Acute pulmonary embolism revisited

Konstantinides, Stavros

doi:10.1136/hrt.2005.071274

Cited by 17 publications

(13 citation statements)

References 24 publications

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“…Studies have consistently demonstrated a poorer prognosis associated with right heart strain [5,6], and data from a number of studies have now confirmed an increased risk of mortality in patients with right heart strain evidenced through either biomarkers of cardiac injury (troponin or BNP) [30][31][32][33] or radiological and echocardiogram evidence [5,6,31]. In the cohort of patients without circulatory collapse, it is still not known whether treatment with thrombolysis is warranted; a recent study [34], currently in press, noted that while pulmonary artery obstruction scores can differentiate between patients with and without RV dysfunction, these were not correlated to adverse clinical outcome.…”

Section: Discussionmentioning

confidence: 99%

Thrombus load and acute right ventricular failure in pulmonary embolism: correlation and demonstration of a “tipping point” on CT pulmonary angiography

Wong¹,

Akram

McGurk

et al. 2012

The British Journal of Radiology

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Objectives: The aim of this study was to determine the correlation between increasing pulmonary embolism thrombus load and right ventricular (RV) dilatation as demonstrated by CT pulmonary angiography (CTPA) and to assess the thrombus load threshold which indicates impending RV decompensation. Methods: 2425 consecutive CTPAs were retrospectively analysed. Thrombus load using a modified Miller score (MMS), RV to left ventricular (RV:LV) ratio, presence of septal shift, and pulmonary artery and aorta size were analysed in 504 positive CTPA scans and a representative cohort of 100 negative scans. Results were correlated using non-parametric analysis (two-tailed t-test or x 2 test) and Pearson's rank correlation. Results: Increasing thrombus load correlated with a higher RV:LV ratio, with a statistically significant difference in RV:LV ratios between the negative and positive pulmonary embolism (PE) cohorts. Larger thrombus loads (MMS $12 vs MMS ,12) were strongly correlated with RV strain (mean RV:LV ratio, 1.323 vs 0.930; p,0.0001). Smaller thrombus loads had no significant influence on RV strain. Septal shift was also more likely with an MMS of $12, as was an increase in pulmonary artery diameter (r50.221, p,0.001). Conclusion: With increasing thrombus load in PE, there is CTPA evidence of RV decompensation with an MMS threshold of 12. This suggests a ''tipping point'' beyond which RV decompensation is more likely to occur. This is the first study to describe this tipping point between a thrombus load of MMS .12 and an increase in RV:LV ratio. This finding may help to improve risk stratification in patients with acute PE diagnosed by CTPA.

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Section: Discussionmentioning

confidence: 99%

Thrombus load and acute right ventricular failure in pulmonary embolism: correlation and demonstration of a “tipping point” on CT pulmonary angiography

Wong¹,

Akram

McGurk

et al. 2012

The British Journal of Radiology

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“…The higher rate of bleeding than expected in the present study could be the result of having more patients with comorbid risks for bleeding and those with a relative contraindication to thrombolysis. Catheter-based treatment is best for patients at risk of bleeding, 22 although it is reported that invasive procedures are an independent factor for major bleeding. 25,30 …”

Section: Discussionmentioning

confidence: 99%

“…15 Catheter-based treatment is currently recommended in patients with contraindications to thrombolysis. 22 Pulmonary emboli resolve by natural thrombolytic processes, but a few patients with acute PE progress to residual thrombus with pulmonary hypertension. Persistent RV dysfunction is a predictor of adverse long-term prognosis.…”

Section: Discussionmentioning

confidence: 99%

Thrombolysis With a Novel Modified Tissue-Type Plasminogen Activator, Monteplase, Combined With Catheter-Based Treatment for Major Pulmonary Embolism

Yamamoto

Murai

Tokita

et al. 2009

Circ J

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Circ J 2009; 73: 106 -110 ajor pulmonary embolism (PE) is a life-threatening disorder with high mortality and morbidity. [1][2][3] Most of the deaths of patients presenting in shock occur within the first hour after presentation, 1 so rapid therapeutic action is essential to save lives. Thrombolysis with a tissue-type plasminogen activator (t-PA) produces a much faster improvement in vascular obstruction and hemodynamics than heparin treatment 4 and is the established treatment for acute major PE. 5 In Japan, a novel modified t-PA, monteplase, was approved in 2005 for high-risk patients with acute PE. Compared with the properties of native t-PA, the third-generation, bioengineered thrombolytic agent, monteplase, has a longer half-life, greater clot sensitivity, and more rapid lytic capacity. 6 In a double-blinded, randomized study of patients with acute myocardial infarction, monteplase administration led to greater rates of coronary recanalization and at an earlier stage than was achieved with native t-PA. 6 Initial experience of thrombolysis with the third-generation agents for acute PE has been reported, 7,8 the efficacy and safety of the third-generation thrombolytic agents, including monteplase, with or without catheter-based treatment in patients with major PE has not been clarified and were examined in the present study. Methods Patient PopulationAll patients referred with symptoms suggestive of acute major PE were considered for inclusion in the study. Major PE included massive and submassive types in severity; 9 definitions followed the guideline of the European Society of Cardiology. 10 Massive PE involves shock or hypotension and the subgroup of patients with submassive PE can be identified by the echocardiographic findings of right ventricular (RV) overload without hypotension. All patients had confirmation of PE by pulmonary angiography. A total of 50 patients were included in the study between June 2003 and March 2008. During the same period, 13 patients with major PE were not included because of a contraindication to thrombolytic therapy (n=4), use of urokinase as the initial thrombolytic agent (n=5), anticoagulation only with unfractionated heparin (n=3), and 1 death soon after admission. Treatment Regimen and Assessment of EfficacyOf the 50 patients, 46 received monteplase (Cleactor, Eisai, Japan) through a catheter tip placed in the most diseased segment of the pulmonary artery and 4 were adminis- Background A novel modified tissue-type plasminogen activator, monteplase, has been approved for acute major pulmonary embolism (PE) in Japan. Monteplase has rapid and sustained lytic effects because of a steep rise in concentration after bolus infusion and a longer half-life. Methods and ResultsTo assess the efficacy and safety of thrombolysis with monteplase in combination with catheter-based treatment, acute hemodynamic changes and clinical outcomes were assessed in 50 patients with angiographically confirmed major PE. Thrombolysis with monteplase in combination with embolus fragmentation and t...

