Secondary Pulmonary Embolism Research Articles

Validating International Classification of Diseases Code 10th Revision algorithms for accurate identification of pulmonary embolism

BackgroundMany research investigations for pulmonary embolism (PE) rely on the International Classification of Diseases 10th Revision (ICD-10) codes for analyses of electronic databases. The validity of ICD-10 codes in identifying PE remains uncertain. MethodsUsing a prespecified protocol, patients in the Mass General-Brigham hospitals (2016-2021) with ICD-10 principal discharge codes for PE, those with secondary codes for PE, and those without PE codes were identified (n = 578 from each group). Weighting was applied to represent each group proportionate to their true prevalence. The accuracy of ICD-10 codes for identifying PE was compared with adjudication by independent physicians. The F1 score, which incorporates sensitivity and positive predictive value (PPV), was assessed. Subset validation was performed at Yale-New Haven Health System. ResultsA total of 1712 patients were included (age: 60.6 years; 52.3% female). ICD-10 PE codes in the principal discharge position had sensitivity and PPV of 58.3% and 92.1%, respectively. Adding secondary discharge codes to the principal discharge codes improved the sensitivity to 83.2%, but the PPV was reduced to 79.1%. Using a combination of ICD-10 PE principal discharge codes or secondary codes plus imaging codes for PE led to sensitivity and PPV of 81.6% and 84.7%, respectively, and the highest F1 score (83.1%; P < .001 compared with other methods). Validation yielded largely similar results. ConclusionAlthough the principal discharge codes for PE show excellent PPV, they miss 40% of acute PEs. A combination of principal discharge codes and secondary codes plus PE imaging codes led to improved sensitivity without severe reduction in PPV.

Patient sex and use of tranexamic acid in liver transplantation.

Differences in medical treatment between women and men are common and involve out-of-hospital emergency care, the intensity of pain treatment, and the use of antifibrinolytic treatment in emergency trauma patients. If woman and man receive different antifibrinolytic treatment in highly-standardized major transplant surgery is unknown. We conducted a retrospective cohort study on patients who underwent liver transplantation at Heidelberg University Hospital, Heidelberg, Germany between 2004 and 2017. Logistic regression analyses were performed to determine if sex is associated with the administration of TXA during liver transplantation. Secondary endpoints included venous thrombotic complications, graft failure, mortality, myocardial infarction, hepatic artery thrombosis, and stroke within the first 30 days after liver transplant as well as length of hospital stay and length of intensive care unit stay. Out of 779 patients who underwent liver transplantation, 262 patients received TXA. Female sex was not associated with intraoperative administration of TXA [adjusted OR: 0.929 (95% CI 0.654; 1.320), p = 0.681]. The secondary endpoints graft failure (13.2% vs. 8.4%, women vs. men, p = 0.039), pulmonary embolism (3.4% vs. 0.9%, women vs. men, p = 0.012), stroke (1.7% vs. 0.4%, women vs. men, p = 0.049), and deep vein thrombosis (0.8% vs. 0%, women vs. men, p = 0.031) within 30 days after liver transplantation were more frequent in women. Mortality, myocardial infarction, and other secondary endpoints did not differ between groups. However, in women, the use of TXA was associated with a lower rate in thromboembolic complications. Our data indicate that different from other scenarios with massive bleeding complications the administration of TXA during liver transplantation is not associated with sex. However, sex is associated with the risk for complications, and in woman TXA might have a preventive effect on the rate of thromboembolic complications. Reasons underlying the observed sex bias rate remain uncertain.

Prediction of mortality in patients with secondary pulmonary embolism based on primary admission indication: A short communication.

We evaluated the prediction of mortality in patients admitted to the intensive care unit (ICU) who subsequently developed a pulmonary embolism (PE) (i.e., secondary PE) using three PE-specific scores, the Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), and modified sPESI (ICU-sPESI) and compared them to the gold standard for the assessment of ICU all-cause mortality, the Acute Physiology and Chronic Health Evaluation-IV (APACHE-IV). All critical care admission indications were grouped into four major categories: post-operative, cardiovascular, infectious (sepsis), and other. The APACHE-IV displayed better discriminative ability to predict in-hospital mortality than the PESI and ICU-sPESI, but these two scores still performed fair for the ICU admissions related to postoperative, cardiovascular, and other admission types. Meanwhile, the sPESI displayed poor predictive performance across all four admission categories. Notably, discriminatory performance for patients with an infection-related admission was consistently low regardless of which score was used.

