scholarly journals Categorical Assignment of Pulmonary Embolism is a Simple and More Accurate Indicator of Right Ventricular Dysfunction and Short Team Mortality

2019 ◽  
Author(s):  
Yu Lin Chen ◽  
Colin Wright ◽  
Anthony P. Pietropaoli ◽  
Ayman Elbadawi ◽  
Joseph Delehanty ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Right Ventricular ◽  
Myocardial Strain ◽  
Area Under The Curve ◽  
Low Risk ◽  
Short Term ◽  
Short Term Mortality ◽  
Acute Pe

AbstractSeveral risk stratification tools are available to predict short-term mortality in patients with acute pulmonary embolism (PE). Right ventricular (RV) dysfunction, which is common to intermediate and high risk PE, is an independent predictor of mortality and may be a faster and simpler way to assess patient risk in acute care settings. We evaluated 571 patients presenting with acute PE as the primary diagnosis, stratifying them by the Pulmonary Embolism Severity Index (PESI), by the BOVA score, or categorically as low risk (no RV dysfunction by imaging), intermediate risk (RV dysfunction by imaging), or high risk PE (RV dysfunction by imaging with sustained hypotension). Using imaging data to firstly define the presence of RV dysfunction, and plasma cardiac troponin T (cTnT) and NT-proBNP as additional evidence for myocardial strain, we evaluated the PESI and BOVA scoring systems compared to categorical assignment of PE as low risk, submassive, and massive PE. Cardiac biomarkers poorly distinguished between PESI classes and BOVA stages in patients with acute PE. Cardiac TnT and NT-proBNP easily distinguished low risk from submassive PE with an area under the curve (AUC) of 0.84 (95% C.I. 0.73 – 0.95, p< 0.0001), and 0.88 (95% C.I. 0.79-0.97, p< 0.0001), respectively, and low risk from massive PE with an area under the curve (AUC) of 0.89 (95% C.I. 0.78 – 1.00, p< 0.0001), and 0.89 (95% C.I. 0.82-0.95, p< 0.0001), respectively. Predicted short-term mortality by PESI score or BOVA stage was lower than the observed mortality for submassive PE by a two-fold order of magnitude. These data suggest the presence of RV dysfunction in the context of acute PE is sufficient for the purposes of risk stratification, while more complicated risk stratification algorithms may under-estimate short-term mortality risk.

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 Renal dysfunction improves risk stratification and may call for a change in the management of intermediate- and high-risk acute pulmonary embolism: results from a multicenter cohort study with external validation

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Romain Chopard ◽  
David Jimenez ◽  
Guillaume Serzian ◽  
Fiona Ecarnot ◽  
Nicolas Falvo ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Renal Dysfunction ◽  
Prognostic Model ◽  
External Validation ◽  
Low Risk ◽  
Model Fit ◽  
The Impact ◽  
Acute Pe

Abstract Background Renal dysfunction influences outcomes after pulmonary embolism (PE). We aimed to determine the incremental value of adding renal dysfunction, defined by estimated glomerular filtration rate (eGFR), on top of the European Society of Cardiology (ESC) prognostic model, for the prediction of 30-day mortality in acute PE patients, which in turn could lead to the optimization of acute PE management. Methods We performed a multicenter, non-interventional retrospective post hoc analysis based on a prospectively collected cohort including consecutive confirmed acute PE stratified per ESC guidelines. We first identified which of three eGFR formulae most accurately predicted death. Changes in global model fit, discrimination, calibration and reclassification parameters were evaluated with the addition of eGFR to the prognostic model. Results Among 1943 patients (mean age 67.3 (17.1), 50.4% women), 107 (5.5%) had died at 30 days. The 4-variable Modification of Diet in Renal Disease (eGFRMDRD4) formula predicted death most accurately. In total, 477 patients (24.5%) had eGFRMDRD4 < 60 ml/min. Observed mortality was higher for intermediate–low-risk and high-risk PE in patients with versus without renal dysfunction. The addition of eGFRMDRD4 information improved model fit, discriminatory capacity, and calibration of the ESC model. Reclassification parameters were significantly increased, yielding 18% reclassification of predicted mortality (p < 0.001). Predicted mortality reclassifications across risk categories were as follows: 63.1% from intermediate–low risk to eGFR-defined intermediate–high risk, 15.8% from intermediate–high risk to eGFR-defined intermediate–low risk, and 21.0% from intermediate–high risk to eGFR-defined high risk. External validation in a cohort of 14,234 eligible patients from the RIETE registry confirmed our findings with a significant improvement of Harrell’s C index and reclassification parameters. Conclusion The addition of eGFRMDRD4-derived renal dysfunction on top of the prognostic algorithm led to risk reclassification within the intermediate- and high-risk PE categories. The impact of risk stratification integrating renal dysfunction on therapeutic management for acute PE requires further studies.

