Therapy For Acute Pulmonary Embolism Research Articles

A hard look in the mirror: disparities in reperfusion therapy for acute pulmonary embolism in the United States and failure to reduce mortality

A hard look in the mirror: disparities in reperfusion therapy for acute pulmonary embolism in the United States and failure to reduce mortality

Initial results of investigator initiated international database on catheter directed therapy of acute pulmonary embolism.

Catheter directed therapies (CDT) are widely used in the treatment of acute pulmonary embolism (PE). A multicenter registry was organized to evaluate their application in real life and to determine efficacy and safety of these procedures. Local experience of participating centers in percutaneous techniques for PE treatment was assessed. An internet-based registry was designed to collect clinical, echocardiographic and laboratory data of consecutive PE patients treated with CDT in participating centers between 2017 and 2022. Under analysis were 145 consecutive patients with acute PE, aged 61 ± 15 years, treated with CDT in 7 centers: 50 (34.5%) patients with high-risk PE (HRPE), and 95 (65.5%) patients with intermediate-high risk PE (IHRPE). 100 (69%) patients were treated with dedicated devices, in 45 (31%) subjects a pigtail catheter was used. Total PE or CDT related in-hospital mortality in HRPE reached 14% (7 patients), while in IHRPE 3.2% (3 patients) (p = 0.032). 50% of PE or CDT related deaths occurred in patients treated with a pigtail catheter. All-cause mortality in 145 patients was 9.7%, and it was higher in HRPE than in IHRPE (18% vs. 5.3%, p = 0.019). The use of pigtail catheters compared to dedicated systems was associated with higher mortality (20% vs. 5%, p = 0.01). Catheter directed therapies is a real option of treating PE. It was used as primary therapy also in patients without contraindication for thrombolysis suggesting that clinical practice does not always follow current PE guidelines. Patients treated with dedicated CDT systems had a higher survival rate than subjects treated with pigtail catheters.

Catheter-directed therapy for acute pulmonary embolism: results of a multicenter national registry

Introduction and objectivesCatheter-directed therapy (CDT) for acute pulmonary embolism (PE) is an emerging therapy that combines heterogeneous techniques. The aim of the study was to provide a nationwide contemporary snapshot of clinical practice and CDT-related outcomes. MethodsThis Investigator-initiated multicenter registry aimed to include consecutive patients with intermediate-high risk (IHR) or high-risk (HR), acute PE eligible for CDT. The primary outcome of the study was in-hospital all-cause death. ResultsA total of 253 patients were included, of whom 93 (36.8%) had HR-PE, and 160 (63.2%) had IHR-PE with a mean age of 62.3±15.1 years. Local thrombolysis was performed in 70.8% and aspiration thrombectomy in 51.8%, with 23.3% of patients receiving both. However, aspiration thrombectomy was favored in the HR-PE cohort (80.6% vs 35%; P<.001). Only 51 patients (20.2%) underwent CDT with specific PE devices. The success rate for CDT was 90.9% (98.1% of IHR-PE patients vs 78.5% of HR-PE patients, P<.001). In-hospital mortality was 15.5%, and was highly concentrated in the HR-PE patients (37.6%) and significantly lower in IHR-PE patients (2.5%), P<.001. Long-term (24-month) mortality was 40.2% in HR-PE patients vs 8.2% in IHR-PE patients (P<.001). ConclusionsDespite the high success rate for CDT, in-hospital mortality in HR-PE is still high (37.6%) compared with very low IHR-PE mortality (2.5%).

Residual pulmonary vascular obstruction and recurrence after acute pulmonary embolism: a systematic review and meta-analysis of individual participant data

We aimed to assess the relationship between residual pulmonary vascular obstruction (RPVO) on planar lung scan after completion of at least 3 months of anticoagulant therapy for acute pulmonary embolism (PE) and the risk of recurrent venous thromboembolism (VTE) or death due to PE one year after treatment discontinuation. The systematic review was registered with the International Prospective Registry of Systematic Reviews (PROSPERO: CRD42017081080). The primary outcome measure was to generate a pooled estimate of the rate of recurrent VTE at one year in patient with RPVO diagnosed on planar lung scan after discontinuation of at least 3 months of anticoagulant treatment for an acute PE. Individual data were obtained for 809 patients. RPVO (ie, obstruction >0%) was found in 407 patients (50.3%) after a median of 6.6 months of anticoagulant therapy for a first acute PE. Recurrent VTE or death due to PE occurred in 114 patients (14.1%), for an annual risk of 6.4% (95% confidence interval, 4.7%-8.6%). Out of the 114 recurrent events, 63 occurred within one year after discontinuation of anticoagulant therapy corresponding to a risk of 8.1% (6.4%-9.8%) at 1 year. The risk of recurrent VTE at one year was 5.8% (4.4-7.2) in participants with RPVO <5%, vs 11.7% (9.5-13.8) in participants with RPVO ≥5%. RPVO is a significant predictor of the risk of recurrent venous thromboembolism. However, the risk of recurrent events remains too high in patients without residual perfusion defect for it to be used as a stand-alone test to decide on anticoagulation discontinuation.

