D-Dimer Levels Among Cancer Patients with Unsuspected Pulmonary Embolism: Clinical Correlates and Relevance

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 1154-1154 ◽  
Author(s):  
Sonia Ali ◽  
Elizabeth Dilday ◽  
Scott Tagawa ◽  
Naveed H. Akhtar ◽  
Howard A Liebman ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Artery ◽  
Cancer Patients ◽  
Main Pulmonary Artery ◽  
Signs And Symptoms ◽  
Adverse Outcomes ◽  
Pulmonary Vasculature ◽  
Shortness Of Breath ◽  
Segmental Artery ◽  
D Dimer

Abstract Abstract 1154 Background D-dimer is a useful biomarker with a high negative predictive value among patients suspected of having deep vein thrombosis (DVT) and pulmonary embolism (PE). Among cancer patients, d-dimer is associated with DVT, PE and adverse outcomes including death. We have previously shown that patients with PE identified incidentally on routine cancer staging CT scans are frequently symptomatic, especially with fatigue and shortness of breath, and have adverse outcomes similar to cancer patients with suspected PE. It is not known if d-dimer levels among cancer patients with unsuspected PE (UPE) are similar to those in cancer patients with suspected PE or whether d-dimer levels correlate with symptoms or PE location. Methods We analyzed data from a prospective, single arm Phase II, IRB-approved clinical trial in which serial high sensitive D-dimer assays were performed in cancer patients diagnosed with DVT/PE and treated with a low molecular weight heparin (tinzaparin 175 units/kg). PE location was determined based on the most proximal segment of the pulmonary vasculature affected (main, lobar, segmental and subsegmental from most to least proximal). We also recorded signs and symptoms reported to the physician or nurse at the time of the PE diagnosis including tachycardia, hypoxia, fatigue, shortness of breath, dyspnea on exertion, cough, and chest pain. We used analysis of variance and linear regression models to evaluate the association between baseline clinical characteristics and baseline, pre-treatment d-dimer levels. We included log transformed d-dimer levels in all the models and report geometric means and 95% confidence intervals (CIs). Results Among 91 treated patients, 62 had PE, of which 47 (75.8%) were UPE. The majority of patients (67%) had genitourinary tract or gastrointestinal tract malignancies, with the remainder having lung (n=11), pancreatic (n=7), or other (n=12) malignancies. Mean d-dimer levels at baseline were not significantly different between patients with UPE (mean 2377 ng/mL; 95% CI 1775–3182) and patients with suspected PE (mean 3694 ng/mL; 95% CI 2448–5574; p=0.11). Among signs and symptoms, only fatigue was significantly associated with higher d-dimer levels (d-dimer without fatigue: mean 1827 ng/mL, 95% CI 1370–2437 vs. with fatigue: mean 4727 ng/mL, 95% CI 2434–9177, p=0.0002); this association was also true for the subgroup of patients with UPE (p=0.0024). There was no significant association between fatigue and the location of PE. Among all patients with PE, there was a significant association between d-dimer and location of PE, with higher d-dimer levels associating with more proximal clots (p for trend=0.0023). Mean d-dimer levels based on the most proximal pulmonary artery segment involved were as follows: main pulmonary artery, 5198 ng/mL (95% CI 2858–9453); lobar artery, 2241 ng/mL (95% CI 1516–3314); segmental artery, 1816 ng/mL (95% CI 875–3769); and subsegmental, 931 ng/mL (95% CI 444–1951). This trend was also statistically significant when we restricted the analysis to UPE patients (p for trend=0.0005). Conclusion Cancer patients with UPE have elevated d-dimers similar to those found among cancer patients with suspected PE. Moreover, fatigue and more proximal clot location are significantly associated with higher d-dimer levels among cancer patients with UPE. Elevated d-dimers and presence of fatigue should prompt suspicion for PE among cancer patients. Disclosures: Liebman: Sanofi Aventis: Honoraria; Glaxo Smith Kline: Honoraria; Esai: Honoraria; Pfizer: Honoraria. O'Connell:Astex Pharmaceuticals: Honoraria; Celgene: Speakers Bureau; Incyte: Honoraria.

scholarly journals Widespread Parenchymal Abnormalities and Pulmonary Embolism on Contrast-Enhanced CT Predict Disease Severity and Mortality in Hospitalized COVID-19 Patients

