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

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.

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Anticoagulant therapies for acute venous thromboembolism: a comparison between those discharged directly from the emergency department versus hospital in two Canadian cities

BMJ Open ◽

10.1136/bmjopen-2018-022063 ◽

2018 ◽

Vol 8 (10) ◽

pp. e022063 ◽

Cited By ~ 3

Author(s):

Tammy J Bungard ◽

Bruce Ritchie ◽

Jennifer Bolt ◽

William M Semchuk

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Severity Index ◽

Vein Thrombosis ◽

Risk Patients ◽

Acute Venous Thromboembolism ◽

Record Review ◽

Deep Vein

ObjectiveTo compare the characteristics/management of acute venous thromboembolism (VTE) for patients either discharged directly from the emergency department (ED) or hospitalised throughout a year within two urban cities in Canada.DesignRetrospective medical record review.SettingHospitals in Edmonton, Alberta (n=4) and Regina, Saskatchewan (n=2) from April 2014 to March 2015.ParticipantsAll patients discharged from the ED or hospital with acute deep vein thrombosis or pulmonary embolism (PE). Those having another indication for anticoagulant therapy, pregnant/breast feeding or anticipated lifespan <3 months were excluded.Primary and secondary outcomesPrimarily, to compare proportion of patients receiving traditional therapy (parenteral anticoagulant±warfarin) relative to a direct oral anticoagulant (DOAC) between the two cohorts. Secondarily, to assess differences with therapy selected based on clot burden and follow-up plans postdischarge.Results387 (25.2%) and 665 (72.5%) patients from the ED and hospital cohorts, respectively, were included. Compared with the ED cohort, those hospitalised were older (57.3 and 64.5 years; p<0.0001), more likely to have PE (35.7% vs 83.8%) with a simplified Pulmonary Embolism Severity Index (sPESI) ≥1 (31.2% vs 65.2%), cancer (14.7% and 22.3%; p=0.003) and pulmonary disease (10.1% and 20.6%; p<0.0001). For the ED and hospital cohorts, similar proportions of patients were prescribed traditional therapies (72.6% and 71.1%) and a DOAC (25.8% and 27.4%, respectively). For the ED cohort, DOAC use was similar between those with a sPESI score of 0 and ≥1 (35.1% and 34.9%, p=0.98) whereas for those hospitalised lower risk patients were more likely to receive a DOAC (31.4% and 23.8%, p<0.055). Follow-up was most common with family physicians for those hospitalised (51.5%), while specialists/VTE clinic was most common for those directly discharged from the ED (50.6%).ConclusionsTraditional and DOAC therapies were proportionately similar between the ED and hospitalised cohorts, despite clear differences in patient populations and follow-up patterns in the community.

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

Geriatric Care ◽

10.4081/gc.2016.6080 ◽

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.

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Prevention of Deep Vein Thrombosis and Pulmonary Embolism in High-Risk Medical Patients

Clinics in Chest Medicine ◽

10.1016/j.ccm.2018.04.002 ◽

2018 ◽

Vol 39 (3) ◽

pp. 483-492 ◽

Cited By ~ 4

Author(s):

Megan McCullough ◽

Cyrus Kholdani ◽

Roham T. Zamanian

Keyword(s):

Pulmonary Embolism ◽

Deep Vein Thrombosis ◽

High Risk ◽

Medical Patients ◽

Vein Thrombosis ◽

Deep Vein

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The first experience of treatment applied to patients with pulmonary embolism that developed on the COVID-19 background

Clinical Medicine (Russian Journal) ◽

10.30629/0023-2149-2020-98-8-612-618 ◽

2021 ◽

Vol 98 (8) ◽

pp. 612-618

Author(s):

