Primary Pulmonary Embolism Research Articles

Long-term prognosis in patients with pulmonary embolism

Venous thromboembolism (VTE), clinically expressed as deep vein thrombosis (DVT) or pulmonary embolism (PE), is, globally, the third most common acute cardiovascular syndrome after myocardial infarction and stroke. Pulmonary embolism is associated with high morbidity and mortality. The long-term prognosis of these patients is insufficiently studied.Aim: To analyze mortality and clinical events at long-term follow-up in patients with confirmed PE. Material and methods: The study included 168 patients with PE, 53% men and 47% women, mean age 61.2±12.8 years, consecutively hospitalized in the Institute of Cardiology. Patients were classified into four risk groups according to the 2019 European Society of Cardiology Guidelines. Patients were followed-up for a mean period of 11.4±0.9 months. Results. During the study period died 23 people (13.7%), 8 of them during hospitalization and another 15 - after discharge from the hospital; in the latter, death occurred suddenly - in 4 cases (26.6%), it was due to cardiovascular causes- in 4 cases (26.6%), through cancer - in 5 (30%) people and from other causes - in 2 (13.3%) patients. Recurrent VTE was observed in 4 (2.5%) subjects, including PE - in 3 and DVT in 1 patient. During the surveillance period 4 (2.5%) patients developed stroke, 5 (3.1%) - acute myocardial infarction, 1 (0.2%) patient - another arterial event. Hemorrhagic complications suffered 20 patients. Chronic thromboembolic pulmonary hypertension was detected in 12.4% of people over 5.4±2.8 months after primary PE. Newly diagnosed cancer was observed in 2 (1.25%) people.Conclusions. The mortality rate in PE patients over an average period of 11.4±0.9 months was 13.7%, including 4.7% - in hospital and 8.9% - at long-term follow-up; in-hospital death was significantly higher in patients in the high and intermediate high risk category compared to those with intermediate-low and low risk and no statistically significant differences were established between these groups in the long-term mortality rate; the main cause of death in the hospital was PE, and during the surveillance period death from cardiovascular causes predominated, followed by death from cancer.

Is it safe to discontinue anticoagulant after surgical treatment of varicose vein disease, which caused pulmonary embolism?

Superficial vein thrombosis, which is mostly caused by lower extremity varicose vein disease, can be complicated by pulmonary embolism. At the same time, the optimal duration of anticoagulant therapy for pulmonary embolism originated from varicose vein thrombosis is still under debate. On the one hand, the presence of varicose veins is considered a small risk factor for the development of venous thromboembolic events, which persistence determines an increased risk of relapse and requires prolonged anticoagulant therapy. On the other hand, elimination of varicose veins is associated with reduced risk of subsequent venous thromboembolic events. The article describes a clinical case of recurrent pulmonary embolism after surgical treatment of varicose vein disease, which caused primary pulmonary embolism. A 45-year-old patient suffering from left lower extremity varicose vein disease for 5 years was admitted to the intensive care unit with suspected pulmonary embolism. The further examination revealed signs of thrombotic occlusion of the segmental and subsegmental branches of the pulmonary arteries bilaterally and the middle lobe branch of the right pulmonary artery, as well as signs of the right-sided heart overload. In this case, pulmonary embolism was found to originate from thrombosis of the trunk of the great saphenous vein ofthe left lower extremity with a proximal border at the level of the lower leg. No signs of deep vein involvement were detected. The parenteral anticoagulant therapy initiated in the hospital was followed by switching to therapeutic doses of rivaroxaban. The signs of recanalization of involved veins were identified after 6 months of treatment, and it was decided to perform endovenous laser coagulation of the trunk of the great saphenous vein combined with mini-phlebectomy of varicose tributaries on continuous oral anticoagulant therapy. The rivaroxaban therapy was completed a month after intervention. However, 7 days later the patient was diagnosed with repeated symptomatic pulmonary embolism, which originated from thrombosis of the left popliteal vein. It was recommended to resume anticoagulant therapy of indefinite duration. The article discusses the issues of optimal duration of treatment for pulmonary embolism originated from thrombosis of superficial varicose veins, as well as the possible timing of completion of anticoagulant therapy after the intervention.

