Diagnosis Of Acute Pulmonary Embolism Research Articles

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.

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 (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.

In-hospital outcomes of acute pulmonary embolism in patients with gastrointestinal cancer: A nationwide study.

624 Background: Cancer is a well-established risk factor for the development of pulmonary embolism (PE), especially the. gastrointestinal (GI) cancers. While multiple studies have reported the burden of PE in cancer patients, recent data comparing in-hospital outcomes among different types of cancer patients are lacking. This study aimed to investigate the clinical and healthcare utilization outcomes of hospitalized patients with acute PE in the context of gastrointestinal (GI) cancers. Methods: A cross-sectional study was conducted using data from the National Inpatient Sample (2016-2020). International Statistical Classification of Diseases (ICD-10) codes were employed to identify hospitalized patients admitted with primary diagnosis acute PE. Data regarding GI cancer diagnosis along with demographic information, baseline clinical characteristics, and outcome variables, including mortality, hospital length of stay, total hospital charges, complications and risk factors were collected and analyzed. Statistical analysis was performed using the survey procedures function in STATA v.17, with statistical significance defined by the t-test at a significance level of p &lt; 0.05. Results: Among the 181,060 patients admitted with primary diagnosis of acute pulmonary embolism, 550 (0.3%) had underlying gastric cancer, 1,790 (0.98%) had pancreatic cancer, 875 (0.48%) had hepatobiliary cancer, and 2,600 (1.61%) had small intestine and colorectal cancer. Mortality was found to be significantly higher in all types of GI cancer, with gastric cancer demonstrating the highest mortality rate (10%). After adjusting for age, sex, race, payment category, comorbidities, and risk factors of PE, gastric cancer (OR 2.6; 95% CI: 1.1-6.2) and pancreatic cancer (OR 2.2; 95% CI: 1.4-3.4) were found as independent risk factors for mortality. There was no significant difference in mean length of hospital stays and mean total hospital charges in patients with or without cancer. Similarly, no significant differences were observed in complications such as requirement for mechanical ventilation, arrhythmia, cardiac arrest, need for vasopressor and thrombolysis. Conclusions: In-hospital mortality in patients with acute pulmonary embolism is significantly higher in all types of GI cancer, however; there is no significant differences in hospital length of stay and total hospital charges in patients with or without cancer.

Trends in the utilization of computed tomography chest for acute pulmonary embolism in the emergency department and the yield in treatment

Background: Acute pulmonary embolism (PE) is a life-threatening condition with high mortality rates. Prompt and accurate diagnosis is crucial to prevent morbidity and mortality. Overutilizing computed tomography pulmonary angiography (CTPA) in low-risk patients can lead to unnecessary health-care costs and radiation exposure. Proper pretest probability assessment is recommended to guide the use of CTPA. Aim: This study aimed to evaluate the utilization of CTPA in the diagnosis of acute PE in the emergency department, with a focus on the application of pretest probability assessment (modified Wells score [MWS] and D-dimer). The primary objectives were to assess the extent of CTPA usage in low-risk patients, determine the effectiveness of D-dimer levels and the MWS in predicting PE, and identify areas for potential improvement in CTPA utilization to reduce unnecessary imaging and enhance patient care. In addition, the study aimed to evaluate the appropriateness of anticoagulant treatment in patients diagnosed with acute PE, particularly in cases of segmental/subsegmental PE. Settings and Design: A retrospective analysis was done on all suspected PE patients in the emergency room at our facility who underwent CTPA over 5 years. Patient demographic information, presenting complaints, physical examination findings, laboratory test results, and imaging findings were all included in the data collection. Materials and Methods: A retrospective review of 758 patient records at a tertiary hospital was conducted over 5 years. Data included demographics, presenting symptoms, test results, and imaging findings. D-dimer levels and the MWS were used for pretest probability evaluation. Anticoagulant treatment and appropriateness were also assessed. Statistical Analysis: Statistical analysis was carried out using RStudio (R version 4.3.0). Numerical variables were expressed as median (interquartile range), and frequencies and percentages were used to present categorical variables. A Fisher’s exact test was applied to assess the differences between patients who received anticoagulants and those who did not, as well as patients with PE statuses across D-dimer levels, Wells score categories, and receiving anticoagulants. A Kruskal–Wallis test explored the time to read reports between PE categories. P &lt;0.05 indicated statistical significance. Results: Among 758 patients, 18.8% had acute PE, with 6.2% being segmental/subsegmental PE. The majority of cases (79.8%) were negative for PE. A high rate of CTPA utilization was observed, especially in low-risk patients. Sixty-eight percent of low-risk patients had negative PE results. Among patients with acute PE, lobar PE (36.4%) and segmental/subsegmental PE (32.9%) were the most common locations. D-dimer and MWS were underutilized. Conclusions: By identifying low-risk patients who might not need CTPA, compliance with pretest probability evaluation using the MWS and D-dimer levels can help minimize unnecessary imaging and its associated risks. The results showed that efforts should be made to adhere to guidelines and recommendations, especially if the patients were categorized as low risk based on MWS or normal D-dimer levels. This will eventually improve patient outcomes and lower health-care costs.

