1
|
Wang X, Wang J, Zhang X, Zhang X, Li Q, Li W, Jiang J, Jiao Y, Zhang T. Trends of Hospital-Acquired Lower Extremity Deep Venous Thrombosis in an Academic Medical Center in China from 2007 to 2021. Ann Vasc Surg 2025; 115:3-12. [PMID: 39894071 DOI: 10.1016/j.avsg.2024.12.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2024] [Revised: 11/18/2024] [Accepted: 12/20/2024] [Indexed: 02/04/2025]
Abstract
BACKGROUND 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. METHODS We performed a retrospective analysis of the HA-LEDVT events in a medical center between January 1, 2007, and December 31, 2021. RESULTS 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). CONCLUSION 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.
Collapse
Affiliation(s)
- Xiao Wang
- Department of Vascular Surgery, Peking University People's Hospital, Peking University, Beijing, China
| | - Jing Wang
- Department of Vascular Surgery, Peking University People's Hospital, Peking University, Beijing, China
| | - Xiaoming Zhang
- Department of Vascular Surgery, Peking University People's Hospital, Peking University, Beijing, China
| | - Xuemin Zhang
- Department of Vascular Surgery, Peking University People's Hospital, Peking University, Beijing, China
| | - Qingle Li
- Department of Vascular Surgery, Peking University People's Hospital, Peking University, Beijing, China
| | - Wei Li
- Department of Vascular Surgery, Peking University People's Hospital, Peking University, Beijing, China
| | - Jingjun Jiang
- Department of Vascular Surgery, Peking University People's Hospital, Peking University, Beijing, China
| | - Yang Jiao
- Department of Vascular Surgery, Peking University People's Hospital, Peking University, Beijing, China
| | - Tao Zhang
- Department of Vascular Surgery, Peking University People's Hospital, Peking University, Beijing, China.
| |
Collapse
|
2
|
Dubois-Silva Á, Bikdeli B, Jiménez D, Barbagelata-López C, Fernández-Capitán C, Skride A, Pham KQ, Porras JA, Pacheco-Gómez N, Monreal M. Clinical presentation and prognosis of acute symptomatic pulmonary embolism in patients with concomitant upper-extremity versus lower-extremity deep vein thrombosis. Thorax 2025; 80:369-377. [PMID: 40081905 DOI: 10.1136/thorax-2024-221960] [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] [Received: 05/21/2024] [Accepted: 02/14/2025] [Indexed: 03/16/2025]
Abstract
BACKGROUND The impact of deep vein thrombosis (DVT) location on acute pulmonary embolism (PE) prognosis remains uncertain. METHODS 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. RESULTS 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. CONCLUSIONS 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.
Collapse
Affiliation(s)
- Álvaro Dubois-Silva
- Venous Thromboembolism Unit, Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
- Universidade da Coruña, A Coruña, Spain
- Hospital at Home and Palliative Care Department, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division and the Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut, USA
- Cardiovascular Research Foundation, New York, New York, USA
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá, Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Cristina Barbagelata-López
- Venous Thromboembolism Unit, Department of Internal Medicine, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | | | - Andris Skride
- Department of Cardiology, Ospedale Pauls Stradins Clinical University Hospital, Riga Stradiņš University, Riga, Latvia
| | | | - José Antonio Porras
- Department of Internal Medicine, Hospital Universitari Joan de Tarragona, Tarragona, Spain
| | | | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, Universidad Católica San Antonio de Murcia, Murcia, Spain
| |
Collapse
|
3
|
Lakhter V, Bichard C, Ouriel K, Firth B, Rali P, Bashir R. Safety and Feasibility of On-the-Table Pharmacomechanical Lysis for Acute Intermediate-Risk Pulmonary Embolism: The RESCUE-II Study. JACC. ADVANCES 2025; 4:101789. [PMID: 40393282 DOI: 10.1016/j.jacadv.2025.101789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2024] [Revised: 03/19/2025] [Accepted: 04/10/2025] [Indexed: 05/22/2025]
Abstract
BACKGROUND 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. OBJECTIVES 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
Collapse
Affiliation(s)
- Vladimir Lakhter
- Division of Cardiovascular Diseases, Temple University Hospital, Philadelphia, Pennsylvania, USA.
| | - Christian Bichard
- Department of Internal Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Kenneth Ouriel
- North American Science Associates, New York, New York, USA
| | | | - Parth Rali
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Riyaz Bashir
- Division of Cardiovascular Diseases, Temple University Hospital, Philadelphia, Pennsylvania, USA
| |
Collapse
|
4
|
Naeem F, Qamar U, Ashraf H, Tabassum S, Daggubati R, Alraies MC, Virk HUH. Large-Bore Thrombectomy Versus Catheter-Directed Thrombolysis for Acute Intermediate & High-Risk Pulmonary Embolism: A Meta-Analysis of Up-to-Date Evidence. Catheter Cardiovasc Interv 2025. [PMID: 40364577 DOI: 10.1002/ccd.31576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2025] [Accepted: 05/01/2025] [Indexed: 05/15/2025]
Affiliation(s)
- Farhan Naeem
- Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Usama Qamar
- Department of Internal Medicine, Mayo Clinic, Rochester, New York, USA
| | - Hadiah Ashraf
- Department of Internal Medicine, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Shehroze Tabassum
- Department of Internal Medicine, King Edward Medical University, Lahore, Pakistan
| | - Ramesh Daggubati
- Department of Cardiology, West Virginia University, Morgantown, West Virginia, USA
| | - M Chadi Alraies
- Department of Cardiology, Department of Medicine, Detroit Medical Center, Detroit, Michigan, USA
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| |
Collapse
|
5
|
Fan J, Tan C, Zhang W, Jiang P, Cui Y, He J, Zhang Z, Mei F. Clinical Profile and Risk Factors Associated with Hospital-Acquired Pulmonary Embolism Hospital-Acquired PE: Clinical Profile & Risk Factors. Ann Vasc Surg 2025:S0890-5096(25)00294-8. [PMID: 40348178 DOI: 10.1016/j.avsg.2025.04.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2024] [Revised: 04/04/2025] [Accepted: 04/06/2025] [Indexed: 05/14/2025]
Abstract
OBJECTIVE 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. METHODS 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. RESULTS 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). CONCLUSION 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.
Collapse
Affiliation(s)
- Jiawei Fan
- Department of Vascular Surgery, Yichang Central People(')s Hospital, The First College of Clinical Medical Science, China Three Gorges University; Hubei Provincial Clinical Research Center for Ischemic Cardiovascular Disease, Yichang, China
| | - Chengpeng Tan
- Department of Vascular Surgery, Yichang Central People(')s Hospital, The First College of Clinical Medical Science, China Three Gorges University; Hubei Provincial Clinical Research Center for Ischemic Cardiovascular Disease, Yichang, China.
| | - Wuming Zhang
- Department of Vascular Surgery, Yichang Central People(')s Hospital, The First College of Clinical Medical Science, China Three Gorges University; Hubei Provincial Clinical Research Center for Ischemic Cardiovascular Disease, Yichang, China
| | - Peng Jiang
- Department of Vascular Surgery, Yichang Central People(')s Hospital, The First College of Clinical Medical Science, China Three Gorges University; Hubei Provincial Clinical Research Center for Ischemic Cardiovascular Disease, Yichang, China
| | - Yongpan Cui
- Department of Vascular Surgery, Yichang Central People(')s Hospital, The First College of Clinical Medical Science, China Three Gorges University; Hubei Provincial Clinical Research Center for Ischemic Cardiovascular Disease, Yichang, China
| | - Jian He
- Department of Vascular Surgery, Yichang Central People(')s Hospital, The First College of Clinical Medical Science, China Three Gorges University; Hubei Provincial Clinical Research Center for Ischemic Cardiovascular Disease, Yichang, China
| | - Zihan Zhang
- Department of Vascular Surgery, Yichang Central People(')s Hospital, The First College of Clinical Medical Science, China Three Gorges University; Hubei Provincial Clinical Research Center for Ischemic Cardiovascular Disease, Yichang, China
| | - Fei Mei
- Department of Vascular Surgery, Yichang Central People(')s Hospital, The First College of Clinical Medical Science, China Three Gorges University; Hubei Provincial Clinical Research Center for Ischemic Cardiovascular Disease, Yichang, China
| |
Collapse
|
6
|
Leiva O, Rosovsky RP, Alviar C, Bangalore S. Early versus delayed catheter-based therapies in patients hospitalised with acute pulmonary embolism. EUROINTERVENTION 2025; 21:e463-e470. [PMID: 40325984 DOI: 10.4244/eij-d-24-00555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2025]
Abstract
BACKGROUND 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. AIMS This study aimed to determine whether the timing of CBT affects outcomes among patients with acute PE managed with CBT. METHODS 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. RESULTS 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). CONCLUSIONS 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.
Collapse
Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Rachel P Rosovsky
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Carlos Alviar
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Sripal Bangalore
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| |
Collapse
|
7
|
Oblitas CM, López-Rubio M, Lago-Rodríguez MO, Galeano-Valle F, Alvarez-Sala Walther LA, Demelo-Rodríguez P. D-dimer to lymphocyte ratio predicts mortality in acute symptomatic pulmonary embolism patients. Br J Haematol 2025. [PMID: 40312995 DOI: 10.1111/bjh.20127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2025] [Accepted: 04/18/2025] [Indexed: 05/03/2025]
Affiliation(s)
- Crhistian-Mario Oblitas
- Internal Medicine Department, Hospital Clínico de Santiago, Galicia, Spain
- Instituto de Investigación Sanitaria de Santiago, Galicia, Spain
- School of Medicine, University Complutense of Madrid, Madrid, Spain
| | - Marina López-Rubio
- School of Medicine, University Complutense of Madrid, Madrid, Spain
- Venous Thromboembolism Unit, Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Marta-Olimpia Lago-Rodríguez
- Venous Thromboembolism Unit, Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Francisco Galeano-Valle
- School of Medicine, University Complutense of Madrid, Madrid, Spain
- Venous Thromboembolism Unit, Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Luis-Antonio Alvarez-Sala Walther
- School of Medicine, University Complutense of Madrid, Madrid, Spain
- Venous Thromboembolism Unit, Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Pablo Demelo-Rodríguez
- School of Medicine, University Complutense of Madrid, Madrid, Spain
- Venous Thromboembolism Unit, Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| |
Collapse
|
8
|
Oblitas CM, Lago-Rodríguez MO, López-Rubio M, García-Gámiz M, Zamora-Trillo A, Alvarez-Sala-Walther LA, Galeano-Valle F, Demelo-Rodríguez P. Role of Cytokines in Predicting Early Major Bleeding in Patients With Acute Pulmonary Embolism. Eur J Haematol 2025; 114:847-851. [PMID: 39825694 DOI: 10.1111/ejh.14387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2024] [Revised: 01/08/2025] [Accepted: 01/09/2025] [Indexed: 01/20/2025]
Abstract
INTRODUCTION 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). METHODS 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). RESULTS 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. CONCLUSION High IL-8 levels at diagnosis were predictive of major bleeding in acute PE patients. Further studies are required to confirm these findings.
Collapse
Affiliation(s)
- Crhistian-Mario Oblitas
- Venous Thromboembolism Unit, Internal Medicine Department, General University Hospital Gregorio Marañón, Madrid, Spain
- School of Medicine, University Complutense of Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Marta-Olimpia Lago-Rodríguez
- Venous Thromboembolism Unit, Internal Medicine Department, General University Hospital Gregorio Marañón, Madrid, Spain
- School of Medicine, University Complutense of Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Marina López-Rubio
- Venous Thromboembolism Unit, Internal Medicine Department, General University Hospital Gregorio Marañón, Madrid, Spain
- School of Medicine, University Complutense of Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Mercedes García-Gámiz
- Department of Clinical Biochemistry, General University Hospital Gregorio Marañón, Madrid, Spain
| | - Angielys Zamora-Trillo
- Department of Clinical Biochemistry, General University Hospital Gregorio Marañón, Madrid, Spain
| | - Luis-Antonio Alvarez-Sala-Walther
- Venous Thromboembolism Unit, Internal Medicine Department, General University Hospital Gregorio Marañón, Madrid, Spain
- School of Medicine, University Complutense of Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Francisco Galeano-Valle
- Venous Thromboembolism Unit, Internal Medicine Department, General University Hospital Gregorio Marañón, Madrid, Spain
- School of Medicine, University Complutense of Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Pablo Demelo-Rodríguez
- Venous Thromboembolism Unit, Internal Medicine Department, General University Hospital Gregorio Marañón, Madrid, Spain
- School of Medicine, University Complutense of Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| |
Collapse
|
9
|
Abouyannis M, Marriott AE, Stars E, Kitchen DP, Kitchen S, Woods TAL, Kreuels B, Amuasi JH, Monteiro WM, Stienstra Y, Senthilkumaran S, Isbister GK, Lalloo DG, Ainsworth S, Casewell NR. Handheld Point-of-Care Devices for Snakebite Coagulopathy: A Scoping Review. Thromb Haemost 2025; 125:405-420. [PMID: 39214143 PMCID: PMC12040437 DOI: 10.1055/a-2407-1400] [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] [Received: 05/15/2024] [Accepted: 08/17/2024] [Indexed: 09/04/2024]
Abstract
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.
