Risk assessment in pulmonary hypertension based on routinely measured laboratory parameters.

BACKGROUND: γ-glutamyl transferase (GGT), the aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio, and the neutrophil-to-lymphocyte ratio (NLR) are prognostic biomarkers in several cardiovascular diseases, but their relevance in pulmonary hypertension (PH) is not fully understood. We aimed to assess their prognostic value in patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic PH (CTEPH). METHODS: We retrospectively analyzed 731 incident patients with idiopathic PAH or CTEPH who entered the Giessen PH registry during 1993-2019. A risk stratification score based on GGT, AST/ALT ratio, and NLR tertiles was compared with a truncated version of the European Society of Cardiology/European Respiratory Society (ESC/ERS) risk stratification scheme. Associations with survival were evaluated using Kaplan-Meier and Cox regression analyses. External validation was performed in 311 patients with various types of PAH or CTEPH from a second German center. RESULTS: GGT levels, AST/ALT, and NLR independently predicted mortality at baseline and during follow-up. The scoring system based on these biomarkers predicted mortality at baseline and during follow-up (both log-rank p < 0.001; hazard ratio [95% confidence interval], high vs low risk: baseline, 7.6 [3.9, 15.0]; follow-up, 13.3 [4.8, 37.1]). Five-year survival of low, intermediate, and high risk groups was 92%, 76%, and 51%, respectively, at baseline and 95%, 78%, and 50%, respectively, during follow-up. Our scoring system showed characteristics comparable to the ESC/ERS scheme, and predicted mortality in the validation cohort. CONCLUSION: GGT, AST/ALT, and NLR were reliable prognostic biomarkers at baseline and during follow-up, with predictive power comparable to the gold standard for risk stratification.

A predictive tool for the assessment of right ventricular dysfunction in non-high-risk patients with acute pulmonary embolism.

BACKGROUND: Rapid and accurate identification of right ventricular (RV) dysfunction is essential for decreasing mortality associated with acute pulmonary embolism (PE), particularly for non-high-risk patients without hypotension on admission. This study aimed to develop a rapid and accurate tool for predicting the risk of RV dysfunction in non-high-risk patients with acute PE. METHODS: The medical records of non-high-risk patients with acute PE admitted to Shengjing Hospital of China Medical University between January 2011 and May 2020 were retrospectively analysed. The primary outcome of this study was RV dysfunction within 24 h after admission. The enrolled patients were randomized into training or validation sets as a ratio of 2:1. In the training set, a nomogram was developed, and the consistency was corroborated in the validation set. The areas under the receiver operating characteristic curves (AUCs) and 95% confidence intervals (CIs) were calculated. RESULTS: A total of 845 patients were enrolled, including 420 men and 425 women with an average age of 60.05 ± 15.43 years. Right ventricular dysfunction was identified in 240 patients (28.40%). The nomogram for RV dysfunction included N-terminal pro-brain natriuretic peptide, cardiac troponin I, and ventricular diameter ratios, which provided AUC values of 0.881 in the training dataset (95% confidence interval (CI): 0.868-0.898, p < 0.001) and 0.839 in the validation set (95% CI: 0.780-0.897, p < 0.001). The predictive tool was published as a web-based calculato ( https://gaoyzcmu.shinyapps.io/APERVD/ ). CONCLUSIONS: The combination of CT and laboratory parameters forms a predictive tool that may facilitate the identification of RV dysfunction in non-high-risk patients with acute PE.

Galectin-3, GDF-15, and sST2 for the assessment of disease severity and therapy response in patients suffering from inoperable chronic thromboembolic pulmonary hypertension.