Debate: Pharmacological or invasive therapy in acute pulmonary embolism. The clinician perspective

Debate: Pharmacological or invasive therapy in acute pulmonary embolism. The clinician perspective

Debate: Pharmacological or invasive therapy in acute pulmonary embolism. The interventional cardiologist perspective

Debate: Pharmacological or invasive therapy in acute pulmonary embolism. The interventional cardiologist perspective

Catheter-directed therapy for acute pulmonary embolism: Time for “debulking and extracting” the gaps

Catheter-directed therapy for acute pulmonary embolism: Time for “debulking and extracting” the gaps

Pulmonary embolism bleeding score index (PEBSI): A new tool for the detection of patients with low risk for major bleeding on thrombolytic therapy

BackgroundEstimation of bleeding risk is an unmet need for individualized therapy in acute pulmonary embolism (PE) patients with increased mortality risk. MethodsWe analyzed the association between various patients' characteristics and occurrence of major bleeding (MB) according to the modified International Society of Thrombosis and Hemostasis (ISTH) criteria (“overt” bleeding is the only modification from the original criteria) at 7 days from admission to the hospital and thrombolytic therapy with a tissue-plasminogen activator (tPA). Pulmonary embolism bleeding score index (PEBSI) was created using multivariate regression analyses, and finely, dichotomous index was used for the discrimination of patients with low risk for MB from those with high risk. ResultsDuring the 6-year period (2015–2021) 367 PE patients were treated with tPA and included in the Regional PE registry. Among them, 29 (7.9%) fulfilled the criteria for MB. Five factors were identified as significantly associated with MB and were used to build the PEBSI score: previous bleeding, recent surgery, diabetes, the use of drugs that could be associated with bleeding, and anemia. PEBSI score showed c-index for 7-day MB 0.794 (95CI% 0.698–0.889). Patients with PEBSI scores of 0 or 1 had a low risk for MB (2.8%) and those with scores>1 had a high risk for MB (18.6%) (p < 0.001). Internal validation of PEBSI score using a randomly, equally split method confirmed the discriminative value of the PEBSI score. ConclusionNovel PEBSI score has significant power to discriminate patients with low risk for MB on thrombolytic therapy from those with high risk.

Surgical embolectomy as a promising treatment of acute pulmonary embolism

Highlights. The article presents current literature data on the results of surgical treatment of acute pulmonary embolism.Abstract. The review article throws light on up to date approaches to the treatment of acute pulmonary embolism. The great variety of treatment methods and controversial results do not allow us to conclusively decide on which method to choose. Traditionally, pharmacological therapies have been favored over invasive methods because of the lower mortality rate. However, based on new studies, it can be established that interventional embolectomy is an effective option, showing good immediate and long-term results. Undoubtedly, additional studies are needed in order that surgical embolectomy developed from a rescue therapy of acute pulmonary embolism into a first-line or priority treatment.

Major bleeding in patients with pulmonary embolism presenting with syncope.