Collapse
Affiliation(s)
- Michael Abouyannis
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Amy E. Marriott
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Emma Stars
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Dianne P. Kitchen
- UK National External Quality Assessment Scheme for Blood Coagulation (UK NEQAS BC), Sheffield, United Kingdom
| | - Steve Kitchen
- UK National External Quality Assessment Scheme for Blood Coagulation (UK NEQAS BC), Sheffield, United Kingdom
| | - Tim A. L. Woods
- UK National External Quality Assessment Scheme for Blood Coagulation (UK NEQAS BC), Sheffield, United Kingdom
| | - Benno Kreuels
- Department of Implementation Research, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - John H. Amuasi
- Department of Implementation Research, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
- Department of Global Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Wuelton M. Monteiro
- College of Health Sciences, University of the State of Amazonas, Manaus, Brazil
- Department of Teaching and Research, Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Manaus, Brazil
| | - Ymkje Stienstra
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Department of Internal Medicine/Infectious Diseases, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Geoff K. Isbister
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW, Australia
| | - David G. Lalloo
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Stuart Ainsworth
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Department of Infection Biology and Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Nicholas R. Casewell
- Centre for Snakebite Research and Interventions, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| |
Collapse
|
10
|
Hyder SN, Gavrila V, Cuttitta A, Greineder C, Barnes GD. Qualitative experience implementing an emergency department-based outpatient low-risk pulmonary embolism management pathway. Vasc Med 2025:1358863X251326585. [PMID: 40305325 DOI: 10.1177/1358863x251326585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2025]
Affiliation(s)
- S Nabeel Hyder
- Department of Internal Medicine, Division of Cardiology (Frankel Cardiovascular Center), University of Michigan Medical School, Ann Arbor, MI, USA
| | - Valerie Gavrila
- Michigan Program on Value Enhancement, Institute for Healthcare Policy and Innovation and Michigan Medicine Department of Quality, University of Michigan, Ann Arbor, MI, USA
| | - Anthony Cuttitta
- Michigan Program on Value Enhancement, Institute for Healthcare Policy and Innovation and Michigan Medicine Department of Quality, University of Michigan, Ann Arbor, MI, USA
| | - Colin Greineder
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- Department of Internal Medicine, Division of Cardiology (Frankel Cardiovascular Center), University of Michigan Medical School, Ann Arbor, MI, USA
- Michigan Program on Value Enhancement, Institute for Healthcare Policy and Innovation and Michigan Medicine Department of Quality, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
11
|
Passey S, Jain H, Jha J, Zhong K, Kuo CL, Iverson M, Patail H, Joshi S, Ingrassia J. Comparison of safety and efficacy of ultrasound-accelerated thrombolysis vs. standard catheter-directed thrombolysis for the management of acute pulmonary embolism - a systematic review and meta-analysis. J Thromb Thrombolysis 2025:10.1007/s11239-025-03100-7. [PMID: 40281265 DOI: 10.1007/s11239-025-03100-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2025] [Indexed: 04/29/2025]
Abstract
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.
Collapse
Affiliation(s)
- Siddhant Passey
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Hritvik Jain
- Department of Internal Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Jagriti Jha
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Kelin Zhong
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Storrs, CT, USA
| | - Chia-Ling Kuo
- The Cato T. Laurencin Institute for Regenerative Engineering, University of Connecticut, Storrs, CT, USA
| | - Marissa Iverson
- Health Sciences Library, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Haris Patail
- Department of Cardiology, Westchester Medical Center, Valhalla, NY, USA
| | - Saurabh Joshi
- Department of Interventional Cardiology, Heart & Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Joseph Ingrassia
- Department of Interventional Cardiology, Heart & Vascular Institute, Hartford Hospital, Hartford, CT, USA.
- Interventional Cardiology Director of Vascular Medicine & Endovascular Intervention, Hartford Healthcare, Hartford, CT, USA.
| |
Collapse
|
12
|
Chrysant G. Editorial: Catheter-based therapy for intermediate risk pulmonary embolism: are we moving in the right direction? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2025:S1553-8389(25)00204-0. [PMID: 40307099 DOI: 10.1016/j.carrev.2025.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2025] [Accepted: 04/21/2025] [Indexed: 05/02/2025]
Affiliation(s)
- George Chrysant
- Baptist Medical Center, 3433 Northwest 56th Street, Bldg. B, Ste. 400, Oklahoma City, OK 73112-4481. United States of America.
| |
Collapse
|
13
|
Cucută S, Badescu MC, Duca ȘT, Chetran A, Cepoi MR, Ponor CG, Bobu AM, Serban IL, Costache-Enache II. Beyond a Single Marker: An Update on the Comprehensive Evaluation of Right Ventricular Dysfunction in Pulmonary Thromboembolism. Life (Basel) 2025; 15:665. [PMID: 40283221 PMCID: PMC12028819 DOI: 10.3390/life15040665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2025] [Revised: 04/10/2025] [Accepted: 04/15/2025] [Indexed: 04/29/2025] Open
Abstract
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.
Collapse
Affiliation(s)
- Sandu Cucută
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (S.C.); (Ș.-T.D.); (A.C.); (M.-R.C.); (I.-I.C.-E.)
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania; (C.-G.P.); (A.M.B.)
| | - Minerva Codruta Badescu
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (S.C.); (Ș.-T.D.); (A.C.); (M.-R.C.); (I.-I.C.-E.)
- IIIrd Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Ștefania-Teodora Duca
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (S.C.); (Ș.-T.D.); (A.C.); (M.-R.C.); (I.-I.C.-E.)
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania; (C.-G.P.); (A.M.B.)
| | - Adriana Chetran
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (S.C.); (Ș.-T.D.); (A.C.); (M.-R.C.); (I.-I.C.-E.)
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania; (C.-G.P.); (A.M.B.)
| | - Maria-Ruxandra Cepoi
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (S.C.); (Ș.-T.D.); (A.C.); (M.-R.C.); (I.-I.C.-E.)
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania; (C.-G.P.); (A.M.B.)
| | - Cosmina-Georgiana Ponor
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania; (C.-G.P.); (A.M.B.)
| | - Amelian Madalin Bobu
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania; (C.-G.P.); (A.M.B.)
| | - Ionela-Lacramioara Serban
- Department of Morpho-Functional Sciences II, Discipline of Physiology, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Irina-Iuliana Costache-Enache
- Department of Internal Medicine I, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (S.C.); (Ș.-T.D.); (A.C.); (M.-R.C.); (I.-I.C.-E.)
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania; (C.-G.P.); (A.M.B.)
| |
Collapse
|
14
|
Moady G, Mobarki L, Or T, Shturman A, Atar S. Echocardiography-Based Pulmonary Artery Pulsatility Index Correlates with Outcomes in Patients with Acute Pulmonary Embolism. J Clin Med 2025; 14:2685. [PMID: 40283514 PMCID: PMC12027907 DOI: 10.3390/jcm14082685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2025] [Revised: 04/04/2025] [Accepted: 04/10/2025] [Indexed: 04/29/2025] Open
Abstract
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.
Collapse
Affiliation(s)
- Gassan Moady
- Department of Cardiology, Galilee Medical Center, Nahariya 2210001, Israel; (L.M.); (T.O.); (A.S.); (S.A.)
- Azrieli Faculty of Medicine, Bar Ilan University, Safed 2210001, Israel
| | - Loai Mobarki
- Department of Cardiology, Galilee Medical Center, Nahariya 2210001, Israel; (L.M.); (T.O.); (A.S.); (S.A.)
- Azrieli Faculty of Medicine, Bar Ilan University, Safed 2210001, Israel
| | - Tsafrir Or
- Department of Cardiology, Galilee Medical Center, Nahariya 2210001, Israel; (L.M.); (T.O.); (A.S.); (S.A.)
- Azrieli Faculty of Medicine, Bar Ilan University, Safed 2210001, Israel
| | - Alexander Shturman
- Department of Cardiology, Galilee Medical Center, Nahariya 2210001, Israel; (L.M.); (T.O.); (A.S.); (S.A.)
- Azrieli Faculty of Medicine, Bar Ilan University, Safed 2210001, Israel
| | - Shaul Atar
- Department of Cardiology, Galilee Medical Center, Nahariya 2210001, Israel; (L.M.); (T.O.); (A.S.); (S.A.)
- Azrieli Faculty of Medicine, Bar Ilan University, Safed 2210001, Israel
| |
Collapse
|
15
|
Noumegni SR, Espinasse B, Didier R, Mao RL, Moreuil CD, Tromeur C, Moigne EL, Roux PYL, Couturaud F. Prediction of Recurrent Venous Thromboembolism and Arterial Cardiovascular Events after Discontinuation of Anticoagulation: The R-VTE-predict and MACE-predict Risk Scores. Semin Thromb Hemost 2025. [PMID: 40203886 DOI: 10.1055/s-0045-1807262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2025]
Abstract
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.
Collapse
Affiliation(s)
- Steve R Noumegni
- Division of Cardiology, Cardiovascular Research Center, University of Florida College of Medicine, Jacksonville, Florida
- Inserm, UMR 1304 (GETBO), University of Brest, France
| | - Benjamin Espinasse
- Inserm, UMR 1304 (GETBO), University of Brest, France
- Internal Medicine, Vascular Medicine and Pneumology Department, CHU Brest, Brest, France
| | - Romain Didier
- Inserm, UMR 1304 (GETBO), University of Brest, France
- Cardiology Department, CHU Brest, Brest, France
| | - Raphael Le Mao
- Inserm, UMR 1304 (GETBO), University of Brest, France
- Internal Medicine, Vascular Medicine and Pneumology Department, CHU Brest, Brest, France
| | - Claire De Moreuil
- Inserm, UMR 1304 (GETBO), University of Brest, France
- Internal Medicine, Vascular Medicine and Pneumology Department, CHU Brest, Brest, France
| | - Cécile Tromeur
- Inserm, UMR 1304 (GETBO), University of Brest, France
- Internal Medicine, Vascular Medicine and Pneumology Department, CHU Brest, Brest, France
| | - Emmanuelle Le Moigne
- Inserm, UMR 1304 (GETBO), University of Brest, France
- Internal Medicine, Vascular Medicine and Pneumology Department, CHU Brest, Brest, France
| | - Pierre-Yves Le Roux
- Inserm, UMR 1304 (GETBO), University of Brest, France
- Department of Nuclear Medicine, CHU Brest, Brest, France
| | - Francis Couturaud
- Inserm, UMR 1304 (GETBO), University of Brest, France
- Internal Medicine, Vascular Medicine and Pneumology Department, CHU Brest, Brest, France
| |
Collapse
|
16
|
Janata K, Lipa AJ, Merrelaar A, Merrelaar M, Azizi-Semrad U, Herkner H, Schwameis M, Grafeneder J. Enhancing Pulmonary Embolism Risk Stratification: The National Early Warning Score and Its Integration into the European Society of Cardiology Classification. Thromb Haemost 2025. [PMID: 39993438 DOI: 10.1055/a-2544-3626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2025]
Abstract
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.
Collapse
Affiliation(s)
- Karin Janata
- Department of Emergency Medicine, Medical University of Vienna, Wien, Austria
| | | | - Anne Merrelaar
- Department of Emergency Medicine, Medical University of Vienna, Wien, Austria
| | - Marieke Merrelaar
- Department of Emergency Medicine, Medical University of Vienna, Wien, Austria
| | - Ursula Azizi-Semrad
- Department of Emergency Medicine, Medical University of Vienna, Wien, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Wien, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Wien, Austria
| | - Juergen Grafeneder
- Department of Emergency Medicine, Medical University of Vienna, Wien, Austria
| |
Collapse
|
17
|
Tandon P, Thompson C, Li K, McLeod SL, de Wit K, Grewal K. Anticoagulation for patients discharged from the emergency department with venous thromboembolism. Am J Emerg Med 2025; 93:182-185. [PMID: 40222342 DOI: 10.1016/j.ajem.2025.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2025] [Revised: 03/21/2025] [Accepted: 04/03/2025] [Indexed: 04/15/2025] Open
Abstract
OBJECTIVE 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. METHODS 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. RESULTS 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). CONCLUSIONS 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.
Collapse
Affiliation(s)
- Pranav Tandon
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, Ontario, Canada
| | - Cameron Thompson
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Karen Li
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shelley L McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kerstin de Wit
- Department of Emergency Medicine, Queens University, Kingston, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, McMaster University, Canada
| | - Keerat Grewal
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
18
|
Cox C, Roberts LN. Basics of diagnosis and treatment of venous thromboembolism. J Thromb Haemost 2025; 23:1185-1202. [PMID: 39938684 DOI: 10.1016/j.jtha.2025.01.009] [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] [Received: 08/23/2024] [Revised: 01/14/2025] [Accepted: 01/27/2025] [Indexed: 02/14/2025]
Abstract
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.
Collapse
Affiliation(s)
- Catrin Cox
- Thrombosis and Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK; Institute of Pharmaceutical Sciences, King's College London, London, UK.
| |
Collapse
|
19
|
Glise Sandblad K, Svensson CJ, Svennerholm K, Philipson J, Pivodic A, Schulman S, Tavoly M. Time Trends and Excess Mortality Compared to Population Controls after a First-Time Pulmonary Embolism or Deep Vein Thrombosis. Thromb Haemost 2025; 125:364-375. [PMID: 39178882 PMCID: PMC11961228 DOI: 10.1055/a-2402-6192] [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] [Received: 06/20/2024] [Accepted: 08/20/2024] [Indexed: 08/26/2024]
Abstract
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.
Collapse
Affiliation(s)
- Katarina Glise Sandblad
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - Carl Johan Svensson
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Anaesthesiology and Intensive Care, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristina Svennerholm
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Anaesthesiology and Intensive Care, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jacob Philipson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | | | - Sam Schulman
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Mazdak Tavoly
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital/Sahlgrenska, Gothenburg, Sweden
- Department of Research, Østfold Hospital, Sarpsborg, Norway
| |
Collapse
|
20
|
Abu-Wardeh AA, Anabtawi AG. Concurrent Acute Limb Ischemia and Pulmonary Embolism in an Adult With Repaired Tetralogy of Fallot: A Case Report. Cureus 2025; 17:e81665. [PMID: 40322389 PMCID: PMC12049185 DOI: 10.7759/cureus.81665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2025] [Indexed: 05/08/2025] Open
Abstract
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.
Collapse
Affiliation(s)
| | - Abdel G Anabtawi
- Interventional Cardiology, First Coast Cardiovascular Institute, Jacksonville, USA
| |
Collapse
|
21
|
Zhang RS, Yuriditsky E, Zhang P, Truong HP, Xia Y, Maqsood MH, Greco AA, Mukherjee V, Postelnicu R, Amoroso NE, Maldonado TS, Alviar CL, Horowitz JM, Bangalore S. Anticoagulation alone versus large-bore mechanical thrombectomy in acute intermediate-risk pulmonary embolism. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2025:S1553-8389(25)00124-1. [PMID: 40234154 DOI: 10.1016/j.carrev.2025.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2024] [Revised: 03/25/2025] [Accepted: 03/25/2025] [Indexed: 04/17/2025]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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). CONCLUSION 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.
