Unstable Pulmonary Embolism Research Articles

Syncope in haemodynamically stable and unstable patients with acute pulmonary embolism \u2013 Results of the German nationwide inpatient sample

Syncope in pulmonary embolism (PE) could be the first sign of haemodynamic compromise. We aimed to investigate pathomechanisms of syncope and its impact on mortality. For this study, patients (aged ≥ 18years) were selected by screening the German nationwide inpatient sample for PE and stratified included patients by syncope (2011–2014). We analysed predictors of syncope in haemodynamically stable PE. Impact of syncope on in-hospital mortality in haemodynamically stable and unstable PE and benefit of systemic thrombolysis in haemodynamically stable PE with syncope (PE + Syncope) were analyzed. The German nationwide inpatient sample comprised 293,640 (84.9%) haemodynamically stable and 52,249 (15.1%) unstable PE patients; among them 2.3% had syncope. Right ventricular dysfunction (RVD) was a key predictor for syncope. In-hospital mortality-rate was lower in haemodynamically stable (6.4% vs. 7.6%, P < 0.001) and unstable PE + Syncope than in PE−Syncope (48.4% vs. 55.5%, P < 0.001) with reduced risk for in-hospital death in stable (OR 0.68 (95%CI 0.61–0.75), P < 0.001) and unstable (OR 0.69 (95% CI 0.62–0.78), P < 0.001) inpatients independent of age and sex. Haemodynamically stable PE + Syncope patients were more often treated with systemic thrombolysis (3.1% vs. 2.1%, P < 0.001). Systemic thrombolysis was associated with reduced in-hospital mortality in haemodynamically stable PE + Syncope (1.9% vs. 6.6%, P = 0.004) independently of age, RVD and tachycardia (OR 0.30 (95%CI 0.11–0.82), P = 0.019). In conclusion, in-hospital mortality was 6.4% in haemodynamically stable PE + Syncope. Haemodynamically stable PE + Syncope patients were more often treated with systemic thrombolysis and showed a trend to improved survial.

Outcomes of Pulmonary Embolectomy for Acute Pulmonary Embolism.

Acute pulmonary embolism (PE) is a major threat to the health and lives of hospitalized patients. This study was conducted to clarify the real-world outcomes of pulmonary embolectomy.Methods and Results:Retrospective investigation of 355 patients who underwent pulmonary embolectomy for acute PE was conducted using the Japanese Cardiovascular Surgery Database. Risk factors for operative death within 30 days after pulmonary embolectomy and major adverse cardiovascular events (MACE), including operative death, postoperative stroke and postoperative coma, were analyzed. Cardiopulmonary resuscitation (CPR) was required preoperatively in 27.6%, and preoperative veno-arterial extracorporeal membrane oxygenation was performed in 26.5%. Urgent or emergency operation was performed in 93% of patients. Operative mortality rate was 73/355 (20.6%). Incidence of MACE was 97/355 (27.3%). In univariate analysis, preoperative predictors of death were obesity, renal dysfunction, chronic obstructive pulmonary disease, liver injury, recent myocardial infarction, shock, refractory shock, CPR, heart failure, inotrope use, poor left ventricular function, preoperative arrhythmia and tricuspid regurgitation. In multivariate analysis, independent risk factors for operative death were heart failure (P=0.013), poor left ventricular function (P=0.007), and respiratory failure (P=0.001). Poor left ventricular function (P=0.033), preoperative CPR (P=0.002) and respiratory failure (P=0.007) were independent risk factors for MACE. The outcomes of pulmonary embolectomy were acceptable, considering the urgency and preoperative comorbidities of patients. Early triage of patients with hemodynamically unstable PE is important.

