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Latsios G, Mantzouranis E, Kachrimanidis I, Theofilis P, Dardas S, Stroumpouli E, Aggeli C, Tsioufis C. Recent advances in risk stratification and treatment of acute pulmonary embolism. World J Cardiol 2025; 17:104983. [DOI: 10.4330/wjc.v17.i5.104983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2025] [Revised: 03/06/2025] [Accepted: 04/08/2025] [Indexed: 05/23/2025] Open
Abstract
Pulmonary embolism (PE) represents the third leading cause of cardiovascular death, despite the implementation of European Society of Cardiology guidelines, the establishment of PE response teams and advances in diagnosis and treatment modalities. Unfavorable prognosis may be attributed to the increasing incidence of the disease and pitfalls in risk stratification using the established risk stratification tools that fail to recognize patients with intermediate-high risk PE at normotensive shock in order to prevent further deterioration. In this light, research has been focused to identify novel risk stratification tools, based on the hemodynamic impact of PE on right ventricular function. Furthermore, a growing body of evidence has demonstrated that novel interventional treatments for PE, including catheter directed thrombolysis, mechanical thrombectomy and computer-assisted aspiration, are promising solutions in terms of efficacy and safety, when targeted at specific populations of the intermediate-high- and high-risk spectrum. Various therapeutic protocols have been suggested worldwide, regarding the indications and proper timing for interventional strategies. A ST-elevation myocardial infarction-like timing approach has been suggested in high-risk PE with contraindications for fibrinolysis, while optimal timing of the procedure in intermediate-high risk patients is still a matter of debate; however, early interventions, within 24-48 hours of presentation, are associated with more favorable outcomes.
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Affiliation(s)
- George Latsios
- 1st Department of Cardiology, “Hippokration” General Hospital, Athens Medical School, Athens 11527, Greece
| | - Emmanouil Mantzouranis
- 1st Department of Cardiology, “Hippokration” General Hospital, Athens Medical School, Athens 11527, Greece
| | - Ioannis Kachrimanidis
- 1st Department of Cardiology, “Hippokration” General Hospital, Athens Medical School, Athens 11527, Greece
| | - Panagiotis Theofilis
- 1st Department of Cardiology, “Hippokration” General Hospital, Athens Medical School, Athens 11527, Greece
| | - Sotirios Dardas
- 1st Department of Cardiology, “Hippokration” General Hospital, Athens Medical School, Athens 11527, Greece
| | - Evaggelia Stroumpouli
- Department of Radiology, “Hippokration” General Hospital, Athens Medical School, Athens 11527, Greece
| | - Constantina Aggeli
- 1st Department of Cardiology, “Hippokration” General Hospital, Athens Medical School, Athens 11527, Greece
| | - Costas Tsioufis
- 1st Department of Cardiology, “Hippokration” General Hospital, Athens Medical School, Athens 11527, Greece
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Dubois-Silva Á, Bikdeli B, Jiménez D, Barbagelata-López C, Fernández-Capitán C, Skride A, Pham KQ, Porras JA, Pacheco-Gómez N, Monreal M. Clinical presentation and prognosis of acute symptomatic pulmonary embolism in patients with concomitant upper-extremity versus lower-extremity deep vein thrombosis. Thorax 2025; 80:369-377. [PMID: 40081905 DOI: 10.1136/thorax-2024-221960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 02/14/2025] [Indexed: 03/16/2025]
Abstract
BACKGROUND The impact of deep vein thrombosis (DVT) location on acute pulmonary embolism (PE) prognosis remains uncertain. METHODS Using the Registro Informatizado de Enfermedad TromboEmbólica registry, we assessed 30-day and 90-day outcomes in patients with acute symptomatic PE and concomitant upper-extremity (UEDVT) versus lower-extremity DVT (LEDVT). Cox regression was employed for analysis, and standardised differences (SRD) were used for reporting clinical characteristics to minimise type I error overinflation. The primary outcome was 30-day all-cause mortality, with secondary outcomes including 90-day mortality, fatal PE, venous thromboembolism (VTE) recurrences, and major bleeding. RESULTS Among 21 617 patients with PE (March 2001-April 2023), 508 had UEDVT, and 21 109 had LEDVT. Patients with UEDVT were younger (SRD: 0.231), more often had cancer (SRD: 0.395) or non-central PEs (SRD: 0.445), but less frequently had raised troponin levels (SRD: 0.376) or right ventricle dysfunction (SRD: 0.249). Thirty-day mortality was higher in UEDVT compared with LEDVT (7.3% vs 3.5%; p<0.001), with similar trends at 90 days (14% vs 6.0%) and in subgroup analysis in patients without cancer. Increased rates of PE-related mortality, VTE recurrences and major bleeding were noted in patients with UEDVT at both 30 and 90 days. UEDVT was associated with a higher risk for 30-day (adjusted HR (aHR): 1.49; 95% CI 1.04 to 2.13) and 90-day (aHR: 1.52; 95% CI 1.15 to 2.00) all-cause mortality on multilevel multivariable analysis. CONCLUSIONS Patients with concomitant UEDVT experienced worse short-term outcomes, including higher mortality, despite fewer clinical signs of PE severity compared with LEDVT. These findings suggest that unrecognised patient characteristics might influence prognosis, warranting further research.
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Affiliation(s)
- Álvaro Dubois-Silva
- Venous Thromboembolism Unit, Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
- Universidade da Coruña, A Coruña, Spain
- Hospital at Home and Palliative Care Department, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division and the Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
- Cardiovascular Research Foundation, New York, New York, USA
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá, Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Cristina Barbagelata-López
- Venous Thromboembolism Unit, Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | | | - Andris Skride
- Department of Cardiology, Ospedale Pauls Stradins Clinical University Hospital, Riga Stradiņš University, Riga, Latvia
| | | | - José Antonio Porras
- Department of Internal Medicine, Hospital Universitari Joan de Tarragona, Tarragona, Spain
| | | | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, Universidad Católica San Antonio de Murcia, Murcia, Spain
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Callori S, Wysokinsk W, Vlazny D, Houghton DE, Froehling DA, Hodge DO, Casanegra AI, McBane RD. Impact of coincident lower extremity deep vein thrombosis on symptomatic and incidental pulmonary embolism outcomes. A single-center prospective cohort study. J Thromb Haemost 2025; 23:1260-1268. [PMID: 39746398 DOI: 10.1016/j.jtha.2024.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 12/03/2024] [Accepted: 12/23/2024] [Indexed: 01/04/2025]
Abstract
BACKGROUND The prognostic implications of co-incident DVT at the time of PE diagnosis remains unclear. OBJECTIVES Study aims were to assess the impact of co-incident lower extremity (LE) deep vein thrombosis (DVT) on clinical outcomes of pulmonary embolism (PE) including venous thromboembolism (VTE) recurrence and mortality. METHODS Consecutive patients with confirmed acute symptomatic or incidental PE (March 1, 2013 to June 30, 2021) who underwent ultrasound imaging were divided into two groups depending on the presence or absence of LE DVT. Patients were followed prospectively for VTE recurrence, bleeding, and all-cause mortality. RESULTS Over the study period, 1907 patients with PE were stratified into groups based on the presence (n = 920) or absence (n = 987) of LE DVT. Patients with co-incident LE DVT were older, heavier, and had a significantly greater frequency of trauma, confinement, thrombophilia, and VTE. Those without LE DVT had a higher prevalence of active cancer, metastatic disease, and active systemic therapy use. All-cause mortality rates (per 100 person-years) were significantly higher for patients without vs with co-incident LE DVT (42.4/100 person-years vs 29.6/100 person- years; P < .001) with no differences in VTE recurrence or bleeding outcomes. After stratification by cancer status, mortality in those without vs. with co-incident DVT only remained significant among noncancer patients (15.2/100 person-years vs 12.1/100 person-years, P = .046). CONCLUSIONS Among patients with acute PE, the absence of co-incident lower extremity DVT is associated with significantly higher mortality rates. Mortality rate differences were only observed for those without cancer. No differences in VTE recurrence or bleeding were observed.
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Affiliation(s)
- Steven Callori
- Alix School of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Waldemar Wysokinsk
- Mayo Clinic, Cardiovascular Medicine Department - Gonda Vascular Center, Rochester, Minnesota, USA
| | - Danielle Vlazny
- Mayo Clinic, Cardiovascular Medicine Department - Gonda Vascular Center, Rochester, Minnesota, USA
| | - Damon E Houghton
- Mayo Clinic, Cardiovascular Medicine Department - Gonda Vascular Center, Rochester, Minnesota, USA
| | - David A Froehling
- Mayo Clinic, Cardiovascular Medicine Department - Gonda Vascular Center, Rochester, Minnesota, USA
| | - David O Hodge
- Mayo Clinic, Quantitative Health Sciences, Jacksonville, Florida, USA
| | - Ana I Casanegra
- Mayo Clinic, Cardiovascular Medicine Department - Gonda Vascular Center, Rochester, Minnesota, USA
| | - Robert D McBane
- Mayo Clinic, Cardiovascular Medicine Department - Gonda Vascular Center, Rochester, Minnesota, USA.
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Batra K, Kay FU, Sibley RC, Peshock RM. Imaging of Acute Pulmonary Embolism: An Update. Radiol Clin North Am 2025; 63:207-222. [PMID: 39863375 DOI: 10.1016/j.rcl.2024.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2025]
Abstract
Imaging is essential in the evaluation and management of acute pulmonary embolism. Advances in multi-energy CT including dual-energy CT and photon-counting CT have allowed faster scans with lower radiation dose and optimal quality. Artificial intelligence has a potential role in triaging potentially positive examinations and could serve as a second reader.
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Affiliation(s)
- Kiran Batra
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA.
| | - Fernando U Kay
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Robert C Sibley
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Ronald M Peshock
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
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Xing Y, Li W, Chen X, Feng H. Red Blood Cell Distribution Width-to-Platelet Ratio Predicts 30-Day Mortality in Postoperative Acute Pulmonary Embolism: A Retrospective Cohort Study. Clin Appl Thromb Hemost 2025; 31:10760296251346174. [PMID: 40420572 PMCID: PMC12117229 DOI: 10.1177/10760296251346174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2025] [Revised: 04/25/2025] [Accepted: 05/13/2025] [Indexed: 05/28/2025] Open
Abstract
ObjectivesTo investigate the correlation between red blood cell distribution width-to-platelet ratio (RPR) and 30-day mortality in patients with postoperative acute pulmonary embolism (PAPE).MethodsThis retrospective cohort study included patients diagnosed with PAPE who were hospitalized in the general surgery ward of our hospital from January 2019 to January 2024. We collected general clinical parameters and laboratory test results at admission and on the day of PAPE diagnosis. Multivariate analysis was performed to identify independent risk factors associated with 30-day mortality. A nomogram was constructed, and its predictive performance was evaluated.Results132 patients with PAPE were included in this study, comprising 36 males and 96 females. The median age was 67 years, PAPE occurred on average 3.2 days after primary disease surgery, 18 patients experienced 30-day mortality. Concurrently with DVT (OR: 0.15, 95% CI: 0.04-0.64, P = .011) and RPR ≥ 0.08 on the diagnosis of PAPE (OR: 9.19, 95% CI: 2.91-29.05, P < .001) were independently associated with 30-day mortality in PAPE patients. The AUC of the multivariate model was 0.77 (95% CI: 0.63-0.91). The Internal validation of nomogram showed the bootstrap-corrected AUC was 0.82 (95%CI 0.76-0.88).ConclusionsRPR on the diagnosis of PAPE is independently associated with the prognosis of PAPE patients. The 30-day mortality prediction model constructed based on independent risk factors demonstrated good predictive performance.
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Affiliation(s)
- Yunchao Xing
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wenrui Li
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xueming Chen
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hai Feng
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Cao Z, Yang L, Han J, Lv X, Wang X, Zhang B, Ye X, Ye H. Development of a predictive nomogram for early identification of pulmonary embolism in hospitalized patients: a retrospective cohort study. BMC Pulm Med 2024; 24:594. [PMID: 39614223 PMCID: PMC11605930 DOI: 10.1186/s12890-024-03377-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Accepted: 11/04/2024] [Indexed: 12/01/2024] Open
Abstract
BACKGROUND Hospitalized patients often present with complex clinical conditions, but there is a lack of effective tools to assess their risk of pulmonary embolism (PE). Therefore, our study aimed to develop a nomogram model for better predicting PE in hospitalized populations. METHODS Data from hospitalized patients (aged ≥ 15 years) who underwent computed tomography pulmonary angiography (CTPA) to confirm PE and non-PE were collected from December 2013 to April 2023. Univariate and multivariate stepwise logistic regression analyses were conducted to identify independent predictors of PE, followed by the construction of a predictive nomogram and internal validation. The efficiency and clinical utility of the nomogram model were assessed using receiver operating characteristic (ROC) curve, decision curve analysis (DCA), and clinical impact curve (CIC). RESULTS The study included 313 PE and 339 non-PE hospitalized patients. Male gender, dyspnea or shortness of breath, interstitial lung disease, lower limb deep vein thrombosis, elevated fibrin degradation product (FDP), pulmonary arterial hypertension, and tricuspid regurgitation were identified as independent risk factors. The AUC of the predictive nomogram model was 0.956 (95% CI: 0.939-0.974), demonstrating superior performance compared with the simplified Wells score of 0.698 (95% CI: 0.654-0.741) and the modified Geneva score of 0.758 (95% CI: 0.717-0.799). CONCLUSION Our study demonstrated that challenges remain in the accuracy of the Wells score and revised Geneva score in assessing PE in hospitalized patients. Fortunately, the nomogram we developed has shown a favorable ability to discriminate PE cases, providing high reference value for clinical practice. However, given that this was a single-center study, we plan to expand efforts to collect data from additional centers to further validate our model.
