Non-massive Pulmonary Embolism Research Articles

Recurrent pulmonary embolism and non-ST elevation acute myocardial infarction: current problems of diagnosis and treatment (clinical case)

A clinical case of a patient with recurrent pulmonary embolism (PE) and non-ST elevation acute myocardial infarction (NSTEMI) is presented. Underestimation of the history data, the clinical course of non-massive pulmonary embolism under the mask of syncope, eventually led to the development of massive pulmonary embolism and clinical death of the patient. The article discusses non-massive PE masks, principles of treatment and secondary prevention of venous thromboembolic complications in a patient with acute NSTEMI.

Concomitant Pulmonary Embolism and Anterior Myocardial Infarction as the Initial Presentation of Antiphospholipid Syndrome

Antiphospholipid antibody syndrome (APLS) is a systematic autoimmune disease characterized by thrombotic events, including arterial, venous, and microvascular complications. Often, patients initially present with either arterial or venous thromboembolism but rarely present simultaneously with arterial and venous thromboembolic events.1Garcia D. Erkan D. Diagnosis and management of the antiphospholipid syndrome.N Engl J Med. 2018; 378: 2010-2021https://doi.org/10.1056/NEJMra1705454Crossref PubMed Scopus (321) Google Scholar We report an unusual case of a 21-year-old woman who presented to our hospital with chest pressure secondary to a concomitant pulmonary embolism (PE) and anterior myocardial infarction. A 21-year-old woman with no significant past medical history, only on oral contraceptive pills, presented to the hospital with complaints of 4 days of progressively worsening substernal chest pressure associated with dizziness and lightheadedness. In the emergency department, she was mildly tachycardic but otherwise hemodynamically stable. An electrocardiogram revealed sinus rhythm with anterior T-wave abnormality (Figure 1A). Initial laboratory testing revealed mild thrombocytopenia and elevated troponin I levels of 9.63 ng/mL. A computed tomography angiography of the chest revealed small nonocclusive emboli in the right lower lobe pulmonary artery (Figure 1B); therefore, venous duplex ultrasound of the lower extremities was performed, which showed no evidence of deep vein thrombosis. Anticoagulation with intravenous heparin was started, and the patient was admitted to the floor with telemetry monitoring. Early morning on day 2 of hospitalization, the patient reported worsening chest pain, and the troponin I levels subsequently trended up to 20.08 ng/mL. A repeat electrocardiogram showed subtle ST-segment elevations, with QS complexes in the anterior leads. A bedside transthoracic echocardiogram revealed hypokinesis of the anterior wall and a severely reduced left ventricular ejection fraction. The patient was transferred to the cardiac catheterization laboratory for emergency coronary angiography. Coronary angiography showed 100% occlusion of the left anterior descending artery (LAD) at the ostium. The right coronary artery was patent with extensive right to left collaterals supplying the LAD. A filling defect was noted in the proximal LAD, consistent with a thrombus. Thrombus aspiration was performed using the Indigo System CAT RX (Penumbra, Inc), followed by the placement of a single 3.0 × 18 mm XIENCE Skypoint (Abbott) drug-eluting stent in the proximal LAD, with resultant TIMI-3 flow. A formal transthoracic echocardiogram demonstrated a left ventricular ejection fraction of 35%-40%, with a large left ventricular thrombus. Subsequent testing revealed antibody positivity for APLS, with elevated titers of anticardiolipin, lupus anticoagulant, and beta-2-glycoprotein antibodies. The patient was discharged on aspirin, ticagrelor, and warfarin along with high-intensity statin therapy, a low-dose angiotensin-converting enzyme inhibitor, and β-blocker therapy. The patient’s oral contraceptive pills were discontinued, and the patient was counseled about the use of an alternative nonhormonal mode of contraception. Approximately 12 weeks after discharge, the patient’s outpatient laboratory reports showed persistent elevation of all 3 antibodies, thus establishing the diagnosis of triple-positive APLS. Massive or submassive PEs can cause acute right heart strain and result in a small elevation of troponin levels. However, a high initial troponin level in patients with a nonmassive PE should raise suspicion of acute coronary syndrome, even with a low pretest probability of acute coronary syndrome.2Meyer T. Binder L. Hruska N. Luthe H. Buchwald A.B. Cardiac troponin I elevation in acute pulmonary embolism is associated with right ventricular dysfunction.J Am Coll Cardiol. 2000; 36: 1632-1636https://doi.org/10.1016/S0735-1097(00)00905-0Crossref PubMed Scopus (277) Google Scholar,3Kilinc G. Dogan O.T. Berk S. Epozturk K. Ozsahin S.L. Akkurt I. Significance of serum cardiac troponin I levels in pulmonary embolism.J Thorac Dis. 2012; 4: 588-593https://doi.org/10.3978/j.issn.2072-1439.2012.10.13Crossref PubMed Scopus (15) Google Scholar Therefore, the detection of a high initial troponin level should be followed by serial troponin level testing and electrocardiograms, an echocardiogram, and an ischemic evaluation. Patients with APLS may present with complications of arterial or venous thromboembolism; however, they rarely present with both simultaneously. Myocardial infarction and PE associated with APLS have been extensively reported in the literature; however, there are limited reports regarding the incidence of simultaneous events as the initial presentation of APLS.4Nazir S. Tachamo N. Lohani S. Hingorani R. Poudel D.R. Donato A. Acute myocardial infarction and antiphospholipid antibody syndrome: a systematic review.Coron Artery Dis. 2017; 28: 332-335https://doi.org/10.1097/MCA.0000000000000476Crossref PubMed Scopus (32) Google Scholar A high index of suspicion should be maintained for APLS in young patients presenting with concomitant arterial and venous thromboembolic events because the timely diagnosis and initiation of anticoagulation can prevent further thromboembolic complications. Further research is required regarding optimal anticoagulation strategies after percutaneous coronary interventions in patients with hypercoagulation disorders. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Characteristics and clinical outcomes of Japanese patients with venous thromboembolism receiving under-dose rivaroxaban: subanalysis of J’xactly