S. A. Fedorov ◽

A. P. Medvedev ◽

A. L. Maksimov ◽

N. Yu. Borovkova ◽

M. B. Sukhanova ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Troponin I ◽

Diastolic Pressure ◽

Systolic Pressure ◽

Systemic Thrombolysis ◽

Reactive Protein ◽

Results Of Treatment ◽

The Moment ◽

The Right

The aim of the study was to evaluate the immediate results of treatment of high-risk PE developed against the background of COVID-19, and to analyze the features of the clinical course. Material and methods. The study is based on the experience of treatment applied to three patients with pulmonary embolism (PE) that developed against the background of COVID-19. The group under consideration is represented by males. The average age was 41 ± 3.1 years old. Verification of the primary diagnosis of COVID-19 was based on positive results of polymerase chain reaction, supplemented by the results of computed tomography. The formation of high-risk PE was noted on the 5th–7th day from the moment of hospitalization. There was also a decrease in SO2 below 85%, РаО2 — below 76 mm Hg, Borg index > 8, which required non-invasive high-flow ventilation. Catheterization of the right chambers of the heart with a Swan–Ganz catheter revealed an increase in systolic pressure in the right ventricle to 57 ± 1.2 mm Hg, and diastolic pressure to 13 ± 0.34 mm Hg. Pulmonary hypertension increased up to 70 mm Hg. Changes in the biochemical analysis of blood consisted in increasing the level of troponin I to 0.65 ± 0.14 ng/ml, С reactive protein — to 5.42 ± 2.1 mg/l, and creatine phosphokinase — to 324 ± 23.1 units. An increase in the D-dimer level was observed (0.68 ± 0.11 mg/l). Systemic thrombolysis actilyse was performed in all the cases. Results. Positive clinical dynamics was observed up to 15 hours after thrombolytic therapy. The level of SO2 came back to the initial values and was in the range 93–96% and RaO2 — from 86–92 mm Hg by the end of the first day after the intervention. The average pressure gradient in the pulmonary artery was 32 ± 4.12 mm Hg at the time of discharge, and at the peak — 44 ± 5.3 mm Hg.

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d-Dimer Assessment Improves the Simplified Pulmonary Embolism Severity Index for In-Hospital Risk Stratification in Acute Pulmonary Embolism

Clinical and Applied Thrombosis/Hemostasis ◽

10.1177/1076029618776799 ◽

2018 ◽

Vol 24 (8) ◽

pp. 1340-1346 ◽

Cited By ~ 2

Author(s):

Marta Kozlowska ◽

Magdalena Plywaczewska ◽

Marcin Koc ◽

Szymon Pacho ◽

Anna Wyzgal ◽

...

Keyword(s):

Pulmonary Embolism ◽

Adverse Event ◽

Risk Stratification ◽

Prognostic Value ◽

Acute Pulmonary Embolism ◽

Clinical Course ◽

Area Under The Curve ◽

Severity Index ◽

Net Reclassification Improvement ◽

D Dimer

d-dimer (DD) levels are used in the diagnostic workup of suspected acute pulmonary embolism (APE), but data on DD for early risk stratification in APE are limited. In this post hoc analysis of a prospective observational study of 270 consecutive patients, we aimed to optimize the discriminant capacity of the simplified pulmonary embolism severity index (sPESI), an APE risk assessment score currently used, by combining it with DD for in-hospital adverse event prediction. We found that DD levels were higher in patients with complicated versus benign clinical course 7.2 mg/L (25th-75th percentile: 4.5-27.7 mg/L) versus 5.1 mg/L (25th-75th percentile: 2.1-11.2 mg/L), P = .004. The area under the curve of DD for serious adverse event (SAE) was 0.672, P = .003. d-dimer =1.35 mg/L showed 100% negative predictive value for SAE and identified 11 sPESI ≥1 patients with a benign clinical course, detecting the 1 patient with SAE from sPESI = 0. d-dimer >15 mg/L showed heart rate for SAE 3.04 (95% confidence interval [CI]: 1-9). A stratification model which with sPESI + DD >1.35 mg/L demonstrated improved prognostic value when compared to sPESI alone (net reclassification improvement: 0.085, P = .04). d-dimer have prognostic value, values <1.35 mg/L identify patients with a favorable outcome, improving the prognostic potential of sPESI, while DD >15 mg/L is an independent predictor of SAE.