Epidemiology, patterns of care and mortality for patients with hemodynamically unstable acute symptomatic pulmonary embolism

BackgroundLimited information exists about the epidemiology, management and outcomes of hemodynamically unstable patients with acute pulmonary embolism (PE). We aimed to evaluate the prevalence and outcomes of unstable PE, and to assess the acute management in routine clinical practice. MethodsThis study included 34,380 patients from the RIETE registry with PE between 2001 and 2016. Primary outcomes included all-cause and PE-specific 30-day mortality. We used multivariable adjustments to calculate hazard ratios among unstable patients who did and did not receive reperfusion. ResultsOverall, 1207 patients (3.5%) presented with hemodynamic instability. All-cause 30-day mortality was 14% and 5.4% in those with versus those without hemodynamic instability (P < 0.001). Two hundred and thirty eight (20%) unstable patients received reperfusion therapy. After multivariable adjustment, reperfusion therapy was associated with non-significantly reduced 30-day all-cause mortality (hazard ratio [HR] 0.71; 95% CI, 0.45 to 1.10; P = 0.12), and significantly reduced 30-day PE-related mortality (HR 0.56; 95% CI, 0.31 to 0.99; P = 0.04). When limiting the adjusted analyses to unstable patients with right ventricular dysfunction, the difference was significant for both all-cause (HR 0.65; 95% CI, 0.42 to 1.00; P = 0.05) and PE-related mortality (HR 0.52; 95% CI, 0.30 to 0.92; P = 0.02). ConclusionsIn a multinational registry of patients with PE, prevalence of hemodynamic instability was 3.5%, with high associated 30-day mortality rates. Although use of reperfusion was associated with lower mortality rates, particularly in patients with right ventricular dysfunction, it was used in only a fifth of patients.

Mechanical circulatory support for acute right ventricular failure in the setting of pulmonary embolism.

Right ventricular (RV) failure due to pulmonary embolism (PE) increases morbidity and mortality and contributes to prolonged hospital length of stay and higher costs of care. RV mechanical circulatory support (MCS) including Impella RP devices have been increasingly used in hemodynamically compromised PE patients who are refractory to intravascular volume expansion and inotropic therapy. However, effectiveness and safety of Impella RP, in hemodynamically unstable PE patients is unknown. We included consecutive patients who presented to Detroit Medical Center between November 3, 2015 and October 2, 2017 with acute PE and had evidence of hemodynamic compromise indicating Impella RP. Total of five cases were identified. All patients met the shock definition due to massive or submassive PE and therefore received Impella RP on admission. Cardiac index was improved from mean of 1.69/min/m2, (0.88-2.15 L/min/m2 ), to 2.5 L/min/m2 (range 1.88-3.4), after 24 h of treatment. Similarly, mean heart rate reduced to 92 beats per minute (79-105), and mean systolic blood pressure increased to 140 mmHg (115-179). No significant changes were found in renal function, hemoglobin and platelets level during device use. One patient experienced hemoglobin drop from 13.7 to 7.3 g/dL but did not require blood transfusion. All patients survived to discharge. In patients with PE and RV shock, Impella RP device resulted in immediate hemodynamic benefit with reversal of shock and favorable survival to discharge.

Rationale, Design and Methodology of the Computerized Registry of Patients with Venous Thromboembolism (RIETE).

Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a preventable cause of in-hospital death, and one of the most prevalent vascular diseases. There is a lack of knowledge with regards to contemporary presentation, management and outcomes of patients with VTE. Many clinically important subgroups (including the elderly, those with recent bleeding and pregnant patients) have been under-represented in clinical trials. Furthermore, design of clinical trials is challenging in some scenarios, such as in those with hemodynamically unstable PE. RIETE (Registro Informatizado Enfermedad TromboEmbolica) is a large prospective multinational ongoing registry, designed to address these unmet needs using representative data from multiple centres. Initiated in Spain in 2001, RIETE currently includes 179 centres in 24 countries and has enrolled more than 72,000 patients. RIETE has helped characterize the pattern of presentation and outcomes of VTE, including the aforementioned understudied subgroups. RIETE has recently expanded to collect long-term outcome data, and has broadened its inclusion criteria to enrol other forms of venous thrombosis (such as cerebral vein thrombosis and splanchnic vein thrombosis). The RIETE platform is also being used to conduct pragmatic comparative effectiveness studies, including randomized trials. Future steps would focus on collaboration with additional centres across the world, and efforts to ensure the quality and expansion of the registry. In conclusion, RIETE is a large ongoing registry of patients with VTE and other thrombotic conditions. Its results could be helpful for improving our understanding of the epidemiology, patterns of care and outcomes of patients with thrombotic disease.