Objective Rivaroxaban is commonly prescribed to prevent venous thromboembolism (VTE). Although lower than standard dosages (under-dosing) may be administered in the real-world setting, data on subsequent clinical outcomes in Japanese patients are lacking. Methods The prospective, multicenter, observational J’xactly study enrolled patients with acute symptomatic/asymptomatic deep vein thromboses (DVT), pulmonary embolism (PE), or both, who were prescribed rivaroxaban. This subanalysis investigated patient characteristics and outcomes associated with rivaroxaban under-dosing. Results Among 1016 evaluable patients, 667 (65.6%) received an initial standard dosage of rivaroxaban (30 mg/day) and 349 (34.4%) received an initial under-dosage (20 mg/day, n = 22; 15 mg/day, n = 282; and 10 mg/day, n = 45). Those receiving an under-dose had significantly lower body weight and slower pulse rate compared with the standard-dose group regardless of DVT or PE status. Under-dosing was common for distal DVTs, but less frequent for massive/submassive PEs. There were no differences between under-dose and standard-dose groups in the incidences of recurring symptomatic VTEs (DVT: 1.77% vs. 3.35% per patient-year, p = .138; PE: 0.84% vs. 2.84% per patient-year, p = .208) or major bleeding (DVT: 3.55% vs. 3.41% per patient-year, p = .960; PE: not observed vs. 2.83% per patient-year, p = .132). Conclusions In the real-world setting, rivaroxaban under-dosing for patients with VTE occurred in those with lower body weight, slower pulse rate, distal DVT, or non-massive PEs. There were no statistically significant differences in the clinical outcomes for patients received under-dose of rivaroxaban at the discretion of the physicians in the clinical practice compared with those received standard dose of rivaroxaban.

The Predictor Potential Role of the Glucose to Potassium Ratio in the Diagnostic Differentiation of Massive and Non-Massive Pulmonary Embolism.

ObjectiveAcute pulmonary embolism (PE) is one of the main causes of death and has a course as massive (MPE) or non-massive (NMPE). The study investigates the indicator potential of Glucose to Potassium ratio (GPR) in the differential diagnosis of MPE and NMPE.Materials and MethodsThe study was designed as a retrospective cross-sectional clinical cohort in patients with PE. A total of 111 participants enrolled in the research separating two groups: MPE (n:54) and NMPE (n:67). The GPR was calculated by dividing serum glucose by potassium levels and its results were compared with D-Dimer, Pulmonary Artery Pressure (PAP), and C-Reactive Protein Test (CRP).ResultsD-Dimer was measured as 6.5 ± 5.7 µg/L in the MPE and found higher than the NMPE (3.9 ± 5.2 µg/L) (P = .019). CRP (100 ± 83.5 to 30.9 ± 42.7 mg/L; P = .0001) and PAP (49.5 ± 11.9 to 34.8 ± 7.3 mmHg; P = .0001) were found increased in the MPE. GPR strongly increased in the MPE (30.7 ± 7.5 to 24.9 ± 4.3; P = .0003) in line with CRP, D-Dimer and PAP. GPR showed a stronger diagnostic value (AUC: 0.733; P = .00001; Sensitivity:72%; Spesifity:70%; Cut-off: 26.5). PAP and GPR showed significant efficiency on occurrence of the MPE according to the binary logistic regression.ConclusionThe GPR, as a novel and cheap marker, can be useful for diagnostic differentiation of MPE from NMPE, but weaker than PAP and better than D-dimer.Type of Study and Level of EvidenceLevel-II, Retrospective clinical cohort study.