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Affiliation(s)
- Zhimin Cao
- Beijing Tuberculosis and Thoracic Tumor Research Institute, Courtyard 1, No.9 Beiguan Street, Tongzhou District, Beijing, 101199, China
| | - Luyu Yang
- Department of Respiratory and Critical Care Medicine, Beijing Chest Hospital, Capital Medical University, Courtyard 1, No.9 Beiguan Street, Tongzhou District, Beijing, 101199, China
| | - Jing Han
- Department of Respiratory and Critical Care Medicine, Guizhou ProvincialPeoplès Hospital, No.83 Zhongshan East Road, Nanming District, Guiyang, 550002, China
| | - Xiuzhi Lv
- Department of Respiratory and Critical Care Medicine, Guizhou ProvincialPeoplès Hospital, No.83 Zhongshan East Road, Nanming District, Guiyang, 550002, China
| | - Xiao Wang
- Department of Respiratory and Critical Care Medicine, Guizhou ProvincialPeoplès Hospital, No.83 Zhongshan East Road, Nanming District, Guiyang, 550002, China
| | - Bangyan Zhang
- Department of Respiratory and Critical Care Medicine, Guizhou ProvincialPeoplès Hospital, No.83 Zhongshan East Road, Nanming District, Guiyang, 550002, China
| | - Xianwei Ye
- Department of Respiratory and Critical Care Medicine, Guizhou ProvincialPeoplès Hospital, No.83 Zhongshan East Road, Nanming District, Guiyang, 550002, China.
| | - Huan Ye
- Beijing Tuberculosis and Thoracic Tumor Research Institute, Courtyard 1, No.9 Beiguan Street, Tongzhou District, Beijing, 101199, China.
- Department of Respiratory and Critical Care Medicine, Beijing Chest Hospital, Capital Medical University, Courtyard 1, No.9 Beiguan Street, Tongzhou District, Beijing, 101199, China.
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Thakkar D, Garden F, Nguyen J, Ta B, Hussaini S, Dobler CC. Practice Variations in the Diagnosis and Treatment of Pulmonary Embolism. Pulm Med 2024; 2024:6633148. [PMID: 39529656 PMCID: PMC11554407 DOI: 10.1155/2024/6633148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 08/05/2024] [Accepted: 10/07/2024] [Indexed: 11/16/2024] Open
Abstract
Venous thromboembolism is responsible for a significant burden of disease worldwide. Despite the publication of multiple international guidelines, anecdotal evidence suggests significant clinical variation exists in the diagnostic and management pathways of pulmonary embolism (PE). We conducted a retrospective cohort study using electronic medical records to examine clinical variation in patients admitted to a tertiary referral center in Australia with a diagnosis of PE between November 2018 and January 2020. Three hundred cases met the inclusion criteria; we found variation in rates of compression ultrasonography, acute investigation of the right ventricle, and planning of repeat imaging at specialist follow-up. Guidelines do not address the use of compression ultrasonography in already diagnosed PE, are conflicting in their recommendation for acute investigation of the right ventricle, and recommend repeat imaging only if there are persistent symptoms at the time of specialist follow-up. The variations we found in this study may in part be due to physician preference or due to the paucity of evidence for some of these diagnostic practices. Robust future studies are required to guide the use of these investigations in PE.
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Affiliation(s)
- Devesh Thakkar
- Department of Respiratory and Sleep Medicine, Liverpool Hospital, Sydney, Australia
| | - Frances Garden
- South West Sydney Clinical Campus, School of Clinical Medicine, University of New South Wales, Sydney, Australia
| | - John Nguyen
- Department of Respiratory and Sleep Medicine, Liverpool Hospital, Sydney, Australia
| | - Brenda Ta
- Department of Respiratory and Sleep Medicine, Liverpool Hospital, Sydney, Australia
| | - Sikandar Hussaini
- Department of Respiratory and Sleep Medicine, Liverpool Hospital, Sydney, Australia
| | - Claudia C. Dobler
- Department of Respiratory and Sleep Medicine, Liverpool Hospital, Sydney, Australia
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Murguia AR, Prakash S, Segovia F, Ayvali F, Brockman M, Nadella S, Singh V, Dwivedi AK, Rajachandran M, Mukherjee D, Nickel NP. Prevalence and clinical significance of deep vein thrombosis in Hispanic patients with acute pulmonary embolism. Angiology 2024; 75:968-975. [PMID: 37542377 DOI: 10.1177/00033197231194234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
The prevalence of concomitant deep vein thrombosis (DVT) and its impact on 30-day outcomes in Hispanic patients with acute pulmonary embolism (PE) is unknown. We retrospectively studied a cohort of Hispanic patients admitted for acute PE to determine the relationship of concomitant DVT to clot burden on chest computer tomography (CT), right heart strain, and 30-day mortality. We identified 391 patients admitted with acute PE; 168 (42.9%) had concomitant DVTs on admission; 39 patients (9.9%) died during the 30-day follow-up: 12 patients without concomitant DVT and 27 with concomitant DVT, respectively (p < .001). The presence of a proximal DVT independently predicted 30-day mortality even after adjusting for age, gender and admission PE severity index scores (PESI) (hazard ratio [HR] 2.0; 95% confidence interval [CI]: 1.4-3.0, p = .001). Proximal DVTs remained a significant predictor of 30-day mortality in patients with low and intermediate PESI scores (HR 2.5; 95% CI: 1.1-6.0, p = .035). The prevalence of concomitant DVT in Hispanic patients presenting with acute DVT is relatively lower than other ethnic groups. However, a proximal location of a DVT is of significant prognostic relevance. Hispanic patients with acute PE should routinely undergo compression doppler ultrasonography (CDUS) of the lower extremities.
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Affiliation(s)
- Adrian Rojas Murguia
- Division of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Swathi Prakash
- Division of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Fernando Segovia
- Division of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Fatih Ayvali
- Division of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Michael Brockman
- Division of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Sahithi Nadella
- Division of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Vishwajeet Singh
- Biostatistics and Epidemiology Consulting Lab, Office of Research, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Alok Kumar Dwivedi
- Biostatistics and Epidemiology Consulting Lab, Office of Research, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Manu Rajachandran
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Nils P Nickel
- Division of Pulmonary and Critical Care Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
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Kim JS, Kwon D, Kim K, Lee SH, Lee SB, Kim K, Kim D, Lee MW, Park N, Choi JH, Jang ES, Cho IR, Paik WH, Lee JK, Ryu JK, Kim YT. Machine learning-based prediction of pulmonary embolism to reduce unnecessary computed tomography scans in gastrointestinal cancer patients: a retrospective multicenter study. Sci Rep 2024; 14:25359. [PMID: 39455658 PMCID: PMC11511972 DOI: 10.1038/s41598-024-75977-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 10/09/2024] [Indexed: 10/28/2024] Open
Abstract
This study aimed to develop a machine learning (ML) model for predicting pulmonary embolism (PE) in patients with gastrointestinal cancers, a group at increased risk for PE. We conducted a retrospective, multicenter study analyzing patients who underwent computed tomographic pulmonary angiography (CTPA) between 2010 and 2020. The study utilized demographic and clinical data, including the Wells score and D-dimer levels, to train a random forest ML model. The model's effectiveness was assessed using the area under the receiver operating curve (AUROC). In total, 446 patients from hospital A and 139 from hospital B were included. The training set consisted of 356 patients from hospital A, with internal validation on 90 and external validation on 139 patients from hospital B. The model achieved an AUROC of 0.736 in hospital A and 0.669 in hospital B. The ML model significantly reduced the number of patients recommended for CTPA compared to the conventional diagnostic strategy (hospital A; 100.0% vs. 91.1%, P < 0.001, hospital B; 100.0% vs. 93.5%, P = 0.003). The results indicate that an ML-based prediction model can reduce unnecessary CTPA procedures in gastrointestinal cancer patients, highlighting its potential to enhance diagnostic efficiency and reduce patient burden.
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Affiliation(s)
- Joo Seong Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, Goyang-si, Korea
| | - Doyun Kwon
- Interdisciplinary Program of Medical Informatics, Seoul National University College of Medicine, Seoul, Korea
| | - Kyungdo Kim
- Department of Biomedical Engineering, Pratt School of Engineering, Duke University, Durham, NC, 27708, USA
- Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
| | - Seung-Bo Lee
- Department of Medical Informatics, Keimyung University School of Medicine, 1095, Dalgubeol-daero, Dalseo-gu, Daegu, 42601, Republic of Korea.
| | - Kwangsoo Kim
- Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, Korea
- Department of Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dongmin Kim
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Min Woo Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Namyoung Park
- Department of Medicine, Kyung Hee University Gangdong Hospital, Seoul, Korea
| | - Jin Ho Choi
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Eun Sun Jang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - In Rae Cho
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Hyun Paik
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University College of Medicine, Dongguk University Ilsan Hospital, Goyang-si, Korea
| | - Ji Kon Ryu
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Yong-Tae Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Roy PM, Sanchez O, Huisman M, Jimenez D. Risk stratification of acute pulmonary embolism. Presse Med 2024; 53:104243. [PMID: 39244020 DOI: 10.1016/j.lpm.2024.104243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2024] Open
Abstract
Risk stratification of patients with acute pulmonary embolism (PE) assists with the selection of appropriate initial therapy and treatment setting. Patients with acute symptomatic PE that present with arterial hypotension or shock have a high risk of death, and treatment guidelines recommend strong consideration of reperfusion in this setting. For haemodynamically stable patients with PE, the combination of a negative clinical prognostic score and the absence of computed tomography-assessed right ventricle enlargement may accurately identify those at low-risk of short-term complications after the diagnosis of PE, and such patients might benefit from an abbreviated hospital stay or outpatient therapy. Some evidence suggests that the accumulation of factors indicating worse outcomes from PE on standard anticoagulation identifies the more severe stable patients with acute PE who might benefit from intensive monitoring and recanalization procedures, particularly if haemodynamic deterioration occurs. Current risk classifications have several shortcomings that might adversely affect clinical and healthcare decisions. Ongoing initiatives aim to address many of those shortcomings, and will hopefully help optimize risk stratification algorithms and treatment strategies.
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Affiliation(s)
- Pierre-Marie Roy
- CHU Angers, 4 rue Larrey, Emergency Department, Angers F-49000, France; Univ. Angers, INSERM, CNRS, MITOVASC, Equipe CARME, SFR ICAT, Angers, France; F-CRIN, INNOVTE, Saint-Etienne, France
| | - Olivier Sanchez
- F-CRIN, INNOVTE, Saint-Etienne, France; University of Paris, INSERM UMR-S 1140 Innovaties Therapies in Haemostasis, Paris, France; Hôpital Européen Georges Pompidou, APHP, Pneumology Department and Intensive Care, 20-40 rue Leblanc, Paris F-75908, France
| | - Menno Huisman
- Leiden University Medical Center, Department of Medicine - Thrombosis and Hemostasis, Leiden, the Netherlands
| | - David Jimenez
- Ramón y Cajal Hospital (IRICYS), Respiratory Department, Madrid, Spain; Universidad de Alcalá (IRICYS), Medicine Department, Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
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11
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Wu KA, Kim JK, Rosser M, Chow B, Bottiger BA, Klapper JA. The impact of bleeding on outcomes following lung transplantation: a retrospective analysis using the universal definition of perioperative bleeding. J Cardiothorac Surg 2024; 19:466. [PMID: 39054519 PMCID: PMC11270926 DOI: 10.1186/s13019-024-02952-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 06/30/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Lung transplantation (LT) represents a high-risk procedure for end-stage lung diseases. This study describes the outcomes of patients undergoing LT that require massive transfusions as defined by the universal definition of perioperative bleeding (UDPB). METHODS Adult patients who underwent bilateral LT at a single academic center were surveyed retrospectively. Patients were grouped by insignificant, mild, or moderate perioperative bleeding (insignificant-to-moderate bleeders) and severe or massive perioperative bleeding (severe-to-massive bleeders) based on the UDPB classification. Outcomes included 1-year survival and primary graft dysfunction (PGD) of grade 3 at 72 h postoperatively. Multivariable models were adjusted for recipient age, sex, body mass index (BMI), Lung allocation score (LAS), preoperative hemoglobin (Hb), preoperative extracorporeal membrane oxygenation (ECMO) status, transplant number, and donor status. An additional multivariable model was created to find preoperative and intraoperative predictors of severe-to-massive bleeding. A p-value less than 0.05 was selected for significance. RESULTS A total of 528 patients were included, with 357 insignificant-to-moderate bleeders and 171 severe-to-massive bleeders. Postoperatively, severe-to-massive bleeders had higher rates of PGD grade 3 at 72 h, longer hospital stays, higher mortality rates at 30 days and one year, and were less likely to achieve textbook outcomes for LT. They also required postoperative ECMO, reintubation for over 48 h, tracheostomy, reintervention, and dialysis at higher rates. In the multivariate analysis, severe-to-massive bleeding was significantly associated with adverse outcomes after adjusting for recipient and donor factors, with an odds ratio of 7.73 (95% CI: 4.27-14.4, p < 0.001) for PGD3 at 72 h, 4.30 (95% CI: 2.30-8.12, p < 0.001) for 1-year mortality, and 1.75 (95% CI: 1.52-2.01, p < 0.001) for longer hospital stays. Additionally, severe-to-massive bleeders were less likely to achieve textbook outcomes, with an odds ratio of 0.07 (95% CI: 0.02-0.16, p < 0.001). Preoperative and intraoperative predictors of severe/massive bleeding were identified, with White patients having lower odds compared to Black patients (OR: 041, 95% CI: 0.22-0.80, p = 0.008). Each 1-unit increase in BMI decreased the odds of bleeding (OR: 0.89, 95% CI: 0.83-0.95, p < 0.001), while each 1-unit increase in MPAP increased the odds of bleeding (OR: 1.04, 95% CI: 1.02-1.06, p < 0.001). First-time transplant recipients had lower risk (OR: 0.16, 95% CI: 0.06-0.36, p < 0.001), whereas those with DCD donors had a higher risk of severe-to-massive bleeding (OR: 3.09, 95% CI: 1.63-5.87, p = 0.001). CONCLUSION These results suggest that patients at high risk of massive bleeding require higher utilization of hospital resources. Understanding their outcomes is important, as it may inform future decisions to transplant comparable patients.
