PESI Score Research Articles

A simple and reliable computed tomographic measure for the evaluation of right ventricle remodelling in acute PE: right ventricle apical angle

Abstract Background and aims In patients with acute pulmonary embolism (PE), right ventricular (RV) dysfunction as assessed by computed tomography (CT) and /or echocardiography has been considered to predict in-hospital and 30-day outcomes. In this study we proposed a novel CT measure for RV function, the apical angle (α1) between the RV free wall and the interventricular septum (IVS), and for the left ventricle (LV) function, the apical angle (α2) between the LV free wall and the IVS. We aimed to evaluate the predictive value of these angles to determine clinical and hemodynamic severity and in-hospital mortality (IHM) in acute PE patients. Methods The study population comprised retrospectively evaluated 536 patients (age 59+-16.2 years, female 55.3 %) with acute PE in whom diagnostic work-up and risk-based treatments have been performed in accordance with currently available acute PE Guidelines. The severity of pulmonary arterial (PA) obstruction (Qanadli score) and RV/LV ratio were assessed on CT, and RV function and non-invasive estimation of pulmonary arterial systolic pressures (PASP) were evaluted with echocardiography. The α1 was defined as the angle between the line from tricuspid medial annulus to the RV apex and second line from tricuspid lateral annulus to the RV apex, whereas α2 was defined as the angle between the line from mitral medial annulus to the LV apex and second line from mitral lateral annulus to the LV apex. Results Anticoagulant treatment only and intravenous tissue plasminogen activator were noted in 49.6 % and 17.9 % of patients, respectively. Ultrasound-assisted thrombolysis and rheolytic thrombectomy were also used in 25% and 7.5 % of patients, respectively. The IHM rate was 5.9 %. The increase in α1 was associated with a decrease in TAPSE/PASP ratio, and an increase in PESI score and a higher risk status (p=0.047, p<0.001, p=0.001 respectively), but α2 showed no relation to PE severity (p=0.78). The value of α1 in predicting in-hospital mortality was evaluated with a logistic regression analysis with a model including PESI score, RV/LV ratio and α1. PESI score and α1 significantly predicted IHM (p= <0.001 and 0.027, respectively. OR for a1 1.15, CI 95%[1.06-1.27]), but RV/LV ratio did not. In the receiver operating curve (ROC) analysis for IHM prediction, the cut-off value of 1.168 for α1/α2 ratio [area under the curve (AUC): 0.721; sensitivity:76.92 % and specificity: 65.8 %] and the cut-off value of 32.47 for α1 ( AUC: 0.718 ; sensitivity: 84.67 % and specificity: 59.5 %) provided higher prediction compared with cut-off value of 1.29 for RV/LV ratio ( AUC : 0.604 ; sensitivity 76.9 % and specificity 45.87 %). Conclusion Either α1 or α1/α2 ratio evaluation on CT seems to represent a simple and reliable approach in the assessment of RV acute remodelling in response to thrombo-obstructive pressure burden and for prediction of outcome in patients with acute PE.Alpha 1 angle of different risk groupsROC curve

Baseline characteristics, management patterns and outcome in patients with pulmonary embolism and malignancy: Insights from a single-centre study

Abstract Background and aim The presence of malignancy is an important factor that increases the risk of venous thromboembolism. On the other hand, acute pulmonary embolism (PE) is one of the main causes of death in this setting. In this study, we evaluated the impact of active malignancy on the treatment choices, and short and long term clinical outcomes in patients with acute PE. Methods In this study conducted in a tertiary center, 872 acute PE patients (age 61.6±16.8 years, female 57.5 %) from different risk categories were treated with thrombolytic, anticoagulant and catheter-based therapies in accordance with currently available acute PE guidelines. The population was retrospectively analyzed and divided into two groups according to the presence of active malignancy. Results Active malignancy was documented in 129 (14.8 %) patients. In the groups with and without malignancy, the proportions of low-, intermediate-low-, intermediate-high-, and high-risk PE patients were 3.1 % vs. 15.6 %, 17.8 % vs. 16.7 %, 60.5 % vs. 60 %, and 18.6 % vs. 7.7 %, respectively (p<0.001). While the two groups did not differ in terms of echocardiographic and computed tomographic pulmonary angiography (CTPA) characteristics, the presence of contraindications for thrombolytic were more frequent in the malignancy group (22.5% vs. 10.9%, p<0.001). Ultrasound-assisted thrombolysis (USAT), rheolytic thrombectomy (RT), systemic thrombolysis (ST) and anticoagulation-alone (AC) therapies were noted in 27.3 %, 6.4 %, 6.4 % and 49.7 % of overall PE patients. The RT and AC therapies were more frequent in PE patients with malignancy whereas ST and USAT were more frequently used in the absence of malignancy. Notably, lytic dosages and treatment durations in USAT and ST protocols were comparable between malignant and non-malignant PE cohorts. Regardless of the presence of malignancy and the treatment modality chosen, significant improvements were achieved in the clinical, echocardiographic and CTPA measures of the PE severity (p<0.001 for all). Major and minor bleeding rates were also similar in both groups, while in-hospital and, as expected, long-term mortality were higher in the malignancy cohort. Active malignancy and PESI score were found to be independent predictors for composite end-point of 60-day mortality and PE-related rehospitalization (adjusted odds ratio (OR): 2.43; 95 % CI: 1.32 - 4.47, p=0.04) and (OR: 1.02; 95 % CI: 1.01-1.01, p<0.001), respectively. Malignancy (OR: 3.5, 95 % CI: 2.15-5.75, p< 0.001) and chronic obstructive pulmonary disease (OR: 2.51, 95 % CI: 1.35-4.68, p< 0.003) were independent predictors of long-term mortality. Conclusion Concomitant malignancy adversely affects both short- and long-term outcomes in patients with acute PE. Although these patients are more vulnerable, it is possible to achieve satisfactory treatment success with acceptable bleeding rates with the inclusion of catheter-based methods as treatment option.Survival plot

