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1.
TH Open ; 3(4): e356-e363, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31815247

RESUMO

Limited information exists about the prevalence, management, and outcomes of intermediate-high risk patients with acute pulmonary embolism (PE). In a prospective cohort study, we evaluated consecutive patients with intermediate-high risk PE at a large, tertiary, academic medical center between January 1, 2015 and March 31, 2019. Adjudicated outcomes included PE-related mortality and a complicated course through 30 days after initiation of PE treatment. Repeat systolic blood pressure (SBP), heart rate (HR), brain natriuretic peptide (BNP), and cardiac troponin I (cTnI) measurements, and echocardiography were performed within 48 hours after diagnosis. Among 1,015 normotensive patients with acute PE, 97 (9.6%) had intermediate-high risk PE. A 30-day complicated course and 30-day PE-related mortality occurred in 23 (24%) and 7 patients (7.2%) with intermediate-high risk PE. Seventeen (18%) intermediate-high risk patients received reperfusion therapy. Within 48 hours after initiation of anticoagulation, normalization of SBP, HR, cTnI, BNP, and echocardiography occurred in 82, 86, 78, 72, and 33% of survivors with intermediate-high risk PE who did not receive immediate thrombolysis. A complicated course between day 2 and day 30 after PE diagnosis for the patients who normalized SBP, HR, cTnI, BNP, and echocardiography measured at 48 hours occurred in 2.9, 1.4, 4.5, 3.3, and 14.3%, respectively. Intermediate-high risk PE occurs in approximately one-tenth of patients with acute symptomatic PE, and is associated with high morbidity and mortality. Normalization of HR 48 hours after diagnosis might identify a group of patients with a very low risk of deterioration during the first month of follow-up.

2.
Med. clín (Ed. impr.) ; 151(4): 136-140, ago. 2018. tab
Artigo em Espanhol | IBECS | ID: ibc-173864

RESUMO

Fundamento y objetivos: Determinar la utilidad de la estratificación pronóstica empírica para identificar a pacientes con tromboembolia de pulmón (TEP) aguda sintomática y bajo riesgo de complicaciones precoces. Pacientes y métodos: Este estudio incluyó a un total de 154 pacientes consecutivos diagnosticados de TEP aguda sintomática en un hospital universitario terciario. Comparamos la capacidad pronóstica de la escala clínica Pulmonary Embolism Severity Index (PESI), la escala PESI simplificada (PESIs) y la evaluación empírica de: 1) 2médicos adjuntos (uno con y otro sin experiencia en el manejo de pacientes con TEP); 2) un residente de cuarto año de Neumología; 3) un residente de tercer año de Neumología, y 4) un residente de segundo año de Neumología. El evento primario de mal pronóstico fue la mortalidad por todas las causas durante el primer mes después del diagnóstico de la TEP. Resultados: Durante los primeros 30 días después del diagnóstico de la TEP se produjo el fallecimiento de 13 pacientes (8,4%; intervalo confianza [IC] del 95%, 4,1-12,8%). Hubo una tendencia (no estadísticamente significativa) a clasificar más pacientes de bajo riesgo mediante la escala PESI o la evaluación empírica que con la escala PESIs (36,4, 31,3 y 28,6%, respectivamente). No se produjo ningún evento en el grupo de pacientes de bajo riesgo según la escala PESIs. Se detectó una mayor eficacia pronóstica de la estratificación empírica conforme mayor fue la experiencia clínica de los evaluadores (84,6 vs. 92,3%; p = 0,049). Conclusiones: La escala PESIs es la herramienta más eficaz para identificar pacientes con TEP aguda sintomática y bajo riesgo de muerte por todas las causas durante el primer mes de seguimiento. La evaluación pronóstica empírica realizada por médicos experimentados no es menos eficaz que la realizada mediante escalas estandarizadas


Background and objective: To determine the accuracy of clinical gestalt to identify patients with acute symptomatic pulmonary embolism (PE) at low-risk for short-term complications. Patients and methods: This study included a total of 154 consecutive patients diagnosed with acute symptomatic PE in a tertiary university hospital. We compared the prognostic accuracy of the Pulmonary Embolism Severity Index (PESI), the simplified PESI (sPESI), and clinical gestalt of 1) 2senior physicians (one with and one without experience in the management of patients with PE), 2) a fourth-year resident of Pneumology, 3) a third-year resident of Pneumology, and 4) a second-year resident of Pneumology. The primary outcome was all-cause mortality during the first month after the diagnosis of PE. Results: Thirty-day all-cause mortality was 8.4% (13/154; 8.4%; 95% confidence interval [CI], 4.1-12.8%). The PESI and clinical gestalt classified more patients as low-risk, compared to the sPESI (36.4%, 31.3% y 28.6%, respectively). There were no deaths in the sPESI low-risk category (negative predictive value 100%). Prognostic accuracy increased with increasing experience (84.6 vs. 92.3%; P=.049). Conclusions: The sPESI showed the best accuracy at correctly identifying low-risk patients with acute symptomatic PE. Clinical gestalt is not inferior to standardized clinical prediction rules to prognosticate patients with acute PE


