Acute Pulmonary Embolism Patients Research Articles

Clinical and hemodynamic features of acute pulmonary embolism patients diagnosed in cold weather predicts adverse clinical outcome.

Acute pulmonary embolism (APE) is associated with peak incidence and mortality rate in winter. The present study sought to characterize the clinical and hemodynamic features of cold weather on APE patients. All enrolled 224 APE patients underwent clinical and hemodynamic evaluation and baseline parameters were collected. Recruited patients were grouped by weather pattern on admission into cold and warm weather group. The correlation and prognostic values among cold weather and other variables were analyzed. Compared to warm weather group, patients in cold weather group present with more severe cardiac function, with adverse WHO-functional class (P = 0.032) and higher NT-proBNP concentration [1,853.0 (398.0, 5,237.0) pg/ml vs. 847.5 (56.8, 3,090.5) pg/ml, P = 0.001]. The cold weather group also displayed much critical hemodynamic status and heavier thrombosis load, with higher mPAP (29.1 ± 11.2mmHg vs. 25.6 ± 14.2mmHg, P = 0.045), higher PVR [3.3 (1.7, 6.0) wood units vs. 1.8 (0.9, 3.8) wood units, P < 0.001], higher Miller index (21.4 ± 5.9 vs. 19.1 ± 8.0, P = 0.024), and higher D-dimer levels [2,172.0 (854.5, 3,072.5) mg/L vs. 1,094.5 (210.5, 2,914.5) mg/L, P = 0.008]. Besides, cold weather showed well correlation with the above variables. Survival analysis showed APE patients in cold weather had significantly higher clinical worsening event rate (P = 0.010) and could be an independent predictor of adverse clinical outcome in the multivariate analysis (HR 2.629; 95% CI 1.127, 6.135; P = 0.025). APE patients in cold weather were associated with thrombus overload, cardiac dysfunction, hemodynamic collapse and higher clinical worsening event rate. Cold weather proves to be an independent predictor of adverse clinical outcome.

Comparison of Efficacy and Safety between Thrombolysis Plus Anticoagulation vs. Anticoagulation Alone for the Treatment of Acute Submassive Pulmonary Embolism: A Systematic Review and Meta-analysis.

The objective of this study is to compare the efficacy and safety of thrombolysis plus anticoagulant therapy vs. anticoagulant therapy alone in acute submassive pulmonary embolism (PE). The PubMed, Embase, and Cochrane Library databases were searched for randomized clinical trials comparing thrombolytic therapy and anticoagulation vs. anticoagulation alone in acute submassive PE patients from 1 Jan 1980 to 20 Jan 2021, with no drug or dose restrictions. Data on upgraded treatment of clinical deterioration, all-cause mortality, PE recurrence and bleeding events were extracted and analyzed using Revman 5.3 software. A total of 10 randomized controlled trials involving 1871 patients were included in the study after screening. In terms of efficacy, thrombolysis combined with anticoagulant therapy reduced the need for upgrading treatment (3.6 vs. 10.9%, risk ratio (RR) 0.36, 95% confidence interval (CI) 0.24- 0.54, p<0.00001) and PE recurrence (0.8 vs. 2.9%, RR 0.33, 95% CI 0.16-0.69, p=0.003) in patients with acute submassive PE. Compared with anticoagulant therapy alone, the concomitant use of thrombolysis was associated with lower all-cause mortality (1.3 vs. 3.0%, RR 0.47, 95% CI 0.26-0.87, p=0.02), but it increased minor bleeding rate (31.4 vs. 8.4%, RR 3.71, 95% CI 2.82-4.88, p<0.0001) and major bleeding rate (8.8 vs. 2.6%, RR 3.35, 95%CI 2.03-5.54, p<0.0001). The use of thrombolysis plus anticoagulant therapy in acute submassive PE was negatively associated with patients requiring escalation of treatment, PE recurrence, and all-cause mortality, but it was positively associated with bleeding.