Collapse
Affiliation(s)
- Robert S Zhang
- Division of Cardiovascular Medicine, New York University, New York, NY, USA
| | - Eugene Yuriditsky
- Division of Cardiovascular Medicine, New York University, New York, NY, USA
| | - Peter Zhang
- Department of Medicine, New York University, New York, NY, USA
| | - Hannah P Truong
- Department of Medicine, New York University, New York, NY, USA
| | - Yuhe Xia
- Department of Population Health, New York University Grossman School of Medicine, NY, USA
| | - Muhammad H Maqsood
- Department of Cardiology, DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, TX, USA
| | - Allison A Greco
- Division of Pulmonary Critical Care, and Sleep Medicine, New York University, NY, USA
| | - Vikramjit Mukherjee
- Division of Pulmonary Critical Care, and Sleep Medicine, New York University, NY, USA
| | - Radu Postelnicu
- Division of Pulmonary Critical Care, and Sleep Medicine, New York University, NY, USA
| | - Nancy E Amoroso
- Division of Pulmonary Critical Care, and Sleep Medicine, New York University, NY, USA
| | - Thomas S Maldonado
- Division of Cardiovascular Medicine, New York University, New York, NY, USA; Department of Surgery, Division of Vascular and Endovascular Surgery, New York University School of Medicine, New York, NY, USA
| | - Carlos L Alviar
- Division of Cardiovascular Medicine, New York University, New York, NY, USA
| | - James M Horowitz
- Division of Cardiovascular Medicine, New York University, New York, NY, USA
| | - Sripal Bangalore
- Division of Cardiovascular Medicine, New York University, New York, NY, USA. https://twitter.com/sripalbangalore
| |
Collapse
|
22
|
Franchin L, Iannaccone M. Limitations and Future Perspectives on Pulmonary Embolism: So Far, So Good. Interv Cardiol 2025; 20:e11. [PMID: 40171023 PMCID: PMC11959576 DOI: 10.15420/icr.2024.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2024] [Accepted: 01/22/2025] [Indexed: 04/03/2025] Open
Affiliation(s)
- Luca Franchin
- Department of Cardiology, Santa Maria della Misericordia Hospital, Azienda Sanitaria Universitaria Friuli CentraleUdine, Italy
| | - Mario Iannaccone
- Department of Cardiology, San Giovanni Bosco HospitalTurin, Italy
| |
Collapse
|
23
|
Ratnayake PR. S1Q3T3, pulmonary embolism diagnosed primarily from ECG results in a patient with dysphagia and low Wells score. BMJ Case Rep 2025; 18:e264036. [PMID: 40107739 DOI: 10.1136/bcr-2024-264036] [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: 03/22/2025] Open
Abstract
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.
Collapse
Affiliation(s)
- Praveen Rahul Ratnayake
- General Internal Medicine, University Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, UK
| |
Collapse
|
24
|
Wang W, Ji J, Han L, Pang J, Mo L, Liu F, Gao Y, Xiong B, Xiang S. Global hotspot and trend of extracorporeal membrane oxygenation for pulmonary embolism. Front Med (Lausanne) 2025; 12:1531716. [PMID: 40171500 PMCID: PMC11958177 DOI: 10.3389/fmed.2025.1531716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2024] [Accepted: 02/24/2025] [Indexed: 04/03/2025] Open
Abstract
Background 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. Methods 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. Results 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. Conclusion 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.
Collapse
Affiliation(s)
- Wei Wang
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of Intensive Care Unit, The Peoples Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Research Center of Communicable and Severe Diseases, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Jianyu Ji
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of Intensive Care Unit, The Peoples Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Research Center of Communicable and Severe Diseases, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Lin Han
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of Intensive Care Unit, The Peoples Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Research Center of Communicable and Severe Diseases, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Jing Pang
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of Intensive Care Unit, The Peoples Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Research Center of Communicable and Severe Diseases, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Li Mo
- Department of Intensive Care Unit, The Peoples Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Research Center of Communicable and Severe Diseases, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Fang Liu
- Department of Intensive Care Unit, The Peoples Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Research Center of Communicable and Severe Diseases, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Yamin Gao
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of Intensive Care Unit, The Peoples Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Research Center of Communicable and Severe Diseases, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Bin Xiong
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of Intensive Care Unit, The Peoples Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Shulin Xiang
- Research Center of Communicable and Severe Diseases, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Guangxi Health Commission Key Laboratory of Diagnosis and Treatment of Acute Respiratory Distress Syndrome, Nanning, Guangxi, China
| |
Collapse
|
25
|
Zhang H, Chen J, Wang J, Kang S, Liu Y, Zhu B, Mei X, Ai X, Li G, Jiang S. A new noninvasive evaluation method of pulmonary thromboembolism in rabbits-pulmonary transit time. Cardiovasc Ultrasound 2025; 23:8. [PMID: 40075411 PMCID: PMC11900611 DOI: 10.1186/s12947-025-00344-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2024] [Accepted: 02/26/2025] [Indexed: 03/14/2025] Open
Abstract
BACKGROUND AND AIM 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
Collapse
Affiliation(s)
- He Zhang
- Department of Ultrasound Medicine, The Second Affiliated Hospital of Harbin Medical University, 146 Baojian Road, Harbin, Heilongjiang Province, 150086, China
| | - Jianfeng Chen
- Laboratory Animal Center, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, 150086, China
| | - Jiayu Wang
- Department of Ultrasound Medicine, The Second Affiliated Hospital of Harbin Medical University, 146 Baojian Road, Harbin, Heilongjiang Province, 150086, China
| | - Song Kang
- Department of Ultrasound Medicine, The Second Affiliated Hospital of Harbin Medical University, 146 Baojian Road, Harbin, Heilongjiang Province, 150086, China
| | - Yingying Liu
- Department of Ultrasound Medicine, The Second Affiliated Hospital of Harbin Medical University, 146 Baojian Road, Harbin, Heilongjiang Province, 150086, China
| | - Binyang Zhu
- Department of Ultrasound Medicine, The Second Affiliated Hospital of Harbin Medical University, 146 Baojian Road, Harbin, Heilongjiang Province, 150086, China
| | - Xue Mei
- Department of Ultrasound Medicine, The Second Affiliated Hospital of Harbin Medical University, 146 Baojian Road, Harbin, Heilongjiang Province, 150086, China
| | - Xin Ai
- Department of Ultrasound Medicine, The Second Affiliated Hospital of Harbin Medical University, 146 Baojian Road, Harbin, Heilongjiang Province, 150086, China
| | - Guangyin Li
- Department of Ultrasound Medicine, The Second Affiliated Hospital of Harbin Medical University, 146 Baojian Road, Harbin, Heilongjiang Province, 150086, China
| | - Shuangquan Jiang
- Department of Ultrasound Medicine, The Second Affiliated Hospital of Harbin Medical University, 146 Baojian Road, Harbin, Heilongjiang Province, 150086, China.
| |
Collapse
|
26
|
Arar A, Rice SL, Alnablsi MW, Pillai A, Benjamin J, Quadri R, Lamus D, Pillai A. Acute pulmonary embolism treatment in lung transplant recipients: mechanical thrombectomy and catheter directed thrombolysis. CVIR Endovasc 2025; 8:19. [PMID: 40067640 PMCID: PMC11896909 DOI: 10.1186/s42155-024-00512-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2024] [Accepted: 12/17/2024] [Indexed: 03/15/2025] Open
Abstract
PURPOSE 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. MATERIALS AND METHODS 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. RESULTS 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%. CONCLUSION 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.
Collapse
Affiliation(s)
- Ahmad Arar
- Department of Radiology, Interventional Radiology Section, UT Southwestern Medical Center, 5959 Harry Hines Blvd., Professional Office Building I (HP6.600) Mail Code 8834, Dallas, TX, 75390-9061, USA.
| | - Samuel L Rice
- Department of Radiology, Interventional Radiology Section, UT Southwestern Medical Center, 5959 Harry Hines Blvd., Professional Office Building I (HP6.600) Mail Code 8834, Dallas, TX, 75390-9061, USA
- Department of Radiology Plesmanlaan 121, Netherlands Cancer Institute- Antoni Van Leeuwenhoekziekenhuis, 1066, Amsterdam, CX, Netherlands
| | - Mhd Wisam Alnablsi
- Department of Radiology, Interventional Radiology Section, UT Southwestern Medical Center, 5959 Harry Hines Blvd., Professional Office Building I (HP6.600) Mail Code 8834, Dallas, TX, 75390-9061, USA
| | - Akhilesh Pillai
- Department of Radiology, Interventional Radiology, University of Texas Health Science Center, 7000 Fannin St, Houston, TX, 77030, USA
| | - Jamaal Benjamin
- Department of Radiology, Interventional Radiology Section, UT Southwestern Medical Center, 5959 Harry Hines Blvd., Professional Office Building I (HP6.600) Mail Code 8834, Dallas, TX, 75390-9061, USA
| | - Rehan Quadri
- Department of Radiology, Interventional Radiology Section, UT Southwestern Medical Center, 5959 Harry Hines Blvd., Professional Office Building I (HP6.600) Mail Code 8834, Dallas, TX, 75390-9061, USA
| | - Daniel Lamus
- Department of Radiology, Interventional Radiology Section, UT Southwestern Medical Center, 5959 Harry Hines Blvd., Professional Office Building I (HP6.600) Mail Code 8834, Dallas, TX, 75390-9061, USA
| | - Anil Pillai
- Department of Radiology, Interventional Radiology Section, UT Southwestern Medical Center, 5959 Harry Hines Blvd., Professional Office Building I (HP6.600) Mail Code 8834, Dallas, TX, 75390-9061, USA
| |
Collapse
|
27
|
Yuan GX, Zhang ZP, Zhou J. Thrombolysis and extracorporeal cardiopulmonary resuscitation for cardiac arrest due to pulmonary embolism: A case report. World J Crit Care Med 2025; 14:97443. [DOI: 10.5492/wjccm.v14.i1.97443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 10/06/2024] [Accepted: 11/20/2024] [Indexed: 12/11/2024] Open
Abstract
BACKGROUND Cardiac arrest caused by acute pulmonary embolism (PE) is the most serious clinical circumstance, necessitating rapid identification, immediate cardiopulmonary resuscitation (CPR), and systemic thrombolytic therapy. Extracorporeal CPR (ECPR) is typically employed as a rescue therapy for selected patients when conventional CPR is failing in settings where it can be implemented.
CASE SUMMARY We present a case of a 69-year-old male who experienced a prolonged cardiac arrest in an ambulance with pulseless electrical activity. Upon arrival at the emergency department with ongoing manual chest compressions, bedside point-of-care ultrasound revealed an enlarged right ventricle without contractility. Acute PE was suspected as the cause of cardiac arrest, and intravenous thrombolytic therapy with 50 mg tissue plasminogen activator was administered during mechanical chest compressions. Despite 31 minutes of CPR, return of spontaneous circulation was not achieved until 8 minutes after initiation of Veno-arterial extracorporeal membrane oxygenation (ECMO) support. Under ECMO support, the hemodynamic status and myocardial contractility significantly improved. However, the patient ultimately did not survive due to intracerebral hemorrhagic complications, leading to death a few days later in the hospital.
CONCLUSION This case illustrates the potential of combining systemic thrombolysis with ECPR for refractory cardiac arrest caused by acute PE, but it also highlights the increased risk of significant bleeding complications, including fatal intracranial hemorrhage.
Collapse
Affiliation(s)
- Guan-Xing Yuan
- Department of Emergency, Wuhan Asia General Hospital, Wuhan 430056, Hubei Province, China
| | - Zhi-Ping Zhang
- Department of Emergency, Wuhan Asia General Hospital, Wuhan 430056, Hubei Province, China
| | - Jia Zhou
- Department of Neurosurgery, Central Theater Command General Hospital, Wuhan 430000, Hubei Province, China
| |
Collapse
|
28
|
Alsararatee HH. Novel insights into pulmonary embolism with negative D-dimer results. BMJ Case Rep 2025; 18:e264995. [PMID: 40044485 DOI: 10.1136/bcr-2025-264995] [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: 05/13/2025] Open
Abstract
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.
Collapse
Affiliation(s)
- Hasan H Alsararatee
- Acute medicine, Northampton General Hospital NHS Trust, Northampton, UK
- Acute medicine, Northampton General Hospital NHS Trust, Northampton, UK
| |
Collapse
|
29
|
Shen MT, Li Y, Shen LT, Qian WL, Yan WF, Fang H, Min CY, Yang ZG. Left Atrial Phasic Function Impairment in Subacute and Chronic Pulmonary Embolism Patients With Different Degrees of Obstruction: An MRI Feature Tracking Study. J Magn Reson Imaging 2025; 61:1338-1350. [PMID: 38944678 DOI: 10.1002/jmri.29494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 06/04/2024] [Accepted: 06/05/2024] [Indexed: 07/01/2024] Open
Abstract
BACKGROUND The alteration of left atrial (LA) phasic function in subacute and chronic pulmonary embolism (PE) patients is unclear. PURPOSE 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). STUDY TYPE Retrospective. POPULATION 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. FIELD STRENGTH/SEQUENCE 3.0 T/balanced steady state free precession sequence. ASSESSMENT 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. STATISTICAL TESTS ANOVA, t-tests, Mann-Whitney U tests, linear regression. P < 0.05 was considered statistically significant. RESULTS 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). DATA CONCLUSION 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. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: Stage 3.
Collapse
Affiliation(s)
- Meng-Ting Shen
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuan Li
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li-Ting Shen
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wen-Lei Qian
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wei-Feng Yan
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Han Fang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chen-Yan Min
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhi-Gang Yang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| |
Collapse
|
30
|
Alexander L, Burnie S, Rossiter C, Isles C. Do low-risk patients really need follow-up after a pulmonary embolism? J R Coll Physicians Edinb 2025; 55:14-18. [PMID: 39773242 DOI: 10.1177/14782715241311959] [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: 01/11/2025] Open
Abstract
BACKGROUND 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. METHODS 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). RESULTS 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. CONCLUSION Our analysis challenges the need for robust follow-up pathways for all patients with pulmonary embolism.