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Embolia Pulmonar/mortalidade , Pesos e Medidas , Prognóstico , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/complicações , Enoxaparina/administração & dosagem , Vitamina K/antagonistas & inibidores
3.
Eur Respir J ; 51(5)2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29724918

RESUMO

The impact of adherence to published guidelines on the outcomes of patients with acute pulmonary embolism (PE) has not been well defined by previous studies.In this prospective cohort study of patients admitted to a respiratory department (n=2096), we evaluated whether patients with PE had better outcomes if they were acutely managed according to international guidelines. Outcomes consisted of all-cause mortality, PE-related mortality, recurrent venous thromboembolism (VTE) and major bleeding events during the first month of follow-up after diagnosis.Overall, 408 patients (19% (95% CI 18-21%)) did not receive guideline-adherent PE management. Patients receiving non-adherent management were significantly more likely to experience all-cause mortality (adjusted odds ratio (OR) 2.39 (95% CI 1.57-3.61) or PE-related mortality (adjusted OR 5.02 (95% CI 2.42-10.42); p<0.001) during follow-up. Non-adherent management was also a significant independent predictor of recurrent VTE (OR 2.19 (95% CI 1.11-4.32); p=0.03) and major bleeding (OR 2.65 (95% CI 1.66-4.24); p<0.001). An external validation cohort of 34 380 patients with PE from the RIETE registry confirmed these findings.PE management that does not adhere to guidelines for indications related to anticoagulation, thrombolytics and inferior vena cava filters is associated with worse patient outcomes.


Assuntos
Anticoagulantes/uso terapêutico , Fibrinolíticos/uso terapêutico , Administração dos Cuidados ao Paciente , Embolia Pulmonar , Filtros de Veia Cava/estatística & dados numéricos , Tromboembolia Venosa , Idoso , Estudos de Coortes , Feminino , Fidelidade a Diretrizes/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/normas , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Embolia Pulmonar/etiologia , Embolia Pulmonar/mortalidade , Embolia Pulmonar/terapia , Melhoria de Qualidade , Recidiva , Unidades de Cuidados Respiratórios/estatística & dados numéricos , Espanha , Tromboembolia Venosa/complicações , Tromboembolia Venosa/epidemiologia , Tromboembolia Venosa/terapia
4.
Eur Respir J ; 51(4)2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29599188

RESUMO

To externally validate the prognostic impact of copeptin, either alone or integrated in risk stratification models, in pulmonary embolism (PE), we performed a post hoc analysis of 843 normotensive PE patients prospectively included in three European cohorts.Within the first 30 days, 21 patients (2.5%, 95% CI 1.5-3.8) had an adverse outcome and 12 (1.4%, 95% CI 0.7-2.5) died due to PE. Patients with copeptin ≥24 pmol·L-1 had a 6.3-fold increased risk for an adverse outcome (95% CI 2.6-15.5, p<0.001) and a 7.6-fold increased risk for PE-related death (95% CI 2.3-25.6, p=0.001). Risk classification according to the 2014 European Society of Cardiology (ESC) guideline algorithm identified 248 intermediate-high-risk patients (29.4%) with 5.6% (95% CI 3.1-9.3) at risk of adverse outcomes. A stepwise biomarker-based risk assessment strategy (based on high-sensitivity troponin T, N-terminal pro-brain natriuretic peptide and copeptin) identified 123 intermediate-high-risk patients (14.6%) with 8.9% (95% CI 4.5-15.4) at risk of adverse outcomes. The identification of patients at higher risk was even better when copeptin was measured on top of the 2014 ESC algorithm in intermediate-high-risk patients (adverse outcome OR 11.1, 95% CI 4.6-27.1, p<0.001; and PE-related death OR 13.5, 95% CI 4.2-43.6, p<0.001; highest risk group versus all other risk groups). This identified 85 patients (10.1%) with 12.9% (95% CI 6.6-22.0) at risk of adverse outcomes and 8.2% (95% CI 3.4-16.2) at risk of PE-related deaths.Copeptin improves risk stratification of normotensive PE patients, especially when identifying patients with an increased risk of an adverse outcome.


