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Laffafchi S, Ebrahimi A, Kafan S. Efficient management of pulmonary embolism diagnosis using a two-step interconnected machine learning model based on electronic health records data. Health Inf Sci Syst 2024; 12:17. [PMID: 38464464 PMCID: PMC10917730 DOI: 10.1007/s13755-024-00276-9] [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: 12/15/2022] [Accepted: 01/17/2024] [Indexed: 03/12/2024] Open
Abstract
Pulmonary Embolism (PE) is a life-threatening clinical disease with no specific clinical symptoms and Computed Tomography Angiography (CTA) is used for diagnosis. Clinical decision support scoring systems like Wells and rGeneva based on PE risk factors have been developed to estimate the pre-test probability but are underused, leading to continuous overuse of CTA imaging. This diagnostic study aimed to propose a novel approach for efficient management of PE diagnosis using a two-step interconnected machine learning framework directly by analyzing patients' Electronic Health Records data. First, we performed feature importance analysis according to the result of LightGBM superiority for PE prediction, then four state-of-the-art machine learning methods were applied for PE prediction based on the feature importance results, enabling swift and accurate pre-test diagnosis. Throughout the study patients' data from different departments were collected from Sina educational hospital, affiliated with the Tehran University of medical sciences in Iran. Generally, the Ridge classification method obtained the best performance with an F1 score of 0.96. Extensive experimental findings showed the effectiveness and simplicity of this diagnostic process of PE in comparison with the existing scoring systems. The main strength of this approach centered on PE disease management procedures, which would reduce avoidable invasive CTA imaging and be applied as a primary prognosis of PE, hence assisting the healthcare system, clinicians, and patients by reducing costs and promoting treatment quality and patient satisfaction.
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Affiliation(s)
- Soroor Laffafchi
- Department of Business Administration and Entrepreneurship, Faculty of Management and Economics, Science and Research Branch, Islamic Azad University, Daneshgah Blvd, Simon Bulivar Blvd, Tehran, Iran
| | - Ahmad Ebrahimi
- Department of Industrial and Technology Management, Faculty of Management and Economics, Science and Research Branch, Islamic Azad University, Daneshgah Blvd, Simon Bulivar Blvd, Tehran, Iran
| | - Samira Kafan
- Department of Pulmonary Medicine, Sina Hospital, International Relations Office, Medical School, Tehran University of Medical Sciences, PourSina St., Tehran, 1417613151 Iran
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2
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Silveira P, McCloskey J, Kassar M. Thrombolysis of incidental pulmonary embolism in a stroke patient. Radiol Case Rep 2024; 19:2600-2602. [PMID: 38645948 PMCID: PMC11026682 DOI: 10.1016/j.radcr.2024.03.053] [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: 01/11/2024] [Revised: 03/09/2024] [Accepted: 03/20/2024] [Indexed: 04/23/2024] Open
Abstract
Both acute ischemic stroke (AIS) and pulmonary embolism (PE) are major causes of morbidity and mortality, with overlapping risk factors. Incidental or silent PE therefore may be discovered during an AIS work-up. Thrombolytic therapy is considered first-line therapy for eligible patients with AIS. We present the case of an 88-year-old man with an AIS, who was incidentally found to have a PE, and then received thrombolytic therapy leading to favorable outcomes in both conditions.
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Affiliation(s)
- Patrick Silveira
- Department of Radiology, West Virginia University Hospital, 1 Medical Center Drive, PO Box 9235 Morgantown, WV, USA
| | - Justin McCloskey
- Department of Radiology, West Virginia University Hospital, 1 Medical Center Drive, PO Box 9235 Morgantown, WV, USA
| | - Mohammad Kassar
- Department of Radiology, West Virginia University Hospital, 1 Medical Center Drive, PO Box 9235 Morgantown, WV, USA
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3
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Raghubeer N, Lahri S, Hendrikse C. The value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism: A cross sectional analysis. Afr J Emerg Med 2024; 14:65-69. [PMID: 38425642 PMCID: PMC10899042 DOI: 10.1016/j.afjem.2024.01.004] [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: 09/18/2023] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction Pulmonary embolism (PE) is a significant global cause of mortality, ranking third after myocardial infarction and stroke. ECG findings may play a valuable role in the prognostication of patients with PE, with various ECG abnormalities proving to be reasonable predictors of haemodynamic decompensation, cardiogenic shock, and even mortality. This study aims to assess the value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism, as diagnosed with computed tomography pulmonary angiogram. Method This study was a cross sectional analysis based at Tygerberg Hospital, Cape Town, South Africa. Eligible patients were identified from all CT-PA performed between 1 January 2017 and 31 December 2019 (2 years). The ECGs were independently screened by two blinded emergency physicians for predetermined signs that are associated with right heart strain and higher pulmonary artery pressures, and these findings were analysed to in-hospital mortality. Results Of the included 81 patients, 61 (75 %) were female. Of the 41 (51 %) patients with submassive PE and 8 (10 %) with massive PE, 7 (17 %) and 3 (38 %) suffered inpatient mortality (p = 0.023) respectively. Univariate ECG analysis revealed that complete right bundle branch block (OR, 8.6; 95 % CI, 1.1 to 69.9; p = 0.044) and right axis deviation (OR, 5.6; 95 % CI, 1.4 to 22.4; p = 0.015) were significant predictors of inpatient mortality. Conclusion Early identification of patients with pulmonary embolism at higher risk of clinical deterioration and in-patient mortality remains a challenge. Even though no clinical finding or prediction tool in isolation can reliably predict outcomes in patients with pulmonary embolism, this study demonstrated two ECG findings at presentation that were associated with a higher likelihood of inpatient mortality. This single-centre observational study with a small sample precludes concrete conclusions and a large follow-up multi-centre study is advised.
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Affiliation(s)
- Nishen Raghubeer
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Sa'ad Lahri
- Division of Emergency Medicine, University of Stellenbosch, Stellenbosch, South Africa
| | - Clint Hendrikse
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
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Sathianathan S, Meili Z, Romero CM, Juarez JJ, Bashir R. Racial and gender disparities in the management of acute pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2024; 12:101817. [PMID: 38296110 DOI: 10.1016/j.jvsv.2024.101817] [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: 12/26/2022] [Revised: 12/15/2023] [Accepted: 12/26/2023] [Indexed: 02/19/2024]
Abstract
OBJECTIVE The aim of this study was to assess race and sex disparities in use and outcomes of various interventions in patient with acute pulmonary embolism (PE). METHODS We included 129,445 patients with acute PE from the NIS from January 2016 to December 2019. Rates of inferior vena cava (IVC) filter placement, catheter-directed thrombolysis (CDT), CDT with ultrasound, systemic thrombolysis, surgical embolectomy, percutaneous thrombectomy, extracorporeal membrane oxygenation, and mechanical ventilation were compared between race and sex subgroups, along with length of hospital stay, major bleeding events, mortality, and other adverse events. Multivariate linear regression analysis was used to adjust for variables that were significantly different between race and sex, including demographic factors, comorbidities, socioeconomic factors, and hospital characteristics. RESULTS Compared with White male patients, all subgroups had significantly higher odds of in-hospital mortality highest in Hispanic male patients (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.090-1.640; P < .01). All subgroups also had a higher odds of major bleeding events and increased length of stay. All subgroups also had lower odds of receiving CDT, lowest in Black female patients (OR, 0.740; 95% CI, 0.660-0.820; P < .001) and Hispanic female patients (0.780; 95% CI, 0.650-0.940; P < .001) compared with White male patients. There was no significant difference in the use of systemic thrombolysis among subgroups. CONCLUSIONS Black and Hispanic patients and female patients are less likely to undergo CDT compared with White male patients, in addition to having higher odds of mortality, major bleeding, and increased length of stay after management of PE. Further efforts are needed to mitigate disparate outcomes of PE management at not only an institutional, but at a national, level to promote health care equality.
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Affiliation(s)
- Shyama Sathianathan
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA
| | - Zachary Meili
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA
| | - Carlos M Romero
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA
| | - Jordan J Juarez
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Riyaz Bashir
- Division of Cardiovascular Disease, Temple University Hospital, Philadelphia, PA.
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Murphy R, Murray RA, O'hEireamhoin S, Murray JG. CT pulmonary arteriogram diagnosis of macroscopic fat embolism to the lung. Radiol Case Rep 2024; 19:2062-2066. [PMID: 38523696 PMCID: PMC10958128 DOI: 10.1016/j.radcr.2024.02.062] [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: 12/20/2023] [Revised: 02/10/2024] [Accepted: 02/15/2024] [Indexed: 03/26/2024] Open
Abstract
Pulmonary fat embolism (PFE) is a recognised complication of long bone fractures. The majority of cases represent microscopic embolism and are not detectable at CT pulmonary arteriography (CTPA). CT can be used to detect macroscopic fat based on Hounsfield attenuation. This case describes a case of macroscopic fat embolism to the pulmonary arteries which was confidently diagnosed at CTPA. Distinction from thromboembolism is important as treatment is supportive and may avoid risks of anticoagulation.
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Affiliation(s)
- Robert Murphy
- Department of Medicine, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Dublin, Ireland
- University College Dublin, Dublin 4, Dublin, Ireland
| | - Róisín A. Murray
- Department of Radiology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Dublin, Ireland
- Present Address: Department of Nursing, University Hospital Galway, Galway city, Ireland
| | - Sven O'hEireamhoin
- University College Dublin, Dublin 4, Dublin, Ireland
- Department of Orthopaedic Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Dublin, Ireland
| | - John G. Murray
- University College Dublin, Dublin 4, Dublin, Ireland
- Department of Radiology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Dublin, Ireland
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Gupta S, Cammarata TM, Cheah D, Haug N, Farooq TB, Paul V, Thameem D. Long-term outcomes and predictors of mortality in patients with pulmonary embolism undergoing catheter-directed thrombolysis: a 10-year retrospective study. Curr Probl Cardiol 2024; 49:102471. [PMID: 38369204 DOI: 10.1016/j.cpcardiol.2024.102471] [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: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Data regarding long-term outcomes of catheter-directed thrombolysis (CDT) post intermediate risk pulmonary embolism (PE), the choice of anticoagulation, and factors affecting mortality are not well studied. METHODS We conducted a ten-year retrospective observational chart review of patients undergoing CDT for intermediate-risk PE. Patients were followed for a period of 1 to a maximum of 5 years from the PE event. Multivariate regression analysis was used to identify independent predictors of mortality post-CDT. RESULTS We had a total of 373 patients in our study. Significant 5-year mortality was observed (18.7 %) in our patient population, with a 9.2 % cardiopulmonary cause of death. Rate was highest in patients without anticoagulation (78.5 %) and least in patients on apixaban [10.9 %, absolute risk reduction - 63.8 % (40.91 % - 86.60 %)]. Age, female sex and no anticoagulation were independently associated with mortality. CONCLUSION CDT for intermediate-risk PE has a high 5-year mortality with no anticoagulation as the only modifiable risk factor.
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Affiliation(s)
- Sushan Gupta
- Department of Internal Medicine, Carle Foundation Hospital, 611 W Park St, Urbana, IL, 61801, United States.
| | | | - Daniel Cheah
- University of Illinois Urbana-Champaign, (Carle Illinois College of Medicine), 506 S Mathews Ave, Urbana, IL, 61801, United States
| | - Nellie Haug
- University of Illinois Urbana-Champaign, (Carle Illinois College of Medicine), 506 S Mathews Ave, Urbana, IL, 61801, United States
| | - Talha Bin Farooq
- Department of Cardiology, Carle Foundation Hospital, 611 W Park St, Urbana, IL, 61801, United States
| | - Vishesh Paul
- Department of Pulmonary and Critical Care Medicine, Carle Foundation Hospital, 611 W Park St, Urbana, IL 61801, United States
| | - Danish Thameem
- Department of Pulmonary and Critical Care Medicine, Carle Foundation Hospital, 611 W Park St, Urbana, IL 61801, United States
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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] [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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Bansal VV, Mitchell O, Bregio C, Witmer HDD, Dhiman A, Godley FA, Ong C, Berger Y, Reddy B, Churpek JE, Drazer MW, Eng OS, Kindler HL, Turaga KK. Venous Thromboembolism in Peritoneal Mesothelioma: Uncovering the Hidden Risk. Ann Surg Oncol 2024; 31:3339-3349. [PMID: 38372861 DOI: 10.1245/s10434-024-15030-4] [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: 10/25/2023] [Accepted: 01/25/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a common complication in patients with abdominal malignancies. Despite known associations between pleural mesothelioma and increased VTE risk, the characteristics of VTE in patients with peritoneal mesothelioma (PeM) remain undescribed. METHODS Patients treated for PeM were retrospectively identified from our institutional database. The frequency of VTE was assessed and logistic regression modeling was employed to assess VTE risk factors. The association between VTE and overall survival was also ascertained. Recommended thromboprophylaxis for patients who underwent surgery at our institution comprised a single preoperative dose of prophylactic anticoagulation, followed by daily dosing for four weeks postoperatively. RESULTS Among 120 PeM patients, 26 (21.7%) experienced VTE, including 19/91 (20.9%) surgical patients, 4/23 (17.4%) patients who received systemic therapy, and 3/6 (50%) patients who underwent observation (p = 0.21). Most events were symptomatic (n = 16, 62%) and were attributable to pulmonary emboli (n = 16, 62%). The 90-day postoperative VTE rate was 4.4% (4/91), including 1 of 60 patients who underwent index surgical intervention at our institution and 3 patients with surgery elsewhere. A low serum albumin concentration was associated with VTE in non-surgical patients (odds ratio 0.12, confidence interval [CI] 0.02-0.72; p = 0.03). No significant difference in overall survival was observed between patients with and without VTE (median 46.0 months [CI 24.9-67.0] vs. 55.0 months [CI 27.5-82.5]; hazard ratio 0.98 [CI 0.54-1.81], p = 0.98). CONCLUSIONS A high risk of VTE was observed in PeM patients, warranting suspicion throughout the disease trajectory. Postoperative VTE rates were within acceptable limits with 4-week thromboprophylaxis.
