Diagnosis Of Acute Pulmonary Embolism Research Articles

Lipoprotein (a) is not associated with thrombus burden derived from CT pulmonary angiography in patients with acute pulmonary embolism

Lipoprotein (a) [Lp(a)] is suspected to have antifibrinolytic effects, however, its relevance for the severity of venous thromboembolic events remains unclear. We studied the association of Lp(a) levels with thrombus load in pulmonary embolism (PE). 90 patients (40% female, median age 70 [56–79] years) at our tertiary care hospital with a diagnosis of acute PE, available Lp(a) levels and CT pulmonary angiography (CT-PA) performed between April 2017 and December 2019 were included. All CT-PA scans were reanalyzed and thrombus load was determined via Qanadli CT obstruction index (CTOI) and most proximal thrombus location. Median Lp(a) levels were 11.4 [9.3–29.1] mg/dL, median D-dimer levels were 4.6 [2.1–9.8] mg/L, median CTOI was 23 [8–50], central PE was present in 27 (30%) patients. Lp(a) did not correlate with CTOI (r = 0.02, p = 0.922) and was not associated with thrombus location (p = 0.369). CTOI significantly correlated with D-dimer (r = 0.43, p < 0.001) and right to left ventricular diameter ratio (r=-0.49, p = < 0.001). Our findings showed that Lp(a) is not associated with thrombus burden in PE, which suggests that a relevant effect of Lp(a) on the extent of venous thromboembolism is unlikely.

Echocardiography in acute pulmonary embolism for the prediction of subsequent CTEPH

Abstract Background Chronic thromboembolic pulmonary hypertension (CTEPH) is a long term complication of acute pulmonary embolism (APE) with poor outcomes if untreated. Identifying already at APE diagnosis patients at risk of subsequent CTEPH can lead to earlier goal-directed management. Since standard echocardiography (TTE) is frequently performed during APE episode for short term risk stratification we aimed to asses prediction vale of echocardiography for subsequent CTEPH. Methods We analyzed retrospectively TTE performed at admission due to APE in consecutive patients, without known CTEPH who were anticoagulated for at least 3 months and were followed up for at least 24 months. After follow-up all patients underwent diagnostic workup for CTEPH according to ESC recommendations. We tried to define a set of echocardiographic parameters recorded during the acute episode predictive for CTEPH. Results The study included consecutive 625 patients with APE diagnosed at computed tomography pulmonary angiogram and managed according to ESC recommendations. During follow up 25 (4%) pts were diagnosed with CTEPH. At APE diagnosis CTEPH(+) group presented more prominent echocardiographic signs of right ventricular (RV) overload than pts without CTEPH (CTEPH(-))(table 1). However, multivariate analysis revealed that only increased TRPG and RV/LV ratio were significant CTEPH predictors with AUC 0.792 (95% CI: 0.683-0.900), p&amp;lt;0.001 and 0.777 (95% CI: 0.675-0.878), p&amp;lt;0.001 respectively (fig 1). Using Youden index in ROC analysis we defined following cut off values useful to identify patients at CTEPH risk and subjects with low probability of CTEPH development. TRPG &amp;gt;44mmHg and RV/LV&amp;gt;1.15 showed PPV for CTPEH 12.9 (95% CI: 9.8-16.7) and 13.8 (95% CI: 10.4-18.1), with high NPV of 98.4 (95% CI: 97.1-99.2) and 98.2 (95% CI: 96.8-99.0) respectively. Importantly, in the group of 61 (9.7%) patients with both signs of RV overload present in the acute phase CTEPH during follow-up was diagnosed in 14 patients (23.0%). Conclusion TRPG above 44 mmHg recorded at APE diagnosis identifies patients at risk of subsequent CTEPH especially in patients with increased RV/LV ratio.

A new electrocardiographic parameter terminal D1S + D3R predicts right ventricular dilatation in acute pulmonary embolism