Collapse
Affiliation(s)
- Lesley Alexander
- Medical and Respiratory Units, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - Susan Burnie
- Medical and Respiratory Units, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - Catherine Rossiter
- Medical and Respiratory Units, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - Chris Isles
- Medical and Respiratory Units, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| |
Collapse
|
31
|
Sista AK, Troxel AB, Tarpey T, Parpia S, Goldhaber SZ, Stringer WW, Magnuson EA, Cohen DJ, Kahn SR, Rao SV, Morris TA, Goldfeld KS, Vedantham S. Rationale and design of the PE-TRACT trial: A multicenter randomized trial to evaluate catheter-directed therapy for the treatment of intermediate-risk pulmonary embolism. Am Heart J 2025; 281:112-122. [PMID: 39638275 PMCID: PMC11810573 DOI: 10.1016/j.ahj.2024.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2024] [Revised: 11/25/2024] [Accepted: 11/28/2024] [Indexed: 12/07/2024]
Abstract
BACKGROUND 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. METHODS 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. CONCLUSION When completed, PE-TRACT will provide important evidence regarding the benefits and risks of CDT to treat intermediate-risk PE compared with anticoagulation alone. TRIAL REGISTRATION clinicaltrials.gov: NCT05591118.
Collapse
Affiliation(s)
- Akhilesh K Sista
- Division of Vascular and Interventional Radiology, Department of Radiology, Weill Cornell Medicine, New York, NY, 10065.
| | - Andrea B Troxel
- Department of Population Heath, NYU Grossman School of Medicine, New York, NY, 10016
| | - Thaddeus Tarpey
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, NY, 10016
| | - Sameer Parpia
- Departments of Oncology and Health Research Methods, Evidence & Impact, McMaster University, Health Sciences Centre, Hamilton, Ontario, Canada
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, 02115; Harvard Medical School, Boston, MA, 02115
| | - William W Stringer
- Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, CA, 90502
| | - Elizabeth A Magnuson
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, MO, 64111
| | - David J Cohen
- Cardiovascular Research Foundation, New York, NY, 10019; St. Francis Hospital, 100 Port Washington Boulevard, Roslyn, NY, 11576
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada; Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada
| | - Sunil V Rao
- NYU Grossman School of Medicine, New York, NY 10016
| | - Timothy A Morris
- Division of Pulmonary and Critical Care Medicine, University of California San Diego Healthcare, La Jolla, CA 92093
| | - Keith S Goldfeld
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, NY 10016
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO 63110
| |
Collapse
|
32
|
Sonne-Holm E, Kjærgaard J, Bang LE, Køber L, Fosbøl E, Hassager C, Beske RP, Carlsen J, Winther-Jensen M. Dynamics of troponins and 30-day mortality in hospitalized patients with pulmonary embolism. Thromb Res 2025; 247:109274. [PMID: 39862753 DOI: 10.1016/j.thromres.2025.109274] [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] [Received: 10/15/2024] [Revised: 12/27/2024] [Accepted: 01/20/2025] [Indexed: 01/27/2025]
Abstract
BACKGROUND In patients with pulmonary embolism (PE), the impact of repeated troponin I or T (TnI/TnT) measurements remains unclear. METHODS 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. RESULTS 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). CONCLUSION 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.
Collapse
Affiliation(s)
- Emilie Sonne-Holm
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark.
| | - Jesper Kjærgaard
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Lia E Bang
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Lars Køber
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Emil Fosbøl
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Christian Hassager
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Rasmus Paulin Beske
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Jørn Carlsen
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Matilde Winther-Jensen
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital Rigshospitalet, Denmark; Department of Data, Biostatistics and Pharmacoepidemiology, Centre for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Denmark
| |
Collapse
|
33
|
Stadlbauer A, Verbelen T, Binzenhöfer L, Goslar T, Supady A, Spieth PM, Noc M, Verstraete A, Hoffmann S, Schomaker M, Höpler J, Kraft M, Tautz E, Hoyer D, Tongers J, Haertel F, El-Essawi A, Salem M, Rangel RH, Hullermann C, Kriz M, Schrage B, Moisés J, Sabate M, Pappalardo F, Crusius L, Mangner N, Adler C, Tichelbäcker T, Skurk C, Jung C, Kufner S, Graf T, Scherer C, Villegas Sierra L, Billig H, Majunke N, Speidl WS, Zilberszac R, Chiscano-Camón L, Uribarri A, Riera J, Roncon-Albuquerque R, Terauda E, Erglis A, Tavazzi G, Zeymer U, Knorr M, Kilo J, Möbius-Winkler S, Schwinger RHG, Frank D, Borst O, Häberle H, De Roeck F, Vrints C, Schmid C, Nickenig G, Hagl C, Massberg S, Schäfer A, Westermann D, Zimmer S, Combes A, Camboni D, Thiele H, Lüsebrink E. Management of high-risk acute pulmonary embolism: an emulated target trial analysis. Intensive Care Med 2025; 51:490-505. [PMID: 39998658 PMCID: PMC12018524 DOI: 10.1007/s00134-025-07805-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2024] [Accepted: 01/17/2025] [Indexed: 02/27/2025]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSION 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.
Collapse
Affiliation(s)
- Andrea Stadlbauer
- Department of Cardiothoracic Surgery, Klinik Für Herz-, Thorax- Und Herznahe Gefäßchirurgie, University Medical Center Regensburg, Universitätsklinik Regensburg, Regensburg, Germany
| | - Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, University of Leuven, Leuven, Belgium
| | - Leonhard Binzenhöfer
- Medizinische Klinik Und Poliklinik I, Klinikum Der Universität München, DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Tomaz Goslar
- Faculty of Medicine, Department of Intensive Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Alexander Supady
- Faculty of Medicine, Interdisciplinary Medical Intensive Care, Medical Center, University of Freiburg, Freiburg, Germany
| | - Peter M Spieth
- Faculty of Medicine, Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Marko Noc
- Faculty of Medicine, Department of Intensive Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Andreas Verstraete
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, University of Leuven, Leuven, Belgium
| | - Sabine Hoffmann
- Institute of Medical Information Processing, Biometry and Epidemiology and Department of Statistics, Ludwig-Maximilians Universität München, Munich, Germany
| | - Michael Schomaker
- Department of Statistics, Ludwig-Maximilians Universität München, Munich, Germany
| | - Julia Höpler
- Institute of Medical Information Processing, Biometry and Epidemiology and Department of Statistics, Ludwig-Maximilians Universität München, Munich, Germany
| | - Marie Kraft
- Institute of Medical Information Processing, Biometry and Epidemiology and Department of Statistics, Ludwig-Maximilians Universität München, Munich, Germany
| | - Esther Tautz
- Faculty of Medicine, Interdisciplinary Medical Intensive Care, Medical Center, University of Freiburg, Freiburg, Germany
| | - Daniel Hoyer
- Universitätsklinik Und Poliklinik Für Innere Medizin III Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Halle (Saale), Halle (Saale), Germany
| | - Jörn Tongers
- Universitätsklinik Und Poliklinik Für Innere Medizin III Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Halle (Saale), Halle (Saale), Germany
| | - Franz Haertel
- Klinik Für Innere Medizin I, Universitätsklinikum Jena, Jena, Germany
| | - Aschraf El-Essawi
- Department of Thoracic and Cardiovascular Surgery, University Medical Center, Göttingen, Germany
| | - Mostafa Salem
- Klinik Für Innere Medizin III, Universitätsklinikum Schleswig-Holstein, and DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Rafael Henrique Rangel
- Klinik Für Innere Medizin III, Universitätsklinikum Schleswig-Holstein, and DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Carsten Hullermann
- Klinik für Kardiologie I: Koronare Herzkrankheit, Herzinsuffizienz und Angiologie, Universitätsklinikum Münster, Münster, Germany
| | - Marvin Kriz
- Department of Cardiology, University Heart and Vascular Center Hamburg, and DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, and DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Jorge Moisés
- Department of Pulmonary Medicine and Department of Cardiology, Hospital Clínic - Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERCV, University of Barcelona, Barcelona, Spain
| | - Manel Sabate
- Department of Pulmonary Medicine and Department of Cardiology, Hospital Clínic - Institut d´Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERCV, University of Barcelona, Barcelona, Spain
| | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia, AO SS Antonio E Biagio E Cesare Arrigo, Alessandria, Italy
| | - Lisa Crusius
- Klinik Für Innere Medizin Und Kardiologie, Technische Universität Dresden, Herzzentrum Dresden, Dresden, Germany
| | - Norman Mangner
- Klinik Für Innere Medizin Und Kardiologie, Technische Universität Dresden, Herzzentrum Dresden, Dresden, Germany
| | - Christoph Adler
- Faculty of Medicine, University of Cologne, and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Tobias Tichelbäcker
- Faculty of Medicine, University of Cologne, and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum Der Charitè (DHZC), Campus Benjamin Franklin, and DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Christian Jung
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, CARID (Cardiovascular Research Institute Düsseldorf), Duesseldorf, Germany
| | - Sebastian Kufner
- Deutsches Herzzentrum München, Klinik Für Herz- Und Kreislauferkrankungen, an der Technischen Universität München, DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Tobias Graf
- Medizinische Klinik II (Kardiologie, Angiologie Und Intensivmedizin), Universitätsklinikum Schleswig-Holstein, Campus Lübeck, and DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Clemens Scherer
- Medizinische Klinik Und Poliklinik I, Klinikum Der Universität München, DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Laura Villegas Sierra
- Medizinische Klinik Und Poliklinik I, Klinikum Der Universität München, DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hannah Billig
- Medizinische Klinik Und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany
| | - Nicolas Majunke
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig Heart Science, Leipzig, Germany
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Robert Zilberszac
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Luis Chiscano-Camón
- Intensive Care Department, SODIR Research Group, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca, Barcelona, Spain; CIBERES, ISCIII, Madrid, Spain
| | - Aitor Uribarri
- Department of Cardiology, CIBER-CV, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Jordi Riera
- Intensive Care Department, SODIR Research Group, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca, Barcelona, Spain; CIBERES, ISCIII, Madrid, Spain
| | - Roberto Roncon-Albuquerque
- Department of Intensive Care Medicine, UnIC@RISE and Department of Surgery and Physiology, Faculty of Medicine of Porto, São João University Hospital Center, Porto, Portugal
| | - Elizabete Terauda
- Latvian Centre of Cardiology, Paul Stradins Clinical University Hospital, Riga, Latvia
| | - Andrejs Erglis
- Latvian Centre of Cardiology, Paul Stradins Clinical University Hospital, Riga, Latvia
| | - Guido Tavazzi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Anaesthesia and Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Medizinische Klinik B, Ludwigshafen, Germany
| | - Maike Knorr
- Zentrum Für Kardiologie, Universitätsklinikum Mainz, Mainz, Germany
| | - Juliane Kilo
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Robert H G Schwinger
- Medizinische Klinik II, Klinikum Weiden, Kliniken Nordoberpfalz AG, Weiden, Germany
| | - Derk Frank
- Klinik Für Innere Medizin III, Universitätsklinikum Schleswig-Holstein, and DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Oliver Borst
- Department of Cardiology and Angiology, University Hospital, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Helene Häberle
- Universitätsklinik Für Anästhesiologie Und Intensivmedizin, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Frederic De Roeck
- Department of Cardiology, Antwerp University Hospital, and Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, Antwerp, Belgium
| | - Christiaan Vrints
- Department of Cardiology, Antwerp University Hospital, and Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, Antwerp, Belgium
| | - Christof Schmid
- Department of Cardiothoracic Surgery, Klinik Für Herz-, Thorax- Und Herznahe Gefäßchirurgie, University Medical Center Regensburg, Universitätsklinik Regensburg, Regensburg, Germany
| | - Georg Nickenig
- Medizinische Klinik Und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany
| | - Christian Hagl
- Herzchirurgische Klinik Und Poliklinik, Klinikum Der Universität München, and DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Steffen Massberg
- Medizinische Klinik Und Poliklinik I, Klinikum Der Universität München, DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Andreas Schäfer
- Klinik Für Kardiologie Und Angiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Dirk Westermann
- Faculty of Medicine, Department of Cardiology and Angiology, Medical Center, University of Freiburg, Bad Krozingen, Germany
| | - Sebastian Zimmer
- Medizinische Klinik Und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, F-75013, and Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, Klinik Für Herz-, Thorax- Und Herznahe Gefäßchirurgie, University Medical Center Regensburg, Universitätsklinik Regensburg, Regensburg, Germany.
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig Heart Science, Leipzig, Germany
| | - Enzo Lüsebrink
- Medizinische Klinik Und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany.
| |
Collapse
|
34
|
Xu Y, Federspiel JJ. Pregnancy-associated venous thromboembolism: a window into future health. J Thromb Haemost 2025; 23:817-819. [PMID: 40057371 PMCID: PMC11964127 DOI: 10.1016/j.jtha.2024.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2024] [Revised: 12/05/2024] [Accepted: 12/11/2024] [Indexed: 04/04/2025]
Affiliation(s)
- Yan Xu
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jerome J Federspiel
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA; Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.
| |
Collapse
|
35
|
Lipa AJ, Andreikovits P, Stoeckl M, Domanovits H, Schoergenhofer C, Schwameis M, Grafeneder J. Fibrinogen-to-Albumin Ratio as Predictor of Mortality in Acute Aortic Syndromes. J Clin Med 2025; 14:1669. [PMID: 40095623 PMCID: PMC11900113 DOI: 10.3390/jcm14051669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2025] [Revised: 02/26/2025] [Accepted: 02/27/2025] [Indexed: 03/19/2025] Open
Abstract
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.
