Association of race, ethnicity and insurance status with outcomes for patients with acute pulmonary embolism treated by PERT: a retrospective observational study.

BACKGROUND: Management of PE has become streamlined with the implementation of PE Response Teams (PERT). Race, ethnicity and insurance status are known to influence the outcomes of patients with acute PE. However, whether the implementation of PERT-based care mitigates these racial and ethnic disparities remains unknown. Our aim was to assess the association of race, ethnicity and insurance with outcomes for patients with acute PE managed by PERT. METHODS: We performed a retrospective chart review of 290 patients with acute PE, who were admitted to one of three urban teaching hospitals in the Mount Sinai Health System (New York, NY) from January 2021 to October 2023. A propensity score-weighted analysis was performed to explore the association of race, ethnicity and insurance status with overall outcomes. RESULTS: Median age of included patients was 65.5 years and 149 (51.4%) were female. White, Black and Asian patients constituted 56.2% (163), 39.6% (115) and 3.5% [10] of the cohort respectively. Patients of Hispanic or Latino ethnicity accounted for 8.3% [24] of the sample. The 30-day rates of mortality, major bleeding and 30-day re-admission were 10.3%, 2.1% and 12.8% respectively. Black patients had higher odds of major bleeding (odds ratio [OR]: 1.445; p < 0.0001) when compared to White patients. Patients of Hispanic or Latino ethnicity had lower odds of receiving catheter-directed thrombolysis (OR: 0.966; p = 0.0003) and catheter-directed or surgical embolectomy (OR: 0.906; p < 0.0001) when compared to non-Hispanic/Latino patients. Uninsured patients had higher odds of receiving systemic thrombolysis (OR: 1.034; p = 0.0008) and catheter-directed thrombolysis (OR: 1.059; p < 0.0001), and lower odds of receiving catheter-directed or surgical embolectomy (OR: 0.956; p = 0.015) when compared to insured patients, although the odds of 30-day mortality and 30-day major bleeding were not significantly different. CONCLUSION: Within a cohort of PE patients managed by PERT, there were significant associations between race, ethnicity and overall outcomes. Hispanic or Latino ethnicity and uninsured status were associated with lower odds of receiving catheter-directed or surgical embolectomy. These results suggest that disparities related to ethnicity and insurance status persist despite PERT-based care of patients with acute PE.

The impact on thirty day readmissions for patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease admitted to an observation unit versus an inpatient medical unit: A retrospective observational study.

OBJECTIVES: We aimed to evaluate the utility of an Observation Unit (OU) in management of acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and to identify the clinical characteristics of patients readmitted within 30-days for AECOPD following index admission to the OU or inpatient floor from the OU. METHODS: This is a retrospective observational study of patients admitted from January to December 2017 for AECOPD to an OU in an urban-based tertiary care hospital. Primary outcome was rate of 30-day readmission after admission for AECOPD for patients discharged from the OU versus inpatient service after failing OU management. Regression analyses were used to define risk factors. RESULTS: 163 OU encounters from 92 unique patients were included. There was a lower readmission rate (33%) for patients converted from OU to inpatient care versus patients readmitted after direct discharge from the OU (44%). Patients with 30-day readmissions were more likely to be undomiciled, with history of congestive heart failure (CHF), pulmonary embolism (PE), or had previous admissions for AECOPD. Patients with >6 annual OU visits for AECOPD had higher rates of substance abuse, psychiatric diagnosis, and prior PE; when these patients were excluded, the 30-day readmission rate decreased to 13.5%. CONCLUSION: Patients admitted for AECOPD with a history of PE, CHF, prior AECOPD admissions, and socioeconomic deprivation are at higher risk of readmission and should be prioritized for direct inpatient admission. Further prospective studies should be conducted to determine the clinical impact of this approach on readmission rates.

Comparison of interventions for intermediate to high-risk pulmonary embolism: A network meta-analysis.

