Incidence Of Recurrent Pulmonary Embolism Research Articles

The incidence of acute pulmonary embolism following syncope in anticoagulant-naïve patients: A retrospective cohort study.

BackgroundA recently published, large prospective study showed unexpectedly high prevalence of acute pulmonary embolism (APE) among patients hospitalized for syncope. In such a case, a high incidence of recurrent pulmonary embolism is expected among patients who were discharged without APE workup.ObjectivesTo determine the incidence of symptomatic APE among patients hospitalized for a first episode of syncope and discharged without APE workup or anticoagulation.MethodsThis retrospective cohort study included patients hospitalized at Rambam Health Care Campus between January 2006 and February 2017 with a primary admission diagnosis of syncope, who were not investigated for APE and were not taking anticoagulants. The patients were followed up for up to three years after discharge. The occurrence of venous thromboembolism (VTE) during the follow-up period was documented.ResultsThe median follow-up duration was 33 months. 1,126 subjects completed a three-year follow-up. During this period, 38 patients (3.38%) developed VTE, 17 (1.51%) of them had APE. The cumulative incidence of VTE and APE was 1.9% (95% CI 1.3%-2.5%) and 0.9% (95% CI 0.4%-1.3%) respectively. Only seven subjects developed APE during the first year of follow-up. The median times from the event of syncope to the development of APE and VTE were 18 and 19 months respectively.ConclusionsThe cumulative incidence of VTE during a three-year follow-up period after an episode of syncope is low. In the absence of clinical suspicion, a routine diagnostic workup for APE in patients with syncope cannot be recommended.

Ultrasound-Assisted Catheter-Directed Thrombolysis in High-Risk and Intermediate-High-Risk Pulmonary Embolism: A Meta-Analysis.

Catheter-directed Ultrasound-Assisted Thrombolysis (USAT) is a novel technology providing a high efficacy with a reduced bleeding risk in patients with pulmonary embolism (PE). We performed a meta-analysis based on presented or published PE series in which USAT was utilized. We searched the MEDLINE, EMBASE and the Cochrane Library for trials published up to December 2015. The primary outcomes were mean pulmonary artery pressure (PAMP), right to left ventricle diameter ratio (RV/LV ratio) and computed tomography (CT) obstruction score. The secondary outcomes were all-cause and cardiovascular mortality, major and minor bleeding episodes and recurrent PE. The 11 trials (n=553) and 15 trials (n=655) met eligibility criteria of primary and secondary outcomes, respectively. USAT was found to significantly reduce PAMP, RV/LV ratio and CT obstruction scores. After adjusting for baseline covariates in meta-regression analysis, male sex and number of high-risk patients were found to be associated with PAMP and RV/LV ratio while only male sex was associated with CT obstruction scores. The pooled incidence of all-cause and cardiovascular mortality were 3.2% and 2.2%, and the incidence of major and minor bleeding episodes were 5.5% and 6.9%, respectively. In the pooled analysis of the remaining trials, the incidence of recurrent PE was 1.7%. USAT compared with three randomized thrombolytic trials showed a similar death rate with a lower rate of major bleeding. This meta-analysis confirmed that USAT significantly reduced PAMP, RV/LV ratio and CT obstruction scores with similar death rates and a lower risk of major bleeding compared with patients with PE undergoing systemic thrombolytic treatment.

The Efficacy and Safety of Rivaroxaban and Dalteparin in the Treatment of Cancer Associated Venous Thrombosis.