PURPOSE: This study examined sST2, GDF-15, and galectin-3 as indicators of disease severity and therapy response in chronic thromboembolic pulmonary hypertension (CTEPH). METHODS: This study included 57 inoperable CTEPH patients who underwent balloon pulmonary angioplasty and 25 controls without cardiovascular disease. Biomarker levels were examined in relation to advanced hemodynamic impairment [tertile with worst right atrial pressure (RAP) and cardiac index], hemodynamic therapy response [normalized hemodynamics (meanPAP ≤25 mmHg, PVR ≤3 WU and RAP ≤6 mmHg) or a reduction of meanPAP ≥25%; PVR ≥ 35%, RAP ≥25%]. RESULTS: GDF-15 [820 (556-1315) pg/ml vs. 370 (314-516) pg/ml; p < 0.001] and sST2 [53.7 (45.3-74.1) ng/ml vs. 48.7 (35.5-57.0) ng/ml; p = 0.02] were higher in CTEPH patients than in controls. At baseline, a GDF-15 level ≥1443 pg/ml (AUC 0.88; OR 31.4) and a sST2 level ≥65 ng/ml (AUC 0.80; OR 10.9) were associated with advanced hemodynamic impairment. At follow-up GDF-15 ≤ 958 pg/ml (AUC = 0.74, OR 18) identified patients with optimal hemodynamic therapy response and ≤760 pg/ml (AUC = 0.79, OR 14). CONCLUSION: GDF-15 and sST2 levels are higher in CTEPH and identified patients with advanced hemodynamic impairment. Further, decreased GDF-15 levels at follow-up were associated with hemodynamic therapy response. The diagnostic strength was not superior to NT-proBNP.

Prevalence of pulmonary thromboembolism in patients undergoing abdominopelvic surgery with respiratory distress.

OBJECTIVE: To determine the prevalence of pulmonary thromboembolism (PET) and identify it's risk factors in patients operated on a scheduled basis, in the general surgery service from the High Specialty Medical Unit Hospital de Especialidades de Puebla, of the Mexican Social Security Institute. METHOD: Descriptive, retrospective and cross sectional study of 52 patients' records with PET and pulmonary angiotomography whose indication was respiratory distress; from 2612 operated patients from November 2015 to March 2018, the sampling was not probabilistic. The statistics was descriptive, with measures of central tendency and dispersion. Fisher test, and Rho Spearman were used. RESULTS: There were association between the development of PET and trans-surgical time (p = 0.018), with the D Dimer (p = 0.014), there was correlation between PET and Wells scale (p=0.001) and blood transfusion (p=0.044). Age, gender, body mass index, preoperative diagnosis, thromboprophylaxis, blood transfusion and surgical approach were not risk factors. CONCLUSION: The prevalence of postoperative PET in patients with respiratory distress after surgical procedure is 5.7% and the mortality is 33.3%.

OBJETIVO: Determinar la prevalencia de la tromboembolia pulmonar (TEP) e identificar sus factores de riesgo en los pacientes intervenidos en el servicio de cirugía general de manera programada de la Unidad Médica de Alta Especialidad Hospital de Especialidades de Puebla, del Instituto Mexicano del Seguro Social. MÉTODO: Estudio descriptivo, retrospectivo y transversal de 52 expedientes de pacientes con TEP y angiotomografía pulmonar cuya indicación fue la dificultad respiratoria, de 2612 pacientes operados de noviembre de 2015 a marzo de 2018. El muestreo fue no probabilístico. La estadística fue descriptiva, con medidas de tendencia central y de dispersión. Se utilizó prueba de Fisher para riesgo y Rho de Spearman. RESULTADOS: Hubo asociación entre el desarrollo de TEP y el tiempo transquirúrgico (p = 0.018), y con el dímero D (p = 0.014); hubo correlación entre la TEP y con la escala de Wells (p = 0.001) y con la transfusión de hemoderivados (p = 0.044). La edad, el sexo, el índice de masa corporal, el diagnóstico preoperatorio, la tromboprofilaxis, la transfusión de hemoderivados y el abordaje quirúrgico no fueron factores de riesgo. CONCLUSIÓN: La prevalencia de TEP posquirúrgica en pacientes que cursan con dificultad respiratoria después del procedimiento quirúrgico es del 5.7% y la mortalidad es del 33.3%.

Impedimetric array in polymer microfluidic cartridge for low cost point-of-care diagnostics.

