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JAMA Network Open May 2023Most patients presenting to US emergency departments (EDs) with acute pulmonary embolism (PE) are hospitalized, despite evidence from multiple society-based guidelines...
IMPORTANCE
Most patients presenting to US emergency departments (EDs) with acute pulmonary embolism (PE) are hospitalized, despite evidence from multiple society-based guidelines recommending consideration of outpatient treatment for those with low risk stratification scores. One barrier to outpatient treatment may be clinician concern regarding findings on PE-protocol computed tomography (CTPE), which are perceived as high risk but not incorporated into commonly used risk stratification tools.
OBJECTIVE
To evaluate the association of concerning CTPE findings with outcomes and treatment of patients in the ED with acute, low-risk PE.
DESIGN, SETTING, AND PARTICIPANTS
This cohort study used a registry of all acute PEs diagnosed in the adult ED of an academic medical center from October 10, 2016, to December 31, 2019. Acute PE cases were divided into high- and low-risk groups based on PE Severity Index (PESI) class alone or using a combination of PESI class and biomarker results. The low-risk group was further divided based on the presence of concerning CTPE findings: (1) bilateral central embolus, (2) right ventricle-to-left ventricle ratio greater than 1.0, (3) right ventricle enlargement, (4) septal abnormality, or (5) pulmonary infarction. Data analysis was conducted from June to October 2022.
MAIN OUTCOMES AND MEASURES
The primary outcome was all-cause mortality at 7 and 30 days. Secondary outcomes included hospitalization, length of stay, need for intensive care, use of echocardiography and/or bedside ultrasonography, and activation of the PE response team (PERT) .
RESULTS
Of 817 patients (median [IQR] age, 58 [47-71] years; 417 (51.0%) female patients; 129 [15.8%] Black and 645 [78.9%] White patients) with acute PEs, 331 (40.5%) were low risk and 486 (59.5%) were high risk by PESI score. Clinical outcomes were similar for all low-risk patients, with no 30-day deaths in the low-risk group with concerning CTPE findings (0 of 151 patients) vs 4 of 180 (2.2%) in the low-risk group without concerning CTPE findings and 88 (18.1%) in the high-risk group (P < .001). Low-risk patients with concerning CTPE findings were less frequently discharged from the ED than those without concerning CTPE findings (3 [2.0%] vs 14 [7.8%]; P = .01) and had more frequent echocardiography (87 [57.6%] vs 49 [27.2%]; P < .001) and PERT activation for consideration of advanced therapies (34 [22.5%] vs 11 [6.1%]; P < .001).
CONCLUSIONS AND RELEVANCE
In this single-center study, CTPE findings widely believed to confer high risk were associated with increased hospitalization and resource utilization in patients with low-risk PE but not short-term adverse clinical outcomes.
Topics: Adult; Humans; Female; Middle Aged; Male; Cohort Studies; Pulmonary Embolism; Risk Factors; Biomarkers; Tomography, X-Ray Computed
PubMed: 37256624
DOI: 10.1001/jamanetworkopen.2023.11455 -
Indian Journal of Hematology & Blood... Jun 2016We report a 42 year old non-smoker male who presented with progressive exertional dyspnoea, productive cough with streaky hemoptysis and progressive pedal edema. His...
We report a 42 year old non-smoker male who presented with progressive exertional dyspnoea, productive cough with streaky hemoptysis and progressive pedal edema. His physical examination, ECG, chest X-ray and 2D-ECHO revealed features suggestive of right heart failure and pulmonary hypertension. On further evaluation for the cause of pulmonary hypertension, his CT pulmonary angiography revealed features of chronic pulmonary thromboembolism with calcified thrombus in the main pulmonary artery along with pulmonary hypertension. Incidentally the CT also revealed a cavity in the right lung with soft tissue within it. A, trans-thoracic needle aspiration of this tissue was suggestive of an aspergilloma. This is a rare case report of co-existence of two uncommon complications of pulmonary embolism-chronic thrombo-embolic pulmonary hypertension and pulmonary Aspergilloma in the same patient.