Objective Right ventricular (RV) overload findings affect the risk classification and treatment approach in acute pulmonary embolism (APE). Recently, it was reported that a new electrocardiography (ECG) parameter, terminal D1S + D3R (T-D1S + D3R) pattern, supported the diagnosis of APE. We aim to search the relationship between T-D1S + D3R pattern and right ventricular dilatation (RVD) in APE. Methods This single-centre, retrospective study was designed with patients aged > 18 years. We screened 267 patients who underwent transthoracic echocardiography (TTE) because of confirmed APE in our emergency department. This study included 72 patients with RVD and 139 patients without RVD [male 41.7%, median age 73,0 (20.8) years; 49.6% male, median age 64,0 (24.0) years]. We compared T-D1S + D3R between RVD (+) and RVD (-) groups. Results We determined that RVD (+) group had more patients with the T-D1S + D3R parameter than RVD (-) group [51 (70.8%) vs. 25 (18.0%), p < 0.001]. In the univariate logistic regression analyses S1Q3T3, (in)complete right bundle branch block (RBBB), T-D1S + D3R, D3-V1 T wave inversion (TWI), V1-3/4 TWI, V1-3/4 ST-segment elevation, and frontal QRS-T [f(QRS-T)] angle predicted RVD, while T-D1S + D3R, V1-3/4 ST-segment elevation, and f(QRS-T) angle remained independent predictors of RVD in patients with APE. Conclusions T-D1S + D3R, a new ECG parameter, was an independent predictor of RVD in patients with APE.

CT Pulmonary Angiogram Clinical Pretest Probability Tool: Impact on Emergency Department Utilization

ObjectiveCurrently, computed tomographic pulmonary angiogram (CTPA) for evaluating acute pulmonary embolism (PE) in Emergency Departments (EDs) is overused and with low yields. The goal of this study is to assess the impact of an evidence-based clinical decision support (CDS) tool, aimed at optimizing appropriate use of CTPA for evaluating PE. MethodsThe study was performed at EDs in a large healthcare system and included 9 academic and community hospitals. The primary outcome was the percent difference in utilization (number of CTPA performed/number of ED visits) and secondary outcome was yield (percentage of CTPA positive for acute PE), comparing 12 months before (6/1/2021-5/31/2022) vs. 12 months after (6/1/2022-5/31/2023) a system-wide implementation of the CDS. Univariate and multivariable analyses using logistic regression were performed to assess factors associated with diagnosis of acute PE. Statistical process control (SPC) charts were used to assess monthly trends in utilization and yield. ResultsAmong 931,677 visits to Emergency Departments, 28,101 CTPAs were performed on 24,675 patients. 14,825 CTPAs were performed among 455,038 visits (3.26%) pre-intervention; 13,276 among 476,639 visits (2.79%) post-intervention, a 14.51% relative decrease in CTPA utilization (chi-square, p<0.001). CTPA yield remained unchanged (1371/14825=9.25% pre- vs. 1184/13276=8.92% post-intervention; chi-square, p=0.34). Patients with COVID diagnosis prior to CTPA had higher probability of acute PE. SPC charts demonstrated seasonal variation in utilization (Friedman test, p=0.047). DiscussionImplementing a CDS based on validated decision rules was associated with a significant reduction in CTPA utilization. The change was immediate and sustained for 12 months post-intervention.

Performance and Interpretation of Lung Scintigraphy: An Evaluation of Current Practices in Australia, Canada, France, Germany, and United States.

Although ventilation/perfusion (V/Q) scintigraphy is a widely used imaging test, different options are possible for the acquisition and interpretation of the scan. The aim of this study was to assess current practices regarding the use and interpretation of lung scintigraphy in various clinical indications. An online survey comprising 25 questions was sent to nuclear medicine departments in Australia, Canada, France, Germany, and United States between 2022 and 2023. A single response per department was consolidated. Four hundred nineteen responses were collected (Australia: 32, Canada: 58, France: 149, Germany: 92, and United States: 88). For acute pulmonary embolism (PE) diagnosis, 82.8% of centers reported using SPECT acquisitions (Australia: 93.3%, Canada: 91.8%, France: 99.2%, Germany: 96.2%, and United States: 32.1%). Among them, SPECT images were combined with a CT scan in 70.5% of centers. A total of 10.6% of centers reported not using ventilation for acute PE diagnosis. SPECT acquisition was used in 97.8% of centers using 99m Tc carbon particles, 97.1% 81m Kr gas, 58.7% 99m Tc-DTPA, and 19.4% 133 Xe gas, respectively. For V/Q SPECT interpretation, the EANM criteria were used in 65.0% of departments. A very wide variety of practices were observed in pregnant women and in COVID-19 patients. SPECT acquisition was widely used in the follow-up of PE and for the screening of chronic thromboembolic pulmonary hypertension (>90% of centers), with inconsistency regarding the interpretation of matched perfusion defects in this setting. This survey shows the strong adoption of SPECT in the various clinical indications of lung scintigraphy, except in the United States, where planar imaging is still mostly used. The survey also shows variability in interpretation criteria both for PE diagnosis and screening for chronic thromboembolic pulmonary hypertension, highlighting the need for further standardizations of practices.

