Intermediate Pulmonary Embolism Research Articles

In-hospital and readmission outcomes of patients with cancer admitted for pulmonary embolism treated with or without catheter-based therapy

BackgroundCancer patients are at risk of pulmonary embolism (PE). Catheter-based therapies (CBT) are novel reperfusion options for PE though data in patients with cancer is lacking. Study design and methodsPatients with intermediate- or high-risk PE were identified using the National Readmission Database (NRD) from 2017 to 2020. Primary outcome were in-hospital death and 90-day readmission. Secondary outcomes were in-hospital bleeding, 90-day readmission for venous thromboembolism (VTE)-related or right heart failure-related reasons and bleeding. Propensity scores were estimated using logistic regression and inverse-probability treatment weighting (IPTW) was utilized to compare outcomes between CBT and no CBT as well as CBT versus systemic thrombolysis. ResultsA total of 7785 patients were included (2511 with high-risk PE) of whom 1045 (13.4%) were managed with CBT. After IPTW, CBT was associated with lower rates of index hospitalization death (OR 0.89, 95% CI 0.83–0.96) and 90-day readmission (HR 0.75, 95% CI 0.69–0.81) but higher rates of in-hospital bleeding (OR 1.11, 95% CI 1.03–1.20) which was predominantly post-procedural bleeding. CBT was associated with lower risk of major bleeding (20.8% vs 24.8%; OR 0.80, 95% CI 0.68–0.94) compared with systemic thrombolysis. InterpretationAmong patients with cancer with intermediate or high-risk PE, CBT was associated with lower in-hospital death and 90-day readmission. CBT was also associated with decreased risk of index hospitalization major bleeding compared with systemic thrombolysis. Prospective, randomized trials with inclusion of patients with cancer are needed to confirm these findings.

Evidence-Based Update on Transcatheter Therapies for Pulmonary Embolism.

Pulmonary embolism (PE) remains a leading cause of cardiovascular morbidity and mortality. Multiple new therapies are in development and under study to improve our contemporary care of patients with PE. We review and compare here these novel therapeutics and technologies. Multiple novel therapeutic devices have been developed and are under active study. This work has advanced the care of patients with intermediate and high-risk PE. Novel therapies are improving care of complex PE patients. These have inspired large multicenter international randomized controlled trials that are actively recruiting patients to advance the care of PE. These studies will work towards advancing guidelines for clinical care of patients with PE.

Reduced mortality associated with pulmonary embolism response team consultation for intermediate and high-risk pulmonary embolism: a retrospective cohort study

BackgroundThe management of acute pulmonary embolism (PE) has become increasingly complex with the expansion of advanced therapeutic options, resulting in the development and widespread adoption of multidisciplinary Pulmonary Embolism Response Teams (PERTs). Much of the literature evaluating the impact of PERTs has been limited by pre- postimplementation study design, leading to confounding by changes in global practice patterns over time, and has yielded mixed results. To address this ambiguity, we conducted a retrospective cohort study to evaluate the impact of the distinct exposures of PERT availability and direct PERT consultation.MethodsAt a single tertiary center, we conducted propensity-matched analyses of hospitalized patients with intermediate or high-risk PE. To assess the impact of PERT availability, we evaluated the changes in 30-day mortality, hospital length of stay (HLOS), time to therapeutic anticoagulation (TAC), in-hospital bleeding complications, and use of advanced therapies between the two years preceding and following PERT implementation. To evaluate the impact of direct PERT consultation, we conducted the same analyses in the post-PERT era, comparing patients who did and did not receive PERT consultation.ResultsSix hundred eighty four patients were included, of which 315 were pre-PERT patients. Of the 367 postPERT patients, 201 received PERT consultation. For patients who received PERT consultation, we observed a significant reduction in 30-day mortality (5% vs 20%, OR 0.38, p = 0.0024), HLOS.(-5.4 days, p < 0.001), TAC (-0.25 h, p = 0.041), and in-hospital bleeding (OR 0.28, p = 0.011).These differences were not observed evaluating the impact of PERT presence in pre-vs postimplementation eras.ConclusionsWe observed a significant reduction in 30-day mortality, hospital LOS, TAC, and in-hospital bleeding complications for patients who received PERT consultation without an observed difference in these metrics when comparing the pre- vs post-implementation eras. This suggests the benefits stem from direct PERT involvement rather than the mere existence of PERT. Our data supports that PERT consultation may provide benefit to patients with acute intermediate or high-risk PE and can be achieved without a concomitant increase in advanced therapies.