The timing of death in acute pulmonary embolism patients regarding the mortality risk stratification at admission to hospital

Abstract Background The management of patients with acute pulmonary embolism (aPE) depend on the risk stratification at hospital admission. It is unknown when normotensive aPE patients with some other risk factors deteriorate. Patients and methods Patients with objectively established acute PE diagnosis enrolled in the regional PE registry from January 2015 to December 2021, were studied in this investigation. According to European Society od Cardiology criteria patients were stratified during admission to hospital in four risk stratums. The timing for death and the main reason for death were recorded. PE-related death was defined if patient has died because of cardiac arrest or obstructive shock if there is no another possible reason for that. Results In the REPER registry. Among 1541 patients (514 low risk, 366 intermediate-low risk, 472 intermediate-high risk and 189 high risk) with aPE, 101 (6.6%) have died primary from aPE and 64 (4.2%) have died from other reasons during the 30-day follow-up. PE-related death across the mortality risk groups were 0.8%, 1.1%, 8.5% and 28.5% in low-risk, intermediate-low, intermediate-high and high risk PE, respectively. Median time from hospital admission to PE related death was significantly longer in intermediate-high than in high risk patients 4.5 (2.0–9.0) vs 1.0 (1.0–4.5) days, p=0.001. In the high risk group 50.9% of patients died during the first 24 hours, 9.0% in the next 24 hours and 83.0% of patients died during the first 5 days from admission. In the intermediate-high risk group 17.5% died in the first 24 hours, 12.5% died in the next 24 hours and next 25% died till the fifth day. There was no difference in timing of non PE-related death between intermediate-high and high risk patients 9.5 (6.0–18.5) vs 7.0 (3.0–23.5) days, p=0.631. Conclusion There is significant delay in timing of death in intermediate-high compare to high risk PE patients, however, almost 50% of patients who died in the intermediate-high risk PE patients have died inside the first 5 days from hospital admission. Funding Acknowledgement Type of funding sources: None.

Signs of chronic thromboembolic pulmonary hypertension in acute pulmonary embolism: results from the FOCUS study

Abstract Background/Introduction Chronic thromboembolic pulmonary hypertension (CTEPH) is considered to be a late complication of acute pulmonary embolism (PE). However, up to one third of CTEPH patients do not report prior symptomatic venous thromboembolism (VTE). Furthermore, a substantial proportion of patients presenting with an acute PE event may exhibit radiological signs of chronicity at baseline computed tomography pulmonary angiography (CTPA). Purpose To determine the prevalence of baseline radiological parameters indicating chronic thrombosis or pulmonary hypertension, and ultimately pre-existing CTEPH, among patients with acute PE enrolled in the prospective multicentre Follow-Up after Acute Pulmonary Embolism (FOCUS) cohort study. Methods Patients with acute symptomatic PE and absence of a known history of CTEPH, enrolled at two large FOCUS centres, were included. The assessment of index CTPA scans was conducted by two independent expert radiologists who were unaware of the clinical characteristics and the follow-up data of the patients. CTPA parameters indicating chronicity were prespecified on the basis of recently proposed criteria in the literature. A third independent expert radiologist provided an assessment in case of disagreement between the first two. Baseline radiological data were prospectively validated with the aid of two-year prospective clinical follow-up data focusing on CTEPH and the post-PE syndrome (co-primary outcomes of the FOCUS study). Results A total of 303 patients (median age: 63 years, 44.6% women) were included. In &amp;gt;95% of the patients, the expert radiologists could confirm signs of acute PE at baseline CTPA. Radiological signs of chronic thrombi or pulmonary hypertension at baseline were detected in 46 (15.2%) patients. In 8 patients, the expert radiologists agreed on the presence of pre-existing CTEPH based on their interpretation of the overall radiological pattern. During follow-up, five (1.7%; 95% CI 0.7–3.8%) of 303 patients were diagnosed with CTEPH, over a median time of 95 days after baseline. Four of them were among the 8 patients in whom the radiological experts suspected pre-existing CTEPH at baseline, and among the 46 patients in whom CTPA findings suggesting chronic thrombi or chronic pulmonary hypertension were present at baseline. The use of the predefined individual parameters of chronicity from the literature also helped identifying patients with chronic disease, and could be used as a tool for screening acute PE patients for pre-existing CTEPH. Conclusion A substantial proportion of patients who are diagnosed with CTEPH during follow-up after acute PE may already have pre-existing CTEPH at the time of the index event. An intensified follow-up programme and focussed screening for CTEPH should be considered in patients with signs of chronicity at baseline CTPA. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Bayer Health Care

OUTCOMES FROM CATHETER-DIRECTED EMBOLECTOMY VERSUS SURGICAL PULMONARY EMBOLECTOMY FOR PATIENTS WITH ACUTE PE

OUTCOMES FROM CATHETER-DIRECTED EMBOLECTOMY VERSUS SURGICAL PULMONARY EMBOLECTOMY FOR PATIENTS WITH ACUTE PE

NATIONWIDE BURDEN, IMPACT, AND PREDICTORS OF TYPE 2 MYOCARDIAL INFARCTION IN ACUTE PULMONARY EMBOLISM-RELATED HOSPITALIZATIONS

NATIONWIDE BURDEN, IMPACT, AND PREDICTORS OF TYPE 2 MYOCARDIAL INFARCTION IN ACUTE PULMONARY EMBOLISM-RELATED HOSPITALIZATIONS

A pilot randomised trial of catheter-directed thrombolysis or standard anticoagulation for patients with intermediate-high risk acute pulmonary embolism.