P6464Acute pulmonary embolism in Argentina. CONAREC XX registry

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
I M Cigalini ◽  
C E Scatularo ◽  
J C C Jauregui ◽  
J I Ortego ◽  
D Cornejo ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Hospital Mortality ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Hemodynamic Instability ◽  
Low Risk ◽  
P Value ◽  
Acute Pe

Abstract Background Pulmonary embolism (PE) represents the third cause of cardiovascular death and one of the leading causes of preventable in-hospital mortality. However, there is lack of information about this entity in our country. Purpose To describe baseline characteristics, in-hospital evolution and treatments among patients (P) admitted for acute PE in Argentina. Methods A prospective multicentric registry of P with acute PE was conducted in 75 academic centers between October 2016 and November 2017. Conventional analysis was used for descriptive and comparative statistics, with a p value <0.05 considered as significant. Cross audit was performed at 20% of participating centers. Results We included 684 consecutive P with an average age of 63,8 years (SD 16,8), with slight majority of female sex (57%). PE was the reason for admission in 484 (71%) of the cases; 68% of those others who developed PE as a complication during hospital stay were under adequate venous thromboembolism prophylaxis. The most frequent predisposing factors were obesity (34%), recent hospitalization (34%), transient rest (30%) and active cancer (22%). Multislice computed tomography was the diagnostic method of choice (81%). An echocardiogram was performed in 625 P (91%), showing right ventricular dilatation or dysfunction in 41% and 35% of the cases, respectively. After initial diagnosis, P were stratified as low risk (24%), intermediate-low risk (34%), intermediate-high risk (27%) and high risk (15%). Anticoagulation was indicated in 661 (97%), mainly with low-molecular-weight heparins (LMWH) (59%) as initial strategy. Reperfusion with either thrombolytics or mechanical therapies was performed in 91 (13%) cases. However, only 50 of the 102 P who presented with hemodynamic instability received any reperfusion therapy (49%). Overall in-hospital mortality was 12%, mainly related to PE (51%), with significant differences according to risk stratification (p<0,01) (Figure 1). 579 out of 601 survivors received anticoagulants at discharge: 60% vitamin K antagonists, 21% LMWH and 19% direct oral anticoagulants (49% Rivaroxaban, 34% Apixaban and 17% Dabigatran). Mortality according risk stratification Conclusions PE presents with high in-hospital mortality in our setting mainly due to the embolic event. This finding could be related to a low use of reperfusion therapies in P with hemodynamic instability, reflecting low adherence to guideline recommendations even in academic centers. This issue should be taken into consideration to improve PE prognosis in Argentina.

scholarly journals Contemporary Clinical Management and Course of ACUTE Pulmonary Embolism: The COPE Study

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 3230-3230
Author(s):  
Cecilia Becattini ◽  
Giancarlo Agnelli ◽  
Aldo P Maggioni ◽  
Francesco Dentali ◽  
Andrea Fabbri ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Major Bleeding ◽  
Acute Pulmonary Embolism ◽  
Low Risk ◽  
Intermediate Risk ◽  
Bayer Healthcare ◽  
Risk Patients ◽  
Acute Pe