Long-term anticoagulant therapy in the aspect of secondary prevention of recurrent pulmonary embolism

Aim. To determine differences in laboratory coagulation parameters using routine and integral monitoring methods in patients depending on anticoagulant therapy >12 months after pulmonary embolism (PE) with a high recurrence risk.Material and methods. The study included 72 patients who, according to indications, received long-term anticoagulant therapy >12 months due to a high risk of recurrent thromboembolism. During the follow-up period (15-20 months from the first pulmonary embolism episode), the plasma coagulation parameters were studied using a conventional panel and D-dimer assessment, as well as a thrombin generation test and thrombodynamics. Patients adherent to prolonged anticoagulation were included in group 1. During the collection period, 8 patients independently stopped taking anticoagulants, despite the high risk of recurrent pulmonary embolism (group 2).Results. There were no significant differences in coagulation parameters and D-dimer levels between the studied groups of patients. In the group of patients continuing to take anticoagulants, there was an increase in clot growth delay parameters in comparison with patients of group 2 according to the thrombodynamics results (p=0,046) and the thrombin generation test in platelet-poor plasma in comparison with reference values (p=0,001).Conclusion. Long-term anticoagulant therapy effectively prevents recurrent venous thromboembolism. In patients after primary pulmonary embolism who refuse anticoagulation, the clot growth delay values are shortened, which indicates an increased risk of recurrent venous thromboembolism. The most stable plasma coagulation parameters are observed in patients taking direct oral anticoagulants.

In-hospital outcomes of acute pulmonary embolism in patients with gastrointestinal cancer: A nationwide study.

624 Background: Cancer is a well-established risk factor for the development of pulmonary embolism (PE), especially the. gastrointestinal (GI) cancers. While multiple studies have reported the burden of PE in cancer patients, recent data comparing in-hospital outcomes among different types of cancer patients are lacking. This study aimed to investigate the clinical and healthcare utilization outcomes of hospitalized patients with acute PE in the context of gastrointestinal (GI) cancers. Methods: A cross-sectional study was conducted using data from the National Inpatient Sample (2016-2020). International Statistical Classification of Diseases (ICD-10) codes were employed to identify hospitalized patients admitted with primary diagnosis acute PE. Data regarding GI cancer diagnosis along with demographic information, baseline clinical characteristics, and outcome variables, including mortality, hospital length of stay, total hospital charges, complications and risk factors were collected and analyzed. Statistical analysis was performed using the survey procedures function in STATA v.17, with statistical significance defined by the t-test at a significance level of p < 0.05. Results: Among the 181,060 patients admitted with primary diagnosis of acute pulmonary embolism, 550 (0.3%) had underlying gastric cancer, 1,790 (0.98%) had pancreatic cancer, 875 (0.48%) had hepatobiliary cancer, and 2,600 (1.61%) had small intestine and colorectal cancer. Mortality was found to be significantly higher in all types of GI cancer, with gastric cancer demonstrating the highest mortality rate (10%). After adjusting for age, sex, race, payment category, comorbidities, and risk factors of PE, gastric cancer (OR 2.6; 95% CI: 1.1-6.2) and pancreatic cancer (OR 2.2; 95% CI: 1.4-3.4) were found as independent risk factors for mortality. There was no significant difference in mean length of hospital stays and mean total hospital charges in patients with or without cancer. Similarly, no significant differences were observed in complications such as requirement for mechanical ventilation, arrhythmia, cardiac arrest, need for vasopressor and thrombolysis. Conclusions: In-hospital mortality in patients with acute pulmonary embolism is significantly higher in all types of GI cancer, however; there is no significant differences in hospital length of stay and total hospital charges in patients with or without cancer.