BACKGROUND: Multiple interventions, including catheter-directed therapy (CDT), systemic thrombolysis (ST), surgical embolectomy (SE), and therapeutic anticoagulation (AC) have been used to treat intermediate to high-risk pulmonary embolism (PE), but the most effective and safest treatment remains unclear. Our study aimed to investigate the efficacy and safety outcomes of each intervention. METHODS: We queried PubMed and EMBASE in January 2023 and performed a network meta-analysis of observational studies and randomized controlled trials (RCT), including high or intermediate-risk PE patients, and comparing AC, CDT, SE, and ST. The primary outcomes were in-hospital mortality and major bleeding. The secondary outcomes included long-term mortality (≥6 months), recurrent PE, minor bleeding, and intracranial hemorrhage. RESULTS: We identified 11 RCTs and 42 observational studies involving 157,454 patients. CDT was associated with lower in-hospital mortality than ST (odds ratio [OR] [95% confidence interval (CI)]: 0.41 [0.31-0.55]), AC (OR [95% CI]: 0.33 [0.20-0.53]), and SE (OR [95% CI]: 0.61 [0.39-0.96]). Recurrent PE in CDT was lower than ST (OR [95% CI]: 0.66 [0.50-0.87]), AC (OR [95% CI]: 0.36 [0.20-0.66]), and trended lower than SE (OR [95% CI]: 0.71 [0.40-1.26]). Notably, ST had higher major bleeding risks than CDT (OR [95% CI]: 1.51 [1.19-1.91]) and AC (OR [95% CI]: 2.21 [1.53-3.19]). By rankogram analysis, CDT presented the highest p-score in in-hospital mortality, long-term mortality, and recurrent PE. CONCLUSION: In this network meta-analysis of observational studies and RCTs involving patients with intermediate to high-risk PE, CDT was associated with improved mortality outcomes compared to other therapies, without significant additional bleeding risk.

Predictors of pulmonary embolism in hospitalized patients with COVID-19.

BACKGROUND: High venous thromboembolism (VTE) rates have been described in critically ill patients with COVID-19. We hypothesized that specific clinical characteristics may help differentiate hypoxic COVID-19 patients with and without a diagnosed pulmonary embolism (PE). METHODS: We performed a retrospective observational case-control study of 158 consecutive patients hospitalized in one of four Mount Sinai Hospitals with COVID-19 between March 1 and May 8, 2020, who received a Chest CT Pulmonary Angiogram (CTA) to diagnose a PE. We analyzed demographic, clinical, laboratory, radiological, treatment characteristics, and outcomes in COVID-19 patients with and without PE. RESULTS: 92 patients were negative (CTA-), and 66 patients were positive for PE (CTA+). CTA + had a longer time from symptom onset to admission (7 days vs. 4 days, p = 0.05), higher admission biomarkers, notably D-dimer (6.87 vs. 1.59, p < 0.0001), troponin (0.015 vs. 0.01, p = 0.01), and peak D-dimer (9.26 vs. 3.8, p = 0.0008). Predictors of PE included time from symptom onset to admission (OR = 1.11, 95% CI 1.03-1.20, p = 0.008), and PESI score at the time of CTA (OR = 1.02, 95% CI 1.01-1.04, p = 0.008). Predictors of mortality included age (HR 1.13, 95% CI 1.04-1.22, p = 0.006), chronic anticoagulation (13.81, 95% CI 1.24-154, p = 0.03), and admission ferritin (1.001, 95% CI 1-1.001, p = 0.01). CONCLUSIONS: In 158 hospitalized COVID-19 patients with respiratory failure evaluated for suspected PE, 40.8% patients had a positive CTA. We identified clinical predictors of PE and mortality from PE, which may help with early identification and reduction of PE-related mortality in patients with COVID-19.

The relationship between asthma, eosinophilia, and outcomes in coronavirus disease 2019 infection.