Sex differences in the prognostic value of computed tomography pulmonary angiography parameters for intrahospital acute pulmonary embolism-related death

Background/Aim. Multidetector computed tomography pulmonary angiography (MCTPA) has emerged as the most suitable method for diagnosing acute pulmonary embolism (APE) in hemodynamically stable patients. In addition to its diagnostic role, MCTPA facil itates the measurement and calculation of certain parameters that can be used as prognostic markers for outcomes in APE. Since the introduction of the method, there have been a lot of studies that pointed out there may be a significant difference in the prognostic value of MCTPA for APE concerning sex. Methods. The study population consisted of consecutive patients with a diagnosis of APE confirmed by MCTPA. Positive MCTPA findings and a diagnosis of APE were established if the patient had at least one segmental artery thrombus. APE severity was estimated using the simplified Pulmonary Embolism Severity Index (sPESI). Allcause and APE-related intrahospital (Ih) deaths were the coprimary outcomes of this study. Results. In total, 1,612 patients were enrolled in the study (750 men and 862 women). Women with a centrally positioned pulmonary thrombus detected on MCTPA were more likely to die from PE-related death than those without one (10.4% vs. 4.2%, respectively; p = 0.016). Women with a right ventricle (RV) and left ventricle (LV) diameter ratio (RV/LV) &gt; 1 died almost twice as often as those with a ratio ? 1 (15.5% vs. 8.6%, respectively; p = 0.017). Women with an RV/LV &gt; 1 detected with MCTPA were significantly more likely to die from PE than those with a ratio ? 1 (11% vs. 5.2%, respectively; p = 0.017). Women who died from PE-related causes had a significantly higher value of the embolic burden score system (EBSS) than did the surviving women (18.00 vs. 11.00, respectively; p = 0.025). Independently of age, sPESI, and renal function, the presence of a central thrombus [odds ratio (OR) 2.278, 95% confidence interval (CI): 1.050-4.944, p = 0.037] and the RV/LV ratio &gt; 1 (OR 2.015, 95% CI: 1.042-3.893, p = 0.037) were associated with Ih PE-related death in women. Conclusion. In women, MCTPA parameters, a centrally placed thrombus, the RV/LV ratio, and the EBSS had prognostic significance for PE-related mortality. The RV/LV ratio had prognostic significance for all-cause Ih mortality. In men, the MCTPA parameters had no prognostic significance for both overall and PE-related mortality.