Collapse
Affiliation(s)
- Alexandra Julia Lipa
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria (J.G.)
| | - Patrick Andreikovits
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria (J.G.)
| | - Marco Stoeckl
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria (J.G.)
| | - Hans Domanovits
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria (J.G.)
| | | | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria (J.G.)
| | - Juergen Grafeneder
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria (J.G.)
| |
Collapse
|
36
|
Thomas A, Sajan R, Prasad S B, Kumar G, Trikkur S, Theresa MM, Nair S, Mohan N, Vijay A. The Potential Effect on the Number of Computerized Tomography Pulmonary Angiography if a Clinical Probability-Adjusted D-dimer Is Added to an Age-Adjusted D-dimer. Cureus 2025; 17:e80472. [PMID: 40225457 PMCID: PMC11990755 DOI: 10.7759/cureus.80472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2025] [Accepted: 03/12/2025] [Indexed: 04/15/2025] Open
Abstract
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.
Collapse
Affiliation(s)
- Abin Thomas
- Department of Emergency Medicine, Amrita Institute of Medical Sciences, Kochi, IND
| | - Ritvik Sajan
- Department of Pharmacy Practice, Amrita Institute of Medical Sciences, Kochi, IND
| | - Bharath Prasad S
- Department of Emergency Medicine, Amrita Institute of Medical Sciences, Kochi, IND
| | - Gireesh Kumar
- Department of Emergency Medicine, Amrita Institute of Medical Sciences, Kochi, IND
| | - Sreekrishnan Trikkur
- Department of Emergency Medicine, Amrita Institute of Medical Sciences, Kochi, IND
| | - Manna M Theresa
- Department of Emergency Medicine, Amrita Institute of Medical Sciences, Kochi, IND
| | - Sabarish Nair
- Department of Emergency Medicine, Amrita Institute of Medical Sciences, Kochi, IND
| | - Naveen Mohan
- Department of Emergency Medicine, Amrita Institute of Medical Sciences, Kochi, IND
| | - Amalendu Vijay
- Department of Emergency Medicine, Amrita Institute of Medical Sciences, Kochi, IND
| |
Collapse
|
37
|
Couturaud F, Schmidt J, Sanchez O, Ballerie A, Sevestre MA, Meneveau N, Bertoletti L, Connault J, Benhamou Y, Constans J, Quemeneur T, Lapébie FX, Pernod G, Picart G, Elias A, Doutrelon C, Neveux C, Khider L, Roy PM, Zuily S, Falvo N, Lacroix P, Emmerich J, Mahé I, Boileau J, Yaici A, Le Jeune S, Stéphan D, Plissonneau-Duquene P, Ray V, des Déserts MD, Belhadj-Chaidi R, Lamia B, Gruel Y, Presles E, Girard P, Tromeur C, Moustafa F, Rothstein V, Lacut K, Melac S, Barillot S, Mismetti P, Laporte S, Mottier D, Meyer G, Leroyer C. Extended treatment of venous thromboembolism with reduced-dose versus full-dose direct oral anticoagulants in patients at high risk of recurrence: a non-inferiority, multicentre, randomised, open-label, blinded endpoint trial. Lancet 2025; 405:725-735. [PMID: 40023651 DOI: 10.1016/s0140-6736(24)02842-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2024] [Revised: 12/15/2024] [Accepted: 12/23/2024] [Indexed: 03/04/2025]
Abstract
BACKGROUND In patients with venous thromboembolism at high risk of recurrence for whom extended treatment with direct oral anticoagulants has been indicated, the optimal dose is unknown. We aimed to assess efficacy and safety of reduced-dose versus full-dose direct oral anticoagulants in patients in whom extended anticoagulation has been indicated. METHODS RENOVE was a non-inferiority, investigator-initiated, multicentre, randomised, open-label, blinded endpoint trial done in 47 hospitals in France. Ambulatory patients aged 18 years or older with acute symptomatic venous thromboembolism (pulmonary embolism or proximal deep vein thrombosis) who had received 6-24 uninterrupted months of full-dose anticoagulation and for whom extended anticoagulation has been indicated were eligible. Eligible participants were categorised as having either a first unprovoked venous thromboembolism, recurrent venous thromboembolism, presence of persistent risk factors, or other clinical situations considered to be a high risk of recurrence. Participants were randomly assigned (1:1) to receive oral treatment with either a reduced dose of apixaban (2·5 mg twice daily) or rivaroxaban (10 mg once daily) or a full dose of apixaban (5 mg twice daily) or rivaroxaban (20 mg once daily) using a centralised randomisation procedure with an interactive web response system. The sequence generation method was a computerised random number generator and was balanced by blocks of different sizes. Randomisation was stratified by centre, type of direct oral anticoagulant, and antiplatelet drug. Physicians and participants were unmasked to treatment allocation; recurrent venous thromboembolism, clinically relevant bleeding, and all-cause death were adjudicated by an independent committee blinded to treatment allocation. The primary outcome was symptomatic recurrent venous thromboembolism, including recurrent fatal or non-fatal pulmonary embolism or isolated proximal deep vein thrombosis (non-inferiority hypothesis 90% power to exclude a hazard ratio [HR] of 1·7). The primary outcome and first two secondary outcomes were included in a hierarchical testing procedure. This trial is registered with ClinicalTrials.gov, NCT03285438. FINDINGS From Nov 2, 2017, to July 6, 2022, 2768 patients were enrolled and randomly assigned to the reduced-dose group (n=1383) or the full-dose group (n=1385). 970 (35·0%) participants were female, 1797 (65·0%) were male, and one (<0·1%) had sex not reported. Median follow-up was 37·1 months (IQR 24·0-48·3). Recurrent venous thromboembolism occurred in 19 of 1383 patients in the reduced-dose group (5-year cumulative incidence 2·2% [95% CI 1·1-3·3]) versus 15 of 1385 patients in the full-dose group (5-year cumulative incidence 1·8% [0·8-2·7]; adjusted HR 1·32 [95% CI 0·67-2·60]; absolute difference 0·40% [95% CI -1·05 to 1·85]; p=0·23 for non-inferiority). Major or clinically relevant bleeding occurred in 96 patients in the reduced-dose group (5-year cumulative incidence 9·9% [95% CI 7·7-12·1]) and 154 patients in the full-dose group (5-year cumulative incidence 15·2% [12·8-17·6]; adjusted HR 0·61 [95% CI 0·48-0·79]). 1136 (82·1%) of 1383 patients in the reduced-dose group and 1150 (83·0%) of 1385 in the full-dose group had an adverse event; 374 (27·0%) patients in the reduced-dose group and 420 (30·3%) in the full-dose group has a serious adverse event. 35 (5-year cumulative incidence 4·3% [95% CI 2·6-6·0]) patients in the reduced-dose group and 54 (5-year cumulative incidence 6·1% [4·3-8·0]) patients in the full-dose group died during the study period. INTERPRETATION In patients with venous thromboembolism requiring extended anticoagulation, reduction of the direct oral anticoagulant dose did not meet the non-inferiority criteria. However, the low recurrence rates in both groups and substantial reduction of clinically relevant bleeding with the reduced dose could support this regimen as an option. Further research will be needed to identify subgroups for whom the anticoagulation dose should not be reduced. FUNDING French Ministry of Health.
Collapse
Affiliation(s)
- Francis Couturaud
- Univ Brest, INSERM U1304-GETBO, CIC INSERM 1412, Brest, France; Centre Hospitalier Universitaire Brest, Département de Médecine Interne et Pneumologie, Brest, France; FCRIN INNOVTE Network, Saint-Etienne, France.
| | - Jeannot Schmidt
- FCRIN INNOVTE Network, Saint-Etienne, France; Service d'urgence, Centre Hospitalier Universitaire de Clermont-Ferrand, Lapsco-UMR UBP-CNRS 6024, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Olivier Sanchez
- FCRIN INNOVTE Network, Saint-Etienne, France; Université Paris Cité, Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, INSERM UMR S 1140, Paris, France
| | - Alice Ballerie
- FCRIN INNOVTE Network, Saint-Etienne, France; Service de Médecine Interne, Centre Hospitalo-Universitaire de Rennes, Rennes, France
| | - Marie-Antoinette Sevestre
- FCRIN INNOVTE Network, Saint-Etienne, France; Service de Médecine Vasculaire, EA Chimère 7516, Centre Hospitalier Universitaire d'Amiens-Picardie, Amiens, France
| | - Nicolas Meneveau
- FCRIN INNOVTE Network, Saint-Etienne, France; Department of Cardiology, University Hospital Besançon, Besançon, France; SINERGIES, University of Burgundy Franche-Comté, Besançon, France
| | - Laurent Bertoletti
- FCRIN INNOVTE Network, Saint-Etienne, France; Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France; INSERM CIC 1408 Centre Hospitalier Universitaire de St-Etienne, Saint-Etienne, France; INSERM UMR 1059, Université Jean Monnet, Saint-Etienne, France
| | - Jérôme Connault
- FCRIN INNOVTE Network, Saint-Etienne, France; Service de Médecine Interne, Centre Hospitalo-Universitaire de Nantes, Nantes, France
| | - Ygal Benhamou
- FCRIN INNOVTE Network, Saint-Etienne, France; UniRouen, U1096, Service de Médecine Interne, Centre Hospitalier Universitaire Charles-Nicolle, Normandie Université, Rouen, France
| | - Joël Constans
- FCRIN INNOVTE Network, Saint-Etienne, France; Department of Vascular Medicine, Bordeaux University Hospital, Bordeaux, France
| | - Thomas Quemeneur
- Nephrology and Internal Medicine Department, Hospital of Valenciennes, Valenciennes, France
| | - François-Xavier Lapébie
- FCRIN INNOVTE Network, Saint-Etienne, France; Vascular Medicine Department, Toulouse University Hospital, Toulouse, France
| | - Gilles Pernod
- FCRIN INNOVTE Network, Saint-Etienne, France; University Grenoble Alpes, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble, France; Department of Vascular Medicine, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Gaël Picart
- FCRIN INNOVTE Network, Saint-Etienne, France; Pneumology Unit, General Hospital, Quimper, France
| | - Antoine Elias
- FCRIN INNOVTE Network, Saint-Etienne, France; Département de Cardiologie et de Médecine Vasculaire, Délégation Recherche Clinique et Innovation, Centre Hospitalier Intercommunal Toulon La Seyne-sur-Mer, Toulon, France
| | - Caroline Doutrelon
- Department of Internal Medicine, Percy Military Teaching Hospital, Clamart, France
| | - Claire Neveux
- FCRIN INNOVTE Network, Saint-Etienne, France; Service de Médecine Vasculaire, Centre Hospitalier Général, Le Mans, France
| | - Lina Khider
- Cardiovascular Department, Hôpital Européen Georges-Pompidou, Paris Cardiovascular Research Center, Inserm UMR_U970, Université Paris-Cité, Paris, France
| | - Pierre-Marie Roy
- FCRIN INNOVTE Network, Saint-Etienne, France; Service des Urgences, Centre Hospitalo-Universitaire d'Angers, Institut MITOVASC, EA 3860, Université d'Angers, Angers, France; Emergency Department, Health Faculty, Angers University Hospital, Angers, France; UMR MitoVasc CNRS 6015 INSERM 1083, Equipe CARME, UNIV Angers, Angers, France
| | - Stéphane Zuily
- FCRIN INNOVTE Network, Saint-Etienne, France; Vascular Medicine Division, French National Referral Center for Systemic and Autoimmune Diseases, Université de Lorraine, Inserm, DCAC, CHRU-Nancy, F-54000, Nancy, France
| | - Nicolas Falvo
- FCRIN INNOVTE Network, Saint-Etienne, France; Department of Vascular Pathology, Centre Hospitalier Universitaire Dijon-Bourgogne, Dijon, France
| | - Philippe Lacroix
- FCRIN INNOVTE Network, Saint-Etienne, France; Department of Cardiovascular and Thoracic Surgery, Vascular Medicine, Limoges University Hospital, UMR 1094 INSERM and IRD, Limoges University, Limoges, France
| | - Joseph Emmerich
- FCRIN INNOVTE Network, Saint-Etienne, France; Department of Vascular Medicine, Paris Saint-Joseph Hospital Group, University of Paris, INSERM CRESS UMR 1153, Paris, France
| | - Isabelle Mahé
- FCRIN INNOVTE Network, Saint-Etienne, France; Service de Médecine Interne, Hôpital Louis-Mourier, Assistance Publique-Hôpitaux de Paris, Colombes, France; Université Paris Cité, Inserm UMR S1140, Innovations Thérapeutiques en Hémostase, Paris, France
| | - Julien Boileau
- Service de Médecine Interne, Centre Hospitalier des Pays de Morlaix, Morlaix, France
| | - Azzedine Yaici
- Service de Pneumologie, Hôpital de la Source, Orléans, France
| | - Sylvain Le Jeune
- Service de Médecine Interne, AP-HP, Hôpital Avicenne, Bobigny, France; Université Paris Cité, INSERM, Paris Center for Cardiovascular Research-ParCC, Paris, France
| | - Dominique Stéphan
- FCRIN INNOVTE Network, Saint-Etienne, France; Department of Hypertension, Vascular Disease and Clinical Pharmacology, Strasbourg Regional University Hospital, Strasbourg, France
| | | | - Valérie Ray
- Service de Médecine Polyvalente, Centre Hospitalier Universitaire de Nîmes, Nîmes, France
| | - Marc Danguy des Déserts
- FCRIN INNOVTE Network, Saint-Etienne, France; Department of Anaesthesia and Intensive Care, Clermont-Tonnerre Military Hospital, University of Brest, INSERM UMR 1304-GETBO, Brest, France
| | - Rafik Belhadj-Chaidi
- Service D'Hématologie Biologique, Centre Hospitalo-Universitaire de Poitiers, INSERM 1313 Ischémie Reperfusion, Métabolisme, Inflammation Stérile en Transplantation, Université de Poitiers, FHU Survival Optimization in Organ Transplantation, Poitiers, France
| | - Bouchra Lamia
- Département de Pneumologie, Centre Hospitalier du Havre, Université de Normandie, UNIROUEN EU 3830, Le Havre, France
| | - Yves Gruel
- FCRIN INNOVTE Network, Saint-Etienne, France; Department of Haemostasis, Regional University Hospital Centre Tours, Tours, France; Institut National de la Santé et de la Recherche Médicale INSERM U1327 ISCHEMIA, Membrane Signalling and Inflammation in Reperfusion Injuries, Université de Tours, Tours, France
| | - Emilie Presles
- FCRIN INNOVTE Network, Saint-Etienne, France; Unité de Recherche Clinique, Innovation, Pharmacologie, Centre Hospitalo-Universitaire de Saint-Etienne, Hôpital Nord, SAINBIOSE INSERM U1059, Université Jean Monnet, Saint-Etienne, France; F-CRIN INNOVTE, Saint-Etienne, France
| | - Philippe Girard
- FCRIN INNOVTE Network, Saint-Etienne, France; Département Thoracique, Institut Mutualiste Montsouris, Paris, France
| | - Cécile Tromeur
- Univ Brest, INSERM U1304-GETBO, CIC INSERM 1412, Brest, France; Centre Hospitalier Universitaire Brest, Département de Médecine Interne et Pneumologie, Brest, France; FCRIN INNOVTE Network, Saint-Etienne, France