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Affiliation(s)
- Kevin A Wu
- Duke School of Medicine, Durham, NC, USA
- Duke Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, 2301 Erwin Rd, 27710, Durham, NC, USA
| | | | - Morgan Rosser
- Division of Cardiothoracic Anesthesiology, Duke University, Durham, NC, USA
| | - Bryan Chow
- Division of Cardiothoracic Anesthesiology, Duke University, Durham, NC, USA
| | - Brandi A Bottiger
- Division of Cardiothoracic Anesthesiology, Duke University, Durham, NC, USA
| | - Jacob A Klapper
- Duke Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, 2301 Erwin Rd, 27710, Durham, NC, USA.
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12
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Ho TAA, Pescatore J, Lio KU, Rali P, Criner G, Gayen S. Predictors of Residual Pulmonary Vascular Obstruction after Acute Pulmonary Embolism Based on Patient Variables and Treatment Modality. J Clin Med 2024; 13:4248. [PMID: 39064289 PMCID: PMC11278327 DOI: 10.3390/jcm13144248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/10/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Residual Pulmonary Vascular Obstruction (RPVO) is an area of increasing focus in patients with acute pulmonary embolism (PE) due to its association with long-term morbidity and mortality. The predictive factors and the effect catheter-directed therapies (CDT) have on RPVO are still under investigation. Methods: This is a single-center retrospective review between April 2017 and July 2021. Patients with intermediate risk of PE were included. Patient variables associated with RPVO were analyzed and the degree of clot burden was quantified using the Qanadli score. Results: A total of 551 patients with acute PE were identified, 288 were intermediate risk and 53 had RPVO based on CT or V/Q scan three months post-PE. Baseline clot burden was higher in patients who received CDT compared to those who received anticoagulation alone (Qanadli score 45.88% vs. 31.94% p < 0.05). In univariate analysis, treatment with CDT showed a HR of 0.32 (95% CI 0.21-0.50, p < 0.001) when compared with anticoagulation alone. Patient variables including intermediate-high risk, sPESI ≥ 1, elevated biomarkers, RV dysfunction on imaging, malignancy, history of or concurrent DVT were also significantly associated with development of RPVO in univariate analysis. In multivariable analysis, only baseline Qanadli score (HR 13.88, 95% CI 1.42-135.39, p = 0.02) and concurrent DVT (HR 2.53, 95% CI 1.01-6.40, p = 0.04) were significantly associated with the development of RPVO. Conclusions: Catheter-directed therapy may be associated with a reduced risk of RPVO at 3 months; however, quantitative clot burden scores, such as the Qanadli score, may be stronger predictors of the risk of developing RPVO at 3 months. Further prospective studies are required.
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Affiliation(s)
- Truong-An Andrew Ho
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA 19140, USA; (J.P.); (S.G.)
| | - Jay Pescatore
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA 19140, USA; (J.P.); (S.G.)
| | - Ka U. Lio
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA 19140, USA; (J.P.); (S.G.)
| | - Gerard Criner
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA 19140, USA; (J.P.); (S.G.)
| | - Shameek Gayen
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA 19140, USA; (J.P.); (S.G.)
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13
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Baumgartner C, Tritschler T, Aujesky D. Subsegmental Pulmonary Embolism. Hamostaseologie 2024; 44:197-205. [PMID: 37871632 DOI: 10.1055/a-2163-3111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023] Open
Abstract
Subsegmental pulmonary embolism (SSPE) is increasingly diagnosed with the growing use and technological advancements of multidetector computed tomography pulmonary angiography. Its diagnosis is challenging, and some presumed SSPE may actually represent imaging artifacts. Indirect evidence and results from small observational studies suggest that SSPE may be more benign than more proximal pulmonary embolism, and may thus not always require treatment. Therefore, guidelines suggest to consider a management strategy without anticoagulation in selected patients with SSPE at low risk of recurrent venous thromboembolism (VTE), in whom proximal deep vein thrombosis is excluded. Recently, a large prospective study among low-risk patients with SSPE who were left untreated showed a higher VTE recurrence risk than initially deemed acceptable by the investigators, and thus was prematurely interrupted after recruitment of 97% of the target population. However, the risk-benefit ratio of anticoagulation for low-risk patients with SSPE remains unclear, and results from randomized trials are needed to answer the question about their optimal management.
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Affiliation(s)
- Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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14
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Sökücü SN, Satıcı C, Tokgöz Akyıl F, Veske NŞ, Koçal FE, Tural Önür S, Özdemir C. The impact of deep venous thrombosis on 90 day mortality in chronic obstructive pulmonary disease patients presenting with pulmonary embolism. Respir Med Res 2024; 85:101090. [PMID: 38657301 DOI: 10.1016/j.resmer.2024.101090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 01/12/2024] [Accepted: 01/13/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND There are a limited number of studies investigating the effect of deep venous thrombosis (DVT) in patients presenting with both pulmonary embolism and chronic obstructive pulmonary disease. The aim of this study is to investigate the prevalence and prognostic significance of DVT in patients with PE-COPD. METHODS COPD patients admitted with a diagnosis of PE to our tertiary hospital between January 2016 and January 2021 were retrospectively evaluated with an electronic hospital database. Univariate and multivariate Cox regression analyses were performed to reveal independent prognostic factors. RESULTS Two hundred thirty-three patients (mean age 65.1 ± 12.2, 158 men (67.5 %)) were included. DVT was present at the time of diagnosis in 45 (19.31 %) of the patients. Patients with DVT tend to have more comorbidities, central pulmonary embolism, higher CRP and d-dimer levels, and SPESI score (p<0.05). After performing multivariate analyses, the presence of DVT (HR=3.48, CI: 1.02- 11.88, p = 0.046), ischemic heart disease (HR=3.82, CI: 1.38- 10.80, p = 0.01), and malignancy (HR=4.85, CI: 1.53- 15.41, p = 0.007) were found to be independent factors in predicting 90-day mortality. CONCLUSIONS In PE-COPD patients, co-existing DVT may predict a worse outcome.
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Affiliation(s)
- Sinem Nedime Sökücü
- University of Health Sciences, Yedikule Chest Disease and Thoracic Surgery Training and Research Hospital, Chest Disease, Turkey
| | - Celal Satıcı
- University of Health Sciences, Yedikule Chest Disease and Thoracic Surgery Training and Research Hospital, Chest Disease, Turkey
| | - Fatma Tokgöz Akyıl
- University of Health Sciences, Yedikule Chest Disease and Thoracic Surgery Training and Research Hospital, Chest Disease, Turkey
| | - Nurdan Şimşek Veske
- University of Health Sciences, Yedikule Chest Disease and Thoracic Surgery Training and Research Hospital, Chest Disease, Turkey.
| | - Fatma Elif Koçal
- University of Health Sciences, Yedikule Chest Disease and Thoracic Surgery Training and Research Hospital, Chest Disease, Turkey
| | - Seda Tural Önür
- University of Health Sciences, Yedikule Chest Disease and Thoracic Surgery Training and Research Hospital, Chest Disease, Turkey
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15
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Ubaldi N, Krokidis M, Rossi M, Orgera G. Endovascular treatments of acute pulmonary embolism in the post-fibrinolytic era: an up-to-date review. Insights Imaging 2024; 15:122. [PMID: 38767729 PMCID: PMC11106225 DOI: 10.1186/s13244-024-01694-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 04/03/2024] [Indexed: 05/22/2024] Open
Abstract
Pulmonary embolism (PE) is a significant contributor to global cardiovascular-related mortality that mainly depends on the severity of the event. The treatment approach for intermediate and high-risk PE remains a topic of debate due to the fine balance between hemodynamic deterioration and bleeding risk. The initial treatment choice for intermediate-risk PE with hemodynamic deterioration and high-risk PE is historically systemic thrombolysis, but this approach is not always effective and carries a notable risk of severe bleeding. For such patients, various interventional treatments have been introduced to clinical practice, including catheter-directed lysis (CDL), ultrasound-assisted CDL, pharmacomechanical CDL, and aspiration thrombectomy. However, the optimal treatment approach remains uncertain. Encouraging outcomes have been presented assessing the novel endovascular treatments, in terms of reducing right ventricular dysfunction and improving hemodynamic stability, opening the possibility of using these devices to prevent hemodynamic instability in less severe cases. However, ongoing randomized trials that assess the efficacy and the association with mortality, especially for aspiration devices, have not yet published their final results. This article aims to offer a comprehensive update of the available catheter-directed therapies for PE, with a focus on novel mechanical thrombectomy techniques, assessing their safety and efficacy, after comparison to the conventional treatment. CRITICAL RELEVANCE STATEMENT: This is a comprehensive review of the indications of use, techniques, and clinical outcomes of the most novel endovascular devices for the treatment of pulmonary embolism. KEY POINTS: Mechanical thrombectomy is an effective tool for patients with PE. Aspiration devices prevent hemodynamic deterioration. Catheter directed therapy reduces bleeding complications.
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Affiliation(s)
- Nicolò Ubaldi
- Department of Radiology, Sant'Andrea University Hospital La Sapienza, School of Medicine and Psychology, "Sapienza" - University of Rome, Rome, Italy
| | - Miltiadis Krokidis
- 1st Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Areteion Hospital, Athens, Greece.
| | - Michele Rossi
- Department of Radiology, Sant'Andrea University Hospital La Sapienza, School of Medicine and Psychology, "Sapienza" - University of Rome, Rome, Italy
| | - Gianluigi Orgera
- Department of Radiology, Sant'Andrea University Hospital La Sapienza, School of Medicine and Psychology, "Sapienza" - University of Rome, Rome, Italy
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16
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Borkowski P, Singh N, Borkowska N, Mangeshkar S, Nazarenko N. Integrating Cardiac Biomarkers and Electrocardiogram in Pulmonary Embolism Prognosis. Cureus 2024; 16:e53505. [PMID: 38440014 PMCID: PMC10911475 DOI: 10.7759/cureus.53505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 03/06/2024] Open
Abstract
Pulmonary embolism (PE) represents a significant clinical challenge that substantially impacts healthcare systems. This case report focuses on the nuances of risk stratification in PE, highlighted through the presentation of a 64-year-old female patient. The uniqueness of this case lies in the patient's atypical presentation, where decreased exercise tolerance was the sole symptom leading to the diagnosis of PE. The patient was found to have new-onset atrial fibrillation, elevated levels of N-terminal pro-brain natriuretic peptide (NT-proBNP), and signs of right ventricular strain on imaging. This scenario underscores the necessity for a comprehensive assessment in PE cases, particularly when classic symptoms (e.g., tachycardia, shortness of breath, chest pain) are absent. We explore the incidence of PE in patients diagnosed with deep vein thrombosis, examining the critical role of cardiac biomarkers, including B-type natriuretic peptide, NT-proBNP, and troponins, in prognostication and their potential use in risk assessment tools for PE patients. Additionally, the significance of electrocardiogram evaluation in these patients and its role in risk stratification is thoroughly assessed.