Intermediate-high risk acute pulmonary embolism (PE) remains associated with substantial mortality despite anticoagulation therapy. The aim of this randomised pilot study was to compare catheter-directed thrombolysis to standard anticoagulation therapy. Intermediate-high risk acute PE patients were admitted to a tertiary care centre (November 2019 to April 2021) and randomised in a 1:1 ratio to catheter-directed thrombolysis (CDT) or standard anticoagulation. Two catheters were used for the infusion of alteplase (1 mg/hr/catheter; total dose 20 mg) in the CDT group. The primary efficacy endpoint targeted improvement of right ventricular (RV) function, a decrease in pulmonary pressure, and a reduction of thrombus burden. Twenty-three patients were included (12 in the CDT group and 11 in the standard care group). The primary efficacy endpoint was achieved more frequently in the CDT group than in the standard care group (7 of 12 patients vs 1 of 11 patients, p=0.0004). An RV/left ventricular ratio reduction ≥25% (evident on computed tomography angiography) was achieved in 7 of 12 patients in the CDT group vs 2 of 11 patients in the standard care group (p=0.03). A systolic pulmonary artery pressure decrease of ≥30% or normotension at 24 hrs after randomisation was present in 10 of 12 patients in the CDT group vs 2 of 11 patients in the standard care group (p=0.001). There was no intracranial or life-threatening bleeding (type 5 or 3c bleeding, according to the Bleeding Academic Research Consortium classification). CDT for intermediate-high risk acute PE appears to be safe and effective. Further research is warranted to assess clinical endpoints.

Angio-TC pulmonar durante la pandemia de COVID-19: comparación en pacientes con y sin la infección y con una serie prepandémica

Background and aimsTo analyze the diagnostic performance of pulmonary CT angiography and to compare different D-dimer cutoffs for the diagnosis of acute pulmonary embolism in patients with and without SARS-CoV-2 infections. Materials and methodsWe retrospectively analyzed all consecutive pulmonary CT angiography studies done for suspected pulmonary embolism in a tertiary hospital during two time periods: the first December 2020 through February 2021 and the second December 2017 through February 2018. D-dimer levels were obtained less than 24hours before the pulmonary CT angiography studies. We analyzed the sensitivity, specificity, positive and negative predictive values, area under the receiver operating curve (AUC), and pattern of pulmonary embolism for six different values of D-dimer and the extent of the embolism. During the pandemic period, we also analyzed whether the patients had COVID-19. ResultsAfter excluding 29 poor-quality studies, 492 studies were analyzed; 352 of these were done during the pandemic, 180 in patients with COVID-19 and 172 in patients without COVID-19. The absolute frequency of pulmonary embolism diagnosed was higher during the pandemic period (34 cases during the prior period and 85 during the pandemic; 47 of these patients had COVID-19). No significant differences were found in comparing the AUCs for the D-dimer values. The optimum values calculated for the receiver operating characteristic curves differed between patients with COVID-19 (2200 mcg/L), without COVID-19 (4800 mcg/L), and diagnosed in the prepandemic period (3200 mcg/L). Peripheral distribution of the emboli was more common in patients with COVID-19 (72%) than in those without COVID-19 and than in those diagnosed before the pandemic [OR 6.6, 95% CI:1.5?24.6, p<0.05 when compared to central distribution]. ConclusionsThe number of CT angiography studies and the number of pulmonary embolisms diagnosed during the pandemic increased due to SARS-CoV-2 infection. The optimal D-dimer cutoffs and the distribution of the pulmonary embolisms differed between the groups of patients with and without COVID-19.

The Diagnostic Value of Bedside Echocardiography and Lower Extremity Blood Vessels in Acute Pulmonary Embolism.

