Intensive care treatment in acute pulmonary embolism in Germany, 2016 to 2020: a nationwide inpatient database study.

Background: Pulmonary embolism (PE) is a potentially life-threatening condition. Admission and treatment in the intensive care unit (ICU) is an important element in critically ill PE patients. Objectives: We aimed to identify risk factors for ICU admission and differences in patient profiles regarding risk factors and comorbidities between PE patients who had to be admitted to an ICU and those who were treated in a normal ward without ICU. Methods: We used the German nationwide inpatient sample to analyze all hospitalizations of PE patients in Germany from 2016 to 2020 stratified for ICU admission. Results: Overall, 484,859 hospitalized PE patients were treated in German hospitals from 2016 to 2020. Among these, 92,313 (19.0%) were admitted to ICU. Patients treated in ICU were younger (69.0 [IQR, 58.0-78.0] vs 72.0 [IQR, 60.0-80.0] years; P < .001) and had higher prevalence of cardiovascular risk factors and comorbidities. In-hospital case fatality rate was elevated in PE patients treated in ICU (22.7% vs 10.7%; P < .001), and ICU admission was independently associated with increased in-hospital case fatality (odds ratio [OR], 2.54; 95% CI, 2.49-2.59; P < .001). Independent risk factors for ICU admission comprised PE with imminent or present decompensation (OR, 3.30; 95% CI, 3.25-3.35; P < .001), hemodynamic instability (OR, 4.49; 95% CI, 4.39-4.59; P < .001), arterial hypertension (OR, 1.20; 95% CI, 1.18-1.22; P < .001), diabetes mellitus (OR, 1.16; 95% CI, 1.14-1.18; P < .001), obesity (OR, 1.300; 95% CI, 1.27-1.33; P < .001), surgery (OR, 2.55; 95% CI, 2.50-2.59; P < .001), stroke (OR, 2.86; 95% CI, 2.76-2.96; P < .001), pregnancy (OR, 1.45; 95% CI, 1.21-1.74; P < .001), heart failure (OR, 1.74; 95% CI, 1.71-1.77; P < .001), atrial fibrillation/flutter (OR, 1.69; 95% CI, 1.66-1.73; P < .001), chronic obstructive pulmonary disease (OR, 1.21; 95% CI, 1.18-1.24; P < .001), and renal failure (OR, 1.92; 95% CI, 1.88-1.95; P < .001). Conclusion: ICU treatment is an important element in the treatment of PE patients. Besides hemodynamic compromise, cardiovascular risk factors, stroke, pregnancy, and cardiopulmonary as well as renal comorbidities were independent predictors of ICU admission. Necessity of ICU admission was afflicted by increased case fatality.

Evolving patterns of intracranial hemorrhage in advanced therapies in patients with acute pulmonary embolism.

BACKGROUND: Dissecting trends and contributing risk factors for intracranial hemorrhage (ICH) in patients treated for acute pulmonary embolism (PE) may allow for a better patient selection for existing and emerging treatment options. METHODS: The German nationwide inpatient sample was screened for patients admitted due to PE 2005-2020. Hospitalizations were stratified for the occurrence of ICH; risk factors for ICH and temporal trends were investigated. RESULTS: Overall, 816,653 hospitalizations due to acute PE in the period 2005-2020 were analyzed in the study. ICH was reported in 2516 (0.3 %) hospitalizations, and time trend analysis revealed a fluctuating but overall, largely unchanged annual incidence. There was an increase of ICH with age. Patients with ICH had a higher comorbidity burden (Charlson-Comorbidity-Index [CCI], 5.0 [4.0-7.0] vs. 4.0 [2.0-5.0]; P < 0.001), and higher CCI was associated with an OR of 1.26 (95%CI 1.24-1.27) for ICH. Further independent risk factors for ICH were age ≥ 70 years (OR 1.23 [1.12-1.34]), severe (versus low-risk) PE (OR 3.09 [2.84-3.35]), surgery (OR 1.59 [1.47-1.72]), acute kidney injury (OR 3.60 [3.09-4.18]), and ischemic stroke (OR 14.64 [12.61-17.00]). The identified risk factors for ICH varied among different reperfusion treatment groups. As expected, ICH had a substantial impact on case-fatality of PE (OR 6.16 [5.64-6.72]; P < 0.001). CONCLUSIONS: Incidence of ICH in patients hospitalized for acute PE in Germany was overall low and depended on the patients' comorbidity burden. Identifying patients at risk for ICH allows tailored patient selection for the different reperfusion treatments and might prevent ICH.