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Affiliation(s)
- Varun V Bansal
- Division of Surgical Oncology, Yale School of Medicine, New Haven, CT, USA
| | - Owen Mitchell
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Celyn Bregio
- Pritzker School of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Hunter D D Witmer
- Division of General Surgery and Surgical Oncology, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Ankit Dhiman
- Department of Surgery, Medical College of Georgia, Augusta, GA, USA
| | - Frederick A Godley
- Division of General Surgery and Surgical Oncology, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Cecilia Ong
- Division of General Surgery and Surgical Oncology, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Yaniv Berger
- Department of Surgery, Sheba Medical Center, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Biren Reddy
- Division of General Surgery and Surgical Oncology, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Jane E Churpek
- Division of Hematology, Medical Oncology, and Palliative Care, Department of Medicine, University of Wisconsin, Madison, WI, USA
| | - Michael W Drazer
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Oliver S Eng
- Division of Surgical Oncology, Department of Surgery, University of California Irvine, Orange, CA, USA
| | - Hedy L Kindler
- Section of Hematology/Oncology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Kiran K Turaga
- Division of Surgical Oncology, Yale School of Medicine, New Haven, CT, USA.
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Lio KU, Bashir R, Lakhter V, Li S, Panaro J, Rali P. Impact of reperfusion therapies on clot resolution and long-term outcomes in patients with pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2024; 12:101823. [PMID: 38369293 DOI: 10.1016/j.jvsv.2024.101823] [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: 11/20/2023] [Revised: 12/23/2023] [Accepted: 12/28/2023] [Indexed: 02/20/2024]
Abstract
OBJECTIVE Major progress in reperfusion strategies has substantially improved the short-term outcomes of patients with pulmonary embolism (PE), however, up to 50% of patients report persistent dyspnea after acute PE. METHODS A retrospective study of the PE response team registry and included patients with repeat imaging at 3 to 12 months. The primary outcome was to determine the incidence of residual pulmonary vascular obstruction following acute PE. Secondary outcomes included the development of PE recurrence, right ventricular (RV) dysfunction, chronic thromboembolic pulmonary hypertension, readmission, and mortality at 12 months. RESULTS A total of 382 patients were included, and 107 patients received reperfusion therapies followed by anticoagulation. Patients who received reperfusion therapies including systemic thrombolysis, catheter-directed thrombolysis, and mechanical thrombectomy presented with a higher vascular obstructive index (47% vs 28%; P < .001) and signs of right heart strain on echocardiogram (81% vs 43%; P < .001) at the time of diagnosis. A higher absolute reduction in vascular obstructive index (45% vs 26%; 95% confidence interval, 14.0-25.6; P < .001), greater improvement in RV function (82% vs 65%; P = .021), and lower 12-month mortality rate (2% vs 7%; P = .038) and readmission rate (33% vs 46%; P = .031) were observed in the reperfusion group. No statistically significant differences were found between groups in the development of chronic thromboembolic pulmonary hypertension (8% vs 5%; P = .488) and PE recurrence (8% vs 6%; P = .646). CONCLUSIONS We observed a favorable survival and greater improvement in clot resolution and RV function in patients treated with reperfusion therapies.
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Affiliation(s)
- Ka U Lio
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA.
| | - Riyaz Bashir
- Division of Cardiovascular Diseases, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Vladimir Lakhter
- Division of Cardiovascular Diseases, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Si Li
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Joseph Panaro
- Department of Radiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
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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] [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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11
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Iwasaki H, Uehara H, Fujimoto Y, Hasuda H, Kusumoto E, Hisamatsu Y, Yoshida R, Sakaguchi Y, Kusumoto T. Fatal pulmonary embolism after surgery for small intestinal necrosis caused by idiopathic portal vein thrombosis: a case report. Surg Case Rep 2024; 10:90. [PMID: 38635121 PMCID: PMC11026322 DOI: 10.1186/s40792-024-01900-2] [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: 02/01/2024] [Accepted: 04/15/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Portal vein thrombosis (PVT) and venous thromboembolism (VTE) both result from partial or complete occlusion of a blood vessel by a blood clot. The prognosis of PVT is generally good; however, PVT with VTE, including pulmonary embolism (PE), has a high mortality rate. We report here a case of PE after surgery for small intestinal necrosis caused by idiopathic PVT. CASE PRESENTATION A 69-year-old female attended our hospital with a chief complaint of upper abdominal discomfort, and was diagnosed with necrosis of the small intestine as a result of unexplained PVT. She underwent partial resection of the small intestine. On the second postoperative day, she suffered from respiratory distress and went into cardiopulmonary arrest. The patient recovered following cardiopulmonary resuscitation, but PE was detected. Extracorporeal veno-arterial cardiopulmonary resuscitation and anticoagulation therapy were initiated immediately and the thrombus was aspirated as much as possible. Two days later, extracorporeal veno-arterial cardiopulmonary resuscitation was withdrawn and anticoagulation therapy was continued. The patient subsequently recovered with no neurological damage and was discharged on day 26 after the above procedure. CONCLUSIONS Idiopathic PVT is often associated with VTE, and a prompt diagnosis and intervention may result in a good prognosis.
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Affiliation(s)
- Hitoshi Iwasaki
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan.
| | - Hideo Uehara
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Yugo Fujimoto
- Department of Cardiology, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Hirofumi Hasuda
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Eiji Kusumoto
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Yuichi Hisamatsu
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Rintaro Yoshida
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Yoshihisa Sakaguchi
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
| | - Tetsuya Kusumoto
- Department of Gastrointestinal Surgery and Clinical Research Institute Cancer Research Division, NHO Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-Ku, Fukuoka, 810-8563, Japan
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Ding CW, Liu C, Zhang ZP, Cheng CY, Pei GS, Jing ZC, Qiu JY. Development and external validation of a nomogram for predicting short-term prognosis in patients with acute pulmonary embolism. Int J Cardiol 2024:132065. [PMID: 38642720 DOI: 10.1016/j.ijcard.2024.132065] [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: 03/18/2024] [Accepted: 04/17/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Accurate assessment and timely intervention play a crucial role in ameliorating poor short-term prognosis of acute pulmonary embolism (APE) patients. The currently employed scoring models exhibit a degree of complexity, and some models may not comprehensively incorporate relevant indicators, thereby imposing limitations on the evaluative efficacy. Our study aimed to construct and externally validate a nomogram that predicts 30-day all-cause mortality risk in APE patients. METHODS Clinical data from APE patients in Intensive Care-IV database was included as a training cohort. Additionally, we utilized our hospital's APE database as an external validation cohort. The nomogram was developed, and its predictive ability was evaluated using receiver operating characteristic (ROC) curves, calibration plots and decision curve analysis. RESULTS A collective of 1332 patients and 336 patients were respectively enrolled as the training cohort and the validation cohort in this study. Five variables including age, malignancy, oxygen saturation, blood glucose, and the use of vasopressor, were identified based on the results of the multivariate Cox regression model. The ROC value for the nomogram in the training cohort yielded 0.765, whereas in the validation group, it reached 0.907. Notably, these values surpassed the corresponding ROC values for the Pulmonary Embolism Severity Index, which were 0.713 in the training cohort and 0.754 in the validation cohort. CONCLUSIONS The nomogram including five indicators had a good performance in predicting short-term prognosis in patients with APE, which was easier to apply and provided better recommendations for clinical decision-making.
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Affiliation(s)
- Chao-Wei Ding
- Department of Respiratory and Critical Care Medicine, Fujian Medical University Xiamen Humanity Hospital, Xiamen 361000, China; Department of Respiratory and Critical Care Medicine, the Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Chao Liu
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China; Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou 510080, China
| | - Zi-Ping Zhang
- Department of Respiratory and Critical Care Medicine, the Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China
| | - Chun-Yan Cheng
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou 510080, China
| | - Guang-Sheng Pei
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang 471003, China
| | - Zhi-Cheng Jing
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou 510080, China.
| | - Jia-Yong Qiu
- Department of Respiratory and Critical Care Medicine, the Second Hospital of Hebei Medical University, Shijiazhuang, 050000, China; Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou 510080, China; Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang 471003, China.
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13
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Maas AFG, Wyers C, Dielis A, Barten DG, van Kampen VEM, van der Krieken TE, de Kruif M, Simsek S, Spaetgens B, van Haaps T, Appelman B, Gritters NC, Doornbos S, Moeniralam HS, Noordzij PG, Reidinga A, Douma RA, Nossent EJ, Beudel M, Elbers P, Middeldorp S, van Es N, van den Bergh JPW, van Osch FHM. The Incidence of Pulmonary Embolism in Hospitalized Non-ICU Patients with COVID-19 during the First Wave: A Multicenter Retrospective Cohort Study in the Netherlands. J Vasc Res 2024:1-8. [PMID: 38631294 DOI: 10.1159/000538312] [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: 12/10/2022] [Accepted: 03/05/2024] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION During the first COVID-19 outbreak in 2020 in the Netherlands, the incidence of pulmonary embolism (PE) appeared to be high in COVID-19 patients admitted to the intensive care unit (ICU). This study was performed to evaluate the incidence of PE during hospital stay in COVID-19 patients not admitted to the ICU. METHODS Data were retrospectively collected from 8 hospitals in the Netherlands. Patients admitted between February 27, 2020, and July 31, 2020, were included. Data extracted comprised clinical characteristics, medication use, first onset of COVID-19-related symptoms, admission date due to COVID-19, and date of PE diagnosis. Only polymerase chain reaction (PCR)-positive patients were included. All PEs were diagnosed with computed tomography pulmonary angiography (CTPA). RESULTS Data from 1,852 patients who were admitted to the hospital ward were collected. Forty patients (2.2%) were diagnosed with PE within 28 days following hospital admission. The median time to PE since admission was 4.5 days (IQR 0.0-9.0). In all 40 patients, PE was diagnosed within the first 2 weeks after hospital admission and for 22 (55%) patients within 2 weeks after onset of symptoms. Patient characteristics, pre-existing comorbidities, anticoagulant use, and laboratory parameters at admission were not related to the development of PE. CONCLUSION In this retrospective multicenter cohort study of 1,852 COVID-19 patients only admitted to the non-ICU wards, the incidence of CTPA-confirmed PE was 2.2% during the first 4 weeks after onset of symptoms and occurred exclusively within 2 weeks after hospital admission.
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Affiliation(s)
- Arno F G Maas
- VieCuri Medical Center, Department of Internal Medicine, Venlo, The Netherlands
| | - Caroline Wyers
- VieCuri Medical Center, Department of Internal Medicine, Venlo, The Netherlands
| | - Arne Dielis
- VieCuri Medical Center, Department of Internal Medicine, Venlo, The Netherlands
| | - Dennis G Barten
- VieCuri Medical Center, Department of Emergency Medicine, Venlo, The Netherlands
| | | | | | - Martijn de Kruif
- Zuyderland Hospital, Department of Pulmonology, Heerlen, The Netherlands
| | - Suat Simsek
- Northwest Clinics, Department of Internal Medicine, Alkmaar, The Netherlands
- Department of Internal Medicine/Endocrinology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Bart Spaetgens
- Department of Internal Medicine, Division of General Internal Medicine, Section Geriatric Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Thijs van Haaps
- Amsterdam University Medical Center, Department of Vascular Medicine, Amsterdam, The Netherlands
| | - Brent Appelman
- Center for Experimental and Molecular Medicine, Amsterdam UMC Location University of Amsterdam, Department(s), Amsterdam, The Netherlands
| | - Niels C Gritters
- Treant Zorggroep, Department of Intensive Care, Emmen, The Netherlands
| | - Stefan Doornbos
- Treant Zorggroep, Department of Intensive Care, Emmen, The Netherlands
| | - Hazra S Moeniralam
- St Antonius Hospital, Department of Internal Medicine, Nieuwegein, The Netherlands
| | - Peter G Noordzij
- St Antonius Hospital, Department of Intensive Care, Nieuwegein, The Netherlands
| | - Auke Reidinga
- Department of Intensive Care, Martini Ziekenhuis, Groningen, The Netherlands
| | - Renée A Douma
- Flevo Hospital, Department of Internal Medicine, Almere, The Netherlands
| | - Esther J Nossent
- Department of Pulmonary Medicine, Free University Amsterdam, Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands
| | - Martijn Beudel
- Department of Neurology, Amsterdam Neuroscience Institute, Amsterdam, The Netherlands
| | - Paul Elbers
- Department of Intensive Care Medicine, Laboratory for Critical Care Computational Intelligence, Amsterdam Institute for Infection and Immunity, Vrije Universiteit, Amsterdam, The Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine, Division of General Internal Medicine, Section Geriatric Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Nick van Es
- Department of Internal Medicine, Division of General Internal Medicine, Section Geriatric Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Joop P W van den Bergh
- VieCuri Medical Center, Department of Internal Medicine, Venlo, The Netherlands
- Maastricht University, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Frits H M van Osch
- Maastricht University, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
- VieCuri Medical Center, Department of Clinical Epidemiology, Venlo, The Netherlands
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14
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Hassan A, Maki R, Aljawad M, Alzayer A, Habeeb A, Alzaher A, Alawami A, Alaithan F, Adnan J. Beyond pulmonary embolism: Alternative diagnosis and incidental findings on CT pulmonary angiography in sickle cell disease. Emerg Radiol 2024:10.1007/s10140-024-02229-x. [PMID: 38619803 DOI: 10.1007/s10140-024-02229-x] [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: 03/06/2024] [Accepted: 04/09/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Sickle cell disease (SCD) is a genetic hematological disorder associated with severe complications, such as vaso-occlusive crises, acute chest syndrome (ACS), and an increased risk of thromboembolic events, including pulmonary embolism (PE). The diagnosis of PE in SCD patients presents challenges due to the overlapping symptoms with other pulmonary conditions. Our previous study revealed that nearly 96% of computed tomography pulmonary angiography (CTPA) scans in SCD patients were negative for PE, highlighting a gap in understanding the significance of CTPA findings when PE is absent. METHODS In this retrospective follow-up study conducted at the Salmaniya Medical Complex in Bahrain, we examined SCD patients with HbSS genotypes who underwent CTPA from January 1, 2018, to December 31, 2021, for suspected PE, but the results were negative. The aim of this study was to identify alternative diagnoses and incidental findings from CTPA scans. Experienced radiologists reviewed the CTPA images and reports to assess potential alternative diagnoses and incidental findings, incorporating an additional analysis of chest X-rays to evaluate the diagnostic value of CTPA. Incidental findings were classified based on their location and clinical significance. RESULTS Among the 230 evaluated SCD patients (average age 39.7 years; 53% male) who were CTPA negative for PE, 142 (61.7%) had identifiable alternative diagnoses, primarily pneumonia (49.1%). Notably, 88.0% of these alternative diagnoses had been previously suggested by chest radiographs. Furthermore, incidental findings were noted in 164 (71.3%) patients, with 11.0% deemed clinically significant, necessitating immediate action, and 87.8% considered potentially significant, requiring further assessment. Notable incidental findings included thoracic abnormalities such as cardiomegaly (12.2%) and an enlarged pulmonary artery (11.3%), as well as upper abdominal pathologies such as hepatomegaly (19.6%), splenomegaly (20.9%), and gallstones (10.4%). CONCLUSION This study underscores the limited additional diagnostic yield of CTPA for identifying alternative diagnoses to PE in SCD patients, with the majority of diagnoses, such as pneumonia, already suggested by chest radiographs. The frequent incidental findings, most of which necessitate further evaluation, highlight the need for a cautious and tailored approach to using CTPA in the SCD population.
