scholarly journals Optimizing the Personalized, Risk-Adjusted Management of Pulmonary Embolism: An Integrated Clinical Trial Programme

2018 ◽  
Vol 39 (02) ◽  
pp. 117-127 ◽  
Author(s):  
Stefano Barco ◽  
Stavros V. Konstantinides
Keyword(s):  
Clinical Trial ◽  
Pulmonary Embolism ◽  
Clinical Pathways ◽  
Early Death ◽  
Cardiac Biomarkers ◽  
Haemodynamic Monitoring ◽  
Haemodynamic Instability ◽  
Clinical Trial Programme ◽  
Personalized Risk ◽  
Acute Pe

AbstractAcute pulmonary embolism (PE) contributes significantly to the global burden of cardiovascular disease. The severity of the acute PE event determines the expected estimated risk of early death. This risk is influenced by the degree of dysfunction of the right ventricle (RV), as assessed by the presence of acute RV pressure overload on imaging and/or elevated cardiac biomarkers, and by demographic and clinical factors, including relevant comorbidities. Haemodynamic instability and cardiogenic shock is at the top of the PE severity spectrum, as it represents the most extreme manifestation of RV failure and a key determinant of poor prognosis. Ideally, risk-adjusted treatment should implement: (1) optimized timing and regimens of reperfusion therapy for unstable patients; (2) early discharge and continuation of anticoagulation treatment at home (low-risk PE); or (3) hospital admission and clinical/haemodynamic monitoring in patients at intermediate risk. The challenge is now to provide the basis for a comprehensive personalized, risk-adjusted care for patients with acute PE. The aim of the integrated academic clinical trial programme of the Center for Thrombosis and Hemostasis at the University of Mainz is to develop and prospectively validate, in multinational studies, strategies for reperfusion and anticoagulant treatment of acute PE across the entire spectrum of early risk as well as clinical pathways for post-PE patient care and follow-up.

scholarly journals Does Baseline BUN Have an Additive Effect on the Prediction of Mortality in Patients with Acute Pulmonary Embolism?

2020 ◽  
Author(s):  
Yaser Jenab ◽  
Ali-Mohammad Haji-Zeinali ◽  
Mohammad Javad Alemzadeh-Ansari ◽  
Shapour Shirani ◽  
Mojtaba Salarifar ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Acute Pulmonary Embolism ◽  
Low Risk ◽  
Cardiac Biomarkers ◽  
Operating Characteristics ◽  
Short Term ◽  
Prediction Of Mortality ◽  
Short Term Mortality ◽  
Acute Pe

Background: In patients with heart failure, elevated levels of blood urea nitrogen (BUN) is a prognostic factor. In this study, we investigated the prognostic value of elevated baseline BUN in short-term mortality among patients with acute pulmonary embolism (PE). Methods: Between 2007 and 2014, cardiac biomarkers and BUN levels were measured in patients with acute PE. The primary endpoint was 30-day mortality, evaluated based on the baseline BUN (≥14 ng/L) level in 4 groups of patients according to the European Society of Cardiology’s risk stratification (low-risk, intermediate low-risk, intermediate high-risk, and high-risk). Results: Our study recruited 492 patients with a diagnosis of acute PE (mean age=60.58±16.81 y). The overall 1-month mortality rate was 6.9% (34 patients). Elevated BUN levels were reported in 316 (64.2%) patients. A high simplified pulmonary embolism severity index (sPESI) score (OR: 5.23, 95% CI: 1.43–19.11; P=0.012), thrombolytic or thrombectomy therapy (OR: 2.42, 95% CI: 1.01–5.13; P=0.021), and elevated baseline BUN levels (OR: 1.04, 95% CI: 1.01–1.03; P=0.029) were the independent predictors of 30-day mortality. According to our receiver-operating characteristics analysis for 30-day mortality, a baseline BUN level of greater than 14.8 mg/dL was considered elevated. In the intermediate-low-risk patients, mortality occurred only in those with elevated baseline BUN levels (7.2% vs. 0; P=0.008). Conclusion: An elevated baseline BUN level in our patients with PE was an independent predictor of short-term mortality, especially among those in the intermediate-risk group.

scholarly journals Elevated Cardiac Biomarkers With Normal Right Ventricular Size Indicate an Unlikely Diagnosis of Acute Pulmonary Embolism in Stable Patients