Deep Vein Thrombosis and pulmonary embolism (DVT/PE) is one of the most common causes of unexpected death for hospital in-patients. D-dimer is used as a biomarker within blood for the diagnosis of DVT/PE. We report a low-cost microfluidic device with a conveniently biofunctionalised interdigitated electrode (IDE) array and a portable impedimetric reader as a point-of-care (POC) device for the detection of D-dimer to aid diagnosis of DVT/PE. The IDE array elements, fabricated on a polyethylenenaphtalate (PEN) substrate, are biofunctionalised in situ after assembly of the microfluidic device by electropolymerisation of a copolymer of polypyrrole to which is immobilised a histidine tag anti-D-Dimer antibody. The most consistent copolymer films were produced using chronopotentiometry with an applied current of 5µA for a period of 50 s using a two-electrode system. The quality of the biofunctionalisation was monitored using optical microscopy, chronopotentiometry curves and impedimetric analysis. Measurement of clinical plasma sample with a D-dimer at concentration of 437 ng/mL with 15 biofunctionalised IDE array electrodes gave a ratiometric percentage of sample reading against the blank with an average value of 124 ±â€¯15 at 95% confidence. We have demonstrated the concept of a low cost disposable microfluidic device with a receptor functionalised on the IDE array for impedimetric detection towards POC diagnostics. Changing the receptor on the IDE array would allow this approach to be used for the direct detection of a wide range of analytes in a low cost manner.

Assessment of Anticoagulation in Patients Receiving Ultrasound-Assisted Catheter-Directed Thrombolysis for Treatment of Pulmonary Embolism.

BACKGROUND: Ultrasound-assisted, catheter-directed thrombolysis (USAT) has emerged as a popular treatment option for submassive pulmonary embolism (PE). The optimal strategy for transitioning patients from full-intensity to reduced-intensity heparin during the procedure has yet to be established. OBJECTIVE: The goal of this study was to evaluate the anticoagulation management in patients receiving catheter-directed thrombolysis with USAT. METHODS: A retrospective chart review was conducted of patients who received USAT for the treatment of PE. Institutional review board approval was obtained. The primary objective was to determine the proportion of patients with a therapeutic activated partial thromboplastin time (aPTT) prior to and during tissue-plasminogen activator (tPA) infusion. Secondary outcomes included heparin requirements, the rate of bleeding complications, and the appropriateness of long-term venous thromboembolism management. RESULTS: A therapeutic aPTT value was achieved in 32 patients (54.2%) prior to USAT and 35 patients (59.3%) during tPA infusion. Heparin requirements were reduced from 15.1 ± 4.1 to 12.8 ± 4.2 U/kg/h for patients who achieved a therapeutic aPTT both prior to and during tPA infusion. Bleeding occurred in 34.4% of patients and tended to be minimal (20.3%) or minor (10.9%). The majority of patients were discharged on a direct oral anticoagulant (63%), followed by warfarin (32%) and enoxaparin (5%). Conclusion and Relevance: To our knowledge, this is the first study that has assessed heparin management in the setting of USAT. The results of these data may aid in empirically dose adjusting unfractionated heparin to ensure safe and effective anticoagulation for patients receiving USAT.

d-Dimer Assessment Improves the Simplified Pulmonary Embolism Severity Index for In-Hospital Risk Stratification in Acute Pulmonary Embolism.

d-dimer (DD) levels are used in the diagnostic workup of suspected acute pulmonary embolism (APE), but data on DD for early risk stratification in APE are limited. In this post hoc analysis of a prospective observational study of 270 consecutive patients, we aimed to optimize the discriminant capacity of the simplified pulmonary embolism severity index (sPESI), an APE risk assessment score currently used, by combining it with DD for in-hospital adverse event prediction. We found that DD levels were higher in patients with complicated versus benign clinical course 7.2 mg/L (25th-75th percentile: 4.5-27.7 mg/L) versus 5.1 mg/L (25th-75th percentile: 2.1-11.2 mg/L), P = .004. The area under the curve of DD for serious adverse event (SAE) was 0.672, P = .003. d-dimer =1.35 mg/L showed 100% negative predictive value for SAE and identified 11 sPESI ≥1 patients with a benign clinical course, detecting the 1 patient with SAE from sPESI = 0. d-dimer >15 mg/L showed heart rate for SAE 3.04 (95% confidence interval [CI]: 1-9). A stratification model which with sPESI + DD >1.35 mg/L demonstrated improved prognostic value when compared to sPESI alone (net reclassification improvement: 0.085, P = .04). d-dimer have prognostic value, values <1.35 mg/L identify patients with a favorable outcome, improving the prognostic potential of sPESI, while DD >15 mg/L is an independent predictor of SAE.