P-11 Case report of Primary Hyperparathyroidism and Pulmonary Embolism

Abstract Introduction Primary hyperparathyroidism (PHPT) is a disorder characterized by excessive parathyroid hormone secretion, resulting in hypercalcaemia. Patients with PHPT are believed to be in a hypercoagulable state due to the role of calcium in the platelet function and the coagulation pathway. Clinical Case An 82-year-old male with a background history of deep vein thrombosis twelve years ago, was admitted with left leg pain following a fall, he was found to have an intra-capsular left neck of femur fracture for which he underwent left hip hemiarthroplasty at a later stage during his admission. He was also found to have adjusted calcium of 2.9 mmol/L at admission, parathyroid hormone of 15.2 pmol/L, raised urine calcium-creatinine ratio of 0.39 and he was vitamin D replete (vitamin D 50.3 nmol/L). He was treated for delirium and a urinary tract infection and his inflammatory markers continued to worsen, this triggered performing a CT scan of the chest, abdomen and pelvis, which revealed a right parathyroid nodule and an acute pulmonary embolism (PE). He was commenced on prophylactic dose of low molecular weight heparin at admission, it was changed to a therapeutic dose of low molecular weight heparin after the PE diagnosis and then to Apixaban for three months. The patient was assessed to not be suitable for parathyroidectomy, the decision was made to manage the PHPT medically and he is going to be followed up locally at the Endocrinology Clinic. Conclusion There have been few case reports suggesting a correlation between the hypercalcaemic PHPT and the risk of venous thromboembolism. Ionised calcium is necessary for thrombin formation, platelet activation and aggregation, as well as activation of various clotting factors, such as factor VII and factor X. Studies have also shown that these patients have increased protein S activity and fibrinogen levels. This case, among other cases that we have observed in our hospital, highlights that the hypercalcaemia could pose an additional hypercoagulability risk in the presence of other risk factors.

A primary pulmonary artery sarcoma masquerading pulmonary embolism: a case report and literature review

BackgroundPrimary pulmonary artery sarcoma (PAS) is an extremely rare malignant tumor with a poor prognosis. The clinical manifestations of PAS are diverse, including dyspnea, chest pain, cough, and hemoptysis. The poor prognosis is often due to delayed diagnosis caused by similarity in imaging findings with pulmonary thromboembolism (PTE). These cues of diagnosis include the “wall eclipsing sign”, lobulated bulging margins, gadolinium enhancement during MRI imaging, and FDG uptake during PET/CT imaging. However, there are still many misdiagnoses.Case presentationThis article reports a woman of reproductive age presenting with a pulmonary artery mass. The computed tomographic pulmonary angiography and positron emission tomography/computed tomography did not show obvious signs of pulmonary artery sarcoma, however, contrast-enhanced echocardiography showed moderate perfusion, which helped differentiate between pulmonary artery sarcoma and pulmonary artery thrombosis, leading to timely surgical treatment.ConclusionsPAS is a rare form of cancer that can occasionally be visually similar to PTE on radiographic images. Early diagnosis of PAS is of vital importance to the prognosis of the patients. There are several visual cues that can help differentiate between the two conditions. Additionally, contrast-enhanced echocardiography provides additional information on tumor perfusion, offering another effective approach for a prompt and accurate diagnosis.

Development of a predictive model of venous thromboembolism recurrence in anticoagulated cancer patients using machine learning

IntroductionPatients with cancer and venous thromboembolism (VTE) show a high risk of VTE recurrence during anticoagulant treatment. This study aimed to develop a predictive model to assess the risk of VTE recurrence within 6 months at the moment of primary VTE diagnosis in these patients. Materials and methodsUsing the EHRead® technology, based on Natural Language Processing (NLP) and machine learning (ML), the unstructured data in electronic health records from 9 Spanish hospitals between 2014 and 2018 were extracted. Both clinically- and ML-driven feature selection were performed to identify predictors for VTE recurrence. Logistic regression (LR), decision tree (DT), and random forest (RF) algorithms were used to train different prediction models, which were subsequently validated in a hold-out data set. ResultsA total of 16,407 anticoagulated cancer patients with diagnosis of VTE were identified (54.4 % male and median age 70). Deep vein thrombosis, pulmonary embolism and metastases were observed in 67.2 %, 26.6 %, and 47.7 % of the patients, respectively. During the study follow-up, 11.4 % of the patients developed a recurrent VTE, being more frequent in patients with lung cancer. Feature selection and model training based on ML identified primary pulmonary embolism, deep vein thrombosis, metastasis, adenocarcinoma, hemoglobin and serum creatinine levels, platelet and leukocyte count, family history of VTE, and patients' age as predictors of VTE recurrence within 6 months of VTE diagnosis. The LR model had an AUC-ROC (95 % CI) of 0.66 (0.61, 0.70), the DT of 0.69 (0.65, 0.72) and the RF of 0.68 (0.63, 0.72). ConclusionsThis is the first ML-based predictive model designed to predict 6-months VTE recurrence in patients with cancer. These results hold great potential to assist clinicians to identify the high-risk patients and improve their clinical management.