[Pulmonary embolism: outpatient treatment and follow-up]. / Lungenembolie: ambulante Therapie und Nachsorge.

Despite declining numbers - older people in particular - often die from pulmonary embolism. A rapid assessment of the risk in the event of a suspected embolism, the exclusion of comorbidities and the appropriate therapy are the focus of the current guidelines. Early and subsequent outpatient treatment of a patient with acute PE generally requires 3 criteria: low risk of early complications, the absence of serious comorbidities and the highest possible safety at home and, in the event of a complication, rapid access to acute care in the hospital. For patients with a high risk of VTE recurrence, the long-term dosage of secondary drug prophylaxis is not yet clear - studies are currently underway. In patients at moderate risk of VTE recurrence, low-dose secondary prophylaxis can be used to reduce the risk of bleeding. Outpatient pulmonary embolism follow-up care is becoming increasingly important, because studies have shown several times that serious long-term consequences can occur. In pulmonary embolism patients with persistent dyspnea, reduced performance or risk of CTEPH, an outpatient evaluation of the right ventricle using echocardiography, if necessary, in combination with the determination of natriuretic peptides or spiroergometry, is recommended.

Atrial Adaptations in Athletes Heart.

BACKGROUND: Intensive training efforts are associated with hemodynamic changes accompanied by increases in cardiac output and stroke volume related to higher peak oxygen consumption and better athletic performance during exercise. These hemodynamic changes induce an enlargement of cardiac chambers, but also of the atria and may result in an athletes' heart (AH). Data from large studies about atrial enlargement in AH are sparse. METHODS: Competitive athletes aged ≥18 years, who presented for pre-participation screening 04/2020-10/2021 were included in this study and stratified for AH (defined as physiologically increased heart volume >13.0 in males and >12.0 mL/kg in females). RESULTS: Overall, 646 athletes aged ≥18 years (median age 24.0 [20.0/31.0] years; 206 [31.9%] females) were included in our study 04/2020-10/2021; among these, 118 (18.3%) had an AH. The computed absolute heart volume was 969.4 (853.1/1083.0) mL in athletes with AH and 841.3 (707.4/966.3) mL in those without AH (p < 0.001). AH was associated with larger left ventricular mass (206.6 ± 39.0 vs. 182.7 ± 44.2 g, p < 0.001). LA area (15.4 [13.7/18.2] vs. 14.3 [12.0/16.3] cm2, p < 0.001) and RA area (15.8 [13.8/18.6] vs. 14.5 [12.3/17.0] cm2, p < 0.001) were enlarged in AH versus those athletes without AH. The logistic regressions confirmed an independent association of AH on LV mass (OR 1.05 [95% CI 1.04-1.06], p < 0.001). LA area (OR 1.29 [95% CI 1.19-1.39], p < 0.001) as well as RA area (OR 1.28 [95% CI 1.19-1.38], p < 0.001) were afflicted by AH. CONCLUSION: An AH is accompanied by significant enlargement of the atria as well as increased cardiac muscle mass.

Prevalence and significance of pulmonary hypertension among hospitalized patients with left heart disease.

BACKGROUND: Pulmonary hypertension associated with left heart disease (PH-LHD) prevalence ranges significantly across studies with limited real-world evidence. OBJECTIVES: To investigate the prevalence and prognostic influence of PH-LHD in a nationwide sample. METHODS: Using the 2018 US Nationwide Inpatient Sample we calculated the prevalence of PH across heart failure (HF), cardiomyopathies, aortic, and mitral valve disease. We used logistic regression to assess the impact of PH on LHD and to find significant contributors to in-hospital mortality in the PH-LHD population. RESULTS: Among 6,270,625 hospitalizations with LHD, 801,535 (12.8 %) had a secondary PH diagnosis. PH-LHD prevalence was 17.2 % in HF with preserved ejection fraction (HFpEF), 11.8 % in HF with reduced ejection fraction (HFrEF), 16.8 % in dilated cardiomyopathy, 12.6 % in hypertrophic cardiomyopathy, 18.7 % in mitral regurgitation, 28.5 % in mitral stenosis, 13.5 % in aortic stenosis, and 13.9 % in aortic regurgitation. PH was associated with increased in-hospital mortality in HFpEF (OR 1.23; 95%CI 1.17-1.28), hypertrophic cardiomyopathy (1.42; 1.06-1.89), mitral regurgitation (1.17; 1.07-1.28), and aortic stenosis (1.14; 1.04-1.26), but not in HFrEF (1.04; 0.99-1.10), or dilated cardiomyopathy (1.13; 0.99-1.29). Among PH-LHD, in-hospital mortality was associated with age, atrial fibrillation/flutter, cancer, and acute cardiac (acute right HF, myocardial infarction, ventricular arrhythmia), or extra-cardiac (stroke, sepsis, pneumonia, acute renal failure, venous thromboembolism) diagnoses. CONCLUSION: In a nationwide inpatient analysis the prevalence of PH-LHD was lower than previously reported indicating reduced recognition of this disease in real world clinical practice. The diagnosis of PH-LHD was associated with worse fatality rates across all forms of LHD, except for HFrEF.