Venous thromboembolism (VTE) is a complication of malignancy that is associated with significant mortality. The CLOT trial showed superiority of dalteparin in comparison to warfarin in preventing VTE recurrence. Rivaroxaban has been approved for treatment of deep venous thrombosis (DVT) and pulmonary embolism (PE). In the absence of large randomized trials in the oncology population, the efficacy and safety of rivaroxaban for the treatment of VTE in cancer patients needs to be assessed. A single-center retrospective chart review was conducted to assess the efficacy and safety of rivaroxaban compared with dalteparin in cancer-associated thrombosis. Out of 671 patients identified, 286 patients (107 in the rivaroxaban group and 179 in the dalteparin group) were eligible for analysis. The rivaroxaban group had a rate of VTE recurrence at 6months of 4.9 versus 11.1% with dalteparin (p=0.252). The incidence of recurrent DVT at 6months was lower in patients treated with rivaroxaban (0%) compared with dalteparin (8.2%) at 6months (p=0.025). Incidence of recurrent PE in the rivaroxaban group (5%) versus dalteparin group (3.1%) at 6months was not statistically significant (p=0.675). No significant difference was identified between the rivaroxaban group and dalteparin group in the rate of major bleeding (2.8 vs. 1.1%, respectively). Rivaroxaban was comparable to dalteparin in prevention of VTE recurrence while having no significant differences with major or minor bleeding.

The short-term efficacy of vena cava filters for the prevention of pulmonary embolism in patients with venous thromboembolism receiving anticoagulation: Meta-analysis of randomized controlled trials.

Objectives To perform a meta-analysis of randomized controlled trials assessing the effectiveness of inferior vena cava filters in patients with deep vein thrombosis for preventing pulmonary embolism. Method Relevant randomized controlled trials of inferior vena cava filters for the prevention of pulmonary embolism were identified by searching electronic databases updated in February 2016. Relative risks of recurrent pulmonary embolism, recurrent deep vein thrombosis, and mortality at three months were analyzed. Results Three published randomized controlled trials were included involving a total of 863 deep vein thrombosis patients. No significant differences were detected with inferior vena cava filters placement with regard to the incidence of recurrent pulmonary embolism or fatal pulmonary embolism. There were also no significant differences in the incidence of recurrent deep vein thrombosis or mortality with inferior vena cava filters placement at three months. Conclusions Inferior vena cava filter in addition to anticoagulation was not associated with a reduction in the incidence of recurrent pulmonary embolism as compared with anticoagulation alone in patients with deep vein thrombosis in the short term.

Thrombolysis for acute intermediate-risk pulmonary embolism: A meta-analysis

BackgroundThe use of thrombolytic therapy in patients with intermediate-risk pulmonary embolism is controversial. To compare with anticoagulation alone, no analysis before has determined whether thrombolytic therapy is associated with improved survival or lower incidence of adverse clinical outcomes for intermediate-risk pulmonary embolism. ObjectiveThis meta-analysis was performed to assess mortality benefits, bleeding and recurrent pulmonary embolism risks associated with thrombolytic therapy compared with anticoagulation in patients with intermediate-risk pulmonary embolism. MethodsThe Web of Science, PubMed, Embase, EBSCO, and the Cochrane Library databases were searched for randomized clinical trials comparing thrombolytic therapy with anticoagulation in intermediate-risk pulmonary embolism patients (in which the mortality data were reported) from inception to August 5, 2014. Primary outcomes were all-cause mortality and major bleeding. Secondary outcomes were recurrent pulmonary embolism and minor bleeding. The pooled relative risk (RR), Mantel–Haenszel corresponding method and fixed-effect model were used to estimate the efficacy and safety of thrombolytic therapy with 95% confidence intervals. ResultsEight clinical randomized controlled trials involving 1755 patients with intermediate-risk pulmonary embolism were included. Patients treated with thrombolytics presented lower mortality than patients in the anticoagulation cohort (RR, 0.52; 95% CI, 0.28–0.97; 1.39% [12/866] vs. 2.92% [26/889]). Compared with anticoagulation, thrombolytic therapy was associated with a higher risk of major (RR, 3.35; 95% CI, 2.03–5.54; 7.80% [64/820] vs. 2.28% [19/834]) and minor (RR, 3.66; 95% CI, 2.77–4.84; 32.78% [197/601] vs. 8.94% [53/593]) bleeding. Furthermore, thrombolytic therapy was associated with a lower incidence of recurrent pulmonary embolism (RR, 0.33; 95% CI, 0.15–0.73; 0.73% [6/826] vs. 2.72% [23/846]). ConclusionCompared with anticoagulation, thrombolytic therapy in patients with intermediate-risk pulmonary embolism is associated with lower all-cause mortality and recurrent pulmonary embolism risk despite increased major and minor bleeding risks.

