Current practices in the diagnosis of acute pulmonary embolism: a comprehensive analysis of adherence to contemporary practice guidelines.

INTRODUCTION: Acute pulmonary embolism (PE) poses significant diagnostic challenges with potentially fatal outcomes if not promptly identified and treated. Despite the availability of clinical guidelines, adherence to diagnostic strategies varies globally, impacting patient outcomes. OBJECTIVES: To investigate the current diagnostic practices for PE among Polish physicians and their adherence to the contemporary European Society of Cardiology (ESC) 2019 Guidelines. PATIENTS AND METHODS: In this cross-sectional study utilizing a web-based survey developed through a Delphi methodology, we included hospital-based physicians across various specialties in Poland. The survey was focused on diagnostic practices, risk stratification, and adherence to the ESC 2019 Guidelines for PE. RESULTS: The study found limited use of guideline-recommended clinical prediction rules, with a large reliance on D-dimer assessments and CT pulmonary angiography. Risk stratification practices varied, often based on individual experience rather than evidence-based strategies. The vast majority of physicians (80.5%) had never contacted a Pulmonary Embolism Response Team (PERT), but 88% stated that they would if it were available. Cardiologists were more likely to employ guideline-recommended methods compared to other specialties. CONCLUSIONS: There is a need for increased adherence to guideline-recommended diagnostic and risk stratification strategies of acute PE among physicians in Poland. Enhancing the availability of Pulmonary Embolism Response Teams (PERTs) and promoting guideline-directed practices could improve diagnostic accuracy and patient outcomes.

Plasma N-terminal pro-brain natriuretic peptide concentrations may help to identify patients with very low-risk acute pulmonary embolism: A preliminary study.

BACKGROUND: Patients with an acute pulmonary embolism (APE) are a heterogeneous group, and some of them may benefit from early discharge and an ambulatory care referral. We aimed to evaluate the use of N-terminal pro-brain natriuretic peptide (NT-proBNP) plasma level assessment in patients with low-risk APE based on clinical findings (0 points on the simplified Pulmonary Embolism Severity Index (sPESI)). MATERIAL AND METHODS: Preliminary analysis of an ongoing prospective study including 1,151 normotensive patients with at least a segmental APE. In the final analysis, 348 patients with a 0-point sPESI were included. Blood samples were collected within the first 24 h of admission. The clinical endpoint (CE) included APE-related mortality and/or rescue thrombolysis in patients with clinical deterioration. RESULTS: Clinical endpoints occurred in 3 patients who had higher plasma NT-proBNP levels than study participants with a favorable clinical course (164 [64-650] pg/mL compared to 2,930 [2,285.5-13,965] pg/mL; p = 0.01). Receiver operating characteristic (ROC) analysis showed that the area under the curve (AUC) for NT-proBNP for the prediction of the CEs was 0.918 (95% confidence interval [95% CI]: 0.831-1.00; p = 0.013). We defined the cutoff value of NT-proBNP at ≥1,641 pg/mL. CONCLUSIONS: Among subjects with 0 points on the sPESI, those with concentrations of NT-proBNP exceeding 1,641 pg/mL might require closer attention; remaining patients could be considered candidates for outpatient treatment. However, these findings warrant further investigation in a large, prospective group of patients.

Optimisation of detecting chronic thromboembolic pulmonary hypertension in acute pulmonary embolism survivors: the InShape IV study.

INTRODUCTION: Chronic thromboembolic pulmonary hypertension (CTEPH) is often diagnosed late in acute pulmonary embolism (PE) survivors: more efficient testing to expedite diagnosis may considerably improve patient outcomes. The InShape II algorithm safely rules out CTEPH (failure rate 0.29%) while requiring echocardiography in only 19% of patients but may be improved by adding detailed reading of the computed tomography pulmonary angiography (CTPA) diagnosing the index PE. METHODS: Twelve new algorithms, incorporating the CTEPH prediction score, ECG reading, NT-proBNP levels and dedicated CTPA reading were evaluated in the international InShape II (n=341) and part of the German FOCUS cohort (n=171). Evaluation criteria included failure rate, defined as the incidence of confirmed CTEPH in PE patients in whom echocardiography was deemed unnecessary by the algorithm, and the overall net reclassification index (NRI) compared to the InShape II algorithm. RESULTS: The algorithm starting with CTPA reading of the index PE for 6 signs of CTEPH, followed by the ECG/NTproBNP assessment and echocardiography resulted in the most beneficial change compared to InShape II with a need for echocardiography in 20% (+5%), a failure rate of 0%, and an NRI of +3.5, reflecting improved performance over the InShape II algorithm. In the FOCUS cohort, this approach lowered echocardiography need to 24% (-6%) and missed no CTEPH cases, with an NRI of +6.0. CONCLUSION: Dedicated CTPA reading of the index PE improved the performance of the InShape II algorithm and may improve the selection of PE survivors who require echocardiography to rule out CTEPH.