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Affiliation(s)
- Ali Hassan
- Radiology Department, Governmental Hospitals, Salmaniya Medical Complex, Manama, Bahrain.
| | - Reem Maki
- Radiology Department, Governmental Hospitals, Salmaniya Medical Complex, Manama, Bahrain
| | - Mahdi Aljawad
- Radiology Department, Eastern Health Cluster, Dammam, Saudi Arabia
| | - Ali Alzayer
- Radiology Department, Eastern Health Cluster, Dammam, Saudi Arabia
| | - Ali Habeeb
- Radiology Department, Eastern Health Cluster, Dammam, Saudi Arabia
| | - Aqeel Alzaher
- Radiology Department, Eastern Health Cluster, Dammam, Saudi Arabia
| | - Adnan Alawami
- Radiology Department, Eastern Health Cluster, Dammam, Saudi Arabia
| | - Fatimah Alaithan
- Radiology Department, Eastern Health Cluster, Dammam, Saudi Arabia
| | - Jalila Adnan
- Radiology Department, Governmental Hospitals, Salmaniya Medical Complex, Manama, Bahrain
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15
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Tong LX, Den C. Intramuscular venous thrombosis and acute pulmonary embolism after vaginal delivery without other risk factors. Asian J Surg 2024:S1015-9584(24)00485-8. [PMID: 38599975 DOI: 10.1016/j.asjsur.2024.03.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 03/14/2024] [Indexed: 04/12/2024] Open
Affiliation(s)
- Long-Xia Tong
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, 610041, China; Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, 610041, China
| | - Chengmin Den
- Department of Gynecology and Obstetrics, Meishan Women and Children'S Hospital, Meishan, 620500, China.
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16
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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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17
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Leiva O, Alviar C, Khandhar S, Parikh SA, Toma C, Postelnicu R, Horowitz J, Mukherjee V, Greco A, Bangalore S. Catheter-based therapy for high-risk or intermediate-risk pulmonary embolism: death and re-hospitalization. Eur Heart J 2024:ehae184. [PMID: 38573048 DOI: 10.1093/eurheartj/ehae184] [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: 08/23/2023] [Revised: 02/18/2024] [Accepted: 03/11/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND AND AIMS Catheter-based therapies (CBTs) have been developed as a treatment option in patients with pulmonary embolism (PE). There remains a paucity of data to inform decision-making in patients with intermediate-risk or high-risk PE. The aim of this study was to characterize in-hospital and readmission outcomes in patients with intermediate-risk or high-risk PE treated with vs. without CBT in a large retrospective registry. METHODS Patients hospitalized with intermediate-risk or high-risk PE were identified using the 2017-20 National Readmission Database. In-hospital outcomes included death and bleeding and 30- and 90-day readmission outcomes including all-cause, venous thromboembolism (VTE)-related and bleeding-related readmissions. Inverse probability of treatment weighting (IPTW) was utilized to compare outcomes between CBT and no CBT. RESULTS A total of 14 903 [2076 (13.9%) with CBT] and 42 829 [8824 (20.6%) with CBT] patients with high-risk and intermediate-risk PE were included, respectively. Prior to IPTW, patients with CBT were younger and less likely to have cancer and cardiac arrest, receive systemic thrombolysis, or be on mechanical ventilation. In the IPTW logistic regression model, CBT was associated with lower odds of in-hospital death in high-risk [odds ratio (OR) 0.83, 95% confidence interval (CI) 0.80-0.87] and intermediate-risk PE (OR 0.76, 95% CI 0.70-0.83). Patients with high-risk PE treated with CBT were associated with lower risk of 90-day all-cause [hazard ratio (HR) 0.77, 95% CI 0.71-0.83] and VTE (HR 0.46, 95% CI 0.34-0.63) readmission. Patients with intermediate-risk PE treated with CBT were associated with lower risk of 90-day all-cause (HR 0.75, 95% CI 0.72-0.79) and VTE (HR 0.66, 95% CI 0.57-0.76) readmission. CONCLUSIONS Among patients with high-risk or intermediate-risk PE, CBT was associated with lower in-hospital death and 90-day readmission. Prospective, randomized trials are needed to confirm these findings.
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Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY 10016, USA
| | - Carlos Alviar
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY 10016, USA
| | - Sameer Khandhar
- Division of Cardiology, Penn Presbyterian Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sahil A Parikh
- Division of Cardiology, Columbia University Irving Medical School, New York-Presbyterian Hospital, New York, NY, USA
| | - Catalin Toma
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Radu Postelnicu
- Department of Medicine, Division of Pulmonology and Critical Care, New York University Grossman School of Medicine, New York, NY, USA
| | - James Horowitz
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY 10016, USA
| | - Vikramjit Mukherjee
- Department of Medicine, Division of Pulmonology and Critical Care, New York University Grossman School of Medicine, New York, NY, USA
| | - Allison Greco
- Department of Medicine, Division of Pulmonology and Critical Care, New York University Grossman School of Medicine, New York, NY, USA
| | - Sripal Bangalore
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY 10016, USA
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18
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Waqar M, Yaseen O, Chadwick A, Lee JX, Khan G, Evans DG, Horner D, Jaiswal A, Freeman S, Bhalla R, Lloyd S, Hammerbeck-Ward C, Rutherford SA, King AT, Pathmanaban ON. Venous thromboembolism chemical prophylaxis after skull base surgery. Acta Neurochir (Wien) 2024; 166:165. [PMID: 38565732 PMCID: PMC10987339 DOI: 10.1007/s00701-024-06035-9] [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: 11/16/2023] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
PURPOSE There is no guidance surrounding postoperative venous thromboembolism (VTE) prophylaxis using pharmacological agents (chemoprophylaxis) in patients undergoing skull base surgery. The aim of this study was to compare VTE and intracranial haematoma rates after skull base surgery in patients treated with/without chemoprophylaxis. METHODS Review of prospective quaternary centre database including adults undergoing first-time skull base surgery (2009-2020). VTE was defined as deep vein thrombosis (DVT) and pulmonary embolism (PE) within 6 months of surgery. Multivariate logistic regression was used to determine factors predictive of postoperative intracranial haematoma/VTE. Propensity score matching (PSM) was used in group comparisons. RESULTS One thousand five hundred fifty-one patients were included with a median age of 52 years (range 16-89 years) and female predominance (62%). Postoperative chemoprophylaxis was used in 81% of patients at a median of 1 day postoperatively. There were 12 VTE events (1.2%), and the use of chemoprophylaxis did not negate the risk of VTE entirely (p > 0.99) and was highest on/after postoperative day 6 (9/12 VTE events). There were 18 intracranial haematomas (0.8%), and after PSM, chemoprophylaxis did not significantly increase the risk of an intracranial haematoma (p > 0.99). Patients administered chemoprophylaxis from postoperative days 1 and 2 had similar rates of intracranial haematomas (p = 0.60) and VTE (p = 0.60), affirmed in PSM. CONCLUSION Postoperative chemoprophylaxis represents a relatively safe strategy in patients undergoing skull base surgery. We advocate a personalised approach to chemoprophylaxis and recommend it on postoperative days 1 or 2 when indicated.
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Affiliation(s)
- Mueez Waqar
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Omar Yaseen
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Annabel Chadwick
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Jing Xian Lee
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Ghazn Khan
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - D Gareth Evans
- Department of Neurogenetics, Manchester Centre for Genomic Medicine, St Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Daniel Horner
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Department of Neurocritical Care, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Archana Jaiswal
- Department of Otorhinolaryngology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Simon Freeman
- Department of Otorhinolaryngology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Rajiv Bhalla
- Department of Otorhinolaryngology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Simon Lloyd
- Department of Otorhinolaryngology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Charlotte Hammerbeck-Ward
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Scott A Rutherford
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Andrew T King
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Omar N Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, UK.
- Geoffrey Jefferson Brain Research Centre, Division of Neuroscience, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.
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19
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Mehrban A, Hajikolaei FA, Karimi M, Khademi R, Ansari A, Qujeq D, Hajian-Tilaki K, Monadi M. Evaluation of elevated serum apelin-13 and D-dimer concentrations in individuals diagnosed with pulmonary embolism. Int J Emerg Med 2024; 17:48. [PMID: 38565984 PMCID: PMC10986010 DOI: 10.1186/s12245-024-00619-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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/17/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Given the limited specificity of D-dimer, there is a perceived need to discover a more precise marker for diagnosing individuals who are suspected of having pulmonary embolism (PE). In this study, by evaluating the increase in the serum level of Apelin-13 and D-dimer, we found valuable findings about Apelin-13, which can be suggested as an auxiliary and non-invasive diagnostic biomarker in individuals with suspected PE, based on the obtained results. METHODS In this case-control study, 52 Iranian individuals were included, all of whom were suspected to have PE. These individuals were then divided into two groups based on the results of CT angiography, which is considered the gold standard imaging method for diagnosing PE. The two groups were patients with PE and patients without PE. Finally, the levels of certain markers in the serum were compared between the two groups. RESULTS The mean serum D-dimer levels in patients with PE were significantly elevated (p < 0.001) in comparison to those without PE (1102.47 to 456.2 ng/ml). Furthermore, the mean level of Apelin-13 was significantly higher in patients with PE (49.8 to 73.11 ng/L) (p < 0.001). The cutoff point of Apelin-13 has been calculated at 58.50 ng/ml, with 90.9% sensitivity and 90% specificity. The D-dimer cutoff point was 500 ng/ml, with 95.5% sensitivity and 43.3% specificity. CONCLUSIONS Based on the results of this study, the serum level of Apelin-13 can be used as a novel diagnostic and screening biomarker in patients with pulmonary thromboembolism.
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Affiliation(s)
- Alireza Mehrban
- Shariati Hospital, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | | | - Mehdi Karimi
- Bogomolets National Medical University (NMU), Kyiv, Ukraine.
| | - Reza Khademi
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical (MUMS) , Mashhad, Iran
| | - Akram Ansari
- Shantou University Medical College, Shantou, Guangdong, China
| | - Durdi Qujeq
- Department of Clinical Biochemistry, Babol University of Medical Sciences (MUBabol), Babol, Iran
| | - Karimollah Hajian-Tilaki
- Department of Social Medicine, Faculty of Medicine, Babol University of Medical Sciences (MUBabol), Babol, Iran
| | - Mahmood Monadi
- Department of Internal Medicine, Babol University of Medical Sciences (MUBabol), Babol, Iran.
- School of Medicine, Babol University of Medical Sciences (MUBabol), Babol, Iran.
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20
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Mohr K, Hobohm L, Kaier K, Farmakis IT, Valerio L, Barco S, Abele C, Münzel T, Neusius T, Konstantinides S, Binder H, Keller K. Drivers and recent trends of hospitalisation costs related to acute pulmonary embolism. Clin Res Cardiol 2024:10.1007/s00392-024-02437-y. [PMID: 38565711 DOI: 10.1007/s00392-024-02437-y] [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: 01/11/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND AND AIMS The socio-economic burden imposed by acute pulmonary embolism (PE) on European healthcare systems is largely unknown. We sought to determine temporal trends and identify cost drivers of hospitalisation for PE in Germany. METHODS AND RESULTS We analysed the totality of reimbursed hospitalisation costs in Germany (G-DRG system) in the years 2016-2020. Overall, 484 884 PE hospitalisations were coded in this period. Direct hospital costs amounted to a median of 3572 (IQR, 2804 to 5869) euros, resulting in average total reimbursements of 710 million euros annually. Age, PE severity, comorbidities and in-hospital (particularly bleeding) complications were identified by multivariable logistic regression as significant cost drivers. Use of catheter-directed therapy (CDT) constantly increased (annual change in the absolute proportion of hospitalisations with CDT + 0.40% [95% CI + 0.32% to + 0.47%]; P < 0.001), and it more than doubled in the group of patients with severe PE (28% of the entire population) over time. Although CDT use was overall associated with increased hospitalisation costs, this association was no longer present (adjusted OR 1.02 [0.80-1.31]) in patients with severe PE and shock; this was related, at least in part, to a reduction in the median length of hospital stay (for 14.0 to 8.0 days). CONCLUSIONS We identified current and emerging cost drivers of hospitalisation for PE, focusing on severe disease and intermediate/high risk of an adverse early outcome. The present study may inform reimbursement decisions by policymakers and help to guide future health economic analysis of advanced treatment options for patients with PE.
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Affiliation(s)
- Katharina Mohr
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Klaus Kaier
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Christina Abele
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Thomas Neusius
- Wiesbaden Business School, RheinMain University of Applied Sciences, Wiesbaden, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece.
| | - Harald Binder
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
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21
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Rajpurkar M, Rosovsky RP, Williams S, Chan AKC, van Ommen CH, Faustino EVS, White M, Parikh M, Sirachainan N, Biss T, Goldenberg NA. Considerations for instituting pediatric pulmonary embolism response teams: A tool kit. Thromb Res 2024; 236:97-107. [PMID: 38417301 DOI: 10.1016/j.thromres.2024.02.019] [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: 12/21/2023] [Revised: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 03/01/2024]
Abstract
The incidence of pediatric pulmonary embolism (PE) has increased by 200 % in the last decade, but at a single center, it is still infrequent. Given the unique epidemiologic features of pediatric PE, diagnosis is often delayed, and the management is empiric, based on individual physician experience or preference. Thus, there is a strong need for center-specific uniform management of pediatric PE patients. In adults, the development of pulmonary embolism response teams (PERTs) or PE critical care pathways has shortened the time to diagnosis and the initiation of definitive management. Evidence to support an improvement in PE outcomes after the development of PERTs does not exist in children. Nonetheless, we have summarized the practical practice guidelines that physicians and institutions can adopt to establish their institutional PERTs or critical pathways. We also provide strategies for resource-challenged institutions for partnering with centers with expertise in the management of pediatric PE.