Outcomes of Septuagenarians and Octogenarians with Monoclonal Gammopathy of Undetermined Significance Admitted for Acute Pulmonary Embolism

Introduction: Monoclonal gammopathy of undetermined significance (MGUS) is clinically defined with a serum monoclonal immunoglobulin of less than 3 g/dL and the presence of less than 10% of plasma cells in the bone marrow, in the absence of any end-organ damage that is typically seen in patients with multiple myeloma. The incidence of MGUS mostly involves the elderly, with a median age estimated at 70 years. While some studies have linked MGUS with a hypercoagulable state, there are no large studies investigating the impact and outcomes of MGUS in the elderly with pulmonary embolism(PE). We thus propose a national analysis to investigate. Methods: Our retrospective study via the National Inpatient Sample (NIS) focused on adults admitted with a primary diagnosis of Acute Pulmonary Embolism. We excluded all cases of ages &amp;lt;70 years and &amp;gt;90 years. Patient characteristics in acute PE cases with and without MGUS such as age, sex, race, and presence of various comorbidities such as diabetes, hypertension, obesity, among many, were explored via Chi-Square tests, t-tests, and Mann-Whitney U tests as appropriate. Differences in outcomes for PE in MGUS and non-MGUS patients were estimated via logistic regression models on SPSS 29.0. A p-value of &amp;lt;0.05 was considered as statistically significant. To comply with the database provider's (HCUP) guidelines, we did not report values &amp;lt;11. Results: Among the 327090 septuagenarians and octogenarians admitted primarily for acute PE in our study, there were 1095 (0.3%) patients with a diagnosis for MGUS that also reported a higher mean Charlson Comorbidity Index (CCI) score (4.26 vs. 2.90, p&amp;lt;0.01) (Table 1). While 51.1% of MGUS cases with acute PE were males, the non-MGUS group mainly consisted of females (56.1%, p&amp;lt;0.01). Medicare covered 91.3% and 90.8% of all MGUS and non-MGUS cases in our study, and 68.9% and 66.3% of all admissions involved Urban-teaching centers, respectively. Around 11.0% of MGUS cases also had a history of prior pulmonary embolism, while it was 8.0% in the non-MGUS cohort (p&amp;lt;0.01). The MGUS cohort also showed a lower prevalence of hypertension (41.1% vs.46.7%, p&amp;lt;0.01) while having a higher prevalence of peripheral vascular disease (11.4% vs. 5.1%, p&amp;lt;0.01), smoking status (40.6% vs. 37.8%, p=0.049), lipid disorders (56.6% vs. 50.6%, p&amp;lt;0.01), and chronic kidney disease (35.6% vs. 20.0%, p&amp;lt;0.01) than the non-MGUS group. MGUS patients showed lower odds of experiencing in-patient events such as myocardial infarction (aOR 0.345, 95% CI 0.221-0.538, p&amp;lt;0.01), acute kidney injury (aOR 0.843, 95% CI 0.719-0.990, p=0.037), and respiratory compromise (aOR 0.749, 95% CI 0.652-0.860, p&amp;lt;0.01). While a higher odds of cardiogenic shock (aOR 1.903, 95% CI 1.316-2.753, p&amp;lt;0.01) was also noted, patients with and without MGUS had no differences related to in-hospital mortality (aOR0.721, 95% CI 0.513-1.013, p=0.060) or the need for IVC filters (aOR 1.156, 95% CI 0.924-1.446, p=0.206). MGUS patients also experienced a longer stay (mean length of stay 4.91 vs. 4.62 days, p&amp;lt;0.01). Conclusion: This nationwide data analysis suggests a higher prevalence of a history of previous PE in MGUS cases admitted for PE than those without MGUS. Furthermore, while odds of events involving in-patient myocardial infarction, acute kidney injury, or respiratory compromise in MGUS patients were lower, they had a higher risk of cardiogenic shock. It is thus vital for physicians to be on the watch-out of such complications and provide adequate testing and care in a timely manner to improve their prognosis and outcomes.

Utility of TAPSE/sPAP Ratio in Acute Pulmonary Embolism as Valuable Prognostic Marker as PESI Score

