performed as part of patient care and later assessed for septal bowing, RV hypokinesis, McConnell sign, RV enlargement, tricuspid annular place systolic excursion, and LV systolic dysfunction. Outcome variables included need for advanced intervention and 30-day mortality. RESULTS The pulmonary embolism response team was activated in 893 patients, of which 718 had a confirmed PE. Of these, 90 had adequate cardiac point-of-care ultrasound images available for review. Patients who needed an advanced intervention were more likely to have septal bowing (odds ratio [OR] 8.69, 95% confidence interval [CI] 2.37-31.86), RV enlargement (OR 4.02, 95% CI 1.43-11.34), and a McConnell sign (OR 2.79, 95% CI 1.09-7.13). LV dysfunction was the only statistically significant predictor of 30-day mortality (OR 9.63, 95% CI 1.74-53.32). CONCLUSION In patients with PE in the ED, sonographic findings of RV strain that are more commonly associated with advanced intervention included septal bowing, McConnell sign, and RV enlargement. LV dysfunction was associated with a higher 30-day mortality. These findings can help inform decisions about ED management and disposition of patients with PE.
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Affiliation(s)
- Andrew S Liteplo
- Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Calvin K Huang
- Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Hui Zheng
- Massachusetts General Hospital, Boston, Massachusetts
| | - Ravish Patel
- Augusta University/University of Georgia Medical Partnership, University of Georgia, Athens, Georgia
| | | | | | - Christopher Kabrhel
- Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Hamid Shokoohi
- Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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32
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Mahan K, Kabrhel C, Goldsmith AJ. Abdominal pain in a patient with COVID-19 infection: A case of multiple thromboemboli. Am J Emerg Med 2020; 38:2245.e3-2245.e5. [PMID: 32513452 PMCID: PMC7248631 DOI: 10.1016/j.ajem.2020.05.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/19/2020] [Accepted: 05/19/2020] [Indexed: 12/31/2022] Open
Abstract
The novel coronavirus SARS-CoV-2 (COVID-19) pandemic has created diagnostic uncertainty with regards to distinguishing this infection from pulmonary embolism (PE). Although there appears to be an increased incidence of thromboembolic disease in patients with COVID-19 infection, recommendations regarding anticoagulation are lacking. We present the case of a 61-year-old woman with clinically significant venous and arterial thromboemboli in the setting of COVID-19 infection requiring tissue plasminogen activator (tPA).
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Affiliation(s)
- Keenan Mahan
- Harvard Medical School, Boston, MA, United States of America; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States of America.
| | - Christopher Kabrhel
- Harvard Medical School, Boston, MA, United States of America; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States of America.
| | - Andrew J Goldsmith
- Harvard Medical School, Boston, MA, United States of America; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States of America; Department of Emergency Medicine, Mt. Auburn Hospital, Cambridge, MA, United States of America.
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Kabrhel C. Cultivating a Better Understanding of COVID-19 Amidst a Shifting Landscape. Acad Emerg Med 2020; 27:925-927. [PMID: 32717144 DOI: 10.1111/acem.14097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Francis S, Kabrhel C. Current Controversies in Caring for the Critically Ill Pulmonary Embolism Patient. Emerg Med Clin North Am 2020; 38:931-944. [PMID: 32981627 DOI: 10.1016/j.emc.2020.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Emergency physicians must be prepared to rapidly diagnose and resuscitate patients with pulmonary embolism (PE). Certain aspects of PE resuscitation run counter to typical approaches. A specific understanding of the pathophysiology of PE is required to avoid cardiovascular collapse potentially associated with excessive intravenous fluids and positive pressure ventilation. Once PE is diagnosed, rapid risk stratification should be performed and treatment guided by patient risk class. Although anticoagulation remains the mainstay of PE treatment, emergency physicians also must understand the indications and contraindications for thrombolysis and should be aware of new therapies and models of care that may improve outcomes.
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Affiliation(s)
- Samuel Francis
- Division of Emergency Medicine, Department of Surgery, Duke University Hospital, DUH Box 3096, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA. https://twitter.com/chriskabrhel
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35
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Barnes GD, Muzikansky A, Cameron S, Giri J, Heresi GA, Jaber W, Wood T, Todoran TM, Courtney DM, Tapson V, Kabrhel C. Comparison of 4 Acute Pulmonary Embolism Mortality Risk Scores in Patients Evaluated by Pulmonary Embolism Response Teams. JAMA Netw Open 2020; 3:e2010779. [PMID: 32845326 PMCID: PMC7450352 DOI: 10.1001/jamanetworkopen.2020.10779] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE The risk of death from acute pulmonary embolism can range as high as 15%, depending on patient factors at initial presentation. Acute treatment decisions are largely based on an estimate of this mortality risk. OBJECTIVE To assess the performance of risk assessment scores in a modern, US cohort of patients with acute pulmonary embolism. DESIGN, SETTING, AND PARTICIPANTS This multicenter cohort study was conducted between October 2016 and October 2017 at 8 hospitals participating in the Pulmonary Embolism Response Team (PERT) Consortium registry. Included patients were adults who presented with acute pulmonary embolism and had sufficient information in the medical record to calculate risk scores. Data analysis was performed from March to May 2020. MAIN OUTCOMES AND MEASURES All-cause mortality (7- and 30-day) and associated discrimination were assessed by the area under the receiver operator curve (AUC). RESULTS Among 416 patients with acute pulmonary embolism (mean [SD] age, 61.3 [17.6] years; 207 men [49.8%]), 7-day mortality in the low-risk groups ranged from 1.3% (1 patient) to 3.1% (4 patients), whereas 30-day mortality ranged from 2.6% (1 patient) to 10.2% (13 patients). Among patients in the highest-risk groups, the 7-day mortality ranged from 7.0% (18 patients) to 16.3% (7 patients), whereas 30-day mortality ranged from 14.4% (37 patients) to 26.3% (26 patients). Each of the risk stratification tools had modest discrimination for 7-day mortality (AUC range, 0.616-0.666) with slightly lower discrimination for 30-day mortality (AUC range, 0.550-0.694). CONCLUSIONS AND RELEVANCE These findings suggest that commonly used risk tools for acute pulmonary embolism have modest estimating ability. Future studies to develop and validate better risk assessment tools are needed.