Evaluation of CHA2DS2-VASc score and R2CHADS2 score in patients with acute pulmonary thromboembolism and right ventricular dysfunction

Background and Aim: Acute pulmonary embolism (APE) is one of the fatal emergencies. Imaging methods are not available to all physicians as an emergency and depend on the individual. For this reason, besides imaging methods, more easily applicable and individual-independent parameters are investigated to help the diagnosis. Some scoring systems are also used according to the patient's current disease status. R2CHADS2 score is used more in patients with chronic renal failure (CRF). The aim of the study was to compare CHA2DS2-VASc and R2CHADS2 scores in patients with APE and right ventricular dysfunction (RVD). Methods: The study was conducted retrospectively. The patient group of the study consisted of 392 patients diagnosed with APE. Patients with nonmassive pulmonary embolism and submassive pulmonary embolism (SPE) without RVD were defined as Group 1 (n = 213) and massive pulmonary embolism and SPE with RVD were defined as Group 2 (n = 179). CHA2DS2-VASc and R2CHADS2 scores were compared as a scoring system in patients. Results: CHA2DS2-VASc scores and R2CHADS2 scores were evaluated in the two groups. The R2CHADS2 score was statistically significant in Group 2 (P < 0.001). There was a statistically significant difference between the groups in terms of CRF and estimated glomerular filtration rate (15 [7.2%] vs. 29 [16.4%], P < 0.001, and 57.6 vs. 46.4 mL/min/1.73 m2, P < 0.001). Conclusions: Our findings show that the CHA2DS2-VASc score and R2CHADS2 are independent predictors of RVD in patients with APE. However, the R2CHADS2 scoring system is observed better than the CHA2DS2-VASc scoring system in patients with APE and RVD.

Острый тромбоз бедренно-подколенного сегмента, осложнившийся ТЭЛА. Описание клинического случая

Deep vein thrombosis (DVT) and PE are classified as venous thromboembolic complications (VTEO), they remain an important problem in clinical medicine and affect the professional sphere of doctors of all specialties, since their pathogenesis is based on hypercoagulation caused by various causes, in particular, genetic defects of blood clotting factors, diseases of the cardiovascular system, severe injuries and subsequent immobilization, iatrogenic lesions, etc. The article describes a clinical case of treatment, observation and treatment of a patient diagnosed with Subacute phlebothrombosis of the left lower limb. Popliteal-femoral segment. VN II. Non-massive bilateral pulmonary embolism. DN 0-1. Arterial hypertension 2 stages, 2 degrees, risk 3.CHF 1. The study was conducted on the basis of the Regional Clinical Hospital No. 2 in Tyumen. Aim. Description of the identified case, subcute thrombosis of the femoral-popliteal segment, complicated by PE, for a more complete understanding of the problem due to the high prevalence of this pathology in the structure of vascular diseases; analysis of the possibility of early diagnosis and treatment on the example of a specific case. Material and methods. A retrospective analysis of the patient’s medical history was carried out and an example from the practice of the admission department of the Regional Clinical Hospital No. 2 in Tyumen of clinical observation of a patient diagnosed with subacute thrombosis of the femoral-popliteal segment, complicated by PE. Anamnesis of life and disease, clinical, laboratory and instrumental data were evaluated. Conclusion. The most realistic prevention of threatening PE is the effective treatment of acute venous thrombosis. It is very important to timely and adequately assess the risk of thrombosis in each individual case. The consequences of the lack of prevention of thrombosis lead to an increased risk of repeated episodes of venous thromboembolism, the development of post-thrombotic disease, and can also lead to death from PE. It should be noted that it is necessary to monitor CT scans – angiopulmonography – to control the development of pulmonary embolism as a complication against the background of newly formed thrombosis of the femoral-popliteal segment. Sanitary and educational work, active tactics, timely treatment and hospitalization of patients with acute deep vein thrombosis BPS will contribute to improving the quality of life of this category of patients, reducing the percentage of PE and deaths.

The role of the multi-inflammatory index as a novel inflammation-related index in the differential diagnosis of massive and non-massive pulmonary embolism.

