scholarly journals A retrospective analysis of outcomes in low- and intermediate–high-risk pulmonary embolism patients managed on an ambulatory medical unit in the UK

2019 ◽  
Vol 5 (2) ◽  
pp. 00184-2018 ◽  
Author(s):  
Michael E. Reschen ◽  
Jonathan Raby ◽  
Jordan Bowen ◽  
Sudhir Singh ◽  
Daniel Lasserson ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Mortality Rate ◽  
Vital Signs ◽  
Admission Rate ◽  
Risk Groups ◽  
Severity Index ◽  
All Cause Mortality ◽  
Specific Mortality ◽  
The Uk

Pulmonary embolism (PE) is common and guidelines recommend outpatient care only for PE patients with low predicted mortality. Outcomes for patients with intermediate-to-high predicted mortality managed as outpatients are unknown.Electronic records were analysed for adults with PE managed on our ambulatory care unit over 2 years. Patients were stratified into low or intermediate-to-high mortality risk groups using the Pulmonary Embolism Severity Index (PESI). Primary outcomes were the proportion of patients ambulated, 30-day all-cause mortality, 30-day PE-specific mortality and 30-day re-admission rate.Of 199 PE patients, 74% were ambulated and at 30 days, all-cause mortality was 2% (four out of 199) and PE-specific mortality was 1% (two out of 199). Ambulated patients had lower PESI scores, better vital signs and lower troponin levels (morning attendance favoured ambulation). Over a third of ambulated patients had an intermediate-to-high risk PESI score but their all-cause mortality rate was low at 1.9% (one out of 52). In patients with intermediate-to-high risk, oxygen saturation was higher and pulse rate lower in those who were ambulated. Re-admission rate did not differ between ambulated and admitted patients.Two-thirds of patients with intermediate-to-high risk PE were ambulated and their mortality rate remained low. It is possible for selected patients with intermediate-to-high risk PESI scores to be safely ambulated.

Abstract 14895: Catheter-Based Treatment for Pulmonary Embolism With Concomitant Use of Intrapulmonary Thrombolysis Improves In-Hospital Mortality Rates

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Rajat Kalra ◽  
Navkaranbir S Bajaj ◽  
Jason L Guichard ◽  
Sameer Ather ◽  
William J Lancaster ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Mortality Rate ◽  
Hospital Mortality ◽  
Heart Association ◽  
Mortality Rates ◽  
All Cause Mortality ◽  
Risk Patients ◽  
Rapid Clearance ◽  
Meta Regression

Introduction: In-hospital mortality rates after catheter-based treatment (CBT) of high-risk pulmonary embolism (PE) are variable. Use of intrapulmonary thrombolytics with other CBT may result in rapid clearance of obstruction, prevent extremis and lead to improved mortality rates. Hypothesis: We hypothesized that the concomitant use of intrapulmonary thrombolysis in conjunction with CBT may affect mortality and explain the heterogeneity among in-hospital mortality rates. Methods: We searched SCOPUS since inception to November 2014 using predefined criteria. Studies reporting in-hospital mortality in patients with massive PE or a combination of massive and submassive PE, as defined by the American Heart Association, were included. In-hospital all-cause mortality rates were estimated in these high-risk patients using standard meta-analytic methods. Heterogeneity in mortality rates was explored with meta-regression. Results: In 54 eligible studies with 1,333 patients, 1357 CBT procedures were performed. All CBT modalities were studied. In-hospital mortality rates varied widely amongst studies (Figure, Panel A). On meta-regression with Logit-in hospital mortality rate as the dependent variable, studies that had a higher proportion of patients who received concomitant intrapulmonary thrombolysis had lower Logit in-hospital mortality rate (β = - 0.01, p <0.001; Figure, Panel B). Conclusions: Concomitant use of intrapulmonary thrombolytics is associated with lower in-hospital mortality rate in patients undergoing CBT for high-risk PE.

scholarly journals Is the Pulmonary Embolism Severity Index Being Routinely Used in Clinical Practice?