Outcomes of Catheter-Based Therapy for Cancer-Associated Intermediate or High-Risk Pulmonary Embolism

Background: Pulmonary embolism (PE) is a well-known complication of cancer and is associated with significant morbidity and mortality. The standard of care for the treatment of PE is anticoagulation and systemic thrombolysis for high-risk PE. However, both carry risk of bleeding, and patients with cancer are particularly at higher risk of both bleeding and thrombotic complications. The development of catheter-based therapies (CBT) has provided an alternative reperfusion therapy for patients with high-risk and select intermediate risk PE patients. However, despite the increased prevalence of PE, patients with cancer are often excluded from clinical trials of invasive medical devices, including CBT for PE. Therefore, we investigated outcomes of patients with cancer hospitalized for intermediate or high-risk PE treated with or without CBT. Methods: This was a retrospective cohort analysis of the National Readmission Database (NRD) of adult patients with a primary diagnosis of intermediate or high-risk PE from 2017 and 2018 with a history of cancer, which was identified using ICD-10 codes. High-risk PE was defined as PE with hemodynamic instability (either cardiac arrest, cardiogenic shock, or vasopressor use). Intermediate-risk PE was defined as PE with signs of right ventricular strain (type 2 myocardial infarction or cor pulmonale) without hemodynamic instability. Primary outcome was in-hospital mortality. Secondary outcomes were in-hospital major bleeding (composite of gastrointestinal, intracranial, and post-procedural bleeding), and 90-day any-cause, VTE-related, and bleeding-related readmissions. Propensity scores (PS) for estimating probability of CBT were calculated using non-parsimonious multivariable logistic regression that included all baseline patient characteristics examined. Inverse-probability treatment weighting (IPTW) was utilized to adjust for potential confounders. Patients treated with CBT were compared to those without and standardized mean difference (SMD) was calculated for variables before and after IPTW. Imbalances between groups were significant if SMD for any given covariable was ≥ 0.10. Hazard ratios (HR) were estimated for 90-day readmission outcomes using Cox proportional hazards regression, and odds ratio (OR) were calculated for estimating in-hospital outcomes using logistic regression. Results: 3,333 patients were identified of which 388 (11.6%) were treated with CBT. Prior to IPTW, patients treated with CBT were younger (mean age 66.3 vs 67.6 years) and less likely to have metastatic cancer (43.3% vs 50.3%), Khorana high or intermediate risk cancer type (40.5% vs 49.4%) or high-risk PE (34.5% vs 46.3%), Table 1. After IPTW, baseline characteristics were well balanced between groups. After IPTW, CBT was associated with lower risk of in-hospital death (23.3% vs 28.3%, OR 0.77, 95% CI 0.69 - 0.86) but higher risk of in-hospital bleeding (16.4% vs 13.7%, OR 2.34, 95% CI 2.11 - 2.60) which was driven by post-procedure bleeding (12.5% vs 9.2%, OR 1.40, 95% CI 1.20 - 1.64). CBT was also associated with lower 90-day any-cause (HR 0.88, 95% CI 0.79 - 0.98) and VTE-related (HR 0.54, 95% CI 0.35 - 0.83) but not bleeding-related (HR 0.69, 95% CI 0.34 - 1.40) readmissions, Figure 1. Conclusions: Patients with cancer admitted with intermediate or high-risk PE have high rates of in-hospital death and bleeding. Treatment with CBT was associated with lower in-hospital death and 90-day any-cause and VTE-related readmissions at the cost of increased in-hospital bleeding driven by post-procedural bleeding. Prospective studies and trials of CBT in PE should include patients with cancer and further investigation is warranted to confirm our findings.