Burden of disease in Germany attributed to ambient particulate matter pollution : Findings from the Global Burden of Disease Study 2019.

INTRODUCTION: Ambient fine particulate matter pollution with a diameter less than 2.5 micrometers (PM2.5) is a significant risk factor for chronic noncommunicable diseases (NCDs), leading to a substantial disease burden, decreased quality of life, and deaths globally. This study aimed to investigate the disease and mortality burdens attributed to PM2.5 in Germany in 2019. METHODS: Data from the Global Burden of Disease (GBD) Study 2019 were used to investigate disability-adjusted life-years (DALYs), years of life lost (YLLs), years lived with disability (YLDs), and deaths attributed to ambient PM2.5 pollution in Germany. RESULTS: In 2019, ambient PM2.5 pollution in Germany was associated with significant health impacts, contributing to 27,040 deaths (2.82% of total deaths), 568,784 DALYs (2.09% of total DALYs), 135,725 YLDs (1.09% of total YLDs), and 433,058 YLLs (2.92% of total YLLs). The analysis further revealed that cardiometabolic and respiratory conditions, such as ischemic heart disease, stroke, chronic obstructive pulmonary disease, lung cancer, and diabetes mellitus, were the leading causes of mortality and disease burden associated with ambient PM2.5 pollution in Germany from 1990-2019. Comparative assessments between 1990 and 2019 underscored ambient PM2.5 as a consistent prominent risk factor, ranking closely with traditional factors like smoking, arterial hypertension, and alcohol use contributing to deaths, DALYs, YLDs, and YLLs. CONCLUSION: Ambient PM2.5 pollution is one of the major health risk factors contributing significantly to the burden of disease and mortality in Germany, emphasizing the urgent need for targeted interventions to address its substantial contribution to chronic NCDs.

Sarcopenia influences usage of reperfusion treatment in patients with pulmonary embolism aged 75 years and older.

Background: Although pulmonary embolism (PE) and sarcopenia are common diseases, only a few studies have assessed the impact of sarcopenia in PE on usage of reperfusion treatments in PE. Methods: All hospitalizations of PE patients aged ≥75 years 2005-2020 in Germany were included in this study and stratified for sarcopenia. Impact of sarcopenia on treatment procedures and adverse in-hospital events were investigated. Results: Overall, 576,364 hospitalizations of PE patients aged ≥75 years (median age 81.0 [78.0-85.0] years; 63.3 % females) were diagnosed in Germany during the observational period 2005-2020. Among these, 2357 (0.4 %) were coded with sarcopenia. PE patients with sarcopenia were in median 2 years older (83.0 [79.0-87.0] vs. 81.0 [78.0-85.0] years, P<0.001) and showed an aggravated comorbidity-profile (Charlson Comorbidity Index 7.00 [5.00-9.00] vs. 6.00 [4.00-7.00], P<0.001). Although signs of hemodynamic compromise such as shock (5.2 % vs. 4.1 %, P=0.005) and tachycardia (4.1 % vs. 2.8 %, P<0.001) were more prevalent in sarcopenic PE patients, systemic thrombolysis (1.9 % vs. 3.5 %, P<0.001) was less often used in these patients. Sarcopenia was independently related to an underuse of systemic thrombolysis (OR 0.537 [95 %CI 0.398-0.725], P<0.001). This underuse might driven by higher rates of bleeding events (gastro-intestinal bleeding: 3.1 % vs. 1.9 %, P<0.001, necessity of transfusion of blood constituents: 18.9 % vs. 11.3 %, P<0.001), but also stroke (5.6 % vs. 3.3 %, P<0.001). Conclusions: Sarcopenia represents a widely overlooked condition in PE patients. Although sarcopenic PE patients were more often afflicted by hemodynamic compromise, systemic thrombolysis was less often administered. This underuse might be caused by contraindications like bleeding events and stroke.

