P5021Hypoperfusion markers identify patients with acute pulmonary embolism at highest risk for an adverse outcome

Abstract Background/Introduction According to the European Society of Cardiology (ESC) 2014 guideline, systemic hypotension (HT) is the critical variable defining high-risk in patients with pulmonary embolism (PE). However, signs of organ hypoperfusion might more adequately identify PE patients with cardiogenic shock due to right ventricular (RV) failure. Purpose We investigated whether hypoperfusion markers provide superior prognostic information for identifying PE patients at highest risk of early adverse outcomes. Methods Consecutive PE patients enrolled in a prospective single-centre registry between 09/2008 and 03/2018 were included. We analysed the predictive value of symptoms and findings suggesting hypoperfusion for in-hospital adverse outcome (catecholamine treatment, resuscitation or PE-related death) and in-hospital all-cause mortality. Results We analysed 814 patients, including 83 (10.2%) ESC 2014 high-risk patients. Patients presenting with cardiac arrest (CA, 4.5%) were a priori defined as high risk. Markers suggesting hypoperfusion of the brain (altered metal status, odds ratio [OR] 8.2 [95% CI, 4.2–16.0]), lung (respiratory insufficiency, 25.0 [9.4–66.7]) and tissue (venous lactate ≥2.2 mmol/l, 6.4 [3.2–12.9]) as well as HT (13.5 [6.7–27.2]) predicted an adverse outcome. The risk for an adverse outcome increased with the number of positive markers (AUC 0.86 [0.80–0.93]). Patients with ≥3 positive hypoperfusion markers had an OR of 42.9 (11.0–167.3) and patients defined as high-risk by the ESC 2014 an OR of 17.2 (8.8–33.3) with regard to an adverse outcome (Figure 1; Table 1). A new definition of high-risk (CA or ≥3 hypoperfusion markers) was associated with an OR of 73.2 (31.3–171.1) for an in-hospital adverse outcome and 26.2 (12.1–56.7) for in-hospital mortality. Table 1. Prognostic performance of hypoperfusion markers Adverse outcome (if negative) Adverse outcome (if positive) Sensitivity Specificity LR+ OR (95% CI) ≥1 hypoperfusion marker 1.1% 21.0% 91.9% 68.2% 2.9 24.4 (7.3–80.8) ≥2 hypoperfusion markers 4.7% 50.0% 48.6% 95.5% 10.9 20.3 (9.1–45.1) ≥3 hypoperfusion markers 6.5% 75.0% 24.3% 99.3% 32.7 42.9 (11.0–167.3) ESC 2014 high-risk 5.7% 51.1% 35.0% 96.9% 11.4 17.2 (8.8–33.3) Cardiac arrest 8.4% 86.5% 33.0% 99.3% 47.3 70.1 (26.4–186.1) Abbreviations: LR+, positive likelihood ratio; OR, odds ratio; CI, confidence interval. Figure 1. Frequency of adverse outcome Conclusions Markers of organ hypoperfusion have high predictive value for early adverse outcomes in acute PE. Risk increases with the number of positive markers and is critically elevated in patients presenting with CA or ≥3 markers. Acknowledgement/Funding This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503).

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Prognostic impact of copeptin in pulmonary embolism: a multicentre validation study

European Respiratory Journal ◽

10.1183/13993003.02037-2017 ◽

2018 ◽

Vol 51 (4) ◽

pp. 1702037 ◽

Cited By ~ 14

Author(s):

Kristian Hellenkamp ◽

Piotr Pruszczyk ◽

David Jiménez ◽

Anna Wyzgał ◽

Deisy Barrios ◽

...

Keyword(s):