Chronic thromboembolic disease among patients undergoing surgical pulmonary embolectomy for acute pulmonary embolism.

BACKGROUND: This study aimed to assess the prevalence of chronic thromboembolic lesions in the pulmonary arteries among patients undergoing pulmonary embolectomy for acute pulmonary embolism and their impact on treatment outcomes. METHODS: We conducted a retrospective, single-center analysis of consecutive patients undergoing emergency pulmonary embolectomy for acute pulmonary embolism between 2013 and August 2021. According to European Society of Cardiology guidelines, the diagnosis was based on clinical presentation, imaging studies and laboratory tests. Surgery was selected as the optimal treatment modality within the Pulmonary Embolism Response Team. Based on the intraoperatively identified chronic lesions patients were divided into two groups: acute only and acute/chronic. The analysis comprised history, laboratory and imaging studies, early and long-term mortality, and postoperative complications. We determined predictive factors for chronic thromboembolic lesions and risk factors for death. RESULTS: The analysis included 33 patients. Intraoperatively, 42% (14) of patients had chronic lesions. Predictive factors for these lesions are the duration of symptoms >1 week (OR=13.75), pulmonary artery dilatation >3.15 cm (OR=39.00) and right ventricle systolic pressure >52 mmHg (OR=29.33). No hospital deaths occurred in the acute only group and two in the acute/chronic group (0% vs. 14.3%; P=0.172). Risk factors for death are the duration of symptoms >3 weeks (HR=7.35) and postoperative use of extracorporeal membrane oxygenation (HR=7.04). CONCLUSIONS: Acute thromboembolic disease overlapping chronic clots is relatively common among patients undergoing pulmonary artery embolectomy. A detailed evaluation of the patient's medical history and imaging studies can identify these patients, as they require special attention when making treatment decisions. Surgical treatment in a center of expertise in pulmonary endarterectomy seems reasonable.

Refined balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension - reference center experience.

Introduction: Chronic thromboembolic pulmonary hypertension (CTEPH), characterized by thromboembolic changes affecting the pulmonary bed, leads to ventricular function deterioration and premature death. The introduction of balloon pulmonary angioplasty (BPA) has significantly improved the prognosis of CTEPH patients. Aim: The authors of this article decided to summarize the experience of the BPA program, conducted between 2014 and 2022, at the reference center. Material and methods: Among 111 CTEPH patients, 55 were included in the analysis. A total of 226 sessions were performed, with a significant percentage of intravascular imaging and pressure catheter use. Results: Mean pulmonary pressure decreased significantly from 42 (22-66) to 26.5 mm Hg (11-54) (p < 0.05). Pulmonary vascular resistance and natriuretic peptide concentration decreased from 6.67 (1.66-14) to 3.295 Wood units (1.09-11.11), respectively, and from 1934 (60-16963) to 296 (21-9901) ng/ml (p < 0.05). There was also an improvement in the functional class (WHO) from 2.85 ±0.61 to 2.15 ±0.62 and an increase in the 6-minute walking distance from 300 ±131 to 367 ±154 m (p < 0.05). There were no in-hospital deaths or within 30 days of the procedure. Arterial damage occurred during nine sessions (n = 9/226, 4%), while 0.9% (n = 2/226) were complicated by acute right ventricular failure. Post-reperfusion pulmonary edema (RPE 0 - none) was observed in almost 90% of the sessions, grade 1 to 3 RPE occurred in 10.2%, and grade 4 RPE was not noted. Conclusions: BPA programs conducted in experienced centers are a safe and effective treatment option for inoperable CTEPH patients.

Predicting Acute Cardiovascular Complications in COVID-19: Insights from a Specialized Cardiac Referral Department.