Comparative Analysis of Mitochondria Surrounding the Intercalated Discs in Heart Diseases-An Ultrastructural Pilot Study.

BACKGROUND: Mitochondria play a crucial role in adapting to fluctuating energy demands, particularly in various heart diseases. This study investigates mitochondrial morphology near intercalated discs in left ventricular (LV) heart tissues, comparing samples from patients with sinus rhythm (SR), atrial fibrillation (AF), dilated cardiomyopathy (DCM), and ischemic cardiomyopathy (ICM). METHODS: Transmission electron microscopy was used to analyze mitochondria within 0-3.5 µm and 3.5-7 µm of intercalated discs in 9 SR, 10 AF, 9 DCM, and 8 ICM patient samples. Parameters included mean size in µm2 and elongation, count, percental mitochondrial area in the measuring frame, and a conglomeration score. RESULTS: AF patients exhibited higher counts of small mitochondria in the LV myocardium, resembling SR. DCM and ICM groups had fewer, larger, and often hydropic mitochondria. Accumulation rates and percental mitochondrial area were similar across groups. Significant positive correlations existed between other defects/size and hydropic mitochondria and between count/area and conglomeration score, while negative correlations between count and size/other defects and between hydropic mitochondria and count could be seen as well. CONCLUSION: Mitochondrial parameters in the LV myocardium of AF patients were similar to those of SR patients, while DCM and ICM displayed distinct changes, including a decrease in number, an increase in size, and compromised mitochondrial morphology. Further research is needed to fully elucidate the pathophysiological role of mitochondrial morphology in different heart diseases, providing deeper insights into potential therapeutic targets and interventions.

Incidence and impact of venous thromboembolism in hospitalized patients with acute pancreatitis.

BACKGROUND: Acute pancreatitis (AP) and venous thromboembolism (VTE) remain common and potentially lethal disease entities. AP might be an important trigger of systemic inflammtion and may activate the coagulation system with increased VTE risk. METHODS: The German nationwide inpatient sample was screened for patients admitted due to AP (ICD-code K85) 2005-2019. AP hospitalizations were stratified for VTE as well as risk-factors and the impact of VTE on in-hospital case-fatality rate were investigated. RESULTS: Overall, 797,364 hospitalizations of patients due to AP (aged in median 56.0 [IQR 44.0-71.0] years), 39.2 % females) were detected in Germany 2005-2019. Incidence of VTE in hospitalized AP patients was 1764.8 per 100,000 hospitalizations (1.8 %) with highest VTE rate between 5th and 6th decade. Cancer (OR 1.656 [95 %CI 1.513-1.812], P < 0.001), any surgery (OR 4.063 [95 %CI 3.854-4.284], P < 0.001), and heart failure (OR 1.723 [95 %CI 1.619-1.833], P < 0.001) were independently associated with VTE occurrence. Case-fatality (8.8 % vs. 2.7 %, P < 0.001) was more than 3-fold higher in AP patients with than without VTE. VTE was associated with increased case-fatality in AP patients (OR 3.925 [95 %CI 3.684-4.181], P < 0.001). CONCLUSIONS: VTE is a life-threatening event in hospitalized AP patients associated with an almost 4-fold increased case-fatality rate. Cancer, any surgery, thrombophilia and heart failure were important risk factors for occurrence of VTE in AP.

Estimated Annual Healthcare Costs After Acute Pulmonary Embolism: Results From a Prospective Multicentre Cohort Study.

