ABSTRACT
BACKGROUND: In hemodynamically stable patients with acute pulmonary embolism (PE), the Composite Pulmonary Embolism Shock (CPES) score predicts normotensive shock. However, it is unknown if CPES predicts adverse clinical outcomes. The objective of this study was to determine whether the CPES score predicts in-hospital mortality, resuscitated cardiac arrest, or hemodynamic deterioration. METHODS: Patients with acute intermediate-risk PE admitted from October 2016 to July 2019 were included. CPES was calculated for each patient. The primary outcome was a composite of in-hospital mortality, resuscitated cardiac arrest, or hemodynamic decompensation. Secondary outcomes included individual components of the primary outcome. The association of CPES with primary and secondary outcomes was evaluated. RESULTS: Among the 207 patients with intermediate-risk PE (64.7% with intermediate-high risk PE), 29 (14%) patients had a primary outcome event. In a multivariable model, a higher CPES score was associated with a worse primary composite outcome (adjusted hazard ratio [aHR], 1.81 [95% CI, 1.29-2.54]; P=0.001). Moreover, a higher CPES score predicted death (aHR, 1.76 [95% CI, 1.04-2.96]; P=0.033), resuscitated cardiac arrest (aHR, 1.99 [95% CI, 1.17-3.38]; P=0.011), and hemodynamic decompensation (aHR, 1.96 [95% CI, 1.34-2.89]; P=0.001). A high CPES score (≥3) was associated with the worse primary outcome when compared with patients with a low CPES score (22% versus 2.4%; P=0.003; aHR, 6.48 [95% CI, 1.49-28.04]; P=0.012). CPES score provided incremental prognostic value for the prediction of primary outcome over baseline demographics and European Society of Cardiology intermediate-risk subcategories (global Χ2 value increased from 0.63 to 1.39 to 13.69; P=0.005). CONCLUSIONS: In patients with acute intermediate-risk PE, the CPES score effectively risk stratifies and prognosticates patients for the prediction of clinical events and provides incremental value over baseline demographics and European Society of Cardiology intermediate-risk subcategories.
Subject(s)
Heart Arrest , Hemodynamics , Hospital Mortality , Predictive Value of Tests , Pulmonary Embolism , Shock , Humans , Pulmonary Embolism/mortality , Pulmonary Embolism/diagnosis , Pulmonary Embolism/physiopathology , Male , Female , Aged , Risk Assessment , Middle Aged , Risk Factors , Heart Arrest/mortality , Heart Arrest/diagnosis , Heart Arrest/physiopathology , Heart Arrest/therapy , Prognosis , Retrospective Studies , Shock/mortality , Shock/diagnosis , Shock/physiopathology , Time Factors , Aged, 80 and over , Decision Support TechniquesABSTRACT
BACKGROUND: Patients with intermediate-risk pulmonary embolism (PE) and normotensive shock may have worse outcomes. However, diagnosis of normotensive shock requires invasive hemodynamics. Our objective was to assess the predictive value of McConnell's sign in identifying normotensive shock in patients with intermediate-risk PE. METHODS: Patients with intermediate-risk PE who underwent percutaneous mechanical thrombectomy between August 2020 and April 2023 at a large academic public hospital were included in the study. Normotensive shock was defined as systolic blood pressureâ¯≥â¯90â¯mmHg without vasopressor support with pre-procedural invasive measures of cardiac index ≤2.2â¯L/min/m2 and clinical evidence of hypoperfusion (i.e. elevated lactate, oliguria). The primary outcome was the association between McConnell's sign and normotensive shock. RESULTS: Those with McConnell's sign (29/40, 72.5â¯%) had higher heart rate (114 vs 99 beats/min, pâ¯=â¯0.008), higher rates of elevated lactate (86â¯% vs 55â¯%, pâ¯=â¯0.038), lower cardiac index (1.9 vs 3.1â¯L/min/m2, pâ¯=â¯0.003), and higher rates of normotensive shock (76â¯% vs 27â¯%, pâ¯=â¯0.005). McConnell's sign had a sensitivity of 88â¯% and specificity of 53â¯% for identifying intermediate-risk PE patients with normotensive shock. Patients with McConnell's sign had an increased odds (odds ratio 8.38, confidence interval: 1.73-40.53, pâ¯=â¯0.008; area under the curve 0.70, 95â¯% confidence interval: 0.56-0.85) of normotensive shock. CONCLUSION: This is the first study to suggest that McConnell's sign may identify those in the intermediate-risk group who are at risk for normotensive shock. Larger cohorts are needed to validate our findings.