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Affiliation(s)
- Geoffrey D. Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor
| | | | - Scott Cameron
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Jay Giri
- Department of Internal Medicine, University of Pennsylvania, Philadelphia
| | - Gustavo A. Heresi
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Wissam Jaber
- Division of Cardiology, Department of Internal Medicine, Emory University, Atlanta, Georgia
| | - Todd Wood
- Division of Cardiology, Department of Internal Medicine, Lancaster General Hospital, Lancaster, Pennsylvania
| | - Thomas M. Todoran
- Division of Cardiovascular Medicine, Department of Internal Medicine, Medical University of South Carolina, Charleston
| | - D. Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern, Dallas
| | - Victor Tapson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Cedars-Sinai Hospital, Los Angeles, California
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Abstract
This article describes 2 relatively rare, but complex situations in pulmonary embolism (PE): clot-in-transit (CIT), incidental PE (IPE). CIT describes a venous thromboembolism that has become lodged in the right heart. CIT is associated with high mortality and presents unique challenges in management. Incidental PE (IPE) describes PE diagnosed on imaging performed for another indication. The treatment is complex because there is often a disconnect between the PE severity on imaging and lack of severity of the clinical presentation. We summarize the available literature and aid clinicians as they manage patients with PE across the clinical severity spectrum.
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Affiliation(s)
- Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA.
| | - Rachel Rosovsky
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Shannon Garvey
- Boston University School of Medicine, 72 E Concord Street, Boston, MA 02118, USA
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Jaber WA, Kabrhel C, Rosenfield K, Tu T, Ouriel K, Tapson VF. Percutaneous Thrombectomy in Emergency Department Patients with Pulmonary Embolism: The FLARE ED Sub-study. J Emerg Med 2020; 58:175-182. [PMID: 32220546 DOI: 10.1016/j.jemermed.2019.11.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 11/08/2019] [Accepted: 11/15/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The FlowTriever Pulmonary Embolectomy Clinical Study (FLARE) was a multicenter, single-arm trial that demonstrated effectiveness of the FlowTriever percutaneous pulmonary embolectomy system in reducing right ventricular/left ventricular (RV/LV) diameter ratio in patients with acute intermediate-risk pulmonary embolism (PE). Patients diagnosed in emergency departments (EDs) with acute PE may have a different presentation from those diagnosed in an in-hospital setting. OBJECTIVES The goal of this sub-study was to evaluate the safety and effectiveness of mechanical embolectomy in ED patients with acute intermediate-risk PE. METHODS ED patients with acute PE and RV/LV ratio ≥ 0.9 enrolled in the FLARE study were core laboratory analyzed. The primary efficacy endpoint was the change in RV/LV ratio from baseline to 48 h post procedure. The change in RV/LV ratio of patients with nonelevated cardiac troponin (cTn) and zero simplified PE Severity Index (sPESI) score (normal cTn-sPESI: intermediate-low risk) was also examined. Major adverse events (MAEs) included major bleeding, device-related death or clinical deterioration, and vascular or cardiac injury. RESULTS Seventy-six ED patients were included. Thirty-nine had a sPESI score of ≥ 1 and 32 had elevated cTn. The median preprocedure RV/LV ratio for all ED patients was 1.50 (0.88-2.52), with a change by -0.37 postprocedure (p < 0.001.) Three patients experienced MAEs. Seventeen patients (22.4%) presented with normal cTn-sPESI and had an RV/LV ratio reduced by 0.27 (p < 0.001) after embolectomy. CONCLUSION ED patients with intermediate-risk PE had significant improvement in their RV/LV ratio and low complication rates when treated with mechanical embolectomy, irrespective of their baseline cTn-sPESI risk score.