Impact of a blood return system on mechanical thrombectomy in treatment of acute pulmonary embolism: a retrospective cohort study comparing 30-day mortality and need for blood transfusion

Abstract Background Mechanical thrombectomy (MT) has become an increasingly popular approach in treatment of pulmonary embolism (PE). Blood loss from aspiration is common during this procedure and can potentially limit clot extraction. A blood return system designed to be used during MT was introduced in January 2022; however, there is limited data demonstrating if its use has impacted mortality or need for blood transfusion in patients treated with MT. Purpose The aim of this study is to assess if there is a difference in outcomes amongst patients with acute PE that underwent MT with a blood return system vs. those that underwent MT without one. We hypothesize that MT with a blood return system will reduce mortality and need for post-procedure blood transfusions. Methods A large retrospective, multicentre database was used to identify patients diagnosed with PE that underwent MT. Patients were subsequently divided into two groups: 1) After and including January 2022, which was after the implementation of a blood return system vs. 2) Before January 2022, which was prior to the implementation of a blood return system. Student’s t-test was performed to compare baseline characteristics between the two cohorts. Propensity matching was performed based on relevant comorbidities and severity of PE estimated by PESI score parameters. Kaplan Meier curves were calculated to compare 30-day post-procedure mortality and need for blood transfusion. Results Patients that underwent MT after implementation of a blood return system (n= 2511) and before implementation of a blood return system (n= 2755) were propensity matched yielding 1915 patients per cohort. MT after implementation of a blood return system was associated with a decreased 30-day mortality compared to MT before implementation (6.99% vs 11.77% HR=0.602; 95% CI [0.486, 0.746], log-rank p<0.0001). Additionally, MT after implementation of a blood return system was associated with a decreased need for blood transfusion (7.52% vs 10.38%; HR=0.717; 95% CI [0.572, 0.898], log-rank p=0.0034). Conclusion MT after implementation of a blood return system was associated with a decreased risk of 30-day mortality and a lower likelihood of requiring blood transfusion when compared to MT prior to implementation of a blood return system.

Clinical outcomes of edoxaban treatment without parenteral anticoagulation therapy for acute venous thromboembolism: Insight from the COMMAND VTE Registry-2

Abstract Background Direct oral anticoagulants (DOACs) including edoxaban are currently widely used all over the world. Each DOAC has a specific usage for the treatment and second prevention of venous thromboembolism (VTE) in the acute phase as well as in the chronic phase. Edoxaban is recommended to be administered after an appropriate initial treatment including parenteral anticoagulation therapy such as heparin. However, because of the rapid anticoagulant effect of edoxaban after oral intake, some physicians could administer edoxaban initially without parenteral anticoagulation therapy in the daily clinical practice, which has not been investigated so far. Purpose The purpose of this study is to explore the effectiveness and safety of edoxaban treatment for VTE without initial parenteral anticoagulation therapy. Methods The COMMAND VTE Registry-2 is a multicenter registry enrolling 5,197 consecutive acute symptomatic VTE patients among 31 centers in Japan between January 2015 and August 2020. Of those, 1842 patients received edoxaban including 848 patients with pulmonary embolism (PE) and 994 patients with deep vein thrombosis (DVT) alone, who were divided into 2 groups based on the presence or absence of initial parenteral anticoagulation therapy with heparin. Propensity score matching (PSM) was performed to adjust for potential baseline differences in the 2 groups. Results PE and DVT patients with initial parenteral anticoagulation therapy with heparin accounted for 623 (73.5%) and 244 (24.5%), respectively. After the PSM, 195 pairs of PE patients and 226 pairs of DVT patients were matched. In PE patients, those matched by the PSM were relatively mild cases compared to the unmatched cases (simplified PESI score=0: 25.9% vs. 12.4%, P<0.001). Whereas, in DVT patients, those matched were relatively severe cases compared to unmatched cases (isolated distal DVT: 24.1% vs. 71.0%, P<0.001). In the matched cohort, there was no significant difference in baseline characteristics between the 2 groups, including simplified PESI score in PE patients and thrombus location profile in DVT patients. In both PE patients and DVT patients, the 30-day cumulative incidences of all-cause death were not significantly different between the 2 groups (PE patients: 3.7% vs. 2.6%, P=0.56; DVT patients: 2.7% vs. 4.5%, P=0.31). Similarly, the 30-day cumulative incidences of recurrent VTE and major bleeding were not significantly different between the 2 groups (recurrent VTE: PE patients: 0% vs. 0.5%, P=0.32; DVT patients: 0.6% vs. 0.9%, P=0.99; major bleeding: PE patients: 1.5% vs. 3.2%, P=0.32; DVT patients: 2.2% vs. 3.2%, P=0.54) Conclusion In this current real-world VTE registry, a certain number of patients received edoxaban without parenteral anticoagulation therapy, who did not show a signal of worse clinical outcomes.