Objective The study aimed to evaluate the value of bedside echocardiography (TTE) and lower extremity blood vessels in diagnosis and prognosis of acute pulmonary embolism (APE). Methods A retrospective study was performed on 53 patients with APE diagnosed by CT pulmonary angiography (CTPA) (systemic systolic blood pressure was >90 mmHg at time of consultation, and systemic systolic blood pressure decreased by <40 mmHg compared with basic value in those with hypertension). All patients underwent TTE examination before treatment. The high-risk factors, clinical manifestations, laboratory tests, and prognosis were retrospectively analyzed. Results The rate of PE-related deterioration (cardiopulmonary resuscitation, tracheal intubation, cardiogenic shock, and death) within 14 days of hospitalization in RVD was 28%, and mortality rate (sudden death) was 20%, compared with non-RVD (both 0%). TTE examination showed that RVD as a predictor of pulmonary embolism-related death had a sensitivity of 100%, a specificity of 58%, a positive predictive value of 20%, and a negative predictive value of 100%. Conclusions (1) TTE has increasingly shown obvious advantages in diagnosis of APE. It can detect direct or indirect signs of pulmonary embolism, confirm diagnosis or suspected diagnosis, and noninvasively and dynamically observe hemodynamic changes of heart in patients with acute PTE before and after treatment.. (2) The PE-related exacerbation rate (28%) or mortality (20%) of APE patients in normotensive with RVD was higher without RVD (0%). RVD is an independent predictor of poor prognosis in normotensive acute PTE. TTE tests allow people to identify people at risk of early death. The short-term prognosis of patients without RVD was better (14 days).

Evaluating cardiopulmonary function following acute pulmonary embolism

Introduction Pulmonary embolism is a common cause of cardiopulmonary mortality and morbidity worldwide. Survivors of acute pulmonary embolism may experience dyspnea, report reduced exercise capacity, or develop overt pulmonary hypertension. Clinicians must be alert for these phenomena and appreciate the modalities and investigations available for evaluation. Areas Covered In this review, the current understanding of available contemporary imaging and physiologic modalities is discussed, based on available literature and professional society guidelines. The purpose of the review is to provide clinicians with an overview of these modalities, their strengths and disadvantages, and how and when these investigations can support the clinical work-up of patients post-pulmonary embolism. Expert Opinion Echocardiography is a first test in symptomatic patients post-pulmonary embolism, with ventilation/perfusion scanning vital to determination of whether there is chronic residual emboli. The role of computed tomography and magnetic resonance in assessing the pulmonary arterial tree in post-pulmonary embolism patients is evolving. Functional testing, in particular cardiopulmonary exercise testing, is emerging as an important modality to quantify and determine cause of functional limitation. It is possible that future investigations of the post-pulmonary embolism recovery period will better inform treatment decisions for acute pulmonary embolism patients.

TCT-227 The Efficacy of Reperfusion Therapy Treating Acute Intermediate High-Risk Pulmonary Embolism Patients

TCT-227 The Efficacy of Reperfusion Therapy Treating Acute Intermediate High-Risk Pulmonary Embolism Patients

An Auxiliary Scoring Model for Patients with Acute Pulmonary Embolism Complicated with Atrial Fibrillation Was Established Based on Random Forests.

The purpose of this study was to explore the establishment of an auxiliary scoring model for patients with acute pulmonary embolism (APE) complicated with atrial fibrillation (AF) based on random forest (RF) and its application effect. A retrospective analysis was performed on the general data, underlying diseases, laboratory indicators, and cardiac indicators of 100 patients with APE admitted to our hospital from 2018 to 2021. The occurrence of atrial fibrillation in patients with pulmonary embolism was taken as a categorical variable, and the general data, underlying diseases, laboratory indicators, and cardiac indicators were taken as input variables. Then, the risk auxiliary scoring model for patients with APE complicated with AF was established based on RF and logistic regression. Finally, the accuracy, sensitivity, specificity, recall rate, accuracy, F1 value, and the receiver operator characteristic (ROC) curve were used to evaluate the predictive value of the models. After statistical analysis, the optimal node value was 3 and the optimal number of decision trees was 500 in the RF model. The importance of predictors in descending order were Hcy, diabetes mellitus, FT3 level, UA level, left atrial diameter, hypertension, and smoking history. The prediction accuracy of the RF model was 0.934, sensitivity 0.966, specificity 0.876, recall rate 0.9660, accuracy 0.934, and F1 value 0.950. The logistic regression model prediction accuracy was 0.816, sensitivity 0.915, specificity 0.125, recall rate 0.902, accuracy 0.811, and F1 value 0.896. The RF model and logistic regression prediction model AUC values were 0.984 and 0.883, respectively. From this, we conclude that the RF model was better than the logistic regression model in predicting AF in APE patients. So, the RF model had the clinical application value.

Clinical and imaging risk factors for the persistence of thromboembolism following acute pulmonary embolism.