Trends in Initial Anticoagulation Among US Patients Hospitalized With Acute Pulmonary Embolism 2011-2020

Guidelines recommend low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOACs) rather than unfractionated heparin (UFH) for treatment of acute pulmonary embolism (PE) given their efficacy and reduced risk of bleeding. Using data from a large consortium of US hospitals, we examined trends in initial anticoagulation among hospitalized patients diagnosed with acute PE. We conducted a retrospective study of inpatient and observation cases between January 1, 2011, and December 31, 2020, among individuals aged more than or equal to 18 years treated at acute care hospitals contributing data to the Premier Healthcare Database. Included cases received a diagnosis of acute PE, underwent imaging for PE, and received anticoagulation at the time of admission. The primary outcome was the initial anticoagulant selected for treatment. Among 299,016 cases at 1,045 hospitals, similar proportions received initial treatment with UFH (47.4%) and LMWH (47.9%). Between 2011 and 2020, the proportion of patients initially treated with UFH increased from 41.9% to 56.3%. Over this period, use of LMWH as the initial anticoagulant was reduced from 58.1% in 2011 to 37.3% in 2020. The proportion of cases admitted to the ICU, treated with mechanical ventilation or vasopressors, and inpatient mortality were stable. Factors most strongly associated with receipt of UFH were admission to the ICU (odds ratio [OR] 6.90; 95% confidence interval [CI] 6.31 to 7.54) or step-down unit (OR 2.30; 95% CI 2.16 to 2.45), receipt of thrombolysis (OR 4.25; 95% CI 3.09 to 5.84) or vasopressors (OR 1.83; 95% CI 1.32 to 2.54), and chronic renal disease (OR 1.67; 95% CI 1.54 to 1.81). Despite recommendations that LMWH and DOACs be considered first-line for most patients with acute PE, use of UFH is common and increasing. Further research is needed to elucidate factors associated with persistent use of UFH and opportunities for deimplementation of low-value care.

Disparities in the prevalence of acute pulmonary embolism in patients with ovarian cancer: A nationwide analysis.

e17560 Background: Ovarian cancer is the leading cause of death among gynecological cancers. It is highly thrombogenic and is associated with increased venous thromboembolism events. We conducted a retrospective analysis to study the prevalence and disparities in the association of Acute Pulmonary embolism(PE) with ovarian cancer. Methods: National Inpatient Sample (2017-2020) was used to identify the patients with primary diagnosis of Acute PE and was stratified into those with and without concurrent diagnosis of Ovarian cancer ( regional and advanced metastatic disease). Basic demographic variables were analyzed to identify disparities in the prevalence of Acute PE among ovarian cancer patients.Multivariate logistic regression analysis was conducted to examine the association between Acute PE and Ovarian cancer. Results: A total of 651435 patients were hospitalized with a primary diagnosis of Acute PE, and 2980 (0.46%) had a secondary diagnosis of Ovarian cancer. The ovarian cancer group had a greater percentage of white (73.4% vs.71.93%), Hispanics (7.98% vs. 6.04%), and fewer Black patients (15.78% vs. 19.86), p=0.021. Compared to the white, Black population with ovarian cancer (OR=0.77(0.6-0.9); p=0.04) had a decreased likelihood of developing Acute PE without any difference noted in the Hispanics (OR=1.13 (0.81-1.58); p=0.44) and other races (OR=1.11 (0.67-1.83); p=0.67). Patients in the high income groups were more likely to be admitted due to acute PE ($65,000-$85,999: OR=1.35 (1.05-1.73), p=0.018; &gt;$86,000: OR=1.24 (1.14-1.62), p=0.01). A greater percentage of patients with ovarian cancer had private insurance (35.2% vs. 28.91%), while a greater percentage of patients without ovarian cancer had Medicare (54.38% vs. 50.34%) and Medicaid (11.9% vs. 12.5%), p=0.003. Patients with private insurance were more likely to be admitted due to acute PE (OR=1.73(1.36-2.22); p&lt;0.001). Patients with a Charlson comorbidity index of 3 or more had higher odds of Acute PE (OR=1.3(1.12-3.4); p=0.02). A greater percentage of Acute PE patients with ovarian cancer were admitted to large (54.03% vs. 47.86%; p=0.014), urban (95.3% vs. 90.35%; p&lt;0.001), and teaching hospitals (79.87% vs. 69.15%; p&lt;0.001). Teaching hospitals had higher odds of admissions due to acute PE in ovarian cancer patients (OR=1.37(1.07-1.75); p=0.01). On multivariate regression analysis, Ovarian cancer patients had higher odds of Acute PE (OR=1.88 (1.73-2.05); p&lt;0.001). Conclusions: Ovarian cancer patients with Black race and private insurance showed a significantly increased likelihood of admissions due to acute pulmonary embolism. Additionally, urban and teaching hospitals demonstrated higher odds of encountering cases of acute pulmonary embolism. Further prospective studies are necessary to validate the findings presented in our study.

