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Yıldız Z, Kayğın MA, Özkara T, Limandal HK, Diler MS, Çüçen Dayı HI, Ergün S, Dağ Ö. Effects of Deep Venous Thrombosis Treatments on Early and Long-term Quality of Life: Medical Therapy vs. Systemic Thrombolysis vs. Pharmacomechanical Thrombolysis. Vasc Endovascular Surg 2024; 58:5-12. [PMID: 37321364 DOI: 10.1177/15385744231184654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVES The present study aimed to compare the effects of medical therapy (MT), systemic thrombolysis (ST), and pharmacomechanical thrombolysis (PMT) methods used in our clinic for the treatment of deep venous thrombosis (DVT) on symptom reduction, the incidence of post-thrombotic syndrome (PTS) development, and quality of life. METHODS Data from160 patients diagnosed with acute DVT between January 2012 and May 2021 and treated and followed up in our clinic were retrospectively analyzed. The patients were divided into three groups according to treatment method. The patients who received MT treatment were defined as Group 1, anticoagulant treatment after ST as Group 2, and anticoagulant treatment after PMT as Group 3. The patients were called to the outpatient clinic, informed consent was obtained, EuroQol-5D-3 L (EQ-5D-3 L) scoring and Villalta scoring were performed, and anamnesis was taken. RESULTS A total of 160 patients were included, with 71 (44.4%) patients in Group 1, 45 (28.1%) in Group 2, and 44 (27.5%) in Group 3. The mean age was 48.9 ± 14.9 years for Group 1, 42.2 ± 10.8 for Group 2, and 29.0 ± 7.2 for Group 3. When the time to return to normal life and the EQ-5D-3 L score index were compared, the differences between Groups 1 and 2 and between Groups 1 and 3 were statistically significant (P = .000 and P = .000, respectively). However, the differences between Groups 2 and 3 were statistically insignificant (P = .213 andp = .074, respectively). When Villalta scores and EQ Visual Analogue Scale (EQ-VAS) scores were compared between groups, the difference between all groups was statistically significant (P = .000). CONCLUSIONS The medical treatment alone was observed to be insufficient in terms of symptomatic improvement, development of PTS, quality of life, and long-term complications. When the ST and PMT groups were compared, it was determined that PMT treatment was more advantageous in terms of EQ-VAS score and PTS development, although there was no statistical difference regarding complications, such as return to normal life and long-term quality of life, the incidence of recurrent DVT development, and pulmonary thromboembolism incidence.
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Affiliation(s)
- Ziya Yıldız
- Department of Cardiovascular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Mehmet A Kayğın
- Department of Cardiovascular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Taha Özkara
- Department of Cardiovascular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Hüsnü K Limandal
- Department of Cardiovascular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Mevriye S Diler
- Department of Cardiovascular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Hatice I Çüçen Dayı
- Department of Cardiovascular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Servet Ergün
- Department of Pediatric Cardiovacscular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Özgür Dağ
- Department of Cardiovascular Surgery, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
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Abstract
Acute pulmonary embolism (PE) is the third most common acute cardiovascular condition, and its prevalence increases over time. D-dimer has a very high negative predictive value, and if normal levels of D-dimer are detected, the diagnosis of PE is very unlikely. The final diagnosis should be confirmed by computed tomographic scan. However, echocardiography is the most available, bedside, low-cost, diagnostic procedure for patients with PE. Risk stratification is of utmost importance and is mainly based on hemodynamic status of the patient. Patients with PE and hemodynamic stability require further risk assessment, based on clinical symptoms, imaging, and circulating biomarkers.
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Cheng CC, Chung CH. A 6-Year Epidemiological Study of Pulmonary Embolism in an Emergency Department. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790501200403] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To identify the epidemiology and early clinical features of patients with pulmonary embolism with a view to facilitate making the correct diagnosis. Methodology A retrospective study of patients admitted through the emergency department with a discharge diagnosis of pulmonary embolism in the computerised Clinical Management System from 1st January 1999 to 31st December 2004 in a public emergency general hospital in Hong Kong. Results Twenty-two patients were newly diagnosed to have pulmonary embolism and included in the study. The patients' clinical features and investigation findings were analysed. Old age and immobilisation were the most common risk factors identified. Nine patients were found to have deep vein thrombosis but none of them complained of calf pain during consultation in the emergency department. Most patients had symptoms of shortness of breath and chest pain on presentation. Fourteen patients had type 1 respiratory failure. The electrocardiogram and chest X-ray findings were non-specific. All the patients with D-dimer done showed positive results. CT scans were used in all patients to make the final diagnosis. Nineteen patients received low molecular weight heparin followed by warfarin and three patients had thrombolytic therapy. Conclusion Pulmonary embolism is not a commonly diagnosed disease in Hong Kong. The symptoms are non-specific and it is difficult to make the correct diagnosis in the emergency department.
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Black KJ, Lock AT, Thomson LM, Cole AR, Tang X, Polizzotti BD, Kheir JN. Hemodynamic Effects of Lipid-Based Oxygen Microbubbles via Rapid Intravenous Injection in Rodents. Pharm Res 2017; 34:2156-2162. [DOI: 10.1007/s11095-017-2222-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 06/23/2017] [Indexed: 10/19/2022]
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Igarashi Y, Akimoto T, Kobayashi T, Iwazu Y, Miki T, Otani-Takei N, Imai T, Sugase T, Masuda T, Takeda SI, Muto S, Nagata D. Performing Anticoagulation: A Puzzling Case of Cholesterol Embolization Syndrome. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2017; 10:1179547616684649. [PMID: 28469497 PMCID: PMC5398301 DOI: 10.1177/1179547616684649] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 11/21/2016] [Indexed: 12/04/2022]
Abstract
The avoidance of any form of anticoagulation is advised in cases of cholesterol embolization syndrome (CES). We herein describe a case of CES in a man with a history of unprovoked pulmonary embolism for which warfarinization was performed. Despite anecdotal reports of successful anticoagulation in CES patients with certain indications, irreversible renal failure, which was sufficiently severe to require chronic hemodialysis, eventually developed in our patient. Our results emphasize the pitfalls of this procedure, which imply its limited feasibility and safety. Several therapeutic concerns associated with this case are also discussed.
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Affiliation(s)
- Yusuke Igarashi
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Takahisa Kobayashi
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Yoshitaka Iwazu
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Takuya Miki
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Naoko Otani-Takei
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Toshimi Imai
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Taro Sugase
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Takahiro Masuda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Shin-Ichi Takeda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Shigeaki Muto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
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Kucher N, Quiroz R, McKean S, Sasahara AA, Goldhaber SZ. Extended enoxaparin monotherapy for acute symptomatic pulmonary embolism. Vasc Med 2016; 10:251-6. [PMID: 16444853 DOI: 10.1191/1358863x05vm634oa] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We investigated the efficacy and safety of extended enoxaparin monotherapy in symptomatic patients with acute pulmonary embolism (PE). We randomized 40 patients in a 1:1 allocation to enoxaparin monotherapy (1 mg/kg twice daily for 10-18 days, and then 1.5 mg/kg once daily until day 90) ( n = 20) or to enoxaparin 1.0 mg/kg twice daily as a bridge to warfarin with a target international normalized ratio of 2.0-3.0 for 90 days (at least 10 doses of enoxaparin overlapping with warfarin for at least 4 days) ( n = 20). All patients underwent echocardiography, cardiac troponin I (TnI), and brain natriuretic peptide testing to identify patients with an increased likelihood of adverse clinical outcomes. The end-points were newly diagnosed deep venous thrombosis (DVT) or PE and bleeding events through day 90. In 15 patients on extended enoxaparin therapy, we used repeated measure analysis of variance (ANOVA) to investigate differences in anti-Xa levels obtained at 2, 4, 8 and 12 weeks. The patients’ mean age was 52 ± 17 years; the most common comorbidities were obesity (58%), hypertension (30%), concomitant DVT (30%) and cancer (15%). Twelve (30%) patients had elevated cardiac TnI >0.1 mg/l and 11 (28%) had moderate or severe right ventricular dysfunction on echocardiography. Ten (25%) patients received thrombolysis with a continuous infusion of 100 mg alteplase prior to randomization. During a 90-day follow-up, one patient from the enoxaparin monotherapy group suffered symptomatic distal DVT; one from the warfarin group had recurrent symptomatic PE (p= 1.0). None of the study patients had major hemorrhage; two warfarin group patients had minor bleeding compared with none in the enoxaparin monotherapy group (p= 0.49). Repeated measure ANOVA did not reveal significant differences in anti-Xa levels over time (p= 0.217). In patients with acute symptomatic PE, extended enoxaparin monotherapy is feasible and warrants further investigation in a large clinical trial.