Thrombosis ◽  
2015 ◽  
Vol 2015 ◽  
pp. 1-5 ◽  
Author(s):  
Ali Shafiq ◽  
Hamza Lodhi ◽  
Zaheer Ahmed ◽  
Ata Bajwa
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Hospital Stay ◽  
Length Of Hospital Stay ◽  
Risk Groups ◽  
Severity Index ◽  
Low Risk ◽  
Significant Difference ◽  
Risk Patients ◽  
Acute Pe

Background. The Pulmonary Embolism Severity Index (PESI) score can risk-stratify patients with PE but its widespread use is uncertain. With the PESI, we compared length of hospital stay between low, moderate, and high risk PE patients and determined the number of low risk PE patients who were discharged early. Methods. PE patients admitted to St. Joseph Mercy Oakland Hospital from January 2005 to August 2010 were screened. PESI score stratified acute PE patients into low (<85), moderate (86–105), and high (>105) risk categories and their length of hospital stay was compared. Patients with low risk PE discharged early (≤3 days) were calculated. Results. Among 315 PE patients, 51.7% were at low risk. No significant difference in hospital stay between low (7.11 ± 3 d) and moderate (6.88 ± 2.9 d) risk, p > 0.05, as well as low and high risk (7.28 ± 3.0 d), p > 0.05, was found. 9% of low risk patients were discharged ≤ 3 days. Conclusions. There was no significant difference in length of hospital stay between low and high risk groups and only a small number of low risk patients were discharged from the hospital early suggesting that risk tools like PESI may not have a widespread use.

Trends in risk stratification, in-hospital management and mortality of patients with acute pulmonary embolism: an analysis from China pUlmonary thromboembolism REgistry Study (CURES)

2021 ◽  
pp. 2002963
Author(s):  
Zhenguo Zhai ◽  
Dingyi Wang ◽  
Jieping Lei ◽  
Yuanhua Yang ◽  
Xiaomao Xu ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Hospital Mortality ◽  
Acute Pulmonary Embolism ◽  
Severity Index ◽  
Disease Diagnosis ◽  
Initial Therapy ◽  
European Respiratory Society ◽  
Systemic Thrombolysis ◽  
All Cause Mortality

BackgroundSimilar trends of management and in-hospital mortality of acute pulmonary embolism (PE) have been reported in European and American populations. However, these tendencies were not clear in Asian countries.ObjectivesWe retrospectively analyzed the trends of risk stratification, management and in-hospital mortality for patients with acute PE through a multicenter registry in China (CURES).MethodsAdult patients with acute symptomatic PE were included between 2009 and 2015. Trends in disease diagnosis, treatment and death in hospital were fully analyzed. Risk stratification was retrospectively classified by hemodynamical status and the simplified Pulmonary Embolism Severity Index (sPESI) score according to the 2014 European Society of Cardiology/European Respiratory Society guidelines.ResultsAmong overall 7438 patients, the proportions with high (hemodynamically instability), intermediate (sPESI≥1) and low (sPESI=0) risk were 4.2%, 67.1% and 28.7%, respectively. Computed tomographic pulmonary angiography was the widely employed diagnostic approach (87.6%) and anticoagulation was the frequently adopted initial therapy (83.7%). Between 2009 and 2015, a significant decline was observed for all-cause mortality (from 3.1% to 1.3%, adjusted Pfor trend=0.0003), with a concomitant reduction in use of initial systemic thrombolysis (from 14.8% to 5.0%, Pfor trend<0.0001). The common predictors for all-cause mortality shared by hemodynamically stable and unstable patients were co-existing cancer, older age, and impaired renal function.ConclusionsThe considerable reduction of mortality over years was accompanied by changes of initial treatment. These findings highlight the importance of risk stratification-guided management throughout the nation.

scholarly journals Features of in-hospital clinical course of pulmonary embolism in patients of different age groups

2020 ◽  
Vol 19 (5) ◽  
pp. 2423
Author(s):  
E. A. Shmidt ◽  
S. A. Berns ◽  
A. G. Neeshpapa ◽  
P. A. Talyzin ◽  
I. I. Zhidkova ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Clinical Course ◽  
Diastolic Pressure ◽  
Age Groups ◽  
Statistical Processing ◽  
Severity Index ◽  
Cardiovascular Comorbidity ◽  
Vein Thrombosis ◽  
Comorbidity Status