Introduction: The pulmonary embolism severity index (PESI) score is used to determine the risk of mortality and severity of complications in acute pulmonary embolism (APE). Tricuspid annular plane systolic excursion/systolic pulmonary arterial pressure (TAPSE/sPAP) ratio has been recently shown to predict poor 30-day clinical outcome in APE. We aimed to analyze the prognostic value of the TAPSE/sPAP ratio for prediction of 30-day adverse clinical outcomes in APE patients, similar to PESI score. Patients and Methods: This study enrolled 203 retrospectively evaluated patients (female 108, mean age= 57.4 ± 15.5 years) with the diagnosis of APE between 2010 and 2020. All patients underwent transthoracic echocardiography before specific APE treatment. Primary endpoints were 30-day mortality, thrombolytic therapy requirement, mechanical ventilation requirement, mental status deterioration, and persistent hypotension (systolic blood pressure &lt;90 mmHg). The study population was divided into two groups according to the TAPSE/sPAP ratio= 114 patients in group 1 with a low TAPSE/sPAP ratio (&lt;0.494) and 89 patients in group 2 with a high TAPSE/sPAP ratio (&gt;0.494). Results: The incidence of in-hospital mortality (4.4 vs. 0%, p= 0.045], 30-day mortality [n= 8 (7.0%); 0 (0%), p= 0.009] and primary adverse outcomes (35.1 vs. 0%, p&lt; 0.001) were higher in group 1. The TAPSE/sPAP ratio was negatively correlated with PESI (r= -0.716, p&lt; 0.001). In multivariate logistic regression analyses revealed that the TAPSE/sPAP ratio [OR= 0.001, 95C% CI= 0.000-0.476, p= 0.028] was an independent predictor of 30-day mortality in APE. Conclusion: The present study showed that the TAPSE/sPAP ratio may be used in clinical practice for the prediction of short-term adverse outcome risk estimation in APE patients, similar to PESI score.

Right ventricular global work efficiency provides the highest prediction for improvements in right ventricle to left ventricle diameter ratio with acute pulmonary embolism treatments

Abstract Introduction In addition to standard echocardiographic measures, global longitudinal strain (GLS) with speckle tracking (ST) and myocardial work (MW) evaluation have been used in the assessment of right ventricle (RV) function in patients with acute pulmonary embolism (PE). In this study we aimed to compare echocardiographic measures, ST and MW in prediction of change in right ventricle (RV) to left ventricle (LV) diameter ratio (r) with treatments. Methods Our study comprised 83 consecutive patients (female %54.6, age 59±14.9 years) who admitted to our hospital with diagnosis of acute PE and underwent evidence-based treatments. Echocardiographic evaluation including ST and MW were performed within first 24 hours of admission. NT-pro-brain natriuretic peptide (NT-proBNP), troponin, pulmonary embolism severity index (PESI) and Qanadli score, RV and LV global work index (GWI), global work efficiency (GWE), global constructive work (GCW) and global wasted work (GWW), and RV-GLS were evaluated. Primary end-point (PEP) of this study was the change in RV to LVr on computed tomography (CT), and generalized additive model (GAM) in addition to classical linear regression (LR) were utilized for prediction of change in RV/LVr with these measures. Results PESI score and RV/LVr at admission were 84.8±23.8 and 1.13±0.39, respectively. Unfractioned or low-molecular weight heparin were treatments of choice in patients. The change in RV/LVr after selected treatments were 0.356. Mean hospital stay and overall follow-up duration were 8.7±3.7 and 328.7±126.8 days, respectively. In-hospital and long-term mortality rates were 1.2% and 13.3% respectively. Correlation co-efficients for intra- and interobserver agreement of MW measures varied from 0.85 to 0.96. The LR revealed that pulmonary arterial systolic, diastolic and mean pressure estimates, fractional area change and RV annular tissue velocity were significantly related with changes in RV/LVr (p values; 0.02, 0.01, 0.004, 0.03 and 0.03, respectively). Moreover, RV-GWE compared with RV-GLS showed a higher prediction for improvements in the RV/LVr (p value were &amp;lt;0.001 and 0.049, respectively). Utilization of GAM increased R2 value (from 0.15 to 0.20), and decreased the complexity of model. RV-GWE showed a moderate correlation with RV-GLS (r=-0.56), RV-GWI (r = 0.42), RV-GCW (r=0.32), LV-GWW(r=-0.55), LV-GLS (r=-0.33), FAC (r=0.26), NT-proBNP (r=-0.38), troponin (r=-0.28) but not with other measures. Conclusions The RV GWE as a novel myocardial work parameter seems to provide a better prediction for improvements in the RV/LVr with acute PE treatments as compared to clinical, laboratory and other echocardiographic measures including GLS.Figure-1Figure-2

