scholarly journals Lifting the fog in intermediate-risk (submassive) PE: full dose, low dose, or no thrombolysis?

F1000Research ◽  
2019 ◽  
Vol 8 ◽  
pp. 330
Author(s):  
Amyn Bhamani ◽  
Joanna Pepke-Zaba ◽  
Karen Sheares
Keyword(s):  
Pulmonary Embolism ◽  
Clinical Practice ◽  
Patient Group ◽  
Acute Pulmonary Embolism ◽  
Low Dose ◽  
Intermediate Risk ◽  
Risk Patients ◽  
Surgical Embolectomy ◽  
Acute Pe

Acute pulmonary embolism (PE) is a disease frequently encountered in clinical practice. While the management of haemodynamically stable, low risk patients with acute PE is well established, managing intermediate disease often presents a therapeutic dilemma. In this review, we discuss the various therapeutic options available in this patient group. This includes thrombolysis, surgical embolectomy and catheter directed techniques. We have also explored the role of specialist PE response teams in the management of such patients. ​

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

scholarly journals The value of ecocardiographic in diagnostication and management of pacients with acute pulmonary embolism

2021 ◽  
Vol 69 (1) ◽  
Author(s):  
Tatiana Cuzor ◽  
◽  
Nadejda Diaconu ◽  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Acute Pulmonary Embolism ◽  
Pulmonary Thromboembolism ◽  
Fatal Disease ◽  
Right Ventricle Dysfunction ◽  
Additional Information ◽  
Risk Patients ◽  
Acute Pe

Pulmonary thromboembolism (TP) remains an underdiagnosed fatal disease at the emergency unit that suggests the need for alternative noninvasive approaches to rapid diagnosis. The role of echocardiography in acute pulmonary embolism (EP) remains incompletely defined. Echocardiography cannot reliably diagnose acute EP and does not improve the prognosis of patients with low-risk acute PE, who lack other clinical characteristics of right ventricle dysfunction (VD). However, echocardiography and dopplerography of the venous system may produce additional information in high-risk patients and may help differentiate chronic VD dysfunction. Specific echocardiographic predictors of VD dysfunction have the potential to increase prognosis in patients at high risk of TP.

Role of echocardiography in managing acute pulmonary embolism

Heart ◽  
2019 ◽  
Vol 105 (23) ◽  
pp. 1785-1792 ◽  
Author(s):  
Noura M Dabbouseh ◽  
Jayshil J Patel ◽  
Paul Anthony Bergl
Keyword(s):  
Pulmonary Embolism ◽  
Right Ventricular ◽  
Prospective Studies ◽  
Acute Pulmonary Embolism ◽  
Economic Value ◽  
Prognostic Information ◽  
Risk Models ◽  
Risk Patients ◽  
Acute Pe

The role of echocardiography in acute pulmonary embolism (PE) remains incompletely defined. Echocardiography cannot reliably diagnose acute PE, and it does not improve prognostication of patients with low-risk acute PE who lack other clinical features of right ventricular (RV) dysfunction. Echocardiography, however, may yield additional prognostic information in higher risk patients and can aid in distinguishing acute from chronic RV dysfunction. Specific echocardiographic markers of RV dysfunction have the potential to enhance prognostication beyond existing risk models. Until these markers are subjected to rigorous prospective studies, the therapeutic utility and economic value of echocardiography in acute PE are uncertain.

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 Current Endovascular Treatment Options in Acute Pulmonary Embolism

2021 ◽  
Vol 11 ◽  
pp. 5
Author(s):  
Kelli Moore ◽  
Jeff Kunin ◽  
Mohammed Alnijoumi ◽  
Prashant Nagpal ◽  
Ambarish P. Bhat
Keyword(s):  
Pulmonary Embolism ◽  
Endovascular Treatment ◽  
Acute Pulmonary Embolism ◽  
Treatment Options ◽  
Mortality And Morbidity ◽  
Response Team ◽  
Promising Treatment ◽  
Level I ◽  
Acute Pe

Acute pulmonary embolism (PE) is a significant cause of mortality and morbidity across the globe. Over the last few decades, there have been major therapeutic advances in acute PE management, including catheter-based therapy. However, the effectiveness of catheter-based therapy in acute PE is not supported by Level I evidence, making the use of this promising treatment rather controversial and ambiguous. In this paper, we discuss the risk stratification of acute PE and review the medical and endovascular treatment options. We also summarize and review the data supporting the use of endovascular treatment options in acute PE and describe the potential role of the PE response team.