Catheter-based therapy for intermediate or high-risk pulmonary embolism is associated with lower in-hospital mortality in patients with cancer: Insights from the National Inpatient Sample.

Pulmonary embolism (PE)is a common complication among patients with cancer and is a significant contributor to morbidity and mortality. Catheter-based therapies (CBT),including catheter-directed thrombolysis (CDT)and mechanical thrombectomy, have been developed and are used in patients with intermediate or high-risk PE. However, there is a paucity of data on outcomes in patients with cancer as most clinical studies exclude this group of patients. To characterize outcomes of patients with cancer admitted with intermediate or high-risk PE treated with CBT compared with no CBT. Patients with an admission diagnosis of intermediate or high-risk PE and a history of cancer from October 2015 to December 2018 were identified using the National Inpatient Sample. Outcomes of interest were in-hospital death or cardiac arrest (CA)and major bleeding. Inverse probability treatment weighting (IPTW)was utilized to compare outcomes between patients treated with and without CBT. Variables that remained unbalanced after IPTW were adjusted using multivariable logistic regression. A total of 2084 unweighted admissions (10,420 weighted) for intermediate or high-risk PE and cancer were included, of which 136 (6.5%) were treated with CBT. After IPTW, CBT was associated with lower death or CA (aOR 0.54, 95% CI 0.46-0.64) but higher major bleeding (aOR1.41, 95% CI 1.21-1.65). After stratifying by PE risk type, patients treated with CBT had lower risk of death or CA in both intermediate (aOR0.52, 95% CI 0.36-0.75) and high-risk PE (aOR0.48, 95% CI 0.33-0.53). However, patients with CBT were associated with increased risk of major bleeding in intermediate-risk PE (aOR2.12, 95% CI 1.67-2.69) but not in those with high-risk PE (aOR0.84, 95% CI 0.66-1.07). Among patients with cancer hospitalized with intermediate or high-risk PE, treatment with CBT was associated with lower risk of in-hospital death or CA but higher risk of bleeding. Prospective studies and inclusion of patients with cancer in randomized trials are warranted to confirm our findings.

Abstract 14389: Mitigating Health Disparities by Improving Access to Advanced Multidisciplinary Care for Vulnerable Patients With Intermediate and High-Risk Pulmonary Embolism

Background: Vulnerable patients, including minorities and underserved populations whose care rely on public hospitals, have limited access to advanced pulmonary embolism (PE) treatment, particularly when catheter-based therapies (CBT) and escalation of care are needed. Our aim is to describe the multidisciplinary pulmonary embolism response team (PERT) program for the largest public health system in the country, as a strategy to mitigate healthcare disparities and improve access to care. Methods: We collected clinical, demographic and socioeconomic data from patients with intermediate-high and high-risk PE undergoing CBT at Bellevue Hospital, a PERT referral center and level 1 shock center for New York City’s Health and Hospitals’ network. Outcomes included in-hospital mortality and complications from CBT. Results: Sixty-one patients were included (42.6% women, age 57 ± 13.7 years) between October, 2022 to April 2023; 80.3% had intermediate-risk PE, 19.7%% had high-risk PE. The majority were black (57.4%), followed by Hispanic (13%). A total of 13% were uninsured, 9.8% were undocumented and 50.8% lived below the poverty level for New York City. The level of education was 8th grade or less in 4.9% of patients, high school in 29.5%, at least 2 years of college in 6.6%, &gt;4 years of college in 8.2%, master’s degree in 4.9% and unknown in 46%. Disease severity markers (CPES, PESI, BOVA, lactate, troponin and BNP) did not vary by ethnic group. There were no differences in mortality between white and non-white patients (figure); 3(4.9%) patients required rescue extracorporeal support and there were no procedural related complications. Conclusions: Our multidisciplinary PERT program demonstrates feasibility to provide care to underserved and vulnerable populations with excellent outcomes, serving as a strategy to help decrease healthcare disparities, particularly for advanced therapies for a challenging condition such as intermediate and high-risk PE.