OBJECTIVE: Patients surviving acute pulmonary embolism (PE) necessitate long-term treatment and follow-up. However, the chronic economic impact of PE on European healthcare systems remains to be determined. METHODS AND RESULTS: We calculated the direct cost of illness during the first year after discharge for the index PE, analyzing data from a multicentre prospective cohort study in Germany. Main and accompanying readmission diagnoses were used to calculate DRG-based hospital reimbursements; anticoagulation costs were estimated from the exact treatment duration and each drug's unique national identifier; and outpatient post-PE care costs from guidelines-recommended algorithms and national reimbursement catalogues. Of 1017 patients enrolled at 17 centres, 958 (94%) completed ≥ 3-month follow-up; of those, 24% were rehospitalized (0.34 [95% CI 0.30-0.39] readmissions per PE survivor). Age, coronary artery, pulmonary and kidney disease, diabetes, and (in the sensitivity analysis of 837 patients with complete 12-month follow-up) cancer, but not recurrent PE, were independent cost predictors by hurdle gamma regression accounting for zero readmissions. Estimated rehospitalization cost was €1138 (95% CI 896-1420) per patient. Anticoagulation duration was 329 (IQR 142-365) days, with estimated average per-patient costs of €1050 (median 972; IQR 458-1197); costs of scheduled ambulatory follow-up visits amounted to €181. Total estimated direct per-patient costs during the first year after PE ranged from €2369 (primary analysis) to €2542 (sensitivity analysis). CONCLUSIONS: By estimating per-patient costs and identifying cost drivers of post-PE care, our study may inform decisions concerning implementation and reimbursement of follow-up programmes aiming at improved cardiovascular prevention. (Trial registration number: DRKS00005939).

Iron deficiency in athletes: Prevalence and impact on VO2 peak.

BACKGROUND: Iron is an important micronutrient in pathways of energy production, adequate nutrient intake and its balance is essential for optimal athletic performance. However, large studies elucidating the impact of iron deficiency on athletes' performance are sparse. METHODS: Competitive athletes of any age who presented for preparticipation screening 04/2020-10/2021 were included in this study and stratified for iron deficiency (defined as ferritin level <20 µg/l with and without mild anemia [hemoglobin levels ≥11 g/dl]). Athletes with and without iron deficiency were compared and the impact of iron deficiency on athletic performance was investigated. RESULTS: Overall, 1190 athletes (mean age 21.9 ± 11.6 years; 34.2% females) were included in this study. Among these, 19.7% had iron deficiency. Patients with iron deficiency were younger (18.1 ± 8.4 vs. 22.8 ± 12.1 years, P < 0.001), more often females (64.5% vs. 26.8%, P < 0.001), had lower VO2 peak value (43.4 [38.5/47.5] vs. 45.6 [39.1/50.6]ml/min/kg, P = 0.022) and lower proportion of athletes reaching VO2 peak of >50 ml/min/kg (8.5% vs. 16.1%, P = 0.003). Female sex (OR 4.35 [95% CI 3.13-5.88], P > 0.001) was independently associated with increased risk for iron deficiency. In contrast, the risk for iron deficiency decreased by every life year (OR 0.97 [95% CI 0.95-0.99], P = 0.003). Iron deficiency was independently associated with reduced VO2 peak (OR 0.94 [0.91-0.97], P < 0.001) and lower probability to reach VO2 peak >50 ml/min/kg (OR 0.42 [95% CI 0.25-0.69], P = 0.001). CONCLUSIONS: Iron deficiency is common in athletes (predominantly in female and in young athletes). Iron deficiency was independently associated with reduced VO2 peak during exercise testing and lower probability to reach a VO2 peak >50 ml/min/kg.

Association between socioeconomic and psychosocial factors with use of interventional and surgical treatments and outcomes in patients with myocardial infarction - Inpatient data of the largest European health care system.

BACKGROUND: Myocardial infarction (MI) is an important driver of both morbidity and mortality on a global scale. Elucidating social inequalities may help to identify vulnerable groups as well as treatment imbalances and guide efforts to improve care for MI. METHODS: All hospitalized patient-cases with confirmed MI 2005-2020 in Germany were included in the study and stratified for socioeconomic or psychosocial factors (SPF) and the impact of SPF on treatment usage and adverse in-hospital events was analyzed. RESULTS: Overall, 4,409,597 hospitalizations of MI patients were included; of these, 17,297 (0.4 %) were coded with SPF. These patients were more often of female sex (49.4 % vs. 36.9 %, P<0.001), older (median 77.0 [IQR: 65.0-84.0] vs. 73.0 [62.0-81.0] years, P<0.001) and revealed an aggravated cardiovascular profile. Although SPF were independently associated with increased usage of cardiac catheterization (OR 1.174 [95 %CI 1.136-1.212]) and percutaneous coronary intervention (OR 1.167 [95 %CI 1.130-1.205]), they were accompanied by higher risk for a prolonged length of in-hospital stay >7 days (OR 1.236 [95 %CI 1.198-1.276]) and >10 days (OR 1.296 [95 %CI 1.254-1.339]). While SPF were associated with increased risk for deep venous thrombosis and/or thrombophlebitis (OR 1.634 [95 %CI 1.427-1.870]), pulmonary embolism (OR 1.337 [95 %CI 1.149-1.555]), and acute renal failure (OR 1.170 [95 %CI 1.105-1.240), these SPF were inversely associated with in-hospital case-fatality (OR 0.461 [95 %CI 0.433-0.490]). CONCLUSIONS: This study demonstrates that SPF in hospitalized MI patients have significant impacts on treatments and outcomes. Fortunately, our data did not revealed an underuse of interventional treatments in MI patients with SPF.