ABSTRACT
BACKGROUND: Clot-in-transit is associated with high mortality, but optimal management strategies remain uncertain. The aim of this study was to compare the outcomes of different treatment strategies in patients with clot-in-transit. METHODS: This is a retrospective study of patients with documented clot-in-transit in the right heart on echocardiography across 2 institutions between January 2020 and October 2023. The primary outcome was a composite of in-hospital mortality, resuscitated cardiac arrest, or hemodynamic decompensation. RESULTS: Among 35 patients included in the study, 10 patients (28.6%) received anticoagulation alone and 2 patients (5.7%) received systemic thrombolysis, while 23 patients (65.7%) underwent catheter-based therapy (CBT; 22 mechanical thrombectomy and 1 catheter-directed thrombolysis). Over a median follow-up of 30 days, 9 patients (25.7%) experienced the primary composite outcome. Compared with anticoagulation alone, patients who received CBT or systemic thrombolysis had significantly lower rates of the primary composite outcome (12% versus 60%; log-rank P<0.001; hazard ratio, 0.13 [95% CI, 0.03-0.54]; P=0.005) including a lower rate of death (8% versus 50%; hazard ratio, 0.10 [95% CI, 0.02-0.55]; P=0.008), resuscitated cardiac arrest (4% versus 30%; hazard ratio, 0.12 [95% CI, 0.01-1.15]; P=0.067), or hemodynamic deterioration (4% versus 30%; hazard ratio, 0.12 [95% CI, 0.01-1.15]; P=0.067). CONCLUSIONS: In this study of CBT in patients with clot-in-transit, CBT or systemic thrombolysis was associated with a significantly lower rate of adverse clinical outcomes, including a lower rate of death compared with anticoagulation alone driven by the CBT group. CBT has the potential to improve outcomes. Further large-scale studies are needed to test these associations.
Subject(s)
Anticoagulants , Fibrinolytic Agents , Hospital Mortality , Thrombectomy , Thrombolytic Therapy , Humans , Male , Female , Retrospective Studies , Aged , Thrombolytic Therapy/adverse effects , Thrombolytic Therapy/mortality , Treatment Outcome , Middle Aged , Anticoagulants/adverse effects , Anticoagulants/therapeutic use , Anticoagulants/administration & dosage , Thrombectomy/adverse effects , Thrombectomy/mortality , Time Factors , Fibrinolytic Agents/administration & dosage , Fibrinolytic Agents/adverse effects , Risk Factors , Aged, 80 and over , Thrombosis/mortality , Thrombosis/diagnostic imaging , Thrombosis/etiology , Heart Arrest/therapy , Heart Arrest/mortality , Heart Arrest/physiopathology , Heart Arrest/diagnosis , Risk Assessment , HemodynamicsABSTRACT
Data comparing catheter-based thrombectomy (CBT) and catheter-directed thrombolysis (CDT) in acute pulmonary embolism are lacking. To address this, we performed a meta-analysis of prospective and retrospective studies of CBT and compared it to performance goal rates of mortality and major bleeding from a recently published network meta-analysis. When compared with performance goal for CDT based on historical studies, CBT was noninferior for all-cause mortality (6.0% vs 6.87%; P-valueNI < .001), non-inferior and superior for major bleeding (4.9% vs 11%; P-valueNI < .001 and P < .001 for superiority).
