scholarly journals The Use of Transthoracic Echocardiograms in Hospitalized Adult Patients with Acute Pulmonary Embolism

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 43-43
Author(s):  
Katherine Steckham ◽  
Craig Ainsworth ◽  
Siraj Mithoowani ◽  
Deborah M Siegal
Keyword(s):  
Pulmonary Embolism ◽  
Right Ventricular ◽  
Cardiac Troponin ◽  
Acute Pulmonary Embolism ◽  
Adverse Outcomes ◽  
Adult Patients ◽  
Hospital Death ◽  
Elevated Troponin ◽  
Systemic Thrombolysis ◽  
Acute Pe

Background: The role of inpatient transthoracic echocardiography (TTE) in patients with acute pulmonary embolism (PE) is unclear. Although right ventricular dysfunction (RVD) predicts adverse outcomes in acute PE, there is no consensus on the optimal TTE findings for prognostication and how they influence management, particularly when CT and/or an elevated cardiac troponin already suggest RVD. Understanding current practices regarding inpatient TTE in acute PE can help direct appropriate use. Our objectives were to (i) characterize inpatient TTE use in adult patients hospitalized with acute PE, (ii) describe and compare findings of RVD by TTE, CT and troponin, and (iii) explore differences in outcomes between patients managed with or without TTE. Methods: We conducted a retrospective cohort study of adult patients hospitalized with acute PE at two academic hospitals in Hamilton, Canada between January and December 2018. Patients with suspected PE that was not objectively confirmed, or PE diagnosed prior to hospitalization were excluded. We also excluded patients who had a TTE prior to the diagnosis of PE. Chi-square tests and independent t-tests were used. P-values less than 0.05 were considered significant. Results: We identified 178 adult patients (mean age 66 ± 15 years; 42% male). Patients were admitted to internal medicine (53%), oncology (19%), surgical specialties (13%) and intensive care units (ICU, 11%). Of 146 patients, 134 (92%) had a PE involving segmental or larger vessels. TTE was conducted in 86 (48%) patients. Systemic thrombolysis was administered to 11 (6%) patients. A higher proportion of patients with an elevated troponin (66% vs. 35% p<0.001) or evidence of RV strain on CT (65% vs. 35%, p=0.001) underwent TTE compared to those without these findings. Patients admitted to the ICU more frequently underwent TTE (69% vs. 44%, p=0.012). RV size and function were normal in 49 (59%) and 53 (63%) cases, respectively. Patients with RV strain on CT were more likely to have RV enlargement (58% vs. 30%, p=0.04) and RVD (58% vs. 25%, p=0.011) on TTE. However, right ventricular internal dimension in diastole (RVIDd) (3.9 ± 0.75 cm vs. 3.7 ± 0.78 cm) and tricuspid annular plane systolic excursion (TAPSE) (1.8 ± 0.44 cm vs. 2.0 ± 0.38 cm) were not statistically different between patients with or without RV strain on CT. A higher proportion of patients with an elevated troponin had RV enlargement (58% vs. 14%, p=0.001) and RVD (50% vs. 18%, p=0.018) on TTE. Length of hospital admission (16 ± 28 days vs. 11 ± 23 days) and in-hospital death (7% vs. 11%) were not statistically different between patients with or without TTE. Conclusions: Inpatient TTE is conducted frequently in hospitalized patients with acute PE, especially in those with evidence of RV strain based on CT and/or an elevated cardiac troponin. Our results suggest that patients with findings of RV strain on CT are more likely to have RV enlargement and RVD on TTE. Future studies should evaluate the diagnostic utility of CT and/or troponin for RVD in the setting of acute PE, which may reduce the routine use of inpatient TTE and associated healthcare resources and costs. Disclosures Mithoowani: Leo Pharma: Honoraria. Siegal:Portola: Honoraria; Novartis: Honoraria; Leo Pharma: Honoraria; Bayer: Honoraria; BMS Pfizer: Honoraria.

scholarly journals Use and clinical outcome of veno-arterial extracorporeal membrane oxygenation in patients with acute pulmonary embolism and cardiopulmonary resuscitation

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
L Hobohm ◽  
I Sagoschen ◽  
T Gori ◽  
FP Schmidt ◽  
T Muenzel ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Cardiac Arrest ◽  
Mortality Rate ◽  
Cardiopulmonary Resuscitation ◽  
Acute Pulmonary Embolism ◽  
Treatment Strategies ◽  
Hospital Death ◽  
Systemic Thrombolysis ◽  
Va Ecmo ◽  
Acute Pe