Клінічне і прогностичне значення рівня нейтрофільно-лімфоцитарного співвідношення у хворих на гостру тромбоемболію легеневої артерії

The aim – to evaluate the association of neutrophil-lymphocyte ratio (NLR) with the clinical course and hospital prognosis of pulmonary embolism (PE).Materials and methods. The study included 291 patients with a diagnosis of PE, verified by multislice computed tomographic pulmonary angiography, with a calculated NLR according to clinical blood count. In addition to the standard general-clinical and laboratory-instrumental examination, patients were assessed for risk factors of PE and risk of early death according to ESC 2019 recommendations. The data obtained were statistically processed.Results and discussion. Patients were divided according to the median NLR: group 1 included 145 patients with NLR <3.4, group 2 – 146 patients with NLR ≥3.4. Also, according to the value of the NLR obtained during the ROC analysis for predicting mortality during the hospital period: group 3 consisted of 245 patients with NLR ≤6.75, group 4 – 46 patients with NLR >6.75. Analyzing demographic indicators, it was found that in group 2, elderly patients (p=0.02) and males (p=0.037) were reliably more common than in group 1. Regardless of the method of division into groups, a reliable predominance of patients at high risk of early death from PE (p<0.001), PESI class V (p<0.01) and high-risk sPESI (p<0.01), with higher PESI scores (p<0.001) was obtained in groups with increased NLR (NLR ≥3.4 and NLR >6.5). In the same groups, analyzing the results of the objective examination, a reliably lower level of saturation (p<0.0001) and SBP (p<0.01) were found. When comparing laboratory parameters, it was found that the average leukocyte levels in the groups with NLR ≥3.4 and NLR >6.5 were reliably higher (p<0.001), and the level of troponin I was reliably increased (p=0.02) only in the group with NLR >6.5. Correlation analysis showed a reliable direct link between the level of NLR and age, heart rate, right atrium (RA) size, LVEDC, mean pulmonary arterial pressure (MPAP), leukocyte and troponin I levels, increased risk of early mortality from PE and hospital mortality, as well as an inverse link with the level of saturation, SBP, LV EF and hemoglobin. Conclusions. The link between the level of NLR and clinical and anamnestic parameters in patients with PE was established. Among patients with NLR above the median (≥3.4), elderly patients, males, and high-risk patients with reliably higher PESI scores predominated. A direct correlation between the level of NLR and age, heart rate, RA size, LVEDC, MPAP, leukocyte and troponin I levels, increased risk of early mortality from PE and hospital mortality, as well as an inverse correlation with saturation, SBP, LV EF and hemoglobin levels were established. NLR >6.5 is associated with an unfavorable prognosis – death in the hospital period, as well as with a higher level of troponin I, a marker of right ventricle dysfunction.

Factors of unfavorable prognosis in patients with non-high risk pulmonary embolism

Abstract Introduction Pulmonary embolism (PE) nowadays is the third leading cause of death in the structure of cardiovascular mortality after myocardial infarction and stroke. Most of patients (pts) with PE are with non-high risk. According to the latest guidelines PESI and sPESI scores are used to predict 30-day outcome of non-high-risk pts. Nevertheless, the question of additional factors which are not included in PESI and sPESI scores and which may be associated with prognosis in such pts remains poorly understood. Purpose To identify factors associated with in-hospital mortality in non-high-risk PE pts. Methods A retrospective analysis of 635 medical cards of pts with diagnosis "PE" hospitalized in our clinical hospital during 2017 – 2023 period. The diagnosis was verified by multispiral computed tomography angiography (CTPA) of pulmonary arteries and/or by autopsy. There were 530 non-high-risk pts (83,4%). Pts were divided into groups: І group - pts who were discharged from hospital with improved status (479 – 90,4%), II group - pts who died in hospital (51 – 9,6%). Clinical, anamnestic, laboratory and instrumental parameters were measured. Statistical analysis was performed. Results According to multivariate analysis of variance, independent factors, which were associated with in-hospital mortality in pts with non-high-risk PE, were: the presence of atrial fibrillation, obesity, age, history of venous thromboembolism, lower levels of O2 saturation, systolic blood pressure (SBP) and higher pulmonary artery pressure (PAP). ROC analysis was performed to determine the thresholds of factors that were associated with in-hospital mortality: SBP ≤124 mmHg, HR≥110 bpm, PAP ≥54 mmHg, age>54 yo. Conclusions The factors which were associated with in-hospital mortality in pts with non-high-risk PE were: age, SBP, history of VTE, obesity, AF; blood saturation level, pulmonary artery pressure level.