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.

Paradoxical pulmonary artery systolic pressure response with catheter-directed therapies for pulmonary embolism

BackgroundEarly data on use of catheter-directed therapies (CDT) for treatment of Intermediate or High-Risk pulmonary embolism (PE) show improvement in pulmonary artery systolic pressures (PAsP) and RV/LV ratios. Occasionally a paradoxical rise in PAsP was observed with CDT utilizing ultrasound-assisted thrombolysis (USAT). It is unclear whether this pattern is seen with CDT utilizing mechanical aspiration. ObjectivesTo investigate and compare the changes in PAsP between those who underwent CDT with USAT to those with mechanical aspiration. MethodsA retrospective analysis of those diagnosed with Intermediate or High-Risk PE who underwent CDT using USAT or mechanical aspiration from 7/2013 to 3/2023. The primary outcome was comparison of PAsP changes between the two modalities. Secondary outcomes include length of stay, mortality, and bleeding complications. ResultsA total of 142 patients were analyzed, of which 93 underwent USAT and 49 underwent mechanical thrombectomy. The mechanical thrombectomy group had significantly lower post-intervention PAsP than the USAT group (42.2 ± 13.4 mmHg vs 54.5 ± 15.2 mmHg, p < 0.0001) and a greater adjusted mean reduction (−16.5 ± 2.7 vs. −7.7 ± 3.2 mmHg. p < 0.0001). A higher frequency of a paradoxical rise in PAsP was observed in the USAT group (22 % vs 4.1 %, p < 0.001). ConclusionsCDT utilizing mechanical thrombectomy was associated with lower post-interventional PAsP and greater mean negative change compared to USAT. Occasional paradoxical rises in PAsP were observed with both types of CDT, but they were more frequent with USAT. Hemodynamic monitoring should be considered after CDT. Condensed unstructured abstractWe report a retrospective comparison of changes to pulmonary artery systolic pressures (PAsPs) between catheter-directed ultrasound-assisted thrombolysis (USAT) and catheter-directed mechanical thrombectomy in Intermediate and High-Risk pulmonary embolism. Those treated with mechanical thrombectomy compared to USAT had significantly lower post-interventional PAsP (42.2 ± 13.4 mmHg vs 54.5 ± 15.2 mmHg, p < 0.0001) and a greater adjusted mean reduction (−16.2 ± 2.7 vs. −7.5 ± 3.2 mmHg, p < 0.0001). A paradoxical rise in PAsP was observed more frequently in the USAT group than the mechanical thrombectomy group (22 % vs 4.1 %, p < 0.001).

Pulmonary embolism in COVID-19 pneumonia patients admitted to temporary hospital - The follow-up study

PurposeCoronavirus disease 2019 (COVID-19) is linked with major coagulation disorders, especially higher risk of developing pulmonary embolism (PE). Our study summarizes COVID-19 patients’ management with concomitant PE during the first weeks of pandemic and underlines the importance of D-dimer concentration assessment at admission in terms of prognosis. Material and methodsStudy group consisted of 107 outpatients (mean age 68.91 ​± ​12.83 years) admitted to the Temporary COVID-19 Hospital in Bialystok, Poland with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and suspicion of PE based on elevated D-dimer concentration (>500 ​μg/l) and/or low saturation rate (<90%). The clinical follow-up lasted 6 months. Death or re-hospitalization were used as composite clinical endpoint (CEP). ResultsCumulative incidence of PE was 62.3% (73/107 patients). Most of the patients were in the intermediate PE risk group according to the pulmonary embolism severity index (PESI) score. The mean total computed tomography (CT) lung involvement of COVID-19 findings was 48.42 ​± ​27.71%. Neither D-dimers nor NT-proBNP concentrations correlated significantly with the percentage of lung abnormalities in CT. Patients with baseline D-dimer concentration higher than 1429 ​μg/l had worse prognosis in 6-months observation, log-rank test, p ​= ​0.009. ConclusionsOngoing SARS-CoV-2 infection along with massive involvement of lung tissue and concomitant thrombi in pulmonary arteries are challenging for physicians. It seems that simple D-dimer concentration assessment at admission may be a helpful tool not only to predict PE but also to estimate the long-term prognosis.

