Hyperuricemia (HUA) is implicated in inflammation and a prothrombotic state, but its prognostic role in antiphospholipid syndrome (APS) remains uncertain. This study aims to evaluate the prognostic value of HUA in APS and identify optimal serum uric acid (SUA) thresholds for predicting adverse outcomes.

All patients fulfilled the 2006 Sydney criteria for APS were followed up at Peking University People's Hospital (2009-2022). Patients with persistent HUA were included in the HUA group. Comparative analyses were conducted between APS patients with and without HUA. Subgroup and ROC analyses were performed to evaluate prognostic value and identify optimal SUA thresholds.

Among 240 primary APS patients, 45 (18.8%) had HUA. APS patients with HUA had a significantly higher 10-year cumulative all-cause mortality (60.8% vs. 6.6%, P = 0.002), APS-related mortality (45.2% vs. 2.0%, P = 0.004), and thrombosis recurrence rates (40.3% vs. 17.2%, P = 0.005). Multivariate Cox mortality analysis showed that HUA was significantly associated with 10-year cumulative all-cause mortality (HR = 6.408, P = 0.010), APS-related mortality (HR = 15.409, P = 0.031), and thrombosis recurrence rates (HR = 3.227, P = 0.014). SUA thresholds predicting all-cause mortality (8.7 mg/dL, OR = 44.121, P < 0.001) and thrombosis recurrence (5.6 mg/dL, OR = 4.145, P = 0.004) were identified.

HUA is associated with a higher risk of adverse outcomes in APS patients. SUA thresholds of 8.7 mg/dL and 5.6 mg/dL may serve as predictors of mortality and thrombotic recurrence, providing potential insights for risk stratification and management in APS. Key Points • APS patients with HUA have higher 10-year cumulative mortality and thrombotic recurrence rates. • HUA may serve as a prognostic marker for APS patients. • SUA thresholds of 8.7 mg/dL and 5.6 mg/dL may serve as predictors of mortality and thrombotic recurrence. • Our observations remind clinicians to focus on APS patients with HUA, and adopt appropriate strategies to reduce the recurrence of thrombosis and mortality.

Routine laboratory screening is typically performed at initial evaluation of the vast majority of presentations to the emergency department (ED). These laboratory results are crucial to the diagnostic process, as they may influence up to 70% of clinical decisions. However, despite the usefulness of biological assessments, many tests performed are inappropriate or of doubtful clinical relevance. This overutilization rate of laboratory testing in hospitals, which represents a significant medical-economic burden, ranges from 20 to 67%, with coagulation tests at the top of the list. While reviews frequently focus on nonintensive care units, there are few published assessments of emergency-specific interventions or guidelines/guidance to date. The aim of this review is to highlight current recommendations for hemostasis evaluation in the emergency setting with a specific analysis of common situations leading to ED admissions, such as suspected venous thrombosis or severe bleeding. We revisit the evidence related to the assessment of patient's hemostatic capacity based on comprehensive history taking and physical examination as well as best practice recommendations for blood sample collection to ensure the reliability of results. This review also includes an examination of various currently available point of care tests and a comprehensive discussion on indications, limitations, and interpretation of these tests.

This study aimed to evaluate the demographic characteristics and changing trends in the incidence of hospital-acquired lower extremity deep venous thrombosis (HA-LEDVT) in Chinese inpatients over the course of 15 years.

We performed a retrospective analysis of the HA-LEDVT events in a medical center between January 1, 2007, and December 31, 2021.

A total of 846,347 eligible patients were analyzed. The overall incidence of HA-LEDVT was 2.53 per 1,000 admissions. The incidence was 0.22 and 4.20 per 1,000 admissions in 2007 and 2017, respectively (P < 0.01). Medical patients had a higher incidence of HA-LEDVT than surgical patients (3.19 vs. 2.14 per 1,000 admissions; P < 0.01). The incidence of HA-LEDVT increased from 0.28 to 11.90 per 1,000 admissions for those aged 17-29 years and 80-89 years, respectively (P < 0.01). The increase in HA-LEDVT incidence mainly occurred in patients aged ≥60 years. The median length of stay of HA-LEDVT patients was longer than that of other eligible patients (17 vs. 7 days; P < 0.01). Most of the HA-LEDVT events (77.8%) were diagnosed between hospital day 3 and 15, and the time from admission to HA-LEDVT diagnosis decreased by year. The rate of vascular surgery consultation for diagnosed or suspected HA-LEDVT and HA-LEDVT-related discharge instructions both decreased by half gradually over the 15 years of this study. Isolated distal deep vein thrombosis (DVT) accounted for 83.3% of all HA-LEDVT events, and the proportion increased significantly from 62.5% in 2007 to 88.7% in 2021 (P < 0.01).

The incidence of HA-LEDVT has been high in the Chinese population. More high-quality prospective studies are needed to guide prevention of HA-LEDVTs.

To describe the rates of adherence to the 2019 European Society of Cardiology guideline recommendations on the setting of care for patients with acute pulmonary embolism (PE) of varying severity.

This was a retrospective cohort study of PE patients treated in a referral hospital in Colombia between 2019 and 2022.

We analyzed 506 patients with acute PE (median age, 67 years). Of those, 58% were women, and 33% had a history of cancer. In-hospital mortality was 9.2%, and 30-day mortality was 17.9%. Of the total of patients, 8.3% were classified as low-risk patients, 77.6% were classified as intermediate-low-risk patients, 11.2% were classified as intermediate-high-risk patients, and 2.7% were classified as high-risk patients. Of the total of low-risk patients, 9.5% were discharged early in accordance with the guideline recommendations. Of the total of intermediate-high-risk patients, 43.8% were treated in the general ward instead of being transferred to the ICU for monitoring. Of the total of high-risk patients, 92.8% were treated in the ICU. No cancer patients were discharged early.

These results suggest that clinical practice guideline recommendations regarding the setting of care for patients with acute PE are not being followed. This is particularly true for low-risk PE patients who may be candidates for early discharge. Further studies are needed to investigate the reasons why low-risk patients are not being discharged early.

The impact of deep vein thrombosis (DVT) location on acute pulmonary embolism (PE) prognosis remains uncertain.

