scholarly journals Biomarkers for Clinical Decision-Making in the Management of Pulmonary Embolism

2017 ◽  
Vol 63 (1) ◽  
pp. 91-100 ◽  
Author(s):  
Evangelos Giannitsis ◽  
Hugo A Katus
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Natriuretic Peptides ◽  
Clinical Decision Making ◽  
Prediction Models ◽  
Severity Index ◽  
Prognostic Models ◽  
Risk Scores ◽  
Fatty Acid Binding ◽  
Cardiac Troponins

Abstract BACKGROUND Pulmonary embolism (PE) is associated with high all-cause and PE-related mortality and requires individualized management. After confirmation of PE, a refined risk stratification is particularly warranted among normotensive patients. Previous prognostic models favored combinations of echocardiography or computed tomography suggestive of right ventricular (RV) dysfunction together with biomarkers of RV dysfunction (natriuretic peptides) or myocardial injury (cardiac troponins) to identify candidates for thrombolysis or embolectomy. In contrast, current predictive models using clinical scores such as the Pulmonary Embolism Severity Index (PESI) or its simplified version (sPESI) rather seek to identify patients, not only those at higher risk requiring observation for early detection of hemodynamic decompensation, and the need for initiation of rescue reperfusion therapy, but also those at low risk qualifying for early discharge and outpatient treatment. Almost all prediction models advocate the additional measurement of biomarkers along with imaging of RV dysfunction as part of a comprehensive algorithm. CONTENT The following mini-review will provide an updated overview on the individual components of different algorithms with a particular focus on guideline-recommended and new, less-established biomarkers for risk stratification, and how biomarkers should be implemented and interpreted. SUMMARY Ideally, biomarkers should be part of a comprehensive risk stratification algorithm used together with clinical risk scores as a basis, and/or imaging. For this purpose, cardiac troponins, including high-sensitivity troponin generations, natriuretic peptides, and h-FABP (heart-type fatty acid–binding protein) are currently recommended in guidelines. There is emerging evidence for several novel biomarkers that require further validation before being applied in clinical practice.

Risk Stratification in Acute Pulmonary Embolism: The Latest Algorithms

2021 ◽  
Vol 42 (02) ◽  
pp. 183-198
Author(s):  
Georgios A. Triantafyllou ◽  
Oisin O'Corragain ◽  
Belinda Rivera-Lebron ◽  
Parth Rali
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Prediction Models ◽  
Bleeding Risk ◽  
Hemodynamic Instability ◽  
Reperfusion Therapy ◽  
Mortality Prediction ◽  
Risk Scores ◽  
Short Term Mortality ◽  
Urgent Patient

AbstractPulmonary embolism (PE) is a common clinical entity, which most clinicians will encounter. Appropriate risk stratification of patients is key to identify those who may benefit from reperfusion therapy. The first step in risk assessment should be the identification of hemodynamic instability and, if present, urgent patient consideration for systemic thrombolytics. In the absence of shock, there is a plethora of imaging studies, biochemical markers, and clinical scores that can be used to further assess the patients' short-term mortality risk. Integrated prediction models incorporate more information toward an individualized and precise mortality prediction. Additionally, bleeding risk scores should be utilized prior to initiation of anticoagulation and/or reperfusion therapy administration. Here, we review the latest algorithms for a comprehensive risk stratification of the patient with acute PE.

Prediction Models and Scores in Pulmonary Hypertension: A Systematic Review

2020 ◽  
Vol 26 ◽  
Author(s):  
Sophia Anastasia Mouratoglou ◽  
Ahmed A. Bayoumy ◽  
Anton Vonk Noordegraaf
Keyword(s):  
Systematic Review ◽  
Risk Stratification ◽  
Prediction Models ◽  
Prognostic Significance ◽  
Morbidity And Mortality ◽  
Prognostic Models ◽  
Risk Scores ◽  
Patient Treatment ◽  
Discrimination Ability ◽  
Mesh Terms

Background:: pulmonary arterial hypertension (PAH) is a serious disease with increased morbidity and mortality. The need of an individualized patient treatment approach necessitates the use of risk assessment in PAH patients. That may include a range of hemodynamic, clinical, imaging and biochemical parameters, derived from clinical studies and registry data. Objective:: in current systematic review, we summarize the available data on risk prognostic models and scores in PAH and we explore the possible concordance amongst different risk stratification tools in PAH. Methods:: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines aided the performance of this systematic review. Eligible studies were identified through literature search in the electronic databases PubMed, Science Direct, Google Scholar and Cochrane with the use of various combinations of MeSH and non-MeSH terms, with focus on PAH Results:: overall, 25 studies were included in the systematic review, out of them, 9 were studies deriving prognostic equations and risk scores and 16 were validating studies of an existing score. The majority of risk stratification scores use hemodynamic data for the assessment of prognosis, while other also include clinical and demographic variables in their equations. The risk discrimination in the overall PAH population, was adequate, especially in differentiating the low versus high risk patients, but their discrimination ability in the intermediate groups remained lower. Current ESC/ERS proposed risk stratification score utilizes a limited number of parameters with prognostic significance, whose prognostic ability is validated in European patient populations. Conclusion:: despite improvement in risk estimation of prognostic tools of the disease, PAH morbidity and mortality remain high, necessitating the need for the risk scores to undergo periodic re-evaluation and refinements to incorporate new data on predictors of disease progression and mortality and, thereby, maintain their clinical utility

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.