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Affiliation(s)
- Pawel Borkowski
- Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, USA
| | - Nikita Singh
- Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, USA
| | - Natalia Borkowska
- Pediatrics, Samodzielny Publiczny Zakład Opieki Zdrowotnej (SPZOZ), Krotoszyn, POL
| | - Shaunak Mangeshkar
- Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, USA
| | - Natalia Nazarenko
- Internal Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, New York, USA
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17
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Yamada N, Fukuda I, Nakamura M, Takayama M, Maeda H, Yamashita T, Ikeda T, Mo M, Yamazaki T, Okumura Y, Hirayama A. Prognostication of Patients with Pulmonary Thromboembolism with and without Residual Deep Vein Thrombosis: A Subanalysis of the J'xactly Study. Ann Vasc Dis 2023; 16:181-188. [PMID: 37779650 PMCID: PMC10539124 DOI: 10.3400/avd.oa.22-00111] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 06/04/2023] [Indexed: 10/03/2023] Open
Abstract
Objectives: It is unclear whether patients with acute pulmonary thromboembolism (PE) with and without residual deep vein thrombosis (DVT) have different prognoses, and there is debate over whether inferior vena cava filters (IVCFs) should be used in conjunction with oral anticoagulants in patients with venous thromboembolism (VTE). Materials and Methods: The J'xactly involved 1,016 patients and was a multicenter, prospective, observational research. In this subanalysis, 419 patients with PE with or without residual DVT who received rivaroxaban with or without IVCFs between February 2016 and April 2018 in Japan were examined. Results: Of 419 patients with PE, 320 had residual DVT. There was no difference between the groups with and without DVT in terms of the percentage of patients who experienced symptomatic PE recurrence (2.8% [9/320] vs. 3.0% [3/99]) or who died from VTE-related complications (0.9% [3/320] vs. 1.0% [1/99]). The percentages of patients with symptomatic PE recurrence were 0% and 3.2%, and the percentages of patients who died from VTE-related causes were 0% and 1.1%, respectively, in the groups with (n=39) and without (n=281) IVCF, albeit not being statistically different. Conclusion: Patients with PE with and without residual DVT did not have a different incidence of symptomatic PE recurrence. These results require additional study to be confirmed.
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Affiliation(s)
- Norikazu Yamada
- Department of Cardiology, Kuwana City Medical Center, Kuwana, Mie, Japan
| | - Ikuo Fukuda
- Department of Cardiology, Keimeikai Yokawa Hospital, Miki, Hyogo, Japan
| | | | - Morimasa Takayama
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan
| | - Hideaki Maeda
- Department of Heart and Vascular Center, Ukima Central Hospital, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Yokohama, Kanagawa, Japan
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, International University of Health and Welfare, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Atsushi Hirayama
- Department of Cardiology, Osaka Police Hospital, Osaka, Osaka, Japan
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18
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Choudry H, Ata F, Ibrahim W, Rana MOR, Ahmad S, Mehmood A, Gill BA, Suheb MK. Saddle pulmonary embolism in the setting of COVID-19 infection: A systematic review of case reports and case series. Open Med (Wars) 2023; 18:20230724. [PMID: 37273918 PMCID: PMC10238810 DOI: 10.1515/med-2023-0724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/02/2023] [Accepted: 05/02/2023] [Indexed: 06/06/2023] Open
Abstract
Saddle pulmonary embolism (SPE) is a rare type of pulmonary embolism that can lead to hemodynamic compromise causing sudden deaths. Due to a dearth of large prospective studies in this area, little is known regarding the epidemiology, and prognosis and factors affecting the latter for COVID-19-associated SPE. We aimed to describe COVID-19-associated SPE and quantify and compare mortality and factors affecting mortality among the cases. We included a total of 25 publications with a total of 35 cases. The average age was 45 ± 16.3 years with 11 females and 24 males. Dyspnoea (82.5%), orthopnoea (43.5%), and cough (43.5%) were the most common symptoms, and obstructive shock was present in five (21.7%) patients. The average reported oxygen (O2) saturation was 85.8% ± 11.9 mm Hg. Hypertension (26.1%), diabetes (21.7%), and deep vein thrombosis (21.7%) were the most commonly reported comorbidities. Right heart strain was recognized in seven (30%) patients on electroencephalogram (S1QIIITIII) and 12 (52.2%) patients on echocardiogram. Anticoagulation, thrombolysis, and percutaneous intervention were tried in 21 (91.3%), 13 (56.5%), and 6 (26.1%) cases, respectively. Despite the aggressive management, 2 of 25 (8.7%) patients died in our smaller case report cohort. We conclude that despite aggressive management modalities, the mortality of SPE remains high in COVID-19.
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Affiliation(s)
- Hassan Choudry
- Department of Respiratory Medicine, University Hospital of Leicester, LeicesterLE1, UK
| | - Fateen Ata
- Department of Endocrinology, Hamad General Hospital, Hammad Medical Corporation, PO BOX 3050, Doha, Qatar
| | - Wanis Ibrahim
- Department of Internal Medicine and Pulmonology, Hammad Medical Corporation, Doha, Qatar
| | - Mohammad Omer Rehman Rana
- Department of Adult Cardiology, Chaudhary Pervaiz Ilahi Institute of Cardiology, Wazirabad, Pakistan
| | - Shoaib Ahmad
- Department of Medicine, Punjab Medical College, Faisalabad, Pakistan
| | - Asim Mehmood
- Respiratory Department, Derriford Hospital, University Hospitals Plymouth, Plymouth, UK
| | - Basir Afzaal Gill
- Intensive Care Unit, Department of Anaesthesia, Jinnah Hospital, Lahore, Pakistan
| | - Mahammed Khan Suheb
- Critical Care Department, St. Luke’s Aurora Hospital, Milwaukee, Wisconsin, USA
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19
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Shi Y, Yuan Y, Kong J, Su H, Chen L, Huang H, Lu Z, Gu J. Impact of Common Iliac Vein Compression on the Incidence of Pulmonary Embolism in Patients with Acute Deep Vein Thrombosis. Eur J Vasc Endovasc Surg 2023; 65:887-894. [PMID: 36931552 DOI: 10.1016/j.ejvs.2023.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/21/2023] [Accepted: 03/07/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVE This study aimed to investigate the association between common iliac vein (CIV) compression and pulmonary embolism (PE) in lower extremity deep vein thrombosis (DVT). METHODS This was a single centre retrospective study. Between January 2016 and December 2021, DVT patients with enhanced computed tomography of the iliac vein and pulmonary artery were included. Patient demographics, comorbidities, risk factors, and degree of CIV compression were collected and analysed. Logistic regression was performed to evaluate the odds ratio (OR) with a 95% confidence interval (CI) of PE in relation to compression severity groups. The association between PE and compression degree was evaluated with restricted cubic splines (RCS) based on an adjusted logistic regression model. RESULTS Two hundred and twenty-six DVT patients (left side, n = 153; right side, n = 73) were included. Univariable analyses suggested that symptomatic or asymptomatic PE (54.4%, 123/226) was more common in men (p = .048) and right side DVT (p = .046) patients. Compared with no CIV compression, multivariable analyses suggested that mild compression did not statistically significantly reduce the PE risk, whereas moderate (adjusted OR 0.36; 95% CI 0.15 - 0.88; p = .025) and severe (adjusted OR 0.18; 95% CI 0.06 - 0.54; p = .002) compression statistically significantly reduced the risk. RCS showed that a smaller minimum diameter or greater compression percentage was correlated with continuously decreasing PE risk at a minimum diameter of < 6.77 mm or compression > 42.9%. CONCLUSION PE is more common in men and right side DVT patients. An increasing severity of CIV compression is consistently associated with a decreasing risk of PE when the minimum diameter is < 6.77 mm or the compression is > 42.9%, indicating that it is a protective factor against PE.
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Affiliation(s)
- Yadong Shi
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yuan Yuan
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jie Kong
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Haobo Su
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Liang Chen
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Hao Huang
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhaoxuan Lu
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jianping Gu
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
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20
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ten Cate V, Prochaska JH, Schulz A, Nagler M, Robles AP, Jurk K, Koeck T, Rapp S, Düber C, Münzel T, Konstantinides SV, Wild PS. Clinical profile and outcome of isolated pulmonary embolism: a systematic review and meta-analysis. EClinicalMedicine 2023; 59:101973. [PMID: 37152363 PMCID: PMC10154961 DOI: 10.1016/j.eclinm.2023.101973] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 05/09/2023] Open
Abstract
Background Isolated pulmonary embolism (PE) appears to be associated with a specific clinical profile and sequelae compared to deep vein thrombosis (DVT)-associated PE. The objective of this study was to identify clinical characteristics that discriminate both phenotypes, and to characterize their differences in clinical outcome. Methods We performed a systematic review and meta-analysis of studies comparing PE phenotypes. A systematic search of the electronic databases PubMed and CENTRAL was conducted, from inception until January 27, 2023. Exclusion criteria were irrelevant content, inability to retrieve the article, language other than English or German, the article comprising a review or case study/series, and inappropriate study design. Data on risk factors, clinical characteristics and clinical endpoints were pooled using random-effects meta-analyses. Findings Fifty studies with 435,768 PE patients were included. In low risk of bias studies, 30% [95% CI 19-42%, I 2 = 97%] of PE were isolated. The Factor V Leiden [OR: 0.47, 95% CI 0.37-0.58, I 2 = 0%] and prothrombin G20210A mutations [OR: 0.55, 95% CI 0.41-0.75, I 2 = 0%] were significantly less prevalent among patients with isolated PE. Female sex [OR: 1.30, 95% CI 1.17-1.45, I 2 = 79%], recent invasive surgery [OR: 1.31, 95% CI 1.23-1.41, I 2 = 65%], a history of myocardial infarction [OR: 2.07, 95% CI 1.85-2.32, I 2 = 0%], left-sided heart failure [OR: 1.70, 95% CI 1.37-2.10, I 2 = 76%], peripheral artery disease [OR: 1.36, 95% CI 1.31-1.42, I 2 = 0%] and diabetes mellitus [OR: 1.23, 95% CI 1.21-1.25, I 2 = 0%] were significantly more frequently represented among isolated PE patients. In a synthesis of clinical outcome data, the risk of recurrent VTE in isolated PE was half that of DVT-associated PE [RR: 0.55, 95% CI 0.44-0.69, I 2 = 0%], while the risk of arterial thrombosis was nearly 3-fold higher [RR: 2.93, 95% CI 1.43-6.02, I 2 = 0%]. Interpretation Our findings suggest that isolated PE appears to be a specific entity that may signal a long-term risk of arterial thrombosis. Randomised controlled trials are necessary to establish whether alternative treatment regimens are beneficial for this patient subgroup. Funding None.
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Affiliation(s)
- Vincent ten Cate
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jürgen H. Prochaska
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Andreas Schulz
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Markus Nagler
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Alejandro Pallares Robles
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - Kerstin Jurk
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Thomas Koeck
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Steffen Rapp
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
| | - Christoph Düber
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Thomas Münzel
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Cardiology – Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Stavros V. Konstantinides
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, 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, Germany
- Department of Cardiology, Democritus University of Thrace, University General Hospital, Greece
| | - Philipp S. Wild
- Preventive Cardiology and Preventive Medicine, Department of Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Institute of Molecular Biology (IMB), Mainz, Germany
- Corresponding author. Clinical Epidemiology, Preventive Cardiology and Preventive Medicine, Department of Cardiology, Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Langenbeckstr. 1, 55131 Mainz, Germany.