BACKGROUND COVID-19 increases the risk of acute cardiovascular diseases (CVDs), including acute coronary syndrome (ACS), acute pulmonary embolism (APE), and acute myocarditis (AMyo). The actual impact of CVDs on mortality of patients with COVID-19 remains unknown. This study aimed to determine whether CVDs influence the course of COVID-19 pneumonia and if they can be easily detected by using common tests and examinations. MATERIAL AND METHODS Data of 249 consecutive patients with COVID-19 hospitalized in a dedicated cardiology department were analyzed. On admission, clinical status, biomarkers, computed tomography, and bedside echocardiography were performed. RESULTS D-dimer level predicted APE (AUC=0.850 95% CI [0.765; 0.935], P<0.001) with sensitivity of 69.4% and specificity of 96.2% for a level of 4968.0 ng/mL, and NT-proBNP predicted AMyo (AUC=0.692 95% CI [0.502; 0.883], P=0.004) and showed sensitivity of 54.5%, with specificity of 86.5% for the cut-off point of 8970 pg/mL. Troponin T levels were not useful for diagnostic differentiation between CVDs. An extent of lung involvement predicted mortality (OR=1.03 95% CI [1.01;1.04] for 1% increase, P<0.001). After adjusting for lung involvement, ACS increased mortality, compared with COVID-19 pneumonia only (OR=5.27 95% CI [1.76; 16.38] P=0.003), while APE and AMyo did not affect risk for death. CONCLUSIONS D-dimer and NT-proBNP, but not troponin T, are useful in differentiating CVDs in patients with COVID-19. ACS with COVID-19 increased in-hospital mortality independently from extent of lung involvement, while coexisting APE or AMyo did not.

A roadmap for therapeutic discovery in pulmonary hypertension associated with left heart failure. A scientific statement of the Heart Failure Association (HFA) of the ESC and the ESC Working Group on Pulmonary Circulation & Right Ventricular Function.

Pulmonary hypertension (PH) associated with left heart failure (LHF) (PH-LHF) is one of the most common causes of PH. It directly contributes to symptoms and reduced functional capacity and negatively affects right heart function, ultimately leading to a poor prognosis. There are no specific treatments for PH-LHF, despite the high number of drugs tested so far. This scientific document addresses the main knowledge gaps in PH-LHF with emphasis on pathophysiology and clinical trials. Key identified issues include better understanding of the role of pulmonary venous versus arteriolar remodelling, multidimensional phenotyping to recognize patient subgroups positioned to respond to different therapies, and conduct of rigorous pre-clinical studies combining small and large animal models. Advancements in these areas are expected to better inform the design of clinical trials and extend treatment options beyond those effective in pulmonary arterial hypertension. Enrichment strategies, endpoint assessments, and thorough haemodynamic studies, both at rest and during exercise, are proposed to play primary roles to optimize early-stage development of candidate therapies for PH-LHF.

High-sensitivity cardiac troponin T in detecting obstructive coronary artery disease in hemodialysis patients listed for kidney transplantation.

BACKGROUND: Cardiovascular diseases are the leading cause of morbidity and mortality in patients with end-stage renal disease. AIMS: This study aimed to assess the prognostic value of high-sensitivity cardiac troponin T (hs-cTnT) in identifying patients with obstructive coronary artery disease (CAD) among patients on hemodialysis listed for kidney transplantation. METHODS: The study prospectively enrolled consecutive adult hemodialysis patients listed for kidney transplantation. They underwent laboratory tests and a standardized set of imaging and functional tests, including coronary angiography, according to patient characteristics. RESULTS: The study included 100 consecutive patients (72 men)at a median age of 56.5 years. Ultimately, 48% of the patients were diagnosed with obstructive CAD. Age and plasma hs-cTnT levels predicted the diagnosis of obstructive CAD (OR, 1.13; 95% CI, 1.08-1.20; P < 0.001 and OR, 1.03; 95% CI, 1.01-1.05; P = 0.001, respectively). The calculated cut-off value for age was 53 years, which showed sensitivity of 87.5% and specificity of 76.9% for obstructive CAD diagnosis. The calculated value for hs-cTnT was 0.067 ng/ml, which showed sensitivity of 61.4% and specificity of 82.2% for the detection of obstructive CAD. In patients aged >52 years, 79.2% were diagnosed with obstructive CAD. However, in the group of patients ≤52 years and with hs-cTnT >0.069 ng/ml, the incidence of obstructive CAD was significantly higher than in the group with hs-cTnT level ≤0.069 ng/ml. CONCLUSIONS: Baseline hs-cTnT level is a useful prognostic biomarker in the diagnosis of obstructive CAD in hemodialysis patients listed for kidney transplantation.

Acute Pulmonary Embolism and Immunity in Animal Models.