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Affiliation(s)
- Wissam A Jaber
- Interventional Cardiology, Emory University Hospital, Atlanta, Georgia
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kenneth Rosenfield
- Vascular Medicine and Intervention, Massachusetts General Hospital, Boston, Massachusetts
| | - Thomas Tu
- General and Interventional Cardiology, Baptist Health Louisville, Louisville, Kentucky
| | | | - Victor F Tapson
- Division of Pulmonary/Critical Care, Cedars-Sinai Medical Center, Los Angeles, California
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Garvey S, Dudzinski DM, Giordano N, Torrey J, Zheng H, Kabrhel C. PULMONARY EMBOLISM WITH CLOT IN TRANSIT: AN ANALYSIS OF RISK FACTORS AND OUTCOMES. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)32857-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Garvey S, Dudzinski DM, Giordano N, Torrey J, Zheng H, Kabrhel C. Pulmonary embolism with clot in transit: An analysis of risk factors and outcomes. Thromb Res 2020; 187:139-147. [DOI: 10.1016/j.thromres.2020.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 12/16/2019] [Accepted: 01/08/2020] [Indexed: 02/06/2023]
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Prucnal CK, Jansson PS, Deadmon E, Rosovsky RP, Zheng H, Kabrhel C. Analysis of Partial Thromboplastin Times in Patients With Pulmonary Embolism During the First 48 Hours of Anticoagulation With Unfractionated Heparin. Acad Emerg Med 2020; 27:117-127. [PMID: 31625654 DOI: 10.1111/acem.13872] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/26/2019] [Accepted: 08/08/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The objective was to determine the proportion of patients with pulmonary embolism (PE) treated with unfractionated heparin (UFH) who achieved therapeutic activated partial thromboplastin time (aPTT) values within 48 hours of treatment. METHODS Retrospective analysis of a PE response team (PERT) database was performed at a large, urban, academic teaching hospital. Inclusion criteria were adult patients with acute PE for whom the PERT was consulted and who received anticoagulation (AC) with UFH according to guideline standard dosing. aPTT values during 6-hour time periods during the first 48 hours of AC were collected and analyzed. RESULTS A total of 505 patients met inclusion criteria. For patients receiving a bolus and infusion of UFH, the proportions (95% confidence interval [CI]) of patients in the therapeutic range were 19.0% (14.2% to 25.0%) at 12 hours, 26.3% (26.3% to 33.1%) at 24 hours, 28.3% (22.0% to 35.4%) at 36 hours, and 28.4% (20.8% to 37.5%) at 48 hours. For titrated infusion only, the proportions (95% CIs) of patients were 23.3% (16.2% to 32.3%) at 12 hours, 41.4% (31.6% to 51.9%) at 24 hours, 37.0% (26.8% to 48.5%) at 36 hours, and 42.1% (30.2% to 55.0%) at 48 hours. No patient had all therapeutic aPTT values. CONCLUSIONS The majority of patients with acute PE spend most of their first 48 hours outside of the therapeutic range of AC when treated with guideline standard dosing of UFH. Over half of the patients fail to achieve any therapeutic PTT level within 24 hours of UFH initiation, and no patient had all therapeutic aPTTs. Future research should focus on identifying factors associated with achieving therapeutic AC with UFH.
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Affiliation(s)
- Christiana K. Prucnal
- Center for Vascular Emergencies Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Paul S. Jansson
- Center for Vascular Emergencies Department of Emergency Medicine Massachusetts General Hospital Boston MA
- Department of Emergency Medicine Brigham and Women’s Hospital Boston MA
- Department of Emergency Medicine Harvard Medical School Boston MA
| | - Erin Deadmon
- Center for Vascular Emergencies Department of Emergency Medicine Massachusetts General Hospital Boston MA
| | - Rachel P. Rosovsky
- Center for Vascular Emergencies Department of Emergency Medicine Massachusetts General Hospital Boston MA
- Division of Hematology Department of Medicine Massachusetts General Hospital Boston MA
| | - Hui Zheng
- Biostatistics Center Massachusetts General Hospital Boston MA
- Department of Medicine Harvard Medical School Boston MA
| | - Christopher Kabrhel
- Center for Vascular Emergencies Department of Emergency Medicine Massachusetts General Hospital Boston MA
- Department of Emergency Medicine Harvard Medical School Boston MA
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Rivera-Lebron B, McDaniel M, Ahrar K, Alrifai A, Dudzinski DM, Fanola C, Blais D, Janicke D, Melamed R, Mohrien K, Rozycki E, Ross CB, Klein AJ, Rali P, Teman NR, Yarboro L, Ichinose E, Sharma AM, Bartos JA, Elder M, Keeling B, Palevsky H, Naydenov S, Sen P, Amoroso N, Rodriguez-Lopez JM, Davis GA, Rosovsky R, Rosenfield K, Kabrhel C, Horowitz J, Giri JS, Tapson V, Channick R. Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practice from the PERT Consortium. Clin Appl Thromb Hemost 2019; 25:1076029619853037. [PMID: 31185730 PMCID: PMC6714903 DOI: 10.1177/1076029619853037] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Pulmonary embolism (PE) is a life-threatening condition and a leading cause of morbidity and mortality. There have been many advances in the field of PE in the last few years, requiring a careful assessment of their impact on patient care. However, variations in recommendations by different clinical guidelines, as well as lack of robust clinical trials, make clinical decisions challenging. The Pulmonary Embolism Response Team Consortium is an international association created to advance the diagnosis, treatment, and outcomes of patients with PE. In this consensus practice document, we provide a comprehensive review of the diagnosis, treatment, and follow-up of acute PE, including both clinical data and consensus opinion to provide guidance for clinicians caring for these patients.