Diagnostic utility of an age-specific cut-off for d-dimer for pulmonary embolism assessment when used with various pulmonary embolism risk scores.

This retrospective cohort study compared the diagnostic utility (sensitivity, specificity and negative predictive value (NPV)) of the age-times-10 adjusted d-dimer cut-off used in combination with the original and simplified Well's pulmonary embolism (PE) scores and the original and simplified revised Geneva scores to identify patients in whom PE is classified as unlikely according to each score. The PE risk scores performed similarly with high sensitivity (97.6, 97.1, 96.9 and 97.1% respectively) and NPV (99.3, 99.3, 99.2 and 99.2% respectively). Each missed only one PE. The age-times-10 age-adjusted d-dimer assay cut-off performed similarly with each of the clinical risk scores tested with high sensitivity and NPV.

The YEARS algorithm for suspected pulmonary embolism: shorter visit time and reduced costs at the emergency department.

Essentials The YEARS algorithm was designed to simplify the diagnostic workup of suspected pulmonary embolism. We compared emergency ward turnaround time of YEARS and the conventional algorithm. YEARS was associated with a significantly shorter emergency department visit time of ˜60 minutes. Treatment of pulmonary embolism was initiated 53 minutes earlier with the YEARS algorithm SUMMARY: Background Recently, the safety of the YEARS algorithm, designed to simplify the diagnostic work-up of pulmonary embolism (PE), was demonstrated. We hypothesize that by design, YEARS would be associated with a shorter diagnostic emergency department (ED) visit time due to simultaneous assessment of pre-test probability and D-dimer level and reduction in number of CT scans. Aim To investigate whether implementation of the YEARS diagnostic algorithm is associated with a shorter ED visit time compared with the conventional algorithm and to evaluate the associated cost savings. Methods We selected consecutive outpatients with suspected PE from our hospital included in the YEARS study and ADJUST-PE study. Different time-points of the diagnostic process were extracted from the to-the-minute accurate electronic patients' chart system of the ED. Further, the costs of the ED visits were estimated for both algorithms. Results All predefined diagnostic turnaround times were significantly shorter after implementation of YEARS: patients were discharged earlier from the ED; 54 min (95% CI, 37-70) for patients managed without computed tomography pulmonary angiography (CTPA) and 60 min (95% CI, 44-76) for the complete study population. Importantly, patients diagnosed with PE by CTPA received the first dose of anticoagulants 53 min (95% CI, 22-82) faster than those managed according to the conventional algorithm. Total costs were reduced by on average €123 per visit. Conclusion YEARS was shown to be associated with a shorter ED visit time compared with the conventional diagnostic algorithm, leading to faster start of treatment in the case of confirmed PE and savings on ED resources.

Causes of Troponin Elevation and Associated Mortality in Young Patients.

BACKGROUND: While increased serum troponin levels are often due to myocardial infarction, increased levels may also be found in a variety of other clinical scenarios. Although these causes of troponin elevation have been characterized in several studies in older adults, they have not been well characterized in younger individuals. METHODS: We conducted a retrospective review of patients 50 years of age or younger who presented with elevated serum troponin levels to 2 large tertiary care centers between January 2000 and April 2016. Patients with prior known coronary artery disease were excluded. The cause of troponin elevation was adjudicated via review of electronic medical records. All-cause death was determined using the Social Security Administration's death master file. RESULTS: Of the 6081 cases meeting inclusion criteria, 3574 (58.8%) patients had a myocardial infarction, while 2507 (41.2%) had another cause of troponin elevation. Over a median follow-up of 8.7 years, all-cause mortality was higher in patients with nonmyocardial infarction causes of troponin elevation compared with those with myocardial infarction (adjusted hazard ratio [HR] 1.30; 95% confidence interval [CI], 1.15-1.46; P < .001). Specifically, mortality was higher in those with central nervous system pathologies (adjusted HR 2.21; 95% CI, 1.85-2.63; P < .001), nonischemic cardiomyopathies (adjusted HR 1.66; 95% CI, 1.37-2.02; P < .001), and end-stage renal disease (adjusted HR 1.36; 95% CI, 1.07-1.73; P = .013). However, mortality was lower in patients with myocarditis compared with those with an acute myocardial infarction (adjusted HR 0.43; 95% CI:, 0.31-0.59; P < .001). CONCLUSION: There is a broad differential for troponin elevation in young patients, which differs based on demographic features. Most nonmyocardial infarction causes of troponin elevation are associated with higher all-cause mortality compared with acute myocardial infarction.