Abstract 14891: Time to Therapeutic Range for Patients With Acute Pulmonary Embolism Undergoing Mechanical Thrombectomy

Introduction: Anticoagulation therapy is the mainstay for the management of patients with acute pulmonary embolism (PE) and achieving a timely time to therapeutic range (TTR) is important. We sought to determine the TTR in patients with acute PE referred for mechanical thrombectomy (MT) and the proportion of patients with therapeutic activated clotting time (ACT) at the time of MT. Methods: This single center retrospective study included all patients who underwent percutaneous MT at a large academic public hospital from January 2020 through April 2023. Therapeutic anticoagulation was defined as an ACT &gt;200 seconds or if the patient received enoxaparin within 6 hours prior to MT. Results: A total of 63 patients (average age 58 years, 43% female) with intermediate or high-risk PE were included in the analysis. The median time from the diagnosis of PE or clot-in-transit (CIT) to MT was 15 (IQR 6.1-23.2) hours. Fifteen patients (23.8%) were initiated on enoxaparin at the diagnosis of acute PE or CIT. Among these patients, 5 (7.9%) were on enoxaparin only and 10 (15.9%) patients were initiated on enoxaparin and then transitioned to a heparin infusion prior to MT. One patient was initiated on argatroban, while the remaining 47 patients were initiated on a heparin infusion at time of diagnosis (77.6% received heparin bolus). In patients who received a heparin infusion, the median ACT in the cath lab was 134 (IQR 118-159) seconds. Only a total of 9/63 (14.3%) were therapeutic by ACT at the time of MT or received therapeutic enoxaparin within 6 hours of MT. Excluding patients who received enoxaparin initially, 34/48 (70.8%) patients reached a therapeutic anti-Xa or partial thromboplastin time (PTT) levels. The median time to reach a therapeutic anti-Xa or aPTT was 5.6 (IQR 3.3-8.2) hours (Figure). Conclusion: In patients with acute PE referred for MT, only a minority of patients had therapeutic ACT prior to mechanical thrombectomy.

Abstract 14494: National Trends in Emergency Department Discharges for Acute Pulmonary Embolism, 2006-2015

Introduction: Outpatient management for selected low-risk patients with acute pulmonary embolism (PE) has emerged as a safe and feasible approach that is currently supported by clinical practice guidelines. However, recent evidence suggests that many patients are still managed with hospital admission. Few studies have assessed recent real-world, national trends in discharge rates for acute PE from the emergency department (ED). Methods: We conducted an observational study leveraging data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between the years 2006-2020. NHAMCS is a nationally representative probability sample which reflects ED visits within the US. All patients with a primary diagnosis of acute PE were included. Subgroup analysis was performed on patients who were hemodynamically stable (heart rate&lt;110 and systolic blood pressure&gt;100) and those with a PESI risk class I or II. Results: Between 2006-2020, there were an estimated 2,519,606 ED visits for acute PE. Among the whole cohort, the mean age was 58.2 (SE: 1.53) and 59.1% were female. Overall, 22.1% of patients with acute PE were discharged from the ED, which increased from 7.8% between 2006-2008 to 32.1% between 2018-2020. A total of 67.9% of patients were hospitalized, which decreased from 83.7% between 2006-2008 to 61.9% between 2018-2020. When stratified by hemodynamic stability or low PESI risk class, similar trends were observed (Figure). Since 2012, 33.0% of patients with PESI class I or II were discharged and 57.8% were hospitalized. Conclusion: In a representative nationwide sample, rates of discharge from the ED for acute PE have increased over the past fifteen years with the largest increase occurring between 2009-2014. However, since 2012, only one-third of low-risk patients presenting to the ED were discharged for outpatient management and rates appear to have stabilized. We speculate that outpatient management for low-risk acute PE is still underutilized in the US.

Validation of the Pulmonary Embolism Severity Index Risk Classification and the 2019 European Society of Cardiology Risk Stratification in the Southeast Asian Population with Acute Pulmonary Embolism.

