Does Baseline BUN Have an Additive Effect on the Prediction of Mortality in Patients with Acute Pulmonary Embolism?

Background: In patients with heart failure, elevated levels of blood urea nitrogen (BUN) is a prognostic factor. In this study, we investigated the prognostic value of elevated baseline BUN in short-term mortality among patients with acute pulmonary embolism (PE). Methods: Between 2007 and 2014, cardiac biomarkers and BUN levels were measured in patients with acute PE. The primary endpoint was 30-day mortality, evaluated based on the baseline BUN (≥14 ng/L) level in 4 groups of patients according to the European Society of Cardiology’s risk stratification (low-risk, intermediate low-risk, intermediate high-risk, and high-risk). Results: Our study recruited 492 patients with a diagnosis of acute PE (mean age=60.58±16.81 y). The overall 1-month mortality rate was 6.9% (34 patients). Elevated BUN levels were reported in 316 (64.2%) patients. A high simplified pulmonary embolism severity index (sPESI) score (OR: 5.23, 95% CI: 1.43–19.11; P=0.012), thrombolytic or thrombectomy therapy (OR: 2.42, 95% CI: 1.01–5.13; P=0.021), and elevated baseline BUN levels (OR: 1.04, 95% CI: 1.01–1.03; P=0.029) were the independent predictors of 30-day mortality. According to our receiver-operating characteristics analysis for 30-day mortality, a baseline BUN level of greater than 14.8 mg/dL was considered elevated. In the intermediate-low-risk patients, mortality occurred only in those with elevated baseline BUN levels (7.2% vs. 0; P=0.008). Conclusion: An elevated baseline BUN level in our patients with PE was an independent predictor of short-term mortality, especially among those in the intermediate-risk group.

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Categorical Assignment of Pulmonary Embolism is a Simple and More Accurate Indicator of Right Ventricular Dysfunction and Short Team Mortality

10.1101/642892 ◽

2019 ◽

Author(s):

Yu Lin Chen ◽

Colin Wright ◽

Anthony P. Pietropaoli ◽

Ayman Elbadawi ◽

Joseph Delehanty ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Risk Stratification ◽

Right Ventricular ◽

Myocardial Strain ◽

Area Under The Curve ◽

Low Risk ◽

Short Term ◽

Short Term Mortality ◽

Acute Pe

AbstractSeveral risk stratification tools are available to predict short-term mortality in patients with acute pulmonary embolism (PE). Right ventricular (RV) dysfunction, which is common to intermediate and high risk PE, is an independent predictor of mortality and may be a faster and simpler way to assess patient risk in acute care settings. We evaluated 571 patients presenting with acute PE as the primary diagnosis, stratifying them by the Pulmonary Embolism Severity Index (PESI), by the BOVA score, or categorically as low risk (no RV dysfunction by imaging), intermediate risk (RV dysfunction by imaging), or high risk PE (RV dysfunction by imaging with sustained hypotension). Using imaging data to firstly define the presence of RV dysfunction, and plasma cardiac troponin T (cTnT) and NT-proBNP as additional evidence for myocardial strain, we evaluated the PESI and BOVA scoring systems compared to categorical assignment of PE as low risk, submassive, and massive PE. Cardiac biomarkers poorly distinguished between PESI classes and BOVA stages in patients with acute PE. Cardiac TnT and NT-proBNP easily distinguished low risk from submassive PE with an area under the curve (AUC) of 0.84 (95% C.I. 0.73 – 0.95, p< 0.0001), and 0.88 (95% C.I. 0.79-0.97, p< 0.0001), respectively, and low risk from massive PE with an area under the curve (AUC) of 0.89 (95% C.I. 0.78 – 1.00, p< 0.0001), and 0.89 (95% C.I. 0.82-0.95, p< 0.0001), respectively. Predicted short-term mortality by PESI score or BOVA stage was lower than the observed mortality for submassive PE by a two-fold order of magnitude. These data suggest the presence of RV dysfunction in the context of acute PE is sufficient for the purposes of risk stratification, while more complicated risk stratification algorithms may under-estimate short-term mortality risk.