At Risk ◽

Pulmonary Embolism ◽

High Risk ◽

Risk Stratification ◽

Adverse Outcome ◽

Adverse Outcomes ◽

Prognostic Impact ◽

High Risk Patients ◽

Increased Risk ◽

Risk Patients

To externally validate the prognostic impact of copeptin, either alone or integrated in risk stratification models, in pulmonary embolism (PE), we performed a post hoc analysis of 843 normotensive PE patients prospectively included in three European cohorts.Within the first 30 days, 21 patients (2.5%, 95% CI 1.5–3.8) had an adverse outcome and 12 (1.4%, 95% CI 0.7–2.5) died due to PE. Patients with copeptin ≥24 pmol·L−1 had a 6.3-fold increased risk for an adverse outcome (95% CI 2.6–15.5, p<0.001) and a 7.6-fold increased risk for PE-related death (95% CI 2.3–25.6, p=0.001). Risk classification according to the 2014 European Society of Cardiology (ESC) guideline algorithm identified 248 intermediate-high-risk patients (29.4%) with 5.6% (95% CI 3.1–9.3) at risk of adverse outcomes. A stepwise biomarker-based risk assessment strategy (based on high-sensitivity troponin T, N-terminal pro-brain natriuretic peptide and copeptin) identified 123 intermediate-high-risk patients (14.6%) with 8.9% (95% CI 4.5–15.4) at risk of adverse outcomes. The identification of patients at higher risk was even better when copeptin was measured on top of the 2014 ESC algorithm in intermediate-high-risk patients (adverse outcome OR 11.1, 95% CI 4.6–27.1, p<0.001; and PE-related death OR 13.5, 95% CI 4.2–43.6, p<0.001; highest risk group versus all other risk groups). This identified 85 patients (10.1%) with 12.9% (95% CI 6.6–22.0) at risk of adverse outcomes and 8.2% (95% CI 3.4–16.2) at risk of PE-related deaths.Copeptin improves risk stratification of normotensive PE patients, especially when identifying patients with an increased risk of an adverse outcome.

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Venous lactate predicts adverse outcomes in normotensive pulmonary embolism

European Heart Journal ◽

10.1093/ehjci/ehaa946.2241 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Ebner ◽

C.F Pagel ◽

C Sentler ◽

V.-P Harjola ◽

H Bueno ◽

...

Keyword(s):

Pulmonary Embolism ◽

Risk Stratification ◽

Predictive Value ◽

Prognostic Value ◽

Adverse Outcome ◽

Adverse Outcomes ◽

Funding Source ◽

Arterial Lactate ◽

Upper Limit ◽

All Cause Mortality

Abstract Background/Introduction Arterial lactate is an established risk marker in patients with acute pulmonary embolism (PE). However, its clinical application is limited by the need for an arterial puncture, a procedure not routinely performed in haemodynamically stable PE patients. In contrast, information on venous lactate can be easily obtained via peripheral venepuncture and might thus be more suitable for risk assessment in normotensive PE. Purpose To investigate the prognostic value of peripheral venous lactate for outcome prediction in normotensive patients with acute PE. Methods Consecutive normotensive PE patients enrolled in a prospective single-centre registry between 09/2008 and 03/2018 were studied. Study outcomes included in-hospital adverse outcome (PE-related death, cardiopulmonary resuscitation or vasopressor treatment) and all-cause mortality. An optimised venous lactate cut-off concentration was identified using receiver operating curve analysis and its prognostic value compared to the established cut-off value for arterial lactate (2.0 mmol/l) and the upper limit of normal for venous lactate (2.3 mmol/l). Furthermore, we tested if addition of venous lactate to the 2019 European Society of Cardiology (ESC) risk stratification algorithm improves risk prediction. Results We analysed data from 419 (age 70 [interquartile range (IQR) 57–79] years; 53% female) patients. Patients with an in-hospital adverse outcome had higher venous lactate concentrations than those with a favourable clinical course (3.1 [IQR 1.3–4.9] vs. 1.6 [IQR 1.2–2.3] mmol/l, p=0.001). An optimized cut-off value of 3.3 mmol/l predicted both, adverse outcome (OR 11.0 [95% CI 4.6–26.3]) and all-cause mortality (OR 3.8 [95% CI 1.3–11.3]). Venous lactate ≥2.0 mmol/l and ≥2.3 mmol/l had lower predictive value for an adverse outcome (OR 3.6 [95% CI 1.5–8.7] and OR 5.7 [95% CI 2.4–13.6], respectively) and did not predict all-cause mortality. If venous lactate was added to the 2019 ESC algorithm (Figure), a cut-off concentration of 2.3 mmol/l had high negative predictive value (0.99 [95% CI 0.97–1.00]) for an adverse outcome in intermediate-low-risk patients, whereas levels ≥3.3 mmol/l predicted adverse outcomes in the intermediate-high-risk group (OR 5.2 (95% CI 1.8–15.0). Conclusions Even modest venous lactate elevations above the upper limit of normal (2.3 mmol/l) were associated with increased risk for an in-hospital adverse outcome and a cut-off value of 3.3 mmol/l provided optimal prognostic performance predicting both, an adverse outcome and all-cause mortality. Adding venous lactate to the 2019 ESC algorithm seems to further improve risk stratification. Importantly, the established cut-off value for arterial lactate (2.0 mmol/l) has limited specificity in venous samples and should not be used. Venous lactate for risk stratification Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the German Federal Ministry of Education and Research (BMBF 01EO1503). The authors are responsible for the contents of this publication. BRAHMS GmbH, part of Thermo Fisher Scientific, Hennigsdorf/Berlin, Germany provided financial support for biomarker measurements. The sponsor was neither involved in biomarker measurements, statistical analyses, writing of the abstract nor had any influence on the scientific contents.