PubMed: 27408402
DOI: 10.1007/s12288-015-0614-2 -
Jornal Brasileiro de Pneumologia :... 2015
Topics: Adult; Cryptogenic Organizing Pneumonia; Diagnosis, Differential; Humans; Lung; Male; Pulmonary Infarction; Tomography, X-Ray Computed
PubMed: 26785969
DOI: 10.1590/S1806-37562015000000235 -
International Heart Journal Sep 2021A 20-year-old man with arrhythmogenic right ventricular cardiomyopathy (ARVC) was resuscitated from ventricular fibrillation. He was transferred to our hospital because...
A 20-year-old man with arrhythmogenic right ventricular cardiomyopathy (ARVC) was resuscitated from ventricular fibrillation. He was transferred to our hospital because of progressive multiorgan dysfunction despite mechanical circulatory support with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) and intra-aortic balloon pump (IABP). At admission to our hospital, chest X-ray showed bilateral complete lung opacification, and echocardiography revealed a massive thrombus occupying the left atrium (LA) and left ventricle (LV). Conversion to central ECMO with transapical LV venting and thrombectomy were performed. The huge LA thrombus occluded all pulmonary veins (PVs). Despite the surgery and intensive care, complete lung opacity remained, and he died of multiorgan failure associated with sepsis. Autopsy demonstrated bilateral pulmonary multiple red infarctions, and histopathology showed alveolar wall necrosis with extensive hemorrhage, confirming a diagnosis of pulmonary hemorrhagic infarction. Extensive pulmonary infarction was attributable to PV occlusion due to massive LA thrombus. PV thrombosis should be considered when refractory lung opacities are encountered during VA-ECMO and necessitates early intervention.
Topics: Arrhythmogenic Right Ventricular Dysplasia; Autopsy; Echocardiography; Extracorporeal Membrane Oxygenation; Fatal Outcome; Heart Atria; Heart Ventricles; Hemorrhage; Humans; Intra-Aortic Balloon Pumping; Male; Multiple Organ Failure; Pulmonary Infarction; Pulmonary Veins; Pulmonary Veno-Occlusive Disease; Resuscitation; Sepsis; Thrombectomy; Thrombosis; Ventricular Fibrillation; Young Adult
PubMed: 34544989
DOI: 10.1536/ihj.21-226 -
Journal of Clinical Pathology Dec 1991Pulmonary and myocardial damage are frequently cited as manifestations of disseminated intravascular coagulation (DIC), but rarely as causes. Three elderly cases of...
Pulmonary and myocardial damage are frequently cited as manifestations of disseminated intravascular coagulation (DIC), but rarely as causes. Three elderly cases of severe DIC due to pulmonary and myocardial infarction are reported. All three patients died. Necropsy showed extensive pulmonary emboli in each case with large pulmonary infarcts in cases 1 and 2 and a ventricular aneurysm containing thrombus in cases 2 and 3. Early diagnosis and treatment of pulmonary embolism requires a high degree of clinical suspicion but may prevent progression to the irreversible stage of severe DIC.
Topics: Aged; Aged, 80 and over; Disseminated Intravascular Coagulation; Female; Humans; Myocardial Infarction; Pulmonary Embolism
PubMed: 1791208
DOI: 10.1136/jcp.44.12.1034 -
The Journal of International Medical... Aug 2021Infected cavitating pulmonary infarction is a rare complication of pulmonary embolism with a high mortality rate. Surgical excision for this complication has been used...