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Affiliation(s)
- Madhvi Rajpurkar
- Department of Pediatrics, Division of Pediatric Hematology Oncology, Central Michigan University, Wayne State University, Children's Hospital of Michigan, Detroit, MI, USA.
| | - Rachel P Rosovsky
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Suzan Williams
- Division of Hematology/Oncology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Canada
| | | | - C Heleen van Ommen
- Department of Pediatric Hematology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - E Vincent S Faustino
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Melissa White
- Division of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mihir Parikh
- Department of Pediatric Anesthesiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nongnuch Sirachainan
- Division of Hematology/Oncology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Bangkok, Thailand
| | - Tina Biss
- Department of Haematology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Neil A Goldenberg
- Department of Pediatrics and Medicine, Division of Hematology, Johns Hopkins, University School of Medicine, Baltimore, MD, USA; Johns Hopkins All Children's Institute for Clinical and Translational Research, Cancer and Blood Disorder Institute, and Heart Institute, Johns Hopkins All Children's, Hospital, St. Petersburg, FL, USA
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22
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Akhan O, Boz M, Guzel T, Kis M. Discrimination of the acute pulmonary embolism subtypes based on the novel MAPH score. J Thromb Thrombolysis 2024; 57:683-690. [PMID: 38416307 DOI: 10.1007/s11239-024-02952-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/14/2024] [Indexed: 02/29/2024]
Abstract
Acute pulmonary embolism (APE) is a thromboembolism situation that can be central or peripheral. APE risk analysis and classification are essential for therapy planning. Our aim is to determine the novel MAPH score (including age, mean platelet volume (MPV), total protein, and hematocrit parameters) that can distinguish APE subtypes. Our retrospective cohort analysis includes 97 APE patients referred to the emergency medicine department who underwent pulmonary computed tomography angiography (CTA) in 24 h from 2020 to 2022. The hospital information system provided demographic, clinical, laboratory, and pulmonary CTA data. APE was classified into central (46 patients) and peripheral (51 patients) depending on the area of vascular involvement. The central APE group had higher hypertension (HT) (67.4%) and atrial fibrillation (AF) (39.1%) incidence than the peripheral APE group (all p values > 0.05). The central APE had higher total protein and platelet counts (p = 0.003 and p = 0.036), but peripheral APE had higher troponin values (p = 0.029). Central APE had 2.17 ± 0.85 MAPH and peripheral APE 1.76 ± 0.95 (p = 0.029). HT, AF, platelet count, and MAPH score differed significantly in univariate logistic regression (all p values < 0.05). However, only platelet count varied in multivariate logistic regression (p = 0.042). ROC curve analysis revealed that the MAPH score predicts central APE with 83% sensitivity and 45% specificity at a cut-off level of 1.5. The new MAPH score as an indicator of blood viscosity may distinguish between central and peripheral APE. Our result is significant, especially for centers with limited examinations, as it may accelerate the diagnosis and treatment processes. We think that our results might guide future investigations.
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Affiliation(s)
- Onur Akhan
- Cardiology Department, Bilecik Training and Research Hospital, Floor 2, 11230, Bilecik, Turkey.
| | - Mustafa Boz
- Emergency Medicine, Bilecik Training and Research Hospital, Bilecik, Turkey
| | - Tuncay Guzel
- Cardiology, Gazi Yasargil Training and Research Hospital, Diyarbakir, Turkey
| | - Mehmet Kis
- Cardiology, Dokuz Eylul University, Izmir, Turkey
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23
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El Marraki Z, Mounaouir K, Fellat N, Fellat R. Postpartum dilated cardiomyopathy and antiphospholipid syndrome: A rare association revealed by a pulmonary embolism (case report). Radiol Case Rep 2024; 19:1298-1303. [PMID: 38292781 PMCID: PMC10825536 DOI: 10.1016/j.radcr.2023.11.056] [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: 10/27/2022] [Revised: 11/15/2023] [Accepted: 11/22/2023] [Indexed: 02/01/2024] Open
Abstract
Antiphospholipid syndrome is a rare entity that must be systematically evoked in front of recurrent miscarriages associated with venous or arterial thrombosis, its diagnosis is based on a set of clinico-biological arguments. In rare cases, it can be associated with postpartum cardiomyopathy, which is defined by a dysfunction of the left ventricle with an LVEF<45%, which may or may not be associated with a dilation of the left ventricle. This association is rare and poorly described in the literature, which makes management difficult and uncodified. In this context we report the case of a 33-year-old patient with cardiovascular risk factors such as arterial hypertension 2 previous miscarriages and repeated phlebitis, she was admitted to the emergency room for the management of acute dyspnea related to a proximal right pulmonary embolism and in whom the transthoracic echocardiography had objectivated a dilated left ventricle and an alteration of the ejection fraction of the left ventricle, the coronary angiography came back without particularity as part of the etiological work-up, a biological work-up was carried out, which came back in favor of an antiphospholipid syndrome. This case shows diagnostic difficulties and management of this disease.
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Affiliation(s)
- Zakaria El Marraki
- Department of Cardiac Intensive Care, Cardiology Intensive Care Unit, Ibn Sina University Hospital, Rabat, Morocco
| | - Karim Mounaouir
- Department of Cardiac Intensive Care, Faculty of Medicine and Pharmacy, Casablanca, Morocco
| | - Nadia Fellat
- Department of Cardiac Intensive Care, Cardiology Intensive Care Unit, Ibn Sina University Hospital, Rabat, Morocco
| | - Rokaya Fellat
- Department of Clinical Cardiology, Faculty of Medicine and Pharmacy, Rabat, Morocco
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24
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Sagoschen I, Scibior B, Farmakis IT, Keller K, Graafen D, Griemert EV, Vosseler M, Treede H, Münzel T, Knorr M, Gori T, Konstantinides S, Hobohm L. A multidisciplinary pulmonary embolism response team (PERT): first experience from a single center in Germany. Clin Res Cardiol 2024; 113:581-590. [PMID: 38112742 PMCID: PMC10954947 DOI: 10.1007/s00392-023-02364-4] [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] [Received: 08/20/2023] [Accepted: 12/07/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Over the last few years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has emerged to encounter the increasing variety and complexity in managing acute pulmonary embolism (PE). PURPOSE To investigate PERT's composition and added clinical value in a university center in Germany. METHODS Over 4 years (01/2019-11/2022), patients with confirmed PE were enrolled in a prospective single-center cohort study (PERT Mainz). We investigated the composition of PERT and compared, after propensity score matching, patients with acute PE before and after the initiation of PERT at our Medical University Centre. The primary outcome was in-hospital PE-related mortality. RESULTS From 2019 to 2022, 88 patients with acute PE with a PERT decision were registered. Of those, 13 (14.8%) patients died during the in-hospital stay. Patients evaluated by a PERT had a median age of 68; 48.9% were females, and 21.7% suffered from malignancy. Right ventricular dysfunction was present in 76.1% of all patients. In total, 42.0% were classified as intermediate-high-risk PE and 11.4% as high-risk PE. First PERT contact mainly originated from emergency departments (33.3%) and intensive care units (30.0%), followed by chest pain units (21.3%) and regular wards (12.0%). The participation rate of medical specialties demonstrated that cardiologists (100%) or cardiac/vascular surgeons (98.6%) were included in almost all PERT consultations, followed by radiologists (95.9%) and anesthesiologists (87.8%). Compared to the PERT era, more patients in the pre-PERT era were classified as simplified pulmonary embolism severity index (sPESI) ≥ 1 (78.4% vs 71.6%) and as high-risk PE according to ESC 2019 guidelines (18.2% vs. 11.4%). In the pre-PERT era, low- and intermediate-low patients with PE received more frequently advanced reperfusion therapies such as systemic thrombolysis or surgical embolectomy compared to the PERT era (10.7% vs. 2.5%). Patients in the pre-PERT were found to have a considerably higher all-cause mortality and PE-related mortality rate (31.8% vs. 14.8%) compared to patients in the PERT era (22.7% vs. 13.6%). After propensity matching (1:1) by including parameters as age, sex, sPESI, and ESC risk classes, univariate regression analyses demonstrated that the PE management based on a PERT decision was associated with lower risk of all-cause mortality (OR, 0.37 [95%CI 0.18-0.77]; p = 0.009). For PE-related mortality, a tendency for reduction was observed (OR, 0.54 [95%CI 0.24-1.18]; p = 0.121). CONCLUSION PERT implementation was associated with a lower risk of all-cause mortality rate in patients with acute PE. Large prospective studies are needed further to explore the impact of PERTs on clinical outcomes.
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Affiliation(s)
- Ingo Sagoschen
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Barbara Scibior
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Karsten Keller
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Medical Clinic VII, University Hospital Heidelberg, Heidelberg, Germany
| | - Dirk Graafen
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Eva-Verena Griemert
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Markus Vosseler
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Hendrik Treede
- Department for Cardiac and Vascular Surgery, University Medical Center Mainz of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Maike Knorr
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Tommaso Gori
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Komotini, Greece
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.
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25
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Bhangu G, Murray A, Qayyum A, Goumeniouk N, Goodacre S, Hunt BJ, Touhami O, Tester J, Rees M, Hammerschlag G, Pascoe D, Ronksley PE, King JA, Choi H, McDermott S, Le Gal G, Skeith L. Diagnostic strategies in postpartum individuals with suspected venous thromboembolism: A scoping review. Thromb Res 2024; 236:108-116. [PMID: 38422980 DOI: 10.1016/j.thromres.2024.02.012] [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] [Received: 12/19/2023] [Revised: 02/02/2024] [Accepted: 02/13/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The risk of venous thromboembolism (VTE) is increased postpartum and contributes to important morbidity and mortality. While there have been advances in evaluating diagnostic algorithms for suspected VTE during pregnancy, there is limited data for postpartum individuals. OBJECTIVE We conducted a scoping review to describe and evaluate diagnostic strategies used to investigate suspected VTE in postpartum individuals. METHODS A comprehensive search strategy was conducted in Ovid MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (January 1, 2000-September 30, 2022) to identify original articles that reported on diagnostic strategies in postpartum individuals with suspected VTE. We extracted demographics, clinical decision rules used, D-dimer and imaging completed, including test performance and VTE outcomes. RESULTS A total of 13 studies conducted across 11 countries with separate postpartum data were included for 759 individuals with suspected PE (n = 634) or DVT (n = 125), including unpublished data (n = 251). Among those with suspected PE, computed tomography pulmonary angiography was conducted more commonly (n = 522) than ventilation-perfusion scans (n = 69), with PE positivity rates that ranged from 4 %-27.6 % and 0-50 % across studies, respectively. Among 131 postpartum individuals with suspected PE who had a D-dimer measured, only 4.6 % (6/131) had a negative D-dimer test. For postpartum individuals with suspected DVT, the most common diagnostic test was compression ultrasonography (positivity rate 12.2 %-18.6 %). There were limited retrospective data evaluating the clinical decision rules. CONCLUSIONS There are heterogeneous approaches globally in the diagnosis of suspected postpartum VTE. Limited high-quality data available underscores the need for more robust evidence to inform clinical practice.
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Affiliation(s)
- Gurjeet Bhangu
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alistair Murray
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Areeb Qayyum
- Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Natasha Goumeniouk
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Beverley J Hunt
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Omar Touhami
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, Hôpital Charles-LeMoyne, Sherbrooke University, Quebec, Canada
| | - Jodie Tester
- Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Megan Rees
- Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Gary Hammerschlag
- Department of Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Diane Pascoe
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia; Department of Radiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Paul E Ronksley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - James A King
- Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta SPOR Support Unit Data Platform, Alberta Health Services, Calgary, Alberta, Canada
| | - Hyun Choi
- Emergency Department, University Hospital Lewisham, London, United Kingdom
| | - Shaunagh McDermott
- Thoracic Imaging Division, Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Gregoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Leslie Skeith
- Department of Medicine, University of Calgary, Calgary, AB, Canada; Centre for Health Informatics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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26
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López N, Zamora-Martinez C, Montoya-Rodes M, Gabara C, Ortiz M, Aibar J. Comparison of inferior vena cava filter use and outcomes between cancer and non-cancer patients in a tertiary hospital. Thromb Res 2024; 236:136-143. [PMID: 38447420 DOI: 10.1016/j.thromres.2024.02.020] [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: 09/07/2023] [Revised: 02/15/2024] [Accepted: 02/19/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND While accepted indications for the use of inferior vena cava filter (IVCF) in patients with a venous thromboembolism (VTE) have remained stable, their use continues to be frequent. Retrieval rates are still low, being particularly notable in the population with cancer. This study aims to review the rate of adherence to guidelines recommendation and to compare retrieval rates and complications in both cancer and non-cancer patients. METHODS A retrospective study was performed including 185 patients in whom an IVCF was placed in Hospital Clinic of Barcelona. Baseline characteristics, clinical outcomes, and IVCF-related outcomes were analyzed. A strongly recommended indication (SRI) was considered if it was included in all the revised clinical guidelines and non-strongly if it was included in only some. RESULTS Overall, 47 % of the patients had a SRI, without differences between groups. IVCF placement after 29 days from the VTE event was more frequent in the cancer group (46.1 vs. 17.7 %). Patients with cancer (48.1 % of the cohort) were older, with higher co-morbidity and bleeding risk. Anticoagulation resumption (75.3 % vs. 92.7 %) and IVCF retrieval (50.6 % vs. 66.7 %) were significantly less frequent in cancer patients. No significant differences were found regarding IVCF-related complications, hemorrhagic events and VTE recurrence. CONCLUSIONS SRI of IVCF placement was found in less than half of the patients. Cancer patients had higher rates of IVCF placement without indication and lower anticoagulation resumption and IVCF retrieval ratios, despite complications were similar in both groups.