A case of transient right ventricular failure secondary to severe pulmonary hypertension in setting of methamphetamine use

Methamphetamine has been documented to be associated with pulmonary hypertension. Past studies have shown the association of methamphetamine abuse with pulmonary hypertension; however, cases of isolated acute to subacute right heart failure secondary to methamphetamine use have not been documented. Acute to subacute right heart failure, secondary to methamphetamine use itself represents a diagnostic challenge as there is no specific protocol in place for evaluation for pulmonary hypertension secondary to methamphetamine use and high degree of suspicion is needed to differentiate it from other cardio-pulmonary conditions. Echocardiographic findings of increased right ventricular systolic pressure along with morphological findings suggesting cardiac remodeling in the setting of methamphetamine use is highly suspicious of acute to subacute right heart failure. Early recognition and management, along with long-term abstinence from methamphetamine use is critical to prevent chronic effects on myocardium and to prevent further cardiac remodeling. Although dedicated cardiothoracic imaging and cardiac catheterization can be beneficial; neither of these modalities are needed to establish the diagnosis and to initiate primary interventions. Computed tomography (CT) scan however would be beneficial in excluding other causes of pulmonary hypertension, such as primary pulmonary conditions and pulmonary embolism.

Abstract 11434: Emergency Department Disposition for Patients with Low-Risk Acute Pulmonary Embolism: A Nationwide Analysis

Background: Outpatient management has been shown to be safe and effective for patients presenting to the emergency department (ED) with low-risk acute pulmonary embolism (PE). The degree to which outpatient management for PE has evolved in contemporary clinical practice is uncertain, as is an understanding of whether certain patient or hospital factors are associated with outpatient PE management. Methods: Using the Nationwide Emergency Department Sample, we identified hospitalizations with primary or secondary PE between 2006-2018. We excluded patients who were <18 years old, died during ED visit, received systemic or catheter-directed thrombolysis, or had any of the following: acute coronary syndrome, heart failure, atrial fibrillation, chronic kidney/lung disease, gastrointestinal bleeding, or respiratory failure. Multivariable regression models were utilized to identify patient and hospital factors that predicted discharge to home from the ED. Results: Among 516,670 ED visits with acute PE, 92,108 (17.8%) patients were discharged to home. As compared to those admitted, patients who were managed as an outpatient were younger (median 52, interquartile range (IQR) 26-78 vs 61 IQR (35-87) years, P<0.001), and more female (57.9% vs 53.1%, P<0.001). In more recent years there was a significant increase in discharge from ED to home (9.2% in 2016 to 29.7% in 2018 (relative increase 69.0%, P<0.001)) Panel A. In a sensitivity analysis, when PE was only a primary diagnosis, the rate of home disposition increased from 4.8% to 27.7%, P<0.001. Patient and hospital factors associated with an increased likelihood of home discharge are listed Panel B . Conclusion: Outpatient management of patients with low-risk PE has become increasingly common, with more than one-quarter of patients evaluated in the ED now discharged to home. Patient demographics, seasonal variation, and hospital characteristics were associated with a differential effect on the home disposition.

Venous thromboembolism prophylaxis for women at risk during pregnancy and the early postnatal period.

Venous thromboembolism prophylaxis for women at risk during pregnancy and the early postnatal period.

"Outpatient Management" of Pulmonary Embolism Defined in the Primary Literature: A Narrative Review.

The evidence for the effectiveness of outpatient treatment of low-risk patients with acute pulmonary embolism (PE) continues to mount. However, lack of definitional clarity may hinder understanding of this emerging management strategy and impede translation into clinical practice. We describe the range of definitions provided in the primary outpatient PE literature. We undertook a narrative review of the English-language medical literature indexed in PubMed and Embase through the end of 2019. We identified studies of outpatient treatment of patients with acute PE. Fifty-one studies met our criteria. All studies provided some degree of definition of "outpatient," even if implicit or broad. Forty-six studies (90%) reported 1 or 2 sites of patient discharge (or departure) to home: emergency department (ED)/ambulatory care unit (n = 31), inpatient ward (n = 13), and secondary care clinic (n = 8). Of the 31 ED-based studies, 9 (29%) delimited duration of care (from < 24 to < 48 hours). All inpatient studies placed an outer boundary on the time to discharge within their definition of outpatient care. Definitions of outpatient care in the PE literature vary considerably. The sites, duration, and intensity of care involved in outpatient PE management prior to home discharge range from comprehensive specialty clinic care to an ED evaluation, sometimes coupled with 1 to 5 days of additional inpatient care. Research on the outpatient management of acute PE would benefit from greater definitional clarity as clinicians, departments, and health systems seek to translate this research into real-world clinical practice.