Using the Registro Informatizado de Enfermedad TromboEmbólica registry, we assessed 30-day and 90-day outcomes in patients with acute symptomatic PE and concomitant upper-extremity (UEDVT) versus lower-extremity DVT (LEDVT). Cox regression was employed for analysis, and standardised differences (SRD) were used for reporting clinical characteristics to minimise type I error overinflation. The primary outcome was 30-day all-cause mortality, with secondary outcomes including 90-day mortality, fatal PE, venous thromboembolism (VTE) recurrences, and major bleeding.

Among 21 617 patients with PE (March 2001-April 2023), 508 had UEDVT, and 21 109 had LEDVT. Patients with UEDVT were younger (SRD: 0.231), more often had cancer (SRD: 0.395) or non-central PEs (SRD: 0.445), but less frequently had raised troponin levels (SRD: 0.376) or right ventricle dysfunction (SRD: 0.249). Thirty-day mortality was higher in UEDVT compared with LEDVT (7.3% vs 3.5%; p<0.001), with similar trends at 90 days (14% vs 6.0%) and in subgroup analysis in patients without cancer. Increased rates of PE-related mortality, VTE recurrences and major bleeding were noted in patients with UEDVT at both 30 and 90 days. UEDVT was associated with a higher risk for 30-day (adjusted HR (aHR): 1.49; 95% CI 1.04 to 2.13) and 90-day (aHR: 1.52; 95% CI 1.15 to 2.00) all-cause mortality on multilevel multivariable analysis.

Patients with concomitant UEDVT experienced worse short-term outcomes, including higher mortality, despite fewer clinical signs of PE severity compared with LEDVT. These findings suggest that unrecognised patient characteristics might influence prognosis, warranting further research.

Acute pulmonary embolism (PE) is a leading cause of morbidity and mortality. Pharmacomechanical lysis (PML) with the Bashir endovascular catheter has been shown to reduce the right ventricular/left ventricular (RV/LV) ratio in patients with intermediate-risk (IR) PE. Nevertheless, the original protocol required a 5-hour postprocedural infusion of recombinant tissue plasminogen activator (r-tPA) and intensive care unit monitoring.

The RESCUE-II (Safety and Feasibility of On-The-Table Pharmacomechanical Lysis for Acute Intermediate-Risk Pulmonary Embolism) study aimed to evaluate the safety and efficacy of on-the-table PML using bolus-only r-tPA, without postprocedural infusion, in patients with IR-PE.

In this single-center, prospective study, symptomatic patients with IR-PE (computed tomographic-derived RV/LV ratio ≥0.9) were treated with bolus-only r-tPA via the Bashir catheter (4 mg per lung, 8 mg total for bilateral PE). The primary efficacy endpoint was the change in RV/LV ratio at 48 hours, and the primary safety endpoint was major bleeding within 72 hours.

Nine patients were enrolled and successfully treated. The median procedure time was 39 ± 13.4 minutes. At 48 hours, the mean RV/LV ratio decreased from 1.66 ± 0.56 to 1.27 ± 0.41 (P = 0.0001), and pulmonary artery obstruction, measured by the Refined Modified Miller index, reduced by 29.2%. There were no major bleeding events. One patient had a minor access site hematoma, managed with manual compression.

On-the-table PML using the Bashir catheter effectively reduced RV/LV ratio and PA obstruction. The procedure was safe, with no major bleeding complications, and offers a rapid, cost-effective treatment option for patients with acute IR-PE.

Hospital-acquired pulmonary embolism (HA-PE) is the first occurrence of PE during hospitalization. This study aimed to analyze the clinical characteristics, incidence and mortality rates, and death-associated risk factors in patients with HA-PE.

A retrospective analysis was conducted on the demographic data, laboratory test results, and examination findings of 196 patients with HA-PE admitted to Yichang Central People's Hospital from June 1, 2018, to May 31, 2023.

Among the 196 patients with HA-PE, 98 (50%) were men and 98 (50%) were women, with a mean age of 65.29 (±12.31) years. Higher risk severity in HA-PE was correlated with elevated in-hospital all-cause (χ2 = 50.581, P < 0.001) and HA-PE-specific mortality rates (χ2 = 44.755, P < 0.001). Critical parameters including heart rate (H = 37.744, P < 0.001), respiratory rate (H = 13.885, P < 0.001), arterial oxygen saturation (SaO2) (H = 48.309, P < 0.001), systolic blood pressure (H = 33.356, P < 0.001), and diastolic blood pressure (H = 27.065, P < 0.001) were significantly associated with HA-PE risk level. Syncope was more prevalent in high-risk patients than in lower-risk groups (χ2 = 53.859, P < 0.001). Multivariate ordinal logistic regression identified increased post-HA-PE heart rate, reduced SaO2, lowered systolic blood pressure, syncope, and recent blood transfusion as independent predictors of HA-PE severity. Kaplan-Meier analysis revealed that high-risk patients had significantly reduced 5-year cumulative survival compared to medium- and low-risk groups. Syncope (odds ratio [OR] = 0.152, 95% confidence interval [CI] 0.031-0.740, P = 0.02) emerged as an independent risk factor for in-hospital mortality in non-surgically and surgically treated patients (OR = 0.032, 95% CI 0.003-0.320, P = 0.003).

The heart rate, SaO2, blood pressure, syncope, and recent blood transfusion history significantly influence HA-PE risk stratification. Syncope is a critical prognostic indicator in patients with HA-PE. Future prospective studies are warranted to further delineate HA-PE risk factors.

Acute pulmonary embolism (PE) is a common cause of cardiovascular morbidity and mortality. Catheter-based therapies (CBT) are emerging technologies that provide reperfusion for patients with PE. However, the optimal timing of these interventions from initial presentation is unknown.

This study aimed to determine whether the timing of CBT affects outcomes among patients with acute PE managed with CBT.

This was a retrospective cohort study of patients with PE who underwent CBT and were included in the Nationwide Readmissions Database between January 2017 and December 2020. Patients who underwent early CBT (≤1 day from admission) were compared with those who underwent delayed CBT (>1 day). The primary outcome was death at 90 days, and secondary outcomes included 90-day readmissions. Propensity scores were estimated using logistic regression, and propensity score weighting (PSW) was utilised to compare outcomes between early and delayed CBT. Cox proportional hazards modelling was used to estimate the risk of primary and readmission outcomes.