BACKGROUND: The impact of asthma diagnosis and asthma endotype on outcomes from coronavirus disease 2019 (COVID-19) infection remains unclear. OBJECTIVE: To describe the association between asthma diagnosis and endotype and clinical outcomes among patients diagnosed as having COVID-19 infection. METHODS: Retrospective multicenter cohort study of outpatients and inpatients presenting to 6 hospitals in the Mount Sinai Health System New York metropolitan region between March 7, 2020, and June 7, 2020, with COVID-19 infection, with and without a history of asthma. The primary outcome evaluated was in-hospital mortality. Secondary outcomes included hospitalization, intensive care unit admission, mechanical ventilation, and hospital length of stay. The outcomes were compared in patients with or without asthma using a multivariate Cox regression model. The outcomes stratified by blood eosinophilia count were also evaluated. RESULTS: Of 10,523 patients diagnosed as having COVID-19 infection, 4902 were hospitalized and 468 had a diagnosis of asthma (4.4%). When adjusted for COVID-19 disease severity, comorbidities, and concurrent therapies, patients with asthma had a lower mortality (adjusted odds ratio [OR], 0.64 (0.53-0.77); P < .001) and a lower rate of hospitalization and intensive care unit admission (OR, 0.43 (0.28-0.64); P < .001 and OR, 0.51 (0.41-0.64); P < .001, respectively). Those with blood eosinophils greater than or equal to 200 cells/µL, both with and without asthma, had lower mortality. CONCLUSION: Patients with asthma may be at a reduced risk of poor outcomes from COVID-19 infection. Eosinophilia, both in those with and without asthma, may be associated with reduced mortality risk.

The characteristics and outcomes of critically Ill patients with COVID-19 who received systemic thrombolysis for presumed pulmonary embolism: an observational study.

Coronavirus disease 2019 (COVID-19) is associated with abnormal hemostasis, autopsy evidence of systemic microthrombosis, and a high prevalence of venous thromboembolic disease. Tissue plasminogen activator (tPA) has been used in patients with critically ill COVID-19 with high clinical suspicion of pulmonary embolism (PE). A retrospective cohort study of 6095 hospitalized COVID-19 patients at 5 acute care hospitals in New York was conducted. 57 patients received tPA for presumed PE during March 10th to April 27th. The mean age was 60.8 ± 10.8 years, and 71.9% (41/57) were male. We defined strongly suspected PE among 75.4% (43/57) of patients who had acute worsening of hypoxia and acute hypotension requiring pressors. The findings suggestive of PE included right ventricular (RV) strain in 15.8% (9/57), deep venous thrombosis (DVT) in 7.0% (4/57), increased dead space ventilation (Vd) in 31.6% (18/57) of patients, respectively. RV strain and RV thrombus were present in 3.5% (2/57), RV strain and DVT in 5.3% (3/57), RV strain and increased Vd in 8.8% (5/57), and DVT and increased Vd in 3.5% (2/57) of patients. Chest CT Angiography was not performed in any of the patients. Following tPA infusion, 49.1% (28/57) of patients demonstrated improvement. Six patients (10.5%) survived to discharge, of whom 2 received extracorporeal membrane oxygenation and were transferred to other facilities for lung transplant, 2 were discharged home, and 2 were discharged to a rehabilitation facility. However, overall mortality was 89.5%. The utility of tPA for critically ill patients with COVID-19 and presumed PE warrants further studies.

Reducing length of stay with the direct oral anti-coagulants in low and intermediate risk pulmonary embolism: a single center experience.