Abstract Background. New management strategies, risk stratification procedures and treatments have become available over the last years for patients with acute pulmonary embolism (PE), leading to changes in clinical practice and potentially influencing patient's course and outcome. Methods: The COntemporary management of Pulmonary Embolism (COPE) is an academical prospective, non-interventional, multicentre study in patients with confirmed acute symptomatic PE. In-hospital and 30-day mortality were the co-primary study outcomes. At first evaluation, patients were categorized at low-risk (simplified PESI [sPESI]=0), intermediate-risk (further classified based presence/absence of increased levels and right ventricle dysfunction [RVD] at echocardiography) and high-risk (shock or cardiac arrest). Results. Among 5213 study patients, PE was confirmed by computed tomography in 96.3% and at least one test for risk stratification was obtained in more than 80% (81% echocardiography, 83% troponin, 56% brain natriuretic peptide/NT-pro BNP). Among 4885 patients entering the Emergency Department for acute PE, 1.2% were managed as outpatients and 5.8% by short-observation. In-hospital, 289 patients underwent reperfusion (5.5%); at discharge, 6.7% received a vitamin K antagonist and 75.6% a direct oral anticoagulant. Median duration of hospitalization was 7 days (IQR 5-12 days). Overall in-hospital mortality was 3.4% (49% due to PE, 16% cancer and 4.5% major bleeding) and 30-day mortality 4.8% (36% PE, 28% cancer and 4% major bleeding). In-hospital major bleeding was 2.6%. Death at 30 days occurred in 22.6% of 177 high-risk patients, in 6% of the 3281 intermediate-risk and in 0.5% of 1702 low-risk patients. Time to death at 30 days in patients at low, intermediate and high risk for death is reported in the Figure. Conclusions: COPE is the largest ever cohort of patients with acute PE. In this contemporary scenario, the majority of patients received CT for diagnosis, at least one test for risk stratification and direct oral anticoagulants as long-term treatment. Short term death remains not negligible in patients with high and intermediate-risk PE. Figure 1 Figure 1. Disclosures Becattini: Bristol Myers Squibb: Honoraria; Daiichi Sankyo: Honoraria; Bayer HealthCare: Honoraria. Agnelli: Bristol Myers Squibb: Honoraria; Pfizer: Honoraria; Daiichi Sankyo: Honoraria; Bayer HealthCare: Honoraria. Dentali: Daiichi Sankyo: Honoraria; Bayer: Honoraria; Sanofi: Honoraria; Pfizer: Honoraria; Bristol-Myers Squibb: Honoraria; Novartis: Honoraria; Boehringer: Honoraria; Alfa Sigma: Honoraria.

scholarly journals Risk stratification in normotensive acute pulmonary embolism patients: focus on the intermediate–high risk subgroup

2019 ◽  
Vol 9 (4) ◽  
pp. 279-285 ◽  
Author(s):  
Ana Rita Santos ◽  
Pedro Freitas ◽  
Jorge Ferreira ◽  
Afonso Oliveira ◽  
Mariana Gonçalves ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Right Ventricular ◽  
Acute Pulmonary Embolism ◽  
Ventricular Dysfunction ◽  
Right Ventricular Dysfunction ◽  
Cardiac Biomarkers ◽  
Cardiac Biomarker ◽  
Imaging Signs