A total of 12,137 patients were included: 1,992 (16.4%) had high-risk PE, and 1,856 (15.3%) were treated with delayed CBT. After PSW, early CBT was associated with a lower risk of 90-day death in both intermediate-risk (hazard ratio [HR] 0.55, 95% confidence interval [CI]: 0.46-0.66) and high-risk (HR 0.89, 95% CI: 0.80-0.99) PE. Early CBT was associated with lower rates of all-cause readmission in patients with intermediate-risk PE (HR 0.86, 95% CI: 0.78-0.95) and in those with high-risk PE (HR 0.84, 95% CI: 0.69-1.05).

Among patients with intermediate- or high-risk PE, early CBT was associated with a lower risk of 90-day death and readmission. A further prospective study on the optimal timing for reperfusion using CBT is needed.

Anticoagulant therapy is critical for venous thromboembolism (VTE) management, though bleeding remains a major concern, ranging from mild to fatal events. This study aimed to assess the predictive value of cytokines for major bleeding in patients with acute pulmonary embolism (PE).

In this prospective, observational study, patients aged ≥ 18 years with acute PE were enrolled from April 2021 to September 2022 and followed for 30 days. Exclusion criteria included asymptomatic PE, VTE without PE, and chronic anticoagulation. Major bleeding was defined as bleeding that required ≥ 2 transfused units of red blood cells, occurred in critical areas, or was fatal. Blood samples were collected at diagnosis to measure IL-6, IL-1beta, IL-8, IL-10, and TNF-alpha. Statistical analyses used bivariate and multivariate logistic regression (p < 0.05).

Out of 191 patients (mean age 68.6 years, 52.9% male), 8.4% died, and 4.2% experienced major bleeding within 30 days. IL-8 > 40 pg/mL and TNF-alpha > 8.5 pg/mL were linked to major bleeding. IL-8 > 40 pg/mL independently predicted early major bleeding (adjusted OR 9.40; 95% CI 1.38-63.69). Cox regression showed HRs of 12.60 for IL-8 and 5.61 for TNF-alpha.

High IL-8 levels at diagnosis were predictive of major bleeding in acute PE patients. Further studies are required to confirm these findings.

Venom-induced consumption coagulopathy (VICC) is a common complication of snakebite that is associated with hypofibrinogenemia, bleeding, disability, and death. In remote tropical settings, where most snakebites occur, the 20-minute whole blood clotting test is used to diagnose VICC. Point-of-care (POC) coagulation devices could provide an accessible means of detecting VICC that is better standardized, quantifiable, and more accurate. In this scoping review, the mechanistic reasons that previously studied POC devices have failed in VICC are considered, and evidence-based recommendations are made to prioritize certain devices for clinical validation studies. Four small studies have evaluated a POC international normalized ratio (INR) device in patients with Australian Elapid, Daboia russelii, and Echis carinatus envenoming. The devices assessed in these studies either relied on a thrombin substrate endpoint, which is known to underestimate INR in patients with hypofibrinogenemia, have been recalled due to poor accuracy, or have since been discontinued. Sixteen commercially available POC devices for measuring INR, activated clotting time, activated partial thromboplastin time, fibrinogen, D-dimer, and fibrin(ogen) degradation products have been reviewed. POC INR devices that detect fibrin clot formation, as well as a novel POC device that quantifies fibrinogen were identified, which show promise for use in patients with VICC. These devices could support more accurate allocation of antivenom, reduce the time to antivenom administration, and provide improved clinical trial outcome measurement instruments. There is an urgent need for these promising POC coagulation devices to be validated in prospective clinical snakebite studies.

Standard catheter-directed thrombolysis (SCDT) and Ultrasound-assisted thrombolysis (USAT) are used in intermediate and high-risk pulmonary embolism (PE). SCDT uses low-dose thrombolytic agents, minimizing bleeding risk. USAT adds acoustic energy to improve fibrin breakdown and thrombolytic penetration. A systematic literature search spanning PubMed/Medline, Embase, CENTRAL, CINAHL, and ClinicalTrials.gov databases (from inception to 17 June 2024) was conducted to retrieve studies comparing USAT to SCDT for managing acute PE. Risk of bias was assessed using Cochrane tools for randomized and non-randomized trials. Odds ratio (OR) and mean difference (MD) were pooled using random effects models. Statistical analyses were performed in R version 4.2.2. 11 studies with 37,398 patients (8,762: USAT and 28,636: SCDT) were included. The mean reduction in right ventricular to left ventricular diameter ratio was lower for USAT (MD: -0.12; 95% CI: -0.19, -0.06) compared to SCDT. There was no statistically significant difference between USAT and SCDT for odds of in-hospital mortality, intracranial hemorrhage, bleeding requiring transfusion or for means of hospital or ICU length of stay, or reduction in pulmonary artery pressures. Safety or efficacy of USAT is not superior to SCDT in patients with acute PE. Results were limited due to variable infusion protocol across studies and heterogeneity of results among studies. Large-scale randomized controlled trials (RCTs) are needed to corroborate these findings.

Pulmonary thromboembolism (PE) is a life-threatening condition that often leads to right ventricular (RV) dysfunction, a key determinant of prognosis and clinical management. Biomarkers play a crucial role in the early detection and risk stratification of RV dysfunction in PE, complementing imaging and hemodynamic assessments. Cardiac troponins, B-type natriuretic peptides, and novel biomarkers, such as heart-type fatty acid-binding protein (H-FABP) and growth differentiation factor-15 (GDF-15), provide valuable insights into myocardial injury, overload, and stress. This article explores the clinical possible significance of these biomarkers, their predictive value, and their potential to guide therapeutic strategies in patients with PE. Understanding the role of biomarkers in RV dysfunction assessment may improve patient outcomes focusing on early intervention and personalized treatment approaches.

