Percutaneous mechanical thrombectomy in acute pulmonary embolism: Outcomes from a safety-net hospital.

BACKGROUND: Our study aims to present clinical outcomes of mechanical thrombectomy (MT) in a safety-net hospital. METHODS: This is a retrospective study of intermediate or high-risk pulmonary embolism (PE) patients who underwent MT between October 2020 and May 2023. The primary outcome was 30-day mortality. RESULTS: Among 61 patients (mean age 57.6 years, 47% women, 57% Black) analyzed, 12 (19.7%) were classified as high-risk PE, and 49 (80.3%) were intermediate-risk PE. Of these patients, 62.3% had Medicaid or were uninsured, 50.8% lived in a high poverty zip code. The prevalence of normotensive shock in intermediate-risk PE patients was 62%. Immediate hemodynamic improvements included 7.4 mmHg mean drop in mean pulmonary artery pressure (-21.7%, p < 0.001) and 93% had normalization of their cardiac index postprocedure. Thirty-day mortality for the entire cohort was 5% (3 patients) and 0% when restricted to the intermediate-risk group. All 3 patients who died at 30 days presented with cardiac arrest. There were no differences in short-term mortality based on race, insurance type, citizenship status, or socioeconomic status. All-cause mortality at most recent follow up was 13.1% (mean follow up time of 13.4 ± 8.5 months). CONCLUSION: We extend the findings from prior studies that MT demonstrates a favorable safety profile with immediate improvement in hemodynamics and a low 30-day mortality in patients with acute PE, holding true even with relatively higher risk and more vulnerable population within a safety-net hospital.

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.

Rural-urban differences in pulmonary embolism mortality by race-ethnicity and sex in the United States, 1999-2020.

INTRODUCTION: Racial and ethnic differences in pulmonary embolism (PE) mortality within rural and urban regions in the U.S. have not previously been described. PE mortality may vary across regions and urbanization given disparities in social and structural determinants and comorbid disease. METHODS: Using surveillance data from the Centers for Disease Control and Prevention, age-adjusted mortality rates (AAMR) related to PE were calculated for rural and urban regions in the U.S., in non-Hispanic Black and White women and men, between 1999 and 2020. RESULTS: Among 137,946 deaths in urban regions and 41,333 deaths in rural regions due to PE during this period, AAMR decreased 1.8% per year in urban regions from 3.1 to 100,000 in 1999 to 2.2 per 100,000 in 2020, and decreased 1% per year in rural regions from 4.3 to 100,000 in 1999 to 3.3 per 100,000 in 2020. Since 2008, AAMR from PE increased in non-Hispanic White males in rural and urban regions, decreased in non-Hispanic Black females in rural regions, and otherwise remained stagnant in all other race-sex groups. CONCLUSIONS: AAMR from PE was higher in rural compared with urban individuals, with differences by race and sex. Mortality rates remained stagnant over the last decade in non-Hispanic Black adults and non-Hispanic White females and increased in non-Hispanic White males.

Sex, Racial, and Geographic Disparities in Pulmonary Embolism-related Mortality Nationwide.

Rationale: Acute pulmonary embolism is a leading cause of cardiovascular death. There are limited data on the national mortality trends from pulmonary embolism. Understanding these trends is crucial for addressing the mortality and associated disparities associated with pulmonary embolism. Objectives: To analyze the national mortality trends related to acute pulmonary embolism and determine the overall age-adjusted mortality rate (AAMR) per 100,000 population for the study period and assess changes in AAMR among different sexes, races, and geographic locations. Methods: We conducted a retrospective cohort analysis using mortality data of individuals aged ⩾15 years with pulmonary embolism listed as the underlying cause of death in the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database from January 2006 to December 2019. These data are produced by the National Center for Health Statistics. Results: A total of 109,992 pulmonary embolism-related deaths were noted in this dataset nationwide between 2006 and 2019. Of these, women constituted 60,113 (54.7%). The AAMR per 100,000 was not significantly changed, from 2.84 in 2006 to 2.81 in 2019 (average annual percentage change [AAPC], 0.2; 95% confidence interval [CI], -0.1 to 0.5; P = 0.15). AAMR increased for men throughout the study period compared with women (AAPC, 0.7 for men; 95% CI, 0.3 to 1.2; P = 0.004 vs. AAPC, -0.4 for women; 95% CI, -1.1 to 0.3; P = 0.23, respectively). Similarly, AAMR for pulmonary embolism increased for Black compared with White individuals, from 5.18 to 5.26 (AAPC, 0.4; 95% CI, 0.0 to 0.7; P = 0.05) and 2.82 to 2.86 (AAPC, 0.0; 95% CI, -0.6 to 0.6; P = 0.99), respectively. Similarly, AAMR for pulmonary embolism was higher in rural areas than in micropolitan and large metropolitan areas during the study period (4.07 [95% CI, 4.02 to 4.12] vs. 3.24 [95% CI, 3.21 to 3.27] vs. 2.32 [95% CI, 2.30-2.34], respectively). Conclusions: Pulmonary embolism mortality remains high and unchanged over the past decade, and enduring sex, racial and socioeconomic disparities persist in pulmonary embolism. Targeted efforts to decrease pulmonary embolism mortality and address such disparities are needed.