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Affiliation(s)
- Nils Kucher
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Kipfmueller F, Quiroz R, Goldhaber SZ, Schoepf UJ, Costello P, Kucher N. Chest CT assessment following thrombolysis or surgical embolectomy for acute pulmonary embolism. Vasc Med 2016; 10:85-9. [PMID: 16013191 DOI: 10.1191/1358863x05vm610oa] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Right ventricular (RV) enlargement, assessed by two-dimensional reconstructed 4-chamber views on contrast-enhanced multirow detector computed tomography (MDCT), is emerging as an important marker for predicting adverse clinical events in patients with acute pulmonary embolism (PE). It is unclear whether dynamic changes occur on chest computed tomography (CT) in response to thrombolysis or embolectomy to treat acute PE. We retrospectively investigated 23 consecutive patients who met the criteria of (1) a positive MDCT PE protocol; (2) RV dysfunction on echocardiography; (3) reperfusion therapy by systemic thrombolysis (n = 17) or surgical embolectomy (n = 6); and (4) follow-up MDCT study after completion of therapy. Two blinded observers reconstructed 4-chamber views on a Leonardo™ (Siemens, Munich, Germany) workstation using multiplanar reformats of axial CT data and then measured right and left ventricular dimensions (RVD, LVD). RV enlargement was defined as RVD/LVD ≥ 0.9. Mean age was 52 years, and there were 10 (43%) women. The median time to MDCT follow-up was 21 (range 2-231) days. Seventeen (74%) patients had their chest MDCT follow-up within 30 days. All 23 patients had RV enlargement (mean RVD/LVD 1.28, range 0.94 to 1.74) prior to initiation of reperfusion therapy. Although right ventricular enlargement was found in 43% of patients at follow-up, the mean RVD/LVD decreased from 1.28 ± 0.21 cm to 0.94 ± 0.16 cm (p = 0.001). The mean change in RVD/LVD was 0.31 ± 0.42 in thrombolysis patients and 0.42 ± 0.09 in embolectomy patients (p = 0.33). Reconstructed 4-chamber views on chest CT provide noninvasive imaging of right ventricular enlargement and permit dynamic assessment of the right ventricular response to thrombolysis and embolectomy in patients with acute PE.
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Affiliation(s)
- Florian Kipfmueller
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Zagorski J, Kline JA. Differential effect of mild and severe pulmonary embolism on the rat lung transcriptome. Respir Res 2016; 17:86. [PMID: 27435598 PMCID: PMC4952270 DOI: 10.1186/s12931-016-0405-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 07/10/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Pulmonary thromboembolism (PTE) is a common diagnosis and a leading cause of cardiovascular morbidity and mortality. A growing literature has associated PE with systemic inflammation, and global hyper-coagulability, which contribute to lung remodeling and clot recurrence. The source and mechanism of inflammation remains unstudied. In humans, inhibition of cholesterol synthesis with statins decreases biomarkers of inflammation. We test the differential effect of pulmonary vascular occlusion during mild and severe pulmonary embolism on the lung transcriptome. METHODS Experimental PE was induced in adult male rats by injection of 25 micron polystyrene microspheres into the jugular vein. The effect of Mild PE, (2-h right ventricular systolic pressure [RVSP] normal, 18-h RVSP 44 mmHg) and Severe PE (2-h RVSP > 50 mmHg; 18-h RVSP 44 mmHg) on lungs was assessed by measuring transcriptome-wide changes in gene expression by DNA microarrays. RESULTS Severe PE was associated with a large change in lung gene expression and in the expression of KEGG pathways and other gene functional annotation groups. Mild PE was also associated with a large number of significant changes in gene expression and in the expression of KEGG pathways and gene functional annotation groups, even after only 2 h of PE. Up-regulated pathways included increased adipocytokine, chemokine and cytokine signaling as well as cholesterol synthesis. CONCLUSIONS Mild PE without acute pulmonary hypertension (PH) increased lung gene expression of inflammatory pathways, including increased cholesterol synthesis. These data indicate that even mild persistent pulmonary vascular occlusion is capable of inciting an inflammatory response from the lung. These data imply the detrimental effect of unresolved pulmonary obstruction from PE.
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Affiliation(s)
- John Zagorski
- Department of Math and Sciences, Gaston College, Dallas, NC, 28014, USA
| | - Jeffrey A Kline
- Department of Emergency Medicine and Department of Cellular and Integrative Physiology, Indiana University Medical School, 720 Eskanazi Avenue, Indianapolis, IN, 46202, USA.
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Sistino JJ, Blackwell M, Crumbley AJ. Transport on emergency bypass for pulmonary embolism followed by surgical repair using retrograde pulmonary perfusion: a case report. Perfusion 2016; 19:385-7. [PMID: 15619974 DOI: 10.1191/0267659104pf775cr] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Joseph J Sistino
- Medical University of South Carolina, Cardiovascular Perfusion Program, 101 Doughty Street 2nd Floor, SC 29425, Charleston, USA.
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Ostovan MA, Ghaffari S, Pourafkari L, Dehghani P, Hajizadeh R, Nadiri M, Ghaffari MR. Modification of Simplified Pulmonary Embolism Severity Index and its Prognostic Value in Patients with Acute Pulmonary Embolism. Heart Lung Circ 2015; 25:184-90. [PMID: 26481399 DOI: 10.1016/j.hlc.2015.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 07/16/2015] [Accepted: 08/17/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Various risk stratification systems have been used to predict the clinical outcome of patients with pulmonary embolism (PE). In this study we present a modification of the simplified Pulmonary Embolism Severity Index (S-PESI) score and evaluate its accuracy in predicting the outcome of these patients. MATERIALS AND METHODS Patients older than 18 years with documented PE were enrolled in this study. S-PESI was calculated in all patients. We added electrocardiographic evidence of right ventricular strain as a new criteria and replaced the O2 saturation of <90% in S-PESI score with PaO2 /PaCO2 ratio obtained from the arterial blood gas analysis as two newly modified criteria to define a modified form of S-PESI system (modified s-PESI). Patients were followed for about one year in outpatient clinics. Any deaths attributable to PE or for unknown reasons were considered as PE related. We defined Major Adverse Cardio-Pulmonary Events (MACPE) as sum of one-year mortality, need for thrombolysis and mechanical ventilation during index hospitalisation. RESULTS Among 300 enrolled patients, in-hospital mortality occurred in 38 (12.7%) and one-year mortality in 73 (24.3%) patients. Considering a cut-off point of 3, modified s-PESI score had a lower sensitivity (49.3% vs. 89%) and higher specificity (79.4% vs. 37.7%) than S-PESI to predict one-year mortality. Area Under Curve (AUC) to predict MACPE was significantly higher for modified s-PESI (0.692 vs 0.730, P=0.012). CONCLUSION The modified s-PESI is superior to S-PESI in predicting one-year outcome in patients with PE and can be used for more accurate risk stratification of these patients.
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Affiliation(s)
| | - Samad Ghaffari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Leili Pourafkari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Pooyan Dehghani
- Cardiology Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Hajizadeh
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Nadiri
- Pulmonology Department, Imam Reza Hospital, Tabriz, Iran
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Hee L, Ng ACC, Huang J, Chow V, Mussap C, Kritharides L, Thomas L. The contribution of cardiovascular mortality to long term outcomes in a relatively young demographic following acute pulmonary embolism: a validation study. Int J Cardiol 2015; 199:13-7. [PMID: 26173168 DOI: 10.1016/j.ijcard.2015.06.169] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 06/08/2015] [Accepted: 06/26/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Long-term studies following acute pulmonary embolism (PE) remain limited in the current era. A recent study from our collaborative group, in a contemporary adult population, showed substantially increased cardiovascular mortality following PE. We sought to evaluate the contribution of cardiovascular mortality to long-term outcomes in a different demographic that comprised of a significantly younger PE cohort. METHODS AND RESULTS Demographic and clinical characteristics were retrospectively collected for this cohort, and similar methods and outcome measures were applied as detailed in the original study. We compared a population from a different metropolitan area (LH: Liverpool Hospital) to that from the original study (CRGH: Concord Hospital) over a similar time period. A total of 815 patients comprised this cohort with mean 5.3±3.8year follow-up. There were similar demographics between the two cohorts, though the mean age was significantly younger in LH group (60 vs 68years, p<0.001). Prior history of cardiovascular disease in the LH group was half of that present in the CRGH cohort. The overall mortality was 7.4% per patient-year. Patients with underlying cardiovascular disease when presenting with an acute PE had a 2.3-fold increased risk of death during follow-up compared to those without. Multivariate analysis showed that older age, male gender, malignancy, diabetes, cardiovascular disease and chronic pulmonary disease were independent predictors of post-discharge mortality. CONCLUSIONS Despite our cohort being significantly younger with a lower incidence of pre-existing cardiovascular disease, cardiovascular disease was still a significant contributor to long-term outcomes and an important predictor of mortality following acute PE.