Aim. To study the clinical course and management of patients with pulmonary embolism (PE) of various age groups hospitalized in a cardiology hospital.Material and methods. This prospective single-center study in the period from 2016 to 2018 included 154 patients with PE verified by computed tomography. Statistical processing was conducted using the MedCalcVersion 16.2.1 software package (Softwa, Belgium).Results. In all groups, female patients dominated, but the highest number of women (70,7%) belonged to the group of senile patients, while in the group <60 years, only half of patients with PE were women. Comorbid cardiovascular disease and deep vein thrombosis was diagnosed in eldest patients significantly more often than in those <60 years of age. The highest prevalence of cancer and recurrent PE were identified in the group of elderly patients. Thrombolytic therapy was performed most often in patients 60-75 years old, since these patients had a high risk of 30-day mortality according to Pulmonary Embolism Severity Index, but did not have severe comorbidities, as patients older than 75 years. An increase of right atrium size was found in the group of elderly and senile patients in comparison with patients <60 years. The highest pulmonary artery systolic and diastolic pressure was observed in the patients older than 75 years.Conclusion. In the Kemerovo Oblast, PE most often develops in patients aged 60-75 years and is characterized by a more severe clinical course compared with patients younger than 60 years. Patients over the 60 years of age have severe cardiovascular comorbidity status, atrial fibrillation/flutter and recurrent PE. Surgical treatment for senile patients is limited due to the high risk of postoperative complications, which specifies high mortality. Patients <60 years of age are a third of all patients hospitalized with PE. They have a low risk of mortality, but have an unfavorable course of the hospital period.

Abstract 16915: Mortality And Safety Outcomes of Various Catheter-based Treatment Modalities in Patients With High-risk Pulmonary Embolism: A Meta-analysis

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Navkaranbir S Bajaj ◽  
Rajat Kalra ◽  
Sameer Ather ◽  
Jason Guichard ◽  
William J Lancaster ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Mortality Rate ◽  
Hospital Mortality ◽  
Heart Association ◽  
Treatment Modalities ◽  
Significant Heterogeneity ◽  
Access Site ◽  
Aspiration Thrombectomy ◽  
Safety Outcomes

Background: Catheter-based treatments (CBTs) are diverse set of techniques aimed at relieving pulmonary arterial obstruction in patients with high-risk pulmonary embolism. Multiple modalities are currently available. The mortality and safety outcomes have not been studied among these different modalities. Hypothesis: We conducted this investigation to determine the mortality and safety of individual modalities. Methods: We searched SCOPUS since inception to November 2014 using predefined criteria. Studies including massive PE or a combination of massive and submassive PE, as defined by the American Heart Association, were included. In-hospital mortality rates and pooled safety complication rate (defined as a composite of peri- and post-procedural cardiac arrest, minor access site bleeding, major access site bleeding, and bleeding at other sites) were estimated using standard meta-analytic methods and compared among six different groups namely aspiration thrombectomy, intrapulmonary thrombolysis (IP), mechanical fragmentation (MF), rheolytic thrombectomy (RT), ultrasound-accelerated thrombolysis (USAT) and multiple simultaneous modalities. Results: In 54 eligible studies with 1,333 patients, 1,357 CBT procedures were performed. Patients undergoing USAT had the lowest in-hospital mortality rate whereas patients undergoing RT had the highest in-hospital mortality rate (p = 0.011, Table). Intrapulmonary thrombolysis had the highest pooled rate of safety outcome whereas MF had the lowest rate among various techniques (p = 0.034, Table). Conclusion: There is significant heterogeneity in mortality and safety outcomes between various CBT modalities. Our analysis is limited by variance in study quality and baseline characteristics. More investigation is required to determine the optimal type of CBT for high-risk PE.

Clinical characteristics and 3-month outcomes in cancer patients with incidental versus clinically-suspected and confirmed pulmonary embolism

2020 ◽  
pp. 2002723
Author(s):  
Marisa Peris ◽  
Juan J. López-Nuñez ◽  
Ana Maestre ◽  
David Jimenez ◽  
Alfonso Muriel ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Mortality Rate ◽  
Cancer Patients ◽  
Major Bleeding ◽  
Management Strategies ◽  
Multivariable Analysis ◽  
Heparin Therapy ◽  
Incidental Pulmonary Embolism ◽  
All Cause Mortality ◽  
Related Mortality

BackgroundCurrent guidelines suggest treating cancer patients with incidental pulmonary embolism (PE) similar to those with clinically-suspected and confirmed PE. However, the natural history of these presentations has not been thoroughly compared.MethodsWe used the data from the RIETE registry to compare the 3-month outcomes in patients with active cancer and incidental PE versus those with clinically-suspected and confirmed PE. The primary outcome was 90-day all-cause mortality. Secondary outcomes were PE-related mortality, symptomatic PE recurrences and major bleeding.ResultsFrom July 2012 to January 2019, 946 cancer patients with incidental asymptomatic PE and 2274 with clinically-suspected and confirmed PE were enrolled. Most patients (95% versus 90%) received low-molecular-weight heparin therapy. During the first 90 days, 598 patients died, including 42 from PE. Patients with incidental PE had a lower all-cause mortality rate than those with suspected and confirmed PE (11% versus 22%; odds ratio [OR]: 0.43; 95%CI: 0.34–0.54). Results were consistent for PE-related mortality (0.3% versus 1.7%; OR: 0.18; 95% CI: 0.06–0.59). Multivariable analysis confirmed that patients with incidental PE were at lower risk to die (adjusted OR: 0.43; 95%CI: 0.34–0.56). Overall, 29 patients (0.9%) developed symptomatic PE recurrences, and 122 (3.8%) had major bleeding. There were no significant differences in PE recurrences (OR: 0.62; 95%CI: 0.25–1.54) or major bleeding (OR: 0.78; 95%CI: 0.51–1.18).ConclusionsCancer patients with incidental PE had a lower mortality rate than those with clinically-suspected and confirmed PE. Further studies are required to validate these findings, and to explore optimal management strategies in these patients.