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Affiliation(s)
- Néstor López
- Internal Medicine Department, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Carles Zamora-Martinez
- Medical Oncology Department, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain.
| | - Marc Montoya-Rodes
- Internal Medicine Department, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Cristina Gabara
- Internal Medicine Department, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - María Ortiz
- Internal Medicine Department, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jesús Aibar
- Internal Medicine Department, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
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27
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Jonard M, Rossignol M, Chiesa-Dubruille C. [Maternal mortality due to venous thromboembolism in France 2016-2018]. Gynecol Obstet Fertil Senol 2024; 52:246-251. [PMID: 38373497 DOI: 10.1016/j.gofs.2024.02.007] [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] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 02/13/2024] [Indexed: 02/21/2024]
Abstract
Pregnancy and the post-partum period represent a thromboembolic risk situation, with pulmonary embolism (PE) remaining one of the leading causes of direct maternal deaths in developed countries. Between 2016 and 2018 in France, twenty maternal deaths were caused by venous thromboembolic complications (VTE), yielding a Maternal Mortality Ratio (MMR) of 0.9 per 100,000 live births (95%CI 0.6-1.3), with no change compared to the periods 2013-2015 or 2010-2012. Among these 20 deaths, 1 death was related to cerebral thrombophlebitis, and the remaining 19 were due to PE. Regarding the timing of death, 2 deaths occurred after an early termination of pregnancy, 40% (8/20) during an ongoing pregnancy, and 50% (10/20) in the post-partum period. Among the 20 VTE deaths, 20% (4/20) occurred outside of a healthcare facility (at home or in a public place). Among the nineteen cases with documented BMI, seven women had obesity (37%), three times more than in the population of parturients in France (11.8%, ENP 2016). Among the nineteen PE deaths and the case of cerebral thrombophlebitis, eleven were considered preventable, six possibly preventable (35%), two probably preventable (12%), and three preventability undetermined. The identified preventability factors were inadequate care and the patient's failure to interact with the healthcare system. From the case analysis, areas for improvement were identified, including insufficient consideration of major and minor risk factors, the early initiation of appropriate prophylactic treatment, and the absence of fibrinolysis in cases of s refractory cardiac arrest due to suspected PE.
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Affiliation(s)
- Marie Jonard
- Centre hospitalier de Lens, 99, route de la Bassée, 62300 Lens, France.
| | - Mathias Rossignol
- Département d'anesthésie-réanimation et SMUR, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75465 Paris, France
| | - Coralie Chiesa-Dubruille
- Département de Maïeutique UFR Simone Veil-Santé, université de Versailles Saint-Quentin en Yvelines - Paris Saclay, Montigny-le-Bretonneux, France; Service de gynecologie - obstétrique, centre hospitalier de Rambouillet, Rambouillet, France
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Endo T, Takayama T, Kimura M, Mochizuki Y, Taniguchi R, Hoshina K. A case of endovascular treatment for iatrogenic left vertebral artery injury due to central line catheter placement. J Vasc Surg Cases Innov Tech 2024; 10:101368. [PMID: 38566912 PMCID: PMC10985260 DOI: 10.1016/j.jvscit.2023.101368] [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: 09/13/2023] [Accepted: 10/24/2023] [Indexed: 04/04/2024] Open
Abstract
We describe a case of endovascular treatment for an iatrogenic left vertebral artery injury after central line catheter placement in a 68-year-old male patient. The patient had a massive pulmonary embolism, and a Swan-Ganz catheter was required to monitor the patient's circulatory condition. However, the catheter was inserted into the left vertebral artery and passed through the left internal jugular vein. Endovascular treatment was indicated due to the patient's poor general health. Complete hemostasis was achieved, and the postoperative course was uneventful without neurologic deficits.
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Affiliation(s)
- Takashi Endo
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshio Takayama
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masaru Kimura
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuaki Mochizuki
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryosuke Taniguchi
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsuyuki Hoshina
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Primmaz S, Rochat Negro T, Suh N, Le Terrier C, Wozniak H, Pugin J, Bendjelid K. Pulmonary embolism impacts clinical outcomes of intubated patients with acute respiratory distress syndrome related to COVID-19. Anaesth Crit Care Pain Med 2024; 43:101348. [PMID: 38278355 DOI: 10.1016/j.accpm.2024.101348] [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: 10/19/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/28/2024]
Abstract
BACKGROUND Pulmonary embolism (PE) in critically ill patients with acute respiratory distress syndrome (ARDS) caused by COVID-19 is a major complication which might impact survival. We aimed to determine the prevalence of PE and assess its impact of PE on clinical outcomes in intubated patients with ARDS due to COVID-19. METHODS All intubated patients with ARDS due to COVID-19 admitted to the intensive care unit (ICU) of Geneva University Hospitals between March 9, 2020, and May 31, 2022, were included. A retrospective analysis was conducted on the occurrence of PE and its association with clinical outcomes. The primary outcome was ventilator-free days during the first 28 days after ICU admission. Linear regressions were performed to investigate the association between PE and outcomes. RESULTS Among the 370 intubated patients with ARDS related to COVID-19, 58 (15.7%) presented with PE. Patients with PE had significantly fewer ventilator-free days than patients without PE (median (IQR) of 3 (0-11) days versus 12 (0-19) days; p < 0.001). Mortality did not differ significantly between groups (12/58 [20.7%] of patients with PE versus 71/312 [22.8%] of patients without PE; p = 0.72). Duration of IMV, and ICU and hospital LOS were significantly longer among patients with PE. The need for ECMO support was similar among both groups. CONCLUSIONS The occurrence of PE in patients with ARDS due to COVID-19 had a significant impact on clinical outcomes. They had fewer ventilator-free days, longer duration of IMV, and longer ICU and hospital lengths of stay. However, pulmonary embolism was not associated with higher mortality. ETHICS APPROVAL Ethical committee of Geneva (BASEC #: 2020-00917).
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Affiliation(s)
- Steve Primmaz
- Division of Intensive Care, Geneva University Hospitals and the University of Geneva Faculty of Medicine, Geneva, Switzerland.
| | - Tommaso Rochat Negro
- Division of Intensive Care, Geneva University Hospitals and the University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Noémie Suh
- Division of Intensive Care, Geneva University Hospitals and the University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Christophe Le Terrier
- Division of Intensive Care, Geneva University Hospitals and the University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Hannah Wozniak
- Division of Intensive Care, Geneva University Hospitals and the University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Jérôme Pugin
- Division of Intensive Care, Geneva University Hospitals and the University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Karim Bendjelid
- Division of Intensive Care, Geneva University Hospitals and the University of Geneva Faculty of Medicine, Geneva, Switzerland
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Kambiré Y, Millogo GRC, Kologo KJ, Tall-Thiam A, Agossou V, Konaté L, Somé H, Diallo I, Yameogo NV, Samadoulougou KA, Zabsonré P. [Comparative prognosis of pulmonary embolism in patients infected with COVID-19 and patients not infected with COVID-19 in Ouagadougou]. Ann Cardiol Angeiol (Paris) 2024; 73:101735. [PMID: 38387249 DOI: 10.1016/j.ancard.2024.101735] [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: 08/10/2023] [Revised: 12/09/2023] [Accepted: 01/22/2024] [Indexed: 02/24/2024]
Abstract
OBJECTIVE the study's objective was to determine impact of COVID-19 on the prognosis of pulmonary embolism. PATIENTS AND METHODS An analytical multicenter cross-sectional study with retrospective data collection was carried out in three university hospitals and a private clinic in Ouagadougou from March, 2020 to July 2021. It included consecutive patients hospitalized for PE confirmed on chest CT angiography or by the association an acute cor pulmonale on echocardiography-Doppler with deep vein thrombosis on venous ultrasound-Doppler of the lower limbs and having carried out a COVID-19 test (RT-PCR or rapid diagnostic test). Control cases consisted of all COVID-19 negative PE cases. Data comparison was carried out using the Epi info 7 software. A univariate then multivariate analysis allowed the comparison of the prognosis of the two subpopulations. The significance level retained was p < 0.05. RESULTS 96 patients with COVID-19+ and 70 COVID-19- PE were included. The prevalence of PE in patients hospitalized for COVID-19 was 7.05%. The average patient age was 61.5±17 years for COVID-19+ patients and 49.6±15.9 years for COVID-19- patients. Pulmonary condensation syndrome (p=0.007), desaturation (p=0.0003) and respiratory distress syndrome (p=0.006) were more common in COVID-19+ patients. The hospital death rate was 27.1% in COVID-19+ patients and 10% in COVID-19- patients (p=0.0024). Age > 65 years and COVID-19 pneumonia were the independent factors of death. CONCLUSION COVID-19 is associated with clinical severity and excess mortality in patients with pulmonary embolism.
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Affiliation(s)
- Y Kambiré
- Département de Médecine et Spécialités Médicales, CHU de Tengandogo, Ouagadougou, Burkina Faso; UFR/SDS, Université Joseph KI-ZERBO, Ouagadougou, Burkina Faso.
| | - G R C Millogo
- UFR/SDS, Université Joseph KI-ZERBO, Ouagadougou, Burkina Faso
| | - K J Kologo
- UFR/SDS, Université Joseph KI-ZERBO, Ouagadougou, Burkina Faso
| | - A Tall-Thiam
- UFR/SDS, Université Joseph KI-ZERBO, Ouagadougou, Burkina Faso
| | - V Agossou
- Département de Médecine et Spécialités Médicales, CHU de Tengandogo, Ouagadougou, Burkina Faso
| | - L Konaté
- Département de Médecine et Spécialités Médicales, CHU de Tengandogo, Ouagadougou, Burkina Faso
| | - H Somé
- Département de Médecine et Spécialités Médicales, CHU de Tengandogo, Ouagadougou, Burkina Faso
| | - I Diallo
- Département de Médecine et Spécialités Médicales, CHU de Tengandogo, Ouagadougou, Burkina Faso
| | - N V Yameogo
- UFR/SDS, Université Joseph KI-ZERBO, Ouagadougou, Burkina Faso
| | | | - P Zabsonré
- UFR/SDS, Université Joseph KI-ZERBO, Ouagadougou, Burkina Faso
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Bellouki O, Soufiani I, Boualaoui I, Ibrahimi A, El Sayegh H, Nouini Y. Renal cell carcinoma with massive cavo-atrial tumor thrombus leading to pulmonary embolism: Case study and literature review. Int J Surg Case Rep 2024; 117:109577. [PMID: 38537371 PMCID: PMC11010595 DOI: 10.1016/j.ijscr.2024.109577] [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: 03/06/2024] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION Renal cell carcinoma (RCC) occasionally involves the inferior vena cava (IVC), but intra-atrial extension is very rare, with the most dreaded complication being thrombi migration into pulmonary arteries. CASE PRESENTATION A 52-year-old male with rheumatoid arthritis and a smoking history presented with dyspnea, weight loss, and a previous episode of hematuria. Echocardiography revealed an intra-atrial thrombus with signs of pulmonary embolism (PE). Subsequent evaluation found a massive right renal tumor with an extensive thrombus extending into the right atrium, causing PE. Multidisciplinary management included surgery involving nephrectomy and thrombectomy via cavotomy and open-heart surgery along with pre- and postoperative anticoagulation. DISCUSSION Intra-caval tumor thrombus (TT) in RCC is infrequent, especially when extending into the right atrium. Accurate diagnosis involves imaging modalities, with echocardiography and MRI playing pivotal roles. Multidisciplinary and personalized management is mandatory to ensure a successful outcome. Surgery remains the primary treatment for RCC with TT but carries significant risks. CONCLUSION Managing RCC with cavo-atrial tumor thrombus is a complex situation that requires a collaborative approach. Accurate staging and tailored treatment are crucial. Surgical intervention remains pivotal in the absence of alternative effective modalities. Ongoing research into adjuvant therapies is crucial for optimal outcomes.
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Affiliation(s)
- Omar Bellouki
- Urology "A" Department, Ibn Sina University Hospital, Rabat, 10000, Morocco; Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, 10000, Morocco.
| | - Ilyas Soufiani
- Urology "A" Department, Ibn Sina University Hospital, Rabat, 10000, Morocco; Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, 10000, Morocco.
| | - Imad Boualaoui
- Urology "A" Department, Ibn Sina University Hospital, Rabat, 10000, Morocco; Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, 10000, Morocco.
| | - Ahmed Ibrahimi
- Urology "A" Department, Ibn Sina University Hospital, Rabat, 10000, Morocco; Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, 10000, Morocco.
| | - Hachem El Sayegh
- Urology "A" Department, Ibn Sina University Hospital, Rabat, 10000, Morocco; Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, 10000, Morocco.
| | - Yassine Nouini
- Urology "A" Department, Ibn Sina University Hospital, Rabat, 10000, Morocco; Faculty of Medicine and Pharmacy of Rabat, Mohammed V University, Rabat, 10000, Morocco.
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Aramberri M, González-Olmedo J, García-Villa A, Villanueva A, Maza CC, García-Gutiérrez S, Diaz-Pedroche C. Prediction of mortality in acute pulmonary embolism in cancer-associated thrombosis (MAUPE-C): derivation and validation of a multivariable model. J Thromb Thrombolysis 2024; 57:668-676. [PMID: 38485844 DOI: 10.1007/s11239-024-02960-9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2024] [Indexed: 04/19/2024]
Abstract
Optimal risk stratification of patients with cancer and pulmonary embolism (PE) remains unclear. We constructed a clinical prediction rule (CPR) named 'MAUPE-C' to identify patients with low 30 days mortality. The study retrospectively developed and internally validated a CPR for 30 days mortality in a cohort of patients with cancer and PE (both suspected and unsuspected). Candidate variables were chosen based on the EPIPHANY study, which categorized patients into 3 groups based on symptoms, signs, suspicion and patient setting at PE diagnosis. The performance of 'MAUPE-C' was compared to RIETE and sPESI scores. Univariate analysis confirmed that the presence of symptoms, signs, suspicion and inpatient diagnosis were associated with 30 days mortality. Multivariable logistic regression analysis led to the exclusion of symptoms as predictive variable. 'MAUPE-C' was developed by assigning weights to risk factors related to the β coefficient, yielding a score range of 0 to 4.5. After receiver operating characteristic (ROC) curve analysis, a cutoff point was established at ≤ 1. Prognostic accuracy was good with an area under the curve (AUC) of 0.77 (95% CI 0.71-0.82), outperforming RIETE and sPESI scores in this cohort (AUC of 0.64 [95% CI 0.57-0.71] and 0.57 [95% CI 0.49-0.65], respectively). Forty-five per cent of patients were classified as low risk and experienced a 2.79% 30 days mortality. MAUPE-C has good prognostic accuracy in identifying patients at low risk of 30 days mortality. This CPR could help physicians select patients for early discharge.
