Aggressive Treatment of Intermediate-Risk Patients with Acute Symptomatic Pulmonary Embolism.
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ABSTRACT:
SUBMITTER: Jimenez D
PROVIDER: S-EPMC6485961 | biostudies-literature | 2018 Sep
REPOSITORIES: biostudies-literature
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Aggressive Treatment of Intermediate-Risk Patients with Acute Symptomatic Pulmonary Embolism.
Jimenez David D Bikdeli Behnood B Marshall Peter S PS Tapson Victor V
Clinics in chest medicine 20180901 3
Contemporary studies of acute pulmonary embolism (PE) have evaluated the role of thrombolytics in intermediate-risk PE. Significant findings are that thrombolytic therapy may prevent hemodynamic deterioration and all-cause mortality but increases major bleeding. Benefits and harms are finely balanced with no convincing net benefit from thrombolytic therapy among unselected patients. Among patients with intermediate risk PE, additional prognostic factors or subtle hemodynamic changes might alter ...[more]
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Project description:Limited information exists about the prevalence, management, and outcomes of intermediate-high risk patients with acute pulmonary embolism (PE). In a prospective cohort study, we evaluated consecutive patients with intermediate-high risk PE at a large, tertiary, academic medical center between January 1, 2015 and March 31, 2019. Adjudicated outcomes included PE-related mortality and a complicated course through 30 days after initiation of PE treatment. Repeat systolic blood pressure (SBP), heart rate (HR), brain natriuretic peptide (BNP), and cardiac troponin I (cTnI) measurements, and echocardiography were performed within 48 hours after diagnosis. Among 1,015 normotensive patients with acute PE, 97 (9.6%) had intermediate-high risk PE. A 30-day complicated course and 30-day PE-related mortality occurred in 23 (24%) and 7 patients (7.2%) with intermediate-high risk PE. Seventeen (18%) intermediate-high risk patients received reperfusion therapy. Within 48 hours after initiation of anticoagulation, normalization of SBP, HR, cTnI, BNP, and echocardiography occurred in 82, 86, 78, 72, and 33% of survivors with intermediate-high risk PE who did not receive immediate thrombolysis. A complicated course between day 2 and day 30 after PE diagnosis for the patients who normalized SBP, HR, cTnI, BNP, and echocardiography measured at 48 hours occurred in 2.9, 1.4, 4.5, 3.3, and 14.3%, respectively. Intermediate-high risk PE occurs in approximately one-tenth of patients with acute symptomatic PE, and is associated with high morbidity and mortality. Normalization of HR 48 hours after diagnosis might identify a group of patients with a very low risk of deterioration during the first month of follow-up.
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Project description:BackgroundTo investigate if acute pulmonary vasodilation by sildenafil improves right ventricular function in patients with acute intermediate-high risk pulmonary embolism (PE).MethodsSingle center, explorative trial. Patients with PE were randomized to a single oral dose of sildenafil 50 mg (n?=?10) or placebo (n?=?10) as add-on to conventional therapy. The time from hospital admission to study inclusion was 2.3?±?0.7 days. Right ventricular function was evaluated immediately before and shortly after (0.5-1.5 h) randomization by right heart catheterization (RHC), trans-thoracic echocardiography (TTE), and cardiac magnetic resonance (CMR). The primary efficacy endpoint was cardiac index measured by CMR.ResultsPatients had acute intermediate-high risk PE verified by computed tomography pulmonary angiography, systolic blood pressure of 135?±?18 (mean?±?SD) mmHg, increased right ventricular/left ventricular ratio 1.1?±?0.09 and increased troponin T 167?±?144 ng/L. Sildenafil treatment did not improve cardiac index compared to baseline (0.02?±?0.36 l/min/m2, p?=?0.89) and neither did placebo (0.00?±?0.34 l/min/m2, p?=?0.97). Sildenafil lowered mean arterial blood pressure (-?19?±?10 mmHg, p?<?0.001) which was not observed in the placebo group (0?±?9 mmHg, p?=?0.97).ConclusionA single oral dose of sildenafil 50 mg did not improve cardiac index but lowered systemic blood pressure in patients with acute intermediate-high risk PE. The time from PE to intervention, a small patient sample size and low pulmonary vascular resistance are limitations of this study that should be considered when interpreting the results.Trial registrationThe trial was retrospectively registered at www.clinicaltrials.gov (NCT04283240) February 2nd 2020, https://clinicaltrials.gov/ct2/show/NCT04283240?term=NCT04283240&draw=2&rank=1 .
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Project description:ImportanceThe risk of death from acute pulmonary embolism can range as high as 15%, depending on patient factors at initial presentation. Acute treatment decisions are largely based on an estimate of this mortality risk.ObjectiveTo assess the performance of risk assessment scores in a modern, US cohort of patients with acute pulmonary embolism.Design, setting, and participantsThis multicenter cohort study was conducted between October 2016 and October 2017 at 8 hospitals participating in the Pulmonary Embolism Response Team (PERT) Consortium registry. Included patients were adults who presented with acute pulmonary embolism and had sufficient information in the medical record to calculate risk scores. Data analysis was performed from March to May 2020.Main outcomes and measuresAll-cause mortality (7- and 30-day) and associated discrimination were assessed by the area under the receiver operator curve (AUC).ResultsAmong 416 patients with acute pulmonary embolism (mean [SD] age, 61.3 [17.6] years; 207 men [49.8%]), 7-day mortality in the low-risk groups ranged from 1.3% (1 patient) to 3.1% (4 patients), whereas 30-day mortality ranged from 2.6% (1 patient) to 10.2% (13 patients). Among patients in the highest-risk groups, the 7-day mortality ranged from 7.0% (18 patients) to 16.3% (7 patients), whereas 30-day mortality ranged from 14.4% (37 patients) to 26.3% (26 patients). Each of the risk stratification tools had modest discrimination for 7-day mortality (AUC range, 0.616-0.666) with slightly lower discrimination for 30-day mortality (AUC range, 0.550-0.694).Conclusions and relevanceThese findings suggest that commonly used risk tools for acute pulmonary embolism have modest estimating ability. Future studies to develop and validate better risk assessment tools are needed.
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