Background: Patients with acute pulmonary embolism are at intermediate–high risk in the presence of imaging signs of right ventricular dysfunction plus one or more elevated cardiac biomarker. We hypothesised that intermediate–high risk patients with two elevated cardiac biomarkers and imaging signs of right ventricular dysfunction have a worse prognosis than those with one cardiac biomarker and imaging signs of right ventricular dysfunction. Methods: We analysed the cumulative presence of cardiac biomarkers and imaging signs of right ventricular dysfunction in 525 patients with intermediate risk pulmonary embolism (intermediate-high risk = 237) presenting at the emergency department in two centres. Studied endpoints were composites of all-cause mortality and/or rescue thrombolysis at 30 days (primary endpoint; n=58) and pulmonary embolism-related mortality and/or rescue thrombolysis at 30 days (secondary endpoint; n=40). Results: Patients who experienced the primary endpoint showed a higher proportion of elevated troponin (47% vs. 76%, P<0.001), elevated N-terminal pro-brain natriuretic peptide (67% vs. 93%, P<0.001) and imaging signs of right ventricular dysfunction (47% vs. 80%, P<0.001). Multivariate analysis revealed N-terminal pro-brain natriuretic peptide (hazard ratio (HR) 3.6, 95% confidence interval (CI) 1.3–10.3; P=0.015) and imaging signs of right ventricular dysfunction (HR 2.8, 95% CI 1.5–5.2; P=0.001) as independent predictors of events. In the intermediate–high risk group, patients with two cardiac biomarkers performed worse than those with one cardiac biomarker (HR 3.3, 95% CI 1.8–6.2; P=0.003). Conclusions: Risk stratification in normotensive pulmonary embolism should consider the cumulative presence of cardiac biomarkers and imaging signs of right ventricular dysfunction, especially in the intermediate–high risk subgroup.

scholarly journals In-hospital and short-term predictors of mortality in patients with intermediate-high risk pulmonary embolism

2020 ◽  
Vol 12 (4) ◽  
pp. 321-327
Author(s):  
Gulay Gök ◽  
Mehmet Karadağ ◽  
Tufan Çinar ◽  
Zekeriya Nurkalem ◽  
Dursun Duman
Keyword(s):  
Heart Failure ◽  
Congestive Heart Failure ◽  
Pulmonary Embolism ◽  
High Risk ◽  
Hospital Mortality ◽  
Medical Records ◽  
Pulmonary Angiography ◽  
Albumin Level ◽  
Short Term ◽  
Acute Pe

Introduction: The aim of this study was to evaluate the in-hospital and short-term predictive factors of mortality in intermediate-high risk acute pulmonary embolism (PE) patients with right ventricle (RV)dysfunction and myocardial injury. Methods: In this retrospective study, the medical records of 187 patients with a diagnosis of intermediate high risk acute PE were evaluated. A contrast-enhanced multi-detector pulmonary angiography was used to confirm diagnosis in all cases. All-cause mortality was determined by obtaining both in hospital and 30 days follow-up data of patients from medical records. Results: During the in-hospital stay (9.5±4.72 days), 7 patients died, resulting in an acute PE related in-hospital mortality of 3.2%. Admission heart rate (HR), (Odds ratio (OR), 1.028 95% Confidence interval (CI), 0.002-1.121; P = 0.048) and blood urea nitrogen (BUN) (OR, 1.028 95% CI, 0.002-1.016; P = 0.044) were found to be independent predictors for in-hospital mortality in a multi variate logistic regression analysis. In total, 32 patients (20.9%) died during 30 days follow-up.The presence of congestive heart failure (OR, 0.015, 95%CI, 0.001-0.211; P = 0.002) and dementia (OR, 0.029, 95%CI,0.002-0.516; P = 0.016) as well as low albumin level (OR, 0.049 95%CI, 0.006-0.383; P = 0.049) were associated with 30 days mortality. Conclusion: HR and BUN were independent predictors of in-hospital mortality and the presence of congestive heart failure, dementia, and low albumin levels were associated with higher 30 days mortality.

scholarly journals Contemporary clinical management of acute pulmonary embolism: the COPE study