Infected cavitating pulmonary infarction is a rare complication of pulmonary embolism with a high mortality rate. Surgical excision for this complication has been used in past decades. Abrupt cavitation and a large oval-shaped lung abscess caused by acute thromboembolic pulmonary infarction during anticoagulation are rare. We present a 70-year-old man who suffered from pleuritic pain and breathlessness, accompanied by nausea and vomiting for 1 day. A physical examination showed tachycardia and tachypnea with moist rales in the left upper chest. High D-dimer levels, leukocytosis, respiratory failure and left upper lobe consolidation were found on plain computed tomography (CT). CT pulmonary angiography was performed 2 days after the previous CT scan because pulmonary embolism was suspected. This scan showed emboli in the main, right upper, middle, lower and left upper pulmonary arteries with deteriorated left upper lobe consolidation and cavitation. Thromboembolic pulmonary infarction and an abscess were diagnosed. Enoxaparin 60 mg was administered every 12 hours for 10 days, followed by rivaroxaban, antibiotics and drainage of the hydrothorax. The patient improved after the strategy of non-surgical treatment and was discharged approximately 1 month later. The patient had an uneventful course during rivaroxaban 20 mg once daily for 1 year.
Topics: Aged; Humans; Lung Abscess; Male; Pulmonary Artery; Pulmonary Embolism; Pulmonary Infarction; Thromboembolism
PubMed: 34369190
DOI: 10.1177/03000605211031682 -
The British Journal of Radiology Apr 2020The clinical diagnosis of pulmonary embolism is often difficult, as symptoms range from syncope and chest pain to shock and sudden death. Adding complexity to this...
The clinical diagnosis of pulmonary embolism is often difficult, as symptoms range from syncope and chest pain to shock and sudden death. Adding complexity to this picture, some patients with non-diagnosed pulmonary embolism may undergo unenhanced imaging examinations for a number of reasons, including the prevention of contrast medium-related nephrotoxicity, anaphylactic/anaphylactoid reactions and nephrogenic systemic fibrosis, as well as due to patients' refusal or lack of venous access. In this context, radiologists' awareness and recognition of indirect signs are cornerstones in the diagnosis of pulmonary embolism. This article describes the indirect signs of pulmonary embolism on chest X-ray, unenhanced CT, and MRI.
Topics: Diagnosis, Differential; Humans; Incidental Findings; Lung Diseases; Magnetic Resonance Imaging; Multimodal Imaging; Pulmonary Artery; Pulmonary Embolism; Pulmonary Infarction; Thrombosis; Tomography, X-Ray Computed
PubMed: 31944831
DOI: 10.1259/bjr.20190635 -
Scientific Reports Sep 2022This study was undertaken to determine the risk of bevacizumab-induced lung toxicity, time to onset, and post hoc outcomes using the Japanese Adverse Drug Event Report...
This study was undertaken to determine the risk of bevacizumab-induced lung toxicity, time to onset, and post hoc outcomes using the Japanese Adverse Drug Event Report database. We analysed data for the period between April 2004 and March 2021. Data on lung toxicities were extracted, and relative risk of adverse events (AEs) was estimated using the reporting odds ratio. We analysed 5,273,115 reports and identified 20,399 reports of AEs caused by bevacizumab. Of these, 1679 lung toxicities were reportedly associated with bevacizumab. Signals were detected for nine lung toxicities. A histogram of times to onset showed occurrence from 35 to 238 days, but some cases occurred even more than one year after the start of administration. Approximately 20% of AEs were thromboembolic events. Among these, pulmonary embolism was the most frequently reported and fatal cases were also reported. The AEs showing the highest fatality rates were pulmonary haemorrhage, pulmonary infarction, and pulmonary thrombosis. In conclusion, we focused on lung toxicities caused by bevacizumab as post-marketing AEs. Some cases could potentially result in serious outcomes, patients should be monitored for signs of onset of AEs not only at the start of administration, but also over a longer period of time.
Topics: Adverse Drug Reaction Reporting Systems; Bevacizumab; Databases, Factual; Drug-Related Side Effects and Adverse Reactions; Humans; Lung
PubMed: 36114412
DOI: 10.1038/s41598-022-19887-x -
American Journal of Physiology. Heart... Feb 2018Myocardial infarction (MI) may result in pulmonary hypertension (PH). Inhibition of phosphodiesterase 5 (PDE5), the enzyme responsible for the breakdown of cGMP in...