Assuntos
Glicopeptídeos/sangue , Embolia Pulmonar/sangue , Embolia Pulmonar/diagnóstico , Medição de Risco/métodos , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Biomarcadores/sangue , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Curva ROC , Fatores de Risco
6.
Thromb Res ; 164: 40-44, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29476988

RESUMO

BACKGROUND: In patients with acute pulmonary embolism (PE), studies have shown an association between coexisting deep vein thrombosis (DVT) and short-term prognosis. It is not known whether complete compression ultrasound testing (CCUS) improves the risk stratification of their disease beyond the recommended prognostic models. METHODS: We included patients with normotensive acute symptomatic PE and prognosticated them with the European Society of Cardiology (ESC) risk model for PE. Subsequently, we determined the prognostic significance of coexisting DVT in patients with various ESC risk categories. The primary endpoint was a complicated course after the diagnosis of PE, defined as death from any cause, haemodynamic collapse, or adjudicated recurrent PE. RESULTS: According to the ESC model, 37% of patients were low-risk, 56% were intermediate-low risk, and 6.7% were intermediate-high risk. CCUS demonstrated coexisting DVT in 375 (44%) patients. Among the 313 patients with low-risk PE, coexisting DVT (46%) did not show a significant increased risk of complicated course (2.8%; 95% confidence interval [CI], 0.8%-7.0%), compared with those without DVT (0.6%; 95% CI, 0%-3.2%), (P = 0.18). Of the 478 patients with intermediate-low risk PE, a complicated course was 14% and 6.8% for those with and without DVT, respectively (P = 0.01). Of the 57 patients that had intermediate-high risk PE, a complicated course occurred in 17% and 18% for those with and without DVT, respectively (P = 1.0). CONCLUSIONS: In normotensive patients with PE, testing for coexisting DVT might improve risk stratification of patients at intermediate-low risk for short-term complications.


Assuntos
Embolia Pulmonar/etiologia , Trombose Venosa/complicações , Doença Aguda , Idoso , Feminino , Humanos , Masculino , Prognóstico , Estudos Prospectivos , Embolia Pulmonar/patologia , Fatores de Risco , Trombose Venosa/patologia
7.
Med Clin (Barc) ; 151(4): 136-140, 2018 08 22.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-29276010

RESUMO

BACKGROUND AND OBJECTIVE: To determine the accuracy of clinical gestalt to identify patients with acute symptomatic pulmonary embolism (PE) at low-risk for short-term complications. PATIENTS AND METHODS: This study included a total of 154 consecutive patients diagnosed with acute symptomatic PE in a tertiary university hospital. We compared the prognostic accuracy of the Pulmonary Embolism Severity Index (PESI), the simplified PESI (sPESI), and clinical gestalt of 1) 2senior physicians (one with and one without experience in the management of patients with PE), 2) a fourth-year resident of Pneumology, 3) a third-year resident of Pneumology, and 4) a second-year resident of Pneumology. The primary outcome was all-cause mortality during the first month after the diagnosis of PE. RESULTS: Thirty-day all-cause mortality was 8.4% (13/154; 8.4%; 95% confidence interval [CI], 4.1-12.8%). The PESI and clinical gestalt classified more patients as low-risk, compared to the sPESI (36.4%, 31.3% y 28.6%, respectively). There were no deaths in the sPESI low-risk category (negative predictive value 100%). Prognostic accuracy increased with increasing experience (84.6 vs. 92.3%; P=.049). CONCLUSIONS: The sPESI showed the best accuracy at correctly identifying low-risk patients with acute symptomatic PE. Clinical gestalt is not inferior to standardized clinical prediction rules to prognosticate patients with acute PE.


Assuntos
Competência Clínica , Embolia Pulmonar/mortalidade , Índice de Gravidade de Doença , Doença Aguda , Idoso , Causas de Morte , Intervalos de Confiança , Feminino , Humanos , Internato e Residência , Masculino , Prognóstico , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/terapia , Pneumologia , Medição de Risco , Avaliação de Sintomas , Fatores de Tempo
8.
Thromb Res ; 162: 1-6, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29247809

RESUMO

BACKGROUND: The inflammatory response associated with acute pulmonary embolism (PE) contributes to the development of right ventricular (RV) dysfunction. Nonsteroidal anti-inflammatory drugs (NSAIDs) may facilitate the reversal of PE-associated RV dysfunction. METHODS: We randomly assigned normotensive patients who had acute PE associated with echocardiographic RV dysfunction and normal systemic blood pressure to receive intravenous (IV) diclofenac (two doses of 75mg in the first 24h after diagnosis) or IV placebo. All patients received standard anticoagulation with subcutaneous low-molecular-weight heparin (LMWH) and an oral vitamin K antagonist. RV dysfunction was defined by the presence of, at least, two of the following criteria: i) RV diastolic diameter>30mm in the parasternal window; ii) RV diameter>left ventricle diameter in the apical or subcostal space; iii) RV free wall hypokinesis; and iv) estimated pulmonary artery systolic pressure>30mmHg. Persistence of RV dysfunction at 48h and 7days after randomization were the primary and secondary efficacy outcomes, respectively. The primary safety outcome was major bleeding within 7days after randomization. RESULTS: Of the 34 patients randomly assigned to diclofenac or placebo, the intention-to-treat analysis showed persistent RV dysfunction at 48h in 59% (95% confidence interval [CI], 33-82%) of the diclofenac group and in 76% (95% CI, 50-93%) of the placebo group (difference in risk [diclofenac minus standard anticoagulation], -17 percentage points; 95% CI, -47 to 17). Similar proportions (35%) of patients in the diclofenac and placebo groups had persistent RV dysfunction at 7days. Major bleeding occurred in none of patients in the diclofenac group and in 5.9% (95% CI, 0.2-29%) of patient in the placebo group. CONCLUSIONS: Due to slow recruitment, our study is inconclusive as to a potential benefit of diclofenac over placebo to reverse RV dysfunction in normotensive patients with acute PE. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01590342.