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Luijten D, Klok FA, van Mens TE, Huisman MV. Clinical controversies in the management of acute pulmonary embolism: evaluation of four important but controversial aspects of acute pulmonary embolism management that are still subject of debate and research. Expert Rev Respir Med 2023; 17:181-189. [PMID: 36912598 DOI: 10.1080/17476348.2023.2190888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/10/2023] [Indexed: 03/14/2023]
Abstract
INTRODUCTION Acute pulmonary embolism (PE) is a disease with a broad spectrum of clinical presentations. While some patients can be treated at home or may even be left untreated, other patients require an aggressive approach with reperfusion treatment. AREAS COVERED (1) Advanced reperfusion treatment in hemodynamically stable acute PE patients considered to be at high risk of decompensation and death, (2) the treatment of subsegmental pulmonary embolism, (3) outpatient treatment for hemodynamically stable PE patients with signs of right ventricle (RV) dysfunction, and (4) the optimal approach to identify and treatpost-PE syndrome. EXPERT OPINION Outside clinical trials, hemodynamically stable acute PE patients should not be treated with primary reperfusion therapy. Thrombolysis and/or catheter-directed therapy are only to be considered as rescue treatment. Subsegmental PE can be left untreated in selected low-risk patients, after proximal deep vein thrombosis has been ruled out. Patients with an sPESI or Hestia score of 0 criteria can be treated at home, independent of the presence of RV overload. Finally, health-care providers should be aware of post-PE syndrome and diagnose chronic thromboembolic pulmonary disease (CTEPD) as early as possible. Persistently symptomatic patients without CTEPD benefit from exercise training and cardiopulmonary rehabilitation.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Thijs E van Mens
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
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22
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Effectiveness and safety of rivaroxaban in patients with venous thromboembolism and active cancer: A subanalysis of the J'xactly study. J Cardiol 2023; 81:268-275. [PMID: 36400414 DOI: 10.1016/j.jjcc.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/17/2022] [Accepted: 11/03/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Data on the effectiveness and safety of rivaroxaban for the treatment of patients with venous thromboembolism (VTE) and active cancer are limited in the Japanese real-world setting. METHODS In this subanalysis of the J'xactly study, which was a multicenter, prospective, observational study, we evaluated the effectiveness and safety of rivaroxaban in patients with acute VTE and active cancer (n = 193) versus those without active cancer (n = 823). RESULTS Compared with patients without active cancer, those with active cancer demonstrated a significantly different age distribution, with fewer aged <65 and ≥75 years; a lower proportion of women; a lower mean body mass index; and a lower proportion of physical inactivity, injury, thrombophilia, and heart failure. There was no difference in the initial dose distribution of rivaroxaban between patients with and without active cancer. The incidences of recurrence or aggravation of symptomatic VTE and major bleeding were not significantly different [VTE: 1.44 % vs. 2.80 % per patient-year, hazard ratio (HR) 0.50, 95 % confidence interval (CI) 0.18-1.39, p = 0.172; major bleeding: 4.49 % vs. 2.55 % per patient-year, HR 1.80, 95 % CI 0.82-3.95, p = 0.137]. Approximately 10 % of patients with active cancer died at 6 months, with a significantly higher cumulative all-cause mortality rate than those without active cancer (23.29 % vs. 2.03 % per patient-year, HR 11.31, 95 % CI 7.30-17.53, p < 0.001). CONCLUSIONS In patients with VTE and active cancer, rivaroxaban showed acceptable effectiveness, although clinically significant bleeding remains a concern. CLINICAL TRIAL REGISTRATION UMIN Clinical Trials Registry number, UMIN000025072.
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Oleksiuk-Bójko M, Lisowska A. Venous thromboembolism: Why is it still a significant health problem? Adv Med Sci 2023; 68:10-20. [PMID: 36368288 DOI: 10.1016/j.advms.2022.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/08/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) remains the third leading cause of acute cardiovascular syndrome following myocardial infarction and ischemic stroke. The global burden of disease worldwide is high and shows a steady upward trend in recent years with an incidence of 1-2 per 1000 adults per year. The overarching goal of the initial management of VTE is to prevent early and late adverse outcomes. Rapid evaluation and therapeutic intervention is vital to improving prognosis. METHODS We searched PubMed, Science Direct and Scopus databases for articles published in the last 10 years. Additionally, some earlier articles were analyzed. RESULTS For the purposes of this review, we discussed how understanding the epidemiology of VTE and the current knowledge of early and late complications of this disease have shaped the current approach to VTE prevention. We also analyzed the current knowledge and the most up-to-date information about VTE in COVID-19 infection. Contemporary perspective presented in this article on mortality in VTE, the incidence of recurrences, the risk of major bleeding during therapy and the chronic complications indicate why this is a major challenge for today's medicine and a current target for further research. CONCLUSIONS Understanding the interaction between environmental and genetic factors appears to be crucial in the diagnostic process. It can provide insight into the pathophysiology of VTE, potentially identifying options for targeted prevention and treatment. However, due to differences in clinical presentation, diagnosing pulmonary embolism may not be an easy task which perfectly illustrates the scale and complexity of the disease.
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Affiliation(s)
- Monika Oleksiuk-Bójko
- Department of Cardiology, University Clinical Hospital in Bialystok, Bialystok, Poland
| | - Anna Lisowska
- Department of Cardiology, University Clinical Hospital in Bialystok, Bialystok, Poland.
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24
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Dubois-Silva Á, Barbagelata-López C, Piñeiro-Parga P, López-Jiménez L, Riera-Mestre A, Schellong S, Catella J, Bosevski M, Roca Toledo M, Monreal M. Deep vein thrombosis symptoms and 30-day mortality in acute pulmonary embolism. Eur J Intern Med 2023; 108:43-51. [PMID: 36400669 DOI: 10.1016/j.ejim.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 09/05/2022] [Accepted: 11/07/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND In patients with acute symptomatic pulmonary embolism (PE), the presence of concomitant lower-limb deep vein thrombosis (DVT) has been associated with a higher mortality rate. The prognostic significance of DVT symptoms among these patients remains uncertain. METHODS We used the RIETE (Registro Informatizado de Enfermedad TromboEmbólica) registry to compare the 30-day mortality rate in patients with PE and concomitant lower-limb DVT, according to the presence or absence of DVT symptoms. Primary outcomes were all-cause death and PE-related death within the first 30 days. RESULTS Since March 2001 to June 2021, there were 17,742 patients with acute symptomatic PE and objectively proven concomitant lower-limb DVT. Of these, 11,984 (68%) had DVT symptoms. Most patients with or without DVT symptoms (82% vs. 81%) received low-molecular-weight heparin initially. Then, most (61% vs. 58%) switched to vitamin K antagonists. During the first 30 days of therapy, 497 patients with DVT symptoms (4.1%) and 164 (2.8%) with no DVT symptoms died (rate ratio [RR]: 1.48; 95%CI: 1.23-1.77). The rates of PE-related death were: 1.0% vs. 0.7%, respectively (RR: 1.50; 95%CI: 1.04-2.16). On multivariable analysis, patients with DVT symptoms were at increased risk for all-cause death (adjusted hazard ratio [aHR]: 1.49; 95%CI: 1.24-1.78), and PE-related death (aHR: 1.52; 95%CI: 1.05-2.20). CONCLUSION Among patients with acute symptomatic PE and concomitant lower-limb DVT, those with DVT symptoms had an increased all-cause and PE-related mortality within 30 days. Assessment of DVT symptoms would assist with risk stratification of these patients.
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Affiliation(s)
- Álvaro Dubois-Silva
- Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain; Universidade da Coruña (UDC), A Coruña, Spain.
| | - Cristina Barbagelata-López
- Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
| | - Patricia Piñeiro-Parga
- Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
| | | | - Antoni Riera-Mestre
- Department of Internal Medicine, Hospital Universitari de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona. Universitat de Barcelona, Barcelona, Spain
| | - Sebastian Schellong
- Department of Medical Clinic, Municipal Hospital of Dresden Friedrichstadt, Dresden, Germany
| | - Judith Catella
- Department of Internal Medicine, Hôpital Édouard Herriot, Lyon, France
| | - Marijan Bosevski
- Faculty of Medicine, University Cardiology Clinic, Skopje, Republic of Macedonia
| | - Mireia Roca Toledo
- Department of Internal Medicine, Hospital Comarcal de L'Alt Penedés, Vilafranca del Penedés, Barcelona, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM, Universidad Católica San Antonio de Murcia. Universidad Autónoma de Barcelona, Badalona, Barcelona, Spain
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25
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Falster C, Egholm G, Wiig R, Poulsen MK, Møller JE, Posth S, Brabrand M, Laursen CB. Diagnostic Accuracy of a Bespoke Multiorgan Ultrasound Approach in Suspected Pulmonary Embolism. Ultrasound Int Open 2023; 8:E59-E67. [PMID: 36726389 PMCID: PMC9886498 DOI: 10.1055/a-1971-7454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 10/23/2022] [Indexed: 01/18/2023] Open
Abstract
Purpose The aims of this study were to prospectively assess the diagnostic accuracy of a bespoke multiorgan point-of-care ultrasound approach for suspected pulmonary embolism and evaluate if this model allows reduced referral to further radiation diagnostics while maintaining safety standards. Materials and Methods Patients with suspected pulmonary embolism referred for CT pulmonary angiography or ventilation/perfusion scintigraphy were included as a convenience sample. All patients were subject to blinded ultrasound investigation with cardiac, lung, and deep venous ultrasound. The sensitivity and specificity of applied ultrasound signs and the hypothetical reduction in the need for further diagnostic workup were calculated. Results 75 patients were prospectively enrolled. The Wells score was below 2 in 48 patients, between 2 and 6 in 24 patients, and above 6 in 3 patients. The prevalence of pulmonary embolism was 28%. The most notable ultrasound signs were presence of a deep venous thrombus, at least two hypoechoic pleural-based lesions, the D-sign, the 60/60-sign, and a visible right ventricular thrombus which all had a specificity of 100%. Additionally, a multiorgan ultrasound investigation with no findings compatible with pulmonary embolism yielded a sensitivity of 95.2% (95%CI: 76.2-99.9). CT or scintigraphy could be safely avoided in 70% of cases (95%CI: 63.0-83.1%). Conclusion The findings of our study suggest that implementation of a multiorgan ultrasound assessment in patients with suspected pulmonary embolism may safely reduce the need for CT or scintigraphy by confirming or dismissing the suspicion.
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Affiliation(s)
- Casper Falster
- Department of Respiratory Medicine, Odense University Hospital, Odense,
Denmark,Odense Respiratory Research Unit (ODIN), Department of Clinical
Research, University of Southern Denmark, Odense, Denmark,OPEN, Open Patient data Explorative Network, Odense University
Hospital, Odense, Denmark,Correspondence Dr. Casper Falster Odense
University HospitalDepartment of respiratory
medicineKløvervænget
25000
OdenseDenmark+4560139562
| | - Gro Egholm
- Department of Cardiology, Odense University Hospital, Odense,
Denmark
| | - Rune Wiig
- Odense Respiratory Research Unit (ODIN), Department of Clinical
Research, University of Southern Denmark, Odense, Denmark
| | | | | | - Stefan Posth
- Department of Emergency Medicine, Odense University Hospital, Odense,
Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense,
Denmark
| | - Christian Borbjerg Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense,
Denmark,Odense Respiratory Research Unit (ODIN), Department of Clinical
Research, University of Southern Denmark, Odense, Denmark
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26
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Qdaisat A, Wechsler AH, Cruz Carreras MT, Menendez JR, Lipe D, Highsmith EA, Kamal M, Al-Breiki A, Rojas Hernandez CM, Wu CC, Yeung SCJ. Concomitant Deep Vein Thrombosis in Cancer Patients with Unsuspected Pulmonary Embolism. Cancers (Basel) 2022; 14:cancers14184510. [PMID: 36139673 PMCID: PMC9496711 DOI: 10.3390/cancers14184510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/10/2022] [Accepted: 09/13/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Cancer patients have a significantly higher risk of developing venous thromboembolism during their disease course when compared with the general population. During routine staging or follow-up imaging studies, incidental venous thromboemboli, including incidental pulmonary embolisms, can be identified. Identifying factors associated with incidental or unsuspected venous thromboembolism is important and can improve the management plan. In the current study, we found that 20.9% of patients with unsuspected pulmonary embolisms had concomitant deep vein thrombosis, and most of these patients were asymptomatic. In addition, we found that concomitant deep vein thrombosis increases the odds of venous thrombosis recurrence in cancer patients presenting with unsuspected pulmonary emboli. Therefore, for patients with isolated incidental subsegmental pulmonary embolism and concomitant deep vein thrombosis, initiating anticoagulants if no contraindications exist is recommended. In addition, the presence of concomitant deep vein thrombosis among cancer patients with unsuspected pulmonary embolisms is associated with poor short- and long-term outcomes in these patients. Abstract Incidental venous thromboembolism (VTE) is common in cancer patients and identifying factors associated with these events can improve the management plan. We studied the characteristics of concomitant deep vein thrombosis (C-DVT) in cancer patients presenting with unsuspected pulmonary embolism (PE) and the association of C-DVT with VTE recurrence and survival outcomes. Patients presenting to our emergency department with confirmed unsuspected/incidental PE between 1 January 2006 and 1 January 2016, were identified. Radiologic reports were reviewed to confirm the presence or absence of C-DVT. Logistic regression analyses and cox regression modeling were used to determine the effect of C-DVT on VTE recurrence and survival outcomes. Of 904 eligible patients, 189 (20.9%) had C-DVT. Patients with C-DVT had twice the odds of developing VTE recurrence (odds ratio 2.07, 95% confidence interval 1.21–3.48, p = 0.007). The mortality rates among C-DVT were significantly higher than in patients without. C-DVT was associated with reduced overall survival in patients with unsuspected PE (hazard ratio 1.33, 95% confidence interval 1.09–1.63, p = 0.005). In conclusion, C-DVT in cancer patients who present with unsuspected PE is common and is associated with an increased risk of VTE recurrence and poor short- and long-term survival. Identifying other venous thrombi in cancer patients presenting with unsuspected PE is recommended and can guide the management plan. For patients with isolated incidental subsegmental pulmonary embolism and concomitant deep vein thrombosis, initiating anticoagulants if no contraindications exist is recommended.