2021 ◽  
Vol 8 ◽  
Author(s):  
Francesca Campoccia Jalde ◽  
Mats O. Beckman ◽  
Ann Mari Svensson ◽  
Max Bell ◽  
Magnus Sköld ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Pulmonary Artery ◽  
Troponin T ◽  
Main Pulmonary Artery ◽  
C Reactive Protein ◽  
Reactive Protein ◽  
Parenchymal Abnormalities ◽  
Pulmonary Artery Diameter ◽  
D Dimer

Purpose: Severe COVID-19 is associated with inflammation, thromboembolic disease, and high mortality. We studied factors associated with fatal outcomes in consecutive COVID-19 patients examined by computed tomography pulmonary angiogram (CTPA).Methods: This retrospective, single-center cohort analysis included 130 PCR-positive patients hospitalized for COVID-19 [35 women and 95 men, median age 57 years (interquartile range 51–64)] with suspected pulmonary embolism based on clinical suspicion. The presence and extent of embolism and parenchymal abnormalities on CTPA were recorded. The severity of pulmonary parenchymal involvement was stratified by two experienced radiologists into two groups: lesions affecting ≤50% or >50% of the parenchyma. Patient characteristics, radiological aspects, laboratory parameters, and 60-day mortality data were collected.Results: Pulmonary embolism was present in 26% of the patients. Most emboli were small and peripheral. Patients with widespread parenchymal abnormalities, with or without pulmonary embolism, had increased main pulmonary artery diameter (p < 0.05) and higher C-reactive protein (p < 0.01), D-dimer (p < 0.01), and troponin T (p < 0.001) and lower hemoglobin (p < 0.001). A wider main pulmonary artery diameter correlated positively with C-reactive protein (r = 0.28, p = 0.001, and n = 130) and procalcitonin. In a multivariant analysis, D-dimer >7.2 mg/L [odds ratio (±95% confidence interval) 4.1 (1.4–12.0)] and ICU stay were significantly associated with embolism (p < 0.001). The highest 60-day mortality was found in patients with widespread parenchymal abnormalities combined with pulmonary embolism (36%), followed by patients with widespread parenchymal abnormalities without pulmonary embolism (26%). In multivariate analysis, high troponin T, D-dimer, and plasma creatinine and widespread parenchymal abnormalities on CT were associated with 60-day mortality.Conclusions: Pulmonary embolism combined with widespread parenchymal abnormalities contributed to mortality risk in COVID-19. Elevated C-reactive protein, D-dimer, troponin-T, P-creatinine, and enlarged pulmonary artery were associated with a worse outcome and may mirror a more severe systemic disease. A liberal approach to radiological investigation should be recommended at clinical deterioration, when the situation allows it. Computed tomography imaging, even without intravenous contrast to assess the severity of pulmonary infiltrates, are of value to predict outcome in COVID-19. Better radiological techniques with higher resolution could potentially improve the detection of microthromboses. This could influence anticoagulant treatment strategies, preventing clinical detoriation.

scholarly journals Risk management in acute pulmonary embolism: correlation between right heart dysfunction, pulmonary clots distribution, biomarkers and prognosis

2013 ◽  
pp. 23-29
Author(s):  
Luca Masotti ◽  
Fabio Antonelli ◽  
Elio Venturini ◽  
Giancarlo Landini
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Artery ◽  
Acute Pulmonary Embolism ◽  
Troponin I ◽  
Main Pulmonary Artery ◽  
Shock Index ◽  
Right Heart ◽  
Heart Dysfunction ◽  
Right Heart Dysfunction ◽  
D Dimer

BACKGROUND Right heart dysfunction (RHD) is related to adverse outcomes in acute pulmonary embolism (PE). AIM OF THE STUDY To evaluate the relation between RHD, pulmonary clots distribution and biomarkers and prognosis of patients with PE. METHODS We analysed echocardiographic data of 70 patients with diagnosis of PE confirmed by pulmonary computer tomography, hCT. We considered the enddiastolic right/left ventricles ratio > 1 as index of RHD; echocardiographic data were compared with clots distribution in pulmonary vascular tree such as hCT findings and biomarkers. For each patient we calculated the shock index (heart rate/systolic blood pressure ratio, shock defined as ratio ≥ 1). RESULTS Hospital mortality was 8.5%. Mean age of dead patients was significantly higher compared to alive (85.67 vs 71.57 years, p < 0.05). 41% of patients revealed unilateral PE, 59% had bilateral. In 10% of patients main pulmonary artery was interested by clot, 48% of patients had involved one of the main branches, 90% had involved at least one of the lobar branches, 59% one of segmental branches of pulmonary arteries. 52% of patients had RHD. Mortality in RHD patients was 14.8% vs 8% in no RHD, p < 0.05. Mean values of troponin I and D-dimer were significantly higher in RHD patients. Shock index was ≥ 1 in 37.5% of RHD and 20% in no RHD. RHD patients showed significantly higher involvement of main pulmonary artery and its branches and higher bilateral involvement. CONCLUSIONS RHD is related to proximal and bilateral pulmonary clots distribution and troponin I and D-dimer values and poorer prognosis.