Assuntos
Anti-Inflamatórios não Esteroides/uso terapêutico , Diclofenaco/uso terapêutico , Embolia Pulmonar/tratamento farmacológico , Disfunção Ventricular Direita/tratamento farmacológico , Idoso , Anti-Inflamatórios não Esteroides/farmacologia , Diclofenaco/farmacologia , Feminino , Humanos , Masculino , Projetos Piloto , Embolia Pulmonar/patologia , Disfunção Ventricular Direita/patologia
9.
Hemasphere ; 2(1): e19, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-31723748

RESUMO

Current guidelines recommend low-molecular-weight-heparins (LMWH) monotherapy for 3 to 6 months as first-line treatment for cancer-associated venous thromboembolism (VTE). In clinical practice, enoxaparin and nadroparin are common agents used. However, differences in therapy adherence between these LMWHs have never been reported. Therefore, our aim was to compare adherence to enoxaparin and nadroparin in patients with cancer-associated VTE. Consecutive patients with active cancer and objectively confirmed VTE, treated at a Dutch or a Spanish hospital, were followed during LMWH therapy with a maximum of 180 days. Cumulative incidences of discontinuation of both LMWHs were estimated and compared according to the Kaplan-Meier method, applying a competing risk analysis to correct for mortality. A total of 366 patients were analyzed during LMWH treatment, of whom 284 patients (78%) were treated with enoxaparin and 82 (22%) with nadroparin. The cumulative incidence of discontinuation of enoxaparin and nadroparin treatment because of side effects was 30% (95% confidence interval [CI] 24-36) and 8.8% (95% CI 1.1-15), respectively. Competing risk analysis revealed a higher number of patients discontinuing enoxaparin due to side effects (adjusted hazard ratio [HR]: 2.8; 95% CI 1.06-7.2). Pain at the injection site was the most common reason of discontinuation in patients using enoxaparin, occurring in 32 patients, while it occurred in 1 patient using nadroparin (adjusted HR: 4.0; 95% CI 0.52-31). This analysis reveals that enoxaparin was associated with a higher risk of discontinuation because of side effects compared to nadroparin. However, given the nature of the patient groups, these findings should be followed by future studies.

10.
Thromb Res ; 163: 246-251, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-28911787

RESUMO

For patients who have acute symptomatic pulmonary embolism (PE), risk of short-term death and adverse outcomes should drive the initial treatment decisions. Practice guidelines recommend that patients who have a high-risk of PE-related death and adverse outcomes, determined by the presence of haemodynamic instability (i.e., shock or hypotension), should receive systemically administered thrombolytic therapy. Intermediate-high risk patients might benefit from close observation, and some should undergo escalation of therapy beyond standard anticoagulation, particularly if haemodynamic deterioration occurs. Low-risk for adverse outcomes should lead to early hospital discharge or full treatment at home. Validated prognostic tools (i.e., clinical prognostic scoring systems, imaging studies, and cardiac laboratory biomarkers) assist with risk classification of patients who have acute symptomatic PE.


Assuntos
Embolia Pulmonar/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Embolia Pulmonar/patologia , Medição de Risco
11.
Thorax ; 73(5): 464-471, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29133351

RESUMO

BACKGROUND: We aimed to review the efficacy and safety of recanalisation procedures for the treatment of PE. METHODS: We searched PubMed, the Cochrane Library, EMBASE, EBSCO, Web of Science and CINAHL databases from inception through 31 July 2015 and included randomised clinical trials that compared the effect of a recanalisation procedure versus each other or anticoagulant therapy in patients diagnosed with PE. We used network meta-analysis and multivariate random-effects meta-regression to estimate pooled differences between each intervention and meta-regression to assess the association between trial characteristics and the reported effects of recanalisation procedures versus anticoagulation. RESULTS: For all-cause mortality, there were no significant differences in event rates between any of the recanalisation procedures and anticoagulant treatment (full-dose thrombolysis: OR 0.60; 95% CI0.36 to 1.01; low-dose thrombolysis: 0.47; 95% CI 0.14 to 1.59; and catheter-associated thrombolysis: 0.31; 95% CI 0.01 to 7.96). Full-dose thrombolysis increased the risk of major bleeding (2.00; 95% CI 1.06 to 3.78) compared with anticoagulation. Catheter-directed thrombolysis was associated with the lowest probability of dying (surface under the cumulative ranking curve (SUCRA), 0.67), followed by low-dose thrombolysis (SUCRA, 0.66) and full-dose thrombolysis (SUCRA, 0.55). Similarly, low-dose thrombolysis was associated with the lowest probability of major bleeding (SUCRA, 0.61), followed by catheter-directed thrombolysis (SUCRA, 0.54) and full-dose thrombolysis (SUCRA, 0.17). The results were similar in sensitivity analyses based on restricting only to studies in haemodynamically stable patients with PE. CONCLUSIONS: In the treatment of PE, recanalisation procedures do not seem to offer a clear advantage compared with standard anticoagulation. Low-dose thrombolysis was associated with the lowest probability of dying and bleeding. TRIAL REGISTRATION NUMBER: PROSPERO CRD42015024670.