Treatment of acute pulmonary embolism as outpatients or following early discharge

2008 ◽  
Vol 100 (05) ◽  
pp. 756-761 ◽  
Author(s):  
Muhammad Janjua ◽  
Aaref Badshah ◽  
Fadi Matta ◽  
Liviu G. Danescu ◽  
Abdo Y. Yaekoub ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Major Bleeding ◽  
Acute Pulmonary Embolism ◽  
Cost Effective ◽  
Early Discharge ◽  
Low Risk ◽  
Exclusion Criteria ◽  
Average Hospital ◽  
Risk Patients ◽  
Acute Pe

SummaryThe purpose of this systematic review is to test the hypothesis that carefully selected low-risk patients with acute pulmonary embolism (PE) can safely be treated entirely as outpatients or after early hospital discharge.Included articles were required to describe inclusion or exclusion criteria and outcome of patients treated for PE.Early hospital discharge was defined as an average hospital stay ≤3 days.Six investigations included patients with PE who were treated entirely as outpatients; two investigations included patients with PE who were treated after early discharge. All investigations included only low-risk patients or patients with small or medium sized PE. Outcome after 3-46 months in patients treated entirely as outpatients showed recurrent PE in 0% to 6.2% of patients, major bleeding in 0% to 2.8% with one death from an intracerebral bleed. Definite death from PE did not occur, but there was one possible death from PE. Outcome in three months in patients treated after early discharge showed no instances of recurrent PE. Major bleeding occurred in 0% to 3.7% of patients.There were no deaths from PE, but there was one death from bleeding. In conclusion, outpatient therapy of acute PE is probably safe in low-risk,carefully selected compliant patients who have access to outpatient care if necessary. Such outpatient treatment would be cost-effective.

scholarly journals Diagnostic Role of Mean-Platelet Volume in Acute Pulmonary Embolism: A Meta-analysis and Systematic Review

2020 ◽  
Vol 14 ◽  
pp. 117954842095636
Author(s):  
Cláudia Febra ◽  
Ana Macedo
Keyword(s):  
Pulmonary Embolism ◽  
Mean Platelet Volume ◽  
Acute Pulmonary Embolism ◽  
Meta Analysis ◽  
Control Group ◽  
Significant Heterogeneity ◽  
Platelet Volume ◽  
Diagnostic Role ◽  
Acute Pe

Background: Acute pulmonary embolism (PE) is the third most fatal cardiovascular disease. PE is frequently misdiagnosed due to its clinical presentation’s heterogeneity and the inexistence of biomarkers for its immediate diagnosis. Mean platelet volume (MPV) has shown a potential role as a biomarker in acute PE. In this analysis, we aimed to systematically compare the MPV in patients with and without definite diagnosis of PE, in emergency departments. Methods: Embase, PubMed and Medline were searched for relevant publications, in English. The main inclusion criteria were studies which compared MPV in patients with acute PEA versus a control group. Results: Thirteen studies consisting of a total number of 2428 participants were included. Of the participants included, 1316 were patients with confirmed acute PE, and 1112 were assigned to the control group. MPV was significantly higher in patients with acute PE than in controls (RR: 0.84, 95% CI: 0.76 – 0.92; P < .00001). There was a significant heterogeneity in the data. Conclusions: This analysis showed higher MPV to be associated with acute PE immediate diagnosis. These data show promise for the use of MPV as a readily available biomarker for the diagnosis of acute PE at the emergency department.

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