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Najarro M, Rodríguez C, Morillo R, Jara-Palomares L, Vinson DR, Muriel A, Álvarez-Mon M, Yusen RD, Bikdeli B, Jimenez D. C-reactive Protein and Risk of Right Ventricular Dysfunction and Mortality in Patients With Acute Symptomatic Pulmonary Embolism. Arch Bronconeumol 2024:S0300-2896(24)00084-X. [PMID: 38644151 DOI: 10.1016/j.arbres.2024.03.024] [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: 02/04/2024] [Revised: 03/21/2024] [Accepted: 03/27/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Right ventricle (RV) dysfunction increases the risk of death from pulmonary embolism (PE). C-reactive protein (CRP) might identify RV inflammation and dysfunction in patients with PE. METHODS This cohort study enrolled consecutive stable patients with acute PE between 2017 and 2023. We stratified patients by quartiles of CRP. We evaluated the association between CRP quartiles and the presence of RV dysfunction, and used multivariable models to assess for an association between CRP and the outcomes of all-cause and PE-specific mortality during the 30 days of follow-up after PE diagnosis. RESULTS The study included 633 stable patients with PE. Patients without RV dysfunction had significantly lower median (IQR) CRP levels compared with patients with RV dysfunction (n=509, 31.7 [10.0-76.4]mg/L vs n=124, 45.4 [16.0-111.4]mg/L; P=0.018). CRP showed a statistically significant positive association with the presence of RV dysfunction (P<0.01). On multivariable analysis, CRP level was not significantly associated with 30-day all-cause mortality (adjusted odds ratio [OR] per mg/L increment, 1.00; 95% CI, 1.00-1.01; P=0.095), but higher CRP was associated with significantly higher PE-related mortality (adjusted OR, 1.01; 95% CI, 1.00-1.01; P=0.026). Compared with patients in CRP quartile 1, patients in quartiles 2, 3, and 4 had a stepwise increase in the adjusted odds of 30-day all-cause death of 2.41 (P=0.148), 3.04 (P=0.062), and 3.15 (P=0.052), respectively. CONCLUSIONS As an indicator of RV dysfunction, CRP may improve risk stratification algorithms for hemodynamically stable patients with acute symptomatic PE.
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Affiliation(s)
- Marta Najarro
- Emergency Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Luis Jara-Palomares
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Hospital Virgen del Rocío, Sevilla, Spain
| | - David R Vinson
- The Permanente Medical Group and Kaiser Permanente Northern California Division of Research, Oakland, CA, USA; Emergency Department, Kaiser Permanente Roseville Medical Center, Roseville, CA, USA
| | - Alfonso Muriel
- Biostatistics Department, Hospital Ramón y Cajal, and Universidad de Alcalá (IRYCIS), Madrid, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | | | - Roger D Yusen
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain.
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Chopard R, Morillo R, Meneveau N, Jiménez D. Integration of Extracorporeal Membrane Oxygenation into the Management of High-Risk Pulmonary Embolism: An Overview of Current Evidence. Hamostaseologie 2024. [PMID: 38531394 DOI: 10.1055/a-2215-9003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
High-risk pulmonary embolism (PE) refers to a large embolic burden causing right ventricular failure and hemodynamic instability. It accounts for approximately 5% of all cases of PE but contributes significantly to overall PE mortality. Systemic thrombolysis is the first-line revascularization therapy in high-risk PE. Surgical embolectomy or catheter-directed therapy is recommended in patients with an absolute contraindication to systemic thrombolysis. Extracorporeal membrane oxygenation (ECMO) provides respiratory and hemodynamic support for the most critically ill PE patients with refractory cardiogenic shock or cardiac arrest. The complex management of these individuals requires urgent yet coordinated multidisciplinary care. In light of existing evidence regarding the utility of ECMO in the management of high-risk PE patients, a number of possible indications for ECMO utilization have been suggested in the literature. Specifically, in patients with refractory cardiac arrest, resuscitated cardiac arrest, or refractory shock, including in cases of failed thrombolysis, venoarterial ECMO (VA-ECMO) should be considered, either as a bridge to percutaneous or surgical embolectomy or as a bridge to recovery after surgical embolectomy. We review here the current evidence on the use of ECMO as part of the management strategy for the highest-risk presentations of PE and summarize the latest data in this indication.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, Besançon, France
- SINERGIES, University of Franche-Comté, Besançon, France
- F-CRIN, INNOVTE network, France
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, Besançon, France
- SINERGIES, University of Franche-Comté, Besançon, France
- F-CRIN, INNOVTE network, France
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
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González S, Najarro M, Briceño W, Rodríguez C, Barrios D, Morillo R, Olavarría A, Lietor A, Gómez Del Olmo V, Osorio Á, Sánchez-Recalde Á, Muriel A, Jiménez D. Impact of a pulmonary embolism response team (PERT) in the prognosis of patients with acute symptomatic pulmonary embolism. Rev Clin Esp 2024; 224:141-149. [PMID: 38336141 DOI: 10.1016/j.rceng.2024.02.001] [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: 02/12/2024]
Abstract
BACKGROUND The effect of a pulmonary embolism response team (PERT) in the short-term prognosis of patients with acute symptomatic pulmonary embolism (PE) lacks clarity. We therefore aimed at evaluating the effect of a PERT team on short-term mortality among patients with acute PE. METHODS We retrospectively reviewed consecutive patients with acute symptomatic PE enrolled in a single-center registry between 2007 and 2022. We used propensity score matching to compare treatment effects for patients with similar predicted probabilities of receiving management by the PERT team. The primary outcome was all-cause mortality within 30 days following the diagnosis of PE. The secondary outcome was 30-day PE-related mortality. RESULTS Of the 2,902 eligible patients who had acute symptomatic PE, 223 (7.7%; 95% confidence interval [CI], 6.7%-8.7%) were managed by the PERT team. Two hundred and seven patients who were treated by the PERT were matched with 207 patients who were not. Matched pairs did not show a statistically significant lower all-cause (odds ratio [OR], 1.09; 95% CI, 0.63-1.89) or PE-related death (OR, 1.30; 95% CI, 0.47-3.62) for PERT management compared with no PERT management through 30 days after diagnosis of PE. CONCLUSIONS Our results suggest that multidisciplinary care of patients with acute symptomatic PE by a PERT team is not associated with a significant reduction in short-term all-cause or PE-related mortality.
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Affiliation(s)
- S González
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - M Najarro
- Servicio de Urgencias, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - W Briceño
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - C Rodríguez
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - D Barrios
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - R Morillo
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - A Olavarría
- Servicio de Radiología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - A Lietor
- Servicio de Medicina Intensiva, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - V Gómez Del Olmo
- Servicio de Medicina Interna, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Á Osorio
- Servicio de Cirugía Vascular, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Á Sánchez-Recalde
- Servicio de Cardiología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Alfonso Muriel
- Servicio de Bioestadística, Hospital Ramón y Cajal, IRYCIS, CIBERESP, Madrid, Spain
| | - D Jiménez
- Servicio de Neumología, Hospital Ramón y Cajal, IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain; Departamento de Medicina, Universidad de Alcalá, Madrid, Spain.