2011 ◽  
Vol 17 (6) ◽  
pp. E153-E157
Author(s):  
Paul D. Stein ◽  
Muhammad Janjua ◽  
Fadi Matta ◽  
Fadel Jaweesh ◽  
Ahmed Alrifai ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Right Ventricular ◽  
Cardiac Troponin ◽  
Acute Pulmonary Embolism ◽  
Troponin I ◽  
Cardiac Biomarkers ◽  
Coronary Syndrome ◽  
Right Ventricular Size ◽  
Acute Pe ◽  
Creatine Kinase Isoenzyme Mb

The purpose of this investigation is to assess the prevalence of elevated cardiac biomarkers, with or without estimates of right ventricular (RV) size, in stable patients with acute pulmonary embolism (PE). Our hypothesis is that the combination of high levels of cardiac troponin I (cTnI), high creatine kinase isoenzyme MB (CK-MB), and normal size RV are sufficiently uncommon in stable patients with PE to make the diagnosis of PE unlikely. Retrospective review showed a high cTnI plus high CK-MB in 20 (3.4%) of 585 stable patients with acute PE. A high cTnI plus high CK-MB with normal RV size was shown in 5 (1.9%) of 264 patients. In stable patients with such findings, therefore, PE is unlikely and other diagnoses, particularly acute coronary syndrome, should be considered before pursuing a diagnosis of PE.

scholarly journals Clinical and anamnestic characteristics and risk factors in patients with acute pulmonary embolism among residents of Kharkiv

2021 ◽  
Vol 17 (3) ◽  
pp. 58-63
Author(s):  
V.Y. Tseluyko ◽  
L.M. Yakovleva ◽  
S.M. Sukhova ◽  
K.Yu. Kinoshenko ◽  
O.V. Radchenko ◽  
...  
Keyword(s):  
Risk Factors ◽  
Pulmonary Embolism ◽  
Acute Pulmonary Embolism ◽  
Varicose Veins ◽  
Pulmonary Arteries ◽  
Lower Extremities ◽  
Right Ventricular Dysfunction ◽  
Early Death ◽  
City Council ◽  
Acute Pe

Background. The purpose was the analysis of the features of the course and the leading factors in the development of pulmonary embolism. Materials and methods. During the period from November 1, 2019, to December 2020, inclusive, 188 patients with acute pulmonary embolism (PE), aged 46 to 80 years old, were hospitalized at the City Clinical Hospital 8 of the Kharkiv City Council; the average age was 62.9 ± 16.7 years. In-hospital mortality was 12.2 % (23 patients). The criterion for inclusion in the study was acute PE, which was diagnosed based on the results of multislice computed tomographic angiography of the pulmonary arteries (MCT angiography of the pulmonary arteries). All patients underwent a general clinical examination, the risk and prognosis were assessed based on the generally accepted scales, standard transthoracic echocardiography (EchoCG), and Doppler ultrasound examination of the veins of the lower extremities were performed. Results. The disease was diagnosed with the same frequency in men and women; there was no difference in age. Among the most significant and important risk factors for the development of pulmonary embolism are the history of venous thrombosis/embolism and active malignant oncological disease (43 and 35 %, respectively), while the less significant ones were advanced age, varicose veins of the lower extremities and arterial hypertension 47.9, 31.4 and 52.1 %, respectively. The vast majority (57.4 %) had a combination of 2 or more risk factors. Signs of right ventricular dysfunction according to MCT angiography of the pulmonary arteries and/or echocardiography were recorded in 45.7 % of patients. A high and medium-high risk of early death associated with acute PE was found in a significant percentage (71.8 %) of patients, which required the inclusion of a thrombolytic agent in the treatment strategy.