Extracorporeal Membrane Oxygenation and Reperfusion Strategies in High-Risk Pulmonary Embolism Hospitalizations.

OBJECTIVES: To investigate the contemporary use of extracorporeal membrane oxygenation (ECMO) in conjunction with reperfusion strategies in high-risk pulmonary embolism (PE). DESIGN: Observational epidemiological analysis. SETTING: The U.S. Nationwide Inpatient Sample (NIS) (years 2016-2020). PATIENTS: High-risk PE hospitalizations. MEASUREMENTS AND MAIN RESULTS: Use of ECMO in conjunction with thrombolysis-based reperfusion (systemic thrombolysis or catheter-directed thrombolysis) or mechanical reperfusion (surgical embolectomy or catheter-based thrombectomy) with regards to in-hospital mortality and major bleeding. We identified high-risk PE hospitalizations in the NIS (years 2016-2020) and investigated the use of ECMO in conjunction with thrombolysis-based (systemic thrombolysis or catheter-directed thrombolysis) and mechanical (surgical embolectomy or catheter-based thrombectomy) reperfusion strategies with regards to in-hospital mortality and major bleeding. Among 122,735 hospitalizations for high-risk PE, ECMO was used in 2,805 (2.3%); stand-alone in 1.4%, thrombolysis-based reperfusion in 0.4%, and mechanical reperfusion in 0.5%. Compared with neither reperfusion nor ECMO, ECMO plus thrombolysis-based reperfusion was associated with reduced in-hospital mortality (adjusted odds ratio [aOR] 0.61; 95% CI, 0.38-0.98), whereas no difference was found with ECMO plus mechanical reperfusion (aOR 1.03; 95% CI, 0.67-1.60), and ECMO stand-alone was associated with increased in-hospital mortality (aOR 1.60; 95% CI, 1.22-2.10). In the cardiac arrest subgroup, ECMO was associated with reduced in-hospital mortality (aOR 0.71; 95% CI, 0.53-0.93). Among all patients on ECMO, thrombolysis-based reperfusion was significantly associated (aOR 0.55; 95% CI, 0.33-0.91), and mechanical reperfusion showed a trend (aOR 0.75; 95% CI, 0.47-1.19) toward reduced in-hospital mortality compared with no reperfusion, without increases in major bleeding. CONCLUSIONS: In patients with high-risk PE and refractory hemodynamic instability, ECMO may be a valuable supportive treatment in conjunction with reperfusion treatment but not as a stand-alone treatment especially for patients suffering from cardiac arrest.

Outcome of Pulmonary Embolism with and without Ischemic Stroke.

Background: Ischemic stroke is the second, and pulmonary embolism (PE) is the third most common cardiovascular cause of death after myocardial infarction. Data regarding risk factors for ischemic stroke in patients with acute PE are limited. Methods: Patients were selected by screening the German nationwide in-patient sample for PE (ICD-code I26) and were stratified by ischemic stroke (ICD code I63) and compared. Results: The nationwide in-patient sample comprised 346,586 hospitalized PE patients (53.3% females) in Germany from 2011 to 2014; among these, 6704 (1.9%) patients had additionally an ischemic stroke. PE patients with ischemic stroke had a higher in-hospital mortality rate than those without (28.9% vs. 14.5%, p < 0.001). Ischemic stroke was independently associated with in-hospital death (OR 2.424, 95%CI 2.278-2.579, p < 0.001). Deep venous thrombosis and/or thrombophlebitis (DVT) combined with heart septal defect (OR 24.714 [95%CI 20.693-29.517], p < 0.001) as well as atrial fibrillation/flutter (OR 2.060 [95%CI 1.943-2.183], p < 0.001) were independent risk factors for stroke in PE patients. Systemic thrombolysis was associated with a better survival in PE patients with ischemic thrombolysis who underwent cardio-pulmonary resuscitation (CPR, OR 0.55 [95%CI 0.36-0.84], p = 0.006). Conclusions: Ischemic stroke did negatively affect the survival of PE. Combination of DVT and heart septal defect and atrial fibrillation/flutter were strong and independent risk factors for ischemic stroke in PE patients. In PE patients with ischemic stroke, who had to underwent CPR, systemic thrombolysis was associated with improved survival.