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Otero R, Lobo JL, López R, Fernández C, Jiménez D, Muriel A, Alfonso M, Ballaz A, Núñez-Ares A, Rodríguez-Matute C, de Miguel-Díez J, Rodríguez-Chiaradía DA, Alcalde M, Elías T, Jara-Palomares L, Rivas A, Alonso Á, García-Ortega A, Sancho T, Morillo R, García-Bragado F, Hernández-Blasco L, Uresandi F, Madridano O, Agüero R, Monreal M. Feasibility of a screening algorithm for chronic thromboembolic pulmonary hypertension: The OSIRIS study. Thromb Res 2023; 228:1-9. [PMID: 37263121 DOI: 10.1016/j.thromres.2023.05.005] [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: 01/15/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Chronic thromboembolic pulmonary hypertension (CTEPH) is a long-term sequel to pulmonary embolism (PE) whose incidence varies according to different published studies. We have carried out this study to determine its incidence within 2 years after index pulmonary embolism and to study limitations to an early diagnosis. MATERIAL AND METHODS OSIRIS is a multicentre, longitudinal cohort study. Patients were followed for 3, 6, 12, and 24 months after pulmonary embolism using a structured three-step algorithm. A physician-centered questionnaire at least one positive response in a screening proceeded to the second step, transthoracic echocardiography. The third step consisted of ventilation/perfusion lung scintigraphy and right heart catheterisation. A transthoracic echocardiography was performed in patients without positive response in the screening questionnaire after 2 years. CTEPH diagnosis required haemodynamic confirmation by right heart catheterisation and mismatched perfusion defects on lung scintigraphy. RESULTS A total of 1191 patients were enrolled in 18 Spanish hospitals. Cumulative CTEPH incidence after 2-years PE was: 2.49 % (95 % CI: 1.68-3.56) and the incidence rate of CTEPH was 1.1 cases per 1000 person-months (95 % CI: 0.725; 1.60). The CTEPH algorithm presented a lack of adherence of 29 %; patient and physician preferences posed barriers to the triage algorithm The screening questionnaire, in patients who completed the follow-up, shows a specificity of 91.3 % (89.0-93.2 %) and negative predictive value of 99.4 % (98.4-99.8 %).. CONCLUSIONS OSIRIS provides practiced clinical based data on the chronic thromboembolic pulmonary hypertension incidence and identified barriers to the implementation of a 3-step triage algorithm for its detection. CLINICAL TRIAL REGISTRATION clinicaltrials.gov identifier: NCT03134898.
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Affiliation(s)
- Remedios Otero
- Hospital Universitario Virgen del Rocío, Instituto de Biomedicina (IBIS), Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
| | - José Luis Lobo
- Hospital de Araba, Vitoria-Gasteiz, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Raquel López
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - David Jiménez
- Hospital Universitario Ramón y Cajal y Universidad de Alcalá, IRYCIS, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Alfonso Muriel
- Hospital Universitario Ramón y Cajal y Universidad de Alcalá, IRYCIS, Madrid, Spain; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | | | | | | | | | | | | | | | - Teresa Elías
- Hospital Universitario Virgen del Rocío, Instituto de Biomedicina (IBIS), Sevilla, Spain
| | - Luis Jara-Palomares
- Hospital Universitario Virgen del Rocío, Instituto de Biomedicina (IBIS), Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | | | | | | | | | - Raquel Morillo
- Hospital Universitario Ramón y Cajal y Universidad de Alcalá, IRYCIS, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | | | | | | | - Olga Madridano
- Hospital Infanta Sofía, San Sebastían de los Reyes, Madrid, Spain
| | - Ramón Agüero
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Manuel Monreal
- Hospital Universitario Germans Trias i Pujol, Badalona, Spain
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Rodríguez C, Jara-Palomares L, Tabernero E, Tenes A, González S, Briceño W, Lobo JL, Morillo R, Bikdeli B, Jiménez D. Adjusted D-dimer cutoff levels to rule out pulmonary embolism in patients hospitalized for COPD exacerbation: results from the SLICE trial. Thromb J 2022; 20:10. [PMID: 35241119 PMCID: PMC8892792 DOI: 10.1186/s12959-022-00368-0] [Citation(s) in RCA: 1] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/14/2022] [Indexed: 11/27/2022] Open
Abstract
Background For patients with suspected pulmonary embolism (PE), age- or clinically-adjusted D-dimer threshold level can be used to define a negative test that safely excludes PE and reduces the use of imaging. However, the utility of this approach in patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbation is undefined. Methods We ran an analysis of the patients hospitalized for COPD exacerbation and randomized to the intervention in the SLICE trial. Using the conventional strategy as the reference, we compared the proportion of patients with a negative D-dimer result, and the negative predictive value and sensitivity of three D-dimer threshold strategies for initial PE or subsequent diagnosis of venous thromboembolism (VTE): the age-adjusted strategy, the Wells-adjusted strategy, and the YEARS-adjusted strategy. Results We included 368 patients. Using a conventional threshold, 182 (49.5%) patients had negative D-dimer values, of whom 1 (0.6%) had PE (sensitivity, 94.1%). The use of an age-adjusted threshold increased the number of patients in whom PE could be excluded from 182 to 233 patients (63.3%), and the proportion of false-negative findings increased from 0.5% to 1.7% (sensitivity, 76.5%). With the use of the Wells or YEARS strategies, 64.4% and 71.5% had negative values, and the proportion of false-negative findings was 2.5% (sensitivity, 64.7%) and 2.7% (sensitivity, 58.8%), respectively. Conclusions In patients hospitalized for COPD exacerbation, compared with the conventional strategy, age- or clinically-adjusted strategies of D-dimer interpretation were associated with a larger proportion of patients in whom PE was ruled out with a higher failure rate. Trial Registration ClinicalTrials.gov number: NCT02238639.
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Affiliation(s)
- Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Colmenar Road, Km. 9,100, 28034, Madrid, Spain
| | - Luis Jara-Palomares
- Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla, Spain.,CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Eva Tabernero
- Respiratory Department, Hospital Universitario Cruces, Biocruces-Bizkaia, Barakaldo, Spain
| | - Andrés Tenes
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Colmenar Road, Km. 9,100, 28034, Madrid, Spain
| | - Sara González
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Colmenar Road, Km. 9,100, 28034, Madrid, Spain
| | - Winnifer Briceño
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Colmenar Road, Km. 9,100, 28034, Madrid, Spain
| | - José Luis Lobo
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Respiratory Department, Hospital Araba, Vitoria, Spain
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Colmenar Road, Km. 9,100, 28034, Madrid, Spain.,CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, CT, USA.,Cardiovascular Research Foundation, New York, USA
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Colmenar Road, Km. 9,100, 28034, Madrid, Spain. .,CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain. .,Medicine Department, Universidad de Alcalá, Madrid, Spain.
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Jiménez D, Rodríguez C, León F, Jara-Palomares L, López-Reyes R, Ruiz-Artacho P, Elías T, Otero R, García-Ortega A, Rivas-Guerrero A, Abelaira J, Jiménez S, Muriel A, Morillo R, Barrios D, Le Mao R, Yusen RD, Bikdeli B, Monreal M, Lobo JL. Randomised controlled trial of a prognostic assessment and management pathway to reduce the length of hospital stay in normotensive patients with acute pulmonary embolism. Eur Respir J 2021; 59:13993003.00412-2021. [PMID: 34385269 DOI: 10.1183/13993003.00412-2021] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/18/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND The length of hospital stay (LOS) for acute pulmonary embolism (PE) varies considerably. Whether the upfront use of a PE prognostic assessment and management pathway is effective in reducing the LOS remains unknown. METHODS We conducted a randomised, controlled trial of adults hospitalised for acute PE: patients were assigned to a prognostic assessment and management pathway involving risk stratification, followed by predefined criteria for mobilisation and discharge (intervention group), or usual care (control group). The primary end point was LOS. The secondary end points were the cost of prognostic tests and of hospitalisation, and 30-day clinical outcomes. RESULTS Of 500 patients who underwent randomisation, 498 were included in the modified intention-to-treat analysis. The median LOS was 4.0 days (interquartile range [IQR], 3.7 to 4.2 days) in the intervention group and 6.1 days (IQR, 5.7 to 6.5 days) in the control group (p<0.001). The mean total cost of prognostic tests was €174.76 in the intervention group, as compared with €233.12 in the control group (mean difference, €-58.37; 95% confidence interval [CI], €-84.34 to €-32.40). The mean total hospitalisation cost per patient was €2085.66 in the intervention group, compared with €3232.97 in the control group (mean difference, €-1147.31; 95% CI, €-1414.97 to €-879.65). No significant differences were observed in 30-day readmissions (4.0% versus 4.8%, respectively), or all-cause (2.4% versus 2.0%) and PE-related mortality rates (0.8% versus 1.2%). CONCLUSIONS The use of a prognostic assessment and management pathway was effective in reducing the LOS for acute PE.