scholarly journals Pulmonary embolism in old age: usefulness of risk stratification in clinical decision-making

2016 ◽  
Vol 2 (2) ◽  
Author(s):  
Carlo Bova ◽  
Vitaliano Spagnuolo ◽  
Alfonso Noto
Keyword(s):  
Decision Making ◽  
Pulmonary Embolism ◽  
High Risk ◽  
Clinical Decision Making ◽  
Clinical Status ◽  
Severity Index ◽  
Common Disease ◽  
Early Complications ◽  
Short Term ◽  
Risk Of Death

Pulmonary embolism (PE) is a common disease with a not negligible short-term risk of death, in particular in the elderly. An adequate evaluation of the prognosis in patients with PE may guide decision-making in terms of the intensity of the initial treatment during the acute phase. Patients with shock or persistent hypotension are at high risk of early mortality and may benefit from immediate reperfusion. Several tools are available to define the short-term prognosis of hemodynamically stable patients. The pulmonary embolism severity index (PESI) score, and the simplified PESI score are particularly useful for identifying patients at low risk of early complications who might be safely treated at home. The identification of patients who are hemodynamically stable at diagnosis but are at a high risk of early complications is more challenging. Current guidelines recommend a multi-parametric prognostic algorithm based on the clinical status, biomarkers and imaging tests. However an aggressive treatment in hemodynamically stable patients is still controversial.

scholarly journals Prophylaxis of venous thromboembolism in general surgery: guidelines differ and we still need local policies

2011 ◽  
Vol 93 (5) ◽  
pp. 370-374
Author(s):  
D Veeramootoo ◽  
L Harrower ◽  
R Saunders ◽  
D Robinson ◽  
WB Campbell
Keyword(s):  
At Risk ◽  
Venous Thromboembolism ◽  
High Risk ◽  
Risk Groups ◽  
Low Risk ◽  
Vte Prophylaxis ◽  
Risk Patients ◽  
Local Policies ◽  
One Year ◽  
The Uk

INTRODUCTION Venous thromboembolism (VTE) prophylaxis has become a major issue for surgeons both in the UK and worldwide. Sev-eral different sources of guidance on VTE prophylaxis are available but these differ in design and detail. METHODS Two similar audits were performed, one year apart, on the VTE prophylaxis prescribed for all general surgical inpatients during a single week (90 patients and 101 patients). Classification of patients into different risk groups and compliance in prescribing prophylaxis were examined using different international, national and local guidelines. RESULTS There were significant differences between the numbers of patients in high, moderate and low-risk groups according to the different guidelines. When groups were combined to indicate simply ‘at risk’ or ‘not at risk’ (in the manner of one of the guidelines), then differences were not significant. Our compliance improved from the first audit to the second. Patients at high risk received VTE prophylaxis according to guidance more consistently than those at low risk. CONCLUSIONS Differences in guidance on VTE prophylaxis can affect compliance significantly when auditing practice, depending on the choice of ‘gold standard’. National guidance does not remove the need for clear and detailed local policies. Making decisions about policies for lower-risk patients can be more difficult than for those at high risk.

Benefit of Targeted Intensification for NCI High Risk Childhood Lymphoblastic Leukaemia: Results of the United Kingdom Medical Research Council Trial ALL97 and ALL97/99.