Pulmonary embolism in acute medicine: a case-based review incorporating latest guidelines in the COVID-19 era

2020 ◽  
Vol 81 (6) ◽  
pp. 1-12 ◽  
Author(s):  
Alexander Stevenson ◽  
Sarah Davis ◽  
Nick Murch
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Acute Pulmonary Embolism ◽  
Severe Disease ◽  
Treatment Options ◽  
Risk Scores ◽  
Pulmonary Vasculature ◽  
Catheter Directed Thrombolysis ◽  
Imaging Results ◽  
Venous Thromboembolic Events

Pulmonary embolism remains an important cause of morbidity and mortality in the UK, particularly following the outbreak of the novel coronavirus 2019 (COVID-19), where those infected have an increased prevalence of venous thromboembolic events. The pathophysiology in COVID-19 patients is thought to relate to a thromboinflammatory state within the pulmonary vasculature, triggered by the infection, but other risk factors such as reduced mobility, prolonged immobilisation and dehydration are likely to contribute. Several societies have released comprehensive guidelines emphasising the importance of risk stratification in patients with acute pulmonary embolism. They advocate the use of clinically validated risk scores in conjunction with biochemical and imaging results. Patients with mild disease can now be managed in the outpatient setting and with newly developed therapies, such as catheter-directed thrombolysis, becoming available in more centres, treatment options for those with more severe disease are also expanding. This article presents four theoretical but realistic cases, each diagnosed with acute pulmonary embolism, but differing in levels of severity. These demonstrate how the guidelines can be applied in a clinical setting, with particular focus on risk stratification and management.

P1858Meta-analysis of performance of risks scores for predicting outcomes after percutaneous Mitraclip implantation

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
T K M Wang ◽  
M T M Wang
Keyword(s):  
Confidence Interval ◽  
Risk Stratification ◽  
Clinical Decision Making ◽  
Operative Mortality ◽  
Data Extraction ◽  
Meta Analysis ◽  
Critical Role ◽  
Clinical Decision ◽  
Risk Scores ◽  
Sts Score

Abstract Background The Mitraclip is the most established percutaneous mitral valve intervention indicated for severe mitral regurgitation at high or prohibitive surgical risk. Risk stratification plays a critical role in selecting the appropriate treatment modality in high risk valve disease patients but have been rarely studied in this setting. We compared the performance of risk scores at predicting mortality after Mitraclip in this meta-analysis. Methods MEDLINE, Embase and Cochrane databases from 1 January 1980 to 31 December 2018 were searched. Two authors reviewed studies which reported c-statistics of risk models to predict mortality after Mitraclip for inclusion, followed by data extraction and pooled analyses. Results Amongst 494 articles searched, 47 full-text articles were evaluated, and 4 studies totalling 879 Mitraclip cases were included for analyses. Operative mortality was reported at 3.3–7.4% in three studies, and 1-year mortality 11.2%-13.5% in two studies. C-statistics (95% confidence interval) for operative mortality were EuroSCORE 0.66 (0.57–0.75), EuroSCORE II 0.72 (0.60–0.85) and STS Score 0.64 (0.56–0.73). Respective Peto's odds ratios (95% confidence interval) to assess calibration were EuroSCORE 0.21 (0.14–0.31), EuroSCORE II 0.43 (0.24–0.76) and STS Score 0.36 (0.21–0.61). C-statistics (95% confidence interval) for 1-year mortality were EuroSCORE II 0.64 (0.57–0.70) and STS Score (0.58–0.64). Conclusion All scores over-estimated operative mortality, and EuroSCORE II had the best moderate discrimination while the other two scores were only modestly prognostic. Development of Mitraclip-specific scores may improve accuracy of risk stratification for this procedure to guide clinical decision-making.

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.

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.

scholarly journals Pulmonary Embolism Severity Index and Simplified Pulmonary Embolism Severity Index Risk Scores Are Useful to Predict Mortality in Japanese Patients With Pulmonary Embolism

2015 ◽  
Vol 79 (4) ◽  
pp. 889-891 ◽  
Author(s):  
Atsushi Mizuno ◽  
Takeshi Yamamoto ◽  
Yasuhiro Tanabe ◽  
Toru Obayashi ◽  
Morimasa Takayama ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Japanese Patients ◽  
Severity Index ◽  
Risk Scores
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