Diagnostic accuracy of magnetic resonance angiography for acute pulmonary embolism - a systematic review and meta-analysis

VASA ◽  
2016 ◽  
Vol 45 (2) ◽  
pp. 149-154 ◽  
Author(s):  
Jie Li ◽  
Lei Feng ◽  
Jiangbo Li ◽  
Jian Tang
Keyword(s):  
Pulmonary Embolism ◽  
Magnetic Resonance ◽  
Magnetic Resonance Angiography ◽  
Diagnostic Accuracy ◽  
Acute Pulmonary Embolism ◽  
Meta Analysis ◽  
Likelihood Ratios ◽  
Summary Receiver Operating Characteristic ◽  
Acute Pe ◽  
Limited Sensitivity

Abstract. Background: The aim of this meta-analysis was to evaluate the diagnostic accuracy of magnetic resonance angiography (MRA) for acute pulmonary embolism (PE). Methods: A systematic literature search was conducted that included studies from January 2000 to August 2015 using the electronic databases PubMed, Embase and Springer link. The summary receiver operating characteristic (SROC) curve, sensitivity, specificity, positive likelihood ratios (PLR), negative likelihood ratios (NLR), and diagnostic odds ratio (DOR) as well as the 95 % confidence intervals (CIs) were calculated to evaluate the diagnostic accuracy of MRA for acute PE. Meta-disc software version 1.4 was used to analyze the data. Results: Five studies were included in this meta-analysis. The pooled sensitivity (86 %, 95 % CI: 81 % to 90 %) and specificity (99 %, 95 % CI: 98 % to 100 %) demonstrated that MRA diagnosis had limited sensitivity and high specificity in the detection of acute PE. The pooled estimate of PLR (41.64, 95 % CI: 17.97 to 96.48) and NLR (0.17, 95 % CI: 0.11 to 0.27) provided evidence for the low missed diagnosis and misdiagnosis rates of MRA for acute PE. The high diagnostic accuracy of MRA for acute PE was demonstrated by the overall DOR (456.51, 95 % CI: 178.38 - 1168.31) and SROC curves (AUC = 0.9902 ± 0.0061). Conclusions: MRA can be used for the diagnosis of acute PE. However, due to limited sensitivity, MRA cannot be used as a stand-alone test to exclude acute PE.

scholarly journals Levosimendan, milrinone and dobutamine in acute experimental pulmonary embolism

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
MD Lyhne ◽  
SJ Dragsbaek ◽  
JV Hansen ◽  
JG Schultz ◽  
A Andersen ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Acute Pulmonary Embolism ◽  
Cardiovascular Effects ◽  
Right Heart Catheterization ◽  
Mechanical Work ◽  
Heart Catheterization ◽  
Funding Sources ◽  
Mean Pulmonary Arterial Pressure ◽  
Acute Pe ◽  
Rv Function

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Laerdal Foundation for Acute Medicine, Novo Nordisk Foundation Background/Introduction: Acute pulmonary embolism (PE) is a frequent condition in acute cardiac care and is potentially fatal. Cause of death is right ventricular (RV) failure due to increased RV afterload from both pulmonary vascular obstruction and vasoconstriction. Inodilators are interesting drugs of choice as they may improve RV function and lower its afterload. Purpose We aimed to investigate the cardiovascular effects of three clinically relevant inodilators: levosimendan, milrinone and dobutamine in acute PE. Methods We conducted a randomized, blinded, animal study using 18 female pigs. Animals received large autologous PE until doubling of baseline mean pulmonary arterial pressure and were randomized to four logarithmically increasing doses of each inodilator. Effects were evaluated with bi-ventricular pressure-volume loop recordings, right heart catheterization and blood gas analyses. Results Induction of PE increased RV afterload and pulmonary pressure (p < 0.05) causing RV dysfunction. Levosimendan and milrinone showed beneficial hemodynamic profiles by lowering RV pressures and volume (p < 0.001) and improved RV function and cardiac output (p < 0.05) without increasing RV mechanical work. Dobutamine increased RV pressure and function (p < 0.01) but at a cost of increased mechanical work at the highest doses, showing an adverse hemodynamic profile. See Figure. Conclusion(s): In a porcine model of acute PE, levosimendan and milrinone reduced RV afterload and improved RV function, whereas dobutamine at higher doses increased RV afterload and RV mechanical work. The study motivates clinical testing of inodilators in patients with acute PE and RV dysfunction. Abstract Figure. Inodilators in acute pulmonary embolism

Renal function improves mortality prediction in acute pulmonary embolism: results of a multicentre cohort study with external validation in the RIETE registry