Assuntos
Fibrinolíticos/administração & dosagem , Hemorragia/induzido quimicamente , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/mortalidade , Doença Aguda , Cateterismo de Swan-Ganz , Fibrinolíticos/efeitos adversos , Humanos , Meta-Análise em Rede , Ensaios Clínicos Controlados Aleatórios como Assunto
12.
Clin Cardiol ; 40(12): 1182-1188, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29247523

RESUMO

In normotensive patients with acute symptomatic pulmonary embolism (PE), the effect of undiagnosed obstructive sleep apnea (OSA) on cardiovascular (CV) outcomes lacks clarity. The Prognostic Significance of Obstructive Sleep Apnea in Patients With Acute Symptomatic Pulmonary Embolism (POPE) study is a multicenter, observational study designed to prospectively assess the prognostic significance of concomitant OSA in hemodynamically stable outpatients with acute symptomatic PE. Adult patients with acute stable PE are eligible. Recruited patients undergo an overnight sleep study using a level III portable diagnostic device within 7 days (and preferably within 48 hours) of diagnosis of PE. The sleep tracings are analyzed by a certified sleep technologist and audited by a sleep physician, both of whom are blinded to other study data. The patients are divided into 2 groups based on apnea-hypopnea index (AHI): OSA (AHI ≥15) and non-OSA (AHI <15) groups. The study uses a composite of PE-related death, CV death, clinical deterioration requiring an escalation of treatment, or nonfatal CV events (recurrent venous thromboembolism, acute myocardial infarction, or stroke) within 30 days after the diagnosis of PE as the primary outcome. The projected sample size of 225 patients will provide 80% power to test the hypothesis that OSA will increase the primary outcome from 7% in the non-OSA group to 20% in the OSA group, with α ≤0.05. The trial results will be important to understand the burden and CV effects of OSA in PE patients.


Assuntos
Doenças Cardiovasculares/etiologia , Embolia Pulmonar/complicações , Pressão Propulsora Pulmonar/fisiologia , Medição de Risco , Apneia Obstrutiva do Sono/complicações , Sono/fisiologia , Idoso , Doenças Cardiovasculares/epidemiologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Polissonografia , Estudos Prospectivos , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/fisiopatologia , Fatores de Risco , Índice de Gravidade de Doença , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/fisiopatologia , Espanha/epidemiologia
13.
PLoS One ; 12(11): e0187648, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29107971

RESUMO

BACKGROUND: We sought to examine sex-related differences in the characteristics and outcome in patients presenting with acute symptomatic pulmonary embolism (PE). METHODS: We conducted a retrospective cohort study of 2,096 patients diagnosed with acute PE. The characteristics were recorded at presentation. Treatment was at the discretion of patients' physicians. The primary study outcome, all-cause mortality, and the secondary outcomes of PE-specific mortality, recurrent venous thromboembolism, and major bleeding were assessed during the first month of follow-up after PE diagnosis. RESULTS: Overall, the women were older than the men and had significantly higher rates of immobilization. They had significantly lower rates of chronic obstructive pulmonary disease and cancer. Women had a higher prevalence of syncope and elevated brain natriuretic peptide levels. Thirty-day all-cause mortality was similar between women and men (7.1% versus 6.2%; P = 0.38). Male gender was not independently significantly associated with PE-related death (adjusted odds ratio [OR] 1.02; 95% CI, 0.50 to 2.07; P = 0.96). Restricting the analyses to haemodynamically stable patients (n = 2,021), female gender was an independent predictor of all-cause (adjusted OR 1.56; 95% CI, 1.07 to 2.28; P = 0.02) and PE-specific mortality (adjusted OR 1.85; 95% CI, 1.02 to 3.33; P = 0.04). Compared with men, women were 2.05 times more likely to experience a major bleed. CONCLUSIONS: Women and men with PE had different clinical characteristics, presentation, and outcomes. Women receiving anticoagulation have a significantly higher risk of major bleeding, suggesting the need for careful monitoring of anticoagulant intensity in women.


