Risk Stratification in Acute Pulmonary Embolism: The Latest Algorithms

2021 ◽  
Vol 42 (02) ◽  
pp. 183-198
Author(s):  
Georgios A. Triantafyllou ◽  
Oisin O'Corragain ◽  
Belinda Rivera-Lebron ◽  
Parth Rali
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Prediction Models ◽  
Bleeding Risk ◽  
Hemodynamic Instability ◽  
Reperfusion Therapy ◽  
Mortality Prediction ◽  
Risk Scores ◽  
Short Term Mortality ◽  
Urgent Patient

AbstractPulmonary embolism (PE) is a common clinical entity, which most clinicians will encounter. Appropriate risk stratification of patients is key to identify those who may benefit from reperfusion therapy. The first step in risk assessment should be the identification of hemodynamic instability and, if present, urgent patient consideration for systemic thrombolytics. In the absence of shock, there is a plethora of imaging studies, biochemical markers, and clinical scores that can be used to further assess the patients' short-term mortality risk. Integrated prediction models incorporate more information toward an individualized and precise mortality prediction. Additionally, bleeding risk scores should be utilized prior to initiation of anticoagulation and/or reperfusion therapy administration. Here, we review the latest algorithms for a comprehensive risk stratification of the patient with acute PE.

scholarly journals Biomarkers for Clinical Decision-Making in the Management of Pulmonary Embolism

2017 ◽  
Vol 63 (1) ◽  
pp. 91-100 ◽  
Author(s):  
Evangelos Giannitsis ◽  
Hugo A Katus
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Natriuretic Peptides ◽  
Clinical Decision Making ◽  
Prediction Models ◽  
Severity Index ◽  
Prognostic Models ◽  
Risk Scores ◽  
Fatty Acid Binding ◽  
Cardiac Troponins

Abstract BACKGROUND Pulmonary embolism (PE) is associated with high all-cause and PE-related mortality and requires individualized management. After confirmation of PE, a refined risk stratification is particularly warranted among normotensive patients. Previous prognostic models favored combinations of echocardiography or computed tomography suggestive of right ventricular (RV) dysfunction together with biomarkers of RV dysfunction (natriuretic peptides) or myocardial injury (cardiac troponins) to identify candidates for thrombolysis or embolectomy. In contrast, current predictive models using clinical scores such as the Pulmonary Embolism Severity Index (PESI) or its simplified version (sPESI) rather seek to identify patients, not only those at higher risk requiring observation for early detection of hemodynamic decompensation, and the need for initiation of rescue reperfusion therapy, but also those at low risk qualifying for early discharge and outpatient treatment. Almost all prediction models advocate the additional measurement of biomarkers along with imaging of RV dysfunction as part of a comprehensive algorithm. CONTENT The following mini-review will provide an updated overview on the individual components of different algorithms with a particular focus on guideline-recommended and new, less-established biomarkers for risk stratification, and how biomarkers should be implemented and interpreted. SUMMARY Ideally, biomarkers should be part of a comprehensive risk stratification algorithm used together with clinical risk scores as a basis, and/or imaging. For this purpose, cardiac troponins, including high-sensitivity troponin generations, natriuretic peptides, and h-FABP (heart-type fatty acid–binding protein) are currently recommended in guidelines. There is emerging evidence for several novel biomarkers that require further validation before being applied in clinical practice.

Pulmonary embolism in acute medicine: a case-based review incorporating latest guidelines in the COVID-19 era

2020 ◽  
Vol 81 (6) ◽  
pp. 1-12 ◽  
Author(s):  
Alexander Stevenson ◽  
Sarah Davis ◽  
Nick Murch
Keyword(s):  
Pulmonary Embolism ◽  
Risk Stratification ◽  
Acute Pulmonary Embolism ◽  
Severe Disease ◽  
Treatment Options ◽  
Risk Scores ◽  
Pulmonary Vasculature ◽  
Catheter Directed Thrombolysis ◽  
Imaging Results ◽  
Venous Thromboembolic Events

Pulmonary embolism remains an important cause of morbidity and mortality in the UK, particularly following the outbreak of the novel coronavirus 2019 (COVID-19), where those infected have an increased prevalence of venous thromboembolic events. The pathophysiology in COVID-19 patients is thought to relate to a thromboinflammatory state within the pulmonary vasculature, triggered by the infection, but other risk factors such as reduced mobility, prolonged immobilisation and dehydration are likely to contribute. Several societies have released comprehensive guidelines emphasising the importance of risk stratification in patients with acute pulmonary embolism. They advocate the use of clinically validated risk scores in conjunction with biochemical and imaging results. Patients with mild disease can now be managed in the outpatient setting and with newly developed therapies, such as catheter-directed thrombolysis, becoming available in more centres, treatment options for those with more severe disease are also expanding. This article presents four theoretical but realistic cases, each diagnosed with acute pulmonary embolism, but differing in levels of severity. These demonstrate how the guidelines can be applied in a clinical setting, with particular focus on risk stratification and management.