Post-Thrombotic Syndrome and Functional Disability in Patients with Upper Extremity Deep Vein Thrombosis: A Prospective Cohort Study

Introduction. Upper extremity deep vein thrombosis (UEDVT) is a relatively uncommon event with potentially serious complications. Its clinical outcomes are not well studied. The objective of this study was to assess the incidence of post-thrombotic syndrome (PTS) and functional disability in patients with UEDVT.Patients and methods. This was a pre-specified analysis of a prospective cohort study at 5 Canadian centres. We enrolled adult patients with a symptomatic UEDVT confirmed by compression ultrasound involving the brachial or more proximal veins, with or without a pulmonary embolism (PE). Exclusions included pregnancy, dialysis catheter thrombosis, active or high bleeding risk, platelet count <100x109/L, creatinine clearance < 30 ml/min, on warfarin for other indications, hemodynamically unstable PE, acute leukemia or undergoing a stem cell transplant within 3 months, geographical inaccessibility, life expectancy <3 months or treatment with low molecular weight heparin (LMWH) or warfarin for more than 7 days since diagnosis. Standardized treatment regimens were used as follows: spontaneous or central venous catheter (CVC)-related UEDVT were treated with dalteparin at therapeutic doses for at least 5 days followed by warfarin adjusted according to INR results. Spontaneous UEDVT was treated for at least 6 months and CVC-related events were treated for at least 3 months or for as long as the line remained in place and for at least 1 month after line removal. Cancer patients with non CVC-related UEDVT were treated using dalteparin alone for a minimum of 6 months. Outcomes were assessed at 12, 18 and 24 months and included the occurrence of PTS evaluated using a modified Villalta Score. PTS was defined for patients with a score of 5 or greater and severe PTS was defined by a score of 15 or higher. Functional disability was evaluated using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Patients were followed for 2 years. Data was analyzed using descriptive statistics. Confidence intervals for proportions were estimated using the Wilson’s score method. Groups were compared using χ2 and Student’s t- tests, as appropriate. The study was approved by all institutional review boards.Results. Between 2009 and 2012, we enrolled 141 patients: 75 with spontaneous and 66 with CVC related UEDVT. Mean age was 51 years and 55% were males. There were 78, 59 and 56 patients with evaluable data at 12, 18 and 24 months, respectively. The percentage of patients with ipsilateral PTS is shown in Table 1. There was no difference between patients with spontaneous or CVC- related UEDVT. Functional disability scores are shown in Table 2. Overall, patients developing PTS had higher functional disability at all time points, compared to patients without PTS.Conclusion. In this prospective cohort study PTS occurred in approximately one fifth of patients after UEDVT and was associated with more functional disability, although the majority of cases were mild according to the modified Villata score. No differences were observed between CVC-related and spontaneous UEDVT. [Display omitted] [Display omitted] DisclosuresLazo-Langner:Bayer: Honoraria; Pfizer: Honoraria; Daiichi Sankyo: Research Funding. Wells:Itreas: Other: Served on a Writing Committee; BMS/Pfizer: Research Funding; Bayer Healthcare: Other: Speaker Fees and Advisory Board; Janssen Pharmaceuticals: Consultancy. Carrier:BMS: Research Funding; Leo Pharma: Research Funding. Kovacs:Daiichi Sankyo Pharma: Research Funding; LEO Pharma: Honoraria; Bayer: Honoraria, Research Funding; Pfizer: Honoraria, Research Funding.

Catheter-Directed Therapy in Acute Pulmonary Embolism with Right Ventricular Dysfunction: A Promising Modality to Provide Early Hemodynamic Recovery.