Systemic inflammatory response and pro-coagulator factors are critical in acute pulmonary embolism. Recently, there is increasing evidence that the multi-inflammatory index (MII) may be prognostic in many clinical situations. The study investigated whether MII-1 and MII-2 can distinguish massive (MPE) and non-massive pulmonary embolism (NMPE). A total of 146 patients (73 MPE and 73 NMPE) were included in the study that was designed as a retrospective cross-sectional analysis. Following haemogram analysis, MII-1 (platelet-to-lymphocyte x CRP) and MII-2 (neutrophil-to-lymphocyte x CRP) were calculated manually. MII-1 and 2 showed a positive significant correlation with PLR and NLR, moderate positive correlation with CPR, and weak positive correlation with PAP (P<.001). CRP, MII-1, MII-2, PAP and systolic BP variables showed strong diagnostic value in distinguishing MPE and NMPE [AUC (SE): 0.816 (0.037), 0.811 (0.038), 0.810 (0.037), 0.870 (0.032) and 0.864 (0.032); respectively] (P<.001). MPR, MPV, RDW, and PLR in distinguishing MPE and NMPE groups did not show significance (P>.05). Although MII-1 and MII-2 are simple, cheap, and easy indexes to calculate, they showed a strong ability to distinguish MPE and NMPE compared with the previously studied classical inflammatory indexes.

Association of Inflammatory Markers with Mortality in Patients Hospitalized with Non-massive Pulmonary Embolism.

Pulmonary embolism (PE) is a serious pathology with high rates of morbidity and mortality. Studies regarding the efficacy of new inflammatory markers as a predictor of mortality in PE have thus far been limited. This study aimed to evaluate the predictive value of platelet/lymphocyte ratio (PLR), neutrophil/lymphocyte ratio (NLR), platelet/mean platelet volume (PLT/MPV), and C-reactive protein (CRP) on short-term and long-term mortality in patients with PE. A retrospective, observational cohort study was carried out in a tertiary teaching hospital. Patients with PE hospitalized in the pulmonology ward were enrolled. Their characteristics, hemogram parameters, PLR, NLR, CRP levels, PLT/MPV on admission, and mortality were recorded. The predictive accuracies of inflammatory markers were determined through receiver operating characteristic curves. The risk factors for mortality were further analyzed with Cox regression analysis. A total of 828 patients with PE were included in the study. The 1-month mortality was 1%, and the 1-year mortality was 8.5%. An NLR value above 6 was associated with an almost 13-fold increase in short-term (30-day) mortality. We found that an NLR above 3.15 and age were independent risk factors for long-term (1-year) mortality. The other inflammatory markers, namely PLR and CRP, were not found to be associated with long-term mortality. PE is a serious condition in the elderly. Elevated NLR values appear to be a good and feasible predictor of inflammation, which can be correlated with higher mortality over both the short-term and long-term periods.

Role of Echocardiography in Assessment of Right Ventricular Function in Patients with Non-massive Pulmonary Embolism

A prognostic value of right ventricular (RV) systolic function assessed by echocardiography in patients with acute non-massive pulmonary embolism (PE) remains controversial. We planned to assess right ventricular capacity in patients with non-enormous aspiratory embolism utilizing tissue Doppler and dot following echocardiography. 50 continuous patients analyzed as intense non-enormous pneumonic embolism were tentatively enlisted and echocardiographic assessments were performed inside multi week of conclusion to gauge different boundaries of RV systolic capacity. The essential endpoint was in-emergency clinic occasions, the composite of in-medical clinic PE-related demise, need of added substance therapies, for example, thrombolysis and need of inotropics because of unsteady fundamental sign. Result: PESI score was essentially higher in those with in emergency clinic occasion (120) contrasted with those with no occasion (72). P esteem was =0.002. As respect PESI grade ≥ 3, It was altogether higher in those with in-emergency clinic occasion (80%) contrasted with those with no occasion (39%). P esteem was 0.004. Mean RV worldwide divider strain was fundamentally lower in those with in-clinic occasion (- 11%) contrasted with those with no occasion (- 19%). P esteem was 0.002. Mean FAC was essentially lower in those with in-medical clinic occasion (34%) contrasted with those with no occasion (43%). P esteem was 0.004. Mean TAPSE was altogether lower in those with in-medical clinic occasion (1.4 cm) contrasted with those with no occasion (1.8 cm). P esteem was 0.005. Mean S speed was altogether lower in those with in-emergency clinic occasion (11 cm/s) contrasted with those with no occasion (14 cm/s). P esteem was 0.006. . RV strain surveyed with dot following echocardiography is a free prognostic marker for in-clinic occasions in patients with intense non-enormous PE. Our outcomes may help recognize high–middle of the road hazard patients who need a closer observing.