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Affiliation(s)
- Mario Aramberri
- Internal Medicine, Gipuzkoa Cancer Unit, OSID-Onkologikoa, Donostia-San Sebastian, Spain.
| | - Jesús González-Olmedo
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Adrián García-Villa
- Department of Internal Medicine, Hospital Virgen del Puerto, Plasencia, Spain
| | - Ane Villanueva
- Research Unit, Hospital de Galdakao-Usansolo, Galdakao, Spain
| | | | | | - Carmen Diaz-Pedroche
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Madrid, Spain
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Boberg E, Hedman A, Hollenberg J. Pulmonary embolism with paradoxical embolization to right coronary artery in the presence of a large patent foramen ovale: a case report. Eur Heart J Case Rep 2024; 8:ytae133. [PMID: 38617591 PMCID: PMC11014684 DOI: 10.1093/ehjcr/ytae133] [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: 02/06/2023] [Revised: 02/28/2024] [Accepted: 03/13/2024] [Indexed: 04/16/2024]
Abstract
Background Pulmonary embolism (PE) is the leading cause of in-hospital death and the third most frequent cause of cardiovascular death. The clinical presentation of PE is variable, and choosing the appropriate treatment for individual patients can be challenging. Case summary A 64-year-old man presented to hospital with acute chest pain, shortness of breath, and pulmonary oedema. Electrocardiogram revealed ST-elevation myocardial infarction. D-dimer was 18.8 mg/L fibrinogen equivalent units (FEU) (normal <0.64), and troponin was 25 (normal 5-14 ng/L). After systemic thrombolysis, respiratory failure persisted, and the arterial blood gas showed PaO2 of 6.0 kPa (normal 10.5-13.5 kPa), with 100% oxygen delivery via high-flow nasal cannula. A computed tomography diagnosed bilateral lobar PE, and coronary angiogram showed multiple thrombus in the right coronary artery. A bubble study with thoracic echocardiogram revealed a large right-left inter-atrial shunt. The patient denied treatment with extracorporeal membrane oxygenation and surgical thrombectomy. With no access to percutaneous catheter-directed thrombectomy, the patient received three separate thrombolysis treatments followed by a continued infusion for 22 h. After 6 weeks in hospital, the patient was discharged to rehab. Discussion For a long time, PE has been largely seen as a medical disease. Intra-cardiac shunts such as patent foramen ovale can complicate thrombo-venous disease and introduce paradoxical shunts leading to arterial emboli and persistent hypoxaemia. Over recent years, modern percutaneous catheter-directed thrombectomy has been developed for both high-risk and intermediate to high-risk PEs. Thrombectomy might improve right ventricular function and haemodynamics, but there is lacking evidence from randomized trials on efficacy, safety, and long-term outcome.
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Affiliation(s)
- Erik Boberg
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Entrevägen 2, 182 88 Stockholm, Sweden
| | - Anders Hedman
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Entrevägen 2, 182 88 Stockholm, Sweden
| | - Jacob Hollenberg
- Department of Clinical Science and Education, Södersjukhuset, Center for Resuscitation Science, Karolinska Institute, Entrevägen 2, 182 88 Stockholm, Sweden
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Karthik V, Anosike C, Zivlas C. A case report of a young woman with pulmonary emboli and a right coronary artery-to-coronary sinus fistula. Eur Heart J Case Rep 2024; 8:ytae130. [PMID: 38567271 PMCID: PMC10986395 DOI: 10.1093/ehjcr/ytae130] [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: 11/29/2023] [Revised: 02/25/2024] [Accepted: 03/12/2024] [Indexed: 04/04/2024]
Abstract
Background Coronary artery fistulae are rare cardiovascular anomalies that can present with atypical symptomatology and therefore pose diagnostic challenges, especially in young patients. Case summary A 34-year-old woman presented with left-sided pleuritic chest pain, haemoptysis, and flu-like symptoms. Initial evaluation revealed multiple left-sided pulmonary emboli, and her transthoracic echocardiography showed turbulent flow in a dilated coronary sinus. A right coronary artery (RCA) to coronary sinus fistula was confirmed by computed tomography coronary angiogram. The patient was treated with lifelong anticoagulation, and a subsequent stress cardiac magnetic resonance imaging did not show inducible myocardial ischaemia. As such, the patient was managed conservatively. Discussion Utilization of multi-modality imaging is of utmost importance for diagnostic and therapeutic purposes in coronary artery fistulae. In this case report, our patient presented with unprovoked pulmonary emboli, which could be caused by the turbulent flow and stasis, due to the RCA-to-coronary sinus fistula.
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Affiliation(s)
- V Karthik
- Warrington Hospital, Warrington and Halton Hospitals NHS Foundation Trust, Lovely Lane, Warrington WA5 1QG, UK
| | - Chinedum Anosike
- Warrington Hospital, Warrington and Halton Hospitals NHS Foundation Trust, Lovely Lane, Warrington WA5 1QG, UK
| | - Christos Zivlas
- Warrington Hospital, Warrington and Halton Hospitals NHS Foundation Trust, Lovely Lane, Warrington WA5 1QG, UK
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Li T, Hu K, Ye L, Ma J, Huang L, Guo C, Huang X, Jiang J, Xie X, Guo C, He Q. Association of Antipsychotic Drugs with Venous Thromboembolism: Data Mining of Food and Drug Administration Adverse Event Reporting System and Mendelian Randomization Analysis. J Atheroscler Thromb 2024; 31:396-418. [PMID: 38030236 PMCID: PMC10999720 DOI: 10.5551/jat.64461] [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: 07/04/2023] [Accepted: 09/25/2023] [Indexed: 12/01/2023] Open
Abstract
AIMS Past observational studies have reported on the association between antipsychotic drugs and venous thromboembolism (VTE); however, the conclusions remain controversial, and its mechanisms are yet to be fully understood. Thus, in this study, we aim to determine the associations of antipsychotic drugs with VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE), and their potential mechanisms. METHODS We first mined the adverse event signals of VTE, DVT, and PE caused by antipsychotic drugs in Food and Drug Administration Adverse Event Reporting System (FAERS). Next, we used two-sample Mendelian randomization (MR) method to investigate the association of antipsychotic drug target gene expression with VTE, DVT, and PE, using single-nucleotide polymorphisms as genetic instruments. We not only used the expression of all antipsychotic drug target genes as exposure to perform MR analyses but also analyzed the effect of single target gene expression on the outcomes. RESULTS In the FAERS, 1694 cases of VTE events were reported by 16 drugs. However, using the MR approach, no significant association was determined between the expression of all antipsychotic target genes and VTE, DVT, or PE, either in blood or brain tissue. Although the analysis of single gene expression data showed that the expression of nine genes was associated with VTE events, these targets lacked significant pharmacological action. CONCLUSIONS Adverse event mining results have supported the claim that antipsychotic drugs can increase the risk of VTE. However, we failed to find any genetic evidence for this causal association and potential mechanisms. Thus, vigilance is still needed for antipsychotic drug-related VTE despite the limited supporting evidence.
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Affiliation(s)
- Tong Li
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Hunan, P.R. China
| | - Kai Hu
- Department of Neurology, Xiangya Hospital, Central South University, Hunan, P.R. China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Hunan, P.R. China
- Clinical Research Center for Epileptic disease of Hunan Province, Central South University, Hunan, P.R. China
| | - Ling Ye
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Hunan, P.R. China
| | - Junlong Ma
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Hunan, P.R. China
| | - Longjian Huang
- Youjiang Medical University for Nationalities, Guangxi, P.R. China
| | - Chengjun Guo
- School of Applied Mathematics, Guangdong University of Technology, Guangdong, P.R. China
| | - Xin Huang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Hunan, P.R. China
| | - Jie Jiang
- Department of Pediatrics, The Affiliated Changsha Central Hospital, University of South China Hengyang Medical School,University of South China, Hunan, P.R. China
| | - Xiaoxue Xie
- Department of Radiotherapy, Hunan Provincial Tumor Hospital and Affiliated Tumor Hospital of Xiangya Medical School, Central South University, Hunan, P.R. China
| | - Chengxian Guo
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Hunan, P.R. China
| | - Qingnan He
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Hunan, P.R. China
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Goyal SK, Wang JJ, McCandlish JA, Cronin PP, Barish M, Sanelli PC, Cohen SL. Ten-Year Trend in Advanced Imaging Utilization for Suspected Pulmonary Embolism in Pregnancy. J Am Coll Radiol 2024; 21:549-557. [PMID: 37775066 DOI: 10.1016/j.jacr.2023.08.045] [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: 02/17/2023] [Revised: 08/18/2023] [Accepted: 08/25/2023] [Indexed: 10/01/2023]
Abstract
PURPOSE Advanced imaging is essential to diagnose pulmonary embolism (PE) in pregnancy, but there are associated maternal and fetal radiation risks. The purpose of this study was to evaluate the 10-year trend in advanced imaging utilization for the evaluation of suspected PE in pregnancy. METHODS The authors evaluated pregnant women with advanced imaging using CT pulmonary angiography (CTPA) or lung scintigraphy (LS) for evaluation of suspected PE presenting to two tertiary hospitals from 2007 to 2016. The rate of imaging was evaluated relative to positive PE rate and local pregnancy rate. positive PE was defined as a new acute PE finding on any advanced imaging within 3 days of first advanced imaging test. Local pregnancy rates were defined per 1,000 pregnancies in the county serviced by both hospitals. Chi-square testing was used to evaluate statistical significance (P < .05) in the utilization trend of advanced imaging and relative to local pregnancy rates and evaluations positive for PE. RESULTS A total of 707 pregnant patients were identified, of whom 92.5% (n = 654) underwent CTPA and 7.5% (n = 53) underwent LS. Regression analysis showed an average increase of 5.2 advanced imaging studies per year (P < .001), with 61 and 105 studies performed in 2007 and 2016, respectively. Additionally, there was an average increase of 0.08 (P < .001) advanced imaging studies per 1,000 local pregnancies per year, doubling from 0.7 in 2007 to 1.4 in 2016 (P < .001). Finally, there was a decrease of 0.004 (P = .009) in advanced imaging positive for PE, from 3% (2 of 61) in 2007 to 0% (0 of 100) in 2016. CONCLUSIONS Advanced imaging utilization increased by 72% over the 10-year window, driven by higher use of CTPA. Although the detection rate of PE on advanced imaging has decreased, the utilization rate among pregnant patients doubled during this period. These results highlight the need to consider the radiation risks and costs of advanced imaging in specific patient populations.
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Affiliation(s)
- Sameer K Goyal
- Department of Radiology, Northwell Health, Manhasset, New York
| | - Jason J Wang
- The Feinstein Institutes for Medical Research, Manhasset, New York
| | | | - Paul P Cronin
- Department of Radiology and Imaging Science, Emory University Hospital, Atlanta, Georgia
| | - Matthew Barish
- Department of Radiology, Northwell Health, Manhasset, New York
| | - Pina C Sanelli
- Vice Chairman of Research and Executive Director, Imaging Clinical Effectiveness and Outcomes Research, Manhasset, New York
| | - Stuart L Cohen
- Department of Radiology, Imaging Clinical Effectiveness and Outcomes Research, Manhasset, New York.
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Andò G, Pelliccia F, Saia F, Tarantini G, Fraccaro C, D'Ascenzo F, Zimarino M, Di Marino M, Niccoli G, Porto I, Calabrò P, Gragnano F, De Rosa S, Piccolo R, Moscarella E, Fabris E, Montone RA, Spaccarotella C, Indolfi C, Sinagra G, Perrone Filardi P. Management of high and intermediate-high risk pulmonary embolism: A position paper of the Interventional Cardiology Working Group of the Italian Society of Cardiology. Int J Cardiol 2024; 400:131694. [PMID: 38160911 DOI: 10.1016/j.ijcard.2023.131694] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024]
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition that remains a major global health concern. Noteworthy, patients with high- and intermediate-high-risk PE pose unique challenges because they often display clinical and hemodynamic instability, thus requiring rapid intervention to mitigate the risk of clinical deterioration and death. Importantly, recovery from PE is associated with long-term complications such as recurrences, bleeding with oral anticoagulant treatment, pulmonary hypertension, and psychological distress. Several novel strategies to improve risk factor characterization and management of patients with PE have recently been introduced. Accordingly, this position paper of the Working Group of Interventional Cardiology of the Italian Society of Cardiology deals with the landscape of high- and intermediate-high risk PE, with a focus on bridging the gap between the evolving standards of care and the current clinical practice. Specifically, the growing importance of catheter-directed therapies as part of the therapeutic armamentarium is highlighted. These interventions have been shown to be effective strategies in unstable patients since they offer, as compared with thrombolysis, faster and more effective restoration of hemodynamic stability with a consistent reduction in the risk of bleeding. Evolving standards of care underscore the need for continuous re-assessment of patient risk stratification. To this end, a multidisciplinary approach is paramount in refining selection criteria to deliver the most effective treatment to patients with unstable hemodynamics. In conclusion, the current management of unstable patients with PE should prioritize tailored treatment in a patient-oriented approach in which transcatheter therapies play a central role.
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Affiliation(s)
- Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, AOU Policlinico "Gaetano Martino", Messina, Italy
| | - Francesco Pelliccia
- Department of Cardiovascular Sciences, "La Sapienza" University, Rome, Italy.
| | - Francesco Saia
- Department of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S Orsola-Malpighi, Bologna, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Chiara Fraccaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Turin, Italy
| | - Marco Zimarino
- Department of Neuroscience, Imaging and Clinical Sciences, "Gabriele D'Annunzio" University of Chieti-Pescara, Chieti, Italy; Department of Cardiology, "SS. Annunziata Hospital", ASL 2 Abruzzo, Chieti, Italy
| | - Mario Di Marino
- Department of Neuroscience, Imaging and Clinical Sciences, "Gabriele D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Giampaolo Niccoli
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Italo Porto
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties, University of Genoa, Genoa, Italy; Cardiology Unit, Cardiothoracic and Vascular Department (DICATOV) IRCCS, Ospedale Policlinico San Martino, Genoa, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Italy; Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Italy; Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Italy; Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Enrico Fabris
- Cardio-thoraco-vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Rocco Antonio Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Carmen Spaccarotella
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Gianfranco Sinagra
- Cardio-thoraco-vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
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Nouhravesh N, Strange JE, Sindet-Pedersen C, Holt A, Tønnesen J, Andersen CF, Nielsen SK, Grove EL, Nielsen D, Schou M, Lamberts M. Impact of breast-, gastrointestinal-, and lung cancer on prognosis in patients with first-time pulmonary embolism: A Danish nationwide cohort study. Int J Cardiol 2024:132001. [PMID: 38561107 DOI: 10.1016/j.ijcard.2024.132001] [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: 10/31/2023] [Revised: 02/28/2024] [Accepted: 03/29/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Pulmonary embolism (PE) is described as a prognostic factor in patients with cancer however, the prognostic impact of PE remains unknown. This study investigated, the 1-year prognosis following PE in patients with breast-, gastrointestinal-, or lung cancer stratified by cancer status. METHODS All Danish patients with first-time PE from 2008 to 2018 were included. Cancer status was categorized as no cancer, history of cancer, non-active cancer and active cancer. Unadjusted and age-stratified 1-year risk of death was estimated using the Kaplan-Meier estimator. Cause of death was reported using the Aalen-Johansen method. RESULTS Of 35,679 patients with PE, 18% had a breast-, gastrointestinal-, or lung cancer. Patients with cancer were older compared with no cancer (69.8 years [IQR: 56.2-79.8]). One-year risk of death (95% confidence interval) for active breast-, gastrointestinal-, and lung cancer was 49.5% (44.0%-54.9%), 75.0% (72.5%-77.4%) and 80.1% (78.0%-82.3%) respectively, compared with 18.9% (18.4%-19.3%) for no cancer. Age-stratified analysis revealed no association with increasing age in non-active lung cancer and all active cancers. Further, non-cardiovascular death accounted for an increasing proportion by cancer status (no cancer < history of cancer < non-active cancer < active cancer). CONCLUSIONS One-year risk of death was dependent on both cancer type and status; no association with age was found for patients with active cancers. Non-cardiovascular death was leading in non-active and active cancers. Thus, the occurrence of first-time PE could be regarded as a marker of cancer severity for patients with breast-, gastrointestinal-, and lung cancer.