BackgroundPredicting the progression of acute pulmonary embolism to chronic pulmonary thromboembolism (CPTE) disease is essential to monitoring and improving the long-term prognosis of pulmonary embolism. We explored the risk factors for chronic persistence of thromboembolism after acute pulmonary embolism.MethodsCases with newly onset acute pulmonary embolism in the China-Japan Friendship Hospital from November 2016 to November 2019 were retrospectively analyzed. The clinical characteristics, serological examination results, and treatment strategies of acute pulmonary embolism patients were obtained through the electronic medical record system (Goodwill E-Health Info Co., Ltd.). Imaging parameters on computed tomography pulmonary angiography (CTPA) images at the onset of the acute pulmonary embolism were measured and counted. Notably, we propose a new parameter based on CTPA images: the ratio of Sd (sum of residual segmental pulmonary artery diameter) to MPAd (the main pulmonary artery diameter) (Sd/MPAd). After 3 months of regular treatment for acute pulmonary embolism, patients were classified into a CPTE group or a non-CPTE group based on the presence of residual embolus. All data were compared between the CPTE group and non-CPTE group. Furthermore, logistic regression analysis was used to investigate risk factors for the progression of acute pulmonary embolism to CPTE.ResultsA total of 77 cases (male:female = 1:1.26) were included in the study. There were 43 cases (55.84%) in the CPTE group and 34 cases in the non-CPTE group (44.16%). The results of univariate analysis showed that there were statistically significant differences between the 2 groups in risk stratification (χ2=8.043; P=0.005), protein S activity (χ2=5.551; P=0.018), the ratio of sum of residual segmental pulmonary artery diameter to the main pulmonary artery diameter (Sd/MPAd; t=–2.103; P=0.039), Mastora score (U=362.500; P<0.001), and embolus location (χ2=16.969; P<0.001). However, there were no statistically significant differences between the 2 groups in treatment options (P=0.381). According to multivariate logistic-regression analysis, protein S activity <55% (P=0.025), Sd/MPAd ≥1.97 (P=0.011), and an embolus being located in the central pulmonary artery (P<0.001) were independent risk factors for chronic persistence of thromboembolism following acute pulmonary embolism.ConclusionsThe protein S activity, location of the embolus, and Sd/MPAd on CTPA at the onset of acute pulmonary embolism may suggest the progression of acute pulmonary embolism to CPTE.

Short-term prognostic value of clinical data in hospitalized patients with intermediate-risk acute pulmonary embolism

BackgroundIntermediate-risk acute pulmonary embolism (APE) patients are usually defined as hemodynamically stable, comprehending a great therapeutic dilemma. Although anticoagulation therapy is sufficient for most intermediate-risk APE patients, some patients can deteriorate and eventually require a systemic fibrinolytic agent or thrombectomy. Hence, this study aimed to evaluate the predictive value of differences in clinical data for the short-term prognosis of intermediate-risk APE patients.MethodsA retrospective cohort of 74 intermediate-risk APE patients confirmed by computed tomography pulmonary angiography was analyzed in the present study. Adverse clinical event outcomes included PE-related in-hospital deaths, critical systolic blood pressure consistently under 90 mmHg, refractory to volume loading and vasopressor infusion requirements, mechanical ventilation, and cardiopulmonary resuscitation. The APE patients were stratified into two groups: adverse outcome (n = 25) and control (n = 49) groups. Then, the clinical data of the two groups were compared. Receiver operating characteristic (ROC) curves were used to explore the predictive value of white blood cell (WBC) counts and the right to left ventricular short-axis (RV/LV) ratio. Model calibration was assessed using the Hosmer–Lemeshow goodness-of-fit statistic.ResultsThe brain natriuretic peptide, WBC count, and the RV/LV ratio were higher in patients with adverse outcomes compared to controls. The APE patients with adverse outcomes presented significantly higher rates of syncope, Negative T waves (NTW) in V1–V3, intermediate-high risk, thrombolytic therapy, and low arterial oxygen saturation (SaO2) compared to controls. In the multivariate logistic regression analysis, the SaO2 < 90%, [odds ratio (OR) 5.343, 95% confidence interval (CI) 1.241–23.008; p = 0.024], RV/LV ratio (OR 7.429, 95% CI 1.145–48.209; p = 0.036), Syncope (OR 12.309, 95% CI 1.702–89.032; p = 0.013), NTW in V1–V3 (OR 5.617, 95% CI 1.228–25.683; p = 0.026), and WBC count (OR 1.212, 95% CI 1.035–1.419; p = 0.017) were independent predictors of in-hospital adverse outcomes among APE patients. The ROC curve analysis indicated that the RV/LV ratio can be used to predict adverse outcomes (AUC = 0.748, p < 0.01) and calibration (Hosmer–Lemeshow goodness of fit test, p = 0.070). Moreover, an RV/LV ratio > 1.165 was predictive of adverse outcomes with sensitivity and specificity of 88.00 and 59.20%, respectively. The WBC counts were also able to predict adverse outcomes (AUC = 0.752, p < 0.01) and calibration (Hosmer–Lemeshow goodness of fit test, p = 0.251). A WBC count > 9.05 was predictive of adverse outcomes with sensitivity and specificity of 68.00 and 73.50%, respectively.ConclusionOverall, a SaO2 < 90%, RV/LV ratio, Syncope, NTW in V1–V3, and WBC counts could independently predict adverse outcomes in hospitalized intermediate-risk APE patients.