A nomogram model based on the systemic immune-inflammation index to predict the risk of venous thromboembolism in elderly patients after hip fracture: A retrospective cohort study

Background and objectivesVenous thromboembolism (VTE), encompassing deep vein thrombosis (DVT) and secondary pulmonary embolism (PE), represents a significant complication post-hip fracture in the elderly. It is a prevalent cause of VTE-related complications, prolonged hospitalization, and mortality. This study aimed to investigate the potential of the systemic immune-inflammation index (SII) as a predictive marker for VTE in older patients following hip fracture. MethodsThe study was structured as an observational, analytical, retrospective cohort analysis. A total of 346 elderly patients diagnosed with hip fracture were included. We retrospectively collated clinical and laboratory data for these patients. Using the bootstrap method, the patients were divided in a 7:3 ratio into a training cohort (DVT group = 170 patients; no-DVT group = 72 patients) and an internal validation cohort (DVT group = 81 patients; no-DVT group = 23 patients). In the training cohort, relevant indices were initially identified using univariate analysis. Subsequently, least absolute shrinkage and selection operator logistic analysis was employed to determine significant potential independent risk factors (P < 0.05). A dynamic online diagnostic nomogram was developed, with its discriminative ability assessed using the area under the receiver operating characteristic curve (AUC). The nomogram's accuracy was further appraised using calibration plots. The clinical utility of the nomogram was evaluated through decision curve analysis (DCA) and corroborated by internal validation within the training set. ResultsSII emerged as the sole independent risk factor identified from the multivariate logistic analysis of the training cohort and was incorporated into the VTE diagnostic nomogram for older patients' post-hip fracture. The nomogram demonstrated AUC values of 0.648 in the training cohort and 0.545 in the internal testing cohort. Calibration curves corroborated the close alignment of the nomogram's predicted outcomes with the ideal curve, indicating consistency between predicted and actual outcomes. The DCA curve suggested that all patients could derive benefit from this model. These findings were also validated in the validation cohort. ConclusionThe systemic immune-inflammation index is a robust predictor of venous thromboembolism in elderly patients following hip fracture, underscoring its potential as a valuable tool in clinical practice.

Validity of mortality risk prediction scores in critically ill patients with secondary pulmonary embolism.

Pulmonary embolism (PE) is a feared complication in the ICU, significantly impacting morbidity and mortality of the patients affected. Herein, we assess the use of the Acute Physiology and Chronic Health Evaluation-IV (APACHE-IV) and PE-specific risk scores to predict mortality among intensive care unit (ICU) patients who developed secondary PE. This retrospective cohort study used information from 208 United States critical care units recorded in the eICU Collaborative Research Database during 2014 and 2015. We calculated APACHE-IV, Pulmonary Embolism Severity Index (PESI), simplified PESI (sPESI), and ICU-sPESI scores and compared their predicting performance using the area under the receiver operating characteristic (AUROC) curve. Of 812 patients included in our study, 150 died (mortality, 18.5% [95% CI, 15.8%-21.1%]). Compared to survivors, non-survivors had higher APACHE-IV (86 vs 52, P<0.001), PESI (170 vs 129, P<0.001), sPESI (2 vs 2, P<0.001), and ICU-sPESI (4 vs 2, P<0.001) scores. AUROCs were 0.790 (APACHE-IV); 0.737 (PESI); 0.726 (ICU-sPESI); and 0.620 (sPESI). APACHE-IV performed significantly better than all 3 PE-specific mortality scores (APACHE-IV vs PESI, P=0.041; APACHE-IV vs sPESI, P=0.001; and APACHE-IV vs ICU-sPESI, P=0.021). Both the PESI and ICU-sPESI outperformed the sPESI (PESI vs sPESI, P=0.001; ICU-sPESI vs sPESI, P<0.001). APACHE-IV score was found to be the best instrument for predicting mortality risk, but PESI and ICU-sPESI scores may be used when APACHE-IV is unavailable. sPESI AUROC suggests absence of sufficient discriminative value to be used as a predictor of mortality in patients with secondary PE.

Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta-analysis.

Pharmacological interventions for the prevention of bleeding in people undergoing elective hip or knee surgery: a systematic review and network meta-analysis.

Fulminant hepatic failure: An unusual suspect.

A 66-year-old man was admitted to the emergency department for bradypsychia and asthenia. He had a history of alcohol consumption and epilepsy with no medical follow-up. Laboratory test results were compatible with acute liver failure and hyperammonemic encephalopathy: international normalized ratio, 3.35; fibrinogen, 2.25 g/L; total/direct bilirubin, 9.27/4.96 mg/dL; aspartate aminotransferase, 2595 U/L; alanine aminotransferase, 1958 U/L; ammonia, 125 µmol/L. Axial (Figure 1A) and coronal (Figure 1B) contrast-enhanced computed tomography shows a 4-cm wide hepatic mass in the VII segment (arrowheads) invading the right sus-hepatic vein (voided arrowheads) and inferior vena cava (IVC; voided arrows). The invaded veins are disproportionately enlarged for a cruoric thrombus, which measures 14 cm in the cranio-caudal axis and extends to the right atrium (arrow). Transthoracic echocardiography (Figure 2) shows a bulky thrombus emerging at the atrio-caval junction. Several therapeutic options, such as in situ thrombolysis, fibrinolysis, and surgical resection, were discarded as first-line therapy because of the risks of thrombus fragmentation, secondary pulmonary embolism, and bleeding. Despite continuous infusion of therapeutic unfractionated heparin and supportive measures, the patient died a week later. Elevated alpha-fetoprotein levels (33,460 µg/L) confirmed probable hepatocellular carcinoma causing intraluminal extension of tumor thrombosis into the IVC, which confers a very poor prognosis in the absence of curative surgical resection. Differential diagnoses, in the absence of congenital abnormalities of IVC, include primary leiomyosarcoma of the vessel wall or adjacent organ carcinoma causing extension of tumoral thrombosis, such as renal cell or adrenocortical carcinoma and retroperitoneal metastasis.1, 2

Sex differences in temporal trends in main and secondary pulmonary embolism diagnosis and case fatality rates: 2003-2019.

There is controversy regarding the incidence and outcomes of pulmonary embolism (PE) according to sex. Our aim was to address sex differences in temporal trends in main and secondary hospital PE diagnoses, management and case fatality rates (CFR). Retrospective analysis of Spain´s National Healthcare System hospital database, years 2003-2019, for patients ≥18 years with main or secondary PE diagnosis. Trends by sex in hospital diagnosis, use of procedures, and CFRs were analysed by joinpoint and Poisson regression models. Of 339 469 PE diagnoses, 52% were in women. Sixty-five percent were main diagnosis, 35.2% secondary. Total annual diagnoses and frequentation rates increased similarly in men and women: average annual percent change (AAPC): 2.0% (95% CI, 1.3-2.6; P<0.005). Secondary PEs were more common in men (37.8% vs. 32.9%, P<0.001). Men showed greater comorbidity than women (Charlson index 2.22 ± 0.01 vs. 1.74 ± 0.01, P<0.001), particularly cancer in the secondary diagnosis group (40.9% vs. 31.6%, P<0.001). CFRs for PE as main diagnosis were comparable and decreased in parallel in men (from 13.8% in 2003 to 7.3% in 2019) and women (from 13.1% in 2003 to 6.9% in 2019). However, for PE as secondary diagnosis, CFRs remained higher (P<0.001) in men (from 42.5% in 2003 to 26.2% in 2019) than women (from 34.4% in 2003 to 22.8% in 2019). PE hospital diagnosis increased significantly between 2003 and 2019 in men and women for both main and secondary diagnosis. Although in-hospital CFR decreased one third still remains very high, especially in men with secondary PE diagnosis.

MiR-513c-5p Suppression Aggravates Pyroptosis of Endothelial Cell in Deep Venous Thrombosis by Promoting Caspase-1.