2022 ◽  
Author(s):  
Cecilia Becattini ◽  
Giancarlo Agnelli ◽  
Aldo Pietro Maggioni ◽  
Francesco Dentali ◽  
Andrea Fabbri ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Acute Pulmonary Embolism ◽  
Management Strategies ◽  
Treatment Strategies ◽  
Low Risk ◽  
Contemporary Management ◽  
Secondary Study ◽  
European Society Of Cardiology ◽  
Acute Pe

Abstract Background New management, risk stratification and treatment strategies have become available over the last years for patients with acute pulmonary embolism (PE), potentially leading to changes in clinical practice and improvement of patients’ outcome. Methods The COntemporary management of Pulmonary Embolism (COPE) is a prospective, non-interventional, multicentre study in patients with acute PE evaluated at internal medicine, cardiology and emergency departments in Italy. The aim of the COPE study is to assess contemporary management strategies in patients with acute, symptomatic, objectively confirmed PE concerning diagnosis, risk stratification, hospitalization and treatment and to assess rates and predictors of in-hospital and 30-day mortality. The composite of death (either overall or PE-related) or clinical deterioration at 30 days from the diagnosis of PE, major bleeding occurring in hospital and up to 30 days from the diagnosis of PE and adherence to guidelines of the European Society of Cardiology (ESC) are secondary study outcomes. Participation in controlled trials on the management of acute PE is the only exclusion criteria. Expecting a 10–15%, 3% and 0.5% incidence of death for patients with high, intermediate or low-risk PE, respectively, it is estimated that 400 patients with high, 2100 patients with intermediate and 2500 with low-risk PE should be included in the study. This will allow to have about 100 deaths in study patients and will empower assessment of independent predictors of death. Conclusions COPE will provide contemporary data on in-hospital and 30-day mortality of patients with documented PE as well as information on guidelines adherence and its impact on clinical outcomes. Trail registration NCT number: NCT03631810.

scholarly journals Comparison of risk assessment strategies for not-high-risk pulmonary embolism

2016 ◽  
Vol 47 (4) ◽  
pp. 1170-1178 ◽  
Author(s):  
Lukas Hobohm ◽  
Kristian Hellenkamp ◽  
Gerd Hasenfuß ◽  
Thomas Münzel ◽  
Stavros Konstantinides ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Adverse Outcome ◽  
Troponin T ◽  
Favourable Outcome ◽  
Low Risk ◽  
Fatty Acid Binding ◽  
Increased Risk ◽  
Risk Patients

We compared the prognostic performance of the 2014 European Society of Cardiology (ESC) risk stratification algorithm with the previous 2008 ESC algorithm, the Bova score and the modified FAST score (based on a positive heart-type fatty acid-binding protein (H-FABP) test, syncope and tachycardia, modified using high-sensitivity troponin T instead of H-FABP) in 388 normotensive pulmonary embolism patients included in a single-centre cohort study.Overall, 25 patients (6.4%) had an adverse 30-day outcome. Regardless of the score or algorithm used, the rate of an adverse outcome was highest in the intermediate-high-risk classes, while all patients classified as low-risk had a favourable outcome (no pulmonary embolism-related deaths, 0–1.4% adverse outcome). The area under the curve for predicting an adverse outcome was higher for the 2014 ESC algorithm (0.76, 95% CI 0.68–0.84) compared with the 2008 ESC algorithm (0.65, 95% CI 0.56–0.73) and highest for the modified FAST score (0.82, 95% CI 0.75–0.89). Patients classified as intermediate-high-risk by the 2014 ESC algorithm had a 8.9-fold increased risk for an adverse outcome (3.2–24.2, p<0.001 compared with intermediate-low- and low-risk patients), while the highest OR was observed for a modified FAST score ≥3 points (OR 15.9, 95% CI 5.3–47.6, p<0.001).The 2014 ESC algorithm improves risk stratification of not-high-risk pulmonary embolism compared with the 2008 ESC algorithm. All scores and algorithms accurately identified low-risk patients, while the modified FAST score appears more suitable to identify intermediate-high-risk patients.

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