Drivers and recent trends of hospitalisation costs related to acute pulmonary embolism.

BACKGROUND AND AIMS: The socio-economic burden imposed by acute pulmonary embolism (PE) on European healthcare systems is largely unknown. We sought to determine temporal trends and identify cost drivers of hospitalisation for PE in Germany. METHODS AND RESULTS: We analysed the totality of reimbursed hospitalisation costs in Germany (G-DRG system) in the years 2016-2020. Overall, 484 884 PE hospitalisations were coded in this period. Direct hospital costs amounted to a median of 3572 (IQR, 2804 to 5869) euros, resulting in average total reimbursements of 710 million euros annually. Age, PE severity, comorbidities and in-hospital (particularly bleeding) complications were identified by multivariable logistic regression as significant cost drivers. Use of catheter-directed therapy (CDT) constantly increased (annual change in the absolute proportion of hospitalisations with CDT + 0.40% [95% CI + 0.32% to + 0.47%]; P < 0.001), and it more than doubled in the group of patients with severe PE (28% of the entire population) over time. Although CDT use was overall associated with increased hospitalisation costs, this association was no longer present (adjusted OR 1.02 [0.80-1.31]) in patients with severe PE and shock; this was related, at least in part, to a reduction in the median length of hospital stay (for 14.0 to 8.0 days). CONCLUSIONS: We identified current and emerging cost drivers of hospitalisation for PE, focusing on severe disease and intermediate/high risk of an adverse early outcome. The present study may inform reimbursement decisions by policymakers and help to guide future health economic analysis of advanced treatment options for patients with PE.

Injection Site Matters: A Comparative Analysis of Transpulmonary Thermodilution via Simultaneous Femoral and Jugular Indicator Injections under Veno-Venous Extracorporeal Membrane Oxygenation Therapy.

Background: The use of veno-venous extracorporeal membrane oxygenation (vv-ECMO) in acute lung failure has witnessed a notable increase. The PiCCO system is frequently used for advanced hemodynamic monitoring in this cohort. Our study aimed to investigate whether the choice of indicator injection site (jugular vs. femoral) in patients undergoing vv-ECMO therapy affects transpulmonary thermodilution (TPTD) measurements using the PiCCO® device (Pulsion Medical Systems SE, Munich, Germany). Methods: In a retrospective single-center analysis, we compared thermodilution-derived hemodynamic parameters after simultaneous jugular and femoral injections in 28 measurements obtained in two patients with respiratory failure who were undergoing vv-ECMO therapy. Results: Elevated values of the extravascular lung water index (EVLWI), intrathoracic blood volume index (ITBVI) and global end-diastolic volume index (GEDVI) were observed following femoral indicator injection compared to jugular indicator injection (EVLWI: 29.3 ± 10.9 mL/kg vs. 18.3 ± 6.71 mL/kg, p = 0.0003; ITBVI: 2163 ± 631 mL/m2 vs. 806 ± 125 mL/m2, p < 0.0001; GEDVI: 1731 ± 505 mL/m2 vs. 687 ± 141 mL/m2, p < 0.0001). The discrepancy between femoral and jugular measurements exhibited a linear correlation with extracorporeal blood flow (ECBF). Conclusions: In a PiCCO®-derived hemodynamic assessment of patients on vv-ECMO, the femoral indicator injection, as opposed to the jugular injection, resulted in an overestimation of all index parameters. This discrepancy can be attributed to mean transit time (MTt) and downslope time-dependent (DSt) variations in GEDVI and cardiac function index and is correlated with ECBF.

Noise annoyance due to different sources is associated with tinnitus presence and distress in the general population.