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Affiliation(s)
- David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain .,Medicine Department, Universidad de Alcalá, Madrid, Spain.,CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Francisco León
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Luis Jara-Palomares
- Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla
| | | | - Pedro Ruiz-Artacho
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Department of Internal Medicine, Clinica Universidad de Navarra, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Interdisciplinar Teragnosis and Radiosomics Research Group (INTRA-Madrid), Universidad de Navarra, Madrid, Spain
| | - Teresa Elías
- Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla
| | - Remedios Otero
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla
| | | | | | - Jaime Abelaira
- Emergency Department, Hospital Clínico San Carlos, Madrid, Spain
| | - Sonia Jiménez
- Emergency Department, Hospital Clinic, Grupo UPP, Área 1 IDIBAPS, Barcelona, Spain
| | - Alfonso Muriel
- Biostatistics Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBERESP, Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain.,CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Deisy Barrios
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain.,CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Raphael Le Mao
- EA3878, Groupe d'Etude de la Thrombose de Bretagne Occidentale (GETBO), Université Européenne de Bretagne, Brest, France
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York-Presbyterian Hospital, New York, USA.,Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, USA.,Cardiovascular Research Foundation, New York, USA
| | - Manuel Monreal
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain.,Universidad Católica de Murcia, Murcia, Spain
| | - José Luis Lobo
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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8
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Morillo R, Jiménez D, Bikdeli B, Rodríguez C, Tenes A, Yamashita Y, Morimoto T, Kimura T, Vidal G, Ruiz-Giménez N, Espitia O, Monreal M. Refinement of a modified simplified Pulmonary Embolism Severity Index for elderly patients with acute pulmonary embolism. Int J Cardiol 2021; 335:111-117. [PMID: 33621625 DOI: 10.1016/j.ijcard.2021.02.039] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/25/2021] [Accepted: 02/12/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the utility of a modified (i.e., without the variable "Age >80 years") simplified Pulmonary Embolism Severity Index (sPESI) in elderly patients with acute symptomatic pulmonary embolism (PE), and to derive and validate a refined version of the sPESI for identification of elderly patients at low risk of adverse events. METHODS The study included normotensive patients aged >80 years with acute PE enrolled in the RIETE registry. We used multivariable logistic regression analysis to create a new risk score to predict 30-day all-cause mortality. We externally validated the new risk score in elderly patients from the COMMAND VTE registry. RESULTS Multivariable logistic regression identified four predictors for mortality: high-risk sPESI, immobilization, coexisting deep vein thrombosis (DVT), and plasma creatinine >2 mg/dL. In the RIETE derivation cohort, the new model classified fewer patients as low risk (4.0% [401/10,106]) compared to the modified sPESI (35% [3522/10,106]). Low-risk patients based on the new model had a lower 30-day mortality than those based on the modified sPESI (1.2% [95% CI, 0.4-2.9%] versus 4.7% [95% CI, 4.0-5.4%]). In the COMMAND VTE validation cohort, 1.5% (3/206) of patients were classified as having low risk of death according to the new model, and the overall 30-day mortality of this group was 0% (95% CI, 0-71%), compared to 5.9% (95% CI, 3.1-10.1%) in the high-risk group. CONCLUSIONS For predicting short-term mortality among elderly patients with acute PE, this study suggests that the new model has a substantially higher sensitivity than the modified sPESI. A minority of these patients might benefit from safe outpatient therapy of their disease.
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Affiliation(s)
- Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; Medicine Department, Universidad de Alcala (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Andrés Tenes
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Gemma Vidal
- Department of Internal Medicine, Corporación Sanitaria Parc Taulí, Barcelona, Spain
| | - Nuria Ruiz-Giménez
- Department of Internal Medicine, Hospital Universitario de La Princesa, Madrid, Spain
| | | | - Manuel Monreal
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Universidad Autónoma de Barcelona, Barcelona, Spain
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9
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Mirambeaux R, Le Mao R, Muriel A, Pintado B, Pérez A, Velasco D, Lobo JL, Barrios D, Morillo R, Bikdeli B, Jiménez D. Implications of Abnormal Troponin Levels With Normal Right Ventricular Function in Normotensive Patients With Acute Pulmonary Embolism. Clin Appl Thromb Hemost 2020; 26:1076029620967760. [PMID: 33315469 PMCID: PMC7739071 DOI: 10.1177/1076029620967760] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Among patients with pulmonary embolism (PE), various permutations of normal or abnormal cardiac troponin results and normal or abnormal echocardiographic right ventricular function are encountered in clinical practice. We aimed to explore whether there is a true gradient of risk based on troponin and echocardiographic results. This study included normotensive patients with PE from the PROgnosTic valuE of CT scan in hemodynamically stable patients with acute symptomatic pulmonary embolism (PROTECT) study. Patients were categorized as having -Troponin/-Echo, -Troponin/+Echo, +Troponin/-Echo, and +Troponin/+Echo. The primary outcome was 30-day “complicated course,” including death from any cause, hemodynamic collapse, or recurrent PE. Secondary outcomes included individual adverse event rates. Of the 834 patients who had echocardiographic and troponin results, 569 patients (68%) had -Troponin/-Echo, 126 patients (15%) had -Troponin/+Echo, 74 patients (8.9%) had +Troponin/-Echo, and 65 patients (7.8%) had +Troponin/+Echo. The incidence of 30-day complicated course was 4.6% in patients with -Troponin/-Echo, 11.9% in patients with -Troponin/+Echo, 13.5% in patients with +Troponin/-Echo, and 16.9% in patients with +Troponin/+Echo (P for trend <0.001). In the subgroup of patients with a high-risk sPESI (i.e., intermediate-risk according to the ESC guidelines) (n = 527), the incidence of 30-day complicated course was 14.9% in patients with -Troponin/+Echo, 18.5% in patients with +Troponin/-Echo, and 17.5% in patients with +Troponin/+Echo (P for trend <0.01). In patiens with PE, there seems to be a risk gradient based on troponin and echocardiographic results. This study did not detect a significant risk difference in those with +Troponin/-Echo compared with -Troponin/+Echo.