Perfusion index: could it be a new tool for early identification of pulmonary embolism severity?

Perfusion index (PI) is a promising indicator for monitoring peripheral perfusion. The present study aimed to compare the efficiency of PI and PESI score in estimating the 30-day mortality and treatment needs of patients diagnosed with pulmonary embolism in the emergency department. This study was prospective and observational. The demographic features of the patients, comorbidities, vital signs, PESI score, PI, treatment applied to the patient and airway management, right ventricular diameter/left ventricular diameter ratio, length of hospital stay, outcome, and 30-day mortality were recorded. A total of 94 patients were included. All patients' vital signs and PI values were recorded on admission. The mean pulse rate (p = 0.001) and shock index (p = 0.017) values of deceased patients were statistically significantly higher, while the mean PI (p = 0.034) was statistically significantly lower. PESI score and PI were statistically significant to predict the need for mechanical ventilation (PI, p = 0.004; PESI score, p < 0.001), inotropic treatment (PI, p = 0.047; PESI score p = 0.005), and thrombolytic therapy (PI, p = 0.035; PESI score p = 0.003). According to the ROC curve, the mortality prediction power of both PESI (AUC: 0.787, 95% CI 0.688-0.886, cutoff: 109.5, p < 0.001) and PI index (AUC: 0.668, 95% CI 0.543-0.793, cutoff: 1, p = 0.011) were determined as statistically significant. PI might be helpful in clinical practice as a tool that can be applied to predict mortality and treatment needs in PE.

Charlson and Elixhauser Comorbidity Indices for Prediction of Mortality and Hospital Readmission in Patients With Acute Pulmonary Embolism.

Several risk stratification systems aid clinicians in classifying pulmonary embolism (PE) severity and prognosis. We compared 2 clinical PE scoring systems, the PESI and sPESI scores, with 2 comorbidity indices, the Charlson Comorbidity Index (CCI) and the val Walraven Elixhauser Comorbidity Index (ECI), to determine the utility of each in predicting mortality and hospital readmission. Information was collected from 436 patients presenting with PE via retrospective chart review. The PESI, sPESI, CCI, and ECI scores were calculated for each patient. Multivariate analysis was used to determine each system's ability to predict in-hospital mortality, 90-day mortality, overall mortality, and all-cause hospital readmission. The impact of various demographic and clinical characteristics of each patient on these outcomes was also assessed. The PESI score was found to be an independent predictor of in-hospital mortality and 90-day mortality. The PESI score and the CCI were able to independently predict overall mortality. None of the 4 risk scores independently predicted hospital readmission. Other factors including hypoalbuminemia, serum BNP, coagulopathy, anemia, and diabetes were associated with increased mortality and readmission at various endpoints. The PESI score was the best tool for predicting mortality at any endpoint. The CCI may have utility in predicting long-term outcomes. Further work is needed to better determine the roles of the CCI and ECI in predicting patient outcomes in PE. The potential prognostic implications of low serum albumin and anemia at the time of PE also warrant further investigation.

Utilization of a Novel Scoring System in Predicting 30-day Mortality in Acute Pulmonary Embolism, the CLOT-5 Pilot Study.

To construct a new scoring system utilizing biomarkers, vitals, and imaging data to predict 30-day mortality in acute pulmonary embolism (PE). Acute PE, a well-known manifestation of venous thromboembolic disease, is responsible for over 100,000 deaths worldwide yearly. Contemporary management algorithms rely on a multidisciplinary approach to care via PE response teams (PERT) in the identification of low, intermediate, and high-risk patients. The PESI and sPESI scores have been used as cornerstones of the triage process in assigning risk of 30-day mortality for patients presenting with acute PE; however, the specificity of these scoring systems has often come into question. This study retrospectively analyzed 488 patients with acute PE who were managed at a tertiary care institution with either conservative therapy consisting of low molecular weight or unfractionated heparin, advanced therapies consisting of catheter directed therapies, aspiration thrombectomy, or a combination of these therapies, or surgical embolectomy. The CLOT-5 score was designed to include vital signs, biomarkers, and imaging data to predict 30-day mortality in patients presenting with acute PE. The CLOT-5 score had an area under the curve (AUC) of 0.901 with a standard error of 0.29, while the PESI and sPESI scores had an AUC and standard errors of 0.793 ±- 0.43 and 0.728 ± 0.55, respectively. When incorporated into the management algorithms of national PERT programs, the CLOT-5 score may allow for rapid and comprehensive assessment of patients with acute PE at high risk for clinical decompensation, leading to early escalation of care where appropriate.

Association between CHA2DS2-VASc and PESI scores and right ventricular dysfunction in patients with acute pulmonary thromboembolism diagnosed by computed tomography pulmonary angiography

Association between CHA2DS2-VASc and PESI scores and right ventricular dysfunction in patients with acute pulmonary thromboembolism diagnosed by computed tomography pulmonary angiography

The relationship between echocardiographic parameters and albumin bilirubin score in patients with acute pulmonary thromboembolism.