To date, no studies representing the Southeast Asian population have validated the Pulmonary Embolism Severity Index (PESI) and 2019 European Society of Cardiology (ESC) risk stratification. Therefore, this study aimed to validate the PESI score, simplified PESI (sPESI), PESI risk classification, and 2019 ESC risk stratification in Southeast Asian patients with acute pulmonary embolism (APE). The present study is a 10-year cross-sectional study. Here, risk regressions were conducted to identify the PESI risk classification, sPESI, and 2019 ESC risk stratification as predictors for 30-day all-cause and PE-related mortalities. Receiver operating characteristic (ROC) curves were constructed to determine the diagnostic ability of the PESI score, sPESI score, PESI risk classification, and 2019 ESC risk stratification to predict 30-day mortality. A total of 696 patients (male, 286; female, 410; mean age, 57.7±15.7 years) were included in this study from 2011 to 2020. The risk of 30-day all-cause mortality progressively increased with the 2019 ESC risk stratification, being approximately 6-fold higher in the high-risk than in the low-risk class [risk ratio: 6.24 (95% confidence interval (CI), 3.12, 12.47), P＜0.001]. The risk of 30-day all-cause mortality with the PESI risk classification also increased with the risk classes, being approximately 6-fold higher in class V than in class I [adjusted risk ratio: 5.91 (95% CI, 2.25, 15.51), P＜0.001]. The highest area under the receiver operating characteristic curve (AuROC) of the predictive model was the PESI score [AuROC=0.733 (95% CI, 0.685, 0.782)]. Our study represents a good validation of the PESI and 2019 ESC risk stratification to predict 30-day mortality after APE diagnosis in the Southeast Asian population.

The level of C-reactive protein in patients with acute pulmonary embolism

Background. Modern risk stratification in patients with pulmonary embolism (PE) does not consider all possible factors that may influence the course and prognosis of the disease. In view of this, it is promising to study inflammatory markers, especially C-reactive protein (CRP), for their prognostic value in PE. The purpose was to study the clinical and prognostic value of increased CRP levels in patients with PE during hospitalization. Material and methods. One hundred and three patients with diagnosis of acute PE confirmed by computed tomographic pulmonary angiography (CTPA) or by autopsy were examined, their СRP level was evaluated during hospitalization. In addition to a general clinical examination, all patients were screened for PE risk factors and risk of premature death according to the ESC 2019 guidelines. La-boratory tests included quantitative determination of CPK-MB, D-dimer and СRP in addition to basic ones. Electrocardiography, echocardiography, and CTPA were performed as part of the instrumental studies. Results. Depending on the СRP median (26 mg/l), patients were divided into two groups. Group 1 (СRP &lt; 26 mg/l) included 52 people, group 2 (СRP &gt; 26 mg/l) — 51 patients. It was found that in group 1, patients with low risk predominated (p = 0.044) and the average pulmonary embolism severity index was significantly lower (p = 0.011). In group 2, the average blood oxygen saturation (SpO2) during hospitalization was significantly lower (p = 0.004), the average parameters of the left ventricle, namely end-diastolic and end-systolic volume, were significantly greater (p = 0.045 and p = 0.043, respectively), and the ejection fraction was significantly lower (p = 0.002). Also, the average levels of leukocytes (p = 0.0003), neutrophils (p = 0.00001), urea (p = 0.008), CPK-MB (p = 0.028) and erythrocyte sedimentation rate (p = 0.012) were significantly higher in group 2. Correlation analysis revealed a reliable inverse connection between CRP levels and initial SpO2 and a direct relationship between CRP level and the size of the right atrium, CPK-MB level, and increased risk of early mortality from PE. Conclusions. Elevated CRP was found in 92 % of patients with acute PE and was associated with a significant decrease in SpO2 (p &lt; 0.004), increased left ventricular size (p &lt; 0.05), and decreased ejection fraction (p &lt; 0.003). Correlation analysis revealed a relationship between CRP level and the risk according to the pulmonary embolism severity index, SpO2, the level of CPK-MB and the size of the left atrium.