Trends in Pulmonary Embolism Deaths Among Young Adults Aged 25 to 44 Years in the United States, 1999 to 2019.

A concerning increase in mortality from acute pulmonary embolism (PE) in young adults in the United States has been reported. We extracted PE-related mortality rates (number of deaths per US population) from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database from 1999 to 2019, focusing on subjects aged 25 to 44 years. Age-adjusted mortality rates (AAMRs) were assessed using the Joinpoint regression modeling and expressed as the estimated average annual percentage change (AAPC) with relative 95% confidence intervals (95% CIs) and stratified by urbanization, gender, age, and race. Between 1999 and 2019, the AAMR from acute PE in US adults aged 25 to 44 years linearly increased without any difference between genders (AAPC +1.5%, 95% CI 1.2 to 1.8, p <0.001). AAMR increase was more pronounced in American-Indians/Alaska Natives and in Asian/Pacific Islanders (AAPC +2.5%, 95% CI 1.6 to 3.4, p <0.001), Whites (AAPC +1.7%, 95% CI 1.4 to 2.0, p <0.001), Latinx/Hispanic patients (AAPC +1.7%, 95% CI 0.6 to 3.0, p = 0.003), and residents of rural areas (AAPC +2.4%, 95% CI 1.9 to 2.8, p <0.001). A higher AAMR (4.02 per 100,000 residents, 95% CI 3.90 to 4.15) and absolute number of PE-related deaths were observed in the South. PE-related mortality in adults aged 25 to 44 years has increased over the last 2 decades in the United States. Stratification by race, ethnicity, urbanization, and census region showed ethnoracial and regional disparities that will require further evaluation and remedy.

Contemporary trends in mortality related to high-risk pulmonary embolism in US from 1999 to 2019.

BACKGROUND: Population-based data on high-risk pulmonary embolism (PE) mortality trends in the United States (US) are scant. OBJECTIVES: To assess current trends in US mortality related to high-risk PE over the past 21 years and determine differences by sex, race, ethnicity, age and census region. METHODS: Data were extracted from the Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER) to determine trends in age-adjusted mortality rates (AAMR) per 100,000 people, due to high-risk PE. To calculate nationwide annual trends, we assessed the average (AAPC) and annual percent change (APC) with relative 95 % confidence intervals (CIs) using Joinpoint regression. RESULTS: Between 1999 and 2019, high-risk PE was listed as the underlying cause of death in 209,642 patients, corresponding to an AAMR of 3.01 per 100,000 people (95 % CI: 2.99 to 3.02). AAMR from high-risk PE remained stable from 1999 to 2007 [APC: -0.2 %, (95 % CI: -2.0 to 0.5, p = 0.22)] and then significantly increased [APC: 3.1 % (95 % CI: 2.6 to 3.6), p < 0.0001], especially in males [AAPC: 1.9 % (95 % CI: 1.4 to 2.4), p < 0.001 vs AAPC: 1.5 % (95 % CI: 1.1 to 2.2), p < 0.001]. AAMR increase was more pronounced in those <65 years, Black Americans, and residents of rural areas. CONCLUSIONS: In an US population analysis, high-risk PE mortality rate increased, with racial, sex-based, and regional variations. Further studies are needed to understand root causes for these trends and to implement appropriate corrective strategies.