The Albumin-Bilirubin (ALBI) score is useful and easy-to-use for objectively assessing liver function. We investigated whether the ALBI score, a parameter indicating liver stiffness, congestion and fibrosis, has any relationship with echocardiographic parameters in patients with acute pulmonary thromboembolism (PTE). A total of 140 patients diagnosed with acute PTE were retrospectively analyzed. These patients were divided into three groups according to the hemodynamic severity of acute PTE: Group I [Low risk]; Group II [Submassive or intermediate-risk]; and Group III [Massive or high-risk]. Biochemical data obtained from venous blood samples taken at admission were analyzed. In addition, data were also analyzed from transthoracic echocardiography and pulmonary computed tomographic angiography performed at admission. ALBI, Bova, and PESI scores were calculated. ALBI scores (-3.32 ± 0.21 vs -2.86 ± 0.15 vs -2.46 ± 0.2, p < .001) were statistically significantly higher in Group III than Groups I and II. There was a significant difference between the three groups in terms of echocardiographic parameters, and LVEF and TAPSE values tended to decrease from group I to group III. In multivariate linear regression analysis, sPAP, RV/RA diameter, and NT-pro-BNP were found to be significantly associated with the ALBI score. An ALBI score higher than -2.87 was associated with Bova stage II-III in patients with Group I and Group II PTE, with a sensitivity of 87% and a specificity of 62% (AUC = 0.804; 95% CI 0.713-0.895; p < .001). The ALBI score, which is a common, easy-to-use, and inexpensive method, may be beneficial to select intermediate and high-risk patients in patients with acute PTE. Additionally, it may have prognostic value in distinguishing low and intermediate-risk acute PTE patients.

Pulmonary Embolism in Senegal: Epidemiology, Diagnosis and Management Challenges

Introduction: Pulmonary embolism (PE) is a life-threatening condition that represents a major challenge in the management of patients in intensive care. Despite recent advances in prophylactic, diagnostic and therapeutic modalities, PE remains an important cause of morbidity and mortality. Hence the interest of this retrospective study on the management of pulmonary embolism of patients hospitalized in the resuscitation unit of the Peace Hospital of Ziguinchor. Methodology: We conducted a retrospective, descriptive and analytical study covering a period of 32 months from September 2020 to May 2023. The data included variables such as age, gender, clinical symptoms, results of paraclinical tests and treatments administered. Results: The sex ratio was 1.72 with a majority age group of 40-59 years. The average age was 58.93 years for a median age at 58 years. Prolonged immobilization greater than 3 days was the risk factor most found in our patients 33.3% followed by hypertension in 13.3%. Respiratory distress is the main reason for hospitalization in 66.7%. The intermediate clinical probability was most found in our population with 90%. In 53.3% of our patients, the lung damage was unilateral against bilateral for 23.3% at CT-scan. Admission shock was found in 6.7%. In 43.3%, amines were used including noradrenaline at 26.7% and dobutamine at 20%. LMWH were the anticoagulants used in all patients followed by VKA (Acenocoumarol) with 40%. Only 6.7% of our patients were thrombolysed. Mortality was 63.3%. The prognosis according to the PESI score is 53.3% for class 5 and the progressive modalities were poor in 70% of cases. Conclusion: The factors of poor prognosis found are disorders of consciousness, respiratory failure and PESI class 5. This study highlights the urgency of strengthening initiatives for the prevention, diagnosis and treatment of PE. It is vital to work to improve access to thrombolysis in order to reduce mortality and improve quality of life for ......

Different impact of each score component in the simplified PESI score on acute mortality of patients with pulmonary embolism in the era of direct oral anticoagulant

Abstract Background The simplified pulmonary embolism severity index (sPESI) score could help the risk stratification of acute mortality in patients with pulmonary embolism (PE) including identification of low-risk patients for outpatient treatment. The sPESI score consisted of six components such as age, history of cancer, history of chronic cardiopulmonary disease, heart rate, systolic blood pressure (sBP), and O2 saturation. However, the prognostic impact of each score component on acute mortality has not been fully evaluated in the era of direct oral anticoagulant (DOAC). Methods The COMMAND VTE Registry-2 is a multicenter registry enrolling 5,197 consecutive acute symptomatic venous thromboembolism (VTE) patients among 31 centers in Japan between January 2015 and August 2020. In the current study, we evaluated 927 PE patients with the sPESI score 1, and investigated the impact of each score component on acute mortality and detailed causes of deaths. Results The distribution of score components of sPESI score were as follows; 80 years or older: 128 patients (14%), history of cancer: 353 patients (38%), history of chronic cardiopulmonary disease: 91 patients (9.9%), heart rate over 110 bpm: 72 patients (7.8%), sBP under 100 mmHg: 18 patients (2.0%), and O2 saturation under 90%: 258 patients (28%). Among the current study population, 736 patients (79%) developed PE out of hospital, and a majority of them (83%) admitted to the hospital with a median length of hospital stay of 14 days. The cumulative 30-day incidence of all-cause death was 2.1%, and the proportions of mortality varied widely depending on different score component of the sPESI (80 years or older: 0.8%, history of cancer: 4.6%, history of chronic cardiopulmonary disease: 1.1%, heart rate over 110 bpm: 0%, sBP under 100 mmHg: 0%, and O2 saturation under 90%: 0.4%). Among all-cause death events, PE-related deaths accounted 1 in patients with history of cancer, 1 in those with history of chronic cardiopulmonary disease, and 1 in those with O2 saturation under 90%. Conclusions The risk of acute mortality in patients with sPESI score 1 was relatively low in the era of DOAC, although that could vary widely according to each score component of the sPESI score, which could be useful for the further risk stratification among these patients.