Myocardial infarction (MI) may result in pulmonary hypertension (PH). Inhibition of phosphodiesterase 5 (PDE5), the enzyme responsible for the breakdown of cGMP in vascular smooth muscle, has become part of the contemporary therapeutic armamentarium for pulmonary arterial hypertension and may also be beneficial for PH secondary to MI. Nitric oxide (NO) is an important activator of cGMP synthesis and can be enhanced in early PH and decreased in severe PH. In the present study, we investigated if PDE5 inhibition ameliorates pulmonary hemodynamics in swine with PH secondary to MI and whether NO is essential. The PDE5 inhibitor EMD360527 was administered in awake, chronically instrumented swine with or without MI. At rest, PDE5 inhibition produced pulmonary vasodilation as evidenced by a decrease in pulmonary vascular resistance, which was more pronounced in MI ( n = 5) compared with normal swine ( n = 10, P ≤ 0.01) and was accompanied by an increase in stroke volume in MI swine. Both pulmonary vasodilation and increased stroke volume were maintained during exercise, suggesting that this therapy may improve exercise capacity in patients with PH secondary to MI. Interestingly, prior inhibition of NO significantly enhanced ( P ≤ 0.01) pulmonary vasodilation by PDE5 inhibition in both normal ( n = 8) and MI swine ( n = 5, P ≤ 0.05 vs. normal). This suggests that the increased vasodilator responses to PDE5 inhibition after MI were not due to an increase in NO-induced cGMP production. These observations indicate that PDE5 inhibition represents an interesting pharmacotherapeutic approach in early PH after a recent MI to prevent overt PH. NEW & NOTEWORTHY This research article is the first to describe that pulmonary vasodilation to phosphodiesterase 5 inhibition is enhanced and nitric oxide independent in resting and exercising swine with pulmonary hypertension as a result of myocardial infarction. This suggests that phosphodiesterase 5 inhibition can normalize pulmonary hemodynamics in postcapillary pulmonary hypertension after a recent myocardial infarction and may improve exercise capacity.
Topics: Animals; Antihypertensive Agents; Arterial Pressure; Cardiac Output; Cyclic Nucleotide Phosphodiesterases, Type 5; Disease Models, Animal; Female; Hypertension, Pulmonary; Male; Myocardial Infarction; Nitric Oxide; Phosphodiesterase 5 Inhibitors; Pulmonary Artery; Signal Transduction; Sus scrofa; Vascular Resistance; Vasodilation; Vasodilator Agents
PubMed: 28986358
DOI: 10.1152/ajpheart.00370.2017 -
Journal of Cardiovascular Development... Nov 2021Inferior vena cava (IVC) aneurysms rarely occur. They are commonly detected incidentally since they present with mild or no symptoms. This was the first study to report...
Inferior vena cava (IVC) aneurysms rarely occur. They are commonly detected incidentally since they present with mild or no symptoms. This was the first study to report a fatal case of a saccular IVC aneurysm with pulmonary embolism and cerebral infarction. The patient developed cardiac arrest five minutes after arriving at the emergency department, and spontaneous circulation was restored after two minutes of cardiopulmonary resuscitation. Computed tomography scans of the brain, chest, and abdomen-pelvis were obtained. The patient was diagnosed with a saccular aneurysm of the IVC measuring 8 × 11 cm, massive embolism of both pulmonary arteries, and cerebral infarction. An electroencephalogram, taken on the third day of hospitalization, suggested brain death, and the patient died on the eleventh day of hospitalization. This case report highlights that an IVC aneurysm with pulmonary embolism can be associated with paradoxical emboli-induced cerebral infarction, which is fatal.
PubMed: 34821700
DOI: 10.3390/jcdd8110147