Abstract Funding Acknowledgements Type of funding sources: None. Background Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for patients with acute pulmonary embolism (PE) and concomitant cardiac arrest with the necessity of cardiopulmonary resuscitation (CPR). Little is known about the use and clinical outcome of veno-arterial (VA)-ECMO and adjunctive treatment strategies in patients with acute PE and CPR. Purpose In this context, we aimed to investigate the use of VA-ECMO alone or after systemic thrombolysis and its impact on in-hospital outcomes of patients with acute PE and CPR. Methods We analyzed data on the characteristics, treatments and in-hospital outcomes for all patients with acute PE (ICD-code I26) and CPR in Germany between the years 2005 and 2018 (source: Research Data Center (RDC) of the Federal Statistical Office and the Statistical Offices of the federal states, DRG Statistics 2005-2018, own calculations). Results Between 2005 and 2018, 1,172,354 patients with acute PE (53.5% females) were included in this analysis; of those, 77,196 (6.5%) presented with cardiac arrest and CPR. While more than one fourth of those patients were treated with systemic thrombolysis alone (n = 20,839 patients; 27.0%), a minority received a combination of thrombolysis + VA-ECMO (n = 165; 0.2%) or singular approach with VA-ECMO treatment alone (n = 588; 0.8%). The overall in-hospital mortality rate of PE patients with cardiac arrest was high with 83.8%. Non-survivors were considerable older than survivors (74 [IQR 63-81] vs. 69 [58-77]). In patients treated with VA ECMO alone the mortality rate was 71.1% and 69.7% when patients received Thrombolysis + VA-ECMO. Patients, who received thrombolysis without VA-ECMO had a higher mortality rate (83.8%). In order to investigate the impact of those different treatment strategies, a multivariate logistic regression analysis (adjusted for age, sex and comorbidities) demonstrated the lowest risk for in-hospital death in patients, who underwent the combination of Thrombolysis + VA-ECMO (OR, 0.61 [95% CI, 0.43-0.86], P = 0.004) or VA-ECMO alone (OR, 0.70 [0.58-0.84], P < 0.001) compared to patients without VA-ECMO and without thrombolysis. Use of thrombolysis alone in patients with PE and CPR lowering the risk regarding in-hospital death as well (OR, 0.95 [0.91-0.99], P = 0.013). Regarding temporal trends, the annual use of VA-ECMO increased from 0 in the year 2005 to the number of 138 in 2018 (ß 6.13 (4.62-6.76); p < 0.001) as well as for the combined treatment Thrombolysis + VA-ECMO (from 0 to 39 [ß 4.28 (3.68-4.89); p < 0.001]). Conclusion Patients with acute PE and CPR had a very high in-hospital mortality rate. Our data suggest, that VA-ECMO alone or after systemic thrombolysis should be considered as an option in this outstanding life-threatening situation to improve in-hospital outcome. Furthermore, our data highlight a marked increase in the number of PE patients treated with VA-ECMO indicating the structural health care progress between 2005 and 2018.

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 Developing a scoring tool to estimate the risk of deterioration for normotensive patients with acute pulmonary embolism on admission

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Yizhuo Gao ◽  
Chao Ji ◽  
Hongyu Zhao ◽  
Jun Han ◽  
Haitao Shen ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Acute Pulmonary Embolism ◽  
Clinical Laboratory ◽  
Systolic Pressure ◽  
Adverse Outcomes ◽  
Web Based ◽  
Derivation Cohort ◽  
Risk Scoring ◽  
Scoring Tool ◽  
Acute Pe

Abstract Background It is important to identify deterioration in normotensive patients with acute pulmonary embolism (PE). This study aimed to develop a tool for predicting deterioration among normotensive patients with acute PE on admission. Methods Clinical, laboratory, and computed tomography parameters were retrospectively collected for normotensive patients with acute PE who were treated at a Chinese center from January 2011 to May 2020 on admission into the hospital. The endpoint of the deterioration was any adverse outcome within 30 days. Eligible patients were randomized 2:1 to derivation and validation cohorts, and a nomogram was developed and validated by the aforementioned cohorts, respectively. The areas under the curves (AUCs) with 95% confidence intervals (CIs) were calculated. A risk-scoring tool for predicting deterioration was applied as a web-based calculator. Results The 845 eligible patients (420 men, 425 women) had an average age of 60.05 ± 15.43 years. Adverse outcomes were identified for 81 patients (9.6%). The nomogram for adverse outcomes included heart rate, systolic pressure, N-terminal-pro brain natriuretic peptide, and ventricle/atrial diameter ratios at 4-chamber view, which provided AUC values of 0.925 in the derivation cohort (95% CI 0.900–0.946, p < 0.001) and 0.900 in the validation cohort (95% CI 0.883–0.948, p < 0.001). A risk-scoring tool was published as a web-based calculator (https://gaoyzcmu.shinyapps.io/APE9AD/). Conclusions We developed a web-based scoring tool that may help predict deterioration in normotensive patients with acute PE.