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Affiliation(s)
- Nina Nouhravesh
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark.
| | - Jarl E Strange
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark; Department of Cardiology, Rigshospitalet, University of Copenhagen, Denmark
| | | | - Anders Holt
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark; Department of Epidemiology and Biostatistics, School of Population Health, University of Auckland, 85 Park Road, Grafton, Auckland 1142, New Zealand
| | - Jacob Tønnesen
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark
| | | | - Sebastian K Nielsen
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Dorte Nielsen
- Department of Oncology, Herlev-Gentofte University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health, Copenhagen University, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health, Copenhagen University, Copenhagen, Denmark
| | - Morten Lamberts
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark
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Yang M, Wan X, Su Y, Xu K, Wen P, Zhang B, Liu L, Yang Z, Xu P. The genetic causal relationship between type 2 diabetes, glycemic traits and venous thromboembolism, deep vein thrombosis, pulmonary embolism: a two-sample Mendelian randomization study. Thromb J 2024; 22:33. [PMID: 38553747 PMCID: PMC10979561 DOI: 10.1186/s12959-024-00600-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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 03/20/2024] [Indexed: 04/02/2024] Open
Abstract
OBJECTIVE To investigate the genetic underpinnings of the association between type 2 diabetes (T2D), glycemic indicators such as fasting glucose (FG), fasting insulin (FI), and glycated hemoglobin (GH), and venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), thereby contributing novel insights to the scholarly discourse within this domain. METHODS Genome-wide association study (GWAS) summary data pertaining to exposures (T2D, FG, FI, GH) and outcomes (VTE, DVT, PE) were acquired from the IEU Open GWAS database, encompassing participants of European descent, including both male and female individuals. Two-sample Mendelian randomization (MR) analyses were conducted utilizing the TwoSampleMR and MRPRESSO packages within the R programming environment. The primary analytical approach employed was the random-effects inverse variance weighted (IVW) method. Heterogeneity was assessed via Cochran's Q statistic for MR-IVW and Rucker's Q statistic for MR-Egger. Horizontal pleiotropy was evaluated using the intercept test of MR Egger and MR pleiotropy residual sum and outlier (MR-PRESSO) analysis, with the latter also employed for outlier detection. Additionally, a "Leave one out" analysis was conducted to ascertain the influence of individual single nucleotide polymorphisms (SNPs) on MR results. RESULTS The random-effects IVW analysis revealed a negative genetic causal association between T2D) and VTE (P = 0.008, Odds Ratio [OR] 95% confidence interval [CI] = 0.896 [0.827-0.972]), as well as between FG and VTE (P = 0.002, OR 95% CI = 0.655 [0.503-0.853]), GH and VTE (P = 0.010, OR 95% CI = 0.604 [0.412-0.884]), and GH and DVT (P = 0.002, OR 95% CI = 0.413 [0.235-0.725]). Conversely, the random-effects IVW analysis did not detect a genetic causal relationship between FI and VTE (P > 0.05), nor between T2D, FG, or FI and DVT (P > 0.05), or between T2D, FG, FI, or GH and PE (P > 0.05). Both the Cochran's Q statistic for MR-IVW and Rucker's Q statistic for MR-Egger indicated no significant heterogeneity (P > 0.05). Moreover, the intercept tests of MR Egger and MR-PRESSO suggested the absence of horizontal pleiotropy (P > 0.05). MR-PRESSO analysis identified no outliers, while the "Leave one out" analysis underscored that the MR analysis was not influenced by any single SNP. CONCLUSION Our investigation revealed that T2D, FG, and GH exhibit negative genetic causal relationships with VTE at the genetic level, while GH demonstrates a negative genetic causal relationship with DVT at the genetic level. These findings furnish genetic-level evidence warranting further examination of VTE, DVT, and PE, thereby making a contribution to the advancement of related research domains.
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Affiliation(s)
- Mingyi Yang
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Xianjie Wan
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Yani Su
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Ke Xu
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Pengfei Wen
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Binfei Zhang
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Lin Liu
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Zhi Yang
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Peng Xu
- Department of Joint Surgery, HongHui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China.
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Barbarossa A, Finori L, Berretta P, Dello Russo A, Di Eusanio M. An idiopathic floating ascending aorta thrombus in a triple rule-in CT. Eur Heart J Cardiovasc Imaging 2024:jeae087. [PMID: 38529941 DOI: 10.1093/ehjci/jeae087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 03/24/2024] [Indexed: 03/27/2024] Open
Affiliation(s)
- Alessandro Barbarossa
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Marche Polytechnic University, 60126 Ancona, Italy
| | - Luca Finori
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Marche Polytechnic University, 60126 Ancona, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Marche Polytechnic University, 60126 Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Marche Polytechnic University, 60126 Ancona, Italy
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Marche Polytechnic University, 60126 Ancona, Italy
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Gotta J, Gruenewald LD, Martin SS, Booz C, Mahmoudi S, Eichler K, Gruber-Rouh T, Biciusca T, Reschke P, Juergens LJ, Onay M, Herrmann E, Scholtz JE, Sommer CM, Vogl TJ, Koch V. From pixels to prognosis: Imaging biomarkers for discrimination and outcome prediction of pulmonary embolism : Original Research Article. Emerg Radiol 2024:10.1007/s10140-024-02216-2. [PMID: 38523224 DOI: 10.1007/s10140-024-02216-2] [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: 12/13/2023] [Accepted: 03/11/2024] [Indexed: 03/26/2024]
Abstract
PURPOSE Recent advancements in medical imaging have transformed diagnostic assessments, offering exciting possibilities for extracting biomarker-based information. This study aims to investigate the capabilities of a machine learning classifier that incorporates dual-energy computed tomography (DECT) radiomics. The primary focus is on discerning and predicting outcomes related to pulmonary embolism (PE). METHODS The study included 131 participants who underwent pulmonary artery DECT angiography between January 2015 and March 2022. Among them, 104 patients received the final diagnosis of PE and 27 patients served as a control group. A total of 107 radiomic features were extracted for every case based on DECT imaging. The dataset was divided into training and test sets for model development and validation. Stepwise feature reduction identified the most relevant features, which were used to train a gradient-boosted tree model. Receiver operating characteristics analysis and Cox regression tests assessed the association of texture features with overall survival. RESULTS The trained machine learning classifier achieved a classification accuracy of 0.94 for identifying patients with acute PE with an area under the receiver operating characteristic curve of 0.91. Radiomics features could be valuable for predicting outcomes in patients with PE, demonstrating strong prognostic capabilities in survival prediction (c-index, 0.991 [0.979-1.00], p = 0.0001) with a median follow-up of 130 days (IQR, 38-720). Notably, the inclusion of clinical or DECT parameters did not enhance predictive performance. CONCLUSION In conclusion, our study underscores the promising potential of leveraging radiomics on DECT imaging for the identification of patients with acute PE and predicting their outcomes. This approach has the potential to improve clinical decision-making and patient management, offering efficiencies in time and resources by utilizing existing DECT imaging without the need for an additional scoring system.
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Affiliation(s)
- Jennifer Gotta
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany.
- University Hospital Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany.
| | | | - Simon S Martin
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian Booz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Katrin Eichler
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Teodora Biciusca
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Philipp Reschke
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Melis Onay
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Eva Herrmann
- Institut for Biostatistics and Mathematic Modelling, Goethe University Frankfurt, Frankfurt, 60590, Germany
| | - Jan-Erik Scholtz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christof M Sommer
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas J Vogl
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Vitali Koch
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
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Spampinato MD, Portoraro A, Sofia SM, Luppi F, Benedetto M, D'Angelo L, Galizia G, Fabbri IS, Pagano T, Perna B, Guarino M, Passarini G, Pavasini R, Passaro A, De Giorgio R. The role of echocardiography in pulmonary embolism for the prediction of in-hospital mortality: a retrospective study. J Ultrasound 2024:10.1007/s40477-024-00874-z. [PMID: 38519765 DOI: 10.1007/s40477-024-00874-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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/11/2024] [Indexed: 03/25/2024] Open
Abstract
PURPOSE Pulmonary Embolism (PE) is the third leading cause of cardiovascular death, following myocardial infarction and stroke. The latest European Society of Cardiology (ESC) guidelines on PE recommend short-term prognostic stratification based on right ventricular (RV) overload detected by transthoracic echocardiography (TTE) or contrast-enhanced chest CT. The aim of the study is to find out which of the signs of right ventricular dysfunction best predicts in-hospital mortality (IHM). METHODS This is a monocentric, retrospective study including adult patients admitted from the emergency department with a c-e cCT confirmed diagnosis of PE between January 2018 and December 2022 who underwent a TTE within 48 h. RESULTS 509 patients (median age 76 years [IQR 67-84]) were included, with 7.1% IHM. At univariate analysis, RV/LV ratio > 1 (OR 2.23, 95% CI 1.1-4.5), TAPSE < 17 mm (OR 4.73, 95% CI 2.3-9.8), the D-shape (OR 3.73, 95% CI 1.71-8.14), and LVEF < 35% (OR 5.78, 95% CI 1.72-19.47) resulted significantly correlated with IHM. However, at multivariate analysis including also haemodynamic instability, PESI class > II, and abnormal hs-cTnI levels, only LVEF < 35% (OR 5.46, 95% CI 1.32-22.61) resulted an independent predictor of IHM. CONCLUSION Despite the recognised role of TTE in the early management of patients with circulatory shock and suspected PE, signs of RV dysfunction have been shown to be poor predictors of IHM, whereas severely reduced LVEF is an independent risk factor for in-hospital death.
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Affiliation(s)
- Michele Domenico Spampinato
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
- Emergency Medicine Unit, St.Anna University Hospital, Ferrara, Italy
| | - Andrea Portoraro
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Soccorsa M Sofia
- Emergency Medicine Unit, Emergency department, Maggiore Hospital Bologna, Azienda Unità Sanitaria Locale Bologna, Bologna, Italy.
| | - Francesco Luppi
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Marcello Benedetto
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Luca D'Angelo
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Giorgio Galizia
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Irma Sofia Fabbri
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Teresa Pagano
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Benedetta Perna
- School of Emergency Medicine, Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Matteo Guarino
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
- Emergency Medicine Unit, St.Anna University Hospital, Ferrara, Italy
| | - Giulia Passarini
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Ferrara, Italy
| | - Rita Pavasini
- Cardiology Unit, Azienda Ospedaliero Universitaria Di Ferrara, Ferrara, Italy
| | - Angelina Passaro
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Roberto De Giorgio
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
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Liu Y, Yang Z, Sun X, Yang M, Zhang T, Li R, Wei Y, Cao H. Successful surgical treatment of impending paradoxical embolism with pulmonary embolism and myocardial infarction. J Cardiothorac Surg 2024; 19:137. [PMID: 38504353 PMCID: PMC10949575 DOI: 10.1186/s13019-024-02606-0] [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: 08/26/2023] [Accepted: 03/05/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Paradoxical embolism is a rare cause of acute arterial occlusion. This phenomenon arises when embolic material travels from the venous system crosses an abnormal shunt such as patent foramen ovale, atrial septal defects, ventricular septal defects, or pulmonary arteriovenous malformations, into the arterial system. Impending paradoxical embolism refers to the presence of an entrapped thrombus in the patent foramen ovale. CASE PRESENTATION We report a case of a 68-year-old female patient who presented with an impending paradoxical embolism, alongside both concomitant pulmonary embolism and myocardial infarction with ST-segment elevation. Swiftly addressed through emergency cardiac surgery and systemic anticoagulation, the patient's condition was effectively treated. CONCLUSIONS While the ideal treatment strategy for impending paradoxical embolism remains a topic of debate due to limited and inconclusive evidence, emergent open surgery should be contemplated in patients as it signifies a critical clinical emergency.
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Affiliation(s)
- Yong Liu
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Zhiyun Yang
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Xinxin Sun
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Mei Yang
- Department of ICU, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Tao Zhang
- Department of ICU, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Ruilin Li
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Ying Wei
- Department of Ultrasound in Medicine, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China
| | - Hao Cao
- Department of Cardiovascular Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China.
- Shanghai Heart Failure Institute, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, China.
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Zhang C, Zhao D, Liu F, Yang J, Ban J, Du P, Lu K, Ma R, Liu Y, Sun Q, Chen S, Li T. Dust particulate matter increases pulmonary embolism onset: A nationwide time-stratified case-crossover study in China. Environ Int 2024; 186:108586. [PMID: 38521047 DOI: 10.1016/j.envint.2024.108586] [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] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/06/2024] [Accepted: 03/17/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Particulate matter (PM) has been found to elevate the risk of pulmonary embolism (PE) onset. Among the contributors to PM, dust PM stands as the second natural source, and its emissions are escalating due to climate change. Despite this, information on the effect of dust PM on PE onset is scarce. Hence, this study aims to investigate the impacts of dust PM10, dust PM2.5-10, and dust PM2.5 on PE onset. METHODS A nationwide time-stratified case-crossover study was conducted between 2015 and 2020, using data from 18,616 PE onset cases across 1,921 hospitals in China. The analysis employed a conditional logistic regression model to quantify the associations between dust PM10, dust PM2.5-10, and dust PM2.5 and PE onset. Furthermore, the study explored the time-distributed lag pattern of the effect of dust PM on PE development. Stratified analyses were performed based on sex, age, region, and season. RESULTS Dust PM10, dust PM2.5-10, and dust PM2.5 exhibited significant health effects on PE onset, particularly concerning exposure on the same day. The peak estimates were observed at lag 01 day, with the odds ratio being 1.011 [95 % confidence interval (CI): 1.003, 1.019], 1.014 (95 % CI: 1.003, 1.026), and 1.039 (95 % CI: 1.011, 1.068), for a 10 μg/m3 increase in the concentration of dust PM10, dust PM2.5-10, and dust PM2.5, respectively. In addition, the study identified a higher risk of PE onset associated with dust PM exposure during the warm season than that in cool season, particularly for dust PM2.5. CONCLUSIONS The findings from this study suggest that short-term exposure to dust PM, particularly dust PM2.5, may trigger PE onset, posing a significant health threat. Implementing measures to mitigate dust PM emissions and protect patients with PE from dust PM exposure is imperative.