Direct oral anti-coagulants (DOACs) reduce hospital length-of-stay (LOS) in patients with acute pulmonary embolism (PE) in clinical trials. There is a paucity of literature describing real world utility of DOACs, particularly in intermediate-risk patients. To evaluate if the utilization of DOACs vs. non-DOACs in acute PE patients, reduces LOS without a difference in safety in patients defined as low and intermediate-risk of mortality by the European Society of Cardiology. This was a retrospective cohort study of prospectively collected data from a single center registry of consecutive adult outpatients diagnosed with acute PE who survived to hospital discharge. Primary outcome was median hospital LOS. Secondary outcomes were 30-day readmission, survival, and incidence of major and minor bleeding. There were 307 outpatients admitted with acute PE 88 (28.7%) low-risk, 213 (69.4%) intermediate-risk, and 6 (2.0%) high-risk. Two hundred and twenty-six (73.6%) received a DOAC. There was a statistically significant shorter median LOS in all patients treated with a DOAC (2.9 days, IQR 1.8-4.7) vs non-DOAC (4.9 days, IQR 3-8.9) (Generalized Linear Model p < 0.001). There was a shorter median LOS between intermediate-risk patients treated with a DOAC (3.6 days, IQR 2-5.8) vs non-DOAC (5, IQR 3-9). There was no difference in 30-day readmission, survival, or bleeding complications in both cohorts. There was a reduction in LOS in low and intermediate risk patients treated with a DOAC without a difference in 30-day safety and efficacy. Treating acute PE patients with DOACs including intermediate-risk patients, compared to conventional anticoagulation, may facilitate early discharge, and potentially reduce hospital costs.

Right Heart Thrombi: Patient Outcomes by Treatment Modality and Predictors of Mortality: A Pooled Analysis.

RATIONALE: Right heart thrombi (RiHT) is characterized by the presence of thrombus within the right atrium or right ventricle (RV). Current literature suggests pulmonary embolism (PE) with RiHT carries a high mortality. Guidelines lack recommendations in managing RiHT. We created a pooled analysis on RiHT and report on our institutional experience in managing RiHT. We aimed to evaluate whether patient characteristics and differing treatment modalities predict mortality. METHODS: We created a pooled analysis of case reports and series of patients with RiHT and PE between January 1956 and 2017. We also reviewed a series of consecutive patients with RiHT identified from our institutional PE registry. Age, shock, RV dysfunction, clot mobility, treatment modality, and hospital outcome had to be reported. RESULTS: We identified 316 patients in our pooled analysis. Patients received the following therapies: no treatment 15 (5%), systemic anticoagulation 73 (23%), systemic thrombolysis 108 (34%), surgical embolectomy 101 (32%), catheter-directed therapy 11 (3%), and systemic thrombolysis with surgery 8 (3%). In-hospital mortality was 18.7%. Univariate analysis showed age and shock reduced odds of survival. Multivariate analysis showed shock reduced odds of survival (odds ratios [OR] 0.36, 95% confidence interval [CI]: 0.19-0.72, P ≤ .01) while age, RV dysfunction, and clot-mobility did not affect mortality. In a reduced multivariate analysis adjusting for shock, treatment modality, and clot location alone, systemic thrombolysis increased odds of survival when compared to systemic anticoagulation (OR 2.72, 95% CI: 1.11-6.64, P = .02). Our institutional series identified 18 patients, where in-hospital mortality was 22.2%, 18 (100%) had RV dysfunction, and 5 (28%) had shock. Patients received the following therapies: systemic anticoagulation 8 (44.4%), systemic thrombolysis 4 (22.2%), surgical embolectomy 4 (22.2%), and catheter-directed thrombolysis 2 (11.1%). CONCLUSION: Presence of shock in RiHT is an independent predictor of mortality. Systemic thrombolysis may offer increased odds of survival when compared to systemic anticoagulation. Our findings should be interpreted with caution as they derive from retrospective reports and subject to publication bias.

A narrative review of red blood cell distribution width as a marker for pulmonary embolism.

Red blood cell distribution width (RDW) is a marker of variability in red blood cell size, and is routinely reported as part of a patient's complete blood count. RDW has been shown to be associated with the prediction, severity and prognosis of pulmonary embolism (PE) in recent studies. The underlying biomolecular mechanism of the relationship of RDW to PE is largely unknown, but is thought to be due to the relationship of RDW with acute inflammatory markers and variations in blood viscosity. This review substantiates that a high RDW level, defined using either an arbitrary number or according to receiver operator curve statistics, is associated with a higher risk of acute PE, increased severity (massive vs. submassive) of PE and increased mortality in patients with PE. Nevertheless, the comparison of current studies is limited due to the definition of high RDW (each study uses a different RDW cutoff level), the broad range of exclusion criteria and the inclusion of differing modalities used to diagnose a PE (computed tomography angiogram, ventilation-perfusion study, or clinical diagnosis). Despite the above limitations, these studies provide a promising future clinical use for RDW as a marker of PE.