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Affiliation(s)
| | | | - Kamran Ahrar
- 3 The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Abdulah Alrifai
- 4 University of Miami of Palm Beach Regional Campus/JFK Hospital, Atlantis, FL, USA
| | - David M Dudzinski
- 5 Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Danielle Blais
- 7 The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Roman Melamed
- 9 Abbott Northwestern Hospital, Minneapolis, MN, USA
| | | | - Elizabeth Rozycki
- 7 The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | - Parth Rali
- 10 Temple University, Philadelphia, PA, USA
| | | | | | | | | | | | - Mahir Elder
- 14 Wayne State University, Detroit, MI, USA.,15 Michigan State University, East Lansing, MI, USA
| | | | | | | | | | | | | | | | - Rachel Rosovsky
- 5 Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kenneth Rosenfield
- 5 Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Jay S Giri
- 16 University of Pennsylvania, Philadelphia, PA, USA
| | - Victor Tapson
- 21 Cedars-Sinai Medical Center, Los Angeles, CA, USA
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42
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Rice JK, Kabrhel C, Wittels K, Wilcox SR. Concern for a Classic Sexually Transmitted Infection. J Emerg Med 2019; 58:330-333. [PMID: 31818609 DOI: 10.1016/j.jemermed.2019.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/17/2019] [Accepted: 10/18/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Justin Keith Rice
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts
| | - Christopher Kabrhel
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kathleen Wittels
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan R Wilcox
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
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43
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Khera AV, Mason-Suares H, Brockman D, Wang M, VanDenburgh MJ, Senol-Cosar O, Patterson C, Newton-Cheh C, Zekavat SM, Pester J, Chasman DI, Kabrhel C, Jensen MK, Manson JE, Gaziano JM, Taylor KD, Sotoodehnia N, Post WS, Rich SS, Rotter JI, Lander ES, Rehm HL, Ng K, Philippakis A, Lebo M, Albert CM, Kathiresan S. Rare Genetic Variants Associated With Sudden Cardiac Death in Adults. J Am Coll Cardiol 2019; 74:2623-2634. [PMID: 31727422 DOI: 10.1016/j.jacc.2019.08.1060] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 08/27/2019] [Accepted: 08/27/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Sudden cardiac death occurs in ∼220,000 U.S. adults annually, the majority of whom have no prior symptoms or cardiovascular diagnosis. Rare pathogenic DNA variants in any of 49 genes can pre-dispose to 4 important causes of sudden cardiac death: cardiomyopathy, coronary artery disease, inherited arrhythmia syndrome, and aortopathy or aortic dissection. OBJECTIVES This study assessed the prevalence of rare pathogenic variants in sudden cardiac death cases versus controls, and the prevalence and clinical importance of such mutations in an asymptomatic adult population. METHODS The authors performed whole-exome sequencing in a case-control cohort of 600 adult-onset sudden cardiac death cases and 600 matched controls from 106,098 participants of 6 prospective cohort studies. Observed DNA sequence variants in any of 49 genes with known association to cardiovascular disease were classified as pathogenic or likely pathogenic by a clinical laboratory geneticist blinded to case status. In an independent population of 4,525 asymptomatic adult participants of a prospective cohort study, the authors performed whole-genome sequencing and determined the prevalence of pathogenic or likely pathogenic variants and prospective association with cardiovascular death. RESULTS Among the 1,200 sudden cardiac death cases and controls, the authors identified 5,178 genetic variants and classified 14 as pathogenic or likely pathogenic. These 14 variants were present in 15 individuals, all of whom had experienced sudden cardiac death-corresponding to a pathogenic variant prevalence of 2.5% in cases and 0% in controls (p < 0.0001). Among the 4,525 participants of the prospective cohort study, 41 (0.9%) carried a pathogenic or likely pathogenic variant and these individuals had 3.24-fold higher risk of cardiovascular death over a median follow-up of 14.3 years (p = 0.02). CONCLUSIONS Gene sequencing identifies a pathogenic or likely pathogenic variant in a small but potentially important subset of adults experiencing sudden cardiac death; these variants are present in ∼1% of asymptomatic adults.
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Affiliation(s)
- Amit V Khera
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts; Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts.