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Affiliation(s)
- Can Zhang
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China; National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China
| | - Dan Zhao
- Key Laboratory for Semi-Arid Climate Change of the Ministry of Education, Lanzhou University, Lanzhou 730000, China
| | - Feng Liu
- Department of Cardiology, Suzhou Kowloon Hospital, Shanghai Jiao Tong University School of Medicine, Suzhou 215127, China
| | - Jing Yang
- Department of Cardiology, Shanghai Xuhui Central Hospital, Zhongshan-Xuhui hospital, Fudan University, Shanghai 200031, China
| | - Jie Ban
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China; National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China
| | - Peng Du
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China; National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China
| | - Kailai Lu
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China; National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China
| | - Runmei Ma
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China; National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China
| | - Yuanyuan Liu
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China; National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China
| | - Qinghua Sun
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China; National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China
| | - Siyu Chen
- National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China
| | - Tiantian Li
- China CDC Key Laboratory of Environment and Population Health, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China; National Key Laboratory of Intelligent Tracking and Forecasting for Infectious Diseases, National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing 100021, China.
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Liu ES, Wu YT, Liang WM, Kuo FY. Association of scrub typhus with the risk of venous thromboembolism and long-term mortality: a population-based cohort study. Eur J Clin Microbiol Infect Dis 2024:10.1007/s10096-024-04793-z. [PMID: 38472518 DOI: 10.1007/s10096-024-04793-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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 02/26/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND The existing literature lacks studies examining the epidemiological link between scrub typhus and deep vein thrombosis (DVT) or pulmonary embolism (PE), and the long-term outcomes. The objective of this study is to explore the potential association between scrub typhus and the subsequent risk of venous thromboembolism, and long-term mortality. METHOD This nationwide cohort study identified 10,121 patients who were newly diagnosed with scrub typhus. Patients with a prior DVT or PE diagnosis before the scrub typhus infection were excluded. A comparison cohort of 101,210 patients was established from the general population using a propensity score matching technique. The cumulative survival HRs for the two cohorts were calculated by the Cox proportional hazards model. RESULT After adjusting for sex, age, and comorbidities, the scrub typhus group had an adjusted HR (95% CI) of 1.02 (0.80-1.30) for DVT, 1.11 (0.63-1.93) for PE, and 1.16 (1.08-1.25) for mortality compared to the control group. The post hoc subgroup analysis revealed that individuals younger than 55 years with a prior scrub typhus infection had a significantly higher risk of DVT (HR: 1.59; 95% CI: 1.12-2.25) and long-term mortality (HR: 1.75; 95% CI, 1.54-1.99). CONCLUSION The scrub typhus patients showed a 16% higher risk of long-term mortality. For those in scrub typhus cohort below 55 years of age, the risk of developing DVT was 1.59 times higher, and the risk of mortality was 1.75 times higher. Age acted as an effect modifier influencing the relationship between scrub typhus and risk of new-onset DVT and death.
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Affiliation(s)
- En-Shao Liu
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist, Kaohsiung City, 813, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Ting Wu
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist, Kaohsiung City, 813, Taiwan
| | - Wen-Miin Liang
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - Feng-Yu Kuo
- Cardiovascular Medical Center, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist, Kaohsiung City, 813, Taiwan.
- Department of Pharmacy and Master Program, College of Pharmacy and Health Care, Tajen University, Pingtung, Taiwan.
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Liley J, Newnham M, Bleda M, Bunclark K, Auger W, Barbera JA, Bogaard H, Delcroix M, Fernandes TM, Howard L, Jenkins D, Lang I, Mayer E, Rhodes C, Simpson M, Southgate L, Trembath R, Wharton J, Wilkins MR, Gräf S, Morrell N, Pepke Zaba J, Toshner M. Shared and Distinct Genomics of Chronic Thromboembolic Pulmonary Hypertension and Pulmonary Embolism. Am J Respir Crit Care Med 2024. [PMID: 38470220 DOI: 10.1164/rccm.202307-1236oc] [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: 07/20/2023] [Accepted: 03/11/2024] [Indexed: 03/13/2024] Open
Abstract
RATIONALE Chronic Thromboembolic Pulmonary Hypertension involves formation and non-resolution of thrombus, dysregulated inflammation, angiogenesis and the development of a small vessel vasculopathy. OBJECTIVES We aimed to establish the genetic basis of chronic thromboembolic pulmonary hypertension to gain insight into its pathophysiological contributors. METHODS We conducted a genome-wide association study on 1907 European cases and 10363 European controls. We co-analysed our results with existing results from genome-wide association studies on deep vein thrombosis, pulmonary embolism and idiopathic pulmonary arterial hypertension. MEASUREMENTS AND MAIN RESULTS Our primary association study revealed genetic associations at the ABO, FGG, F11, MYH7B, and HLA-DRA loci. Through our co-analysis we demonstrate further associations with chronic thromboembolic pulmonary hypertension at the F2, TSPAN15, SLC44A2 and F5 loci but find no statistically significant associations shared with idiopathic pulmonary arterial hypertension. CONCLUSIONS Chronic thromboembolic pulmonary hypertension is a partially heritable polygenic disease, with related though distinct genetic associations to pulmonary embolism and to deep vein thrombosis.
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Affiliation(s)
- James Liley
- Durham University, 3057, Mathematical Sciences, Durham, United Kingdom of Great Britain and Northern Ireland
| | - Michael Newnham
- University of Birmingham, 1724, Birmingham, United Kingdom of Great Britain and Northern Ireland
| | - Marta Bleda
- University of Cambridge, 2152, Cambridge, United Kingdom of Great Britain and Northern Ireland
| | - Katherine Bunclark
- Papworth Hospital NHS Foundation Trust, 2144, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland
| | | | | | - Harm Bogaard
- Vrije Universiteit Amsterdam, 1190, Pulmonary Medicine, Amsterdam, Noord-Holland, Netherlands
| | | | - Timothy M Fernandes
- University of California, San Diego, Division of Pulmonary and Critical Care Medicine, La Jolla, California, United States
| | - Luke Howard
- Imperial College, National Heart & Lung Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - David Jenkins
- Papworth Hospital NHS Foundation Trust, 2144, Cardiac Surgery, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland
| | - Irene Lang
- Medical University of Vienna, Cardiology, Vienna, Austria
| | - Eckhard Mayer
- Kerckhoff-Klinik , Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Chris Rhodes
- Imperial College London, National Heart & Lung Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - Michael Simpson
- King's College London, 4616, London, United Kingdom of Great Britain and Northern Ireland
| | - Laura Southgate
- University of London St George's, 4915, Molecular and Clinical Sciences Research Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - Richard Trembath
- King's College London, London, United Kingdom of Great Britain and Northern Ireland
| | - John Wharton
- Imperial College London, Experimental Medicine & Toxicology, London, United Kingdom of Great Britain and Northern Ireland
| | - Martin R Wilkins
- Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Stefan Gräf
- University of Cambridge, 2152, Department of Medicine, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland
| | - Nicholas Morrell
- University of Cambridge, Cambridge, United Kingdom of Great Britain and Northern Ireland
| | - Joanna Pepke Zaba
- Papworth Hospital NHS Foundation Trust, 2144, Pulmonary Vascular Disease Unit, Cambridge, Cambridgeshire, United Kingdom of Great Britain and Northern Ireland
| | - Mark Toshner
- Papworth Hospital NHS Foundation Trust, Pulmonary Vascular Diseases Unit, Cambridge, United Kingdom of Great Britain and Northern Ireland;
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47
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Alotaibi M, Yang JZ, Papamatheakis DG, McGuire WC, Fernandes TM, Morris TA. Cardiopulmonary exercise test to detect cardiac dysfunction from pulmonary vascular disease. Respir Res 2024; 25:121. [PMID: 38468264 PMCID: PMC10926602 DOI: 10.1186/s12931-024-02746-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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/22/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Cardiac dysfunction from pulmonary vascular disease causes characteristic findings on cardiopulmonary exercise testing (CPET). We tested the accuracy of CPET for detecting inadequate stroke volume (SV) augmentation during exercise, a pivotal manifestation of cardiac limitation in patients with pulmonary vascular disease. METHODS We reviewed patients with suspected pulmonary vascular disease in whom CPET and right heart catheterization (RHC) measurements were taken at rest and at anaerobic threshold (AT). We correlated CPET-determined O2·pulseAT/O2·pulserest with RHC-determined SVAT/SVrest. We evaluated the sensitivity and specificity of O2·pulseAT/O2·pulserest to detect SVAT/SVrest below the lower limit of normal (LLN). For comparison, we performed similar analyses comparing echocardiographically-measured peak tricuspid regurgitant velocity (TRVpeak) with SVAT/SVrest. RESULTS From July 2018 through February 2023, 83 simultaneous RHC and CPET were performed. Thirty-six studies measured O2·pulse and SV at rest and at AT. O2·pulseAT/O2·pulserest correlated highly with SVAT/SVrest (r = 0.72, 95% CI 0.52, 0.85; p < 0.0001), whereas TRVpeak did not (r = -0.09, 95% CI -0.47, 0.33; p = 0.69). The AUROC to detect SVAT/SVrest below the LLN was significantly higher for O2·pulseAT/O2·pulserest (0.92, SE 0.04; p = 0.0002) than for TRVpeak (0.69, SE 0.10; p = 0.12). O2·pulseAT/O2·pulserest of less than 2.6 was 92.6% sensitive (95% CI 76.6%, 98.7%) and 66.7% specific (95% CI 35.2%, 87.9%) for deficient SVAT/SVrest. CONCLUSIONS CPET detected deficient SV augmentation more accurately than echocardiography. CPET-determined O2·pulseAT/O2·pulserest may have a prominent role for noninvasive screening of patients at risk for pulmonary vascular disease, such as patients with persistent dyspnea after pulmonary embolism.
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Affiliation(s)
- Mona Alotaibi
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA
| | - Jenny Z Yang
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA
| | - Demosthenes G Papamatheakis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA
| | - W Cameron McGuire
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA
| | - Timothy M Fernandes
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA
| | - Timothy A Morris
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA.
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Arrigo M, Price S, Harjola VP, Huber LC, Schaubroeck HAI, Vieillard-Baron A, Mebazaa A, Masip J. Diagnosis and treatment of right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale): a clinical consensus statement of the Association for Acute CardioVascular Care of the European Society of Cardiology. Eur Heart J Acute Cardiovasc Care 2024; 13:304-312. [PMID: 38135288 PMCID: PMC10927027 DOI: 10.1093/ehjacc/zuad157] [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] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 12/24/2023]
Abstract
Acute right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale) is a life-threatening condition that may arise in different clinical settings. Patients at risk of developing or with manifest acute cor pulmonale usually present with an acute pulmonary disease (e.g. pulmonary embolism, pneumonia, and acute respiratory distress syndrome) and are managed initially in emergency departments and later in intensive care units. According to the clinical setting, other specialties are involved (cardiology, pneumology, internal medicine). As such, coordinated delivery of care is particularly challenging but, as shown during the COVID-19 pandemic, has a major impact on prognosis. A common framework for the management of acute cor pulmonale with inclusion of the perspectives of all involved disciplines is urgently needed.
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Affiliation(s)
- Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Birmensdorferstrasse 497, 8063 Zürich, Switzerland
| | - Susanna Price
- Royal Brompton Hospital, National Heart & Lung Institute, Imperial College London, London, UK
| | - Veli-Pekka Harjola
- Department of Emergency Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Lars C Huber
- Department of Internal Medicine, Stadtspital Zurich, Birmensdorferstrasse 497, 8063 Zürich, Switzerland
| | | | | | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care Medicine, AP-HP, Hôpitaux Universitaires Saint-Louis-Lariboisière, FHU PROMICE, INI-CRCT, and Université de Paris, MASCOT, Inserm, Paris, France
| | - Josep Masip
- Research Direction, Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain
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Fumagalli S, Di Pasquale G, Pupo S, Agnelli G, Marchionni N. Patient-reported outcomes and apixaban therapy in older patients. The results of the APULEIO study. Eur J Intern Med 2024:S0953-6205(24)00092-X. [PMID: 38472046 DOI: 10.1016/j.ejim.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024]
Affiliation(s)
- Stefano Fumagalli
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit, University of Florence, Largo Brambilla, 3, Florence 50134, Italy.
| | - Giuseppe Di Pasquale
- Direzione Generale Cura della Persona, Salute e Welfare, Regione Emilia-Romagna, Bologna, Italy
| | - Simone Pupo
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit, University of Florence, Largo Brambilla, 3, Florence 50134, Italy
| | - Giancarlo Agnelli
- Internal, Vascular and Emergency Medicine, University of Perugia, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit, University of Florence, Largo Brambilla, 3, Florence 50134, Italy
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50
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Zuin M, Becattini C, Piazza G. Early predictors of clinical deterioration in intermediate-high risk pulmonary embolism: clinical needs, research imperatives, and pathways forward. Eur Heart J Acute Cardiovasc Care 2024; 13:297-303. [PMID: 37967341 DOI: 10.1093/ehjacc/zuad140] [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] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/17/2023]
Abstract
A subset of intermediate-high risk pulmonary embolism (PE) patients will suffer clinical deterioration in the early hours following the acute event. Current evidence-based guidelines for the management of acute PE have provided limited direction for identification of which intermediate-high risk PE patients will go on to develop haemodynamic decompensation. Furthermore, a paucity of data further hampers guideline recommendations regarding the optimal approach and duration of intensive monitoring, best methods to assess the early response to anticoagulation, and the ideal window for reperfusion therapy, if decompensation threatens. The aim of the present article is to identify the current unmet needs related to the early identification of intermediate-high risk PE patients at higher risk of clinical deterioration and mortality during the early hours after the acute cardiovascular event and suggest some potential strategies to further explore gaps in the literature.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Via Luigi Borsari, 46 - 44121 Ferrara, Italy
| | - Cecilia Becattini
- Department of Internal Medicine, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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