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Affiliation(s)
- L Hee
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, The University of NSW, Sydney, NSW, Australia
| | - A C C Ng
- Cardiology Department, Concord Hospital, Sydney, NSW, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - J Huang
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, The University of NSW, Sydney, NSW, Australia
| | - V Chow
- Cardiology Department, Concord Hospital, Sydney, NSW, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - C Mussap
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, The University of NSW, Sydney, NSW, Australia
| | - L Kritharides
- Cardiology Department, Concord Hospital, Sydney, NSW, Australia; Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - L Thomas
- Cardiology Department, Liverpool Hospital, Sydney, NSW, Australia; South Western Sydney Clinical School, The University of NSW, Sydney, NSW, Australia.
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Luchini F, Medda P, Mariani MG, Mauri M, Toni C, Perugi G. Electroconvulsive therapy in catatonic patients: Efficacy and predictors of response. World J Psychiatry 2015; 5:182-92. [PMID: 26110120 PMCID: PMC4473490 DOI: 10.5498/wjp.v5.i2.182] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 02/12/2015] [Accepted: 03/05/2015] [Indexed: 02/05/2023] Open
Abstract
Recent evidence favors the view of catatonia as an autonomous syndrome, frequently associated with mood disorders, but also observed in neurological, neurodevelopmental, physical and toxic conditions. From our systematic literature review, electroconvulsive therapy (ECT) results effective in all forms of catatonia, even after pharmacotherapy with benzodiazepines has failed. Response rate ranges from 80% to 100% and results superior to those of any other therapy in psychiatry. ECT should be considered first-line treatment in patients with malignant catatonia, neuroleptic malignant syndrome, delirious mania or severe catatonic excitement, and in general in all catatonic patients that are refractory or partially responsive to benzodiazepines. Early intervention with ECT is encouraged to avoid undue deterioration of the patient's medical condition. Little is known about the long-term treatment outcomes following administration of ECT for catatonia. The presence of a concomitant chronic neurologic disease or extrapyramidal deficit seems to be related to ECT non-response. On the contrary, the presence of acute, severe and psychotic mood disorder is associated with good response. Severe psychotic features in responders may be related with a prominent GABAergic mediated deficit in orbitofrontal cortex, whereas non-responders may be characterized by a prevalent dopaminergic mediated extrapyramidal deficit. These observations are consistent with the hypothesis that ECT is more effective in "top-down" variant of catatonia, in which the psychomotor syndrome may be sustained by a dysregulation of the orbitofrontal cortex, than in "bottom-up" variant, in which an extrapyramidal dysregulation may be prevalent. Future research should focus on ECT response in different subtype of catatonia and on efficacy of maintenance ECT in long-term prevention of recurrent catatonia. Further research on mechanism of action of ECT in catatonia may also contribute to the development of other brain stimulation techniques.
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Vuilleumier N, Limacher A, Méan M, Choffat J, Lescuyer P, Bounameaux H, Aujesky D, Righini M. Cardiac biomarkers and clinical scores for risk stratification in elderly patients with non-high-risk pulmonary embolism. J Intern Med 2015; 277:707-16. [PMID: 25285747 DOI: 10.1111/joim.12316] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To determine the prognostic accuracy of cardiac biomarkers alone and in combination with clinical scores in elderly patients with non-high-risk pulmonary embolism (PE). DESIGN Ancillary analysis of a Swiss multicentre prospective cohort study. SUBJECTS A total of 230 patients aged ≥65 years with non-high-risk PE. MAIN OUTCOME MEASURES The study end-point was a composite of PE-related complications, defined as PE-related death, recurrent venous thromboembolism or major bleeding during a follow-up of 30 days. The prognostic accuracy of the Pulmonary Embolism Severity Index (PESI), the Geneva Prognostic Score (GPS), the precursor of brain natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) was determined using sensitivity, specificity, predictive values, receiver operating characteristic (ROC) curve analysis, logistic regression and reclassification statistics. RESULTS The overall complication rate during follow-up was 8.7%. hs-cTnT achieved the highest prognostic accuracy [area under the ROC curve: 0.75, 95% confidence interval (CI): 0.63-0.86, P < 0.001). At the predefined cut-off values, the negative predictive values of the biomarkers were above 95%. For levels above the cut-off, the risk of complications increased fivefold for hs-cTnT [odds ratio (OR): 5.22, 95% CI: 1.49-18.25] and 14-fold for NT-proBNP (OR: 14.21, 95% CI: 1.73-116.93) after adjustment for both clinical scores and renal function. Reclassification statistics indicated that adding hs-cTnT to the GPS or the PESI significantly improved the prognostic accuracy of both clinical scores. CONCLUSION In elderly patients with nonmassive PE, NT-proBNP or hs-cTnT could be an adequate alternative to clinical scores for identifying low-risk individuals suitable for outpatient management.
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Affiliation(s)
- N Vuilleumier
- Faculty of Medicine, Division of Laboratory Medicine, Department of Genetics and Laboratory Medicine, Geneva University Hospital, Geneva, Switzerland
| | - A Limacher
- Clinical Trials Unit (CTU) Bern, Department of Clinical Research and Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - M Méan
- Division of General Internal Medicine, Bern University Hospital and University of Bern, Bern, Switzerland
| | - J Choffat
- Faculty of Medicine, Division of Laboratory Medicine, Department of Genetics and Laboratory Medicine, Geneva University Hospital, Geneva, Switzerland
| | - P Lescuyer
- Faculty of Medicine, Division of Laboratory Medicine, Department of Genetics and Laboratory Medicine, Geneva University Hospital, Geneva, Switzerland
| | - H Bounameaux
- Faculty of Medicine, Division of Angiology and Haemostasis, Geneva University Hospital, Geneva, Switzerland
| | - D Aujesky
- Division of General Internal Medicine, Bern University Hospital and University of Bern, Bern, Switzerland
| | - M Righini
- Faculty of Medicine, Division of Angiology and Haemostasis, Geneva University Hospital, Geneva, Switzerland
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Value of monoenergetic low-kV dual energy CT datasets for improved image quality of CT pulmonary angiography. Eur J Radiol 2014; 83:322-8. [DOI: 10.1016/j.ejrad.2013.11.005] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 11/02/2013] [Accepted: 11/07/2013] [Indexed: 11/20/2022]
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Gomaa M, Fahmy H, Farouk A. Catheter direct thrombolysis: Role of actilyse in treatment of acute deep venous thrombosis. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2013. [DOI: 10.1016/j.ejrnm.2012.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Apfaltrer P, Walter T, Gruettner J, Weilbacher F, Meyer M, Henzler T, Neumaier M, Schoenberg SO, Fink C. Prediction of adverse clinical outcome in patients with acute pulmonary embolism: Evaluation of High-Sensitivity Troponin I and quantitative CT parameters. Eur J Radiol 2013; 82:563-7. [DOI: 10.1016/j.ejrad.2012.11.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 10/30/2012] [Accepted: 11/05/2012] [Indexed: 11/25/2022]
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17
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Algahtani FH, Bayoumi N, Abdelgadir A, Al-Nakshabandi N, Al Aseri Z, Al Ghamdi M, Al Saeed E. Clinical characteristics and risk factors of pulmonary embolism: data from a Saudi tertiary-care center. J Thromb Haemost 2013; 11:388-90. [PMID: 23205904 DOI: 10.1111/jth.12083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 11/20/2012] [Indexed: 11/29/2022]
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18
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Watts JA, Gellar MA, Fulkerson MBK, Kline JA. A soluble guanylate cyclase stimulator, BAY 41-8543, preserves right ventricular function in experimental pulmonary embolism. Pulm Pharmacol Ther 2012; 26:205-11. [PMID: 23142020 DOI: 10.1016/j.pupt.2012.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 09/20/2012] [Accepted: 10/26/2012] [Indexed: 11/24/2022]
Abstract
Pulmonary embolism (PE) increases pulmonary vascular resistance, causing right ventricular (RV) dysfunction, and poor clinical outcome. Present studies test if the soluble guanylate cyclase stimulator BAY 41-8543 reduces pulmonary vascular resistance and protects RV function. Experimental PE was induced in anesthetized, male Sprague-Dawley rats by infusing 25 μm polystyrene microspheres (1.95 million/100 g body wt, right jugular vein) producing moderate PE. Pulmonary artery vascular resistance, estimated as RVPSP/CO, increased 3-fold after 5 h of PE. Treatment with BAY 41-8543 (50 μg/kg, I.V.; given at the time of PE induction) normalized this index by reducing RVPSP and markedly increasing CO, via preservation of heart rate and stroke volume. Ex vivo RV heart function showed minimal changes at 5 h of PE, but decreased significantly after 18 h of PE, including peak systolic pressure (PSP, Control 39 ± 1 mmHg vs. 19 ± 3 PE), +dP/dt (1192 ± 93 mmHg/s vs. 444 ± 64) and -dP/dt (-576 ± 60 mmHg/s vs. -278 ± 40). BAY 41-8543 significantly improved all three indices of RV heart function (PSP 35 ± 3.5, +dP/dt 1129 ± 100, -dP/dt -568 ± 87). Experimental PE produced increased PVR and RV dysfunction, which were ameliorated by treatment with BAY 41-8543. Thus, there is vasodilator reserve in this model of experimental PE that can be exploited to reduce the stress upon the heart and preserve RV contractile function.