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Age-adjusted high-sensitivity troponin T cut-off value for risk stratification of pulmonary embolism

European Respiratory Journal ◽

10.1183/09031936.00174514 ◽

2015 ◽

Vol 45 (5) ◽

pp. 1323-1331 ◽

Cited By ~ 17

Author(s):

Anja Kaeberich ◽

Valerie Seeber ◽

David Jiménez ◽

Maciej Kostrubiec ◽

Claudia Dellas ◽

...

Keyword(s):

Pulmonary Embolism ◽

Adverse Outcome ◽

Troponin T ◽

High Sensitivity ◽

Severity Index ◽

Characteristic Analysis ◽

Prognostic Information ◽

High Sensitivity Troponin ◽

Advanced Therapy ◽

High Sensitivity Troponin T

High-sensitivity troponin T (hsTnT) helps in identifying pulmonary embolism patients at low risk of an adverse outcome. In 682 normotensive pulmonary embolism patients we investigate whether an optimised hsTnT cut-off value and adjustment for age improve the identification of patients at elevated risk.Overall, 25 (3.7%) patients had an adverse 30-day outcome. The established hsTnT cut-off value of 14 pg·mL−1 retained its high prognostic value (OR (95% CI) 16.64 (2.24–123.74); p=0.006) compared with the cut-off value of 33 pg·mL−1 calculated by receiver operating characteristic analysis (7.14 (2.64–19.26); p<0.001). In elderly (aged ≥75 years) patients, an age-optimised hsTnT cut-off value of 45 pg·mL−1 but not the established cut-off value of 14 pg·mL−1 predicted an adverse outcome. An age-adjusted hsTnT cut-off value (≥14 pg·mL−1 for patients aged <75 years and ≥45 pg·mL−1 for patients aged ≥75 years) provided additive and independent prognostic information on top of the simplified pulmonary embolism severity index (sPESI) and echocardiography (OR 4.56 (1.30–16.01); p=0.018, C-index=0.77). A three-step approach based on the sPESI, hsTnT and echocardiography identified 16.6% of all patients as being at higher risk (12.4% adverse outcome).Risk assessment of normotensive pulmonary embolism patients was improved by the introduction of an age-adjusted hsTnT cut-off value. A three-step approach helped identify patients at higher risk of an adverse outcome who might benefit from advanced therapy.

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Perioperative management after elective cardiac surgery: the predictive value of procalcitonin for infective and noninfective complications

Future Cardiology ◽

10.2217/fca-2020-0245 ◽

2021 ◽

Author(s):

Alice Laudisio ◽

Antonio Nenna ◽

Marta Musarò ◽

Silvia Angeletti ◽

Francesco Nappi ◽

...

Keyword(s):

Cardiac Surgery ◽

Postoperative Complications ◽

Predictive Value ◽

Odds Ratio ◽

Rate Ratio ◽

Perioperative Management ◽

Incidence Rate Ratio ◽

Adverse Outcomes ◽

Elective Cardiac Surgery ◽

The Third

Objective: Procalcitonin (PCT) has been associated with adverse outcomes after cardiac surgery. Nevertheless, there is no consensus on thresholds and timing of PCT measurement to predict adverse outcomes. Materials & methods: A total of 960 patients undergoing elective cardiac surgery were retrospectively evaluated. PCT levels were measured from the first to the seventh postoperative day (POD). The onset of complications was recorded. Results: Complications occurred in 421 (44%) patients. PCT on the third POD was associated with the occurrence of any kind of complications (odds ratio: 1.06; p: 0.037), and noninfectious complications (odds ratio: 1.05; p: 0.035), after adjusting. PCT above the median value at the third POD (>0.33 μg/l) predicted postoperative complications (incidence rate ratio: 1.13; p = 0.035). Conclusion: PCT seems to predict postoperative complications in cardiac surgery. The determination at the third POD yields the greatest sensitivity and specificity.

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Abstract 11: Improved Prediction of Adverse Pregnancy Outcome With the sFlt-1/PlGF Ratio in Patients Suspected of Preeclampsia?