Deep vein thrombosis (DVT) is a common peripheral vascular disease. Secondary pulmonary embolism (PE) caused by DVT leads to substantial patient death. Inflammation has been suggested as a key factor in the pathophysiology of DVT, however, involvement of pyroptosis-related inflammatory factors in DVT formation remains unclear. Here, we proposed that post-transcriptional modification of caspase-1 might be a crucial trigger for enhanced pyroptosis in vascular endothelial cells (VECs), and consequently contributed to severer symptoms in DVT patients. In order to explore the involvement of pyroptosis in DVT, peripheral blood mononuclear cells were collected from 30 DVT patients, and compared with the healthy controls, we found caspase-1 was increased both in mRNA and protein levels. miRNA microarray analysis demonstrated that down-regulated miR-513c-5p was significantly negatively correlated with the expression of caspase-1. In vitro assays suggested that miR-513c-5p overexpression could ameliorate the expression of caspase-1, and thus decreased the production of cleaved gasdermin D (GSDMD) and interleukin (IL)-1β and IL-18 in VECs. The dual-luciferase reporter assay identified direct binding between miR-513c-5p and the 3′ untranslated region of caspase-1 encoding gene. The administration of miR-513c-5p mimics through tail vein injection or caspase-1 inhibitor (vx-765) by intraperitoneal injection remarkably decreased the volume of blood clots in vivo, whereas miR-513c-5p inhibitor aggravated thrombosis formation and this effect was dramatically weakened when treated in combination with vx-765. Collectively, these results revealed that the pyroptosis of VECs induced by decreased miR-513c-5p was involved in DVT progression and indicated a potential therapeutic strategy of targeting the miR-513c-5p/caspase-1/GSDMD signal axis for DVT management.

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 &lt;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&lt;0.001), and more female (57.9% vs 53.1%, P&lt;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&lt;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&lt;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.

Differences in mortality and complication rates following revision knee arthroplasty performed for urgent versus elective indications.

To compare rates of serious adverse events in patients undergoing revision knee arthroplasty with consideration of the indication for revision (urgent versus elective indications), and compare these with primary arthroplasty and re-revision arthroplasty. Patients undergoing primary knee arthroplasty were identified in the national Hospital Episode Statistics (HES) between 1 April 1997 to 31 March 2017. Subsequent revision and re-revision arthroplasty procedures in the same patients and same knee were identified. The primary outcome was 90-day mortality and a logistic regression model was used to investigate factors associated with 90-day mortality and secondary adverse outcomes, including infection (undergoing surgery), pulmonary embolism, myocardial infarction, and stroke. Urgent indications for revision arthroplasty were defined as infection or fracture, and all other indications (e.g. loosening, instability, wear) were included in the elective indications cohort. A total of 939,021 primary knee arthroplasty procedures were included (939,021 patients), of which 40,854 underwent subsequent revision arthroplasty, and 9,100 underwent re-revision arthroplasty. Revision surgery for elective indications was associated with a 90-day rate of mortality of 0.44% (135/30,826; 95% confidence interval (CI) 0.37 to 0.52) which was comparable to primary knee arthroplasty (0.46%; 4,292/939,021; 95% CI 0.44 to 0.47). Revision arthroplasty for infection was associated with a much higher mortality of 2.04% (184/9037; 95% CI 1.75 to 2.35; odds ratio (OR) 3.54; 95% CI 2.81 to 4.46), as was revision for periprosthetic fracture at 5.25% (52/991; 95% CI 3.94 to 6.82; OR 6.23; 95% CI 4.39 to 8.85). Higher rates of pulmonary embolism, myocardial infarction, and stroke were also observed in the infection and fracture cohort. Patients undergoing revision arthroplasty for urgent indications (infection or fracture) are at higher risk of mortality and serious adverse events in comparison to primary knee arthroplasty and revision arthroplasty for elective indications. These findings will be important for patient consent and shared decision-making and should inform service design for this patient cohort. Cite this article: Bone Joint J2021;103-B(10):1578-1585.

Early and Mid-Term Outcomes of Femoro-Ilio-Caval Vein Stent Implantation.