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Affiliation(s)
- John A Watts
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, USA.
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19
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Removable vena cava filter: single-centre experience with a single device. Radiol Med 2012; 118:816-25. [DOI: 10.1007/s11547-012-0893-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Accepted: 02/08/2012] [Indexed: 10/27/2022]
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20
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Zhang K, Zeng X, Zhu C, Xu L, Fu X, Jiang H, Wang J, Lu W. Successful thrombolysis in postoperative patients with acute massive pulmonary embolism. Heart Lung Circ 2012; 22:100-3. [PMID: 23068907 DOI: 10.1016/j.hlc.2012.08.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Revised: 08/15/2012] [Accepted: 08/20/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE The standard medical management for patients with acute massive pulmonary embolism (MPE) is systemic thrombolysis. However, it is generally thought that recent surgeries are a contraindication to thrombolytic therapy. In this study, we evaluated the efficacy and safety of systemic thrombolysis for postoperative patients with acute MPE and assessed the risk of bleeding. METHODS A retrospective review was performed on 21 postoperative patients with MPE in a timeframe of five years (from 2005 to 2010). The criteria for study inclusion were postoperative patients who received systemic thrombolysis for confirmed acute MPE within three weeks after surgery. RESULTS Seventeen postoperative patients, including men (12) and women (five) aged 53±16 (range 23-71) years, were treated with systemic thrombolysis. Significant haemodynamic improvement (shock index<0.9) was observed in 16 of 17 cases (94%). The remaining patient (6%) died of cardiac arrest within 24h. No major bleeding complication was observed. Sixteen patients survived and remained stable for 34±16 (range 11-52) days until hospital discharge. CONCLUSION Recent surgery is not an absolute contraindication to systemic thrombolysis. Further, to obtain a successful outcome, it is crucial to exclude patients who have received neurosurgical operations or those with other contraindications to thrombolytic therapy.
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Affiliation(s)
- Kedong Zhang
- Guangzhou Institute of Respiratory Disease, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital, Guangzhou Medical University, People's Republic of China
| | - Xiansheng Zeng
- Guangzhou Institute of Respiratory Disease, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital, Guangzhou Medical University, People's Republic of China
| | - Caixia Zhu
- Department of Rheumatology, The General Hospital, Ningxia Medical University, Ningxia, People's Republic of China
| | - Lei Xu
- Guangzhou Institute of Respiratory Disease, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital, Guangzhou Medical University, People's Republic of China
| | - Xin Fu
- Guangzhou Institute of Respiratory Disease, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital, Guangzhou Medical University, People's Republic of China
| | - Hua Jiang
- Guangzhou Institute of Respiratory Disease, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital, Guangzhou Medical University, People's Republic of China
| | - Jian Wang
- Guangzhou Institute of Respiratory Disease, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital, Guangzhou Medical University, People's Republic of China; Division of Pulmonary & Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD 21224, United States.
| | - Wenju Lu
- Guangzhou Institute of Respiratory Disease, State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital, Guangzhou Medical University, People's Republic of China; Division of Pulmonary & Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD 21224, United States.
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21
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Apfaltrer P, Bachmann V, Meyer M, Henzler T, Barraza JM, Gruettner J, Walter T, Schoepf UJ, Schoenberg SO, Fink C. Prognostic value of perfusion defect volume at dual energy CTA in patients with pulmonary embolism: correlation with CTA obstruction scores, CT parameters of right ventricular dysfunction and adverse clinical outcome. Eur J Radiol 2012; 81:3592-7. [PMID: 22495202 DOI: 10.1016/j.ejrad.2012.02.008] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Revised: 02/22/2012] [Accepted: 02/23/2012] [Indexed: 11/19/2022]
Abstract
PURPOSE To investigate the prognostic value of perfusion defect volume (PDvol) at dual-energy-CT-angiography (DE-CTA) in patients with acute pulmonary embolism (PE) by correlating PDvol with CTA-obstruction-scores (OS), CT parameters of right-ventricular-dysfunction (RVD), and adverse-clinical-outcome. MATERIALS AND METHODS DE-CTA of 60 patients (mean age: 65±14.4 years) with PE were analyzed. Iodine maps were generated, and normalized PDvol--defined as volume of perfusion defects/total lung volume--was quantified. Furthermore, established prognostic parameters (Qanadli and Mastora-OS, and CT parameters of RVD) were obtained. CT parameters of RVD--namely the right ventricle/left ventricle (RV/LV) diameter ratio measured on transverse sections (RV/LVtrans), four-chamber views (RV/LV4ch), and RV/LV volume ratios (RV/LVvol)--were assessed. PDvol was correlated with OS, CT parameters of RVD and adverse clinical outcome (defined as the need for intensive care treatment or death). RESULTS 10 of 60 patients with PE experienced adverse clinical outcome. Patients with adverse clinical outcome showed significantly higher PDvol (35±11% vs. 23±10%, p=0.002), RV/LV ratios (RV/LV4ch 1.46±0.32 vs. 1.18±0.26, p=0.005; RV/LVvol 2.25±1.33 vs. 1.19±0.56, p=0.002) and higher Mastora global scores (52 vs. 13, p=0.02) compared to those without adverse clinical outcome. A weak correlation was observed between PDvol and the Mastora global score (r=0.5; p=0.0003), as well as between PDvol and RV/LV4Ch (r=0.432, p=0.0006). No correlation was found between PDvol and the Qanadli score or the remainder of the RVD-CT parameters. CONCLUSION The extent of perfusion defects as assessed by DE-CTA correlates with adverse clinical outcome in patients with PE. Therefore, volumetric quantification of perfusion defects at DE-CTA allows the identification of low-risk patients who do not require intensified monitoring and treatment.
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Affiliation(s)
- Paul Apfaltrer
- Department of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim-Heidelberg University, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany.
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22
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Pellegrini L, Le Dolley Y, Marot B, Riberi A, Bellezza M, Kerbaul F. [Interest of echocardiography in the diagnosis and monitoring of a pulmonary embolism complicating a free-floating thrombus in right heart cavities]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:246-250. [PMID: 22305401 DOI: 10.1016/j.annfar.2011.10.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 10/26/2011] [Indexed: 05/31/2023]
Abstract
We report the case of a 50-year-old patient admitted in ICU for a pulmonary embolism associated with a large thrombus in right heart cavities discovered during an assessment of faintness. Despite an excellent haemodynamic tolerance, there was a systolic and diastolic right ventricular failure and immediate threat to life. The treatment mainly relies on intravenous thrombolysis with excellent results both on thrombus lysis and on the right heart performance. Echocardiography proved to be an essential tool during the management of this patient to ensure the effectiveness and to monitor the whole procedure of thrombolysis.
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Affiliation(s)
- L Pellegrini
- Service d'anesthésie réanimation 2, hôpital de la Timone-Adultes, Assistance publique-Hôpitaux de Marseille, and UMR PCO2E, université de la Méditerranée, Aix-Marseille II, 264, rue Saint-Pierre, 13385 Marseille cedex 5, France.