Subject(s)
Pulmonary Embolism , Thrombectomy , Thrombolytic Therapy , Humans , Pulmonary Embolism/therapy , Thrombectomy/methods , Thrombolytic Therapy/methods , Acute Disease , Treatment Outcome , Fibrinolytic Agents/administration & dosage , Fibrinolytic Agents/therapeutic useABSTRACT
OBJECTIVES: Clot-in-transit (CIT) in patients with pulmonary embolism (PE) has been associated with a high mortality rate and poor prognosis. The aim of this study was to evaluate the pooled efficacy of each of the 4 interventions (anticoagulation [AC] alone, systemic thrombolytic [ST] therapy, surgical thrombectomy, and catheter-based thrombectomy [CBT]) using mortality as the primary outcome. METHODS: A time limited search until March 28, 2024 was conducted using PubMed (National Institutes of Health) and EMBASE (Elsevier) databases. RESULTS: Thirteen studies (6 retrospective, 4 non-randomized prospective, and 3 pooled studies of case-reports) were included in the calculation of weighted proportion of mortality, including a total of 492 patients with CIT and PE with a mean age of 60.6 years; 50.1% were males. ST was the most frequently used treatment intervention (38.2%), followed by surgical thrombectomy (33.8%), AC alone (22.6%), and CBT (5.9%). The unweighted mortality was highest with AC alone 32.4% (36/111), followed by surgical thrombectomy 23.2% (38/164), CBT 20.7% (6/29), and ST 13.8% (26/188). The weighted mortality for AC alone was 35% (95% CI, 21% to 49%; 12 studies), surgical thrombectomy was 31% (95% CI, 16% to 47%; 12 studies), CBT was 20% (95% CI, 6% to 34%; 3 studies), and ST was 12% (95% CI, 5% to 19%; 12 studies). CONCLUSIONS: In this meta-analysis of patients with CIT and PE, the highest mortality was observed with AC alone, followed by surgical thrombectomy, CBT, and ST therapy. However, there remains a need for randomized clinical trial data to determine the best treatment.
ABSTRACT
In this study, we found that a low LVOT VTI (<15 cm), a simple bedside point-of-care measurement, predicts normotensive shock in patients with acute intermediate-risk PE.
Subject(s)
Pulmonary Embolism , Humans , Pulmonary Embolism/physiopathology , Pulmonary Embolism/complications , Pulmonary Embolism/diagnosis , Pulmonary Embolism/diagnostic imaging , Male , Female , Acute Disease , Shock/physiopathology , Shock/etiology , Shock/diagnosis , Middle Aged , Aged , Blood Pressure/physiology , Prognosis , Predictive Value of TestsABSTRACT
PURPOSE OF REVIEW: Targeting traditional cardiovascular risk factors is effective in reducing recurrent cardiovascular events, yet the presence of residual cardiovascular risk due to underlying systemic inflammation is a largely unaddressed opportunity. This review aims to comprehensively assess the evolving role of colchicine as a therapeutic approach targeting residual inflammatory risk in the context of those with coronary artery disease (CAD). RECENT FINDINGS: Inflammation plays a significant role in promoting atherosclerosis, and targeting anti-inflammatory pathways has the potential to decrease cardiovascular events. Low-dose colchicine (0.5 mg/day orally), when added to guideline-directed medical care for CAD, safely decreases major adverse cardiovascular events (MACE) by 31% in stable atherosclerosis patients and 23% in those after recent myocardial infarctions. Meta-analyses of recent randomized control trials further support both the efficacy and safety of colchicine, particularly when added to other standard cardiovascular therapies, including statin therapy. The European Society of Cardiology and other national guidelines endorse the use of low-dose colchicine in patients across the spectrum of CAD. Recently, colchicine was FDA-approved in the United States as the first anti-inflammatory therapy for the reduction of cardiovascular events. In a period of a rising incidence of CAD across the globe, colchicine represents a unique opportunity to decrease MACE due to its large magnitude of benefits and general affordability. However, challenges with drug interactions must be addressed, especially in those regions where HIV, hepatitis, and tuberculosis are prevalent. Colchicine is safe and effective at reducing cardiovascular events across a broad spectrum of coronary syndromes. The ability to simultaneously target traditional risk factors and mitigate residual inflammatory risk marks a substantial advancement in cardiovascular prevention strategies, heralding a new era in the global battle against CAD.
