Journal of Clinical Medicine

Research

9 pages, 471 KiB

Open AccessCommunication

Predictors of Residual Pulmonary Vascular Obstruction after Acute Pulmonary Embolism Based on Patient Variables and Treatment Modality

by Truong-An Andrew Ho, Jay Pescatore, Ka U. Lio, Parth Rali, Gerard Criner and Shameek Gayen

J. Clin. Med. 2024, 13(14), 4248; https://doi.org/10.3390/jcm13144248 - 20 Jul 2024

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Abstract

Background: Residual Pulmonary Vascular Obstruction (RPVO) is an area of increasing focus in patients with acute pulmonary embolism (PE) due to its association with long-term morbidity and mortality. The predictive factors and the effect catheter-directed therapies (CDT) have on RPVO are still under [...] Read more.

Background: Residual Pulmonary Vascular Obstruction (RPVO) is an area of increasing focus in patients with acute pulmonary embolism (PE) due to its association with long-term morbidity and mortality. The predictive factors and the effect catheter-directed therapies (CDT) have on RPVO are still under investigation. Methods: This is a single-center retrospective review between April 2017 and July 2021. Patients with intermediate risk of PE were included. Patient variables associated with RPVO were analyzed and the degree of clot burden was quantified using the Qanadli score. Results: A total of 551 patients with acute PE were identified, 288 were intermediate risk and 53 had RPVO based on CT or V/Q scan three months post-PE. Baseline clot burden was higher in patients who received CDT compared to those who received anticoagulation alone (Qanadli score 45.88% vs. 31.94% p < 0.05). In univariate analysis, treatment with CDT showed a HR of 0.32 (95% CI 0.21–0.50, p < 0.001) when compared with anticoagulation alone. Patient variables including intermediate-high risk, sPESI ≥ 1, elevated biomarkers, RV dysfunction on imaging, malignancy, history of or concurrent DVT were also significantly associated with development of RPVO in univariate analysis. In multivariable analysis, only baseline Qanadli score (HR 13.88, 95% CI 1.42–135.39, p = 0.02) and concurrent DVT (HR 2.53, 95% CI 1.01–6.40, p = 0.04) were significantly associated with the development of RPVO. Conclusions: Catheter-directed therapy may be associated with a reduced risk of RPVO at 3 months; however, quantitative clot burden scores, such as the Qanadli score, may be stronger predictors of the risk of developing RPVO at 3 months. Further prospective studies are required Full article

(This article belongs to the Special Issue Pulmonary Embolism and Its Complications: Causes, Diagnosis and Treatment)

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8 pages, 395 KiB

Open AccessArticle

The Obesity Mortality Paradox in Patients with Pulmonary Embolism: Insights from a Tertiary Care Center

by Fahad Alkhalfan, Syed Bukhari, Akiva Rosenzveig, Rohitha Moudgal, Syed Zamrak Khan, Mohamed Ghoweba, Pulkit Chaudhury, Scott J. Cameron and Leben Tefera

J. Clin. Med. 2024, 13(8), 2375; https://doi.org/10.3390/jcm13082375 - 19 Apr 2024

Cited by 1 | Viewed by 1242

Abstract

Background: While obesity is associated with an increased risk of venous thromboembolism (VTE), there is some data to suggest that higher BMI is also associated with decreased all-cause mortality in patients with a pulmonary embolism (PE). Methods: Using PE Response Team (PERT) activation [...] Read more.

Background: While obesity is associated with an increased risk of venous thromboembolism (VTE), there is some data to suggest that higher BMI is also associated with decreased all-cause mortality in patients with a pulmonary embolism (PE). Methods: Using PE Response Team (PERT) activation data from a large tertiary hospital between 27 October 2020 and 28 August 2023, we constructed a multivariate Cox proportional hazards model to assess the association between obesity as a dichotomous variable (defined as BMI ≥ 30 vs. BMI 18.5–29.9), BMI as a continuous variable, and 30-day PE-related mortality. Results: A total of 248 patients were included in this analysis (150 with obesity and 98 who were in the normal/overweight category). Obesity was associated with a lower risk of 30-day PE-related mortality (adjusted HR 0.29, p = 0.036, 95% CI 0.09–0.92). A higher BMI was paradoxically associated with a lower risk of PE-related mortality (HR = 0.91 per 1 kg/m² increase, p = 0.049, 95% CI 0.83–0.999). Conclusions: In our contemporary cohort of patients with a PERT activation, obesity was associated with a lower risk of PE-related mortality. Full article