Prevalence and clinical significance of deep vein thrombosis in Hispanic patients with acute pulmonary embolism.

The prevalence of concomitant deep vein thrombosis (DVT) and its impact on 30-day outcomes in Hispanic patients with acute pulmonary embolism (PE) is unknown. We retrospectively studied a cohort of Hispanic patients admitted for acute PE to determine the relationship of concomitant DVT to clot burden on chest computer tomography (CT), right heart strain, and 30-day mortality. We identified 391 patients admitted with acute PE; 168 (42.9%) had concomitant DVTs on admission; 39 patients (9.9%) died during the 30-day follow-up: 12 patients without concomitant DVT and 27 with concomitant DVT, respectively (p < .001). The presence of a proximal DVT independently predicted 30-day mortality even after adjusting for age, gender and admission PE severity index scores (PESI) (hazard ratio [HR] 2.0; 95% confidence interval [CI]: 1.4-3.0, p = .001). Proximal DVTs remained a significant predictor of 30-day mortality in patients with low and intermediate PESI scores (HR 2.5; 95% CI: 1.1-6.0, p = .035). The prevalence of concomitant DVT in Hispanic patients presenting with acute DVT is relatively lower than other ethnic groups. However, a proximal location of a DVT is of significant prognostic relevance. Hispanic patients with acute PE should routinely undergo compression doppler ultrasonography (CDUS) of the lower extremities.

Pulmonary embolism post-Covid-19 infection: physiopathological mechanisms and vascular damage biomarkers

Covid-19 infection is characterized by several acute complications, as well long-term sequelae, mostly sustained by endothelial dysfunction; several studies show that complications as pulmonary embolism (PE) are described both in the acute phase and after negativization. Aim of research was to evaluate anthropometric, bio-humoral, instrumental parameters in a group of patients affected by PE after recent Covid-19 infection compared to PE patients without previous Covid-19 infection. We enrolled 72 consecutive patients (35M, 37F) with acute PE, distinguished in relation to previous acute Covid-19 infection: 54 pts without previous acute Covid-19 infection and 18 pts with previous Covid-19 infection within negativity at least 2 months before PE diagnosis; 44 healthy subjects (21M, 23F) were recruited as control group. Patients who had previously developed Covid-19 needed hospitalization in high percentage (84%); this group showed significantly higher prevalence of diabetes mellitus than Covid-19-free PE patients, reduced serum levels of C-reactive protein, sST2 and PESI score. In post-Covid-19 PE group, we observed higher mean IMPROVE risk score, whereas in Covid-19-free group lower P/F ratio, higher radiological severity, and worse PESI score and severity index. Covid-19 infection affects not just the lung parenchyma but also other organs; endothelial damage plays pivotal role in long-term alterations; in high thrombotic risk group (recent hospitalization due to acute Covid-19 infection), we have described thrombotic complications characterized by persistent prothrombotic state after recovery, highlighted by well-known markers as PCR and D-Dimer as well as novel vascular marker (sST2).

Predictors of pulmonary embolism in hospitalized patients with COVID-19

BackgroundHigh venous thromboembolism (VTE) rates have been described in critically ill patients with COVID-19. We hypothesized that specific clinical characteristics may help differentiate hypoxic COVID-19 patients with and without a diagnosed pulmonary embolism (PE).MethodsWe performed a retrospective observational case-control study of 158 consecutive patients hospitalized in one of four Mount Sinai Hospitals with COVID-19 between March 1 and May 8, 2020, who received a Chest CT Pulmonary Angiogram (CTA) to diagnose a PE. We analyzed demographic, clinical, laboratory, radiological, treatment characteristics, and outcomes in COVID-19 patients with and without PE.Results92 patients were negative (CTA-), and 66 patients were positive for PE (CTA+). CTA + had a longer time from symptom onset to admission (7 days vs. 4 days, p = 0.05), higher admission biomarkers, notably D-dimer (6.87 vs. 1.59, p < 0.0001), troponin (0.015 vs. 0.01, p = 0.01), and peak D-dimer (9.26 vs. 3.8, p = 0.0008). Predictors of PE included time from symptom onset to admission (OR = 1.11, 95% CI 1.03–1.20, p = 0.008), and PESI score at the time of CTA (OR = 1.02, 95% CI 1.01–1.04, p = 0.008). Predictors of mortality included age (HR 1.13, 95% CI 1.04–1.22, p = 0.006), chronic anticoagulation (13.81, 95% CI 1.24–154, p = 0.03), and admission ferritin (1.001, 95% CI 1-1.001, p = 0.01).ConclusionsIn 158 hospitalized COVID-19 patients with respiratory failure evaluated for suspected PE, 40.8% patients had a positive CTA. We identified clinical predictors of PE and mortality from PE, which may help with early identification and reduction of PE-related mortality in patients with COVID-19.