Objectives: The pulmonary artery pulsatility index (PAPI) is a novel hemodynamic parameter that reflects right ventricular (RV) function. PAPI was shown to be useful in predicting outcomes following left ventricular assist device (LVAD) implantation, acute RV infarction, and in patients with chronic RV failure. The standard method to estimate PAPI is during right heart catheterization (RHC); however, echocardiography-based PAPI was also shown to be accurate. In the current study, we evaluated the ability of echocardiography-based PAPI to predict outcomes of patients with acute pulmonary embolism (PE). Methods: A total of 177 patients (mean age 67 ± 15, 54.1% male) with acute PE were included in the study. PAPI was calculated based on measurements from standard transthoracic echocardiography. Results: 27% of patients needed oxygen support, 5.6% were on mechanical ventilation, and 7.3% were on inotropic support. The 30-day mortality rate in the whole cohort was 8.3%. Lower PAPI measurements were associated with increased 30-day mortality (p < 0.05), a higher rate of RV failure (p < 0.001), and the need for inotropic support (p < 0.05). There was no association between PAPI and the need for oxygen support (p = 0.59), mechanical ventilation (0.06), or length of stay (LOS) (p = 0.414). PAPI was superior to tricuspid annular plane systolic excursion (TAPSE) in predicting mortality and RV failure. Conclusions: Echocardiography-derived PAPI is feasible and superior over TAPSE in predicting RV failure and mortality among patients with acute PE.

Patients who had venous thromboembolism (VTE) are not only at increased risk of recurrent VTE but also of major adverse cardiovascular events (MACEs) than the general population. Therefore, the prediction of the risk of these events is important for a tailored prevention and mitigation strategy. We aimed to develop simple scores to estimate recurrent VTE and MACE risks after the discontinuation of anticoagulation in a large cohort of individuals who suffered VTE (EDITH cohort). The primary endpoints were recurrent symptomatic VTE and MACE (composite of non-fatal acute coronary syndrome, stroke and cardiovascular death). Arterial thrombotic event (ATE) exclusively was also considered. Independent predictors of main outcomes were derived from multivariable Cox regression models. Weighted integer points based on the effect estimate of identified predictors were used to derive the final risk scores. A total of 1,999 participants (mean age: 54.78 years, 46.4% male, 43.6% unprovoked VTE) were included in the derivation cohort and 10,000 in the validation cohort (built using bootstrapping). During a median post-anticoagulation follow-up of 6.9 years, recurrent VTE occurred in 29.5% of participants and MACE in 14.8%. Independent predictors of recurrent VTE were male sex, age >65 years, cancer-associated VTE, and unprovoked VTE (vs. transient risk factor-associated VTE). Independent predictors of MACE were age >65 years, cancer-associated VTE, hypertension, renal insufficiency, and atrial fibrillation. The risk of recurrent VTE (moderate vs. low: hazard ratio [HR]: 2.62, 95% confidence interval [CI]: 2.06-3.34; high vs. low: HR: 3.78, 95% CI: 2.91-4.89), MACE (moderate vs. low: HR: 6.37, 95% CI: 3.19-12.69; high vs. low: HR: 12.32, 95% CI: 6.09-24.89), and ATE (based on MACE-predict risk score) increased gradually from the lowest to highest of the respective prediction risk score groups. These results were confirmed in the validation cohort with overall reasonable models' discrimination performance (recurrent VTE C-statistic: 0.62-0.63, MACE and ATE C-statistic: 0.72-0.77). Contemporary simple risk scores based on readily available clinical characteristics can reasonably predict the risk of recurrent VTE and MACE after the discontinuation of anticoagulation. These findings may influence the choice of anticoagulation strategy after the acute phase of VTE and, therefore, need confirmation by further studies.

Pulmonary embolism (PE) requires accurate risk assessment. We investigated the prognostic performance of the National Early Warning Score (NEWS) in emergency department patients with PE.We included patients ≥ 18 years from our PE registry (2017 to 2021), excluding patients after cardiac arrest or intubation before admission. The primary outcome was a composite of 30-day all-cause mortality or the need for advanced therapy (i.e., systemic or catheter-directed thrombolysis). We used logistic regression and the Cox proportional hazards models to estimate associations. The Pulmonary Embolism Severity Index (PESI) and the European Society of Cardiology (ESC) classification served as covariates. The overall score performances were quantified using receiver operating characteristic analysis.We included 524 patients. Each increase in NEWS points increased the odds of the primary outcome by 69% (odds ratio: 1.69, 95% confidence interval [CI]: 1.51-1.89, p < 0.001) and 30-day mortality by 44% (hazard ratio: 1.44, 95% CI: 1.30-1.60, p < 0.001). Within the ESC intermediate-high and high-risk group, the 30-day mortality rate was higher in patients with a NEWS ≥ 7 compared with NEWS < 7 (24 vs. 1%, p < 0.001). With a NEWS ≥ 7, 30-day mortality was lower in patients who received advanced therapy (18 vs. 39%) but not significantly. The NEWS predicted the primary outcome better than the PESI (area under the curve: 0.853 vs. 0.752, p < 0.001).The NEWS was associated with 30-day mortality and the need for advanced therapy. Incorporating the NEWS into the ESC classification could help to assess patient outcomes early and thus support timely treatment decisions.

Direct oral anticoagulants (DOACs) are increasingly being used over low molecular weight heparin (LMWH) and vitamin K antagonists for the treatment of venous thromboembolism (VTE). The objective of this study was to examine predictors of anticoagulant type (DOAC vs. LMWH) prescribed at discharge from the emergency department (ED) among patients diagnosed with VTE in the ED.

We conducted a retrospective chart review of adult (>17 years) patients discharged from an Ontario, Canada ED in a tertiary care centre with an ED diagnosis of deep vein thrombosis or pulmonary embolism from January 2019 to December 2021. A multivariable logistic regression model was used to examine the predictors of the anticoagulant (DOAC vs. LMWH) prescribed at discharge. Covariables included: age, sex, history of major bleeding, history of cancer, and previous anticoagulation.

VTE was confirmed in 390 ED visits by 365 unique patients. Among unique patients, 239 (65.5 %) patients were discharged from the ED and included in analysis. Of the 239 patients included, 12.1 % of patients were over the age of 80, 46.4 % were female and 29.7 % had a history of cancer. The majority of patients discharged from the ED were prescribed DOACs (70.7 %,169/239). Cancer history was associated with anticoagulation with LMWH (vs. DOAC) on discharge (adjusted odds ratio [aOR] =12.81, 95 % CI: 6.60-25.90).

While most patients diagnosed with VTE in the ED setting were discharged with DOACs, most cancer patients included in our study were treated with LMWH over DOACs, despite increasing evidence around the efficacy and safety of DOACs in most cancer patients. Further research is needed to understand longitudinal trends in anticoagulation.