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Affiliation(s)
- Aiham Qdaisat
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Adriana H. Wechsler
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Maria T. Cruz Carreras
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jazmin R. Menendez
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Demis Lipe
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Emily A. Highsmith
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Mona Kamal
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Aisha Al-Breiki
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Emergency Medicine, Sultan Qaboos University Hospital, Al Seeb 121, Oman
| | | | - Carol C. Wu
- Department of Thoracic Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sai-Ching J. Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Correspondence: ; Tel.: +1-713-745-9911
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27
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Wu Z, Liu X, Zhu Q, Li H, Li K, Wang G, Tang Z, Wang Z. Pulmonary embolism following urological non-oncological surgery: The clinical features, management, and long-term follow-up outcome from a tertiary hospital of China. Front Surg 2022; 9:930968. [PMID: 36132209 PMCID: PMC9483021 DOI: 10.3389/fsurg.2022.930968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To evaluate the clinical features, treatment, and outcomes of pulmonary embolism (PE) after urological non-oncological surgery in a tertiary hospital of China. Methods A total of eight patients who suffered from PE after urological non-oncological surgery from 2016 to 2019 were recruited to the study. Clinical data such as symptoms, vital signs, electrocardiogram, echocardiography, and computed tomographic pulmonary arteriography (CTPA) were reviewed. In addition, the management and long-term follow-up outcome of PE were reported. Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire was applied for five patients to evaluate health-related quality of life after PE. Results All patients survived during their hospitalization, and five patients were contacted during follow-up. Five of the eight patients were anticoagulated regularly until the re-examination results of CTPA and lower extremities ultrasound were normal. The period of anticoagulant sustained at least one month for each patient. The long-term follow-up outcomes showed that PE had little impact on the patients' quality of life. Conclusions The study demonstrated that the prognosis of PE patients was not as terrible as feared when treated immediately in the ward. Early diagnosis and treatment of PE is vital for prognosis. However, further verifications based on the results of large studies are still needed.
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Affiliation(s)
- Ziqiang Wu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Xuesong Liu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha, China
| | - Quan Zhu
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Haozhen Li
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Kaixuan Li
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Guilin Wang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhengyan Tang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
- Provincial Laboratory for Diagnosis and Treatment of Genitourinary System Disease, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Correspondence: Zhengyan Tang Zhao Wang
| | - Zhao Wang
- Department of Urology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Correspondence: Zhengyan Tang Zhao Wang
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Affiliation(s)
- Susan R Kahn
- From Lady Davis Institute at Jewish General Hospital and the Department of Medicine, McGill University, Montreal (S.R.K.), the Department of Emergency Medicine, Queen's University, Kingston, ON (K.W.), and the Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (K.W.) - all in Canada
| | - Kerstin de Wit
- From Lady Davis Institute at Jewish General Hospital and the Department of Medicine, McGill University, Montreal (S.R.K.), the Department of Emergency Medicine, Queen's University, Kingston, ON (K.W.), and the Departments of Medicine and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON (K.W.) - all in Canada
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Mora D, Nieto JA, Mateo J, Bikdeli B, Barco S, Trujillo-Santos J, Soler S, Font L, Bosevski M, Monreal M. Machine Learning to Predict Outcomes in Patients with Acute Pulmonary Embolism Who Prematurely Discontinued Anticoagulant Therapy. Thromb Haemost 2022; 122:570-577. [PMID: 34107539 DOI: 10.1055/a-1525-7220] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Patients with pulmonary embolism (PE) who prematurely discontinue anticoagulant therapy (<90 days) are at an increased risk for death or recurrences. METHODS We used the data from the RIETE (Registro Informatizado de Pacientes con Enfermedad TromboEmbólica) registry to compare the prognostic ability of five machine-learning (ML) models and logistic regression to identify patients at increased risk for the composite of fatal PE or recurrent venous thromboembolism (VTE) 30 days after discontinuation. ML models included decision tree, k-nearest neighbors algorithm, support vector machine, Ensemble, and neural network [NN]. A "full" model with 70 variables and a "reduced" model with 23 were analyzed. Model performance was assessed by confusion matrix metrics on the testing data for each model and a calibration plot. RESULTS Among 34,447 patients with PE, 1,348 (3.9%) discontinued therapy prematurely. Fifty-one (3.8%) developed fatal PE or sudden death and 24 (1.8%) had nonfatal VTE recurrences within 30 days after discontinuation. ML-NN was the best method for identification of patients experiencing the composite endpoint, predicting the composite outcome with an area under receiver operating characteristic (ROC) curve of 0.96 (95% confidence interval [CI]: 0.95-0.98), using either 70 or 23 variables captured before discontinuation. Similar numbers were obtained for sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. The discrimination of logistic regression was inferior (area under ROC curve, 0.76 [95% CI: 0.70-0.81]). Calibration plots showed similar deviations from the perfect line for ML-NN and logistic regression. CONCLUSION The ML-NN method very well predicted the composite outcome after premature discontinuation of anticoagulation and outperformed traditional logistic regression.
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Affiliation(s)
- Damián Mora
- Department of Internal Medicine, Hospital Virgen de la Luz, Cuenca, Spain
| | - José A Nieto
- Department of Internal Medicine, Hospital Virgen de la Luz, Cuenca, Spain
| | - Jorge Mateo
- Neurobiological Research Group, Institute of Technology, Universidad de Castilla-La Mancha, Cuenca, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States.,Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, Connecticut, United States.,Cardiovascular Research Foundation (CRF), New York, New York, United States
| | - Stefano Barco
- Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland.,Center for Thrombosis and Hemostasis, University Hospital Mainz, Mainz, Germany
| | - Javier Trujillo-Santos
- Department of Internal Medicine, Hospital General Universitario Santa Lucía, Universidad Católica de Murcia, Murcia, Spain
| | - Silvia Soler
- Department of Internal Medicine, Hospital Olot i Comarcal de la Garrotxa, Gerona, Spain
| | - Llorenç Font
- Department of Haematology, Hospital de Tortosa Verge de la Cinta, Tarragona, Spain
| | - Marijan Bosevski
- Faculty of Medicine, University Cardiology Clinic, Skopje, Republic of Macedonia
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain.,Department of Medicine, Universidad Católica de Murcia, Murcia, Spain
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Di Bari V, Gualano G, Musso M, Libertone R, Nisii C, Ianniello S, Mosti S, Mastrobattista A, Cerva C, Bevilacqua N, Iacomi F, Mondi A, Topino S, Goletti D, Girardi E, Palmieri F. Increased Association of Pulmonary Thromboembolism and Tuberculosis during COVID-19 Pandemic: Data from an Italian Infectious Disease Referral Hospital. Antibiotics (Basel) 2022; 11:antibiotics11030398. [PMID: 35326861 PMCID: PMC8944753 DOI: 10.3390/antibiotics11030398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/09/2022] [Accepted: 03/14/2022] [Indexed: 02/01/2023] Open
Abstract
Pulmonary thromboembolism (PTE) has been associated with tuberculosis (TB), but the true incidence is unknown. The aim of our study was to retrospectively evaluate the PTE prevalence in TB patients hospitalized at the National Institute for Infectious Diseases L. Spallanzani during the January 2016–December 2021 period. Retrospective data collection and evaluation were conducted. Among 1801 TB patients, 29 (1.61%) exhibited PTE. Twenty (69%) had comorbidities; eleven (37.9%) had predisposing factors for PTE. Nineteen (65.5%) had extensive TB disease. The commonest respiratory symptoms were cough (37.9%), dyspnea (31%), chest pain (10.3%), and hemoptysis (6.9%). Twenty-five (86.2%) had elevated serum D-dimer levels. An increased prevalence of PTE from 0.6% in the pre-COVID-19 pandemic period to 4.6% in the pandemic period was found. Acute respiratory failure and extensive TB disease increased significantly in the pandemic period. The increase in PTE could be explained by the increased severity of TB in patients in the pandemic period and by increased clinical suspicion and, consequently, increased requests for D-dimer testing, including in patients with non-COVID-19 pneumonia. Patients with extensive pulmonary disease are at high risk of developing PTE. Clinicians should be aware of this potentially life-threatening complication of TB, and patients should receive a thromboembolism risk assessment.
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Affiliation(s)
- Virginia Di Bari
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149 Rome, Italy
| | - Gina Gualano
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149 Rome, Italy
| | - Maria Musso
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149 Rome, Italy
| | - Raffaella Libertone
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149 Rome, Italy
| | - Carla Nisii
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149 Rome, Italy
| | - Stefania Ianniello
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149 Rome, Italy
| | - Silvia Mosti
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149 Rome, Italy
| | | | - Carlotta Cerva
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149 Rome, Italy
| | - Nazario Bevilacqua
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149 Rome, Italy
| | - Fabio Iacomi
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149 Rome, Italy
| | - Annalisa Mondi
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149 Rome, Italy
| | - Simone Topino
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149 Rome, Italy
| | - Delia Goletti
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149 Rome, Italy
| | - Enrico Girardi
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149 Rome, Italy
| | - Fabrizio Palmieri
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, 00149 Rome, Italy
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Kabrhel C, Vinson DR, Mitchell AM, Rosovsky RP, Chang AM, Hernandez‐Nino J, Wolf SJ. A clinical decision framework to guide the outpatient treatment of emergency department patients diagnosed with acute pulmonary embolism or deep vein thrombosis: Results from a multidisciplinary consensus panel. J Am Coll Emerg Physicians Open 2021; 2:e12588. [PMID: 34950930 PMCID: PMC8673564 DOI: 10.1002/emp2.12588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/24/2022] Open
Abstract
The outpatient treatment of select emergency department patients with acute pulmonary embolism (PE) or deep vein thrombosis (DVT) has been shown to be safe, cost effective and associated with high patient satisfaction. Despite this, outpatient PE and DVT treatment remains uncommon. To address this, the American College of Emergency Physicians assembled a multidisciplinary team of content experts to provide evidence-based recommendations and practical advice to help clinicians safely treat patients with low-risk PE and DVT without hospitalization. The emergency clinician must stratify the patient's risk of clinical decompensation due to their PE or DVT as well as their risk of bleeding due to anticoagulation. The clinician must also select and start an anticoagulant and ensure that the patient has access to the medication in a timely manner. Reliable follow-up is critical, and the patient must also be educated about signs or symptoms that should prompt a return to the emergency department. To facilitate access to these recommendations, the consensus panel also created 2 web-based "point-of-care tools."
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Affiliation(s)
- Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular EmergenciesMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - David R. Vinson
- Department of Emergency Medicine, Kaiser Permanente Division of Research and the CREST Network, Oakland, CAKaiser Permanente Roseville Medical CenterRosevilleCaliforniaUSA
| | - Alice Marina Mitchell
- Department of Emergency Medicine, Richard L. Roudebush VAMCIndiana University School of MedicineIndianapolisIndianaUSA
| | - Rachel P. Rosovsky
- Division of HematologyDepartment of MedicineMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Anna Marie Chang
- Department of Emergency MedicineThomas Jefferson University HospitalsPhiladelphiaPennsylvaniaUSA
| | | | - Stephen J. Wolf
- Department of Emergency MedicineDenver Health and University of Colorado School of MedicineDenverColoradoUSA
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Tranexamic acid administration and pulmonary embolism in combat casualties with orthopaedic injuries. OTA Int 2021; 4:e143. [PMID: 34765896 PMCID: PMC8575417 DOI: 10.1097/oi9.0000000000000143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 06/02/2021] [Accepted: 06/15/2021] [Indexed: 01/22/2023]
Abstract
Objectives: In combat casualty care, tranexamic acid (TXA) is administered as part of initial resuscitation effort; however, conflicting data exist as to whether TXA contributes to increased risk of venous thromboembolism (VTE). The purpose of this study is to determine what factors increase risk of pulmonary embolism after combat-related orthopaedic trauma and whether administration of TXA is an independent risk factor for major thromboembolic events. Setting: United States Military Trauma Centers. Patients: Combat casualties with orthopaedic injuries treated at any US military trauma center for traumatic injuries sustained from January 2011 through December 2015. In total, 493 patients were identified. Intervention: None. Main Outcome Measures: Occurrence of major thromboembolic events, defined as segmental or greater pulmonary embolism or thromboembolism-associated pulseless electrical activity. Results: Regression analysis revealed TXA administration, traumatic amputation, acute kidney failure, and hypertension to be associated with the development of a major thromboembolic event for all models. Injury characteristics independently associated with risk of major VTE were Injury Severity Score 23 or greater, traumatic amputation, and vertebral fracture. The best performing model utilized had an area under curve = 0.84, a sensitivity=0.72, and a specificity=0.84. Conclusions: TXA is an independent risk factor for major VTE after combat-related Orthopaedic injury. Injury factors including severe trauma, major extremity amputation, and vertebral fracture should prompt suspicion for increased risk of major thromboembolic events and increased threshold for TXA use if no major hemorrhage is present. Level of evidence: III, Prognostic Study
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Lee YH, Cha SI, Shin KM, Lim JK, Lee WK, Park JE, Choi SH, Seo H, Yoo SS, Lee SY, Lee J, Kim CH, Park JY. Clinical characteristics and outcomes of patients with isolated pulmonary embolism. Blood Coagul Fibrinolysis 2021; 32:387-393. [PMID: 34010169 DOI: 10.1097/mbc.0000000000001050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The clinical relevance of concomitant deep vein thrombosis (DVT) in patients with pulmonary embolism remains controversial. The aim of the present study was to assess clinical characteristics of patients with isolated pulmonary embolism, thereby investigating isolated pulmonary embolism related clinical factors. Patients hospitalized for pulmonary embolism who underwent DVT workup within 3 days of pulmonary embolism diagnosis were retrospectively classified into two groups: patients with isolated pulmonary embolism and patients with DVT-associated pulmonary embolism (DVT-PE). The clinical, laboratorial and radiological parameters were compared between the two groups. Of 1012 patients, 322 (31.8%) presented with isolated pulmonary embolism, and 690 (68.2%) presented with DVT-PE. In a multivariate analysis, female sex was an independent factor for predicting isolated pulmonary embolism [odds ratio (OR) 1.69, 95% confidence interval (CI) 1.26-2.26, P < 0.001], whereas cancer (OR 0.64, 95% CI 0.43-0.96, P = 0.031), leg pain or swelling (OR 0.08, 95% CI 0.04-0.18, P < 0.001), and central pulmonary embolism (OR 0.44, 95% CI 0.32-0.59, P < 0.001) were negatively associated with isolated pulmonary embolism. There were no significant differences between the two groups with regard to risk stratification and short-term prognosis of pulmonary embolism, including adverse outcomes and pulmonary embolism related in-hospital mortality. Of pulmonary embolism patients who underwent imaging tests for DVT, approximately 32% presented with isolated pulmonary embolism. Isolated pulmonary embolism was positively associated with female sex, whereas it was negatively associated with cancer, leg pain or swelling, and central pulmonary embolism. The presence or absence of concomitant DVT did not influence the severity and short-term prognosis of pulmonary embolism.