Increased Brain Natriuretic Peptide as a Marker for Right Ventricular Dysfunction in Acute Pulmonary Embolism

2001 ◽  
Vol 86 (11) ◽  
pp. 1193-1196 ◽  
Author(s):  
Igor Tulevski ◽  
Alexander Hirsch ◽  
Bernd-Jan Sanson ◽  
Hans Romkes ◽  
Ernst van der Wall ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Brain Natriuretic Peptide ◽  
Right Ventricular ◽  
Natriuretic Peptide ◽  
Acute Pulmonary Embolism ◽  
Prognostic Significance ◽  
Systolic Pressure ◽  
Clinical Importance ◽  
Acute Pe ◽  
Rv Function

SummaryRight ventricular (RV) function is of major prognostic significance in patients with acute pulmonary embolism (PE). The aim of the present study was to evaluate the role of neurohormone plasma brain natriuretic peptide (BNP) in assessing RV function in patients with acute PE.BNP levels were measured in 16 consecutive patients with acute PE as diagnosed by high probability lung scintigraphy or pulmonary angiography. Twelve healthy age-matched volunteers served as controls. All 16 patients underwent standard echocardiography and blood tests during the first hour of presentation. In the patient group, survival was studied for a period of 30 days. Plasma BNP levels in patients with acute PE were higher than in controls (7.2 [95% CI 0.4 to 144.6] versus 1.4[95% CI 0.4 to 4.6] pmol/L, p = 0.0008). Plasma BNP was significantly higher in 5 patients with RV dysfunction compared to 11 patients with normal RV function (40.2 [95% CI 7.5 to 214.9] versus 3.3 [95% CI 0.4 to 24.9] pmol/L, p = 0.0003). RV systolic pressure was not significantly correlated with BNP (r = 0.42, p = ns).In conclusion, plasma BNP neurohormone levels might be of clinical importance as a supplementary tool for assessment of RV function in patients with acute PE.

A novel echocardiographic parameter for assessment of right ventricular function in acute pulmonary embolism: an experimental study

2019 ◽  
Author(s):  
Decai Zeng ◽  
Ji Wu ◽  
Hui Chen ◽  
Ying Tan ◽  
Xueyu Che ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Right Ventricular ◽  
Acute Pulmonary Embolism ◽  
Autologous Blood ◽  
Left Ventricular ◽  
Control Group ◽  
Tei Index ◽  
Significant Difference ◽  
Acute Pe ◽  
Rv Function

Abstract Background Right ventricular (RV) dysfunction played a decisive role in clinical management and associated with poor prognosis in acute pulmonary embolism (PE). It still remains challenging to estimate RV function accurately for the reason of complex structure and geometry. The present study aimed to determine the value of right ventricular outflow tract systolic excursion (RVOT-SE) in evaluating RV function in an animal model with acute PE. Methods Thirty-three healthy New Zealand rabbits were randomly assigned to massive thrombus group, sub-massive thrombus group and control group, 11 rabbits per group. The acute PE model was established by intravenous infusion of autologous blood clots. After 1h of thrombus injection, transthoracic echocardiography was performed to assess RV function in all rabbits. Results The acute PE model was successfully made in 18 rabbits (massive thrombus group, n = 8; sub-massive thrombus group n = 10). Right/left ventricular end-diastolic diameter (RV/LV) ratio and RV myocardial performance (Tei) index were significantly increased, while RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE) and RVOT_SE were reduced in massive thrombus group. The value of RVOT-SE and RVFAC in sub-massive thrombus group decreased significantly compared with control group (P < 0.05). But there was no significant difference in RV/LV, TAPSE and Tei index (P > 0.05). ROC analysis showed that RVOT-SE had high sensitivity (94.4%) and specificity (72.7%) in identifying RV dysfunction in acute PE. The area under the ROC curve (AUC) for combined TAPSE and RVOT-SE was greater than that of TAPSE or RVOT-SE alone (AUC= 0.962, P < 0.01). Conclusion RV function in acute PE is significantly decreased, which is closely related to the size of embolus. RVOT_SE is a simple and highly distinctive parameter in identifying RV dysfunction and tends to be superior to conventional parameters in acute PE. The combination of RVOT-SE and TAPSE can further improve the diagnostic accuracy of acute PE.

