Intermediate-High Risk Pulmonary Embolism

Rosa Mirambeaux; Francisco León; Behnood Bikdeli; Raquel Morillo; Deisy Barrios; Edwin Mercedes; Lisa Moores; Victor Tapson; Roger D. Yusen; David Jiménez

doi:10.1055/s-0039-3401003

TH Open, Inhaltsverzeichnis

CC BY 4.0 · TH Open 2019; 03(04): e356-e363
DOI: 10.1055/s-0039-3401003

Original Article

Georg Thieme Verlag KG Stuttgart · New York

Intermediate-High Risk Pulmonary Embolism

Rosa Mirambeaux‡^*

¹Respiratory Department, Ramon y Cajal Hospital, Madrid, Spain

,

Francisco León‡^*

¹Respiratory Department, Ramon y Cajal Hospital, Madrid, Spain

,

Behnood Bikdeli

²Division of Cardiology, Department of Medicine, Columbia University Medical Center, NewYork–Presbyterian Hospital, New York, New York, United States

³Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, Connecticut, United States

⁴Cardiovascular Research Foundation (CRF), New York, New York, United States

,

Raquel Morillo

¹Respiratory Department, Ramon y Cajal Hospital, Madrid, Spain

,

Deisy Barrios

¹Respiratory Department, Ramon y Cajal Hospital, Madrid, Spain

,

Edwin Mercedes

¹Respiratory Department, Ramon y Cajal Hospital, Madrid, Spain

,

Lisa Moores

⁵F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, Maryland, United States

,

Victor Tapson

⁶Pulmonary/Critical Care Division, Cedars-Sinai Medical Center, Los Angeles, California, United States

,

Roger D. Yusen

⁷Divisions of Pulmonary and Critical Care Medicine and General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri, United States

,

David Jiménez

¹Respiratory Department, Ramon y Cajal Hospital, Madrid, Spain

⁸Medicine Department, Universidad de Alcala, Madrid, Spain

⁹CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain

› Institutsangaben

Abstract

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.

Keywords

pulmonary embolism - intermediate-high risk - survival - prognosis

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Referenzen

References
1 Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Massive pulmonary embolism. Circulation 2006; 113 (04) 577-582
2 Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353 (9162): 1386-1389
3 Jiménez D, Bikdeli B, Barrios D. , et al; RIETE investigators. Epidemiology, patterns of care and mortality for patients with hemodynamically unstable acute symptomatic pulmonary embolism. Int J Cardiol 2018; 269: 327-333
4 Konstantinides SV, Torbicki A, Agnelli G. , et al; Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35 (43) 3033-3069 , 3069a–3069k
5 Jiménez D, Aujesky D, Moores L. , et al. Combinations of prognostic tools for identification of high-risk normotensive patients with acute symptomatic pulmonary embolism. Thorax 2011; 66 (01) 75-81
6 Bova C, Sanchez O, Prandoni P. , et al. Identification of intermediate-risk patients with acute symptomatic pulmonary embolism. Eur Respir J 2014; 44 (03) 694-703
7 Jimenez D, Lobo JL, Fernandez-Golfin C. , et al; PROTECT investigators. Effectiveness of prognosticating pulmonary embolism using the ESC algorithm and the Bova score. Thromb Haemost 2016; 115 (04) 827-834
8 Becattini C, Agnelli G, Lankeit M. , et al. Acute pulmonary embolism: mortality prediction by the 2014 European Society of Cardiology risk stratification model. Eur Respir J 2016; 48 (03) 780-786
9 Remy-Jardin M, Remy J, Wattinne L, Giraud F. Central pulmonary thromboembolism: diagnosis with spiral volumetric CT with the single-breath-hold technique--comparison with pulmonary angiography. Radiology 1992; 185 (02) 381-387
10 PIOPED Investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). JAMA 1990; 263 (20) 2753-2759
11 Kearon C, Ginsberg JS, Hirsh J. The role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism. Ann Intern Med 1998; 129 (12) 1044-1049
12 Jiménez D, Aujesky D, Moores L. , et al; RIETE Investigators. Simplification of the Pulmonary Embolism Severity Index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med 2010; 170 (15) 1383-1389
13 Jiménez D, Kopecna D, Tapson V. , et al; On Behalf Of The Protect Investigators. Derivation and validation of multimarker prognostication for normotensive patients with acute symptomatic pulmonary embolism. Am J Respir Crit Care Med 2014; 189 (06) 718-726
14 Grifoni S, Olivotto I, Cecchini P. , et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation 2000; 101 (24) 2817-2822
15 Jiménez D, Díaz G, Molina J. , et al. Troponin I and risk stratification of patients with acute nonmassive pulmonary embolism. Eur Respir J 2008; 31 (04) 847-853
16 Pieralli F, Olivotto I, Vanni S. , et al. Usefulness of bedside testing for brain natriuretic peptide to identify right ventricular dysfunction and outcome in normotensive patients with acute pulmonary embolism. Am J Cardiol 2006; 97 (09) 1386-1390
17 Scridon T, Scridon C, Skali H, Alvarez A, Goldhaber SZ, Solomon SD. Prognostic significance of troponin elevation and right ventricular enlargement in acute pulmonary embolism. Am J Cardiol 2005; 96 (02) 303-305
18 Binder L, Pieske B, Olschewski M. , et al. N-terminal pro-brain natriuretic peptide or troponin testing followed by echocardiography for risk stratification of acute pulmonary embolism. Circulation 2005; 112 (11) 1573-1579
19 Dellas C, Tschepe M, Seeber V. , et al. A novel H-FABP assay and a fast prognostic score for risk assessment of normotensive pulmonary embolism. Thromb Haemost 2014; 111 (05) 996-1003
20 Konstantinides SV, Meyer G, Becattini C. , et al; ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2019 Doi: 10.1093/eurheartj/ehz405 [Epub ahead of print]
21 Meyer G, Vicaut E, Danays T. , et al; PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014; 370 (15) 1402-1411
22 Kearon C, Akl EA, Ornelas J. , et al. Antithrombotic therapy for VTE disease: Chest guideline and expert panel report. Chest 2016; 149 (02) 315-352
23 Jiménez D, Bikdeli B, Barrios D. , et al; RIETE investigators. Management appropriateness and outcomes of patients with acute pulmonary embolism. Eur Respir J 2018; 51 (05) 1800445

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