Subject(s)
Cardiovascular Diseases , Colchicine , Colchicine/therapeutic use , Humans , Cardiovascular Diseases/prevention & control , Coronary Artery Disease/prevention & control , Coronary Artery Disease/drug therapy , Anti-Inflammatory Agents/therapeutic use , Inflammation/drug therapy , Inflammation/prevention & control , Heart Disease Risk Factors , Randomized Controlled Trials as Topic , Global Health , Risk FactorsABSTRACT
BACKGROUND: Our study aims to present clinical outcomes of mechanical thrombectomy (MT) in a safety-net hospital. METHODS: This is a retrospective study of intermediate or high-risk pulmonary embolism (PE) patients who underwent MT between October 2020 and May 2023. The primary outcome was 30-day mortality. RESULTS: Among 61 patients (mean age 57.6 years, 47% women, 57% Black) analyzed, 12 (19.7%) were classified as high-risk PE, and 49 (80.3%) were intermediate-risk PE. Of these patients, 62.3% had Medicaid or were uninsured, 50.8% lived in a high poverty zip code. The prevalence of normotensive shock in intermediate-risk PE patients was 62%. Immediate hemodynamic improvements included 7.4 mmHg mean drop in mean pulmonary artery pressure (-21.7%, p < 0.001) and 93% had normalization of their cardiac index postprocedure. Thirty-day mortality for the entire cohort was 5% (3 patients) and 0% when restricted to the intermediate-risk group. All 3 patients who died at 30 days presented with cardiac arrest. There were no differences in short-term mortality based on race, insurance type, citizenship status, or socioeconomic status. All-cause mortality at most recent follow up was 13.1% (mean follow up time of 13.4 ± 8.5 months). CONCLUSION: We extend the findings from prior studies that MT demonstrates a favorable safety profile with immediate improvement in hemodynamics and a low 30-day mortality in patients with acute PE, holding true even with relatively higher risk and more vulnerable population within a safety-net hospital.
Subject(s)
Pulmonary Embolism , Safety-net Providers , Thrombectomy , Humans , Female , Male , Pulmonary Embolism/mortality , Pulmonary Embolism/physiopathology , Pulmonary Embolism/therapy , Pulmonary Embolism/diagnosis , Retrospective Studies , Middle Aged , Treatment Outcome , Risk Factors , Aged , Time Factors , Risk Assessment , Thrombectomy/adverse effects , Thrombectomy/mortality , Acute Disease , Adult , HemodynamicsABSTRACT
AIMS: Among patients with acute pulmonary embolism (PE) undergoing mechanical thrombectomy, the cardiac index (CI) is frequently reduced even among those without a clinically apparent shock. The purpose of this study is to describe the mixed venous-to-arterial carbon dioxide gradient (CO2 gap), a surrogate of perfusion adequacy, among patients with acute PE undergoing mechanical thrombectomy. METHODS AND RESULTS: This was a single-centre retrospective study of consecutive patients with PE undergoing mechanical thrombectomy and simultaneous pulmonary artery catheterization over a 3-year period. Of 107 patients, 97 had simultaneous mixed venous and arterial blood gas measurements available. The CO2 gap was elevated (>6â mmHg) in 51% of the cohort and in 49% of patients with intermediate-risk PE. A reduced CI (≤2.2â L/min/m2) was associated with an increased odds [odds ratio = 7.9; 95% confidence interval (CI) 3.49-18.1, P < 0.001] for an elevated CO2 gap. There was an inverse relationship between the CI and the CO2 gap. For every 1â L/min/m2 decrease in the CI, the CO2 gap increased by 1.3â mmHg (P = 0.001). Among patients with an elevated baseline CO2 gap >6â mmHg, thrombectomy improved the CO2 gap, CI, and mixed venous oxygen saturation. When the CO2 gap was dichotomized above and below 6, there was no difference in the in-hospital mortality rate (9 vs. 0%; P = 0.10; hazard ratio: 1.24; 95% CI 0.97-1.60; P = 0.085). CONCLUSION: Among patients with acute PE undergoing mechanical thrombectomy, the CO2 gap is abnormal in nearly 50% of patients and inversely related to the CI. Further studies should examine the relationship between markers of perfusion and outcomes in this population to refine risk stratification.