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“…3,19 Its overutilization not only exposes the patient to radiation and contrast kidney disease risk, 21,22 but it is weighed as well by exceeding costs; costs that are enhanced by overtreatment of incidental pulmonary embolism, that should not be treated at all. 8,21 Despite the undoubted advantage of this tool in the diagnostic pathway of thrombosis, its use should be targeted and limited to patients with a high pre-test clinical probability or an elevated Ddimer test. 3,6 Lastly, if lower limbs compression ultrasound, which should precede imaging tests in pregnant women and in patients with a contraindication to CT, 4,[23][24][25] is performed as a first step, CT or scintigraphy could be avoided in about 10% of patients.…”

Section: Score Interpretation Points Prevalencementioning

confidence: 99%

“…Conversely, the threshold that rules out pulmonary embolism, advising against anticoagulant therapy, is a probability pre-test ≤2%. [6][7][8] Two validated scores are widely used: the Wells score 9 and the revised Geneva one 10 (Tables 1 and 2). We refer mainly to the Wells score, validated in inpatients; Geneva score is reserved to outpatients.…”

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confidence: 99%

The diagnostic pathway embolism: from the Emergency Department to the Internal Medicine Unit

et al. 2016

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Symptomatic venous thromboembolism occurs in 1-2 per 1000 adults each year; a third of these patients present with pulmonary embolism, 1 which is the most common cause of vascular death after myocardial infarction and stroke. Symptomatic pulmonary embolism is thought to be rapidly fatal in 10% of cases, plus 5% after starting treatment. About 2% of pulmonary embolism patients develop thromboembolic pulmonary hypertension. 1,2 This is why the diagnostic pathway, both in the emergency unit and in the medical department, should be guided by two principles: i) a fast and accurate identification of patients affected, as a diagnostic delay might be fatal and a diagnostic mistake might increase the bleeding risk; and ii) a correct risk stratification, in order to choose the most appropriate treatment. 3,4 Diagnostic scores (Wells and Geneva) and principal markers for pulmonary embolism risk stratification (hypotension-shock, markers of right ventricular dysfunction or myocardial injury), together with the optimal radiological and laboratory testing [scintigraphy and computed tomography (CT) scan, D-dimer], can lead to a prompt diagnosis and address the patient to the most appropriate in-hospital pathway (discharge, admission or intensive care unit). We describe the diagnostic pathway, based on the evidence from literature, which we adopted in our hospital. DiscussionThe clinical presentation of acute pulmonary embolism varies widely among patients, depending on ABSTRACTThe diagnostic pathway of pulmonary embolism, both in the Emergency Department and in the Medical Unit, is not a standardized one. Pulmonary embolism, often but not always complicating surgery, malignancies, different medical diseases, sometimes but not often associated with a deep vein thrombosis, is not infrequently a sudden onset life-threatening and rapidly fatal clinical condition. Most of the deaths due to pulmonary embolism occur at presentation or during the first days after admission; it is therefore of vital importance that pulmonary embolism should promptly be diagnosed and treated in order to avoid unexpected deaths; a correct risk stratification should also be made for choosing the most appropriate therapeutic options. We review the tools we dispose of for a correct clinical assessment, the existing risk scores, the advantages and limits of available diagnostic instruments. As for clinical presentation we remind the great variability of pulmonary embolism signs and symptoms and underline the importance of obtaining clinical probability scores before making requests for further diagnostic tests, in particular for pulmonary computer tomography; the Wells score is the only in-hospital validated one, but unfortunately is still largely underused. We describe our experience in two different periods of time and clinical settings in the initial evaluation of a suspected pulmonary embolism; in the first one we availed ourselves of a computerized support based on Wells score, in the second one we did not. Analysing the results we obtained in terms of...

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Acute pulmonary embolism revisited

Cited by 17 publications

References 24 publications

Thrombus load and acute right ventricular failure in pulmonary embolism: correlation and demonstration of a “tipping point” on CT pulmonary angiography

Thrombus load and acute right ventricular failure in pulmonary embolism: correlation and demonstration of a “tipping point” on CT pulmonary angiography

Thrombolysis With a Novel Modified Tissue-Type Plasminogen Activator, Monteplase, Combined With Catheter-Based Treatment for Major Pulmonary Embolism

The diagnostic pathway embolism: from the Emergency Department to the Internal Medicine Unit

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