scholarly journals Evaluation of the Therapeutic Effect of Pulmonary Embolism by CT Pulmonary Angiography Combined With Clinical Indexes

2021 ◽  
Author(s):  
Meng Yuan ◽  
XinYuan Cui ◽  
ChunXue Yang ◽  
XinYang Zhang ◽  
DeLi Zhao ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Artery ◽  
Heart Function ◽  
Main Pulmonary Artery ◽  
Pulmonary Angiography ◽  
Trunk Diameter ◽  
Right Heart Function ◽  
Before And After ◽  
Pulmonary Artery Obstruction ◽  
D Dimer

Abstract Background To evaluate the value of CT pulmonary angiography (CTPA) in evaluating the therapeutic efficacy of pulmonary embolism (PE) through the study of CT pulmonary artery obstruction index (PAOI),right ventricular function parameters and some clinical indexes related to coagulation function and cardiac function injury.Materials and methods Select 30 patients with pulmonary embolism who underwent CTPA examination before and after treatment in our hospital, sort out their CTPA images before and after treatment, and obtain PAOI and right heart function parameters, including ascending aorta diameter (AAd), main pulmonary artery diameter (MPAd), ratio of main pulmonary artery diameter to ascending aorta diameter (MPAd/AAd), right pulmonary artery trunk diameter (RPAd), left pulmonary artery trunk diameter (LPAd), the ratio of the maximum short axis diameter of the right ventricle to the maximum short axis diameter of the left ventricle (RVd/LVd), and calculate the pulmonary artery obstruction index (PAOI).At the same time obtain the required clinical indicators, including serum D-dimer, N-terminal B-type natriuretic peptide precursor (NT-proBNP), cardiac troponin I (cTnI), myocardial enzyme profile (aspartate aminotransferase (AST), lactate dehydrogenase (LDH), creatine kinase (CK)).Results MPAd, RPAd, LPAd, RVd / LVd, PAOI, D-dimer, cTnI, CK, LDH, AST had significant changes after treatment (P < 0.05), while the other parameters and indexes had no significant differences before and after treatment (P > 0.05). PAOI is positively correlated with RVd/LVd, MPAd, D-dimer. The correlation coefficient ranges from 0.281 to 0.423, among which, the correlation with D-dimer is the closest, with a correlation coefficient of 0.423. There was no significant correlation between other parameters and PAOI (P < 0.05).Conclusion CTPA is of great significance in evaluating the severity of pulmonary embolism, right heart function and therapeutic efficacy.

scholarly journals Diagnostic Challenges of Pneumocystis Pneumonia during the COVID-19 Pandemic: A Case of a Young Patient with Ground Glass Opacities and Pulmonary Embolism on Chest CT

2021 ◽  
Vol 2021 ◽  
pp. 1-6
Author(s):  
William Lim ◽  
Maham Suhail ◽  
Keith Diaz
Keyword(s):  
Pulmonary Embolism ◽  
Signs And Symptoms ◽  
Clinical History ◽  
Pneumocystis Pneumonia ◽  
Chest Ct ◽  
Ground Glass ◽  
Shortness Of Breath ◽  
Radiological Features ◽  
Laboratory Features ◽  
D Dimer

The coronavirus disease 2019 (COVID-19) pandemic is wreaking havoc across the globe. This pandemic has given rise to a mindset where physicians tend to neglect other causes of pneumonia, especially if the patient presents with signs and symptoms commonly associated with COVID-19. Herein, we report a case of a young man presenting to the emergency department with common clinical, radiological, and laboratory features of COVID-19 pneumonia such as shortness of breath, hypoxia, pulmonary embolism, elevated D-dimer, and bilateral ground glass opacities on computed tomography of the chest but was later diagnosed with Pneumocystis pneumonia that was treated with appropriate antibiotics and corticosteroids. This case highlights the importance of performing a thorough clinical history and differentiating the clinical and radiological features of COVID-19 pneumonia from pneumonia of other etiologies.

scholarly journals Evaluation of the Therapeutic Effect of Pulmonary Embolism by CT Pulmonary Angiography Combined With Clinical Indexes