Electrocardiogram Signal Analysis With a Machine Learning Model Predicts the Presence of Pulmonary Embolism With Accuracy Dependent on Embolism Burden

ObjectiveTo develop an artificial intelligence deep neural network (AI-DNN) algorithm to analyze 12-lead electrocardiogram (ECG) for detection of acute pulmonary embolism (PE) and PE categories. Patients and MethodsA cohort of patients seen between January 1, 1999, and December 31, 2020, from across the Mayo Clinic Enterprise with computed tomography pulmonary angiogram (CTPA) and ECG performed ±6 hours was identified. Natural language processing algorithms were applied to radiology reports to determine the diagnosis of acute PE, acute right ventricular strain pulmonary embolism (RVSPE), saddle pulmonary embolism (SADPE), or no PE. Diagnostic performance parameters of the AI-DNN reported were area under the receiver operating characteristics curve (AUROC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). ResultsA cohort of patients with CTPA report and ECG consisted of 79,894 patients including 7423 (9.3%) with acute PE, among whom 1138 patients had RVSPE or SADPE. Artificial intelligence deep neural network predicted acute PE with a modest accuracy of AUROC of 0.69 (95% CI, 0.68-0.71), sensitivity of 63.5%, specificity of 64.7%, PPV of 15.6%, and NPV of 94.5%. The AI-DNN prediction using the same algorithm for RVSPE or SADPE was higher (AUROC, 0.84; 95% CI, 0.81-0.86) with a sensitivity of 80.8%, specificity of 64.7.8%, PPV of 3.5%, and NPV of 99.5%. ConclusionAn AI-based analysis of 12-lead ECG shows modest detection power for acute PE in patients who underwent CTPA, with higher accuracy for high-risk PE. Moreover, with the high NPV, it has the clinical potential to exclude high-risk PE quickly and correctly.

Abstract 1070: Predicting Short Term Mortality In Patients With Acute Pulmonary Embolism With Deep Learning

Background: Pulmonary embolism (PE) is one of the leading causes of short-term mortality among cardiovascular diseases. Rapid and accurate stratification of PE-related risk is vital for effective patient management. A strong potential research in this direction is to utilize deep learning (DL) approaches. DL approaches have enhanced risk prediction performance by leveraging novel risk predictors and analyzing complex interrelationships among them. In this study, we developed a DL based new scoring system superior to the current standard, the Pulmonary Embolism Severity Index (PESI) , when predicting the short-term (0-30 days) mortality of PE. Materials and Methods: Our study included a total of 207 patients. The diagnosis of acute PE was confirmed using contrast-enhanced computed tomography (CT) scans. DL model was created using CT scans and corresponding ground truth labels (short term mortality). We have benchmarked different DL architectures for this purpose including CNN and Transformers. Results: Out of 207 patients, 53 of them died during short term . The research group was categorized into two groups based on their short term survival status. Multivariable logistic regression analysis was used to determine the independent relationships between variables and short term mortality. Short-term mortality was predicted statistically significantly (p&lt;0.001) in the DL model developed from the patient's CT images (Figure 1). Then, we developed a new scoring model by uniquely combining the short-term mortality independent predictors, baseline data and the DL model (Figure 1). The ROC analysis demonstrated an AUC of 0.976 (p&lt;0.001) for the Baseline-DL model and an AUC of 0.865 (p&lt;0.001) for the PESI score The Baseline-DL model was statistically significantly superior to the PESI (p&lt;0.001). Conclusion: We developed a DL based new scoring system to predict short term mortality of patients with PE, significantly superior to the PESI.

Diagnosis of acute pulmonary embolism: when photon-counting-detector CT replaces energy-integrating-detector CT in daily routine.