| | - Heather Mason-Suares
- Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge, Massachusetts
| | - Deanna Brockman
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts; Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Minxian Wang
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Martin J VanDenburgh
- Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ozlem Senol-Cosar
- Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge, Massachusetts; Janssen Pharmaceuticals, Cambridge, Massachusetts
| | - Candace Patterson
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Christopher Newton-Cheh
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts; Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Seyedeh M Zekavat
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Julie Pester
- Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel I Chasman
- Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher Kabrhel
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Majken K Jensen
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - JoAnn E Manson
- Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - J Michael Gaziano
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kent D Taylor
- The Institute for Translational Genomics and Population Sciences, Departments of Pediatrics and Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Nona Sotoodehnia
- Cardiovascular Health Research Unit, Department of Medicine, University of Washington, Seattle, Washington
| | - Wendy S Post
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephen S Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia
| | - Jerome I Rotter
- The Institute for Translational Genomics and Population Sciences, Departments of Pediatrics and Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California
| | - Eric S Lander
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts; Department of Biology, MIT, Cambridge, Massachusetts; Department of Systems Biology, Harvard Medical School, Boston, Massachusetts
| | - Heidi L Rehm
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kenney Ng
- Center for Computational Health, IBM Research, Cambridge, Massachusetts
| | - Anthony Philippakis
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Matthew Lebo
- Laboratory for Molecular Medicine, Partners HealthCare Personalized Medicine, Cambridge, Massachusetts
| | - Christine M Albert
- Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Klarin D, Busenkell E, Judy R, Lynch J, Levin M, Haessler J, Aragam K, Chaffin M, Haas M, Lindström S, Assimes TL, Huang J, Min Lee K, Shao Q, Huffman JE, Kabrhel C, Huang Y, Sun YV, Vujkovic M, Saleheen D, Miller DR, Reaven P, DuVall S, Boden WE, Pyarajan S, Reiner AP, Trégouët DA, Henke P, Kooperberg C, Gaziano JM, Concato J, Rader DJ, Cho K, Chang KM, Wilson PWF, Smith NL, O'Donnell CJ, Tsao PS, Kathiresan S, Obi A, Damrauer SM, Natarajan P. Genome-wide association analysis of venous thromboembolism identifies new risk loci and genetic overlap with arterial vascular disease. Nat Genet 2019; 51:1574-1579. [PMID: 31676865 PMCID: PMC6858581 DOI: 10.1038/s41588-019-0519-3] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 09/24/2019] [Indexed: 12/22/2022]
Abstract
Venous thromboembolism is a significant cause of mortality1, yet its genetic determinants are incompletely defined. We performed a discovery genome-wide association study in the Million Veteran Program and UK Biobank, with testing of approximately 13 million DNA sequence variants for association with venous thromboembolism (26,066 cases and 624,053 controls) and meta-analyzed both studies, followed by independent replication with up to 17,672 venous thromboembolism cases and 167,295 controls. We identified 22 previously unknown loci, bringing the total number of venous thromboembolism-associated loci to 33, and subsequently fine-mapped these associations. We developed a genome-wide polygenic risk score for venous thromboembolism that identifies 5% of the population at an equivalent incident venous thromboembolism risk to carriers of the established factor V Leiden p.R506Q and prothrombin G20210A mutations. Our data provide mechanistic insights into the genetic epidemiology of venous thromboembolism and suggest a greater overlap among venous and arterial cardiovascular disease than previously thought.
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Affiliation(s)
- Derek Klarin
- Veterans Affairs Boston Healthcare System, Boston, MA, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Vascular Surgery and Endovascular Therapy, University of Florida School of Medicine, Gainesville, FL, USA
| | - Emma Busenkell
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Renae Judy
- Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Julie Lynch
- Veterans Affairs Informatics and Computing Infrastructure, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- University of Massachusetts College of Nursing & Health Sciences, Boston, MA, USA
| | - Michael Levin
- Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffery Haessler
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Krishna Aragam
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Mark Chaffin
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Mary Haas
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Sara Lindström
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - Themistocles L Assimes
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jie Huang
- Massachusetts Veterans Epidemiology Research and Information Center, Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Kyung Min Lee
- Veterans Affairs Informatics and Computing Infrastructure, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
- Boston University School of Public Health, Department of Health Law, Policy & Management, Boston, MA, USA
| | - Qing Shao
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
| | - Jennifer E Huffman
- Massachusetts Veterans Epidemiology Research and Information Center, Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Christopher Kabrhel
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yunfeng Huang
- Department of Epidemiology, Emory University Rollins School of Public Health, Department of Biomedical Informatics Emory University School of Medicine, Atlanta, GA, USA
- Atlanta Veterans Affairs Health Care System, Decatur, GA, USA
| | - Yan V Sun
- Department of Epidemiology, Emory University Rollins School of Public Health, Department of Biomedical Informatics Emory University School of Medicine, Atlanta, GA, USA
- Atlanta Veterans Affairs Health Care System, Decatur, GA, USA
| | - Marijana Vujkovic
- Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, Philadelphia, PA, USA
| | - Danish Saleheen
- Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, Philadelphia, PA, USA
| | - Donald R Miller
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
- Boston University School of Public Health, Department of Health Law, Policy & Management, Boston, MA, USA
| | - Peter Reaven
- Phoenix Veterans Affairs Health Care System, Phoenix, AZ, USA
| | - Scott DuVall
- Veterans Affairs Informatics and Computing Infrastructure, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - William E Boden
- Massachusetts Veterans Epidemiology Research and Information Center, Veterans Affairs Boston Healthcare System, Boston, MA, USA
| | - Saiju Pyarajan
- Massachusetts Veterans Epidemiology Research and Information Center, Veterans Affairs Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alex P Reiner
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - David-Alexandre Trégouët
- Bordeaux Population Health Research Center (INSERM UMR S 1219), University of Bordeaux, Bordeaux, France
| | - Peter Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Charles Kooperberg
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - J Michael Gaziano
- Massachusetts Veterans Epidemiology Research and Information Center, Veterans Affairs Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John Concato
- Clinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Daniel J Rader
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kelly Cho
- Massachusetts Veterans Epidemiology Research and Information Center, Veterans Affairs Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kyong-Mi Chang
- Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter W F Wilson
- Atlanta Veterans Affairs Health Care System, Decatur, GA, USA
- Emory Clinical Cardiovascular Research Institute, Atlanta, GA, USA
| | - Nicholas L Smith
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Office of Research and Development, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Christopher J O'Donnell
- Veterans Affairs Boston Healthcare System, Boston, MA, USA
- Massachusetts Veterans Epidemiology Research and Information Center, Veterans Affairs Boston Healthcare System, Boston, MA, USA
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philip S Tsao
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Sekar Kathiresan
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Verve Therapeutics, Cambridge, MA, USA
| | - Andrea Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Scott M Damrauer
- Corporal Michael Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pradeep Natarajan
- Veterans Affairs Boston Healthcare System, Boston, MA, USA.