2021 ◽  
Author(s):  
Meng Yuan ◽  
XinYuan Cui ◽  
ChunXue Yang ◽  
XinYang Zhang ◽  
DeLi Zhao ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Artery ◽  
Heart Function ◽  
Main Pulmonary Artery ◽  
Pulmonary Angiography ◽  
Trunk Diameter ◽  
Right Heart Function ◽  
Before And After ◽  
Pulmonary Artery Obstruction ◽  
D Dimer

Abstract BackgroundTo evaluate the value of CT pulmonary angiography (CTPA) in evaluating the therapeutic efficacy of pulmonary embolism (PE) through the study of CT pulmonary artery obstruction index (PAOI), right ventricular function parameters and some clinical indexes related to coagulation function and cardiac function injury.Materials and methodsSelect 30 patients with pulmonary embolism who underwent CTPA examination before and after treatment in our hospital, sort out their CTPA images before and after treatment, and obtain PAOI and right heart function parameters, including ascending aorta diameter (AAd), main pulmonary artery diameter (MPAd), ratio of main pulmonary artery diameter to ascending aorta diameter (MPAd/AAd), right pulmonary artery trunk diameter (RPAd), left pulmonary artery trunk diameter (LPAd), the ratio of the maximum short axis diameter of the right ventricle to the maximum short axis diameter of the left ventricle (RVd/LVd), and calculate the pulmonary artery obstruction index (PAOI).At the same time obtain the required clinical indicators, including serum D-dimer, N-terminal B-type natriuretic peptide precursor (NT-proBNP), cardiac troponin I (cTnI), myocardial enzyme profile (aspartate aminotransferase (AST), lactate dehydrogenase (LDH), creatine kinase (CK)).ResultsMPAd, RPAd,LPAd,RVd / LVd, PAOI, D-dimer, cTnI, CK, LDH, AST had significant changes after treatment (P < 0.05), while the other parameters and indexes had no significant differences before and after treatment (P > 0.05). PAOI is positively correlated with RVd/LVd, MPAd, D-dimer. The correlation coefficient ranges from 0.281 to 0.423, among which, the correlation with D-dimer is the closest, with a correlation coefficient of 0.423. There was no significant correlation between other parameters and PAOI (P < 0.05).ConclusionCTPA is of great significance in evaluating the severity of pulmonary embolism, right heart function and therapeutic efficacy.

scholarly journals A visualized pulmonary arterial thrombus by using a new  echocardiographic view in an intermediate-risk a cute pulmonary embolism  patient: a case report

2019 ◽  
Author(s):  
Guanyu Mu ◽  
Feixue Li ◽  
Xiaolin Chen ◽  
Bo Zhao ◽  
Guangping Li ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Pulmonary Embolism ◽  
Pulmonary Artery ◽  
Acute Pulmonary Embolism ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Pulmonary Angiography ◽  
Normal Blood ◽  
Intermediate Risk ◽  
Normal Blood Pressure

Abstract BackgroundAcute pulmonary embolism (APE) is a life-threatening disease with nonspecific clinical signs and symptoms. Rapid and accurate diagnosis is crucial for the clinical management of patients with acute pulmonary embolism. A new recommended echocardiography view may be of further help in the diagnosis, evaluate the change of the thrombosis and treatment effect.Case presentationWe report a case of a 74-year-old man with a 12-day history of decreased exercise capacity and dyspnoea. The patient was diagnosed intermediate-risk APE as several pulmonary emboli in pulmonary artery were seen in multidetector computed tomographic pulmonary angiography with normal blood pressure and echocardiographic right ventricular overload. And we found a pulmonary artery clot in the right pulmonary artery through transthoracic echocardiography. After 11-days anticoagulation, the patient underwent a reassessment, showed decrease in RV diameter and pulmonary artery thrombus. ConclusionThis case highlights the significant role that echocardiography played in a patient who presented pulmonary embolism with a stable hemodynamic situation and normal blood pressure. The new echocardiographic view could provide correct diagnoses by identifying the clot size and location visually. Knowledge of the echocardiography results of APE would aid the diagnosis.