To compare the diagnostic approach of acute pulmonary embolism (PE) with photon-counting-detector CT (PCD-CT) and energy-integrating-detector CT (EID-CT). Two cohorts underwent CT angiographic examinations with EID-CT (Group 1; n = 158) and PCD-CT (Group 2; n = 172), (b) with two options in Group 1, dual energy (Group 1a) or single energy (Group 1b) and a single option in Group 2 (spectral imaging with single source). In Group 2, all patients benefited from spectral imaging, only accessible to 105 patients (66.5%) in Group 1, with a mean acquisition time significantly shorter (0.9 ± 0.1 s vs 4.0 ± 0 .3 s; p < 0.001) and mean values of CTDIvol and DLP reduced by 46.3% and 47.7%, respectively. Comparing the quality of 70 keV (Group 2) and averaged (Group 1a) images: (a) the mean attenuation within pulmonary arteries did not differ (p = 0.13); (b) the image noise was significantly higher (p < 0.001) in Group 2 with no difference in subjective image noise (p = 0.29); and (c) 89% of examinations were devoid of artifacts in Group 2 vs 28.6% in Group 1a. The percentage of diagnostic examinations was 95.2% (100/105; Group 1a), 100% (53/53; Group 1b), and 95.3% (164/172; Group 2). There were 4.8% (5/105; Group 1a) and 4.7% (8/172; Group 2) of non-diagnostic examinations, mainly due to the suboptimal quality of vascular opacification with the restoration of a diagnostic image quality on low-energy images. Compared to EID-CT, morphology and perfusion imaging were available in all patients scanned with PCD-CT, with the radiation dose reduced by 48%. PCD-CT enables scanning patients with the advantages of both spectral imaging, including high-quality morphologic imaging and lung perfusion for all patients, and fast scanning-a combination that is not simultaneously accessible with EID-CT while reducing the radiation dose by almost 50%.

Detection of acute pulmonary embolism using native repeated magnetic resonance imaging acquisitions under free-breathing and without respiratory or cardiac gating. A diagnostic accuracy study

ObjectivesComputed tomography pulmonary angiography (CTPA) is the gold standard diagnostic method for patients with suspected pulmonary embolism (PE), but it has its drawbacks, including exposure to ionizing radiation and iodinated contrast agent. The present study aims to evaluate the diagnostic performance of our in-house developed non-contrast MRI protocol for PE diagnosis in reference to CTPA. Methods107 patients were included, all of whom underwent MRI immediately before or within 36 hours after CTPA. Additional cases examined only with MRI and a negative result were added to reach a PE prevalence of approximately 20%. The protocol was a non-contrast 2D steady-state free precession (SSFP) sequence under free-breathing, without respiratory or cardiac gating, and repeated five times to capture the vessels at different breathing/cardiac phases. The MRIs were blinded and read by two radiologists and the results were compared to CTPA. ResultsOf the 243 patients included, 47 were positive for PE. Readers 1 and 2 demonstrated 89% and 87% sensitivity, 100% specificity, 98% accuracy and Cohen’s kappa of 0.88 on patient level. In the per embolus comparison, readers 1 and 2 detected, 60 and 59/61 (98, 97%) proximal, 101 and 94/113 (89, 83%) segmental, and 5 and 2/32 (16, 6%) subsegmental emboli, resulting in 81 and 75% sensitivity respectively. ConclusionThe repeated 2D SSFP can reliably be used for the diagnosis of acute PE at the proximal and segmental artery levels.

Clinical Features and Predictors of Mortality in Patients With Acute Pulmonary Embolism: A Retrospective Study From Southern Saudi Arabia.

We aimed to investigate the clinical characteristics, outcomes, and mortality predictors in patients with acute pulmonary embolism (PE). Adult patients who were admitted to the Armed Forces Hospital Southern Region, Khamis Mushait, a large tertiary hospital in Southern Saudi Arabia, with the diagnosis of acute PE were retrospectively examined for the predictors of one-year mortality. The overall in-hospital mortality was 15.6% among 212 patients. In univariate analysis, only age was significantly associated with increased early mortality, whereas age, obesity, presence of active malignancy, hypertension, use of thrombolytics, and Simplified Pulmonary Embolism Severity Index (sPESI) were significantly associated with increased late mortality. By use of binary logistic regression, the presence of obesity (HR 6.010, 95%CI 0.048-16.853, p=0.030), active malignancy (HR 3.040, 95%CI 1.147-8.059, p=0.025), and the use of thrombolytics (HR 8.074, 95%CI 2.719-23.977, p<0.001), were independently significant factors for late (overall) mortality, respectively. Among Saudi Arabian patients in the Southern Region, our data show that age is an independent factor for increased early and late mortality. The presence of obesity, active malignancy, and the use of thrombolytics, were independently significant factors for increased late (one-year) mortality. These factors should be taken into account for risk stratification and decisions on tailored management of patients with PE. Further prospective multicenter studies are needed.

Differentiating electrocardiographic indications of massive and submassive pulmonary embolism: A cross-sectional study in Southern Iran from 2015 to 2020.