We sought to investigate mid-term clinical outcomes and identify risk factors in one of the largest comprehensive series reported of femoro-ilio-caval (FIC) vein stent placement. Endovascular intervention with balloon angioplasty and stenting of the iliac and common femoral veins has become first-line treatment for symptomatic deep venous outflow obstruction. We conducted a single-center, retrospective analysis of 180 patients who underwent FIC stent implantation between May 2017 and May 2019; 327 procedures were performed. Our primary objective was to evaluate a composite of stent thrombosis and stent restenosis. Secondary outcomes included individual predictors of in-stent restenosis (ISR) and in-stent thrombosis (IST), primary and secondary patency, access-site complications, major bleeding, pulmonary embolism, cardiovascular death, any death, intracranial bleeding, all-cause mortality, and components of major adverse cardiac and cerebrovascular events (MACCE) in a 24-month period. A total of 327 procedures were performed for 180 patients. At 2-year follow up, 78.3% of cases remained free of any complication. Primary outcome occurred in 53 procedures (16.2%) and was highest at early (<30 days) follow-up. Primary patency at 2-year follow-up was 78.43%. There were no deaths, 1 patient (0.3%) had a subdural hematoma, and 3 patients (0.9%) had MACCE. Age and post-thrombotic syndrome (PTS) were significant predictors of primary outcome. PTS and Venous Clinical Severity score (VCSS) ≥10 were found to have higher rates of thrombosis. Active smokers, the elderly, history of deep vein thrombosis (DVT), and VCSS ≥10 had a statistically significant elevated risk of ISR. Endovascular treatment with stent implantation for non-thrombotic iliac vein lesion and PTS is safe, with low morbidity, zero mortality, low complications, and persistent improvement of symptoms. Age and PTS were significant predictors of primary outcome.

Hemodynamic regulation of perivalvular endothelial gene expression prevents deep venous thrombosis.

Deep venous thrombosis (DVT) and secondary pulmonary embolism cause approximately 100,000 deaths per year in the United States. Physical immobility is the most significant risk factor for DVT, but a molecular and cellular basis for this link has not been defined. We found that the endothelial cells surrounding the venous valve, where DVTs originate, express high levels of FOXC2 and PROX1, transcription factors known to be activated by oscillatory shear stress. The perivalvular venous endothelial cells exhibited a powerful antithrombotic phenotype characterized by low levels of the prothrombotic proteins vWF, P-selectin, and ICAM1 and high levels of the antithrombotic proteins thrombomodulin (THBD), endothelial protein C receptor (EPCR), and tissue factor pathway inhibitor (TFPI). The perivalvular antithrombotic phenotype was lost following genetic deletion of FOXC2 or femoral artery ligation to reduce venous flow in mice, and at the site of origin of human DVT associated with fatal pulmonary embolism. Oscillatory blood flow was detected at perivalvular sites in human veins following muscular activity, but not in the immobile state or after activation of an intermittent compression device designed to prevent DVT. These findings support a mechanism of DVT pathogenesis in which loss of muscular activity results in loss of oscillatory shear-dependent transcriptional and antithrombotic phenotypes in perivalvular venous endothelial cells, and suggest that prevention of DVT and pulmonary embolism may be improved by mechanical devices specifically designed to restore perivalvular oscillatory flow.

Role of rehabilitation in prevention of early thromboembolic complications in hemorrhagic stroke

Hemorrhagic strokes (ICH) affects mainly young active people, with increasing incidence in developing countries. Mortality is high in acute phase, and patients are prone to complications related to stroke itself and to coexisting medical conditions. Patients with ICH are at high risk in developing deep venous thrombosis (DVT) with secondary pulmonary embolism (PE). Prevention of venous thrombotic events in hemorrhagic stroke patients requires intermittent pneumatic compression and preventive doses of low molecular weight heparins (LMWH) in high-risk patients. If DVT and /or PE occurs, the therapeutic management should balance the risk of recurrent cerebral bleeding and the life-threatening risk of PE, making the decision to start anticoagulation challenging. We present a case of a young patient with a large hypertensive capsulo-lenticular hemorrhage, who was diagnosed with pulmonary embolism 21 days after stroke onset. The decision was for anticoagulant treatment initial with LWMH, and switch to direct oral anticoagulants (DOAC) after 10 days; strict control of vascular risk factors of the patients (hypertension, diabetes and obesity) was achieved. Rehabilitation treatment, delayed until day 21, was recommended with progressive intensity. Evolution of the patient was favorable, with complete hematoma resorbtion under DOAC treatment at 10 weeks follow-up and important motor recovery. Rehabilitation program was intensive during this interval, and strongly contributive to neurologic improvement.