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23
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Pulmonary vascular reserve during experimental pulmonary embolism: Effects of a soluble guanylate cyclase stimulator, BAY 41-8543*. Crit Care Med 2011; 39:2700-4. [DOI: 10.1097/ccm.0b013e318226678e] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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24
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Ozsu S, Abul Y, Yilmaz I, Ozsu A, Oztuna F, Bulbul Y, Ozlu T. Prognostic significance of PaO2/PaCO2 ratio in normotensive patients with pulmonary embolism. CLINICAL RESPIRATORY JOURNAL 2011; 6:104-11. [DOI: 10.1111/j.1752-699x.2011.00253.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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25
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Evaluation of right ventricular dysfunction and prediction of clinical outcomes in acute pulmonary embolism by chest computed tomography: comparisons with echocardiography. Int J Cardiovasc Imaging 2011; 28:979-87. [DOI: 10.1007/s10554-011-9912-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Accepted: 06/12/2011] [Indexed: 11/30/2022]
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26
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Weininger M. Subjective assessment of right ventricle enlargement from computed tomography pulmonary angiography images. Int J Cardiovasc Imaging 2011; 28:975-7. [DOI: 10.1007/s10554-011-9909-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Accepted: 06/09/2011] [Indexed: 12/01/2022]
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27
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Maestre A, Sánchez R, Rosa V, Aujesky D, Lorenzo A, Barillari G, Monreal M. Clinical characteristics and outcome of inpatients versus outpatients with venous thromboembolism: findings from the RIETE Registry. Eur J Intern Med 2010; 21:377-82. [PMID: 20816588 DOI: 10.1016/j.ejim.2010.07.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Revised: 07/02/2010] [Accepted: 07/06/2010] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with venous thromboembolism (VTE) treated with anticoagulants are at risk of death from pulmonary embolism (PE) and/or bleeding. However, whether patients who develop VTE in hospital have a higher complication rate than those who develop VTE in an outpatient setting is unclear. PATIENTS AND METHODS RIETE is an ongoing, prospective registry of consecutive patients with acute, objectively confirmed, symptomatic VTE. We compared the 3-month incidence of fatal PE and fatal bleeding in patients in whom the VTE had developed while in hospital for another medical condition (inpatients) with those who presented to the emergency ward because of VTE (outpatients). RESULTS Up to April 2008, 22,133 patients with acute VTE were enrolled: 10,461 (47%) presented with PE, 11,672 with deep vein thrombosis. Overall, 6445 (29%) were inpatients. During the study period, those who developed VTE as inpatients had a significantly higher incidence of fatal PE (2.1% vs. 1.5%; odds ratio: 1.4; 95% CI: 1.1-1.7), overall death (7.0% vs. 5.4%; odds ratio: 1.3; 95% CI: 1.2-1.5), and major bleeding (2.9% vs. 2.1%; odds ratio: 1.4; 95% CI: 1.1-1.6) than outpatients. The incidence of fatal bleeding was not significantly increased (0.7% vs. 0.5%; odds ratio: 1.2; 95% CI: 0.9-1.8). In multivariable analysis, inpatient status was significantly associated with a higher risk for fatal PE (odds ratio: 1.3; 95% CI: 1.1-1.7). CONCLUSIONS VTE occurring in hospitalized patients carries a significantly higher risk for death of PE than in outpatients, underscoring the importance of VTE prevention strategies in the hospital setting.
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Affiliation(s)
- Ana Maestre
- Department of Internal Medicine, Hospital Universitario de Elche, Elche, Alicante, Spain
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28
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Adatia I, Shekerdemian L. The role of calcium channel blockers, steroids, anticoagulation, antiplatelet drugs, and endothelin receptor antagonists. Pediatr Crit Care Med 2010; 11:S46-52. [PMID: 20216164 DOI: 10.1097/pcc.0b013e3181c76bab] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The rationale for the drug therapy of pulmonary artery hypertension is to reduce mortality and morbidity caused by failure of right ventricular adaptation to an elevated pulmonary vascular resistance. We review the evidence for the use of calcium-channel blockers, steroids, anticoagulation, antiplatelet drugs, and endothelin receptor antagonists in the management of pulmonary artery hypertension. The drugs we discuss are more suited to long-term outpatient therapy. These drugs have not found a routine place in intensive care management, and calcium-channel blockers are contraindicated in patients with right-heart failure. The efficacy of many agents has been extrapolated from data acquired in adult patients and applied to children. All of us involved in the care of young patients with pulmonary artery hypertension should advocate for both the inclusion of younger patients in clinical trials and the design of distinctly pediatric trials with pharmaceutical and drug administration agencies. It is only with data derived from pediatric inclusive studies that we shall be able to recommend therapy with strong evidence. However, it is important to point out that the use of newer agents for the treatment of chronic pulmonary artery hypertension (prostacyclin, endothelin receptor antagonists, nitric oxide, and sildenafil) have not been shown to improve survival unequivocally and have relied on surrogates, such as exercise capacity. There are no long-term studies of survival benefit. Recent studies have included data on time to clinical worsening, which may be a more predictive surrogate of survival.
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Affiliation(s)
- Ian Adatia
- Pediatric Cardiac Critical Care and Intermediate Care Program, University of Alberta, Edmonton, AB, Canada.
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29
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Abstract
Echocardiography can be used for rapid and accurate risk stratification of patients with pulmonary embolism to appropriately direct the therapeutic strategies for those at high risk. Echocardiography is an ideal risk stratification tool in this regard because of its easy portability to the emergency room or to the bed side. It can be performed at a relatively low cost and at no risk to the patient. Furthermore, echocardiography allows repetitive noninvasive assessment of the cardiovascular and hemodynamic status of the patient and the response to the therapeutic interventions. Right ventricular hypokinesis, persistent pulmonary hypertension, a patent foramen ovale, and a free floating right heart thrombus are echocardiographic markers that identify patients at a higher risk for morbidity and mortality. Such patients warrant special consideration for thrombolysis or embolectomy.
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30
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Rendina D, De Bonis S, Gallotta G, Piedimonte V, Mossetti G, De Filippo G, Farina F, Vargas G, Barbella MR, Postiglione A, Strazzullo P. Clinical, historical and diagnostic findings associated with right ventricular dysfunction in patients with central and non-massive pulmonary embolism. Intern Emerg Med 2010; 5:53-9. [PMID: 19937481 DOI: 10.1007/s11739-009-0330-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Accepted: 10/19/2009] [Indexed: 11/27/2022]
Abstract
Right ventricular dysfunction during acute pulmonary embolism (PE) predisposes to hemodynamic instability and cardiogenic shock. Aim of this case-control study was to determine the clinical, historical and diagnostic findings associated with right ventricular dysfunction in patients with acute PE involving the main or segmental pulmonary arteries (central PE) and without hemodynamic instability on admission to the Emergency Department (ED) (non-massive PE). From January 1, 2002 to December 31, 2005, 211 patients with central PE were admitted to the Department of Emergency Medicine of the "Antonio Cardarelli" Hospital (Naples, Italy). One hundred eighteen of them had echocardiographic evidence of right ventricular dysfunction on admission to the ED. A history of type 2 diabetes mellitus and chronic obstructive pulmonary disease were significantly associated with an increased risk of this PE-related complication. Compared to patients without right ventricular dysfunction, those with right ventricular dysfunction showed higher levels of markers of cardiac damage, and a significant impairment of respiratory function. Echocardiographic evidence of right ventricular dysfunction on admission to the ED was significantly associated with the occurrence of hemodynamic instability and cardiogenic shock during the PE clinical course. The study results indicate that a history of type 2 diabetes mellitus and chronic obstructive pulmonary disease are significantly associated with the occurrence of right ventricular dysfunction in patients with non-massive and central PE independent of age, gender and other historical and clinical variables detectable on admission to the ED.
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Affiliation(s)
- Domenico Rendina
- Department of Clinical and Experimental Medicine, Federico II University Medical School, via S. Pansini, 5, 80131, Naples, Italy.
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31
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Watts JA, Marchick MR, Kline JA. Right ventricular heart failure from pulmonary embolism: key distinctions from chronic pulmonary hypertension. J Card Fail 2010; 16:250-9. [PMID: 20206901 DOI: 10.1016/j.cardfail.2009.11.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 11/05/2009] [Accepted: 11/30/2009] [Indexed: 01/05/2023]
Abstract
BACKGROUND The right ventricle normally operates as a low pressure, high-flow pump connected to a high-capacitance pulmonary vascular circuit. Morbidity and mortality in humans with pulmonary hypertension (PH) from any cause is increased in the presence of right ventricular (RV) dysfunction, but the differences in pathology of RV dysfunction in chronic versus acute occlusive PH are not widely recognized. METHODS AND RESULTS Chronic PH that develops over weeks to months leads to RV concentric hypertrophy without inflammation that may progress slowly to RV failure. In contrast, pulmonary embolism (PE) results in an abrupt vascular occlusion leading to increased pulmonary artery pressure within minutes to hours that causes immediate deformation of the RV. RV injury is secondary to mechanical stretch, shear force, and ischemia that together provoke a cytokine and chemokine-mediated inflammatory phenotype that amplifies injury. CONCLUSIONS This review will briefly describe causes of pulmonary embolism and chronic PH, models of experimental study, and pulmonary vascular changes, and will focus on mechanisms of right ventricular dysfunction, contrasting mechanisms of RV adaptation and injury in these 2 settings.
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Affiliation(s)
- John A Watts
- Emergency Medicine Research, Carolinas Medical Center, 1542 Garden Terrace, Charlotte, NC 28203, USA.