| | - Farès Moustafa
- FCRIN INNOVTE Network, Saint-Etienne, France; Service d'urgence, Centre Hospitalier Universitaire de Clermont-Ferrand, Lapsco-UMR UBP-CNRS 6024, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Vincent Rothstein
- Université Paris Cité, Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, INSERM UMR S 1140, Paris, France
| | - Karine Lacut
- Univ Brest, INSERM U1304-GETBO, CIC INSERM 1412, Brest, France; Centre Hospitalier Universitaire Brest, Département de Médecine Interne et Pneumologie, Brest, France; FCRIN INNOVTE Network, Saint-Etienne, France
| | - Solen Melac
- Centre Hospitalier Universitaire Brest, Département de Médecine Interne et Pneumologie, Brest, France
| | - Sophie Barillot
- Centre Hospitalier Universitaire Brest, Département de Médecine Interne et Pneumologie, Brest, France
| | - Patrick Mismetti
- FCRIN INNOVTE Network, Saint-Etienne, France; Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France; INSERM CIC 1408 Centre Hospitalier Universitaire de St-Etienne, Saint-Etienne, France; INSERM UMR 1059, Université Jean Monnet, Saint-Etienne, France
| | - Silvy Laporte
- FCRIN INNOVTE Network, Saint-Etienne, France; Unité de Recherche Clinique, Innovation, Pharmacologie, Centre Hospitalo-Universitaire de Saint-Etienne, Hôpital Nord, SAINBIOSE INSERM U1059, Université Jean Monnet, Saint-Etienne, France; F-CRIN INNOVTE, Saint-Etienne, France
| | - Dominique Mottier
- Univ Brest, INSERM U1304-GETBO, CIC INSERM 1412, Brest, France; Centre Hospitalier Universitaire Brest, Département de Médecine Interne et Pneumologie, Brest, France; FCRIN INNOVTE Network, Saint-Etienne, France
| | - Guy Meyer
- FCRIN INNOVTE Network, Saint-Etienne, France; Université Paris Cité, Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, INSERM UMR S 1140, Paris, France
| | - Christophe Leroyer
- Univ Brest, INSERM U1304-GETBO, CIC INSERM 1412, Brest, France; Centre Hospitalier Universitaire Brest, Département de Médecine Interne et Pneumologie, Brest, France; FCRIN INNOVTE Network, Saint-Etienne, France
| |
Collapse
|
38
|
Luijten D, Rodenburg T, Bogaard HJ, Kianzad A, Ruigrok D, Croon P, Smeele P, Vliegen HW, Noordegraaf AV, Meijboom LJ, Klok FA. The value of vector ECG in predicting residual pulmonary hypertension in CTEPH patients after pulmonary endarterectomy. PLoS One 2025; 20:e0317826. [PMID: 40009598 PMCID: PMC11864536 DOI: 10.1371/journal.pone.0317826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2024] [Accepted: 01/06/2025] [Indexed: 02/28/2025] Open
Abstract
INTRODUCTION Right heart catheterization (RHC) is the diagnostic standard for establishing residual pulmonary hypertension (PH) after pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). A potential non-invasive alternative diagnostic test could be electrocardiography (ECG)-derived ventricular gradient optimized for right ventricular pressure overload (VG-RVPO). METHODS We studied 66 CTEPH patients who underwent PEA. A subgroup of 20 patients also had a cardiac MRI before and after PEA. The diagnostic performance of the VG-RVPO for the detection of residual PH as well as the potential to replace RHC were assessed. Different cut-off values to define a normal VG-RVPO were evaluated. Also, we evaluated the association between mean pulmonary artery pressure (mPAP) and CMR derived indexed right ventricular (RV) mass and the VG-RVPO. RESULTS During follow-up, 28 patients had residual PH (42%). A decrease in VG-RVPO after PEA was associated with decrease in mPAP or indexed RV mass post PEA (r = 0.55, p < 0.05 and r = 0.64, p < 0.05, respectively). If a normal VG-RVPO would exclude residual PH, the need for RHC would be reduced with 15-48%, but up to 36% of the CTEPH patients with residual PH would have been missed as they had a normal VG-RVPO. CONCLUSION Although there was an association between the change in VG-RPVO and changes in mPAP or indexed RV mass, our study demonstrated that VG-RPVO has limited value in excluding the presence of residual PH post-PEA as up to 36% of the CTEPH patients with residual PH would have been missed if residual PH would have been excluded based on a normal VG-RVPO.
Collapse
Affiliation(s)
- Dieuwke Luijten
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Tamara Rodenburg
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Harm-Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Azar Kianzad
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Dieuwertje Ruigrok
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Philip Croon
- Department of Cardiology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Patrick Smeele
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Hubert W. Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Lilian J. Meijboom
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
39
|
Tian Y, Liu J, Wu S, Zheng Y, Han R, Bao Q, Li L, Yang T. Development and validation of a deep learning-enhanced prediction model for the likelihood of pulmonary embolism. Front Med (Lausanne) 2025; 12:1506363. [PMID: 39981086 PMCID: PMC11839595 DOI: 10.3389/fmed.2025.1506363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2024] [Accepted: 01/24/2025] [Indexed: 02/22/2025] Open
Abstract
Background Pulmonary embolism (PE) is a common and potentially fatal condition. Timely and accurate risk assessment in patients with acute deep vein thrombosis (DVT) is crucial. This study aims to develop a deep learning-based, precise, and efficient PE risk prediction model (PE-Mind) to overcome the limitations of current clinical tools and provide a more targeted risk evaluation solution. Methods We analyzed clinical data from patients by first simplifying and organizing the collected features. From these, 37 key clinical features were selected based on their importance. These features were categorized and analyzed to identify potential relationships. Our prediction model uses a convolutional neural network (CNN), enhanced with three custom-designed modules for better performance. To validate its effectiveness, we compared this model with five commonly used prediction models. Results PE-Mind demonstrated the highest accuracy and reliability, achieving 0.7826 accuracy and an area under the receiver operating characteristic curve of 0.8641 on the prospective test set, surpassing other models. Based on this, we have also developed a Web server, PulmoRiskAI, for real-time clinician operation. Conclusion The PE-Mind model improves prediction accuracy and reliability for assessing PE risk in acute DVT patients. Its convolutional architecture and residual modules substantially enhance predictive performance.
Collapse
Affiliation(s)
- Yu Tian
- Vascular Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University, Tongji Shanxi Hospital, Taiyuan, China
- School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Jingjie Liu
- Institute of Cardiovascular Diseases, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Shan Wu
- Radiology Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University, Tongji Shanxi Hospital, Taiyuan, China
| | - Yucong Zheng
- Radiology Department, Tsinghua University Hospital, Tsinghua University, Beijing, China
| | - Rongye Han
- Clinical Laboratory Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University, Tongji Shanxi Hospital, Taiyuan, China
| | - Qianhui Bao
- School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Lei Li
- School of Clinical Medicine, Tsinghua University, Beijing, China
- Vascular Department, Beijing Hua Xin Hospital (1st Hospital of Tsinghua University), Beijing, China
| | - Tao Yang
- Vascular Surgery Department, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University, Tongji Shanxi Hospital, Taiyuan, China
| |
Collapse
|
40
|
Luijten D, Abbel D, Cannegieter SC, Eikenboom J, den Exter PL, Gussekloo J, Huisman MV, van Mens TE, Tahir L, Trompet S, Mooijaart SP, Klok FA. Risk assessment and management strategies in older patients with acute pulmonary embolism. J Thromb Haemost 2025; 23:588-599. [PMID: 39454882 DOI: 10.1016/j.jtha.2024.10.015] [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] [Received: 06/04/2024] [Revised: 10/07/2024] [Accepted: 10/09/2024] [Indexed: 10/28/2024]
Abstract
BACKGROUND Managing older patients with acute pulmonary embolism (PE) is challenging due to their underrepresentation in clinical trials, comorbidities, and increased complication risk. OBJECTIVES To evaluate risk assessment and management outcomes in older patients with PE focusing on home and reperfusion treatment. METHODS A retrospective analysis was conducted on patients aged 70 years or older diagnosed with acute PE at an academic medical center (2015-2022). RESULTS In total, 242 patients with a mean age of 77 years were included. All 59 patients with negative Hestia criteria were discharged ≤24 hours, and in total, 81 patients (35%) received home treatment. Among these 14-day mortality and recurrent venous thromboembolism were 0% and major bleeding occurred in 1.3% (1 patient, 95% CI: 0.11-6.1). European Society of Cardiology risk classification showed 9 low-risk (3.9%), 199 intermediate-risk (87%), and 20 high-risk (8.8) patients with PE. In 5 of the 20 high-risk patients, hypotension was mainly caused by another condition, that is, sepsis. Eight high-risk patients received reperfusion therapy. The 14-day mortality rate was 51% in high-risk patients (95% CI: 27-71); 5 of 8 patients receiving reperfusion treatment died within 5 days. Patients with an Acute Presenting Older Patient score of ≥45% had higher 14-day mortality (28%; 95% CI: 12-46) compared with <45% (3.2%; 95% CI: 0.85-8.3; hazard ratios: 10.2; 95% CI: 2.6-39). CONCLUSION Selecting for home treatment using Hestia criteria was safe for older patients with PE in our cohort. Mortality in the high-risk group was high also when receiving reperfusion treatment. The European Society of Cardiology risk classification and Acute Presenting Older Patient score identified patients at higher mortality risk, suggesting their potential utility in clinical decision-making.
Collapse
Affiliation(s)
- Dieuwke Luijten
- Department of Internal Medicine-Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands.
| | - Denise Abbel
- Department of Internal Medicine-Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands; Department of Internal Medicine-Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Netherlands; LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, Netherlands
| | - Suzanne C Cannegieter
- Department of Internal Medicine-Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jeroen Eikenboom
- Department of Internal Medicine-Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Paul L den Exter
- Department of Internal Medicine-Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Jacobijn Gussekloo
- Department of Internal Medicine-Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Netherlands; LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, Netherlands; Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands
| | - Menno V Huisman
- Department of Internal Medicine-Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Thijs E van Mens
- Department of Internal Medicine-Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Lara Tahir
- Department of Internal Medicine-Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
| | - Stella Trompet
- Department of Internal Medicine-Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Netherlands; LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, Netherlands
| | - Simon P Mooijaart
- Department of Internal Medicine-Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, Netherlands; LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, Netherlands
| | - Frederikus A Klok
- Department of Internal Medicine-Section of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands. https://twitter.com/Erik_Klok_MD
| |
Collapse
|
41
|
Galeano-Valle F, Alonso-Beato R, Moragón-Ledesma S, Pire-García T, Huergo-Fernández O, Ordieres-Ortega L, Oblitas CM, Walther LAAS, Demelo-Rodríguez P. External validation of a prognostic score to identify low-risk outpatients with acute deep venous thrombosis in the lower limbs. Eur J Intern Med 2025; 132:76-83. [PMID: 39406608 DOI: 10.1016/j.ejim.2024.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 09/04/2024] [Accepted: 10/09/2024] [Indexed: 02/07/2025]
Abstract
BACKGROUND Current clinical guidelines suggest home treatment for patients diagnosed with acute deep venous thrombosis (DVT). A prognostic score has been proposed to identify low-risk patients; however, its validation remains limited. METHOD This prospective observational study aimed to externally validate the prognostic score in selecting low-risk outpatients with acute DVT in the lower limbs. Consecutive outpatients diagnosed with acute DVT in a tertiary hospital were included. The score included 6 variables: heart failure, kidney failure, recent major bleeding, altered platelet count, immobilization, and cancer. The primary outcome was the incidence of a composite outcome, including confirmed diagnosis of PE, major bleeding, or all-cause death at 7 days. Patients meeting zero criteria were considered low risk. RESULTS Among the 1035 patients included, 485 (46.9 %) met zero criteria. Of these, 0.2 % (95 % CI 0.0-1.1 %) and 0.4 % (95 % CI, 0.0-1.5 %) patients experienced the composite outcome at 7 and 30 days, respectively. Among patients who met 1 or more criteria for admission, 344 patients (62.5 %) were discharged. Among these, the composite outcome at 7 and 30 days occurred in 2 (0.6 %) and 5 (1.4 %) patients, respectively. The C-statistics of the score were 0.68 (95 % CI, 0.57-0.79) and 0.69 (95 % CI, 0.64-0.76) at 7 and 30 days, respectively. CONCLUSION This study demonstrates the efficacy of the prognostic score in identifying low-risk outpatients with acute DVT. It also suggests that a considerable proportion of patients with acute DVT may benefit from outpatient treatment despite having some risk criteria, highlighting the potential for optimizing ambulatory care pathways.