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Affiliation(s)
- Rosa Mirambeaux
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain
| | - Raphael Le Mao
- Groupe d'Etude de la Thrombose de Bretagne Occidentale (GETBO), 137662Université Européenne de Bretagne, Brest, France
| | - Alfonso Muriel
- Biostatistics Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBERESP, Madrid, Spain
| | - Beatriz Pintado
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain
| | - Andrea Pérez
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain
| | - Diurbis Velasco
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain
| | - José Luis Lobo
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Respiratory Department, 37487Hospital Araba, Vitoria, Spain
| | - Deisy Barrios
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York-Presbyterian Hospital, NY, USA.,Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, USA.,Cardiovascular Research Foundation, NY, USA
| | - David Jiménez
- Respiratory Department, 16507Ramón y Cajal Hospital and Alcala de Henares University, IRYCIS, Madrid, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Medicine Department, Alcala de Henares University, IRYCIS, Madrid, Spain
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10
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Mirambeaux R, León F, Bikdeli B, Morillo R, Barrios D, Mercedes E, Moores L, Tapson V, Yusen RD, Jiménez D. Intermediate-High Risk Pulmonary Embolism. TH Open 2019; 3:e356-e363. [PMID: 31815247 PMCID: PMC6892655 DOI: 10.1055/s-0039-3401003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 08/01/2019] [Accepted: 10/28/2019] [Indexed: 12/12/2022] Open
Abstract
Limited information exists about the prevalence, management, and outcomes of intermediate-high risk patients with acute pulmonary embolism (PE). In a prospective cohort study, we evaluated consecutive patients with intermediate-high risk PE at a large, tertiary, academic medical center between January 1, 2015 and March 31, 2019. Adjudicated outcomes included PE-related mortality and a complicated course through 30 days after initiation of PE treatment. Repeat systolic blood pressure (SBP), heart rate (HR), brain natriuretic peptide (BNP), and cardiac troponin I (cTnI) measurements, and echocardiography were performed within 48 hours after diagnosis. Among 1,015 normotensive patients with acute PE, 97 (9.6%) had intermediate-high risk PE. A 30-day complicated course and 30-day PE-related mortality occurred in 23 (24%) and 7 patients (7.2%) with intermediate-high risk PE. Seventeen (18%) intermediate-high risk patients received reperfusion therapy. Within 48 hours after initiation of anticoagulation, normalization of SBP, HR, cTnI, BNP, and echocardiography occurred in 82, 86, 78, 72, and 33% of survivors with intermediate-high risk PE who did not receive immediate thrombolysis. A complicated course between day 2 and day 30 after PE diagnosis for the patients who normalized SBP, HR, cTnI, BNP, and echocardiography measured at 48 hours occurred in 2.9, 1.4, 4.5, 3.3, and 14.3%, respectively. Intermediate-high risk PE occurs in approximately one-tenth of patients with acute symptomatic PE, and is associated with high morbidity and mortality. Normalization of HR 48 hours after diagnosis might identify a group of patients with a very low risk of deterioration during the first month of follow-up.
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Affiliation(s)
- Rosa Mirambeaux
- Respiratory Department, Ramon y Cajal Hospital, Madrid, Spain
| | - Francisco León
- Respiratory Department, Ramon y Cajal Hospital, Madrid, Spain
| | - Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, New York, United States.,Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, Connecticut, United States.,Cardiovascular Research Foundation (CRF), New York, New York, United States
| | - Raquel Morillo
- Respiratory Department, Ramon y Cajal Hospital, Madrid, Spain
| | - Deisy Barrios
- Respiratory Department, Ramon y Cajal Hospital, Madrid, Spain
| | - Edwin Mercedes
- Respiratory Department, Ramon y Cajal Hospital, Madrid, Spain
| | - Lisa Moores
- F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, Maryland, United States
| | - Victor Tapson
- Pulmonary/Critical Care Division, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri, United States
| | - David Jiménez
- Respiratory Department, Ramon y Cajal Hospital, Madrid, Spain.,Medicine Department, Universidad de Alcala, Madrid, Spain.,CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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11
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Jiménez D, Bikdeli B, Barrios D, Morillo R, Nieto R, Guerassimova I, Muriel A, Jara-Palomares L, Moores L, Tapson V, Yusen RD, Monreal M. Management appropriateness and outcomes of patients with acute pulmonary embolism. Eur Respir J 2018; 51:13993003.00445-2018. [DOI: 10.1183/13993003.00445-2018] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 03/30/2018] [Indexed: 01/24/2023]
Abstract
The impact of adherence to published guidelines on the outcomes of patients with acute pulmonary embolism (PE) has not been well defined by previous studies.In this prospective cohort study of patients admitted to a respiratory department (n=2096), we evaluated whether patients with PE had better outcomes if they were acutely managed according to international guidelines. Outcomes consisted of all-cause mortality, PE-related mortality, recurrent venous thromboembolism (VTE) and major bleeding events during the first month of follow-up after diagnosis.Overall, 408 patients (19% (95% CI 18–21%)) did not receive guideline-adherent PE management. Patients receiving non-adherent management were significantly more likely to experience all-cause mortality (adjusted odds ratio (OR) 2.39 (95% CI 1.57–3.61) or PE-related mortality (adjusted OR 5.02 (95% CI 2.42–10.42); p<0.001) during follow-up. Non-adherent management was also a significant independent predictor of recurrent VTE (OR 2.19 (95% CI 1.11–4.32); p=0.03) and major bleeding (OR 2.65 (95% CI 1.66–4.24); p<0.001). An external validation cohort of 34 380 patients with PE from the RIETE registry confirmed these findings.PE management that does not adhere to guidelines for indications related to anticoagulation, thrombolytics and inferior vena cava filters is associated with worse patient outcomes.
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12
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Hellenkamp K, Pruszczyk P, Jiménez D, Wyzgał A, Barrios D, Ciurzyński M, Morillo R, Hobohm L, Keller K, Kurnicka K, Kostrubiec M, Wachter R, Hasenfuß G, Konstantinides S, Lankeit M. Prognostic impact of copeptin in pulmonary embolism: a multicentre validation study. Eur Respir J 2018; 51:13993003.02037-2017. [DOI: 10.1183/13993003.02037-2017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 02/28/2018] [Indexed: 12/23/2022]
Abstract
To externally validate the prognostic impact of copeptin, either alone or integrated in risk stratification models, in pulmonary embolism (PE), we performed a post hoc analysis of 843 normotensive PE patients prospectively included in three European cohorts.Within the first 30 days, 21 patients (2.5%, 95% CI 1.5–3.8) had an adverse outcome and 12 (1.4%, 95% CI 0.7–2.5) died due to PE. Patients with copeptin ≥24 pmol·L−1 had a 6.3-fold increased risk for an adverse outcome (95% CI 2.6–15.5, p<0.001) and a 7.6-fold increased risk for PE-related death (95% CI 2.3–25.6, p=0.001). Risk classification according to the 2014 European Society of Cardiology (ESC) guideline algorithm identified 248 intermediate-high-risk patients (29.4%) with 5.6% (95% CI 3.1–9.3) at risk of adverse outcomes. A stepwise biomarker-based risk assessment strategy (based on high-sensitivity troponin T, N-terminal pro-brain natriuretic peptide and copeptin) identified 123 intermediate-high-risk patients (14.6%) with 8.9% (95% CI 4.5–15.4) at risk of adverse outcomes. The identification of patients at higher risk was even better when copeptin was measured on top of the 2014 ESC algorithm in intermediate-high-risk patients (adverse outcome OR 11.1, 95% CI 4.6–27.1, p<0.001; and PE-related death OR 13.5, 95% CI 4.2–43.6, p<0.001; highest risk group versus all other risk groups). This identified 85 patients (10.1%) with 12.9% (95% CI 6.6–22.0) at risk of adverse outcomes and 8.2% (95% CI 3.4–16.2) at risk of PE-related deaths.Copeptin improves risk stratification of normotensive PE patients, especially when identifying patients with an increased risk of an adverse outcome.