Right ventricular functional recovery assessment with stress echocardiography and cardiopulmonary exercise testing after pulmonary embolism: a pilot prospective multicentre study

BackgroundData on right ventricular (RV) exercise adaptation following acute intermediate and high-risk pulmonary embolism (PE) remain limited. This study aimed to evaluate the symptom burden, RV functional recovery during exercise...

Association between Hispanic or Latino ethnicity and pulmonary embolism severity, management, and in-hospital outcomes.

Hispanic and Latino patients are under-represented in existing healthcare disparities research in pulmonary embolism (PE). The goal of this study was to determine if differences in PE severity, treatment modality, or in-hospital outcomes exist for Hispanic or Latino patients with PE. All PE cases from 2013 to 2019 at a single institution were reviewed. Clinical characteristics, imaging findings, intervention types, and in-hospital and 30-day outcomes were collected. Two cohorts were created based on patients' self-reported ethnicity. Outcomes were compared using univariate and multivariate analysis. A total of 1265 patients were identified with confirmed PE; 474 (37%) identified as Hispanic or Latino. Hispanic or Latino patients presented with high-risk PE significantly less often (19% vs 25%, p = 0.03). On univariate analysis, Hispanic or Latino patients had lower rates of PE-specific intervention (15% vs 19%, p = 0.03) and similar rates of inpatient mortality (6.8% vs 7.5%, p = 0.64). On ordinal regression analysis, Hispanic or Latino ethnicity was associated with lower PE severity (OR 0.69, 95% CI 0.54-0.89, p = 0.003). In subgroup analyses of intermediate and high-risk PEs, ethnicity was not a significant predictor of receipt of PE-specific intervention or in-hospital mortality. At this institution, Hispanic or Latino patients were less likely to present with high-risk PE but had similar rates of inpatient mortality. Future research is needed to identify if disparities in in-hospital care are driving perceived differences in PE severity and what addressable systematic factors are driving higher-than-expected in-hospital mortality for Hispanic or Latino patients.

A Meta-analysis of Standard Versus Ultrasound-Assisted Catheter-Directed Thrombolysis in the Management of Acute Pulmonary Embolism

<h2>Abstract</h2><h3>Background</h3> Standard catheter-directed thrombolysis (SCDT) harnesses the therapeutic benefit of systemic thrombolytics while minimizing bleeding complications in patients presenting with pulmonary embolism (PE). Ultrasound-assisted catheter-directed thrombolysis (USAT) theoretically improves upon SCDT by disrupting fibrin and increasing the surface area exposed to thrombolytic agent. However, it is unclear if this translates into improved outcomes. <h3>Methods</h3> A systematic search of prior publications comparing SCDT and USAT in patients with intermediate or high-risk PE was conducted. Primary outcomes of interest were bleeding events, ICU and hospital length of stay. Secondary outcomes included changes in pulmonary artery systolic pressure (PASP), mean pulmonary artery pressure (mPAP), and right ventricle to left ventricle diameter (RV/LV) ratio. Studies that lacked comparison groups were excluded. Bias assessments were performed using the Cochrane tools for randomized and nonrandomized studies. Data was collated utilizing the Cochrane Review Manager software, and all analyses assumed random effects. <h3>Results</h3> Our search yielded 7 observational studies and 1 randomized control trial. The studies included a total of 543 patients who underwent either SCDT (n = 273) or USAT (n = 270) for intermediate or high-risk PE. The synthesized analysis showed no significant differences in bleeding between the groups. There were no differences in ICU or hospital lengths of stay, changes in PASP, or mPAP. Reductions in RV/LV ratio were greater with SCDT (mean difference, −0.16; 95% CI, −0.27 to −0.06; <i>P</i> = .003). <h3>Conclusions</h3> In comparison to SCDT, USAT did not result in improved clinical or hemodynamic outcomes in patients presenting with PE. Results were limited by heterogeneity among the included studies.