BackgroundCatheter-directed therapy (CDT) for pulmonary embolism (PE) is considered as an alternative to systemic thrombolysis (ST) in patients with hemodynamically unstable acute PE who are considered at high bleeding risk for ST. We aimed to evaluate the efficacy and safety of CDT in the management of acute PE with right ventricular dysfunction (RVD). The primary outcomes were mortality, clinical success, and complications. Secondary outcomes were change in hemodynamic parameters in the first 24 hours following the procedure.Material/MethodsMedical records of consecutive patients diagnosed as having acute massive or submassive PE with accompanying RVD treated by immediate CDT at our institution from January 2007 to January 2014 were reviewed. Patient characteristics, mortality, achievement of clinical success, and minor and major bleeding complications were analyzed in the overall study group, as well as massive vs. submassive PE subgroups. Change in hemodynamic parameters in the second, eighth, and 24th hours after the CDT procedure were also analyzed.ResultsThe study included 15 consecutive patients (M/F=10/5) with a mean age of 54.2±16.6 years who underwent immediate CDT. Nine of the patients had submassive PE, and 6 had massive PE. In-hospital mortality rate was 13.3% (95% CI, 0.04–0.38). One major, but not life-threatening, bleeding episode was evident in the whole group. Hemodynamic parameters were stabilized and clinical success was achieved in 14/15 (93.3%; 95% CI, 70.2–98.8) of the patients in the first 24 hours. Notably, the hemodynamic recovery was significantly evident in the first 8 hours after the procedure.ConclusionsCDT is a promising treatment option for patients with acute PE with RVD with no fatal bleeding complication. In experienced centers, CDT should be considered as a first-line treatment for patients with acute PE and RVD and contraindications for ST, with the advantage of providing early hemodynamic recovery.

A Prospective Cohort Study of Upper Extremity Deep Vein Thrombosis

Introduction. Upper extremity deep vein thrombosis (UEDVT) is a relatively uncommon event with potentially serious complications. Its optimal treatment and clinical outcomes are not well studied. The objective of our study was to assess the safety and efficacy of a standardized management protocol for UEDVT as well as its long term complications.Patients and methods. We conducted a prospective cohort study at 5 Canadian centres and enrolled adult patients with a symptomatic UEDVT confirmed by compression ultrasound involving the brachial or more proximal veins, with or without a pulmonary embolism (PE). Exclusions included pregnancy, dialysis catheter thrombosis, active or high bleeding risk, platelet count <100x109/L, creatinine clearance < 30 ml/min, on warfarin for other indications, hemodynamically unstable PE, acute leukemia or undergoing a stem cell transplant within 3 months, geographical inaccessibility, life expectancy <3 months or treatment with low molecular weight heparin (LMWH) or warfarin for more than 7 days since diagnosis. Standardized treatment regimens were as follows: spontaneous or central venous catheter (CVC)-related UEDVT were treated with dalteparin at therapeutic doses for at least 5 days followed by warfarin adjusted according to INR results. Spontaneous UEDVT was treated for at least 6 months and CVC-related events were treated for at least 3 months or for as long as the line remained in place and for at least 1 month after line removal. Cancer patients with non CVC-related UEDVT were treated using dalteparin alone for a minimum of 6 months. Main outcomes were objectively documented venous thromboembolism (VTE) recurrence, major bleeding and death. All outcomes were centrally adjudicated. Patients were followed for 2 years. Data was analyzed using descriptive statistics. Survival data was analyzed using the Kaplan-Meier Method. Post-hoc analyses were conducted comparing CVC and spontaneous events. The study was approved by all institutional review boards.Results. Between 2009 and 2012, we enrolled 141 patients: 75 with spontaneous and 66 with CVC related UEDVT. Mean age was 51 years; 55% were males. The population characteristics are shown in the Table. The 2 year cumulative incidence of VTE recurrence was 3.5% (95% CI 1.5-8), of major bleeding was 2.8% (95% CI 1.1-7.1) and of death was 22% (95% CI 16-29.5). VTE recurrence rate was no different for spontaneous vs. CVC-related groups (4% vs. 3%; Log-Rank P = 0.690; Figure).Conclusion. The use of a standardized management protocol for patients with UEDVT results in a low risk of VTE recurrence and major bleeding at 2 years of follow up, in both CVC-related and spontaneous UEDVT.Table 1Population characteristicsSpontaneous UEDVTCatheter-related UEDVTTotalP-valueN%N%N%DemographicsAge (Mean [SD])48.6[17.8]54.9[13.6]51.6[16.2]NSMale gender4458.73451.57855.3NSCaucasian6789.36497.013192.9NSComorbiditiesPrevious VTE34.023.053.5NSPrior or concurrent cancer2229.34872.77049.6<0.001Prior gastrointestinal Bleeding68.057.6117.8NSType of CatheterNEHickman--11.510.7PICC--4974.24934.8Porta Cath--1624.21611.3Thrombus LocationSubclavian5472.04365.29768.8NSSuperior vena cava00.023.021.4NSBrachiocephalic56.71015.21510.6NSInternal Jugular1621.31421.23021.3NSAxillary3952.03451.57351.8NSExternal Jugular11.323.032.1NSTreatment Duration3 Months2634.71928.84531.9<0.0016 Months3749.346.14129.10.000Other1216.04365.25539.00.000 [Display omitted] DisclosuresLazo-Langner:Bayer: Honoraria; Pfizer: Honoraria. Wells:Bayer: Honoraria; BMS/Pfizer: Research Funding. Carrier:BMS: Research Funding; Bayer: Consultancy; Pfizer: Consultancy; LEO Pharma: Consultancy, Research Funding. Kovacs:Bayer: Honoraria, Research Funding; LEO Pharma: Honoraria; Daiichi Sankyo Pharma: Research Funding; Pfizer: Honoraria, Research Funding.