The long-term prognostic value of highly sensitive cardiac troponin I in patients with acute pulmonary embolism.

BACKGROUND: In patients with acute pulmonary embolism (PE), detectable levels of cardiac troponin I (cTnI) using a highly sensitive assay have been associated with increased in-hospital mortality. We sought to investigate the impact of detectable cTnI on long-term survival following acute PE. HYPOTHESIS: Detectable cTnI levels in patients presenting with acute PE predict increased long-term mortality following hospital discharge. METHODS: In a retrospective cohort study, we analyzed consecutive patients with confirmed acute PE and cTnI assay available from the index hospitalization. The detectable cTnI level was ≥0.012 ng/mL. Patients were classified into low and high clinical risk groups according to the Pulmonary Embolism Severity Index (PESI) at presentation. Subjects were followed for all-cause mortality subsequent to hospital discharge using chart review and Social Security Death Index. RESULTS: A cohort of 289 acute PE patients (mean age 56 years, 51% men), of whom 152 (53%) had a detectable cTnI, was followed for a mean of 3.1 ± 1.8 years after hospital discharge. A total of 71 deaths were observed; 44 (29%) and 27 (20%) in the detectable and undetectable cTnI groups, respectively (P = 0.05). Detectable cTnI was predictive of long-term survival among low-risk (P = 0.009) but not high-risk patients (P = 0.78) who had high mortality rates irrespective of cTnI status. CONCLUSIONS: In patients with acute PE, detectable cTnI is predictive of long-term mortality, particularly among patients who were identified as low risk according to PESI score.

Heart-type Fatty Acid Binding Protein in the Assessment of Acute Pulmonary Embolism.

OBJECTIVE: To explore the predictive value of heart-type fatty acid binding protein (H-FABP) in the stratification and prognosis of patients with acute pulmonary embolism (APE). METHODS: According to risk stratification, 69 patients with APE admitted into the emergency department within 24 hours after onset were divided into the following 3 groups: high-risk group, moderate-risk group and low-risk group. H-FABP- and cardiac troponin I (cTNI)-positive rates of all groups were analyzed and compared, and the correlation between major adverse events (death, endotracheal intubation and cardiopulmonary resuscitation) and the cardiac markers (heart rate, arterial partial pressure of oxygen, right ventricular dimension, pulmonary arterial pressure, etc.) during the in-hospital period were statistically analyzed. Then the prognosis (death, embolic pulmonary hypertension, right heart failure and recurrence of APE) at 6 months after onset of APE was followed-up on and compared between groups. RESULTS: The admission time of high-risk group patients was earlier than non-high-risk group (7.1 ± 2.9 versus 13.5 ± 6.7 versus 15.2 ± 10.7 hours, P = 0.001), had larger right ventricular dimension (33.1 ± 10.4 versus 26.7 ± 7.3 versus 20.5 ± 8.9mm, P = 0.002) and higher pulmonary arterial pressure (45.8 ± 14.6 versus 29.4 ± 13.9 versus 23.1 ± 12.6mmHg, P = 0.001). The major adverse events during in-hospital period, including death, endotracheal intubation and cardiopulmonary resuscitation, were more prevalent in the high-risk group than those in the other 2 risk groups. Further analysis indicated that the positive rate of H-FABP was remarkably higher than cTNI (52/69, 75.4% versus 28/69, 40.6%, P = 0.003). The H-FABP (r = 0.881, P = 0.020) was significantly correlated to the major adverse events; however, this was not so regarding cTNI (r = 0.115, P = 0.059). At 6 months after onset of APE, the follow-up data indicated that cTNI and H-FABP were both significantly correlated with the major adverse events. CONCLUSIONS: The positive rate of H-FABP was higher than cTNI during the 24 hours after the onset of APE. The H-FABP was significantly correlated to the major adverse events during hospitalization and to the primary prognosis at 6 months after onset of APE.

The role of NT-proBNP and Apelin in the assessment of right ventricular dysfunction in acute pulmonary embolism.