Impact of pulmonary embolism response teams on acute pulmonary embolism: a systematic review and meta-analysis.

The impact of pulmonary embolism response teams (PERTs) on treatment choice and outcomes of patients with acute pulmonary embolism (PE) is still uncertain. To determine the effect of PERTs in the management and outcomes of patients with PE. PubMed, Embase, Web of Science, CINAHL, WorldWideScience and MedRxiv were searched for original articles reporting PERT patient outcomes from 2009. Data were analysed using a random effects model. 16 studies comprising 3827 PERT patients and 3967 controls met inclusion criteria. The PERT group had more patients with intermediate and high-risk PE (66.2%) compared to the control group (48.5%). Meta-analysis demonstrated an increased risk of catheter-directed interventions, systemic thrombolysis and surgical embolectomy (odds ratio (OR) 2.10, 95% confidence interval (CI) 1.74-2.53; p<0.01), similar bleeding complications (OR 1.10, 95% CI 0.88-1.37) and decreased utilisation of inferior vena cava (IVC) filters (OR 0.71, 95% CI 0.58-0.88; p<0.01) in the PERT group. Furthermore, there was a nonsignificant trend towards decreased mortality (OR 0.87, 95% CI 0.71-1.07; p=0.19) with PERTs. The PERT group showed an increased use of advanced therapies and a decreased utilisation of IVC filters. This was not associated with increased bleeding. Despite comprising more severe PE patients, there was a trend towards lower mortality in the PERT group.

C-15 | Outcomes of Percutaneous Mechanical Thrombectomy in Patients with Pulmonary Embolism

The third leading cause of cardiovascular death worldwide is Pulmonary embolism (PE). The technological landscape for the management of acute intermediate and high-risk PE is rapidly evolving. Real-world data on the outcome of PE thrombectomy is unknown.

Diuretics Versus Volume Expansion in the Initial Management of Acute Intermediate High-Risk Pulmonary Embolism.

The very early management of pulmonary embolism (PE), a part from antithrombotic treatment, has been little studied. Our aim was to compare the effects of diuretic therapy (DT) versus volume expansion (VE) in patients hospitalized for PE with RV dysfunction. We conducted a randomized open-label multicentric study including patients with intermediate high-risk PE. Patients were randomized between diuretics or saline infusion. The primary endpoint was time to troponin (Tp) normalization. Secondary endpoints were time to normalization of B-type natriuretic peptide (BNP), changes in echocardiographic RV function parameters and treatment tolerance. Sixty patients presenting intermediate high-risk PE were randomized. Thirty received DT and 30 VE. We noted no changes in Tp kinetics between the two groups. In contrast, faster normalization of BNP was obtained in the DT group: 56 [28-120] vs 108 [48-144] h: p = 0.05, with a shorter time to 50%-decrease from peak value 36 [24-48] vs 54 [41-67] h, p = 0.003 and a higher rate of patients with a lower BNP concentration within the first 12h (42% vs 12% p < 0.001). RV echocardiographic parameters were unchanged between the groups. One dose 40mg furosemide was well-tolerated and not associated with any serious adverse events. In the acute management of intermediate high-risk PE, initial therapy including diuretic treatment is well-tolerated and safe. Although changes in Tp kinetics and echocardiographic RV dysfunction parameters did not differ, normalization of BNP is achieved more quickly in the DT group. This finding, which need to be confirmed in trials with clinical end points, may reflects a rapid improvement in RV function using one dose 40mg furosemide. Clinical Trial Registration NCT02531581.