Although using electrocardiogram (ECG) for pulmonary embolism (PE) risk stratification has shown mixed results, it is currently used as supplementary evidence in risk stratification. This cross-sectional study aimed to assess and compare ECG findings of massive and submassive PE versus segmental PE. This cross-sectional study included 250 hospitalized patients with a confirmed diagnosis of acute PE from 2015 to 2020 in Southern Iran. Demographic variables, clinical data, troponin levels, on-admission ECG findings, echocardiography findings, and ECG findings 24 h after receiving anticoagulants or thrombolytics were extracted. Patients diagnosed with submassive or massive PE exhibited significantly higher rates of right axis deviation (p = .010), abnormal ST segment (p < .0001), S1Q3T3 pattern (p < .0001), inverted T wave in leads V1-V3 (p < .0001), inverted T wave in leads V4-V6 (p < .0001), and inverted T wave in leads V1-V6 (p < .0001). In a multivariable model, inverted T wave in leads V1-V3, inverted T wave in leads V4-V6, pulse rate, and positive troponin test were the statistically independent variables for predicting submassive or massive PE. Furthermore, inverted T wave in leads V1-V3 (sensitivity: 85%, specificity: 95%, accuracy: 93%, AUC: 0.902) and troponin levels (sensitivity: 72%, specificity: 86%, accuracy: 83%, AUC: 0.792) demonstrated the best diagnostic test performance for discriminating submassive or massive PE from segmental PE. In addition to clinical rules, ECG can serve as an ancillary tool for assessing more invasive testing and earlier aggressive treatments among patients with PE, as it can provide valuable information for the diagnosis and risk stratification of submassive or massive PE.

Зв’язок рівня інтерлейкіну-6 з клінічним перебігом гострої тромбоемболії легеневої артерії

The aim – to investigate the possible influence of the level of interleukin-6 (IL-6) on the clinical course and remodeling of the right ventricle (RV) in patients with acute pulmonary embolism (PE).Materials and methods. 56 patients with a diagnosis of acute PE, confirmed by сomputed tomographic pulmonary angiography (CTPA), and in whom the level of IL-6 was determined, were studied. The patients were divided into two groups: 1 group with a normal IL-6 level (less than 5.9 pg/ml), 2 group with an elevated IL-6 level (more than 5.9 pg/ml). Clinical and anamnestic and laboratory-instrumental data were analyzed, statistical analysis of the resulting figures was carried out.Results and discussion. When comparing the groups depending on the level of IL-6, it was found that in group 1, not a single case of high-risk PE was recorded (p=0.052), while there was a significantly higher percentage of moderate-low-risk patients, p&lt;0.05. Patients in group 2 had a higher heart rate (p=0.0006), lower SBP (p=0.04) at admission, and a tendency to increase body mass index (p=0.089). In addition, in group 2, the average levels of leukocytes (p=0.046), d-dimer (p=0.007), CRP (p=0.004) were higher, and the level of lymphocytes (p=0.008) was lower than in group 1, and the trend was determined to an increase in neutrophils (p=0.07) and CPK MB (p=0.89) in the 2nd group. According to the ultrasound data, in group 2 there was more often the detection of thrombosis of the veins of the lower extremities (p=0.003), a significantly larger size of the RV (p=0.02), a tendency to increase the size of the right atrium (RA) and a higher level of systolic pulmonary pressure (p=0.068 ). Analysis of the CTPA showed a greater dilatation of the left LA (p=0.0297) and an increase in the LV/LV index (p=0.0072) in the 2nd group. Correlation analysis revealed an inverse connection with the level of SpO2 (p=0.03) and lymphocytes (p=0.0065), a direct connection with heart rate (p&lt;0.001), the ratio of LV/LV index (p=0.046), with the level of troponin I (p=0.014), D-dimer (p=0.026), leukocytes (p=0.026), neutrophils (0.038) and glucose (0.016), as well as the trend regarding the connection between the IL-6 level and the size of the RV according to echocardiography (p=0.07) and CPK MB level (p=0.086). The data of ROC analysis showed the connection of dilatation of the RV and Il-6 from the level of more than 7.65 pg/ml, with a sensitivity of the indicator of 90 %, specificity of 50 %.Conclusions. An Il-6 level increase is more common in elderly patients, patients with venous thrombosis of the lower extremities, tachycardia, hypotension, and with a greater risk of an adverse course during the hospital period. In 2 groups, a higher level of other markers of inflammation (leukocytes, CRP), larger sizes of the RV, a higher level of pulmonary artery pressure according to echocardiography and values of RV/LV according to CTPA results are observed. A direct connection between IL-6 level and heart rate, troponin level, D-dimer level, LV/LV ratio and inverse connection with saturation and lymphocyte level was established according to correlation analysis. Multivariate regression analysis established an independent connection between the IL-6 level and some laboratory (CPK MB, blood glucose) and echocardiographic parameters (RA, LV ESD, LV EDV, LV ESV, LV EF). The threshold level of Il-6, which is accompanied by dilatation of the RV according to Roc-analysis data, was determined.