Impact of a pulmonary embolism response team initiative on hospital mortality of patients with bilateral pulmonary embolism / Impacto de una iniciativa de equipo de respuesta a la embolia pulmonar en la mortalidad hospitalaria de pacientes con embolia pulmonar bilateral

Introduction Pulmonary embolism (PE) response teams (PERT) for the management of high-risk PE (HR-PE) and intermediate-high risk PE (IHR-PE) are encouraged in PE guidelines. We aimed to assess the impact of a PERT initiative on mortality in these groups of patients, compared with standard care. Methods We conducted a prospective, single-center registry, including consecutive patients with HR-PE and IHR-PE with PERT activation from February-2018 to December-2020 (PERT group, n=78 patients) and compared it with an historic cohort of patients admitted to our hospital in a previous 2-year period (2014–2016), managed with standard of care (SC-group, n=108 patients). Results Patients in the PERT group were younger and less comorbid. The risk profile at admission and the percentage of HR-PE was similar in both cohorts (13% in SC-group and 14% in PERT-group, p=0.82). Reperfusion therapy was more frequently indicated in PERT-group (24.4% vs 10.2%, p=0.01), with no differences in fibrinolysis treatment, while catheter-directed therapy (CDT) was more frequent in PERT group (16.7% vs 1.9%, p<0.001). Reperfusion and CDT were associated with lower in-hospital mortality (2.9% vs 15.1%, p=0.001 for reperfusion and 1.5% vs 16.5%, p=0.001 for CDT). The primary outcome, 12-month mortality, was lower in the PERT-group (9% vs 22.2%, p=0.02), There were no differences in 30-day readmissions. In multivariate analysis PERT activation was associated with lower mortality at 12 months (HR 0.25, 95% confidence interval 0.09–0.7, p=0.008). Conclusion A PERT initiative in patients with HR-PE and IHR-PE was associated with a significant reduction in 12-month mortality compared with standard of care, and also with an increase in the use of reperfusion, especially catheter-directed therapies (AU)

Introducción Las guías de manejo de embolia pulmonar (EP) recomiendan organizar equipos de respuesta a la embolia pulmonar (PERT) para el manejo de la EP de riesgo intermedio-alto (EP-IAR) y de alto riesgo (EP-AR). Nuestro objetivo fue evaluar el impacto de una iniciativa PERT sobre la mortalidad en estos pacientes, en comparación con la atención estándar. Métodos Realizamos un registro prospectivo unicéntrico, incluyendo pacientes consecutivos con EP-IAR y EP-AR con activación del PERT desde febrero de 2018 hasta diciembre de 2020 (grupo PERT, n=78 pacientes) y lo comparamos con una cohorte histórica de pacientes ingresados en nuestro hospital en un período previo de 2 años (2014-2016), manejados con atención estándar (grupo SC, n=108 pacientes). Resultados Los pacientes del grupo PERT eran más jóvenes y con menos comorbilidades. El perfil de riesgo al ingreso y el porcentaje de EP-AR fue similar en ambas cohortes (13% en el grupo SC y 14% en el grupo PERT, p=0,82). La terapia de reperfusión fue más frecuentemente indicada en el grupo PERT (24,4% vs. 10,2%, p=0,01), sin diferencias en el uso de fibrinólisis, mientras que la terapia dirigida por catéter (CDT) fue más frecuente en el grupo PERT (16,7% vs. 1,9%, p<0,001). La reperfusión y la CDT se asociaron con una menor mortalidad hospitalaria (2,9% vs. 15,1%, p=0,001 para reperfusión y 1,5% vs. 16,5%, p=0,001 para CDT). El objetivo primario, la mortalidad a los 12 meses, fue menor en el grupo PERT (9% frente al 22,2%, p=0,02). No hubo diferencias en los reingresos a los 30 días. En el análisis multivariado la activación de PERT se asoció con una menor mortalidad a los 12 meses (hazard ratio 0,25, intervalo de confianza del 95%: 0,09-0,7, p=0,008)(AU)

What are the mortality markers in elderly patients with acute pulmonary embolism?