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Giri J, Sista AK, Weinberg I, Kearon C, Kumbhani DJ, Desai ND, Piazza G, Gladwin MT, Chatterjee S, Kobayashi T, Kabrhel C, Barnes GD. Interventional Therapies for Acute Pulmonary Embolism: Current Status and Principles for the Development of Novel Evidence: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e774-e801. [PMID: 31585051 DOI: 10.1161/cir.0000000000000707] [Citation(s) in RCA: 202] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pulmonary embolism (PE) represents the third leading cause of cardiovascular mortality. The technological landscape for management of acute intermediate- and high-risk PE is rapidly evolving. Two interventional devices using pharmacomechanical means to recanalize the pulmonary arteries have recently been cleared by the US Food and Drug Administration for marketing, and several others are in various stages of development. The purpose of this document is to clarify the current state of endovascular interventional therapy for acute PE and to provide considerations for evidence development for new devices that will define which patients with PE would derive the greatest net benefit from their use in various clinical settings. First, definitions and limitations of commonly used risk stratification tools for PE are reviewed. An adjudication of risks and benefits of available interventional therapies for PE follows. Next, considerations for optimal future evidence development in this field are presented in the context of the current US regulatory framework. Finally, the document concludes with a discussion of the pros and cons of the rapidly expanding PE response team model of care delivery.
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46
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Rosovsky R, Zhao K, Sista A, Rivera‐Lebron B, Kabrhel C. Pulmonary embolism response teams: Purpose, evidence for efficacy, and future research directions. Res Pract Thromb Haemost 2019; 3:315-330. [PMID: 31294318 PMCID: PMC6611377 DOI: 10.1002/rth2.12216] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 04/09/2019] [Indexed: 12/20/2022] Open
Abstract
Pulmonary embolism (PE) is a major cause of morbidity and mortality in the United States. Although new therapeutic tools and strategies have recently been developed for the diagnosis and treatment of patients with PE, the outcomes for patients who present with massive or high-risk PE remain dismal. To address this crisis, pulmonary embolism response teams (PERTs) are being created around the world in an effort to immediately and simultaneously engage multiple specialists to determine the best course of action and coordinate the clinical care for patients with acute PE. The scope of this review is to describe the PERT model and purpose, present the structure and organization, examine the available evidence for efficacy and usefulness, and propose future directions for research that is needed to demonstrate the value of PERT and determine if this multidisciplinary approach represents a new standard of care.
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Affiliation(s)
- Rachel Rosovsky
- Division of Hematology & OncologyDepartment of MedicineMassachusetts HospitalBostonMassachusetts
| | - Ken Zhao
- Division of Interventional RadiologyDepartment of RadiologyNew York University Langone Medical CenterNew YorkNew York
| | - Akhilesh Sista
- Division of Interventional RadiologyDepartment of RadiologyNew York University Langone Medical CenterNew YorkNew York
| | - Belinda Rivera‐Lebron
- Division of Pulmonary, Allergy and Critical Care MedicineDepartment of MedicineUniversity of PittsburghPittsburghPennsylvania
| | - Christopher Kabrhel
- Center for Vascular EmergenciesDepartment of Emergency MedicineMassachusetts General HospitalBostonMassachusetts
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47
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Kabrhel C, Rosovsky R, Baugh C, Connors J, White B, Giordano N, Torrey J, Deadmon E, Parry BA, Hagan S, Zheng H. Multicenter Implementation of a Novel Management Protocol Increases the Outpatient Treatment of Pulmonary Embolism and Deep Vein Thrombosis. Acad Emerg Med 2019; 26:657-669. [PMID: 30341928 DOI: 10.1111/acem.13640] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective was to determine whether a protocol combining risk stratification, treatment with the direct-acting oral anticoagulant rivaroxaban, and defined follow-up is associated with a greater proportion of patients with venous thromboembolism (VTE) treated as outpatients, without hospital admission. METHODS We performed a multicenter study of patients diagnosed with VTE (pulmonary embolism [PE] or deep vein thrombosis [DVT]) in two urban EDs, 18 months before and 18 months after implementation of an outpatient VTE treatment protocol. Patients with radiographically confirmed acute VTE were eligible. Our primary outcome was the proportion of VTE patients discharged from the ED or observation unit (i.e., without hospital admission). We performed subgroup analyses according to hospital, DVT and PE, and low-risk PE. We also assessed 7- and 30-day mortality, major bleeding, and returns to the ED. We compared proportions using chi-square and Fisher's exact tests. RESULTS We enrolled 2,212 patients, 1,081 (49%) before protocol and 1,131 (51%) after protocol. Mean age (59 years vs. 60 years), female sex (49% vs. 49%), other demographics, comorbid illness, and PE risk stratification were similar before and after. After protocol, more VTE (35% from 26%, p < 0.001), PE (18% from 12%, p = 0.002), low-risk PE (28% from 18%, p < 0.001), and DVT (60% from 49%, p = 0.002) patients were treated as outpatients. Mortality, bleeding, and returns to ED were rare and did not increase after protocol. CONCLUSIONS A treatment protocol combining risk-stratification, rivaroxaban treatment and defined follow-up is associated with an increase in PE and DVT patients treated as outpatients, with no increase in adverse outcomes.