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Affiliation(s)
| | | | | | | | - Won Kee Lee
- Biostatistics, Medical Research Collaboration Center, Kyungpook National University, Daegu, Korea
| | - Ji-Eun Park
- Department of Internal Medicine, School of Medicine
| | - Sun Ha Choi
- Department of Internal Medicine, School of Medicine
| | - Hyewon Seo
- Department of Internal Medicine, School of Medicine
| | | | - Shin-Yup Lee
- Department of Internal Medicine, School of Medicine
| | - Jaehee Lee
- Department of Internal Medicine, School of Medicine
| | - Chang-Ho Kim
- Department of Internal Medicine, School of Medicine
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Saba L, Sverzellati N. Is COVID Evolution Due to Occurrence of Pulmonary Vascular Thrombosis? J Thorac Imaging 2021; 35:344-345. [PMID: 32349055 PMCID: PMC7253049 DOI: 10.1097/rti.0000000000000530] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
In this hypothesis paper, we suggest that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may induce intravascular pulmonary thrombosis, which may result in the rapid worsening of clinical conditions and, eventually, exitus. Previously published papers have demonstrated that increased levels of D-dimer at hospital admission correlate with a more severe disease (0.5 mg/L) or occurrence of death (1 mg/L). The potential prothrombotic action of the SARS-CoV-2 is supported by the topographical involvement of the lung regions with a predilection for the lower lobe with peripheral involvement. If this hypothesis is demonstrated, this could suggest the benefit of using antithrombotic/coagulation regimens for SARS-CoV-2 and, at the same time, the urgency to identify drugs that could alter the inflammatory storm, thus protecting the vessel wall.
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Affiliation(s)
- Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), Monserrato (Cagliari)
| | - Nicola Sverzellati
- Department of Medicine and Surgery, Division of Radiology, University of Parma, Parma, Italy
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35
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Chronic CT features in PE patients with co-existing DVT. Am J Emerg Med 2021; 46:126-131. [PMID: 33744749 DOI: 10.1016/j.ajem.2021.03.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/07/2021] [Accepted: 03/10/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Clinical features may be different in patients with PE without co-existing DVT compared to those with PE with co-existing DVT. This prospective study aims to investigate the different clinical features between patients with isolated pulmonary embolism (PE) and those with PE associated with deep venous thrombosis. METHOD This is a prospective study conducted in 107 consecutive patients diagnosed with acute PE in the emergency department or other departments of Kırıkkale University Hospital. The diagnosis of PE was confirmed by computed tomography pulmonary angiography (CTPA), which was ordered on the basis of symptoms and findings. Bilateral lower extremity compression ultrasound with standard 7.5 MHz linear array probe was applied to all patients. According to compression ultrasound results, the patients were divided into two classes as with and without deep venous thrombosis. Embolism in the main or lobar pulmonary arteries were classified as central, and those found only in segmental or subsegmental arteries were classified as peripheral. Laboratory parameters and Oxygen saturation were assessed on admission. RESULTS 67 of 107 (62.6%) patients with PE were isolated pulmonary embolism, and 40 (37.4%) were PE + DVT. Patients with PE with co-existing DVT have wider pulmonary artery, higher d-dimer and pro BNP level, and lower saturation than those with isolated pulmonary embolism. Central pulmonary embolism is more common in patients with deep vein thrombus than those without it. (87.5% (35/40) vs 32.8% (22/67),p = 0.001). 38.6% of central pulmonary embolism occur without deep vein thrombosis of the lower extremities. Patients with PE with co-existing DVT have 42.5% mosaic perfusion pattern,70% chronic infarct appearance such as linear band, pleural nodüle, %15.0 thickened, small arteries and, %12.5 shrunken complete artery occlusion, suggesting the chronic background. CONCLUSION PE patients with co-existing DVT are clinically more serious than those who do not have a DVT. An acute picture may be present in the chronic background in a significant proportion of patients with PE with co-existing DVT. In the presence of deep vein thrombosis, pulmonary embolism is usually central, but more than one-third of central pulmonary emboli occur without lower extremity deep vein thrombosis.
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2021; 41:543-603. [PMID: 31504429 DOI: 10.1093/eurheartj/ehz405] [Citation(s) in RCA: 2531] [Impact Index Per Article: 632.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Morillo R, Jiménez D, Bikdeli B, Rodríguez C, Tenes A, Yamashita Y, Morimoto T, Kimura T, Vidal G, Ruiz-Giménez N, Espitia O, Monreal M. Refinement of a modified simplified Pulmonary Embolism Severity Index for elderly patients with acute pulmonary embolism. Int J Cardiol 2021; 335:111-117. [PMID: 33621625 DOI: 10.1016/j.ijcard.2021.02.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/25/2021] [Accepted: 02/12/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the utility of a modified (i.e., without the variable "Age >80 years") simplified Pulmonary Embolism Severity Index (sPESI) in elderly patients with acute symptomatic pulmonary embolism (PE), and to derive and validate a refined version of the sPESI for identification of elderly patients at low risk of adverse events. METHODS The study included normotensive patients aged >80 years with acute PE enrolled in the RIETE registry. We used multivariable logistic regression analysis to create a new risk score to predict 30-day all-cause mortality. We externally validated the new risk score in elderly patients from the COMMAND VTE registry. RESULTS Multivariable logistic regression identified four predictors for mortality: high-risk sPESI, immobilization, coexisting deep vein thrombosis (DVT), and plasma creatinine >2 mg/dL. In the RIETE derivation cohort, the new model classified fewer patients as low risk (4.0% [401/10,106]) compared to the modified sPESI (35% [3522/10,106]). Low-risk patients based on the new model had a lower 30-day mortality than those based on the modified sPESI (1.2% [95% CI, 0.4-2.9%] versus 4.7% [95% CI, 4.0-5.4%]). In the COMMAND VTE validation cohort, 1.5% (3/206) of patients were classified as having low risk of death according to the new model, and the overall 30-day mortality of this group was 0% (95% CI, 0-71%), compared to 5.9% (95% CI, 3.1-10.1%) in the high-risk group. CONCLUSIONS For predicting short-term mortality among elderly patients with acute PE, this study suggests that the new model has a substantially higher sensitivity than the modified sPESI. A minority of these patients might benefit from safe outpatient therapy of their disease.
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Affiliation(s)
- Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; Medicine Department, Universidad de Alcala (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Andrés Tenes
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Gemma Vidal
- Department of Internal Medicine, Corporación Sanitaria Parc Taulí, Barcelona, Spain
| | - Nuria Ruiz-Giménez
- Department of Internal Medicine, Hospital Universitario de La Princesa, Madrid, Spain
| | | | - Manuel Monreal
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Universidad Autónoma de Barcelona, Barcelona, Spain
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Impact of pulmonary embolism on in-hospital mortality of patients with ischemic stroke. J Neurol Sci 2020; 419:117174. [PMID: 33059297 DOI: 10.1016/j.jns.2020.117174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 09/09/2020] [Accepted: 10/05/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is a frequent complication in immobile stroke patients and an important cause of death in stroke patients. We aimed to investigate predictors of PE and the impact of PE on survival of ischemic stroke patients. METHODS Patients were selected by screening the German nationwide inpatient sample (2005-2017) for ischemic stroke (ICD-code I63) and stratified for occurrence of PE (ICD-code I26). Impact of PE on mortality and predictors for PE in ischemic stroke patients were analysed. RESULTS Overall, 2,914,546 patients were hospitalized due to ischemic stroke (50.5% females; 69.3% aged ≥70 years) in Germany 2005-2017. Among these, 0.4% had PE and 7.2% died during hospitalization. In-hospital mortality rate of ischemic stroke patients with PE was substantially higher compared to those patients without PE (28.4% vs. 7.1%, P < 0.001). PE was strongly associated with in-hospital death (OR 5.786, 95%CI 5.515-6.070, P < 0.001). Important predictors of PE were cancer (OR 3.165, 95%CI 2.969-3.374, P < 0.001), coagulation abnormalities (OR 2.672, 95CI 2.481-2.878, P < 0.001), heart failure (OR 1.553, 95%CI 1.472-1.639, P < 0.001) and obesity (OR 1.559, 95%CI 1.453-1.672, P < 0.001). Systemic thrombolysis was not beneficial regarding survival in unselected ischemic stroke patients. In contrast, systemic thrombolysis was beneficial in ischemic stroke patients without PE, who had to undergo cardio-pulmonary resuscitation (OR 0.866, 95%CI 0.782-0.960, P = 0.006). CONCLUSIONS Patients with ischemic stroke revealed still a high in-hospital mortality of 7.2% in Germany. While only a minority of 0.4% of the ischemic stroke patients suffered from occurrence of PE, PE was accompanied by a substantial increase regarding in-hospital mortality. Systemic thrombolysis was beneficial regarding short-term survival in ischemic stroke patients without PE, who had to undergo cardio-pulmonary resuscitation.
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Marchetti AA, Davila BO, Oddi FM, Ippoliti A. Pulmonary embolism: Successful treatment of floating thrombus in SFJ after vena cava filter insertion and surgical thrombectomy. JRSM Cardiovasc Dis 2020; 9:2048004020976256. [PMID: 33294173 PMCID: PMC7708661 DOI: 10.1177/2048004020976256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/03/2020] [Accepted: 11/04/2020] [Indexed: 11/16/2022] Open
Abstract
The floating venous thrombus in the common femoral vein has a high potential risk for pulmonary embolization. Clinical treatments, using anticoagulants or fibrinolytic, open thrombectomies, or thrombectomies by endovascular devices have all been used. Our case describe an obese patient affected by floating thrombus coming from GSV and diving in common femoral vein successful treated by combined both temporary vena cava insertion and open surgical thrombectomy.
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Affiliation(s)
- Andrea Ascoli Marchetti
- Vascular Surgery Unit, Biomedicine and Prevention Department, University of Rome, Rome, Italy
| | | | - Fabio Massimo Oddi
- Vascular Surgery Unit, Biomedicine and Prevention Department, University of Rome, Rome, Italy
| | - Arnaldo Ippoliti
- Vascular Surgery Unit, Biomedicine and Prevention Department, University of Rome, Rome, Italy
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Baumgartner C, Klok FA, Carrier M, Limacher A, Moor J, Righini M, Beer JH, Peluso M, Rakovic D, Huisman MV, Aujesky D. Clinical Surveillance vs. Anticoagulation For low-risk patiEnts with isolated SubSegmental Pulmonary Embolism: protocol for a multicentre randomised placebo-controlled non-inferiority trial (SAFE-SSPE). BMJ Open 2020; 10:e040151. [PMID: 33444199 PMCID: PMC7678381 DOI: 10.1136/bmjopen-2020-040151] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION The clinical significance of subsegmental pulmonary embolism (SSPE) is currently unclear. Although growing evidence from observational studies suggests that withholding anticoagulant treatment may be a safe option in selected patients with isolated SSPE, most patients with this condition receive anticoagulant treatment, which is associated with a 90-day risk of recurrent venous thromboembolism (VTE) of 0.8% and major bleeding of up to 5%. Given the ongoing controversy concerning the risk-benefit ratio of anticoagulation for isolated SSPE and the lack of evidence from randomised-controlled studies, the aim of this clinical trial is to evaluate the efficacy and safety of clinical surveillance without anticoagulation in low-risk patients with isolated SSPE. METHODS AND ANALYSIS SAFE-SSPE (Surveillance vs. Anticoagulation For low-risk patiEnts with isolated SubSegmental Pulmonary Embolism, a multicentre randomised placebo-controlled non-inferiority trial) is an international, multicentre, placebo-controlled, double-blind, parallel-group non-inferiority trial conducted in Switzerland, the Netherlands and Canada. Low-risk patients with isolated SSPE are randomised to receive clinical surveillance with either placebo (no anticoagulation) or anticoagulant treatment with rivaroxaban. All patients undergo bilateral whole-leg compression ultrasonography to exclude concomitant deep vein thrombosis before enrolment. Patients are followed for 90 days. The primary outcome is symptomatic recurrent VTE (efficacy). The secondary outcomes include clinically significant bleeding and all-cause mortality (safety). The ancillary outcomes are health-related quality of life, functional status and medical resource utilisation. ETHICS AND DISSEMINATION The local ethics committees in Switzerland have approved this protocol. Submission to the Ethical Committees in the Netherlands and Canada is underway. The results of this trial will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04263038.