Trivial Complaint in an Eisenmenger Syndrome Patient: A Case Report

Acute pulmonary embolism (PE) is a life-threatening cardiorespiratory condition. Shortness of breath and cyanosis in an active daily living patient with Eisenmenger Syndrome (ES) obscuring the early diagnosis of acute PE. We reported a case of a 41-year-old lady with underlying Eisenmenger syndrome presented to Emergency Department with sudden onset of palpitation. Otherwise, she did not complain of any worsening shortness of breath or reduced effort tolerance. Compensation of the heart causing normalization of the blood pressure in ES may mask the features of massive PE and make it more challenging in managing this kind of patient. However, with the complaint of acute onset palpitation trigger the managing team to think about PE. Computed Tomography Pulmonary Angiography (CTPA) had done, and there were significant blood clots in the right main pulmonary artery. Luckily, she survived after thrombolytic therapy, warded a few days, and discharge well with a life-long oral anticoagulant.

Systematic pulmonary embolism follow-up increases diagnostic rates of chronic thromboembolic pulmonary hypertension and identifies less severe disease: results from the ASPIRE Registry.

Diagnostic rates and risk factors for the subsequent development of chronic thromboembolic pulmonary hypertension (CTEPH) following pulmonary embolism (PE) are not well defined. Over a 10-year period (2010-2020), consecutive patients attending a PE follow-up clinic in Sheffield, UK (population 554 600) and all patients diagnosed with CTEPH at a pulmonary hypertension (PH) referral centre in Sheffield (referral population estimated 15-20 million) were included. Of 1956 patients attending the Sheffield PE clinic 3 months following a diagnosis of acute PE, 41 were diagnosed with CTEPH with a cumulative incidence of 2.10%, with 1.89% diagnosed within 2 years. Of 809 patients presenting with pulmonary hypertension (PH) and diagnosed with CTEPH, 32 were Sheffield residents and 777 were non-Sheffield residents. Patients diagnosed with CTEPH at the PE follow-up clinic had shorter symptom duration (p<0.01), better exercise capacity (p<0.05) and less severe pulmonary haemodynamics (p<0.01) compared with patients referred with suspected PH. Patients with no major transient risk factors present at the time of acute PE had a significantly higher risk of CTEPH compared with patients with major transient risk factors (OR 3.6, 95% CI 1.11-11.91; p=0.03). The presence of three computed tomography (CT) features of PH in combination with two or more out of four features of chronic thromboembolic pulmonary disease at the index PE was found in 19% of patients who developed CTEPH and in 0% of patients who did not. Diagnostic rates and pulmonary endarterectomy (PEA) rates were higher at 13.2 and 3.6 per million per year, respectively, for Sheffield residents compared with 3.9-5.2 and 1.7-2.3 per million per year, respectively, for non-Sheffield residents. In the real-world setting a dedicated PE follow-up pathway identifies patients with less severe CTEPH and increases population-based CTEPH diagnostic and PEA rates. At the time of acute PE diagnosis the absence of major transient risk factors, CT features of PH and chronic thromboembolism are risk factors for a subsequent diagnosis of CTEPH.

Diagnosis of acute pulmonary embolism with EKG changes Similar to acute coronary syndrome by bedside cardiac Ultrasound evaluation: case report and review of article

Diagnosis of acute pulmonary embolism with EKG changes Similar to acute coronary syndrome by bedside cardiac Ultrasound evaluation: case report and review of article

Distinct age-adjusted D-dimer threshold to rule out acute pulmonary embolism in outpatients and inpatients.