(This article belongs to the Special Issue Pulmonary Embolism and Its Complications: Causes, Diagnosis and Treatment)

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Review

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12 pages, 535 KiB

Open AccessReview

Sequelae of Acute Pulmonary Embolism: From Post-Pulmonary Embolism Functional Impairment to Chronic Thromboembolic Disease

by John H. Fountain, Tyler J. Peck and David Furfaro

J. Clin. Med. 2024, 13(21), 6510; https://doi.org/10.3390/jcm13216510 - 30 Oct 2024

Viewed by 671

Abstract

Among survivors of acute pulmonary embolism (PE), roughly half report persistent dyspnea, impaired functional status, and decreased quality of life. Post-pulmonary embolism syndrome (PPES) is a broad condition which has been increasingly recognized in recent years and may be due to post-pulmonary embolism [...] Read more.

Among survivors of acute pulmonary embolism (PE), roughly half report persistent dyspnea, impaired functional status, and decreased quality of life. Post-pulmonary embolism syndrome (PPES) is a broad condition which has been increasingly recognized in recent years and may be due to post-pulmonary embolism functional impairment, chronic thromboembolic disease, or the most severe long-term complication of PE, chronic thromboembolic pulmonary hypertension. Despite guideline recommendations for appropriate follow-up for post-pulmonary embolism patients, PPES remains underrecognized and diagnostic testing underutilized. Patients with symptoms suggestive of PPES at follow-up should undergo a transthoracic echocardiogram to screen for the presence of pulmonary hypertension; additional testing, such as a ventilation/perfusion scan, right heart catheterization, and cardiopulmonary exercise testing may be indicated. The pathophysiology of post-pulmonary embolism syndrome is complex and heterogeneous. In chronic thromboembolic pulmonary hypertension, the pathophysiology reflects persistent pulmonary arterial thrombi and a progressive small vessel vasculopathy. In patients with chronic thromboembolic disease or chronic thromboembolic pulmonary hypertension, medical therapy, balloon pulmonary angioplasty, or pulmonary thromboendarterectomy should be considered, and in cases of chronic thromboembolic pulmonary hypertension, pulmonary thromboendarterectomy significantly improves mortality. In all causes of post-pulmonary embolism syndrome, rehabilitation is a safe treatment option that may improve quality of life. Full article

(This article belongs to the Special Issue Pulmonary Embolism and Its Complications: Causes, Diagnosis and Treatment)

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16 pages, 305 KiB

Open AccessFeature PaperReview

Diagnosis of Pulmonary Embolism: A Review of Evidence-Based Approaches

by Sneha E. Thomas, Ido Weinberg, Robert M. Schainfeld, Kenneth Rosenfield and Gaurav M. Parmar

J. Clin. Med. 2024, 13(13), 3722; https://doi.org/10.3390/jcm13133722 - 26 Jun 2024

Cited by 1 | Viewed by 7961

Abstract

Venous thromboembolism, commonly presented as pulmonary embolism and deep-vein thrombosis, is a paramount and potentially fatal condition with variable clinical presentation. Diagnosis is key to providing appropriate treatment in a safe and timely fashion. Clinical judgment and assessment using clinical scoring systems should [...] Read more.

Venous thromboembolism, commonly presented as pulmonary embolism and deep-vein thrombosis, is a paramount and potentially fatal condition with variable clinical presentation. Diagnosis is key to providing appropriate treatment in a safe and timely fashion. Clinical judgment and assessment using clinical scoring systems should guide diagnostic testing, including laboratory and imaging modalities, for optimal results and to avoid unnecessary testing. Full article

(This article belongs to the Special Issue Pulmonary Embolism and Its Complications: Causes, Diagnosis and Treatment)

8 pages, 220 KiB

Open AccessReview

Age-Adjusted and Clinical Probability Adapted D-Dimer Cutoffs to Rule Out Pulmonary Embolism: A Narrative Review of Clinical Trials

by Marc Righini, Helia Robert-Ebadi and Grégoire Le Gal

J. Clin. Med. 2024, 13(12), 3441; https://doi.org/10.3390/jcm13123441 - 12 Jun 2024

Viewed by 820

Abstract

Diagnosis of pulmonary embolism remains a challenge for clinicians as its differential diagnosis is wide. The use of sequential diagnostic strategies based on the assessment of clinical probability, D-dimer measurement, and computed tomography pulmonary angiography have been validated in large prospective outcome studies. [...] Read more.