Hypertension ◽

10.1161/hyp.62.suppl_1.a11 ◽

2013 ◽

Vol 62 (suppl_1) ◽

Author(s):

Koen Verdonk ◽

Manon van Ingen ◽

Johanna E Smilde ◽

Eric A Steegers ◽

A. H. Jan Danser ◽

...

Keyword(s):

Pregnancy Outcome ◽

Gestational Age ◽

Predictive Value ◽

Odds Ratio ◽

Adverse Outcome ◽

Adverse Pregnancy Outcome ◽

Positive Test ◽

Positive Ratio ◽

Adverse Pregnancy ◽

Plgf Ratio

The sFlt-1/PlGF ratio has high sensitivity and specificity to diagnose preeclampsia (PE) and to predict pregnancy outcome. Especially in patients with preexisting hypertension and/or proteinuria, diagnosis and management of PE is challenging. We studied the predictive value of the sFlt-1/PlGF ratio for the occurrence of adverse outcome in patients with a high prevalence of preexisting hypertension or proteinuria, clinically suspected of having PE. A sFlt-1/PlGF ratio >= 85 was considered to be a positive test. Adverse pregnancy outcome was defined as HELPP syndrome, intra-uterine growth restriction, or perinatal death. The predictive value of adverse pregnancy outcome of preeclampsia based on clinical grounds (clinical PE) or of a positive ratio was compared using a logistic regression model corrected for gestational age at testing. Results: So far 64 patients with a gestational age (GA) of 29.3 wks (range 20-37 wks) were included. 19 had preexisting hypertension, 5 had preexisting proteinuria and 6 had both conditions. At time of measurement 23 patients had clinical PE (4 with a negative ratio) and 30 patients had a positive sFlt-1/PlGF test (11 without clinical PE at testing of whom 7 developed clinical PE within 2 wks). 27% of patients had an adverse outcome of pregnancy. GA between patients with clinical PE or a positive test did not differ. Patients with clinical PE at the time of testing had an odds ratio of 2.5 (95% CI: 0.75 - 7.8) and patients with a positive test had an odds ratio of 6.8 (95% CI;2.1 - 33.9) for an adverse outcome. Patients with clinical PE had an absolute risk for an adverse outcome of 39% (9/23) compared to 46%(14/30) for patients with a positive sFlt-1/PlGF test (p=.075) In patients where the diagnosis of PE is challenging because of preexisting hypertension and/or proteinuria a positive sFlt-1/PlGF is a stronger determinant for poor pregnancy outcome than the clinical diagnosis of PE. An explanation could be that a positive ratio can select patients that will develop PE in the near future and because of misclassification of patients with preexisting hypertension and/or proteinuria.

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Comparison of Risk-Adjusted Outcomes in Medicare Open versus Laparoscopic Cholecystectomy

The American Surgeon ◽

10.1177/000313481808400108 ◽

2018 ◽

Vol 84 (1) ◽

pp. 12-19 ◽

Cited By ~ 1

Author(s):

Donald E. Fry ◽

Michael Pine ◽

Susan M. Nedza ◽

Agnes M. Reband ◽

Chun-Jung Huang ◽

...

Keyword(s):

Laparoscopic Cholecystectomy ◽

High Risk ◽

Length Of Stay ◽

Adverse Outcome ◽

Adverse Outcomes ◽

High Risk Population ◽

Hospital Level ◽

Prolonged Length ◽

Medicare Patients ◽

Open Versus

More than 90 per cent of cholecystectomies are performed laparoscopically and this has resulted in concern that surgeons will not have sufficient experience to perform open procedures when clinical circumstances require it. We reviewed the open cholecystectomies (OCs) of Medicare patients from 2010 to 2012 in hospitals with 20 or more cases, created risk-adjusted models for adverse outcomes which were evaluated for 90-days after discharge, and compared the hospital-level outcomes with laparoscopic cholecystectomy performed in the same hospitals for the same period of time. Results demonstrated that inpatient deaths, inpatient prolonged length-of-stay outliers, 90-day postdischarge deaths without readmission, and 90-day readmissions were statistically the same with an overall adverse outcome rate of 21.6 per cent in OC versus 20.9 per cent in laparoscopic cholecystectomy. Conversion of laparoscopic to open procedures was not associated with increased adverse outcomes. Laparoscopic cholecystectomy provides patients with many advantages, but when clinical circumstances are necessary, OC continues to be performed with the same overall adverse outcome rates, and the conversion process is not associated with poorer results in this high-risk population of patients.