Treatment of superior vena cava syndrome using AngioJet\u2122 thrombectomy system

BackgroundSuperior vena cava syndrome is a relatively rare presentation in which diminished venous return to the heart produces congestion of the neck, face and upper extremities. Typically, a mediastinal mass produces external compression on the superior vena cava and reduces venous return. However, superior vena cava syndrome can present acutely in the setting of vena cava thrombosis. Multiple scoring systems are available to assist clinicians with appropriate timing of interventions for SVC syndrome. When specific criteria are met, endovascular intervention can be beneficial to patients to prevent rapid deterioration.Case presentationA 75-year-old female with no significant past medical history presented to the emergency department with increased facial swelling, nausea and vomiting which began the night prior to presentation. The patient underwent a CT chest which revealed a 3.2 × 3.0 × 3.8 cm spiculated mass compressing the right main bronchus and right pulmonary artery. The patient was intubated and interventional radiology was consulted. The patient underwent venography which showed extensive thrombosis of the innominate veins. Rheolytic thrombectomy with AngioJet™ was performed to alleviate clot burden and minimize risk of secondary pulmonary embolism. Kissing stents were placed in the bilateral innominate veins to maintain patency after thrombectomy. After the procedure, the patient was successfully extubated and had near complete resolution of facial swelling approximately 12 h post procedure. A follow up venogram performed on post procedure day 4 showed patent bilateral subclavian, innominate, and internal jugular veins as well as a patent superior vena cava.ConclusionsAcute occlusion of superior vena cava can present with life threatening symptoms such as loss of airway. AngioJet™ thrombectomy is another tool available to interventional radiologists when a patient’s clinical condition necessitates treatment.

Long term prognosis of acute pulmonary embolism

BackgroundAcute pulmonary embolism (PE) can be fatal if left untreated. Long-term prognosis of acute PE in the 21st century has not been fully reported. We aimed to determine the long-term prognosis of patients hospitalized with acute PE and compare survivalof patients with idiopathic and secondary PE. Materials and methodsWe retrospectively analysed a cohort of hospitalized patients with acute PE between 2006 and 2013. Exclusion criteria:<18 years, venous embolism of non-pulmonary veins, chronic thromboembolic pulmonary hypertension, and presumptive diagnosis without image confirmation. Only patients with a first PE episode were included. End-point: all-cause mortality. Patients were compared according to PE aetiology: idiopathic, secondary to neoplastic conditions and secondary to non-neoplastic conditions. A Cox-regression analysis was used to study the prognostic impact of PE aetiology. RESULTS: We studied 872 hospitalized acute PE patients. Median age 70 years, 56.9% were women. PE was idiopathic in 376 (43.1%), secondary to a neoplastic condition in 284 (32.6%) and secondary to a condition other than neoplasia in 212 (24.3%). Patients were followed for a median 25 months period and 508 (58.3%) died. Patients with PE attributed to a neoplastic condition had the worst survival. Patients with idiopathic PE had a multivariate-adjusted HR of mortality of 1.46 (1.08–1.99) during the over 2-year follow-up period when compared to those with acute PE attributed to a non-neoplastic condition. ConclusionsPatients with idiopathic acute PE have an almost 50% higher death risk in a median 2-year follow-up period than those with acute PE secondary to a condition other than neoplasia.

Five-year follow-up of pulmonary embolism under anticoaugulation: The PISA-PEET (Pulmonary Embolism Extension Therapy) study.

Benefits and harms of long-term anticoagulant therapy (AT) after acute pulmonary embolism (PE) are poorly known. The aim of this study was to investigate the outcome of patients with PE treated with AT for 5 years according to American College of Chest Physicians (ACCP) guidelines.Patients with both unprovoked and secondary PE were consecutively enrolled in a “real life” study. After a 12-month AT, they continued or stopped the treatment according to ACCP guidelines, and were followed-up for 5 years. Outcomes were all-cause mortality, recurrence, and fatal recurrence under AT.Of the original consecutive 585 patients, 471 were included (83 dead, 31 lost during the 1st year). Of these, 361 (76.6%) continued AT. During 5 years, death occurred in 109 (30.2%) patients, with a mortality rate of 8.00 events/100 person-years of follow-up; recurrence in 34 (9.4%), with an incidence rate of 2.58 events/person-years; fatal recurrence in 13 (3.6%), with an incidence rate of 0.95 events/person-years. The case fatality rate for recurrence was 38.2%. In the subgroup of patients with unprovoked PE, the chance of dying was significantly lower (RR 0.35; 95% confidence interval 0.24–0.53) and the tendency to fatal recurrence (not significantly) greater (0.11 events/100 person-years vs 0.07 events/100 person-years) than in the remaining patients. Major bleeding occurred in 5 (1.3%) patients. The case fatality rate for bleeding was 14.3%.During 5-year AT, 30% of patients dies, 10% experiences recurrences, and 5% has fatal recurrences. According to guidelines, most patients need to continue AT; the case fatality rate for bleeding is lower than that for recurrence.