Syncope has been shown to be a risk factor of bleeding in patients receiving thrombolytic therapy for acute pulmonary embolism (PE). Whether syncope predicts bleeding in a broader population of patients with PE remains unknown. We used the RIETE registry data to assess whether initial presentation with syncope could predict bleeding in PE patients receiving anticoagulant therapy, and to explore the association between presence of syncope and timing and site of major bleeding events. Among 45,765 patients with acute PE from March 2001 to January 2021, 6760 (14.8%) had syncope. Patients with syncope were older and more likely to have hypotension, tachycardia, hypoxaemia or elevated troponin levels than those without syncope. They also were more likely to receive thrombolytics. During the first 90days, 1097 patients (2.4%) suffered major bleeding (gastrointestinal 335, hematoma 271 and intracranial 163) and 3611 died (158had fatal bleeding). Patients with syncope had a higher rate of major bleeding (odds ratio [OR]: 1.63; 95% CI: 1.41-1.89) and a nonsignificantly higher rate of fatal bleeding (OR: 1.47; 95% CI: 0.99-2.17) than those without syncope. Multivariable analysis confirmed that patients with syncope were at increased risk for major bleeding (adjusted hazard ratio [aHR]: 1.34; 95% CI: 1.15-1.55). On sensitivity analysis, the increased risk for major bleeding was confirmed in patients initially receiving anticoagulant therapy without thrombolytics at 7days (aHR: 1.47; 95% CI: 1.13-1.91) and 90days (aHR: 1.33; 95%CI: 1.13-1.56). Syncope is a predictor of major bleeding events in patients with PE, even among those receiving anticoagulation monotherapy.

National trends in utilization of thrombolytic therapy for acute pulmonary embolism.

National trends in utilization of thrombolytic therapy for acute pulmonary embolism.

Anticoagulant Therapy of Acute Pulmonary Embolism with Right Heart Thrombi

Acute pulmonary embolism (PE) is a relatively common vascular disease with potentially life-threatening complications. Right heart thrombi deteriorate the prognosis. Due to the known high lethality, such a clinical situation requires immediate diagnosis and treatment. With the existing different management options for intracardiac blood clots, the optimal one is still uncertain. The article describes the experience of therapeutic and diagnostic tactics in a patient with PE and thrombosis of two right chambers of the heart with a favorable outcome while the conservative approach was used.

Thrombolytic therapy for pulmonary embolism.

Thrombolytic therapy is usually reserved for people with clinically serious or massive pulmonary embolism (PE). Evidence suggests that thrombolytic agents may dissolve blood clots more rapidly than heparin and may reduce the death rate associated with PE. However, there are still concerns about the possible risk of adverse effects of thrombolytic therapy, such as major or minor haemorrhage. This is the fourth update of the Cochrane review first published in 2006. To assess the effects of thrombolytic therapy for acute pulmonary embolism. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 17 August 2020. We undertook reference checking to identify additional studies. We included randomised controlled trials (RCTs) that compared thrombolytic therapy followed by heparin versus heparin alone, heparin plus placebo, or surgical intervention for people with acute PE (massive/submassive). We did not include trials comparing two different thrombolytic agents or different doses of the same thrombolytic drug. Two review authors (ZZ, QH) assessed the eligibility and risk of bias of trials and extracted data. We calculated effect estimates using the odds ratio (OR) with a 95% confidence interval (CI) or the mean difference (MD) with a 95% CI. The primary outcomes of interest were death, recurrence of PE and haemorrhagic events. We assessed the certainty of the evidence using GRADE criteria. We identified three new studies for inclusion in this update. We included 21 trials in the review, with a total of 2401 participants. No studies compared thrombolytics versus surgical intervention. We were not able to include one study in the meta-analysis because it provided no extractable data. Most studies carried a high or unclear risk of bias related to randomisation and blinding. Meta-analysis showed that, compared to control (heparin alone or heparin plus placebo), thrombolytics plus heparin probably reduce both the odds of death (OR 0.58, 95% CI 0.38 to 0.88; 19 studies, 2319 participants; low-certainty evidence), and recurrence of PE (OR 0.54, 95% CI 0.32 to 0.91; 12 studies, 2050 participants; low-certainty evidence). Effects on mortality weakened when six studies at high risk of bias were excluded from analysis (OR 0.71, 95% CI 0.45 to 1.13; 13 studies, 2046 participants) and in the analysis of submassive PE participants (OR 0.61, 95% CI 0.37 to 1.02; 1993 participants). Effects on recurrence of PE also weakened after removing one study at high risk of bias for sensitivity analysis (OR 0.60, 95% CI 0.35 to 1.04; 11 studies, 1949 participants). We downgraded the certainty of evidence to low because of 'Risk of bias' concerns. Major haemorrhagic events were probably more common in the thrombolytics group than in the control group (OR 2.84, 95% CI 1.92 to 4.20; 15 studies, 2101 participants; moderate-certainty evidence), as were minor haemorrhagic events (OR 2.97, 95% CI 1.66 to 5.30; 13 studies,1757 participants; low-certainty evidence). We downgraded the certainty of the evidence to moderate or low because of 'Risk of bias' concerns and inconsistency. Haemorrhagic stroke may occur more often in the thrombolytics group than in the control group (OR 7.59, 95% CI 1.38 to 41.72; 2 studies, 1091 participants). Limited data indicated that thrombolytics may benefit haemodynamic outcomes, perfusion lung scanning, pulmonary angiogram assessment, echocardiograms, pulmonary hypertension, coagulation parameters, composite clinical outcomes, need for escalation and survival time to a greater extent than heparin alone. However, the heterogeneity of the studies and the small number of participants involved warrant caution when interpreting results. The length of hospital stay was shorter in the thrombolytics group than in the control group (mean difference (MD) -1.40 days, 95% CI -2.69 to -0.11; 5 studies, 368 participants). Haemodynamic decompensation may occur less in the thrombolytics group than in the control group (OR 0.36, 95% CI 0.20 to 0.66; 3 studies, 1157 participants). Quality of life was similar between the two treatment groups. None of the included studies provided data on post-thrombotic syndrome or on cost comparison. Low-certainty evidence suggests that thrombolytics may reduce death following acute pulmonary embolism compared with heparin (the effectiveness was mainly driven by one trial with massive PE). Thrombolytic therapy may be helpful in reducing the recurrence of pulmonary emboli but may cause more major and minor haemorrhagic events, including haemorrhagic stroke. More studies of high methodological quality are needed to assess safety and cost effectiveness of thrombolytic therapy for people with pulmonary embolism.