Venous thromboembolism, encompassing acute pulmonary embolism (APE) and deep vein thrombosis (DVT), is a potentially fatal disease with complex pathophysiology. Traditionally, the Virchow triad provided a framework for understanding the pathogenic contributors to thrombus formation, which include endothelial dysfunction, alterations in blood flow and blood hypercoagulability. In the last years, it has become apparent that immunity plays a central role in thrombosis, interacting with classical prothrombotic mechanisms, oxidative stress and vascular factors. Thrombosis amplifies inflammation, and exaggerated inflammatory processes can trigger thrombosis mainly due to the activation of leukocytes, platelets, and endothelial cells. APE-related endothelium injury is a major trigger for immune system activation. Endothelium is also a key component mediating inflammatory reaction and it is relevant to maintain vascular permeability. Exaggerated right ventricular wall stress and overload, with coexisting systemic hypotension and hypoxemia, result in myocardial injury and necrosis. Hypoxia, tissue factor activation and cytokine storm are engaged in the thrombo-inflammatory processes. Thrombus development is characterized by inflammatory state vascular wall caused mainly by an early extravasation of leukocytes and intense selectins and cytokines production. Nevertheless, immunity of DVT is well described, little is known about potential chemokine and cellular differences between thrombus that develops in the vein and thrombus that detaches and lodges in the pulmonary circulation being a cause of APE. There is a paucity of data considering inflammatory state in the pulmonary artery wall during an acute episode of pulmonary embolism. The main aim of this review is to summarize the knowledge of immunity in acute phase of pulmonary embolism in experimental models.

The timing of death in acute pulmonary embolism patients regarding the mortality risk stratification at admission to the hospital.

Background: The management of patients with acute pulmonary embolism (aPE) depends on the severity of aPE. The timing of death in various aPE risk subgroups is only partially known. Methods: 1618 patients with an objectively established aPE diagnosis with computed tomography pulmonary angiography enrolled in the regional PE registry were included in the study. According to ESC criteria, patients were stratified at admission to the hospital in four risk strata. The timing of PE-related and non-PE-related deaths was analyzed regarding mortality risk. Results: PE-related, and non-PE-related hospital death rates were 1.1 % and 1.5 % in low, 1.1 % and 4.8 % in intermediate-low, 8.1 % and 5.9 % in intermediate-high, and 27.7 % and 6.9 % in high-risk groups, respectively. The median time of PE-related and non-PE-related death across the PE mortality risk were: 4 (1.7-7.5) and 7.0 (4-14.7) days in low, 1.5 (1.0-9.5) and 11.5 (2.0-21.0) days in intermediate-low, 4.0 (2.0-9.0) and 9.0 (5.7-18.2) days in intermediate-high, 2.0 (1.0-4.75) and 7.0 (3.0-21.2) days in high-risk subgroups. 48.2 % and 17.1 % of patients who died in the high and intermediate-high risks died during the first hospital day. After the 6th hospitalization day, PE-related deaths were recorded in 43.9 % of deaths from intermediate-high and 17.9 % from high-risk subgroups. Conclusion: PE-related mortality is prominent on the first hospitalization day in high and intermediate-high-risk PE. A substantial proportion of intermediate-high and high-risk patient's PE deaths occurred after the first 6 days of hospitalization.

The Vulnerable Elders Survey-13 scale is superior to the simplified Pulmonary Embolism Score Index in predicting 3-month postdischarge mortality in elderly survivors of acute pulmonary embolism.

INTRODUCTION: Acute pulmonary embolism (APE) is the most serious manifestation of venous thromboembolism. The simplified Pulmonary Embolism Severity Index (sPESI) is employed for prediction of 30-day mortality in APE. The Vulnerable Elders Survey (VES-13) is used to identify participants at a risk of health impairment. OBJECTIVES: We aimed to compare the VES-13 and sPESI scales for prediction of 3-month mortality inelderly patients hospitalized for APE. PATIENTS AND METHODS: All patients with APE were managed according to the European Society of Cardiology (ESC) guidelines and followed up for at least 3 months after discharge. Clinical evaluation of all patients involved the Charlson Comorbidity Index (CCI) and biochemical tests. The patients with VES-13 score equal to or above 3 (VES-13≥3) were evaluated with comprehensive geriatric assessment (CGA). RESULTS: A total of 164 patients met the inclusion criteria. There were significantly fewer men in the VES-13≥3 than the VES-13<3 group (34% vs 54.5%; P <0.01). The patients in the VES-13≥3 group had lower median (interquartile range [IQR]) body mass index and higher sPESI score than those in the VES-13<3 group (25.6 [21.8-28.4] kg/m2 vs 28 [25.3-31] kg/m2; P = 0.001 and 2 [1-2] points vs 1 [0-1] point; P <0.001, respectively). There were no differences in APE severity according to the ESC stratification and CCI. Logistic regression analysis identified the VES-13 score as a significant independent risk factor for 3-month mortality. CONCLUSIONS: The VES-13 score is a better tool than sPESI for predicting 3-month mortality. Geriatric survivors of APE characterized with VES-13≥3 points should be closely monitored after discharge. The Norton Scale Score in a combination with the VES-13 may be useful in predicting 3-month mortality among numerous tests used in the CGA.