Characteristics and Treatment Patterns of Patients with Deep Vein Thrombosis and/or Pulmonary Embolism in the US Hospital Setting

Introduction:Current practice guidelines in the United States (US) recommend that anticoagulation treatment for deep vein thrombosis (DVT) and/or pulmonary embolism (PE) is initiated with parenteral administration of low-molecular-weight heparin (LMWH), fondaparinux or low-dose unfractionated heparin (UFH), followed by the use of warfarin or other vitamin K antagonist therapies (Kearon et al Chest 2012). Given the relatively recent introduction of novel oral anticoagulants (NOACs), it is essential to understand the demographic and clinical characteristics of DVT/PE patients receiving these therapies. The objective of this study was to evaluate characteristics and treatment patterns of patients with DVT and/or PE in the US hospital setting.Methods:This retrospective observational cohort study used hospital administrative claims data spanning 11/1/2011-12/31/2013 from more than 600 hospitals. Patients ≥18 years old with a primary discharge diagnosis of DVT and/or PE in the inpatient setting during the identification period (11/1/2012-12/31/2013) were selected. The first-observed hospitalization for DVT/PE during the identification period was defined as the index hospitalization, and thus the principal event for analysis. Patients with a secondary diagnosis of atrial fibrillation, atrial flutter, cardiomyopathy, or a coagulation disorder during the index hospitalization were excluded. Patients needed to have had a complete hospital stay defined as (1) observed admission and discharge dates and (2) a discharge status other than expired or unknown. Patients were categorized into mutually-exclusive treatment cohorts based on the anticoagulant (AC) treatment regimen received during the index hospitalization, including lack of receipt of any AC treatment. Parenteral anticoagulant (PAC) therapy was defined as LMWH, fondaparinux or UFH. Demographic, hospital, and clinical characteristics were assessed during the index hospitalization. A logistic regression was conducted to assess the likelihood of receiving rivaroxaban with PAC and/or warfarin (vs. rivaroxaban alone) adjusting for the following covariates: age, sex, race, geographic region, payer type, primary or secondary diagnosis of DVT and/or PE, history of DVT/PE, discharge status, receipt of thrombolytic drugs, presence of primary malignancy, presence of renal disease, attending provider specialty, hospital setting, and hospital size.Results:In this study, 46,214 patients met the selection criteria (mean age: 61 years; 53% female). Sixty-eight percent of all patients were white and 50% were Medicare beneficiaries. The majority of patients received a primary diagnosis of PE during the index hospitalization (54%), followed by those with a primary diagnosis of DVT without mention of PE (38%) and primary diagnosis of DVT and secondary PE (8%). The most common AC treatment during the index hospitalization was PAC + warfarin (70%), PAC alone (16%), PAC + rivaroxaban (6%), PAC + warfarin + rivaroxaban (4%), warfarin alone (1%), rivaroxaban alone (1%), and no AC therapy (2%). Among the patients who received rivaroxaban, more than 90% additionally received PAC. The mean [SD] Deyo-Charlson Comorbidity Index scores were lowest for the cohorts receiving rivaroxaban (rivaroxaban alone, 1.1 [1.7]; PAC + rivaroxaban, 1.2 [1.8]; and PAC + warfarin + rivaroxaban cohorts, 1.2 [1.6]). In logistic regression analyses, patients with a primary PE diagnosis (odds ratio (OR): 1.49; 95% CI 1.17-1.88), a primary DVT diagnosis with a secondary PE diagnosis (OR 2.07; 95% CI 1.31-3.26), receipt of thrombolytic drugs (OR: 12.45; 95% CI 3.95-39.23), presence of renal disease (OR: 1.61; 95% CI 1.02-2.54), and receipt of care in an urban hospital (OR: 1.53; 95% CI 1.16-2.00) were significantly more likely to receive rivaroxaban with PAC and/or warfarin compared to rivaroxaban alone.Conclusion:This study evaluated characteristics and treatment patterns among patients with DVT and/or PE in the US hospital setting, following the introduction of the NOACs. Our findings indicate that the standard of care (PAC + warfarin) remains the dominant treatment regimen despite the availability of newer NOACs. Future studies of treated patients with DVT and/or PE should examine whether these preliminary observations of treatment patterns change with increased clinical experience with NOACs. DisclosuresLim:Boehringer Ingelheim Pharmaceuticals Inc.: Employment. Sander:Boehringer Ingelheim Pharmaceuticals Inc.: Employment.