Measurement of High-Sensitivity Cardiac Troponin in Pulmonary Embolism: Useful Test or a Clinical Distraction

2019 ◽  
Vol 45 (08) ◽  
pp. 784-792
Author(s):  
Giuseppe Lippi ◽  
Emmanuel J. Favaloro ◽  
Peter Kavsak
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Cardiac Troponin ◽  
Laboratory Tests ◽  
High Sensitivity ◽  
Severity Index ◽  
Adverse Outcomes ◽  
Incremental Value ◽  
Risk Patients ◽  
Acute Pe

AbstractThe ability to predict death or other unfavorable outcomes after an acute pulmonary embolism (PE) is challenging, with current available risk score models having relatively unsatisfactory prognostic performance in this area. For example, the simplified pulmonary embolism severity index (sPESI), the most frequently used stratification tool, misclassifies a significant percentage of low- and high-risk patients. This gap in care, along with the increasing clinical availability of high-sensitivity cardiac troponin (hs-cTn) laboratory tests and the recent emphasis on detecting myocardial injury, may foster further evaluation of hs-cTn testing in patients with acute PE. Our analysis of the current scientific literature on hs-cTn in patients with acute PE identified that hs-cTn testing may provide valuable information for predicting future adverse outcomes and mortality, independently from baseline clinical risk assessment. Although the risk of an adverse event is indeed higher in patients with higher sPESI scores, cTns retain their prognostic value also in those at low risk, suggesting that a combination of hs-cTn with sPESI may provide an incremental value over assessment of either variable alone. Accordingly, the future development of updated risk stratification models, with the inclusion of laboratory tests such as hs-cTn, may represent an enhanced approach for risk stratification in patients with acute PE. Additional research, however, is needed to verify whether the combination of cTns, specifically as measured with hs-cTn assays, with other biomarkers may further improve the current capacity to efficiently manage patients with acute PE.

Bleeding, death, and costs of care during hospitalization for acute pulmonary embolism: Insights from the Saint Luke’s Outcomes of Pulmonary Embolism (SLOPE) study

2020 ◽  
pp. 1358863X2096741
Author(s):  
Matthew C Bunte ◽  
Kensey Gosch ◽  
Ahmed Elkaryoni ◽  
Anas Noman ◽  
Erin Johnson ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Major Bleeding ◽  
Hospital Readmission ◽  
Common Adverse Event ◽  
Hospital Length Of Stay ◽  
Hospital Death ◽  
Systemic Thrombolysis ◽  
Catheter Directed Thrombolysis ◽  
Acute Pe

Limited data exist that comprehensively describe the practical management, in-hospital outcomes, healthcare resource utilization, and rates of post-hospital readmission among patients with submassive and massive pulmonary embolism (PE). Consecutive discharges for acute PE were identified from a single health system over 3 years. Records were audited to confirm presence of acute PE, patient characteristics, disease severity, medical treatment, and PE-related invasive therapies. Rates of in-hospital major bleeding and death, hospital length of stay (LOS), direct costs, and hospital readmission are reported. From January 2016 to December 2018, 371 patients were hospitalized for acute massive or submassive PE. In-hospital major bleeding (12.1%) was common, despite low utilization of systemic thrombolysis (1.8%) or catheter-directed thrombolysis (3.0%). In-hospital death was 10-fold higher among massive PE compared to submassive PE (36.6% vs 3.3%, p < 0.001). Massive PE was more common during hospitalizations not primarily related to venous thromboembolism, including hospitalizations primarily for sepsis or infection (26.8% vs 8.2%, p = 0.001). Overall, the median LOS was 6.0 days (IQR, 3.0–11.0) and the median standardized direct cost of admissions was $10,032 (IQR, $4467–$20,330). Rates of all-cause readmission were relatively high throughout late follow-up but did not differ between PE subgroups. Despite low utilization of thrombolysis, in-hospital bleeding remains a common adverse event during hospitalizations for acute PE. Although massive PE is associated with high risk for in-hospital bleeding and death, those successfully discharged after a massive PE demonstrate similar rates of readmission compared to submassive PE into late follow-up.

