Association of risk stratification and mortality outcomes in patients of acute pulmonary embolism

Background: To study the association of risk stratification and mortality outcomes of patients with high/intermediate risk acute pulmonary embolism who are given the guideline directed therapy after the diagnosis of pulmonary embolism.Methods: Prospective observational study of demographics, clinical profile, risk stratification, management and outcome of patients presenting with acute pulmonary embolism from October 2019to December 2020. Risk stratification was done as per ESC 2019 guidelines into high and intermediate categories, intermediate category patients were further stratified into intermediate-high and intermediate-low-risks.Results: 100 patients who were detected to have acute pulmonary thromboembolism with a mean age of 45.08 years with 60% being males were included in the study. There were 31 patients in high-risk group, 59 patients in intermediate-high subgroup, 10 patients in intermediate-low subgroup. Echocardiography was done in all patients. Outcome was relatively grave in these subgroups with overall mortality of 56 patients. 49 patients were thrombolysed with rTPA, 27patients with alteplase, 4 patients with streptokinase, 12patients who had contraindication to systemic thrombolysis were subjected to catheter directed thrombolysis and 8 patients were taken up for surgical embolectomy.Conclusions: Pulmonary embolism can present with unexplained dyspnea and atypical chest pain among other signs and symptoms. Early diagnosis, risk stratification and guideline directed prompt management can lead to favorable outcomes however; patients with high and intermediate risk at presentation are associated with higher mortality rate despite GDT.

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

European Respiratory Journal ◽

10.1183/13993003.02963-2020 ◽

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.

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

10.21203/rs.2.19164/v1 ◽

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.

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

British Journal of Hospital Medicine ◽

10.12968/hmed.2020.0300 ◽

2020 ◽

Vol 81 (6) ◽

pp. 1-12 ◽

Cited By ~ 1

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.

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Midterm outcomes of catheter-directed interventions for the treatment of acute pulmonary embolism

Vascular ◽

10.1177/1708538116654638 ◽

2016 ◽

Vol 25 (2) ◽

pp. 130-136 ◽

Cited By ~ 6

Author(s):

Nathan L Liang ◽

Rabih A Chaer ◽

Luke K Marone ◽

Michael J Singh ◽

Michel S Makaroun ◽

...

Keyword(s):

Pulmonary Embolism ◽

Large Scale ◽

Acute Pulmonary Embolism ◽

Treatment Time ◽

Clinical Success ◽

Interventional Therapy ◽

Bleeding Complications ◽

Intermediate Risk ◽

Catheter Directed Thrombolysis ◽

One Year

Objective The hemodynamic benefits of catheter-directed thrombolysis for acute pulmonary embolism have not been clearly defined beyond the periprocedural period. The objective of this study is to report midterm outcomes of catheter-directed thrombolysis for treatment of acute pulmonary embolism. Methods Records of all patients undergoing catheter-directed thrombolysis for high- or intermediate-risk pulmonary embolism were retrospectively reviewed. Endpoints were clinical success, procedure-related complications, mortality, and longitudinal echocardiographic parameter improvement. Results A total of 69 patients underwent catheter-directed thrombolysis (mean age 59 ± 15 y, 56% male). Eleven had high-risk and 58 intermediate-risk pulmonary embolism. Baseline characteristics did not differ by pulmonary embolism subtype. Fifty-two percent of patients underwent ultrasound-assisted thrombolysis, 39% standard catheter-directed thrombolysis, and 9% other interventional therapy; 89.9% had bilateral treatment. Average treatment time was 17.7 ± 11.3 h with average t-Pa dose of 28.5 ± 19.6 mg. The rate of clinical success was 88%. There were two major (3%) and six minor (9%) periprocedural bleeding complications with no strokes. All echocardiographic parameters demonstrated significant improvement at one-year follow-up. Pulmonary embolism-related in-hospital mortality was 3.3%, and estimated survival was 81.2% at one year. Conclusions Catheter-directed thrombolysis is safe and effective for treatment of acute pulmonary embolism, with sustained hemodynamic improvement at one year. Further prospective large-scale studies are needed to determine comparative effectiveness of interventions for acute pulmonary embolism.

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Systemic Thrombolysis Compared to Catheter Directed Thrombolysis in Acute Pulmonary Embolism

CHEST Journal ◽

10.1378/chest.2265015 ◽

2015 ◽

Vol 148 (4) ◽

pp. 919A

Author(s):

Nileshkumar Patel ◽

Amina Saqib ◽

Jasvinder Singh ◽

Abdul Siddiqui ◽

Uroosa Ibrahim ◽

...

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Systemic Thrombolysis ◽

Catheter Directed Thrombolysis

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Risk stratification in intermediate-risk acute pulmonary embolism

Journal of Critical Care ◽

10.1016/j.jcrc.2016.06.015 ◽

2016 ◽

Vol 36 ◽

pp. 292

Author(s):

Murat Biteker ◽

Volkan Doğan ◽

Özcan Başaran ◽

Marwa Mouline Doğan

Keyword(s):

Pulmonary Embolism ◽

Risk Stratification ◽

Acute Pulmonary Embolism ◽

Intermediate Risk

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Catheter-directed therapy for acute pulmonary embolism: navigating gaps in the evidence

European Heart Journal Supplements ◽

10.1093/eurheartj/suz224 ◽

2019 ◽

Vol 21 (Supplement_I) ◽

pp. I23-I30 ◽

Cited By ~ 4

Author(s):