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Surgical Treatment in a High-Risk Pulmonary Embolism: Case Report

Medicina ◽

10.3390/medicina57070725 ◽

2021 ◽

Vol 57 (7) ◽

pp. 725

Author(s):

Horatiu Moldovan ◽

Andra-Madalina Sibisan ◽

Robert Tiganasu ◽

Elena Nechifor ◽

Daniela Gheorghita ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Ct Scan ◽

Preoperative Evaluation ◽

Hemodynamic Instability ◽

Pulmonary Embolectomy ◽

Vein Thrombosis ◽

Severe Hypotension ◽

Lower Limb Pain ◽

The Right

We present the case of a 35-year-old woman who had a high-risk pulmonary embolism (according to ESC risk stratification for pulmonary embolism) after she had undergone a Caesarion section. Postoperatively, she presented with acute left lower limb pain, swelling and erythema. A diagnosis was made of deep vein thrombosis (DVT) of the ilio-femoral and popliteal veins. She was started on anticoagulant therapy, which proved to be inefficient, the patient developing a left calf and thigh oedema and shortness of breath. A CT scan revealed high-risk embolus located in the right atrium and through the tricuspid valve. The decision was made to refer her to a cardiovascular surgeon. During her preoperative evaluation, the patient became hemodynamically unstable and was rushed into the operating room, severely desaturated, bradycardic, without consciousness, with severe hypotension. On the basis of the severe state of the patient and the CT scan findings we performed an emergency pulmonary embolectomy, with the patient on cardio-pulmonary by-pass, without cross-clamping the aorta, using a modified Trendelenburg procedure. This case supports using open pulmonary embolectomy for patients with hemodynamic instability on the basis of clinical diagnosis.

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The Risk of Thromboembolism in Asymptomatic Patients with Protein C and Protein S Deficiency: A Prospective Cohort Study

Thrombosis and Haemostasis ◽

10.1055/s-0038-1642457 ◽

1994 ◽

Vol 71 (04) ◽

pp. 441-445 ◽

Cited By ~ 68

Author(s):

Ingrid Pabinger ◽

Paul A Kyrle ◽

Max Heistinger ◽

Sabine Eichinger ◽

Eva Wittmann ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Protein C ◽

Protein S ◽

Thromboembolic Events ◽

Protein S Deficiency ◽

Vein Thrombosis ◽

S Deficiency ◽

Superficial Vein Thrombosis ◽

Deep Vein

SummaryBackground: Prospective studies on the incidence of thrombosis in asymptomatic individuals with hereditary protein C- or protein S deficiency have not been performed so far.Objective: We have carried out a prospective cohort study in 44 asymptomatic protein C- and protein S deficient subjects and in 49 asymptomatic non-deficient relatives (age at study entry > 14 years) of symptomatic deficient patients.Methods: 20 asymptomatic protein C deficient (median age 20 years) and 24 asymptomatic protein S deficient patients (median age 21.5 years) were prospectively followed and compared with 20 asymptomatic non-deficient relatives (median age 25 years) of protein C- and 29 (median age 27 years) of protein S deficient patients. The total observation period was 118.8 patient years for protein C deficient and 92.8 for protein S deficient patients. Patients were not on anticoagulants except for short duration in case of high risk situations.Results: Eight thromboembolic events (1 pulmonary embolism, 1 deep vein thrombosis + pulmonary embolism, 3 deep vein thrombosis, 1 caval vein thrombosis and 2 superficial vein thrombosis) occurred in 6 deficient patients. The incidence of thromboembolism was 2.5% per patient year for protein C deficient and 3.5% per patient year for protein S deficient patients. 4 events occurred spontaneously, in 2 patients thromboembolic events were triggered by high risk situations (caesarean section, minor trauma). In the controls no thromboembolic events occurred. The probability for thromboembolism was significantly higher in protein C and protein S deficient patients compared to the control group (Wilcoxon test, p = 0.002, log rank test, p = 0.001). One major and 5 minor uneventful surgeries were carried out in the deficient patients using heparin prophylaxis. 1/8 pregnancies was complicated by superficial vein thrombosis during the second trimester despite prophylactic heparin administration. The same pregnancy was complicated by pulmonary embolism 5 weeks after delivery after discontinuation of heparin.Conclusions: Asymptomatic deficient relatives of symptomatic patients with protein C or protein S deficiency are at an increased risk of thrombosis compared to nondeficient individuals. Prophylactic treatment seems to be highly effective in high risk situations.