Examination of pulmonary embolism inpatients in a university hospital

Aim: Pulmonary embolism (PE) is responsible for 5-15% of hospital deaths. The rate of mortality from PE in untreated cases is about 25-30%, while this rate drops down to 2-8% in treated cases. In this study, we aimed to investigate general features of the patients hospitalized in our center due to PE and the factors affecting prognosis. Material and Methods: Patients hospitalized due to PE in Harran University Medical Faculty Hospital between January 2015 and December 2017. Patients’ demographic data, comorbidities, hemogram outcomes at the time of admission, liver function tests, renal function tests, electrolytes and cardiac markers, status of the patients during follow-up (referral to intensive care unit, exitus, ward follow-up) and PE clinical picture (massive, submassive, nonmassive) were recorded. All patients requiring hospitalization due to PE were included in the study, while patients with chronic thromboembolic pulmonary disease, those requiring recurrent hospitalization and patients discharged on own demand were excluded from the study.Results: The study included 40 (38.8%) male and 63 (61.2%) female patients with a mean age of 66±18.1 years. The mean duration of hospitalization was found as 11 days. Of the patients included in this study, 7.7% (n=8) were diagnosed with massive, 10.6% (n=11) with submassive, and 81.5% (n=84) with non-massive PE. Four patients (3.8%) were accepted as in-hospital exitus, 30 (29.1%) patients were transferred to the intensive care unit and 69 (66.9%) patients were followed-up in the thoracic diseases service. When patients diagnosed with non-massive PE were compared with those diagnosed with submassive and massive PE; the levels of magnesium (p=0.003), and troponin (p=0.000) were statistically significantly higher in the group diagnosed with submassive and massive PE. When the groups with and without the need for intensive care were compared, platelet counts were statistically lower in the group which required intensive care (p=0.038).Conclusion: More often hospitalization is needed in female patients due to PE. Although routine laboratory tests give a partial information about the prognosis of PE, cardiac markers are the most commonly used in clinical practice.

Tricuspid Annular Plane Systolic Excursion (TAPSE) for Risk Stratification and Prognostication of Patients with Pulmonary Embolism.

The categorization of pulmonary embolism (PE) as non-massive, sub-massive, and massive helps guide acute management. The presence of right ventricular (RV) strain differentiates sub-massive from non-massive PEs. Unlike laboratory markers and electrocardiogram changes, the classic parameters used in the echocardiographic diagnosis of RV strain have a technical component that is operator-dependent. This narrative review will describe the physiologic effects of a PE on the RV and how this affects prognosis. It will summarize the literature evaluating the accuracy and prognostic ability of tricuspid annular plane systolic excursion (TAPSE) in the echocardiographic assessment of RVfunction. The review will describe the appeal of TAPSE for this purpose, provide cutoff measurements, and then illustrate how to perform the technique itself, while offering associated pearls and pitfalls in this bedside evaluation. RV function and dynamics undergo acute changes in the setting of a PE. RV dysfunction predicts poor outcomes in both the short and long term. However, RV strain is difficult to capture on echocardiography due to the chamber's complex geometric shape and contraction. From the apical four-chamber window, TAPSE offers a quantitative measure that is more easily performed with high interobserver reliability for evaluating systolic RV contraction. This measurement carries prognostic value in patients diagnosed with PE. Along with other more qualitative echocardiographic parameters, TAPSE can be used as a simple quantitative measure of RV dysfunction for differentiating sub-massive from non-massive PEs. This categorization helps guide acute management and disposition.

High-sensitive cardiac troponin T as a marker of hemorrhagic complications in elderly patients anticoagulated for non-massive pulmonary embolism

BackgroundRecent data have raised concerns about the risk/benefit ratio of thrombolysis in non-high risk pulmonary embolism patients due to increased serious bleeding events. Whether cardiac biomarkers could be of help for bleeding risk stratification in this setting remains elusive. ObjectivesTo determine the prognostic accuracy of hs-cTnT, NT-proBNP, RIETE and PESI score for the occurrence of clinically relevant bleeding (CRB) in elderly patients under conventional anticoagulation therapy for non-massive pulmonary embolism (NMPE). MethodsWe evaluated 230 elderly patients with available blood sample taken within one day from diagnosis. The primary study endpoint was CRB at 1, 3 and 24 months. Prognostic accuracies and associations were determined using C-statistics and subhazard ratios (SHR), respectively. Resultshs-cTnT displayed the highest discriminatory power at 1 month (C-statistics: 0.77, 95% CI: 0.68–0.88) which remained stable over time. Although C-statistics comparison indicated that hs-cTnT was not statistically superior to RIETE score (0.77 vs 0.67, p = 0.11), adding hs-cTnT to RIETE score significantly improved the C-statistics from 0.67 to 0.78 (p = 0.02). SHRs indicated that for each hs-cTnT log-unit increase, there was a 58% increase in the risk of CRB independently of the RIETE score (adjusted SHR: 1.58, 95% CI: 1.31–1.92). At the pre-specified cut-off of 14 ng/l, the negative predictive value of hs-cTnT was 96.9% (95% CI: 91.4–99.0) and 94.9 (95%CI: 88.6–97.8) at 1 and 3 months, respectively. ConclusionIn elderly, hs-cTnT provides incremental prognostic information over the RIETE score and could represent a valuable tool to identify NMPE patients at low risk of bleeding.