Pulmonary Embolism

2019 ◽  
Author(s):  
Nadav Granat ◽  
Evan Avraham Alpert
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Blood Clot ◽  
Pretest Probability ◽  
Treatment Modalities ◽  
Pulmonary Vasculature ◽  
Pulmonary Angiogram ◽  
Catheter Directed Thrombolysis ◽  
D Dimer ◽  
Rule Out

Pulmonary embolism is caused by a blood clot that travels from the deep veins through the heart and then lodges in the pulmonary vasculature. Common symptoms include pleuritic chest pain, dyspnea, or palpitations. Clinical scores such as the Wells score and Revised Geneva score can be used to assess the pretest probability of pulmonary embolism (PE) and guide work-up such as deciding to order D-dimer testing or imaging. However, clinical gestalt can also accurately assess the pretest probability of PE. The Pulmonary Embolism Rule-out Criteria is a decision rule that can be used to rule out PE without further testing. Imaging modalities include computed tomography pulmonary angiogram or ventilation/perfusion scanning. Novel or new oral anticoagulants are becoming the mainstay of treatment for the hemodynamically stable patient with pulmonary embolism. For the patient who is hemodynamically unstable, treatment modalities include intravenous alteplase, catheter-directed thrombolysis, surgical embolectomy, and catheter-directed embolectomy. A subset of patients with PE can be treated as outpatients. This review contains 1 figure, 4 tables, and 55 references. Key Words: anticoagulants, antithrombins, D-dimer, low-molecular-weight heparin, mechanical thrombolysis, multidetector computed tomography, radionuclide imaging, unfractionated heparin, pulmonary embolism, tissue plasminogen activator, warfarin

scholarly journals Vasoactive Substances in Pulmonary Embolism

1977 ◽  
Author(s):  
M.H. Todd ◽  
J.B. Forrest ◽  
J. Hirsh
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Artery ◽  
Pulmonary Artery Pressure ◽  
Autologous Blood ◽  
Venous Blood ◽  
Pulmonary Vasculature ◽  
Artery Pressure ◽  
Vasoactive Substances ◽  
Arterial Blood ◽  
The Right

Embolisation of the pulmonary vasculature with microspheres releases prostaglandin-1ike substances, PGLS (Piper and Vane, N.Y. Acad. Sei. 180: 363, 1971) but the capacity of autologous blood clots (ABC) to release pulmonary vasoactive substances is disputed. Ten normal mongrel dogs were anesthetised with pentobarbitone sodium and instrumented. Pulmonary venous blood was continuously superfused over isolated tissues for bioassay and then returned to the animal. Injection of ABC into the right atrium increased pulmonary artery pressure from 21 ± 6.5 mm Hg to 38 ± 15 mm Hg (mean ± S.D.), increased arterial pCO2 and decreased arterial pO2. No significant changes in heart rate, systemic arterial blood pressure or cardiac output occurred. In three animals contractions of the blood superfused assay tissues occurred following embolism. This effect was produced in normal assay tissues and those pretreated with antagonists of ACh, Serotonin, Histamine and Catecholamines and could therefore be attributed to PGLS. No cardiovascular or assay tissue tension changes were observed when equivalent volumes of saline or clot lysate were injected into the right atrium.Therefore, pulmonary embolism with ABC can release PGLS which may contribute to the pulmonary artery pressure rise. Vasoactive substances may normally be inactivated in the lung but in some animals appear in pulmonary venous blood.(Supported by the Ontario Heart Foundation)

scholarly journals Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery

2017 ◽  
Vol 5 (1) ◽  
pp. 232470961668462 ◽  
Author(s):  
Venkat Gangadharan ◽  
Kamesh Sivagnanam ◽  
Ghulam Murtaza ◽  
Michael Ponders ◽  
Otto Teixeira ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Pulmonary Artery ◽  
Left Main Coronary Artery ◽  
Main Pulmonary Artery ◽  
Shortness Of Breath ◽  
Left Heart ◽  
Coronary Angiogram ◽  
Left Main ◽  
Large Area ◽  
The Right

A 36-year-old woman was seen with complaints of exertional chest pain and shortness of breath. Her medical history included atrial fibrillation and diabetes. Physical examination was unremarkable except for an irregular cardiac rhythm. Myocardial perfusion imaging revealed the presence of a large area of infarction involving the entire anterior and apical walls and part of the anteroseptal wall with minimal periinfarct ischemia. Computed tomography coronary angiogram revealed an anomalous left main coronary artery arising from the main pulmonary artery. Right and left heart catheterizations demonstrated moderate pulmonary hypertension with a slight step-up in oxygen saturation between the right ventricle and main pulmonary artery. Coronary angiography showed a large tortuous right coronary artery with collaterals to the left anterior descending artery that drained into the main pulmonary artery. She was referred for surgery. This case demonstrates a rare coronary artery anomaly in an adult where survival is dependent on collateral circulation.

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