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32
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Yoon JC, Kim WY, Choi SS, Jung SK, Sohn CH, Kim W, Lim KS, Jeong TO, Jin YH, Lee JB. D-dimer as a Prognostic Tool in Patients with Normotensive Pulmonary Embolism. Tuberc Respir Dis (Seoul) 2010. [DOI: 10.4046/trd.2010.68.2.87] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jae Chol Yoon
- Department of Emergency Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Sik Choi
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Ku Jung
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chang Hwan Sohn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Won Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kyoung Soo Lim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Tae O Jeong
- Department of Emergency Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Young Ho Jin
- Department of Emergency Medicine, Chonbuk National University Hospital, Jeonju, Korea
| | - Jae Baek Lee
- Department of Emergency Medicine, Chonbuk National University Hospital, Jeonju, Korea
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Lobo JL, Zorrilla V, Aizpuru F, Grau E, Jiménez D, Palareti G, Monreal M. D-dimer levels and 15-day outcome in acute pulmonary embolism. Findings from the RIETE Registry. J Thromb Haemost 2009; 7:1795-801. [PMID: 19691481 DOI: 10.1111/j.1538-7836.2009.03576.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND A number of variables have been evaluated for risk stratification in patients with acute pulmonary embolism (PE). Whereas increased D-dimer levels have been associated with mortality at 3 months, its role in predicting short-term outcome (the period of time during which any therapeutic decision has to be taken) remains unclear. METHODS RIETE is an ongoing, prospective registry of consecutive patients with acute venous thromboembolism. We assessed the prognostic value of D-dimer levels at baseline, measured with an automated latex agglutination test (IL Test D-dimer), on the 15-day outcome in patients with acute PE. Overall mortality, fatal PE and major bleeding rates were compared by quartile. RESULTS As of February 2008, 1707 patients with acute PE underwent D-dimer testing. Of these, 72 patients (4.2%) died during the first 15 days, 11 (0.6%) had recurrent PE, and 29 (1.7%) had major bleeding. Overall mortality increased with increasing D-dimer levels, from 2.7% in the first quartile (< 1050 ng mL(-1)) to 7.0% in the fourth quartile (>or= 4200 ng mL(-1)). The rates of fatal PE and major bleeding also increased. On multivariate analysis, patients with D-dimer levels in the fourth quartile had an increased risk for overall death (odds ratio, 1.8; 95% CI, 1.1-3.2), fatal PE (odds ratio, 2.0; 95% CI, 1.0-3.8) or major bleeding (odds ratio, 3.2; 95% CI, 1.5-7.0). CONCLUSIONS PE patients with D-dimer levels in the fourth quartile had an increased incidence of overall death, fatal PE and major bleeding within 15 days both before and after multivariate adjustment.
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Affiliation(s)
- J L Lobo
- Servicio de Neumología, Hospital Txagorritxu, Vitoria, Spain
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Zagorski J, Obraztsova M, Gellar MA, Kline JA, Watts JA. Transcriptional changes in right ventricular tissues are enriched in the outflow tract compared with the apex during chronic pulmonary embolism in rats. Physiol Genomics 2009; 39:61-71. [PMID: 19602618 DOI: 10.1152/physiolgenomics.00076.2009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Moderate to severe pulmonary embolism (PE) can cause pulmonary arterial hypertension and right ventricular (RV) heart damage. Previous studies from our laboratory indicate that the basal outflow tract of the RV is injured and has acute inflammation followed by tissue remodeling while the apex appears normal. The present studies examine transcription responses to chronic PE in RV apex and outflow tracts using DNA microarrays to identify transcription responses by region. Changes predominated in the RV outflow tract (8,575 genes showed >/=1.5-fold expression change). Gene ontology and KEGG analyses indicated a significant decrease in genes involved in cellular respiration and energy metabolism and increases in inflammatory cell adhesion molecules and extracellular matrix proteins. Signal pathways for wound healing such as fibroblast growth factor, collagen synthesis, and CCN proteins (named for the first three members of the family: cysteine-rich protein 61, connective tissue growth factor, and nephroblastoma overexpressed gene) were strongly upregulated. In comparison, few genes (422) showed significant change in the RV apex tissue. Apex-selective genes included two genes affecting metabolism and a stretch-sensitive transcription factor (ankyrin repeat domain 1). We conclude that the RV outflow tract is subject to strong proinflammatory and profibrotic remodeling transcriptional responses in chronic PE. Severe loss of genes involved in cellular respiration is consistent with previous histology indicating a shift in cell types present within the outflow tract tissue away from highly energy-dependant cardiomyocytes to less metabolically active cells during remodeling. The apex region of the RV had few compensating adaptations.
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Affiliation(s)
- John Zagorski
- Department of Emergency Medicine, James G. Cannon Research Center, Carolinas Medical Center, Charlotte, North Carolina 28203, USA
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35
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Vuilleumier N, Le Gal G, Verschuren F, Perrier A, Bounameaux H, Turck N, Sanchez JC, Mensi N, Perneger T, Hochstrasser D, Righini M. Cardiac biomarkers for risk stratification in non-massive pulmonary embolism: a multicenter prospective study. J Thromb Haemost 2009; 7:391-8. [PMID: 19087222 DOI: 10.1111/j.1538-7836.2008.03260.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Troponins (cTnI and cTnT), N-terminal pro-Brain Natriuretic Peptide (NT-proBNP), myoglobin, heart-type fatty acid-binding protein (H-FABP) and fibrin D-Dimer are emergent candidates for risk stratification in pulmonary embolism (PE). OBJECTIVE To compare the respective prognostic values of biomarker with non-massive PE to predict an adverse outcome at 3 months. PATIENTS/METHODS One hundred and forty-six consecutive patients with non-massive PE were included in this multicenter prospective study. The combined outcome consisted of intensive care monitoring on admission, death or hospitalization attributable to either a PE-related complication [defined by PE/deep vein thrombosis (DVT) relapse or major bleeding under anticoagulation] or to dyspnoea with or without chest pain during follow-up. RESULTS The outcome was met in 12% of patients. In univariate analysis, a NT-proBNP level above 300 pg/ml was the strongest predictor of unfavorable outcome with an odds ratio (OR) of 15.8 [95% confidence interval (CI): 2.05-122). ORs for the other variables were: 8.0 for D-dimer >2000 ng/ml (95% CI: 1.1-64), 4.7 for H-FABP >6 ng/ml (95% CI:1.5-14.8), 3.5 for cTnI >0.09 ng/ml (95% CI:1.2-9.7), 3.4 for myoglobin >70 ng/ml (95% CI:0.9-12.2). Receiver operating curve (ROC) analysis indicated that NT-proBNP was the best predictor [area under the curve (AUC) 0.84; 95%CI: 0.76-0.92; P < 0.0001] with a negative predictive value of 100% (95% CI: 91-100) at 300 pg/ml. At that cut-off, the true negative rate for NT-proBNP was 40%. In multivariate analysis, NT-proBNP was the only significant independent predictors. CONCLUSIONS NT-proBNP appears to be a good risk stratification marker in identifying low-risk patients with non-massive PE who could be treated in an outpatient setting.
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Affiliation(s)
- N Vuilleumier
- Division of Laboratory Medicine, Department of Genetics and Laboratory Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.
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Kjaergaard J, Schaadt BK, Lund JO, Hassager C. Prognostic importance of quantitative echocardiographic evaluation in patients suspected of first non-massive pulmonary embolism. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 10:89-95. [DOI: 10.1093/ejechocard/jen169] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Watts JA, Gellar MA, Obraztsova M, Kline JA, Zagorski J. Role of inflammation in right ventricular damage and repair following experimental pulmonary embolism in rats. Int J Exp Pathol 2008; 89:389-99. [PMID: 18808531 DOI: 10.1111/j.1365-2613.2008.00610.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Right ventricular (RV) dysfunction is associated with poor clinical outcome following pulmonary embolism (PE). Previous studies in our laboratory show that influx of neutrophils contributes to acute RV damage seen in an 18 h rat model of PE. The present study describes the further progression of inflammation over 6 weeks and compares the neutrophil and monocyte responses. The RV outflow tract became white in colour by day 1 with influx of neutrophils (tissue myeloperoxidase activity increased 17-fold) and mononuclear cells with characteristics of M1 phenotype (high in Ccl20, Cxcl10, CcR2, MHCII, DNA microarray analysis). Matrix metalloproteinase activities were increased and tissue was thinned to produce a translucent appearance in weeks 1 through 6 in 40% of hearts. RV contractile function was significantly reduced at 6 weeks of PE. In this later phase, there was accumulation of myofibroblasts, the presence of mononuclear cells with M2 characteristics (high in scavenger mannose receptors, macrophage galactose lectin 1, PDGFR1, PDGFRbeta), enrichment of the subendocardial region of the RV outflow tract with neovesels (alpha-smooth muscle immunohistochemistry) and deposition of collagen fibres (picrosirius red staining) beginning scar formation. Thus, while neutrophil response is associated with the early, acute inflammatory events, macrophage cells continue to be present during the proliferative phase and initial deposition of collagen in this model, changing from the M1 to the M2 phenotype. This suggests that the macrophage cell response is biphasic.
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Affiliation(s)
- John Albert Watts
- Emergency Medicine Research, Carolinas Medical Center, Charlotte, NC 28203, USA.