Prevalence and Predictor of Pulmonary Embolism in a Cohort of Chinese Patients with Acute Proximal Deep Vein Thrombosis

The aim of this study is to investigate the incidence of pulmonary embolism (PE) in a cohort of Chinese patients with acute (<14days) proximal (above-knee) deep vein thrombosis (DVT) in the lower limbs, and to evaluate whether the location of thrombosis is associated with the existence of PE. A retrospective review of patients diagnosed with acute proximal DVT from January 2014 to June 2018 at a single center was performed. Helical computed tomography angiography was performed to screen PE within 48hr after admission. Multiple factors associated with PE were compared between the PE group and the non-PE group. A total of 100 patients with acute proximal DVT were screened for PE. The mean age was 56.9±18.1 (range 21-88) years, and 55% were male. The most common risk factors of DVT were immobilization (38%), malignancy (27%), and trauma or surgery (21%). Majority of the patients' thrombosis was located at the left leg (66%) and 8 patients had bilateral lower limb DVT. Femoral vein was involved in 52 patients (52%), while iliofemoral thrombosis was identified in 48 patients (48%). PE was identified in 58 patients (58%), including 3 massive and 55 nonmassive PE. There was no statistical difference between the PE group and the non-PE group in terms of age, sex, and risk factors. The D-dimer level was associated with the existence of PE (P=0.038). Patients with iliofemoral thrombosis had a similar incidence of PE compared with those with femoral thrombosis alone (P=1.000). PE occurred in more than half of patients with acute proximal DVT, despite the fact that most of them were asymptomatic. In this study, existence of PE did not correlate with pelvic thrombosis. Increasing D-dimer level was statistically associated with the presence of PE.

Conservatively managed saddle pulmonary embolism.

Massive, submassive, and nonmassive pulmonary embolism relate to the hemodynamic state, while saddle pulmonary embolus is a purely radiologic term. Patients with saddle embolus often present with hemodynamic compromise. However, treatment depends on the clinical presentation, and stable patients with a saddle pulmonary embolus can respond well to conventional anticoagulation.

Outcomes and risk factors of massive and submassive pulmonary embolism in children: a retrospective cohort study

Little is known about severe pulmonary embolism in children. We aimed to report pulmonary embolism outcomes, identify risk factors for unfavourable outcomes, and evaluate the discriminative ability of two clinical-severity indices in children. In this retrospective cohort study, we included consecutive patients aged 18 years or younger with acute pulmonary embolism, objectively diagnosed radiologically or pathologically, between Jan 1, 2000, and Dec 31, 2016, from two Canadian paediatric hospitals (The Hospital for Sick Children, Toronto, ON, and the Children's Hospital of Eastern Ontario, Ottawa, ON). Exclusion criteria were sudden death without radiological or pathological pulmonary embolism confirmation and non-thromboembolic pulmonary embolism. The primary outcome was a composite of unfavourable outcomes of pulmonary embolism-related death and pulmonary embolism recurrence or progression. Potential predictors of the composite unfavourable outcome (ie, age at pulmonary embolism diagnosis, sex, underlying cardiac disease, severity of the pulmonary embolism, presence of a central venous catheter, associated venous thromboembolism, family history of thrombosis, treatment modalities, thrombophilia, obesity, and recent surgery) were explored with logistic regression. We calculated pulmonary embolism severity index (PESI) and simplified PESI (sPESI) using age-adjusted parameters; we estimated the ability of PESI and sPESI to predict mortality using receiver-operating characteristic (ROC) curve analysis. Of the 170 patients included, 37 (22%) had massive, 12 (7%) submassive, and 121 (71%) non-massive pulmonary embolism. Patients with massive or submassive pulmonary embolism were younger (median age 12·5 years [IQR 0·6-15·1] vs 14·4 years [9·3-16·1], p<0·0001), more likely to have a cardiac condition (16 [33%] vs 17 [14%] patients, p=0·009), and had more central venous catheters (29 [59%] vs 48 [40%] patients, p=0·027) than patients with non-massive pulmonary embolism. Aggressive treatment modalities were more commonly used in massive or submassive pulmonary embolism (22 [45%] vs 7 [6%] patients, p<0·0001). Of the predictors tested, only pulmonary embolism severity was associated with the composite unfavourable outcome in the multivariable analysis (odds ratio 3·53, 95% CI 1·69-7·36; p=0·011). The area under the ROC curve for PESI to predict 30-day mortality was 0·76 (95% CI 0·64-0·87). Sensitivity of sPESI was 100% and specificity was 30%. Massive or submassive pulmonary embolism led to higher rates of unfavourable outcomes than non-massive pulmonary embolism in children. Further adaptations of PESI and sPESI are required to improve their clinical usefulness in paediatric patients. Trainee Start-Up Fund (The Hospital for Sick Children).