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 1869-1869
Author(s):  
Ajay Vora ◽  
Rachel Ward ◽  
Jeanette Payne ◽  
Chris Mitchell ◽  
Tim Eden ◽  
...  
Keyword(s):  
High Risk ◽  
Risk Groups ◽  
Cell Phenotype ◽  
Cranial Radiotherapy ◽  
Childhood All ◽  
Relapse Risk ◽  
Treatment Regimens ◽  
Cns Relapse ◽  
Low Incidence ◽  
The Uk

Abstract In November1999, the UK childhood ALL trial, ALL 97, adopted CCG risk stratification and treatment regimens in favour of the UKALL approach due to concerns over lower event-free survival (EFS) in the UK compared to the US. A key new feature in the amended trial, ALL97/99, was NCI risk group and early marrow response targeted intensification. Of 1935 patients registered in the trial between January 1997 and June 2002, 997 were treated on ALL97 and 938 on ALL97/99. EFS was better in ALL97/99 compared with ALL 97 (5 year EFS: ALL 97 = 74.1%, 95% CI 71.4%–76.8% vs ALL 97/99 = 78.9%, 76.0%–81.8%, p=0.002). To investigate whether particular sub-groups benefited more or less with the CCG approach, we compared outcomes for different risk groups within the two parts of the trial in regard to EFS, overall survival (OS) and CNS relapse risk. All p values quoted are two-sided. EFS and OS were significantly better in ALL97/99 compared with ALL97 for NCI high risk (HR) patients (5 year EFS: ALL 97 = 61.8%, 95% CI: 56.9–66.7%, ALL 97/99 = 71.8% 95% CI: 66.7–76.9%, p = 0.0006. 5 year OS: ALL97 = 71.3%, 95% CI: 66.8–75.8%, ALL97/99 = 80.3% 95% CI: 76.0–84.6%, p = 0.005), but did not differ significantly for NCI standard risk (SR) patients (5 year EFS: ALL 97 = 81.7% 95% CI: 78.6–84.8%, ALL 97/99 = 83.3% 95% CI: 79.8–86.8%, p = 0.3. 5 year OS: ALL97 = 91.2% 95% CI: 89.0–93.4%, ALL97/99 = 92.6% 95% CI: 90.4–94.8%, p = 0.5). The incidence of isolated CNS relapse was also significantly lower in ALL97/99 for NCI HR (ALL97 = 8% vs ALL97/99 = 3.5%, p = 0.01) but not NCI SR patients (ALL97 = 3.5% vs ALL97/99 = 2.7%, p = 0.6). Despite restricting the use of cranial radiotherapy to patients with overt CNS disease (CNS 3, <5% of all patients), the incidence of isolated CNS relapse in ALL97/99 was reassuringly low, even for sub-groups at high risk of CNS relapse such as those with WCC > 100 × 10 9/l (4.8%) or T cell phenotype (3.8%). Isolated CNS relapse risk in ALL97/99 patients randomised to dexamethasone (which was compared with prednisolone in the trial) was 1.8%, similar to that reported with use of cranial radiotherapy for a higher proportion of patients. A targeted intensification approach improves EFS for NCI HR patients and, especially when combined with systemic dexamethasone, results in a low incidence of isolated CNS relapse for high risk sub-groups without use of cranial radiotherapy.

An evaluation of the performance of OraQuick® ADVANCE Rapid HIV-1/2 Test in a high-risk population attending genitourinary medicine clinics in East London, UK

2008 ◽  
Vol 19 (10) ◽  
pp. 665-667 ◽  
Author(s):  
J Zelin ◽  
N Garrett ◽  
J Saunders ◽  
F Warburton ◽  
J Anderson ◽  
...  
Keyword(s):  
High Risk ◽  
Test Performance ◽  
Predictive Value ◽  
Risk Groups ◽  
Antibody Detection ◽  
High Risk Population ◽  
Antibody Testing ◽  
Observer Error ◽  
The Uk ◽  
Hiv 1

To date, no data have been published on the use of OraQuick® ADVANCE Rapid HIV-1/2 Test (OraQuick) in the UK. We report preliminary findings of an ongoing evaluation of OraQuick in UK genitourinary (GU) medicine clinics. A total of 820 samples from patients in high-risk groups for HIV were tested with OraQuick and results were compared with standard HIV antibody testing. HIV prevalence (enzyme immunoassay [EIA]) was 5.73%, sensitivity of OraQuick was 93.64% (95% CI 82.46–98.66%), specificity 99.87% (99.28–100%), positive predictive value 97.78% (88.27–99.94%) and negative predictive value 99.61% (98.87–99.92%). This includes three false-negatives considered to be due to observer error and now rectified by further training. This has increased test sensitivity to 100%. Our observed test performance of OraQuick compares well with EIA and with other rapid tests. We believe that simple, non-invasive antibody detection tests such as OraQuick can increase HIV testing and diagnosis in UK GU medicine and community settings.

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