Venous thromboembolism (VTE), comprising deep vein thrombosis and pulmonary embolism (PE), is common and associated with significant morbidity and mortality. The symptoms and signs of VTE are nonspecific. Well-established integrated diagnostic strategies combining clinical probability scores and D-dimer are used to identify patients with a low probability of VTE, where the diagnosis can be safely excluded without imaging. In patients with confirmed VTE, anticoagulation is the mainstay of treatment. However, patients with high-risk features at presentation may benefit from advanced reperfusion therapies such as thrombolysis and/or interventional approaches to reduce early mortality and/or long-term morbidity. The advent of direct oral anticoagulants has greatly simplified the treatment of VTE for most patients, with a persisting role for low molecular weight heparin and vitamin K antagonists in select patient groups. Following an initial 3 to 6 months of anticoagulation, those with major transient provoking factors can safely discontinue anticoagulation. Balancing the risk of recurrent VTE and bleeding risk is central to decisions regarding long-term anticoagulation, and patients should be included in shared decision-making. Assessment and recognition of common long-term complications such as postthrombotic syndrome and post-PE syndrome are also essential, given they are associated with significant adverse impact on long-term quality of life, with a significant risk of mortality associated with the less frequent complication of chronic thromboembolic pulmonary hypertension. This review provides a basic overview and framework for the diagnostic approach to deep vein thrombosis and PE, risk stratification of confirmed diagnoses, and management.

Recent data on temporal trends in excess mortality for patients with pulmonary embolism (PE) and deep vein thrombosis (DVT) compared with the general population are scarce.A nationwide Swedish register study conducted from 2006 to 2018 including 68,960 PE and 70,949 DVT cases matched with population controls. Poisson regression determined relative risk (RR) for 30-day and 1-year mortality trends while Cox regression determined adjusted hazard ratios (aHRs). A significance level of 0.001 was applied.In PE cases, both 30-day mortality (12.5% in 2006 to 7.8% in 2018, RR: 0.95 [95% CI: 0.95-0.96], p < 0.0001) and 1-year mortality (26.5 to 22.1%, RR: 0.98 [0.97-0.98], p < 0.0001) decreased during the study period. Compared with controls, no significant change was seen in 30-day (aHR: 33.08 [95% CI: 25.12-43.55] to 24.64 [95% CI: 18.81-32.27], p = 0.0015 for interaction with calendar year) or 1-year (aHR: 5.85 [95% CI: 5.31-6.45] to 7.07 [95% CI: 6.43-7.78], p = 0.038) excess mortality. The 30-day excess mortality decreased significantly (aHR: 39.93 [95% CI: 28.47-56.00) to 24.63 [95% CI: 17.94-33.83], p = 0.0009) in patients with PE without known cancer before baseline, while the excess 1-year mortality increased (aHR: 3.55 [95% CI: 3.16-3.99] to 5.38 [95% CI: 4.85-5.98], p < 0.0001) in PE cases surviving to fill a prescription of anticoagulation. In DVT cases, 30-day and 1-year mortality declined, while excess mortality compared with controls remained stable.In general, the improved mortality following PE and DVT paralleled population trends. However, PE cases without cancer had decreasing excess 30-day mortality, whereas those surviving to fill a prescription for anticoagulant medication showed increasing excess 1-year mortality.

Simultaneous acute limb ischemia (ALI) and pulmonary embolism (PE) are extremely rare, with the current literature providing a limited understanding of shared mechanisms. We report a rare case of concurrent ALI and PE presentation in a patient with a history of repaired tetralogy of Fallot (TOF), emphasizing the possible association between congenital heart disease and thromboembolic risk, potentially through residual hemodynamic abnormalities or arrhythmias. The case involves a 48-year-old male with a history of TOF repair in childhood who developed simultaneous ALI and PE approximately 48 years after the surgical repair. The patient presented with sudden right lower extremity pain and swelling; was classified as Rutherford IIa ALI; and underwent urgent endovascular revascularization that included an overnight tissue plasminogen activator infusion and a relook angiogram the next day. During admission, the common embolic etiologies of his presentation were excluded by multiple investigations, including transthoracic echocardiography, thrombophilia panel, and occult malignancy screens. Although the patient had multiple cardiovascular risk factors, including obesity, smoking, and hypertension, it is most likely the history of TOF repair that contributed the most to the concurrent thromboembolic presentation, especially given that TOF repair has been reported to be associated with chronic complications in adult patients, such as persistent right ventricular dysfunction and arrhythmias. A multidisciplinary team of interventional cardiologists, pulmonologists, and hematologists managed the case, reflecting the difficulty of managing concomitant thromboembolic events and monitoring and evaluating thromboembolic risk factors for treated congenital heart disease, most specifically TOF, in adult patients.

Patients with intermediate-risk pulmonary embolism (PE) have outcomes worse than uncomplicated ST elevation myocardial infarction. Yet, no large-scale study has compared the outcomes of large-bore mechanical thrombectomy (LBMT) with anticoagulation alone (AC). The aim of this study was to compare the clinical outcomes among patients receiving LBMT vs AC alone.

This was a two-center retrospective study that included patients with intermediate-risk PE from October 2016 - October 2023 from the institution's Pulmonary Embolism Response Team (PERT) database. The primary outcome was a composite of 30-day mortality, resuscitated cardiac arrest or hemodynamic decompensation. Inverse probability of treatment weighting (IPTW) was used to balance covariates; Kaplan Meir curves and IPTW multivariable Cox regression were used to assess the relationship between treatment groups and outcomes.

Of the 273 patients included in the analysis, 192 (70 %) patients received AC alone and 81 (30 %) patients received LBMT and AC. A total of 30 (10.9 %) patients experienced the primary composite outcome over a median follow-up of 30 days. The primary composite outcome was significantly lower in the group that received LBMT compared to those on AC alone (1.2 % vs 15.1 %, log-rank p < 0.001; adjusted HR: 0.02; 95 % CI: 0.002-0.17, p < 0.001) driven by a lower rate of 30-day all-cause mortality (0 % vs 7.3 %, log-rank p = 0.01), resuscitated cardiac arrest (0 % vs 6.8 %, log-rank p = 0.016) and new or worsening hemodynamic instability (4 % vs 11.1 %, log-rank p = 0.007).