Prognostic role of serial electrocardiographic changes in patients with acute pulmonary embolism. Data from the Italian Pulmonary Embolism Registry

BackgroundThe prognostic role of serial electrocardiographic modifications in patients with acute pulmonary embolism (PE) have been poorly investigated. We evaluate the electrocardiographic changes in PE patients during their hospitalization and the prognostic role of such ECG modifications in respect to 30-day mortality in patients enrolled in the Italian Pulmonary Embolism Registry (IPER). MethodsSubjects enrolled into the IPER (September 2006–August 2010) were stratified according to their hemodynamic status, as high- (hemodynamically unstable) and non-high-risk (hemodynamically stable) patients. ECG features were analysed at three fixed time points: at presentation, on day 3 and at discharge. ResultsOverall, 687 patients (286 males, mean age 69.0 ± 15.5 years) were included in the study. Among these, 71 (10.3 %) were at high-risk. In these patients, multivariate analysis revealed that the persistence of right ventricular strain (RVS) after three days from hospitalization was a predictor of 30-day mortality [HRa: 2.78 (95 % CI: 1.05–7.31, p = 0.003)]. Moreover, the persistence of right bundle branch block (RBBB) [HRa: 2. 48 (95 % CI: 1.03–5.09, p = 0.002)], negative T waves in V1-V4 (NTWs) [HRa: 1.63 (95 % CI: 1.04–2.55), p < 0.0001] and qR complex in lead V1 [HRa: HR: 5.44, (95 % CI: 3.22–9.44, p < 0.0001)] were associated with an increased risk of 30-day mortality. When RBBB, NTWs and qR complex in V1 lead were present concomitantly, the 30-day risk of death resulted significantly higher [HR: 12.5 (95 % CI: 3.39–46.4,) p < 0.0001]. ConclusionsPersistence of RBBB, NTWs, and qR pattern in V1 lead at day 3 of hospitalization are independent prognostic factors of death within 30 days in high-risk acute PE patients. The prognostic power of any single ECG abnormality is lower compared to the combination of the three ECG variables.

Acil Serviste Pulmoner Emboli Tanısı Alan Hastalarda Laktat ve Laktat Klerensinin Mortalite Üzerine Etkisinin Retrospektif Değerlendirilmesi

Aim: Pulmonary embolism (PE) is the third leading cause of death due to cardiovascular disease. The presence of shock or hypotension remains the main prognostic clinical marker and to date, it is the only factor that indicates the need for aggressive treatment. Most patients with pulmonary embolism are normotensive. Prognostic indicators are needed to better classify patients with pulmonary embolism. This study aimed to investigate the effect of lactate level on predicting hospital mortality in patients diagnosed with pulmonary embolism in the emergency department, and the effect of lactate clearance on mortality in patients with high lactate levels (lactate ≥2 mmol/L). Material and Methods: This study was designed as a retrospective study. Adult patients (&amp;gt;18-years old) who were diagnosed with PE by computed tomography angiography of the thorax in the university hospital emergency between January 1, 2018, and December 31, 2019, were analyzed. Results: A total of 367 patients were diagnosed with pulmonary embolism in the emergency department. In-hospital mortality rate of the patients was 29.8% and the pulmonary embolism-related mortality rate was 12.4%. Lactate clearance was not significant in predicting mortality risk. In the logistic regression analysis performed among the risk factors affecting mortality in patients with pulmonary embolism, lactate ≥3 mmol/L and normotensive + lactate ≥3 mmol/L were significant in predicting in-hospital mortality. Conclusion: The lactate level in the emergency department could be an effective screening method for identifying mortality in acute pulmonary embolism patients.