Pulmonary infarction secondary to pulmonary embolism: An evolving paradigm.

BACKGROUND AND OBJECTIVE: Pulmonary infarction (PI) from pulmonary embolism (PE) remains an entity of unclear aetiology. PI has been thought to occur in elderly patients with cardiopulmonary disease. We hypothesize younger patients without cardiopulmonary comorbidities are at highest risk. Our study aims to characterize PI clinically and radiographically, determine associated risk factors and determine their clinical significance. METHODS: We conducted a single-centre retrospective review of 367 consecutive patients with PE. Clinical and radiographic data were compared between patients with and without PI using chi-square and F-tests. Univariate and multivariate analyses were performed to evaluate risk factors for PI. RESULTS: PI occurred in 62 of 367 patients with acute PE (16.9%). Patients with PI were significantly younger (48 ± 20.3 vs 59.6 ± 17.2 years, P < 0.01), with lower pulmonary embolism severity index (PESI) scores (73.7 ± 38.1 vs 91.9 ± 37.5 years, P < 0.01) and endorsed chest pain with significantly higher frequency (65% vs 39%, P < 0.01). There was no significant difference in other clinical symptoms, hospital length of stay or mortality between groups. Presence of radiographic cardiopulmonary disease was significantly lower in patients with PI (emphysema: 5% vs 22%, P = <0.01; aortic atherosclerosis: 23% vs 43%, P = <0.01). In multivariate analysis, age ≤33 (OR 3.5 CI: 1.37-8.95, P < 0.01), chest pain (OR 2.15 CI: 1.15-4.00, P = 0.02) and pleural effusion (OR 2.18 CI: 1.08-4.41, P = 0.03) increased PI risk and presence of emphysema decreased risk (OR 0.21 CI: 0.06-0.70, P = 0.01). CONCLUSION: Younger patients without cardiopulmonary comorbidities are at highest risk of PI. Chest pain and pleural effusion significantly increased risk of PI while presence of radiographic emphysema reduced risk.

Prevalence of Neurocognitive Dysfunction and Its Effects on Postoperative Outcomes in Total Joint Arthroplasty.

BACKGROUND: The prevalence of neurocognitive dysfunction (NCD) and its effects on postoperative outcomes have not been well characterized following total joint arthroplasty (TJA) population. This study aims at better understand this relationship. METHODS: Patients were evaluated for neurocognitive function using the grooved pegboard test for the dominant (PEG-D) and nondominant hand (PEG-N), and the Rey Auditory Verbal Learning Test (RAVLT). The patient scores for each test was compared to age-controlled normative values in order to identify NCD. Baseline characteristics and postoperative outcomes were then compared amongst the two cohorts. RESULTS: Ninety-nine consecutive patients were prospectively enrolled. Nearly 54% were identified as neurocognitively deficient on at least 1 of the 3 tests (31% by RAVLT, 21% by PEG-D, and 30% by PEG-N). There was a statistically significant prevalence of NCD in patients older than 60 years when compared to normative controls for RAVLT (P < .001). Patients with depression or an American Society of Anesthesiologist score of 3 were 5 times as likely to have NCD, while patients with a body mass index between 20-30 kg/m2 were 5 times less likely to have NCD. Furthermore, patients identified as NCD preoperatively were significantly more likely to be transferred to the intensive care unit (48% vs 14%) and fail physical therapy (64% vs 17%), respectively. CONCLUSION: NCD is highly prevalent within total joint arthroplasty candidates and may be correlated with higher body mass index, American Society of Anesthesiologist scores, and rates of depression. The condition predisposes patients to suboptimal postoperative outcomes including increased intensive care unit admissions and prolonged rehabilitation.

Diagnostic Accuracy of Point-of-Care Ultrasound Performed by Pulmonary Critical Care Physicians for Right Ventricle Assessment in Patients With Acute Pulmonary Embolism.