In this largest cohort to date comparing LBMT versus AC alone in acute intermediate-risk PE, LBMT had a significantly lower rate of the primary composite outcome including a lower rate of all-cause mortality when compared to AC alone. Ongoing randomized trials will test these associations.

A man in his late 60s with previous chronic obstructive pulmonary disease and insulin-dependent diabetes presented with a 10-day history of shortness of breath and cough and progressive breathlessness accompanied with significant weight loss over 6 months. On examination, it revealed poor swallow, dysphagia for both solid foods and liquids and not taking any regular medications due to problems with swallowing. On further history taking, the patient had a positive first relative family history for oesophageal cancer and lung cancer on the paternal side. Patient acutely desaturated and increased New Early Warning Score during the evening on call, and prominent S1Q3T3 was seen on ECG, which prompted immediate anticoagulation and CT pulmonary angiogram confirmed an acute thrombus with significant right heart strain. This case highlights the importance and sometimes neglected signs of right heart strain and elusive recognition of the S1Q3T3 phenomenon in acutely unwell and deteriorating patients to aid in the diagnosis of pulmonary embolism.

Research on extracorporeal membrane oxygenation (ECMO)-assisted support for pulmonary embolism (PE) has been increasing, yet no systematic bibliometric analysis has been conducted. This study evaluates global research trends in this field by analyzing countries, institutions, authors, journals, references, and keywords.

Relevant articles and reviews published up to August 15, 2023, were retrieved from the Web of Science Core Collection (WOSCC). VOSviewer and CiteSpace software were used for bibliometric analysis of collected data.

Publications on ECMO-assisted support for PE surged from 2015 to 2023, comprising 82.7% (306/370) of total studies. The United States, Germany, and China contributed 62.97% (233/370) of the research. Perfusion-UK had the most publications, while Journal of the American College of Cardiology was the most cited journal. The University of Maryland, Massachusetts General Hospital, and Harvard Medical School were the leading institutions. Chetan Pasrija published the highest number of papers, while Konstantinidis SV was the most co-cited author. Research hot spots include: (1) ECMO management and survival rates, (2) combined treatments with thrombolysis or surgical thrombectomy, (3) anticoagulation and clot formation, and (4) ECMO support in COVID-19.

This study aims to increase awareness of research hot spots on ECMO-assisted support for PE by determining the collaboration and impact of authors, countries, institutions, and journals. In addition, it comprehensively reviews research trends on ECMO regarding PE. It also provides a reference for potential collaborators, institutions, and future research prospects.

Pulmonary thromboembolism (PTE) is a common cause of cardiovascular death worldwide. Due to its nonspecific clinical symptoms, PTE is easy to be missed or misdiagnosed. Pulmonary transit time (PTT) is a noninvasive cardiopulmonary hemodynamic index, which is the time required for a blood sample to pass through pulmonary circulation. This study is aim to establish a rabbit PTE model using auto-thrombus, evaluating the dynamic changes in a rabbit's heart structure and function at multiple time points before and after modeling by echocardiography and exploring the application value of PTT obtained by contrast enhanced ultrasound (CEUS) in evaluating a PTE model.

Twenty-four healthy rabbits were intubated by femoral vein puncture to establish the PTE model. Echocardiography was performed before embolization, 2 h, 24 h, 3 days, 5 days, and 7 days after embolization to obtain conventional ultrasonic parameters. Then, CEUS was performed to obtain the PTT.

Seventh day after modeling, nineteen rabbits were alive. Compared with pre-modeling, right heart parameters and heart rate in echocardiography were significantly impaired in the acute phase (2 and 24 h after modeling) and gradually returned to normal in the compensatory phase (3, 5, and 7 days after modeling). In contrast with conventional ultrasound parameters, PTT and nPTT revealed a gradually increasing trend at each time point. Receiver operating characteristic (ROC) curve analysis revealed with an extension of molding time, the area under the curve (AUC) of (n)PTT is larger and larger.

Right heart parameters obtained using conventional echocardiography can accurately indicate changes in the structure and function of the right heart during the acute phase of PTE, while (n)PTT measured by CEUS continues to extend during the acute and compensatory phases of PTE. Therefore, PTT (nPTT) obtained by CEUS is a useful clinical indicator for the diagnosis of PTE and can be utilized as a supplement to conventional echocardiography parameters.

Acute pulmonary embolism (PE) presents a significant challenge in lung transplant recipients (LTR), even with prophylactic anticoagulation. Due to the heightened risk of complications in this population, the optimal treatment approach for acute PE remains uncertain. This retrospective case series aims to elucidate the outcomes of percutaneous mechanical thrombectomy with the Inari device (MT) and catheter-directed thrombolysis (CDT) in managing acute PE in lung transplant patients.

This study examines the treatment outcomes of nine consecutive post-lung transplantation patients with acute PE confirmed with Computed Tomography Angiography (CTA). Treatment interventions included either MT or CDT. Follow-up assessments encompassed a minimum of one year and up to 3 years post-treatment, evaluating various parameters including ICU stay, ventricular pressures, pulmonary function, and laboratory tests.

Both MT and CDT achieved a 100% technical success rate, leading to the successful restoration of pulmonary blood flow and improvements in hemodynamic parameters, with a one-year survival rate of 100%.

Percutaneous treatments, including MT and CDT, demonstrate feasibility and efficacy in managing acute PE among lung transplant patients. These treatments lead to rapid thrombus resolution, post-treatment improvements, and enhanced overall survival.

A patient in his mid-40s presented with exertional dyspnoea and pleuritic chest pain persisting for 6 weeks. Despite repeated normal investigations, including D-dimer tests, chest X-rays, serial troponins and ECGs, a CT pulmonary angiogram (CTPA) was performed to rule out pulmonary embolism (PE) or other pulmonary abnormalities, revealing a left main pulmonary artery thrombus with no evidence of right ventricular strain. The patient was managed with oral rivaroxaban 15 mg two times per day for 21 days followed by 20 mg once daily for 6 months. The patient showed full recovery at the 6-month follow-up. This case highlights the diagnostic challenges in patients with persistent symptoms, low risk of venous thromboembolisms (VTEs) and normal initial investigations. It is novel because previous case reports of PE with negative D-dimer results have predominantly involved patients with identifiable risk factors, such as prior VTEs, malignancy or other conditions that increase the likelihood of PE. In contrast, this case demonstrates that PE can occur even in the absence of these risk factors, emphasising the importance of clinical diligence and the use of advanced imaging in diagnosing PE in atypical presentations.