A Case of Bilateral Spontaneous Pneumothorax in a Patient with COVID-19 Pneumonia

One of the rare complications of coronavirus disease-2019 (COVID-19), which can present with different clinical pictures, is pneumothorax. In our case, a patient who did not have predisposing risk factors for pneumothorax such as a history of trauma, smoking, past intubations, asthma, chronic obstructive pulmonary disease, and who developed bilateral spontaneous pneumothorax while under treatment with the diagnosis of COVID-19 is presented. Acute worsening in COVID-19 patients may be due to primary disease or pulmonary embolism. With this case, we emphasize the importance of considering spontaneous pneumothorax in patients with acute clinical deterioration.

Hospitalizations for High-Risk Pulmonary Embolism

BackgroundThe incidence of pulmonary embolism has been increasing. It has been suggested that this may reflect overdiagnosis due to widespread use of computed tomographic pulmonary angiography. The purpose of the present investigation is to further evaluate whether the increasing incidence of pulmonary embolism represents overdiagnosis. MethodsThis was a retrospective cohort study based on administrative data from the National (Nationwide) Inpatient Sample 1999-2014. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used. The population of the United States according to year was determined from the Centers for Disease Control and Prevention. ResultsThe incidence of pulmonary embolism increased from 65/100,000 population in 1999 to 137/100,000 population in 2014 (P < .0001). High-risk pulmonary embolism increased from 2.2/100,000 population to 9.9/100,000 population (P < .0001). The incidence of primary pulmonary embolism increased from 40/100,000 population in 1999 to 73/100,000 population in 2014 (P < .0001). High-risk pulmonary embolism in patients with a primary diagnosis of pulmonary embolism increased from 0.8/100,000 population in 1999 to 2.3/100,000 population in 2014 (P < .0001). Among patients with pulmonary embolism, the incidence of high-risk pulmonary embolism increased from 1999-2014 (P = .0025). In-hospital all-cause mortality in high-risk patients was 102,402 of 195,909 (52.2%). ConclusionsThe incidence of high-risk pulmonary embolism has increased concordantly with the increasing incidence of all pulmonary embolism. Increasing proportions of patients with potentially lethal pulmonary embolism are being diagnosed.

COVID-19 Complicated by Massive Acute Pulmonary Embolism: A Case Report

Introduction: COVID-19 is an emerging disease that has been spread all over the world. Not all the dimensions and manifestations of the disease have yet been fully explored. One such manifestation is vascular thrombosis that occurs in the lungs and other vessels. However, it is often ignored or mistaken for pulmonary manifestations. Herein, we presented a case with dominant pulmonary embolism manifestations. The COVID-19 symptoms were detected in the patient a few days after heart surgery, and he was appropriately treated and discharged. Case Presentation: The patient was a 62-year-old man visiting with the signs and symptoms of pulmonary embolism. In the CT-angiography, massive pulmonary embolism was reported in the right and left pulmonary arteries of the patient. Moreover, the patient’s echocardiogram showed a clot in the right ventricle in addition to severe right ventricular dysfunction. The patient underwent emergency heart surgery to remove the clot. In the 3 - 4 postoperative days, the pulmonary manifestations of COVID-19 emerged. The throat swab test was positive for COVID-19, and the patient received treatment. After receiving appropriate treatments for about two weeks, the patient was discharged with good general health. Conclusions: The presented case had the primary pulmonary embolism symptoms. However, in the 2 - 3 postoperative days, he showed the COVID-19 symptoms and received treatment. Pulmonary embolism can be a manifestation of COVID-19.

A retrospective observational study investigating the factors associated with right heart failure in patients with primary acute pulmonary embolism and deep vein thrombosis.