Contemporary clinical management of acute pulmonary embolism: the COPE study

BackgroundNew management, risk stratification and treatment strategies have become available over the last years for patients with acute pulmonary embolism (PE), potentially leading to changes in clinical practice and improvement of patients’ outcome.MethodsThe COntemporary management of Pulmonary Embolism (COPE) is a prospective, non-interventional, multicentre study in patients with acute PE evaluated at internal medicine, cardiology and emergency departments in Italy. The aim of the COPE study is to assess contemporary management strategies in patients with acute, symptomatic, objectively confirmed PE concerning diagnosis, risk stratification, hospitalization and treatment and to assess rates and predictors of in-hospital and 30-day mortality. The composite of death (either overall or PE-related) or clinical deterioration at 30 days from the diagnosis of PE, major bleeding occurring in hospital and up to 30 days from the diagnosis of PE and adherence to guidelines of the European Society of Cardiology (ESC) are secondary study outcomes. Participation in controlled trials on the management of acute PE is the only exclusion criteria. Expecting a 10–15%, 3% and 0.5% incidence of death for patients with high, intermediate or low-risk PE, respectively, it is estimated that 400 patients with high, 2100 patients with intermediate and 2500 with low-risk PE should be included in the study. This will allow to have about 100 deaths in study patients and will empower assessment of independent predictors of death.ConclusionsCOPE will provide contemporary data on in-hospital and 30-day mortality of patients with documented PE as well as information on guidelines adherence and its impact on clinical outcomes.Trail registrationNCT number: NCT03631810.

Catheter-directed therapy in pulmonary embolism.

Acute pulmonary embolism (PE) is alife-threatening condition with high mortality rates and potential long-term sequelae. Systemic thrombolysis has been virtually the only therapeutic option available for patients with hemodynamic instability over decades. Recently, interventional therapy of PE has gained increasing interest. Multiple devices were developed; these include devices for local thrombolysis, thrombus fragmentation, thrombus aspiration, and combined approaches. However, the available evidence is limited to mostly small, nonrandomized studies. In these studies, safety and efficacy data from patients with intermediate or high-risk PE are promising. However, due to the lack of adequately powered randomized trials, interventional treatment of intermediate or high-risk PE cannot be recommended as standard-of-care. The decision on whether and how to perform acatheter-based intervention should therefore be left to the discretion of the local team, depending on the patients' clinical status, bleeding risk, local expertise, and available devices. The implementation of local multidisciplinary PE response teams is recommended by international guidelines to provide the best possible treatment.

Contemporary Catheter-Based Treatment Options for Management of Acute Pulmonary Embolism.

IntroductionAcute pulmonary embolism (PE) remains an important cause of cardiovascular mortality and morbidity in the USA and worldwide. Catheter-based therapies are emerging as a new armamentarium for improving outcomes in these patients.Purpose of reviewThe purpose of this review is to familiarize the clinicians with (1) various types of catheter-based modalities available for patients with acute PE, (2) advantages, disadvantages, and appropriate patient selection for the use of these devices, and (3) evidence base and the relevance of such therapies in the COVID-19 pandemic.Recent findingsThere are four main types of catheter-based therapies in acute PE: (1) standard catheter-directed thrombolysis (CDT), (2) ultrasound-assisted CDT, (3) pharmacomechanical CDT, and (4) mechanical thrombectomy without thrombolysis. Ultrasound-assisted thrombolysis is the most widely studied modality in this group; however, evidence base for other catheter-based technologies is rapidly emerging.SummaryCurrent use of catheter-based therapies is most suitable for patients with intermediate and high-risk acute PE. The adoption of a multidisciplinary approach like the pulmonary embolism response team (PERT) is desirable for appropriate patient selection and possibly/potentially improving patient outcomes. We discuss the current status of these therapies.