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Affiliation(s)
- Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Marc Carrier
- Department of Medicine, The Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | | | - Jeanne Moor
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc Righini
- Division of Angiology and Haemostasis, Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - Jürg-Hans Beer
- Department of Internal Medicine, Cantonal Hospital of Baden, Baden, Switzerland
| | - Martina Peluso
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Damiana Rakovic
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Nishiwaki S, Morita Y, Yamashita Y, Morimoto T, Amano H, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Izumi T, Tada T, Chen PM, Murata K, Tsuyuki Y, Saga S, Sasa T, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Shiomi H, Kato T, Makiyama T, Ono K, Inoko M, Kimura T. Impact of no, distal, and proximal deep vein thrombosis on clinical outcomes in patients with acute pulmonary embolism: From the COMMAND VTE registry. J Cardiol 2020; 77:395-403. [PMID: 33218901 DOI: 10.1016/j.jjcc.2020.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The majority of acute pulmonary embolism (PE) is caused by thrombus developed from leg veins. However, impact of concomitant deep venous thrombosis (DVT) on clinical outcomes has not been fully evaluated in patients with acute PE. METHODS The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic venous thromboembolism (VTE) in Japan. The current study population consisted of 655 acute PE patients who underwent lower extremities ultrasound examination at diagnosis for the assessment of concomitant DVT status. RESULTS There were 424 patients with proximal DVT (64.7%), 162 patients with distal DVT (24.7%), and 69 patients with no DVT (10.5%). The cumulative 90-day incidence of all-cause death was higher in proximal DVT patients than in distal DVT and no DVT patients (7.9%, 2.5%, and 1.4%, p = 0.01). Regarding the causes of death, the cumulative 90-day incidence of PE-related death was low, and not significantly different across the 3 groups (1.4%, 0.6%, and 1.7%, p = 0.62). The most frequent cause of death was cancer in proximal and distal DVT patients. There were no significant differences in 90-day rates of recurrent VTE and major bleeding, regardless of the status of concomitant DVT (2.9%, 3.2%, and 2.2%, p = 0.79, and 1.5%, 4.4%, and 4.9%, p = 0.46, respectively). CONCLUSIONS Acute PE with proximal DVT at diagnosis was associated with a higher risk for short-term mortality than in patients without DVT, while the risk for short-term mortality was not significantly different between distal DVT patients and patients without DVT.
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Affiliation(s)
- Shushi Nishiwaki
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Yusuke Morita
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan.
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hidewo Amano
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Seiichi Hiramori
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Toshiaki Izumi
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yoshiaki Tsuyuki
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Syunsuke Saga
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Jiro Sakamoto
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | | | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Ikoma, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | | | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Impact of concomitant deep or superficial venous thrombosis of the legs on survival of patients with pulmonary embolism. Int J Cardiol 2020; 315:92-98. [DOI: 10.1016/j.ijcard.2020.05.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 04/04/2020] [Accepted: 05/13/2020] [Indexed: 11/21/2022]
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Prognostic Significance of Incidental Deep Vein Thrombosis in Patients with Cancer Presenting with Incidental Pulmonary Embolism. Cancers (Basel) 2020; 12:cancers12082267. [PMID: 32823554 PMCID: PMC7463961 DOI: 10.3390/cancers12082267] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 01/13/2023] Open
Abstract
In symptomatic acute pulmonary embolism (PE), the presence of deep vein thrombosis (DVT) is a risk factor for 30- and 90-day mortality. In patients with cancer and incidental PE, the prognostic effect of concomitant incidental DVT is unknown. In this retrospective study, we examined the effect of incidental DVT on all-cause mortality in such patients. Adjusted Cox multivariate regression analysis was used for relevant covariates. From January 2010 to March 2018, we included 200 patients (mean age, 65.3 ± 12.4 years) who were followed up for 12.5 months (interquartile range 7.4-19.4 months). Of these patients, 62% had metastases, 31% had concomitant incidental DVT, and 40.1% (n = 81) died during follow-up. All-cause mortality did not increase in patients with DVT (hazard ratio [HR] 1.01, 95% confidence interval [CI] 0.43-2.75, p = 0.855). On multivariate analysis, weight (adjusted HR 0.96, 95% CI 0.92-0.99, p = 0.032), and metastasis (adjusted HR 10.26, 95% CI 2.35-44.9, p = 0.002) were predictors of all-cause mortality. In conclusion, low weight and presence of metastases were associated with all-cause mortality, while presence of concomitant DVT was unrelated to poorer survival.
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Dubois-Silva Á, Barbagelata-López C, Mena Á, Piñeiro-Parga P, Llinares-García D, Freire-Castro S. Pulmonary embolism and screening for concomitant proximal deep vein thrombosis in noncritically ill hospitalized patients with coronavirus disease 2019. Intern Emerg Med 2020; 15:865-870. [PMID: 32592114 PMCID: PMC7318906 DOI: 10.1007/s11739-020-02416-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/20/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Álvaro Dubois-Silva
- Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain.
- Universidade da Coruña (UDC), A Coruña, Spain.
| | - Cristina Barbagelata-López
- Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
| | - Álvaro Mena
- Universidade da Coruña (UDC), A Coruña, Spain
- Infectious Diseases Unit, Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
| | - Patricia Piñeiro-Parga
- Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
| | - Diego Llinares-García
- Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
| | - Santiago Freire-Castro
- Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña (CHUAC), Servizo Galego de Saúde (SERGAS), A Coruña, Spain
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Adverse Events and Mortality in Anticoagulated Patients with Different Categories of Pulmonary Embolism. Mayo Clin Proc Innov Qual Outcomes 2020; 4:249-258. [PMID: 32542216 PMCID: PMC7283932 DOI: 10.1016/j.mayocpiqo.2020.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective To determine whether the pulmonary embolism (PE) categories of massive, submassive, PE with no right ventricle dysfunction (NRVD), and subsegmental only (SSO) adequately predict clinical outcome. Methods Patients treated for acute PE (March 1, 2013, through July 31, 2019) were followed forward prospectively to compare venous thromboembolism (VTE) recurrence, all-cause mortality, major bleeding, and clinically relevant nonmajor bleeding (CRNMB) across 4 PE categories. Results Of 2703 patients with VTE, 1188 (44%) had PE, of which 1021 (85.9%) completed at least 3 months of therapy or had clinical outcomes precluding further treatment (27 with massive, 217 submassive, 557 NRVD, and 220 SSO PE). One patient with massive, 8 with submassive, 23 with NRVD, and 5 with SSO PE had recurrent VTE (3.90, 5.33, 5.36, and 3.66 per 100 person-years, respectively; P=.84). There were 3 deaths in massive, 27 in submassive, 140 in NRVD, and 34 in SSO PE groups (11.59, 17.37, 31.74, and 24.74 per 100 person-years, respectively; P=.02); when adjusted for cancer, the relationship was no longer significant (P=.27). One patient with massive, 5 with submassive, 22 with NRVD, and 5 with SSO PE had major bleeding (3.90, 3.31, 5.24, and 3.75 per 100 person-years, respectively; P=.66). Similar cumulative rates for CRNMB were observed (P=.87). Three-month rates of VTE recurrence, death, major bleeding, and CRNMB did not differ by PE category. Conclusion In the setting of anticoagulation therapy with maximal standardization and evidence-based practice, there is no evidence of a difference between PE categories and outcomes. Trial Registration clinicaltrials.gov Identifier: NCT03504007.
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Key Words
- AHA, American Heart Association
- CRNMB, clinically relevant nonmajor bleeding
- CT, computed tomography
- DVT, deep vein thrombosis
- HR, hazard ratio
- NRVD, no right ventricle dysfunction
- PE, pulmonary embolism
- PESI, Pulmonary Embolism Severity Index
- RV, right ventricle
- SSO, subsegmental only
- VTE, venous thromboembolism
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Kabrhel C, Rosovsky R, Garvey S. Special Considerations in Pulmonary Embolism: Clot-in-Transit and Incidental Pulmonary Embolism. Crit Care Clin 2020; 36:531-546. [PMID: 32473697 DOI: 10.1016/j.ccc.2020.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This article describes 2 relatively rare, but complex situations in pulmonary embolism (PE): clot-in-transit (CIT), incidental PE (IPE). CIT describes a venous thromboembolism that has become lodged in the right heart. CIT is associated with high mortality and presents unique challenges in management. Incidental PE (IPE) describes PE diagnosed on imaging performed for another indication. The treatment is complex because there is often a disconnect between the PE severity on imaging and lack of severity of the clinical presentation. We summarize the available literature and aid clinicians as they manage patients with PE across the clinical severity spectrum.
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Affiliation(s)
- Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA.
| | - Rachel Rosovsky
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Shannon Garvey
- Boston University School of Medicine, 72 E Concord Street, Boston, MA 02118, USA
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Wang XH, Cui LB, Liu Y, Han X, Chi J, Yang B, Chen H. Association between risk stratification for pulmonary embolism and deep vein thrombosis of lower extremities. CLINICAL RESPIRATORY JOURNAL 2020; 14:631-637. [PMID: 32125778 DOI: 10.1111/crj.13177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 02/09/2020] [Accepted: 02/23/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The association of clinical risk factors, in particular deep vein thrombosis (DVT), with risk stratification for pulmonary embolism (PE) remains to be identified. We therefore aimed to establish the relationship between risk stratification of PE patients and DVT of lower extremities. METHODS In this retrospective study, 93 out of 485 PE patients with uncompleted clinical data were excluded, resulting in 392 patients included for analysis. Based on the ESC criteria, 24, 171, and 197 patients were categorized into high (6.1%), intermediate (43.6%), and low risk (50.3%) subgroups, respectively. RESULTS DVT was detected in 304 patients (77.6%). The incidence of DVT in patients with high and intermediate risk PE was much lower than in those patients with low risk PE (67.2% vs 87.8%, P < .0001). Further analyses of the 304 patients with DVT showed higher incidence of high and intermediate risk PE in patients with isolated distal DVT than proximal DVT (59.0% vs 39.1%, P = .005), with asymptomatic DVT than symptomatic DVT (63.0% vs 36.8%, P < .0001), and with bilateral DVT than unilateral DVT (54.5% vs 39.9%, P = .03). Stepwise logistic regression showed that symptomatic or asymptomatic DVT was an independent risk factor for risk stratification of PE patients with DVT (0.320, 95% confidence interval, 0.186-0.550). CONCLUSIONS Patients with high and intermediate risk PE presented lower incidence of DVT compared with patients with low risk PE. In PE patients with comorbid DVT, asymptomatic DVT is an independent risk factor for high and intermediate risk of PE.
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Affiliation(s)
- Xiao-Hui Wang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China
| | - Long-Biao Cui
- Department of Radiology, The Second Medical Center, Chinese PLA General Hospital, Beijing, P. R. China
| | - Yuliang Liu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China
| | - Xiaoli Han
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China
| | - Jing Chi
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China
| | - Bijun Yang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P. R. China
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48
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Moya Mateo E, Muñoz Rivas N. Clinical ultrasonography in venous thromboembolism disease. Rev Clin Esp 2020. [DOI: 10.1016/j.rceng.2019.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Moya Mateo E, Muñoz Rivas N. Ecografía clínica en la enfermedad tromboembólica venosa. Rev Clin Esp 2020; 220:126-134. [DOI: 10.1016/j.rce.2019.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 05/27/2019] [Indexed: 10/26/2022]
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Abstract
Venous thromboembolism is a common disease which remains underdiagnosed because of nonspecific presentations which can range from asymptomatic incidental imaging findings to sudden death. Symptoms can overlap with comorbid cardiopulmonary disease, and risk factors that offer clues to the clinician are not always present. The diagnostic approach can vary depending on the specific clinical presentation, but ruling in the diagnosis nearly always depends on lung imaging. Overuse of diagnostic testing is another recognized problem; a cautious, evidence-based approach is required, although physician gestalt must be acknowledged. The following review offers an approach to the diagnosis of acute pulmonary embolism based on the assessment of symptoms, signs, risk factors, laboratory findings, and imaging studies.
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Affiliation(s)
- Ella Ishaaya
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, 19129, USA
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
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