Collapse
Affiliation(s)
- Francisco Galeano-Valle
- Venous Thromboembolism Unit. Internal Medicine Department, Hospital General Universitario Gregorio Marañón, C/. Doctor Esquerdo, 46, Madrid 28007, Spain; School of Medicine, Universidad Complutense de Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Rubén Alonso-Beato
- Venous Thromboembolism Unit. Internal Medicine Department, Hospital General Universitario Gregorio Marañón, C/. Doctor Esquerdo, 46, Madrid 28007, Spain; School of Medicine, Universidad Complutense de Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Sergio Moragón-Ledesma
- Venous Thromboembolism Unit. Internal Medicine Department, Hospital General Universitario Gregorio Marañón, C/. Doctor Esquerdo, 46, Madrid 28007, Spain; School of Medicine, Universidad Complutense de Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
| | - Tatiana Pire-García
- Venous Thromboembolism Unit. Internal Medicine Department, Hospital General Universitario Gregorio Marañón, C/. Doctor Esquerdo, 46, Madrid 28007, Spain
| | - Olaya Huergo-Fernández
- Venous Thromboembolism Unit. Internal Medicine Department, Hospital General Universitario Gregorio Marañón, C/. Doctor Esquerdo, 46, Madrid 28007, Spain
| | - Lucía Ordieres-Ortega
- Venous Thromboembolism Unit. Internal Medicine Department, Hospital General Universitario Gregorio Marañón, C/. Doctor Esquerdo, 46, Madrid 28007, Spain; School of Medicine, Universidad Complutense de Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Crhistian-Mario Oblitas
- Venous Thromboembolism Unit. Internal Medicine Department, Hospital General Universitario Gregorio Marañón, C/. Doctor Esquerdo, 46, Madrid 28007, Spain; School of Medicine, Universidad Complutense de Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Luis Antonio Alvarez-Sala Walther
- Venous Thromboembolism Unit. Internal Medicine Department, Hospital General Universitario Gregorio Marañón, C/. Doctor Esquerdo, 46, Madrid 28007, Spain; School of Medicine, Universidad Complutense de Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Pablo Demelo-Rodríguez
- Venous Thromboembolism Unit. Internal Medicine Department, Hospital General Universitario Gregorio Marañón, C/. Doctor Esquerdo, 46, Madrid 28007, Spain; School of Medicine, Universidad Complutense de Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| |
Collapse
|
42
|
Wang D, Chen R, Wang W, Yang Y, Yu Y, Liu L, Yang F, Cui S. Prediction of short-term adverse clinical outcomes of acute pulmonary embolism using conventional machine learning and deep Learning based on CTPA images. J Thromb Thrombolysis 2025; 58:331-339. [PMID: 39342072 DOI: 10.1007/s11239-024-03044-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2024] [Indexed: 10/01/2024]
Abstract
To explore the predictive value of traditional machine learning (ML) and deep learning (DL) algorithms based on computed tomography pulmonary angiography (CTPA) images for short-term adverse outcomes in patients with acute pulmonary embolism (APE). This retrospective study enrolled 132 patients with APE confirmed by CTPA. Thrombus segmentation and texture feature extraction was performed using 3D-Slicer software. The least absolute shrinkage and selection operator (LASSO) algorithm was used for feature dimensionality reduction and selection, with optimal λ values determined using leave-one-fold cross-validation to identify texture features with non-zero coefficients. ML models (logistic regression, random forest, decision tree, support vector machine) and DL models (ResNet 50 and Vgg 19) were used to construct the prediction models. Model performance was evaluated using receiver operating characteristic (ROC) curves and the area under the curve (AUC). The cohort included 84 patients in the good prognosis group and 48 patients in the poor prognosis group. Univariate and multivariate logistic regression analyses showed that diabetes, RV/LV ≥ 1.0, and Qanadli index form independent risk factors predicting poor prognosis in patients with APE(P < 0.05). A total of 750 texture features were extracted, with 4 key features identified through screening. There was a weak positive correlation between texture features and clinical parameters. ROC curves analysis demonstrated AUC values of 0.85 (0.78-0.92), 0.76 (0.67-0.84), and 0.89 (0.83-0.95) for the clinical, texture feature, and combined models, respectively. In the ML models, the random forest model achieved the highest AUC (0.85), and the support vector machine model achieved the lowest AUC (0.62). And the AUCs for the DL models (ResNet 50 and Vgg 19) were 0.91 (95%CI: 0.90-0.92) and 0.94(95%CI: 0.93-0.95), respectively. Vgg 19 model demonstrated exceptional precision (0.93), recall (0.76), specificity (0.95) and F1 score (0.84). Both ML and DL models based on thrombus texture features from CTPA images demonstrated higher predictive efficacy for short-term adverse outcomes in patients with APE, especially the random forest and Vgg 19 models, potentially assisting clinical management in timely interventions to improve patient prognosis.
Collapse
Affiliation(s)
- Dawei Wang
- Department of Thoracic Surgery, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, 075000, China
| | - Rong Chen
- Hebei North University, Zhangjiakou, Hebei, 075000, China
| | - Wenjiang Wang
- Hebei North University, Zhangjiakou, Hebei, 075000, China
| | - Yue Yang
- Hebei North University, Zhangjiakou, Hebei, 075000, China
| | - Yaxi Yu
- Hebei North University, Zhangjiakou, Hebei, 075000, China
| | - Lan Liu
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, 12 Changqing Road, Zhangjiakou, Hebei, 075000, China
| | - Fei Yang
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, 12 Changqing Road, Zhangjiakou, Hebei, 075000, China.
| | - Shujun Cui
- Department of Medical Imaging, The First Affiliated Hospital of Hebei North University, 12 Changqing Road, Zhangjiakou, Hebei, 075000, China
| |
Collapse
|
43
|
Tarras E, Khosla A, Heerdt PM, Singh I. Right Heart Failure in the Intensive Care Unit: Etiology, Pathogenesis, Diagnosis, and Treatment. J Intensive Care Med 2025; 40:119-136. [PMID: 38031338 DOI: 10.1177/08850666231216889] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Right heart (RH) failure carries a high rate of morbidity and mortality. Patients who present with RH failure often exhibit complex aberrant cardio-pulmonary physiology with varying presentations. The treatment of RH failure almost always requires care and management from an intensivist. Treatment options for RH failure patients continue to evolve rapidly with multiple options available, including different pharmacotherapies and mechanical circulatory support devices that target various components of the RH circulatory system. An understanding of the normal RH circulatory physiology, treatment, and support options for the RH failure patients is necessary for all intensivists to improve outcomes. The purpose of this review is to provide clinical guidance on the diagnosis and management of RH failure within the intensive care unit setting, and to highlight the different pathophysiological manifestations of RH failure, its hemodynamics, and treatment options available at the disposal of the intensivist.
Collapse
Affiliation(s)
- Elizabeth Tarras
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Akhil Khosla
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Paul M Heerdt
- Department of Anesthesiology, Division of Applied Hemodynamics, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| | - Inderjit Singh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
44
|
Kenny C, Lennon O, Klok FA, Matthews J, Ainle FN, Rosovsky R, Donoghue GO. Effectiveness of rehabilitation programmes targeting quality of life, psychological wellbeing, and functional capacity in pulmonary embolism survivors; a systematic review and best evidence synthesis. Thromb Res 2025; 246:109242. [PMID: 39731975 DOI: 10.1016/j.thromres.2024.109242] [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] [Received: 06/17/2024] [Revised: 08/28/2024] [Accepted: 12/09/2024] [Indexed: 12/30/2024]
Abstract
BACKGROUND Half of people post pulmonary embolism (PE) experience ongoing symptoms such as dyspnoea, anxiety and depression, exercise limitation and fatigue. These symptoms can reduce their quality of life (QoL), psychological wellbeing, and functional capacity. The efficacy of rehabilitation interventions to prevent and manage these symptoms has not been established. The objectives of this review were to synthesise the evidence on interventions targeting QoL, psychological wellbeing, and functional capacity post PE, and to identify intervention characteristics and behaviour change techniques (BCTs) that contribute to successful rehabilitation programmes. METHODS The PRISMA reporting guidelines were followed. Five electronic databases were searched; PubMED, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. Searching began in November 2023, with the final search run in December 2023. Studies using experimental designs, in adult populations, employing rehabilitation programmes to target patient outcomes post PE were included. The Template of Intervention Description and Replication (TIDieR) 12 item checklist was used to score the description and replicability of the intervention and control conditions and the BCT taxonomy V1 was used to identify BCTs across the included interventions. Data was extracted and a best evidence synthesis was conducted. RESULTS Of 7321 studies identified, 12 studies (n = 648 participants) met the inclusion criteria; four randomised controlled trials (RCTs), one pilot RCT study and seven prospective cohort studies, all conducted at different timepoints in the disease course, using different selection criteria and with different interventions. Eight of the 12 included studies were evaluated as being of low quality based on the Effective Public Health Practice Project (EPHPP) tool. The mean TIDieR score was six out of 24 for intervention completeness and reporting. Twenty five BCTs were identified across the included studies, three of which were identified in all studies ("Instruction on how to perform the behaviour", "demonstration of the behaviour" and "behaviour practice/ rehearsal"). Overall the best evidence synthesis provided a mixed level of evidence for the effectiveness of rehabilitation interventions post PE. There is a limited level of evidence that rehabilitation has a positive effect on patient perceived QoL and inconsistent evidence that rehabilitation has any effect on psychological wellbeing. There is however, a moderate level of evidence to support the effectiveness of rehabilitation when it comes to improving functional capacity. CONCLUSION This review highlights heterogeneity across available studies and provides some evidence supporting rehabilitation programmes to improve functional capacity in people living post PE. However, further research is required to establish their effectiveness for improving QoL and psychological wellbeing. Although a number of BCTs were identified, few of those identified were linked to behaviour change theory. This, combined with limited reporting of components of the rehabilitation interventions, restricted evaluation of their effectiveness. PROSPERO REGISTRATION PROSPERO 2020 CRD42023459411 Available from: https://www.crd.york.ac.uk/prospero/#recordDetails.
Collapse
Affiliation(s)
- Caoimhe Kenny
- School of Public Health, Physiotherapy & Sports Science, Health Sciences Building, University College Dublin, D04 V1W8, Ireland.
| | - Olive Lennon
- School of Public Health, Physiotherapy & Sports Science, Health Sciences Building, University College Dublin, D04 V1W8, Ireland.
| | | | - James Matthews
- School of Public Health, Physiotherapy & Sports Science, Health Sciences Building, University College Dublin, D04 V1W8, Ireland.
| | | | - Rachel Rosovsky
- Yawkey Center Outpatient Care, 32 Fruit Street, Boston, MA 02114, United States of America.
| | - Grainne O Donoghue
- School of Public Health, Physiotherapy & Sports Science, Health Sciences Building, University College Dublin, D04 V1W8, Ireland.
| |
Collapse
|
45
|
Di Marino M, Cicchitti V, Ianni U, Ricci F, Mantini C, Niccoli G, Pelliccia F, Gallina S, De Caterina R, Kaski JC, Mamas MA, Zimarino M. Clot-in-transit and pulmonary embolism: an urgent call for awareness and action. Heart 2025; 111:151-158. [PMID: 39613455 DOI: 10.1136/heartjnl-2024-324747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2024] [Accepted: 10/24/2024] [Indexed: 12/01/2024] Open
Abstract
Patients with acute pulmonary embolism (PE) have a wide spectrum of clinical presentations, from incidental findings to sudden cardiac death. Management and treatment recommendations in currently available guidelines vary according to patient risk and haemodynamic profile. A clot-in-transit (CiT) in the right heart chambers may be occasionally identified and is, therefore, an under-recognised but challenging condition, often preceding an abrupt clinical deterioration, and associated with increased mortality. Data on the detection of a CiT are sparse but consistent in attributing negative prognostic relevance, and therefore the presence of CiT should be systematically investigated and recorded in the setting of PE.In this review, the challenges related to the identification of a CiT are highlighted. Here, we propose an algorithm where the role of the Pulmonary Embolism Response Team (PERT) is reinforced. The PERT should convene once the CiT is suspected, to define the timeline for the diagnostic steps and subsequent management on a case-by-case basis. A patient with PE and CiT requires close bedside monitoring and rapid escalation therapy in case of clinical deterioration. Beyond anticoagulation alone, more aggressive strategies can be considered, including systemic thrombolysis, surgical pulmonary embolectomy and the currently emerging catheter-directed therapies. PROSPERO registration number: CRD42024493303.
Collapse
Affiliation(s)
- Mario Di Marino
- Department of Neuroscience and Imaging and Clinical Sciences, Gabriele d'Annunzio University of Chieti and Pescara, Chieti, Abruzzo, Italy
| | - Vincenzo Cicchitti
- Department of Cardiology, SS Annunziata Hospital, Chieti, Abruzzo, Italy
| | - Umberto Ianni
- Cardiology and Cardiac Rehabilitation Unit, Provincial Hospital Madonna del Soccorso, San Benedetto del Tronto, Italy
| | - Fabrizio Ricci
- Department of Neuroscience and Imaging and Clinical Sciences, Gabriele d'Annunzio University of Chieti and Pescara, Chieti, Abruzzo, Italy
| | - Cesare Mantini
- Department of Neuroscience and Imaging and Clinical Sciences, Gabriele d'Annunzio University of Chieti and Pescara, Chieti, Abruzzo, Italy
| | - Giampaolo Niccoli
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Pelliccia
- Department of Cardiovascular Sciences, University of Rome La Sapienza, Rome, Lazio, Italy
| | - Sabina Gallina
- Department of Neuroscience and Imaging and Clinical Sciences, Gabriele d'Annunzio University of Chieti and Pescara, Chieti, Abruzzo, Italy
| | | | - Juan-Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's University of London, London, London, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Newcastle-under-Lyme, UK
| | - Marco Zimarino
- Department of Cardiology, SS Annunziata Hospital, Chieti, Abruzzo, Italy
| |
Collapse
|
46
|
Lauriero F, Mazza G, Perazzolo A, Ottoni G, Cipriani A, Castro Pereira JF, Marano R, Natale L. Pregnancy-Related Cardiovascular Diseases: A Radiological Overview. J Cardiovasc Dev Dis 2025; 12:43. [PMID: 39997477 PMCID: PMC11856395 DOI: 10.3390/jcdd12020043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2024] [Revised: 01/18/2025] [Accepted: 01/23/2025] [Indexed: 02/26/2025] Open
Abstract
Pregnancy induces significant hemodynamic changes, and cardiovascular diseases (CVDs) are one of the leading causes of non-obstetric maternal morbidity and mortality during pregnancy or the postpartum period in developed countries. The effective diagnosis and management of CVDs in pregnant women require a thorough evaluation that considers the health of both the mother and the fetus. Imaging plays a pivotal role in this evaluation, offering essential insights into the most significant pregnancy-related CVDs. However, due to concerns about fetal exposure, the use of contrast agents and radiation exposure must be carefully managed. Following to the principle of "As Low As Reasonably Achievable" (ALARA), strategies to minimize these risks are crucial for ensuring patient safety while maintaining diagnostic accuracy. This review highlights the contribution of cardiovascular imaging techniques, particularly computed tomography (CT) and magnetic resonance imaging (MRI), in the assessment of common pregnancy-related CVDs, and outlines strategies to reduce radiation exposure and limit contrast agent use when feasible, aiming to increase radiologists' awareness of this crucial topic.