P372 PULMONARY EMBOLISM IN CARDIAC INTENSIVE CARE UNIT–REAL–WORLD EXPERIENCE OF A TERTIARY CENTER

Abstract Introduction Pulmonary thromboembolism represents a therapeutic challenge for patients admitted to cardiology intensive care units, given the variety of clinical presentations and available treatment opportunities. Methods This retrospective, single–center study recruited patients hospitalized in cardiology intensive care units with a diagnosis of pulmonary thromboembolism between April 2010 and May 2022. For each hospitalized patient, Wells and PESI scores were calculated, the location of the PE was identified, and acute PE resolution at discharge was determined. Patients with cardiac arrest (CCA) and/or cardiogenic shock were identified, and RV longitudinal systolic function (TAPSE) and pulmonary arterial systolic pressure (PASP) were studied. Patients were then stratified based on their clinical risk of in–hospital or 30–day mortality (early mortality); acute phase and discharge treatments and patients who developed major bleeding complications were identified. Results A total of 148 patients were recruited, with a median age of 66 years and predominantly male (51.4%). In 6.4% of patients, in–hospital death occurred (from 0% in low–risk patients to 25% in high–risk patients), 12.2% developed cardiogenic shock and/or CCA. 25.0% of patients had an ongoing neoplasm. Systemic thrombolytic therapy and Sonos were the most effective in terms of mortality (p=0.015) and RV function at discharge in high–risk patients, although associated with a high risk of bleeding. Intermediate–low–risk patients treated with reperfusion therapy showed better RV function parameters, although the sample size did not allow for statistical significance. Conclusions The results obtained are in line with those of the literature with regard to epidemiology, total hospital stay, correlation between acute PE and neoplasms, in–hospital death and FU death. Furthermore, Sonos represents an effective alternative to full–dose systemic thrombolysis in high–risk patients who cannot undergo the latter. Finally, in intermediate–low risk patients, there may be a role for reperfusion therapy in selected patients with very low bleeding risk.

Фібриляція передсердь як прогностичний фактор у пацієнтів з тромбоемболією легеневої артерії

Мета роботи – проаналізувати особливості клінічного перебігу та визначення прогностичних критеріїв у пацієнтів з тромбоемболією легеневої артерії (ТЕЛА) та супутньою фібриляцією передсердь (ФП).Матеріали і методи. Проведено ретроспективний аналіз 243 медичних карток стаціонарних пацієнтів з діагнозом «ТЕЛА», що були послідовно госпіталізовані до КНП «МКЛ № 8» ХМР у період з 01.01.2018 до 01.01.2020. Критерій залучення – діагноз «ТЕЛА», верифікований мультиспіральною комп’ютерною томографічною ангіогра­­фією (МСКТ-ангіографія) легеневих судин та/або за результатами автопсії. Хворі були розподілені на групи: 1 – 45 (18,5 %) пацієнтів з ТЕЛА і ФП, 2 – 198 (81,5 %) пацієнтів з ТЕЛА без ФП. Пацієнти групи 1 були розподілені на підгрупи: 1А – 22 (48,8 %) хворих з ТЕЛА і ФП de novo; 1Б – 23 (51,2 %) хворих з ТЕЛА і ФП, що була наявна до епізоду гострої ТЕЛА. Проаналізовано клініко-анамнестичні, лабораторно-інструментальні параметри, рівні летальності, проведено статистичний аналіз даних.Результати та обговорення. Пацієнти з групи 1 були старшими (відповідно (67,2±10,6) і (58,6±14,6) року), мали більше випадків ішемічного інсульту в анамнезі. Під час госпіталізації пацієнтів з високим ризиком було більше в групі 1; у хворих з невисоким ризиком за індексом PESI було більше балів, вони мали нижчу сатурацію крові, більшу частоту серцевих скорочень. За лабораторними показниками групи відрізнялися за рівнем нейтрофілів та креатиніну. За даними МСКТ-ангіографії легеневої артерії (ЛА) групи відрізнялися за розмірами легеневого стовбура, діаметрами легеневих артерій; за даними ехокардіографії – за розмірами лівого та правого передсердь, кінцеводіастолічним і кінцевосистолічним розмірами лівого шлуночка (ЛШ), фракцією викиду ЛШ, середнім тиском у ЛА. При порівнянні груп 1А та 1Б була виявлена різниця щодо кількості ішемічних інсультів (більше в групі 1Б). Значна частина хворих з групи 1А були з високим ризиком, крім того, пацієнти обох груп мали великі індекси за шкалою PESI. За лабораторними показниками групи статистично значуще відрізнялися за рівнем нейтрофілів та креатиніну. Розмір лівого передсердя був статистично значуще більшим у групі 1Б, проте середній тиск у ЛА був вищим у групі 1А. Загальна летальність становила 18,5 %, летальність в осіб без ФП та з ФП суттєво відрізнялася (відповідно 13,6 і 44,4 %). Статистично значуща різниця також спостерігалася за рівнем летальності в групах 1А та 1Б (відповідно 67,5 і 21,7 %). За даними уні- та мультиваріантного аналізу визначено фактори, що впливають на прогноз, зокрема ФП.Висновки. У хворих з ТЕЛА ФП трапляється у 18,5 %, а у 9 % – уперше діагностована. Хворі з ФП і ТЕЛА в середньому були старшими за хворих з ТЕЛА без ФП на 8,6 року. У групі хворих з ФП рідше виявляють тромбоз вен нижніх кінцівок. У хворих з ФП статистично значуще більші розміри не тільки лівого, а й правого передсердя та нижча ФВ ЛШ. ФП, як і вік, сатурація крові киснем, наявність ожиріння, кількість балів за індексом PESI, є незалежним чинником, що пов’язаний з несприятливим прогнозом (госпітальною летальністю). За результатами моделі Каплана – Мейєра, найбільш виразний негативний вплив на найближчий прогноз має вперше діагностована ФП.