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Surveillance and Early Management of Deep Vein Thrombosis Decreases the Rate of Pulmonary Embolism in High-Risk Trauma Patients

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2015.07.400 ◽

2015 ◽

Vol 221 (4) ◽

pp. S167

Author(s):

Casey J. Allen ◽

Jonathan P. Meizoso ◽

Joyce Kaufman ◽

Laura F. Teisch ◽

Xiomara D. Ruiz ◽

...

Keyword(s):

Pulmonary Embolism ◽

Deep Vein Thrombosis ◽

High Risk ◽

Trauma Patients ◽

Early Management ◽

Vein Thrombosis ◽

Deep Vein

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P118: Pulmonary Embolism Severity Index (PESI) score as a predictor for readmission in acute pulmonary embolism in emergency department?

CJEM ◽

10.1017/cem.2018.316 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S98-S99

Author(s):

D. Prajapati ◽

D. Suryanarayan ◽

E. S. Lang

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

High Risk ◽

Readmission Rate ◽

Significant Risk ◽

Severity Index ◽

Low Risk ◽

Secondary Outcome ◽

Patient Disposition ◽

Discharged Patients

Introduction: Pulmonary Embolism (PE) management in Emergency Department (ED) confers a substantial cost burden representing opportunities for improvements in decision-making. The Pulmonary Embolism Severity Index (PESI) is a validated tool to prognosticate patients with PE supporting admit versus (vs.) discharge decisions from the ED. Despite existing evidence, PESI is under-used in patients with PE. We sought to evaluate PESI scores and patient disposition from 4 EDs within Calgary to determine discordance between them and the effect of the discordance on readmission and mortality. Methods: Retrospective review of adult patients 18 years, diagnosed with PE between January-June 2016 at 4 EDs in Calgary Health Region. Patients were divided into high-risk PESI (score>85) and low-risk PESI (score 0-85). Chi-Square (2) test was used for comparison between the groups. Primary outcome measure was rate of discordance between PESI risk and disposition decision and identify factors driving the discordance. Secondary outcome measures included comparing 30-day readmission rate, 30-day and 90-day mortality between the discordant PESI groups. Results: 365 patients were diagnosed with PE in the study period with 60% being admitted and 40% discharged. The median PESI score in admitted patients was 85 (26-172) vs. 68 (20-163) in discharged patients. 51% of admitted patients had a low-risk PESI score and 24% of the discharged patients were high-risk PESI. 30-day readmission rate was 22.9% vs 5.3% (p=0.002) in discharged patients with high-risk PESI vs. discharged patients with low-risk PESI. Hypoxemia was the most common (62%) justification for admission in low-risk PESI groups. Among discharged patients we noted an 8.6% 90-day mortality in the high-risk vs. 0% in the low-risk PESI groups. Conclusion: Discharging a PE patient from the ED with a high PESI score carries a significant risk of ED revisit and readmission. Hypoxia was the reason for admission in majority of low risk PE patients.

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

Thrombosis ◽

10.1155/2015/175357 ◽

2015 ◽

Vol 2015 ◽

pp. 1-5 ◽

Cited By ~ 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.

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