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Castro Añón O, González Barcala FJ, Álvarez Dobaño JM, Valdés Cuadrado L. Estratificación del riesgo en la embolia pulmonar. Med Clin (Barc) 2008; 131:505-8. [DOI: 10.1157/13127278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Yardan T, Altintop L, Baydin A, Yilmaz O, Guven H. B-type natriuretic peptide as an indicator of right ventricular dysfunction in acute pulmonary embolism. Int J Clin Pract 2008; 62:1177-82. [PMID: 17537186 DOI: 10.1111/j.1742-1241.2007.01380.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE B-type natriuretic peptide (BNP) is a neurohormone secreted from cardiac ventricles in response to ventricular strain. The aim of present study was to evaluate the role of BNP in the diagnosis of the right ventricular (RV) dysfunction in acute pulmonary embolism (PE). METHODS BNP levels were measured in patients with acute PE as diagnosed by high probability lung scan or positive spiral computed tomography. All patients underwent standard echocardiography and blood tests during the second hour of the diagnosis. RESULTS Forty patients diagnosed as acute PE (mean age, 60.4 +/- 13.2 years; 62.5% women) were enrolled in this study. Patients with RV dysfunction had significantly higher BNP levels than patients without RV dysfunction (426 +/- 299.42 pg/ml vs. 39.09 +/- 25.22 pg/ml, p < 0.001). BNP-discriminated patients with or without RV dysfunction (area under the receiver operating characteristic curve, 0.943; 95% CI, 0.863-1.022). BNP > 90 pg/ml was associated with a risk ratio of 165 (95% CI, 13.7-1987.2) for the diagnosis of RV dysfunction. There was a significant correlation between RV end-diastolic diameter and BNP (r = 0.89, p < 0.001). Sixteen patients (40%) were diagnosed as having low-risk PE, 19 patients (47.5%) with submassive PE and five patients (12.5%) with massive PE. The mean BNP was 39.09 +/- 25.2, 378.4 +/- 288.4 and 609.2 +/- 279.2 pg/ml in each group respectively. CONCLUSION Measurement of BNP levels may be a useful approach in diagnosis of RV dysfunction in patients with acute PE. The possibility of RV dysfunction in patients with plasma BNP levels > 90 pg/ml should be strongly considered.
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Affiliation(s)
- T Yardan
- Ministry of Health, Ankara Training & Research Hospital, Emergency Service, Ankara, Turkey.
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Zagorski J, Sanapareddy N, Gellar MA, Kline JA, Watts JA. Transcriptional profile of right ventricular tissue during acute pulmonary embolism in rats. Physiol Genomics 2008; 34:101-11. [DOI: 10.1152/physiolgenomics.00261.2007] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Acute pulmonary embolism (PE) is the third leading cause of cardiovascular death in the United States. Moderate to severe PE can cause pulmonary arterial hypertension (PH) with resultant right ventricular (RV) heart damage. The mechanisms leading to RV failure after PE are not well defined, although it is becoming clear that PH-induced inflammatory responses are involved. We previously demonstrated profound neutrophil-mediated inflammation and RV dysfunction during PE that was associated with increased expression of several chemokine genes. However, a complete assessment of transcriptional changes in RVs during PE is still lacking. We have now used DNA microarrays to assess the alterations in gene expression in RV tissue during acute PE/PH in rats. Key results were confirmed with real-time RT-PCR. Nine CC-chemokine genes (CCL-2, -3, -4, -6, -7, -9, -17, -20, -27), five CXC-chemokine genes (CXCL-1, -2, -9, -10, -16), and the receptors CCR1 and CXCR4 were upregulated after 18 h of moderate PE, while one C-chemokine (XCL-1) and one CXC-chemokine (CXCL-12) were downregulated. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses indicated increased expression of many inflammatory genes. There was also a major shift in the expression of components of metabolic pathways, including downregulation of fatty acid transporters and oxidative enzymes, a change in glucose transporters, and upregulation of stretch-sensing and hypoxia-inducible transcription factors. This pattern suggests an extensive shift in cardiac physiology favoring the expression of the “fetal gene program.”
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Affiliation(s)
- John Zagorski
- Department of Emergency Medicine, James G. Cannon Research Center, Carolinas Medical Center, Charlotte, North Carolina
| | - Nina Sanapareddy
- Department of Emergency Medicine, James G. Cannon Research Center, Carolinas Medical Center, Charlotte, North Carolina
| | - Michael A. Gellar
- Department of Emergency Medicine, James G. Cannon Research Center, Carolinas Medical Center, Charlotte, North Carolina
| | - Jeffrey A. Kline
- Department of Emergency Medicine, James G. Cannon Research Center, Carolinas Medical Center, Charlotte, North Carolina
| | - John A. Watts
- Department of Emergency Medicine, James G. Cannon Research Center, Carolinas Medical Center, Charlotte, North Carolina
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Palmieri V, Gallotta G, Rendina D, De Bonis S, Russo V, Postiglione A, Martino S, Di Minno MND, Celentano A. Troponin I and right ventricular dysfunction for risk assessment in patients with nonmassive pulmonary embolism in the Emergency Department in combination with clinically based risk score. Intern Emerg Med 2008; 3:131-8. [PMID: 18270791 DOI: 10.1007/s11739-008-0134-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2007] [Accepted: 10/18/2007] [Indexed: 10/22/2022]
Abstract
To determine whether troponin I (cTnI) and right ventricular (RV) dysfunction predict adverse in-hospital outcomes in patients admitted to the Emergency Department (ED) with definite nonmassive pulmonary embolism (PE) independent of and in addition to a recently validated clinical prognostic risk score. From a pool of 168 patients with suspected PE, 89 had nonmassive PE confirmed by spiral lung angio-computed tomography. By the clinical prognostic score, in our study sample, 14% had very low risk; 17% had low risk, 20% had intermediate risk, whereas high risk and very high risk were identified in 29 and 20%, respectively. Prevalence of elevated cTnI (>0.1 microg/L, 57%) at admission was comparable among patients grouped by clinical prognostic score (P = NS); echocardiographic RV dysfunction (54%) was more prevalent with intermediate or high clinical risk score (P < 0.02). Increased cTnI predicted primary end-point (development of hemodynamic instability, overall 33 cases, 37%) independent of and in addition to the clinical risk class and RV dysfunction (P < 0.01 for interaction). Fatal events (12 cases, 14%, 5 definite, 7 possible PE-related) were predicted by higher clinical risk score (P < 0.05). In patients with nonmassive central PE admitted to the ED, increased cTnI contributed to identifying those with increased risk of development of hemodynamic instability independent of and in addition to a validated clinically based risk score.
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Affiliation(s)
- Vittorio Palmieri
- Cardiology Unit, Ospedale dei Pellegrini, ASL-Napoli 1, Naples, Italy.
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Zhu L, Yang Y, Wu Y, Zhai Z, Wang C. Value of right ventricular dysfunction for prognosis in pulmonary embolism. Int J Cardiol 2008; 127:40-5. [PMID: 17716753 DOI: 10.1016/j.ijcard.2007.06.093] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2006] [Revised: 06/24/2007] [Accepted: 06/30/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Acute pulmonary embolism (APE) patients with right ventricular dysfunction (RVD) have a worse prognosis. We assessed RVD, deciding the indexes correlating best with prognosis. METHODS The prospective multi-center study included 520 consecutive APE patients from 41 collaborating hospitals in China, between June 2002 and November 2004. RVD was diagnosed in the presence of at least 2 of the following: right ventricular (RV) dilatation, loss of inspiratory collapse of inferior vena cava (IVC), right ventricular hypokinesis, tricuspid regurgitant jet velocity >2.8 m/s. RESULTS Mean age was 57.4+/-14.1 years and 323 patients (62.1%) were male. The 14-day mortality in normotensive patients with RVD was higher (2.0% vs 0.4%, p<0.01) than without RVD. RVD was associated with adverse 14-day outcomes (OR 5.23, 95% CI, 2.44-11.23) and the combination of RV dilation and IVC broadening was more valuable than the combination of RV dilation and RV hypokinesis (p<0.01). A multiple logistic regression model implied that RVD, right/left ventricular end-diastolic diameter ratio (RVED/LVED) and systolic pulmonary artery pressure (SPAP) be independent predictors of adverse 14-day clinical outcomes (p<0.01). ROC curve showed that the best cut-off values of RVED/LVED and SPAP were 0.67 and 60 mm Hg, respectively. Hemodynamic instability, 14-day clinical outcome, and SPAP were independent harbingers for 3-month outcomes (p<0.01). CONCLUSIONS RVD was a discriminator for a poor prognosis in normotensive patients. Early detection of RVD (especially combination of RV dilation and IVC broadening, RVED/LVED>0.67 and/or SPAP>60 mm Hg) was beneficial for identifying high-risk patients. Hemodynamic instability, 14-day clinical outcomes, and SPAP independently predicted 3-month clinical outcomes.