OBJECTIVE: This study investigates characteristics and predictors of mortality among elderly patients with acute pulmonary embolism (APE). PATIENTS AND METHODS: Data on patients with the diagnosis of APE at the first admission to two centers between January 2012 and March 2022 were screened retrospectively. Patients aged 65 years and older were categorized as the elderly group while patients between 18 and 64 years of age constituted the non-elderly group. RESULTS: Among the 361 enrolled patients, the average age in the non-elderly group was 51.0 (18.0-64.0) years and the average age in the elderly group was 76 (65.0-92) years. While male patients were the majority in the non-elderly group, there was a higher proportion of female patients in the elderly group (p=0.001). In multivariate regression analysis, the independent risk factors of mortality among elderly patients were oxygen saturation [odds ratio (OR): 1.163, 95% confidence interval (CI): 1.613-9.476; p=0.044], C-reactive protein (CRP) (OR: 1.133, 95% CI: 1.041-1.234; p=0.004), simplified Pulmonary Embolism Severity Index (sPESI) score (OR: 3.910, 95% CI: 1.613-9.476; p=0.003), absence of deep vein thrombosis (OR: 12.88, 95% CI: 1.321-125.739; p=0.028), and leukocyte count (OR: 2.591, 95% CI: 1.015-6.617; p=0.047). In ROC analysis, the cut-off values for mortality prediction were ≥7.7 mg/dL for CRP, >0.125 ng/mL for troponin, and ≥2 for the sPESI score. CONCLUSIONS: If CRP of ≥7.7, troponin of >0.125, and sPESI score of ≥2 are present in elderly patients with APE, extra attention should be paid to the risk of mortality and the utmost care should be taken in planning the monitoring of these patients.

Analysis of contemporary mortality trends in pulmonary embolism, United States, 1999-2020.

BACKGROUND: A contemporary and comprehensive examination of mortality trends in pulmonary embolism (PE) is needed for the United States (US), as previous studies were either based on preceding data or limited to specific demographic subgroups. We aimed to assess the trends in PE deaths by age, sex, race/ethnicity, and census region in the US from 1999 through 2020. METHODS: We analyzed national mortality data using the CDC WONDER database. PE deaths were identified using the ICD-10 Code- I-26. Age adjusted mortality rates (AAMR) were abstracted by age, sex, race/ethnicity, and census region. Temporal trends were assessed using five-year moving averages and Joinpoint regression models. Annual percentage changes (APC) in AAMR were estimated using Monte Carlo Permutation, and 95 % confidence intervals using the Parametric Method. RESULTS: Overall mortality trends have stabilized since 2009 (APC = 0.6; 95 % CI: -0.3, 1.6), as were trends among Non-Hispanic Whites (APC = 0.6; 95 % CI: -0.2, 1.4), Non-Hispanic Blacks (APC = 0.7; 95 % CI: -0.2, 1.6), and Hispanics (APC = 1.4; 95 % CI: -0.7, 3.6). AAMR declined by 1.7 % per year (95 % CI: -2.8, -0.7) among Asians/Pacific Islanders and by 1.4 % per year (95 % CI: -2.8, -0.0) among American Indians/Alaska Natives, from 1999 to 2020. Contemporary trends have increased among males (APC = 1.0; 95 % CI: 0.2, 1.9), persons below 65 years of age (APC = 18.6; 95 % CI: 18.6, 18.6; APC = 2.3; 95 % CI: 1.4, 3.1), and persons from the Northeastern (APC = 1.0; 95 % CI: 0.1, 2.0) and Western regions (APC = 1.6; 95 % CI: 0.7, 2.6). CONCLUSIONS: The decline in PE mortality recorded from 1999 through the mid-2000s has not been sustained in the last decade-overall trends have stabilized since 2009. However, there were differences by age, sex, race/ethnicity, and the US census region, with some subgroups demonstrating stationary, increasing, or declining trends. Further studies should examine the drivers of differential trends in the US population to inform evidence-based and culturally competent public health intervention efforts.

Post Pulmonary Embolism Syndrome

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Morbi-mortalidad de la enfermedad tromboembólica venosa en el Hospital Universitario "Arnaldo Milián Castro" / Morbi-mortality of venous thromboembolic disease at "Arnaldo Milián Castro" University Hospital