P5588Early versus delayed oral anticoagulation in patients with acute pulmonary embolism: determinants and outcome

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
C Becattini ◽  
L A Cimini ◽  
M Lankeit ◽  
P Pruszczyk ◽  
S Vanni ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Oral Anticoagulation ◽  
Acute Pulmonary Embolism ◽  
Oral Anticoagulants ◽  
Hospital Death ◽  
Intermediate Risk ◽  
Right Ventricle Dysfunction ◽  
Risk Of Death ◽  
Risk Patients ◽  
Acute Pe

Abstract Background Whether early oral anticoagulant treatment is appropriate for patients with acute pulmonary embolism (PE) regardless of PE severity is undefined. The aim of this study in patients with acute PE at intermediate risk of death were: I) to assess the determinants for the use of early vs delayed vs no oral anticoagulants in patients with acute PE and II) to assess the association between timing of oral anticoagulation and in-hospital mortality. Methods Prospective cohorts of patients with acute PE at intermediate risk of death according to the European Society of Cardiology Guidelines 2014 were merged in a collaborative database. The initiation of oral anticoagulation was classified as early (≤3 days) or delayed (between day 3 and 10 from diagnosis). Patients treated with parenteral anticoagulants for longer than 10 days were also included. In-hospital death was the primary study outcome. Results Overall, 557 patients were included in the study, 23 received thrombolytic treatment during the hospital stay. The mean duration of parenteral anticoagulation was 7±8 days (5 median), 348 patients were initiated on a direct oral anticoagulant and 79 on a vitamin K antagonist during the hospital stay. Initiation of oral anticoagulants occurred early or delayed in 209 (37%) and 218 (39%) patients, respectively and never occurred during the first 30 days in 130 (23%). Intermediate-low risk patients more commonly received early and intermediate high delayed oral anticoagulation. Simplified PESI score of zero (OR 1.9, 95% CI 1.3–2.7) was independently associated with early oral anticoagulation; among sPESI components absence of cancer (OR 5.9, 95% CI 3.3–10) and heart rate <110 (OR 1.8, 95% CI 1.01–3.16) were independent predictors of early initiation of oral anticoagulants. The presence of both right ventricle dysfunction and injury was associated with delayed initiation of oral anticoagulants. The incidence of death was 5.5%. Death occurred in 32 patients and was not related to the duration of parenteral anticoagulation (OR 1.01 per day, 95% CI 0.98–1.06) nor to right ventricle dysfunction but to sPESI 1 (OR 3.32, 95% CI 1.14–9.66). These results were partially confirmed in the 435 intermediate risk patients without cancer (OR 1.03, 95% CI 0.99–1.08 for days of parenteral treatment; OR 4.17, 95% CI 0.95–18 for sPESI 1). Conclusion The clinical severity of PE and not the timing of initiation of oral anticoagulants are associated with in-hospital death in patients with intermediate risk PE. Randomized studies are needed to definitively assess the role of heparin lead-in in patients with PE at intermediate risk for death.

Intrapulmonary Artery Thrombolysis in Acute Pulmonary Embolism: Case Series from King Chulalongkorn Memorial Hospital Experience

2021 ◽  
Vol 104 (8) ◽  
pp. 1376-1380
Keyword(s):  
Pulmonary Embolism ◽  
Plasminogen Activator ◽  
Acute Pulmonary Embolism ◽  
Case Series ◽  
Systemic Thrombolysis ◽  
Tissue Plasminogen ◽  
Surgical Embolectomy ◽  
Surgical Thrombectomy ◽  
Acute Pe

Acute pulmonary embolism (PE) is a life-threatening condition. In patient who has contraindication for systemic thrombolysis and inappropriate for surgical embolectomy, there is a role of catheter interventions. However, the data are limited. The aim of the present report was to assess a role of intrapulmonary artery thrombolysis bolus in acute PE. A retrospective review of the use of intrapulmonary artery thrombolysis in acute PE. The data were collected from 14 patients with massive or submassive PE who had contraindication or inappropriate for systemic thrombolysis and unsuitable for surgical embolectomy. After intrapulmonary thrombolysis was given, patients were followed clinically and hemodynamically until discharged and after 1 month. Pulmonary pressure was collected at pre and post intervention. Of the 14 patients (age 59±19 years, 78.6% female), 86% were diagnosed as submassive PE. Mean dose of tissue plasminogen activator (rt-PA) was 28±14 mg given as bolus and continuous infusion (19±10 hours). One patient died after completion of intrapulmonary infusion rt-PA at day 90, which did not relate to PE and the treatment. After intervention, mean PA pressure was significantly reduced from 32.3±6.0 to 21.0±4.3 mmHg (p<0.001). Three patients (21%) had minor bleeding (hematoma at access site). The present case series showed that intrapulmonary infusion of rt-PA was effective and safe in patient with massive and submassive PE who had contraindication or inappropriate to systemic thrombolysis or inoperable surgical thrombectomy. Keywords: Acute pulmonary embolism; Intrapulmonary thrombolysis; Tissue plasminogen activator; Surgical thrombectomy

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