Prognostic value of echocardiographic parameters for right ventricular function in patients with acute non-massive pulmonary embolism.

A prognostic value of right ventricular (RV) systolic function assessed by echocardiography in patients with acute non-massive pulmonary embolism (PE) remains controversial. The hypothesis was RV free wall strain measured using speckle-tracking echocardiography might be a powerful prognostic factor in those patients. We aimed to evaluate the prognostic value of echocardiographic measurements of RV systolic function for clinical outcomes and to assess the correlation between the echocardiographic RV function parameters in patients with acute non-massive PE. Between November 2013 and September 2016, 144 consecutive patients diagnosed as acute non-massive pulmonary embolism were prospectively enrolled and echocardiographic evaluations were performed within 1week of diagnosis to measure various parameters of RV systolic function. The primary endpoint was in-hospital events, the composite of in-hospital PE-related death, need of additive treatments such as thrombolysis or pulmonary artery thromboembolectomy, and need of inotropics due to unstable vital sign. Among patients (mean age 60.3 ± 14.7years, 50% female) with acute non-massive PE, the in-hospital event rate was 11.1% (16 of 144 patients). In multivariate logistic regression analysis, after adjustment of confounding factors such as age, gender, and diabetes mellitus, RV free wall strain [odd ratio (OR) 1.12, 95% confidence interval (CI) 1.04-1.21, p = 0.002] and RV global wall strain (OR 1.20, 95% CI 1.07-1.35, p = 0.002) were independent predictors for in-hospital events. The event rates were significantly different between groups classified based on RV free wall strain with cut-off value of -15.85% (p < 0.001). RV strain assessed with speckle-tracking echocardiography is an independent prognostic marker for in-hospital events in patients with acute non-massive PE. Our results may help identify high-intermediate risk patients who need a closer monitoring.

Incidence, Characteristics and Management of Venous Thromboembolism in Japan During 2011

This study aimed to determine the incidence, characteristics and management of venous thromboembolism (VTE) in Japan during 2011.Methods and Results:A retrospective study assessed responses to a questionnaire regarding treating newly diagnosed VTE at all admitting hospitals throughout Japan during 2011. More individuals were diagnosed with VTE than ever before, with 16,096 cases of diagnosed pulmonary embolism (PE) and 24,538 cases of diagnosed deep vein thrombosis (DVT). Almost half (47.2%) of the PE patients had a relatively mild condition with no right ventricular overload. Similarly, almost half (43.8%) of the DVT patients had a relatively mild condition with isolated calf thrombus. Most of PE patients were treated by anticoagulation, and fewer were treated using thrombolytic agent or inferior vena cava (IVC) filter. The present study showed a remarkable increase in the incidence of VTE in Japan during 2011. Relatively mild conditions such as non-massive PE and isolated calf DVT were frequently diagnosed. Among PE patients, thrombolytic therapy or IVC filter implantation decreased compared with previous surveys. The appropriate management of isolated calf DVT requires further investigation.

Short-Term Subcutaneous Fondaparinux and Oral Edoxaban for Acute Venous Thromboembolism.

No studies have compared treatment efficacy between subcutaneous (SC) fondaparinux and oral edoxaban, which are categorized as factor Xa inhibitors, for venous thromboembolism (VTE) in the acute phase, and only a limited number of imaging-based quantitative studies have evaluated treatment.Methods and Results:In this open-label, randomized study, 50 patients with acute non-massive pulmonary embolism (PE) and/or deep-vein thrombosis (DVT) were assigned to fondaparinux or edoxaban groups. Lower-limb venous ultrasonography (US), and chest computed tomography (CT) were compared before and 7 days after treatment. Thrombus volume in DVT was calculated using quantitative ultrasound thrombosis (QUT) score on US. For evaluation of PE thrombus volume, lung perfused blood volume (PBV) on CT was calculated. The measurements before and after treatment, respectively, were as follows: QUT score: fondaparinux, 8.1±7.3 to 4.1±4.5; edoxaban, 7.7±6.3 to 4.4±4.3, both significant decreases (P=0.001, P<0.001, respectively); lung PBV: fondaparinux, 32.0±7.8 to 32.1±8.2 HU; edoxaban, 34.2±8.6 to 38.5±11.8 HU (P=0.732, P=0.426, respectively). On subjective CT-based evaluation, all pulmonary artery-related filling defects decreased/disappeared after treatment in both groups (P=NS). Both SC fondaparinux and oral edoxaban are effective in acute VTE. Effects on thrombus regression on imaging-based quantitative measurement did not differ between the 2 drugs.