OBJECTIVES: Risk stratification for acute pulmonary embolism using imaging presence of right ventricular dysfunction is essential for triage; however, comprehensive transthoracic echocardiography has limited availability. We assessed the accuracy and timeliness of Pulmonary Critical Care Medicine Fellow's performance of goal-directed echocardiograms and intensivists' interpretations for evaluating right ventricular dysfunction in acute pulmonary embolism. DESIGN: Prospective observational study and retrospective chart review. SETTING: Four hundred fifty bed urban teaching hospital. PATIENTS: Adult in/outpatients diagnosed with acute pulmonary embolism. INTERVENTIONS: Pulmonary critical care fellows performed and documented their goal-directed echocardiogram as normal or abnormal for right ventricular size and function in patients with acute pulmonary embolism. Gold standard transthoracic echocardiography was performed on schedule unless the goal-directed echocardiogram showed critical findings. Attending intensivists blinded to the clinical scenario reviewed these exams at a later date. MEASUREMENTS AND MAIN RESULTS: Two hundred eighty-seven consecutive patients were evaluated for acute PE. Pulmonary Critical Care Medicine Fellows performed 154 goal-directed echocardiograms, 110 with complete cardiology-reviewed transthoracic echocardiography within 48 hours for comparison. Pulmonary Critical Care Medicine Fellow's area under the curve for size and function was 0.83 (95% CI, 0.75-0.90) and 0.83 (95% CI, 0.75-0.90), respectively. Intensivists' 1/2 area under the curve for size and function was (1) 0.87 (95% CI, 0.82-0.94), (1) 0.87 (95% CI, 0.80-0.93) and (2) 0.88 (95% CI, 0.82-0.95), (2) 0.88 (95% CI, 0.82-0.95). Median time difference between goal-directed echocardiogram and transthoracic echocardiography was 21 hours 18 minutes. CONCLUSIONS: This is the first study to evaluate pulmonary critical care fellows' and intensivists' use of goal-directed echocardiography in diagnosing right ventricular dysfunction in acute pulmonary embolism. Pulmonary Critical Care Medicine Fellows and intensivists made a timely and accurate assessment. Screening for right ventricular dysfunction using goal-directed echocardiography can and should be performed by pulmonary critical care physicians in patients with acute pulmonary embolism.

End Tidal Carbon Dioxide as a Screening Tool for Computed Tomography Angiogram in Postoperative Orthopaedic Patients Suspected of Pulmonary Embolism.

BACKGROUND: Computed tomography pulmonary angiography (CTA) is the gold standard for diagnosing pulmonary embolism (PE) but involves radiation and iodinated contrast exposure. Of orthopedic patients evaluated for PE, a minority have a positive CTA study. Herein, we evaluate end tidal carbon dioxide (ETCO2) as a method to identify patients at low risk for PE and may not require a CTA. We hypothesize that ETCO2 will be useful for predicting the absence of PE in postoperative orthopedic patients. METHODS: In this prospective study, all patients older than 18 years who were admitted for orthopedic surgery and who had a CTA performed for PE were eligible. These patients underwent an ETCO2 measurement. Patients were determined to have PE if they had a positive PE-protocol CT. RESULTS: Between May 2014 and April 2015, 121 patients met the inclusion criteria for the study. Of these patients, 84 had a negative CTA examination, 25 had a positive examination, and 12 had a nondiagnostic examination. We found a statistically significant difference (P = .03) when comparing the average ETCO2 values for the positive and negative CTA groups. An ETCO2 cutoff value of 43 mm Hg was 100% sensitive with a negative predictive value of 100% for absence of PE on CTA. CONCLUSION: This study demonstrates a significant difference in ETCO2 measurements between postoperative orthopedic patients with and without CTA-detected PE. A cutoff value of >43 mm Hg may be useful in excluding patients from undergoing CTA.

Platelet aggregation and coagulation factors in orthopedic surgery.