The alteration of left atrial (LA) phasic function in subacute and chronic pulmonary embolism (PE) patients is unclear.

To investigate LA phasic strain and LA-right ventricular (RV) interaction in subacute and chronic PE patients with different degrees of obstruction by MRI-feature tracking (MRI-FT).

Retrospective.

One hundred three PE patients (54 subacute [2 weeks to 3 months after initial symptoms], 49 chronic [>3 months after initial symptoms]) and 80 controls.

3.0 T/balanced steady state free precession sequence.

Patients were divided into mild (pulmonary artery obstruction index [PAOI] < 30%, N = 57), moderate (30% ≤ PAOI < 50%, N = 27), and severe (50% ≥ PAOI, N = 19) PE subgroups. LA reservoir, conduit, and active pump longitudinal strains (εs, εe, and εa) and strain rates (SRs, SRe, and SRa) and biventricular global strains were measured. Determinants of LA strains were investigated.

ANOVA, t-tests, Mann-Whitney U tests, linear regression. P < 0.05 was considered statistically significant.

For both subacute and chronic PE patients, LA reservoir, conduit, and active pump strains and strain rates were significantly lower than in controls. However, there were no significant differences in LA strains between patients with subacute and chronic PE (P = 0.933, 0.625, and 0.630 for εs, εe, and εa). The severe PE subgroup had significantly higher εa and SRa than the mild and moderate PE subgroups. LA strains were significantly correlated with RV diameter and biventricular strains, and RV diameter (β = -6.836, -4.084, and -1.899 for εs, εe, and εa) was independently associated with LA strains after adjustment for other factors (R2 = 0.627, 0.536, and 0.437 for εs, εe, and εa).

LA phasic function evaluated by MRI-FT was significantly impaired in subacute and chronic PE patients, and LA active pump function in the severe PE subgroup was higher than that in the mild and moderate PE subgroups. The independent association between RV diameter and LA strains demonstrates that RV diameter may be an important indicator for monitoring LA dysfunction in PE patients.

3 TECHNICAL EFFICACY: Stage 3.

The British Thoracic Society recommend that pulmonary embolism (PE) patients with low-risk Pulmonary Embolism Severity Index (PESI) scores are considered for outpatient (OP) management, in settings where robust pathways for follow-up and monitoring exist.

Retrospective cohort study. We reviewed the electronic records of 109 consecutive PE patients considered appropriate for OP management. Primary outcomes were the incidence of recurrent venous thromboembolism, major bleeding, mortality at 1 year and evidence of chronic thromboembolic pulmonary hypertension (CTEPH).

Low-risk PESI scores (I-II) were recorded in 78 (72%) patients, with higher scores a consequence of age and comorbidity rather than haemodynamic instability. There was a low rate of adverse outcomes despite a lack of formal follow up for most patients. There was no evidence of CTEPH in 34 patients who underwent echocardiography.

Our analysis challenges the need for robust follow-up pathways for all patients with pulmonary embolism.

The optimal management of patients with intermediate-risk pulmonary embolism (PE), who have right heart dysfunction (determined by a combination of imaging and cardiac biomarkers) but a normal blood pressure, is uncertain. These patients suffer from reduced functional capacity and a lower quality of life over the long-term, despite use of anticoagulant therapy. Catheter-directed therapy (CDT) is a promising treatment for acute PE that rapidly removes thrombus and potentially improves cardiac dysfunction. However, CDT has risk and is costly, and it is not known whether it improves long-term cardiorespiratory fitness and/or quality of life compared with anticoagulation alone.

We are therefore conducting an open-label, assessor-blinded, multicenter randomized trial, the Pulmonary Embolism: Thrombus Removal with Catheter-Directed Therapy (PE-TRACT) Study, to compare CDT plus anticoagulation (CDT group) with anticoagulation alone (No-CDT group) in 500 patients with intermediate-risk PE. The primary study hypothesis is that CDT will increase the peak oxygen uptake (peak VO2) with cardiopulmonary exercise testing at 3 months and reduce New York Heart Association (NYHA) Class at 12 months compared with No-CDT. These 2 primary efficacy outcomes will be analyzed sequentially using a "gatekeeping" procedure; for NYHA class to be compared, peak oxygen consumption must first be shown to be significantly increased by CDT. Safety and cost-effectiveness will also be assessed.

When completed, PE-TRACT will provide important evidence regarding the benefits and risks of CDT to treat intermediate-risk PE compared with anticoagulation alone.

clinicaltrials.gov: NCT05591118.

In patients with pulmonary embolism (PE), the impact of repeated troponin I or T (TnI/TnT) measurements remains unclear.

Using Danish national registries, we identified PE patients (≥18 years) hospitalized between 2013 and 2018 with initial TnI or TnT measurement within -1/+1 day from admission and >1 repeated measurement within three days. Trajectories of TnI and TnT were identified using latent class trajectory modeling. Hazard ratios for 30-day mortality were compared across trajectories via multivariable Cox regression.

Among 1539 patients with TnI measurements and 1323 with TnT measurements, three distinct trajectories were identified. Trajectory I (nTnI = 286, nTnT = 472) exhibited consistently low TnI/TnT concentrations, trajectory II (nTnI = 1076, nTnT = 724) demonstrated initial elevated TnI/TnT decreasing within 24 h, and trajectory III (nTnI = 177, nTnT = 127) was characterized by elevated index TnI/TnT increasing within 10 h. 30-day mortality rates were higher in trajectory II and III compared to I in both the TnI (3 %, 7 % and 18 % across trajectory I to III) and the TnT (1 %, 9 % and 20 % across trajectory I to III) cohort. After adjustment hazard ratio of 30-day mortality for trajectory II vs. I was 7.42 (95 % CI 1.00-54.84, p = 0.04, TnI) and 2.93 (95 % CI 1.17-7.33, p = 0.02 TnT); and for trajectory III vs. I, 16.42 (95 % CI 2.42-127.29, p = 0.007, TnI) and 8.21 (95 % CI 2.78-24.19, p < 0.001, TnT).