Surgical Embolectomy for Acute Massive and Submassive Pulmonary Embolism in a Series of 115 Patients

Pulmonary embolectomy is often indicated for central pulmonary embolism (PE) with hemodynamic instability, but remains controversial for hemodynamically stable patients with signs of right ventricular dysfunction. Because thrombolytic therapy is often contraindicated postoperatively, we reviewed risk factors and outcomes of pulmonary embolectomy for stable and unstable central PE, particularly in the early postoperative period. Between October 1999 and September 2013, 115 patients underwent pulmonary embolectomy for central, hemodynamically unstable PE (49 of 115, 43%) or hemodynamically stable PE (56 of 115, 49%). Ten operations for alternate indications (right atrial mass, endocarditis) were excluded for comparison analysis, leaving 105 patients. Mean age was 59 ± 13 years; 46 of 105 patients (44%) had recent surgery (within 5 weeks): orthopedic (12 of 46, 25%), neurosurgery (11 of 46, 24%), or general surgery (10 of 46, 22%). Preoperative demographics did not differ between groups, except for the frequency of cardiopulmonary resuscitation among unstable patients (11 of 49, 22%) versus stable patients (0 of 56, 0%; p < 0.001). Operative mortality for the combined groups was 6.6% (7 of 105): unstable 10.2% (5 of 49) versus stable 3.6% (2 of 56; p = 0.247). Of 11 patients requiring preoperative cardiopulmonary resuscitation, 4 died. Six-month, 1-year, and 3-year survival rates were, respectively, 75%, 68.4%, and 65.8% for unstable PE, and 92.6%, 86.7%, and 80.4% for stable PE (p = 0.018). This large series of pulmonary embolectomies demonstrates excellent early and late survival rates for patients with stable PE and unstable PE. These findings confirm pulmonary embolectomy as a beneficial therapeutic option for central PE, especially during the postoperative period when thrombolytic therapy is often contraindicated.

Heart rate in pulmonary embolism.

Heart rate is a rapidly available risk stratification parameter in acute pulmonary embolism (PE). We aimed to investigate the effectiveness of heart rate in predicting the outcome in acute PE. Data of 182 patients with acute PE were analysed retrospectively. Logistic regression models were calculated to investigate the associations between heart rate and in-hospital death, myocardial necrosis, PE status and presence of right ventricular dysfunction (RVD), respectively. ROC curve and cut-off values for heart rate predicting RVD as well as intermediate risk PE status in normotensive PE patients and for heart rate predicting in-hospital death and myocardial necrosis in all PE patients were calculated. ROC analysis for heart rate predicting RVD and intermediate risk PE were 0.706 and 0.718, respectively, with cut-off value of 86 beats/min. Regression models showed associations between heart rate >85 beats/min and both RVD (OR 4.871, 95 % CI 2.256-10.515, P = 0.000055) and intermediate risk PE (OR 5.244, 95 % CI 2.418-11.377, P = 0.000027). In hemodynamically stable and unstable PE patients, logistic regression models showed a borderline significant association between tachycardia and in-hospital death (OR 7.066, 95 % CI 0.764-65.292, P = 0.0849) and a significant association between heart rate and myocardial necrosis (OR 0.975, 95 % CI 0.959-0.991, P = 0.00203). ROC analysis for heart rate predicting in-hospital death and myocardial necrosis revealed AUC of 0.655 and 0.703 with heart rate cut-off values of 99.5 beats/min and 92.5 beats/min, respectively. An elevated heart rate in acute PE is connected with a worse outcome. Effectiveness in the prediction of RVD, intermediate PE status, cardiac injury and in-hospital death is acceptable. The cut-off value for the prediction of RVD and intermediate risk PE status in normotensive PE is 86 beats/min, while tachycardia predicts in-hospital death.