Subject(s)
Carbon Dioxide , Pulmonary Embolism , Thrombectomy , Humans , Male , Female , Pulmonary Embolism/blood , Pulmonary Embolism/diagnosis , Retrospective Studies , Carbon Dioxide/blood , Acute Disease , Middle Aged , Aged , Thrombectomy/methods , Blood Gas Analysis/methods , Pulmonary Artery , Cardiac Output/physiologyABSTRACT
PURPOSE OF REVIEW: Although rare, the development of mechanical complications following an acute myocardial infarction is associated with a high morbidity and mortality. Here, we review the clinical features, diagnostic strategy, and treatment options for each of the mechanical complications, with a focus on the role of echocardiography. RECENT FINDINGS: The growth of percutaneous structural interventions worldwide has given rise to new non-surgical options for management of mechanical complications. As such, select patients may benefit from a novel use of these established treatment methods. A thorough understanding of the two-dimensional, three-dimensional, color Doppler, and spectral Doppler findings for each mechanical complication is essential in recognizing major causes of hemodynamic decompensation after an acute myocardial infarction. Thereafter, echocardiography can aid in the selection and maintenance of mechanical circulatory support and potentially facilitate the use of a percutaneous intervention.
Subject(s)
Myocardial Infarction , Humans , Myocardial Infarction/diagnostic imaging , Myocardial Infarction/complications , Myocardial Infarction/therapy , Percutaneous Coronary Intervention , Heart-Assist Devices/adverse effects , Echocardiography/methods , Echocardiography, Doppler, ColorSubject(s)
Pulmonary Embolism , Shock , Humans , Treatment Outcome , Pulmonary Embolism/diagnostic imaging , ThrombectomyABSTRACT
The primary objective of our study was to determine the proportion of intermediate-risk PE patients undergoing mechanical thrombectomy (MT) who achieved therapeutic anticoagulation (AC) at the time of the procedure. The salient findings of our study showed that only a minority of patients (14.3%) were in the therapeutic range by ACT at the time of MT (primary outcome). Furthermore, in this higher-risk PE cohort selected for MT, 18.2% of patients were subtherapeutic after initially reaching therapeutic AC, 43% experienced supratherapeutic AC at some point before MT, and less than half (43%) attained therapeutic AC at 6 hours, highlighting the necessity for optimizing anticoagulation practices in acute PE.
Subject(s)
Pulmonary Embolism , Thrombectomy , Humans , Thrombectomy/adverse effects , Pulmonary Embolism/drug therapy , Thrombolytic Therapy/methods , Acute Disease , Retrospective Studies , Anticoagulants/therapeutic use , Treatment OutcomeABSTRACT
BACKGROUND: The optimal treatment strategy of patients with pulmonary embolism (PE) (especially those with intermediate risk) continues to evolve and remains controversial. OBJECTIVES: This study sought to compare the efficacy and safety of anticoagulation (AC) alone, catheter-directed thrombolysis (CDT), and systemic thrombolysis (ST) in patients with acute PE. METHODS: PubMed and EMBASE were searched for randomized controlled trials or observational studies which compared outcomes of AC alone, CDT, and ST in acute PE. Efficacy outcome was all-cause mortality. Safety outcomes were major bleeding and intracranial hemorrhage (ICH). RESULTS: We identified 45 studies (17 randomized controlled trials, 2 prospective nonrandomized trials, and 26 retrospective observational trials), which included 81,705 patients. When compared with AC alone, CDT had lower mortality (OR: 0.55; 95% CI: 0.39-0.80) but higher major bleeding (OR: 1.84; 95% CI: 1.10-3.08) and numerically higher ICH (OR: 1.51; 95% CI: 0.75-3.04). ST was associated with no difference in mortality but higher major bleeding (OR: 2.16; 95% CI: 1.38-3.38) and ICH (OR: 2.26; 95% CI: 1.14-4.48) when compared with AC alone. The risk of mortality (OR: 2.05; 95% CI: 1.46-2.89) and ICH (OR: 1.50; 95% CI: 1.13-1.99) was higher with ST when compared with CDT. Findings were similar when analysis was restricted to trials of intermediate risk PE. CONCLUSIONS: In patients with acute PE, when compared with AC alone, CDT was associated with a lower mortality but higher risk of bleeding. Moreover, CDT had an enhanced safety profile when compared with ST.