Diagnosis of pulmonary embolism remains a challenge for clinicians as its differential diagnosis is wide. The use of sequential diagnostic strategies based on the assessment of clinical probability, D-dimer measurement, and computed tomography pulmonary angiography have been validated in large prospective outcome studies. D-dimer measurement at a standard cutoff of 500 μg/L has gained wide acceptance to rule out pulmonary embolism in around 20 to 30% of patients with a clinically suspected pulmonary embolism. To improve the efficiency of D-dimer measurement, different ways of selecting a higher, albeit safe cutoff were explored: the age-adjusted D-dimer cutoff and the clinical adapted D-dimer cutoff. While both have been prospectively validated in large studies, some differences do exist. In particular, the prevalence of pulmonary embolism in these different validation studies was very different. Overall, the age-adjusted cutoff seems to be safer and less efficient, while the clinical probability adapted cutoff seems more efficient and less safe. Here, we report the available data regarding these two different ways to increase the diagnostic yield of D-dimer. Also, well beyond the accuracy of these adjusted/adapted cutoffs, some external factors, such as the prevalence of pulmonary embolism in the tested population and the clinical setting, have an important impact of the negative predictive value and on the overall efficiency of these cutoffs. Therefore, we also discuss which cutoff should be used according to the expected prevalence of the disease and according to the clinical setting. Full article

(This article belongs to the Special Issue Pulmonary Embolism and Its Complications: Causes, Diagnosis and Treatment)

14 pages, 1324 KiB

Open AccessReview

The Role of IVC Filters in the Management of Acute Pulmonary Embolism

by Samer Asmar, George Michael, Vincent Gallo and Mitchell D. Weinberg

J. Clin. Med. 2024, 13(5), 1494; https://doi.org/10.3390/jcm13051494 - 5 Mar 2024

Cited by 2 | Viewed by 3990

Abstract

Venous thromboembolism (VTE), comprising deep venous thrombosis (DVT) and pulmonary embolism (PE), is a prevalent cardiovascular condition, ranking third globally after myocardial infarction and stroke. The risk of VTE rises with age, posing a growing concern in aging populations. Acute PE, with its [...] Read more.

Venous thromboembolism (VTE), comprising deep venous thrombosis (DVT) and pulmonary embolism (PE), is a prevalent cardiovascular condition, ranking third globally after myocardial infarction and stroke. The risk of VTE rises with age, posing a growing concern in aging populations. Acute PE, with its high morbidity and mortality, emphasizes the need for early diagnosis and intervention. This review explores prognostic factors for acute PE, categorizing it into low-risk, intermediate-risk, and high-risk based on hemodynamic stability and right ventricular strain. Timely classification is crucial for triage and treatment decisions. In the contemporary landscape, low-risk PE patients are often treated with Direct Oral Anticoagulants (DOACS) and rapidly discharged for outpatient follow-up. Intermediate- and high-risk patients may require advanced therapies, such as systemic thrombolysis, catheter-directed thrombolysis, mechanical thrombectomy, and IVC filter placement. The latter, particularly IVC filters, has witnessed increased usage, with evolving types like retrievable and convertible filters. However, concerns arise regarding complications and the need for timely retrieval. This review delves into the role of IVC filters in acute PE management, addressing their indications, types, complications, and retrieval considerations. The ongoing debate surrounding IVC filter use, especially in patients with less conventional indications, reflects the need for further research and data. Despite complications, recent studies suggest that clinically significant issues are rare, sparking discussions on the appropriate and safe utilization of IVC filters in select PE cases. The review concludes by highlighting current trends, gaps in knowledge, and potential avenues for advancing the role of IVC filters in future acute PE management. Full article

(This article belongs to the Special Issue Pulmonary Embolism and Its Complications: Causes, Diagnosis and Treatment)

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20 pages, 354 KiB

Open AccessEditor’s ChoiceReview

A Comprehensive Review of Risk Factors and Thrombophilia Evaluation in Venous Thromboembolism

by Andrew B. Dicks, Elie Moussallem, Marcus Stanbro, Jay Walls, Sagar Gandhi and Bruce H. Gray

J. Clin. Med. 2024, 13(2), 362; https://doi.org/10.3390/jcm13020362 - 9 Jan 2024

Cited by 11 | Viewed by 5981

Abstract

Venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant cause of morbidity and mortality worldwide. There are many factors, both acquired and inherited, known to increase the risk of VTE. Most of these result in increased [...] Read more.