Vena Cava Filters in Unstable Elderly Patients With Acute Pulmonary Embolism

Abstract Background Inferior vena cava filters are associated with a reduced in-hospital all-cause case fatality rate of unstable patients with acute pulmonary embolism. Whether vena cava filters are associated with a reduced case fatality rate in adults of all ages with unstable pulmonary embolism, particularly the elderly, has not been determined. Methods Unstable patients with pulmonary embolism (in shock or ventilator dependent) 1999-2008 were identified from the Nationwide Inpatient Sample. Results Among 21,095 unstable patients with pulmonary embolism who received thrombolytic therapy, in-hospital all-cause case fatality rate was lower in every age group who received a vena cava filter in addition to thrombolytic therapy ( P = .0012 to P Conclusion Vena cava filters are associated with a reduced in-hospital all-cause case fatality rate in unstable adults with pulmonary embolism, irrespective of age.

Massive Pulmonary Embolism in a Pregnant Woman with an Excellent Response to Early Thrombolytic Therapy

Thrombolytic agents have been used successfully to treat patients with massive pulmonary embolism and cardiorespiratory insufficiency. Experience with these drugs in pregnancy is limited, nevertheless. We report a 32-year-old pregnant female, who was at 16 weeks of gestation, presented with acute collapse and progressive dyspnea caused by massive pulmonary embolism. The diagnosis was rapidly made in the emergency department with two dimensional-doppler echocardiography that showed signs of right ventricular dysfunction and pulmonary hypertension, as well as direct visualisation of large thrombus at the bifurcation of the main pulmonary artery. Because of significant haemodynamic instability and no improvement after intravenous heparin, the patient was successfully treated with recombinant tissue plasminogen activator and low-molecular-weight heparin. The response to fibrinolytic therapy was excellent without haemorrhagic complications and a healthy child was born at term. We conclude that early thrombolytic therapy may be a reasonable treatment for pregnant patients with unstable pulmonary embolism. (Hong Kong j.emerg.med. 2014;21:260-265)

Abstract 567: A Successful Use of Tissue Plasminogen Activator and Argatroban for Acute Therapy of a Submassive Pulmonary Embolism Caused by Heparin-Induced Thrombocytopenia

The field of anticoagulation has become a highly relevant and expanding division of medicine. Clinicians must maintain an adequate knowledge of the indications, risks, and benefits of each particular anticoagulant before utilizing them in patient care. Despite great advancements in anticoagulate therapies, areas of uncertainty exist when applying combined use of anticoagulants. This vignette illustrates a unique circumstance of initial therapy combining argatroban with tissue plasminogen activator (tPA) and subsequent transition to warfarin in the management of submassive pulmonary embolism (PE) caused by heparin-induced thrombocytopenia (HIT). There are currently no other published cases or guidelines that have demonstrated this treatment strategy. We present the case of a 56-year-old African American female who was started on argatroban therapy for submassive bilateral PE secondary to HIT. She required tPA after becoming progressively unstable. The argatroban drip was continued without any hemorrhagic complications. This combination of therapy led to her stabilization, and she was ultimately safely transitioned to warfarin therapy for long term maintenance anticoagulation. Argatroban is effective in the prevention and treatment of life-threatening complications of HIT. Very little research has been conducted in patients receiving tPA followed by anticoagulation therapy. This case highlights the successful therapy with combined use of tPA and argatroban followed by warfarin transition in the treatment of submassive PE caused by HIT. We find that tPA was safe and effective when the initial argatroban failed to stabilize our patient. The continued use of argatroban infusion after tPA did not cause any hemorrhagic complications. Furthermore, the overlap use of warfarin with argatroban until an INR greater than 4 was achieved for maintenance therapy did not contribute to any hemorrhagic complications. We conclude that the combination of tPA and argatroban is effective in the acute management of hemodynamically unstable PE caused by HIT without significant hemorrhagic complications.