Pulmonary embolism, acute coronary syndrome and ischemic stroke in the Spanish National Discharge Database

BackgroundVenous and arterial thrombosis share a number of pathogenic mechanisms, but the burden of pulmonary embolism (PE) has not been consistently compared with that in other arterial diseases. MethodsWe used the Spanish National Discharge Database to compare the frequency, clinical characteristics and mortality rate of all patients with PE, acute coronary syndrome (ACS) or ischemic stroke admitted from 2001 to 2010. Patients were classified as having primary diagnosis (the process leading to hospital admission) or secondary diagnosis (it appeared during hospital stay for other reasons) ResultsDuring the study period, 31,949,739 patients were discharged. Of these, 165,229 (0.52%) were diagnosed with PE, 562,837 (1.76%) with ACS and 495,427 (1.55%) with ischemic stroke. Overall, 31% of patients with PE, 8.4% with ACS and 13% with ischemic stroke had secondary diagnoses. The most common reasons for admission in patients with secondary PE were: cancer (21%), acute respiratory failure (11%), acute heart failure (6.4%) and stroke (5.5%). Mean hospital stay was: 14±13days in PE patients, 9.7±9.7 in those with ACS and 13±14days in those with stroke. In-hospital mortality rate was: 10.5%, 10.1% and 12.3% respectively in patients with primary diagnosis, and 36%, 34% and 29% in those with secondary diagnosis. ConclusionsPatients hospitalized with PE were 3–4 times less frequent than those with ACS or stroke, but had a higher mortality. One in every 3 patients with PE (but only one in every 10 with ACS or stroke) had secondary diagnosis, and these patients had the highest mortality.

Incidence of hospital readmission in patients diagnosed with DVT and PE: clinical burden of recurrent events.

Venous thromboembolism (VTE), which comprises deep-vein thrombosis (DVT) and pulmonary embolism (PE), is associated with significant morbidity and mortality and represents a considerable economic burden to the US healthcare system. Although it is well established that patients with an initial VTE are at increased risk for recurrent VTE, limited data exist on the clinical burden of a secondary DVT or PE event. The objective of this retrospective observational study was to conduct an epidemiologic evaluation, from a hospital perspective, of patients with an initial DVT or PE who experienced a recurrent event postdischarge requiring hospital readmission. Hospital claims containing DVT or PE as a primary diagnosis for hospitalisation during the period October 2009 to April 2013 were identified by retrospective analysis using the MarketScan database. The time to hospital readmission for DVT or PE was assessed using the MarketScan Treatment Pathways tool. Of 214,901 patient admissions identified with a diagnosis of DVT or PE at hospital admission, approximately 4% were subsequently readmitted to the hospital with a diagnosis of PE (8217) or DVT (9138). Of all readmitted patients with a diagnosis of DVT on initial admission, 66% were rehospitalised with a diagnosis of DVT, and 34% were rehospitalised with a diagnosis of PE. Of all readmitted patients with a diagnosis of PE on initial admission, 63% were rehospitalised with a diagnosis of PE and 37% with a diagnosis of DVT. Of all hospital readmissions with a diagnosis of PE or DVT, 62% and 58% occurred within the first 30 days following an initial PE or DVT event, respectively. The burden of DVT or PE is large, not only because of the initial hospitalisation event but also because of the high number of hospital readmissions, more than half of which occur within 30 days.