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13
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Barbero E, Bikdeli B, Chiluiza D, Barrios D, Morillo R, Quezada A, Monreal M, Yusen RD, Jimenez D. Performance of Early Prognostic Assessment Independently Predicts the Outcomes in Patients with Acute Pulmonary Embolism. Thromb Haemost 2018; 118:798-800. [PMID: 29554702 DOI: 10.1055/s-0038-1637746] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Esther Barbero
- Department of Respiratory, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain.,Department of Medicine, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York-Presbyterian Hospital, New York, New York, United States.,Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, Connecticut, United States
| | - Diana Chiluiza
- Department of Respiratory, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain.,Department of Medicine, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Deisy Barrios
- Department of Respiratory, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain.,Department of Medicine, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Raquel Morillo
- Department of Respiratory, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain.,Department of Medicine, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Andrés Quezada
- Department of Respiratory, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain.,Department of Medicine, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain.,Universidad Católica de Murcia, Murcia, Spain
| | - Roger D Yusen
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, United States.,Division of General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri, United States
| | - David Jimenez
- Department of Respiratory, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain.,Department of Medicine, Universidad de Alcalá (IRYCIS), Madrid, Spain
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14
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Quezada CA, Bikdeli B, Barrios D, Morillo R, Nieto R, Chiluiza D, Barbero E, Guerassimova I, García A, Yusen RD, Jiménez D. Assessment of coexisting deep vein thrombosis for risk stratification of acute pulmonary embolism. Thromb Res 2018; 164:40-44. [PMID: 29476988 DOI: 10.1016/j.thromres.2018.02.140] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 12/06/2017] [Revised: 02/12/2018] [Accepted: 02/16/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND In patients with acute pulmonary embolism (PE), studies have shown an association between coexisting deep vein thrombosis (DVT) and short-term prognosis. It is not known whether complete compression ultrasound testing (CCUS) improves the risk stratification of their disease beyond the recommended prognostic models. METHODS We included patients with normotensive acute symptomatic PE and prognosticated them with the European Society of Cardiology (ESC) risk model for PE. Subsequently, we determined the prognostic significance of coexisting DVT in patients with various ESC risk categories. The primary endpoint was a complicated course after the diagnosis of PE, defined as death from any cause, haemodynamic collapse, or adjudicated recurrent PE. RESULTS According to the ESC model, 37% of patients were low-risk, 56% were intermediate-low risk, and 6.7% were intermediate-high risk. CCUS demonstrated coexisting DVT in 375 (44%) patients. Among the 313 patients with low-risk PE, coexisting DVT (46%) did not show a significant increased risk of complicated course (2.8%; 95% confidence interval [CI], 0.8%-7.0%), compared with those without DVT (0.6%; 95% CI, 0%-3.2%), (P = 0.18). Of the 478 patients with intermediate-low risk PE, a complicated course was 14% and 6.8% for those with and without DVT, respectively (P = 0.01). Of the 57 patients that had intermediate-high risk PE, a complicated course occurred in 17% and 18% for those with and without DVT, respectively (P = 1.0). CONCLUSIONS In normotensive patients with PE, testing for coexisting DVT might improve risk stratification of patients at intermediate-low risk for short-term complications.
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Affiliation(s)
- Carlos Andrés Quezada
- Respiratory Department, Ramón y Cajal Hospital and Universidad de Alcalá IRYCIS, Madrid, Spain
| | - Behnood Bikdeli
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York-Presbyterian Hospital, New York, USA.; Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, USA
| | - Deisy Barrios
- Respiratory Department, Ramón y Cajal Hospital and Universidad de Alcalá IRYCIS, Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, Ramón y Cajal Hospital and Universidad de Alcalá IRYCIS, Madrid, Spain
| | - Rosa Nieto
- Respiratory Department, Ramón y Cajal Hospital and Universidad de Alcalá IRYCIS, Madrid, Spain
| | - Diana Chiluiza
- Respiratory Department, Ramón y Cajal Hospital and Universidad de Alcalá IRYCIS, Madrid, Spain
| | - Esther Barbero
- Respiratory Department, Ramón y Cajal Hospital and Universidad de Alcalá IRYCIS, Madrid, Spain
| | - Ina Guerassimova
- Respiratory Department, Ramón y Cajal Hospital and Universidad de Alcalá IRYCIS, Madrid, Spain
| | - Aldara García
- Respiratory Department, Ramón y Cajal Hospital and Universidad de Alcalá IRYCIS, Madrid, Spain
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital and Universidad de Alcalá IRYCIS, Madrid, Spain.
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15
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Quezada CA, Zamarro C, Gómez V, Guerassimova I, Nieto R, Barbero E, Chiluiza D, Barrios D, Morillo R, Jiménez D. Clinical gestalt versus prognostic scores for prognostication of patients with acute symptomatic pulmonary embolism. Med Clin (Barc) 2017; 151:136-140. [PMID: 29276010 DOI: 10.1016/j.medcli.2017.11.023] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 10/08/2017] [Accepted: 11/02/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE To determine the accuracy of clinical gestalt to identify patients with acute symptomatic pulmonary embolism (PE) at low-risk for short-term complications. PATIENTS AND METHODS This study included a total of 154 consecutive patients diagnosed with acute symptomatic PE in a tertiary university hospital. We compared the prognostic accuracy of the Pulmonary Embolism Severity Index (PESI), the simplified PESI (sPESI), and clinical gestalt of 1) 2senior physicians (one with and one without experience in the management of patients with PE), 2) a fourth-year resident of Pneumology, 3) a third-year resident of Pneumology, and 4) a second-year resident of Pneumology. The primary outcome was all-cause mortality during the first month after the diagnosis of PE. RESULTS Thirty-day all-cause mortality was 8.4% (13/154; 8.4%; 95% confidence interval [CI], 4.1-12.8%). The PESI and clinical gestalt classified more patients as low-risk, compared to the sPESI (36.4%, 31.3% y 28.6%, respectively). There were no deaths in the sPESI low-risk category (negative predictive value 100%). Prognostic accuracy increased with increasing experience (84.6 vs. 92.3%; P=.049). CONCLUSIONS The sPESI showed the best accuracy at correctly identifying low-risk patients with acute symptomatic PE. Clinical gestalt is not inferior to standardized clinical prediction rules to prognosticate patients with acute PE.
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Affiliation(s)
| | - Celia Zamarro
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Vicente Gómez
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Ina Guerassimova
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Rosa Nieto
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Esther Barbero
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Diana Chiluiza
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Deisy Barrios
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - Raquel Morillo
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - David Jiménez
- Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, España; IRYCIS, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, España; Facultad de Medicina, Universidad de Alcalá, Madrid, España.
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16
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Mañas E, Barbero E, Chiluiza D, García A, Morillo R, Barrios D, Martínez-García MÁ, Albalat A, Cano I, Jiménez D. Impact of obstructive sleep apnea on cardiovascular outcomes in patients with acute symptomatic pulmonary embolism: Rationale and methodology for the POPE study. Clin Cardiol 2017; 40:1182-1188. [PMID: 29247523 DOI: 10.1002/clc.22834] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 08/25/2017] [Revised: 09/29/2017] [Accepted: 10/04/2017] [Indexed: 01/07/2023] Open
Abstract
In normotensive patients with acute symptomatic pulmonary embolism (PE), the effect of undiagnosed obstructive sleep apnea (OSA) on cardiovascular (CV) outcomes lacks clarity. The Prognostic Significance of Obstructive Sleep Apnea in Patients With Acute Symptomatic Pulmonary Embolism (POPE) study is a multicenter, observational study designed to prospectively assess the prognostic significance of concomitant OSA in hemodynamically stable outpatients with acute symptomatic PE. Adult patients with acute stable PE are eligible. Recruited patients undergo an overnight sleep study using a level III portable diagnostic device within 7 days (and preferably within 48 hours) of diagnosis of PE. The sleep tracings are analyzed by a certified sleep technologist and audited by a sleep physician, both of whom are blinded to other study data. The patients are divided into 2 groups based on apnea-hypopnea index (AHI): OSA (AHI ≥15) and non-OSA (AHI <15) groups. The study uses a composite of PE-related death, CV death, clinical deterioration requiring an escalation of treatment, or nonfatal CV events (recurrent venous thromboembolism, acute myocardial infarction, or stroke) within 30 days after the diagnosis of PE as the primary outcome. The projected sample size of 225 patients will provide 80% power to test the hypothesis that OSA will increase the primary outcome from 7% in the non-OSA group to 20% in the OSA group, with α ≤0.05. The trial results will be important to understand the burden and CV effects of OSA in PE patients.