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
R Chopard ◽  
D Jimenez ◽  
G Serzian ◽  
F Ecarnot ◽  
N Falvo ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Renal Function ◽  
High Risk ◽  
Renal Dysfunction ◽  
External Validation ◽  
Mortality Prediction ◽  
Model Fit ◽  
Funding Source ◽  
Risk Of Death ◽  
Acute Pe

Abstract Background Renal dysfunction may influence outcomes after pulmonary embolism (PE). We determined the incremental value of adding renal function impairment (estimated glomerular filtration rate, eGFR <60 ml/min/1.73m2) on top of the 2019 ESC prognostic model, for the prediction of 30-day all-cause mortality in acute PE patients from a prospective, multicenter cohort. Methods and results We identified which of three eGFR formulae predicted death most accurately. Changes in global model fit, discrimination, calibration and net reclassification index (NRI) were evaluated with addition of eGFR. We prospectively included consecutive adult patients with acute PE diagnosed as per ESC guidelines. Among 1,943 patients, (mean age 67.3±17.1, 50.4% women), 107 (5.5% (95% CI 4.5–6.5%)) died during 30-day follow-up. The eGFRMDRD4 formula was the most accurate for prediction of death. The observed mortality rate was higher for intermediate-low risk (OR 1.8, 95% CI 1.1–3.4) and high-risk PE (OR 10.3, 95% CI 3.6–17.3), and 30-day bleeding was significantly higher (OR 2.1, 95% CI 1.3–3.5) in patients with vs without eGFRMDRD4 <60 ml/min/1.73m2. The addition of eGFRMDRD4 information improved model fit, discriminatory capacity, and calibration of the ESC models. NRI was significantly improved (p<0.001), with 18% reclassification of predicted mortality, specifically in intermediate and high-risk PE. External validation using data from the RIETE registry confirmed our findings (Table). Conclusion Addition of eGFRMDRD4-derived renal dysfunction on top of the ESC prognostic algorithm yields significant reclassification of risk of death in intermediate and high-risk PE. Impact on therapy remains to be determined. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): BMS-Pfizer Alliance, Bayer Healthcare

scholarly journals Computed Tomography Pulmonary Perfusion for Prediction of Short-Term Clinical Outcome in Acute Pulmonary Embolism

TH Open ◽  
2021 ◽  
Vol 05 (01) ◽  
pp. e66-e72
Author(s):  
Lisette F. van Dam ◽  
Lucia J. M. Kroft ◽  
Menno V. Huisman ◽  
Maarten K. Ninaber ◽  
Frederikus A. Klok
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Predictive Value ◽  
Acute Pulmonary Embolism ◽  
Clinical Presentation ◽  
Reperfusion Therapy ◽  
Pulmonary Perfusion ◽  
Short Term ◽  
Acute Pe ◽  
Related Mortality

Abstract Background Computed tomography pulmonary angiography (CTPA) is the imaging modality of choice for the diagnosis of acute pulmonary embolism (PE). With computed tomography pulmonary perfusion (CTPP) additional information on lung perfusion can be assessed, but its value in PE risk stratification is unknown. We aimed to evaluate the correlation between CTPP-assessed perfusion defect score (PDS) and clinical presentation and its predictive value for adverse short-term outcome of acute PE. Patients and Methods This was an exploratory, observational study in 100 hemodynamically stable patients with CTPA-confirmed acute PE in whom CTPP was performed as part of routine clinical practice. We calculated the difference between the mean PDS in patients with versus without chest pain, dyspnea, and hemoptysis and 7-day adverse outcome. Multivariable logistic regression analysis and likelihood-ratio test were used to assess the added predictive value of PDS to CTPA parameters of right ventricle dysfunction and total thrombus load, for intensive care unit admission, reperfusion therapy and PE-related death. Results We found no correlation between PDS and clinical symptoms. PDS was correlated to reperfusion therapy (n = 4 with 16% higher PDS, 95% confidence interval [CI]: 3.5–28%) and PE-related mortality (n = 2 with 22% higher PDS, 95% CI: 4.9–38). Moreover, PDS had an added predictive value to CTPA assessment for PE-related mortality (from Chi-square 14 to 19, p = 0.02). Conclusion CTPP-assessed PDS was not correlated to clinical presentation of acute PE. However, PDS was correlated to reperfusion therapy and PE-related mortality and had an added predictive value to CTPA-reading for PE-related mortality; this added value needs to be demonstrated in larger studies.

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