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Affiliation(s)
- Christopher Kabrhel
- Center for Vascular Emergencies Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston MAUSA
| | - Rachel Rosovsky
- Division of Hematology / Oncology Department of Medicine Massachusetts General Hospital Harvard Medical School BostonMA USA
| | - Christopher Baugh
- Department of Emergency Medicine Brigham and Women's Hospital Harvard Medical School Boston MAUSA
| | - Jean Connors
- Division of Hematology / Oncology Department of Medicine Brigham and Women's Hospital Harvard Medical School Boston MAUSA
| | - Benjamin White
- Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston MAUSA
| | - Nicholas Giordano
- Center for Vascular Emergencies Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston MAUSA
| | - Jasmine Torrey
- Center for Vascular Emergencies Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston MAUSA
| | - Erin Deadmon
- Center for Vascular Emergencies Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston MAUSA
| | - Blair Alden Parry
- Center for Vascular Emergencies Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston MAUSA
| | - Sean Hagan
- Department of Emergency Medicine Brigham and Women's Hospital Harvard Medical School Boston MAUSA
| | - Hui Zheng
- Department of Biostatistics Massachusetts General Hospital Boston MA USA
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Lindström S, Brody JA, Turman C, Germain M, Bartz TM, Smith EN, Chen MH, Puurunen M, Chasman D, Hassler J, Pankratz N, Basu S, Guan W, Gyorgy B, Ibrahim M, Empana JP, Olaso R, Jackson R, Brækkan SK, McKnight B, Deleuze JF, O’Donnell CJ, Jouven X, Frazer KA, Psaty BM, Wiggins KL, Taylor K, Reiner AP, Heckbert SR, Kooperberg C, Ridker P, Hansen JB, Tang W, Johnson AD, Morange PE, Trégouët DA, Kraft P, Smith NL, Kabrhel C. A large-scale exome array analysis of venous thromboembolism. Genet Epidemiol 2019; 43:449-457. [PMID: 30659681 PMCID: PMC6520188 DOI: 10.1002/gepi.22187] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/26/2018] [Accepted: 12/11/2019] [Indexed: 01/12/2023]
Abstract
Although recent Genome-Wide Association Studies have identified novel associations for common variants, there has been no comprehensive exome-wide search for low-frequency variants that affect the risk of venous thromboembolism (VTE). We conducted a meta-analysis of 11 studies comprising 8,332 cases and 16,087 controls of European ancestry and 382 cases and 1,476 controls of African American ancestry genotyped with the Illumina HumanExome BeadChip. We used the seqMeta package in R to conduct single variant and gene-based rare variant tests. In the single variant analysis, we limited our analysis to the 64,794 variants with at least 40 minor alleles across studies (minor allele frequency [MAF] ~0.08%). We confirmed associations with previously identified VTE loci, including ABO, F5, F11, and FGA. After adjusting for multiple testing, we observed no novel significant findings in single variant or gene-based analysis. Given our sample size, we had greater than 80% power to detect minimum odds ratios greater than 1.5 and 1.8 for a single variant with MAF of 0.01 and 0.005, respectively. Larger studies and sequence data may be needed to identify novel low-frequency and rare variants associated with VTE risk.
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Affiliation(s)
- Sara Lindström
- Department of Epidemiology, University of Washington, Seattle, United States
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, United States
| | - Jennifer A. Brody
- Department of Medicine, University of Washington, Seattle, United States
| | - Constance Turman
- Department of Epidemiology Harvard TH Chan School of Public Health, Boston, United States
| | - Marine Germain
- University of Bordeaux, Inserm 1219, Bordeaux Population Health Research Center, Bordeaux, France
| | - Traci M. Bartz
- Department of Medicine, University of Washington, Seattle, United States
- Department of Biostatistics University of Washington, Seattle, United States
| | - Erin N. Smith
- Department of Pediatrics and Rady Children’s Hospital University of California, San Diego, La Jolla, United State
- Department of Clinical Medicine, UiT - The Arctic University of Norway, K.G. Jebsen Thrombosis Research and Expertise Center (TREC), Tromsø, Norway
| | - Ming-Huei Chen
- Population Sciences Branch, National Heart, Lung and Blood Institute’s The Framingham Heart Study, Framingham, United States
| | - Marja Puurunen
- School of Medicine, Boston University, Boston, United States
| | - Daniel Chasman
- Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, United States
| | - Jeffrey Hassler
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, United States
| | - Nathan Pankratz
- Department of Laboratory Medicine and Pathology, School of Medicine, University of Minnesota, Minneapolis, USA
| | - Saonli Basu
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, USA
| | - Weihua Guan
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, USA
| | - Beata Gyorgy
- Team Genomics & Pathophysiology of Cardiovascular Diseases, Sorbonne Universités, UPMC Univ. Paris 06, INSERM, UMR_S 1166, Paris, France
- ICAN Institute for Cardiometabolism and Nutrition, Paris, France
| | - Manal Ibrahim
- Laboratory of Haematology, La Timone Hospital, Marseille, France
- Aix-Marseille University, INSERM, INSERM, INRA, C2VN, Marseille, France
- CRB Assistance Publique Hopitaux de Marseille HemoVasc, Marseille, France
| | - Jean-Philippe Empana
- Department of Epidemiology, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR_S 970, Paris, France
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Robert Olaso
- Centre National de Recherche en Génomique Humaine (CNRGH), Direction de la Recherche Fondamentale, CEA, Institut de Biologie François Jacob, Evry, France
| | | | - Sigrid K. Brækkan