Vena Cava Filters in Unstable Elderly Patients with Acute Pulmonary Embolism

BackgroundInferior vena cava filters are associated with a reduced in-hospital all-cause case fatality rate of unstable patients with acute pulmonary embolism. Whether vena cava filters are associated with a reduced case fatality rate in adults of all ages with unstable pulmonary embolism, particularly the elderly, has not been determined. MethodsUnstable patients with pulmonary embolism (in shock or ventilator dependent) 1999-2008 were identified from the Nationwide Inpatient Sample. ResultsAmong 21,095 unstable patients with pulmonary embolism who received thrombolytic therapy, in-hospital all-cause case fatality rate was lower in every age group who received a vena cava filter in addition to thrombolytic therapy (P = .0012 to <.0001). Patients aged ≥81 years showed the greatest absolute reduction of case fatality rate with filters (19.3%). Among 50,210 unstable patients who did not receive thrombolytic therapy, case fatality rate also was lower in every age group who received a vena cava filter (all P <.0001). Patients aged ≥81 years with vena cava filters showed the greatest absolute risk reduction of case fatality rate (27.7%). ConclusionVena cava filters are associated with a reduced in-hospital all-cause case fatality rate in unstable adults with pulmonary embolism, irrespective of age.

Treatment of Unstable Pulmonary Embolism in the Elderly and Those with Comorbid Conditions

BackgroundAlthough the in-hospital case fatality rate is lower in unstable patients with pulmonary embolism who receive thrombolytic therapy, less than one third receive it. The purpose of this investigation is to try to assess why most unstable patients fail to receive thrombolytic therapy and whether evidence might support a more aggressive approach. MethodsData were obtained from the Nationwide Inpatient Sample 1999-2008. ResultsFewer unstable patients with pulmonary embolism accompanied by comorbid conditions received thrombolytic therapy than patients with no comorbid conditions, 11,670 of 60,100 (19.4%) vs 9710 of 12,130 (80.0%) (P<.0001). Fewer patients aged>60 years received thrombolytic therapy than patients aged≤60 years, both among those with comorbid conditions, 6330 of 37,320 (17.0%) vs 5340 of 22,780 (23.4%) (P<.0001), and among those without comorbid conditions, 3560 of 5060 (70.4%) vs 6150 of 7070 (87.0%) (P<.0001). However, even among elderly patients and those with comorbid conditions, the case fatality rate was lower with thrombolytic therapy. The odds ratio of in-hospital death (0.11-0.62) favored thrombolytic therapy irrespective of age or comorbidity. ConclusionUnstable patients with pulmonary embolism were less likely to receive thrombolytic therapy if they were elderly or had comorbid conditions, but those who received thrombolytic therapy had a lower in-hospital case fatality rate irrespective of age or comorbid conditions. The cautious approach of withholding thrombolytic therapy in those who might have major bleeding might not be the safest approach in terms of mortality and needs to be prospectively evaluated.

Abstract No. 97: Hemodinamically unstable massive pulmonary embolism: Fibrinolysis in situ and fragmentation as treatment of choice

Abstract No. 97: Hemodinamically unstable massive pulmonary embolism: Fibrinolysis in situ and fragmentation as treatment of choice

Thrombolytic Therapy in a Patient With Suspected Pulmonary Embolism Despite a Negative Computed Tomography Pulmonary Angiogram

We report a case of a 62-year-old male who presented to our intensive care unit with hypoxemia 6 hours after retinal surgery. He had a negative computed tomography (CT) pulmonary angiogram, but an emergency echocardiogram revealed the McConnell sign. He was thrombolysed and had rapid improvement in oxygenation and hemodynamics. Thrombolysis in hemodynamically unstable pulmonary embolism is not controversial, but most algorithms require confirmation of the diagnosis. Our patient had a negative CT pulmonary angiogram but was thrombolysed based on the clinical picture. Autopsy confirmed the diagnosis of multiple pulmonary emboli and unexpectedly discovered a patent foramen ovale that explained paradoxical embolism to the brain.