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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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Computed Tomography Pulmonary Perfusion for Prediction of Short-Term Clinical Outcome in Acute Pulmonary Embolism

TH Open ◽

10.1055/s-0041-1723782 ◽

2021 ◽

Vol 05 (01) ◽

pp. e66-e72

Author(s):

Lisette F. van Dam ◽

Lucia J. M. Kroft ◽

Menno V. Huisman ◽

Maarten K. Ninaber ◽

Frederikus A. Klok

Keyword(s):

Computed Tomography ◽

Pulmonary Embolism ◽

Predictive Value ◽

Acute Pulmonary Embolism ◽

Clinical Presentation ◽

Reperfusion Therapy ◽

Pulmonary Perfusion ◽

Short Term ◽

Acute Pe ◽

Related Mortality

Abstract Background Computed tomography pulmonary angiography (CTPA) is the imaging modality of choice for the diagnosis of acute pulmonary embolism (PE). With computed tomography pulmonary perfusion (CTPP) additional information on lung perfusion can be assessed, but its value in PE risk stratification is unknown. We aimed to evaluate the correlation between CTPP-assessed perfusion defect score (PDS) and clinical presentation and its predictive value for adverse short-term outcome of acute PE. Patients and Methods This was an exploratory, observational study in 100 hemodynamically stable patients with CTPA-confirmed acute PE in whom CTPP was performed as part of routine clinical practice. We calculated the difference between the mean PDS in patients with versus without chest pain, dyspnea, and hemoptysis and 7-day adverse outcome. Multivariable logistic regression analysis and likelihood-ratio test were used to assess the added predictive value of PDS to CTPA parameters of right ventricle dysfunction and total thrombus load, for intensive care unit admission, reperfusion therapy and PE-related death. Results We found no correlation between PDS and clinical symptoms. PDS was correlated to reperfusion therapy (n = 4 with 16% higher PDS, 95% confidence interval [CI]: 3.5–28%) and PE-related mortality (n = 2 with 22% higher PDS, 95% CI: 4.9–38). Moreover, PDS had an added predictive value to CTPA assessment for PE-related mortality (from Chi-square 14 to 19, p = 0.02). Conclusion CTPP-assessed PDS was not correlated to clinical presentation of acute PE. However, PDS was correlated to reperfusion therapy and PE-related mortality and had an added predictive value to CTPA-reading for PE-related mortality; this added value needs to be demonstrated in larger studies.

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Pleural effusion as an indicator of short term mortality in acute pulmonary embolism

Tuberkuloz ve Toraks ◽

10.5578/tt.67203 ◽

2018 ◽

Vol 66 (3) ◽

pp. 185-196

Author(s):

Şehnaz Olgun Yıldızeli ◽

Umut Sabri Kasapoğlu ◽

Hüseyin Arıkan ◽

Canan Çimşit ◽

Nuri Çagatay Çimşit ◽

...

Keyword(s):

Pulmonary Embolism ◽

Pleural Effusion ◽

Acute Pulmonary Embolism ◽

Short Term ◽

Short Term Mortality

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Impact of syncope and pre-syncope on short-term mortality in patients with acute pulmonary embolism

European Journal of Internal Medicine ◽

10.1016/j.ejim.2018.04.004 ◽

2018 ◽

Vol 54 ◽

pp. 27-33 ◽

Cited By ~ 9

Author(s):

Loris Roncon ◽

Marco Zuin ◽

Franco Casazza ◽

Cecilia Becattini ◽

Claudio Bilato ◽

...

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Short Term ◽

Short Term Mortality

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Risk stratification in normotensive acute pulmonary embolism patients: focus on the intermediate–high risk subgroup

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872619846506 ◽

2019 ◽

Vol 9 (4) ◽

pp. 279-285 ◽

Cited By ~ 2

Author(s):

Ana Rita Santos ◽

Pedro Freitas ◽

Jorge Ferreira ◽

Afonso Oliveira ◽

Mariana Gonçalves ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Risk Stratification ◽