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Affiliation(s)
- Eva Mañas
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Esther Barbero
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Diana Chiluiza
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Aldara García
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Deisy Barrios
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | | | - Alicia Albalat
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Irene Cano
- Respiratory Department, Hospital de Getafe, Madrid, Spain
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal, and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
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17
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Jimenez D, Nieto R, Corres J, Fernández-Golfín C, Barrios D, Morillo R, Quezada CA, Huisman M, Yusen RD, Kline J. Diclofenac for reversal of right ventricular dysfunction in acute normotensive pulmonary embolism: A pilot study. Thromb Res 2017; 162:1-6. [PMID: 29247809 DOI: 10.1016/j.thromres.2017.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 11/24/2017] [Accepted: 12/03/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND The inflammatory response associated with acute pulmonary embolism (PE) contributes to the development of right ventricular (RV) dysfunction. Nonsteroidal anti-inflammatory drugs (NSAIDs) may facilitate the reversal of PE-associated RV dysfunction. METHODS We randomly assigned normotensive patients who had acute PE associated with echocardiographic RV dysfunction and normal systemic blood pressure to receive intravenous (IV) diclofenac (two doses of 75mg in the first 24h after diagnosis) or IV placebo. All patients received standard anticoagulation with subcutaneous low-molecular-weight heparin (LMWH) and an oral vitamin K antagonist. RV dysfunction was defined by the presence of, at least, two of the following criteria: i) RV diastolic diameter>30mm in the parasternal window; ii) RV diameter>left ventricle diameter in the apical or subcostal space; iii) RV free wall hypokinesis; and iv) estimated pulmonary artery systolic pressure>30mmHg. Persistence of RV dysfunction at 48h and 7days after randomization were the primary and secondary efficacy outcomes, respectively. The primary safety outcome was major bleeding within 7days after randomization. RESULTS Of the 34 patients randomly assigned to diclofenac or placebo, the intention-to-treat analysis showed persistent RV dysfunction at 48h in 59% (95% confidence interval [CI], 33-82%) of the diclofenac group and in 76% (95% CI, 50-93%) of the placebo group (difference in risk [diclofenac minus standard anticoagulation], -17 percentage points; 95% CI, -47 to 17). Similar proportions (35%) of patients in the diclofenac and placebo groups had persistent RV dysfunction at 7days. Major bleeding occurred in none of patients in the diclofenac group and in 5.9% (95% CI, 0.2-29%) of patient in the placebo group. CONCLUSIONS Due to slow recruitment, our study is inconclusive as to a potential benefit of diclofenac over placebo to reverse RV dysfunction in normotensive patients with acute PE. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01590342.
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Affiliation(s)
- David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain.
| | - Rosa Nieto
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Jesús Corres
- Emergency Department, Hospital Ramón y Cajal, Madrid, Spain
| | - Covadonga Fernández-Golfín
- Cardiology Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Deisy Barrios
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Carlos Andres Quezada
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Menno Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Jeffrey Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Jimenez D, Martin-Saborido C, Muriel A, Zamora J, Morillo R, Barrios D, Klok FA, Huisman MV, Tapson V, Yusen RD. Efficacy and safety outcomes of recanalisation procedures in patients with acute symptomatic pulmonary embolism: systematic review and network meta-analysis. Thorax 2017; 73:464-471. [DOI: 10.1136/thoraxjnl-2017-210040] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 10/13/2017] [Accepted: 10/23/2017] [Indexed: 01/21/2023]
Abstract
BackgroundWe aimed to review the efficacy and safety of recanalisation procedures for the treatment of PE.MethodsWe searched PubMed, the Cochrane Library, EMBASE, EBSCO, Web of Science and CINAHL databases from inception through 31 July 2015 and included randomised clinical trials that compared the effect of a recanalisation procedure versus each other or anticoagulant therapy in patients diagnosed with PE. We used network meta-analysis and multivariate random-effects meta-regression to estimate pooled differences between each intervention and meta-regression to assess the association between trial characteristics and the reported effects of recanalisation procedures versus anticoagulation.ResultsFor all-cause mortality, there were no significant differences in event rates between any of the recanalisation procedures and anticoagulant treatment (full-dose thrombolysis: OR 0.60; 95% CI0.36 to 1.01; low-dose thrombolysis: 0.47; 95% CI 0.14 to 1.59; and catheter-associated thrombolysis: 0.31; 95% CI 0.01 to 7.96). Full-dose thrombolysis increased the risk of major bleeding (2.00; 95% CI 1.06 to 3.78) compared with anticoagulation. Catheter-directed thrombolysis was associated with the lowest probability of dying (surface under the cumulative ranking curve (SUCRA), 0.67), followed by low-dose thrombolysis (SUCRA, 0.66) and full-dose thrombolysis (SUCRA, 0.55). Similarly, low-dose thrombolysis was associated with the lowest probability of major bleeding (SUCRA, 0.61), followed by catheter-directed thrombolysis (SUCRA, 0.54) and full-dose thrombolysis (SUCRA, 0.17). The results were similar in sensitivity analyses based on restricting only to studies in haemodynamically stable patients with PE.ConclusionsIn the treatment of PE, recanalisation procedures do not seem to offer a clear advantage compared with standard anticoagulation. Low-dose thrombolysis was associated with the lowest probability of dying and bleeding.Trial registration numberPROSPERO CRD42015024670.
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Barrios D, Morillo R, Yusen RD, Jiménez D. Pulmonary embolism severity assessment and prognostication. Thromb Res 2017; 163:246-251. [PMID: 28911787 DOI: 10.1016/j.thromres.2017.09.007] [Citation(s) in RCA: 12] [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: 02/26/2017] [Revised: 07/04/2017] [Accepted: 09/04/2017] [Indexed: 01/08/2023]
Abstract
For patients who have acute symptomatic pulmonary embolism (PE), risk of short-term death and adverse outcomes should drive the initial treatment decisions. Practice guidelines recommend that patients who have a high-risk of PE-related death and adverse outcomes, determined by the presence of haemodynamic instability (i.e., shock or hypotension), should receive systemically administered thrombolytic therapy. Intermediate-high risk patients might benefit from close observation, and some should undergo escalation of therapy beyond standard anticoagulation, particularly if haemodynamic deterioration occurs. Low-risk for adverse outcomes should lead to early hospital discharge or full treatment at home. Validated prognostic tools (i.e., clinical prognostic scoring systems, imaging studies, and cardiac laboratory biomarkers) assist with risk classification of patients who have acute symptomatic PE.
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Affiliation(s)
- Deisy Barrios
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Alcala de Henares University, Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Alcala de Henares University, Madrid, Spain
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS, Alcala de Henares University, Madrid, Spain.
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Abellás M, Menéndez A, Morillo R, Jara-Palomares L, Barrios D, Nieto R, Barbero E, Corres J, Ruiz-Artacho P, Jiménez D. Clinical Characteristics and Prognosis of Pulmonary Embolism Caused by Economy Class Syndrome. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.arbr.2017.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Hellenkamp K, Pruszczyk P, Jimenez D, Wyzgal A, Barrios D, Ciurzynski M, Morillo R, Hobohm L, Keller K, Kurnicka K, Kostrubiec M, Wachter R, Hasenfuss G, Konstantinides S, Lankeit M. P4922Validation of the prognostic impact of copeptin in normotensive pulmonary embolism in a European multicentre study. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx493.p4922] [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: 11/13/2022] Open
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Plywaczewska M, Jimenez D, Lankeit M, Dzikowska-Diduch O, Ciurzynski M, Barrios D, Morillo R, Kozlowska M, Kurnicka K, Koc M, Pacho S, Konstantinides S, Pruszczyk P, Kostrubiec M. P1614Validation of prognostic value glomerular filtration rate in risk assessment of patients with acute pulmonary embolism. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx502.p1614] [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: 11/12/2022] Open
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Jimenez D, Martin-Saborido C, Muriel A, Zamora J, Morillo R, Barrios D, Klok E, Huisman M, Tapson V, Yusen R. P1613Efficacy and safety outcomes of recanalization procedures in patients with acute symptomatic pulmonary embolism: systematic review and network meta-analysis. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx502.p1613] [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: 11/13/2022] Open
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Abstract
AbstractRapid and accurate risk stratification is critical in determining the optimal treatment strategy for patients with acute pulmonary embolism (PE). Early identification of patients with normal blood pressure and a favorable prognosis (low-risk PE) might select a subset of patients for outpatient treatment, which is associated with reduced cost and improved patient satisfaction, and has been shown to be effective and safe. Alternatively, identification of normotensive patients deemed as having a high risk for PE-related adverse clinical events (intermediate-high-risk PE) might select a subset of patients for close observation and consideration of escalation of therapy. Clinical prognostic scores have been gaining importance in the classification of patients into these categories. They should be derived and validated following strict methodological standards, and their use in clinical practice should be encouraged.