Introducción: La enfermedad tromboembólica venosa es un proceso grave y mortal, considerado un problema de salud a escala mundial. Objetivo: Caracterizar la morbi-mortalidad por enfermedad tromboembólica venosa en el Hospital Universitario "Arnaldo Milián Castro". Métodos: Se realizó un estudio descriptivo retrospectivo de corte transversal a una muestra de 290 casos atendidos en el Hospital Universitario "Arnaldo Milián Castro" de Villa Clara, entre febrero de 2014 y febrero de 2016. Las variables fueron: edad, sexo, factores de riesgo, forma de presentación de la enfermedad y tipo de diagnóstico. Resultados: Se observó un predominio del sexo femenino y de los pacientes mayores de 70 años, independientemente del sexo y la inmovilidad como factor de riesgo. La trombosis venosa profunda del sector íleo-femoral fue la forma de presentación más común. El diagnóstico clínico primó, aunque el tromboembolismo pulmonar, como la complicación principal, se diagnosticó por necropsia. La mayor cantidad de trombosis venosa profunda se registró en el Servicio de Angiología, mientras que las muertes por embolia pulmonar predominaron en el Servicio de Terapia Intensiva. El tratamiento médico más utilizado fue la heparina sódica más warfarina; el profiláctico se realizó solo en el 24,7 por ciento de los casos. La heparina sódica se utilizó más en los servicios de Terapia Intensiva. Conclusiones: La enfermedad tromboembólica venosa fue la principal causa de muerte prevenible en el hospital, lo que sugiere que la profilaxis antitrombótica debe resultar una práctica esencial en los pacientes hospitalizados(AU)

Introduction: Venous thromboembolic disease is a serious and fatal process considered a health problem on a global scale. Objective: Characterize morbidity and mortality due to venous thromboembolic disease at "Arnaldo Milián Castro" University Hospital. Methods: A retrospective descriptive cross-sectional study was conducted on a sample of 290 cases treated at "Arnaldo Milián Castro" University Hospital in Villa Clara between February 2014 and February 2016. The variables were: age, sex, risk factors, form of presentation of the disease and type of diagnosis. Results: A predominance of the female sex and patients over 70 years of age was observed, regardless of sex and immobility as risk factors. Deep vein thrombosis of the ileus-femoral sector was the most common form of presentation. Clinical diagnosis prevailed, although pulmonary thromboembolism, as the main complication, was diagnosed by necropsy. The highest amount of deep vein thrombosis was recorded in the Angiology Service, while deaths from pulmonary embolism predominated in the Intensive Care Service. The most commonly used medical treatment was sodium heparin plus warfarin; prophylaxis was performed only in 24.7 percent of cases. Sodium heparin was more used in Intensive Care services. Conclusions: Venous thromboembolic disease was the leading cause of preventable death in the hospital, suggesting that antithrombotic prophylaxis should be an essential practice in hospitalized patients.

Institutional trends over a decade in catheter-directed interventions for pulmonary embolism.

OBJECTIVE: Catheter-directed interventions (CDIs) are commonly performed for acute pulmonary embolism (PE). The evolving catheter types and treatment algorithms impact the use and outcomes of these interventions. This study aimed to investigate the changes in CDI practice and their impact on outcomes. METHODS: Patients who underwent CDIs for PE between 2010 and 2019 at a single institution were identified from a prospectively maintained database. A PE team was launched in 2012, and in 2014 was established as an official Pulmonary Embolism Response Team. CDI annual use trends and clinical failures were recorded. Clinical success was defined as physiologic improvement in the absence of major bleeding, perioperative stroke or other procedure-related adverse event, decompensation for submassive or persistent shock for massive PE, the need for surgical thromboembolectomy, or death. Major bleeding was defined as requiring a blood transfusion, a surgical intervention, or suffering from an intracranial hemorrhage. RESULTS: There were 372 patients who underwent a CDI for acute PE during the study period with a mean age of 58.9 ± 15.4 years; there were males 187 (50.3%) and 340 patients has a submassive PE (91.4%). CDI showed a steep increase in the early Pulmonary Embolism Response Team years, peaking in 2016 with a subsequent decrease. Ultrasound-assisted thrombolysis was the predominant CDI technique peaking at 84% of all CDI in 2014. Suction thrombectomy use peaked at 15.2% of CDI in 2019. The mean alteplase dose with catheter thrombolysis techniques decreased from 26.8 ± 12.5 mg in 2013 to 13.9 ± 7.5 mg in 2019 (P < .001). The mean lysis time decreased from 17.2 ± 8.3 hours in 2013 to 11.3 ± 8.2 hours in 2019 (P < .001). Clinical success for the massive and the submassive PE cohorts was 58.1% and 91.2%, respectively; the major bleed rates were 25.0% and 5.3%. There were two major clinical success peaks, one in 2015 mirroring our technical learning curve and one in 2019 mirroring our patient selection learning curve. The clinical success decrease in 2018 was primarily derived from blood transfusions owing to acute blood loss during suction thrombectomy. CONCLUSIONS: CDIs for acute PE have rapidly evolved with high success rates. Multidisciplinary approaches among centers with appropriate expertise are advisable for the safe and successful implementation of catheter interventions.