Collapse
Affiliation(s)
- Francesco Lauriero
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (R.M.); (L.N.)
| | - Giulia Mazza
- Department of Radiological and Haematological Sciences-Section of Radiology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (G.M.); (A.P.); (G.O.); (A.C.)
| | - Alessio Perazzolo
- Department of Radiological and Haematological Sciences-Section of Radiology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (G.M.); (A.P.); (G.O.); (A.C.)
| | - Giacomo Ottoni
- Department of Radiological and Haematological Sciences-Section of Radiology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (G.M.); (A.P.); (G.O.); (A.C.)
| | - Alessia Cipriani
- Department of Radiological and Haematological Sciences-Section of Radiology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (G.M.); (A.P.); (G.O.); (A.C.)
| | - José F. Castro Pereira
- Department of Radiology, Unidade Local de Saúde de Almada-Seixal, E.P.E., 2805-267 Almada, Portugal
| | - Riccardo Marano
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (R.M.); (L.N.)
- Department of Radiological and Haematological Sciences-Section of Radiology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (G.M.); (A.P.); (G.O.); (A.C.)
| | - Luigi Natale
- Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, 00168 Rome, Italy; (R.M.); (L.N.)
- Department of Radiological and Haematological Sciences-Section of Radiology, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (G.M.); (A.P.); (G.O.); (A.C.)
| |
Collapse
|
47
|
Abdul Aziz NI, Palaniappan S, Kamal Rodin NS, Chong GY, Jerome TTC, Aizuddin AN, Tumian NR. Incidence of Venous Thromboembolism and Its Associated Risk Factors in Newly Diagnosed Multiple Myeloma Patients in the Klang Valley, Malaysia. J Clin Med 2025; 14:759. [PMID: 39941428 PMCID: PMC11818754 DOI: 10.3390/jcm14030759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2024] [Revised: 12/21/2024] [Accepted: 01/01/2025] [Indexed: 02/16/2025] Open
Abstract
Background: Venous thromboembolism (VTE) is a potentially severe medical problem among multiple myeloma (MM) patients, with evolving treatment regimens potentially increasing the thrombotic risk. Data on VTE incidence and risk factors in multiethnic Malaysian MM patients are limited. This study aimed to assess VTE incidence and risk factors in newly diagnosed MM (NDMM) patients at two tertiary centres in Klang Valley, Malaysia. Methods: This retrospective cohort study included NDMM patients, aged ≥18, diagnosed between January 2015 and December 2022 at Hospital Canselor Tuanku Muhriz and Hospital Ampang. Patient demographics, clinical characteristics, MM therapies, and thromboprophylaxis data were analysed. VTE is defined as deep vein thrombosis (DVT) or pulmonary embolism (PE), confirmed by imaging. Results: Among the 216 NDMM patients (mean age: 62.4 ± 10.6 years), 22 (10.2%) developed VTE (15 DVT, five PE, and two both). The median time from MM diagnosis to VTE was 3.5 months (IQR 5.3). A univariate analysis identified the female sex, an ECOG performance status ≥ 2, diabetes mellitus, a recent orthopaedic surgery (<6 months), a SAVED score ≥ 2, and an IMPEDE-VTE score > 3 as significant risk factors. In the multivariable logistic regression, the female sex (aOR 8.56, 95% CI: 1.95-37.48), an ECOG status ≥ 2 (aOR 12.74, 95% CI: 3.37-48.17), and a recent orthopaedic surgery (aOR 21.79, 95% CI: 3.10-153.38) were the independent risk factors of VTE among NDMM patients. Conclusions: VTE incidence in our NDMM cohort was 10.2%. Independent risk factors included the female sex, a poor performance status, and a recent orthopaedic surgery. Individualised thromboprophylaxis strategies are crucial, warranting further real-world studies to optimise anticoagulation regimens.
Collapse
Affiliation(s)
- Nurul Izzati Abdul Aziz
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia; (N.I.A.A.); (S.P.); (G.Y.C.)
- Hospital Canselor Tuanku Muhriz (HCTM), Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia;
| | - Sivakumar Palaniappan
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia; (N.I.A.A.); (S.P.); (G.Y.C.)
- Hospital Canselor Tuanku Muhriz (HCTM), Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia;
| | - Nor Saaidah Kamal Rodin
- Hospital Canselor Tuanku Muhriz (HCTM), Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia;
| | - Guang Yong Chong
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia; (N.I.A.A.); (S.P.); (G.Y.C.)
- Hospital Canselor Tuanku Muhriz (HCTM), Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia;
| | - Tan Tsen Chuen Jerome
- Hematology Department, Hospital Ampang, Jalan Mewah Utara, Ampang 68000, Selangor, Malaysia;
| | - Azimatun Noor Aizuddin
- Department of Public Health Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia;
| | - Nor Rafeah Tumian
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia; (N.I.A.A.); (S.P.); (G.Y.C.)
- Hospital Canselor Tuanku Muhriz (HCTM), Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia;
| |
Collapse
|
48
|
Aalam A, Bokhary D, Alsabban A, Bakhribah A. National Trends in Pulmonary Embolism Visit in United State Emergency Departments and Associated Costs (2006-2018). Emerg Med Int 2025; 2025:6610196. [PMID: 39872080 PMCID: PMC11772062 DOI: 10.1155/emmi/6610196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2024] [Accepted: 01/02/2025] [Indexed: 01/29/2025] Open
Abstract
Introduction: Pulmonary embolism (PE) poses substantial morbidity and mortality risks, necessitating timely and accurate management in emergency departments (EDs). Objectives: This study explores the trends in PE presentations to US EDs from 2006 to 2018 and assesses the impact of different factors on management and cost. Methodology: This is a retrospective descriptive study conducted using the US Healthcare Cost and Utilization Project (HCUP) PE ED visits database. Data on ED visits, dispositions, and related costs were collected and analyzed. Results: From 2006 to 2018 there were more than 2 million PE ED visits in the US. There was an increase in visits per 100,000 persons from 42.17 in 2006-2008 to 64.27 in 2016-2018 (p value < 0.001). The proportion of uninsured patients declined from 5.07% to 4.70%, and the percentage of Medicaid-insured patients increased. There was a decrease in the admission rates from 92.47% to 75.97% in 2016-2018 (p value < 0.001). The mean cost per admitted patient increased from $32,794 to $47,344 in 2016-2018 (p value < 0.001). Conclusion: From 2006 to 2018, PE ED visits in the US increased with a noticeable decrease in admission rates and length of stay, likely secondary to advancement in diagnostic and therapeutic modalities like computed tomography pulmonary angiography and novel oral anticoagulants. However, the observed rising healthcare costs pose challenges to sustainable management. Further research studies are needed to address cost-effective strategies.
Collapse
Affiliation(s)
- Ahmad Aalam
- Department of Emergency Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Diyaa Bokhary
- Department of Emergency Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Awad Alsabban
- Department of Internal Medicine, Taif University College of Medicine, Taif, Saudi Arabia
| | - Ahmad Bakhribah
- Department of Emergency Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| |
Collapse
|
49
|
Stubblefield WB, Helderman R, Strokes N, Greineder CF, Barnes GD, Vinson DR, Westafer LM. Factors in Initial Anticoagulation Choice in Hospitalized Patients With Pulmonary Embolism. JAMA Netw Open 2025; 8:e2452877. [PMID: 39752158 PMCID: PMC11699532 DOI: 10.1001/jamanetworkopen.2024.52877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2024] [Accepted: 10/28/2024] [Indexed: 01/04/2025] Open
Abstract
Importance Despite guideline recommendations to use low-molecular-weight heparins (LMWHs) or direct oral anticoagulants in the treatment of most patients with acute pulmonary embolism (PE), US-based studies have found increasing use of unfractionated heparin (UFH) in hospitalized patients. Objective To identify barriers and facilitators of guideline-concordant anticoagulation in patients hospitalized with acute PE. Design, Setting, and Participants This qualitative study conducted semistructured interviews from February 1 to June 3, 2024, that were recorded, transcribed, and analyzed in an iterative process using reflexive thematic analysis. Interview participants were physicians in emergency medicine, hospital medicine (hospitalist), interventional cardiology, and interventional radiology. Participants were recruited using maximum variation sampling targeting UFH-dominant vs LMWH-dominant approaches in hospitalized patients with acute PE. We triangulated results with a group of interventional cardiologists and radiologists (interventionalists). Main Outcomes and Measures Common themes and factors associated with anticoagulant selection for hospitalized patients with acute PE. Reflexive thematic analysis was used to identify these themes and factors. Results Of the 46 interviewees (median [IQR] age, 43 [36-50] years; 33 who identified as men [71.7%]), 25 (54.3%) were emergency physicians, 17 (37.0%) were hospitalists, and 4 (8.7%) were interventionalists. Each interview lasted a median (IQR) of 29 (25-32) minutes. Prominent themes associated with anticoagulant selection included agnosticism regarding choice of anticoagulant, the inertia of learned practice, and therapeutic momentum after anticoagulation initiation. Institutional culture and support were factors associated with choice of the dominant anticoagulation strategy. Additionally, factors associated with UFH use were fear of decompensation and misperceptions regarding the pharmacology of anticoagulants and catheter-directed treatments. Conclusions and Relevance In this qualitative study, physicians across a spectrum of specialties and geographical settings reported common barriers and facilitators to the use of guideline-concordant anticoagulation in patients hospitalized with acute PE, particularly agnosticism regarding choice of anticoagulant, inertia of learned practice, therapeutic momentum after anticoagulation initiation, and institutional culture and support. Future implementation efforts may consider targeting these domains.
Collapse
Affiliation(s)
- William B. Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ron Helderman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas
| | - Natalie Strokes
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield
| | | | - Geoffrey D. Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - David R. Vinson
- Division of Research, Kaiser Permanente Northern California, Pleasanton
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California
| | - Lauren M. Westafer
- Department of Emergency Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield
- Department of Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield
| |
Collapse
|
50
|
Søgaard M, Ørskov M, Jensen M, Goedegebuur J, Kempers EK, Visser C, Geijteman ECT, Abbel D, Mooijaart SP, Geersing GJ, Portielje J, Edwards A, Aldridge SJ, Akbari A, Højen AA, Klok FA, Noble S, Cannegieter S, Ording AG. Use of antithrombotic therapy and the risk of cardiovascular outcomes and bleeding in cancer patients at the end of life: a Danish nationwide cohort study. J Thromb Haemost 2025; 23:190-200. [PMID: 39393778 DOI: 10.1016/j.jtha.2024.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 08/27/2024] [Accepted: 09/16/2024] [Indexed: 10/13/2024]
Abstract
BACKGROUND Despite uncertain benefit-risk profile near the end of life, antithrombotic therapy (ATT) is prevalent in patients with terminal cancer. OBJECTIVES To examine adherence and persistence with ATT in terminally ill cancer patients and investigate risks of major and clinically relevant bleeding, venous thromboembolism (VTE), and arterial thromboembolism (ATE) by ATT exposure. METHODS Using a Danish nationwide cohort of terminal cancer patients, ATT adherence in the year following terminal illness declaration was measured by the proportion of days covered (PDC) by prescription. Discontinuation was defined as a treatment gap of ≥30 days between prescription renewals. One-year cumulative incidences of bleeding complications, VTE, and ATE were calculated, considering the competing risk of death. RESULTS During 2013-2022, 86 732 terminally ill cancer patients were identified (median age, 75 years; 47% female; median survival, 57 days). At terminal illness declaration, 37.5% were receiving ATT (66.6% platelet inhibitors, 23.0% direct oral anticoagulants, and 10.4% vitamin K antagonists [VKAs]). The mean PDC with ATT was 88% (SD, 30%), highest among platelet inhibitor users (mean PDC, 89%) and lowest among VKA users (73%). One-year ATT discontinuation incidence was 7.9% (95% CI, 7.7%-8.1%). Most patients continued ATT until death (74.8% platelet inhibitors, 58.8% direct oral anticoagulants, and 61.6% VKAs). Patients receiving ATT had a lower 1-year VTE risk but higher risks of ATE and major bleeding. CONCLUSION Despite uncertain benefit-risk profile, most terminally ill cancer patients continue ATT until the end of life. These findings provide insights into current ATT utilization and discontinuation dynamics in the challenging context of terminal illness.
Collapse
Affiliation(s)
- Mette Søgaard
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, Gistrup, Denmark.
| | - Marie Ørskov
- Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark; Department of Ophthalmology, Aalborg University Hospital, Gistrup, Denmark
| | - Martin Jensen
- Unit for Clinical Biostatistics, Aalborg University Hospital, Gistrup, Denmark
| | - Jamilla Goedegebuur
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Eva K Kempers
- Department of Hematology, Erasmus University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Chantal Visser
- Department of Hematology, Erasmus University Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - Eric C T Geijteman
- Department of Medical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Denise Abbel
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands; Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands; LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, the Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands; LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, the Netherlands
| | - Geert-Jan Geersing
- Department of General Practice & Nursing Science, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Johanneke Portielje
- Department of Medical Oncology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Sarah J Aldridge
- Population Data Science, Swansea University, Swansea, United Kingdom
| | - Ashley Akbari
- Population Data Science, Swansea University, Swansea, United Kingdom
| | - Anette A Højen
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, Gistrup, Denmark
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Simon Noble
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Suzanne Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Anne Gulbech Ording
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, Gistrup, Denmark
| |
Collapse
|