Contemporary in-hospital mortality of pulmonary embolism

Abstract Funding Acknowledgements Type of funding sources: None. Background Recent data on mortality of hospitalised patients with pulmonary embolism (PE) are scarce. Purpose To compare in-hospital mortality between a contemporary and a historical cohort of patients treated for PE. Methods We retrospectively analysed clinical and imaging data of 372 consecutive patients who were admitted to our department for PE between February 2010 and November 2020. Patients in whom PE presented as an out-of-hospital cardiac arrest without sustained return of spontaneous circulation (n = 12) were not included. In-hospital mortality was compared between patients admitted before and after January 2016 (n = 178 and n = 194, respectively). The patients were classified as low, intermediate and high clinical risk, according to the 2019 European Society of Cardiology guidelines. Results The diagnosis of PE was based on computed tomography angiography (85%), ventilation/perfusion lung scan (7%), echocardiography (7%), and autopsy (1%). The majority of patients presented with intermediate-risk (288 [77%]), followed by low-risk (46 [12%]) and high-risk PE (38 [10%]). The risk profile did not differ between the contemporary vs. historical cohort (78% vs. 77%, 13% vs. 11%, and 9% vs. 12%, respectively, all p &amp;gt;0.05). Eleven patients (3%) died of PE during the index hospitalization: eight with high-risk PE (21%), three (1%) with intermediate-risk and zero (0%) with low-risk PE (p &amp;lt; 0.0001). The in-hospital mortality did not differ between the contemporary vs. historical cohort (5 [3%] vs. 6 [3%], p = 0.76). In the multivariate regression analysis, the initial manifestation of cardiogenic shock, presence of provoking factors for PE, and a history of stroke were associated with higher in-hospital mortality. Conclusion The mortality of hospitalised patients with intermediate and low-risk PE is lower than previously reported and did not change over the last decade. High-risk PE is associated with in-hospital mortality of 21%. Abstract Figure.

Analysis of the 60/60 Sign and Other Right Ventricular Parameters by 2D Transthoracic Echocardiography as Adjuncts to Diagnosis of Acute Pulmonary Embolism.

IntroductionThe 60/60 sign in 2D transthoracic echocardiography (TTE) - a combination of pulmonary acceleration time (PAT) less than 60 milliseconds and tricuspid regurgitation (TR) jet gradient of less than 60 mmHg - has been found to be specific for the diagnosis of pulmonary embolism (PE).Materials and methodsAn observational prospective analysis was carried out on cases of suspected PE presenting to the emergency room (ER). TTE was performed on all cases with suspected PE prior to computed tomography pulmonary angiography (CTPA). Emphasis was placed on measurement of PAT and early systolic notching (ESN) on the pulsed wave (PW) Doppler of the pulmonary valve, TR jet gradient, right ventricle systolic excursion velocity (RV S’) by tissue doppler imaging (TDI), tricuspid annular plane systolic excursion (TAPSE), and right ventricle to left ventricle end-diastolic dimension ratio (RV:LV EDD) in modified parasternal short-axis view. These signs were taken as screening tests and compared to CTPA as the standard test. Patients were followed up until hospital discharge or death.ObservationsFifty-six cases of suspected PE were enrolled for the study. Of these, 24 cases of PE were confirmed by CTPA. Out of 24 cases of PE, 15 were high-risk PE, six were intermediate high-risk PE, and three were intermediate low-risk PE. The mean age was 53.07±9.79 years with a male-to-female ratio of 1.95:1. The 60/60 sign was present in 70.83% of cases of PE. RV:LV EDD in a modified short-axis view of more than 0.9 was present in 91.67% of cases of PE, and ESN on the PW Doppler of the pulmonary valve was present in 75% of cases of PE. The 60/60 sign, RV:LV EDD ratio more than 0.9, and ESN showed sensitivities of 70.83%, 91.67%, 75%, and specificities of 93.75%, 75%, and 100%, respectively for PE. For prediction of mortality, presence of the 60/60 sign (Odds Ratio=8.13, p-value=0.034) and ESN (Odds Ratio=17.50, p-value=0.02) were statistically significant.Conclusions60/60 sign and ESN are specific for the diagnosis of PE but have poor sensitivity.