BackgroundThe relationship between the risk of right heart failure in primary acute pulmonary embolism after embolization and the residual thrombus sites in the pelvis and lower limbs is not clear.MethodsThis single‐center retrospective observational study examined the results of contrast‐enhanced computed tomography and venous ultrasonography of patients with primary acute PE and DVT. We assessed the association between the occurrence of right heart failure and age; gender; pulmonary thrombosis distribution; most proximal site of deep vein thrombosis in the soleal vein, inferior vena cava (IVC), or common iliac vein (CIV); DVT distribution; and malignancy using univariate and multivariate logistic regression.ResultsIn all, 77 of 165 patients were male (mean age: 65.1 ± 13.7 years). Right heart failure occurred in 53 patients (32.1%). Multivariate analysis revealed that the odds ratio (OR) for right heart failure was significantly lower in patients with the most proximal site of DVT in the IVC/CIV (OR = 0.07, 95% confidence interval [CI] 0.01‐0.62, P = .017), while it was significantly higher in females (OR = 2.51, 95% CI 1.05‐6.01, P = .039), and in patients who exhibited the presence of bilateral venous thrombosis (OR = 3.89, 95% CI 1.60‐9.48, P = .003).ConclusionA significant factor involved in PE without right heart failure was the most proximal site of DVT in the IVC/CIV, and significant risk factors associated with PE with right heart failure were more prevalent in females and in patients who exhibited the presence of bilateral venous thrombosis.

Urban-Rural Variation in Use of Thrombolytic Therapy for Pulmonary Embolism

Background: Thrombolytic therapy is widely accepted for persistent hypotension or shock due to acute pulmonary embolism (PE), with randomized and observational studies demonstrating earlier hemodynamic improvement and possible mortality benefit. The extent to which thrombolytic therapy is used in urban versus non-urban settings is unclear. Methods: We conducted a retrospective cohort study of 92,706 (unweighted) and 180,189 (weighted) admissions with primary diagnosis of PE, for patient aged 18 years and above, that occurred in 2016, at all general acute-care hospitals within the 27 states included in the Nationwide Readmissions Database (NRD). Admissions for primary PE diagnosis and their respective severity levels (minor, moderate, major, extreme) were identified using the All Patient Refined Diagnosis Related Groups. We identified systemic and catheter-directed thrombolytic use using ICD-10-PCS codes. Hospital locations were classified as metropolitan (population ≥50K), micropolitan (10K-50K), and noncore (&amp;lt;10K). National estimates were calculated using post-stratification weights designed to compensate for any over- or under-represented hospital types in the NRD relative target universe of all hospitals in the U.S. PROC SURVEYFREQ and SURVEYLOGISTICS (SAS 9.4) were used to account for complex sampling design in variance calculations. Results: Of all primary PE admissions, 89.5% (95% CI, 88.7-90.2%) occurred at hospitals in metropolitan, 8.0% (95% CI, 7.3-8.7%) in micropolitan, and 2.6% (95% CI, 2.3-2.8%) in noncore areas. Rates of systemic thrombolytic use differed by location: 2.5% (95% CI, 2.3-2.6%) of admissions in metropolitan, 1.1% (95% CI, 0.7-1.4%) in micropolitan, and 0.1% (95% CI, 0-0.3%) in noncore areas (P&amp;lt;.001 for block test; Figure 1). Rates of catheter-directed thrombolytic use also differed: 2.4% (95% CI, 2.1-2.8%) of admissions in metropolitan, 1.5% (95% CI, 0.5-2.5%) in micropolitan, and 0.1% (95% CI, 0-0.2%) in noncore areas (P&amp;lt;.001 for block test). Differences persisted after adjusting for severity of illness for both approaches of thrombolysis (P&amp;lt;.001 in each block test of hospital location). Of patients with highest severity (major and extreme), systemic thrombolysis occurred in 4.0% (95% CI, 3.7-4.3%) of admissions in metropolitan, 1.9% (95% CI, 1.2-2.6%) in micropolitan, and 0.5% (95% CI, 0-1.1%) in noncore hospitals. In this same population, catheter-directed thrombolysis occurred in 2.4% (95% CI, 2.1-2.8%) of admissions in metropolitan, 1.5% (95% CI 0.5-2.5%) in micropolitan, and 0.1% (95% CI, 0-0.2%) in noncore hospitals. Conclusion: There was significant variation in use of systemic and catheter-directed thrombolysis for pulmonary embolism by hospital location. Thrombolytic therapy was rarely reported among noncore hospitals and occurred at a substantially lower rate at micropolitan than at metropolitan hospitals even when adjusted for illness severity. Implications: Efforts should be directed to understand drivers of urban-rural differences in use of thrombolytic therapies (e.g., knowledge, experience, support, resources) to identify potential levers to increase appropriate use of thrombolytic therapy particularly at hospitals in smaller, non-metropolitan communities. Disclosures Rosovsky: Janssen Pharmaceuticals: Consultancy, Research Funding; Bristol-Myers Squibb: Research Funding; Dova Pharmaceuticals: Consultancy.