Mass-spectrometric identification of oxidative modifications in plasma-purified plasminogen: Association with hypofibrinolysis in patients with acute pulmonary embolism

ObjectivesMechanisms behind disturbed fibrinolysis in pulmonary embolism (PE) are poorly understood. We hypothesized that oxidative stress-induced changes in plasminogen contribute to impaired fibrinolysis in patients with acute PE. MethodsOxidative and other modifications were investigated using mass-spectrometry in plasminogen purified from pooled plasma of 5 acute PE patients on admission and after 3 months of anticoagulant treatment, along with plasma clot lysis time, a measure of global efficiency of fibrinolysis, and a stable oxidative stress marker, plasma 8-isoprostane. ResultsTwenty sites of oxidation, 3 sites of carbonylation and 4 sites of S-nitrosylation were identified in plasminogen. The intensity of peptides oxidized at cysteine residues with respect to unmodified peptides decreased after 3 months of anticoagulation (p = 0.018). This was not observed for oxidized methionine residues (p = 0.9). Oxidized tryptophan (n = 4) and proline (n = 2), as well as carbonylation at 3 threonine residues were selectively identified in acute PE episode, not after 3 months. This was accompanied by 12.8% decrease in clot lysis time (p = 0.043). Deamidation occurred at the arginine, previously identified to undergo the cleavage by plasminogen activator. Methylated were two lysine-binding sites important for an interaction of plasminogen with fibrin. Other identified modifications involved: glycation, acetylation, phosphorylation, homocysteinylation, carbamylation and dichlorination (88 modifications at 162 sites). ConclusionsData suggest that oxidative stress-induced changes in plasminogen molecules may contribute to less effective global fibrinolysis in patients with acute PE. The comprehensive library of posttranslational modifications in plasminogen molecules was provided, including modifications of sites reported to be involved in important biological functions.

P285 PROGNOSTIC ROLE OF ELECTROCARDIOGRAPHIC TEMPORAL CHANGES IN PATIENTS WITH ACUTE PULMONARY EMBOLISM. DATA FROM THE ITALIAN PULMONARY EMBOLISM REGISTRY (IPER)

Abstract Background The potential prognostic role of ECG changes during the course of acute pulmonary embolism (PE) has been poorly investigated over the years. Methods Data of patients prospectively enrolled in the IPER registry, having three ECGs (the first perfromed on admission, the second after three days of hospitalization and the third at discharge) were extracted and analyzed. Results Overall, 687 patients (286 males, mean age 69.0 ± 15.5 years) were included in the study. The negativization of electrocardiographic signs of right ventricualr strain (RVS) (Right bundle branch block –RBBB), S1Q3T3 and negative T waves from V1 to V4) followed the same pattern in both non–high (i.e. hemodynamically stable) and high–risk (i.e. hemodynamically unstable) patients, showing firstly the normalization of the S1QT3 pattern followed by the resolution of the RBBB. Conversely, additional NTWs appeared between the first and second ECGs in about 20% of cases and then partially normalized at discharge. Persistence of RVS at the second ECG was associated with a higher risk of death within 30 days only in high–risk patients [HRa: 2.78 (95% CI: 1.05–7.31. P = 0.03), with a sensitivity, specificity, PPV and PPN of 90.0%, 94.1%, 85.7% and 96.0%, respectively. Furthermore, the lack of normalization of the RBBB [HRa: 2.78 (95% CI: 1.05–7.31, p = 0.003)], of the NTW [HRa: 1.63 (95% CI: 1.04–2.55), p &amp;lt; 0.0001] and of the resolution of qR complex in V1 [HRa: 12.5 (95% CI: 3.39–46.4,) p &amp;lt; 0.0001] were independent predictors of poor prognosis in the short term. High–risk patients showing at the second–ECG the persitence of RBBB and NTWs as well as disappearance of the qR complex in V1 had a higher 30–day increased risk of death [HR: 9.44, (95% CI: 5.22–17.05, p &amp;lt; 0.0001]. The C–statistic confirmed in high–risk subjects an improvement in short–term prognostic power using the persistence of all three ECG signs (0.77, 95% CI: 0.51–0.94) or they single presence (0.61, 95% CI 0.42–0.79; 0.70; 95% CI: 0.52–0.88 and 0.74, 95% CI: 0.56–0.96, RBBB, NTWs and qR in V1, respectively). Conclusions The persistence of RBBB, NTWs, and qR pattern in V1 after 3 days from the hospitalization for acute PE represent an independent prognostic factors of death within 30 days in high–risk acute PE patients. In terms of prognostic power, the single evaluation of each ECG sign was lower compared to the overall or combined assessment.