Hemostasis is a major concern during the perioperative period. Changes in platelet aggregation and coagulation factors may contribute to the delicate balance between thrombosis and bleeding. We sought to better understand perioperative hemostasis by investigating the changes in platelet aggregation and coagulation factors during the perioperative period. We performed a prospective cohort analysis of 70 subjects undergoing non-emergent orthopedic surgery of the knee (n = 28), hip (n = 35), or spine (n = 7) between August 2011 and November 2011. Plasma was collected preoperatively (T1), 1-h intraoperatively (T2), 1-h (T3), 24-h (T4) and 48-h (T5) postoperatively. Platelet function testing was performed using whole blood impedance aggregometry. Coagulation assays were performed for factor VII, factor VIII, von Willebrand Factor (vWF), and fibrinogen. Of the 70 patients, mean age was 64.1 ± 9.8 years, 61% were female, and 74% were Caucasian. Platelet activity decreased until 1 h postoperatively and then significantly increased above baseline at 24- and 48-h postoperatively. Compared to baseline, coagulation factors decreased intraoperatively. Factor VII activity continued to decrease, while FVIII, vWF, and fibrinogen all increased above baseline postoperatively. The results of our study indicate significant changes in platelet activity and coagulation factors during the perioperative period. Both platelet activity and markers of coagulation decrease during the intraoperative period and then some increase postoperatively. These changes may contribute to the hypercoagulabity and/or bleeding risk that occurs in the perioperative period. Future prospective studies aimed at correlating hemostatic changes with perioperative outcomes are warranted.

Association of Different Anticoagulation Strategies With Outcomes in Patients Hospitalized With Acute Pulmonary Embolism.

Background Therapeutic anticoagulation is the cornerstone of treatment for pulmonary embolism (PE), but the impact of different anticoagulation strategies on patient outcomes remains unclear. In this study, we assessed the association of different anticoagulation strategies with the outcomes of patients with acute PE. Methods A retrospective chart review of 207 patients with acute PE who were admitted to one of three urban teaching hospitals in the Mount Sinai Health System (in New York City) from January 2020 to September 2022 was performed. Demographic, clinical, and radiographic data were recorded for all patients. Multivariate regression analyses were performed to assess the association of different outcomes with the approach of therapeutic anticoagulation used. Results The median age of the included patients was 65 years, and 50.2% were women. The most common approach (n = 153, 73.9%) to therapeutic anticoagulation was initial treatment with unfractionated or low molecular weight heparin followed by a direct-acting oral anticoagulant (DOAC), while heparin alone (either unfractionated or low molecular weight heparin) was used in 37 (17.9%) patients, and another 17 (8.2%) patients were treated with heparin followed by bridging to warfarin. Hospital length of stay was longer for patients in the "heparin to warfarin" group (risk-adjusted incidence rate ratio of 2.52). The rates of in-hospital bleeding, all-cause 30-day mortality, and all-cause 30-day re-admissions did not have any significant association with the therapeutic anticoagulation approach used. Conclusion Patients with acute PE who were initially treated with heparin and subsequently bridged to warfarin had a longer hospital stay. Rates of in-hospital bleeding, 30-day mortality, and 30-day re-admission were not associated with the strategy of therapeutic anticoagulation employed.

Fatal acute necrotizing eosinophilic myocarditis temporally related to use of adalimumab in a patient with relapsing polychondritis.

Tumor necrosis factor α (TNF-α) antagonists are being increasingly used as maintenance therapies for rheumatic diseases, and therefore knowledge of their adverse effects is important. We report a case of fatal acute necrotizing eosinophilic myocarditis temporally related to use of a second course of the TNF-α antagonist, adalimumab. A 51-year-old woman with relapsing polychondritis took adalimumab 2 weeks before presenting with acute myocarditis. Within hours of presentation to the emergency department, she had cardiac arrest due to fulminant heart failure. Autopsy demonstrated necrotizing eosinophilic myocarditis. This is a rare cause of fulminant heart failure. This is the first report of a TNF-α antagonist potentially associated with acute necrotizing eosinophilic myocarditis.