Assuntos
Embolia Pulmonar/patologia , Fatores Sexuais , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemorragia/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Embolia Pulmonar/complicações , Embolia Pulmonar/mortalidade , Recidiva , Resultado do Tratamento
14.
Arch. bronconeumol. (Ed. impr.) ; 53(9): 495-500, sept. 2017. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-166279

RESUMO

Objetivo: No se conocen suficientemente las características clínicas y el pronóstico de los pacientes con tromboembolia de pulmón (TEP) aguda sintomática asociada a los viajes prolongados (síndrome de clase turista [SCT]). Métodos: Se analizaron retrospectivamente las características basales de los pacientes con TEP aguda y se estratificaron según el factor de riesgo desencadenante. Se determinaron la mortalidad por todas las causas, la mortalidad por la propia TEP, las recurrencias trombóticas no fatales y los sangrados mayores no fatales durante los primeros 30 días de seguimiento. Resultados: De los 2.333 pacientes incluidos, un total de 124 (5,3%; intervalo de confianza del 95%: 4,4-6,3) fueron diagnosticados de TEP secundaria a SCT. Estos pacientes fueron más jóvenes, presentaron menos frecuentemente comorbilidad y más frecuentemente síncope (48% vs. 14%; p<0,001), taquicardia (37% vs. 21%; p<0,001), disfunción de ventrículo derecho (VD) (31% vs. 19%; p<0,01) y daño miocárdico (57% vs. 28%; p<0,001) que los demás pacientes con TEP. La mortalidad por todas las causas a 30 días fue significativamente menor para los pacientes con TEP secundaria a SCT (1,6% vs. 9,6%; p<0,01). La mortalidad a 30 días por TEP no fue diferente entre los dos grupos de pacientes (0,8% vs. 3,1%; p=0,18). Conclusiones: Los pacientes con TEP y SCT son más jóvenes y tienen menos comorbilidad que los demás pacientes con TEP. Aunque se presentan más frecuentemente con disfunción de VD y daño miocárdico, el pronóstico a corto plazo es excelente (AU)


Objective: Clinical presentation and short-term prognosis of patients with travel-associated acute pulmonary embolism (PE) (i.e., economy class syndrome [ECS]) is not well understood. Methods: In this retrospective cohort study of patients with acute PE identified from a single center registry, we assessed the clinical presentation and the association between ECS and the outcomes of all-cause mortality, PE-related mortality, nonfatal venous thromboembolism and nonfatal major bleeding rates through 30 days after initiation of PE treatment. Results: Of the 2,333 patients with acute symptomatic PE, 124 (5.3%; 95% confidence interval, 4.4-6.3%) had ECS. Patients with ECS were younger and had fewer comorbid diseases (recent bleeding, chronic obstructive pulmonary disease, congestive heart failure), but they presented with more signs of clinical severity (syncope [48% vs. 14%; P<.001], tachycardia [37% vs. 21%; P<.001], right ventricular dysfunction [31% vs. 19%; P<.01] and myocardial injury [57% vs. 28%; P<.001]) compared to those without ECS. Regression analyses showed a significantly lower risk of all-cause mortality for patients with ECS compared to patients without ECS (1.6% vs. 9.6%; P<.01). We did not detect a difference in PE-related mortality at 30 days between those with and those without ECS (0.8% vs. 3.1%; P=.18). Conclusions: PE patients with ECS are younger and have fewer comorbid diseases compared to those without ECS. Though they present with more signs of clinical severity, their short-term prognosis is excellent (AU)


Assuntos
Humanos , Embolia Pulmonar/fisiopatologia , Trombose Venosa/complicações , Embolia Pulmonar/etiologia , Prognóstico , Estudos Retrospectivos , Mortalidade , Recidiva , Fatores de Risco
15.
Arch Bronconeumol ; 53(9): 495-500, 2017 Sep.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-28366298

RESUMO

OBJECTIVE: Clinical presentation and short-term prognosis of patients with travel-associated acute pulmonary embolism (PE) (i.e., economy class syndrome [ECS]) is not well understood. METHODS: In this retrospective cohort study of patients with acute PE identified from a single center registry, we assessed the clinical presentation and the association between ECS and the outcomes of all-cause mortality, PE-related mortality, nonfatal venous thromboembolism and nonfatal major bleeding rates through 30days after initiation of PE treatment. RESULTS: Of the 2,333 patients with acute symptomatic PE, 124 (5.3%; 95% confidence interval, 4.4-6.3%) had ECS. Patients with ECS were younger and had fewer comorbid diseases (recent bleeding, chronic obstructive pulmonary disease, congestive heart failure), but they presented with more signs of clinical severity (syncope [48% vs. 14%; P<.001], tachycardia [37% vs. 21%; P<.001], right ventricular dysfunction [31% vs. 19%; P<.01] and myocardial injury [57% vs. 28%; P<.001]) compared to those without ECS. Regression analyses showed a significantly lower risk of all-cause mortality for patients with ECS compared to patients without ECS (1.6% vs. 9.6%; P<.01). We did not detect a difference in PE-related mortality at 30days between those with and those without ECS (0.8% vs. 3.1%; P=.18). CONCLUSIONS: PE patients with ECS are younger and have fewer comorbid diseases compared to those without ECS. Though they present with more signs of clinical severity, their short-term prognosis is excellent.