Right Ventricular ◽

Acute Pulmonary Embolism ◽

Ventricular Dysfunction ◽

Right Ventricular Dysfunction ◽

Cardiac Biomarkers ◽

Cardiac Biomarker ◽

Imaging Signs

Background: Patients with acute pulmonary embolism are at intermediate–high risk in the presence of imaging signs of right ventricular dysfunction plus one or more elevated cardiac biomarker. We hypothesised that intermediate–high risk patients with two elevated cardiac biomarkers and imaging signs of right ventricular dysfunction have a worse prognosis than those with one cardiac biomarker and imaging signs of right ventricular dysfunction. Methods: We analysed the cumulative presence of cardiac biomarkers and imaging signs of right ventricular dysfunction in 525 patients with intermediate risk pulmonary embolism (intermediate-high risk = 237) presenting at the emergency department in two centres. Studied endpoints were composites of all-cause mortality and/or rescue thrombolysis at 30 days (primary endpoint; n=58) and pulmonary embolism-related mortality and/or rescue thrombolysis at 30 days (secondary endpoint; n=40). Results: Patients who experienced the primary endpoint showed a higher proportion of elevated troponin (47% vs. 76%, P<0.001), elevated N-terminal pro-brain natriuretic peptide (67% vs. 93%, P<0.001) and imaging signs of right ventricular dysfunction (47% vs. 80%, P<0.001). Multivariate analysis revealed N-terminal pro-brain natriuretic peptide (hazard ratio (HR) 3.6, 95% confidence interval (CI) 1.3–10.3; P=0.015) and imaging signs of right ventricular dysfunction (HR 2.8, 95% CI 1.5–5.2; P=0.001) as independent predictors of events. In the intermediate–high risk group, patients with two cardiac biomarkers performed worse than those with one cardiac biomarker (HR 3.3, 95% CI 1.8–6.2; P=0.003). Conclusions: Risk stratification in normotensive pulmonary embolism should consider the cumulative presence of cardiac biomarkers and imaging signs of right ventricular dysfunction, especially in the intermediate–high risk subgroup.

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Short-term Mortality in Acute Pulmonary Embolism: Clot Burden and Signs of Right Heart Dysfunction at CT Pulmonary Angiography

Radiology ◽

10.1148/radiol.12110802 ◽

2012 ◽

Vol 265 (1) ◽

pp. 283-293 ◽

Cited By ~ 87

Author(s):

Alessandro Furlan ◽

Ayaz Aghayev ◽

Chung-Chou H. Chang ◽

Amol Patil ◽

Kyung Nyeo Jeon ◽

...

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Pulmonary Angiography ◽

Ct Pulmonary Angiography ◽

Short Term ◽

Right Heart ◽

Heart Dysfunction ◽

Short Term Mortality ◽

Clot Burden ◽

Right Heart Dysfunction

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In-hospital and short-term predictors of mortality in patients with intermediate-high risk pulmonary embolism

Journal of Cardiovascular and Thoracic Research ◽

10.34172/jcvtr.2020.51 ◽

2020 ◽

Vol 12 (4) ◽

pp. 321-327

Author(s):

Gulay Gök ◽

Mehmet Karadağ ◽

Tufan Çinar ◽

Zekeriya Nurkalem ◽

Dursun Duman

Keyword(s):

Heart Failure ◽

Congestive Heart Failure ◽

Pulmonary Embolism ◽

High Risk ◽

Hospital Mortality ◽

Medical Records ◽

Pulmonary Angiography ◽

Albumin Level ◽

Short Term ◽

Acute Pe

Introduction: The aim of this study was to evaluate the in-hospital and short-term predictive factors of mortality in intermediate-high risk acute pulmonary embolism (PE) patients with right ventricle (RV)dysfunction and myocardial injury. Methods: In this retrospective study, the medical records of 187 patients with a diagnosis of intermediate high risk acute PE were evaluated. A contrast-enhanced multi-detector pulmonary angiography was used to confirm diagnosis in all cases. All-cause mortality was determined by obtaining both in hospital and 30 days follow-up data of patients from medical records. Results: During the in-hospital stay (9.5±4.72 days), 7 patients died, resulting in an acute PE related in-hospital mortality of 3.2%. Admission heart rate (HR), (Odds ratio (OR), 1.028 95% Confidence interval (CI), 0.002-1.121; P = 0.048) and blood urea nitrogen (BUN) (OR, 1.028 95% CI, 0.002-1.016; P = 0.044) were found to be independent predictors for in-hospital mortality in a multi variate logistic regression analysis. In total, 32 patients (20.9%) died during 30 days follow-up.The presence of congestive heart failure (OR, 0.015, 95%CI, 0.001-0.211; P = 0.002) and dementia (OR, 0.029, 95%CI,0.002-0.516; P = 0.016) as well as low albumin level (OR, 0.049 95%CI, 0.006-0.383; P = 0.049) were associated with 30 days mortality. Conclusion: HR and BUN were independent predictors of in-hospital mortality and the presence of congestive heart failure, dementia, and low albumin levels were associated with higher 30 days mortality.