BACKGROUND: The pathophysiology of tinnitus is not yet fully understood. Although there is a large amount of evidence associating traffic noise exposure with non-auditory health outcomes, there is no evidence regarding the impact of noise annoyance on auditory disorders such as tinnitus. OBJECTIVE: Thus, we aimed to investigate the association between noise annoyance due to different sources and tinnitus presence and distress in the general population. METHODS: Data of 6813 participants from a large German population-based cohort were used (Gutenberg Health Study). Participants were asked about the presence of tinnitus and how much they were bothered by it. In addition, information on annoyance from road traffic, aircraft, railways, industrial, and neighborhood noise during the day and sleep was collected through validated questionnaires. RESULTS: The prevalence of tinnitus was 27.3%, and the predominant sources of noise annoyance in these subjects were aircraft, neighborhood, and road traffic noise. Overall, logistic regression results demonstrated consistent positive associations between annoyance due to different noise sources and prevalent risk of tinnitus with increases in odds ratios ranging from 4 to 11% after adjustment for sex, age, and socioeconomic status. Likewise, consistent increases in odds ratios were observed for tinnitus distress in subjects with prevalent tinnitus. For instance, neighborhood noise annoyance during the sleep was associated with a 26% increase in tinnitus distress (OR 1.26, 95% CI 1.13; 1.39). IMPACT: This is the first study investigating the association between noise annoyance and tinnitus presence and distress in a large cohort of the general population. Our results indicate consistent and positive associations between various sources of noise annoyance and tinnitus. These unprecedented findings are highly relevant as noise annoyance and tinnitus are widespread. The precise etiology and locus of tinnitus remain unknown, but excessive noise exposure is thought to be among the major causes. This study suggests that transportation and neighborhood noise levels thought merely to contribute to annoyance and non-auditory health effects may be sufficient to cause or exacerbate tinnitus.

Diagnosis of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: data from a practice-based longitudinal cohort.

BACKGROUND: A large prospective multicenter cohort study with systematic follow-up recently reported a 2.3% 2-year cumulative incidence of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE). OBJECTIVES: The present investigation aimed to determine the reported prevalence and incidence of CTEPH diagnosis after acute PE in real-world practice over a 12-year period. METHODS: This study was based on nationwide ambulatory billing claims and drug prescription data of all residents with public health insurance in Germany from 2010 to 2021. RESULTS: A total of 573 972 patients with acute PE (median age, 71 years; 57.4% women) were identified between 2010 and 2021. Prevalence of CTEPH among patients with history of PE increased during the period from 0.4% in 2010 to 0.9% in 2021. CTEPH was diagnosed in 2556 patients after acute PE, with most (17.6%) diagnoses reported within the first 3 months after the index PE event. The cumulative incidence rate after 3 months (first quarter) was calculated at 0.08% and after the first 2 years (eighth quarter) at 0.36%; it was 0.75% over the entire (90-month) follow-up period. Patients with CTEPH diagnosis during follow-up more often had right ventricular dysfunction at the index acute PE (14.9% vs 8.3%; P < .001). CONCLUSION: The low CTEPH incidence rate after acute PE in the present analysis suggests low awareness of CTEPH. It further suggests a lack of systematic follow-up protocols for acute PE survivors in the real world. Improved implementation of existing recommendations on follow-up strategies after PE is warranted.

Categorization of Patients With Pulmonary Embolism by Charlson Comorbidity Index.

BACKGROUND: Short-term outcomes of pulmonary embolism are closely related to right ventricular dysfunction and patient's hemodynamic status, but also to individual comorbidity profile. However, the impact of patients' comorbidities on survival during pulmonary embolism might be underrated. Although the Charlson Comorbidity Index (CCI) is the most extensively studied comorbidity index for detecting comorbidity burden, studies analyzing the impact of CCI on pulmonary embolism patients' survival are limited. METHODS: We used the German nationwide inpatient sample to analyze all hospitalized patients with pulmonary embolism in Germany 2005-2020 and calculated CCI for each patient, compared the CCI classes (very low: CCI = 0 points, mild: CCI = 1-2 points, moderate: CCI = 3-4, high severity: CCI >4 points) and impact of CCI class on outcomes. RESULTS: Overall, 1,373,145 hospitalizations of patients with acute pulmonary embolism (53.0% females, 55.9% aged ≥70 years) were recorded in Germany between 2005 and 2020; the CCI class stratified them. Among these, 100,156 (7.3%) were categorized as very low; 221,545 (16.1%) as mild; 394,965 (28.8%) as moderate; and 656,479 (47.8%) as patients with a high comorbidity burden according to CCI class. In-hospital case fatality increased depending on the CCI class: 3.6% in very low, 6.5% in mild, 12.1% in moderate, and 22.1% in high CCI class (P < .001). CCI class was associated with increased in-hospital case fatality (odds ratio 2.014; 95% confidence interval, 2.000-2.027; P < .001). CONCLUSION: Our study results may help practitioners to better understand and measure the association between an aggravated comorbidity profile and increased in-hospital case fatality in patients with pulmonary embolism.