Aggressive Therapy for Acute Pulmonary Embolism: Systemic Thrombolysis and Catheter-Directed Approaches.

Venous thromboembolism (VTE) is the third most common cause of cardiovascular disease after myocardial infarction and stroke. Population-based studies estimate that up to 94,000 new cases of pulmonary embolism (PE) occur in the United States annually with an increasing incidence with age. Mortality from PE is the greatest in the first 24 hours, with a decreased survival extending out 3 months. Thus, acute PE is a potentially fatal illness if not recognized and treated in a timely manner. Contemporary management includes systemic anticoagulation, thrombolysis, catheter-based procedures, and surgical embolectomy. This article reviews current clinical evidence and societal guidelines for the use of systemic and catheter-directed thrombolysis for treatment of acute PE.

Current Endovascular Treatment Options in Acute Pulmonary Embolism.

Acute pulmonary embolism (PE) is a significant cause of mortality and morbidity across the globe. Over the last few decades, there have been major therapeutic advances in acute PE management, including catheter-based therapy. However, the effectiveness of catheter-based therapy in acute PE is not supported by Level I evidence, making the use of this promising treatment rather controversial and ambiguous. In this paper, we discuss the risk stratification of acute PE and review the medical and endovascular treatment options. We also summarize and review the data supporting the use of endovascular treatment options in acute PE and describe the potential role of the PE response team.

Safety, Efficacy of an Accelerated Regimen of Low-Dose Recombinant Tissue-Type Plasminogen Activator for Reperfusion Therapy of Acute Pulmonary Embolism.

Controversy persists regarding the safety and efficacy of an accelerated low-dose recombinant tissue-type plasminogen activator (rt-PA) regimen for reperfusion therapy in acute pulmonary embolism. This study describes the outcomes of an accelerated low-dose rt-PA regimen for the treatment of acute pulmonary embolism in Vietnamese patients. This was a case series from October 2014 to October 2020 from 9 hospitals across Vietnam. Patients presenting with acute pulmonary embolism with high to intermediate mortality risk were administered alteplase 0.6 mg per kilogram (maximum of 50 mg) over 15 min. The main outcomes were the proportion who survived to hospital discharge and at 3 months as well as in-hospital hemorrhage (major and minor according to International Society of Thrombosis and Hemhorrage definitions). A total of 80 patients were enrolled: 48 (60%) with high risk for mortality and 32 patients (40%) with intermediate risk for mortality. A total of 7 (8.8%) died in hospital. All deaths occurred in the high-risk mortality group. The 73 patients who were discharged alive remained alive at 3 months follow up. During hospitalization, 1 patient (1.3%) suffered major bleeding, and 7 (8.8%) had minor bleeding. An accelerated thrombolytic regimen with alteplase 0.6 mg/kg (maximum of 50 mg) over 15 min for acute pulmonary embolism appeared be effective and safe in a case series of Vietnamese patients.