Statin Treatment Reduces the Incidence of Recurrent Pulmonary Embolism: a Population Based Case-Control Study

AbstractAbstract 808 Background:Recurrence of pulmonary embolism (PE) has a high incidence of 5–10% and is associated with increased mortality. Long-term anticoagulant treatment is however associated with an increased bleeding risk. It is therefore essential to investigate other treatment strategies to reduce the long-term recurrence of PE. Statins seem to reduce a first episode of thrombosis, but whether they also have an effect on recurrent pulmonary embolism (PE) is unknown. Methods:A case-control study was conducted using data from the PHARMO Record Linkage System, a Dutch population-based registry of pharmacy records linked with hospital discharge records. Cases were patients hospitalized with a primary diagnosis of PE between 1998 and 2006. Four controls without a history of PE were matched to each case for age, gender and geographic region. Results:The study population consisted of 4.495 PE cases and 16.802 controls. The median age of the study population was 60 years (range 18–96) and 57% was female. Overall, 9% of both cases and controls used statins (odds ratio (OR) 0.95; 95% confidence interval (CI) 0.84–1.07); only rosuvastatin use reduced PE (OR 0.47; 95% CI 0.24–0.92). During a median follow-up period of 4.1 years (range 2.2–6.6), 396 (11%) patients had a recurrent PE. Statin treatment strongly reduced the incidence of recurrent PE (HR 0.57; 95% CI 0.42–0.79), which persisted after adjustment for vitamin K antagonists, duration of statin use, type of VTE or cardiovascular history. Conclusions:Statin treatment seems to be highly effective in the reduction of recurrent pulmonary embolism. Considering the low rate of side effects, statins may be an interesting option for long-term secondary prevention in patients with PE. Disclosures:No relevant conflicts of interest to declare.

Massive pulmonary embolism

Conclusion: Mortality of pulmonary embolism in patients with massive pulmonary embolism (PE) is not reduced by thrombolysis or embolectomy. There does appear to be reduced mortality in patients with massive PE who have placement of inferior vena cava filters. Summary: The International Cooperative Pulmonary Embolism Registry (ICOPER) enrolled 2454 consecutive patients with acute PE from January 1995 through November 1996. Fifty-two institutions in 7 countries were represented. There were 2392 patients with acute PE and known systolic blood pressure at presentation. Massive PE was defined as a systolic arterial pressure <90 mm Hg at presentation. Massive PE was present in 108 patients (4.5%), and 2284 patients (95.5%) had nonmassive PE. Sixteen patients with massive PE and 29 patients with nonmassive PE had the diagnosis of PE at autopsy (P < .01). For patients with massive PE, the 90-day mortality rate was 52.4% (95% confidence interval [CI], 43.3% to 62.1%). For patients with nonmassive PE, the 90-day mortality rate was 14.7% (95% CI, 13.3% to 16.2%). Within 90 days, recurrent PE occurred in 12.6% of patients with massive PE and in 7.6% with nonmassive PE (P < .001). In patients with massive PE, thrombolysis was performed in 33 patients, catheter embolectomy in one, and surgical embolectomy in three, for an overall active intervention rate for massive PE of 32%. These treatments were withheld in 68% (n = 73). The 90-day mortality rate was not reduced with thrombolytic therapy: thrombolysis, 46.6% (95% CI, 31.1 to 64.8%) vs no thrombolysis, 55.1% (95% CI, 44.3% to 66.7%; hazard ratio 0.79; 95% CI, 0.44 to 1.43). The incidence of recurrent PE at 90 days was 12% in patients with and without thrombolytic therapy (P = 0.99). Eleven patients received an inferior vena cava filter. None of these patients had recurrent PE within 90 days, and 10 (90.9%) survived at least 90 days. Inferior vena cava filters were associated with a decreased 90-day mortality (hazard ratio, 0.12; 95% CI, 0.02 to 0.85). Comment: It is probably wrong to conclude from these data that thrombolytic therapy cannot reduce mortality in patients with massive pulmonary embolism syndrome. ICOPER is a registry. Patients receiving thrombolytic therapy may have been the worst among the worst. The apparent significant reduction in mortality associated with inferior vena cava filters deserves further investigation, but it may also reflect those patients who are actually well enough to receive a filter. Clearly, improved and more standardized treatment of massive PE syndrome is needed.