Computed tomographic pulmonary angiography in the assessment of severity of acute pulmonary embolism and right ventricular dysfunction

The distinction between severe pulmonary embolism (PE) and right heart dysfunction is important for predicting patient mortality. To identify the role of computed tomographic pulmonary angiography (CTPA) in the assessment of the severity of acute PE and right ventricular dysfunction. Eighty-five patients suspected of having PE, as diagnosed by CTPA and scintigraphy, were divided into three groups: hemodynamically unstable PE (HUPE) (n = 20), hemodynamically stable PE (HSPE) (n = 33), and no PE (n = 32). For each patient, obstruction scores, including short-axis diameters of the right ventricle (RV) and left ventricle (LV), main pulmonary artery, and superior vena cava (SVC), were measured. The RV/LV short-axis ratios were calculated. The shapes of the interventricular septum and the reflux of the contrast medium into the inferior vena cava (IVC) were evaluated. The mortality due to PE within a 1-month follow-up period was recorded. The median CTPA obstruction score (HUPE 64%, HSPE 28%, P < 0.001), median RV/LV short-axis ratio (HUPE 1.4, HSPE 1.0, P < 0.01), median RV diameter (HUPE 55 mm, HSPE 42 mm, P < 0.001), median SVC diameter (HUPE 23 mm, HSPE 19 mm, P < 0.01), interventricular septum convex toward the LV (HUPE 70%, HSPE 18%, P < 0.001), and reflux of the contrast medium into the IVC (HUPE 65%, HSPE 33%, p < 0.05) were significantly different between the HUPE and HSPE groups. With ROC analysis, the CTPA obstruction score and RV/LV short-axis ratio threshold values for the HUPE patients were calculated to be 48% (95% sensitivity, 76% specificity) and 1.1 (85% sensitivity, 76% specificity), respectively. Three patients in the HUPE group died within the first 24 hours. Logistic regression methods revealed only the RV diameter as a significant predictor of death (odds ratio 1.24; 95% CI 1.04-1.48; P = 0.01). This study found that the parameters useful for distinguishing HUPE and HSPE included CTPA obstruction score, RV and SVC diameters, RV/LV short-axis ratio, interventricular septum shape, and reflux into the IVC. RV dilatation may be a significant predictor for mortality.

Quality Improvement Guidelines for the Treatment of Lower Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal

Suresh Vedantham, MD, Akhilesh K. Sista, MD, Seth J. Klein, MD, Lina Nayak, MD, Mahmood K. Razavi, MD, Sanjeeva P. Kalva, MD, Wael E. Saad, MD, Sean R. Dariushnia, MD, Drew M. Caplin, MD, Christine P. Chao, MD, Suvranu Ganguli, MD, T. Gregory Walker, MD, and Boris Nikolic, MD, MBA, for the Society of Interventional Radiology and Cardiovascular and Interventional Radiological Society of Europe Standards of Practice Committees

Haemodynamically unstable pulmonary embolism in the RIETE Registry: systolic blood pressure or shock index?

Patients with acute pulmonary embolism (PE) presenting with haemodynamic instability have the worst prognosis. However, what is understood by haemodynamic instability has not been clearly defined. The Registro Informatizado de la Enfermedad Tromboembólica (RIETE) is an ongoing registry of consecutive patients with symptomatic, objectively confirmed, acute deep vein thrombosis or PE. The present authors compared the predictive value of a systolic blood pressure (SBP) value of <100 mmHg and <90 mmHg and the shock index (cardiac frequency divided by SBP) on 30-day mortality in consecutive patients with PE. As of May 2006, 6,599 patients with PE were enrolled in the study. Of these, 417 (6.3%) died within 30 days: 153 of the initial PE, 29 of recurrent PE and 235 due to other causes. Of the 417 individuals who died, 127 (30%) had a positive shock index, 60 (14%) had SBP <100 mmHg and 33 (7.9%) had SBP <90 mmHg. On multivariate analysis any of the three parameters were independently associated with an increased mortality. The shock index had a higher sensitivity (30.5 versus 14.4 and 7.9% for SBP <100 mmHg and <90 mmHg, respectively) but lower specificity (86.3 versus 93.0 and 96.6). All three measures of haemodynamic instability are independent predictors of 30-day mortality. However, while the shock index had the highest sensitivity, a systolic blood pressure value <90 mmHg had the highest specificity.