scholarly journals Direct comparison of predictive performance of PRECISE-DAPT versus PARIS versus CREDO-Kyoto: a subanalysis of the ReCre8 trial

2020 ◽  
Author(s):  
R. Rozemeijer ◽  
W. P. van Bezouwen ◽  
N. D. van Hemert ◽  
J. A. Damen ◽  
S. Koudstaal ◽  
...  
Keyword(s):  
Risk Stratification ◽  
Risk Score ◽  
Invasive Procedure ◽  
Predictive Performance ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
Risk Scores ◽  
Drug Eluting Stent ◽  
Bleeding Events ◽  
Post Discharge

Abstract Background Multiple scores have been proposed to guide risk stratification after percutaneous coronary intervention. This study assessed the performance of the PRECISE-DAPT, PARIS and CREDO-Kyoto risk scores to predict post-discharge ischaemic or bleeding events. Methods A total of 1491 patients treated with latest-generation drug-eluting stent implantation were evaluated. Risk scores for post-discharge ischaemic or bleeding events were calculated and directly compared. Prognostic performance of both risk scores was assessed with calibration, Harrell’s c‑statistics net reclassification index and decision curve analyses. Results Post-discharge ischaemic events occurred in 56 patients (3.8%) and post-discharge bleeding events in 34 patients (2.3%) within the first year after the invasive procedure. C‑statistics for the PARIS ischaemic risk score was marginal (0.59, 95% confidence interval (CI) 0.51–0.68), whereas the CREDO-Kyoto ischaemic risk score was moderate (0.68, 95% CI 0.60–0.75). With regard to post-discharge bleeding events, CREDO-Kyoto displayed moderate discrimination (c-statistic 0.67, 95% CI 0.56–0.77), whereas PRECISE-DAPT (0.59, 95% CI 0.48–0.69) and PARIS (0.55, 95% CI 0.44–0.65) had a marginal discriminative capacity. Net reclassification index and decision curve analysis favoured CREDO-Kyoto-derived bleeding risk assessment. Conclusion In this contemporary all-comer population, PARIS and PRECISE-DAPT risk scores were not resilient to independent testing for post-discharge bleeding events. CREDO-Kyoto-derived risk stratification was associated with a moderate predictive capability for post-discharge ischaemic or bleeding events. Future studies are warranted to improve risk stratification with more focus on robustness and rigorous testing.

D-dimer levels enhance the discriminatory capacity of bleeding risk scores for predicting in-hospital bleeding events in acute pulmonary embolism

2019 ◽  
Vol 69 ◽  
pp. 8-13 ◽  
Author(s):  
Marta Skowrońska ◽  
Aleksandra Furdyna ◽  
Michał Ciurzyński ◽  
Szymon Pacho ◽  
Piotr Bienias ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Acute Pulmonary Embolism ◽  
Bleeding Risk ◽  
Risk Scores ◽  
Bleeding Events ◽  
Discriminatory Capacity ◽  
D Dimer

scholarly journals Reperfusion Treatment for Acute Pulmonary Embolism

2018 ◽  
Vol 38 (02) ◽  
pp. 98-105 ◽  
Author(s):  
Rolf Engelberger ◽  
Nils Kucher
Keyword(s):  
Pulmonary Embolism ◽  
Acute Pulmonary Embolism ◽  
Treatment Options ◽  
Bleeding Risk ◽  
Good Alternative ◽  
Reperfusion Therapy ◽  
Systemic Thrombolysis ◽  
Favourable Safety ◽  
Favourable Safety Profile ◽  
Surgical Embolectomy

AbstractDue to the manifold treatment options for the management of acute pulmonary embolism, state-of-the-art management requires risk stratification for choosing the adapted treatment for each patient. Reperfusion therapy is an integral part of therapy for patients with pulmonary embolism at high risk for mortality, but its role in patients with intermediate risk pulmonary embolism is more debated. The largest amount of evidence exists for systemic thrombolysis, which is an efficient therapy, but at the prize of an increased bleeding risk. In recent years, various types of catheter-based reperfusion therapies have been introduced, and evidence is growing that this therapy is as efficient as systemic thrombolysis, but with a more favourable safety profile. Surgical embolectomy remains a good alternative for unstable patients, especially for those with absolute contraindications for thrombolysis or after failed systemic thrombolysis. While the early benefits of reperfusion therapy are well documented, evidence for long-term benefit is still scarce. The scope of this review is to summarize the evidence for the currently available reperfusion therapies in the management of acute pulmonary embolism.