Venous thromboembolism (VTE), which encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE), is a significant cause of morbidity and mortality worldwide. There are many factors, both acquired and inherited, known to increase the risk of VTE. Most of these result in increased risk via several common mechanisms including circulatory stasis, endothelial damage, or increased hypercoagulability. Overall, a risk factor can be identified in the majority of patients with VTE; however, not all risk factors carry the same predictive value. It is important for clinicians to understand the potency of each individual risk factor when managing patients who have a VTE or are at risk of developing VTE. With this, many providers consider performing a thrombophilia evaluation to further define a patient’s risk. However, guidance on who to test and when to test is controversial and not always clear. This comprehensive review attempts to address these aspects/concerns by providing an overview of the multifaceted risk factors associated with VTE as well as examining the role of performing a thrombophilia evaluation, including the indications and timing of performing such an evaluation. Full article

(This article belongs to the Special Issue Pulmonary Embolism and Its Complications: Causes, Diagnosis and Treatment)

12 pages, 1119 KiB

Open AccessReview

Choice and Duration of Anticoagulation for Venous Thromboembolism

by Aroosa Malik, Nghi B. Ha and Geoffrey D. Barnes

J. Clin. Med. 2024, 13(1), 301; https://doi.org/10.3390/jcm13010301 - 4 Jan 2024

Cited by 4 | Viewed by 11969

Abstract

Venous thromboembolism (VTE) is a prevalent medical condition with high morbidity, mortality, and associated costs. Anticoagulation remains the main treatment for VTE, though the decision on when, how, and for how long to administer anticoagulants is increasingly complex. This review highlights the different [...] Read more.

Venous thromboembolism (VTE) is a prevalent medical condition with high morbidity, mortality, and associated costs. Anticoagulation remains the main treatment for VTE, though the decision on when, how, and for how long to administer anticoagulants is increasingly complex. This review highlights the different phases of VTE management, with special circumstances for consideration such as antiphospholipid syndrome, coronary artery disease, cancer-associated thrombus, COVID-19, and future anticoagulation options. Anticoagulation management will continue to be a complex decision, applying evidence-based medicine to individual patients with the hope of maximizing effectiveness while minimizing risks. Full article

(This article belongs to the Special Issue Pulmonary Embolism and Its Complications: Causes, Diagnosis and Treatment)

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20 pages, 1260 KiB

Open AccessReview

Risk Stratification and Management of Intermediate-Risk Acute Pulmonary Embolism

by Nichole Brunton, Robert McBane, Ana I. Casanegra, Damon E. Houghton, Dinu V. Balanescu, Sumera Ahmad, Sean Caples, Arashk Motiei and Stanislav Henkin

J. Clin. Med. 2024, 13(1), 257; https://doi.org/10.3390/jcm13010257 - 2 Jan 2024

Cited by 6 | Viewed by 15675

Abstract

Pulmonary embolism (PE) is the third most common cause of cardiovascular death and necessitates prompt, accurate risk assessment at initial diagnosis to guide treatment and reduce associated mortality. Intermediate-risk PE, defined as the presence of right ventricular (RV) dysfunction in the absence of [...] Read more.

Pulmonary embolism (PE) is the third most common cause of cardiovascular death and necessitates prompt, accurate risk assessment at initial diagnosis to guide treatment and reduce associated mortality. Intermediate-risk PE, defined as the presence of right ventricular (RV) dysfunction in the absence of hemodynamic compromise, carries a significant risk for adverse clinical outcomes and represents a unique diagnostic challenge. While small clinical trials have evaluated advanced treatment strategies beyond standard anticoagulation, such as thrombolytic or endovascular therapy, there remains continued debate on the optimal care for this patient population. Here, we review the most recent risk stratification models, highlighting differences between prediction scores and their limitations, and discuss the utility of serologic biomarkers and imaging modalities to detect right ventricular dysfunction. Additionally, we examine current treatment recommendations including anticoagulation strategies, use of thrombolytics at full and reduced doses, and utilization of invasive treatment options. Current knowledge gaps and ongoing studies are highlighted. Full article

(This article belongs to the Special Issue Pulmonary Embolism and Its Complications: Causes, Diagnosis and Treatment)

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Other

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13 pages, 858 KiB

Open AccessSystematic Review

The Outcomes of Surgical Pulmonary Embolectomy for Pulmonary Embolism: A Meta-Analysis

by Mohamed Rahouma, Shaikha Al-Thani, Haitham Salem, Alzahraa Mahmoud, Sherif Khairallah, David Shenouda, Batool Sultan, Laila Khalil, Mohammad Alomari, Mostafa Ali, Ian A. Makey, John C. Haney, Stephanie Mick and Magdy M. El-Sayed Ahmed

J. Clin. Med. 2024, 13(14), 4076; https://doi.org/10.3390/jcm13144076 - 12 Jul 2024

Viewed by 1354

Abstract

Objectives: The purpose of this study is to assess the efficacy, short- and long-term cardiovascular and non-cardiovascular mortalities and postoperative morbidities of surgical pulmonary embolectomy (SPE) for patients with massive or submassive pulmonary embolism. Methods: A comprehensive literature review was performed to identify [...] Read more.

