High-risk Acute Pulmonary Embolism Research Articles

Treatment of acute high-risk pulmonary embolism

At present, high-risk pulmonary embolism represents a cardiovascular emergency burdened with high in-hospital mortality and characterized by acute right ventricular dysfunction and hemodynamic impairment. In addition to circulatory support and anticoagulation, thrombolytic therapy has become the cornerstone of the treatment in patients presenting with this condition. Despite the recommendations, a consistent proportion of patients does not currently receive thrombolytic therapy. Although performed in a limited number of patients, transcatheter and surgical embolectomy procedures are an alternative or synergistic therapeutic strategy to thrombolysis, enabling a prompt resolution of right ventricular volume overload. In this review, data from the literature are discussed with the aim of defining an algorithm for the treatment of high-risk patients.

Catheter directed lysis and thrombectomy of submassive pulmonary embolism

Acute pulmonary embolism (PE) is a common and potentially highly morbid disease. However, there are a broad range of clinical presentations, varying from asymptomatic to life-threatening hemodynamic compromise. Accordingly, the aggressiveness of treatment for acute PE must be adjusted to the acuity of the presentation and patient-specific comorbidities. Thrombolysis is FDA approved for massive PE with hemodynamic compromise. However, this therapy has associated risk, most notably intracranial hemorrhage and other bleeding complications. This has prompted interest in catheter-directed therapies to mechanically remove thrombus and to locally deliver reduced doses of thrombolytics. Guidelines support use of this catheter-based strategy in cases of increased bleeding risk or high acuity with insufficient time for systemic pharmacologic therapy to be effective. We present the case of an 83-year-old man with acute high-risk PE and worsening hemodynamic and respiratory status who was treated with catheter-directed thrombolysis and rheolytic thrombectomy. There was significant improvement in thrombus burden, symptoms, and hemodynamic parameters including right ventricular function and pulmonary artery pressures. However, his course was complicated by intracranial hemorrhage and access site hematoma, demonstrating that even reduced doses and local delivery of thrombolytics do not ensure freedom from bleeding complications.

Therapy for acute high-risk pulmonary embolism: thrombolytic therapy and embolectomy

Acute pulmonary embolism remains associated with high morbidity and mortality rates despite currently available therapeutic options. This review outlines the most recent changes in this field and summarizes the main indications for thrombolytic therapy and surgical or catheter-based embolectomy in patients with high-risk pulmonary embolism. There have been no major advances in therapy for high-risk pulmonary embolism over the past few years. The main change concerns risk stratification, which now classifies patients as high risk versus intermediate or low risk, replacing the former terminology of acute massive, submassive or nonmassive pulmonary embolism. Risk stratification is now oriented toward evaluation of the risk of early pulmonary embolism-related death. Thrombolysis is the mainstay of therapy in high-risk pulmonary embolism. Surgical embolectomy has become more frequent, due to the reduction in mortality risk associated with this technique. However, it remains limited to patients unsuitable for thrombolysis. Catheter-based embolectomy is reserved for situations in which neither thrombolysis nor surgical embolectomy is possible. Thrombolytic treatment should be first-line therapy in patients with high-risk pulmonary embolism presenting with cardiogenic shock and/or persistent arterial hypotension, with very few absolute contraindications. Both surgical and catheter pulmonary embolectomy are valuable therapeutic options in patients in whom thrombolysis is absolutely contraindicated or has failed.

Assessment of renal dysfunction improves troponin-based short-term prognosis in patients with acute symptomatic pulmonary embolism.

Current risk stratification in acute pulmonary embolism (APE) includes assessment of clinical status, right ventricular overload and plasma troponin concentrations. As impaired renal function is one of the important predictors of mortality in cardiovascular diseases, we hypothesized that it is an independent early mortality marker in APE. In prospective cohort study, we observed 220 consecutive patients (86M/134F, 64 +/- 18 years) with APE proven by spiral computed tomography (CT). On admission, echocardiography was performed and blood samples were collected for troponin and creatinine assays. The calculated glomerular filtration rate (GFR) differed significantly between 81 pts with low-, 131 pts with moderate- and 8 pts with high-risk APE [71 (19-181) vs. 55 (9-153) vs. 41 (14-68) mL min(-1); respectively P < 0.0001]. Twenty-three patients died during the 30-day observation. Importantly, GFR was lower in non-survivors than in survivors [35 (9-92) vs. 63 (14-181) mL min(-1), P < 0.0001]. The area under the curve (AUC) of the GFR receiver-operating characteristic (ROC) curve for predicting mortality was 0.760 (95% CI: 0.698-0.815). In multivariable analysis, independent mortality predictors were GFR, troponin, heart rate and history of chronic heart failure. In normotensive patients, the GFR and cardiac troponins (cTn) ROC curves for prediction of mortality showed no difference (AUC 0.789 and 0.781, respectively). However, Kaplan-Meier analysis showed an additive prognostic value of renal dysfunction. Thus, troponin-positive patients with a GFR < or = 35 mL mn(-1) showed 48% 30-day mortality, whereas troponin-positive patients with a GFR > 35 mL mn(-1) had 11% mortality, and troponin-negative patients with a GFR > 35 mL mn(-1) had good prognosis, P < 0.0001. Impaired kidney function, present in 47% of APE patients, is related to all-cause mortality. In initially normotensive patients, a GFR < 35 mL min(-1) predicts 30-day mortality. Moreover, GFR assessment can improve troponin-based risk stratification of APE.

Mean platelet volume predicts early death in acute pulmonary embolism

BackgroundRecently, mean platelet volume (MPV) was reported to predict venous thromboembolism. Moreover, MPV correlates with platelet reactivity and indicates poor outcome in acute coronary syndromes.ObjectiveTo examine the hypothesis that in...