- Department of Clinical Medicine, UiT - The Arctic University of Norway, K.G. Jebsen Thrombosis Research and Expertise Center (TREC), Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Barbara McKnight
- Department of Biostatistics University of Washington, Seattle, United States
| | - Jean-Francois Deleuze
- Centre National de Recherche en Génomique Humaine (CNRGH), Direction de la Recherche Fondamentale, CEA, Institut de Biologie François Jacob, Evry, France
| | | | - Xavier Jouven
- Department of Epidemiology, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMR_S 970, Paris, France
- Department of Cardiology, Georges Pompidou European Hospital, APHP, Paris, France
| | - Kelly A. Frazer
- Department of Pediatrics and Rady Children’s Hospital University of California, San Diego, La Jolla, United State
- Department of Clinical Medicine, UiT - The Arctic University of Norway, K.G. Jebsen Thrombosis Research and Expertise Center (TREC), Tromsø, Norway
- Institute for Genomic Medicine, University of California, San Diego, La Jolla, United States
| | - Bruce M. Psaty
- Department of Epidemiology, University of Washington, Seattle, United States
- Department of Medicine, University of Washington, Seattle, United States
- Department of Health Services, University of Washington, Seattle, United States
- Kaiser Permanente Washington Research Institute, Kaiser Permanente Washington, Seattle, United States
| | - Kerri L. Wiggins
- Department of Medicine, University of Washington, Seattle, United States
| | | | - Alexander P. Reiner
- Department of Epidemiology, University of Washington, Seattle, United States
| | - Susan R. Heckbert
- Department of Epidemiology, University of Washington, Seattle, United States
| | - Charles Kooperberg
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, United States
| | - Paul Ridker
- Division of Preventive Medicine, Brigham and Women’s Hospital, Boston, United States
| | - John-Bjarne Hansen
- Department of Clinical Medicine, UiT - The Arctic University of Norway, K.G. Jebsen Thrombosis Research and Expertise Center (TREC), Tromsø, Norway
- Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Weihong Tang
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, United States
| | - Andrew D. Johnson
- Population Sciences Branch, National Heart, Lung and Blood Institute’s The Framingham Heart Study, Framingham, United States
| | - Pierre-Emmanuel Morange
- Laboratory of Haematology, La Timone Hospital, Marseille, France
- Aix-Marseille University, INSERM, INSERM, INRA, C2VN, Marseille, France
- CRB Assistance Publique Hopitaux de Marseille HemoVasc, Marseille, France
| | - David A. Trégouët
- University of Bordeaux, Inserm 1219, Bordeaux Population Health Research Center, Bordeaux, France
| | - Peter Kraft
- Department of Epidemiology Harvard TH Chan School of Public Health, Boston, United States
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, United States
| | - Nicholas L. Smith
- Department of Epidemiology, University of Washington, Seattle, United States
- Kaiser Permanente Washington Research Institute, Kaiser Permanente Washington, Seattle, United States
- Department of Veteran Affairs Office of Research and Development, Seattle Epidemiologic Research and Information Center, Seattle, United States
| | - Christopher Kabrhel
- Center for Vascular Emergencies, Department of Emergency Medicine, Massachusetts General Hospital, Boston, United States
- Channing Network Medicine, Brigham and Women’s Hospital, Boston, United States
- Harvard Medical School, Boston, United States
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49
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McNeill JN, Witkin AS, Chang Y, Kabrhel C, Channick RN. Does the Time of Day a Pulmonary Embolism Response Team Is Activated Affect Time to Intervention or Outcome? Chest 2019; 152:1353-1354. [PMID: 29223267 DOI: 10.1016/j.chest.2017.09.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 09/08/2017] [Indexed: 10/18/2022] Open
Affiliation(s)
| | | | - Yuchiao Chang
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Christopher Kabrhel
- Department of Pulmonary and Critical Care, Boston, MA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
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50
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Rosovsky R, Borges J, Kabrhel C, Rosenfield K. Pulmonary Embolism Response Team: Inpatient Structure, Outpatient Follow-up, and Is It the Current Standard of Care? Clin Chest Med 2019; 39:621-630. [PMID: 30122185 DOI: 10.1016/j.ccm.2018.04.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Pulmonary Embolism Response Teams (PERTs) are being created around the United States to immediately and simultaneously bring together multiple specialists to determine the best course of action and coordinate clinical care for patients with severe pulmonary embolism (PE). The organization and structure of each PERT will depend on local clinical demands and resources. Creating a follow up clinic for PE patients after discharge from the hospital is an essential component of any PERT program. PERT programs, which have come together to form the PERT Consortium®, are changing the landscape of PE treatment and may represent a new standard of care.
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Affiliation(s)
- Rachel Rosovsky
- Division of Hematology and Oncology, Department of Medicine, Massachusetts Hospital, 55 Fruit Street, Boston, MA 02114, USA.
| | - Jorge Borges
- Division of Cardiology, Section of Vascular Medicine and Intervention, Department of Medicine, Massachusetts Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Kenneth Rosenfield
- Division of Cardiology, Section of Vascular Medicine and Intervention, Department of Medicine, Massachusetts Hospital, 55 Fruit Street, Boston, MA 02114, USA
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