THE POTENTIALLY PROVOKED PULMONARY EMBOLISM

SESSION TITLE: Medical Student/Resident Pulmonary Manifestations of Systemic Disease 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Venous thromboembolism (VTE) is a common medical diagnosis, but the cause is not always apparent at presentation. Compared to the general population, patients with unprovoked venous thromboembolisms have a higher incidence of underlying cancer. Despite this, aggressive investigation into an underlying malignancy has been controversial. This case demonstrates the observed relationship between an unprovoked venous thromboembolism and underlying malignancy. CASE PRESENTATION: A 29 year-old man with no significant past medical history presented to the emergency department with a three-day history of intermittent left sided chest pain. His symptoms worsened with coughing and with deep inhalation. He denied any palpitations, fevers, chills, but did complain of an unintentional 17-pound weight loss over the past six months. Social history was pertinent for tobacco smoking of 10 cigarettes per day for the past 10 years. He has no recent surgical procedures, periods of prolonged immobility, or recent travel. Blood work was obtained and showed an elevated D-dimer of 1.5 (normal range 0.19 - 0.91 mg/L). Chest x-ray revealed no abnormalities. A CT with contrast of the chest revealed bilateral pulmonary emboli with lingular consolidation, suspicious for an evolving infarct. He was started on therapeutic enoxaparin twice daily with transition to warfarin anticoagulation. Initial thrombophilia testing was unremarkable, revealed normal Protein C, S, antithrombin, and anti-phospholipid antibody levels. A year later, the patient went to his primary care physician due to a right scrotal mass that he noticed increasing in size two months prior to presentation. Physical examination revealed a palpable 2 - 3 cm nodule on the lower right testicle. Testing for sexually transmitted infections was negative. An ultrasound revealed scattered punctate calcifications within a 3.7 x 3.3 x 1.9 cm mass. MRI of the pelvis with gadolinium showed a lobulated, intratesticular mass measuring 1.8 x 2.5 cm. He underwent a right orchiectomy with pathology revealing two hemorrhagic and encapsulated masses in the lower pole of the testes measuring 2.3 x 2.0 cm and 1.0 x 0.8 cm without local invasion into the tunica albuginea. The tumor was found to be a seminoma with negative margins. Decision was made to continue anticoagulation indefinitely, as cancer relapse could occur, and bleeding risk is low. DISCUSSION: Current observational studies show a significant risk of occult malignancy within six months of initial diagnosis of a VTE, but the incidence tends to decline after that timeframe. Despite this association, there has not been substantial evidence to support aggressive diagnostic testing above basic laboratory testing and a thorough history and physical to investigate for underlying cancer. CONCLUSIONS: Continued attention to this association may help clinicians remain vigilant to malignancy in this higher risk population. Reference #1: Sørensen H. "The Risk of a Diagnosis of Cancer after Primary Deep Venous Thrombosis or Pulmonary Embolism". NEJM 1998 Reference #2: Puurunen MK. "Epidemiology of venous thromboembolism in the Framingham Heart Study” Pubmed Central 2016 Reference #3: Robertson L. "Effect of testing for cancer on cancer- and venous thromboembolism (VTE)-related mortality and morbidity in patients with unprovoked VTE” Cochrane Library 2015 DISCLOSURES: No relevant relationships by Michael Adashek, source=Web Response No relevant relationships by Kellen Mulhern, source=Web Response

Short-term outcomes of pulmonary embolism: A National Perspective.