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MR-proADM and MR-proANP levels in patients with acute pulmonary embolism

Journal of Medical Biochemistry ◽

10.2478/jomb-2019-0049 ◽

2019 ◽

Vol 0 (0) ◽

Cited By ~ 1

Author(s):

Önsel Öner ◽

Figen Deveci ◽

Selda Telo ◽

Mutlu Kuluöztürk ◽

Mehmet Balin

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Mortality Rate ◽

Hospital Mortality ◽

Acute Pulmonary Embolism ◽

Low Risk ◽

Control Group ◽

High Risk Patients ◽

Risk Patients ◽

The Relationship

Summary Background The aim of this study was to determine levels of Mid-regional Pro-adrenomedullin (MR-proADM) and Mid-regional Pro-atrial Natriuretic Peptide (MR-proANP) in patients with acute pulmonary embolism (PE), the relationship between these parameters and the risk classification in addition to determining the relationship between 1- and 3-month mortality. Methods 82 PE patients and 50 healthy control subjects were included in the study. Blood samples for MR-proANP and MR-proADM were obtained from the subjects prior to the treatment. Risk stratification was determined according to sPESI (Simplified Pulmonary Embolism Severity Index). Following these initial measurements, cases with PE were assessed in terms of all causative and PE related mortalities. Results The mean serum MR-proANP and MR-proADM levels in acute PE patients were found to be statistically higher compared to the control group (p < 0.001, p < 0.01; respectively) and statistically significantly higher in high-risk patients than low-risk patients (p < 0.01, p < 0.05; respectively). No statistical difference was determined in high-risk patients in case of sPESI compared to low-risk patients while hospital mortality rates were higher. It was determined that the hospital mortality rate in cases with MR-proANP ≥ 123.30 pmol/L and the total 3-month mortality rate in cases with MR-proADM ≥ 152.2 pg/mL showed a statistically significant increase. Conclusions This study showed that MR-proANP and MR-proADM may be an important biochemical marker for determining high-risk cases and predicting the mortality in PE patients and we believe that these results should be supported by further and extensive studies.

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Contemporary clinical management of acute pulmonary embolism: the COPE study

Internal and Emergency Medicine ◽

10.1007/s11739-021-02855-0 ◽

2022 ◽

Author(s):

Cecilia Becattini ◽

Giancarlo Agnelli ◽

Aldo Pietro Maggioni ◽

Francesco Dentali ◽

Andrea Fabbri ◽

...

Keyword(s):

Pulmonary Embolism ◽

Risk Stratification ◽

Acute Pulmonary Embolism ◽

Management Strategies ◽

Treatment Strategies ◽

Low Risk ◽

Contemporary Management ◽

Secondary Study ◽

European Society Of Cardiology ◽

Acute Pe

Abstract Background New management, risk stratification and treatment strategies have become available over the last years for patients with acute pulmonary embolism (PE), potentially leading to changes in clinical practice and improvement of patients’ outcome. Methods The COntemporary management of Pulmonary Embolism (COPE) is a prospective, non-interventional, multicentre study in patients with acute PE evaluated at internal medicine, cardiology and emergency departments in Italy. The aim of the COPE study is to assess contemporary management strategies in patients with acute, symptomatic, objectively confirmed PE concerning diagnosis, risk stratification, hospitalization and treatment and to assess rates and predictors of in-hospital and 30-day mortality. The composite of death (either overall or PE-related) or clinical deterioration at 30 days from the diagnosis of PE, major bleeding occurring in hospital and up to 30 days from the diagnosis of PE and adherence to guidelines of the European Society of Cardiology (ESC) are secondary study outcomes. Participation in controlled trials on the management of acute PE is the only exclusion criteria. Expecting a 10–15%, 3% and 0.5% incidence of death for patients with high, intermediate or low-risk PE, respectively, it is estimated that 400 patients with high, 2100 patients with intermediate and 2500 with low-risk PE should be included in the study. This will allow to have about 100 deaths in study patients and will empower assessment of independent predictors of death. Conclusions COPE will provide contemporary data on in-hospital and 30-day mortality of patients with documented PE as well as information on guidelines adherence and its impact on clinical outcomes. Trail registration NCT number: NCT03631810.

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