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Affiliation(s)
- Ling Zhu
- Department of Respiratory Medicine, Shandong Provincial Hospital, Shandong University, Jinan, China
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Wang J, Guo X, Liu M, Guo Y, Wang C, Yang Y, Zhai Z, Zhu L, Ma H, Guo Y. The dynamic study of the pulmonary artery obstruction degree and the right ventricular function in massive pulmonary embolism on CT pulmonary angiography. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s1007-4376(08)60062-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pulmonary embolism in the ECT patient: a case report and discussion. Gen Hosp Psychiatry 2008; 30:87-9. [PMID: 18164948 DOI: 10.1016/j.genhosppsych.2007.08.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2007] [Revised: 08/10/2007] [Accepted: 08/21/2007] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Our objective was to discuss the risk for pulmonary embolism (PE) in the patient population with comorbid psychiatric and medical issues and risk management. It was also our objective to discuss the potential use of electroconvulsive therapy (ECT) following a PE with a case presentation format. METHODS We present a case report, a review of the literature and a discussion. RESULTS We report on the case of a 68-year-old man with bipolar disorder who had a PE after two ECTs. He required stabilization and treatment in the intensive care unit before returning to the psychiatry unit for completion of a course of ECT, which was well tolerated and highly effective. CONCLUSIONS Patients with comorbid medical and psychiatric illness are at high risk of developing deep venous thrombus/PE and need to be monitored for this. They often require ECT, which can be administered safely even after a PE.
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Zagorski J, Gellar MA, Obraztsova M, Kline JA, Watts JA. Inhibition of CINC-1 Decreases Right Ventricular Damage Caused by Experimental Pulmonary Embolism in Rats. THE JOURNAL OF IMMUNOLOGY 2007; 179:7820-6. [DOI: 10.4049/jimmunol.179.11.7820] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Almahameed A, Carman TL. Outpatient management of stable acute pulmonary embolism: proposed accelerated pathway for risk stratification. Am J Med 2007; 120:S18-25. [PMID: 17916455 DOI: 10.1016/j.amjmed.2007.08.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Pulmonary embolism (PE) is a major health problem and a cause of worldwide morbidity and mortality. The current standard therapy for acute PE encourages admitting patients to the hospital for administration of parenteral anticoagulation therapy as a bridge to oral vitamin K antagonists. Prognostic models that identify patients with stable (nonmassive) acute PE (SPE) who are at low risk for adverse outcome have recently been reported. Based on these risk stratification models, hospital-based therapy is warranted for patients with PE who meet the criteria associated with a high risk for adverse outcome. However, a growing body of evidence suggests the feasibility of partial outpatient management and accelerated hospital discharge (AHD) in a subset of patients with SPE. Prospective validation of these risk stratification models for predicting patient suitability for AHD is needed.
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Affiliation(s)
- Amjad Almahameed
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Mühl D, Füredi R, Gecse K, Ghosh S, Falusi B, Bogár L, Roth E, Lantos J. Time course of platelet aggregation during thrombolytic treatment of massive pulmonary embolism. Blood Coagul Fibrinolysis 2007; 18:661-7. [PMID: 17890954 DOI: 10.1097/mbc.0b013e3282e38e61] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We studied changes in platelet aggregation and fibrinogen levels during thrombolysis with massive or submassive pulmonary embolism. Fifteen patients were randomized into ultrahigh-dose streptokinase (UH-SK n = 8) or alteplase (tPA n = 7) groups. Arterial blood samples were taken before and after thrombolysis every 4 h between 4 and 36 h, and once daily between 2 and 30 days. In-vitro platelet aggregation was examined as spontaneous (0.9% NaCl) and induced aggregation with adrenaline 10 micromol/l, collagen 2 microg/ml and ADP 10 micromol/l. D-dimer and fibrinogen were measured every 8 h on first day, and later as above. In the UH-SK group, adrenaline-induced platelet aggregation decreased at 4 and 8 h compared with baseline (P < 0.03). Adrenaline-induced platelet aggregation was significantly lower in the UH-SK group than in the tPA group at 36 h and on day 3 (P < 0.03). Platelet aggregation induced by ADP was lower at 4 h than at baseline in the UH-SK group (P < 0.05). Collagen-induced platelet aggregation was lower at 4 and 8 h than at baseline (P < 0.05) in the UH-SK group. Compared with baseline, fibrinogen levels decreased in both groups after thrombolysis. D-dimer levels were elevated in both groups at 8 h (tPA group, P < 0.0004; UH-SK group, P < 0.05). Spontaneous platelet aggregation, major bleeding or re-embolism was not documented. Platelet aggregation decreased after thrombolysis with UH-SK for 12 h, in comparison tPA caused an insignificant decrease. Fibrinogen level decreased with UH-SK treatment for 5 days but in case of tPA we could not measure significant changes. According to our findings, tPA is a more suitable drug but streptokinase is also effective because of its cost-benefit ratio.
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Affiliation(s)
- Diána Mühl
- Department of Anaesthesiology and Intensive Therapy, University of Pécs, Pécs, Hungary.
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Shmuter Z, Frederic FI, Gill JR. Fatal migration of vena caval filters. Forensic Sci Med Pathol 2007; 4:116-21. [DOI: 10.1007/s12024-007-9001-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2007] [Indexed: 10/22/2022]
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Abstract
Multidetector-row computed tomographic (CT) angiography of pulmonary arteries is the first-line imaging technique in patients suspected of having pulmonary embolism (PE). Patient risk stratification is important because optimal management, monitoring, and therapeutic strategies depend on the patient's prognosis. Acute right-sided heart failure is known to be responsible for circulatory collapse and death in patients with severe PE. Acute right-sided heart failure can be assessed on CT pulmonary angiography by measuring the dimensions of the right-sided heart cavities or systemic veins. The magnitude of PE can be calculated on CT pulmonary angiography by applying dedicated CT scores or angiographic scores adapted. This article reviews and discusses the various CT-based methods for risk stratification of patients with acute PE.
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Affiliation(s)
- C Engelke
- Institut für Röntgendiagnostik, Klinikum der Bayerischen Julius-Maximilians-Universität Würzburg, Josef-Schneider-Strasse 2, 97080 Würzburg, Germany.
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Ganesh SK, Sharma Y, Dayhoff J, Fales HM, Van Eyk J, Kickler TS, Billings EM, Nabel EG. Detection of venous thromboembolism by proteomic serum biomarkers. PLoS One 2007; 2:e544. [PMID: 17579716 PMCID: PMC1891085 DOI: 10.1371/journal.pone.0000544] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Accepted: 03/14/2007] [Indexed: 11/26/2022] Open
Abstract
Background Available blood assays for venous thromboembolism (VTE) suffer from diminished specificity. Compared with single marker tests, such as D-dimer, a multi-marker strategy may improve diagnostic ability. We used direct mass spectrometry (MS) analysis of serum from patients with VTE to determine whether protein expression profiles would predict diagnosis. Methods and Results We developed a direct MS and computational approach to the proteomic analysis of serum. Using this new method, we analyzed serum from inpatients undergoing radiographic evaluation for VTE. In a balanced cohort of 76 patients, a neural network-based prediction model was built using a training subset of the cohort to first identify proteomic patterns of VTE. The proteomic patterns were then validated in a separate group of patients within the cohort. The model yielded a sensitivity of 68% and specificity of 89%, which exceeded the specificity of D-dimer assay tested by latex agglutination, ELISA, and immunoturbimetric methods (sensitivity/specificity of 63.2%/60.5%, 97.4%/21.1%, 97.4%/15.8%, respectively). We validated differences in protein expression between patients with and without VTE using more traditional gel-based analysis of the same serum samples. Conclusion Protein expression analysis of serum using direct MS demonstrates potential diagnostic utility for VTE. This pilot study is the first such direct MS study to be applied to a cardiovascular disease. Differences in protein expression were identified and subsequently validated in a separate group of patients. The findings in this initial cohort can be evaluated in other independent cohorts, including patients with inflammatory conditions and chronic (but not acute) VTE, for the diagnosis of VTE.
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Affiliation(s)
- Santhi K. Ganesh
- National Heart, Lung and Blood Institute, Bethesda, Maryland, United States of America
- National Human Genome Research Institute, Bethesda, Maryland, United States of America
| | - Yugal Sharma
- National Heart, Lung and Blood Institute, Bethesda, Maryland, United States of America
| | - Judith Dayhoff
- National Heart, Lung and Blood Institute, Bethesda, Maryland, United States of America
| | - Henry M. Fales
- National Heart, Lung and Blood Institute, Bethesda, Maryland, United States of America
| | - Jennifer Van Eyk
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Thomas S. Kickler
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Eric M. Billings
- National Heart, Lung and Blood Institute, Bethesda, Maryland, United States of America
| | - Elizabeth G. Nabel
- National Heart, Lung and Blood Institute, Bethesda, Maryland, United States of America
- National Human Genome Research Institute, Bethesda, Maryland, United States of America
- * To whom correspondence should be addressed. E-mail:
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