Assuntos
Aeronaves , Embolia Pulmonar/etiologia , Viagem , Adulto , Fatores Etários , Idoso , Comorbidade , Feminino , Cardiopatias/epidemiologia , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Heparina de Baixo Peso Molecular/efeitos adversos , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/cirurgia , Recidiva , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Terapia Trombolítica , Veia Cava Inferior
16.
Am Heart J ; 185: 123-129, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28267465

RESUMO

The optimal approach to assess right ventricular (RV) function in patients with acute symptomatic pulmonary embolism (PE) lacks clarity. METHODS: This study aimed to evaluate the optimal approach to assess RV function in normotensive patients with acute symptomatic PE. Outcomes assessed through 30-days after the diagnosis of PE included all-cause mortality and complicated course. RESULTS: Eight hundred forty-eight patients were enrolled. Multidetector computed tomography (MDCT) and transthoracic echocardiography agreed on the presence or absence of RV overload in 449 (53%) patients. The combination of the simplified Pulmonary Embolism Severity Index (sPESI) and MDCT showed a negative predictive value for 30-day all-cause mortality of 100%. Of the 43% that had an sPESI of >0 points and MDCT RV enlargement, 41 (11.3%) experienced a complicated course that included 24 (6.6%) deaths. One hundred twenty-nine patients (15%) had an sPESI of >0 points, MDCT, and echocardiographic RV overload. Of these, 21 (16.3%) experienced a complicated course within the first 30days, and 10 (7.7%) of them died. CONCLUSIONS: Incorporation of echocardiographic RV overload to the sPESI and MDCT did not improve identification of low-risk PE patients, whereas it improved identification of those at intermediate-high risk for short-term complications.


Assuntos
Mortalidade , Embolia Pulmonar/fisiopatologia , Disfunção Ventricular Direita/diagnóstico por imagem , Doença Aguda , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Comorbidade , Ecocardiografia , Feminino , Insuficiência Cardíaca/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores , Prognóstico , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Embolia Pulmonar/complicações , Embolia Pulmonar/epidemiologia , Medição de Risco , Índice de Gravidade de Doença , Disfunção Ventricular Direita/complicações , Disfunção Ventricular Direita/epidemiologia , Disfunção Ventricular Direita/fisiopatologia , Função Ventricular Direita
17.
Semin Thromb Hemost ; 43(5): 486-492, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28166600

RESUMO

Rapid and accurate risk stratification is critical in determining the optimal treatment strategy for patients with acute pulmonary embolism (PE). Early identification of patients with normal blood pressure and a favorable prognosis (low-risk PE) might select a subset of patients for outpatient treatment, which is associated with reduced cost and improved patient satisfaction, and has been shown to be effective and safe. Alternatively, identification of normotensive patients deemed as having a high risk for PE-related adverse clinical events (intermediate-high-risk PE) might select a subset of patients for close observation and consideration of escalation of therapy. Clinical prognostic scores have been gaining importance in the classification of patients into these categories. They should be derived and validated following strict methodological standards, and their use in clinical practice should be encouraged.


Assuntos
Embolia Pulmonar/mortalidade , Medição de Risco/métodos , Doença Aguda , Humanos , Prognóstico , Análise de Sobrevida
18.
Chest ; 151(2): 409-416, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27746202

RESUMO

BACKGROUND: For patients diagnosed with acute pulmonary embolism (PE), the prognostic significance of concomitant right heart thrombi (RHT) lacks clarity. METHODS: We performed a meta-analysis of studies that enrolled patients with acute PE to assess the prognostic value of echocardiography-detectable RHT for the primary outcome of short-term all-cause mortality and the secondary outcome of short-term PE-related mortality. Unrestricted searches were conducted of PubMed and Embase from 1980 through January 31, 2016, and used the terms "right heart thrombi," "pulmonary embolism," and "prognos.*" A random effects model was used to pool study results; Begg rank correlation method was used to evaluate for publication bias; and I2 testing was used to assess for heterogeneity. RESULTS: Six of 79 potentially relevant studies met the inclusion criteria (15,220 patients). Overall, 99 of 593 patients with echocardiography-detectable RHT died (16.7% [95% CI, 13.8-19.9]) compared with 639 of 14,627 without RHT (4.4% [95% CI, 4.0-4.7]). RHT had a significant association with short-term all-cause mortality in all patients (OR, 3.0 [95% CI, 2.2 to 4.1]; I2 = 20%) and with PE-related death (three cohorts, 12,955 patients; OR: 4.8 [95% CI, 2.0-11.3; I2 = 76%). Results were consistent for the prospective (two cohorts, 514 patients; OR, 4.8 [95% CI, 1.7-13.6]; I2 = 56%) and the retrospective (four cohorts, 14,706 patients; OR, 2.8 [95% CI, 2.1 to 3.8]; I2 = 0%) studies. CONCLUSIONS: In patients diagnosed with acute PE, concomitant RHT were significantly associated with an increased risk of death within 30 days of PE diagnosis. TRIAL REGISTRY: PROSPERO registry; No.: CRD42016033960; URL: https://www.crd.york.ac.uk/prospero/.