A steep increase in TnI or TnT concentration within 10 h of PE diagnosis significantly escalates 30-day mortality risk indicating that early serial sampling may enhance risk stratification of PE patients.

High-risk acute pulmonary embolism (PE) is a life-threatening condition necessitating hemodynamic stabilization and rapid restoration of pulmonary perfusion. In this context, evidence regarding the benefit of advanced circulatory support and pulmonary recanalization strategies is still limited.

In this observational study, we assessed data of 1060 patients treated for high-risk acute PE with 991 being included in a target trial emulation to investigate all-cause in-hospital mortality estimates with different advanced treatment strategies. The four treatment groups consisted of patients undergoing (I) veno-arterial extracorporeal membrane oxygenation (VA-ECMO) alone (n = 126), (II) intrahospital systemic thrombolysis (SYS) (n = 643), (III) surgical thrombectomy (ST) (n = 49), and (IV) percutaneous catheter-directed treatment (PCDT) (n = 173). VA-ECMO was allowed as bridging to pulmonary recanalization in groups II, III, and IV. Marginal causal contrasts were estimated using the g-formula with logistic regression models as the primary approach. Sensitivity analyses included targeted maximum likelihood estimation (TMLE) with machine learning, inverse probability of treatment weighting (IPTW), as well as variations of estimands, handling of missing values, and a complete target trial emulation excluding the VA-ECMO alone group.

In the overall target trial population, the median age was 62.0 years, and 53.3% of patients were male. The estimated probability of in-hospital mortality from the primary target trial intention-to-treat analysis for VA-ECMO alone was 57% (95% confidence interval [CI] 47%; 67%), compared to 48% (95% CI 44%; 53%) for intrahospital SYS, 34% (95%CI 18%; 50%) for ST, and 43% (95% CI 35%; 51%) for PCDT. The mortality risk ratios were largely in favor of any advanced recanalization strategy over VA-ECMO alone. The robustness of these findings was supported by all sensitivity analyses. In the crude outcome analysis, patients surviving to discharge had a high probability of favorable neurologic outcome in all treatment groups.

Advanced recanalization by means of SYS, ST, and several promising catheter-directed systems may have a positive impact on short-term survival of patients presenting with high-risk PE compared to the use of VA-ECMO alone as a bridge to recovery.

Background: Acute aortic syndrome (AAS) is a life-threatening condition characterized by a high mortality, yet reliable prognostic biomarkers are still lacking. The fibrinogen-to-albumin ratio (FAR) has recently gained attention in cardiovascular research but has not been explored in the context of AAS. This study assessed the association between the FAR and 30-day mortality in AAS patients who presented to the emergency department. Methods: We included all AAS patients aged 18 years and older who presented to the emergency department between 2013 and 2021. The outcome measured was 30-day all-cause mortality. Cox regression analysis assessed the relationship between the FAR and the outcome. Results: A total of 171 patients (mean age 67, SD 13.7; 33% female) were included, with 68 (40%) dying within 30 days of admission. Non-survivors had a significantly lower FAR (mean 8.9, SD 4.97) than survivors (mean 10.8, SD 5.44, p = 0.02). FAR was significantly associated with 30-day mortality (crude HR 0.935, 95% CI 0.88-0.99, p = 0.02). This association remained significant after adjusting for age, sex, cardiopulmonary resuscitation, catecholamine administration, bleeding on admission, and type of AAS (adjusted HR 0.92, 95% CI 0.87-0.98, p = 0.01). Conclusions: FAR was independently associated with 30-day mortality in AAS patients who presented to the emergency department. Given its simplicity and cost-effectiveness, it could be a valuable biomarker, especially in resource-limited settings, to improve risk assessment and optimize resource allocation in AAS.

Introduction Computerized tomography pulmonary angiography (CTPA) is the gold standard test for diagnosing pulmonary embolism (PE); however, owing to its high cost, contrast dye toxicity, and radiation exposure, it is necessary to ensure that CTPA is not performed unnecessarily. European Society of Cardiology (ESC) guidelines recommend the use of pretest clinical assessment tools and D-dimer levels to stratify patients according to risk, thereby determining the need for CTPA. However, such a broad classification incorporates a large population, where cases of CTPA could have been avoided. In this retrospective observational study, we established a new cohort within the moderate risk group, using a D-dimer threshold of 1000 ng/dL, and thereby aimed to identify its impact in identifying the number of cases of CTPA and to identify the number of cases of PE missed. Materials and methods This observational retrospective study was conducted over 24 months in the emergency medicine department of a tertiary care hospital in south India. Our study comprised of evaluation of electronic medical records of patients based on the inclusion and exclusion criteria. An overall 182 samples (n=182) were recruited, past medical records were evaluated, and classified patients were classified according to the new stratification criteria based on the Wells score, pulmonary embolism rule-out criteria (PERC), and D-dimer levels. The study outcomes of the number of CTPA cases avoided and PE cases missed out were analyzed. Results Assuming all samples (n=182) fell into the low moderate risk (LMR) category (Wells score<2 and PERC positive, or Wells score 2-4), 95 cases (n=95, 95/182) had D-dimer<1000 ng/dL, among which PE was absent in 93 patients (n=93, 97.89%) and present in 2 patients (n=2, 2.10%). The remaining 87 (n=87, 87/182) had D-dimer≥1000 ng/dL where all cases had PE (n=87, 100%). Assuming the samples (n=182) fell into the high moderate risk (HMR) category (Wells score 4.5-6), 21 cases (n=21, 21/182) had D-dimer< age-adjusted D-dimer (AADD) among which, PE was absent in 20 patients (n=20, 95.23 %) and present in 1 patient (n=1, 4.76%). The remaining 161 (n=161, 161/182) had D-dimer≥AADD, whereas all cases had PE (n=161, 100%). The false negative rates were 2.1% in LMR and 4.8% in HMR, while the reduction in CTPA procedures amounted to 95 scans in LMR and 21 scans in HMR. Conclusions  We identified that establishing a higher threshold of D-dimer (1000 ng/dL) was effective in determining the need for CTPA and potentially reducing the number of CTPAs performed in suspected cases of PE.