Heart Rate and Mortality in Patients With Acute Symptomatic Pulmonary Embolism.

BACKGROUND: The association between heart rate (HR) and pulmonary embolism (PE) outcomes has not been well studied. Furthermore, optimal cutoffs to identify low-risk and intermediate- to high-risk patients are not well known. RESEARCH QUESTION: Does an association exist between baseline HR and PE outcome across the continuum of HR values? STUDY DESIGN AND METHODS: The current study included 44,331 consecutive nonhypotensive patients with symptomatic PE from the Registro Informatizado de la Enfermedad TromboEmbólica registry between 2001 and 2021. Outcomes included 30-day all-cause and PE-specific mortality. We used hierarchical logistic regression to assess the association between admission HR and outcomes. RESULTS: A positive relationship was found between admission HR and 30-day all-cause and PE-related mortality. Considering an HR of 80 to 99 beats/min as a reference, patients in the higher HR strata showed higher rates of all-cause death (adjusted OR, 1.5 for HR of 100-109 beats/min; adjusted OR, 1.7 for HR of 110-119 beats/min; adjusted OR, 1.9 for HR of 120-139 beats/min; and adjusted OR, 2.4 for HR of ≥ 140 beats/min). Patients in the lower strata of HR showed significantly lower rates of 30-day all-cause mortality compared with the same reference group (adjusted OR, 0.6 for HR of 60-79 beats/min; and adjusted OR, 0.5 for HR of < 60 beats/min). The findings for 30-day PE-related mortality were similar. For identification of low-risk patients, a cutoff value of 80 beats/min (vs 110 beats/min) increased the sensitivity of the simplified Pulmonary Embolism Severity Index (sPESI) from 93.4% to 98.8%. For identification of intermediate- to high-risk patients, a cutoff value of 140 beats/min (vs 110 beats/min) increased the specificity of the Bova score from 93.2% to 98.0%. INTERPRETATION: In nonhypotensive patients with acute symptomatic PE, a high HR portends an increased risk of all-cause and PE-related mortality. Modifying the HR cutoff in the sPESI and the Bova score improves prognostication of patients with PE.

Efficacy and Safety of Low Molecular Weight Heparin Versus Unfractionated Heparin for Prevention of Venous Thromboembolism in Trauma Patients: A Systematic Review and Meta-analysis.

PURPOSE: Trauma patients are at high risk of VTE. We summarize the efficacy and safety of LMWH versus UFH for the prevention of VTE in trauma patients. METHODS: We searched 6 databases from inception through March 12, 2021. We included randomized controlled trials (RCTs) or observational studies comparing LMWH versus UFH for thromboprophylaxis in adult trauma patients. We pooled effect estimates across RCTs and observational studies separately, using random-effects model and inverse variance weighting. We assessed risk of bias using the Cochrane tool for RCTs and the Risk of Bias in Non-Randomized Studies (ROBINS)-I tool for observational studies and assessed certainty of findings using Grading of Recommendations, Assessment, Development and Evaluations methodology. RESULTS: We included 4 RCTs (879 patients) and 8 observational studies (306,747 patients). Based on pooled RCT data, compared to UFH, LMWH reduces deep vein thrombosis (RR 0.67, 95% CI 0.50 to 0.88, moderate certainty) and VTE (RR 0.68, 95% CI 0.51 to 0.90, moderate certainty). As compared to UFH, LMWH may reduce pulmonary embolism [adjusted odds ratio from pooled observational studies 0.56 (95% CI 0.50 to 0.62)] and mortality (adjusted odds ratio from pooled observational studies 0.54, 95% CI 0.45 to 0.65), though based on low certainty evidence. There was an uncertain effect on adverse events (RR from pooled RCTs 0.80, 95% CI 0.48 to 1.33, very low certainty) and heparin induced thrombocytopenia [RR from pooled RCTs 0.26 (95% CI 0.03 to 2.38, very low certainty)]. CONCLUSIONS: Among adult trauma patients, LMWH is superior to UFH for deep vein thrombosis and VTE prevention and may additionally reduce pulmonary embolism and mortality. The impact on adverse events and heparin induced thrombocytopenia is uncertain.