Objectives: The purpose of this study is to assess the efficacy, short- and long-term cardiovascular and non-cardiovascular mortalities and postoperative morbidities of surgical pulmonary embolectomy (SPE) for patients with massive or submassive pulmonary embolism. Methods: A comprehensive literature review was performed to identify articles reporting SPE for pulmonary embolism. The outcomes included in-hospital and long-term mortality in addition to postoperative morbidities. The random effect inverse variance method was used. Cumulative meta-analysis, leave-one-out sensitivity analysis, subgroup analysis and meta-regression were performed. Results: Among the 1949 searched studies in our systematic literature search, 78 studies met our inclusion criteria, including 6859 cases. The mean age ranged from 42 to 65 years. The percentage of males ranged from 25.6% to 86.7%. The median rate of preoperative cardiac arrest was 27.6%. The percentage of contraindications to preoperative systemic thrombolysis was 30.4%. The preoperative systemic thrombolysis use was 11.5%. The in-hospital mortality was estimated to be 21.96% (95% CI: 19.21–24.98); in-hospital mortality from direct cardiovascular causes was estimated to be 16.05% (95% CI: 12.95–19.73). With a weighted median follow-up of 3.05 years, the late cardiovascular and non-cardiovascular mortality incidence rates were 0.39 and 0.90 per person-year, respectively. The incidence of pulmonary bleeding, gastrointestinal bleeding, surgical site bleeding, non-surgical site bleeding and wound complications was 0.62%, 4.70%, 4.84%, 5.80% and 7.2%, respectively. Cumulative meta-analysis showed a decline in hospital mortality for SPE from 42.86% in 1965 to 20.56% in 2024. Meta-regression revealed that the publication year and male sex were associated with lower in-hospital mortality, while preoperative cardiac arrest, the need for inotropes or vasopressors and preoperative mechanical ventilation were associated with higher in-hospital mortality. Conclusions: This study demonstrates acceptable perioperative mortality rates and late cardiovascular and non-cardiovascular mortality in patients who undergo SPE for massive or submassive pulmonary embolism. Full article

(This article belongs to the Special Issue Pulmonary Embolism and Its Complications: Causes, Diagnosis and Treatment)

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13 pages, 1447 KiB

Open AccessSystematic Review

The Benefits and Imperative of Venous Thromboembolism Risk Screening for Hospitalized Patients: A Systematic Review

by Ebtisam Bakhsh

J. Clin. Med. 2023, 12(22), 7009; https://doi.org/10.3390/jcm12227009 - 9 Nov 2023

Viewed by 1704

Abstract

Venous thromboembolism (VTE) is a major preventable condition in hospitalized patients globally. This systematic review evaluates the effectiveness and clinical significance of venous thromboembolism (VTE) risk-screening protocols in preventing VTE events among hospitalized patients. Databases, including PubMed, Embase and Cochrane, were searched without [...] Read more.

Venous thromboembolism (VTE) is a major preventable condition in hospitalized patients globally. This systematic review evaluates the effectiveness and clinical significance of venous thromboembolism (VTE) risk-screening protocols in preventing VTE events among hospitalized patients. Databases, including PubMed, Embase and Cochrane, were searched without date limits for studies comparing outcomes between hospitalized patients who did and did not receive VTE risk screening using standard tools. Twelve studies, enrolling over 139,420 patients, were included. Study quality was assessed using the ROBVIS tool. The results were summarized narratively. The findings show significant benefits of using VTE risk screening versus usual care across various outcomes. Using recommended tools, like Caprini, Padua and IMPROVE, allowed for the accurate identification of high-risk patients who benefited most from prevention. Formal screening was linked to much lower VTE rates, shorter hospital stays, fewer deaths and better use of preventive strategies matched to estimated clot risk. This review calls for the widespread adoption of VTE risk screening as an important safety step for at-risk hospital patients. More high-quality comparative research is needed to validate screening tools in different settings and populations. In summary, VTE risk screening is essential for healthcare systems to reduce life-threatening VTE events and improve patient outcomes through properly targeted preventive methods. Full article

(This article belongs to the Special Issue Pulmonary Embolism and Its Complications: Causes, Diagnosis and Treatment)

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