The diagnosis of acute pulmonary embolism (PE) is combinations of clinical probability assessments, plasma D-dimer (DD) test results, and/or computed tomographic pulmonary angiography (CTPA). The aim of this study is to explore the appropriate DD cutoff using the immunoturbidimetric method in outpatients and inpatients. We retrospectively enrolled 2689 patients with suspected PE between January 2014 and December 2019. All patients underwent clinical probability assessments, DD tests, and CTPA. We investigated the appropriate cutoff level for plasma DD tests in the correlation analysis and receiver operating characteristic (ROC) curves. Among all patients, 1263 were confirmed acute PE. The age-adjusted DD level was determined to be age × 10μg/L (for patients aged >50 years) in outpatients. This cutoff value resulted in a sensitivity of 96.75% and a specificity of 87.02%, with the area under the curve (AUC) of 0.908 and the number needed to treat (NNT) of 1.18. For inpatients, the age-adjusted cutoff values for the biomarker DD demonstrated poor specificity (13.34%) and NNT (9.88). However, when the DD cutoff was adjusted to 2 × the upper limit of normal (ULN), the sensitivity increased to 93.19%, while the specificity remained at 29.55%, with the AUC of 0.610 and the NNT of 4.76. The optimal DD cut-off value was 3010 μg/L (about 5 × ULN), resulting in a sensitivity of 75.22% and specificity of 61.72%, with the AUC of 0.727 and the NNT of 2.7. Using the immunoturbidimetric method to measure DD, an age-adjusted DD cutoff (age × 10μg/L, if aged >50 years) should be considered for outpatients with suspected PE. For inpatients, increasing the DD cutoff value to at least 2 × ULN yields the best test performance.

Venoarterial Extracorporeal Life Support Use in Acute Pulmonary Embolism Shows Favorable Outcomes

BackgroundDifferences in outcomes by indication for venoarterial extracorporeal life support (VA-ECLS) are poorly described. We hypothesized that patients on VA-ECLS for acute pulmonary embolism (PE) have fewer complications and better survival than patients on VA-ECLS for other indications. MethodsAll patients ≥18 years on VA-ECLS from the Extracorporeal Life Support Organization global registry (2010-2019) were evaluated (n = 29,842). After excluding patients aged >79 years (n = 729) and those with incomplete indication data (n = 2530), patients were stratified by VA-ECLS indication for PE vs all other indications. The association between being discharged alive and each type of complication with VA-ECLS indication was assessed. ResultsOf 26,583 patients included in the analysis, 978 (3.7%) were on VA-ECLS for a primary diagnosis of acute PE. Acute PE patients were younger (53.1 vs 56.7 years, P < .001) and were more likely to be women (52.1% vs 32.3%, P < .001). Patients who underwent VA-ECLS for acute PE were 78% more likely to be discharged alive vs patients supported with VA-ECLS for other reasons (52.8% vs 40.4%; P < .001). Acute PE patients had fewer cardiovascular and renal complications (26.6% vs 38.0% and 31.1% vs 39.4%, respectively; adjusted P < .001). Acute PE patients had higher odds of having clots and mechanical complications (8.7% vs 7.9% and 16.7% vs 14.6%, respectively; adjusted P < .001). ConclusionsPatients undergoing VA-ECLS for acute PE have higher odds of survival to hospital discharge compared with those supported for other indications. Additionally, VA-ECLS in this population is associated with fewer cardiovascular and renal complications but higher mechanical complications.

Successfully conservative management of the uterus in acute pulmonary embolism during cesarean section for placenta previa: a case report from Tu Du Hospital, Vietnam and literature review

BackgroundCardiopulmonary collapse is a catastrophic event in cesarean section, which leads to adverse outcomes for both the mother and the fetus. Pulmonary embolism is one of the rare etiologies of this entity. We herein reported the successful management of acute embolism pulmonary associated with cesarean delivery on a healthy pregnant woman at our tertiary referral hospital.Case presentationA full-term pregnant woman hospitalized for planned cesarean delivery due to placenta previa without cardiorespiratory diseases. She was scheduled uneventfully for a planned cesarean section. After placental delivery, the patient spontaneously fell into cardiopulmonary collapse and her vital signs deteriorated rapidly. The obstetricians promptly completed the cesarean section and performed all procedures to prevent the PPH and preserve the uterus. At the same time, the anesthesiologists continued to carry out advanced heart-lung resuscitation in order to control her vital signs. After surgery, the multidisciplinary team assessed the patient and found a thrombus in her pulmonary circulation. Therefore, the patient was managed with therapeutic anticoagulation. The patient recovered in good clinical condition and was discharged after 2 weeks without any complications.ConclusionsThe diagnosis of acute pulmonary embolism is extremely difficult due to uncommon occurrence, sudden onset, and non-specific presentation. Awareness of this life-threatening pathology during cesarean delivery should be raised. Interdisciplinary assessment must be essentially established in this life-threatening condition. After the whole conventional management, uterine conservation may be acceptable where applicable. Further data is required to encourage this finding.