Clinical Prognosis of Nonmassive Central and Noncentral Pulmonary Embolism: A Registry-Based Cohort Study

Whether the localization of nonmassive pulmonary embolism (PE) is associated with the short-term and long-term prognosis of patients remains unknown. Our aim was to characterize associations of nonmassive PE localization with risks of recurrent VTE, major bleeding, and mortality during and after anticoagulation. Among participants of the Registro Informatizado de la Enfermedad ThromboEmbòlica (RIETE) registry with incident symptomatic nonmassive PE diagnosed by CT scan, we compared risks of recurrent VTE, major bleeding, and mortality during and after anticoagulation between central PE (main pulmonary artery) and noncentral PE (more peripheral arteries) using Cox proportional hazard-adjusted models. Of the 6,674 participants, patients with central PE (40.5%) had age (mean 66 years), sex (46.9%male sex), and proportion of idiopathic (45.0%) and cancer-related (22.3%) PE that were similar to those of patients with noncentral PE. During anticoagulation (5,256.1 patient-years), the risk of recurrent VTE was similar between the two groups (2.5 vs2.1 per 100 patient-years; adjusted hazard ratio [aHR], 1.32; 95%CI, 0.91-1.90), as were risks of major bleeding and mortality. After anticoagulation was discontinued (2,175.4 patient-years), participants with central PE had a borderline greater risk of recurrent VTE than did participants with noncentral PE (11.0 vs8.0 per 100 patient-years; aHR, 1.34; 95%CI, 1.01-1.78) but not when restricted to participants after unprovoked PE (13.8 vs11.9 per 100 patient-years; aHR, 1.15; 95%CI, 0.79-1.68; P= .48). Risks of major bleeding and mortality were similar. In nonmassive PE, central localization of PE is associated with greater risk of recurrent VTE after anticoagulation cessation. However, the low magnitude of this association and the absence of association after unprovoked PE suggest that the clinical relevance of this finding is limited and that the duration of anticoagulation should not be tailored to PE localization after nonmassive unprovoked PE.

Abstract PR518

Background & Objectives: Hip replacement (HR) involves application of modern thromboprophylaxis schemes, which has reduced the rate of postoperative venous thromboembolism (VTE) to 1−9%. Consideration and modification of individual thrombogenic risk factors (TRFs) may be critical for further reducing the VTE rate. The study aim was to determine significance of the psycho-emotional state as one of TRFs in the period before HP in association with modern thromboprophylaxis schemes involving pharmacological and non-pharmacological modalities. Materials & Methods: The prospective, randomized, controlled study included 351 patients (156 (44.4%) males and 195 (55.6%) females). The patients were aged 30 to 74 years; body weight ranged from 54 to 158 kg. All patients were hospitalized for grade 2−3 coxarthrosis and, after randomization, were allocated into 3 groups, depending on the used anticoagulant: enoxaparin (156 patients), dabigatran etexilate (122 patients), and rivaroxaban (73 patients). To visualize venous thrombosis, ultrasound angiography of the lower limbs was used for the period of up to 3 months after surgery. Potential TRFs in the preoperative period were identified using a survey of patients, a study of medical records, and a number of laboratory tests. The psychological status was assessed using a subjective psychometric test, the Hospital Anxiety and Depression Scale (HADS). Results: A total of 7.1% VTE cases were identified. In 1 (0.3%) case, non-massive pulmonary embolism developed within the 1st postoperative day. With allowance for these data, 6 thrombogenic risk factors (out of 27 TRFs considered) were defined that significantly increased the risk of VTE: type 2 diabetes mellitus (odds ratio (OR) 5.6; 95% confidence interval (CI) 1.8−17.0), female gender (OR 4.6; CI 1.5−13.6), a low level of physical activity before surgery (OR 4.4; CI 1.7−11.1), age of 60 years or older (OR 4.3; CI 1.8−10.6), an elevated level of D-dimers (> 500 ng/mL) immediately before surgery (OR 3.5; CI 1.4−8.9), and varicose veins of the lower limbs (OR 3.4; CI 1.5−7.7). The clinical level of anxiety/depression (A/D) was ≥11 in general, did not demonstrate a statistically significant correlation with the development of VTE (OR 2.1; CI 0.9−4.9; p=0.37). However, the risk of VTE increased 4.1 times (CI 1.5−11.5; p=0.02) in the group of patients aged 60 years and older, while in the group of patients <60 years, the risk of these complications is increased only 0.7 times (CI 0,1-5,8; p = 1.00). Conclusion: Despite the use of recommended doses of anticoagulants, the identified TRFs enable detection of patients at high risk of VTE. In this case, the anxiety/depression level manifests as a TRF in old age.