OBJECTIVE: To investigate the role of N-terminal pro-brain natriuretic peptide and apelin in the assessment of right ventricular dysfunction in acute pulmonary embolism. METHODS: The prospective case-control study was conducted at Ondokuz Mayis University, Samsun, Turkey, from January 2008 to June 2009, and comprised adult patients with acute pulmonary embolism. A smaller group of healthy adults served as the control. Blood N-terminal pro-brain natriuretic peptide and apelin levels were measured on admission to the Emergency Department. SPSS 15 was used for data analysis. RESULTS: There were 56 cases and 20 controls in the study. Blood N-terminal pro-brain natriuretic peptide levels were higher in cases than the controls (p<0.05). Apelin levels were not different between the groups (p>0.05). Patients with right ventricular dysfunction had significantly higher peptide levels than those without the dysfunction (p<0.05). The cut-off value of peptide for the prediction of right ventricular dysfunction was 1000 pg/ml, with a sensitivity of 92.1% and specificity of 77.8%. CONCLUSIONS: There was no significant change in plasma apelin levels in acute pulmonary embolism. The blood N-terminal pro-brain natriuretic peptide maybe a useful parameter in the assessment of right ventricular dysfunction in acute pulmonary embolism.

Assessment of heat shock proteins and endothelial dysfunction in acute pulmonary embolism.

We determined the levels of some heat shock proteins (HSP27, HSP70, and HSP90), L-arginine, asymmetric dimethylarginine (ADMA), and symmetric dimethylarginine (SDMA) levels in patients with acute pulmonary embolism. The present case-control study comprised a healthy control group (n = 57) and patients with acute pulmonary embolism (n = 84). HSPs, L-arginine, ADMA, and SDMA levels were measured in all of the cases. The mean age of the control group was 56.72 ±â€Š8.44 years, and the mean age of the patients with acute pulmonary embolism was 60.20 ±â€Š16.56 years (P = 0.104). Compared with controls, patients with acute pulmonary embolism had significantly higher mean serum HSP27, HSP90, and ADMA levels, whereas the mean serum L-arginine and SDMA levels were lower (P < 0.001, for all parameters). In patients with acute pulmonary embolism serum HSP27, HSP70, and ADMA levels were negatively correlated with partial pressures of arterial oxygen levels (r = -0.281, P = 0.01; r = -0.263, P = 0.016; and r = -0.275, P = 0.011, respectively) and arterial oxygen saturation (r = -0.225, P = 0.039; r = -0.400, P < 0.001; r = -0.299, P = 0.006, respectively). The findings of the present study demonstrated that oxidative stress and endothelial damage increase in acute pulmonary embolism.

Extended-Duration Thromboprophylaxis Among Acute Medically Ill Patients: An Unmet Need.

Acute medical illnesses are associated with a prolonged elevation in inflammatory markers that predisposes patients to thrombosis beyond the duration of their hospital stay. In parallel, both observational and randomized data have demonstrated a rate of postdischarge venous thromboembolic events that often exceeds that observed in the hospital setting. Despite this significant residual risk of venous thromboembolic events following discharge among acute medically ill patients, no therapeutic strategies have been recommended to address this unmet need. Available randomized trials have demonstrated the efficacy of extending the duration of thromboprophylaxis with available anticoagulants; however, the efficacy is offset, at least in part, by an increase in bleeding events. Identification of the optimal therapeutic strategies, treatment duration, and risk assessment tools that reconcile both efficacy and safety of extended-duration thromboprophylaxis among acute medically ill patients is an area of ongoing investigation.

Gender-related differences in clinical presentation, electrocardiography signs, laboratory markers and outcome in patients with acute pulmonary embolism.