Romain Chopard ◽

Fiona Ecarnot ◽

Nicolas Meneveau

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Pressure Overload ◽

Efficacy And Safety ◽

Bleeding Events ◽

Systemic Thrombolysis ◽

Risk Of Death ◽

Risk Of Bleeding ◽

Catheter Directed Thrombolysis ◽

Acute Pe

Abstract Systemic thrombolysis for acute pulmonary embolism (PE) reduces the risk of death and cardiovascular collapse but is associated with an increased rate of bleeding. The desire to minimize the risk of bleeding events has driven the development of catheter-based strategies for pulmonary reperfusion in PE. These catheter-based strategies utilize lower-dose fibrinolytic regimens or purely mechanical techniques to expedite removal of the embolus. Several devices providing mechanical or suction embolectomy and catheter-directed thrombolysis, with or without facilitation by ultrasound, have been tested. Data are inconsistent regarding the efficacy and safety of mechanical and suction embolectomy. The most comprehensive data on catheter-based techniques stem from trials of ultrasound-facilitated catheter fibrinolysis. Ultrasound-facilitated catheter fibrinolysis relieves right ventricular pressure overload with a lower risk of major bleeding and intracranial haemorrhage than historical rates with systemic fibrinolysis. However, further research is required to determine the optimal application of ultrasound-facilitated catheter fibrinolysis and other catheter-based therapies in patients with acute PE.

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Contemporary Clinical Management and Course of ACUTE Pulmonary Embolism: The COPE Study

Blood ◽

10.1182/blood-2021-149144 ◽

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.

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Thrombolysis in Acute Pulmonary Embolism : are we overdoing it?

10.1101/2020.09.13.20193672 ◽

2020 ◽

Author(s):

REFAI SHOWKATHALI ◽

Radhapriya Yalamanchi ◽

Balasubramanian Ramakrishnan ◽

Abraham Oommann ◽

Aruna Sivaprakash ◽

...

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

South India ◽

Risk Group ◽

Outcome Data ◽

High Risk Group ◽

Systemic Thrombolysis ◽

Tertiary Centre ◽

The Mean ◽

Rv Function

Aim and Method: We aimed to study the clinical data and outcome of patients admitted in our centre with acute pulmonary embolism (PE) over a five year period from May 2013 to April 2018. The main outcome data included were- in-hospital bleeding, in hospital RV function improvement, PAH improvement, duration of hospital stay, 30 and 90 day mortality. Results: A total of 114 (69 m, 55 f) patients with the mean age of 55+/- 15 yrs were included. Patients who had involvement of central pulmonary trunk- called as Central PE group (n=82) and others as Peripheral PE group (n= 32). There were more women in the peripheral PE group (53.1% vs 34.1%, p 0.05), while RBBB (22% vs 3.1%, p 0.02) and RV dysfunction (59.8% vs 25%, p 0.002) were noted more in the central PE group. Systemic thrombolysis was done in 53 patients (49 central, 4 peripheral), of which only 3 had hypotension and 28 patients were in the Intermediate-high risk group. The overall in-hospital, 30 day and 90 day mortality were 3.6, 13.2 and 22.8% respectively. Bleeding was significantly higher in thrombolysed group compared to the non-thrombolysed group (18.9% vs 0, p 0.0003). However, improvement in pulmonary hypertension was noted more in thrombolysis group compared to non-thrombolytic group. (49% vs 21.2%, p 0.01). Conclusion: This retrospective data from a tertiary centre in South India showed that short and mid-term mortality of patients with PE still remains high. The high non-guideline use of thrombolysis has reflected in the increased bleeding noted in our study.

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Risk Stratification of Acute Pulmonary Embolism and Determining the Effect on Chronic Cardiopulmonary Complications: The REACH Study

TH Open ◽

10.1055/s-0040-1708558 ◽

2020 ◽

Vol 04 (01) ◽

pp. e45-e50 ◽

Cited By ~ 1

Author(s):

Hannah Stevens ◽

Wendy Fang ◽

Warren Clements ◽

Jason Bloom ◽

James McFadyen ◽

...

Keyword(s):

Pulmonary Embolism ◽

Risk Stratification ◽

Acute Pulmonary Embolism ◽

Intermediate Risk ◽

Chronic Complications ◽

Classification Of Diseases ◽

Cardiopulmonary Complications ◽

International Statistical Classification ◽

Perfusion Defects ◽

Standard Risk

Abstract Introduction Patients with acute pulmonary embolism (PE) are at risk of developing chronic complications including the post-PE syndrome with reduced cardiopulmonary function and chronic thromboembolism pulmonary hypertension (CTEPH). Risk stratification at PE diagnosis is an important tool in predicting early mortality; however, its use in predicting chronic complications has not been evaluated. Objective This study investigates the effect of initial risk stratification of intermediate risk and standard risk PE on the rate of development of chronic complications including right ventricular (RV) dysfunction, residual perfusion defects, and CTEPH. Methods Cases of acute PE (n = 1,524) were identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification discharge diagnosis coding for PE. Evidence of RV dysfunction and systolic blood pressure < 90 mm Hg were used to risk stratify into high, intermediate and standard risk PE. Results There were 508 patients included in the analysis. Intermediate risk PE was associated with higher rates of persistent RV dysfunction as well as residual perfusion defects on repeat imaging. The overall rate of CTEPH was low (0.6%) and there was no difference between the intermediate risk and standard risk PE groups. Conclusion These findings demonstrate that acute intermediate risk PE is associated with higher rates of RV dysfunction on follow-up imaging than standard risk PE. However, the rate of CTEPH was similar between the two groups and overall the CTEPH rate was low among all patients with intermediate and standard risk PE.

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