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Affiliation(s)
- Raquel Morillo
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS and Alcala de Henares University, Madrid, Spain
| | - Lisa Moores
- F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, Maryland
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, IRYCIS and Alcala de Henares University, Madrid, Spain
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van der Wall SJ, Klok FA, den Exter PL, Barrios D, Morillo R, Cannegieter SC, Jimenez D, Huisman MV. Continuation of low-molecular-weight heparin treatment for cancer-related venous thromboembolism: a prospective cohort study in daily clinical practice. J Thromb Haemost 2017; 15:74-79. [PMID: 28012224 DOI: 10.1111/jth.13563] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [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: 06/29/2016] [Accepted: 10/24/2016] [Indexed: 12/21/2022]
Abstract
Essentials Low-molecular-weight heparin (LMWH) injections for venous thromboembolism (VTE) may be burdensome. Patients with active cancer and confirmed VTE were included to evaluate LMWH continuation. The cumulative incidence of discontinuation was 21% after a median period of 90 days. One out of five patients discontinued LMWH injections because of side effects. SUMMARY Background Current guidelines recommend low-molecular-weight heparin (LMWH) monotherapy for 3-6 months as the first-line treatment for cancer-associated venous thromboembolism (VTE). However, although daily administration of LMWH injections over a course of several months may be burdensome, the number of patients who stop treatment because of LMWH side-effects is unknown. Objectives To evaluate the continuation rate and complications of daily LMWH injections in patients with cancer-associated VTE. Methods Consecutive patients with active cancer and objectively confirmed symptomatic proximal deep vein thrombosis and/or pulmonary embolism, treated at three Dutch hospitals and one Spanish hospital, were included to evaluate continuation LMWH therapy during LMWH treatment. Patients were excluded when they received other anticoagulants, were lost to follow-up, or experienced a venous catheter-associated thrombosis. Results A total of 372 patients were analyzed during LMWH treatment for a maximum of 180 days. The cumulative incidence of discontinuation was 21% (95% confidence interval [CI] 17-25) after a median period of 90 days (interquartile range 60-120 days). Only female sex was found to be significantly associated with premature LMWH discontinuation (odds ratio 1.6; 95% CI 1.03-2.5). Thirty patients (8.1%) developed recurrent VTE, 30 patients (8.3%) suffered a major bleed, and 106 patients (28%) died. Conclusion Our study reveals that one of five patients with cancer-associated VTE stopped LMWH injections because of side-effects. This finding provides relevant background information for current clinical trials investigating the efficacy and safety of direct oral anticoagulants as compared with LMWH.
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Affiliation(s)
- S J van der Wall
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - F A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - P L den Exter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - D Barrios
- Respiratory Department, Ramon y Cajal Hospital IRYCIS, Seville, Spain
| | - R Morillo
- Respiratory Department, Ramon y Cajal Hospital IRYCIS, Seville, Spain
| | - S C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - D Jimenez
- Respiratory Department, Ramon y Cajal Hospital IRYCIS, Seville, Spain
| | - M V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Barrios D, Rosa-Salazar V, Morillo R, Nieto R, Fernández S, Zamorano JL, Monreal M, Torbicki A, Yusen RD, Jiménez D. Prognostic Significance of Right Heart Thrombi in Patients With Acute Symptomatic Pulmonary Embolism: Systematic Review and Meta-analysis. Chest 2016; 151:409-416. [PMID: 27746202 DOI: 10.1016/j.chest.2016.09.038] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [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: 08/15/2016] [Revised: 09/26/2016] [Accepted: 09/29/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND For patients diagnosed with acute pulmonary embolism (PE), the prognostic significance of concomitant right heart thrombi (RHT) lacks clarity. METHODS We performed a meta-analysis of studies that enrolled patients with acute PE to assess the prognostic value of echocardiography-detectable RHT for the primary outcome of short-term all-cause mortality and the secondary outcome of short-term PE-related mortality. Unrestricted searches were conducted of PubMed and Embase from 1980 through January 31, 2016, and used the terms "right heart thrombi," "pulmonary embolism," and "prognos.*" A random effects model was used to pool study results; Begg rank correlation method was used to evaluate for publication bias; and I2 testing was used to assess for heterogeneity. RESULTS Six of 79 potentially relevant studies met the inclusion criteria (15,220 patients). Overall, 99 of 593 patients with echocardiography-detectable RHT died (16.7% [95% CI, 13.8-19.9]) compared with 639 of 14,627 without RHT (4.4% [95% CI, 4.0-4.7]). RHT had a significant association with short-term all-cause mortality in all patients (OR, 3.0 [95% CI, 2.2 to 4.1]; I2 = 20%) and with PE-related death (three cohorts, 12,955 patients; OR: 4.8 [95% CI, 2.0-11.3; I2 = 76%). Results were consistent for the prospective (two cohorts, 514 patients; OR, 4.8 [95% CI, 1.7-13.6]; I2 = 56%) and the retrospective (four cohorts, 14,706 patients; OR, 2.8 [95% CI, 2.1 to 3.8]; I2 = 0%) studies. CONCLUSIONS In patients diagnosed with acute PE, concomitant RHT were significantly associated with an increased risk of death within 30 days of PE diagnosis. TRIAL REGISTRY PROSPERO registry; No.: CRD42016033960; URL: https://www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Deisy Barrios
- Respiratory Department, Ramón y Cajal Hospital, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Vladimir Rosa-Salazar
- Department of Internal Medicine, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Raquel Morillo
- Respiratory Department, Ramón y Cajal Hospital, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Rosa Nieto
- Respiratory Department, Ramón y Cajal Hospital, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Sara Fernández
- Cardiology Department, Ramón y Cajal Hospital, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - José Luis Zamorano
- Cardiology Department, Ramón y Cajal Hospital, Universidad de Alcalá (IRYCIS), Madrid, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona and Universidad Católica de Murcia, Spain
| | - Adam Torbicki
- Department of Cardiovascular and Pulmonary Thromboembolic Diseases, European Health Centre, Otwock, Poland
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, MO
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, Universidad de Alcalá (IRYCIS), Madrid, Spain.
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Barrios D, Rosa-Salazar V, Jiménez D, Morillo R, Muriel A, Del Toro J, López-Jiménez L, Farge-Bancel D, Yusen R, Monreal M. Right heart thrombi in pulmonary embolism. Eur Respir J 2016; 48:1377-1385. [PMID: 27799388 DOI: 10.1183/13993003.01044-2016] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/19/2016] [Indexed: 01/01/2023]
Abstract
There is a lack of comprehensive data on the prevalence, predictors and prognostic significance of right heart thrombi (RHT) in pulmonary embolism.In this study of patients with pulmonary embolism from the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) registry, we assessed the prevalence and predictors of RHT, and the association between the presence of RHT and the outcomes of all-cause mortality, pulmonary embolism-related mortality, recurrences, and major bleeding through 30 days after initiation of pulmonary embolism treatment.Of 12 441 patients with pulmonary embolism and baseline echocardiographic data, 2.6% had RHT. The following increased the risk of RHT: younger age, previous bleeding, congestive heart failure, cancer, syncope, systolic blood pressure <100 mmHg, and arterial oxyhaemoglobin saturation <90%. Patients with RHT were significantly more likely to die from any cause (adjusted OR 2.50 (95% CI 1.62-3.84); p<0.001) and from pulmonary embolism (adjusted OR 4.29 (95% CI 2.45-7.48); p<0.001) during follow-up. RHT was associated with an increased risk of recurrence during follow-up (1.8% versus 0.7%; p=0.04). Major bleeding was similar in patients with and without RHT.In patients presenting with pulmonary embolism, RHT is relatively infrequent. Patients with RHT had a worse outcome when compared with those without RHT.