Background/Aim: Acute pulmonary embolism (PE) is a potentially life threating event, but there are scarce data about genderrelated differences in this condition. The aim of this study was to identify gender-specific differences in clinical presentation, the diagnosis and outcome between male and female patients with PE. Methods: We analysed the data of 144 consecutive patients with PE (50% women) and compared female and male patients regarding clinical presentation, electrocardiography (ECG) signs, basic laboratory markers and six-month outcome. All the patients confirmed PE by visualized thrombus on the multidetector computed tomography with pulmonary angiography (MDCTPA), ECG and echocardiographic examination at admission. Results: Compared to the men, the women were older and a larger proportion of them was in the third tertile of age (66.0% vs 34.0%, p = 0.008). In univariate analysis the men more often had hemoptysis [OR (95% CI) 3.75 (1.16-12.11)], chest pain [OR (95% CI) 3.31 (1.57-7.00)] febrile state [OR (95% CI) 2.41 (1.12-5.22)] and pneumonia at PE presentation [OR (95% CI) 3.40 (1.25-9.22)] and less likely had heart decompensation early in the course of the disease [OR (95%CI) 0.48 (0.24-0.97)]. In the multivariate analysis a significant difference in the rate of pneumonia and acute heart failure between genders disappeared due to strong influence of age. There was no significant difference in the occurrence of typical ECG signs for PE between the genders. Women had higher level of admission glycaemia [7.7 mmol/L (5.5-8.2 mmol/L) vs 6.9 mmol/L (6.3-9.6 mmol/L), p = 0.006] and total number of leukocytes [10.5 x 109/L (8.8-12.7 x 109/L vs 8.7 x 109/L (7.0-11.6 x 109/L)), p = 0.007]. There was a trend toward higher plasma level of brain natriuretic peptide in women compared to men 127.1 pg/mL (55.0-484.0 pg/mL), p = 0.092] vs [90.3 pg/mL (39.2-308.5 pg/mL). The main 6-month outcomes, death and major bleeding, had similar frequencies in both sexes. Conclusion: There are several important differences between men and women in the clinical presentation of PE and basic laboratory findings which can influence the diagnosis and treatment of PE.

Assessment of the safety and efficiency of using an age-adjusted D-dimer threshold to exclude suspected pulmonary embolism.

BACKGROUND: D-dimer levels increase with age, and research has suggested that using an age-adjusted D-dimer threshold may improve diagnostic efficiency without compromising safety. The objective of this study was to assess the safety of using an age-adjusted D-dimer threshold in the workup of patients with suspected pulmonary embolism (PE). METHODS: We report the outcomes of 923 patients aged > 50 years presenting to our ED with suspected PE, a calculated Revised Geneva Score (RGS), and a D-dimer test. All patients underwent CT pulmonary angiography (CTPA). We compared the false-negative rate for PE of a conventional D-dimer threshold with an age-adjusted D-dimer threshold and report the proportion of patients for whom an age-adjusted D-dimer threshold would obviate the need for CTPA. RESULTS: Among 104 patients with a negative conventional D-dimer test result and an RGS ≤ 10, no PE was observed within 90 days (false-negative rate, 0%; 95% CI, 0%-2.8%). Among 273 patients with a negative age-adjusted D-dimer result and an RGS ≤ 10, four PEs were observed within 90 days (false-negative rate, 1.5%; 95% CI, 0.4%-3.7%). We observed an 18.3% (95% CI, 15.9%-21.0%) absolute reduction in the proportion of patients aged > 50 years who would merit CTPA by using an age-adjusted D-dimer threshold compared with a conventional D-dimer threshold. CONCLUSIONS: Use of an age-adjusted D-dimer threshold reduces imaging among patients aged > 50 years with an RGS ≤ 10. Although the adoption of an age-adjusted D-dimer threshold is probably safe, the CIs surrounding the additional 1.5% of PEs missed necessitate prospective study before this practice can be adopted into routine clinical care.

Bemiparin, an effective and safe low molecular weight heparin: a review.

Bemiparin is a low molecular weight heparin (LMWH) indicated for the acute treatment of deep vein thrombosis with or without pulmonary embolism, for the prophylaxis of venous thromboembolism in surgical and non-surgical patients and for the prevention of clotting in the extracorporeal circuit during hemodialysis. Due to its excellent pharmacological profile-the second-generation LMWH with the lowest molecular weight, the longest half-life and the highest anti-Factor Xa/anti-Factor IIa activity ratio-it can be safely used in special categories of patients (children, elderly, patients with renal impairment and congestive heart failure). Several studies demonstrated its safety and efficacy, while cost analyses show the economic benefits of bemiparin treatment as compared to other heparins. Recent evidences suggested the application of bemiparin even in the management of diabetic foot ulcers. The aim of this narrative review was to evaluate literature according to results coming from studies involving bemiparin administration in various clinical conditions.