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Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model

European Respiratory Journal ◽

10.1183/13993003.00024-2016 ◽

2016 ◽

Vol 48 (3) ◽

pp. 780-786 ◽

Cited By ~ 90

Author(s):

Cecilia Becattini ◽

Giancarlo Agnelli ◽

Mareike Lankeit ◽

Luca Masotti ◽

Piotr Pruszczyk ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Risk Stratification ◽

Negative Predictive Value ◽

European Society ◽

Predictive Value ◽

Acute Pulmonary Embolism ◽

Risk Stratification Model ◽

Risk Patients ◽

European Society Of Cardiology

The European Society of Cardiology (ESC) has proposed an updated risk stratification model for death in patients with acute pulmonary embolism based on clinical scores (Pulmonary Embolism Severity Index (PESI) or simplified PESI (sPESI)), right ventricle dysfunction (RVD) and elevated serum troponin (2014 ESC model).We assessed the ability of the 2014 ESC model to predict 30-day death after acute pulmonary embolism. Consecutive patients with symptomatic, confirmed pulmonary embolism included in prospective cohorts were merged in a collaborative database. Patients’ risk was classified as high (shock or hypotension), intermediate-high (RVD and elevated troponin), intermediate-low (RVD or increased troponin or none) and low (sPESI 0). Study outcomes were death and pulmonary embolism-related death at 30 days.Among 906 patients (mean±sd age 68±16, 489 females), death and pulmonary embolism-related death occurred in 7.2% and 4.1%, respectively. Death rate was 22% in “high-risk” (95% CI 14.0–29.8), 7.7% in “intermediate-high-risk” (95% CI 4.5–10.9) and 6.0% in “intermediate-low-risk” patients (95% CI 3.4–8.6). One of the 196 “low-risk” patients died (0.5%, 95% CI 0–1.0; negative predictive value 99.5%).By using the 2014 ESC model, RVD or troponin tests would be avoided in about 20% of patients (sPESI 0), preserving a high negative predictive value. Risk stratification in patients at intermediate risk requires further improvement.

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Intracardiac thrombi in pulmonary embolism of a priori non high risk: therapeutic dilemma

Kardiologia Polska ◽

10.5603/kp.2013.0069 ◽

2013 ◽

pp. 399-402

Author(s):

Bartosz Krakowiak ◽

Dorota Kustrzycka-Kratochwil ◽

Małgorzata Sukiennik-Kujawa ◽

Joanna Ogórkowska ◽

Monika Seifert ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

A Priori ◽

Intracardiac Thrombi

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Adverse obstetric outcomes in two Brazilian maternity hospitals

International Journal of Health Care Quality Assurance ◽

10.1108/ijhcqa-02-2020-0026 ◽

2021 ◽

Vol ahead-of-print (ahead-of-print) ◽

Author(s):

Alessa Leila Andrade ◽

Zenewton André da Silva Gama ◽

Marise Reis de Freitas ◽

Wilton Rodrigues Medeiros ◽

Kelienny de Meneses Sousa ◽

...

Keyword(s):

Patient Safety ◽

High Risk ◽

Adverse Outcome ◽

Obstetric Care ◽

Care Quality ◽

Adverse Outcomes ◽

Content Type ◽

Maternity Hospitals ◽

One Year

PurposeObstetric adverse outcomes (AOs) are an important topic and the use of composite measures may favor the understanding of their impact on patient safety. The aim of the present study was to estimate AO frequency and obstetric care quality in low and high-risk maternity hospitals.Design/methodology/approachA one-year longitudinal follow-up study in two public Brazilian maternity hospitals. The frequency of AOs was measured in 2,880 randomly selected subjects, 1,440 in each institution, consisting of women and their newborn babies. The frequency of 14 AOs was estimated every two weeks for one year, as well as three obstetric care quality indices based on their frequency and severity as follows: the Adverse Outcome Index (AOI), the Weighted Adverse Outcome Score and the Severity Index.FindingsA significant number of mothers and newborns exhibited AOs. The most prevalent maternal AOs were admission to the ICU and postpartum hysterectomy. Regarding newborns, hospitalization for > seven days and neonatal infection were the most common complications. Adverse outcomes were more frequent at the high-risk maternity, however, they were more severe at the low-risk facility. The AOI was stable at the high-risk center but declined after interventions during the follow-up year.Originality/valueHigh AO frequency was identified in both mothers and newborns. The results demonstrate the need for public patient safety policies for low-risk maternity hospitals, where AOs were less frequent but more severe.

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