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Affiliation(s)
- Deisy Barrios
- Respiratory Dept, Ramón y Cajal Hospital and Universidad de Alcala (IRYCIS), Madrid, Spain.,Both authors contributed equally to the manuscript
| | - Vladimir Rosa-Salazar
- Dept of Internal Medicine, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain.,Both authors contributed equally to the manuscript
| | - David Jiménez
- Respiratory Dept, Ramón y Cajal Hospital and Universidad de Alcala (IRYCIS), Madrid, Spain
| | - Raquel Morillo
- Respiratory Dept, Ramón y Cajal Hospital and Universidad de Alcala (IRYCIS), Madrid, Spain
| | - Alfonso Muriel
- Respiratory Dept, Ramón y Cajal Hospital and Universidad de Alcala (IRYCIS), Madrid, Spain
| | - Jorge Del Toro
- Dept of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Roger Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, MO, USA
| | - Manuel Monreal
- Dept of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Universidad Católica de Murcia, Spain
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Castejón B, Morillo R, Barrios D, Nieto R, Jaureguizar A, Portillo A, Jiménez D. Significado pronóstico de la trombosis venosa profunda asintomática en pacientes con tromboembolia de pulmón aguda sintomática. Angiología 2016. [DOI: 10.1016/j.angio.2015.12.007] [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] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Morillo R, Jiménez D, Aibar MÁ, Mastroiacovo D, Wells PS, Sampériz Á, Saraiva de Sousa M, Muriel A, Yusen RD, Monreal M. DVT Management and Outcome Trends, 2001 to 2014. Chest 2016; 150:374-83. [PMID: 27071810 DOI: 10.1016/j.chest.2016.03.046] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [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: 02/13/2016] [Revised: 03/08/2016] [Accepted: 03/29/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND A comprehensive evaluation of temporal trends in the treatment of patients who have DVT may assist with identification of modifiable factors that contribute to short-term outcomes. METHODS We assessed temporal trends in length of hospital stay and use of pharmacological and interventional therapies among 26,695 adults with DVT enrolled in the Registro Informatizado de la Enfermedad TromboEmbólica registry between 2001 and 2014. We also examined temporal trends in risk-adjusted rates of all-cause, pulmonary embolism-related, and bleeding-related death to 30 days after diagnosis. RESULTS The mean length of hospital stay decreased from 9.0 days in 2001 to 2005 to 7.6 days in 2010 to 2014 (P < .01). For initial DVT treatment, the use of low-molecular-weight heparin decreased from 98% to 90% (P < .01). Direct oral anticoagulants use increased from 0.5% in 2010 to 13.4% in 2014 (P < .001). Risk-adjusted rates of 30-day all-cause mortality decreased from 3.9% in 2001 to 2005 to 2.7% in 2010 to 2014 (adjusted rate ratio per year, 0.84; 95% CI, 0.74-0.96; P < .01). VTE-related mortality showed a nonstatistically significant downward trend (adjusted rate ratio per year, 0.70; 95% CI, 0.44-1.10; P = .13), whereas 30-day bleeding-related mortality significantly decreased from 0.5% in 2001 to 2005 to 0.1% in 2010-2014 (adjusted rate ratio per year, 0.55; 95% CI, 0.40-0.77; P < .01). CONCLUSIONS This international registry-based temporal analysis identified reductions in length of stay for adults hospitalized for DVT. The study also found a decreasing trend in adjusted rates of all-cause and bleeding-related mortality.
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Affiliation(s)
- Raquel Morillo
- Respiratory Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain.
| | - Miguel Ángel Aibar
- Department of Internal Medicine, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Daniela Mastroiacovo
- UOSD Angiologia e Diagnostica Vascolare, Ospedale SS, Filippo e Nicola, Avezzano, Italy
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ontario, Canada
| | - Ángel Sampériz
- Department of Internal Medicine, Hospital Reina Sofía, Navarra, Spain
| | - Marta Saraiva de Sousa
- Department of Internal Medicine, Centro Hospitalar Gaia/Espinho, Entidade Pública Empresarial, Vila Nova de Gaia, Portugal
| | - Alfonso Muriel
- Biostatistics Department, Ramón y Cajal Hospital and IRYCIS, Centro de Investigación Biomédica En Red, Epidemiología y Salud Pública, Madrid, Spain
| | - Roger D Yusen
- Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona; Universidad Católica de Murcia, Murcia, Spain
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Lopez Martin C, Arenas J, Nieto M, Robustillo A, Morillo R, Aguilar E, Rios E, Garrido M, Faus V, Tortajada B. CP-067 Use of validated care quality indicators to identify improvements in hiv pharmaceutical care:. Eur J Hosp Pharm 2015. [DOI: 10.1136/ejhpharm-2015-000639.63] [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] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Manzano M, Jimenez R, Tristancho A, Morillo R, Haro C, Cantudo R, Calvo E, Alvaro E, Robustillo M, Guzman MI. DI-072 Mobile phone text messaging to improve adherence to antiretroviral treatment in hiv-infected patients. Eur J Hosp Pharm 2015. [DOI: 10.1136/ejhpharm-2015-000639.247] [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] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Sánchez V, Vila V, Ramón L, Ferrer M, Elías T, Arellano E, Jara L, Martinez V, Cano A, Gao L, Morillo R, Otero Candelera R. C0324: Correlations Using Two High-Sensitivity Flow Cytometers to Determine Positive Annexinv Microparticles (MPS) and Platelet-Derived Microparticles (PMPS) in Venous Thromboembolic Diseases (VTD). Thromb Res 2014. [DOI: 10.1016/s0049-3848(14)50308-8] [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] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Ferrer M, Morillo R, Elías T, Jara L, García L, Nieto R, Sandoval E, Uresandi F, Otero R, Jiménez D. Validation of two clinical prognostic models in patients with acute symptomatic pulmonary embolism. Arch Bronconeumol 2013; 49:427-31. [PMID: 23664248 DOI: 10.1016/j.arbres.2013.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [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: 12/20/2012] [Revised: 02/23/2013] [Accepted: 03/03/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of this study was to compare the predictive value of two clinical prognostic models, the Spanish score and the simplified Pulmonary Embolism Severity Index (sPESI), in an independent cohort of patients diagnosed of acute symptomatic pulmonary embolism (PE). METHODS We performed a retrospective analysis of a cohort composed of 1447patients with acute symptomatic PE. The Spanish score and the sPESI were calculated for each patient according to different clinical variables. We assessed the predictive accuracy of these scores for 30-day mortality, and a composite of non fatal recurrent venous thromboembolism and non fatal major bleeding, using Cstatistic, which was obtained by means of logistic regression and ROC curves. RESULTS Overall, 138 patients died (9.5%) during the first month of follow-up. Both scores showed an excellent predictive value for 30-day all-cause mortality (Cstatistic, 0.72 and 0.74), but the performance was poor for the secondary endpoint (Cstatistic, 0.60 and 0.59). The sPESI classified fewer patients as low risk (32% versus 62%; P<.001). Low-risk patients based on the sPESI had a lower 30-day mortality than those based on the Spanish score (1.1% versus 4.2%), while the 30-day rate of non fatal recurrent VTE or major bleeding was similar (2.2% versus 2.3%). CONCLUSIONS Both scores provide excellent information to stratify the risk of mortality in patients treated of PE. The usefulness of these models for nonfatal adverse events is questionable. The sPESI identified low-risk patients with PE better than the Spanish score.
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Affiliation(s)
- Marta Ferrer
- Servicio de Neumología, Hospital Virgen del Rocío-IBIS, CIBERES, Sevilla, España
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