Utilization and Outcomes of Thrombolytic Therapy for Acute Pulmonary Embolism: A Nationwide Cohort Study

There are increased options to deliver thrombolytic treatment for acute, high-risk pulmonary embolism (PE). The goals of this study were to examine practice patterns of systemic thrombolysis and catheter-directed thrombolysis (CDT) and to compare outcomes following CDT with ultrasound facilitation (CDT-ultrasound) and CDT alone. The study analyzed adults aged > 18 years with hospitalizations associated with acute PE and thrombolysis in the 2016 Nationwide Readmissions Database. The study identified characteristics associated with the use of systemic thrombolysis and CDT. Comparisons of CDT-ultrasound vsCDT alone were then made by evaluating in-hospital events and readmissions. The primary outcomes were in-hospital mortality and 30-day readmission rates. Among 5,436 hospitalizations, systemic thrombolysis was used more often (n= 3,376; 62.1%) than CDT (n= 2,060; 37.9%). Compared with CDT, systemic thrombolysis was used more frequently in patients with higher rates of vasopressor use (4.3%vs1.0%), shock (15.8%vs. 6.9%), cardiac arrest (12.7%vs3.4%), and mechanical ventilation (19.0%vs5.9%). Among patients who underwent CDT, 417 (20.2%) received CDT-ultrasound, and 1,643 (79.8%) received CDT alone. Rates of bleeding events, vasopressor use, and mechanical ventilation were similar between therapeutic strategies. Following adjustment, in-hospital mortality (OR, 1.19; 95%CI, 0.63-2.26; P= .59) and 30-day readmission rates (OR, 0.75; 95%CI, 0.47-1.22; P= .25) were not significantly different between CDT-ultrasound and CDT alone. Systemic thrombolysis is used more often than CDT in patients with acute PE, in particular among those with a greater prevalence of high-risk features. Among patients treated with CDT, there were no differences in events between CDT-ultrasound and CDT alone.

Catheter-directed therapy for acute pulmonary embolism: navigating gaps in the evidence.

Systemic thrombolysis for acute pulmonary embolism (PE) reduces the risk of death and cardiovascular collapse but is associated with an increased rate of bleeding. The desire to minimize the risk of bleeding events has driven the development of catheter-based strategies for pulmonary reperfusion in PE. These catheter-based strategies utilize lower-dose fibrinolytic regimens or purely mechanical techniques to expedite removal of the embolus. Several devices providing mechanical or suction embolectomy and catheter-directed thrombolysis, with or without facilitation by ultrasound, have been tested. Data are inconsistent regarding the efficacy and safety of mechanical and suction embolectomy. The most comprehensive data on catheter-based techniques stem from trials of ultrasound-facilitated catheter fibrinolysis. Ultrasound-facilitated catheter fibrinolysis relieves right ventricular pressure overload with a lower risk of major bleeding and intracranial haemorrhage than historical rates with systemic fibrinolysis. However, further research is required to determine the optimal application of ultrasound-facilitated catheter fibrinolysis and other catheter-based therapies in patients with acute PE.

Massive Spontaneous Haemothorax after Rivaroxaban Therapy for Acute Pulmonary Embolism.

Spontaneous haemothorax complicating the treatment of pulmonary embolism is rare and potentially fatal. We describe a patient with pulmonary embolism and severe pleuritic pain who developed a life-threatening haemothorax 10 days later while on rivaroxaban therapy. This case highlights the fact that severe pleuritic pain associated with pulmonary embolism may indicate subclinical infarction of tissue near the visceral pleura with an increased risk of pleural effusion and the subsequent development of a haemothorax. It is important to recognise such danger signs warranting closer attention, especially since the increased use of direct oral anticoagulants has facilitated ambulatory care and this complication may manifest in the outpatient setting.LEARNING POINTSSpontaneous haemothorax may occur in the first 2 weeks after a patient starts anticoagulation.Severe pleuritic pain in a patient with pulmonary embolism may indicate subclinical infarction near the visceral pleura with an increased risk of pleural effusion and the subsequent development of a spontaneous haemothorax.Patients with severe pain and pleural effusion should be monitored closely, especially if they are outpatients, even though initial radiological findings are not significant.

Long-term results of low-dose tissue plasminogen activator therapy in acute pulmonary embolism

Recombinant tissue plasminogen activator (rt-PA) is the most commonly used thrombolytic agent in patients with high risk and intermediate to high mortality risk acute pulmonary embolism (PE). Clinical trials have...