Extended evaluation of the titanium Greenfield vena caval filter

Purpose: The purpose of this study was to evaluate the long-term safety and efficacy of the titanium Greenfield filter—modified hook for prevention of pulmonary embolism.Methods: We conducted a prospective study in 173 patients from four institutions who underwent clinical examination, abdominal radiography, and duplex ultrasound examinations of the vena cava and lower extremities. If indicated by protocol or clinical presentation, computed tomography scans, pulmonary angiograms, or venacavograms were obtained.Results: The most common procedural event was filter limb asymmetry (10%), which had no clinical significance. A variety of other minor procedural events occurred in another 10% of cases. Early follow-up (< 6 months) was completed in 149 patients, and long-term evaluation was completed in 113 (> 12 months). Deaths in 24 patients were from nonembolic causes in all but one. There were four suspected or confirmed recurrent pulmonary emboli, for an incidence of 3.5% (four of 113), with one death (0.9%). Four patients had inferior vena cava occlusion at early follow-up and at long-term evaluation, only one remained occluded (1%). Insertion site venous thrombosis was seen in only two patients (2%).Conclusion: The titanium Greenfield filter provides protection comparable to the standard stainless steel Greenfield filter after 1 year with a low incidence of recurrent pulmonary embolism (3.5%) and a high caval patency rate (99%).

Recurrent Pulmonary Embolism from Thrombi in Greenfield Filter—Case Report

Vena cava interruption using the Greenfield filter has proved to be a safe and effective method. In a series of 156 patients receiving the filter, published by Greenfield, the patency rate was 98%, and there was no mortality secondary to the filter placement. The incidence of recurrent pulmonary embolism resulting from the proximal propagation of a thrombus has been reported to be 5%. The present work reports on a case of recurrent pulmonary embolism resulting from the proximal propagation of a thrombus originating in a Greenfield filter.

Pulmonary embolism

The natural history diagnosis and immediate treatment of patients suffering from pulmonary embolism has been discussed. Anaesthetists should use their influence to bring about a high standard of prophylactic care against deep venous thrombosis and consequently of pulmonary embolism. They are likely to be involved in the resuscitation and treatment in intensive care units of those cases who suffer from major symptoms and massive emboli and some of them will rarely be involved in anaesthetising for pulmonary embolectomy aided by cardiopulmonary by-pass and, less rarely, for IVC ligation or plication and venous disobliteration. Anticoagulant drugs appear to limit the mortality of pulmonary embolism to 5%. The mortality of IVC ligation or plication varies in different reports from 2 to 50%; it should therefore be reserved for the special indications which have been discussed. There is also an incidence of recurrent pulmonary embolism after IVC ligation and plication and leg troubles from stasis in about 30% of cases. Streptokinase is usually indicated in the immediate treatment of major pulmonary emboli which cause shock and severe distress with an immediate threat to life. In hospitals having access to cardiopulmonary by-pass, pulmonary embolectomy has a small role to play in major emboli with cardiovascular collapse, if surgery can start within 2 hours and pulmonary angiography is available. Cardiopulmonary by-pass on its own may be life-saving in supporting the circulation while the clot fragments. If cardiac arrest occurs, external cardiac massage should be undertaken as it is sometimes successful and disseminates and fragments the clot in the pulmonary artery.

CHAPTER XI: Morbidity and Mortality

A comparison of morbidity and mortality following urokinase and heparin infusions showed few differences between the two treatment groups, other than an increased incidence of bleeding at cutdown sites during urokinase infusion. The incidence of recurrent pulmonary embolism among patients in both treatment groups was greater if they received inadequate anticoagulant therapy.