Pulmonary embolism (PE) is associated with significant morbidity and mortality in hospitalized patients. Real time data on 90-day mortality, bleeding, and readmission is sparse. The study cohort was derived from the National Readmission Data (NRD) 2013 to 2014. PE was identified using International Classification of Diseases, ninth Revision (ICD-9-CM) code 415.11/3/9 in the primary diagnosis field. Any admission within 90 days of primary admission was considered a 90-day readmission. Readmission etiologies were identified by ICD-9 code in the primary diagnosis field. Co-primary outcomes were 90-day readmission and 90-day mortality. We identified 260 614 patients with primary admission PE, 55 659 (21.36%) patients were readmitted within 90 days. Most of them were of old age (age ≥ 65 years: 49.04%) and females (52.78%). Among the etiologies of readmission pulmonary disorders (22.94%) (Including recurrent PE 7.33%), malignancies (8.31%), and bleeding disorders (6.75%) were the most important causes of 90-day readmissions. On multivariate analysis, higher readmission rates and 90 days mortality were seen in patients with heart failure, chronic pulmonary disease, Anemia, malignancy, and with higher Charlson score. Patients with longer length of stay during primary admission and who discharged to short/long-term facility were more likely get readmitted and die in 90 days. Paradoxically, obese patients showed an inverse relationship with co-primary outcomes. Older female patients were more likely to have a pulmonary embolism. High-risk groups such as heart failure, chronic pulmonary disease, anemia, and malignancy need to be given extra attention to prevent worse outcomes.

Early onset pneumonia after successful resuscitation : Incidence after mild invasive hypothermia therapy

Targeted temperature management (TTM) represents an effective therapy to improve neurologic outcome in patients who survive an out-of-hospital cardiac arrest (OHCA). First publications about this therapy reported a higher incidence of infections in patients who underwent TTM induced by external cooling devices. Whether intravascular cooling devices are also associated with an increased infection rate has not been investigated so far. In a single center retrospective study, the incidence of early onset pneumonia (EOP) in OHCA patients with or without intravascular TTM at 33°C target temperature for 24h who survived at least 24h after admission was analyzed. A total of 68OHCA survivors (mean age 65± 15years) were included in this analysis. The most common causes of OHCA were myocardial infarction (35 %), primary ventricular fibrillation (24 %), asystole (15 %), and pulmonary embolism (7 %). Of those, 32patients (48 %) received TTM. The overall incidence of EOP was 38 %. Incidence of EOP did not differ significantly between groups, was more frequent in the group without TTM (42 % vs. 34 %, p= 0.57) and had no impact on mortality (hazard ratio= 1.02; 95 % confidence interval 0.25-4.16; p= 0.97). Intravascular TTM at 33°C with a cooling catheter is not associated with more infective complications in OHCA patients. This finding underscores the safety of TTM.

Inferior Vena Cava Filters in Elderly Patients with Stable Acute Pulmonary Embolism

BackgroundPatients aged >60 years with pulmonary embolism who were stable and did not require thrombolytic therapy were shown to have a somewhat lower in-hospital all-cause mortality with vena cava filters. In this investigation we further assess mortality with filters in stable elderly patients. MethodsIn-hospital all-cause mortality according to use of inferior vena cava filters was assessed from the National (Nationwide) Inpatient Sample, 2003-2012, in: 1) All patients with pulmonary embolism; 2) All with pulmonary embolism who had none of the comorbid conditions listed in the Charlson Comorbidity Index; 3) Patients with a primary (first-listed) diagnosis of pulmonary embolism, and 4) Patients with a primary diagnosis of pulmonary embolism and none of the comorbid conditions listed in the Charlson Comorbidity Index. ResultsFrom 2003-2012, 2,621,575 stable patients with pulmonary embolism were hospitalized in the US. Patients aged >80 years showed lower mortality with vena cava filters (all pulmonary embolism, 6.1% vs 10.5%; all pulmonary embolism with no comorbid conditions, 3.3% vs 6.3%; primary pulmonary embolism, 4.1% vs 5.7%; primary pulmonary embolism with no comorbid conditions, 2.1% vs 3.7%; all P <.0001). In the all-patient category, patients aged 71-80 years showed somewhat lower mortality with filters, 6.3% vs 7.4% (P <.0001), and those without comorbid conditions, 2.5% vs 2.8% (P = .04). Those aged 71-80 years with primary pulmonary embolism, irrespective of comorbid conditions, did not show lower mortality with filters. ConclusionAt present, in the absence of a randomized controlled trial, it seems prudent to consider a vena cava filter in very elderly (aged >80 years) stable patients with acute pulmonary embolism.