Prediction Models and Scores in Pulmonary Hypertension: A Systematic Review

2020 ◽  
Vol 26 ◽  
Author(s):  
Sophia Anastasia Mouratoglou ◽  
Ahmed A. Bayoumy ◽  
Anton Vonk Noordegraaf
Keyword(s):  
Systematic Review ◽  
Risk Stratification ◽  
Prediction Models ◽  
Prognostic Significance ◽  
Morbidity And Mortality ◽  
Prognostic Models ◽  
Risk Scores ◽  
Patient Treatment ◽  
Discrimination Ability ◽  
Mesh Terms

Background:: pulmonary arterial hypertension (PAH) is a serious disease with increased morbidity and mortality. The need of an individualized patient treatment approach necessitates the use of risk assessment in PAH patients. That may include a range of hemodynamic, clinical, imaging and biochemical parameters, derived from clinical studies and registry data. Objective:: in current systematic review, we summarize the available data on risk prognostic models and scores in PAH and we explore the possible concordance amongst different risk stratification tools in PAH. Methods:: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines aided the performance of this systematic review. Eligible studies were identified through literature search in the electronic databases PubMed, Science Direct, Google Scholar and Cochrane with the use of various combinations of MeSH and non-MeSH terms, with focus on PAH Results:: overall, 25 studies were included in the systematic review, out of them, 9 were studies deriving prognostic equations and risk scores and 16 were validating studies of an existing score. The majority of risk stratification scores use hemodynamic data for the assessment of prognosis, while other also include clinical and demographic variables in their equations. The risk discrimination in the overall PAH population, was adequate, especially in differentiating the low versus high risk patients, but their discrimination ability in the intermediate groups remained lower. Current ESC/ERS proposed risk stratification score utilizes a limited number of parameters with prognostic significance, whose prognostic ability is validated in European patient populations. Conclusion:: despite improvement in risk estimation of prognostic tools of the disease, PAH morbidity and mortality remain high, necessitating the need for the risk scores to undergo periodic re-evaluation and refinements to incorporate new data on predictors of disease progression and mortality and, thereby, maintain their clinical utility

P6464Acute pulmonary embolism in Argentina. CONAREC XX registry

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
I M Cigalini ◽  
C E Scatularo ◽  
J C C Jauregui ◽  
J I Ortego ◽  
D Cornejo ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Hospital Mortality ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Hemodynamic Instability ◽  
Low Risk ◽  
P Value ◽  
Acute Pe

Abstract Background Pulmonary embolism (PE) represents the third cause of cardiovascular death and one of the leading causes of preventable in-hospital mortality. However, there is lack of information about this entity in our country. Purpose To describe baseline characteristics, in-hospital evolution and treatments among patients (P) admitted for acute PE in Argentina. Methods A prospective multicentric registry of P with acute PE was conducted in 75 academic centers between October 2016 and November 2017. Conventional analysis was used for descriptive and comparative statistics, with a p value <0.05 considered as significant. Cross audit was performed at 20% of participating centers. Results We included 684 consecutive P with an average age of 63,8 years (SD 16,8), with slight majority of female sex (57%). PE was the reason for admission in 484 (71%) of the cases; 68% of those others who developed PE as a complication during hospital stay were under adequate venous thromboembolism prophylaxis. The most frequent predisposing factors were obesity (34%), recent hospitalization (34%), transient rest (30%) and active cancer (22%). Multislice computed tomography was the diagnostic method of choice (81%). An echocardiogram was performed in 625 P (91%), showing right ventricular dilatation or dysfunction in 41% and 35% of the cases, respectively. After initial diagnosis, P were stratified as low risk (24%), intermediate-low risk (34%), intermediate-high risk (27%) and high risk (15%). Anticoagulation was indicated in 661 (97%), mainly with low-molecular-weight heparins (LMWH) (59%) as initial strategy. Reperfusion with either thrombolytics or mechanical therapies was performed in 91 (13%) cases. However, only 50 of the 102 P who presented with hemodynamic instability received any reperfusion therapy (49%). Overall in-hospital mortality was 12%, mainly related to PE (51%), with significant differences according to risk stratification (p<0,01) (Figure 1). 579 out of 601 survivors received anticoagulants at discharge: 60% vitamin K antagonists, 21% LMWH and 19% direct oral anticoagulants (49% Rivaroxaban, 34% Apixaban and 17% Dabigatran). Mortality according risk stratification Conclusions PE presents with high in-hospital mortality in our setting mainly due to the embolic event. This finding could be related to a low use of reperfusion therapies in P with hemodynamic instability, reflecting low adherence to guideline recommendations even in academic centers. This issue should be taken into consideration to improve PE prognosis in Argentina.

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