Assuntos
Cardiopatias/epidemiologia , Embolia Pulmonar/mortalidade , Trombose/epidemiologia , Causas de Morte , Comorbidade , Ecocardiografia , Cardiopatias/diagnóstico por imagem , Humanos , Mortalidade , Prognóstico , Embolia Pulmonar/epidemiologia , Trombose/diagnóstico por imagem
19.
Eur Respir J ; 48(5): 1377-1385, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27799388

RESUMO

There is a lack of comprehensive data on the prevalence, predictors and prognostic significance of right heart thrombi (RHT) in pulmonary embolism.In this study of patients with pulmonary embolism from the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) registry, we assessed the prevalence and predictors of RHT, and the association between the presence of RHT and the outcomes of all-cause mortality, pulmonary embolism-related mortality, recurrences, and major bleeding through 30 days after initiation of pulmonary embolism treatment.Of 12 441 patients with pulmonary embolism and baseline echocardiographic data, 2.6% had RHT. The following increased the risk of RHT: younger age, previous bleeding, congestive heart failure, cancer, syncope, systolic blood pressure <100 mmHg, and arterial oxyhaemoglobin saturation <90%. Patients with RHT were significantly more likely to die from any cause (adjusted OR 2.50 (95% CI 1.62-3.84); p<0.001) and from pulmonary embolism (adjusted OR 4.29 (95% CI 2.45-7.48); p<0.001) during follow-up. RHT was associated with an increased risk of recurrence during follow-up (1.8% versus 0.7%; p=0.04). Major bleeding was similar in patients with and without RHT.In patients presenting with pulmonary embolism, RHT is relatively infrequent. Patients with RHT had a worse outcome when compared with those without RHT.


Assuntos
Anticoagulantes/uso terapêutico , Embolia Pulmonar/complicações , Trombose/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Comorbidade , Ecocardiografia , Feminino , Coração/fisiologia , Insuficiência Cardíaca , Hemorragia , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Razão de Chances , Oxiemoglobinas/metabolismo , Prevalência , Prognóstico , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/mortalidade , Sistema de Registros , Estudos Retrospectivos , Risco , Sístole , Trombose/epidemiologia , Trombose/mortalidade , Resultado do Tratamento
20.
Chest ; 150(2): 374-83, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-27071810

RESUMO

BACKGROUND: A comprehensive evaluation of temporal trends in the treatment of patients who have DVT may assist with identification of modifiable factors that contribute to short-term outcomes. METHODS: We assessed temporal trends in length of hospital stay and use of pharmacological and interventional therapies among 26,695 adults with DVT enrolled in the Registro Informatizado de la Enfermedad TromboEmbólica registry between 2001 and 2014. We also examined temporal trends in risk-adjusted rates of all-cause, pulmonary embolism-related, and bleeding-related death to 30 days after diagnosis. RESULTS: The mean length of hospital stay decreased from 9.0 days in 2001 to 2005 to 7.6 days in 2010 to 2014 (P < .01). For initial DVT treatment, the use of low-molecular-weight heparin decreased from 98% to 90% (P < .01). Direct oral anticoagulants use increased from 0.5% in 2010 to 13.4% in 2014 (P < .001). Risk-adjusted rates of 30-day all-cause mortality decreased from 3.9% in 2001 to 2005 to 2.7% in 2010 to 2014 (adjusted rate ratio per year, 0.84; 95% CI, 0.74-0.96; P < .01). VTE-related mortality showed a nonstatistically significant downward trend (adjusted rate ratio per year, 0.70; 95% CI, 0.44-1.10; P = .13), whereas 30-day bleeding-related mortality significantly decreased from 0.5% in 2001 to 2005 to 0.1% in 2010-2014 (adjusted rate ratio per year, 0.55; 95% CI, 0.40-0.77; P < .01). CONCLUSIONS: This international registry-based temporal analysis identified reductions in length of stay for adults hospitalized for DVT. The study also found a decreasing trend in adjusted rates of all-cause and bleeding-related mortality.


Assuntos
Anticoagulantes/uso terapêutico , Tempo de Internação/tendências , Sistema de Registros , Terapia Trombolítica/tendências , Filtros de Veia Cava/tendências , Trombose Venosa/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Estudos de Coortes , Gerenciamento Clínico , Feminino , Hemorragia/induzido quimicamente , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Crescimento Demográfico , Prognóstico , Estudos Retrospectivos , Terapia Trombolítica/estatística & dados numéricos , Filtros de Veia Cava/estatística & dados numéricos , Trombose Venosa/mortalidade
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