Analysis of the relationship between syncope and poor prognosis in patients with acute pulmonary embolism and related factors

Objective: To explore the association between syncope and poor prognosis and related factors of syncope in patients with acute pulmonary embolism (APE). Methods: A total of 740 patients with first diagnosed APE treated in West China Hospital of Sichuan University from September 1, 2016 to December 30, 2019 were enrolled. The basic information and clinical information (including clinical manifestations, complications, auxiliary examination, treatment and prognosis, etc.) of the patients were obtained from inpatient medical records. The patients were divided into the syncope group and the non-syncope group according to whether they had syncope or not. The basic and clinical conditions of the two groups were compared, and the factors related to syncope in APE patients were analyzed by multiple logistic regression model. Results: The proportion of APE patients with syncope was 12.6% (93/740). Age was (59±16) years in the syncope group (93 cases) and (59±17) years in the non-syncope group (647 cases), with 57.0% (53/93) and 60.4% (391/647) males, respectively. The body mass index, in-hospital mortality, proportions with high risk APE and mechanical ventilation of the syncope group were higher than those of the non-syncope group [(24.5±4.0) kg/m2 vs (23.3±3.8) kg/m2, 16.1% vs 7.7%, 4.4% vs 1.3% and 9.7% vs 2.5%, respectively]. The length of hospital stay [M (Q1, Q3)] of the syncope group was longer than that of the non-syncope group [15 (10, 22) d vs 14 (9, 22) d], and the proportions with chest pain and hemoptysis were lower than those of the non-syncope group (19.4% vs 36.8% and 14.0% vs 27.2%, respectively) (all P values<0.05). Multivariate logistic regression analysis showed that enlargement of the right heart [OR (95%CI): 2.46 (1.07, 5.64)] was a factor associated with syncope in APE patients. Conclusion: The proportion of APE patients with syncope is relatively high and is associated with poor prognosis, while enlargement of the right heart is associated with syncope in APE patients.

Clinical Application of Echocardiography in Evaluating Left Ventricular Diastolic Function in Patients with Acute Pulmonary Embolism.

Objective To explore the clinical application of echocardiography in assessing left ventricular diastolic function in patients with acute pulmonary embolism (APE). Methods About 90 patients with APE treated in our hospital from March 2016 to March 2019 were enrolled as the study group. The enrolled patients were assigned into three groups in accordance with the risk stratification of APE, with 30 patients in each group, including high-risk group, medium-risk group, and low-risk group. Approximately 90 healthy persons who underwent physical examination in the same period were enrolled as the control group. The two groups were used to analyze the clinical value of echocardiography in evaluating left ventricular diastolic function in patients with APE and to explore the correlation between left ventricular diastolic function and different risk stratification of APE. Results First of all, we compared the side values of echocardiography. Compared to the control group, right ventricular end-diastolic diameter/left ventricular end-diastolic diameter (RVED/LVED) and pulmonary artery systolic pressure (PASP) in the study group were higher, while left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), left ventricular volume per stroke (LVSV), and left ventricular ejection fraction (LVEF) in the study group were lower (P < 0.05). Secondly, we compared the echocardiographic side values of patients with different APE risk stratifications: (1) RVED/LVED, PASP: low‐risk group < medium‐risk group < high‐risk group; (2) LVEDV, LVESV, LVSV, LVEF: low‐risk group > medium‐risk group > high‐risk group (P < 0.05). The routine echocardiographic findings of APE patients: M-type left ventricular wave group of pulmonary embolism (PE) indicated right ventricular enlargement and interventricular septum shifted to the left ventricle; short-axis section of PE artery indicated thrombosis at the opening of the right pulmonary artery (indicated by arrow); long-axis section of the left ventricle of PE indicated right ventricular enlargement (RV 3.5 cm, LV 3.9 cm); four-chamber view of PE indicated enlargement of the right atrium and the right ventricle, and interventricular septum shifted like left ventricle. In terms of mitral annulus displacement, early diastolic ESD and ELD in the study group were lower compared to those in the normal control group, while late diastolic ASD and ALD in the study group were higher compared to those in the normal control group (P < 0.05). The results of Pearson correlation analysis indicated that there was a positive correlation between RVED/LVED, PASP, and APE risk stratification, while APE risk stratification was negatively correlated with LVEDV, LVESV, LVSV, and LVEF (P < 0.05). Conclusion Echocardiography attaches importance to the evaluation of left ventricular diastolic function in APE. The side value of echocardiography can sensitively reflect the changes of left ventricular diastolic function in APE. The predictive value in the diagnosis of APE is better than other traditional parameters of left ventricular diastolic function, especially in patients with different APE risk stratifications. There is a remarkable correlation between the changes of left ventricular diastolic function and different APE risk stratifications. Echocardiographic measurement can be employed to assess left ventricular diastolic function in APE, which can be developed in clinical treatment and prognosis evaluation to provide a new evaluation method.