Subject(s)
Pulmonary Embolism , Thrombolytic Therapy , Humans , Anticoagulants/adverse effects , Catheters , Fibrinolytic Agents/adverse effects , Hemorrhage/chemically induced , Intracranial Hemorrhages/chemically induced , Prospective Studies , Pulmonary Embolism/diagnostic imaging , Pulmonary Embolism/drug therapy , Retrospective Studies , Thrombolytic Therapy/adverse effects , Thrombolytic Therapy/methods , Treatment Outcome , Randomized Controlled Trials as Topic , Observational Studies as TopicABSTRACT
Discrepancy between computed tomography (CT) and transthoracic echocardiography (TTE) regarding pericardial effusion (PEff) size is common, but there is limited data regarding the correlation between these 2 imaging methods. The aim of this study is to examine the real-world concordance of observed PEff size between CT and TTE. We performed a retrospective analysis of all imaging reports available from 2013 to 2019 and identified patients with a PEff who underwent both a chest CT and TTE within a 24-hour period. We evaluated the agreement between CT and TTE in assessing PEff size. Of 1,118 patients included in the study, mean age was 66 (±17 years) and 54% were female. The median time interval between the 2 studies was 9.4 hours (interquartile range 3.5 to 16.6). Patients within a half-grade or full-grade of agreement were 71.9% and 97.2%, respectively. The mean difference in grade of agreement (TTE minus CT) between the 2 imaging methods was -0.1 (±0.6, p <0.0001). CT was more likely to report a higher grade (i.e. larger PEff size) when compared with TTE (261 patients vs 157 patients, p <0.001). The weighted kappa was 0.73 (95% confidence interval 0.69 to 0.76). After excluding patients with trace/no effusion, 42.3% and 94.1% of patients' studies were within a half-grade or full-grade of agreement, respectively. Of the 18 patients who had large discrepancies, 9 patients had loculated effusions, 2 patients had large pleural effusions, and 6 patients had suboptimal TTEs images. In conclusion, TTE and CT showed relatively strong agreement in estimation of PEff size, with CT sizes larger than TTE, on average. Large discrepancies in size may be related to reduced image quality, large pleural effusions, and loculated PEff.
Subject(s)
Pericardial Effusion , Pleural Effusion , Humans , Female , Aged , Male , Pericardial Effusion/diagnostic imaging , Retrospective Studies , Echocardiography/methods , Tomography, X-Ray Computed/methods , Pleural Effusion/diagnostic imagingABSTRACT
BACKGROUND: In patients with tricuspid valve infective endocarditis, percutaneous debulking is a treatment option. However, the outcomes of this approach are less well known. METHODS: We performed a retrospective analysis of all patients who underwent percutaneous vegetation debulking for tricuspid valve infective endocarditis from August 2020 to November 2022 at a large academic tertiary care public hospital. The primary efficacy outcome was procedural success defined by clearance of blood cultures. The primary safety outcome was any procedural complication. For the composite outcome of in-hospital mortality or heart block, outcomes were compared (sequential noninferiority and superiority) with published surgical outcomes data. RESULTS: Of the 29 patients with tricuspid valve infective endocarditis who underwent percutaneous debulking, the average age was 41.3±10.1 years, all patients had septic pulmonary emboli with 27 (93.1%) patients having cavitary lung lesions before the procedure. For the efficacy outcomes, 28 patients (96.6%) had clearance of cultures after their procedure, mean white blood cell count significantly decreased from 16.8±1.4×103 to 12.6±1.0×103 per µL (P<0.01), and mean body temperature significantly decreased from 99.8F ±0.30 to 98.3F ±0.20 (P<0.001) post-procedure. For safety outcomes, there were no procedural complications (0%). Two patients (6.9%) died during the follow-up period, both during the index hospitalization due to severe necrotizing pneumonia. When compared with published data on surgical outcomes, percutaneous debulking was noninferior and superior for the composite of in-hospital death or heart block (noninferiority, P<0.001; superiority, P=0.016). CONCLUSIONS: Percutaneous debulking is feasible, effective, and safe in treating patients with tricuspid valve infective endocarditis refractory to medical therapy.