Prediction of in-hospital mortality in patients with acute pulmonary embolism requiring invasive mechanical ventilation: comparation of risk scores

Abstract Funding Acknowledgements Type of funding sources: None. Introduction High-risk pulmonary embolism (PE) is a life-threatening disorder associated with high mortality and morbidity. Multiple scores are used to predict in-hospital mortality of patients admitted to intensive care units. The purpose of this study is to assess which risk score is best at predicting in-hospital mortality in a specific population of patients requiring invasive mechanical ventilation. Methods Retrospective analysis of 33 patients admitted for high-risk pulmonary embolism requiring invasive mechanical ventilation in a general intensive care unit during a period of 15 years. Clinical, analytical, and imaging parameters were evaluated. The PESI, Apache II, SAPS II, and SOFA scores were obtained at ICU admission. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive value of each score for in-hospital mortality. Results Mean age was 59,1±16 years; 55% were men. 27% presented with a cardiorespiratory arrest at admission. Mean values risk scores were: PESI 138±51, Apache II 23±9, SAPS II 49±23, and SOFA 8±3. In-hospital mortality was 45,4%. The mean duration of hospitalization was 14,8±17,9 days. Mean pulmonary systolic arterial pressure was 51,5±14,63mmHg. Mean values of maximum troponin I and d-dimers were 2,97±7,99 and 6603±5541 ng/mL, respectively. ROC curve analysis revealed that Apache II (AUC 0,752; p=0,02; CI 95% 0,58;0,92), SAPS II (AUC 0,718; p=0,04; CI 95% 0,52;0,91) and PESI (AUC 0,754; p=0,02; CI 95% 0,6;0,91) had best predictive performance for in-hospital mortality compared to SOFA (AUC 0,641; p=0,2; CI 95% 0,42;0,9). The following cut-off values were obtained: PESI of 130 (sensitivity (S)≈85% and specificity (E)≈53%), Apache II of 26 (S≈62% and E≈77%), and SAPS II of 52 (S≈69% and E≈70%). Conclusion In this population, PESI, Apache II, and SAPS II scores were better predictors of in-hospital compared to SOFA score.

Utility of Combining High-Sensitive Cardiac Troponin I and PESI Score for Risk Management in Patients with Pulmonary Embolism in the Emergency Department.

Pulmonary embolism (PE) has a major burden of morbidity and mortality, consequently the need for a prompt risk stratification for these subjects is crucial. In order to evaluate the risk management and final disposition of patients with PE in the Emergency Department (ED), we conducted a study that was divided in two phases: Phase I retrospective study (RS), Phase II prospective study (PS). In Phase I, 291 patients were enrolled while in Phase II, 83 subjects were evaluated. In both study phases, the enrolled subjects were analyzed for final disposition in ED using PESI score, right ventricle (RV) imaging, and high-sensitive cardiac troponin I (hs-cTnI) data. The RS patients were divided into low risk and high risk according to the sPESI score, while PS patients were grouped in low, intermediate, and high risk classes according to PESI score. In both study phases, all the studied patients were further divided into negative (hs-cTnI-) or positive (hs-cTnI+) groups according to hs-cTnI levels within normal or above cutoff values, respectively. For all enrolled subjects, CT pulmonary angiography was analyzed to assess the RV/LV diameter and volume ratio as an indicator of RV involvement. In both RS and PS phases, hs-cTnI+ group showed a higher PESI score. Nevertheless, a significant percentage of hs-cTnI+ patients resulted to be in the low-risk PESI class. Patients with a positive RV/LV ratio were more likely to have a hs-cTnI+ (p < 0.01), while among those with a negative ratio, 24 to 32% showed as hs-cTnI+. In the hs-cTnI+ group from both study phases, patients were more likely to be admitted in an ICU (RR 3.7, IC: 2.1-6.5). In conclusion, in patients with PE in the ED compared PESI score alone, the combination of hs-cTnI and PESI seems to be of greater utility in improving risk stratification and final disposition decision-making.